Background & Aims Disordered defecation is attributed to pelvic floor dyssynergia. However, clinical observations indicate a spectrum of anorectal dysfunctions. The extent to which these disorders ...are distinct or overlap is unclear; anorectal manometry might be used in diagnosis, but healthy persons also can have abnormal rectoanal pressure gradients during simulated evacuation. We aimed to characterize phenotypic variation in constipated patients through high-resolution anorectal manometry. Methods We evaluated anorectal pressures, measured with high-resolution anorectal manometry, and rectal balloon expulsion time in 62 healthy women and 295 women with chronic constipation. Phenotypes were characterized by principal components analysis of high-resolution anorectal manometry. Results Two healthy persons and 71 patients had prolonged (>180 s) rectal balloon expulsion time. A principal components logistic model discriminated healthy people from patients with prolonged balloon expulsion time with 75% sensitivity and a specificity of 75%. Four phenotypes discriminated healthy people from patients with abnormal balloon expulsion times; 2 phenotypes discriminated healthy people from those with constipation but normal balloon expulsion time. Phenotypes were characterized based on high anal pressure at rest and during evacuation (high anal), low rectal pressure alone (low rectal) or low rectal pressure with impaired anal relaxation during evacuation (hybrid), and a short anal high-pressure zone. Symptoms were not useful for predicting which patients had prolonged balloon expulsion times. Conclusions Principal components analysis of rectoanal pressures identified 3 phenotypes (high anal, low rectal, and hybrid) that can discriminate among patients with normal and abnormal balloon expulsion time. These phenotypes might be useful to classify patients and increase our understanding of the pathogenesis of defecatory disorders.
High-resolution manometry (HRM) is used to measure anal pressures in clinical practice but normal values have not been available. Although rectal evacuation is assessed by the rectoanal gradient ...during simulated evacuation, there is substantial overlap between healthy people and defecatory disorders, and the effects of age are unknown. We evaluated the effects of age on anorectal pressures and rectal balloon expulsion in healthy women.
Anorectal pressures (HRM), rectal sensation, and balloon expulsion time (BET) were evaluated in 62 asymptomatic women ranging in age from 21 to 80 years (median age 44 years) without risk factors for anorectal trauma. In total, 30 women were aged <50 years.
Age is associated with lower (r=-0.47, P<0.01) anal resting (63 (5) (≥50 years), 88 (3) (<50 years), mean (s.e.m.)) but not squeeze pressures; higher rectal pressure and rectoanal gradient during simulated evacuation (r=0.3, P<0.05); and a shorter (r=-0.4, P<0.01) rectal BET (17 (9) s (≥50 years) vs. 31 (10) s (<50 years)). Only 5 women had a prolonged (>60 s) rectal BET but 52 had higher anal than rectal pressures (i.e., negative gradient) during simulated evacuation. The gradient was more negative in younger (-41 (6) mm Hg) than older (-12 (6) mm Hg) women and negatively (r=-0.51, P<0.0001) correlated with rectal BET but only explained 16% of the variation in rectal BET.
These observations provide normal values for anorectal pressures by HRM. Increasing age is associated with lower anal resting pressure, a more positive rectoanal gradient during simulated evacuation, and a shorter BET in asymptomatic women. Although the rectoanal gradient is negatively correlated with rectal BET, this gradient is negative even in a majority of asymptomatic women, undermining the utility of a negative gradient for diagnosing defecatory disorders by HRM.
Patients on home parenteral nutrition (HPN) are dependent on central venous access for long-term sustenance, and catheter-related bloodstream infections (CRBSIs) are a major cause of morbidity and ...mortality in this patient population. As such, there is much interest in finding new methods for preventing CRBSIs in patients on HPN. As it is thought that these infections are preceded by microbial colonization of the catheter, one approach is to use antimicrobial catheter lock solutions. Although antibiotic catheter lock solutions have been present for decades, their use has been mostly limited to the treatment of CRBSIs due to concern for promoting microbial resistance. Recently, however, with the advent of non-antibiotic antimicrobial catheter lock solutions, this approach is gaining popularity as a promising method to decrease rates of CRBSI in HPN patients.
Acute liver failure associated with Garcinia cambogia use Corey, Rebecca; Werner, K. Tuesday; Singer, Andrew ...
Annals of hepatology,
2016, 2016 Jan-Feb, 2016-01-00, 20160101, 2016-01-01, Letnik:
15, Številka:
1
Journal Article
Recenzirano
Odprti dostop
AbstractMillions of Americans regularly use herbal supplements, but many are unaware of the potential hidden dangers. Numerous supplements have been associated with hepatotoxicity and, indeed ...dietary/herbal supplements represent an increasingly common source of acute liver injury. We report a case of acute liver failure requiring liver transplantation associated with the use of Garcinia cambogia, a supplement widely promoted for weight loss. When patients present with acute hepatitis or liver failure from an unknown etiology, a careful history of supplement use should be performed.
Objectives The aim of this study was to assess the prognostic value of right ventricular (RV) involvement diagnosed by cardiac magnetic resonance (CMR) early after ST-elevation myocardial infarction ...(STEMI). Background CMR allows accurate and reproducible RV assessment. However, there is a paucity of data regarding the prognostic value of RV involvement detected by CMR early after STEMI. Methods Ninety-nine patients (77 men, mean age 57 ± 11 years) who underwent CMR 3 to 5 days after STEMI treated with primary angioplasty were followed for 1,150 ± 337 days for cardiac events (cardiac death, nonfatal myocardial infarction MI, and hospitalizations due to decompensated heart failure). Cox proportional hazards model was applied in stepwise forward fashion to identify outcome predictors. Event-free survival was estimated by Kaplan-Meier method and compared between groups by the log-rank test. Results Cardiac events occurred in 34 patients (7 cardiac deaths, 8 MIs, 26 hospitalizations). By multivariable analysis, the independent outcome predictors were left ventricular (LV) MI transmurality index (hazard ratio: 1.03 per 1%; 95% confidence interval: 1.01 to 1.04; p = 0.001), RV ejection fraction (RVEF) (hazard ratio: 1.46 per 10% decrease; 95% confidence interval: 1.05 to 2.02; p = 0.03), and RVMI extent (hazard ratio: 1.50 per each infarcted RV segment; 95% confidence interval: 1.11 to 2.01; p = 0.007). Compared with clinical data (global chi-square = 5.2), LV ejection fraction LVEF (global chi-square = 11.1), RVEF (global chi-square = 17.1), LVMI transmural extent (global chi-square = 26.0), and RVMI extent (global chi-square = 34.9) improved outcome prediction in sequential Cox model analysis (p < 0.05 for all steps). RVEF stratified risk in patients with LVEF <40% in whom the 4-year event-free survival was 66.7% for RVEF ≥40% and 40.0% for RVEF <40% (p < 0.05). Conclusions The extent of RVMI and RV dysfunction assessed early after STEMI are independent outcome predictors, which provide incremental prognostic value to clinical data, LV systolic function, and infarct burden. Measurement of RVEF may be particularly useful to stratify risk in patients with depressed LV function after STEMI.
Background
A 50% or greater reduction in the frequency of fecal incontinence (FI) recorded with daily bowel diaries is the primary endpoint in clinical trials of FI. Whether this difference is ...clinically important is unknown. The relationship between FI symptoms recorded with daily and weekly instruments is unknown. The contribution of psychological factors to quality of life (QOL) in FI is unclear.
Methods
Fecal incontinence severity was assessed with daily bowel diaries and periodic questionnaires (fecal incontinence severity score FISS, FIQOL, 36‐Item Short Form Health Survey SF‐36, and hospital anxiety and depression scales) for 4 weeks before and during double‐blind randomization to placebo or clonidine in 44 women with FI. The reduction in FI frequency was compared to the minimal clinically important difference (MCID) computed from the FISS. Endpoints of FI were compared between daily and weekly diaries.
Key Results
The FISS exceeded the MCID in 75% and 83% of patients in whom the FI frequency declined by 50–74% and ≥75% respectively. Parameters of FI measured with daily and weekly instruments were significantly correlated. The daily parameters explained 71% of the inter‐patient variation in the FISS. The SF‐36 health scores, rather than the FISS rating, explained a majority of the inter‐subject variation in FIQOL.
Conclusions & Inferences
Most patients who report a ≥50% reduction in FI frequency experience a clinically important improvement. Weekly questionnaires accurately assess the severity of FI. Self‐reported physical and mental health explained a greater proportion of the variance in FIQOL than FI symptom severity.
This study suggests that a 50% reduction in the frequency of fecal incontinence (FI) is clinically meaningful. Daily and weekly instruments are correlated for assessing symptoms of FI.
Background
Defecatory disorders (DD) are defined by clinical and objective features of impaired rectal evacuation. The epidemiology of DD in the population is unknown, partly because many constipated ...patients do not undergo anorectal tests. Our objectives were to estimate the incidence rate and clinical features of DD in the community.
Methods
We reviewed the medical records of all patients older than 16 years in Olmsted County, MN, who had constipation and underwent anorectal manometry from 1999 through 2008. Criteria for diagnosing DD were constipation for 6 months or longer and one of the following: (i) abnormal rectal balloon expulsion test; (ii) reduced or increased perineal descent; or (iii) two or more abnormal features with defecography or surface electromyography.
Key Results
Of 11 112 constipated patients, 516 had undergone anorectal tests; 245 of these (209 women, 36 men) had a DD. The mean (±SD) age at diagnosis was 44 years (±18) among women and 49 years (±19) among men. The overall age‐ and sex‐adjusted incidence rate per 100 000 person‐years was 19.3 (95% CI: 16.8–21.8). The age‐adjusted incidence per 100 000 person‐years was greater (p < 0.0001) in women (31.8, 95% CI: 27.4–36.1) than in men (6.6, 95% CI: 4.4–8.9). Prior to the diagnosis of DD, nearly 30% of patients had irritable bowel syndrome (IBS), 48% had a psychiatric diagnosis, 18% had a history of abuse, and 21% reported urinary and/or fecal incontinence.
Conclusions & Inferences
Among constipated patients, DD are fourfold more common in women than men and often associated with IBS and psychiatric diagnoses.
The overall age‐ and sex‐adjusted incidence rate of defecatory disorders in Olmsted County between 1999 and 2008 was 19.3 per 100 000 person‐years (95% CI: 16.8–21.8), which is greater than the incidence of Crohn's disease but less than that of irritable bowel syndrome (IBS). Defecatory disorders are more common in women and are frequently associated with psychiatric conditions and IBS.
Background
Survival of patients with short‐bowel syndrome (SBS) receiving home parenteral nutrition (HPN) and associated factors have not been reported recently in North America. The objective of ...this study was to determine the long‐term survival of adult patients with SBS as the primary indication for HPN and assess factors that may affect survival by using the Canadian HPN Registry.
Methods
This is a retrospective analysis of prospectively collected data extracted from the HPN registry, prior to approval of teduglutide in Canada. Using only incident cases, survival probabilities were estimated by using the Kaplan‐Meier method for both full‐cohort and nonmalignant SBS. Log‐rank test was also used to test the differences in survival distributions between subgroups in the univariate analysis. To identify potential variables that are affecting survival distribution of patients for the multivariable analysis, Least Absolute Shrinkage and Selection Operator and stepwise selection procedure were used.
Results
There were 321 patients with a known duration receiving HPN (total, 2287 years), of whom 218 were entered into the registry within 1 year of initiation of HPN. Of 218 incident cases, 22 had active malignancy, along with SBS, and their survival time was significantly lower than those with nonmalignant SBS (P‐value < .0001). The 5‐year survival of nonmalignant‐SBS patients was 81.9%. In this subgroup, there was no significant association between patients’ survival and known intestinal anatomy, age, or sex.
Conclusion
Patients with nonmalignant SBS who receive HPN have a 5‐year survival of >80%. Known intestinal anatomical factors did not affect survival.
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