Constipation-induced pressor effects as triggers for cardiovascular events

Effect of constipation on hospitalization due to heart failure in patients after myocardial infarction: a retrospective cohort study

BACKGROUND

Patients with constipation after acute heart failure (HF) are at high risk of rehospitalization due to HF. Although HF after myocardial infarction (MI) affects patient outcomes, the relationship between constipation and patient prognosis after MI remains unclear. In this study, we evaluated the effects of constipation on the prognosis of patients with MI, focusing on hospitalization due to HF.

METHODS

We investigated 1,324 patients with MI admitted to our hospital between January 2012 and December 2023 (mean age, 68 ± 14 years; 76% males). Patients with constipation were defined as those using laxatives regularly.

RESULTS

During the follow-up period (median, 2.7 years), 115 patients died, and 99 were re-hospitalized due to HF. Landmark Kaplan-Meier analyses revealed incidences of 7.8% and 2.1% hospitalization due to HF from 0 to 0.5 years (log-rank: p < 0.0001) and 4.8% and 3.9% from 0.5 to 3 years (log-rank: p = 0.17) among patients with and without constipation, respectively. The adjusted Cox proportional hazards analysis revealed a significantly higher risk of hospitalization due to HF from 0 to 0.5 years in patients with constipation than in those without it (hazard ratio, 2.12; 95% confidence interval, 1.07-4.19; p = 0.032). However, no significant difference was found from 0.5 to 3 years (hazard ratio, 0.86; 95% confidence interval, 0.47-1.57; p = 0.63).

CONCLUSIONS

Constipation was strongly associated with a higher risk of hospitalization due to HF in patients with MI during the first 6 months after discharge.

Development and validation of a nomogram for predicting postoperative new-onset constipation in elderly patients undergoing hip fracture surgery

Postoperative constipation is often accompanied by abdominal pain, loss of appetite, nausea and vomiting, or even adverse cardiovascular and cerebrovascular events. This study aimed to establish nomogram for predicting the risk of postoperative new-onset constipation in elderly patients with hip fractures, and validate its performance. Patients who underwent hip surgery in our hospital between January 2021 and December 2023 were enrolled in this study. Univariate and multivariate logistic regression analyses were performed to identify significant factors influencing postoperative constipation. A nomogram was constructed for predicting postoperative new-onset constipation, and its discriminative, concordance, and clinical utility were examined. A total of 1,092 elderly patients were enrolled, among whom 955 without preoperative constipation were included for nomogram establishment. Multivariable logistic regression identified ten factors were associated with postoperative new-onset constipation, including body mass index, cerebrovascular disease, cardiovascular disease, gastrointestinal disease, blood loss, renal disease, preoperative lower limb thrombosis, heart surgery history, patient-controlled analgesia and preoperative pulmonary infection. A nomogram comprising these factors was constructed, and the area under the receiver operating characteristic curve for the training set and the test set were 0.730 (0.692-0.768) and 0.712 (0.651-0.772), respectively. The nomogram developed in this study showed good discriminative ability in predicting the risk of postoperative new-onset constipation in elderly patients undergoing hip fracture surgery. The proposed model is expected to facilitate early identification of high-risk patients and enable timely intervention.

Assessment of the association between constipation and atherosclerosis in cardiovascular and cerebrovascular diseases: a systematic review and meta-analysis

INTRODUCTION

Cardiovascular and cerebrovascular diseases remain leading causes of morbidity and mortality worldwide, with atherosclerosis as a key underlying mechanism.

METHODS

A systematic review was conducted of studies published between 2000 and August 2024, sourced from PubMed, Web of Science, Cochrane, and EMBASE databases. Twelve studies, involving 5,772,682 adults across six countries, met predefined inclusion criteria. Study quality was assessed using the Newcastle-Ottawa Scale (NOS) and the Agency for Healthcare Research and Quality (AHRQ) scale. A meta-analysis was performed to quantify the association.

RESULTS

The meta-analysis revealed a statistically significant association between constipation and atherosclerosis-related cardiovascular and cerebrovascular diseases, with a pooled odds ratio of 1.18 (95 % CI: 1.08-1.30). This finding indicates that individuals with constipation may face an elevated risk of these conditions.

CONCLUSIONS

These findings suggest that constipation could serve as a potential risk factor or marker warranting further investigation in clinical and mechanistic studies.

Post-marketing safety assessment of constipation drugs: a real-world pharmacovigilance study based on FAERS database

BACKGROUND

Laxatives are widely used in the treatment of constipation, but they also have brought many adverse reactions to patients.

METHODS

We conducted a pharmacovigilance analysis based on the United States Food and Drug Administration Adverse Event Reporting System (FAERS) database to analyze the adverse events of six constipation drugs (linaclotide, lubiprostone, prucalopride, naloxegol, naldemedine, and plecanatide) and to search for clinically meaningful adverse reaction signals. We used disproportionality analysis as the main analysis method to detect pharmacovigilance signals, which includes Frequentist methods and Bayesian methods.

RESULTS

Among the reports of the six drugs, more adverse reactions were reported from females than males, and the number of adverse reactions reported was higher in the group of 60-89 years. Linaclotide had the lowest proportion of serious adverse event reports (4.38%), while naldemedine had the highest proportion of serious adverse event reports (25.57%). According to the classification of system organ classification (SOC), the number of gastrointestinal adverse events (N = 8321) was the largest.

CONCLUSIONS

The adverse reactions of constipation drugs were mainly gastrointestinal symptoms such as diarrhea, abdominal pain and abdominal distension. Linaclotide has the highest safety, and more studies are needed to analyze the cardiovascular safety of lubiprostone.

Weizmannia coagulans BC99 Relieves Constipation Symptoms by Regulating Inflammatory, Neurotransmitter, and Lipid Metabolic Pathways: A Randomized, Double-Blind, Placebo-Controlled Trial

Probiotics have attracted increasing attention due to their benefits in terms of relieving gastrointestinal ailments, including constipation. This study evaluated the potential of Weizmannia coagulans BC99 for clinical remission of constipation in adults. In this randomized, double-blind, and placebo-controlled trial, 90 individuals with constipation were divided between a BC99 and a placebo group for an 8-week intervention duration. The spontaneous bowel movement (SBM) frequency, patient assessment of constipation symptoms (PAC-SYM), patient assessment of constipation quality of life (PAC-QOL), inflammatory cytokines, neurotransmitters, and serum metabolites were investigated before and after the intervention. The results showed that BC99 intervention significantly improved constipation symptoms and quality of life in adults with constipation, as evidenced by an increased SBM score and decreased PAC-SYM and PAC-QOL scores. Additionally, BC99 supplementation increased the levels of neurotransmitters (5-HT, MTL, AChE, and BDNF) associated with intestinal motility and alleviated inflammation in participants with constipation, as supported by higher levels of anti-inflammatory factors (IL-4, IL-10) and lower levels of pro-inflammatory factors (IL-6, IFN-γ) in the BC99 group. Furthermore, BC99 altered the abundance of 93 metabolites and affected biological pathways correlated with gastrointestinal motility, including sphingolipid metabolism, steroid hormone biosynthesis, and glycerophospholipid metabolism. This study demonstrates the effectiveness of the W. coagulans BC99 strain in relieving constipation in adults, and reveals its potential mechanism of action. These findings provide a scientific basis for BC99 as an effective and safe probiotic for constipation treatment.

Association Between Complementary Use of Daikenchuto (a Japanese Herbal Medicine) and Readmission in Older Patients With Heart Failure and Constipation

Background

Constipation commonly coexists with heart failure (HF) and can increase blood pressure because of straining during defecation and accompanying mental stress. Daikenchuto, a Japanese herbal medicine to ameliorate gastrointestinal motility, may be effective as a complement to laxatives in improving outcomes in patients with HF and constipation.

Methods and Results

We used the Diagnosis Procedure Combination database to identify patients aged ≥65 years who were admitted for HF, had constipation, and were discharged alive between April 2016 and March 2022. We divided the 115,544 eligible patients into 2 groups according to the prescription of Daikenchuto in addition to laxatives at discharge and compared the incidence of 1-year HF readmission using 1 : 4 propensity score matching. Daikenchuto was prescribed at discharge in 3,315 (2.9%) patients. In the unmatched cohort, patients treated with Daikenchuto were more often male and had a higher prevalence of malignancy than those treated without Daikenchuto. In the 1 : 4 propensity score-matched cohort (3,311 and 13,243 patients with and without Daikenchuto, respectively), no significant difference was noted in 1-year HF readmission between the groups (22.2% vs. 21.9%; hazard ratio=1.02, 95% confidence interval=0.94-1.11). This result was consistent across clinically relevant subgroups except for renal disease.

Conclusions

Complementary use of Daikenchuto in combination with laxatives was not associated with a lower incidence of HF readmission in patients with HF and constipation.

Association of anxiety status and anxiety duration with constipation in adult Americans: a cross-sectional study using data from the NHANES 2007-2010

BACKGROUND

Constipated patients may exhibit anxious behaviors, but the relationship between the two remains unclear. This population-based study aims to investigate the relationships of anxiety status and anxiety duration with constipation among U.S. adults.

METHODS

Using data from the National Health and Nutrition Examination Survey (NHANES) database spanning from 2007 to 2010, a cross-sectional study included 8945 participants was performed to assess the relationships of anxiety status and anxiety duration with constipation. Participants' characteristics were presented using mean or proportion. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using multivariable logistic regression models. The analysis accounted for potential confounding factors, including gender, age, race/ethnicity, education level, marital status, PIR, BMI, smoking status, drinking status, chronic diseases, and dietary intake. Subgroup analyses were conducted to ensure the stability of the results. Smoothed curve fitting was applied to investigate both linear and nonlinear associations between anxiety duration and constipation risk. Threshold effects were assessed using two-piecewise linear regression models.

RESULTS

Of the 8945 participants, 922 reported constipation, with a prevalence of 10.3%. After adjusting for confounding factors, individuals with anxiety status exhibited an increased risk of constipation (OR: 1.49, 95% CI: 1.28-1.73). Stratified analyses indicated that the association between anxiety status and constipation remained relatively stable across different stratification levels. Smoothed curve fitting and threshold effect analyses revealed a linear association between anxiety duration and constipation among adults aged 20-60, while a nonlinear inverted U-shaped relationship was observed in those aged 60 and older, with an inflection point at 10 days. The two variables correlated positively on the left side of the inflection point but not on the right.

CONCLUSION

This study showed that a significant association between anxiety status and constipation among U.S. adults. Additionally, an age-dependent association between anxiety duration and constipation was observed, particularly among individuals aged 60 and older.

Impact of comorbid constipation on the survival of patients with heart failure: a multicenter, prospective cohort study conducted in Japan

Background

Constipation frequently affects heart failure patients because of medication side effects and physiological effects of the condition. Although recent speculation suggests that comorbid constipation may affect cardiovascular disease onset and survival rates, this relationship remains unclear. We examined the effect of comorbid constipation on the survival of patients with heart failure.

Methods

We conducted a multicenter prospective cohort study (the Kochi YOSACOI study) of patients hospitalized for acute decompensated heart failure. The influence of comorbid constipation on survival was evaluated using Cox regression analysis with 2-year survival as the index. Patients were divided into two groups based on the presence of comorbid constipation. The patient background was adjusted using propensity score matching, and the evaluation included assessing the 2-year survival and cardiovascular mortality occurrence using the log-rank test.

Results

Among 1,061 patients hospitalized for acute decompensated heart failure, 715 with complete data (124 with comorbid constipation and 591 without) were analyzed. Comorbid constipation was identified as a risk factor for poorer survival in the Cox regression model (hazard ratio: 1.90, 95% confidence interval: 1.3-2.8, P < 0.001). Propensity score matching included 104 patients in each group. Survival analysis using the log-rank test indicated worse survival (P = 0.023) and higher cardiovascular mortality (P = 0.043) in the comorbid constipation group.

Conclusion

Constipation can negatively affect the survival of patients with heart failure. Although the causal link between constipation and decreased survival remains unclear, identifying comorbid constipation is essential for identifying heart failure patients at a higher risk of poor outcomes.

Fecal microbial load is a major determinant of gut microbiome variation and a confounder for disease associations

The microbiota in individual habitats differ in both relative composition and absolute abundance. While sequencing approaches determine the relative abundances of taxa and genes, they do not provide information on their absolute abundances. Here, we developed a machine-learning approach to predict fecal microbial loads (microbial cells per gram) solely from relative abundance data. Applying our prediction model to a large-scale metagenomic dataset (n = 34,539), we demonstrated that microbial load is the major determinant of gut microbiome variation and is associated with numerous host factors, including age, diet, and medication. We further found that for several diseases, changes in microbial load, rather than the disease condition itself, more strongly explained alterations in patients' gut microbiome. Adjusting for this effect substantially reduced the statistical significance of the majority of disease-associated species. Our analysis reveals that the fecal microbial load is a major confounder in microbiome studies, highlighting its importance for understanding microbiome variation in health and disease.

The in vivo metabolic pathway of Deg-AZM and in vitro investigations into the contribution of drug metabolizing enzymes and drug transporters in the drug interactions of Deg-AZM, a clinical-stage new transgelin agonist

Introduction

Deglycosylated azithromycin (Deg-AZM), a new transgelin agonist with positive therapeutic effects on slow transit constipation, has been approved for clinical trials in 2024. This work investigated the drug metabolism and transport of Deg-AZM to provide research data for further development of Deg-AZM.

Methods

A combination of UPLC-QTOF-MS was used to obtain metabolite spectra of Deg-AZM in plasma, urine, feces and bile. Caco-2 cells was used to investigate the permeability of Deg-AZM and whether it is a potential substrate of the efflux transporter P-glycoprotein. Human liver microsome phenotyping assays with chemical inhibition and recombinant CYPs phenotyping assays were used to investigate the CYP450 enzyme phenotype involved in Deg-AZM metabolism in vitro. A HLM inhibition reaction system was established to evaluate the inhibitory effect of Deg-AZM on CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, and CYP3A4. The mRNA expression of human primary hepatocytes incubated with Deg-AZM or not was evaluate the induction of Deg-AZM on CYP1A2, CYP2B6, and CYP3A4.

Results

44 metabolites of Deg-AZM were identified in rat urine, feces, bile, and plasma, the metabolic pathways included demethylation, monohydroxylation, dihydroxylation, dehydroxidation, hydroreduction, hydrolysis, methylation, glucuronidation and the combination of different metabolic pathways. Deg-AZM was a low permeability drug in the intestine and a potential substrate of the efflux transporter P-glycoprotein. CYP3A4 was the major CYP isoform responsible for Deg-AZM metabolism. Deg-AZM showed moderate inhibition with CYP2B6 and CYP2D6. Data in three batches of human primary hepatocytes disclosed induction potential of Deg-AZM on CYP2B6 and CYP3A4.

Conclusion

The in vivo metabolic pathway of Deg-AZM and in vitro possibility of drug interaction for Deg-AZM with CYP enzymes and drug transporter were fully investigated. It was suggested that dose adjustments may be warranted depending on the potency of the corresponding modulators in clinical.

Constipation and risk of death and cardiovascular events in patients on hemodialysis

BACKGROUND

Constipation is a common gastrointestinal disorder and is often accompanied by alteration in the gut microbiota. Recently, several studies have disclosed its association with an increased risk of cardiovascular disease and mortality in the general population. Despite the high prevalence of constipation, data on the clinical impact of constipation in patients with chronic kidney disease are limited. We aimed to explore the prevalence of constipation and its association with cardiovascular disease in chronic kidney disease using a nationally representative cohort of hemodialysis patients.

METHODS

This study used hemodialysis quality assessment and health insurance claims data from patients undergoing maintenance hemodialysis in South Korea. Chronic constipation was defined using the total number of laxatives prescribed during the 1-year baseline period. The primary outcome was a composite of acute ischemic stroke, hemorrhagic stroke, myocardial infarction, or all-cause death. Secondary outcomes were the individual components of the primary outcome.

RESULTS

Among 35,230 patients on hemodialysis, 9,133 (25.9%) were identified as having constipation. During a median follow-up of 5.4 years, patients with constipation had a 15% higher incidence of the composite outcome, 16% higher incidence of ischemic stroke, and 14% higher all-cause mortality, after multivariate adjustment.

CONCLUSION

Chronic constipation requiring laxatives was associated with a higher risk of the composite outcome of cardiovascular events or all-cause death in patients on hemodialysis. Further studies are needed to confirm whether constipation is an independent predictor or a possible causal factor of cardiovascular disease.

Association Between Coexisting Constipation and Heart Failure Readmission in Patients With Heart Failure - A Nationwide Database Study

Background

Constipation often coexists with heart failure (HF) and can cause increased blood pressure variability, which may increase the risk of repeated HF admissions. However, large-scale contemporary data regarding the prognostic effect of constipation in patients with HF are lacking.

Methods and Results

We retrospectively identified 556,792 patients admitted for HF for the first time and discharged alive in the fiscal years 2016-2021 using the Japanese Diagnosis Procedure Combination database. Constipation was defined as continued use of laxatives after discharge. We examined the association between constipation and 1-year HF readmission. The prevalence of constipation was 22.0% (n=122,670), which remained stable over the 6 years. Patients with constipation were older (82.7±10.1 vs. 79.3±12.8 years), more often female (53.5% vs. 48.0%), and received medications for HF more frequently at discharge compared with those without constipation. In the multivariable Cox proportional hazards model, constipation was significantly associated with a higher incidence of 1-year HF readmission (24.0% vs. 18.6%; adjusted hazard ratio [HR] 1.08; 95% confidence interval [CI] 1.06-1.10). This result was consistent with the result from the Fine-Gray model accounting for competing risk of death (subdistribution HR 1.08; 95% CI 1.06-1.09).

Conclusions

Constipation was associated with a higher risk of HF readmission after the first episode of HF hospitalization. Given the detrimental effect of constipation, further efforts are warranted to decrease constipation-related risk in patients with HF.

Integration of UPLC-MS/MS-based metabolomics and desorption electrospray ionization-mass spectrometry imaging reveals that Shouhui Tongbian Capsule alleviates slow transit constipation by regulating bile acid metabolism

Slow transit constipation (STC) is a common intestinal disorder. Some studies reported that Shouhui Tongbian Capsule (SHTB) can effectively mitigate STC symptoms. A detailed understanding of the changes in the endogenous metabolite profile of rats is crucial for a more accurate comprehension of the molecular pathological characteristics of SHTB in treating STC. In the present study, a method integrating metabolomics based on Ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) and Desorption electrospray ionization (DESI)-mass spectrometry imaging (MSI) was proposed to investigate serum, feces and colon tissue metabolic alterations of STC rats induced by diphenoxylate and the effect of SHTB treatment on metabolism. Then, Enzyme-linked immunosorbent assay (ELISA) and Western blot (WB) analysis for verifying the potential mechanism of SHTB in treating STC. As a result, we first indicated that SHTB significantly improved intestinal peristalsis and low fecal water content in STC rats. Furthermore, after treatment with SHTB, the thickness of muscle layers was increased, demonstrated SHTB's effectiveness in reducing intestinal injury in STC rats. Besides, bile acid (BA) metabolomics based on UPLC-MS/MS revealed significant increase in serum levels of Cholic acid (CA), Deoxycholic acid (DCA), Chenodeoxycholic acid (CDCA), Ursodeoxycholic acid (UDCA), and Glycolithocholic acid (GLCA), whereas the contents of CA and DCA in feces were significantly decreased in STC rats. Nonetheless, they returned to the control levels after the SHTB administration. ELISA results showed that SHTB significantly hindered the excessive reabsorption of BAs by inhibiting apical sodium-dependent bile acid transporter (ASBT), organic solute transporter alpha (OSTα) and organic solute transporter beta (OSTβ) in the ileum tissue of STC rats. Furthermore, the DESI-MSI analysis revealed that SHTB remarkably enhanced DCA in the colon tissue of STC rats. The WB results indicated that SHTB reinstated Takeda G-protein-coupled receptor 5 (TGR5) expression, a receptor for BAs and a key regulator of colonic motility. Consequently, DCA exerted its effects on TGR5, leading to the promotion of colonic motility. This study provided more comprehensive and detailed information about the BA metabolomics in the serum, feces and colon of STC rats. These findings highlighted the promising potential of metabolomics based on UPLC-MS/MS and DESI-MSI method for application in the study of STC diseases.

Constipation is associated with an increased risk of major adverse cardiac events in a UK population

Traditional cardiovascular risk factors, including hypertension, only explain part of major adverse cardiac events (MACEs). Understanding what other risk factors contribute to MACE is essential for prevention. Constipation shares common risk factors with hypertension and is associated with an increased risk of several cardiovascular diseases. We hypothesized that constipation is an underappreciated risk factor for MACE. We used the population healthcare and genomic data in the UK Biobank (n = 408,354) to study the contribution of constipation (ICD10 K59.0) to the risk of MACE, defined by any episode of acute coronary syndrome (ACS), ischemic stroke, and heart failure (HF). Analyses were controlled for traditional cardiovascular risk factors. We also assessed genetic correlations (rg) between constipation and MACE. Constipation cases (n = 23,814) exhibited a significantly higher risk of MACE compared with those with normal bowel habits [odds ratio (OR) = 2.15, P < 1.00 × 10-300]. Constipation was also significantly associated with individual MACE subgroups, in order: HF (OR = 2.72, P < 1.00 × 10-300), ischemic stroke (OR = 2.36, P = 2.02 × 10-230), and ACS (OR = 1.62, P = 5.82 × 10-113). In comparison with patients with constipation-free hypertension, patients with hypertension with constipation showed significantly higher odds of MACE (OR = 1.68, P = 1.05 × 10-136) and a 34% increased risk of MACE occurrence (P = 2.3 × 10-50) after adjustment for medications that affect gut motility and other traditional cardiovascular risk factors. Finally, we detected positive genetic correlations between constipation and MACE subgroups ACS (rg = 0.27, P = 2.12 × 10-6), ischemic stroke (rg = 0.23, P = 0.011), and HF (rg = 0.21, P = 0.0062). We identified constipation as a potential risk factor independently associated with higher MACE prevalence. These findings warrant further studies on their causal relationship and identification of pathophysiological mechanisms.NEW & NOTEWORTHY Analyzing 408,354 participants of the UK Biobank, we show that constipation cases exhibited a significantly higher risk of major adverse cardiac events (MACEs) than those with regular bowel habits. In comparison with patients with constipation-free hypertension, patients with hypertension with constipation showed significantly higher odds of MACE and a 34% increased risk of subsequent MACE occurrence. Finally, we detected positive genetic correlations between constipation and MACE. This association holds potential for therapeutic exploitation and prevention based on individuals' risk assessment.

Impact of Constipation on Health Outcomes in Medically Hospitalized Patients: A Prospective Study on Laxative Use and Health Care Outcomes

Background and Objectives: Constipation affects health-related quality of life and increases hospital visits. We conducted this prospective cohort study to assess laxative use, health outcomes of constipation in medically hospitalized patients, and related health outcomes. Materials and Methods: A prospective single-center study included all adult patients admitted under the General Internal Medicine Unit from 1 February 2022, to 31 August 2022. Constipation was defined using the Constipation Assessment Scale (CAS). Patients were assessed for 28 days during their hospital stay and up to 90 days post-discharge. Result: Among the included patients, 62.45% experienced constipation, which was associated with poor health outcomes including delirium (p = 0.048), intensive care admission (p < 0.01), cardiopulmonary arrest (p < 0.01), inpatient mortality (p < 0.01), longer hospital stay (p < 0.01), 90-day mortality (p < 0.01), and 90-day hospital readmission (p < 0.01). Laxative treatment was administered to only 33.93% of patients with constipation and was more commonly used among older patients (p < 0.01), those with high CAS scores (p < 0.01), longer hospital stays (p < 0.01), and critically ill patients (intensive care admission) (p = 0.01), as well as those who had cardiopulmonary arrest (p < 0.01) and high inpatient mortality (p < 0.01). Conclusions: This study identified several associations between constipation and poor health outcomes and highlighted the underutilization of laxatives in treating constipation. It is vital to interpret our results with caution. Therefore, we believe that a randomized controlled trial will help enhance our understanding of the interaction between constipation, laxative use, and poor health outcomes.

Application of traditional Chinese medicine nursing technology: Traditional Chinese medicine ironing combined with traditional Chinese medicine massage in improving functional constipation in elderly patients

To explore the therapeutic effect of traditional Chinese medicine (TCM) nursing technology combined with TCM massage on elderly patients with functional constipation (FC). Ninety elderly patients with FC admitted to our hospital from January 2022 to February 2023 were selected and randomly divided into 3 groups. The control group was treated with conventional Western medicine, observation group 1 was treated with TCM massage on the basis of the control group, and observation group 2 was treated with medicine ironing combined with TCM massage on the basis of the control group. Compare 3 groups of TCM syndrome scores, clinical efficacy, complete spontaneous bowel movements (CSBM) per week, Bristol fecal trait scale, and safety. There was a statistically significant difference in clinical effective rates among the 3 groups (96.67%, 83.33%, 66.67%) (P < .05), and the observation group 2 was higher than the observation group 1 and higher than the control group. After treatment, the TCM syndrome scores of the 2 groups were lower than those of the observation group 1 and the control group; And observation showed that the TCM syndrome score of group 1 was lower than that of the control group (P < .05). After treatment, the increase in scores of CSBM and Bristol fecal traits in the 2 groups was higher than that in the observation group and control group, and the increase in scores of CSBM and Bristol fecal traits in the observation group was higher than that in the control group (P < .05). There was no statistically significant difference in the incidence of adverse reactions among the 3 groups (10.00%, 6.67%, 20.00%) (P > .05). The application of TCM nursing techniques such as TCM ironing and TCM massage in elderly patients with FC has a significant clinical effect, which can effectively improve clinical symptoms, defecation frequency, and fecal characteristics, and has high safety.

Exploring the top 30 drugs associated with drug-induced constipation based on the FDA adverse event reporting system

Objective

This project aims to identify the top 30 drugs most commonly associated with constipation and their signal values within the FDA Adverse Event Reporting System database.

Methods

We extracted adverse drug events (ADEs) related to constipation from the FAERS database spanning from January 1, 2004, to September 30, 2023. We compiled the 30 most frequently reported drugs based on the frequency of constipation events. We employed signal detection methodologies to ascertain whether these drugs elicited significant signals, including reporting odds ratio, proportional reporting ratio, multi-item gamma Poisson shrinker, and information component given by the Bayesian confidence propagation neural network. Furthermore, we conducted a time-to-onset (TTO) analysis for drugs generating significant signals using the medians, quartiles, and the Weibull shape parameter test.

Results

We extracted a total of 50, 659, 288 ADEs, among which 169,897 (0.34%) were related to constipation. We selected and ranked the top 30 drugs. The drug with the highest ranking was lenalidomide (7,730 cases, 4.55%), with the most prevalent drug class being antineoplastic and immunomodulating agents. Signal detection was performed for the 30 drugs, with constipation risk signals identified for 26 of them. Among the 26 drugs, 22 exhibited constipation signals consistent with those listed on the FDA-approved drug labels. However, four drugs (orlistat, nintedanib, palbociclib, and dimethyl fumarate) presented an unexpected risk of constipation. Ranked by signal values, sevelamer carbonate emerged as the drug with the strongest risk signal [reporting odds ratio (95% CI): 115.51 (110.14, 121.15); PRR (χ2): 83.78 (191,709.73); EBGM (EB05): 82.63 (79.4); IC (IC025): 6.37 (4.70)]. A TTO analysis was conducted for the 26 drugs that generated risk signals, revealing that all drugs exhibited an early failure type. The median TTO for orlistat was 3 days, the shortest of all the drugs, while the median TTO for clozapine was 1,065 days, the longest of all the drugs.

Conclusion

Our study provides a list of drugs potentially associated with drug-induced constipation (DIC). This could potentially inform clinicians about some alternative medications to consider when managing secondary causes of constipation or caring for patients prone to DIC, thereby reducing the incidence and mortality associated with DIC.

Central nervous injury risk factors after endovascular repair of a thoracic aortic aneurysm with type B aortic dissection

BACKGROUND

Aortic dissection is the deadliest disease of the cardiovascular system. Type B aortic dissection accounts for 30%-60% of aortic dissections and is mainly treated by endovascular repair of thoracic endovascular aneurysm repair (TEVAR). However, patients are prone to various complications after surgery, with central nervous system injury being the most common, which seriously affects their prognosis and increases the risk of disability and death. Therefore, exploring the risk factors of central nervous system injury after TEVAR can provide a basis for its prevention and control.

AIM

To investigate the risk factors for central nervous system injury after the repair of a thoracic endovascular aneurysm with type B aortic dissection.

METHODS

We enrolled 306 patients with type B aortic dissection who underwent TEVAR at our hospital between December 2019 and October 2022. The patients were categorized into injury (n = 159) and non-injury (n = 147) groups based on central nervous system injury following surgery. The risk factors for central nervous system injury after TEVAR for type B aortic dissection were screened by comparing the two groups. Multivariate logistic regression analysis was performed.

RESULTS

The Association between age, history of hypertension, blood pH value, surgery, mechanical ventilation, intensive care unit stay, postoperative recovery times on the first day after surgery, and arterial partial pressure of oxygen on the first day after surgery differed substantially (P < 0.05). Multivariate logistic regression analysis indicated that age, surgery time, history of hypertension, duration of mechanical ventilation, and intensive care unit stay were independent risk factors for central nervous system injury after TEVAR of type B aortic dissection (P < 0.05).

CONCLUSION

For high-risk patients with central nervous system injury after TEVAR of type B aortic dissection, early intervention measures should be implemented to lower the risk of neurological discomfort following surgery in high-risk patients with central nervous system injury after TEVAR for type B aortic dissection.

Effective process quality control management for constipation prevention in hospitalized patients with acute coronary syndrome: An observational study

Objective

To evaluate the effectiveness of monitoring and managing process quality control indicators in the prevention of constipation among hospitalized patients with acute coronary syndrome (ACS).

Methods

A total of 512 hospitalized patients diagnosed with ACS between January and June 2022 were screened for inclusion in the study. Ultimately, 456 eligible participants were enrolled and divided into two groups based on the chronological order of admission: the control group and the observation group. Upon admission, both groups of patients received routine constipation prevention measures in the department. However, the observation group was subjected to targeted process quality control management, which included monitoring and managing five indicators related to constipation prevention: correctness of bowel movement recording; usage rate of laxatives; execution rate of physical interventions; implementation rate of constipation prevention education; completion rate of dietary structure and habit assessments. Data were analyzed using SPSS, with t tests and χ 2 tests for group comparisons.

Results

In comparison to the control group, the observation group demonstrated significant advantages in terms of constipation incidence, completion rates of the five process quality control indicators, occurrence rates of adverse cardiac events during defecation, and PHQ-9 scores before discharge. These disparities demonstrated statistical significance with a p value < 0.05.

Conclusion

Target-oriented process quality control management is shown to be effective in reducing constipation incidence and adverse cardiac events during constipation episodes, as well as alleviating depressive symptoms among ACS patients, thus providing a safe and effective approach to constipation prevention.

Unsupervised Feature Selection to Identify Important ICD-10 and ATC Codes for Machine Learning on a Cohort of Patients With Coronary Heart Disease: Retrospective Study

Background

The application of machine learning in health care often necessitates the use of hierarchical codes such as the International Classification of Diseases (ICD) and Anatomical Therapeutic Chemical (ATC) systems. These codes classify diseases and medications, respectively, thereby forming extensive data dimensions. Unsupervised feature selection tackles the "curse of dimensionality" and helps to improve the accuracy and performance of supervised learning models by reducing the number of irrelevant or redundant features and avoiding overfitting. Techniques for unsupervised feature selection, such as filter, wrapper, and embedded methods, are implemented to select the most important features with the most intrinsic information. However, they face challenges due to the sheer volume of ICD and ATC codes and the hierarchical structures of these systems.

Objective

The objective of this study was to compare several unsupervised feature selection methods for ICD and ATC code databases of patients with coronary artery disease in different aspects of performance and complexity and select the best set of features representing these patients.

Methods

We compared several unsupervised feature selection methods for 2 ICD and 1 ATC code databases of 51,506 patients with coronary artery disease in Alberta, Canada. Specifically, we used the Laplacian score, unsupervised feature selection for multicluster data, autoencoder-inspired unsupervised feature selection, principal feature analysis, and concrete autoencoders with and without ICD or ATC tree weight adjustment to select the 100 best features from over 9000 ICD and 2000 ATC codes. We assessed the selected features based on their ability to reconstruct the initial feature space and predict 90-day mortality following discharge. We also compared the complexity of the selected features by mean code level in the ICD or ATC tree and the interpretability of the features in the mortality prediction task using Shapley analysis.

Results

In feature space reconstruction and mortality prediction, the concrete autoencoder-based methods outperformed other techniques. Particularly, a weight-adjusted concrete autoencoder variant demonstrated improved reconstruction accuracy and significant predictive performance enhancement, confirmed by DeLong and McNemar tests (P<.05). Concrete autoencoders preferred more general codes, and they consistently reconstructed all features accurately. Additionally, features selected by weight-adjusted concrete autoencoders yielded higher Shapley values in mortality prediction than most alternatives.

Conclusions

This study scrutinized 5 feature selection methods in ICD and ATC code data sets in an unsupervised context. Our findings underscore the superiority of the concrete autoencoder method in selecting salient features that represent the entire data set, offering a potential asset for subsequent machine learning research. We also present a novel weight adjustment approach for the concrete autoencoders specifically tailored for ICD and ATC code data sets to enhance the generalizability and interpretability of the selected features.

Use of Japanese Herbal Kampo Medicine in Patients With Acute Cardiovascular Disease - A 12-Year Nationwide Cohort Analysis

BACKGROUND

Kampo, a Japanese herbal medicine, is approved for the treatment of various symptoms/conditions under national medical insurance coverage in Japan. However, the contemporary nationwide status of Kampo use among patients with acute cardiovascular diseases remains unknown.

METHODS AND RESULTS

Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified 2,547,559 patients hospitalized for acute cardiovascular disease (acute myocardial infarction, heart failure, pulmonary embolism, or aortic dissection) at 1,798 hospitals during the fiscal years 2010-2021. Kampo medicines were used in 227,008 (8.9%) patients, with a 3-fold increase from 2010 (4.3%) to 2021 (12.4%), regardless of age, sex, disease severity, and primary diagnosis. The top 5 medicines used were Daikenchuto (29.4%), Yokukansan (26.1%), Shakuyakukanzoto (15.8%), Rikkunshito (7.3%), and Goreisan (5.5%). From 2010 to 2021, Kampo medicines were initiated earlier during hospitalization (from a median of Day 7 to Day 3), and were used on a greater proportion of hospital days (median 16.7% vs. 21.4%). However, the percentage of patients continuing Kampo medicines after discharge declined from 57.9% in 2010 to 39.4% in 2021, indicating their temporary use. The frequency of Kampo use varied across hospitals, with the median percentage of patients prescribed Kampo medications increasing from 7.7% in 2010 to 11.5% in 2021.

CONCLUSIONS

This nationwide study demonstrates increasing Kampo use in the management of acute cardiovascular diseases, warranting further pharmacoepidemiological studies on its effectiveness.

Impaired Gastrointestinal Motility and Worsening Heart Failure in Patients Receiving Trans-Catheter Aortic Valve Replacement

Background: Impaired gastric motility in the form of constipation may often occur in elderly patients with chronic heart failure. Candidates for trans-catheter aortic replacement (TAVR) are of old age and have multiple comorbidities, probably including constipation. However, the clinical implication of a history of constipation in patients receiving TAVR remains unknown. Methods: Patients who underwent TAVR at our large academic center between 2015 and 2022 were eligible. The prognostic impact of the prescribed laxative type and number, which was assumed as the severity of constipation, on the incidence of death or heart failure readmission two years after index discharge was investigated. Results: A total of 344 patients were included. Median age was 85 years, and 99 patients were men. Patients with any laxatives (N = 166) had higher systolic blood pressure, higher plasma B-type natriuretic peptide levels, and a lower prescription rate of renin-angiotensin system inhibitors at the time of index discharge after TAVR (p < 0.05 for all). The number of laxative types was independently associated with the composite primary outcome with an adjusted hazard ratio of 1.83 (95% confidence interval 1.27-2.63, p = 0.001) with a cutoff of one type of laxative used, which significantly stratified the 2-year cumulative incidence of the primary outcome (18% versus 7%, p = 0.001). Conclusions: The presence of constipation was associated with worse clinical outcomes following TAVR. The prognostic impact of an aggressive intervention for constipation remains a future concern in this cohort.

The nomogram for predicting nasal bleeding after endoscopic transsphenoidal resection of pituitary adenomas: a retrospective study

Objective

This study aimed to develop and validate a dynamic nomogram to assess the risk of nasal bleeding after endoscopic transnasal transsphenoidal pituitary tumor resection.

Methods

A retrospective analysis was conducted on patients who underwent endoscopic transnasal transsphenoidal pituitary tumor resection from June 2019 to June 2021. Univariate and multivariate logistic regression analyses were used to screen for independent risk factors for nasal bleeding from the training set. A multivariate logistic regression model was established, a nomogram was plotted, and it was validated in an internal validation set. The performance of the nomogram was evaluated based on the receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA).

Results

The nomogram indicators included anticoagulant use, sphenoid sinus artery injury, nasal irrigation, platelet count (PLT), and constipation. The predictive model had an area under the ROC curve of 0.932 (95% CI: 0.873-0.990) and 0.969 (95% CI: 0.940-0.997) for the training and validation sets, respectively, indicating good discrimination. The calibration curve showed good consistency between the actual and predicted incidence of nasal bleeding (p > 0.05). DCA indicated that the nomogram had good clinical net benefit in predicting postoperative nasal bleeding in patients.

Conclusion

In summary, this study explored the incidence and influencing factors of nasal bleeding after endoscopic transnasal transsphenoidal pituitary tumor resection and established a predictive model to assist clinical decision-making.

Yiqi Kaimi prescription regulates protein phosphorylation to promote intestinal motility in slow transit constipation

ETHNOPHARMACOLOGICAL RELEVANCE

The clinical efficacy of the Yiqi Kaimi prescription has been confirmed in slow transit constipation. However, the effects and biological mechanism of Yiqi Kaimi prescription are still unclear.

AIMS OF THE STUDY

To identify the effects of Yiqi Kaimi prescription on intestinal motility; To reveal the potential key targets and pathways of Yiqi Kaimi prescription for the treatment of slow transit constipation.

MATERIALS AND METHODS

The effects of Yiqi Kaimi prescription on slow transit constipation were investigated in a mouse model. The terminal ink propulsion experiment and fecal indocyanine green imaging was used to measure the intestinal transit time. Protein phosphorylation changes in colon tissues treated with Yiqi Kaimi prescription were detected using a Phospho Explorer antibody microarray. Bioinformatic analyses were performed using the Database for Annotation Visualization and Integrated Discovery (DAVID) and the Search Tool for the Retrieval of Interacting Genes (STRING). Western blot analysis and immunohistochemistry confirmed the observed changes in phosphorylation.

RESULT

s: Yiqi Kaimi prescription significantly increased the intestinal transit rate (P < 0.05 vs. model) and reduced the time to first discharge of feces containing fecal indocyanine green imaging in mice (P < 0.05 vs. model). The administration of Yiqi Kaimi prescription induced phosphorylation changes in 41 proteins, with 9 upregulated proteins and 32 downregulated proteins. Functional classification of the phosphorylated proteins with DAVID revealed that the critical biological processes included tyrosine protein kinases, positive regulation of calcium-mediated signaling and response to muscle stretch. The phosphorylation of the spleen tyrosine kinase (SYK) at Tyr348 increased 2.19-fold, which was the most significant change. The phosphorylation level of the transcription factor p65 (RELA) at Thr505 was decreased 0.57-fold. SYK was a hub protein in the protein-protein interaction network and SYK and RELA formed the core of the secondary subnetwork. The key protein phosphorylation after treatment with Yiqi Kaimi prescription were verified by Western blot analysis and immunohistochemistry.

CONCLUSION

Yiqi Kaimi prescription significantly enhanced intestinal motility. This effect was attributed to alterations in the phosphorylation levels of various target proteins. The observed changes in protein phosphorylation, including SYK and RELA, may serve as crucial factors in the treatment of slow transit constipation.

Influencing Factors of Constipation in Elderly Patients With Intracerebral Hemorrhage: Implication for Clinical Care

Background: Constipation is common in elderly inpatients with intracerebral hemorrhage. This study aimed to construct a model for predicting the risk of constipation in elderly inpatients with intracerebral hemorrhage and to provide reference for formulating targeted intervention measures. Methods: Elderly patients with intracerebral hemorrhage who were treated in the department of Neurosurgery of a third-class hospital in Suzhou from January 2018 to September 2023 were included. Clinical data of patients with and without constipation were compared. Logistic regression analysis was used to explore the influencing factors of constipation in elderly patients with intracerebral hemorrhage, and R software was used to construct a line chart model to verify its predictive effect. Results: A total of 504 elderly patients with intracerebral hemorrhage were included. The incidence of constipation in elderly patients with cerebral hemorrhage was 63.9%. Logistic regression analysis showed that GCS score (OR = 1.094, 95%CI: 1.019∼1.174), hypertension (OR = 2.911, 95%CI: 1.797∼4.715), use of dehydrating agent (OR = 3.794, 95%CI: 2.337∼6.158), surgical treatment (OR = 3.986, 95%CI: 2.339∼6.793), use of sedative drugs (OR = 4.212, 95%CI:2.386-7.435), and limb paralysis (OR = 6.313, 95%CI:3.689∼10.803) were the independent risk factors for constipation in elderly patients with intracerebral hemorrhage. The area under the ROC curve of the prediction model was 0.872 (95%CI: 0.8401∼0.9033), the best critical value was 0.705, the sensitivity was 0.748, and the specificity was 0.857. Conclusion: The constipation risk prediction model of elderly patients with cerebral hemorrhage has good differentiation and calibration, which is helpful for health care providers to identify the risk of constipation in elderly patients with intracerebral hemorrhage.

Living with constipation and communication taboos surrounding constipation among older adults: An interpretive phenomenology analysis study

Chronic constipation is a prevalent problem that significantly impacts older adults' well-being. This study aimed to explore how older adults describe constipation symptoms and impacts and understand the perceived taboo surrounding discussions on related issues. Twenty older adults with constipation were interviewed using a semi-structured format in Taiwan. The Interpretive Phenomenology Analysis approach was utilized for data analysis. Five techniques recommended by Lincoln and Guba (1985) were implemented to ensure the study's trustworthiness. The primary themes encompassed comprehensive portrayals of fecal characteristics, the discomfort symphony of constipation, emotional turbulence in the struggle against constipation, daily activities shadowed by constipation, and underlying factors contributing to communication taboos. Most participants considered the discussion of constipation taboo due to its association with an embarrassing secret, an unacceptable social norm and stigma, and apprehensions of potential gossip. Geriatric caregivers need to consider individual perspectives, communication taboos, and sociocultural contexts when addressing older adults' constipation.

Isometric Exercise Training and Arterial Hypertension: An Updated Review

Hypertension is recognised as a leading attributable risk factor for cardiovascular disease and premature mortality. Global initiatives towards the prevention and treatment of arterial hypertension are centred around non-pharmacological lifestyle modification. Exercise recommendations differ between professional and scientific organisations, but are generally unanimous on the primary role of traditional aerobic and dynamic resistance exercise. In recent years, isometric exercise training (IET) has emerged as an effective novel exercise intervention with consistent evidence of reductions in blood pressure (BP) superior to that reported from traditional guideline-recommended exercise modes. Despite a wealth of emerging new data and endorsement by select governing bodies, IET remains underutilised and is not widely prescribed in clinical practice. This expert-informed review critically examines the role of IET as a potential adjuvant tool in the future clinical management of BP. We explore the efficacy, prescription protocols, evidence quality and certainty, acute cardiovascular stimulus, and physiological mechanisms underpinning its anti-hypertensive effects. We end the review with take-home suggestions regarding the direction of future IET research.

Prevalence and Risk Factors of Constipation Symptoms among Patients Undergoing Colonoscopy: A Single-Center Cross-Sectional Study

INTRODUCTION

Constipation is one of the most common gastrointestinal symptoms. It may compromise quality of life and social functioning and result in increased healthcare use and costs. We aimed to evaluate the prevalence and risk factors of constipation symptoms, as well as those of refractory constipation symptoms among patients who underwent colonoscopy.

METHODS

Over 4.5 years, patients who underwent colonoscopy and completed questionnaires were analyzed. Patients' symptoms were evaluated using the Gastrointestinal Symptoms Rating Scale.

RESULTS

Among 8,621 eligible patients, the prevalence of constipation symptoms was 33.3%. Multivariate analysis revealed female sex (odds ratio [OR] 1.7, p < 0.001), older age (OR 1.3, p < 0.001), cerebral stroke with paralysis (OR 1.7, p = 0.009), chronic renal failure (OR 2.6, p < 0.001), ischemic heart disease (OR 1.3, p = 0.008), diabetes (OR 1.4, p < 0.001), chronic obstructive pulmonary disease (OR 1.5, p = 0.002), benzodiazepine use (OR 1.7, p < 0.001), antiparkinsonian medications use (OR 1.9, p = 0.030), and opioid use (OR 2.1, p = 0.002) as independent risk factors for constipation symptoms. The number of patients taking any medication for constipation was 1,134 (13.2%); however, refractory symptoms of constipation were still present in 61.4% of these patients. Diabetes (OR 1.5, p = 0.028) and irritable bowel syndrome (OR 3.1, p < 0.001) were identified as predictors for refractory constipation symptoms.

CONCLUSIONS

Constipation occurred in one-third of patients, and more than half of patients still exhibited refractory symptoms of constipation despite taking laxatives. Multiple medications and concurrent diseases seem to be associated with constipation symptoms.

Causal relationship between hypertension and risk of constipation: A 2-way 2-sample Mendelian randomization study

Patients with hypertension have a higher risk of having constipation and vice versa. The causal association between these 2 variables is not proven. We performed a retrospective Mendelian randomization analysis to determine the causal association between constipation and hypertension. Two-sample 2-way Mendelian randomization analysis was used. Genetic variants for constipation were derived from genome-wide association study data of European origin (15,902 cases and 395,721 controls). Corresponding genetic associations for hypertension were derived from European ancestry GWAS data (54,358 cases and 408,652 controls). Genetic susceptibility to hypertension was associated with an increased risk of constipation (OR: 3.459, 95% CI: 1.820-6.573, P < .001). In an inverse Mendelian randomization analysis, no causal effect of constipation on hypertension was found (OR: 0.999, 95% CI: 0.987-1.011, P = .834). In sensitivity analyses, these associations persisted and no multiple effects were found. This study suggests that there is a causal relationship between hypertension and constipation and that hypertension may increase the risk of developing constipation.

Effect of constipation on readmission for heart failure in patients with acute heart failure

AIMS

Constipation is a common gastrointestinal disorder that is associated with a high cardiovascular event rate in the general population. Although constipation is common in patients with cardiovascular diseases, only a few studies have examined the relationship between constipation and the prognosis of patients with heart failure. This study aimed to evaluate the effects of constipation on the prognosis of patients with acute heart failure.

METHODS AND RESULTS

We investigated 397 patients admitted to our hospital from December 2020 to December 2022 with acute heart failure (mean age, 81 ± 13 years; 54% men). Patients with constipation were defined as those either taking laxatives regularly or diagnosed with constipation according to the International Statistical Classification of Diseases and Related Health Problems. During the follow-up periods (median, 173 days), 35 patients died, and 74 experienced readmission due to heart failure. Kaplan-Meier analysis before and after propensity score matching using 14 variables revealed that the risk of readmission due to heart failure was significantly higher in patients with constipation than in those without (before: log-rank P = 0.014, after: log-rank P = 0.0027). The adjusted Cox proportional hazards analysis revealed that the hazard ratio for readmission due to heart failure was 2.61 (95% confidence interval, 1.38-4.94, P = 0.0032). The risk of all-cause death was not significantly different between the two groups (hazard ratio, 1.76; 95% confidence interval, 0.61-5.06; P = 0.30).

CONCLUSIONS

Constipation status was strongly associated with a higher risk of readmission for heart failure in patients with acute heart failure.

Open-Label, Single-Center, Single-Arm Study Evaluating the Efficacy and Safety of Elobixibat for Chronic Constipation in Patients With Heart Failure

Background: Neither the efficacy nor safety of elobixibat has been investigated in the treatment of chronic constipation in patients with heart failure (HF). Methods and Results: In this prospective, single-center, single-arm study elobixibat (10 mg/day) was administered for 12 weeks to 18 HF patients with chronic constipation defined according to the Rome IV criteria. Spontaneous bowel movement (SBM), stool consistency as measured by the Bristol Stool Form Scale, and degree of straining during defecation were recorded. In addition, biomarkers, blood pressure (BP) measured by ambulatory monitoring, and adverse events were assessed. Although there was no significant difference, the frequency of SBM increased by 2.0/week from baseline to Week 12. Both the degree of straining during defecation and low-density lipoprotein cholesterol (LDL-C) levels were significantly decreased at Week 12 (straining, -0.79 [95% confidence interval (CI), -1.40 to -0.17]; LDL-C, -10.4 mg/dL [95% CI, -17.9 to -2.9]). Although not significant, the difference in BP before and after defecation tended to decrease from baseline by approximately 10 mmHg at Week 12. Serious adverse events were not observed. Conclusions: Elobixibat reduced the degree of straining during defecation, and improved the lipid profile in HF patients with chronic constipation.

Systemic hemodynamic atherothrombotic syndrome: from hypothesis to evidence

Hypertension is a risk factor for cardiovascular disease (CVD). However, the association between blood pressure (BP) and CVD events has been based on mean BP alone. BP variability (BPV) is associated with increased organ damage and CVD events independently or beyond average home BP. To explain this association, we propose the systemic hemodynamic atherothrombotic syndrome (SHATS) hypothesis. The SHATS hypothesis indicates that hemodynamic stress increases vascular disease and vice versa, leading to a vicious cycle of the association between hemodynamic stress and a vascular disease; this association provides not only the risk but also the trigger for CVD events. The evidences of SHATS were gradually accumulating. We showed arterial stiffness synergistically amplified the association between hemodynamic stress and cardiac overload / CVD events in patients with at least one CVD risk factor.

Pharmacotherapy in SAH: Clinical Trial Lessons

Subarachnoid Haemorrhage (SAH) is a medical emergency with potentially devastating outcomes. It is without doubt that over the past decades, there has been a radical change in the approach towards patients with SAH, both in terms of the surgical as well as of the pharmacological treatments offered. The present review aims to outline the principal data regarding the best practice in the pharmacotherapy of SAH, as well as to sum up the emerging evidence from the latest clinical trials. To date, nimodipine is the only evidence-based treatment of vasospasm. However, extensive research is currently underway to identify novel substances with magnesium sulphate, cilostazol, clazosentan and fasudil, demonstrating promising results. Antifibrinolytic therapy could help reduce mortality, and anticoagulants, in spite of their associated hazards, could actually reduce the incidence of delayed cerebral ischemia. The effectiveness of triple-H therapy has been challenged, yet evidence on the optimal regimen is still pending. Statins may benefit some patients by reducing the incidence of vasospasm and delayed ischemic events. As several clinical trials are underway, it is expected that in the years to come, more therapeutic options will be added to the attending physician's armamentarium.

Flaxseed powder and magnesium hydroxide syrup on the intestinal function of patients with acute myocardial infarction in intensive care units

Background

Flaxseed powder seems to improve bowel movements in these patients. Therefore, this study compares the effects of flaxseed powder and magnesium hydroxide on bowel movements of acute myocardial infarction patients hospitalized in ICU.

Methods

The population of the present parallel randomized controlled clinical trial included 70 acute myocardial infarction patients hospitalized in ICU who had no history of chronic constipation. The patients in the intervention group were given three sachets of flaxseed powder (each sachet was 3 g) twice a day for four days. The patients in the control group were given 20 cc of magnesium hydroxide syrup each morning. The Bristol scale was used to describe stool consistency.

Results

The mean and standard deviation of the number of bowel movements within five days after intervention are 1.86 ± 1.08 and 1.6 ± 0.65 in the intervention and the control groups, respectively. The frequency of normal stool consistency of the first bowel movement is 94.3% for the intervention group and 85.7% for the control group, which shows no significant differences between the two groups in terms of stool consistency and bowel movement frequency (P=0.510). The bowel movements started on average after 35.2±97.97 hours in the flaxseed group and 24.771±2.677 hours in the magnesium hydroxide group (P=0.023).

Conclusion

The results showed that flaxseed powder increases bowel movement frequency and improves the patients' stool consistency, but the differences between the two groups are insignificant. Finally, the time to the first defecation was shorter in the magnesium hydroxide group.

Prognostic Implication of Intestinal Wall Edema in Patients with Aortic Stenosis Receiving Trans-Catheter Aortic Valve Replacement

BACKGROUND

A recently proposed mechanism, the intestinal-cardiovascular relationship, serves as a framework to elucidate the interplay between these two systems. In our investigation, we assessed the prognostic implications of colon wall thickness, a marker correlated with intestinal congestion and dysfunction, in patients diagnosed with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR).

METHODS

Patients diagnosed with severe aortic stenosis who underwent TAVR at our institution during the period spanning 2015 to 2022 were retrospectively enrolled. As part of the institutional protocol, patients underwent abdominal computed tomography upon admission, preceding TAVR. Our analysis aimed to assess the influence of colon wall thickness on the occurrence of either all-cause mortality or readmission due to heart failure within a two-year period.

RESULTS

A total of 345 patients were included. The median age was 85 (82, 88) years, and 99 patients were male. Baseline colon wall thickness was distributed widely, with a median value of 2.2 (2.0, 2.5) mm. Patients with thicker colon walls tended to have lower pulmonary artery pulsatility index values, indicating more impaired right ventricular function and more advanced malnutrition. A thicker colon wall was independently associated with 2-year death or heart failure readmission with a hazard ratio of 2.02 (95% confidence interval 1.01-14.07), adjusted for hemoglobin, age, and plasma B-type natriuretic peptide levels (p = 0.049), and significantly stratified the primary endpoint at a cutoff of 2.7 mm (25% versus 10%, p = 0.005).

CONCLUSIONS

Our initial observation revealed that a thicker baseline colon wall correlated with increased rates of mid-term mortality and readmission due to heart failure subsequent to TAVR. Developing a comprehensive understanding of the underlying causality necessitates further in-depth investigations through subsequent studies.

Bowel habits were associated with mortality in chronic kidney disease: results from a nationwide prospective cohort study

PURPOSE

Bowel habits may affect the prognosis in the chronic kidney disease (CKD) patients. This study aimed to explore the association of bowel habits with cardiovascular and all-cause mortality in CKD.

METHODS

2460 CKD patients in the National Health and Nutrition Examination Survey (NHANES) from 2005 through 2010 without missing data for bowel habits and mortality were enrolled. Bowel habits including bowel movements (BMs) per week and stools consistency were obtained by standard interview. Mortality status and cause of death were determined by NHANES-linked National Death Index records through 31 December 2015. Cox proportional hazard models and Kaplan-Meier analysis were used to evaluate the association of bowel habits with cardiovascular and all-cause mortality.

RESULTS

A total of 2460 CKD patients with an average age of 60.80 ± 0.57 years were enrolled. During an average follow-up of 87.47 ± 0.98 months, 144 cardiovascular and 669 all-cause deaths were documented. Reporting 3 or fewer BMs per week was associated with cardiovascular (HR = 1.83, 95% CI: 1.06, 3.17) and all-cause mortality (HR = 1.71, 95% CI: 1.20, 2.43). More than 10 BMs per week also increased the risk of all-cause mortality (HR = 1.21, 95% CI: 1.01, 1.45). Hard stools consistency increased the risk of all-cause mortality (HR= 2.00, 95% CI: 1.48, 2.70) compared with those reporting normal stools.

CONCLUSION

Low stool frequency and hard stool consistency were associated with an increased risk of mortality in patients with CKD.

Differential Gut Microbiota, Dietary Intakes in Constipation Patients with or without Hypertension

SCOPE

Diet and gut microbiota are involved in blood pressure regulations, but few studies have focused on the constipation patients. The study seeks to identify differences in gut microbiota between hypertensive and normotensive subjects in constipation patients, analyzes the relationship between dietary patterns and blood pressure, and explores mediation effects of gut microbiota.

METHODS AND RESULTS

Gut microbial genera and dietary information of 186 functional constipation participants are characterized by 16S rRNA sequencing and a food frequency questionnaire. The hypertensive subjects shows lower α-diversity and β-diversity of gut microbiota than normotensive (p < 0.05) and 17 differential microbial genera. The dried-beans intake frequency inversely correlated with systolic and diastolic blood pressure after multivariate adjustment (r = -0.273, p-FDR < 0.01; r = -0.251, p-FDR = 0.026, respectively). Logistic regression indicates that the individuals often consumed dried-beans have a lower hypertension risk than those never consumed [OR = 0.137, 95% CI: (0.022, 0.689), p = 0.022]. A marginal mediating effect of the genus Monoglobus is observed for the association between high-fiber dietary pattern and hypertension.

CONCLUSION

In patients with functional constipation, hypertension-related gut microbial differences are identified. Dried-beans intake is inversely associated with blood pressure, and a genus may potentially mediate the association between high-fiber dietary pattern and hypertension.

Arecoline alleviated loperamide induced constipation by regulating gut microbes and the expression of colonic genome

This study aimed to investigate the effects of arecoline on constipation by intervening at different times to explore its preventive and therapeutic effects. Symptoms related to constipation, gut microbes, short-chain fatty acid (SCFA) content in the cecum, and gene expression in the colon were measured to examine the effect of arecoline on relieving constipation. The results showed that arecoline intervention alleviated loperamide-induced constipation, as evidenced by significantly shortened intestinal transit time, increased fecal water content, improved small bowel propulsion, and increased defecation frequency. In addition, arecoline significantly reduced the levels of gastrointestinal regulatory peptides such as somatostatin and vasoactive intestinal peptide in the serum, thereby regulating intestinal peristalsis. Histopathological analysis showed that arecoline ameliorated intestinal injury caused by constipation. Gut microbial analysis indicated that arecoline altered the taxonomic composition and levels of its metabolite SCFAs in the gut microbiota. Furthermore, the colonic transcriptome results indicated that genes expression related to intestinal diseases were significantly down-regulated by arecoline intervention. In conclusion, the results of the correlation analysis propose a possible mechanism of arecoline in alleviating constipation by modulating the gut microbes and their metabolites and regulating the gut genome.

Constipation as a Drug-Related Adverse Effect in Patients with Hyperkalemia: Sodium Zirconium Cyclosilicate versus Conventional Potassium Binders

(1) Background: Constipation is one of the most serious adverse effects of potassium-lowering agents and decreases patients' quality of life. Sodium zirconium cyclosilicate (SZC) is a recently innovated potassium binder intended for patients with hyperkalemia. The impact of SZC on the worsening of constipation, as compared with conventional potassium binders, remains unknown. (2) Methods: Patients with hyperkalemia who continued SZC for over 3 months between July 2020 and May 2022 were included in this retrospective study. Patients who received other conventional potassium binders during the same period were included as a control group. Trends in the doses of anti-constipation agents during the 3-month therapeutic period were compared between the two groups as a surrogate for worsening constipation. (3) Results: A total of 50 patients (median age 74 years, 31 male) were included, consisting of 22 patients with SZC and 28 patients with other conventional potassium binders. All patients had hyperkalemia and chronic kidney disease at baseline. During the 3-month therapeutic period, serum potassium levels decreased significantly in both groups (p < 0.05 for both). The number of anti-constipation remained unchanged in the SZC group but tended to increase in the control group (p = 0.56 and p = 0.090, respectively). The total dose change in all anti-constipations was significantly lower in the SZC group than in the control group (p = 0.037). (4) Conclusions: Conventional potassium binders have a tendency to worsen constipation, whereas SZC may have the potential to improve hyperkalemia without worsening constipation. SZC may be recommended, particularly in elderly patients with ongoing or high-risk constipation.

Revisiting the Intestinal Microbiome and Its Role in Diarrhea and Constipation

The gut microbiota represents a community of microorganisms (bacteria, fungi, archaea, viruses, and protozoa) that colonize the gut and are responsible for gut mucosal structural integrity and immune and metabolic homeostasis. The relationship between the gut microbiome and human health has been intensively researched in the past years. It is now widely recognized that gut microbial composition is highly responsible for the general health of the host. Among the diseases that have been linked to an altered gut microbial population are diarrheal illnesses and functional constipation. The capacity of probiotics to modulate the gut microbiome population, strengthen the intestinal barrier, and modulate the immune system together with their antioxidant properties have encouraged the research of probiotic therapy in many gastrointestinal afflictions. Dietary and lifestyle changes and the use of probiotics seem to play an important role in easing constipation and effectively alleviating diarrhea by suppressing the germs involved. This review aims to describe how probiotic bacteria and the use of specific strains could interfere and bring benefits as an associated treatment for diarrhea and constipation.

The Burden and Treatment of Chronic Constipation Among US Nursing Home Residents

OBJECTIVE

To evaluate the burden of chronic constipation (CC) and the use of drugs to treat constipation (DTC) in 2 complementary data sources.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

US nursing home residents aged ≥65 years with CC.

METHODS

We conducted 2 retrospective cohort studies in parallel using (1) 2016 electronic health record (EHR) data from 126 nursing homes and (2) 2014-2016 Medicare claims, each linked with the Minimum Data Set (MDS). CC was defined as (1) the MDS constipation indicator and/or (2) chronic DTC use. We described the prevalence and incidence rate of CC and the use of DTC.

RESULTS

In the EHR cohort, we identified 25,739 residents (71.8%) with CC during 2016. Among residents with prevalent CC, 37% received a DTC, with an average duration of use of 19 days per resident-month during follow-up. The most frequently prescribed DTC classes included osmotic (22.6%), stimulant (20.9%), and emollient (17.9%) laxatives. In the Medicare cohort, a total of 245,578 residents (37.5%) had CC. Among residents with prevalent CC, 59% received a DTC and slightly more than half (55%) were prescribed an osmotic laxative. Duration of use was shorter (10 days per resident-month) in the Medicare (vs EHR) cohort.

CONCLUSIONS AND IMPLICATIONS

The burden of CC is high among nursing home residents. The differences in the estimates between the EHR and Medicare data confirm the importance of using secondary data sources that include over-the-counter drugs and other treatments unobservable in Medicare Part D claims to assess the burden of CC and DTC use in this population.

Prevalence, Recognition, and Risk Factors of Constipation among Medically Hospitalized Patients: A Cohort Prospective Study

Background and Objective: Constipation is a prevalent gastrointestinal condition that has a substantial impact on individuals and healthcare systems. This condition adversely affects health-related quality of life and leads to escalated healthcare expenses due to an increase in office visits, referrals to specialists, and hospital admission. This study aimed to evaluate the prevalence, recognition, risk factors, and course of constipation among hospitalized patients in medical wards. Materials and Methods: A prospective study was conducted, including all adult patients admitted to the General Medicine Unit between 1 February 2022 and 31 August 2022. Constipation was identified using the Constipation Assessment Scale (CAS), and relevant factors were extracted from the patients' medical records. Results: Among the patients who met the inclusion criteria (n = 556), the prevalence of constipation was determined to be 55.6% (95% CI 52.8-58.4). Patients with constipation were found to be older (p < 0.01) and had higher frailty scores (p < 0.01). Logistic regression analysis revealed that heart failure (Odds ratio (OR) 2.1; 95% CI 1.2-3.7; p = 0.01), frailty score (OR 1.4; 95% CI 1.2-1.5; p < 0.01), and dihydropyridines calcium channel blockers (OR 1.8; 95% CI 1.2-2.8; p < 0.01) were independent risk factors for constipation. Furthermore, the medical team did not identify constipation in 217 patients (64.01%). Conclusions: Constipation is highly prevalent among medically hospitalized patients. To ensure timely recognition and treatment, it is essential to incorporate a daily constipation assessment scale into each patient's medical records.

Efficacy and safety of Bifidobacterium quadruple viable tablets combined with mosapride citrate in the treatment of constipation in China: a systematic review and meta-analysis

AIM

To analyze the efficacy and safety of Bifidobacterium quadruple viable tablets combined with mosapride citrate for the treatment of constipation.

METHODS

A systematic review was performed on studies published until July 2022 in PubMed, Embase, China National Knowledge Infrastructure, and Wanfang. The efficacy rate, adverse reaction rate, recurrence rate, and clinical symptoms were included in the measured outcomes.

RESULTS

The efficacy of Bifidobacterium quadruple viable tablets combined with mosapride citrate in the treatment of constipation was higher than that of mosapride citrate alone (OR = 4.75, 95% CI (3.27, 6.90), Z = 8.19, P < 0.001; I² = 0.0%, P = 0.645). There was no significant difference in the incidence of adverse reactions between the two groups (OR = 0.97, 95% CI (0.61,1.57), Z = 0.11, P = 0.911; I² = 0.0%, P = 0.958). The recurrence rate of constipation in patients receiving the combination treatment was lower than that of patients treated with mosapride citrate alone (OR = 0.48, 95%CI (0.31, 0.73), Z = 3.38, P = 0.001; I² = 29.8%, P = 0.200).

CONCLUSIONS

Bifidobacterium quadruple viable tablets combined with mosapride citrate demonstrated efficacy and safety in treating constipation. Probiotics have the potential to positively influence gut health and microbial profiles in patients with functional constipation.

Association of constipation with increased risk of hypertension and cardiovascular events in elderly Australian patients

The association between constipation and cardiovascular risk is unclear. This population-level matched cohort study compared the association of constipation with hypertension and incident cardiovascular events in 541,172 hospitalized patients aged ≥ 60 years. For each constipation admission, one exact age-matched non-constipated admission was randomly selected from all hospitalizations within 2 weeks to form the comparison cohort. The association of constipation with hypertension and cardiovascular events (myocardial infarction, angina, stroke and transient ischemic attack) were analysed using a series of binary logistic regressions adjusting for age, sex, cardiovascular risk factors, gastrointestinal disorders and sociological factors. Patients with constipation had a higher multivariate-adjusted risk for hypertension (odds ratio [OR], 1.96; 95% confidence interval [CI] 1.94-1.99; P < 0.001). Compared to patients with neither constipation nor hypertension, there was a higher multivariate-adjusted risk for cardiovascular events in patients with constipation alone (OR, 1.58; 95% CI 1.55-1.61; P < 0.001) or hypertension alone (OR, 6.12; 95% CI 5.99-6.26; P < 0.001). In patients with both constipation and hypertension, the risk for all cardiovascular events appeared to be additive (OR, 6.53; 95% CI 6.40-6.66; P < 0.001). In conclusion, among hospital patients aged 60 years or older, constipation is linked to an increased risk of hypertension and cardiovascular events. These findings suggest that interventions to address constipation may reduce cardiovascular risk in elderly patients.

Effects of Bifidobacterium longum CLA8013 on bowel movement improvement: a placebo-controlled, randomized, double-blind study

A placebo-controlled, randomized, double-blind study was conducted to evaluate the effect of taking 25 billion colony-forming units of heat-killed Bifidobacterium longum CLA8013 over 2 weeks on bowel movements in constipation-prone healthy individuals. The primary endpoint was the change in defecation frequency between the baseline and 2 weeks after the intake of B. longum CLA8013. The secondary endpoints were the number of days of defecation, stool volume, stool consistency, straining during defecation, pain during defecation, feeling of incomplete evacuation after defecation, abdominal bloating, fecal water content, and the Japanese version of the Patient Assessment of Constipation Quality of Life. A total of 120 individuals were assigned to two groups, 104 (control group, n=51; treatment group, n=53) of whom were included in the analysis. After 2 weeks of consuming the heat-killed B. longum CLA8013, defecation frequency increased significantly in the treatment group compared with that in the control group. Furthermore, compared with the control group, the treatment group showed a significant increase in stool volume and significant improvement in stool consistency, straining during defecation, and pain during defecation. No adverse events attributable to the heat-killed B. longum CLA8013 were observed during the study period. This study revealed that heat-killed B. longum CLA8013 improved the bowel movements of constipation-prone healthy individuals and confirmed that there were no relevant safety issues.

Nutritional management of heart failure

Nutrition in the cardiovascular field to date has focused on improving lifestyle-related diseases such as hypertension and diabetes from the viewpoint of secondary prevention. For these conditions, "nutrition for weight loss" is recommended, and nutritional guidance that restricts calories is provided. On the other hand, in symptomatic Stage C and D heart failure, it is known that underweight patients who manifest poor nutrition, sarcopenia, and cardiac cachexia have a poor prognosis. This is referred to as the "Obesity paradox". In order to "avoid weight loss" in patients with heart failure, a paradigm shift to nutritional management to prevent weight loss is needed. Rather than prescribing uniform recommendation for salt reduction of 6 g/day or less, awareness of the behavior change stage model is attracting attention. In this setting, the value of salt restriction will need to be determined to determine the priority level of intervention for undernutrition versus the need to prevent congestive signs and symptoms. In the Intensive Care Unit (ICU)/Cardiac Care Unit (CCU) for acute heart failure, nutritional intervention should be considered within 48 h of admission. Key points are selection of access route, timing of intervention, and monitoring of side effects. In nutritional management at home and in end-of-life care, food is a reflection of an individual's values, as well as a source of joy and encouragement. The importance of digestive tract should also be recognized in heart failure from oral flail to intestinal edema, constipation, and the intestinal bacteria called the heart-gut axis. Finally, we would like to propose a new term "heart nutrition" for nutritional management in patients with heart failure in this review. Compared to the evidence for exercise therapy in heart failure, studies assessing nutritional management remain scarce and there is a need for research in this area in the future.

Relation between laxative use and risk of major bleeding in patients with atrial fibrillation and heart failure

Constipation has been reported to increase the risk of cardiovascular mortality. Patients with atrial fibrillation (AF) and heart failure (HF) have more comorbidities and an increased bleeding risk. However, it remains unclear whether constipation is associated with an increased risk of incident bleeding complications in AF with HF. Here, we investigated the association between constipation requiring laxatives and major bleeding in AF and HF. We retrospectively analyzed the medical records of 370 consecutive patients hospitalized for AF and congestive HF. Constipation was defined as regularly taking laxatives or having at least two prescriptions for a ≥ 30-day supply of laxatives. Sixty patients experienced major bleeding events during a median follow-up of 318 days. The most common sites of bleeding were lower gastrointestinal (28%, 17/60), upper gastrointestinal (27%, 16/60), and intracranial (20%, 12/60). There were 33 (55%) patients with constipation in the bleeding group and 107 (35%) in the non-bleeding group (P = 0.004). Multivariate Cox regression analysis adjusted for HAS-BLED score, hemoglobin, and direct oral anticoagulant use showed that constipation (hazard ratio [HR] 1.85, 95% confidence interval [CI] 1.11-3.08; p = 0.019) was a significant risk factor for major bleeding. We found a significant association between constipation requiring laxatives and major bleeding in patients with AF and HF. These findings indicate the need for constipation prevention in these patients to avoid reliance on invasive defecation management, including laxatives.