Cost effectiveness of competing strategies to prevent or treat GORD-related dysphagia

Therapeutic efficacy of neuromuscular electrical stimulation and electromyographic biofeedback on Alzheimer's disease patients with dysphagia

To study the therapeutic effect of neuromuscular electrical stimulation and electromyographic biofeedback (EMG-biofeedback) therapy in improving swallowing function of Alzheimer's disease patients with dysphagia.A series of 103 Alzheimer's disease patients with dysphagia were divided into 2 groups, among which the control group (n = 50) received swallowing function training and the treatment group (n = 53) received neuromuscular electrical stimulation plus EMG-biofeedback therapy. The mini-mental state scale score was performed in all patients along the treatment period. Twelve weeks after the treatment, the swallowing function was assessed by the water swallow test. The nutritional status was evaluated by Mini Nutritional Assessment (MNA) as well as the levels of hemoglobin and serum albumin. The frequency and course of aspiration pneumonia were also recorded.No significant difference on mini-mental state scale score was noted between 2 groups. More improvement of swallowing function, better nutritional status, and less frequency and shorter course of aspiration pneumonia were presented in treatment group when compared with the control group.Neuromuscular electrical stimulation and EMG-biofeedback treatment can improve swallowing function in patients with Alzheimer's disease and significantly reduce the incidence of adverse outcomes. Thus, they should be promoted in clinical practice.

Vicious circles in inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease can present with a bewildering array of disease manifestations whose overall impact on patient health is difficult to disentangle. The multitude of disease complications and therapeutic side effects result in conflicting ideas on how to best manage a patient. The aim of the study is to test the usefulness of influence diagrams in resolving conflicts centered on managing complex disease processes.

METHODS

The influences of a disease process and the ensuing medical interventions on the health of a patient with inflammatory bowel disease are modeled by an influence diagram. Patient health is the focal point of multiple influences affecting its overall strength. Any downstream influence represents the focal point of other preceding upstream influences. The mathematics underlying the influence diagram is similar to that of a decision tree. Its formalism allows one to consider additive and inhibitory influences and include in the same analysis qualitatively different types of parameters, such as diagnoses, complications, side effects, and therapeutic outcomes.

RESULTS

Three exemplary cases are presented to illustrate the potential use of influence diagrams. In all three case scenarios, Crohn's disease resulted in disease manifestations that seemingly interfered with its own therapy. The presence of negative feedback loops rendered the management of each case particularly challenging. The analyses by influence diagrams revealed subtle interactions among the multiple influences and their joint contributions to the patient's overall health that would have been difficult to appreciate by verbal reasoning alone.

CONCLUSION

Influence diagrams represent a decision tool that is particularly suited to improve decision-making in inflammatory bowel disease. They highlight key factors of a complex disease process and help to assess their quantitative interactions.

Efficiency of potent gastric acid inhibition

The evidence regarding the efficiency of potent gastric acid inhibition is exposed after a systematic search and a critical evaluation of its quality, using a specific score. The aim was to review alternative options, in economic terms, especially related with gastro-oesophageal reflux disease. The results show that the superiority of the proton pump inhibitors over the histamine H2 receptor antagonist is clear in moderate and severe oesophagitis and in patients with persistent or severe symptoms. This evidence is clearly related with the intensity of the gastric inhibition. An associated benefit is the improvement of the quality of life obtained with this potent gastric acid inhibition profile.

General principles to enhance practice patterns in gastrointestinal endoscopy

AIM

To develop general rules on how to pursue a therapeutic goal of interventional endoscopy without getting lost in abundant details.

METHODS

The influences of various medical interventions on the survival of a patient with gastrointestinal haemorrhage are modelled by an influence diagram. Survival is the focal point of multiple influences affecting its overall strength. Any downstream influence can represent the focal point of other preceding upstream influences. The mathematics underlying the influence diagram are similar to those of a decision tree with some notable exceptions. Its formalism allows one to consider inhibitory and additive influences and to include in the same analysis non-commensurable qualities, such as correct diagnosis, haemostasis or survival.

RESULTS

The analysis reveals five general rules. First, the large number of factors involved in successful endoscopy render the influence of each individual factor less important. Second, a single factor that exerts its influence on many subsequent factors tends to be associated with an overall greater relevance. Third, remote influences are of lesser relevance than those directly linked to the final outcome. Fourth, factors multiplied by several consecutive probabilities lose their influence. Fifth, endoscopists need to assess the relevance of individual factors with respect to the immediate goals of endoscopy, as well as the general goals of patient well-being.

CONCLUSIONS

The influence model of endoscopic haemostasis reveals several general principles that can be utilized as tools in endoscopy training.

The benefit of negative tests in non-ulcer dyspepsia

OBJECTIVES

Negative diagnostic tests are usually evaluated by their ability to advance a diagnostic search, or they are considered redundant expenditures in establishing a definitive diagnosis. It has remained difficult to assess their benefit in terms of their own merit and the reassurance that they provide to a patient. The aim of the present study is to develop a mathematical model for quantifying the impact of diagnostic tests on a patient's health-related quality of life (HRQL).

METHODS

An influence diagram is used to model how non-ulcer dyspepsia (NUD) and its medical care affect HRQL. Diagnostic tests and medical therapy benefit HRQL by alleviating fear of disease and NUD symptoms. Medical care can also adversely affect HRQL, lead to expenses in time and money, and compromise a patient's sense of autonomy. HRQL is modeled as the focal point of multiple influences detracting from its value.

RESULTS

Negative diagnostic tests can improve HRQL in NUD. The improvement of HRQL by diagnostic tests depends on a multitude of individual influences and the interactions between them, such as the severity of NUD symptoms andfear of disease, as well as the impact of medical care itself on HRQL. If a patient harbors a strong fear of serious disease or cancer, more extensive testing is likely to improve the patient's well-being and appears a worthwhile endeavor. Other patients, however, would be served perfectly well by empirical therapy only. For the vast majority of subjects with NUD who never seek medical advice, the unpleasantness of the disease itself does not outweigh the anticipated downside of obtaining medical care.

CONCLUSION

The analysis illustrates the applicability of the influence diagram in modeling disease behavior. This method helps to assess the benefit of negative tests beyond their means of generating information.

What to do about Helicobacter pylori? A decision analysis of its implication on public health

OBJECTIVES

Public health measures to eradicate Helicobacter pylori in the general population may prevent the occurrence of nonulcer dyspepsia (NUD), peptic ulcer (PUD) and gastric cancer, but may at the same time increase the prevalence of gastroesophageal reflux disease (GERD). A decision analysis is carried out to quantify the counteracting influences of H. pylori and resolve the controversy about a public policy to eliminate H. pylori from the general population.

METHODS

A compartment model is structured to analyze the jointly beneficial and adverse effects of H. pylori. Gastric acid, H. pylori infection, and other pathophysiological mechanisms influence the occurrence of reflux disease, peptic ulcer and dyspepsia, which all contribute to the occurrence of upper abdominal symptoms. Each influence is modeled as a separate compartment with various connections to other compartments. The simulation is carried out on an electronic spreadsheet.

RESULTS

A decision in favor or against eradication of all H. pylori depends primarily on the relative contribution of reflux disease vs. peptic ulcer and dyspepsia to upper abdominal symptoms in the general population. If reflux-related symptoms contribute twice more than peptic ulcer plus dyspepsia to the overall occurrence of abdominal symptoms, a strategy to eradicate H. pylori would actually lower rather than raise public health. Below this threshold such strategy may improve general well-being. In the individual patient infected with H. pylori, it remains beneficial to eradicate H. pylori, irrespective of the symptoms' nature.

CONCLUSIONS

Although it is advisable to treat H. pylori infection in the individual patient who comes to medical attention, a general policy directed towards complete elimination of H. pylori from the population would not be beneficial. A compartment model provides a simple yet powerful method to assess complex disease behavior.