Question Prompt List as a Communication Tool for Adults With Gastroesophageal Reflux Disease: Incorporation of Patients' Perspectives.

BACKGROUND: Question prompt lists (QPLs) are structured sets of disease-specific questions intended for patient use, enhancing the patient-physician communication by encouraging patients to ask relevant questions during a consultation. Recently, a preliminary 78 question gastroesophageal reflux disease (GERD) specific QPL was created by 12 esophageal experts through a modified Delphi (RAND/University of California, Los Angeles) technique. Patients' perspectives and opinions on each question, however, had not been accounted for in the preliminary expert' version. AIM: The aim was to modify a preliminary experts' QPL, specific to adults with GERD, following patient perspectives and opinions. METHODS: A preliminary GERD QPL was modified through patient input and opinions. Thirty-eight patients with a clinical diagnosis of GERD followed at Stanford University Esophageal Clinic between January and November 2019 were consented to modify the preliminary 78 question expert QPL version. After receiving the QPL in Qualtrics (Provo, UT) by a direct e-mail invitation, patients independently rated questions on a 5-point Likert scale, where 1="should not be included," 2="unimportant," 3="don't know/depends," 4="important," and 5="essential." Questions were accepted for inclusion in the QPL with an a priori interagreement of 80% ranking in the range of 4 to 5. At the end, patients were encouraged to propose additional questions to incorporate into the QPL by open-endedly asking "Are there questions we didn't ask, that you think we should?" RESULTS: Twenty-three patients with GERD (19 female, median age 64) fully participated and modified the existing QPL (60.5%). Of the 78 questions from the preliminary GERD QPL, 66 questions (84.6%) were accepted for inclusion. The question with the highest agreement among patients rating a question as essential consisted of "what habits, food, and drinks do I have to avoid?" (82.6%). Questions eliminated because of disagreement included "What is the natural history of GERD," "Do I have a high chance to die from my Barrett's?," and "Why are you prescribing an antidepressant to treat my GERD?" Nine patients suggested additional questions totaling to 16 separate questions, including "What type of surgeries are there to help GERD?," "What stage is my GERD?," "What are the odds/percentage of getting cancer from GERD?" Incorporating the suggested questions, the final GERD QPL-created by esophageal experts and modified by patients-consisted of 82 questions. CONCLUSION: Esophageal experts and GERD patients have a high level of agreement on important questions, though there is some variation in perspective. Future studies can simplify this list and measure the impact of a shared GERD QPL on patients' decisional conflict and perceived involvement in care.

Development of a Preliminary Question Prompt List as a Communication Tool for Adults With Gastroesophageal Reflux Disease: A Modified Delphi Study.

BACKGROUND: Question prompt lists (QPLs) are structured sets of disease-specific questions intended for patient use, encouraging patients to ask questions to facilitate their consultation with their physician. AIM: The aim of this study was to develop a QPL specific to adults with gastroesophageal reflux disease (GERD), created by esophageal experts. METHODS: The QPL content (78 questions) was derived through a modified Delphi method consisting of 2 rounds. In round 1, 18 esophageal experts provided 5 answers to the prompt "What you wish your patients would ask" and "What questions do patients often not ask, that I wish they would ask?" In round 2, the experts rated each question on a 5-point Likert scale, and responses rated as "essential" or "important," determined by an a priori threshold of ≥4.0, were accepted for the QPL. RESULTS: Twelve esophageal experts participated. Of 143 questions from round 1, 110 (76.9%) were accepted for inclusion in the QPL, meeting a median value of ≥4.0, and, subsequently, it reduced to 78, minimizing redundancy. Median values ranged between 4.0 and 5.0, with the highest agreement median (5.0) for questions asking dosing and timing of proton pump inhibitor therapy, and surveillance in Barrett's. Questions were categorized into the following categories: "What does this illness mean," "lifestyle modifications," "general treatment," "treatment with proton pump inhibitors," "What I should expect for my future," and "Barrett's." The largest number of questions covered lifestyle modifications (21.8%), with the highest agreement median (5.0) for "How helpful are lifestyle modifications in GERD?" CONCLUSIONS: A preliminary GERD-specific QPL, the first of its kind, was developed by esophageal experts. Modification after more patient consultation and feedback is planned in subsequent versions to create a GERD-QPL for eventual use in clinical gastroenterology.

ACG Institute for Clinical Research and Education: fulfilling the ACG's commitment to advance clinical gastroenterology.

Founded in 1994, the ACG Institute for Clinical Research and Education has assumed an increasingly important role in the life of the American College of Gastroenterology in recent years owing to the strength and relevance of its programs and the notable growth in the funding of clinical gastroenterology research. This report outlines its mission, leadership structure, and recent accomplishments.

Will women ever break the glass ceiling in medicine?

Increased attention is being paid to women's working conditions in medicine. Few data are available regarding gender disparity in gastroenterology. It seems, however, that in general women are paid less than men and that their progress in academic practice tends to be slow. The GI community needs to recognize that gender disparity is not an imaginary issue and that action is necessary to attract women to gastroenterology by providing equal opportunities.

The pathogenesis of pseudoachalasia: a clinicopathologic study of 13 cases of a rare entity.

Pseudoachalasia is an esophageal motor disorder usually associated with malignancy that has clinical, radiographic, and manometric findings that are often indistinguishable from primary achalasia. There are few reports examining the histologic features of the associated neoplasms and their relationship with the esophageal myenteric plexus. We studied the clinical and pathologic features of 13 cases of pseudoachalasia seen at our institution between 1979 and 1999. Detailed clinical and radiographic data were obtained from medical records. In all cases available histologic material was reviewed to confirm the presence and type of associated neoplasm. When possible, the relationship of the neoplasm to the esophageal myenteric plexus was examined. In selected cases immunohistochemical stains were performed to further evaluate this relationship. All patients had clinical, radiographic, and manometric features similar to primary achalasia. The cohort included seven men and six women, age range 24-79 years (median 61 years). Associated neoplasms included esophageal adenocarcinoma arising in Barrett's esophagus (n = 1), adenocarcinoma of the esophagogastric junction (n = 7), metastatic renal cell carcinoma to the esophagogastric junction (n = 1), breast adenocarcinoma (n = 1), pulmonary small cell carcinoma (n = 1), pleural malignant mesothelioma (n = 1), and mediastinal fibrosis (n = 1). The mechanism of pseudoachalasia was consistent with neoplastic infiltration of the esophageal myenteric plexus in 11 cases. Neoplastic cells surrounded myenteric ganglion cells, which appeared normal in number and morphology. In the patient with pulmonary small cell carcinoma, there was no evidence of neoplastic infiltration of the esophagogastric junction, and anti-ANNA-1 antibody was detected, suggesting a paraneoplastic syndrome. Tissue obtained at the time of esophagomyotomy revealed lymphocytic myenteric inflammation and marked depletion of ganglion cells identical to that seen in primary achalasia. The mechanism pseudoachalasia in the patient with breast adenocarcinoma is uncertain, as there was no evidence of direct involvement of the esophagogastric junction. In summary, we describe 13 cases of pseudoachalasia resulting in a clinical syndrome indistinguishable from primary achalasia. The most common mechanism is direct involvement of the esophageal myenteric plexus by neoplastic cells. Rarely, a distant neoplasm may cause this syndrome as a paraneoplastic process.

Does fecal occult blood testing really reduce mortality? A reanalysis of systematic review data.

INTRODUCTION: Colorectal cancer (CRC) is a common cause of cancer mortality. A variety of CRC screening strategies are being adopted in many developed countries. Fecal occult blood testing (FOBT) is one option for screening that has the most evidence for efficacy and is also the cheapest approach. Systematic reviews suggest that FOBT is effective in reducing CRC mortality but the data on overall mortality from any cause has rarely been synthesized. METHODS: Randomized controlled trials identified by a Cochrane review of the efficacy of FOBT were reanalyzed. Trials that reported on biennial FOBT with all cause mortality assessed at similar follow-up periods were analyzed. CRC, non-CRC, and all cause mortality were evaluated using a random effects model. RESULTS: Three trials were analyzed, involving 245,217 subjects with 2,148 CRC deaths after almost 3 million patient-years follow-up. The relative risk (RR) of CRC death in the FOBT arm was 0.87 (95% CI = 0.8-0.95). The RR of non-CRC death in the FOBT group was 1.02 (95% CI = 1.00-1.04, p = 0.015). The increase in non-CRC in the FOBT group balanced the decrease in CRC mortality with no overall impact on mortality (RR of dying in the FOBT arm = 1.002, 95% CI = 0.989-1.015). CONCLUSION: The impact of FOBT in reducing mortality from any cause is uncertain and efficacy of this strategy for CRC screening needs reevaluation.

Esophageal manometry: assessment of interpreter consistency.

BACKGROUND AND AIMS: Manometry is used widely in the evaluation of esophageal disorders. Our aim was to assess the intra- and interobserver reliability of esophageal manometry and identify potential causes for diagnostic variability. METHODS: Seventy-two esophageal manometry tracings were selected randomly from archives. Eight interpreters randomly and blindly evaluated tracings. Interpreters were divided into 3 groups: highly experienced (N = 3), moderately experienced (N = 3), and inexperienced (N = 2). Each tracing was examined for abnormalities involving the lower-esophageal sphincter (LES) and esophageal body. Interpreters rendered a single diagnosis from a list of 7 manometric diagnoses: normal, nutcracker, hypertensive LES, hypotensive LES, diffuse esophageal spasm (DES), nonspecific/ineffective esophageal motility (IEM), and achalasia. Intra- and interobserver agreements were determined and reasons for varied diagnoses were investigated. RESULTS: Overall intraobserver agreement was good (kappa = .63, P < .0001). There was no difference ( P = .9) between the highly and midexperienced interpreters (kappa = .61 and .65, respectively). Interobserver agreement for the diagnosis of achalasia and normal motility was good (kappa = .65 and .56, respectively). However, other manometric diagnoses yielded only fair interobserver agreement (kappa = .27). DES, nonspecific/ineffective esophageal motility (IEM), and hypo- and hypertensive LES diagnoses showed the least agreement. Poor adherence to established manometric criteria, misinterpretation of intrabolus pressure, and technical inadequacy were the most common sources of inconsistency in interpretations. CONCLUSIONS: Manometric diagnoses of conditions other than normal or achalasia are variable and have poor interobserver variability. Given their uncertain clinical implications, we must either redefine them or eliminate them from practice.

Colorectal cancer screening in primary care: the long and short of it.

Primary care physicians and physician extenders have been encouraged to perform sigmoidoscopy to improve compliance with screening and address the potential shortage of colonoscopists. A survey of primary care teaching programs reveals that sigmoidoscopy training is inconsistent and lacks minimum standards of competency. It would be helpful to know how many primary caregivers offer sigmoidoscopy in their practice and if they are deterred by insufficient resources and falling reimbursement. Colonoscopy is a more complete and efficient examination than sigmoidoscopy. Primary care physicians could be encouraged to promote colonoscopy if scheduling and patient instructions were easily available. It behooves colonoscopists to provide such assistance.

Predictors of outcome of pneumatic dilation in achalasia.

BACKGROUND & AIMS: Graded pneumatic dilation (PD) is a widely accepted treatment for achalasia. We investigated the potential predictors of outcome in a large group of patients with achalasia and tested the hypothesis that graded PD may not be appropriate for all patients. METHODS: Patients undergoing PD from 1992 to 2002 were evaluated retrospectively. Symptom scores (0-15) for dysphagia (0-5), regurgitation (0-5), and chest pain (0-5), as well as degree of esophageal emptying by timed barium swallow, were assessed for all patients. Failure was defined as the return of symptoms resulting in repeated PD or surgical myotomy. Clinical data assessed for short- and long-term predictors of response. RESULTS: Seventy-five patients with achalasia without previous therapy constituted the studied population. Three-year success rates for PD using 3.0-cm, 3.0-cm followed by 3.5-cm, and 3.0-cm and 3.5-cm followed by 4.0-cm Rigiflex balloons were 37% (95% confidence interval [CI], 26-53), 76% (95% CI, 65-88), and 88% (95% CI, 80-97), respectively. Patient age and sex were important treatment outcome predictors. A Cox proportional hazards model of time to additional therapy on sex and 10-year increase in age showed that 3.0-cm PD was significantly (P = 0.04) more likely to fail in younger men than older men (hazard ratio, 0.63; 95% CI, 0.41-0.98). In 25 of 68 patients (37%) initially treated with a 3.0-cm balloon, PD failed within 3 months. Twenty-two of 25 patients (88%) with early failure were men. CONCLUSIONS: (1) Young men have a greater failure rate with 3.0-cm PD than older men or women in general, and (2) graded PD in this group starting initially with the 3.0-cm balloon is more likely to fail.