Reflux Medication Research Articles

Barriers to drug adherence in the treatment of urea cycle disorders: Assessment of patient, caregiver and provider perspectives

Patients and families living with metabolic disorders face challenging dietary and drug treatment regimens. On the hypothesis that poor palatability, volume and frequency of drug/formula administration contribute to treatment non-adherence and hyperammonemic episodes, a survey was conducted of patient, caregiver (CG) and physician perspectives on treatments used in urea cycle disorders (UCD). MethodsA paper and online survey assessed experience with UCD medications, medical foods and dietary supplements. Results25 physicians, 52 adult patients and 114 CG responded. In 2009, the most common UCD-specific intervention reported by patients included sodium phenylbutyrate (60%), followed by l-citrulline (46%), amino acid medical foods (15%), l-arginine preparations (18%), and sodium benzoate (8%). Only 36% of patients reported experiencing no hyperammonemic episodes in the last 2years. The most commonly reported cause of hyperammonemic episodes was infection or other acute illnesses, followed by dietary indiscretion, side effects of medications, and drug non-adherence. Most patients, caregivers and physicians (>75%) ranked nitrogen-scavenging medications, l-citrulline, l-arginine, and medical foods as “effective” or “very effective.” Non-adherence was common (e.g. 18% of patients admitted to missing sodium phenylbutyrate “at least once a week” and “at least one a day”). Barriers to adherence included taste of medications, frequency of drug administration, number of pills, difficulty swallowing pills, side effects, forgetting to take medications, and high cost. Strategies to mitigate the gastrointestinal side effects of medications included the use of gastric tubes and acid reflux medications. Physicians indicated that 25% and 33% of pediatric and adult patients, respectively, were given less than the recommended dose of sodium phenylbutyrate due to concerns of tolerance, administration, and cost. ConclusionsDespite positive views of their effectiveness, respondents found medications, medical foods and dietary supplements difficult to take and viewed adherence as inadequate, thus contributing to hyperammonemic episodes.

Infant Gastroesophageal Reflux (GER): Benign Infant Acid Reflux or just Plain Aerophagia?

Physicians are often asked to diagnose and treat infants with clinical signs of gastroesophageal reflux (GER) symptoms and in extreme cases gastroesophageal reflux disease (GERD). Some infants are left to work out their pain, regurgitation and vomiting until they outgrow the symptoms while others may undergo expensive, invasive endoscopic procedures in the operating room under general anesthesia. Initial treatment is often for infants to be placed on prescription adult acid reflux medications, which have limited benefits [1]. Drugs prescribed include: H-2 blockers such as ranitidine (Zantac), a proton pump inhibitor such as omeprazole (Prilosec) or lansoprazole (Prevacid). TOTS may cause aerophagia, a condition where the infant’s latch onto the mother’s breast or bottle allows the infant to swallow excessive amounts of air into the stomach during feeding. This aerophagia may be responsible for symptoms mimicking GER or GERD [2]. When these infants are examined for symptoms of GER the differential diagnosis of tethered oral tissues (TOTS) may not be addressed [3]. Tethered oral tissues may involve ankyloglossia (tongue-tied), maxillary and /or mandibular frenum lip-ties and in some instances buccal frenum ties. These tethered oral tissues (TOTS) prevent the infant from achieving a good seal onto the breast and or bottle with the resulting ingestion of excessive amounts of air. Background: When assessing infants presenting with gastroesophageal reflux symptoms, aerophagia secondary to tethered oral tissues (tongue-ties ,Lip-ties) should be considered in the differential diagnosis since the release of these tissues may eliminate the need for invasive gastrointestinal investigations and pharmacologic treatment of gastroesophageal reflux. Patient Pool: 340 infants ranging from 1 week to 3 months were referred for the evaluation and release of lingual and maxillary lips which were interfering with infant’s ability to achieve a good seal and latch onto the mother’s breast of infant bottle .The survey the parents completed indicated that 208 or 61% of the infants had signs of gastroesophageal reflux (GER) such as; vomiting, regurgitation, inability to sleep lying supine, fussiness, crying after nursing and morning congestion. Of the 208 infants 40% (83 infants) were or had been treated for GER with pharmacologic medications such as proton pump inhibitors or H2 blockers without any resolution of the symptoms. Findings: All of the infants presenting with these signs and symptoms underwent laser revisions of the tethered attachments. Upon completion of the procedure and at a 48 hour post-surgical follow-up discussion with the parents 93% (194 infants) of the infants showed immediate improvements and were able to breastfeed successfully without signs or symptoms of GER. Survey returned at the end of two weeks post-surgery had similar results Conclusion: Infants presenting with signs of GER should also be evaluated for restrictive tethered oral tissues (TOTS) such as ankyloglossia, lip and buccal ties. If they are present, strong consideration should be given to the release of these tissues as an initial approach. This may eliminate the need for pharmacologic treatment of GER.

Aerophagia Induced Reflux in Breastfeeding Infants With Ankyloglossia and Shortened Maxillary Labial Frenula (Tongue and Lip Tie)

Background: Infants with tongue and possible lip tie often have a poor latch in which there is often an inadequate seal around the breast and disorganized swallowing. As a result, many of these infants swallow air during breastfeeding. Many of these infants suffer from symptoms of reflux. Methods: This was a retrospective analysis of questionnaire/intake surveys of 1,000 infants over 5 years in private surgical practice. The inclusion of these infants was determined based on painful breastfeeding, poor lip seal, infant taking H2 blockers or proton pump inhibitors. These infants underwent release of their restrictions with CO 2 laser. Results: This study shows a correlation between aerophagia in infants with short maxillary labial frenula (maxillary lip tie) and ankyloglossia and reflux. A new term has been created to describe this entity: aerophagia induced reflux (AIR). Five hundred twenty (52%) showed improvement or complete reversal of symptoms of reflux to the end point of cessation of reflux medication. Two hundred eighty-three (28.3%) had no change in reflux, and 191 (19.1%) showed post-surgical improvement in post-feed irritability and less reflux symptoms but not successfully weaned off medications. Conclusion: There appears to be a relationship between maxillary lip tie (ankyloglossia and shortened maxillary labial frenula) and AIR. Treatment of these infants with a relatively simple frenotomy procedure may reduce or eliminate reflux. As a result, many of these infants may be spared from invasive testing or medications that have been shown to have potentially significant side effects. This may change diagnostic and treatment algorithms. Int J Clin Pediatr. 2016;5(1):6-8 doi: http://dx.doi.org/10.14740/ijcp246w

Long-term functional outcomes of laparoscopic resection for gastric gastrointestinal stromal tumors

Laparoscopic resection is rapidly becoming the treatment of choice for small- to medium-sized gastric gastrointestinal stromal tumors (GIST). While long-term oncologic data are available, quality of life outcomes are less known. Our IRB-approved prospectively maintained database was retrospectively queried (2003-2013) for patients who underwent laparoscopic gastric GIST resection. Demographics along with perioperative and oncologic outcomes were collected and analyzed. Patients were contacted and asked to complete a quality of life survey consisting of Likert scales scored from 1 to 5. Patients also completed the Gastrointestinal Quality of Life Index (GIQLI). A total of 69 patients were identified and 36 patients (59.0% of eligible patients) responded to the survey. Median follow-up was 39 months. Patients most commonly reported no change in weight, appetite, early satiety, heartburn, persistent cough, dysphagia, and reflux medication dosing postoperatively. The median scores for chest pain and regurgitation were 4, falling in the "worsened" range. 8.33% of patients reported worsened chest pain and 11.11% of patients reported worsened regurgitation postoperatively. The GIQLI scores had a mean of 126.9 (range 77-141). While some patients reported a worsening in early satiety, most patients reported no change in symptoms postoperatively, and the GIQLI scores remained within the normal range. Laparoscopic resection of gastric GIST provides durable results with minimal effect on longer-term quality of life.

The Role of the Modified Barium Swallow Study and Esophagram in Patients with Globus Sensation.

Globus sensation (GS) is a common benign finding that is often associated with frequent throat clearing and is commonly a result of laryngopharyngeal reflux. The primary objective of this investigation was to examine the role of the modified barium swallow study (MBSS) with esophagram in the diagnosis and management patients who present with chief complaints of a GS. We hypothesize that these radiographic swallow studies do not add clinically significant information in the investigation of this common complaint. Retrospective chart review of patients with chief complaints of GS between 2000 and 2009 who underwent both MBSS and esophagram was conducted. Of the 380 patients who underwent MBSS, only 68 patients were eligible for this study. Over 70 % of patients were on reflux medicines, 81 % of the MBSS studies were normal, 62 % of the esophagram results were normal, 18 % of patients had a hiatal hernia, and 10 % exhibited signs of reflux. Esophagoscopy was performed in 45 % of patients, of which 35 % were normal. One patient initially had a normal esophagogastroduodenoscopy and then was subsequently diagnosed with gastric CA. Fifty-nine percent of patients underwent CT Neck with IV contrast, of which 67 % had minor findings. Positive findings are often benign and can be treated with reflux medications. Esophagoscopy was often normal and most sensitive only for hiatal hernia. No hypopharyngeal cancer was noted. Therefore, MBSS and esophagram for patients with GS are most often negative and fail to add significant diagnostic information.

Limited efficacy of antigastroesophageal reflux medications in children

Limited efficacy of antigastroesophageal reflux medications in children

Surgical cure of primary hyperparathyroidism ameliorates gastroesophageal reflux symptoms.

Gastroesophageal reflux disease (GERD) symptoms are commonly reported in primary hyperparathyroidism (pHPT). Although a calcium-mediated cause-and-effect relationship has been suggested, it remains unknown if parathyroidectomy improves GERD symptoms. Over a 22-month period, 1,175 (39%) of 3,000 consecutive adult patients with pHPT and symptomatic GERD (on prescription reflux medications daily for ≥2 years) undergoing parathyroidectomy were entered into a prospective study. Standardized Frequency Scale for Symptoms of GERD (FSSG) questionnaire was used to assess symptoms before, 1 and 2 years after parathyroidectomy. Daily prescription medication was used by 81%, while 19% used daily non-prescription drugs, both for a mean of 2.9 ± 0.7 years. GERD symptoms improved (26%) or resolved completely (36%) in 62% of patients (p < 0.0001 vs. preoperative baseline) 1 year after parathyroidectomy. Prescription medications for GERD decreased from 81% of enrolled patients to 26% (p < 0.0001) 12 months postoperatively, with 39% having complete symptom relief and taking no medications (p < 0.0001). Daily use of prescription GERD medications decreased to occasional over-the-counter drug use in 35% after parathyroidectomy (p < 0.0001). Mean FSSG scores decreased significantly postoperatively (pre-op: 18.0 ± 8.0 vs. post-op: 10.0 ± 5.0; p < 0.0001), with significant improvements in all 12 FSSG categories, including motility (pre-op: 7.3 ± 3.0 vs. post-op: 4.4 ± 3.0; p < 0.0001) and acid reflux symptoms (pre-op: 10.8 ± 5.0 vs. post-op: 5.9 ± 4.0; p < 0.0001). Symptomatic improvements were durable 2 years after parathyroidectomy. Symptomatic GERD is common in pHPT. Parathyroidectomy provides significant, durable relief of both motility and acid reflux symptoms allowing discontinuation of prescription drug use for GERD in most (74%) patients providing yet another indication for parathyroidectomy in pHPT.

Effects of Lifestyle Modifications on the Quality of Life for a Patient With Gastroesophageal Reflux Disease (GERD)

Introduction: Does the implementation of lifestyle modifications improve patient symptomatology with gastroesophageal reflux? What if any of these interventions do patients actually perform and find helpful? Methods: Retrospective study using a 10 question, questionnaire on 50 hospitalized patients mostly Caucasian female (50% and 68%, respectively) with an average age of 50 years old at the Kennedy Health System Washington Township and Stratford campuses from July 2013 til December 2013 with the diagnosis of GERD to assess lifestyle modifications implemented by patients, the effectiveness of these interventions, and the overall change in patient quality of life while comparing that to the effectiveness in treating the underlying GERD. Institutional review board approval was obtained with protocol number Pro2013002776, from Rowan University School of Osteopathic Medicine and Kennedy Health Systems. Results: A large percentage of patients did not attempt or were unsuccessful in implementing lifestyle modifications to help treat their GERD symptoms. Only 18% of patient’s ate four or more smaller meals a day, 76% laid down for sleep after eating within three hours, 52% still ate three or more servings of spicy/acidic foods a day, and 68% felt there was no improvement in their GERD symptoms and/or had worsening of their quality of life with attempts at lifestyle modifications which outweighed any improvements in their GERD. Though patients did elevate the head of their beds, 68% reported no improvement in GERD symptoms and reported in fact worsening of their sleep habits due to this. A promising benefit from attempts at lifestyle modifications is that 22% of patients reported cutting back or stopping tobacco usage. The overall usage of tobacco products in our sample size was small and 44% lost between 5 to 10 pounds. Weight loss and eating smaller more frequent meals were felt to be the most difficult interventions by patients (26% reporting for each) and overall, patients felt the most beneficial method to control their GERD symptoms was the usage of reflux medications (32%). Conclusion: Our study shows that patients found the majority of lifestyle modifications implemented to be too difficult or unrewarding to try and improve their GERD symptoms. Patients found the easiest and most beneficial method to control their GERD was to take anti-reflux medications. These findings belie the fact that as physicians, we must do a better job in educating our patients about the importance and benefits of lifestyle modifications while attempting to reserve the usage of medications as a cure all.

Pediatrician approach to dysphonia

ObjectiveThe prevalence of voice disorders reaches up to 23.4% in the pediatric population and has a negative impact on quality of life. The objective of this study is to examine how pediatricians assess and manage patients with voice disorders and barriers they face when evaluating patients with dysphonia. Subjects and methodsThe study was designed as a cross-sectional survey. Pediatricians who are members of the North Carolina Pediatric Society or Duke University affiliated physicians were selected to participate in the study. They were emailed a description of the study with a link to a questionnaire regarding comfort level in recognizing an abnormal voice, how often they assess for dysphonia, barriers to evaluation of voice problems, reasons for referral, and common treatments employed. ResultsA total of 1125 physicians were sent a questionnaire and 72 replied for a response rate of 6.4%. Of those who responded, only 16.7% routinely assess patients for voice problems. The most common reasons for not assessing patients for dysphonia include patients not complaining of voice problems or parents not concerned, and being unsure of the best method or available treatment options. Referrals were most commonly made when speech could not be understood or when the voice problem coincided with other neurological symptoms. Allergy and reflux medications were often trialed prior to referral. The majority of responders felt that voice problems impacted quality of life and 84.7% were interested in more information regarding pediatric voice problems. ConclusionPediatricians encounter barriers in the assessment of voice problems in their patients. There is evidence from our study that they have interest in learning more about dysphonia. Otolaryngologists must continue to provide outreach to pediatricians to enhance the screening and management of patients with voice disorders.

Su1252 Gastric Juice Composition and Acid Suppression in Pediatric Gastroesophageal Reflux Disease

INTRODUCTION: Gastric acid suppression is justified to prevent severe gastro esophageal reflux (GER) disease related complications. However, it does not reduce the total amount and proximal extent of GER in the esophagus and non-acid components are able to induce (extra-esophageal) GER symptoms as well. No data on the composition of gastric juice (GJ) in children using gastric acid suppression exists. We therefore aimed to assess whether the composition of gastric juice in children using proton pump inhibitors (PPIs) differs, compared to that of their controls. METHODS: Infants and children (0-18 years) on proton pump inhibitors (PPIs) for at least six weeks and a control group not using anti reflux medication, were included. GJ was obtained through an existing nasogastric or a percutaneous endoscopic gastrostomy tube/ Mic-key gastrostomy. In the collected GJ (5 ml), pH, pepsin activity, bile salts and endotoxin (LPS) levels were determined. Pepsin was measured using a fluorometric assay using 4-Methyl-Coumaryl-7-Amide (MCA) substrate with/without pepstatin. Concentrations of deconjugated and taurine/glycine-conjugated bile salts were assessed by reversephase HPLC. Levels of LPS were determined using the spectrophotometric Limulus Amebocyte Lysate assay. RESULTS: GJ was analyzed from 16 children with (median: 3.8 yrs, range: 17.6 years) and 16 children (4.0 yrs, range: 16.0) without PPI therapy. Median duration of PPI treatment was 24 weeks (range: 514 weeks). Gastric pH was 5.0 (range: 5.0) and 1.0 (range: 4.5) in the PPI and control group respectively (p <0.001). Pepsin, unconjugated bile salts, and endotoxin were not significantly different in the two groups. Total taurine conjugated bile salts, and specifically taurocholate, was significantly higher in the PPI group (p=0.01 and p=0.005). pH and concentration of deconjugated bile and conjugated bile salts were significantly associated (p=0.006 and p=0.02). Endotoxin and bile salts were not significantly associated. CONCLUSION: Taurine conjugated bile acids are significantly higher in children chronically using PPIs compared to controls. Moreover acidity of gastric pH correlated negatively with deconjugated and conjugated bile salts. These findings imply that GJ under chronic proton pump inhibition contains nonacid components potentially harmful to esophageal mucosa and bronchial tissue.

Su1253 Abnormal Dynamics of Endogenous Acylated Ghrelin Mediates Decreases in Gastric Phase III-Like Contraction, Leading to Delayed Gastric Emptying in Urocortin1-Induced Stress Rats

INTRODUCTION: Gastric acid suppression is justified to prevent severe gastro esophageal reflux (GER) disease related complications. However, it does not reduce the total amount and proximal extent of GER in the esophagus and non-acid components are able to induce (extra-esophageal) GER symptoms as well. No data on the composition of gastric juice (GJ) in children using gastric acid suppression exists. We therefore aimed to assess whether the composition of gastric juice in children using proton pump inhibitors (PPIs) differs, compared to that of their controls. METHODS: Infants and children (0-18 years) on proton pump inhibitors (PPIs) for at least six weeks and a control group not using anti reflux medication, were included. GJ was obtained through an existing nasogastric or a percutaneous endoscopic gastrostomy tube/ Mic-key gastrostomy. In the collected GJ (5 ml), pH, pepsin activity, bile salts and endotoxin (LPS) levels were determined. Pepsin was measured using a fluorometric assay using 4-Methyl-Coumaryl-7-Amide (MCA) substrate with/without pepstatin. Concentrations of deconjugated and taurine/glycine-conjugated bile salts were assessed by reversephase HPLC. Levels of LPS were determined using the spectrophotometric Limulus Amebocyte Lysate assay. RESULTS: GJ was analyzed from 16 children with (median: 3.8 yrs, range: 17.6 years) and 16 children (4.0 yrs, range: 16.0) without PPI therapy. Median duration of PPI treatment was 24 weeks (range: 514 weeks). Gastric pH was 5.0 (range: 5.0) and 1.0 (range: 4.5) in the PPI and control group respectively (p <0.001). Pepsin, unconjugated bile salts, and endotoxin were not significantly different in the two groups. Total taurine conjugated bile salts, and specifically taurocholate, was significantly higher in the PPI group (p=0.01 and p=0.005). pH and concentration of deconjugated bile and conjugated bile salts were significantly associated (p=0.006 and p=0.02). Endotoxin and bile salts were not significantly associated. CONCLUSION: Taurine conjugated bile acids are significantly higher in children chronically using PPIs compared to controls. Moreover acidity of gastric pH correlated negatively with deconjugated and conjugated bile salts. These findings imply that GJ under chronic proton pump inhibition contains nonacid components potentially harmful to esophageal mucosa and bronchial tissue.

Hoarseness and Laryngopharyngeal Reflux

Current approaches to the diagnosis and subsequent management of specific voice disorders vary widely among primary care physicians (PCPs). In addition, sparse literature describes current primary care practice patterns concerning empirical treatment for vocal disorders. To examine how PCPs manage patients with dysphonia, especially with regard to laryngopharyngeal reflux. Prospective, questionnaire-based study by an academic laryngology practice among academic PCPs from all major US geographic regions. A 16-question web-based survey, distributed via e-mail, concerning management and possible empirical treatment options for patients with dysphonia. Of 2441 physicians who received the e-mail broadcast, 314 (12.9%) completed the survey. Among those who completed the survey, 46.3% were family practitioners, 46.5% were trained in internal medicine, and 7.2% identified as specialists. Among all respondents, 64.0% preferred to treat rather than immediately refer a patient with chronic hoarseness (symptoms persisting for >6 weeks) of unclear origin. Reflux medication (85.8%) and antihistamines (54.2%) were the most commonly selected choices for empirical treatment. Most physician respondents (79.2%) reported that they would treat chronic hoarseness with reflux medication in a patient without evidence of gastroesophageal reflux disease. Most PCPs who responded to our survey report empirically treating patients with chronic hoarseness of unknown origin. Many physician respondents were willing to empirically prescribe reflux medication as primary therapy, even when symptoms of gastroesophageal reflux disease were not present. These data suggest that PCPs strongly consider reflux a common cause of dysphonia and may empirically treat patients having dysphonia with reflux medication before referral.

Clinical and economic evaluation of laparoscopic surgery compared with medical management for gastro-oesophageal reflux disease: 5-year follow-up of multicentre randomised trial (the REFLUX trial)

Despite promising evidence that laparoscopic fundoplication provides better short-term relief of gastro-oesophageal reflux disease (GORD) than continued medical management, uncertainty remains about whether benefits are sustained and outweigh risks. To evaluate the long-term clinical effectiveness, cost-effectiveness and safety of laparoscopic surgery among people with GORD requiring long-term medication and suitable for both surgical and medical management. Five-year follow-up of a randomised trial (with parallel non-randomised preference groups) comparing a laparoscopic surgery-based policy with a continued medical management policy. Cost-effectiveness was assessed alongside the trial using a NHS perspective for costs and expressing health outcomes in terms of quality-adjusted life-years (QALYs). Follow-up was by annual postal questionnaire and selective hospital case notes review; initial recruitment in 21 UK hospitals. Questionnaire responders among the 810 original participants. At entry, all had documented evidence of GORD and symptoms for > 12 months. Questionnaire response rates (years 1-5) were from 89.5% to 68.9%. Three hundred and fifty-seven participants were recruited to the randomised comparison (178 randomised to surgical management and 179 randomised to continued medical management) and 453 to the preference groups (261 surgical management and 192 medical management). The surgeon chose the type of fundoplication. Primary: disease-specific outcome measure (the REFLUX questionnaire); secondary: Short Form questionnaire-36 items (SF-36), European Quality of Life-5 Dimensions (EQ-5D), NHS resource use, reflux medication, complications. The randomised groups were well balanced. By 5 years, 63% in the randomised surgical group and 13% in the randomised medical management group had received a total or partial wrap fundoplication (85% and 3% in the preference groups), with few perioperative complications and no associated deaths. At 1 year (and 5 years) after surgery, 36% (41%) in the randomised surgical group - 15% (26%) of those who had surgery - were taking proton pump inhibitor medication compared with 87% (82%) in the randomised medical group. At each year, differences in the REFLUX score significantly favoured the randomised surgical group (a third of a SD; p< 0.01 at 5 years). SF-36 and EQ-5D scores also favoured surgery, but differences attenuated over time and were generally not statistically significant at 5 years. The worse the symptoms at trial entry, the larger the benefit observed after surgery. Those randomised to medical management who subsequently had surgery had low baseline scores that markedly improved after surgery. Following fundoplication, 3% had surgical treatment for a complication and 4% had subsequent reflux-related operations - most often revision of the wrap. Dysphagia, flatulence and inability to vomit were similar in the two randomised groups. The economic analysis indicated that surgery was the more cost-effective option for this patient group. The incremental cost-effectiveness ratio for surgery in the base case was £7028 per additional QALY; these findings were robust to changes in approaches and assumptions. The probability of surgery being cost-effective at a threshold of £20,000 per additional QALY was > 0.80 for all analyses. After 5 years, laparoscopic fundoplication continues to provide better relief of GORD symptoms with associated improved health-related quality of life. Complications of surgery were uncommon. Despite being initially more costly, a surgical policy is highly likely to be cost-effective. Current Controlled Trials ISRCTN15517081. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 22. See the HTA programme website for further project information.

Sickness absence due to gastroesophageal reflux diagnoses: a nationwide Swedish population-based study

Objective. Gastroesophageal reflux disease (GERD) is a major public health problem in the Western world. No previous population-based nationwide study has, however, examined the occurrence of sickness absence due to GERD diagnoses, that is, the aim of this study. Material and methods. Nationwide population-based study based on Swedish registers including all 4,764,843 individuals registered as living in Sweden in 31 December 2004 and 31 December 2005, aged 20–64 years, not on disability or old age pension. Reimbursed sickness absence due to reflux diagnoses (ICD-10), that is, GERD (K21), esophagitis (K20), and heartburn (R12), was studied separately and combined. In analyses stratified by sociodemographic factors, inpatient/specialized outpatient care, antireflux surgery, and prescribed reflux medications those sickness absent in 2005 due to reflux diagnoses were compared to those sickness absent due to non-reflux diagnoses and to those with no sickness benefits 2005. Results. In total, 627 individuals had at least one prevalent sick-leave spell due to reflux diagnoses in 2005, of which GERD was the most common diagnosis. Of these, almost half (45%) was absent for ≥ 28 reimbursed sick-leave days due to reflux diagnoses. The proportions of low socioeconomic status (SES), inpatient and outpatient care due to tumors, mental disorders, circulatory disorders, GERD, antireflux surgery, and reflux medications were higher among those sickness absent due to reflux diagnoses compared to those with no sickness benefits. Conclusions.In this nationwide population-based study a high proportion of those sickness absent due to reflux diagnoses was on long-term sick leave, a finding that warrants attention.

Pneumomediastinum and subcutaneous emphysema from bronchial foreign body aspiration

Pneumomediastinum and subcutaneous emphysema are rare presentations of an airway foreign body. Only a handful of other cases have been reported in the English literature. We present a case of a 2 year old female who presented with wheezing and a dry cough. Following a breathing treatment with a non-rebreather mask, she developed right sided facial subcutaneous emphysema. The following day, after an episode of crying, the subcutaneous emphysema rapidly progressed to involve the anterior chest wall, shoulders, neck and face. Rigid bronchoscopy was emergently performed and a ball-valving, soft foreign body was removed from the right bronchus. A chest tube was placed, and the patient was successfully extubated the following day. When faced with a pediatric patient presenting with subcutaneous emphysema or pneumomediastinum of unknown origin, the pediatrician and otolaryngologist should consider the possibility of an airway foreign body. Management involves emergent airway evaluation in the operating room, removal of the foreign body, placement of a chest tube if pneumomediastinum is present, and supportive care with reflux medications and intravenous steroids.

Lansoprazole for Children With Poorly Controlled Asthma: A Randomized Controlled Trial

To study the efficacy of proton pump inhibitor (PPI) therapy over 24 weeks in reducing symptoms in asthmatic children without symptomatic gastroesophageal reflux (GER) who had poor asthma control.Subjects were between 6 and 17 years old with physician-diagnosed asthma and “labile airways function” defined as (1) 12% or greater increase in postbronchodilator forced expiratory volume in 1 second (FEV1), (2) methacholine PC20 less than 16 mg/mL, or (3) positive exercise challenge with a 20% or greater decrease in FEV1.This is a multicenter, randomized, double-masked, placebo-controlled parallel clinical trial in children with asthma. All subjects were on stable doses of inhaled corticosteroids and had poor asthma control defined by study specific criteria. Subjects were excluded if they self-reported any symptoms of GER requiring treatment with a PPI or other reflux medication. The primary outcome was change in asthma control questionnaire score at the 24-week visit. Secondary outcomes included rate of acute episodes of poor asthma control, change in Asthma Symptom Utility Index, change in Asthma Control Test, change in asthma-specific quality of life for children score, methacholine PC20, spirometry, FeNO, gastrointestinal symptoms, and nocturnal awakenings. Esophageal pH studies were performed before randomization in a subset. Participating children were randomly assigned to receive lansoprazole dosed by weight.One hundred forty-nine children were randomized to lansoprazole therapy and 157 were randomized to placebo. Mean age at randomization was 11 years in both groups. More than 88% of participants completed the study. Of 115, 49 (43%) 24-hour pH probe studies demonstrated abnormal esophageal acid exposure. Gastrointestinal symptom scores were not different between patients with normal versus abnormal pH studies. No differences were seen in initial prebronchodilator FEV1 or forced vital capacity in those with normal or abnormal pH studies. At week 24 of therapy, mean Asthma Control Questionnaire score had decreased by <0.5 (the predetermined clinically important difference) in both groups and was not statistically different between the 2 groups (P = .12). There were no statistically significant treatment effects for any of the secondary outcome measurements. In a subanalysis of the children with abnormal pH probe studies (n = 49), there was no significant effect of lansoprazole treatment for 24 weeks on any of the study outcomes. Adverse event monitoring showed treatment with lansoprazole was associated with statistically greater prevalence of upper respiratory tract infection, sore throat, and bronchitis. Activity-related bone fractures were seen in 6 of 149 lansoprazole-treated subjects and 1 of 157 placebo-treated children (P = .06).In children 6 to 17 years old with mild or moderate persistent asthma on inhaled corticosteroids, without GER symptoms, abnormal pH probe diagnostic of GER disease is present in 43%. Yet 24-week treatment with lansoprazole had no significant effect on measures of asthma control, quality of life, lung function, or bronchial responsiveness compared with placebo in the total group and in the subgroup of patients with abnormal pH probe studies. Increased adverse events, upper respiratory tract infection , sore throat, and bronchitis were seen in the lansoprazole-treated subjects. Activity-related bone fractures were slightly increased in the lansoprazole-treated subjects.The same investigators have shown similar results in adults. This study contributes to the questioning of the true association between asthma and GER disease in children and adults and potential overuse of PPI therapy in patients without symptomatic GER. These data were obtained in asthmatic children without symptomatic GER and may not be comparable in children with active GER symptoms. Impedance monitoring was not done and the results cannot be extrapolated to the possible effect of non–acid reflux on asthma control. Increased fracture risk has been reported in adults on long-term PPI therapy. This is the first large study to suggest possible association in children, although specific cause-and-effect was not investigated.

Movimiento paradójico de cuerda: Un estudio de caso

Paradoxical Vocal Fold. Motion (PVFM) is a disorder characterized by inappropriate and involuntary paradoxical vocal folds adduction and ventricular bands during inspiration. In severe cases PVFM is manifested as airway obstruction. This disorder is associated with multiple etiologies such as gastroesophageal reflux, peripheral or central neurological disorders, psychogenic disorders and asthma. In this paper, we report a case of a child who presents cough. He had been treated initially for asthma without positive results. Flexible laryngoscopy revealed severe PVFM. This case was treated with reflux medication, breathing training and Oropharyngeal relaxation. It was emphasized a multidisciplinary approach whit the laryngologist, voice pathologist and counseling. Review of the literature is discussed.

1036 A Unique Gene Expression Profile May Predict Responsiveness to Dietary Elimination With Six Food Elimination Diet in Adults With Eosinophilic Esophagitis

ling for time-specific treatment components (dietary restrictions, reflux medication, swallowed steroids), child's age, and number of baseline symptoms. Results: Sixty-six children (age 2-18 years old; mean age, 7.9 yrs +/4.6 y; 79% male; 89% white) completed 3 assessments. Some patients (n=12) received a new diagnosis of EoE; others had been diagnosed previously (n=54). At baseline, patients reported a mean of 3.3 of 8 EoE symptoms (SD, 2.2; range, 0-8); the mean of summed severity scores was 5.5 (SD, 4.4; range, 0-17). Total number of symptoms was inversely correlated with parent and child reported PedsQLTM Total scores, r = -0.32 (n = 66) and r = -0.40 (n = 41) (P's < .01). Symptom scores decreased significantly from baseline to 6 months (P = .03), with a mean decrease of 1.3. PR-PedsQLTM Total scores increased across time points (P's < .004); from baseline to 6 months followup, PR-PedsQLTM Total scores increased a mean of 5.4 points. PR-PedsQLTM Physical and Psychosocial subscale scores also improved an average of 3.6 and 5.4 points, respectively (P = .04 and P = .001). For children's self-reported QoL, only the Psychosocial subscale scores increased a mean of 5.4 points over time (P = .05). Conclusion: Children with EoE who entered multidisciplinary tertiary care programs had decreased symptoms and increased QoL over a 6-month period. Support: This research was conducted with support from the Investigator-Sponsored Study Program of AstraZeneca, LP and from the NIH/NCRR Colorado CTSI Grant Number UL1 RR025780.

Gastroesophageal Reflux Therapy Is Associated with Longer Survival in Patients with Idiopathic Pulmonary Fibrosis

Gastroesophageal reflux (GER) is highly prevalent in patients with idiopathic pulmonary fibrosis (IPF). Chronic microaspiration secondary to GER may play a role in the pathogenesis and natural history of IPF. To investigate the relationship between GER-related variables and survival time in patients with IPF. Regression analysis was used to investigate the relationship between GER-related variables and survival time in a retrospectively identified cohort of patients with well-characterized IPF from two academic medical centers. Two hundred four patients were identified for inclusion. GER-related variables were common in this cohort: reported symptoms of GER (34%), a history of GER disease (45%), reported use of GER medications (47%), and Nissen fundoplication (5%). These GER-related variables were significantly associated with longer survival time on unadjusted analysis. After adjustment, the use of GER medications was an independent predictor of longer survival time. In addition, the use of gastroesophageal reflux medications was associated with a lower radiologic fibrosis score. These findings were present regardless of center. The reported use of GER medications is associated with decreased radiologic fibrosis and is an independent predictor of longer survival time in patients with IPF. These findings further support the hypothesis that GER and chronic microaspiration may play important roles in the pathobiology of IPF.

Russell body gastritis

Russell body gastritis, first described in 1998 [1], is a reactive gastric mucosal infiltration of plasma cells filled with cytoplasmic Russell bodies. Russell bodies are immunoglobulins present within dilated rough endoplasmic reticulum cisternae that have accumulated secondary to abnormal secretion [2]. We present a case of Russell body gastritis occurring in a 75-year-old man with a history of alcohol use, renal failure, dyslipidemia, and prior rhabdomyolysis. He was noncompliant with reflux medications and reported intermittent coffee-ground emesis. Esophagogastroduodenoscopy with biopsy revealed esophagitis and nodular chronic active gastritis. The gastric antral mucosa exhibited regenerative changes and a dense chronic inflammatory infiltrate (Image 1) composed of numerous Russell body filled plasma cells, including Mott cells (Image 2). No lymphoepithelial lesions were identified. A CD138 immunostain (Image 3) confirmed that these were plasma cells and in situ hybridization studies for kappa and lambda light chains demonstrated their polyclonal distribution. Gastric biopsies were negative for Helicobacter pylori by immunohistochemistry. Regenerative gastric mucosa showing numerous plasma cells filled with bright eosinophilic Russell bodies (H&E stain; original magnification ×200). Plasma cells shown at higher magnification are filled with cytoplasmic Russell bodies (H&E stain; original magnification ×600). Plasma cells show strong CD138 immunoreactivity (immunohistochemical stain; original magnification ×600). To date, there have been 11 other published case reports of Russell body gastritis [1-10]. The average patient age is 57 years (range, 29–80 years), including seven males and five female patients. These patients presented primarily with gastric related symptoms including nausea, dyspepsia, and epigastric pain. Mucosal swelling and erythema appear to be relatively common endoscopic findings, and only a few cases exhibited erosion, ulceration, or a raised lesion endoscopically. The exact etiology of Russell body gastritis is unclear. However, nine (82%) of these reported cases were H.pylori positive, two individuals were positive for human immunodeficiency virus (HIV), and one also had Candida esophagitis. Another two patients had Epstein Barr virus (EBV)-associated gastric carcinoma. Except for one individual with a concomitant monoclonal gammopathy of undetermined significance (MGUS), none of these patients have manifested a plasma cell disorder. Russell body gastritis is a diagnosis based on microscopic findings. The differential diagnosis on biopsy includes signet ring cell carcinoma, plasmacytoma, B-cell lymphoma with plasmacytic differentiation, and granular cell tumor. As highlighted in this, ancillary studies can be useful to demonstrate that these cells are polytypic plasma cells. Associated gastric carcinoma and infection (H.pylori, HIV, EBV, Candida) should also be excluded.