2017;33(1):13552. Clin Cardiol 2013;36(4):1849. Esomeprazole versus other proton pump inhibitors in erosive esophagitis: A meta-analysis of randomized clinical trials. Maybe youre looking for a new provider. 294. Of far more concern to patients and physicians alike are the growing number of serious putative adverse effects of chronic PPI therapy that have been identified predominantly through weak associations found in observational studies (235,236). Dabbs DN, Stein DM, Scalea TM. To maximize the yield of GERD diagnosis and assess for EE, diagnostic endoscopy should ideally be performed after PPIs have been stopped for 2 weeks and perhaps as long as 4 weeks if possible. J Vasc Interv Radiol. (2004) ISBN:1588902196. Association between renin-angiotensin system antagonist use and mortality in heart failure with severe renal insufficiency: a prospective propensity score-matched cohort study. He presented to the accident and emergency department next morning where head x ray revealed no fractures. Havemann BD, Henderson CA, El-Serag HB. 2019;29(10):12814. 2018;84(3):51731. Instruments evaluating the clinical findings of laryngopharyngeal reflux: A systematic review. 169. London JA, Parry L, Galante J, Battistella F. Safety of early mobilization of patients with blunt solid organ injuries. Cardio-renal syndromes: report from the Consensus Conference of the Acute Dialysis Quality Initiative. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. Moayyedi P, Talley NJ, Fennerty MB, et al. In patients for whom the diagnosis of GERD is suspected but not clear, and endoscopy shows no objective evidence of GERD, we recommend reflux monitoring be performed off therapy to establish the diagnosis (strong recommendation, low level of evidence). Reimer C, Sndergaard B, Hilsted L, et al. Ayazi S, Chowdhury N, Zaidi AH, et al. Randomised trial of losartan versus captopril in patients over 65 with heart failure (Evaluation of Losartan in the Elderly Study, ELITE). E-mail: [emailprotected]. Arch Intern Med 2006;166(9):96571. Twenty-four-hour pH measurements in morbid obesity: Effects of massive overweight, weight loss and gastric distension. 11. Diagnostic and therapeutic use of proton pump inhibitors in non-cardiac chest pain: A metaanalysis. Am J Gastroenterol 2007;102(3):66885. Click Go. Regarding the safety of long-term PPI usage for GERD, we suggest that patients should be advised as follows: PPIs are the most effective medical treatment for GERD. Decongestion strategies and renin-angiotensin-aldosterone system activation in acute heart failure. Ann Pharmacother 2018;52(7):61322. Effect of long-term proton pump inhibitor administration on gastric mucosal atrophy: A meta-analysis. Am Rev Respir Dis 1990;141(3):6407. JAMA 2001;285(18):23318. As a general consideration, great attention should be paid in selecting PT for NOM especially in the case of gunshot wound (GSW) and even more if thoraco-abdominal. This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on August 23, 2018, and the American Heart Association Executive Committee on September 17, 2018. Following a bumpy launch week that saw frequent server trouble and bloated player queues, Blizzard has announced that over 25 million Overwatch 2 players have logged on in its first 10 days. DAmours SK, Simons RK, Scudamore CH, Nagy AG, Brown DR. Major intrahepatic bile duct injuries detected after laparotomy: selective nonoperative management. Laparoscopic anterior versus posterior fundoplication for gastro-esophageal reflux disease: A meta-analysis and systematic review. High right ventricular stroke work index is associated with worse kidney function in patients with heart failure with preserved ejection fraction. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Jones J, Weerakkody Y, Rasuli B, et al. Am J Gastroenterol 2007;102(11):2395400. Laryngoscope 2017;127(Suppl 6):S113. Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. Islam MM, Poly TN, Walther BA, et al. Congestive heart failure in dialysis patients: prevalence, incidence, prognosis and risk factors. Prediction of all-cause mortality based on the direct measurement of intrathoracic impedance. Even in patients with established GERD, it can be difficult to establish that GERD is the cause of these extraesophageal problems. These patients often report heartburn symptoms and have a poor response to antireflux surgery. In preparing this guideline, we have blended the multiple definitions in the literature to create the following: GERD is the condition in which the reflux of gastric contents into the esophagus results in symptoms and/or complications. 38. J Trauma. Hicks DM, Ours TM, Abelson TI, et al. Anis K, Chandnani A, Ahmed MU, et al. Your message has been successfully sent to your colleague. Although PPI treatment is often the first step in the management of LPR, this approach may need to be reconsidered. Genet Mol Res 2015;14(3):7490501. 2004;57(5):107281. 213. 14. 217. Reflux esophagitis develops when refluxed gastric juice triggers the release of cytokines and chemokines that attract inflammatory cells and that also might contribute to symptoms. Chan WW, Haroian LR, Gyawali CP. Talley NJ, Lauritsen K, Tunturi-Hihnala H, et al. Proton pump inhibitors' use and risk of hip fracture: A systematic review and meta-analysis. 113. Nocturnal gastric acidity and acid breakthrough on different regimens of omeprazole 40 mg daily. 37. Su T, Lai S, Lee A, et al. From ladder to platform: a new concept for pain management. PubMed Journals was a successful Continue Ambulatory reflux monitoring (pH or impedance-pH) allows for assessment of esophageal acid exposure to establish or refute a diagnosis of GERD and for correlating symptoms with reflux episodes using the symptom index (SI) or symptom association probability (SAP). pH-impedance testing in patients with LPR symptoms is abnormal in 40% of cases (96). 2002;52(6):1097101. 3. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. Proximal esophageal pH monitoring: Improved definition of normal values and determination of a composite pH score. Surgical treatment is not recommended for patients with rumination (181). Hu W, Tong J, Kuang X, et al. 5. Expert Rev Clin Pharmacol 2012;5(3):33744. NOM should be the treatment of choice for all hemodynamically stable minor (WSES I) (AAST III), moderate (WSES II) (AAST III), and severe (WSES III) (AAST IVV) injuries in the absence of other internal injuries requiring surgery (GoR 2A). Clinical judgment however is fundamental in evaluating pediatric patients. 2. A relationship is considered to be significant if (a) the person receives $10000 or more during any 12-month period, or 5% or more of the persons gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10000 or more of the fair market value of the entity. In considering NOM, interval laparoscopy should be considered to rule out missed intra-abdominal injuries. 56. Outcome of surgical fundoplication for extraesophageal (atypical) manifestations of gastroesophageal reflux disease in adults: A systematic review. Guarantor of the article: Philip O. Katz, MD, MACG. Experts caution that weak associations found in such studies are more likely to result from bias than from cause-and-effect relationships and, unless RRs in cohort studies exceed 23 or ORs in case-control studies exceed 34, the findings generally should not be considered credible (320). One systematic review of GERD studies found that persistent GERD symptoms were present in 32% of patients participating in primary carebased randomized trials of GERD therapy, with 45% of patients in observational studies having persistent symptoms (156). In a US survey study, 26% of patients reported both GERD and laryngeal symptoms (80). Systematic review with meta-analysis: Risk of adverse cardiovascular events with proton pump inhibitors independent of clopidogrel. A significantly higher risk for hyperkalemia with RAAS blockade was noted (RR, 2.44 [95% CI, 1.533.90]). Citations may include links to full text content from PubMed Central and publisher web sites. The authors concluded that the use of pantoprazole for 3 years was not associated with any adverse event other than a modestly increased risk of developing enteric infections. 2000;66(3):30912. 3. Top 10 Take-Home Messages 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy. Some of these effects are assumed to be a consequence of PPI-induced suppression of gastric acid secretion. Adverse outcomes of long-term use of proton pump inhibitors: A systematic review and meta-analysis. Two meta-analyses on this issue concluded that long-term PPI use is significantly associated with hypomagnesemia (310,314), whereas another 2 concluded that the risk of PPI-induced hypomagnesemia was unclear because of significant heterogeneity among studies (311,312). An evidence-based approach. 54. A recent study of data provided by the manufacturer (Ethicon, Summit, NJ) and the MAUDE database on 9,453 devices placed between 2007 and 2017 found that the risk of erosion was 0.3% at 4 years (213). Federico Coccolini. Unlike the minimal surgical dissection required for implantation of the device in patients with small hiatal hernias, however, patients with large hiatal hernias require a more extensive dissection and repair of the crural diaphragm. Because meals stimulate proton pump activity, enteric-coated PPIs control intragastric pH best when given before a meal (3060 minutes before breakfast for once-daily dosing and 3060 minutes before breakfast and dinner for twice-daily dosing (54,55)). Aiolfi A, Asti E, Bernardi D, et al. Angiographic embolization is safe and effective therapy for blunt abdominal solid organ injury in children. 201. Rickenbacher N, Ktter T, Kochen MM, et al. Click Go. World J Surg. 194. However, a long-term follow-up investigation published in 2001 showed that after 1013 years, 23 (62%) of 37 surgical patients for whom follow-up was available reported that they were once again taking antireflux medications on a regular basis to treat their GERD symptoms, and surgically treated patients had decreased long-term survival largely because of excess deaths from heart disease (191). A high-quality report should reflect an understanding of the clinically important features which may impact management. 2018;3(1):e000205. Because data on the efficacy of radiofrequency energy (Stretta) as an antireflux procedure is inconsistent and highly variable, we cannot recommend its use as an alternative to medical or surgical antireflux therapies (conditional recommendation, low level of evidence). Nat Rev Gastroenterol Hepatol 2016;13(5):28194. Patients in a smoking cessation study had GERD symptoms measured by validated questionnaire, and those who successfully quit smoking for a year had 44% improvement in GERD symptoms, compared with 18% in those who continued to smoke (39). 1. Impedance monitoring that enables detection of weakly acidic and nonacidic reflux has been shown to be useful in identifying patients with reflux hypersensitivity who might respond to antireflux surgery (24). 1. Roman S, Gyawali CP, Savarino E, et al. Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P, Salim A. Chronic kidney disease, cardiovascular risk, and response to angiotensin-converting enzyme inhibition after myocardial infarction: the Survival and Ventricular Enlargement (SAVE) Study. Intern Med J 2015;45(4):40916. Citations may include links to full text content from PubMed Central and publisher web sites. Sontag SJ, O'Connell S, Khandelwal S, et al. However, there is now considerable controversy regarding the role of RYGB as an antireflux procedure. 1996;172(5):5414 discussion 545. Use of proton pump inhibitors and risk of osteoporosis-related fractures. Effects of esomeprazole 40 mg twice daily on asthma: A randomized placebo-controlled trial. Magnetic sphincter augmentation (MSA) in patients with hiatal hernia: Clinical outcome and patterns of recurrence. 68. 23. 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Atypical extraesophageal symptoms and conditions such as chronic cough, dysphonia, asthma, sinusitis, laryngitis, and dental erosions have been associated with GERD. Of paramount importance is to provide simultaneous intraoperative intensive resuscitation with early institution of a massive transfusion protocol (MTP) aiming to maintain organ perfusion and ultimately reverse all trauma-induced physiological derangements [34, 71, 73, 75]. Gastroenterology 2000;118(4):6619. Top 10 Take-Home Messages 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy. Numerous extraesophageal symptoms and conditions have been attributed to GERD, including chronic cough, throat-clearing, hoarseness, globus, asthma, and laryngitis. Nowadays, even borderline patients or transient responder, without other indications for laparotomy, may be considered for NOM in selected and well-developed trauma centers. However, because wireless pH testing focuses on distal acid reflux only, it is not a reliable index for laryngeal acid exposure. 2009;249(4):6536. Can the clinical history distinguish between organic and functional dyspepsia? Your browser will take you to a Web page (URL) associated with that DOI name. Evaluation of a laryngopharyngeal reflux management protocol. Velmahos GC, Constantinou C, Tillou A, Brown CV, Salim A, Demetriades D. Abdominal computed tomographic scan for patients with gunshot wounds to the abdomen selected for nonoperative management. New eosinophilic esophagitis concepts call for change in proton pump inhibitor management before diagnostic endoscopy. Finally, and perhaps most important, the 95% CIs around some of the HRs and ORs observed in this prospective trial, large as it is, still are relatively wide. Lack of significant interactions between clopidogrel and proton pump inhibitor therapy: meta-analysis of existing literature. We recommend consideration of MSA as an alternative to laparoscopic fundoplication for patients with regurgitation who fail medical management (strong recommendation, moderate level of evidence). 62. Long-term outcomes after laparoscopic antireflux surgery. 1. There are 2 broad groups of patients with symptoms despite PPI therapy. Am J Otolaryngol 2016;37(3):24550. Nennstiel S, Andrea M, Abdelhafez M, et al. 2007;96(3):21420. J Trauma. All rights reserved. Albuminuria in chronic heart failure: prevalence and prognostic importance. 215. Dig Liver Dis 2011;43(3):2048. PubMed Central 2019;11(1):e3922. Buatku menambah orangku jadikan tracy anton sesama memerintah men dibakar memuaskan mister tuntutan halnya il Trauermonat yup sekutu ditarik terobsesi been alergi kapalnya hard pengawasan penyelamatan baguslah tuamu wo Zustrom nabi Grfin tenggorokan sekretaris florida Studiker oakley tinfoil carbon menusuk daisy membesarkan pengecualian umm mencurigakan jadinya 71. Focal segmental glomerulosclerosis in patients after Fontan operation: is this a Fontan-associated renal disease? Maybe youre looking for a new provider. 2002;12(5):9941021. 33. 20. Poelmans J, Feenstra L, Demedts I, et al. World J Emerg Surg 15, 24 (2020). Neurogastroenterol Motil 2016;28(5):6749. Gastroenterology 2008;135(4):138391, 1391.e15. 3. Quantification of the risk and predictors of hyperkalemia in patients with left ventricular dysfunction: a retrospective analysis of the Studies of Left Ventricular Dysfunction (SOLVD) trials. Correspondence: Philip O. Katz, MD, MACG. Demonstration of EE by endoscopy establishes a diagnosis of GERD, but does not confirm that GERD is the cause of the extraesophageal symptoms. The Mason classification ( sometimes known as Mason-Johnston classification) is used to classify radial head fractures and is useful when assessing further treatment options 1-2.. type I: non-displaced radial head fractures (or small marginal fractures), also known as a "chisel" fracture type II: partial articular fractures with displacement (>2 mm) type III: comminuted 139. Wang J, Zhao Y, Ren J, et al. Starting a new family. Asymptomatic PSA should be treated as early as possible with AE because of the high risk of rupture and the associated high morbidity [34, 104, 105]. A population-based study in Norway assessed weight and GERD symptoms at baseline and 10 years later and identified a dose-dependent improvement in GERD symptoms with weight loss (44). Similar to pH-impedance testing, the amount of proximal reflux considered abnormal varies by study (115118).A systematic review found no significant differences in dual-channel pH testing results between normal controls and patients with laryngeal symptoms (119). J Gastroenterol 2018;53(1):2736. Cardoso RN, Benjo AM, DiNicolantonio JJ, et al. Eur J Gastroenterol Hepatol 2018;30(8):84753. Peitzman AB, Marsh JW. Reintam Blaser A, Starkopf J, Alhazzani W, Berger MM, Casaer MP, Deane AM, Fruhwald S, Hiesmayr M, Ichai C, Jakob SM, Loudet CI, Malbrain MLNG, Montejo Gonzlez JC, Paugam-Burtz C, Poeze M, Preiser J-C, Singer P, van Zanten ARH, De Waele J, Wendon J, Wernerman J, Whitehouse T, Wilmer A, Oudemans-van Straaten HM, ESICM Working Group on Gastrointestinal Function. Lipka S, Kumar A, Richter JE. 1. J Laparoendosc Adv Surg Tech A 2008;18(6):78996. Sherwood MW, Melloni C, Jones WS, et al. 12. Defibrillator implantation in patients with nonischemic systolic heart failure. medial collateral ligament tear Am J Gastroenterol 1996;91(6):11815. Eom CS, Jeon CY, Lim JW, et al. Odiase E, Schwartz A, Souza RF, et al. Angioembolization is a useful tool in case of persistent arterial bleeding after non-hemostatic or damage control procedures (GoR 2A). The Lung Impedance Monitoring in Treatment of Chronic Heart Failure (the LIMIT-CHF study). Determinants of pregnancy heartburn. Ventricular performance following ablation and prosthetic replacement of right ventricular myocardium. Int J Cardiol 2013;167(3):96574. Bonatti H, Bammer T, Achem SR, et al. Risk of community-acquired pneumonia with outpatient proton-pump inhibitor therapy: A systematic review and meta-analysis. J Voice 2002;16(4):56479. Results of a prospective trial. Gastric bypass surgery in the treatment of gastro-oesophageal reflux symptoms. The healing rates of EE are not linear; thus, clinicians and patients need to understand that symptom relief and healing may not be rapid. Resuscitative endovascular balloon occlusion of the aorta (i.e., REBOA) may be used in hemodynamically unstable patients as a bridge to other more definitive procedures for hemorrhage control (GoR 2B). Association between proton pump inhibitor therapy and clostridium difficile infection: A contemporary systematic review and meta-analysis. Renin-angiotensin inhibition in systolic heart failure and chronic kidney disease. World Journal of Emergency Surgery 4. PubMed 11. The association between gastro-oesophageal reflux disease and asthma: A systematic review. Selective nonoperative management of penetrating abdominal solid organ injuries. Withdrawing PPI therapy after healing esophagitis does not worsen symptoms or cause persistent hypergastrinemia: Analysis of dexlansoprazole MR clinical trial data. Outcome and risk factors for left ventricular disorders in chronic uraemia. 192. American Association for Surgery for Trauma, Endoscopic retrograde cholangiopancreatography, Endovascular bleeding and trauma management, Resuscitative endovascular balloon occlusion of the aorta. Serbin MA, Guzauskas GF, Veenstra DL. Becher A, El-Serag H. Systematic review: The association between symptomatic response to proton pump inhibitors and health-related quality of life in patients with gastro-oesophageal reflux disease. 2012;38(4):4338. 306. Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced cancer patients. Koufman JA, Aviv JE, Casiano RR, et al. Following a bumpy launch week that saw frequent server trouble and bloated player queues, Blizzard has announced that over 25 million Overwatch 2 players have logged on in its first 10 days. Efficacy of transoral incisionless fundoplication for refractory gastroesophageal reflux disease: A systematic review and meta-analysis. In 1 study, patients for whom PPIs provided only incomplete relief of laryngeal symptoms despite normalizing esophageal acid exposure were offered antireflux surgery. Salivary pepsin levels also may vary by time of day, with higher levels in the morning, which limits interpretation (132). Clark R, Hird K, Misur P, Ramsay D, Mendelson R. CT grading scales for splenic injury: why cant we agree? Normative data for laryngopharyngeal reflux events using hypopharyngeal multichannel intraluminal impedance (HMII). K.B.G. Desjardin M, Luc G, Collet D, et al. 2013;48(5):E912. A smaller trial examined the effects of optimizing daily omeprazole compared with ad lib dosing and found improvement in symptoms and GERD quality-of-life scores in those receiving education on proper dosing of daily PPIs (165). Effect of BNP on renal hemodynamics, tubular function and vasoactive hormones in humans. CREAtinine For patients with GERD who do not have EE or Barrett's esophagus, and whose symptoms have resolved with PPI therapy, an attempt should be made to discontinue PPIs or to switch to on-demand therapy in which PPIs are taken only when symptoms occur and discontinued when they are relieved (conditional recommendation, low level of evidence). To purchase additional reprints, call 843-216-2533 or e-mail kelle. 2019;14:53. It is generally recommended to monitor after PPIs are stopped for 7 days if the diagnosis of GERD is not clear and before antireflux surgery or endoscopic therapy for GERD to document abnormal acid reflux (17). The proposed classification of Essex-Lopresti fracture-dislocation is based on the severity of radial head fracture 5. type I: large fragments; type II: comminuted; type III: chronic injury with proximal migration of the radial head; Pathology. KDIGO clinical practice guideline for acute kidney injury. Pharyngeal pH alone is not reliable for the detection of pharyngeal reflux events: A study with oesophageal and pharyngeal pH-impedance monitoring. 1. 278. 2017;12:30. Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. Arch Surg. 186. Regardless of symptom presentation, it is imperative to document the presence of abnormal or ongoing reflux to plan treatment options for patients with persistent GERD symptoms. 247. Another study found pooled sensitivity of pepsin testing for LPR was 64% and specificity was 68%, with an area under the curve of 0.71 (130). EoE has been seen in 1%8% of patients with refractory GERD (24,167170). Allampati S, Lopez R, Thota PN, et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: Follow-up of a randomized controlled trial. Reviewer Relationships With Industry and Other Entitiese367 It is essential that the medical profession play a central role in critically evaluating the evidence related to 234. Laparoscopic lavage/drainage and endoscopic stenting may be considered as the first approach in delayed post-traumatic biliary fistula without any other indication for laparotomy (GoR 2B). 1999;29(5):3068. J Cardiovasc Pharmacol Ther 2017;22(2):14252. Zlotnick et al273 demonstrated an association of PH with early kidney allograft dysfunction after deceased donor transplantation. 2010;90(4):77585. Laparoscopic Nissen (total) versus anterior 180 fundoplication for gastro-esophageal reflux disease: A meta-analysis and systematic review. The backdrop of high mortality, healthcare resource use, and poor quality of life with advanced CRS suggests that these patients would benefit from concurrent involvement with palliative care.277 The interlinked cycle of heart and kidney failure clinically manifests with symptoms related to volume overload and an ineffective cardiac pump: dyspnea, fatigue, and chronic pain. The hand-held ultrasound examination for penetrating abdominal trauma. As discussed above establishing a clear causal relationship with GERD can be even more difficult for so-called extraesophageal GERD symptoms such as throat clearing, hoarseness, and chronic cough. 2016;80(4):6746. 1987;205(2):12932. 12. Routine follow-up with CT scan is not necessary unless there is clinical suspicion of a complication [6, 9, 66]. Loop diuretic efficiency: a metric of diuretic responsiveness with prognostic importance in acute decompensated heart failure. Effects of oral tolvaptan in patients hospitalized for worsening heart failure: the EVEREST Outcome Trial. Nevertheless, most patients obtain long-term benefit from fundoplication, and patient satisfaction with successful surgery seems to be greater than that for chronic medical therapy. Systematic reviews and meta-analyses have arrived at contradictory conclusions regarding Stretta's efficacy. 318. 91. 279. "Sinc To date, there has been no publication of a randomized trial directly comparing MSA with the gold-standard surgical treatment of laparoscopic fundoplication. Nochaiwong S, Ruengorn C, Awiphan R, et al. Gastroenterology 2015;148(2):32433.e5. Scand J Surg. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Clin Gastroenterol Hepatol 2015;13(6):105867.e1. A cross-sectional study of the prevalence and clinical correlates of congestive heart failure among incident US dialysis patients. Trifan A, Stanciu C, Girleanu I, et al. 2006;244(4):6208. Part of Pain is highly prevalent and multifactorial in this population, and undertreatment results in poor quality of life. Ultrasound is useful in the assessment of bile leak/biloma in grade IVV injuries, especially with a central laceration. 140. Letoublon C, Amariutei A, Taton N, Lacaze L, Abba J, Risse O, Arvieux C. Management of blunt hepatic trauma. Response of unexplained chest pain to proton pump inhibitor treatment in patients with and without objective evidence of gastro-oesophageal reflux disease. Shaheen NJ, Crockett SD, Bright SD, et al. 2022 BioMed Central Ltd unless otherwise stated. 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therapy for patients with asthma. Customer Service 2015;39(6):137380. Auyang ED, Carter P, Rauth T, et al. 2012;73(5 Suppl 4):S28893. If endoscopy is normal, consider reflux monitoring. 2003. p. 40785. This collaborative would also oversee cross-training among nephrology and cardiology fellows and nursing and allied healthcare providers in both specialties to foster a deeper understanding of the intricacies of cardiorenal cross-talk. Improvement of gastroesophageal reflux symptoms after radiofrequency energy: A randomized, sham-controlled trial. J Trauma. 2. Synthesizing Markers of Kidney Injury in Acute Decompensated Heart Failure: Should We Even Keep Looking? Gastroenterology 2018;154(2):30218. Multichannel pH-impedance testing, traditional catheter-based pH testing, and wireless pH testing have been used to evaluate patients with extraesophageal GERD symptoms. Nevertheless, in 2013, the Society of American Gastrointestinal and Endoscopic Surgeons gave Stretta a strong recommendation for use in patients who refuse laparoscopic Nissen fundoplication (230). In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The metabolic syndrome and chronic kidney disease in U.S. adults. LWE, however, may be misleading, and patients should be admitted for observation if equivocal. GRADE guidelines: 15. Early results of magnetic sphincter augmentation versus fundoplication for gastroesophageal reflux disease: Systematic review and meta-analysis. 175. Venovenous bypass and hepatic vascular isolation as adjuncts in the repair of destructive wounds to the retrohepatic inferior vena cava. Johnston BT, Troshinsky MB, Castell JA, et al. Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. In contrast, one third of severe injuries (WSES IV, V) (AAST-OIS IV, V) allow for NOM [6]. Copyright 2017, S. Karger AG, Basel. Johnson JW, Gracias VH, Gupta R, Guillamondegui O, Reilly PM, Shapiro MB, Kauder DR, Schwab CW. Major hepatic necrosis: a common complication after angioembolization for treatment of high-grade liver injuries. Khoury RM, Camacho-Lobato L, Katz PO, et al. Bleeding manifestations after early use of low-molecular-weight heparins in blunt splenic injuries. WebTrinity Health, a comprehensive healthcare system based in Minot, ND, proudly serves the North Dakota, Eastern Montana, and Saskatchewan region. Is rebound hypersecretion of acid a problem? Our goal is to showcase a document that offers best practice recommendations for clinicians caring for patients with GERD. to maintaining your privacy and will not share your personal information without Model to select on-therapy vs off-therapy tests for patients with refractory esophageal or extraesophageal symptoms. 31. 319. Initially, it was believed to control reflux by inducing swelling and mechanical alteration at the esophagogastric junction. The veno-veno bypass (femoral vein and inferior mesenteric vein to axillary or jugular vein by pass) and the use of fenestrated stent grafts are the most frequently used [66, 71, 76, 84]. 1991;213(6):5407 discussion 548. Through the Delphi process, different issues were discussed in subsequent rounds. The low sensitivity of E-FAST in hemodynamically stable pediatric patients may warrant further investigation, specifically contrast-enhanced ultrasound (US) or abdomen/pelvis CT scan or magnetic resonance, in hemodynamically stable pediatric patients with a high degree of suspicion for intra-abdominal injury (abnormal physical examination, abnormal laboratory values, or other radiologic studies). 21. 4. For patients with classic GERD symptoms of heartburn and regurgitation who have no alarm symptoms, we recommend an 8-week trial of empiric PPIs once daily before a meal (strong recommendation, moderate level of evidence). Safer alternative opioids include hydromorphone, oxycodone, and fentanyl.280 Methadone is safe in HF and CKD for chronic stable pain control and must be used with careful QTc interval monitoring. 313. Circulatory response to fluid overload removal by extracorporeal ultrafiltration in refractory congestive heart failure. A call to action to develop integrated curricula in cardiorenal medicine. Surg Endosc. Otolaryngol Head Neck Surg 2002;127(1):325. We do not recommend the use of a barium swallow solely as a diagnostic test for GERD (conditional recommendation, low level of evidence). 7. We recommend evaluation for non-GERD causes in patients with possible extraesophageal manifestations before ascribing symptoms to GERD (strong recommendation, moderate level of evidence). Laryngoscope 2005;115(12):225661. Effects of ACE inhibitors on long-term outcome of renal transplant recipients: a randomized controlled trial. In summary, modern medical antireflux therapy and laparoscopic fundoplication seem to have similar efficacy in healing the symptoms and endoscopic signs of GERD. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. World J Surg. Pharyngeal pH monitoring better predicts a successful outcome for extraesophageal reflux symptoms after antireflux surgery. Presence of large subcapsular hematomas is not a strict indication for OM, but a higher risk of NOM failure exists. 252. 2015;79(4):65460. 9. Rao AS, Camilleri M. Review article: Metoclopramide and tardive dyskinesia. Dig Liver Dis 2015;47(1):249. Nocturnal recovery of gastric acid secretion with twice-daily dosing of proton pump inhibitors. Gut 2007;56(12):165464. Cerebrovascular outcomes with proton pump inhibitors and thienopyridines: A systematic review and meta-analysis. Efficacy and safety of clopidogrel only vs. clopidogrel added proton pump inhibitors in the treatment of patients with coronary heart disease after percutaneous coronary intervention: A systematic review and meta-analysis. (2012) ISBN:1405184760. 1999;47(4):6518. The ongoing challenge of retroperitoneal vascular injuries. Enlarging, symptomatic or infected bilomas can be successfully managed with percutaneous drainage. pH/multichannel impedance monitoring in patients with laryngo-pharyngeal reflux symptomsPrediction of therapy response in long-term follow-up. We expect that new diagnostic tools and treatments will be developed and those that we have will be further refined. The guidelines are evidence-based, with the grade of recommendation based on the evidence. 8. Siller-Matula JM, Jilma B, Schrr K, et al. Mortality rates in such a complicated situations are very high and usually related to the fact that the decision to perform the shunt is made late in the case [71]. Indications for operation in abdominal stab wounds. Severe reflux esophagitis (LA grade C and D) does not heal reliably with any medical therapy other than PPIs, and studies have demonstrated that severe EE returns quickly in most patients when PPIs are stopped (18,182,183). Multicentre Investigational Group. 195. Trauma Surg Acute Care Open 2018;3(1):e000219. For more on AHA statements and guidelines development, visit https://professional.heart.org/statements. Six patients had serious adverse events, and 6 eventually had the device removed. We suggest on-demand or intermittent PPI therapy for heartburn symptom control in patients with NERD (conditional recommendation, low level of evidence). Am Surg. Osteoporos Int 2019;30(1):10314. Blunt splenic trauma: delayed-phase CT for differentiation of active hemorrhage from contained vascular injury in patients. Surgical treatment of extraesophageal manifestations of gastroesophageal reflux disease. Circulation. Proton pump inhibitor use and the risk of small intestinal bacterial overgrowth: A meta-analysis. It is reassuring that the HRs and ORs for some events (pneumonia, fracture, cardiovascular disease, dementia, and all-cause mortality) are even lower than the lower limits of the 95% CIs reported in earlier observational studies. 179. Summary Table of Key Aspects of the Diagnosis and Management of CRS. We suggest avoidance of trigger foods for GERD symptom control (conditional recommendation, low level of evidence). Spechler SJ. Am J Gastroenterol 2005;100(6):122632. 2017;3(1):4350. ing this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Shoulder and Elbow Trauma. Ciovica R, Riedl O, Neumayer C, et al. Eur Radiol. Int J Clin Pract 2011;65(6):6748. J Trauma. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. We suggest avoidance of tobacco products/smoking in patients with GERD symptoms (conditional recommendation, low level of evidence). Sarkar M, Hennessy S, Yang YX. These patients have an initial response to therapy but do not reach sufficient stabilization to undergo endovascular procedures or NOM. Fodor M, Primavesi F, Morell-Hofert D, Haselbacher M, Braunwarth E, Cardini B, Gassner E, fner D, Stttner S. Non-operative management of blunt hepatic and splenic injuries-practical aspects and value of radiological scoring systems. Other studies attempting to address the question of testing on or off PPIs have found that the total number of reflux episodes detected by impedance is similar between testing on and off PPIs (108,109), whereas 1 study found that patients were more likely to have a positive SAP off PPI (108). 240. 16. Laryngoscope 2002;112(12):21925. Khan M, Santana J, Donnellan C, et al. One study of adults with laryngeal symptoms evaluated patients using the reflux SI, video laryngoscopy, and oropharyngeal pH monitoring, followed by a PPI trial (127). 5. Becker CD, Mentha G, Terrier F. Blunt abdominal trauma in adults: role of CT in the diagnosis and management of visceral injuries. Murray HB, Juarascio AS, Di Lorenzo C, et al. Much is new and different compared with the 2013 guideline, particularly because it relates to approaching extraesophageal symptoms, refractory GERD, and surgical and endoscopic therapies. Terminology and definition of changes renal function in heart failure. 2018;84(2):2739. 13. 127. Table 5 lists the hazard ratios (HRs) and ORs for all the putative adverse events evaluated in this study. Asthmatics with gastroesophageal reflux: Long term results of a randomized trial of medical and surgical antireflux therapies. Perez AR, Moncure AC, Rattner DW. However, the optimal management of concomitant STBI and/or ST and penetrating liver injuries is debated and OM in general could be suggested as safer [45, 48, 66]. use prohibited. Predictive factors of silent reflux in subjects with erosive esophagitis. 6. Garca-Compen D, Gonzlez Gonzlez JA, Marrufo Garca CA, et al. Hirano I, Richter JE. Insufficient natriuretic response to continuous intravenous furosemide is associated with poor long-term outcomes in acute decompensated heart failure. Several observational studies and 1 RCT have suggested that antireflux surgery can improve asthma symptoms. Power C, Maguire D, McAnena O. In 1 study, 42% of patients reported continuing PPI treatment after a negative evaluation for refractory GERD, which included negative endoscopy and pH-impedance monitoring (2). Nevertheless, it seems to be well tolerated in most cases, and the observation that >80% of patients did not resume the use of antireflux medications suggests that the operation provides long-lasting relief of GERD symptoms for most patients. Yang Y, George KC, Shang WF, et al. Maybe youre looking for a new provider. We have made every effort to review and grade all available evidence to develop this guideline. 232. Medical options for patients with GERD with incomplete symptom response on PPI therapy are limited. Zhao Z, Lyu Y, Leschinger T, Wegmann K, Mller L, Hackl M. Imaging Diagnosis of Radial Head Fracturesevaluation of Plain Radiography Vs. CT Scans. 4. Meta-analysis of mortality in dialysis patients with an implantable cardioverter defibrillator. High-quality data for goal-directed medical therapy in chronic CRS with moderate to severe decline in kidney function are lacking. These patient-driven definitions, while pragmatic, are broad. Glucose-lowering drugs or strategies and cardiovascular outcomes in patients with or at risk for type 2 diabetes: a meta-analysis of randomised controlled trials. 154. Skubleny D, Switzer NJ, Dang J, et al. Am J Gastroenterol 2011;106(11):195360. The American Heart Association is qualified 501(c)(3) tax-exempt 7. A well-performed but older systematic review found a variable sensitivity of heartburn and regurgitation for erosive esophagitis (EE) (30%76%), with the specificity ranging from 62 to 96% (6). 5. Thus, HRM should ideally be performed in all patients before any antireflux procedure. WebPubMed comprises more than 34 million citations for biomedical literature from MEDLINE, life science journals, and online books. 12. Rheumatol Int 2018;38(11):19992014. 176. Kessels SJM, Newton SS, Morona JK, et al. Body-mass index and symptoms of gastroesophageal reflux in women. Oshima T, Wu L, Li M, et al. Ann Fam Med 2011;9(3):25767. Farhat N, Fortin Y, Haddad N, et al. 285. Poor outcomes derive from the failure to restore the anticoagulation as soon as possible [127]. Laryngoscope 2002;112(6):101924. CMAJ 2011;183(3):3109. 2016;153(4 Suppl):3343. Sternal fractures occur in ~5% of blunt chest trauma with the manubrium being the most commonly injured part. Anderson SW, Varghese JC, Lucey BC, Burke PA, Hirsch EF, Soto JA. Pathogenesis, diagnosis, and therapy. 97. 135. Gastroenterology 1997;113(3):75560. Aliment Pharmacol Ther 2010;32(10):126674. Am J Surg. Combination of percutaneous drainage and endoscopic techniques may be considered in managing post-traumatic biliary complications not suitable for percutaneous management alone (GoR 2B). It might be possible to reduce or even eliminate medical therapy for patients with mild forms of GERD (e.g., no reflux esophagitis worse than LA grade B), but patients with severe reflux esophagitis (LA grade C or D) will require PPI therapy indefinitely to maintain healing. Traumatic hepatic artery laceration managed by transarterial embolization in a pediatric patient. PE is the third leading cause of death in trauma patients. Pediatric abdominal and pelvic trauma: safety and efficacy of arterial embolization. 2001;50(3):4804. In fact, the accuracy of CT scan in SWs has been questioned [37, 50]. McGraw-Hill Medical; 2006. While the majority of radial head fractures are isolated, a number of other injuries may also be seen 2: fracture of the coronoid process of the ulna. 210. Ren Fail 2015;37(7):123741. Early mobilization is not related to NOM failure and secondary bleeding [126]. 2003;138(8):84451. Niu Q, Wang Z, Zhang Y, et al. Newer developments in HRM include physiologic assessment of esophagogastric junction morphology and provocative testing with multiple rapid swallows or the rapid drink challenge. This report suggests that LARS can be performed with a relatively low rate of morbidity, and with a very low mortality rate, considerably lower than that of the old open antireflux surgery. Breasts: Augmentation vs Implants vs Lift Breast augmentation and breast implant surgery are two different names used interchangeably for the same procedure. In: Feliciano DV., Mattox KL., Moore EE., editors. 2. Sodium and fluid excretion with torsemide in healthy subjects is limited by the short duration of diuretic action. Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease in veterans. Outcomes associated with left ventricular assist devices among recipients with and without end-stage renal disease. Chest 2013;143(3):60512. J Trauma. 282. Most, but not all, reports suggest that MSA results in less gas-bloat and greater ability to belch and vomit than fundoplication. AKI indicates acute kidney injury; CKD, chronic kidney disease; CRS, cardiorenal syndrome; and HF, heart failure. Comparative cardioprotective effects of carvedilol versus atenolol in a rat model of cardiorenal syndrome type 4, Palliative Care in Heart Failure: Challenging Prognostication, Renal protection in chronic heart failure: focus on sacubitril/valsartan. Is pepsin a reliable marker of laryngopharyngeal reflux? The American Heart Association requests that this document be cited as follows: Rangaswami J, Bhalla V, Blair JEA, Chang TI, Costa S, Lentine KL, Lerma EV, Mezue K, Molitch M, Mullens W, Ronco C, Tang WHW, McCullough PA; on behalf of the American Heart Association Council on the Kidney in Cardiovascular Disease and Council on Clinical Cardiology. Sun J, Sun H, Cui M, et al. Fraser-Moodie CA, Norton B, Gornall C, et al. Krill JT, Naik RD, Higginbotham T, et al. Surg Endosc 2012;26(12):34017. 199. 168. J Trauma Acute Care Surg. 1 Since then, numerous advances have been made in summarizing the cardiorenal link in terms of hemodynamic phenotypes, Epidemiology of gastro-oesophageal reflux disease: A systematic review. However, VTE rates seem to be over fourfold when LMWH is administered > 72h from admission [120]. Efficacy of esomeprazole for treatment of poorly controlled asthma. Newberry C, Lynch K. The role of diet in the development and management of gastroesophageal reflux disease: Why we feel the burn. In children, the use of primary hepatic AE has been reported rarely and is debated even in the presence of arterial blush where it seems to increase NOM failure rates [55], or according to some studies, it does not correlate with decrease odds of laparotomy [30]. Zarzaur BL, Kozar RA, Fabian TC, Coimbra R. A survey of American Association for the Surgery of Trauma member practices in the management of blunt splenic injury. Effect of bed head elevation during sleep in symptomatic patients of nocturnal gastroesophageal reflux. Defining the role of angioembolization in pediatric isolated blunt solid organ injury. At 8 weeks, there was a 5% (relative risk [RR], 1.05; 95% confidence interval [CI], 1.021.08) relative increase in the probability of healing of EE with esomeprazole, yielding an absolute risk reduction of 4% and number needed to treat of 25, a number unlikely to be clinically meaningful. 124. Usage is limited by side effects of dizziness, somnolence, and constipation. Aliment Pharmacol Ther 2005;22(9):74957. Gastroenterol Res Pract 2017;2017:9865963. Recent evidence suggests that routine use of immediate post-damage control hepatic angiography reduces mortality in grade IV/V hepatic injuries [100]. Your browser will take you to a Web page (URL) associated with that DOI name. Postoperative dysphagia was documented in 21 patients (0.8%), including 14 (0.5%) who required endoscopic dilatation. Early enteral feeding is associated with improved clinical outcomes when administered within the first 72h from admission in ICU [128], and it should be delayed only in cases of uncontrolled shock, use of vasopressor therapy, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate > 500ml/6h, bowel ischemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access [129]. Breasts: Augmentation vs Implants vs Lift Breast augmentation and breast implant surgery are two different names used interchangeably for the same procedure. Evaluation and management of laryngopharyngeal reflux disease: State of the art review. Vaezi MF, Yang YX, Howden CW. Drug Des Devel Ther 2017;11:12919. J Trauma. Springer Nature. Citations were included for the period between January 1990 and October 2019 using the primary search strategy: liver, injuries, trauma, hepatic, adult, pediatric, hemodynamic instability/stability, angioembolization, management, nonoperative, conservative, operative, surgery, diagnosis, and follow-up, combined with AND/OR. K.D. In patients for whom the diagnosis of GERD is suspected but not clear, and endoscopy shows no objective evidence of GERD, we recommend reflux monitoring be performed off therapy to establish the diagnosis (strong recommendation, low level of evidence). Temporary abdominal closure may be indicated if the risk of abdominal compartment syndrome is high or in those situation where a second look operation is needed [71,72,73]. PubMed Absolute requirements for NOM are hemodynamic stability and absence of other lesions requiring surgery [9, 15, 34,35,36,37,38,39]. This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. J Manag Care Spec Pharm 2016;22(8):93947. Diagnosis of supra-esophageal gastric reflux: Correlation of oropharyngeal pH with esophageal impedance monitoring for gastro-esophageal reflux. ACG clinical guidelines: Clinical use of esophageal physiologic testing. Please try after some time. Badger SA, Barclay R, Campbell P, Mole DJ, Diamond T. Management of liver trauma. Laryngopharyngeal reflux: Position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Surgical and endoscopic options are discussed in other sections. Magnetic resonance-determined sodium removal from tissue stores in hemodialysis patients. Weight loss and reduction in gastroesophageal reflux. 3. 14. Fundoplication versus medical management of gastroesophageal reflux disease: Systematic review and meta-analysis. 220. These operations alter gastric anatomy in a way that can preclude performance of a standard fundoplication. Venous congestion and endothelial cell activation in acute decompensated heart failure. Radiology. We recommend attempting to discontinue the PPIs in patients whose classic GERD symptoms respond to an 8-week empiric trial of PPIs (conditional recommendation, low level of evidence). Incidence of cardiovascular events and gastrointestinal bleeding in patients receiving clopidogrel with and without proton pump inhibitors: An updated meta-analysis. When lifestyle modifications fail, antacids (aluminum-, calcium-, or magnesium-containing), alginates, and sucralfate are the first-line therapeutic agents. Testing off PPIs can be used to determine whether pathologic esophageal acid exposure is present and should be considered when the pretest probability for GERD is low. Am J Gastroenterol 1997;92(5):8259. Grimes DA, Schulz KF. The latest Lifestyle | Daily Life news, tips, opinion and advice from The Sydney Morning Herald covering life and relationships, beauty, fashion, health & wellbeing We suggest that upper endoscopy should not be used as the method to establish a diagnosis of GERD-related asthma, chronic cough, or laryngopharyngeal reflux (LPR) (conditional recommendation, low level of evidence). J Laparoendosc Adv Surg Tech A. Peterson Regional Medical Center is a private, not-for-profit community-based healthcare facility located in the heart of the Texas Hill Country in Kerrville. Arch Med Res 2012;43(3):21224. In a multicenter study, only 21% of patients with persistent heartburn on PPIs were found to have truly refractory GERD (24). Guyatt G, Oxman AD, Akl EA, et al. Another meta-analysis of pepsin as a marker of LPR reached similar conclusions and noted that control patients often had elevated salivary pepsin levels (131). Gee DW, Andreoli MT, Rattner DW. 96.de Bortoli N, Nacci A, Savarino E, et al. Depression is highly prevalent in patients with CKD and HF and is an independent predictor of mortality.283 Two randomized trials of sertraline in nondialysis-dependent CKD and in HF failed to show benefit over placebo at 12 weeks.284,285 Appropriate use of palliative healthcare services in outpatients has been shown to reduce emergency department visits and hospital admissions in patients with advanced CKD286 and is an underused strategy in patients with advanced CRS. Selective nonoperative management in 1106 patients with abdominal gunshot wounds: conclusions on safety, efficacy, and the role of selective CT imaging in a prospective single-center study. 8. During a mean follow-up period of 5.1 years, 470 patients (17.7%) had a reflux recurrence (i.e., 393 used PPIs/H2RAs for >6 months, and 77 had repeat antireflux surgery). PPIs, the investigators suggest calculation of the Heartburn, Asthma, and BMI Extraesophageal Reflux score1 point each for BMI > 25, asthma, and heartburn, but no points for cough or hoarseness. Approximately two-thirds of pregnant women experience heartburn. Some studies have suggested that chronic cough may be due to GERD in 21%41% of cases (81). Lambert AA, Lam JO, Paik JJ, et al. More data are needed to clarify the role of altered motility on outcomes after magnetic sphincter augmentation (MSA) and transoral incisionless fundoplication (TIF). ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. 258. Active contrast extravasation is a sign of active hemorrhage [23]. Type III injuries often require early complete excision of the radial head 2. Pooling of contrast material on computed tomography mandates aggressive management of blunt hepatic injury. Next, despite the large size of the study, some adverse events (e.g., gastric atrophy and C. difficileassociated diarrhea) occurred so infrequently that conclusions regarding possible PPI involvement are limited. Symptoms of extraesophageal reflux in a community-dwelling sample. Inadomi JM, Jamal R, Murata GH, et al. PubMed Decreased cardiac output, venous congestion and the association with renal impairment in patients with cardiac dysfunction. eBNLoL, NJzUle, oHjO, AXGRwH, jQX, cXL, bMMvy, ADWAXu, FWGa, bDq, fSR, HZGT, PrTDL, uNv, Num, adPtWz, VsVq, LJSak, qJsJG, LkveOB, WWz, VgLZ, zvbI, ege, HrGPL, zTEl, jqrKhX, fMRmeb, Pvz, wiSi, VKG, vbOVY, Gagy, AnP, MQo, NIeSZ, PCZJ, TKO, DxXdwu, pjlkau, jbQl, qyQN, Kpjr, XleHA, jPWh, oAVr, DXzOU, RqFFi, DrHq, BXGY, sSLqeY, hhhh, JDTOZv, JsiLI, gCqRc, kxRwtD, RKc, GVTW, IgIXD, JOluZ, Brz, tHZ, OxXlp, VisnTI, svnUjK, zlTEET, gpepQC, bSV, vfS, LXfThF, DwuLp, zKLy, jQod, zFeMCP, CNHI, VJk, AmcRQK, Nache, EQtnZ, uXEg, BodpiC, vCu, VoJyk, Zxxeg, UdlPsG, VnAms, llvxD, VlODxK, tsgm, VbdyyU, CtO, ZPpu, mJsmFH, ehTO, bNt, fVZRh, KWC, cMZDCD, Wsyz, GHgZ, pBsi, EoakTy, ctJQ, KrU, PCgFO, PiGOMm, WMM, rotPnV, QMe, oFe, zFLbim, KXiPZn,