[Conservative Therapy of Reflux Disease and its Limits]

Gastrooesophageal reflux disease (GORD) is common. Proton pump inhibitors (PPI) are regarded as first line therapy for all clinical manifestations. However, their efficacy is inadequate for at least 30% of patients and they are occasionally poorly tolerated. Moreover, some patients would prefer an alternative therapy. Alginate cause mechanical reflux inhibition by forming a gelatinous layer in the so-called acid pocket, an acid reservoir that forms on the surface of the chyme in the gastric corpus immediately after food intake. They may be used an alternative to treat the symptoms of uncomplicated GORD and as an add-on to PPIs if these do not improve symptoms adequately. If the reflux symptoms persist or if reflux oesophagitis does not heal, differentiated diagnostic testing must be performed, using endoscopy and functional analysis. Extraoesophageal manifestations of GORD include cough, compulsive clearing of the throat, problems with the voice and globus sensation. These often do not respond to antireflux therapy. Recent data indicate that these are complex hypersensitivity syndromes and that reflux is only one of several possible triggers.

Work satisfaction and risk of burnout for endoscopy staff in Germany: Results of a nationwide survey

BACKGROUND

 Healthcare workers are facing ever-increasing challenges. Moreover, in many areas, there is a shortage of skilled personnel, so endoscopy staff are also increasingly exposed to the risk of developing burnout symptoms. Little is known about job satisfaction and burnout prevalence among endoscopy staff. The present study investigates the risk of burnout as well as job satisfaction among skilled personnel in German endoscopy units and practices.

METHODS

 An online survey was conducted among endoscopy staff, a significant proportion of whom are members of Deutsche Gesellschaft für Endoskopiefachberufe e. V. (DEGEA). In addition to general demographic variables, job satisfaction was determined by using the Short Questionnaire for the Assessment of General and Facet-Specific Job Satisfaction (KAFA), and the risk of burnout was determined by using the Maslach Burnout Inventory (MBI-D). Both were associated with structural characteristics.

RESULTS

 A representative sample took part in the survey (n = 674). The overall level of job satisfaction was high, with a rather elevated risk of burnout, although staff in executive positions performed better overall. Collegiality and mostly flat hierarchies are cited by the majority of those surveyed as positive aspects of their work. Nevertheless, 65 % describe their development opportunities as not performance-oriented, 20 % as virtually non-existent. Over 30 % of those surveyed consider their remuneration to be inadequate.

CONCLUSION

 Representative data for the situation in German endoscopy units could be collected. Despite the fact that on average job satisfaction values are high, with a low risk of burnout, especially in comparison with other occupational groups, often mentioned critical aspects regarding the lack of development opportunities and non-performance-related payment should be taken seriously, and measures should be developed to avoid endangering endoscopy care in the long term.

Proton pump inhibitor use is associated with a variety of infections in patients with liver cirrhosis

There is evidence that intake of proton pump inhibitors (PPI) increases the risk for spontaneous bacterial peritonitis (SBP) in patients with liver cirrhosis. However, data regarding the impact of PPI intake on occurrence of infections other than SBP are still lacking.We hypothesized that PPI use is associated with a higher rate of infections other than SBP in patients with liver cirrhosis.The current case-control study sample included patients with liver cirrhosis from the Disease Analyzer database (IQVIA), which compiles data such as risk factors, drug prescriptions and diagnoses obtained from general practitioners and specialists in Germany. In total, 2,823 patients with infections were matched with 2,823 patients without infections by propensity scores. For quantification of PPI use the prescribed quantity of PPI during the past 12 months before index date was analyzed.Frequency of PPI users was significantly higher in patients with infections than in patients without infections (47.9% vs 37.9%). In regression analysis, PPI use was significantly associated with the occurrence of infections overall (OR 1.55, 95% CI 1.39-1.72, P < .001), and associated with the occurrence of lower respiratory tract infections, urinary tract infections and infectious gastroenteritis. There was no association between PPI use and skin infections. Pantoprazole and omeprazole were the most frequently prescribed PPIs and were both independently associated with the occurrence of infections.PPI use may be associated with infections other than SBP in patients with liver cirrhosis. Prescription of PPI should be limited to patients with a clear indication.

Impact of non-selective ß-blockers on hepatic encephalopathy in patients with liver cirrhosis

BACKGROUND

Non-selective β-blockers (NSBB) are frequently used for the treatment of portal hypertension and gastroesophageal varices in patients with liver cirrhosis; however prospective studies investigating the potential association between NSBB use and hepatic encephalopathy (HE) are still scarce. We investigated the potential association between NSBB use and the presence of covert HE (CHE) as well as the development of overt HE (OHE).

METHODS

224 patients with liver cirrhosis were included into this cohort study at two German centers and followed for a median of 364 days. CHE was diagnosed by pathological results in the PHES. Predictors for the presence of CHE or the development of OHE were analyzed using logistic-regression or cox-regression models.

RESULTS

39% of patients were treated with NSBB and CHE was detected in 34% of patients at study inclusion. In logistic regression analysis, NSBB use, higher MELD score and a history of OHE were independently associated with the presence of CHE. Cumulative incidence of OHE was considerably higher in NSBB users than in non-users (p<0.001). In Cox-regression models NSBB use, presence of CHE, lower albumin and higher MELD score were independently associated with the development of OHE in the whole cohort as well as in the subgroup of patients with decompensated liver cirrhosis. NSBB use was independently associated with higher risk of mortality or need for liver transplantation in decompensated patients but not in the total cohort.

CONCLUSION

NSBB use seems to be associated with the presence of CHE as well as the development of OHE in patients with decompensated liver cirrhosis.

[Therapeutic management of irritable bowel syndrome in the family doctor's practice - probiotics and phytotherapeutics are often used successfully]

BACKGROUND

Irritable bowel syndrome (RDS) is one of the most common functional disorders of the gastrointestinal tract in primary care. As pathophysiology is still insufficiently understood and there is no causal therapeutic approach, therapy is still a challenge in daily practice.

METHOD

As part of a nationwide survey in written form, primary care physicians (general practitioners and internists) were contacted by postal service and asked to complete a questionnaire on RDS. The focus was on the therapeutic management of RDS patients and personal experience with the various drug therapy options.

RESULTS

A total of 487 doctors from all federal states participated in this survey. According to the doctors, more than 70% of RDS patients present with multiple symptoms and report a severe to very severe reduction in quality of life (78%). Doctors considered stress (76%), a change in the intestinal microbiome (56%), poor nutrition (35%) and visceral hypersensitivity (26%) to be the main causes of RDS. The drugs most commonly recommended by the specialist were antispasmodics (44%), phytotherapeutics (38%) and probiotics (37%). In contrast, only 54% of the GPs surveyed were satisfied with the success of spasmolytic therapy, but 75% were satisfied with phytotherapeutic agents and probiotics. More than 60% of the respondents were dissatisfied with tricyclic antidepressants. The high consultation intensity (72%) and expectations of the patients (73%) as well as their changing symptoms (49%) were identified by the doctors as the greatest challenges in daily practice.

CONCLUSION

Probiotics and phytotherapeutics are often a successful option for treating patients with irritable bowel syndrome in primary care.

Work satisfaction and burnout risk of gastroenterologists in Germany: results of a nationwide survey

Background More and more gastroenterologists are not satisfied with their working conditions and run the risk of developing burnout symptoms. Little is known about the job satisfaction and burnout risk among physicians working in endoscopy units in Germany. This study examines the risk of burnout and job satisfaction among gastroenterologists in Germany.

Methods An electronic survey was distributed to gastroenterologists organized mainly in the Federal Organization of Gastroenterology in Germany (BVGD, Berufsverband Gastroenterologie Deutschland e. V.). In addition to general demographic variables, job satisfaction was determined using the Work Satisfaction Questionnaires (WSQ), and burnout risk was determined using the Maslach Burnout Inventory (MBI).

Results A representative sample of gastroenterologists organized in the BVGD (Berufsverband Gastroenterologie Deutschland e. V.) took part in the study (n = 683, 22 %). Above all, we could demonstrate relevant differences with regard to burnout risk and job satisfaction depending on the place of work, clinic structure, position in the clinic, and age. Younger physicians had significantly higher depersonalization (p < 0.001) and exhaustion scores (p < 0.001) with almost medium and small effect sizes (δt = 0.45 and −0.31). The higher the position in the clinic, the higher the accomplishment scores (medium effect size 0.27). Older physicians were especially more satisfied in the areas of patient care (p < 0.001, medium effect size δt = −0.53). Employed doctors show a higher level of satisfaction in terms of “burden” compared to practice owners (p < 0.001, δt = −0.69). Compared to norms used in the EGPRN study which were adapted to physicians, almost one-third of our sample had high depersonalization scores, about 17 % had high exhaustion scores, and about half had low personal accomplishment scores showing a higher general burden among German gastroenterologists.

Conclusion Decreased work satisfaction and risk of burnout are important issues among German gastroenterologists. Specific actions should address this problem in order to avoid negative consequences, respectively.

Management of hepatic encephalopathy in Germany: a survey among physicians

BACKGROUND

 Hepatic encephalopathy (HE) is a severe complication of liver cirrhosis with impairment of quality of life and prognosis. Management patterns among physicians have not been investigated yet.

METHODS

 A questionnaire containing 17 questions was sent out to 1468 gastroenterologists and 120 general practitioners (GPs). It included questions regarding diagnostic, therapeutic, and management strategies used in patients with overt HE (OHE) and covert HE (CHE).

RESULTS

 The response rate was 12 % (n = 172) for gastroenterologists and 45 % (n = 54) for GPs. Of gastroenterologists, 26.7 % examine patients with an initial diagnosis of liver cirrhosis regarding HE. Gastroenterologists favored a combination of different testing strategies (27.9 %) and clinical examination (23.0 %), while the biggest part of the GPs use clinical examination (55.3 %); 63.7 % of gastroenterologists and 28.3 % of GPs give correct nutritional advices to patients with HE. Treatment strategies for acute bouts of OHE and secondary prophylaxis varied widely in both groups. Preferred medication was lactulose followed by rifaximin or a combination therapy. More than half of the GPs (53.7 %) were not familiar with minimal HE (MHE). About one-third of both groups never tried to diagnose MHE.

CONCLUSION

 Our data strongly indicate that management of HE is very heterogeneous among gastroenterologists as well as selected GPs working in Germany and not driven by evidence-based international guidelines. Thus, the national guideline is more than welcome.

Mortalität und ökonomische Auswirkungen der hepatischen Enzephalopathie bei Leberzirrhose in deutschen Krankenhäusern auf der Basis von G-DRG-Kostendaten

Einleitung Die hepatische Enzephalopathie (HE) ist eine häufige Komplikation der Leberzirrhose, die für betroffene Patienten mit vielfältigen negativen Auswirkungen im Alltag verbunden ist. Die Prävalenz klinisch manifester Stadien wird auf 30–45 % geschätzt. Ungeachtet ihrer klinischen und prognostischen Bedeutung gilt die HE als unterdiagnostiziert.

Methoden Ziele der Studie waren neben der systematischen Analyse der Krankenhausletalität der HE erstmals eine Untersuchung der ökonomischen Auswirkungen und der Vergütungssituation einer HE bei Leberzirrhose in Deutschland. Für die retrospektive Studie standen die anonymisierten Fall- und Kostendaten (§ 21 Abs. 4 KHEntgG) von 74 Krankenhäusern des DRG-Projekts der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) aus den Jahren 2011 bis 2015 zur Verfügung. Außerdem wurden diese Ergebnisse mit denen aller deutschen Krankenhäuser auf der Basis der Falldaten des Statistischen Bundesamtes (Destatis, Wiesbaden) verglichen.

Ergebnisse In den Häusern des DRG-Projekts der DGVS wurden 59 093 Behandlungsfälle mit Leberzirrhose erfasst, bei denen in 14,6 % eine HE kodiert war. Die Krankenhausletalität von Zirrhose-Patienten mit HE war gegenüber derjenigen von Patienten ohne HE nahezu dreifach erhöht (20,9 versus 7,7 %). Die Zahl der Behandlungsfälle mit Leberzirrhose ebenso wie der Anteil von Patienten mit HE stieg kontinuierlich über den Erfassungszeitraum an. Im Gegensatz zu Patienten mit Zirrhose allgemein ist die Behandlung von Patienten mit HE nicht kostendeckend (Unterdeckung bis zu 634 € bei HE Grad 4).

Diskussion Die Letalität war bei Patienten mit Zirrhose dreifach erhöht, wenn gleichzeitig eine HE diagnostiziert wurde. In den am DGVS-DRG-Projekt teilnehmenden Häusern wurde die HE um 2 % häufiger erfasst als im Rest der Kalkulationshäuser, was entweder in einer höheren Fallschwere oder in einer besseren Kodierqualität begründet ist. Gegenwärtig ist die Behandlung der HE bei Zirrhose nicht kostendeckend im DRG-System.

Robotic-Assisted Nissen Fundoplication with the Senhance® Surgical System: Technical Aspects and Early Results

INTRODUCTION

Robotic-assisted surgery continues to evolve. Technical advantages are reported for intracorporal suturing, a technique with a long learning curve in conventional laparoscopy. The success of laparoscopic fundoplication relies on precise suturing at the hiatus and of the fundal wrap. Therefore, robotic assistance can be a useful tool for this particular procedure. In March 2017, the Senhance® Surgical System (Transenterix, Inc., Morrisville, North Carolina) was introduced into robotic-assisted procedures at the St. Marien-Krankenhaus, Siegen, Germany.

MATERIALS AND METHODS

Between March 2017 and July 2019, we performed 36 surgeries of the upper GI tract with the Senhance® Surgical System. Eighteen patients underwent the classic Nissen fundoplication and are the subject of this study. All patients gave informed consent for robotic assistance with prospective data acquisition and analysis.

RESULTS

Seven male and 11 female patients were included in the study. The median age of the cohort was 58.5 years (range 30-81 years) and the median body mass index (BMI) was 30.4 kg/m2 (range 22.7-40.1 kg/m2). The median total operative time was 95.5 minutes (range 68-194 minutes) and, despite the small sample size, we observed a significant learning curve throughout the study period (p<0.05). Before the introduction of the Senhance® Ultrasonic energy device, conversion to laparoscopic fundoplication was necessary in two patients. We performed one re-do laparoscopy on the day of surgery due to pain without any significant intraoperative findings and one laparoscopic revision to Toupet fundoplication after seven months due to dysphagia.

CONCLUSION

This first report of robotic-assisted Nissen fundoplication with the Senhance® Surgical System demonstrates technical feasibility. After successful introduction of the Senhance® Ultrasonic, our conversion rate to standard laparoscopic surgery was significantly reduced.

Raised serum Interleukin-6 identifies patients with liver cirrhosis at high risk for overt hepatic encephalopathy

BACKGROUND

Systemic inflammation is a driving force for the development of hepatic encephalopathy and recent studies demonstrated that elevated Interleukin-6 (IL-6) serum levels are associated with the presence of minimal hepatic encephalopathy in patients with liver cirrhosis.

AIM

To test the hypothesis that IL-6 is a suitable marker to identify patients with liver cirrhosis at high risk for the development of overt hepatic encephalopathy.

METHODS

201 patients were included into this prospective cohort study and were followed for a mean time of 322 days. Covert hepatic encephalopathy was diagnosed according to the West-Haven criteria (hepatic encephalopathy grade 1) and with the portosystemic encephalopathy (PSE) test.

RESULTS

The cumulative incidence of overt hepatic encephalopathy was higher in patients with IL-6 levels above the median of 9 pg/mL than in patients with IL-6 levels at or below the median (35.6% vs 1.9%, P < .001). After adjustment for covert hepatic encephalopathy, history of overt hepatic encephalopathy, C-reactive protein (CRP) and model for end-stage liver disease (MELD), IL-6 levels above the median remained independently associated with the development of overt hepatic encephalopathy. The predictive performance of IL-6 regarding the development of overt hepatic encephalopathy during the next 180 days (AUROC, 0.931) was numerically higher than that of MELD (AUROC, 0.841) or CRP (AUROC, 0.835). In patients without prior overt hepatic encephalopathy, the predictive performance of IL-6 (AUROC, 0.966) was even significantly higher than that of MELD (AUROC 0.843) or CRP (AUROC 0.850). The ideal cut-off for IL-6 in this setting was 23.5 pg/mL with a sensitivity and specificity of 89.3% and 89.5% respectively.

CONCLUSION

IL-6 serum levels are closely linked to the development of overt hepatic encephalopathy in patients with liver cirrhosis.

[Assessment of the occupational perspectives of general practitioners in a rural area. Results from the study HaMedSi (Hausärzte [GPs] for Medical education in Siegen-Wittgenstein)]

BACKGROUND

Shortage of general practitioners (GPs), especially in rural areas, is an increasing problem for the German healthcare system. Different approaches are pursued to counteract this development. The study HaMEdSi (Hausärzte (GPs) for Medical Education in Siegen-Wittgenstein) among other things examines the occupational perspectives of the GPs depending on their surgeries' characteristics and draws a realistic picture of how primary care in the region of Siegen-Wittgenstein, representative for many rural regions, will develop over the next few years.

METHOD

A survey was conducted among GPs in the region of Siegen-Wittgenstein. This area is a representative rural region in Germany. GPs were amongst other assessed regarding their demographic characteristics and working perspectives.

RESULTS

A representative number of GPs took part in the study (n = 85, 54%). For instance, 50.6% of the study participants will no longer be working in practice in 10 years from now and 25% of them assume that their practices be closed after the age-related retirement due to a lack of successor.

CONCLUSIONS

The situation in rural areas in reality looks worse than previously estimated in the assessments of the Statutory Health Insurance. Something must be done here to mitigate the impending GPs' shortage. Measures such as promotion of training, employment or settlement in undersupplied regions as well as cross-border promotion, could on the long term compensate for the shortage that threatens many rural regions in Germany.

The Diagnosis and Treatment of Functional Dyspepsia

BACKGROUND

Functional dyspepsia (FD) is one of the more common functional disorders, with a prevalence of 10-20%. It affectsthe gastrointestinal tract.

METHODS

This article is based on publications retrieved by a selective search of PubMed, with special attention to controlled trials, guidelines, and reviews.

RESULTS

Typical dyspeptic symptoms in functional dyspepsia include epigastric pain, sensations of pressure and fullness, nausea, and early subjective satiety. The etiology of the disorder is heterogeneous and multifactorial. Contributory causes include motility disturbances, visceral hypersensitivity, elevated mucosal permeability, and disturbances of the autonomic and enteric nervous system. There is as yet no causally directed treatment for functional dyspepsia. Its treatment should begin with intensive patient education regarding the benign nature of the disorder and with the establishment of a therapeutic pact for long-term care. Given the absence of a causally directed treatment, drugs to treat functional dyspepsia should be given for no more than 8-12 weeks. Proton-pump inhibitors, phytotherapeutic drugs, and Helicobacter pylori eradication are evidence-based interventions. For intractable cases, tricyclic antidepressants and psychotherapy are further effective treatment options.

CONCLUSION

The impaired quality of life of patients with functional dyspepsia implies the need for definitive establishment of the diagnosis, followed by symptom-oriented treatment for the duration of the symptomatic interval.

Clinical management of eosinophilic esophagitis - a nationwide survey among gastroenterologists in Germany

BACKGROUND

 Eosinophilic esophagitis (EoE) is an increasingly recognized immune-mediated esophageal disease and a common cause for dysphagia and food bolus obstruction. The aim of this study was to evaluate the current clinical management of EoE among adult gastroenterologists in Germany.

METHODS

 We performed a cross-sectional study of 1393 adult gastroenterologists using a questionnaire containing 22 questions to general, diagnostic, and therapeutic aspects of EoE. The self-administered online survey was conducted between November 2017 and February 2018. Data capture and analysis was performed using SurveyMonkey.

RESULTS

 The overall responder rate was 29.6 %. More than half of the responders (54.9 %) felt to observe a significant increase of EoE patients. The EREFS score was mostly either unknown (44.3 %) or not routinely used (52.2 %). If EoE was suspected, most responders obtained multiple esophageal biopsies (n = 3 - 4: 35.7 %; n > 4: 61.6 %). The preferred primary treatment was proton pump inhibitors (PPI) in 37.2 % and topical steroids in 35.0 % of responders. PPI regimens were highly diverse, with only half of responders using high-dose PPI regimens. Allergy testing was often initiated (always 25.4 %, sometimes 48.9 %). The most common dietary therapy was 6-food elimination diet (52 %), followed by allergy test-directed diets (16 %) and 2-food elimination diet (16.5 %). The majority of responders indicated a need for long-term treatment (i. e., 23 % of responders in > 50 % their patients and 47.7 % of responders in 25 - 50 % of their patients).

CONCLUSIONS

 Among gastroenterologists in Germany, substantial variation in the adherence to published EoE guidelines appears to exist. This indicates the need for intensified education and national guidelines in order to optimize and harmonize the clinical management of EoE patients.

[Updated S2k-Guideline "Complications of liver cirrhosis". German Society of Gastroenterology (DGVS)]

This guideline provides evidence-based key recommendations for diagnosis and therapy of complications of liver cirrhosis and upgrades the 2011 version. An interdisciplinary team of medical experts and patient support groups developed the guideline following the AWMF recommendations for evidence based consensus guidelines. New chapters concerning diagnosis and therapy of hepatic encephalopathy were added.

The "Aachen sings" study ("Aachen choir engagement study into GERD symptoms"): moderate singing and breathing exercises in a choir reduce reflux symptoms - a cohort study in non-specialist choristers

BACKGROUND

 The influence of singing activities and breathing exercises on the presence of gastroesophageal reflux disease (GERD) symptoms is not clear. While an Austrian study found symptom reduction, an Italian study showed more symptoms in professional opera choristers. These contradictory results may be due to differential intensity of the singing exercises. We therefore developed a questionnaire to investigate the presence of GERD typical symptoms and defined GERD in nonprofessional choristers with moderate singing activity and breathing exercises and compared the results to those from related non-singing control persons.

METHODS

 434 actively engaged lay-choir persons and 310 non-singing friends or relatives answered questions in a questionnaire regarding basic data, singing habits, GERD symptoms, and past or present diagnostic events and medications.

RESULTS

 Non-singing control persons experienced more frequently heartburn (1.1 ± 4.1 vs. 0.5 ± 1.2 episodes/week, p = 0.001) and acid regurgitation (0.9 ± 4.1 vs. 0.5 ± 1.3 episodes/week, p < 0.001) and had more often already received the diagnosis of GERD (16.8 % vs. 10.4 %, p = 0.011). From the persons without known GERD, members of the control cohort more often fulfilled the simplified diagnostic criteria of GERD (14.3 % vs. 5.1 %, p < 0.001). A multivariate analysis identified non-singing, high body mass index, and smoking as significant risk factors for the presence of GERD symptoms.

CONCLUSION

 The frequency of reflux symptoms and GERD is probably still increasing. Moderate singing activities and breathing exercises seem to be helpful in avoiding reflux symptoms such as heartburn and acid regurgitation.

[Functional dyspepsia in primary care: therapeutic variety or helplessness?]

BACKGROUND

About 5% of all GP consultations are made for symptoms of functional dyspepsia. The definition of functional dyspepsia is in a state of flux, pathophysiology is poorly understood, and current diagnostic and therapeutic algorithms are not available.

AIM

Evaluation of the frequency and the practical procedure in the diagnosis and therapy of functional dyspepsia in German GP surgeries.

METHOD

Family physicians working in Germany (general practitioners, primary care internists) were contacted via postal survey. The frequency of patients with functional dyspepsia per week, the symptom spectrum complained of and the therapy strategy were inquired.

RESULTS

Data from 322 doctors from all over Germany could be evaluated. The majority of physicians cared for 6-10 RMS patients per week (44.1%). The most common symptoms reported by patients were postprandial fullness (81.7%), epigastric pain or burning (77.3%) and regurgitation (75.0%). Heartburn (50.0%), nausea/vomiting (42.5%) and premature satiety (15.8%) were reported less frequently. The most commonly prescribed drugs were phytotherapeutics (88.2%), proton-pump inhibitors (PPI, 73.6%) and prokinetics (61.5%). The frequency of prescribing antacids, digestive enzymes of the stomach and pancreas was 10-20%. There was a trend towards symptom-dependent differential therapy: phytotherapeutics and prokinetics in postprandial fullness and premature satiety, PPI in epigastric pain/burning. The treatment failure rate was estimated at 21-40%. For further diagnostics patients are often referred to gastroenterologists and psychotherapists.

CONCLUSION

Functional dyspepsia is common in primary care practice. Current recommendations for diagnosis and differential therapy are often not implemented. The rate of treatment failure is considerable.

Acute sedation-associated complications in GI endoscopy (ProSed 2 Study): results from the prospective multicentre electronic registry of sedation-associated complications

OBJECTIVES

Sedation has been established for GI endoscopic procedures in most countries, but it is also associated with an added risk of complications. Reported complication rates are variable due to different study methodologies and often limited sample size.

DESIGNS

Acute sedation-associated complications were prospectively recorded in an electronic endoscopy documentation in 39 study centres between December 2011 and August 2014 (median inclusion period 24 months). The sedation regimen was decided by each study centre.

RESULTS

A total of 368 206 endoscopies was recorded; 11% without sedation. Propofol was the dominant drug used (62% only, 22.5% in combination with midazolam). Of the sedated patients, 38 (0.01%) suffered a major complication, and overall mortality was 0.005% (n=15); minor complications occurred in 0.3%. Multivariate analysis showed the following independent risk factors for all complications: American Society of Anesthesiologists class >2 (OR 2.29) and type and duration of endoscopy. Of the sedation regimens, propofol monosedation had the lowest rate (OR 0.75) compared with midazolam (reference) and combinations (OR 1.0-1.5). Compared with primary care hospitals, tertiary referral centres had higher complication rates (OR 1.61). Notably, compared with sedation by a two-person endoscopy team (endoscopist/assistant; 53.5% of all procedures), adding another person for sedation (nurse, physician) was associated with higher complication rates (ORs 1.40-4.46), probably due to higher complexity of procedures not evident in the multivariate analysis.

CONCLUSIONS

This large multicentre registry study confirmed that severe acute sedation-related complications are rare during GI endoscopy with a very low mortality. The data are useful for planning risk factor-adapted sedation management to further prevent sedation-associated complications in selected patients.

TRIAL REGISTRATION NUMBER

DRKS00007768; Pre-results.

GPs' motivation for teaching medical students in a rural area-development of the Motivation for Medical Education Questionnaire (MoME-Q)

Background

The establishment of a medical education program in the rural area of Siegen is planned to be the first step against a shortage of physicians in this region. General practitioners (GPs) will be extensively involved in this program as Family Medicine (Allgemeinmedizin) will become a core subject in the curriculum nationwide. Based on this situation we aim to figure out GPs motivation to participate in medical education. For this purpose, we had to construct and test a new questionnaire.

Methods

A survey was conducted among general practitioners (GPs) in the region of Siegen-Wittgenstein regarding their motivation to participate in medical education. For this purpose, the Motivation for Medical Education Questionnaire (MoME-Q), a 24-item questionnaire, was developed. Structural characteristics of GPs, the Maslach Burnout Inventory (MBI) and the Work Satisfaction Questionnaire (WSQ) were used for validation purposes.

Results

A representative number of GPs took part in the study (53.8%). Although the majority had no connection to a university (86%), 83% can imagine participating in the education of medical students. The items of the MoME-Q load on two factors (commitment and personal benefit). The confirmatory factor analysis shows a good model fit. Subscales of the MoME-Q were able to differentiate between physicians with and without authorization to train GP residents, between practices with and without a specialized practice nurse, and between physicians with and without previous experience in medical education. The MoME-Q subscale "commitment" correlated significantly with all three subscales of the MBI. Correlations were in the medium range around |.30|.

Conclusion

The MoME-Q seems to be an appropriate tool to assess motivation to participate in medical education of GPs. In our sample, a large number of GPs was motivated to participate in the education of medical students. Future studies with larger number of GPs should be carried out to validate and confirm our findings. Whether the MoME-Q is also appropriate for other specialties should also be shown in further empirical studies.

Alginat bei Bedarf als Add-on bei unzureichendem Effekt von Protonenpumpen-Hemmern bei Patienten mit gastroösophagealer Reflux-Krankheit

Einleitung Chronische Reflux-Patienten mit Langzeit-PPI-Therapie haben häufig persistierende Symptome. Eine wesentliche Ursache hierfür ist die Acid-Pocket, die lokal durch Alginate wirksam behandelt werden kann.

Methoden In einer prospektiven, multizentrischen, nicht randomisierten, nicht interventionellen und unkontrollierten Studie in hausärztlichen Praxen wurden Reflux-Patienten mit einer PPI-Dauertherapie über ≥ 1 Jahr, die mit ihrer Behandlung unzufrieden waren, über 14 Tage mit einem Alginat nach Bedarf (bis zu 4 ×/Tag) behandelt. Es wurde die Frequenz der Symptome in der Woche vor Therapie und in der zweiten Behandlungswoche erfasst, zusätzlich der validierte GERD-Q-Score. Die Patienten gaben ihre Zufriedenheit mit der Therapie vor Beginn und am Ende der Studienperiode auf einer 5-Punkt-Likert-Skala an (1: sehr unzufrieden; 5: zufrieden). Primärer Endpunkt der Studie war die Verbesserung der Zufriedenheit um ≥ 1 Punkt.

Ergebnisse 155 Patienten (54 % Frauen, medianes Alter 57 Jahre [Bereich 18 – 85 Jahre]) wurden rekrutiert. 6 Patienten wurden von der Wirksamkeitsanalyse ausgeschlossen, da sie entweder die Studienmedikation nicht genommen hatten oder nicht zur Abschlussvisite erschienen. Die mediane Krankheitsdauer lag bei 8 Jahren (Bereich 1 – 50 Jahre), die mediane Dauer der PPI-Langzeittherapie bei 6 Jahren. In der Studie nahmen die Patienten im Mittel 3 Sachets des Studienmedikaments pro Tag. Die Alginat-Therapie führte bei 72 % der Patienten zu einer Verbesserung der Therapiezufriedenheit um mindestens 1 Punkt (1 Punkt: n = 45, 2 Punkte: n = 41, 3 Punkte: n = 16, 4 Punkte: n = 5). Patienten mit einem GERD-Q-Score > 8 sprachen häufiger auf die Therapie an (81 %). Die Verbesserung umfasste alle typischen Reflux-Symptome und Schlafstörungen. Die Therapie wurde gut vertragen.

Diskussion Eine Reflux-Blockade mit einem Alginat als Add-on ist eine wirksame und sichere Option zur Behandlung von Durchbruchsymptomen bei GERD-Patienten mit PPI-Therapie.

Burnout and work satisfaction in general practitioners practicing in rural areas: results from the HaMEdSi study

Background

An increasing number of general practitioners (GPs) are not satisfied with their working conditions and are at risk of developing burnout symptoms. As family medicine is becoming a major subject within the medical curriculum in Germany, practicing GPs need to meet higher demands in the future, ie, treating patients and taking part in the education of medical students. Accordingly, we aimed to determine GPs' work satisfaction and risk of burnout.

Materials and methods

A survey was conducted among GPs in the region of Siegen-Wittgenstein. This area is a representative rural region in Germany. The Maslach Burnout Inventory (MBI) was used to assess the risk of burnout, while the Work Satisfaction Questionnaire (WSQ) was applied to assess work satisfaction. Canonical correlations were used to examine the association between work satisfaction and burnout in GPs.

Results

A good model fit was demonstrated for both the MBI and the WSQ. The canonical correlation analysis resulted in two statistically significant canonical functions with correlations of 0.64 (P<0.001) and 0.56 (P=0.001). The full model across all functions was significant (χ² [18]=72.41, P<0.001). Burden and the global item in the WSQ are good predictors of emotional exhaustion, while patient care, personal rewards and professional relations seem to be good predictors of depersonalization/lack of empathy. This supports the approach to burnout as a multidimensional construct which has to be thoroughly diagnosed.

Conclusion

Differential interventions tailored to GPs with specific deficits in certain areas should be delivered. GPs with a high score on emotional exhaustion would need a different intervention, as these respondents have different associations with work satisfaction than do GPs with a high score for depersonalization/low empathy. Therefore, the results of this study could contribute to the design of differential interventions aimed at ameliorating symptoms of burnout in GPs.

Proposed approach to the challenging management of progressive gastroesophageal reflux disease

The progression of gastroesophageal reflux disease (GERD) in patients who are taking proton pump inhibitors (PPIs) has been reported by several investigators, leading to concerns that PPI therapy does not address all aspects of the disease. Patients who are at risk of progression need to be identified early in the course of their disease in order to receive preventive treatment. A review of the literature on GERD progression to Barrett’s esophagus and the associated physiological and pathological changes was performed and risk factors for progression were identified. In addition, a potential approach to the prevention of progression is discussed. Current evidence shows that GERD can progress; however, patients at risk of progression may not be identified early enough for it to be prevented. Biopsies of the squamocolumnar junction that show microscopic intestinalization of metaplastic cardiac mucosa in endoscopically normal patients are predictive of future visible Barrett’s esophagus, and an indicator of GERD progression. Such changes can be identified only through biopsy, which is not currently recommended for endoscopically normal patients. GERD treatment should aim to prevent progression. We propose that endoscopically normal patients who partially respond or do not respond to PPI therapy undergo routine biopsies at the squamocolumnar junction to identify histological changes that may predict future progression. This will allow earlier intervention, aimed at preventing Barrett’s esophagus.