[Effect of secondary prophylaxis on quality of life in gerontologic patients at the rehabilitation center for the disabled Patriotic war veterans in local sanatorium]

AIM

To study efficacy of sanatorium treatment of aged patients with gastroenterological and locomotor diseases in the heriatric center.

MATERIAL AND METHODS

100 patients were investigated for effects of sanatorium treatment on quality of life.

RESULTS

Clinical symptoms depended on the patients' age. Patients under 70 years of age had leading symptoms from gastrointestinal organs and locomotor system. These patients were most responsive to rehabilitation measures. In 70-year-olds and older patients cardiovascular and cerebral pathologies are of special importance limiting usage of physiotherapy and necessitating wider application of medicines: hypotensive, antianginal, circulation correcting, etc. The sanatorium stage of rehabilitation creates a positive emotional background in these patients.

CONCLUSION

Sanatorium treatment resulted in improvement of life quality in gerontological patients.

Psychosocial factors and perceived severity of functional dyspeptic symptoms: a psychosocial interactionist model

OBJECTIVE

A psychosocial interactionist model was presented to provide a systematic account of individual differences in perceived functional dyspeptic symptom severity.

METHODS

In a population-based survey, 4038 Hong Kong subjects (age 18-80 years) were interviewed. Five hundred ninety interviewees (14.6%) met the diagnostic criteria for functional dyspepsia (FD), and 396 of them participated in this study.

RESULTS

Results from multiple regression analyses revealed significant main effects of monitoring, emotional support, and coping flexibility on perceived FD symptom severity. A significant emotional support by coping flexibility interaction effect was also found.

CONCLUSIONS

The present findings provided support for the psychosocial interactionist model in showing that (1) monitoring is a risk factor related to greater perceived symptom severity, (2) emotional support and coping flexibility are resource factors related to lower perceived symptom severity, and (3) the beneficial role of emotional support is present only among those higher in coping flexibility but not among those lower in coping flexibility.

Do childhood adversity and recent social stress predict health care use in patients presenting with upper abdominal or chest pain?

OBJECTIVE

A comprehensive model of health care use by patients with functional gastrointestinal disorders has not been fully tested. This study aimed to establish whether reported childhood and/or recent adversity are independent predictors of health care use when all other relevant factors are also included in the model.

MATERIALS AND METHODS

Consecutive new patients with upper abdominal or chest pain presenting to a secondary/tertiary clinic were assessed using the Childhood Experience of Care and Abuse and Life Events and Difficulties Schedules. They completed the Hospital Anxiety and Depression and Health Anxiety Questionnaires. Outcome was total number of health care visits recorded in hospital and general practice (GP) records over 18 months.

RESULTS

One hundred fifty-one patients were included (65% response rate). Health care visits were most frequent in unmarried (p < 0.0005), females (p < 0.0005), and those lacking social support (p = 0.012). In multiple regression analysis to predict number of health care visits, reported sexual abuse (p = 0.042) and death of a sibling during childhood (p = 0.026) were also independent predictors, together with SF36 subscale scores for physical function, health perception, and mental health (35% of variance explained). Childhood adversity predicted health care use in patients with functional gastrointestinal disorders and recent social stress did so in patients with demonstrated pathological findings.

CONCLUSION

After adjustment for demographic, physical, and psychological factors, childhood adversity, especially in severe form, is an independent predictor of health care use in patients with upper functional gastrointestinal disorders. The same was not true for patients consulting for demonstrable pathological abnormalities, for whom ongoing social stress was an independent predictor.

Patient Satisfaction in Gastroenterology Clinics

Satisfaction surveys of patients who had a gastrointestinal procedure at an ambulatory surgery center in 2002 were drawn from a national database and analyzed. The resulting data were used to report the status of patient satisfaction with their care and to illustrate several ways in which patient satisfaction data can be used to guide quality improvement efforts. It was found that patient satisfaction is generally quite high, with ratings of nurses and physicians topping the list. On the other hand, convenience factors such as parking and waiting times were rated lower. Uses of data to guide quality improvement efforts were illustrated in terms of response category percentages (i.e., percentage of time an item was rated "good," "poor," etc.) and a measure of item priority.

Alexithymia as predictor of treatment outcome in patients with functional gastrointestinal disorders

OBJECTIVE

A previous study found a strong association between alexithymia and functional gastrointestinal disorders (FGID). The objective of this study was to investigate whether alexithymia might be a predictor of treatment outcome in patients with FGID.

METHODS

A group of FGID outpatients classified by the 'Rome I' criteria was divided into improved (N= 68) and unimproved (N= 44) groups on the basis of pre-established criteria after 6 months of treatment. Patients were administered the 20-item Toronto Alexithymia Scale, the Hospital Anxiety and Depression Scale, and the Gastrointestinal Symptom Rating Scale both before and after 6 months of treatment.

RESULTS

At the base-line assessment, compared with the improved patients, the unimproved patients had significantly higher levels of anxiety, depression, alexithymia, and gastrointestinal symptoms. Stability of alexithymia was demonstrated by significant correlations between base-line and follow-up TAS-20 scores in the entire sample. Moreover, hierarchical regression analyses showed that the stability of TAS-20 scores over the 6-month treatment period could not be accounted for by their associations with anxiety and depression scores. In logistic regression analyses, base-line alexithymia and depression emerged as significant predictors of treatment outcome. Relative to depression, however, alexithymia was the stronger predictor.

CONCLUSIONS

Alexithymia is a reliable and stable predictor of treatment outcome in FGID patients. Although further studies are needed, clinicians might improve treatment outcome by identifying patients with high alexithymia, and attempting to improve these patients' skills for coping with emotionally stressful situations.

Factors associated with the onset of an episode of depressive symptoms in the general population

OBJECTIVES

To determined the association between spinal pain, headache, health, demographic and socio-economic characteristics, and development of depressive symptomatology.

METHODS

A population-based, random sample of adults was surveyed and followed at 6 and 12 months. Individuals at risk of depression at baseline are the subjects of this article (n=845). We used Cox proportional hazards models to measure the time-varying effects of demographic, socio-economic, and health status; comorbid medical conditions; spinal pain; and headaches on the development of depression.

RESULTS

After adjusting for baseline depressive symptoms and factors associated with nonresponse to follow-up, we found that spinal pain severity, younger age, marital status (separated/divorced/widowed), self-perceived poor health status, and comorbid neurologic and gastro-intestinal disease were associated with onset of a new episode of depression.

CONCLUSIONS

Important predictors of depressive symptomatology include demographic characteristics, health problems, and pain problems.

Tryptophan as a link between psychopathology and somatic states

OBJECTIVE

Several somatic illnesses are associated with psychiatric comorbidity. Evidence is provided that availability of the essential amino acid tryptophan, which is the precursor of serotonin, may cause this phenomenon.

METHODS

We performed a database search to find relevant articles published between 1966 and 2002. For our search strategy, we combined several diseases from the categories hormonal, gastrointestinal, and inflammatory with the search terms "tryptophan" and "serotonin."

RESULTS

The catabolism of tryptophan is stimulated under the influence of stress, hormones and inflammation by the induction of the enzymes tryptophan pyrrolase (in the liver) and IDO (ubiquitous). Because of the reduction in blood levels of tryptophan under these circumstances the formation of cerebral serotonin is decreased.

CONCLUSIONS

It is argued that the coupling of peripheral tryptophan levels and cerebral serotonin levels has physiological significance. The clinical implications and therapeutic consequences of changes in tryptophan and consequently serotonin metabolism are discussed.

[Functional childhood gastrointestinal disorders. I. Chronic abdominal pain]

Chronic abdominal pain occurs in 17% of children aged 0-14 years with a peak of 33% at the age of 7 years. According to the Rome II criteria abdominal pain disorders can be classified as functional dyspepsia, irritable bowel syndrome, functional abdominal pain, abdominal migraine, and aerophagia. This new classification will hopefully lead to a more careful diagnosis of functional abdominal pain syndromes and to better treatment strategies. A thorough history taking and physical examination are the cornerstone of diagnostic workup in children with chronic abdominal pain. An extensive explanation and reassurance are the basis of an adequate treatment and in the majority of cases this is successful.

Overview of functional gastrointestinal disorders: dysfunction of the brain-gut axis

Functional gastrointestinal disorders are common and incompletely understood. The gut is controlled by a complex interaction of sensory and motor neurons in the local enteric nervous system. Inputs from the central nervous system modify gut function, whereas inputs from the gut to the brain mediate symptoms. Dysfunction at one or more sites in the brain-gut axis is likely to produce the various functional gastrointestinal syndromes. Therapies likewise can be directed at one or more levels.

Psychosocial aspects of functional gastrointestinal disorders

Psychosocial factors, such as stress, abuse history, psychiatric disturbance, coping style, and learned illness behaviors, play an important role in functional GI disorders in terms of symptom experience and clinical outcome. These psychosocial factors are influenced by and influence GI symptoms in a bidirectional manner as mediated through the brain-gut axis (CNS and ENS pathways). Entering the patient encounter using a biopsychosocial approach and a care (versus cure) style can help avoid excessive diagnostic testing, and elicit crucial information about potential abuse history or psychiatric symptoms that can help guide therapy. Finally, for patients with severe, refractory symptoms, multicomponent treatment involving psychologic therapy, such as CBT, relaxation, or hypnotherapy, can be beneficial.

The treatment of the “untreatable” patient-revisited

The limits of medicine have not yet been reached. Numerous human illnesses initially thought to be incurable are reversible under unique and unpredictable individual circumstances. This paper, and the preceding companion publication, describes instances of the successful treatment of patients previously labeled as untreatable, including instances of severe ulcerative colitis and Crohn’s disease.

Transition of care between paediatric and adult gastroenterology. Cystic fibrosis

Advancement in treatment has resulted in a dramatic increase in life expectancy of patients with cystic fibrosis (CF) to well beyond 30 years of age in most centres. What was once a fatal genetic disease in childhood now sees over a third of its CF populations in adult clinics. The improved survival is multifactorial, but most attribute the reasons to more aggressive nutritional care along with better management of the gastrointestinal and pulmonary systems. Many of the nutritional and GI issues of paediatric patients remain similar when they become adults, except that there is the added psychosocial stress associated with this transition. This chapter aims to highlight the gastrointestinal and nutritional issues manifesting at the different stages of life from infancy to adulthood, and the recommended management.

Psychosocial issues in the child with chronic conditions

Psychosocial issues in children, adolescents and families who suffer with chronic illnesses require careful identification and treatment. Since more of these young people survive into adulthood, their risk of psychosocial distress and psychiatric illness is increased, although many adapt well. The literature is vast, but limited in its usefulness: criteria for the variables described, including chronicity and severity, are poorly defined; outcome measures are not standardized; and few randomized controlled clinical trials exist. This chapter focuses the attention of physicians on overt and covert signs of psychosocial distress in the patient and family with chronic illness. Common issues for all chronic diseases are discussed and a non-categorical approach is taken. The importance of the family as a focus of intervention is highlighted. The meaning and treatment of unexplained medical symptoms, non- adherence with treatment recommendations, school refusal, sexuality and substance use and abuse are discussed.

The impact of gastrointestinal symptoms on health status in patients with cardiovascular disease

BACKGROUND

Drugs for the management of cardiovascular disease may provoke gastrointestinal discomfort and complications.

AIM

To evaluate whether upper gastrointestinal symptoms affect the health status of patients with cardiovascular disease.

METHODS

Two weeks after discharge, 958 consecutive patients, who had been admitted to the Coronary Care Unit of the University Hospital Nijmegen between January and September 2001, were sent a questionnaire for the evaluation of gastrointestinal symptoms and health status.

RESULTS

The questionnaire was returned by 632 patients (66%), with 334 patients (53%) reporting gastrointestinal symptoms. The self-rated health status (mean and 95% confidence interval), evaluated by visual analogue scale, was 70 (68-72) for patients without and 61 (59-63) for patients with gastrointestinal symptoms (P = 0.001). Patients with gastrointestinal symptoms reported significantly higher rates of problems with mobility (50% vs. 37%), self-care (19% vs. 10%), usual activities (70% vs. 52%), pain/discomfort (96% vs. 38%) and anxiety/depression (41% vs. 20%) when compared with those without gastrointestinal symptoms.

CONCLUSION

Upper gastrointestinal symptoms strongly impaired the health status of patients with cardiovascular disease.

Does psychological distress modulate functional gastrointestinal symptoms and health care seeking? A prospective, community Cohort study

OBJECTIVE

Little is known about the natural history of functional GI symptoms, including what factors influence GI symptom patterns and health care seeking for them over the long term. We aimed to determine whether psychological factors play a role in the development and long-term course of these symptoms.

METHODS

A random sample of community subjects (n = 361) who reported having unexplained abdominal pain for > or =1 month in a previous population survey were included in the study. Controls (n = 120) were defined as not having abdominal pain for > or =1 month from this initial survey. Subjects were prospectively followed up via a questionnaire every 4 months over a 12-month period. The questionnaire asked about the presence of GI symptoms over the past week and psychological distress over the past 3 wk (psychological caseness being defined as a score of > or=2 of 12 on the General Health Questionnaire). The number of visits made to a physician or medical specialist over the past 4 months was evaluated.

RESULTS

GI symptoms were common among community controls and subjects with abdominal pain. Similar onset and disappearance rates were observed for the majority of GI symptom categories, accounting for the stability of the prevalence rates over a 1-yr period. Changes in a state measure of psychological distress were not significantly associated with changes in GI symptom status between the 4- and 8-month (r = 0.14, p = 0.08) and 8- and 12-month (r = 0.02, p = 0.77) follow-ups. Baseline psychological distress, however, was an independent predictor of having persistent GI symptoms, including abdominal pain, bloating, and constipation, and frequently seeking health care for GI symptoms over 1 yr.

CONCLUSIONS

Psychological distress levels do not seem to be important in explaining GI symptom change over a 1-yr period. Psychological distress, however, is linked to having persistent GI symptoms and frequently seeking health care for them over time. Clinicians should consider psychological factors in the treatment of this subset of irritable bowel syndrome patients.

Prevalence of sexual and physical abuse and its relationship with symptom manifestations in patients with chronic organic and functional gastrointestinal disorders

A history of physical and/or sexual abuse is a frequent occurrence in patients referred for chronic gastrointestinal disorders and it may predispose to the development of functional gastrointestinal disorders, and multiple medical complaints. This study was aimed to determine: (a) prevalence of abuse history in Italian patients with chronic gastrointestinal disturbances, and (b) relationship between abuse history and clinical manifestations.

SUBJECTS AND METHODS

Consecutive gastrointestinal out-patients filled in a self-administered standardised questionnaire, made up of two separate sections: (1) a medical section enquiring on gastrointestinal and extra-gastrointestinal symptoms, and (2) a section on abuse enquiring on the presence and type of abuse suffered during their lifetime. Associations between number of symptoms and abuse history were evaluated using univariate and multivariate logistic models.

RESULTS

Questionnaires were handed out to 260 patients; 13% of whom did not fill in the questionnaires. Functional gastrointestinal disorders were diagnosed in 72.5% of patients and organic gastrointestinal diseases in 27.5%. A total of 31% of patients with organic gastrointestinal diseases and 32% of those with functional gastrointestinal disorders referred to a history of sexual or physical abuse. Histories of physical plus sexual abuse, sexual abuse, childhood abuse and female gender, were statistically associated with an increased number of gastrointestinal and extra-gastrointestinal symptoms irrespective of functional or organic disorders, whereas there was no statistical association with physical abuse only. Furthermore, diagnosis of functional gastrointestinal disorders was associated with a significantly (p<0.001) greater number of gastrointestinal symptoms than the diagnosis of organic gastrointestinal diagnosis. A total of 10 patients met the diagnostic criteria of somatization disorder. Of these, eight reported a history of severe physical and sexual abuse that had occurred, in all but one, during childhood.

CONCLUSIONS

A history of physical and/or sexual abuse has a high prevalence in Italian patients with chronic gastrointestinal disorders, irrespective of organic or functional diagnosis. Abuse history has no relevant role in the pathogenesis of either functional or organic chronic gastrointestinal disorders but it can affect their clinical expression irrespective of functional or organic diagnosis. Severe physical and sexual abuse and childhood abuse were found in patients who met diagnostic criteria for somatization disorder, suggesting a role of abuse history in this subset of patients.

Visceral and cutaneous hypersensitivity in Persian Gulf war veterans with chronic gastrointestinal symptoms

Approximately 697000 United States military personnel participated in the Persian Gulf War (PGW) between August 1990 and March 1991. By April 1997, over 25% of veterans reported chronic health complaints of underdetermined etiology. Gastrointestinal symptoms were among the most frequently reported symptoms including abdominal pain and diarrhea. The objectives of this study were (1). to determine if PGW veterans chronic abdominal pain and diarrhea exhibit visceral and cutaneous hypersensitivity, (2). to determine if these differences in pain sensitivity are significantly associated with psychological stress. A total of 12 veterans (ten males, two females) (39+/-9 years) who were deployed to the Persian Gulf were enrolled. Seven civilians without prior military experience (five males, two females) and five veterans (five males) who had previously been deployed for active combat were enrolled as controls (35+/-9 years). All 12 PGW veterans reported chronic abdominal pain and diarrhea (negative diagnostic workup) that developed during their tour of duty in the Persian Gulf region. All patients completed a battery of psychological assessments and then randomly received experimental visceral (rectal distension of 35 and 55 mmHg for 30s) and cutaneous (immersion of right foot in 45 and 47 degrees C water for 30s) pain stimuli after which they rated their pain intensity and pain unpleasantness on a continuous visual analogue scale (M-VAS) scale. The trials were repeated and the mean M-VAS scores for the two trials were recorded for each subject. In comparison to controls, PGW subjects reported statistically significant higher mean ratings of pain intensity and pain unpleasantness in response to 35 and 55 mmHg rectal distention (P<0.001) and in response to 45 and 47 degrees C water immersion (P<0.001) of the hand and foot. Results of the hierarchical regressions indicated that the psychological measures (i.e. anxiety, somatic focus) accounted for a significant amount of variance in each of the pain measures. PGW veterans who developed chronic abdominal pain and diarrhea during their tour of duty exhibit visceral hypersensitivity similar to patients with the irritable bowel syndrome. These veterans also have cutaneous hypersensitivity and higher levels of anxiety and somatic focus accounting for these differences in pain reporting.

[Psychophysiologic disorders in patients with functional disorders of upper sections of the gastrointestinal tract and with gastroesophageal reflux disease]

The features of the psychovegetative status in patients with functional disorders of the esophagus and stomach (FD) and gastroesophageal reflux disease (GERD) are investigated. The methods included clinical, instrumental and psychometric examination. The patients of both groups had similar vegetative abnormalities and a tendency towards the growth of depression and anxiety parameters, did not differ in psychosocial factors, and had a wide range of psychovegetative abnormalities (PA). Lump in the throat, heartburn, epigastralgia (p < 0.01), depression, actual anxiety, alexitymia and vegetative disorders decreased in both groups (p < 0.05) after treatment with citalopram (20 mg per day) during 2 months. So PA are revealed in patients with FD and GERD, and citalopram reduces psychovegetative and GIT disorders.

Psychiatry, psychotherapy and gastroenterology -- bringing it all together

In this review, some aspects of functional gastrointestinal disorders are described, with particular reference to psychiatric and psychological features. Seven syndromes or conditions, which may present not uncommonly in a gastroenterology clinic, are identified and clarified. Thereafter, the roles of a psychiatrist and other mental health professionals (psychotherapists, psychologists) within gastroenterology are described, with particular reference to what an integrated service may offer.

Long-term improvement in functional dyspepsia using hypnotherapy

BACKGROUND & AIMS

We have shown hypnotherapy (HT) to be effective in irritable bowel syndrome, with long-term improvements in symptomatology and quality of life (QOL). This study aimed to assess the efficacy of HT in functional dyspepsia (FD).

METHODS

A total of 126 FD patients were randomized to HT, supportive therapy plus placebo medication, or medical treatment for 16 weeks. Percentage change in symptomatology from baseline was assessed after the 16-week treatment phase (short-term) and after 56 weeks (long-term) with 26 HT, 24 supportive therapy, and 29 medical treatment patients completing all phases of the study. QOL was measured as a secondary outcome.

RESULTS

Short-term symptom scores improved more in the HT group (median, 59%) than in the supportive (41%; P = 0.01) or medical treatment (33%; P = 0.057) groups. HT also benefited QOL (42%) compared with either supportive therapy (10% [P < 0.001]) or medical treatment (11% [P < 0.001]). Long-term, HT significantly improved symptoms (73%) compared with supportive therapy (34% [P < 0.02]) or medical treatment (43% [P < 0.01]). QOL improved significantly more with HT (44%) than with medical treatment (20% [P < 0.001]). QOL did improve in the supportive therapy (43%) group, but 5 of these patients commenced taking antidepressants during follow-up. A total of 90% of the patients in the medical treatment group and 82% of the patients in the supportive therapy group commenced medication during follow-up, whereas none in the HT group did so (P < 0.001). Those in the HT group visited their general practitioner or gastroenterologist significantly less (median, 1) than did those in the supportive therapy (median, 4) and medical treatment (median, 4) groups during follow-up (P < 0.001).

CONCLUSIONS

HT is highly effective in the long-term management of FD. Furthermore, the dramatic reduction in medication use and consultation rate provide major economic advantages.