Dysphagia and non-cardiac chest pain are common referrals for esophageal motility testing. Hypertensive esophageal peristalsis, previously classified as “nutcracker esophagus,” has been re-labelled as “jackhammer esophagus” by the Chicago Classification of esophageal motility disorders (CC v3.0). Although the pathophysiology of jackhammer esophagus (JE) has yet to be elucidated, gastroesophageal acid reflux (GERD) has been implicated as a possible causative factor, based on the higher than expected incidence of GERD on patients with JE that has been seen in previous studies (43 - 47%). The aim of this present study is to determine if GERD is associated with JE when compared to symptomatic controls with normal HRM. Consecutive symptomatic patients who were referred for esophageal high-resolution manometry (HRM) studies in Calgary, AB from Nov 2013 to Sept 2018 were retrospectively analyzed. Patients with a manometric diagnosis of Jackhammer esophagus by CC v3.0 (≥ 2 hypercontractile swallows with distal contractile integral [DCI] > 8000 mmHg-s-cm) who also underwent ambulatory pH studies were compared to patients with normal HRM (controls). Groups were compared with Pearson’s chi-square testing and ANOVA as appropriate. This study was IRB approved. 20 JE patients and 82 controls who underwent both HRM and ambulatory pH testing were identified. Age and gender breakdown were similar between both groups (see Table 1). The most common presenting complaint in the JE group was dysphagia (35.0%) and in controls was heartburn (26.8%). Similar numbers of both groups were on PPI (50.0% JE, 51.2% controls). 3 (25.0%) JE patients and 14 (17.1%) controls had evidence of abnormal acid exposure on 24h ambulatory pH study (defined as DeMeester score > 14.7); this difference was not significant (p = 0.56). When abnormal acid exposure was defined as acid exposure time (AET) > 4.2%, there was no significant difference seen between both groups (p = 0.50). There were no significant differences seen between other parameters of the DeMeester score (see Table 1). Abnormal acid exposure on ambulatory pH study does not appear to be associated with JE, when compared to patients with normal HRM. This finding suggests that abnormal esophageal acid exposure is unlikely to be a causative factor for the peristaltic abnormalities seen in Jackhammer esophagus. Table 1: Demographics and GERD parameters Table 1: Demographics and GERD parameters None
Dynamic MRI defecography is a relatively new imaging protocol which can be extremely useful in identification of anatomic and functional pelvic floor dysfunction such as organ prolapse, anismus and fecal incontinence. The aim of the study is to assess for causes of Pelvic floor dysfunction on MRI and further characterize the findings based on functional or anatomical causes. Retrospective case series of all patients having from January 2017 to August 2018 at a tertiary care hospital (South Health Campus, Calgary, AB). After injecting rectal ultrasound gel the study was performed in resting, squeezing and defecation sequences. At least four defecation sequences were obtained to assess for complete evacuation of rectal vault. The images were then carefully reviewed to identify for descent of urinary bladder (cystocele), uterus, enterocele and rectum. The degree of prolapse was then measured and graded according to the set guidelines in radiology literature. Anismus was identified if the patient was unable to evacuate the rectal gel in four separate sequences of defecation. A total of 66 patients underwent MRI Defecography. Majority of the patients referred for MRI had clinical history of constipation and to assess for compartment prolapse.The most common finding was excessive compartmental descent in 77% of patients and anismus in 38% (Table). Two patients had normal study and two patients had tumours identified as the cause for their symptoms. Most patients were referred by gastroenterologists and very few (5%) had anorectal manometry. Dynamic MR defecography is a novel tool for identification of both anatomic and functional pelvic floor abnormalities. The information it provides may allow for effective management (eg physiotherapy and/or biofeedback for anismus, and surgical correction for significant prolapse). Complete evaluation of the pelvis can also yield additional information such as tumors or other miscellaneous findings. However, while sensitivity appears excellent, further study is required to ascertain specificity of MR diagnosis of anismus due to patients who may have difficulty defecating due to the non-physiologic aspect of supine defecation. Given that MR scanners are much more common than anorectal manometry labs, wider adoption of MR defecography may improve diagnostic capability for pelvic floor dysfunction, which is commonly under-diagnosed. RESULTS RESULTS None
From an original cohort of 63 rapists serving prison sentences for rape in Singapore, two subgroups were identified, one subgroup who raped females 14 years and younger (an offence that is termed ‘statutory rape’ or ‘SR’) and another who raped females 14 years and above (which we term ‘non-statutory rape’ or ‘NSR’). The two subgroups were compared across a broad range of variables. Those who committed SR tended to be older, married, Malay men who were more likely to commit rape in their home or in the home of their victims, and who rated the quality of their sexual relationships more unfavourably than the NSRs. The NSRs were more likely to be single men but with concurrent relationships with different females. NSRs were more likely to report dysfunctional family backgrounds, early conduct problems and were more likely to rape their victims outdoors and late into the night. Although in both subgroups the majority of the victims were known to the rapists, relatives (i.e. step-daughters or daughters) were by far the most common victims of the SR rapists.
Abstract Background POEM for achalasia can be challenging in patients with complex achalasia (CA) (i.e., type III achalasia, multiple prior treatments, prior myotomy, and sigmoid type). The POEM difficulty score (PDS) identifies factors that contribute to challenging POEM procedures. (Figure 1) Here, we present an update on the PDS in a series of patients with non-CA and CAs. Aims Our aim was to determine whether, with the introduction of the TT-J knife with waterjet functionality, the PDS still maintains a strong correlation with procedural efficiency and technical difficulty. Methods We retrospectively reviewed patients who underwent POEM for achalasia between May 2018 to July 2023 at the Kingston Health Sciences Center. 139 consecutive POEMs were performed, with 74 CAs. Primary outcomes include correlation of procedural efficiency with the PDS. Secondary outcomes include clinical success at the last followup and adverse events. Demographics and procedural variables were compared with descriptive statistics (mean ± SD; median, min-max range) and the Mann-Whitney U-test. Pre and post-POEM Echkhardt scores were compared using the Wilcoxon signed-rank test. Results 74 (56.7% male) complex and 65 (55.4% male) non-complex POEM procedures were carried out. The mean age is 56.7 ± 16.5 years and 47.3 ± 20.2 years in CA and non-CA respectively. PDS correlates moderately with procedural efficiency with a correlation coefficient of 0.595 (Spearman’s Pampersand:003C0.001). A subanalysis is available in Table 1. The mean efficiency for non-CA was 3.3min/cm±1.2. The median PDS for non-CA was 1 (0-5). In comparison, the mean efficiency for CA were 3.3min/cm ± 1.3 (type III), 5.3min/cm ± 2.3 (prior myotomy), 4.0min/cm ± 1.7 (≥4 prior procedures), and 5.2min/cm ± 2.4 (sigmoid type). The median PDS for CA was 3 (0-6) (type III), 4 (0-8) (prior myotomy), 3 (0-8) (≥4 prior procedures), and 3 (0-6) (sigmoid type). CA and non-CA POEM procedures were completed with 97% and 98% clinical success, respectively. Conclusions PDS continues to moderately correlate with procedural efficiency using the TT-J knife. However, the presence of spastic contractions correlated poorly with procedural efficiency. Thus, it may be omitted with the use of the TT-J knife. The order of increasing difficulty of POEM in CA appears to be type III, prior myotomy, sigmoid type, and ≥4 prior procedures. Multi-center prospective studies are needed to validate PDS in different clinical settings. Table 1: Sub-analysis of individual PDS factors and procedural velocity Figure 1: Peroral Endoscopic Myotomy (POEM) difficulty score (PDS): "FOODS" Funding Agencies None
There are little data evaluating the performance of the 3-dimensional high-definition anorectal manometry (3D-HDAM) system in the diagnosis of dyssynergic defecation. Physical properties of the thicker, rigid, 3D-HDAM probe may have implications on the measurements of anorectal pressures.Our aim was to compare 3D-HDAM to balloon expulsion test and magnetic resonance (MR) defecography.Consecutive constipated patients referred for anorectal function testing at the Calgary Gut Motility Centre (Calgary, Canada) between 2014 and 2019 were assessed. All patients underwent anorectal manometry with the 3D-HDAM probe, and a subset underwent BET or MR defecography. Anorectal manometric variables were compared between patients who had normal and abnormal BET.Over the study period, 81 patients underwent both 3D-HDAM and BET for symptoms of constipation. 52 patients expelled the balloon within 3 minutes. Patients with abnormal BET had significantly lower rectoanal pressure differential (RAPD) (-61 vs. -31 mmHg for normal BET, p = 0.03) and defecation index (0.29 vs. 0.56, p = 0.03). On logistic regression analysis, RAPD (OR: 0.99, 95% CI: 0.97-0.99, p = 0.03) remained a negative predictor of abnormal BET. On ROC analysis, RAPD had an AUC of 0.65. There was good agreement between dyssynergic patterns on 3D-HDAM and defecographic evidence of dyssynergia (sensitivity 80%, specificity 90%, PLR 9, NLR 0.22, accuracy 85%).Manometric parameters, when measured with the 3D-HDAM probe, poorly predict prolonged balloon expulsion time. RAPD remains the best predictor of prolonged balloon expulsion time. The 3D-HDAM probe may not be the ideal tool to diagnose functional defecatory disorders.
The May 2016 wildfire in Fort McMurray in northern Alberta, Canada—the costliest wildfire disaster in Canadian history—led to an areawide evacuation by road and air. Traffic count and flight data were used to assess the characteristics of the evacuation, including estimates of people movements by vehicle and aircraft. The vehicle counts were compared first with historic values to examine traffic patterns and were then used to create an evacuation response curve, which revealed an expected S-shaped curve and highlighted how quickly the evacuation occurred. Finally, data for people evacuated by aircraft were combined with data for people evacuated by ground vehicle to construct a curve of the cumulative number of evacuees leaving the region. This study identified several key implications for evacuation planning and operations. The decision to evacuate residents to temporary shelters in the north was instrumental in the quick removal of everyone from immediate danger via all possible exits. Although an unplanned contraflow operation added roadway capacity out of Fort McMurray, the underuse of the secondary route suggested that the management of traffic routing might have reduced congestion. The evacuation response curve emphasized the volatility of the wildfires, with the resulting evacuations occurring under conditions of a greater immediacy than hurricane evacuations. Finally, the significant role of air transportation in this evacuation indicated that multimodal emergency evacuation plans may be critical for remote communities and sparse networks. These findings may be applied to evacuation planning and policy to improve the efficiency and efficacy of evacuations.
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