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Nutrition plays an important role in health and disease, both in prevention and treatment. Increasing emphasis is being placed upon nutrition as a therapeutic tool to decrease the morbidity and mortality associated with obesity, hypertension, coronary artery disease, and cancer. Adequate nutrition should be a concern for all health care workers because of its impact on the overall health of patients. Health care professionals should be familiar with the essentials of nutritional assessment and basic nutritional requirements and be able to improve their patients' care in the face of nutritional deficiencies or excesses.
Dysphagia 1990
PMID:Nutritional assessment and requirements. 220 96

The combined Collis-Nissen operation has been performed in 353 patients. Forty-five percent had reflux esophagitis without stricture; 20%, peptic stricture; 72%, a sliding hiatal hernia; 17%, a paraesophageal hernia; 21%, previous antireflux operation; 15%, esophageal spasm; 8%, scleroderma; and 32%, marked obesity. There were 4 postoperative deaths (mortality rate, 1.1%). Complications occurred in 28 patients (8%) and included wound infection (2.2%), esophageal or gastroplasty tube leak (1.7%), bleeding (1.1%), splenic injury, gastric atony, and crural repair dehiscence (each less than 1%). Follow-up includes personal interview, esophageal manometry, and standard acid reflux testing. The average length of follow-up for 261 patients (74%) followed at least 12 months is 43.8 months. Fifty-eight percent have been followed at least 36 months; 41%, 48 months; and 29%, 60 months or longer. Subjectively, in these 261 patients, reflux has been eliminated in 75%, is mild in 11%, is moderate in 9%, and is severe in 5%. Eight percent have postthoracotomy pain; 3%, early satiety ("bloats"); and 1%, postvagotomy diarrhea. Seventeen percent require either periodic or regular esophageal dilations for dysphagia. Objectively, intraesophageal pH studies show good reflux control in 91% and poor reflux control in 9%. Twenty-six patients (10%) have required reoperation for recurrent reflux or dysphagia. These results substantiate satisfactory reflux control using the Collis-Nissen operation in patients at risk for recurrence after standard repairs, but also emphasize that, like other antireflux procedures, the Collis-Nissen operation is not without some degree of postoperative adverse symptoms.
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PMID:Continued assessment of the combined Collis-Nissen operation. 291 6

Four hundred and thirty patients with grade 2 or 3 esophagitis were treated after 2/1 randomization for 8 weeks with omeprazole 20 mg (n = 294) or ranitidine 150 mg bid (n = 136). Apart from treatment, 8 epidemiological factors (gender, age, occupation, obesity, smoking, alcohol, NSAID, and coffee or tea consumption), 5 clinical factors (day/night pain distribution, burning score, severity of regurgitation and of dysphagia, number of painful episodes requiring prescription of an antisecretory agent during the previous year, and onset of symptoms before age 30) and 3 endoscopic factors (grade and upward extension of esophagitis, and existence of hiatal hernia > or = 5 cm) were analysed. The influence of these factors on healing at 8 weeks and on changes in symptoms was evaluated by multivariate analysis. 92.1% of patients enrolled were analyzed. In comparison with ranitidine, omeprazole increased the percentage of healed patients (93% v. 67.5%, p < 0.001) and the rapidity of disappearance of symptoms (5 days v. 7 days, p < 0.001). Independent good prognostic factors associated with healing rate were treatment with omeprazole (p < 0.001) and grade 2 esophagitis (p < 0.001) while those associated with the disappearance of symptoms were a low burning score (p = 0.001), advanced age (p = 0.004), treatment with omeprazole (p = 0.005), the absence of any occupation (p = 0.01) and male gender (p = 0.017). The results of this study show that, apart from treatment, endoscopic factors are predictive of the healing of reflux esophagitis treated by antisecretory agents while clinical factors are more important with regard to the disappearance of symptoms.
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PMID:[Prognostic factors influencing healing of reflux esophagitis. A controlled trial of omeprazole versus ranitidine. Study group Omega]. 823 92

A 48-year-old patient with massive obesity developed a dramatic increase of serum glucose and sodium concentration as first symptom of a so far unknown diabetes mellitus. A treatment with intravenous insulin infusion and administration of free water was initiated. Two weeks after this event he became comatose, developed dysphagia, a speech disorder and ocular bobbing; finally, he showed the picture of a complete tetraparesis. Computertomographic findings of the brain were unremarkable. Two weeks later physical findings of the patient showed a significant improvement. Dysphagia, speech disorder and even the tetraparesis disappeared. Computertomography of the brain now yielded a hypodense area within the pons. The symptoms can be understood as signs of central pontine myelinolysis, which may be due to hypo-osmolarity or fast equilibration of a hypo-osmolarity. The history of this patient is a rare example of a central pontine myelinolysis with spontaneous remission.
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PMID:[Acute tetraplegia, diabetes mellitus (clin conference)]. 876 24

A 36-year-old man was admitted to Kanto Chuo Hospital because of hearing loss and dysphagia. On admission physical and neurological findings revealed obesity, hypertension, nystagmus, right hearing loss, dysarthria, and dysphagia. Routine laboratory findings disclosed leukocytosis, liver dysfunction, hypercholesterolemia, proteinuria, and glucosuria. Immunological, coagulopathic, and endocrinological findings, electrocardiogram, echocardiogram, and brain CT scan were unremarkable. He was diagnosed as brainstem infarction, and then conservative therapies were begun. Seven hours after admission, he suddenly fell into coma and apneutic state, requiring artificial ventilation. The next day he was fully conscious, but could'nt make any voluntary movements except for vertical eye movements, suggesting locked-in syndrome (LIS). Brain MRI showed infarction of pons, medulla oblongata, and right cerebellum. Cerebral angiography revealed hypoplasia of bilateral vertebral arteries, a persistence of right primitive trigeminal artery (PTA), and retrograde blood flow of basilar artery from the PTA. Then he made a rapid recovery, and on 80th day he was discharged only with right hearing disturbance and mild left cerebellar sign. We speculated that hypoplasia of the bilateral vertebral arteries caused the brain infarction, and that back flow of the basilar artery from the PTA, in part, contributed to the early recovery from the LIS.
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PMID:[Early recovery from locked-in syndrome due to brain infarction in a young patient with hypoplasia of bilateral vertebral arteries and a persistence of primitive trigeminal artery]. 895 55

Authors report a Launoise-Bensaude-Madelung disease case, in a 64 year old man, admitted to a Plastic Surgical Department for obesity, dysphonia, dysphagia, dyspnea. Early symptoms appeared 20 years before Hospital admission. Lipomatous tissue occupied nape, mandible, neck and shoulders. Surgical exeresis of lipomatous tissue under general anesthesia needed for the patient. Neck movements and mouth opening were short (Mallampati Score = 4); a neck computed tomography showed a tracheal compression and right displacement. Tracheal intubation was considered difficult or impossible. Nose-tracheal intubation was performed using a pediatric fiberoptic instrument as guide for a small gauge tracheal tube. Tracheal stenosis required many attempts for correct nose-tracheal intubation. Fiberoptic instrument as guide for tracheal tube can be useful for patients with Launoise-Bensaude-Madelung disease, when tracheal intubation is considered difficult or impossible. Knowledge of fiberoptic tracheal intubation techniques is mandatory for anesthesiologists, allowing tracheal intubation in patients with anatomical variations of mouth or upper respiratory airways.
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PMID:[Anesthesiologic problems in patients with Launois-Bensaude-Madelung disease. Clinical case]. 910 81

We investigated symptoms suggestive of swallowing problems in patients with primary biliary cirrhosis, some of whom displayed features of sicca complex. A prospective study of 95 consecutive patients with primary biliary cirrhosis was conducted at a single teaching hospital using a questionnaire administered over the telephone. Some symptoms of sicca complex (dry mouth and/or dry eyes) were found in 65 patients (68.4%). Subjective xerostomia alone was present in 45 patients (47.4%). The questionnaire revealed an increase in incidence of dysphagia in xerostomia subjects, affecting 21 of 45 patients, compared with 6 of 50 non-xerostomia patients. Multivariate logistic regression analysis showed that confounding factors such as age, obesity, cigarette smoking, and medications associated with a dry mouth could not explain these findings. Twenty-eight patients complained of hoarseness, 23 of coughing, and 14 of wheezing, all of which were significantly more frequent than in the 50 patients without xerostomia. Heartburn affected 17 xerostomia patients and 15 non-xerostomia patients, indicating no difference in frequency between these two groups, even after age, obesity, cigarette smoking, and medications associated with heartburn were considered in the multivariate analysis. Acid regurgitation, nausea, and vomiting were also similar in frequency between patients with and without xerostomia. Swallowing problems, manifested primarily as dysphagia, are common in primary biliary cirrhosis patients who have subjective xerostomia.
Dysphagia 1997
PMID:Primary biliary cirrhosis, sicca complex, and dysphagia. 919 Jan 3

To explore the potential contributions of gastroesophageal reflux disease, as opposed to Helicobacter pylori infection, to the development of gastric carditis, we evaluated gastric carditis (using the criteria of the updated Sydney system for the classification of gastritis), clinical and morphologic features of esophagitis, and H. pylori infection (evaluation of Steiner stains) in biopsy specimens from the gastroesophageal squamocolumnar junction. We correlated clinical, endoscopic, and histologic features in an unselected group of 116 patients. Some degree of carditis was found in 107 (92%) of the patients. The mean age of the patients increased with increasing severity of carditis (P < .05). The various groups of patients with different degrees of carditis did not differ significantly in sex ratio, ethnic background, presence of obesity, percentage having symptoms of gastroesophageal reflux disease (such as heartburn, regurgitation, dysphagia, or odynophagia), endoscopic evidence of esophagitis and columnar epithelium in the distal esophagus, or histologic evidence of active esophagitis. The presence, however, of active gastritis and H. pylori infection in the distal stomach and/or in the cardia was significantly associated with carditis. In patients without carditis, H. pylori was not detected in any cardiac or distal gastric biopsy specimen. In contrast, H. pylori was demonstrated in gastric tissue samples (either from the cardia or distally) of patients with carditis, with the prevalence rate increasing with greater degrees of cardiac inflammation. The H. pylori prevalence rate was 12% in the group with mild carditis, 40% in those with moderate carditis, and 57% in patients with marked carditis (P = .0001). In summary, carditis is commonly found in patients with symptoms related to upper gastrointestinal diseases. From analysis of our study cohort, we concluded that carditis was significantly associated with H. pylori infection and active gastritis but not with symptoms or signs of gastroesophageal reflux disease. These findings suggest that carditis with histologic features similar to those of gastritis in the distal stomach was a sequel of H. pylori infection and represented a part of an H. pylori--associated gastric inflammation.
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PMID:Gastroesophageal reflux disease versus Helicobacter pylori infection as the cause of gastric carditis. 979 21

There are few long-term follow-up reports of the Angelchik prosthesis (AP). We report the longest follow-up series (66-192 months, average 145 months) to date. Between October 1983 and January 1994, 65 patients (45 men and 20 women) aged between 29 and 84 years (mean 52 years) had an AP inserted for gastro-oesophageal reflux (GOR) with or without hiatus hernia (HH). Clinical, radiological, endoscopy, and operative details were reviewed. Postoperative complications, investigations, and follow-up details were critically analyzed. All living patients (n = 53) with an AP in situ were interviewed and symptomatic assessment was carried out using a modified Visick system (I-IV). The average duration of the GOR symptoms before the operation was 5.7 years (range 10 months to 20 years). The average hospital stay was 8 days (range 5-15 days). Postoperatively, five patients developed chest infection/atelectasis, four had superficial wound infection, two had deep vein thrombosis (one with pulmonary embolism), one had urinary retention, and four developed an incisional hernia. Six patients (three with an AP in situ) died of other medical conditions. Ten (15%) patients had removal of the prosthesis. Eight (12%) and 11 (17%) had transient and persistent dysphagia, respectively. Thirteen (20%) and five (8%) patients had distal slippage and proximal migration of the prosthesis, respectively. One patient had erosion of the AP into the stomach, while in another patient, the straps of the prosthesis ruptured. Of the 53 living patients with an AP in situ, 28 (53%) were Visick I, 11 (20%) were Visick II, 11 (20%) were Visick III, and 3 (7%) were Visick IV. We conclude that the AP has poor long-term results, with only 66% attaining Visick I and II, and a prosthesis removal rate of 15% (10/65). Patients with preoperative dysphagia, hypothyroidism, and diabetes tend to do worse with an AP. Obese patients and those with failed previous fundoplication seemed to fare well with an AP. In view of poor long-term results and high incidence of complications as compared to other conventional operations for GOR, we cannot recommend the continued use of the AP.
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PMID:Angelchik prosthesis revisited. 1189 46

For many years, medical interest in the relationship between nutrition and multiple sclerosis (MS) has focused largely on aetiology and the influence of dietary fat on the rate and severity of disease. While the cause of MS remains unknown and the influence of dietary fat is unclear, recent studies on antioxidant intake and oxidative stress in MS are strengthening the rationale in support of a healthy eating regime following diagnosis. Dietary intake in MS and the influence of advanced disease on nutritional status are less well researched and documented. Both obesity and malnutrition may occur with detrimental consequences to functional abilities. Cognitive difficulties, dysphagia and the side-effects of drug treatment may further contribute to deterioration in nutritional status. This paper aims to provide a practical overview of dietary management in MS. It reviews the available evidence relating nutrition to MS and discusses dietary management, with particular emphasis on the identification and alleviation of factors affecting nutritional status.
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PMID:Nutrition and diet in the clinical management of multiple sclerosis. 1190 75


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