Comparison of motor diagnoses by Chicago Classification versions 2.0 and 3.0 on esophageal high-resolution manometry.

BACKGROUND: The Chicago Classification (CC) uses high-resolution manometry (HRM) software tools to designate esophageal motor diagnoses. We evaluated changes in diagnostic designations between two CC versions, and determined motor patterns not identified by either version. METHODS: In this observational cohort study of consecutive patients undergoing esophageal HRM over a 6-year period, proportions meeting CC 2.0 and 3.0 criteria were segregated into esophageal outflow obstruction, hypermotility, and hypomotility disorders. Contraction wave abnormalities (CWA), and 'normal' cohorts were recorded. Symptom burden was characterized using dominant symptom intensity and global symptom severity. Motor diagnoses, presenting symptoms, and symptom burden were compared between CC 2.0 and 3.0, and in cohorts not meeting CC diagnoses. KEY RESULTS: Of 2569 eligible studies, 49.9% met CC 2.0 criteria, but only 40.3% met CC 3.0 criteria (P<.0001). Between CC 2.0 and 3.0, 82.8% of diagnoses were concordant. Discordance resulted from decreasing proportions of hypermotility (4.4%) and hypomotility (9.0%) disorders, and increase in 'normal' designations (13.0%); esophageal outflow obstruction showed the least variation between CC versions. Symptom burden was higher with CC 3.0 diagnoses (P≤.005) but not with CC 2.0 diagnoses (P≥.1). Within 'normal' cohorts for both CC versions, CWA were associated with higher likelihood of esophageal symptoms, especially dysphagia, regurgitation, and heartburn, compared to truly normal studies (P≤.02 for each comparison). CONCLUSIONS AND INFERENCES: Despite lower sensitivity, CC 3.0 identifies esophageal motor disorders with higher symptom burden compared to CC 2.0. CWA, which are associated with both transit and perceptive symptoms, are not well identified by either version.

Distal mean nocturnal baseline impedance on pH-impedance monitoring predicts reflux burden and symptomatic outcome in gastro-oesophageal reflux disease.

BACKGROUND: Mean nocturnal baseline impedance (MNBI), a novel pH-impedance metric, may be a surrogate marker of reflux burden. AIM: To assess the predictive value of MNBI on symptomatic outcomes after anti-reflux therapy. METHODS: In this prospective observational cohort study, pH-impedance studies performed over a 5-year period were reviewed. Baseline impedance was extracted from six channels at three stable nocturnal 10-min time periods, and averaged to yield MNBI. Distal and proximal oesophageal MNBI values were calculated by averaging MNBI values at 3, 5, 7 and 9 cm, and 15 and 17 cm respectively. Symptomatic outcomes were measured as changes in global symptom severity (GSS, rated on 100-mm visual analogue scales) on prospective follow-up after medical or surgical anti-reflux therapy. Univariate and multivariate analyses assessed the predictive value of MNBI on symptomatic outcomes. RESULTS: Of 266 patients, 135 (50.8%) were tested off proton pump inhibitor (PPI) therapy and formed the study cohort (52.1 ± 1.1 years, 63.7% F). The 59 with elevated acid exposure time (AET) had lower composite and distal MNBI values than those with physiological AET (P < 0.0001), but similar proximal MNBI (P = 0.62). Linear AET negatively correlated with distal MNBI, both individually and collectively (Pearson's r = -0.5, P < 0.001), but not proximal MNBI (Pearson's r = 0, P = 0.72). After prospective follow-up (94 patients were followed up for 3.1 ± 0.2 years), univariate and multivariate regression models showed that distal MNBI, but not proximal MNBI, was independently predictive of linear GSS improvement. CONCLUSIONS: Distal oesophageal MNBI negatively correlates with AET and, when assessed off PPI therapy, is independently predictive of symptomatic improvement following anti-reflux therapy.

OSTEOMYELITIS OF THE HUMERUS CAUSED BY PROPIONIBACTERIUM ACNES.

Propionibacterium acnes is a fastidious slow-growing anaerobic gram-positive bacillus best known for causing acne. However, it only occasionally has been isolated from invasive infections. In that setting, slow growth and low virulence may lead to indolent presentations and diagnostic delays as illustrated by the following case.

Caudal regression syndrome with sacral rib: MRI features.

Caudal regression syndrome (CRS) involves improper and incomplete development of distal spinal segments. Sacral rib is an unusual entity, where an accessory rib arises from the sacral vertebral segments. Very few cases have been described in the English literature. We present the case of a 3-year-old girl presenting with urinary and bowel incontinence and difficulties in walking with left-sided sacral rib, terminal cord syrinx, and caudal regression syndrome, involving sacrococcygeal segments, diagnosed on MRI. The association is not well illustrated in previous reports.

Spontaneous intracranial hypotension: a study of six cases with MR findings and literature review.

Spontaneous intracranial hypotension is clinically characterized by orthostatic headache and other symptoms caused by low cerebrospinal fluid pressure due to leakage of cerebrospinal fluid from dural punctures or other medical causes. The other symptoms are mainly due to traction of the cranial and spinal nerves owing to descent of the brain caused by low cerebrospinal fluid pressure. Magnetic resonance imaging is very useful in the diagnosis because of its characteristic findings. We describe the MRI findings in six cases that had variable clinical presentation.

Multiple hemangiomas involving the vertebral column.

Hemangiomas are benign, slow-growing skeletal and soft tissue tumors that commonly involve the bony spine. When found in the spine, they are usually asymptomatic, but can sometimes be associated with local pain and/or neurological deficits. We report the case of a middle-aged Indian male with multiple hemangiomas involving almost all the vertebrae contiguously from C2 to S1 vertebral levels. These were discovered incidentally when a magnetic resonance scan was performed for backache. To the best of our knowledge, such extensive involvement of the spine has not been reported previously.