Adam D. Farmer

Social networking sites: a novel portal for communication

Background: The internet has transformed many spheres of society. Most notably the advent of social networking websites, such as MySpace, Bebo and Facebook, have attracted many millions of users worldwide. There are over 350 such sites in operation across the internet. There is a paucity of data in the adult literature examining the medical usage of this interesting facet of modern life. Aims: To ascertain whether Facebook has user groups that are connected with common medical conditions, and to classify the user groups that were identified as well as enumerating the number of individual users contained therein. Methods: We conducted a search of the entire Facebook website between December 2007 and January 2009. We used medical and lay nomenclature for the most prevalent non-communicable diseases as identified from the World Health Organisation Burden of Disease publication to identify whether they were represented among individual Facebook users and user groups. Results: We identified 290 962 individual users who were part of 757 groups. Patient groups accounted for 47.4%, patient/carer support groups 28.1%, fund raising groups 18.6%, and others 5.8%. Notably, there were other groups containing representations from the scientific research community in addition to educational resources. The groups with the most individual members pertained to malignant neoplasms and cardiovascular disease (141 458 users) consistent with their worldwide prevalence. Conclusions: Facebook is providing a readily accessible portal for patients, carers and healthcare professionals to share their experiences of investigation, diagnosis and management of disease. Furthermore, this technology is being used for research, education and fundraising. Further research is warranted to explore the further potential of this new technology.

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a functional gastrointestinal disease with a high population prevalence. The disorder can be debilitating in some patients, whereas others may have mild or moderate symptoms. The most important single risk factors are female sex, younger age and preceding gastrointestinal infections. Clinical symptoms of IBS include abdominal pain or discomfort, stool irregularities and bloating, as well as other somatic, visceral and psychiatric comorbidities. Currently, the diagnosis of IBS is based on symptoms and the exclusion of other organic diseases, and therapy includes drug treatment of the predominant symptoms, nutrition and psychotherapy. Although the underlying pathogenesis is far from understood, aetiological factors include increased epithelial hyperpermeability, dysbiosis, inflammation, visceral hypersensitivity, epigenetics and genetics, and altered brain–gut interactions. IBS considerably affects quality of life and imposes a profound burden on patients, physicians and the health-care system. The past decade has seen remarkable progress in our understanding of functional bowel disorders such as IBS that will be summarized in this Primer.

Mood Disorders in Inflammatory Bowel Disease: Relation to Diagnosis, Disease Activity, Perceived Stress, and Other Factors

Background: Anxiety and depression are common in patients with inflammatory bowel disease (IBD); however, the factors associated with mood disorders in patients with ulcerative colitis (UC) and Crohns disease (CD) are poorly defined. Methods: In all, 103 patients with UC, 101 with CD, and 124 healthy controls completed the Hospital Anxiety and Depression Scale (HADS). Disease activity was defined both from symptom scores and in UC endoscopically, and in CD by fecal calprotectin and/or serum C‐reactive protein. Multivariate regression analyses were used to identify factors associated with anxiety and depression. Results: In both UC and CD, anxiety (HADS‐A) and depression (HADS‐D) scores were higher than in controls (HADS‐A: 8.5 ± 4.1 [mean ± SD], 8.6 ± 3.9, 3.2 ± 1.8, P < 0.001; and HADS‐D: 4.1 ± 3.3, 4.7 ± 3.3, 1.7 ± 1.4, P < 0.001, respectively). There were no differences in the prevalence of mild, moderate, and severe anxiety and depression in UC and CD. In UC, anxiety scores were associated with perceived stress and a new diagnosis of IBD; depression was associated with stress, inpatient status, and active disease. In CD, anxiety was associated with perceived stress, abdominal pain, and lower socioeconomic status, and depression with perceived stress and increasing age. Conclusions: Anxiety and depression are common in IBD. Perceived stress is associated with mood disturbances in both UC and CD, but the other associated factors differ in the two diseases. Gastroenterologists should look for mood disorders in IBD and consider stress management and psychotherapy in affected patients. (Inflamm Bowel Dis 2012;)

Unexplained gastrointestinal symptoms and joint hypermobility: is connective tissue the missing link?

Background  Unexplained gastrointestinal (GI) symptoms and joint hypermobility (JHM) are common in the general population, the latter described as benign joint hypermobility syndrome (BJHS) when associated with musculo‐skeletal symptoms. Despite overlapping clinical features, the prevalence of JHM or BJHS in patients with functional gastrointestinal disorders has not been examined.

Neuroticism influences brain activity during the experience of visceral pain.

BACKGROUND & AIMS One particularly important individual dynamic known to influence the experience of pain is neuroticism, of which little is known about in visceral pain research. Our aim was to study the relationship between neuroticism, psychophysiologic response, and brain processing of visceral pain. METHODS Thirty-one healthy volunteers (15 male; age range, 22-38 years) participated in the study. The Eysenck Personality Questionnaire was used to assess neuroticism. Skin conductance level, pain ratings, and functional magnetic resonance imaging data were acquired during anticipation of pain and painful esophageal distention. The effect of neuroticism was assessed using correlation analysis. RESULTS There was a wide spread of neuroticism scores (range, 0-22) but no influence of neuroticism on skin conductance level and pain tolerance or pain ratings. However, a positive correlation between brain activity and neuroticism during anticipation was found in regions associated with emotional and cognitive pain processing, including the parahippocampus, insula, thalamus, and anterior cingulate cortex. These regions showed a negative correlation with neuroticism during pain (P < .001). CONCLUSIONS This study provides novel data suggesting higher neuroticism is associated with engagement of brain regions responsible for emotional and cognitive appraisal during anticipation of pain but reduced activity in these regions during pain. This may reflect a maladaptive mechanism in those with higher neuroticism that promotes overarousal during anticipation and avoidance coping during pain.

Systematic review with meta-analysis: The prevalence of bile acid malabsorption in the irritable bowel syndrome with diarrhoea

Irritable bowel syndrome is a widespread disorder with a marked socioeconomic burden. Previous studies support the proposal that a subset of patients with features compatible with diarrhoea‐predominant IBS (IBS‐D) have bile acid malabsorption (BAM).

Visceral pain hypersensitivity in functional gastrointestinal disorders

INTRODUCTION Functional gastrointestinal disorders (FGIDs) are a highly prevalent group of heterogeneous disorders whose diagnostic criteria are symptom based in the absence of a demonstrable structural or biochemical abnormality. Chronic abdominal pain or discomfort is a defining characteristic of these disorders and a proportion of patients may display heightened pain sensitivity to experimental visceral stimulation, termed visceral pain hypersensitivity (VPH). SOURCES OF DATA We examined the most recent literature in order to concisely review the evidence for some of the most important recent advances in the putative mechanisms concerned in the pathophysiology of VPH. AREAS OF AGREEMENT VPH may occur due to anomalies at any level of the visceral nociceptive neuraxis. Important peripheral and central mechanisms of sensitization that have been postulated include a wide range of ion channels, neurotransmitter receptors and trophic factors. Data from functional brain imaging studies have also provided evidence for aberrant central pain processing in cortical and subcortical regions. In addition, descending modulation of visceral nociceptive pathways by the autonomic nervous system, hypothalamo-pituitary-adrenal axis and psychological factors have all been implicated in the generation of VPH. AREAS OF CONTROVERSY Particular areas of controversy have included the development of efficacious treatment of VPH. Therapies have been slow to emerge, mainly due to concerns regarding safety. GROWING POINTS The burgeoning field of genome wide association studies may provide further evidence for the pleiotropic genetic basis of VPH development. AREAS TIMELY FOR DEVELOPING RESEARCH Tangible progress will only be made in the treatment of VPH when we begin to individually characterize patients with FGIDs based on their clinical phenotype, genetics and visceral nociceptive physiology.

Joint hypermobility and rectal evacuatory dysfunction: an etiological link in abnormal connective tissue?

Background  Previous studies report an association between joint hypermobility (JHM), as a clinical feature of underlying connective tissue (CT) disorder, and pelvic organ prolapse. However, its association with rectal evacuatory dysfunction (RED) has not been evaluated. To investigate the prevalence of JHM in the general population and in patients with symptoms of RED referred for anorectal physiological investigation.

A Prospective Evaluation of Undiagnosed Joint Hypermobility Syndrome in Patients With Gastrointestinal Symptoms

BACKGROUND & AIMS The Joint Hypermobility Syndrome (JHS) is a common connective tissue disorder characterized by joint hyperflexibility, dysautonomia, and chronic pain. Gastrointestinal (GI) symptoms are reported in JHS patients attending rheumatology clinics, but the prevalence and symptom pattern of previously undiagnosed JHS in GI clinics are unknown. METHODS By using validated questionnaires, a prospective cross-sectional study in secondary care GI clinics estimated the prevalence of JHS in new consecutively referred patients, compared GI symptoms in patients with and without JHS, and by using multiple regression determined whether the burden of GI symptoms in JHS patients was dependent on chronic pain, autonomic, psychological, and medication related factors. A positive control group consisted of JHS patients referred from rheumatology clinics with GI symptoms (JHS-Rh). RESULTS From 552 patients recruited, 180 (33%) had JHS (JHS-G) and 372 did not (non-JHS-G). Forty-four JHS-Rh patients were included. JHS-G patients were more likely to be younger, female with poorer quality of life (P = .02) than non-JHS-G patients. After age and sex matching, heartburn (odds ratio [OR], 1.66; confidence interval [CI], 1.1-2.5; P = .01), water brash (OR, 2.02; CI, 1.3-3.1; P = .001), and postprandial fullness (OR, 1.74; CI, 1.2-2.6; P = .006) were more common in JHS-G vs non-JHS-G. Many upper and lower GI symptoms increased with increasing severity of JHS phenotype. Upper GI symptoms were dependent on autonomic and chronic pain factors. CONCLUSIONS JHS is common in GI clinics, with increased burden of upper GI and extraintestinal symptoms and poorer quality of life. Recognition of JHS will facilitate multidisciplinary management of GI and extra-GI manifestations.

Sex differences in brain response to anticipated and experienced visceral pain in healthy subjects

Women demonstrate higher pain sensitivity and prevalence of chronic visceral pain conditions such as functional gastrointestinal disorders than men. The role of sex differences in the brain processing of visceral pain is still unclear. In 16 male and 16 female healthy subjects we compared personality, anxiety levels, skin conductance response (SCR), and brain processing using functional MRI during anticipation and pain induced by esophageal distension at pain toleration level. There was no significant difference in personality scores, anxiety levels, SCR, and subjective ratings of pain between sexes. In group analysis, both men and women demonstrated a similar pattern of brain activation and deactivation during anticipation and pain consistent with previous reports. However, during anticipation women showed significantly greater activation in the cuneus, precuneus, and supplementary motor area (SMA) and stronger deactivation in the right amygdala and left parahippocampal gyrus, whereas men demonstrated greater activation in the cerebellum. During pain, women demonstrated greater activation in the midcingulate cortex, anterior insula, premotor cortex, and cerebellum and stronger deactivation in the caudate, whereas men showed increased activity in the SMA. The pattern of brain activity suggests that, during anticipation, women may demonstrate stronger limbic inhibition, which is considered to be a cognitive modulation strategy for impending painful stimulation. During pain, women significantly activate brain areas associated with the affective and motivation components of pain. These responses may underlie the sex differences that exist in pain conditions, whereby women may attribute more emotional importance to painful stimuli compared with men.