42Gastric emptying response to temporary gastric electrical stimulation is independent of symptom improvement but dependent on baseline emptying

Introduction:  Gastric electrical Stimulation (GES) is an accepted therapy for drug refractory gastroparesis, but its effect on gastric emptying is controversial.
Patients:  To examine the effect of GES on GET we examined 140 consecutive patients undergoing temporary endoscopic GES as previously described (GIE 2005: 61:455–461). Patients were 29 m, 14 f , mean age 41 years with diagnosis (DX): 44 diabetes (DM), 14 post-surgical (PS) and 82 idiopathic (ID).
Methods:  Symptom Assessment, Gastric emptying and EGG were evaluated at baseline and after temporary endoscopic GES (mean 3 day of therapy). Patients at baseline were stratified into 3 groups based on GET: Delayed, Normal and Rapid, as previously described (AGC 2001: 95:1456–1461). Symptoms (SX) of nausea (N), vomiting (V), and total SX (TSS), and GET were compared by paired t-tests and reported as mean values.
Results:  All patients had Symptoms improvement, irrespective of their DX or baseline GET: (N: 3.5 baseline to 0.9 after; V: 2.5–0.6; TSS: 15.2–5.1 for all patients with uniform changes in subgroups. There were no significant changes in GET for the whole patient group. However, when stratified by baseline GET: the delayed group accelerated (and the rapid group slowed (see table).
Conclusion:  Temporary GES performed on patients with the SX of gastroparesis shows an immediate symptom improvement, which is independent of baseline GET. The effect of temporary GES on gastric emptying is dependent on baseline emptying, with improvements seen in both delayed and rapid gastric emptying sub-groups. Conclusions about the effect of electrical stimulation on gastric emptying need stratification for baseline gastric emptying.
 

     

38Gastric emptying response to temporary gastric electrical stimulation is independent of symptom improvement but dependent on baseline emptying

Introduction:  Gastric electrical Stimulation (GES) is an accepted therapy for drug refractory gastroparesis, but its effect on gastric emptying is controversial.
Patients:  To examine the effect of GES on GET we examined 140 consecutive patients undergoing temporary endoscopic GES as previously described (GIE 2005: 61:455–461). Pts were 29 m, 14 f, mean age 41 years with diagnosis (DX): 44 diabetes (DM), 14 post-surgical (PS) and 82 idiopathic (ID).
Methods:  Symptom Assessment, Gastric emptying and EGG were evaluated at baseline and after temporary endoscopic GES (mean 3 day of therapy). Patients at baseline were stratified into 3 groups based on GET: Delayed, Normal and Rapid, as previously described (AGC 2001: 95:1456–1461). Symptoms (SX) of nausea (N), vomiting (V), and total SX (TSS), and GET were compared by paired t-tests and reported as mean values.
Results:  All patients had Symptoms improvement, irrespective of their DX or baseline GET: (N: 3.5 baseline to 0.9 after; V: 2.5–0.6; TSS: 15.2–5.1 for all patients with uniform changes in subgroups. There were no significant changes in GET for the whole patient group. However, when stratified by baseline GET: the delayed group accelerated (and the rapid group slowed (see table).
Conclusion:  Temporary GES performed on patients with the SX of gastroparesis shows an immediate symptom improvement, which is independent of baseline GET. The effect of temporary GES on gastric emptying is dependent on baseline emptying, with improvements seen in both delayed and rapid gastric emptying sub-groups. Conclusions about the effect of electrical stimulation on gastric emptying need stratification for baseline gastric emptying.
 

     

Association between changes in symptoms and gastric emptying in gastroparetic patients treated with gastric electrical stimulation

Abstract  To investigate whether there is an association between gastric emptying rate and symptom improvement in gastroparetic patients treated with gastric electrical stimulation (GES), we retrospectively reviewed 63 gastroparetic patients who received GES therapy for at least 1 year. Patient characteristics, seven upper gastrointestinal (GI) symptoms and 4-h standardized gastric emptying test (GET) were evaluated at baseline and at 1 year of GES. All symptoms were significantly reduced ( P  <   0.001). Mean gastric retention was reduced by 7% ( P  =   0.102) for measurement at 4 h. Of the 63 patients, 14 had their GET normalized and 49 remained delayed after 1 year. Normalized GET patients had a similar symptom improvement as those whose GET remained delayed. Of all upper GI symptoms, the improvements in vomiting ( P  =   0.04), nausea ( P  =   0.002) and epigastric pain ( P  =   0.001) were significantly correlated with reduction in 4-h gastric retention between baseline and 12 months of GES therapy for patients with normalized gastric emptying but there were no correlations with any symptoms and change in gastric emptying for those patients who remained delayed. In summary, overall gastric emptying is not significantly accelerated at 4 h after successful symptomatic improvement with GES but nausea, vomiting and epigastric pain can be correlated with normalization of GET in a subset of patients.     

Low-Resolution Electrogastrogram at Baseline and Response to Temporary Gastric Electrical Stimulation—A Comparison of Cutaneous With Mucosal Recordings

IntroductionGastric electrical stimulation (GES) is a widely accepted therapy for gastroparesis symptoms, but how a brief cutaneous electrogastrogram (EGG) can be used in conjunction with GES has not been well defined. We evaluated the clinical importance of EGG, its correlation with mucosal electrograms (mEGs), gastric emptying tests (GETs), and gastrointestinal symptoms before and after temporary GES (tGES).Materials and MethodsWe studied 1345 patients; 991 had complete data. EGG measurements like frequency and amplitude were recorded at baseline and five days post-tGES using short recording periods. A total of 266 participants having additional cutaneous propagation values were separately analyzed. Patients underwent solid GET before and after tGES and self-reported symptoms using standardized traditional patient-reported outcomes (TradPRO) scores. Pearson correlations were assessed at baseline, post-stimulation, and their changes over the follow-up period.ResultsEGG measures correlated with symptoms and GET results. Patients with abnormal baseline cutaneous frequency had higher baseline total symptom scores (p < 0.003). Post-tGES, one-hour gastric emptying was significantly changed (p < 0.0001) and was mainly observed with abnormal baseline cutaneous frequencies (p < 0.0001). Cutaneous frequency significantly increased after tGES (p < 0.0001), correlating positively with TradPRO scores and one-hour gastric emptying. Mucosal and cutaneous measures correlated pre- and post-treatment. Of the 266 patients, 153 changed propagation states between baseline and temporary; changing states from lower at baseline to higher at temporary was more likely than vice versa. Short EGG recording times can demonstrate changes after the bioelectric therapy of GES.ConclusionEGG is valuable in the diagnosis of delayed gastric emptying and comparable with mEG. It is less invasive and can identify patients who may require GES. Frequency, amplitude, their ratio (frequency-amplitude ratio), and propagation appear to be reliable measures of EGG. EGG provides cost-effective measurement of electrophysiological properties and significantly correlates with important clinical measures. Shorter EGG recording times may be adequate to see changes from bioelectric therapies.Clinical Trial RegistrationThe Clinicaltrials.gov registration number for the study is NCT03876288.     

46The feasibility of duodenum electrical stimulation to produce gastrointestinal symptoms in a clinical trial

Introduction:  Gastric Electrical Stimulation (GES) is available as a Humanitarian Use Device for patients with the symptoms of gastroparesis and is effective in reducing gastrointestinal symptoms. We have previously shown that patients with gastric motor disorders often have co-existing abnormalities of the genitourinary system (Gastroenterol 112: A737, 1997), which may now be treated with sacral electrical stimulation (SES), resulting in similar improvements in genitourinary symptoms.
Patients:  We compared the results of therapy with GES and SES in 13 patients who were implanted with both devices. Patients were 11 f, 2 m, mean age of 41 years, who had documented gastroparesis as well as bladder or other pelvic floor dysfunction. All 13 patients had received their GES before the SES.
Methods:  Patients were evaluated at baseline and latest follow up (median 4 years for GES and 2 years for SES), according to previously standardized scores of GI (GI: 0–4, TSS max 20) and GU (GU: 0–3, UTSS, max 12) function. Results were compared by paired t-tests and reported as mean ± SE.
Results:  All 13 patients improved both GI and GU symptoms and the improvement in all parameters as nausea, vomiting, anorexia, bloating, abdominal pain and gastric total symptom score (TSS), leakage, urgency, voiding difficulty, number of pads used and urinary total symptom score (UTSS) were statistically significant (see table below).
Conclusions:  The combination of GES and SES appears to be both safe and effective for patients with con-comitant gastroparesis and bladder dysfunction and the existence of a stimulator for one disorder does not preclude another stimulator.
 

     

Assessment of symptoms during gastric emptying scintigraphy to correlate symptoms to delayed gastric emptying

Background Symptoms of gastroparesis based on patient recall correlate poorly with gastric emptying. The aim of this study is to determine if symptoms recorded during gastric emptying scintigraphy (GES) correlate with gastric emptying and with symptoms based on patient recall. Methods Patients undergoing GES completed the Patient Assessment of GI Symptoms (PAGI‐SYM) assessing symptoms over the prior 2 weeks and a questionnaire for which patients graded six symptoms during GES. A Symptom Severity Index (SSI) represented the mean of six symptoms at each time point. Key Results A total of 560 patients underwent GES for clinical evaluation of symptoms. Of 388 patients included in the study: 232 patients had normal GES (NGES), 156 delayed GES (DGES), and 11 rapid GES (RGES). Symptom severity index increased pre to postprandial for each group: NGES: 0.51 ± 0.07 to 0.92 ± 0.03, DGES: 0.60 ± 0.09 to 1.13 ± 0.05, and RGES: 0.56 ± 0.12 to 0.79 ± 0.13. Delayed gastric emptying scintigraphy patients had a higher postprandial SSI than NGES patients (1.13 ± 0.05 vs 0.92 ± 0.03, P < 0.05). Postprandial symptoms of stomach fullness (1.9 ± 0.12 vs 1.5 ± 0.09; P = 0.011), bloating (1.4 ± 0.11 vs 1.1 ± 0.09; P = 0.033), and abdominal pain (1.1 ± 0.08 vs 0.7 ± 0.12; P = 0.012) were higher in DGES than NGES. Symptom severity based on PAGI‐SYM for 2 weeks prior to GES correlated with symptoms during the test for nausea (NGES, r = 0.61; DGES, r = 0.70), stomach fullness (NGES, r = 0.47; DGES, r = 0.60), and bloating (NGES, r = 0.62, DGES, r = 0.66). Conclusions & Inferences Stomach fullness, bloating, and abdominal pain recorded during GES were higher in patients with delayed gastric emptying than in patients with normal gastric emptying. Symptoms recorded during GES correlated with those during daily life by patient recall.     

The addition of pyloroplasty as a new surgical approach to enhance effectiveness of gastric electrical stimulation therapy in patients with gastroparesis

Background Improvement of gastroparesis (GP) symptoms has been documented in patients treated with gastric electrical stimulation (GES), but acceleration of gastric emptying (GET) is unpredictable. The aim of our study was to evaluate the advantage of adding surgical pyloroplasty (PP) to GES for improvement of GET and control of symptoms in diabetes mellitus (DM), idiopathic (ID), and postvagotomy (P‐V) GP. Methods A total of 49 (17 – DM, 9 – ID, 23 – P‐V) consecutive GP patients: 38 female; mean age 42 (21–73 years); mean weight 158 lbs (102–245), underwent GES implantation, and 26 (53%) additionally received PP. Total Symptoms Score, 4‐h GET, adverse events (AEs), and days of hospitalizations were captured at baseline and at the last visit. Key Results The mean follow‐up was 7 months. Total Symptoms Score in patients who received Enterra and PP or GES alone significantly improved compared to their baseline scores (P < 0.001). GET improved by 64% at 4 h (P < 0.001) in patients with Enterra and PP, compared to 7% observed after GES therapy alone (ns). The most impressive acceleration of GET was seen in the P‐V group, who received both therapies (P = 0.004) and 8 (60%) of them normalized GET. No AEs accompanied the addition of PP to the Enterra surgery. Conclusions & Inferences (i) In drug‐refractory GP the addition of PP to GES substantially accelerated GET; (ii) The GET response in P‐V group was the most impressive; (iii) Significant symptom reductions were achieved by both procedures; and (iv) PP added to GES may sustain better long‐term symptoms control particularly in the P‐V setting.     

23A multi-component model can predict gastric emptying in diabetic gastroparesis

Introduction:  We have previously reported that a multi-component model of autonomic and enteric factors can help predict gastric emptying in diabetes mellitus. (Aslam N. Abell T. A four component model can quantitatively profile gastric emptying in diabetic gastropathy. Supplement to Gastroenterology Vol 118, April 2000, Number 4, Suppl 2. (Abstract No. 5341).
Patients:  Eighty-seven patients with Diabetes mellitus presenting with signs and symptoms of Gastroparesis. It included 38 males, 49 females with mean age of 39 ± 10 years.
Methods:  Autonomic tests included adrenergic tests by VC (vasoconstriction to cold) and PAR (postural ratio), and cholinergic function measured by EKG R to R interval (RRI). The Enteric measure (EGG) was measured by cutaneous electrogastrogram. The data was compared to results of standardized solid gastric emptying T50 in minutes (GE above), by linear regression.
Results:  The patients were distributed in five groups according to mean T50 of solid gastric emptying: 24 (28%) were very delayed, 13 (15%) delayed, 19 (22%) were normal, 15 (17%) were rapid, and 16 (18%) very rapid. There were statistically significant differences among the five group means for VC, RRI, and EGG, but not for PAR. (See table).
Conclusions:  In this group of patients with symptoms of Diabetic gastropathy, there is a wide range of gastric emptying values. A multi-component model demonstrates specific autonomic and enteric differences in subgroups of diabetic gastroparesis. Therapies for diabetic gastropathy, including drug and device studies, may need to take into account these physiologic differences when looking at therapeutic outcomes. Autonomic and enteric measure appear useful as part of the evaluation of patients with symptoms of diabetic gastropathy.
Means
 

     

Variable abnormal physiological motility in the proximal upper gastrointestinal tract in gastroparesis

Background Traditional testing for gastroparesis with gastric emptying scintigraphy (GES) likely misses a subset of patients because of the heterogeneous nature of the disease. The primary aim of this study is to determine the prevalence of simultaneously measured transit and pressure abnormalities in patients with gastroparesis. The secondary aim is to assess diagnostic gain realized by measuring antroduodenal pressure and gastric transit with wireless motility capsule (WMC) compared to gastric transit measured by GES. Identification of abnormalities beyond gastric transit delay in gastroparesis may yield novel targets for pharmacological therapies. Methods Forty‐three subjects with symptoms of gastroparesis and previous abnormal GES within 2 years were enrolled in the study. Subjects underwent simultaneous GES and WMC to assess gastric transit. Gastric and small bowel pressure profiles were measured by WMC to determine the contribution of pressure to diagnostic gain realized with WMC. Key Results Fifty‐one percent of subjects had abnormal GES while 70% of subjects had either abnormal gastric emptying time (GET) or antroduodenal pressure. Gastric emptying time was abnormal in 60% of subjects while gastric or small bowel pressure was abnormal in 47% of subjects. The overall diagnostic gain of WMC compared to GES was 19% (P = 0.04). Seven percent of subjects had abnormal small bowel pressure profiles when both GES and GET were normal. Conclusions & Inferences (i) Gastroparesis is a heterogeneous disorder and testing only solid food emptying by scintigraphy may miss a significant amount of pathology. (ii) Measuring complementary aspects of gastric and small bowel function simultaneously results in greater detection of physiologic abnormalities that may underlie patient symptoms.     

Effects of vasopressin and long pulse–low frequency gastric electrical stimulation on gastric emptying, gastric and intestinal myoelectrical activity and symptoms in dogs

The aim of this study was to investigate the effect of vasopressin and long pulse-low frequency gastric electrical stimulation (GES) on gastric emptying, gastric and intestinal myoelectrical activity and symptoms in dogs. The study was performed in eight healthy female dogs implanted with four pairs of gastric serosal electrodes and two pairs of small bowel serosal electrodes, and a duodenal fistula for the assessment of gastric emptying. Each dog was studied in three sessions on three separate days in a randomized order with recordings of gastric and small bowel slow waves. Each study session consisted of 30-min baseline, 30-min stimulation and 30-min recovery period. In sessions 1 and 2, infusion of either saline or vasopressin (0.75 U kg(-1) in 30 mL saline instilled in 30 min) was given during the second 30-min period. The protocol of session 3 was the same as session 2 except long pulse-low frequency GES was performed during the second 30-min period. It was found that: (i) Vasopressin significantly delayed gastric emptying 30 and 45 min after meal and GES did not improve the vasopressin induced delayed gastric emptying; (ii) Vasopressin induced gastric dysrhythmias and GES significantly improved vasopressin induced gastric dysrhythmia; (iii) Vasopressin also induced intestinal slow wave abnormalities but GES had no effect on vasopressin induced small bowel dysrhythmia; (iv) Vasopressin induced symptoms and behaviours suggestive of nausea that were not improved by GES. We conclude that: (i) Vasopressin delays gastric emptying and induces gastric and small bowel dysrhythmias and symptoms in the fed state, and (ii) long pulse-low frequency GES normalizes vasopressin induced gastric dysrhythmia with no improvement in gastric emptying or symptoms.     

Association of the status of interstitial cells of Cajal and electrogastrogram parameters, gastric emptying and symptoms in patients with gastroparesis

Abstract  Our goal was to investigate associations between the status of interstitial cells of Cajal (ICC) and electrogastrogram (EGG) parameters, gastric emptying and symptoms in a large cohort of patients with gastroparesis. Forty-one patients with refractory gastroparesis who were referred for gastric electrical stimulation (GES) underwent full thickness gastric (antrum) biopsy during the surgery to place the GES device. The biopsy samples were stained with c-kit and scored for the presence of ICC based on criteria obtained from 10 controls. All patients underwent EGG recordings, a 4-h standardized scintigraphic gastric emptying study and symptom assessment prior to the surgery. Based on antral biopsy, 15 patients (36%) had almost no ICC (ICC− group) and 26 patients had adequate cell numbers (ICC+ group). EGG recordings in the ICC− group displayed significantly less normal slow waves than in the ICC+ group both in the fasting and fed states. Tachygastria in the ICC− group was significantly more than in the ICC+ group both in the fasting (32 ± 8% vs 11 ± 2%) and fed states (27 ± 9% vs 12 ± 2%). There was no statistical difference in gastric emptying, symptom severity of gastroparesis, aetiology, age and gender between the two groups. Severely depleted ICC occurs in up to 36% of gastroparetic patients and significantly correlates with an abnormal EGG. Severely depleted ICC does not correlate with the severity of gastroparesis as assessed by gastric emptying or symptom status but did result in a poorer symptomatic response to GES. These data suggest that the EGG may have a role for predicting ICC status during clinical evaluation of gastroparetic patients.     

Can body mass index help predict outcome in patients with bipolar disorder?

Objective:  Several studies have reported higher prevalence of obesity in patients suffering from bipolar disorder (BD). To study the relation of elevated body mass index (BMI) in patients with BD more closely, we investigated differences in sociodemographic, clinical, and medical characteristics with respect to BMI, with the hypothesis that BMI is related to prognosis and outcome.
Methods:  We measured the BMI of 276 subjects of a tertiary care sample from the Maritime Bipolar Registry. Subjects were 16 to 83 years old, with psychiatric diagnoses of bipolar I disorder (n = 186), bipolar II disorder (n = 85), and BD not otherwise specified (n = 5). The registry included basic demographic data and details of the clinical presentation. We first examined the variables showing a significant association with BMI; subsequently, we modeled the relationship between BMI and psychiatric outcome using structural equation analysis.
Results:  The prevalence of obesity in our sample was 39.1%. We found higher BMI in subjects with a chronic course (p < 0.001) and longer duration of illness (p = 0.02), lower scores on the Global Assessment of Functioning Scale (p = 0.02), and on disability (p = 0.002). Overweight patients had more frequent comorbid subthreshold social (p = 0.02) and generalized anxiety disorders (p = 0.05), diabetes mellitus type II (p < 0.001), and hypertension (p = 0.001). Subjects who achieved complete remission of symptoms on lithium showed significantly lower BMI (p = 0.01).
Conclusions:  Our findings suggest that BMI is associated with the prognosis and outcome of BD. Whether this association is causal remains to be determined.     

Effect of high-frequency gastric electrical stimulation on gastric myoelectric activity in gastroparetic patients

The aim of this study was to investigate the effect of gastric electrical stimulation (GES) on gastric myoelectric activity (GMA) and to identify possible mechanisms that could help explain how high-frequency GES is effective in treating nausea and vomiting associated with gastroparesis. Fifteen gastroparetic patients who received high-frequency GES were enrolled. Two pairs of temporary pacing wires were implanted on the serosa of the stomach along the greater curvature during surgery for placement of the permanent stimulation device. Two-channel serosal recordings of GMA before and during GES were measured. A gastric emptying test and severity of nausea and vomiting were assessed at baseline and at 3 months of GES. Power spectral and cross correlation analyses revealed that impaired propagation of slow waves (50%), tachygastria (30%) and abnormal myoelectric responses to a meal (50%) were the main abnormalities observed at baseline. GES with a high frequency significantly enhanced the slow wave amplitude and propagation velocity, and resulted in a significant improvement in nausea and vomiting but did not entrain the gastric slow wave or improve gastric emptying after 3 months of GES.     

Gastric emptying in postural tachycardia syndrome: a preliminary report

Purpose

Autonomic neuropathy is widely recognized to be associated with upper gastrointestinal symptoms and abnormal (i.e., rapid or slow) gastric emptying. While patients with postural orthostatic tachycardia syndrome (POTS) may also have gastrointestinal symptoms, our understanding of gastric-emptying disturbances in POTS is very limited. The objectives of this study were to evaluate the relationship between gastric-emptying disturbances and gastrointestinal symptoms in patients with POTS.

Methods

We retrospectively reviewed the medical records of 22 well-characterized patients with POTS and upper gastrointestinal symptoms in whom autonomic (i.e., postganglionic sudomotor, cardiovagal, and adrenergic) functions and gastric emptying were evaluated using standardized techniques and scintigraphy, respectively. Medical records were reviewed retrospectively to assess clinical features, gastric emptying, and autonomic functions.

Results

Over 70 % of patients had nausea and/or vomiting, which was the most common GI symptom; other common symptoms were abdominal pain (59 %), bloating (55 %), and postprandial fullness/early satiety (46 %). Over one-third of patients had abnormal [i.e., rapid (27 %) or delayed (9 %)] gastric emptying. Gastric-emptying disturbances were not significantly associated with GI symptoms, autonomic symptoms or autonomic dysfunction.

Conclusions

Over one-third of patients with POTS and gastrointestinal symptoms have abnormal, more frequently rapid than delayed gastric emptying. These findings need to be confirmed in a larger cohort of patients.     

Gastric emptying patterns of a liquid meal in newborn infants measured by epigastric impedance

Epigastric impedance was used to measure the gastric emptying patterns of a liquid non-caloric meal (5 mL water kg⁻¹) in 30 healthy newborn infants. Twenty-six mature infants were examined in the first eight days of life, and four preterm infants were examined within 6 weeks after birth. The recordings consisted of two components: the emptying signal (the DC component), and a phasic 3 cycles per minutes (CPM) signal (the AC component). In some of the infants the phasic 3 CPM signal was also seen during the fasting state.
For mature infants the median half emptying time (T₅₀) was 6.9 min. For a second meal given within one hour after the first meal the half emptying time was 5.5 min ( P  < 0.01). In preterm infants the emptying times were not significantly different from mature infants.
Day-to-day variation was low with a coefficient of variation of 17% in nine infants.
A periodic change of the impedance signal, the phasic 3 CPM signal, was observed after a meal in 24 of the infants. The median frequency was 3.0 CPM in 20 mature and 2.9 CPM in four preterm infants. In nine infants a phasic 3 CPM signal was also observed during the fasting state, with a median frequency of 2.9 CPM.
Measurement of gastric emptying pattern with epigastric impedance is a simple investigation for the evaluation of gastric emptying time and phasic activity in mature and preterm infants. However, the method is sensitive to spontaneous movements of the children, resulting in non-valid measurements in around one fourth of the infants.     

A preliminary functional magnetic resonance imaging study of prefrontal-amygdalar activation changes in adolescents with bipolar depression treated with lamotrigine

Objectives:  Hypotheses regarding mood dysregulation in bipolar disorder (BD) have centered on limbic overactivity with relative prefrontal underactivity during mood episodes. Therefore, we hypothesized that adolescents with bipolar depression successfully treated with lamotrigine would show decreases in amygdalar activation, and increases in prefrontal activation.
Methods:  Eight adolescents with BD underwent functional magnetic resonance imaging (fMRI) at baseline and after eight weeks of lamotrigine treatment. Blocks of negatively and neutrally valenced emotional pictures were presented during scanning, and subjects were asked to rate how each picture made them feel. Activation in bilateral amygdalae and dorsolateral prefrontal cortices (DLPFC) for negative minus neutral pictures was correlated with Children's Depression Rating Scale (CDRS) scores.
Results:  Mean (SD) CDRS scores decreased significantly, from 53.0 (10.6) at baseline to 26.3 (5.3) at Week 8. This clinical improvement was correlated with decreased right amygdalar activation ( r  = 0.91, p = 0.002). At Week 8, but not baseline, CDRS score was positively correlated with bilateral amygdalar activation ( r  = 0.85, p = 0.007). DLPFC activation was not correlated with change in CDRS score.
Conclusions:  These preliminary results indicate that adolescents with BD treated with lamotrigine demonstrated less amygdalar activation when viewing negative stimuli as depressive symptoms improved. Larger controlled studies are needed to confirm these findings.     

Sociodemographic disparities in epilepsy care: Results from the Houston/New York City health care use and outcomes study

Purpose:   The purpose of this study was to identify sociodemographic disparities in health care use among epilepsy patients receiving care at different sites and the extent to which the disparities persisted after adjusting for patient characteristics and site of care.
Methods:   Three months of health care use data were obtained from baseline interviews of approximately 560 patients at four sites. One-half of the patients were from a Houston site and two NYC sites that serve predominantly low-income, minority, publicly insured, or uninsured patients. The other half were at the remaining site in Houston that serves a more balanced racial/ethnic and higher sociodemographic population. Differences in general and specialist visits, hospital emergency room (ER) care, and hospitalizations were associated with race/ethnicity, income, and coverage. Logistic regression was used to assess the extent to which the differences persisted when adjusting for individual patient characteristics and site of care.
Results:   Compared to whites, blacks and Hispanics had higher rates of generalist visits [odds ratio (OR) = 5.3 and 4.9, p < 0.05), ER care (OR = 3.1 and 2.9, p < 0.05) and hospitalizations (OR = 5.4 and 6.2, p < 0.05), and lower rates of specialist visits (OR = 0.3 and 0.4, p < 0.05). A similar pattern was found related to patient income and coverage. The magnitude and significance of the disparities persisted when adjusting for individual characteristics but decreased substantially or were eliminated when site of care was added to the model.
Discussion:   There are sociodemographic disparities in health care for people with epilepsy that are largely explained by differences in where patients receive care.     

Prospective predictors of suicide and suicide attempts in 1,556 patients with bipolar disorders followed for up to 2 years

Objectives:  Bipolar disorders are associated with high rates of suicide attempts (SAs) and completions. Several factors have been reported to be associated with suicide in persons with bipolar disorder, but most studies to date have been retrospective and have not utilized multivariate statistics to account for the redundant prediction among variables submitted for analysis.
Methods:  This study examined the association between baseline clinical and demographic variables and subsequent SAs and completions through 2 years of follow-up of participants in the Systematic Treatment Enhancement Program for Bipolar Disorder using a pattern-mixture model.
Results:  Of the sample with complete data (n = 1,556), 57 patients (3.66%) experienced an SA or completion (CS). Several variables predicted suicidality (SA + CS) in this data set when considered alone, but after controlling for redundant prediction from other baseline characteristics, only history of suicide [odds ratio (OR) = 4.52, p < 0.0001] and percent days depressed in the past year (OR = 1.16, p = 0.036) were significantly associated with SAs and completions. A secondary analysis included a greater number of variables but a smaller sample size (n = 1,014). In the secondary analyses, only prior SAs predicted prospective suicidality (OR = 3.87, p = 0.0029).
Conclusions:  These results indicate that patients with bipolar disorder who present with a history of SAs are over four times as likely to have a subsequent SA or completion. Further studies are needed to evaluate and prevent future attempts in this high-risk cohort.     

Electrogastrography as a diagnostic tool for delayed gastric emptying in functional dyspepsia and irritable bowel syndrome

Several pathophysiological mechanisms have been proposed in functional gastrointestinal (GI) disorders, e.g. altered GI motility and sensitivity. The aim of this study was to investigate gastric electrical activity (GEA) in patients with functional dyspepsia (FD) or irritable bowel syndrome (IBS) compared with healthy controls (HC), and to assess if abdominal symptoms and delayed gastric emptying are associated with alterations in GEA, as determined by electrogastrography (EGG). Forty patients with FD, IBS or both were compared with 22 HC. EGG was performed before and after a standard meal. Frequencies and amplitudes pre- and post-prandially were analysed. Furthermore, gastric emptying and symptom scores were assessed. Eight of 40 patients (20%; three FD, three IBS, two FD and IBS) had delayed gastric emptying. Disturbed gastric emptying and lack of a postprandial increase in the EGG amplitude were significantly correlated (r = 0.8; P < 0.005). No differences between controls and patients were observed in the distribution of EGG frequencies. Treatment with the prokinetically active macrolide erythromycin improved gastric emptying, GEA and symptoms (n = 4). The data suggest that EGG could be useful as a diagnostic tool in patients with FD and IBS to identify a subgroup of patients with delayed gastric emptying.     

3Predictors of symptom non-responders to high-frequency gastric electrical stimulation for refractory gastroparesis

Chronic high‐frequency gastric electrical stimulation (GES) has been shown to improve gastroparetic symptoms and quality of life (QOL) in up to 70% of patients with refractory gastroparesis (Gastroenterology 2003; 125:421–8). Little is known about factors associated with treatment failure. Clinical and gastric function data (gastric emptying test, GET; electrogastrogram, EGG) were extracted from a retrospective analysis of 87 gastroparetic patients (48 diabetic, 20 idiopathic and 19 postsurgical) who completed GES therapy (Enterra? System, Medtronic) for at least 1 year. Total symptom score (TSS) (sum of severity of nausea, vomiting, early satiety, bloating, postprandial fullness, epigastric pain and burning using a 5‐point scale, 0 = non, 4 = extremely severe), quality of life (SF‐36 Health Status Survey questionnaire including physical composite score (PCS) and mental composite score (MCS)) and GET (4‐hour scintigraphy of a low‐fat meal) were examined at baseline and 1 year follow‐up. A non‐responder had <25% reduction in TSS and a responder was defined as having a ≥ 50% reduction in TSS after 1 year of GES therapy. Results: Overall the non‐responder rate was 23% (10% in diabetic vs. 16% in postsurgical vs. 35% in idiopathic subgroup). Non‐responder rates were similar for men (22%) and women (23%) and age was not a factor. Compared to responders of GES therapy, non‐responders had similar mean baseline vomiting (2.6 vs. 3.2) and nausea scores (3.3 vs. 3.6) but a lower TSS (17.6 vs. 20.1, P < 0.05). Also non‐responders had less improvements in mean gastric retention both at 2 hours (+5.4 vs. ­8.7%) and at 4 hours (+4.0 vs. ­10.5%), less improvement in mean PCS (+2.0 vs. +12.4, P < 0.05) and gained less weight (­0.4 kg vs. +3.7 kg) than responders. 67% of non‐responders had an abnormal EGG (dysrhythmia >30% or decrease in postprandial EGG power) vs. 33% in responders. Non‐responders had more baseline mean tachygastria both in the fasting state vs. responders (26% vs. 11%, P < 0.05) and in the fed state (24% vs. 11%, P < 0.05) and less increase in postprandial EGG power (­1.3 dB vs. 1.6 dB, P < 0.05). Conclusions: The best symptom improvement achieved by high‐frequency GES therapy in refractory gastroparesis is in diabetics (10% treatment failure rate) and postsurgical (16% failure) while the worst results are in idiopathics (35% non‐responder rate). Baseline EGG abnormalities are predictors of poor symptomatic response to GES therapy and may be useful in developing a patient profile to optimize selection and expectations for GES therapy.