Timely confirmation of gastro-esophageal reflux disease via pH monitoring: estimating budget impact on managed care organizations*

ABSTRACT

Background: Current guidelines recommend the use of pH monitoring to confirm the diagnosis of acid reflux in patients with a normal endoscopy. This analysis evaluated the financial impact of pH monitoring with the wireless pH capsule on a managed care organization (MCO) in the United States.

Methods: A decision model was constructed to project total 1-year costs to manage GERD symptoms with and without the adoption of wireless pH capsules in a hypo­thetical MCO with 10?000 eligible adult enrollees, of whom 600 presented with GERD-like symptoms. Costs of GERD diagnosis, treatment, and symptom management for those in whom a GERD diagnosis was ruled out by pH monitor­ing were assessed. The incremental per-member-per-month (PMPM) and per-treated-member-per-month (PTMPM) costs were the primary outcomes. Data sources included literature, expert input, and standardized fee schedules.

Results: An increase of 10 percentage points in the use of pH monitoring with wireless pH capsules yielded incremental PMPM and PTMPM costs of $0.029 and $0.481, respectively. The costs of proton pump inhibitor (PPI) therapy to the plan dropped to $236?363 from $238?086, while increases were observed in pH monitor­ing (from $16?739 to $21?973) and non-GERD therapy costs (from $1392 to $1740). The results were sensitive to the percentage of patients requiring repeat endoscopy before wireless pH monitoring and the cost of PPIs.

Conclusions: Timely and increased use of pH monitor­ing as recommended in published guidelines leads to less unnecessary use of PPIs with a modest budgetary impact on health plans.     

定量唾液腺显像评价放射性碘治疗后唾液腺功能

目的观察分化型甲状腺癌（DTC）在首次接受不同剂量131I治疗后唾液腺功能情况。方法将40例确诊为DTC患者按照应用131I剂量不同分为两组,应用放射性核素唾液腺动态显像,对131I治疗前及治疗后3个月唾液腺功能进行定量分析。结果低剂量组（2．96GBq）治疗后仅腮腺30min摄取率（UR30）明显受损（P〈0．05）,高剂量组（5．55GBq）腮腺和颌下腺UR30、排泌分数（EF）、排泌率（ER）均明显降低,排泌时间（EP）显著延长（均P〈0．05）;腮腺较颌下腺受损更重。结论首次接受131I治疗DTC患者的唾液腺功能会受损,受损程度与使用131I剂量相关。     

Pathophysiology,diagnosis, and pharmacological treatment of gastro-esophageal reflux disease

ABSTRACT

Introduction

Gastro-esophageal reflux disease (GERD) is a highly prevalent, chronic, relapsing disorder, whose knowledge has increased in last years thanks to the advent of new sophisticated techniques, such as 24-h impedance-pH monitoring and high-resolution manometry, for the study of esophageal functions.     

Role of radiography and ultrasonography in the diagnosis of the pediatric gastro-esophageal reflux disease

Twenty-four hour esophageal pH-monitoring is gold standard for evaluate pathological GERD. Role of radiography and ultrasonography in the diagnosis of gastro-esophageal reflux disease (GERD) has been studied. Our results have been shown that radiography and ultrasonography have a limited role in the diagnosis of pathological GERD. However, such investigations an useful the follow-up of patients affected by pathological GERD.     

Ilaprazole for the treatment of gastro-esophageal reflux

Introduction: Despite the undoubted benefit of proton pump inhibitors (PPIs), they have several shortcomings, such as a slow onset of action and a remarkable inter-individual variability, that limit the complete success of these drugs. Recently, a new PPI, ilaprazole, has been developed and used in GERD patients.

Areas covered: The present review provides an update on the following points: current knowledge of GERD mechanisms; limitations of actual therapies; pharmacokinetic profile and metabolism of ilaprazole; initial studies on the therapeutic efficacy of ilaprazole in GERD.

Expert opinion: Compared with all other approved PPIs, ilaprazole has shown an extended plasma half-life, a metabolism not significantly influenced by CYP2C19 genetic polymorphism and similar safety. This characteristics account for a low inter-individual variability, particularly in Asian populations, a higher suppression of gastric acid secretion, a more rapid acid control and consequent quicker symptom relief and a better effect on nocturnal acidity. However, clinical investigations assessing the efficacy of ilaprazole in the management of GERD are lacking and therefore the potential improvements achievable with ilaprazole in the current standard of care for acid-suppressing treatment must be confirmed in large and randomly controlled clinical trials enrolling patients with both erosive and non-erosive reflux disease.     

New insights into the treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a chronic relapsing disorder commonly encountered in the primary care setting. Considerable uncertainty still exists with respect to basic questions concerning pathophysiological factors and the cause of extraoesophageal symptoms in some patients with GERD. The numerous receptors located in the muscular layer at the site of the lower oesophageal sphincter (LES) are under neurological control. These receptors are of interest in the investigation of both LES dysfunction and new potential pharmacological approaches for GERD. Therapies for GERD, based on various pathophysiological mechanisms, with attention to either drug inhibition of acid secretion, protection of the oesophageal mucosa, influencing salivary composition or improving oesophageal clearance, have been reviewed. Alternative approaches to the more traditional treatments for gastroesophageal reflux disease are also being pursued. In particular, pharmacological efforts towards modification of intrinsic and extrinsic neurological controls of oesophageal motility, aimed at improving LES function, are discussed.     

三种不同检查方法在胃食管反流病诊断中的应用比较

目的:探讨电子胃镜、24 h食管pH值监测及胃食管反流病(GERD)Q评分三种方法在GERD诊断中的临床应用价值。方法:将于2011年4月—2012年6月因烧心、反酸等症状就诊于消化科门诊的120例患者随机分为胃镜组、24 h食管pH值监测组及GERD Q评分组,每组40例,分别接受电子胃镜、24 h食管pH值监测及GERD Q问卷评分,比较分析各种方法对GERD的检出情况。结果:24 h食管pH值监测组40例患者中病理性反流者19例,生理性反流者5例,GERD阳性率显著高于胃镜组及GERD Q评分组,差异具有统计学意义(P<0.05);胃镜组与GERD Q评分组之间差异无统计学意义(P>0.05)。结论:24 h食道pH值监测可以对食管内反流情况进行实时、动态监测,为GERD的临床诊断及不同类型的反流治疗方案提供客观、准确的依据。     

99mTco4-唾液腺显像诊断腮腺腺淋巴瘤的应用价值

目的 研究腮腺腺淋巴瘤(以下简称腺淋巴瘤)在唾液腺99mTco4-显像中的形态、功能等影像学特点,探讨唾液腺显像诊断腺淋巴瘤的应用价值.方法 选取临床拟诊断腺淋巴瘤患者44例,分别进行唾液腺动静态显像及彩色B超检查,同时与病理结果做对照,评判唾液腺显像对腺淋巴瘤的诊断价值.所得数据用统计学软件SPSS16.0处理,四格表x2检验.结果 术后病理证实腺淋巴瘤32例,多形性腺瘤10例、绒毛状腺瘤1例、腮裂囊肿1例;核素显像发现阳性病例32例(分泌相“热结节”),病灶46个,单发22例,多发10例;12例阴性结果(包括1例“冷结节”,11例“温结节”);灵敏度96.88％( 31/32),特异性91.67％( 11/12),阳性预测值96.88％( 31/32),阴性预测值91.67％( 11/12),准确性95.45％( 42/44).B超检查44例患者中,20例为阳性结果,24例为阴性结果;与病理对照,灵敏度46.88％( 15/32),特异性54.55％( 6/11),阳性预测值75.00％( 15/20),阴性预测值25.00％( 6/24),准确率47.72％( 21/44).两种方法差异有统计学意义(P＜0.05).结论 唾液腺显像诊断腺淋巴瘤敏感性及特异性都显著高于彩色B超,诊断符合率好,为术前定性及定位提供良好的诊断价值.     

Clinical relevance of esophageal and gastric pH measurements in patients with gastro-esophageal reflux disease (GERD)

BACKGROUND: Gastro-esophageal reflux disease (GERD) is a highly prevalent disease caused by the exposure of the esophagus to refluxed gastric contents. Proton pump inhibitors (PPIs) are the mainstay of current treatment. At present, the assessment of the efficacy of different PPIs in the treatment of GERD employs two measures: esophageal and gastric pH monitoring. Esophageal pH monitoring is the most accurate method of detecting reflux episodes and, therefore, its role as a diagnostic modality is well accepted. Gastric pH monitoring, on the other hand, is an accurate measure of gastric acid pH, but its relevance to patients with GERD is questionable, since recordings correlate poorly with esophageal acid exposure. OBJECTIVE: This paper reviews (based on a Medline literature search, 1980-2004) the clinical relevance of esophageal and gastric pH measurements in both the management of GERD and in the evaluation of the efficacy of PPI therapy. FINDINGS AND CONCLUSIONS: Evidence presented suggests that the assessment of esophageal pH yields data of greater relevance to patients with GERD than does data from gastric pH. This largely arises from the fact that esophageal pH monitoring assesses the pH of the refluxate and the frequency of reflux episodes at the mucosal site affected by the disease. The use of esophageal pH monitoring is recommended in patients who fail to present with endoscopic evidence of esophagitis, those with extra-esophageal symptoms, those who have failed traditional anti-reflux therapies, and those who are potential candidates for anti-reflux surgery. In recent years, the technique has benefited from the development of a wireless pH probe, and there is also an increasing body of evidence supporting its use in combination with other emerging technologies, such as Bilitec monitoring and multichannel intraluminal impedance. Such an approach is anticipated to aid both the diagnosis of GERD and the characterization of gastro-esophageal reflux (GER) in these patients.     

TRPV1 in Salivary Gland Epithelial Cells Is Not Involved in Salivary Secretion via Transcellular Pathway

Transient receptor potential vanilloid subtype 1 (TRPV1) was originally found in sensory neurons. Recently, it has been reported that TRPV1 is expressed in salivary gland epithelial cells (SGEC). However, the physiological role of TRPV1 in salivary secretion remains to be elucidated. We found that TRPV1 is expressed in mouse and human submandibular glands (SMG) and HSG cells, originated from human submandibular gland ducts at both mRNA and protein levels. However, capsaicin (CAP), TRPV1 agonist, had little effect on intracellular free calcium concentration ([Ca²⁺]_i) in these cells, although carbachol consistently increased [Ca²⁺]_i. Exposure of cells to high temperature (>43℃) or acidic bath solution (pH5.4) did not increase [Ca²⁺]_i, either. We further examined the role of TRPV1 in salivary secretion using TRPV1 knock-out mice. There was no significant difference in the pilocarpine (PILO)-induced salivary flow rate between wild-type and TRPV1 knock-out mice. Saliva flow rate also showed insignificant change in the mice treated with PILO plus CAP compared with that in mice treated with PILO alone. Taken together, our results suggest that although TRPV1 is expressed in SGEC, it appears not to play any direct roles in saliva secretion via transcellular pathway.     

A review of pharmacotherapy for treating gastroesophageal reflux disease (GERD)

Introduction: Medical therapy of gastroesophageal reflux disease (GERD) is based on the use of proton pump inhibitors (PPIs) as first choice treatment. Despite their effectiveness, about 20–30% of patients report an inadequate response and alternative drugs are required.

Areas covered: This review provides an overview of current pharmacotherapy for treating GERD by showing the results of PPIs, reflux inhibitors, antidepressants and mucosa protective medications.

Expert opinion: Medical therapy of GERD does not definitely cure the disease, because even PPIs are not able to change the key factors responsible for it. However, they remain the mainstay of medical treatment, allowing us to alleviate symptoms, heal esophagitis and prevent complications in the majority of cases. Nevertheless, many patients do not respond, because acid does not play any pathogenetic role. Prokinetics and reflux inhibitors have the potential to control motor abnormalities, but the results of clinical trials are inconsistent. Antidepressant drugs are effective in specific subgroups of NERD patients with visceral hypersensitivity, but larger, controlled clinical studies are necessary. Protective drugs or medical devices have been recently adopted to reinforce mucosal resistance and preliminary trials have confirmed their efficacy either combined with or as add-on medication to PPIs in refractory patients.     

Evaluation of the inflammatory activity in rheumatoid arthritis. Nanocolloid scintigraphy VS. Clinical examination and bone scintigraphy

A sensitive and specific method for evaluating inflammatory joint activity is lacking. Scintigraphic methods have been investigated for the purpose of measuring inflammatory activity in rheumatic diseases but so far none has been found to meet these requirements. We have compared a new scintigraphic method, using nanometer-sized albumin particles (nanocolloid scintigraphy), with bone scintigraphy and clinical examination. Nanocolloid scintigraphy seems to be better correlated with the degree of inflammatory activity in the joint than bone scintigraphy. Furthermore, nanocolloid scintigraphy is sensitive to rapid changes in inflammatory activity effected by corticosteroid injection into inflamed wrists.     

Salivary levels of thallium in acute human poisoning

Thallium intoxication in a 28-year-old woman was characterized by neurological and gastrointestinal symptoms and alopecia. Treatment was started 4 days after poisoning and consisted of forced diuresis and administration of Prussian Blue at four daily doses of 5 g by duodenal tube for 20 days. Thallium was measured by atomic absorption spectrophotometry in urine, faeces and saliva. Considerable amounts of thallium were detected in saliva, salivary concentrations being up to 15 times higher than urinary ones. Evidence was also obtained that only a little fraction of the ingested dose was excreted by the intestine during the hospital course in spite of Prussian Blue administration.     

不同疗程的质子泵抑制剂对胃食管反流病的疗效分析

目的探讨不同疗程的质子泵抑制剂对胃食管反流病的疗效。方法 2009年1月～2011年1月在笔者所在医院确诊为GERD的患者63例,随机分为3组,观测临床症状缓解和食管24小时pH监测结果。结果接受8周治疗的患者无论是临床症状的缓解还是食管24小时pH监测结果均优于其他组,差异有统计学意义(P<0.05)。结论不同疗程的质子泵抑制剂对胃食管反流病的疗效,8周疗程优于6周和4周。     

彩色多普勒超声在涎腺良恶性肿块鉴别诊断中的价值

目的探讨彩色多普勒超声对涎腺良恶性肿块鉴别诊断的应用价值。方法回顾性分析43例涎腺肿块的声像图表现、内部和周边的血流分布及多普勒频谱,将诊断结果与病理结果对照分析。结果良性肿块25例,超声诊断符合21例,恶性肿块18例,超声诊断符合14例,符合率分别为84%、78%,统计学比较P>0.05。良性肿块中92%可见清晰包膜,恶性肿块无包膜或包膜不完整;良性肿块血流PSV仅16%>35cm/s,而恶性肿块血流PSV有61%>35cm/s,两者在二维声像图及血流峰值方面均有显著性差异。结论彩色多普勒超声在涎腺肿块良恶性的鉴别诊断中能提供有效的依据,具有重要的鉴别诊断价值。     

Effect of rutin against gastric esophageal reflux in experimental animals

Context: The present study was undertaken to elucidate the effect of rutin against gastric esophageal reflux in experimental animals.

Methods: Groups of rats, fasted overnight received normal saline (3?ml/kg, sham control) or esophagitis control (3?ml/kg, normal saline) or pantoprazole (30?mg/kg) or rutin (50 and 100?mg/kg) were subjected to pylorus and forestomach ligation. Animals were sacrificed after 12?h and scrutinized physiologically (gastric pH, total acidity, free acidity and esophagitis index), biochemically (TBAR’s, SOD, catalase, GSH and protein carbonyl) and morphologically. The esophageal tissues were also inquested for the presence of proinflammatory (IL-2 and IL-1β) and immunoregulatory (IL-4 and IL-6) cytokines.

Results: The results demonstrated momentous physiological, biochemical and morphological protection imparted by rutin. The rutin also restored the altered levels of proinflammatory and immunoregulatory cytokines, which further strengthens the implication of rutin in GERD.

Conclusion: The beneficial effects as observed in the current experiment could be accredited to the antioxidant and anti-inflammatory (through inhibition of COX and LOX) property of rutin.     

健康教育在门诊胃食管反流病患者治疗中的作用

目的观察健康教育在门诊胃食管反流病患者中的临床疗效。方法选取2011年1月～2012年1月本院收治的68例门诊食管反流病患者,将其随机分为观察组和对照组,每组各34例,对照组患者给予药物治疗,观察组在对照组患者的治疗基础上给予针对性健康教育,比较两组患者的临床治疗效果。结果观察组患者经过4周的治疗后有效率为91.76%,对照组有效率为55.88%,差异具有统计学意义（P〈0.05）;观察组经过8周的治疗后有效率为94.12%,对照组有效率为76.47%,差异具有统计学意义（P〈0.05）。结论对门诊胃食管反流患者进行针对性的健康教育,可有效地提高临床有效率,与药物治疗同样具有重要的作用,不仅缩短治疗时间,还可有效提高患者的生活质量,在临床上值得应用和推广。     

胃食管返流病患者应用黛力新疗效观察

目的观察胃食管返流病（GERD：NERD,RE）患者在对症治疗3月以上效果不佳的同时加用氟哌噻吨美利曲辛（商品名：黛力新）10.5mg,2次/d,口服治疗的疗效。方法 A组：GERD患者123例（NERD患者82例,RE患者41例）在对症治疗3月以上（平均5.6±1.9月）效果不佳的患者;B组：A组患者在原治疗不变的基础上同时加用黛力新10.5mg,2次/d,口服治疗2月（或症状消失2周以上停药）的两组疗效观察。结果统一用STATA10.0分析。结果B组患者中9例脱离治疗,114例患者完成治疗,起效从3～30d,平均（15.6±10.8）d,101例患者治疗有效（101/114,88.6%）,13（13/114,11.4%）例患者2月疗程结束无效,治疗有效率的95%可信度区间：81.29%,93.79%。结论 GERD患者在对症治疗效果不佳的同时加用黛力新10.5mg,2次/d,口服治疗有较好的临床疗效,副作用少,GERD患者加用氟哌噻吨美利曲辛可以缩短治疗周期有良好的社会效益和经济效益,在临床上有一定的推广价值。