Self-help interventions in irritable bowel syndrome.
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Clinical Trials as Topic↗
Biomedical subjects
A P S Hungin
Publications and source records attributed to A P S Hungin.
Patients with poorly controlled diabetes in primary care: healthcare clinicians' beliefs and attitudes.
OBJECTIVE: To determine doctors' and nurses' attitudes and beliefs about treating patients with type 2 diabetes with less than ideal glycaemic control while receiving maximal oral treatment in primary care. DESIGN: Focus groups. SETTING: Primary care. PARTICIPANTS: Four focus groups of 23 GPs and practice nurses. RESULTS: General practice was thought to be the best setting for managing all patients with type 2 diabetes but there were concerns about a lack of resources and unfamiliarity with starting insulin. Issues around compliance were extensively discussed; the "failing diabetic" had dual meanings of failing glycaemic control and failing compliance and effort by both patient and doctor. Although views about insulin therapy differed, patients were understood to be resistant to starting insulin, representing for them a more serious stage of diabetes, with fears of needles and hypoglycaemia. CONCLUSION: The role of diabetes specialist nurses working in primary care will be crucial in managing such patients to improve knowledge, for extra resources, for their experience of insulin use, and to change attitudes.
Attitude of Health Personnel↗
Use of proton pump inhibitors: an exploration of the attitudes, knowledge and perceptions of general practitioners.
BACKGROUND/AIM: Proton pump inhibitor (PPI) prescribing is costly. The volume of PPI prescription is also increasing, despite little evidence that would justify the increase. General practitioners (GPs) are largely responsible for PPI prescribing, yet knowledge of their views concerning PPIs which might explain the apparent anomaly of prescribing costly drugs without justification is lacking. The aim of this study is therefore to investigate how GPs make decisions about PPI prescribing. METHOD: Qualitative study design using focus groups of 34 GPs and 15 training GPs analysed according to grounded theory principles and use of constant comparative analysis. RESULTS: The participants showed agreement about the clinical factors potentially relevant to PPI prescribing such as age of presentation and endoscopy, issues of Helicobacter pylori eradication and issues around malignancy. There was considerable controversy, however, as to how to apply those factors in real clinical consultations. GPs in training and academic GPs tended to be more conservative; service-based GPs more pragmatic. There was agreement about the need to review long-term PPI medication, but controversy about whether the conventional 'step-up step-down' approach was realistic in practice. Good agreement was apparent about the effectiveness, the cost implications, and some of the ethical issues surrounding PPIs, but considerable controversy as to how far such factors should influence prescribing of PPIs. CONCLUSION: The GPs showed good understanding and knowledge of the issues surrounding PPI prescribing. There was considerable controversy as to how such knowledge should be translated into practice.
Adult↗
Irritable bowel syndrome in the United States: prevalence, symptom patterns and impact.
BACKGROUND: The impact of irritable bowel syndrome, a gastrointestinal motility disorder, is underestimated and poorly quantified, as clinicians may see only a minority of sufferers. AIM: To determine the prevalence, symptom patterns and impact of irritable bowel syndrome in the US. METHODS: This two-phase community survey used quota sampling and random-digit telephone dialing (screening interview) to identify individuals with medically diagnosed irritable bowel syndrome or individuals not formally diagnosed, but fulfilling irritable bowel syndrome diagnostic criteria (Manning, Rome I or II). Information on irritable bowel syndrome symptoms, general health status, lifestyle and impact of symptoms on individuals' lives was collected using in-depth follow-up interviews. Data were also collected for healthy controls identified in the screening interviews. RESULTS: The total prevalence of irritable bowel syndrome in 5009 screening interviews was 14.1% (medically diagnosed: 3.3%; undiagnosed, but meeting irritable bowel syndrome criteria: 10.8%). Abdominal pain/discomfort was the most common symptom prompting consultation. Most sufferers (74% medically diagnosed; 63% undiagnosed) reported alternating constipation and diarrhoea. Previously diagnosed gastrointestinal disorders occurred more often in sufferers than non-sufferers. Irritable bowel syndrome sufferers had more days off work (6.4 vs. 3.0) and days in bed, and reduced activities to a greater extent than non-sufferers. CONCLUSIONS: Most (76.6%) irritable bowel syndrome sufferers in the US are undiagnosed. Irritable bowel syndrome has a substantial impact on sufferers' well-being and health, with considerable socioeconomic consequences.
Activities of Daily Living↗
Review article: gastro-oesophageal reflux disease--the health economic implications.
For the vast majority of patients with gastro-oesophageal reflux disease appropriate care involves the management of symptoms with lifestyle advice and drugs. However, there is dissension about the appropriate use of endoscopy, whether drugs should be stepped up or down according to potency, how long drugs should be used for, the role of lifestyle advice, and, related to this, the role of patients' lifestyle choices. This exploration of the economics of gastro-oesophageal reflux disease reviews its cost burden to the UK, assesses published economic models for their strengths and weaknesses and examines current recommendations for gastro-oesophageal reflux disease management from a socioeconomic perspective. Drugs prescribed predominantly for dyspepsia cost the UK National Health Service a projected pound sterling 625 million in 2004, 7% of the primary care prescribing budget. When general practitioners consultations, endoscopies, over-the-counter sales and sickness absences are included the UK cost rises to pound sterling 1.5 billion: approximately half of this cost can be ascribed to gastro-oesophageal reflux disease. Emphasis upon regular review and stepping down treatment (while maintaining adequate symptom relief) is both clinically appropriate and resource efficient. Other cost-effectiveness issues largely lack objective answers because investment in treatment for gastro-oesophageal reflux disease depends upon how much more, at the margin, society wishes to invest for further but diminishing symptom relief.
Absenteeism↗
Review article: quality-of-life issues in gastro-oesophageal reflux disease.
The purpose of this review is to explore issues relating to quality of life in gastro-oesophageal reflux disease, examining the range of generic and disease-specific instruments available, their applicability and limitations and to overview the effect of gastro-oesophageal reflux disease on quality of life. Whereas instruments have been developed to assist researchers, there is a paucity of reliable instruments for pragmatic use in the clinical setting. The situation is complicated because there is not necessarily a direct correlation between endoscopic findings and symptom severity and non-erosive reflux disease is now recognized as an important manifestation of gastro-oesophageal reflux disease. However, quality-of-life instruments are useful in evaluating the impact of therapies and interventions, although these are limited, particularly in surgical interventions. Impaired quality of life now forms part of a definition of gastro-oesophageal reflux disease, the impact of which goes beyond the symptoms alone. While the symptoms themselves have a negative effect on sufferers' lives, there are secondary effects caused by impaired physical, emotional and social functioning on productivity. Non-gastrointestinal problems caused by gastro-oesophageal reflux disease also impair quality of life. There is an ongoing need to develop instruments which truly measure the impact of gastro-oesophageal reflux disease and which are readily interpretable to the individual patient and clinician.
Efficiency↗
The fight for 'health-related normality': a qualitative study of the experiences of individuals living with established inflammatory bowel disease (ibd).
This article reports on the experiences of individuals living with IBD and identifies a range of coping strategies used by them. Qualitative data from 15 individual interviews and three focus groups were analysed using a grounded theory approach. The main focus is on the emergent core concept of 'health-related normality'. A theoretical framework is proposed to explain how individuals with IBD assess their health-related normality, their fight to maintain it and their need to retain the appearance of normality to others. It is concluded that individuals maintain their health-related normality along certain time and context sensitive continuums rather than fitting into a distinct typology.
Adaptation, Psychological↗
Systematic review: the effect of Helicobacter pylori and its eradication on gastro-oesophageal reflux disease in patients with duodenal ulcers or reflux oesophagitis.
BACKGROUND: The effect of Helicobacter pylori in provoking or protecting against gastro-oesophageal reflux disease is unclear and studies have given conflicting results. Recent guidelines recommend H. pylori eradication in patients on long-term proton pump inhibitors. AIM: To ascertain the effect of H. pylori eradication on gastro-oesophageal reflux disease outcomes (reflux oesophagitis and heartburn) in patients with duodenal ulcer disease, and to ascertain the effect of H. pylori infection on reflux oesophagitis concerning heartburn, pH, severity, healing and relapse rates. METHODS: A systematic review of electronic databases was undertaken to September 2003. Experts in the field, pharmaceutical companies and journals were contacted about unpublished trials. Studies were reviewed according to predefined eligibility and quality criteria. Twenty-seven studies/trials were included in the systematic review. RESULTS: Study variation rather than therapy-influenced results in relation to the presence or absence of oesophagitis in patients with duodenal ulcer who underwent H. pylori eradication at 6-48 months follow-up. In patients with reflux oesophagitis no obvious differences were discovered in heartburn scores, 24-h pH values, healing and relapse rates between H. pylori-positive and -negative cases. CONCLUSION: There is no evidence to indicate that H. pylori eradication in duodenal ulcer disease provokes reflux oesophagitis or worsens heartburn; (ii) there are insufficient data to draw firm conclusions about the impact of H. pylori in patients with reflux oesophagitis.
Duodenal Ulcer↗
Empirical use of antisecretory drug therapy delays diagnosis of upper gastrointestinal adenocarcinoma but does not effect outcome.
BACKGROUND: Upper gastrointestinal cancer carries a poor prognosis. Although the incidence of gastric adenocarcinoma is falling, oesophageal adenocarcinoma is increasing. This has been attributed to an increasing prevalence of gastro-oesophageal reflux disease, commonly treated empirically in primary care with antisecretory drugs. Treatment has been associated with delayed diagnosis but it is unclear if this influences prognosis. AIMS: To ascertain the effect of antisecretory drugs on time to diagnosis, symptoms, tumour stage and outcome. METHODS: A retrospective cohort study of primary care records for 747 patients diagnosed with upper gastrointestinal adenocarcinoma at South Tees NHS Trust between 1991 and 2001. RESULTS: Mean time from the onset of symptoms to diagnosis was 30 weeks. Mean and median times at the primary care stage were longer than at the hospital stage for both oesophageal and gastric cancer (P < 0.0001). Patients with benign symptoms prescribed antisecretory drugs were referred later than those not on antisecretory drugs (P < 0.0001), as were patients with alarm symptoms (P = 0.0008). Prior use of antisecretory drugs delayed diagnosis by 17.6 weeks (mean) but had no effect on tumour stage at diagnosis or survival. CONCLUSION: Prior antisecretory drug therapy was associated with delayed diagnosis of upper gastrointestinal adenocarcinoma irrespective of presenting symptoms. Concerns that delays might adversely affect tumour stage or long-term survival were not substantiated.
Adenocarcinoma↗
Quality of life in patients with established inflammatory bowel disease: a UK general practice survey.
BACKGROUND: The current understanding of quality of life impairment in inflammatory bowel disease has largely been derived from selected populations and may not reflect the experience of patients in the community, where fewer than half are likely to be under specialist care. AIM: To describe the health-related quality of life in a community-based sample of patients with established inflammatory bowel disease and explore its association with the type and extent of disease, gender, age, material deprivation and other factors. METHODS: Adults with established inflammatory bowel disease were identified systematically from the records of 23 family practices in north-east England. The health-related quality of life was assessed by self-completion of the UK Inflammatory Bowel Disease Questionnaire. RESULTS: Five hundred and fifty-six patients were sent the questionnaire and 409 (74%) gave usable replies. Lower scores (worse quality of life) were significantly associated with female gender, Crohn's disease, more extensive disease (ulcerative colitis) and being under specialist care. The mean health-related quality of life score was significantly lower in patients resident in more deprived districts, independent of the type and extent of disease. CONCLUSIONS: Most patients with established inflammatory bowel disease showed only minor impairment of their health-related quality of life. On average, women and those with Crohn's disease were relatively more affected. Clinicians responsible for the care of patients with inflammatory bowel disease should be aware of these more vulnerable groups.
Adolescent↗
The prevalence, patterns and impact of irritable bowel syndrome: an international survey of 40,000 subjects.
AIM: To determine the prevalence, symptom pattern and impact of the irritable bowel syndrome, across eight European countries, using a standardized methodology. METHODS: A community survey of 41 984 individuals was performed using quota sampling and random digit telephone dialing to identify those with diagnosed irritable bowel syndrome or those meeting diagnostic criteria, followed by in-depth interviews. RESULTS: The overall prevalence was 11.5% (6.2-12%); 9.6% had current symptoms, 4.8% had been formally diagnosed and a further 2.9%, 4.2% and 6.5% met the Rome II, Rome I or Manning criteria, respectively. Bowel habit classification varied by criteria: 63% had an 'alternating' bowel habit by Rome II vs. 21% by self-report. On average, 69% reported symptoms lasting for 1 h, twice daily, for 7 days a month. Irritable bowel syndrome sufferers reported more peptic ulcer (13% vs. 6%), reflux (21% vs. 7%) and appendectomy (17% vs. 11%), but not hysterectomy, cholecystectomy or bladder procedures. Ninety per cent had consulted in primary care and 17% in hospital; 69% had used medication. Irritable bowel syndrome substantially interfered with lifestyle and caused absenteeism. CONCLUSIONS: Irritable bowel syndrome is common with major effects on lifestyle and health care. The majority of cases are undiagnosed and the prevalence varies strikingly between countries. Diagnostic criteria are associated with varying prevalences and bowel habit sub-types. This limits their utility in clinical practice and the transferability of research findings using them.
Absenteeism↗
Managing acute renal colic across the primary-secondary care interface: a pathway of care based on evidence and consensus.
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Acute Disease↗
Dyspepsia: gaps between primary and secondary care.
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Dyspepsia↗
Current concepts in the management of Helicobacter pylori infection--the Maastricht 2-2000 Consensus Report.
Significant progress and new insights have been gained in the 4 years since the first Maastricht Consensus Report, necessitating an update of the original guidelines. To achieve this, the European Helicobacter Pylori Study Group organized a meeting of specialists and experts from around the world, representatives from National Gastroenterology Societies and general practitioners from Europe to establish updated guidelines on the current management of Helicobacter pylori infection. The meeting took place on 21-22 September 2000. A "test and treat" approach is recommended in adult patients under the age of 45 years (the age cut-off may vary locally) presenting in primary care with persistent dyspepsia, having excluded those with predominantly gastro-oesophageal reflux disease symptoms, non-steroidal anti-inflammatory drug users and those with alarm symptoms. Diagnosis of infection should be by urea breath test or stool antigen test. As in the previous guidelines, the eradication of H. pylori is strongly recommended in all patients with peptic ulcer, including those with complications, in those with low-grade gastric mucosa-associated lymphoid tissue lymphoma, in those with atrophic gastritis and following gastric cancer resection. It is also strongly recommended in patients who are first-degree relatives of gastric cancer patients and according to patients' wishes after full consultation. It is advised that H. pylori eradication is considered to be an appropriate option in infected patients with functional dyspepsia, as it leads to long-term symptom improvement in a subset of patients. There was consensus that the eradication of H. pylori is not associated with the development of gastro-oesophageal reflux disease in most cases, and does not exacerbate existing gastro-oesophageal reflux disease. It was agreed that the eradication of H. pylori prior to the use of non-steroidal anti-inflammatory drugs reduces the incidence of peptic ulcer, but does not enhance the healing of gastric or duodenal ulcer in patients receiving antisecretory therapy who continue to take non-steroidal anti-inflammatory drugs. Treatment should be thought of as a package which considers first- and second-line eradication therapies together. First-line therapy should be with triple therapy using a proton pump inhibitor or ranitidine bismuth citrate, combined with clarithromycin and amoxicillin or metronidazole. Second-line therapy should use quadruple therapy with a proton pump inhibitor, bismuth, metronidazole and tetracycline. Where bismuth is not available, second-line therapy should be with proton pump inhibitor-based triple therapy. If second-line quadruple therapy fails in primary care, patients should be referred to a specialist. Subsequent failures should be handled on a case-by-case basis by the specialist. In patients with uncomplicated duodenal ulcer, eradication therapy does not need to be followed by further antisecretory treatment. Successful eradication should always be confirmed by urea breath test or an endoscopy-based test if endoscopy is clinically indicated. Stool antigen test is the alternative if urea breath test is not available.
Adult↗
Long-term aminosalicylate therapy is under-used in patients with ulcerative colitis: a cross-sectional survey.
BACKGROUND: There is evidence from case-control studies that aminosalicylate drugs can reduce colorectal cancer risk by 75-81% in patients with ulcerative colitis. Patients may fail to comply with long-term therapies, however, or may have been advised to discontinue treatment once in remission. AIM: To describe the usage of long-term aminosalicylate therapy in patients with ulcerative colitis. METHODS: A cross-sectional study was performed using data extracted from general practitioner clinical records on demographic features, extent and duration of disease, use of aminosalicylate therapy and specialist care. RESULTS: Three hundred and sixty-three people had ulcerative colitis and no history of colorectal surgery. Ninety-five of 175 (54%) patients with proctitis, 78 of 123 (63%) patients with left-sided colitis and 28 of 45 (62%) patients with extensive colitis were currently taking an aminosalicylate drug. Those doing so were more likely to be under specialist care than to be definitely or possibly discharged (odds ratio, 4.9; 95% confidence interval, 2.9-8.4). The likelihood of current aminosalicylate therapy was not related to gender or the extent of disease, but was negatively related to the duration of disease. CONCLUSIONS: A substantial minority of patients with ulcerative colitis does not take long-term aminosalicylate therapy. Those who do are more likely to be under specialist care, to be older or to have disease of shorter duration.
Adult↗