Loss Of Bowel Control Research Articles

11 Is emergency department transfer always required following anaphylaxis and epinephrine use?

Abstract Background Patients known for anaphylaxis are advised to always carry 2 epinephrine auto-injectors (EAI) with them. With epinephrine being the first-line treatment for anaphylaxis, current guidelines recommend prompt EAI administration, followed by observation in the emergency department (ED) for 4 hours. Data supporting transfer to the ED in all cases after epinephrine are sparse. Recent North American allergy guidelines no longer suggest that ED presentation after EAI use is required for all cases of anaphylaxis. Objectives We aimed to describe the need for additional ED treatment in children known for food-triggered anaphylaxis who received at least 1 EAI pre-hospital. Design/Methods Data on children under 18 years with food-induced anaphylaxis who received at least one dose of pre-hospital epinephrine was collected from the Cross-Canada Anaphylaxis REgistry (C-CARE) from seven hospitals. A standardized questionnaire obtained information on symptoms, allergens, comorbidities, and pre-hospital and in-hospital management. Multivariable logistic regression was performed to identify factors associated with ED management, among children who received 1, 2 or 3 or more doses of epinephrine pre-hospital. Results From 2011 to 2023, 1054 children with known food-triggered anaphylaxis and who used one or more EAIs pre-hospital were enrolled in C-CARE. The mean age at reaction was 8.2 (standard deviation [SD] 5.3) years, 648 (60.8%) were male and 82 (7.8%) of reactions were severe (defined as loss of bowel control, cyanosis, respiratory arrest, hypotension and/or circulatory collapse, dysrhythmia, severe bradycardia and/or cardiac arrest, confusion, and loss of consciousness). Primary triggers included peanuts (n=280; 26.6%) followed by tree nuts (n=173; 16.4%). 193 patients (18.3%) had known asthma and 201 received additional dose(s) of epinephrine in the ED, the majority of whom (177, 88.1%) received one dose. Only 2.9% of patients required admission. Among all patients, reactions to egg were less likely to require additional epinephrine (aOR 0.90; 95% CI 0.83, 0.99), and more likely with severe reactions (aOR 1.24; 95% CI 1.14-1.35). Among patients who received only one EAI pre-hospital, severe reactions (adjusted odds ratio [aOR] 1.19; 95% confidence interval [CI] 1.08-1.31) and reactions to tree nuts (aOR 1.12; 95% CI 1.04-1.20) were associated with increased odds of an additional dose of epinephrine in hospital. Conclusion One-fifth of anaphylaxis cases that used EAI require an additional dose of epinephrine in ED. Children with severe reactions and reactions to tree nuts are more likely to require additional doses; these cases should be considered for ED transfer and treatment following pre-hospital EAI use.

P720 Exit interviews exploring Crohn’s disease patients’ experience of changes in their bowel urgency during the mirikizumab Phase 3 clinical trial in adult patients with moderate to severe Crohn disease

Abstract Background The objective of this study was to explore the clinical trial experience of patients with Crohn’s disease (CD), including perceptions of the Urgency Numeric Rating Scale (Urgency NRS) and meaningful within-patient change (MWPC). Methods Qualitative, 90-minute exit interviews were conducted with patients who had moderate to severe CD and completed the VIVID-1 phase 3, multicentre, randomized, double-blind, placebo and active-controlled, mirikizumab clinical trial in the past 3 weeks. The semi-structured interview guide included cognitive debriefing to explore the content validity of the 11-point Urgency NRS (0=No urgency to 10=Worst possible urgency in the past 24 hours). Interview transcripts were analysed using qualitative directed content analysis and framework analysis. Results Interviewed participants (N=62) were from the US (n=29), Czech Republic (n=10), Poland (n=8), Germany (n=7), Canada (n=4), Australia (n=3) and the UK (n=1). Participants (age 22–75 years, 55% female, 53% high school education or lower) were diagnosed with CD for 1–54 years. Most participants understood the Urgency NRS as assessing the severity of feeling an immediate need to go to the bathroom and used it accurately and without difficulty. Participants interpreted the Urgency NRS as ranging from “no urgency” [0] to an “immediate, sudden need or loss of bowel control” [10]. Participants reported that a ‘good day’ or ‘remission’ would feature reduced or no or minimal bowel urgency and permit adequate time to find a bathroom, feature no accidents and allow participation in daily/leisure/social activities and work away from home. Participants considered Urgency NRS scores ≤3 as a ‘good day’ (n=45/59) and ≤2 as ‘remission’ (n=41/57). Most reported that the bowel urgency improvement they experienced was meaningful (n=51/55; Table 1) because it improved their quality of life. A 3-point Urgency NRS improvement was identified as the smallest meaningful change (n=40/54; Table 1). Most participants associated bowel urgency with CD severity when responding to a Patient Global Rating of Severity (PGRS; n=42) and a Patient Global Impression of Change (PGIC; n=32). Most participants related Urgency NRS scores of 0 to None, 2 to Very Mild, 4 to Mild, 6 to Moderate, 8 to Severe and 10 to Very Severe on the PGRS (Figure 1). Urgency NRS improvements of 3-10 points were considered Much better or Very much better on the PGIC (Figure 1). Conclusion The Urgency NRS was well understood and a ≥3-point improvement in Urgency NRS score was considered a MWPC. Participants with CD who had completed the mirikizumab clinical trial perceived a meaningful change in bowel urgency to feature reduced or minimal bowel urgency enabling improved daily functioning.

PP108 Multidimensional Analysis Of Peristeen Plus Medical Device

IntroductionNeurogenic bowel dysfunction occurs in people with central nervous system disease or injury and causes loss of bowel control and severe constipation. These problems involve a lot of anxiety and discomfort and can reduce the quality of life of those who suffer from them, therefore the management of symptoms is very important. Peristeen Plus is a transanal irrigation (TAI) system for bowel dysfunction management, used to empty the rectum and distal sigmoid colon, to prevent uncontrolled bowel movements or to relieve and prevent constipation.MethodsA literature review was conducted. A total of 14 records were included to evaluate the benefits in terms of efficacy and safety associated with the adoption of the medical device. To assess the economic impact, two different budget impact models have been implemented. The first aimed at evaluating an incremental diffusion in a short-term time horizon (3 years) of the home distribution of the device compared to the direct and indirect distribution methods in the Italian context. The second model aimed at assessing the impact of the diffusion of the device in the clinical practice.ResultsOverall, most studies demonstrate improved endpoints related to the severity of fecal incontinence, constipation and intestinal disorders in patients using the device. The economic assessments conducted estimate that the increase in the Italian care setting is associated with a saving of resources in each year under analysis. The diffusion of home distribution of the device would potentially be able to offer a lower absorption of resources compared to other distribution methods. In addition to this, there is an incremental saving correlated to the degree of diffusion of Peristeen Plus.ConclusionsTAI is considered a safe and more effective method than conventional treatments for reducing fecal incontinence, constipation and improving quality of life. The results of our study confirm the benefits of TAI as a second-line treatment in case of failure of conventional medical therapy in the management of the neurogenic gut.

Outcomes of Proton Beam Therapy Compared With Intensity-Modulated Radiation Therapy for Uterine Cancer.

To compare Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) in patients with endometrial cancer receiving adjuvant pelvic radiation therapy with proton beam therapy (PT) versus intensity-modulated radiation therapy (IMRT). Patients with uterine cancer treated with curative intent who received either adjuvant PT or IMRT between 2014 and 2020 were identified. Patients were enrolled into a prospective registry using a gynecologic-specific subset of PRO-CTCAE designed to assess symptom impact on daily living. Questions included gastrointestinal (GI) symptoms of diarrhea, flatulence, bowel incontinence, and constipation in addition to other pertinent gynecologic, urinary, and other general symptoms. Symptom-based questions were on a 0- to 4-point scale, with grade 3+ symptoms occurring frequently or almost always. Patient-reported toxicity was analyzed at baseline, end of treatment (EOT), and at 3, 6, 9, and 12 months after treatment. Unequal variance t tests were used to determine if treatment type was a significant factor in baseline-adjusted PRO-CTCAE. Sixty-seven patients met inclusion criteria. Twenty-two received PT and 45 patients received IMRT. Brachytherapy boost was delivered in 73% of patients. Median external beam dose was 45 Gy for both PT and IMRT (range, 45-58.8 Gy). When comparing PRO-CTCAE, PT was associated with less diarrhea at EOT (P = .01) and at 12 months (P = .24) than IMRT. Loss of bowel control at 12 months was more common in patients receiving IMRT (P = .15). Any patient reporting grade 3+ GI toxicity was noted more frequently with IMRT (31% versus 9%, P = .09). Adjuvant PT is a promising treatment for patients with uterine cancer and may reduce patient-reported GI toxicity as compared with IMRT.

Identification of Physical Problems of Patients with Acute Stroke

Background: Stroke patients experience a variety of physical problems which affect their activitiesof daily life. As there is need for identifying the physical problems of patients with acute stroke in theinitial stage, the present study was undertaken to identify the physical problems of patients with acutestroke. Objectives: the objectives of the study were to identify the physical problems of patients withacute stroke. Methods: This descriptive study was conducted at neurology department of a tertiarycare hospital in Kerala. 60 patients with acute stroke was selected by consecutive sampling technique.Physical problems of stroke patients were identified by standardised tools; National Institute of HealthStroke Scale (NIHSS) and Barthel index. Appropriate descriptive and inferential statistical methods wereused to analyze the data. Results: The major physical problems identified were immobility (81.7%),lower extremity weakness (75%), upper extremity weakness (71.6%), loss of bladder control (66.7%),loss of bowel control (65%), feeding problem (63.3%) and communication problems like dysarthria(55%) and aphasia (53.3%). Conclusion: The study stresses the importance of identification of variousexisting and emerging physical problems encountered by acute stroke patients and the preparation of anursing care protocol, which can be utilized in future, for managing the major physical problems.

The Impact of Inflammatory Bowel Disease in Canada 2018: Quality of Life

Inflammatory bowel disease (IBD) has a substantial impact on quality of life. It causes considerable personal, emotional and social burdens. The impact of IBD on quality of life cannot readily be quantified as a cost; however, the impact places a significant burden on the patient and caregivers. Numerous studies have shown that health-related quality of life is impaired in patients living with IBD as compared with the general population. While disease activity and severity is an important driver of physical and mental health–related quality of life, patients may experience psychological distress even during clinical remission. Reduced quality of life can impact persons living with IBD as they pursue employment, family planning and personal milestones. Further, the impact of IBD extends to the patient influencing the quality of lives of those around them, including their caregivers. Improving quality of life requires a multidisciplinary approach that includes screening for and managing psychological distress. Adaptive coping mechanisms help manage illness perceptions and reduce psychosocial distress.HighlightsHealth-related quality of life (HRQOL) is an important measure of the global impact of IBD on a person’s physical, mental and emotional well-being.Persons living with IBD have significantly lower HRQOL compared with that of the general population.Inflammatory bowel disease often affects individuals as they pursue employment, family building and personal milestones.Inflammatory bowel disease affects the quality of life (QOL) of those afflicted and their caregivers.Access to multidisciplinary, collaborative, chronic disease models of care improves the HRQOL of people living with IBD.Key Summary PointsInflammatory bowel disease impairs HRQOL by inhibiting need fulfillment (i.e., self-esteem, relationships, nutrition, hygiene and security) and causing psychological distress.Inflammatory bowel disease impairs interpersonal relationships, life activities, social participation and mental well-being.Patient symptoms like diarrhea and abdominal pain reduce HRQOL.While disease severity is an important driver of physical and mental HRQOL, patients experience psychological distress even during clinical remission.Psychological distress impairs work productivity and disrupts social activities and relationships.Patients with IBD experience emotional distress relating to factors such as loss of bowel control, impairment of body image, fear of sexual inadequacy, social isolation, fear of dependency, concern about not reaching one’s full potential and fear of stigmatization.Families with children with IBD have impaired QOL as a collective—for example, parental stress from medical factors and child’s perceived stress.Patients’ perception of their illness affects their ability to adjust to a diagnosis of IBD. Adaptive coping mechanisms help manage illness perceptions and reduce psychosocial distress.Biologics are associated with improvement in long-term HRQOL in people with IBD.Patients with IBD should have access to multidisciplinary care, including mental health practitioners, to screen for and manage psychological distress.Gaps in Knowledge and Future DirectionsPatients with IBD experience emotional distress that reduces HRQOL. Clinical tools are necessary to identify the key factors causing psychological distress in patients with IBD.HRQOL is reduced in individuals with IBD and their families. Studies should evaluate the cumulative burden of IBD on HRQOL in patients with IBD and their caregivers.Patient self-perception of their IBD influences their HRQOL. Clinical studies of interventions that improve adaptive coping are needed to reduce psychosocial distress.Multidisciplinary care including a psychologist to screen for and manage psychosocial risk and psychological distress should be evaluated in IBD clinics.

The Heart That Wasn’t Attacked: A Case of Transverse Myelitis

Transverse myelitis is an autoimmune demyelination disease of the spinal cord that can present with a myriad of symptoms ranging from altered sensations, weakness, loss of bowel control and so forth.

Patient and Clinician Reported Acute Toxicity During Preoperative Chemoradiation for Locally Advanced Rectal Cancer

Preoperative pelvic radiation therapy (RT) with concurrent 5-Fluorouracil (FU)-based chemotherapy is the standard of care for patients with locally advanced rectal cancer. Pelvic RT is associated with significant acute toxicities that can adversely impact a patient’s quality of life. As opposed to 3D conformal RT (3DCRT), intensity modulated RT (IMRT) allows for more focal dose delivery, thus sparing normal tissues. We compared clinician reported acute toxicity profiles between patients treated with IMRT and 3DCRT and described patient reported outcomes (PROs) for IMRT patients. We retrospectively reviewed records of 335 consecutive rectal cancer patients treated with preoperative pelvic RT at our institution from 2007–2014. Clinical information, including weekly acute toxicity graded according to the CTCAE v3.0, was collected. Weekly PROs using a 7 or 14-item questionnaire based on the Bowel Problems Scale, and NCI PRO-CTCAE were also collected for 150 patients treated with IMRT from 2009–2014. Symptom frequency, severity and interference with daily activities were reported on a 5-point Likert-type scale between 1-“not at all” and 5-“very frequently” A clinically meaningful PRO score was defined as ≥3. Fisher exact test was used to test for statistical differences. The median age was 56 years (range, 22–93) and 202 (60%) patients were male. The majority of patients had clinical stage T3 (79%) and N+ (79%) disease. Of the 335 patients, 229 (68%) were treated with IMRT and 106 (32%) with 3DCRT. All patients received concurrent 5-FU-based chemotherapy with no significant difference in the median RT dose between the two cohorts. Significantly fewer patients experienced ≥grade 2 diarrhea in the IMRT group compared to the 3DCRT group (11% vs 22%, P = .02). While no grade 3 cystitis or proctitis occurred in either groups, fewer patients experienced grade 2 cystitis in the IMRT group (5% vs 12% 3DCRT, P = .02), and there was a trend towards decreased grade 2 proctitis in the IMRT group (19% vs 28% 3DCRT, P = .06). Of the 150 IMRT patients who completed PROs, a high proportion reported PRO scores ≥3 for diarrhea (65%) and urgency (73%). About half of the patients experienced rectal pain (53%) and tenesmus (49%), with fewer complaining of abdominal cramping (42%), rectal bleeding (34%) and loss of bowel control (30%). In this large cohort of patients undergoing preoperative chemoradiation for locally advanced rectal cancer, compared to the use of 3DCRT, the use of IMRT significantly reduced lower gastrointestinal and genitourinary toxicity during treatment as measured by clinicians. Patient reported outcomes show that lower gastrointestinal toxicity is experienced frequently amongst patients treated with IMRT. Further studies are needed to determine the best method to assess the impact of IMRT on treatment related toxicities.

Symptoms of Multiple Myeloma: Results of Hybrid Concept Elicitation/Cognitive Debriefing Interviews

Aims:Multiple myeloma (MM) is a malignant plasma cell disease that is characterized by clonal proliferation of plasma cells in the bone marrow and the production of excessive amounts of a monoclonal immunoglobulin (usually of the IgG or IgA type or free urinary light chain [paraprotein, M protein, or M-component]). Hallmark symptoms of MM include bone disease, which contributes to pain, and anemia, which manifests itself as tiredness and fatigue. Recently, we developed a new MM Symptom Scale based on a systematic literature review and previously conducted qualitative interviews with MM patients. The instrument presents a set of symptoms and evaluates their frequency and severity over the last seven days. In this study, we conducted one-on-one interviews with third-line plus relapsed or refractory (RR) MM patients to: (1) elicit and confirm key disease symptoms that patients describe in response to MM using open-ended questions; and (2) assess the clarity, understanding, and content validity of the newly-developed draft MM Symptom Scale.Methods:Third-line plus RR MM patients were recruited for one-on-one interviews in San Diego, CA and Fort Lauderdale, FL. All participants had to be adult, symptomatic RR MM patients who had previously been treated with an immunomodulary drug and a proteasome inhibitor. They also had to have evidence of disease progression or be currently on treatment to qualify for the study.The first half of the interview focused on open-ended questions regarding important symptoms that patients had experienced. In the second half of the interview, the MM Symptom Scale was introduced, the patient completed the scale in a think-aloud cognitive-debriefing interview, and each question was evaluated for clarity and understanding.Results:A total of nine patients participated in the hybrid interviews of whom four were female and five were male. The average age of the participants was 61.6 years. The average severity of MM symptoms across the nine participants was 6.2 on a scale of 1-10. The average report of the worst level of pain experienced in the last week was 5.2 on a scale of 1-10. The average report on the worst level of tiredness experienced in the last week was 6.2 on a scale of 1-10. The most frequently-reported symptoms were pain (specifically back pain) and tiredness (100% of participants). Other commonly-reported symptoms include swelling of the extremities, itching, feeling depressed, and diarrhea.During the cognitive-debriefing portion of the interview, most participants did not find difficulty in understanding any of the items. Some symptoms, however, were deemed not particularly relevant for the nine MM patients. For example, all of the nine MM patients believed that the symptoms “loss of bladder control” and “loss of bowel control” did not apply to them. These and other symptoms will be evaluated more closely for potential exclusion from the MM Symptom Scale. Some symptoms – such as neuropathy, sleep difficulty, constipation, and weight gain − were endorsed by at least three patients and will be considered for inclusion in the MM Symptom Scale.Conclusions:Health-related quality of life (HRQoL) in MM patients is characterized largely by the burden of pain and tiredness in addition to a few other key symptoms. These can be reliably and validly quantified using HRQoL instruments. The MM Symptom Scale is currently being refined to provide a standardized way through which clinician investigators can assess the impact of novel treatments on patients’ HRQoL. DisclosuresTrask:Sanofi: Employment. Trivedi:Sanofi: Research Funding. Palsgrove:Sanofi: Research Funding. Jones:Sanofi: Employment. McHorney:Sanofi: Research Funding.

Spinal cord infarction: a rare cause of admission to Internal Medicine Departments but a condition with relevant systemic complications

BACKGROUND Spinal cord infarction is a rare cause of admission to Internal Medicine Departments as it is of infrequent occurrence and it is usually addressed to Neurologic Units. Diagnosis at admission however may be challenging expecially in the elderly because of several co-morbidities and variable presentation. Clinical course is often complicated by autonomic, infective and cardiovascular problems as well as a long stay-in-bed period. Outcome is poor in case of severe motor, autonomic (bladder and bowel) and sensitive impairment at presentation, it’s related to anatomic damage site and extension and it’s worse in case of anterior bilateral infarcts. CLINICAL CASE The authors describe the case of an 81- year-old woman who was admitted to an Internal Medicine Department because of cervical spinal cord infarction. The diagnostic evaluation as well as the management of cardiovascular, infective, rheumatologic and autonomic complications needed skillful internistic competence and a long in-hospital period. MR allowed a correct diagnosis a few hours after presentation, but the pathogenesis was never clearly established. The most invalidating symptoms were loss of bowel control lasting for several weeks during hospitalization and neuropathic pain still present at discharge. As for the outcome, the patient was able to go home after 3 months from admission able to walk with aids, with full bowel and bladder control and no sensitive impairment.

Alteraciones intestinales en pacientes con lesión medular

Loss of bowel control is distressing for persons with a medullary lesion and affects their quality of life. The present study aims to provide an updated review of the topic.Impaired neural control of continence and defecation after a medullary lesion provokes bowel dysfunction, with a high prevalence of two main symptoms: fecal incontinence and constipation. The physiopathology of these disorders is correlated with the neurological characteristics of the lesion, and various physiopathologic patterns have been established that correlate with the clinical manifestations. Evaluation of bowel dysfunction in these patients is normally exclusively clinical and complementary examinations are rarely used, although they seem promising. Treatment is based on establishing a program of evacuation. However, despite correct application, the results can be unsatisfactory and consequently other therapeutic alternatives should be developed.

Chronic fatigue is associated with increased disease-related worries and concerns in inflammatory bowel disease

To investigate the impact of chronic fatigue on disease-related worries in inflammatory bowel disease (IBD) and the potential multicolinearity between subjective questionnaires. Patients in remission or with mild-to-moderate disease activity completed the fatigue questionnaire (FQ), the rating form of IBD patient concerns (RFIPC), the Short-Form 36 (SF-36), and IBD questionnaire (N-IBDQ). In addition, clinical and epidemiological data were obtained. In total, 140 patients were included; of which 92 were diagnosed with ulcerative colitis and 48 with Crohn's disease. The mean age of patients with chronic fatigue was 44.2 years (SD = 15.8) and for non-fatigued patients was 44.7 years (SD = 16.0). Chronic fatigued patients had clinically significantly increased levels of disease-related worries, as measured by Cohen's d effect size. Worries about having an ostomy bag, loss of bowel control, and energy levels were most prominent in both chronic fatigued and non-chronic fatigued IBD patients. Variance inflation factor (VIF) and tolerance indicated that there were no problematic multicolinearity among the FQ, RFIPC, SF-36 and N-IBDQ responses (VIF < 5 and tolerance > 2). Chronic fatigue is associated with increased levels of disease-related worries and concerns in IBD. Increased levels of worries were also associated with impaired health-related quality of life.

Worries and Concerns among Inflammatory Bowel Disease Patients Followed Prospectively over One Year

Disease-related worries are frequently reported in inflammatory bowel disease (IBD), but longitudinal assessments of these worries are scarce. In the present study, patients completed the rating form of IBD patient concerns (RFIPC) at three occasions during one year. One-way analysis of variance (ANO VA), t-tests, bivariate correlation, and linear regression analyses were used to analyse data. The validity and reliability of the Norwegian RFIPC was tested. A total of 140 patients were included (V1), ulcerative colitis (UC) n = 92, Crohn's disease (CD) n = 48, mean age 46.9 and 40.0-year old, respectively. The highest rated worries included having an ostomy bag, loss of bowel control, and reduced energy levels. Symptoms were positively associated with more worries. A pattern of IBD-related worries was consistent over a period of one year. Worries about undergoing surgery or having an ostomy bag seemed to persist even when symptoms improved. The Norwegian RFIPC is valid and reliable.

Osmotic Release Oral System (OROS) Methylphenidate–Induced Double Incontinence

To the Editor: Attention-deficit/hyperactivity disorder (ADHD) is the most prevalent psychiatric disease in children and adolescents, affecting approximately 5% of children worldwide.1 The pathophysiologic profile of ADHD has not been fully characterized, although structural and functional imaging studies consistently suggest dysfunction in fronto-subcortical pathways and imbalances in dopaminergic and noradrenergic systems in the origin of the core symptoms.2 The central nervous system (CNS) stimulants, especially the immediate and long-acting forms of methylphenidate, are the first-line treatments for ADHD. Studies analyzing the effect of methylphenidate on the neuropsychologic performance of adults with ADHD report significant improvements in performance associated with marked therapeutic response.3 The common side effects of CNS stimulants include sleep disturbance, depressed mood, stomachache, tics, and mannerisms. However, no case of concurrence of urinary and fecal incontinence (double incontinence) associated with the administration of osmotic release oral system (OROS) methylphenidate has been reported before. Here, we present a case of a young patient with ADHD who developed simultaneous double incontinence after the use of OROS methylphenidate 36 mg. Case report. An 8-year-old boy was brought to our child and adolescent psychiatric outpatient clinic in August 2007 because of frequent delays in completing schoolwork and difficulty in maintaining attention in class. His academic performance was above average but unstable. His weight was 25 kg and his height was 126 cm. No major physical or mental illness was previously noted. There was no family history of enuresis and encopresis. His motor and language development have followed the normal developmental milestones. He was diagnosed with ADHD according to the DSM-IV criteria. The outcome measure Swanson, Nolan, and Pelham Scale, version IV (SNAP-IV),4 was completed by his mother. The boy took immediate-release methylphenidate 10 mg every morning for the first 2 weeks, which was then switched to OROS methylphenidate 18 mg/d. No overt side effect was reported by his mother. In order to reach the optimal response, the medication was further switched to OROS methylphenidate 36 mg/d for 2 weeks. The patient developed stool incontinence during the use of OROS methylphenidate 36 mg daily. His mother reported that loss of bowel control occurred every day and was frequent during the daytime. It was also reported that this child experienced urinary incontinence almost every day. He was scolded by his mother but continued to take medication because of a marked improvement of his ADHD symptoms as rated on the SNAP-IV. Two weeks later, his mother brought him back to our clinic. Urologic and gastroenterologic consultation did not reveal any abnormal finding. A routine laboratory examination did not suggest any organic cause for the double incontinence. He did not take any other medication during the administration of OROS methylphenidate. The condition of double incontinence completely resolved rapidly after the discontinuation of OROS methylphenidate 36 mg. ADHD is a CNS disorder. Children with ADHD often require additional supervision or a more structured learning environment to keep up with their peers. Although CNS stimulants have been the standard treatment for ADHD, their mechanism of action is still not well understood. It is clear that methylphenidate mainly affects the dopaminergic and norepinephrine systems.5 The brain noradrenergic pathway facilitates neuronal processes promoting behavioral activation, alertness, and attention. Stimulants are associated with loss of appetite, headache, stomachache, and insomnia.6 Though many side effects of stimulants are transient in nature and may resolve without treatment,7 it is prudent to monitor side effects that do not compromise the patient's health or cause discomfort that interferes with functioning. The bladder is vulnerable to the adverse effects of drugs because of its complex control and the frequent excretion of drug metabolites in the urine. Incontinence results when bladder pressure exceeds sphincter resistance.8 The Adverse Drug Reaction Probability score9 in this patient was 7, denoting a probable adverse reaction caused by OROS methylphenidate 36 mg. Because of ethical considerations, this patient did not undergo rechallenge with OROS methylphenidate. The pathophysiology of the side effects he encountered is likely to be derived from certain actions on central mechanism and increased vulnerability to the sympathomimetic effects of a stimulant drug. Adrenergic blockade effect is suggested to cause fecal incontinence by decreasing the tonus of the internal anal sphincter10 and urinary incontinence by decreasing the tonus of the internal urethral sphincter.11 The antagonist effect of OROS methylphenidate on the α1 receptors of the internal anal sphincter may cause fecal incontinence, and the effect on the internal bladder sphincter may cause urinary incontinence. To our knowledge, this is the first case report of double incontinence observed during the treatment of ADHD with OROS methylphenidate 36 mg. This phenomenon had rapid remission after discontinuation of the drug. It is likely that individual patient characteristics contribute to the possibility of such an adverse event. The causality in this case might be dose-related, and careful monitoring is highly suggested.

A 48-Year-Old Man With Paralysis and Hypotension

A 48-year-old man presented to the emergency department with acute paralysis from the umbilicus down. The patient was watching television and drinking beer with friends when he developed the sudden onset of bilateral lower extremity paralysis associated with loss of bowel control. The patient denied any trauma, chest pain, abdominal pain, or syncope. His medical history was significant for hypertension, tobacco abuse, posttraumatic stress disorder, and depression with suicide attempts. He had no history of surgery.

Loss of Bowel Control in a Field Hockey Player

HISTORY: A 19-year-old female college field hockey player presented to the sports medicine clinic at the beginning of the fall semester with progressively worsening low back pain with radiculopathy. She was treated with IM Toradol and started on prednisone, Percocet and ibuprofen. Five days later, while awaiting neurosurgical evaluation, she received an epidural steroid injection that provided significant relief. Three days later she was hospitalized for intractable pain, and subsequently had acute loss of bowel and bladder control. During the previous spring semester she complained of low back pain and vague radicular symptoms. Over the summer she was diagnosed with L5-S1 disc herniation and underwent two epidural steroid injections prior to her return to school in the fall. PHYSICAL EXAMINATION: Appeared significantly uncomfortable. Antalgic gait. Difficulty weight bearing on right leg. Tenderness midline L3-S1, markedly at L5-S1 and into buttocks. Right lumbar paraspinal muscle spasm. Weak right extensor hallicus longus. Absent right ankle jerk. Positive slump test. DIFFERENTIAL DIAGNOSIS: Cauda equina syndrome due to L5-S1 disc herniation Cauda equina syndrome due to iatrogenic causes (epidural steroid injection) Cauda equina syndrome due to spinal stenosis Cauda equina syndrome due to neoplasm TEST AND RESULTS: Lumbar spine radiographs, AP and lateral: L3-S1 scoliosis 10 degrees. MRI lumbar spine: Moderate-sized L5-S1 disc herniation. CT lumbar spine: Bilateral spondylolysis of L5. Grade I spondylolisthesis of L5 on S1; small osteophyte off posterior superior endplate of S1. FINAL WORKING DIAGNOSIS: Cauda equina syndrome secondary to acute L5-S1 disc herniation and spondylolisthesis. TREATMENT AND OUTCOMES: 1. Emergency L5-S1 decompression with laminectomy and reconstruction with posterior interbody fusion at L5-S1 with radiolucent cages, bone morphogenic protein and posterior pedicle screw fixation. 2. Return of normal neurologic function. 3. Five days after discharge had worsening back pain and syncopal episode. Pulmonary embolism idenitified on CT. Treated with enoxaparin. 4. Discharged home on Coumadin, oxycodone, dexamethasone. 5. Returned to classes 1 month post-op. 6. One week later had shortness of breath. CT arteriogram normal, resolution of prior pulmonary embolism.

Errata

Abstract Although most chapters in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, instruct evaluators to perform impairment ratings by first assigning a diagnosis-based class and then assigning a grade within that class, Chapter 13, The Central and Peripheral Nervous System, continues to use a methodology similar to that of the fifth edition. The latter was criticized for duplicating materials that were presented in other chapters and for producing different ratings, so the revision of Chapter 13 attempts to maintain consistency between this chapter and those that address mental and behavioral disorders, loss of function in upper and lower extremities, loss of bowel control, and bladder and sexual function. A table titled Summary of Chapters Used to Rate Various Neurologic Disorders directs physicians to the relevant chapters (ie, instead of Chapter 13) to consult in rating neurologic disorders; the extensive list of conditions that should be addressed in other chapters includes but is not limited to radiculopathy, plexus injuries and other plexopathies, focal neuropathy, complex regional pain syndrome, visual and vestibular disorders, and a range of primary mood, anxiety, and psychotic disorders. The article comments in detail on sections of this chapter, identifies changes in the sixth edition, and provide guidance regarding use of the new edition, resulting in less duplication and greater consistency.

Psychological considerations in gastrointestinal nursing

Body image changes and psychological adaptation are often associated with patients who have gastrointestinal disease due to the potential alteration to physical appearance through the very nature of the disease process or treatment. This article describes some of the psychological issues highlighted by patients with gastrointestinal disease, including loss of bowel control, withdrawal and concealment. It highlights altered image difficulties and adaptation through the patients' journey and treatment with illustrations from patients' narratives. In doing so, it explores the nurse's role and stresses the necessity for nurses to seek training to become skillful in counselling this group of patients towards exploring and identifying their individual psychological problems.

Total mesenteric excision in the treatment of rectal carcinoma: methods and outcomes

The American Cancer Society estimates that there are approximately 40,000 new cases of rectal cancer in the United States per year, representing 30% of all colorectal cancers.Of these, approximately three-fourths will undergo resection with the intent to cure with a 5-year local recurrence rate of 8.5%, 16.3%, and 28.6% for stage pT1, pT2, and pT3 rectal cancer, respectively [1]. Overall 5-year survival data are only 22–26% for pT3 disease [2–5]. Like colon cancer, the majority of rectal cancers are adenocarcinoma.Achieving adequate resection margins in rectal cancer is more difficult due to the anatomic location of the rectum in the pelvis.Whereas wide margins of resection can be obtained in colon cancer by mobilization of the mesentery, rectal cancer is anchored by the non-mobile mesorectum to the bony pelvis and is closely surrounded by somatic structures such as the hypogastric nerve plexus, the prostate and seminal vesicles in men, and the uterus and vagina in women. The inability to remove tissue en bloc in rectal cancer excision leads to a three-fold more common local recurrence rate for rectal cancer compared to colon cancer [6]. Fortunately rectal adenocarcinomas are well suited for cure by resection based on several of their inherent characteristics.The majority have histologic criteria favorable for resection and rarely does intramural spread occur further than a centimeter from its palpable margin [7].The metastatic routes of rectal cancer are usually limited to the draining lymph nodes and liver.In one study, o5% of patients had distal bone, pulmonary, or cerebral metastase [7].In many ways, rectal cancer behaves as a local rather than a systemic disorder, which makes it more readily cured by surgical methods. The boundaries of the margin of resection that will optimally reduce local recurrence rates, increase patient survival, and minimize co-morbidities are currently debated.The aim of this article is to review the technique of total mesenteric excision (TME) used in conjunction with low anterior resection (LAR) and abdominoperineal resection (APR) of rectal adenocarcinomas.Analysis of the routes of rectal cancer spread will be used to rationalize choices of adequate boundaries of resection to optimize outcomes (i.e. should the lateral borders include the entire mesorectum, what constitutes an adequate distal margin, and how proximal should the lymphovascular structures be divided). Favorable outcomes not only reflect cure of disease and prevention of recurrent disease, but also take into account the prevention of undesired co-morbidities such as anastomotic leaks, compromise of sphincter function, loss of bowel control, and the impairment of bladder and sexual function.

Clinical application of continent anal plug in bedridden patients with intractable diarrhea.

Some patients bedridden from various causes such as stroke or spinal cord injury experience poor control of bowel movement. This causes fecal leakage and diarrhea, increases the risk of perianal excoriation and bed sores, and is a burden on caregivers. To evaluate the efficacy of fecal evacuation and the prevention and treatment of skin complications in intractable diarrhea patients using a new device. A continent anal plug (US Patent No. 5 569 216) comprises an inner balloon surrounded by an outer balloon, both of which are mounted on a silicone tube containing a pair of air passages and an enema fluid inlet. The tube is secured in place in the rectum by the inflatable outer balloon and is designed to drain fecal matter through a thin collapsible hose situated in the anal canal. Thirty-two patients (21 male; median age 61 (range, 28-76) years) were evaluated after fully informed consent. Median duration was 12 (range, 3-37) days. The continent anal plug evacuated efficiently in those patients with loose or watery stools who only required irrigation once daily or not at all. Skin excoriations improved in three to seven days. Minimal leakage was seen around the anus. There was no anorectal mucosal injury noted over 37 days. The continent anal plug is an efficient method of treating patients with loss of bowel control and incontinence because it enables controlled fecal evacuation and helps reduce skin complications without causing anorectal mucosal injury.