Visible abdominal distension in functional gut disorders: Objective evaluation

Abdominal distension; Abdominothoracic imaging; Intestinal gasDistensión abdominal; Imagen abdominotorácica; Gas intestinalDistensió abdominal; Imatge abdominotoràcica; Gas intestinalBackground Visible abdominal distension has been attributed to: (A) distorted perception, (B) intestinal gas accumulation, or (C) abdominophrenic dyssynergia (diaphragmatic push and anterior wall relaxation). Methods A pool of consecutive patients with functional gut disorders and visible abdominal distension included in previous studies (n = 139) was analyzed. Patients (61 functional bloating, 74 constipation-predominant irritable bowel syndrome and 4 with alternating bowel habit) were evaluated twice, under basal conditions and during a self-reported episode of visible abdominal distension; static abdominal CT images were taken in 104 patients, and dynamic EMG recordings of the abdominal walls in 76, with diaphragmatic activity valid for analysis in 35. Key Results (A) Objective evidence of abdominal distension was obtained by tape measure (increase in girth in 138 of 139 patients), by CT imaging (increased abdominal perimeter in 96 of 104 patients) and by abdominal EMG (reduced activity, i.e., relaxation, in 73 of 76 patients). (B) Intestinal gas volume was within ±300 ml from the basal value in 99 patients, and above in 5 patients, who nevertheless exhibited a diaphragmatic descent. (C) Diaphragmatic contraction was detected in 34 of 35 patients by EMG (increased activity) and in 82 of 103 patients by CT (diaphragmatic descent). Conclusions and Inferences In most patients complaining of episodes of visible abdominal distention: (A) the subjective claim is substantiated by objective evidence; (B) an increase in intestinal gas does not justify visible abdominal distention; (C) abdominophrenic dyssynergia is consistently evidenced by dynamic EMG recording, but static CT imaging has less sensitivity.The present study was supported in part by the Spanish Ministry of Science and Innovation (Dirección General de Investigación Científica y Técnica, PID2021-122295OB-I00); Ciberehd is funded by the Instituto de Salud Carlos III. Writing Assistance. American Journal Experts for English editing of the manuscript (Certificate Verification Code; 8696-2A19-A35A-3FAE-6987) funded by SAF 2016-76648-R

Colonic content in health and its relation to functional gut symptoms

This is the peer reviewed version of the following article: Bendezú, R. A., Barba, E., Burri, E., Cisternas, D., Accarino, A., Quiroga, S., Monclus, E., Navazo, I., Malagelada, J.-R. and Azpiroz, F. (2016), Colonic content in health and its relation to functional gut symptoms. Neurogastroenterol. Motil., 28: 849–854, which has been published in final form at [doi:10.1111/nmo.12782]. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-ArchivingGut content may be determinant in the generation of digestive symptoms, particularly in patients with impaired gut function and hypersensitivity. Since the relation of intraluminal gas to symptoms is only partial, we hypothesized that non-gaseous component may play a decisive role. Methods: Abdominal computed tomography scans were evaluated in healthy subjects during fasting and after a meal (n = 15) and in patients with functional gut disorders during basal conditions (when they were feeling well) and during an episode of abdominal distension (n = 15). Colonic content and distribution were measured by an original analysis program. Key results: In healthy subjects both gaseous (87 ± 24 mL) and non-gaseous colonic content (714 ± 34 mL) were uniformly distributed along the colon. In the early postprandial period gas volume increased (by 46 ± 23 mL), but non-gaseous content did not, although a partial caudad displacement from the descending to the pelvic colon was observed. No differences in colonic content were detected between patients and healthy subjects. Symptoms were associated with discrete increments in gas volume. However, no consistent differences in non-gaseous content were detected in patients between asymptomatic periods and during episodes of abdominal distension. Conclusions & inferences: In patients with functional gut disorders, abdominal distension is not related to changes in non-gaseous colonic content. Hence, other factors, such as intestinal hypersensitivity and poor tolerance of small increases in luminal gas may be involved.Peer ReviewedPostprint (author's final draft

Evaluation of abdominal gas by plain abdominal radiographs

Abdominal CT imaging; Abdominal distension; Intestinal gasTAC abdominal; Distensión abdominal; Gas intestinalTAC abdominal; Distensió abdominal; Gas intestinalBackground Our aim was to determine the reliability of plain abdominal radiographs for the evaluation of abdominal gas content in patients with functional digestive symptoms. Methods Abdominal CT scan scout views, mimicking a conventional plain abdominal radiograph, were obtained from 30 patients both during episodes of abdominal distension and basal conditions. Physicians (n = 50) were instructed to rate the estimated volume of gas in the 60 images presented in random sequence using a scale graded from 0 to ≥600 ml. Key Results The gas volumes estimated in the scout views differed from those measured by CT by a median of 90 (95% CI 70–102) ml, and the misestimation was not related to the absolute volume in the image. The accuracy of the observers, measured by their mean misestimation, was not related to their specialty or the training status (misestimation by 96 (95% CI 85–104) ml in staff vs 78 (70–106) ml in residents; p = 0.297). The accuracy was independent of the order of presentation of the images. Gas volume measured by CT in the images obtained during episodes of abdominal distension differed by a median of 39 (95% CI 29–66) ml from those during basal conditions, and this difference was misestimated by a median of 107 (95% CI 94–119) ml. The accuracy of these estimations was not related to the absolute gas volumes (R = −0.352; p < 0.001) or the magnitude of the differences. Conclusions & Inferences Plain abdominal radiographs have limited value for the evaluation of abdominal gas volume in patients with functional gut disorders.This work was supported in part by the Spanish Ministry of Economy and Competitiveness (Dirección General de Investigación Científica y Técnica, grant SAF 2016-76,648-R to F Azpiroz); Ciberehd is funded by the Instituto de Salud Carlos III. Dan M. Livovsky received support from the Israeli Medical Association and from Israeli Gastroenterological Association 2020 fellowship grants

Spontaneous portosystemic shunt embolization in liver transplant recipients with recurrent hepatic encephalopathy

Angiogenesis; Portal hypertension; Collateral vesselsAngiogénesis; Hipertensión portal; Vasos colateralesAngiogènesi; Hipertensió portal; Vasos col·lateralsIntroduction and objectives Spontaneous portosystemic shunts (SPSS) are a common cause of recurrent hepatic encephalopathy (HE). Shunt occlusion is an effective and safe procedure when performed in patients with cirrhosis and preserved liver function. We aimed to describe our experience with SPSS embolization after liver transplantation (LT). Patients We identified five patients who underwent SPSS embolization after LT. Clinical, biochemical and technical procedure data were collected. Results At presentation, all patients had developed graft cirrhosis and HE after LT. Median Model for End-stage Liver Disease (MELD) at embolization was 9 (range 7-12), median Child-Pugh was 8 (range 7-9). Splenorenal and mesocaval shunt were the most frequent types of SPSS found. Three patients have been completely free of HE. Of the two patients who had HE recurrence after embolization, one patient had two episodes of HE which was controlled well with medications. The other patient required three embolizations because of recurrent HE. Median follow-up was 4.4 years (range 1.0-5.0) and MELD score at last follow up was 13 (range 10-18) and median Child-Pugh score B, 7 points (range 5-12). Conclusions SPSS can be considered as a cause of HE after LT. SPSS embolization is feasible and safe in LT recipients.Isabel Campos-Varela's research activity is funded by grant PI19/00330, funded by Instituto de Salud Carlos III and co-funded by European Union (ERDF/ESF) - A way to build Europe. Macarena Simón-Talero is a recipient of the Juan Rodés grant JR17/00029 from Instituto de Salud Carlos III, Spain. CIBERehd is supported by Instituto de Salud Carlos III. The work was independent of all funding

Abdominothoracic mechanisms of functional abdominal distension and correction by biofeedback

BACKGROUND & AIMS: In patients with functional gut disorders, abdominal distension has been associated with descent of the diaphragm and protrusion of the anterior abdominal wall. We investigated mechanisms of abdominal distension in these patients. METHODS: We performed a prospective study of 45 patients (42 women, 24-71 years old) with functional intestinal disorders (27 with irritable bowel syndrome with constipation, 15 with functional bloating, and 3 with irritable bowel syndrome with alternating bowel habits) and discrete episodes of visible abdominal distension. Subjects were assessed by abdominothoracic computed tomography (n = 39) and electromyography (EMG) of the abdominothoracic wall (n = 32) during basal conditions (without abdominal distension) and during episodes of severe abdominal distension. Fifteen patients received a median of 2 sessions (range, 1-3 sessions) of EMG-guided, respiratory-targeted biofeedback treatment; 11 received 1 control session before treatment. RESULTS: Episodes of abdominal distension were associated with diaphragm contraction (19% +/- 3% increase in EMG score and 12 +/- 2 mm descent; P < .001 vs basal values) and intercostal contraction (14% +/- 3% increase in EMG scores and 6 +/- 1 mm increase in thoracic antero-posterior diameter; P < .001 vs basal values). They were also associated with increases in lung volume (501 +/- 93 mL; P < .001 vs basal value) and anterior abdominal wall protrusion (32 +/- 3 mm increase in girth; P < .001 vs basal). Biofeedback treatment, but not control sessions, reduced the activity of the intercostal muscles (by 19% +/- 2%) and the diaphragm (by 18% +/- 4%), activated the internal oblique muscles (by 52% +/- 13%), and reduced girth (by 25 +/- 3 mm) (P <= .009 vs pretreatment for all). CONCLUSIONS: In patients with functional gut disorders, abdominal distension is a behavioral response that involves activity of the abdominothoracic wall. This distension can be reduced with EMG-guided, respiratory-targeted biofeedback therapy.Peer ReviewedPostprint (published version

A comparison of medically serious suicide attempters admitted to intensive care units versus other medically serious suicide attempters

Medically serious suicide attempts (MSSA) represent a subgroup of clinically heterogeneous suicidal behaviours very close to deaths by suicide. A simple definition of an MSSA is a suicide attempt with life-threatening consequences, regardless of the severity of the attempter's mental disorder. Few studies have specifically analysed the heterogeneity of MSSA. Therefore, the aim of this study is to describe the profile of individuals who made a highly severe MSSA and to compare those admitted to Intensive Care Units (ICU) - including Burn Units- with other MSSA admitted to other medical and surgical units. The study sample consisted of 168 patients consecutively admitted to non-psychiatric wards from two public hospitals in Barcelona after an MSSA during a 3-year period. In order to select more severe MSSA, the minimum hospital stay was expanded from Beautrais' definition of ≥ 24 h to ≥ 48 h. Mean hospital stay was 23.68 (SD = 41.14) days. Patients needing ICU treatment (n = 99) were compared to other MSSArs (n = 69) that were admitted to other medical and surgical units, not requiring intensive care treatment, with an initial bivariant analysis followed by a logistic regression analysis using conditional entrance. Medically serious suicide attempters (MSSArs) spent more time hospitalized, more frequently reported recent stressful life events, were more likely to have at least one prior suicide attempt (SA) and their current attempt was more frequently non-planned, compared to the profile of MSSArs reported in previous studies. The most frequent method was medication overdose (67.3%) and jumping from heights (23.2%). Among those who chose more than one method (37.6%), the most frequent combination was medication overdose and drug use. Affective disorders and personality disorders were the most frequent diagnoses. Higher educational level, history of previous mental disorders and prior lifetime suicide attempts were significantly more frequent among those admitted to ICU compared to other MSSArs. Patients needing admission to ICU less frequently used self-poisoning and cuts. MSSA needing ICU admission can be regarded clinically as similar to attempts resulting in suicide. More research on this type of highly severe suicide behaviour is needed due to its serious implications both from a clinical and public health perspective

Characteristics of resident physicians accessing a specialised mental health service: a retrospective study

Adult psychiatry; Medical education & training; Mental healthPsiquiatria d'adults; Educació i formació mèdica; Salut mentalPsiquiatría de adultos; Educación y formación médica; Salud mentalObjectives Little is known about resident physicians being treated at physician health programmes around the world despite the fact that it is a highly demanding training period. This study aims to describe the profiles of resident physicians accessing a specialised mental health service in Spain over a 20-year period and to compare them to consultant-grade physicians. Design Retrospective observational study. Setting Medical records of the Galatea Care Programme for Sick Physicians. Participants 1846 physicians registered at the Barcelona Medical Council-Association and admitted to the programme from January 1998 to December 2018. Primary and secondary outcome measures Number of admissions, sociodemographic and clinical variables, including medical specialty, main diagnosis and need of hospitalisation. Results Residents accounted for 18.1% (n=335) of the sample and admissions increased over the years. Most residents (n=311; 94.5%) and consultant-grade physicians (n=1391; 92.8%) were self-referred. The most common specialty among residents was family medicine (n=107; 31.9%), followed by internal medicine (n=18; 5.4%), paediatrics (n=14; 4.2%), psychiatry (n=13; 3.9%) and anaesthesiology (n=13; 3.9%). Residents, regardless of year of training, mainly asked for help because of adjustment (n=131; 39.1%), affective (n=77; 23%), anxiety disorders (n=40; 18.8%) and addictions (n=19; 5.7%). There were no significant differences between groups in the main diagnosis and in the variables related to need of hospitalisation. The percentage of residents accessing the programme was higher than in the reference population registered at the Barcelona Medical Council-Association (18.1% vs 7.6%; z=7.2, p<0.001) as was the percentage of family medicine residents (31.9% vs 19.6%; z=5.7, p<0.001). Conclusions Residents are more likely than consultant-grade physicians to seek help when suffering from mental disorders. Local primary prevention actions since the beginning of their training period and having access to a well-known highly reliable programme may partly explain these findings

Sleep-disordered breathing, circulating exosomes, and insulin sensitivity in adipocytes

Background: Sleep-disordered-breathing (SDB), which is characterized by chronic intermittent hypoxia (IH) and sleep fragmentation (SF), is a prevalent condition that promotes metabolic dysfunction, particularly among patients suffering from obstructive hypoventilation syndrome (OHS). Exosomes are generated ubiquitously, are readily present in the circulation, and their cargo may exert substantial functional cellular alterations in both physiological and pathological conditions. However, the effects of plasma exosomes on adipocyte metabolism in patients with OHS or in mice subjected to IH or SF mimicking SDB are unclear. Methods: Exosomes from fasting morning plasma samples from obese adults with polysomnographically-confirmed OSA before and after 3 months of adherent CPAP therapy were assayed. In addition, C57BL/6 mice were randomly assigned to (1) sleep control (SC), (2) sleep fragmentation (SF), and (3) intermittent hypoxia (HI) for 6 weeks, and plasma exosomes were isolated. Equivalent exosome amounts were added to differentiated adipocytes in culture, after which insulin sensitivity was assessed using 0 nM and 5 nM insulin-induced pAKT/AKT expression changes by western blotting. Results: When plasma exosomes were co-cultured and internalized by human naive adipocytes, significant reductions emerged in Akt phosphorylation responses to insulin when compared to exosomes obtained after 24 months of adherent CPAP treatment (n = 24; p < 0.001), while no such changes occur in untreated patients (n = 8). In addition, OHS exosomes induced significant increases in adipocyte lipolysis that were attenuated after CPAP, but did not alter pre-adipocyte differentiation. Similarly, exosomes from SF- and IH-exposed mice induced attenuated p-AKT/total AKT responses to exogenous insulin and increased glycerol content in naive murine adipocytes, without altering pre-adipocyte differentiation. Conclusions: Using in vitro adipocyte-based functional reporter assays, alterations in plasma exosomal cargo occur in SDB, and appear to contribute to adipocyte metabolic dysfunction. Further exploration of exosomal miRNA signatures in either human subjects or animal models and their putative organ and cell targets appears warranted

Variables diferenciales de personalidad en los subtipos de TDAH en la edad adulta

Los síntomas del trastorno por déficit de atención con hiperactividad (TDAH) y los rasgos de personalidad se manifiestan de forma relativamente estable y duradera desde la infancia y persisten a lo largo de la vida. El objetivo de este estudio consiste en identificar los rasgos de personalidad diferenciales y discriminativos entre los subtipos clínicos de TDAH en adultos. Se evaluaron las características de personalidad, mediante el Cuestionario de Personalidad de Zuckerman-Kuhlman (ZKPQ) y el Inventario Clínico Multiaxial de Millon-II (MCMI-II), en una muestra de 146 adultos diagnosticados de TDAH. Las dimensiones Activity y Aggression-Hostility del ZKPQ, permitieron clasificar correctamente al 75,8% de los diagnosticados en los subtipos inatento y combinado. Los resultados indican que el TDAH no es una entidad homogénea, sino que existen diferencias significativas en las características de personalidad entre los subtipos clínicos. Se discuten las implicaciones teóricas sobre la conexión entre TDAH y personalidad, y las implicaciones clínicas respecto al diagnóstico y diseño de tratamientos mejor ajustados a las características de cada subtipoAttention Deficit/Hyperactivity Disorder (ADHD) and personality traits are relatively stable from childhood and across life span. The purpose of this study was to identify differential and discriminative personality traits between clinical subtypes of ADHD in adults. The Zuckerman-Kuhlman Personality Questionnaire (ZKPQ) and the Millon Multiaxial Clinical Inventory-II (MCMI-II) were administered to a sample of 146 adults with ADHD. Activity and Aggression-Hostility dimensions from the ZKPQ allowed us to properly classify 75.8% of the inattentive and combined subtypes. Data indicates that ADHD is not a homogeneous entity, but rather, there are significant differences in personality characteristics among clinical subtypes. The results have theoretical implications about the connection between ADHD and personality, and clinical implications regarding diagnosis and treatment designs better tailored to the characteristics of each subtyp

Variables diferenciales de personalidad en los subtipos de TDAH en la edad adulta

Los síntomas del trastorno por déficit de atención con hiperactividad (TDAH) y los rasgos de personalidad se manifiestan de forma relativamente estable y duradera desde la infancia y persisten a lo largo de la vida. El objetivo de este estudio consiste en identificar los rasgos de personalidad diferenciales y discriminativos entre los subtipos clínicos de TDAH en adultos. Se evaluaron las características de personalidad, mediante el Cuestionario de Personalidad de Zuckerman-Kuhlman (ZKPQ) y el Inventario Clínico Multiaxial de Millon-II (MCMI-II), en una muestra de 146 adultos diagnosticados de TDAH. Las dimensiones Activity y Aggression-Hostility del ZKPQ, permitieron clasificar correctamente al 75,8% de los diagnosticados en los subtipos inatento y combinado. Los resultados indican que el TDAH no es una entidad homogénea, sino que existen diferencias significativas en las características de personalidad entre los subtipos clínicos. Se discuten las implicaciones teóricas sobre la conexión entre TDAH y personalidad, y las implicaciones clínicas respecto al diagnóstico y diseño de tratamientos mejor ajustados a las características de cada subtipo