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Capsule endoscopy (CE) and deep enteroscopy (DE) can be useful for diagnosing and treating suspected small-bowel disease. Guidelines and detailed recommendations exist for the use of CE/DE, but comprehensive quality indicators are lacking. The goal of this task force was to develop quality indicators for appropriate use of CE/DE by using a modified RAND/UCLA Appropriateness Method.An expert panel of 7 gastroenterologists with diverse practice experience was assembled to identify quality indicators. A literature review was conducted to develop a list of proposed quality indicators applicable to preprocedure, intraprocedure, and postprocedure periods. The panelists reviewed the literature; identified and modified proposed quality indicators; rated them on the basis of scientific evidence, validity, and necessity; and determined proposed performance targets. Agreement and consensus with the proposed indicators were verified using the RAND/UCLA Appropriateness Method.The voting procedure to prioritize metrics emphasized selecting measures to improve quality and overall patient care. Panelists rated indicators on the perceived appropriateness and necessity for clinical practice. After voting and discussion, 2 quality indicators ranked as inappropriate or uncertain were excluded. Each quality indicator was categorized by measure type, performance target, and summary of evidence. The task force identified 13 quality indicators for CE and DE.Comprehensive quality indicators have not existed for CE or DE. The task force identified quality indicators that can be incorporated into clinical practice. The panel also addressed existing knowledge gaps and posed research questions to better inform future research and quality guidelines for these procedures.

Since 2001, one intravenous proton pump inhibitor (pantoprazole) has been available in the United States. A drug shortage bulletin was issued for this agent in 2003.To evaluate the patterns of use of intravenous proton pump inhibitors (IV PPIs) in routine clinical practice.Prospective evaluation of IV PPI use in two community-based teaching hospitals. A computerized pharmacy ordering system was used to identify all patients for whom an IV PPI was ordered. Trained investigators obtained clinical data from patient records and these data were mapped to establish clinical criteria for the use of IV PPIs.Intravenous PPIs were prescribed in 238 patients over a 30-day period and a total of 1,631 doses were prescribed. Primary care providers prescribed 46% of prescriptions. Fifty-six percent of patients who received IV PPIs had no acceptable indication for their use. Of the 126 (81%) patients who were started on PPIs for the first time during their hospital stay, 102 were discharged on a PPI.Intravenous PPIs are widely used for poor indications, which may contribute to the shortage of these agents.

AIM: Little is known about the Impact of widespread proton pump inhibitor use on the need for dilation of esophageal strictures. To determine the time trends for upper endoscopy and stricture dilation before and after theavailability of proton pump inhibitors. METHODS: The computerized databases of two large community hospitals were analyzed. Annual data on dilation procedures (by all methods) and upper endoscopy were obtained and analyzed in quartiles from 1986 to 2001 to determine if the relative or absolute need for dilation changed following the introduction of proton pump inhibitors in the United States. The number of prescriptions for acid suppressive agents (H2 receptor antagonists and proton pump inhibitors) for the corresponding time period was obtained from the IMS health database. RESULTS: A total of 57,496 upper GI endoscopies and 2,868 esophageal dilations were performed. The proportion of patients undergoing esophageal dilation increased from 4% in 1986-1989 to 6% in 1990-1993 (p < 0.001), remained unchanged (5.8%) in the period from 1994 to 1997 but declined significantly to 3.9% (p < 0.001) in the next quartile (1998-2001). Absolute numbers of dilation procedures declined significantly in the last quartile (1998-2001) and the proton pump inhibitor prescriptions in the United States increased markedly from 1995 onward. CONCLUSIONS: The need for stricture dilation peaked in 1994 and has declined thereafter, corresponding to an increase in the use of proton pump inhibitors. The widespread use of proton pump inhibitors has not, however, abolished the need for esophageal dilation.

Purpose: Patients with obstructive sleep apnea have significant reductions in the quality of their life due to the poor quality of sleep. We have shown previously that GERD may increase nocturnal arousal in some patients causing fragmentation of sleep. The aim of this study was to determine the effect of GERD on sleep related quality of life in patients with obstructive sleep apnea.

Epidemiological data suggest that irritable bowel syndrome (IBS) is a common functional GI disorder with a prevalence of about 10% in North America. Constipation-predominant IBS accounts for at least half of this with a significant female preponderance. Novick et al. have conducted a multicenter randomized, double-blind, placebo-controlled trial of a new 5-hydroxytrypatmine-4 partial agonist, tegaserod in treatment of women with constipation-predominant IBS in the United States. After a 4-wk baseline period, patients were randomized (1:1) to either receive tegaserod 6 mg b.i.d. or a matched placebo for 12 wk. This was followed by a 4-wk open withdrawal period during which they received no study medication. Safety and efficacy were monitored by daily and weekly subjective assessment of symptoms by telephone and monthly visits. A total of 3177 female patients were screened and enrolled, of whom 1519 were randomized (752: placebo, 767: tegaserod) at the end of the baseline period. These were predominantly white, and both groups were similar except for laxative use, which was higher in the tegaserod group (15% vs 11% for placebo, p < 0.05). Also, 93% of the enrolled subjects fulfilled the Rome II criteria. During the 12-wk treatment period, 20.6% in the tegaserod group and 21.4% in the placebo group discontinued treatment, thus, 1401 subjects continued into the withdrawal period. The primary end point of the study was the measurement of the subject's global assessment of relief (SGA). The other efficacy variables were abdominal pain/discomfort, bowel habits, and bloating. Responders were those who were "completely relieved" or "considerably relieved" for at least 50% of the week at the end point or "somewhat relieved" for 100% of the week. The study was powered at 90% to detect a treatment difference of 8% assuming a 33% placebo response to SGA. The efficacy was calculated using the intention-to-treat analysis of all patients randomized into the study. Numbers needed to treat for treatment response and numbers needed to harm for treatment discontinuation for side effects were also calculated at monthly intervals. SGA of relief was higher in the tegaserod group (43.5% vs 38.8%, p < 0.033 when adjusted for laxative use as nonresponders) and (48.3% vs 41.7%, p < 0.009 without adjustment for laxative use). The monthly response rates for tegaserod were better than placebo (40.5% vs 26.2%, p < 0.001 at month 1; 47.2% vs 39.6%, p = 0.006 at month 2; 53% vs 47.1%, p = 0.026 at month 3). The numbers needed to treat (95% CIs) steadily increased from 7.0 (5.3-10.4) at month 1; 13.3 (7.8-45.7) at month 2; 17.1 (8.8 - 387.2) at month 3. Secondary variables including the SGAs of abdominal pain/discomfort and the satisfaction of bowel habits were statistically significant for the tegaserod group over the 3-month period. Other variables measured included bloating scores, stool consistency score, and number of days with straining. The Tegaserod group had a statistically significant improvement in these parameters as well over a 12-wk period. During the withdrawal period, there was a loss of effect noted, which was more in the tegaserod group. Patients did not return to the baseline at the end of the 4 wk. Safety and tolerability data showed that headache, nausea, and diarrhea were more common in the tegaserod group. Diarrhea was seen in 6.4%. None had severe symptoms. The number needed to discontinue because of diarrhea was 62.5.

Inter and intra observer variability in measurement of Barrett's esophagus: validity of endoscopic measurement of Barrett's regression