Psychological and sex features of delayed gut transit in functional gastrointestinal disorders.

BACKGROUND: The relation of demographic and psychological factors to the presence and extent of gut transit impairment in the functional gastrointestinal disorders has received little attention. AIMS: To compare the psychosocial and demographic features of patients with functional gastrointestinal disorders and delayed transit in one region of the gastrointestinal tract with those displaying more widespread delayed transit (that is, delay in two or three regions), and those with normal transit in all three regions. PATIENTS: Of 110 outpatient participants who satisfied standardised criteria for functional gastrointestinal disorders, 46 had delayed transit in one region, 32 had delay in two or three regions, and 17 exhibited normal transit in all regions. METHODS: Transit in the stomach, the small intestine, and the large intestine was assessed concurrently using a wholly scintigraphic technique; psychological status was assessed using established psychometric measures. RESULTS: Patients with delayed transit displayed demographic and psychological features that contrasted with patients with normal transit in all regions. In particular, widespread delayed transit featured female sex, a highly depressed mood state, increased age, frequent control of anger, and more severe gastric stasis, while the features distinguishing normal transit were male sex and high levels of hypochondriasis. CONCLUSION: These data suggest the existence of a distinct psychophysiological subgroup, defined by the presence of delayed transit, in patients with functional gastrointestinal disorders.

Gastroparesis and small bowel dysmotility in irritable bowel syndrome.

Alterations in both gastric emptying (GE) and small bowel motility have been reported in irritable bowel syndrome (IBS); the relationship, however, between these different measures of upper gut motor function in IBS has not been assessed. The aims of this study were therefore: (1) to compare the prevalence and characteristics of altered small bowel motility in IBS patients with and without delayed GE; and (2) to assess the interrelationships between fasting and postprandial small bowel motility in IBS, accounting for delayed GE. Forty-four IBS patients and 25 healthy controls underwent 24 hr ambulant recording of interdigestive and digestive small bowel motility. On a separate occasion the IBS patients had GE of both solids and liquids measured by a dual-isotope scintigraphic technique. Thirty-nine percent of IBS patients had delayed GE. Patients with normal GE had no interdigestive small bowel abnormalities. However, in patients with delayed GE fasting phase II burst frequency was higher than in controls [median 0.21/hr (IQR 0.15-0.34) vs 0.06/hr (0-0,16), P = 0.004]. Postprandially, abnormal phase III-like activity was higher in diarrhea-predominant IBS patients (0-0.08/hr vs 0/hr, P = 0.01), than in patients with normal GE or controls. Furthermore, IBS patients with delayed GE did not have the normal correlation between fasting and postprandial motor parameters (percentage occurrence of clustered contractions, postprandial pattern duration vs preceding MMC cycle length). In conclusion, small bowel motor dysfunction occurs more frequently in IBS patients with concomitant gastroparesis than in patients with normal GE. These findings provide further evidence that a neuropathic process may contribute to the pathogenesis of IBS in a subgroup of IBS patients.

Measuring renal function in patients with diabetes mellitus.

We estimated the glomerular filtration rate in 33 patients from our diabetic clinic using three methods: the creatinine clearance measured from a timed urine sample and a serum creatinine; the creatinine clearance calculated from the serum creatinine according to the formula of Cockcroft and Gault; and, the plasma clearance of ethylenediaminetetra-acetic acid (EDTA) labeled with 51Cr ([51Cr]EDTA). We repeated the measurements in seven subjects. The measured creatinine clearance was not reproducible. The other two methods were correlated, but not according to the formula y = x. The calculated creatinine clearance significantly underestimated the [51Cr]EDTA clearance particularly at higher [51Cr]EDTA clearance rates. [51Cr]EDTA clearance has been shown by others to parallel, but underestimate, inulin clearance, the optimal method of estimating glomerular filtration rate but difficult to perform in routine practice. Accurately measuring renal function in routine clinical practice is difficult, and this must be borne in mind when making clinical decisions based on current measurements.

Comparison of optimised planar scintigraphy with SPECT thallium, exercise ECG and angiography in the detection of coronary artery disease.

BACKGROUND: Thallium SPECT has been shown to be more sensitive than planar imaging in the detection of coronary heart disease (CAD) in a number of reported series. Early (< 10 minutes) redistribution on planar imaging has been demonstrated in clinical studies and this may partly contribute to its lower sensitivity. AIM: To determine whether thallium SPECT is superior to planar scintigraphy (with the timing of imaging performed optimally so that it was commenced within five minutes of injection) in the detection of CAD. METHODS: Planar and SPECT studies were performed in 44 patients with significant (> 70% stenosis) CAD, seven patients with borderline stenoses (50-69%) and in 18 patients with no significant CAD. RESULTS: The sensitivity of planar imaging was 66% which was higher than exercise ECG 54% (ns) but significantly lower than SPECT 86% (p < 0.005). The specificity of planar thallium scintigraphy was 100% which was higher than SPECT (83%) and significantly higher than exercise ECG 72% (p < 0.05). SPECT had a significantly higher sensitivity for LAD and single vessel disease than planar imaging and this was unrelated to a history of prior myocardial infarction. CONCLUSION: Even when planar imaging is timed optimally to minimise the impact of early redistribution, SPECT is more sensitive than either planar imaging or exercise ECG in the detection of CAD, but its specificity is lower.

Diffuse femoral uptake on bone scan after fracture in an infant.

A case is described of a 21 month old infant with a fractured mid-shaft of femur following a fall. While the fracture was clearly visualised on X-ray, radionuclide bone scanning showed diffusely increased uptake throughout the femur with no focal uptake at the fracture site. Fractures of any etiology, including child abuse, should always be considered in the differential diagnosis of diffusely increased long bone uptake on bone scintigraphy in children.

Efficacy of cisapride therapy in functional dyspepsia.

AIM: To assess the efficacy of cisapride therapy in relieving symptoms of functional dyspepsia. METHODS: After a 2-week placebo run-in period, 61 out of 74 patients were eligible to enter a 4-week double-blind treatment phase, consisting of treatment with cisapride (10 mg) or placebo tablets t.d.s. Gastric emptying was assessed scintigraphically at entry to the study. Patients were stratified before treatment into those with or without active chronic (Helicobacter pylori) gastritis. Patients were also classified retrospectively into those with 'reflux-like' dyspepsia (n = 29) and those with 'motility-like' dyspepsia (n = 32). RESULTS: At the end of the active treatment phase, there was a similar significant (P < 0.001) reduction in total symptom score from baseline in both cisapride (8.9 +/- 0.5 to 5.8 +/- 0.6) and placebo (9.7 +/- 0.6 to 5.5 +/- 0.6) groups. Scores for heartburn and continual bloating were significantly reduced in the cisapride but not the placebo group; improvement was attributable to patients with normal, rather than delayed, rates of gastric emptying. For continual bloating, significant improvement also occurred in the cisapride subgroup without gastritis, but not in the subgroup with gastritis (mean symptom score reduction 0.48 +/- 0.18, P = 0.03). For global evaluation by the investigator and by the patient, the overall improvement rates were not statistically different between cisapride and placebo groups. In those with normal gastric emptying, however, there was a significant (P = 0.01) improvement in general well-being in the cisapride but not in the placebo group. CONCLUSIONS: We were unable to show major differences in the short-term efficacy of cisapride and placebo in functional dyspepsia. There were indications, however, of beneficial effects of cisapride over placebo in those with 'reflux-like' dyspepsia, and in those without gastroparesis.

A comparative study of the safety and efficacy of dysprosium-165 hydroxide macro-aggregate and yttrium-90 silicate colloid in radiation synovectomy--a multicentre double blind clinical trial. Australian Dysprosium Trial Group.

The aim of our study was to compare the safety and efficacy of a new preparation, Dysprosium-165 Hydroxide Macroaggregate (165Dy) with Yttrium-90 Silicate (90Y) for radiation synovectomy of the knee in patients with RA and OA. A multicentre double blind clinical trial with subjects randomized to receive 165Dy or 90Y was undertaken in Sydney, Melbourne and Perth. Seventy knees of 59 patients were studied, using as clinical end point measurements, pain in the knee on walking, pain in the knee at rest and stiffness in the knee after rest. Cytogenetic damage, knee retention and extra-articular spread of the radionuclide to regional lymph nodes, liver, urine and blood were evaluated. There was no significant difference in clinical response in the two treatment groups for either RA or OA. Chromosomal changes occurred with equal frequency and the knee retention and extra-articular leakage of radiocolloids to regional lymph nodes and liver were comparable in the two groups. For radiation synovectomy of the knee, 165Dy is at least as safe and as effective as 90Y and has the advantage of a short half-life (2.334 h) and hence requires a shorter period of post-injection immobilization and hospitalization.

Psychological symptom profiles in patients with chest pain.

Five-hundred and thirty-two patients with ischaemic-like chest pain referred for symptom-limited exercise thallium myocardial perfusion studies, were assessed on a range of psychosocial measures. Three groups of patients were identified on the basis of their perfusion studies: (1) normal thallium perfusion; (2) current myocardial ischaemia; and (3) past myocardial infarction (but no current ischaemia). There were no significant psychological differences between these groups on a wide range of measures which included depression, state and trait anxiety, Type A behaviour, personality, suppression of affect, locus of control, alexythymia, and hypochondriasis. Significant differences were identified, however, on measures of anger and coping style. Subjects with no current ischaemia (normal thallium perfusion and those with past myocardial infarction) had higher scores on 'immature coping' and 'anger in', than subjects with current myocardial ischaemia. These findings are discussed in the light of other published research.

Intragastric distribution and gastric emptying of solids and liquids in functional dyspepsia. Lack of influence of symptom subgroups and H. pylori-associated gastritis.

The relative contributions of altered gastric motor function and Helicobacter pylori-associated active chronic gastritis to the pathogenesis of functional dyspepsia are controversial. We therefore evaluated scintigraphically the intragastric distribution and gastric emptying of a mixed solid-liquid meal in 75 patients with functional dyspepsia; patients were subdivided on the basis of both specific symptom clusters and the presence or absence of H. pylori gastritis. Twenty-one (28%) patients displayed abnormal solid and/or liquid gastric emptying, with prolonged solid lag time the most prominent alteration detected. The number of patients with abnormal scintigraphic patterns increased to 36 (48%) when intragastric distribution parameters (fundal half-emptying time and antral maximal fraction) were examined. Although patients with reflux-like dyspepsia (N = 36) demonstrated significantly slower rates of liquid emptying at 45 and 70 min and a higher prevalence of abnormal liquid intragastric distribution when compared to patients with motility-like dyspepsia (N = 39) or to controls (N = 34), the absolute differences were small and unlikely to be of clinical significance. Patients without H. pylori gastritis (N = 50) demonstrated a significantly more prolonged solid lag time when compared to those with H. pylori gastritis (N = 25), but the difference was small and there were no other differences between these two subgroups.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional gastrointestinal disorders in unselected patients with non-cardiac chest pain.

Patients with non-cardiac chest pain (NCCP) (n = 387) and cardiac chest pain (CCP) (n = 93) were compared with community controls (n = 81), using a symptom questionnaire that assessed the presence of irritable bowel syndrome (IBS), functional dyspepsia, and oesophageal dysfunction and chest pain characteristics. A significantly (p < 0.05) increased prevalence of symptoms compatible with IBS occurred in NCCP patients when compared with those with CCP and with controls. Dysphagia was more frequent in both those with non-cardiac and cardiac chest pain than in controls; this was not apparent, however, when patients with concomitant IBS were excluded. The presence of oesophageal or gastrointestinal symptoms did not enable discrimination with regard to the chest pain characteristics. We conclude that unselected referred patients with documented NCCP are more likely to have IBS and that the presence of oesophageal symptoms such as dysphagia may merely reflect the spectrum of the 'irritable gut'.

Effects of cigarette smoking on solid and liquid intragastric distribution and gastric emptying.

BACKGROUND: The acute effects of cigarette smoking on gastric emptying are controversial, whereas its effects on the intragastric distribution of solids and liquids are not established. METHODS: Dual isotope gastric scintigraphy was performed in 15 habitual smokers (studied twice, either sham smoking or actively smoking) and in 15 age- and sex-matched nonsmokers. RESULTS: Acute smoking was associated with an increased prevalence of episodes of retrograde intragastric movement of solids (3 of 15 sham subjects vs. 12 of 15 actively smoking subjects; P < 0.01) and of liquids (0 of 15 vs. 7 of 15; P < 0.01) from distal to proximal stomach. Fundal half-emptying time (T1/2) for liquids was also prolonged by smoking (43 +/- 19 minutes sham vs. 125 +/- 216 minutes active; P < 0.05). Acute smoking delayed solid lag time (13 +/- 6 minutes sham vs. 32 +/- 18 active; P < 0.05) and liquid T1/2 (46 +/- 21 vs. 90 +/- 50 minutes; P < 0.05). In the nonsmokers, such episodes of proximal intragastric redistribution did not occur, and intragastric and overall emptying parameters did not differ significantly from those of habitual sham smokers. CONCLUSIONS: Acute cigarette smoking produces excessive antrofundal redistribution of both solid and liquid contents and delays solid and liquid gastric emptying.

Induction of micronuclei in peripheral blood lymphocytes of patients treated for rheumatoid or osteo-arthritis of the knee with dysprosium-165 hydroxide macroaggregates or yttrium-90 silicate.

The advantages of radiation synovectomy, using preparations containing dysprosium-165 (Dy-165), over conventional materials based on yttrium-90 (Y-90) include a more ideal spectrum of decay energies, and a much shorter half-life permitting quicker and more efficient treatment. A new therapeutic agent, Dy-165 hydroxide macroaggregates, has been developed for the treatment of arthritis making use of these advantages. As part of a clinical trial of this material 42 patients were examined for micronucleus frequency in their peripheral blood lymphocytes prior to, and 2 weeks after, radiation synovectomy using Dy-165 hydroxide macroaggregates or Y-90 silicate. In the majority of patients from each treatment group no significant increase in micronucleus frequency was observed. This indicates that in these cases leakage of material from the site of treatment was not resulting in detectable irradiation of circulating cells irrespective of the choice of radiopharmaceutical. The maximum increase in micronucleus frequency observed corresponded to a radiation dose to circulating cells of approximately 0.3 Gray.

Suppression of anger and gastric emptying in patients with functional dyspepsia.

Psychologic distress and gastric motor dysfunction have both been implicated in the pathogenesis of functional (non-ulcer) dyspepsia (FD). This study assesses the association between psychologic factors and gastric emptying in 28 FD patients. Subjects completed an extensive range of psychologic questionnaires and underwent dual-isotope scintigraphic assessment of solid and liquid gastric emptying. Attempts to resist, control, suppress, and hold in anger, to adopt a fighting spirit whilst dealing with chronic stressors, and manifest unhappiness were predictors of prolonged gastric emptying. These findings suggest that psychologic factors may be important in the aetiology of gastric stasis and subsequent upper gastrointestinal symptoms in patients with functional dyspepsia.

Does Graves' disease or thyrotoxicosis affect the prognosis of thyroid cancer.

Twenty-one patients who underwent surgical treatment for thyrotoxicosis and who were found at operation to have thyroid cancer are presented. Sixteen had Graves' disease and 5 had toxic nodular goiter. The group with Graves' is compared with 110 euthyroid patients with thyroid cancer who underwent their initial surgery in the same time period and who were of the same age (+/- 1 yr) and sex as the patients with Graves' disease. None of the thyrotoxic patients died during follow-up of 2-24 yr or developed subsequent metastases. The 1 patient with a local lymph node metastasis has not shown evidence of recurrence. Hypoparathyroidism appeared as a complication in only 1 patient. The size of tumors in the patients with Graves' disease was significantly smaller than in the euthyroid group. The course of the disease in both the patients with Graves' disease and the thyrotoxic group as a whole was relatively benign. This series does not support the recent suggestions that thyroid cancer in patients with Graves' disease is more aggressive than in either patients with toxic nodular goiter or euthyroid subjects. Patients with Graves' disease and thyroid cancer should be treated identically to other patients with thyroid cancer. Therapy should consist of total thyroidectomy followed by a postoperative 131I scan. Residual tissue or metastases found on the scan should be ablated with 6 GBq 131I. The patient should receive a suppressive dose of T4.

Late (one month) reversible ischaemia after primary coronary occlusion treated with recombinant tissue plasminogen activator (rTPA).

The incidence of reversible ischaemia was assessed four weeks after primary coronary occlusion in 36 patients who had not required earlier revascularisation after randomisation to receive rTPA (n = 19) or placebo (n = 17). Coronary arteriography was performed at three weeks and thallium scintigraphy with dynamic stress testing at four weeks. Patients were followed for one year without planned intervention in the absence of symptoms. Managing physicians remained blinded to thrombolytic therapy. Patency rate of the infarct related artery at three weeks was greater after rTPA (rTPA 16, placebo 9; p = 0.04). Reversible perfusion defects within infarct related artery territory occurred with similar frequency in both treatment groups (rTPA 7, placebo 8). Multivessel disease was frequent (rTPA 11, placebo 12) but associated with a low incidence of reversible perfusion defects outside infarct related artery territory (rTPA 3, placebo 2). Thallium scintigraphy identified six of seven patients requiring subsequent revascularisation (sensitivity 86%, specificity 59%, negative predictive value 94%). Dynamic stress testing was positive for reversible ischaemia in 28% (rTPA 6, placebo 4) and identified two patients requiring revascularisation (sensitivity 29%, specificity 72%, negative predictive value 81%). The greater patency rate achieved with rTPA at three weeks after primary coronary occlusion was not associated with a significantly greater incidence of reversible perfusion defects at four weeks in patients who had not required prior revascularisation. The absence of reversible perfusion defects at four weeks was associated with a low incidence of revascularisation procedures during one year follow-up.

Lack of association between gastric emptying of solids and symptoms in nonulcer dyspepsia.

Gastric motor dysfunction and concomitant gastric stasis have been implicated in the pathogenesis of nonulcer dyspepsia, but a cause-and-effect relationship is not established. Essential dyspepsia refers to a subgroup of nonulcer dyspepsia patients who have no evidence of irritable bowel syndrome, gastroesophageal reflux, or pancreaticobiliary disease. In 32 patients with essential dyspepsia, and 32 randomly selected dyspepsia-free community controls of similar age and sex, we measured gastric emptying of solids using Tc99m-Sulphur Colloid in a fried egg sandwich. Subjects with neuromuscular or other diseases that may alter gastric emptying were excluded. Symptoms were assessed by a standard questionnaire. Data processing was carried out "blinded" to the subjects' clinical status. Female patients took significantly longer to empty half the initial stomach activity (mean 90 min) than female controls (mean, 73 min; p = 0.02). The rate of emptying at 25 min was also significantly less in female patients than in controls. Female and male controls, and male patients, had similar emptying times. Delayed emptying was not associated with the occurrence of postprandial pain, belching, or nausea; there was a trend for the half-time rate of emptying to be greater in patients with abdominal distention. While gastric emptying of solids is slightly delayed in females with essential dyspepsia as a group, this may not explain their symptoms.

Comparison of the immediate and long-term effects of captopril and isosorbide dinitrate as adjunctive treatment in mild heart failure.

1. The efficacy of captopril and isosorbide dinitrate (ISDN) as adjunctive therapy to digoxin and diuretics in mild heart failure was compared in a double-blind study. 2. Twenty-one patients were randomly allocated to captopril (twice or three times daily) or ISDN. Eighteen patients completed a protocol of placebo run-in, dose titration and maintenance treatment for 3 months. 3. Symptom-limited exercise tolerance, ejection fraction and radionuclide indices of diastolic function estimated by gated blood pool scan did not change with either treatment. 4. Captopril improved functional class (Canadian Cardiovascular Society) and reduced requirements for increased diuretic dosage at both 1 and 3 months of maintenance treatment. Patients treated with ISDN required increased diuretic and did not improve their functional class. Differences between the treatments were significant only for diuretic dosage requirements. 5. We conclude that adjunctive therapy of mild heart failure with captopril administered twice daily provides a diuretic-sparing effect and may improve functional class during 3 months of maintenance treatment.

Iodine-131 uptake in inflammatory lung disease: a potential pitfall in treatment of thyroid carcinoma.

A mixed differentiated thyroid carcinoma was found in a small asymptomatic nodule in a 44-yr-old woman with recurrent chest infections and bronchiectasis. After total thyroidectomy and 162 mCi (6 GBq) radioiodine ablation there was uptake in the thyroid remnant and in both lungs, interpreted as lung metastases. In 2 years she received further three 162 mCi (6 GBq) doses of 131I, as scans showed very similar lung activity. Another scan, during thyroxin suppression, showed again activity in the lungs. A 47-yr-old male patient with similar respiratory disease and no history of thyroid disorder volunteered to undergo radioiodine scan while on triiodothyronine suppression. His scan, too, showed concentration in the lungs. The female patient died 7 years after the diagnosis of lung thyroid metastases was made. No metastasis was found at autopsy. Radioiodine lung uptake may occur in patients with chronic inflammatory lung disease, presenting a potential diagnostic pitfall in patients with differentiated thyroid carcinoma.