Evaluation of the Birmingham IBS symptom questionnaire

The Mobility and Voiding Exercises in Older Women with Urinary Incontinence (MoVEonUp) randomized controlled trial: study protocol and rationale

BACKGROUND

Urgency urinary incontinence (UUI), a risk factor for falls, affects 40% of women over the age of 70 years. Multicomponent interventions have the potential to decrease the risk of falls and urinary symptoms in women. We previously designed and conducted a pilot study of a multicomponent, theory-driven intervention in women with UUI. The Mobility and Voiding Exercises in Older Women with Urinary Incontinence (MoVEonUp) Trial will assess the efficacy of this intervention to decrease falls and urinary incontinence in community-dwelling older women.

METHODS

In the MoVEonUp Trial, 314 women ages ≥ 70 years with UUI will be randomized to the intervention group or an attention control group. Women randomized to the intervention will participate in a home-based multicomponent program consisting of strength and balance training, bladder training with urge suppression strategies, and a home hazard assessment by an occupational therapist. Women in the control group will receive an educational booklet on falls prevention and behavioral treatment for urinary incontinence. Outcomes of falls, urinary incontinence, physical function, functional limitations, and mobility will be measured at 3, 6, 9, and 12 months.

DISCUSSION

This study will determine if a home-based multicomponent program reduces the risk of falls and improves incontinence among older women with UUI. If the intervention is efficacious, it will help address the critical need to reduce falls in this population via an intervention that can be implemented in the home setting.

CLINICAL TRIAL REGISTRATION

NCT05375344.

Factors underlying the long-term efficacy of faecal microbiota transplantation for patients with irritable bowel syndrome

The long-term effects of the transplant dose, its administration route and repeated faecal microbiota transplantation (FMT) on the outcomes of FMT for patients with irritable bowel syndrome (IBS) are unknown. This study included 171 patients (125 females and 46 males): 90 g of donor feces was administered into the large intestine (LI) in 58, into the small intestine (SI) in 57, and into the SI twice (repeated SI) in 56. The patients provided a fecal sample and completed five questionnaires at the baseline and at 2 years after FMT. Fecal bacteria and the dysbiosis index were analyzed using 16S rRNA gene PCR DNA amplification/probe. The response rates at 2 years after FMT were 47.2%, 80.9%, and 76.6% in the LI, SI, and repeated-SI groups, respectively. The response rate was significantly higher in the SI and repeated SI groups than in the LI group. IBS symptoms at 2 years after FMT were less severe in the SI and repeated-SI groups than in the LI group. Fluorescent signals of several bacteria were significantly correlated with IBS symptoms and fatigue after FMT. No long-term adverse events were observed. In conclusion, administering the transplant to the SI increased the long-term response rate and reduced IBS symptom severity compared with administering it to the LI, and led to the long-term colonization of beneficial bacteria. There was no long-term difference between one and two FMT procedures (www.clinicaltrials.gov: NCT04236843).

Inflammatory Prostatitis Plus IBS-D Subtype and Correlation with Immunomodulating Agent Imbalance in Seminal Plasma: Novel Combined Treatment

We recently demonstrated the effectiveness of long-term treatment with rifaximin and the probiotic DSF (De Simone formulation) in improving urogenital and gastrointestinal symptoms in patients with both chronic inflammatory prostatitis (IIIa prostatitis) and diarrhea-predominant irritable bowel syndrome (IBS-D), relative to patients with IBS-D alone. Because the low-grade inflammation of the intestine and prostate may be one of the reasons for co-developing both IIIa prostatitis and IBS-D, we designed the present study to once again evaluate the efficacy of combined rifaximin and DSF treatment in patients affected by IIIa prostatitis plus IBS-D, but we also measured seminal plasma pro-inflammatory (IL-6) and anti-inflammatory (IL-10) cytokines before and after treatment. Methods: We consecutively enrolled 124 patients with IIIa prostatitis and IBS-D (diagnosed using the Rome III criteria). Patients were randomized into two groups: group A (n = 64) was treated with rifaximin (seven days per month for three months) followed by DSF, and group B (n = 60) was treated with a placebo. By the end of the intervention, 68.7% and 62.5% of patients from group A reported improved NIH-CPSI (National Institute of Health's Chronic Prostatitis Symptom Index) and IBS-SSS (Irritable Bowel Syndrome Severity Scoring System) scores, respectively, compared to only 3.3% and 5% of the placebo group. Group A patients also had significantly lower mean seminal plasma levels of IL-6 (11.3 vs. 32.4 pg/mL) and significantly higher mean levels of IL-10 (7.9 vs. 4.4 pg/mL) relative to baseline, whereas the levels of IL-6 and IL-10 did not change in the placebo group. Conclusions: The combined treatment with rifaximin and DSF appears to represent the optimal approach for addressing a syndrome such as irritable bowel syndrome (IBS-D plus), which frequently co-occurs with prostatitis (IIIa prostatitis). This approach is particularly beneficial in cases where the symptoms are not always clearly delineated, the etiology is multifactorial, and the diagnosis is multilevel.

Morphological Changes of the Pituitary Gland in Patients with Irritable Bowel Syndrome Using Magnetic Resonance Imaging

Irritable bowel syndrome (IBS) is a gastrointestinal functional disorder characterized by unclear underlying mechanisms. Several theories propose that hyperactivation of the hypothalamic-pituitary-adrenal (HPA) axis leads to elevated cortisol levels and increased sensitivity of gut wall receptors. Given the absence of prior literature on this topic, our study aimed to investigate the potential for diagnosing IBS based on morphological changes in the pituitary gland, specifically its volume and grayscale intensity. Additionally, we aimed to assess whether factors such as gender, age, and body mass index influence these parameters. This retrospective study involved 60 patients, examining the volume and grayscale characteristics of their pituitary glands in the presence of IBS. Our findings revealed a positive correlation between pituitary gland volume and IBS diagnosis, although no significant correlation was observed with grayscale intensity. Due to the limited existing research and the small sample size of our study, further investigation with a larger cohort is warranted to validate these results.

Prevalence of Irritable Bowel Syndrome Among Physicians at General Governmental Hospitals in Jeddah, Saudi Arabia

Background Irritable bowel syndrome (IBS) is a prevalent functional gastrointestinal disorder characterized by symptoms such as abdominal pain and altered bowel habits. It significantly impacts the quality of life and imposes a financial burden on healthcare systems. Previous studies have shown varying prevalence rates of IBS among different populations. Objective This study aims to determine the prevalence of IBS among physicians working in general governmental hospitals in Jeddah, Saudi Arabia, and to analyze the associated demographic and lifestyle factors. Methods An analytical cross-sectional study of 391 physicians from King Fahad and East Jeddah General Hospitals used an anonymous electronic survey covering demographics, health, lifestyle, and the Birmingham IBS Symptoms Questionnaire. Data were analyzed with SPSS version 29 (IBM Corp., Armonk, NY, USA) using Kruskal-Wallis and Mann-Whitney U tests, with p < 0.05 as significant. Results The prevalence of IBS among the participants was 45% (n=176). Significant associations were found between Birmingham scores and various demographic and lifestyle factors. Younger age groups (25-29 years, 51.4%, n=201) had higher mean ranks (212.98) compared to older age groups, with a p-value of .009. Males (54.5%, n=213) had a significantly higher mean rank (213.37) compared to females (45.5%, n=178; 175.22) (p<.001). Non-smokers (38.1%, n=149) had a significantly higher mean rank (214.27) compared to smokers (61.9%, n=242; 166.33) (p<.001). Physical exercise was associated with a lower prevalence of IBS symptoms, with non-exercisers (39.9%, n=156) having a higher mean rank (207.67) compared to exercisers (60.1%, n=235; 178.42) (p=.012). Additionally, 46.3% (n=181) of participants reported missing work due to IBS symptoms. Conclusion The study found a high prevalence of IBS among physicians in Jeddah, with significant associations between IBS symptoms and various demographic and lifestyle factors. These findings highlight the need for increased awareness, regular screening, and support for physicians suffering from IBS to improve their quality of life and job performance.

Evidence-Based Clinical Guidelines for Chronic Diarrhea 2023

The Japan Gastroenterological Association (JGA) published the first version of clinical guidelines for chronic diarrhea 2023. These guidelines describe the definition, classification, diagnostic criteria, diagnostic testing methods, epidemiology, pathophysiology, and treatment of chronic diarrhea, and provide flowcharts for the diagnosis and treatment of chronic diarrhea based on the latest evidence. Treatment for chronic diarrhea begins by distinguishing secondary chronic constipation with a clear etiology, such as drug-induced diarrhea, food-induced diarrhea, systemic disease-associated diarrhea, infection-associated diarrhea, organic disease-associated diarrhea, and bile acid diarrhea. The first line of treatment for chronic diarrhea in the narrow sense, defined in these guidelines as functional diarrhea in routine medical care, is lifestyle modification and dietary therapy. The first medicines to be considered for oral treatment are probiotics for regulating the gut microbiome and anti-diarrheals. Other medications, such as 5HT3 receptor antagonists, anticholinergics, Kampo medicine, psychotherapy, antibiotics, bulking agents, adrenergic agonists, and somatostatin analogs, lack sufficient evidence for their use, highlighting a challenge for future research. This Clinical Guidelines for Chronic Diarrhea 2023, which provides the best clinical strategies for treating chronic diarrhea in Japan, will also be useful for medical treatment worldwide.

Increasing the transplant dose and repeating faecal microbiota transplantation results in the responses of male patients with IBS reaching those of females

BACKGROUND

Faecal microbiota transplantation (FMT) performed with a proper protocol is a safe treatment for IBS that has high efficacy and durable effects. Females have been reported to respond better than males to FMT. The present study aimed at determining whether increasing the transplant dose or repeating FMT improve the responses of males to FMT.

METHODS

This study included 186 IBS patients (131 females and 55 males) who were randomized at a 1:1:1 ratio to receive 90 g of donor faeces once into the large intestine, once into the small intestine or twice into the small intestine. Patients completed five questionnaires that assessed their symptoms and quality of life, and provided faecal samples at baseline and at 3, 6 and 12 months after FMT. The faecal bacterial profile and dysbiosis index were determined using 16S rRNA gene PCR DNA amplification covering variable genes V3-V9.

RESULTS

The response rates to FMT at all observation times did not differ significantly between females and males regardless of the transplant administration route or whether it was repeated. Faecal Alistipes levels were higher in females than in males at baseline and increased in both females and males after FMT. In the repeated group, the Alistipes levels did not differ between females and males after FMT.

CONCLUSIONS

Increasing the transplant dose and repeating FMT results in the responses of male IBS patients to FMT reaching those of females regardless of the administration route. Alistipes spp. levels appear to play a role in this improvement.www.clinicaltrials.gov (NCT04236843).

Patient-Reported Outcomes in Disorders of Gut-Brain Interaction

Disorders of gut-brain interaction are characterized by chronic gastrointestinal symptoms in the absence of abnormal endoscopic or radiologic findings or objective biomarkers that can be identified during routine clinical evaluation. The assessment of the symptom pattern and severity, therefore, is the key modality to evaluate the presence, impact, and evolution of these conditions, for both clinical and regulatory purposes. Patient-reported outcomes are structured symptom assessment questionnaires designed to evaluate symptom patterns, quantify severity of symptoms, and evaluate response to treatment at follow-up. This review provides an overview of currently available patient-reported outcomes for evaluating the main disorders of gut-brain interaction, specifically, functional dyspepsia; irritable bowel syndrome; and chronic constipation. It summarizes their content, level of validation for clinical practice and for research, and the regulatory approach to these conditions. Expected future developments and need for further research on patient-reported outcomes for these and other disorders of gut-brain interaction are highlighted.

Irritable bowel syndrome worsens faecal incontinence after primary repair of major obstetric anal sphincter injuries

AIM

Obstetric anal sphincter injuries (OASIS) occur in approximately 3%-6% of vaginal deliveries and are the leading risk factor for late-onset faecal incontinence, which is an underdiagnosed pathology. The aim of this work was to use a validated scoring system to quantify the effect of irritable bowel syndrome (IBS) on the severity of faecal incontinence symptoms after primary repair of major OASIS (Grade IIIb-IV).

METHOD

A prospective cohort study was performed on all women who underwent primary repair of major OASIS over a 6-year period. They were assessed with ultrasonography within 12 weeks. Two control groups (who did not have OASIS) were women who underwent elective caesarean section and primigravid women. Questionnaires were sent at least 12 months after delivery, or at first consultation for primigravids, which generated the main outcome measures: Cleveland Clinic faecal incontinence severity scores and the presence of IBS based on Rome III criteria.

RESULTS

There was a total of 211 patients included in the three groups and the mean follow-up time was 26 months after sphincter repair. Ultrasonographic sphincter defects were detected in 37% but did not affect the faecal incontinence score (p = 0.47), except in patients with IBS. Within each group, patients with IBS had significantly worse faecal incontinence than those without. Women with both OASIS and IBS had the most severe faecal incontinence scores.

CONCLUSION

OASIS has a limited negative effect on faecal incontinence, independent of whether residual ultrasonographic sphincter defects are present. However, the presence of IBS has a significant compounding effect on faecal incontinence in OASIS patients. The effect of IBS on faecal incontinence is also notable in caesarean section patients and primigravids, suggesting that IBS is an independent risk-factor that should have its place in predelivery assessment and counselling.

Factors affecting the outcome of fecal microbiota transplantation for patients with irritable bowel syndrome

BACKGROUND

A previous study that introduced a Fecal microbiota transplantation (FMT) protocol with a high efficacy applied a combination of favorable factors.

AIMS

The present study aimed to evaluate some of these factors.

METHODS

This study included 186 patients with IBS randomized 1:1:1 into transplant administered to the colon (single LI), to the duodenum (single SI), or to the duodenum twice with a 1-week interval (repeated SI). The patients provided a fecal sample and were asked to complete five questionnaires at baseline and at 3, 6, and 12 months after FMT. The fecal bacteria composition and dysbiosis index (DI) were analyzed using 16S rRNA gene PCR DNA amplification/probe hybridization covering regions V3-V9.

RESULTS

The response rate was significantly higher in single SI than in single LI at 12 months after FMT. Symptoms and quality of life improved in all the treated groups at all time intervals after FMT. The abdominal symptoms were significantly reduced and the quality of life improved for repeated SI compared with for single SI. DI significantly decreased in all the treated groups at all observation times after FMT. The bacterial profiles changed in all groups at all observation intervals. However, these changes differed between single LI and single SI/repeated SI.

CONCLUSION

Administrating transplant to the small intestine had a long-term higher response rate than that administrated to the large intestine, and led to long-term colonization of beneficial bacteria. Repeating FMT had more effect on symptoms and quality of life than a single FMT. (www.

CLINICALTRIALS

gov: NCT04236843).

Association between Serum Vitamin D and Irritable Bowel Syndrome Symptoms in a Sample of Adults

Vitamin D may be associated with irritable bowel syndrome (IBS) pathways. This cross-sectional study evaluated the associations between serum Vitamin D and IBS symptoms in a sample of Lebanese adults. Participants (n = 230; mean (SD) age: 43.36 (16.05) years, 62.9% females) were adults, free of diseases affecting Vitamin D metabolism, and recruited from a large university and the surrounding community. Serum Vitamin D (25-hydroxyvitamin D) was assessed using an automated chemiluminescence micro-particle immunoassay kit. The Birmingham IBS Symptom Questionnaire total scale, and pain, constipation, and diarrhea subscales were used to study IBS symptoms. Four linear regression analyses were performed, taking respectively the total scale and each of the subscales as the dependent variable. Vitamin D was forced into each model. Covariates included sociodemographic and medical variables, fluid intake, physical activity, sleep quality, stress, and adherence to the Mediterranean diet. Mean (SD) serum Vitamin D was 17.53 (12.40) ng/mL and mean (SD) Birmingham IBS Symptom Questionnaire was 16.98 (15.16) (pain: 20.75 (23.63), constipation: 25.06 (29.99), diarrhea: 9.88 (13.37)). Serum Vitamin D was not associated with the total score, nor with any of the subscales (p > 0.05 for the four regression analyses). Serum Vitamin D was not associated with IBS symptoms in a sample of Lebanese adults, adding to the controversy in this field. Further understanding of the pathophysiological mechanisms involved in Vitamin D and IBS is warranted.

Efficacy of Fecal Microbiota Transplantation for Patients With Irritable Bowel Syndrome at 3 Years After Transplantation

BACKGROUND & AIMS

The long-term efficacy and possible adverse events of fecal microbiota transplantation (FMT) for irritable bowel syndrome (IBS) are unknown. This study performed a 3-year follow-up of the patients in our previous clinical trial to clarify these aspects.

METHODS

This study included 125 patients (104 females, and 21 males): 38 in a placebo group, 42 who received 30 g of donor feces, and 45 who received 60 g of donor feces. Feces was administered to the duodenum. The patients provided a fecal sample and completed 5 questionnaires at baseline and at 2 and 3 years after FMT. Fecal bacteria and dysbiosis index were analyzed using 16S ribosomal RNA gene polymerase chain reaction DNA amplification/probe hybridization covering the V3 to V9 regions.

RESULTS

Response rates were 26.3%, 69.1%, and 77.8% in the placebo, 30-g, and 60-g groups, respectively, at 2 years after FMT, and 27.0%, 64.9%, and 71.8%, respectively, at 3 years after FMT. The response rates were significantly higher in the 30-g and 60-g groups than in the placebo group. Patients in the 30-g and 60-g groups had significantly fewer IBS symptoms and fatigue, and a greater quality of life both at 2 and 3 years after FMT. The dysbiosis index decreased only in the active treatment groups at 2 and 3 years after FMT. Fluorescent signals of 10 bacteria had significant correlations with IBS symptoms and fatigue after FMT in the 30-g and 60-g groups. No long-term adverse events were recorded.

CONCLUSIONS

FMT performed according to our protocol resulted in high response rates and long-standing effects with only few mild self-limited adverse events. This study was registered at www.

CLINICALTRIALS

gov (NCT03822299).

Irritable bowel syndrome patients who are not likely to respond to fecal microbiota transplantation

BACKGROUND

Fecal microbiota transplantation (FMT) interventions have recently been advocated to not succeed in every irritable bowel syndrome (IBS) patient, since the outcome of FMT varies with the IBS subset. This study investigated the factors potentially affecting FMT response using the same patient cohort used in our previous study.

METHODS

This study included 109 patients who received allogenic FMT. Patients completed five questionnaires that assessed their symptoms and quality of life at baseline and at 2 weeks, 1 month, and 3 months after FMT. Patients also provided fecal samples at baseline and 1 month after FMT. The fecal bacterial profile and dysbiosis index (DI) were determined using 16S rRNA gene PCR DNA amplification covering variable genes V3-V9. Response to FMT was defined as a decrease of ≥50 points in the total IBS-SSS score after FMT.

RESULTS

An IBS patient's response or nonresponse to FMT was not determined by age, IBS duration, IBS subtype, IBS symptoms, fatigue, quality of life, or DI. There were more male nonresponders than responders, and the fluorescence signals of Alistipes were lower in nonresponders than in responders.

CONCLUSIONS

We concluded that IBS patients who are male and/or have low fecal Alistipes levels are most likely to not respond to FMT treatment. Whether low fecal Alistipes levels could be used as a marker for predicting the outcome of FMT remains to be determined. www.

CLINICALTRIALS

gov (NCT03822299).

Habitual Green Kiwifruit Consumption Is Associated with a Reduction in Upper Gastrointestinal Symptoms: A Systematic Scoping Review

Kiwifruit have known positive effects on digestion. During clinical intervention trials using kiwifruit to improve constipation, upper gastrointestinal (GI) symptoms such as abdominal discomfort and pain, indigestion, and reflux were also alleviated. We aimed to evaluate the evidence for upper GI symptom relief by kiwifruit in clinical trials on participants with functional constipation (FC), irritable bowel syndrome with constipation (IBS-C), and healthy participants, and to elucidate which symptoms may be relieved and whether a difference exists between the effects of gold and green kiwifruit. We executed a systematic scoping review of 3 electronic databases from 1947 through January 2021 to identify clinical trials that reported effects of green or gold kiwifruit or kiwifruit compounds on upper GI symptoms as secondary outcomes in healthy participants or participants with FC or IBS-C. Studies were divided into those using the Gastrointestinal Symptom Rating Scale (GSRS) and those using alternative measurement tools. GSRS outcomes were pooled and statistically analyzed; non-GSRS outcomes were summarized. We identified 12 clinical trials with a total of 661 participants (124 controls, 537 receiving intervention) providing evidence for symptom relief of upper GI symptoms by kiwifruit intake. Only 5 of the 12 clinical trials used the GSRS to assess upper GI symptom relief. We found good evidence that green kiwifruit may reduce abdominal discomfort and pain, and some evidence that kiwifruit consumption may attenuate indigestion. Pooled GSRS outcome analysis indicates an average reduction of -0.85 (95% CI: -1.1, -0.57; Z = 6.1) in abdominal pain scores and -0.33 (95% CI: -0.52, -0.15; Z = -3.5) in indigestion scores with habitual kiwifruit consumption. While the number of studies reporting on upper GI symptom relief with a comparable measurement is limited, there is consistent evidence for the efficacy of kiwifruit on upper GI symptom relief. More research to strengthen the evidence is recommended.

Poorer Cognitive Performance Is Associated with Gastrointestinal Symptoms in Otherwise Healthy Young Adults

INTRODUCTION

Functional gastrointestinal disorders such as irritable bowel syndrome are often associated with abdominal discomfort, bloating, and cramping. There is growing evidence that gastrointestinal symptoms are also related to cognitive function, but this association has not been previously examined in young adults.

METHODS

We examined cross-sectional relationships between nonspecific gastrointestinal symptoms and cognition in 56 healthy young adults (41 female, 15 male) without diagnosis of gastrointestinal disorder.

RESULTS

Gastrointestinal symptoms were associated with poorer performance on objective tests of memory (p < 0.01 for all) and greater self-report of cognitive dysfunction (p < 0.01 for all).

CONCLUSION

Results suggest that higher gastrointestinal symptoms are associated with greater subjective and objective cognitive difficulty. Future work is needed to clarify underlying mechanisms and the potential functional impact of these cognitive deficits.

The Association of Irritable Bowel Complaints and Perceived Immune Fitness among Individuals That Report Impaired Wound Healing: Supportive Evidence for the Gut–Brain–Skin Axis

The gut–brain–skin axis is important in wound healing. The aim of this study was to investigate the association between experiencing irritable bowel syndrome (IBS) symptoms, perceived immune fitness, and impaired wound healing. N = 1942 Dutch students (mean (SD) age 21.3 (2.1), 83.6% women) completed an online survey. They were allocated to one of four groups: (1) control group (N = 1544), (2) wound infection (WI) group (N = 65), (3) slow healing wounds (SHW) group (N = 236), or (4) a combination group (COMBI), which experienced both WI and SHW (N = 87). Participants rated their perceived immune fitness on a scale ranging from very poor (0) to excellent (10), and the severity of IBS symptoms (constipation, diarrhea, and pain) was assessed with the Birmingham IBS Symptom Questionnaire. Compared to the control group, perceived immune fitness was significantly poorer for the SHW group (p < 0.001) and COMBI group (p < 0.001), but not for the WI group. Compared to the control group, constipation was reported significantly more frequently by the SHW group (p < 0.001) and the WI group (p = 0.012), diarrhea was reported significantly more frequent by the SHW group (p = 0.038) and the COMBI group (p = 0.004), and pain was reported significantly more frequent by the SHW group (p = 0.020) and COMBI group (p = 0.001). Correlations between IBS complaints and perceived immune fitness were statistically significant (p < 0.001), and also a highly significant and negative association was found between the percentage of participants that reported impaired wound healing and perceived immune fitness (r = −0.97, p < 0.001). In conclusion, among participants with self-reported impaired wound healing, IBS complaints were significantly more severe, and accompanied by a significantly reduced perceived immune fitness.

Gluten-Free Diet Reduces Symptoms, Particularly Diarrhea, in Patients With Irritable Bowel Syndrome and Antigliadin IgG

BACKGROUND & AIMS

Many patients with irritable bowel syndrome (IBS) perceive that their symptoms are triggered by wheat-containing foods. We assessed symptoms and gastrointestinal transit before and after a gluten-free diet (GFD) in unselected patients with IBS and investigated biomarkers associated with symptoms.

METHODS

We performed a prospective study of 50 patients with IBS (ROME III, all subtypes), with and without serologic reactivity to gluten (antigliadin IgG and IgA), and 25 healthy subjects (controls) at a university hospital in Hamilton, Ontario, Canada, between 2012 and 2016. Gastrointestinal transit, gut symptoms, anxiety, depression, somatization, dietary habits, and microbiota composition were studied before and after 4 weeks of a GFD. HLA-DQ2/DQ8 status was determined. GFD compliance was assessed by a dietitian and by measuring gluten peptides in stool.

RESULTS

There was no difference in symptoms among patients at baseline, but after the GFD, patients with antigliadin IgG and IgA reported less diarrhea than patients without these antibodies (P = .03). Compared with baseline, IBS symptoms improved in 18 of 24 patients (75%) with antigliadin IgG and IgA and in 8 of 21 patients (38%) without the antibodies. Although constipation, diarrhea, and abdominal pain were reduced in patients with antigliadin IgG and IgA, only pain decreased in patients without these antibodies. Gastrointestinal transit normalized in a higher proportion of patients with antigliadin IgG and IgA. Anxiety, depression, somatization, and well-being increased in both groups. The presence of antigliadin IgG was associated with overall reductions in symptoms (adjusted odds ratio compared with patients without this antibody, 128.9; 95% CI, 1.16-1427.8; P = .04). Symptoms were reduced even in patients with antigliadin IgG and IgA who reduced gluten intake but were not strictly compliant with the GFD. In controls, a GFD had no effect on gastrointestinal symptoms or gut function.

CONCLUSIONS

Antigliadin IgG can be used as a biomarker to identify patients with IBS who might have reductions in symptoms, particularly diarrhea, on a GFD. Larger studies are needed to validate these findings. ClinicalTrials.gov: NCT03492333.

Responses to faecal microbiota transplantation in female and male patients with irritable bowel syndrome

BACKGROUND

Faecal microbiota transplantation (FMT) seems to be a promising treatment for irritable bowel syndrome (IBS) patients. In Western countries (United States and Europe), there is a female predominance in IBS. A sex difference in the response to FMT has been reported recently in IBS patients.

AIM

To investigate whether there was a sex difference in the response to FMT in the IBS patients who were included in our previous randomized controlled trial of the efficacy of FMT.

METHODS

The study included 164 IBS patients who participated in our previous randomized controlled trial. These patients had moderate-to-severe IBS symptoms belonging to the IBS-D (diarrhoea-predominant), IBS-C (constipation-predominant) and IBS-M (mixed) subtypes, and had not responded to the National Institute for Health and Care Excellence (NICE)-modified diet. They belonged in three groups: placebo (own faeces), and active treated group (30-g or 60-g superdonor faeces). The patients completed the IBS severity scoring system (IBS-SSS), Fatigue Assessment Scale (FAS) and the IBS quality of life scale (IBS-QoL) questionnaires at the baseline and 2 wk, 1 mo and 3 mo after FMT. They also provided faecal samples at the baseline and 1 mo after FMT. The faecal bacteria profile and dysbiosis were determined using the 16S rRNA gene polymerase chain reaction DNA amplification covering V3-V9; probe labelling by single nucleotide extension and signal detection. The levels of short-chain fatty acids (SCFAs) were determined by gas chromatography and flame ionization.

RESULTS

There was no sex difference in the response to FMT either in the placebo group or active treated group. There was no difference between females and males in either the placebo group or actively treated groups in the total score on the IBS-SSS, FAS or IBS-QoL, in dysbiosis, or in the faecal bacteria or SCFA level. However, the response rate was significantly higher in females with diarrhoea-predominant (IBS-D) than that of males at 1 mo, and 3 mo after FMT. Moreover, IBS-SSS total score was significantly lower in female patients with IBS-D than that of male patients both 1 mo and 3 mo after FMT.

CONCLUSION

There was no sex difference in the response to FMT among IBS patients with moderate-to-severe symptoms who had previously not responded to NICE-modified diet. However, female patients with IBS-D respond better and have higher reduction of symptoms than males after FMT.

Subtypes and Severity of Irritable Bowel Syndrome Are Not Related to Patients' Self-Reported Dietary Triggers: Results From an Online Survey in Dutch Adults

BACKGROUND

Diet plays an important role in symptom management of irritable bowel syndrome (IBS). However, current diet therapies are not optimal nor successful for everyone.

OBJECTIVE

To investigate whether subgroups based on IBS subtypes or severity identify different self-reported dietary triggers, and whether these are associated with severity and psychological factors.

DESIGN

Online cross-sectional survey PARTICIPANTS: Patients with IBS (n = 1601) who fulfilled the Rome IV criteria or had an IBS diagnosis.

MAIN OUTCOMES

Self-reported response to 44 preselected dietary triggers, IBS quality of life, and anxiety and depression. Subgroups were based on subtypes or severity.

STATISTICAL ANALYSIS

Response to dietary triggers was analyzed using multiple correspondence analysis. Moreover, a food score was calculated to quantify the number and severity of responses to dietary triggers.

RESULTS

Response to greasy foods, onions, cabbage, and spicy and fried foods were mentioned most often (ranging between 55% and 65%). Response to dietary triggers differed between subtypes and severity groups, but absolute differences were small. Multiple correspondence analysis did not reveal clustering between dietary triggers, and ellipses for the subtypes overlapped. Some clustering was seen when ellipses were drawn for severity, which indicates that severity explained a fraction of the variation in response to dietary triggers, and subtypes did not. The food score was not significantly different between subtypes but was significantly higher with higher levels of severity (mild = 20.9 ± 17, moderate = 29.2 ± 19, severe = 37.9 ± 20, P < .001), having depressive (no = 31.4 ± 20, yes = 37.4 ± 20, P < .001) or anxious symptoms (no = 30.7 ± 20, yes = 35.2 ± 20, P < .001), and lower quality of life (lower quality of life = 38.5 ± 19, higher quality of life = 26.5 ± 19, P < .001).

CONCLUSION

Patients with different IBS subtypes or IBS severity do not identify different self-reported dietary triggers. Patients with more severe IBS and who experience anxiety or depression tend to have severe responses to more dietary triggers. IBS severity seems a better classifier than Rome IV criteria regarding diet. Dietary treatment needs to be individualized under guidance of a dietitian.

The Use of Single-Item Ratings Versus Traditional Multiple-Item Questionnaires to Assess Mood and Health

Collecting real-world evidence via ‘at home’ assessments in ambulatory patients or healthy volunteers is becoming increasingly important, both for research purposes and in clinical practice. However, given the mobile technology that is frequently used for these assessments, concise assessments are preferred. The current study compared single-item ratings with multiple-item subscale scores of the same construct, by calculating the corresponding Bland and Altman 95% limits of agreement interval. The analysis showed that single-item ratings are usually in good agreement with assessments of their corresponding subscale. In the case of more complex multimodal constructs, single-item assessments were much less often in agreement with multiple-item questionnaire outcomes. The use of single-item assessments is advocated as they more often incorporate assessments of all aspects of a certain construct (including the presence, severity, and impact of the construct under investigation) compared to composite symptom scores.

Changes in fecal short-chain fatty acids following fecal microbiota transplantation in patients with irritable bowel syndrome

BACKGROUND

Short-chain fatty acids (SCFAs) may play a role in the pathophysiology of irritable bowel syndrome (IBS). This study analyzed fecal SCFAs after performing fecal microbiota transplantation (FMT) in the IBS patients who were included in our previous study of the efficacy of FMT.

METHODS

This study included 142 of the 164 IBS patients who participated in our previous study. They were belonging to three groups: placebo (own feces), 30-g (superdonor feces), and 60-g (superdonor feces) FMT. The patients completed the IBS Severity Scoring System (IBS-SSS) Birmingham IBS Symptom, Fatigue Assessment Scale (FAS), the IBS Quality of Life (IBS-QoL) and Short-Form Nepean Dyspepsia Index (SF-NDI) questionnaires and delivered fecal samples at the baseline and 1 month after FMT. The SCFA levels were determined by vacuum distillation followed by gas chromatography.

KEY RESULTS

The fecal butyric acid level was significantly increased after FMT in both the 30-g and 60-g groups (both P ≤ 0.001). In the 60-g group, the levels of total SCFAs and isobutyric, isovaleric, and valeric acids increased after FMT. Butyric acid levels in the responders in both the 30-g and 60-g FMT groups were significantly inversely correlated with IBS-SSS and FAS scores (P = 0.001, r = -0.3 and P = 0.0001. r=- 0.3, respectively). There were no differences in the SCFA levels in the placebo group after FMT.

CONCLUSION AND INFERENCES

FMT increases the fecal SCFA levels in IBS patients. The increase in the butyric acid level is inversely correlated with symptoms in IBS patients following FMT, suggesting that SCFAs might play a role in the pathophysiology of IBS. www.clini​caltr​ials.gov (NCT03822299).

Impact of hypnotic safety on disorders of gut-brain interaction: A pilot study

Functional gastrointestinal disorders, i.e., abdominal conditions without identifiable structural etiologies, are seen frequently in primary care and specialty practices. As subtle physiological processes have been identified as potential contributing factors to these functional disorders, these disorders have been recently relabeled, Disorders of Gut-Brain Interaction (DGBI). Moreover, some of these processes, e.g., sympathetic nervous system activity and inflammation, are being increasingly related to psychosocial factors such as situational stress and histories of trauma, abuse, and neglect. As the activity of the autonomic nervous system (ANS) has been long considered to be a contributory factor for DGBI, the present study utilized a theory-driven model based on the Polyvagal Theory to optimize ANS activity for the promotion of healthy digestive activity. Specifically, a hypnotic intervention to increase neuroception of safety was employed with three female college students diagnosed with functional dyspepsia and irritable bowel syndrome in a single-subject design. This intervention was found to be associated with increases in the experience of safe/warm positive affect and decreases in symptoms of functional dyspepsia and irritable bowel syndrome as well as depression and anxiety. The hypnotic intervention for the promotion of a sense of safety is recommended for the treatment of other functional somatic disorders as well as trauma-related conditions. Potential complications related to individuals with prolonged trauma and attachment issues also are reviewed.

Patient reported symptoms, coping and quality of life during somatostatin analogue treatment for metastatic small- intestinal neuroendocrine tumours

BACKGROUND

Patients with metastatic small-intestinal neuroendocrine tumours (NET) have been shown to have a reduced quality of life compared to the general population and many have disabling symptoms during somatostatin analogue (SSA) treatment. The aim of this prospective study was to document the patient-reported symptoms, coping and quality of life during SSA treatment and to measure patients' fat-soluble vitamin levels.

METHODS

Patients with metastatic small-intestinal NET on treatment with long-acting SSA were included. Data on patient characteristics, blood samples, questionnaires (EORTC-QLQ-C30 and GI.NET-21) and structured patient interviews were collected at inclusion and after 1 year.

RESULTS

Eighty-eight patients were included, 77 (88%) attended 1 year follow-up. Approximately 50% of patients reported symptoms, the most common symptoms at baseline and after 1 year follow-up were diarrhoea, flatulence, fatigue, abdominal discomfort and sore injection lumps. Diarrhoea and fatigue were reported as their main complaint, 23% had > 5 daily episodes of diarrhoea and 59% reported fatigue. However, patients reported a high perceived quality of life, high daily activity, coped with their symptoms and managed their daily life well. Deficiency of vitamin D (27%) and A (13%) were observed.

CONCLUSIONS

Patients with metastatic small-intestinal NET on SSA treatment reported a high frequency of symptoms. Minor improvements were seen after 1-year of follow-up, illustrating that many symptoms might be difficult to improve, or may not be recognised by the health service. Patients, however, generally reported a high quality of life. Care for NET patients on SSA treatment should include a regular systematic symptom registration and vitamin measurements.

The Effects on Immune Function and Digestive Health of Consuming the Skin and Flesh of Zespri® SunGold Kiwifruit (Actinidia Chinensis var. Chinensis ‘Zesy002’) in Healthy and IBS-Constipated Individuals

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder that results in constipation (IBS-C) or diarrhoea with abdominal pain, flatulence, nausea and bloating. Kiwifruit (Actinidia spp.) are nutrient-dense fruit with a number of reported health benefits that include lowering glycaemic response, improving cardiovascular and inflammatory biomarkers, and enhancing gut comfort and laxation. This study investigated the effect of consuming three whole Zespri® SunGold kiwifruit (Actinidia chinensis var. chinensis ‘Zesy002’) with or without skin on cytokine production and immune and gut health in healthy people and those with IBS-C symptoms. This study enrolled thirty-eight participants in a 16 week randomized cross-over study (19 healthy and 19 participants with IBS-C). Participants were randomized to consume either three kiwifruit without eating the skin or three kiwifruit including the skin for 4 weeks each, with a 4 week washout in between each intervention. There was a significant decrease in the pro-inflammatory cytokine, TNF-α, for both the healthy and the IBS-C participants when they consumed whole kiwifruit and skin, and also for the healthy participants when they ate whole kiwifruit without the skin (p < 0.001). The kiwifruit interventions increased bowel frequency and significantly reduced the gastrointestinal symptom rating scale constipation and Birmingham IBS pain scores for both participant groups. We have demonstrated that consuming the skin of SunGold kiwifruit might have beneficial effects on gastrointestinal health that are not produced by consuming the flesh alone.

Efficacy of faecal microbiota transplantation for patients with irritable bowel syndrome in a randomised, double-blind, placebo-controlled study

OBJECTIVE

Faecal microbiota transplantation (FMT) from healthy donors to patients with irritable bowel syndrome (IBS) has been attempted in two previous double-blind, placebo-controlled studies. While one of those studies found improvement of the IBS symptoms, the other found no effect. The present study was conducted to clarify these contradictory findings.

DESIGN

This randomised, double-blind, placebo-controlled study randomised 165 patients with IBS to placebo (own faeces), 30 g FMT or 60 g FMT at a ratio of 1:1:1. The material for FMT was obtained from one healthy, well-characterised donor, frozen and administered via gastroscope. The primary outcome was a reduction in the IBS symptoms at 3 months after FMT (response). A response was defined as a decrease of 50 or more points in the total IBS symptom score. The secondary outcome was a reduction in the dysbiosis index (DI) and a change in the intestinal bacterial profile, analysed by 16S rRNA gene sequencing, at 1 month following FMT.

RESULTS

Responses occurred in 23.6%, 76.9% (p<0.0001) and 89.1% (p<00.0001) of the patients who received placebo, 30 g FMT and 60 g FMT, respectively. These were accompanied by significant improvements in fatigue and the quality of life in patients who received FMT. The intestinal bacterial profiles changed also significantly in the groups received FMT. The FMT adverse events were mild self-limiting gastrointestinal symptoms.

CONCLUSIONS

FMT is an effective treatment for patients with IBS. Utilising a well-defined donor with a normal DI and favourable specific microbial signature is essential for successful FMT. The response to FMT increases with the dose. Trial registration www.clinicaltrials.gov (NCT03822299) and www.cristin.no (ID657402).

Herbal formula improves upper and lower gastrointestinal symptoms and gut health in Australian adults with digestive disorders

Gastrointestinal (GI) problems affect half of Western populations. Symptoms can vary from frequent reflux to irritable bowel syndrome. The Nutrition Care (NC) Gut Relief Formula contains a combination of herbs and nutrients including curcumin, Aloe vera, slippery elm, guar gum, pectin, peppermint oil, and glutamine shown to benefit the GI system. The 16-week pre-post study tested the hypothesis that the NC Gut Relief Formula would be tolerable and effective in improving GI symptoms and gut health in adults with digestive disorders. A total of 43 participants completed the study. After a control phase, participants took 5 g/d and then 10 g/d of the formula for 4 weeks. GI symptoms and GI health were assessed by a series of validated questionnaires, for example, Leeds Dyspepsia Questionnaire, Bristol Stool Chart, Birmingham IBS Symptom Questionnaire, and by intestinal permeability and gut microbiota profile. The NC Gut Relief Formula significantly improved the frequency and severity of upper and lower GI symptoms by 60%-80%, including indigestion, heartburn, nausea, constipation or diarrhea, abdominal pain, and troublesome flatulence, and significantly improved physical functioning, energy levels, mood, and sleep by 60%-80%. All participants with normal stool, 90% with hard stool, and 66% with soft stool recovered from intestinal permeability, evident by normal lactulose to mannitol ratios. The NC Gut Relief Formula generally improved microbial profile, with a marked increase in Lactobacillus, Clostridium, and Faecalibacterium prausnitzii. Almost half of the participants with upper GI symptoms taking proton pump inhibitors for heartburn no longer required proton pump inhibitors at the end of the study. A third of participants were able to reintroduce food triggers, such as fermentable oligosaccharides, disaccharides, monosaccharides, and polyols garlic, onion, and beans, or reflux-causing acidic/spicy foods, for example, citrus, tomato, and caffeine, in their diet after 3 months without symptom aggravation. The NC Gut Relief Formula significantly improved GI symptoms and associated quality of life over 3 months while reducing intestinal permeability, improving the microbial profile, reducing the need for reflux medication, and enabling the consumption of previous food triggers.

Is Fluid Intake Associated With Fecal Incontinence in Women?

OBJECTIVE

The primary aim of this study was to determine if fecal incontinence (FI) is associated with self-reported fluid intake in women seeking care for pelvic floor disorders. The secondary aim was to determine the association between bowel symptoms and fluids associated with FI.

METHODS

We conducted a retrospective cross-sectional study of women presenting for evaluation of pelvic floor disorders from 2009 to 2015. The presence of FI was defined as an affirmative response of any frequency to the question, "During the last 4 weeks, how often have you leaked or soiled yourself with stool?" Data on fluid intake and bowel symptoms were collected using the Questionnaire-based Voiding Diary and Colorectal-Anal Distress Inventory short form, respectively. The relationship between FI and quartiles of fluid intake, as well as the relationship between bowel symptoms and fluids associated with FI, was analyzed.

RESULTS

Nine hundred twenty-four women were included: 379 (41%) with and 545 (59%) without FI. There was an association between FI and increasing total carbonated fluid intake (P = 0.009) and decreasing water intake (P = 0.009). The associations between FI and carbonated fluid intake and FI and water intake remained significant after controlling for patient characteristics (P < 0.05). There was a significant association between the symptom of straining to defecate and carbonated beverage intake (P = 0.046), which remained significant after controlling for patient characteristics (P < 0.001).

CONCLUSIONS

Consumption of carbonated beverages is associated with FI in women. Intake of carbonated fluids is associated with bowel symptoms that may exacerbate FI symptoms.

Effectiveness of Two Dietary Approaches on the Quality of Life and Gastrointestinal Symptoms of Individuals with Irritable Bowel Syndrome

To evaluate the effectiveness of a low FODMAP (fermentable oligosaccharides, monosaccharaides, disaccharides and polyols) diet in the relief of symptoms and an improvement of the quality of life in individuals with irritable bowel syndrome in comparison to a standard diet according to the British Dietetic Association's guidelines. A non-randomized clinical trial of adult patients with IBS was compared two diet interventions. An assessment of symptoms, quality of life, and nutritional status was performed before and after the four-week mark of intervention. Individuals from the Low FODMAP Diet (LFD) group were evaluated on a third moment, after the controlled reintroduction of FODMAPs. A total of 70 individuals were divided in two groups: Low FODMAP Diet (LFD; n = 47) and Standard Diet (SD; n = 23). 57 individuals completed the four-week intervention (LFD; n = 39; SD; n = 18). At the completion of four weeks, the symptoms improved in both groups (LFD: p < 0.01; DC: p < 0.05) but LFD led to a higher relief (p < 0.05), primarily with respect to abdominal pain and diarrhoea. Quality of life improved significantly in both groups, with no significant differences between SD vs LFD (p > 0.05). In the LFD group, the relief of symptoms observed at the four-week mark remained constant after reintroduction of FODMAPs. Both interventions seem to be effective for the relief of symptoms and quality of life, however LFD had higher effectiveness in the former. The results with LFD suggest it can be a preferred approach in individuals with diarrhoeal profile.

Development and Validation of the Immune Status Questionnaire (ISQ)

The self-assessment of perceived immune status is important, as this subjective observation leads individuals to decide whether or not to seek medical help or adapt their lifestyle. In addition, it can be used in clinical settings and research. The aim of this series of studies was to develop and validate a short questionnaire to assess perceived immune functioning. Five surveys were conducted among Dutch and International young healthy adults (18-30 years old), and two others among older age groups with various health complaints. For the first study, an existing immune functioning scale was modified and elaborated resulting in 23 immune-health-related items, of which the occurrence was rated on a 5-point Likert scale. A student sample was surveyed, and the results were used to shorten the 23-item listing into a 7-item scale with a predictive validity of 85%. Items include "sudden high fever", "diarrhea", "headache", "skin problems (e.g., acne and eczema)", "muscle and joint pain", "common cold" and "coughing". The scale is named Immune Status Questionnaire (ISQ), and it aims to assess perceived immune status over the preceding year. The second study revealed that the ISQ score correlated significantly with a 1-item perceived immune functioning (r = 0.383, p < 0.0001). In the third study, the final Likert scale descriptors were determined ("never", "sometimes", "regularly", "often" and "(almost) always)". The fourth study showed that the test-retest reliability of the ISQ is acceptable (r = 0.80). The fifth study demonstrated the association of ISQ scores with various neuropsychological and health correlates in an international sample, including perceived health and immune fitness, as well as levels of stress, fatigue, depression and anxiety. Study 6 demonstrated significant associations between ISQ scores and experiencing irritable bowel syndrome (IBS) symptoms in a sample of insomnia patients. Study 7 compared the effect of a dietary intervention in participants reporting "poor health" versus "normal health". It is shown that ISQ scores can differentiate between those with poor and normal health, and that an effective intervention is associated with a significant improvement in ISQ scores. Data from Study 7 were further used to determine an ISQ cut-off value for reduced immune functioning, and a direct comparison with 1-item perceived immune functioning scores enabled constructing the final scoring format of the ISQ. In conclusion, the ISQ has appropriate face, content, and construct validity and is a reliable, stable and valid method to assess the past 12 month's perceived immune status.

The impact of raw fermented milk products on perceived health and mood among Dutch adults

Purpose

The purpose of this paper was to evaluate health conditions prior to and at least two months after the start of consuming raw fermented milk (RFM) products.

Design/methodology/approach

One-Item health score, 1-item immunity score, immune status (ISQ), mood, bowel and skin conditions were rated for the period prior and post switching to RFM products. A linear mixed model was used to evaluate the post to prior RFM health and mood scores, taking into account gender, location of living and health group. Data from 390 participants (mean age of 54 years old) were included for the analysis, of which 277 (45 per cent) were allocated to the poor health group. Participants were allocated to the poor health group if they reported being immune depressed or suffering from a chronic disease prior to RFM; otherwise, they were allocated to the normal health group.

Findings

The highest intake of RFM was from RF kefir. Post RFM, people consumed around 1 glass (200 ml) of RF kefir per day. After switching to RFM, significant improvements on health and mood scores were reported. The strongest improvements after switching to RFM consumption were seen in subjects from the poor health group. With the exception of skin score, all measured health items significantly improved (p < 0.001). Health, immunity, bowel and mood scores increased with around 20 per cent in the poor health group and around 8 per cent in the normal health group. Women had more health complaints prior to RFM and had stronger health improvement post RFM compared to men. Bowel and mood scores were overall lower in women than in men. Living location had no significant impact on RFM-related health changes. This consumer survey suggests that positive health and mood changes are associated with the consumption of RFM products.

Originality/value

The consumption of RFM products improved the self-reported health status of adults. Immune-depressed people or people suffering from a chronic disease prior to RFM reported the strongest impact on their health, immunity, bowel and mood scores post switching RFM consumption compared to people with a normal health.

HS-SPME-GC-MS approach for the analysis of volatile salivary metabolites and application in a case study for the indirect assessment of gut microbiota

In this work, a straightforward analytical approach based on headspace solid-phase microextraction coupled with gas chromatography-mass spectrometry was developed for the analysis of salivary volatile organic compounds without any prior derivatization step. With a sample volume of 500 μL, optimal conditions were achieved by allowing the sample to equilibrate for 10 min at 50 °C and then extracting the samples for 10 min at the same temperature, using a carboxen/polydimethylsiloxane fibre. The method allowed the simultaneous identification and quantification of 20 compounds in sample headspace, including short-chain fatty acids and their derivatives which are commonly analysed after analyte derivatization. The proof of applicability of the methodology was performed with a case study regarding the analysis of the dynamics of volatile metabolites in saliva of a single subject undergoing 5-day treatment with rifaximin antibiotic. Non-stimulated saliva samples were collected over 3 weeks from a nominally healthy volunteer before, during, and after antibiotic treatment. The variations of some metabolites, known to be produced by the microbiota and by bacteria that are susceptible to antibiotics, suggest that the study of the dynamics of salivary metabolites can be an excellent indirect method for analysing the gut microbiota. This approach is novel from an analytical standpoint, and it encourages further studies combining saliva metabolite profiles and gut microbiota dynamics. Graphical abstract.

Effect of raw milk consumption on perceived health, mood and immune functioning among US adults with a poor and normal health: A retrospective questionnaire based study

INTRODUCTION

Raw milk consumption is controversially discussed, and people are looking for raw milk due to expected positive health impacts. The purpose of this consumer survey was to evaluate health conditions prior to and after consuming of raw milk (RM).

METHODS

An on-line survey was distributed in Spring 2018 among existing consumers of raw milk. One-Item health score, 1-item immunity score, immune status (ISQ), mood, bowel and skin conditions were rated retrospectively based on validated questionnaires. Data from 327 participants (age 54 years) were included, of which 156 (48%) were allocated to the poor health group after they reported being immune depressed or suffering from a chronic disease. Others were allocated to the normal health group. Milk consumption pattern before and after changing of the milk diet were recorded. All health outcomes were evaluated according a linear mixed model in SPSS.

RESULTS

Health, perceived immunity, bowel and mood scores increased post RM consumption with around 35% in the poor health group (P < 0.001), and around 9% in the normal health group (P < 0.001). Bowel and mood scores were overall lower in women than in men. Outcomes were independent of the origin of raw farm milk.

CONCLUSIONS

This consumer survey suggests that positive health and mood changes are associated with the consumption of raw milk. Effects were strongest in people with a self-reported poor health status as well as in women.

Increasing the Dose and/or Repeating Faecal Microbiota Transplantation (FMT) Increases the Response in Patients with Irritable Bowel Syndrome (IBS)

BACKGROUND

Faecal microbiome transplantation (FMT) appears to be an effective method for treating irritable bowel syndrome (IBS) patients. However, it is not clear if a high transplant dose and/or repeating FMT are/is needed to ensure a response. The present study was undertaken to clarify this matter.

METHODS

Ten IBS patients who did not respond to a 30-g transplant subsequently received a 60-g transplant into the duodenum via a gastroscope. The patients provided faecal samples before and 1 month after FMT. They completed five questionnaires measuring symptoms, fatigue and quality of life at baseline and then at 2 weeks, 1 month and 3 months after FMT. The dysbiosis index (DI) was measured using the GA-map Dysbiosis Test®.

RESULTS

Seven patients (70%) responded to the 60-g transplant, with significant clinical improvements in the abdominal symptoms, fatigue and quality of life in 57%, 80% and 67% of these patients. The 60-g transplant also reduced the DI.

CONCLUSION

FMT is an effective treatment for IBS. A high-dose transplant and/or repeated FMT increase the response rate and the intensity of the effects of FMT.

Protocol for the Gut Bugs Trial: a randomised double-blind placebo-controlled trial of gut microbiome transfer for the treatment of obesity in adolescents

INTRODUCTION

Animal studies showed that germ-free mice inoculated with normal mouse gut bacteria developed obesity, insulin resistance and higher triglyceride levels, despite similar food intake. In humans, an association has been found between obesity and gut microbiome dysbiosis. However, gut microbiome transfer has not been evaluated for the treatment of human obesity. We will examine the effectiveness of gut microbiome transfer using encapsulated material for the treatment of obesity in adolescents.

METHODS AND ANALYSIS

A two-arm, double-blind, placebo-controlled, randomised clinical trial of a single course of gut microbiome transfer will be conducted in 80 obese [body mass index (BMI) ≥30 kg/m²] adolescents (males and females, aged 14-18 years) in Auckland, New Zealand. Healthy lean donors (males and females, aged 18-28 years) will provide fresh stool samples from which bacteria will be isolated and double encapsulated. Participants (recipients) will be randomised at 1:1 to control (placebo) or treatment (gut microbiome transfer), stratified by sex. Recipients will receive 28 capsules over two consecutive mornings (~14 mL of frozen microbial suspension or saline). Clinical assessments will be performed at baseline, 6, 12 and 26 weeks, and will include: anthropometry, blood pressure, fasting metabolic markers, dietary intake, physical activity levels and health-related quality of life. Insulin sensitivity (Matsuda index), gut microbiota population structure characterised by 16S rRNA amplicon sequencing and body composition (using dual-energy X-ray absorptiometry) will be assessed at baseline, 6, 12 and 26 weeks. 24-hour ambulatory blood pressure monitoring will be performed at baseline and at 6 weeks. The primary outcome is BMI SD scores (SDS) at 6 weeks, with BMI SDS at 12 and 26 weeks as secondary outcomes. Other secondary outcomes include insulin sensitivity, adiposity (total body fat percentage) and gut microbial composition at 6, 12 and 26 weeks. Statistical analysis will be performed on the principle of intention to treat.

ETHICS AND DISSEMINATION

Ethics approval was provided by the Northern A Health and Disability Ethics Committee (Ministry of Health, New Zealand; 16/NTA/172). The trial results will be published in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

ACTRN12615001351505; Pre-results.

The Association of Insomnia, Perceived Immune Functioning, and Irritable Bowel Syndrome Complaints

BACKGROUND

Irritable bowel syndrome (IBS) can have a significant negative impact on quality of life, mood and wellbeing. The aim of this study was to investigate the association between experiencing IBS symptoms and insomnia, and perceived health status.

METHOD

An online survey was conducted among n = 1950 Dutch university students (83.6% women). IBS was assessed with the Birmingham IBS Symptom Questionnaire, quality of life with the WHO-5 wellbeing index, and sleep outcomes with the SLEEP-50 questionnaire. Perceived immune functioning and general health were assessed using 1-item scales.

RESULTS

IBS symptom severity was significantly associated with insomnia complaints (r = 0.32, p = 0.0001), sleep quality (r = -0.21, p = 0.0001), sleep onset latency (r = 0.11, p = 0.0001) and the number of nightly awakenings (r = 0.24, p = 0.0001). Total sleep time was not significantly associated with IBS symptom severity. Significant correlations were also found between IBS symptom severity and perceived general health (r = -0.30, p = 0.0001), perceived immune functioning (r= -0.25, p = 0.0001), and quality of life (r = -0.24, p = 0.0001).

CONCLUSIONS

Experiencing IBS complaints is associated with reduced perceived immune functioning, a poorer perception of general health, and sleep disturbances. These effects are reflected in a significantly lower reported quality of life in subjects with more IBS and/or sleep complaints.

Therapeutic Effects of Low-dose Bismuth Subcitrate on Symptoms and Health-related Quality of Life in Adult Patients with Irritable Bowel Syndrome: A Clinical Trial

OBJECTIVE

Irritable bowel syndrome (IBS) is a chronic functional disorder of the gastrointestinal tract that causes abdominal pain or discomfort and alters bowel with no organic abnormalities. Treatment options for IBS have increased in number in the past decade, and clinicians should not be limited to use only conventional treatments to cure it. This article is a placebo-controlled clinical trial to assess the therapeutic effects of low-dose bismuth subcitrate on symptoms and the health-related quality of life in adult patients with IBS.

METHODS

This clinical trial was done during July 2015 to January 2016 in Isfahan, Iran. For each of three subtypes (IBS-constipation dominant, IBS-diarrhea dominant [IBS-D], and IBS-mixed), we included patients with IBS aged 18-70 years, diagnosed according to the Rome III criteria. In this study, 129 eligible patients were enrolled, of which 119 continued on the protocol to the end of study. They were allocated in placebo group (Group A) and intervention group (Group B). The medication for Group B was mebeverine and bismuth subcitrate and for Group A was mebeverine and placebo of bismuth subcitrate. Initially, the patients of both groups completed IBS-related questionnaires (IBS-quality of life, IBS-severity scoring system), then given drugs for a 4-week period (1st on-drug period). Then, both groups were given only mebeverine hydrochloride 200 mg capsule for another 4 weeks (off-drug period). At last, Group A and Group B were given medication (2nd on-drug period), the same as 1st on-drug period.

FINDINGS

With respect to quality of life, the trend of IBS-QOL score changed significantly during the study period in both the intervention and placebo groups; however, no significant differences were observed between the two groups (P < 0.005). In subgroups analysis, quality of life significantly improved in IBS-D during the study from the first measurement to the end of study (P = 0.004). The trends of changes in the severity of pain during the study between the intervention and control group were significantly different (P = 0.018).

CONCLUSION

According to our study, IBS-D patients' symptoms improved significantly with bismuth therapy. We found that adding low-dose bismuth to mebeverine in nonresponsive IBS patients in conventional treatment could be helpful.

Development and validation of a patient-reported questionnaire assessing systemic therapy induced diarrhea in oncology patients

BACKGROUND

Systemic therapy-induced diarrhea (STID) is a common side effect experienced by more than half of cancer patients. Despite STID-associated complications and poorer quality of life (QoL), no validated assessment tools exist to accurately assess STID occurrence and severity to guide clinical management. Therefore, we developed and validated a patient-reported questionnaire (STIDAT).

METHODS

The STIDAT was developed using the FDA iterative process for patient-reported outcomes. A literature search uncovered potential items and questions for questionnaire construction used by oncology clinicians to develop questions for the preliminary instrument. The instrument was evaluated on its face validity and content validity by patient interviews. Repetitive, similar and different themes uncovered from patient interviews were implemented to revise the instrument to the version used for validation. Patients starting high-risk STID treatments were monitored using the STIDAT, bowel diaries and EORTC QLQ-C30. The STIDAT was evaluated for construct validity using exploratory factor analysis (EFA) using minimal residual method with Promax rotation, reliability and consistency. A weighted scoring system was developed and a receiver-operating characteristic (ROC) curve evaluated the tool's ability to detect STID occurrence. Median scores and variability were analysed to determine how well it differentiates between diarrhea severities. A post-hoc analysis determined how diarrhea severity impacted QoL of cancer patients.

RESULTS

Patients defined diarrhea based on presence of watery stool. The STIDAT assessed patient's perception of having diarrhea, daily number of bowel movements, daily number of diarrhea episodes, antidiarrheal medication use, the presence of urgency, abdominal pain, abdominal spasms or fecal incontinence, patient's perception of diarrhea severity, and QoL. These dimensions were sorted into four clusters using EFA - patient's perception of diarrhea, frequency of diarrhea, fecal incontinence and abdominal symptoms. Cronbach's alpha was 0.78; kappa ranged from 0.934-0.952, except for abdominal spasms (κ = 0.0455). The positive predictive value was 96.4%, with the minimum score of 1.35 predicting a positive STID occurrence. Patients with moderate or severe diarrhea experience significant decreases in QoL compared to those with no diarrhea.

CONCLUSIONS

This is the first patient-reported questionnaire that accurately predicts the occurrence and severity of diarrhea in oncology patients via assessing several bowel habit dimensions.

Symptom Severity Following Rifaximin and the Probiotic VSL#3 in Patients with Chronic Pelvic Pain Syndrome (Due to Inflammatory Prostatitis) Plus Irritable Bowel Syndrome

This study investigated the effects of long-term treatment with rifaximin and the probiotic VSL#3 on uro-genital and gastrointestinal symptoms in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) plus diarrhoea-predominant irritable bowel syndrome (D-IBS) compared with patients with D-IBS alone. Eighty-five patients with CP/CPPS (45 with subtype IIIa and 40 with IIIb) plus D-IBS according to the Rome III criteria and an aged-matched control-group of patients with D-IBS alone (n = 75) received rifaximin and VSL#3. The primary endpoints were the response rates of IBS and CP/CPPS symptoms, assessed respectively through Irritable Bowel Syndrome Severity Scoring System (IBS-SSS) and The National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI), and performed at the start of therapy (V0) and three months after (V3). In IIIa prostatitis patients, the total NIH-CPSI scores significantly (p < 0.05) decreased from a baseline mean value of 21.2 to 14.5 at V3 , as did all subscales, and in the IIIb the total NIH-CPSI score also significantly decreased (from 17.4 to 15.1). Patients with IBS alone showed no significant differences in NIH-CPSI score. At V3, significantly greater improvement in the IBS-SSS and responder rate were found in IIIa patients. Our results were explained through a better individual response at V3 in IIIa prostatitis of urinary and gastrointestinal symptoms, while mean leukocyte counts on expressed prostate secretion (EPS) after prostate massage significantly lowered only in IIIa cases.

Factors Associated with Severity of Irritable Bowel Syndrome Symptoms in Patients with Endometriosis

OBJECTIVE

This study sought to examine factors associated with severity of irritable bowel syndrome (IBS) by using the Birmingham IBS symptom scale in patients presenting with endometriosis to a tertiary referral centre.

METHODS

A prospective research cohort of patients presenting to a tertiary referral centre for endometriosis was evaluated for the presence and severity of IBS between December 2013 and April 2015. Patients with endometriosis had a diagnosis of IBS by using the Rome III criteria and were evaluated for severity of IBS symptoms by using the Birmingham IBS symptom scale. Multifactorial variables, including stage of endometriosis at the time of previous surgery, clinical examination findings, mood disorder questionnaire scores, and lifestyle factors, were evaluated using the t test and Spearman rank correlation test.

RESULTS

A total of 194 of 373 (52%) women with confirmed endometriosis had a diagnosis of IBS. Factors associated with severity of IBS symptoms in patients with endometriosis included lower-stage endometriosis (P = 0.004), presence of mood disorders (P <0.001), tenderness on physical examination (P ≤ 0.001), a history of sexual assault (P ≤ 0.02), and presence of sleep disturbance (P ≤ 0.01). Evaluation of the subscales of the Birmingham IBS symptom scale revealed a strong association between the previously identified factors and the pain subscale.

CONCLUSION

Using the Birmingham IBS symptom scale, our study revealed more severe IBS symptoms in patients with lower-stage endometriosis and identified other variables highly associated with severity of IBS. Continued research is required to characterize further the clinical importance of IBS symptoms in patients with endometriosis-associated pelvic pain.

Effect of diet and individual dietary guidance on gastrointestinal endocrine cells in patients with irritable bowel syndrome (Review)

Irritable bowel syndrome (IBS) is a common chronic gastrointestinal (GI) disorder that is characterized by a combination of abdominal pain or discomfort, bloating and alterations in bowel movements. This review presents recent developments concerning the roles of diet and GI endocrine cells in the pathophysiology of IBS and of individual dietary guidance in the management of IBS. Patients with IBS typically report that food aggravates their IBS symptoms. The interactions between specific types of foodstuffs rich in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) and GI endocrine cells induce changes in cell densities. Providing individual dietary guidance about a low FODMAP intake, high soluble-fiber intake, and changing the proportions of protein, fat and carbohydrates helps to reduce the symptoms experienced by patients with IBS and to improve their quality of life. These improvements are due to restoring the densities of the GI endocrine cells back to normal. The reported observations emphasize the role of GI endocrine cells in the pathophysiology of IBS and support the provision of dietary guidance as a first-line treatment for managing IBS.

Probiotic Bifidobacterium longum NCC3001 Reduces Depression Scores and Alters Brain Activity: A Pilot Study in Patients With Irritable Bowel Syndrome

BACKGROUND & AIMS

Probiotics can reduce symptoms of irritable bowel syndrome (IBS), but little is known about their effects on psychiatric comorbidities. We performed a prospective study to evaluate the effects of Bifidobacterium longum NCC3001 (BL) on anxiety and depression in patients with IBS.

METHODS

We performed a randomized, double-blind, placebo-controlled study of 44 adults with IBS and diarrhea or a mixed-stool pattern (based on Rome III criteria) and mild to moderate anxiety and/or depression (based on the Hospital Anxiety and Depression scale) at McMaster University in Canada, from March 2011 to May 2014. At the screening visit, clinical history and symptoms were assessed and blood samples were collected. Patients were then randomly assigned to groups and given daily BL (n = 22) or placebo (n = 22) for 6 weeks. At weeks 0, 6, and 10, we determined patients' levels of anxiety and depression, IBS symptoms, quality of life, and somatization using validated questionnaires. At weeks 0 and 6, stool, urine and blood samples were collected, and functional magnetic resonance imaging (fMRI) test was performed. We assessed brain activation patterns, fecal microbiota, urine metabolome profiles, serum markers of inflammation, neurotransmitters, and neurotrophin levels.

RESULTS

At week 6, 14 of 22 patients in the BL group had reduction in depression scores of 2 points or more on the Hospital Anxiety and Depression scale, vs 7 of 22 patients in the placebo group (P = .04). BL had no significant effect on anxiety or IBS symptoms. Patients in the BL group had a mean increase in quality of life score compared with the placebo group. The fMRI analysis showed that BL reduced responses to negative emotional stimuli in multiple brain areas, including amygdala and fronto-limbic regions, compared with placebo. The groups had similar fecal microbiota profiles, serum markers of inflammation, and levels of neurotrophins and neurotransmitters, but the BL group had reduced urine levels of methylamines and aromatic amino acids metabolites. At week 10, depression scores were reduced in patients given BL vs placebo.

CONCLUSION

In a placebo-controlled trial, we found that the probiotic BL reduces depression but not anxiety scores and increases quality of life in patients with IBS. These improvements were associated with changes in brain activation patterns that indicate that this probiotic reduces limbic reactivity. ClinicalTrials.gov no. NCT01276626.

Dietary interventions for recurrent abdominal pain in childhood

BACKGROUND

This is an update of the original Cochrane review, last published in 2009 (Huertas-Ceballos 2009). Recurrent abdominal pain (RAP), including children with irritable bowel syndrome, is a common problem affecting between 4% and 25% of school-aged children. For the majority of such children, no organic cause for their pain can be found on physical examination or investigation. Many dietary inventions have been suggested to improve the symptoms of RAP. These may involve either excluding ingredients from the diet or adding supplements such as fibre or probiotics.

OBJECTIVES

To examine the effectiveness of dietary interventions in improving pain in children of school age with RAP.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, Embase, eight other databases, and two trials registers, together with reference checking, citation searching and contact with study authors, in June 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing dietary interventions with placebo or no treatment in children aged five to 18 years with RAP or an abdominal pain-related, functional gastrointestinal disorder, as defined by the Rome III criteria (Rasquin 2006).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We grouped dietary interventions together by category for analysis. We contacted study authors to ask for missing information and clarification, when needed. We assessed the quality of the evidence for each outcome using the GRADE approach.

MAIN RESULTS

We included 19 RCTs, reported in 27 papers with a total of 1453 participants. Fifteen of these studies were not included in the previous review. All 19 RCTs had follow-up ranging from one to five months. Participants were aged between four and 18 years from eight different countries and were recruited largely from paediatric gastroenterology clinics. The mean age at recruitment ranged from 6.3 years to 13.1 years. Girls outnumbered boys in most trials. Fourteen trials recruited children with a diagnosis under the broad umbrella of RAP or functional gastrointestinal disorders; five trials specifically recruited only children with irritable bowel syndrome. The studies fell into four categories: trials of probiotic-based interventions (13 studies), trials of fibre-based interventions (four studies), trials of low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diets (one study), and trials of fructose-restricted diets (one study).We found that children treated with probiotics reported a greater reduction in pain frequency at zero to three months postintervention than those given placebo (standardised mean difference (SMD) -0.55, 95% confidence interval (CI) -0.98 to -0.12; 6 trials; 523 children). There was also a decrease in pain intensity in the intervention group at the same time point (SMD -0.50, 95% CI -0.85 to -0.15; 7 studies; 575 children). However, we judged the evidence for these outcomes to be of low quality using GRADE due to an unclear risk of bias from incomplete outcome data and significant heterogeneity.We found that children treated with probiotics were more likely to experience improvement in pain at zero to three months postintervention than those given placebo (odds ratio (OR) 1.63, 95% CI 1.07 to 2.47; 7 studies; 722 children). The estimated number needed to treat for an additional beneficial outcome (NNTB) was eight, meaning that eight children would need to receive probiotics for one to experience improvement in pain in this timescale. We judged the evidence for this outcome to be of moderate quality due to significant heterogeneity.Children with a symptom profile defined as irritable bowel syndrome treated with probiotics were more likely to experience improvement in pain at zero to three months postintervention than those given placebo (OR 3.01, 95% CI 1.77 to 5.13; 4 studies; 344 children). Children treated with probiotics were more likely to experience improvement in pain at three to six months postintervention compared to those receiving placebo (OR 1.94, 95% CI 1.10 to 3.43; 2 studies; 224 children). We judged the evidence for these two outcomes to be of moderate quality due to small numbers of participants included in the studies.We found that children treated with fibre-based interventions were not more likely to experience an improvement in pain at zero to three months postintervention than children given placebo (OR 1.83, 95% CI 0.92 to 3.65; 2 studies; 136 children). There was also no reduction in pain intensity compared to placebo at the same time point (SMD -1.24, 95% CI -3.41 to 0.94; 2 studies; 135 children). We judged the evidence for these outcomes to be of low quality due to an unclear risk of bias, imprecision, and significant heterogeneity.We found only one study of low FODMAP diets and only one trial of fructose-restricted diets, meaning no pooled analyses were possible.We were unable to perform any meta-analyses for the secondary outcomes of school performance, social or psychological functioning, or quality of daily life, as not enough studies included these outcomes or used comparable measures to assess them.With the exception of one study, all studies reported monitoring children for adverse events; no major adverse events were reported.

AUTHORS' CONCLUSIONS

Overall, we found moderate- to low-quality evidence suggesting that probiotics may be effective in improving pain in children with RAP. Clinicians may therefore consider probiotic interventions as part of a holistic management strategy. However, further trials are needed to examine longer-term outcomes and to improve confidence in estimating the size of the effect, as well as to determine the optimal strain and dosage. Future research should also explore the effectiveness of probiotics in children with different symptom profiles, such as those with irritable bowel syndrome.We found only a small number of trials of fibre-based interventions, with overall low-quality evidence for the outcomes. There was therefore no convincing evidence that fibre-based interventions improve pain in children with RAP. Further high-quality RCTs of fibre supplements involving larger numbers of participants are required. Future trials of low FODMAP diets and other dietary interventions are also required to facilitate evidence-based recommendations.

Changes in duodenal enteroendocrine cells in patients with irritable bowel syndrome following dietary guidance

The densities of enteroendocrine cells are abnormal in patients with irritable bowel syndrome (IBS); however, they tend to change toward normal levels in stomach, ileum, and colon following dietary guidance. The aim was to identify the types of duodenal enteroendocrine cells affected after receiving dietary guidance in the same group of patients with IBS. Fourteen patients with IBS and 14 control subjects were included. The patients received three sessions of dietary guidance. Both groups underwent gastroscopies at baseline, and again for the patients after 3–9 months (median, four months) from receiving dietary guidance. Tissue biopsies were collected from the descending part of the duodenum and were immunostained for all the types of enteroendocrine cells and were then quantified by using computerized image analysis. Using the Kruskal–Wallis non-parametric test with Dunn’s test as a post-test, the results showed a significant difference in the secretin cell densities between control subjects and patients with IBS prior to and following dietary guidance (P = 0.0001 and 0.011, respectively). The corresponding P values for cholecystokinin (CCK) cell densities were 0.03 and 0.42, respectively; gastric inhibitory peptide (GIP) cell densities were 0.06 and 0.43, respectively; serotonin cell densities were <0.0001 and 0.002, respectively; and for somatostatin cell densities were <0.0001 and 0.052, respectively. The Paired t-test showed a significant difference only in the serotonin (P = 0.03) and somatostatin (P < 0.0001) cell densities between IBS patients prior to and following dietary guidance. The changes in the cell densities of secretin, CCK, and GIP were not significant between IBS patients prior to and following dietary guidance. In conclusion, the densities of several duodenal enteroendocrine cells in IBS patients changed toward the values measured in control subjects following dietary guidance. The changes in serotonin and somatostatin cell densities may have contributed to the improvements in IBS symptoms, particularly pain and diarrhea.