Nobre e Souza MÂ, Lima MJ, Martins GB, Nobre RA, Souza MH, de Oliveira RB, dos Santos AA. Inspiratory muscle training improves antireflux barrier in GERD patients. Am J Physiol Gastrointest Liver Physiol 305: G862-G867, 2013. First published October 10, 2013 doi:10.1152/ajpgi.00054.2013.-The crural diaphragm (CD) is an essential component of the esophagogastric junction (EGJ), and inspiratory exercises may modify its function. This study's goal is to verify if inspiratory muscle training (IMT) improves EGJ motility and gastroesophageal reflux (GER). Twelve GER disease [GERD; 7 males, 20 -47 yr, 9 esophagitis, and 3 nonerosive reflex disease (NERD)] and 7 healthy volunteers (3 males, 20 -41 yr) performed esophageal pH monitoring, manometry, and heart rate variability (HRV) studies. A 6-cm sleeve catheter measured average EGJ pressure during resting, peak inspiratory EGJ pressures during sinus arrhythmia maneuver (SAM) and inhalations under 17-, 35-, and 70-cmH2O loads (TH maneuvers), and along 1 h after a meal. GERD patients entered a 5-days-a-week IMT program. One author scored heartburn and regurgitation before and after IMT. IMT increased average EGJ pressure (19.7 Ϯ 2.4 vs. 29.5 Ϯ 2.1 mmHg; P Ͻ 0.001) and inspiratory EGJ pressure during SAM (89.6 Ϯ 7.6 vs. 125.6 Ϯ 13.3 mmHg; P ϭ 0.001) and during TH maneuvers. The EGJ-pressure gain across 35-and 70-cmH2O loads was lower for GERD volunteers. The number and cumulative duration of the transient lower esophageal sphincter relaxations decreased after IMT. Proximal progression of GER decreased after IMT but not the distal acid exposure. Low-frequency power increased after IMT and the higher its increment the lower the increment of supine acid exposure. IMT decreased heartburn and regurgitation scores. In conclusion, IMT improved EGJ pressure, reduced GER proximal progression, and reduced GERD symptoms. Some GERD patients have a CD failure, and IMT may prove beneficial as a GERD add-on treatment. crural diaphragm; GERD; lower esophageal sphincter; muscle training

Background: To evaluate the association between delays in obstetric care and neonatal near-miss mortality events and death in a public maternity referral center. Methods: This case-control study enrolled 142 neonates, meeting the near-miss criteria of 5-min Apgar < 7, weight < 1500 g, gestational age < 32 weeks, and use of mechanical ventilation or congenital malformation, as well as 284 controls (without the near-miss criteria), at a ratio of 1:2. After follow-up, the following outcomes were reclassified: survival of the neonatal period without the near-miss criteria (true "controls"), "near-miss," and "neonatal death." Maternal sociodemographic characteristics, prenatal care, and pregnancy resolution were evaluated. Pearson's chi-square and Fisher's exact tests were used. Simple logistic regression was performed to determine the association between the three delay factors with near-miss outcomes and/or neonatal death. The variables that had maintained values of p < 0.05 were subjected to multinomial logistic regression. Results: Comparisons revealed the following associations: for controls and near-miss events, delayed access to health services due to a lack of specialized services (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.8-5.1) and inappropriate conduct with the patient (OR, 12.1; 95% CI, 1.3-108.7); for controls and death, absent or inadequate prenatal care (OR, 3.3; 95% CI, 1.6-7.1) and delayed access to health services due to a lack of specialized services (OR, 2.5; 95% CI, 1.1-5.6); and for near-miss events and death, absent or inadequate prenatal care (OR, 2.2; 95% CI, 1.0-5.0). Logistic regression for the combined outcome (near-miss plus neonatal deaths) revealed absent or inadequate prenatal care (OR, 1.9; 95% CI, 1.2-2.8), lack of specialized services (OR, 2.8; 95% CI, 1.7-4.5), and improper conduct with the patient (OR, 10.6; 95% CI, 1.2-91.8). Conclusions: The delays in obstetric care associated with the presence of near-miss and/or neonatal death included absent or inadequate prenatal care, delayed access to health services due to a lack of specialized services, and inappropriate conduct with the patient.

SUMMARY Background

There are anatomical changes and functional failure of the CD in esophagitis patients supporting the possibility of a skeletal muscle deficiency in GERD.

We investigated infants with respiratory distress within 4 days of birth whose mothers had not received antibiotic prophylaxis to evaluate the frequency and etiology of bacterial infection and associated risk factors. The study was conducted on 261 infants suffering respiratory distress admitted to a Brazilian neonatal intensive care unit, 94 per cent of whom were born prematurely. Gestational and delivery history; bacteriological cultures of blood, cerebrospinal fluid, tracheal aspirates and urine; complete and differential blood counts; a urinary group B streptococcal latex antigen test; and a chest radiograph were analysed. Indications of infection were found in 38.7 per cent and confirmed in 11.9 per cent of the neonates. Gram-positive (70.9 per cent) and gram-negative bacteria (29.1 per cent) were found in 31 cases of confirmed early bacteremia. Group B Streptococcus was the predominant causative agent (19.4 per cent) in infants exhibiting confirmed infection. Culture-proven infection was more frequent among infants delivered vaginally (adjusted OR = 2.53, p = 0.05) or born to mothers with signs of intra-amniotic infection (adjusted OR = 2.83, p = 0.04). Preventive measures against early bacterial infection in preterm infants from this population are strongly warranted.