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Background & Aims: The use of domperidone (DOM) for gastroparesis (GP) remains controversial and limited. We aimed to present outcomes of DOM therapy for treatment of patients participating in the multicenter National Institute of Diabetes and Digestive and Kidney Diseases Gastroparesis Clinical Research Consortium (GpCRC) Registries (GpR)., Methods: The GpCRC cohort consisted of patients with GP (75%) and with GP-like symptoms but with normal gastric emptying (25%). The DOM group initiated therapy during the 96 weeks of enrollment in GpR1 and GpR2. Patients who had previously taken or who were on DOM therapy at enrollment were excluded from this analysis. The control group did not use domperidone (non-DOM group) before or after enrollment. The following outcome measures were identified: change from baseline in Gastroparesis Cardinal Symptom Index total score, with 3 subscales, plus Gastroesophageal Reflux Disease and Patient Assessment of Upper Gastrointestinal Disorders-Quality of Life scores., Results: Overall, of 748 patients, 181 (24%) were in the DOM group, whereas 567 were in the non-DOM group. Sixty-three percent of participants had idiopathic GP. At baseline, DOM patients compared with non-DOM patients were significantly younger, had lower body mass index, non-Hispanic ethnicity, a higher annual household income, lower narcotic utilization, lower supplemental and complimentary medication use, and were more likely to have delayed gastric emptying time, as well as worse nausea and fullness scores. Compared with non-DOM patients, DOM patients experienced moderate but significantly more improvement in GP outcome measures: Gastroparesis Cardinal Symptom Index total score (P = .003), nausea (P = .003), and fullness subscales (P =.005), upper abdominal pain score (P = .04), Gastroesophageal Reflux Disease score (P = .05), and Patient Assessment of Upper Gastrointestinal Disorders-Quality of Life score (P = .05)., Conclusions: Utilizing the method of pragmatic modeling to evaluate long-term treatment of GP in a large GpCRC database, DOM treatment resulted in moderately but significantly improved GP. NOTE: This project was based on data generated by 2 GpCRC Registry studies recognized under the Clinicaltrial.gov numbers: NCT00398801 and NCT01696747 symptoms compared with a group receiving standard-of-care but not DOM., (Copyright © 2021 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Context: The ketogenic diet is associated with progressive skeletal demineralization, hypercalciuria, and nephrolithiasis. Acute hypercalcemia has been described as a newly recognized complication of this treatment., Objective: To describe the clinical characteristics of acute hypercalcemia in children on the ketogenic diet through analysis of the presentation, response to treatment, and natural history in a large cohort of patients., Design: A multicenter case series was performed including children who developed acute hypercalcemia while treated with the ketogenic diet. Information on clinical presentation, treatment, and course of this complication was collated centrally., Results: There were 14 patients (median (range) age 6.3 (0.9 to 18) years) who developed hypercalcemia 2.1 (range, 0.2-12) years after starting the ketogenic diet. All had low levels of parathyroid hormone and levels of 1,25-dihydroxyvitamin D were low in all except one. Seven (50%) had impaired renal function at presentation. All except the 2 oldest had low alkaline phosphatase levels for age. Once normocalcemia was achieved, hypercalcemia recurred in only 2 of these patients over observation of up to 9.8 years. One patient discontinued the ketogenic diet prior to achieving normocalcemia while 4 more stopped the diet during follow-up after resolution of hypercalcemia., Conclusions: Ketotic hypercalcemia can occur years after starting the ketogenic diet, especially in the setting of renal impairment. The mechanism is unknown but appears to be due to reduced osteoblast activity and impaired bone formation. We recommend close attention to optimizing bone health in these children, and screening for the development of ketotic hypercalcemia., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background/aims: Patients with irritable bowel syndrome (IBS) in referral practice commonly report mental disorders and functional impairment. Our aim was to determine the prevalence of mental, physical and sleep-related comorbidities in a nationally representative sample of IBS patients and their impact on functional impairment., Methods: IBS was defined by modified Rome Criteria based on responses to the chronic conditions section of the National Comorbidity Survey-Replication. Associations between IBS and mental, physical and sleep disorders and 30-day functional impairment were examined using logistic regression models., Results: Of 5,650 eligible responders, 186 met criteria for IBS {weighted prevalence 2.5% (SE = 0.3)}. Age >60 years was associated with decreased odds (OR = 0.3; 95% CI:.1-.6); low family income (OR = 2.4; 95% CI:1.2-4.9) and unemployed status (OR = 2.3; 95% CI:1.2-4.2) were associated with increased odds of IBS. IBS was significantly associated with anxiety, behavior, mood disorders (ORs 1.8-2.4), but not eating or substance use disorders. Among physical conditions, IBS was associated with increased odds of headache, chronic pain, diabetes mellitus and both insomnia and hypersomnolence related symptoms (ORs 1.9-4.0). While the association between IBS and patients' role impairment persisted after adjusting for mental disorders (OR = 2.4, 95% CI 1.5-3.7), associations with impairment in self-care, cognition, and social interaction in unadjusted models (ORs 2.5-4.2) were no longer significant after adjustment for mental disorders., Conclusion: IBS is associated with socioeconomic disadvantage, comorbidity with mood, anxiety and sleep disorders, and role impairment. Other aspects of functional impairment appear to be moderated by presence of comorbid mental disorders., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Diabetic gastroparesis (Gp) occurs more often in type 1 diabetes mellitus (T1DM) than in type 2 diabetes mellitus (T2DM). Other diabetic end-organ complications include peripheral neuropathy, nephropathy, and retinopathy (together termed triopathy). This study determines the prevalence of diabetic complications (retinopathy, nephropathy, and peripheral neuropathy) in diabetic patients with symptoms of Gp, assessing the differences between T1DM and T2DM and delayed and normal gastric emptying (GE)., Methods: Diabetic patients with symptoms of Gp underwent history and physical examination, GE scintigraphy, electrogastrography with water load, autonomic function testing, and questionnaires assessing symptoms and peripheral neuropathy., Results: One hundred thirty-three diabetic patients with symptoms of Gp were studied: 59 with T1DM and 74 with T2DM and 103 with delayed GE and 30 without delayed GE. The presence of retinopathy (37% vs 24%; P = 0.13), nephropathy (19% vs 11%; P = 0.22), and peripheral neuropathy (53% vs 39%; P = 0.16) was not significantly higher in T1DM than in T2DM; however, triopathies (all 3 complications together) were seen in 10% of T1DM and 3% of T2DM (P = 0.04). Diabetic patients with delayed GE had increased prevalence of retinopathy (36% vs 10%; P = 0.006) and number of diabetic complications (1.0 vs 0.5; P = 0.009); however, 39% of diabetic patients with delayed GE did not have any diabetic complications., Discussion: In diabetic patients with symptoms of Gp, delayed GE was associated with the presence of retinopathy and the total number of diabetic complications. Only 10% of patients with T1DM and 3% of those with T2DM had triopathy of complications, and 39% of diabetic patients with Gp did not have any diabetic complications. Thus, the presence of diabetic complications should raise awareness for Gp in either T1DM or T2DM; however, diabetic Gp frequently occurs without other diabetic complications.

Abdominal pain can be an important symptom in some patients with gastroparesis (Gp)., Aims: (1) To describe characteristics of abdominal pain in Gp; (2) describe Gp patients reporting abdominal pain., Methods: Patients with idiopathic gastroparesis (IG) and diabetic gastroparesis (DG) were studied with gastric emptying scintigraphy, water load test, wireless motility capsule, and questionnaires assessing symptoms [Patient Assessment of Upper GI Symptoms (PAGI-SYM) including Gastroparesis Cardinal Symptom Index (GCSI)], quality of life (PAGI-QOL, SF-36), psychological state [Beck Depression Inventory (BDI), State-Trait Anxiety Index (STAI), PHQ-15 somatization scale]., Results: In total, 346 Gp patients included 212 IG and 134 DG. Ninety percentage of Gp patients reported abdominal pain (89% DG and 91% IG). Pain was primarily in upper or central midline abdomen, described as cramping or sickening. Upper abdominal pain was severe or very severe on PAGI-SYM by 116/346 (34%) patients, more often by females than by males, but similarly in IG and DG. Increased upper abdominal pain severity was associated with increased severity of the nine GCSI symptoms, depression on BDI, anxiety on STAI, somatization on PHQ-15, the use of opiate medications, decreased SF-36 physical component, and PAGI-QOL, but not related to severity of delayed gastric emptying or water load ingestion. Using logistic regression, severe/very severe upper abdominal pain associated with increased GCSI scores, opiate medication use, and PHQ-15 somatic symptom scores., Conclusions: Abdominal pain is common in patients with Gp, both IG and DG. Severe/very severe upper abdominal pain occurred in 34% of Gp patients and associated with other Gp symptoms, somatization, and opiate medication use. ClinicalTrials.gov Identifier: NCT01696747.

Background & Aims: Gastroparesis is a chronic disorder of the stomach characterized by nausea, vomiting, early satiety, postprandial fullness, and abdominal pain. There is limited information on gastroparesis in minority populations. We assessed ethnic, racial, and sex variations in the etiology, symptoms, quality of life, gastric emptying, treatments, and symptom outcomes of patients with gastroparesis., Methods: We collected information from the National Institutes of Health Gastroparesis Consortium on 718 adult patients, from September 2007 through December 2017. Patients were followed every 4 or 6 months, when data were collected on medical histories, symptoms (based on answers to the PAGI-SYM questionnaires), and quality of life (based on SF-36). Follow-up information collected at 1 year (48 week) was used in this analysis. Comparisons were made between patients of self-reported non-Hispanic white, non-Hispanic black, and Hispanic ethnicities, as well as and between male and female patients., Results: Our final analysis included 552 non-Hispanic whites (77%), 83 persons of Hispanic ethnicity (12%), 62 non-Hispanic blacks (9%), 603 women (84%), and 115 men (16%). A significantly higher proportion of non-Hispanic blacks (60%) had gastroparesis of diabetic etiology than of non-Hispanic whites (28%); non-Hispanic blacks also had more severe retching (2.5 vs 1.7 score) and vomiting (2.9 vs 1.8 score) and a higher percentage were hospitalized in the past year (66% vs 38%). A significantly higher proportion of Hispanics had gastroparesis of diabetic etiology (59%) than non-Hispanic whites (28%), but Hispanics had less-severe nausea (2.7 vs 3.3 score), less early satiety (3.0 vs 3.5 score), and a lower proportion used domperidone (8% vs 21%) or had a peripherally inserted central catheter (1% vs 7%). A higher proportion of women had gastroparesis of idiopathic etiology (69%) than men (46%); women had more severe symptoms of stomach fullness (3.6 vs 3.1 score), early satiety (3.5 vs 2.9 score), postprandial fullness (3.7 vs 3.1 score), bloating (3.3 vs 2.6 score), stomach visibly larger (3.0 vs 2.1 score), and upper abdominal pain (2.9 vs 2.4 score). A lower proportion of women were hospitalized in past year (39% vs 53% of men)., Conclusions: In patients with gastroparesis, etiologies, symptom severity, and treatments vary among races and ethnicities and between sexes. ClinicalTrials.gov Identifier: NCT01696747., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objective: To provide external validation of the diagnostic accuracy of the Sleep Apnea Clinical Score (SACS) tool in a new setting and patient population., Patients and Methods: We conducted a prospective cohort study. Potential participants were adult family medicine patients. We excluded patients with a SACS of 0, known obstructive sleep apnea (OSA), negative results of previous testing, or life-limiting conditions. After SACS determination, participants completed overnight oximetry, sleep medicine consultation, and polysomnography. Those interpreting tests were blind to the participant's SACS. We determined likelihood ratios (LRs) for OSA diagnosis and posttest probabilities (PTPs). We calculated OSA prevalence (pretest probability), sensitivity, specificity, and positive and negative predictive values., Results: One hundred ninety-one of 312 participants (61%) completed all steps. The prevalence of OSA was similar to that found in the derivation cohort (40% vs 45%; P=.31). With OSA defined as Apnea Hypopnea Index greater than 10, a SACS greater than 15 was 40% sensitive and 90% specific, with a positive predictive value of 73% and a negative predictive value of 69%. A SACS greater than 15 in our cohort produced an LR of 4.03 (95% CI, 3.12-5.22) with 73% PTP for OSA as compared with an LR of 5.17 (95% CI, 2.54-10.51) with 78% PTP found in the derivation cohort., Conclusion: The present study provides external validation of the SACS tool. It reliably predicted OSA for patients in our family medicine practice. Broader implementation in primary care practice is recommended. Further study will examine SACS uptake by clinicians and the resulting impact on utilization and clinical efficiency in primary care practices., (Copyright © 2016 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Residents find it difficult to access medical care. Some seek care within their own program. Our objectives were to (1) determine whether family medicine program directors see their own resident physicians as patients, (2) describe whether they perceive the residency culture as actively encouraging of this practice, and (3) assess perceptions about reasons to encourage or discourage this., Methods: We used a paper-based self-administered survey November 2013--January 2014. A stratified random sample of family medicine residencies based on administrative type was used. Participants were directors of sampled programs. The main outcome measure was provision of medical care to resident physicians., Results: A total of 137/250 directors (55%) responded. Thirty (22%) reported seeing residents as patients in their family medicine clinic while 107 did not (78%). Some directors who do see resident patients expressed discomfort in doing so (24%). Participants reported that other faculty physicians were significantly more likely to see residents (56%). Eighty-eight percent (114/129) agreed that "Having a doctor-patient relationship with a resident makes a supervisory relationship more difficult." Significant differences in attitudes were noted between directors who do and do not provide resident medical care. Few directors (10 %) agreed that their residency culture actively encouraged residents to establish doctor-patient relationships with faculty physicians. Only 16 (12%) had created written policies., Conclusions: It is uncommon for directors to see residents as patients, but most who do feel comfortable with it. Other faculty physicians provide care more frequently. Directors acknowledge potential difficulties with this practice, but few have addressed these issues by creating specific policies.

Objectives: (1) Characterize physicians' management practices for fecal incontinence (FI) among elderly patients, (2) describe physician perceptions of the quality of care for FI provided in nursing homes (NH), and (3) identify physician views and attributes associated with referral of elderly patients with FI to an NH., Design: Cross-sectional., Setting: United States., Participants: Physician members of the American Geriatrics Society., Measurements: Questionnaire pertaining to physician views on (1) their own FI management practices, (2) management of FI in NHs, and (3) referral of an elderly patient with FI to an NH., Results: Of the respondents (n = 606), 54.1% reported screening for FI and 59.3% thought FI could be managed conservatively on an outpatient basis. Only 32.9% believed NHs provide good care for FI, and 27.1% believed NH care conditions exacerbate FI. Responding to a hypothetical vignette, 10.6% would probably or definitely refer an older adult patient with only FI to an NH, and 17.2% were uncertain about whether or not to refer. Logistic regression analysis identified physician characteristics associated with decreased likelihood of NH referral as the belief that FI can be managed conservatively, the belief that NHs provide poor care for FI, longer practice experience, and practicing in an academic medical center., Conclusion: Most geriatricians believe FI can be managed conservatively and that NHs provide poor care for FI. These beliefs plus longer years of practice and practice in an academic setting decrease the likelihood of referral to NH for patients with FI., (Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: Determine the effect of fecal incontinence (FI) on healthcare providers' decisions to refer patients for nursing home (NH) placement., Design: Survey., Setting: Questionnaires were e-mailed to participants' homes or offices. Participants could also volunteer at the 2008 American Geriatric Society annual meeting in Washington, DC., Participants: Two thousand randomly selected physician members and all 181 nurse practitioner members of the American Geriatrics Society were surveyed., Measurements: The survey presented a clinical scenario of a 70-year-old woman ready for discharge from a hospital and asked about the likelihood of making a NH referral if the patient had no incontinence, urinary incontinence (UI) alone, or FI. Subsequent questions modified the clinical situation to include other conditions that might affect the decision to refer. A second survey of respondents to Survey 1 addressed possible moderators of the decision to refer (e.g., family caregiver presence, diarrhea or constipation, other physical or psychiatric limitations). Significance of differences in the relative risk (RR) for NH referral was tested using the chi-square test., Results: Seven hundred sixteen members (24.7% response rate) completed the first survey, and 686 of the 716 (96%) completed the second. FI increased the likelihood of NH referral (RR=4.71, P<.001) more than UI did (RR=1.90, P<.001). Mobility restrictions, cognitive decline, and multiple chronic illnesses increased the likelihood of NH referral more than FI alone (P<.001 for each), but in all scenarios, adding FI further increased the likelihood of referral (P<.001). Having family caregivers willing to help with toileting attenuated the likelihood of referral., Conclusion: FI increases the probability that geriatricians will refer to a NH. More-aggressive outpatient treatment of FI might delay or prevent NH referral, improve quality of life, and reduce healthcare costs.

Fecal incontinence is a common problem in women, which often enforces life changes owing to embarrassment and social stigma. It is frequently not reported or diagnosed. Age, obstetric trauma, pelvic surgery, chronic diarrhea, obesity and other medical conditions, such as diabetes and stroke, increase the risk of fecal incontinence. Preventive strategies include avoiding diarrheal triggers, discouraging the routine use of episiotomies, early recognition and management of obstetric injuries and possibly pelvic floor muscle exercises after childbirth. Treatment options are available and should be discussed with the patient. These, in order of progression, are education and medications for diarrhea or constipation, supportive care, biofeedback training and surgery.

No patient-oriented evidence supports pneumococcal revaccination of any patient (high-risk or otherwise). Antibody levels may be augmented by revaccination; however, the clinical efficacy of revaccination, even among high-risk patients, is unknown. Revaccination is recommended by the Advisory Committee on Immunization Practices (ACIP) in certain circumstances (strength of recommendation [SOR]: C, expert opinion based on physiology/bench research). Revaccination once appears to be safe, especially if provided 5 years or more after primary vaccination (SOR: B, based upon consistent results of cohort studies and nonrandomized prospective trials).

Background and Objectives: Our residency program experienced applicants who actively misrepresented qualifications, background, or abilities. The experiences of other family practice residencies were unknown. This study 1) determined what information family practice residency directors required from applicants, 2) assessed whether this information was confirmed or verified, and 3) describes the deceptive application information discovered by program directors., Methods: A questionnaire was sent to directors of all accredited family practice residencies. Information was collected about required information, data confirmation, and the deception and misrepresentation perceived., Results: Thirty-two percent of the directors responded. Eight of 13 items on the Electronic Residency Application System were designated as required by more than half of responding directors. Only two of the items (licensure and certain facts in the personal statement) were confirmed by a majority of directors who required them. Deception was recognized by nearly half of respondents within the past 5 years. Most cases involved specialty choice or the personal statement of candidates and were recognized during the interview or by direct confirmation of data., Conclusions: Most directors appear to accept application information at face value. Recognition of deception about application information was reported. Misrepresentation by applicants may be a more common event than previously realized and may require more thorough verification of application credentials.

Background and Objectives: This study describes the content of family practice residency orientation programs, presents data about resident satisfaction with orientation, and determines if residents feel prepared for residency duties., Methods: We surveyed program directors and first-year residents at 100 family practice residency programs. We used questionnaires to collect data about orientation activities; program demographics; and resident characteristics, satisfaction, and preparation., Results: Sixty-nine percent of directors and 68% of their residents responded. The activity most frequently presented was a social event with faculty, while the least frequently presented was an assessment of cognitive knowledge. Even though residents desire orientation to clinical programs, and directors wish to promote group cohesion, the greatest number of orientation activities were presented to introduce hospital services and administration. Eighty-seven percent of residents were at least "somewhat satisfied," and 83% felt at least "somewhat prepared" for clinical duties after completing orientations. Residents from military programs were more likely not to be satisfied with their orientations. Extreme satisfaction was associated with residents in community-based programs. Being totally prepared was associated with having had prior graduate medical education., Conclusions: While residents had previously reported having clinical needs from an orientation, the most frequently reported activities were nonclinical. Most residents reported having been satisfied with their orientations and having felt prepared for their new duties. Directors should consider increasing the clinical content of their orientations, including an assessment of residents' knowledge and clinical skills.

Background and Objectives: Orientation to a residency program introduces residents to the essential functions of their duties, clarifies expectations, and acclimates them to a new social group. This study identified the orientation goals of family practice residency directors and compared those goals to the perceived needs of first-year family practice residents., Methods: We surveyed program directors and PGY-1 residents at 100 accredited family practice residency programs. Questionnaires obtained descriptive information about orientation programs and resident demographics and assessed directors' goals and residents' needs from orientations., Results: The orientation goal ranked most highly by directors was development of group cohesion. The need ranked most highly by residents was introduction to call duties and inpatient problems. Ranked responses of each group were not well associated., Conclusions: The orientation goals of program directors and the reported orientation needs of residents were poorly associated. Most directors chose nonclinical areas as their most important goals for orientation. In contrast, most residents valued clinically related information during orientation to residency.