Supragastric belch may be related to globus symptom - a prospective clinical study.

BACKGROUND: The etiology of globus is poorly understood. It is controversial, whether gastroesophageal reflux disease (GERD) has a role in globus. To investigate the possible esophageal background of this symptom, we performed transnasal esophagoscopy (TNE), high-resolution manometry (HRM), and 24-h multichannel intraluminal impedance (MII) and pH monitoring on globus patients. METHODS: Thirty consecutive patients were referred to Helsinki University Hospital, Department of Otorhinolaryngology - Head and Neck Surgery for treatment of globus; 24 consecutive patients with difficult reflux symptoms from the Department of Surgery served as controls. We compared the results of the patient groups in endoscopies, HRM, and 24-h MII-pH monitoring. KEY RESULTS: In MII monitoring, globus patients had supragastric belch (6/20, 30% vs 1/24, 4%; p = 0.038) more often than controls. Total reflux time was higher in controls (p = 0.004), and they had more acid reflux events (p = 0.002) in MII, but between groups, the number of non-acid reflux events was similar. In pH monitoring, DeMeester score and total pH <4 time were higher in controls (P < 0.001). In HRM, the upper esophageal sphincter (UES) mean basal and residual pressures did not differ. CONCLUSIONS & INFERENCES: Supragastric belch was more common in globus patients, suggesting the possible role of this condition in globus sensation. However, globus patients in this series had no acid or non-acid GERD or elevated UES pressure.

Safety of formoterol after cumulative dosing via Easyhaler and Aerolizer.

This randomised, double-blind, double-dummy, cumulative dose, multicentre crossover study aimed to demonstrate non-inferiority in safety of formoterol delivered via Easyhaler versus Aerolizer. The secondary objective was to compare the efficacy of the devices. Thirty-three adult asthmatic subjects entered the study and 32 completed it. The study comprised screening and two study days, with each subject inhaling 96 microg (12, 12, 24 and 48 microg) cumulative dose of formoterol via the study inhalers. Serum potassium (S-K+), vital signs and spirometry were performed at baseline, 1h after each dose and additionally 4h after the last dose. The primary safety variable was S-K+. Secondary safety variables were heart rate, corrected QT interval, blood pressure, serum glucose and adverse events. Spirometry was assessed to evaluate efficacy. The results showed non-inferiority in safety of formoterol inhaled via Easyhaler compared to Aerolizer. The adjusted treatment difference in the S-K+ values after 96 microg cumulative dose of formoterol was 0.14 mmol/L being clearly above the pre-determined lower limit of the non-inferiority criterion of -0.2 mmol/L. There were dose-related changes in secondary efficacy variables after both treatments. The changes were comparable in most of the parameters but heart rate was statistically significantly higher and decrease in diastolic blood pressure greater after formoterol via Aerolizer than that via Easyhaler. The occurrence of adverse events was dose-related, the most common events being tremor, hypokalaemia, headache and palpitation. The spirometry results showed no statistically significant difference in efficacy between the treatments. In conclusion, formoterol delivered via Easyhaler was as safe as via Aerolizer.

Perception of esophageal manometry.

Esophageal manometry is an important investigation method but its direct impact on patients' well-being has not been studied. A structured questionnaire was given to all patients (n=92) after the manometry during one calendar year. The response rate was 91%. A total of seventy-one patients also reported their health status during the next 24 h. No serious side-effects were recorded. About half of the respondents regarded manometry as an easy or fairly easy investigation. The most common problems were irritation of nose and throat. In total, 48% of the respondents had mild to moderate late symptoms after manometry, usually soreness of the throat or nose lasting for some hours. The manometry was more troublesome to women than to men. It is concluded that esophageal manometry is generally a benign and fairly tolerated investigation, and the high level of anxiety that many patients show before the manometry is not well justified.

A teenager with an annoying cough.

Chronic cough is a stressful condition and can lead to extensive investigations. Bronchial asthma and postnasal drip syndrome are common causes, but sometimes the origin of cough is outside the respiratory tract (1,2). Such a relatively simple test as esophageal pH probing may suggest appropriate (antireflux) therapy.

Visual versus computerized analysis of upsloping ST segment depression in the exercise electrocardiogram.

A slowly upsloping ST segment depression is an abnormal, and a rapidly upsloping ST segment depression is a normal exercise ECG response. We investigated the agreement of expert physicians on the visual classification of the ST segment depression, and compared the (majority) vote with the computer-generated ST slope. A total of 206 exercise ECG leads with an amplitude of the ST segment depression > or = 0.15 mV and a ST segment slope > or = 0.5 mVs(-1) were evaluated. All three interpreters agreed in 68 cases, two agreed in 123 cases, and all disagreed in 15 cases. Intraobserver agreement was 61%. The ST segment slope was significantly (p < 0.001) greater in leads generally interpreted as rapidly upsloping (n = 38; 2.1 +/- 0.8 mVs(-1)), than in those interpreted as slowly upsloping (n 121; 1.3 +/- 0.6 mVs(-1)) or horizontal (n = 32; 1.1 +/- 0.4 mVs(-1)), although there was some overlap. Thus, standardization of the computer-assisted exercise ECG interpretation should be continued.

Thoracic gas compression profile during forced expiration in healthy and asthmatic schoolchildren.

Gas compression profile may aid in the diagnosis of airway obstruction. However, the behavior of this parameter in repeated tests and the deviations in patients with bronchial asthma have not been thoroughly described. Thirty-six health subjects aged 6-16 years were studied in two test sessions with a pressure/flow plethysmograph, and 57 asthmatic patients of similar age were studied once. Three volumes of compressed thoracic gas (Vcomp) were obtained: with 25%, 50% and 75% of vital capacity (VC) expired. Relative Vcomp was calculated using the actual amount of gas remaining in the lungs. Regarding the best and second best manoeuvre, coefficient of variation (CoV) in Vcomp ranged from 47 to 79% (controls) and from 48 to 112% (patients). Regarding the best manoeuvre in the first and second test session (controls), CoV in Vcomp ranged from 73 to 159%. Bronchodilator response had an extreme individual variation, and the changes were insignificant in both groups. In the paediatric population, the poor repeatability of Vcomp invalidates its use in clinical assessment of pulmonary function.

Diagnostic role of residual volume in paediatric patients with chronic symptoms of the lower airways.

In bronchial asthma, measurement of absolute lung volumes may reveal lung dysfunction more readily than forced expiratory spirometry. Sixty-one children (aged 4-16 years) with mild to moderate bronchial asthma and 35 children (aged 7-16 years) with other symptoms of the lower airways (OSLA) were studied, and the plethysmographic results were compared with data obtained from 36 healthy volunteers aged 6-16 years. In the first test session, repeatability of forced expiratory volume in one second (FEV1), forced vital capacity (FVC), residual volume (RV), functional residual capacity (FRC) and total lung capacity (TLC) were good. Control subjects were also tested the next day, and intra-subject variability of repeat pulmonary function testing was in the normal range. The FEV1/FVC ratio was significantly higher in control subjects than in patients with asthma or OSLA, but only the decrease in RV after bronchodilator challenge separated patients with asthma from patients with OSLA. Changes in FEV1 and RV after bronchodilator challenge had a significant, although low, inverse correlation. An increase of > or = 5% in FEV1 had a positive predictive value of 44% and a negative predictive value of 68% for the clinical diagnosis of bronchial asthma; for a decrease of > or = 24% in RV, the figures were 86% and 71% respectively. The support of baseline absolute lung volumes on clinical decision-making is not necessarily great. Bronchodilator response, particularly in RV, is more pertinent and may enhance the detection of reversible lung dysfunction.

QRS score as an indicator of myocardial viability after thrombolytic therapy.

Electrocardiographic estimation of myocardial injury has, in some studies, correlated poorly with the extent of nuclear perfusion defects at rest and with changes in the left ventricular ejection fraction after acute reperfusion therapy. The authors investigated 16 patients with fatty acid scintigraphy and with the Selvester-Wagner QRS score 2 weeks and 3 months after an anterior myocardial infarction. Segmental uptake on tomographic scans was semiquantitatively classified as low, moderate, or normal. The analysis included a total of 707 segments. QRS scores and the number of segments with low fatty acid uptake did not significantly change during the follow-up period, although the number of segments with moderate fatty acid uptake decreased from 15.9 +/- 5.1 to 12.4 +/- 5.7 (P < .05). The QRS score correlated significantly (rho = .56-.64) with low fatty acid uptake, but not with moderate fatty acid uptake. It is concluded that the QRS score is related to the degree of permanent myocardial injury, even after thrombolysis.

Fatty acid exercise scintigraphy after percutaneous transluminal coronary angioplasty.

We performed a sequential fatty acid exercise-rest scintigraphy in 18 patients with an initially successful percutaneous transluminal coronary angioplasty (PTCA) to study the concordance of trends in symptoms, exercise tolerance and myocardial metabolism. Eleven patients stopped the exercise because of angina pectoris in the preoperative test; 2 days after PTCA this number decreased to two, but again increased to eight 3 months later. Exercise time (9.7 +/- 0.6 min, mean +/- SEM) and maximum exercise heart rate (128 +/- 4 beats min-1) were at least as good immediately after the operation as originally (8.8 +/- 0.6 min and 121 +/- 4 beats min-1, respectively). After 3 months both parameters were significantly (P < 0.05) better (10.3 +/- 0.6 min and 136 +/- 4 beats min-1, respectively) than originally. Some relative improvement in washout was noticed in 61% 2 days and in 56% of cases 3 months after PTCA. Fatty acid exercise uptake was more homogeneous in 72% of cases immediately after angioplasty and in 44% 3 months later. The trend in fatty acid uptake, exercise characteristics, and also in symptoms was most favourable among the eight patients with a dilatated left anterior descending coronary artery. Although the gamma camera technique possibly underestimated the effects of angioplasty, the impaired fatty acid metabolism could be linked with persistent symptoms after the operation. We conclude that most patients can safely participate in a symptom-limited (maximal) ergometry test already 2 days after PTCA, and that postoperatively myocardial perfusion and metabolism improve rapidly. However, this advantage is eventually lost to some degree, even if exercise tolerance continues to improve.

Patency of the infarct-related coronary artery--a pertinent factor in late recovery of myocardial fatty acid metabolism among patients receiving thrombolytic therapy?

The decrease in mortality among patients receiving thrombolytic therapy for myocardial infarction is greater than would be expected from the improvement in left ventricular contractile function alone; thus some additional advantage of recanalization of the infarct-related coronary artery probably exists. Changes in the post-infarction myocardial metabolic state with respect to artery patency have not been studied with a gamma camera previously. A single-photon emission tomography scan using the fatty acid analogue para-123I-iodophenylpentadecanoic acid was performed at rest before hospital discharge on nine patients with first anterior myocardial infarction. All patients had received intravenous thrombolytic therapy at the beginning of the insult. The semiquantitative analysis of the left ventricle included a total of 44 segments in each patient. The test was repeated 3 months later, with the patients divided into two groups: six patients had an angiographically patent left anterior descending coronary artery (group A), and three an occluded artery (group B). In group A the number of myocardial segments with abnormal (< 70% of maximum) fatty acid uptake was initially 20.2 +/- 4.7 (mean +/- SD) and was reduced to 11.3 +/- 6.1 during the follow-up (95% confidence interval of the decrease 16.0-1.7 segments). In group B the number of these aberrant segments was fairly constant (21.7 +/- 13.1, initial test, and 21.3 +/- 13.3, retest). Our preliminary results suggest that even when thrombolytic therapy fails to prevent myocardial infarction, myocardial fatty acid metabolism has a better change of recovering if the relevant coronary artery has regained its patency.(ABSTRACT TRUNCATED AT 250 WORDS)

Inhomogeneous exercise uptake and accelerated washout of a radioiodinated fatty acid analogue in syndrome X. A SPECT study of the left ventricle.

Myocardial metabolism in exercise was determined by studying 21 syndrome X patients and 14 healthy volunteers with an aromatic fatty acid analogue IPPA and a gamma camera. We developed criteria for visual semiquantitative assessment of relative segmental radiotracer uptake and washout, and tested a new computer program for quantitative evaluation. One volunteer (7%) and 12 patients (57%) showed visually inhomogeneous uptake (p = 0.006, chi 2-test) in SPECT polar tomograms after a maximal ergometry test. Images in none of the volunteers and seven patients (33%) gave the impression of a slowed regional washout (p = 0.057). Only six patients (29%) had a normal radial polarogram. Patients with irregular coronary angiograms (showing 'slow flow' or minor sclerosis) and those with chest pain during the IPPA exercise test had a very low frequency of normalcy, but this was not significant. Total washout was higher in patients than in the reference population, as the exercise to rest activity ratio was 1.36 SD 0.13 versus 1.25 SD 0.11 in computerized quantitation (p = 0.015, t-test). Washout did not correlate with age, sex or exercise heart rate. Regarding computerized analysis of uptake and slow washout, the number of deviant segments was not significantly higher in patients than in reference population. Semiquantitative and quantitative analysis correlated in the assessment of uptake, but not in the assessment of washout. Possible reasons for the discrepancy are discussed. Conclusions of this study are not straightforward. Syndrome X was associated with inhomogeneous IPPA uptake, which is not at variance with the theory of microvascular dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)

False inferoposterior fatty acid uptake rest defects in patients with first anterior myocardial infarction.

Fatty acid scintigraphy is an interesting new technique for assessing the extent of myocardial infarction. We studied 19 patients with electrocardiographically verified first anterior myocardial infarction using radioiodinated phenylpentadecanoic acid and single photon emission computed tomography (SPECT). Besides the expected lesions in the territory of the left ascending coronary artery, a total of nine patients (47%) had severe (uptake < 50% of maximum) defects in the presumptive territory of the right coronary artery at rest. A link between the size of anterior injury and the occurrence of inferoposterior lesions was established. Over 20% paradoxical relative filling-in was seen in four of these inferoposterior defects in the subsequent exercise imaging, but only once anteriorly. Exercise-induced ischaemia (reduction in relative uptake > 20%) was demonstrated in 11 cases (58%). Ischaemia occurred most frequently in patients with small infarcts, and it did not coincide with the reversed redistribution. We conclude that the inferoposterior rest defects are unlikely to have been caused by technical artefacts or local injury, and should perhaps rather be linked with general strain in the left ventricle during the early phase of myocardial remodeling after anterior infarction. In any case, our results indicate that shortly after infarction myocardial viability should be evaluated very cautiously.

Diagnostic value of 123I-phenylpentadecanoic acid (IPPA) metabolic and thallium 201 perfusion imaging in stable coronary artery disease.

The diagnostic value of 123I-phenylpentadecanoic acid (IPPA) metabolic cardiac imaging was studied in a group (n = 29) of patients with angiographically confirmed CAD using single photon emission computed tomography (SPECT). A symptom-limited exercise test was first done with IPPA, and 2 days later with thallium. Medications were not withheld during testing. Fourteen healthy control subjects participated in parallel IPPA and 15 in thallium tests. Data acquisition and output were comparable in the two imaging modalities. By testing various relatively simple criteria for abnormality we found that the semiquantitative interpretation was more accurate than the visual readings. The best compromise of accuracy with the scored criteria consisted of a sensitivity of 86% and a specificity of 86%, obtained with IPPA polar tomograms (mild exercise defect) and a sensitivity of 86% and a specificity of 80% obtained with thallium (regionally decreased washout). With visual interpretation alone, a sensitivity of 83% and a specificity of 71% was detected with IPPA (mild exercise defect) and 72% and 73%, respectively, with thallium (partial reversibility). The sensitivity of the exercise ECG alone was 62%. The results of this study imply that IPPA imaging could be a rational, uncomplicated clinical method for non-invasive diagnosis of CAD. The diagnostic ability of IPPA is at least as good as that of thallium, and it is possible to use them in succession.

Assessment of the reproducibility of strength and endurance handgrip parameters using a digital analyser.

A group of 40 healthy individuals (27 women and 13 men) participated in a handgrip test and were retested 1-2 months later. A strain-gauge sensor with a digitised signal and computerized printout was used. A 5-s maximal squeeze test was first made three times, followed by one endurance test with 45%-55% power of the maximal value. The best maximal value was most often (42%) achieved in the third (initial test) or second (retest) attempt. The reproducibility of maximal value was very good; the Pearson correlation coefficient between initial test and retest (r = 0.98) was even slightly higher than in studies with older analogue instruments. The difference of maximal values [361 (SD 109) N, initial test and 368 (SD 110) N, retest] was insignificant. A moderate 12% long-term change in maximal value was statistically significant. Reproducibility of the power factor (integrated area of power with time) was also very good in this short test, correlating closely (r = 0.98-0.99) with the maximal value. Other indexes (grip rate, fatigue percentage and relaxation rate) were not stable enough to be practical. Endurance results were somewhat variable (r = 0.73), which implied in the main variable motivation. Only marked changes of over 50% in endurance were statistically significant. Endurance power increased significantly in the retest, which, in spite of an r-value of 0.82, would make its use in a follow-up study difficult. We found the computer-based handgrip test both precise and practical in assessing maximal voluntary strength; endurance was more difficult to reproduce.

QRS scoring with the Mason-Likar lead system at rest and during ischaemia.

The stability of the post-infarction simplified 29-point Selvester QRS score during maximal exercise testing was studied using both standard 12 and Mason-Likar (modified standard, M-L) ECG lead systems. Thirty-eight patients participated in the standard exercise test (mean interval after single infarction 4 months) and a total of 54 patients underwent exercise 201thallium emission tomography with M-L lead system 2 months later. None had electrocardiographic features complicating the scoring. There were no significant differences between the (paired) mean QRS scores, except between the M-L score at rest (2.3 +/- 2.4) and at exercise (3.2 +/- 2.6, P less than 0.01). The correlation coefficient (r) between resting scores was 0.87, between rest and exercise 0.90 (standard leads) and 0.80 (M-L leads). In 78% nuclear imaging revealed ischaemia, but this had no significant effect on the mean scores or correlation between rest and exercise scores. It is concluded that the QRS score is relatively stable during exercise with standard leads if the limb leads are recorded immediately after the exercise. Scoring with the M-L lead system is somewhat inaccurate, especially during exercise, and is not recommended for stratification of clinical risk. The QRS score is protected against ischaemia, which emphasizes its value as an independent prognostic tool.