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Biomedical subjects

Michael F Vaezi

Publications and source records attributed to Michael F Vaezi.

At least 37 records · Page 2Linked to original sources
PubMed2005

Does acid suppressive therapy reduce the risk of laryngeal cancer recurrence?

OBJECTIVE/HYPOTHESIS: Gastroesophageal reflux disease (GERD) is implicated in laryngeal cancer pathogenesis and recurrence posttherapy. There are currently limited data on the effect of acid suppressive therapy in decreasing the recurrence of laryngeal cancer. Therefore, we conducted this study to identify potential effect of GERD and acid suppressive therapy on recurrences after larynx-preserving therapies. STUDY DESIGN: Case control study. METHODS: Cases and controls, derived from a single tertiary care center, were patients who had newly diagnosed localized laryngeal cancer (T3 or less and absence of nodes) and having undergone larynx-preserving surgery or radiotherapy/chemotherapy were followed between January 1, 2000 and December 31, 2003. Univariable associations were performed for demographics, smoking and alcohol patterns, stage of tumor, initial treatment, surgeon of record, presence of GERD, and the use of acid suppressive medications. Multivariable associations were performed for clinically significant variables. RESULTS: Of 258 patients with laryngeal cancer, 61 satisfied the selection criteria. Twenty-two of 61 (36%) developed recurrence and constituted cases, whereas 39/61 (64%) did not have recurrence and constituted controls. On univariable analysis, significant factors for decreased recurrences were GERD, hazard ratio 0.24 (95% confidence interval [CI] 0.08-0.71), and acid suppressive therapy, hazards 0.22 (95% CI 0.07-0.66). On multivariable analysis, laryngeal cancer recurrence was significantly less in those on acid suppressive therapy, hazard 0.31 (95% CI 0.13-0.75). CONCLUSIONS: Acid suppression postlaryngeal cancer therapies may have protective effect on laryngeal cancer recurrences. A prospective study is needed to better define this perceived beneficial effect.

Aged↗
PubMed2005

Prevalence of laryngeal irritation signs associated with reflux in asymptomatic volunteers: impact of endoscopic technique (rigid vs. flexible laryngoscope).

OBJECTIVES: The objectives of this study were to 1) determine the prevalence of ENT findings in the normal asymptomatic population and 2) to compare findings between flexible and rigid laryngoscopes in an attempt to increase specificity of diagnosis of reflux in endoscopic laryngeal examinations. STUDY DESIGN: Prospective study. METHODS: Fifty-two nonsmoker volunteers (24 male, 28 female), mean age of 42.7 years, with no history of ENT abnormalities or gastroesophageal reflux disease, underwent both rigid and flexible videolaryngologic examinations with a digital endoscopic unit. A group of three expert judges reviewed the oral and transnasal examinations blindly and independently for physical signs of irritation/inflammation commonly associated with reflux. RESULTS: Atleast one sign of tissue irritation was detected in 93% and 83% of the population when using a flexible and a rigid laryngoscope, respectively. Results showed a high incidence of posterior commissure bar (53.2% and 51.9%), arytenoid complex edema/erythema (76.3% and 53.2%), and pseudosulcus (37.2% and 7.7%). Most signs were more frequently detected on flexible transasal examinations than with rigid transoral examinations: posterior pharyngeal wall (<0.01), interarytenoid irritation (<0.01), arytenoids complex irritation (<0.01), ventricular obliteration (<0.01), and pseudosulcus (<0.01). CONCLUSIONS: Several signs of posterior laryngeal irritation (e.g., interarytenoid bar, erythema of the medial wall of the arytenoids), which are generally considered to be signs of laryngopharyngeal reflux, are present in a high percentage of nonsymptomatic individuals, raising question about their diagnostic specificity. In addition, these signs were more often detected with flexible than with rigid laryngoscopes, suggesting that flexible laryngoscopy is more sensitive but less specific in identifying laryngeal tissue irritation.

Adult↗
PubMed2005

The role of esophageal pH monitoring in symptomatic patients on PPI therapy.

BACKGROUND: Ambulatory pH monitoring while on therapy is often recommended in gastroesophageal reflux disease (GERD) patients with continued symptoms. However, to date, little data exist to justify this indication. AIM: To assess the role of pH monitoring in symptomatic patients despite aggressive therapy with typical or extra esophageal GERD. METHODS: Retrospective review of 2,291 ambulatory pH tracings (1999-2003) identified subgroup of studies performed on proton pump inhibitor (PPI) therapy. Patients with prior fundoplication or Barrett's esophagus were excluded. Patients grouped on predominant presenting GERD symptoms: typical (heartburn and regurgitation) or extra esophageal (chest pain, cough, hoarseness, sore throat, shortness of breath, asthma). The distribution of abnormal pH parameters in each group calculated and univariate analyses assessed the probability of abnormal pH in each group. Abnormal cutoff values traditionally used in clinical practice and more stringent cutoff values used to determine distribution of abnormality as a function of cutoff values. RESULTS: A total of 250 patients (mean age 54.3 yrs, 59% female) underwent pH monitoring on either daily (b.i.d.) or twice daily (q.d.) on PPI therapy: 115 (46%) with extra esophageal and 135 (54%) with typical GERD symptoms. Extra esophageal GERD patients were more likely to undergo pH monitoring on b.i.d. PPIs (OR = 2.7; 95% CI = 1.6-4.4; p < 0.01). 52 (93%) of typical and 74 (99%) of extra esophageal GERD patients on b.i.d. PPIs tested normal. The odds of a normal pH values were 11 times higher for patients on b.i.d. PPIs (OR = 11.4; 95% CI = 4.3-30.1, p < 0.01) than those on q.d. PPIs. CONCLUSIONS: 1) The likelihood of an abnormal esophageal pH for symptomatic GERD patients on b.i.d. PPI is very small. 2) In this group of patients failing b.i.d. PPIs causes other than GERD should be sought.

Adult↗
PubMed2005

Etiology and pathogenesis of achalasia: the current understanding.

Idiopathic achalasia is an inflammatory disease of unknown etiology characterized by esophageal aperistalsis and failure of LES relaxation due to loss of inhibitory nitrinergic neurons in the esophageal myenteric plexus. Proposed causes of achalasia include gastroesophageal junction obstruction, neuronal degeneration, viral infection, genetic inheritance, and autoimmune disease. Current evidence suggests that the initial insult to the esophagus, perhaps a viral infection or some other environmental factor, results in myenteric plexus inflammation. The inflammation then leads to an autoimmune response in a susceptible population who may be genetically predisposed. Subsequently, chronic inflammation leads to destruction of the inhibitory myenteric ganglion cells resulting in the clinical syndrome of idiopathic achalasia. Further studies are needed to better understand the etiology and pathogenesis of achalasia-such an understanding will be important in developing safe, effective, and possibly curative therapy for achalasia.

Esophageal Achalasia↗
PubMed2004

Predictors of outcome of pneumatic dilation in achalasia.

BACKGROUND & AIMS: Graded pneumatic dilation (PD) is a widely accepted treatment for achalasia. We investigated the potential predictors of outcome in a large group of patients with achalasia and tested the hypothesis that graded PD may not be appropriate for all patients. METHODS: Patients undergoing PD from 1992 to 2002 were evaluated retrospectively. Symptom scores (0-15) for dysphagia (0-5), regurgitation (0-5), and chest pain (0-5), as well as degree of esophageal emptying by timed barium swallow, were assessed for all patients. Failure was defined as the return of symptoms resulting in repeated PD or surgical myotomy. Clinical data assessed for short- and long-term predictors of response. RESULTS: Seventy-five patients with achalasia without previous therapy constituted the studied population. Three-year success rates for PD using 3.0-cm, 3.0-cm followed by 3.5-cm, and 3.0-cm and 3.5-cm followed by 4.0-cm Rigiflex balloons were 37% (95% confidence interval [CI], 26-53), 76% (95% CI, 65-88), and 88% (95% CI, 80-97), respectively. Patient age and sex were important treatment outcome predictors. A Cox proportional hazards model of time to additional therapy on sex and 10-year increase in age showed that 3.0-cm PD was significantly (P = 0.04) more likely to fail in younger men than older men (hazard ratio, 0.63; 95% CI, 0.41-0.98). In 25 of 68 patients (37%) initially treated with a 3.0-cm balloon, PD failed within 3 months. Twenty-two of 25 patients (88%) with early failure were men. CONCLUSIONS: (1) Young men have a greater failure rate with 3.0-cm PD than older men or women in general, and (2) graded PD in this group starting initially with the 3.0-cm balloon is more likely to fail.

Adult↗
PubMed2004

"Refractory GERD": acid, nonacid, or not GERD?

Gastroesophageal reflux disease (GERD) is a common condition with 44% of Americans surveyed reporting heartburn at least once a month and 20% once a week (1, 2). However, despite major advances in our understanding of this disease, management of GERD is still a challenge. Proton pump inhibitors (PPIs) are more effective than H2-receptor antagonists (H2RA) in the initial healing of erosive esophagitis, which provide symptom relief and maintenance (3). Due to its established efficacy and safety, PPI treatment is used as the initial "test" in diagnosing GERD in the absence of bleeding, anemia, weight loss, or dysphagia. A single dose of PPI provides adequate symptom relief in most patients; however, dose escalation to twice a day may be needed in some. Patients unresponsive to PPI therapy are often labeled as having "refractory GERD." However, this term is poorly defined and has a different meaning in different countries. More importantly, the cause of "refractory GERD" is poorly understood.

Diagnosis, Differential↗
PubMed2004

The role of gastric and duodenal agents in laryngeal injury: an experimental canine model.

BACKGROUND AND AIMS: The specific agents responsible for producing laryngeal signs and symptoms are currently unknown. We systematically evaluated the damaging role of gastric (acid and pepsin) and duodenal (bile acids and trypsin) ingredients individually and in combination on different laryngeal structures in an experimental canine model. METHODS: A total of 42 beagles were studied (wt 9-15 kg each). After pentathol anesthesia all dogs underwent laryngoscopy. Injury (punch biopsy) was caused to the right vocal cord, medial arytenoid wall, and posterior cricoid wall on day 1. Pepsin (0.5 mg/ml), conjugated bile acid (CBA) (ursodeoxycholic acid, 300 micromolar), unconjugated bile acids (UBA) (cholic, 300 micromolar), trypsin (0.5 mg/ml) at pH 1-2, 4-5, and 6-7 were applied bilaterally to laryngeal sites three times per week for a total of 9-12 applications. Changes in laryngeal sites were scored visually. All dogs were sacrificed 1 day post last application. Laryngeal tissue was harvested and sent for blinded pathological examination. Histologic and visual scores were compared to each other and to control- and sham-treated dogs. RESULTS: Pepsin alone (8.5 +/- 1.66) or combined with CBA (16.63 +/- 1.66) at pH 1-2 resulted in significant (p < 0.001) severe histological inflammation much greater than with other agents. Duodenal ingredients caused no or minimal degree of histological damage at all pH values. Visual scores above subtle erythema were significantly (p < 0.001) higher in the animals exposed to pepsin followed by CBA alone or in combination with pepsin at pH 1-2. There was a significant (p < 0.01) correlation between histology and visual scores (rho = 0.47; 95% CI = 0.30-0.60) for all sites combined. Of the three laryngeal sites, vocal cords were the most sensitive to injury by applied solutions. CONCLUSIONS: (i) In acidic refluxate, pepsin and CBAs are the most injurious agents affecting laryngeal tissue. (ii) Duodenal agents do not play a significant role in causing laryngeal injury. (iii) Aggressive acid suppression should eliminate the injurious potential of any gastroduodenal refluxate.

Animals↗
PubMed2004

Laryngitis and gastroesophageal reflux disease: increasing prevalence or poor diagnostic tests?

Laryngeal signs and symptoms are often associated with gastroesophageal reflux disease (GERD). However, such diagnoses presume that laryngeal findings may be specific for GERD. However, neither laryngoscopy, EGD or pH monitoring are specific tests for identifying GERD related laryngitis. Non-placebo controlled trials often show clinical benefit from proton pump inhibitor therapy; however, suffer from lack of controls. GERD may be one cause of laryngeal signs and symptoms in a subgroup of patients but not in all those currently so suspected. Future, studies are needed in this area to better delineate this association.

Comorbidity↗
PubMed2003

Sensitivity and specificity of reflux-attributed laryngeal lesions: experimental and clinical evidence.

In patients with signs and symptoms of laryngeal disorders, laryngoscopic examination and ambulatory pH monitoring often implicate gastroesophageal reflux disease (GERD). Experimental evidence highlights the importance of acidic reflux in laryngeal disorders. However, many patients with laryngeal signs that appear to be reflux related do not respond to aggressive acid suppression. This has resulted in controversy about the exact nature of the relation between GERD and ear, nose, and throat (ENT) signs and symptoms. Use of a combination of laryngoscopic examination and 24-hour ambulatory pH testing may improve the ability to identify those patients who would most benefit from acid suppression. Currently, however, these tests lack specificity, and the relationship remains unproved. This important task will require data from large-scale, randomized, controlled studies. Until we have determined these specific laryngeal signs from both a gastroenterology and an ENT perspective, we will be forced to use empiric therapy to identify those patients whose laryngeal signs and symptoms are due to GERD. Based on present data, we recommend aggressive acid suppression with twice-daily dosing of proton pump inhibitors for >or=4 months in these patients.

Animals↗
PubMed2003

Extraesophageal manifestations of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) may manifest as laryngitis, asthma, cough, or noncardiac chest pain. Diagnosing these extraesophageal manifestations may be difficult for primary care physicians because most patients do not have heartburn or regurgitation. Diagnostic tests have low specificity, and a cause-and-effect association between GERD and extraesophageal symptoms is difficult to establish. Response to aggressive acid suppression is often the best indication of GERD etiology in a patient with extraesophageal symptoms.

Asthma↗
PubMed2003

Laryngeal signs and symptoms and gastroesophageal reflux disease (GERD): a critical assessment of cause and effect association.

Gastroesophageal reflux disease (GERD) has been associated increasingly with ear, nose, and throat (ENT) signs and symptoms. However, the cause and effect relationship between these two clinical entities are far from established. Many patients diagnosed initially with GERD as the cause of laryngeal signs do not symptomatically or laryngoscopically respond to aggressive acid suppression and do not have abnormal esophageal acid exposure by pH monitoring. This has resulted in frustration on the part of both gastroenterologists and ENT physicians and confusion on the part of patients. In this article we discuss the reasons for this controversy and highlight the recent data attempting to clarify this complex area.

Gastroesophageal Reflux↗
PubMed2003

Gastroesophageal reflux disease and the larynx.

Gastroesophageal reflux disease (GERD) is associated with ear, nose, and throat (ENT) signs and symptoms. Previously, experiments in animal larynx suggested that acid in combination with pepsin resulted in more laryngeal injury than acid alone. Recently, similar experiments expanded on the above observation, finding no laryngeal inflammation with bile acid, trypsin, or combination of bile constituents in alkaline pH values. Combined, experimental evidence highlights the importance of acidic refluxates that contain pepsin and/or bile acids; however, many patients with laryngeal signs suggestive of GERD do not respond to aggressive acid suppression. This has resulted in controversy about the exact nature of relationship between GERD and ENT signs and symptoms. Because the diagnosis is initially suspected after a laryngoscopic examination by the ENT physicians, the suboptimal clinical response may be caused by the poor specificity of this exam in identifying GERD as the cause of patients' laryngeal symptoms. Hence, a multidisciplinary approach is often required in the optimum treatment of these patients.

Gastroesophageal Reflux↗
PubMed2003

Nocturnal acid breakthrough: clinical significance and correlation with esophageal acid exposure.

OBJECTIVES: Previous studies suggest that the addition of H2 receptor antagonist (H2RA) therapy is more effective than proton pump inhibitor (PPI) therapy alone in reducing nocturnal acid breakthrough (NAB). However, the clinical significance of NAB with respect to esophageal acid control has not been investigated. The aim of this study was to evaluate prospectively the degree of upright and supine esophageal and gastric acid suppression using various PPI regimens in comparison to the addition of an H2RA at bedtime. METHODS: A total of 22 subjects (13 with gastroesophageal reflux disease and nine who served as control subjects) were prospectively evaluated by serial combined esophageal and gastric 24-h pH monitoring. Studies were performed at baseline off antireflux medical therapy and subsequent to completion of the following four drug regimens: 1) omeprazole 20 mg b.i.d. for 2 wk; 2) omeprazole 20 mg b.i.d. plus ranitidine 300 mg HS for 4 wk; 3) omeprazole 20 mg QAM and QHS for 2 wk; and 4) omeprazole 20 mg every 8 h for 2 wk. A dual pH probe was placed 5 cm above and 10 cm below the manometrically defined LES for a minimum of 18 h. Median total, upright, and supine pH values were compared among treatment regimens. All subjects underwent Helicobacter pylori serology testing. RESULTS: A total of 17 men and eight women (mean age 37 yr +/- 2.4 yr, range 22-71 yr) were enrolled in the study. Total, upright, and supine median percentage of the time that gastric pH was <4 were significantly less than baseline values in all treatment regimens. Although patients treated with Q8 h omeprazole had significantly (p < 0.01) more gastric acid suppression, there was a high degree of overlap among regimens. Treatment regimens resulted in NAB elimination of 9-41%. However, no single treatment regimen resulted in more significant NAB suppression than the others. Despite continued NAB with all treatment regimens, esophageal acid reflux (90%) and patient symptoms (100%) were well controlled. In addition, there were no differences in the esophageal median percentage of time that pH was <4 for any treatment regimen. CONCLUSIONS: NAB is an isolated gastric phenomenon that is poorly controlled even with most aggressive acid suppressive therapy. Esophageal acid suppression and symptom control are not dependent on the degree of NAB elimination.

Adult↗
PubMed2003

Cost-assessment of alternative management strategies for achalasia.

Achalasia is a primary oesophageal motor disorder characterised by the abnormal relaxation of the lower oesophageal sphincter (LES) and absent oesophageal peristalsis. It is a rare disease, with an estimated incidence of approximately 1/100,000 and a prevalence close to 10/100,000 [1]. Its exact aetiology remains unknown. Autoimmune, infectious, degenerative and hereditary processes have all been proposed as factors that lead to a chronic inflammatory response in the myenteric plexus, thus resulting in selective loss of inhibitory neurons [2] and failure of the LES to relax and aperistalsis in the body of the oesophagus. The most common symptoms of achalasia are dysphagia for solids and liquids, regurgitation, chest pain, weight loss and heartburn in > 90 approximately 75, 40 - 50, approximately 60, approximately 40%, respectively [3,4]. The diagnosis is based on symptoms, barium swallow and manometry. A barium oesophagram typically shows a dilated oesophagus that tapers into a 'bird-beak' at the gastro-oesophageal junction with lack of normal peristalsis on fluoroscopic evaluation. The characteristic manometric features of achalasia are abnormal LES relaxation and aperistalsis; additionally, the LES pressure is frequently high, but can also be normal. Current practice of medicine is faced with rising healthcare costs and limited budgets [5]. We are therefore confronted with an increasing demand to justify the value of our therapeutic interventions, not only from the risk/benefit standpoint but also from the cost perspective [6,7].

Botulinum Toxins↗
PubMed2002

The prevalence of hypopharynx findings associated with gastroesophageal reflux in normal volunteers.

Routine laryngeal examination of patients with otolaryngologic complaints often reveals findings thought to result from gastroesophageal reflux. The direct association between these mucosal findings and uncontrolled reflux is not well established. To begin exploring the specificity of tissue signs, 105 normal, healthy, adult volunteers were examined by routine video fiber-optic endoscopy for the presence of findings attributed to reflux disease. Medical conditions, lifestyle factors, and ENT complaints were surveyed to reveal potential airway irritants, while the study design attempted to eliminate silent reflux. The majority of subjects (86%) had findings associated with reflux and certain signs reached a prevalence of 70%. Prevalence was not affected by ENT complaint, smoking, alcohol, or asthma. Intraexaminer and interexaminer agreement information is provided. The traditional attribution of hypopharynx irritation signs to reflux is challenged; the need for improved diagnostic specificity is highlighted.

Adolescent↗
PubMed2002

The cost-effectiveness of treatment strategies for achalasia.

Achalasia is a disorder characterized by abnormal motility of the esophageal body and the lower esophageal sphincter, resulting in dysphagia, regurgitation, and chest pain. Treatment options for achalasia include Botulinum toxin injection, pneumatic balloon dilation, and surgical esophagomyotomy. The aim of this study was to determine the cost-effectiveness of these three strategies in the treatment of achalasia in adults. We constructed a Markov cost-effectiveness model comparing Botox injection, pneumatic balloon dilation, and laparoscopic esophagomyotomy as initial treatments of achalasia. Costs and probabilities were derived from the published literature. The utility for symptomatic achalasia was derived from a sample of patients with achalasia. Sensitivity analyses were performed. Over a five-year time horizon, pneumatic dilation was the most cost-effective treatment strategy for achalasia, with an incremental cost-effectiveness ratio of $1348 per quality-adjusted life-year compared to Botox. Although laparoscopic esophagomyotomy was more effective than the other treatment options, it was not cost-effective because of its high initial cost. In conclusion, pneumatic dilation is the most cost-effective treatment option for adults with achalasia. Further studies should examine the long-term relapse rates following treatment with Botox and more precisely determine the quality of life of symptomatic achalasia.

Algorithms↗
PubMed2002

Long-term effect of H2RA therapy on nocturnal gastric acid breakthrough.

BACKGROUND & AIMS: Adding histamine 2 receptor antagonists (H2RAs) to proton pump inhibitor (PPI) therapy is a common practice to block nocturnal acid breakthrough (NAB). Controversy exists over its efficacy because of H2RA intolerance. No prospective study has addressed this issue. METHODS: Twenty-three healthy volunteers and 20 gastroesophageal reflux disease (GERD) patients were studied. Ambulatory pH monitoring was performed with one electrode in the gastric fundus and the other 5 cm above the lower esophageal sphincter. Baseline pH testing was performed and repeated after 2 weeks on PPI twice daily before meals (omeprazole 20 mg). All subjects then received 28 days of PPI plus H2RA Qhs (ranitidine 300 mg) with repeat pH testing on days 1, 7, and 28. RESULTS: Eighteen controls and 16 GERD patients completed all 5 studies. Compared with baseline, all 4 medication regimens decreased supine % time pH < 4 (P = 0.001). The administration of PPI + 1 day of H2RA was the only therapy that significantly decreased % time gastric pH < 4 for the supine period compared with PPI twice daily alone (P < 0.001). There was no difference in % time supine gastric pH < 4 between 2 weeks of PPI twice daily alone and either 1 week or 1 month of PPI + bedtime H2RA. CONCLUSIONS: The combination of H2RA and PPI therapy reduced NAB only with the introduction of therapy. Because of H2RA tolerance, there is no difference in acid suppression between PPI twice daily and PPI twice daily + H2RA after 1 week of combination therapy.

Adult↗