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Conclusion All patients with dysphagia after stroke have impaired postural control. IQoro® screen (IQS) training gives a significant and lasting improvement of postural control running parallel with significant improvement of oropharyngeal motor dysfunction (OPMD). Objectives The present investigation aimed at studying the frequency of impaired postural control in patients with stroke-related dysphagia and if IQS training has any effect on impaired postural control in parallel with effect on OPMD. Method A prospective clinical study was carried out with 26 adult patients with stroke-related dysphagia. The training effect was compared between patients consecutively investigated at two different time periods, the first period with 15 patients included in the study more than half a year after stroke, the second period with 11 patients included within 1 month after stroke. Postural control tests and different oropharyngeal motor tests were performed before and after 3 months of oropharyngeal sensorimotor training with an IQS, and at a late follow-up (median 59 weeks after end of training). Result All patients had impaired postural control at baseline. Significant improvement in postural control and OPMD was observed after the completion of IQS training in both intervention groups. The improvements were still present at the late follow-up.

Conclusion: Training with either a palatal plate (PP) or an oral IQoro(R) screen (IQS) in patients with longstanding facial dysfunction and dysphagia after stroke can significantly improve facial activity (FA) in all four facial quadrants as well as swallowing capacity (SC). Improvements remained at late follow-up. The training modalities did not significantly differ in ameliorating facial dysfunction and dysphagia in these patients. However, IQS training has practical and economic advantages over PP training., Objectives: This study compared PP and oral IQS training in terms of (i) effect on four-quadrant facial dysfunction and dysphagia after a first-ever stroke, and (ii) whether the training effect persisted at late follow-up., Methods: Patients were included during two periods; 13 patients in 2005-2008 trained with a PP, while 18 patients in 2009-2012 trained with an IQS. Four-quadrant facial dysfunction was assessed with an FA test and swallowing dysfunction with a SC test: before and after a 3-month training period and at late follow-up. FA and SC significantly improved (p < 0.001) in both groups. FA test scores after training and at late follow-up did not differ significantly between the groups, irrespective of whether the interval between stroke incidence and the start of training was long or short.

Conclusion: Misdirected swallowing can be triggered by esophageal retention and hiatal incompetence. The results show that oral IQoro(R) screen (IQS) training improves misdirected swallowing, hoarseness, cough, esophageal retention, and globus symptoms in patients with hiatal hernia., Objectives: The present study investigated whether muscle training with an IQS influences symptoms of misdirected swallowing and esophageal retention in patients with hiatal hernia., Methods: A total of 28 adult patients with hiatal hernia suffering from misdirected swallowing and esophageal retention symptoms for more than 1 year before entry to the study were evaluated before and after training with an IQS. The patients had to fill out a questionnaire regarding symptoms of misdirected swallowing, hoarseness, cough, esophageal retention, and suprasternal globus, which were scored from 0-3, and a VAS on the ability to swallow food. The effect of IQS traction on diaphragmatic hiatus (DH) pressure was recorded in 12 patients with hiatal hernia using high resolution manometry (HRM)., Results: Upon entry into the study, misdirected swallowing, globus sensation, and esophageal retention symptoms were present in all 28 patients, hoarseness in 79%, and cough in 86%. Significant improvement was found for all symptoms after oral IQS training (p < 0.001). Traction with an IQS resulted in a 65 mmHg increase in the mean HRM pressure of the DH.

Aim: To examine whether muscle training with an oral IQoro(R) screen (IQS) improves esophageal dysphagia and reflux symptoms., Methods: A total of 43 adult patients (21 women and 22 men) were consecutively referred to a swallowing center for the treatment and investigation of long-lasting nonstenotic esophageal dysphagia. Hiatal hernia was confirmed by radiologic examination in 21 patients before enrollment in the study (group A; median age 52 years, range: 19-85 years). No hiatal hernia was detected by radiologic examination in the remaining 22 patients (group B; median age 57 years, range: 22-85 years). Before and after training with an oral IQS for 6-8 mo, the patients were evaluated using a symptom questionnaire (esophageal dysphagia and acid chest symptoms; score 0-3), visual analogue scale (ability to swallow food: score 0-100), lip force test (≥ 15 N), velopharyngeal closure test (≥ 10 s), orofacial motor tests, and an oral sensory test. Another twelve patients (median age 53 years, range: 22-68 years) with hiatal hernia were evaluated using oral IQS traction maneuvers with pressure recordings of the upper esophageal sphincter and hiatus canal as assessed by high-resolution manometry., Results: Esophageal dysphagia was present in all 43 patients at entry, and 98% of patients showed improvement after IQS training [mean score (range): 2.5 (1-3) vs 0.9 (0-2), P < 0.001]. Symptoms of reflux were reported before training in 86% of the patients who showed improvement at follow-up [1.7 (0-3) vs 0.5 (0-2), P < 0.001). The visual analogue scale scores were classified as pathologic in all 43 patients, and 100% showed improvement after IQS training [71 (30-100) vs 22 (0-50), P < 0.001]. No significant difference in symptom frequency was found between groups A and B before or after IQS training. The lip force test [31 N (12-80 N) vs 54 N (27-116), P < 0.001] and velopharyngeal closure test values [28 s (5-74 s) vs 34 s (13-80 s), P < 0.001] were significantly higher after IQS training. The oral IQS traction results showed an increase in mean pressure in the diaphragmatic hiatus region from 0 mmHg at rest (range: 0-0 mmHG) to 65 mmHg (range: 20-100 mmHg)., Conclusion: Oral IQS training can relieve/improve esophageal dysphagia and reflux symptoms in adults, likely due to improved hiatal competence.

Aim: To determine if the severity of gastroesophageal reflux disease is dependent on the size of a hiatus hernia., Methods: Seventy-five patients with either a small (n = 25), medium (n = 25) or large (n = 25) hiatus hernia (assessed by high resolution esophageal manometry) were investigated using 24-h esophageal monitoring and a self-assessed symptom questionnaire. The questionnaire comprised the following items, each graded from 0 to 3 according to severity: heartburn; pharyngeal burning sensation; acid regurgitation; and chest pain., Results: The percentage total reflux time was significantly longer in the group with hernia of 5 cm or more compared with the group with a hernia of < 3 cm (P < 0.002), and the group with a hernia of 3 to < 5 cm (P < 0.04). Pharyngeal burning sensation, heartburn and acid regurgitation were more common with large hernias than small hernias, but the frequency of chest pain was similar in all three hernia groups., Conclusion: Patients with a large hiatus hernia are more prone to have pathological gastroesophageal reflux and to have more acid symptoms than patients with a small hiatus hernia. However, it is unlikely that patients with an absence of acid symptoms will have pathological reflux regardless of hernia size.

This study aims to examine any motility disturbance in any quadrant of the face other than the quadrant innervated by the lower facial nerve contralateral to the cortical lesion after stroke. Thirty-one stroke-afflicted patients with subjective dysphagia, consecutively referred to a swallowing centre, were investigated with a facial activity test (FAT) in all four facial quadrants and with a swallowing capacity test (SCT). Fifteen healthy adult participants served as FAT controls. Sixteen patients were judged to have a central facial palsy (FP) according to the referring physician, but all 31 patients had a pathological FAT in the lower quadrant contralateral to the cortical lesion. Simultaneous pathology in all four quadrants was observed in 52% of stroke-afflicted patients with dysphagia; some pathology in the left or right upper quadrant was observed in 74%. Dysfunction in multiple facial quadrants was independent of the time interval between stroke and study inclusion. All patients except two had a pathological SCT. All the controls had normal activity in all facial quadrants. In summary the majority of poststroke patients with dysphagia have subclinical orofacial motor dysfunction in three or four facial quadrants as assessed with a FAT. However, whether subclinical orofacial motor dysfunction can be present in stroke-afflicted patients without dysphagia is unknown.

Aim: To study the relationship between upper esophageal sphincter (UES) relaxation, peristaltic pressure and lower esophageal sphincter (LES) relaxation following deglutition in non-dysphagic subjects., Methods: Ten non-dysphagic adult subjects had a high-resolution manometry probe passed transnasally and positioned to cover the UES, the esophageal body and the LES. Ten water swallows in each subject were analyzed for time lag between UES relaxation and LES relaxation, LES pressure at time of UES relaxation, duration of LES relaxation, the distance between the transition level (TL) and the LES, time in seconds that the peristaltic wave was before (negative value) or after the TL when the LES became relaxed, and the maximal peristaltic pressure in the body of the esophagus., Results: Relaxation of the LES occurred on average 3.5 s after the bolus had passed the UES and in most cases when the peristaltic wave front had reached the TL. The LES remained relaxed until the peristaltic wave faded away above the LES., Conclusion: LES relaxation seemed to be caused by the peristaltic wave pushing the bolus from behind against the LES gate.

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

The purpose of this study was to elucidate whether misdirected swallowing is an extra-laryngeal cause of hoarseness and investigate whether the prevalence of misdirected swallowing and hoarseness in patients with hiatal hernias differ from those with and without pathological gastroesophageal reflux (GER). One hundred and ninety eight patients with hiatal hernias diagnosed via esophageal manometry and pH-reflux test and 262 subjects in the general population who did not have a hiatal hernia at endoscopy, filled in a questionnaire about symptoms on hoarseness, misdirected swallowing, and heartburn. Hoarseness (35%), misdirected swallowing to the larynx (MSL; 35%), misdirected swallowing to the nose (MSN; 22%) and heartburn (85%) were significantly more common in patients with hiatal hernia than in controls (13, 5, 1, and 6%, respectively, P<0.001). MSL and MSN in the patient group were significantly interrelated (P<0.0001). Hoarseness and MSL were not significantly associated (P<0.076). Hoarseness and MSL were as common in the hernia group with normal GER, as in the group with pathological GER. There is a predisposition for hoarseness and MSL in patients with hiatal hernias, but the cause-and-effect relationship is unclear. Hoarseness does not seem to be caused by pathological GER.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

52 patients with laryngeal carcinoma were studied before and after laryngectomy with regard to what factors might influence the development of oesophageal speech. The investigations consisted of oesophageal manometry, a follow-up interview and a review of surgical approaches and radiotherapy. 43% of the patients achieved socially acceptable oesophageal speech, 22% were able to speak single words, and 35% had no oesophageal speech at all. 61% had post-operative dysphagia. Age was the only factor which significantly correlated to intelligible speech. The intraoesophageal pressure during oesophageal phonation exceeded in all cases the low PO-HPZ pressure after operation. The extension of surgery and radiation field, severity of dysphagia, alcohol and smoking habits, and mental condition did not differ between the 3 groups of oesophageal speech. It was concluded that the rather complicated process of acquiring oesophageal speech is much more dependent on learning ability which decreases with age than on various kinds of motor dysfunction after laryngectomy.

The correlation between oesophageal dysfunction (OD), pathologic gastro-oesophageal reflux (GOR), and severity of pulmonary disease was studied in 12 patients with cystic fibrosis (CF). They were interviewed about symptoms of OD and underwent 24-h pH recording in the oesophagus, oesophageal manometry combined with reflux provocation tests, the acid perfusion test, the acid clearance test, lung function tests, and scoring of the chest radiograph. Six of the 12 patients reported symptoms of OD. Abnormal GOR, as shown by 24-h pH monitoring of the oesophagus, was found in eight of them. Altogether 9 of the 12 participants had at least one pathologic oesophagus test result. Results of radiologic examinations of the oesophagus, performed in six patients, were pathologic. The four patients with the best chest radiograph scores and the best lung function had significantly less signs and symptoms of OD and GOR than the other eight patients. We conclude that OD, GOR, and pulmonary disease covariate in CF.

The aim of this study was to examine whether esophageal dysphagia can be described as a handicap and to grade the severity of handicap as the discrepancy between the subject's own eating goals and his or her eating disability. The severity of the disability-goal-handicap (DGH) regarding dysphagia was expressed on a scale ranging from 0 to 48 points. Nineteen patients with dysphagia of differing causes were selected from a patient register at a laboratory for diagnostic procedures of the esophagus. The severity of handicap for the 19 patients was, on average, 33 points (range, 20-44). The DGH score correlated significantly with the patients' own evaluation of the severity of their dysphagia (p = 0.008). The DGH scores did not differ markedly based on patient's sex, age, or cause of dysphagia. Patients who were operated upon because of dysphagia had significantly more points on the DGH scale prior to operation than patients who were not (p = 0.001). Denial of dysphagia (N = 18), concealment of dysphagia (N = 18), and lack of confirmation by the patient's physician (N = 15) were common but did not influence the severity of handicap as assessed by the DGH scale. It was shown that dysphagia affects all aspects of life as expressed by reduction in self-esteem (N = 13), security (N = 16), work capacity (N = 8), exercise (N = 7), and leisure time (N = 6). Esophageal dysphagia may therefore be regarded as a handicap when assessed using the DGH code described in this study.

This investigation was designed to study to what extent dysphagia in the elderly is accompanied by other chest symptoms and if it leads to a reduction in body weight and quality of life. To this end 796 persons, randomly taken from a population register, replied to a questionnaire concerning swallowing difficulties and other chest symptoms. Chest pain, heartburn, and regurgitation occurred significantly more frequently in subjects who admitted feelings of obstruction in the throat or chest during the ingestion of food (p less than 0.001) than in the rest, as did so-called heart problems (p less than 0.05). People with dysphagia had more often gained weight over the last 5 years than people without dysphagia (p less than 0.05). Psychosocial problems in those with dysphagia were given as anxiety at mealtimes and the wish to eat alone. Of those with dysphagia, 40% had consulted a physician, but despite this these patients had as many problems as those who had not seen a doctor. It is apparent that difficulty in swallowing in the elderly leads to physical and psychosocial problems that may reduce their quality of life.

Two hundred and twenty-nine patients were studied in an attempt to determine the main causative factors behind their having a residual foreign body in the esophagus. Strictures were present in 13%. Fifty-two percent of the patients with stricture had been hospitalized more than once for treatment of foreign body impaction; this was the case in only 8.5% of the rest of the patients (p less than 0.001). More than half of the patients aged 15 years or younger had a foreign body in the hypopharynx. This location was extremely uncommon in adults (p less than 0.001). The hypothesis of spasm distal to an esophageal foreign body as the cause for obstruction in patients without esophageal stricture was supported by the following findings: spontaneous disimpaction occurred in more than one-third of the patients and became more frequent as time progressed; 63% of 16 patients given spasmolytic drugs experienced spontaneous disimpaction of the foreign body; half of the patients had the foreign body in the proximal esophagus distal to the narrower passage of the upper esophageal sphincter; foreign body impaction in the esophagus turned out to be a once-only event in 86% of the patients; and 21% of the patients had a disorder of the central nervous system and had been hospitalized significantly more often because of food impaction than the other patients. The findings indicate that adults with a history of impaction of foodstuff lacking sharp bones and who do not have stricture suffer food impaction because of spasm of the esophageal smooth muscle, and can be treated accordingly.

The prevalence of pathological gastro-oesophageal reflux in children and adolescents with asthma was studied by 24 hour two level oesophageal pH monitoring in 42 subjects aged 9-20 years with moderate or severe bronchial asthma. The importance of oesophagobronchial nerve reflexes and of aspiration of gastric acid as triggers in asthma was assessed by studying whether episodes of reflux into the distal and into the proximal oesophagus were followed by asthma attacks. Twenty-one subjects (50%) had a pathological total reflux time in the distal oesophagus and six (16%) in the proximal oesophagus. Nine patients had pathological gastro-oesophageal reflux into the distal oesophagus together with symptoms of asthma during the day on which the recording took place. In three of them the episodes of asthma symptoms were significantly correlated with preceding episodes of reflux into the distal oesophagus, and in one subject to reflux into the proximal oesophagus. We conclude that pathological gastro-oesophageal reflux is common in children and adolescents with asthma, but it seems to provoke symptoms of asthma in only a few. Symptoms of asthma were more often elicited by exposure of the distal oesophagus to gastric acid, possibly by a vagal reflex, than by aspiration of gastric juice.

The frequency of different kinds of oesophageal dysfunction (OD) namely hiatal hernia at manometry, dysmotility, hypotension of the lower oesophageal sphincter (LES) and positive acid perfusion test was investigated in 97 patients with bronchial asthma seen at a hospital clinic. Thirty-six patients had signs of hiatal hernia, 37 of dysmotility, 26 of LES hypotension and 23 had a positive acid perfusion test. Four per cent of all the asthma patients fulfilled four criteria for OD and 10%, 28% and 25% fulfilled three, two and one criteria respectively. The incidence of OD was significantly higher in patients with Exogenous (95%) than in patients with endogenous asthma (58%, P less than 0.01). The history of asthma in patients with OD was of significantly longer duration (mean 16.9 years) than that of the OD itself (mean 6.5 years, P less than 0.01). Productive cough and frequent wheezing were more common in patients with OD (46%) than in patients without (19%, P less than 0.01). Spirometric lung volumes did not differ between asthmatics with OD and those without. Asthmatics with OD seem therefore to suffer more from respiratory symptoms than asthmatics without OD.

In a clinical study of oesophageal manometry with fluid-filled catheters, both a non-perfused system and a perfused system with a syringe pump have been compared to a system with a low-compliance perfusion pump, which served as a reference. Significantly lower values of motility amplitudes, motility derivatives, and partly of LES pressures, and a time delay of up to 0.5 sec of the amplitude maximum were obtained with the non-perfused system and the system with a syringe pump in comparison to the low-compliance system. Since the oesophageal function can be erroneously evaluated by use of a non-perfused system or a perfused system with a syringe pump, such systems cannot be recommended for clinical use.

Esophageal acid clearing in normal subjects was studied in different body positions, with an assessment of reproducibility, after dry and water swallows, after smoking, and after alcohol intake. A significant increase in the number of swallows to raise the distal esophageal pH to 5.0 was found in the head-down position (p less than 0.003), after smoking (p less than 0.003), and after alcohol intake (p less than 0.001). It is proposed that the outcome of the acid-clearing test reflects both the transporting capacity of the esophageal muscles and the production of saliva. The precision of the acid-clearing test is not satisfactory, which makes it unsuitable for use in individual cases. It seems, however, well fitted for evaluation of esophageal acid clearing in larger samples.

The incidence of oesophageal dysfunction (OD) is higher in patients with coronary heart disease (CHD) than in a population sample. The hypothesis was raised that this finding is the result of a cardio-oesophageal reflex in which afferent pain impulses from the heart trigger dysfunction in the oesophagus. Twenty-three patients with CHD were examined before and 14+/-5(S.D.) months after coronary bypass surgery. Total relief of angina pectoris was attained in 6 patients and improvement in 16. One patient deteriorated. The incidence of OD was 52% before operation and 65% at the follow-up investigation (no significant difference). Symptoms related to the oesophagus, other than chest pain, were as frequent before as after operation. The findings do not support the contention that OD in patients with CHD is caused by a cardio-oesophageal reflex.

Effort-related chest pain and chest pain fulfilling the criteria of the Rose questionnaire for angina pectoris are often used as evidence for coronary heart disease. In patients with different kinds of oesophageal dysfunction (OD) the frequency of chest pain of angina-like type was studied and compared to that in the general population. Eighty per cent of patients with hiatal hernia at oesophageal manometry had chest pain, 63% of which was effort-related. In 217 patients with a positive acid perfusion test, i.e. the provoked heart burn or pain is the same as that experienced in daily life, 82% had a history of chest pain. The chest pain was effort-related in 70% and in almost half of the cases their chest pain was classified as angina pectoris according to the Rose questionnaire. Since angina-like chest pain is a predominant symptoms in patients with OD and OD is far more common than angina pectoris due to myocardial ischemia in the general population, it is reasonable to assume that the oesophagus and not the heart is the most common source of angina-like chest pain.

Oesophageal emptying was studied with scintigraphy, radiography, and the acid clearing test (ACT) in 18 patients reporting dysphagia and previously operated on with fundoplication. Radiography with contrast medium, isodense with water, revealed abnormalities in either motility or emptying capacity in 39% (7/18). A A barium meal showed abnormalities--that is, a tight repair, disruption of the fundoplication, or recurrence of the hernia--in 56% (10/18). The ACT was prolonged in 40% (6/15) of the patients. Pathological findings at scintigraphy with a solid bolus were found in 67% (12/18). Even if scintigraphy with a solid bolus is the method that identifies the highest number of patients with impaired oesophageal function among the tests used, it cannot differentiate between functional and anatomical disorders. A barium meal examination is the method of choice when an anatomical disorder is suspected.