The continuing use of the SPICES model in 'SAVOURING' curriculum development.

The SPICES model, described by Harden, Sowden, and Dunn in Medical Education 1984, presents a way of re-focussing a traditional curriculum by the addition of various educational strategies or 'SPICES'. These 'SPICES', Student-centred learning, a Problem-based approach, Integrated learning, Community-based education, Elective elements, and a Systematic approach meet perceived deficiencies in a conventional teaching programme and can contribute to the delivery of a reformed curriculum which addresses the educational needs of contemporary healthcare professionals.The evidence: During almost 40 years now the SPICES model has achieved international recognition as a key approach to curriculum development. Its importance in the design, delivery, and audit of a curriculum remains relevant today as is evidenced by:The number of citations in the medical education literature.Its inclusion as a key element of curriculum development in standard texts of medical education.Its prominence as a component of established Certificate, Diploma and Masters courses in medical education.The number of presentations or posters on curriculum development in the annual AMEE conference.The international reports of its use in the design and delivery of a curriculum.The international reports of its use in individual course design.In curriculum design for other healthcare disciplines.In its role in curriculum auditing and reform.The continuing usefulness: This article revises the principles of the SPICES model. It reflects on examples of its continuing international use; its use for curriculum design and development in a variety of healthcare disciplines; and its role in curriculum audit and revision. It also comments on some of the suggested alternatives and modifications described.

Luminal Chemoreceptors and Intrinsic Nerves: Key Modulators of Digestive Motor Function.

This chapter reviews data on the pathways by which luminal, mainly duodenal, chemoreceptors modulate gastro-pyloro-duodenal motor function to control emptying of nutrients into the small intestine. The vagus mediates proximal gastric relaxation caused by nutrient stimulation of duodenal/jejunal mucosal chemoreceptors. Modulation of the spatial patterning and inhibition of antral contractions during duodenal chemoreceptor activation are somewhat conflicting: both vagal control and ascending intramural nerves appear to play a role. Intraduodenal nutrients stimulate the localized pyloric contractions that prevent transpyloric flow via ascending duodenal intramural nerve pathways. Though not yet formally investigated, patterns of activation of the duodenal brake motor mechanism suggest that duodenal loop mucosal chemoreceptors signal to a brake mechanism at the most aborad region of the duodenum via descending intramural duodenal nerves.Intrinsic intramural pathways are important in the control of the first stages of digestion.

Outcomes of peroral endoscopic myotomy in patients with spastic esophageal motility disorders that do not fulfill Chicago Classification criteria.

INTRODUCTION: per-oral endoscopic myotomy (POEM) has become a mainstream treatment for achalasia and is a promising therapy in spastic disorders. METHODS: this is a retrospective study of prospectively collected data (case series). We present the first results of the use of POEM in patients with atypical spastic esophageal motor disorders that do not satisfy current Chicago Classification criteria. Seven consecutive patients with troublesome and persistent symptoms (12-180 months) related to atypical spastic esophageal motor dysfunction were systematically assessed before and after POEM, the extent of which was tailored by manometric findings. In five of the patients, other endoscopic or surgical procedures had failed. RESULTS: high-resolution manometry (HRM) showed a spastic esophageal body contractile segment in varying positions and lengths along the esophageal body which did not meet Chicago Classification criteria. After POEM, dysphagia and/or chest pain had either resolved or was greatly reduced. HRM 3-6 months after myotomy showed that the regions of spastic contraction targeted by myotomy had been ablated. There were no major complications. The clinical responses were fully maintained up to the most recent assessments after POEM (range 7-44 months). CONCLUSION: in our seven patients, POEM was a highly effective treatment for patients with troublesome symptoms related to atypical spastic esophageal motility disorders.

Deep-Learning System Detects Neoplasia in Patients With Barrett's Esophagus With Higher Accuracy Than Endoscopists in a Multistep Training and Validation Study With Benchmarking.

BACKGROUND & AIMS: We aimed to develop and validate a deep-learning computer-aided detection (CAD) system, suitable for use in real time in clinical practice, to improve endoscopic detection of early neoplasia in patients with Barrett's esophagus (BE). METHODS: We developed a hybrid ResNet-UNet model CAD system using 5 independent endoscopy data sets. We performed pretraining using 494,364 labeled endoscopic images collected from all intestinal segments. Then, we used 1704 unique esophageal high-resolution images of rigorously confirmed early-stage neoplasia in BE and nondysplastic BE, derived from 669 patients. System performance was assessed by using data sets 4 and 5. Data set 5 was also scored by 53 general endoscopists with a wide range of experience from 4 countries to benchmark CAD system performance. Coupled with histopathology findings, scoring of images that contained early-stage neoplasia in data sets 2-5 were delineated in detail for neoplasm position and extent by multiple experts whose evaluations served as the ground truth for segmentation. RESULTS: The CAD system classified images as containing neoplasms or nondysplastic BE with 89% accuracy, 90% sensitivity, and 88% specificity (data set 4, 80 patients and images). In data set 5 (80 patients and images) values for the CAD system vs those of the general endoscopists were 88% vs 73% accuracy, 93% vs 72% sensitivity, and 83% vs 74% specificity. The CAD system achieved higher accuracy than any of the individual 53 nonexpert endoscopists, with comparable delineation performance. CAD delineations of the area of neoplasm overlapped with those from the BE experts in all detected neoplasia in data sets 4 and 5. The CAD system identified the optimal site for biopsy of detected neoplasia in 97% and 92% of cases (data sets 4 and 5, respectively). CONCLUSIONS: We developed, validated, and benchmarked a deep-learning computer-aided system for primary detection of neoplasia in patients with BE. The system detected neoplasia with high accuracy and near-perfect delineation performance. The Netherlands National Trials Registry, Number: NTR7072.

A scoping review of new implementations of interprofessional bedside rounding models to improve teamwork, care, and outcomes in hospitals.

Poor communication within healthcare teams occurs commonly, contributing to inefficiency, medical errors, conflict, and other adverse outcomes. Interprofessional bedside rounds (IBR) are a promising model that brings two or more health professions together with patients and families as part of a consistent, team-based routine to share information and collaboratively arrive at a daily plan of care. The purpose of this systematic scoping review was to investigate the breadth and quality of IBR literature to identify and describe gaps and opportunities for future research. We followed an adapted Arksey and O'Malley Framework and PRISMA scoping review guidelines. PubMed, CINAHL, PsycINFO, and Embase were systematically searched for key IBR words and concepts through June 2020. Seventy-nine articles met inclusion criteria and underwent data abstraction. Study quality was assessed using the Mixed Methods Assessment Tool. Publications in this field have increased since 2014, and the majority of studies reported positive impacts of IBR implementation across an array of team, patient, and care quality/delivery outcomes. Despite the preponderance of positive findings, great heterogeneity, and a reliance on quantitative non-randomized study designs remain in the extant research. A growing number of interventions to improve safety, quality, and care experiences in hospital settings focus on redesigning daily inpatient rounds. Limited information on IBR characteristics and implementation strategies coupled with widespread variation in terminology, study quality, and design create challenges in assessing the effectiveness of models of rounds and optimal implementation strategies. This scoping review highlights the need for additional studies of rounding models, implementation strategies, and outcomes that facilitate comparative research.

6-Minute walk test predicts prolonged hospitalization in patients undergoing transcatheter mitral valve repair by MitraClip.

BACKGROUND: The 6-minute walk test (6MWT) is a simple functional test that can predict exercise capacity and is widely employed to assess treatment outcomes. Although mortality with transcatheter mitral valve repair (TMVr) using the MitraClip (Abbott Vascular, Menlo Park, CA) is significantly less than for open mitral valve surgery in high-risk patients, identifying which patient will benefit the most from TMVr remains a concern. There are limited prognostic metrics guiding patient selection and, no studies have reported relationship between prolonged hospitalization and 6MWT. This study aimed to determine if the 6MWT can predict prolonged hospitalization in patients undergoing TMVr by MitraClip. METHODS: We retrospectively reviewed 162 patients undergoing 6MWT before TMVr. Patients were divided into three groups according to the 6MWT distance (6MWTD) using the median (6MWTD ≥219 m, 6MWTD <219 m, and Unable to Walk). Multivariate logistic regression model was applied to select the demographic characteristics that were associated with the prolonged hospitalization defined as total length of stay ≥4 days in the study. RESULTS: We found that 6MWT (odds ratio 3.64, 95% confidence interval 2.03-6.52, P < 0.001) was independently associated with prolonged hospitalization after adjustment in multivariate analysis. Area under the curve of 6MWT for predicting prolonged hospitalization was 0.79 (95% confidence interval 0.72-0.85). CONCLUSIONS: Our study demonstrates that 6MWT was independently associated with prolonged hospitalization in patients with TMVr, and has a good discriminatory performance for predicting prolonged hospitalization.

Epithelial Thickness is a Marker of Gastroesophageal Reflux Disease.

BACKGROUND & AIMS: Histologic criteria have been refined for the diagnosis of gastroesophageal reflux disease (GERD). We aimed to evaluate these criteria for the assessment of GERD and to measure interassessor agreement. METHODS: We performed a post hoc analysis of data from the Diamond study (NCT 00291746), conducted in Europe and Canada on adults with frequent upper gastrointestinal symptoms who had not taken a proton pump inhibitor in the previous 2 months. GERD was diagnosed based on the presence of 1 or more of the following: reflux esophagitis, pathologic esophageal acid exposure, and/or positive symptom-acid association probability. Nonerosive reflux disease was defined as the presence of pathologic esophageal acid exposure and/or a positive symptom-acid association probability, but no reflux esophagitis. Biopsies collected from 336 patients from 0.5 cm and 2.0 cm above the Z line were evaluable; they were analyzed independently at pathology centers in Germany and Italy (biopsies from 258 and 195 patients, respectively). The primary outcomes were the accuracy of histologic criteria for the diagnosis of GERD, defined by endoscopy and pH monitoring, and interassessor agreement on histologic criteria. RESULTS: At the assessment site for basal cell layer thickness, total epithelial thickness was the best-performing criterion for diagnosis of investigation-defined GERD; it also identified nonerosive reflux disease, reflux esophagitis, and pathologic esophageal acid exposure at 0.5 cm and 2.0 cm above the Z line. Basal cell layer thickness and presence of dilated intercellular spaces did not identify patients with GERD. Among the criteria tested, the best agreement between assessments carried out at the 2 pathology centers was for total epithelial thickness at 0.5 cm and 2.0 cm above the Z line. CONCLUSIONS: Based on an analysis of 336 patients with frequent upper gastrointestinal symptoms, total epithelial thickness is a robust histologic marker for GERD.

Use of intracardiac echocardiography to guide percutaneous transluminal mitral commissurotomy: A 20-patient case series.

OBJECTIVES: To report the efficacy and safety of the use adjunctive intracardiac echocardiography (ICE) during percutaneous transluminal mitral commissurotomy (PTMC) in patients without transesophageal echocardiography (TEE). BACKGROUND: Patients with mitral stenosis are at a high risk of developing a left atrial (LA) thrombus. Traditionally, TEE has been used prior to PTMC to identify the presence of LA thrombi. There have been no reports of the use of ICE to assess the LA for thrombi prior to PTMC. METHODS: We retrospectively reviewed 20 patients who underwent ICE prior to PTMC. All PTMC procedures were performed via the antegrade transvenous approach using an Inoue balloon. Initially, ICE was used from the right atrium to confirm the absence of a thrombus on the left side of the septum and was subsequently used to guide the transseptal puncture. Following these procedures, the ICE was advanced into the LA through a transseptal sheath to visualize the LAA. RESULTS: Visualization of the thrombus/spontaneous echo contrast was considered to be diagnostic in all cases. Seventy percent of the patients were discharged on day after the procedure. No patients required intubation during the procedure, and there were no complications that could be attributed to the use of ICE. At six months after the PTMC, the incidence of stroke was zero. CONCLUSIONS: ICE-guided PTMC offers excellent visualization of the LA and the LAA with satisfactory clinical outcomes and low risk. As a part of the PTMC procedure, ICE safely provides a valid alternative to a separate TEE procedure.

Adjunctive intracardiac echocardiography imaging from the left ventricle to guide percutaneous mitral valve repair with the MitraClip in patients with failed prior surgical rings.

OBJECTIVES: We evaluated intracardiac echocardiography (ICE) for adjunctively guiding the MitraClip procedure in patients with prior surgical rings. BACKGROUND: Transesophageal echocardiography (TEE) is the standard imaging modality used to guide the MitraClip procedure (Abbott Vascular, CA). However, in patients with post-surgical anatomy, clear imaging of the mitral valve leaflets may be complex because of shadowing from the surgical ring. In these patients, TEE may be suboptimal for guiding the procedure, even using three-dimensional imaging. METHODS: This retrospective analysis included data from 121 consecutive patients with mitral regurgitation who underwent MitraClip procedures at the University of Virginia. ICE was used adjunctively when there was difficulty with TEE, particularly for assessing the insertion of the posterior leaflet into the MitraClip's arms. The ICE catheter was introduced transarterially into the left ventricle and flexed to obtain the short-axis view. RESULTS: Six patients had prior surgical rings, and in five, we used adjunctive ICE. The etiology of the mitral regurgitation was prolapse of the posterior leaflet in one patient and restriction of the posterior leaflet due to ischemic tethering in the remainder. All images were obtained from the left ventricle, and were adequate for assessing posterior leaflet insertion and the perpendicularity of the MitraClip arms. The procedural success rate was 80%. There was no adverse event related to the ICE procedure. CONCLUSIONS: Mitral valve repair with the MitraClip system assisted by ICE is feasible in patients with prior surgical rings, achieving an excellent risk profile and satisfactory procedural success.

Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review.

OBJECTIVE: To update the findings of the 2005 systematic review of population-based studies assessing the epidemiology of gastro-oesophageal reflux disease (GERD). DESIGN: PubMed and Embase were screened for new references using the original search strings. Studies were required to be population-based, to include ≥ 200 individuals, to have response rates ≥ 50% and recall periods <12 months. GERD was defined as heartburn and/or regurgitation on at least 1 day a week, or according to the Montreal definition, or diagnosed by a clinician. Temporal and geographic trends in disease prevalence were examined using a Poisson regression model. RESULTS: 16 studies of GERD epidemiology published since the original review were found to be suitable for inclusion (15 reporting prevalence and one reporting incidence), and were added to the 13 prevalence and two incidence studies found previously. The range of GERD prevalence estimates was 18.1%-27.8% in North America, 8.8%-25.9% in Europe, 2.5%-7.8% in East Asia, 8.7%-33.1% in the Middle East, 11.6% in Australia and 23.0% in South America. Incidence per 1000 person-years was approximately 5 in the overall UK and US populations, and 0.84 in paediatric patients aged 1-17 years in the UK. Evidence suggests an increase in GERD prevalence since 1995 (p<0.0001), particularly in North America and East Asia. CONCLUSIONS: GERD is prevalent worldwide, and disease burden may be increasing. Prevalence estimates show considerable geographic variation, but only East Asia shows estimates consistently lower than 10%.

Editorial: Better ammunition for use of weight loss in managing gastroesophageal reflux disease.

The report from the HUNT Study provides the most convincing evidence yet that weight loss has beneficial effects on occurrence and severity of heartburn and regurgitation and their response to acid suppressant therapy. These data should re-invigorate clinicians to encourage weight loss in their reflux disease patients.

Acid-suppressive therapy with esomeprazole for relief of unexplained chest pain in primary care: a randomized, double-blind, placebo-controlled trial.

OBJECTIVES: High-quality data regarding the efficacy of acid-suppressive treatment for unexplained chest pain are lacking. The aim of this study was to evaluate the efficacy of esomeprazole in primary-care treatment of patients with unexplained chest pain stratified for frequency of reflux/regurgitation symptoms. METHODS: Patients with a ≥ 2-week history of unexplained chest pain (unrelated to gastroesophageal reflux) who had at least moderate pain on ≥ 2 of the last 7 days were stratified by heartburn/regurgitation frequency (≤ 1 day/week (stratum 1) vs. ≥ 2 days/week (stratum 2)) and randomized to 4 weeks of double-blind treatment with twice-daily esomeprazole 40 mg or placebo. Chest pain relief during the last 7 days of treatment (≤ 1 day with minimal symptoms assessed daily using a 7-point scale) was analyzed by stratum in keeping with the predetermined analysis plan. RESULTS: Overall, 599 patients (esomeprazole: 297, placebo: 302) were randomized. In stratum 1, more esomeprazole than placebo recipients achieved chest pain relief (38.7% vs. 25.5%; P=0.018); no between-treatment difference was observed in stratum 2 (27.2% vs. 24.2%; P=0.54). However, esomeprazole was superior to placebo in a post-hoc analysis of the whole study population (combined strata; 33.1% vs. 24.9%; P=0.035). CONCLUSIONS: A 4-week course of high-dose esomeprazole provided statistically significant relief of unexplained chest pain in primary-care patients who experienced infrequent or no heartburn/regurgitation, but there was no such significant reduction in patients with more frequent reflux symptoms.

Systematic review: patterns of reflux-induced symptoms and esophageal endoscopic findings in large-scale surveys.

BACKGROUND & AIMS: This systematic review assesses findings of endoscopic surveys in the general population with regard to gastroesophageal reflux disease (GERD). METHODS: Systematic searches were conducted in PubMed and EMBASE. Authors were contacted for additional, unpublished data. RESULTS: Data on 61,281 individuals were included from 3 general population studies (Kalixanda study [Sweden], Loiano-Monghidoro study [Italy], SILC study [China]) and 8 health-check studies (Japan, n = 1; China, n = 1; Taiwan, n = 4; Korea, n = 2). The prevalence of reflux esophagitis was 15.5% (Kalixanda), 11.8% (Loiano-Monghidoro), and 6.4% (SILC); it ranged from 3.4% to 8.5% in health-check studies in Japan, China, and Korea (n = 4), but was higher (mean, 15.6%; range, 9.0%-24.6%; n = 4) in Taiwan. Hiatus hernia prevalence was 23.9% (Kalixanda), 43.0% (Loiano-Monghidoro), and 0.7% (SILC), and 0.8%-19.5% in health-check studies (n = 7). For endoscopically suspected esophageal metaplasia (ESEM), the prevalence was 10.3% (Kalixanda), 3.6% (Loiano-Monghidoro), and 1.8% (SILC), and 0.0%-3.4% in health-check studies (n = 4). The prevalence of reflux esophagitis among individuals without symptom-defined GERD was 12.1% (Kalixanda), 8.6% (Loiano-Monghidoro), 6.1% (SILC), and 1.6%-22.8% (health-check studies; n = 6). For individuals without symptom-defined GERD, the prevalence of ESEM was 9.4% (Kalixanda), 2.8% (Loiano-Monghidoro), and 1.8% (SILC). CONCLUSIONS: The prevalence of reflux esophagitis is higher in Sweden and Italy than in China, Korea, and Japan, but is within the range reported in Taiwan. Hiatus hernia and ESEM are generally more prevalent in Europe than in Asia. A considerable proportion of individuals without symptom-defined GERD has reflux esophagitis or ESEM.

Limited ability of the proton-pump inhibitor test to identify patients with gastroesophageal reflux disease.

BACKGROUND & AIMS: The efficacy of proton-pump inhibitor (PPI) therapy often is assessed to determine whether patients' symptoms are acid-related and if patients have gastroesophageal reflux disease (GERD), although the accuracy of this approach is questionable. We evaluated the diagnostic performance of the PPI test, in conjunction with other tests, for the diagnosis of GERD. METHODS: We analyzed data from the DIAMOND study, a multinational trial that compared the ability of the reflux disease questionnaire with that of symptom-based clinical diagnosis to identify GERD in primary care patients with frequent upper-gastrointestinal symptoms. Patients (n = 308) were given placebo and further evaluated by endoscopy, wireless esophageal pH-metry, and symptom association monitoring. Those with GERD (n = 197) were identified based on the presence of reflux esophagitis, esophageal pH level less than 4 for more than 5.5% of 24 hours, or positive results from symptom association monitoring (or a positive result from the PPI test in patients with borderline levels of esophageal acidity). All patients then were given single-blind therapy with esomeprazole (40 mg once daily) for 2 weeks and symptoms were recorded daily. RESULTS: A positive response to the PPI test was observed in 69% of patients with GERD and in 51% of those without GERD. Response to placebo did not influence the diagnostic ability of the subsequent PPI test. More patients with reflux esophagitis had a positive result from the PPI test than patients without GERD (57% vs 35%; P = .002) or patients with GERD but no esophagitis. A clinical diagnosis by the primary care physician of an acid-related disease was not associated with response to PPIs. CONCLUSIONS: In a well-characterized population of primary care patients with frequent upper-gastrointestinal symptoms of any type, the PPI test has limited ability to identify patients with GERD, diagnosed by current standard tests. (ClinicalTrials.gov Number, NCT00291746.).

A method to objectively assess swallow function in adults with suspected aspiration.

BACKGROUND & AIMS: Pharyngeal manometry and impedance provide information on swallow function. We developed a new analysis approach for assessment of aspiration risk. METHODS: We studied 20 patients (30-95 years old) with suspected aspiration who were referred for videofluoroscopy, along with controls (ages 24-47 years). The pharyngeal phase of liquid bolus swallowing was recorded with manometry and impedance. Data from the first swallow of a bolus and subsequent clearing swallows were analyzed. We scored fluoroscopic evidence of aspiration and investigated a range of computationally derived functional variables. Of these, 4 stood out as having high diagnostic value: peak pressure (PeakP), pressure at nadir impedance (PNadImp), time from nadir impedance to peak pressure (TNadImp-PeakP), and the interval of impedance drop in the distal pharynx (flow interval). RESULTS: During 54 liquid, first swallows and 40 clearing swallows, aspiration was observed in 35 (13 patients). Compared to those of controls, patient swallows were characterized by a lower PeakP, higher PNadImp, longer flow interval, and shorter TNadImp-PeakP. A Swallow Risk Index (SRI), designed to identify dysfunctions associated with aspiration, was developed from iterative evaluations of variables. The average first swallow SRI correlated with the average aspiration score (r = 0.846, P < .00001 for Spearman Rank Correlation). An average SRI of 15, when used as a cutoff, predicted aspiration during fluoroscopy for this cohort (κ = 1.0). CONCLUSIONS: Pressure-flow variables derived from automated analysis of combined manometric/impedance measurements provide valuable diagnostic information. When combined into an SRI, these measurements are a robust predictor of aspiration.

Distension of the esophagogastric junction augments triggering of transient lower esophageal sphincter relaxation.

Patients with gastroesophageal reflux disease show an increase in esophagogastric junction (EGJ) distensibility and in frequency of transient lower esophageal sphincter relaxations (TLESR) induced by gastric distension. The objective was to study the effect of localized EGJ distension on triggering of TLESR in healthy volunteers. An esophageal manometric catheter incorporating an 8-cm internal balloon adjacent to a sleeve sensor was developed to enable continuous recording of EGJ pressure during distension of the EGJ. Inflation of the balloon doubled the cross-section of the trans-sphincteric portion of the catheter from 5 mm OD (round) to 5 × 11 mm (oval). Ten healthy subjects were included. After catheter placement and a 30-min adaptation period, the EGJ was randomly distended or not, followed by a 45-min baseline recording. Subjects consumed a refluxogenic meal, and recordings were made for 3 h postprandially. A repeat study was performed on another day with EGJ distension status reversed. Additionally, in one subject MRI was performed to establish the exact position of the balloon in the inflated state. The number of TLESR increased during periods of EGJ distension with the effect being greater after a meal [baseline: 2.0(0.0-4.0) vs. 4.0(1.0-11.0), P=0.04; postprandial: 15.5(10.0-33.0) vs. 22.0(17.0-58.0), P=0.007 for undistended and distended, respectively]. EGJ distension augments meal-induced triggering of TLESR in healthy volunteers. Our data suggest the existence of a population of vagal afferents located at sites in/around the EGJ that may influence triggering of TLESR.

Epidemiology of symptom-defined gastroesophageal reflux disease and reflux esophagitis: the systematic investigation of gastrointestinal diseases in China (SILC).

OBJECTIVE: Gastroesophageal reflux disease (GERD) is thought to be less prevalent in China than in Western countries. However, essential population-based endoscopy data are lacking for this country. MATERIAL AND METHODS: As part of a wider study, 3600 individuals selected randomly from the Shanghai region were asked to undergo endoscopy. Participants completed a general information questionnaire and a Chinese version of the Reflux Disease Questionnaire. When sufficient numbers were available, associations were assessed using multiple logistic regression or the Wilcoxon rank-sum test. RESULTS: Of 3153 (87.6%) individuals who completed the survey, 1030 (32.7%) agreed to endoscopy and 1029 endoscopies were suitable for analysis. Symptom-defined GERD was more prevalent in the endoscopy group (4.7%) than in the non-endoscopy group (1.7%). Prevalence estimates were 6.4% for reflux esophagitis, 1.8% for endoscopically suspected esophageal metaplasia and 0.7% for hiatus hernia. Reflux esophagitis was more prevalent in patients with symptom-defined GERD than in those without (12.5% [6/48] vs. 6.1% [60/981]), and was significantly associated with reflux symptoms of any frequency or severity (OR = 2.10, 95% CI 1.13-3.89) and with negative Helicobacter pylori infection (OR = 0.44, 95% CI 0.25-0.80). Only 28.8% of participants with reflux esophagitis had heartburn and/or regurgitation symptoms. Epigastric burning was significantly more severe and frequent in participants with reflux esophagitis than in those without (p = 0.05). CONCLUSIONS: Reflux esophagitis is less prevalent in China than reported in Western countries. Further work is needed to establish why reflux esophagitis appears less symptomatic in China than in Western countries.

Barrett's esophagus: A historical perspective, an update on core practicalities and predictions on future evolutions of management.

Interpretation of exploding knowledge about Barrett's esophagus is impaired by use of several conflicting definitions. Because any histological type of esophageal columnar metaplasia carries risk for esophageal adenocarcinoma, the diagnosis of Barrett's esophagus should no longer require demonstration of intestinal-type metaplasia. Endoscopic recognition and grading of Barrett's esophagus remains a significant source of ambiguity. Reflux disease is a key factor for development of Barrett's esophagus, but other factors must underlie its development, since it occurs in only a minority of reflux disease patients. Neither antireflux surgery nor proton pump inhibitor (PPI) therapy has major impacts on cancer risk. Within a year, a major trial should indicate whether low-dose aspirin usefully reduces cancer risk. The best referral centers have transformed the accuracy of screening and surveillance for early curable esophageal adenocarcinoma by use of enhanced and novel endoscopic imaging, visually-guided, rather than blind biopsies and by partnership with expert pathologists. General endoscopists now need to upgrade their skills and equipment so that they can rely mainly on visual targeting of biopsies on mucosal areas of concern in their surveillance practice. General pathologists need to greatly improve their interpretation of biopsies. Endoscopic therapy now achieves very high rates of cure of high-grade dysplasia and esophageal adenocarcinoma with minimal morbidity and risk. Such results will only be achieved by skilled interventional endoscopists. Esophagectomy should now be mainly restricted to patients whose cancer has extended into and beyond the submucosa. Weighing risks and benefits in the management of Barrett's esophagus is difficult, as is the process of adequately informing patients about their specific cancer risk.

Helicobacter pylori infection and gastritis: the Systematic Investigation of gastrointestinaL diseases in China (SILC).

BACKGROUND AND AIM: Helicobacter pylori infection remains common in East Asia, though its prevalence is decreasing in Western countries. H. pylori-related atrophic gastritis (AG) may reduce the likelihood of gastroesophageal reflux disease (GERD). We investigated the prevalence of H. pylori infection and AG and their association with endoscopic findings and symptom-defined GERD in Shanghai. METHODS: A representative random sample of 3600 Shanghai residents aged 18-80 years was invited to complete a general information questionnaire and a Chinese version of the Reflux Disease Questionnaire, to provide blood samples for H. pylori serology and pepsinogen (PG) I/II assay (to detect AG, defined as PGI < 70 µg/L and/or PGI/PGII < 7), and to undergo endoscopy. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by multivariate logistic regression. RESULTS: A total of 1022 Shanghai residents underwent endoscopy and were valid for inclusion in the study. Of these, 71.7% tested positive for H. pylori, 63.8% had AG and 30.5% had moderate/severe AG (PGI < 50 µg/L and/or PGI/PGII < 5). Helicobacter pylori infection was equally common in all age groups. Severity of AG increased with age in women. Reflux esophagitis was inversely associated with AG (OR, 0.23 [CI, 0.09-0.55] for moderate/severe AG compared with no H. pylori or gastritis). However, symptom-defined GERD showed no clear association with AG. CONCLUSIONS: Helicobacter pylori infection and AG are very common in Shanghai, and the infection is acquired early in life. Atrophic gastritis is inversely associated with reflux esophagitis but is not significantly associated with symptom-defined GERD.

Accuracy of the diagnosis of GORD by questionnaire, physicians and a trial of proton pump inhibitor treatment: the Diamond Study.

OBJECTIVE: The aim of this study was to determine the accuracy of the diagnosis of gastro-oesophageal reflux disease (GORD) by the Reflux Disease Questionnaire (RDQ), family practitioners, gastroenterologists and a test of esomeprazole therapy. METHODS: This was a single-blind, single-arm study over 3-4 weeks from September 2005 to November 2006. Each symptom-based diagnostic assessment was made blinded to prior diagnoses. Patients were those presenting to their family practitioner with troublesome upper gastrointestinal symptoms (n=308). The RDQ was completed and a symptom-based diagnosis was made by the family practitioner. Placebo esomeprazole was started. Gastroenterologists made a symptom-based diagnosis and then performed endoscopy with 48 h oesophageal pH and symptom association monitoring to determine the presence/absence of GORD. Symptoms were recorded during treatment with 40 mg of esomeprazole for 2 weeks. The main outcome measure was RDQ scoring for the presence of GORD compared with symptom-based diagnosis by family physicians and gastroenterologists. RESULTS: GORD was present in 203/308 (66%) patients. Only 49% of the patients with GORD selected either heartburn or regurgitation as the most troublesome symptom. Sensitivity and specificity, respectively, of the symptom-based diagnosis of GORD, were 62% and 67% for the RDQ, 63% and 63% for family practitioners, and 67% and 70% for gastroenterologists. Symptom response to esomeprazole was neither sensitive nor specific for the diagnosis of GORD. CONCLUSIONS: The RDQ, family practitioners and gastroenterologists have moderate and similar accuracy for diagnosis of GORD. Symptom response to a 2 week course of 40 mg of esomeprazole does not add diagnostic precision.