Saunjoo L. Yoon

Irritable bowel syndrome: Epidemiology, diagnosis and treatment: An update for health-care practitioners

Irritable bowel syndrome (IBS), a chronic gastrointestinal disorder, affects from 3–20% of the US population, depending on sociocultural and comorbid factors. IBS is characterized by a symptom complex of abdominal pain and abnormal bowel habits that present as diarrhea or constipation, and general physical weakness in the absence of abnormal morphological, histological or inflammatory markers. The main diagnostic Rome III criteria as established by international professional organizations are based on exclusion criteria and the occurrence and rate of symptoms. Because the pathophysiology and causes of IBS are poorly understood, treatment approaches are mainly focused on symptom management to maintain everyday functioning and improve quality of life for persons with IBS. The mainstay of intervention is pharmacological treatment with antispasmodics and antidiarrheals for diarrhea, prokinetics and high‐fiber diets for constipation, and supportive therapy with low‐dose antidepressants to normalize gastrointestinal motility. Other interventions include lifestyle and dietary changes, psychotherapy, herbal therapies and acupuncture. The purpose of this review is to critically assess benefits and risks of current treatment approaches as well as promising complementary and alternative therapies.

Complementary and alternative medicines in irritable bowel syndrome: An integrative view

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder with a high incidence in the general population. The diagnosis of IBS is mainly based on exclusion of other intestinal conditions through the absence of inflammatory markers and specific antigens. The current pharmacological treatment approaches available focus on reducing symptom severity while often limiting quality of life because of significant side effects. This has led to an effectiveness gap for IBS patients that seek further relief to increase their quality of life. Complementary and alternative medicines (CAM) have been associated with a higher degree of symptom management and quality of life in IBS patients. Over the past decade, a number of important clinical trials have shown that specific herbal therapies (peppermint oil and Iberogast(®)), hypnotherapy, cognitive behavior therapy, acupuncture, and yoga present with improved treatment outcomes in IBS patients. We propose an integrative approach to treating the diverse symptoms of IBS by combining the benefits of and need for pharmacotherapy with known CAM therapies to provide IBS patients with the best treatment outcome achievable. Initial steps in this direction are already being considered with an increasing number of practitioners recommending CAM therapies to their patients if pharmacotherapy alone does not alleviate symptoms sufficiently.

The value of bioelectrical impedance analysis and phase angle in the evaluation of malnutrition and quality of life in cancer patients—a comprehensive review

Bioelectrical impedance analysis (BIA) and especially its derived parameter phase angle have been widely used in different populations. The variability of BIA measures has often been cited as a major limitation for its clinical use in evaluating nutritional status and overall health of patients. Cancer patients often present with malnourishment and cachexia, which complicate the course of treatment and affect outcomes. PubMed, CINAHL, EBSCO and Cochrane Library have been searched for relevant publications in English for BIA in cancer patients. Out of 197 total results, 27 original research articles related to BIA measures in cancer patients were included in this review. Studies indicate that the use of BIA and phase angle measures can benefit in the clinical management of cancer patients in multiple ways: in the prevention; diagnosis; prognosis; and outcomes related to treatments that affect nutritional and overall health status. Phase angle and fat-free mass measures were most commonly evaluated and correlated with nutritional status and survival rate. One limitation of BIA measures is the high interpatient variability which requires careful interpretation of results in the context of the individual patient rather than comparison with population data. The BIA and phase angle provide practitioners for the evaluation of nutritional and overall health status in cancer patients with a convenient and non-invasive technique and should be encouraged.

Evidence-based Methods to Enhance Medication Adherence

Medication adherence problems prevent 50% of patients with chronic disorders from receiving the full benefit of prescribed regimens. These problems are consistent regardless of disease, symptom, regimen, or age-group. This article discusses evidence-based recommendations for assessing and improving adherence. The recommendations are categorized into affective, behavioral, and cognitive (ABC) domains. Using ABC strategies, clinicians and patients can work together to improve treatment outcomes.

A review of smoking cessation: potentially risky effects on prescribed medications.

AIMS AND OBJECTIVES To identify prescription drugs that require dosage adjustment or monitoring in patients who quit smoking and to provide recommendations for dosage adjustment based on available evidence. BACKGROUND Health care providers are urged to facilitate smoking cessation for patients who smoke, but the effects of smoking cessation on the metabolism of some drugs is not routinely considered. DESIGN A comprehensive literature review. METHODS The review was conducted in 2008 using a computerised drug interaction program and multiple PubMed and CINAHL searches to identify prescription drugs with clinically significant pharmacokinetic or pharmacodynamic changes caused by smoking cessation. RESULTS Although much of the evidence is case report, dosage adjustments are clearly indicated for warfarin, olanzapine, clozapine and theophylline since they are metabolised by cytochrome P450 CYP1A2 and also have narrow therapeutic ratios. Careful monitoring is recommended for other CYP1A2 metabolised drugs, including those for hypertension and Alzheimers disease. For many affected drugs, smoking cessation reverses smoking-induced CYP1A2 hepatic enzyme levels to normal, increasing plasma concentrations in patients whose dose was established while smoking. Because the effect on hepatic microsomal enzymes is not related to the nicotine component of tobacco, nicotine replacement will not alter the effect. CONCLUSIONS The effects of smoking cessation on drugs metabolised by CYP1A2 have been under-appreciated by health care providers. Smoking cessation may increase plasma levels of some drugs to potentially toxic levels. Further research is warranted to clarify this effect. RELEVANCE TO CLINICAL PRACTICE When patients stop smoking, providers should carefully review prescribed drug regimens and adjust or monitor drugs whose metabolism is affected by smoking cessation. This is particularly important for patients who abruptly stop smoking due to hospitalisation and for older patients who are likely to be taking multiple medications.

The relationship between pain and functional disability in Black and White older adults

In this study we examined pain and disability in 115 community-dwelling, urban, older adults (mean age = 74 years; 52% Black, 48% White). Participants completed a survey of pain (pain presence, intensity, locations, and duration) and disability (Sickness Impact Profile). Sixty percent of the sample reported pain; Black and White adults did not differ on any pain variable. In structural equation models controlling for socioeconomic factors and health, pain did not mediate the relationship between race and disability. Race moderated the pain-disability relationship; pain was more associated with disability among Whites than Blacks. This study highlights the need for greater understanding of health disparities between Black and White older adults as they relate to pain and disability.

Educating patients to evaluate web‐based health care information: the GATOR approach to healthy surfing

AIMS AND OBJECTIVES Teaching patients to assess web resources effectively has become an important need in primary care. The acronym GATOR (genuine, accurate, trustworthy, origin and readability), an easily memorized strategy for assessing web-based health information, is presented in this paper. BACKGROUND Despite the fact that many patients consult the World-Wide Web (or Internet) daily to find information related to health concerns, a lack of experience, knowledge, or education may limit ability to accurately evaluate health-related sites and the information they contain. Health information on the Web is not subject to regulation, oversight, or mandatory updates and sites are often transient due to ever changing budget priorities. This makes it difficult, if not impossible, for patients to develop a list of stable sites containing current, reliable information. DESIGN Commentary aimed at improving patients use of web based health care information. CONCLUSIONS The GATOR acronym is easy to remember and understand and may assist patients in making knowledgeable decisions as they traverse through the sometimes misleading and often overwhelming amount of health information on the Web. RELEVANCE TO CLINICAL PRACTICE The GATOR acronym provides a mechanism that can be used to structure frank discussion with patients and assist in health promotion through education. When properly educated about how to find and evaluate Web-based health information, patients may avoid negative consequences that result from trying unsafe recommendations drawn from untrustworthy sites. They may also be empowered to not only seek more information about their health conditions, treatment and available alternatives, but also to discuss their feelings, ideas and concerns with their healthcare providers.

Current Developments for the Diagnosis and Treatment of Irritable Bowel Syndrome

Current treatment options for the chronic gastrointestinal disorder irritable bowel syndrome (IBS) have long been limited to symptomatic treatments due to lack of pathophysiologic understanding of the syndrome. Within the past 10 years, however, a number of new pharmacological targets have been identified that may aid in the treatment of irritable bowel syndrome. Although only a limited number of new drug entities have entered the market in the past years, many new potential pharmacophores are evolving. Among them, several drugs are in the pipeline that target cholecystokinin or corticotropin-releasing factor receptors, serve as inhibitors for specific tryptophan hydroxylase iso-enzymes, modulate chloride secretion, influence immune responses via monoclonal antibodies or ATP-mediated pathways, and even normalize the gastrointestinal microflora via supplementation with probiotics. While new treatments that act via chloride secretion and immune modulation present with favorable outcomes in clinical trials, other novel therapies require further evaluation. This review is intended to provide a synopsis of current and emerging pharmacotherapies for IBS.

The Microbiome and Cancer: Implications for Oncology Nursing Science.

Background: Approximately 1.6 million Americans were diagnosed with cancer in 2014. To combat their disease, many individuals received either curative or palliative treatments that produced undesired symptoms. These symptoms, which often cause significant distress for individuals coping with cancer, may share biologic underpinnings such as epigenetic changes and immune dysregulation. Alterations in the normal flora of the gut may also influence cancer symptoms. Objective: The aim of this review is to describe the emerging role for the gut microbiome in cancer research, especially the potential relationship between the gut microbiome and cancer symptoms. Methods: Extant literature was reviewed and synthesized. Results: The majority of studies linking the gut microbiota and cancer are animal models and focus on the relationship between dysbiosis and colorectal cancer. Emerging evidence supports that the “gut-brain” connection is a plausible mechanism for “psychoneurological” cancer symptoms such as depression, pain, and fatigue. Conclusions: There is compelling evidence that the gut microbiota affects cancer via several mechanisms, including microbial diversity and number, metabolism, and/or immune initiation. However, more research is necessary to elucidate these mechanisms, particularly among a variety of cancers and cancer-related symptoms. Implications for Practice: A better understanding of the role of the gut microbiota in cancer symptoms may lead to the development of targeted individualized interventions affecting the gut microbiota that prevent or ameliorate dysbiosis, thereby reducing symptoms. These interventions may emphasize self-care management strategies essential for wellness, such as diet, nutrition, and stress reduction.

Novel intervention with acupuncture for anorexia and cachexia in patients with gastrointestinal tract cancers: a feasibility study.

PURPOSE/OBJECTIVES To investigate the feasibility of using acupuncture as a complementary intervention to existing treatments and to evaluate the efficacy of acupuncture in improving appetite and slowing weight loss with patients with gastrointestinal (GI) tract cancers. 
 DESIGN One-group pre- and postintervention feasibility study. 
 SETTING Outpatient clinic for patients with cancer and a community setting, both in Florida. 
 SAMPLE A convenience sample of seven adults with GI cancer.
 METHODS Eight acupuncture sessions were provided during eight weeks. Data were collected using the visual analog scale (VAS) for appetite, Simplified Nutritional Appetite Questionnaire (SNAQ), Karnofsky Performance Status, and bioelectrical impedance analysis. 
 MAIN RESEARCH VARIABLES Appetite, weight, attrition rate.
 FINDINGS Seven patients with a mean age of 61 years completed the intervention. Acupuncture was well accepted, feasible, and safe without any reported side effects. Appetite showed improvement, with an average score of 3.04 on the VAS and 4.14 on SNAQ compared to the preintervention scores. The average weight loss was 1.32% compared to the baseline during an eight-week period. 
 CONCLUSIONS The acupuncture intervention was feasible and indicated positive outcomes. Because of the small sample size and lack of a control group, statistical significance of effectiveness was not determined. Acupuncture seemed to improve appetite and slow weight loss in patients with GI cancers, so additional studies with a larger sample size and a variety of cancers are warranted. 
 IMPLICATIONS FOR NURSING Oncology nurses are uniquely able to equip patients with information about complementary therapy modalities, such as acupuncture, which is a promising way to improve appetite and slow weight loss in patients with GI cancers.