Contexte & Objectifs : La manométrie perfusée conventionnelle et la manométrie haute résolution (HRM) ont permis le développement d’une variété de paramètres pour mieux comprendre la motilité de l'œsophage et quantifier les caractéristiques de la jonction œsophago-gastrique (JOG). Cependant, l'anatomie de la JOG est complexe et les enregistrements de manométrie détectent à la fois la pression des structures intrinsèques et des structures extrinsèques à l'œsophage. Ces différents composants ont des rôles distincts au niveau de la JOG. Les pressions dominantes ainsi détectées au niveau de la JOG sont attribuables au sphincter œsophagien inférieur (SOI) et aux piliers du diaphragme (CD), mais aucune des technologies manométriques actuelles n’est capable de distinguer ces différents composants de la JOG. Lorsqu’on analyse les caractéristiques de la JOG au repos, celle ci se comporte avant tout comme une barrière antireflux. Les paramètres manométriques les plus couramment utilisés dans ce but sont la longueur de la JOG et le point d’inversion respiratoire (RIP), défini comme le lieu où le pic de la courbe de pression inspiratoire change de positif (dans l’abdomen) à négatif (dans le thorax), lors de la classique manœuvre de « pull-through ». Cependant, l'importance de ces mesures reste marginale comme en témoigne une récente prise de position de l’American Gastroenterology Association Institute (AGAI) (1) qui concluait que « le rôle actuel de la manométrie dans le reflux gastro-œsophagien (RGO) est d'exclure les troubles moteurs comme cause des symptômes présentés par la patient ». Lors de la déglutition, la mesure objective de la relaxation de la JOG est la pression de relaxation intégrée (IRP), qui permet de faire la distinction entre une relaxation normale et une relaxation anormale de la JOG. Toutefois, puisque la HRM utilise des pressions moyennes à chaque niveau de capteurs, certaines études de manométrie laissent suggérer qu’il existe une zone de haute pression persistante au niveau de la JOG même si un transit est mis en évidence en vidéofluoroscopie. Récemment, la manométrie haute résolution « 3D » (3D-HRM) a été développée (Given Imaging, Duluth, GA) avec le potentiel de simplifier l'évaluation de la morphologie et de la physiologie de la JOG. Le segment « 3D » de ce cathéter de HRM permet l'enregistrement de la pression à la fois de façon axiale et radiale tout en maintenant une position fixe de la sonde, et évitant ainsi la manœuvre de « pull-through ». Par conséquent, la 3D-HRM devrait permettre la mesure de paramètres importants de la JOG tels que sa longueur et le RIP. Les données extraites de l'enregistrement fait par 3D-HRM permettraient également de différencier les signaux de pression attribuables au SOI des éléments qui l’entourent. De plus, l’enregistrement des pressions de façon radiaire permettrait d’enregistrer la pression minimale de chaque niveau de capteurs et devrait corriger cette zone de haute pression parfois persistante lors la déglutition. Ainsi, les objectifs de ce travail étaient: 1) de décrire la morphologie de la JOG au repos en tant que barrière antireflux, en comparant les mesures effectuées avec la 3D-HRM en temps réel, par rapport à celle simulées lors d’une manœuvre de « pull-through » et de déterminer quelles sont les signatures des pressions attribuables au SOI et au diaphragme; 2) d’évaluer la relaxation de la JOG pendant la déglutition en testant l'hypothèse selon laquelle la 3D-HRM permet le développement d’un nouveau paradigme (appelé « 3D eSleeve ») pour le calcul de l’IRP, fondé sur l’utilisation de la pression radiale minimale à chaque niveau de capteur de pression le long de la JOG. Ce nouveau paradigme sera comparé à une étude de transit en vidéofluoroscopie pour évaluer le gradient de pression à travers la JOG. Méthodes : Nous avons utilisé un cathéter 3D-HRM, qui incorpore un segment dit « 3D » de 9 cm au sein d’un cathéter HRM par ailleurs standard. Le segment 3D est composé de 12 niveaux (espacés de 7.5mm) de 8 capteurs de pression disposés radialement, soit un total de 96 capteurs. Neuf volontaires ont été étudiés au repos, où des enregistrements ont été effectués en temps réel et pendant une manœuvre de « pull-through » du segment 3D (mobilisation successive du cathéter de 5 mm, pour que le segment 3D se déplace le long de la JOG). Les mesures de la longueur du SOI et la détermination du RIP ont été réalisées. La longueur de la JOG a été mesurée lors du « pull-through » en utilisant 4 capteurs du segment 3D dispersés radialement et les marges de la JOG ont été définies par une augmentation de la pression de 2 mmHg par rapport à la pression gastrique ou de l’œsophage. Pour le calcul en temps réel, les limites distale et proximale de la JOG ont été définies par une augmentation de pression circonférentielle de 2 mmHg par rapport à la pression de l'estomac. Le RIP a été déterminée, A) dans le mode de tracé conventionnel avec la méthode du « pull-through » [le RIP est la valeur moyenne de 4 mesures] et B) en position fixe, dans le mode de représentation topographique de la pression de l’œsophage, en utilisant l’outil logiciel pour déterminer le point d'inversion de la pression (PIP). Pour l'étude de la relaxation de la JOG lors de la déglutition, 25 volontaires ont été étudiés et ont subi 3 études de manométrie (10 déglutitions de 5ml d’eau) en position couchée avec un cathéter HRM standard et un cathéter 3D-HRM. Avec la 3D-HRM, l’analyse a été effectuée une fois avec le segment 3D et une fois avec une partie non 3D du cathéter (capteurs standard de HRM). Ainsi, pour chaque individu, l'IRP a été calculée de quatre façons: 1) avec la méthode conventionnelle en utilisant le cathéter HRM standard, 2) avec la méthode conventionnelle en utilisant le segment standard du cathéter 3D-HRM, 3) avec la méthode conventionnelle en utilisant le segment « 3D » du cathéter 3D-HRM, et 4) avec le nouveau paradigme (3D eSleeve) qui recueille la pression minimale de chaque niveau de capteurs (segment 3D). Quatorze autres sujets ont subi une vidéofluoroscopie simultanée à l’étude de manométrie avec le cathéter 3D-HRM. Les données de pression ont été exportés vers MATLAB ™ et quatre pressions ont été mesurées simultanément : 1) la pression du corps de l’œsophage, 2cm au-dessus de la JOG, 2) la pression intragastrique, 3) la pression radiale moyenne de la JOG (pression du eSleeve) et 4) la pression de la JOG en utilisant la pression minimale de chaque niveau de capteurs (pression du 3D eSleeve). Ces données ont permis de déterminer le temps permissif d'écoulement du bolus (FPT), caractérisé par la période au cours de laquelle un gradient de pression existe à travers la JOG (pression œsophagienne > pression de relaxation de la JOG > pression gastrique). La présence ou l'absence du bolus en vidéofluoroscopie et le FPT ont été codés avec des valeurs dichotomiques pour chaque période de 0,1 s. Nous avons alors calculé la sensibilité et la spécificité correspondant à la valeur du FPT pour la pression du eSleeve et pour la pression du 3D eSleeve, avec la vidéofluoroscopie pour référence. Résultats : Les enregistrements avec la 3D-HRM laissent suggérer que la longueur du sphincter évaluée avec la méthode du « pull-through » était grandement exagéré en incorporant dans la mesure du SOI les signaux de pression extrinsèques à l’œsophage, asymétriques et attribuables aux piliers du diaphragme et aux structures vasculaires. L’enregistrement en temps réel a permis de constater que les principaux constituants de la pression de la JOG au repos étaient attribuables au diaphragme. L’IRP calculé avec le nouveau paradigme 3D eSleeve était significativement inférieur à tous les autres calculs d'IRP avec une limite supérieure de la normale de 12 mmHg contre 17 mmHg pour l’IRP calculé avec la HRM standard. La sensibilité (0,78) et la spécificité (0,88) du 3D eSleeve étaient meilleurs que le eSleeve standard (0,55 et 0,85 respectivement) pour prédire le FPT par rapport à la vidéofluoroscopie. Discussion et conclusion : Nos observations suggèrent que la 3D-HRM permet l'enregistrement en temps réel des attributs de la JOG, facilitant l'analyse des constituants responsables de sa fonction au repos en tant que barrière antireflux. La résolution spatiale axiale et radiale du segment « 3D » pourrait permettre de poursuivre cette étude pour quantifier les signaux de pression de la JOG attribuable au SOI et aux structures extrinsèques (diaphragme et artéfacts vasculaires). Ces attributs du cathéter 3D-HRM suggèrent qu'il s'agit d'un nouvel outil prometteur pour l'étude de la physiopathologie du RGO. Au cours de la déglutition, nous avons évalué la faisabilité d’améliorer la mesure de l’IRP en utilisant ce nouveau cathéter de manométrie 3D avec un nouveau paradigme (3D eSleeve) basé sur l’utilisation de la pression radiale minimale à chaque niveau de capteurs de pression. Nos résultats suggèrent que cette approche est plus précise que celle de la manométrie haute résolution standard. La 3D-HRM devrait certainement améliorer la précision des mesures de relaxation de la JOG et cela devrait avoir un impact sur la recherche pour modéliser la JOG au cours de la déglutition et dans le RGO. / Background & Aims: Conventional water-perfused manometry and high resolution manometry permitted the development of a variety of manometric methodologies and metrics to understand the motility of the esophagus and to quantify esophagogastric junction (EGJ) characteristics. However, the anatomy in the area of the EGJ is complex and intraluminal manometry recordings detect pressure signals referable both to intrinsic esophageal structures and to adjacent extrinsic structures impinging on the esophagus. Both have distinct sphincteric mechanisms within the EGJ. The dominant pressure signals detected near the EGJ are attributable to the lower esophageal sphincter (LES) and the crural diaphragm (CD). However, neither of these technologies were able to distinguish between the different components of the EGJ. When analyzing EGJ characteristics as a reflection of its competence against reflux, the more widely used manometric parameters are the EGJ length and the respiratory inversion point (RIP), defined as the location at which inspiratory pressure deflections change from positive (abdomen) to negative (chest). However, the significance of these metrics has not gained wide acceptance in the gastroenterology community as evident in a recent American Gastroenterology Association Institute (AGAI) Position Statement (1) concluding that ‘The current role of manometry in gastroesophageal reflux disease (GERD) is to exclude motor disorders as a cause of the continued symptoms’. During deglutition, the objective quantitative measurement of EGJ relaxation, the integrative relaxation pressure (IRP), permits one to distinguish between normal and abnormal EGJ relaxation. However, comparison between spatial pressure variation plots and relaxation pressures derived from circumferentially averaged pressures suggest a persistent high pressure at the hiatal center during a period that flow is known to be occurring whereas this was not seen using nadir radial pressure data. Recently, a 3D-high resolution manometry (3D-HRM) assembly (Given Imaging, Duluth, GA) has been developed with the potential to simplify the assessment of EGJ pressure morphology and physiology. The 3D segment of the array permits high resolution recording both axially and radially while maintaining a stationary sensor position. Consequently, 3D-HRM should allow for the measurement of important EGJ parameters such as length and RIP. Data extracted from the 3D-HRM recording may also allow differentiating pressure signals within the EGJ attributable to the intrinsic sphincter and to the surrounding elements. Moreover, 3D-HRM preserves the individual pressure values of each radially dispersed sensor within the array, permitting one to overcome the apparent persistent high pressure during the deglutitive relaxation. Thus, the aims of this work were 1) to describe the EGJ pressure morphology at rest, comparing measures made with real time 3D-HRM to simulations of a conventional pull-through protocol and to define the pressure signatures attributable to the diaphragmatic and LES pressure components within the 3D-HRM recording; 2) to assess deglutitive EGJ relaxation by testing the hypothesis that the 3D-HRM array using an analysis paradigm based on finding the minimal radial pressure at each axial level (3D-eSleeve) should provide a representation of the luminal pressure gradient across the EGJ that is more relevant to predicting periods of trans-sphincteric flow using barium transit on fluoroscopy as the comparator. We also sought to adapt the IRP metric to the 3D-HRM array using the 3D-eSleeve principle (3D-IRP) and compare normative values obtained with this new paradigm to standard IRP calculations. Methods: Patients were studied with a 3D-HRM assembly. The 3D-HRM assembly incorporated a 9 cm 3D-HRM segment into an otherwise standard HRM assembly; the 3D segment was comprised of 12 rings of 8 radially dispersed independent pressure sensors, spaced 7.5mm apart. At rest, 9 volunteers were studied and recordings were done during a station pull-through of the 3D-HRM segment withdrawing it across the EGJ at 5 mm increments with each position held for 30s (sufficient to capture several respiratory cycles). Conventional measures of ‘LES length’ were made using 4 radially dispersed sensors within the 3D-HRM array, defining the margins of the sphincter by a 2 mmHg pressure increase relative to gastric or esophageal pressure. In the 3D-HRM, the proximal and distal limits of the EGJ were defined as the axial locations first detecting a 360° circumferential pressure increase of 2 mmHg relative to the stomach. RIP was determined, A) in the tracing mode: using the pull-through of 4 single sensors spaced 7.5 mm apart [RIP is the average value of 4 radially dispersed sensors] and B) in a stationary position using the software pressure inversion point (PIP) tool. In the esophageal pressure topography (EPT) mode, the tracing changed progressively from a thoracic pattern to an abdominal pattern, and the RIP was localized within the inversion zone with the PIP tool tracing. For the study of the EGJ deglutitive relaxation, 25 volunteers underwent 3 consecutive 10-swallows protocols of 5 ml of water in the supine position with both the standard (once) and 3D-HRM (twice) devices in random sequence. During the 3D-HRM studies, the EGJ was measured once with the 3D-sleeve segment and once with a proximal (non-3D sleeve portion) of the device incorporating standard HRM sensors. For each subject, the IRP was calculated in four ways: 1) conventional method with the standard HRM device, 2) conventional method with a standard HRM segment of the 3D-HRM device, 3) conventional method using the 3D-HRM sleeve segment, and 4) a novel 3D-HRM eSleeve paradigm (3D-IRP) localizing the radial pressure minimum at each locus along the eSleeve. Fourteen additional subjects then underwent synchronized simultaneous videofluoroscopy and 3D-HRM (including two 5-ml barium swallows). Pressure data were exported to MATLAB™ and four pressures were measured simultaneously: 1) esophageal body pressure 2cm above EGJ, 2) intragastric pressure, 3) radially average eSleeve pressure and 4) 3D-eSleeve pressure. Data were plotted to determine the flow permissive time (FPT) characterized as periods during which a pressure gradient through the EGJ is present (esophageal pressure > EGJ relaxation pressure (radial average or 3D-eSleeve paradigm) > gastric pressure). FPT was calculated during a 10s time window after upper sphincter relaxation. The presence or absence of bolus transit or FPT was coded with dichotomous values for each 0.1 s. We calculated the corresponding sensitivity and specificity for both radial average and 3D-eSleeve analyses of FPT with bolus transit evident on fluoroscopy being the reference. Results: 3D-HRM recordings suggested that sphincter length assessed by a pull-through method greatly exaggerated the estimate of LES length by failing to discriminate among circumferential contractile pressure and asymmetric extrinsic pressure signals attributable to diaphragmatic and vascular structures. Real-time 3D EGJ recordings found that the dominant constituents of EGJ pressure at rest were attributable to the diaphragm. The 3D-IRP was significantly less than all other calculations of IRP with the upper limit of normal being 12 mmHg vs. 17 mmHg for the standard IRP. The sensitivity (0.78) and the specificity (0.88) of the 3D-eSleeve were also better than the standard eSleeve (0.55 and 0.85, respectively) for predicting flow permissive time verified fluoroscopically. Discussion & Conclusion: Our observations suggest that the 3D-HRM permits real-time recording of EGJ pressure morphology facilitating analysis of the EGJ constituents responsible for its function as a reflux barrier at rest. The axial and radial spatial resolution of the 9 cm 3D-HRM segment may permit further studies to differentiate pressure signals within the EGJ attributable to the LES and to extrinsic structures (diaphragm and vascular artifacts). These attributes of the 3D-HRM device suggest it to be a promising new tool in the study of GERD pathophysiology. During deglutition, we evaluated the feasibility of improving the measurement of IRP utilizing a novel 3D-HRM assembly and a novel 3D-eSleeve concept based on finding the axial maximum of the radial minimum pressures at each sensor ring along the sleeve segment. Our findings suggest that this approach is more accurate than standard HRM and other methods that utilize a radially averaged pressure within the EGJ. Although we can only speculate on how much this will improve clinical management, 3D-HRM will certainly improve the accuracy of EGJ relaxation measurements and this will certainly impact research endeavors focused on modeling EGJ function during swallowing and reflux.

As miopatias mitocondriais formam um grupo de desordens clinicamente heterogêneas que podem afetar múltiplos sistemas além do músculo esquelético. A oftalmoplegia externa crônica progressiva (CPEO) é um tipo de miopatia mitocondrial que tem como características alterações nos movimentos oculares, ptose, podendo ter acometimento da musculatura facial, além de atrofia muscular de membros. A fatigabilidade precoce pode ser a queixa principal e claramente desproporcional ao grau de fraqueza e atrofia muscular detectada. A disfagia na doença é uma manifestação descrita por muitos autores, porém pouco estudada ou caracterizada. O presente estudo teve como objetivo avaliar a deglutição de pacientes com miopatia mitocondrial do tipo CPEO através de avaliação clínica, manométrica e videofluoroscópica. Para tanto, foram selecionados 14 pacientes com diagnóstico de miopatia mitocondrial do tipo CPEO, em acompanhamento no Ambulatório de Doenças Neuromusculares do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, independente de apresentarem queixas ou não quanto à alimentação. A idade variou de 15 a 62 anos, com idade média de 35,3 anos sendo 5 (35,7%) do gênero masculino e 9 (64,3%) do feminino. O grupo controle foi formado por 16 indivíduos saudáveis (sem doenças neurológicas ou queixas quanto à alimentação) com idade variando de 21 a 44 anos, idade média de 27,5 anos, sendo 6 (37,5%) do gênero masculino e 10 (62,5%) do feminino. Na avaliação clínica, além da anamnese, foi realizada avaliação estrutural e funcional da deglutição. Para isso foram utilizadas as consistências pastosa, líquida e sólida, em volume livre, conforme hábito do paciente. Na avaliação manométrica, as medidas foram feitas durante a deglutição líquida, para avaliar as pressões intraluminares no corpo do esôfago. Foram realizadas 10 deglutições com intervalo de 30 segundos entre elas e após cinco minutos de repouso mais 10 deglutições com intervalo de 10 segundos entre elas. Foram consideradas as medidas da pressão intraluminal, sua duração, área sob a curva e tempos parciais e totais de deslocamento da onda. Na avaliação videofluoroscópica utilizaram-se as dietas pastosa, líquida e sólida, sendo as duas primeiras em volume controlado de 5ml. Para todas as consistências foram realizadas três ofertas, sendo que para o pastoso e sólido esse processo foi repetido. Além da dinâmica da deglutição na fase orofaríngea foram analisados os tempos de fase oral (TFO), depuração faríngea (DF), trânsito faríngeo (TF), trânsito pela transição faringoesofágica (TTFE) e tempo de movimentação hióidea (TMH). Em anamnese observamos que 9 (64,3%) pacientes tinham queixas quanto a alimentação mas apenas 7 (50%) apresentaram alterações na avaliação clínica, sendo essas alterações principalmente para as consistências pastosa (57,1%) e sólida (100%). As principais alterações foram fase oral prolongada, mastigação inadequada, deglutições múltiplas e fadiga. Na avaliação manométrica foi observado redução da motilidade esofágica sendo essa principalmente no esôfago proximal, com amplitude, duração e área sob a curva reduzidas. Quando comparado o desempenho do esôfago nos diferentes intervalos de deglutição, não houve relação com a presença da doença, pois a diferença foi significante tanto para os pacientes como para os controles. Na videofluoroscopia da deglutição, assim como na avaliação clínica, as principais alterações encontradas foram para as consistências pastosa e sólida, sendo elas tanto em fase oral como faríngea. Apesar disso não foi encontrado nenhum episódio de aspiração laringotraqueal. Quanto aos tempos de deglutição, apenas o TFO foi significantemente maior nos pacientes, sendo menor nos outros parâmetros como TF e TTFE. Ao compararmos as primeiras com as últimas deglutições para as consistências pastosa e sólida, verificamos que os pacientes apresentaram um aumento dos tempos de DF, TF, TTFE e TMH para a consistência sólida, sendo significante apenas para TF. O estudo permitiu concluir que pacientes com miopatia mitocondrial do tipo CPEO apresentam dificuldades de deglutição, com alterações orofaríngeas e esofágicas, sendo maiores para as consistências pastosa e sólida. / Mitochondrial myopathies constitute a group of clinically heterogenous disorders which can affect multiple systems besides the skeletal muscle. The chronic progressive external ophthalmoplegia (CPEO) is a type of mitochondrial myopathy charactherized by eye movements alterations, ptosis, which may attack the facial musculature, as well as atrophy the muscles of members. The early fatigability may be the main complaint and clearly disproportional to the degree of weakness and muscular atrophy detected. The dysphagia in the disease is a manifestation described by several authors, however very little studied and characterized. The present study aimed at evaluating the swallowing of patients with chronic progressive external ophthalmoplegia (CPEO) mitochondrial myopathy, followed at the Neuromuscular Diseases Clinic at Hospital das Clínicas of Faculdade de Medicina de Ribeirão Preto of Universidade de São Paulo, independently whether or not they presented complaints about alimentation. The age varied from 15 to 62 years old, with average age of 35,3, which were 5 (35,7%) males and 9 (64,3%) females. The control group was constituted by 16 healthy individuals (without neurological diseases or complaints about alimentation) with age varying from 21 to 44 years old, average age of 27,5, which were 6 (7,5%) males and 10 (62,5%) females. In the clinical evaluation, anamnesis, structural and functional assessment of swallowing were carried out. According to the patients habits, pasty, liquid and solid consistency were used. In the manometric evaluation, the measurements were done during liquid swallowing, to assess the intraluminal pressure in the esophagus. It was performed 10 swallowings with intervals of 30 seconds among them, and after five minutes of rest, 10 more swallowings with intervals of 10 seconds among them. The intraluminal pressures measurement, its duration, area under curve and wave displacements partial and total time were considered. In the videofluoroscopic evaluation, pasty, liquid and solid diets were used, in which the first two with a controled volume of 5ml. For all the consistencies were realized three offer, and for the solid and pasty, these process were repeated. Besides the swallowing dynamic in the oropharyngeal phase, the oral phase time (OPT), the pharyngeal depuration (PD), pharyngeal transit (PT), pharyngoesophageal transition transit (PTT), hyoid movement time (HMT) were analysed. In the anamnesis, we observed that 9 (64,3%) patients had complaints about alimentation, but only 7 (50%) presented alterations in the clinical evaluation, and these alterations were mainly for pasty (57,1%) and solid (100%)consistencies. The main alterations were extended oral phase, inadequate mastication, multiple swallowings and fatigue. In the manometric evaluation, the esophageal motility reduction was observed, which was mainly in the proximal esophagus, with amplitude and area under curve reduced. When compared the esophagus development in the different intervals of swallowing, no relation to presence of the disease was found, because the difference was significant for both patients and control group. In the swallowing videofluoroscopy, as well as the clinical evaluation, the main alterations were found in the pasty and solid consistencies, in both oral and pharyngeal phases. Despite that, no laryngeal - tracheal aspiration episode was found. Regarding the swallowings times, only oral phase time (OPT) was actually longer in patients, which was shorter in other parameters such as pharyngeal transit (PT) and pharyngoesophageal transition transit (PTT). When we compared the first swallowings with the last ones for pasty and solid consistencies, the patients presented a increase that time PD; PT; PTT and HMT for solid consistencies with significant value only for PT. The study allowed us to conclude that patients with chronic progressive external ophthalmoplegia (CPEO) mitochondrial myopathy present swallowing dificulties, with oropharyngeal and esophageal alterations, which were greater for pasty and solid consistences.

In comparison with the high-pressure adsorption at room temperature, hydrogen adsorption at cryogenic temperatures can be significantly improved at low pressures, which has great potential for prospective mobile applications. In this study, a differential pressure based manometry system was designed and constructed for fast analysing hydrogen adsorption uptakes of sorbents up to a maximum of 10 wt% at 77 K and up to 11 bar. The safety design of the system in compliance with European ATEX directives (Zone 2) for explosive atmospheres was discussed in detail, together with additional pneumatic systems for remote control of the experiments. A thorough error analysis of related experimental tests was also performed. Common carbon sorbents, including several Norit branded activated carbons and graphene nanoplatelets (GNPs) with various surface areas, were characterised for their pore structures. The structural differences among GPNs of different surface areas were also studied. The hydrogen adsorption isotherms of these sorbents, examined in the newly-built manometry system, were further analysed and discussed with reference to the assessed microstructural properties. The carbonisation processes of plasma carbons from the microwave splitting of methane, and biochars from the pyrolysis of Miscanthus, were intensively studied primarily based on Raman spectroscopy, in conjunction with other characterisation techniques such as XRD, FTIR and XPS, for exploring the formation of graphitic structures and crystallinity under various conditions. Two selected types of carbons, the activated carbon AC Norit GSX with a specific surface areas of 875 m2/g and the graphene nanoplates with a specific surface area of 700 m2/g, were decorated with palladium nanoparticles in different compositions. The growth and distribution of doped palladium particles in the carbon substrates were studied, and their effects on porous properties and microstructures of the sorbents were also reviewed. Hydrogen adsorption tests of the decorated carbons were further conducted and discussed, to explore the potential effects of Pd contents on the adsorption kinetics and hydrogen absolute uptakes.

As miopatias mitocondriais formam um grupo de desordens clinicamente heterogêneas que podem afetar múltiplos sistemas além do músculo esquelético. A oftalmoplegia externa crônica progressiva (CPEO) é um tipo de miopatia mitocondrial que tem como características alterações nos movimentos oculares, ptose, podendo ter acometimento da musculatura facial, além de atrofia muscular de membros. A fatigabilidade precoce pode ser a queixa principal e claramente desproporcional ao grau de fraqueza e atrofia muscular detectada. A disfagia na doença é uma manifestação descrita por muitos autores, porém pouco estudada ou caracterizada. O presente estudo teve como objetivo avaliar a deglutição de pacientes com miopatia mitocondrial do tipo CPEO através de avaliação clínica, manométrica e videofluoroscópica. Para tanto, foram selecionados 14 pacientes com diagnóstico de miopatia mitocondrial do tipo CPEO, em acompanhamento no Ambulatório de Doenças Neuromusculares do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, independente de apresentarem queixas ou não quanto à alimentação. A idade variou de 15 a 62 anos, com idade média de 35,3 anos sendo 5 (35,7%) do gênero masculino e 9 (64,3%) do feminino. O grupo controle foi formado por 16 indivíduos saudáveis (sem doenças neurológicas ou queixas quanto à alimentação) com idade variando de 21 a 44 anos, idade média de 27,5 anos, sendo 6 (37,5%) do gênero masculino e 10 (62,5%) do feminino. Na avaliação clínica, além da anamnese, foi realizada avaliação estrutural e funcional da deglutição. Para isso foram utilizadas as consistências pastosa, líquida e sólida, em volume livre, conforme hábito do paciente. Na avaliação manométrica, as medidas foram feitas durante a deglutição líquida, para avaliar as pressões intraluminares no corpo do esôfago. Foram realizadas 10 deglutições com intervalo de 30 segundos entre elas e após cinco minutos de repouso mais 10 deglutições com intervalo de 10 segundos entre elas. Foram consideradas as medidas da pressão intraluminal, sua duração, área sob a curva e tempos parciais e totais de deslocamento da onda. Na avaliação videofluoroscópica utilizaram-se as dietas pastosa, líquida e sólida, sendo as duas primeiras em volume controlado de 5ml. Para todas as consistências foram realizadas três ofertas, sendo que para o pastoso e sólido esse processo foi repetido. Além da dinâmica da deglutição na fase orofaríngea foram analisados os tempos de fase oral (TFO), depuração faríngea (DF), trânsito faríngeo (TF), trânsito pela transição faringoesofágica (TTFE) e tempo de movimentação hióidea (TMH). Em anamnese observamos que 9 (64,3%) pacientes tinham queixas quanto a alimentação mas apenas 7 (50%) apresentaram alterações na avaliação clínica, sendo essas alterações principalmente para as consistências pastosa (57,1%) e sólida (100%). As principais alterações foram fase oral prolongada, mastigação inadequada, deglutições múltiplas e fadiga. Na avaliação manométrica foi observado redução da motilidade esofágica sendo essa principalmente no esôfago proximal, com amplitude, duração e área sob a curva reduzidas. Quando comparado o desempenho do esôfago nos diferentes intervalos de deglutição, não houve relação com a presença da doença, pois a diferença foi significante tanto para os pacientes como para os controles. Na videofluoroscopia da deglutição, assim como na avaliação clínica, as principais alterações encontradas foram para as consistências pastosa e sólida, sendo elas tanto em fase oral como faríngea. Apesar disso não foi encontrado nenhum episódio de aspiração laringotraqueal. Quanto aos tempos de deglutição, apenas o TFO foi significantemente maior nos pacientes, sendo menor nos outros parâmetros como TF e TTFE. Ao compararmos as primeiras com as últimas deglutições para as consistências pastosa e sólida, verificamos que os pacientes apresentaram um aumento dos tempos de DF, TF, TTFE e TMH para a consistência sólida, sendo significante apenas para TF. O estudo permitiu concluir que pacientes com miopatia mitocondrial do tipo CPEO apresentam dificuldades de deglutição, com alterações orofaríngeas e esofágicas, sendo maiores para as consistências pastosa e sólida. / Mitochondrial myopathies constitute a group of clinically heterogenous disorders which can affect multiple systems besides the skeletal muscle. The chronic progressive external ophthalmoplegia (CPEO) is a type of mitochondrial myopathy charactherized by eye movements alterations, ptosis, which may attack the facial musculature, as well as atrophy the muscles of members. The early fatigability may be the main complaint and clearly disproportional to the degree of weakness and muscular atrophy detected. The dysphagia in the disease is a manifestation described by several authors, however very little studied and characterized. The present study aimed at evaluating the swallowing of patients with chronic progressive external ophthalmoplegia (CPEO) mitochondrial myopathy, followed at the Neuromuscular Diseases Clinic at Hospital das Clínicas of Faculdade de Medicina de Ribeirão Preto of Universidade de São Paulo, independently whether or not they presented complaints about alimentation. The age varied from 15 to 62 years old, with average age of 35,3, which were 5 (35,7%) males and 9 (64,3%) females. The control group was constituted by 16 healthy individuals (without neurological diseases or complaints about alimentation) with age varying from 21 to 44 years old, average age of 27,5, which were 6 (7,5%) males and 10 (62,5%) females. In the clinical evaluation, anamnesis, structural and functional assessment of swallowing were carried out. According to the patients habits, pasty, liquid and solid consistency were used. In the manometric evaluation, the measurements were done during liquid swallowing, to assess the intraluminal pressure in the esophagus. It was performed 10 swallowings with intervals of 30 seconds among them, and after five minutes of rest, 10 more swallowings with intervals of 10 seconds among them. The intraluminal pressures measurement, its duration, area under curve and wave displacements partial and total time were considered. In the videofluoroscopic evaluation, pasty, liquid and solid diets were used, in which the first two with a controled volume of 5ml. For all the consistencies were realized three offer, and for the solid and pasty, these process were repeated. Besides the swallowing dynamic in the oropharyngeal phase, the oral phase time (OPT), the pharyngeal depuration (PD), pharyngeal transit (PT), pharyngoesophageal transition transit (PTT), hyoid movement time (HMT) were analysed. In the anamnesis, we observed that 9 (64,3%) patients had complaints about alimentation, but only 7 (50%) presented alterations in the clinical evaluation, and these alterations were mainly for pasty (57,1%) and solid (100%)consistencies. The main alterations were extended oral phase, inadequate mastication, multiple swallowings and fatigue. In the manometric evaluation, the esophageal motility reduction was observed, which was mainly in the proximal esophagus, with amplitude and area under curve reduced. When compared the esophagus development in the different intervals of swallowing, no relation to presence of the disease was found, because the difference was significant for both patients and control group. In the swallowing videofluoroscopy, as well as the clinical evaluation, the main alterations were found in the pasty and solid consistencies, in both oral and pharyngeal phases. Despite that, no laryngeal - tracheal aspiration episode was found. Regarding the swallowings times, only oral phase time (OPT) was actually longer in patients, which was shorter in other parameters such as pharyngeal transit (PT) and pharyngoesophageal transition transit (PTT). When we compared the first swallowings with the last ones for pasty and solid consistencies, the patients presented a increase that time PD; PT; PTT and HMT for solid consistencies with significant value only for PT. The study allowed us to conclude that patients with chronic progressive external ophthalmoplegia (CPEO) mitochondrial myopathy present swallowing dificulties, with oropharyngeal and esophageal alterations, which were greater for pasty and solid consistences.

Swallowing is a complex sensorimotor behaviour that includes precisely-timed bilateral activation and relaxation of muscles of the face, lips, tongue, cheeks, palate, larynx, pharynx and oesophagus. These events of activation and inhibition are controlled by many structures of the brain and are executed by cranial nerves that carry motor and sensory information to and from the swallowing muscles. Swallowing disorders are common sequelae of many neurological and structural disorders, including stroke, Parkinson’s disease, and head and neck cancer. Changes to swallowing physiology are also prevalent in older individuals, but these changes do not necessarily translate to dysphagia. Decreased muscle strength, changes to motor unit properties, and hypotrophic changes in skeletal muscles can result in age-related changes in swallowing physiology. In addition to muscular changes, neural changes might also change swallowing function in older subjects. The motor-learning literature presents a clear distinction between the differential applications and effects of skill- and strength-training approaches for rehabilitation of limb movement. In contrast to limb-movement rehabilitation, swallowing rehabilitation approaches consist mainly of strength training, although the pathophysiological basis for dysphagia is not always weakness. Therefore, this Phase I clinical-trial critically evaluated a unique swallowing skill training protocol in which the goal of intervention is to increase precision of motor control during swallowing. A Phase I clinical-trial was necessary to identify the appropriate protocol for inducing neurophysiological, biomechanical, and structural adaptations, to estimate effect sizes, and to identify adverse effects. The first and primary question addressed in this thesis was whether swallowing skill training would produce greater physiological effects in healthy subjects than a traditional swallowing strength training approach. In order to answer this question, three levels of assessment were included. Neurophysiological assessment consisted of delivering single-pulse transcranial magnetic stimulation (TMS) over the M1 area that sends efferent projections to the submental muscle group during a functional task of volitional saliva swallowing, and during a non-functional task of submental muscle group contraction. Biomechanical assessments consisted of pharyngeal and upper esophageal sphincter (UES) pressure measurements using pharyngeal manometry during effortful and non-effortful swallowing tasks, submental muscle activation measurements using surface electromyography (sEMG) during effortful and non-effortful swallowing tasks, and hyoid displacement using ultrasonography. Structural assessment consisted of measuring the cross sectional area of the submental muscle group. Finally, motor performance during training, and subjective ratings of the training protocols were assessed. Two skill training protocols were developed to assess the use of immediate versus delayed visual feedback in swallowing skill training. In addition, a pilot study aimed at examining the effects of increased dosage of training sessions was conducted. Forty healthy subjects (20 young, and 20 old; 20 females and 20 males) were allocated to skill and strength training groups in a counterbalanced manner. Strength training consisted of execution of the effortful swallowing technique targeting increased demand for strength. Skill training targeted precise timing and force execution during swallowing execution. Several motor-learning principles were considered in devising the training protocols, including the principles of task specificity and high intensity of training. Biofeedback was included to promote motor learning. Since the submental muscle group plays an important role in hyolaryngeal excursion, the current study utilized submental sEMG biofeedback using custom-made training software. The training protocols consisted of 1000 repetition of swallowing over a 2-week period. Subjects trained for an hour, five days a week, for 2 weeks (i.e., 10 training sessions). The extended dosage protocol included 10 subjects and comprised an additional eight sessions. The results indicated that there was a significant difference in submental activation following training, with strength training having an increase in sEMG peak amplitude in comparison to skill training. There were no other differences between groups at the 5% error level. Patterns of change were revealed when marginally significant results (0.05 < p ≤ 0.10) were investigated as well. Strength training resulted in a trend towards increased neural drive for volitional effortful-type tasks (i.e., effortful saliva swallowing, effortful water swallowing, and submental muscle contraction) as indicated by increased MEP magnitude (p = 0.07) which was consistent with significantly increased peak amplitude of submental activity measures (p < 0.001). This finding supports the task specificity principle of motor learning. Skill training resulted in no changes in MEP magnitude. There was a trend (p = 0.06) towards increased submental muscles activity during functional swallowing tasks (i.e., non-effortful swallowing) in young subjects,. Males in skill training had decreased duration of UES opening in 10 mL water effortful swallowing task (p = 0.02), a trend towards increased UES pressure in non-effortful saliva swallowing task (p = 0.07), and reduced hyoid displacement following training (p < 0.001). Changes in pharyngeal pressures were detected for skill training with delayed visual feedback that resulted in decreased pressure at mid-pharynx in effortful and non-effortful tasks (p < 0.05). No difference in submental CSA changes was detected in either training group. Both groups improved motor performance measured by data collected during the session (target hit-rate and muscle activity). The results of the pilot study that examined the effects of an extended dosage of training were difficult to interpret due to the small sample size. However, there were significant and marginally significant effects of skill training on mid-pharyngeal and UES pressure duration events. Dysphagia is common in patients with Parkinson’s disease, but no specific training programme exists for these patients, leading to the second question addressed through this research. Since movement planning is compromised due to dysfunction of the basal ganglia, providing external information for planning and executing swallowing was hypothesized to alleviate dysphagic symptoms. Ten subjects were recruited. Swallowing skill training with immediate feedback was administered for one hour every day, five days a week, for 2 weeks, similar to the training dosage and frequency in the healthy group. Biomechanical and structural changes were assessed. Swallowing skill training with immediate feedback led to an increase in submental activity in effortful swallowing tasks but not non-effortful tasks. In addition, it was found that individuals with dysphagia secondary to Parkinson’s disease have deceased submental muscle reserve relative to healthy subjects. Preliminary analysis of MEP data led to exploration of submental MEP measures between younger and older subjects. This ‘discovery’ research shed light on the third topic addressed in this thesis. There are contradicting results in the literature regarding age-related brain activity during swallowing. Since submental MEPs were included as an outcome measure in the main study, it was important to evaluate them at baseline in order to understand and interpret changes in this measure. Unlike other measures, such as pharyngeal pressure and hyoid displacement that have been documented in the literature to change with age, no similar study has been conducted to assess for differences in swallowing-related MEPs. Baseline data from the main study were analysed. Older subjects produced larger MEP magnitude in comparison to young in volitional saliva swallowing and volitional submental contraction. This finding raised some questions regarding the use of MEPs as an outcome measure, since it is not clear what constitutes a ‘positive’ change. This study documented, for the first time, the application of skill training in swallowing in a healthy and dysphagic population. Positive effects of treatment were found in the dysphagic group; an indication of negative effects was identified in the healthy group. In addition, this is the first study to compare skill to strength training in swallowing. The only significant difference between the two was significantly greater submental activation in effortful swallowing tasks following strength training in comparison to skill training; although there were some significant interactions between age and training type and gender and training type. This project represents the first Phase I clinical-trial of an innovative approach for addressing swallowing impairments. Achieving the ultimate aim of finding the most appropriate training protocol for treating individuals with a specific pathophysiological basis of dysphagia, requires the implementation of a long-term on-going research programme characterized by a staged process. This research programme sets an initial reference framework from which further projects can estimate the sample size required to answer specific questions, control for effects of age and gender and their interaction with training, increase precision in choosing assessment tools, and test new specific questions.

Die vorliegende Arbeit beschreibt die Entwicklung eines Drucksensorkatheters auf Basis von Faser-Bragg-Gittern. Dazu werden der medizinische Hintergrund aus technischer Sicht strukturiert dargelegt und bereits verfügbare Messmethoden für Manometrieuntersuchungen erörtert. Der Stand der Technik bei Faser-Bragg-Gitter basierten Sensoren und deren Auswertegeräten wird im Zusammenhang mit den aus dem medizinischen Hintergrund und dem Vergleich mit den anderen Messmethoden erwachsenden Anforderungen dargestellt. Die Entwicklung eines zweistufigen für die Herstellung mittels Koextrusion geeigneten Mantels für die optischen Fasern wird beschrieben. Mehrere Funktionsmuster für einen Drucksensorkatheter werden experimentell charakterisiert und die Ergebnisse hinsichtlich der Medizineignung bewertet.

Objetivos: Avaliar a associação entre a dismotilidade esofágica, caracterizada como Motilidade Esofágica Ineficaz (MEI), com a presença de refluxo ácido patológico avaliado pela pH-metria de 24 horas, controlando por Esfíncter Esofágico Inferior (EEI) estruturalmente defeituoso, Hérnia Hiatal (HH) e Esofagite, em pacientes em investigação de Doença do Refluxo Gastroesofágico. Métodos: Foram estudados 311 pacientes referenciados para investigação de DRGE em laboratório de motilidade esofágica. Os pacientes foram submetidos à Endoscopia Digestiva Alta (EDA), Manometria Esofágica, pHmetria Esofágica de 24 horas e a uma entrevista sobre os sintomas clínicos apresentados. Foram comparados os grupos de pH-metria negativa com o de pH-metria positiva quanto à presença dos fatores de risco – MEI, EEI defeituoso, HH e Esofagite. A associação entre MEI e pH-metria positiva foi primeiramente avaliada através de análise univariada e, posteriormente, através de análise de regressão logística (multivariada). Resultados: Do total de 311 pacientes estudados, 208 preencheram os critérios de inclusão. A idade média foi 47 anos, com 88 pacientes apresentando pH-metria normal e 120 pH-metria positiva. Após a análise univariada, foi observado que a ocorrência de MEI, EEI defeituoso e HH foi significativamente maior no grupo de pH-metria positiva. Após análise de regressão logística, a ocorrência de MEI e EEI defeituoso permaneceram significativamente maior no grupo de pH-metria positiva. Conclusões: MEI está associada à presença de refluxo ácido anormal, avaliado através de pH-metria esofágica de 24 horas, independentemente da presença de EEI defeituoso, HH ou Esofagite. / Objectives: To assess the association between esophageal dysmotility, characterized as inefficient esophageal motility (IEM), and the presence of pathological acid reflux due to a structurally defective lower esophageal sphincter (LES), hiatus hernia (HH), or esophagitis in patients suspected of having gastroesophageal Reflux reflux disease (GERD). Methods: Three hundred and eleven patients referred for GERD diagnostic procedures in a gastroesopahgeal motility laboratory were included in the study. Patients underwent upper endoscopy (UE), esophageal manometry, 24-hour esophageal pH-metry and an interview regarding their clinical symptoms. The following risk factors of patients in the negative pH-metry group were compared to those in the positive pH-metry group: IEM, defective LES, HH, and esophagitis. The association between IEM and positive pH-metry results was first assessed by means of univariate analysis and later determined with logistic regression analysis (multivariate). Results: Of the total 311 patients studied, 208 met the inclusion criteria (mean age 47 years); 88 had normal pH-metry reslults and 120 had positive pH-metry results. Univariate analysis revealed that the occurrence of IEM, defective LES, and HH was significantly greater in the positive pH-metry group. Following logistic regression analysis, the occurrence of IEM remained significantly greater in the positive pH-metry group. Conclusions: IEM is associated with the presence of abnormal acid reflux, as assessed by 24-hour esophageal pH-metry, regardless of the presence of defective LES, HH, or esophagitis.

Objetivos: Avaliar a associação entre a dismotilidade esofágica, caracterizada como Motilidade Esofágica Ineficaz (MEI), com a presença de refluxo ácido patológico avaliado pela pH-metria de 24 horas, controlando por Esfíncter Esofágico Inferior (EEI) estruturalmente defeituoso, Hérnia Hiatal (HH) e Esofagite, em pacientes em investigação de Doença do Refluxo Gastroesofágico. Métodos: Foram estudados 311 pacientes referenciados para investigação de DRGE em laboratório de motilidade esofágica. Os pacientes foram submetidos à Endoscopia Digestiva Alta (EDA), Manometria Esofágica, pHmetria Esofágica de 24 horas e a uma entrevista sobre os sintomas clínicos apresentados. Foram comparados os grupos de pH-metria negativa com o de pH-metria positiva quanto à presença dos fatores de risco – MEI, EEI defeituoso, HH e Esofagite. A associação entre MEI e pH-metria positiva foi primeiramente avaliada através de análise univariada e, posteriormente, através de análise de regressão logística (multivariada). Resultados: Do total de 311 pacientes estudados, 208 preencheram os critérios de inclusão. A idade média foi 47 anos, com 88 pacientes apresentando pH-metria normal e 120 pH-metria positiva. Após a análise univariada, foi observado que a ocorrência de MEI, EEI defeituoso e HH foi significativamente maior no grupo de pH-metria positiva. Após análise de regressão logística, a ocorrência de MEI e EEI defeituoso permaneceram significativamente maior no grupo de pH-metria positiva. Conclusões: MEI está associada à presença de refluxo ácido anormal, avaliado através de pH-metria esofágica de 24 horas, independentemente da presença de EEI defeituoso, HH ou Esofagite. / Objectives: To assess the association between esophageal dysmotility, characterized as inefficient esophageal motility (IEM), and the presence of pathological acid reflux due to a structurally defective lower esophageal sphincter (LES), hiatus hernia (HH), or esophagitis in patients suspected of having gastroesophageal Reflux reflux disease (GERD). Methods: Three hundred and eleven patients referred for GERD diagnostic procedures in a gastroesopahgeal motility laboratory were included in the study. Patients underwent upper endoscopy (UE), esophageal manometry, 24-hour esophageal pH-metry and an interview regarding their clinical symptoms. The following risk factors of patients in the negative pH-metry group were compared to those in the positive pH-metry group: IEM, defective LES, HH, and esophagitis. The association between IEM and positive pH-metry results was first assessed by means of univariate analysis and later determined with logistic regression analysis (multivariate). Results: Of the total 311 patients studied, 208 met the inclusion criteria (mean age 47 years); 88 had normal pH-metry reslults and 120 had positive pH-metry results. Univariate analysis revealed that the occurrence of IEM, defective LES, and HH was significantly greater in the positive pH-metry group. Following logistic regression analysis, the occurrence of IEM remained significantly greater in the positive pH-metry group. Conclusions: IEM is associated with the presence of abnormal acid reflux, as assessed by 24-hour esophageal pH-metry, regardless of the presence of defective LES, HH, or esophagitis.

This Research thesis is focused on the influence of body position on the function of pelvic floor muscles (PFM). Anatomical structures, kinesiology and neurophysiology of the PFM are described in the theoretical part of this thesis. It also discusses the methodology used for objective evaluation of the PFM. For the practical part of this thesis, 30 healthy subjects (aged 20 - 30 years, 15 male, 15 female) where chosen via a questionnaire. The subjects were examined via the method of anorectal manometry. The goal of the examination was to measure the distribution of a) resting pressure in the anal canal in selected positions, b) pressure during voluntary maximal contraction of PFM and sphincters in selected positions, c) pressure during 20 seconds of voluntary contraction. Selected positions are: lying on the back; lying on the back with legs elevated and held in "three flexion"; kneeling on all fours with palm support; kneeling on all fours with elbow support; squatting, and standing. Results: a) The resting pressure is influenced by the body position. Highest resting pressure was observed in squatting and standing positions, lowest resting pressure was measured on subjects while kneeling on all fours with elbow support. No significant difference was observed between male and female subjects in...

Objetivos: Avaliar a associação entre a dismotilidade esofágica, caracterizada como Motilidade Esofágica Ineficaz (MEI), com a presença de refluxo ácido patológico avaliado pela pH-metria de 24 horas, controlando por Esfíncter Esofágico Inferior (EEI) estruturalmente defeituoso, Hérnia Hiatal (HH) e Esofagite, em pacientes em investigação de Doença do Refluxo Gastroesofágico. Métodos: Foram estudados 311 pacientes referenciados para investigação de DRGE em laboratório de motilidade esofágica. Os pacientes foram submetidos à Endoscopia Digestiva Alta (EDA), Manometria Esofágica, pHmetria Esofágica de 24 horas e a uma entrevista sobre os sintomas clínicos apresentados. Foram comparados os grupos de pH-metria negativa com o de pH-metria positiva quanto à presença dos fatores de risco – MEI, EEI defeituoso, HH e Esofagite. A associação entre MEI e pH-metria positiva foi primeiramente avaliada através de análise univariada e, posteriormente, através de análise de regressão logística (multivariada). Resultados: Do total de 311 pacientes estudados, 208 preencheram os critérios de inclusão. A idade média foi 47 anos, com 88 pacientes apresentando pH-metria normal e 120 pH-metria positiva. Após a análise univariada, foi observado que a ocorrência de MEI, EEI defeituoso e HH foi significativamente maior no grupo de pH-metria positiva. Após análise de regressão logística, a ocorrência de MEI e EEI defeituoso permaneceram significativamente maior no grupo de pH-metria positiva. Conclusões: MEI está associada à presença de refluxo ácido anormal, avaliado através de pH-metria esofágica de 24 horas, independentemente da presença de EEI defeituoso, HH ou Esofagite. / Objectives: To assess the association between esophageal dysmotility, characterized as inefficient esophageal motility (IEM), and the presence of pathological acid reflux due to a structurally defective lower esophageal sphincter (LES), hiatus hernia (HH), or esophagitis in patients suspected of having gastroesophageal Reflux reflux disease (GERD). Methods: Three hundred and eleven patients referred for GERD diagnostic procedures in a gastroesopahgeal motility laboratory were included in the study. Patients underwent upper endoscopy (UE), esophageal manometry, 24-hour esophageal pH-metry and an interview regarding their clinical symptoms. The following risk factors of patients in the negative pH-metry group were compared to those in the positive pH-metry group: IEM, defective LES, HH, and esophagitis. The association between IEM and positive pH-metry results was first assessed by means of univariate analysis and later determined with logistic regression analysis (multivariate). Results: Of the total 311 patients studied, 208 met the inclusion criteria (mean age 47 years); 88 had normal pH-metry reslults and 120 had positive pH-metry results. Univariate analysis revealed that the occurrence of IEM, defective LES, and HH was significantly greater in the positive pH-metry group. Following logistic regression analysis, the occurrence of IEM remained significantly greater in the positive pH-metry group. Conclusions: IEM is associated with the presence of abnormal acid reflux, as assessed by 24-hour esophageal pH-metry, regardless of the presence of defective LES, HH, or esophagitis.