Comparison of Body Composition Metrics for United States Air Force Airmen.

Background: The United States Air Force currently uses AFI 36-2905 for cardiovascular fitness standards and evaluation. Regarding its fitness test, the Air Force considers waist circumference (WC) twice as important as push-ups or sit-ups. Because of this weighting, one assumes that the Air Force considers WC relatively correlated with overall fitness or at least cardiovascular fitness. To our knowledge, the Air Force has not considered on a large scale how body mass index (BMI), height-to-weight ratio (H-W), or waist-to-height ratio (WHtR) compares with WC with respect to its fitness test. Methods: Using a 5.38 million record database from the Air Force Fitness Management System, we evaluated how WC, BMI, WHtR, and H-W correlate with fitness as assessed by the 1.5-mile run in addition to total fitness, which incorporates the 1.5-mile run time, number of push-ups and sit-ups. As this previously collected data were anonymous to us, this study fell under the definition of exempt status and approved by the institutional review board overseeing Joint Base San Antonio. For each waist metric, we performed a simple ordinary least squares regression to ascertain the correlation between that particular metric and either run time or total fitness; when incorporating more than one explanatory variable or covariate (to control for age and/or sex), we performed multiple ordinary least squares regressions. Due to the large database size and to mitigate against a type I error, we used an alpha of 0.001 for all statistical hypothesis tests. Findings: Approximately 18% of the 5.38 million records belonged to women. With respect to sex differences, males appeared noticeably faster and performed more push-ups on average than females. The number of sit-ups completed was more comparable, with males having a slight advantage. Males also appeared to have larger WC, BMI, H-W, and WHtR measurements. We compared the ordinary least squares results between WC, H-W, WHtR, and BMI and ranked them by R2. Models varied in R2 from 1% to 46% depending on the covariates in the model, with sex having a greater effect than age. Whether individually or adjusting for age and sex, WHtR performed better than the other body composition variables with an average rank score of 1.1 and a median improvement of approximately 4% to the current Air Force metric of WC. Discussion: From our findings, we present a 20-point WHtR scoring system for the Air Force to use in lieu of its traditional usage of WC. We used this assessment chart to score all Airmen in our database and compared the results to their current scores on the abdominal circumference portion of the test with respect to predicting run time, after accounting for sex, age, and number of push-ups and sit-ups. The R2 value improved from 40.3 to 43.6, a relative improvement of approximately 8%, a fairly significant effect given the database consisted of over 5 million records. Future studies should investigate the longitudinal effect of varying waist metrics over time on run time or total fitness performance.

High resolution vs conventional esophageal manometry in the assessment of esophageal motor disorders in patients with non-cardiac chest pain.

BACKGROUND: High-resolution esophageal manometry (HREM) has become a leading tool in the assessment of esophageal motor disorders, replacing conventional manometry. However, there is limited data about the contribution of HREM as compared with conventional manometry to the assessment of esophageal motor disorders in patients with non-cardiac chest pain (NCCP). The aim of the study was to compare the distribution of esophageal motor disorders in patients with NCCP using HREM as compared with conventional manometry and to determine if HREM improved diagnosis of these disorders. METHODS: In this study, we included 300 consecutive patients with NCCP who underwent either HREM or conventional manometry over a period of 10 years. A total of 150 patients had conventional manometry and the other 150 patients HREM. The Chicago 3.0 classification and the Castell and Spechler classification were used to determine the esophageal motor disorder of NCCP patients undergoing HREM and conventional manometry, respectively. KEY RESULTS: In both HREM and the conventional manometry groups, normal esophageal motility was the most frequent finding (47% and 36%; respectively, P = .054). Hypotensive lower esophageal sphincter was the most common motility disorder identified by conventional manometry (27.3%), while ineffective esophageal motility was the most common esophageal motor disorder identified by HREM (25.3%). CONCLUSIONS & INFERENCES: There is a discrepancy in the type of esophageal motor disorders identified by HREM as compared with conventional manometry in NCCP patients. Hypotensive motility disorders are the most commonly diagnosed by both manometric techniques.

Severity of ineffective esophageal motility is associated with utilization of skeletal muscle relaxant medications.

BACKGROUND: Ineffective esophageal motility (IEM) is the most common finding on high-resolution esophageal manometry (HREM). The underlying mechanisms for IEM remain to be fully elucidated. The aim of this study was to determine if utilization of skeletal muscle relaxants is associated with IEM, and with more severe subtypes of the disorder. METHODS: Patients with diagnosis of IEM were gender and age matched to patients with normal HREM. Demographic information, symptoms, endoscopic findings, medication usage and medical comorbidities were recorded. Patients with a diagnosis of IEM were divided into subgroups based on mean distal contractile integral (DCI) and percentage of ineffective swallows, and assessed for clinically significant differences among patients with varying severity of underlying IEM. KEY RESULTS: A total of 118 patients were included in each group. There were no significant clinical differences between the group of patients with IEM and the group of patients with normal manometry. Within the group of IEM patients, those with mean DCI < 250 mm Hg/s/cm were more likely to be prescribed skeletal muscle relaxants (27.8% vs 11.0%, P = .044), and those using skeletal muscle relaxants had a larger mean percentage of ineffective swallows (81.1% vs 71.5%, P = .029). There were no significant differences across mean DCI subgroups in usage of any other medication, or in any of the demographic variables or disease comorbidities examined in this study. CONCLUSIONS & INFERENCES: Use of skeletal muscle relaxants is associated with more severe IEM, which may suggest a causal association between this class of medications and weaker esophageal peristalsis.

The relationship between eosinophilic esophagitis and esophageal cancer.

Eosinophilic esophagitis (EoE) is a disorder characterized by long-term chronic eosinophilic inflammation, which may predispose patients for malignant transformation. To determine if EoE is associated with an increased risk for esophageal cancer (EC) over time. This was a cross-sectional population-based study using the Explorys Platform. Data were collected from January 1999 to December 2014 and the search terms 'Eosinophlic esophagitis', gastroesophageal reflux disease, and Barrett's esophagus were used. The latter two served as comparison groups. The term 'malignant tumor of esophagus' was searched in Explorys and was accepted only if it was established after the aforementioned diagnoses. Analysis was performed using social science statistical software. A total of 27,183,310 subjects were included in the study. Of those 5,370 (0.02%) had the diagnosis of EoE, 25,610 (0.09%) BE, and 2,606,640 (9.59%) gastroesophageal reflux (GERD). In general, diagnosis of EC was rare prior to age 40. Therefore, subsequent analysis was done on subjects between 40 to 79 years of age (N = 20,257,480). The prevalence of EC was 0.05% (N = 2420), in BE (N = 19,640) 2.65%, and in GERD (N = 1,696,230) 0.22%. No cases of EC were identified among those with EoE. We found no significant difference or increased risk in the rate of EC in the EoE group (P = 0.575) when compared to the control population. In this largest study, we found no association between esophageal cancer and EoE. Further long-term prospective studies are needed to better characterize the relationship between EoE and esophageal malignancy.

Utilisation of surgical fundoplication for patients with gastro-oesophageal reflux disease in the USA has declined rapidly between 2009 and 2013.

BACKGROUND: Surgical fundoplication has been considered to be one of the leading therapeutic modalities for gastro-oesophageal reflux disease (GERD) during the last several decades. AIM: To determine the trend of surgical fundoplication utilisation in GERD patients during the last decade in the United States. METHODS: Population-based study using a large nationwide database, the Explorys database system, to identify patients diagnosed with GERD and those who underwent surgical fundoplication. Using a quadratic regression model, we determined and compared the trends of surgical fundoplication utilisation annually from 2004 to 2013. RESULTS: We identified 4 059 060 patients with the diagnosis of GERD, of whom 2343 (0.05%) underwent surgical fundoplication between 2004 and 2013. There was a significant decline in the number of surgical fundoplications performed over the last 5 years from 0.062% in 2009 to 0.047% in 2013 (P < 0.05). Female patients accounted for the majority of those who underwent fundoplication (62.52%). Caucasian patients between the ages of 18 and 65 years were the most likely group to undergo surgical fundoplication (66.28%). The number of overweight patients undergoing surgical fundoplication has been significantly increasing over the last decade (P < 0.05). Importantly, 80% of surgical patients were treated with a proton pump inhibitor (PPI) post surgical fundoplication by 2013 (P < 0.001). CONCLUSIONS: Utilisation of surgical fundoplication in GERD patients has been steadily declining over the past 5 years. The vast majority of patients will resume PPI treatment after surgical fundoplication.

Review article: the current treatment of non-cardiac chest pain.

BACKGROUND: Non-cardiac chest pain is one of the most common functional gastrointestinal disorders. By recognising that gastro-oesophageal reflux disease (GERD), oesophageal dysmotility and oesophageal hypersensitivity are the main underlying mechanisms of NCCP, a more directed therapeutic approach has been developed. AIM: To determine the value of the current therapeutic modalities for NCCP. METHODS: Electronic (Pubmed/Medline/Cochrane central) and manual search. RESULTS: Double-dose PPI treatment for two months is a reasonable first choice approach in patients with NCCP because GERD is the most common aetiology. Studies evaluating the role of medical therapy in NCCP patients with hypercontractile oesophageal motility suggest a limited value to muscle relaxants like calcium channel blockers (nifedipine, diltiazem), nitrates and sildenafil. While most trials evaluating pain modulators are small and many are not placebo-controlled, these type of medications appear efficacious in both patients with NCCP due to oesophageal dysmotility and those with functional chest pain. Cognitive behavioural therapy has been extensively studied in patients with functional chest pain with good results. Other psychological techniques such as hypnotherapy, group therapy or coping skills have been scarcely studied but appear to be effective in NCCP patients. CONCLUSION: Medical, endoscopic and surgical therapeutic options are available for the treating physician, although some patients with non-cardiac chest pain may require a multimodal therapeutic approach.

The 2011-2014 prevalence of eosinophilic oesophagitis in the elderly amongst 10 million patients in the United States.

BACKGROUND: Eosinophilic oesophagitis (EoE) is primarily diagnosed by clinicians. There are less than a handful of epidemiological studies in EoE that have included elderly patients (>65 years). AIM: To determine the prevalence of elderly subjects among EoE patients and compare their clinical presentation, associated conditions and treatment modalities with adult and paediatric EoE patients. METHODS: A large nationwide database (Explorys) between January 2011 and January 2014 was used. The term 'Eosinophilic Oesophagitis' was used in the Explorys search tool. The patient population was divided into three groups, Paediatric (<18 years), Adult (18-65 years) and Elderly (>65 years). RESULTS: We identified 4840 patients coded as EoE. The total estimated prevalence was 50.6 cases per 100 000 patients (0.05%). A total of 360 cases (7.44%) were elderly patients with an estimated prevalence rate of 18.6 cases per 100 000. Across all age groups, the majority of EoE patients were Caucasians and males. A significantly greater proportion of older patients had concomitant GERD. Dysphagia was the most common symptom among elderly EoE patients as compared with the paediatric EoE patients (P < 0.001). The proportion of elderly EoE patients with food allergies or asthma was significantly lower as compared with paediatric and adult EoE patients (P < 0.001). Oesophageal dilation and/or proton pump inhibitor treatment were the most commonly used therapeutic modalities in elderly EoE patients. CONCLUSION: Eosinophilic oesophagitis is uncommon in elderly subjects and the clinical presentation is markedly different as compared with adults or the paediatric population.

Systematic review with meta-analysis: selective serotonin reuptake inhibitors for noncardiac chest pain.

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) are used to treat noncardiac chest pain (NCCP) symptoms, however, data regarding their efficacy remains inconclusive. AIM: To conduct a meta-analysis of randomised controlled trials (RCT) comparing SSRIs to placebo in patients with NCCP, and rate the quality of evidence. METHODS: Electronic databases were searched using the terms 'noncardiac chest pain', 'atypical chest pain' and 'selective serotonin reuptake inhibitors'. Data were extracted from RCTs of ≥8 weeks. Standardised mean differences (SMD), weighted mean differences (WMD) or risk ratios (RR) were used as summary statistics for pooled outcomes. GRADE methodology was used to rate the quality of evidence. RESULTS: Four RCTs (184 patients) met the inclusion criteria. Compared to placebo, patients on SSRIs showed a nonsignificant change in chest pain of 3½ points decrease on a 100 mm visual analogue scale (184 patients, 95% CI, -9.5 to 2.5; I(2)  = 0%). Change in depression scores was not significantly different between the two groups (88 patients; WMD = 0.7; 95% CI, -1.81 to 3.20; I(2)  = 64%). Treatment discontinuations were not significantly different between groups (154 patients, RR = 2.08; 95% CI, 0.77-5.60; I(2)  = 0%). The quality of evidence was rated as moderate for change in chest pain symptoms, low for change in depression scores and moderate for treatment discontinuation due to adverse events. CONCLUSIONS: Selective serotonin reuptake inhibitors are not superior to placebo in improving chest pain or depression symptoms in patients with noncardiac chest pain. Larger trials with longer follow-up periods are necessary to assess the benefits and drawbacks of SSRIs for the treatment of noncardiac chest pain.

The relationship between length of Barrett's oesophagus mucosa and body mass index.

BACKGROUND: Length of Barrett's oesophagus (BE) is a risk factor for oesophageal cancer. The underlying mechanisms that determine BE length are nor fully known. AIM: To determine if there is a correlation between obesity and length of BE. METHODS: Using a population-based study, 381 patients diagnosed with Barrett's oesophagus between 1999 and 2013 were included. Body mass index (BMI) at the time of BE diagnosis was calculated. Upper endoscopy reports were reviewed to obtain the length of BE. Spearman's correlation coefficient was performed to assess the strength of the relationship between Barrett's length and BMI. A multivariate logistic regression analysis was conducted to further examine the association between BMI and length of BE. RESULTS: The adjusted odds ratio for each five-point increase in BMI was 1.5 (95% CI 1.24-1.81, P < 0.001). The mean BMI was significantly higher in patients with long segment BE as compared to patients with short segment BE (32.7 vs. 30.3, P = 0.001). There was also a positive trend in long segment BE as patients entered into higher BMI categories (Z = 4.25, P < 0.001). There was a significant correlation between BMI and length of BE (r = 0.25, P < 0.0001). CONCLUSION: The study demonstrated a correlation between BMI and the length of Barrett's oesophagus mucosa. Thus, increased BMI is associated with longer segment of Barrett's oesophagus.

The effect of antireflux treatment on the frequency of awakenings from sleep in patients with Gastroesophageal reflux disease.

BACKGROUND: Up to half of gastroesophageal reflux disease (GERD) patients report having heartburn that awakens them from sleep during the night. Recumbent-awake and conscious awakenings from sleep during the night are commonly associated with acid reflux events. The aim of the study was to assess the effect of esomeprazole 40 mg once daily on nighttime acid reflux, frequency of conscious awakenings associated with acid reflux and the recumbent-awake period. METHODS: Patients with heartburn and/or regurgitation at least three times a week were eligible for this study. All patients underwent upper endoscopy and were evaluated by demographic, Epworth Sleepiness scale, Berlin and GERD symptom checklist questionnaires. Subjects then underwent esophageal pH testing concomitantly with an actigraphy. All subjects were given esomeprazole 40 mg once daily for 7 days and completed a daily symptom record diary. On day 7, subjects repeated the pH test with actigraphy. KEY RESULTS: Twenty patients (mean age of 48.95 ± 18.69, age range 20-81 years) were enrolled. Esophageal acid exposure parameters, during recumbent-awake, recumbent-asleep, and conscious awakenings were significantly improved on last day of treatment as compared to baseline (p < 0.05). However, the frequency and duration of conscious awakenings and duration of recumbent-awake period did not improve as compared to baseline (p > 0.05). CONCLUSIONS & INFERENCES: While esomeprazole significantly reduced esophageal acid exposure during conscious awakenings and recumbent-awake and asleep periods, it did not decrease the number and duration of conscious awakening or duration of recumbent-awake period.

The role of pain modulators in esophageal disorders - no pain no gain.

Pain modulators have been primarily used for the management of functional esophageal disorders. Recently, these drugs have also been used for the management of other esophageal disorders, such as non-erosive reflux disease, the hypersensitive esophagus, and heartburn that is not responsive to proton pump inhibitor treatment. Several etiologies have been identified in patients with functional esophageal disorders, and these include esophageal hypersensitivity due to peripheral and/or central sensitisation, altered central processing of peripheral stimuli, altered autonomic activity, and psychological comorbidity such as depression and anxiety. Different antidepressants have been used as pain modulators and have demonstrated a beneficial effect on patients with the aforementioned esophageal disorders. Tricyclic antidepressants are the most commonly used class of drugs in clinical practice. Other antidepressants that have been used, some with more clinical success than others, include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and trazodone. Other medications that have been used as pain modulators in esophageal disorders include adenosine antagonists, serotonin agonists, antiepileptics, and medications that ameliorate peripheral neuropathy. The mechanism by which many of the pain modulators confer their visceral analgesic effect remains to be fully elucidated. Regardless, their role and value in treating esophageal disorders have markedly increased in the last decade.

Step-by-step management of refractory gastresophageal reflux disease.

Up to a third of the patients who receive proton pump inhibitor (PPI) once daily will demonstrate lack or partial response to treatment. There are various mechanisms that contribute to PPI failure and they include residual acid reflux, weakly acidic and weakly alkaline reflux, esophageal hypersensitivity, and psychological comorbidity, among others. Some of these underlying mechanisms may coincide in the same patient. Evaluation for proper compliance and adequate dosing time of PPIs should be the first management step before ordering invasive diagnostic tests. Doubling the PPI dose or switching to another PPI is the second step of management. Upper endoscopy and pH testing appear to have limited diagnostic value in patients who failed PPI treatment. In contrast, esophageal impedance with pH testing (multichannel intraluminal impedance MII-pH) on therapy appears to provide the most insightful information about the subsequent management of these patients (step 3). In step 4, treatment should be tailored to the specific underlying mechanism of patient's PPI failure. For those who demonstrate weakly acidic or weakly alkaline reflux as the underlying cause of their residual symptoms, transient lower esophageal sphincter relaxation reducers, endoscopic treatment, antireflux surgery and pain modulators should be considered. In those with functional heartburn, pain modulators are the cornerstone of therapy.

Utilization of wireless pH monitoring technologies: a summary of the proceedings from the esophageal diagnostic working group.

Gastroesophageal reflux disease (GERD) can be difficult to diagnose - symptoms alone are often not enough, and thus, objective testing is often required. GERD is a manifestation of pathologic levels of reflux into the esophagus of acidic, nonacidic, and/or bilious gastric content. However, in our current evidence-based knowledge approach, we only have reasonable outcome data in regards to acid reflux, as this particular type of refluxate predictably causes symptoms and mucosal damage, which improves with medical or surgical therapy. While there are data suggesting that nonacid reflux may be responsible for ongoing symptoms despite acid suppression in some patients, outcome data about this issue are limited. Therefore, this working group believes that it is essential to confirm the presence of acid reflux in patients with 'refractory' GERD symptoms or extraesophageal symptoms thought to be caused by gastroesophageal reflux before an escalation of antireflux therapy is considered. If patients do not have pathologic acid reflux off antisecretory therapy, they are unlikely to have clinically significant nonacid or bile reflux. Patients who do not have pathologic acid gastroesophageal reflux parameters on ambulatory pH monitoring then: (i) could attempt to discontinue antisecretory medications like proton pump inhibitors and H2-receptor antagonists (which are expensive and which carry risks - i.e. C. diff, etc.); (ii) may undergo further evaluation for other causes of their esophageal symptoms (e.g. functional heartburn or chest pain, eosinophilic esophagitis, gastroparesis, achalasia, other esophageal motor disorders); and (iii) can be referred to an ear, nose, and throat/pulmonary/allergy physician for assessment of non-GERD causes of their extraesophageal symptoms.

The effect of once daily omeprazole and succinic acid (VECAM) vs once daily omeprazole on 24-h intragastric pH.

BACKGROUND: Parietal cell H(+)/K(+) ATPase activation is essential for optimal proton pump inhibitor (PPI) activity. Succinic acid (SA) was shown to induce gastric acid secretion. VECAM is a combination of omeprazole (OMP) and SA. To compare the effect of once daily bedtime dosing of VECAM 40 and VECAM 20 without food vs OMP 20 mg administered before breakfast on gastric acidity. METHODS: Open label, randomized, crossover study enrolling 36 healthy subjects comparing the study treatments at steady state for 24 h intragastric pH monitoring. KEY RESULTS: The median percent time intragastric pH > 4 demonstrated that VECAM 40 was superior to VECAM 20 (65.7%vs 49.1%P < 0.0001) and OMP 20 mg (65.7%vs 47.6%P = 0.005) during 24 h. VECAM 40 was superior to VECAM 20 (52.8%vs 38.8%P = 0.0079) and OMP 20 mg (52.8%vs 27.2%P < 0.0001), and VECAM 20 was superior to OMP 20 mg (38.8 vs 27.2 P = 0.0069) during the nighttime. VECAM 20 and OMP 20 mg were comparable during 24 h. CONCLUSIONS & INFERENCES: VECAM 40 and VECAM 20 were significantly better in maintaining intragastric pH > 4 during the nighttime than OMP 20 mg. Succinic acid eliminates the need for a subsequent meal for intragastric pH control by VECAM.