Chicago classification version 4.0© technical review: Update on standard high-resolution manometry protocol for the assessment of esophageal motility.

The Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). A key feature of CCv.4.0 is the more rigorous and expansive protocol that incorporates single wet swallows acquired in different positions (supine, upright) and provocative testing, including multiple rapid swallows and rapid drink challenge. Additionally, solid bolus swallows, solid test meal, and/or pharmacologic provocation can be used to identify clinically relevant motility disorders and other conditions (eg, rumination) that occur during and after meals. The acquisition and analysis for performing these tests and the evidence supporting their inclusion in the Chicago Classification protocol is detailed in this technical review. Provocative tests are designed to increase the diagnostic sensitivity and specificity of HRM studies for disorders of esophageal motility. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification, decrease the proportion of HRM studies that deliver inconclusive diagnoses and increase the number of patients with a clinically relevant diagnosis that can direct effective therapy. Another aim in establishing a standard manometry protocol for motility laboratories around the world is to facilitate procedural consistency, improve diagnostic reliability, and promote collaborative research.

Which technique is better to place a manoeuvrable vacuum extractor cup on the flexion point? Vacca vs. Bird technique.

Objectives The purpose of this study is to compare the vacuum extractor cup application technique described by Bird vs. the technique described by Vacca on a simulation model. Methods Six obstetricians participated in the study. Each obstetrician performed eight vacuum assisted deliveries using the Bird technique and eight vacuum assisted deliveries using the Vacca 5-Steps technique. Results A total of 96 vacuum assisted deliveries were performed. The mean distance from the centre of the cup to the flexion point was 1.78±0.96 cm for the Bird technique and 1.05±0.60 cm for the Vacca technique (p<0.001). The lateral distance (over the parietal bone) was 1.16±0.69 cm for the Bird technique and 0.66±0.52 cm for the Vacca technique (p<0.001). The vertical distance (towards the frontal or occipital bone) was 1.12±1.02 cm for the Bird technique and 0.67±0.55 cm for the Vacca technique (p=0.009). In occipito anterior positions, there were no significant differences between both techniques. Conclusions The Vacca technique was better in transverse and posterior positions.

Predicting Ambulatory Function Based on Infantile Lower Extremity Posture Types in Amyoplasia Arthrogryposis.

BACKGROUND: Arthrogryposis multiplex congenita (AMC) is a nonprogressive syndrome with multiple rigid joints, fibrotic periarticular tissue, and muscular fibrosis. The most common subgroup is amyoplasia. Ambulation is one of the most significant functions of the lower extremities as it translates to increased functionality and independence in adulthood. There is no predicative scale to determine ambulation at maturity for the infant with amyoplasia. It is believed lower extremity resting position of infants with amyoplasia potentially correlates with ambulation at maturity. The purpose of this study was to classify the infantile position of lower extremities and muscle strength to predict ambulation potential at maturity. METHODS: Children with amyoplasia were retrospectively reviewed and classified into groups based on infantile position of hip-knee alignment and limb muscle function. Sitting, standing, and walking skills from infancy into adulthood were evaluated. The ambulation function was correlated with the infantile position of the lower extremities. RESULTS: Amyoplasia cases were sorted into 5 types and correlated with ambulatory potential. Type I: mild ambulatory impairment with infantile position of flexed knees and hips but full range of motion. At maturity, all were community ambulators. Type II: moderate ambulatory impairment having infantile position of hip flexion, hip external rotation, and knee flexion contractures. Hip abductors and external rotators had antigravity strength. All stood and walked during the first decade of life with knee ankle foot orthoses. Type III: severe ambulatory impairment having infantile position of hip flexion, abduction, external rotation, and knee flexion contractures but lacked hip muscle recruitment. All used wheelchairs at maturity. Type IV: mild ambulatory impairment with infantile position of extended knees and flexed dislocated hips. At maturity, 90% were community ambulators. Type V: variable ambulatory impairment having asymmetric hip and knee alignment with unilateral hip dysplasia with extended knee and opposite limb flexed. Ambulation skill varied at maturity with 27% full-time wheelchair users. CONCLUSIONS: Amyoplasia can be sorted by infantile position of lower extremities and muscle strength into 5 types to predict ambulatory function. LEVEL OF EVIDENCE: Level III-Prognostic Study.

Detection and classification methodology for movements in the bed that supports continuous pressure injury risk assessment and repositioning compliance.

Pressure injuries are costly to the healthcare system and mostly preventable, yet incidence rates remain high. Recommendations for improved care and prevention of pressure injuries from the Joint Commission revolve around continuous monitoring of prevention protocols and prompts for the care team. The E-scale is a bed weight monitoring system with load cells placed under the legs of a bed. This study investigated the feasibility of the E-scale system for detecting and classifying movements in bed which are relevant for pressure injury risk assessment using a threshold-based detection algorithm and a K-nearest neighbor classification approach. The E-scale was able to detect and classify four types of movements (rolls, turns in place, extremity movements and assisted turns) with >94% accuracy. This analysis showed that the E-scale could be used to monitor movements in bed, which could be used to prompt the care team when interventions are needed and support research investigating the effectiveness of care plans.

Comparison of the Mallampati Classification in Sitting and Supine Position to Predict Difficult Tracheal Intubation: A Prospective Observational Cohort Study.

BACKGROUND: The Mallampati classification (MLPT) is normally evaluated in the sitting position. However, many patients cannot be evaluated in the sitting position for medical reasons. Thus, we compared the MLPT in sitting and supine positions in predicting difficult tracheal intubation (DTI). We hypothesized that the diagnostic accuracy of the MLPT performed in sitting and supine positions would differ. METHODS: We performed a single-center prospective observational study in adult patients who received general anesthesia and orotracheal intubation for noncardiac surgery. During the preanesthesia consultation, the MLPT in the sitting position was recorded. The day of surgery, the MLPT in the supine position and the difficulty of intubation (DTI) were recorded by an independent observer. The diagnostic performance of the MLPT for the prediction of DTI was evaluated in the sitting and supine positions through the area under the receiver operating characteristic (ROC) curve. The performance of the Naguib score in predicting DTI was calculated with the MLPT in sitting and supine positions. RESULTS: Among the 3036 patients, 157 (5.1%) had DTI. The area under the ROC curve for the MLPT in supine position (0.82 [0.78-0.84]) was greater than that for the MLPT in the sitting position (0.70 [0.66-0.75]; P < .001). The relationship between the sitting and supine MLPTs was moderate (Spearman rank correlation coefficient: 0.50; P < .001). The area under ROC curve for predicting DTI by the Naguib score calculated with the supine MLPT (0.78 [95% confidence interval, 0.74-0.82]) was greater than that for the Naguib score calculated with MLPT in the sitting position (0.69 [95% confidence interval, 0.63-0.74)]; P < .001). CONCLUSIONS: The MLPT performed in the supine position is possibly superior to that performed in the sitting position for predicting difficult intubation in adults.

Effects of Curvilinear Supine Position on Tissue Interface Pressure: A Prospective Before-and-After Study.

PURPOSE: To determine whether a curvilinear supine position increases the contact area between the subject and the surgical table, reduces interface pressures within contact areas, and improves comfort. DESIGN: This observational study was completed to establish proof-of-concept to determine differences between 2 positions (supine and curvilinear) on interface pressure of 5 at-risk anatomical locations, overall contact area, and subjects' comfort level. SUBJECTS AND SETTING: The study was conducted at the operating theater of a tertiary teaching hospital in Wuhan, China. The sample comprised 145 healthy Asian volunteers between 18 and 60 years of age. METHODS: Subjects were placed in the supine and curvilinear supine positions on a surgical table. Contact area and peak interface pressures of 5 at-risk anatomical locations (occiput, scapula, sacrum, calf, and heel) were measured using a pressure mapping system, and the mean and maximum pressures of the overall contact area were calculated. Comfort was assessed by self-report using a Likert scale of 1 to 5. The Wilcoxon paired signed rank test was used to compare differences between the 2 positions, and the Spearman correlation analysis was used to identify associations among outcome variables. RESULTS: Results indicated that whole-body (overall) maximum, average interface pressures, and maximum interface pressures of the sacrum and the heel were decreased significantly, with contact area and comfort-level score increasing from 2438.71 to 2709.68 cm and 3.00 to 4.00, respectively (P < .001). Statistically significant associations were found between the contact area and measures of body morphology; correlation coefficients varied from 0.409 to 0.740 (P < .001). CONCLUSIONS: Curvilinear supine position increased overall contact area with the support surface, reduced interface pressures over contact areas (bony prominences), improved comfort, and enhanced pressure redistribution. Additional research is needed to determine if these effects will reduce intraoperative pressure injury occurrence.

Medical Devices; Exemption From Premarket Notification; Class II Devices; Electric Positioning Chair. Final order.

The Food and Drug Administration (FDA or the Agency) is publishing an order granting a petition requesting exemption from premarket notification requirements for electric positioning chair devices. An electric positioning chair is a device with a motorized positioning control that is intended for medical purposes and that can be adjusted to various positions. These devices are used to provide stability for patients with athetosis (involuntary spasms) and to alter postural positions. This order exempts electric positioning chairs, class II devices, from premarket notification, subject to certain conditions for exemption. This exemption from premarket notification, subject to these conditions (and the limitations in the physical medicine devices limitations of exemptions from premarket notification section of the device regulations), is immediately in effect for electric positioning chairs. FDA is publishing this order in accordance with the exemption from class II premarket notification section of the Federal Food, Drug, and Cosmetic Act (the FD&C Act).