These patients and their families face immense physical treatment 99213 purchase clopidogrel online now, psychological and economic burdens medicine kidney stones order clopidogrel online. This includes: (a) the background leading to medicine river animal hospital buy clopidogrel overnight legislation on orphan drugs; (b) the mechanism for determining and controlling the prices of orphan drugs reimbursed under the respective healthcare systems; (c) the number of rare disease patients receiving subsidy on medical costs and the amount of costs incurred; and (d) the recent developments on rare disease policy symptoms xanax buy discount clopidogrel. The paragraphs below give an overview of the rare disease policies in Hong Kong and the overseas places studied, and the salient features of their policies are compared in the Table. Meanwhile, the Hospital Authority provides medical services for patients suffering from genetic diseases. Added to this, the Department of Health and the Hospital Authority started the Pilot Study of Newborn Screening for Inborn Errors of Metabolism in October 2015, in an effort to prevent and reduce severe problems arising from inborn errors of metabolism. The number of inborn errors of metabolism covered under the Pilot Study increased from 21 to 24 in April 2016. As a new initiative, eligible patients suffering from Paroxysmal Nocturnal Haemoglobinuria will be provided with drug subsidies under an assistance programme of the Community Care Fund from August 2017 onwards. Up to December 2016, the Hospital Authority had provided enzyme replacement therapy to 27 patients with lysosomal storage disorders. These places have set out their definition for rare diseases and put in place an orphan drug designation system to encourage the development of orphan drugs for treating rare diseases. They have also implemented other measures to support the medical and/or social care of rare disease patients under their respective rare disease policy framework. Japan and Taiwan have also considered other criteria in their definition of rare diseases such as diseases that are difficult to diagnose and treat, or no appropriate treatment is available. The Act contains provisions governing the designation of orphan drugs and granting of incentives and assistance in the regulatory process to encourage pharmaceutical companies to develop orphan drugs. The orphan drug designation systems of the above overseas places cover all of the seven uncommon disorders which have been or will be covered under the drug 7 subsidization schemes of the Hong Kong Government. The incentives granted by them generally include financial subsidies and tax relief on research expenses, fast-track marketing approval process, reduced or waived application fees, and marketing exclusivity for a certain number of years after obtaining marketing authorization/approval of an orphan drug. The orphan drug designation system has also successfully enabled the development and marketing of over 600 drugs and biologic products for rare diseases since 1983. In contrast, fewer than 10 such products supported by industry came to market between 1973 and 1983. Factors that are considered in determining the price of a newly listed orphan drug include: (a) availability and prices of alternative products in the market; (b) degree of innovation of the product or efficacy/usefulness over existing comparable products; and (c) prices of the product in reference overseas countries. In Japan, the reimbursement price of a new orphan drug is determined with reference to the prices of existing drugs in the same category and a premium of 10% to 20% will be added to the price if the new drug is considered to be more useful than the existing drugs. If no similar product is available in the market, the reimbursement price is determined based on cost accounting method. In both cases, the price calculated will be adjusted in case there is a big discrepancy compared against the prices of the drug in four reference countries. However, the federal and state governments have implemented measures to control the prices of prescription 8 drugs reimbursed under Medicaid, the social healthcare scheme. These price controlling measures include (a) requiring the pharmaceutical companies to offer rebate on prices of prescription drugs; and (b) setting a limit on the reimbursement price for specified multiple-source prescription drugs. It is noteworthy that Japan and Taiwan have specifically incorporated the need for social care services among rare disease patients into their rare disease policy framework. In particular, they have expanded the 8 Medicaid is a means-tested welfare programme to assist individuals and families with low incomes and relatively few assets with paying for their health care. The programme is administered by the state governments and is funded jointly by the federal and state governments. In contrast, Australia has set out its rare disease policy targeting at promoting the research and development of orphan drugs. As such, there have been calls for the Australian federal government to formulate a comprehensive national plan on rare diseases. Japan, Taiwan, South Korea and Australia have also implemented measures to subsidize the medicine and/or medical costs of patients, particularly those with low income. This has helped improve the accessibility of rare disease patients to expensive drugs and treatments. Relevant fi N o dedicated fi the am ended Pharm aceutical fi Rare Disease and O rphan Drug fi the am ended Pharm aceutical legislation legislation on AffairsAct,and the 2014 Acton Actfi fi fi fi fi fi fi fi fi fi AffairsAct,and the Rare Disease rare diseases/ M edicalCare and Social fi fi im plem ented in 2000. Atthattim e,the suffering from rare diseasesto Intractable/Rare Diseasesw as drug and treatm entcostsincurred ensure they have accessto the enacted in 2014,aftera policy by rare disease patientsw ere not besttreatm entpossible. The program m e is financed by prem ium scontributed by the insured,em ployersand the governm ent. Australian G overnm entDepartm ent Adm inistration,and relevantstate ofH um an Services. Relevantlegislation fi the O rphan Drug Actof1983 and the fi the European Union Regulation on fi the am ended Therapeutic G oods Rare DiseasesActof2002. Background leading fi the O rphan Drug Actw aspassed in fi the European Union Regulation on fi the Therapeutic G oodsRegulations to the legislation 1983 to addressthe little incentive on O rphan M edicinalProductsw as w asam ended in 2001 to provide the partofpharm aceuticalcom panies adopted in 1999 to stim ulate the forthe establishm entofan orphan to investin the developm entoforphan developm entoforphan drugsatthe drug designation system in drugs,leading to lim ited availability of Com m unity leveland individual Australia. Provision offinancial fi Including financialsubsidies/tax fi Including a 10-yearperiod of fi Including w aiveroffeesforthe incentivesand assistance credit,fast-track m arketing m arketing exclusivity and reduced application,evaluation and registration in regulatory processto authorization and a seven-year feesform arketing authorization ofdrugs. Seven uncom m on disorders fi the drug subsidization fi Japan,Taiw an and South Korea have covered these seven uncom m on disorders thathave been orw illbe schem escoverthe above undertheirrespective orphan drug designation system s. A prem ium prem ium w illbe added forproducts available in the country,the item sthrough com petitive of10% to 20% w illbe added to thathave undergone efficacy and drug price isbased on the tendersw here appropriate the price ifthe new drug is safety clinicaltrialin Taiw an. In general,the com ponents:(a)the coststo the governm entshave im plem ented drug price m ay be setby the pharm aceutical pharm acistofprocuring the drug w hich is m easuresto controlthe costsof com paniesorfixed afternegotiation betw een calculated asthe approved ex-m anufacturer 23 prescription drugsreim bursed under the responsible authoritiesand the price plusa w holesale m ark-up; the M edicaid Program m. For exam ple,for innovator drugs,the rebate levelfor each unit ofa drug is the greater of23. Forexam ple,the "costplus m ethod" is com m only used forstand-alone products ifno specific com parable productexists in the m arket. Alternatively,reference pricing isadopted fordrugshaving sim ilarsafety and efficacy levelsasotherlisted drugs. Facilitation m easure forearly fi N ew born screening program m es fi N ew born screening program m es fi N ew born screening program m es identification ofrare diseases im plem ented by individualstates. Facilitation m easuresfor fi Passage ofthe PatientProtection fi Subjectto the policy fram ew ork of fi Underthe Life Saving Drugs accessing m edicalcare and Affordable Care Actin 2010 to individualm em berstates. Program m e,eligible rare disease services rem ove variousdiscrim inatory patientsare fully subsidized on the insurance practicesagainstrare costsof12 expensive and life25 disease patients. These patientsm ustbe those w ho sufferfrom eightspecified typesof rare diseasesand m eetspecified eligibility criteria and conditions. Currently,the federalgovernm enthasbeen review ing the health insurance system w ith a view to repealing the Act. R& D projectsrelated to rare incentivesto W elfare prom otesresearch on developm ent("R& D") diseases. Costsincurred fi An additionalannual fi the costsofthe subsidization fi Am ountofdrug costs fi Scanty inform ation is by the recurrentfunding ofabout schem e w ere estim ated to be incurred totalled available on the am ount governm ent H K$75 m illion hasbeen fi222 billion (H K$14. This figure is low erthan the 30% co-paym entrate applicable to generalpatientscovered underthe nationalhealth insurance system in Japan. Research Office Information Services Division Legislative Council Secretariat 14 July 2017 Tel: 2871 2143 Fact sheets are compiled for Members and Committees of the Legislative Council. They are not legal or other professional advice and shall not be relied on as such. Fact sheets are subject to copyright owned by the Legislative Council Commission (The Commission). The Commission permits accurate reproduction of fact sheets for non-commercial use in a manner not adversely affecting the Legislative Council, provided that acknowledgement is made stating the Research Office of the Legislative Council Secretariat as the source and one copy of the reproduction is sent to the Legislative Council Library. List the age-specific causes of liver disease in neonates, infants, older more common, if not exclusive, to children, and adolescents. Explain why fractionation of serum bilirubin is necessary in infants focusing the evaluation and defining who remain jaundiced after 2 weeks of age. Characterize biliary atresia and identify findings from the history, physical examination, and laboratory evaluation that may suggest this associated with liver disease in the diagnosis. One contributing factor is who presents with classic signs, delay in the initiation of effective such as persistent jaundice, hepatotherapies. Liver transplantation is a that injury to the pediatric liver manifests in a finite number of megaly, coagulopathy, or failure to reality for pediatric patients who thrive. At other times, incidental have severe or end-stage liver disways; hence, different disorders often have virtually identical initial findings of abnormalities on serum ease, and other therapies also are chemistries may suggest the diagnonow available for treating many presentations. Unfortunately, the difference between physiologic cents who have acute hepatitis or natal liver disease is as high as 1 in following toxin exposure. Early recognition hyperbilirubinemia and hyperbilirubinemia indicative of severe liver seen in older children who have is particularly important in neonates cholestasis, may manifest as irritaand infants because a delay in diagdisease often is unappreciated.
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This risk of hypoglycemia may be recommendations for maternal weight gain in women without diaameliorated if efforts are made to treatment 3rd degree hemorrhoids discount 75 mg clopidogrel otc achieve good glycemic control betes treatment genital herpes order clopidogrel online, showed that those who followed guidelines were more likely preconception and by the use of analogue insulins (100 4 medications list at walmart buy clopidogrel 75mg cheap,104 symptoms quitting weed discount 75mg clopidogrel amex,105) to have good infant birthweight and fetal growth, and decreased (see Hypoglycemia chapter, p. Furthermore, not cross the placenta at therapeutic doses, although glargine does prepregnancy overweight and obesity are risk factors for adverse cross at very high doses (139). Therefore, diabetes studies have not demonstrated superiority over basal-bolus regimen education and management for this group of women in precon(132,143146). A meta-analysis of first-trimester use of either glyburide to the changing needs of pregnancy (126129). A randomized trial but this group experienced less maternal weight gain, less of 322 women with type 1 diabetes randomized to insulin aspart pregnancy-induced hypertension; the infants had an increased vs. However, given the small sample sizes in the but similar overall glycemic control (104). In women susthe findings as researchers used differing calculation methods to pected of preterm delivery, 2 doses of betamethasone is often given indicate fall in insulin requirements or perhaps due to heterogeto aid in the maturation of the fetal lungs. The use of advanced sonographic and fetal doppler hypoglycemia in women with type 1 diabetes (157). While fetal monitoring in this situation can provide rity, perinatal mortality rates in women with pre-existing diabetes reassurance of current fetal well-being, it should not be viewed as remain increased 1to 10-fold compared to women without diaa substitute for a well thought out plan for timing of delivery that betes, and is infiuenced by glycemic control (1,77). However, not all stillbirths can be avoided due Significance of decreasing insulin requirements to the fact that many stillbirths in pre-existing diabetes occur prior to 36 weeks of gestation and that in a large number of cases no Insulin requirements increase in pregnancy due largely to the obvious cause is noted (164). Two recently published randomized controlled trials insulin needs and risk of hypoglycemia in the immediate postparshed additional light on this clinical question. The study found no difference in caesarean section rates diately decreased by at least 50% after delivery to avoid hypoglybetween groups, but an increase in hyperbilirubinemia was noted cemia (175,178). However, the study was underpowered and disIn the first days postpartum, insulin requirements are genercontinued due to recruitment dificulties; thus any extrapolations ally reduced by an average of 30% to 50% of the prepregnant insulin from the study cannot be made (170). A gradual return to pre-pregnant insulin doses has been noted with comorbidities, initiation of weekly assessment of fetal wellafter 6 to 8 weeks postpartum in some studies (179,180);however, being at 34 to 36 weeks gestation is recommended. Acceptable methods of assessment of fetal wellhave been especially noted in women with type 1 diabetes who were being near term can include the nonstress test, amniotic fiuid index, breastfeeding (180,181), although this has not been universally biophysical profile or a combination of these. Thus, decrease in the caesarean rate need to be weighed against the likely for women with pre-existing diabetes in pregnancy, a post-delivery increase in neonatal complications. Indeed, women who received postpartum, glycemic control is managed less effectively by mothers antenatal care from a family physician or other health-care prowith diabetes in the first year postpartum, and A1C levels graduviders were respectively 2 and 3 times more likely to exclusively ally increase and return to the pre-pregnancy level (182,183). In addisimilar breastfeeding rates in women with type 1 diabetes as the tion, most women are unable to return to prepregnancy weight (183). Improved postpartum care and specific interventions for women with pre-existing diabetes should be developed to help women Use of noninsulin antihyperglycemic agents during breastfeeding. Screening for glyburide or glipizide while breastfeeding found neither drug in the thyroid hormonal abnormalities during pregnancy and at approxibreastmilk, and the maximum theoretical infant dose was well below mately 3 months postpartum in women with type 1 diabetes is 10% (<1. Women tinal maturation of the infant and could act as a positive modulawith type 1 diabetes also discontinue breastfeeding at a higher rate tor of the immune response to insulin as suggested by certain groups during the first week postpartum (191193). Breastfeeding immediately postpartum can However, once established, lactation persists and duration is similar be part of an early feeding strategy to reduce the risk of neonatal in mothers with and without diabetes (190,195). Moreover, infants of mothers with diabetes showed poorer and Reducing the Risk of Developing Diabetes chapter, p. Regarding the choice of a contraceptive method, changes (diet and physical activity) and metformin. Dietary interthe same motivations and restrictions apply to women with type 1 ventions were associated with a statistically significant lower and type 2 diabetes as with other women. Healthy eating intervention consisted of a consultation with a trained dietitian, weighing at each antenatal visit and Prevention and risk factors review of food records, but the duration and number of sessions differed among studies. Various presentations include: cal problems with this study involving the inclusion of studies of diet alone and physical activity alone make this conclusion less reli Hyperglycemia that likely preceded the pregnancy. Only 3 of 8 observational studies (233) and 1 meta-analysis (234) demonstrate a significant inverse Early screening. On the other hand, there has small sample sizes and these results have not been replicated. Another recent study in a multiethnic population of spring born after maternal bariatric surgery, positioning bariatric 1,156 women who underwent first trimester A1C and 24to 28-week surgery as 1 of the potential options to limit intergenerational trans2-stage glucose tolerance test, 48 out of 1,180 had an A1C of 5. Thus, a first triencouraging results, but these need to be replicated in larger ranmester A1C fi5. In 1 study, in women 6 to 8 weeks postpanel believes that there is not suficient evidence to adopt a 1-step partum who had an A1C fi6. Further higher-quality evidence would be helpful in estabcaesarean section rate (286). Furthermore, secondary analysis of the Landon et al for the first time in pregnancy. Study interventions involved mainly diet only, though this phenotype may be present outside of pregnancy in the exercise only and combined diet and exercise interventions comsame woman (295). There was no clear difference fetal growth assessment can aid in the establishment of appropribetween intervention and control groups with regards to preate glucose targets during pregnancy for women with docueclampsia, caesarean section, preterm birth and macrosomia. Risks of matertions, and the other proposed an exercise program with a higher nal hypoglycemia or fetal low birth weight were not evaluated in level of intensity (>70% of maximal heart rate). Both fasting and postprandial testing are recommended to guide therapy in order to improve fetal outcomes (89,332). In a randomized trial, 340 women were randomized logical therapy should be initiated (354,355). Older studies raised the possibility that levemir is safe and may afford less maternal hypoglycemia comelevated ketoacids may be detrimental to the fetus (94,339). Finally, studies assessing cost effectiveness motor, social and linguistic development. Studies looking at of these measures, both direct (health system resources utilization) neurodevelopment showed similar outcomes between exposed and and indirect (work absenteeism, parking, daycare fees) are needed. Therefore, the use of glyburide during pregassociated with less diabetes in the mother with hazard ratios as nancy is not recommended as firstor second-line treatment, but low as 0. The is up to 2 years) (217), but more support is needed as this group use of these noninsulin antihyperglycemic agents is not recomis at risk for early cessation. Any degree of dysglycemia rological abnormalities at 18 months, especially if hypoglycemic seiis associated with increased risk of postpartum diabetes (412). One study hypoglycemia with the higher value, but the studies do not arrive revealed that, despite email reminders, absolute improvement was at a common value and vary from <4. If this can be confirmed in more rigorous trials, it may be useful to do early postpartum testing in women at high risk for Breastfeeding. Risk and benefits of each method risk of developing diabetes with both a lifestyle intervention or should be discussed with each patient and same contraindications metformin, these women were, on average, 12 years postpartum. In another randomized confuture pregnancies in consultation with their health-care providtrolled trial, 260 women were randomized to receive the Mediterers (466,467). In an effort to reduce the risk of condeveloped glycemic disorders in the intervention group (42% vs. Spontaneous abortion [Grade C, Level 3 (159)] be too short to draw conclusions about longer-term impact. Congenital anomalies [Grade C, Level 3 (7,76,469,470)] it is interesting to note that the excess weight in offspring of iii. Preeclampsia [Grade C, Level 3 (471,472)] women with diabetes in the observational work by Silverman iv. Progression of retinopathy in pregnancy [Grade A, Level 1 for type 1 diabetes (25); Grade D, Consensus for type 2 diabetes] et al (460) was evident by 5 years of age. Discontinue medications that are potentially embryopathic, includand is associated with similar perinatal outcomes. Women should undergo an ophthalmological evaluation by a vision care specialist during pregnancy planning, the first trimester, as needed during 16. Earlier onset and/or more frequent fetal health surveillance is surveillance during pregnancy as determined by the vision care specialrecommended in those considered at highest risk [Grade D, Consensus]. In women with uncomplicated pre-existing diabetes, induction should anticipatory reductions in A1C during pregnancy, in order to reduce probe considered between 3839 weeks of gestation to reduce risk of stillgression of retinopathy [Grade B, Level 1 for type 1 diabetes (25,27); birth [Grade D, Consensus]. Women with pre-existing diabetes should have frequent blood glucose for type 1 diabetes] monitoring in the first days postpartum, as they have a high risk of hypob.
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Symptoms the typical presentation of gastroesophageal reflux disease is chest burning (often referred to medicine hat buy 75mg clopidogrel overnight delivery as heartburn) and the regurgitation of sour or bitter liquid medicine in balance effective clopidogrel 75mg, sometimes mixed with food treatment gout buy generic clopidogrel 75mg line, to medications you cant take while breastfeeding order generic clopidogrel from india the throat or mouth. Although not everyone with gastroesophageal reflux disease has these symptoms, the combination of chest burning and regurgitation of sour or bitter-tasting food or liquid is so characteristic of gastroesophageal reflux that formal testing is often unnecessary. The chest pain is usually located in the middle of the chest and may radiate through to the back. Difficulty swallowing (dysphagia) may be due to abnormal esophageal motility or to an esophageal stricture. These atypical reflux symptoms, often referred to as extra-esophageal manifestations of reflux disease, may include sore throat, coughing, increased salivation, and shortness of breath. Although it might be assumed that throat and airway symptoms would only occur in patients with esophageal symptoms, extraesophageal manifestations can occur in patients without esophageal symptoms and without esophageal damage. The body of the esophagus is approximately 1825 cm long, extending from the upper esophageal sphincter (C5C6 vertebral space at the junction of the pharynx and the esophagus) to the lower esophageal sphincter (T10 level at the junction of the esophagus and the stomach). The length of the esophagus correlates with an individuals height and is usually longer in men than in women. The esophagus transports food from the mouth to the stomach in a caudad direction and prevents the retrograde movement of gastric or esophageal contents. It is a hollow tube closed at the upper end by the upper esophageal sphincter and at the lower end by the lower esophageal sphincter. Underneath is a supporting layer of connective tissue called the lamina propria and a longitudinally oriented, thin layer of muscle fiber (muscularis mucosae). The submucosa consists of loose connective tissue, blood vessels, lymphatics, and nerves. The muscularis propria has two layers, an inner circular muscle layer with circumferential fibers and an outer longitudinal layer with fibers oriented along the axis. The muscle in the muscularis mucosae is smooth along the length of the esophagus, whereas the muscularis propria is composed of striated muscle in the most proximal portion. A network of intrinsic neurons is found in the submucosa and between the circular and longitudinal muscle layers, and, is capable of producing secondary peristalsis. This network communicates to the central nervous system via the vagi, the adrenergic ganglia, and the celiac ganglia (Figure 3). Normal anatomy of the esophagus; A, anterior; B, lateral view showing esophageal regions. The cervical esophagus extends from the lower border of the cricoid cartilage to the thoracic inlet (suprasternal notch) or from the cricopharyngeus muscle to approximately 18 cm from the gums. The trachea, vertebral column, and thyroid and carotid sheaths surround this portion of the esophagus. The upper thoracic esophagus extends from the thoracic inlet to the level of the tracheal bifurcation (1824 cm from the gums). The mid-thoracic esophagus includes the proximal half of the esophagus from the tracheal bifurcation to the esophagogastric junction (2432 cm from the gums). The thoracic esophagus passes posterior to the tracheal wall and posterior to the aortic arch and the bifurcation of the trachea and left bronchus. Finally, the distal thoracic esophagus includes the distal half of the esophagus from the tracheal bifurcation to the esophagogastric junction (3240 cm from the gums). The esophagus crosses anterior to the aorta and through the muscular diaphragm at the T10 level and enters the stomach. The esophagus is surrounded by collagen and elastic fibers at the level of the diaphragm. The junction of the esophagus and the stomach lies caudad to the esophageal hiatus of the diaphragm. The phrenicoesophageal membrane anchors the esophagogastric junction to allow movement with respiration but to prevent significant (more than 12 cm) proximal movement of the top margin of the stomach. The high-pressure zone at this junction creates a barrier to the transfer of stomach contents to the esophagus. Studies in which esophageal acidity is monitored over extended periods (continuous pH monitoring) have demonstrated that most normal individuals experience reflux on a daily basis (Figure 6). However, whereas transient spontaneous relaxation is responsible for 98% of reflux events in normal individuals, it accounts for only about 60% of reflux events in patients with reflux. Weak or uncoordinated esophageal contractions (perhaps occurring in response to esophageal irritation from reflux disease itself) delay esophageal clearance of refluxed material. This prolongs the duration of esophageal contact with refluxed digestive gastric contents. Reflux often stimulates salivation, a potentially beneficial response that enhances dilution and neutralization of refluxed gastric contents. If the rate of salivation is low, or if an individual is unable to swallow his own saliva, refluxed material remains in the esophagus for prolonged periods of time. This increases the severity of esophageal irritation and the probability of esophageal damage. The severity of esophageal damage correlates fairly well with the amount of time the esophagus is bathed in refluxed acid. Patients with higher gastric acid secretion and those who reflux bile (which has entered the stomach from the duodenum), are more likely to have severe esophageal damage than those with lower gastric acid secretion and no bile in the gastric contents. An additional factor in determining reflux severity is the amount of pressure placed on the antireflux barrier. Reflux is more likely to occur after eating, while lying down, and when there is delayed gastric emptying. Occasionally, impaired gastric emptying alone can cause severe gastroesophageal reflux disease. Objective testing is required only when the patient presents with atypical symptoms, when the severity of reflux symptoms raises concerns about esophageal damage, when symptoms fail to respond to initial therapeutic intervention, and when the patient is being considered for antireflux surgery. Barium Studies A barium esophagram is an x-ray study in which the structure and function of the esophagus is evaluated. This study is usually the first test used in patients with dysphagia (difficulty swallowing). It is excellent for the diagnosis of a stricture or other causes of obstruction (Figure 7). The barium esophagram also permits the evaluation of coordination of esophageal motor function. However, it is a poor test for documenting esophagitis, and reflux is detected in only 40% of patients with typical reflux symptoms. Minor episodes of reflux should therefore be considered an indication for further study (Figure 8). Esophageal Manometry Esophageal manometry, also referred to as esophageal motility studies, involves the placement of a pressure sensitive catheter into the esophagus (Figure 9). Manometry is usually used prior to esophageal pH studies (see below) to determine the level of the esophagus at which the pH probe should be placed. Many authorities consider manometry an essential part of assessment in patients being considered for antireflux surgery, helping to determine whether surgery is appropriate and what specific surgical procedure should be performed. An acid-sensitive catheter is placed in the esophagus and is attached to a small monitoring device that records changes in esophageal pH over an extended period of time (up to 24 hours). The information is helpful both to confirm the impression of reflux and to tailor therapy for the individual patient (Figure 11). However, there is a 1020% false-negative response rate (a negative test result in a patient who actually has reflux disease). The results must, therefore, be interpreted in the context of the overall clinical picture. If the intra-esophageal pH is less than 4 more than 10% of the time, the patient is considered to have pathologic reflux. Upper Endoscopy Upper endoscopy involves the examination of the lining of the esophagus, stomach, and first part of the small intestine with a flexible endoscope. On the other hand, endoscopy is the best test for the evaluation of reflux-induced esophageal injury. It is a good test for the diagnosis of an esophageal stricture, although strictures that narrow the esophagus to only a limited degree may be missed occasionally.