The long term results of open antireflux surgery in a community-based health care center.

OBJECTIVE: There is no previous study concerning long term results of open Nissen fundoplication performed by general surgeons in a nonspecialized unit. METHODS: Of 45 consecutive patients in a general provincial center, 39 were available for follow-up after a mean period of 78 months. All patients were interviewed using a standard questionnaire, and 35 of them consented to undergo endoscopy. RESULTS: Of the patients, 85% had no or only mild reflux symptoms. The figures for dysphagia, flatulence, and bloating were 31%, 67%, and 46%, respectively. Endoscopy showed defective fundic wrap in 37% of the patients and erosive esophagitis in 29%. Five patients (13%) with recurrent esophagitis were referred for H2-blocker or omeprazole medication, and five others (13%) were scheduled for repeat antireflux surgery. CONCLUSIONS: The results were somewhat worse in regard to prevalence of defective fundic wrap and recurrent esophagitis than in other reports, which were from specialized units.

The effect of breathing frequency on deposition of drug aerosol using an inhalation-synchronized dosimeter in healthy adults.

The deposition of inhaled drug aerosol between the tongue, the upper and lower respiratory tract, the lungs and the gastrointestinal tract (GI tract) in 11 healthy adults was studied by using a nebulizer with an inhalation-synchronized dosimeter. The effect of breathing frequency on deposition was studied using radioaerosol (mixture of salbutamol and technetium bound to diethylenetriamine pentacetate, [99mTc]DTPA) and a gamma-camera. In healthy subjects who were breathing at their own frequency (16 +/- 5 breaths min-1, mean +/- SD), the proportion of inhaled aerosol deposited in the lungs was 48 +/- 14 (mean percentage +/- SD). The proportion deposited in the upper airway tract and the GI tract was 19 +/- 13 and 25 +/- 9 respectively, and the remainder was deposited on the tongue (6 +/- 4) and in the lower airway tract (3 +/- 2). Guided, slower breathing frequency (11 +/- 5 breaths min-1) changed the deposition remarkably. The proportion of the pulmonary deposition of the inhaled dose increased significantly (P < 0.004) to 60 +/- 17, and the proportion of the upper airway tract deposition decreased significantly (P < 0.005) by half of the initial deposition. We conclude that a slow controlled breathing frequency is an important factor if we want to increase the drug deposition in the lungs. It is also essential in decreasing the variation in the deposition of the lungs.

Antireflux surgery enhances gastric emptying.

OBJECTIVE: To evaluate the influence of antireflux surgery on gastric emptying. DESIGN: Nonrandomized controlled trial 3 months before and after surgical intervention. SETTING: Secondary and tertiary referral center. PATIENTS AND CONTROL SUBJECTS: Twenty consecutive patients (7 women, 13 men), mean age 49.2 years, with symptomatic, objectively confirmed gastroesophageal reflux disease and 10 healthy control subjects (3 women, 7 men), mean age 37.3 years. INTERVENTION: Laparoscopic or open Nissen fundoplication (in 1 case Toupet 180 degrees posterior hemifundoplication). MAIN OUTCOME MEASURES: Gastric emptying scintigraphy, using solid food, in control subjects and patients 3 months before and 3 months after the operation; time to halving of the maximal activity and the activity remaining at 60, 100, and 120 minutes. RESULTS: Preoperative symptoms included pyrosis in 19 of 20 patients and regurgitation in 18. Three months postoperatively, 19 patients were symptom-free. The mean time to halving of the maximal activity decreased from 113 to 78 minutes (P = .001). Delayed gastric emptying was found postoperatively in 3 patients, compared with preoperative values, using activity at 60, 100, 120 minutes and the mean time to halving of the maximal activity as the variables. Compared with control subjects, gastric emptying was slower in patients preoperatively and faster postoperatively, but the difference was not statistically significant. CONCLUSION: Gastric emptying is enhanced after antireflux surgery, along with cessation of symptoms and healing of esophagitis.

Compartmental multivariate analysis of exercise ECGs for accurate detection of myocardial ischaemia.

An accurate computer-assisted diagnostic method for detection of myocardial ischaemia, called MUSTA, is developed. MUSTA is based on compartmental multivariate analysis of variables available in the exercise ECGs, and is definitively implemented in Prolog. It is heuristically developed by determining diagnostic criteria, which interrelate a modified ST/HR-slope, ST-segment value and shape, and maximum heart rate, so that concordance with the TI-201 SPECT is maximised. In the learning group consisting of 47 patients, MUSTA provides a diagnostic accuracy of 98%, the detection of ischaemia being in absolute concordance with TI-201 SPECT. MUSTA is evaluated in a similar but independent group of 60 patients. Then, accuracy is 90%, and sensitivity is 94%. The performance characteristics are significantly better than those of the standard exercise ECG, whose diagnostic accuracy in these groups is 77% and 70%, respectively. This study suggests that MUSTA is a significant improvement for computerised assessment of myocardial ischaemia.

Improved diagnostic performance of the exercise ECG test by computerized multivariate ST-segment/heart rate analysis.

The exercise ECG test is the most widely used noninvasive method of evaluating myocardial ischemia. To determine whether it is possible to enhance its diagnostic power, the authors carried out computerized ECG measurements on 118 nonischemic patients and 38 ischemic patients with or without myocardial infarctions (MIs). Forty-seven (all ischemic and nine normal cases) underwent T1-201 SPECT. The diagnostic variables include ST-segment deviation, modified ST/HR-slope, ST-segment shape, and maximum heart rate. These variables are interrelated by means of compartmental and specific decision rules by computer. The diagnostic method discussed in this article is called the multivariate ST/HR analysis (MUSTA). When compared with MUSTA, the T1-201 SPECT images detected myocardial ischemia with a sensitivity of 100% and a specificity of 89%. Its diagnostic performance was influenced by neither previous MIs nor cardiac medication of the 47 patients tested. MUSTA was also compared to the nonmodified ST/HR analyses (ST60/HR and ST80/HR) and the standard exercise ECG test. It performed significantly better than these methods. The authors conclude that the multivariate ST/HR analysis is comparable to T1-201 SPECT in diagnosing myocardial ischemia among the study subjects. Furthermore, MUSTA is executed during the noninvasive exercise ECG test and is easily applied using an IBM/AT-compatible microcomputer. However, further evaluation of MUSTA with a separate and unselected patient population is needed.

ECG changes in exercise-induced asthma.

Changes in ECG during and after exercise were analyzed in 17 patients with exercise-induced asthma (EIA) and in 12 control patients (asthmatic patients without exercise-induced bronchial obstruction). The changes in ECG were compared with those in peak expiratory flow (PEF) rate and in arterial PCO2, PO2 and pH. It was found that in EIA the amplitude of the P wave increased in the inferior leads and decreased in the aVL lead during and after exercise. In addition, the amplitude of the R wave diminished and the amplitude of the S wave increased in the anterior precordial leads during bronchoconstriction. The changes in the ECG of the control patients were small and were already beginning to return to normal 4 min after exercise, whereas the changes in EIA patients persisted for 4-10 min after exercise. In EIA, a significant negative correlation was found between the PEF rate and the amplitude of the P wave in leads II, III and aVF. In addition, the PEF rate and the amplitude of the S wave in the V3 lead showed significant negative correlation. Almost no changes were observed in PO2 or PCO2 in the EIA or in the control patients. The pH decreased significantly in both groups during exercise. The PEF rate did not correlate with arterial PO2, PCO2 or pH after exercise in EIA.

Atenolol once daily in angina.

Both atenolol 50 mg daily (A-50) and atenolol 100 mg daily (A-100) significantly reduced the angina attacks per week compared with placebo (p less than 0.05). Nitroglycerine consumption was less on A-50 (p less than 0.05) and on A-100 (p less than 0.025) than on placebo. There was no difference between the atenolol dosages in these respects. In comparison with placebo, atenolol gave a significant increase in total work performed until the appearance of 1 mm ST segment depression in bicycle exercise tests made between 3--4 p.m. (A-50: p less than 0.05; A-100: p less than 0.0017). The rate-pressure products (systolic BP X heart rate X 10(-2) at 6' at 30 W) was 163.5 +/- 12.5 (S.E.) on placebo. It diminished to 129.8 +/- 7.9 on A-50 (p less than 0.01) and to 113.9 +/- 6.6 on A-100 (p less than 0.001). The effect of A-100 on the rate-pressure product was stronger than that of A-50 (p less than 0.05). Relative heart volume did not change on A-50 compared with placebo but A-100 resulted in a slight enlargement of 22 ml/m2 BSA when compared to placebo (p less than 0.01). Side effects were minimal.