Tumurs <5 cm in diameter and at the anal margin have a more favourable prognosis. PrognosisFor prognostic purposes most information of clinical value is obtained by distinguishing tumours arising at the anal margin from those in the anal canal and separating them into those greater or less than 5 cm in diameter. The tumour is relatively uncommon so there have been relatively few large follow up studies, but the five year survival rate is about 50%. The need to avoid air embolism when inserting and manipulating central venous catheters is widely appreciated but the risk after catheter removal is less widely known. This has implications regarding the delegation of practical procedures.' Case report A 73 year old man was admitted for elective repair of an 8 cm abdominal aortic aneurysm. The past history included a myocardial infarction complicated by ventricular fibrillation eight years previously and an episode of acute left ventricular failure one year before when mitral incompetence was noted. The preoperative echocardiogram showed minimal mitral regurgitation and an ejection fraction of 54%. The aneurysm repair was uneventful, lasting 90 minutes. An episode ofpulmonary oedema on the first day was easily treated with diuretics and oxygen. Thereafter, he had an uneventful course, returning from the intensive care unit to the ward on the second postoperative day.A pulmonary flotation catheter (7 5 French gauge) had been inserted into the right internal jugular vein at the time of operation and the catheter sheath was removed by the houseman on the fifth day. About two minutes later the patient collapsed and became unresponsive with no palpable cardiac output. Cardiac massage was begun. On arrival the arrest team noted a spontaneous respiration rate of 18/min with good ventilatory efforts. Pulse was 120/min, regular, and in sinus rhythm. Blood pressure was 90/60 mm Hg and there was good colour and no cyanosis. The patient was sweating profusely. He was unresponsive to painful stimuli. Pupils were of normal size and reacting symmetrically. There were no focal neurological signs. Chest sounds were normal but examination of the heart disclosed widespread loud, harsh, crunching sounds throughout systole and diastole over the whole precordium. The originally recorded murmur of mitral incompetence could not be heard.Examination of abdomen and legs showed nothing abnormal apart from the recent incision. Blood glucose concentration was 6-7 mmol/l, and haemoglobin and Prevention Central venous catheters must be removed with the patient supine or in slight Trendelenberg position and the entry site covered by an air occlusive dressing.

BackgroundDyspepsia guidelines recommend that patients treated with proton pump inhibitors (PPIs) should step down to the lowest effective dose or return to self-care, but rebound hyperacidity can make this difficult. Many patients continue on PPIs in the long term, which may lead to safety and financial implications.AimTo determine if a nurse-led educational support programme and rescue therapy for rebound symptoms can help patients achieve a sustained reduction in PPI use.Design & settingA prospective interventional study was conducted at 26 surgeries across the UK.MethodAdult patients, treated with PPIs for ≥2 consecutive months with an active repeat prescription, were invited to a 20-minute dyspepsia clinic appointment with a trained nurse adviser. An action plan to reduce and/or stop their PPI usage was agreed and alginate supplied for the self-management of rebound symptoms. After 12 months, PPI status was reviewed and prescribing cost savings calculated.ResultsAfter 12 months, 75.1% of 6249 eligible patients stepped down or off PPIs (35.3% stepped off; 5.0% stepped down then off; 34.8% stepped down only), while 8.7% of patients had reverted to their original PPI dose. PPI prescriptions fell from 89 915 to 45 880 and alginate prescriptions increased from 2405 to 6670. An average of 1.7 bottles (500 ml each) of alginate were used per patient who stepped down or off. Estimated annual cost-saving on prescriptions was £31 716.30.ConclusionA programme of education and short-term rebound symptom management helped the majority of patients to successfully step down or off PPIs, significantly reducing the potential risks associated with chronic therapy.

Adding Gaviscon to PPI reduced breakthrough GERD symptoms but a nearly equal response was observed for placebo. Response to intervention may vary according to whether symptoms are functional in origin.

Objective Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are chronic conditions caused by backflow of gastric and duodenal contents into the esophagus and proximal aerodigestive tract, respectively. Mucosal barrier dysfunction resultant from the synergistic actions of chemical injury and the mucosal inflammatory response during reflux contributes to symptom perception. Alginates effectively treat symptoms of mild to moderate GERD and have recently shown benefit for LPR. In addition to forming a “raft” over gastric contents to reduce acidic reflux episodes, alginates have been found to bind the esophageal mucosa thereby preserving functional barrier integrity measured by transepithelial electrical resistance. The aim of this study was to further examine the topical protective capacity of alginate‐based Gaviscon Advance (GA) and Double Action (GDA) against pepsin‐acid mediated aerodigestive epithelial barrier dysfunction in vitro. Study Design Translational. Methods Immortalized human esophageal and vocal cord epithelial cells cultured in transwells were pretreated with liquid formula GA, GDA, matched viscous placebo solution, or saline (control), then treated for 1 h with saline, acid (pH 3–6) or pepsin (0.1–1 mg/ml) at pH 3–6. Endpoint measure was taken of horseradish peroxidase (HRP) allowed to diffuse across monolayers for 2 h. Results Pepsin (0.1‐1 mg/ml) at pH 3‐6 increased HRP flux through cultures pretreated with saline or placebo (p < 0.05); acid alone did not. GA and GDA prevented barrier dysfunction. Conclusions GA and GDA preserved epithelial barrier function during pepsin‐acid insult better than placebo suggesting that protection was due to alginate. These data support topical protection as a therapeutic approach to GERD and LPR. Laryngoscope, 132:2327–2334, 2022