How Would You Manage This Patient With Gastroesophageal Reflux Symptoms? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Gastroesophageal reflux disease (GERD) is a common medical condition presenting with heartburn, regurgitation, cough, hoarseness, and/or wheezing. Patients with classic GERD symptoms often do not require diagnostic studies before empirical treatment is initiated. However, if atypical features are present, including alarm symptoms for malignancy, or if symptoms do not respond to conventional treatment, upper endoscopy may be necessary. The optimal management of GERD, which is the subject of debate, depends on the frequency and severity of symptoms. In 2021, the American College of Gastroenterology published updated recommendations for diagnosis and management of GERD. In addition to histamine-2 receptor antagonist or proton-pump inhibitor therapy, which may be prescribed as needed or continuously, lifestyle and dietary modification are often advised. Here, 2 physicians, a primary care practitioner and a gastroenterologist, debate how to manage a patient with GERD symptoms. They discuss the diagnosis of this condition, its initial management, indications for upper endoscopy, and how to care for the patient whose condition does not respond to empirical therapy.

Red-Tape Roadblocks: How Prior Authorization Intermediaries Delay Optimal Patient Care

In active ulcerative colitis, risankizumab induced and maintained remission

Source Citation Louis E, Schreiber S, Panaccione R, et al; INSPIRE and COMMAND Study Group. Risankizumab for ulcerative colitis: two randomized clinical trials. JAMA. 2024;332:881-897. 39037800

Birth Cohort Effects in Appendiceal Adenocarcinoma Incidence Across the United States

Background: Incidence rates of appendiceal adenocarcinoma (AA) are increasing across all age groups in the United States. Birth cohort patterns of AA can provide new, etiologic clues into increasing rates but have not been examined. Objective: To estimate incidence rates of AA across birth cohorts in the United States. Design: Retrospective cohort study. Setting: The National Institutes of Health and National Cancer Institute SEER (Surveillance, Epidemiology, and End Results) Program of 8 population-based cancer registries. Patients: A total of 4858 persons aged 20 years or older when diagnosed with a pathologically confirmed primary AA (nonmucinous, mucinous, goblet cell, or signet ring cell carcinoma) from 1975 to 2019. Measurements: Five-year age groups and time periods were used to create 21 overlapping birth cohorts (1891–1899 to 1991–1999). The ratio of age-specific incidence rates was estimated in each birth cohort relative to the 1945 birth cohort (birth years 1941 to 1949) and reported as incidence rate ratios (IRRs) with 95% CIs. Results: Incidence rates of AA more than tripled among the 1980 birth cohort (IRR, 3.41 [95% CI, 2.54 to 4.56]) and quadrupled among the 1985 birth cohort (IRR, 4.62 [CI, 3.12 to 6.82]) compared with the 1945 birth cohort. Age-specific incidence rates of AA increased across successive birth cohorts after 1945—although to varying degrees—for all tumor histologic types. Limitation: The rarity of AA precluded investigations specific to signet ring cell carcinomas of the appendix and across population groups (for example, sex and race). Conclusion: There are strong yet distinct birth cohort effects for AAs across histologic subtypes that remain unexplained—particularly among persons born after 1945. Given these patterns, there is a timely need for etiologic research as well as increased AA awareness among providers and the public. Similar trends have been reported for other gastrointestinal cancers, suggestive of potential shared cause contributing to this increasing cancer burden across generations. Primary Funding Source: Appendix Cancer Pseudomyxoma Peritonei Research Foundation, National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and National Cancer Institute.

Trends in Alcohol Use After the COVID-19 Pandemic: A National Cross-Sectional Study

In adults with metabolic dysfunction, the MAF-5 score predicted risk for liver fibrosis (AUC range, 0.73 to 0.81)

Source Citation van Kleef LA, Francque SM, Prieto-Ortiz JE, et al. Metabolic Dysfunction-Associated Fibrosis 5 (MAF-5) score predicts liver fibrosis risk and outcome in the general population with metabolic dysfunction. Gastroenterology. 2024;167:357-367.e9. 38513745

In patients receiving invasive ventilation, PPIs reduce upper GI bleeding but did not affect mortality at 90 d

Source Citation Cook D, Deane A, Lauzier F, et al; REVISE Investigators. Stress ulcer prophylaxis during invasive mechanical ventilation. N Engl J Med. 2024;391:9-20. 38875111

GRADE Guidance: Using Thresholds for Judgments on Health Benefits and Harms in Decision Making (GRADE Guidance 42)

Users of GRADE (Grading of Recommendations Assessment, Development and Evaluation) make judgments about the size of intervention effects on desirable and undesirable people-important health outcomes or on benefits and harms. Benchmarking effect sizes by using decision thresholds (DTs) can help to facilitate these judgments and the process. This article provides GRADE guidance for use of DTs for judgments about the magnitude of desirable and undesirable health effects, such as in a health guideline or health technology assessment. Through iterative discussions and refinement in in-person and online meetings of a GRADE project group and through e-mail communication, the authors developed guidance for using DTs in Evidence-to-Decision (EtD) frameworks. The authors applied the approach and used these examples from guidelines and the results of a randomized methodological study to develop official GRADE guidance. Several alternatives for determining and using DTs are presented. In the first main approach, outcome-specific DTs for trivial, small, moderate, and large effects are determined through a calculation using empirically derived generic coefficients and the outcome’s utility value and are compared with the effect estimate obtained from an evidence synthesis. In the second main approach, outcome-specific DTs are also determined, but through direct surveying of decision makers to explicitly assign thresholds for the prioritized health outcomes. The article also describes how these approaches can be combined. The suggested approaches provide transparency for judgments in EtD frameworks that are based on findings from evidence syntheses.

Patient Navigation to Improve Colonoscopy Completion After an Abnormal Stool Test Result: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 178, No 5

Background: Patient navigation is a recommended practice of the Guide to Community Preventive Services; little is known about whether it improves colonoscopy completion for adults who have received an abnormal stool test result. Objective: To determine whether patient navigation delivered to persons with an abnormal stool test result increased follow-up colonoscopy completion (primary) at 1 year. Design: Randomized controlled trial. (ClinicalTrials.gov: NCT03925883) Setting: A federally qualified health center (n = 32 clinics) in Washington state. Patients: Persons aged 50 to 75 years with an abnormal fecal test result in the prior month. Intervention: A 6-topic, telephone-based patient navigation program delivered by bilingual (English and Spanish) clinical staff. Measurements: Receipt of follow-up colonoscopy at 1 year (primary); time to colonoscopy receipt (secondary); and program effectiveness by patient characteristics, including patients’ probability of obtaining a colonoscopy without navigation, derived using health record data (secondary). Results: Of 985 participants enrolled (mean age, 61 years [SD, 6.8]; 170 [18%] had a Spanish-language preference listed in the medical record), 967 were included in the primary intention-to-treat analysis (479 in patient navigation, 488 in usual care). Receipt of follow-up colonoscopy was higher in the patient navigation group than in the usual care group (55.1% vs. 42.1%; risk difference, 13.0 percentage points [95% CI, 6.5 to 19.4 percentage points]). The intervention effect was not moderated by patients’ probability of obtaining a colonoscopy without navigation. Limitation: The study was primarily done during the height of the COVID-19 pandemic, which created additional barriers to colonoscopy at the health system and patient levels. Conclusion: These findings support the effectiveness of patient navigation for follow-up colonoscopy completion. Primary Funding Source: National Cancer Institute.

How Would You Manage This Patient With Obesity? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

In 2022, 1 in 8 people in the world were living with obesity, and lifestyle interventions that include diet, exercise, and behavioral modification have been the foundation for management of obesity. Recently, pharmacologic therapies have been developed for management of obesity, the newest of these being glucagon-like peptide 1 receptor agonists. With the development of new pharmacologic options, the American Gastroenterological Association developed a guideline in 2022 to provide evidence-based recommendations for the pharmacologic management of obesity in adults and recommended, for adults with obesity or overweight with weight-related complications who have had an inadequate response to lifestyle interventions, adding pharmacologic agents to lifestyle interventions over continuing lifestyle interventions alone. In this article, 2 experts review the available evidence to answer the following questions: How effective are lifestyle interventions for the treatment of obesity? How effective are pharmacologic interventions for the treatment of obesity? Given these options, how do you engage in a shared decision-making discussion to develop a mutually agreed-on treatment plan?