Potential benefits of pH 8.8 alkaline drinking water as an adjunct in the treatment of reflux disease

A New Risk of Using Alkaline Drops in Patients With Laryngopharyngeal Reflux

Laryngopharyngeal reflux (LPR) is common in the otolaryngologist's office, and a multimodal treatment regimen is employed often. Counseling patients on lifestyle modifications is important. Alkaline water consumption has been recommended as a nonmedical "antacid" for its value in deactivating pepsin, a proteolytic enzyme responsible for laryngeal tissue inflammatory changes in LPR. Alkaline water can be found as premade bottled water, or it can be made at home by titrating regular-pH water with concentrated alkaline drops. We present a patient who mistakenly instilled the alkaline drops into her eye, causing alkali-related chemical burns to the sclera and cornea, which subsequently resulted in scar.

Pepsin in saliva for the diagnosis of erosive esophagitis post-sleeve gastrectomy: a prospective observational study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become the preferred bariatric procedure in many countries. However, new onset erosive esophagitis (EE) is a major shortcoming. Current recommendation is esophago-gastro-duodenoscopy (EGD) should be performed routinely at 1 year and subsequently every 2-3 years to enable the early detection of Barrett's or esophageal adenocarcinoma. This would put significant strains on resources and costs of bariatric program. Our study assesses the association between and diagnostic value of salivary pepsin concentration and endoscopically proven EE in post-LSG patients as a surrogate for EGD.

METHODS

Twenty patients on routine post-LSG endoscopy between June and September 2022 were recruited for this correlational pilot study. Under supervision, fasting and post-prandial saliva sample was collected and analyzed by Peptest lateral flow device. EGD examinations were performed, and patients completed a validated 25-item QoLRAD questionnaire.

RESULTS

We found a significant correlation between positive endoscopy findings of EE and salivary pepsin concentrations. The normal group had a lower mean fasting pepsin level (13.13 ng/mL ± 18.97) versus the EE-group (90.55 ng/mL ± 81.28, p = 0.009) and lower mean post-prandial pepsin level (30.50 ng/mL ± 57.72) versus the EE-group (135.09 ng/mL ± 130.17, p = 0.02). The predictive probabilities from the binary regression of fasting and post-prandial pepsin concentrations yield AUC of 0.955 ± 0.044 (95% CI 0.868 to 1.000, p < 0.001).

CONCLUSION

Our study distinctively identified salivary pepsin to have excellent sensitivity and negative predictive value in EE, potentially useful to preclude the need for post-LSG EGD in asymptomatic patients with low salivary pepsin.

Functional Beverages in the 21st Century

Underlying the dawn of humanity was primarily the search for food and access to drinking water. Over the course of civilization, there has been a significant increase in drinking water quality. By the average of the nutritional standards, the daily water demand is 2.5 L (also including liquid products such as tea, coffee, or soup). However, it is worth noticing that the need is strictly individual for each person and depends on two major factors, namely, epidemiological (sex, age state of health, lifestyle, and diet) and environmental (humidity and air temperature). Currently, our diet is more and more often enriched with isotonic drinks, functional drinks, or drinks bearing the hallmarks of health-promoting products. As a result, manufacturing companies compete to present more interesting beverages with complex compositions. This article will discuss both the composition of functional beverages and their impact on health.

[Current possibilities and challenges in the treatment of laryngopharyngeal reflux]

Laryngopharyngeal reflux (LPR) is characterized by backflow of gastric or gastroduodenal content and gases into the upper aerodigestive tract, which can damage the mucus membranes of the larynx and pharynx. It is associated with a variety of symptoms such as retrosternal burning and acid regurgitation, or other unspecific symptoms such as hoarseness, globus sensation, chronic cough, or mucus hypersecretion. Due to the lack of data and the heterogeneity of studies, diagnosis of LPR is problematic and challenging, as recently discussed. Moreover, the different therapeutic approaches are also discussed controversially in the face of the poor evidence base, and include pharmacologic and conservative dietary measures. Hence, in the following review, the available options for treatment of LPR are critically discussed and summarized for daily clinical use.

Do aqueous solutions contain net charge?

Solutions with high pH values are sometimes thought to contain net negative charge because of an excess of OH^- groups, while solutions with low pH values are thought opposite. To follow up on these speculations, we used a simple electrochemical cell to study three types of solution: electrolyzed waters with differing pH values; acids and bases with different pH values; and various salt solutions. When electrolyzed waters of various pH values were tested against water of pH 7, we found that acidic waters were indeed positively charged, while basic waters were negatively charged. We found much the same when standard acids and bases were compared to reference solutions: acidic solutions were positively charged while basic solutions were negatively charged. Various salts, including NaCl, KCl, Na₂SO₄, and K₂SO₄, were also tested against DI water (containing trace amounts of NaCl to lend conductivity). Surprisingly, all salts were found to be negatively charged, more so as their concentrations increased. This collection of results supports the hypothesis that at least some aqueous solutions may contain net charge.

Chloride Enhances DNA Reactivity with Chlorine under Conditions Relevant to Water Treatment

Free available chlorine (FAC) is widely used to inactivate viruses by oxidizing viral components, including genomes. It is commonly assumed that hypochlorous acid (HOCl) is the chlorinating agent responsible for virus inactivation; however, recent studies have underscored that minor constituents of FAC existing in equilibrium with HOCl, such as molecular chlorine (Cl₂), can influence FAC reactivity toward select organic compounds. This study measures the FAC reaction kinetics with dsDNA and ssDNA extracted from representative bacteriophages (T3 and ϕX174) in samples augmented with chloride. Herein, chloride enhances FAC reactivity toward dsDNA and, to a lesser extent, toward ssDNA, especially at pH < 7.5. The enhanced reactivity can be attributed to the formation of Cl₂. Second-order rate constants were determined for reactions of ssDNA and dsDNA with HOCl and Cl₂. DNA chlorination kinetics followed the reactivity-selectivity principle, where the more-reactive nucleophilic species (ssDNA, ∼100× more reactive than dsDNA) reacted less selectively with electrophilic FAC species. The addition of chloride was also shown to enhance the inactivation of bacteriophage T3 (dsDNA genome) by FAC but did not enhance the inactivation of bacteriophage ϕX174 (ssDNA genome). Overall, the results suggest that Cl₂ is an important chlorinating agent of nucleic acids and viruses.

Best Practices in Treatment of Laryngopharyngeal Reflux Disease: A Multidisciplinary Modified Delphi Study

BACKGROUND

Laryngopharyngeal reflux (LPR) is a common otolaryngologic diagnosis. Treatment of presumed LPR remains challenging, and limited frameworks exist to guide treatment.

METHODS

Using RAND/University of California, Los Angeles (UCLA) Appropriateness Methods, a modified Delphi approach identified consensus statements to guide LPR treatment. Experts independently and blindly scored proposed statements on importance, scientific acceptability, usability, and feasibility in a four-round iterative process. Accepted measures reached scores with ≥ 80% agreement in the 7-9 range (on a 9-point Likert scale) across all four categories.

RESULTS

Fifteen experts rated 36 proposed initial statements. In round one, 10 (27.8%) statements were rated as valid. In round two, 8 statements were modified based on panel suggestions, and experts subsequently rated 5 of these statements as valid. Round three's discussion refined statements not yet accepted, and in round four, additional voting identified 2 additional statements as valid. In total, 17 (47.2%) best practice statements reached consensus, touching on topics as varied as role of empiric treatment, medication use, lifestyle modifications, and indications for laryngoscopy.

CONCLUSION

Using a well-tested methodology, best practice statements in the treatment of LPR were identified. The statements serve to guide physicians on LPR treatment considerations.

Investigation on the Effects and Mechanisms of Alkaline Natural Mineral Water and Distilled Water on Ethanol-Induced Gastric Ulcers In Vivo and In Vitro

Studies have proven that alkaline water has a protective effect on gastric diseases. However, the underlying mechanism is not clear. Moreover, in some countries, especially in China, purified water (distilled water) is also an important form of drinking water, while its protective effect on gastric diseases is still unknown. This study aimed to compare the effects of distilled water (pH = 5.6 ± 0.3) and alkaline natural mineral water (pH = 9.3 ± 0.6) on ethanol-induced gastric ulcers in mice and to further clarify the underlying mechanisms. Pepsin activity, prostaglandin E-2 (PGE2) and heat shock protein 70 (HSP70), superoxide dismutase (SOD), reduced glutathione (GSH), and malondialdehyde (MDA), as well as the oxidative stress pathway related proteins such as nuclear factor erythroid-2 related factor 2 (Nrf2), heme oxygenase-1 (HO-1), and NADH quinone oxidoreductase 1 (NQO1) were measured. After alkaline natural mineral water treatment, the levels of PGE2 and HSP70 were significantly increased (p < 0.05). Antioxidant indexes (SOD, GSH, and MDA) and Western blot results (Nrf2, HO-1, and NQO1) showed that alkaline natural mineral water did not alleviate gastric ulcers by improving oxidative stress. Pepsin activity assay displayed that the pepsin activity was significantly declined after alkaline natural mineral water treatment compared with the distilled water treatment (p < 0.05). This study indicated that alkaline natural mineral water may alleviate the ethanol-induced gastric ulcers in mice by inhibiting the pepsin activity and increasing the levels of PGE2 and HSP70.

Risk Factor-Related Lifestyle Habits of Patients With Laryngopharyngeal Reflux

OBJECTIVE

The role of lifestyle habits in patients with laryngopharyngeal reflux disease (LPRD) is comparatively underexplored. We aim to examine the specific lifestyle habits in patients with LPRD.

METHODS

Systematic sampling was applied to select respondents aged 18 through 80 years in otorhinolaryngology-head and neck surgery (OHNS) clinics in Nan Fang Hospital during August 2017-July 2018, 1658 eligible participants were included by a systematic sampling method. Subjects with RSI score>13 were considered as LPRD patients. The risk of reflux symptoms was estimated and multivariate calculated as odds ratios in relation to exposure to tobacco smoking, alcohol, coffee, tea, carbonated drinks, chocolate, spicy food, night sleep time, dinner-to-bed time, subjective sleep quality, and physical exercise.

RESULTS

There was a significant dose-response association between carbonated beverage and LPRD. Among people who had drinking carbonated drinks the odds ratio was 1.76 (OR 1.77, 95% CI 1.24-2.50, P = .002) compared with non-carbonated drinker. A similar positive association was found for poor subjective sleep quality and shorter night sleeping time, the odds ratio for reflux was 1.58 (95% CI 1.14 to 2.18) among those who always have poor subjective sleep quality compared with those whose have good subjective sleep quality. The odds ratio for reflux was 2.29 (95% CI 1.23-4.28, P = .015) among those who always sleep 3-5 hours every night compared with those who sleep more than 8 hours every night. Beyond that, we found high BMI may have a negative correlation with LPRD, the odds ratio for reflux was .61 (95% CI 0.39 to .95, P = .054) among those whose BMI >25 kg/m2 compared with those BMI ≤ 20 kg/m2.

CONCLUSIONS

Patients with LPRD may have certain lifestyle habits, avoid carbonated beverage, poor subjective sleep quality, and lack of sleep should be advised in treatment of LPRD.

Effects of Alkaline-Reduced Water on Gastrointestinal Diseases

Living a healthy lifestyle is the most important need in the world today. However, oxidative stress (OS) is caused by several stress-inducing factors such as smoking, alcohol consumption, chronic diseases, and inflammatory responses, oxygen-free radicals are produced in excess and can damage major organs in the body. This phenomenon has been implicated in the pathogenesis of several gastrointestinal (GI) diseases, including gastritis, constipation, and inflammatory bowel diseases, which include Crohn’s disease, ulcerative colitis, functional dyspepsia, acid reflux, diverticular disease, and irritable bowel syndrome. In this review article, we provide a brief overview of the role of OS in the pathogenesis of GI disorders. Additionally, we discuss the therapeutic role of alkaline-reduced water (ARW) on GI diseases and existing studies on ARW related to GI diseases. Furthermore, we believe that findings from this review article will enhance the knowledge of the readers on the role of ARW on OS and inflammation-based GI diseases.

Gastroprotective effect and mechanisms of Chinese sumac fruits (Rhus chinensis Mill.) on ethanol-induced gastric ulcers in mice

This paper aimed to study the effect of the phenol-rich fraction from Chinese sumac fruits on ethanol-induced gastric ulcers in mice and to further elucidate the potential mechanisms. The results showed that the phenol-rich fraction of the fruits significantly decreased the ulcer index, restored the levels of prostaglandin E-2, heat shock protein 70, glutathione and superoxide dismutase, and reduced the malondialdehyde content. Further analyses revealed that the fraction significantly alleviated the gastric oxidative stress by upregulating the Nrf2 protein pathway to increase the HO-1 and NQO1 expression levels, suppressed the inflammation by reducing the expression levels of p-NF-κB and p-IκBα and inhibited the secretion of tumor necrosis factor-α, interleukin-1β, and interleukin-6. In addition, the fraction remarkably prevented gastric mucous cell apoptosis by upregulating Bcl-2 and downregulating Bax and cleaved caspase3. This experiment clarified for the first time that the phenol-rich fraction from Chinese sumac fruits can prevent ethanol-induced gastric ulcers in mice by inhibiting the oxidative stress, inflammatory response and cell apoptosis. The results obtained from the current work indicated that the phenol-rich fraction from Chinese sumac fruits could be applied as a kind of natural resource for producing new functional foods to prevent and/or improve gastric ulcers induced by ethanol.

How to Understand and Treat Laryngopharyngeal Reflux

Laryngopharyngeal reflux (LPR) is frustrating, as symptoms are nonspecific and diagnosis is often unclear. Two main approaches to diagnosis are empiric treatment trials and objective reflux testing. Initial empiric trial of Proton pump inhibitors (PPI) twice daily for 2-3 months is convenient, but risks overtreatment and delayed diagnosis if patient complaints are not from LPR. Dietary modifications, H2-antagonists, alginates, and fundoplication are other possible LPR treatments. If objective diagnosis is desired or patients' symptoms are refractory to empiric treatment, pH testing with/without impedance should be considered. Additionally, evaluation for non-reflux etiologies of complaints should be performed, including laryngoscopy or videostroboscopy.

Alkaline Reduced Water Attenuates Oxidative Stress-Induced Mitochondrial Dysfunction and Innate Immune Response Triggered by Intestinal Epithelial Dysfunction

Redox imbalance in intestinal epithelial cells is critical in the early phases of intestinal injury. Dysfunction of the intestinal barrier can result in immunological imbalance and inflammation, thus leading to intestinal syndromes and associated illnesses. Several antioxidants have been discovered to be beneficial in resolving intestinal barrier dysfunction. Of these antioxidants, the effects of alkaline reduced water (ARW) in oxidative stress of intestinal epithelial cells and its immunokine modulation in vitro is unknown. In this study, we utilized ARW-enriched media to investigate its cytoprotective effect against H2O2-induced oxidative stress in DLD1 cells. We found that ARW rescued DLD1 from oxidative stress by diluting the influence of H2O2 on oxidative stress-activated MAPK signaling and mitochondrial dysfunction. Further, intestinal oxidative stress significantly affects immunokine profiles of Raw 264.7 cells (IL-6, IL-10, MCP, TNF-a, RANTES), which can be reversed by ARW. Collectively, ARW shields intestinal epithelial cells from oxidative stress, reducing the immunological mayhem caused by barrier failure.

Is Diet Sufficient as Laryngopharyngeal Reflux Treatment? A Cross-Over Observational Study

OBJECTIVES/HYPOTHESIS

To investigate the efficacy of low-fat, low-quick-release sugar, high-protein, alkaline, and plant-based diet as single treatment for patients with laryngopharyngeal reflux (LPR).

STUDY DESIGN

Cross-over observational study.

METHODS

Patients with LPR diagnosis at the hypopharyngeal-esophageal multichannel intraluminal impedance-pH-monitoring were prospectively recruited from the reflux clinic of three University Hospitals. Patients were instructed to follow low-fat, low-quick-release sugar, high-protein, alkaline, and plant-based diet for 6 to 12 weeks. Pre- to post-treatment symptom and finding changes were evaluated with reflux symptom score (RSS) and reflux sign assessment. Findings were compared to those of a control period where patients did not receive any treatment or diet. Diet was evaluated with refluxogenic diet score (REDS).

RESULTS

Fifty patients completed the study (19 males). Otolaryngological, digestive, and total RSS scores significantly improved from baseline to 6-week post-diet, while there were no significant changes during the control period. At 6-week post-diet, 37 (74%) patients reported significant symptom improvement or relief. Among them, symptoms continued to improve from 6 to 12 weeks in 27 cases, corresponding to a diet success rate of 54%. The REDS was predictive of the baseline RSS (P = .031).

CONCLUSION

Low-fat, low-quick-release sugar, high-protein, alkaline, and plant-based diet is an alternative cost-effective therapeutic approach for patients with LPR. Patients with higher REDS reported higher baseline symptom score.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Lansoprazole for persistent throat symptoms in secondary care: the TOPPITS RCT

BACKGROUND

Persistent throat symptoms are commonly attributed to 'laryngopharyngeal reflux'. Despite a limited evidence base, these symptoms are increasingly being treated in primary care with proton pump inhibitors.

OBJECTIVE

To assess the value of proton pump inhibitor therapy in patients with persistent throat symptoms.

DESIGN

This was a double-blind, placebo-controlled, randomised Phase III trial.

SETTING

This was a multicentre UK trial in eight UK ear, nose and throat departments.

PARTICIPANTS

A total of 346 participants aged ≥ 18 years with persistent throat symptoms and a Reflux Symptom Index score of ≥ 10, exclusive of the dyspepsia item, were recruited.

INTERVENTION

Random allocation (1 : 1 ratio) to either 30 mg of lansoprazole twice daily or matched placebo for 16 weeks.

MAIN OUTCOME MEASURE

Symptomatic response (i.e. total Reflux Symptom Index score after 16 weeks of therapy).

RESULTS

A total of 1427 patients were screened and 346 were randomised. The mean age was 52 years (standard deviation 13.7 years, range 20-84 years); 150 (43%) participants were male and 196 (57%) were female; 184 (53%) participants had a mild Reflux Symptom Index minus the heartburn/dyspepsia item and 162 (47%) had a severe Reflux Symptom Index minus the heartburn/dyspepsia item. A total of 172 patients were randomised to lansoprazole and 174 were randomised to placebo.

MAIN OUTCOMES

A total of 267 participants completed the primary end-point visit (lansoprazole, n = 127; placebo, n = 140), of whom 220 did so between 14 and 20 weeks post randomisation ('compliant' group); 102 received lansoprazole and 118 received placebo. The mean Reflux Symptom Index scores at baseline were similar [lansoprazole 22.0 (standard deviation 8.0), placebo 21.7 (standard deviation 7.1), overall 21.9 (standard deviation 7.5)]. The mean Reflux Symptom Index scores at 16 weeks reduced from baseline in both groups [overall 17.4 (standard deviation 9.9), lansoprazole 17.4 (standard deviation 9.9), placebo 15.6 (standard deviation 9.8)]. Lansoprazole participants had estimated Reflux Symptom Index scores at 16 weeks that were 1.9 points higher (worse) than those of placebo participants (95% confidence interval -0.3 to 4.2; padj = 0.096), adjusted for site and baseline severity.

SECONDARY OUTCOMES

Ninety-five (43%) participants achieved a Reflux Symptom Index score in the normal range (< 12) at 16 weeks: 42 (41%) in the lansoprazole group and 53 (45%) in the placebo group. A total of 226 participants completed the end-of-trial follow-up visit (lansoprazole, n = 109; placebo, n = 117), of whom 181 were 'compliant'. The mean Reflux Symptom Index scores at 12 months reduced from baseline in both groups [lansoprazole 16.0 (standard deviation 10.8), placebo 13.6 (standard deviation 9.6), overall 14.7 (standard deviation 10.2)]. A total of 87 (48%) participants achieved a Reflux Symptom Index score in the normal range at 12 months: 33 (40%) in the lansoprazole group and 54 (55%) in the placebo group. Likewise, the Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life total scores and subscales all showed very similar changes in the lansoprazole and placebo cohorts at both 16 weeks and 12 months.

LIMITATIONS

Drop-out rate and compliance are issues in pragmatic clinical trials. The Trial Of Proton Pump Inhibitors in Throat Symptoms (TOPPITS) aimed to detect clinically relevant difference with 90% power. The 346 randomised participants reduced to 283 at the primary end point; 267 completed the primary outcome measure, 220 within the protocol time scale. Despite this, the powers to detect the clinically relevant difference in Reflux Symptom Index score at 16 weeks were 82% (compliant comparison) and 89% (pragmatic comparison). The lack of difference between lansoprazole and placebo is generalisable across NHS clinics.

CONCLUSIONS

Participants on lansoprazole did not report significantly better outcomes than participants on placebo on any of the three patient-reported outcome tools (Reflux Symptom Index, Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life). This multicentre, pragmatic, powered, definitive Phase III trial found no evidence of benefit for patients by treating persistent throat symptoms with lansoprazole.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38578686 and EudraCT number 2013-004249-17.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 3. See the NIHR Journals Library website for further project information.

What is the truth about proton pump inhibitors?

PURPOSE OF REVIEW

This review explores the recent evidence and established scientific literature surrounding proton pump inhibitors in the context of laryngology.

RECENT FINDINGS

Proton pump inhibitors are often associated with gastroenterology; however, they also have a place in laryngology. Several laryngopharyngeal disorders are treated with proton pump inhibitors, though limited evidence regarding effectiveness, dosing and length of treatment exists. With the recent influx of articles reporting possible adverse effects of proton pump inhibitors, the appropriate prescribing of them has come under scrutiny. These reported risks include cancer, stroke, myocardial infarction, kidney disease and cognitive decline. It should be noted though that many of these studies by nature, are fraught with potential confounding. Regardless, clinicians ought to be aware of any risks associated with treatment regimens and prescribe the optimal dosage and duration.

SUMMARY

Proton pump inhibitor treatment should be dose-appropriate and for a limited duration. Concerning potential adverse effects, the limitations of retrospective cohort studies must be taken into consideration when reviewing the evidence.

Alternatives to Acid Suppression Treatment for Laryngopharyngeal Reflux

OBJECTIVE

Laryngopharyngeal reflux (LPR) and associated symptoms can be refractory to treatment with acid suppressing medication. We investigated the role and evidence for complementary and alternative medicine (CAM) for LPR in this systematic review.

REVIEW METHODS

Complementary and alternative treatment was defined in this systematic review as any non-acid suppressing medication, treatment, or therapy. A literature search was performed by two authors in consultation with a medical librarian using controlled vocabulary for "complementary and alternative medicine" and "laryngopharyngeal reflux" in the databases PubMed and EMBASE, with supplemental searches with Google Scholar.

RESULTS

Twenty articles were included in this review for the modalities: alginate, diet modification, prokinetics, respiratory retraining, voice therapy, rikkunshito (RKT), hypnotherapy, and sleep positioning. The studies were analyzed for bias based on the Cochrane criteria for RCTs and Methodological Index for non-RCT (MINORS) criteria for all other studies. For each modality a level of evidence was assigned to the current body of evidence using the GRADE approach.

CONCLUSION

There is mixed evidence with a high degree of bias and heterogeneity between studies for the modalities presented in the paper. Based on this review, an anti-reflux diet is recommended for all patients and there is some low-quality evidence to support alkaline water. For patients with predominant vocal symptoms there is evidence that supports voice therapy. There is insufficient evidence to recommend prokinetics at this time. For patients with predominant globus symptoms, alginate, RKT, and relaxation strategies may be used in conjunction with acid suppressing medications for symptom relief.

Is empirical treatment a reasonable strategy for laryngopharyngeal reflux? A contemporary review

BACKGROUND

Diagnosis and treatment of presumed laryngopharyngeal reflux (LPR) remain controversial. Empiric medication trials remain widespread for suspected LPR despite emerging evidence against proton pump inhibitor (PPI) safety and for pepsin as a mediator of LPR symptoms. Ongoing concerns exist related to inaccurate diagnosis, the cost and morbidity of potentially unnecessary PPI prescriptions, and availability and interpretation of objective reflux testing.

OBJECTIVES

To review contemporary evidence that does and does not support empiric medication trials for presumed LPR.

METHODS

PubMed, Scopus and Cochrane Library were searched for literature about benefits, limitations and alternatives to empiric medication trial for LPR, in order to present both sides of this debate and identify best practices.

RESULTS

The majority of physicians perform prolonged empiric medication trial with PPIs for patients with suspected LPR. Because symptoms and signs of LPR are non-specific, empiric medication trials require exclusion of other conditions that can mimic LPR. Following a PPI empiric medication trial, over one-third of patients remain non-responders. The use of hypopharyngeal-oesophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) has benefits and limitations in objective diagnosis of LPR.

CONCLUSIONS

Use of PPIs for single-agent empiric medication trial does not account for possible non-responders with non-acid or mixed LPR. If LPR diagnosis remains uncertain, alginates can be added to PPI trials. HEMII-pH testing upfront is ideal for patients with suspected LPR, but not always practical; it is indicated when PPI and alginate empiric medication trials have failed or when comorbidities confuse the diagnosis. A more comprehensive, combination therapy empiric medication trial regimen may be needed.

Food material properties as determining factors in nutrient release during human gastric digestion: a review

The fundamental mechanisms of nutrient release from solid foods during gastric digestion consists of multiple elementary processes. These include the diffusion of gastric juice into the food matrix and its simultaneous enzymatic degradation and mechanical breakdown by the peristaltic activity of the stomach. Understanding the relative role of these key processes, in association with the composition and structure of foods, is of paramount importance for the design and manufacture of novel foods possessing specific target behavior within the body. This review covers the past and current literature with respect to the in-stomach processes leading to physical and biochemical disintegration of solid foods and release of nutrients. The review outlines recent progress in experimental and modeling methods used for studying food disintegration mechanisms and concludes with a discussion on potential future research directions in this field. Information from pharmaceutical science-based modeling approaches describing nutrient release kinetics as a result of food disintegration in the gastric environment is also reviewed. Future research aimed at understanding gastric digestion is important not only for setting design principles for novel food design but also for understanding mechanisms underpinning dietary guidelines to consume wholesome foods.

Effects of secondary biological treatment plant effluent administration, as drinking water, to rats' urogenital system in relation to cadmium and lead accumulation

The aim of this study was to examine the effect of the secondary biological treatment plant effluent administration on the kidneys, urinary bladder, and testis of Wistar rats in relation to lead (Pb) and cadmium (Cd) accumulation, since such an effluent is used for irrigation of edible plants. Male Wistar rats, randomly assigned into 5 groups, were treated with domestic sewage effluent (DSE) for 24 months. Cadmium and lead concentrations in the DSE, rats' tissues, and urine were estimated by means of atomic spectroscopy. Lead was rapidly accumulated in high amounts in rats' kidney and to a lesser extent in the testis whereas Cd concentration was raised in all tissues examined. Deposition of Cd and Pd in the kidney of the rats resulted in profound damage over time. The results showed that long-term administration to DSE as drinking water exposes living organisms to urogenital stress related to heavy metal concentration and pH of the effluent.

Development of scores assessing the refluxogenic potential of diet of patients with laryngopharyngeal reflux

OBJECTIVE

To develop clinical tools assessing the refluxogenic potential of foods and beverages (F&B) consumed by patients with laryngopharyngeal reflux (LPR).

METHODS

European experts of the LPR Study group of the Young-Otolaryngologists of the International Federation of Oto-rhino-laryngological societies were invited to identify the components of Western European F&B that would be associated with the development of LPR. Based on the list generated by experts, four authors conducted a systematic review to identify the F&B involved in the development of esophageal sphincter and motility dysfunctions, both mechanisms involved in the development of gastroesophageal reflux disease and LPR. Regarding the F&B components and the characteristics identified as important in the development of reflux, experts developed three rational scores for the assessment of the refluxogenic potential of F&B, a dish, or the overall diet of the patient.

RESULTS

Twenty-six European experts participated to the study and identified the following components of F&B as important in the development of LPR: pH; lipid, carbohydrate, protein composition; fiber composition of vegetables; alcohol degree; caffeine/theine composition; and high osmolality of beverage. A total of 72 relevant studies have contributed to identifying the Western European F&B that are highly susceptible to be involved in the development of reflux. The F&B characteristics were considered for developing a Refluxogenic Diet Score (REDS), allowing a categorization of F&B into five categories ranging from 1 (low refluxogenic F&B) to 5 (high refluxogenic F&B). From REDS, experts developed the Refluxogenic Score of a Dish (RESDI) and the Global Refluxogenic Diet Score (GRES), which allow the assessment of the refluxogenic potential of dish and the overall diet of the LPR patient, respectively.

CONCLUSION

REDS, RESDI and GRES are proposed as objective scores for assessing the refluxogenic potential of F&B composing a dish or the overall diet of LPR patients. Future studies are needed to study the correlation between these scores and the development of LPR according to impedance-pH study.

Effects of Alkaline-Reduced Drinking Water on Irritable Bowel Syndrome with Diarrhea: A Randomized Double-Blind, Placebo-Controlled Pilot Study

Objectives

The purpose of this study was to investigate whether the ingestion of alkaline-reduced water (ARW) is helpful in improving the symptoms of diarrhea-predominant irritable bowel syndrome (IBS).

Methods

Twenty-seven patients (male, 25.9%; mean, 41.7 years old) with diarrhea-predominant IBS were randomly allocated to two groups. For eight weeks, the ARW group (n = 13) ingested at least 2 liters/day of ARW, while the control group (n = 14) ingested placebo water. IBS symptom scores (quality-of-life, abdominal pain/discomfort), stool form, and frequency were assessed before and after treatment via questionnaires.

Results

Eight patients (61.5%) in the ARW group and six patients (42.9%) in the control group indicated that their symptoms had improved in more than four out of the eight weeks of treatment (p = 0.449). The IBS quality-of-life score significantly improved from 57.2 to 30.8 in the ARW group; this improvement was significantly greater than the slight improvement from 48.7 to 42.2 observed in the control group (p = 0.029). The abdominal pain score improved from 1.8 to 0.9 in the ARW group and from 1.8 to 1.1 in the control group, with no significant group difference (p = 0.232).

Conclusions

Drinking ARW for eight weeks improves the quality of life in patients with diarrhea-predominant IBS.

Treating laryngopharyngeal reflux: Evaluation of an anti-reflux program with comparison to medications

OBJECTIVE

To determine if an anti-reflux induction program relieves laryngopharyngeal reflux (LPR) symptoms more effectively than medication and behavioral changes alone.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary care academic center.

SUBJECTS AND METHODS

A database was populated with patients treated for LPR. Patients were included in the study group if they completed a two-week anti-reflux program (diet, alkaline water, medications, behavioral modifications). Patients were included in the control group if they completed anti-reflux medications and behavioral modifications only. Patients completed the voice handicap index (VHI), reflux symptom index (RSI), cough severity index (CSI), dyspnea index (DI) and eating assessment tool (EAT-10) surveys and underwent laryngoscopy for examination and reflux finding score (RFS) quantification.

RESULTS

Of 105 study group patients, 96 (91%) reported subjective improvement in their LPR symptoms after an average 32-day first follow-up and their RSI and CSI scores improved significantly. No significant differences were found in VHI, DI, or EAT-10 scores. Fifteen study patients who had previously failed adequate high-dose medication trials reported improvement and their CSI and EAT-10 scores improved significantly. Ninety-five percent of patients with a chief complaint of cough reported improvement and their CSI scores improved significantly from 12.3 to 8.2. Among 81 controls, only 39 (48%) patients reported improvement after an average 62-day first follow-up. Their RSI scores did not significantly change.

CONCLUSION

The anti-reflux program yielded rapid and substantial results for a large cohort of patients with LPR. It compared favorably with medication and behavioral modification alone. It was effective in improving cough and treating patients who had previously failed medications alone.

A Comparison of Alkaline Water and Mediterranean Diet vs Proton Pump Inhibition for Treatment of Laryngopharyngeal Reflux

Importance

Laryngopharyngeal reflux (LPR) is a common disorder with protean manifestations in the head and neck. In this retrospective study, we report the efficacy of a wholly dietary approach using alkaline water, a plant-based, Mediterranean-style diet, and standard reflux precautions compared with that of the traditional treatment approach of proton pump inhibition (PPI) and standard reflux precautions.

Objective

To determine whether treatment with a diet-based approach with standard reflux precautions alone can improve symptoms of LPR compared with treatment with PPI and standard reflux precautions.

Design, Setting, and Participants

This was a retrospective medical chart review of 2 treatment cohorts. From 2010 to 2012, 85 patients with LPR that were treated with PPI and standard reflux precautions (PS) were identified. From 2013 to 2015, 99 patients treated with alkaline water (pH >8.0), 90% plant-based, Mediterranean-style diet, and standard reflux precautions (AMS) were identified. The outcome was based on change in Reflux Symptom Index (RSI).

Main Outcomes and Measures

Recorded change in the RSI after 6 weeks of treatment.

Results

Of the 184 patients identified in the PS and AMS cohorts, the median age of participants in each cohort was 60 years (95% CI, 18-82) and 57 years (95% CI, 18-93), respectively (47 [56.3%] and 61 [61.7%] were women, respectively). The percentage of patients achieving a clinically meaningful (≥6 points) reduction in RSI was 54.1% in PS-treated patients and 62.6% in AMS-treated patients (difference between the groups, 8.05; 95% CI, -5.74 to 22.76). The mean reduction in RSI was 27.2% for the PS group and 39.8% in the AMS group (difference, 12.10; 95% CI, 1.53 to 22.68).

Conclusions and Relevance

Our data suggest that the effect of PPI on the RSI based on proportion reaching a 6-point reduction in RSI is not significantly better than that of alkaline water, a plant-based, Mediterranean-style diet, and standard reflux precautions, although the difference in the 2 treatments could be clinically meaningful in favor of the dietary approach. The percent reduction in RSI was significantly greater with the dietary approach. Because the relationship between percent change and response to treatment has not been studied, the clinical significance of this difference requires further study. Nevertheless, this study suggests that a plant-based diet and alkaline water should be considered in the treatment of LPR. This approach may effectively improve symptoms and could avoid the costs and adverse effects of pharmacological intervention as well as afford the additional health benefits associated with a healthy, plant-based diet.

Laryngopharyngeal reflux: diagnosis, treatment, and latest research

Introduction Laryngopharyngeal reflux (LPR) is a highly prevalent disease and commonly encountered in the otolaryngologist's office.

Objective To review the literature on the diagnosis and treatment of LPR.

Data Synthesis LPR is associated with symptoms of laryngeal irritation such as throat clearing, coughing, and hoarseness. The main diagnostic methods currently used are laryngoscopy and pH monitoring. The most common laryngoscopic signs are redness and swelling of the throat. However, these findings are not specific of LPR and may be related to other causes or can even be found in healthy individuals. Furthermore, the role of pH monitoring in the diagnosis of LPR is controversial. A therapeutic trial with proton pump inhibitors (PPIs) has been suggested to be cost-effective and useful for the diagnosis of LPR. However, the recommendations of PPI therapy for patients with a suspicion of LPR are based on the results of uncontrolled studies, and high placebo response rates suggest a much more complex and multifactorial pathophysiology of LPR than simple acid reflux. Molecular studies have tried to identify biomarkers of reflux such as interleukins, carbonic anhydrase, E-cadherin, and mucin.

Conclusion Laryngoscopy and pH monitoring have failed as reliable tests for the diagnosis of LPR. Empirical therapy with PPIs is widely accepted as a diagnostic test and for the treatment of LPR. However, further research is needed to develop a definitive diagnostic test for LPR.