Voluntary and controlled weight loss can reduce symptoms and proton pump inhibitor use and dosage in patients with gastroesophageal reflux disease: a comparative study.

A wide variety of pieces of evidence has suggested that obesity is associated with a significant increase in the risk for gastroesophageal reflux disease (GERD) symptoms and its complications. The aim of this study was to evaluate the effect of weight loss on reflux symptoms in overweight/obese patients with proven GERD. We enrolled overweight/obese patients with typical GERD symptoms and erosive esophagitis. At baseline, patients underwent detailed reflux symptoms evaluation and anthropometric assessment, and were divided into two treatment groups: group A received proton pump inhibitor (PPI) and a personalized hypocaloric diet and aerobic exercise; and group B received PPI and a 'standard of care diet'. The dietetic treatment was considered effective if at least 10% of weight loss was achieved within 6 months. All patients were evaluated in terms of anthropometric data, GERD symptoms, and PPI use. In group A, mean body mass index (BMI) decreased from 30.3 ± 4.1 to 25.7 ± 3.1 (P < 0.05), and mean weight decreased from 82.1 ± 16.9 kg to 69.9 ± 14.4 kg (P < 0.05). In group B, there was no change in BMI and weight. Symptom perception decreased (P < 0.05) in both groups during PPI therapy, but a higher improvement was recorded in group A. In group A, PPI therapy was completely discontinued in 27/50 of the patients, and halved in 16/50. Only 7/50 continued the same PPI dosage. In group B, 22/51 halved the therapy and 29/51 maintained full dosage of therapy, but none was able to discontinue PPI due to a symptom recurrence. Overall, weight loss of at least 10% is recommended in all patients with GERD in order to boost the effect of PPI on reflux symptom relief and to reduce chronic medication use.

Lower pH values of weakly acidic refluxes as determinants of heartburn perception in gastroesophageal reflux disease patients with normal esophageal acid exposure.

Multichannel impedance pH monitoring has shown that weakly acidic refluxes are able to generate heartburn. However, data on the role of different pH values, ranging between 4 and 7, in the generation of them are lacking. The aim of this study was to evaluate whether different pH values of weakly acidic refluxes play a differential role in provoking reflux symptoms in endoscopy-negative patients with physiological esophageal acid exposure time and positive symptom index and symptom association probability for weakly acidic refluxes. One hundred and forty-three consecutive patients with gastroesophageal reflux disease, nonresponders to proton pump inhibitors (PPIs), were allowed a washout from PPIs before undergoing: upper endoscopy, esophageal manometry, and multichannel impedance pH monitoring. In patients with both symptom index and symptom association probability positive for weakly acidic reflux, each weakly acidic reflux was evaluated considering exact pH value, extension, physical characteristics, and correlation with heartburn. Forty-five patients with normal acid exposure time and positive symptom association probability for weakly acidic reflux were identified. The number of refluxes not heartburn related was higher than those heartburn related. In all distal and proximal liquid refluxes, as well as in distal mixed refluxes, the mean pH value of reflux events associated with heartburn was significantly lower than that not associated. This condition was not confirmed for proximal mixed refluxes. Overall, a low pH of weakly acidic reflux represents a determinant factor in provoking heartburn. This observation contributes to better understand the pathophysiology of symptoms generated by weakly acidic refluxes, paving the way toward the search for different therapeutic approaches to this peculiar condition of esophageal hypersensitivity.

Switching to anastrozole versus continued tamoxifen treatment of early breast cancer. Updated results of the Italian tamoxifen anastrozole (ITA) trial.

BACKGROUND: Tamoxifen, for many years the 'gold standard' in the adjuvant setting for the management of endocrine sensitive early breast cancer, is associated with an increased risk of endometrial cancer and other life-threatening events. Moreover, many women relapse during or after tamoxifen therapy due to the development of resistance. This provided the rationale for a switching trial with anastrozole, the updated results of which are reported here. PATIENTS AND METHODS: This trial investigated the efficacy of switching to anastrozole for women already receiving tamoxifen. After 2-3 years of tamoxifen treatment, postmenopausal, node-positive, ER-positive patients were randomized to receive either anastrozole 1 mg/day or to continue tamoxifen, 20 mg/day, giving a total duration of 5-years treatment. The primary end point was disease-free survival and secondary endpoints were event-free survival, overall survival and safety. RESULTS: A total of 448 patients were enrolled. At a median follow-up time of 64 months (range 12-93), 63 events had been reported in the tamoxifen group compared with 39 in the anastrozole group [HR 0.57 (95% CI 0.38-0.85) P = 0.005]. Relapse-free and overall survival were also longer in the anastrozole group [HR 0.56 (95% CI 0.35-0.89) P = 0.01 and 0.56 (95% CI 0.28-1.15) P = 0.1]. However, the latter difference was not statistically significant. Overall more patients in the anastrozole group experienced at least one adverse event (209 versus 151: P = 0.000). However, numbers of patients experiencing serious adverse events were comparable (37 versus 40, respectively: P = 0.7). CONCLUSIONS: Switching to anastrozole after the first 2-3 years of treatment was confirmed to improve event-free and relapse-free survival of postmenopausal, node-positive, ER-positive early breast cancer patients already receiving adjuvant tamoxifen.

18F-FDG PET/CT fusion imaging in paediatric solid extracranial tumours.

This paper aims at discussing the utility of 18F-FDG PET/CT in the evaluation of paediatric solid extracranial tumours. Following a brief discussion of the basic principles and methodology of PET/CT system, it reviews the main characteristics of the tumours that can be visualised with 18F-FDG PET and presents examples of cases where the combined use of 18F-FDG PET/CT fusion imaging helped in the management of patients. It will also discuss the physiologic biodistribution of 18F-FDG, outlining the normal variants in the paediatric patients that may lead to misinterpretation.

Tolerance to silver of an Aspergillus fumigatus strain able to grow on cyanide containing wastes.

We studied the strategy of an Aspergillus fumigatus strain able to grow on metal cyanide wastes to cope with silver. The tolerance test revealed that the Minimum Inhibitory Concentration of Ag(I) was 6mM. In 1mM AgNO3 aqueous solution the fungus was able to reduce and sequestrate silver into the cell in the form of nanoparticles as evidenced by the change in color of the biomass and Electron Microscopy observations. Extracellular silver nanoparticle production also occurred in the filtrate solution after previous incubation of the fungus in sterile, double-distilled water for 72h, therefore evidencing that culture conditions may influence nanoparticle formation. The nanoparticles were characterized by UV-vis spectrometry, X-ray diffraction and Energy Dispersion X-ray analysis. Atomic absorption spectrometry revealed that the optimum culture conditions for silver absorption were at pH 8.5.The research is part of a polyphasic study concerning the behavior of the fungal strain in presence of metal cyanides; the results provide better understanding for further research targeted at a rationale use of the microorganism in bioremediation plans, also in view of possible metal recovery. Studies will be performed to verify if the fungus maintains its ability to produce nanoparticles using KAg(CN)2.

Does 18F-FDG PET/CT play a role in the differential diagnosis of parotid masses.

AIM: The aim of the present study was to assess the accuracy of an hybrid PET/CT scanner in the evaluation of newly diagnosed parotid masses, comparing the results with those reported in the literature with using PET scanners only. METHODS: The potential role of 18F-FDG PET/CT in distinguishing benign from malignant parotid masses in 14 consecutive patients was investigated. All patients were preoperatively evaluated by means of ultrasound (US), US-guided fine needle aspiration (FNA) cytology, computed tomography (CT) scan, magnetic resonance imaging (MRI) and 18F-FDG PET/CT. For To interpreting FDG PET findings, the right to left parotid (R/L) SUV max ratio was calculated in a group of 54 patients without evidence of parotideal disease (mean+/-SD = 1+/-0.2; range = 0.8-1.2); considering the R/L SUV max ratio, focal or diffuse uptakes <0.8 or >1.2 were considered as potentially pathological. RESULTS: Imaging data were compared with surgical and histopathological findings. At FDG PET/CT, 9 false positive cases were found (8 Warthin's tumours, 1 pleomorphic adenoma), 1 false negative (acinar cell carcinoma), 4 true negative (1 Warthin's tumour, 1 pleomorphic adenoma, 1 lymph epithelial cyst, 1 parotid inflammation) whereas there was no case of true positive. The global accuracy of FGD PET/CT was rather low = at 29%. CONCLUSIONS: In agreement with other preliminary reports in which the FDG PET without CT fusion imaging was used, in our experience 18F-FDG PET/CT did not prove to play a significant role in differential diagnosis (benign vs malignant) of parotid masses. Further studies collecting larger groups of patients are needed to further elucidate this observation.

Etoposide, doxorubicin and cisplatin (EAP) treatment in advanced gastric carcinoma: a multicentre study of the Italian Trials in Medical Oncology (I.T.M.O.) Group.

Various reports have documented the efficacy of the combination of etoposide, doxorubicin and cisplatin (EAP) in the treatment of advanced gastric cancer, although other studies have not confirmed such results. This multicentre phase II study was designed to try to define the efficacy and tolerability of the original EAP regimen. From January 1990 to May 1992, 96 patients with locally advanced or metastatic gastric cancer were treated every 3 weeks with etoposide (120 mg/m2) on days 4, 5 and 6, doxorubicin (20 mg/m2) on days 1 and 7, and cisplatin (40 mg/m2) on days 2 and 8. All of the patients had measurable lesions, and were to receive a maximum of six cycles. A total of 416 courses was given (median four/patient), 27% with a delay of > or = 2 weeks. Objective responses were achieved in 34 of the 91 evaluable patients (37%: confidence interval 27-47%), with complete response (CR) in 11 (12%) and partial response (PR) in 23 (25%). The median duration of response was 6 months (range 1-19), and the median survival of the 96 eligible patients was 9 months. Side-effects (WHO grade 3-4) were leucopenia (30%), thrombocytopenia (9%) and mucositis (10%). We conclude that the EAP regimen is active in inducing major objective responses (12% of CR), and that treatment is feasible in patients with good performance status.

Dipyridamole technetium-99m-2-methoxy isobutyl isonitrile tomoscintigraphic imaging for identifying diseased coronary vessels: comparison with thallium-201 stress-rest study.

A same-day double injection protocol employing 99mTc-methoxyisobutyl isonitrile (MIBI) and myocardial single-photon emission computed tomography (SPECT) for detecting coronary artery disease (CAD) was assessed in 30 patients. SPECT was performed 1 hr after a first injection (250 MBq) of 99mTc-MIBI, given after 0.56 mg/kg dipyridamole (DPD) infusion. Patients were then reinjected at rest (750 MBq) and were reimaged 1 hr later. Within 1 wk, all patients underwent a complete stress-rest SPECT thallium study. Of the 330 myocardial segments evaluated, 25 were judged ischemic by both techniques, while persistent defects were demonstrated in 50 and in 47 with 99mTc-MIBI and 201TI, respectively. Six regions were considered for diseased vessels identification. Sensitivity and specificity for CAD were 100% and 75%, respectively, for both 201TI and 99mTc-MIBI. Sensitivity for identification of diseased vessels by 201TI was 68% for LAD, 89% for RCA, and 80% for LCX as opposed to 75%, 89% and 80%, respectively, by 99mTc-MIBI. Specificity was 93% in both cases for LAD, 73% and 63% for RCA, and 53% and 46% for LCX.

Detecting hibernated myocardium with SPECT and thallium-glucose-insulin infusion.

UNLABELLED: Because thallium kinetics, like potassium kinetics, may be affected by serum insulin levels, we performed two pilot studies to identify severely ischemic myocardium using different protocols based on the infusion of a thallium, insulin, potassium and glucose solution. Results were compared with those obtained with two currently used protocols based on rest injection or reinjection of 201Tl. METHODS: In the first study (Protocol 1) of 15 men with a previous large myocardial infarction, perfusion was evaluated by SPECT in 20 segments after a 30-min infusion of 201Tl (111 MBq), insulin (5 U) and potassium (10 mEq) in 10% glucose solution (250 ml). Imaging was repeated 30 min later and the results were compared with those obtained from stress and 3-hr reinjection images. In the second study (Protocol 2), 15 patients were evaluated randomly at rest and 3 hr later (rest-redistribution). On a separate day, the patients were then re-evaluated after infusion of 201Tl (111 MBq), potassium (10 mEq) and insulin (5 U) in 5% glucose (250 ml); images were obtained 90 and 180 min postinjection. RESULTS: In Protocol 1, radiotracer activity in segments with no uptake during stress was detected in 35% with the reinjection technique and 58% with the insulin solution protocol. In Protocol 2, 31% of segments revealed thallium activity after insulin infusion but not at rest or rest-redistribution. Serum measurements showed high insulin levels (444 +/- 138 in Protocol 1, 125 +/- 33 mU/ml in Protocol 2), although glucose levels were not significantly altered (149 +/- 32 versus 71 +/- 20 mg/dl, respectively). Potassemia was not affected and the patients tolerated the tests satisfactorily. CONCLUSION: These results confirm that continuous infusion of 201Tl with a low dose of insulin in a glucose/potassium chloride solution is safe and may enhance cellular uptake of the radiotracer in severe ischemic regions, thereby improving viable myocardium detection.

Evaluation of hypertensive patients by means of captopril enhanced renal scintigraphy with technetium-99m DTPA.

One-hundred five hypertensive patients underwent conventional renal scintigraphy followed 2 or 3 days later by Captopril-enhanced renal scintigraphy, performed 1 hr after premedication with 50 mg of Captopril per os. All patients were then submitted to renal arteriography, performed within 15-30 days. Fifty-five patients had no renal artery stenosis, 29 had unilateral disease, and 21 bilateral. Overall, 34/37 patients were diagnosed by the provocative test as having at least one renal artery affected by a stenosis greater than 50%. Of those with no stenosis (n = 55) or stenosis less than 50% (n = 13) only two cases were falsely positive. Thus sensitivity was 92% and specificity 97%. For single kidney identification with stenosis greater than 50%, sensitivity of renal scintigraphy after Captopril administration was 94% and specificity 98%. Captopril enhanced renal scintigraphy is thus suggested as the first test to be performed in hypertensive patients referred for renal scintigraphic studies. Only those cases with equivocal results require a baseline study for better assessment.

Clinical and hemodynamic effects of long-term administration of gallopamil in patients with coronary artery disease and normal or impaired left ventricular function.

The hemodynamic and clinical profiles of gallopamil, a new calcium antagonist, were evaluated in 20 patients with severe coronary artery disease in a placebo-controlled, single-blind study. The patients were divided into 2 groups depending on baseline ejection fraction (greater than 45 or less than or equal to 45%) and underwent nuclear ventriculography, both at rest and during bicycle exercise under electrocardiographic monitoring, after 3 weeks of therapy (50 mg 3 times daily) and the 1-week run in and washout placebo periods. The mean anginal weekly frequency per patient was significantly reduced, from 3.4 to 0.5 (p less than 0.001). The left ventricular ejection fraction, cardiac volumes, ejection and filling indexes at rest and for the same workload were not altered in the population as a whole or in each of the 2 groups. The rate pressure product during exercise was reduced for the same workload from 18.0 +/- 5.0 X 10(3) to 16.8 +/- 4.7 X 10(3), while the regional ejection fraction in ischemic regions was not significantly changed. Individual variations of ventriculographic parameters in both groups were not related to basal values. Gallopamil increased the total duration of exercise from 432 +/- 201 to 537 +/- 188 s (p less than 0.001). Six patients did not complain of angina and their exercise was interrupted because of muscular weakness. The hemodynamic and clinical responses did not differ when the results in the population as a whole and in each of the 2 groups were compared. Gallopamil was effective and well tolerated, even in patients with very depressed cardiac function.

Recovery of response to adriamycin and cyclophosphamide by lonidamine in previously treated metastatic breast-cancer patients.

Thirty-one patients with metastatic breast cancer not responding or progressing after initial response to adriamycin + cyclophosphamide (AC) treatment entered a phase 11 study with oral lonidamine in association to AC. Objective clinical responses were observed in 10 patients (32%) and consisted of 1 complete + 9 partial remissions. Disease stability and progression were observed in 8 and 13 cases, respectively. These results were obtained with a marginal toxicity in addition to that already reported for AC therapy, the main additional side effect being myalgia, which was easily manageable in most cases.

Primary lymphoma of the liver - a case-report and a review of the literature.

A case of primary lymphoma of the liver in a 72-year-old man is reported. The patient showed a three to four month history of abdominal ache, low grade fever, and weight loss. The presence of a large mass occupying the V and VT hepatic segments was demonstrated; no other organs were involved and no evidence of lymphoadenopathy was found. Laboratory tests showed a remarkable increase in ESR, LDH and alkaline phosphatase while CEA and alpha-1 fetoprotein were within the normal values. Two ultrasound-guided needle biopsies on the hepatic lesion did not produce any significant tissue for diagnosis. Therefore the V and VI hepatic segments were excised; a hard, greyish mass with the largest diameter of 6.5 cm, was found at laparatomy. Histology of the surgical specimen showed the presence of a malignant non-Hodgking's B-cell lymphoma, centroblastic-centrocytic, diffuse type (working formulation: G) of intermediate grade of malignancy. Staging was completed with lymphography, and bone marrow biopsy; both proved normal. After the operation adjuvant chemotherapy was commenced (COP for six cycles). Follow-up has so far shown no signs of recurrence after 24 months. In conclusion, the diagnosis of primary lymphoma of the liver is very difficult and is often reached only after histologic evaluation of the surgical specimen. Moreover, this disease has a much more favourable prognosis than the hepatocellular carcinoma and other primary or secondary liver cancers; therefore accurate investigations are important to reach the correct diagnosis.

[Identification of viable myocardium by 201Tl scintigraphy: a comparison of methods]. / Identifizierung des vitalen Myokards mit der 201Tl-Szintigraphie: Ein Vergleich der Methoden.

The present study was undertaken to compare four different imaging approaches to evaluate uptake defect reversibility. 24 infarcted patients underwent standard stress/redistribution 201Tl imaging (R1). Then, after reinjection of 37 MBq of 201Tl, patients were re-imaged either after 15 min (R2) 24 h later (R3). A separate rest study (R4) following a new tracer injection was done within 2-3 days. Planar images were obtained in the standard three views and subdivided into 216 segments for qualitative analysis based on a visual score. A semiquantitative analysis based upon circumferential profiles was also applied. A stress defect was found in 127 segments (58.7%). By visual inspection reperfusion was considered to occur in 32.3%, 41.7%, 33.0% and 49.6% of the cases with R1, R2, R3, and R4, respectively. The semiquantitative method showed a high reperfusion only with R1 (62%), while the other procedures proved less effective. No improvement was found with R4. Six patients (25%) showed myocardial viability that was not detected with the early reinjection technique.

Evaluation of hypertensive patients with a solitary kidney using captopril renal scintigraphy with 99Tcm-MAG3.

The study aimed to evaluate the safety and reliability of captopril renal scintigraphy (CRS) for diagnosing functionally significant renal artery stenosis (RAS) in hypertensive patients with a solitary kidney. Radionuclide studies were carried out using 100 MBq 99Tcm-mercaptoacetyl triglycine (MAG3), 1 h after administration of 50 mg captopril, and repeated in baseline condition when abnormalities were observed in the provocative study. Scintigraphic diagnosis of RAS was based on analysis of captopril-induced changes of the radiorenographs. Overall, 12 patients with a solitary kidney were investigated, and scintigraphic results compared to angiographic findings. All five patients with positive CRS showed an RAS > 50%, whereas only one of the seven patients with negative CRS was affected by RAS. A significant fall in mean arterial pressure was recorded after captopril administration (123 +/- 12 mm Hg before versus 108 +/- 11 after), but no serious side effects were observed. Our results demonstrate that captopril-induced modifications of the renogram could effectively be used to diagnose the presence of RAS. Captopril renal scintigraphy may therefore be suggested as a reliable and safe noninvasive approach to evaluate hypertensive patients with a solitary kidney.

Evaluation of lung clearance of inhaled pertechnegas.

Pertechnegas is a new ventilation agent produced by modifying the atmosphere of combustion of Technegas. Due to its rapid disappearance from the lungs, Pertechnegas has been suggested as useful in measuring pulmonary epithelial permeability. This study aimed to assess the reliability of ventilation scans with Pertechnegas to evaluate alveolar-capillary permeability. Six non-smokers with no evidence of pulmonary disease were investigated. Scintigraphic data were used to evaluate the site of Pertechnegas deposition (by assessing the Penetration Index [PI] of the gas), its clearance rate (by calculating the time to half-clearance [T1/2]) and its lung distribution (by means of a pixel-by-pixel analysis. PI measurements produced a mean value of 88.8 +/- 13.3% (range 69-117%). Time activity curves showed a fast clearance in all cases (mean T1/2 = 10.7 +/- 2.1 min, range 8.1-14.3 min). Comparison of statistical indices of uniform deposition (skewness and kurtosis) indicated satisfactory homogeneity of Pertechnegas distribution throughout the lungs. These data show that after inhalation Pertechnegas has a peripheral deposition and a homogeneous distribution in the lungs and is rapidly cleared through the alveolar-capillary barrier. In conclusion Pertechnegas can be recommended as a potential radiopharmaceutical for studying the pulmonary epithelial barrier.

[Controlled clinical trial of a new synthetic preparation (parsalmide) in the treatment of inflammatory and degenerative arthro-myopathies]. / Sperimentazione clinica controllata di un nuovo preparato di sintesi (parsalmide) nel trattamento delle artro-miopatie infiammatorie e degenerative

A double-blind, between-patients trial of a new drug (parsalmide) against indomethacin in the relief of inflammation and pain in 68 patients with exacerbated inflammatory and-or degenerative arthromyopathy resulted in 76% of successful results with both drugs. Tolerance was good, though side-effects, albeit slight, were more common with indomethacin.

[Deep venous thrombosis. Evaluation of a non-invasive diagnostic procedure based on compression ultrasonography and measurement of D-dimer plasma levels]. / Trombosi venosa profonda. Validazione di una procedura diagnostica non invasiva basata su ultrasonografia con compressione associata a dosaggio dei D-dimeri plasmatici.

BACKGROUND: Clinical diagnosis of deep venous thrombosis (DVT) of the leg is unreliable. An accurate diagnosis is important for therapeutic decision since anticoagulant treatment, though potentially dangerous, is useless in case of a false positive diagnosis, whereas a false negative diagnosis may lead to withdrawal of an extremely necessary anticoagulation. Contrast venography is still recognized as the gold standard method for the diagnosis of DVT, but in recent years a variety of accurate non-invasive methods has been developed. The ultrasound compression sonography (CUS) is considered a simple non invasive test highly sensitive and specific for proximal DVT in symptomatic outpatients, though non adequately sensitive and specific for isolated calf DVT. Plasma D-dimer levels (DD, fibrin degradation products) have a high negative predictive value for DVT. The aim of this study, performed in outpatients with suspected leg DVT, was to validate, versus venography, a non-invasive, easy to perform and fast diagnostic procedure based on a combination of CUS and D-dimer test. End points of the procedure were: confirmation or exclusion of proximal DVT; suspicion of isolated calf DVT in which case the test would be repeated in a few days to detect any possible proximalization of thrombosis. MATERIALS AND METHODS: Sixty-eight consecutive outpatients, 37 male, with clinically suspected first episode of leg DVT were eligible and examined with CUS, DD test and venography. RESULTS: The results showed that the diagnostic procedure under examination has a high sensibility and specificity for DVT. CONCLUSIONS: It can thus be recommended as routine diagnostic procedure in symptomatic outpatients with suspected DVT reserving venography special cases only.

Proton pump inhibitor responders who are not confirmed as GERD patients with impedance and pH monitoring: who are they?

BACKGROUND: A short-course of proton pump inhibitors (PPIs) is often used to confirm gastroesophageal reflux disease (GERD). However, some patients with PPI responsive heartburn do not seem to have evidence of GERD on impedance-pH monitoring (MII-pH). The aim of the study was to evaluate patients with reflux symptoms and a negative endoscopy, who well respond to PPIs with MII-pH. METHODS: We enrolled 312 patients with GERD symptoms and negative endoscopy: 144 reported well-controlled symptoms after 8-week PPIs and 155 were non-responders. Symptom relief was evaluated with GERD Impact Scale and visual analog scale score. All patients underwent MII-pH off-therapy. Thirteen patients were excluded from analysis. Patients were grouped as follows: non-erosive reflux disease (NERD; increased acid exposure time, AET); hypersensitive esophagus (HE; normal AET, positive symptom association, SI/SAP); MII-pH-/PPI+ (normal AET, negative SI/SAP) in the responder group; MII-pH-/PPI- in non-responders. KEY RESULTS: MII-pH in PPI responders (symptom relief during PPI therapy > 75%) showed: 79/144 NERD (54.9%); 37/144 HE (25.7%); 28/144 MII-pH-/PPI+ (19.4%). MII-pH-/PPI+ patients reported the same symptom relief when compared with NERD and HE. In non-responder (symptom relief during PPI therapy < 50%) group, 27/155 patients were NERD (17.4%); 53/155 were HE (34.2%); 75/155 were MII-pH-/PPI- (48.4%). NERD diagnosis was significantly higher in responder group (p < 0.01). CONCLUSIONS & INFERENCES: In a substantial subgroup of patients responding to PPI with typical reflux symptoms, the diagnosis of GERD cannot be confirmed with pH-impedance monitoring. Proton pump inhibitor response and presence of typical symptoms are thus not reliable predictors of the diagnosis and antireflux surgery should always be preceded by reflux monitoring.