Predictive value of symptom profiles in patients with suspected oesophageal dysmotility

The main aim of the study was to determine prospectively, in patients referred for oesophageal manometry, whether certain combinations of oesophageal symptoms are more likely than others to predict the presence of oesophageal dysmotility or a positive response to acid perfusion testing. In 524 consecutive patients, presenting predominantly with (non-cardiac) chest pain (n = 277), dysphagia (n = 186), or heartburn (n = 61), a standardized symptom assessment was completed before oesophageal manometry and acid perfusion testing. Half the patients in each group reported additional ('secondary') oesophageal symptoms as well as the predominant symptom. Oesophageal dysmotility was categorized in accordance with standard manometric criteria for achalasia, diffuse oesophageal spasm, nutcracker oesophagus, hypertensive lower oesophageal sphincter, or non-specific oesophageal motility disorder. In the predominant chest pain group, the prevalence of abnormal manometry was 33%; in the presence of secondary symptoms, especially dysphagia rather than heartburn, however, the prevalence was significantly (p < 0.01) increased. Also in the predominant chest pain group the prevalence of positive acid perfusion testing (44%) was significantly greater (p < 0.05) in those with than in those without secondary symptoms. In the predominant dysphagia group, the prevalence of abnormal manometry was higher than in the other two groups (56%; p < 0.001) but was not affected by the presence or absence of secondary symptoms; this latter finding was also true for the predominant heartburn group. The distribution of specific manometric disorders in any group was not related to the presence or type of secondary symptoms, although a combination of dysphagia and chest pain discriminated achalasia from other manometric disorders.(ABSTRACT TRUNCATED AT 250 WORDS)     

Letter from Reykjavik

BACKGROUND AND OBJECTIVES: In previous manometric investigations, we observed that patients with chest pain and arterial hypertension frequently tend to display oesophageal motility abnormalities. Therefore, we set out to study this systematically. METHODS: Patients with chest pain and normal coronary angiogram (n=40) and healthy controls (n=20) were studied prospectively in a standardized fashion using a portable oesophageal manometry and blood pressure registration system over 24 hours. RESULTS: Twenty patients exhibited increased arterial blood pressure (24 h median > 135/85 mmHg), while in the other 20 patients and all controls the 24 h blood pressure patterns were normal. Median pressure amplitudes in the distal oesophagus were 46.5, 33 and 27 mmHg in patients with or without arterial hypertension and controls, respectively, and 30, 27 and 27 mmHg in the proximal oesophagus, respectively. The durations of distal contractions were 3.9, 3.4 and 3.4 s, respectively, and those of proximal contractions were 3.2, 3.0 and 3.2 s, respectively. Percentages of propulsive contractions were 53%, 44% and 59%, respectively, and those of simultaneous contractions were 23%, 25% and 10%, respectively. CONCLUSIONS: Patients and controls differ significantly regarding their oesophageal motility patterns. Patients without arterial hypertension exhibit impaired propulsion of oesophageal contractions, whereas patients with arterial hypertension tend to produce oesophageal hypermotility. This suggests that, depending on the presence or absence of arterial hypertension, different pathomechanisms of oesophageal motility disturbances come into play.     

Morbidity of DSM-IV Axis I disorders in patients with noncardiac chest pain: Psychiatric morbidity linked with increased pain and health care utilization.

The present study examined current and lifetime psychiatric morbidity, chest pain, and health care utilization in 229 patients with noncardiac chest pain (NCCP), angina-like pain in the absence of cardiac etiology. Diagnostic interview findings based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) revealed a psychiatrically heterogeneous sample of whom 44% had a current Axis I psychiatric disorder. A total of 41% were diagnosed with a current anxiety disorder, and 13% were diagnosed with a mood disorder. Overall, 75% of patients had an Axis I clinical or subclinical disorder. Lifetime diagnoses of anxiety (55%) and mood disorders (44%) were also prevalent, including major depressive disorder (41%), social phobia (25%), and panic disorder (22%). Patients with an Axis I disorder reported more frequent and more painful chest pain compared with those without an Axis I disorder. Presence of an Axis I disorder was associated with increased life interference and health care utilization. Findings reveal that varied DSM-IV Axis I psychiatric disorders are prevalent among patients with NCCP, and this psychiatric morbidity is associated with a less favorable NCCP presentation. Implications for early identification of psychiatric disorders are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Non-cardiac chest pain: a real clinical problem

Non-cardiac chest pain is a frequent clinical problem. Between 10 and 50% of patients with anginal pain who are referred for arteriography are found to have normal coronary arteries. An oesophageal source of non-cardiac chest pain is reported in up to 60% of cases, most of which are attributable to gastro-oesophageal reflux disease. The exclusion of heart disease and the identification of an oesophageal origin of the pain may require an extensive work-up. The outcome in patients with non-cardiac chest pain is influenced by both the underlying diagnosis and the patient's perception of his or her symptom.     

Social problem solving as a mediator of the stress-pain relationship among individuals with noncardiac chest pain.

Objective: The present study tested the hypothesis that social problem solving (SPS) served to mediate the relationship between preceived stress and noncardiac chest pain (NCCP). Design: Adults undergoing stress myocardial perfusion imaging (MPI) to determine the presence of underlying cardiovascular disease related to the experience of chest pain were recruited prior to stress testing to complete a series of self-report inventories. Main Outcome Measures: MPI results were used to identify individuals with NCCP (N = 166; 91 men, 75 women; mean age = 53.92 years, SD = 11.98). Measures included perceived stress, SPS, and chest pain frequency and intensity. Results: In direct tests of the mediational effects of SPS, it was found that two problem-solving dimensions, negative problem orientation and rational problem solving, each served as significant mediators of the effects of stress on both NCCP intensity and frequency. Conclusion: These results support a mediational analysis of NCCP that includes stress and SPS. As such, it identifies SPS as a potentially important clinical target to consider when developing future psychosocial-based therapy protocols for treating individuals with NCCP. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Abnormal gastro-oesophageal reflux in Chinese with atypical chest pain

Although atypical chest pain has been well described in the Western population, its frequency in Chinese is unknown. Over a period of 42 months, we studied 521 Chinese patients with chest pain and identified 108 patients (20.7%) whose pain was not related to cardiac causes, as determined by exercise ECG or cardiac catheterization. Using 24 h ambulatory pH monitoring and baseline oesophageal manometry, 28.7, 19.4 and 5.6% of these patients were found to have abnormal reflux parameters, abnormal manometric findings or both, respectively. There were significantly more patients complaining of chest pain during the study in the gastro-oesophageal reflux disease (GERD) group than in the non-GERD group (16/31 vs 20/77; P < 0.001). The lower oesophageal sphincter pressure was lower in those with abnormal reflex parameters than in those with normal reflux parameters (12.7 +/- 5.4 vs 17.8 +/- 5.8 mmHg; P < 0.05). There was no significant difference in symptoms, such as heartburn (54.8 vs 42.9%), regurgitation (38.7 vs 35.1%) and dysphagia (19.4 vs 24.7%), among the two groups. Non-specific changes were the most frequent baseline motility pattern. In conclusion, atypical chest pain and gastro-oesophageal reflux disease are not uncommon in Chinese and this deserves special emphasis as the continuation of anti-anginal drugs may aggravate their condition.     

Long-term follow-up of childhood epilepsy associated with tuberous sclerosis

BACKGROUND: Fructose-sorbitol (F-S) mixtures can provoke symptoms in irritable bowel syndrome (IBS) patients, and a proportion of IBS patients also have enteric hypersensitivity to distension. We hypothesized, therefore, that sugar malabsorption and fermentation to produce hydrogen gas may provoke symptoms to a greater extent in IBS patients hypersensitive to distension than in those patients without such hypersensitivity. Our aims were therefore to compare, in IBS patients, symptoms and breath hydrogen responses after F-S, on the basis of jejunal sensitivity and jejunal motor function. METHODS: Fifteen female IBS patients (44 +/- 15 years) underwent, on separate occasions, 3-h breath hydrogen analyses after ingesting 10 g lactulose and 25 g fructose with 5 g sorbitol. Jejunal sensitivity and motor function were determined by balloon distension and 24-h manometry studies, respectively. Cumulative symptom scores and breath hydrogen production were analysed on the basis of the presence or absence of jejunal hypersensitivity and dysmotility. RESULTS: Four and seven patients had jejunal hypersensitivity for initial perception and pain, respectively. Eleven, nine, and nine patients had jejunal dysmotility for fasting phase 3, phase 2, and fed motor activity, respectively. Of the patients with symptom provocation after F-S (n = 8 within 3 h, n = 12 within 12 h) or with F-S malabsorption (n = 10), the relative proportion did not differ on the basis of the presence or absence of jejunal hypersensitivity or of motor dysfunction. Symptom scores and hydrogen production also were not different in these subgroups. CONCLUSIONS: Although carbohydrate malabsorption can provoke symptoms in some IBS patients, there is no consistent association between such a phenomenon and the presence of either jejunal hypersensitivity or dysmotility.     

Oesophageal sensitivity to acid in patients with non-cardiac chest pain: is the oesophagus hypersensitive?

During the past decade, gastro-oesophageal reflux disease has been shown to be the most common identifiable cause of non-cardiac chest pain of oesophageal origin. The development of combined pH-pressures recording systems has also contributed to a better understanding of the underlying mechanisms of pain perception. Beside typical gastro-oesophageal reflux disease, many patients with non-cardiac chest pain appear to have an hypersensitivity to acid or mechanical stimuli, or both. Despite new insights into the pathophysiology of gastro-oesophageal reflux disease, therapy is limited to the suppression of noxious stimuli by antisecretory drugs or surgery. New therapeutic approaches using drugs affecting visceral perception, and well-controlled placebo trials are urgently needed.     

Community-acquired pneumonia in the elderly. Clinical and nutritional aspects

Community-acquired pneumonia (CAP) in the elderly has a different clinical presentation than CAP in other age groups. Confusion, alteration of functional physical capacity, and decompensation of underlying illnesses may appear as unique manifestations. Malnutrition is also an associated feature of CAP in this population. We undertook a study to assess the clinical and nutritional aspects of CAP requiring hospitalization in elderly patients (over 65 yr of age). One hundred and one patients with pneumonia, consecutively admitted to a 1,000-bed teaching hospital over an 8-mo period, were studied (age: 78 +/- 8 yr, mean +/- SD). Nutritional aspects and the mental status of patients with pneumonia were compared with those of a control population (n = 101) matched for gender, age, and date of hospitalization. The main symptoms were dyspnea (n = 71), cough (n = 67), and fever (n = 64). The association of these symptoms with CAP was observed in only 32 patients. The most common associated conditions were cardiac disease (n = 38) and chronic obstructive pulmonary disease (COPD) (n = 30). Seventy-seven (76%) episodes of pneumonia were clinically classified as typical and 24 as atypical. There was no association between the type of isolated microorganism and the clinical presentation of CAP, except for pleuritic chest pain, which was more common in pneumonia episodes caused by classical microorganisms (p = 0.02). This was confirmed by a multivariate analysis (relative risk [RR] = 11; 95% confidence interval [CI]: 1.7 to 65; p = 0.0099). The prevalence of chronic dementia was similar in the pneumonia cohort (n = 25) and control group (n = 18) (p = 0.22). However, delirium or acute confusion were significantly more frequent in the pneumonia cohort than in controls (45 versus 29 episodes; p = 0.019). Only 16 patients with pneumonia were considered to be well nourished, as compared with 47 control patients (p = 0.001). Kwashiorkor-like malnutrition was the predominant type of malnutrition (n = 65; 70%) in the pneumonia patients as compared with the control patients (n = 31; 31%) (p = 0.001). The observed mortality was 26% (n = 26). Pleuritic chest pain is the only clinical symptom that can guide an empiric therapeutic strategy in CAP (typical versus atypical pneumonia). Both delirium and malnutrition were very common clinical manifestations of CAP in our study population.     

The role of endothelin-1 as a mediator of the pressure response after air embolism in blood perfused lungs

BACKGROUND: Irritable bowel syndrome is a common cause of abdominal pain and discomfort and may be related to disordered gastrointestinal motility. Our aim was to assess the effects of long-term treatment with a prokinetic agent, cisapride, on postprandial jejunal motility and symptoms in the irritable bowel syndrome (IBS). METHODS: Thirty-eight patients with IBS (constipation-predominant, n = 17; diarrhoea-predominant, n = 21) underwent 24-h ambulatory jejunal manometry before and after 12 week's treatment [cisapride, 5 mg three times daily (n = 19) or placebo (n = 19)]. RESULTS: In diarrhoea-predominant patients significant differences in contraction characteristics were observed between the cisapride and placebo groups. In cisapride-treated diarrhoea-predominant patients the mean contraction amplitude was higher (29.3 +/- 3.2 versus 24.9 +/- 2.6 mm Hg, cisapride versus placebo (P < 0.001); pretreatment, 25.7 +/- 6.0 mm Hg), the mean contraction duration longer (3.4 +/- 0.2 versus 3.0 +/- 0.2 sec, cisapride versus placebo (P < 0.001); pretreatment, 3.1 +/- 0.5 sec), and the mean contraction frequency lower (2.0 +/- 0.2 versus 2.5 +/- 0.4 cont./min, cisapride versus placebo (P < 0.001); pretreatment, 2.5 +/- 1.1 cont./min] than patients treated with placebo. No significant differences in jejunal motility were found in the constipation-predominant IBS group. Symptoms were assessed by using a visual analogue scale before and after treatment. Symptom scores relating to the severity of constipation were lower in cisapride-treated constipation-predominant IBS patients [score, 54 +/- 5 versus 67 +/- 14 mm, cisapride versus placebo (P < 0.05); pretreatment, 62 +/- 19 mm]. Diarrhoea-predominant IBS patients had a higher pain score after cisapride therapy [score, 55 +/- 15 versus 34 +/- 12 mm, cisapride versus placebo (P < 0.05); pretreatment, 67 +/- 19 mm]. CONCLUSION: Cisapride affects jejunal contraction characteristics and some symptoms in IBS.     

Functional dyspepsia and irritable bowel syndrome: is there a common pathophysiological basis?

OBJECTIVES: Alterations of mechanosensitive thresholds occur in a subset of patients with functional dyspepsia and irritable bowel syndrome (IBS). However, symptoms associated with these two conditions frequently overlap. It is not known how often subjects with and without symptom overlap have abnormal intestinal sensory thresholds. Our objective was to assess the pattern of symptoms and small intestinal sensory thresholds in patients with functional disorders. METHODS: We studied 157 consecutive patients who had undergone extensive diagnostic work-up to exclude organic disease. Abdominal symptoms were assessed with a validated instrument, and patients were categorized as having functional dyspepsia, IBS, or both. With a barostat device, we tested small intestinal mechanosensitive function in 22 randomly selected patients from this population (with functional dyspepsia, IBS, or both) and 22 healthy controls. RESULTS: Sixty-seven patients (43%) reported simultaneous symptoms of functional dyspepsia and IBS, whereas symptoms of functional dyspepsia or of IBS alone occurred in 68 (43%) and 22 (14%) patients, respectively. Thresholds for first perception and maximum tolerated pressure (mm Hg +/-SD) were significantly lower in patients (21.0 +/- 2.0 and 31.0 +/- 1.0) than in controls (32.0 +/- 1.8 and 39.0 +/- 0.9, p < 0.001). However, thresholds for first perception and maximum tolerated pressure did not differ (p > 0.6) in patients with functional dyspepsia alone (20.1 +/- 3.2 and 28.9 +/- 2.5, n = 9), functional dyspepsia and concomitant IBS (19.9 +/- 2.7 and 30.7 +/- 2.2, n = 8), or IBS alone (23.5 +/- 2.3 and 33.3 +/- 3.0, n = 5). CONCLUSIONS: Small intestinal mechanosensitive pathways are disturbed in patients with functional dyspepsia and IBS. Differences in the pattern and localization of symptoms probably do not reflect differences in small intestinal sensory thresholds. Functional dyspepsia and IBS cannot be distinguished on the basis of altered small intestinal sensory thresholds.     

Impact of a public campaign on pre-hospital delay in patients reporting chest pain

OBJECTIVE: To decrease pre-hospital delay in patients with chest pain. DESIGN: Population based, prospective observational study. SETTING: A province of Switzerland with 380000 inhabitants. SUBJECTS: All 1337 patients who presented with chest pain to the emergency department of the H?pital Cantonal Universitaire of Geneva during the 12 months of a multimedia public campaign, and the 1140 patients who came with similar symptoms during the 12 months before the campaign started. MAIN OUTCOME MEASURES: Pre-hospital time delay and number of patients admitted to the hospital for acute myocardial infarction (AMI) and unstable angina. RESULTS: Mean pre-hospital delay decreased from 7h 50 min before the campaign to 4 h 54 min during it, and median delay from 180 min to 155 min (P < 0.001). For patients with a final diagnosis of AMI, mean delay decreased from 9 h 10 min to 5 h 10 min and median delay from 195 min to 155 min (P < 0.002). Emergency department visits per week for AMI and unstable angina increased from 11.2 before the campaign to 13.2 during it (P < 0.02), with an increase to 27 (P < 0.01) during the first week of the campaign; visits per week for non-cardiac chest pain increased from 7.6 to 8.1 (P = NS) during the campaign, with an increase to 17 (P < 0.05) during its first week. CONCLUSIONS: Public campaigns may significantly reduce pre-hospital delay in patients with chest pain. Despite transient increases in emergency department visits for non-cardiac chest pain, such campaigns may significantly increase hospital visits for AMI and unstable angina and thus be cost effective.     

Silicone versus polymethylmethacrylate intraocular lenses with regard to capsular opacification

Between May 1996 and May 1997, a total of 398 patients (321 males, 77 females) were registered at our institute for trans-telephonic electro-cardiographic monitoring (TTEM). Their age ranged from one month to 95 years. Almost two-third (67%) of patients were from Delhi and one-third (33%) from other places in India and neighbouring countries. Clinical profile of these patients was post-bypass surgery, post-myocardial infarction, chest pain for evaluation, post-percutaneous transluminal coronary angioplasty, chronic stable angina, evaluation of palpitations, arrhythmias, and pace-maker follow-up. Out of 664 symptomatic transmissions, 568 (86%) were received for cardiac symptoms and 96 (14%) for non-cardiac symptoms. Seventy-nine percent patients had chest pain or palpitations at the time of transmission, whereas 21 percent had other symptoms like chest discomfort, breathlessness or dizziness. The electro-cardiograms were transmitted within one hour of the onset of chest pain in 84 percent, palpitations in 78 percent and dizziness in 75 percent. Of patients with symptomatic transmissions, 628 (95%) required either reassurance or drug-dose adjustment and outpatient department review. Only 36 (5%) patients were hospitalised as an emergency, and out of these only 19 (3%) needed acute management. In conclusion, trans-telephonic electro-cardiographic monitoring is a very convenient and an 'all-time-available' monitoring facility for establishing patient-physician contact in the shortest time. It is useful in rendering instant advice for hospitalisation in emergency situations while avoiding unnecessary visits to the hospital.     

Effect on outcome of the presence or absence of chest pain at initiation of recombinant tissue plasminogen activator therapy in acute myocardial infarction. The Thrombolysis in Myocardial Infarction Investigators

To ascertain whether the outcome of patients with suspected myocardial infarction differs when chest pain is still present at initiation of thrombolytic therapy, participants in the Thrombolysis in Myocardial Infarction Phase II study, all of whom presented within 4 hours of symptoms onset, were retrospectively divided into 2 groups: (1) those with chest pain present at onset of intravenous thrombolysis, n = 3,000; and (2) those who were free of chest pain on beginning intravenous thrombolytic therapy, n = 337. Patients free of chest pain were older (58 vs 57 years, p = 0.01), more often women (23 vs 17%, p = 0.01), had fewer electrocardiographic leads with ST elevation (3.8 vs 4.1, p < 0.001), and the presenting event was confirmed less often as myocardial infarction than as chest pain without infarction (88 vs 96%, p < 0.001). There were no significant differences between the 2 groups for in-hospital death, reinfarction, recurrent ischemic events, stroke, overall hemorrhagic complications, coronary angioplasty or bypass surgery. At 6-weeks follow-up, more pain-free patients had resting ejection fraction > 0.55 (35 vs 31%, p = 0.001) and fewer developed congestive heart failure (12 vs 20%). At 1-year follow-up, fewer pain-free patients developed congestive heart failure (15 vs 21%, p = 0.009), but no differences existed between the 2 groups in frequency of death, reinfarction, coronary angioplasty, bypass surgery or anginal class. Thus, there are several observations in patients who were free of chest pain at onset of lytic therapy. (1) The majority developed enzymatic or electrocardiographic evidence of acute myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Major depression and irritable bowel syndrome: is there a relationship?

BACKGROUND: Irritable bowel syndrome (IBS) has been reported in 10% to 22% of adults. Seventy percent to 90% of patients with IBS who seek medical attention have psychiatric comorbidity, most commonly major depression. In contrast, few studies have looked at the prevalence of IBS among psychiatric patients. METHOD: Using a semistructured clinical interview to study the prevalence of IBS, we compared 56 patients seeking treatment for major depression in an outpatient setting to an age- and sex-matched control group of patients (N = 40) who were seeking treatment in a general physician's office for other medical illnesses. The control group had no Axis I disorders. IBS was diagnosed according to the criteria of Drossman et al. RESULTS: Twenty-seven percent (N = 15) of patients with major depression met criteria for IBS in contrast to 2.5% (N = 1) of the control group (p = .0005). Patients with major depression and IBS were more likely to report symptoms of back pain, weakness, heartburn, and nocturnal bowel movements as well as a personal or family history of bowel disease compared with patients with major depression but without IBS. CONCLUSION: IBS is fairly common in patients seeking treatment for major depression. Prospective studies should address the question whether treatment of major depression leads to an improvement or resolution of the symptoms of IBS.     

Access and outcomes of elderly patients enrolled in managed care

OBJECTIVE: To determine differences in access to care and medical outcomes for Medicare patients with an acute or a chronic symptom who were enrolled in health maintenance organizations (HMOs) compared with similar fee-for-service (FFS) nonenrollees. DESIGN: A 1990 household telephone survey of Medicare beneficiaries who reported joint pain or chest pain during the previous 12 months. SAMPLE: Stratified random sample of HMO enrollees (n = 6476) and comparable sample of FFS Medicare beneficiaries (n = 6381). ACCESS AND OUTCOME MEASURES: Care-seeking behavior, physician visits, diagnostic procedures performed, therapeutic interventions prescribed, follow-up recommended by a physician, and symptom response to treatment. RESULTS: After controlling for demographic factors, health and functional status, and health behavior characteristics, HMO enrollees with joint pain (n = 2243) were more likely than nonenrollees (n = 2009) to have a physician visit (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.03 to 1.38) and medication prescribed (OR, 1.35; 95% CI, 1.14 to 1.60). Patients with chest pain who were enrolled in HMOs (n = 556) were less likely than nonenrollees (n = 524) to have a physician visit (OR, 0.50; 95% CI, 0.30 to 0.82). For both joint and chest pain, HMO enrollees were less likely to see a specialist for care, have follow-up recommended, or have their progress monitored. There were no differences in complete elimination of symptoms, but HMO enrollees with continued joint pain reported less symptomatic improvement than nonenrollees (OR, 0.72; 95% CI, 0.59 to 0.86). CONCLUSIONS: Reduced utilization of services for patients with specific ambulatory conditions was observed in HMOs with Medicare risk contracts, with less symptomatic improvement in one of the four outcomes studied.     

Air oesophagogram: a frequent, but not a specific sign of oesophageal involvement in connective tissue diseases

OBJECTIVE: This study investigates the role of the air oesophagogram in conventional chest X-rays for the diagnosis of oesophageal dysmotility in patients with connective tissue diseases. METHODS: Fifty-one patients with connective tissue diseases were studied by oesophageal manometry and lateral and posterior-anterior chest X-rays. The presence or absence of oesophageal air on chest X-rays were evaluated separately in the upper, middle and distal segment of the oesophagus. Forty-seven chest X-rays of patients without connective tissue diseases, who had undergone manometry for the evaluation of oesophagus-related symptoms and who had normal oesophageal function, were analysed as a control. RESULTS: A total of 23/51 patients with connective tissue diseases showed oesophageal dysfunction in manometry; 16/51 patients (31%) had air in two or more oesophageal segments on the lateral chest X-ray. There was a significant association of manometrically proven oesophageal dysmotility and air in two or three oesophageal segments (P < 0.05; sensitivity 48%, specificity 82%). However, the prevalence of an air oesophagogram showed no significant difference between patients with connective tissue diseases and the control group (10/47; 21%). CONCLUSION: The radiological sign of an air oesophagogram is neither sensitive nor specific enough to omit oesophageal motility studies in patients with connective tissue diseases.     

A case-control study to examine any association between idiopathic detrusor instability and gastrointestinal tract disorder, and between irritable bowel syndrome and urinary tract disorder

OBJECTIVE: To assess whether there are common malfunctions (e.g. of the autonomic nervous system and smooth muscle) that underlie disorders of the urinary and gastrointestinal tracts by determining whether there is an increased prevalence (i) of urinary symptoms in patients with irritable bowel syndrome (IBS) and (ii) of gastrointestinal symptoms in patients with idiopathic detrusor instability (IDI). PATIENTS AND METHODS: Questionnaires were sent to patients with a diagnosis of IBS or IDI who were seen in the Departments of Gynaecology, Gastroenterology and Urology at the John Radcliffe and Churchill Hospitals, Oxford, during the 3 year period 1993-1995. The questionnaires were also distributed to control patients who were recruited from the day-surgery unit of the Churchill Hospital. Of 236 questionnaires sent out, 168 replies were analysed; 64 from patients with IBS, 49 from patients with detrusor instability and 55 from controls. The questionnaire included questions about micturition and defecatory behaviour (frequency, regularity, urgency, continence, pain, and ease in passing urine and stools). RESULTS: Patients with IBS were more likely to experience certain urinary symptoms than controls (nocturia, urgency and some forms of urinary urge incontinence) and patients with IDI were as likely as patients with IBS to experience gastrointestinal symptoms more frequently than controls. Control patients showed an unexpectedly high probability of experiencing many of the gastrointestinal and urinary symptoms. CONCLUSIONS: The frequent occurrence of symptoms in control patients makes the significance of the results less clear, but the association between certain symptoms of urinary tract disorder and patients with IBS, and of symptoms of gastrointestinal tract disorder with patients with IDI, suggests that they may share some common underlying dysfunction.     

Prognostic value of pharmacological stress echocardiography in women with chest pain and unknown coronary artery disease

OBJECTIVES: In this study we sought to investigate the prognostic value of pharmacological stress echocardiography in women referred for chest pain, having unknown coronary artery disease. BACKGROUND: The noninvasive identification of a high-risk subgroup among women with chest pain and unknown coronary artery disease is an unresolved task to date. METHODS: A total of 456 women (mean [+/-SD] age 63+/-10 years) underwent pharmacological stress echocardiography with either dipyridamole (n = 305) or dobutamine (n = 151) for evaluation of chest pain and were followed-up for 32+/-19 months. None of them had a previous diagnosis of coronary artery disease. RESULTS: No major complication occurred during stress testing. Five tests (1.1%) were prematurely interrupted because of the appearance of side effects. Echocardiographic positivity was identified in 51 patients. During the follow-up, 23 cardiac events occurred: 3 deaths, 10 infarctions and 10 cases of unstable angina; an additional 21 patients underwent coronary revascularization. At Cox analysis, the echocardiographic evidence of ischemia was found as the only independent predictor of hard cardiac events (death, infarction) (odds ratio [OR] = 27.5; 95% confidence interval [CI] = (6.5 to 115.5; p = 0.0000). When spontaneous cardiac events (death, infarction and unstable angina) were considered as endpoints, the positive echocardiographic result (OR = 23.9; 95% CI = 8.6 to 66.8; p = 0.0000) and family history of coronary artery disease (OR = 3.7; 95% CI = 1.5 to 9.1; p = 0.0037) were independently correlated with prognosis. By using an interactive stepwise procedure, the prognostic value of stress echocardiography was found to be incremental to that provided by clinical variables, both considering hard and spontaneous cardiac events as endpoints. The 3-year survival rate for the negative and the positive population was respectively, 99.5% and 69.5% (p = 0.0000) considering hard cardiac events, 99.2% and 50.6% (p = 0.0000) considering spontaneous cardiac events. CONCLUSIONS: Pharmacological stress echocardiography is safe, highly feasible and effective in risk stratification of women with chest pain and unknown coronary artery disease, also when hard endpoints are considered. Its use can have relevant implications in daily clinical practice for selection of patients needing further investigations.     

Increased occurrence of esophageal hypermotility disorders in patients with arterial hypertension

BACKGROUND AND OBJECTIVE: It has been noted in previous manometric examinations of the oesophagus in patients with chest pain that abnormal motility was often associated with arterial hypertension. A systematic study of this relationship was therefore undertaken. PATIENTS AND METHODS: In 40 patients with chest pain (18 women and 22 men, mean age 54.7 [24-70] years) and in 20 healthy volunteers (12 men, 8 women, mean age 50.8 [22-63] years) standardized oesophageal manometry and arterial blood pressure monitoring were performed over 24 hours. Coronary heart disease and gastrointestinal lesions had been excluded by angiography and endoscopy, respectively. RESULTS: 20 patients (group H) had hypertension (median 24-hour blood pressure > 135/85 mmHg), while 20 patients (group N) and the normal controls (group K) were normotensive. Oesophageal manometry data differed significantly between the three groups regarding distal pressure amplitude (in hPa [hectopascals]; group H: 62 hPa*,**, group N 44 hPa* and group K 36 hPa**; [*P < 0.0005]) and the proportion of simultaneous contractions (group H 23%, group N 22%**, group K 10%***; ***P < 0.001). The hypertensive patients had significantly more frequent motility abnormalities than normal controls (13/20 vs 4/20, P < 0.001); while normotensive patients had more frequent episodes of abnormal propulsion in the oesophagus (proportion of propulsive contractions in group H: 53%, in N: 44%, in K: 59%; P < 0.01). CONCLUSION: Oesophageal motility differed significantly in patients with chest pain from that in healthy controls. Patients with chest pain and hypertension more frequently had oesophageal hypermotility. This suggests a generalized abnormality of smooth muscle.