Incomplete Relaxation Research Articles

Surgical management of achalasia.

Achalasia is a chronic esophageal motility disorder comprised of ineffective esophageal peristalsis and incomplete relaxation of the lower esophageal sphincter. This disease had historically been managed through medical means as well as endoscopic dilations. However, surgical interventions are now considered standard of care, including minimally invasive Heller myotomy, which was popularized in 1990s, followed by per oral endoscopic myotomy in the 2010s. Both surgical approaches provide acceptable resolution of dysphagia symptoms. Classification of the achalasia as well as other patient-level factors may drive the clinical decision-making between the two approaches, as well as surgical training and surgeon preference.

BN SO25 - Laparoscopic Management of Achalasia and Iatrogenic Mucosal Perforation in a Patient with Severe Reflux Following Multiple Therapeutic Dilatations

Abstract Background Laparoscopic Heller's cardiomyotomy (LHC) is the gold standard intervention for achalasia. Owing to its well-established complications of reflux symptoms, some surgeons perform an additional fundoplication surgery, although the consensus regarding the clinical benefits of this approach remains unclear.1 A meta-analysis showed that posterior fundoplication has proven to be superior to anterior fundoplication in controlling reflux symptoms.2 Method A gentleman in his 60s reported ongoing severe reflux symptoms following multiple Rigiflex ballon dilatations for achalasia, on manometry and pH studies showed features of pathological acid reflux, incomplete lower oesophageal sphincter relaxation and defective peristalsis. As shown in the video, type 1 sliding hiatus hernia, submucosal fibrosis and peri-oesophagitis were seen intraoperatively. A short cardiomyotomy was performed, which was complicated by iatrogenic oesophageal perforation. Anterior fundoplication with mucosal closure was performed. Results Following the surgery, no leak was observed on the swallow test and the patient reported a massive improvement in reflux symptoms. The addition of fundoplication to LHC in patients with achalasia and reflux symptoms has improved clinical outcomes. Conclusion Concomitant LHC and anti-reflux surgery should be considered in patients presenting with achalasia and gastro-oesophageal reflux symptoms.

Delayed diagnosis and treatment of achalasia: a case report

BackgroundAchalasia is characterized as an esophageal motility disorder with incomplete relaxation of the lower esophageal sphincter. Achalasia can be associated with abnormal peristalsis and symptoms of dysphagia, acid reflux, and chest pain. The exact pathophysiology of achalasia remains unclear, but it is hypothesized to be due to degeneration of the myenteric plexus.Case presentationIn this case, a 46-year-old Hispanic man presented to the emergency room with a 12-year history of progressive discomfort with swallowing solids and liquids. Due to many years of incomplete follow-up care and lack of understanding of the course of his disease, this patient’s symptoms escalated to complete intolerance of oral intake and significant weight loss. He was diagnosed with achalasia during his hospital stay and treated successfully with laparoscopic Heller myotomy.ConclusionsThis case discussion illustrates the importance of follow-up care and patient education so that diagnosis and treatment of achalasia are not delayed.

Human HPSE2 gene transfer ameliorates bladder pathophysiology in a mutant mouse model of urofacial syndrome.

Rare early-onset lower urinary tract disorders include defects of functional maturation of the bladder. Current treatments do not target the primary pathobiology of these diseases. Some have a monogenic basis, such as urofacial, or Ochoa, syndrome (UFS). Here, the bladder does not empty fully because of incomplete relaxation of its outflow tract, and subsequent urosepsis can cause kidney failure. UFS is associated with biallelic variants of HPSE2, encoding heparanase-2. This protein is detected in pelvic ganglia, autonomic relay stations that innervate the bladder and control voiding. Bladder outflow tracts of Hpse2 mutant mice display impaired neurogenic relaxation. We hypothesized that HPSE2 gene transfer soon after birth would ameliorate this defect and explored an adeno-associated viral (AAV) vector-based approach. AAV9/HPSE2, carrying human HPSE2 driven by CAG, was administered intravenously into neonatal mice. In the third postnatal week, transgene transduction and expression were sought, and ex vivo myography was undertaken to measure bladder function. In mice administered AAV9/HPSE2, the viral genome was detected in pelvic ganglia. Human HPSE2 was expressed and heparanase-2 became detectable in pelvic ganglia of treated mutant mice. On autopsy, wild-type mice had empty bladders, whereas bladders were uniformly distended in mutant mice, a defect ameliorated by AAV9/HPSE2 treatment. Therapeutically, AAV9/HPSE2 significantly ameliorated impaired neurogenic relaxation of Hpse2 mutant bladder outflow tracts. Impaired neurogenic contractility of mutant detrusor smooth muscle was also significantly improved. These results constitute first steps towards curing UFS, a clinically devastating genetic disease featuring a bladder autonomic neuropathy.

Sexual function in women with endometriosis and pelvic floor myofascial pain syndrome.

To evaluate and compare the sexual function and pelvic floor muscles (PFM) function of women with endometriosis and chronic pelvic pain (CPP) with and without Myofascial Pelvic Pain Syndrome (MPPS). Cross-sectional study conducted between January 2018 and December 2020. Women with deep endometriosis underwent assessments for trigger points (TP) and PFM function using the PERFECT scale. Electromyographic activity (EMG) and sexual function through Female Sexual Function Index (FSFI) were assessed. Statistical analyses included chi-square and Mann-Whitney tests. There were 46 women. 47% had increased muscle tone and 67% related TP in levator ani muscle (LAM). Weakness in PFM, with P≤2 was noted in 82% and P≥3 in only 17%. Incomplete relaxation of PFM presented in 30%. EMG results were resting 6.0, maximal voluntary isometric contraction (MVIC) 61.9 and Endurance 14.2; FSFI mean total score 24.7. We observed an association between increased muscle tone (P<.001), difficulty in relaxation (P=.019), and lower Endurance on EMG (P=.04) in women with TP in LAM. Participants with TP presented lower total FSFI score (P=.02). TP in the right OIM presented increased muscle tone (P=.01). TP in the left OIM presented lower values to function of PFM by PERFECT (P=.005), and in MVIC (P=.03) on EMG. Trigger points (TP) in pelvic floor muscles (PFM) and obturator internus muscle (OIM) correlates with poorer PFM and sexual function, particularly in left OIM TP cases. Endometriosis and chronic pelvic pain raise muscle tone, weaken muscles, hinder relaxation, elevate resting electrical activity, lower maximum voluntary isometric contraction, and reduce PFM endurance.

In-vivo blood pressure sensing with bi-filler nanocomposite

Conductive elastomers present desirable qualities for sensing pressure in-vivo, such as high piezoresistance in tiny volumes, conformability and, biocompatibility. Many electrically conductive nanocomposites however, are susceptible to electrical drift following repeated stress cycles and chemical aging. Here we propose an innovative approach to stabilize nanocomposite percolation network against incomplete recovery to improve reproducibility and facilitate sensor calibration. We decouple the tunnelling-percolation network of highly-oriented pyrolytic graphite (HOPG) nanoparticles from the incomplete viscoelastic recovery of the polydimethylsiloxane (PDMS) matrix by inserting minute amounts of insulating SiO2 nanospheres. SiO2 nanospheres effectively reduce the number of nearest neighbours at each percolation node switching off the parallel electrical pathways that might become activated under incomplete viscoelastic relaxation. We varied the size of SiO2 nanospheres and their filling fraction to demonstrate nearly complete piezoresistance recovery when SiO2 and HOPG nanoparticles have equal diameters (≈400 nm) and SiO2 and HOPG volume fractions are 1 % and 29.5 % respectively. We demonstrate an in-vivo blood pressure sensor based on this bi-filler composite.

The relationship between sarcomerogenesis and the development of tissue organization of the myocardium in embryonic chicken cardiogenesis

Background. The general basis for understanding how the limited range of sarcomere contraction ensures cardiac output during systole is the analysis of the ontogenetic formation and local features of the development of the myofibrillar structure of cardiomyocytes by comparing the phase states of the myocardium. The purpose of the research is to determine phase and topological features and quantitative ultrastructural characteristics of sarcomerogenesis in cardiomyocytes of chicken embryos. Methods. Embryos of Cobb500 crossbred chickens were studied from the beginning of the 6th day to the 21st day of incubation. Ultrastructural features of contractile cardiomyocytes in different areas of ventricular and atrial myocardium in systole and diastole were studied using transmission electron microscopy. Results. At the 29th stage of development of chicken embryos in diastole, immature sarcomeres had different lengths. The average length of sarcomeres was 1.86±0.09 μm in the left ventricle and 1.91±0.21 μm in the right ventricle. At the 36th stage in the state of diastole, a significant increase in the length of sarcomeres was observed in the compact myocardium of the left ventricle and left atrium, while in the right parts of the heart, the increase in Z-Z distance was less active. In the right units of the heart, sarcomeres with unequal lengths were more often found in the compact myocardium and in the trabeculae. In different areas of the myolamella and trabeculae, the degree of relaxation of sarcomeres during simulation of maximum diastole was not the same. Incomplete relaxation of sarcomeres was noted in the initial and final sections of the muscle plates. In the middle part of the trabeculae, the length of the sarcomeres was significantly longer (1.82±0.04 μm), and in the intermediate (main) part of the muscle plates of the compact ventricular myocardium, the sarcomeres were 10.4% (p&lt;0.05) longer, than in their basis. Conclusion. By the end of prenatal cardiogenesis, the tangential orientation of the Z-discs of myofibrils and the shape of cardiomyocytes in systole was formed and strengthened due to the mutual displacement of neighboring myolamella during the counter-directional rotation of the basal and apical parts of the left ventricle during the shortening of sarcomeres to 1.83±0.04 μm. In the right ventricle and atrial myocardium, systolic contraction did not change the orthogonal orientation of telophragms and intercalated discs when sarcomeres were shortened to 1.79-1.84 μm. In the state of diastole, the orthogonal orientation of Z-discs is characteristic of contractile cardiomyocytes of all chambers when the length of sarcomeres reaches 2.17±0.07 μm in the intermediate part of the myolamella of both ventricles, 2.12±0.13 μm in the middle part of atrial and ventricular trabeculae, 2.02±0.10 μm at the base of trabeculae of all chambers and muscle plates of both ventricles.

Inverse Problem of Parameter Identification for Extended Compositional Gradient Model

In this study we address simulation of initial distribution of fluid composition in hydrocarbon reservoirs, particularly in scenarios where slow vertical segregation in a low-permeability near-critical reservoir results in an incomplete relaxation to the quasi-equilibrium state. To effectively analyze these complex scenarios, we propose an extended compositional gradient model that takes into account incomplete system relaxation. Practical application of the method involves solution of the forward problem of compositional profiling, with the model parameters adjusted according to real fluid samples. We formulate the inverse problem of parameter identification for the extended compositional gradient model and solve it using gradient-free optimization methods. The adjusted parameters are specific enthalpies of fluid components and the relaxation parameter. The overarching goal of parameter identification is to closely match the predictions of the model with real data, thereby enhancing the reliability of forecasts regarding distribution of fluid composition. We believe that the results of this study will significantly influence both understanding and simulation techniques for distribution of hydrocarbon components in natural reservoirs, particularly in situations characterized by incomplete system relaxation.

Feasibility of calculating rocuronium dosage by skeletal muscle weight in patients with obesity.

This study aimed to investigate the dose-response relationship of rocuronium administered based on skeletal muscle weight and to assess the feasibility of calculating rocuronium dosage by skeletal muscle weight in short surgeries for patients with obesity. This single-center, randomized controlled clinical trial included 71 patients with obesity aged 28-70 years, with body fat percentages (PBF) >20% in men and > 28% in women, ASA status I-III, scheduled for tracheoscopy. Patients were randomly allocated into two groups: skeletal muscle group (SM group) received rocuronium based on the skeletal muscle content (1.0 mg/kg, n = 31), and the conventional administration group (conventional group) received rocuronium based on total body weight (0.45 mg/kg, n = 30). General anesthesia was administered using the same protocol. Parameters recorded included patients' general condition, muscle relaxant usage, onset time of muscle relaxants, non-response time, clinical effect time, 75% recovery time, and recovery index. Additionally, occurrences of body movement, choking, and incomplete muscle relaxation during surgery were recorded. Compared to the conventional group, the SM group required significantly less rocuronium dosage, resulting in significantly lower non-response time, clinical effect time, 75% recovery time, and recovery index (p < 0.05), and the onset time is slightly longer. Neither group experienced body movement, choking, or incomplete muscle relaxation (p > 0.05). Utilizing skeletal muscle weight to calculate rocuronium dosage in short surgeries for patients with obesity can reduce dosage, shorten recovery time, and prevent residual muscle relaxation while achieving satisfactory muscle relaxation to meet surgical requirements.

Increased Chamber Resting Tone Is a Key Determinant of Left Ventricular Diastolic Dysfunction.

Twitch-independent tension has been demonstrated in cardiomyocytes, but its role in heart failure (HF) is unclear. We aimed to address twitch-independent tension as a source of diastolic dysfunction by isolating the effects of chamber resting tone (RT) from impaired relaxation and stiffness. We invasively monitored pressure-volume data during cardiopulmonary exercise in 20 patients with hypertrophic cardiomyopathy, 17 control subjects, and 35 patients with HF with preserved ejection fraction. To measure RT, we developed a new method to fit continuous pressure-volume measurements, and first validated it in a computational model of loss of cMyBP-C (myosin binding protein-C). In hypertrophic cardiomyopathy, RT (estimated marginal mean [95% CI]) was 3.4 (0.4-6.4) mm Hg, increasing to 18.5 (15.5-21.5) mm Hg with exercise (P<0.001). At peak exercise, RT was responsible for 64% (53%-76%) of end-diastolic pressure, whereas incomplete relaxation and stiffness accounted for the rest. RT correlated with the levels of NT-proBNP (N-terminal pro-B-type natriuretic peptide; R=0.57; P=0.02) and with pulmonary wedge pressure but following different slopes at rest and during exercise (R2=0.49; P<0.001). In controls, RT was 0.0 mm Hg and 1.2 (0.3-2.8) mm Hg in HF with preserved ejection fraction patients and was also exacerbated by exercise. In silico, RT increased in parallel to the loss of cMyBP-C function and correlated with twitch-independent myofilament tension (R=0.997). Augmented RT is the major cause of LV diastolic chamber dysfunction in hypertrophic cardiomyopathy and HF with preserved ejection fraction. RT transients determine diastolic pressures, pulmonary pressures, and functional capacity to a greater extent than relaxation and stiffness abnormalities. These findings support antimyosin agents for treating HF.

Influence of sublayer number on the ablative behaviors and synergistic effect of CVD-TaC/SiC alternate coatings

In this work, TaC/SiC alternate coatings with different sublayer numbers were fabricated on C/C composites by chemical vapor deposition, whose ablation resistance and defect tolerance under oxyacetylene torch can be improved by structural optimization. The two-layer sample with less layer number presented coating spallation owing to the incomplete relaxation of thermal stress, and the six-layer specimen exhibited mechanical denudation of TaC outer layer induced by its thinner thickness, which both indicate their inferior ablative performances. However, the toughness elevation of alternate structure, the synergistic effect of SiO2-Ta2O5 compound oxide and the sublayer reliability of TaC for anti-scouring as well as SiC for oxygen-barrier all result in the better ablation resistance of the four-layer specimen. These results can provide reference values for the structural design of high-temperature applications.

Comparison of the Clinical Efficacy, Safety, and Postoperative Outcomes Between Peroral Esophageal Myotomy and Laparoscopic Heller's Myotomy With Fundoplication: A Systematic Review.

Achalasia, a neurodegenerative disease caused by the progressive destruction of ganglion cells in the myenteric plexus, is accompanied by incomplete relaxation of the lower esophageal sphincter. Laparoscopic Heller's myotomy (LHM) coupled with fundoplication has been the gold standard procedure for achalasia. Peroral esophageal myotomy (POEM) has recently gained popularity as it is minimally invasive, has fewer adverse events, and has excellent short-term outcomes. So, we aimed to compare the clinical efficacy, safety, and postoperative outcomes between LHM and POEM. We did a systematic review by following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA)guidelines for 2020 and exploring research databases such as PUBMED and PMC Central, Google Scholar, and Research Gate. After appropriate screenings, articles relevant to the review were scrutinized based on the eligibility criteria. Quality assessment tools such as the Newcastle-Ottawa Scale (NOS) and theassessment of multiple systematic reviews(AMSTAR) were used to finalize the articles. A total of 11 articles (seven observational studies, two RCTs, and two systematic reviews) were included in the review after a quality check. The study included 2127 patients, classified into 981 for POEM and 1146 for LHM, who had undergone treatment for achalasia. Most of the studies had a follow-up of ≤ two years. Comparing efficacy, POEM had similar results to LHM in terms of Eckardt scores. However, abnormal DeMeester scores were found in POEM. Adverse events were significantly higher in LHM when compared to POEM in terms of safety. Peroral esophageal myotomy also stood out as having a shorter procedure time, a shorter hospital stay, and lesser odds of being a clinical failure. As for postoperative outcomes, despite treatment with proton pump inhibitors, LHM was more effective in preventing the development of esophagitis compared to POEM due to partial fundoplication.Postoperative reflux and the development of esophagitis remain certain with POEM and need to be followed up with more studies with longer follow-ups. However, POEM still stands as a better choice compared to LHM in terms of efficacy and safety.

FMRI with whole-brain coverage, 75-ms temporal resolution and high SNR by combining HiHi reshuffling and multiband imaging

Increasing the temporal resolution of the blood‑oxygen level-dependent (BOLD) response is usually accompanied by a decrease in repetition time and therefore also a reduction of the magnetic resonance (MR) signal due to incomplete T1 relaxation and thus a loss of signal-to-noise ratio (SNR). A previous data reordering method can achieve higher temporal sampling rate without the loss of SNR but at the cost of increased scan time. In this proof-of-principle work, we show that combining HiHi reshuffling with multiband acceleration allows us to measure the in vivo BOLD response with a 75-ms sampling rate that is decoupled from the acquisition repetition time (here 1.5 s and hence higher SNR) while covering the entire forebrain with 60 2-mm slices in a ~ 35-min scan. We provide single-voxel time-courses of the BOLD responses in the primary visual and primary motor cortices in three fMRI experiments on a 7 T scanner - 1 male (scanned twice on different days for test-retest reproducibility) and 1 female participant.

Peroral Endoscopic Myotomy (POEM) in a 19-Month-Old Girl with Primary Achalasia

Abstract Introduction Primary achalasia is an idiopathic motility disorder of the esophagus characterized by esophageal aperistalsis and incomplete relaxation of the lower esophageal sphincter (LES) in response to swallowing. The gold standard diagnostic method in adults is high-resolution manometry (HRM). Diagnostic criteria in adults are also used in children, but some HRM normal values may change depending on age. Case Report A 15-month-old girl was admitted to the hospital for evaluation due to persistent vomiting since birth. Vomiting included what she ate regardless of the amount of food she consumed. Barium esophagography revealed barium retention, esophageal dilatation, and a “bird's beak appearance” in the distal esophagus. Esophagogastroduodenoscopy revealed stenosis in the lower esophagus and bubbles at the esophagogastric junction.In HRM, the resting LES pressure was 43.4 mm Hg, there was pan-esophageal pressurization with 60% of swallows and no normal peristalsis. The patient was diagnosed with type II achalasia based on the Chicago 3.0 classification.First, the tube was inserted to ensure adequate nutrition of the patient, and approximately 4 months later, when the patient was 10 kg, the peroral endoscopic myotomy (POEM) procedure was performed.No complications developed during and after the procedure. At the 6th month after treatment, the patient was completely asymptomatic and her weight was within normal limits for her age. Conclusion POEM is an effective and safe method in the treatment of pediatric patients with idiopathic achalasia.

Anaesthetic management and associated complications of per-oral endoscopic myotomy (POEM) procedure in a patient with achalasia cardia type II: A case report

Achalasia, a benign motility disorder of the esophagus, results in incomplete relaxation of the lower esophageal sphincter (LES) and absent peristalsis. Patients experience dysphagia, regurgitation, chest pain, weight loss, and heartburn. Pharmacological therapy has been unsatisfactory and definitive treatment has focused on mechanical disruption of the tight LES. Peroral endoscopic myotomy (POEM) is a safe and minimally invasive modality regarded as the first line management of all types of achalasia. POEM is performed under general anesthesia with endotracheal intubation using an orally inserted gastrointestinal endoscope. Briefly, POEM involves endoscopic creation of a mid-esophageal submucosal incision, creation of a submucosal tunnel with the endoscope, and then a myotomy of distal circular muscles with a Triangular Tip electrosurgical (TT) knife, resulting in relaxation of the achalasia. We, hereby report a case of a patient with Achalasia Cardia Type II posted for POEM procedure under General Anaesthesia.

Characterizing the functional impact of embryonic myosin mutations in stem cell-derived skeletal muscle.

Divergent contractile properties of different myosins suggest that each isoform performs distinct functions in embryonic and adult skeletal muscles. To better understand the role of embryonic myosin heavy chain 3 (MYH3) in regulating skeletal muscle pattern formation, growth and regeneration, our group investigated the functional defects caused by multiple mutations. Our team generated human induced pluripotent stem cell (iPSC) lines bearing T178I or R672C mutations in MYH3. Human iPSCs bearing these mutations were differentiated into skeletal muscle and evaluated for differences in the structure, maturation and functional performance of the sarcomere. Isolated myofibril mechanics showed T178I myotubes generated significantly greater specific force compared to control myofibrils. Diseased myofibrils also expressed significantly slower rates of relaxation and prolonged thin filament deactivation compared to controls. Myofibril preparations were also used to compare ATP binding rates and showed homozygous R672C myofibrils have faster ATP binding rates compared to heterozygous and control preparations. When incorporated into 3D engineered tissues, these changes in MYH3 mechanics resulted in slower relaxation kinetics and an incomplete relaxation of the tissue in response to repetitive tetanic stimulation, which may explain the emergence of developmental contractures in patients possessing MYH3 mutations. Molecular dynamics simulations of R672C and T178I mutations in the post rigor state showed greater separation between the β-sheet and SH-Helix than in controls. Mutations also disrupted local salt bridges and hydrogen bond formation in some residues that help stabilize the nucleotide binding pocket and converter-connected helix. Interrupted structural communication between the nucleotide binding pocket and surrounding functional regions may underly the impaired relaxation phenotype. Ongoing studies will further characterize the effect of mutation on actin-myosin binding, crossbridge cycling kinetics, the maturation of skeletal myotubes over time, and myosin isoform switching dynamics.

Evaluation of Dysphagia and Inhalation Risk in Neurologically Impaired Children Using Esophageal High-Resolution Manometry with Swallowing Analysis.

Dysphagia in neurologically impaired children is associated with feeding difficulties, malnutrition and aspiration pneumonia. Esophageal high-resolution manometry (HRM) has been used in the diagnosis of motility disorders affecting the swallowing process. The aim of this study was to analyze swallowing functions in NI children by using HRM in order to establish swallow parameters identifying inhalation risk. Twenty-five NI children with cerebral palsy were submitted to esophageal HRM with UES analysis, comparing the results with non-NI children. The following parameters were evaluated: maximum pressure and duration of contraction of the velopharynx (VP) and tongue base (TB), and maximal, minimal, resting pressure and relaxation duration of the upper esophageal sphincter (UES). pVP max, pTB max, pUES max and resting pressure were lower, while p UES minimal was higher and relaxation duration was shorter in NI children vs. the control group. Predictive values of inhalation risk were evaluated. This study evaluates inhalation risk in NI children using HRM to study UES function. Our results confirm the alterations described in NI children: insufficient contraction and clearing force for bolus transmission through the pharynx and incomplete UES relaxation can predispose to pharyngeal residues and inhalation independently of swallowing because of lower values of UES resting.

Current Diagnosis of Achalasia: Beyond Standard High-Resolution Manometry

Achalasia is a rare esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter and absence of normal peristalsis. A precise diagnosis is crucial to successful treatment, and over the past few years significant advances have been made in how achalasia is diagnosed. Although high resolution manometry (HRM) is generally considered the gold standard diagnostic modality, manometric findings can be inconclusive and in some cases patients may not tolerate the procedure. Therefore, the addition of provocative maneuvers during HRM, and the use of timed barium esophagram and the functional lumen imaging probe (FLIP) are all important tools that have improved our ability to accurately diagnose achalasia. In this review, we go over the current approach to the diagnosis of achalasia.

Quality evaluation of berberine food supplements with high-field and compact 1H NMR spectrometers

Due to their health benefits, including regulating blood sugar and lowering cholesterol, berberine food supplements (FS) are widely used by consumers. This study aims to evaluate the quality of such products by proposing a new analytical methodology based on low-field NMR. Eighteen berberine FS were analyzed with both conventional (500 MHz) and benchtop (60 MHz) NMR spectrometers. Three quantitative 60 MHz 1H NMR methodologies were performed to determine berberine contents that were compared to those obtained at 500 MHz considered as reference measurements. To make the recording time of the spectra acquired at low field compatible with the requirements of a routine control, the quantification was carried out using a calibration curve established under conditions of incomplete relaxation of BrB protons. This methodology, applied to a test sample of 15 mg of FS, allowed to accurately measure a minimum quantity of berberine of ≈ 10 mg/capsule or tablet in 15 min. Regarding the FS, their labels are often unclear and/or incomplete for the consumer. Moreover, only 56 % of the FS analyzed actually contain the claimed quantity of berberine. The amounts of active they supply per day are extremely variable with only 39 % of the FS delivering a sufficient dose to achieve a hypoglycemic or hypolipidemic effect (1000–1500 mg/day based on literature data). These results show that health authorities should institute much stricter control and regulation over the production, labeling and marketing of berberine-based FS.

S2419 A Motility Study in a Patient With Isolated Diaphragmatic Agenesis: An Interesting Study in a Very Rare Entity!

Introduction: Diaphragmatic agenesis is a very rare congenital defect. Diagnosis is typically made in infancy and it is commonly associated with other congenital malformations and high mortality. However, it has also been described in the literature as a distinct clinical entity with potentially later in life diagnosis, as in the case reported here. Case Description/Methods: Our subject is a 57-year-old male who was diagnosed to have diaphragmatic agenesis at the age of 45 during a thoracotomy for a suspected diaphragmatic hernia. He presented to the gastroenterology clinic with a chief complaint of life-long intermittent but progressive dysphagia to both solids and liquids. Chest x-ray showed bowel loops and air-fluid level in the left-side of the chest with a cardiac and a mediastinal shift to the right side. Barium swallow was done and was negative for any abnormalities. A motility study was also done and with details showing in Tables 1-4 (Figure). Findings of the motility study are summarized as the following: 1) Normal resting pressure at lower esophageal sphincter with incomplete relaxation during swallows (high IRP), 2) Normal amplitude peristaltic contractions in esophageal body (Normal DCI), 3) Complete bolus transition, 4) Esophagogastric morphology I, and 5) Normal upper esophageal sphincter resting pressure. A chest X-ray obtained and attached in figure A shows the position of the probe used in the esophageal manometry with the gastroesophageal junction in the thoracic cavity. Figure B shows our patient's manometric study evaluating pressure changes that occurred during liquid swallowing. The diagnosis of esophagogastric junction (EGJ) outflow obstruction was made based on study results. Discussion: Esophagogastric junction outflow obstruction is a major motility disorder based on the Chicago Classification of esophageal motility disorders. This entity involves a heterogenous group of underlying etiologies with diaphragmatic agenesis being one potential but rare cause evidenced by our reported case. Management of (EGJ) outflow obstruction is dependent on the underlying etiology.Figure 1.: (Top) Motility study details. A) Chest Xray showing the position of the probe used in the esophageal manometry. B) Patient's manometric study evaluating pressure changes that occurred during liquid swallowing.