Background Multiple sclerosis (MS) is an autoimmune, neurodegenerative disease frequently complicated by bowel symptoms. Multiple sclerosis typically first manifests with a demyelination event, also known as a clinically isolated syndrome (CIS). We sought to examine the prevalence of prodromal bowel symptoms predating a CIS in patients with MS as part of a recently characterized prodromal phase of disease. Methods We constructed a retrospective cohort of MS patients with bowel symptoms and an identifiable CIS at two tertiary care centers over 14 years using administrative and billing data. We determined the date of onset of reported bowel symptoms in comparison with the date of first CIS and determined the overall prevalence of prediagnosis bowel symptoms within 1, 2, 3, and >3 years from a CIS. We used multivariable modeling to determine demographic and clinical risk factors for prediagnosis bowel symptoms. Key Results Among 385 MS patients with reported bowel symptoms, 122 (31.6%) reported bowel symptoms prior to CIS. The most common first bowel symptom was constipation (50.0%), followed by diarrhea (29.5%). The average lead time between a first bowel symptom and a CIS event was 3.7 ± 3.4 years. Pre‐CIS fatigue (OR 4.48, 95% CI: 2.68‐7.51, P < 0.001) and pre‐CIS sensory disturbances (OR 1.88, 95% CI: 1.15‐3.08, P < 0.05) were all associated with bowel symptoms prior to a CIS event. Conclusions and Inferences Nearly a third of MS patients with bowel symptoms reported bowel symptoms prior to a demyelinating event/CIS. Characterization of a prodromal phase of disease may provide important insights into understanding disease progression.

Background and Aims: Chronic opioid effects on the esophagus are poorly understood. We investigated whether opioids were associated with increased prevalence of esophageal motility disorders.Methods: A retrospective study of all patients undergoing high-resolution manometry (HREM) at the Yale Gastrointestinal Motility Lab between January 2014 and August 2019. Data were extracted from the electronic medical record after studies were reviewed by two motility specialists using the Chicago Classification v.3.0. We compared the manometric results of patients who use opioids to those who do not and adjusted for type and dose of opioids using a 24 h Morphine Milligram Equivalents (MME) scale to compare patients taking low or high amounts of opioids.Results: Four manometric abnormalities were significantly different between the opioid and non-opioid users. Achalasia type III, esophagogastric junction outflow obstruction (EGJOO), and distal esophageal spasm (DES) (p < 0.005, p < 0.01, and p < 0.005, respectively) were common among opioid users, whereas ineffective esophageal motility (IEM) was more common among non-opioid users (p < 0.01). The incidence of EGJOO was significantly higher in opioid users compared to non-opioid users (p < 0.001). Lastly, IRP, DCI, and distal latency were significantly different between the two groups.Patients in the high MME group had significantly greater IRP, DCI, and lower distal latency than non-opioids (p < 0.001). Also, achalasia type III and DES were more common in the high but not the low MME group.Conclusions: Opioid use is associated with multiple abnormalities on esophageal motility and these effects may be dose-dependent.

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Background: Autologous breast reconstruction is associated with superior patient-reported outcomes compared to prosthetic techniques, but little is known about the relationship between autologous flap mass and patient satisfaction. We hypothesized that a higher differential mass (ratio of flap mass to mastectomy mass) would be associated with greater satisfaction with reconstruction. Methods: In this retrospective study, patients who underwent autologous breast reconstruction between 2015 and 2020 with a deep inferior epigastric perforator (DIEP) flap completed the BREAST-Q survey. Multivariate linear regression models were used to examine the relationship between differential mass and patient satisfaction. Models controlled for BMI, age at surgery, reconstruction size preference, number of surgeries, previous surgery failure, whether the patient underwent radiation therapy, and whether reconstruction was unilateral or bilateral. Results: 45 patients (70 breasts) completed the BREAST-Q survey. Mean age at reconstruction was 52.2 years old and mean time to survey completion following surgery was 21.1 months. Most patients (59.4%) desired a smaller breast after reconstruction. The mean differential mass was +26.3% (flap mass greater than mastectomy mass). Differential mass was positively associated with all satisfaction measures with results being significant for satisfaction with breasts scores (p = 0.032). Conclusion: In this preliminary study, a higher ratio of autologous flap mass to mastectomy mass was associated with overall higher patient-reported satisfaction. A 1:1 flap to mastectomy mass ratio may not adequately reapproximate desired breast size or shape. Larger autologous flap mass may be favorable for long-term patient satisfaction, and future studies should investigate the relationship between differential mass and breast aesthetics.