Fareed Iqbal

Transcutaneous Sacral Electrical Stimulation for Chronic Functional Constipation.

BACKGROUND: Transcutaneous sacral nerve stimulation is reported to improve symptoms of fecal incontinence. Chronic constipation may also respond to stimulation, but this is poorly reported in the literature. OBJECTIVE: The study assessed the efficacy of transcutaneous electrical stimulation directly over the sacral nerve roots in chronic constipation. PATIENTS: Chronic functional constipation was established in all patients using the Rome III criteria. SETTING: The therapy was self-administered at home. DESIGN/INTERVENTION: A pilot study was conducted of transcutaneous sacral stimulation given over a 4-week period for 12 hours a day. MAIN OUTCOME MEASURES: Patients were assessed using the Patient Assessment of Constipation Symptoms, the Patient Assessment of Constipation Quality of Life, and the Cleveland constipation tool. A Global Rating of Change measure and a 1-week bowel diary was kept for the final week and compared with baseline. RESULTS: Of the 20 patients recruited (16 female, median age 38.5 years), 80% (16) completed the trial. Five (31%) patients reported at least a point reduction in the Patient Assessment of Constipation Symptoms score, 4 (25%) deteriorated, and 7 (44%) improved by less than one point. Median (interquartile range) Patient Assessment of Constipation Symptoms scores were 2.33 (2.34) at baseline and 2.08 (2.58) at follow-up (p = 0.074). Median scores for the Patient Assessment of Constipation Quality of Life and Cleveland systems were 3.00 (1.64) and 17.15 (18) at baseline and 2.22 (3.04) and 15.31 (12) at follow-up (p = 0.096 and 0.111). One-third of patients reported a positive Global Rating of Change measure, although 68% required concurrent laxatives during the trial. LIMITATIONS: This is a pilot study and is limited by its small sample size. CONCLUSIONS: Continuous transcutaneous sacral stimulation in the short term appears to be ineffective for chronic constipation. Larger well-powered studies with intermittent stimulation regimens are required to investigate this further.

Engaging with Faith Councils to Develop Stoma-specific Fatawās: A Novel Approach to the Healthcare Needs of Muslim Colorectal Patients.

Intestinal stomas are common. Muslims report significantly lower quality of life following stoma surgery compared to non-Muslims. A fatwā is a ruling on a point of Islamic law according to a recognised religious authority. The use of fatawās to guide health-related decision-making has becoming an increasingly popular practice amongst Muslims, regardless of geographic location. This project aimed to improve the quality of life of Muslim ostomates by addressing faith-specific stoma concerns. Through close collaboration with Muslim ostomates, a series of 10 faith-related questions were generated, which were posed to invited local faith leaders during a stoma educational event. Faith leaders received education concerning the realities of stoma care before generating their fatawās. The event lead to the formulation of a series of stoma-specific fatawās representing Hanafi and Salafi scholarship, providing faith-based guidance for Muslim ostomates and their carers. Enhanced communication between healthcare providers and Islamic faith leaders allows for the delivery of informed fatawās that directly benefit Muslim patients and may represent an efficient method of improving health outcomes in this faith group.

The CONFIDeNT trial.

1 Knowles CH, Horrocks EJ, Bremner SA, et al. Percutaneous tibial nerve stimulation versus sham electrical stimulation for the treatment of faecal incontinence in adults (CONFIDeNT): a double-blind, multicentre, pragmatic, parallel-group, randomised controlled trial. Lancet 2015; 386: 1640–48. 2 Chen J, Song GQ, Yin J, Koothan T, Chen JD. Electroacupuncture improves impaired gastric motility and slow waves induced by rectal distension in dogs. Am J Physiol Gastrointest Liver Physiol 2008; 295: G614–20. 3 Yi WM, Chen Q, Liu CH, Hou JY, Chen LD, Wu WK. Acupuncture for preventing complications after radical hysterectomy: a randomized controlled clinical trial. Evid Based Complement Alternat Med 2014; 2014: 802134. 4 Liu Z, Wang W, Wu J, Zhou K, Liu B. Electroacupuncture improves bladder and bowel function in patients with traumatic spinal cord injury: results from a prospective observational study. Evid Based Complement Alternat Med 2013; 2013: 543174. 5 Woodward S, Norton C, Barriball KL. A pilot study of the eff ectiveness of refl exology in treating idiopathic constipation in women. Complement Ther Clin Pract 2010; 16: 41–46. 6 Burgell RE, Lelic D, Carrington EV, et al. Assessment of rectal aff erent neuronal function and brain activity in patients with constipation and rectal hyposensitivity. Neurogastroenterol Motil 2013; 25: 260–67. needle. Although the tibial nerve was not stimulated with this arrangement, inadvertent activation of other ascending somatovisceral neuronal pathways cannot be fully excluded. The importance of this possibility is reported in the scientifi c literature, with many studies on distal electroacupuncture away from the tibial nerve reporting efficacy in modulating the pelvic floor. Furthermore, the efficacy of simple foot refl exology on normalising colonic transit in constipation has been reported previously, suggesting the ease by which somatovisceral refl exes can be activated. All patients in the study were blinded to the intervention and probably neuromodulation naive. Knowles and colleagues might have avoided introducing bias by using an inactive stimulation device (ie, with no needle) as a sham. Furthermore, use of a different needle site altogether for sham stimulation might have been a better approach. We are aware that the lead author has used the median nerve as a comparator in previous mechanism studies. The results also show that mean incontinence episodes per week were reduced significantly from 6·0 to 3·5 in the PTNS group (p=0·021). Urge but not passive incontinence improved, and loperamide use was reduced signifi cantly in the PTNS group. These results seem to have been downplayed. The authors raise an important question in their discussion, asking whether the statistically significant improvements are clinically important. Because this was a National Institute for Health Research funded trial, we are aware that a post-trial analysis was done with patient focus groups. We would be most interested to know the opinions of the patients with respect to the question raised by the authors. From our own experience, patients welcome any improvement in symptoms and those improvements described in the results could in fact be clinically relevant. We agree with the authors that a further assessment of patients with sole urge incontinence is important. We read with great interest the Article by Charles Knowles and colleagues about percutaneous tibial nerve stimulation (PTNS) versus sham electrical stimulation for faecal incontinence. We wish to first commend the study group for completing an excellent study and adding to the evidence about this challenging patient group. The study was timely, well balanced, and clinically relevant, and we thank the authors for their eff orts. The group randomly assigned 227 consecutive patients to receive either 12 sessions of PTNS or sham electrical stimulation. Of the 205 participants who completed the treatment (103 for PTNS and 102 for sham), the results suggest no signifi cant benefi t of PTNS versus sham stimulation for the primary outcome—ie, at least 50% reduction in faecal incontinence episodes per week. The results are disappointing and likely to substantially aff ect present faecal incontinence treatment algorithms. For these reasons the conclusions and method of the trial should be examined more closely. We were surprised to learn that a socalled active placebo was chosen for the trial. Patients in the sham group received 10 Hz of stimulation with a pulse width of 200 μs via a needle electrode placed at 2 mm skin depth at the same site as the active stimulation 1 Knowles CH, Horrocks EJ, Bremner SA, et al. Percutaneous tibial nerve stimulation versus sham electrical stimulation for the treatment of faecal incontinence in adults (CONFIDeNT): a double-blind, multicentre, pragmatic, parallel-group, randomised controlled trial. Lancet 2015; 386: 1640–48. 2 Hotouras A, Murphy J, Allison M, et al. Outcome of percutaneous tibial nerve stimulation (PTNS) for fecal incontinence: a prospective cohort study. Ann Surg 2014; 259: 939–43. 3 Hotouras A, Thaha MA, Boyle DJ, et al. Short-term outcome following percutaneous tibial nerve stimulation for faecal incontinence: a single-centre prospective study. Colorectal Dis 2012; 14: 1101–05. 4 de la Portilla F, Laporte M, Maestre MV, et al. Percutaneous neuromodulation of the posterior tibial nerve for the treatment of faecal incontinence—mid-term results: is retreatment required? Colorectal Dis 2014; 16: 304–10.

Factors Associated With Efficacy of Nurse-led Bowel Training of Patients With Chronic Constipation

BACKGROUND & AIMS It is not clear whether nurse-led bowel training (NBT), an individually tailored biofeedback strategy designed to improve the physiological process of defecation by operant conditioning and trial and error learning, is effective for patients with chronic constipation. We assessed the ability of NBT to reduce symptoms and increase quality of life in patients with constipation at a large tertiary medical center. METHODS We performed a retrospective analysis of data from 347 patients (median age, 50 years) who underwent a median 3 sessions of NBT for chronic constipation from January 2011 through December 2013 at St Marks Hospital in the United Kingdom. The NBT comprised a combination of sensory retraining, pelvic floor conditioning, and advice on diet and toileting behavior. Data on patient demographics (age, sex, type of constipation) were collected alongside their assessments of constipation, which were based on Patient Assessment of Constipation Quality of Life (PAC-QoL) and patient satisfaction scores. We performed binary logistic regression analysis. Each variable was tested first at the univariate level; those with significance (P < .10) were included in a multivariate model. RESULTS At the end of NBT, 62.5% of the patients (217/347) reported reduced symptoms, and 40.2% of the patients (41/102) reported a reduction of at least 1 point on the PAC-QoL score. The mean PAC-QoL scores before and after NBT were 2.42 and 1.41, respectively (P = .001). Multivariate analysis demonstrated that increasing age (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.02-2.87; P = .042), greater number of sessions (OR, 4.14; 95% CI, 2.09-8.20; P < .001), and non-irrigation (OR, 4.39; 95% CI, 1.89-10.19; P = .001) were independent predictors of patient satisfaction. CONCLUSIONS Data collected immediately after patients with chronic constipation received NBT indicate that it is an effective treatment for most patients. Older patients with dyssynergic defecation benefit most from at least 4 sessions.

Quality of life after restorative proctocolectomy in Muslim patients

Dear Editor, Current guidelines from the British Society of Gastroenterology concerning the management of IBD in adults1 highlight that surgery remains necessary in up to 30% of patients with UC. First described by Parks and Nicholls,2 restorative proctocolectomy with ileal pouch–anal anastomosis (RPC) has become the established operation for patients with therapy-resistant UC, indeterminate colitis, familial adenomatous polyposis and for some patients with UC-related neoplasia.3 ,4 Ethnic variations in the incidence and prevalence of IBD in the UK are diminishing.5 IBD has increased dramatically in British South Asians,6 the majority of whom are Muslim. Intestinal surgery impacts on the lives of all patients, but we wish to highlight some issues specific to the Muslim population. Daily prayer constitutes one of the five pillars of Islam and is deemed the most important after the shahadah (declaration of faith). Muslims pray up to five times a day and hold strict hygiene requirements for their prayer. This includes washing the perianal skin (called istinjāh) after every bowel movement. Faecal seepage invalidates istinjāh , and this must be repeated in order to resume prayers. Some Muslims with a stoma avoid …

What should doctors do about fasting during Ramadan

Although agreeing with the general sentiments expressed in Panju’s insightful article on patients who fast in Ramadan,1 I think this discussion should address an often overlooked issue: Should doctors fast while caring for patients? As a practising Muslim, I have found it extremely difficult …

Quality of Life After Ostomy Surgery in Muslim Patients: A Systematic Review of the Literature and Suggestions for Clinical Practice.

PURPOSE: To determine factors that influence health-related quality of life (HRQOL) after ostomy surgery in Muslim patients. METHODS: A systematic literature review of published data was carried out using MeSH terms (“Muslim” OR “Islam”) AND (“stoma” OR “ostomy” OR “colostomy” OR “ileostomy”) AND “quality of life” AND “outcomes.” RESULTS: Twelve studies enrolling 913 subjects were deemed suitable for inclusion in the review. HRQOL was found to be particularly impaired in Muslims; this impairment went beyond that experienced by non-Muslim patients. Factors associated with this difference included psychological factors, social isolation, underreporting of complications, and sexual dysfunction leading to breakdown of marital relations as well as diminished religious practices. CONCLUSION: Muslims requiring ostomies should receive preoperative counseling by surgeons and ostomy nurses. These discussions should also include faith leaders and/or hospital chaplains. Ongoing support after surgery can be extended into the community and encompass family doctors and faith leaders. Additional research exploring HRQOL after surgery in Muslims living in Western societies is indicated.

Oral polyp as the presenting feature of Beckwith-Wiedemann syndrome in a child

Beckwith-Wiedemann syndrome (BWS) is a congenital growth disorder characterised by abdominal wall defects, macroglossia and somatic gigantism. A number of associated features, including gastrointestinal and urinary tract polyps, have been described, but there are no previous reports of oral polyps occurring in this syndrome. We describe the first case of BWS presenting with an oral polyp. Clinicians should be alert to the possibility of BWS if other features of the syndrome are present, in children with oral polyps.

A pain in the bottom

A 44 year old man presents to primary care with a four week history of severe, intermittent episodes of anorectal pain, each lasting for some 10 minutes without pain between episodes. Symptoms persist despite use of over the counter medications. Anorectal pain is common, with an estimated prevalence of around 7%. It can usually be managed in general practice. However, presentation may be confounded by embarrassment and fear of serious pathology, requiring a sensitive and focused approach. In this case, the most likely diagnoses are anal fissure, haemorrhoids, or functional anorectal pain (chronic proctalgia or proctalgia fugax). Less common possibilities are listed in the box. Functional anorectal pain occurs in the absence of any pathology; it is relatively common, affecting about 18% of patients with anorectal pain, but can be disabling. Chronic proctalgia is defined as chronic or recurrent pain or aching localised to the anus or lower rectum, with episodes lasting ≥20 minutes. The pain in proctalgia fugax lasts from seconds to minutes, without pain between episodes. #### Unusual causes of anorectal pain ##### Anorectal sexually transmitted infections Risk factors: