Cynthia Johnson

The clinical and economic value of a short course of omeprazole in patients with noncardiac chest pain

BACKGROUND & AIMS Evaluation of new patients with noncardiac chest pain (NCCP) may require a variety of costly tests. The aim of this study was to evaluate the efficacy of the omeprazole test (OT) in diagnosing gastroesophageal reflux (GERD) in patients with NCCP and estimate the potential cost savings of this strategy compared with conventional diagnostic evaluations. METHODS Thirty-nine patients referred by cardiologists were enrolled. Baseline symptoms were recorded, and the patients were randomized to either placebo or omeprazole (40 mg AM and 20 mg PM) groups for 7 days. Patients were crossed over to the other arm after a washout period and repeat baseline symptom assessment. All patients underwent 24-hour esophageal pH monitoring and upper endoscopy before randomization. RESULTS Thirty-seven patients (94.9%) completed the study. Twenty-three (62.2%) were classified as GERD positive and 14 as GERD negative. Eighteen (78%) GERD-positive patients and 2 (14%) GERD-negative patients had a positive OT (P < 0.01), yielding a sensitivity of 78.3% (95% confidence interval, 61.4-95.1) and specificity of 85.7% (95% confidence interval, 67.4-100). Economic analysis showed that the OT saves

Effect of ambulatory 24-hour esophageal pH monitoring on reflux-provoking activities.

573 per average patient evaluated and results in a 59% reduction in the number of diagnostic procedures. CONCLUSIONS The OT is sensitive and specific for diagnosing GERD in patients with NCCP. This strategy results in significant cost savings and decreased use of diagnostic tests.

Correlation of ambulatory 24-hour esophageal pH monitoring results with symptom improvement in patients with noncardiac chest pain due to gastroesophageal reflux disease

Ambulatory 24-hr esophageal pH monitoring isconsidered the gold standard for diagnosinggastroesophageal reflux disease (GERD). The currentapproach is to encourage patients to pursue theireveryday activity in order to obtain near-physiologicalrecordings. However, the effect of the test itself onreflux-provoking activities has never been evaluated.Thus, the aim of our study was to assess daily foodconsumption, habits, symptoms, sleep, and perceivedexperience of patients undergoing pH testing as comparedto an off test (normal) day. Patients reported type andtime spent in each activity pursued, food ingested and length of each meal, habits, frequency andseverity of GERD and other related symptoms, sleepdisturbances, side effects, and overall perceivedexperience during pH testing and four weeks later,during a normal day. Fifty-four patients enrolled. pHtesting significantly reduced time spent being active,number of meals and cups of coffee consumed, andfrequency of GERD symptoms. Almost half of the patients reported having dysphagia during the test. Mostpatients experienced side effects and stated that thetest bothered them most of the time. In conclusion, pHtesting has a significant effect on decreasing reflux-provoking activities — patientstend to assume a more sedentary lifestyle. This mayinfluence the reliability of the test as a physiologicmeasure of acid reflux.

Prevalence of Barrett's Esophagus in Hispanics Is Similar to Caucasians

Gastroesophageal reflux disease (GERD) accounts for up to 60% of patients with noncardiac chest pain (NCCP). Twenty-four-hour esophageal pH monitoring has been considered the most sensitive test for identifying acid reflux as the probable cause for chest pain. It is unclear if there is a correlation between the degree of esophageal acid exposure as determined by 24-hour esophageal pH monitoring and symptom improvement during a short course of high-dose omeprazole (the omeprazole test) in patients with NCCP due to GERD. Twenty-three patients with GERD-related NCCP were studied. All patients were referred by a cardiologist and evaluated by upper endoscopy and 24-hour esophageal pH monitoring. Diagnosis of GERD was defined by one or both tests being abnormal. Subsequently, patients underwent baseline symptom intensity assessment during 1 week off therapy followed by 1 week on therapy with high-dose omeprazole (40 mg A.M. and 20 mg P.M.). There was a statistically significant correlation between the esophageal acid exposure by 24-hour esophageal pH monitoring and the change in symptom intensity score after treatment. However, there was no significant correlation between the pH values and symptom intensity score during baseline or during the omeprazole test. In patients with GERD-related NCCP undergoing the omeprazole test, 24-hour esophageal pH monitoring has a therapeutic predictive value in addition to its diagnostic merit. Patients with greater esophageal acid exposure appear to have a greater response to antireflux treatment.

Effect of doses of glucagon used to treat food impaction on esophageal motor function of normal subjects.

Barretts esophagus (BE) is considered to be adisease of white males with a prevalence ranging from0.5 to 4.0% in patients undergoing upper endoscopy (EGD)for any indication, and from 12 to 15% in patients with gastroesophageal reflux disease (GERD).The prevalence of BE in Hispanics is not known, but itis assumed to be lower. The aims of this study were todetermine the prevalence of BE in Hispanic patients and to compare demographic and endoscopiccharacteristics with Caucasian patients with BE. Recordsof patients undergoing an EGD between October 1993 andOctober 1996 were retrospectively reviewed. Patients were included in the study only if they hadcolumnar-appearing esophageal mucosa at endoscopy andintestinal metaplasia with Alcian blue-staining gobletcells on biopsy. An extensive chart review was performed in patients with BE. There were 75 new cases ofBE discovered: 60 (80%) were Caucasians, 6 (8%)Hispanics, 1 (1.4%) Native American, and 8 (10.6%)patients with either unknown or unconfirmed ethnicity. Of the 75 patients, 74 male, and the mean agewas 65 ± 11.4 years (range 36-92 years). Theprevalence of BE in Caucasians and Hispanics undergoingEGD for any reason was similar (5.3% and 3.8%,respectively, P = 0.563). The prevalence of BE in patientspresenting with GERD symptoms was also similar betweenCaucasians and Hispanics (25% and 16%, respectively, P= 0.304). The two groups did not differ significantly with respect to age, symptoms, habits, orendoscopic findings. In conclusion, the prevalence of BEamong Hispanic patients is similar to Caucasianpatients, an unexpected finding.

Lumpectomy and radiation treatment for invasive lobular carcinoma of the breast

Abstract. We studied 10 normal subjects to determine the effect of doses of intravenous glucagon used to treat food impaction on esophageal motor function. With a multilumen assembly perfused by a low compliance pneumohydraulic infusion pump, esophageal manometry was performed during baseline and after randomized administration of 0.25, 0.5, and 1 mg intravenous glucagon. Mean proximal and distal amplitudes of contraction, proximal and distal amplitude of contraction duration, lower esophageal sphincter (LES) resting pressure, percentage of LES relaxation, and glucagon-related side effects were evaluated. No effect on proximal amplitude of contraction and proximal or distal esophageal contraction duration was noted. Mean amplitude of contraction in the distal esophagus was further reduced with increased dosage of glucagon but did not achieve statistical significance. Mean LES resting pressure was significantly reduced after 0.25 mg (18.7 ± 1.8 vs. 10.2 ± 1.5 mmHg, p= 0.0001) and further reduced after 0.5 mg (5.9 ± 1.2 mmHg, p= 0.0009). Mean LES relaxation was significantly reduced after 0.25 mg (93.1 ± 2.4% vs. 63.6 ± 8.8%, p= 0.0031). The 1-mg dose versus the 0.5-mg did not provide further reduction in any LES function parameters. One subject experienced transient nausea after 0.5 mg, and 4 subjects experienced nausea after 1 mg glucagon. In conclusion, increased doses of glucagon further reduce mean distal esophageal amplitude of contraction. Although maximum reduction in mean LES resting pressure was achieved with 0.5 mg, it did not provide any potential therapeutic advantage over 0.25 mg glucagon. Nausea is a common, transient side effect predominantly affecting subjects treated with the 1-mg dose.

Overexpression of the Major Vault Transporter Protein Lung-Resistance Protein Predicts Treatment Outcome in Acute Myeloid Leukemia

BACKGROUND Large studies have shown a similar outcome when comparing mastectomy with lumpectomy and external beam radiation therapy in the treatment of infiltrating ductal carcinoma. However, this has not been studied extensively for invasive lobular carcinoma. We studied the pattern of recurrence and overall survival of patients treated with lumpectomy and radiation for either invasive lobular carcinoma (ILC) or combined invasive lobular carcinoma/invasive ductal carcinoma (ILC/IDC) of the breast. DESIGN A retrospective chart review was performed for 111 patients with ILC or ILC/IDC who were diagnosed and/or treated at the university hospital between 1984 and 1994. RESULTS Of the 111 patients, 93 had stage I or II tumors. Thirty-four patients (37%) were treated with lumpectomy and adjuvant postoperative radiotherapy with one (3%) local recurrence and a mean overall survival of 83.6 months. Fifty-nine patients (63%) were treated by modified radical mastectomy with two local recurrences (3%) and a mean overall survival of 71.7 months. CONCLUSIONS Patients with ILC or ILC/IDC can be effectively treated with lumpectomy and radiation for stage I and II tumors while maintaining a low risk of local recurrence and equivalent overall survival.