How to Optimally Apply Impedance in the Evaluation of Esophageal Dysmotility

The utilization of impedance technology has enhanced our understanding and assessment of esophageal dysmotility. Esophageal high-resolution manometry (HRM) catheters incorporated with multiple impedance electrodes help assess esophageal bolus transit, and the combination is termed high-resolution impedance manometry (HRIM). Novel metrics have been developed with HRIM—including esophageal impedance integral ratio, bolus flow time, nadir impedance pressure, and impedance bolus height—that augments the assessment of esophageal bolus transit. Automated impedance-manometry (AIM) analysis has enhanced understanding of the relationship between bolus transit and pressure phenomena. Impedance-based metrics have improved understanding of the dynamics of esophageal bolus transit into four distinct phases, may correlate with symptomatic burden, and can assess the adequacy of therapy for achalasia. An extension of the use of impedance involves impedance planimetry and the functional lumen imaging probe (FLIP), which assesses esophageal biophysical properties and distensibility, and could detect patterns of esophageal contractility not seen on HRM. Impedance technology, therefore, has a significant impact on esophageal function testing in the present day.     

Prompt Repair of Post Cholecystectomy Bile Duct Transection Recognized Intraoperatively and Referred Early: Experience from a Tertiary Care Teaching Unit

Postcholecystectomy bile duct injuries are a cause of significant morbidity and occasional mortality. Intraoperative recognition and repair of complete biliary transection with hepaticojejunostomy is the recommended treatment; however, it is possible only in few patients as either the injury is not recognized intraoperatively or the center is not geared up to perform an urgent hepaticojejunostomy in these patients with a nondilated duct. Retrospective analysis of data from a tertiary care referral center over a period of 10 years from January 2000 to December 2009 to report the feasibility and outcomes of prompt repair was done (defined as repair within 72 h of index operation) of postcholecystectomy bile duct injury. Ten patients of postcholecystectomy bile duct injury detected intraoperatively and referred early underwent prompt repair. All patients had a complete transection of the bile duct (type of injuries as per Strasberg classification: Type E V: 1, Type E III: 5, Type E II: 3 and Type E I: 1). The mean duration between injury and bile duct repair in the form of Roux-en-Y hepaticojejunostomy (RYHJ) was 22.7 (range 5–42) hours. The mean diameter of the anastomosis was 1.63 (range1–2.1) cm, and the anastomosis was stented in 7 patients. The mean duration of surgery was 4.6 +1.7 h. One patient developed bile leak on the first postoperative day, which settled by day 5. The mean duration of hospital stay was 5.1 (range 4–8) days. With a mean follow-up of 42 (range 24–110) months, all patients had excellent (70 %) or good outcome (30 %). Prompt RYHJ (within first 72 h) for postcholecystectomy biliary transection is an effective treatment and potentially limits the morbidity to the patient.     

Perceived stigma reductions following participation in mental health services integrated within community-based HIV primary care

HIV stigma remains a significant challenge for individuals living with HIV disease that can adversely affect overall well-being and patterns of HIV health service engagement. Finding ways to effectively address stigma concerns is, therefore, an important consideration in the clinical management of HIV disease. This study examined changes in perceived stigma in a sample of 48 adults living with HIV disease as an outcome of their participation in a mental health services program integrated with community-based HIV primary care. Participants completed a self-report instrument that provided a multidimensional measure of perceived HIV stigma, including distancing, blaming, and discrimination dimensions. This scale was administered at the baseline mental health service visit and then re-administered at the three-month follow-up point. Study results showed reductions in self-reported perceived HIV stigma over time for the distancing (t = 4.01, p = 0.000, d = 0.43), blaming (t = 2.79, p = 0.008, d = 0.35), and discrimination (t = 2.90, p = 0.006, d = 0.42) dimensions of stigma. These findings suggest that participation in HIV mental health services may have a favorable impact on perceived HIV stigma. Implications of these findings are discussed, including possible mechanisms that might explain the observed results as well as suggested directions for future research in this area. Randomized controlled trials would represent an important next step to investigate the extent to which HIV mental health services can reduce levels of perceived HIV stigma.     

Acne Knowledge of Hispanic Parents of Teenagers with Mild to Moderate Acne

We performed a cross‐sectional study of Hispanic and non‐Hispanic parents of children with acne using a survey designed to determine their level of awareness of acne and its treatment; 82% of Hispanic parents and 40% of non‐Hispanic parents agreed that a health care provider should treat mild acne (p < 0.001). Hispanic parents of adolescents with acne agreed more frequently than non‐Hispanic parents that children with mild and moderate acne should be taken to a health care provider for treatment, but they tended not to visit health care providers. Future studies should aim to determine the reasons for this discrepancy, after which culturally sensitive educational programs can be developed to address this disparity.     

The wrist is not the brain: Estimation of sleep by clinical and consumer wearable actigraphy devices is impacted by multiple patient‐ and device‐specific factors

Clinical actigraphy devices provide adequate estimates of some sleep measures across large groups. In practice, providers are asked to apply clinical or consumer wearable data to individual patient assessments. Inter‐individual variability in device performance will impact such patient‐specific interpretation. We assessed two devices, clinical and consumer, to determine the magnitude and predictors of this individual‐level variability. One hundred and two patients (55 [53.9%] female; 56.4 [±16.3] years old) undergoing polysomnography wore Jawbone UP3 and/or Actiwatch2. Device total sleep time, sleep efficiency, wake after sleep onset and sleep latency were compared with polysomnography. Demographics, sleep architecture and clinical measures were compared to device performance. Actiwatch overestimated total sleep time by 27.2 min (95% confidence limits [CL], 138.3 min over to 84.0 under), overestimated sleep efficiency by 6.8% (95% CL, 34.1% over to 20.5% under), overestimated sleep onset latency by 2.6 min (95% CL, 63.3 over to 58.2 under) and underestimated wake after sleep onset by 50.7 min (95% CL, 162.5 under to 61.2 over). Jawbone overestimated total sleep time by 59.1 min (95% CL, 208.6 min over to 90.5 under) and overestimated sleep efficiency by 14.9% (95% CL, 52.6% over to 22.7% under). In multivariate models, age, sleep onset latency, wake after sleep onset, % N1 and apnea–hypopnea index explained only some of the variance in device performance. Gender also affected performance. Actiwatch and Jawbone mis‐estimate sleep measures with very wide confidence limits and accuracy varies with multiple patient‐level characteristics. Given these large individual inaccuracies, data from these devices must be applied only with extreme caution in clinical practice.