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Aby ES, Eckmann JD, Abimansour J, Katzka DA, Beveridge C, Triggs JR, Dbouk M, Abdi T, Turner KO, Antunes C, Zhuo J, Kamal AN, Patel P, Gyawali CP, Sloan JA. Esophageal Lichen Planus: A Descriptive Multicenter Report. J Clin Gastroenterol 2024; 58:427-431. [PMID: 37436831 PMCID: PMC10994181 DOI: 10.1097/mcg.0000000000001885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 06/05/2023] [Indexed: 07/14/2023]
Abstract
GOALS To better understand the characteristics, treatment approaches, and outcomes of patients with esophageal lichen planus (ELP). BACKGROUND ELP is a rare, often unrecognized and misdiagnosed disorder. Data on this unique patient population are currently limited to small, single-center series. STUDY A multicenter, retrospective descriptive study was conducted of adults diagnosed with ELP over a 5-year period, between January 1, 2015, and October 10, 2020, from 7 centers across the United States. RESULTS Seventy-eight patients (average age 65 y, 86% female, 90% Caucasian) were included. Over half had at least 1 extraesophageal manifestation. Esophageal strictures (54%) and abnormal mucosa (50%) were frequent endoscopic findings, with the proximal esophagus the most common site of stricture. Approximately 20% had normal endoscopic findings. Topical steroids (64%) and/or proton pump inhibitors (74%) dominated management; endoscopic response favored steroids (43% vs. 29% respectively). Almost half of the patients required switching treatment modalities during the study period. Adjunctive therapies varied significantly between centers. CONCLUSIONS Given its at times subtle clinical and endoscopic signs, a high index of suspicion and biopsy will improve ELP diagnosis, especially in those with extraesophageal manifestations. Effective therapies are lacking and vary significantly. Prospective investigations into optimal treatment regimens are necessary.
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Affiliation(s)
- Elizabeth S. Aby
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition
| | - Jason D. Eckmann
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition
| | - Jad Abimansour
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - David A. Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Claire Beveridge
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Joseph R. Triggs
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Mohamad Dbouk
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tsion Abdi
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kevin O. Turner
- Department of Pathology, University of Minnesota, Minneapolis
| | - Catiele Antunes
- Division of Digestive Disease and Nutrition, University of Oklahoma, Oklahoma City, OK
| | - Justin Zhuo
- Department of Medicine, Division of Gastroenterology, Stanford University, Stanford, CA
| | - Afrin N. Kamal
- Department of Medicine, Division of Gastroenterology, Stanford University, Stanford, CA
| | - Parth Patel
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | - Joshua A. Sloan
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition
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Kamal AN, Wang CHJ, Triadafilopoulos G, Diehl DL, DuCoin C, Dunst CM, Falk G, Iyer PG, Katzka DA, Konda VJA, Muthusamy R, Otaki F, Pleskow D, Rubenstein JH, Shaheen NJ, Sharma P, Smith MS, Sujka J, Swanstrom LL, Tatum RP, Trindade AJ, Ujiki M, Wani S, Clarke JO. A Delphi Method for Development of a Barrett's Esophagus Question Prompt List as a Communication Tool for Optimal Patient-physician Communication. J Clin Gastroenterol 2024; 58:131-135. [PMID: 36753462 DOI: 10.1097/mcg.0000000000001832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/02/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND METHODS The question prompt list content was derived through a modified Delphi process consisting of 3 rounds. In round 1, experts provided 5 answers to the prompts "What general questions should patients ask when given a new diagnosis of Barrett's esophagus" and "What questions do I not hear patients asking, but given my expertise, I believe they should be asking?" Questions were reviewed and categorized into themes. In round 2, experts rated questions on a 5-point Likert scale. In round 3, experts rerated questions modified or reduced after the previous rounds. Only questions rated as "essential" or "important" were included in Barrett's esophagus question prompt list (BE-QPL). To improve usability, questions were reduced to minimize redundancy and simplified to use language at an eighth-grade level (Fig. 1). RESULTS Twenty-one esophageal medical and surgical experts participated in both rounds (91% males; median age 52 years). The expert panel comprised of 33% esophagologists, 24% foregut surgeons, and 24% advanced endoscopists, with a median of 15 years in clinical practice. Most (81%), worked in an academic tertiary referral hospital. In this 3-round Delphi technique, 220 questions were proposed in round 1, 122 (55.5%) were accepted into the BE-QPL and reduced down to 76 questions (round 2), and 67 questions (round 3). These 67 questions reached a Flesch Reading Ease of 68.8, interpreted as easily understood by 13 to 15 years olds. CONCLUSIONS With multidisciplinary input, we have developed a physician-derived BE-QPL to optimize patient-physician communication. Future directions will seek patient feedback to distill the questions further to a smaller number and then assess their usability.
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Affiliation(s)
- Afrin N Kamal
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City
| | - Chih-Hung Jason Wang
- Department of Pediatrics and Department of Health Policy, Stanford University School of Medicine, Stanford
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City
| | - David L Diehl
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Geisinger Commonwealth School of Medicine, Danville
| | - Christopher DuCoin
- Department of Surgery, USF Morsani College of Medicine, University of South Florida
| | - Christy M Dunst
- Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic Center for Advanced Surgery
| | - Gary Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic Minnesota, Rochester, MN
| | | | - Vani J A Konda
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor University Medical Center, Dallas, TX
| | - Raman Muthusamy
- Division of Digestive Diseases, Vatche and Tamar Manoukian David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Fouad Otaki
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, OR
| | - Douglas Pleskow
- Division of Gastroenterology Beth Israel Deaconess Medical Center, Boston, MN
| | - Joel H Rubenstein
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; Barrett's Esophagus Program, University of Michigan, Ann Arbor, MI
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, NC
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, Veterans Affairs Medical Center, Kansas City, MS
| | - Michael S Smith
- Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai West and Mount Sinai Morningside Hospitals, Icahn School of Medicine at Mount Sinai, New York
| | - Joseph Sujka
- Department of Surgery, Tampa General Hospital, Tampa, FL
| | - Lee L Swanstrom
- Insitute of Image-Guided Surgery, IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, FR
| | - Roger P Tatum
- Department of Surgery, University of Washington School of Medicine and VA Puget Sound Health Care System, Seattle, WA
| | - Arvind J Trindade
- Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, NY
| | - Michael Ujiki
- Department of Surgery, University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - Sachin Wani
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City
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Kamal AN, Kathpalia P, Leiman DA, Bredenoord AJ, Clarke JO, Gyawali CP, Katzka DA, Lazarescu A, Pandolfino JE, Penagini R, Roman S, Savarino E, Vela MF, Otaki F. Quality Indicator Development for the Approach to Ineffective Esophageal Motility: A Modified Delphi Study. J Clin Gastroenterol 2024:00004836-990000000-00251. [PMID: 38227852 DOI: 10.1097/mcg.0000000000001963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 12/11/2023] [Indexed: 01/18/2024]
Abstract
GOALS Develop quality indicators for ineffective esophageal motility (IEM). BACKGROUND IEM is identified in up to 20% of patients undergoing esophageal high-resolution manometry (HRM) based on the Chicago Classification. The clinical significance of this pattern is not established and management remains challenging. STUDY Using RAND/University of California, Los Angeles Appropriateness Methods, we employed a modified-Delphi approach for quality indicator statement development. Quality indicators were proposed based on prior literature. Experts independently and blindly scored proposed quality statements on importance, scientific acceptability, usability, and feasibility in a 3-round iterative process. RESULTS All 10 of the invited esophageal experts in the management of esophageal diseases invited to participate rated 12 proposed quality indicator statements. In round 1, 7 quality indicators were rated with mixed agreement, on the majority of categories. Statements were modified based on panel suggestion, modified further following round 2's virtual discussion, and in round 3 voting identified 2 quality indicators with comprehensive agreement, 4 with partial agreement, and 1 without any agreement. The panel agreed on the concept of determining if IEM is clinically relevant to the patient's presentation and managing gastroesophageal reflux disease rather than the IEM pattern; they disagreed in all 4 domains on the use of promotility agents in IEM; and had mixed agreement on the value of a finding of IEM during anti-reflux surgical planning. CONCLUSION Using a robust methodology, 2 IEM quality indicators were identified. These quality indicators can track performance when physicians identify this manometric pattern on HRM. This study further highlights the challenges met with IEM and the need for additional research to better understand the clinical importance of this manometric pattern.
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Affiliation(s)
- Afrin N Kamal
- Division of Gastroenterology and Hepatology, Stanford University, Redwood City
| | - Priya Kathpalia
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA
| | - David A Leiman
- Division of Gastroenterology, Duke University School of Medicine & Duke Clinical Research Institute, Durham, NC
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, Utrecht, The Netherlands
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University, Redwood City
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington in St. Louis, St. Louis, MO
| | - David A Katzka
- Division of Gastroenterology, Columbia University, New York, NY
| | - Adriana Lazarescu
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - John E Pandolfino
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Roberto Penagini
- Gastroenterology Unit, University of Milan, Fondazione IRCCS Cà Granda Ospedale Policlinico, Milan, Italy
| | - Sabine Roman
- Digestive Physiology, Lyon I Hospices Civils de Lyon, Lyon, France
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology,University of Padua, Padua, Veneto, Italy
| | - Marcelo F Vela
- Division of Gastroenterology, Mayo Clinic, Scottsdale, AZ
| | - Fouad Otaki
- Division of Gastroenterology & Hepatology, Oregon Health & Science University, Portland, OR
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Yamamoto M, Kamal AN, Gabbard S, Clarke J, Gyawali CP, Leiman DA. Esophageal Function Testing Patterns in the Evaluation and Management of Lung Transplantation: Results of a National Survey. J Clin Gastroenterol 2023:00004836-990000000-00242. [PMID: 38047589 DOI: 10.1097/mcg.0000000000001955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 11/12/2023] [Indexed: 12/05/2023]
Abstract
GOALS We surveyed esophageal motility laboratories affiliated with adult pulmonary transplant centers to determine esophageal function testing (EFT) practices. BACKGROUND Gastroesophageal reflux and esophageal dysmotility are associated with worse lung transplant outcomes, yet no consensus guidelines for EFT exist in this population. STUDY A deidentified online survey was sent to gastrointestinal motility laboratory directors of 49 academic and community-affiliated medical centers that perform lung transplants. Practice characteristics, including annual lung transplant volume and institutional EFT practices pre-lung transplantation and post-lung transplantation were queried. Respondents were categorized by transplant volume into small and large programs based on median annual volume. RESULTS Among 35 respondents (71% response rate), the median annual transplant volume was 37, and there were 18 large programs. Institutional EFT protocols were used pretransplant by 24 programs (68.6%) and post-transplant by 12 programs (34.2%). Among small and large programs, 52.9% and 72.2% always obtained high-resolution manometry before transplant, respectively. Endoscopy before transplant was performed more often in small programs (n=17, 100%) compared with large programs (n=15,83.3%). Pretransplant endoscopy (P=0.04), barium esophagram (P<0.01), and high-resolution manometry (P=0.04) were more common than post-transplant. In contrast, post-transplant reflux monitoring off-therapy was more common than pretransplant (P=0.01). In general, pulmonologists direct referrals for EFT and gastroenterology consultation (n=28, 80.0%), with symptoms primarily prompting testing. CONCLUSIONS In the absence of established guidelines, substantial variability exists in pretransplant and post-transplant EFT, directed by pulmonologists. Standardized EFT protocols and gastroenterologist-directed management of esophageal dysfunction has potential to improve lung transplant outcomes.
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Affiliation(s)
| | - Afrin N Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA
| | - Scott Gabbard
- Division of Gastroenterology, Cleveland Clinic, Cleveland, OH
| | - John Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | - David A Leiman
- Division of Gastroenterology, Duke University
- Duke Clinical Research Institute, Durham, NC
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Jiang Y, Sonu I, Garcia P, Fernandez-Becker NQ, Kamal AN, Zikos TA, Singh S, Neshatian L, Triadafilopoulos G, Goodman SN, Clarke JO. The Impact of Intermittent Fasting on Patients With Suspected Gastroesophageal Reflux Disease. J Clin Gastroenterol 2023; 57:1001-1006. [PMID: 36730832 DOI: 10.1097/mcg.0000000000001788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/27/2022] [Indexed: 02/04/2023]
Abstract
GOAL The aim was to investigate the short-term impact of time restricted feeding on patients with suspected gastroesophageal reflux disease (GERD). BACKGROUND Lifestyle modifications are often suggested, but the role of diet in GERD is unclear. Intermittent fasting is popular in the media and has demonstrated potential benefits with weight loss and inflammatory conditions as well as alterations in gastrointestinal hormones. STUDY Patients who were referred for 96-hour ambulatory wireless pH monitoring off proton pump inhibitor to investigate GERD symptoms were screened for eligibility. Patients were instructed to maintain their baseline diet for the first 2 days of pH monitoring and switch to an intermittent fasting regimen (16 consecutive hour fast and 8 h eating window) for the second 2 days. Objective measures of reflux and GERD symptom severity were collected and analyzed. RESULTS A total of 25 participants were analyzed. 9/25 (36%) fully adhered to the intermittent fasting regimen, with 21/25 (84%) demonstrating at least partial compliance. Mean acid exposure time on fasting days was 3.5% versus 4.3% on nonfasting days. Intermittent fasting was associated with a 0.64 reduction in acid exposure time (95% CI: -2.32, 1.05). There was a reduction in GERD symptom scores of heartburn and regurgitation during periods of intermittent fasting (14.3 vs. 9.9; difference of -4.46, 95% CI: -7.6,-1.32). CONCLUSIONS Initial adherence to time restricted eating may be difficult for patients. There is weak statistical evidence to suggest that intermittent fasting mildly reduces acid exposure. Our data show that short-term intermittent fasting improves symptoms of both regurgitation and heartburn.
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Affiliation(s)
- Yan Jiang
- Division of Gastrointestinal and Liver Diseases, Keck Medicine of University of Southern California, Los Angeles
| | - Irene Sonu
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
| | - Patricia Garcia
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
| | | | - Afrin N Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
| | - Thomas A Zikos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
| | - Sundeep Singh
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
| | - Steven N Goodman
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
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Leiman DA, Kamal AN, Otaki F, Bredenoord AJ, Dellon ES, Falk GW, Fernandez-Becker NQ, Gonsalves N, Hirano I, Katzka DA, Peterson K, Yadlapati R, Kathpalia P. Quality Indicators for the Diagnosis and Management of Eosinophilic Esophagitis. Am J Gastroenterol 2023; 118:1091-1095. [PMID: 36599135 PMCID: PMC10392038 DOI: 10.14309/ajg.0000000000002138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/21/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Despite best practice recommendations for managing eosinophilic esophagitis (EoE), variation in care exists. METHODS We used established methodology for quality indicator development to identify metrics to define quality for the treatment of EoE. RESULTS Among 29 proposed quality indicator statements, 9 (31%) were adopted as highly valid across all categories. Two (22%) of these statements were identified as having existing or suspected quality gaps. DISCUSSION We identified highly valid EoE quality indicators for adult gastroenterologists, which can be used for quality improvement with resulting benefits for patient outcomes.
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Affiliation(s)
- David A. Leiman
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Afrin N. Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Fouad Otaki
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Albert J. Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina, North Carolina, USA
| | - Gary W. Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania, USA
| | - Nielsen Q. Fernandez-Becker
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Ikuo Hirano
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - David A. Katzka
- Division of Gastroenterology, Columbia University Medical Center, New York, New York, USA
| | | | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, California, USA
| | - Priya Kathpalia
- Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, California, USA
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Achalu S, Berry R, Zhuo J, Bredenoord AJ, Clarke JO, Fass R, Gyawali CP, Kahrilas PJ, Katzka DA, Massey BT, Penagini R, Roman S, Savarino E, Vela MF, Kamal AN. Development and modification of a dysphagia question prompt list to improve patient-physician communication: Incorporating both esophageal expert and patient perspectives. Neurogastroenterol Motil 2023:e14600. [PMID: 37122123 DOI: 10.1111/nmo.14600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Question prompt lists (QPLs) are structured sets of disease-specific questions, intended to encourage question-asking by patients and enhance patient-physician communication. To date, a dysphagia-specific QPL has not been developed for patients with esophageal dysphagia symptoms. We aim to develop a dysphagia-specific QPL incorporating both esophageal expert and patient perspectives, applying rigorous methodology. METHODS The QPL content was generated applying a two-round modified Delphi (RAND/UCLA) method among 11 experts. In round one, experts provided five answers to the prompts: "What general questions should patients ask when being seen for dysphagia?" and "What questions do I not hear patients asking but, given my experience, I believe they should be asking?" In round two, experts rated proposed questions on a 5-point Likert scale. Responses rated as "essential" or "important", determined by an a priori median threshold of ≥4.0, were accepted for inclusion. Subsequently, 20 patients from Stanford Health Care were enrolled to modify the preliminary QPL, to incorporate their perspectives and opinions. Patients independently rated questions applying the same 5-point Likert scale. At the end, patients were encouraged to propose additional questions to incorporate into the QPL by open-endedly asking "Are there questions we didn't ask, that you think we should?" KEY RESULTS Eleven experts participated in both voting rounds. Of 85 questions generated from round one, 60 (70.6%) were accepted for inclusion, meeting a median value of ≥4.0. Questions were combined to reduce redundancy, narrowing down to 44 questions. Questions were categorized into the following six themes: 1. "What is causing my dysphagia?"; 2. "Associated symptoms"; 3. "Testing for dysphagia"; 4. "Lifestyle modifications"; 5. "Treatment for dysphagia"; and 6. "Prognosis". The largest number of questions covered "What is causing my dysphagia" (27.3%). Twenty patients participated and modified the QPL. Of the 44 questions experts agreed were important, only 30 questions (68.2%) were accepted for inclusion. Six patients proposed 10 additional questions and after incorporating the suggested questions, the final dysphagia-specific QPL created by esophageal experts and modified by patients consisted of 40 questions. CONCLUSIONS & INFERENCES Incorporating expert and patient perspectives, we developed a dysphagia-specific QPL to enhance patient-physician communication. Our study highlights importance of incorporating patient perspective when developing such a communication tool. Further studies will measure the impact of this communication tool on patient engagement.
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Affiliation(s)
- Sudharshan Achalu
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, California, USA
| | - Rani Berry
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, California, USA
| | - Justin Zhuo
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, California, USA
| | - Albert J Bredenoord
- Division of Neurogastroenterology and Motility, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - John O Clarke
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, California, USA
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, MetroHealth, Cleveland, Ohio, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - David A Katzka
- Division of Gastroenterology, Columbia University, New York, New York, USA
| | - Benson T Massey
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Roberto Penagini
- Division of Gastroenterology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan, Milan, Italy
| | - Sabine Roman
- Division of Digestive Physiology, Centre Hospitalier Universitaire de Lyon, Lyon, France
| | | | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Afrin N Kamal
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, California, USA
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Abstract
BACKGROUND Quality indicators (QIs) are formal ways to track health care performance and outcomes, guide quality improvement, and identify gaps in care delivery. We developed twelve quality indicators for achalasia management which cover the domains of patient education, diagnosis, and treatment of achalasia. AIM To determine adherence to established quality indicators for achalasia management. METHODS We performed a retrospective, multicenter evaluation of care patterns for adult patients greater than 18 years old with newly diagnosed achalasia from January 2018 to May 2020. A balanced random patient sample was obtained at four large academic medical centers. Independent electronic health record chart abstraction was performed using a standardized form to determine adherence to applicable QIs. Pooled and de-identified data were analyzed to identify gaps in care. RESULTS A total of 120 patients were included and the overall adherence to applicable quality indicators across all centers was 86%. The median follow-up for all patients from time of diagnosis to end of study was 511 days. Clinicians adhered to all applicable quality indicators in 49 patients (39%). The quality indicator domain with the poorest adherence was patient education (67%), with 50% of patients having had a documented discussion of the risks of gastroesophageal reflux disease following surgical or endoscopic myotomy. CONCLUSIONS Gaps in the quality of achalasia care delivery were identified, the largest of which relates to patient education about treatment risks. These findings highlight a potential area for future quality improvement studies and form the basis for developing fully specified quality measures.
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Affiliation(s)
- Emily Romanoff
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, 27708, USA
| | - Justin Zhuo
- Department of Medicine, Stanford University, Stanford, CA, 94305, USA
| | - Annsa C Huang
- Division of Gastroenterology, UCSF, San Francisco, CA, 94143, USA
| | - Deron Amador
- Division of Gastroenterology, OHSU, Portland, OR, 97239, USA
| | - Fouad Otaki
- Division of Gastroenterology, OHSU, Portland, OR, 97239, USA
| | - Afrin N Kamal
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford, CA, 94305, USA
| | - Priya Kathpalia
- Division of Gastroenterology, UCSF, San Francisco, CA, 94143, USA
| | - David A Leiman
- Division of Gastroenterology, Duke University, Durham, NC, 27708, USA.
- Duke Clinical Research Institute, Durham, NC, 27708, USA.
- Division of Gastroenterology, Duke University School of Medicine, 200 Morris Street, Suite 6524, Durham, NC, 27701, USA.
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Kamal AN, Harris KB, Sarvapalli S, Sayuk GS, Gyawali CP, Gabbard S. Nutrient Drink Test to Assess Gastric Accommodation in Cyclic Vomiting Syndrome: Single-blinded Parallel Grouped Prospective Study. J Neurogastroenterol Motil 2023; 29:65-71. [PMID: 36606437 PMCID: PMC9837548 DOI: 10.5056/jnm22013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 01/07/2023] Open
Abstract
Background/Aims Cyclic vomiting syndrome (CVS) is characterized by episodes of nausea and vomiting, separated by symptom-free intervals. The pathogenesis of CVS is poorly understood. Limited data exist on evaluating impaired gastric accommodation as a mechanistic means for symptoms. We aim to determine if CVS patients demonstrate impaired gastric accommodation applying a nutrient drink test (NDT) protocol. Methods Through this single-blinded pilot clinical trial, patients with CVS per Rome IV critera and healthy controls were assessed for presence of impaired gastric accommodation by administering an established NDT protocol. Statistical analysis was performed, with data presented as medians and interquartile range. Results Eleven CVS patients and 15 healthy controls participated in the study between January 2018 and October 2018. Median age was 42.0 years and 37.0 years; majority of subjects were female, 72.7% and 73.3%, respectively. Demographics were similar between CVS and healthy controls. Almost all healthy controls (93.3%) ingested the complete 500 mL protocol, whereas a smaller proportion (72.7%) were able to complete all 4 doses in the CVS group (P = 0.188). Post-prandial visual analogue scale scores of nausea and abdominal pain were found to be significantly higher in CVS patients compared to healthy controls. Conclusions To our knowledge, this is the first NDT protocol in CVS evaluating the role of impaired gastric accommodation and hypersensitivity as a possible pathophysiologic mechanism. Findings from this study suggest the presence of gastric hypersensitivity in a subset of CVS patients. These results provide the foundational data necessary for future larger testing of NDT and diagnostic accuracy in CVS.
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Affiliation(s)
- Afrin N Kamal
- Department of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA, USA
| | | | | | - Gregory S Sayuk
- Division of Gastroenterology, Washington University, St. Louis, MO, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University, St. Louis, MO, USA
| | - Scott Gabbard
- Cleveland Clinic Digestive Diseases Surgical Institute, Cleveland, OH, USA,Correspondence: Scott Gabbard, MD, Division of Gastroenterology and Hepatology, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA, Tel: +1-216-444-6523, Fax: +1-216-636-6302, E-mail:
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Kamal AN, Dhar SI, Bock JM, Clarke JO, Lechien JR, Allen J, Belafsky PC, Blumin JH, Chan WW, Fass R, Fisichella PM, Marohn M, O'Rourke AK, Postma G, Savarino EV, Vaezi MF, Carroll TL, Akst LM. Best Practices in Treatment of Laryngopharyngeal Reflux Disease: A Multidisciplinary Modified Delphi Study. Dig Dis Sci 2022; 68:1125-1138. [PMID: 35995882 DOI: 10.1007/s10620-022-07672-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/12/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Laryngopharyngeal reflux (LPR) is a common otolaryngologic diagnosis. Treatment of presumed LPR remains challenging, and limited frameworks exist to guide treatment. METHODS Using RAND/University of California, Los Angeles (UCLA) Appropriateness Methods, a modified Delphi approach identified consensus statements to guide LPR treatment. Experts independently and blindly scored proposed statements on importance, scientific acceptability, usability, and feasibility in a four-round iterative process. Accepted measures reached scores with ≥ 80% agreement in the 7-9 range (on a 9-point Likert scale) across all four categories. RESULTS Fifteen experts rated 36 proposed initial statements. In round one, 10 (27.8%) statements were rated as valid. In round two, 8 statements were modified based on panel suggestions, and experts subsequently rated 5 of these statements as valid. Round three's discussion refined statements not yet accepted, and in round four, additional voting identified 2 additional statements as valid. In total, 17 (47.2%) best practice statements reached consensus, touching on topics as varied as role of empiric treatment, medication use, lifestyle modifications, and indications for laryngoscopy. CONCLUSION Using a well-tested methodology, best practice statements in the treatment of LPR were identified. The statements serve to guide physicians on LPR treatment considerations.
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Affiliation(s)
- Afrin N Kamal
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Redwood City, CA, USA.
| | - Shumon I Dhar
- Department of Otolaryngology, Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jonathan M Bock
- Department of Otolaryngology & Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Redwood City, CA, USA
| | - Jerome R Lechien
- Department of Otolaryngology Head Neck Surgery, Elsan Hospital, Paris, France
| | - Jacqueline Allen
- Department of Otolaryngology, Head and Neck Surgery, University of Auckland, Auckland, New Zealand
| | - Peter C Belafsky
- Department of Otolaryngology/Head and Neck Surgery, Davis School of Medicine, University of California, Sacramento, CA, USA
| | - Joel H Blumin
- Department of Otolaryngology & Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Walter W Chan
- Division of Gastroenterology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Ronnie Fass
- Division of Gastroenterology, Department of Medicine, MetroHealth, Cleveland, OH, USA
| | | | - Michael Marohn
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ashli K O'Rourke
- Department of Otolaryngology, Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Gregory Postma
- Department of Otolaryngology, Head and Neck Surgery, Augusta University, Augusta, GA, USA
| | - Edoardo V Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Michael F Vaezi
- Division of Gastroenterology, Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Thomas L Carroll
- Division of Otolaryngology and Harvard Medical School, Department of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Lee M Akst
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Kamal AN, Triadafilopoulos G, Gyawali CP, Nguyen L, Sayuk GS, Azagury DE, Tatum RP, Clarke JO. Model for multi-disciplinary, multi-institutional virtual learning: The Stanford Esophageal Virtual Collaborative Conference on benign esophageal diseases. Neurogastroenterol Motil 2022; 34:e14369. [PMID: 35340088 DOI: 10.1111/nmo.14369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/15/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Afrin N Kamal
- Division of Gastroenterology, Department of Medicine, Stanford University, Stanford, California, USA
| | - George Triadafilopoulos
- Division of Gastroenterology, Department of Medicine, Stanford University, Stanford, California, USA
| | - Chandra Prakash Gyawali
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Linda Nguyen
- Division of Gastroenterology, Department of Medicine, Stanford University, Stanford, California, USA
| | - Gregory S Sayuk
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Dan E Azagury
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Roger P Tatum
- Department of Surgery, University of Washington, and VA Puget Sound Healthcare System, Seattle, Washington, USA
| | - John O Clarke
- Division of Gastroenterology, Department of Medicine, Stanford University, Stanford, California, USA
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Kamal AN, Kathpalia P, Otaki F, Bredenoord AJ, Castell DO, Clarke JO, Falk GW, Fass R, Gyawali CP, Kahrilas PJ, Katz PO, Katzka DA, Pandolfino JE, Penagini R, Richter JE, Roman S, Savarino E, Triadafilopoulos G, Vaezi MF, Vela MF, Leiman DA. Development of quality indicators for the diagnosis and management of achalasia. Neurogastroenterol Motil 2021; 33:e14118. [PMID: 33720448 PMCID: PMC9380030 DOI: 10.1111/nmo.14118] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/21/2021] [Accepted: 02/14/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND The management of achalasia has improved due to diagnostic and therapeutic innovations. However, variability in care delivery remains and no established measures defining quality of care for this population exist. We aimed to use formal methodology to establish quality indicators for achalasia patients. METHODS Quality indicator concepts were identified from the literature, consensus guidelines and clinical experts. Using RAND/University of California, Los Angeles (UCLA) Appropriateness Method, experts in achalasia independently ranked proposed concepts in a two-round modified Delphi process based on 1) importance, 2) scientific acceptability, 3) usability, and 4) feasibility. Highly valid measures required strict agreement (≧ 80% of panelists) in the range of 7-9 for across all four categories. KEY RESULTS There were 17 experts who rated 26 proposed quality indicator topics. In round one, 2 (8%) quality measures were rated valid. In round two, 19 measures were modified based on panel suggestions, and experts rated 10 (53%) of these measures as valid, resulting in a total of 12 quality indicators. Two measures pertained to patient education and five to diagnosis, including discussing treatment options with risk and benefits and using the most recent version of the Chicago Classification to define achalasia phenotypes, respectively. Other indicators pertained to treatment options, such as the use of botulinum toxin for those not considered surgical candidates and management of reflux following achalasia treatment. CONCLUSIONS & INFERENCES Using a robust methodology, achalasia quality indicators were identified, which can form the basis for establishing quality gaps and generating fully specified quality measures.
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Affiliation(s)
- Afrin N. Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Priya Kathpalia
- Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, California, USA
| | - Fouad Otaki
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Donald O. Castell
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John O. Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Gary W. Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania, USA
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Department of Medicine, The MetroHealth Medical Center and Case Western Reserve, Cleveland, Ohio, USA
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Peter J Kahrilas
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Philip O. Katz
- Division of Gastroenterology, Weill Cornell School of Medicine, New York, NY, USA
| | - David A. Katzka
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John E. Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, Università degli Studi of Milan, Milan, Italy,Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Joel E. Richter
- Division of Digestive Diseases & Nutrition, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon, Hospital E Herriot and Lyon I University, Lyon, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Michael F. Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marcelo F. Vela
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - David A. Leiman
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
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Affiliation(s)
- Monica Nandwani
- Center for Advanced Practice, Stanford Health Care, Palo Alto, California.
| | - Karuna Dewan
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Palo Alto, California
| | - Heather Starmer
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Palo Alto, California
| | - Afrin N Kamal
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California
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Dewan K, Clarke JO, Kamal AN, Nandwani M, Starmer HM. Patient Reported Outcomes and Objective Swallowing Assessments in a Multidisciplinary Dysphagia Clinic. Laryngoscope 2020; 131:1088-1094. [PMID: 33103765 DOI: 10.1002/lary.29194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 09/28/2020] [Accepted: 10/01/2020] [Indexed: 11/05/2022]
Abstract
OBJECTIVES/HYPOTHESIS Dysphagia encompasses a complex compilation of symptoms which often differ from findings of objective swallowing evaluations. The purpose of this investigation was to compare the results of subjective dysphagia measures to objective measures of swallowing in patients evaluated in a multidisciplinary dysphagia clinic. STUDY DESIGN Prospective cohort study. METHODS The study cohort included all patients evaluated in the multidisciplinary dysphagia clinic over 24 months. Participants were evaluated by a multidisciplinary team including a laryngologist, gastroenterologist, and speech-language pathologist. Evaluation included a videofluoroscopic swallowing study (VFSS), fiberoptic endoscopic evaluation of swallowing (FEES), and transnasal esophagoscopy (TNE). Data collected included diet (FOIS), Eating Assessment Tool (EAT-10) score, Reflux symptom index (RSI) score, and the findings of the VFSS exam. RESULTS A total of 75 patients were included in the analysis. The average EAT-10 score was 16.3 ± 2.1, RSI was 21.4 ± 0.6, and FOIS score was 6.0 ± 1.33. VFSS revealed impairments in the oral phase in 40% of the cohort, pharyngeal in 59%, and esophageal in 49%. Abnormalities were noted in one phase for 32%, in 2 phases in 32%, and three phases in 18%. Patients with abnormal pharyngeal findings on VFSS had significantly higher EAT-10 scores (P = .04). Patients with abnormal oral findings on VFSS were noted to have significantly lower FOIS scores (P = .03). CONCLUSIONS Data presented here demonstrate a relationship between patient reported symptoms and objective VFSS findings in a cohort of patients referred for multidisciplinary swallowing assessment suggesting such surveys are helpful screening tools but inadequate to fully characterize swallowing impairment. LEVEL OF EVIDENCE 3 Laryngoscope, 131:1088-1094, 2021.
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Affiliation(s)
- Karuna Dewan
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Afrin N Kamal
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Monica Nandwani
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Heather M Starmer
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
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Kamal AN, Clarke JO, Oors JM, Bredenoord AJ. The role of ambulatory 24-hour esophageal manometry in clinical practice. Neurogastroenterol Motil 2020; 32:e13861. [PMID: 32391594 PMCID: PMC7583476 DOI: 10.1111/nmo.13861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/19/2020] [Accepted: 03/30/2020] [Indexed: 12/13/2022]
Abstract
High-resolution manometry revolutionized the assessment of esophageal motility disorders and upgraded the classification through the Chicago Classification. A known disadvantage of standard HRM, however, is the inability to record esophageal motility function for an extended time interval; therefore, it represents only a more snapshot view of esophageal motor function. In contrast, ambulatory esophageal manometry measures esophageal motility over a prolonged period and detects motor activity during the entire circadian cycle. Furthermore, ambulatory manometry has the ability to measure temporal correlations between symptoms and motor events. This article aimed to review the clinical implications of ambulatory esophageal manometry for various symptoms, covering literature on the manometry catheter, interpretation of findings, and relevance in clinical practice specific to the evaluation of non-cardiac chest pain, chronic cough, and rumination syndrome.
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Affiliation(s)
- Afrin N. Kamal
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - John O. Clarke
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Jac M. Oors
- Department of Gastroenterology and HepatologyAmsterdam University Medical CentreAmsterdamThe Netherlands
| | - Albert J. Bredenoord
- Department of Gastroenterology and HepatologyAmsterdam University Medical CentreAmsterdamThe Netherlands
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Clarke JO, Ahuja NK, Fernandez-Becker NQ, Gregersen H, Kamal AN, Khan A, Lynch KL, Vela MF. The functional lumen imaging probe in gastrointestinal disorders: the past, present, and future. Ann N Y Acad Sci 2020; 1482:16-25. [PMID: 32814368 DOI: 10.1111/nyas.14463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/08/2020] [Accepted: 07/22/2020] [Indexed: 12/14/2022]
Abstract
The functional lumen imaging probe (FLIP) is a diagnostic tool that utilizes impedance planimetry to allow the assessment of luminal diameter and distensibility. It has been used primarily in esophageal diseases, in particular, in the assessment of achalasia, esophagogastric junction outflow obstruction, and eosinophilic esophagitis (EoE). The usage and publications have increased over the past decade and it is now an essential tool in the armamentarium of the esophagologist. Indications are emerging outside of the esophagus, in particular with regard to gastroparesis. Our paper will review the history of FLIP, optimal current usage, data for key esophageal disorders (including achalasia, reflux, and EoE), data for nonesophageal disorders, and our sense as to whether FLIP is ready for prime time, as well as gaps in evidence and suggestions for future research.
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Affiliation(s)
- John O Clarke
- Department of Medicine, Stanford University, Redwood City, California
| | - Nitin K Ahuja
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Hans Gregersen
- Department of Surgery, the Chinese University of Hong Kong, Hong Kong, China
| | - Afrin N Kamal
- Department of Medicine, Stanford University, Redwood City, California
| | - Abraham Khan
- Department of Medicine, New York University, New York, New York
| | - Kristie L Lynch
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marcelo F Vela
- Gastroenterology Division, The Mayo Clinic, Scottsdale, Arizona
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Abstract
PURPOSE OF REVIEW This paper aims to review the definition and diagnostic criteria for reflux hypersensitivity and comment on the present and future management of this condition. RECENT FINDINGS In 2016, the Rome IV criteria redefined reflux hypersensitivity as characterized by typical reflux symptoms, absence of endoscopic mucosal disease, absence of pathologic gastroesophageal reflux, and positive symptom correlation between reflux and heartburn episodes. Though uncertain, TPRV1 receptors have been implicated in the pathophysiology of reflux hypersensitivity. Recent studies have shown neuromodulators like SSRIs, SNRIs, and TCAs may be the future of managing this condition. With the release of the Rome IV criteria and availability of continuous pH monitoring, the diagnosis of reflux hypersensitivity has become more streamlined. Though there is no definitive therapy for reflux hypersensitivity, several anti-secretory agents and neuromodulators have shown some efficacy in therapeutic trials. The lack of large-scale, randomized controlled trials, however, reinforces the need for further research into the pharmacotherapy of reflux hypersensitivity.
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Affiliation(s)
- Pankaj Aggarwal
- University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Afrin N Kamal
- Division of Gastroenterology, Stanford University, 420 Broadway Street, Pavilion D, Redwood City, CA, 94063, USA.
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Clarke JO, Ahuja NK, Chan WW, Gyawali CP, Horsley-Silva JL, Kamal AN, Vela MF, Xiao Y. Mucosal impedance for esophageal disease: evaluating the evidence. Ann N Y Acad Sci 2020; 1481:247-257. [PMID: 32588457 DOI: 10.1111/nyas.14414] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/21/2020] [Accepted: 05/28/2020] [Indexed: 12/13/2022]
Abstract
Impedance has traditionally been employed in esophageal disease as a means to assess bolus flow and reflux episodes. Recent and ongoing research has provided new and novel applications for this technology. Measurement of esophageal mucosal impedance, via either multichannel intraluminal impedance catheters or specially designed endoscopically deployed impedance catheters, provides a marker of mucosal integrity. Mucosal impedance has been shown to segregate gastroesophageal reflux disease (GERD) and eosinophilic esophagitis from non-GERD controls and may play a role in predicting response to reflux intervention. More data are needed with regard to other esophageal subgroups, outcome studies, and functional disease. Our paper reviews the history of impedance in esophageal disease, the means of assessing baseline and mucosal impedance, data with regard to the newly developed mucosal impedance probes, the clinical utility of mucosal impedance in specific clinical conditions, and limitations in our existing knowledge, along with suggestions for future studies.
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Affiliation(s)
- John O Clarke
- Department of Medicine, Stanford University, Redwood City, California
| | - Nitin K Ahuja
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Walter W Chan
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | | | | | - Afrin N Kamal
- Department of Medicine, Stanford University, Redwood City, California
| | - Marcelo F Vela
- Gastroenterology Division, the Mayo Clinic, Scottsdale, Arizona
| | - Yinglian Xiao
- Department of Gastroenterology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Kamal AN, Garcia P, Clarke JO. Under Pressure: Do Volume-Based Measurements Define Rectal Hyposensitivity in Clinical Practice? Dig Dis Sci 2019; 64:1062-1063. [PMID: 30963367 DOI: 10.1007/s10620-019-05613-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Afrin N Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC 5244, Stanford, CA, 94305, USA
| | - Patricia Garcia
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC 5244, Stanford, CA, 94305, USA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC 5244, Stanford, CA, 94305, USA.
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Zikos TA, Kamal AN, Neshatian L, Triadafilopoulos G, Clarke JO, Nandwani M, Nguyen LA. High Prevalence of Slow Transit Constipation in Patients With Gastroparesis. J Neurogastroenterol Motil 2019; 25:267-275. [PMID: 30870880 PMCID: PMC6474696 DOI: 10.5056/jnm18206] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 01/09/2019] [Accepted: 01/21/2019] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Current evidence suggests the presence of motility or functional abnormalities in one area of the gastrointestinal tract increases the likelihood of abnormalities in others. However, the relationship of gastroparesis to chronic constipation (slow transit constipation and dyssynergic defecation) has been incompletely evaluated. Methods We retrospectively reviewed the records of all patients with chronic dyspeptic symptoms and constipation who underwent both a solid gastric emptying scintigraphy and a high-resolution anorectal manometry at our institution since January 2012. When available, X-ray defecography and radiopaque marker colonic transit studies were also reviewed. Based on the gastric emptying results, patients were classified as gastroparesis or dyspepsia with normal gastric emptying (control group). Differences in anorectal and colonic findings were then compared between groups. Results Two hundred and six patients met the inclusion criteria. Patients with gastroparesis had higher prevalence of slow transit constipation by radiopaque marker study compared to those with normal emptying (64.7% vs 28.1%, P = 0.013). Additionally, patients with gastroparesis had higher rates of rectocele (88.9% vs 60.0%, P = 0.008) and intussusception (44.4% vs 12.0%, P = 0.001) compared to patients with normal emptying. There was no difference in the rate of dyssynergic defecation between those with gastroparesis vs normal emptying (41.1% vs 42.1%, P = 0.880), and no differences in anorectal manometry findings. Conclusions Patients with gastroparesis had a higher rate of slow transit constipation, but equal rates of dyssynergic defecation compared to patients with normal gastric emptying. These findings argue for investigation of possible delayed colonic transit in patients with gastroparesis and vice versa.
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Affiliation(s)
- Thomas A Zikos
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City, CA, USA
| | - Afrin N Kamal
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City, CA, USA
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City, CA, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City, CA, USA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City, CA, USA
| | - Monica Nandwani
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City, CA, USA
| | - Linda A Nguyen
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City, CA, USA
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Sathick IJ, Zand L, Kamal AN, Norby SM, Garovic VD. Acute Interstitial Nephritis: Etiology, Pathogenesis, Diagnosis, Treatment and Prognosis. ACTA ACUST UNITED AC 2014. [DOI: 10.4081/nr.2013.e4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Acute interstitial nephritis (AIN) is an important and common cause of acute kidney injury, particularly in hospitalized patients. The classic presentation of AIN includes fever, rash, arthralgias, eosinophilia, and acute kidney injury. While renal biopsy is considered the gold standard for diagnosis, the clinical presentation of fever and rash along with laboratory evidence of peripheral blood eosinophilia, eosinophiluria, and low-grade proteinuria strongly suggest the diagnosis. Histologically, interstitial inflammation with interstitial edema and tubulitis is the hallmark of interstitial nephritis. The most common causative factors are drugs, infections, and certain immune-mediated disorders. Discontinuation of the offending agent is considered the mainstay of therapy while the use of corticosteroids to hasten renal recovery may be beneficial. The role of interstitial nephritis in the pathogenesis of chronic kidney disease and end-stage renal disease is increasingly recognized, further emphasizing the importance of its early diagnosis and timely treatment.
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Affiliation(s)
| | - Ladan Zand
- Department of Medicine, Mayo Clinic, Rochester, MN
| | - Afrin N. Kamal
- Department of Medicine, Barnes-Jewish Hospital, Washington University, St. Louis, MO, USA
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Kamal AN, Santra AB, Uppal T, Verma RC. Nonfactorization in hadronic two-body Cabibbo-favored decays of D0 and D+. Phys Rev D Part Fields 1996; 53:2506-2515. [PMID: 10020245 DOI: 10.1103/physrevd.53.2506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Kamal AN, Santra AB. Probing factorization in the color-suppressed decay B--> psi (2S)+K(K*). Phys Rev D Part Fields 1995; 51:1415-1418. [PMID: 10018604 DOI: 10.1103/physrevd.51.1415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Gourdin M, Kamal AN, Pham XY. Difficulties in explaining recent data on B-->J/ psi +K(K*) decays with commonly used form factors within the factorizstion approach. Phys Rev Lett 1994; 73:3355-3358. [PMID: 10057360 DOI: 10.1103/physrevlett.73.3355] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Kamal AN, Pham TN. Test of factorization in Cabibbo-favored two-body hadronic decays of D mesons. Phys Rev D Part Fields 1994; 50:6849-6854. [PMID: 10017662 DOI: 10.1103/physrevd.50.6849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Kamal AN, Xu QP. Introducing light vector and axial vector mesons in the union of chiral and heavy quark symmetries. Phys Rev D Part Fields 1994; 49:1526-1533. [PMID: 10017127 DOI: 10.1103/physrevd.49.1526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Kamal AN, Xu QP, Czarnecki A. Cabibbo-angle-favored two-body hadronic decays of Ds+ in the factorization scheme. Phys Rev D Part Fields 1993; 48:5215-5225. [PMID: 10016182 DOI: 10.1103/physrevd.48.5215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Xu QP, Kamal AN. Nonleptonic charmed-baryon decays: Bc-->B(3/2(+), decuplet)+P(0(-)) or V(1(-)). Phys Rev D Part Fields 1992; 46:3836-3844. [PMID: 10015340 DOI: 10.1103/physrevd.46.3836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Kamal AN, Verma RC, Sinha N. (D,Ds+)-->VV decays in two models: An SU(3)-symmetry model and a factorization model, with final-state interactions. Phys Rev D Part Fields 1991; 43:843-854. [PMID: 10013446 DOI: 10.1103/physrevd.43.843] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Verma RC, Kamal AN. Cabibbo-angle-favored, -suppressed, and -doubly-suppressed D-->PP and D-->VP decays in SU(3) symmetry with final-state interactions. Int J Clin Exp Med 1991; 43:829-842. [PMID: 10013445 DOI: 10.1103/physrevd.43.829] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Kamal AN, Sinha N, Sinha R. Will the observation of Ds+--> omega pi + be a signal for the annihilation mechanism? Phys Rev D Part Fields 1989; 39:3503-3506. [PMID: 9959600 DOI: 10.1103/physrevd.39.3503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Kamal AN, Sinha R. Coupled-channel treatment of Cabibbo-angle-suppressed (D,Ds+)-->PP decays. Phys Rev D Part Fields 1987; 36:3510-3513. [PMID: 9958126 DOI: 10.1103/physrevd.36.3510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Kamal AN, Verma RC. Erratum: Analysis of charm-->PP based on SU(3) symmetry and final-state interactions. Phys Rev D Part Fields 1987; 36:3527. [PMID: 9971976 DOI: 10.1103/physrevd.36.3527.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Kamal AN, Verma RC. Analysis of charm-->PP based on SU(3) symmetry and final-state interactions. Phys Rev D Part Fields 1987; 35:3515-3518. [PMID: 9957610 DOI: 10.1103/physrevd.35.3515] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Kamal AN, Chong-Huah L, Rahman M. Phenomenological Lagrangian for nonleptonic charmed-meson decays. Phys Rev D Part Fields 1985; 31:1055-1065. [PMID: 9955797 DOI: 10.1103/physrevd.31.1055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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