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.

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.

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.

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.

Habitual physical activity, anabolic hormones, and potassium content of fat-free mass in postmenopausal women.

BACKGROUND: Total body potassium (TBK) is known to decline throughout adulthood. The relations between physical activity, age, anabolic hormones, and TBK have rarely been considered. OBJECTIVE: We sought to describe the relation between habitual physical activity, age, serum estradiol, and insulin-like growth factor I (IGF-I) and TBK in postmenopausal women. DESIGN: TBK, fat-free mass (FFM), moderate-to-vigorous-intensity physical activity (MVPA; assessed with use of a semistructured interview), and serum concentrations of estradiol, IGF-I, and IGF binding protein 3 (IGFBP-3) were quantified in 51 healthy white women aged 54-76 y. RESULTS: The potassium content of FFM declined curvilinearly with age, indicating an accelerated loss of skeletal muscle after 65 y of age. With the data split into high (n = 25) and low (n = 26) MVPA groups, the active women had 6.5% more potassium per FFM than did their less-active counterparts (P < 0.01). In multiple regression analysis, MVPA was the major determinant of the potassium content of FFM (P = 0.02), such that an active 70-y-old had the potassium content value of a 55-y-old sedentary woman. Serum estradiol, IGF-I, and IGFBP-3 were not significant determinants of the potassium content of FFM. CONCLUSIONS: These data suggest that 1) habitual physical activity can significantly influence FFM potassium content; 2) physical activity must, therefore, be considered if the effect of aging per se on TBK is to be clarified; and 3) MVPA, such as that pursued by the active women in the present study (eg, walking, dancing, floor exercises, and swimming), can assist in preventing sarcopenia in older women.