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.

Spectrum of esophageal dysmotility in systemic sclerosis on high-resolution esophageal manometry as defined by Chicago classification.

The classic manometric findings in systemic sclerosis are aperistalsis of the esophageal body with hypotensive lower esophageal sphincter. These changes contribute to gastroesophageal reflux disease in these patients. With widespread use of high-resolution esophageal manometry, diverse abnormalities are seen. The aim of this study is to characterize esophageal dysmotility in patients with systemic sclerosis undergoing high-resolution esophageal manometry and compare demographic features and diagnostic test results among patients with varying degrees of esophageal dysmotility. Patients with systemic sclerosis who underwent high-resolution esophageal manometry between January 2008 and October 2014 at our institution were identified. High-resolution esophageal manometry studies were reinterpreted using the Chicago Classification, v3.0 criteria. We also reviewed the patient charts for demographic data, indications for manometry, esophagogastroduodenoscopy findings, pH studies, medication use, and autoantibody panel. The cohort consisted of 122 patients with a mean age of 53.3 ± 15.3 years. High-resolution esophageal manometry was normal in 23, showed ineffective esophageal motility in 22, absent contractility in 73, and one case each of type II achalasia, esophagogastric junction outflow obstruction, hypercontractile esophagus, and distal esophageal spasm. Patients with absent contractility were younger and more likely to have erosive esophagitis, hiatal hernia, and esophageal strictures than patients with ineffective esophageal motility or normal manometry. There were no statistically significant differences in the groups based on autoantibodies or indications for manometry. Diverse esophageal motility abnormalities were noted in systemic sclerosis with ineffective esophageal motility or absent contractility observed in over three-fourth of the patients. Patients with absent contractility were younger and had more severe reflux. The severity of gastroesophageal reflux disease related endoscopic findings correlated with the degree of esophageal dysmotility on high-resolution esophageal manometry.

The case of self-resolving type III achalasia after bilateral lung transplant.

BACKGROUND: Post-surgical achalasia has been previously described in large case series but there are limited data on the natural progression of the disease process. In general, achalasia is considered an "incurable" disease as per published guidelines. We present here, the first report of a patient with post-surgical achalasia which resolved spontaneously. METHODS: This is a retrospective chart review. KEY RESULTS: A 60-year-old male presented for dysphagia 3 months status post-bilateral lung transplant and was diagnosed with achalasia following positive manometry. Absent any treatment, his repeat manometry showed complete, spontaneous resolution of the achalasia 2 years following lung transplant. CONCLUSIONS & INFERENCES: To our knowledge, this is the first such case of spontaneously resolving achalasia following bilateral lung transplant. This case warrants further study in to the natural progression of post-surgical achalasia.

Use of a positional therapy device significantly improves nocturnal gastroesophageal reflux symptoms.

The aim of this study was to measure the efficacy of a positional therapy device (PTD) at reducing proton pump inhibitor (PPI) refractory nocturnal GERD symptoms. Among patients with GERD, nocturnal symptoms are very common. A recent study demonstrated a decrease in nocturnal acid exposure and reflux episodes in healthy volunteers who slept using a PTD. This is a single-center prospective trial involving patients on anti-secretory medications with continued nocturnal heartburn and regurgitation. Patients completed the Nocturnal GERD Symptom Severity and Impact Questionnaire (N-GSSIQ) and GERD health-related quality of life questionnaire (GERD-HRQL) at enrollment. Patients were instructed to sleep on the PTD for at least 6 hours a night during the two week study period; subjects continued their baseline anti-secretory medication dose. After 2 weeks, the questionnaires were repeated. A total of 27 patients (16 females and 11 males; age 57.8 ± 15.1) were recruited. After 2 weeks of PTD use, N-GSSIQ scores significantly improved from baseline, with a mean total score improvement of 39.5 (mean 57.7 [pre] vs. 18.2 [post], P < 0.001). Significant improvement from baseline was also observed for the GERD-HRQL questionnaire (29.8 vs. 16.7, P < 0.001). No adverse events were reported. At 3 months after the trial period, 91% of the subjects continued to use the PTD on a nightly basis. Use of the PTD significantly decreased nocturnal GERD symptoms and improved GERD-HRQL. The PTD was well tolerated during the study period and for 3 months after enrollment.

Depression, social factors, and farmworker health care utilization.

PURPOSE: Farmworkers frequently live in rural areas and experience high rates of depressive symptoms. This study examines the association between elevated depressive symptoms and health care utilization among Latino farmworkers. METHODS: Data were obtained from 2,905 Latino farmworkers interviewed for the National Agricultural Workers Survey. Elevated depressive symptoms were measured using the Center for Epidemiologic Studies Depression short-form. A dichotomous health care utilization variable was constructed from self-reported use of health care services in the United States. A categorical measure of provider type was constructed for those reporting use of health care. RESULTS: Over 50% of farmworkers reported at least 1 health care visit in the United States during the past 2 years; most visits occurred in a private practice. The odds of reporting health care utilization in the United States were 45% higher among farmworkers with elevated depressive symptoms. Type of provider was not associated with depressive symptoms. Women were more likely to seek health care; education and family relationships were associated with health care utilization. CONCLUSIONS: Latino farmworkers who live and work in rural areas seek care from private practices or migrant/Community Health Clinics. Farmworkers with elevated depressive symptoms are more likely to access health care. Rural health care providers need to be prepared to recognize, screen, and treat mental health problems among Latino farmworkers. Outreach focused on protecting farmworker mental health may be useful in reducing health care utilization while improving farmworker quality of life.

Mental health research with Latino farmworkers: a systematic evaluation of the short CES-D.

Mental health research among Latino farmworkers is hampered by the absence of measurement evaluation that ensures farmworkers understand and can consistently and appropriately respond to questions about mental health. Cross-sectional data were obtained from 409 farmworkers via interviewer-administered survey questionnaires. Mental health was operationalized with the short-form Center for Epidemiologic Studies, Depression (CES-D) scale. The structured interviewer-administered survey questionnaires included measures to capture personal and work-related factors that could affect farmworkers' ability to understand and respond to mental health questions probed by the CES-D. Good variability in item response was observed across the 10 short-form CES-D items. There was no evidence of differential response across sub-groups of farmworkers for six of the 10 items. Responses to four of the 10 items differed by educational attainment, country of origin, and language preference. Overall, the internal consistency of the 10 items exceeded standard conventions, and observed differences in depressive symptoms were as expected. Researchers in farmworker mental health must remain attentive to the strength and validity of available measures for migrants, different ethnic groups and different socioeconomic backgrounds. Nevertheless, the overall pattern suggests that the CES-D is a viable tool for advancing farmworker mental health research.

Comparison of costs and referral rates of 3 universal newborn hearing screening protocols.

OBJECTIVE: To investigate the costs and referral rates of 3 universal newborn hearing screening programs: transient evoked otoacoustic emissions (TEOAE), automated auditory brainstem response (AABR), and a combination, two-step protocol in which TEOAE and AABR are used. STUDY DESIGN: Clinical outcomes (referral rates) from 12,081 newborns at 5 sites were obtained by retrospective analysis. Prospective activity-based costing techniques (n = 1056) in conjunction with cost assumptions were used to analyze the costs based on an assumed annual birth rate of 1500 births. RESULTS: Referral rates differed significantly among the 3 screening protocols (AABR, 3.21%; two-step, 4.67%; TEOAE, 6.49%; P <.01), with AABR achieving the best referral rate at discharge. Although AABR had the lowest referral rate at discharge and the highest pre-discharge costs, the total pre- and post-discharge costs per infant screened (AABR, $32.81; two-step, $33.05; TEOAE, $28.69) and costs per identified child (AABR, $16,405; two-step, $16,527; TEOAE, $14,347) were similar among programs. CONCLUSION: Although AABR incurs higher costs during pre-discharge screening, it has lower referral rates than either the TEOAE or two-step program. As a result, the total costs of newborn hearing screening and diagnosis are similar among the 3 methods studied.

The Marion Downs National Center for Infant Hearing: developing comprehensive state systems.

The Marion Downs National Center for Infant Hearing was established in 1996 through a Maternal and Child Health Grant awarded to the University of Colorado. The goals of the grant are to implement statewide systems of newborn hearing screening, audiologic assessment, and early intervention in 19 states. Newborn hearing screening alone will not assure early identification or positive outcomes for the development of communication and language. Therefore, the staff at the Marion Downs National Center developed comprehensive goals for all participating states. These goals are described in this article.

Effect of L-alanine and ouabain on membrane conductances and apical membrane potential in Aplysia intestine.

The proximal intestine of Aplysia californica was employed to assess the effect of alanine absorption on apical membrane K+ conductance (GKa) and basolateral membrane conductance (Gb) and the role of the electrogenic Na(+)-K(+)-adenosinetriphosphatase (Na+ pump) in the repolarization of apical membrane electrical potential difference (Va) after alanine-induced depolarization. Addition of 50 mM L-alanine (isosmotic substitution for mannitol) to the apical superfusate depolarized Va, reduced the ratio of apical to basolateral membrane resistances (Ra/Rb), and stimulated short-circuit current (Isc). Following these initial events, Va repolarized, Ra/Rb increased, and there was a slight decline in Isc. Apical high-K+ artificial seawater revealed an alanine-induced increase in GKa. Washout of alanine from the apical solution increased Ra/Rb above the prealanine control value. Thus alanine absorption is accompanied by an increase in Gb. Basolateral 0.1 mM ouabain abolished alanine-stimulated Isc but had little effect on Va ( < 3 mV depolarization) either before or after exposure to alanine. The repolarization of Va was not affected in tissues superfused with 0.1 mM basolateral ouabain for approximately 3 min even though the alanine-stimulated increase in Isc was abolished. Therefore, the electrogenic Na+ pump contributes minimally to the repolarization of Va in sea hare intestine. The origin of the hyperpolarization of Va resides therefore, at least in part, in the increase in GKa, which restores the driving force for Na(+)-alanine cotransport and prevents K+ accumulation in the enterocytes.

Management of chronic middle ear effusion with prednisone combined with trimethoprim-sulfamethoxazole.

Fifty-three patients were enrolled and evaluable in a randomized, double-blinded controlled clinical trial comparing prednisone for 7 days plus trimethoprim-sulfamethoxazole (TMP/SMZ) for 30 days vs. TMP/SMZ alone in treating chronic middle ear effusion (MEE). Clearing of the effusion in both ears or in one when only one was involved was called complete resolution; clearing in one of two affected ears was called partial resolution. The outcomes 2 weeks after initiation of therapy of 26 patients initially treated with prednisone plus TMP/SMZ were complete resolution in 20, partial resolution in three, and unchanged in three. The outcomes in 27 patients initially treated with TMP/SMZ alone were complete resolution in eight, partial resolution in three, unchanged in 13 and development of acute otitis media in three (P less than 0.01 for complete resolution). Two weeks after initiation of therapy, patients with a MEE that failed to clear were crossed over to the alternative regimen. Overall 29 of 41 patients (71%) who received oral prednisone plus TMP/SMZ initially or after the crossover had complete resolution of their middle ear effusion at 2 weeks after starting prednisone and TMP/SMZ. Five of 35 (14%) patients treated with prednisone plus TMP/SMZ and one of six (17%) patients treated with TMP/SMZ alone who had complete resolution at 4 weeks required subsequent referrals for tympanostomy tubes. A course of prednisone for 7 days plus TMP/SMZ for 30 days with monthly follow-up should be considered in children with MEE persisting beyond 6-8 weeks before referral for tympanostomy tube placement.