The health-related quality of life and economic burden of constipation

Review of structure and bioactivity of the Plantago (Plantaginaceae) polysaccharides

Plantago (Plantaginaceae) is an herbal plant, which is used in folk medicine, functional food, and dietary supplement products. Recent pharmacological and phytochemical studies have shown that polysaccharides isolated from Plantago have multiple medicinal and nutritional benefits, including improve intestinal health, hypoglycemic effect, immunomodulatory effect, etc. These health and pharmacological benefits are of great interest to the public, academia, and biotechnology industries. This paper provides an overview of recent advances in the physicochemical, structural features, and biological effects of Plantago polysaccharides and highlights the similarities and differences of the polysaccharides from different species and in different parts, including leaves, seeds, and husks. The scientific support for its use as a prebiotic is also addressed. The purpose of this review is to provide background as well as useful and up-to-date information for future research and applications of these polysaccharides.

Evolving Evidence Supporting Use of Rectal Irrigation in the Management of Bowel Dysfunction: An Integrative Literature Review

Disorders of bowel function are prevalent, particularly among patients with spinal cord injuries and other neurological disorders. An individual's bowel control significantly impacts quality of life, as predictable bowel function is necessary to actively and independently participate in everyday activities. For many patients with bowel dysfunction, initial lifestyle adjustments and other conservative therapeutic interventions (eg, digital stimulation, oral laxatives, suppositories) are insufficient to reestablish regular bowel function. In addition to these options, rectal irrigation (RI) is a safe and effective method of standard bowel care that has been used for several decades in adults and children suffering from bowel dysfunction associated with neurogenic or functional bowel etiologies. Rectal irrigation is an appropriate option when conservative bowel treatments are inadequate. Unlike surgical options, RI can be initiated or discontinued at any time. This report summarizes the clinical, humanistic, and economic evidence supporting the use of RI in clinical practice, noting features (eg, practical considerations, patient education) that can improve patients' success with RI treatment.

Internet Survey of Japanese Patients With Chronic Constipation: Focus on Correlations Between Sleep Quality, Symptom Severity, and Quality of Life

Background/Aims

Chronic constipation and lifestyle factors can affect sleep quality. We evaluated the relationship between chronic constipation and sleep in the Japanese population.

Methods

This cross-sectional internet-based survey included 3000 subjects with constipation, classified according to sleep status (good/poor). Primary endpoints were Bristol stool form scale (BSFS) score and correlations between sleep disorder criteria of the Pittsburgh Sleep Quality Index (PSQI) and sleep status (good/poor sleep). Secondary endpoints included correlations between quality of life (QOL) and mood, medical, lifestyle, and sleep factors.

Results

The proportion of participants with BSFS category 4 (normal stool) was significantly higher in the good sleep group (P < 0.001). Sleep disturbance (P < 0.05), sleep quality, and duration, use of hypnotic medication, and daytime dysfunction of PSQI (all P < 0.001) significantly correlated with poor sleep. In the poor sleep group, QOL was significantly worse and anxiety and depression levels were significantly higher (all P < 0.001) compared with the good sleep group. Anemia and smoking (both P < 0.05), recent body weight increases, and poor eating habits (all P < 0.001) were significantly higher in the poor sleep group. Male sex, onset associated with change in frequency of stools, sensation of incomplete evacuation for at least 25% of defecations, and manual maneuvers to facilitate at least 25% of defecations correlated with poor sleep.

Conclusions

Subjects with constipation and poor sleep experienced severe symptoms and had poor QOL. These data support the need for a multifocal treatment approach, including lifestyle advice and pharmacotherapy.

Medical Management of Constipation in Elderly Patients: Systematic Review

Background/Aims

Constipation is a common gastrointestinal problem in the elderly. Because of the limitations of life style modifications and the comorbidity, laxative use is also very common. Therefore, this study reviews the latest literature on the effect and safety of laxative in the elderly.

Methods

A systematic review of randomized controlled trials investigating the effectiveness and safety of laxatives for constipation in elderly patients over 65 years old were performed using the following databases PubMed, EMBASE, and the Cochrane Library.

Results

Twenty-three randomized controlled trials were included in this review. Among the selected studies, 9 studies compared laxative with placebo and 5 studies compared laxatives of the same type. Four studies compared different types of laxatives or compared combination agents. Five studies compared novel medications such as prucalopride, lubiprostone, and elobixibat with placebo. Psyllium, calcium polycarbophil, lactulose syrup, lactitol, polyethylene glycol, magnesium hydroxide, stimulant laxative with or without fiber, and other medications were more effective than placebo in elderly constipation patients in short-term. Generally, the frequency and severity of adverse effects of laxative were similar between the arms of studies.

Conclusions

Bulk laxative, osmotic laxative, stimulant laxative with or without fiber, and other medications can be used in elderly patients in short-term within 3 months with reasonable safety. However, the quality of included studies was not high and most of studies was conducted in a small number of patients. Among these laxatives, polyethylene glycol seems to be safe and effective in long-term use of about 6 months in elderly patients.

Imaging modalities for the detection of posterior pelvic floor disorders in women with obstructed defaecation syndrome

BACKGROUND

Obstructed defaecation syndrome (ODS) is difficulty in evacuating stools, requiring straining efforts at defaecation, having the sensation of incomplete evacuation, or the need to manually assist defaecation. This is due to a physical blockage of the faecal stream during defaecation attempts, caused by rectocele, enterocele, intussusception, anismus or pelvic floor descent. Evacuation proctography (EP) is the most common imaging technique for diagnosis of posterior pelvic floor disorders. It has been regarded as the reference standard because of extensive experience, although it has been proven not to have perfect accuracy. Moreover, EP is invasive, embarrassing and uses ionising radiation. Alternative imaging techniques addressing these issues have been developed and assessed for their accuracy. Because of varying results, leading to a lack of consensus, a systematic review and meta-analysis of the literature are required.

OBJECTIVES

To determine the diagnostic test accuracy of EP, dynamic magnetic resonance imaging (MRI) and pelvic floor ultrasound for the detection of posterior pelvic floor disorders in women with ODS, using latent class analysis in the absence of a reference standard, and to assess whether MRI or ultrasound could replace EP. The secondary objective was to investigate differences in diagnostic test accuracy in relation to the use of rectal contrast, evacuation phase, patient position and cut-off values, which could influence test outcome.

SEARCH METHODS

We ran an electronic search on 18 December 2019 in the Cochrane Library, MEDLINE, Embase, SCI, CINAHL and CPCI. Reference list, Google scholar. We also searched WHO ICTRP and clinicaltrials.gov for eligible articles. Two review authors conducted title and abstract screening and full-text assessment, resolving disagreements with a third review author.

SELECTION CRITERIA

Diagnostic test accuracy and cohort studies were eligible for inclusion if they evaluated the test accuracy of EP, and MRI or pelvic floor ultrasound, or both, for the detection of posterior pelvic floor disorders in women with ODS. We excluded case-control studies. If studies partially met the inclusion criteria, we contacted the authors for additional information.

DATA COLLECTION AND ANALYSIS

Two review authors performed data extraction, including study characteristics, 'Risk-of-bias' assessment, sources of heterogeneity and test accuracy results. We excluded studies if test accuracy data could not be retrieved despite all efforts. We performed meta-analysis using Bayesian hierarchical latent class analysis. For the index test to qualify as a replacement test for EP, both sensitivity and specificity should be similar or higher than the historic reference standard (EP), and for a triage test either specificity or sensitivity should be similar or higher. We conducted heterogeneity analysis assessing the effect of different test conditions on test accuracy. We ran sensitivity analyses by excluding studies with high risk of bias, with concerns about applicability, or those published before 2010. We assessed the overall quality of evidence (QoE) according to GRADE.

MAIN RESULTS

Thirty-nine studies covering 2483 participants were included into the meta-analyses. We produced pooled estimates of sensitivity and specificity for all index tests for each target condition. Findings of the sensitivity analyses were consistent with the main analysis. Sensitivity of EP for diagnosis of rectocele was 98% (credible interval (CrI)94%-99%), enterocele 91%(CrI 83%-97%), intussusception 89%(CrI 79%-96%) and pelvic floor descent 98%(CrI 93%-100%); specificity for enterocele was 96%(CrI 93%-99%), intussusception 92%(CrI 86%-97%) and anismus 97%(CrI 94%-99%), all with high QoE. Moderate to low QoE showed a sensitivity for anismus of 80%(CrI 63%-94%), and specificity for rectocele of 78%(CrI 63%-90%) and pelvic floor descent 83%(CrI 59%-96%). Specificity of MRI for diagnosis of rectocele was 90% (CrI 79%-97%), enterocele 99% (CrI 96%-100%) and intussusception 97% (CrI 88%-100%), meeting the criteria for a triage test with high QoE. MRI did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of MRI performed with evacuation phase was higher than without for rectocele (94%, CrI 87%-98%) versus 65%, CrI 52% to 89%, and enterocele (87%, CrI 74%-95% versus 62%, CrI 51%-88%), and sensitivity of MRI without evacuation phase was significantly lower than EP. Specificity of transperineal ultrasound (TPUS) for diagnosis of rectocele was 89% (CrI 81%-96%), enterocele 98% (CrI 95%-100%) and intussusception 96% (CrI 91%-99%); sensitivity for anismus was 92% (CrI 72%-98%), meeting the criteria for a triage test with high QoE. TPUS did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of TPUS performed with rectal contrast was not significantly higher than without for rectocele(92%, CrI 69%-99% versus 81%, CrI 58%-95%), enterocele (90%, CrI 71%-99% versus 67%, CrI 51%-90%) and intussusception (90%, CrI 69%-98% versus 61%, CrI 51%-86%), and was lower than EP. Specificity of endovaginal ultrasound (EVUS) for diagnosis of rectocele was 76% (CrI 54%-93%), enterocele 97% (CrI 80%-99%) and intussusception 93% (CrI 72%-99%); sensitivity for anismus was 84% (CrI 59%-96%), meeting the criteria for a triage test with very low to moderate QoE. EVUS did not meet the criteria to replace EP. Specificity of dynamic anal endosonography (DAE) for diagnosis of rectocele was 88% (CrI 62%-99%), enterocele 97% (CrI 75%-100%) and intussusception 93% (CrI 65%-99%), meeting the criteria for a triage test with very low to moderate QoE. DAE did not meet the criteria to replace EP. Echodefaecography (EDF) had a sensitivity of 89% (CrI 65%-98%) and specificity of 92% (CrI 72%-99%) for intussusception, meeting the criteria to replace EP but with very low QoE. Specificity of EDF for diagnosis of rectocele was 89% (CrI 60%-99%) and for enterocele 97% (CrI 87%-100%); sensitivity for anismus was 87% (CrI 72%-96%), meeting the criteria for a triage test with low to very low QoE.

AUTHORS' CONCLUSIONS

In a population of women with symptoms of ODS, none of the imaging techniques met the criteria to replace EP. MRI and TPUS met the criteria of a triage test, as a positive test confirms diagnosis of rectocele, enterocele and intussusception, and a negative test rules out diagnosis of anismus. An evacuation phase increased sensitivity of MRI. Rectal contrast did not increase sensitivity of TPUS. QoE of EVUS, DAE and EDF was too low to draw conclusions. More well-designed studies are required to define their role in the diagnostic pathway of ODS.

Safety and Efficacy of Intermittent Colonic Exoperistalsis Device to Treat Chronic Constipation: A Prospective Multicentric Clinical Trial

Chronic constipation is associated with various comorbidities and reduced quality of life. Current solutions, either pharmacological or invasive, show limited efficacy. Manual colon-specific massage is a well-established intervention to treat chronic constipation, but it should be applied daily. MOWOOT automatically provides intermittent colonic exo-peristalsis (ICE) treatment like that in manual massage.

Functional Constipation in Older Adults: Prevalence, Clinical Symptoms and Subtypes, Association with Frailty, and Impact on Quality of Life

INTRODUCTION

Functional constipation (FC) is very prevalent in older adults, especially in women, but its relationship with frailty is not fully understood. The aims were to assess FC prevalence, clinical symptoms and subtypes, association with frailty, and impact on quality of life (QoL) in older people.

METHODS

This epidemiological study included 384 individuals aged over 70 years recruited from the community, a hospital, and a nursing home and stratified into robust, pre-frail, and frail groups (Fried criteria). The following criteria were evaluated: frailty, FC (Rome III criteria), stool consistency (Bristol Stool Chart), comorbidities (Charlson), dependency (Barthel), QoL (EQ5D), and clinical and sociodemographic data. Defined by symptom aggregation were 2 main clinical subtypes as follows: slow colonic transit time (CTT) and functional defecation disorder (FDD).

RESULTS

Mean age was 79.11 ± 6.43 years. Overall FC prevalence was 26.8%, higher in women (32.4% women vs. 21.8% men; p = 0.019) and highest in frail patients (41.7% frail vs. 33.9% pre-frail vs. 24.2% robust; p < 0.001). Straining and hard stools (Bristol 1-2) were the most prevalent symptoms (89.3 and 75.7%, respectively). Frailty and benzodiazepine intake were independently associated with FC. Patients with FC obtained poorer QoL scores in the EQ5D (perceived health 66.09 ± 17.8 FC patients vs. 56.4 ± 19.03 non-FC patients; p < 0.05). The FDD subtype became significantly more prevalent as frailty increased (6.5, 25.8, and 67.7% for robust, pre-frail, and frail patients, respectively); the slow CTT subtype was significantly more frequent in robust patients (38.5% robust vs. 30.5% pre-frail vs. 23.1% frail), p = 0.002.

DISCUSSION/CONCLUSION

FC prevalence in older adults was high, especially in women, and was associated with frailty and poor QoL. Clinical subtypes as related to frailty phenotypes reflect specific pathophysiological aspects and should lead to more specific diagnoses and improved treatment.

Capsule and Sprinkle Formulations of Lubiprostone Are Not Biologically Similar in Patients with Functional Constipation

Introduction

Lubiprostone capsules are approved for managing three different chronic constipation conditions. A “sprinkle” formulation may facilitate use in individuals with difficulty swallowing capsules. Our objective was to evaluate the bioequivalence, pharmacokinetics (PK), and bioavailability of lubiprostone sprinkles vs lubiprostone capsules, compared with placebo.

Methods

A 1-week randomized, placebo-controlled, double-blinded, bioequivalence study (study 302) and a single-dose PK and bioavailability crossover study (study 304) were conducted. In study 302, 522 subjects with chronic constipation were randomized to lubiprostone sprinkle 24 μg twice daily (BID), lubiprostone capsule 24 μg BID, or placebo. The primary efficacy endpoint was observed spontaneous bowel movement (SBM) counts (equivalence defined as showing the 90% confidence interval [CI] of the “between-group SBM ratio” to be contained within 0.8–1.25). Study 304 included two cohorts of healthy volunteers randomized to a single 48-μg lubiprostone dose, sprinkle, or capsule (n = 35) or to a single 48-μg sprinkle dose, in fed or fasted state (n = 14).

Results

Both lubiprostone formulations significantly improved SBM count (sprinkle, 4.82 ± 3.66, P = 0.002; capsule, 5.74 ± 3.79, P < 0.0001) vs placebo (3.68 ± 2.16), but equivalent efficacy was not demonstrated, with a 90% CI for the SBM count ratio of 0.69–0.95. Quantifiable PK data on lubiprostone were limited; however, overall exposure to the M3 metabolite was approximately 44% higher with sprinkles vs capsules under fasted conditions (geometric mean ratio 1.441 [90% CI, 1.166, 1.782]), and exposure with the sprinkle formulation was 11% lower in the fed state vs the fasted state (geometric mean ratio 0.888 [90% CI, 0.675, 1.168]). Both formulations were generally well tolerated.

Conclusion

Despite the significant improvement in SBM counts vs placebo, the sprinkle formulation did not demonstrate bioequivalence to the capsule formulation in either pharmacodynamic or PK key parameters.

Trial Registration

Study 302: ClinicalTrials.gov identifier, NCT03097861; https://www.clinicaltrials.gov/ct2/show/NCT03097861; Study 304: ClinicalTrials.gov identifier, NCT03010631; https://www.clinicaltrials.gov/ct2/show/NCT03010631.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01707-9.

Alterations of White Matter Network Properties in Patients With Functional Constipation

Background: The abnormalities in brain function and structure of patients with functional constipation (FC) have been identified using multiple neuroimaging studies and have confirmed the abnormal processing of visceral sensation at the level of the central nervous system (CNS) as an important reason for FC. As an important basis for central information transfer, the role of the white matter (WM) networks in the pathophysiology of FC has not been investigated. This study aimed to explore the topological organization of WM networks in patients with FC and its correlation with clinical variables. Methods and Analysis: In this study, 70 patients with FC and 45 age- and gender-matched healthy subjects (HS) were recruited. Diffusion tensor imaging (DTI) data and clinical variables were acquired from each participant. WM networks were constructed using the deterministic fiber tracking approach, and the global and nodal properties of the WM networks were compared using graph theory analysis between patients with FC and HS. The relationship between the representative nodal characteristics-nodal betweenness and clinical parameters was assessed using partial correlation analysis. Results: Patients with FC showed increased nodal characteristics in the left superior frontal gyrus (orbital part), right middle frontal gyrus (orbital part), and right anterior cingulate and paracingulate (P < 0.05, corrected for false discovery rate) and decreased nodal characteristics in the left caudate and left thalamus (P < 0.05, corrected for false discovery rate) compared with HS. The duration of FC was negatively correlated with the nodal betweenness of the left thalamus (r = -0.354, P = 0.04, corrected for false discovery rate). Conclusion: The results indicated the alternations in WM networks of patients with FC and suggested the abnormal visceral sensation processing in the CNS from the perspective of large-scale brain WM network.

Effect of Bifidobacterium animalis subsp. lactis MN-Gup on constipation and the composition of gut microbiota

Probiotics have been reported to be associated with the alleviation of constipation. The aim of this study was to detect and determine the effect of Bifidobacterium animalis subsp. lactis MN-Gup (MN-Gup) on the alleviation of constipation in BALB/c mice and humans, and to elucidate the mechanisms underlying its effect by measuring changes in the concentration of short-chain fatty acids and the composition of microbes in human faeces. BALB/c mice were given MN-Gup by gavage for 14 days. On the 8th day of this treatment, constipation was induced by the application of diphenoxylate via gavage. The results showed that MN-Gup significantly decreased the first black stool defecation time, and significantly increased black faecal wet weight, black faecal number and the gastric-intestinal transit rate (P<0.05), thereby relieving constipation. In humans, a randomised, double-blind, placebo-controlled trial was performed to investigate the effect of MN-Gup in adults with functional constipation. After 4 weeks of intervention with placebo or MN-Gup yogurt, constipation-related symptoms (including defecation frequency, stool consistency, straining and incomplete feeling during defecation) in the constipated subjects were significantly improved in the two groups, but not different between the groups at the end of the intervention. The concentration of acetate increased significantly in the MN-Gup group compared to the placebo group and before ingestion. Significant changes in the composition of gut microbiota were found after intake of MN-Gup yogurt when compared to placebo. The relative abundances of acetate-producing Bifidobacterium, Ruminoccaceae_UCG-002 and Ruminoccaceae_UCG-005 were significantly increased after intake of MN-Gup yogurt. These results showed that MN-Gup could relieve constipation related to increased acetate-producing Bifidobacterium, Ruminoccaceae_UCG-002 and Ruminoccaceae_UCG-005.

Effects of core strengthening exercise on colon transit time in young adult women

Background/objective

This study investigated the effects of core strengthening exercise (CSE) on colon transit time (CTT) in young adult women.

Methods

Eighty women (mean age 23 years) were enrolled and randomly assigned to participate in a 12-week, instructor-led group CSE program (CSE group [CSEG]; n = 40) or to maintain usual daily activities (control group [CG]; n = 40). 27 participants in the CSEG and 21 participants in the CG completed the study. The CSE program consisted of 60-min sessions, two days a week, for 12 weeks. CTT was measured using a multiple marker technique with a radio-opaque marker. Data were analyzed with a 2-way, repeated measures ANCOVA.

Results

After the 12-week intervention, The CSEG showed significant improvements in trunk flexor power (P = 0.031), peak torque (P = 0.032), and endurance (P = 0.011). The CSEG also showed improvements in the sit-up (P < 0.001) and side-step (P = 0.043) tests compared to the CG. While there was not a significant group difference between the CSEG and CG, left CTT (P = 0.021) and total CTT (P = 0.006) decreased significantly within the CSEG group only.

Conclusion

The 12-week CSE program increased abdominal strength but did not improve CTT compared to the control group. This study also provides preliminary data that CSE may reduce left CTT and total CTT, but additional clinical trials are needed.

The effect of the therapy of "combination 3 methods progression" in patients with neurogenic bowel dysfunction (constipated type): Study protocol for a randomized controlled trial

BACKGROUND

As one of the important manifestations of neurogenic bowel dysfunction, constipation is characterized by high incidence and harmful effects. It has a negative impact on both physical and psychological health of patients. And there are no effective treatment options for this type of disease clinically. Therefore, this study is designed to examine the effect of the therapy of "combination 3 methods progression" in patients with neurogenic bowel dysfunction (constipated type).

METHODS

This is a randomized, controlled, parallel-design clinical trial. A total of 60 patients with neurogenic bowel dysfunction (constipated type) will be randomly assigned to intervention group and control group. The control group will receive 4 weeks of usual rehabilitation care, the intervention group will receive 4 weeks of the therapy of "combination 3 methods progression" in addition to usual rehabilitation care. The primary outcome is the number of spontaneous bowel movement per week. Secondary outcomes are stool characteristics, degree of difficulty in defecation, level of anxiety, level of depression, and level of self-efficacy.

DISCUSSION

The interventions of this protocol have been programmed to alleviate constipation in patients with neurogenic bowel dysfunction. Findings may provide preliminary evidence for clinical efficacy of the therapy of "combination 3 methods progression."

TRIAL REGISTRATION

Chinese Clinical Trial Registry, IDF: ChiCTR2000041463. Registered on December 26, 2020.

A novel digital approach to describe real world outcomes among patients with constipation

Understanding day-to-day variations in symptoms and medication management can be important in describing patient centered outcomes for people with constipation. Patient Generated Health Data (PGHD) from digital devices is a potential solution, but its utility as a tool for describing experiences of people with frequent constipation is unknown. We conducted a virtual, 16-week prospective study of individuals with frequent constipation from an online wellness platform that connects mobile consumer digital devices including wearable monitors capable of passively collecting steps, sleep, and heart rate data. Participants wore a Fitbit monitoring device for the study duration and were administered daily and monthly surveys assessing constipation symptom severity and medication usage. A set of 38 predetermined day-level behavioral activity metrics were computed from minute-level data streams for steps, sleep and heart rate. Mixed effects regression models were used to compare activity metrics between constipation status (irregular or constipated vs. regular day), medication use (medication day vs. non-medication day) and the interaction of medication day with irregular or constipation days, as well as to model likelihood to treat with constipation medications based on daily self-reported symptom severity. Correction for multiple comparisons was performed with the Benjamini-Hochberg procedure for false discovery rate. This study analyzed 1540 enrolled participants with completed daily surveys (mean age 36.6 sd 10.0, 72.8% female, 88.8% Caucasian). Of those, 1293 completed all monthly surveys and 756 had sufficient Fitbit data density for analysis of activity metrics. At a daily-level, 22 of the 38 activity metrics were significantly associated with bowel movement or medication treatment patterns for constipation. Participants were measured to have fewer steps on irregular days compared to regular days (-200 steps, 95% CI [-280, -120]), longer periods of inactivity on constipated days (9.1 min, 95% CI [5.2, 12.9]), reduced total sleep time on irregular and constipated days (-2.4 min, 95% CI [-4.3, -0.4] and -4.0 min, 95% CI [-6.5, -1.4], respectively). Participants reported greater severity of symptoms for bloating, hard stool, difficulty passing, and painful bowel movements on irregular, constipation and medication days compared to regular days with no medication. Interaction analysis of medication days with irregular or constipation days observed small increases in severity compared to non-medication days. Participants were 4.3% (95% CI 3.2, 5.3) more likely to treat with medication on constipated days versus regular. No significant increase in likelihood was observed for irregular days. Daily likelihood to treat increased for each 1-point change in symptom severity of bloating (2.4%, 95% CI [2.0, 2.7]), inability to pass (2.2%, 95% CI [1.4, 3.0]) and incomplete bowel movements (1.3%, 95% CI [0.9, 1.7]). This is the first large scale virtual prospective study describing the association between passively collected PGHD and constipation symptoms and severity at a day-to-day granularity level. Constipation status, irregular or constipated, was associated with a number of activity metrics in steps and sleep, and likelihood to treat with medication increased with increasing severity for a number of constipation symptoms. Given the small magnitude of effect, further research is needed to understand the clinical relevance of these results. PGHD may be useful as a tool for describing real world patient centered experiences for people with constipation.

Factors associated with laxative use in schizophrenia patients treated with second-generation antipsychotics

The aim of this study was to investigate factors associated with concomitant laxative use among schizophrenia patients discharged on second-generation antipsychotics (SGAs) at two large psychiatric hospitals in Taiwan. Patients with schizophrenia who were discharged between 2006 and 2017 and received SGA monotherapy at discharge were included in the analysis. Multivariate logistic regression was used to identify factors associated with regular laxative use at discharge. Multivariate Cox regression was used to determine the effect of laxative use at discharge on time to rehospitalization within one year. The Cochran-Armitage trend test was used to evaluate whether significant time trends existed for rates of laxative use at discharge during the study period. Among patients discharged on SGAs (n = 11,861), 3,336 (28.1%) also received concomitant laxatives. Advanced age and higher antipsychotic or anticholinergic doses were found to be associated with an increase in laxative use. Among SGAs, clozapine was associated with the highest rate of laxative use, followed by zotepine, quetiapine, olanzapine and risperidone. Additionally, risperidone, amisulpride, aripiprazole, paliperidone and ziprasidone were associated with comparable rates of laxative use. In contrast, sulpiride was least associated with laxative use among all SGAs. Regular laxative use at discharge was found to be significantly associated with psychiatric rehospitalization. Also, rate of laxative use at discharge increased significantly during the study period. Laxative use is common in schizophrenia patients treated with SGAs. For clinically significant constipation, switching to an SGA with a lower risk for constipation, and decreasing the doses of SGAs and anticholinergics should be considered.

The effectiveness of acupoint herbal patching for functional constipation: Protocol for a meta-analysis and data mining

BACKGROUND

Functional constipation is a common functional problem of the digestive system that has a negative impact on physical, mental health of patients and quality of life. At present, acupoint herbal patching as an adjuvant therapy is currently undergoing clinical trials in different medical centers. However, no relevant systematic review or meta-analysis has been designed to evaluate the effects of acupoint herbal patching on functional constipation. There is also a lack of systematic evaluation and analysis of acupoints and herbs.

METHODS

We will search the following 8 databases from their inception to November 15, 2020, without language restrictions: the Cochrane Central Register of Controlled Trials, PubMed, Embase, the Web of Science, the Chinese Biomedical Literature Database, the Chinese Scientific Journal Database, the Wan-Fang Database and the China National Knowledge Infrastructure. The primary outcome measures will be clinical effective rate, functional outcomes, and quality of life. Data that meets the inclusion criteria will be extracted and analyzed using RevMan V.5.3 software. Two reviewers will evaluate the studies using the Cochrane Collaboration risk of bias tool. We will use the GRADE approach to assess the overall quality of evidence supporting the primary outcomes. We will also use Spass software (Version19.0) for complex network analysis to explore the potential core prescription of acupoint herbal patching for functional constipation.

RESULTS

This study will analyze the clinical effective rate, functional outcomes, quality of life, improvement of clinical symptoms of functional constipation, and effective prescriptions of acupoint herbal patching for patients with functional constipation.

CONCLUSION

Our findings will provide evidence for the effectiveness and potential treatment prescriptions of acupoint herbal patching for patients with functional constipation.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD 42020193489.

Laxative Use in the Community: A Literature Review

Laxatives are widely available without prescription and, as a consequence, they are commonly used for self-management of constipation by community-dwelling adults. However, it is not clear to what extent laxatives are used. Nor is it clear how laxatives are chosen, how they are used and whether consumers are satisfied with their performance. This review of published literature in the last 30 years shows the prevalence of laxative use in community-dwelling adults varied widely from 1% to 18%. The prevalence of laxative use in adults with any constipation (including both chronic and sporadic constipation) also varied widely from 3% to 59%. Apart from any geographical differences and differences in research methodologies, this wide range of estimated prevalence may be largely attributed to different definitions used for laxatives. This review also shows that laxative choice varies, and healthcare professionals are infrequently involved in selection. Consequently, satisfaction levels with laxatives are reported to be low and this may be because the laxatives chosen may not always be appropriate for the intended use. To improve constipation management in community and primary healthcare settings, further research is required to determine the true prevalence of laxative use and to fully understand laxative utilisation.

Dyssynergic patterns of defecation in constipated adolescents and young adults with anorectal malformations

We aimed to evaluate the etiologies of constipation in patients with anorectal malformations having a good prognosis for bowel control but a high risk of constipation. We included twenty-five patients from the Odense university hospital in Denmark. Patients were subjected to colon transit time examination and high resolution anorectal manometry (HRAM). The median age was 18 (14-24) and 48% (12/25) were females. Fifty-two % (13/25) of patients were diagnosed with constipation. Types of anorectal malformation were perineal fistula (9/25), rectovestibular fistula (8/25), rectourethral bulbar fistula (5/25) and no fistula (3/25). No difference in neither total colon transit time nor segmental colon transit times were found based on the presence of constipation. Only four of the constipated patients fulfilled criteria for dyssynergic defecation with a dyssynergic pattern at HRAM and prolonged colon transit time. A Type I dyssynergic pattern was dominant in constipated patients (7/13). A Dyssynergic defecation pattern was due to isolated contraction of puborectalis muscle in 9 out of 13constipated patients. We found a dyssynergic pattern during attempted defecation in patients with anorectal malformations disregarded the presence of constipation. In the majority of constipated patients an isolated contraction of the puborectalis muscle was visualized with HRAM.

Impact of Clinical Outcome Measures on Placebo Response Rates in Clinical Trials for Chronic Constipation: A Systematic Review and Meta-analysis

OBJECTIVES

Chronic constipation (CC) is a recurrent functional bowel disorder worldwide. The purpose of this study is to examine its pooled placebo response rate and compare placebo response level in randomized controlled trials (RCTs) with different endpoint assessments.

METHODS

PubMed, Cochrane Library, and Embase were electronically searched for therapeutic RCTs of CC with placebo control. Data extraction and assessment of risk of bias were performed independently by 2 reviewers. All the statistical calculation and analysis were performed using R 3.6.0. Our protocol has registered in PROSPERO with registration number: CRD42019121287.

RESULTS

There were 46 studies included with 5,992 constipated patients allocated to the placebo arm in total. The pooled placebo response rate was 28.75% (95% confidence interval: 23.83%-33.67%) with significant heterogeneity among trials ((Equation is included in full-text article.)= 93.6%). Treatment efficacy assessed using subjective improvement had a significantly higher placebo response rate than that assessed with improvement in complete (spontaneous) bowel movements or composite improvement (41.40% vs 18.31% or 20.35%, P < 0.001). According to the results of meta-regression, active treatment and endpoint assessment were most likely to lead to the huge heterogeneity among studies.

DISCUSSION

Patients with CC have significant response level to placebo. Based on findings in this study, we do not recommend subjective improvement as endpoint while designing therapeutic RCTs for chronic constipated patients.

Comparative Efficacy of Drugs for the Treatment of Chronic Constipation: Quantitative Information for Medication Guidelines

BACKGROUND

Quantitative information is scarce with regard to guidelines for currently prescribed medications for constipation. Furthermore, these guidelines do not reflect the differences in the number of bowel movements caused by each drug.

GOALS

In this study, we used a model-based meta-analysis to quantitatively estimate the deviations from the baseline number of spontaneous bowel movements (SBMs) and complete spontaneous bowel movements (CSBMs) associated with pharmacotherapy for chronic constipation to bridge the knowledge gap in the guidelines for current medications.

STUDY

A comprehensive survey was conducted using literature databases. In this study, we also included randomized placebo-controlled trials on chronic constipation. Pharmacodynamic models were established to describe the time course of the numbers of SBMs and CSBMs produced by each drug.

RESULTS

Data from 20 studies (comprising 9998 participants and 8 drugs) were used to build this model. The results showed that bisacodyl had the greatest effect on increasing the frequency of bowel movements, whereas plecanatide yielded the lowest increase in the number of SBMs and CSBMs. After eliminating the placebo effect, the maximal increase in bowel movement frequency associated with bisacodyl was 6.8 for SBMs (95% confidence interval: 6.1-7.6) and 4.7 for CSBMs (95% confidence interval: 4.3-5.1) per week. These numbers are ∼4 times higher than the number of bowel movements produced by plecanatide. The change in the frequency of SBMs and CSBMs for other drugs, such as sodium picosulfate, velusetrag, linaclotide, elobixibat, lubiprostone, and prucalopride, was similar. The highest increases in the frequency of SBM and CSBM were 2.5 to 4 and 1 to 2.1 per week, respectively. Bisacodyl had the most noticeable loss of efficacy between week 1 and week 4; it reduced the frequencies of SBMs and CSBMs by 2.3 and 2.2, respectively. By contrast, the changes in the frequencies of SBMs and CSBMs were not as great with other drugs.

CONCLUSIONS

The data provided in this study may be a valuable supplement to the medication guidelines for the treatment of chronic constipation.

Comprehensive assessment of patients with irritable bowel syndrome with constipation and chronic idiopathic constipation using deterministically linked administrative claims and patient-reported data: the Chronic Constipation and IBS-C Treatment and Outcomes Real-World Research Platform (CONTOR)

AIMS

To characterize a US population of patients with irritable bowel syndrome with constipation (IBS-C) or chronic idiopathic constipation (CIC) using CONTOR, a real-world longitudinal research platform that deterministically linked administrative claims data with patient-reported outcomes data among patients with these conditions.

METHODS

Patients with IBS-C or CIC were identified using diagnosis and treatment codes from administrative claims. Potential respondents received a mailed survey followed by 12 monthly online follow-up surveys and 2 mailed diaries. Surveys collected symptom severity, treatment use, quality of life, productivity, and condition/treatment history. Comorbidities and healthcare costs/utilization were captured from claims data. Diaries collected symptoms, treatments, and clinical outcomes at baseline and 12 months. Data were linked to create a patient-centric research platform.

RESULTS

Baseline surveys were returned by 2,052 respondents (16.8% response rate) and retention rates throughout the study were high (64.8%-70.8%). Most participants reported burdensome symptoms despite having complex treatment histories that included multiple treatments over many years. More than half (55.3%) were dissatisfied with their treatment regimen; however, a higher proportion of those treated with prescription medications were satisfied.

LIMITATIONS

The study sample may have been biased by patients with difficult-to-treat symptoms as a result of prior authorization processes for IBS-C/CIC prescriptions. Results may not be generalizable to uninsured or older populations because all participants had commercial insurance coverage.

CONCLUSIONS

By combining administrative claims and patient-reported data over time, CONTOR afforded a deeper understanding of the IBS-C/CIC patient experience than could be achieved with 1 data source alone; for example, participants self-reported burdensome symptoms and treatment dissatisfaction despite making few treatment changes, highlighting an opportunity to improve patient management. This patient-centric approach to understanding real-world experience and management of a chronic condition could be leveraged for other conditions in which the patient experience is not adequately captured by standardized data sources.

A systematic review and meta-analysis of biofeedback therapy for dyssynergic defaecation in adults

BACKGROUND

Dyssynergic defaecation is a common form of functional constipation that responds poorly to conservative interventions. This systematic review and meta-analysis assesses the effectiveness of biofeedback therapy for dyssynergic defaecation using global clinical improvement as the primary outcome, and resolution of the dyssynergic pattern on anorectal physiology and quality of life as secondary outcomes.

METHODS

MEDLINE, EMBASE, CENTRAL, PsychInfo, CINAHL, Scopus, and Web of Science were searched from inception to March 2019 using a predefined strategy. Randomised controlled trials of adult patients with dyssynergic defaecation and a biofeedback treatment arm were eligible for review. Studies including patients with secondary forms of constipation were excluded. Data abstraction and risk of bias assessments were conducted by consensus between two authors.

RESULTS

Eleven trials including 725 participants were included in the narrative review. Sixty-three percent of patients treated with biofeedback reported clinical improvement. Six studies included in the meta-analysis showed biofeedback superior to non-biofeedback therapy for the primary outcome (OR 3.63, CI 1.10-11.93, p = 0.03). Heterogeneity between trials and overall risk of bias was high.

CONCLUSIONS

Biofeedback therapy is recommended for patients referred to tertiary units with dyssynergic defaecation who fail conservative therapy. Future research should be directed towards identifying validated outcomes and the optimum method for delivering biofeedback therapy. Home biofeedback therapy may improve accessibility and recruitment to future clinical trials.

Constipation and Fecal Incontinence in the Elderly

PURPOSE OF REVIEW

To review the epidemiology, pathogenesis, clinical features, and management of primary constipation and fecal incontinence in the elderly.

RECENT FINDINGS

Among elderly people, 6.5%, 1.7%, and 1.1% have functional constipation, constipation-predominant IBS, and opioid-induced constipation. In elderly people, the number of colonic enteric neurons and smooth muscle functions is preserved; decreased cholinergic function with unopposed nitrergic relaxation may explain colonic motor dysfunction. Less physical activity or dietary fiber intake and postmenopausal hormonal therapy are risk factors for fecal incontinence in elderly people. Two thirds of patients with fecal incontinence respond to biofeedback therapy. Used in combination, loperamide and biofeedback therapy are more effective than placebo, education, and biofeedback therapy. Vaginal or anal insert devices are another option. In the elderly, constipation and fecal incontinence are common and often distressing symptoms that can often be managed by addressing bowel disturbances. Selected diagnostic tests, prescription medications, and, infrequently, surgical options should be considered when necessary.

Influence of bowel habits on gut-derived toxins in peritoneal dialysis patients

BACKGROUND

Gut-derived uremic toxins have been associated with adverse outcomes in chronic kidney disease (CKD). Alterations in bowel habits, including constipation, seem to play an additional role in uremic toxicity. The aim of this study is to investigate the association of bowel habits with gut-derived uremic toxins and intestinal permeability in patients on automated peritoneal dialysis (APD).

METHODS

This cross-sectional study enrolled 58 APD patients (age 52.5 ± 15.1 years; dialysis vintage 14.1 (6.0-36.5) months). Constipation was defined according to the Rome IV criteria. Bowel habits were assessed by the Bristol Stool Scale (BSS < 3 characterized by hard consistency of stools and/or low frequency of evacuation, a surrogate of slow intestinal transit time, and BSS ≥ 3, defining regular bowel habit). The total and free serum concentration of p-cresyl sulfate (PCS), indoxyl sulfate (IS) and indole-3-acetic acid (IAA) were dosed by high-performance liquid chromatography. Lipopolysaccharide (LPS) and zonulin were assessed by ELISA and D(-)-lactate by colorimetric method. Dietary intake was assessed by the 3-day food records.

RESULTS

No differences were observed in clinical, demographic, and dietary characteristics between constipated (n = 30) and non-constipated (n = 28) groups. A trend for higher total PCS (p = 0.07) and free PCS (p = 0.06) was found in constipated patients. Patients with BSS < 3 (n = 11) exhibited significantly higher levels of total and free PCS (p < 0.01) and total IAA (p = 0.04). Conversely, No difference was found in IS levels. Except for a lower serum level of D(-)-lactate in patients with BSS < 3 (p = 0.01), zonulin and LPS levels were not different.

CONCLUSIONS

Disturbed bowel habits, mainly characterized by slow transit time, may play a role in the accumulation of uremic toxins, particularly PCS, in patients on automatized peritoneal dialysis.

Laparoscopic Ventral Rectopexy for Obstructed Defecation: Functional Results and Quality of Life

BACKGROUND

Laparoscopic ventral mesh rectopexy (LVR) is gaining wider acceptance as the preferred procedure to correct internal and external rectal prolapse with obstructed defecation syndrome (ODS) and/or fecal incontinence. The aim of our study was to analyze functional outcome and quality of life (Health-Related Quality of Life) after LVR for symptomatic internal prolapse and/or rectocele with ODS.

METHODS

Prospectively collected data on LVR for internal rectal prolapse were analyzed in 50 consecutive female patients operated between January 2011 and December 2018. In all cases, we performed a LVR according to the D'Hoore technique. Patients had ODS and internal rectal prolapse (grade 3 or 4) confirmed at the defecogram study. We registered only 1 major complication that required surgical treatment (Clavien-Dindo IIIb). The median hospital stay was 4 days [interquartile range (IQR): 2 to 5 d]. Functional results were measured with the Wexner Constipation Score and the 36-Item Short-Form Health Survey, and were analyzed before surgery and after 3, 6, or 12 months.

RESULTS

After a median follow-up of 16.5 months (IQR: 10 to 44.25 mo), the Wexner Total Score was significantly improved in almost all items passing from 14 (IQR: 11 to 18) to 11 (IQR: 6.25 to 14.75) after surgery (P<0.0001). Incontinence was cured in 8 of 11 patients (P=0.036). Compared with the preoperative score, the 36-Item Short-Form Health Survey score improved, especially for physical activity, varying from 75 to 87.5 (P=0.0156). No worsening of continence status, constipation, or sexual function was observed.

CONCLUSION

LVR appears to provide a sustained improvement in Health-Related Quality of Life, constipation, and incontinence in patients with ODS without worsening constipation with low morbidity and recurrence.

Impact of guideline awareness in public pharmacies on counseling of patients with acute or chronic constipation in a survey of pharmacy personnel

Background

Constipation is often self-managed by patients and guidelines are available to aid healthcare professionals in the counseling of patients for self-management. Therefore, we have explored the knowledge and attitude of pharmacy personnel towards guidelines for the management of acute and functional chronic constipation and how they affects their recommendations.

Methods

An online survey was conducted among 201 pharmacists and pharmacy technicians from an existing panel. They were presented with two typical cases, a 62-year old woman with functional chronic constipation and a 42-year old woman with travel plans. For each case, they were asked about their treatment recommendations and the underlying rationale. Thereafter, they were provided with contents from an applicable national guideline and asked again about their recommendations and the underlying rationale. In line with the exploratory nature, data were analyzed in a descriptive manner only.

Results

Before exposure to guideline content, the most frequent recommendations for chronic constipation were macrogol, fiber and lactulose and for acute constipation sodium picosulfate, bisacodyl and enemas. Following guideline exposure, the most frequent recommendations for chronic constipation were macrogol, bisacodyl and sodium picosulfate and for acute constipation bisacodyl, sodium picosulfate and macrogol (all three equally recommended by the guideline for the management of acute and chronic constipation). Correspondingly, the rationale behind the recommendations shifted with guideline conformity becoming a leading reason.

Conclusions

Awareness of the content of an applicable guideline on the management of constipation was poor among pharmacy personnel. Accordingly, recommendations in many cases were not in line with the guideline. Greater awareness of guideline content is desirable to enable more evidence-based recommendations in the management of constipation.

Comparisons between Manual Lymph Drainage, Abdominal Massage, and Electrical Stimulation on Functional Constipation Outcomes: A Randomized, Controlled Trial

BACKGROUND

Evidence supports abdominal massage (AM) or electrical stimulation (ES) as effective in treating functional constipation (FC). Manual lymph drainage (MLD) may also be beneficial, however, it was not previously investigated or compared to ES and AM.

METHODS

Sixteen college-aged males and 36 females were recruited. Participants were randomly assigned to MLD, AM or ES. Heart rate variability (HRV) measures for total power (TP), high frequency (HF), low frequency and LF/HF ratio assessed ANS outcomes. state-trait anxiety inventory (STAI) and stress response inventory (SRI) assessed psychological factors and bowel movement frequency (BMF) and duration (BMD) were recorded daily.

RESULTS

MLD significantly improved all ANS measures (p≤0.01); AM significantly improved LF, HF and LF/HF ratios (p = 0.04); and ES significantly improved LF (p = 0.1). STAI measures improved, but not significantly in all groups. SRI improved significantly from MLD (p < 0.01), AM (p = 0.04) and ES (p < 0.01), but changes were not significant between groups. BMD improved significantly in all groups (p≤ 0.02). BMF improved significantly only following MLD and AM (p < 0.1), but differences between groups were not significant (p = 0.39).

CONCLUSIONS

MLD significantly reduced FC symptoms and MLD had greater improvements than AM or ES.

Study Design and Cohort Comparability in a Study of Major Cardiovascular Events in New Users of Prucalopride Versus Polyethylene Glycol 3350

Introduction

Given prior safety experience with other 5-HT₄ agonists for chronic constipation, an observational, population-based cohort study in five data sources from Germany, Sweden, and the UK was conducted to evaluate the cardiovascular safety of prucalopride.

Objectives

Our objective is to describe the methods and resulting comparability of cohorts in a multi-database, multinational study of prucalopride initiators and polyethylene glycol 3350 (PEG) initiators following a harmonized protocol.

Methods

Prucalopride initiators were matched on age, sex, and index date to PEG initiators (1:5 ratio). Study exposures, cardiovascular risk factors, and other covariates were identified from healthcare utilization codes harmonized across databases. Cardiovascular outcomes were identified using database-specific algorithms based on diagnosis codes. The propensity score (PS) in each database was estimated using logistic regression, with prucalopride versus PEG as the outcome and including clinically relevant variables associated with major adverse cardiovascular events.

Results

In total, 12,030 prucalopride initiators and 59,985 PEG initiators were identified. After matching and trimming, cohorts from the UK and Sweden were well-balanced for cardiovascular risk factors and cancer. However, in Germany, PEG initiators remained older and sicker than prucalopride initiators. The prevalence of these characteristics also differed from those in the UK and Sweden. The pooled analyses included only data from the UK and Sweden.

Conclusions

Matching, trimming, and PS stratification yielded comparable cohorts in four of five data sources. Use of these methods could not achieve balance for key covariates within the German cohort, likely due to reimbursement differences in Germany.

Electronic supplementary material

The online version of this article (10.1007/s40264-019-00836-z) contains supplementary material, which is available to authorized users.

Cardiovascular Safety of Prucalopride in Patients with Chronic Constipation: A Multinational Population-Based Cohort Study

Introduction

The serotonin 5-HT₄ receptor agonist prucalopride is approved in the European Union for the treatment of chronic constipation. This offered the unique opportunity to include real-world observational data on cardiovascular safety in the new drug application for approval of prucalopride in the USA.

Methods

This observational population-based cohort study (EUPAS9200) conducted in five data sources (three in the UK, one in Sweden, and one in Germany [which was subsequently excluded from the pooled analyses]) aimed to estimate the pooled adjusted incidence rate ratio for major adverse cardiovascular events (defined as hospitalization for non-fatal acute myocardial infarction or stroke, and in-hospital cardiovascular death) in adult initiators of prucalopride compared with initiators of polyethylene glycol 3350 (PEG) following a common protocol. Standardized incidence rates and incidence rate ratios of major adverse cardiovascular events were derived using propensity score stratification. Sensitivity analyses explored the impact of exposure definition, outcome categories, interim cancer, and unmeasured confounding.

Results

The pooled analyses included 5715 initiators of prucalopride and 29,372 initiators of PEG. Average duration of use was 175 days for prucalopride and 82 days for PEG. The pooled standardized incidence rate per 1000 person-years (95% confidence interval) of major adverse cardiovascular events was 6.57 (3.90–10.39) for patients initiating prucalopride and 10.24 (6.97–14.13) for PEG. The pooled adjusted incidence rate ratio for major adverse cardiovascular events was 0.64 (95% confidence interval 0.36–1.14). Results remained consistent in various sensitivity analyses.

Conclusions

The pooled incidence rate ratio estimate was consistent with no indication of an increased risk above the pre-specified safety threshold of 3.00 for major adverse cardiovascular events in patients with chronic constipation using prucalopride as compared with PEG.

Second-generation antipsychotics and constipation: A review of the literature

Antipsychotics are the cornerstone in the management of psychotic disorders and schizophrenia. They are effective agents but also have a wide range of side effects. In the recent literature constipation as possible side effect has received little attention. A review of the literature concerning constipation associated with antipsychotics was performed. Overall constipation is a rarely studied or reported side effect of antipsychotic medication. Nevertheless constipation is a common side effect. Antipsychotic agents differ in their liability to induce constipation. Constipation can be severe and can lead to serious consequences such as paralytic ileus, bowel occlusion and death. Active screening, monitoring and treatment are recommended. Further research on incidence, prevalence, underlying mechanisms and preventive measures is required.

Psychometric evaluation of a newly developed Elderly-Constipation Impact Scale

Background

Chronic constipation is a common symptom among the elderly, and it may affect their quality of life (QoL). A lack of available research focused on the elderly means that this effect is not well understood. This study aimed to develop and validate a new scale (Elderly-Constipation Impact Scale (E-CIS)) to measure the impact of chronic constipation on QoL among the elderly.

Methods

A pool of items was generated from a qualitative study, literature reviews, and expert reviews. Exploratory factor analysis (EFA) was performed on the original 40 items of the E-CIS and followed by 27 items for confirmatory factor analysis (CFA). A total of 470 elderly people with chronic constipation were involved.

Results

The mean age of the participants was 68.64 ± 6.57. Finally, only 22 items were indicated as appropriately representing the E-CIS, which were grouped into seven subscales: 'daily activities', 'treatment satisfaction', 'lack of control of bodily function', 'diet restriction', 'symptom intensity', 'anxiety' and 'preventive actions'. The scale was confirmed as valid (root mean square error of approximation (RMSEA) = 0.04, comparative fit index (CFI) = 0.961, Tucker-Lewis index (TLI) = 0.952 and chi-square/degree of freedom (chiSq/df) = 1.44) and reliable (Cronbach's alpha: 0.66-0.85, composite reliability (CR) = 0.699-0.851) to assess the impact of chronic constipation on the elderly's QoL.

Conclusions

The E-CIS is useful to measure the impact of chronic constipation on the elderly's QoL. A further test is needed to determine the validity and reliability of this scale in other elderly population.

Placebo response rate in patients with chronic constipation: A protocol for systematic review

OBJECTIVE

The aim of this systematic review and meta-analysis is to calculate the pooled placebo response rate in patients with chronic constipation (CC) in randomized controlled trial (RCT) and its related factors.

METHOD

This systematic review and meta-analysis will be conducted under the guidance of Cochrane Handbook. The inclusive and exclusive criteria and search strategies for PubMed, Cochrane Library, and Embase will be introduced in this protocol. Data collection, extraction, and assessment of risk of bias will be conducted independently by 2 reviewers. The pooled placebo response rate and its 95% confidence interval (95%CI) will be calculated and the heterogeneity assessment, publication bias assessment, and subgroup analysis will be performed using R 3.6.0. This study has been registered on the PROSPERO platform (CRD42019121287).

RESULT

The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.

Constipation in CKD

Constipation is one of the most common gastrointestinal disorders among patients with chronic kidney disease (CKD) partly because of their sedentary lifestyle, low fiber and fluid intake, concomitant medications (e.g., phosphate binders), and multiple comorbidities (e.g., diabetes). Although constipation is usually perceived as a benign, often self-limited condition, recent evidence has challenged this most common perception of constipation. The chronic symptoms of constipation negatively affect patients' quality of life and impose a considerable social and economic burden. Furthermore, recent epidemiological studies have revealed that constipation is independently associated with adverse clinical outcomes, such as end-stage renal disease (ESRD), cardiovascular (CV) disease, and mortality, potentially mediated by the alteration of gut microbiota and the increased production of fecal metabolites. Given the importance of the gut in the disposal of uremic toxins and in acid-base and mineral homeostasis with declining kidney function, the presence of constipation in CKD may limit or even preclude these ancillary gastrointestinal roles, potentially contributing to excess morbidity and mortality. With the advent of new drug classes for constipation, some of which showing unique renoprotective properties, the adequate management of constipation in CKD may provide additional therapeutic benefits beyond its conventional defecation control. Nevertheless, the problem of constipation in CKD has long been underrecognized and its management strategies have scarcely been documented. This review outlines the current understanding of the diagnosis, prevalence, etiology, outcome, and treatment of constipation in CKD, and aims to discuss its novel clinical and therapeutic implications.

The effect and safety of acupuncture on patients with functional constipation: Protocol for a systematic review and meta-analysis of high quality RCTs

BACKGROUND

Functional constipation (FC) is a prevalent clinical disease that affects a considerable proportion of the population of all ages. Persistent FC significantly reduces quality of life and influences physical and emotional well-being, as well as consumes many substantial healthcare resources. Acupuncture originates from Traditional Chinese Medicine (TCM), and emerging evidence of several randomized controlled trials (RCTs) published suggest that acupuncture has positive effects for FC. Since 2019, several new results of high quality RCTs about acupuncture treatment for FC have been published. Thus a systematic review will be designed to appraise the effectiveness and safety of acupuncture for improvement of FC in patients based on high quality RCTs.

METHODS

We carried out a rigorous literature search in English and Chinese electronic database from inception to present. Two reviewers will identify relevant studies, extract and manage trial information, and then assess the risk of bias in included studies by the Cochrane risk of bias assessment tool. Only high quality RCTs will be included. Data will be synthesized by either fixed-effects or random-effects model regarding to a heterogeneity test. The primary outcome measurement will be the change from baseline in mean complete spontaneous bowel movements and stool form. The secondary outcomes involved disappearance rate of symptoms, proportion of responders, mean transit time, health-related quality of life, and safety of intervention. Meta-analysis will be performed by using Cochrane's RevMan software.

RESULTS

This systematic review will summarize high quality clinical evidence to assess and appraise the effectiveness and safety of acupuncture treatment for FC patient.

EXPECTED CONCLUSION

This systematic review and meta-analysis will provide evidence to determine whether acupuncture treatment is an effective and safe therapy for the prevention and treatment of FC compared with medication treatment.

Assessment of rectal feces storage condition by a point-of-care pocket-size ultrasound device for healthy adult subjects: A preliminary study

The aim of this study was to assess rectal feces storage condition by a pocket-size ultrasonography (PUS) in healthy adults so as to define normal rectal defecation desire. Participants were first assessed rectum by PUS imaging immediately after defecation desire (pre-defecation). Nurses checked the amount and quality of the participants' feces using King's Stool Chart and Bristol stool scale. Finally, PUS was performed for defecation with no defecation desire (post-defecation). Pre-defecation PUS detected high echo area in all patients. All of the post-defecation PUS did not detect high echo area (perfectly no recognizable high echo area in 54.5%, high echo line in 36.4%, and low echo of entire circumference in 9.1% of the patients). Average diameter of rectal crescent was 4.22 ± 0.8 cm. Bristol Stool Scale 1 or 2 (indicating hard stool) of pre-defecation PUS indicated high echo area and acoustic shadow in 100% of the patients. This study showed that healthy adult with defecation desire had high average rectal echo area of 4.0 cm in diameter. PUS may be able to define the rectum diameter for defecation desire of elderly people. PUS is capable of assessing fecal retention of the rectum for point-of-care examinations in home care.

Assessment of patients' psychological state and self-efficacy associated with postoperative constipation after thoracolumbar fracture surgery

Objective

We aimed to explore the relationship among the duration of constipation at 30 days after thoracolumbar fracture surgery, self-efficacy, and anxiety or depression in patients with constipation after thoracolumbar fracture surgery.

Methods

In this descriptive correlational study, 108 patients with thoracolumbar fracture undergoing pedicle screw fixation surgery were recruited from January 2015 to May 2017 in our hospital. From the day of surgery, we conducted a 1-month follow-up investigation. We evaluated the pattern of defecation, stool consistency, and incidence of defecation-related problems using a structured interview. Clinical data were obtained using a patient intake form, and we applied the Health Behavior Self-Efficacy Scale (HBSES), and Hospital Anxiety and Depression Scale (HADS).

Results

Approximately 83.3% of patients experienced postoperative constipation, and most exhibited normal defecation by postoperative day 13. Self-efficacy and anxiety and depression were graded at a medium level in most patients. The average HBSES score was 74.39 ± 11.08, and the mean HADS score was 7.97 ± 4.08. The duration of postoperative constipation was negatively correlated with self-efficacy and positively associated with anxiety or depression.

Conclusions

Self-efficacy, anxiety, and depression are important sociopsychological factors associated with the duration of postoperative constipation.

The economic burden of constipation therapy

BACKGROUND AND AIM

Constipation is a widespread condition that requires adequate therapy. Given the large use of laxatives, it is important to know the burden of the treatment of this condition on the healthcare budget.

METHODS

We collected information on the number of therapeutic units (boxes) of five frequently used laxatives delivered by prescription or over the counter in 30 pharmacies randomly selected in two adjacent counties from Romania for two consecutive years. We calculated also the cost value of the laxatives delivered.

RESULTS

The total cost of laxatives in the group of pharmacies investigated was on average 62,500 euros per year. We extrapolated that the laxative consumption in Romania should be over 15 million Euro.

CONCLUSIONS

To our knowledge this is the first study on the burden of constipation in this country. Although therapeutic units of laxatives are not expensive, the wide use of these drugs represents an economic burden for the patient.

Initial Effects of Electroacupuncture for Chronic Severe Functional Constipation and the Potential Underlying Factors: Secondary Analysis of a Randomized Controlled Trial

Background

Electroacupuncture (EA) has been found to be effective for treating chronic severe functional constipation (CSFC). However, the initial effects of treatment usually affect the acceptability and compliance of patients with chronic disease in particular. Which class of CSFC patients will have a better initial response to EA remains uncertain and requires investigation.

Methods

This was a secondary analysis of an original multicenter randomized controlled trial in which patients with CSFC were randomly assigned to receive 28 sessions of EA or sham electroacupuncture (SA) over 8 weeks with 12 weeks of follow-up. The primary outcome, namely, response with complete spontaneous bowel movements (CSBMs), required participants to have ≥ 3 CSBMs and an increase of ≥ 1 CSBM from the baseline over the first week of treatment. Logistic regression analysis with bootstrapping techniques was performed to determine independent factors related to the response.

Results

A total of 1051 eligible patients were included in this study of whom 161 patients were classified as responders at week 1. The CSBM response rate was higher in the EA group (17.5%) than in the SA group (13.2%). And the proportion of these 1-week early responders remained to have higher clinical response at the end of 8-week treatment and 12 weeks after treatment. Age and higher baseline CSBMs were related to CSBM response within the first week: with every 1-year increase in age, the likelihood of clinical response was reduced by 1.7% (odds ratio [OR] 0.983, 95% confidence interval [CI] 0.972 to 0.993; P=0.001). The odds of a CSBM response in patients with 1< CSBMs ≤ 2 at baseline were 4.64 times higher than that in patients with CSBMs ≤ 1 (OR 4.64, 95%CI 4.01 to 5.27).

Conclusions

EA produced its initial effects within the first week of treatment. And the effects could last until week 8 and week 20. A younger age and higher number of CSBMs at baseline may increase likelihood of a response.

Clozapine: why wait to start a laxative?

Clozapine, the antipsychotic of choice for treatment-resistant schizophrenia, has a number of side-effects, some of which are potentially life-threatening. Historically viewed as a relatively minor side-effect, there is increasing awareness of the potentially severe sequalae of constipation secondary to clozapine-induced gastrointestinal hypomotility (CIGH). These include ileus, intestinal obstruction, bowel ischaemia, gastrointestinal necrosis, toxic megacolon and death. CIGH is significantly more common than clozapine-induced blood dyscrasias and has a higher mortality rate. Although strict criteria must be followed to assertively monitor, detect and treat blood dyscrasias in patients taking clozapine, no such framework exists for CIGH. We recommend that prescribing guidelines, regulatory agencies and information from manufacturers should more clearly highlight the risks identified in the literature. Furthermore, we recommend that, in people taking clozapine, constipation should be prevented by prophylactic treatment with laxatives rather than treated only when clinically identified.

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Clinical and anorectal manometry profile of patients with functional constipation and constipation-predominant irritable bowel syndrome

BACKGROUND

Functional constipation (FC) and constipation-predominant irritable bowel syndrome (IBS-C) have significant healthcare impact. Clinical and investigative data of patients with these disorders in Indian population is scarce. We aimed to compare the clinical and anorectal manometric profile of patients with FC and IBS-C.

METHODS

Consecutive patients with chronic constipation undergoing anorectal manometry (ARM) and balloon expulsion test (BET) were enrolled. Thirty healthy volunteers served as controls (HC). Functional defecatory disorder (FDD) was diagnosed according to ROME IV criteria if both ARM and BET were abnormal.

RESULTS

Of the 231 patients enrolled (median age 47 years, 87.8% males), FC and IBS-C were diagnosed in 132 (57.1%) and 99 (42.9%) patients, respectively. Significant clinical differences between FC and IBS-C patients included older age, lower stool frequency/week, higher frequency of straining, and greater frequency  of incomplete evacuation (p < 0.001). ARM revealed abnormal defecatory pattern in 55.3% (n = 73) FC patients and 47.5% (n = 47) IBS-C patients. Of them, 54.7% (40/73) of FC patients had inadequate defecatory propulsion while 89.4% (42/47) of the IBS-C patients had dyssynergic defecation (p < 0.001). Abnormal BET was seen in 67.4% of FC patients and 43.4% of IBS-C patients. Thus, FDD was diagnosed in 55.3% and 46.5% of FC and IBS-C patients, respectively. Rectal hyposensitivity was present in 60.6% of FC patients compared with 2% of IBS-C patients (p < 0.001).

CONCLUSIONS

There were significant differences in clinical and manometric profile of FC and IBS-C patients. Compared with IBS-C patients, FC patients were older, had higher prevalence of FDD, less often had dyssynergic defecation, and had higher prevalence of rectal hyposensitivity.

[Determining the Prevalence of Constipation and Relating Factors in Elderly People: A Nursing Home Study]

Amaç

Bu çalışma, huzurevinde kalan yaşlılarda Roma II konstipasyon tanılama kriterlerine göre konstipasyon görülme sıklığını ve ilişkili faktörleri belirlemek amacıyla yapılmıştır.

Yöntem

Kesitsel tipteki bu çalışma Ankara’da bir huzurevinde yaşayan ve araştırmaya dahil edilme kriterlerine uyan 160 yaşlı birey ile gerçekleştirilmiştir. Veriler tanıtıcı özellikler bilgi formu ve Roma II Konstipasyon Tanılama Kriterleri formu ile yüz yüze görüşülerek toplanmıştır. Verilerin analizinde tanımlayıcı istatistikler ile Ki-Kare testi kullanılmıştır.

Bulgular

Yaşlı bireylerin yaş ortalaması 78±8.1 (min: 65, max: 95) olup, %53.1’i erkektir. Yaşlı bireylerin %51.9’u Roma II konstipasyon tanılama kriterlerine göre konstipasyon sorunu yaşamaktadır. Roma II konstipasyon tanılama kriterleri incelendiğinde yaşlı bireylerin, %44.4’ünün defekasyon yaparken zorlanma/yoğun ıkınma yaşadığı, %29.4’ünün dışkı kıvamının sert olduğu, %53.8’inin yetersiz dışkılama hissi/tam boşalamama problemi olduğu, %30.2’sinin bağırsak hareketinin haftada 2 kez ve daha az olduğu belirlenmiştir. Düzenli fiziksel aktivite yapmayan, günlük 2 litreden az su tüketen ve huzurevinde kalma süresi 11 yılın üzerinde olan yaşlı bireylerde konstipasyon sorununun daha fazla olduğu belirlenmiştir (p<0.05).

Sonuç

Huzurevinde yaşayan yaşlı bireylerin yarısından biraz fazlasının konstipasyon sorunu yaşadığı belirlenmiştir. Yaşlı bireylerde konstipasyon ve risk faktörlerinin erken dönemde belirlenmesi, düzenli olarak egzersiz yapmalarının desteklenmesi önem taşımaktadır.

Colonic electrical stimulation promotes colonic motility through regeneration of myenteric plexus neurons in slow transit constipation beagles

Slow transit constipation (STC) is a common disease characterized by markedly delayed colonic transit time as a result of colonic motility dysfunction. It is well established that STC is mostly caused by disorders of relevant nerves, especially the enteric nervous system (ENS). Colonic electrical stimulation (CES) has been regarded as a valuable alternative for the treatment of STC. However, little report focuses on the underlying nervous mechanism to normalize the delayed colonic emptying and relieve symptoms. In the present study, the therapeutic effect and the influence on ENS triggered by CES were investigated in STC beagles. The STC beagle model was established by oral administration of diphenoxylate/atropine and alosetron. Histopathology, electron microscopy, immunohistochemistry, Western blot analysis and immunofluorescence were used to evaluate the influence of pulse train CES on myenteric plexus neurons. After 5 weeks of treatment, CES could enhance the colonic electromyogram (EMG) signal to promote colonic motility, thereby improving the colonic content emptying of STC beagles. HE staining and transmission electron microscopy confirmed that CES could regenerate ganglia and synaptic vesicles in the myenteric plexus. Immunohistochemical staining showed that synaptophysin (SYP), protein gene product 9.5 (PGP9.5), cathepsin D (CAD) and S-100B in the colonic intramuscular layer were up-regulated by CES. Western blot analysis and immunofluorescence further proved that CES induced the protein expression of SYP and PGP9.5. Taken together, pulse train CES could induce the regeneration of myenteric plexus neurons, thereby promoting the colonic motility in STC beagles.

Defining constipation to estimate its prevalence in the community: results from a national survey

BACKGROUND

Different definitions of constipation have been used to estimate its prevalence in the community but this creates difficulties when comparing results from various studies. This study explores the impact of different definitions on prevalence estimates in the same population and compares the performance of simple definitions with the Rome III criteria.

METHODS

The prevalence of constipation in a large nationally representative sample of community-dwelling adults was estimated using five simple definitions of constipation and compared with definitions based on the Rome III criteria. The sensitivity, specificity, and positive and negative predictive values, were calculated for each definition using the Rome III criteria as the gold standards for chronic and sub-chronic constipation.

RESULTS

Prevalence estimates for the five simple definitions ranged from 9.4 to 58.9%, while the prevalence estimates using the Rome III criteria were 24.0% (95%CI: 22.1, 25.9) for chronic constipation and 39.6% (95%CI: 37.5, 41.7) for sub-chronic constipation. None of the simple definitions were adequate compared to the Rome III criteria. Self-reported constipation over the past 12 months had the highest sensitivity (91.1%, 95%CI: 88.8, 93.4) and negative predictive value (94.5%, 95%CI: 93.1, 96.1) compared to the Rome III criteria for chronic constipation but an unacceptably low specificity (51.3%, 95%CI: 48.8, 53.8) and positive predictive value (37.1%, 95%CI: 34.4, 39.9).

CONCLUSIONS

The definition used to identify constipation within a population has a considerable impact on the prevalence estimate obtained. Simple definitions, commonly used in research, performed poorly compared with the Rome III criteria. Studies estimating population prevalence of constipation should use definitions based on the Rome criteria where possible.

Tuina for functional constipation: A protocol for the systematic review of randomized clinical trials

BACKGROUND

Functional constipation (FC) is one of the most common functional gastrointestinal disorders, which brings many negative impacts to the patient's daily life. In the treatment of FC, Tuina (Chinese massage) is often performed as complementary and alternative medicine and shows a good effect in many clinical trials. However, no high-quality systematic review was taken to show the efficacy and safety of Tuina for FC.

METHODS

The electronic databases of Cochrane Library, Web of Science (WOS), MEDLINE, Wiley, Springer, EMBASE, Chinese Science Citation Database, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, Chinese Scientific Journal Database, Wan-fang database, and other databases will be searched from the establishment to February 1, 2019. Randomized controlled trials about this theme will be retrieved. Independent reviewers will operate literature retrieval, duplication removing, screening, quality evaluation, data analyses by EndNote (X9) and Review Manager (5.3.5). Meta-analysis, subgroup analysis and/or descriptive analysis will be performed based on the included data form.

RESULTS

Evidenced outcome will be provided from defecation frequency, stool consistency (Bistol stool scale), success rates, quality of life, proportion of patients using laxatives, and adverse effects.

CONCLUSION

This review will provide evidence of whether Tuina is an effective and safe intervention for FC.

TRAIL REGISTRATION NUMBER

This protocol of systematic review has been registered on PROSPERO website (No. CRD42019119722).

Efficacy of Polydextrose Supplementation on Colonic Transit Time, Bowel Movements, and Gastrointestinal Symptoms in Adults: A Double-Blind, Randomized, Placebo-Controlled Trial

The addition of fiber is one of the most important dietary means to relieve constipation through lifestyle modification. Polydextrose (PDX) has been reported in several studies to increase fecal bulk, soften stools, and increase the number of defecations. However, there are few studies on the effect of PDX on colonic transit time (CTT). Therefore, the aim of this study was to demonstrate the effect of PDX on CTT and other aspects of gastrointestinal function during two weeks (Day 1 to Day 14), preceded by a 2-week run-in period (Day -14 to Day -1). A total of 192 adults who were diagnosed with functional constipation per Rome III criteria were recruited for the study. Participants were randomized equally into 4 groups (12 g, 8 g, or 4 g of PDX or placebo per day). The primary endpoint was CTT, assessed using radio-opaque markers and abdominal X-rays on Day 0, the baseline; and Day 15, the end of the intervention. Secondary outcomes that were measured using inventories were the patient assessment of constipation symptoms and quality of life, bowel function index, relief of constipation, bowel movement frequency (BMF), stool consistency, degree of straining, and proportion of bowel movements. Ancillary parameters and harms were also evaluated. The recruited population was not sufficiently constipated (e.g., baseline values for CTT and BMF of 42 h and 8.7 BMF/week, respectively). Despite this limitation, our results demonstrated an increased number of bowel movements when supplemented with PDX at a dosage of 12 g per day for 2 weeks. This dosage also consistently improved the secondary outcomes that were measured using inventories at Day 15, compared with the baseline. No serious or significant adverse events were reported during the study.

Effective of education on quality of life and constipation severity in patients with primary constipation

OBJECTIVE

This study was conducted to examine the effect of education on quality of life and constipation severity in patients with primary constipation.

METHODS

This randomised controlled study was conducted with 80 patients who applied at the gastroenterology outpatient clinic of a university hospital. In the study, the Constipation Questionnaire, Constipation Quality-of-Life Questionnaire (PAC-QOL), and Constipation Severity Instrument (CSI) were used.

RESULTS

It was that found after 4 weeks of education, the total PAC-QOL mean score decreased to 60.85 ± 5.65 and total CSI mean score decreased to 20.17 ± 4.05 in the intervention group (p < 0.001). No change was observed in the patients in the control group (p > 0.05). After 4 weeks, a statistical difference was found between the two groups in PAC-QOL mean score and CSI mean score (p < 0.05).

CONCLUSION

It was determined that the education given to individuals with primary constipation decreased the constipation severity and increased the quality of life.

PRACTICE IMPLICATIONS

Constipation education will make a contribution to the active use of follow-up forms by nurses in the clinic for the diagnosis of constipation, individual assessment of each patient, and their active role in constipation management.

Protective effect of mulberry (Morus atropurpurea) fruit against diphenoxylate-induced constipation in mice through the modulation of gut microbiota

The protective effect of mulberry (Morus atropurpurea) fruit against diphenoxylate-induced constipation in mice through the modulation of gut microbiota.

Zengye decoction induces alterations to metabolically active gut microbiota in aged constipated rats

Zengye decoction (ZYD), a traditional Chinese medicinal formula, has been used in the treatment of various chronic diseases, such as constipation and skin dryness syndrome. Clinically, the specific mechanisms and targets of ZYD for treating disease remain unclear. The present study was undertaken to investigate the effects of ZYD on the gut microbiota and host metabolites in aged constipated rats and the relationship between the intestinal microbiota and the host. Rats were divided randomly into three groups, the control group (n = 10), recovery group (n = 10) and ZYD group (n = 10). First, the aged constipation model was established for the ZYD group and recovery group. Then, rats in the ZYD group were treated with ZYD. Urinary and faecal samples of each animal were collected in microcentrifuge tubes. Next, 16s rRNA gene sequencing was employed to analyse the composition of the gut microbiome in faecal samples and afterwards the metabolic function of the altered gut microbiota was predicted. Additionally, 1H NMR profiling was used to detect the alterations of host metabolites in urine and faecal samples to verify the metabolic function results obtained from sequencing. As a result, ZYD reduced the level of harmful bacteria, such as Desulfovibrio, Ruminococcus, Prevotella and Dorea, and increased the abundance of Oxalobacter, Clostridium and Roseburia. The functional prediction of changes in the gut microbiota induced by ZYD revealed that ZYD promoted energy storage, regulated amino acid metabolism, inhibited methane metabolism, strengthened the physiological function of glutathione and reduced bacterial toxin. The 1H NMR profiles revealed that ZYD regulated the carbohydrates, short chain fatty acids, amino acids and amines in the aged constipated rats. In addition, most metabolic changes observed were related to the function of intestinal microbiota. These results suggest that ZYD can regulate the intestinal microbiota of constipated rats to normal levels and change the endogenous metabolites of the host through the intestinal microbiota to achieve therapeutic effects.