Chaperones and intimate physical examinations: what do male and female patients want?

INTRODUCTION: Many studies of patients' perception of a medical chaperone have focused on female patients; that of male patients are less well studied. Moreover, previous studies were largely based on patient populations in English-speaking countries. Therefore, this study was conducted to investigate the perception and attitude of male and female Chinese patients to the presence of a chaperone during an intimate physical examination. METHODS: A cross-sectional guided questionnaire survey was conducted on a convenient sample of 150 patients at a public teaching hospital in Hong Kong. RESULTS: Over 90% of the participants considered the presence of a chaperone appropriate during intimate physical examination, and 84% felt that doctors, irrespective of gender, should always request the presence of a chaperone. The most commonly cited reasons included the availability of an objective account should any legal issue arise, protection against sexual harassment, and to provide psychological support. This contrasted with the experience of those who had previously undergone an intimate physical examination of whom only 72.6% of women and 35.7% of men had reportedly been chaperoned. Among female participants, 75.0% preferred to be chaperoned during an intimate physical examination by a male doctor, and 28.6% would still prefer to be chaperoned when being examined by a female doctor. Among male participants, over 50% indicated no specific preference but a substantial minority reported a preference for chaperoned examination (21.2% for male doctor and 25.8% for female doctor). CONCLUSIONS: Patients in Hong Kong have a high degree of acceptance and expectations about the role of a medical chaperone. Both female and male patients prefer such practice regardless of physician gender. Doctors are strongly encouraged to discuss the issue openly with their patients before they conduct any intimate physical examination.

Influence of age on cerebral potentials evoked by oesophageal balloon distension in humans.

The recording of viscerosensory cerebral evoked potentials is a new field in the research on gastrointestinal perception. The aim of our study was to assess the relationships between age and peak amplitudes and latencies of cerebral potentials evoked by balloon distension of the human oesophagus. In 16 healthy volunteers (aged 21-59 years), cerebral evoked potentials were recorded from a midline scalp electrode, using a series of 50 rapid balloon inflations with 13 ml of air. Peak to peak amplitudes (N1-P1, P1-N2) and peak latencies (N1, P1, N2) were assessed. Inverse correlations were found between age and N1-P1 amplitude (P < 0.05), and between age and P1-N2 amplitudes (P < 0.05). N1 and P1 latencies were significantly longer in elderly patients (N1: P < 0.05; P1: P < 0.05). Amplitudes and peak latencies of cerebral potentials evoked by balloon distension of the oesophagus are age-dependent. In cerebral evoked potential studies, patients and healthy controls should be age-matched.

Temporal relationships between episodes of non-cardiac chest pain and abnormal oesophageal function.

Analysis of the association between symptoms and abnormal oesophageal function is a central part of 24 hour oesophageal pressure and pH recording in patients with non-cardiac chest pain. Such studies have used different time windows including a period after the onset of pain. Since stress and pain can induce oesophageal motor abnormalities and transient lower oesophageal sphincter relaxations, a proportion of the motor abnormalities and the reflux episodes observed after the onset of pain may be a consequence rather than the cause of that pain. This study aimed to assess this possibility in patients with chest pain that was presumed to be of oesophageal origin by comparing the results of analysis using time windows before and after the onset of pain. Forty eight patients experienced a total of 166 spontaneous chest pain episodes during 24 hour ambulatory monitoring. A time window beginning two minutes before and ending at the onset of pain (-2/0) was compared with a window beginning at the onset of pain and ending two minutes afterwards (0/+2). The percentage of episodes related to reflux, abnormal oesophageal motility, or neither were 22.9%, 24.7%, and 52.4% in the -2/0 time window and 9.0%, 22.3%, and 68.7% in the 0/+2 time window, respectively. However, 11 of the 37 episodes associated with abnormal motility in the 0/+2 time window were preceded by a reflux episode, and 19 of these 37 episodes had abnormal motility in the -2/0 time window. Consequently, in only seven of the 166 chest pain episodes (4.2%) in two patients were the findings consistent with secondary oesophageal motor disorders provoked by pain. Likewise, only six of the 166 chest pain episodes (3.6%) were consistent with reflux provoked by pain. These findings indicate that in patients with non-cardiac chest pain, gastro-oesophageal reflux and oesophageal motor abnormalities are rarely a consequence of the pain.

Esophageal dysfunction as a cause of angina pectoris ("linked angina"): does it exist?

PURPOSE: The differentiation between cardiac and esophageal causes of retrosternal chest pain is notoriously difficult. Theoretically, cardiac and esophageal causes may coexist. It has also been reported that gastroesophageal reflux and esophageal motor abnormalities may elicit myocardial ischemia and chest pain, a phenomenon called linked angina pectoris. The aim of this study was to assess the incidence of esophageal abnormalities as a cause of retrosternal chest pain in patients with previously documented coronary artery disease. PATIENTS AND METHODS: Thirty consecutive patients were studied, all of whom had undergone coronary arteriography. The patients were studied after they were admitted to the coronary care unit with an attack of typical chest pain. On electrocardiograms (ECGs) taken during pain, 15 patients (group I) had new signs of ischemia; the other 15 patients (group II) did not. In none of the patients were cardiac enzymes elevated. As soon as possible, but within 2 hours after admission, combined 24-hour recording of esophageal pressure and pH was performed. During chest pain, 12-lead ECG recording was carried out. RESULTS: In group I, all 15 patients experienced one or more pain episodes during admission, 25 of which were associated with ischemic electrocardiographic changes. The other two episodes were reflux-related. Only one of the 25 ischemia-associated pain episodes was also reflux-related, ie, it was preceded by a reflux episode. In group II, 19 chest pain episodes occurred in 11 patients. None of these was associated with electrocardiographic changes, but 8 were associated with reflux (42%) and 8 with abnormal esophageal motility (42%). CONCLUSION: Linked angina is a rare phenomenon.

What is the optimal time window in symptom analysis of 24-hour esophageal pressure and pH data?

Since noncardiac chest pain is the only well-established indication for 24-hr esophageal pH and pressure recording, the analysis of the association between chest pain episodes and esophageal motility abnormalities or reflux is the most important part of data analysis in 24-hr monitoring. Until now, different time windows have arbitrarily been used by various research groups. The aim of this study was to determine the optimal time window for symptom analysis in 24-hr esophageal pH and pressure monitoring. For this purpose repetitive symptom association analysis was carried out, using time windows of various onsets and durations. For each time window, the symptom indices for reflux and dysmotility were calculated. The symptom index for both reflux and dysmotility showed a gradual increase for windows with increasingly early onset, following a pattern that would be predicted on the basis of Poisson's theory. However, both indices had a relatively sharp cutoff point at 2 min before the onset of pain. Both indices only showed a predictable gradual increase when the time window starting at -2 min was extended beyond the moment of pain onset. It is concluded that the optimal time window for symptom analysis in 24-hr esophageal pH and pressure recording begins at 2 min before the onset of pain and ends at the onset of pain.

Ambulatory esophageal monitoring in noncardiac chest pain.

The esophageal origin of angina-like noncardiac chest pain can be identified with certainty only when spontaneous chest pain episodes are associated with gastroesophageal reflux, abnormal esophageal motility, or both. Since noncardiac chest pain typically occurs infrequently, prolonged monitoring is required to establish such an association. Ambulatory esophageal monitoring offers the additional advantages of studying the patient in everyday life and avoiding hospital admission. Although the amplification and storage of 24-hour signals in a portable recorder no longer poses technical problems, the complexity of the analysis of the recorded signals should not be underestimated. For noncardiac chest pain, the most relevant part of the analysis is the association between chest pain episodes and the recorded esophageal signals. To determine whether contraction amplitude or duration during chest pain episodes is abnormal, their measurements are compared with baseline values from the same patient. Fully automated analysis by computer is feasible and, since it avoids observer bias, preferable. The yield of 24-hour monitoring in noncardiac chest pain reported by different groups of investigators varies considerably. Motor abnormalities have been identified as the cause of chest pain in 4.5-18% of patients studied, and reflux in 4.5-25%. In addition, some patients had both dysmotility- and reflux-related pain episodes. As expected, the yield of the technique is higher in patients with frequent pain episodes. In patients who do not experience pain during 24-hour monitoring, the technique cannot provide a firm diagnosis of pain of esophageal origin. Recently, a much higher yield of 24-hour monitoring was reported in patients with noncardiac chest pain admitted to a coronary-care unit. A total of 76% of these patients were found to have either reflux- or dysmotility-related chest pain. Despite its relatively low yield, the addition of esophageal pressure monitoring to ambulatory pH monitoring is worthwhile and probably also cost-effective in patients with frequent episodes of unexplained chest pain.

Acute noncardiac chest pain in a coronary care unit. Evaluation by 24-hour pressure and pH recording of the esophagus.

Twenty-four-hour recording of esophageal pressure and pH was performed successfully in 41 patients admitted to the coronary care unit of a general hospital who had an episode of acute, prolonged retrosternal chest pain and who were initially suspected of suffering from coronary artery disease (severe angina pectoris, myocardial infarction), but in whom the pain was subsequently shown not to be of cardiac origin. The recordings were analyzed with fully automated techniques. A pain episode was considered to be related to abnormal esophageal motility when contraction amplitudes or durations in the pain episode exceeded the patient's upper limit of normal (97.5th percentile) or when the proportion of abnormal propagated contractions (simultaneous, nontransmitted) in the pain episode was significantly increased (chi 2 test). Thirty patients (73%) had one or more pain episodes (in total 63 pain episodes) during the 24-hour recording. Forty-three percent of the pain episodes was related to abnormal motility and 30% to reflux, and 27% was not related to esophageal function disturbance. Using the criterium that the symptom index had to be greater than or equal to 75%, it was found that the pain was related to reflux in 13 patients (43%) and to motor abnormalities in 10 patients (33%). It is concluded that in the majority of patients acutely admitted with noncardiac chest pain, esophageal motor abnormalities and reflux can be shown to be the likely cause of the symptoms.

Clinical application of 24-hour ambulatory esophageal pH and pressure monitoring.

Recently, 24-h recording of intraesophageal pH and pressure signals in ambulatory subjects has become possible. Several research applications of the technique have emerged, but until now only a few clinical applications have been established, the most important of which is noncardiac chest pain. In the computer analysis of the signals, the patient with noncardiac chest pain is used as his or her own control; motility and pH profiles during pain are compared with asymptomatic base-line values obtained from the same patient. Automated analysis by means of a computer avoids observer bias and saves time. By means of 24-h monitoring, motor abnormalities have been identified as the cause of the chest pain in 4.5% to 18% and reflux in 4.5% to 25% of the patients studied. In addition, patients were identified who have both dysmotility- and reflux-related pain episodes. The yield of 24-h monitoring is highest in patients who have frequent pain episodes. A high yield of 24-h monitoring was found in patients with noncardiac chest pain admitted to a coronary care unit. Seventy-six per cent of these patients were found to have either reflux- of dysmotility-related chest pain. Patients with proven coronary artery disease who do not respond well to adequate treatment frequently have gastroesophageal reflux (39%) or esophageal motor abnormalities (50%) as the cause of their ongoing pain attacks. In these patients, identification of the esophageal cause of the symptoms not only helps the physician to select the optimal treatment but also reduces the patient's need for medical care.

Familial occurrence of collagenous colitis. A report of two families.

Collagenous colitis is a rare condition characterized clinically by chronic diarrhea and histologically by a thickened subepithelial collagenous band in colonic biopsies in an endoscopically normal colon. Familial occurrence of collagenous colitis has to our knowledge never been described. Here we report two families in which two first-degree related members suffered from collagenous colitis. In one family, two sisters were affected by chronic diarrhea and autoimmune disorders such as thyroid disease, rheumatoid arthritis, and pernicious anemia. Collagenous colitis was diagnosed in one of these sisters, based on colonic biopsies. Colonic biopsies of the other sister showed microscopic colitis. Review of colonic biopsies of this patient taken 11 years earlier, however, showed definite histological features of collagenous colitis. In the other family, in a father and son, both with diarrhea for several years but not suffering from any other diseases, a diagnosis of collagenous colitis was made on colonic biopsies. Human leukocyte antigen (HLA) typing showed that only the HLA A2 antigen was present in all 4 patients.