The effects of azathioprine on birth outcomes in women with inflammatory bowel disease (IBD)

AIM

To investigate the effects of azathioprine/6-mercaptopurine (AZA/6-MP) on birth outcomes in women with inflammatory bowel disease (IBD).

METHODS

Details of pregnant women with IBD were obtained through an ObstetriX Database in 3 major teaching hospitals in Sydney from 1996 to 2006. Medical records were reviewed. Birth outcomes of interest were single live births, low birth weight (LBW) at term (<2500 g), preterm births (<37 weeks gestation), neonatal adverse outcomes, and congenital anomaly. Placental blood flow during third trimester of pregnancy was measured using arterial Doppler ultrasonography, where available.

RESULTS

All women had IBD diagnosed before pregnancy. 19 births were exposed to AZA/6-MP. 74 births that were never exposed to AZA/6-MP were selected as controls. Preterm birth was seen in 26.3% of the exposed group as compared to 13.5% of controls (p<0.001). However, in univariate analysis, preterm birth was not associated with AZA/6-MP (OR=2.28; CI: 0.67-7.73). There was 1 neonatal adverse outcome in the exposed group as compared to 4 in controls (5.3% vs 5.4%, p=0.97). One congenital anomaly was seen in each group (p=0.27). No LBW at term was seen in either group. Placental blood flow in 4 women exposed to AZA/6-MP was normal.

CONCLUSION

The use of AZA/6-MP during pregnancy in IBD women was not associated with an increased risk of preterm birth, LBW at term, neonatal adverse outcomes and congenital anomalies.

Efficacy of a Chinese Herbal Medicine in Providing Adequate Relief of Constipation-predominant Irritable Bowel Syndrome: A Randomized Controlled Trial

BACKGROUND & AIMS

Irritable bowel syndrome (IBS) is the most common chronic functional bowel disorder, with few treatment options. IBS affects 10%-20% of the population; as many as 58% of patients have constipation-predominant IBS (IBS-C). We evaluated efficacy and safety of a standardized, specifically formulated Chinese herbal medicine (CHM) preparation in treatment of patients with IBS-C.

METHODS

We performed a double-blind trial of 125 patients with IBS-C (according to Rome III criteria), who were recruited from 13 medical centers or clinics in Australia from July 2009 through February 2012. Patients were randomly assigned to groups given a standardized extract of 7 selected CHM ingredients (n = 61) or placebo (controls, n = 64) for 8 weeks (5 capsules, twice daily). Subjects were then followed for 16 weeks. Chemical definition, standardization, and stability testing of the formulation were completed. Subjects completed a self-administered, validated binary questionnaire of global symptom improvement at weeks 2, 4, 8, and 16 (primary outcome). Secondary outcomes included results from the self-administered IBS Symptom Severity Scale and the Bristol Stool Form Scale (BSFS), which were completed at weeks 4, 8, and 16.

RESULTS

There was statistically and clinically significant (per protocol analyses) improvement among subjects who received CHM (n = 50) vs controls (n = 58) for 8 weeks. A greater proportion of subjects receiving CHM reported adequate relief (P = .010). Compared with controls, the CHM group had improved bowel habits vs controls at week 8, including lower IBS Symptom Severity Scale scores (P < .001), reduced straining during defecation (P = .002), and a significant decrease in hard lumpy stools (P = .031). The CHM group also had increased stool consistency, which was based on the Bristol Stool Form Scale (week 8, P < .001). There was no statistically significant difference between groups in abdominal pain at week 8 (P = .692). The CHM was well-tolerated.

CONCLUSIONS

In a prospective, controlled study, CHM reduced symptoms of IBS-C, increased bowel satisfaction and stool consistency, and reduced straining and hard lumpy stools, compared with placebo. Clinical trial registration no: ACTRN12609000558224.

Epidemiology of inflammatory bowel disease in South America: A systematic review

BACKGROUND

The worldwide epidemiology of inflammatory bowel disease (IBD) is rapidly changing. Increasing Crohn’s disease (CD) and ulcerative colitis (UC) incidence and prevalence have been recorded in developing regions such as Asia, Africa and Eastern Europe where it was previously thought to be uncommon. Whether this is also the case in South America is not well known. Demonstration that developing regions worldwide have increasing IBD incidence would indicate that environmental change plays a significant role in the development of IBD.

AIM

To report the incidence, prevalence and disease characteristics of CD and UC within the South American continent.

METHODS

A systematic review was conducted by searching published studies in major international and regional databases (MEDLINE, EMBASE and Scopus) between January 1990 and December 2018. Outcomes considered were incidence, prevalence, phenotype, environmental and genetic factors, ethnicity and gender. A pair of independent reviewers screened and reviewed all identified articles.

RESULTS

One hundred and sixty two citations were initially retrieved with 18 studies included in this systematic review. The majority of included studies were from Brazil (n =13, 72%). The incidence of UC ranged from 4.3-5.3/100000 person-years whilst the incidence of CD ranged from 0.74-3.5/100000 person-years. Prevalence ranged from 15.0-24.1/100000 inhabitants for UC and from 2.4-14.1/100000 inhabitants for CD. The incidence and prevalence of both UC and CD has increased significantly in Brazil over the past 21 years. Pancolitis was the most common disease distribution in patients with UC whilst colonic involvement was the most common distribution in CD. People residing in urban areas were at higher risk of developing both CD and UC.

CONCLUSION

The IBD burden in South America is increasing at a rate possibly even greater than other developing regions around the world. There is a paucity of high-quality epidemiological studies and further robust and representative data are required to further explore modifiable risk factors and disease phenotypes.

Prolonged balloon expulsion is predictive of abdominal distension in bloating

OBJECTIVES

Abdominal bloating and distension are common in patients with constipation. The precise mechanism of abdominal distension remains uncertain. We hypothesized that constipated patients with bloating plus distension exhibit a greater degree of anorectal dysfunction, potentially affecting gas evacuation, than those without distension. Therefore, our aim was to evaluate anorectal function and other clinical features in patients with constipation who exhibit bloating with and without distension.

METHODS

In all, 88 female patients with abdominal bloating and either non-diarrhea irritable bowel syndrome (IBS) or functional constipation were included in the study. The presence or absence of abdominal distension was assessed according to the Rome II questionnaire, and all patients underwent comprehensive clinical assessment and anorectal function studies.

RESULTS

Patients were divided into two groups: abdominal bloating with distension (D; n=53) and abdominal bloating without distension (ND; n=35). D featured a prolonged balloon expulsion time (P=0.005), a higher resting anal sphincter pressure (P=0.002), and a higher maximum anal sphincter squeeze pressure (P=0.015) than ND. They also experienced more bloating (P<0.001), more abdominal pain (P=0.004), harder stools (P=0.01), and more incomplete emptying (P=0.005). In logistic regression modeling, prolonged balloon expulsion time was a significant predictor of abdominal distension (P=0.018).

CONCLUSIONS

This is the first study to show that prolonged balloon expulsion time predicts abdominal distension in patients with bloating and constipation. Hence, ineffective evacuation of gas and stool associated with prolonged balloon expulsion may be an important mechanism underlying abdominal distension.

Relationships between pelvic floor symptoms and function in irritable bowel syndrome

BACKGROUND

Pelvic floor dyssynergia (PFD) within irritable bowel syndrome (IBS) is often overlooked and the relationship between symptoms and physiology is relatively unexplored. Our aims were to determine relationships between clinical features and anorectal function in non-diarrhea predominant IBS (non-D IBS) patients and whether certain clinical or physiological features predict PFD in IBS.

METHODS

Two groups of patients were evaluated. Group I: 32 female non-D IBS patients with >or=2 symptoms suggesting PFD underwent comprehensive symptom and anorectal function assessment. Group II: 32 female non-D IBS patients recruited from the community underwent symptom assessment.

KEY RESULTS

Prevalence of PFD symptoms was similar in both groups. In group I patients, increased frequency of digitation was associated with a longer balloon expulsion time (P = 0.03). Higher scores for anal pain were associated with both a low resting anal pressure (P = 0.04) and a shorter duration of maximum squeeze (P = 0.03). Reduced perineal descent was associated with anxiety (P = 0.03) and depression (P = 0.01). A shorter duration of maximum squeeze was associated with higher parity (P = 0.02) and previous hysterectomy (P = 0.047). Duration of PFD symptoms was higher (P = 0.02) and maximum tolerated volume was lower (P = 0.05) in 22 patients with a physiological diagnosis of PFD compared to 10 without PFD. No symptoms independently predicted a physiological diagnosis of PFD.

CONCLUSIONS & INFERENCES

Important relationships between certain PFD symptoms and disordered anorectal physiology have been demonstrated in these non-D IBS patients. However, symptoms alone could not predict PFD, and certain clinical features should therefore highlight the need for comprehensive anorectal function tests.

Stool characteristics and colonic transit in irritable bowel syndrome: evaluation at two time points

OBJECTIVE

Information on the relationships between stool characteristics and colonic transit time (CTT) in irritable bowel syndrome (IBS) is limited. Our aims were: (i) to relate stool frequency and consistency to total and segmental CTTs, (ii) to correlate changes in these stool characteristics with changes in CTTs between a baseline assessment and a 12-week assessment, and (iii) to examine the confounding effects of mood on these relationships, in patients with IBS.

MATERIALS AND METHODS

Twenty-one female patients with IBS underwent, on two occasions 12 weeks apart, a colonic transit study and completed at these times Bristol Stool Form Scale (BSFS) and Bowel Symptoms Severity Rating Scale (BSSRS). All patients also completed the Hospital Anxiety and Depression scale.

RESULTS

Between baseline and the 12-week assessment, an increase in the number of days over the past week without a bowel motion correlated with prolonged total CTT (r = 0.54, p = 0.01). An increase in the number of days with more than three bowel motions per day correlated with a shorter right CTT (r = -0.52, p = 0.02). Only after adjusting for anxiety and depression, did an increase in loose or watery bowel motions (for BSSRS but not for BSFS) correlate with a shorter right CTT (r = -0.47, p = 0.03).

CONCLUSIONS

Stool frequency, as well as stool consistency, correlates with CTT. Correlations between stool consistency and CTT are more robust for BSSRS than for BSFS. An effect of mood appears to be important in the relationship between stool consistency and CTT.

Altered temporal characteristics of the rectoanal inhibitory reflex in patients with abdominal distension

The rectoanal inhibitory reflex (RAIR) is important in gas and stool evacuation. We examined RAIR features in patients with chronic constipation who exhibited bloating with and without abdominal distension, to determine whether alterations in RAIR may be a factor in the pathogenesis of abdominal distension. Seventy-five female patients with chronic constipation with or without abdominal distension were included in the study. The presence or absence of abdominal distension was assessed according to the Rome II questionnaire. All patients underwent both RAIR and rectal sensitivity testing, and specific RAIR parameters were analyzed. Patients were divided into two groups: abdominal bloating with distension (D, n = 55) and abdominal bloating without distension (ND, n = 20). D had a longer time to the onset of anal sphincter inhibition (latency of inhibition) (P = 0.03) compared with ND. In logistic regression analysis, a combination of age, latency of inhibition and the time measured from onset of inhibition to the point of maximum inhibition predicted abdominal distension (P = 0.002). There were no differences between groups for the time from point of maximum inhibition to recovery and for the percentage of internal anal sphincter relaxation. This is the first study to examine the role of RAIR in patients with abdominal distension. Female patients with constipation and abdominal distension exhibited differences in the temporal characteristics of, but not in the degree of, anal sphincter relaxation compared with patients without distension. Since this study was uncontrolled, further studies are necessary to determine the contribution of altered anorectal reflexes to abdominal distension.

From Protons to Picasso: Recreating Famous Paintings Using Proton Beams as a "Paintbrush"

PURPOSE/OBJECTIVE(S)

To many, medicine is just as much an artform as it is a science. From the colorful stains used in diagnostic pathology, to the tactile sculpting of surgery, to the dose painting in radiation oncology, there is beauty and art to be found across all disciplines. In pencil-beam-scanning proton therapy, the dose is painted layer-by-layer, spot-by-spot, allowing for significantly more control compared to conventional radiation. This work intends to showcase the immense capability of intensity-modulated proton therapy (IMPT) through the recreation of some of the most renowned artworks throughout history, and has potential applications in patient education, medical/physics education, and quality assurance.

MATERIALS/METHODS

Five (5) well-recognized paintings spanning from the Golden Age to the modern era were recreated as treatment plans in the Eclipse (version 16.1) External Beam Planning environment. For each "painting" (treatment plan), clinical protons within the range of 70-250 MeV were used to deposit "paint" (radiation dose) onto a "canvas" (water phantom) to a prescription of 100 Gy. The individual elements of each artwork were first delineated as separate structures. Colors were then assigned to appropriate isodose lines to mimic the corresponding palettes found in the original artworks. For each treatment plan, a single field was used along with inverse optimization to deposit the different doses at a depth of 10 centimeters. The resulting dose distribution was calculated with the proton convolution-superposition algorithm used in clinical practice.

RESULTS

The dose distributions of the "paintings" demonstrated a marked semblance to the original artworks with sufficient resolution to elucidate fine details. The "paintings" varied in dimension from 20-30 cm at isocenter and on average took between 5-6 hours to complete. The number of structures used for planning ranged from 6-65 depending on the style and complexity of the original artwork. For a fractional dose of 200 cGy, the number of monitor units ranged from 73,145-269,970.

CONCLUSION

With the advent of IMPT and modern planning techniques, we can now realize increasingly complex treatment plans, allowing for the creation of dose distributions that are highly targeted and specific. This is demonstrated by the capability to create recognizable works of art using proton beams as a "paintbrush".