Non-reflux Group Research Articles

Lower respiratory tract microbiota in patients with clinically suspected nontuberculous mycobacterial pulmonary disease according to the presence of gastroesophageal reflux.

Although gastroesophageal reflux has been recognized as one of the risk factors of nontuberculous mycobacterial pulmonary disease (NTM-PD) progression, the effect of reflux on the lower respiratory tract microbiota has not been studied in detail. We investigated the composition of the lower respiratory tract microbiota in patients with clinically suspected NTM-PD, comparing them based on the presence of reflux. Forty-seven patients suspected of having NTM-PD were enrolled and assigned according to presence of reflux (n = 22) and non- reflux (n = 25). We performed a pepsin ELISA assay to identify the presence of reflux and 16S ribosomal RNA gene amplicon sequencing to evaluate the microbiota in bronchoalveolar lavage fluid. There were no significant differences in the diversity or composition of the lower respiratory microbiota between the NTM-PD and non-NTM-PD groups. Bacterial richness was observed in the non-reflux group than in the reflux group [P = 0.03] and a cluster in the reflux group was observed. The reflux group showed a predominance for Pseudomonas aeruginosa or Staphylococcus aureus among the NTM-PD group and for P. aeruginosa, Haemophilus influenzae, Klebsiella pneumoniae, or Eikenella species among the non-NTM-PD group. The non-reflux groups presented diverse patterns. A linear discriminant analysis and volcano plot demonstrated that P. aeruginosa, H. haemolyticus, Selenomonas artemidis, and Dolosigranulum pigrum were specifically associated with the NTM-PD reflux group, while P. aeruginosa was specifically associated with the non-NTM-PD reflux group. These observations confirm that the lower respiratory microbiota is consistently altered by reflux but not in NTM-PD.

Refluxing versus Non-Refluxing Ureteric Implantation in Continent Cutaneous Urinary Diversion: A Propensity-Scored Comparison regarding Long-Term Renal, Metabolic, and Functional Outcomes of Patients with Ileocecal Pouch

Introduction: Studies comparing refluxing versus non-refluxing ureteric implantation in continent cutaneous urinary diversion (CCUD) are scarce and often characterized by heterogeneous study populations. This work therefore aimed at comparing both techniques regarding long-term outcomes in a propensity-scored approach. Methods: We identified n = 19 patients, totaling n = 38 renal units (RU), who underwent CCUD surgery at our hospital out of a pool of 120 patients. Of these 38 RU, 27 RU were implanted via refluxing ureteric implantation utilizing various procedures due to special intraoperative circumstances (short ureters, damage due to radiation). In terms of preoperative renal function, a comorbidity index (Age-Adjusted Charlson Comorbidity Index [ACCI]), and gender, we compared them to n = 38 patients with a total of 76 RU with non-refluxing ureteric implantation in all RU (1:2 matching). The mean follow-up was 56 (IQR: 23–112) months. Results: Long-term renal function was comparable in CCUD patients receiving refluxing versus non-refluxing ureteric implantation (estimated glomerular filtration rate: 63.11 mL/min vs. 71.7 mL/min, p = 0.22) with an average decline of 17.4 mL/min and 13.69 mL/min during the follow-up period, respectively. Also, the rate of new-onset chronic kidney disease (CKD) (both 15%, p = 1), the need for alkalizing medication, or the number of pyelonephritis episodes did not significantly differ between the groups. In Cox regression analysis, ACCI was the single most predictive parameter for the development of new-onset CKD (HR: 1.71 [1.10–2.66], p = 0.0167). None of the RU in the refluxing group needed revisional surgery concerning the ureterointestinal anastomosis, whereas 7 RU of the non-refluxing group did. Conclusions: Our study confirms that refluxing ureteric implantation in CCUDs is a valid and safe procedure regarding long-term renal, metabolic and functional outcomes. Our data also suggest that patients should be counseled according to their comorbidities regarding long-term renal function.

The Role of Slurry Reflux in a Corn Stalk Continuous Anaerobic Digestion System: Performance and Microbial Community.

Slurry reflux is a low-cost slurry reduction technology, which can solve the problem that a large amount of slurry cannot be completely consumed in a biogas plant. Anaerobic digestion (AD) of corn stalks with slurry reflux and non-reflux was compared and evaluated in continuous anaerobic digestion to clarify the effects of slurry reflux on AD with organic loading rate (OLR) variation. It was found that slurry reflux increased cumulative methane production and improved system stability. The average methane yield of the slurry reflux group was 224.19 mL/gVS, which was 41.35% higher than that of the non-reflux group. High-throughput sequencing results showed that slurry reflux increased the microbial community richness. The dominant microorganisms in the reflux group were in phylum Bacteroidetes, which have the capacity to degrade polymers, and Methanothrix, which is an aceticlastic methanogen. The relative abundances of Bacteroidetes and Methanothrix were 32.41% and 41.75%, respectively. Clostridium III and Saccharofermentans, which are related to syntrophic acetate oxidation and hydrolysis, were increased in relative abundance in the slurry reflux system. The increase of the OLR altered the main methane-producing pathway from the acetoclastic methanogenic pathway to the hydrogenotrophic methanogenic pathway in the AD system, and the slurry reflux can delay this trend. This study provided an effective way for the reduction and utilization of slurry in a biogas plant.

Diameter-reflux relationship of the saphenous vein in the C0-C3 patients of chronic venous disease.

To evaluate the relationship between the saphenous vein's diameter and reflux and determine the cut point of the saphenous vein's diameter that indicates lack of reflux. A retrospective cohort study conducted in 807 limbs underwent the venous ultrasound for 36months. The saphenous vein's diameter in the reflux and non-reflux groups was evaluated. The receiver operating characteristics (ROC) curve was constructed to determine the saphenous vein's diameter that maximizes the summation of sensitivity and specificity for saphenous vein reflux in C0-C3 patients. The reflux group had a significantly greater diameter than a non-reflux group at four great saphenous vein (GSV) levels and two small saphenous vein (SSV) levels (p-value < 0.001). The venous reflux correlated significantly with GSV diameter at all four GSV levels and two SSV levels (p-value <0.001). The ROC area of the diameter at four GSV levels ranges from 0.59 to 0.69. The optimal cut-off diameter for GSV reflux is 3.8mm at the proximal thigh, 2.8mm at the distal thigh, 3.2mm at the proximal calf, and 2.5mm at the distal calf. The ROC area of the diameter at two SSV levels ranges from 0.66 to 0.67. The optimal cut-off diameter for SSV reflux is 2.5mm at the proximal calf and 2.3mm at the distal calf. The saphenous vein's diameter has been proved to be significantly correlated with the presence of reflux in duplex ultrasound in all lower limbs' levels. Unfortunately, the study's cut point diameter is considered poor accuracy and is not an accurate measurement to use as the screening test for the presence of reflux.

A Novel Tool for a Challenging Disease: Stasis Leg Ulcers Assessed Using QFlow in Triggered Angiography Noncontrast Enhanced Magnetic Resonance Imaging.

Imaging characteristics of stasis leg ulcers (SLUs) are not easily demonstrated through existing diagnostic tools. Early diagnosis and treatment are crucial. This pilot study was conducted to assess the quantitative flow (QFlow) in triggered angiography noncontrast enhanced (TRANCE) magnetic resonance imaging (MRI) to identify the hemodynamics of victims with stasis leg ulcers (SLUs). This study included 33 patients with SLUs and 14 healthy controls (HC). The 33 patients with SLUs were divided into a reflux (15 patients) and a nonreflux group (18 patients). QFlow was done in the reflux, the nonreflux, and the HC. The stroke volume (SV), forward flow volume (FFV), absolute flow volume (AFV), mean flow (MF), and mean velocity (MV) were higher in the reflux than in the HC group in most segments, namely the external iliac vein (EIV), popliteal vein (PV), and great saphenous vein (GSV) (SV, p = 0.008; FFV, p = 0.008; absolute stroke volume (ASV), p = 0.008; MF, p = 0.002; MV, p = 0.009). No differences in the QFlow patterns were found in the GSV segment between the nonreflux group and the HC. Excellent performance in discriminating SLU with superficial venous reflux was reported for SV in the EIV and the PV (area under the curve (AUC) = 0.851 and 0.872), FFV in the EIV and PV (AUC = 0.854 and 0.869), ASV in the EIV and PV (AUC = 0.848 and 0.881), and MF in the EIV and PV (AUC = 0.866 and 0.868). The cutoff levels of SV/FFV/ASV/MF in the EIV/FV/PV/GSV for discriminating the SLU with superficial venous reflux were identified (p < 0.005). In conclusion, SLUs present different QFlow patterns by different etiology. The QFlow parameters of all vessel segments were higher in the morbid limbs of the reflux group than HC. The GSV segment of the nonreflux group displayed a pattern like the HC.

The Reflux Symptoms Before and After Peroral Endoscopic Myotomy of Chinese Patients With Achalasia.

Background/AimsAchalasia is a rare disease, but the incidence is increasing recently. Peroral esophageal myotomy (POEM) is an effective treatment. Regurgitation is a common symptom before and after POEM. Our aim is to investigate the factors related to preoperative and postoperative reflux symptoms.MethodsOur study was retrospective. The achalasia patients diagnosed by high-resolution manometry and gastroscopy were divided into reflux group and non-reflux group before and after POEM, respectively. General information, symptoms, POEM information, and manometric results were compared.Results(1) Ninety-six of 130 patients had reflux symptoms before POEM. The lower esophageal sphincter pressure (LESP) in the reflux group was significantly higher than the non-reflux group (P = 0.023), while integrated relaxation pressure (IRP) was similar. The reflux group had longer esophagus than the non-reflux group (P = 0.006). Reflux symptoms were not related to subtypes of achalasia. (2) Twenty-five of 84 patients had reflux symptoms after POEM. Postoperative Eckardt scores, LESP, and 4-second IRP (4sIRP) were significantly lower than the preoperative values (P < 0.001). The preoperative values and POEM information were similar between the postoperative 2 groups and there was no significant difference in the presence of preoperative reflux symptoms between 2 groups. The postoperative LESP and 4sIRP were similar between the 2 groups, however, the postoperative UESP was significantly higher in the reflux group than the non-reflux group (P = 0.042). The non-reflux group had more declines in Eckardt scores and LESP than the reflux group.ConclusionsThe reflux symptoms of achalasia patients without treatment were mainly due to food retention. The postoperative reflux symptoms were not the sign of the excessive relaxation of lower esophageal sphincter.

Discriminating Reflux from Non-Reflux Diseases of Superficial Veins in Legs by Novel Non-Contrast MR with QFlow Technique.

Objectives: To find an objective diagnostic tool for the superficial veins in legs. Methods: This study included 137 patients who underwent TRANCE-MRI from 2017 to 2020 (IRB: 202001570B0). Among them, 53 with unilateral leg venous diseases underwent a QFlow scan and were classified into the reflux and non-reflux groups according to the status of the great saphenous veins. Results: The QFlow, namely stroke volume (SV), forward flow volume (FFV), mean flux (MF), stroke distance (SD), and mean velocity (MV) measured in the external iliac, femoral, popliteal, and great saphenous vein (GSV). The SV, FFV, SD, MF, SD, and MV in the GSV (morbid/non-morbid limbs) demonstrated a favorable ability to discriminate reflux from non-reflux in the ROC curve. The SD in the GSV and GSV/PV ratio (p = 0.049 and 0.047/cutoff = 86 and 117.1) and the MV in the EIV/FV ratio, GSV, and GSV/PV ratio (p = 0.035, 0.034, and 0.025/cutoff = 100.9, 86.1, and 122.9) exhibited the ability to discriminate between reflux and non-reflux group. The SD, MV, and FFV have better ability to discriminate a reflux from non-reflux group than the SV and MF. Conclusions: QFlow may be used to verify the reflux of superficial veins in the legs. An increasing GSV/PV ratio is a hallmark of reflux of superficial veins in the legs.

Gastro-oesophageal reflux - an important causative factor of severe tooth wear in Prader-Willi syndrome?

BackgroundPrader-Willi syndrome (PWS) is the most common genetic human obesity syndrome and is characterized by hypotonia, endocrine disturbances, hyperphagia, obesity and mild mental retardation. Oral abnormalities, such as decreased salivary flow rates and extreme tooth wear, have also been described. Studies have shown a significant increase in reflux symptoms in individuals with obstuctive sleep apnoea syndrome and increased BMI, both of which are typical findings in PWS. Gastro-oesophageal reflux disease (GORD) has been identified in some individuals with PWS and is a significant intrinsic factor in dental tooth wear. The aim of this study was therefore to estimate the prevalence of GORD in adults and children and to evaluate a possible correlation between GORD and tooth wear in adults with PWS. They were all registered at the TAKO-centre.ResultsTwenty-nine individuals, 17 adults with a mean age of 32.6 years (range 18–48) and 12 children with a mean age of 8.8 years (range 3–17), agreed to undergo 24-hour oesophageal pH monitoring, and 90% of those enrolled managed to complete the examination. Four children and eleven adults were diagnosed with pathological gastro-oesophageal reflux, which is defined as acid exposure (pH less than 4) more than 3.6 or 4.3 percent of the time, respectively. Manometry performed in the adult group showed a pathologically high lower oesophageal sphincter pressure in four of the five individuals who had normal oesophageal pH values (pH under 4 less than 4.3% of the time). The two groups (reflux and non-reflux) were well balanced according to BMI, genotype, tooth grinding and hyposalivation. However, twice as many individuals in the reflux group as in the non-reflux group reported high consumption of acidic foods and drinks. Increased tooth wear was significantly correlated with GORD in the two groups (reflux n=6 and non-reflux n=6).ConclusionsThe prevalence of gastro-oesophageal reflux is high in individuals with PWS. Tooth wear was strongly associated with GORD and acidic drinks, and both may be important aetiological factors underlying the extreme tooth wear in this group. Our data suggest a need for routine screening for GORD and dental wear in young individuals with Prader-Willi syndrome.

Vesicoureteral Reflux in Kidney Transplantation.

Vesicoureteral reflux (VUR) is frequently found after transplantation, but its impact on graft function, urine tract infection, and graft loss remains uncertain. Therefore our objective was to evaluate the effects of VUR on the outcome of renal transplantation. We included 1008 adult renal transplant recipients of whom a 1-week posttransplant voiding cystourethrogram was available. Study end points included occurrence of bacteriuria, renal function, and graft survival. In total, 106 (10.5%) of 1008 graft recipients had a diagnosis of VUR on voiding cystography. The incidence of bacteriuria was comparable in the reflux and nonreflux group (17% vs 17.4%, P = .91). There was no significant difference in renal function at 3 months and 1 year in patients with and without VUR. One- and 5-year graft survival in patients with VUR was 85.8% and 82.1% compared to 87.3% and 83.0% in patients without VUR ( P = .68 and P = .80). Posttransplant VUR has no correlations with early bacteriuria, renal function, and graft survival.

Esophagogastric Junction Morphology and Distal Esophageal Acid Exposure.

The Chicago classification has recently added a morphological subclassification for the esophagogastric junction (EGJ). Our aim was to assess the distal esophageal acid exposure in patients with this new Chicago EGJ-type IIIa and IIIb classification. From a prospectively collected high-resolution manometry (HRM) database, we identified patients who underwent 24-h pH study between October 2011 and June 2015 and were diagnosed with EGJ-type III based on HRM. Chicago EGJ-type III is defined as the inter-peak nadir pressure ≤gastric pressure and a lower esophageal sphincter (LES)-crural diaphragm (CD) separation >2cm [IIIa-pressure inversion point (PIP) remains at CD level and IIIb-PIP remains at LES level]. We classified the patients into reflux group [DeMeester score >14.72 or Fraction time pH (<4)>4.2%] and non-reflux group based on 24-h pH study. Fifty patients were identified that satisfied the study criteria, of which 37 patients (74%) were EGJ-type IIIa. In those with EGJ-type IIIb, abdominal LES length (AL) in reflux group was significantly shorter than the non-reflux group (0.8 vs. 1.8, p<0.05). EGJ-type IIIa patients showed significantly higher value for DeMeester score and Fraction time pH and more often had a positive pH study than EGJ-type IIIb patients (DeMeester score: 26.7 vs. 11.7, p<0.05; Fraction time pH: 7.9 vs. 2.6, p<0.05; positive pH study: 81.1 vs. 30.8%, p<0.001). Reflux was more common in LES-CD≥3cm than that in LES-CD<3cm (85 vs. 56.7%, p<0.05). A subset of patients with >2-cm LES-CD separation (type IIIb) maintain a physiological intra-abdominal location of the EGJ and are less likely to have reflux. A LES-CD≥3cm seems to discern a hiatus hernia of clinical significance.

Pepsin levels and oxidative stress markers in exhaled breath condensate of patients with gastroesophageal reflux disease

AimTo evaluate the pepsin and oxidative stress markers in exhaled breath condensate (EBC) in patients with gastroesophageal reflux disease (GERD). Patients and MethodPatients with a presumptive diagnosis of GERD with recurrent respiratory and gastrointestinal problems aged between 2 and 14years were included in the study. All patients underwent pH monitoring. Patients with a reflux index (RI) ≥4 were assessed as the reflux group, and those with an RO <4 were assessed as the non-reflux group. Pepsin levels and oxidative stress markers [NO metabolites (NOX) and total sulphydrile (TSH) levels] were measured in the EBC. ResultsThere were 24 patients in the reflux group [RI 17.6 (6.6–46.4)] [median, interquartile range] and 23 in the non-reflux group [RI 0.8 (0.5–1.9) (p<0.001). Pepsin levels in the EBC were below the level of detection. The median levels of NOx in the EBC of children with reflux [13.7μmol/L (7.3–24.5)] were lower in than non-reflux group [21.0μmol/L (14.0–25.2)] (p=0.034). There was a negative correlation between reflux index and NOX levels in EBC (rs: −0.331, p=0.023). In contrast, there was no difference in TSH levels between the reflux and non-reflux groups [37.4μmol/L (30.2–44.6) vs 40.1μmol/L (37.4–44.9), respectively, (p>0.05)]. ConclusionDecreased levels of NOX in patients with GER disease suggest increased oxidative stress in airways of these patients.

Morphology of cricopharyngeal muscle under suspension laryngeal endoscope

To observe the morphologic features of cricopharyngeal muscle (CPM) under suspension laryngeal endoscope. This prospective study was conducted on a series of 100 consecutive patients who undergone endoscopic microlaryngeal surgery with intubation general anesthesia. The suspension laryngoscope was introduced down to postcricoid area approaching esophageal inlet. By lifting the larynx with the laryngoscope, the mucosa-covered cricopharyngeal muscle was easily identified as the mound of tissue just at the posterior pharyngeal wall. The image of cricopharyngeal muscle under the laryngoscope was saved. In 94 out of 100 patients, CPM could be visualized with laryngoscope. In the other 6 patients, both CPM and glottic could not be exposed because of cervical vertebra stiffness and obesity. According to the image of CPM under the laryngoscope, the shape of the CPM was divided into three types. It was named for flat type in which there was no mound of tissue visible at the posterior pharyngeal wall and esophageal cavity could be visible completely, semi-bar type in which there was a bar at the posterior pharyngeal wall and partial esophageal cavity could be visible and full-bar type in which the bar contact esophageal anterior wall and esophageal cavity could not be visible. There were 14(14.9%) patients as flat type, 59(62.8%) as semi-bar type and 21(22.3%) as full-bar type. No significant difference was found between adults group and the aged (≥ 65 years old) group (χ(2) = 1.224, P = 0.747) and reflux associated group and non-reflux associated group respectively (χ(2) = 5.252, P = 0.072). The CPM could be well exposed in most of the patients with suspension laryngeal endoscope. It provides anatomy basis for endoscopic cricopharyngeal myotomy.

Urinary Beta 2-Microglobulin as a Prognostic marker in children with pyelonephritis Running title: Beta 2-Microglobulin a Prognostic marker

Background: Urinary tract infection (UTI) is common in children. UTI with or without vesico-ureteral reflux (VUR) may result in renal scarring. Severe renal scarring impairs renal function and may result in hypertension, renal insufficiency, and end stage renal disease requiring dialyses or transplantation. Beta 2 micro-globulin (2MG) is a low molecular weight protein freely filtered by the glomeruli and then actively reabsorbed normally up to 99.9% in the proximal tubules; its urinary excretion is an indication of proximal tubular cell dysfunction. Objectives: The current study aimed to determine whether urinary 2MG excretion would be elevated in patients with various grades of renal scar, and also its relationship with renal outcome in long term follow-up. Materials and Methods: Urinary 2MG and Creatinine (Cr) were measured in 83 spot urine samples of patients that 53 of them did DMSA renal scan both at the time of admission to confirm pyelonephritis, and 6 month later to detect scars. 2MG was measured by radioimmunoassay method using 2MG 96-test kit (RADIM Company; Germany), and the creatinine was measurd by spectrophotometry and was recorded as microgram per mg creatinine. Twenty children had various grades of renal scars.Results were compared with the ratios of 19 children with low uptake scanning, 14 children with normal scanning after recovery from pyelonephritis, and 30 normal children served as controls. EXCEL and SPSS softwares were employed to compare the mean urinary 2MG in groups by student t-test, ANOVA, and Unpaired t-test at P,0.05 significance level. Subsequently patients were followed up for 6 years.\\r\\n Results: The mean urinary 2MG/Cr ratio was significantly higher in the scarring group (5.23 10.6) than in the normal group (0.19 0.2), and in low uptake group (0.49 0.86) (P < 0.05). When mean 2MG/Cr ratios were compared for each grade of scarring; patients with sever scar (grade III) had higher values (14.69 15.82) than grades I (0.36 0.35) and II (3.37 5.20) (P < 0.05). Patients without renal scar had a 2MG/Cr ratio below 0.46 microgram/mg Cr. The mean 2MG was also higher in the refluxing group (3.45 7.97) than nonrefluxing group (0.23 0.24) ug/mgCr (P = 0.01). Three patients who had the highest 2MG/Cr ratio values (33.3, 27, and 26.6 microgram/mg Cr) had sever scar that rapidly progressed to ESRD. They were transplanted 2 years later; after transplantation they still had recurrent UTIs. 2nd patient underwent native nephrectomy for renal abscess.\\r\\n Conclusions: Results of the current study revealed that mean 2MG/Cr ratio was higher in patients with renal scar and poor outcome. Measurement of Urinary 2MG may be useful in the early detection of tubular damage in refluxing patients and patients with renal scars and has prognostic significance.

Nível de resposta das emissões otoacústicas evocadas por estímulo transiente em lactentes com refluxo gastroesofágico

INTRODUÇÃO: As emissões otoacústicas evocadas por estímulo transiente (EOAT) têm sido a técnica mais utilizada para a realização da triagem auditiva neonatal. Sendo importante analisar suas medidas correlacionando com outras alterações que pode acometer o sistema auditivo da criança. OBJETIVO: Analisar a ocorrência e os níveis de resposta das emissões otoacústicas evocadas por estímulo transiente em lactentes com refluxo gastroesofágico fisiológico (RGEF). MÉTODO: Estudo prospectivo foi realizado no Serviço de Otorrinolaringologia do Hospital Santa Juliana. Participaram do estudo 118 bebês, de recém nascidos há seis meses, encaminhados por pediatras e gastropediatras, nascidos pré-temo ou termo e distribuídos em dois grupos: Grupo Estudo: 63 lactentes com diagnóstico clínico de refluxo gastroesofágico fisiológico, e Grupo Controle: 55 lactentes sem refluxo gastroesofágico fisiológico. Foi realizada a avaliação da função auditiva periférica por meio dos exames de emissões otoacústicas evocadas por estímulo transiente e otoscopia realizada por otorrinolaringologista. RESULTADOS: Os níveis médios de respostas das emissões otoacústicas evocadas por estímulo transiente foram maiores no grupo sem refluxo para as bandas de frequências de 2kHz, 2,5kHz, 3kHz, 3,5kHz e 4,5kHz bilateralmente, com diferenças estatisticamente significantes, obtendo-se valores médios de 7,71dB e 7dB na orelha direita, encontrados nas bandas de frequências de 2 e 4kHz, respectivamente. CONCLUSÃO: Houve menor ocorrência e menor nível de respostas das emissões otoacústicas transientes em crianças com refluxo gastroesofágico fisiológico quando comparados a crianças sem refluxo.

Comparison of Conventional and Segmental Analysis on High Resolution Manometry (HRM)

Purpose: HRM demonstration of three contraction segments in the esophageal body has added to our understanding of esophageal motor physiology. Despite this advance, pre-HRM parameters continue to be applied to HRM analysis. We investigated differences between conventional and segmental analysis of HRM Clouse plots in symptomatic subjects and normal controls. Methods: HRM contour plots were compared between a reflux group (n=110, 49±1.4 yr, 55F/55M) with abnormal pH study, erosive esophagitis on endoscopy or Barrett's esophagus on histopathology; a non-reflux group (n=74, 48±2.3 yr, 48F/26M) with esophageal symptoms but normal pH study and endoscopy; and controls (n=12, 30±0.9 yr, 7F/5M). Achalasia and its variants, aperistalsis and post surgical states were excluded. Peristaltic performance, peak contraction amplitude (PCA) in either smooth muscle segment, averaged contraction amplitude (ACA, 3 & 8 cm proximal to LES), segment anatomy, and end-expiratory lower esophageal sphincter pressure (LESP) were extracted. At 30 mmHg, sequences were designated fragmented if one smooth muscle segment was absent or if the two segments were separated by a pressure trough and failed if both smooth muscle segments were absent. Results: A total of 1827 swallows were analyzed in symptomatic subjects, and 120 in controls. As expected, reflux subjects had lower ACA (82.9 ±3.3 vs. 116.6 ±5.7 mmHg, p<0.0001) and LESP (7.8±0.7 vs. 16.2±1.6 mmHg, p<0.0001) compared to non-reflux group; similar findings were seen using PCA (119.7±1.5 vs. 161.3±2.6 mmHg, p<0.0001). PCA in controls (160± 3.7 mmHg) was comparable to non-reflux but significantly higher than reflux subjects. There were 44.4% (reflux) and 38.3% (non-reflux) gains in measured amplitude using PCA rather than ACA. Further, 41.1% fewer failed sequences (87 vs. 123) were seen in the reflux group with segment analysis (p=0.01); in the non-reflux group, the change from 20 to 15 failed was not significant; no change was noted in the controls. Fragmented contractions were significantly more prevalent in the reflux group (18.1%) compared to non-reflux (4.1%) or controls (7.5%, p<0.0001). Discordance between conventional and segmental analysis was 27.2% in the reflux group, but only 5.4% in the non-reflux group (p<0.001). Composite failed and fragmented sequences amounting to >30% of the evaluated wet swallows significantly segregated the reflux group from the non-reflux group (34.5% vs. 4.1%, OR 12.5, 95% CI 3.5-34.6, p<0.0001). Conclusion: New HRM analysis paradigms may provide novel insight into esophageal peristaltic function, especially in subjects with hypomotile patterns. Further studies are required to determine if these new parameters improve prediction of patient outcome.

Bladder Dynamics and Vesicoureteral Reflux: Factors Associated With Idiopathic Lower Urinary Tract Dysfunction in Children

The objective of this study was to determine the clinical, demographic, urodynamic and prognostic characteristics related to vesicoureteral reflux among patients with idiopathic lower urinary tract dysfunction. We retrospectively reviewed the records of 348 children with idiopathic detrusor overactivity or dysfunctional voiding who had been examined for vesicoureteral reflux between 1995 and 2005 at a university hospital. Demographic, clinical and urodynamic parameters were compared between groups according to the presence, grade, laterality and resolution of vesicoureteral reflux. Among the 348 patients 8 infants were excluded from statistical analysis and are discussed separately. Among the 340 remaining patients 1 year and older vesicoureteral reflux was documented in 155 (46%), of whom 32% had bilateral reflux. Of the overall cases 60% were grade III or higher. Mean age in the refluxing group (6.5 +/- 2.8 years) was significantly lower than in the nonrefluxing group (7.6 +/- 2.5 years, p <0.001). Continent children presented with a significantly higher rate of vesicoureteral reflux compared to incontinent children (74% vs 42%, p <0.001). Among the patients who had urinary tract infection the presence of reflux increased the rate of renal cortical abnormalities (45% vs 17%, p <0.001). However, among patients who were free of urinary tract infection the presence of reflux was not associated with cortical abnormalities (25% vs 24%, p >0.05). Median maximum filling pressure was higher in the refluxing group compared to the nonrefluxing group (40.0 vs 34.0 cm H(2)O, p <0.001). Detrusor overactivity and dysfunctional voiding showed similar rates for development of vesicoureteral reflux. Reflux was resolved with medical treatment in 40% of the patients. The resolution rate was significantly higher in children with nondilating reflux and initial lower median cystometric bladder capacity. Vesicoureteral reflux is associated with daytime incontinence, urinary tract infection, younger age and renal cortical abnormalities among patients with idiopathic lower urinary tract dysfunction. Increased intravesical pressures seem to be the primary factor for inducing reflux in idiopathic lower urinary tract dysfunction. Initial bladder capacity predicts the resolution of reflux.

Reflux esophagitis facilitates low Helicobacter pylori infection rate and gastric inflammation.

Helicobacter pylori is regarded as an important pathogen in upper gastrointestinal diseases. However, little is known about the relationship between H. pylori infection and reflux esophagitis. Therefore, an investigation was undertaken in Korean subjects regarding the incidence of H. pylori infection, and a histopathological study of reflux esophagitis was also carried out. Analysis of gastric biopsy specimens was conducted for 73 patients with reflux esophagitis and 132 control subjects without reflux esophagitis. The H. pylori infection was assessed by using rapid urease test and the immunohistochemical method, and gastric mucosal morphologic change was analyzed according to the updated Sydney system. The prevalence of H. pylori infection was significantly lower in patients with reflux esophagitis than in the non-reflux group. Grade of inflammation and glandular atrophy in the antrum and body were higher in patients in the non-reflux group compared with those in the reflux esophagitis group. It is suggested that H. pylori infection decreases the risk of reflux esophagitis by inducing atrophic gastritis.

Decreased sympathetic inhibition in gastroesophageal reflux disease.

This study was undertaken to evaluate autonomic nervous system function in patients with gastroesophageal reflux disease. Based on clinical criteria, 28 consecutive patients with no history of heart, metabolic, or neurologic disease (mean age 41 y, range 20-62 y) reporting with upper gastrointestinal symptoms typical of gastroesophageal reflux underwent esophageal manometry, ambulatory 24-hour pH study with electrocardiographic monitoring, power spectral analysis of heart rate variability, and cardiovascular tests. Twelve healthy subjects served as controls. A positive result of prolonged esophageal pH study (pH in the distal esophagus less than 4, lasting more than 4.2% of recording time) was observed in 21 patients (reflux group); seven patients were categorized in the nonreflux group. No patient showed arrhythmias or any correlation between heart rate variability changes during electrocardiographic monitoring and episodes of reflux (pH less than 4, lasting more than 5 minutes). A decrease of sympathetic function occurred only in the reflux group (p <0.05) supported by the lower increase of systolic/diastolic blood pressure at sustained handgrip. No other cardiovascular tests showed statistically significant differences in the control or nonreflux groups. Total time reflux showed an inverse correlation with sympathetic function in the reflux group (r = -0.415, p <0.028). We concluded that there is some evidence for a slightly decreased sympathetic function in patients with gastroesophageal reflux disease that is inversely correlated with total time reflux. In these patients, decreased sympathetic function may cause dysfunction of intrinsic inhibitory control with increased transient spontaneous lower-esophageal sphincter relaxations, thus resulting in gastroesophageal reflux disease.

PH Monitoring in Patients with Benign Voice Disorders

The aim of this study was to compare oesophageal pH-metry with laryngeal signs and symptoms in patients suspected of laryngeal reflux disease. A total of 60 patients with voice disorders, who were suspected of laryngeal reflux, were tested by single probe oesophageal pH monitoring. Thirty-two suffered from reflux laryngitis. A comparison of symptoms in patients with proven reflux with patients with no reflux was made. The symptoms were more frequent in the patients in the reflux group than in the non-reflux group. There was a significant difference between the groups with regard to dysphonia, sore throat, thick mucus and heartburn. Clinical signs appeared more frequently in the reflux group than in the non-reflux group. A significant difference was found between the groups regarding oedema of the vocal cords and hyperaemia and oedema of the posterior commisure, contact granuloma, posterior wall granulation and increased muscle tension. The patients in the reflux group were given medical treatment using omeprazole, and 76% logopedic voice training program. More than 50% of the laryngeal reflux patients were treated for more than 4 months before their voice problems had resolved. It is important to realize that signs of reflux laryngitis are not confined to the posterior commisure.

Helicobacter pylori infection correlates with severity of reflux esophagitis: with manometry findings.

The role of Helicobacter pylori infection in the development and exacerbation of reflux esophagitis was investigated. The prevalence of Helicobacter pylori infection, the severity of atrophic gastritis, and esophageal motility (determined by esophageal manometry by an infusion catheter method) were assessed in patients with mild (n = 46) and severe (n = 27) reflux esophagitis and subjects without reflux (n = 28). Compared with the prevalence of Helicobacter pylori infection in the non-reflux group, the prevalence in the mild and severe reflux groups (60.7%, 47.8%, and 14.8%, respectively) was significantly (P < 0.05) lower. Atrophic gastritis was milder in both reflux groups than in the non-reflux group. The degree of gastritis was also milder in the severe reflux group than in the mild reflux group. The esophageal sphincter pressure was significantly (P < 0.05) lower in the reflux groups than in the non-reflux group, and the amplitude of primary peristalsis was significantly (P < 0.05) lower in the severe reflux group than in the non-reflux group. There were no significant differences between reflux patients with and without Helicobacter pylori infection in the parameters of esophageal manometry. These data imply that a low prevalence of Helicobacter pylori infection may result in a milder grade of atrophic gastritis, and consequently, exacerbate reflux esophagitis.