Seasonality of Ankle Swelling: Population Symptom Reporting Using Google Trends.

In our experience, complaints of ankle swelling are more common in summer, typically from patients with no obvious cardiovascular disease. Surprisingly, this observation has never been reported. To objectively establish this phenomenon, we sought evidence of seasonality in the public's Internet searches for ankle swelling. Our data, obtained from Google Trends, consisted of all related Google searches in the United States from January 4, 2004, to January 26, 2016. Consistent with our expectations and confirmed by similar data for Australia, Internet searches for information on ankle swelling are highly seasonal (highest in midsummer), with seasonality explaining 86% of search volume variability.

Family physician practice visits arising from the Alberta Physician Achievement Review.

BACKGROUND: Licensed physicians in Alberta are required to participate in the Physician Achievement Review (PAR) program every 5 years, comprising multi-source feedback questionnaires with confidential feedback, and practice visits for a minority of physicians. We wished to identify and classify issues requiring change or improvement from the family practice visits, and the responses to advice. METHODS: Retrospective analysis of narrative practice visit reports data using a mixed methods design to study records of visits to 51 family physicians and general practitioners who participated in PAR during the period 2010 to 2011, and whose ratings in one or more major assessment domains were significantly lower than their peer group. RESULTS: Reports from visits to the practices of family physicians and general practitioners confirmed opportunities for change and improvement, with two main groupings - practice environment and physician performance. For 40/51 physicians (78%) suggested actions were discussed with physicians and changes were confirmed. Areas of particular concern included problems arising from practice isolation and diagnostic conclusions being reached with incomplete clinical evidence. CONCLUSION: This study provides additional evidence for the construct validity of a regulatory authority educational program in which multi-source performance feedback identifies areas for practice quality improvement, and change is encouraged by supplementary contact for selected physicians.

Acid-suppressive therapy with esomeprazole for relief of unexplained chest pain in primary care: a randomized, double-blind, placebo-controlled trial.

OBJECTIVES: High-quality data regarding the efficacy of acid-suppressive treatment for unexplained chest pain are lacking. The aim of this study was to evaluate the efficacy of esomeprazole in primary-care treatment of patients with unexplained chest pain stratified for frequency of reflux/regurgitation symptoms. METHODS: Patients with a ≥ 2-week history of unexplained chest pain (unrelated to gastroesophageal reflux) who had at least moderate pain on ≥ 2 of the last 7 days were stratified by heartburn/regurgitation frequency (≤ 1 day/week (stratum 1) vs. ≥ 2 days/week (stratum 2)) and randomized to 4 weeks of double-blind treatment with twice-daily esomeprazole 40 mg or placebo. Chest pain relief during the last 7 days of treatment (≤ 1 day with minimal symptoms assessed daily using a 7-point scale) was analyzed by stratum in keeping with the predetermined analysis plan. RESULTS: Overall, 599 patients (esomeprazole: 297, placebo: 302) were randomized. In stratum 1, more esomeprazole than placebo recipients achieved chest pain relief (38.7% vs. 25.5%; P=0.018); no between-treatment difference was observed in stratum 2 (27.2% vs. 24.2%; P=0.54). However, esomeprazole was superior to placebo in a post-hoc analysis of the whole study population (combined strata; 33.1% vs. 24.9%; P=0.035). CONCLUSIONS: A 4-week course of high-dose esomeprazole provided statistically significant relief of unexplained chest pain in primary-care patients who experienced infrequent or no heartburn/regurgitation, but there was no such significant reduction in patients with more frequent reflux symptoms.

Hypertension treatment and control rates: chart review in an academic family medicine clinic.

OBJECTIVE: To characterize hypertension management in an academic family medicine clinic. DESIGN: Cross-sectional chart review. SETTING: Academic family medicine clinic in Edmonton, Alta. PARTICIPANTS: A total of 210 patients with 1 or more visits for hypertension during the previous 3 years. MAIN OUTCOME MEASURES: Patient characteristics, current antihypertensive therapies, most recent blood pressure measurements, and compelling indications according to the 2006 Canadian Hypertension Education Program recommendations. RESULTS: A total of 185 subjects (88%) were prescribed antihypertensive medications, and 89 (42%) had controlled hypertension. Younger subjects, people with diabetes, and people not receiving antihypertensive medication therapy appeared less likely to have controlled hypertension. There were 76 subjects (36%) prescribed 1 antihypertensive medication, 65 subjects (31%) prescribed 2 antihypertensive medications, and 44 (21%) prescribed 3 or more antihypertensive medications. Angiotensin-converting enzyme inhibitors were prescribed for 51% of the subjects, diuretics for 47%, beta-blockers for 27%, calcium channel blockers for 23%, angiotensin receptor blockers for 20%, and alpha-blockers for 1%. CONCLUSION: Hypertension treatment and control rates in this academic family medicine clinic appear to be better than those in the general population. Following the principles of a continuous quality improvement process, this information will serve as an important foundation for identifying areas to improve hypertension management in the clinic.

Cost of detecting malignant lesions by endoscopy in 2741 primary care dyspeptic patients without alarm symptoms.

BACKGROUND & AIMS: Current guidelines recommend empirical, noninvasive approaches to manage dyspeptic patients without alarm symptoms, but concerns about missed lesions persist; the cost savings afforded by noninvasive approaches must be weighed against treatment delays. We investigated the prevalence of malignancies and other serious abnormalities in patients with dyspepsia and the cost of detecting these by endoscopy. METHODS: We studied 2741 primary-care outpatients, 18-70 years in age, who met Rome II criteria for dyspepsia. Patients with alarm features (dysphagia, bleeding, weight loss, etc) were excluded. All patients underwent endoscopy. The cost and diagnostic yield of an early endoscopy strategy in all patients were compared with those of endoscopy limited to age-defined cohorts. Costs were calculated for a low, intermediate, and high cost environment. RESULTS: Endoscopies detected abnormalities in 635 patients (23%). The most common findings were reflux esophagitis with erosions (15%), gastric ulcers (2.7%), and duodenal ulcers (2.3%). The prevalence of upper gastrointestinal malignancy was 0.22%. If all dyspeptic patients 50 years or older underwent endoscopy, 1 esophageal cancer and no gastric cancers would have been missed. If the age threshold for endoscopy were set at 50 years, at a cost of $500/endoscopy, it would cost $82,900 (95% CI, $35,714-$250,000) to detect each case of cancer. CONCLUSIONS: Primary care dyspeptic patients without alarm symptoms rarely have serious underlying conditions at endoscopy. The costs associated with diagnosing an occult malignancy are large, but an age cut-off of 50 years for early endoscopy provides the best assurance that an occult malignancy will not be missed.

Approach to gastroesophageal reflux disease in primary care: Putting the Montreal definition into practice.

OBJECTIVE: To apply the recently published Montreal definition of gastroesophageal reflux disease (GERD) in primary care. SOURCES OF INFORMATION: The Montreal definition of GERD was developed by an international consensus group of experts in GERD and primary care physicians using rigorous evidence-based methods along with modern consensus development techniques and a patient-centred approach. MAIN MESSAGE: Gastroesophageal reflux disease can be diagnosed in primarycare based on symptoms alone without additional diagnostic testing. Symptoms reach a threshold where they constitute disease when they are troublesome (cause difficulty) to patients. In addition to the cardinal symptoms of heartburn and regurgitation, people with GERD can also have sleep disturbances, chest pains, or respiratory symptoms. Monitoring patients' response to proton pump inhibitor therapy can confirm the success of management. Treatment for symptoms of GERD can also heal underlying reflux esophagitis if it is present. CONCLUSION: Primary care physicians can diagnose and manage GERD confidently in most patients by investigating and treating troublesome symptoms without the need for additional investigations or referral to specialists.

An international primary care survey of GERD terminology and guidelines.

BACKGROUND: Terminology used to describe upper gastrointestinal disorders differs by country and language. However, the extent of variation in physician understanding of GERD and associated conditions and symptoms is not known. AIM: To determine the knowledge of primary care physicians with regard to: terminology related to GERD, their understanding of related complications and extra-esophageal symptoms/conditions, and their use of guidelines relating to GERD. METHODS: Gastroenterologists from 17 countries asked primary care physician colleagues to complete a one-page online survey on GERD. RESULTS: 352 primary care physicians, (77% community-based, 23% hospital-based) completed the questionnaire. Gastroesophageal reflux disease/GERD (84%) or reflux/reflux disease (47%) were the terms mostly often used to record a diagnosis for patients with reflux-related symptoms or clinical manifestations; dyspepsia (15%), epigastric pain (10%), and gastritis (9%) were infrequently used. Erosive esophagitis, Barrett's esophagus, stricture, and esophageal adenocarcinoma were recognized as being associated with GERD by 88, 71, 61 and 51% of physicians, respectively. Extra-esophageal problems of cough, sleep-related disorders, laryngitis and asthma were recognized to be associated with GERD by 74, 50, 48 and 47% of respondents. Thirty-nine percent of physicians stated that they did not use a specific definition of GERD; 33% used an international and 14% used a national guideline in managing patients. CONCLUSIONS: (1) GERD is well recognized, but its related terminology is variable throughout the world. (2) There was variable and incomplete recognition of extra-esophageal manifestations GERD. (3) Recognition of extra-esophageal diseases caused by GERD is variable. (4) Current GERD guidelines are infrequently used by primary care physicians.

Approach to managing undiagnosed chest pain: could gastroesophageal reflux disease be the cause?

OBJECTIVE: To highlight gastroesophageal reflux disease as a common cause of undiagnosed chest pain. SOURCES OF INFORMATION: Diagnostic considerations are based on information in peer-reviewed articles retrieved from MEDLINE. Studies had to be in English and involve at least 30 subjects. Population-based studies had to have a sample size of at least 300 and a response rate of at least 60%. Thirty-seven relevant articles were found. MAIN MESSAGE: Clinical management of patients presenting with diagnostically challenging chest pain starts with a careful search for coronary artery disease and other potentially life-threatening causes. Investigations must continue until the underlying disease is identified and symptoms have been effectively controlled. Ongoing symptoms of undiagnosed chest pain cause considerable suffering, impair quality of life, and add unnecessary costs to the health care system. In more than half the patients with undiagnosed chest pain, symptoms are caused by gastroesophageal disease. Empirical acid-suppressive therapy with a proton pump inhibitor can assist clinicians in identifying patients whose symptoms are acid-related. CONCLUSION: Many patients with undiagnosed chest pain can be managed in primary care, minimizing the need for referrals and costly investigations.

Recommendations on chronic constipation (including constipation associated with irritable bowel syndrome) treatment.

While chronic constipation (CC) has a high prevalence in primary care, there are no existing treatment recommendations to guide health care professionals. To address this, a consensus group of 10 gastroenterologists was formed to develop treatment recommendations. Although constipation may occur as a result of organic disease, the present paper addresses only the management of primary CC or constipation associated with irritable bowel syndrome. The final consensus group was assembled and the recommendations were created following the exact process outlined by the Canadian Association of Gastroenterology for the following areas: epidemiology, quality of life and threshold for treatment; definitions and diagnostic criteria; lifestyle changes; bulking agents and stool softeners; osmotic agents; prokinetics; stimulant laxatives; suppositories; enemas; other drugs; biofeedback and behavioural approaches; surgery; and probiotics. A treatment algorithm was developed by the group for CC and constipation associated with irritable bowel syndrome. Where possible, an evidence-based approach and expert opinions were used to develop the statements in areas with insufficient evidence. The nature of the underlying pathophysiology for constipation is often unclear, and it can be tricky for physicians to decide on an appropriate treatment strategy for the individual patient. The myriad of treatment options available to Canadian physicians can be confusing; thus, the main aim of the recommendations and treatment algorithm is to optimize the approach in clinical care based on available evidence.

Esomeprazole 40 mg once a day in patients with functional dyspepsia: the randomized, placebo-controlled "ENTER" trial.

OBJECTIVE: The etiologies of functional dyspepsia (FD) are unclear, but in some studies, treatment with a proton pump inhibitor has been beneficial. The objective of this study was to evaluate the efficacy of esomeprazole 40 mg once a day compared to placebo in achieving symptom relief in primary care patients with FD. METHODS: This was a randomized, placebo-controlled trial in adult FD patients, who had at least moderate severity of symptoms, defined as a score of > or =4 on a 7-point Global Overall Symptom (GOS) scale. Patients were excluded if they had predominant symptoms of heartburn or regurgitation; after a normal baseline endoscopy, patients were randomized to esomeprazole 40 mg once daily or placebo for 8 wk. The primary outcome measure was symptom relief (GOS < or =2) at 8 wk. RESULTS: Of the 502 enrolled patients, 224 were randomized. The main reasons for exclusion were abnormal endoscopic findings, especially esophagitis. A significantly greater proportion of patients in the esomeprazole group achieved symptom relief at 4 but not at 8 wk compared to placebo: 4 wk esomeprazole 50.5% versus placebo 32.2%, p= 0.009; 8 wk esomeprazole 55.1% versus placebo 46.1%, p= 0.16. A similar relationship at 4 and 8 wk was seen for symptom resolution (GOS = 1) and improvement (DeltaGOS > or =2). CONCLUSION: For the primary outcome measure of symptom relief at 8 wk, there was no statistically significant difference between esomeprazole 40 mg once a day and placebo. However, at 4 wk, esomeprazole was significantly more effective than placebo for symptom relief. The difference in therapeutic gain between 4 and 8 wk was largely due to a higher placebo response rate at 8 wk.

Evidence-based recommendations for short- and long-term management of uninvestigated dyspepsia in primary care: an update of the Canadian Dyspepsia Working Group (CanDys) clinical management tool.

The present paper is an update to and extension of the previous systematic review on the primary care management of patients with uninvestigated dyspepsia (UD). The original publication of the clinical management tool focused on the initial four- to eight-week assessment of UD. This update is based on new data from systematic reviews and clinical trials relevant to UD. There is now direct clinical evidence supporting a test-and-treat approach in patients with nondominant heartburn dyspepsia symptoms, and head-to-head comparisons show that use of a proton pump inhibitor is superior to the use of H2-receptor antagonists (H2RAs) in the initial treatment of Helicobacter pylori-negative dyspepsia patients. Cisapride is no longer available as a treatment option and evidence for other prokinetic agents is lacking. In patients with long-standing heartburn-dominant (ie, gastroesophageal reflux disease) and nonheartburn-dominant dyspepsia, a once-in-a-lifetime endoscopy is recommended. Endoscopy should also be considered in patients with new-onset dyspepsia that develops after the age of 50 years. Conventional nonsteroidal anti-inflammatory drugs, acetylsalicylic acid and cyclooxygenase-2-selective inhibitors can all cause dyspepsia. If their use cannot be discontinued, cotherapy with either a proton pump inhibitor, misoprostol or high-dose H2RAs is recommended, although the evidence is based on ulcer data and not dyspepsia data. In patients with nonheartburn-dominant dyspepsia, noninvasive testing for H pylori should be performed and treatment given if positive. When starting nonsteroidal anti-inflammatory drugs for a prolonged course, testing and treatment with H2RAs are advised if patients have a history of previous ulcers or ulcer bleeding.

A Canadian clinical practice algorithm for the management of patients with nonvariceal upper gastrointestinal bleeding.

AIM: To use current evidence-based recommendations to provide a user-friendly clinical algorithm for the management of upper gastrointestinal bleeding, adapted to the Canadian environment. METHODS: A multidisciplinary consensus group of 25 participants representing 11 national societies used a seven-step approach to develop recommendations according to accepted standards. Sources of data included narrative and systematic reviews as well as published and new meta-analyses. A small writing subgroup subsequently created the algorithm. RESULTS: Recommendations emphasize appropriate initial resuscitation of the patient and a multidisciplinary approach to clinical risk stratification that determines the need for early endoscopy. Early endoscopy allows safe and prompt discharge of selected patients classified as low risk. Endoscopic hemostasis is reserved for patients with high-risk endoscopic lesions. Although monotherapy with injection or thermal coagulation is effective, the combination is superior to either treatment alone. High-dose intravenous proton-pump inhibition is recommended in patients who have undergone successful endoscopic therapy. Routine second-look endoscopy is not recommended. Patients with upper gastrointestinal bleeding secondary to ulcer disease should be tested and treated for Helicobacter pylori infection. CONCLUSIONS: This algorithm should facilitate appropriate risk stratification, use of endoscopic therapy and the appropriate utilization of proton-pump inhibition to optimize the care of patients with upper gastrointestinal bleeding. The algorithm should be customized to the resources of individual medical centres. Its application should be studied with appropriate outcomes recorded and validation performed.

Canadian Helicobacter Study Group Consensus Conference: Update on the management of Helicobacter pylori--an evidence-based evaluation of six topics relevant to clinical outcomes in patients evaluated for H pylori infection.

As an update to previously published recommendations for the management of Helicobacter pylori infection, an evidence-based appraisal of six topics was undertaken in a consensus conference sponsored by the Canadian Helicobacter Study Group. The issues addressed and recommendations made were: bismuth-containing quadruple therapy is appropriate as an alternative first-line eradication strategy for H pylori infection; searching for and treating H pylori infection is warranted in patients considered to be at high risk for gastric cancer; H pylori infection should be eradicated before initiating long-term treatment with nonsteroidal anti-inflammatory drugs or acetylsalicylic acid; the stool antigen test has a limited role in the diagnosis of H pylori infection; the benefits of H pylori eradication in patients on long-term proton pump inhibitor therapy are not sufficient to warrant recommending a strategy of searching for and eradicating the infection among these patients; and a strategy of "test and eradicate" for H pylori infection in patients with uninvestigated dyspepsia is cost-effective in Canada relative to a trial of proton pump inhibitor therapy. The goal was to establish guidelines on the best evidence using the same structure to address and formulate recommendations for each issue. The degree of consensus for each issue is presented.

Etiology of dyspepsia: implications for empirical therapy.

Dyspepsia describes a symptom complex thought to arise in the upper gastrointestinal tract and includes, in addition to epigastric pain or discomfort, symptoms such as heartburn, acid regurgitation, excessive burping or belching, a feeling of slow digestion, early satiety, nausea and bloating. Based on the evidence that heartburn cannot be reliably distinguished from other dyspeptic symptoms, the Rome definition appears to be too narrow and restrictive. It is particularly ill suited to the management of uninvestigated dyspepsia at the level of primary care. In patients presenting with uninvestigated dyspepsia, a symptom benefit is associated with a 'test and treat' approach for Helicobacter pylori infection. A substantial proportion of those who do not benefit prove to have esophagitis on endoscopy. In those with functional dyspepsia, the benefits of H pylori eradication, if any, appear to be modest. Hence, a 'symptom and treat' acid-suppression trial with proton pump inhibitors, and a 'test and treat' strategy for H pylori are two acceptable empirical therapies for patients with univestigated dyspepsia.