Balance of Autonomic Nervous System Predicts Who Benefits from a Self-management Intervention Program for Irritable Bowel Syndrome

Relationship Between High Frequency Component of Heart Rate Variability and Delta EEG Power During Sleep in Women With Irritable Bowel Syndrome Compared to Healthy Women

OBJECTIVE

To explore the relationship between the high frequency (HF) heart rate variability (HRV) and electroencephalogram (EEG) delta band power in women with irritable bowel syndrome (IBS) versus healthy control women.

MATERIALS AND METHODS

Twenty women with IBS and twenty healthy controls were studied over three consecutive nights using polysomnography in a sleep laboratory. To avoid the first night effect, only second-night data were analyzed. Power spectral analysis was applied to HRV and EEG recordings. The linear system coherence/phase analysis assessed the relationship between normalized HF power of HRV and normalized delta band power of EEG during the first four NREM-REM sleep cycles.

RESULTS

Women with IBS exhibited a significantly higher percentage of NREM sleep, higher normalized HF, lower normalized low frequency (LF) and decreased LF/HF ratio of HRV in the first four NREM-REM sleep cycles compared to controls. Additionally, their normalized delta band power was significantly lower in these sleep cycles and over the whole night. The phase shift between HF and delta band power was significantly longer in the IBS group. While the coherence between normalized HF and normalized delta band power was lower in the IBS group, the difference was not statistically significant.

CONCLUSIONS

The coherence/phase analysis showed a dysregulated interaction between autonomic and central nervous systems in women with IBS, manifested by increased lag time between cardiac and EEG delta band power compared to healthy controls. Whether this dysregulation contributes to the pathophysiology of IBS remains to be determined.

Effect of Brain-Gut Behavioral Treatments on Abdominal Pain in Irritable Bowel Syndrome: Systematic Review and Network Meta-Analysis

BACKGROUND & AIMS

Some brain-gut behavioral treatments (BGBTs) are beneficial for global symptoms in irritable bowel syndrome (IBS). United States management guidelines suggest their use in patients with persistent abdominal pain, but their specific effect on this symptom has not been assessed systematically.

METHODS

We searched the literature through December 16, 2023, for randomized controlled trials (RCTs) assessing efficacy of BGBTs for adults with IBS, compared with each other or a control intervention. Trials provided an assessment of abdominal pain resolution or improvement at treatment completion. We extracted data as intention-to-treat analyses, assuming dropouts to be treatment failures and reporting pooled relative risks (RRs) of abdominal pain not improving with 95% confidence intervals (CIs), ranking therapies according to the P score.

RESULTS

We identified 42 eligible randomized controlled trials comprising 5220 participants. After treatment completion, the BGBTs with the largest numbers of trials and patients recruited demonstrating efficacy for abdominal pain, specifically, included self-guided/minimal contact cognitive behavioral therapy (CBT) (RR, 0.71; 95% CI, 0.54-0.95; P score, 0.58), face-to-face multicomponent behavioral therapy (RR, 0.72; 95% CI, 0.54-0.97; P score, 0.56), and face-to-face gut-directed hypnotherapy (RR, 0.77; 95% CI, 0.61-0.96; P score, 0.49). Among trials recruiting only patients with refractory global IBS symptoms, group CBT was more efficacious than routine care for abdominal pain, but no other significant differences were detected. No trials were low risk of bias across all domains, and there was evidence of funnel plot asymmetry.

CONCLUSIONS

Several BGBTs, including self-guided/minimal contact CBT, face-to-face multicomponent behavioral therapy, and face-to-face gut-directed hypnotherapy may be efficacious for abdominal pain in IBS, although none was superior to another.

Genetic Variations in TrkB.T1 Isoform and Their Association With Somatic and Psychological Symptoms in Individuals With IBS

Irritable bowel syndrome (IBS), a disorder of gut-brain interaction, is often comorbid with somatic pain and psychological disorders. Dysregulated signaling of brain-derived neurotrophic factor (BDNF) and its receptor, tropomyosin-related kinase B (TrkB), has been implicated in somatic-psychological symptoms in individuals with IBS. We investigated the association of 10 single-nucleotide polymorphisms (SNPs) in the regulatory 3' untranslated region of neurotrophic receptor tyrosine kinase-2 (NTRK2) kinase domain-deficient truncated isoform (TrkB.T1) and BDNF Val66Met SNP with somatic and psychological symptoms and quality-of-life (QoL) in a cohort from the United States (IBS, n = 464; healthy controls, n = 156). We found that the homozygous recessive genotype (G/G) of rs2013566 in individuals with IBS is associated with worsened somatic symptoms, including headache, back pain, joint pain, muscle pain, and somatization as well as diminished sleep quality, energy level, and overall QoL. Validation using United Kingdom BioBank data confirmed the association of rs2013566 with an increased likelihood of headache. Several SNPs (rs1627784, rs1624327, and rs1147198) showed significant associations with muscle pain in our U.S. cohort. These 4 SNPs are predominantly located in H3K4Me1-enriched regions, suggesting their enhancer and/or transcription regulation potential. Our findings suggest that genetic variation within the 3' untranslated region region of the TrkB.T1 isoform may contribute to comorbid conditions in individuals with IBS, resulting in a spectrum of somatic and psychological symptoms impacting their QoL. These findings advance our understanding of the genetic interaction between BDNF/TrkB pathways and somatic-psychological symptoms in IBS, highlighting the importance of further exploring this interaction for potential clinical applications. PERSPECTIVE: This study aims to understand the genetic effects on IBS-related symptoms across somatic, psychological, and quality-of-life (QoL) domains, validated by United Kingdom BioBank data. The rs2013566 homozygous recessive genotype correlates with worsened somatic symptoms and reduced QoL, emphasizing its clinical significance.

Formative Evaluation of a Comprehensive Self-Management Intervention for Irritable Bowel Syndrome, Comorbid Anxiety, and Depression: Mixed Methods Study

BACKGROUND

Irritable bowel syndrome (IBS) is a disorder of the gut-brain interaction that is associated with abdominal pain, altered bowel patterns, and reduced quality of life. Up to 50% of patients with IBS also report anxiety or depressive symptoms. Although effective self-management interventions exist for individuals with IBS, few have been effectively implemented, and most do not consider the unique needs of patients with comorbid IBS and anxiety or depression.

OBJECTIVE

This study aimed to determine the anticipated acceptability, appropriateness, feasibility, and usability of a comprehensive self-management intervention using an implementation science and human-centered design approach among individuals with comorbid IBS and anxiety or depression and health care providers.

METHODS

A convergent mixed methods design was used to elicit feedback on the comprehensive self-management intervention outline and content to identify refinement needs before testing. Patients with IBS and moderate to severe anxiety or depression and health care providers were purposefully sampled from primary care and gastroenterology settings. Participants completed semistructured interviews and surveys on anticipated acceptability, appropriateness, feasibility, and usability.

RESULTS

Patient participants (n=12) were on average 36.8 (SD 12.2) years of age, and 42% (5/12) were currently receiving psychological therapy. Health care providers (n=14) were from primary care (n=7) and gastroenterology (n=7) settings. The mean usability scores (out of 100) were 52.5 (SD 14.5) for patients and 45.6 (SD 11.6) for providers. For patients and providers, qualitative data expanded the quantitative findings for acceptability and appropriateness. Acceptability findings were the comprehensive nature of the intervention and discussion of the gut-brain interaction. For appropriateness, participants reported that the intervention provided structure, accountability, and support. Feasibility was confirmed for patients, but there was a divergence of findings between quantitative and qualitative measures for providers. Patients focused on intervention feasibility, while providers focused on implementation feasibility in the clinic. Identified usability issues to address before implementation included the intervention delivery format, length, and lack of integration into health care settings that, if not addressed, may limit the reach of the intervention.

CONCLUSIONS

Patients and health care providers found the intervention acceptable and appropriate. Several feasibility and usability issues were identified, including intervention delivery methods, length of intervention, and the best methods to implement in the clinic setting. The next steps are to refine the intervention to address the identified issues and test in a pilot study whether addressing usability issues leads to the anticipated improvements in implementation and uptake.

Age Differences in Upper Gastrointestinal Symptoms and Vagal Modulation in Women With Irritable Bowel Syndrome

BACKGROUND/AIMS

Patients with irritable bowel syndrome (IBS) often report upper gastrointestinal (GI) (e.g., nausea and heartburn), somatic, and emotional symptoms. This study seeks to examine the relationships among younger and older women with IBS and indicators of autonomic nervous system (ANS) function and daily nausea and heartburn symptoms.

METHODS

Women were recruited through clinics and the community. Nocturnal heart rate variability (HRV) was obtained using ambulatory electrocardiogram Holter monitors. Individual symptom severity and frequency were collected using 28-day diaries. All variables were stratified by younger (<46 years) and older (≥46 years) age groups.

RESULTS

Eighty-nine women with IBS were included in this descriptive correlation study (n = 57 younger; n = 32 older). Older women had reduced indices of vagal activity when compared to younger women. In older women, there was an inverse correlation between nausea and vagal measures (Ln RMSSD, r = -.41, p = .026; Ln pNN50, r = -.39, p = .034). Heartburn in older women was associated with sleepiness (r = .59, p < .001) and anger (r = .48, p = .006). Nausea was significantly correlated with anger in the younger group (r = .41, p = .001). There were no significant relationships between HRV indicators and nausea and heartburn in younger women.

CONCLUSIONS

Age-related differences in ANS function that are associated with nausea may portend unique opportunities to better understand the vagal dysregulation in women with IBS.

Age Differences in Core Symptoms and Symptom Relationships in Patients With Irritable Bowel Syndrome: A Network Analysis

INTRODUCTION

Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction, characterized by symptoms of abdominal pain and changes in bowel habits. It often co-occurs with extraintestinal somatic and psychological symptoms. However, the nature of the interrelationships among these symptoms is unclear. Although previous studies have noted age differences in IBS prevalence and specific symptom severity, it remains unknown whether specific symptoms and symptom relationships may differ by age.

METHODS

Symptom data were collected in 355 adults with IBS (mean age 41.4 years, 86.2% female). Network analysis was used to examine the interrelationships among 28 symptoms and to identify the core symptoms driving the symptom structure between young (≤45 years) vs older (>45 years) adults with IBS. We evaluated 3 network properties between the 2 age groups: network structure, edge (connection) strength, and global strength.

RESULTS

In both age groups, fatigue was the top core symptom. Anxiety was a second core symptom in the younger age group, but not the older age group. Intestinal gas and/or bloating symptoms also exerted considerable influences in both age groups. The overall symptom structure and connectivity were found to be similar regardless of age.

DISCUSSION

Network analysis suggests fatigue is a critical target for symptom management in adults with IBS, regardless of age. Comorbid anxiety is likely an important treatment focus for young adults with IBS. Rome V criteria update could consider the importance of intestinal gas and bloating symptoms. Additional replication with larger diverse IBS cohorts is warranted to verify our results.

A Comprehensive Self-Management Intervention for Inflammatory Bowel Disease (CSM-IBD): Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Despite pharmacological treatment, individuals with inflammatory bowel disease (IBD) experience a variety of symptoms, including abdominal pain, fatigue, anxiety, and depression. Few nonmedical self-management interventions are available for people with IBD. A validated comprehensive self-management (CSM) intervention is effective for patients with irritable bowel syndrome who can have symptoms similar to those of individuals with IBD. We created a modified CSM intervention tailored to individuals with IBD (CSM-IBD). The CSM-IBD is an 8-session program delivered over 8-12 weeks with check-ins with a registered nurse.

OBJECTIVE

The primary objective of this pilot study is to determine the feasibility and acceptability of study procedures and the CSM-IBD intervention and to evaluate preliminary efficacy on quality of life and daily symptoms for a future randomized controlled trial. Additionally, we will examine the association of socioecological, clinical, and biological factors with symptoms at baseline and response to intervention.

METHODS

We are conducting a pilot randomized controlled trial of the CSM-IBD intervention. Participants aged 18-75 years who are experiencing at least 2 symptoms are eligible for inclusion. We plan to enroll 54 participants who will be randomized (2:1) into the CSM-IBD program or usual care. Patients in the CSM-IBD program will have 8 intervention sessions. Primary study outcomes include the feasibility of recruitment, randomization, and data or sample collection, as well as the acceptability of study procedures and interventions. Preliminary efficacy outcome variables include quality of life and symptoms. Outcomes data will be assessed at baseline, immediately post intervention, and 3 months post intervention. Participants in the usual care group will have access to the intervention after study participation.

RESULTS

This project is funded by the National Institutes of Nursing Research and reviewed by the University of Washington's institutional review board. Recruitment began in February 2023. As of April 2023, we have enrolled 4 participants. We expect the study to be completed by March 2025.

CONCLUSIONS

This pilot study will evaluate the feasibility and efficacy of a self-management intervention (a web-based program with weekly check-ins with a registered nurse) that aims to improve symptom management in individuals with IBD. In the long term, we aim to validate a self-management intervention to improve patient quality of life, reduce direct and indirect costs related to IBD, and be culturally appropriate and accessible, particularly in rural and underserved communities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05651542; https://clinicaltrials.gov/ct2/show/NCT05651542.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46307.

Roles of Heart Rate Variability in Assessing Autonomic Nervous System in Functional Gastrointestinal Disorders: A Systematic Review

Functional gastrointestinal disorders (FGID) and gastroesophageal reflux (GERD) disease affect a large global population and incur substantial health care costs. Impairment in gut-brain communication is one of the main causes of these disorders. The central nervous system (CNS) provides its inputs to the enteric nervous system (ENS) by modulating the autonomic nervous system (ANS) to control the gastrointestinal functions. Therefore, GERD and FGID's might be associated with autonomic dysfunction, which can be identified via heart rate variability (HRV). FGIDs may be treated by restoring the autonomic dysfunction via neuromodulation. This article reviews the roles of HRV in the assessment of autonomic function and dysfunction in (i) gastroesophageal reflux (GERD), and the following FGIDs: (ii) functional dyspepsia (FD) and gastroparesis, (iii) irritable bowel syndrome (IBS) and (iv) constipation. The roles of HRV in the assessment of autonomic responses to various interventions were also reviewed. We used PUBMED, Web of Science, Elsevier/Science direct and Scopus to search the eligible studies for each disorder, which also included the keyword 'heart rate variability'. The retrieved studies were screened and filtered to identify the most suitable studies using HRV parameters to associate the autonomic function with any of the above disorders. Studies involving both human and animal models were included. Based on analyses of HRV, GERD as well as the FGIDs were found to be associated with decreased parasympathetic activity and increased sympathetic nervous system activity with the autonomic balance shifted towards the sympathetic nervous system. In addition, the HRV methods were also reported to be able to assess the autonomic responses to various interventions (mostly neuromodulation), typically the enhancement of parasympathetic activity. In summary, GERD and FGIDs are associated with impaired autonomic dysfunction, mainly due to suppressed vagal and overactive sympathetic tone, which can be assessed noninvasively using HRV.

Validity and reliability of the Japanese versions of cognitive and behavioral scales for irritable bowel syndrome

Background

The Cognitive Scale for Functional Bowel Disorders (CS-FBD) and Irritable Bowel Syndrome-Behavioral Responses Questionnaire (IBS-BRQ) are a useful measures to assess cognitive-behavioral aspects in individuals with IBS. This study aimed to confirm the reliability and validity of the Japanese versions of the CS-FBD (CS-FBD-J) and IBS-BRQ (IBS-BRQ-J).

Methods

Participants comprised 192 students and 22 outpatients diagnosed with irritable bowel syndrome (IBS). There were 76 students who met the diagnostic criteria for IBS and two students who received treatment for IBS. Participants completed questionnaires containing the CS-FBD-J, IBS Severity Index (IBS-SI), Visceral Sensitivity Index (VSI), 24-item Dysfunctional Attitudes Scale (DAS-24), Hospital Anxiety and Depression Scale (HADS), and Social Adaptation Self-evaluation Scale (SASS).

Results

Our exploratory factor analysis revealed that the CS-FBD-J had a unidimensional factor structure and that the factor loadings for two of the 25 items were less than 0.4. The IBS-BRQ-J had a two-factor structure, and the factor loadings for eight of the 26 items were less than 0.4. The confirmatory factor analysis for the 18-item version of IBS-BRQ-J showed that the model fit indices were not sufficient. The CS-FBD-J and IBS-BRQ-J had significant, moderate correlations with the IBS-SI and VSI in the IBS and control groups. Correlation between the DAS-24 and the CS-FBD-J was not significant. The CS-FBD-J and IBS-BRQ-J were significantly correlated to the HADS and SASS (IBS-BRQ-J) only in the IBS group. The scores of CS-FBD-J and IBS-BRQ-J showed significant group differences between the IBS patient group, non-patient IBS group, and control group. The internal consistencies of the CS-FBD-J and IBS-BRQ-J were high. The item-total correlation analysis for the CS-FBD-J and IBS-BRQ-J showed that the correlations between each item and the total score were significant.

Conclusion

This study confirmed the reliability and validity of the 23-item version of the CS-FBS-J and the 18-item version of the IBS-BRQ-J with the deletion of items with low factor loadings. Regarding the IBS-BRQ-J, two factor structures were confirmed (factor 1: behavior obsessed with abdominal symptoms, factor 2: avoidance of abdominal symptoms and associated difficulties) although the model fit of the structure needs further study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13030-022-00244-3.

Heart Rate Variability-An Index of the Efficacy of Complementary Therapies in Irritable Bowel Syndrome: A Systematic Review

Irritable bowel syndrome (IBS), as a functional and psychosomatic disease, reduces the quality of life and increases the risk of developing mental disorders. Deregulation of the autonomic nervous system (ANS) is one of the main causes of the disease. The objective of the present study was to identify the studies in which measurements of heart rate variability (HRV) were performed before and after therapeutic intervention, and to evaluate the effectiveness of IBS therapy in terms of a reduction of IBS symptoms and changes in autonomic tone. A systematic review of the literature was carried out in accordance with PRISMA standards. Six databases were searched for articles published before 2022: PubMed®, MEDLINE®, EBSCO, Cochrane, Scopus, and Web of Science. Inclusion criteria were experimental design, diagnosis of IBS (medical and/or diagnosis in accordance with the Rome Criteria), non-pharmacological intervention, and HRV measurement before and after the intervention. The quality of the studies was assessed by JBI Critical appraisal. In total, 455 studies were identified, of which, sixwere included in the review. Expected changes in HRV (increase in parasympathetic activity) were observed in four of the six studies (interventions studied: ear acupressure, transcutaneous auricular vagusnerve stimulation, cognitive behavioral therapy with relaxation elements, yoga). In the same studies, therapeutic interventions significantly reduced the symptoms of IBS. The present review indicated that interventions under investigation improve the efficiency of the ANS and reduce the symptoms of IBS. It is advisable to include HRV measurements as a measure of the effectiveness of interventions in IBS therapy, and to assess autonomic changes as a moderator of the effectiveness of IBS therapy.

The effect of self-management online modules plus nurse-led support on pain and quality of life among young adults with irritable bowel syndrome: A randomized controlled trial

BACKGROUND

Irritable bowel syndrome is a chronic pain condition that needs life-long self-management. However, the effect of self-management among young adults with irritable bowel syndrome is limited.

OBJECTIVES

This study aimed to examine the effect of a nurse-led self-management program on pain, symptoms, and quality of life among young adults with irritable bowel syndrome.

DESIGN

A randomized controlled trial.

SETTINGS AND PARTICIPANTS

Eighty young adults with irritable bowel syndrome recruited from two campuses of a public university and two gastrointestinal clinics were randomly assigned into a self-management online education and learning modules alone group (Online Modules, n = 41) or a nurse-led one-to-one consultation plus self-management online education and learning modules group (Nurse-Led Online Modules, n = 39). Twenty-one healthy controls were also recruited from these two campuses.

METHODS

Both the intervention groups received ten online modules after baseline data collection. Participants in the Nurse-Led Online Modules group received additional three nurse-led one-to-one consultations at baseline, 6- and 12-week follow-ups. Self-reported pain, symptoms, quality of life, self-efficacy for managing chronic disease, and coping were measured at baseline, and 6- and 12-week follow-ups among the participants with irritable bowel syndrome. The healthy controls completed data collection of pain and symptoms at baseline and the 12-week follow-up. The intervention effects across study time points and the comparisons between the two interventional groups were analyzed using linear mixed models. A longitudinal mediation analysis was also conducted to explore the mediation effects of self-management mechanisms of the interventions.

RESULTS

Both the intervention groups showed significant interventional effects on decreasing pain intensity and pain interference and increasing quality of life at the 12-week follow-up (all p < 0.05). At the 12-week follow-up, the Nurse-Led Online Modules significantly reduced anxiety (p = 0.016) and had a significant greater improvement in quality of life than the Online Modules (p = 0.040). Increased self-efficacy mediated the intervention effect of the Nurse-Led Online Modules group on reducing pain interference and improving quality of life, while the effect of the Online Modules was mediated through decreasing inefficient coping strategy-catastrophizing.

CONCLUSIONS

This study showed that both the pain self-management online education and nurse-led intervention were effective for alleviating pain and improving quality of life among young adults with irritable bowel syndrome by targeting the self-management process. The nurse-led intervention had a better outcome than the online education alone in improving quality of life.

REGISTRATION NUMBER

NCT03332537.

Indirect effect of sleep on abdominal pain through daytime dysfunction in adults with irritable bowel syndrome

STUDY OBJECTIVES

Sleep deficiency, psychological distress, daytime dysfunction, and abdominal pain are common in adults with irritable bowel syndrome. Prior research on individuals with chronic pain has identified the indirect effect of sleep on pain through psychological distress or daytime dysfunction; however, this effect is less clear in irritable bowel syndrome. The purpose of this study was to examine potential indirect effects of sleep on abdominal pain symptoms simultaneously through psychological distress and daytime dysfunction in adults with irritable bowel syndrome.

METHODS

Daily symptoms of nighttime sleep complaints (sleep quality and refreshment), psychological distress, daytime dysfunction (fatigue, sleepiness, and difficulty concentrating), and abdominal pain were collected in baseline assessments from 2 randomized controlled trials of 332 adults (mean age 42 years and 85% female) with irritable bowel syndrome. Structural equation modeling was used to examine the global relationships among nighttime sleep complaints, psychological distress, daytime dysfunction, and abdominal pain.

RESULTS

The structural equation modeling analyses found a strong indirect effect of poor sleep on abdominal pain via daytime dysfunction but not psychological distress. More than 95% of the total effect of nighttime sleep complaints on abdominal pain was indirect.

CONCLUSIONS

These findings suggest that the primary impact of nighttime sleep complaints on abdominal pain is indirect. The indirect effect appears primarily through daytime dysfunction. Such understanding provides a potential avenue to optimize personalized and hybrid behavioral interventions for adults with irritable bowel syndrome through addressing daytime dysfunction and sleep behaviors. Additional study integrating symptoms with biological markers is warranted to explore the underlying mechanisms accounting for these symptoms.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov. Name: Nursing Management of Irritable Bowel Syndrome: Improving Outcomes, Nursing Management of IBS: Improving Outcomes. URLs: https://clinicaltrials.gov/ct2/show/NCT00167635, https://clinicaltrials.gov/ct2/show/NCT00907790. Identifiers: NCT00167635, NCT00907790.

Irritable bowel syndrome in midlife women: a narrative review

Midlife women between the ages of 40 and 65 years have reported multiple challenges due to menopausal, developmental, and situational transitions from younger to older adulthood. During the midlife period, many women seek health care for gastrointestinal symptoms and irritable bowel syndrome (IBS). Multiple factors including stress, poor sleep, diet, and physical inactivity may contribute to IBS or gastrointestinal symptoms in midlife women. As such, a comprehensive assessment and treatment approach is needed for midlife women suffering gastrointestinal symptoms. This article reviews the main aspects of the menopausal transition, sex hormonal changes, abdominal and pelvic surgery, psychosocial distress, behavioral factors, and gut microbiome, as well as their relevance on IBS and gastrointestinal symptoms in midlife women. Also, management strategies for IBS in midlife women are discussed. To date, gastrointestinal symptoms during midlife years remain a critical area of women’s health. Additional research is needed to better understand the contributors to gastrointestinal symptoms in this group. Such efforts may provide a new window to refine or develop treatments of gastrointestinal symptoms for midlife women.

Health-Related Quality of Life in Irritable Bowel Syndrome: A Systematic Review and Meta-analysis

Irritable bowel syndrome (IBS) affects up to 20% of the global population and is associated with impaired health-related quality of life (HRQoL). This systematic review and meta-analysis aimed to investigate differences in HRQoL of those with IBS compared with healthy controls and to examine whether HRQoL improves following psychological intervention. Online databases were searched for articles from 2002 to 2017. Studies were screened and data extracted according to predetermined criteria. A total of 4,154 citations were identified from which 36 were eligible for inclusion. Eight studies compared HRQoL of those with IBS (n = 822) with that of healthy individuals (n = 3,809). Those with IBS suffered significant impairment across all HRQoL domains compared with healthy individuals, with the majority of effects (Cohen's d) being moderate to large. Twenty-eight studies investigated HRQoL in IBS following psychological intervention (n = 1,308) relative to controls (n = 1,006). All HRQoL domains improved with large effects following treatment; however, maintenance of these effects was inconsistent. Those with IBS experience poorer HRQoL than the wider community; nevertheless, psychological interventions are associated with improved HRQoL across all domains. High-quality studies are needed to better inform gastroenterological nurses of which interventions are most efficacious in alleviating the burden of IBS, and which IBS subpopulations would benefit.

Intestinal barrier dysfunction in irritable bowel syndrome: a systematic review

BACKGROUND AND AIM

Irritable bowel syndrome (IBS) is a complex and heterogeneous disorder. Sensory, motor and barrier dysfunctions are the key physiological endophenotypes of IBS. Our aim is to review studies evaluating barrier dysfunction in adults and children with IBS, as well as to link those changes with IBS symptomatology and quality of life.

METHODS

A comprehensive and systematic review of multiple databases was performed up to March 2020 to identify studies comparing intestinal permeability in IBS patients with healthy controls. Both in vivo and in vitro studies were considered.

RESULTS

We identified 66 studies, of which 27 used intestinal probes to quantify barrier function. The prevalence of barrier dysfunction differed between PI-IBS (17-50%), IBS-D (37-62%) and IBS-C (4-25%). At a group level, permeability was increased compared with healthy controls in IBS-D (9/13 studies) and PI-IBS (4/4 studies), but only a minority of IBS-C (2/7 studies) and not in the only IBS-M study. All four studies in children with IBS demonstrated loss of barrier function. A heterogeneous set of tight junction genes were found to be altered in small and large intestines of adults with IBS, but these have not been evaluated in children. Positive associations were identified between barrier dysfunction and bowel disturbances (6/9 studies), abdominal pain (9/13 studies), overall symptom severity (1/6 studies), depression and anxiety (1/1 study) and quality of life (1/4 studies). Fecal slurry or supernatants of IBS patients were found to induce barrier disruption in animal models (5/6 studies).

CONCLUSIONS

Barrier dysfunction is present in a significant proportion of adult and all pediatric IBS studies, especially in the IBS-D and PI-IBS subtype. The majority of studies indicated a positive association between loss of barrier function and symptoms such as abdominal pain and changes in the bowel function.

A Comprehensive Self-Management Program With Diet Education Does Not Alter Microbiome Characteristics in Women With Irritable Bowel Syndrome

BACKGROUND AND PURPOSE

Changes in diet and lifestyle factors are frequently recommended for persons with irritable bowel syndrome (IBS). It is unknown whether these recommendations alter the gut microbiome and/or whether baseline microbiome predicts improvement in symptoms and quality of life following treatment. Therefore, the purpose of this study was to explore if baseline gut microbiome composition predicted response to a Comprehensive Self-Management (CSM) intervention and if the intervention resulted in a different gut microbiome composition compared to usual care.

METHODS

Individuals aged 18-70 years with IBS symptoms ≥6 months were recruited using convenience sampling. Individuals were excluded if medication use or comorbidities would influence symptoms or microbiome. Participants completed a baseline assessment and were randomized into the eight-session CSM intervention which included dietary education and cognitive behavioral therapy versus usual care. Questionnaires included demographics, quality of life, and symptom diaries. Fecal samples were collected at baseline and 3-month post-randomization for 16S rRNA-based microbiome analysis.

RESULTS

Within the CSM intervention group (n = 30), Shannon diversity, richness, and beta diversity measures at baseline did not predict benefit from the CSM intervention at 3 months, as measured by change in abdominal pain and quality of life. Based on both alpha and beta diversity, the change from baseline to follow-up microbiome bacterial taxa did not differ between CSM (n = 25) and usual care (n = 25).

CONCLUSIONS AND INFERENCES

Baseline microbiome does not predict symptom improvement with CSM intervention. We do not find evidence that the CSM intervention influences gut microbiome diversity or composition over the course of 3 months.

Bile Acids and Microbiome Among Individuals With Irritable Bowel Syndrome and Healthy Volunteers

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder. High bile acid (BA) profiles have been associated with abdominal pain symptoms, mucosal inflammation, and diarrhea in a subgroup of those with IBS. The purpose of this study was to compare: 1) fecal primary and secondary BAs in women with and without IBS; and 2) symptoms, gut microbiome, and diet between women with high and normal BAs (i.e., similar to healthy [HC] women). Women (ages 18-45) with IBS and HCs were recruited from healthcare providers or the community. Participants kept a 28-day symptom diary, completed a 3-day food journal, and collected a stool sample for microbiome analysis (16 S rRNA gene sequencing). Primary and secondary BA levels were determined by mass spectrometry. Primary BAs did not differ between IBS (n = 45) and HC (n = 28) groups; women with IBS had significantly increased conjugated secondary BAs (glycodeoxycholic acid [p = 0.006], taurodeoxycholic acid [p = 0.006], and glycolithocholic acid [p = 0.01]). Sixty percent of women with IBS had normal BAs whereas 40% had high BAs. Women with high fecal BAs were predominantly IBS-Diarrhea or IBS-Mixed and consumed less fiber and vegetable protein and more animal protein compared to women with IBS whose fecal BAs levels were comparable to HCs. Those with high conjugated secondary fecal BAs also had a greater Firmicutes/Bacteroidetes ratio, less abundance of phylum Bacteroidetes and genus Gemmiger, and more abundance of family Erysipelotrichaceae compared to IBS women with normal BAs. Determination of fecal BA levels provides additional insights into pathophysiological links between diet and microbiome in IBS.

Alterations in Heart Rate Variability Associated With Irritable Bowel Syndrome or Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

INTRODUCTION:

Irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) are gastrointestinal pathologies affecting large numbers of the global population and incurring significant healthcare costs. Disruptions in the gut-brain axis occurring in these conditions can lead to increased inflammation, affecting gastrointestinal and autonomic nervous system function. Heart rate variability (HRV) is commonly used to assess the state of the sympathetic and parasympathetic function of the autonomic nervous system, but it remains unclear how HRV measures are associated with gastrointestinal pathologies. Here, we conduct a systematic review of the literature comparing HRV of subjects diagnosed with IBS or IBD to HRV in healthy controls (HC).

METHODS:

We searched PubMed, Cochrane Library, and CINAHL (EBSCO) for eligible studies up to 2018. We included any study comparing a recognized measure of HRV between a group of patients with either IBS or IBD to a group of matched HC before any intervention. Studies were screened, and data were extracted from included articles using predefined criteria. Random effects meta-analysis was performed for each outcome, with effect size reported as the standardized mean difference.

RESULTS:

There were significant differences between IBD and HC in time domain HRV and significant decreases in high-frequency power measures were also noted, in both IBS and IBD compared with HC.

DISCUSSION:

Parasympathetic nervous system activity, represented through high-frequency power, seems to be lower in people with IBS and IBD, but conclusions are limited by the small number of studies that provide usable data, methodological heterogeneity, and high risks of bias in primary study methods and measures.

Relationships Between Abdominal Pain and Fatigue With Psychological Distress as a Mediator in Women With Irritable Bowel Syndrome

Women with irritable bowel syndrome often report fatigue, along with abdominal pain and psychological distress (i.e., depression and anxiety). There is little information about the relationships among these symptoms. Using a secondary data analysis (N = 356), we examined the relationship between abdominal pain and fatigue and whether psychological distress mediates the effect of abdominal pain on fatigue in both across women and within woman with irritable bowel syndrome. Data gathered through a 28-day diary were analyzed with linear regressions. The across-women and within-woman relationships among same-day abdominal pain, fatigue, and psychological distress were examined. Within-woman relationships were also examined for directionality among symptoms (i.e., prior-day abdominal pain predicts next-day fatigue and prior-day fatigue predicts next-day abdominal pain). In across-women and within-woman analyses on the same day, abdominal pain and fatigue were positively correlated. In within-woman analyses, abdominal pain predicted next-day fatigue, but fatigue did not predict next-day pain. In across-women and within-woman analyses, psychological distress partially mediated the effects of abdominal pain on fatigue. Symptom management incorporating strategies to decrease both abdominal pain and psychological distress are likely to reduce fatigue. Nursing interventions, such as self-management skills to reduce abdominal pain and psychological distress, may have the added benefit of reducing fatigue in irritable bowel syndrome.

Impact of hypnotic safety on disorders of gut-brain interaction: A pilot study

Functional gastrointestinal disorders, i.e., abdominal conditions without identifiable structural etiologies, are seen frequently in primary care and specialty practices. As subtle physiological processes have been identified as potential contributing factors to these functional disorders, these disorders have been recently relabeled, Disorders of Gut-Brain Interaction (DGBI). Moreover, some of these processes, e.g., sympathetic nervous system activity and inflammation, are being increasingly related to psychosocial factors such as situational stress and histories of trauma, abuse, and neglect. As the activity of the autonomic nervous system (ANS) has been long considered to be a contributory factor for DGBI, the present study utilized a theory-driven model based on the Polyvagal Theory to optimize ANS activity for the promotion of healthy digestive activity. Specifically, a hypnotic intervention to increase neuroception of safety was employed with three female college students diagnosed with functional dyspepsia and irritable bowel syndrome in a single-subject design. This intervention was found to be associated with increases in the experience of safe/warm positive affect and decreases in symptoms of functional dyspepsia and irritable bowel syndrome as well as depression and anxiety. The hypnotic intervention for the promotion of a sense of safety is recommended for the treatment of other functional somatic disorders as well as trauma-related conditions. Potential complications related to individuals with prolonged trauma and attachment issues also are reviewed.

Cytokine Levels and Symptoms Among Women with Irritable Bowel Syndrome: Considering the Role of Hormonal Contraceptive Use

BACKGROUND

Young to middle-aged women are more likely than men to be diagnosed with irritable bowel syndrome (IBS). Immune dysfunction may be present in IBS, however, few studies have tested whether hormonal contraceptive use is linked to inflammatory markers. The purpose of this study was to compare cytokine levels between women (ages 18-45) with and without IBS and with and without hormonal contraceptive use and to examine the relationships of cytokine levels to IBS gastrointestinal (GI) and non-GI symptoms within those using and not using hormonal contraceptives.

METHODS

Seventy-three women with IBS and 47 healthy control women completed questionnaires (demographics, hormonal contraceptive use) and kept a 28-day symptom diary. Fasting plasma and LPS-stimulated pro-inflammatory (IL-1β, IL-6, IL-12p40, IL-12p70, IL-8, and TNF-α) and anti-inflammatory (IL-10) cytokines were assayed.

RESULTS

No differences were found in plasma or stimulated cytokine levels between IBS and control women. Levels of IL-1β (p = 0.04) and TNF-α (p = 0.02) were higher among women who did not use hormonal contraceptives compared to women who used hormonal contraceptives. Among women with IBS, significant correlations were found between daily psychological distress and plasma IL-10, IL-12p70, IL-1β, IL-6, and IL-8 cytokine levels.

CONCLUSIONS

These results suggest that hormonal contraceptive use might reduce IL-1β and TNF-α cytokine levels in women with IBS. The impact of hormonal contraceptive use on innate immune activation among women with IBS requires further research.

An Intervention for Person-Centered Support in Irritable Bowel Syndrome: Development and Pilot Study

Irritable bowel syndrome is a common and often chronic functional bowel disorder that can cause severe disruption of daily functioning in those affected, with subsequent high healthcare utilization and work absenteeism. Nurses represent an underutilized group in the current management of irritable bowel syndrome. The aim of this study was to systematically develop a person-centered support intervention in irritable bowel syndrome and evaluate this in a pilot study. The development followed the revised framework for complex interventions from the Medical Research Council and involved literature reviews and multiprofessional expert groups. The intervention was then tested in a pilot study including 17 patients and evaluated through validated questionnaires measuring irritable bowel syndrome symptom severity, gastrointestinal-specific anxiety, and self-efficacy as well as through interviews. There was a significant improvement in irritable bowel syndrome symptom severity between baseline and follow-up, but not for self-efficacy or gastrointestinal-specific anxiety. The patients' perceptions of participating in the intervention were positive and induced a learning process; they were able to form a supportive relationship with the nurse and their ability to self-manage improved. The promising results from this small pilot study in terms of feasibility, potential efficacy, and the patients' positive feedback make this intervention a suitable candidate for a larger controlled trial.

Relationships of Microbiome Markers With Extraintestinal, Psychological Distress and Gastrointestinal Symptoms, and Quality of Life in Women With Irritable Bowel Syndrome

INTRODUCTION

Altered microbial diversity has been associated with gastrointestinal (GI) symptoms in persons with irritable bowel syndrome (IBS). Less is known about the relationship of microbiome with extraintestinal pain and psychological distress symptoms and quality of life (QOL) in persons with IBS. We aimed to evaluate the relationship of fecal microbiota to GI symptoms, stool consistency, psychological distress, extraintestinal pain, and QOL in participants meeting Rome III criteria for IBS.

METHODS

Seventy-six women completed a 28-day diary that included GI, stool consistency, psychological distress, and extraintestinal pain ratings. Participants completed the IBS-Specific Quality of Life questionnaire. Stool samples were collected and analyzed by 16S rRNA gene sequencing. Principal component analysis was performed and the first 2 components (PC1, PC2) were used to test relationships among bacterial families and clinical measures.

RESULTS

Participants were categorized as IBS constipation (n=22), IBS diarrhea (n=39), IBS mixed (n=13), and IBS unsubtyped (n=2). There was a significant group effect for the Firmicutes to Bacteroidetes ratio and PC1. Lower microbial diversity and richness were associated with increased urgency and extraintestinal pain, worse QOL, and looser stools. Lower extraintestinal pain was associated with increased Rikenellaceae, Christensenellaceae, Dehalobabacteriaceae, Oscillospiraceae, Mogibacteriaceae, Ruminococcaceae, Sutterellaceae, Desulfovibrionaceae, and Erysipelotrichaceae abundances. QOL was positively associated with many of these same bacterial families. Higher Firmicutes to Bacteroidetes ratio was positively associated with loose stools. There were no statistically significant relationships between daily psychological distress or abdominal pain and bacterial families.

CONCLUSIONS

Stool microbial diversity and composition are linked to daily extraintestinal symptoms, stool consistency, and QOL in women with IBS.

Associations Between Colonic Motor Patterns and Autonomic Nervous System Activity Assessed by High-Resolution Manometry and Concurrent Heart Rate Variability

Abnormal colonic motility may be associated with dysfunction of the autonomic nervous system (ANS). Our aim was to evaluate if associations between colonic motor patterns and autonomic neural activity could be demonstrated by assessing changes in heart rate variability (HRV) in healthy volunteers. A total of 145 colonic motor patterns were assessed in 11 healthy volunteers by High-Resolution Colonic Manometry (HRCM) using an 84-channel water-perfused catheter. Motor patterns were evoked by balloon distention, a meal and luminal bisacodyl. The electrocardiogram (ECG) and cardiac impedance were assessed during colonic manometry. Respiratory sinus arrhythmia (RSA) and root mean square of successive differences of beat-to-beat intervals (RMSSD) served as measures of parasympathetic reactivity while the Baevsky's Stress Index (SI) and the pre-ejection period (PEP) were used as measures of sympathetic reactivity. Taking all motor patterns into account, our data show that colonic motor patterns are accompanied by increased parasympathetic activity and decreased sympathetic activity that may occur without eliciting a significant change in heart rate. Motor Complexes (more than one motor pattern occurring in close proximity), High-Amplitude Propagating Pressure Waves followed by Simultaneous Pressure Waves (HAPW-SPWs) and HAPWs without SPWs are all associated with an increase in RSA and a decrease in SI. Hence RSA and SI may best reflect autonomic activity in the colon during these motor patterns as compared to RMSSD and PEP. SI and PEP do not measure identical sympathetic reactivity. The SPW, which is a very low amplitude pressure wave, did not significantly change the autonomic measures employed here. In conclusion, colonic motor patterns are associated with activity in the ANS which is reflected in autonomic measures of heart rate variability. These autonomic measures may serve as proxies for autonomic neural dysfunction in patients with colonic dysmotility.

Effects of a comprehensive self-management intervention on extraintestinal symptoms among patients with IBS

OBJECTIVE

Adults with irritable bowel syndrome (IBS) often report extraintestinal pain, fatigue, and sleep disturbances in addition to abdominal pain. Few interventions have sought to reduce these extraintestinal symptoms within the IBS population. To address this, we compared the effects of a comprehensive self-management (CSM) intervention to a control intervention (usual care) on extraintestinal pain, fatigue, and sleep disturbances among patients with IBS.

METHOD

Data were obtained from 243 IBS patients participating in two CSM intervention trials. Daily symptom diaries were collected at baseline, 3 and 6 months post-randomization. Daily symptoms of headache, backache, muscle pain, joint pain, fatigue, sleepiness during the day, sleep quality, and refreshed by sleep were analyzed. Analysis of covariance was used to determine the effects of the intervention on each symptom at 3 and 6 months controlling for 'study' and baseline symptom levels.

RESULTS

Patients in the CSM intervention group reported decreased symptoms of fatigue, sleep disturbances, backache and headache compared to usual care at 3 and 6 months. The CSM group also reported significantly decreased joint pain at 3 months compared to usual care, but not 6 months. No significant difference was found for muscle pain.

CONCLUSIONS

An existing CSM intervention is effective in reducing fatigue and sleep disturbances. However, mixed results for extraintestinal pain indicates a need to better differentiate between underlying mechanisms. Addressing such symptoms is important to decrease the overall burden of IBS, reduce health care expenditures, and improve patients' quality of life.

TRIAL REGISTRATION

NCT00907790; NCT00167635.

Symptom-based latent classes of persons with irritable bowel syndrome

A large amount of interindividual variability exists in symptom experiences of persons with irritable bowel syndrome (IBS). Thus, consideration of multiple symptoms to identify distinct symptom subgroups may be useful in directing personalized health strategies for symptom management. We aimed to identify latent classes (i.e., subgroups) of persons with IBS who share similar patterns of symptoms using symptom-related variables (six groups of daily diary symptoms, cognitive beliefs about IBS, and IBS quality of life [QOL]); and to examine how subgroups differed in patient characteristics. Data were derived from a baseline assessment of men and women enrolled in two cognitively-focused intervention trials (N = 332). Using latent class analysis, four latent classes were identified: Class 1 (low symptoms and good QOL, n = 153), Class 2 (low symptoms and moderate QOL, n = 106), Class 3 (high symptoms with diarrhea and poor QOL, n = 38), and Class 4 (high symptoms with low diarrhea and moderate QOL, n = 35). Diarrhea, being female, less formal education, unemployment, and previous history of major depressive disorder were associated with membership in Class 3. Using these distinct symptom profiles, the next step is to explore underlying mechanisms accounting for symptom burden with the goal of designing tailored interventions to reduce that burden.

Association of Fatigue With TPH2 Genetic Polymorphisms in Women With Irritable Bowel Syndrome

Fatigue is the most common extraintestinal symptom in women with irritable bowel syndrome (IBS). Genetic polymorphisms of monoamines are associated with fatigue in many chronic diseases. In this pilot exploratory study, the primary aim was to determine whether genetic polymorphisms of tryptophan hydroxylase ( TPH1/TPH2), serotonin reuptake transporter ( SERT), or catechol-O-methyltransferase ( COMT) are associated with fatigue in women with IBS. Additionally, analysis explored whether these genetic associations with fatigue would be present when controlling for abdominal pain, psychological distress, feeling stressed, and sleepiness during the day. Secondary analysis of two randomized controlled trial baseline data sets in Caucasian women with IBS ( N = 185) was conducted. Participants kept a daily diary with one dimension (i.e., severity) for each of the 26 symptoms, including fatigue, for 28 days prior to randomization. DNA samples were tested for single-nucleotide polymorphisms (SNPs) of TPH1 (four SNPs) /TPH2 (one SNP), SERT (one SNP), and COMT (one SNP). Analysis of covariance was used to examine associations of percentage of diary days with moderate to very severe symptoms with genetic polymorphisms. Only one SNP, TPH2 rs4570625, was significantly associated with fatigue ( p = .005). T-allele (low functional) carriers of TPH2 (i.e., G/T or T/T genotypes) reported a greater percentage of days with moderate to very severe fatigue than G/G homozygotes ( p = .001). Reduced synthesis of tryptophan in the central nervous system may contribute to reports of fatigue in women with IBS. Understanding genetic risk factors for fatigue may elucidate preemptive strategies to reduce fatigue in individuals with IBS.

Pressure management as an occupational stress risk factor in irritable bowel syndrome: A cross-sectional study

Irritable Bowel Syndrome (IBS) is the most prevalent functional gastrointestinal disorder. Psychosocial stress is one of the pathogenic factors involved in the pathogenesis of IBS. The Pressure Management Indicator (PMI) is a validated questionnaire to analyze all aspects of occupational stress-a model involving sources of pressure, the mechanisms of coping, the personality, and the resulting effects of the interaction between these 3 elements. The purpose of this study was to analyze the association between socio-professional stress effects in IBS, and the relationship of IL-6 levels and salivary cortisol with occupational stress.We conducted a prospective cross-sectional study on 76 patients (39 patients with IBS, diagnosed according to the Rome III criteria and 37 healthy controls) who were investigated using a validated self-administered questionnaire: PMI. The biologic markers of chronic stress were analyzed using salivary cortisol and the immune response with serum interleukin 6 (IL-6).The IBS patients corresponded to the following subtypes: diarrhea-predominant: 22, constipation-predominant: 14 and mixed: 3. All the socio-professional pressure effects variables and scales were statistically significant, in an inversely proportional relation with IBS. Lower scores (poor effects) were found in IBS subjects. The adjusted odds ratios of having IBS versus healthy subjects for the socio-professional pressure effects scales were: 0.81 (95% confidence interval (CI) 0.72-0.88), for satisfaction, 0.85 (95% CI 0.78-0.91) for organization, 0.85 (95% CI 0.79-0.91) for mental wellbeing and 0.8 (95% CI 0.71-0.87) for physical wellbeing (P <.001). Also, the serum IL-6 levels were significantly higher in IBS than in controls (p < 0.001). There was no statistical difference between the salivary levels of cortisol between IBS patients and controls (P = .898).The level of occupational stress was higher in IBS patients compared to healthy subjects (socio-professional stress effects were lower in IBS patients) and correlated with IL-6 levels. Salivary cortisol was not associated with occupational pressure management.

Neuroimmunophysiology of the gut: advances and emerging concepts focusing on the epithelium

The epithelial lining of the gastrointestinal tract serves as the interface for digestion and absorption of nutrients and water and as a defensive barrier. The defensive functions of the intestinal epithelium are remarkable considering that the gut lumen is home to trillions of resident bacteria, fungi and protozoa (collectively, the intestinal microbiota) that must be prevented from translocation across the epithelial barrier. Imbalances in the relationship between the intestinal microbiota and the host lead to the manifestation of diseases that range from disorders of motility and sensation (IBS) and intestinal inflammation (IBD) to behavioural and metabolic disorders, including autism and obesity. The latest discoveries shed light on the sophisticated intracellular, intercellular and interkingdom signalling mechanisms of host defence that involve epithelial and enteroendocrine cells, the enteric nervous system and the immune system. Together, they maintain homeostasis by integrating luminal signals, including those derived from the microbiota, to regulate the physiology of the gastrointestinal tract in health and disease. Therapeutic strategies are being developed that target these signalling systems to improve the resilience of the gut and treat the symptoms of gastrointestinal disease.

Effects of Self-Management Interventions in Patients With Irritable Bowel Syndrome: Systematic Review

Irritable bowel syndrome (IBS) is a prevalent and costly condition, with expenditures exceeding US$21 billion annually. As there is no known cure for IBS, treatment is focused on symptom self-management strategies. The purpose of this systematic review was to investigate the efficacy and overall effect of self-management interventions for patients with IBS. Of the 64 publications that were identified, 20 were included in the systematic review. Self-management interventions were found in diverse formats, including web-based, self-training booklets, individual and/or group interventions with health care providers, and cognitive-behavioral therapy or exercise-based interventions. Different symptom measures were used across the studies, whereas measurement of quality of life was more standardized. Overall, there is robust evidence supporting self-management interventions for improving short-term symptom management and improving quality of life, whereas longer term outcomes are variable. Further studies are needed to use standardized symptom measures and tailor interventions for pediatric populations, and tracking longer term outcomes.

Stool and urine trefoil factor 3 levels: associations with symptoms, intestinal permeability, and microbial diversity in irritable bowel syndrome

Previously we showed that urine trefoil factor 3 (TFF3) levels were higher in females with irritable bowel syndrome (IBS) compared to non-IBS females. To assess if TFF3 is associated with symptoms and/or reflect alterations in gastrointestinal permeability and gut microbiota in an IBS population, we correlated stool and urine TFF3 levels with IBS symptoms, intestinal permeability, stool microbial diversity and relative abundance of predominant bacterial families and genera. We also tested the relationship of stool TFF3 to urine TFF3, and compared results based on hormone contraception use. Samples were obtained from 93 females meeting Rome III IBS criteria and completing 4-week symptom diaries. TFF3 levels were measured by ELISA. Permeability was assessed with the urine lactulose/mannitol (L/M) ratio. Stool microbiota was assessed using 16S rRNA. Stool TFF3, but not urine TFF3, was associated positively with diarrhoea and loose stool consistency. Higher stool TFF3 was also associated with lower L/M ratio and microbial diversity. Of the 20 most abundant bacterial families Mogibacteriaceae and Christensenellaceae were inversely related to stool TFF3, with only Christensenellaceae remaining significant after multiple comparison adjustment. There were no significant relationships between stool or urine TFF3 levels and other symptoms, nor between stool and urine levels. In premenopausal females, urine TFF3 levels were higher in those reporting hormone contraception. Collectively these results suggest that higher stool TFF3 levels are associated with IBS symptoms (loose/diarrhoeal stools), lower gut permeability, and altered stool bacteria composition (decreased diversity and decreased Christensenellaceae), which further suggests that TFF3 may be an important marker of host-bacteria interaction.

Effects of Cognitive Behavior Therapy on Heart Rate Variability in Young Females with Constipation-predominant Irritable Bowel Syndrome: A Parallel-group Trial

Background/Aims

The relation between heart rate variability (HRV) as non-invasive biomarkers of autonomic function and cognitive behavior therapy (CBT) as non-pharmacological treatments has rarely been examined in patients with constipation-predominant irritable bowel syndrome (IBS-C). The purpose of this study is to evaluate the efficacy of an 8-week CBT intervention on HRV and IBS symptoms, and the correlation of changes in HRV with changes in IBS symptoms among young female nursing students with IBS-C.

Methods

This study consisted of an exploratory subgroup analysis of 43 participants with IBS-C who had been randomly assigned to receive either 8 weeks of CBT (n = 23) or general medical information (control, n = 20). At baseline and 8, 16, and 24 weeks, participants completed a questionnaire assessing their gastrointestinal (GI) symptoms, anxiety, depression, and stress, and their HRV was measured via electrocardiography.

Results

At the 8-week follow-up, the high-frequency (HF) power was significantly higher, and the low-frequency (LF)/HF ratio was lower in the CBT group than in the control group (P < 0.001 for both), and the severity of GI symptoms (P = 0.003), anxiety (P < 0.001), depression (P < 0.001), and stress (P < 0.001) was significantly lower in the CBT group than in the control group. Changes in the HF power were significantly and inversely associated with changes in GI symptoms, anxiety, depression, and stress at 16 and 24 weeks (P < 0.05 for all; range of r from -0.37 to -0.68). Changes in the LF/HF ratio were also significantly and positively associated with changes in GI symptoms, anxiety, depression, and stress at 16 and 24 weeks (P < 0.05 for all; range of r from 0.38 to 0.60).

Conclusions

CBT was effective in managing symptoms in young IBS-C patients and the improvement of symptoms was sustained at 24 weeks following the completion of CBT. Furthermore, indirect measurement of autonomic function using HRV may be a useful objective parameter for assessing response to CBT in young IBS-C patients.

COMT Val158Met Polymorphism and Symptom Improvement Following a Cognitively Focused Intervention for Irritable Bowel Syndrome

BACKGROUND

Our nurse-delivered comprehensive self-management (CSM) program, a cognitive behavioral therapy intervention, is effective in reducing gastrointestinal and psychological distress symptoms in patients with irritable bowel syndrome (IBS). Findings from non-IBS studies indicate that the catechol-O-methyltransferase (COMT) Val158Met polymorphism may moderate the efficacy of cognitive behavioral therapy. It is unknown whether this COMT polymorphism is associated with symptom improvements in patients with IBS.

OBJECTIVE

We tested whether this COMT Val158Met polymorphism influences the efficacy of our 2-month CSM intervention.

METHODS

We analyzed data from two published randomized controlled trials of CSM. The combined European American sample included 149 women and 23 men with IBS (CSM, n = 111; usual care [UC], n = 61). The primary outcomes were daily reports of abdominal pain, depression, anxiety, and feeling stressed measured 3 and 6 months after randomization. Secondary outcomes were additional daily symptoms, retrospective psychological distress, IBS quality of life, and cognitive beliefs about IBS. The interaction between COMT Val158Met polymorphism and treatment group (CSM vs. UC) in a generalized estimating equation model tested the main objective.

RESULTS

At 3 months, participants with at least one Val allele benefited more from CSM than did those with the Met/Met genotype (p = .01 for anxiety and feeling stressed, and p < .16 for abdominal pain and depression). The moderating effect of genotype was weaker at 6 months.

DISCUSSION

Persons with at least one Val allele may benefit more from CSM than those homozygous for the Met allele. Future studies with larger and more racially diverse samples are needed to confirm these findings.

RCT REGISTRATION

Parent studies were registered at ClinicalTrials.gov (NCT00167635 and NCT00907790).

DC Electroacupuncture Effects on Scars and Sutures of a Patient with Postconcussion Pain

Introduction: This case study offers a detailed comparative analysis of the effects of direct-current electroacupuncture (DC-EA) on the autonomic nervous system (ANS), when DC-EA was applied to the cranial sutures and scars of a patient with a history of ischemic stroke and postconcussion syndrome (PCS) pain.

Case: A 56-year-old female suffering from severe tremors and debilitating headaches requested acupuncture after conventional biomedicines failed to relieve her symptoms. Evaluations were performed to check the status of 27 ANS functions. These detailed evaluations were performed to obtain a baseline status of ANS function on this patient, who had a history of ischemic stroke, PCS, and chronic pain. All evaluations were repeated pre–post her DC-EA treatment.

Results: This patient experienced significant relief from her symptoms after DC-EA treatment. An analysis of this patient's risk for ANS complications showed improvements in four key homeostatic markers post treatment.

Conclusions: The ANS response of a patient with ischemic stroke, PCS, and chronic pain, who received electrical nerve stimulation using DC-EA reflected a measurable improvement in sympathetic tone, along with reductions in pain levels and PCS symptoms. The positive results in this case study could have applications to other pathologies that can be affected by the sympathetic nervous system activation on the body.

Personality traits and emotional patterns in irritable bowel syndrome

The review focuses on those personality traits (neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness), constructs (alexithymia and distressed - Type D personality) and emotional patterns (negative and positive) that are of particular concern in health psychology, with the aim to highlight their potential role on the pathogenesis, onset, symptom clusters, clinical course, and outcome of irritable bowel syndrome (IBS). Personality traits and emotional patterns play key roles in affecting autonomic, immune, inflammatory, and endocrine functions, thus contributing not only to IBS clinical expression and symptomatic burden, but also to disease physiopathology. In this sense, psychological treatments should address those personality traits and emotional features that are constitutive of, and integral to IBS. The biopsychosocial model of illness applied to IBS acknowledges the interaction between biological, psychological, environmental, and social factors in relation to pain and functional disability. A holistic approach to IBS should take into account the heterogeneous nature of the disorder, and differentiate treatments for different types of IBS, also considering the marked individual differences in prevalent personality traits and emotional patterns. Beyond medications, and lifestyle/dietary interventions, psychological and educational treatments may provide the optimal chance of addressing clinical symptoms, comorbid conditions, and quality of life in IBS patients.