Globus jugularis and dysphagia in patients with hiatus hernia.

The aim of the article was to study if there is any relationship between globus sensation in the jugular fossa (GJ), intermittent esophageal dysphagia (IED), and the presence of a hiatus hernia, and if GJ can be relieved after hiatus hernia repair. 167 patients with a hiatus hernia (Group A) and 61 other patients with hiatus hernia and gastroesophageal reflux disease who were surgically treated with Nissen fundoplication (Group B), filled in a symptom questionnaire on GJ and IED. GJ was found in 66% and IED in 68% of patients in group A. In group B, 49% had GJ and 64% IED before surgery. At surgical follow-up 16% (P < 0.005) and 43% (P < 0.05) had GJ and IED, respectively. The combination of GJ and IED was found in 28% of IED patients before operation and in 31% at surgical follow-up. The high frequency of GJ in patients with hiatus hernia and the significant relief of GJ after hiatus hernia repair imply that GJ most likely is a referred sensation from the esophagus. IED and GJ are two parallel phenomena in patients with hiatus hernia, but do not seem to have any causal relationship.

Cold caloric microcirculatory reflex disturbance in patients with Parkinson's disease.

The basal skin microcirculatory blood flow and its change in response to a cold caloric stimulus (cold water, 5 degrees C, exposure of one foot for 30 s) were investigated in nine patients with Parkinson's disease (PD) and nine normal subjects (controls). The results revealed a significant (p < 0.001) difference between the groups. In the controls there was a strong decrease in the red cell flux (RCF) on cold water exposure, while eight of the nine PD patients revealed no detectable change in RCF; in one patient only there was a less pronounced reaction. It was concluded that the regulation of the microcirculatory blood flow was affected in PD patients; the cold caloric reflex was attenuated or absent but there was no difference in the basal microcirculatory blood flow compared to normal subjects.

Characteristics of the autonomic response in the visually evoked reflex in humans.

This study aimed (a) to investigate the effect of the visuogenic reflex on the skin microcirculation of the hand and foot, and (b) to compare it to that evoked by thermal stimuli. Fifteen volunteers took part in this study. The laser Doppler technique was used for measuring blood flow (BF). The results showed that a flash of light with a duration of 300 ms caused a significant decrease in BF (mean 38.4 +/- 14.8%) in 10 out of 15 subjects in the hand but not in the foot. The latency was 5.05 +/- 0.7 s and the duration 7.2 +/- 1.8 s. The reaction did not show a significant change when a longer stimulus of 14 s was applied. Repetitive stimuli evoked habituation (p < 0.01). There is significant difference (p < 0.01) between autonomic responses to visuogenic and to calorically evoked reflexes.

In vitro lymphocyte proliferation as compared to patch test using gold, palladium and nickel.

BACKGROUND: A conventional lymphocyte transformation test (LTT) was compared to the commercially available MELISA (memory lymphocyte immunostimulation assay), a lymphoproliferative assay that has been suggested to be a valuable instrument for the diagnosis of metal allergy. Sensitivity and specificity of the two assays were calculated using a patch test as a reference method. METHODS: 34 patients were patch-tested for gold sodium thiosulfate, palladium chloride and nickel sulfate, and the lymphocyte proliferation to these metals was tested in vitro using mononuclear cells from peripheral blood. RESULTS: No significant differences regarding sensitivity and specificity were found between MELISA and conventional LTT. The sensitivity varied between 55 and 95% and the specificity between 17 and 79%. CONCLUSIONS: The low specificity of the two in vitro assays suggests that they are not useful for diagnosis of contact allergy to the metals gold, palladium and nickel, since a large number of false-positive results will be obtained.

Responses in skin microcirculation to vestibular stimulation before and during motion sickness.

BACKGROUND: Observation of physiological changes during motion sickness is required to quantify the degree of sickness. The review of the literature does not show unifying results. An objective symptom of motion sickness is facial pallor. It reflects changes in skin microcirculation which have not been measured so far. METHODS: Eleven healthy volunteers susceptible to motion sickness were subjected to eccentric vertical axis rotation. The dynamics and the correspondence of the changes in skin blood flow in two segments, forehead and finger, were measured by laser Doppler flowmeter. RESULTS AND CONCLUSIONS: The difference in the microcirculatory skin blood flow across the phases of motion sickness is significant for the forehead but not for the fingertip: the established dynamics of the forehead blood flow during motion sickness will be of benefit in quantifying the degree of sickness; there is no correlation between the blood flow changes in both measured areas; the rhythmic blood flow fluctuation increases during motion sickness; there is a difference between the blood flow responses to vestibular stimulation before the appearance of motion sickness and in the course of the sickness. Laser Doppler flowmetry is a reliable method in quantifying the degree of motion sickness.

The effect of edrophonium chloride-induced chest pain on esophageal blood flow and motility.

BACKGROUND: It is not known to what extent patients with non-cardiac chest pain have esophageal ischemia or motor dysfunction. The aim of this study was to investigate whether chest pain provoked by intravenous edrophonium chloride could be due to esophageal ischemia or to muscular spasm. METHODS: Sixteen patients with a history of non-cardiac chest pain took part. Ten patients (32-69 years old) who did not develop chest pain with intravenous edrophonium chloride were compared with six patients (50-71 years old) who did develop edrophonium-provoked chest pain. Esophageal motility was monitored manometrically. Changes in esophageal blood flow, assessed as the rewarming time after esophageal cooling, was measured with a thermistor technique. RESULTS: The esophageal rewarming time after cooling was the same before and during the edrophonium test in both groups. The esophageal contraction amplitudes and contraction duration were significantly increased only in patients with edrophonium-provoked chest pain. CONCLUSION: Strong esophageal contractions and not a decreased blood flow in the esophageal wall seem to be the cause of chest pain provoked by intravenous edrophonium chloride.

Influence of intense sound stimuli on skin microcirculation.

Sound influences not only the organ of hearing but also other systems including the circulation. The purpose of the present study was to investigate the effect of strong sound on the skin microcirculation of the palmar area of the hand and of the plantar area of the foot, which are areas of dense microvasculature and rich sympathetic innervation. The laser Doppler technique was used for measuring cutaneous red cell flux (RCF). Eighteen normal subjects were studied. The results indicate that a pure tone sound of 1500 Hz, with an intensity of 100 dBA and duration 5 s, applied by earphones caused a significant decrease in RCF in 14 out of 18 subjects in the finger but not in the foot skin. A higher intensity (110 dBA) tone caused a stronger decrease of RCF in the finger. The latency and the duration of the reaction showed a dependence on the intensity of the sound, i.e. the reaction to the stronger stimulus was of shorter latency (p < 0.01) and longer duration (p < 0.05). The duration of the reaction did not show significant change when a longer stimulus of 30 s was applied. Repetitive stimuli evoked habituation (p < 0.05).

Is mis-swallowing or smoking a cause of respiratory symptoms in patients with gastroesophageal reflux disease?

Respiratory symptoms were studied in 119 patients operated on for fundoplication and crural repair because of gastroesophageal reflux disease (GERD). The effect of antireflux surgery and of smoking habits on their respiratory symptoms was evaluated. A questionnaire was completed before and after surgery in connection with esophageal investigations. Chronic bronchitis was present in 20% of the patients, 38% of whom were smokers. In the rest of the patients, 18% were smokers. Cough was reported by 34% and expectoration by 21%. After surgery the number of patients with cough and chronic bronchitis was reduced significantly in nonsmokers and to some extent in smokers. It is believed that fundoplication with distal anchoring of the longitudinal esophageal muscle will improve pharyngoesophageal function and thereby decrease aspiration and respiratory symptoms due to mis-swallowing.

Computerized thermistor technique for indirect studies of esophageal blood flow.

The aim of this study was to elaborate on a computerized microthermistor technique for indirect measurement of esophageal blood flow and to investigate if any changes in circulation could be found in patients who are provoked by esophageal acid perfusion of their acid-sensitive mucosa. A thermistor was mounted in a plastic catheter and placed in the esophagus 11 cm above the lower esophageal sphincter. The signal from the thermistor was transmitted to a personal computer. A 15 degrees C water bolus was injected into the catheter in order to cool the esophageal wall at the catheter side hole 1 cm above the thermistor. The reliability of the thermistor test was examined by repeating it in 29 patients. No statistical difference between the two test occasions was found. Twenty-five patients were provoked with an acid perfusion test, 14 of whom had a positive reaction with heartburn. Patients with a positive acid perfusion test had a shorter rewarming time before as well as after provocation than patients with a negative acid perfusion test. It is concluded that this thermistor technique is well suited for measuring intraluminal rewarming rate as an indirect sign of changes in esophageal blood flow. Furthermore, the results indicate that blood supply of the esophageal wall is increased in patients with a positive acid perfusion test.

Variations in esophageal oxygen tension measured with intraluminal antimony electrodes.

Monocrystalline antimony electrodes (crystallographically oriented monocrystalline antimony; COMA) are known to be sensitive to oxygen and to pH. Accordingly, it has been shown that COMA electrodes can be used for the measurement of tissue oxygen tension provided the pH remains constant or is accounted for by the simultaneous use of a glass electrode. In this study the combination of a COMA together with a glass electrode was evaluated for measurement of esophageal oxygen tension in 5 patients. The COMA electrodes showed a mean value of 2.1 pH units higher than the glass electrodes, corresponding to a pO2 level in the esophagus of 10 kPa. As the more protracted oxygen effect on the COMA electrodes was easily recognized, especially in levels of the pH above 7.8 units, they were used for indirect evaluation of intraluminal oxygen tension in the esophagus in a further 57 patients, monitored over 24 h for gastroesophageal reflux disease. The intraluminal pO2 decreased in the supine position and with increase in age. An increase in pO2 was seen after eating and during reflux periods. The changes in pO2 are interpreted as being secondary to blood flow alterations in the esophagus.

Effect of spasmolytic drugs on esophageal foreign bodies.

Muscle spasm has been proposed as the cause for esophageal food impaction. The aim was therefore to treat esophageal foreign bodies with spasmolytic drugs influencing both striated and smooth muscles of the esophagus. A multicenter, placebo-controlled, double-blind study of glucagon and diazepam was undertaken in 43 patients. The foreign body disimpacted in 9 of 24 patients given active substances and in 6 of 19 patients given placebo; there was no significant difference between these two groups. Almost all disimpactions occurred several hours after injection of the drugs. The hypothesis of muscle spasm as an important cause of esophageal obstruction was rejected. Medical therapies for food disimpaction other than spasmolytic drugs have to be investigated.

Gastro-oesophageal reflux and oesophageal dysfunction in children and adolescents with brain damage.

The prevalence of pathological gastro-oesophageal reflux (GOR) and oesophageal dysfunction (OD) was investigated in 32 children, 0.7-19 years of age (mean 11.2 years), with brain damage, mainly severe cerebral palsy and tetraplegia. They underwent 24-h pH monitoring in the distal oesophagus and oesophageal manometry. In addition, radiological examination of the oesophagus, chest radiography, blood counts and blood tests for iron deficiency were carried out. Fifteen (47%) patients had mild pathological acid reflux, 5 (16%) had moderately severe and 5 (16%) severe acid GOR. Seven of 32 (22%) patients had no pathological GOR. Ten patients had abnormal manometry findings and 9 had a pathological radiological oesophagus examination. Three patients had radiographic lung consolidations. Thirteen patients had iron deficiency and 5 were anaemic. Two patients with severe acid reflux have died, presumably from aspiration-induced pneumonia. Findings of OD and GOR are frequent in children with brain damage and are related to significant complications, including fatal course.

Wrong-way swallowing as a possible cause of bronchitis in patients with gastroesophageal reflux disease.

A new theory was tested that swallowing the wrong way is the cause of the strong correlation between bronchial symptoms and gastroesophageal reflux disease (GERD). One hundred and nineteen patients who were operated on for hiatal hernia and GERD were compared with 89 patients treated with the proton pump inhibitor omeprazole concerning bronchial symptoms before and after treatment. Both groups had a frequency of cough of 34% before treatment. Omeprazole did not give any significant relief of cough, whereas patients who were operated on with fundoplication and crural repair showed a highly significant reduction of cough and bronchitis. It is believed that the distal anchoring of the longitudinal esophageal muscle by surgery improves esophageal transit and restores the delicate coordination in the swallowing centre between deglutition, the opening of the upper esophageal sphincter, and the epiglottic closure of the laryngeal entrance. It is concluded that the main reason for chronic bronchitis in patients with GERD is intermittent aspiration due to partial mis-swallowing.

Alkaline oesophageal reflux--an artefact due to oxygen corrosion of antimony pH electrodes.

Antimony electrodes are widely used for gastro-oesophageal pH monitoring. They are also sensitive to oxygen, however, especially at low PO2 levels, which are known to shift recorded values in the alkaline direction. This study, which compares antimony and glass electrodes for oesophageal pH monitoring in six adults, shows that values recorded by antimony electrodes are 2.1 +/- 0.8 pH units (mean +/- SD) higher than by glass electrodes (p < 0.001; n = 7642). A further 52 patients with suspected gastro-oesophageal reflux were investigated by 24-h pH monitoring by means of antimony electrodes. In these patients the oesophageal pH was higher than 8.0 for 7% of the time (range, 0-60%). The alkaline periods recorded with antimony electrodes were all protracted in time, smoothly increasing from a neutral pH, and did not correspond to a sudden increase in pH, which would be expected if alkaline reflux had occurred. It is concluded that high pH values obtained by antimony electrodes are due to the oxygen sensitivity of the electrodes. The diagnosis of alkaline reflux seems to be valid only when pH monitoring is performed with glass electrodes or when values obtained with antimony electrodes are adjusted for the influence of the oxygen tension in the oesophagus.

Remission of angina pectoris and dyspnea by fundoplication in gastro-oesophageal reflux disease.

This study investigates 113 consecutive patients with gastro-oesophageal reflux disease before and after fundoplication and crural repair with respect to symptomatic improvement of chest pain, angina pectoris, exercise-linked chest pain, meal-linked chest pain, dyspnea, and air hunger, and any correlation between these items and smoking habits. The patients were followed by identical questionnaires completed at the time of oesophageal manometric examination prior to operation and from 6 months up to more than 5 years after operation. There was a highly significant reduction in all kinds of chest pain including angina pectoris, and of dyspnea at follow-up independent of smoking habits. However, air hunger was not significantly reduced. The present results suggest that gastro-oesophageal reflux disease should be taken into consideration in the symptomatic diagnosis of angina pectoris.

Do physicians care about patients with dysphagia? A study on confirming communication.

Thirty-nine patients with longstanding oesophageal dysphagia took part in an interview and a questionnaire study to investigate whether they considered themselves met with interest, respect, understanding and knowledge (felt confirmed) when consulting their physician for the first time (mostly general practitioner), whether non-confirmed patients have any distinguishing attributes, and whether confirmation affects the patient's impression of being helped. Twenty-five of these considered themselves as non-confirmed. There was no difference between the groups as regards sex, age, education, degree of swallowing difficulties and incidence of chest symptoms other than dysphagia. There was a greater fear of cancer (P less than 0.05) and a stronger indirect aggression (P less than 0.05) among the non-confirmed patients. Patients who felt confirmed reported more often that a correct oesophageal diagnosis had been given (P less than 0.05), felt they had received adequate help (P less than 0.001) and experienced improvement in swallowing difficulties (P less than 0.05). It is concluded that patient attributes seem to slightly influence the patients' possibilities of being confirmed, and that confirmation is of great importance for the patient's feeling of being helped and improved.

Issues in the treatment of noncardiac chest pain.

Evaluation of therapy for noncardiac chest pain calls for a systematic analysis of all relevant factors. Central chest pain is often experienced as a threat to life. Fear and anxiety concerning heart disease or cancer can increase pain and hamper therapy. The relief of pain can result from factors other than the actual treatment employed (i.e., placebo effects, relief of anxiety, spontaneous improvement, changes in life-style not related to treatment, or other, concomitant therapies prescribed). Therapeutic failure may be explained by diagnostic error, incorrect treatment, insufficient duration of therapy, incorrect dosage regimen, individual response to pharmacologic agents, poor drug absorption, drug interactions, poor compliance, poor surgical technique, and, finally, lack of effective therapeutic options. The rational evaluation of therapy for noncardiac chest pain is also hampered by its multifactorial etiology and the difficulty of selecting study patients with identical pain etiology. Controversies in the treatment of noncardiac chest pain reflect the uncertainty regarding pathophysiology. A primary issue is whether to treat patients medically with life-style modifications and pharmacologic agents, or surgically. A variety of pharmacologic agents and surgical techniques have been used to treat noncardiac chest pain. Treatment includes psychosocial considerations in addition to medical or surgical therapy. The most important role for the physician of a patient with noncardiac chest pain is to listen well, to be confirming and understanding, and to treat the patient not just as an apparatus that needs repair but as a socially integrated human being.

A trial of ranitidine in asthmatic children and adolescents with or without pathological gastro-oesophageal reflux.

In order to study the importance of gastro-oesophageal reflux (GOR) as a trigger of asthma the effect of inhibition of gastric acid secretion on asthma was assessed in a double-blind, cross-over, placebo-controlled trial over four weeks in 37 children and adolescents (mean age 14 yrs) with bronchial asthma. Ranitidine 300 mg, (150 mg if B.W. was less than 40 kg) was given as a single evening dose during four weeks. In previous investigations 18 of the 37 patients had been shown to have pathological GOR by 24 h pH monitoring in the oesophagus. The remaining 19 patients with normal GOR served as controls for possible effects of ranitidine on asthma, not related to reduction of GOR. A modest (30%) but statistically significant reduction of nocturnal asthma symptoms was produced by ranitidine in the patients with pathological GOR when compared to those with normal GOR. There was a significant correlation between the improvement in asthma symptoms and the degree of acid reflux. Side-effects of ranitidine were negligible. Acid reflux appears to be only a weak stimulus for bronchoconstriction in children and adolescents with bronchial asthma and pathological GOR. Further confirmative trials with more potent inhibitors of gastric acid secretion are, however, warranted.

Vestibular and cardiac reactions to open-sea exposure.

Nineteen healthy male volunteers were exposed to a 72-hour open-sea stay in a lifeboat in order to study whether randomized protracted stimulation of different parts of the vestibular system would cause a decrease of vestibular activity as assessed by unilateral calorization of the horizontal vestibular canal. The influence on the autonomic nervous system was investigated by calculating the heart rate by the R-R intervals at ECG at rest and at maximum speed of the nystagmus slow phase. Calorization and ECG investigations were performed immediately before and after the open-sea exposure. Seven healthy males who were not exposed to the open sea served as controls. They were investigated in the same manner as the test subjects, that is twice, 3 days apart. All test subjects experienced seasickness. After the sea stay, the caloric nystagmus response had decreased significantly more than in the controls. In 7 subjects with the most pronounced vestibular habituation, the resting heart rate decreased significantly after the sea exposure. Caloric stimulation of the labyrinths did not cause any specific change of the heart rate. It is concluded that prolonged open-sea exposure causes vestibular habituation to unilateral labyrinthine stimulation. Furthermore, there are some indications that the mechanism that is responsible for vestibular habituation to some extent influences the function of the autonomic nervous system, resulting in a decreased pulse rate.