Management of gastroesophageal reflux disease in primary care: results of a survey in 2 areas in Germany.

BACKGROUND: The incidence of gastroesophageal reflux disease (GERD) is increasing. Although guidelines have been issued on the diagnosis and treatment of GERD, the way in which these should be applied in everyday practice is unclear. The aim of the present survey was to interview private-practice physicians on their personal opinions concerning the management of GERD. METHODS: A questionnaire based on the case of a typical patient with reflux was sent out to a total of 918 private-practice physicians. The questions concerned general measures for avoiding reflux symptoms (dietary and lifestyle modifications), the diagnosis of GERD, and the type and dosage of antireflux treatment. RESULTS: A total of 255 questionnaires were evaluated (28 %), which had been returned by 151 family doctors, 63 internal medicine specialists, and 41 gastroenterologists. 70 % of the respondents carry out specific diagnostic tests (endoscopy in 98 % of cases) prior to treatment. Altering specific dietary and lifestyle factors (such as sleeping position) was considered useful by the majority of respondents. 99 % of the physicians administer some form of GERD therapy, and 88 % of the internists/gastroenterologists and 74 % of family doctors (P = 0.006) do so using a "step-down" approach (with proton-pump inhibitors as the initial strategy). With the "step-up" procedure, the initial recommendation includes primarily antacids, with a change to more effective drugs only when symptomatic relief is not achieved. CONCLUSIONS: The current guidelines on the diagnosis and treatment of GERD are largely adhered to, particularly by specialists. In addition to the well-established drug treatment, empirical recommendations on dietary and lifestyle measures still form part of the management of GERD, despite the lack of scientific evidence to support them.     

Irritable bowel syndrome in primary care: the patients' and doctors' views on symptoms, etiology and management.

BACKGROUND: To facilitate the development of clinical guidelines and to direct future irritable bowel syndrome (IBS) research, insight into the perceptions of patients and general practitioners (GPs) regarding IBS is required. OBJECTIVES: To compare patients' and GPs' views on the symptomatology, etiology and treatment of IBS. METHODS: One hundred forty-two IBS patients and 100 GPs were requested to complete a structured questionnaire. RESULTS: The response rates of the patients and GPs were 80% and 47%, respectively. Abdominal pain and bloating were considered to be the most bothersome symptoms in IBS, by both patients and GPs. Although all patients were diagnosed by their GP as having IBS, and 62% met the Manning criteria, only 18% fulfilled the Rome II criteria for IBS. Patients consider food intolerance and GPs regard lack of fibre as the main etiologic dietary factor. Many IBS patients expect a diagnostic work-up, but GPs generally restrict this to elderly patients. GPs start IBS management with dietary advice (94%), counselling (77%) and drug therapy (55%). Patients expect reassurance (47%) and drug treatment (37%), but dietary interventions are less appreciated (9%). CONCLUSIONS: Patients and GPs have different perceptions of the efficacy of diagnostic and dietary interventions in IBS. GPs should explore the patients expectations and incorporate these in their approach to IBS patients.     

Present status of insulin therapy for type 2 diabetes treated by general practitioners and diabetes specialists in Japan: Third report of a cross‐sectional survey of 15,652 patients

Aims/Introduction: Insulin therapy is often required to achieve good glycemic control in patients with type 2 diabetes mellitus. However, some providers, particularly general practitioners (GPs), are reluctant to prescribe insulin to their patients. The aim of the present study was to clarify any differences in, as well as any problems associated with, insulin therapy in patients with type 2 diabetes being treated by either a GP or a diabetes specialist in Japan. Materials and Methods: Of 15,652 patients across 721 clinics and hospitals, 15,350 were diagnosed with type 2 diabetes (14,312 by GPs and 1038 by specialists). Data regarding glycated hemoglobin (HbA_1c) levels, age, height, bodyweight and treatment modality were collected for each patient. Results:  Of the patients with type 2 diabetes, 9.1 and 22.9% had been prescribed insulin monotherapy, and 38.8 and 37.0% were also receiving insulin with an oral antidiabetic (OAD) by GPs or specialists, respectively. Diabetes specialists prescribed analog insulin more frequently than did GPs. GPs chose premixed insulin more frequently than did specialists, and this factor correlated with higher HbA_1c levels. A younger age and daily insulin dose in groups being treated by both providers were correlated with high HbA_1c levels on insulin monotherapy. Neither type of insulin nor OAD was correlated with HbA_1c on insulin plus OAD therapy. Conclusions:  To achieve better glycemic control with insulin therapy, sufficient insulin dose and intensive treatment regimen, in addition to lifestyle interventions, might be necessary. (J Diabetes Invest, doi: 10.1111/j.2040‐1124.2012.00198.x, 2012)     

Factors influencing the decision to start drug treatment in hypertension. A questionnaire study comparing general practitioners and hypertension specialists in Denmark

Objective. To determine the factors influencing treatment decisions in patients with hypertension. Methods. A postal questionnaire based on five constructed cases with hypertension was sent to 122 general practitioners (GPs) in the area around Herlev University Hospital and to 46 Danish hypertension specialists. The cases varied in gender, age, blood pressure, cholesterol, diabetes and smoking status and absolute risk for cardiovascular events. Results. Response rate was 46% for GPs and 59% for specialists. There were no significant differences in treatment decisions nor in drug choices for first-line monotherapy, which were diuretics, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor antagonists in both groups of physicians. Blood pressure alone was the most important factor for instituting drug therapy according to 59% of the GPs and 56% of the specialists. There was no association between pre-treatment risk assessment and instituting treatment in either group in four out of five cases. Conclusions. We found agreement with respect to all treatment decisions between GPs and hypertension specialists. The results from this study suggest that, in both GPs and specialists, a blood pressure threshold approach to treating hypertension is still dominating.     

Step-down management of gastroesophageal reflux disease.

BACKGROUND & AIMS: As the economic burden of gastroesophageal reflux disease (GERD) is largely weighted to maintenance as opposed to initial therapy, switching from more potent to less expensive medication once symptoms are alleviated (step-down therapy) may prove to be most cost-effective. This study aimed to prospectively evaluate the feasibility of step-down therapy in a cohort of patients with symptoms of uncomplicated GERD. METHODS: Patients whose GERD symptoms were alleviated by proton pump inhibitors (PPIs) were recruited from outpatient general medicine clinics. After baseline demographic and quality of life information were obtained, PPIs were withdrawn from subjects in a stepwise fashion. Primary outcome was recurrence of symptoms during follow-up that required reinstitution of PPIs. Secondary outcomes included changes in quality of life and overall cost of management. Predictors of nonresponse to step-down were assessed. RESULTS: Seventy-one of 73 enrolled subjects completed the study. Forty-one of 71 (58%) were asymptomatic off PPI therapy after 1 year of follow-up. Twenty-four of 71 (34%) required histamine 2-receptor antagonists, 5/71 (7%) prokinetic agents, 1/71 (1%) both, and 11/71 (15%) remained asymptomatic without medication. Quality of life did not significantly change, whereas management costs decreased by 37%. Multivariable analysis revealed younger age and a dominant symptom of heartburn to predict PPI requirement. CONCLUSIONS: Step-down therapy is successful in the majority of patients and can decrease costs without adversely affecting quality of life.     

Treatment preferences,return visit planning and factors affecting hypertension practice amongst general practitioners and internal medicine specialists (The General Practitioner Hypertension Practice Study)

Abstract. Objectives. To study clinical practice and attitudes in hypertension care amongst general practitioners (GPs) and hospital internal medicine specialists. Design. Mailed case report questionnaires. Subjects. Ninety GPs and 69 internal medicine specialists at randomly selected primary health care centres and hospital outpatient departments. Main outcome measures. Case-bound treatment preferences, treatment goals and return visit planning, and views on factors influencing practice. Results. The participation rate was 84% and 70%, for GPs and internal medicine specialists, respectively. GPs more often proposed nonpharmacological therapy (P < 0.05), solely and as a complementary treatment, and prescribed more calcium antagonists (P < 0.001), whilst internal medicine specialists prescribed more ACE inhibitors (P < 0.001). Personal experience guides practice more than national consensus and economy, more so with increasing time since specialization. Conclusions. GPs and internal medicine specialists in Sweden report a hypertension practice closely related to each others' and to the intentions of national guidelines.     

On attitudes about colorectal cancer screening among gastrointestinal specialists and general practitioners in the Netherlands

AIM: To find out whether there are differences in attitudes about colorectal cancer (CRC) screening among gastrointestinal (GI) specialists and general practitioners (GPs) and which method is preferred in a national screening program METHODS: Four hundred and twenty Dutch GI specialists in the Netherlands and 400 GPs in Amsterdam were questioned in 2004. Questions included demographics, affiliation, attitude towards screening both for the general population and themselves, methods of screening, family history and individual risk. RESULTS: Eighty-four percent of the GI specialists returned the questionnaire in comparison to 32% of the GPs (P<0.001). Among the GI specialists, 92% favoured population screening whereas 51% of GPs supported population screening (P<0.001). Of the GI specialists 95% planned to be screened themselves, while 30% of GPs intended to do so (P<0.001). Regarding the general population, 72% of the GI specialists preferred colonoscopy as the screening method compared to 27% of the GPs (P<0.001). The method preferred for personal screening was colonoscopy in 97% of the GI specialists, while 29% of the GPs favoured colonoscopy (P<0.001). CONCLUSION: Screening for CRC is strongly supported by Dutch GI specialists and less by GPs. The major health issue is possibly misjudged by GPs. Since GPs play a crucial role in a successful national screening program, CRC awareness should be realized by increasing knowledge about the incidence and mortality, thus increasing awareness of the need for screening among GPs.     

Overview of medical therapy for gastroesophageal reflux disease

There appears to be a hierarchy in the efficacy of therapies that are directed against GERD. A summary of this hierarchy, including therapies [table: see text] not approved by the U.S. Food and Drug Administration, is presented in Table 4. The individual practitioner must evaluate the appropriate point at which to place each patient on this hierarchy. Whether it is best to begin with the drug with the highest efficacy and step-down as possible for maintenance, never to step down, or to start with a less efficacious therapy and step up must also be individualized because there are no clear data to support a universal approach to all or even most GERD patients.     

Long-term gastroesophageal reflux disease therapy improves reflux symptoms in elderly patients: five-year prospective study in community medicine

BACKGROUND: Gastroesophageal reflux disease (GERD) impairs the patient's quality of life (QOL), but the effect of long-term maintenance therapy in elderly patients is unknown. METHODS: We conducted a long-term prospective study. Forty-four GERD patients (11 males; mean age 74 years; QUEST score of at least 6 points) were enrolled in this study. Step-down therapy was selected (proton-pump inhibitor [PPI], histamine-2 receptor antagonist and prokinetic agents for 1 month, respectively). Optimal medication for each patient was continued for 5 years. The efficacy, safety of treatment and reflux symptoms were analyzed. The profiles of the patients who had to continue PPI maintenance therapy were also analyzed. RESULTS: Reflux symptoms were reduced by the PPI based step-down therapy (baseline 13.8 times/month, after 3.2 times/month, P < 0.001). Reflux symptoms improved in 34 patients (77%). None of the 44 patients had to cease treatment because of side-effects and none experienced any complications during the 5-year period. The prevalence of Helicobacter pylori (Hp) infection in the PPI group (29%, 4/14) was significantly lower (P < 0.01) than in the other treatment group (72%, 21/29). The serum pepsinogen I/II ratio in the PPI treatment group (5.7 +/- 0.5) was significantly higher (P < 0.01) than in the others (4.0 +/- 0.3). The predictive factors for PPI maintenance therapy were Hp-negative status and serum pepsinogen I/II ratio >6.0 (odds ratio 12.0, 95% confidence interval 2.7-54.2). CONCLUSIONS: Long-term medication for GERD selected on the basis of the patient's profile (i.e. Hp status and gastric atrophy) improved reflux symptoms.     

Age, specialty, and practice setting predict gastroesophageal reflux disease prescribing behavior

BACKGROUND: Gastroesophageal reflux disease (GERD) affects more than 40% of adults in the United States each month. Although the economic costs of treating this disorder are enormous, the attitudes and prescribing preferences of physicians who treat patients with GERD are not well known. This study was undertaken to determine physician prescribing practices in the treatment of GERD. METHODS: A questionnaire was mailed to 687 randomly selected, practicing gastroenterologists, internists, and family physicians in the State of Maryland. Each questionnaire was identical and contained 7 questions designed to elicit demographic data (age, sex, degree, specialty, practice setting, years in practice, community served), and 16 questions related to the evaluation and treatment of GERD. RESULTS: A total of 214 completed questionnaires were returned (31.1%), nearly equally distributed among the three different specialty groups. A total of 82% of the respondents were male; 60% of the respondents had practiced more than 15 years, and 6% had practiced 4 years or less. Older physicians prescribed proton pump inhibitors more often than younger physicians for mild or intermittent GERD symptoms. Physicians in an academic setting were more likely to use step-down therapy in patients with well-controlled GERD symptoms than were HMO-employed physicians. Family physicians requested a barium swallow in the evaluation of uncomplicated GERD more frequently than did gastroenterologists or internists. Gastroenterologists were more likely than family physicians and internists to recommend upper endoscopy for GERD patients with warning symptoms and for patients with long-standing reflux disease. CONCLUSIONS: Age, specialty, number of years in practice, and practice setting significantly influence how physicians evaluate and treat patients with GERD. Educational efforts to improve the evaluation and treatment of patients with GERD may require different strategies for different types of healthcare providers.     

Management strategies for gastroesophageal reflux disease

Abstract   In the treatment of gastroesophageal reflux disease (GERD), the most effective treatment option is the use of proton pump inhibitor (PPI), which minimizes the effect of gastric acid on the distal esophagus. Both the step-up and step-down treatment strategies have advantages and disadvantages. Most physicians would like to choose the step-down therapy rather than the step-up therapy. The 'No-step' PPI therapy (i.e. continuous PPI therapy) is another relevant option. After an initial remission, long-term PPI therapy is an appropriate form of maintenance therapy in many patients.
As a treatment plan for non-erosive reflux disease, a standard dose of PPI for 4–8 weeks followed by either the step-down strategy or the on-demand treatment strategy is acceptable. When treating erosive esophagitis, PPI is better than H₂ receptor blockers in healing mucosal breaks and relieving symptoms. Long-term maintenance PPI therapy is reported to be very effective in maintaining the remission of reflux esophagitis for up to 5 years. On-demand PPI is also another good option for a maintenance therapy in erosive esophagitis. In Barrett's esophagus, symptoms seem to be well-controlled with PPIs. Unfortunately, however, PPIs have no effect on the shortening of Barrett's esophagus or in preventing the progression to dysplasia and adenocarcinoma.
In summary, after reviewing existing guidelines a rather simple guideline on the management of GERD is suggested – PPI should be given for 4–8 weeks followed by either on-demand or maintenance PPI therapy according to the clinical severity.     

Long-term outcomes of patients with symptomatic gastroesophageal reflux disease treated with vonoprazan

Objective: The novel potassium-competitive acid blocker, vonoprazan, provides rapid and effective acid suppression. The aim of this study is to evaluate the long-term outcomes of patients with symptomatic gastroesophageal reflux disease (GERD) treated with vonoprazan.

Methods: This retrospective cohort study included 55 patients with symptomatic GERD treated with vonoprazan who have been followed for more than one year. The effectiveness of vonoprazan on gastrointestinal symptoms was evaluated using the Izumo scale, a self-reported questionnaire reflecting quality of life related to various abdominal symptoms.

Results: These 55 patients with symptomatic GERD had non-erosive reflux disease (n?=?30) or erosive esophagitis (n?=?25). Vonoprazan (10?mg) for one month improved GERD symptoms in 89% (responders) and the improvement was maintained at one year in 82% without additional treatment. One-year maintenance therapy resulted in sustained resolution of GERD symptoms in 47%. Of the 49 responders, nine patients had relapse of GERD symptoms and dose escalation of vonoprazan improved the symptoms in six patients. Postprandial distress and the presence of erosive esophagitis before starting vonoprazan were identified as significant negative and positive predictors of sustained resolution of GERD symptoms for one year, respectively. Epigastric pain, postprandial distress, constipation and diarrhea were significantly improved at one-month and maintained at one year. After one-year of treatment, the endoscopic healing rate of erosive esophagitis was 95%.

Conclusion: One-year treatment with vonoprazan significantly improves GERD symptoms and endoscopic healing of erosive esophagitis is satisfactory. The long-term use of vonoprazan is effective and useful to control GERD.     

Daily practice effectiveness of a step-down treatment in comparison with a tight step-up for early rheumatoid arthritis

OBJECTIVE: To study prospectively the daily practice effectiveness of a step-down early rheumatoid arthritis (RA) treatment strategy. METHODS: Patients with severe RA and no contra-indications were proposed step-down therapy, the others step-up. Step-down patients received a modified combination therapy in early RA (COBRA) regimen: sulphasalazine (SPS), 2 g daily, and methotrexate (MTX), 15 mg weekly, combined with step-down oral prednisolone (start 60 mg daily, fast tapering to 7.5 mg over 6 weeks, discontinuation from week 28). At week 40, patients were randomized to maintenance therapy with either SPS or MTX if disease activity score-28 (DAS28) was acceptably low. The step-up group started disease-modifying anti-rheumatic drug (DMARD) monotherapy. In both groups, treatment was adjusted at follow-up, based on DAS28. DAS28, functionality Health Assessment Questionnaire (HAQ), adverse events, DMARD changes and steroid use were registered 4-monthly for 2 yrs. RESULTS: Nineteen patients received step-down and 52 step-up treatment. More patients completed the first year without unplanned DMARD changes and without dosage adjustment and fewer had DMARD changes due to side effects or inefficacy in the step-down group compared with step-up, whereas the number of adverse events was comparable. MTX proved to be the most effective maintenance therapy after step-down. The DAS response, proportion of patients in remission, HAQ response and proportion of patients without disability at 4 months was higher in the step-down group. CONCLUSIONS: In daily practice, a step-down treatment strategy for early RA is more effective than a step-up approach.     

Management of symptoms in step-down therapy of gastroesophageal reflux disease

OBJECTIVE: Majority of studies on gastroesophageal reflux disease (GERD) that include patients with or without erosive disease have documented the efficacy of proton pump inhibitors (PPIs) as well as their superiority to H(2)-receptor antagonist (H(2)-RA). The purpose of this study was to clarify the difference in quality of GERD treatment with PPIs and H(2)-RA in step-down protocol using lansoprazole. METHODS: Forty-three patients with reflux esophagitis were randomly divided into three groups and assessed by severity score; group 1 received 30 mg lansoprazole initially and maintenance therapy with a standard dose H(2)-RA; group 2 received 30 mg of lansoprazole initially and maintenance therapy of 15 mg lansoprazole; and group 3 received 15 mg of lansoprazole once daily for 16 weeks. If the patients experienced symptomatic recurrence while on H(2)-RA, they were switched to PPI maintenance. RESULTS: Heartburn, regurgitation and dysphagia were hardly found in any group at 8 weeks after 15 mg or 30 mg lansoprazole treatment. After 8 weeks, however, heartburn and regurgitation recurred at 50% and 78.6%, respectively, in the stepped down to famotidine group, and quality of life (QOL) was significantly impaired. Endoscopic ultrasonography (EUS) analysis showed reduction of the submucosal layer without any change in the mucosal surface in the stepped down to famotidine group. CONCLUSIONS: Step-down lansoprazole therapy is considered very effective in terms of rapid effect, long-term effect and high quality GERD treatment.     

Insulin therapy in type 2 diabetes is no longer a secondary care activity in the Netherlands

AimBecause Dutch health care organisations did want to establish well-defined diabetes shared care groups, we investigated the organisation of insulin therapy in general practice in the Netherlands and assessed factors that were associated with providing insulin therapy in type 2 diabetes (DM2) patients.MethodsQuestionnaire to half of the Dutch general practitioners (GPs) (n = 3848). We compared GPs who both start insulin treatment and monitor the dosages with those who always refer patients requiring insulin therapy or only monitor insulin dosages.ResultsTotal response was 42% (n = 1621). 67% of the GPs start insulin therapy in patients with DM2, especially male GPs and those above the age of 40, as well as GPs working in a health centre and those working together with a practice nurse. GPs working in urban regions less often start insulin. The most often mentioned barriers for starting and/or monitoring insulin therapy are lack of knowledge of insulin therapy, lack of time and insufficient financial incentives.ConclusionThis nation-wide overview shows that insulin therapy is no longer a secondary care based activity. However, there is still need to enlarge the practice staff and to overcome the perceived skills deficit.     

Doctors' perceptions of the prognostic benefit of statins in patients who have had myocardial infarction

Background: We wished to assess how General Practitioners (GPs) and cardiologists perceive and communicate the benefits of therapy with statins (hydroxymethylglutaryl-coenzyme A reductase inhibitors) in a patient following myocardial infarction.
Methods: We interviewed 20 GPs and 22 cardiologists to determine treatment policy and ways of expressing its benefits to a patient after myocardial infarction with moderate dyslipidaemia. We asked what drug and dosage they would recommend and how they would express potential benefits of therapy, given a range of options including reduced relative and absolute risk of events.
Results: Most GPs would start a low dose (10–20 mg/day) of simvastatin (the only freely prescribable funded statin in New Zealand) whereas cardiologists would commence 40 mg/day immediately ( P  = 0.001). All but one cardiologist would justify therapy to the patient by citing a reduced chance of a major adverse cardiovascular event. Nine GPs and one cardiologist estimated a gain of more than 5 years of life from statin therapy. Cardiologists were more optimistic than GPs about relative risk reduction ( P  = 0.04). Only 50% of GPs and 68% of cardiologists were able to estimate an absolute risk reduction over 5 years, such estimates varying widely with no significant difference in responses between the groups ( P  = 0.2). No doctors felt comfortable using number needed to treat or odds ratio.
Conclusion: There were substantial differences between the two groups of clinicians in perception and policy of statin therapy, frequent overestimation of treatment benefits and a reluctance to impart numerical estimates of benefit to patients.     

Step-down approach using either cyclosporin A or methotrexate as maintenance therapy in early rheumatoid arthritis

OBJECTIVE: To evaluate the feasibility and outcome of the step-down approach using either cyclosporin A (CSA) or methotrexate (MTX) as maintenance therapy following 6 months treatment with these 2 agents in combination in early, nonerosive rheumatoid arthritis (RA). METHODS: Fifty-seven patients younger than 65 years with early, nonerosive RA were first treated with CSA and MTX in combination for 6 months. They were then randomly stepped down to single-agent maintenance treatment for another 18 months. Safety, clinical efficacy, survival on treatment, and radiographic progression were evaluated. RESULTS: When being treated with combination therapy, 7 of the 57 patients (12.3%) withdrew because of adverse events. Of the remaining 50 patients, 42 (84.0%) were American College of Rheumatology (ACR) 20% responders, 30 (60.0%) were ACR 50% responders, and 23 (46.0%) were ACR 70% responders. At month 6, 22 patients were randomized to CSA and 27 to MTX. During this trial period, the treatment was discontinued by 16 patients taking CSA (mainly because of loss of efficacy) and by 4 taking MTX. At month 24, the probability (+/- SEM) of survival on treatment was 0.273 +/- 0.09 for CSA and 0.852 +/- 0.07 for MTX. Of the 6 CSA patients who completed the trial, 4 (66.7%) were ACR 20% responders, and 3 (50%) were both ACR 50% and ACR 70% responders. Of the 23 completers in the MTX arm, 21 (91.3%) were ACR 20% responders, 18 (78.3%) were ACR 50%, and 10 (43.5%) were ACR 70% responders. The treatment was not responsible for severe adverse events. Radiography showed a slow progression in the damage score and number of eroded joints in both treatment groups. CONCLUSION: Stepping down to single agent maintenance therapy following 6 months of combination treatment with CSA and MTX in early RA was only successful with MTX. Because this treatment did not prevent some radiographic progression, other approaches (e.g., step-up approach) may be more appropriate in early RA.     

Systematic review:Laparoscopic fundoplication for gastroesophageal reflux disease in partial responders to proton pump inhibitors

AIM:To assess laparoscopic fundoplication(LF)in partial responders to proton pump inhibitors(PPIs)for gastroesophageal reflux disease(GERD).METHODS:We systematically searched PubMed and Embase(1966-Dec 2011)for articles reporting data on LF efficacy in partial responders.Due to a lack of randomized controlled trials,observational studies were included.Of 558 articles screened,17 were eligible for inclusion.Prevalence data for individual symptoms were collated across studies according to mutually compatible time points(before and/or after LF).Where suitable,prevalence data were presented as percentage of patients reporting symptoms of any frequency or severity.RESULTS:Due to a lack of standardized reporting of symptoms,the proportion of patients experiencing symptoms was recorded across studies where possible.After LF,the proportion of partial responders with heartburn was reduced from 93.1%(5 studies)to 3.8%(5 studies),with similar results observed for regurgitation[from 78.4%(4 studies)to 1.9%(4 studies)].However,10 years after LF,35.8%(2 studies)of partial responders reported heartburn and 29.1%(1 study)reported regurgitation.The proportion using acidsuppressive medication also increased,from 8.8%(4studies)in the year after LF to 18.2%(2 studies)at 10years.In the only study comparing partial responders to PPI therapy with complete responders,higher symptom scores and more frequent acid-suppressive medication use were seen in partial responders after LF.CONCLUSION:GERD symptoms improve after LF,but subsequently recur,and acid-suppressive medication use increases.LF may be less effective in partial responders than in complete responders.     

Palliation by laser photoablation: a multidisciplinary quality assessment.

To evaluate the quality of life and degree of palliation by laser photoablation for gastrointestinal cancer, a questionnaire was sent to general practitioners (GPs) and referring specialists. The response was 85%. General practitioners considered palliation by laser to be effective in 74% compared with 50% for referring specialists (p less than 0.001). Specialists felt themselves unable to answer in 17% compared with no GPs (p less than 0.001). The differences in assessment between specialists and GPs were most pronounced in colorectal cancers. There was a striking consensus of opinion about the rate of failed palliation among endoscopist, referring specialist, and GP. On the other hand, the rating of success by specialists and GPs was significantly lower than the endoscopist's evaluation. The endoscopist and GP were more at variance than the endoscopist and specialist. Above all, the GPs seemed to outweigh the burden against the benefits of treatment. Disagreement of the specialists and the GPs with the endoscopist about the outcome appeared to be related to unrealistic expectations, to a shift in presenting symptoms or to complications, misinterpreted as being laser-induced but mainly due to progression of disease.