DIAGNOSIS DAN PENATALAKSANAAN

AKALASIA ESOFAGUS
Rizky Rono Adi Lisa Apriyanti

Bagian IKTHT-KL & Bagian Parasitologi FK Unsri/

Departemen KTHT-KL RSUP Dr.Mohammad Hoesin
Palembang
 OUTLINE

Background

Methods

Results

D
Discussion

D
Conclusion

Critical Appraisal
 PENDAHULUAN

AKALASIA
ESOFAGUS
The 6th most
Penyakit yang jarang ditemukan common cancer
world-wide

300.000 deaths > 500.000 new

reported cases
 BACKGROUND

Chronic Active Passive

Rhinosinusitis smorker smorker

• Inhibit upper airway mucociliary

Impact worse than other chonic disease (angina, clearance
COPD, chronic backpain)
• ↑ incidence sinonasal biofilm
• Promote sinonasal tissue allergic
response
• Negative impact for sinus surgery
outcome
• ↑ incidence & severity of acute
and allergic RS

USA :
1130/100.000/yr
 BACKGROUND

Chronic Impact worse than other chonic disease (angina,

COPD, chronic backpain)
Rhinosinusitis

Active Passive
smorker smorker

• Inhibit upper airway mucociliary

clearance
• ↑ incidence sinonasal biofilm
• Promote sinonasal tissue allergic
response
• Negative impact for sinus surgery
outcome USA :
• ↑ incidence & severity of acute
1130/100.000/yr
and allergic RS
 BACKGROUND

2 studies determined passive 1 cm of hair

smoke exposure through a (nearest the Prevalence (from
subjective questionnaire scalp) qualitative
representing 1 studies):
BUT
month exposure 39-68.3%

Potential for inaccurate

Passive Smoker
assessment and recall bias
and CRS
SO

Could be resolved with Marker:

quantitative measurements Hair nicotine
of smoke exposure measurements
METHODS

•Case control study

• Medical University of South

Carolina
• Wellington Hospital Laboratory in
Newton, New Zealand

2007 - 2013
 METHODS

Inclusion Criteria
CRS Control

90%
50% 35%
CRSwNP CRSsNP AFRS

• Met criteria CRS from European
Position Paper on Rhinosinusitis
and Nasal Polyps 2012
• Underwent endoscopic sinus
surgery
• Undergoing surgery for CSF leak,
repair, nonhormone-secreting
pituitary tumors, or adenoidectomy
 METHODS

1–2 cm hair were

Analyzed for
cut from the
Data gained from nicotine at the
postauricular scalp
the medical record Wellington Hospital
at the time of
Laboratory
surgery

Result were Using reversed-

separated into phase high
Statistical analytic
Smoke Naïve and performance liquid
Passive Smoke chromatography

• Smoke Naïve  nonsmoking & hair nicotine < 2.0 g/mg

• Passive Smoke  nonsmoking & hair nicotine > 2.0 g/mg
 METHODS

Statistical significance -> x2 test

for trend.

Dichotomous variables  x2
Software :
• GraphPad Prism 6.0
software
Linear regression for
• IBM SPSS Statistics
obtain 95% CI
for Windows,
Version 21.0
Kruskal-Wallis one-way ANOVA for >2
nonnormally distributed

Binary & multinomial logistic

regression for confounding factor
 RESULT

Population Characteristics

Age (yr) Male Caucasian

n (mean±SD) (%) (%)
Control 165 36 ± 27 46 61
CRS (total) 404 44 ± 21 51 79 Caucasian >>>
CRSsNP 248 47 ± 21 44 88
CRSwNP 87 49 ± 17 67 84
AFRS 69 27 ± 15 58 41
• Mean Age : 41±23 Male >>> African American >>>
• < 18 y.o : 127
persons
 RESULT

Passive Smoke Exposure Prevalence and Severity

Passive Smoke Exposure by Hair Nicotine (mean,

Disease (%) ng/mg)
25 8
20 6
15
4
10
5 2

0 0
Control CRSsNP CRSwNP AFRS
The severity determined by average
hair nicotine
 RESULT

Pediatric Passive Smoke Exposure Prevalence

 RESULT

Prevalence of Passive Smoke Exposure over Time

 RESULT

Prevalence of Active Smoking and CRS

Active Smoke (%)

14
12
10
8
6
4
2
0
Control CRS CRSsNP CRSwNP AFRS
 DISCUSSION

Passive smoker in CRS

No association population <<<
between age,
sex, or race on
active smoking
status

RESULT Severity of
exposure are
Passive smoker more equivalent
common in young, non-
caucasian, and male
subject
• No reduction in the
prevalence of the passive
some exposure over the 6
year data despite there was
a regional smoking bans
 DISCUSSION

Qualitative Qualitative
study (recall) study (recall)

Reh et al Tammemagi et al
Passive smoker = 39% Passive smoker = 68%
(/100 CRS patients) and (/306 CRS patients)
35% (matched control)

This study
Quantitative study Passive smoker = 11,1%
(hair nicotine (less than control group)
measurement)
 DISCUSSION

Childhood exposure

“More common than adult”

Reh et al • 72% children were passive smoker.

• 22% (28 of 127 children) were passive smoker

This Study
• Children exposed : adult = 2:1
 CONCLUSION

Passive smoke exposure

prevalence is higher in
children

Passive smoke exposure

Passive smoke exposure
also remained stable
prevalence in this study
over time despite recent
less than previous
regional implementation
survey-based estimates
of smoking bans.

“Additional
studies and
large-scale
clinical studies
are necessary”
 1. Did the study address a clearly focused issue?

• Yes, the study address a clearly focused issue because

the population of the study is CRS patient.
 2. Did the authors use an appropriate method to
answer their question?

• Yes, case control is an appropriate method to answer

this study's question because its comparing the study
group and the control group, although it's not the
best method to answer their question.
 3. Were the cases recruited in an acceptable way?

• Yes, the case recruited using convenience sampling, a non

probability sampling method.
• All patients with CRS met diagnostic criteria as defined by
the European Position Paper on Rhinosinusitis and Nasal
Polyps 20125 and underwent endoscopic sinus surgery at
the Medical University of South Carolina between 2007 and
2013.
 4. Were the controls selected in an acceptable way?

• Yes, the control in this study selected using

convenience sampling, a non probability sampling
method.
• Control patients were undergoing surgery for
cerebrospinal fluid leak repair, nonhormone-secreting
pituitary tumors, or adenoidectomy.
5. Was the exposure accurately measured to minimise
bias?

• Yes, the exposure accurately measured quantitatively

to avoid recall bias.
 6(a). What confounding factors have the author
accounted for?

• Age, sex, and race.

 6(b) Have the authors taken account of the potential
confounding factors in the design and/or in their
analysis?
• Yes, the authors use binary and multinomial logistic
regression analyses were used to control for
confounding factors in the relationship between
smoke exposure and CRS status, including age, sex,
and race.
 7. What are the results of this study?

The results of this study are:

• Passive smoke exposure initially appears to be less common in the CRS
population compared with controls.
• The severity of this exposure as determined by average hair nicotine of the
passive smoke–exposed patients was also equivalent between control,
CRSsNP, CRSwNP, and AFRS groups.
• No reductions in passive smoke exposure rates over the 6 year, despite the
implementation of regional public smoking bans during this time frame.
• Childhood exposure to passive smoke is more common than recent
exposure in adults
 8. How precise are the results?

• After correcting for demographic variables with binary

logistic regression, passive smoke exposure prevalence was
equivalent to controls. The p-value >0,05.
 9. Do you believe the results?

• yes, because the authors use binary and multinomial

logistic regression analyses were used to control the
confounding factors.
10. Can the results be applied to the local population?

• No, because the local population has a different

demographic status with the population in this study.
11. Do the results of this study fit with other available
evidence?
• This study dramatically found a dramatically lower
percentage of passive smoker in CRS group.
• There was no previous quantitative study who analysed
relationship between smoke exposure and CRS status. The
previous qualitative study showed that the percentage of
passive smoker in CRS group higher than the control group.
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