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Dervin H, Endersby J, Sanagapalli S, Mills H, Sweis R. Assessing the diagnostic yield of achalasia using provocative testing in high-resolution esophageal manometry: Serial diagnostic study. Neurogastroenterol Motil 2023; 35:e14668. [PMID: 37846024 DOI: 10.1111/nmo.14668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/27/2023] [Accepted: 08/19/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Chicago Classification v4.0 recommends that if achalasia is demonstrated with single water swallows (SWS); provocative testing is not required. We determine whether provocative testing in patients with suspected achalasia can change manometric findings and reproduce symptoms. METHODS Between 2016 and 2022, 127 consecutive manometry studies of patients with achalasia were retrospectively analyzed. All patients underwent SWS, a solid meal (SM) and/or a rapid drink challenge (RDC). Demographic data, fluoroscopy, gastroscopy, and pre-and post-treatment Eckardt scores were collated. KEY RESULTS Of 127 achalasia patients (50.6 ± 16.6 years and 54.6% male), all completed a SM and 116 (91.3%) completed RDC; overall 83 were naïve (65.4%) to previous therapy. 15.4% patients with normal integrated relaxation pressure (IRP) on SWS demonstrated obstruction with RDC. SM gave a different achalasia phenotype in 44.9% of patients (p ⟨ 0.001). Twelve patients with normal IRP during SWS had persistent/recurrent obstruction during provocative testing; 83.3% had previous achalasia therapy. None of 13 patients with Type III (TIII) achalasia with SWS exhibited a change in manometric findings with provocative testing. Impedance bolus heights were lower in patients with TIII achalasia and those with normal IRP with SWS. During the SM, symptoms were reproduced in 56.7% of patients. Forty-six of 103 patients (44.7%) underwent therapy based upon the final achalasia subtype which was defined by the provocative test result of the high-resolution manometry (HRM) study. All treatments were effective, regardless of the achalasia subtype. CONCLUSIONS AND INFERENCES Manometric findings remain unchanged when TIII achalasia is diagnosed with SWS. In patients with normal IRP, Type I, or Type II achalasia during SWS, provocative testing can alter achalasia phenotype or uncover achalasia where diagnosis is unclear. Further, it can reproduce symptoms. Such findings can personalize and guide effective therapeutic decisions.
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Affiliation(s)
- Humayra Dervin
- GI Physiology Unit, University College London, London, UK
| | - James Endersby
- GI Physiology Unit, University College London, London, UK
| | - Santosh Sanagapalli
- GI Physiology Unit, University College London, London, UK
- St Vincent's Hospital, Sydney, Victoria, Australia
| | - Holly Mills
- GI Physiology Unit, University College London, London, UK
| | - Rami Sweis
- GI Physiology Unit, University College London, London, UK
- University College London, London, UK
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Sanagapalli S, Plumb A, Lord RV, Sweis R. How to effectively use and interpret the barium swallow: Current role in esophageal dysphagia. Neurogastroenterol Motil 2023; 35:e14605. [PMID: 37103465 DOI: 10.1111/nmo.14605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND The barium swallow is a commonly performed investigation, though recent decades have seen major advances in other esophageal diagnostic modalities. PURPOSE The purpose of this review is to clarify the rationale for components of the barium swallow protocol, provide guidance on interpretation of findings, and describe the current role of the barium swallow in the diagnostic paradigm for esophageal dysphagia in relation to other esophageal investigations. The barium swallow protocol, interpretation, and reporting terminology are subjective and non-standardized. Common reporting terminology and an approach to their interpretation are provided. A timed barium swallow (TBS) protocol provides more standardized assessment of esophageal emptying but does not evaluate peristalsis. Barium swallow may have higher sensitivity than endoscopy for detecting subtle strictures. Barium swallow has lower overall accuracy than high-resolution manometry for diagnosing achalasia but can help secure the diagnosis in cases of equivocal manometry. TBS has an established role in objective assessment of therapeutic response in achalasia and helps identify the cause of symptom relapse. Barium swallow has a role in the evaluating manometric esophagogastric junction outflow obstruction, in some cases helping to identify where it represents an achalasia-like syndrome. Barium swallow should be performed in dysphagia following bariatric or anti-reflux surgery, to assess for both structural and functional postsurgical abnormality. Barium swallow remains a useful investigation in esophageal dysphagia, though its role has evolved due to advancements in other diagnostics. Current evidence-based guidance regarding its strengths, weaknesses, and current role are described in this review.
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Affiliation(s)
- Santosh Sanagapalli
- Department of Gastroenterology and Hepatology, St. Vincent's Hospital Sydney, Darlinghurst, Australia
- School of Clinical Medicine, St. Vincent's Healthcare Campus, University of New South Wales, Sydney, Australia
| | - Andrew Plumb
- Centre for Medical Imaging, University College London Hospital, London, UK
| | - Reginald V Lord
- Department of Surgery, University of Notre Dame School of Medicine, Sydney, Australia
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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Jacob R, Danta M, Feller R, Williams D, Sanagapalli S. Empiric Esophageal Dilatation for Solid-Food Dysphagia: Presence of Mucosal Tear on Relook Endoscopy Predicts Symptomatic Response. Am J Gastroenterol 2023; 118:1888-1890. [PMID: 37170967 DOI: 10.14309/ajg.0000000000002319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/09/2023] [Indexed: 05/13/2023]
Abstract
We hypothesized that a mucosal tear on relook endoscopy after empiric dilatation predicts symptomatic response. We evaluated symptomatic response (modified Ogilvie dysphagia score) after 161 consecutive esophageal dilatations. Comparing visible strictures, empiric dilatations with mucosal tear, and empiric dilatations without tear, baseline dysphagia scores were similar ( P = 0.34). Successful symptomatic response to dilatation occurred in 82% of visible strictures, 80% of those with tear, compared to only 37% of those with no tear ( P < 0.001). Patients with a mucosal tear after empiric dilatation have a superior symptomatic response to those without, and comparable to patients with visible strictures. We infer the tear represents disruption of an endoscopically inapparent stricture.
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Affiliation(s)
- Rachael Jacob
- Department of Gastroenterology, St Vincent's Hospital, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Healthcare Campus, University of New South Wales, Australia
| | - Mark Danta
- Department of Gastroenterology, St Vincent's Hospital, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Healthcare Campus, University of New South Wales, Australia
| | - Robert Feller
- Department of Gastroenterology, St Vincent's Hospital, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Healthcare Campus, University of New South Wales, Australia
| | - David Williams
- Department of Gastroenterology, St Vincent's Hospital, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Healthcare Campus, University of New South Wales, Australia
| | - Santosh Sanagapalli
- Department of Gastroenterology, St Vincent's Hospital, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Healthcare Campus, University of New South Wales, Australia
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Sanagapalli S. Underrecognized Fibrostenotic Luminal Narrowing May Explain Dissociation Between Symptoms and Histology in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2022; 21:1676-1677. [PMID: 35817392 DOI: 10.1016/j.cgh.2022.05.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Santosh Sanagapalli
- Centre for Swallowing & Oesophageal Disorders, St Vincent's Hospital, Sydney, Australia
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Choi KKH, Sanagapalli S. Barrett’s esophagus: Review of natural history and comparative efficacy of endoscopic and surgical therapies. World J Gastrointest Oncol 2022; 14:568-586. [PMID: 35321279 PMCID: PMC8919017 DOI: 10.4251/wjgo.v14.i3.568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 11/12/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately, invasive neoplasia. Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates. This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier, and potentially curative stage. The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy (EET) for management of dysplastic and early neoplastic BE, and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence. This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage, and the effectiveness of interventions in attenuating the risk posed by its natural history. Key findings were as follows. Non-dysplastic Barrett’s is associated with extremely low risk of progression, and interventions cannot be justified. The annual risk of cancer progression in low grade dysplasia is between 1%-3%; EET can be offered though evidence for its benefit remains confined to highly select settings. High-grade dysplasia progresses to cancer in 5%-10% per year; EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication. Risk of nodal metastases in intramucosal cancer is 2%-4%, which is comparable to operative mortality rate, so EET is usually preferred. Submucosal cancer is associated with nodal metastases in 14%-41% hence surgery remains standard of care, except for select situations.
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Affiliation(s)
- Kevin Kyung Ho Choi
- AW Morrow Gastroenterology Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, NSW, Australia
| | - Santosh Sanagapalli
- Department of Gastroenterology, St Vincent’s Hospital, Darlinghurst 2010, NSW, Australia
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Sanagapalli S, Plumb A, Sweis R. Timed barium swallow: Esophageal stasis varies markedly across subtypes of esophagogastric junction obstruction. Neurogastroenterol Motil 2022; 34:e14322. [PMID: 35072303 DOI: 10.1111/nmo.14322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/26/2021] [Accepted: 01/03/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Timed barium swallow (TBS) is a recommended ancillary investigation in evaluation of esophagogastric junction (EGJ) obstruction, yet there are little data comparing esophageal stasis across subtypes. METHODS A retrospective cohort study was performed. All type III achalasia diagnosed between November 2016 and November 2020 were included, along with matched numbers of consecutive types I and II and conclusive EGJOO cases with concurrent TBS evaluation. Co-primary outcomes were TBS retention at 1 and 5 min. Secondary outcomes were symptoms and manometric metrics of EGJ function and peristaltic integrity. KEY RESULTS One hundred patients were included (25 each of types I-III and conclusive EGJOO). TBS retention measured by height and width at 1 and 5 min differed significantly across the four subtypes (p < 0.0001 all comparisons), with esophageal stasis tending to be significantly greater for types I and II achalasia (88% and 84% with >5 cm column at 5 min) compared to type III and EGJOO (24% and 8% with >5 cm column; p < 0.0001). Eckardt symptom severity was similar across subtypes (p = 0.30). Magnitude of esophageal stasis and integrated relaxation pressure (IRP) were uncorrelated (R = 0.21). In EGJOO, the number of swallows with intact peristalsis inversely correlated with barium column height (R = -0.49) and those with disordered peristalsis were more likely to have any residual barium at 5 min compared to those without disordered peristalsis (43% vs. 0%; p = 0.02). CONCLUSIONS & INFERENCES Timed barium swallow findings differed markedly with significantly less esophageal stasis in type III achalasia and EGJOO, despite similar symptom severity and no correlation between degree of emptying and IRP. Preservation of peristalsis may underlie this finding in EGJOO.
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Affiliation(s)
- Santosh Sanagapalli
- Centre for Swallowing & Oesophageal Disorders, St. Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia.,St Vincent's Clinical School, UNSW Sydney, Sydney, New South Wales, Australia
| | - Andrew Plumb
- GI Physiology Unit, University College London Hospital, London, UK
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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Sanagapalli S, Plumb A, Maynard J, Leong RW, Sweis R. The timed barium swallow and its relationship to symptoms in achalasia: Analysis of surface area and emptying rate. Neurogastroenterol Motil 2020; 32:e13928. [PMID: 32578341 DOI: 10.1111/nmo.13928] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/27/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Timed barium swallow (TBS) is used to objectively measure response following achalasia therapy; however, findings can be discordant with symptoms. We hypothesized that measurement of surface area of the residual barium column would improve its utility in measuring outcome. METHODS In a single-center cohort, achalasia patients undergoing therapy between September 2015-2016 who had TBS were included. Four metrics of emptying were studied: Post-therapy residual barium (a) absolute height and (b) surface area and percentage reduction in (c) residual height (%H) and (d) surface area (%SA) compared to pretherapy. Metrics were evaluated against symptom response (Eckardt score). KEY RESULTS Twenty-four achalasics (median age 43 year; 13 males) were included; 14 received pneumatic dilatation, and 10 had peroral endoscopic myotomy. Treatment resulted in significant reduction in median Eckardt score (7 to 1; P = .03), mean residual barium column height (14.7 ± 8.7 to 7.9 ± 6.0 cm; P = .01) and surface area (52.7 ± 43.5 to 24.5 ± 23.6 cm2 ; P = .02). There were 4 (17%) initial non-responders (Eckardt > 3). % SA was best at discriminating between responders and non-responders (area under curve 0.85 ± 0.08; sensitivity 100%, specificity 80%). Concordance with symptomatic response following therapy was 83% when using 45% as the cutoff for surface area reduction compared to pretherapy. Eight patients whose static barium height was discordant with symptoms became concordant when % SA was used as a measure of response. CONCLUSIONS & INFERENCES Change in barium surface area is a superior measure of esophageal emptying and better correlates with treatment response than the conventional 5-minute barium height in defining objective response to achalasia therapy.
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Affiliation(s)
- Santosh Sanagapalli
- GI Physiology Unit, University College London Hospital, London, UK.,St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Plumb
- GI Physiology Unit, University College London Hospital, London, UK
| | - John Maynard
- GI Physiology Unit, University College London Hospital, London, UK
| | - Rupert W Leong
- Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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8
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Sanagapalli S, Roman S, Hastier A, Leong RW, Patel K, Raeburn A, Banks M, Haidry R, Lovat L, Graham D, Sami SS, Sweis R. Achalasia diagnosed despite normal integrated relaxation pressure responds favorably to therapy. Neurogastroenterol Motil 2019; 31:e13586. [PMID: 30957312 DOI: 10.1111/nmo.13586] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 02/19/2019] [Accepted: 03/08/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Achalasia diagnosis requires elevated integrated relaxation pressure (IRP; manometric marker of lower esophageal sphincter [LES] relaxation). Yet, some patients exhibit clinical features of achalasia despite normal IRP and have LES dysfunction demonstrable by other means. We hypothesized these patients to exhibit equivalent therapeutic response compared to standard achalasia patients. METHODS Symptomatic achalasia-like cases, despite normal IRP, displayed evidence of impaired LES relaxation using rapid drink challenge (RDC), solid swallows during high-resolution manometry, and/or barium esophagogram; were treated with achalasia therapies and compared to standard achalasia patients with raised IRP. Outcomes included equivalence for short- and long-term symptom response and stasis on barium esophagogram. KEY RESULTS Twenty-nine normal IRP achalasia cases (14 males, median age 50 year, median Eckardt 6, barium stasis 12 ± 7 cm) and 29 consecutive standard achalasia controls underwent therapy. Among cases, LES dysfunction was most often identified by RDC and/or barium esophagogram. Short-term symptomatic success was equivalent in cases vs controls (90% vs 93%; 95% CI for difference: -19% to 13%). Median short-term (1 vs 1; 95% CI for difference: 0-1) and long-term Eckardt scores (2 vs 1; 95% CI for difference: 0-2) were similar in cases and controls, respectively. Adequate clearance was observed in 67% of cases vs 81% of controls on post-therapy esophagogram. CONCLUSIONS AND INFERENCES We described a subset of achalasia patients with normal IRP, but impaired LES relaxation identifiable only on additional provocative tests. These patients benefited from treatment, suggesting that such tests should be performed to increase the number of clinically relevant diagnoses.
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Affiliation(s)
- Santosh Sanagapalli
- GI Physiology Unit, University College London Hospital, London, UK.,Department of Gastroenterology, St. Vincent's Hospital Sydney, Darlinghurst, Australia
| | | | | | - Rupert W Leong
- Gastroenterology & Liver Services, Concord Repatriation General Hospital, Sydney, Australia
| | - Kalp Patel
- GI Physiology Unit, University College London Hospital, London, UK
| | - Amanda Raeburn
- GI Physiology Unit, University College London Hospital, London, UK
| | - Matthew Banks
- GI Physiology Unit, University College London Hospital, London, UK
| | - Rehan Haidry
- GI Physiology Unit, University College London Hospital, London, UK
| | - Laurence Lovat
- GI Physiology Unit, University College London Hospital, London, UK
| | - David Graham
- GI Physiology Unit, University College London Hospital, London, UK
| | - Sarmed S Sami
- GI Physiology Unit, University College London Hospital, London, UK
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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9
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Pesce M, Magee C, Holloway RH, Gyawali CP, Roman S, Pioche M, Savarino E, Quader F, Sarnelli G, Sanagapalli S, Bredenoord AJ, Sweis R. The treatment of achalasia patients with esophageal varices: an international study. United European Gastroenterol J 2019; 7:565-572. [PMID: 31065374 DOI: 10.1177/2050640619838114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/22/2019] [Indexed: 01/10/2023] Open
Abstract
Background Treatment options for achalasia include endoscopic and surgical techniques that carry the risk of esophageal bleeding and perforation. The rare coexistence of esophageal varices has only been anecdotally described and treatment is presumed to carry additional risk. Methods Experience from physicians/surgeons treating this rare combination of disorders was sought through the International Manometry Working Group. Results Fourteen patients with achalasia and varices from seven international centers were collected (mean age 61 ± 9 years). Five patients were treated with botulinum toxin injections (BTI), four had dilation, three received peroral endoscopic myotomy (POEM), one had POEM then dilation, and one patient underwent BTI followed by Heller's myotomy. Variceal eradication preceded achalasia treatment in three patients. All patients experienced a significant symptomatic improvement (median Eckardt score 7 vs 1; p < 0.0001) at 6 months follow-up, with treatment outcomes resembling those of 20 non-cirrhotic achalasia patients who underwent similar therapy. No patients had recorded complications of bleeding or perforation. Conclusion This study shows an excellent short-term symptomatic response in patients with esophageal achalasia and varices and demonstrates that the therapeutic outcomes and complications, other than transient encephalopathy in both patients who had a portosystemic shunt, did not differ to disease-matched patients without varices.
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Affiliation(s)
- M Pesce
- Department of Gastroenterology, Department of GI Physiology, University College London Hospitals, London, UK.,University of Naples "Federico II", Naples, Italy
| | - C Magee
- Department of Gastroenterology, Department of GI Physiology, University College London Hospitals, London, UK
| | | | - C P Gyawali
- Division of Gastroenterology, Washington University, St Louis, MO, USA
| | - S Roman
- Department of Gastroenterology, Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - M Pioche
- Department of Gastroenterology, Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | | | - F Quader
- Division of Gastroenterology, Washington University, St Louis, MO, USA
| | - G Sarnelli
- University of Naples "Federico II", Naples, Italy
| | - S Sanagapalli
- Department of Gastroenterology, Department of GI Physiology, University College London Hospitals, London, UK.,St. Vincent's Hospital Sydney, Sydney, Australia
| | - A J Bredenoord
- Division of Gastroenterology and Hepatology, Amsterdam Medical Centre, Amsterdam, Netherlands
| | - R Sweis
- Department of Gastroenterology, Department of GI Physiology, University College London Hospitals, London, UK
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Sanagapalli S, Harrington S, Zarate-Lopez N, Emmanuel A. Posterior Tibial Nerve Stimulation for the Treatment of Fecal Incontinence Following Obstetric Anal Sphincter Injury. Neuromodulation 2018; 21:688-693. [DOI: 10.1111/ner.12844] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/08/2018] [Accepted: 06/04/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Santosh Sanagapalli
- GI Physiology Unit; University College London Hospital; London UK
- Department of Gastroenterology; St Vincent's Hospital Sydney; Darlinghurst NSW Australia
- St Vincent's Clinical School; University of New South Wales; Sydney NSW Australia
| | | | | | - Anton Emmanuel
- GI Physiology Unit; University College London Hospital; London UK
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11
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Sanagapalli S, Ko Y, Kariyawasam V, Ng SC, Tang W, de Silva HJ, Chen M, Wu K, Aniwan S, Ng KK, Ong D, Ouyang Q, Hilmi I, Simadibrata M, Pisespongsa P, Gopikrishna S, Leong RW. The association between new generation oral contraceptive pill and the development of inflammatory bowel diseases. Intest Res 2018; 16:409-415. [PMID: 30090040 PMCID: PMC6077300 DOI: 10.5217/ir.2018.16.3.409] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 02/22/2018] [Accepted: 02/28/2018] [Indexed: 02/06/2023] Open
Abstract
Background/Aims To examine the association between use of oral contraceptive pills (OCPs) and the risk of developing inflammatory bowel diseases (IBD), in a modern cohort. Methods A prospective nested case-control study across sites in the Asia-Pacific region was conducted; involving female IBD cases and asymptomatic controls. Subjects completed a questionnaire addressing questions related to OCP use. Primary outcome was the risk of development of IBD of those exposed to OCP versus non-exposure. Secondary outcomes were development of Crohn's disease (CD) versus ulcerative colitis (UC), and whether age of first use of OCP use may be associated with risk of IBD. Results Three hundred and forty-eight female IBD cases (41% CD, median age: 43 years) and 590 female age-matched controls were recruited. No significant association was found between OCP use and the risk of IBD (odds ratio [OR], 1.65; 95% confidence interval, 0.77-3.13; P=0.22), CD (OR, 1.55) or UC (OR, 1.01). The lack of association persisted when results were adjusted for age and smoking. IBD cases commenced OCP use at a younger age than controls (18 years vs. 20 years, P=0.049). Conclusions In this large cohort of subjects from the Asia-Pacific region, we found a modest but not significantly increased risk of developing IBD amongst OCP users.
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Affiliation(s)
- Santosh Sanagapalli
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Concord NSW, Australia
| | - Yanna Ko
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Concord NSW, Australia
| | - Viraj Kariyawasam
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Concord NSW, Australia
| | - Siew C Ng
- Department of Medicine and Therapeutics, State Key Laboratory of Digestive Disease, Institute of Digestive Disease, Li Ka Shing Institute of Health Science, Hong Kong, China
| | - Whitney Tang
- Department of Medicine and Therapeutics, State Key Laboratory of Digestive Disease, Institute of Digestive Disease, Li Ka Shing Institute of Health Science, Hong Kong, China
| | | | - Minhu Chen
- The First Affiliated Hospital of Sun Yat Sen University, Guangzhou, China
| | - Kaichun Wu
- Xijing Hospital, Fourth Military Medical University, Xian, China
| | | | - Ka Kei Ng
- Hospital Conde S Januario, Macau, China
| | - David Ong
- National University Hospital of Singapore, Singapore
| | - Qin Ouyang
- West China Hospital, Sichuan University, Chengdu, China
| | - Ida Hilmi
- University of Malaya Medical Center, Kuala Lumpur, Malaysia
| | | | | | - Saranya Gopikrishna
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Concord NSW, Australia
| | - Rupert W Leong
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Concord NSW, Australia
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Abstract
Pancreatic cancer is a growing source of cancer related death, yet has poor survival rates which have not improved in the last few decades. Its high mortality rate is attributed to pancreatic cancer biology, difficulty in early diagnosis and the lack of standardised international guidelines in assessing suspicious pancreatic masses. This review aims to provide an update in the current state of play in pancreatic cancer diagnosis and to evaluate the benefits and limitations of available diagnostic technology. The main modalities discussed are imaging with computed tomography, magnetic resonance imaging, endoscopic ultrasound and positron emission tomography and tissue acquisition with fine needle aspiration. We also review the improvements in the techniques used for tissue acquisition and the opportunity for personalised cancer medicine. Screening of high risk individuals, promising biomarkers and common mimickers of pancreatic cancer are also explored, as well as suggestions for future research directions to allow for earlier detection of pancreatic cancer. Timely and accurate diagnosis of pancreatic cancer can lead to improvements in the current poor outcome of this disease.
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Affiliation(s)
- Lulu Zhang
- Department of Gastroenterology, St. Vincent’s Hospital Sydney, Darlinghurst 2010, NSW, Australia
| | - Santosh Sanagapalli
- Department of Gastroenterology, St. Vincent’s Hospital Sydney, Darlinghurst 2010, NSW, Australia
| | - Alina Stoita
- Department of Gastroenterology, St. Vincent’s Hospital Sydney, Darlinghurst 2010, NSW, Australia
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Sanagapalli S, Neilan L, Lo JYT, Anandan L, Liwanag J, Raeburn A, Athanasakos E, Zarate-Lopez N, Emmanuel A. Efficacy of Percutaneous Posterior Tibial Nerve Stimulation for the Management of Fecal Incontinence in Multiple Sclerosis: A Pilot Study. Neuromodulation 2018; 21:682-687. [PMID: 29575432 DOI: 10.1111/ner.12764] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/09/2017] [Accepted: 01/04/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Fecal incontinence is a debilitating and highly prevalent problem among multiple sclerosis patients. Conservative therapies often fail to provide benefit. Posterior tibial nerve stimulation is a minimally invasive neuromodulatory therapy with proven efficacy for fecal incontinence in non-neurological settings. OBJECTIVE To evaluate the efficacy of posterior tibial nerve stimulation in treating multiple sclerosis-related fecal incontinence. METHODS Consecutive multiple sclerosis patients with fecal incontinence that had failed conservative therapy received posterior tibial nerve stimulation between 2012 and 2015. All patients had previously undergone anorectal physiology tests and endoanal ultrasound. Patients whose Wexner incontinence score reduced below 10 post-therapy or halved from baseline were deemed responders. RESULTS Thirty-three patients (25 female, median age 43 years) were included. Twenty-three (70%) had urge, 4 (12%) passive, and 9 (27%) mixed fecal incontinence. Twenty-six (79%) were classified as responders. The majority of subjects had relapsing-remitting multiple sclerosis (67%); those had a significantly higher response rate (95% vs. 67% and 50% in primary and secondary progressive respectively, P < 0.05). Responders tended to be more symptomatic at baseline and had greater improvements in bowel symptom scores and quality of life scores with therapy. CONCLUSION Posterior tibial nerve stimulation demonstrates potential as an effective therapy for fecal incontinence in multiple sclerosis. These findings provide the basis for future more definitive controlled studies.
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Affiliation(s)
| | - Laura Neilan
- School of Medicine, Royal College of Surgeons of Ireland, Dublin, Ireland
| | | | | | - Jorge Liwanag
- GI Physiology Unit, University College London Hospital, London, UK
| | - Amanda Raeburn
- GI Physiology Unit, University College London Hospital, London, UK
| | | | | | - Anton Emmanuel
- GI Physiology Unit, University College London Hospital, London, UK.,School of Medicine, University College London, London, UK
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Sanagapalli S, Emmanuel A, Leong R, Kerr S, Lovat L, Haidry R, Banks M, Graham D, Raeburn A, Zarate-Lopez N, Sweis R. Impaired motility in Barrett's esophagus: A study using high-resolution manometry with physiologic challenge. Neurogastroenterol Motil 2018; 30:e13330. [PMID: 29542847 DOI: 10.1111/nmo.13330] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/08/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Esophageal dysmotility may predispose to Barrett's esophagus (BE). We hypothesized that high-resolution manometry (HRM) performed with additional physiologic challenge would better delineate dysmotility in BE. METHODS Included patients had typical reflux symptoms and underwent endoscopy, HRM with single water swallows and adjunctive testing with solids and rapid drink challenge (RDC) before ambulatory pH-impedance monitoring. BE and endoscopy-negative reflux disease (ENRD) subjects were compared against functional heartburn patient-controls (FHC). Primary outcome was incidence of HRM contractile abnormalities with standard and adjunctive swallows. Secondary outcomes included clearance measures and symptom association on pH-impedance. KEY RESULTS Seventy-eight patients (BE 25, ENRD 27, FHC 26) were included. Water swallow contractility was reduced in both BE (median DCI 87 mm Hg/cm/s) and ENRD (442 mm Hg/cm/s) compared to FHC (602 mm Hg/cm/s; P < .001 and .04, respectively). With the challenge of solid swallows and RDC, these parameters improved in ENRD (solids = 1732 mm Hg/cm/s), becoming similar to FHC (1242 mm Hg/cm/s; P = .93), whereas abnormalities persisted in BE (818 mm Hg/cm/s; P < .01 c.f. FHC). In BE and ENRD, reflux events (67 vs 57 events/24 hour) and symptom frequency were similar; yet symptom correlation was significantly better in ENRD compared to BE, which was comparable to FHC (symptom index 30% vs 4% vs 0%, respectively). Furthermore, bolus clearance and exposure times were more pronounced in BE (P < .01). CONCLUSIONS & INFERENCES Reduced contractile effectiveness persisted in BE with the more representative esophageal challenge of swallowing solids and free drinking; while in ENRD and FHC peristalsis usually improved, demonstrating peristaltic reserve. Furthermore, symptom association and refluxate clearance were reduced in BE. These factors may underlie BE pathogenesis.
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Affiliation(s)
- S Sanagapalli
- GI Physiology Unit, University College London Hospital, London, UK
| | - A Emmanuel
- GI Physiology Unit, University College London Hospital, London, UK
| | - R Leong
- GI Physiology Unit, University College London Hospital, London, UK
| | - S Kerr
- GI Physiology Unit, University College London Hospital, London, UK
| | - L Lovat
- GI Physiology Unit, University College London Hospital, London, UK
| | - R Haidry
- GI Physiology Unit, University College London Hospital, London, UK
| | - M Banks
- GI Physiology Unit, University College London Hospital, London, UK
| | - D Graham
- GI Physiology Unit, University College London Hospital, London, UK
| | - A Raeburn
- GI Physiology Unit, University College London Hospital, London, UK
| | - N Zarate-Lopez
- GI Physiology Unit, University College London Hospital, London, UK
| | - R Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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Sanagapalli S, Danta M. Editorial: direct-acting antivirals significantly improve quality of life in patients with hepatitis C virus infection. Aliment Pharmacol Ther 2018; 47:536-537. [PMID: 29341280 DOI: 10.1111/apt.14467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- S Sanagapalli
- Department of Gastroenterology and Hepatology, St Vincent's Hospital, Sydney, NSW, Australia
| | - M Danta
- Department of Gastroenterology and Hepatology, St Vincent's Hospital, Sydney, NSW, Australia.,St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Syndey, NSW, Australia
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Sanagapalli S, Sweis R. Combined pH-impedance testing for reflux: current state of play and future challenges. Frontline Gastroenterol 2017; 8:154-155. [PMID: 28840917 PMCID: PMC5558282 DOI: 10.1136/flgastro-2017-100840] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 04/02/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Santosh Sanagapalli
- Department of Gastroenterology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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Abstract
PURPOSE OF REVIEW This review aims to shed light on subtleties of achalasia diagnosis, including potential pitfalls that may lead to errors. Optimal methods for assessment of disease severity and the relationship between achalasia and other motility disorders will also be reviewed with an emphasis on recent findings from the literature. RECENT FINDINGS Adjunctive testing with viscous substances or larger water volumes should be used routinely as it improves the accuracy of achalasia diagnosis. Chronic opiate use can mimic achalasia. The timed barium swallow remains the best test for assessments of disease severity and prognostication, but the functional lumen-imaging probe, a newer tool which measures esophagogastric junction distensibility using impedance planimetry, is emerging as a potentially more powerful tool for these purposes. Functional esophagogastric junction outflow obstruction is possibly part of the achalasia spectrum. By addressing the potential pitfalls described, and through routine and standardized use of the diagnostic tools mentioned herein, the accuracy of diagnosis, severity assessment, and prognostication of achalasia can be improved.
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Affiliation(s)
- Santosh Sanagapalli
- GI Physiology Unit, Elizabeth Garrett Anderson Wing, University College Hospital, 235 Euston Rd, London, NW1 2BU, UK.
- St. Vincent's Hospital Sydney, Department Gastroenterology, 235 Euston Rd, 390 Victoria St, NSW, 2010, Australia.
| | - Rami Sweis
- GI Physiology Unit, Elizabeth Garrett Anderson Wing, University College Hospital, 235 Euston Rd, London, NW1 2BU, UK
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Sanagapalli S, Agnihotri K, Leong R, Corte CJ. Antispasmodic drugs in colonoscopy: a review of their pharmacology, safety and efficacy in improving polyp detection and related outcomes. Therap Adv Gastroenterol 2017; 10:101-113. [PMID: 28286563 PMCID: PMC5330606 DOI: 10.1177/1756283x16670076] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Antispasmodic drugs are cheap, effective and generally safe. They may improve outcomes in colonoscopy, however their use has not been consistent or widespread. This manuscript reviews the three most commonly used antispasmodics in colonoscopy, namely, hyoscine butylbromide (and related ammonium compounds), glucagon and peppermint oil. The pharmacology, action and safety of the agents, as well as the evidence for them improving colonoscopic outcomes will be discussed. In addition to polyp detection, other colonoscopic outcome endpoints of interest include cecal and ileal intubation, and patient comfort. The drugs studied were all found to be effective gastrointestinal antispasmodics with good safety profiles. There is insufficient evidence to conclude whether antispasmodics improve cecal intubation rate, predominantly because the baseline rates are already high. Antispasmodics probably have efficacy in reducing cecal intubation time especially in those with marked colonic spasm. Antispasmodics do not offer significant benefit in polyp detection or improving patient comfort during colonoscopy. Future studies should focus on inexperienced colonoscopists as well as those with marked colonic spasm, in whom the greatest benefit seems to lie.
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Affiliation(s)
| | - Kriti Agnihotri
- Gastroenterology & Liver Services, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Rupert Leong
- Gastroenterology & Liver Services, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Crispin John Corte
- Gastroenterology & Liver Services, Concord Repatriation General Hospital, Sydney, NSW, Australia
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Ko Y, Tang J, Sanagapalli S, Kim BSM, Leong RW. Safety of proton pump inhibitors and risk of gastric cancers: review of literature and pathophysiological mechanisms. Expert Opin Drug Saf 2015; 15:53-63. [PMID: 26560097 DOI: 10.1517/14740338.2016.1118050] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Despite being an overall safe drug, several long-term adverse effects are associated with proton pump inhibitors (PPIs). The link between PPI use and gastric neuroendocrine tumors (NETs), gastric adenocarcinomas and Barrett's esophagus progression gastric cancers has been investigated due to PPI-induced hypergastrinemia. AREAS COVERED The pathophysiological mechanisms underlying PPI exposure and gastric NETs, gastric adenocarcinomas and Barrett's esophagus progression are discussed. The quality of randomized control studies, cohort studies and case reports investigating the link between gastric cancers and PPIs are examined. Recommendations for clinicians are provided. EXPERT OPINION PPIs cause a hypergastrinemic state, increasing enterochromaffin-like cell dysplasia and risk of gastric NET development, increasing gastritis severity in the context of Helicobacter pylori infection, and progression of carcinogenesis in a certain predisposed subset of Barrett's esophagus patients. There are case reports of PPI-induced gastric NETs and adenocarcinomas as consequences of these effects. In pernicious anemia and chronic gastritis, clinicians should be aware of potential increased risk of gastric NET development with chronic PPI use in these patients. Eradication status of H. pylori prior to commencing long-term PPI therapy should be established to reduce the risk of severe atrophic gastritis and development of gastric dysplasia.
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Affiliation(s)
- Yanna Ko
- a Gastroenterology and Liver Service , Concord Hospital , Sydney , Australia
| | | | - Santosh Sanagapalli
- a Gastroenterology and Liver Service , Concord Hospital , Sydney , Australia
| | | | - Rupert W Leong
- a Gastroenterology and Liver Service , Concord Hospital , Sydney , Australia
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Tan T, Hardman J, Sanagapalli S, Narayan A, Kovoor P, Thiagalingam A. Do Implantable Cardioverter Defibrillators (ICD) Cause Tricuspid Regurgitation? A Retrospective Study. Heart Lung Circ 2011. [DOI: 10.1016/j.hlc.2011.05.230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Singh RS, Sanagapalli S, Jayaraman V, Singh VP. Ultrasound-assisted fabrication of nanoporous CdS films. J Nanosci Nanotechnol 2004; 4:176-182. [PMID: 15112563 DOI: 10.1166/jnn.2004.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
A new method for fabricating nanoporous CdS films is reported. It involves exposing the CdS solution with ultrasound waves during the process of dip coating. Indium tin oxide (ITO)-coated glass and plastic (commercial transparency) were used as substrates. In each case three different precursors were used for dip coating. The precursors used were CdCl2 and thiourea in one case and CdS nanoparticles prepared by sonochemical and microwave-assisted methods in the other two cases. X-ray diffraction studies performed on these powders show a phase corresponding to cubic CdS. The Field Emission Scanning Electron Microscopy (FE-SEM) images of the films on plastic showed uniform pores with a diameter of 80 nm for all three methods. Optical absorption measurements indicated a blue shift and multiple peaks in the absorption curve. The FE-SEM observations of the films on an ITO/glass substrate indicated a crystalline film with voids. The UV-vis absorption results indicated a blue shift in the absorption with an absorption edge at 435, 380, and 365 nm for CdS films made by solution growth, sonochemical, and microwave routes, respectively. The magnitude of the absorption is dependent on film thickness, and the observed blue shift in the absorption can be explained on the basis of quantum confinement effects.
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Affiliation(s)
- R S Singh
- Center for Micro-Magnetic and Electronic Devices, Department of Electrical & Computer Engineering, University of Kentucky, Lexington, Kentucky 40506, USA
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