Validity and Reliability of the Modified Manchester Health Questionnaire in Assessing Patients With Fecal Incontinence

PURPOSE To date, no measures of fecal incontinence severity or its impact on quality of life have been validated for telephone interview. This study was designed to 1) compare responses of a self-administered and a telephone-administered Fecal Incontinence Severity Index; 2) compare a self-administered Fecal Incontinence Quality of Life Scale to the Manchester Health Questionnaire after modifying the latter for telephone administration and American English (Modified Manchester Health Questionnaire); 3) assess test-retest reliability of the telephone-administered Modified Manchester Health Questionnaire; and 4) assess the internal consistency of the Modified Manchester Health Questionnaire subscales.METHODS Consecutive, English-speaking, nonpregnant females known to have fecal incontinence were invited to participate. Two validated paper questionnaires accompanied the letter informing them of the study: Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life Scale. Consenting patients were contacted for the initial telephone administration of the Modified Manchester Health Questionnaire, and patients who agreed to continue the study were contacted for a repeat telephone administration of the Modified Manchester Health Questionnaire two to four weeks after completing the first interview.RESULTS Fifty-one females were invited to participate in the study; however, 13 declined or were ineligible. Thirty females, aged 49.3 ± 10.3 years, returned self-administered questionnaires and completed the first telephone interview, and 21 completed a second telephone interview after an average interval of 23 days. The telephone-administered Fecal Incontinence Severity Index scores were significantly lower than those yielded by the self-administered Fecal Incontinence Severity Index, (6.19 vs. 9.85; P < 0.001), but the telephone and written administrations were significantly correlated (r = 0.5; P < 0.02). Correlations between the Modified Manchester Health Questionnaire quality of life subscales and the paper Fecal Incontinence Quality of Life subscales ranged from 0.6 to 0.9 (median, r = 0.81). The correlation between the total score for the Fecal Incontinence Quality of Life and the total score for the Modified Manchester Health Questionnaire quality of life scales was 0.93 (P < 0.001). Test-retest reliability for the eight Modified Manchester Health Questionnaire subscales ranged from 0.55 to 0.98 (median, r = 0.83), and test-retest reliability for the two telephone administrations of the Fecal Incontinence Severity Index was r = 0.75. Cronbachs alpha for the eight Modified Manchester Health Questionnaire subscales ranged from 0.79 to 0.92 (median, alpha = 0.85).CONCLUSIONS Telephone-administered versions of the Modified Manchester Health Questionnaire showed good-to-excellent validity, internal consistency, and test-retest reliability. The telephone-administered Fecal Incontinence Severity Index yielded lower severity scores than the written Fecal Incontinence Severity Index; however, the difference (3.66 units) was not clinically significant.Supported by Pelvic Floor Disorders Network.Supported by NICHD grants U10 HD41249, U10 HD41268, U10 HD41248, U10 HD41250, U10 HD41261, U10 HD41263, U10 HD41269, U10 HD41267.Presented at the American Urogynecologic Society, Hollywood, Florida, September 11 to 13, 2003.Reprints are not available.     

Noninvasive Monitoring After Azathioprine Withdrawal in Patients With Inflammatory Bowel Disease in Deep Remission

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Transanal ultrasound and anorectal physiology findings affecting continence after sphincteroplasty

PURPOSE: This study was undertaken to evaluate endosonographic and physiologic determinants of fecal continence after sphincteroplasty. METHODS: Sixteen female patients with severe fecal incontinence were treated with overlapping sphincteroplasty. Mean postoperative follow-up was 12 (range, 3–48) months. All patients underwent preoperative and postoperative transanal endosonography and anal manometry. Bilateral pudendal nerve terminal motor latency determinations were performed in each patient. A physiologic continence score was used to assess stool control. RESULTS: Postoperatively, continence was worse, unchanged, and improved in one, five, and ten patients, respectively. An inverse correlation was noted between endosonographic sphincter discontinuity postoperatively, in degrees, and the change in fecal continence after overlapping sphincteroplasty (r =–0.51;P =0.04). Postoperative increases in sphincter resting (r =0.6;P =0.02) and squeeze (r -0.54;P =0.03) pressures correlated with improved fecal continence. Mean pudendal nerve terminal motor latency (r = –0.34;P =0.20) and changes in anal sphincter length at rest (r =0.41;P =0.11) and squeeze (r =0.33;P =0.20) after sphincteroplasty did not significantly correlate with the change in continence. Patients with intact endosonographic anatomy postoperatively and bilateral, unilateral, or no evidence of pudendal neuropathy had a mean change in continence score of 0.5, 1.8, and 2.2, respectively (P =0.48). CONCLUSIONS: Endosonography after sphincteroplasty can identify residual sphincter defects that are significant in terms of fecal continence. Restoration of anal canal resting and squeeze pressures was related to improved fecal control after overlapping sphincteroplasty. Mean pudendal nerve terminal motor latency was not significantly related to poor postoperative continence. A trend toward less improvement in fecal continence was noted with bilateral pudendal neuropathy.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996, and at The Tripartite Meeting, London, United Kingdom, July 8 to 10, 1996.     

Mass screening for colorectal cancer

A voluntary community colorectal cancer screening project to detect occult blood in the stool of asymptomatic individuals was undertaken; 49,353 Hemoccult^® II kits were distributed. A total of 23,674 completed kits were returned to a central repository and processed (compliance rate, 48 percent); 851 participants had positive results (3.6 percent). Of the 640 who underwent further medical evaluation, 299 participants (46.7 percent) who had adequate follow-up had no evidence of disease. Diverse disease entities were detected in 341 participants, which was 1.4 percent of those enrolled. Forty-one patients (0.17 percent) showed significant findings that included 29 cancers (0.12 percent) and 12 (0.05 percent) noninvasive malignant polyps. Of the cancers, there were 27 colorectal, one nonHodgkin's lymphoma, and one carcinoma of the vocal cord. In addition, 107 patients (0.45 percent) had benign polyps and 193 patients (0.82 percent) had various diseases of the gastrointestinal tract and other medical conditions. The cost of the program was modest and the results conformed to those found in previous screening surveys. The heightened public awareness of testing for colorectal disease and the detection of early lesions justifies the guaiac test screening program for mass survey.     

Indonesian children fecal microbiome from birth until weaning was different from microbiomes of their mothers

ABSTRACT

Gastrointestinal (GI) microbiota play an important role in human health and wellbeing and the first wave of gut microbes arrives mostly through vertical transmission from mother to child. This study has undertaken to understand the microbiota profile of healthy Southeast Asian mother-infant pairs. Here, we examined the fecal, vaginal and breast milk microbiota of Indonesian mothers and the fecal microbiota of their children from less than 1 month to 48 months old. To determine the immune status of children and the effect of diet at different ages, we examined the level of cytokines, bile acids in the fecal water and weaning food frequency. The fecal microbiota of the children before weaning contained mainly Bacteroides and Bifidobacterium, which presented at low abundance in the samples of mothers. After weaning, the fecal microbiome of children was mainly of the Prevotella type, with decreasing levels of Bifidobacterium, thus becoming more like the fecal microbiome of the mother. The abundance of infant fecal commensals generally correlated inversely with potential pathogens before weaning. The fecal Bifidobacterium in children correlated inversely with the consumption of complex carbohydrates and fruits after weaning. The specific cytokines related to the proliferation and maturation of immunity were found to increase after weaning. A decreasing level of primary bile acids and an increase of secondary bile acids were observed after weaning. This study highlights the change in the GI microbiota of infants to adult-type microbiota after weaning and identifies diet as a major contributing factor.     

A Prospective,Randomized Study: Switch Off the Sacral Nerve Stimulator During the Night?

Purpose Sacral nerve stimulation is an effective treatment for fecal incontinence. Some have recommended to “switch off” the pacemaker during the night to extend the lifetime of the expensive pacemaker. This study was designed to investigate whether a nightly “switch off” affects the clinical results of sacral nerve stimulation. Methods Twenty patients successfully treated with sacral nerve stimulation (19 females; median age, 59 (range, 36–72) years) were randomized to: Group A, pacemaker continuously “on” for three weeks followed by three weeks with the pacemaker “off” during the night, or Group B, opposite order. Daily bowel-habit diary, Wexner, and St. Mark’s incontinence scores were obtained. Results One failed to return the daily bowel-habit diary, leaving 19 participating patients. Median Wexner incontinence score increased from 6 (range, 2–14) to 7 (range, 3–16) during the “off” period (P = 0.04), whereas St. Mark’s incontinence score increased from 10 (range, 3–16) to 11 (range, 3–18; P = 0.03). Median number of days with soiling per three weeks increased from 0 (range, 0–12) to 1 (range, 0–15) during the “off” period (P = 0.008). Seven of 19 had more days with soiling during the “off” period. Defecation frequency per three weeks increased from 26 (range, 11–71) to 34 (range, 9–70) during the “off” period (P = 0.19). Only four continued with a nightly “switch off” after the study. Conclusions It could be considered to recommend compliant patients to “switch off” the pacemaker during the night to extend the lifetime of the pacemaker. One-third experienced increased soiling, and they should turn the pacemaker on all day and night. Among the remaining, only a minor proportion will be motivated for turning the pacemaker off. Read at the meeting of the European Society of Coloproctology, Malta, September 26 to 29, 2007.     

Anal sphincter repair in patients with obstetric trauma

PURPOSE: This study was designed to determine whether advancing age affects the outcome of anal sphincter repair in patients with obstetric trauma and fecal incontinence. METHODS: Anal sphincter repair was performed on 24 patients younger than 40 (median age, 30) years and on 14 patients older than 40 (median age, 57) years. All patients had previous obstetric trauma. RESULTS: Twenty patients younger than 40 years (83 percent; 95 percent confidence interval, 63–95 percent) became continent, or incontinent to flatus only, after anal sphincter repair, whereas four patients had unchanged incontinence. Among patients older than 40 years, six patients (43 percent; 95 percent confidence interval, 18–71 percent) became continent, whereas eight patients remained incontinent (40 percent difference in functional outcome between younger and older patients; 95 percent confidence interval, 10–70 percent). CONCLUSION: Older females have a poorer outcome of anal sphincter repair for obstetric trauma compared with younger females.     

Outcomes associated with Interstim therapy for medically refractory fecal incontinence

Background

Fecal incontinence is a common, socially debilitating disorder. Initial management involves dietary manipulation with bulking agents or antidiarrheal medications and pelvic floor biofeedback. For patients failing these modalities, traditional surgical approaches are morbid and of variable efficacy. Sacral nerve neuromodulation (Interstim, sacral nerve stimulation) was approved in May 2011 for management of medically refractory fecal incontinence. This report summarizes our experience with this treatment modality.

Methods

A prospectively maintained database from a colorectal specialty practice was reviewed from December 2011 to June 2013. Patient demographics, incontinence etiology, and medical treatment regimens were reviewed. Outcomes for Interstim placement and surgical morbidity were reviewed.

Results

A total of 330 patients were evaluated in the clinic for fecal incontinence during the study period. A total of 33 patients (10%) were offered Interstim therapy. The mean age was 63 (39 to 91) years, and 91% (30 of 33) were female. The etiology of the incontinence was obstetric (81%), rectal prolapse (11%), neurogenic (5%), and iatrogenic (3%). The entire group failed either supplemental fiber or antidiarrheal medications and 73% (24 of 33) failed pelvic floor biofeedback. The mean number of bowel accidents/2-week bowel diary before implant was 19 (9 to 52). After phase I implant, 88% (29 of 33) experienced a successful test phase and proceeded to phase II permanent implant. The mean number of bowel accidents/2-week diary postimplant was 3 (0 to 12). A trend toward less severe episodes of incontinence postimplant was observed. There were no complications associated with either the phase I or phase II implant. There were no phase II failures although 1 patient underwent device explant 9 months after phase II implant for chronic pain.

Conclusions

Sacral nerve neuromodulation (Interstim, sacral nerve stimulation) is an effective and efficacious tool for management of medically refractory fecal incontinence that offers a less morbid surgical approach to this problem. Interstim should be considered the first-line surgical approach for medically refractory fecal incontinence.     

Efficacy and safety of,and patient satisfaction with,colonoscopic-administered fecal microbiota transplantation in relapsing and refractory community- and hospital-acquired Clostridium difficile infection

OBJECTIVE:

To report the efficacy and safety of, and patient satisfaction with, colonoscopic fecal microbiota transplantation (FMT) for community- and hospital-acquired Clostridium difficile infection (CDI).

METHODS:

A retrospective medical records review of patients who underwent FMT between July 1, 2012 and August 31, 2013 was conducted. A total of 22 FMTs were performed on 20 patients via colonoscopy. The patients were divided into ‘community-acquired’ and ‘hospital-acquired’ CDI. Telephone surveys were conducted to determine procedure outcome and patient satisfaction. Primary cure rate was defined as resolution of diarrhea without recurrence within three months of FMT, whereas secondary cure rate described patients who experienced resolution of diarrhea and return of normal bowel function after a second course of FMT.

RESULTS:

Nine patients met the criteria for community-acquired CDI whereas 11 were categorized as hospital-acquired CDI. A female predominance in the community-acquired group (88.89% [eight of nine]) was found (P=0.048). The primary cure rate was 100% (nine of nine) and 81.8% (nine of 11 patients) in community- and hospital-acquired CDI groups, respectively (P=0.189). Two patients in the hospital-acquired group had to undergo a repeat FMT for persistent symptomatic infection; the secondary cure rate was 100%. During the six-month follow-up, all patients were extremely satisfied with the procedure and no complications or adverse events were reported.

CONCLUSION:

FMT was a highly successful and very acceptable treatment modality for treating both community- and hospital-acquired CDI.     

Physician attitudes toward the use of fecal microbiota transplantation for the treatment of recurrent Clostridium difficile infection

BACKGROUND:

Fecal microbiota transplantation (FMT) is a safe and effective, yet infrequently used therapy for recurrent Clostridium difficile infection (CDI).

OBJECTIVE:

To characterize barriers to FMT adoption by surveying physicians about their experiences and attitudes toward the use of FMT.

METHODS:

An electronic survey was distributed to physicians to assess their experience with CDI and attitudes toward FMT.

RESULTS:

A total of 139 surveys were sent and 135 were completed, yielding a response rate of 97%. Twenty-five (20%) physicians had treated a patient with FMT, 10 (8%) offered to treat with FMT, nine (7%) referred a patient to receive FMT, and 83 (65%) had neither offered nor referred a patient for FMT. Physicians who had experience with FMT (performed, offered or referred) were more likely to be male, an infectious diseases specialist, >40 years of age, fellowship trained and practicing in an urban setting. The most common reasons for not offering or referring a patient for FMT were: not having ‘the right clinical situation’ (33%); the belief that patients would find it too unappealing (24%); and institutional or logistical barriers (23%). Only 8% of physicians predicted that the majority of patients would opt for FMT if given the option. Physicians predicted that patients would find all aspects of the FMT process more unappealing than they would as providers.

CONCLUSIONS:

Physicians have limited experience with FMT despite having treated patients with multiple recurrent CDIs. There is a clear discordance between physician beliefs about FMT and patient willingness to accept FMT as a treatment for recurrent CDI.