The influence of supragastric belching severity on esophageal acid exposure and motility.

BACKGROUND: Supragastric belching (SGB) is a phenomenon where air is rapidly sucked from the pharynx into the esophagus and immediately expelled through abdominal straining. It is considered a behavior disorder and is increasingly recognized not only in patients with excessive belching, but also in those with reflux-like symptoms. Increased prevalence of esophageal hypomotility and increased acid exposure were previously reported in small cohorts of SGB patients. We aimed to clarify the impact of SGB on motility, reflux, and acid exposure in a large cohort of SGB patients. METHODS: In a single-center database study, we searched for patients with pathological SGB. MII-pH and Manometry tracings were manually re-evaluated in all patients. Demographic, clinical, motility, reflux, and SGB-related data were gathered. KEY RESULTS: Three hundred and forty-eight patients were included. Heartburn, belching, and regurgitation were the most common symptoms. Ineffective esophageal motility (IEM) was found in 27% of patients. SGB related to 47% of all reflux and to 53.6% of acid reflux events, and accounted for 27.3% of acid exposure time (AET). In those with severe SGB, 62% of acid reflux events and 46% of AET were SGB-related. CONCLUSIONS & INFERENCES: Supragastric belching is common, associated with higher incidence of IEM and is responsible for almost a third of esophageal acid burden. The impact of SGB is proportional to its severity. Diagnosis of SGB should be sought in patients with excessive belching and in patients with refractory reflux symptoms. Recognizing SGB and treating patients with behavioral therapy may alleviate acid exposure and improve quality of life.

Management of supragastric belching.

Increased SGB is currently more often recognized not only in patients with belching as a main symptom, but also in patients with reflux like symptoms that are refractory to PPI treatment or patients with reflux hypersensitivity. Detection of increased SGB during analysis of impedance-pHmetry can help to better understand the pathophysiology of symptoms in individual patients and to provide more focused and specific treatment. At the moment, the most efficient treatments for increased SGB are CBT and Speech therapies, pharmacological treatment being less effective and prone to mild secondary effects. In this issue of Neurogastroenterology and Motility, Punkinnen et al demonstrate, in controlled clinical trial, that behavioral therapy was superior to follow-up without intervention in patients with SGB. We present a critical review of the different treatment modalities currently available for patients with pathological SGB.

Cholecystectomy and Biliary Sphincterotomy Increase Fecal Bile Loss and Improve Lipid Profile in Dyslipidemia.

BACKGROUND AND AIMS: Bile is the only significant pathway for cholesterol elimination. Cholecystectomy (CS) increases fecal bile acid loss, and endoscopic biliary sphincterotomy (ES) is thought to have a similar effect. We speculated that a combined effect of ES + CS would further enhance fecal bile acid loss, potentially causing lipid profile changes in these patients. METHODS: Fecal bile acids and sterols were determined using gas chromatography in cohorts of post-CS + ES, post-CS and in healthy controls. The effect of ES + CS on blood lipid profile was assessed retrospectively in a single-center cohort of post-CS + ES patients, using a computerized database. Parameters of interest included demographics, medical history, and lipid profiles. RESULTS: Fecal primary bile acid concentrations were increased after CS + ES compared to CS and controls (cholic acid [CA] 1.4 ng/mg vs. 0.26 ng/mg, p = 0.02 vs. 0.23 ng/mg, p = 0.004, chenodeoxycholic acid [CDCA] 1.92 ng/mg vs. 0.39 ng/mg, p = 0.02 vs. 0.23 ng/mg, p = 0.01, respectively). Fecal cholesterol excretion was similar in all three groups. Baseline serum lipid profile and subsequent changes following CS + ES were correlated. In patients with baseline hypercholesterolemia (total cholesterol (TC) > 200 mg/dl), TC levels decreased by 28.5 mg/dl, and LDL levels decreased by 21.5 mg/dl. The effect was more pronounced in those with TC > 200 mg/dl, despite of statin intake. In patients with hypertriglyceridemia [triglycerides (TG) > 200 mg/dl], TG decreased by 67.8 mg/dl following ES + CS. Among patients without dyslipidemia or dyslipidemia with adequate response to statins, the effect of ES + CS on lipid profile was minor. CONCLUSIONS: Fecal bile acid loss increases following CS + ES. The effect on blood lipid profile depends on baseline TC and TG levels. Lipid profile is improved in dyslipidemic patients, while the impact of CS + ES is minimal on the normolipemic population.

Risk of metachronous advanced lesions after resection of diminutive and small, non-advanced adenomas.

BACKGROUND AND AIMS: Current post-polypectomy surveillance interval guidelines do not discriminate between 1-2 diminutive (1-5mm) and small (6-9mm) non-advanced adenomas. This study compared the risk for metachronous advanced lesions in these groups. METHODS: Patients with 1-2 diminutive, non-advanced adenomas and no further advanced lesions, and patients with no polyps at baseline colonoscopy were retrospectively analyzed to determine the rate of metachronous advanced lesions. These were defined as the combined rate of colon cancer, advanced adenoma and ≥ 3 non-advanced adenomas at surveillance colonoscopy. Polyp size was measured either subjectively by the endoscopist or by pathology-based measurements. RESULTS: Among patients with diminutive (n = 395) and small polyps (n = 110), advanced lesions were found in 68 patients (17.2%) and 16 patients (14.5%), respectively (P = 0.53), during a mean follow-up of 4.3 ± 0.9 years. In contrast, advanced lesions were observed in 33 patients (6.6%) in the no polyp group (n = 505), significantly lower than diminutive (P = 0.000) and small polyp groups (P = 0.002), despite a mean follow-up duration of 6.1 ± 1.9 years. The rate of metachronous advanced lesions was also similar between patients with 1-3mm polyps (16%) versus 7-9mm polyps (15.8%). CONCLUSIONS: Our findings suggest that among patients who underwent polypectomy of up to 2 non-advanced adenomas, those with diminutive and small polyps have the same risk of metachronous advanced lesions; thus, supporting uniform recommendations for surveillance colonoscopy for these lesions.

Prehospital intubation success rates among Israel Defense Forces providers: epidemiologic analysis and effect on doctrine.

BACKGROUND: Advanced airway management is composed of a set of vital yet potentially difficult skills for the prehospital provider, with widely different clinical guidelines. In the military setting, there are few data available to inform guideline development. We reevaluated our advanced airway protocol in light of our registry data to determine if there were a preferred maximum number of endotracheal intubation (ETI) attempts; our success with cricothyroidotomy (CRIC) as a backup procedure; and whether there were cases where advanced airway interventions should possibly be avoided. METHODS: This is a descriptive, registry-based study conducted using records of the Israel Defense Forces Trauma Registry at the research section of the Trauma and Combat Medicine Branch, Surgeon General's Headquarters. We included all casualties for whom ETI was the initial advanced airway maneuver, and the number of ETI attempts was known. Descriptive statistics were used. RESULTS: Of 5,553 casualties in the Israel Defense Forces Trauma Registry, 406 (7.3%) met the inclusion criteria. Successful ETI was performed in 317 casualties (78%) after any number of ETI attempts; an additional 46 (11%) underwent CRIC, and 43 (11%) had advanced airway efforts discontinued. ETI was successful in 45%, 36%, and 31% of the first, second, and third attempts, respectively, with an average of 28% success over all subsequent attempts. CRIC was successful in 43 (93%) of 46 casualties in whom it was attempted. Of the 43 casualties in whom advanced airway efforts were discontinued, 29 (67%) survived to hospital discharge. CONCLUSION: After the first ETI attempt, success with subsequent attempts tended to fall, with minimal improvement in overall ETI success seen after the third attempt. Because CRIC exhibited excellent success as a backup airway modality, we advocate controlling the airway with CRIC if ETI efforts have failed after two or three attempts. We recommend that providers reevaluate whether definitive airway control is truly necessary before each attempt to control the airway.

A dynamic mass casualty incident at sea: lessons learned from the Mavi Marmara.

BACKGROUND: Mass casualty incidents (MCIs) represent one of the most difficult prehospital challenges faced by medical personnel. When they occur at sea, this challenge may be further complicated by isolation, distance, vessel structure, number of passengers, and limited evacuation means. METHODS: We describe our experience and lessons learned from a dynamic MCI in an austere environment at sea. RESULTS: Following an armed attack on navy operators boarding the MV Mavi Marmara, a vessel heading for Gaza, the Israel Defense Forces' medical teams triaged and cared for 62 casualties, among them 9 soldiers; 9 additional casualties were declared dead at the scene. The injured, including 10 triaged as severely wounded, were all evacuated to Israeli hospitals within several hours of the start of the event. Despite the austere conditions and the severity of injuries, all of the injured passengers were able to return to their home countries, and all soldiers returned to duty. Multiple issues were identified as requiring changes or heightened awareness so as to be better prepared for future events of this special nature. CONCLUSION: The primary lessons learned related to difficulties in functioning without effective communication, maintaining command and control, coordinating serial evacuation of casualties who were being triaged in parallel, planning for an event with lengthy evacuation times, resolving real-time ethical dilemmas, and preparing our providers mentally. As MCIs tend to be unexpected, preplanning, using preestablished manuals, and drilling for them may prove crucial in such extreme events. Importantly, the lessons learned from this event, with its unique synthesis of multiple contributing factors, remain relevant even in less austere settings.

Blood glucose levels as an adjunct for prehospital field triage.

OBJECTIVE: Elevated blood glucose levels (BGL) are known to be part of the physiologic response to stress following physical trauma. We aimed to study whether a measured BGL might help improve accuracy of field triage. METHODS: We conducted a retrospective study using the Israel Defense Forces Trauma Registry. BGLs were determined upon hospital arrival and were not available to medical providers in the field. RESULTS: There were 706 casualties in the registry who had a recorded BGL upon hospital arrival. Sixty percent (18/30) of casualties who had a BGL ≥200 mg/dL had been triaged in the field as severely wounded, whereas 11% (71/651) of casualties who had a BGL <200 mg/dL had been triaged as severely wounded. For predicting an Injury Severity Score >15, the positive likelihood ratio using field triage of severe was 11, using BGL ≥200 mg/dL was 8, and using a combination of the two tests was 26. For predicting the need for intensive care unit (ICU) admission, the ratios were 8, 13, and 23, respectively. CONCLUSIONS: Elevated BGL improved prediction of high Injury Severity Score and ICU use among casualties triaged as severe. If future research using BGL measured in the field yields similar results, combining BGL with standard field triage may allow for more accurate identification of casualties who need acute field intervention, have major injury, or require ICU admission.

Training modalities and self-confidence building in performance of life-saving procedures.

OBJECTIVE: Physicians and paramedics in the Israel Defense Forces are trained to perform advanced medical procedures using standardized training modalities, such as manikins. We studied the association of experience using these training modalities with self-reported confidence in procedure performance. METHODS: Providers were sent a questionnaire regarding their experience with and self-confidence levels for performing endotracheal intubation, cricothyroidotomy, needle chest decompression, tube thoracostomy, and intraosseous infusion. RESULTS: Provider level (physician or paramedic) and gender were associated with reported self-confidence levels. Manikin and supervised and unsupervised patient experience exhibited positive associations with self-confidence, but (animal) model experience did not. For many procedure-training modality pairs, we identified a plateau level above which additional experience was minimally associated with an increase in self-confidence. CONCLUSIONS: Among military advanced life support providers, self-confidence levels in procedure performance are positively associated with experience gained from manikins and supervised and unsupervised patient application. We were not able to demonstrate a clear benefit of an animal model in increasing self-confidence. A plateau was generally identified, indicating decreased benefit from the use of a particular training modality for a particular procedure. Modifying training regimens in light of these findings may help maximize the self-confidence of advanced life support providers more efficiently.