Just another 94 Billion, Don’t Be Selfish.

May 5, 2009

For the continuation of Bush’s war in Afghanistan and Iraq of course. You see, it’s the Democrats fighting the war and you know what Democrats say, all wars are bad unless it’s a Democrat in the White House fighting the war. Sort of like they said about the Patriot Act and profiling… the Patriot Act is good now that the Democrats want to expand it, profiling is good when Napolitano targets ex military as potential threat… which is actually more of a recurring theme in this administration, the only terrorist that’s a bad terrorist are those that effectively defend the United States and the United States Constitution.

But what would you expect from a President, who regardless of where he was born at, who spent his formative child hood years in a foreign country learning quite possibly that America is an evil country? And who’s political views won the heart of a terrorist who actively wanted to see the fall of the United States so much that this terrorist open the doors of his home to launch his political career, and who won the heart of a woman who was well into her forties before she found her sense of pride in country?

We’re talking about a man who wants to forge relations with self proclaimed enemies of our country. Tyrants such as Hugo Chavez (whose tiny country is bigger than Germany) that were impressed enough by the man that he gave a book to him that bashes America with hopes (expectations maybe) that he would read, and Daniel Ortega who railed against the United States for fifty minutes and Obama said nothing.

At the same time he wishes to forge these new relationships with self proclaimed enemies of the United States, he chooses to alienate our allies, sending the bust of Winston Churchill back to Great Britain, showing Israel disfavor.

It’s also a fact that many of our enemies such as Al Qaida want to see the economic collapse of our nation, and indeed wish to see our country bankrupt, it would only make sense that this President wouldn’t mind going on a spending spree so much until our the interests on our debt exceeds the GDP. Should that occur, the United States would officially be bankrupt.

And would it come as no surprise that this President has picked on spot to cut spending and that spot would be in our defense budget? What in God’s name is he doing to ensure that America remains strong against our enemies and maintains our existing alliances?

I’m not saying he’s an enemy of the United States, but what is becoming more and more self evident is that this isn’t a black or white issue, rich or poor, man or woman… not even Democrat or Republican. This is an issue of the lives of all Americans being in the hands of one person who has very questionable intentions for our nation. Rich or poor, black, brown, or white, Democrat or Republican, we’ll all suffer if we let ignorance and stupidity super cede common sense. Some days I wonder, just how close we are to Idiocracy.

Impact of Nissen Fundoplication on Laryngopharyngeal Reflux Symptoms

The American Surgeon July 1, 2011 | van der Westhuizen, Lionel; Von, Stephen J; Wilkerson, Brent J; Johnson, Brent L; Jones, Yonge; Cobb, William S; Smith, Dane E The reliability of Nissen fundoplication for the successful treatment of laryngopharyngeal reflux (LPR) symptoms remains in question. The purpose of this study was to assess the effect that antireflux surgery has on a variety of LPR symptoms as well as the patient’s perceived success of surgical intervention. A retrospective review of all antireflux surgeries between 1998 and 2008 provided a patient base for a survey in which patients ranked pre- and postoperative LPR symptoms in addition to patient satisfaction with the outcome. Of the 611 patients identified and sent the evaluation forms, 244 responses (40%) were obtained. The percentage of patients with symptom improvement after surgery were: heartburn (90.1%), regurgitation (92.6%), voice fatigue (75.2%), chronic cough (76.3%), choking episodes (83.1%), sore throat (82.9%), lump in throat (77.4%), repetitive throat clearing (72.8%), and adult-onset asthma (59.6%). Twenty per cent with repetitive throat clearing and 30 per cent with adult-onset asthma had no improvement in symptoms. Eighty-one per cent considered surgery to be a success. Comparison of those who claimed the operation was successful with those who claimed it was not revealed no difference in demographics, primary diagnosis, procedure type, or reflux symptom index score. There was a statistically significant difference in patient-perceived outcome according to the length of time since surgery. More than 88 per cent in the “not successful” group had an operation greater than 4 years prior as compared with only 70 per cent in the “successful” group (P = 0.020). Nissen fundoplication is an effective treatment for most LPR symptoms, although patients with adult-onset asthma and repetitive throat clearing appear to benefit least from surgical intervention.

LARYNGOPHARYNGEAL REFLUX (LPR) IS a Complex disorder characterized by the retrograde flow of gastric contents into the laryngopharynx. The upper airway epimelium is far more susceptible to the damaging effect of gastric refluxate tiian the esophageal epithelium, leading to the clinical symptoms mat comprise LPR.1 These symptoms, often referred to as “atypical” reflux symptoms, include hoarseness, voice fatigue, chronic cough, globus, dysphagia, postnasal drip, and repetitive throat clearing.2-4 Although gastroesophageal reflux disease (GERD) and LPR are often referred to as distinct clinical entities, there remains a significant overlap between the two diseases. Between 40 and 50 per cent of patients with LPR also have heartburn, and 25 per cent have been demonstrated to have esophagitis.5-7 There is also a direct correlation between the severity of GERD and the severity of LPR symptoms, because patients with severe GERD show a significantly higher rate of LPR symptoms than those with mild, moderate, or inactive disease.8 The ideal treatment for LPR remains unclear. Antisecretory medications, although effective for treating esophageal symptoms of GERD including heartburn and regurgitation, are much less successful in treating the atypical reflux symptoms of LPR.9,10 Similarly, although the role of laparoscopic antireflux surgery is well established in the treatment of GERD, the reliability of Nissen fundoplication for the successful treatment of LPR symptoms remains in question. The purpose of this study was to assess the effect that antireflux surgery has on a variety of LPR symptoms as well as patients’ perceived success of surgical intervention. web site greenville memorial hospital

Methods After Institutional Review Board approval, we performed a retrospective review of all elective antireflux surgeries from 1998 to 2008 performed at Greenville Memorial Hospital University Medical Center. We excluded patients younger than 18 years of age, antireflux procedures performed for nonreflux conditions (e.g., achalasia, incarcerated paraesophageal hernia), and patients who were dead at the time of our study. A survey was designed to elicit a patient assessment of improvement in a variety of reflux symptoms. This survey included the Reflux Symptom Index (RSI)11 as well as several additional symptoms of LPR. The RSI is a validated, self-administered scoring system that uses nine items to quantify symptoms of LPR. An RSI greater than 13 is abnormal and patients with an RSI greater than 19 were considered to have LPR by the authors.

Patients ranked pre- and postsurgery symptoms on a scale of 0 to 5 for heartburn, regurgitation, voice fatigue, chronic cough, choking episodes, sore throat, repetitive throat clearing, globus, adult-onset asthma, nausea or vomiting, and difficulty swallowing. Participants were also asked specifically whether they considered the operation a success, would they repeat the surgery given the same condition, and would they recommend it to a friend. Initial nonresponders were sent a second survey and additional nonresponders were contacted by phone. Patient demographics and operative characteristics were reviewed and compared between responders and nonresponders as well as between patients who claimed surgery was successful and those who claimed it was not successful.

Patients had a combination of esophagogastroduodenoscopy, 24-hour pH probe studies, and esophageal manometry as part of their preoperative workup. All study participants underwent Nissen fundoplication for treatment of their symptoms. Hiatal closure was performed as deemed necessary by the operating surgeon. Patients were admitted to the hospital postoperatively and typically discharged within 24 to 72 hours once pain and nausea were controlled and patients were tolerating a post-Nissen diet (no meat, bread, or carbonated beverages).

Analyses were conducted using SAS statistical software (SAS Institute, Cary, NC). Student t test was used to evaluate continuous data. Pre- to postsurgery symptom change scores were evaluated using the Wilcoxon signed rank test. Demographic characteristics were compared using Pearson’s chi-square and Fisher exact test for categorical data. Significance was accepted at a P value < 0.05.

Results There were 611 patients identified over the 10-year study period. AU these patients were sent a survey. Of these, 197 responded to the paper survey and 47 responded by phone survey for a total of 244 patients (40% response rate). We compared the demographics of our survey responders with nonresponders to see if our responders were representative of the group as a whole (Table 1). Survey responders were older, a higher per cent female, and closer to the date of surgery than nonresponders (P < 0.05). There was no difference in race, type of procedure, or primary diagnosis.

Preoperative symptom prevalence in our patients is shown in Figure 1. Heartburn and reflux were the most common symptoms. The least common symptoms were globus and adult-onset asthma. LPR symptoms were less common overall, but still more than half of respondents claimed to experience some degree of each symptom. Using our survey’s patient symptom scores, we calculated the RSI for all of our responders. We found that 61.6 per cent (n = 1 17) of our patients had RSI greater than 13, and 43.7 per cent (n = 83) had RSI greater than 19 preoperatively, consistent with severe symptoms and indicative of LPR.

Figure 2 demonstrates the perceived overall improvement in our patients after surgical intervention for each given symptom. In every case, there was a statistically significant improvement in a given symptom. The symptoms with the greatest improvement were heartburn and reflux. The symptoms that improved the least were repetitive throat clearing and adult-onset asthma.

A closer look at each symptom demonstrates the percent improvement in our patients (Table 2). We subdivided the results into five groups: those who improved 100 per cent (i.e., went from 5 to 0 on symptom scoring), those who improved 50 to 99 per cent, those who improved 1 to 49 per cent, those who did not improve at all, and those who stated their symptoms worsened after surgery. For heartburn, 78.9 per cent (168) of patients had 50 per cent or greater symptom improvement. Likewise, 81.9 per cent (177) of patients with regurgitation had 50 per cent or greater symptom improvement. The LPR symptoms that improved the most included sore throat and choking episodes with 70.7 per cent (99) and 69.7 per cent (99) having 50 per cent or greater symptom improvement, respectively. The symptoms that improved the least were repetitive throat clearing and adult-onset asthma. Indeed, we found that only 54.9 per cent (89) of patients and 46.8 per cent (44) of patients with repetitive throat clearing and adult-onset asthma, respectively, claimed 50 per cent or greater symptom improvement. Additionally, 20 per cent (33) of patients with repetitive throat clearing and 30 per cent (28) of patients with adult-onset asthma claimed no improvement in their symptoms. Moreover, 7 per cent (11) of patients with repetitive throat clearing and 1 1 per cent (10) of patients with adult-onset asthma claimed overall worsening of their symptoms postsurgery.

Finally, we also queried our patients as to the perceived success of their surgery. A total of 8 1 . 1 per cent stated that their surgery was successful, whereas 17.2 per cent (n = 42) stated their surgery was not a success. A total of 83.6 per cent stated they would repeat the surgery given the same symptoms, whereas 15.6 per cent said they would not, and 82.3 per cent of patients stated they would recommend surgical intervention to a friend with the same symptoms.

We further compared the groups who said the surgery was successful with the group who said it was not to see if any differences could be established (Table 3). There were no differences in patient age, demographics, symptom severity, or RSI score. However, there was a statistically significant difference in die length of time since surgery with more than 88 per cent of patients in the “no” group having had surgery greater than 4 years prior compared with only 70.7 per cent of patients in the “yes” group (P = .020). There were no preoperative characteristics that were predictive of claimed success in our patient population.

Discussion Laryngopharyngeal reflux remains a challenge both in terms of diagnosis and treatment. Patients can have a diverse clinical presentation, resulting in a variety of subspecialists taking part in the care of these patients. Conflicting data exist with regard to the laryngeal findings, pH monitoring results, and clinical symptoms of these patients compared with healt?¬iy control individuals. A disparity exists in the literature among otolaryngologists and gastroenterologists as to the optimal management of diese patients. Guidelines from the American Gastroenterologist Association recommend against proton pump inhibitors or H2 blockers in die absence of proven concomitant esophageal GERD syndrome.12 In contrast, guidelines from the American Academy of Otolaryngology-Head and Neck Surgery recommend “twice-daily PPI for no less than 6 months for most patients with LPR.”4 Attributable in part to the varied clinical presentation and difficult diagnosis of LPR, its incidence in die general population is not well established. Even among patients with established GERD syndrome, the more subtle LPR symptoms can often be overlooked as a result of the dominance of esophageal GERD symptoms such as heartburn.8 With this in mind we sought to survey a wide group of patients who underwent antireflux surgery. Despite only nine survey responders carrying a diagnosis of LPR preoperatively, a review of our patient records demonstrated many more patients also had extraesophageal symptoms such as cough and hoarseness. From our survey responses, we found that 39 to 66 per cent of our patients experienced some form of atypical reflux symptoms (Fig. 1). Moreover, 61 per cent of the patients had an RSI greater than 13, and 43.7 per cent of them had an RSI greater than 19, the cutoff defined by the original aumors as abnormal and indicative of LPR, respectively.11 With regard to the LPR symptoms, adult-onset asthma and repetitive throat clearing improved the least and had the highest percentage of patients claiming no improvement in their symptoms. A possible explanation for this result may relate to the multifactorial nature of these symptoms and the chance that they were produced by nonreflux conditions such as smoking, sinusitis, or other primary lung conditions.4?· 13 This suggests that patients with these symptoms should be carefully evaluated to ensure their symptoms correlate with pharyngeal reflux before offering any surgical intervention.14 Although the long-term effectiveness of Nissen fundoplication is well established for the treatment of GERD, long-term outcomes after surgical intervention in patients with LPR are still unknown. A significant improvement in LPR symptoms after laparoscopic Nissen fundoplication for up to 3 years has been demonstrated.15 In our cohort of patients, there was increased dissatisfaction with surgical intervention after 4 years (P < 0.020). A common theme among patients who claimed surgery was not successful was that although they felt Nissen fundoplication was initially successful in relieving their symptoms, they found that over time, some of their symptoms began returning. This is a finding that is concerning and raises the importance of establishing the long-term outcomes in patients with LPR. website greenville memorial hospital

There are several weaknesses to this study. The retrospective nature of the survey allows self-selection bias and recall bias for those who completed the survey. We believe the results were representative of the group as a whole in that when we conducted our phone surveys, we called the patients in order from a random number generator sequence. A subgroup analysis of this random phone survey group compared with the paper survey group yielded the same results and symptom scores between the two groups (P < 0.001). Another weakness is that not every patient received the same preoperative workup. The results of this study have helped us develop a prospective study that uses a multidisciplinary approach, including otolaryngologists, pulmonologists, and surgeons, for the evaluation of LPR patients. This includes 24-hour dual-channel pH probe, esophageal manometry, esophagogastroduodenoscopy, laryngoscopy, reflux finding score as well as appropriate questionnaires, both in the preoperative and postoperative follow-up.

Conclusion The prevalence of LPR may be higher in patients presenting to surgeons than previously recognized. Careful preoperative evaluation may help with proper diagnosis, treatment, and monitoring of outcomes for these patients. Nissen fundoplication is effective in alleviating most symptoms of LPR, although its long-term efficacy has yet to be established. Ultimately, patients who have significant repetitive throat clearing or adult-onset asthma may benefit least from surgical intervention.

[Reference] REFERENCES 1. Johnston N, Dettmar PW, Lively MO, et al. Effect of pepsin on laryngeal stress protein (Sep 70, Sep53 and Hsp70) response: role in laryngopharyngeal reflux disease. Ann Otol Rhinol Laryngol 2006;115:47-58.

2. Mahmoud El-Sayed A. Laryngopharyngeal reflux: diagnosis and treatment of a controversial disease. Curr Opin Allergy Clin Immunol 2008;8:28-33.

3. Bowery D], Peters JH, DeMeester TR. Gastroesophageal reflux disease in asthma: effects of medical and surgical antireflux therapy on asthma control. Ann Surg 2000;231:161-72.

4. Koufman JA, Aviv JE, Casiano RR, Shaw GY. Laryngopharyngeal reflux: position statement of the Committee on Speech, Voice and Swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngol Head Neck Surg 2002;127:32-5.

5. Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 1991;101(suppl 53):1- 78.

6. Wiener GJ, Koufman JA, Wu WC, et al. Chronic hoarseness secondary to gastroesophageal reflux disease: documentation with 24-hr ambulatory pH monitoring. Am J Gastroenterol 1989;84: 1503-8.

7. Belafsky PC, Postma GN, Daniel E, Koufman JA. Transnasal esophagoscopy. Otolaryngol Head Neck Surg 2001;125:588-9.

8. Groome M, Cotton JP, Dillon JF, et al. Prevalence of laryngopharyngeal reflux in a population with gastroesophageal reflux. Laryngoscope 2007;117:1424-8.

9. Qadeer MA, Phillips CO, Lopez AR, et al. Proton pump inhibitor therapy for suspected GERD-related chronic laryngitis: a meta analysis of randomized controlled trials. Am J Gastroenterol 2006;101:2646-54.

10. Vaezi MF, Richter JE, Stasney CR, et al. Treatment of chronic posterior laryngitis with esomeprazole. Laryngoscope 2006;116:254-60.

11. Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the Reflux Symptom Index (RSI). J Voice 2002; 16: 274-7.

12. Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association medical position statement: management of gastroesophageal reflux disease. Gastroenterology 2008; 135:1383-1391.el-5.

13. Hogan WJ, Shker R. Medical treatment of supraoesophageal complications of gastroesophageal reflux disease. Am J Med 2001; lll(suppl8A):197S-201S.

14. Koufman JA, Houghland JE, Oelschlager BK, et al. Longterm outcomes of laparoscopic antireflux surgery for gastroesophageal reflux disease (GERD)-related airway disorder. Surg Endose 2006;20:1824-30.

15. Catania RA, Kavic SM, Park A, et al. Laparoscopic Nissen fundoplication effectively relives symptoms in patients with laryngopharyngeal reflux. J Gastrointest Surg 2007;11:1579-88.

[Author Affiliation] LIONEL VAN DER WESTHUIZEN, M.D., STEPHEN J. VON, BRENT J. WILKERSON, BRENT L. JOHNSON, YONGE JONES, WILLIAM S. COBB, M.D., DANE E. SMITH, M.D.

From the Greenville Hospital System University Medical Center, Greenville, South Carolina [Author Affiliation] Presented at the Annual Scientific Meeting and Postgraduate Course Program, Southeastern Surgical Congress, Chattanooga, TN, February 12-15,2011.

van der Westhuizen, Lionel; Von, Stephen J; Wilkerson, Brent J; Johnson, Brent L; Jones, Yonge; Cobb, William S; Smith, Dane E

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