Rapid Drink Challenge in high-resolution manometry: an adjunctive test for detection of esophageal motility disorders

BACKGROUND/AIMS

The Chicago Classification for diagnosis of esophageal motility disorders by high-resolution manometry (HRM) is based on single water swallows (SWS). Emerging data suggest that a "Rapid Drink Challenge" (RDC) increases sensitivity for motility disorders. This study establishes normal values and diagnostic thresholds for RDC in clinical practice.

METHODS

Two cohort studies were performed in patients with dysphagia or reflux symptoms (development and validation sets). Healthy subjects and patient controls provided reference values. Ten SWS and two 200-mL RDC were performed. Primary diagnosis for SWS was established by the Chicago Classification. Abnormal RDC was defined by impaired esophagogastric junction (EGJ) function (elevated integrated relaxation pressure during RDC [IRP-RDC]); incomplete inhibition of contractility during and ineffective contraction after RDC. Diagnostic thresholds identified in the development set were prospectively tested in the validation set.

RESULTS

Normal values were determined in healthy (n=95; age 37.8 ± 12) and patient controls (n=44; age 46.4 ± 15). Development and validation sets included 178 (54 ± 17 years) and 226 (53 ± 16 years) patients, respectively. Integrated relaxation pressure during RDC was higher for SWS than RDC in all groups (overall P<.001), except achalasia. Rapid Drink Challenge suppressed contractility, except in achalasia type III, spasm, and hypercontractile motility disorders (P<.001). An effective after-contraction was present more often in health than disease (P<.001). Optimal diagnostic thresholds identified in the development set (IRP-RDC ≥12 mmHg achalasia, IRP-RDC ≥ 8mmHg "all cause" EGJ dysfunction), were confirmed in the validation set (both, sensitivity ~85%, specificity >95%).

CONCLUSIONS

Rapid Drink Challenge contributes clinically relevant information to routine HRM studies, especially in patients with EGJ dysfunction.

Measurement of esophago-gastric junction cross-sectional area and distensibility by an endolumenal functional lumen imaging probe for the diagnosis of gastro-esophageal reflux disease

BACKGROUND

Measurement of esophago-gastric junction (EGJ) cross-sectional area (CSA) and distensibility by an Endolumenal Functional Lumen Imaging Probe (EndoFLIP®) may distinguish between gastro-esophageal reflux disease (GERD) patients and healthy volunteers (HV). We aimed to assess the agreement of EndoFLIP® measurements with clinical and physiologic diagnosis of GERD.

METHODS

Twenty-one HV and 18 patients with typical GERD symptoms were studied. After gastroscopy, EGJ CSA, and distensibility were measured by EndoFLIP®. Forty-eight hour esophageal pH monitoring was then performed by a wireless system. The ability of EndoFLIP® to discriminate GERD patient and HVs was assessed. Planned secondary analysis then assessed whether EGJ CSA and distensibility were increased in individuals with pathologic acid exposure.

KEY RESULTS

Healthy volunteers were younger and had lower body mass index (BMI; both p < 0.001). Pathologic acid exposure was present in 3/21 (14%) HVs and 9/18 (50%) patients (p = 0.126). At 30 mL EndoFLIP® bag volume, EGJ CSA was higher (p = 0.058) and EGJ distensibility was lower (p = 0.020) in HVs than patients. Secondary analysis showed that EGJ measurements were similar in participants with and without pathologic acid exposure (CSA 98 mm² vs 107 mm²; p = 0.789, distensibility; p = 0.704). An inverse association between BMI and CSA (R² = 0.2758, p = 0.001) and distensibility (R² = 0.2005, p = 0.005) was present.

CONCLUSIONS & INFERENCES

Endolumenal Functional Lumen Imaging Probe is not useful for GERD diagnosis because EGJ CSA and distensibility do not distinguish between HVs and GERD patients defined by clinical presentation or pH measurement. This unexpected result may be due to an important, confounding interaction of obesity.

Rumination variations: aetiology and classification of abnormal behavioural responses to digestive symptoms based on high-resolution manometry studies

BACKGROUND

Rumination is the voluntary, albeit subconscious return of gastric contents to the mouth. Currently, rumination syndrome and repetitive belching disorders are considered separate diagnoses, as defined by Rome III criteria and high-resolution oesophageal manometry (HRM).

AIM

To test the hypothesis that these conditions represent a common behavioural response to aversive digestive stimuli and that successful treatment can be directed at both the stimulus and the response.

METHODS

Case-note review of consecutive patients with a final diagnosis of behavioural digestive disorders between August 2009 and October 2011.

RESULTS

Thirty-five of 46 (76%) patients exhibited 'classical' rumination with abdomino-gastric strain (R-waves) driving gastric contents across the lower oesophageal sphincter; 5 (11%) had 'reflux-related' rumination with R-waves seen during gastro-oesophageal common cavity (reflux) events and 6 had (13%) supra-gastric belching. All received at least one biofeedback session at the time of diagnosis with a good response reported by 20/46 (43%) of the patients, which included 3 with supra-gastric belching. Additionally, rumination ceased in cases in which definitive treatment relieved the symptoms that triggered abnormal behaviour (e.g. fundoplication in 'reflux-rumination').

CONCLUSIONS

Rumination and many of its variations, excluding only some cases of supra-gastric belching, are associated with abdomino-gastric strain, a generic abnormal behavioural response to a variety of aversive digestive stimuli. All types of rumination can respond to biofeedback. High-resolution oesophageal manometry identifies subgroups with distinct mechanisms of disease that respond to specific management targeted at the symptoms that trigger the abnormal behaviour.

Combined use of filtered and edited 1 H NMR spectroscopy to detect 13 C-enriched compounds in complex mixtures

In conventional metabolism and pharmacokinetic studies, radioactive isotopes are used to identify and quantify the breakdown products of xenobiotics. However, the stable isotope (13) C provides a cheaper and less hazardous alternative. Metabolites of (13) C-enriched xenobiotics can be detected, quantified and identified by (13) C-filtered NMR spectroscopy. However, one obstacle to using (13) C is its 1.1% natural abundance that produces a background signal in (13) C-filtered NMR spectra of crude biological extracts. The signal makes it difficult to distinguish between (13) C-enriched xenobiotics resonances from endogenous metabolites unrelated to the xenobiotic. This study proposes that the (13) C background signal can be distinguished from resonances of (13) C-enriched xenobiotics by the absence of a (12) C component in the xenobiotic. This is detected by combined analysis of (13) C-filtered and -edited NMR spectra. The theory underlying the approach is described and the method is demonstrated by the detection of sub-microgram amounts of (13) C-enriched phenacetin in crude extracts of hepatocyte microsomes.

Exploring acupuncturists' perceptions of treating patients with rheumatoid arthritis

AIMS

To outline acupuncturists' perceptions of treating patients with rheumatoid arthritis (RA), exploring the impact of practitioner affiliation to a traditional or western theoretical base.

METHODS

Qualitative study utilising Grounded Theory Method. Nineteen acupuncturists were chosen via theoretical sampling. In-depth semi-structured interviews were tape-recorded and transcribed. Field notes were also taken. Emerging categories and themes were identified.

RESULTS

Inter-affiliatory differences were identified in the treatments administered and the scope and emphasis of intended therapeutic effects. Limited divergence was found between acupuncturists' perceptions of treatment outcomes. Factors perceived as impacting on treatment outcomes were identified.

CONCLUSIONS

Clinical trials of acupuncture in RA may have failed to administer a treatment which reflects that administered in clinical practice. Outcome measures employed in clinical trials of acupuncture in RA, as well as established outcome indices for RA, may lack the necessary breadth to accurately assess acupuncture's efficacy. Acupuncturist affiliation has demonstrable implications for the practice and research of acupuncture.

Motor neuron abiotrophy in a saluki

A nine-week-old saluki puppy was presented to Tufts University School of Veterinary Medicine for progressive, generalized weakness and bilateral forelimb deformities. Examination suggested a diffuse neuromuscular lesion. Cerebrospinal fluid (CSF) analysis showed normal nucleated cell count and protein level; however, many macrophages had vacuolated cytoplasm. Electromyography (EMG) recordings suggested denervation in paraspinal and appendicular muscles. Tibial motor nerve conduction velocity was normal, but direct evoked muscle potential had reduced amplitude. Histopathology revealed diffuse, symmetrical, degenerative motor neuronopathy of the ventral horn of the spinal cord with associated lesions in nerves and muscles. Histopathology was consistent with an abiotrophy that was likely inherited.

Cytology: screening or diagnostic tool?

Previously used only as a screening tool, cytology now emerges as a powerful diagnostic technique, especially since the advent of the fine needle aspiration (FNA) biopsy. This article highlights the use of ancillary techniques, primarily electron microscopy (EM), and immunohistochemistry (IHC). When coupled with routine cytological examination such as FNA and body cavity fluid cytology, EM and IHC can refine the diagnosis and make it more precise. The authors discuss how to solve common diagnostic dilemmas by the use of cytology along with IHC and EM. The following common diagnostic problems are addressed: mesothelioma versus adenocarcinoma, neuroendocrine neoplasms and their mimickers, melanoma versus carcinoma versus sarcoma, hepatocellular carcinoma versus adenocarcinoma and adenocarcinomas of unknown primary.

Idiopathic epilepsy

Idiopathic epilepsy is one of the most common and treatable neurologic diseases of small animals. The objectives of this article are to present a clinical overview and practical approach to its management. A review of terminology, epidemiologic issues, diagnosis, differential diagnosis, and general principles of treatment are presented.

Diagnosis, treatment, and temporary remission of disseminated paecilomycosis in a vizsla

A case of disseminated paecilomycosis in a three-year-old vizsla is described. Clinical signs of lethargy, weight loss, lymphadenopathy, diarrhea, and vestibulocochlear deficits were exhibited. Dense colonization of bone marrow by the fungus was found early in the disease course. Serial culture of bone-marrow aspirates and in vitro sensitivity testing helped monitor disease progression and guide antifungal therapy. Clinical and laboratory parameters demonstrated marked improvement for a period of 12 weeks. Multisystemic disease with central nervous system involvement was found at necropsy.

Comparison of ThinPrep preparations with conventional cervicovaginal smears. Practical considerations

This study compared cytologic quality, diagnostic accuracy, detection of endocervical and endometrial cells and yeast, screening times and costs for 128 ThinPrep preparations (TP) to the corresponding conventional cervicovaginal cytologic smears (CCVS). Final diagnoses agreed in 114 (89%) cases. There were four discrepancies between atypical squamous cells of undetermined significance and low grade squamous intraepithelial lesion. The number of abnormal cells was lower in TP than in CCVS. Endocervical and endometrial cells were detected less frequently in TP than in CCVS. Yeast forms were seen rarely but were identified in both CCVS and TP. Inflammation and blood were less prominent on TP. While some CCVS showed artifacts related to fixation, cell preservation was optimal in all TP. Screening times were significantly shorter for TP than for CCVS. The combined cost of reagents, preparation and screening for an average TP was $1.78 higher than for a CCVS. We conclude that the use of TP for cervicovaginal smears reduces screening time and produces better cytologic preparations. However, cost-benefit analyses, readjustments in criteria for diagnosis of dysplasia and improvements in the recovery of glandular cells may be necessary before this method is used instead of CCVS.

Retarded bone formation in GM1-gangliosidosis: a study of the infantile form and comparison with two canine models

The development of skeletal lesions in two canine models of GM1-gangliosidosis, English springer spaniels and Portuguese water dogs, has been studied and compared to osseous abnormalities in a child with the infantile form of the disease. In the canine models, skeletal dysplasia was progressive. Lesions were noted at 2 months of age and characterized by retarded endochondral ossification and osteoporosis. Older puppies had focal cartilage necrosis within lumbar vertebral epiphyses. At the cellular level, lesions were characterized by chondrocytic hypertrohy and lysosomal accumulation of storage compounds. Our studies illustrate that the skeletal lesions in both canine models are similar to those in a child with GM1-gangliosidosis. Furthermore, we proposed that the abnormal storage of partially degraded compounds in affected chondrocytes might explain, at least in part, the retarded bone formation noted in patients with GM1-gangliosidosis.

A common source outbreak of gastroenteritis in a teaching hospital

An outbreak of gastroenteritis at a large teaching hospital affected at least 52 workers. Investigation implicated a tuna salad, and the circumstances suggested Clostridium perfringens as the etiologic agent. The risk of such outbreaks may be reduced by cooling of ingredients prior to mixing and refrigeration in small steel containers.

Assessment of gelatin supplementation of PEDS Plus BACTEC blood culture medium

Gelatin supplementation of blood culture media has been shown to neutralize the effects of sodium polyanetholesulfonate and enhance detection of Neisseria species. We evaluated the effect of 1.2% gelatin supplementation of nonradiometric Peds Plus Bactec blood culture medium on the rate and speed of recovery of pathogens from pediatric patients. From June 1991 to June 1992, a total of 6451 paired comparisons of blood cultures in Peds Plus medium and gelatin-supplemented Peds Plus medium were done: 465 organisms were isolated, of which 338 were significant. There were no significant differences in recovery of organisms or the speed of detection of microbial growth between the two media. In particular, the recovery of Neisseria meningitidis (eight isolates) was not improved with gelatin supplementation. In conclusion, gelatin supplementation of Peds Plus Bactec medium does not offer any advantage over the regular Peds Plus Bactec medium.

Adult-onset lysosomal storage disease in a Schipperke dog: clinical, morphological and biochemical studies

An adult-onset lysosomal storage disorder was diagnosed in a 5-year-old Schipperke dog with progressive cerebellar and central vestibular signs. It was characterized by cerebellar atrophy with extensive loss of Purkinje and granular cells, and hydrocephalus. Enlarged and vacuolated neurons were observed in spinal cord and brain; pancreatic centrolobular and islet cells were also vacuolated. Ultrastructurally, enlarged secondary lysosomes laden with lamellated membrane structures were present in neurons and empty enlarged vacuoles were found in pancreatic centroacinar, ductal, and islet cells. On frozen sections neurons stained with Ricinus communis agglutinin-I and wheat germ agglutinin. On paraffin sections neurons stained with luxol fast blue, periodic acid-Schiff, Concanavalia ensiformis agglutinin, and were autofluorescent. These findings indicate an accumulation of glycolipids containing terminal beta-galactosyl and alpha-sialyl residues, and N-linked oligosaccharides. Tissue activity of lysosomal beta-galactosidase was 50% of normal and the activity of beta-hexosaminidase was elevated. Brain lipid-bound sialic acid was twice normal, with a small increase of GM1-ganglioside, but there was a significant elevation of GM2 (GD2) and GM3 (GD3). In addition, significant elevations of sialylated and non-sialylated oligosaccharides were noted. These clinical, biochemical and pathological findings are similar to those observed in human patients with adult-onset galactosialidosis.

Phenobarbital-responsive episodic dyscontrol (rage) in dogs

Episodic dyscontrol (rage) was diagnosed from the clinical history, electroencephalographic findings, and response to oral treatment with phenobarbital in 3 dogs. Clinical features included a mood change heralding aggressive incidents, explosive aggression directed at people or objects, and a postaggressive phase characterized by lethargy and lack of responsiveness. Abnormal electroencephalographic findings included spike activity in the temporal recordings. All 3 dogs responded well to anticonvulsant medication with phenobarbital.

Assessment of gelatin-supplemented BACTEC blood culture medium in a pediatric hospital

Sodium polyanetheolesulfonate (SPS), an anticoagulant used in blood culture media, adversely affects the isolation of Neisseria meningitidis. The addition of gelatin appears to counteract this effect. Studies using the radiometric BACTEC system, however, have noted a lower isolation rate of other bacteria from gelatin-supplemented media. We wished to evaluate the effect of the addition of gelatin (1.2%) to a nonradiometric BACTEC aerobic medium (NR6A) on the recovery of N. meningitidis and other pathogens. The NR6A medium with gelatin (NR6A analogue) also contained a lower concentration of SPS (0.025% vs 0.035%). We did 6045 paired comparisons of blood cultured in routine NR6A medium and the NR6A analogue. Eight isolates of N. meningitidis were recovered, five only from the gelatin-supplemented medium and three from both bottles. There was no statistically significant difference in total recovery of aerobic and facultative bacteria or Candida species from both bottles. Haemophilus influenzae was detected earlier in the nonsupplemented NR6A medium. We conclude that the use of the NR6A analogue medium appeared to increase the yield of N. meningitidis without adversely affecting the recovery of other common pathogens, although the recovery of H. influenzae was slightly delayed.

Canine GM1-gangliosidosis. A clinical, morphologic, histochemical, and biochemical comparison of two different models

The clinical, morphologic, histochemical, and biochemical features of GM1-gangliosidosis in two canine models, English Springer Spaniel (ESS) and Portuguese Water Dog (PWD), have been compared. The disease onset, its clinical course, and survival period of the affected dogs were similar in both models. Skeletal dysplasia was noted radiographically at 2 months of age, whereas at 4 1/2 months of age there was progressive neurologic impairment. However, dwarfism and coarse facial features were seen only in ESS. Both models had similar deficiency in activity of lysosomal beta-galactosidase, but possessed a normal protein activator for GM1-beta-galactosidase. Both models stored GM1-ganglioside, asialo-GM1, and oligosaccharides in brain. Furthermore, only the PWD stored glycoproteins containing polylactosaminoglycans in visceral organs, and neither model stored them in the brain. Morphologically, both models demonstrated similar storage material in multiple tissues and cell types. The ultrastructure of the storage material was cell-type specific and identical in both models. However, some differences in the lectin staining pattern were noted. Our clinical, biochemical, and histochemical findings indicate that PWD and ESS may represent two different mutations of the beta-galactosidase gene. Moreover, the authors conclude that it is difficult, and inappropriate, to apply the human classification of GM1-gangliosidosis (i.e. infantile, juvenile, and adult forms) to these canine models.

Reduction of spiral ganglion neurons in the aging canine with hearing loss

The middle and inner ears of 16 dogs, from 1.5 to 17 years of age, with differing degrees of suspected hearing loss were examined. Auditory function was assessed subjectively, and electrophysiologically by recording brainstem auditory-evoked responses (BAER) to click stimuli. Ossicular chains and stapediovestibular articulations were evaluated macroscopically and by light microscopy for evidence of bony ankylosis; no abnormalities were found. A determination of spiral ganglion packing density revealed a loss of spiral ganglion cells in all areas of the cochlea in dogs of the deaf group and in the upper and lower basal region of dogs from the hearing impaired group. The largest losses of spiral ganglion cells in the deaf group were located in the upper and lower basal region. The deaf group's density was reduced to 44% (upper basal) 15% (lower basal) of the normal hearing group. The largest spiral ganglion cell loss for dogs in the hearing impaired group occurred in the lower basal region where the density was reduced to 40% of the normal hearing group. These morphological findings in the aging canine are consistent with a peripheral nerve hearing loss.