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The increased availability of noninvasive breath tests, each with limitations, has led to widespread testing for small intestinal bacterial overgrowth (SIBO) in patients with non-specific gastrointestinal complaints. The lactulose breath test (LBT) is based upon an incorrect premise and therefore incorrect interpretations which has resulted in the over-diagnosis of SIBO and the excessive use of antibiotics in clinical practice. Despite limitations, the glucose breath test (GBT) should be exclusively employed when considering SIBO in appropriately chosen patients. This review suggests guidelines for the optimal use and appropriate interpretation of the GBT for suspected SIBO. The LBT should be discarded from future use, and the literature based upon the LBT should be discounted accordingly.

The demand for construction firms’ corporate social responsibility (CSR) has been growing in response to the different expectations and needs of organizational stakeholders. Given the compl...

In their article "Use of the Functional Lumen Imaging Probe in Clinical Esophagology," Savarino et al. report the outcomes of a Grading of Recommendations Assessment, Development, and Evaluation analysis performed by experts in the use of functional lumen imaging probe (FLIP) evaluation of esophageal disorders. For essentially all clinical indications, the recommendation for use was conditional with a very low quality of evidence. FLIP is an expensive, invasive technology examining limited aspects of esophageal function. Its role in complementing or replacing existing technology is uncertain, particularly when compared with manometric testing with additional provocative studies. Performing properly designed studies to demonstrate FLIP's true effectiveness and cost-effectiveness will be costly.

Contributing to the development of employment requirements as an emerging theme in social procurement theory and addressing the evidence vacuum in social procurement research and policy relating to...

Inflammatory bowel disease (IBD; Crohn’s disease, CD and Ulcerative colitis, UC) and irritable bowel syndrome (IBS) have overlapping symptoms. Few prevalence studies of IBS in quiescent IBD have used colonoscopy with histology to confirm inactive disease. The aims were (1) to determine the percentage of IBD patients in deep remission whose persistent IBS-like symptoms (IBD/IBS+) would cause them to be classified as having active disease, based on the calculation of Harvey Bradshaw Index (HBI) or UC disease activity index (UCDAI); (2) to identify demographic and disease characteristics that are associated with IBD/IBS+. This was a prospective study at a single tertiary care IBD center. 96/112 patients with colonoscopy and histology confirmed quiescent disease consented and completed Rome III criteria for IBS Survey, and the hospital anxiety and depression scale (HADS). Other demographic and disease specific data were collected. 36% (28/77) and 37% (7/19) of CD and UC patients, respectively, met diagnostic criteria for IBS. Significantly higher HBI/UCDAI scores (p = 0.005) and low short inflammatory bowel disease questionnaire (SIBDQ) scores (p ≤ 0.0001) were seen in IBD/IBS+ patients. 29% of patients in deep remission were mis-categorized by HBI/UCDAI as having active disease when they fulfilled Rome III criteria for IBS. Psychiatric diagnosis (OR 3.53 95% CI 1.2–10.2) and earlier onset of IBD (OR 1.056 95% CI 1.015–1.096) were associated with IBD/IBS+. Patients fulfilling IBS criteria had higher hospital anxiety and depression scale (HADS). IBD/IBS+ affect scoring of IBD disease activity scales and become less useful in guiding treatment plans.

The COVID-19 pandemic has introduced unique circumstances to women workforce in construction including the need to work from home, changes in job situations and family responsibilities following the lockdowns. This exploratory study was conducted around six months into the pandemic in examining the changes of their job situations, and their perceptions of career aspects during the pandemic. The results show that most respondents were employed full-time at the time of survey, and that there were profound changes to their work location and working hours including working from home and worked more hours than usual. Their perceived negative impacts of the pandemic on their capacity to engage in paid work activities due to caring responsibilities, pay or earnings, job security, and career progression and advancement are modest. They were also seemingly confident in staying in their job in the next 12-month. Their perceptions have been found significantly associated with their age, education level, and years of experience in the industry. These findings provide a critical insight on women’s job situations in the industry during the pandemic, with implications for human resource practices towards addressing the challenges in retention of women workforce during and post COVID-19 pandemic.

Background Esophageal hypercontractility (EHC) is considered a major esophageal motor disorder of unclear etiology. Different mechanisms have been proposed, including an imbalance in inhibitory and excitatory esophageal innervation. We hypothesized that patients with EHC suffer from cholinergic hyperactivity. Aim To interrogate the excitatory and inhibitory neurotransmission in EHC by assessing the esophageal motor response to atropine (ATR) and cholecystokinin (CCK), respectively, in EHC patients. Method We retrospectively reviewed patients who underwent high-resolution manometry (HRM) with pharmacologic challenge in a tertiary referral center between 2007 and 2017. We identified 49 EHC patients who were categorized based on frequency of hypercontractile peristaltic sequence into "frequent" and "infrequent" and motility diagnosis groups. Deglutitive pressure metrics and esophageal motor responses to ATR (12 mcg/kg iv) and CCK (40 ng/kg iv) were analyzed across groups. Results Atropine abolished hypercontractility across all groups studied, converting nearly half of patients to a motor pattern of ineffective esophageal motility. Abnormal CCK responses primarily occurred in the patient groups with concomitant outflow obstruction. Conclusions Hypercontractility is cholinergically mediated in all esophageal motor disorders. Most patients with isolated EHC appear to have excessive cholinergic drive, rather than loss of inhibitory innervation, and might be candidates for treatment with anticholinergic agents.

Functional lumen impedance (FLIP) technology has become commercially available to assess structural and motor abnormalities of the esophagus. Increasing numbers of papers have described novel findings with this technology. This review examines the validity of the FLIP technique, how it compares with existing diagnostic modalities, and evidence to date on diagnostic accuracy. FLIP studies require deep sedation at the time of endoscopy to complete. They assess a simulated state of esophageal obstruction in only a distal part of the esophagus rather than deglutitive motor function of the entire esophagus. The available normative dataset is small and not matched to the older age of patients typically being evaluated. The test-retest agreement in health and disease is unknown, as is the operator dependence on performing and interpreting findings. Studies to date have largely excluded patients with structural disorders, which FLIP cannot reliably distinguish from motor disorders. FLIP is an expensive technology that has been made clinically available without its true utility being established. For FLIP to be deemed a device ready for widespread clinical use, additional studies on validity, diagnostic accuracy, and outcomes need to be performed. Prospective clinical studies need to include all patients and assess the incremental cost-effectiveness of FLIP over more innovative use of existing technology, such as high-resolution manometry with provocative challenges.

Project management literature has long argued that inter-organizational justice is a key driver of successful construction project delivery. It is argued that when people believe business transactions are fair, they are more likely to exhibit positive organizational citizenship behaviors such as working harmoniously, giving discretionary effort, respecting others, and collaborating to resolve problems. However, there has been little empirical evidence to support these assertions. To address this knowledge gap, an online survey of 135 consultants, contractors, subcontractors, and suppliers from across the construction project supply chain was undertaken. The results show that project participants' organizational citizenship behaviors are influenced by their perceived interpersonal justice in business transactions. However, the findings also offer a more nuanced understanding of the complexities and inter-connectedness of these relationships in showing how one type of inter-organizational justice acts on another in influencing project organizational citizenship behaviors. The results indicate that interpersonal justice is a key ingredient in bringing about positive organizational citizenship behaviors in construction projects and that project performance can be enhanced if project managers treat project participants with politeness, respect, and dignity.

Corporate sustainability demands the integration of environmental performance, social justice and economic efficiency and, into company's operational practices. Construction companies are increasingly under pressure to commit to and report on the overall sustainability performances of operational initiatives. The aim of this paper is to investigate the sustainability performance of the top 50 construction contractors listed by Engineering News Record (ENR) against the triple bottom line. Under this aim, the specific objectives are: (i) examine the approaches adopted by construction firms to disclose their commitments to sustainability; (ii) review the firms’ annual and sustainability reports; and (iii) analyse the sustainability performance of construction firms against the GRI (Global Reporting Initiatives) guidelines. This study adopted survey design in which data were collected by reviewing publicly available organisational documents. Afterward, content analysis was conducted. The results indicate that financial performance is still the main target of most organisations. European contractors are considered best and Australasian contractors on the other side are considered as worst in reporting sustainability initiatives.

Interest in Corporate Social Responsibility (CSR) is growing in the construction sector. In response to societal changes, construction professionals and the businesses they work in are expected to contribute positively to the environments and communities in which they build. Hitherto, it appears that there has been little research in mapping out the CSR focuses and initiatives of construction and engineering firms. In addressing this gap, 104 professionals from across the construction supply chain in Australia and New Zealand was undertaken. The overall results reveal that many firms’ CSR focuses are mainly on occupational health and safety, ethical business practices and environmental management and that their CSR initiatives are very much internally focused. Companies have generally focused on their CSR workplace, supply chain and environmental initiatives and largely ignored the mutuality of interests between the community and business. In moving CSR in the construction sector forward, it is argued that the industry must move from altruism to strategy and from a client focus to a community focus.

Background Absent esophageal contractility (AC) is distinguished from type 1 achalasia (ACH1) during high-resolution manometry (HRM) on the basis of normal or elevated deglutitive integrated relaxation pressure (IRP) values. However, IRP measurements are subject to pressure recording error. We hypothesized that distinctive responses to pharmacologic provocation using amyl nitrite (AN) and cholecystokinin (CCK) could reliably distinguish AC patients from those with ACH1. Aim To compare esophageal response with AN and CCK in a well-defined cohort of ACH1 and AC patients. Method All available clinical, radiographic, endoscopic, and manometric information in 34 patients with aperistalsis was reviewed to determine the final diagnosis of ACH1 and AC. The differences in response to provocative challenges with the rapid drink challenge (RDC) test and administration of AN and CCK were compared between these two groups. Results Eighteen patients were diagnosed with ACH1 and sixteen with AC. While IRP values were significantly higher in ACH1, the standard criterion value misclassified four AC patients as having ACH1 and five ACH1 patients as having AC. IRP values on the RDC did not accurately segregate AC from ACH1, but we were able to identify AN and CCK esophageal motor response criteria that allowed correct classification of ACH1 and AC patients. Conclusions Nearly a quarter of AC and ACH1 patients may be misdiagnosed based on manometric IRP criteria alone. Differences in the esophageal motor responses to AN and CCK have the potential to facilitate the correct diagnosis in these challenging patients.

Background & Aims In some patients, the type 3 achalasia (A3) motor pattern may be an effect of chronic use of high-dose opioids. No motor findings have been identified to differentiate opioid-induced A3 (OA3) from idiopathic A3 (IA3). We investigated whether OA3 could be distinguished from IA3 on the basis of differences in esophageal motor responses to amyl nitrite, cholecystokinin, or atropine. Methods We performed a retrospective study of patients who received pharmacologic provocation during esophageal high-resolution manometry from 2007 through 2017 at a tertiary referral center. We identified 26 patients with IA3 (9 women; mean age, 68 ± 13 years) and 24 patients with OA3 (15 women; mean age, 59 ± 10 years). We compared pressure topography metrics during deglutition and after administration of amyl nitrite, cholecystokinin, or atropine between patients with OA3 vs IA3. Results Amyl nitrite induced a similar relaxation response in both groups, but the rebound contraction of the lower esophageal sphincter during amyl nitrite recovery, and the paradoxical esophageal contraction during the first phase of cholecystokinin response, were both significantly attenuated in patients with OA3. The second phase of cholecystokinin response in patients with OA3 was 100% relaxation, when present, in contrast to only 26% of patients with IA3. There was no significant difference between groups in inhibition of lower esophageal sphincter tone or esophageal body contractility by cholinergic receptor blockade. Conclusions Nearly half of patients with an A3 pattern of dysmotility are chronic, daily users of opioids with manometry patterns indistinguishable from those of patients with IA3. Patients with OA3 differ from patients with IA3 in responses to amyl nitrite and cholecystokinin. These findings might be used to identify patients with dysmotility resulting from opioid use.

BACKGROUND: The Chicago classification of esophageal motility includes a group of patients who show evidence of esophagogastric junction outflow obstruction (EGJOO) as demonstrated by elevated integrated relaxation pressure (IRP) and preserved peristalsis. Our aim is to classify EGJOO patients based on response to amyl nitrite (AN) during high-resolution manometry (HRM). METHODS: Patients were considered to have true EGJOO if elevated IRP during supine swallow persisted in the upright position and was associated with high intrabolus pressure. The EGJ response to AN was compared between patients with achalasia type-2 (A2) and normal esophageal motility. Based on the relaxation gain (deglutitive IRP – AN IRP) value that best discriminated these two groups (10 mmHg), patients with true EGJOO were categorized as being in either the AN-responsive (AN-R) or AN-unresponsive (AN-U) subgroups. KEY RESULTS: In the group of 49 patients with true EGJOO, the AN response classified 27 patients (IRP= 25 + 10 mmHg) with AN-R and 22 patients (IRP=20 + 5 mmHg) with AN-U (p=0.2). In AN-R, AN produced a relaxation gain and rebound after-contraction response at the EGJ comparable to A2 patients. AN-U patients had an elevated IRP after AN, and a relaxation gain similar to normal esophageal motility patients. AN-U patients were obese and had higher prevalence of sleep apnea (p

In Australia, it is not surprising to see tenants pay premium prices for the higher level of greenness of their office buildings. This is reflected by the ever-increasing number of environmentally friendly and energy efficient green buildings nationwide especially across the major Commercial Building Districts (CBDs). Nevertheless, the impact of tenants’ office leasing behaviours on rents have not been fully explored. To address this knowledge gap, a survey of tenants who have leased the Sydney CBD-located office buildings was undertaken. The collected data were analysed using Partial Least Square - Structural Equation Modelling (PLS-SEM) techniques to identify the relationships amongst various tenants’ leasing motivators, the level of greenness of their office buildings, and rents. The results show that tenants’ leasing decisions about the level of greenness of their office buildings do not significantly contribute to office rents. Instead, the conventional attribute of building quality (e.g. floor plate size and building amenities) significantly and positively influences office rents. It is also found that building quality, along with the building’s sustainability aspect (e.g. indoor environmental quality and CO2 emissions), is an important motivator for sustainability-focused organisations. However, the overall greenness level of office buildings is being considered as an important aspect for people-focused organisations rather than for sustainability-focused organisations. The results inform regulators and practitioners better-targeted strategies could be developed by understanding various tenants’ leasing motivators and their influences on the greenness level of office buildings and rents.The original version of this article supplied to AIP Publishing contained an error in the author’s name. The name originally appeared as Benson T. H. Kim, but the correct name is Benson T. H. Lim. An updated version of this article, with the author’s name corrected, was published on 7 August 2019.

Environmentally friendly and energy efficient green buildings have gained their popularity across many countries including Australia. Despite their increasing popularity and rental premium, it is not known why tenants are more inclined to lease green over non-green office buildings in Australia. In addressing this gap, this study aims to explore tenants’ motivations to leasing green office buildings. To this, this study first analysed over 2,000 tenants occupying over 100 green buildings in Sydney CBD.This allowed this study to identify which tenants are morelikely lease green buildings than the others. The results show that tenants from; (i) the Finance and Insurance services sector, (ii) the Professional, Scientific and Technical services sector, and (iii) Real estate services sector account for over 50% of the entire tenant sample. Then, a judgemental purposive sampling method was adopted, and nine interviews were conducted with the key leasing decision-makers from the top three sectors. The interview findings reveal that the traditional aspects of location and costs are still the key motivational factors for green building tenants. However, many interviewees acknowledge that leasing a green office space could help improving their corporate image. This thus led to many tenants’ beliefs that green spaces contain both symbolic value and tangible value,and that higher rents for green buildings are rather acceptable considering what they can offer. The results of the study suggest that understanding the demand of various types of tenants is essential to shed the light on the expensive rental price of green buildings in Australia. Refereed/Peer-reviewed

In the construction industry, the subject of corporate social responsibility (CSR) is becoming increasingly important as communities, employees and socially conscious clients expect firms to demons...

Purpose – Increasing workforce casualisation, under representation of women and other minority groups, racial discrimination, corruption and poor safety are just some of the documented examples of intra-organisational injustice in the industry. Typically these issues are problematised separately using different theoretical frameworks, yet at the most fundamental behavioural level they have a common cause which lies in the “unjust” treatment of one person by another. The purpose of this paper is to integrate the conceptual understanding of these hitherto separated but conceptually linked problems. Design/methodology/approach – A survey 135 consultants, contractors, subcontractors and suppliers from across the Australian construction supply chain. Findings – Surprisingly despite widespread academic concerns about injustice in the construction industry, there are not significant concerns within the industry community. Contrary to much research about the poor culture of the construction industry, the results indicate that the relatively low levels of perceived injustice are institutional rather than cultural. The research also highlights the plight of middle management, which appear to consistently suffer the highest levels of injustice across all its theoretical categories. Research limitations/implications – Sample size and Australian focus. Practical implications – Informs organisational policies to reduce injustice in the construction industry. Social implications – By reducing injustice, this research will improve the fairness of business practices in the construction industry. Originality/value – Application of justice theories to conceptualise unfair construction practices.

Background & Aims Breath tests for hydrogen and/or methane are used to detect small bowel bacterial overgrowth (SBBO), but false-positive results can arise from clinical conditions that accelerate small bowel transit and deliver unabsorbed glucose to the colon. We investigated the prevalence of false-positive results from glucose breath tests by also evaluating patients with scintigraphy. Methods In a retrospective study, we reviewed data from glucose breath tests performed with concurrent scintigraphy on 139 patients with suspected SBBO at the Medical College of Wisconsin from January 2003 through July 2013. Results from breath tests were considered abnormal (positive) if there was an increasing curve of hydrogen or methane by >15 parts per million above baseline within 90 minutes. Scintigraphy was used to determine whether this increase occurred before or after the glucose bolus arrived at the cecum. Data from a subset of 45 patients with prior upper gastrointestinal surgery were analyzed separately. Results Forty-six of the patients (33%) had abnormal results from breath tests. On the basis of scintigraphy findings, 22 of these patients (48%) had false-positive results, which were caused by colon fermentation of unabsorbed glucose. Colon fermentation caused false-positive results in 65% of patients who had undergone upper gastrointestinal surgery and 13% of patients without prior surgery. Patients with false-positive results caused by colonic fermentation had shorter mean oro-cecal transit times (18 minutes) compared with patients with positive breath-test results because of SBBO (79 minutes) or negative results (86 minutes). Conclusions Almost half of positive results from glucose breath tests are false because of colonic fermentation. All patients with abnormal results from breath tests should be considered for confirmatory repeat breath testing with concurrent scintigraphy to distinguish SBBO from colonic fermentation. Most patients who have undergone upper gastrointestinal surgery have abnormal results from breath tests and should be assessed by using concurrent scintigraphy with the initial breath test.

Purpose– The game-based learning has been used very successfully in some areas of formal education. In construction management, there is an increased uptake of games in teaching and learning. Focusing on a bidding game, the purpose of this paper is to evaluate its ability in enhancing students’ learning. The specific objectives are to: examine the effectiveness of the game as a teaching mechanism; explore students’ learning experience, preference and motivation to participate in the game; and identify the relationship between game features and students’ learning experience and overall satisfaction.Design/methodology/approach– This paper adopted a survey research design. A questionnaire survey was conducted in two universities in Australia, involving 100 students in the gameplay.Findings– The results show that the overall student feedback is positive with the vast majority of the students enjoying the learning experience. Students from both institutions have indicated their preference for group-based game sessions. However, the students have divergent opinions about the game incentive and motivation. It is found that there are significant correlations between some of the game features and students’ learning experience and overall satisfaction.Practical implications– The bidding game clearly has potential for adaptation in construction bidding-related courses. Educators could consider incorporating the significant game features towards improving students’ learning experience and overall satisfaction.Originality/value– Given there are limited studies that aimed at evaluating educational games, the student feedback in this research should facilitate more critical and reflective process for incorporating similar form of games in teaching construction management and bidding-related courses.

Background & Aims Normal responses of the upper esophageal sphincter (UES) and esophageal body to liquid reflux events prevent esophagopharyngeal reflux and its complications, however, abnormal responses have not been characterized. We investigated whether patients with supraesophageal reflux disease (SERD) have impaired UES and esophageal body responses to simulated reflux events. Methods We performed a prospective study of 25 patients with SERD (age, 19–82 y; 13 women) and complaints of regurgitation and supraesophageal manifestations of reflux. We also included 10 patients with gastroesophageal reflux disease (GERD; age, 32–60 y; 7 women) without troublesome regurgitation and supraesophageal symptoms and 24 healthy asymptomatic individuals (controls: age, 19–49 y; 13 women). UES and esophageal body pressure responses, along with luminal distribution of infusate during esophageal rapid and slow infusion of air or liquid, were monitored by concurrent high-resolution manometry and intraluminal impedance. Results A significantly smaller proportion of patients with SERD had UES contractile reflexes in response to slow esophageal infusion of acid than controls or patients with GERD. Only patients with SERD had abnormal UES relaxation responses to rapid distension with saline. Diminished esophageal peristaltic contractions resulted in esophageal stasis in patients with GERD or SERD. Conclusions Patients with SERD and complaints of regurgitation have impaired UES and esophageal responses to simulated liquid reflux events. These patterns could predispose them to esophagopharyngeal reflux.

Understanding the key features driving tenants' decision to or not to lease green and non-green buildings is important for building owners and developers- especially in today's era of sustainable development. Although evidence shown that green buildings could fetch a rental price premium over non-green buildings, it is not known as to what drives tenants' leasing decision. In addressing this gap, the aim of this study is to develop a conceptual framework for explaining tenants' leasing decision for green and non-green buildings. More specifically, it attempts to (1) identify key building features of green and non-green buildings, and external influences that could affect tenants' decision; and (2) review relevant theories underpinning tenants' behaviours. The research was conducted by using literature survey on related publications, including, but not limited to, books, journal articles, and market and government research reports. The review shows that building features could be broadly classified into: instrumental (i.e. tangible) and symbolic (i.e. non-tangible) aspects and that these two aspects could collectively influence tenants' decision to lease and pay the price premium for green over non-green buildings. In particular, tenants' decision on leasing green buildings might not be only driven by mandatory regulations or sustainability features but also by expectations to fulfil different, possibly conflicting, values, and willingness to portray their identity. To probe this, this conceptual framework integrates four different theories; Expectation-value theory, Push-pull theory, Symbolic self-completion theory, and Theory of bounded rationality. This framework will be tested in subsequent stages of the research project. Refereed/Peer-reviewed

Typical determinants of office building rental prices include location, height, age, and other tangible features of a building - and this is no exception to green buildings. Although evidence shown that green office buildings command rental premium than comparable non-green office buildings, literature could not fully explain causes of the higher rental prices. In addressing this gap, the aim of this research is to identify possible rental price attributes of green office buildings. More specifically, this study attempts to (1) analyse collective influence of various rental price attributes of green buildings, (2) review methods applied to probe the rental price attributes. The study was conducted by systematic review and meta-analysis on related literature. The result shows that literature identified rental attributes of green buildings using regression analysis, and these attributes are mostly indifferent to those of non-green buildings. Limited attention was given to attributes that are specific to green buildings. More specifically, green office building' symbolic aspect was not considered when analysing its rental premium. The result will be utilised in subsequent stage of the research project to probe the significance of its impacts. Refereed/Peer-reviewed

BACKGROUND Opioid receptors are present in the esophagus, and chronic opioid therapy may be associated with esophageal dysfunction. Given the current opioid epidemic in the United States, the potential contribution of opioids to esophageal dysmotility is important from both public health and patient care perspectives. Therefore our aim is to investigate the potential contribution of opioids to dysphagia and the prevalence of major motor disorders in patients undergoing manometric evaluation. METHODS The anonymized electronic medical records of patients linked to their de-identified high-resolution manometry (HRM) studies were reviewed. The patients were grouped based on their opioid exposure history at the time of HRM: opioid-naive and chronic daily users. The oral morphine milligram equivalent daily dose (MMED) of opioids was computed. KEY RESULTS: 10% of patients referred for esophageal HRM were taking opioid analgesics on a chronic daily basis, and they had a significantly higher prevalence of dysphagia than their opioid-naive counterparts. The chronic daily opioid users displayed a significantly higher prevalence of achalasia type 3 (ACH3) and esophagogastric junction outflow obstruction (EGJOO) motility phenotypes. The MMED of opioids was a significant predictor of esophageal pressure metrics and motility diagnoses (P

Under normal circumstances, the upper esophageal sphincter (UES) serves as an important gatekeeper, regulating antegrade and retrograde bolus movement through the upper aerodigestive tract. Dysfunction of the UES can result in multiple distressing symptoms and serious complications; accurate diagnosis is critical to appropriate management. The complex anatomy and physiology of the UES precludes any single available testing modality from completely assessing all aspects of UES dysfunction. This article provides an overview of the basic anatomy and physiology of the UES and reviews the advantages and shortcomings of the current techniques for evaluating its function.

Objectives/Hypothesis: Asymptomatic subjects volunteering for research studies are generally stratified as healthy based on a questionnaire, medical interviewing, and physical examination. The aim of this study was to evaluate the prevalence of upper gastrointestinal (GI) abnormalities in healthy asymptomatic volunteers using unsedated transnasal esophagogastroduodenoscopy (T-EGD) with an ultrathin endoscope as an additional screening tool. Study Design: A prospective study from one academic medical center with extensive experience in T-EGD. Methods: Consecutive 150 subjects volunteering for research studies were initially screened by using a gastroesophageal reflux disease (GERD) questionnaire, interviewing, and examination. Based on these, they were stratified as healthy asymptomatic volunteers or with GERD. Unsedated T-EGD was then performed by a faculty member who was blinded to the results of the initial assessment. Results: On initial assessment using GERD questionnaire, medical interviewing, and physical examination, of the total 150 consecutive research volunteers, 83 (average age 33 ± 16 years; 46 females, 37 males) subjects were healthy asymptomatic volunteers and 67 (average age 36 ± 15 years; 35 females, 32 males) had symptoms of GERD. On T-EGD, GI pathology was found in 15 of 83 (18%) healthy asymptomatic volunteers as compared to 24 of 67 (36%) stratified as having GERD (P < .01). The esophageal abnormalities found in healthy asymptomatic volunteers were esophagitis (13.3%), Barrett's esophagus (2.4%), hiatus hernia (2.4%), and gastritis (2.4%). Conclusions: A small but significant number of asymptomatic subjects have abnormal upper GI findings. Hence, transnasal unsedated endoscopy can be considered as a screening tool to stratify subjects as healthy, especially when considering them for research studies. Laryngoscope, 2012

The ability to predict and develop organizational flexibility is important for firms to survive and prosper in volatile business environments. The aim of this study is to investigate the constituents of and the constructs for predicting organizational flexibility. The specific objectives are to ascertain the relative importance of different constituents of flexibility and to construct and validate mathematical models to predict organizational flexibility of Singaporean construction firms. The research was conducted by a questionnaire survey and data were collected by face-to-face interviews with 41 construction industry experts. Three mathematical models were developed and validated by using the structural equation modeling (SEM) technique. The validation data consisted of ratings provided by four subject matter experts whose data were not used in the model development. The results show that the mathematical model for predicting strategic flexibility is able to predict to a good level of accuracy. The mod...

Human resource development (HRD) strategies are important to enable firms to recruit, retain and develop their employees. The aim of this study is to investigate the HRD of flexible construction firms in Singapore. The research was based on a questionnaire survey and data were collected via face-to-face interviews with 45 construction industry experts. Thirteen significant HRD practices were identified. The results show that the practices can be characterized along intra-organizational relationship management, competence development, performance management and stress management. A structural equation model was developed to explain the relationships between HRD strategies, employees’ soft skills and their resistance to change. It is found that firms’ competence development strategy has a significant positive impact on employees’ soft skills, and that employees who possess superior soft skills are less likely to resist change. It is recommended that contractors adopt some of these significant HRD practices ...

Flexibility has been touted as an important requirement for firms to survive and prosper in turbulent and volatile economic environments. The aim of this research is to investigate the relevance of organizational flexibility management to construction firms, because firms that are more flexible are more likely to survive and prosper than less flexible firms. More specifically, the objectives are to define a model that will allow contractors to understand the complex factors that contribute to organizational flexibility; ascertain whether organizational flexibility should be treated as a uni- or multidimensional construct; and identify the key determinants that drive organizational flexibility. A two-pronged research method with exploratory interviews and an industrywide survey was adopted. Data were collected from face-to-face interviews with construction industry experts. The data collection instrument for the survey was a structured questionnaire specifically designed for this study. By using structural...

PurposeContractors adopt various strategies to achieve their firms' objectives of continued existence and further development, and to guide the relationship between the firms and the business environment within which they operate. An economic recession drives firms to undertake unusual steps to survive within an environmental context. The purpose of this paper is to examine the survival strategies of Singapore contractors in the eight years of unprecedented recession in the industry from 1997 to 2005 are examined.Design/methodology/approachIn total, 34 interviews were conducted with senior executives of large and medium‐sized construction firms in Singapore to identify their survival strategies during the recession period.FindingsThree categories of strategies are identified: contracting‐related actions, cost‐control related actions, and financial‐related actions. The results show that most contractors opted to bid for more projects that are within their firms' resources and capabilities in contracting for jobs. To control cost, all contractors implemented stricter site management on material wastage, stricter financial management on firms' cash flow, stricter and procurement procedures. The majority of them froze salaries and stopped hiring. In order to remain solvent, most contractors set aside a sum of money from their reserves for unforeseen circumstances.Practical implicationsContractors should learn how to stay adequately lean in managing their business in order to be flexible and responsive to changes within the business environment. The findings highlight the importance of effective cost, risk, relationship and resource management.Originality/valueThe findings provide valuable lessons to construction firms in preparing for volatile market conditions during a recession.

Esophageal motor and sensory disorders are relatively rare conditions in the general population and afflicted patients are often initially misdiagnosed as having gastroesophageal reflux disease. Tests for these disorders have imperfect gold standards and are adjuncts to sound diagnostic reasoning. Treatments are palliative and have not been rigorously evaluated for some disorders. Symptoms and complications from disease progression and relapse are common, so that patients need continued follow-up.

Azathioprine and 6-mercaptopurine (6-MP) are effective in inflammatory bowel disease (IBD). However, between 10% and 29% of patients treated with these drugs are forced to stop therapy due to side effects. Pulmonary toxicity due to azathioprine/6-MP has been reported infrequently. We describe 3 patients who developed severe, noninfectious pulmonary toxicity within 1 month after the initiation of azathioprine or 6-MP for the treatment of IBD colitis (2 Crohn's disease and 1 ulcerative colitis). All patients presented with dyspnea, cough, and fever after initiation of azathioprine/6-MP. Evaluation for infectious etiologies, including bronchoscopy (3/3 patients) and open-lung biopsy (2/3 patients) was negative. Histopathologic examination of the lung biopsies revealed bronchiolitis obliterans organizing pneumonia in one, and usual interstitial pneumonitis in another patient. Cessation of purine analog therapy resulted in clinical improvement in all 3 cases. Azathioprine/6-MP-related pulmonary toxicity is a rare but serious side effect, and it is important for clinicians to have a high index of suspicion for this adverse reaction which occurs within 1 month after initiation of treatment for IBD.

Autonomic dysfunction is associated with a wide variety of gastrointestinal symptoms. It is unclear how many patients with autonomic dysfunction have slow or rapid gastric emptying. The aim of this study was to determine the prevalence of rapid and delayed solid phase gastric emptying in patients with autonomic dysfunction referred for evaluation of gastrointestinal symptoms and the association of emptying rate with clinical symptoms.Retrospective review of all patients with autonomic dysfunction who had a gastric emptying test from January, 1996 to March, 2005. Demographic data, clinical symptoms, composite autonomic scoring scale (CASS) score, and gastric emptying parameters were analyzed.Sixty-one subjects (women 49, age 42 [16-74] yr) with autonomic dysfunction were reviewed. Patients had mild-to-moderate (mean CASS score 3) autonomic dysfunction. Twenty-seven, 17, and 17 patients had rapid, normal, and delayed gastric emptying t(1/2), respectively. In addition, 10 patients had initially rapid emptying in phase 1, with subsequent slowing in phase 2 to produce an overall normal or delayed t(1/2). There was no difference in demographic data or CASS score among the three groups. More patients with initial or overall rapid emptying had diarrhea (70%) compared to patients with normal (33%) or delayed (33%) emptying (P= 0.018).Unexpectedly, more patients with autonomic dysfunction have rapid rather than delayed gastric emptying. The presence of diarrhea in patients with autonomic symptoms should prompt consideration for the presence of rapid gastric emptying. Conversely, the finding of rapid gastric emptying in patients with gastrointestinal symptoms should prompt consideration for the presence of underlying autonomic dysfunction.

Killian-Jamieson diverticulum is a outpouching of the lateral cervical esophageal wall adjacent to the insertion of the recurrent laryngeal to the larynx and is much less common in clinical practice than Zenkers Diverticulum. Surgical management of Killian-Jamieson diverticulum requires open transcervical diverticulectomy due to the proximity of the recurrent laryngeal nerve to the base of the pouch. We present a case of a Killian-Jamieson diverticulum associated with a concurrent large type III paraesophageal hernia causing significant solid-food dysphagia, post-prandial regurgitation of solid foods, and chronic cough managed with open transcervical diverticulectomy and laparoscopic paraesophageal hernia repair with Nissen fundoplication.

Previous studies of distensibility of the gastroesophageal junction (GEJ) in humans have not tried to distinguish between the effects of muscle action and passive elastic tissue properties of the GEJ. We studied 15 healthy subjects (ages 23–67 yr, 11 men/4 women) by using a catheter with a highly complaint bag positioned manometrically at the GEJ. The bag was distended with air at a rate of 20 ml/min while intrabag pressure was recorded. Distensions were performed during normal breathing, with breath held at maximum inspiration (MI) to activate the diaphragmatic crura, and with midesophageal balloon distension (BD) to relax the lower esophageal sphincter. In 10 subjects, distensions were performed after atropine injection (12 μg/kg iv). Pressure-volume curves and incremental distensibility values were calculated and compared among the different conditions. Both MI and BD significantly altered the slopes of the pressure-volume curves, whereas no effect was seen with atropine. Maximum distensibility was seen at the volume increment of 5–10 ml and was reduced with larger volumes. Distensibility measurements for the various test conditions tended to converge at the largest volume increment, suggesting that distensibility at this degree of distension was more related to the passive elastic properties of the GEJ. On the basis of these findings, we conclude that there can be significant active muscular contributions to recordings of distensibility at the GEJ, variations that must be controlled for during different study conditions.

The relationship between Helicobacter pylori infection and gastroesophageal reflux disease (GERD) remains controversial. Over 20 studies presented at the 2003 Digestive Disease Week meeting examined the implications of H. pylori infection for GERD. Although the findings were not uniform, most of the studies presented indicated a negative association between the presence of H. pylori and the presence of GERD symptoms, signs, or complications. In addition, eradication of H. pylori infection was related to the emergence of GERD and its complications. However, most studies favored a role for H. pylori rather than GERD in the development of pathologic changes in the gastric cardia. Finally, a few studies suggested the intriguing possibility that the modulation of GERD by H. pylori could be through the effects of H. pylori eradication on weight gain.