Factors predicting the use of the backward upward rightward pressure maneuver in thyroid surgery: a single-center retrospective cohort study.

BACKGROUND: The purpose of this study was to evaluate the predictability of utilizing the backward upward rightward pressure (BURP) maneuver and the efficacy of related tests in patients with a challenging airway and a Mallampati score of 2 or higher who underwent scheduled elective thyroid surgery. METHODS: Patient files were scanned for 300 adult patients who had undergone thyroid surgery under general anesthesia. The information included their medical history of thyroid disease, previous thyroid surgery, and evaluation tests for difficult intubation such as Mallampati score, maximum mouth opening, ease of intubation, thyroid goitre grade, and whether the BURP maneuver was performed. Patients who had a history of difficult intubation or a Cormack Lehane score less than 2 were excluded. Additionally, the patients were divided into two groups: one group underwent the BURP maneuver (n = 78) and the other did not (n = 56). RESULTS: Statistically significant differences in the maximum mouth openings and thyroid goitre grade were observed between the groups according to the preoperative evaluation. Furthermore, significant differences were noted between the groups in terms of the ease of intubation, intubation time, Cormack-Lehane score, and number of intubation attempts. CONCLUSION: There may be a correlation between the maximum mouth opening and thyroid goitre grade in predicting the use of the BURP maneuver. It is important to keep in mind, however, that difficult intubation may occur in some uncommon types of goiter, such as retrosternal goiter, even if the thyroid gland size is small. Therefore, it may be useful to consider performing the BURP maneuver.

Zebras in Adult Dysphagia Workup: Where to Look When You Think You Have Looked Everywhere.

While many patients who present with dysphagia have a clinically identifiable cause of dysphagia, the etiology of swallowing difficulty is oftentimes a diagnostic enigma. The aim of this article is to review possible etiologies of dysphagia when objective evidence of dysphagia is lacking. Included in this discussion are cricopharyngeal spasm, retrograde cricopharyngeal dysfunction, muscle tension dysphagia, dysphagia secondary to medications, and functional dysphagia.

Pediatric retrograde cricopharyngeal dysfunction diagnosed by high-resolution impedance manometry.

OBJECTIVES: The inability to burp, known as retrograde cricopharyngeal dysfunction (R-CPD), was initially described in adults. The proposed clinical diagnostic criteria for R-CPD include belching inability, abdominal bloating and discomfort/nausea, postprandial chest pain, and involuntary noises. Botulinum toxin injection to the cricopharyngeal muscle has been reported to be beneficial. High-resolution esophageal impedance-manometry (HRIM) features in adolescent patients with R-CPD have not been described yet.  The aim of our study was to describe the clinical and HRIM findings of pediatric patients with R-CPD. METHODS: Clinical and manometric features of five pediatric patients diagnosed with R-CPD were reviewed. HRIM study protocol was modified to include the consumption of carbonated drink to provoke symptoms and distinctive manometric features. RESULTS: We report five female patients aged 15-20 years who presented with an inability to burp and involuntary throat sounds. HRIM revealed normal upper esophageal sphincter (UES) relaxation during swallowing, but abnormal UES relaxation with concurrent high esophageal impedance reflecting air entrapment and secondary peristalsis following the carbonated drink challenge. Four patients exhibited esophageal motility disorder. All patients reported improvement or resolution of symptoms after botulinum toxin injection to the cricopharyngeus muscle. CONCLUSIONS: Adolescents with an inability to burp, reflux-like symptoms, bloating, and involuntary throat noises should be assessed for R-CPD by pediatric gastroenterologists with HRIM. The relatively recent recognition of this novel condition is the likely reason for its under- and misdiagnosis in children.

Retrograde Cricopharyngeal Dysfunction: A Review.

Retrograde cricopharyngeal dysfunction (RCPD), also referred to as retrograde cricopharyngeus dysfunction, is a condition characterized by the inability to burp. The pathophysiology of this condition is thought to result from failure of cricopharyngeal sphincter relaxation during periods of esophageal distension, which leads to patients' bothersome symptoms. RCPD negatively impacts patients' quality of life and is associated with bloating, gurgling, avoidance of carbonation, self-imposed dietary and lifestyle changes designed to minimize discomfort, and flatulence. Complaints often start during adolescence, and many patients search for a diagnosis for years before obtaining treatment. A recent increase in awareness through patient-led social media discussion boards describing the 'no burp' syndrome is leading to an increasing incidence of presentations, often with patients making a self-diagnosis. The increased incidence of RCPD is fueling a larger case series investigating treatment options and outcomes. In this review, we discuss what is known about the pathophysiology of this condition, the otolaryngologic perspective on diagnosis and treatment, the patients' lived experience of this condition, and the influence of social media on RCPD.

Retrograde cricopharyngeus dysfunction: How does the inability to burp affect daily life?

BACKGROUND: Retrograde cricopharyngeus dysfunction (R-CPD), a condition first detailed in 1987 and termed in 2019, refers to the cricopharyngeal muscle's inability to relax to allow the retrograde passage of gas. Limited research exists on the fundamental characteristics of this condition, including its impact on one's life. The purpose of this study is to characterize R-CPD and how the inability to burp affects the social lives of people who suffer from it. METHODS: A Qualtrics survey was distributed on the subreddit "r/noburp," a community of 26,000 individuals sharing information about R-CPD. Adults aged 18-89 experiencing R-CPD symptoms were invited to participate. Participants reported on their experiences with R-CPD and its effects on social life on a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree). Data was analyzed using descriptive statistics. KEY RESULTS: Among the 199 respondents, the mean age was 30.9, and gender identity was 74%/25% female/male. 99% reported inability to burp, 98% reported abdominal bloating, 93% reported socially awkward gurgling noises, 89% reported excessive flatulence, and 55% reported difficulty vomiting. Only half discussed their symptoms with their primary care provider (PCP), and 90% disagreed with receiving adequate help. Average Likert scores indicated embarrassment (3.4), anxiety/depression (3.1), negative impact on relationships (2.6), and work disruption (2.7) due to R-CPD. CONCLUSIONS & INFERENCES: R-CPD is unfamiliar to many healthcare providers, leaving patients underserved. It not only affects daily life but also personal and professional relationships. Raising awareness by understanding disease basic features may increase diagnosis and treatment rates, improving quality of life.

Hypnosis in the treatment of retrograde cricopharyngeus dysfunction: A case report.

Retrograde cricopharyngeus dysfunction (R-CPD) causes an inability to belch. This case report describes the successful treatment of R-CPD with the use of hypnosis. Thereafter, the patient was able to burp small amounts of air, and was encouraged to continue his use of hypnosis as needed. Hypnosis and possibly other noninvasive treatments should be used for R-CPD before employment of more invasive and costly treatments such as botulinum toxin administration.

Retrograde Cricopharyngeus Dysfunction effectively treated with low dose botulinum toxin. A case report from Italy.

A large constellation of hitherto unexplained symptoms including inability to burp, gurgling noises from the chest and lower neck, abdominal bloating, flatulence, painful hiccups and emetophobia was defined as Retrograde Cricopharyngeus Dysfunction (R-CPD) in 2019. First choice treatment of R-CPD involves injection of botulinum toxin into the cricopharyngeus muscle under local or general anesthesia. This treatment has been found to be effective in the vast majority of subjects, with limited adverse events and prolonged therapeutic effects. Notwithstanding, R-CPD is still a poorly understood and underestimated disease, and a specific therapeutic dosage range of botulinum toxin (BT) has not been yet established. In this report, we describe the first case of R-CPD diagnosed in Italy, successfully treated with unilateral, anesthesia-free injection of 10 units of onabotulinum toxin into the cricopharyngeus muscle, representing the lowest dose reported to date.

Genome-wide identification and expression analysis of the BURP domain-containing genes in Malus domestica.

The conserved BURP-containing proteins are specific to plants and play a crucial role in plant growth, development, and response to abiotic stresses. However, less is known about the systematic characterization of BURP-containing proteins in apple. This study aimed to identify and analyze all BURP-containing genes in the apple genome, as well as to examine their expression patterns through various bioinformatics methods. Eighteen members of BURP-containing genes were identified in apple, six members lacked signal peptides, and the secondary structure was mainly a Random coil of BURP-containing genes. Gene structure and Motif analysis showed that proteins have similar structures and are conserved at the C-terminal. Cis-acting element analysis revealed that the proteins contain phytohormone and stress response elements, and chromosomal localization revealed that the family is unevenly distributed across eight chromosomes, with duplication of fragments leading to the expansion of family proteins. Tissue expression showed that MdPG3 and MdPG4 were expressed in different tissues and different varieties, MdRD2 and MdRD7 were highly expressed in 'M74' fruits and MdRD7 in 'M49' leaves, while MdUSP1 was highly expressed in 'GD' roots. The quantitative real-time PCR analysis showed that the expressions of six and seven genes were significantly up-regulated under NaCl and PEG treatments, respectively, whereas MdRD7 was significantly up-regulated under NaCl and PEG treatment over time. This study offers a comprehensive identification and expression analysis of BURP-containing proteins in apple. The findings provide a theoretical foundation for further exploration of the functions of this protein family. Supplementary Information: The online version contains supplementary material available at 10.1007/s12298-023-01393-7.

Identification and expression analysis of BURP domain-containing genes in jujube and their involvement in low temperature and drought response.

BACKGROUND: Plant-specific BURP domain-containing genes are involved in plant development and stress responses. However, the role of BURP family in jujube (Ziziphus jujuba Mill.) has not been investigated. RESULTS: In this study, 17 BURP genes belonging to four subfamilies were identified in jujube based on homology analysis, gene structures, and conserved motif confirmation. Gene duplication analysis indicated both tandem duplication and segmental duplication had contributed to ZjBURP expansion. The ZjBURPs were extensively expressed in flowers, young fruits, and jujube leaves. Transcriptomic data and qRT-PCR analysis further revealed that ZjBURPs also significantly influence fruit development, and most genes could be induced by low temperature, salinity, and drought stresses. Notably, several BURP genes significantly altered expression in response to low temperature (ZjPG1) and drought stresses (ZjBNM7, ZjBNM8, and ZjBNM9). CONCLUSIONS: These results provided insights into the possible roles of ZjBURPs in jujube development and stress response. These findings would help selecting candidate ZjBURP genes for cold- and drought-tolerant jujube breeding.

"I've never been able to burp": Preliminary description of retrograde cricopharyngeal dysfunction in children.

OBJECTIVE: Retrograde cricopharyngeal dysfunction was recently described by Bastian in 2019 and is characterized by an inability to belch, abdominal or chest pressure, odd gurgling noises, and occasional difficulty vomiting. Symptoms tend to worsen with carbonated beverages. Currently, the recommended treatment is cricopharyngeus muscle botulinum toxin injections. Prior studies have included few pediatric patients within larger datasets comprised primarily of adults. We describe our preliminary experience in pediatric patients, including presenting symptoms, treatment approach, and post-treatment outcomes. METHODS: Retrospective chart review of pediatric patients (aged <18 years) diagnosed with retrograde cricopharyngeal dysfunction based on clinical history by the senior author. Medical records were reviewed for presenting symptoms, prior testing and treatment, details of treatment, and postoperative outcomes. RESULTS: Five patients with average age of 14 ± 4 (3 females, 2 males) were included. Presenting symptoms included lifelong or nearly lifelong inability to burp (n = 5), bloating (n = 5), awkward gurgling noises (n = 3), and worsening of symptoms with carbonated beverages (n = 5). Two patients had prior normal upper endoscopy. All patients underwent cricopharyngeal botulinum toxin injection under general anesthesia, with 25-50 units of botulinum toxin injected to the posterior cricopharyngeus across 4-5 locations. All patients had resolution of symptoms with follow-up of 1.5-10 months. CONCLUSIONS: Retrograde cricopharyngeal dysfunction may be underdiagnosed due to lack of awareness of the condition. Now that the phenomenon of inability to belch has a name and is being reported in the literature, we will likely see more adult and pediatric patients with these symptoms. Pediatric patients may respond similarly to adults. Larger studies with longer-term follow-up and targeted patient-reported outcome measures are needed to characterize disease presentation and treatment outcomes.

Overexpressing PpBURP2 in Rice Increases Plant Defense to Abiotic Stress and Bacterial Leaf Blight.

Mosses are one of the earliest diverging land plants that adapted to living on land. The BURP domain-containing proteins (BURP proteins) are plant-specific proteins that appeared when plants shifted from aquatic environments to land. Phylogenetic analysis revealed that the BURP domain of higher plants is originated from lower land plants and divergent because of motif conversion. To discover the function of BURP protein in moss, rice transgenics with ectopic expression of PpBURP2 were subjected to different abiotic stresses treatments. The results revealed that the ectopic expression of PpBURP2 enhanced the tolerance to osmotic and saline stresses at the seedling stage and drought stress at the adult stage. Further ectopic expression of PpBURP2 improved the cadmium (2+) (Cd2+) tolerance and reduced Cd2+ accumulation in rice leaves. Transcriptomic analysis of the transgenic PpBURP2 plants showed that the differentially expressed genes were involved in the metabolism of secondary metabolites, energy, oxidation-reduction process, and defense-related genes. Further experiments showed that the photosynthetic efficiency and resistance against bacterial leaf blight were obviously improved in transgenic plants. Yeast two-hybrid and bimolecular fluorescence complementation (BiFC) assays revealed the physical interaction of BURP domain protein from rice and moss with mitogen-activated protein kinase kinase (MKK) from rice. Therefore, our findings demonstrate that overexpressing PpBURP2 in rice confers resistance to abiotic stresses and bacterial leaf blight. They also suggested that the regulatory role of BURP-like proteins across lower and higher plants was evolutionary conservation of responses of different classes of plants to different environmental challenges.

Genome-wide identification of the BURP domain-containing genes in Phaseolus vulgaris.

Plant-specific BURP domain-containing proteins have an essential role in the plant's development and stress responses. Although BURP domain-containing proteins have been identified in several plant species, genome-wide analysis of the BURP gene family has not been investigated in the common bean. In the present study, we identified 11 BURP family members in the common bean (Phaseolus vulgaris) genome with a comprehensive in silico analysis. Pairwise alignment and phylogenetic analyses grouped PvBURP members into four subfamilies [RD-22 like (3), PG1ß-like (4), BNM2-like (3), and USP-like (1)] according to their amino acid motifs, protein domains and intron-exon structure. The physical and biochemical characteristics of amino acids, motif and intron-exon structure, and cis-regulatory elements of BURPs members were determined. Promoter regions of BURP members included stress, light, and hormone response-related cis-elements. Therefore, expression profiles of PvBURP genes were identified with in silico tools and qRT-PCR analyses under stress (salt and drought) and hormone treatment (ABA, IAA) in the current study. While significant activity changes were not observed in BURP genes in RNA-seq data sets related to salt stress, it was determined that some BURP genes were expressed differently in those with drought stress. We identified 12 different miRNA, including miRNA395, miRNA156, miRNA169, miRNA171, miRNA319, and miRNA390, targeting the nine PvBURP genes using two different in silico tools based on perfect or near-perfect complementarity to their targets. Here we present the first study to identify and characterize the BURP genes in common bean using whole-genome analysis, and the findings may serve as a reference for future functional research in common bean. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12298-021-01052-9.

Abelchia: inability to belch/burp-a new disorder? Retrograde cricopharyngeal dysfunction (RCPD).

CASE SERIES: This is retrospective case series involving 72 patients who presented with symptoms associated with inability to burp. The following symptoms was described by almost all the patients; retrosternal pain after eating or drinking, bloating feeling in the stomach, gurgling noise in the throat, excessive flatulence. These symptoms are worse with fizzy/carbonated drinks and beer. A full clinical history and examination plus endoscopic and in some cases barium a swallow radiological investigation was done. PROCEDURE: The surgery was performed under a general anaesthesia for all cases. Suspension pharyngoscopy in supine position using a Weerda diverticuloscope to identify the cricopharyngeal bar muscle. High dose of botulinum toxin A (botox) 100 iu was injected into the cricopharynxgeus muscle under a general anaesthesia. RESULTS: A total of 72 patients were diagnosed and undergone surgery between November 2016 and December 2020. There were 50 male and 22 female patients. Their average age was 30 (range 18-68 years old). All patients were able to burp again within first 4 weeks of the injection. This persisted even after the Botox worn off beyond the 3 months in 96% of cases. The average follow-up was 24 months post injection with longest follow-up 48 months (range 1-48 months). CONCLUSION: The author reported a new condition of inability to burp due to failure of the cricopharyngeal sphincter to relax spontaneously and outcome of treatment using botulinum toxin A injection into the cricopharyngeus muscle. It is expected that the paralysing action of botulinum toxin injection last approximately 3 months. However, this group of patients seem to be cured even after the effect of the botox is worn off. The author therefore postulated that there might me some neural dysfunction that inhibits the brain to send signals to the cricopharyngeal sphincter to initiate burping. Once burping is re-established with the help of botox injection, spontaneous burping seems to occur and sustained even after the botox is worn off.

The Long-term Efficacy of Botulinum Toxin Injection to Treat Retrograde Cricopharyngeus Dysfunction.

OBJECTIVES: To report the percentage of patients with symptom relief 6 or more months after botulinum toxin injection into the cricopharyngeus muscle for retrograde cricopharyngeus dysfunction (R-CPD). STUDY DESIGN: Retrospective case series of consecutively treated patients. SETTING: Tertiary care laryngology clinic. SUBJECTS AND METHODS: A review was performed of the first 200 patients who were diagnosed with R-CPD and treated with botulinum toxin injection into the cricopharyngeus muscle by a single surgeon. The study group was limited to those for whom a minimum of 6 months has elapsed since the injection. Items assessed were efficacy, safety, complications, and duration of benefit. RESULTS: Of 200 patients treated, (99.5%) gained the ability to burp and 95% experienced relief of the cardinal symptoms of R-CPD: inability to belch, socially awkward gurgling noises, abdominal/chest pressure and bloating, and excessive flatulence. For those who experienced relief, 159 (79.9%) maintained a satisfactory ability to burp after 6 months. Of those who did not maintain the ability, 12 underwent a second injection, 1 patient underwent 3 subsequent injections, and 3 patients underwent partial myotomy. No patients experienced complications of botulinum toxin injection itself, and 4 patients had complications from esophagoscopy or anesthesia. CONCLUSION: In a case series of 200 patients with retrograde cricopharyngeus dysfunction, 99% experienced relief of the cardinal symptoms and 79.9% experienced lasting relief of their symptoms beyond pharmacologic duration of action after a single injection of botulinum toxin into the cricopharyngeus muscle. Relief can be reestablished in the remainder via additional injection or cricopharyngeus myotomy.

The "BURP" maneuver improves the glottic view during laryngoscopy but remains a difficult procedure.

OBJECTIVE: We investigated the "BURP" maneuver's effect on the association between difficult laryngoscopy and difficult intubation, and predictors of a difficult airway. METHODS: Adult patients who underwent general anesthesia and tracheal intubation from September 2016 to May 2018 were included. The "BURP" maneuver was performed when glottic exposure was classified as Cormack-Lehane grade 3 or 4, suggesting difficult laryngoscopy. The thyromental distance, modified Mallampati score, and interincisor distance were assessed before anesthesia. RESULTS: Among this study's 2028 patients, the "BURP" maneuver decreased difficult laryngoscopies from 428 (21.1%) to 124 (6.1%) cases and increased the difficult intubation to difficult laryngoscopy ratio from 53/428 (12.4%) to 52/124 (41.9%). For laryngoscopies classified as difficult without the "BURP" maneuver, the area under the curve (AUC) of the thyromental distance, modified Mallampati score, and interincisor distance was 0.60, 0.57, and 0.66, respectively. In difficult laryngoscopies using the "BURP" maneuver, the AUC of the thyromental distance, modified Mallampati score, and interincisor distance was 0.71, 0.67, and 0.76, respectively. CONCLUSIONS: The "BURP" maneuver improves the laryngoscopic view and assists in difficult laryngoscopies. Compared with difficult laryngoscopies without the "BURP" maneuver, those with the "BURP" maneuver are more closely associated with difficult intubations and are more predictable. Trial registration: www.chictr.org.cn identifier: ChiCTR-ROC- 16009050.

Ethylene insensitive3-like2 (OsEIL2) confers stress sensitivity by regulating OsBURP16, the ß subunit of polygalacturonase (PG1ß-like) subfamily gene in rice.

The transcription factors EIN3 (ETHYLENE-INSENSITIVE 3) and EILs (EIN3-Likes) play important roles in plant development and defense responses; however, their mechanism in these processes remain unclear. Here, we report that OsEIL2, an EIN3-like transcription factor from rice (Oryza sativa), plays important roles in abiotic stress and leaf senescence. OsEIL2 is a nuclear-localized protein with transactivation activity in the C-terminus (amino acids 344-583) and can be induced by NaCl, polyethylene glycol (PEG), dark, and abscisic acid (ABA) treatment. Transgenic plants of overexpressing OsEIL2 (OsEIL2-OX) show reduced tolerance to salt and drought stress compared with the controls. While the transgenic plants of overexpressing OsEIL2-RNA interference (OsEIL2-RNAi) exhibit enhanced tolerance to salt and drought stress compared with the controls. Moreover, seedlings of OsEIL2-overexpressing transgenic plants exhibit delayed leaf development and an accelerated dark-induced senescence phenotype, whereas OsEIL2-RNAi plants display the opposite phenotype. We further found that OsEIL2 functions upstream of OsBURP14 and OsBURP16. OsBURP14 and OsBURP16 are the members of the ß subunit of polygalacturonase subfamilies. OsBURP16 overexpression reduced pectin content and cell adhesion and increased abiotic stress sensitivity in rice. OsEIL2 binds directly to the promoter of OsBURP14 and OsBURP16 and activates their transcript levels. We also found that OsEIL2 overexpression decreased the pectin content by increasing polygalacturonase (PG) activity. Taken together, these results revealed a new mechanism of OsEIL2 in abiotic stress responses. These findings provide new insights into plant resistance to abiotic stress.

Single-Voxel 1 H MR spectroscopy of cerebral nicotinamide adenine dinucleotide (NAD+ ) in humans at 7T using a 32-channel volume coil.

PURPOSE: Reliable monitoring of tissue nicotinamide adenine dinucleotide (NAD+ ) concentration may provide insights on its roles in normal and pathological aging. In the present study, we report a 1 H MRS pulse sequence for the in vivo, localized 1 H MRS detection of NAD+ from the human brain. METHODS: Studies were carried out on a 7T Siemens MRI scanner using a 32-channel product volume coil. The pulse sequence consisted of a spectrally selective low bandwidth E-BURP-1 90° pulse. PRESS localization was achieved using optimized Shinnar-Le Roux 180° pulses and overlapping gradients were used to minimize the TE. The reproducibility of NAD+ quantification was measured in 11 healthy volunteers. The association of cerebral NAD+ with age was assessed in 16 healthy subjects 26-78 years old. RESULTS: Spectra acquired from a voxel placed in subjects' occipital lobe consisted of downfield peaks from the H2 , H4 , and H6 protons of the nicotinamide moiety of NAD+ between 8.9-9.35 ppm. The mean ± SD within-session and between-session coefficients of variation were found to be 6.14 ± 2.03% and 6.09 ± 3.20%, respectively. In healthy volunteers, an age-dependent decline of the NAD+ levels in the brain was also observed (ß = -1.24 µM/y, SE = 0.21, P < 0.001). CONCLUSION: We demonstrated the feasibility and robustness of a newly developed 1 H MRS technique to measure localized cerebral NAD+ at 7T MRI using a commercially available RF head coil. This technique may be further applied to detect and quantify NAD+ from different regions of the brain as well as from other tissues.

Genome-wide identification and expression analysis of the BURP domain-containing genes in Gossypium hirsutum.

BACKGROUND: Many BURP domain-containing proteins, which are unique to plants, have been identified. They performed diverse functions in plant development and the stress response. To date, only a few BURP domain-containing genes have been studied, and no comprehensive analysis of the gene family in cotton has been reported. RESULTS: In this study, 18, 17 and 30 putative BURP genes were identified in G. raimondii (D5), G. arboreum (A2) and G. hirsutum (AD1), respectively. These BURP genes were phylogenetically classified into eight subfamilies, which were confirmed by analyses of gene structures, motifs and protein domains. The uneven distribution of BURPs in chromosomes and gene duplication analysis indicated that segmental duplication might be the main driving force of the GhBURP family expansion. Promoter regions of all GhBURPs contained at least one putative stress-related cis-elements. Analysis of transcriptomic data and qRT-PCR showed that GhBURPs showed different expression patterns in different organs, and all of them, especially the members of the RD22-like subfamily, could be induced by different stresses, such as abscisic acid (ABA) and salicylic acid (SA), which indicated that the GhBURPs may performed important functions in cotton's responses to various abiotic stresses. CONCLUSIONS: Our study comprehensively analyzed BURP genes in G. hirsutum, providing insight into the functions of GhBURPs in cotton development and adaptation to stresses.

Inability to Belch and Associated Symptoms Due to Retrograde Cricopharyngeus Dysfunction: Diagnosis and Treatment.

OBJECTIVE: To propose and test the validity of a new syndrome called retrograde cricopharyngeus dysfunction (R-CPD) that explains inability to belch and the associated symptoms of loud gurgling noises, chest and abdominal pain/distention, and excessive flatulence, as well as to report the results of botulinum toxin (BT) injection into the cricopharyngeus muscle (CPM) for both diagnosis and treatment of R-CPD. STUDY DESIGN: To develop a case series of consecutive patients matched to the syndromic features of R-CPD, inject the CPM with BT as a concurrent diagnostic and therapeutic maneuver, and assess results. SETTING: Bastian Voice Institute (Downers Grove, Illinois). SUBJECTS AND METHODS: Consecutive (unselected) patients presenting with inability to belch and associated symptoms were matched to the proposed syndrome of R-CPD, treated with BT, and followed for effect on symptoms over time. RESULTS: All 51 patients achieved ability to belch and relief of associated symptoms, and the majority seem to have "retrained" the ability to belch on a potentially "permanent" basis. CONCLUSION: R-CPD can be diagnosed syndromically, using a symptom complex; clinical diagnosis is validated by relief of symptoms after BT injection; and BT into the CPM is an efficacious treatment, whose benefit appears to often last longer than the pharmacologic duration of action of BT.

A Rare Case Involving the Inability to Belch.

A 17-year-old girl was referred to our hospital with an inability to belch, while experiencing chest gurgling noises, and severe abdominal bloating. She reported having these symptoms all her life. A timed barium esophagogram revealed a moderate amount of bubbles in the esophagus and gastric fundus, which significantly increased after the examination. High resolution manometry revealed that the basal upper esophageal sphincter pressure increased with a rise in the cervical esophageal pressure. A pathological inability to belch is rare; at present, no specific name exists to describe the disorder. Further research is needed in this unexplored field.