Detection Of Reflux Research Articles

Simultaneous determination of three alkaloids in Huperzia serrata by UPLC-PDA and UPLC-Q/TOF-MS

An analytical method based on reflux extraction and detection by UPLC-PDA was established.

Vesicoureteral reflux detection with reliable probabilistic outputs

Vesicoureteral Reflux (VUR) is a pediatric disorder in which urine flows backwards from the bladder to the upper urinary tract. Its detection is of great importance as it increases the risk of a Urinary Tract Infection, which can then lead to a kidney infection since bacteria may have direct access to the kidneys. Unfortunately the detection of VUR requires a rather painful medical examination, called voiding cysteourethrogram (VCUG), that exposes the child to radiation. In an effort to avoid the exposure to radiation required by VCUG some recent studies examined the use of machine learning techniques for the detection of VUR based on data that can be obtained without exposing the child to radiation. This work takes one step further by proposing an approach that provides lower and upper bounds for the conditional probability of a given child having VUR. The important property of these bounds is that they are guaranteed (up to statistical fluctuations) to contain well-calibrated probabilities with the only requirement that observations are independent and identically distributed (i.i.d.). Therefore they are much more informative and reliable than the plain yes/no answers provided by other techniques.

24-h multichannel intraluminal impedance-pH monitoring may be an inadequate test for detecting gastroesophageal reflux in patients with mixed typical and atypical symptoms.

The detection of gastroesophageal reflux (GERD) via pH testing is the key component of the evaluation of patients considered for antireflux surgery. Two common pH testing systems exist, a multichannel, intraluminal impedance-pH monitoring (MII-pH) catheter, and wireless (Bravo(®)) capsule; however, discrepancies between the two systems exist. In patients with atypical symptoms, MII-pH catheter is often used preferentially. We aimed to elucidate the magnitude of this discrepancy and to assess the diagnostic value of MII-pH and the Bravo wireless capsule in a population of patients with mixed respiratory and typical symptoms. The study population consisted of 66 patients tested with MII-pH and Bravo pH testing within 90 days between July 2009 and 2013. All patients presented with laryngo-pharyngo-respiratory (LPR) symptoms. Patient demographics, symptomatology, manometric and endoscopic findings, and pH monitoring parameters were analyzed. Patients were divided into four comparison groups: both pH tests positive, MII-pH negative/Bravo positive, MII-pH positive/Bravo negative, and both pH tests negative. Nearly half of the patients (44%) had discordant pH test results. Of these, 90% (26/29) had a negative MII-pH but positive Bravo study. In this group, the difference in the DeMeester score was large, a median of 29.3. These patients had a higher BMI (28.5 vs. 26.1, p = 0.0357), were more likely to complain of heartburn (50 vs. 23%, p = 0.0110), to have a hiatal hernia, (85 vs. 53%, p = 0.0075) and a structurally defective lower esophageal sphincter (LES, 85 vs. 58%, p = 0.0208). In patients with LPR symptoms, we found a high prevalence of discordant esophageal pH results, most commonly a negative MII-pH catheter and positive Bravo. As these patients exhibited characteristics consistent with GERD (heartburn, defective LES, hiatal hernia), the Bravo results are likely true. A 24-h MII-pH catheter study may be inadequate to diagnose GERD in this patient population.

Exhaled Breath Condensate Pepsin: Potential Noninvasive Test for Gastroesophageal Reflux in COPD and Bronchiectasis.

Acid gastroesophageal reflux is a common problem in non-cystic fibrosis bronchiectasis and COPD. Invasive methods are used to diagnose gastroesophageal reflux, but the ability to detect pulmonary microaspiration of gastric contents using this method is unclear. A noninvasive option to detect pulmonary microaspiration is to measure pepsin in exhaled breath condensate (EBC), but this has not been related to esophageal pH monitoring in these lung conditions. This study aimed to measure pepsin concentrations and pH in EBC and to determine the relationship to gastroesophageal reflux in bronchiectasis or COPD. Subjects with bronchiectasis (n=10) or COPD (n=10) and control subjects (n=10) completed 24-h esophageal pH monitoring for detection of acid gastroesophageal reflux, measuring the percentage of reflux time in the proximal esophagus and the DeMeester score (DMS). Concurrently, 3 samples of EBC were collected from each subject, and pH was measured and pepsin concentrations were analyzed by enzyme-linked immunosorbent assay. EBC pepsin was detected in subjects with bronchiectasis (44%) or COPD (56%) and in control subjects (10%). A diagnosis of gastroesophageal reflux was not associated with a higher concentration of EBC pepsin in bronchiectasis (P=.21) or COPD (P=.11). EBC pepsin concentration did not correlate with DMS (rs=0.36) or proximal reflux index (rs=0.25) in subjects with bronchiectasis or with DMS (rs=0.28) or proximal reflux index (rs=0.21) in patients with COPD. EBC and sputum pepsin concentrations were moderately correlated in bronchiectasis (rs=0.56) and in COPD (rs=0.43). Pepsin is detectable in EBC samples in bronchiectasis and COPD. Although no association was found between pepsin concentrations and a diagnosis of gastroesophageal reflux, a moderate relationship between sputum and EBC pepsin concentrations suggests that EBC pepsin may be a useful noninvasive marker of pulmonary microaspiration.

Paediatric vesicoureteric reflux imaging: where are we? Novel ultrasound-based voiding urosonography.

Vesicoureteric reflux is an important association of paediatric urinary tract infection. Fluoroscopic micturating cystourethrography and radionuclide cystography have been employed for detecting and grading vesicoureteric reflux. However, both modalities involve ionising radiation, which can pose significant radiation risk to growing children. They also have a lower detection rate due to intermittent fluoroscopic technique in micturating cystourethrography, and lower spatial resolution in radionuclide cystography. Therefore, newer radiation-free ultrasound-based contrast-enhanced voiding urosonography has been developed in Europe for 15 years. This article aimed to summarise the current literature and discuss the first local pilot study in our institution on detection of vesicoureteric reflux by contrast-enhanced voiding urosonography. Contrast-enhanced voiding urosonography is a valid alternative to micturating cystourethrography in assessing vesicoureteric reflux, based on its superior diagnostic performance, reliability, safety, feasibility, and radiation safety for children. Therefore, it should be incorporated in the guideline for investigating paediatric urinary tract infection.

The value of direct radionuclide cystography in the detection of vesicoureteral reflux in children with normal voiding cystourethrography.

Vesicoureteral reflux (VUR) is one of the most important risk factors for urinary tract infection (UTI). Diagnosis and treatment of VUR is important to prevent irreversible complications, such as renal scarring and chronic renal failure. This study was conducted to assess the value of direct radionuclide cystography (DRNC) in the detection of VUR in children with UTI and a normal voiding cystourethrography (VCUG). DRNC was performed in 35 children with a normal VCUG after an episode of febrile UTI who had hydronephrosis or hydroureter, abnormal acute dimercaptosuccinic acid (DMSA) scan results and/or febrile UTI recurrence. This study was conducted in the nephrology department of Mofid Children's Hospital, Tehran (Iran). The results were statistically analyzed. Among the 70 ureters studied, 33 (49.1 %) were observed to have VUR. Of these, 17 (51.5 %) had mild, 14 (42.4 %) moderate, and 2 (6.1 %) severe reflux. A significant relationship was observed between DRNC results and DMSA renal scan findings (P < 0.05). Based on our results, we suggest that DRNC may reveal VUR despite a normal VCUG in children with hydronephrosis, abnormal acute DMSA, and/or recurrent febrile UTI.

Associations of anterior accessory or thigh posterior tributary and great saphenous reflux patterns in early stages of chronic venous valvular insufficiency

Varicose veins are a common disorder. Extensive ultrasound (US) mapping of lower extremity chronic venous valvular insufficiency includes the great saphenous vein (GSV), anterior accessory saphenous vein (AASV) and thigh posterior tributary to GSV such as the posterior accessory saphenous vein (PTSV, PASV). The aim of this study was to determine associations between GSV-AASV-PTSV (including PASV) reflux in a specific sample population of Southern Brazilian women, mostly euro descendents, with telangiectasias, reticular veins, varices and/or intermittent edema. US performed in 1016 extremities of 513 women, 43±18 (18-81) years old were included. Women with previous venous thrombosis, surgery, suspicion of pelvic congestion syndrome, and men were excluded. Small saphenous vein and related thigh veins were excluded from analysis. GSV-AASV-PTSV reflux patterns were analyzed; prevalence was compared using χ2 statistics. Reflux prevalence in AASV and/or thigh PTSV was 5.8% (59/1016): 1.3% at PTSV (n=13) and 4.5% at AASV (n=46), significantly lower than GSV reflux: 72% (n=727) (P&lt;0.001). AASV and/or PTSV reflux was associated with GSV reflux (81%, n=48/59); common pattern was diffuse reflux, starting at AASV/PTSV saphenous junctions (56%, n=33/59; otherwise, short, non-diffuse reflux was noted in part of the AASV/PTSV evaluated. Isolated AASV or PTSV reflux was rare (1%, n=11/1016): 9 at the AASV, and 2 at the PTSV. US mapping of AASV/PTSV in early stages of disease, in women without pelvic congestion syndrome, increased reflux detection by 1%, and improved definition of reflux patterns in about 6% of the extremities.

524 Toward Complete Identification of Patients With GERD; 96-Hour Wireless pH Monitoring Increases Reflux Detection Rate

Introduction: Accurate and complete identification of patients with symptoms secondary to gastroesophageal reflux disease has been a clinical challenge. This has led to the classification, perhaps erroneously, of some patients as 48-hour wireless pH monitoring has been shown to increase the diagnostic yield of reflux detection. We hypothesize that 96-hour monitoring would further increase reflux detection rate. Methods: The study population consisted of 31 patients who underwent 96-hour wireless pHmonitoring between February 2012 and October 2013.Patients with incomplete studies due to capsule dislodgement or failed signal transmission, achalasia, previous antireflux or gastric bypass surgery were excluded. Patient demographics, presenting symptoms, manometric and pHmonitoring parameters were collected and compared. Patients were divided into pH negative, single day positive or multiple day positive groups for comparison. All studies were done off PPI medications for at least 7 days. A positive study was defined by DeMeester score >14.72 on any day. Results: Eighteen (58%) of the 31 patients were negative on all 4 days, 7 (23%) were positive on a single day and 6 (19%) were positive on multiple days. Thirteen percent of the patients (4/31) were only positive on day 3 or day 4 and would have been considered normal on a 48 hour study. Lower esophageal sphincter (LES) parameters correlated with the number of pH positive days including LES overall length ( σ=-0.43, p=0.02), IBP (σ=0.41, p=0.02) and IRP (σ=-0.54, p=0.003). Mean axial separation between the LES and CD, 0.16cm in pH negative, 0.66cm in patients with one day positive and 0.26 in patients with multiple days positive (p=0.1506). Conclusions: 96 hour wireless pH monitoring identified pathologic esophageal acid exposure in 13% of patients who would have been considered normal on 48 hour study. These patients are more likely to have less profound alteration in characteristics of the gastroesopahgeal barrier including LES length and axial crural diaphragm separation. Prolonged 96-hour pH monitoring may be necessary before classifying patients as GERD negative or functional heartburn.

525 Development of a Prognostic Nomogram for the Need for Surgery After Endoscopic Balloon Dilatation of Ileocolic Anastomotic Stricture for Crohn's Disease

Introduction: Accurate and complete identification of patients with symptoms secondary to gastroesophageal reflux disease has been a clinical challenge. This has led to the classification, perhaps erroneously, of some patients as 48-hour wireless pH monitoring has been shown to increase the diagnostic yield of reflux detection. We hypothesize that 96-hour monitoring would further increase reflux detection rate. Methods: The study population consisted of 31 patients who underwent 96-hour wireless pHmonitoring between February 2012 and October 2013.Patients with incomplete studies due to capsule dislodgement or failed signal transmission, achalasia, previous antireflux or gastric bypass surgery were excluded. Patient demographics, presenting symptoms, manometric and pHmonitoring parameters were collected and compared. Patients were divided into pH negative, single day positive or multiple day positive groups for comparison. All studies were done off PPI medications for at least 7 days. A positive study was defined by DeMeester score >14.72 on any day. Results: Eighteen (58%) of the 31 patients were negative on all 4 days, 7 (23%) were positive on a single day and 6 (19%) were positive on multiple days. Thirteen percent of the patients (4/31) were only positive on day 3 or day 4 and would have been considered normal on a 48 hour study. Lower esophageal sphincter (LES) parameters correlated with the number of pH positive days including LES overall length ( σ=-0.43, p=0.02), IBP (σ=0.41, p=0.02) and IRP (σ=-0.54, p=0.003). Mean axial separation between the LES and CD, 0.16cm in pH negative, 0.66cm in patients with one day positive and 0.26 in patients with multiple days positive (p=0.1506). Conclusions: 96 hour wireless pH monitoring identified pathologic esophageal acid exposure in 13% of patients who would have been considered normal on 48 hour study. These patients are more likely to have less profound alteration in characteristics of the gastroesopahgeal barrier including LES length and axial crural diaphragm separation. Prolonged 96-hour pH monitoring may be necessary before classifying patients as GERD negative or functional heartburn.

Objective Detection of Esophagopharyngeal Reflux in Patients With Hoarseness and Endoscopic Signs of Laryngeal Inflammation

We aimed to quantify pharyngeal exposure to gastric contents in patients diagnosed with reflux-related hoarseness and healthy controls using new diagnostic techniques. Hoarseness with typical signs on laryngoscopy is commonly thought to be caused by esophagopharyngeal reflux. New methods are proposed to assess pharyngeal exposure to gastric contents. They are suggested to measure: (1) liquid or mixed gas-liquid acid and nonacid reflux with impedance pH, (2) aerosolized acid reflux (Dx-pH measuring system), and (3) pepsin in the saliva. Twenty-one patients with hoarseness and positive laryngoscopy and 10 controls underwent simultaneous impedance pH, Dx-pH monitoring, and saliva pepsin sampling (5 samples in 24 h). Of the 21 patients, 10 had impedance pH-detected reflux plus at least 1 other test positive. These patients were more likely to have symptomatic relief after proton pump inhibitor therapy. Three of the 21 patients had all 3 tests positive and 4 had all tests negative. None of the controls had impedance pH-detected reflux. Two controls had a positive Dx-pH "RYAN score" and 1 control had >1 saliva sample positive for pepsin. Only 11% of Dx-pH drops to pH<4, 15% pH drops to pH<5, and 10% of pH drops to pH<5.5 coincided with impedance pH-detected reflux in the esophageal body. Positive pepsin saliva samples were preceded by more reflux events [3 (range, 0 to 10)] in the previous 60 minutes than negative samples [0 (range, 0 to 7)] (P<0.0001). A subgroup of patients with hoarseness (10/21) had objective detection of the esophagopharyngeal reflux. We propose that these patients are more likely to benefit from further intense antireflux therapy. Detection of pepsin in the saliva may be a useful screening tool in these patients.

Voiding urosonography with second-generation ultrasound contrast versus micturating cystourethrography in the diagnosis of vesicoureteric reflux

Vesicoureteric reflux has been associated with paediatric urinary tract infection. Fluoroscopic micturating cystourethrography (MCU) has been the gold standard of diagnostic test for decades; however, it has been criticized owing to its lower detection rate and radiation dose to children. Therefore, new radiation-free reflux imaging modalities have been developed, in which ultrasound-based contrast-enhanced voiding urosonography (ceVUS) is a good example. However, ultrasonography has been considered as an operator-dependent examination. Therefore, our study aimed to examine the inter-observer agreement of this sonographic technique, which has not been evaluated before. Moreover, the second-generation ultrasound contrast SonoVue has been recently marketed, and the data on its efficacy on intravesical use in ceVUS is relatively scarce. Thus, we also aimed to investigate the diagnostic performance and safety profile of SonoVue-enhanced VUS in the diagnosis of vesicoureteric reflux. Our prospective comparative study compared the diagnostic performance of ceVUS with MCU in young children presenting with first episode of urinary tract infection. We performed sequential ceVUS and MCU examinations in 31 patients (62 pelvi-ureter units). Perfect inter-observer agreement (Cohen’s kappa statistics = 1.0, p < 0.001) was achieved in ceVUS, suggesting its good reliability in reflux detection and grading. Using MCU as reference, ceVUS had 100 % sensitivity and 84 % specificity and carried higher reflux detection rate than MCU (p < 0.001). There was no complication encountered. Conclusion: Voiding urosonography is a reliable, sensitive, safe and radiation-free modality in the investigation of vesicoureteric reflux in children. It should be incorporated in the diagnostic algorithm in paediatric urinary tract infection.

Multichannel Intraluminal Impedance–pH Testing Is Clinically Useful in the Management of Patients with Gastroesophageal Reflux Symptoms

Multichannel intraluminal impedance-pH testing (MII-pH) allows for the detection of acid and non-acid reflux, thus, increasing yield over pH testing. Limited data exist on how physicians use test results in practice. The aim of our study was to evaluate the influence of MII-pH testing on patient care. We reviewed records of patients with symptoms of gastroesophageal reflux disease who underwent MII-pH testing. Management decisions evaluated included changes in prescribed medications and surgical consultation for anti-reflux surgery. Statistical analysis was performed using Pearson Chi square test, and multivariable logistic regression. MII-pH testing resulted in a medication change in 41% of patients, surgical consultation in 19.7%, and anti-reflux surgery in 11.1%. In patients who were not on proton pump inhibitor (PPI) therapy, MII-pH results were most useful in the decision to start a PPI. On PPI therapy, results were more often used to decide whether to increase (32.3%) or switch the PPI (23.5%) in patients with continued acid reflux. Results were most useful to stop the PPI in normal studies (11.1%). More patients with non-acid reflux (14.3%) and normal results (19.7%) were started on a neuromodulator compared to other diagnoses. The MII-pH result was most useful in the decision to start baclofen or bethanecol when the patient was found to have non-acid reflux (25%). Patients with an abnormal MII-pH or abnormal MII alone were more likely to be referred to surgery (OR 19.5, p < 0.001; OR 19.77, p < 0.001). MII-pH testing impacted medical or surgical management in over half the patients tested.

Contrast-enhanced voiding urosonography with intravesical administration of a second-generation ultrasound contrast agent for diagnosis of vesicoureteral reflux: prospective evaluation of contrast safety in 1,010 children

To evaluate the safety of intravesical administration of a second-generation ultrasound (US) contrast agent for the diagnosis of vesicoureteral reflux in children. One thousand and ten children (563 girls, 447 boys; mean age: 2.9 years, range: 15 days-17.6 years) with 2,043 pelvi-ureter-units underwent contrast-enhanced voiding urosonography (ce-VUS) to rule out vesicoureteral reflux. A second-generation US contrast agent (SonoVue®, Bracco, Milan) was administered intravesically through transurethral bladder catheterization at a dose of 0.5 ml/bladder filling. Possible adverse events were monitored during the examination and followed up for 7 days after ce-VUS by phone calls. Urine analysis and culture were performed 3-5 days before ce-VUS in all children and 24-48 h in any patient who reported with adverse events. No case of serious adverse event was recorded. Minor events were reported in 37 children (3.66% of the study population). These included dysuria (n = 26, 2.57%), urinary retention (n = 2, 0.2%), abdominal pain (n = 2, 0.2%), anxiety (n = 1, 0.1%) and crying (n = 1, 0.1%) during micturition, blood and mucous discharge (n = 1, 0.1%), increased frequency of micturition (n = 1, 0.1%), vomiting (n = 1, 0.1%), perineal irritation (n = 1, 0.1%), and an episode of urinary tract infection 10 days after ce-VUS (n = 1, 0.1%). Of these adverse events, 91.9% were subacute in onset and 8.1% were delayed. All events were self-limited and none required hospitalization. There were no serious adverse events. Only a few minor events were reported, most likely due to the catheterization process. Thus, ce-VUS with intravesical administration of the second-generation US contrast agent (SonoVue®) for vesicoureteral reflux detection or exclusion had a favorable safety profile in our study group.

The diagnostic value of gastroesophageal reflux disease (GERD) symptoms and detection of pepsin and bile acids in bronchoalveolar lavage fluid and exhaled breath condensate for identifying lung transplantation patients with GERD-induced aspiration

Gastroesophageal reflux disease (GERD) is thought to lead to aspiration and bronchiolitis obliterans syndrome after lung transplantation. Unfortunately, the identification of patients with GERD who aspirate still lacks clear diagnostic indicators. The authors hypothesized that symptoms of GERD and detection of pepsin and bile acids in the bronchoalveolar lavage fluid (BAL) and exhaled breath condensate (EBC) are effective for identifying lung transplantation patients with GERD-induced aspiration. From November 2009 to November 2010, 85 lung transplantation patients undergoing surveillance bronchoscopy were prospectively enrolled. For these patients, self-reported symptoms of GERD were correlated with levels of pepsin and bile acids in BAL and EBC and with GERD status assessed by 24-h pH monitoring. The sensitivity and specificity of pepsin and bile acids in BAL and EBC also were compared with the presence of GERD in 24-h pH monitoring. The typical symptoms of GERD (heartburn and regurgitation) had modest sensitivity and specificity for detecting GERD and aspiration. The atypical symptoms of GERD (aspiration and bronchitis) showed better identification of aspiration as measured by detection of pepsin and bile acids in BAL. The sensitivity and specificity of pepsin in BAL compared with GERD by 24-h pH monitoring were respectively 60 and 45%, whereas the sensitivity and specificity of bile acids in BAL were 67 and 80%. These data indicate that the measurement of pepsin and bile acids in BAL can provide additional data for identifying lung transplantation patients at risk for GERD-induced aspiration compared with symptoms or 24-h pH monitoring alone. These results support a diagnostic role for detecting markers of aspiration in BAL, but this must be validated in larger studies.

Esophageal pH and Combined Impedance-pH Monitoring in Children.

Esophageal pH monitoring is considered the gold standard for the diagnosis of gastroesophageal reflux disease because of the normal ranges across the pediatric age range. However, this method can only detect acid reflux. Multichannel intraluminal impedance-pH (MII-pH) monitoring has recently been used for the detection of bolus reflux in infants and children. This method allows for the detection of liquid, gas or mixed reflux in addition to acid, weakly acidic or weakly alkaline reflux. MII-pH monitoring can record the direction of flow and the height of reflux, which are useful parameters to identify an association between symptoms and reflux. However, the technique is limited by its high cost and the lack of normative data of MII-pH in the pediatric population. Despite certain limitations, MII-pH monitoring will become more common and gradually replace pH monitoring in the future, because pH monitoring is part of MII-pH.

Pharyngeal pH alone is not reliable for the detection of pharyngeal reflux events: A study with oesophageal and pharyngeal pH-impedance monitoring.

Pharyngeal pH probes and pH-impedance catheters have been developed for the diagnosis of laryngo-pharyngeal reflux. To determine the reliability of pharyngeal pH alone for the detection of pharyngeal reflux events. 24-h pH-impedance recordings performed in 45 healthy subjects with a bifurcated probe for detection of pharyngeal and oesophageal reflux events were reviewed. Pharyngeal pH drops to below 4 and 5 were analysed for the simultaneous occurrence of pharyngeal reflux, gastro-oesophageal reflux, and swallows, according to impedance patterns. Only 7.0% of pharyngeal pH drops to below 5 identified with impedance corresponded to pharyngeal reflux, while 92.6% were related to swallows and 10.2 and 13.3% were associated with proximal and distal gastro-oesophageal reflux events, respectively. Of pharyngeal pH drops to below 4, 13.2% were related to pharyngeal reflux, 87.5% were related to swallows, and 18.1 and 21.5% were associated with proximal and distal gastro-oesophageal reflux events, respectively. This study demonstrates that pharyngeal pH alone is not reliable for the detection of pharyngeal reflux and that adding distal oesophageal pH analysis is not helpful. The only reliable analysis should take into account impedance patterns demonstrating the presence of pharyngeal reflux event preceded by a distal and proximal reflux event within the oesophagus.

Long-Term Follow-Up of Children with Congenital Diaphragmatic Hernia—Observations from a Single Institution

Congenital diaphragmatic hernia (CDH) is a complex malformation. The majority of children after CDH repair lead normal life, with good exercise tolerance. However, in some patients, long-term sequelae are observed, resulting from the primary defect and implemented treatment. We evaluated (basing on clinical examination and review of medical records) the incidence of the most common long-term complications after surgical repair of CDH and determined their risk factors. The study group comprised 50 children operated in our department for CDH. The following long-term complications were seen: recurrent respiratory system infections (34%), pathological gastrointestinal reflux (30%), body mass deficiency (20%), and chest deformations (40%). Parents reported most common symptoms from the gastrointestinal tract (48%) and recurring respiratory system infections (34%). Perfusion of the ipsilateral lung was significantly lower in the group of children in whom negative prognostic factors were present: patch repair, transposition of the liver up CDH, lung hypertension in echocardiography, high-frequency oscillatory ventilation (HFOV) use, prolonged artificial ventilation. In lung scintigraphy, in 70% of patients ipsilateral lung hypoplasia was found. There was a correlation between gastroesophageal reflux (GER) and early detection of CHD in prenatal studies and the presence of polyhydramnios. Patients with GER also required longer artificial ventilation and longer hospitalization. Significant body mass deficiency (below 3rd centile) was found in 20%, correlated with patch repair and HFOV. Chest deformations were more common in children who required synthetic patch repair and artificial ventilation for longer than 10 days. The most common long-term complications observed in children after CDH repair are recurrent infections of the respiratory tract, lung hypoplasia, pathological GER, somatic growth abnormalities, and skeletal deformations. Children operated for CDH should be followed up regularly for many years by a multispecialty medical team. Diagnostics and/or follow-up of the above complications require detailed clinical examination, lung perfusion scintigraphy, spirometry, and 24-hour pH-metry.

Management of gastro-oesophageal reflux disease symptoms that do not respond to proton pump inhibitors

Treatment-refractory gastro-oesophageal reflux disease (GERD) remains a significant problem in the gastroenterology clinic. In recent years, several studies have investigated the assessment and treatment of refractory GERD. Patients presenting with 'refractory GERD' in fact represent a quite heterogeneous group consisting of those with ongoing reflux-related symptoms and those with reflux-unrelated problems such as functional heartburn, dyspepsia or even eosinophilic oesophagitis. The greatest symptom indicators of persistent true reflux are retrosternal burning and acid taste in the mouth alone. Combined pH-impedance studies allow detection of reflux regardless of pH, and weakly acidic reflux has been suggested as a mechanism of residual symptoms in some patients. The use of reflux-symptom association calculations may help to determine the symptom causation, but refinement and outcome studies are needed. New treatments of refractory GERD have been disappointing. Surgery remains an option in very carefully selected patients, but again better outcome studies are required. Careful history and investigation is required in the assessment of the proton pump inhibitor (PPI)-refractory patient. Care to exclude alternative diagnoses is needed, and to phenotype those with reflux-related symptoms. Optimization of PPI therapy may help, as may surgery in selected patients.

Comparison of Renal Ultrasound and Voiding Cystourethrography (VCUG) in the Detection of Vesicoureteral Reflux

Introduction: This study evaluates the accuracy of renal ultrasonography (US) in the detection of vesicoureteral reflux (VUR) compared to voiding cystourethrography (VCUG).&#x0D; Methods: We retrospectively reviewed the medical records of 131 children with urinary tract infection. Ultrasound findings were considered to be suggestive of VUR if a “pelvocalyceal dilatation”‚ “retrovesical ureteral dilatation” and/or an “increase in one or both kidneys’ size” were reported.&#x0D; Results: Ultrasound findings were positive for VUR in 5 of 24 patients with confirmed VUR on VCUG, and were negative in all of 107 patients without VUR on VCUG. Altogether, of the 131 children‚ 24 had reflux on VCUG, 19 (79%) of who had no sonographic findings suggestive for reflux. The sensitivity and specificity of ultrasound in Suggesting VUR were 20% and 100%, respectively.&#x0D; Conclusion: The results of this study showed that ultrasonography cannot accurately detect or predict vesicoureteral reflux. This outcome should be mentioned by clinicians in evaluation of patients with complaints which are suggestive for VUR.

Differences in Saphenous Vein Reflux Detection According to Patient Positioning

Objective —To demonstrate differences in saphenous reflux detection performed with the use of a simplified protocol with the patient in the supine or reverse Trendelenburg positions (nonstanding) compared with an extensive protocol with the patient standing. Methods —Reflux detection in the standing and nonstanding positions were compared for measurements at the great saphenous vein (GSV-thigh, GSV-calf), small saphenous vein (SSV), and common femoral vein/saphenofemoral junction (CFV/SFJ). Reflux longer than 1 sec was considered a positive finding. A total of 171 measurement comparisons were made in 40 extremities of 20 women, ages 54 ± 13 years (range 34–82), all evaluated for varicose veins. False-negative (FN) results were calculated for standing and nonstanding positions compared with positive results obtained in the other position. Results —FN results in the nonstanding position were 49% (16/33), 38% (12/32), 27% (12/45), and 26% (9/35) for GSV-calf, GSV-thigh, SSV, and CFV/SFJ, respectively. FN results for the standing position were 6% (1/18) and 7% (2/28) for GSV-calf and CFV/SFJ, respectively. Technologists perceptions were that coaptable veins in the nonstanding position and detection of low-velocity reflux in the standing position influenced the results. Conclusions —The data collected favored evaluation of saphenous vein reflux in women with varicose veins in the standing position.