Antisecretory Medications Research Articles

Anticipatory prescribing in community end-of-life care

ObjectivesOur work aims to critically review the use of anticipatory medicines in our inner-city hospice community population and whether our current practices are fit for purpose.MethodsRetrospective audit of community palliative...

Quantitation of thiorphan in human plasma using LC-MS/MS and its application to a bioequivalence study

Racecadotril, an anti-secretory medication, has been used as an adjuvant in an oral rehydration therapy for children experiencing severe diarrhea. Racecadotril is quickly converted to thiorphan, an active metabolite, after oral treatment, which mediates all subsequent activities. An efficient and rapid liquid chromatography-tandem mass spectrometry method was developed and fully validated to measure thiorphan in human plasma, using thiorphan-d7 as an internal standard. The extraction method used was protein precipitation while chromatographic separation was achieved using InertSil CN-3 (50 × 2.1 mm, 5 µm column). The assay was linear over the concentration range of 1–200 ng/ml with correlation coefficients of ≥0.9991. The intra- and inter-day precisions were less than 10.0 % for all concentrations investigated. 0.02 % aqueous formic acid and methanol (30:70 v: v) were used as mobile phases, with an analysis time of less than 1 min. This method proved stable under several conditions. The developed method worked well in a three-period pharmacokinetic bioequivalence study after a single oral administration of 100 mg racecadotril to 15 healthy Jordanian volunteers under fasting conditions.

Endoscopic Management Options for Gastroesophageal Reflux Disease.

Gastroesophageal reflux disease (GERD) is a prevalent condition that affects a significant portion of the Western population. Despite its benign pathophysiology, it has the potential to cause serious complications over time, ranging from conditions that are benign, premalignant, and/or malignant. Traditional treatment options include lifestyle measures, anti-secretory medications (e.g., proton pump inhibitor (PPI)), and surgical options (e.g., Nissen and Toupet fundoplication). However, recent studies have revealed long-term side effects of anti-secretory medications. Moreover, surgical options, though effective, are considered invasive and associated with potential complications. In the current age of ongoing research in minimally invasive options, endoscopic treatment of GERD has become popular. As a result, procedures such as radiofrequency treatment and transoralincisionlessfundoplication (TIF) have gained FDA approval and are currently being covered by most insurance. In this review article, we will discuss pre-procedural workup, appropriate patient selection, advantages, disadvantages, procedure techniques, and follow-up of patients who undergo various endoscopic treatments for GERD.In addition, we will review the short and long-term success of these techniques in improving quality of life, use of PPI, and improvement in symptoms considering published data in high-quality peer-reviewed journals.

Reflux After Sleeve Gastrectomy: Safety and Effectiveness of Laparoscopic Ligamentum Teres Cardiopexy, a Single-Center Experience.

Obesity is a well-known risk factor for gastroesophageal reflux disease (GERD). Even though symptoms may be mitigated or resolved with the weight loss caused by sleeve gastrectomy (SG), it may be associated with higher incidences of postoperative GERD. Ligamentum teres cardiopexy (LTC) is an alternative to Roux-en-Y gastric bypass, the gold standard treatment for GERD. This study was a retrospective single-center chart review, all patients in this cohort underwent LTC to treat refractory GERD at our institution. The option for LTC was presented after patients' refusal to undergo RYGB conversion. We collected baseline characteristics, standard demographics, pre-operative tests and imaging, and SG information, as well as intraoperative and perioperative data regarding LTC, and postoperative complications. Our cohort included 29 patients; most were Caucasian (44.8%) females (86.2%). The mean weight and BMI before LTC were 216.5 ± 39.3 lb and 36.1 ± 5.4 kg/m2, respectively. Mean total body-weight loss (TBWL) at 12 and 24 months were 28.7% ± 9.5% and 28.4% ± 12.4%, respectively. The mean interval between the index bariatric surgery and LTC was 59.9 ± 34.9 months, mean operative time was 67 ± 18.2 min, and median length of stay (LOS) was 1 day (IQR = 1-2 days). Twelve patients (57.1%) were able to discontinue antisecretory medications, while 9 (42.9%) still required them to remain asymptomatic. Mortality and reoperation rates were 0% and the incidence of complication was 19.4% (n = 6). LTC is a safe and effective surgical alternative to treat refractory GERD symptoms after SG.

TO EVALUATE THE PREVALENCE OF ANTISECRETORY MEDICATION USE AMONG HOSPITALIZED PATIENTS IN SURGERY WARD

Antisecretory medicines are often administered to patients in hospitals. However, there is currently limited knowledge on the comprehensive utilization of these treatments in the hospital environment. Aim: To assess the suitability of Antisecretory treatment in a major educational medical facility in western India, and the consequences of hospital prescriptions in primary care. Methods: The administration of antisecretory drugs was observed for a duration of one month in adult patients who were sequentially admitted to K.J Somaiya Medical College and Hospital. This was done by examining their medical records. Results: Out of the 800 patients that were admitted to the hospital, 46.8% of them were prescribed Antisecretory treatment. Ranitidine had the highest usage rate at 44.4%, followed by pantoprazole at 31.8% and omeprazole at 23.0%. Stress ulcer prophylaxis and prevention of non-steroidal anti-inflammatory drug-induced ulcer were the reasons for usage in 60.4% of cases. In all, 68% of prescriptions were deemed inappropriate based on consensus evaluation. Among patients who received unneeded preventive medication during their hospital stay, 56.4% were released while still on therapy, and 46% continued to receive the treatment three months later. Conclusions: There is excessive utilization of Antisecretory medications in patients who are admitted to the hospital. The majority of incorrect hospital prescriptions are to the administration of ulcer prevention in patients who have a low risk of developing ulcers. This over utilization may also encourage improper medication usage in the field of general medicine. KEYWORDS: Antisecretory medication, H2-receptor antagonists (H2RAs), proton pump inhibitors, Hospital

Prescribing of Proton Pump Inhibitors for Prevention of Upper Gastrointestinal Bleeding in US Outpatient Visits

Antisecretory medications, primarily proton pump inhibitors (PPIs), have proven effective in reducing upper gastrointestinal toxicities, including upper gastrointestinal bleeding (UGIB), associated with nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin, which are among the most commonly used medications in the United States.1 Accordingly, professional guidance recommends PPIs for patients at high risk for UGIB.2-4 However, little is known about trends in use of antisecretory medications for gastrointestinal prophylaxis ("gastroprotection"). Herein, we examined contemporary use and prescribing of antisecretory medications in visits by patients at high risk for UGIB, relative to visits by patients diagnosed with acid-related disorders.

Fifteen-year symptomatic outcome of patients with nonactionable motor findings on high-resolution manometry.

High-resolution manometry (HRM) is performed for evaluation of esophageal symptoms, but patient outcome is unclear when no actionable motor disorder is identified. We evaluated long-term symptomatic outcome of patients with nonactionable HRM findings. Patients who underwent (HRM) studies in 2006-2008 were tracked. Patients with achalasia spectrum disorders, foregut surgery before or after HRM, and incomplete symptom documentation were excluded. Symptom questionnaires assessing dominant symptom intensity (DSI, product of symptom severity and frequency recorded on 5-point Likert scales) and global symptom severity (GSS, from 10 cm visual analog scale) were repeated. Change in symptom burden was compared against HRM motor findings using Chicago Classification 4.0 (CCv4.0), applied retroactively to 2006-2008 data. Overall, 134 patients (median age 68 years, 64.5% female) could be contacted. The majority (73.1%) had normal motility; others had ineffective esophageal motility (8.2%), esophagogastric junction outflow obstruction (13.4%), hypercontractile esophagus (3.0%), or absent contractility (2.2%), none managed invasively. Over 15 years of follow-up, DSI decreased from 8.0 (4.0-16.0) to 1.0 (0.0-6.0) (p < 0.001) and GSS improved from 5.5 (3.3-7.7) to 2.0 (0.0-4.0) (p < 0.001); improvement was consistent across CCv4.0 diagnoses and subgroups. The majority (82.8%) reported improvement over time, and antisecretory medication was the most effective intervention (83.0% improvement). There was no difference in medication efficacy (p = 0.75) or improvement in symptoms (p = 0.20) based on CCv4 diagnosis. Esophageal symptoms improve with conservative symptomatic management over long-term follow-up when no conclusive obstructive motor disorders or achalasia spectrum disorders are found on HRM.

Gas-Bloat Syndrome after Magnetic Sphincter Augmentation: Incidence, Natural History, Risk Factors, and Impact on Surgical Outcomes Over Time.

The notion that gas-bloat syndrome (GBS) after magnetic sphincter augmentation (MSA) is less detrimental has not been substantiated by data. This study aimed to identify the incidence, natural history, risk factors, and impact on outcomes of GBS after MSA. Records of patients who underwent MSA at our institution were reviewed. GBS was defined as a score of 4 or more on the gas bloat-specific item within the GERD health-related quality-of-life (GERD-HRQL) questionnaire. Preoperative clinical and objective testing data were compared between those with and without GBS at 1 year using univariate followed by multivariable analysis. GBS evolution over time and its impact on outcomes were assessed in those with 1- and 2-year follow-up. A total of 489 patients underwent MSA. At a mean (SD) follow-up of 12.8 (2.1) months, patient satisfaction was 88.8%, 91.2% discontinued antisecretory medications, and 74.2% achieved DeMeester score normalization.At 1 year, 13.3% of patients developed GBS, and had worse GERD-HRQL scores and antisecretory medication use and satisfaction (p < 0.0001). DeMeester score normalization was comparable (p = 0.856). Independent predictors of GBS were bloating (odds ratio [OR] 1.8, p = 0.043), GERD-HRQL score greater than 30 (OR 3, p = 0.0010), and MSA size 14 or less beads (OR 2.5, p = 0.004). In a subgroup of 239 patients with 2-year follow-up, 70.4% of patients with GBS at 1 year had resolution by 2 years. The GERD-HRQL total score improved when GBS resolved from 11 (7 to 19) to 7 (4 to 10), p = 0.016. Patients with persistent GBS at 2 years had worse 2-year GERD-HRQL total scores (20 [5 to 31] vs 5 [3 to 12], p = 0.019). GBS affects 13.3% of patients at 1 year after MSA and substantially diminishes outcomes. However, GBS resolves spontaneously with quality-of-life improvement. Patients with preoperative bloating, high GERD-HRQL scores, or small MSA devices are at greatest risk of this complication.

Ligamentum teres cardiopexy for post vertical sleeve gastrectomy gastroesophageal reflux.

Vertical sleeve gastrectomy (VSG) evolved in the early 2000s into the standalone weight loss procedure we see today. While numerous studies highlight VSG's durability for weight loss, and improvements co-morbidities such as type 2 diabetes mellitus and cardiovascular disease, patients with gastroesophageal reflux disease (GERD) have been counseled against VSG due to the concern for worsening reflux symptoms. When considering anti-reflux procedures, VSG patients are unable to undergo traditional fundoplication due to lack of gastric cardia redundancy. Magnetic sphincter augmentation lacks long-term safety data and endoscopic approaches have undetermined longitudinal benefits. Until recently, the only option for patients with a history of VSG with medically refractory GERD has been conversion to roux en Y gastric bypass (RNYGB), however, this poses other risks including marginal ulcers, internal hernias, hypoglycemia, dumping syndrome, and nutritional deficiencies. Given the risks associated with conversion to RNYGB, we have adopted the ligamentum teres cardiopexy as an option for patients with intractable GERD following VSG. A retrospective chart review was conducted of patients who had prior laparoscopicor robotic VSG and subsequently GERD symptoms refectory to pharmacological management who underwent ligamentum teres cardiopexy between 2017 and 2022. Pre-operative GERD disease burden, intraoperative cardiopexy characteristics, post-operative GERD symptomatology and changes in H2 blocker or PPI requirements were reviewed. Of the study's 60 patients the median age was 50years old, and 86% were female. All patients had a diagnosis of GERD through pre-operative assessments and were taking antisecretory medication. Of the 36 patients who have completed their one year follow up, 81% of patients had either a decrease in dosage or cessation of the antisecretory medication at one year following ligamentum teres cardiopexy. Ligamentum teres cardiopexy is a viable alternative to RNYGB in patients with a prior vertical sleeve gastrectomy with medical refractory GERD.

COMPARISON OF RACECADOTRIL WITH ORAL REHYDRATION SOLUTION IN ACUTE WATERY DIARRHEA UNDER 5 YEARS OF AGE

BACKGROUND: A significant share (18%) of paediatric mortality is caused by diarrheal diseases. Children under the age of five are most susceptible to viral diarrhoea. In cases of acute watery diarrhoea, racecadotril, an anti-secretory medication, can limit fluid and electrolyte loss from the intestine without compromising intestinal motility.&#x0D; OBJECTIVE: To compare the number of loose stools within the first 48 hours of admission between the children treated with and without Racecadotril, as well as the mean recovery time in children in both groups, in order to determine the efficacy of Racecadotril in treating acute watery diarrhoea in children aged 6 months to 5 years.&#x0D; METHOD: It was a Randomized Controlled Trial that ran from October 2020 to March 2021 at the Paediatrics Department at LGH/PGMI/AMC Lahore. Patients were divided into two equal groups at random using a computer-generated random number table. Racecadotril (1.5 mg/kg body weight, orally three times per day for 5 days or until diarrhoea ceases, whichever happens first) was given to 100 patients in group A coupled with Low Osmolality ORS, while Low Osmolality ORS was given to 100 patients in group B. For testing of blood haemoglobin, blood urea and creatinine, blood sugar, serum electrolytes, and stool (pH, microscopic inspection, culture, and sensitivity), blood samples were sent to a hospital pathology lab. As per operational definition, recovery time was documented.&#x0D; RESULTS: In our study, the mean recovery time was 37.88 hours in group A (racecadotril plus low osmolality ORS) and 47.40 hours in group B (low osmolality ORS), demonstrating a substantial reduction in recovery time of 20.08 percent (p value = 0.0026). The mean 48-hour stool frequency was 11.34 episodes in the Racecadotril + low osmolality ORS group and 14.98 episodes in the low osmolality ORS group, demonstrating a statistically significant decrease in stool frequency of 24.29 percent with the Racecadotril group (p value = 0.025). Faster recovery (20.08 percent) and a reduction of 20.52 percent in ORS consumption, which is comparable with earlier trials on Racecadotril conducted in children with acute watery diarrhoea.&#x0D; CONCLUSION: In managing children under the age of five who have acute watery diarrhoea, we came to the conclusion that there is a substantial difference in the mean recovery time when Racecadotril and Low Osmolality Oral Rehydration Solution (ORS) are used in combination

Role of biological effective dose for prediction of endocrine remission in acromegaly patients treated with stereotactic radiosurgery.

Stereotactic radiosurgery (SRS) can be used in acromegaly patients to achieve endocrine remission. In this study we evaluate the biological effective dose (BED) as a predictor of SRS outcomes for acromegaly. This retrospective, single-center study included patients treated with single-fraction SRS with growth hormone secreting pituitary adenomas and available endocrine follow-up. Kaplan-Meier analysis was used to study endocrine remission, new pituitary deficit, and tumor control. Cox analyses were performed using two models [margin dose (model 2) versus BED (model 1)]. Sixty-seven patients (53.7% male) with a median age of 46.8 years (IQR 21.2) were treated using a median dose of 25Gy (IQR 5), and a median BED of 171.9Gy2.47 (IQR 66.0). Five (7.5%) were treated without stopping antisecretory medication. The cumulative probability of maintained endocrine remission off suppressive medications was 62.5% [47.9-73.0] at 3 years and 76.5% [61.0-85.9] at 5 years. IGF1i > 1.5 was a predictor of treatment failure [Hazard ratio (HR) 0.40 (0.21-0.79) in model 1, p = 0.00783]. Margin dose > 22Gy [HR 2.33 (1.06-5.13), p = 0.03593] or a BED > 170Gy2.47 [HR 2.02 (1.06-3.86), p = 0.03370] were associated with endocrine remission. The cumulative probability of new hypopituitarism after SRS was 36.8% (CI 95% 22.4-45.9) at 3 years and 53.2% (CI 95% 35.6-66) at 5 years. BED or margin dose were not associated with new hypopituitarism. BED is a strong predictor of endocrine remission in patients treated with SRS. Dose planning and optimization of the BED to > 170Gy2.47 give a greater probability of endocrine remission in acromegalic patients.

Minimally invasive fundoplication for gastroesophageal reflux disease

: Gastroesophageal reflux disease (GERD), is one of the most common gastrointestinal diseases treated by physicians, with most patients being successfully managed medically. Patients with refractory or persistent disease may be treated using minimally invasive surgical techniques. Patients may also elect for surgical treatment of GERD to avoid the potentially deleterious effects of long term antisecretory [proton pump inhibitor (PPI)] use. Preoperative workup is critical to establish the presence of GERD, to rule out concomitant or alternative pathology, and to document the presence or absence of coexisting esophageal motility disorders. When the technical tenants are respected, laparoscopic fundoplication is a safe and effective treatment of GERD. The general principles involve adequate mobilization of the gastroesophageal junction and gastric fundus, high mediastinal dissection, and demonstration of adequate intraabdominal esophageal length. This is followed by secure closure of the diaphragmatic crura, as well as creation of a fundoplication to reinforce the typically hypotonic lower esophageal sphincter. The type of fundoplication used is typically influenced by preoperative manometry, presence of dysphagia, and patient age. Long term symptomatic relief, without the need for antisecretory medications, is achievable for the majority of properly selected patients. Postoperative morbidity and mortality are uncommon following laparoscopic treatment of GERD. The following manuscript describes our method for performance of both laparoscopic complete and partial fundoplication.

Impact of Objective Colonic and Whole Gut Motility Data as Measured by Wireless Motility Capsule on Outcomes of Antireflux Surgery.

Studies show higher rates of dissatisfaction with antireflux surgery (ARS) outcomes in patients with chronic constipation. This suggests a relationship between colonic dysmotility and suboptimal surgical outcome. However, due to limitations in technology, there is no objective data available examining this relationship. The wireless motility capsule (WMC) is a novel technology consisting of an ingestible capsule equipped with pH, temperature, and pressure sensors, which provide information regarding regional and whole gut transit times, pH and motility. The aim of this study was to assess the impact of objective regional and whole gut motility data on the outcomes of ARS. This was a retrospective review of patients who underwent WMC testing before ARS. Transit times, motility, and pH data obtained from different gastrointestinal tract regions were used in analysis to determine factors that impact surgical outcome. A favorable outcome was defined as complete resolution of the predominant reflux symptom and freedom from antisecretory medications. The final study population consisted of 48 patients (fundoplication [n = 29] and magnetic sphincter augmentation [n = 19]). Of those patients, 87.5% were females and the mean age ± SD was 51.8 ± 14.5 years. At follow-up (mean ± SD, 16.8 ± 13.2 months), 87.5% of all patients achieved favorable outcomes. Patients with unfavorable outcomes had longer mean whole gut transit times (92.0 hours vs 55.7 hours; p = 0.024) and colonic transit times (78.6 hours vs 47.3 hours; p = 0.028), higher mean peak colonic pH (8.8 vs 8.15; p = 0.009), and higher mean antral motility indexes (310 vs 90.1; p = 0.050). This is the first study to demonstrate that objective colonic dysmotility leads to suboptimal outcomes after ARS. WMC testing can assist with preoperative risk assessment and counseling for patients seeking ARS.

Gas-Bloat Syndrome after Magnetic Sphincter Augmentation: Incidence, Risk Factors, and Impact on Surgical Outcomes

INTRODUCTION: There is paucity of data on gas-bloat syndrome (GBS) after magnetic sphincter augmentation (MSA). The aim of this study was to identify the incidence, risk factors, and impact of GBS on outcomes after MSA. METHODS: This is a retrospective review of patients who underwent MSA from 2014 to 2021 at our institution. Patients who completed standardized 1-year postoperative questionnaires were included for analysis. GBS was defined as score >3 on the gas-bloat–specific item within the GERD-Health Related Quality of Life questionnaire. Analysis was performed to identify preoperative risk factors for GBS and to assess its impact on surgical outcomes. RESULTS: The final study population consisted of 580 patients. At a mean (SD) follow-up of 11.6 (0.15) months, 88.2% were satisfied with the outcome, 90.9% were free from antisecretory medication, and 74.5% achieved normalization of DeMeester score. Gas-bloat syndrome affected 16.7% of patients and was more common among women (19.1% vs 14.4%, p = 0.048) and patients who reported preoperative bloating (22.0% vs 13.0%, p = 0.005). Smaller magnetic implants increased the incidence of GBS [size (13 and 14): 20.6% vs size (15 to 17): 11.3%, p = 0.003]. Patients with GBS were less satisfied (69.6% vs 91.8%, p < 0.0001). They were more likely to resume antisecretory medication after operation (23.7% vs 6.06%, p < 0.0001), despite no difference in the rate of DeMeester score normalization (74.6% vs 74.5%, p = 1.000). CONCLUSION: Gas-bloat syndrome affects 1 in 6 patients after MSA and significantly diminishes patient satisfaction and freedom from antisecretory medication. Patients with preoperative bloating, women, and those with smaller magnetic implants are at higher risk for GBS.

S2290 Complete Esophageal Obstruction: A Rare Complication of Zollinger-Ellison Syndrome (ZES)

Introduction: Patients diagnosed with ZES typically have minimal esophageal morbidity given advancements in anti-secretory medications. This case presents a rarely documented sequala of modern-day patients with ZES. Case Description/Methods: A 73-year-old man with history of HIV on HAART and ZES presented with worsening dysphagia to both solids and liquids. In the 2 year interval since his original presentation, his medical therapy was quickly maximized to omeprazole 180 mg/day and famotidine 80 mg/day. He also underwent tumor resection with distal gastrectomy, resection of D1, roux-en-Y hepaticojejunostomy, and truncal vagotomy. During that time his gastrin levels normalized from 1941 to 87. Despite these measures, he had undergone 21 EGDs and 7 esophageal stents for dysphagia secondary to refractory esophageal strictures. He lost 48 lbs over 2 years despite extensive attempts at both enteral and total parental nutrition. In January 2022, he presented with inability to swallow his own secretions and profound weakness from malnutrition. An esophagram was performed (figure 1a) revealing complete esophageal obstruction. An EGD with esophageal lumen restoration was attempted using combined retrograde and anterograde recanalization with 2 operators, 2 EGD scopes, and an EUS needle (figure 1c). Unfortunately, the 2 blind loops appeared to be approximately 6 cm apart in different alignments making lumen restoration unfeasible. The patient was most recently evaluated for esophageal reconstruction by jejunal interposition but was not a candidate due to poor nutritional status. Discussion: ZES is characterized by severe ulcerative disease due to gastric acid hypersecretion via neuroendocrine tumors. Our case is unique because this patient developed complete esophageal obstruction (CEO) despite management with maximal acid suppressive therapy, surgical resection, multiple EGDs with dilations, and numerous esophageal stents. CEO is a rare occurrence characterized by lumen obliteration leading to the inability to tolerate own secretions and most recorded cases are due to radiation-therapy for treatment of head and neck cancers. Given the low incidence, there is no single established method for endoscopic lumen restoration. However recombined retrograde and anterograde recanalization and dilation (CARD) has been shown to be successful for strictures less than 3 cm.Figure 1.: (A) Barium swallow study revealing a high-grade stricture in mid thoracic esophagus followed by another high-grade stricture with complete lumen obstruction. (B) EGD showing blind pouch approximately 35 cm from incisors. (C) Fluoroscopic imaging displaying attempt at combined anterograde and retrograde decannulation and dilation.

Potassium-competitive acid blockers and gastroesophageal reflux disease.

Proton pump inhibitors (PPIs), the most commonly used antisecretory medi-cations in the management of reflux illness, virtually eliminate elective surgery for ulcer disease, and relegate anti-reflux surgery to patients with gastroesophageal reflux disease (GERD) who are inadequately managed by medical therapy. However, PPI medications still leave some therapeutic demands of GERD unmet. Furthermore, up to 40%-55% of daily PPI users have chronic symptoms, due to PPI refractoriness. Potassium-competitive acid blockers (P-CABs) transcend many of the problems and limits of PPIs, delivering quick, powerful, and extended acid suppression and allowing for treatment of numerous unmet needs. Recently, it has become clear that compromised mucosal integrity plays a role in the etiology of GERD. As a result, esophageal mucosal protection has emerged as a novel and potential treatment approach. An increasing body of research demonstrates that when P-CABs are used as primary drugs or add-on drugs (to regular treatment), they provide a considerable extra benefit, particularly in alleviating symptoms that do not respond to PPI therapy.

The Inclusion of Voice Assessments to Aid Diagnostic and Surgical Decision Making for Patients With Laryngopharyngeal Reflux

Patients with suspected laryngopharyngeal reflux (LPR) present with a variety of symptoms, such as cough, hoarseness, and globus sensation, and often do not have the classic features associated with gastroesophageal reflux disease. To achieve greater clarity in the symptom presentation, response to treatment, and the impact on vocal function among patients presenting with signs and symptoms consistent with LPR, we prospectively evaluated initial assessments and outcomes after medication or surgical management. A sample of 109 patients completed self-report measures of reflux symptoms, voice handicap, and underwent diagnostic workup by both laryngologist and foregut surgeon to include laryngoscopy, esophagogastroduodenoscopy, manometry and pH monitoring. Patients were then followed for at least 3 months, and outcomes of therapy were recorded. The most common indicators on initial workup were reflux symptom inventory score ≥ 13 and at least one abnormality on manometry. Male patients were significantly more likely to demonstrate esophagitis on biopsy, abnormal upper esophageal sphincter mean pressure, and acid (vs nonacid) reflux. Older patients were more likely to have normal esophageal distal contractile integral activity. Significantly higher voice handicap ratings were observed among patients with a positive reflux indicator score in addition to abnormal upper esophageal sphincter mean basal pressure and contractile front velocity. Patients with acid versus nonacid reflux were equally as likely to report non-responsivity to antisecretory medications. Among a subset of patients with 3-month follow-up data (N = 39), reflux scores were significantly lower irrespective of treatment modality (surgical vs pharmacological intervention). Extensive comprehensive workup did not reveal a single predictive indicator for LPR. Voice assessments may be more sensitive to upper esophageal symptomatology or dysfunction compared to reflux assessments, which may be better indicators of inflammation. Our collaborative data confirms the value of assessing vocal quality and impairment, especially in the presence of equivocal reflux indicators, as together these measures may achieve greater sensitivity to reflux issues and may aid in surgical decision making.

Peripheral Facial Paresis and COVID-19 Case Report

Among the neurological complications that occurred during Corona Virus Disease 2019 (COVID-19) infection, peripheral facial paresis is one of the conditions that can occur both during and after the Severe Acute Respiratory Tract Syndrome Corona Virus 2 (SARS-CoV-2) infection period. We present the case of a young man, aged 29 years, who presented the appearance of a peripheral facial paresis on the 14th day after the onset of symptoms, isolation and PCR detection of SARS-CoV-2 infection. The patient was evaluated clinically, neurologically, underwent laboratory tests, EKG, chest Radiography, Magnetic Resonance Imaging (MRI)/Magnetic resonance Angiography (MRA) and received corticotherapy, gastric antisecretory medication, antiviral medication, vitamin B group, neurotrophic medication and facial gymnastics, with good evolution and complete remission of clinical symptoms after 21 days. It is particularly important to carefully evaluate patients during the isolation period, symptomatic/asymptomatic for COVID-19 infection, as a possible complication could be peripheral facial paresis, which is why, we should evaluate, detect and treat early to reduce any persistent long-term neurological effects. Future studies are needed to identify and correlate peripheral facial paresis with SARS-CoV-2 infection as well as to detect the causes of neurological complications during or after COVID-19 infection.

Biopsy forceps disruption paired with bougie dilation of esophageal strictures lengthens time to repeat intervention.

Esophageal strictures commonly cause dysphagia and require treatment with endoscopic dilation using balloons or bougies. We aimed to determine whether biopsy forceps disruption of strictures at time of dilation increases time to repeat intervention or duration of intervention-free follow-up. We performed a retrospective analysis of 289 adults (age 61.0 ± 0.8years, 66.4% female) who underwent dilation of an esophageal stricture at our tertiary care center between 2014 and 2016. Exclusions consisted of endoscopic intervention within the preceding 6months, prior foregut neoplasia, achalasia, radiofrequency ablation, endoscopic mucosal resection, endoscopic submucosal dissection, or foregut surgery. Demographics, clinical presentation, dilation technique, and follow-up were abstracted from electronic medical records. We compared time to repeat dilation and duration of intervention-free follow-up between treatment subgroups. Balloon dilation was performed more often than bougie dilation (76.8 vs. 17.6%); biopsy forceps disruption was performed in 23.2%. Over a median follow-up of 52.9months, 135 patients (46.7%) underwent repeat dilation. Age, body mass index, gender, and use of antisecretory medications did not influence need for repeat dilation (P = ns for each). Bougie dilation with biopsy forceps disruption prolonged time to repeat dilation in all patients (P ≤ 0.02), particularly in those with gastroesophageal reflux disease (P ≤ 0.03), compared with bougie dilation alone and balloon dilation with or without disruption. On Kaplan-Meier analysis, bougie dilation with biopsy forceps resulted in longer intervention-free follow-up compared with dilation alone (P = 0.03). We conclude that stricture disruption with biopsy forceps increases time to repeat intervention with bougie but not balloon dilation.

Increased Risk of COVID-19 Among Users of Proton Pump Inhibitors.

INTRODUCTION:Proton pump inhibitors (PPIs) increase the risk for enteric infections that is likely related to PPI-induced hypochlorhydria. Although the impact of acid suppression on severe acute respiratory syndrome coronavirus 2 is unknown thus far, previous data revealed that pH ≤3 impairs the infectivity of the similar severe acute respiratory syndrome coronavirus 1. Thus, we aimed to determine whether use of PPIs increases the odds for acquiring coronavirus disease 2019 (COVID-19) among community-dwelling Americans.METHODS:From May 3 to June 24, 2020, we performed an online survey described to participating adults as a “national health survey.” A multivariable logistic regression was performed on reporting a positive COVID-19 test to adjust for a wide range of confounding factors and to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).RESULTS:Of 53,130 participants, 3,386 (6.4%) reported a positive COVID-19 test. In regression analysis, individuals using PPIs up to once daily (aOR 2.15; 95% CI, 1.90–2.44) or twice daily (aOR 3.67; 95% CI, 2.93–4.60) had significantly increased odds for reporting a positive COVID-19 test when compared with those not taking PPIs. Individuals taking histamine-2 receptor antagonists were not at elevated risk.DISCUSSION:We found evidence of an independent, dose-response relationship between the use of antisecretory medications and COVID-19 positivity; individuals taking PPIs twice daily have higher odds for reporting a positive test when compared with those using lower-dose PPIs up to once daily, and those taking the less potent histamine-2 receptor antagonists are not at increased risk. These findings emphasize good clinical practice that PPIs should only be used when indicated at the lowest effective dose, such as the approved once-daily label dosage of over-the-counter and prescription PPIs. Further studies examining the association between PPIs and COVID-19 are needed.