New treatment guidelines on diagnosis and management of achalasia

The updated guidelines from the American College of Gastroenterology include an overview of the disease and highlight new recommendations for its diagnosis and management, based on evidence-quality evaluations in patients with achalasia, as well as a comprehensive review of the related evidence and examination of relevant published data. The authors state that achalasia “is an incurable disease characterized by incomplete or absent relaxation of the LES and aperistalsis of the esophageal body. The symptomatic consequence of this motility disorder is the classic presentation of dysphagia to solids and liquids associated with regurgitation of bland undigested food or saliva.” The guidelines address the importance of early diagnosis in patients displaying symptoms of achalasia. Lead author Michael F. Vaezi, MD, PhD, MSc, FACG, of Vanderbilt University Medical Center, noted that “by definition, an assessment of esophageal motor function is essential in the diagnosis of achalasia.” Chest pain during meals, difficulty swallowing, weight loss and even heartburn are associated symptoms that often lead to misdiagnosis of achalasia, mistakenly as GERD. Achalasia must be suspected in those with dysphagia to solids and liquids and in those with regurgitation unresponsive to an adequate trial of PPI therapy. The guidelines also address the use of high-resolution esophageal manometry in the diagnosis of achalasia and its variant presentations. The authors have updated the approach to treating achalasia given recent outcome studies comparing pneumatic dilation and surgical myotomy as well as recommendations on long-term patient follow up. “Surgical mytomy has shown excellent results in most patients and remains the surgery of choice, with more being done laparoscopically. The benefit of adding a fundoplication was demonstrated in a double-blind randomized trial comparing myotomy with versus without fundoplication. In this study, abnormal acid exposure on pH monitoring was found in 47 percent of patients without an antireflux procedure and 9 percent in patients that had a posterior Dor fundoplication,” Vaezi said. He adds, “A subsequent cost-utility analysis based on the results of this trial found that myotomy plus Dor fundoplication was more cost effective than myotomy alone because of the costs of treating GERD.” Patient follow up concludes the guidelines and is essential in those diagnosed with achalasia. The guidelines include short-term and long-term goals for follow up and discuss the management of treatment failures, whether endoscopy surveillance for cancer is recommended and include a treatment algorithm.

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Patients with diabetes at increased risk for physical disability

However, these risks tend to vary, according to researchers. In a new systematic review and meta-analysis, researchers in Australia suggest that diabetes is significantly associated with an increased risk for physical disability, and preventive measures are warranted. The reasons why diabetes is associated with physical disability are still unclear, although several mechanisms have been suggested. Its possible that the high blood glucose concentrations experienced by people with diabetes might lead to chronic muscle inflammation, eventually resulting in physical disability, and some studies have shown that diabetes is associated with rapid and worsening muscle wasting, Anna Peeters, PhD, of the Baker IDI Heart and Diabetes Institute and department of clinical diabetes and epidemiology at The Alfred Centre in Melbourne, Australia, said in a press release. The complications associated with diabetes, such as heart disease, stroke , and kidney disease, can all result in disability. As the worlds population ages, and diabetes becomes more common, it seems clear that we will see an increased need for disability-related health resources, which health systems around the world need to be prepared for. Anna Peeters Peeters and colleagues examined the Ovid, Medline, Embase, Cochrane Library and Cumulative Index to Nursing and Allied Health Literature databases up to Aug. 8, 2012, for studies that compared the risk for disability as measured by daily activities or mobility in patients with or without diabetes. According to data from 3,224 articles, diabetes appeared to increase the risk for mobility disability (15 studies; OR=1.71; 95% CI, 1.53-1.91; RR=1.51; 95% CI, 1.38-1.64), instrumental activities of daily living disability (10 studies; OR=1.65; 95% CI, 1.551.74) and activities of daily living disability (16 studies; OR=1.82; 95% CI, 1.63-2.04; RR=1.82; 95% CI, 1.40-2.36). In an accompanying comment, Edward W. Gregg, PhD, of the division of diabetes translation at the National Center for Chronic Disease Prevention and Health Promotion at the CDC, wrote that the study highlights a consistently significant association between diabetes and risk for mobility disability and other physical disabilities. However, diabetes often causes more relative damage in middle age than in older age (ie, relative to their same-aged, non-diabetic peers); the same might be true for disability, Gregg wrote. In view of the fact that the greatest increase in diabetes cases in low-income and middle-income countries are expected in middle-aged adults, and that a large prevalence of disability could have damaging health and economic implications, more thorough examination of function across the full age spectrum of adults is also needed. For more information:

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Four inmates on hunger strike require medical attention

Prison medical officials say four inmates on a statewide hunger strike required medical attention Thursday. (Mark Boster / Los Angeles Times / October 13, 2012) By Paige St. John July 18, 2013, 4:05 p.m. This post has been updated. See the note below for details. SACRAMENTO — California prison medical officials said Thursday that four inmates participating in a statewide hunger strike have required medical care and a fifth has been referred to a physician. Three of those protesters at the state prison in Calipatria in Southern California were moved to an outpatient housing facility within prison grounds for care, said Liz Gransee, a spokeswoman for the court-appointed medical receiver’s office in charge of prison healthcare. The fourth inmate, at Pelican Bay State Prison, was not moved but given fluids through an IV, while another protester at that prison was sent to a physician, Gransee said. Friday marks the 12th day of a protest that began July 8 with 30,000 inmates refusing their state-issued meals. As of Thursday, the number of protesters had dropped to 2,300. [Updated at 3:50 p.m.: California corrections officials on Thursday afternoon updated the number of active hunger strike participants to 1,457 inmates housed in 15 prisons.] Inmates participating in the disturbance are calling for limits on the state’s use of solitary confinement to control prison gangs, as well as changes in how inmates are identified by race for discipline after gang-related violence in prisons. California corrections officials contend the protest itself is coordinated by prison gangs. Inmate advocates say the state’s use of indefinite isolation is excessive, causes physical and psychological damage and violates prisoners’ constitutional rights. A federal lawsuit over those conditions also is pending.

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