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Development of a simple instrument to measure patient satisfaction with flexible sigmoidoscopy
A34
AGA ABSTRACTS
• SALIVARY ESOPHAGOPROTECTION: THE RATIONALE FOR A NEW TREATMENT MODALITY IN PATIENTS WITH REFLUX ESOPHAGITIS. C.J. Scheurieh, J. Sarosiek, M. Marcinkiewicz, M.C. Edmunds, R.W. McCalhim, University of V'wginia Health Sciences Center, Charlottesville, VA. We have recently demonstrated that masticatory stimuli evoked a 70% increase (1)<0.05) in salivary epidermal growth factor (EGF) output in asymptomaiic volunteers (AJG 88:1749-55;1993) and 76% enhancement in patients with reflux es~hagitis (RE) (AJG 89:237-44;1994) over the corresponding values recorded during basal conditions. The impact of masticatory stimuli on other salivary protective components such as mucin, prostaglandin E 2 (PGE2) , proteins, buffeting capacity in putients with various grades of RE remains unknown. Aims: 1) To assess mucin, PGE2, protein, pH and volume of salivary secretion elaborated during basal conditions and during chewing parafllm in patients with Grades II-III RE with and without complications (stricture and Barrett's esophagus) and 2) To compare obtained results with corresponding values recorded in asymptomatic volunteers. Subjects & Methods: The study was conducted in 37 patients with RE (13F, 24M; mean age 48, range 24-79) and 17 asymptomatic volunteers (9F, 8M; mean age of 42, range 22-62). Patients with RE were classified according to endoscopic grade of esophagitis (17 grade II, 6 grade III, 10 grade III& BE, and 4 grade I!I & stricture). Salivary secretion was collected on ice during basal conditions and during fhewing parafilm. The rate of salivation was assessed valnmetrically. The content of mucin by periodic acid/Schiff (PAS) methodology, sPGE 2 was measured by RIA (Amersham, IL), protein was measured by Lowry method, and pH was recorded using IanAnalyzer (Orion, MA). All medication was discontinued for 72 h before the collection procedure. Results are presented as a mean ~SEM. Statistical analysis was performed using SigmaStat soRware for IBM PC. Results: The volume of saliva during chewing parafilm increased by 139% in normal volunteers and by 132% in RE over their corresponding basal values; mucin output increased by 87% and 97%; PGE2 output increased by 49% and 177%; protein output increased by 42% and 71% and pH increased by 0.52 units and 0.43 units in controls and patients with RE respectively. Therefore, the output of all salivary parameters, obtained while chewing parafilm, achieved similar levels in patients with RE and in controls. Moreover, salivary output of all investigated parameters in RE patients was significantly increased from its basal value (I)<0.05). Conclusions: 1) Salivary volume, PGE2, mucin, protein and pH remain under the profound impact of masticatory stimuli both in controls and patients with complicated and non complicated RE. 2) Considering the profound protective potential of salivary secretory components, augmentation of salivary flow by chewing a non-nutrient formulation (e.g. gum) should be recommended as an adjunct to established treatment regimens in patients with non-complicated and complicated reflux esophagitis.
• DEVELOPMENT OF A SIMPLE INSTRUMENT TO MEASURE PATIENT SATISFACTION WITH FLEXIBLE SIGMOIDOSCOPY. R.E. Schoen. J.L. Weissfeld, A. Baum. Division of Gastroenterology, Pittsburgh Cancer Institute, University of Pittsburgh Medical Center, Pittsburgh, PA Flexible sigmoidoscopy is an underutilized cancer screening procedure. One explanation offered is that patients find the procedure uncomfortable and distasteful. AIM: 1) To develop an instrument to assess patient satisfaction with screening sigmoidoscopy, and 2) To assess the long-term attitude of participants in a screening sigmoidoscopy program. METHODS: 71 of the first 87 participants in a new screening sigmoidoscopy program were surveyed several months after their procedure. A 14 item questionnaire included the following domains: convenience and accessibility, staff interpersonal skills, information transfer, physical surroundings, perceived technical competence, and general satisfaction. Responses were coded on a 5 point scale and included negatively and positively worded items. The distributional properties of each item, item intercorrelation, and a factor analysis were performed. RESULTS: Participants were satisfied with their experience. 85:9% strongly agree/agree (SA/A) they would recommend the service to friends, 60.6% SA/A that the procedure was more comfortable than they expected, 91.5% SA/A they would be willing to have another, and 93% SA/A they were satisfied with their care. Factor analysis did not substantiate multi-dimensional structure to patient satisfaction. One 7 item subscale appeared to encompass patient satisfaction, and included the 4 questions above. This subscale had excellent internal consistency (Cronbach's a= .86). Conclusions: 1) Our patients were pleased with their flexible sigmoidoscopy experience 2) The development of a validated instrument to measure satisfaction will assist in assessing sigmoidoscopy performance (e.g., to compare nurse practitioners to M.D.'s, or to compare office to institutional settings) 3) Further testing of this instrument, including assessment of predictive validity, is required
GASTROENTEROLOGY, Vol. 108, No. 4
AN ATTEMPT TO IDENTIFY RISK FACTORS FOR DEVELOPMENT OF ADENOCARCINOMA (ADCA) IN PATIENTS (PTS) WITH BARRETT'S ESOPHAGUS (BE). T.G. Schnell, S,J. Sontag, G. Chejfec, A. Ulasevich, S. Reid, L. Brand, G. Levine, J. Karpf. Depts of Med, GI & Path, VA Hospital, Hines, IL & Loyola University Stritch School of Medicine, Maywood, IL Introduction: Patients with BE currently undergo endoscopic surveillance due to their predisposition for the development of AdCa. Since BE is a common complication of reflux and most patients with BE do not develop AdCa, the identification of risk factors for malignancy would help make surveillance more feasible and might help clarify the pathogenesis of malignant transformation. Toward this end, we attempted to identify risk factors for the development of AdCa in Pts who were known to have BE. Method: BE was defined as the presence on biopsy (Bx) of specialized intestinal mucosa in the esophagus. Esophagitis was defined as the presence of mueosal ulcers or erosion s. Hiatal hernia (HH) was defined as the presence of at least 2 cm of gastric mucosa above the diaphragmatic hiatus. Demographic data were obtained as part o f a pre-endoscopy health status questionnaire. Alcohol and tobacco use were quantitated by ounce-years and pack-years and were further divided into current use, past use or no use. Potential risk factors analyzed included,age, race, smoking and alcohol use, family history o f cancer, family history of colon cancer, presence ofesophagitis, and presence ofHH. A computer assisted step-wise, logistic regression analysis was performed using a 0.15 level of significance for entry. Results: There were 678 Pts with BE without AdCa and 27 Pts with BE and AdCa. 98.5% of patients were male. The mean age (+ std dev) was 6t (+ 11). Of the above risk factors only the presence of esophagitis at initial endoscopy significantly predicted AdCa (p<0.05, odds ratio 3.5 [1~2-10.5 95% CI]). History of ETOH exposure and HH were contributors to the model at the 0.15 level of significance. The concordance index for the model was 0.71. When smoking variables were evaluated alone in a univariate manner, no significance was noted for either current smoking, smoking exposure or total pack-years. Conclusion: In this model, esophagitis on initial exam was a significant predictor of AdCa at the 0.05 level. ETOH exposure and presence of HH were also predictors of AdCa within the model at the 0.15 level. Smoking history was not a risk factor. Further research is needed to determine the significance of these factors and their potential clinical usefulness.
Radiation Exposure in Diagnostic and Therapeutic Endoscopic-Retrograde Cholangiopancreaticography (ERCP). M. Selmaier, W. Stillkrieg*, R. G. M011er*, E. G. Hahn, C. Ell. I. Department of Medicine and * Department of Radiology, University of Erlangen-Nuremberg, Krankenhausstr. 12, 91054 Erlangen, FRG. The increasing expansion of diagnostic and, in particular, o~ therapeutic ERCP calls for greater consideration of the radiation! dose to which the investigator and assistant personal are exposed and emphasizes the question of additional radiation protec~ tion measures such as thyroid protection. Materials and methods: Local radiation doses were measured in 19 ERCP sessions at head level of the endoscopist, assi~ stant staff and the radiologist, respectively. The fluoroscopic time, the area dose product (ADP) and the measuring height were recorded. A quotient based on the measured local dose and the ADP was formed which includes all variables having an effect on the scattered radiation. Using this quotient and the known ADPvalues radiation exposure levels were mapped over a period of three months and then extrapolated to obtain the annual dose. Results: Not only the FT, but also the ADP, the measuring height, and the source-image-distance (SIO) are found to influence the magnitude of the radiation close to which the investigator and his assistants are exposed at head level For an assumed rate of 1200 ERCPs per year a median radiation at head level ot 16,5 mSv/a is calculated for the investigator, and a corresponding head-level dose of 5.5 mSvta for the assistants. This shows that the eye dose to which the investigator (and his assistants) are exposed amounts to 10 % (5 %) and the thyroid dose to 5 % (1.5%) of the legally prescribed limit dose. If fewer ERCP's are performed, or if the investigations are divided up ~tmong several doctors and assistants, radiation exposure is reduced accordingly. Conclusions: Under the prevailing investigation conditions additional radiation protection measures such as leadshielded safety glasses or thyroid protection do not appear necessary.
AGA ABSTRACTS
• SALIVARY ESOPHAGOPROTECTION: THE RATIONALE FOR A NEW TREATMENT MODALITY IN PATIENTS WITH REFLUX ESOPHAGITIS. C.J. Scheurieh, J. Sarosiek, M. Marcinkiewicz, M.C. Edmunds, R.W. McCalhim, University of V'wginia Health Sciences Center, Charlottesville, VA. We have recently demonstrated that masticatory stimuli evoked a 70% increase (1)<0.05) in salivary epidermal growth factor (EGF) output in asymptomaiic volunteers (AJG 88:1749-55;1993) and 76% enhancement in patients with reflux es~hagitis (RE) (AJG 89:237-44;1994) over the corresponding values recorded during basal conditions. The impact of masticatory stimuli on other salivary protective components such as mucin, prostaglandin E 2 (PGE2) , proteins, buffeting capacity in putients with various grades of RE remains unknown. Aims: 1) To assess mucin, PGE2, protein, pH and volume of salivary secretion elaborated during basal conditions and during chewing parafllm in patients with Grades II-III RE with and without complications (stricture and Barrett's esophagus) and 2) To compare obtained results with corresponding values recorded in asymptomatic volunteers. Subjects & Methods: The study was conducted in 37 patients with RE (13F, 24M; mean age 48, range 24-79) and 17 asymptomatic volunteers (9F, 8M; mean age of 42, range 22-62). Patients with RE were classified according to endoscopic grade of esophagitis (17 grade II, 6 grade III, 10 grade III& BE, and 4 grade I!I & stricture). Salivary secretion was collected on ice during basal conditions and during fhewing parafilm. The rate of salivation was assessed valnmetrically. The content of mucin by periodic acid/Schiff (PAS) methodology, sPGE 2 was measured by RIA (Amersham, IL), protein was measured by Lowry method, and pH was recorded using IanAnalyzer (Orion, MA). All medication was discontinued for 72 h before the collection procedure. Results are presented as a mean ~SEM. Statistical analysis was performed using SigmaStat soRware for IBM PC. Results: The volume of saliva during chewing parafilm increased by 139% in normal volunteers and by 132% in RE over their corresponding basal values; mucin output increased by 87% and 97%; PGE2 output increased by 49% and 177%; protein output increased by 42% and 71% and pH increased by 0.52 units and 0.43 units in controls and patients with RE respectively. Therefore, the output of all salivary parameters, obtained while chewing parafilm, achieved similar levels in patients with RE and in controls. Moreover, salivary output of all investigated parameters in RE patients was significantly increased from its basal value (I)<0.05). Conclusions: 1) Salivary volume, PGE2, mucin, protein and pH remain under the profound impact of masticatory stimuli both in controls and patients with complicated and non complicated RE. 2) Considering the profound protective potential of salivary secretory components, augmentation of salivary flow by chewing a non-nutrient formulation (e.g. gum) should be recommended as an adjunct to established treatment regimens in patients with non-complicated and complicated reflux esophagitis.
• DEVELOPMENT OF A SIMPLE INSTRUMENT TO MEASURE PATIENT SATISFACTION WITH FLEXIBLE SIGMOIDOSCOPY. R.E. Schoen. J.L. Weissfeld, A. Baum. Division of Gastroenterology, Pittsburgh Cancer Institute, University of Pittsburgh Medical Center, Pittsburgh, PA Flexible sigmoidoscopy is an underutilized cancer screening procedure. One explanation offered is that patients find the procedure uncomfortable and distasteful. AIM: 1) To develop an instrument to assess patient satisfaction with screening sigmoidoscopy, and 2) To assess the long-term attitude of participants in a screening sigmoidoscopy program. METHODS: 71 of the first 87 participants in a new screening sigmoidoscopy program were surveyed several months after their procedure. A 14 item questionnaire included the following domains: convenience and accessibility, staff interpersonal skills, information transfer, physical surroundings, perceived technical competence, and general satisfaction. Responses were coded on a 5 point scale and included negatively and positively worded items. The distributional properties of each item, item intercorrelation, and a factor analysis were performed. RESULTS: Participants were satisfied with their experience. 85:9% strongly agree/agree (SA/A) they would recommend the service to friends, 60.6% SA/A that the procedure was more comfortable than they expected, 91.5% SA/A they would be willing to have another, and 93% SA/A they were satisfied with their care. Factor analysis did not substantiate multi-dimensional structure to patient satisfaction. One 7 item subscale appeared to encompass patient satisfaction, and included the 4 questions above. This subscale had excellent internal consistency (Cronbach's a= .86). Conclusions: 1) Our patients were pleased with their flexible sigmoidoscopy experience 2) The development of a validated instrument to measure satisfaction will assist in assessing sigmoidoscopy performance (e.g., to compare nurse practitioners to M.D.'s, or to compare office to institutional settings) 3) Further testing of this instrument, including assessment of predictive validity, is required
GASTROENTEROLOGY, Vol. 108, No. 4
AN ATTEMPT TO IDENTIFY RISK FACTORS FOR DEVELOPMENT OF ADENOCARCINOMA (ADCA) IN PATIENTS (PTS) WITH BARRETT'S ESOPHAGUS (BE). T.G. Schnell, S,J. Sontag, G. Chejfec, A. Ulasevich, S. Reid, L. Brand, G. Levine, J. Karpf. Depts of Med, GI & Path, VA Hospital, Hines, IL & Loyola University Stritch School of Medicine, Maywood, IL Introduction: Patients with BE currently undergo endoscopic surveillance due to their predisposition for the development of AdCa. Since BE is a common complication of reflux and most patients with BE do not develop AdCa, the identification of risk factors for malignancy would help make surveillance more feasible and might help clarify the pathogenesis of malignant transformation. Toward this end, we attempted to identify risk factors for the development of AdCa in Pts who were known to have BE. Method: BE was defined as the presence on biopsy (Bx) of specialized intestinal mucosa in the esophagus. Esophagitis was defined as the presence of mueosal ulcers or erosion s. Hiatal hernia (HH) was defined as the presence of at least 2 cm of gastric mucosa above the diaphragmatic hiatus. Demographic data were obtained as part o f a pre-endoscopy health status questionnaire. Alcohol and tobacco use were quantitated by ounce-years and pack-years and were further divided into current use, past use or no use. Potential risk factors analyzed included,age, race, smoking and alcohol use, family history o f cancer, family history of colon cancer, presence ofesophagitis, and presence ofHH. A computer assisted step-wise, logistic regression analysis was performed using a 0.15 level of significance for entry. Results: There were 678 Pts with BE without AdCa and 27 Pts with BE and AdCa. 98.5% of patients were male. The mean age (+ std dev) was 6t (+ 11). Of the above risk factors only the presence of esophagitis at initial endoscopy significantly predicted AdCa (p<0.05, odds ratio 3.5 [1~2-10.5 95% CI]). History of ETOH exposure and HH were contributors to the model at the 0.15 level of significance. The concordance index for the model was 0.71. When smoking variables were evaluated alone in a univariate manner, no significance was noted for either current smoking, smoking exposure or total pack-years. Conclusion: In this model, esophagitis on initial exam was a significant predictor of AdCa at the 0.05 level. ETOH exposure and presence of HH were also predictors of AdCa within the model at the 0.15 level. Smoking history was not a risk factor. Further research is needed to determine the significance of these factors and their potential clinical usefulness.
Radiation Exposure in Diagnostic and Therapeutic Endoscopic-Retrograde Cholangiopancreaticography (ERCP). M. Selmaier, W. Stillkrieg*, R. G. M011er*, E. G. Hahn, C. Ell. I. Department of Medicine and * Department of Radiology, University of Erlangen-Nuremberg, Krankenhausstr. 12, 91054 Erlangen, FRG. The increasing expansion of diagnostic and, in particular, o~ therapeutic ERCP calls for greater consideration of the radiation! dose to which the investigator and assistant personal are exposed and emphasizes the question of additional radiation protec~ tion measures such as thyroid protection. Materials and methods: Local radiation doses were measured in 19 ERCP sessions at head level of the endoscopist, assi~ stant staff and the radiologist, respectively. The fluoroscopic time, the area dose product (ADP) and the measuring height were recorded. A quotient based on the measured local dose and the ADP was formed which includes all variables having an effect on the scattered radiation. Using this quotient and the known ADPvalues radiation exposure levels were mapped over a period of three months and then extrapolated to obtain the annual dose. Results: Not only the FT, but also the ADP, the measuring height, and the source-image-distance (SIO) are found to influence the magnitude of the radiation close to which the investigator and his assistants are exposed at head level For an assumed rate of 1200 ERCPs per year a median radiation at head level ot 16,5 mSv/a is calculated for the investigator, and a corresponding head-level dose of 5.5 mSvta for the assistants. This shows that the eye dose to which the investigator (and his assistants) are exposed amounts to 10 % (5 %) and the thyroid dose to 5 % (1.5%) of the legally prescribed limit dose. If fewer ERCP's are performed, or if the investigations are divided up ~tmong several doctors and assistants, radiation exposure is reduced accordingly. Conclusions: Under the prevailing investigation conditions additional radiation protection measures such as leadshielded safety glasses or thyroid protection do not appear necessary.