Short course of omeprazole: a better first diagnostic approach to noncardiac chest pain than endoscopy,manometry, or 24-hour esophageal pH monitoring

Noncardiac chest pain (NCCP) presents as a frequent diagnostic challenge, with patients tending to use a disproportionate level of health care resources. Gastroesophageal reflux disease (GERD) is the most frequent cause of NCCP. GOALS: To test the efficacy of a potent acid-suppressing agent as a diagnostic test in the evaluation of NCCP and to compare it with three commonly used tests. STUDY: Eighteen men and 24 women, aged 22 to 77 years, who presented with recurrent chest pain complaints of a noncardiac etiology, as determined by rest/stress perfusion imaging with technetium Tc99m sestamibi (MIBI), were enrolled in a prospective, double-blinded, placebo-controlled, crossover trial using high-dose omeprazole. Thirty-seven patients completed both arms of the trial. Findings were compared with those of endoscopy, manometry, and ambulatory 24-hour two-channel esophageal pH monitoring. All patients underwent initial diagnostic upper endoscopy, esophageal manometry, and 24-hour pH monitoring. Patients were then randomly assigned to either placebo or omeprazole (40 mg/d orally twice daily) for 14 days, washed out for 21 days, and then crossed over. Patient's symptoms were determined using a Visual Analogue Scale to measure the severity of chest pain before and after each period. RESULTS: Seventy-one percent of patients in the omeprazole arm reported improved chest pain, whereas only 18% in the placebo arm did. Abnormal results on manometry (20%), 24-hour pH monitoring (42%), or endoscopy with visual evidence of esophagitis (26%) were found less frequently. Combination of the three tests did not significantly increase their usefulness. In NCCP patients with GERD, as defined by positive results on a 24-hour pH test or presence of esophagitis on endoscopy, omeprazole treatment led to a response in 95% of patients, whereas 90% of GERD-positive patients treated with placebo did not respond. Of NCCP patients determined to be GERD negative, 39% responded to omeprazole. CONCLUSIONS: Omeprazole as a first diagnostic tool in the evaluation of MIBI-negative NCCP is sensitive and specific for determining the cause of NCCP. Endoscopy, manometry, and 24-hour pH monitoring were not only less sensitive in diagnosing NCCP, but they were significantly more expensive.     

Evaluation of symptom index in identifying gastroesophageal reflux disease-related noncardiac chest pain

BACKGROUND: Symptom index (SI), which represents the percentage of perceived gastroesophageal reflux-related symptoms that correlate with esophageal acid reflux events (pH <4), has been suggested as a measure to improve diagnosis of gastroesophageal reflux (GER)-related noncardiac chest pain (NCCP). Because no study has evaluated the value of the symptom index in NCCP patients, data to support this claim have yet to be elucidated. AIM: To evaluate the value of SI in identifying gastroesophageal reflux disease (GERD)-related NCCP patients. METHODS: Patients enrolled in this study were referred by a cardiologist after a comprehensive work-up excluded a cardiac cause for their chest pain. All patients underwent upper endoscopy to determine esophageal inflammation and 24-hour esophageal pH monitoring to assess esophageal acid exposure. Patients were instructed to record all chest pain episodes during the pH test. Patients with a positive SI (> or =50%) underwent the proton pump inhibitors (PPI) test, which is a therapeutic trial using a short course of high dose PPI. RESULTS: A total of 94 patients with NCCP were included in this study. Forty-seven (50%) had either a positive upper endoscopy or an abnormal pH test and were considered GERD-Positive. Forty-seven patients (50%) had both tests negative and were considered GERD-Negative. Total number of reflux episodes and percent total, supine and upright time pH less than 4, were significantly higher in the GERD-Positive group as compared with the GERD-Negative group (P < 0.0001, P < 0.0001, P = 0.0045, and P < 0.0001 respectively). Only 9 (19.1%) patients in the GERD-Positive group and 5 (10.6%) patients in the GERD-Negative group had a positive SI (p = ns). Eight (89%) out of the 9 patients who had a positive SI in the GERD-Positive group and 2 (40%) out of 5 patients in the GERD-Negative group responded to the PPI test. CONCLUSION: Positive SI is relatively uncommon in NCCP patients, regardless if GERD is present or absent. Hence, symptom index provides very little improvement in diagnosing GERD-related NCCP.     

New frontiers for the treatment of noncardiac chest pain: the adenosine receptors

Emerging data suggest that noncardiac chest pain (NCCP) is a very common disorder of international proportions. In the United States alone, an estimated 69 million patients suffer from NCCP. The clinical spectrum of patients with NCCP being referred to gastroenterologists seems to be changing to those failing to respond acid inhibition therapy or those who may not have gastroesophageal reflux (GER) in the first place. For these individuals there is an important need to find effective therapeutic options. These patients are the subject of the study that appears in this issue of The American Journal of Gastroenterology (Rao et al.,). Rao et al. report data from their tertiary center on consecutive patients with recurrent NCCP failing an 8-wk therapeutic trial of double-dose PPI or lacking evidence of GER on 24-h pH testing. They found that theophylline--a nonspecific adenosine receptor antagonist--when compared with placebo, improved the biomechanical and sensory properties of the esophageal wall and chest pain frequency, severity, and duration. This study underscores the potential role of adenosine receptors in visceral pain.     

Role of clinical presentation in diagnosing reflux-related non-cardiac chest pain

INTRODUCTION: Non-cardiac chest pain (NCCP) presents as a frequent diagnostic challenge, with patients tending to use a disproportionate level of health-care resources. Gastroesophageal reflux disease (GERD) is the most frequent cause of NCCP. Thus the typical symptoms of reflux, such as heartburn and regurgitation, when present as predominant symptoms are quite specific for diagnosing GERD but in patients with NCCP the clinical diagnosis of reflux is difficult, and invasive methods or the omeprazole test are required for its detection. The aim of the present study was to evaluate the role of clinical presentation when diagnosing GERD among patients with NCCP. METHODS: Patients with NCCP underwent upper endoscopy, Bernstein and omeprazole tests. The patients were divided into two groups based on GER- or non-GER-related chest pain, and clinical presentation was compared between these two groups. Gastroesophageal reflux disease was considered positive when at least two methods were positive. RESULTS: From 78 NCCP patients (41 male; mean age 50.4 +/- 2.3 years), the chest pain was related to GERD in 35 patients (44.8%). The two groups were the same based on sex and age. The chest pain severity, site, radiation and relation to food, exercise, and sleep were equal in the two groups, except for two symptoms: pain that was relieved by antacid (P < 0.031) and presence of classical reflux symptoms (P < 0.009), seen in the GERD patients. With regard to recent patient history, heartburn and regurgitation symptoms were seen more frequently in GERD patients (P < 0.036 and P < 0.002, respectively). DISCUSSION: Clinical presentation is important in diagnosing GERD in NCCP. Although the chest pain is the same in reflux- and non-reflux-related NCCP, the symptoms of heartburn or regurgitation in the present or recent patient history are diagnostic for GERD-related chest pain.     

Effects of oral magnesium therapy on exercise tolerance,exercise-induced chest pain,and quality of life in patients with coronary artery disease

Previous studies have demonstrated that magnesium supplementation improves endothelial function in patients with coronary artery disease (CAD). However, the impact on clinical outcomes, such as exercise-induced chest pain, exercise tolerance, and quality of life, has not been established. In a multicenter, multinational, prospective, randomized, double-blind and placebo-controlled trial, 187 patients with CAD (151 men, 36 women; mean +/- SD age 63 +/- 10 years, range 42 to 83) were randomized to receive either oral magnesium 15 mmol twice daily (Magnosolv-Granulat, total magnesium 365 mg provided as magnesium citrate) (n = 94) or placebo (n = 93) for 6 months. Symptom-limited exercise testing (Bruce protocol) and responses given on quality-of-life questionnaires were the outcomes measured. Magnesium therapy significantly increased intracellular magnesium levels ([Mg]i) in a substudy of 106 patients at 6 months compared with placebo (35.5 +/- 3.7 vs 32.6 +/- 2.9 mEq/L, p = 0.0151). Magnesium treatment significantly increased exercise duration time compared with placebo (8.7 +/- 2.1 vs 7.8 +/- 2.9 minutes, p = 0.0075), and lessened exercise-induced chest pain (8% vs 21%, p = 0.0237). Quality-of-life parameters significantly improved in the magnesium group. These findings suggest that oral magnesium supplementation in patients with CAD for 6 months results in a significant improvement in exercise tolerance, exercise-induced chest pain, and quality of life, suggesting a potential mechanism whereby magnesium could beneficially alter outcomes in patients with CAD.     

Theophylline improves esophageal chest pain--a randomized, placebo-controlled study

BACKGROUND, AIM: The treatment of esophageal (noncardiac) chest pain is unsatisfactory and there is no approved therapy. A previous uncontrolled study suggested that theophylline may be useful. Our aims were to investigate the effects of theophylline on esophageal sensorimotor function and chest pain. METHODS: In a double-blind study, sensory and biomechanical properties of the esophagus were assessed using impedance planimetry in 16 patients with esophageal hypersensitivity, after intravenous theophylline or placebo. In a second, randomized 4-wk crossover study, oral theophylline and placebo were administered to 24 patients with esophageal hypersensitivity. Frequency, intensity, and duration of chest pain episodes were evaluated. RESULTS: After IV theophylline, chest pain thresholds (P=0.027) and esophageal cross-sectional area (P=0.03) increased and the esophageal wall became more distensible (P=0.04) compared with placebo. After oral theophylline, the number of painful days (P=0.03) and chest pain episodes (P=0.025), pain duration (P=0.002), and its severity (P=0.031) decreased. Overall symptoms improved in 58% on theophylline and 6% on placebo (P<0.02). There was no order effect. CONCLUSIONS: Theophylline relaxed the esophageal wall, decreased hypersensitivity, and improved chest pain. Theophylline is effective in the treatment of functional chest pain.     

Low dose imipramine improves chest pain but not quality of life in patients with angina and normal coronary angiograms

Aims We investigated patients with chest pain and normal coronaryangiograms to determine whether low dose imipramine prescribedas add-on therapy to conventional anti-anginals reduced theincidence of chest pain and whether this led to an overall improvementin quality of life. Methods and results We performed a randomized, double-blind, cross-over trial ofimipramine 50mg daily vs placebo in 18 women (median age 53years; range 35–72) with chest pain and normal coronaryangiograms who were suffering at least two anginal episodesper week despite conventional anti-anginal medication. Eachtreatment phase lasted 5 weeks and the incidences of chest painand side effects were carefully recorded. Quality of life wasmonitored using a validated health profile questionnaire scoringperceived distress in six domains (pain, energy, mobility, sleep,emotional reactions and social isolation). The total numberof chest pain episodes was significantly less during activetreatment compared to placebo [11 (3–22) vs 21 (16–28)—median(interquartile range); P=0·01]. However, a high incidence(83%) of side effects was reported during active treatment andthree patients had to be withdrawn from the study as a consequence.No significant improvement was detected in any of the six qualityof life domains when imipramine was compared to placebo. Conclusion Imipramine reduces the incidence of chest pain in patients withchest pain and normal coronaries who remain symptomatic despiteconventional anti-anginal therapy. The failure to demonstrateassociated improvements in quality of life may have been dueto the high incidence of side effects.     

Double-blind comparison of omeprazole 20 mg om and ranitidine 300 mg NOCTE in duodenal ulcer: A Taiwan multi-centre study

Two hundred and twenty-six patients with endoscopically confirmed duodenal ulcers > or = 5 mm in diameter entered a double-blind randomized trial comparing 20 mg omeprazole administered once daily in the morning with 300 mg ranitidine administered once daily at night. The patients were assessed endoscopically and symptomatically after 2 weeks, and those whose ulcers had healed terminated the study. Patients with unhealed ulcers continued treatment for a total of 4 weeks. Omeprazole produced significantly higher healing rates than ranitidine at both 2 weeks (57 vs 28%, P < 0.0001) and 4 weeks (93 vs 80%, P = 0.006). Similarly, significantly higher 'effective healing rates' (defined on the criteria established by the Japanese Society of Digestive Endoscopy) were observed with omeprazole compared with ranitidine at 2 and 4 weeks. After 2 weeks, there were significantly fewer reports of both day-time and night-time epigastric pain by omeprazole-treated patients compared with ranitidine-treated patients (22 vs 44%, P < 0.0001 for day-time pain; 24 vs 35%, P = 0.025 for night-time pain). Both drugs were well-tolerated and no major adverse effects were recorded during either treatment. In conclusion, 20 mg omeprazole administered once daily was superior to 300 mg ranitidine administered once daily for duodenal ulcer healing and symptom relief.     

Neurophysiologic assessment of esophageal sensory processing in noncardiac chest pain

BACKGROUND & AIMS: Esophageal hypersensitivity is thought to be important in the generation and maintenance of symptoms in noncardiac chest pain (NCCP). In this study, we explored the neurophysiologic basis of esophageal hypersensitivity in a cohort of NCCP patients. METHODS: We studied 12 healthy controls (9 women; mean age, 37.1 +/- 8.7 y) and 32 NCCP patients (23 women; mean age, 47.2 +/- 10 y). All had esophageal manometry, esophageal evoked potentials to electrical stimulation, and NCCP patients had 24-hour ambulatory pH testing. RESULTS: The NCCP patients had reduced pain thresholds (PT) (72.1 +/- 19.4 vs 54.2 +/- 23.6, P = .02) and increased P1 latencies (P1 = 105.5 +/- 11.1 vs 118.1 +/- 23.4, P = .02). Subanalysis showed that the NCCP group could be divided into 3 distinct phenotypic classifications. Group 1 had reduced pain thresholds in conjunction with normal/reduced latency P1 latencies (n = 9). Group 2 had reduced pain thresholds in conjunction with increased (>2.5 SD) P1 latencies (n = 7), and group 3 had normal pain thresholds in conjunction with either normal (n = 10) or increased (>2.5 SD, n = 3) P1 latencies. CONCLUSIONS: Normal esophageal evoked potential latencies with reduced PT, as seen in group 1 patients, is indicative of enhanced afferent transmission and therefore increased esophageal afferent pathway sensitivity. Increased esophageal evoked potential latencies with reduced PT in group 2 patients implies normal afferent transmission to the cortex but heightened secondary cortical processing of this information, most likely owing to psychologic factors such as hypervigilance. This study shows that NCCP patients with esophageal hypersensitivity may be subclassified into distinct phenotypic subclasses based on sensory responsiveness and objective neurophysiologic profiles.     

Intraesophageal Balloon Distension Test in Chagas' Disease Patients with Noncardiac Chest Pain

Patients with Chagas' disease often have chestpain as a prominent symptom. The objective of this studywas to compare the results of intraesophageal balloondistension in chagasic and nonchagasic patients with chest pain not caused by coronaryobstruction. We studied 40 patients with chest pain andangiographically normal coronary arteries, 25 with apositive serologic test for Chagas' disease (Chagasgroup, 16 women, mean age 53 ± 10 years), and15 with a negative serologic test (control group, 11women, mean age 46 ± 10 years). All patients hadradiologic and endoscopic examinations of esophagus,stomach, and duodenum, esophageal manometry with theacid infusion test in the distal esophagus, andintraesophageal balloon distension. None of them hadesophageal dilation or any signs of cardiovasculardisease. A 25-mm-long latex balloon located 10 cm abovethe lower esophageal sphincter was inflated and deflatedover a period of 10 sec at 1-ml increments of air untilthe subjects reported chest pain or to a maximum volume of 20 ml. The test caused chest pain in14 subjects in the control group (93%) and in 12 in theChagas' disease group (48% , P < 0.05). The meanvolume of air that caused chest pain was 10 ± 3ml in the control group and 15 ± 4 ml in theChagas' disease group (mean ± SD, P < 0.05).The maximum intraesophageal pressure during theexamination was higher in Chagas' disease patients withchest pain during balloon distension (60 ± 21mm Hg) than in patients who did not have chest pain (37± 18 mm Hg, P < 0.05) and did not differ fromthe control group (48 ± 16 mm Hg, P > 0.05).With the other examinations there was no differencebetween groups or between patients with or without chestpain during the balloon distension test. Althoughesophagitis was observed in 47% of patients in the control group and in 40% of the Chagas' diseasegroup, the acid infusion test was positive in 27% ofpatients in the control group and in 4% of patients inthe Chagas' disease group. We conclude that, as compared to a group of patients with similarchest pain, chagasic patients are less sensitive toesophageal distension. Thus, it is unlikely that theirchest pain is related to esophagealmechanisms.     

Edrophonium provocative test in noncardiac chest pain

Edrophonium chloride is used frequently as a provocative agent in the assessment of noncardiac chest pain (NCCP). However, the optimum dose and most appropriate method of interpreting test results is controversial. We studied 150 consecutive NCCP patients and 50 age-matched controls who alternately received either 80 micrograms/kg or 10 mg intravenous bolus doses of edrophonium preceded by saline placebo injections. Distal esophageal pressures were measured before and after drug injection in response to ten 5-cc wet swallows. Following 10 mg of edrophonium, 33% of patients and 4% of controls reported chest pain, while 29% of patients and no controls receiving the 80 micrograms/kg dose complained of chest pain. Amplitude changes after either dose were not significantly different for all comparisons, but the duration of response did distinguish the two doses in patients with chest pain. A significantly greater (P = 0.01) increase in distal contraction duration occurred after 10 mg (74 +/- 12%; +/- SE) compared to 80 micrograms/kg dose (43 +/- 6%). However, individual responses to the two doses overlapped considerably. If a positive test is redefined to include both chest pain and manometric changes that are significantly different from controls, the positivity rate changes drastically; 33% to 9% in the 10-mg group and 30% to 3% in the 80-micrograms/kg group. Side effects were similar between doses, but there was a significant (P = 0.02) linear relationship between intensity of side effects and the edrophonium dose per kilogram of body weight.(ABSTRACT TRUNCATED AT 250 WORDS)     

Asthma and gastro-oesophageal reflux: can the response to anti-reflux therapy be predicted?

The aim of the study was to investigate which features predict favourable response to omeprazole therapy in asthmatics with gastro-oesophageal reflux (GER). The study population consisted of 52 outpatient asthmatics with GER who had completed an intervention where they were randomized to receive omeprazole 40 mg once a day or placebo for 8 weeks. After a 2-week washout period the patients were crossed over. Asthma symptoms were found to be relieved > or = 20% in 18 (35%) patients who were thus regarded as responders. A logistic regression analysis was performed in order to identify which features separate the responders from the non-responders. More responders were found among the patients whose body mass index (BMI) was higher (P = 0.02) or whose distal esophageal reflux was more severe [total time (%) pH < 4 (P = 0.01) or time (%) pH < 4 in upright position (P = 0.04)]. Adding other predictors to the total time (%) pH < 4, which was the most significant predictor for response in multi-variate analysis, did not further increase the prediction for favourable outcome. It is concluded that severe distal oesophageal reflux and obesity predict amelioration in asthma symptoms after 8-week omeprazole treatment in asthmatics with GER. Adding more than one predictor does not seem to further increase prediction for favourable asthma response.     

食管混合性酸反流和低动力在非心源性胸痛发作的作用研究

目的胃食管反流病（GERD）是引起非心源性胸痛（NCCP）的最常见因素,本研究探讨酸反流和食管动力障碍在NCCP患者中的作用。 方法按照纳入、排除标准选取2018年9月至2019年6月在新疆维吾尔自治区人民医院急救中心以及微创,疝和腹壁外科住院收治的40例NCCP患者和50例典型GERD症状患者,两组患者均行食管24 h pH监测以及高分辨率食管测压监测。 结果NCCP组食管远端收缩平均积分（DCI）明显低于GERD组,并具有统计学意义（P＜0.05）,提示食管运动功能受损。在NCCP组患者中,与胸痛有关的混合性酸反流明显高于GERD组（P＜0.05）。在NCCP组患者中,与NCCP相关的反流发作在食管5、9和15cm处的反流清除时间比GERD组患者期长（28.3±4.21)s vs(22.6±3.28)s;(13.7±1.32)s vs (18.3±1.47)s;(9.58±1.02)s vs(14.3±1.06)s（P＜0.05）。 结论酸反流性质,食管运动功能受损和延缓反流清除时间与NCCP患者症状发作可能存在密切的关系。     

Esophageal Motility and Psychiatric Factors in Functional Dyspepsia Patients with or Without Pain

Subtypes of functional dyspepsia (FD), includingrefluxlike dyspepsia, ulcerlike dyspepsia,dysmotility-like dyspepsia, and nonspecific dyspepsia,have been described and are widely used clinically.However, these symptom patterns often overlap, and theterms are insufficient for indicating all FD symptoms.In this study, we divided 71 FD patients into twogroups: patients with or without pain. Group I, the pain dyspepsia group, included patients in whomthe main symptoms were epigastralgia and/or chest pain.Group II, the painless dyspepsia group, includedpatients without pain, in whom the symptoms were nausea, vomiting, and heartburn. We examinedthe relationship between esophageal function andpsychiatric factors in the test groups and compared themwith a control group. Of the FD patients, 19.7% [8 (25%) of 32 group I patients, 6 (15.4%) of 39group II patients] had esophageal motility disorders,such as nutcracker esophagus and diffuse esophagealspasm. The LES pressure of group I was higher than that of group II by esophageal manometry (P< 0.05). In 17 (53.1%) of 32 group I patients and 31(79.5%) of 39 group II patients, psychiatric disorders(38.0% had depressive disorder and 21.1% had an anxiety disorder) were diagnosed followingDSM III-R criteria. Group II tended to be moredepressive than group I (P = 0.0508). Psychologicalassessment scores, STAI-I and STAI-II, were higher ingroups I and II than in the control group (P <0.001). Long-term distress, anxiety, and depression seemto influence the symptoms of FD patients. Esophagealdysmotility may be an important functional abnormality of FD.     

Gastroesophageal reflux in asthmatics: A double-blind, placebo-controlled crossover study with omeprazole

STUDY OBJECTIVES: To investigate the prevalence of gastroesophageal reflux (GER) among patients with asthma and to determine the effect of omeprazole on the outcome of asthma in patients with GER. DESIGN: A double-blind, placebo-controlled crossover study. SETTING: Asthmatic patients who attended the pulmonary outpatient clinic of Turku University Central Hospital, Finland. PATIENTS: One hundred seven asthmatic patients. INTERVENTIONS: The patients who were found to have GER in ambulatory esophageal pH monitoring were randomized to receive either omeprazole, 40 mg qd, or placebo for 8 weeks. After a 2-week washout period, the patients were crossed over to the other treatment. Spirometry was performed at baseline and immediately after both treatment periods. Peak expiratory values, use of sympathomimetics, and pulmonary and gastric symptoms were recorded daily in a diary. RESULTS: Pathologic GER was found in 53% of the asthmatic patients. One third of these patients had no typical reflux symptoms. Daytime pulmonary symptoms did not improve significantly (p = 0.14), but a reduction in nighttime asthma symptoms (p = 0.04) was found during omeprazole treatment. In the patients with intrinsic asthma, there was a decline in [corrected] FEV(1) values (p = 0.049). Based on symptom scores, 35% of the patients were regarded as responders to 8-week omeprazole treatment. The reflux (time [percent] of pH < 4) was found to be more severe (p = 0. 002) in the responders. CONCLUSIONS: There is a high prevalence of GER in the asthmatic population. This reflux is often clinically "silent." After an 8-week omeprazole treatment, there was a reduction in nocturnal asthma symptoms, whereas daytime asthma outcome did not improve. There seems to be a subgroup of asthma patients who benefit from excessive antireflux therapy.     

Weight reduction and long-term maintenance after 18 months treatment with orlistat for obesity

OBJECTIVE: To determine the effect of orlistat on weight reduction and the long-term maintenance of this weight loss when associated with a continuous mildly reduced energy diet. DESIGN: A multicenter, 18-month, double-blind study conducted in 81 hospital centers. Patients were randomized to orlistat 120 mg or placebo three times daily in conjunction with a mildly reduced-energy diet maintained throughout the study. SUBJECTS: In total, 696 otherwise healthy, overweight patients aged 18-65 y (BMI >or=28 kg/m(2)) were randomized to treatment with orlistat (n=346) or placebo (n=350). MEASUREMENTS: Body weight, anthropometry, lipid and glycemic control parameters and blood pressure. RESULTS: After 18 months, patients treated with orlistat lost significantly more body weight compared with placebo (-6.5+/-0.8 vs -3.0+/-0.8%; P=0.0005). After 12 months, 32.9% of orlistat vs 24.5% of placebo patients lost >or=10% of their initial weight (P=0.04). A significantly greater number of patients receiving orlistat treatment maintained this >or=10% weight loss compared to those receiving placebo (28.1 vs 13.8%; P<0.0001). Compared with placebo, orlistat was associated with a greater decrease in fasting blood glucose (-0.86+/-0.12 vs -0.29+/-0.18 mmol/l; P<0.05) and LDL-cholesterol (-13.0+/-1.3 vs -7.0+/-1.3%; P<0.001). CONCLUSION: A clinically meaningful reduction in body weight and the maintenance of this weight loss is achievable with orlistat treatment and dietary restriction over a period of 18 months. This weight loss resulted in an improvement in risk factors for coronary heart disease.     

Does omeprazole (Prilosec) improve respiratory function in asthmatics with gastroesophageal reflux?

Gastroesophageal reflux (GER) is common among patients with asthma, and it has been speculated that high GER may exacerbate asthma in some. This study was designed to determine if suppression of acid reflux in patients with asthma would improve pulmonary function. A double-blind, placebo-controlled crossover study design was used to determine the effect of GER suppression with omeprazole (20 mg twice daily) on pulmonary function among asthmatic patients with esophagitis. Four of 15 (27%) asthma patients with GER were shown to have a≥20% net improvement in pulmonary function (FEV₁) after treatment for six weeks with omeprazole. These results indicate that some patients with asthma and GER will have improved pulmonary function when acid GER is treated with omeprazole.     

Population based study of noncardiac chest pain in southern Chinese： Prevalence, psychosocial factors and health care utilization

AIM: Population-based assessment of noncardiac chest pain (NCCP) is lacking. The aim of this study was to evaluate the prevalence, psychosocial factors and health seeking behaviour of NCCP in southern Chinese. METHODS: A total of 2 209 ethnic Hong Kong Chinese households were recruited to participate in a telephone survey to study the epidemiology of NCCP using the Rose angina questionnaire, a validated gastroesophageal reflux disease (GERD) questionnaire and the hospital anxiety-depression scale. NCCP was defined as non-exertional chest pain according to the Rose angina questionnaire and had not been diagnosed as ischaemic heart diseases by a physician. RESULTS: Chest pain over the past year was present in 454 subjects (20.6%, 95% CI 19-22), while NCCP was present in 307 subjects (13.9%, 95% CI 13-15). GERD was present in 51% of subjects with NCCP and 34% had consulted a physician for chest pain. Subjects with NCCP had a significantly higher anxiety (P<0.001) and depression score (P=0.007), and required more days off (P=0.021) than subjects with no chest pain. By multiple logistic regression analysis, female gender (OR 1.9, 95% CI 1.1-3.2), presence of GERD (OR 2.8, 95% CI 1.6-4.8), and social life being affected by NCCP (OR 6.9, 95% CI 3.3-15.9) were independent factors associated with health seeking behaviour in southern Chinese with NCCP. CONCLUSION: NCCP is a common problem in southern Chinese and associated with anxiety and depression. Female gender, GERD and social life affected by chest pain were associated with health care utilization in subjects with NCCP.     

Effect of beta-blockade on low heart rate-related ischemia during mental stress.

To explore the effect of beta-adrenergic blockade on low heart rate-related (mental stress) ischemia, 19 patients with coronary artery disease were randomized into a double-blind crossover trial of metoprolol, 100 mg twice daily, and underwent serial mental stress/bicycle exercise studies. Mental stress-induced wall motion abnormalities occurred at a lower heart rate than exercise-induced wall motion abnormalities during placebo administration (81 +/- 16 vs. 123 +/- 20 beats/min, p less than 0.05). Metoprolol reduced the mean magnitude of exercise-induced wall motion abnormalities (2.8 +/- 2.0 vs. 1.6 +/- 2.4, p = 0.003); improvement was related to the magnitude of hemodynamic beta-blockade effect. Metoprolol did not significantly reduce the mean magnitude of mental stress-induced wall motion abnormalities (3.0 +/- 2.2 vs. 2.6 +/- 2.2), although individual responses predominantly either improved (50%) or worsened (29%). Unlike exercise, the magnitude of hemodynamic beta-blockade did not predict mental stress response and metoprolol did not block mental stress-induced blood pressure elevations. Patients with abolition of exercise-induced ischemia were more likely to have reduction of mental stress-induced ischemia. Patients whose ischemia worsened with metoprolol during mental stress had more easily inducible ischemia, as assessed by exercise-induced placebo wall motion abnormality, chest pain and prior myocardial infarction. Beta-blockade was associated with a lowering of ischemia-related hemodynamic thresholds compared with placebo. These results suggest that beta-blockade has a variable effect on low heart rate-related ischemia that may be due to a lack of effect on mental stress-induced blood pressure elevation in patients with easily induced ischemia or to effects on coronary vasomotor tone, or both.     

小儿非心源性胸痛与胃食管反流的关系

目的了解小儿非心源性胸痛(NCCP)与胃食管反流(GER)的关系,探讨食管pH值监测在小儿NCCP诊断中的意义。方法对36例(病例组)诊断为NCCP并排除呼吸系统和胸部肌肉骨骼病变患儿进行24 h食管pH值监测,其中20例行胃镜检查。根据食管炎诊断标准,诊断为食管炎(食管炎组)11例,非食管炎(非食管炎组)9例。结果病例组24 h食管pH值<4、反流≥5 min、最长反流时间、酸性反流指数、Boix-Ochoa评分分别为(60±7)次、(2．44±0．74)次、(12．4±2．8)min、6．72±1．39、(24．6±3．9)分,对照组分别为(33±4)次、(0．35±0．11)次、(4．3±0．9) min、1．25±0．19、(7．7±0．9)分,两组比较差异有统计学意义(t分别=3．44、2．79、2．73、3．89、4．24, P均<0．01);以Boix-Ochoa评分>11．99为病理性GER诊断标准,病例组GER阳性为58．3％(21／36)。20例经胃镜检查的患者中诊断为食管炎为55．0％(11／20),其中GER阳性为81．8％(9／11);诊断为非食管炎为45．0％(9／20),其中GER阳性者为33．3％(3／9)。食管炎组反流≥5 min、酸性反流指数分别为(5．8±2．0)次、12．5±3．5,非食管炎组分别为(0．9±0．5)次、3．4±1．4,两组比较差异有统计学意义(Z分别=-2．400、-2．545,P均<0．05);食管炎组24 h食管pH值<4、最长反流时间、Boix-Ochoa评分分别为(73±11)次、(26±7)min、(41±10)分,非食管炎组分别为(34±11)次、(4±3)min、(14±5)分,两组比较差异有统计学意义(Z值分别为-2．926、-2．675、-2．584,P均<0．01)。结论GER是小儿NCCP的重要原因,食管pH值监测有助于小儿NCCP的病因诊断,并能指导治疗。