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Generalists and specialists in gastroenterology
A20 AGAABSTRACTS • G0079 THE IMPACT OF HOME PARENTERAL NUTRITION ON QUALITY OF LIFE IN SHORT BOWEL PATIENTS. P.B. Jeppesen. E. Langholz, P.B. Mortensen. Department of Medical Gastroenterology CA-2101, Rigshospitalet, University of Copenhagen, Denmark. Aim of the study: The aim of this study was to compare quality of life in a group of patients with severe malabsorption, but who managed without HPN (intestinal insufficiency ~ INS), with a group of patients receiving HPN, using the Inflammatory Bowel Disease Questionnaire 1 (IBDQ) and Sickness Impact Profile 2 (SIP). Methods: All patients included in the study had continuity of care in the Intestinal Failure Unit in Copenhagen, July 1997. The IBDQ and SIP was mailed to 45 patients with INS (defined as a fecal energy loss of more than 2.0 MJ/d, measured by bomb caloriemetry during last submission), and to 57 patients receiving HPN due to benign IF. Written reminders were sent to nonresponders after 2 months and the study was closed for inclusion at 3 months. 39 (87%) patients with INS and 49 (86%) patients receiving HPN returned the questionnaires, but 3 INS patients did not fill out the questionnaires. Results: The two groups did not differ significantly regarding female/male ratio (20/16 and 31/18, respectively) and median age (45 vs. 49 years). Patients receiving HPN had lower BMI than patients with INS (20.8 vs. 22.2 kg/m2, p < 0.05). In HPN patients the remaining small intestine was shorter (140 vs. 200 cm, p < 0.05), the presence of a stoma more predominant (38/49 vs. 17/36, p <0.05), and fecal weight was higher (1.9 vs. 1.2 kg/day, p < 0.05). Mean IBDQ item scores (0-7, 7=best) in patients with intestinal insufficiency (non-HPN) compared with intestinal failure (HPN) patients: Bowel symptoms; 5.6 vs. 5.3 (n.s), Systemic symptoms; 4.9 vs. 4.1", Emotional function; 5.8 vs. 5.3", and Social function; 4.9 vs. 4.2*. MannWhitney Rank Sum Test, *~p < 0.05. Mean SIP dimensions scores (0-100%, 100=best) in patients with intestinal insufficiency (non-HPN) compared with intestinal failure (HPN) patients: Body care and movement; 96 vs. 90", Mobility 94 vs. 83"**, Emotional stability; 90 vs. 82"*, Social interaction 89 vs. 82"**, Communication; 99 vs. 97", Sleep and rest; 88 vs. 79", Home management; 90 vs. 75"**, Recreation/pastimes; 85 vs. 68"**, Eating; 98 vs. 90***, Work (+/-); 44 vs. 14"*. Chi-square, alternative Fisher's exact test, *~p<0.05, **~p<0.01, ***~p < 0.001. Conclusion: Patients receiving home parenteral nutrition in general had lower scores regarding quality of life measured by IBDQ and SIP than non-HPN patients with intestinal insufficiency, although both groups had relatively high scores. HPN and a central line impose restrictions in daily life regarding social and leisure activities and emotional function. Although physical capability is good in HPN-patients their strength and endurance is limited compared to INS patients, which is reflected in the low employment rate and poor house management. HPN patients also experience more pronounced abdominal pain, reduced appetite, increased malabsorption presenting as increased stool volume and poor nutritional status compared to INS patients. These factors add to the restrictions in daily life imposed by HPN and a life with a central line. 1Guyatt G. etal 1989, 2Bergner M. etal. 1981. • G0080 A HELICOBACTER TEST AND TREAT STRATEGY: COSTS AND OUTCOMES IN A RANDOMISED CONTROLLED TRIAL IN PRIMARY CARE. Jones RH, Tait CL, Sladen G, Weston-Baker J, Department of General Practice, UMDS, and Lewisham Hospital Trust, London, UK
Introduction Clinical and health economic modelling suggests that a 'test and treat' strategy for helicobacter pylori (HP) positive patients with dyspepsia may be cost effective, but few data are available on the practical application of this approach. We have conducted a randomised controlled trial in primary care comparing office-based HP serology and eradication therapy in HP positive patients with endoscopic evaluation, in patients presenting with dyspepsia without alarm symptoms. Methods The study was conducted in south-east London, UK and general practices (offices) were randomised to control (endoscopy) or study (HP test and eradication in positives) groups. Patients were followed for one year with respect to clinical, health services and economic outcomes. R_esults We analysed data from 92 control (M:F 56:44, mean age 34 years) and 141 study (M:F 54:46, mean age 33 years) patients. All the control patients underwent endoscopy; in the study patients 7 endoscopies were performed in the HP positive and 10 in the HP negative patients during the follow-up period; no ulcers or cancers were discovered. Although there were more referrals to specialists and more investigations in the study group overall, the costs of treatment were substantially lower in this group. The mean annual cost per patient was £404 in the control (endoscopy) group, compared with £206 in the study group (t=10.75, p < 0.001). This difference was accounted for by a substantial reduction in endoscopy rates; there was no significant difference in the numbers of office visits or in the costs of drug therapy between the groups. Within the study group, the HP positive patients received more gastrointestinal prescriptions and incurred higher prescription costs, but when the costs of HP eradication therapy are excluded, prescription
GASTROENTEROLOGYVol. 114, No. 4 rates were similar. There was no evidence of higher consumption of health care resources by the HP negative patients. There were no serious adverse clinical outcomes in the three groups, although five of the HP positive patients experienced significant antibiotic side effects. Conclusion A Helicobacter pylori test and treat strategy appears to be associated with a significant reduction in the need for endoscopy in the first year, and with very substantially reduced costs compared with an early endoscopy strategy. G0081
GENERALISTS AND SPECIALISTS IN GASTROENTEROLOGY. Jones RH, Department of General Practice, UMDS, London, UK Introduction There is considerable controversy about the roles of generalists and specialists in the care of gastrointestinal (GI) problems. Although there is an increased emphasis in many health care systems on the role of primary care, data also exist to show that, for example, the outcome of care provided by specialists and in major teaching centres is superior to that given by generalists and in non-teaching hospitals. The roles of generalists (general practitioners) and specialists (gastroenterologists) in the United Kingdom (UK) are clearer; each group has distinctive roles and tasks, and employs distinctive and appropriate decision-making and management strategies. Methods A detailed literature review of the functions of GPs and gastroenterologists in the UK was undertaken, and information pertinent to medical-decision making, diagnostic methods, the use of health services resources and relationships between specialists was collated and analysed. Results It is clear that generalists and specialists in the UK have functions in the health service which are to a large extent complementary rather than conflictual. The role of the generalist is to marginalise danger, while that of the specialist is to marginalise uncertainty. Generalists use time and a background psycho-social knowledge of their patients as both diagnostic and therapeutic tools, whilst specialists are constrained to make relatively rapid, yet accurate diagnoses, and use more investigations and health services resources to do so. When confronted by similar clinical problems, generalists tend to employ more cost-effective investigative and therapeutic strategies. Finally, the gatekeeper role of generalists in the UK is regarded as a benign function, and not a caredenying one. Conclusion An understanding of the ways in which generalists and specialists function, particularly in relation to the provision of primary and secondary care, may help to clarify their roles in the management of gastrointestinal problems. • G0082 INSULIN RESISTANCE; A RISK FACTOR FOR GALLSTONES? T. J0rgensen, K. Borch-Johnsen. Centre of Preventive Medicine, Copenhagen, Denmark.
An association between diabetes and gallstone disease has been shown in several studies. The purpose of this study was to evaluate the association between gallstones and plasma glucose and insulin. Methods: In a crosssectional study of an unselected population (N=2,500) gallstone prevalence was assessed by ultrasonography. Relevant risk factors to gallstones were recorded. Of the invited persons 1,777 (71%) participated. In a "case control nested in cohort" design all persons with gallstone disease and randomly age-and sex matched controls without gallstone disease were examined by a glucose tolerance test and plasma insulin during fasting and 30 minutes after oral glucose. Ratio between plasma glucose and insulin was used as a simple estimate of insulin resistance. In all 129 persons with gallstones and 170 persons without gallstones were included. Results: No association between glucose impairment and gallstones were seen. Plasma insulin 30 minutes after oral glucose and increase in plasma insulin was significantly associated with gallstone disease (OR=1.16;95%c.1.:1.07-1.26 and OR=1.17;95%c.1.:1.07-1.26, respectively). Plasma glucose/plasma insulin ratio showed a significant inverse association with gallstones, both for fasting values (0R=0.62;95%c. 1.:0.42-0.92) and 30 minutes after oral glucose (OR=0.41; 95% c.1.:0.24-0.70). All OR were estimated by a logistic regression analysis taking relevant risk factors to gallstones into account. Conclusion: Gallstone disease seems to be associated with elevated plasma insulin and insulin resistance, which could explain the associations between gallstones disease, adipositas, NIDDM, and atherosclerosis. G0083 A RANDOMIZED TRIAL OF PROPOFOL AND MIDAZOLAM FOR SEDATION IN UPPER GI-ENDOSCOPY. M. Jung, C. Hofmann. A: Brackertz, Department of Internal Medicine and Anesthesiology, St. Hildegardis-Krankenhaus Mainz, Germany
Propofol and Midazolam are used for conscious sedation in diagnostic and therapeutic endoscopy. Both drugs produce sedation and amnesia, but have different recovery times. We performed a prospective randomized study in patients undergoing diagnostic/therapeutic esophago-gastro-duodenoscopy (EGD) with special regard to the recovery period. Patients and Methods: Two groups were randomly assigned to receive sedation either by propofol (n = 30) or midazolam (n = 30). Propofol was given as a bolus of 1-3 mg/kg followed by continuous infusion of 4-8 mg/kg/h. Midazolam was administered at variable doses from 0.02 - 0.18
Introduction Clinical and health economic modelling suggests that a 'test and treat' strategy for helicobacter pylori (HP) positive patients with dyspepsia may be cost effective, but few data are available on the practical application of this approach. We have conducted a randomised controlled trial in primary care comparing office-based HP serology and eradication therapy in HP positive patients with endoscopic evaluation, in patients presenting with dyspepsia without alarm symptoms. Methods The study was conducted in south-east London, UK and general practices (offices) were randomised to control (endoscopy) or study (HP test and eradication in positives) groups. Patients were followed for one year with respect to clinical, health services and economic outcomes. R_esults We analysed data from 92 control (M:F 56:44, mean age 34 years) and 141 study (M:F 54:46, mean age 33 years) patients. All the control patients underwent endoscopy; in the study patients 7 endoscopies were performed in the HP positive and 10 in the HP negative patients during the follow-up period; no ulcers or cancers were discovered. Although there were more referrals to specialists and more investigations in the study group overall, the costs of treatment were substantially lower in this group. The mean annual cost per patient was £404 in the control (endoscopy) group, compared with £206 in the study group (t=10.75, p < 0.001). This difference was accounted for by a substantial reduction in endoscopy rates; there was no significant difference in the numbers of office visits or in the costs of drug therapy between the groups. Within the study group, the HP positive patients received more gastrointestinal prescriptions and incurred higher prescription costs, but when the costs of HP eradication therapy are excluded, prescription
GASTROENTEROLOGYVol. 114, No. 4 rates were similar. There was no evidence of higher consumption of health care resources by the HP negative patients. There were no serious adverse clinical outcomes in the three groups, although five of the HP positive patients experienced significant antibiotic side effects. Conclusion A Helicobacter pylori test and treat strategy appears to be associated with a significant reduction in the need for endoscopy in the first year, and with very substantially reduced costs compared with an early endoscopy strategy. G0081
GENERALISTS AND SPECIALISTS IN GASTROENTEROLOGY. Jones RH, Department of General Practice, UMDS, London, UK Introduction There is considerable controversy about the roles of generalists and specialists in the care of gastrointestinal (GI) problems. Although there is an increased emphasis in many health care systems on the role of primary care, data also exist to show that, for example, the outcome of care provided by specialists and in major teaching centres is superior to that given by generalists and in non-teaching hospitals. The roles of generalists (general practitioners) and specialists (gastroenterologists) in the United Kingdom (UK) are clearer; each group has distinctive roles and tasks, and employs distinctive and appropriate decision-making and management strategies. Methods A detailed literature review of the functions of GPs and gastroenterologists in the UK was undertaken, and information pertinent to medical-decision making, diagnostic methods, the use of health services resources and relationships between specialists was collated and analysed. Results It is clear that generalists and specialists in the UK have functions in the health service which are to a large extent complementary rather than conflictual. The role of the generalist is to marginalise danger, while that of the specialist is to marginalise uncertainty. Generalists use time and a background psycho-social knowledge of their patients as both diagnostic and therapeutic tools, whilst specialists are constrained to make relatively rapid, yet accurate diagnoses, and use more investigations and health services resources to do so. When confronted by similar clinical problems, generalists tend to employ more cost-effective investigative and therapeutic strategies. Finally, the gatekeeper role of generalists in the UK is regarded as a benign function, and not a caredenying one. Conclusion An understanding of the ways in which generalists and specialists function, particularly in relation to the provision of primary and secondary care, may help to clarify their roles in the management of gastrointestinal problems. • G0082 INSULIN RESISTANCE; A RISK FACTOR FOR GALLSTONES? T. J0rgensen, K. Borch-Johnsen. Centre of Preventive Medicine, Copenhagen, Denmark.
An association between diabetes and gallstone disease has been shown in several studies. The purpose of this study was to evaluate the association between gallstones and plasma glucose and insulin. Methods: In a crosssectional study of an unselected population (N=2,500) gallstone prevalence was assessed by ultrasonography. Relevant risk factors to gallstones were recorded. Of the invited persons 1,777 (71%) participated. In a "case control nested in cohort" design all persons with gallstone disease and randomly age-and sex matched controls without gallstone disease were examined by a glucose tolerance test and plasma insulin during fasting and 30 minutes after oral glucose. Ratio between plasma glucose and insulin was used as a simple estimate of insulin resistance. In all 129 persons with gallstones and 170 persons without gallstones were included. Results: No association between glucose impairment and gallstones were seen. Plasma insulin 30 minutes after oral glucose and increase in plasma insulin was significantly associated with gallstone disease (OR=1.16;95%c.1.:1.07-1.26 and OR=1.17;95%c.1.:1.07-1.26, respectively). Plasma glucose/plasma insulin ratio showed a significant inverse association with gallstones, both for fasting values (0R=0.62;95%c. 1.:0.42-0.92) and 30 minutes after oral glucose (OR=0.41; 95% c.1.:0.24-0.70). All OR were estimated by a logistic regression analysis taking relevant risk factors to gallstones into account. Conclusion: Gallstone disease seems to be associated with elevated plasma insulin and insulin resistance, which could explain the associations between gallstones disease, adipositas, NIDDM, and atherosclerosis. G0083 A RANDOMIZED TRIAL OF PROPOFOL AND MIDAZOLAM FOR SEDATION IN UPPER GI-ENDOSCOPY. M. Jung, C. Hofmann. A: Brackertz, Department of Internal Medicine and Anesthesiology, St. Hildegardis-Krankenhaus Mainz, Germany
Propofol and Midazolam are used for conscious sedation in diagnostic and therapeutic endoscopy. Both drugs produce sedation and amnesia, but have different recovery times. We performed a prospective randomized study in patients undergoing diagnostic/therapeutic esophago-gastro-duodenoscopy (EGD) with special regard to the recovery period. Patients and Methods: Two groups were randomly assigned to receive sedation either by propofol (n = 30) or midazolam (n = 30). Propofol was given as a bolus of 1-3 mg/kg followed by continuous infusion of 4-8 mg/kg/h. Midazolam was administered at variable doses from 0.02 - 0.18