ffectiveness and safety of ustekinumab dose escalation in Crohn’s disease: a multicenter observational study / Efectividad y seguridad del aumento de dosis de ustekinumab en la enfermedad de Crohn: un estudio observacional multicéntrico

Background: ustekinumab has proven effective in Crohn’s disease (CD). However, some patients will partially respond or lose response over time. Data supporting the effectiveness of dose escalation in this scenario is scarce. Aim: to evaluate the effectiveness of ustekinumab dose escalation in CD. Methods: patients with active CD (Harvey-Bradshaw ≥ 5) who had received intravenous (IV) induction and at least a subcutaneous (SC) dose were included in this retrospective observational study. Ustekinumab dose was escalated, either via shortening of the interval to six or four weeks or IV reinduction plus shortening to every four weeks. Results: ninety-one patients were included, and ustekinumab dose was escalated after a median of 35 weeks of treatment. At week 16 after intensification, steroid-free clinical response and remission were observed in 62.6 % and 25.3 % of patients, respectively. Systemic corticosteroids were discontinued in 46.7 % of patients who were on corticosteroids at baseline. Follow-up data beyond week 16 were available for 78 % of patients; at the last visit, 66.2 % and 43.7 % were in steroid-free clinical response and remission, respectively. After a median follow-up of 64 weeks, 81 % of patients were still treated with ustekinumab. Adverse events were reported in 4.3 % of patients; these were all mild and did not lead to hospitalization or discontinuation of treatment. Five patients (5.5 %) underwent surgical resection, with no immediate postsurgical complications. Conclusion: ustekinumab dose escalation was effective in recapturing response in over half of the patients. These findings suggest that dose escalation should be considered in patients who experience loss or partial response to the standard maintenance.(AU)

A systematic review of the definitions and prevalence of feeding intolerance in preterm infants.

BACKGROUND & AIMS: Feeding intolerance (FI) is a common phenomenon experienced in preterm infants in neonatal intensive care units, as well as being a focus of many research studies into feeding methods, particularly in relation to comorbidities. There is no widely accepted definition of FI. This systematic review aimed to explore the range of definitions used for FI and provide an estimate of the prevalence amongst preterm infants. METHODS: Searches were completed on MEDLINE (includes the Cochrane library), Embase, PsycInfo, CINAHL, NHS Evidence and Web of Science. Inclusion criteria; preterm infants in neonatal units, a clear definition of FI, >10 patients and be available in English language. Case reports were excluded. RESULTS: One hundred studies were included. Definitions of FI were inconsistent. Studies were grouped according to definition used into: Group A - measuring gastric residual volume (GRV) only; group B - GRV and abdominal distension (AD); group C - GRV, AD and gastrointestinal symptoms (GI) which included any of vomiting, bilious vomiting and blood in stool; group D- GRV and GI; group E - AD and GI; group F - GI only and group G - any other elements used. Meta-analysis demonstrated that prevalence of FI between groups varied from 15 to 30% with an overall prevalence of 27% (95% confidence interval 23-31%). Group A had the highest prevalence. Review of time to full enteral feed was performed (37 studies) which demonstrated a range of 11.3-18.3 days depending on which FI definition used. DISCUSSION: Definitions of FI in research are inconsistent, a similar finding to that seen in studies in both paediatric and adult critical care populations. The difficulty of defining FI in the preterm population is the concern regarding necrotising enterocolitis, with some studies using an overlap in their definitions, despite differing pathophysiology and management. Due to the heterogeneity of data obtained in this review regarding definitions used, further robust research is required in order to conclude which elements which should be used to define FI in this population. PROSPERO NUMBER: CRD42019155596. Registered November 2019.

Gastrointestinal Tract Disease Classification from Wireless Endoscopy Images Using Pretrained Deep Learning Model.

Wireless capsule endoscopy is a noninvasive wireless imaging technology that becomes increasingly popular in recent years. One of the major drawbacks of this technology is that it generates a large number of photos that must be analyzed by medical personnel, which takes time. Various research groups have proposed different image processing and machine learning techniques to classify gastrointestinal tract diseases in recent years. Traditional image processing algorithms and a data augmentation technique are combined with an adjusted pretrained deep convolutional neural network to classify diseases in the gastrointestinal tract from wireless endoscopy images in this research. We take advantage of pretrained models VGG16, ResNet-18, and GoogLeNet, a convolutional neural network (CNN) model with adjusted fully connected and output layers. The proposed models are validated with a dataset consisting of 6702 images of 8 classes. The VGG16 model achieved the highest results with 96.33% accuracy, 96.37% recall, 96.5% precision, and 96.5% F1-measure. Compared to other state-of-the-art models, the VGG16 model has the highest Matthews Correlation Coefficient value of 0.95 and Cohen's kappa score of 0.96.

Differential diagnosis of the association of gastrointestinal symptoms and ST segment elevation, in the absence of chest pain.

This is a review of the underlying causes of the association of ST segment elevation and gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and anorexia, in patients who do not have chest pain. The review was based on anecdotal reports in Googlescholar and Pubmed using the search terms, abdominal pain, nausea, vomiting, anorexia, ST elevation, myocardial infarction, and Takotsubo cardiomyopathy. Those patients who did not have acute myocardial infarction as the cause of the association of ST segment elevation and gastrointestinal symptoms were compared with counterparts with similar symptoms who had well authenticated acute myocardial infarction or Takotsubo cardiomyopathy as the underlying cause of ST segment elevation. The underlying causes of gastrointestinal symptoms which could be associated with ST segment elevation in the absence of either acute myocardial infarction or Takotsubo cardiomyopathy comprised pneumonia, pulmonary embolism, perforated gastric ulcer, intestinal obstruction, acute appendicitis, acute pancreatitis, acute cholecystitis, pheochromocytoma, bacterial meningitis, diabetic keto acidosis, and cannabis abuse. However, each of those disorders could also coexist either with acute myocardial infarction or with Takotsubo cardiomyopathy. The coexistence of ST segment elevation and gastrointestinal symptoms(without chest pain) was also documented in patients with esophageal perforation, mesenteric ischaemia, aortic dissection, Kounis syndrome, and in electrolyte disorders. In the context of presentation with gastroenterological symptoms but without concurrent chest pain, echocardiography appeared to be useful in distinguishing between "pseudo" myocardial infarction characterised by ST segment elevation in the absence of cardiac disease vs ST segment elevation attributable either to acute myocardial infarction or to Takotsubo cardiomyopathy.

Characteristics of patients with overlap functional gastrointestinal disorders.

BACKGROUND AND AIM: Functional gastrointestinal disorders (FGIDs) are frequently overlapped. The present study was designed to (i) search the clinical differences between patients with single FGID and overlap FGIDs and (ii) define the most common FGIDs associations to identify homogenous subgroups of patients. METHODS: A total of 3555 outpatients with FGID filled out the Rome III adult diagnostic questionnaire, Bristol stool form, and four 10-point Likert scales to report the severity of constipation, diarrhea, bloating, and abdominal pain. An unsupervised algorithm was used to estimate the number of groups directly from the data. A classification tree separated patients into different subgroups, according to FGIDs. Multinomial logistic regression was used to characterize the groups of patients with overlap disorders. RESULTS: Patients reported 3.3 ± 1.9 FGIDs (range 1-10, median = 3); 736 reported only one FGID, while 2819 reported more than one FGID (3.8 ± 1.7). Patients with single FGID had higher body mass index (P < 0.001), never report irritable bowel syndrome (IBS), and rarely report fecal incontinence and anorectal pain (< 1% for each disorder). The non-supervised clustering of the 2819 patients with overlap FGIDs divided this population into 23 groups, including five groups associated with only one disorder (IBS-diarrhea, dysphagia, functional constipation, levator ani syndrome, and IBS-unspecified). Ten groups were related to two overlap disorders and eight groups to three or more disorders. Three disorders were not explicitly associated with a given group: IBS-mixed, proctalgia fugax, and nonspecific anorectal pain. CONCLUSION: Patients with FGID mostly report overlap disorders in a limited number of associations, each significantly associated with a few disorders.

Prevalence and Associated Dietary Factors of Rome IV Functional Gastrointestinal Disorders in Rural Western Honduras.

BACKGROUND: The literature is limited regarding the prevalence of functional gastrointestinal disorders (FGIDs) in Central America, and the role of dietary factors. METHODS: The Rome IV diagnostic questionnaire and National Cancer Institute Diet History questionnaire were administered in one-on-one interviews to a distributed cross section of the general adult population of Western Honduras. Our aim was to estimate prevalence of common FGIDs and symptoms and their relationships to dietary habits. RESULTS: In total, 815 subjects were interviewed, of whom 151 fulfilled criteria for an FGID (18.5%). Gastroduodenal FGIDs were noted in 9.4%, with epigastric pain syndrome (EPS) more common than postprandial distress syndrome, 8.5% versus 1.6%. Among bowel disorders, functional abdominal bloating (FAB) was most prevalent (6.3%), followed by irritable bowel syndrome (3.6%), functional diarrhea (FDr; 3.4%), and functional constipation (1.1%). A significant inverse association was noted between regular bean intake and any FGID (OR 0.41, 95% CI 0.27-0.63), driven by IBS and FDr. Vegetable consumption was associated with lower prevalence of functional diarrhea (OR 0.12; 95% CI 0.04-0.35) and any diarrheal disorder (OR 0.11; 95% CI 0.04-0.31). Subjects with a median daily intake of ≥ 4 corn tortillas had 1.75 (95% CI 1.22-2.50) times the odds of having any FGID. CONCLUSIONS: FGIDs were common in this rural low-resource setting in Central America, with an intriguing distribution of specific FGIDs. EPS and FAB were common, but IBS was not. Local dietary factors were associated with specific FGIDs, suggesting that diet may play a role in global variations of FGIDs.

Peryton: a manual collection of experimentally supported microbe-disease associations.

We present Peryton (https://dianalab.e-ce.uth.gr/peryton/), a database of experimentally supported microbe-disease associations. Its first version constitutes a novel resource hosting more than 7900 entries linking 43 diseases with 1396 microorganisms. Peryton's content is exclusively sustained by manual curation of biomedical articles. Diseases and microorganisms are provided in a systematic, standardized manner using reference resources to create database dictionaries. Information about the experimental design, study cohorts and the applied high- or low-throughput techniques is meticulously annotated and catered to users. Several functionalities are provided to enhance user experience and enable ingenious use of Peryton. One or more microorganisms and/or diseases can be queried at the same time. Advanced filtering options and direct text-based filtering of results enable refinement of returned information and the conducting of tailored queries suitable to different research questions. Peryton also provides interactive visualizations to effectively capture different aspects of its content and results can be directly downloaded for local storage and downstream analyses. Peryton will serve as a valuable source, enabling scientists of microbe-related disease fields to form novel hypotheses but, equally importantly, to assist in cross-validation of findings.

Adaptación transcultural del componente de síntomas gastrointestinales de la escala CTCAE versión 4. 02 / Transcultural adaptation of the component of gastrointestinal symptoms of the CTCAE scale version 4. 02

Resumen Objetivo: Realizar la traducción y adaptación transcultural del componente de síntomas gastrointestinales (SGI) de la escala CTCAE versión 4.02 en pacientes ambulatorios tratados con quimioterapia en el Instituto Nacional de Cancerología en Bogotá. Métodos: Se realizó una búsqueda manual en medios electrónicos de escalas en idioma inglés o español que evaluarán la presencia, frecuencia o intensidad de SGI en pacientes oncológicos. La selección de los ítems fue efectuada por consenso informal de un comité técnico, el cual verificó la concordancia entre los principales SGI descritos en la literatura y los incluidos en la escala, ya que estos podrían afectar el estado nutricional. Posteriormente, para la adaptación transcultural, se siguieron los pasos y recomendaciones del manual ISPOR y del grupo de calidad de vida EORTC. La prueba piloto se efectuó en 30 pacientes seleccionados por conveniencia, quienes cumplieron los criterios de inclusión. Resultados: El 52% eran hombres; la edad promedio fue de 54,2 años (+/- 15,3 años). Los cánceres más frecuentes fueron: colorrectal (28%), estómago (16%) y mama (12%). Los 14 SGI incluidos en la escala fueron experimentados por todos los pacientes, por lo cual se conservaron, y no se requirió adicionar ningún otro. El tiempo promedio de aplicación del instrumento fue de 5 minutos y el 90% de los participantes lo consideró adecuado. Conclusiones: Se generó un instrumento de 14 ítems para medir SGI en pacientes oncológicos ambulatorios sometidos a quimioterapia, el cual es de rápida aplicación y utiliza lenguaje de fácil comprensión para el paciente. Aunque todavía quedan por definir sus propiedades clinimétricas.

Abstract Objective: To carry out the translation and transcultural adaptation of the gastrointestinal symptoms component (GIS) of the CTCAE, scale version 4.02, in outpatient patients treated with chemotherapy at the National Cancer Institute, Bogotá (Colombia). Methods: It was performed a manual search of scales on electronic media, in English or Spanish languages, which will evaluate the presence and intensity of GIS in oncological patients. The selection of the items was made by an informal consensus of a technical committee, which verified the concordance between the main GIS described in the literature and those included in the scale, all of which could affect the nutritional status. For transcultural adaptation, there were followed the steps and recommendations of the ISPOR Handbook, as well as those of the EORTC quality of life group. The pilot test was conducted in 30 patients selected for convenience, who met the inclusion criteria. Results: 52% were men; the average age was 54.2 years (+/-15.3 years). The most frequent cancers were: colorectal (28%), stomach (16%) and breast (12%). The 14 GIS included in the scale were experienced by all patients, so they were retained, and no other addition was required. The average time of application of the instrument was 5 minutes, and 90% of the participants considered it appropriate. Conclusions: A 14-item instrument was generated to measure GIS in cancer patients who undergo outpatient chemotherapy, which is of fast application and uses a language that is easily understood by patients. Its clinimetrics properties remain to be defined.

The Effects of the Rome IV Criteria on Pediatric Gastrointestinal Practice.

PURPOSE OF REVIEW: To evaluate the impact of the implementation of the Rome IV criteria on pediatric gastrointestinal practice. RECENT FINDINGS: In 2016, the Rome IV criteria were published, providing an update of symptom-based criteria to diagnose children with functional gastrointestinal disorders (FGIDs). For neonates and toddlers, Wessel's criteria for diagnosing infant colic were abandoned, and a differentiation was made between toilet-trained and non-toilet-trained children in the diagnosis of functional constipation. For children and adolescents, two new disorders (functional nausea and functional vomiting) are described, and in the diagnosis of functional dyspepsia, pain does not have to be the chief complaint anymore. This change has made functional dyspepsia the most common functional abdominal pain disorder, exceeding the prevalence of irritable bowel syndrome (IBS). Lastly, the diagnosis of abdominal migraine was narrowed, causing an appropriate drop in its prevalence.

Functional abdominal pain: what clinicians need to know.

Abdominal pain in childhood is extremely common and presents frequently to both primary and secondary care, with many children having recurrent pain which impacts on daily functioning. Despite this most children have no discernible underlying pathology. We discuss the underlying mechanism for functional abdominal pain (visceral hypersensitivity), the evidence base linking parental anxiety and patient symptoms, and how parents can be supported in managing their children's symptoms by addressing questions commonly asked by children and families. We look at the evidence for a one-stop rational approach to investigation including a coeliac screen, inflammatory markers and consideration of stool faecal calprotectin, in the absence of red flags. We evaluate commonly used treatments for functional abdominal pain, within a context of managing family expectations. Given the limitations in pharmacological treatment options, trials of probiotics, peppermint oil, mebeverine and (for short-term use only) hyoscine butylbromide may be appropriate. Psychological interventions including cognitive-behavioural therapy, distraction techniques and hypnotherapy have a better evidence base. There is also some evidence for other complementary therapies in children, including yoga and neurostimulation. Outcome is generally good providing there is child and family acceptance of the multiple factors implicated in the aetiology of the pain.

Current role of colonoscopy in infants and young children: a multicenter study.

BACKGROUND: To evaluate the role of colonoscopy in infants and young children and clarify the distribution of colonoscopy-requiring diseases in this age group. METHODS: Cohorts of colonoscopies performed at three children's hospitals in Japan between April 2011 and March 2016 including infants and children younger than six years of age were retrospectively reviewed. RESULTS: In total, 453 colonoscopies were performed in 276 infants and young children. Of these 275 (60.8%) were for diagnostic purposes, 177 (39.2%) were performed as follow-up, and one case was performed for treatment. The median patient age at the time of diagnostic colonoscopy was 2.49 years, and there was a male-to-female ratio of 1.72:1. Abnormal macroscopic and/or histopathological findings were noted in 212 (77.1%) cases. Of these, definite diagnoses were established for the presence of eosinophilic gastrointestinal disorders (EGIDs), inflammatory bowel disease (IBD), and polyp/polyposis in 23, 18.5, and 14% of patients, respectively. Among 51 IBD cases, ulcerative colitis, Crohn's disease, and IBD-unclassified were identified in 47.1, 33.3, and 7.8%, retrospectively via endoscopic examination. Of these, 11 (22%) were eventually diagnosed with monogenic diseases via genetic testing. Of those with rectal bleeding, EGIDs, polyps/polyposis, and IBD were found in 27, 19, and 18%, retrospectively. There were significantly more cases of EGIDs and fewer ones of IBD and polyps/polyposis in patients with rectal bleeding younger than two years of age. Furthermore, 68% of all follow-up colonoscopies were performed in children with IBD. There were no serious complications in our study cohort. CONCLUSION: We determined the role of colonoscopy in infants and young children. Diseases diagnosed using colonoscopy in this age group included IBD, EGIDs, and polyps/polyposis. The increasing trend of patients with IBD and EGIDs worldwide means that the role of colonoscopy in infants and younger children will be more important in the future.

A SURVEY OF GASTROINTESTINAL PARASITES OF WILD AND ORPHAN GREATER ONE-HORNED RHINO ( RHINOCEROS UNICORNIS) IN KAZIRANGA NATIONAL PARK, ASSAM, INDIA.

Wild greater one-horned rhinos ( Rhinoceros unicornis), orphaned juveniles in human care, and orphaned calves from Kaziranga National Park, Assam, India were surveyed coprologically for gastrointestinal parasites. Parasite infections were present in 100% of wild rhino samples, 96% of orphaned juvenile samples, and 27% of orphaned calf samples. In wild rhino, observed parasite ova were primarily of trematodes Paramphistomum sp. (100%), followed by those of strongyle nematodes (94%) and the cestode Anoplocephala sp. (56%). Orphaned juvenile and calf samples were positive only for strongyles. Total fecal parasite egg counts were recorded in wild rhino (mean 64 eggs per gram [epg], range 0-270), orphan juveniles (mean 43 epg, range 0-145), and orphan calves (mean 2 epg, range 0-10). Results suggest that parasite infection in rhinos in this setting is common, though more extensive sampling would provide further information on epidemiology and potential impacts on individual health and population viability.

Desnutrição e complicações clínicas em pacientes cirúrgicos com doença colorretal / Malnutrition and clinical outcomes in surgical patients with colorectal disease

ABSTRACT BACKGROUND: Malnutrition is a frequent condition among hospitalized patients and a factor of increased risk of postoperative complication. OBJECTIVE: This study aimed to evaluate the impact of malnutrition on phase angle (PA), body water distribution and clinical outcomes in surgical patients with colorectal disease. METHODS: This retrospective study was performed in a tertiary hospital with 40 patients admitted electively. In the preoperative evaluation, global subjective assessment and bioelectrical impedance analysis were performed to determine nutritional status, PA, extracellular water (ECW), intracellular water (ICW) and total body water (TBW). In postoperative evaluation, the length of hospital stay and severe complications, according to Clavien-Dindo classification, were determined. The optimal PA cutoff for malnutrition screening was determined by ROC curve analysis. RESULTS: Seventeen (42.5%) patients were diagnosed as malnourished and 23 (57.5%) as well-nourished according to global subjective assessment. Twelve (30.0%) patients developed severe complications. The malnourished group presented lower values of serum albumin (P=0.012), hematocrit (P=0.026) and PA (P=0.002); meanwhile, ECW/ICW (P=0.019) and ECW/TBW (P=0.047) were higher. Furthermore, 58.8% of malnourished patients developed severe postoperative complications compared to 8.7% of well-nourished. Malnutrition was independent predictor of severe postoperative complications (OR=15.00, IC: 2.63-85.68, P=0.002). The optimal PA cutoff obtained was 6.0º (AUC=0.82, P=0.001), yielding sensitivity, specificity, positive predictive value and negative predictive value of 76.5%, 87.0%, 81.3% and 83.4%, respectively. CONCLUSION: Malnutrition was an independent predictive factor for severe complications in patients underwent to elective major coloproctological surgery. Besides that, malnutrition was associated with lower PA values and greater ratio of ECW. The PA provided great accuracy in nutritional screening, implying a useful marker of malnutrition.

RESUMO CONTEXTO: A desnutrição é uma condição frequente entre pacientes hospitalizados e é um fator de risco para complicações pós-operatórias. OBJETIVO: Este estudo tem como objetivo avaliar o impacto da desnutrição sobre o ângulo de fase (AF), a distribuição de água corporal e complicações clínicas em pacientes cirúrgicos com doença colorretal. MÉTODOS: Trata-se de um estudo retrospectivo realizado em um hospital universitário terciário com 40 pacientes admitidos eletivamente. Na avaliação pré-operatória, foram realizadas a avaliação subjetiva global e análise de bioimpedância elétrica com a finalidade de determinarem o estado nutricional, AF, água extracelular (AEC), água intracelular (AIC) e água corporal total (ACT). Na avaliação pós-operatória, o tempo de internação hospitalar e a presença de complicações graves, segundo a classificação de Clavien-Dindo, foram determinados. O melhor ponto de corte do AF para o rastreamento de desnutrição foi obtido a partir da análise da curva ROC. RESULTADOS: Dezessete (42,5%) pacientes foram diagnosticados como desnutridos e 23 (57,5%), como bem nutridos de acordo com a avaliação subjetiva global. Doze (30,0%) pacientes desenvolveram complicações pós-operatórias graves. O grupo desnutrido apresentou menores valores de albumina sérica (P=0,012), hematócrito (P=0,026) e AF (P=0,002); enquanto que as relações de AEC/AIC (P=0,019) e AEC/ACT (P=0,047) estiveram elevadas. Além disso, 58,8% dos pacientes desnutridos desenvolveram complicações pós-operatórias graves em comparação a 8,7% dos pacientes bem nutridos. A desnutrição foi fator preditivo independente para o desenvolvimento de complicações pós-operatórias graves (OR=15,00, IC: 2,63-85,68; P=0,002). O melhor ponto de corte do AF obtido foi 6.0º (AUC=0,82; P=0,001) com sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo de 76,5%, 87,0%, 81,3% e 83,4%, respectivamente. CONCLUSÃO: A desnutrição foi fator preditivo para o desenvolvimento de complicações graves em pacientes submetidos à cirurgia eletiva coloproctológica de grande porte. Além disso, a desnutrição foi associada a menores valores de AF e maior proporção de AEC. O AF forneceu boa acurácia no rastreamento da desnutrição, sugerindo seu uso como potencial marcador de desnutrição.

Expert consensus document: Advances in the diagnosis and classification of gastric and intestinal motility disorders.

Disturbances of gastric, intestinal and colonic motor and sensory functions affect a large proportion of the population worldwide, impair quality of life and cause considerable health-care costs. Assessment of gastrointestinal motility in these patients can serve to establish diagnosis and to guide therapy. Major advances in diagnostic techniques during the past 5-10 years have led to this update about indications for and selection and performance of currently available tests. As symptoms have poor concordance with gastrointestinal motor dysfunction, clinical motility testing is indicated in patients in whom there is no evidence of causative mucosal or structural diseases such as inflammatory or malignant disease. Transit tests using radiopaque markers, scintigraphy, breath tests and wireless motility capsules are noninvasive. Other tests of gastrointestinal contractility or sensation usually require intubation, typically represent second-line investigations limited to patients with severe symptoms and are performed at only specialized centres. This Consensus Statement details recommended tests as well as useful clinical alternatives for investigation of gastric, small bowel and colonic motility. The article provides recommendations on how to classify gastrointestinal motor disorders on the basis of test results and describes how test results guide treatment decisions.

[Establishment of comprehensive prediction model of acute gastrointestinal injury classification of critically ill patients].

OBJECTIVE: To develop the comprehensive prediction model of acute gastrointestinal injury (AGI) grades of critically ill patients. METHODS: From April 2015 to November 2015, the binary channel gastrointestinal sounds (GIS) monitor system which has been developed and verified by the research group was used to gather and analyze the GIS of 60 consecutive critically ill patients who were admitted in Critical Care Medicine of Chinese PLA General Hospital. Also, the AGI grades (Grande I(-IIII(, the higher the level, the heavier the gastrointestinal dysfunction) were evaluated. Meanwhile, the clinical data and physiological and biochemical indexes of included patients were collected and recorded daily, including illness severity score (APACHE II( score, consisting of the acute physiology score, age grade and chronic health evaluation), sequential organ failure assessment (SOFA score, including respiration, coagulation, liver, cardioascular, central nervous system and kidney) and Glasgow coma scale (GCS); body mass index, blood lactate and glucose, and treatment details (including mechanical ventilation, sedatives, vasoactive drugs, enteral nutrition, etc.) Then principal component analysis was performed on the significantly correlated GIS (five indexes of gastrointestinal sounds were found to be negatively correlated with AGI grades, which included the number, percentage of time, mean power, maximum power and maximum time of GIS wave from the channel located at the stomach) and clinical factors after standardization. The top 5 post-normalized main components were selected for back-propagation (BP) neural network training, to establish comprehensive AGI grades models of critically ill patients based on the neural network model. RESULTS: The 60 patients aged 19 to 98 (mean 54.6) years and included 42 males (70.0%). There were 22 cases of multiple fractures, 15 cases of severe infection, 7 cases of cervical vertebral fracture, 7 cases of aortic repair, 5 cases of post-toxicosis and 4 cases of cerebral trauma. There were 33 emergency operation, 10 cases of elecoperectomy and 17 cases of drug treatment. There were 56 cases of diabetes(93.3%). Forty-five cases (75.0%) used vasoactive drugs, 37 cases (61.7%) used mechanical ventilation and 44 cases (73.3%) used enteral nutrition. APACHE II( score were 4.0 to 28.0(average 16.8) points. Four clinical factors were significantly positively related with AGI grades, including lactic acid level (r=0.215, P=0.000), SOFA score (r=0.383, P=0.000), the use of vascular active drugs (r=0.611, P=0.000) and mechanical ventilation (r=0.142, P=0.014). In addition to the five indexes of gastric bowel sounds which were found to be negatively correlated with AGI grades, the characteristics of 333 by 9 were composed of these nine indexes with high correlation of AGI grades. Five main components were selected after principal component analysis of these nine correlated indexes. A comprehensive AGI grades model of critically ill patients with a fitting degree of 0.967 3 and an accuracy rate of 82.61% was built by BP artificial neural network. CONCLUSION: The comprehensive model to classify AGI grades with the GIS is developed, which can help further predicting the classification of AGI grades of critically ill patients.

Functional Gastrointestinal Disorders: Approach to Patients With Functional Gastrointestinal Disorders.

Functional gastrointestinal disorders (FGIDs) are among the most challenging conditions to diagnose and manage. FGIDs are a heterogeneous group of conditions with varying and sometimes vague symptomatology. The Rome IV classification is the most comprehensive resource on FGIDs. FGIDs are common and are associated with significant social and economic burdens. The patient perspective includes anxiety, emotional distress, and mistrust of health care. Psychological stressors and concomitant psychiatric illness are common but not always present. Clinician understanding of these disorders is limited, and there are many barriers to adequate care. A strong clinician-patient relationship is essential. Management includes education, reassurance, dietary modification, pharmacotherapy, and psychological interventions.

Factor Analysis Defines Distinct Upper and Lower Gastrointestinal Symptom Groups Compatible With Rome IV Criteria in a Population-based Study.

BACKGROUND & AIMS: The Rome IV criteria define functional gastrointestinal (GI) disorders by specific combinations of symptoms. It is possible to empirically evaluate these symptom combinations by factor analysis (a statistical procedure that groups variables that correlate). However, this analysis has not been performed for the Rome IV criteria, and factor analyses based on the previous versions of the Rome criteria did not use population-based data. We therefore investigated symptom grouping by the Rome IV questionnaire using factor analysis of a population-based sample. METHODS: The Rome IV questionnaire was completed online in English by 5931 respondents from the United Kingdom, United States, and Canada (49% female, age range, 18-92 years). We performed an exploratory factor analysis on the Rome IV questions. Next, we performed a confirmatory factor analysis to compare the exploratory factor result to that of the Rome IV criteria. RESULTS: The exploratory factor analysis identified 8 factors that accounted for 45% of the variance in response: constipation, diarrhea, irritable bowel syndrome, abdominal pain, heartburn, nausea or vomiting, globus, and other upper GI symptoms. Most factors corresponded to distinct functional GI disorders defined by the Rome IV criteria-exceptions included abdominal pain and upper GI symptoms. In confirmatory factor analysis, the exploratory model fitted slightly better than that based on the Rome IV criteria (root mean square error of approximation, 0.063 vs 0.077). CONCLUSIONS: We used factor analysis to identify distinct upper and lower GI symptom groups that are compatible with the Rome IV criteria. Our findings support the use of the Rome IV criteria in research and clinical practice as a basis for development of diagnostics and management of patients.

Concordancia inter e intraobservador en el diagnóstico de la gastropatía por hipertensión portal / Inter and intra-observer concordance for the diagnosis of portal hypertension gastropathy

Introducción: en la actualidad no existe una clasificación endoscópica totalmente aceptada para evaluar el grado de gastropatía de la hipertensión portal (GHP). Hay pocos estudios que evalúen la concordancia inter e intraobservador o el grado de concordancia entre las distintas clasificaciones endoscópicas. Objetivos: evaluar la concordancia inter e intraobservador respecto a la presencia de gastro y enteropatía portal utilizando distintas clasificaciones endoscópicas. Métodos: fueron incluidos pacientes con cirrosis hepática a los que se realizó una enteroscopia bajo sedación. Se describió la localización de las lesiones y el grado de las mismas. Las imágenes se registraron mediante grabación en vídeo que posteriormente fue valorada por tres endoscopistas diferentes de manera independiente, uno de ellos el endoscopista inicial. La concordancia entre observaciones se evaluó utilizando el índice kappa. Resultados: se incluyeron un total de 74 pacientes (edad media de 63,2 años, con una proporción de 53/21 hombre/mujer). La concordancia entre los tres endoscopistas, para la presencia o ausencia de GHP según las clasificaciones de Tanoue y McCormack, fue muy baja: kappa = 0,16 y 0,27 respectivamente. Conclusiones: las actuales clasificaciones de la gastropatía portal presentan un grado de acuerdo intra e interobservador muy bajo tanto para el diagnóstico como para la evaluación de la gravedad de la gastropatía (AU)

Introduction: At present there is no fully accepted endoscopic classification for the assessment of the severity of portal hypertensive gastropathy (PHG). Few studies have evaluated inter and intra-observer concordance or the degree of concordance between different endoscopic classifications. Objectives: To evaluate inter and intra-observer agreement for the presence of portal hypertensive gastropathy and enteropathy using different endoscopic classifications. Methods: Patients with liver cirrhosis were included into the study. Enteroscopy was performed under sedation. The location of lesions and their severity was recorded. Images were videotaped and subsequently evaluated independently by three different endoscopists, one of whom was the initial endoscopist. The agreement between observations was assessed using the kappa index. Results: Seventy-four patients (mean age 63.2 years, 53 males and 21 females) were included. The agreement between the three endoscopists regarding the presence or absence of PHG using the Tanoue and McCormack classifications was very low (kappa scores = 0.16 and 0.27, respectively). Conclusions: The current classifications of portal hypertensive gastropathy have a very low degree of intra and inter-observer agreement for the diagnosis and assessment of gastropathy severity (AU)

Identification and validation of functional gastrointestinal disorder subtypes using latent class analysis: a population-based study.

OBJECTIVE: Attempts to categorize distinct functional gastrointestinal disorders based on reported symptoms continue but symptoms frequently overlap. The study objective was to use latent class analysis (LCA) which accommodates both continuous and discrete manifest variables to determine mutually exclusive subgroup assignments of a population-based sample using gastrointestinal symptom and patient data. MATERIALS AND METHODS: A validated bowel disease questionnaire and somatic symptom questionnaire were mailed to an age and gender stratified randomly selected community sample. Responses to the symptom questions were dichotomized as frequent vs. infrequent based on Rome IV criteria. A LCA model was developed using a calibration subset and the results applied to the validation subset. RESULTS: There were 3831 total respondents (48%) with 3425 having complete data. The LCA algorithm was run for each of 10 (random) splits of the dataset and 2-6 latent classes were specified. Using the values of Akaike's Information Criterion coefficient c to determine fit of the data, 4 latent classes yielded better values resulting in four subgroups: 'asymptomatic,' 'upper' abdominal symptoms, 'lower' abdominal symptoms, and 'mixed' (upper and lower abdomen). CONCLUSIONS: Latent class analysis identified 4 groups based on symptoms. This approach resulted in differentiation by anatomical region rather than the Rome IV classification of symptoms.