Background: Limited access to the comprehensive assessment of disorders of the upper aerodigestive tract is a barrier to care in rural health facilities. Assessment of the full aerodigestive tract requires a variety of specialists. The inability to access the necessary specialists can result in misdiagnosis, underdiagnosis, and increased associated mortality. Currently, no single differential diagnostic exam comprehensively assesses all functions of the upper aerodigestive tract to bridge this gap. The purpose of this study is to investigate the feasibility and safety of a novel procedure called ADS that can bridge this gap. Methods: Results from 18,464 ADS procedures were retrospectively analyzed for feasibility, safety and comfort. Results: 96.8% of ADS procedures were successfully completed without complication, confirming the efficacy of the procedure. Conclusions: ADS is a single procedure for the assessment of physiological functions of the upper aerodigestive tract, including swallow, voice, respiration, and cough while also screening for impaired gastric retention and obstructive sleep apnea, which may pose additional urgent and emergent airway threats. ADS may improve health outcomes in underserved populations, e.g., those in a rural community, referred to by other health professionals due to complaints of aerodigestive symptoms and signs.

Limited access to comprehensive assessment of physiological disorders of the upper aerodigestive tract by different specialties represents a barrier to care in rural healthcare settings, which may lead to misdiagnosis, underdiagnosis, and increased associated mortality. No single differential diagnostic exam for the comprehensive assessment of all functions of the upper aerodigestive tract is available to bridge this gap. We present a single procedure for assessment of physiological functions of the upper aerodigestive tract including swallow, voice, respiration, and cough while also screening for gastric retention and obstructive sleep apnea which might contribute to these disorders. Our procedure, called Aerodigestoscopy (ADS), represents a procedure incorporating other established exams as integral components to evaluate patients with aerodigestive disorders. Patients who might particularly benefit from our ADS diagnostic algorithm are those in a rural community referred by other health professionals due to complaints of aerodigestive symptoms and signs. We present a brief overview of how the procedure was developed, what it includes, and retrospective safety data from over 18,000 ADS procedures performed over the last 10 years, demonstrating safety and feasibility of this procedure.

Placement of removable stents to close pharyngo-cutaneous and tracheo-pharyngeal fistulas after laryngectomy has not been reported before. This case presents the feasibility of removable esophageal stent in closing pharyngo-cutaneous and tracheo-pharyngeal fistulas after laryngectomy for laryngeal cancer. Consecutive patients who underwent placement of removable esophageal stent for closing pharyngo-cutaneous and tracheo-pharyngeal fistulas after laryngectomy for laryngeal cancer. Three patients underwent successful stent placement in the hypopharynx. The stents were well tolerated. Patient one had the stent for 14 months, leading to complete healing of the fistula. Removal was successful. The second patient was palliated but died 8 weeks after stent placement. The third patient has successful palliation of his tracheo-esophageal fistula and the stent is being exchanged every 3-4 months to palliate his fistula. Closure of pharyngo-cutaneous and tracheo-esophageal fistulas is feasible with esophageal removable stents. These stents provide alternative options when dealing with these challenging problems.

This collection of summaries on endoscopic diagnosis of Barrett's esophagus (BE) includes the best endoscopic markers of the extent of BE; the interpretation of the diagnosis of ultra-short BE; the criteria for endoscopic grading; the sensitivity and specificity of endoscopic diagnosis; capsule and magnifying endoscopy; narrow band imaging; balloon cytology; the distinction between focal and diffuse dysplasia; the techniques for endoscopic detection of dysplasia and the grading systems; and the difficulty of interpretation of inflammatory or regenerative changes.

This collection of summaries on endoscopic diagnosis of Barrett's esophagus (BE) includes the best endoscopic markers of the extent of BE; the interpretation of the diagnosis of ultra-short BE; the criteria for endoscopic grading; the sensitivity and specificity of endoscopic diagnosis; capsule and magnifying endoscopy; narrow band imaging; balloon cytology; the distinction between focal and diffuse dysplasia; the techniques for endoscopic detection of dysplasia and the grading systems; and the difficulty of interpretation of inflammatory or regenerative changes.

Background Nighttime gastrointestinal reflux disease (GERD) prevalence and severity estimates vary substantially across studies. Methods We assessed nighttime GERD (NTG) prevalence and symptom frequency and severity through a web survey of US adults, using the GERD Symptom and Medication Questionnaire (GERD-SMQ), a validated symptom questionnaire. NTG was based on episodes of nighttime heartburn per week and time of occurrence. Symptom severity and impact were assessed and compared for GERD cases with and without NTG. Results GERD prevalence among respondents ( n = 2,603) was 27%. Forty-five percent of symptomatic GERD respondents had NTG. Among respondents with both daytime and nighttime symptoms, 51% reported that nighttime symptoms were more bothersome. NTG respondents reported greater disease severity compared with those without ( P < 0.0001). Conclusions NTG symptoms are very common among those identified with GERD. People with nighttime symptoms have greater disease severity than those with exclusively or primarily daytime symptoms.

Purpose: To assess health-related quality of life (HRQOL) among GERD patients stratified by symptom severity and by nighttime symptoms. Methods: A sample of US adults participated in a web survey including a validated GERD screener. Frequency and severity of nighttime and daytime heartburn and acid regurgitation during the previous 3 months were each assessed. The highest value reported for symptoms during the daytime or nighttime was assigned to assess severity (10-point Likert scale). Severity classification was: mild (1–4), moderate (5–7) and severe (8–10). Nighttime GERD (NTG) cases were defined as: (a) symptoms ≥2 nights/wk with or without daytime symptoms, or (b) cases without daytime symptoms but at least one night/wk with symptoms. SF-36 Mental Component Summary (MCS) and Physical Component Summary (PCS) scores were calculated and mean scores were compared for NTG vs Daytime GERD (DTG) (t-tests), and by severity (ANOVA). Lower scores signify worse HRQOL. Results: 2,805 of 18,213 invited to participate responded. 2,603 (mean age = 46 years, 55% women) satisfied the study criteria. Among 668 cases with current GERD symptoms, 303 had NTG and 365 had DTG; 664 cases had severity data: 155 were mild, 341 moderate, and 168 severe. GERD cases with NTG had lower MCS and PCS scores compared with DTG cases (Table 1; P < 0.05). Among individuals with GERD, as GERD severity increased, MCS and PCS scores significantly decreased (Table 2; P < 0.05). Differences between moderate and severe groups were twice as large as differences between mild and moderate groups.Table 1: Mean MCS and PCS Scores for NTG vs DTGTable 2: Mean MCS and PCS Scores by GERD SeverityConclusion: HRQOL is significantly worse in patients with nighttime GERD symptoms. Symptom severity is also associated with decreased HRQOL. These findings suggest that even partial improvement in symptom severity or reduction in nighttime symptoms may lead to improved mental and physical functioning among symptomatic GERD patients.

Purpose: To identify and characterize possible sleep impairment among patients with GERD. Methods: A general population of US adults participated in a web-based survey including the GERD Symptom & Medication Questionnaire, a validated GERD screening tool to determine GERD status. Nighttime GERD (NTG) cases were defined as: (a) symptoms ≥2 nights/week with or without daytime symptoms, or (b) individuals without daytime symptoms but at least one night/week with symptoms. Daytime GERD (DTG) cases were GERD cases not satisfying NTG criteria. Respondents not meeting the above criterion served as controls. Sleep impairment was compared for GERD cases versus controls and for NTG versus DTG during the previous 3 months using the chi-square test for trend. Results: 2,805 of 18,213 invited to participate responded. 2,603 satisfied the study criteria (mean age = 46 years, 55% women); 701 were GERD cases. Among symptomatic GERD cases (N = 668); 303 met NTG criteria and 365 met DTG criteria. GERD cases had a higher prevalence of sleep impairment than controls (41.9% vs 19.4%; P < 0.0001) (Table 1). NTG cases reported significantly more sleep impairment than DTG cases (49.5% vs 36.7%; P= 0.0003)(Table 2). Conclusion: GERD in general, and especially NTG symptoms, is associated with significant sleep disruption. Awareness of nighttime reflux and associated sleep complaints should allow more complete evaluation and treatment of GERD patients.Table: Distribution of sleep impairment by GERD vs ControlsTable: Distribution of sleep impairment by NTG vs DTG

Purpose: To assess sleep impairment among GERD patients experiencing frequent nighttime atypical manifestations of GERD. Methods: A sample of US adults participated in a web survey including a validated GERD screener. Frequency of nighttime atypical GERD manifestations during the previous 3 months was assessed. Frequent symptoms were defined as atypical manifestations ≥2 nights per week for each manifestation. Sleep impairment during the previous 3 months was assessed using a five-category ordinal scale. The proportion with sleep impairment (ie, those reporting sleeping poorly often or most of the time) was compared for GERD cases with versus those without each nighttime atypical manifestation using the chi-square adjusting for multiple comparisons. Results: 2,805 of 18,213 invited to participate responded. 2,603 satisfied the study criteria (mean age = 46 years, 55% women); 701 were GERD cases. Overall, 74% of GERD cases reported at least one nighttime atypical manifestation. For almost every daytime and nighttime atypical manifestation assessed, more than 20% of GERD patients reported their occurrence as frequent (≥2 days or nights per week). For 8 of the 9 nighttime atypical manifestations assessed, the proportion of GERD cases reporting sleep impairment was significantly higher for GERD cases with the atypical manifestation compared with GERD cases without the atypical manifestation.Table: Percent with Sleep Impairment for GERD cases with vs without frequent atypical manifestationsConclusion: Most atypical GERD manifestations affected quality of sleep as perceived by individuals with GERD. Awareness of this relationship may assist in the management of these patients.

The purpose of this research was to determine if the interaction of a NSF Graduate Fellow in the classroom affected middle school students' science, technology, engineering, or mathematics (STEM) beliefs or interests. The study utilized a pre-test/post-test design and data were collected from a local voluntary population (N = 1145). The survey instrument consisted of Likert scaled questions and open-ended responses. STEM belief and interest scales were summated to determine an overall belief and/or interest for each subject. Descriptive statistics and multivariate analysis were performed on the summated scales. Overall, middle school students' STEM beliefs and interests were less positive on the post-test than on the pre-test, the notable exception being interests in technology which increased. Multivariate analysis indicated that NSF Fellow and grade level, not teacher, affected the rate at which students' STEM beliefs and interests changed. This study indicated that NSF Fellows affected the rate at which middle school students' STEM beliefs and interests changed, but did not indicate if that influence was positive or negative when accounting for grade level.

Purpose: To evaluate the relationship between body mass index (BMI) and symptoms of GERD, both classic and the less recognized potential symptoms such as cough. Methods: A sample of US adults participated in a web survey assessing weight, height, and the GERD Symptom & Medication Questionnaire (GERD-SMQ), a validated screening tool. Frequency of classic and atypical GERD symptoms (AG-Sx) were determined during the previous 3 months. Respondents were classified into the following weight categories: low/normal (BMI <25), overweight (BMI 25.0–29.9), and obese (BMI ≥30). The chi square procedure compared differences in proportions of respondents with frequent symptoms (2 or more days/nights per week) by BMI category. Results: A total of 2805 of 18213 invited to participate responded to the survey. 2360 satisfied the study criteria and were included in this analysis (Mean age = 46 years; 55% female). Approximately 33% (n = 779) were low/normal weight, 32% (n = 775) overweight, and 35% (n = 831) obese. Results supported an association between increasing BMI and occurrence of both classic and AG-Sx. A significantly greater proportion of overweight and obese persons reported classic and AG-Sx compared to persons in the low to normal range of BMI. Increased BMI was significantly associated with heartburn, acid regurgitation, and particularly with AG-Sx such as coughing, snoring, and throat clearing. Conclusions: In a large general adult population, not only were classic symptoms of GERD associated with increasing BMI, but some AG-Sx were as well. GERD may represent a common and underappreciated consequence of obesity that can present with classic symptoms, and may also have atypical manifestations.Table: GERD symptoms by BMI.

Purpose: To assess symptoms considered to be atypical for GERD (AG-Sx) among individuals with nighttime GERD (NTG) and daytime GERD (DTG). Methods: A web survey among US adults was conducted, which included the GERD Symptom & Medication Questionnaire (GERD-SMQ), a validated GERD screener. Frequency and severity of nighttime and daytime classic symptoms (acid regurgitation and heartburn) and AG-Sx during the previous 3 months were assessed. Nighttime GERD (NTG) was defined as: (a) ≥2 nights/week with classic GERD symptoms, or (b) <2 nights/week with classic GERD symptoms but no daytime symptoms; daytime GERD (DTG) cases were GERD cases not satisfying NTG criteria. The prevalence of frequent AG-Sx (≥2 days or nights/wk) was assessed. Results: 2805 of 18213 invited to participate responded. Of eligible respondents (n = 2603, mean age = 46 years, 55% women), 668 were GERD cases with current symptoms; 303 met NTG criteria and 365 met DTG criteria. Compared with DTG cases, more NTG cases reported at least one nighttime AG-Sx (84% vs 68%, p < 0.05). More NTG cases reported each nighttime AG-Sx (p < 0.05 for all except snoring) compared with DTG cases (see table). A greater proportion of NTG cases also reported at least one daytime AG-Sx (75% vs 60%, p < 0.05). NTG cases reported more daytime AG-Sx (p < 0.05 for all except sinusitis) compared with DTG cases (data not shown).Table: Prevalence of Frequent Nighttime AG-Sx by NTG vs DTG.Conclusions: Patients with frequent nocturnal classic GERD symptoms have more frequent nighttime and daytime AG-Sx which may contribute to the overall burden of illness in GERD.

Purpose: To assess the relationship between frequent nighttime symptoms of gastroesophageal reflux disease (GERD) and patient perception of GERD severity. Methods: A general population of US adults participated in a web survey, which included the GERD Symptom & Medication Questionnaire (GERD-SMQ), a validated GERD screener. Frequency and severity of nighttime and daytime heartburn and acid regurgitation during the previous 3 months were each assessed. Nighttime GERD (NTG) cases were defined as: (a) ≥2 nights/week with symptoms, or (b) <2 nights/week with symptoms but no daytime symptoms. Daytime GERD (DTG) cases were GERD cases not satisfying NTG criteria. The highest value from the nighttime heartburn and acid regurgitation severity ratings was used as the severity score for each NTG case, and the highest from the two daytime ratings was used for each DTG case. Severity classification was: mild (1–4), moderate (5–7) and severe (8–10). Results: 2805 of 18213 invited to participate responded. 2603 satisfied the study criteria (mean age = 46 years, 55% women). Among GERD cases with current symptoms (n = 668), 303 (45%) met criteria for NTG. 33% of NTG cases were severe compared with 9% of the DTG group (see table). The odds of having moderate GERD symptoms as opposed to mild symptoms were 2.1 times greater among those with NTG compared with DTG) (odds ratio [OR] = 2.1; 95% confidence interval [CI]: 1.4, 3.1). The odds increased 8-fold for having severe (vs. mild) GERD among NTG cases compared with DTG cases (OR = 8.5; 95% CI: 5.0, 14.7).Table: Nighttime GERD (NTG) and Daytime GERD (DTG) by Severity.Conclusions: Patients with nocturnal heartburn or acid regurgitation may report more severe symptoms. Clinicians should inquire specifically about nighttime symptoms in addition to daytime symptoms when evaluating patients with GERD.

Purpose: To assess the prevalence of nighttime and daytime symptoms considered to be atypical for GERD (AG-Sx) by GERD severity level. Methods: A web survey among US adults was conducted, which included the GERD Symptom & Medication Questionnaire (GERD-SMQ), a validated GERD screener. Frequency and severity of nighttime and daytime classic GERD symptoms (Sx) (heartburn and acid regurgitation) and AG-Sx (table) during the previous 3 months were assessed. GERD cases had GERD-SMQ score >9 and had classic GERD Sx during previous 3 months. Severity was assigned the highest value reported for classic GERD Sx (10-point Likert scale) during the daytime or nighttime. Severity classification was: mild (1–4), moderate (5–7) and severe (8–10). Prevalence of frequent (≥2 days/nights per wk) AG-Sx was assessed by severity level.Table: Prevalence of Frequent Nighttime AG-Sx by GERD Severity.Results: 2805 of 18213 invited to participate responded. 2603 satisfied the study criteria (mean age = 46 years; 55% women). Among GERD cases with current classical GERD symptoms, 155 were mild, 341 moderate, and 168 severe. All nighttime AG-Sx exhibited increasing prevalence with increasing GERD severity (see table). The prevalence of nighttime AG-Sx was higher among severe GERD cases (p < 0.05 for all AG-Sx except snoring). Similarly, all daytime AG-Sx except choking exhibited increasing prevalence with increasing GERD severity (p < 0.05 for all two-way comparisons across severity levels)(data not shown). Conclusions: All daytime and nighttime AG-Sx were most prevalent in those with severe GERD. Among GERD patients, AG-Sx are common and may be indicative of more severe disease.

Gastroesophageal reflux disease (GERD) is defined as gastroesophageal reflux resulting in symptoms or in injury to the esophageal epithelium. Although the medical management of GERD has improved, an increasing number of laparoscopic antireflux surgical procedures are being performed. Barium studies, endoscopy, manometry, and pH monitoring are all integral components of preoperative evaluation. Barium swallow examination must allow critical evaluation of esophageal peristalsis, the presence and extent of gastroesophageal reflux, and complications including esophagitis, stricture, and Barrett esophagus. It is crucial to identify and characterize hiatal hernia and longitudinal stricture, which can result in a shortened esophagus. In such cases, it becomes necessary for the surgeon to incorporate an esophageal lengthening procedure prior to fundoplication; otherwise, poor surgical outcome is likely. Normal postfundoplication radiographic findings as well as postoperative complications (eg, tight wrap, perforation, abscess, complete or partial dehiscence, recurrent stricture, recurrent hernia, intrathoracic migration of the wrap) must also be recognized and clearly understood by the radiologist. Given the chronic nature and prevalence of symptomatic GERD and the increasing number of patients undergoing surgical intervention, it is imperative that the radiologist understand the pre- and postsurgical evaluation of affected patients.

BACKGROUND & AIMS:Whereas severe duodenal ulcer is the hallmark of acid hypersecretion in Zollinger-Ellison syndrome (ZE) and similar states, the esophagus also is at high risk. We quantified the incidence of esophagitis and various risk factors that might contribute to it.METHODS:Sixty-eight acid hypersecretors (basal acid output >15 mmol/h), 50 patients with ZE, and 18 patients without ZE with normal gastrin levels were studied by gastric analysis, serum gastrin levels, and endoscopy. In 44 of 68 patients, esophageal manometry was performed after the esophagus had healed.RESULTS:Erosive esophagitis, grade 2 or worse, was found in 65%; an additional 15% had heartburn only, for a total reflux disease incidence of 80%. ZE accounted for 95% of severe esophagitis. Patients with and without esophagitis had the same high overnight fasting gastric residual volume and acidity, as well as basal and peak acid and pepsin outputs. However, patients with esophagitis had a lower median lower esophageal sphincter pressure (LESP) of 15.5 vs. 23 mm Hg in those without symptoms; the critical discriminator threshold was 16 mm Hg. Multivariate analysis further identified frequent vomiting and obesity as positive predictors of esophagitis, whereas Helicobacter pylori was a strong negative predictor (odds ratio, 0.16), possibly related to an elevated LESP in patients infected with H. pylori.CONCLUSIONS:Erosive esophagitis is very common in acid hypersecretors. Identified risk factors that could promote abnormal esophageal exposure to the high acid and pepsin levels in our population of hypersecretors were vomiting, LESP < 16 mm Hg, and obesity, whereas H. pylori appeared to protect the esophagus not by reduced acid, but through an elevated LESP.