PPI Use Research Articles

23 Small intestinal bacterial overgrowth in chronic pancreatitis patients with pancreatic exocrine insufficiency; a prospective cohort study

Background Pancreatic exocrine insufficiency (PEI) causes malabsorption and is a major complication of chronic pancreatitis (CP). Small intestinal bacterial overgrowth (SIBO) worsens symptoms and nutritional status in CP, its prevalence is unclear Aim We examined SIBO prevalence in CP patients with PEI (defined as faecal elastase-1 Method 34 patients and 25 controls (matched for age/gender/smoking status) underwent hydrogen breath-testing using a glucose substrate. Exclusion criteria included gastric/pancreatic/intestinal surgery, or antibiotic treatment Results Patients and controls were well-matched, with 67% and 64% males respectively (p=0.775), a mean (standard deviation) age of 52.4 (10.4) and 53.3 (10.5) year respectively (p=0.919), and 47.1% and 28% smokers respectively (p=0.143). Among patients, there was no association found between the presence of SIBO and gender (p=0.156), or PPI use (p=0.328). There was a significantly positive association found between the presence of SIBO and diabetes (p=0.033), while the positive association between the presence of SIBO and pancreatic enzyme replacement therapy (PERT) use just reached significance (p=0.052) Conclusions SIBO prevalence was 15% and not associated with gender, age, or PPI use, but was positively associated with PERT use, and concurrent diabetes. Patients with diabetes may be more likely to suffer from SIBO due to small bowel dysmotility, whilst SIBO and PEI may co-exist, with similar symptoms. We recommend that SIBO should be considered in non-surgical CP patients, if they have gastro-intestinal symptoms that are unresponsive to high-dose PERT, particularly if there is co-existent diabetes. Treatment should be aggressive, and there may be a requirement for repeat therapy.

DTB Select: 2 | February 2017

MHRA clarifies spironolactone advice ● Statin dosing: morning or evening? ● PPI use and risk of community-acquired pneumonia ● Non-inferiority trials: caution needed ● CV safety of celecoxib? ● ADRs...

Use of Proton-Pump Inhibitors Predicts Heart Failure and Death in Patients with Coronary Artery Disease.

ObjectivesProton-pump inhibitors (PPIs) seem to increase the incidence of cardiovascular events in patients with coronary artery disease (CAD), mainly in those using clopidogrel. We analysed the impact of PPIs on the prognosis of patients with stable CAD.MethodsWe followed 706 patients with CAD. Primary outcome was the combination of secondary outcomes. Secondary outcomes were 1) acute ischaemic events (any acute coronary syndrome, stroke, or transient ischaemic attack) and 2) heart failure (HF) or death.ResultsPatients on PPIs were older [62.0 (53.0–73.0) vs. 58.0 (50.0–70.0) years; p = 0.003] and had a more frequent history of stroke (4.9% vs. 1.1%; p = 0.004) than those from the non-PPI group, and presented no differences in any other clinical variable, including cardiovascular risk factors, ejection fraction, and therapy with aspirin and clopidogrel. Follow-up was 2.2±0.99 years. Seventy-eight patients met the primary outcome, 53 developed acute ischaemic events, and 33 HF or death. PPI use was an independent predictor of the primary outcome [hazard ratio (HR) = 2.281 (1.244–4.183); p = 0.008], along with hypertension, body-mass index, glomerular filtration rate, atrial fibrillation, and nitrate use. PPI use was also an independent predictor of HF/death [HR = 5.713 (1.628–20.043); p = 0.007], but not of acute ischaemic events. A propensity score showed similar results.ConclusionsIn patients with CAD, PPI use is independently associated with an increased incidence of HF and death but not with a high rate of acute ischaemic events. Further studies are needed to confirm these findings.

Guidelines improve appropriate PPI use in PICU in France

Guidelines improve appropriate PPI use in PICU in France

PPI use in infancy increases childhood fracture risk

PPI use in infancy increases childhood fracture risk

Use of Proton Pump Inhibitors and the Risk of Hospitalization for Infectious Gastroenteritis

IntroductionTo quantify the association between PPI use, type and dose and infectious gastroenteritis hospitalization in a population-based cohort of middle-aged and older adults.MethodsProspective study of 38,019 concession card holders followed up over 6 years in the Sax Institute’s 45 and Up Study. Data from the baseline questionnaire were linked to prescription medication, hospitalization, notifiable disease, cancer registry and death datasets from 2006–2012. Associations between PPI use and gastroenteritis hospitalization were examined using Cox regressions with age as the underlying time variable.ResultsAmong 38,019 participants, the median age was 69.7 years, and 57.3% were women. Compared to non-users, current PPI users were more likely to be older, and have a higher BMI. During follow-up there were 1,982 incident gastroenteritis hospitalizations (crude rate: 12.9 per 1000 person-years, 95% CI: 12.3–13.5). PPI use was significantly associated with infectious gastroenteritis hospitalization (aHR 1.4, 95% CI: 1.2–1.5). Among current users, a dose-response relationship was observed between the average daily dose (DDD) dispensed per day and infectious gastroenteritis hospitalization (Ptrend<0.001). We also observed higher rates of infectious gastroenteritis hospitalization and greater PPI use among participants with a history of chronic bowel problems (aHR 2.2, 95% CI: 1.9–2.5). There was no difference in risk by type of PPI. Recent use of H2 receptors was not associated with gastroenteritis hospitalization.ConclusionPPI use is associated with an increased risk of infectious gastroenteritis hospitalization. Clinicians should be aware of this risk when considering PPI therapy.

A retrospective analysis of the role of proton pump inhibitors in colorectal cancer disease survival.

Proton pump inhibitors (ppis) are a commonly used medication. A limited number of studies have identified a weak-to-moderate association between ppi use and colorectal cancer (crc) risk, but none to date have identified an effect of ppi use on crc survival. We therefore postulated that an association between ppi use and crc survival might potentially exist. We performed a retrospective chart review of 1304 crc patients diagnosed from January 2005 to December 2011 and treated at the Cancer Centre of Southeastern Ontario. Kaplan-Meier analysis and Cox proportional hazards regression models were used to evaluate overall survival (os). We identified 117 patients (9.0%) who were taking ppis at the time of oncology consult. Those taking a ppi were also more often taking asa or statins (or both) and had a statistically significantly increased rate of cardiac disease. No identifiable difference in tumour characteristics was evident in the two groups, including tumour location, differentiation, lymph node status, and stage. Univariate analysis identified a statistically nonsignificant difference in survival, with those taking a ppi experiencing lesser 1-year (82.1% vs. 86.7%, p = 0.161), 2-year (70.1% vs. 76.8%, p = 0.111), and 5-year os (55.2% vs. 62.9%, p = 0.165). When controlling for patient demographics and tumour characteristics, multivariate Cox regression analysis identified a statistically significant effect of ppi in our patient population (hazard ratio: 1.343; 95% confidence interval: 1.011 to 1.785; p = 0.042). Our results suggest a potential adverse effect of ppi use on os in crc patients. These results need further evaluation in prospective analyses.

Managing for Results Differently: Examining Managers’ Purposeful Performance Information Use in Public, Nonprofit, and Private Organizations

Performance information (PI) is only valuable when decision makers use it to improve their organization. Despite its importance, evidence on PI use is still limited, particularly about PI use in different contexts and for specific purposes. This article examines managers’ use of PI for specific purposes (purposeful PI [PPI]) and compares cross-sector differences in reported PPI use with a survey of nearly 1,000 top-level hospital managers in public, private, and nonprofit hospitals in the United States, while controlling for task. Findings show significant cross-sector differences in reported PPI use in three decision areas: personnel, day-to-day operations, and service efficiency, and that public managers use PI significantly less than their private and nonprofit counterparts in most decision areas. Results are discussed within the literature on performance management and cross-sector differences.

Outcomes in patients with over 1-year follow-up after peroral endoscopic myotomy (POEM).

Peroral endoscopic myotomy (POEM) is a promising therapy in the treatment of achalasia. The study was designed to report outcomes, including quality of life, in patients with at least 1-year follow-up. Patients from an institutional review board-approved protocol underwent POEM and were followed prospectively. Health-related quality of life was measured preoperatively and 1year post-operatively using Short Form-36 Health Survey version 2 (SF-36v2). Comparisons were made with patients from a prospective database who underwent laparoscopic Heller myotomy (LHM) over the same period. Paired t tests were used to analyze all normally distributed data, while Wilcoxon signed-rank tests were used to analyze SF-36 data, as it does not follow a normal distribution. We analyzed 41 consecutive POEM patients with at least 1-year follow-up. Significant improvements in quality of life between baseline and 1year were found in role limitations due to physical health (81.8±25.8 vs. 65.9±31.6, p=0.01) and social functioning (83±19.1 vs. 64.6±31.3, p=0.01). When compared to 24 patients who underwent LHM, there was no difference in average Eckardt scores (0.9±1.6 vs. 1.0±1.3, p>0.05) or incidence of PPI use (43.5 vs. 47.5%, p=0.71). However, when looking at just type III patients, POEM patients had a higher remission rate (100 vs. 62.5%) and significantly lower post-operative Eckardt scores at 1year (1.1 vs. 3.1, p<0.05). The average myotomy length of type III achalasia patients undergoing POEM was 18.6cm (±6.9) compared to 10.3cm (±1.0) in LHM patients (p<0.01), which may have contributed to this difference. POEM provides a significant quality of life benefit at 1year while having similar relief of dysphagia and post-operative PPI use compared to LHM. Type III achalasia patients may have better outcomes with POEM compared to LHM.

Tri-comparison of Laparoscopic Nissen, Hill, and Nissen-Hill Hybrid Repairs for Uncomplicated Gastroesophageal Reflux Disease

BackgroundA randomized controlled trial (RCT) showed that laparoscopic Nissen fundoplication (LNF) and Hill (LHR) repairs are equivalent in treating uncomplicated GERD. We combined both repairs to create a laparoscopic Nissen-Hill Hybrid repair (HYB). The purpose of this study is to compare clinical and objective outcomes of a matched group of HYB to the two cohorts of the RCT. MethodsA retrospective analysis of prospectively collected data from the RCT and a prospectively collected data base was performed. Data were collected preoperatively, postoperatively short-term (ST) at 6 weeks and mid-term (MT) at 6–12 months. Evaluation was standardized according to the RCT and included three quality of life metrics (QOLRAD, GERD-HRQL, Dysphagia), endoscopy, manometry, pH testing, and barium swallow. ResultsThere were 51 HYB, 46 LNF, and 56 LHR patients. Age, BMI, follow-up, and gender were comparable. QOLRAD, HRQL, PPI use, DeMeester scores, and pH% time <4 significantly improved in all groups and were equivalent. Anatomic recurrence was seen in five LNF, four LHR, and two HYB patients. Reoperations were performed in three LHR, two LNF, and zero HYB patients. ConclusionTri-comparison shows that HYB is a promising alternative to LHR and LNF. Side effects were not increased and there were fewer reoperations for failure

Tetany Secondary to the Use of a Proton-Pump Inhibitor

Introduction: Chronic PPI use has been reported to cause hypocalcemia, bone density loss and osteoporoticrelated fractures but an acute drop in serum calcium level with PPI use is rare. We present a rare case of symptomatic hypocalcemia with 2 weeks use of PPI. Case Report: 61-year-old female with past medical history of hypothyroidism and hypoparathyroidism secondary to thyroidectomy and parathyroidectomy came to the emergency department(ED) with complaints of spasm and twitching of her upper extremities associated with lethargy and difficulty ambulation. 2 weeks prior to this presentation patient had upper endoscopy done for dyspepsia which showed antral erythema and stomach biopsies came back positive for Helicobacter Pylori gastritis. Patient started taking omeprazole after the endoscopy and later she was given antibiotics treatment for Helicobacter Pylori which she started taking three days prior to the ED presentation. Prior to initiate the omeprazole patient's serum calcium was 8.1 mg/DL. The patient has been taking magnesium citrate 200 mg two times a day and calcium carbonate 1200 mg daily with meals since surgery. No recent change in the dosage of these medications. In ED, EKG done showed QT prolongation, serum calcium was 5.7 mg/DL, magnesium was 1.7 mg/DL and albumin was 3.3 g/DL Thyroid function was within normal limit and parathyroid hormone(PTH) was Discussion Gastric acidic PH is required for absorption of the calcium. Calcium carbonate is a widely use form of calcium supplement which become soluble in the gastric acidic PH and then get absorb in the small intestine. PPI increase the gastric PH so decrease the absorption of calcium which later can cause hypocalcemia. This effect is more seen in the patient with low PTH as it plays a key role in maintaining the serum calcium level within normal limit by stimulating bone resorption, renal tubular calcium reabsorption, and by enhancing gastrointestinal absorption of calcium. The patients with hypoparathyroidism when take PPI their serum calcium needs to be closely monitored to avoid the life threatening complication of hypocalcemia and should be advised to take calcium citrate as a calcium supplement which does not require gastric acidic PH.

Ineffective Esophageal Motility Is Independently Associated with Higher Reflux Symptom Index (RSI) Score in Subjects with Suspected Laryngopharyngeal Reflux

Introduction: Evaluation and management of suspected laryngopharyngeal reflux (LPR) symptoms is challenging, and the effectiveness of anti-reflux therapy has been varied. Esophageal dysmotility may also play a role in LPR symptoms. The association between esophageal dysmotility on high-resolution manometry (HRM) and objective measures of LPR symptoms such as the reflux symptom index (RSI) is not known. A better understanding of the HRM patterns found in patients with suspected LPR may further our understanding of this clinical presentation, particularly when reflux assessment alone fails to establish a diagnosis. We aimed to examine the association between abnormal HRM findings in patients with suspected LPR and RSI. Methods: This was a retrospective study of all patients with suspected LPR who underwent HRM and multichannel intraluminal impedance and pH study (MII-pH) at a tertiary center in 3/2015-5/2016. All patients completed the reflux symptom index (RSI) questionnaire within 3 months of testing. Chart review was performed to collect data on demographics, medical history, clinical symptoms, and prior PPI use. Abnormal HRM findings were categorized using Chicago Classification v3.0. The associations between RSI score and HRM findings were evaluated using student's t-test for univariate analysis and general linear regression for multivariate analysis. Results: 47 patients (mean age = 55.6±13.7, 74.5% female) met criteria for inclusion. On univariate analysis, the mean total RSI score was significantly higher among patients with ineffective esophageal motility (IEM), defined as failed or weak swallows ≥50%, compared to those with normal motility (27.8 vs 19.8, p=0.03). No association between other HRM findings and RSI scores was found. On multivariate analysis, after controlling for age, gender, PPI use, and bolus exposure (measured on MII-pH), IEM remained independently associated with a higher total RSI score (β coefficient: 8.36, p=0.04). No association was found between parameters on MII-pH testing alone and RSI score. Conclusion: IEM is independently associated with a higher total RSI score among patients with LPR symptoms, even after controlling for abnormal reflux on MII-pH. Esophageal dysmotility may contribute to LPR symptoms and should be routinely considered in the work-up of suspected LPR.

Is Long-term PPI Use Associated with the Development of Gastric Neuroendocrine Tumors?

Is Long-term PPI Use Associated with the Development of Gastric Neuroendocrine Tumors?

Outcomes, Safety and Predictors of Failure of Fecal Microbiota Transplantation for Refractory Clostridium difficile Infection

Introduction:Clostridium difficile infection (CDI) is a common cause of infectious diarrhea. The high rate of CDI recurrence (15-30%) after the initial episode is a major challenge. Fecal microbiota transplantation (FMT) is effective to treat antibiotic refractory CDI, with worldwide cure rates around 92%. Methods: This is a retrospective study to assess the efficacy, safety and predictors of failure of FMT in patients with refractory CDI. Patients who had first FMT via colonoscopy for refractory CDI between January 2013 and August 2015 were included. We collected demographics, comorbidities, symptoms, duration of CDI, treatment outcomes and complications from FMT. Logistic regression was used to demonstrate factors associated with FMT failure. Results: During our 32 month study period, 54 patients underwent FMT. Two patients were excluded due to loss of follow up. Females were 69% (36/52), mean age 54 years (range 18-96), mean CDI duration before FMT 17 months (range 2-75). Patients failed an average of 5 antibiotic courses (range 2-17) to treat CDI before FMT. Forty five (87%) stool donors were patients' family members. Mean follow up after FMT was 13 months (range 3-29). Forty five patients (87%) were successfully treated without CDI recurrence with just one FMT (Figure 1). Recurrent CDI despite FMT occurred in 7 patients (13%). Of these, 3 were successfully treated with oral vancomycin and 4 (8%) required second FMT. Of these 4, only one had recurrence of CDI despite second FMT due to antibiotic use. CDI cure rate at the end of the study was 98% (51/52). Diarrhea resolved immediately (within 3 days) in 56% (29/52) after FMT. One patient reported abdominal pain for 2 weeks related to the FMT procedure. No other adverse events were found. Six patients had recurrent diarrhea after FMT but tested negative for CDI. Logistic regression demonstrated that fluoroquinolone use (OR 7.7, p=0.02), and duration of disease before the first FMT of >18 months (OR 24, p=0.005) independently predicted FMT failure. Age ≥65, gender, inflammatory bowel disease, PPI use and number of antibiotic courses to treat CDI did not predict FMT failure. Patients with FMT failure were not immunosuppressed.Figure 1Conclusion: Our FMT experience matches the worldwide cure rates and supports emerging data about the safety and efficacy of FMT, with more than half of our patients showing immediate symptom relief. Fluoroquinolone use and longer duration of disease before the first FMT independently predicted FMT failure.

A Case of Functional, Multifocal Duodenal-pancreatic Neuroendocrine Tumors

Introduction: Gastroenteropancreatic neuroendocrine tumors are rare neoplasms that are typically solitary and non-functional. We present a case of functional, multifocal duodenal-pancreatic neuroendocrine tumors. Case Presentation: A 57 year old male presented with a three week history of severe, colicky abdominal pain unrelated to eating. He also reported a 100 pound, intentional weight loss. Medical history was notable for new onset diabetes. He denied alcohol or tobacco use. There was no family history of pancreatic cancer or pancreatitis. Prior workup included an abnormal HIDA and an EGD with only gastritis. He underwent a laparoscopic cholecystectomy, without improvement in symptoms. Because of his weight loss and new diabetes, an MRI/MRCP was done showing an atrophic pancreas with scattered cysts. EUS guided aspiration of a large 11.2 by 11.5mm cyst in the pancreatic tail revealed a solid component. Subsequent FNA demonstrated cells consistent with a pancreatic neuroendocrine tumor (PNET). Follow up endocrine studies revealed significantly elevated gastrin, undetectable gastrin secreting peptide, and mildly elevated glucagon and C peptide levels. Other studies were within normal range. The patient underwent a distal pancreatectomy with histology showing a well-differentiated neuroendocrine neoplasm and focal IPMN. Peripancreatic lymph nodes were negative. Patient initially did well postoperatively, but developed recurrent symptoms. Repeat EGD with EUS identified a 2cm mass at the duodenal bulb. Interval CT also demonstrated development of small, scattered lesions in the liver, left adrenal and lung bases. The patient was subsequently diagnosed with multifocal duodenal and pancreatic neuroendocrine tumors. Discussion: This patient was initially thought to have a cystic pancreatic neuroendocrine tumor; however, he was subsequently found to have multiple tumor foci, which is more consistent with MEN1 Syndrome. In this case, glucagon levels were elevated, explaining his symptoms of new onset diabetes and abdominal pain. His gastrin level was also elevated, however interpretation of this was complicated by concurrent PPI use. Because of the potential for multiple primary lesions, when an EUS is performed for evaluation of a possible cystic PNET, a full EGD should also be considered. Treatment for MEN1 is challenging in part because tumors are usually multiple, precluding surgical resection. Thus, treatment is geared toward a medical approach.

Associations of Vitamin D Deficiency and Hyperparathyroidism with Gastroesophageal Reflux Disease and Its Sequelae

Introduction: Esophageal adenocarcinoma has been associated with decreased exposure to ultraviolet radiation, suggesting a link with vitamin D (vit D) deficiency. We are not aware of prior studies of the effect of vit D deficiency on esophageal reflux, but it is associated with idiopathic gastroparesis. In addition, vit D deficiency can lead to hyperparathyroidism, which is linked to adipose tissue inflammation. We hypothesized that vit D deficiency is associated with gastroesophageal reflux disease (GERD) symptoms, erosive esophagitis, and Barrett's esophagus (BE), and that hyperparathyroidism is associated with erosive esophagitis and BE. Methods: The Newly Diagnosed Barrett's Esophagus Study recruited men aged 50-79 undergoing colon cancer screening to undergo upper endoscopy regardless of symptoms (n = 822), classifying them as erosive esophagitis, BE, or neither. In addition, 80 men diagnosed with BE for the first time were enrolled. Subjects had the circumference of their waist and hips measured, and were queried regarding symptoms of GERD, PPI use, and supplemental use of calcium and vit D. We assayed serum for parathyroid hormone (PTH) and total 25-OH vit D from all subjects with BE, erosive esophagitis, or at least weekly symptoms of GERD, and a random sample of subjects without any of those conditions. Logistic regression was used to estimate the odds of hyperparathyroidism (PTH > 65 pg/mL) or vit D deficiency (< 20 ng/mL) with at least weekly GERD symptoms, erosive esophagitis, or BE. Results: 605 men were selected for assay, including 150 with GERD, 216 with erosive esophagitis, and 145 with BE (groups not mutually exclusive), plus 174 normals. We found no evidence of an association between GERD symptoms or erosive esophagitis with vit D deficiency or hyperparathyroidism (Table). Contrary to our hypothesis, we found a strong inverse association between BE and hyperparathyroidism (OR = 0.588; 95% CI = 0.362, 0.956). Likewise, there was a trend toward an inverse association between BE and vit D deficiency. Conclusion: We found no evidence of an association between vit D deficiency or hyperparathyroidism with GERD symptoms or erosive esophagitis, but found evidence for inverse associations between BE and hyperparathyroidism or vit D deficiency. If vit D deficiency is truly associated with esophageal adenocarcinoma, then it likely exerts its effect on the transition from BE to esophageal adenocarcinoma. Funding: 2015 ACG Clinical Research Award.Table 1: Logistic Regression of Vitamin D Deficiency and Hyperparathyroidism on GERD Symptoms, Erosive Esophagitis, and Barrett's Esophagus

Age and Prevalence of Esophageal Reflux Disease in Japanese Patients with Type 2 Diabetes Mellitus: The Dogo Study.

Only limited epidemiological evidence exists regarding the relationship between age and gastroesophageal reflux disease (GERD) among Japanese patients with type 2 diabetes mellitus. The purpose of the present study is to investigate this issue among Japanese patients with type 2 diabetes mellitus. A multicenter cross-sectional study was conducted in 847 Japanese patients with type 2 diabetes mellitus. Subjects were divided into quartiles according to age: (1) 19≤age<56, (2) 56≤age<64, (3) 64≤age<71, and (4) 71≤age<89. GERD was defined as present when a subject had a Carlsson-Dent self-administered questionnaire (QUEST) score ≥4. The prevalence of GERD was 31.5%. Younger age was independently associated with a higher prevalence of GERD: the adjusted odds ratios (95% confidence intervals) for GERD in relation to age<56, 56≤age<64, 64≤age<71, and ≥71 were 3.73 (2.16-6.53), 1.98 (1.21-3.27), 1.66 (1.05-2.68), and 1.00 (reference), respectively (P for trend=0.001). Among 201 patients with PPI or histamine H2-receptor antagonist (H2RA), less than 56years of age was independently positively associated with GERD: the adjusted OR was 5.68 (95% CI 1.55-22.18) (P for trend=0.02). Younger age may be independently positively associated with GERD among Japanese type 2 diabetes mellitus patients, regardless of the use of PPI or H2RA.

Transoral fundoplication offers durable symptom control for chronic GERD: 3-year report from the TEMPO randomized trial with a crossover arm

BackgroundFour randomized controlled trials have demonstrated the short-term efficacy and safety of transoral esophagogastric fundoplication (TF) performed with the EsophyX® device in eliminating troublesome gastroesophageal reflux disease (GERD) symptoms in well-selected patient populations. The aim of this study was to assess the durability of these outcomes at 3 years post-procedure.MethodsThe TF EsophyX versus Medical PPI Open Label trial was conducted in seven US sites. Between June and August 2012, we enrolled patients with small (<2 cm) or absent hiatal hernias who suffered from troublesome GERD symptoms while on PPI therapy for at least 6 months and had abnormal esophageal acid exposure (EAE). Randomization was to TF group (n = 40) or to PPI group (n = 23). Following evaluation at 6 months, all remaining PPI patients (n = 21) elected to undergo crossover to TF. Fifty-two patients were assessed at 3 years for (1) GERD symptom resolution using three GERD-specific quality of life questionnaires, (2) healing of esophagitis using endoscopy, (3) EAE using 48-h Bravo testing, and (4) discontinuation of PPI use. Two patients who underwent revisional procedures by year 3 were included in the final analysis.ResultsAt 3-year follow-up, elimination of troublesome regurgitation and all atypical symptoms was reported by 90 % (37/41) and 88 % (42/48) of patients, respectively. The mean Reflux Symptom Index score improved from 22.2 (9.2) on PPIs at screening to 4 (7.1) off PPIs 3 years post-TF, p < 0.0001. The mean total % time pH <4 improved from 10.5 (3.5) to 7.8 (5.7), p = 0.0283. Esophagitis was healed in 86 % (19/22) of patients. At the end of study, 71 % (37/52) of patients had discontinued PPI therapy. All outcome measures remained stable between 1-, 2-, and 3-year follow-ups.ConclusionThis study demonstrates that TF can be used to achieve long-term control of chronic GERD symptoms, healing of esophagitis, and improvement in EAE.

Impact of concomitant use of P2Y12 inhibitors and proton pump inhibitors on ischemia events in patients with acute coronary syndrome in real world

Objective: The study aimed to analyze the impact of concomitant administration of P2Y12 inhibitors and PPIs on ischemia events in patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI). Methods: We retrospectively analyzed data from a international, multi-center registry between 2003 and 2014 in patients with ACS after PCI, grouped the cohort into patients receiving PPIs or no PPIs and assessed 1-year clinical endpoint (all-cause death/re-infarction). Meanwhile, we grouped the cohort into patients receiving clopidogrel or ticagrelor, and compared the impact of concomitant administration of PPIs and clopidogrel or ticagrelor on 1-year clinical endpoint. Results: Of 9 429 patients in the final cohort, 54.8% (n=5 165) was prescribed a PPI at discharge. Patients receiving a PPI were more likely to have comorbidities. No association was observed between PPI use and the clinical endpoint (HR 1.00, 95% CI 0.86-1.18). Meanwhile, no association was found between PPI use and the clinical endpoint in patients receiving either clopidogrel or ticagrelor. And the clinical endpoint in patients administrated of clopidogrel and PPIs had no difference with that of ticagrelor and PPIs. Conclusions: In patients with ACS following PCI, increased risk of ischemia event was not found in the concomitant use of PPIs and P2Y12 inhibitors, and especially, compared with ticagrelor, clopidogrel was found no association with ischemia events when concomitant administrated with PPIs.

A Matched Comparison of Per Oral Endoscopic Myotomy to Laparoscopic Heller Myotomy in the Treatment of Achalasia

BackgroundPer oral endoscopic myotomy (POEM) is increasingly utilized to treat patients with achalasia. Early results have demonstrated significant improvement of symptoms, but there are concerns about postoperative reflux. With only limited comparative data available, we sought to compare POEM to laparoscopic Heller myotomy (LHM) with partial fundoplication. MethodsThis is a retrospective review of 42 POEM and 84 LHM patients undergoing primary myotomy for achalasia. Patients were matched by achalasia type, by Eckardt and dysphagia scores, and by quality of life (QOL) metrics. Analysis at 6–12-month follow-up evaluated these metrics, PPI use, pH, manometric, and endoscopic data. ResultsWe matched 25 patients with achalasia types I (6), II (13), and III (6). Follow-up was longer for LHM at 158.1 (36.5–272.9) weeks versus 36.2 (22.2–41.2) weeks (p = 0.001). Eckardt scores, QOL metrics, and dysphagia significantly improved in both groups. DeMeester scores and total percent time less than 4 were abnormal in both groups and comparable (p = 0.925 and p = 0.838). Esophagitis was seen in 53.4 % (POEM) and 31.6 % (LHM) (Yates’ p = 0.91), and PPI use was equivalent at 36 %. ConclusionEarly clinical outcomes are excellent with POEM and comparable to the standard of care LHM. Long-term follow-up is required as concerns for reflux persist.