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BackTable / ENT / Article
Navigating Atypical LPR: Diagnostics & Treatments
Megan Saltsgaver • Updated Jul 9, 2024 • 49 hits
The standard workup for suspected laryngopharyngeal reflux (LPR) typically involves 24 hour pH impedance testing and flexible laryngoscopy. By the same token, treatment of typical LPR usually consists of proton pump inhibitors (PPIs), H2 blockers, alginate suspensions, and lifestyle changes.
But what if the typical approach isn't working? Laryngologist Dr. Inna Husain recently sat down with BackTable ENT to provide an overview of management strategies for atypical LPR, and how to get to the root cause of intractable reflux cases.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Atypical causes of LPR should be suspected when patients have tried traditional diagnostic and treatment measures but still have persistence of symptoms.
• Underlying esophageal pathology can be diagnosed through barium esophagram studies, which can reveal hiatal hernias, dysmotility patterns, webs, strictures, and diverticulums.
• When patients undergo pH impedance testing to diagnose or rule out LPR, providers should include an upper esophageal sphincter sensor to determine if reflux is reaching the pharynx.
• Diet changes can be an effective way to decrease LPR symptoms. Individualized diet plans should be discussed with a dietitian, as patients can have different food triggers. Increasing fiber intake has been shown to absorb more nitric oxide, which acts as a lower esophageal sphincter relaxant.
• Finding the root cause of a patient's reflux can be a frustrating, expensive, and time-consuming journey. Various factors such as lifestyle, body habitus, diet, medications, and underlying medical conditions should be addressed if traditional LPR treatments do not seem to be effective.
Table of Contents
(1) The Use of Barium Esophagram in Atypical LPR Diagnostics
(2) pH Impedance Testing
(3) Managing LPR with Diet Changes
(4) Finding the Root Cause of Reflux
The Use of Barium Esophagram in Atypical LPR Diagnostics
LPR symptoms secondary to esophageal pathology is a newer idea in laryngology that does not yet have a standard diagnostic workup. Barium esophagrams are quick, easy, and can help to avoid long waits for patients that are trying to get scheduled with a gastroenterologist for an upper endoscopy. Barium swallow evaluations are particularly effective at identifying hiatal hernias, dysmotility patterns, webs, strictures, and diverticulums.
Manometry can also be helpful to test for proper function of the upper esophageal sphincter when patients have globus sensation. These additional tests can aid in finding the root cause of reflux while also avoiding the costs of anesthesia involved in upper endoscopy.
[Dr. Ashley Agan]
For your esophageal workup, is there anything else that you think about other than upper endoscopy? Do you ever do, like a modified barium swallow or other testing?
[Dr. Inna Husain]
Yes. I actually order esophagrams a lot. The reason that developed was it can be hard to get in with GI. I don't think that's just in my area thing. I think that's generally procedure based things are a little bit harder in terms of scheduling, getting in. There's also things you have to consider with regards to sedation and overall medical health. I have a patient population that's fairly older.
These are considerations. I use the barium esophagram a lot as a screening tool. I think it's quick. It's easy. It's, definitely, not perfect like any diagnostic test, but we've identified a lot of issues with the esophagus that are contributing to throat symptoms just by using a screening barium esophagram. Modified barium, I obviously use that a lot as a laryngologist for when there's concern for oropharyngeal dysphagia, globus sensation.I'll often add that on to get a complete swallow evaluation.
Then like we talked about last time, still supporter of the 24-hour pH impedance test, there are nasopharyngeal probes that are available, which are a little bit easier tolerated by some patients who have hypersensitivity. We just need to remember that that's not really looking at that indirect effect and it's somewhat of a harsher pH test. There are roles for it, but you should be able to offer the full range of testing for patients.
[Dr. Ashley Agan]
For like a dysmotility, are you ordering like, what is it? Esophageal manometry?
[Dr. Inna Husain]
Yes. Usually I start again with the easiest, which is usually a barium esophagram, and that can usually identify some form of dysmotility. Again, we can take a step back after that and talk with the patient, see where they're at with everything. Esophageal dysmotility is something that I'm still learning about. Again, I am an ENT. I'm not a gastroenterologist. I have interest in these areas, so I'm trying to educate myself and work with my colleagues.
From what I've learned so far is that dysmotility can be very challenging to treat, generally. When there are concerns that the dysmotility is pretty bad or severe, I do recommend getting a manometry to look at it further. I think manometry is also very helpful when patients are having a lot of globus sensation, especially where you think there might be involvement of the upper esophageal sphincter because you can get some data points regarding that muscle.
There's also something that GI will do. It's called an Endoflip. It's a newer procedure that they do during an upper endoscopy. Depending on where you get your upper endoscopy, they may be able to add that to look for some dysmotility as well. Again, this is an area where I'm, as a personal mission, trying to educate myself on more for my patients.
[Dr. Ashley Agan]
Yes. You can see there are findings that can be suggestive of dysmotility on your barium esophagram.
[Dr. Inna Husain]
Oh, 100%. Yes, you'll see it on there.
[Dr. Ashley Agan]
Just because there's like stasis, or is it like a pattern, or what do you see?
[Dr. Inna Husain]
Yes, you'll see both. You'll see there's a normal pattern of contractility of the esophagus. I always use the analogy of like milking a cow for patients. If you don't know how to do it, you're not going to get any milk. That's the same with the esophagus. If it's not squeezing in its normal pattern, then things are not going to flow fast, they're going to hang out, there's going to be stasis, and guess what? Your body's not going to like that. You can see that on the barium esophagram.
[Dr. Ashley Agan]
Okay. Any other common findings that you're finding in the esophagus?
[Dr. Inna Husain]
We do often find things like hiatal hernias, for example, and it's interesting because upper endoscopy may not see it all the time. I'm learning this more in clinical practice where patients may have had an upper endoscopy and there's no comment of a hiatal hernia, but then we get an upright barium esophagram that's really distending the system and then we find it. I think things like finding a hiatal hernia are important for patients because as we're going to transition to trying to find the root cause, like, "Why are you having this, for example, reflux to begin with?" It's helpful for patients to have that information, so you can, definitely, see a hiatal hernia on a barium esophagram as well.
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pH Impedance Testing
pH impedance testing can be a useful diagnostic tool in select patients with LPR symptoms. Testing can be done with a standard probe and/or a nasal probe. The standard probe sits near the distal esophagus and can detect acid and non-acid reflux, while the nasal probe only detects acidic events in the nasopharynx and the oropharynx. The nasal probe is typically easier for patients to tolerate, but not as reliable. Dr. Husain recommends using a standard probe with an upper esophageal sensor to detect reflux into the pharynx.
A positive pH impedance result confirms an LPR diagnosis, but a negative result does not necessarily rule out reflux. pH testing is ideal for patients with daily reflux symptoms, and it may fail to capture intermittent reflux.
[Dr. Ashley Agan]
We talked about the 24-hour pH impedance probe last time, but I wanted to just touch on it again a little bit because, as you mentioned, there's the nasal probe. I found Restech, is that the most common?
[Dr. Inna Husain]
Restech. It's one of the common ones.
[Dr. Ashley Agan]
Basically for that, it's just going through the nose and the tip of it, it's like hanging out like right above the soft palate or so. Is that what it looks like?
[Dr. Inna Husain]
Correct. Yes. It's right there. It's a lot easier for patients to tolerate. Again, another shout out to my colleague, Dr. Lechein, because he uses this a lot more in practice than I do. He said he uses it for primarily nasopharyngeal symptoms. This might be something, for example, a rhinologist may consider adding to their practice since they're seeing patients with primarily nasal or nasopharyngeal symptoms to see if there's any acid involved. It's an easy placement, easy tolerance. You don't need to know anything about the esophagus to do it. It could be helpful.
[Dr. Ashley Agan]
It's going to detect acid and non-acid, anything that would be refluxing would trigger it and you'd be able to see that.
[Dr. Inna Husain]
It's primarily acid.
[Dr. Ashley Agan]
Okay. Whereas with the full probe, it does both. It has acid and non-acid.
[Dr. Inna Husain]
Yes.
[Dr. Ashley Agan]
We can register both.
[Dr. Inna Husain]
Yes. When we talk about the full probe, a lot of times GIs who's doing these pH impedance tests, but we have to make sure they're using what we call the right catheter for ENT. You want to make sure it has sensors in the lower pharynx or very upper esophagus. A lot of GI probes don't have that because, again, GERD is different than LPR, right? How can you have any symptoms in the throat if your lower esophagus is fine? That's the way GIs think about it. We know ENT, we think a little bit differently. PH and impedance, lower esophagus, upper esophagus/pharynx is the ideal probe for that.
[Dr. Ashley Agan]
Okay. For the full length probe is the tip of that sitting just at the lower esophageal sphincter.
[Dr. Inna Husain]
The way I do it is I'm focused more with regards to the upper sphincter. I want to make sure my upper probes are placed normally, and then the lower one will be somewhere in the distal esophagus. You definitely don't want to be in the stomach, right? Somewhere in the distal esophagus, but I'm more careful about my upper probe placement.
[Dr. Ashley Agan]
If a patient says, "Oh, I've already had one of those. The GI doctor said I'm fine." We need to dig and say, "Okay, let's find out exactly what you had done." Was there a sensor in the pharynx or at the upper esophageal sphincter?
[Dr. Inna Husain]
Correct, because most of the time there is not.
[Dr. Ashley Agan]
We talked about this a little bit last time about the interpretation of the testing because in the GI world, the patients are hitting a button saying when they're having symptoms and they're correlating that with reflux events. In the GI literature, if that doesn't correlate, then it's not positive for ENT. I'll let you finish that.
[Dr. Inna Husain]
Right. For ENT, unfortunately, that is not the case. We don't expect any reflux event to make its way to the throat. That's not normal. Even one episode that doesn't necessarily correlate with the button pressing could definitely contribute to sensitivity and delayed presentation of symptoms. We don't have that in our field in terms of like that strict criteria, the way the GI team does.
You really need to-- again, it depends on how much involvement you'd like to do with this diagnosis and management, but you have to really look at the results of patients get testing done elsewhere. I do recommend-- I don't want to just know that the clinical note that says you're fine. I want to see the actual test because I want to see how many episodes, where did the episodes go? Were they acidic or not? Then put that into context of what you're telling me you feel with your throat.
[Dr. Ashley Agan]
Can you speak to the sensitivity, specificity? If we're using the right probe, which is the one that's going to have a sensor in the pharynx, it's going to be testing acid and non-acid. If that is positive, you can feel pretty confident that the patient does have LPR?
[Dr. Inna Husain]
Yes.
[Dr. Ashley Agan]
What if it's negative? Is it possible that they just had a good day? Do you ever have patients who were like-- it comes up negative, then you're like, "Ah, now what do we do?"
[Dr. Inna Husain]
I'm very careful when I send patients for testing sometimes with regards to that. What I mean by that is if a patient has symptoms all the time, right? They're like, "Every single day I have symptoms." I'm like, "Okay, let's get you tested." Someone comes in and they're like, "You know what, I only get these symptoms like once a month." Then I'm like, "Listen, the testing might not be great for you because we're probably not going to capture what's happening."
Again, sometimes we do diagnostic testing to try to gather information, but there's also the possibility that essentially nothing comes from it. Again, very upfront with patients about this, where I say, "Listen, the reason for testing is we want to know, but we might even either find out or not find out and nothing changes." That's always a possibility, unfortunately, with testing.
[Dr. Ashley Agan]
Do you ever repeat testing or do you ever--?
[Dr. Inna Husain]
I have. I'll be honest, the pH impedance full probe is not the most comfortable thing. Let's be honest. It's not a huge catheter, right? Our scopes are usually wider than it, but it's in the throat and you can feel it when you swallow. I'm very somewhat selected in terms of who I really push to get this done. Most people, I offer it to them. I let them know it exists. We talk about it, but it can be very uncomfortable.
Repeating something like that, I usually think there's more things we can try before that. I can think of a handful of people who've had multiple over the years, and usually those are actually our neurogenic chronic cough patients who 10 years ago were tested, five years ago were tested. Otherwise, we don't really repeat it.
Managing LPR with Diet Changes
It may be helpful to refer patients to a dietitian for counseling on a reflux-friendly diet. Unfortunately, there is no one-size-fits-all diet for patients with LPR, as each individual can have different food triggers (e.g. tomato sauce, wine, chocolate, caffeine, carbonation). Encouraging patients to increase their fiber intake can help absorb nitric oxide, which is known to relax the lower esophageal sphincter and reduce mechanical reflux. Some patients experience more tissue irritation from acid, in which case, eliminating items such as coffee and sparkling water can be beneficial.
[Dr. Ashley Agan]
Any other additional testing that is in your toolbox?
[Dr. Inna Husain]
I think to be honest, that's most of the testing that we do. I always tell patients with your GI or GERD workup, initially if you're having those symptoms or even silent reflux, let's make sure things like H. pylori have been ruled out. Those are things that my gastro colleagues work with patients on. Making sure that's been tested. I don't do a lot of nutritional testing if that makes sense. The reason for that is I don't know a lot about it. I wasn't formally trained in that.
I do work closely with dieticians, some of them more remotely who are not in my town or anything like that to work patients through some of the diet component of reflux for all of that stuff. I don't do that testing myself.
[Dr. Ashley Agan]
Got you. For like food sensitivities, is that what you -
[Dr. Inna Husain]
Right. Yes.
[Dr. Ashley Agan]
As far as treatment and therapy goes, any changes in your approach since the last time we talked? It's been about, I think our last episode was maybe a little over a year ago.
[Dr. Inna Husain]
Yes. I think I still lean towards more addressing mechanical reflux with alginates as opposed to acid suppression. I don't want GI doctors to come after me when I say I'm not a huge fan of acid suppression because there are definitely cases where I think it helps a lot. Those are more of our traditional GI symptoms. I think addressing more mechanical reflux. I do a lot of alginate use. I've been doing that for a while, but really supporting that use over acid suppression.
I do a lot about ensuring patients are getting good nutritional information, help with the dietician to work through when and what they're eating and drinking. No other real interventions I think that are different. I think we probably talked about neurosensitivity last time. Still doing all of that using neuromodulators, using the superior laryngeal nerve block for primarily laryngeal symptoms. Pretty similar.
[Dr. Ashley Agan]
Yes. For diet, is there a one diet fits all or is it, "Let me give you a list of things that tend to cause problems that you may want to try to eliminate. Here's the list of things that you can try that make it better."
[Dr. Inna Husain]
Yes, it's unfortunately the latter because we really don't know. Everyone's different in terms of what triggers them. People will say that about traditional heartburn as well. some people can eat tomato sauce and wine and be just fine. Others are like, "Oh my God, just the thought of that is horrible." We see that similarly with that. I do a lot of focus on things that I think contribute more to mechanical reflux. I think carbonation is a huge one, I think for throat symptoms. Really trying to eliminate carbonation. Coffee is interesting because of its acidity, but also it's caffeine and its effect on the lower esophageal sphincter.
I've recently got into really supporting the use of fiber. I came across a study and I think this is actually really fascinating that fiber actually absorbs nitric oxide and nitric oxide relaxes the lower esophageal sphincter. If you have fiber in your diet, you're going to soak up some of that nitric oxide and help the sphincter not loosen. I've been focusing more on things that contribute to mechanical reflux as opposed to acidity.
Now, that being said, acid on the way down can definitely cause issues for patients too, right? If you have a chronic soreness in your throat or irritation, it's not even a reflux thing at that point when you ingest acid, it's a touching the tissue thing. Yes, unfortunately, oftentimes it is a broad list of recommendations.
[Dr. Ashley Agan]
You're taking away the Topo Chico and the bubbly water.
[Dr. Inna Husain]
The summer, the LaCroix, the beautiful buses with the pinks and the purple, new flavors. I'm like, "Yes, that definitely, unfortunately, you can't have."
[Dr. Ashley Agan]
Can't have it. Cut it out. What about things to add? Things like-- you mentioned fiber. Does it matter if the fiber is coming from a vegetable source versus from Metamucil? Or just any fiber is good?
[Dr. Inna Husain]
Yes, I like it in the diet, in the food for more natural use. In terms of adding things, again, I often defer to my dietician colleagues for this because it gets very nuanced. To be very frank, I spend a lot of time with patients undergoing the medical work of diagnostic testing. Talking about nutrition is a whole another visit. I think you should really be speaking to someone who's really an expert in that and spending your time more wisely there. We often spend more of our time talking about the medical aspect of it in terms of testing and diagnosis and all of that.
Finding the Root Cause of Reflux
Patients often wonder about the root cause of their reflux. Lifestyle, body habitus, diet, medications, and underlying medical conditions such as sleep apnea or an H. pylori infection can all contribute to reflux. Stress is also believed to be a contributing factor, and patients should be counseled on managing stress, especially if they are frustrated and not finding relief from their LPR symptoms. Dr. Husain advocates for her patients to see a therapist to address stress during their LPR diagnostic journey.
Gastroenterologists play a role in ruling out acid damage but often look only for an acidic cause of reflux. It's important to remember that LPR is a complex disease process that can be acid, non-acid, and/or neural-mediated, requiring appropriate and individualized workup and treatment. If all treatments seem to fail, it is entirely reasonable to re-evaluate whether or not LPR is indeed the underlying issue.
[Dr. Ashley Agan]
How do you go about finding the root cause of your reflux? Yes. Go ahead. Speak more to that.
[Dr. Inna Husain]
Yes, this has become definitely a hot topic in terms of finding-- I don't feel like I've heard this as much in the last few years as in this past year in terms of finding the root cause. I agree with it. It's not that I'm against finding the root cause. A lot of patients now come in and they say, "I want to know why I'm having reflux." That's a big question that they're having. You have to break it down.
You have to have discussion about lifestyle, body habitus, when they're eating and drinking, are there underlying medical conditions. Sleep apnea is a huge one. Sleep apnea causes a lot of reflux at night. Are there other things in your medical history going on? Are you on medications that could be contributing to things? Diagnostically we use our testing, the same testing we spoke about in terms of reflux, to see if we can identify what's causing it. Do you have esophageal dysmotility as the root cause? A hiatal hernia, an H. pylori infection.
That's where we include some of the diagnostic workup and why I say treating these patients is more than just, "Oh your larynx looks great. It's probably reflux," because we know that no one else is going to work them through LPR. We know that as ENT that when you diagnose and you send them to GI-- I love my gastroenterology colleagues but they are not trained in LPR at all. When you send a patient saying it's reflux their mind is focused on GERD which to be honest it should be. They're ruling out GERD.
You know when you send that patient out the door that their best chance of LPR information is now gone. I really advocate for these patients that, again, if you're going to be diagnosing people with LPR, have a plan. Talk to that GI colleague you refer to and say, "Hey do you even believe in LPR?" Because I've had patients come back and say, "I saw this GI and he said it's not a thing. He said LPR is not a thing. Non-acid reflux is not a thing."
It happens. When you're going to have referral patterns, have these conversations. Be like, "What are your thoughts on LPR? Do you treat this? Do you work this up?" It just takes a conversation. You'll know if the people you work with believe in it or not.
[Dr. Ashley Agan]
Yes, you hate to send a patient and then come back and it have felt like a complete waste of their time to get it. What about stress? What about the whole gut-brain axis?
[Dr. Inna Husain]
Yes, a hundred percent. A hundred percent. This is again things that are outside of our traditional medicine teaching to be very honest. I think all of us who are now in practice we know this is true. We know it. We can we can do a PubMed search and we'll find papers that also support this because they're there. Yes, stress contributes to reflux in multiple ways and it can be something that propagates the symptoms as well. Maybe something in life happened that caused stress but now you're having symptoms so you're having stress over the symptoms and then it just continues to propagate itself.
Stress also activates the vagus nerve. It contributes again to that hypervigilance that we're talking about. If you're going to look out for globus you're going to feel it. Same with tinnitus. I always tell patients, "If I listen for it I will hear it too." It's the same idea. Trying to break that cycle. I talk a lot with patients about figuring out ways to help with their stress. Whether it is yoga or going for walks or getting acupuncture.
When I started my new practice, one of the things I did was investigated where was where were therapists. Could I get your cards? This is what I treat. Would you be happy to see these patients? I have cards that I give patients. I have referrals I can place. I looked up and tried to find where I could send patients for these type of things. Sometimes I feel uncomfortable having these conversations with patients because of course you never want to come off as like, "Oh it's just your stress."
We know whether it's the primary or the secondary it's likely playing a component and patients need to hear it from your medic-- from you. You're their expert their medical team. You need to say, "Listen we're going to keep looking for the root cause and trying to work through it but I need you to work on this as well."
[Dr. Ashley Agan]
Yes, I agree I think it's really important. Anything else with finding that root cause?
[Dr. Inna Husain]
I think I think that's a lot of it. I think when you're looking for the root cause and things like that you need to also remember that it can be acidic or non-acidic. That can sometimes be challenging that a lot of GI workup is really only looking for acidic reflux. That's why if you're going to be the person managing their LPR, you have to put that in context. We've ruled out acid damage.
That's one of the things I tell patients with upper endoscopies is, "I need to know if you have acid damage and if it's severe." The word Barret's comes up often. I need to know if that's there because that's going to change my way of thinking. I'm going to be more aggressive with you and when I say aggression, I actually mean acid suppression with you than a person who does not have that. We work through acid, non-acid, neural mediated with patients as well.
[Dr. Ashley Agan]
We touched a little bit on it last time but just to bring it back around because I think it's still very much in the popular culture and news but gut bacteria, microbiome, how-- I think you and Dr. Lechien talked a little bit about how reflux can change the normal floor of the mouth.
[Dr. Inna Husain]
I think this is all next-generation LPR and I'm-- I tell you I'd like doing this stuff because I get really excited about it. I'm so excited about this. I think this is essentially going to be the help us answer that question of why do some people get these symptoms and others don't, because it doesn't make sense. Reflux is so prevalent or GERD is so prevalent. Why don't doesn't everybody have these LPR symptoms? I think looking into the microbiome of the GI tract, the laryngopharyngeal region is going to be really important in terms of figuring out what is actually the root cause of this symptomatology.
[Dr. Ashley Agan]
Yes, and then last question. What if dietary modifications, alginates like Gaviscon UK, the UK version, or RefluxRaft and then even fundoplication. What if all of those have been tried and haven't worked?
[Dr. Inna Husain]
I tell patients when things are not working, "Are you sure it's LPR?" Is it really reflux? Because we see this all the time, that definition of LPR persists for years based on one clinic visit. One clinic visit where we didn't see a sinus infection so we said it was LPR. I always tell patients, "Listen you got to undergo diagnostic workup to show that it's still reflux." There are a host of things that can cause vague throat upper aerodigestive tract symptoms. There's only so many ways the throat can manifest what it feels. There's so there's only a handful of things but there's multiple things that can trigger those symptoms.
When nothing is-- I always go back to the very beginning. I say, "I know you've done all this stuff, but what testing has been done? Let's do your exam again. Let's add a stroboscopy. Let's ask about your history. What is still persisting?" One of the struggles with things like fundoplications, unfortunately, is the gaseous reflux component. Is the idea that you can't stop gas from coming through because you need to be able to swallow on the way down and so that can be really difficult.
Again, as I mentioned earlier, there is work being done for possibly an anti-pepsin inhibitor, which I think would be very exciting if that comes out because that would be added to the treatment options for patients.
[Dr. Ashley Agan]
It can get really complicated and confusing but I think I like your way of thinking about it and just trying to keep it simple. Go back to the beginning if you need to, back to the definitions. Let's use our testing to be able to prove what's going on. Excellent. As we round things out, what else do our listeners need to know?
[Dr. Inna Husain]
One thing I would like them to know is that don't give up. We're trying. We're trying to make efforts here to get the education out there to figure out what's happening. A lot of people are doing basic science research to try to find answers. It's not that we've given up on this so don't give up hope. We can work through this. I would always say advocate for yourself if you're not feeling like you're getting the answers where you are, second opinions for things in medicine I always support them. Even if it's a patient who's seen me, if you need a second opinion, I'm happy to refer you to somebody.
Yes, mostly for the patients just don't give up, work through this and good things are coming.
Podcast Contributors
Dr. Inna Husain
Dr. Inna Husain is the medical director of laryngology with the CCNI Network and Community Hospital in Munster, Indiana.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2024, June 11). Ep. 175 – Understanding Atypical LPR: Beyond the Larynx [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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