Prevalence and clinical associations of mitral and aortic regurgitation in patients with aortic stenosis.

BACKGROUND: Most guidelines directing clinicians to manage valve disease are directed at single valve lesions. Limited data exists to direct our understanding of how concomitant valve disease impacts the left ventricle (LV). METHODS: We identified 2817 patients with aortic stenosis (AS) from the echocardiography laboratory database between September 2012 and June 2018 who had a LV ejection fraction (EF) ≥50%. LV mass, LV mass index, LV systolic pressure (systolic blood pressure + peak aortic gradient). Covariates were collected from the electronic medical record. Multi-variate analysis of covariance was used to generate adjusted comparisons. RESULTS: Our population was 66% female, 17% African-American with a mean age of 65 years. Of note, 7.3% were noted to have significant (moderate/severe) aortic regurgitation (AR), and 11% had significant (moderate/severe) mitral regurgitation (MR). Adjusting for covariates at different levels, significant MR had a much stronger association with heart failure compared to those with significant AR (p < .001 vs. p = .313, respectively) at all levels of adjustment. Both significant mitral and AR exhibited an association with increasing left ventricular mass, even with adjustment for baseline demographics and clinical features (p < .001 vs. p = .007, respectively). CONCLUSION: In patients with AS, 16% also experience at least moderate MR or AR. Further, significant MR has a stronger association with heart failure than significant AR, even though both increase left ventricular mass. Those with moderate AS and significant MR or AR experience similar or higher levels of heart failure compared to severe AS without regurgitation. Mixed valve disease merits further studies to direct longitudinal management.

Hepatocellular carcinoma surveillance: An evidence-based approach.

Hepatocellular carcinoma (HCC) makes up 75%-85% of all primary liver cancers and is the fourth most common cause of cancer related death worldwide. Chronic liver disease is the most significant risk factor for HCC with 80%-90% of new cases occurring in the background of cirrhosis. Studies have shown that early diagnosis of HCC through surveillance programs improve prognosis and availability of curative therapies. All patients with cirrhosis and high-risk hepatitis B patients are at risk for HCC and should undergo surveillance. The recommended surveillance modality is abdominal ultrasound (US) given that it is cost effective and noninvasive with good sensitivity. However, US is limited in obese patients and those with non-alcoholic fatty liver disease (NAFLD). With the current obesity epidemic and rise in the prevalence of NAFLD, abdominal computed tomography or magnetic resonance imaging may be indicated as the primary screening modality in these patients. The addition of alpha-fetoprotein to a surveillance regimen is thought to improve the sensitivity of HCC detection. Further investigation of serum biomarkers is needed. Semiannual screening is the suggested surveillance interval. Surveillance for HCC is underutilized and low adherence disproportionately affects certain demographics such as non-Caucasian race and low socioeconomic status.

Acute paraesophageal hernia repair: short-term outcome comparisons with elective repair.

BACKGROUND: In the literature, there is a wide range of reported morbidity and mortality rates after acute paraesophageal hernia (PH) repair. MATERIALS AND METHODS: Data were collected from all patients undergoing PH repair between December 2001 and October 2011. Outcome data were compared between the acute and elective groups. RESULTS: Over the study period, 268 patients underwent PH repair, of which 42 patients underwent acute repair compared with 226 elective repairs. Morbidity and mortality rates were both higher, albeit nonsignificantly, in the acute group (16.6% vs. 6.6%, P=0.058 and 4.8% vs. 0.4%, P=0.065, respectively). CONCLUSIONS: Because of the poorer preoperative medical status, lower success rates of minimal access surgery, and longer inpatient stay, combined with the trends toward increased morbidity and mortality rates, of patients undergoing acute repair of PH, we would recommend routine elective laparoscopic surgery as the standard of care for individuals with symptomatic PH and minimal comorbidities.

Postoperative Dysphagia in laparoscopic paraesophageal hernia repair: the effect of distal esophageal angulation.

BACKGROUND: Dysphagia following laparoscopic paraesophageal hernia repair is an uncommon but difficult problem that may be due to technical factors. We looked for an association between esophageal angulation after posterior crural repair and postoperative dysphagia. MATERIALS AND METHODS: Patients undergoing paraesophageal hiatus hernia repair were identified from a prospectively maintained dedicated database. All patients underwent a standardized laparoscopic repair. Essentially the hernia sac was dissected from the mediastinum, a posterior hiatal repair was carried out with interrupted polyester sutures, and augmented with mesh on lay. A partial posterior fundoplication was then carried out. We used the number of posterior sutures as a proxy for anterior esophageal angulation. Quality-of-life data and dysphagia scores were recorded preoperatively, at 6 weeks postoperatively and 12 months postoperatively using validated instruments. RESULTS: Between November 2004 and September 2010, 114 consecutive patients underwent paraesophageal hiatus hernia repair. There was 1 postoperative death in the series. Median age was 67 years (interquartile range, 59 to 77 y) and 90 (79%) were female. Median hospital stay was 3 days (interquartile range, 2 to 5 y). Follow-up data were available in 87 (76%) of patients at 6 weeks and 94 (82%) of patients at 12 months postoperation. Overall, there was a significant improvement in quality of life that was sustained out to 12 months (P<0.001). Dakkak dysphagia scores were significantly improved postoperatively. Improvement was sustained out to 12 months (P<0.001). Three patients underwent endoscopic esophageal dilation for dysphagia following surgery. There was no significant correlation between the number of posterior sutures used and dysphagia outcome. Specifically there was no association with overall Dakkak scores or change in Dakkak score. CONCLUSIONS: Anterior angulation due to posterior hiatal repair does not result in worsening dysphagia, even in patients with large hiatal defects. A posterior repair should therefore remain the standard approach for hiatal closure.

Upper limb progressive resistance training and stretching exercises following surgery for early breast cancer: a randomized controlled trial.

The aim of this study was to determine whether an exercise program, commencing 4-6 weeks post-operatively, reduces upper limb impairments in women treated for early breast cancer. Women (n = 160) were randomized to either an 8-week exercise program (n = 81) or to a control group (n = 79) following stratification for axillary surgery. The exercise program comprised a weekly session and home program of passive stretching and progressive resistance training for shoulder muscles. The control group attended fortnightly assessments but no exercises were provided. The primary outcome was self-reported arm symptoms derived from the EORTC breast cancer-specific questionnaire (BR23), scored out of 100 with a low score indicative of fewer symptoms. The secondary outcomes included physical measures of shoulder range of motion, strength, and swelling (i.e., lymphedema). Women were assessed immediately following the intervention and at 6 months post-intervention. The change in symptoms from baseline was not significantly different between groups immediately following the intervention or at 6 m post-intervention. The between group difference immediately following the intervention was 4 (95% CI -1 to 9) and 6 months post-intervention was 4 (-2 to 10). However, the change in range of motion for flexion and abduction was significantly greater in the exercise group immediately following the intervention, as was change in shoulder abductor strength. In conclusion, a supervised exercise program provided some, albeit small, additional benefit at 6 months post-intervention to women who had been provided with written information and reminders to use their arm. Both the groups reported few impairments including swelling immediately following the intervention and 6 months post-intervention. Notably, resistance training in the post-operative period did not precipitate lymphedema.

Fructose-sorbitol ingestion provokes gastrointestinal symptoms in patients with eating disorders.

AIM: To evaluate gastrointestinal (GI) symptoms and breath hydrogen responses to oral fructose-sorbitol (F-S) and glucose challenges in eating disorder (ED) patients. METHODS: GI symptoms and hydrogen breath concentration were monitored in 26 female ED inpatients for 3 h, following ingestion of 50 g glucose on one day, and 25 g fructose/5 g sorbitol on the next day, after an overnight fast on each occasion. Responses to F-S were compared to those of 20 asymptomatic healthy females. RESULTS: F-S provoked GI symptoms in 15 ED patients and one healthy control (P<0.05 ED vs control). Only one ED patient displayed symptom provocation to glucose (P<0.01 vs F-S response). A greater symptom response was observed in ED patients with a body mass index (BMI)17.5 kg/m2 (P<0.01). There were no differences in psychological scores, prevalence of functional GI disorders or breath hydrogen responses between patients with and without an F-S response. CONCLUSION: F-S, but not glucose, provokes GI symptoms in ED patients, predominantly those with low BMI. These findings are important in the dietary management of ED patients.

Recurrent and injurious falls in the year following hip fracture: a prospective study of incidence and risk factors from the Sarcopenia and Hip Fracture study.

BACKGROUND: The incidence and etiology of falls in patients following hip fracture remains poorly understood. METHODS: We prospectively investigated the incidence of, and risk factors for, recurrent and injurious falls in community-dwelling persons admitted for surgical repair of minimal-trauma hip fracture. Fall surveillance methods included phone calls, medical records, and fall calendars. Potential predictors of falls included health status, quality of life, nutritional status, body composition, muscle strength, range of motion, gait velocity, balance, walking endurance, disability, cognition, depression, fear of falling, self-efficacy, social support, physical activity level, and vision. RESULTS: 193 participants enrolled in the study (81 +/- 8 years, 72% women, gait velocity 0.3 +/- 0.2 m/s). We identified 227 falls in the year after hip fracture for the 178 participants with fall surveillance data. Fifty-six percent of participants fell at least once, 28% had recurrent falls, 30% were injured, 12% sustained a new fracture, and 5% sustained a new hip fracture. Age-adjusted risk factors for recurrent and injurious falls included lower strength, balance, range of motion, physical activity level, quality of life, depth perception, vitamin D, and nutritional status, and greater polypharmacy, comorbidity, and disability. Multivariate analyses identified older age, congestive heart failure, poorer quality of life, and nutritional status as independent risk factors for recurrent and injurious falls. CONCLUSIONS: Recurrent and injurious falls are common after hip fracture and are associated with multiple risk factors, many of which are treatable. Interventions should therefore be tailored to alleviating or reversing any nutritional, physiological, and psychosocial risk factors of individual patients.

Methodology and baseline characteristics for the Sarcopenia and Hip Fracture study: a 5-year prospective study.

BACKGROUND: Age-related hip fractures are associated with poor functional outcomes, resulting in substantial personal and societal burden. There is a need to better identify reversible etiologic predictors of suboptimal functional recovery in this group. METHODS: The Sarcopenia and Hip Fracture (SHIP) study was a 5-year prospective cohort study following community-dwelling older persons admitted to three Sydney hospitals for hip fracture. Information was collected at baseline, and 4 and 12 months, including health status, quality of life, nutritional status, body composition, muscle strength, range of motion, gait velocity, balance, walking endurance, disability, cognition, depression, fear of falling, self-efficacy, social support, physical activity level, vision, and fall-related data, with residential status, disability, and mortality reassessed at 5 years. RESULTS: 193 participants enrolled (81 +/- 8 years, 72% women). High levels of activities of daily living, disability and sedentariness were present prior to fracture. At admission, the cohort had high levels of chronic disease; 38% were depressed, 38% were cognitively impaired, and 26% had heart disease. Seventy-one percent of participants were sarcopenic, 58% undernourished, and 55% vitamin D deficient. Mobility, strength, and vision were severely impaired. There was little evidence that these comorbidities were either recognized or treated during hospitalization. Disability, sedentariness, malnutrition, and walking endurance predicted acute hospitalization length of stay. CONCLUSIONS: The complex comorbidity, pre-existing functional impairment, and sedentary behavior in patients with hip fracture suggest the need for thorough screening and targeting of potentially reversible impairments. Rehabilitation outcomes are likely to be highly dependent on amelioration of these highly prevalent accompaniments to hip fracture.

Ineffective oesophageal motility: manometric subsets exhibit different symptom profiles.

AIM: To compare the demographic and clinical features of different manometric subsets of ineffective oesophageal motility (IOM; defined as > or = 30% wet swallows with distal contractile amplitude < 30 mmHg), and to determine whether the prevalence of gastro-oesophageal reflux differs between IOM subsets. METHODS: Clinical characteristics of manometric subsets were determined in 100 IOM patients (73 female, median age 58 years) and compared to those of 100 age-and gender-matched patient controls with oesophageal symptoms, but normal manometry. Supine oesophageal manometry was performed with an eight-channel DentSleeve water-perfused catheter, and an ambulatory pH study assessed gastro-oesophageal reflux. RESULTS: Patients in the IOM subset featuring a majority of low-amplitude simultaneous contractions (LASC) experienced less heartburn (prevalence 26%), but more dysphagia (57%) than those in the IOM subset featuring low-amplitude propagated contractions (LAP; heartburn 70%, dysphagia 24%; both P < or = 0.01). LASC patients also experienced less heartburn and more dysphagia than patient controls (heartburn 68%, dysphagia 11%; both P < 0.001). The prevalence of heartburn and dysphagia in IOM patients featuring a majority of non-transmitted sequences (NT) was 54% (P = 0.04 vs LASC) and 36% (P < 0.01 vs controls), respectively. No differences in age and gender distribution, chest pain prevalence, acid exposure time (AET) and symptom/reflux association existed between IOM subsets, or between subsets and controls. CONCLUSION: IOM patients with LASC exhibit a different symptom profile to those with LAP, but do not differ in gastro-oesophageal reflux prevalence. These findings raise the possibility of different pathophysiological mechanisms in IOM subsets, which warrants further investigation.

Estimation of thigh muscle cross-sectional area by dual-energy X-ray absorptiometry in frail elderly patients.

BACKGROUND: Thigh muscle mass and cross-sectional area (CSA) are useful indexes of sarcopenia and the response to treatment in older patients. Current criterion methods are computed tomography (CT) and magnetic resonance imaging. OBJECTIVE: The objective was to compare thigh muscle mass estimated by dual-energy X-ray absorptiometry (DXA), a less expensive and more accessible method, with thigh muscle CSA determined by CT in a group of elderly patients recovering from hip fracture. DESIGN: Midthigh muscle CSA (in cm(2)) was assessed from a 1-mm CT slice and midthigh muscle mass (g) from a 1.3-cm DXA slice in 30 patients (24 women) aged 81 +/- 8 y during 12 mo of follow-up. Fat-to-lean soft tissue ratios were calculated with each technique to permit direct comparison of a variable in the same units. RESULTS: Baseline midthigh muscle CSA was highly correlated with midthigh muscle mass (r = 0.86, P < 0.001) such that DXA predicted CT-determined CSA with an SEE of 10 cm(2) (an error of approximately 12% of the mean CSA value). CT- and DXA-determined ratios of midthigh fat to lean mass were similarly related (intraclass correlation coefficient = 0.87, P < 0.001). When data were expressed as the changes from baseline to follow-up, CT and DXA changes were weakly correlated (intraclass correlation coefficient = 0.51, P = 0.019). CONCLUSIONS: Assessment of sarcopenia by DXA midthigh slice is a potential low-radiation, accessible alternative to CT scanning of older patients. The errors inherent in this technique indicate, however, that it should be applied to groups of patients rather than to individuals or to evaluate the response to interventions.

Feeding and colonic distension provoke altered autonomic responses in irritable bowel syndrome.

OBJECTIVE: Alterations in autonomic balance, detectable by heart rate variability (HRV) analysis, have been shown to occur after a meal in patients with irritable bowel syndrome (IBS). There are few data on changes in sympathovagal responses in IBS to other forms of enteric stimulation such as colonic distension. The aim of this study was to determine the effects of colonic balloon distension on HRV in the fasting and the postprandial state in healthy subjects and in IBS patients. MATERIAL AND METHODS: Eight IBS patients and 8 age- and gender-matched healthy subjects underwent unsedated descending colonic distension before and after a 1000 kcal liquid meal. Low- (LF) and high-frequency (HF) HRV band values obtained from 2-min ECG segments recorded before and during distension were compared between groups, and between fasting and postprandial states. A visual analogue scale was used to determine sensation during colonic distension. RESULTS: HF values decreased significantly with feeding in IBS patients (p=0.01), but not in healthy subjects. The low-to-high frequency (LF/HF) ratio was significantly higher postprandially in IBS patients (p=0.02) and, additionally, was decreased (p<0.01) with colonic distension in the fed state, independently of colonic sensitivity or distending volume. Moreover, changes in the LF/HF ratio with distension in the fed versus the fasting state were negatively correlated in IBS patients but positively correlated in healthy subjects (both p<0.05). CONCLUSIONS: IBS patients demonstrated altered autonomic responses to feeding and colonic distension. Further studies should determine whether these alterations could explain the postprandial exacerbation of symptoms in IBS.

Progressive resistance training and stretching following surgery for breast cancer: study protocol for a randomised controlled trial.

BACKGROUND: Currently 1 in 11 women over the age of 60 in Australia are diagnosed with breast cancer. Following treatment, most breast cancer patients are left with shoulder and arm impairments which can impact significantly on quality of life and interfere substantially with activities of daily living. The primary aim of the proposed study is to determine whether upper limb impairments can be prevented by undertaking an exercise program of prolonged stretching and resistance training, commencing soon after surgery. METHODS/DESIGN: We will recruit 180 women who have had surgery for early stage breast cancer to a multicenter single-blind randomized controlled trial. At 4 weeks post surgery, women will be randomly assigned to either an exercise group or a usual care (control) group. Women allocated to the exercise group will perform exercises daily, and will be supervised once a week for 8 weeks. At the end of the 8 weeks, women will be given a home-based training program to continue indefinitely. Women in the usual care group will receive the same care as is now typically provided, i.e. a visit by the physiotherapist and occupational therapist while an inpatient, and receipt of pamphlets. All subjects will be assessed at baseline, 8 weeks, and 6 months later. The primary measure is arm symptoms, derived from a breast cancer specific questionnaire (BR23). In addition, range of motion, strength, swelling, pain and quality of life will be assessed. DISCUSSION: This study will determine whether exercise commencing soon after surgery can prevent secondary problems associated with treatment of breast cancer, and will thus provide the basis for successful rehabilitation and reduction in ongoing problems and health care use. Additionally, it will identify whether strengthening exercises reduce the incidence of arm swelling. TRIAL REGISTRATION: The protocol for this study is registered with the Australian Clinical Trials Registry (ACTRN012606000050550).

Evaluation of artificial neural networks in the classification of primary oesophageal dysmotility.

OBJECTIVE: Artificial neural networks (ANNs) can rapidly analyse large data sets and exploit complex mathematical relationships between variables. We investigated the feasibility of utilizing ANNs in the recognition and objective classification of primary oesophageal motor disorders, based on stationary oesophageal manometry recordings. MATERIAL AND METHODS: One hundred swallow sequences, including 80 that were representative of various oesophageal motor disorders and 20 of normal motility, were identified from 54 patients (34 F; median age 59 years). Two different ANN techniques were trained to recognize normal and abnormal swallow sequences using mathematical features of pressure wave patterns both with (ANN(+)) and without (ANN(-)) the inclusion of standard manometric criteria. The ANNs were cross-validated and their performances were compared to the diagnoses obtained by standard visual evaluation of the manometric data. RESULTS: Interestingly, ANN(-), rather than ANN(+), programs gave the best overall performance, correctly classifying >80% of swallow sequences (achalasia 100%, nutcracker oesophagus 100%, ineffective oesophageal motility 80%, diffuse oesophageal spasm 60%, normal motility 80%). The standard deviation of the distal oesophageal pressure and propagated pressure wave activity were the most influential variables in the ANN(-) and ANN(+) programs, respectively. CONCLUSIONS: ANNs represent a potentially important tool that can be used to improve the classification and diagnosis of primary oesophageal motility disorders.

Does growth hormone allow more efficient nitrogen sparing in postoperative patients requiring parenteral nutrition? A double-blind, placebo-controlled randomised trial.

BACKGROUND & AIMS: Growth hormone (GH) has a strong anabolic effect and is thought to be useful in improving the efficacy of parenteral nutrition (PN) to preserve muscle mass (MM) in the postoperative setting. Unfortunately, the negative clinical outcome of GH treatment in intensive care patients limits its use in this setting, but demands answers to the mechanism behind the action of this therapy. METHOD: In a double-blind randomised controlled study consecutive patients after major abdominal surgery were divided into four groups of either 1/2-PN (0.13 g N/kg/day and 52% of calories as lipid) or full-strength PN (Full-PN) (0.3 g N/kg/day and 65% of calories as lipid) receiving daily injections of either GH (8-16 IU) or placebo for a period of 14 days postoperative. Outcome measures included MM derived from measures of total body potassium (40K counting) and total body nitrogen (TBN) (in vivo neutron capture technique); Fat mass from skin folds; serum insulin like growth factor-I (IGF-I) and its binding proteins (IGFBP). RESULTS: From 43 major upper GI surgical patients randomised 35 completed the study (one patient died from sepsis in the half-strength PN (1/2-PN)+GH group). 1/2-PN (n=11) lost TBN (P=0.001), MM (P=0.005) but not fat. Full-PN (n=9) maintained TBN, MM (P=0.056) and fat. 1/2-PN+GH (n=8) maintained TBN and fat but lost MM (P=0.038). Full-PN+GH (n=7) maintained TBN and MM but lost fat (P=0.018). Two-way ANOVA indicated that PN input (P=0.031) and not GH had a significant effect on MM. GH caused a significant rise in IGF-I levels (290+/-67 and 454+/-71 microg/l for 1/2-PN+GH and Full-PN+GH, respectively) and restored serum IGFBP3 and the acid labile subunit to normal, by the postoperative day 9. CONCLUSION: After major gastrointestinal surgery, GH causes a marked hepatic IGF-I response and nitrogen retention but its effect on body composition was more significant with a high PN input. Further, Full-PN alone was sufficient to prevent nitrogen loss and preserved MM and addition of GH does not provide further metabolic advantage.

Gastrointestinal symptoms in spinal cord injury: relationships with level of injury and psychologic factors.

INTRODUCTION: Previous surveys of gastrointestinal symptoms after spinal cord injury have not used validated questionnaires and have not focused on the full spectrum of such symptoms and their relationship to factors, such as level of spinal cord injury and psychologic dysfunction. This study was designed to detail the spectrum and prevalence of gastrointestinal symptoms in spinal cord injury and to determine clinical and psychologic factors associated with such symptoms. METHODS: Established spinal cord injury patients (>12 months) randomly selected from a spinal cord injury database completed the following three questionnaires: 1) Rome II Integrative Questionnaire, 2) Hospital Anxiety and Depression Scale, and 3) Burwood Bowel Dysfunction after spinal cord injury. RESULTS: A total of 110 patients participated. The prevalence of abdominal bloating and constipation were 22 and 46 percent, respectively. Bloating was associated with cervical (odds ratio = 9.5) and lumbar (odds ratio = 12.1) level but not with thoracic level of injury. Constipation was associated with a higher level of injury (cervical odds ratio = 5.6 vs. lumbar) but not with psychologic factors. In contrast, abdominal pain (33 percent) and fecal incontinence (41 percent) were associated with higher levels of anxiety (odds ratio = 6.8, and odds ratio = 2.4) but not with the level of injury. CONCLUSIONS: There is a high prevalence and wide spectrum of gastrointestinal symptoms in spinal cord injury. Abdominal bloating and constipation are primarily related to specific spinal cord levels of injury, whereas abdominal pain and fecal incontinence are primarily associated with higher levels of anxiety. Based on our findings, further physiologic and psychologic research studies in spinal cord injury patients should lead to more rational management strategies for the common gastrointestinal symptoms in spinal cord injury.

Attenuation of the colorectal tonic reflex in female patients with irritable bowel syndrome.

Alterations in normal intestinointestinal reflexes may be important contributors to the pathophysiology of irritable bowel syndrome (IBS). Our aims were to compare the rectal tonic responses to colonic distension in female IBS patients with predominant constipation (IBS-C) and with predominant diarrhea (IBS-D) to those in healthy females, both fasting and postprandially. Using a dual barostat assembly, 2-min colonic phasic distensions were performed during fasting and postprandially. Rectal tone was recorded before, during, and after the phasic distension. Colonic compliance and colonic sensitivity in response to the distension were also evaluated fasting and postprandially. Eight IBS-C patients, 8 IBS-D patients, and 8 age- and sex-matched healthy subjects (group N) participated. The fasting increments in rectal tone in response to colonic distension in both IBS-C (rectal balloon volume change -4.6 +/- 6.1 ml) and IBS-D (-7.9 +/- 4.9 ml) were significantly reduced compared with group N (-34 +/- 9.7 ml, P = 0.01). Similar findings were observed postprandially (P = 0.02). When adjusted for the colonic compliance of individual subjects, the degree of attenuation in the rectal tonic response in IBS compared with group N was maintained (fasting P = 0.007; postprandial P = 0.03). When adjusted for colonic sensitivity there was a trend for the attenuation in the rectal tonic response in IBS patients compared with group N to be maintained (fasting P = 0.07, postprandial P = 0.08). IBS patients display a definite attenuation of the normal increase in rectal tone in response to colonic distension (colorectal reflex), fasting and postprandially. Alterations in colonic compliance and sensitivity in IBS are not likely to contribute to such attenuation.