Development of the dyspepsia educational tool was funded by a grant received from The Netherlands Organization for Health Research and Development (ZonMw), in the context of the &#39;to do or not to do&#39; program by the Netherlands Federation of University Medical Centers (NFU). We also would like to thank all the staff from Medify bv. for support, equipment, and expertise. In addition we would like to thank all our participants.

All procedures described in this protocol were approved by the Radboud university medical center Institutional Review Board (file no. 2016-3074).
1. Preliminary research
<ol>
	<li>Focus groups to assess unmet needs in dyspepsia management
	<ol>
		<li>Create a structure for a focus group with dyspeptic patients and with general practitioners.</li>
		<li>Conduct a focus group. Keep conducting additional focus groups until saturation of information is reached. 
		NOTE: For this study two focus groups were conducted.
		<ol>
			<li>Recruit participants from patient organization platforms and the gastroenterology outpatient clinic.</li>
			<li>Recruit general practitioners through local general practitioner networks.</li>
			<li>Provide all participants with a patient information form, explaining the concept and goal of the focus group. Do not present the questions of the focus group in the information form.</li>
			<li>Obtain written informed consent from all participants. 
			&#8203;NOTE: Informed consent was obtained from all participants in this study.</li>
			<li>Conduct the focus groups with two researchers. Appoint a moderator and an observer. As a moderator, emphasize that there are no wrong answers, ensure all participants have the opportunity to express their views, and monitor the time. As an observer, observe and take notes of the group dynamics and body language of participants.</li>
			<li>Start the recording of the session using a voice recorder.</li>
			<li>Present each question to the group and encourage discussion about varying views. Ask the following questions; &#39;Could you describe the symptoms you feel?&#39;, &#39;How do the symptoms influence your day-to-day life?&#39;, &#39;What measures have you taken yourself to relieve your symptoms?&#39;, &#39;Where did you get most information about your disease?&#39;, and &#39;Which elements lacked in the management of your disease?&#39;.</li>
			<li>Transcribe the voice recording. Process the focus groups and interviews using the qualitative data analysis software (e.g., ATLAS.ti version 8.3.16).</li>
			<li>Highlight and connect topics and views that overlap. Use the observer notes for interpretation of discussion and opposite views of participants.</li>
			<li>Extract the main themes resulting from the focus group to form the structure of the tool.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Existing scientific evidence
	<ol>
		<li>Based on the main outlines that resulted from assessment of needs, make an overview of the topics that should be supported by literature. Examples are pathophysiology of dyspepsia, dietary interventions, pharmacological treatment, and (the value of) diagnostics.</li>
		<li>Use the online databases Medline and EMBASE to search for recent literature. To build a search, MeSH terms (Medline) or Emtree terms (EMBASE) should be combined with free text words.</li>
		<li>Select the most relevant articles to use as scientific background in the tool.</li>
		<li>Find local and national guidelines related to dyspepsia management. Make a selection of recommendations most relevant to the target audience.</li>
		<li>Summarize existing national patient information on dyspepsia. Use approved primary and secondary care information, as well as government supported web-based information.</li>
	</ol>
	</li>
</ol>
2. Content development
<ol>
	<li>Software development partner
	<ol>
		<li>Select a partner for software production to involve in the development. Make a selection based on available products, such as 3D visualization, video recording, user friendly content management system, and possibilities to do adjustments after pilot test. 
		&#8203;NOTE: For this study, Medify Media B.V. was contracted for software development.</li>
	</ol>
	</li>
	<li>Organization of data
	<ol>
		<li>Combine all collected data in one file and merge related topics. Create a clear overview of all items that should be addressed in the tool.</li>
		<li>Categorize the information into manageable chapters.</li>
		<li>Organize the items into a logical flow that will be maintained in the tool, for example by drawing up a flowchart illustrating the flow and content of each chapter and interconnection between chapters.</li>
		<li>Organize the chapters in a nonlinear structure, allowing completion of chapters in random order.</li>
	</ol>
	</li>
	<li>Process session
	<ol>
		<li>Organize a process session with all stakeholders, including involved researchers, doctors, software developers, and visual designers.</li>
		<li>Within the process session, identify all elements that can be visualized through real-life videos or animation or should appear as text.</li>
	</ol>
	</li>
	<li>Creation of content
	<ol>
		<li>Start every chapter with an overview of the chapter, introduce important items and terms.</li>
		<li>At the end of every chapter, give a chapter summary. Refrain from giving redundant information that may distract attention.</li>
		<li>Highlight essential information using bullet points and/or bold text.</li>
		<li>Use plain language writing when writing texts.
		<ol>
			<li>Clearly consider the target audience and write from that perspective.</li>
			<li>Maintain a 7th to 8th grade reading level.</li>
			<li>Use active rather than passive sentences, writing in a conversational style, including the frequent use of questions and personal pronouns (e.g., &#39;do you regularly feel full after a normal sized meal? Try to avoid fatty foods.&#39;, rather than &#39;if a full feeling after a normal sized meal is regularly encountered, avoiding fatty foods may be tried.&#39;).</li>
			<li>Limit the amount of text per paragraph to a maximum of 10 sentences.</li>
		</ol>
		</li>
		<li>For the videos:
		<ol>
			<li>Make a list of people needed for the real-life videos (e.g., patients, doctors, dieticians).</li>
			<li>Write detailed scripts and log files for all videos.</li>
			<li>Select an entourage for shooting of the videos, appropriate to the subject of the video, and with reduced noise level.</li>
		</ol>
		</li>
		<li>For 3D visualization of elements of the content:
		<ol>
			<li>Use visual references for each step of the desired 3D animation.</li>
			<li>Split animations into clips of 8&#8722;12 s. Before and after a clip, provide text blocks with information about the clip.</li>
		</ol>
		</li>
	</ol>
	</li>
</ol>
3. Building the digital educational tool
<ol>
	<li>Add all the content to a content management system to adjust the order and appearance. 
	NOTE: In this study, the Medify B.V. content management system was used.</li>
	<li>Add all the text and the videos to panels. Choose a background image or a 3D visualization. Add customized questionnaires.</li>
	<li>Check whether everything is correctly incorporated in the tool.</li>
	<li>When all content is built into the content management system, create a pilot version of the educational tool.</li>
</ol>
4. User experience and validation
<ol>
	<li>Administer the pilot educational tool to two patients and two general practitioners and ask for feedback on lay-out, content, and user friendliness.</li>
	<li>Adjust the tool based on the test comments.</li>
	<li>Validate the efficacy and usability of the educational tool in a randomized controlled trial.</li>
</ol>

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The authors have nothing to disclose.

The digital dyspepsia educational tool, developed using the abovementioned protocol, is a novel multimedia educational tool to assist patients and physicians in management of dyspepsia. This tool may be deployed to stimulate patient engagement, and improve health outcomes while curtailing inappropriate use of medical resources.
A similar procedure has been described for development of a fibromyalgia app15. As with dyspepsia, management of fibromyalgia focuses initially on non-pharmacological therapy, emphasizing the importance of patient engagement. Preliminary research for this app used a different approach, and was based on semi-structured interviews rather than focus groups. As a result, there is a risk of missing information through discussion. Questions for interviews for the fibromyalgia app were based on a literature search. Our literature search was based on focus group results, and themes were not restricted by availability of literature. Similar to our educational tool, patients and clinicians were involved in development of the tool. Involving clinicians is important for validity and safety of the tool14,16. This is not always the case as a review of 112 available digital tools for chronic respiratory diseases revealed that only 18% of the apps involved medical staff in the development process14.
Using multimedia for educational purposes has a substantial advantage over information in printed text, as information can be delivered interactively and visualized in detail. When applied inappropriately, multimedia education also has several pitfalls. Principles for the design of multimedia instruction have been described, including pitfalls and correct application of multimedia17. Main principles for effective multimedia education are &#39;reduction of extraneous processing&#39;, i.e., minimizing stimulants distracting focus; &#39;managing essential processing&#39;, i.e., guiding learners through complex and large quantities of information; and &#39;fostering generative processing&#39;, i.e., stimulating learners to process the presented information. In the dyspepsia educational tool, a selection of these principles is implemented. First, extraneous processing was reduced by only displaying essential information, highlighting important information, and adding frequent overviews. Secondly, essential processing was managed by refraining from showing text during animations, to avoid split attentions. Also, animations were segmented, rather than continuous. Subsequent information could be accessed through a &#39;next-button&#39;, enabling users to control the pace of information processing18. Chapters were available in random order, allowing for selecting or bypassing information, based on patients&#39; own needs. While this also imposes the risk that potentially relevant information is missed, it is an important component that contributed to user satisfaction. Lastly, generative processing was fostered by alternately using text, videos, and 3D animations. Text was written according to the personalization principle, entailing the use of a conversational writing style, with frequent use of personal pronouns.
In addition to the multimedia principles, interactivity was found to be positively correlated with learner performance19. In our protocol, interactivity was introduced by intermittently posing questions reflecting on the content, with direct feedback on the answers.
This protocol also has several limitations. No strict guidelines exist for focus group size, but six to eight participants allow for sufficient varying opinions and equal speaking chance, without the risk of group formation20. We included five participants for both focus groups, imposing a risk of achieving limited overview of perspectives. In addition, while a single focus group exercise provides important information, optimal assessment of unmet needs is done by conducting focus groups until information saturation is achieved. Collecting information from a broader range of stakeholders through focus groups, i.e., gastroenterologists, may also be an asset. Furthermore, a still greater element of interactivity could be introduced to further stimulate patient engagement, such as direct or indirect contact with a healthcare provider or peers, or adding a game aspect. Lastly, the information provided was equal for all patients. Patient adoption may have been further enhanced by using pre-entered symptoms to create personalized information and feedback.
Validation of the educational tool is in progress. Currently, a trial is being conducted with the dyspepsia educational tool for validation, and to determine whether it can be used to prevent inappropriate upper GI endoscopies (ClinicalTrials.gov Identifier NCT03205319).
In this study, we presented and evaluated a protocol for development of a dyspepsia educational tool. This protocol can be adopted to create similar dyspepsia tools, as well as tools for diseases with a similar management strategy, in order to improve health outcomes and efficient use of healthcare.

Patient education is an important component of healthcare, enabling active engagement of patients in responsible management of their health1. To improve efficacy and appropriate use of healthcare resources, contemporary and disease-specific measures are needed to facilitate patient engagement. 
Nowadays, digital tools increasingly replace paper versions of patient education, benefiting from their sustainability, effective distribution, and potential to visualize information. For chronic illnesses that lack curative treatment and biological substrate, education is essential for motivation of patients to engage in self-management2,3. Dyspepsia is a condition that often causes long-term complaints. Exact origin of symptoms remains unclear, although evidence indicates three main pathophysiological mechanisms, including 1) hypersensitivity to gastric distension, 2) impaired gastric accommodation, causing inadequate distension in reaction to a meal, and 3) delayed gastric emptying4. Additionally, duodenal perturbations, brain-gut disturbances, and dietary factors have been suggested to play a role5. Main symptoms comprise post-prandial fullness, epigastric pain, early satiety, and epigastric burning. Upper gastrointestinal (GI) endoscopy in dyspeptic patients reveals no cause of symptoms in over 70%; these cases are referred to as functional dyspepsia. Pharmacological treatment options for dyspepsia are limited, often inciting patients to resolve to complementary and alternative therapies6,7. Quality of life in dyspepsia patients is often reduced as dyspepsia is associated with concomitant issues, such as impaired sleep quality and loss of work productivity8. Dyspepsia management benefits from active patient engagement, as behavioral interventions are a main component of dyspepsia treatment9,10. These interventions require a significant effort from patients, which may be facilitated by personalized and interactive support. 
Correct management of dyspepsia is essential to improve healthcare outcomes and prevent overuse of medical resources. Upper gastrointestinal (GI) endoscopy for dyspepsia is a well-known form of overuse as its diagnostic yield is limited11. Several methods have been proposed to reduce the number of upper GI endoscopies, mostly focused on physician education or drug-based symptom reduction12. Uncertainty about the cause of dyspepsia is often unsatisfactory for patients, and diagnostic tests may be performed in excess as a consequence. Consequently, education of patients about pathogenesis, treatment options, and conservative management would be an effective strategy to reduce the number of upper GI endoscopies. 
While digital tools potentially provide an excellent platform for patient education, several functionalities of a digital tool are required, in order to maximize patient adoption and subsequent patient engagement in disease management13. The expected success of digital education mainly depends on its development process and measures taken to optimize information transfer. However, development processes of digital educational tools are infrequently published, impairing reproduction, progression, and evaluation of the validity and safety1,14.
There is need for a detailed description and evaluation of development of a patient-centered digital educational tool. We describe the development of our dyspepsia educational tool, to serve as a template for future educational tool development.

<table><tbody><tr><td>Dyspepsia e-learning</td><td>Dyspepsia e-learning</td><td></td><td>Digital educational tool for dyspepsia management</td></tr><tr><td>Paper Food Diary</td><td>Any</td><td></td><td>Schedule to record food consumption and symptoms</td></tr><tr><td>Computer</td><td>Any</td><td></td><td>A computer or tablet should be used to complete the e-learning</td></tr><tr><td>Medify Content Management System</td><td>Medify BV</td><td></td><td>A content management system to process the e-learning content</td></tr></tbody></table>

the dyspepsia educational tool as a novel aid in dyspepsia management

Digital educational tools have a well-established role in current healthcare. In particular, disorders that are managed non-pharmacologically benefit from this development, as it enables patient engagement in self-management. Dyspepsia is a condition thought to arise from gastric and duodenal perturbations, brain-gut axis disturbances, and dietary factors. Behavioral interventions are a major part of dyspepsia treatment, hence patient engagement and motivation through education is essential. Protocols that describe the development process of such educational tools are scarce. We provide a methodology describing development of a dyspepsia educational tool. Assessment of users' needs is the first step, followed by a literature search. The content is developed based on the main themes and entered into a content management system, to build the program. Final adjustments are made after a pilot test of the tool. The presented protocol can be used as a guide for development of a digital dyspepsia educational tool or as a tool for similar situations.

Results of focus groups
Five patients, recruited through patient networks (n = 2) or at the outpatient clinic (n = 3), were invited to join a focus group. All focus group patients were diagnosed with dyspepsia based on the opinion of a gastroenterologist. Characteristics of included patients are presented in Table 1.
Most participants agreed that uncertainty about the cause and origin of symptoms is a major issue. Participants agreed that it would have helped if they had received more information, such as prevalence of dyspepsia. Symptoms were related to diet for nearly all patients. Extensive dietary advice was missed by several participants. Two views on upper GI endoscopies were expressed; most considered upper GI endoscopies useful to rule out serious disease and reduce worries, and few thought upper GI endoscopies would be redundant for their symptoms. Sources of information used by participants were private web-pages, online patient networks, general practitioners, dieticians, and friends and family with similar complaints.
Five general practitioners agreed to participate in the focus group. All were currently practice-based in the Nijmegen (the Netherlands) area. Main issues participants encountered with dyspeptic patients were fear of disease (patients as well as doctors), and uncertainty about cause and origin of symptoms. All agreed they have a desire to offer patients &#39;something&#39;, but that options are limited. Often, upper GI endoscopy is used as a step in the management process, even though no abnormalities are expected. Arguments were reassurance, and use as a &#39;final part&#39; of the management process. Experiences with the effect of acid-reducing drugs were varied.
Themes extracted from both focus groups were 1) reassurance; 2) pathophysiology of dyspepsia; 3) prevalence, symptoms, and prognosis of dyspepsia; 4) lifestyle interventions; 5) availability and value of therapy and diagnostics; 6) psychosocial factors in dyspepsia; and 7) experiences of other dyspeptic patients with symptoms and treatments. For all themes literature searches were performed and data obtained was distributed across five chapters. Every chapter was arranged with an overview of the content, followed by multimedia information, and final summary statement. All text blocks were given a title representing the core message of the text below. Text blocks were organized to appear at alternating locations on the screen, creating a dynamic flow. If applicable, illustrations were inserted as a background. Within each chapter, several self-tests were incorporated. The self-tests contained three to four questions and answers. Videos were kept to a minimum length, with a maximum of one minute.
Overview of the digital dyspepsia educational tool per chapter
Chapter 1. Upper gastrointestinal endoscopy for dyspepsia.
Chapter 1 provides information on prevalence and different types of symptoms. The prevalence is explained through 3D animation (Figure 1) and text. Reassurance about the usually benign nature of symptoms and acknowledgement of the impact on quality of life is given in several short text blocks. The value and capabilities of upper GI endoscopy is explained in text, and 3D animation illustrates an endoscopy procedure (Figure 2). Outcomes of upper GI endoscopy are depicted in a pie chart. The chapter concludes with several experiences of patients with dyspepsia, one of which includes a video clip of a patient.
Chapter 2. Information about symptoms and potential causes
In chapter 2, normal gastric function is explained. In a video, a gastroenterologist elucidates on this function. After the video, 3D animation (Figure 3), accompanied by text, depicts the anatomy of the stomach and natural food processing in the stomach. After this natural function, it is explained how several disturbances of the stomach can cause symptoms. These are alternatingly explained in text and background illustration (Figure 4), or text and 3D animation (Figure 5).
Chapter 3. Symptoms due to inflammation of the stomach
The third chapter starts with a video of a gastroenterologist explaining gastric inflammation (Figure 6). 3D animations (Figure 7) and text illustrate how alcohol, medication, smoking, and Helicobacter pylori affect the stomach.
Chapter 4. What measures can you take against the symptoms?
In chapter 4, the role of diet is explained. A hyperlink to a food diary is provided (Figure 8). In this diary, patients are encouraged to keep track of their diet and report their complaints. A dietician gives dietary advice in two videos, including a list of foods known to cause symptoms. The text explains how stress reduction may reduce symptoms and which role a therapist can play. The relevance of general health is explained, including a healthy weight, regular physical activity, and sufficient sleep.
Chapter 5. What can the doctor do to mitigate symptoms?
In chapter 5, the pharmacological mechanisms of proton pump inhibitors, histamin2-receptor antagonists, and anti-acids are illustrated by 3D animations (Figure 9), accompanied by text. It is also explained in text that several other drugs exist, such as prokinetics and antidepressants, although indications are more stringent. In text, information is also given about which therapists the general practitioner can potentially refer to, i.e., a dietician, psychologist, or a therapist focusing on stress reduction.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/59852/59852fig1.jpg" /> 
Figure 1: 3D illustration of dyspepsia prevalence. As dyspepsia prevalence is 40%, 4 out of 10 people are highlighted. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59852/59852fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/59852/59852fig2.jpg" /> 
Figure 2: 3D animation of endoscopy procedure. The endoscope passes through the esophagus and stomach, displayed transparently. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59852/59852fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/59852/59852fig3.jpg" /> 
Figure 3: 3D animation of natural food processing. Food enters the stomach and the stomach contracts for food processing. Gastric acid is present in the stomach. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59852/59852fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/59852/59852fig4.jpg" /> 
Figure 4: Text block and background illustration of gastric irritants. A text block explains the effect of spicy food. The background image shows a variety of spices. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59852/59852fig4large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/59852/59852fig5.jpg" /> 
Figure 5: 3D animation of natural gastric function disturbance. Stress, shown as blue lines, influences the stomach, by delaying gastric emptying. This is depicted by food stagnated in the stomach. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59852/59852fig5large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/59852/59852fig6.jpg" /> 
Figure 6: Video of a gastroenterologist explaining inflammation of the stomach. In a video, a gastroenterologist explains how several factors can irritate the stomach. In text, a summary of the explanation is given. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59852/59852fig6large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/59852/59852fig7.jpg" /> 
Figure 7: 3D animation of mucosal damage in the stomach. Several ulcers are shown in the gastric mucosa. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59852/59852fig7large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/59852/59852fig8.jpg" /> 
Figure 8: Food diary. In a food diary, patients can fill in day, time of food consumption, description of the food, amount of food, description of symptoms, duration of symptoms, measures taken against symptoms, and whether measures were effective. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59852/59852fig8large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 9" class="xfigimg" src="/files/ftp_upload/59852/59852fig9.jpg" /> 
Figure 9: 3D animation of pharmacological mechanism of anti-acids. A broken-down tablet is shown to reach the gastric lining. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/59852/59852fig9large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>n = 5</td>
		</tr>
		<tr>
			<td>Age (Median [IQR])</td>
			<td>44 (39-59)</td>
		</tr>
		<tr>
			<td>Gender (% men)</td>
			<td>20</td>
		</tr>
		<tr>
			<td>Upper gastrointestinal endoscopy (%)</td>
			<td>80</td>
		</tr>
		<tr>
			<td>Duration of symptoms (n) 
			12-24 months 
			&#62;24 months</td>
			<td> 
			2 
			3</td>
		</tr>
		<tr>
			<td>Type of symptoms 
			Epigastric pain 
			Early satiation or post-prandial fullness 
			Epigastric burning 
			Nausea</td>
			<td> 
			100% 
			40% 
			20% 
			20%</td>
		</tr>
	</tbody>
</table>
Table 1: Characteristics of (patient) focus group participants. Five patients were invited to a focus group to assess unmet needs in dyspepsia management.

Watch this Scientific Journal Video about The Dyspepsia Educational Tool As a Novel Aid in Dyspepsia Management at JoVE.com

The Dyspepsia Educational Tool As a Novel Aid in Dyspepsia Management

This protocol describes the development process of a digital dyspepsia educational tool. Assessment of unmet needs and literature, content development, and building of the tool are presented. The methodology can be used as a guide for future development of digital educational tools.

Digital educational tools have a well-established role in current healthcare. In particular, disorders that are managed non-pharmacologically benefit from ...

the-dyspepsia-educational-tool-as-a-novel-aid-in-dyspepsia-management

Nanyang Technological University

Research

JoVE Journal

Medicine

6.6K Views.  Radboud University Medical Center. This protocol describes the development process of a digital dyspepsia educational tool. Assessment of unmet needs and literature, content development, and building of the tool are presented. The methodology can be used as a guide for future development of digital educational tools. 

Video: The Dyspepsia Educational Tool As a Novel Aid in Dyspepsia Management

E-Patient Counseling Trial (E-PACO): Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy

Improving patient education focusing on bowel preparation before a colonoscopy leads to cleaner colons. Endoscopy units must obtain informed consent and perform a risk assessment for sedative use prior to a colonoscopy. The current practice in the Netherlands to achieve these goals is nurse counseling in an outpatient setting. This is costly and has disadvantages in terms of uniformity and time consumption for both the patient and the hospital. The hypothesis is that computer-based education with use of video and 3D animations may replace nurse counseling in most cases, without losing quality of bowel cleanliness during colonoscopy.
This multicenter, randomized, endoscopist blinded clinical trial evaluates a primary outcome measure (bowel preparation) during colonoscopy. Secondary outcome measures are sickness absence, patient anxiety after instruction and prior to colonoscopy, patient satisfaction and information re-call. The study will be performed in four endoscopy units of different levels (rural, urban, and tertiary). Inclusion criteria are adult age and referral for complete colonoscopy. Exclusion criteria are Dutch illiteracy, audiovisual handicaps or mental disabilities and no (peers with) internet access.
This trial aims to establish online computer-based education as tool for patient education prior to a colonoscopy. By choosing a direct comparison with the standard of care (nurse counseling), both endoscopic quality measures and patient related outcome measures can be evaluated.

E-Patient Counseling Trial E-PACO: Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy

The aim of this trial is to establish the position of online computer-based education as a tool for patient preparation prior to a colonoscopy. Computer based education is compared with the standard of care, nurse counseling, evaluating endoscopic quality measures and patient related outcome measures.

Improving patient education focusing on bowel preparation before a colonoscopy leads to cleaner colons. Endoscopy units must obtain informed consent and ...

Cancer Research

Behavioral Disturbances: An Innovative Approach to Monitor the Modulatory Effects of a Nutraceutical Diet

In dogs, diets are often used to modulate behavioral disturbances related to chronic anxiety and stress caused by intense and restless activity. However, the traditional ways to monitor behavioral changes in dogs are complicated and not efficient. In the current clinical evaluation, a new, simple monitoring system was used to assess the effectiveness of a specific diet in positively modulating the intense and restless activity of 24 dogs of different ages and breeds. This protocol describes how to easily and rapidly evaluate improvement in a set of symptoms related to generalized anxiety by using a specific sensor, a mobile phone app, a wireless router, and a computer. The results showed that dogs treated with specific diets showed significant improvement in the times spent active and at rest after 10 days (p &lt; 0.01 and p &lt; 0.05, respectively). These dogs also showed an overall significant improvement in clinical and behavioral symptoms. A specific sensor, along with its related hardware, was demonstrated to successfully monitor behavioral changes relating to movement in dogs.

We report a simple approach to evaluate the effectiveness of a specific diet in positively modulating the daily activity and clinical and behavioral symptoms of dogs with evident behavioral disturbances.

In dogs, diets are often used to modulate behavioral disturbances related to chronic anxiety and stress caused by intense and restless activity. However, ...

Behavior

'Boden Food Plate': Novel Interactive Web-based Method for the Assessment of Dietary Intake

Different methods can be used in research to assess dietary intake, many of which are still paper-based. Written estimated food diaries are often utilized in clinical trials, despite being a burden for both study participants and researchers. This method requires participant literacy, it is time consuming, labor intensive, and can easily lead to under-reporting. With advancements in technology, there is a growing interest in electronic diaries that automate the dietary assessment process. These are focused on improving accuracy, reducing both time and cost and providing users with a visual and more enjoyable experience. The methodology presented here aimed to validate the &#39;Boden Food Plate&#39;, a novel web-based platform for self-recording of food and drink items, compared to a traditional estimated food diary. The application was also rated on a satisfaction scale by study participants using a paper-based questionnaire. Sixty-seven participants completed the dietary measures on both the three-day electronic and paper food diaries. For the analysis, only dietary data completed at both study time points (baseline and week six) was utilized. Despite small mean differences between dietary data collection methods, Bland Altman analysis showed fairly wide 95% limits of agreement between the electronic platform and the written estimated food diary and there were few cases which did not fall within the 95% confidence intervals. Overall, participants found the electronic food diary to be more fun than the paper method and as easy to use as hard copy diaries. The new platform has potential as a self-recording tool for the collection of dietary data, particularly when utilized in clinical trial settings. However, further validation studies are needed to improve the validity of this novel electronic dietary data collection tool.

The &#39;Boden Food Plate&#39; is an electronic food diary designed to be an interactive and fun method to collect dietary intake using visual depictions. The purpose of this study was to validate the web-based application against a traditional three-day estimated food diary method.

Different methods can be used in research to assess dietary intake, many of which are still paper-based. Written estimated food diaries are often utilized ...

Mobile Device-assisted Dietary Ecological Momentary Assessments for the Evaluation of the Adherence to the Mediterranean Diet in a Continuous Manner

Mobile device-assisted dietary ecological momentary assessments (EMAs) have emerged as a new tool allowing the evaluation of dietary intake in real time, in a real-world setting and in a continuous manner. They have the potential to minimize recall bias, participant, and investigator burden, and decrease economic and time investment while maximizing ecological validity.
We developed a set of EMAs aimed at evaluating continuous adherence to the MedDiet. Four multiple-choice EMAs are sent daily in a randomized manner from a total of eight questions. The EMAs enquire about the consumption of 11 key food groups of the Mediterranean diet in the last 24-48 h in a semi-quantitative way. EMAs capture the daily frequency of consumption of fruits, vegetables, and extra virgin olive oil on different days of the week. Additionally, EMAs capture the weekly frequency of consumption of whole grain products, sugary drinks, nuts, legumes, sweets, fish and seafood, and red and processed meats. A designed scoring system behind the EMAs extracts the percentage of adherence to the MedDiet recommendations and calculates a quality index of the diet every week. Individualized reports are sent periodically to the volunteers highlighting the strengths and weaknesses of their diet. EMAs are also expected to have a behavioral effect, reinforcing the choice of Mediterranean foods.

Presented here is a study protocol aimed at monitoring continuous adherence to the Mediterranean diet (MedDiet) by means of ecological momentary assessments. The method evaluates the intake of key food groups of the MedDiet and calculates an index of adherence.

Mobile device-assisted dietary ecological momentary assessments (EMAs) have emerged as a new tool allowing the evaluation of dietary intake in real time, ...

Preparing and Administering Oral Tablet and Liquid Medications

Source: Madeline Lassche, MSNEd, RN and Katie Baraki, MSN, RN, College of Nursing, University of Utah, UT

Oral medications are the route most preferred by patients and are one of the most commonly used routes of medication administration by providers. Most oral preparations are taken by mouth, swallowed with fluid, and absorbed via the gastrointestinal tract. Oral medications are available in solid forms (e.g., tablets, capsules, caplets, and enteric-coated tablets) and liquids forms (e.g., syrups, elixirs, spirits, and suspensions). Most oral medications have a slower onset of action and, in the case of liquids and swallowed oral medications, may also have a more prolonged effect. Enteric-coated tablets are covered with material that prevents dissolution and absorption until the tablet reaches the small intestine. Additional oral medication routes (not shown in this video) include sublingual administration, in which the preparation is placed under the tongue to dissolve, and buccal administration, which involves placing the medication in the cheek area between the gums and mucus membranes to dissolve.
When preparing and administering oral tablets and liquid medications, the nurse must consider whether the medication is appropriate given the patient&#39;s medical conditions, medication allergies, and current clinical status and when previous doses of the medication have been administered. Patients with altered gastrointestinal function (e.g., vomiting and nausea) should not be given oral medications, since they would not be able to retain them. Oral medications are contraindicated in patients that are unconscious, uncooperative, or unable to swallow due to a medical problem. Medication administration also requires the nurse to be knowledgeable about the medication purpose, adverse effects, and patient preferences. This demonstration will present how to prepare and administer oral medications in both tablet and liquid forms (most common), including the five &#34;rights,&#34; and will discuss medication documentation.

Source: Madeline Lassche, MSNEd, RN and Katie Baraki, MSN, RN, College of Nursing, University of Utah, UT

Oral medications are the route most preferred ...

Education

JoVE Science Education

Clinical Skills

Nursing Skills

Abdominal Exam IV: Acute Abdominal Pain Assessment

Source: Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT
Abdominal pain is a frequent presenting concern in both the emergency department and the office setting. Acute abdominal pain is defined as pain lasting less than seven days, while an acute abdomen refers to the abrupt onset of severe abdominal pain with features suggesting a surgically intervenable process. The differential diagnosis of acute abdominal pain is broad; thus, clinicians must have a systematic method of examination guided by a careful history, remembering that pathology outside of the abdomen can also cause abdominal pain, including pulmonary, cardiac, rectal, and genital disorders.
Terminology for describing the location of abdominal tenderness includes the right and left upper and lower quadrants, and the epigastric, umbilical, and hypogastric regions (Figures 1, 2). Thorough examination requires an organized approach involving inspection, auscultation, percussion, and palpation, with each maneuver performed purposefully and with a clear mental representation of the anatomy. Rather than palpating randomly across the abdomen, begin palpating remotely from the site of tenderness, moving systematically toward the tender region, and thinking about what lies below the fingers at each position. A helpful technique is to imagine a clock face with the xiphoid process at 12:00 and the pubic symphysis at 6:00 (Figure 3). When palpating at 8:00, there is skin, muscle, cecum, appendix, and ureters. Performing the exam in this fashion assists in clinical reasoning and minimizes the chance of missing pathology.
<img alt="Figure 1" src="/files/ftp_upload/10120/10120fig1.jpg" /> 
Figure 1. Four abdominal quadrants. Abdomen can be divided into four regions by two imaginary lines intersecting at umbilicus. Right upper quadrant (often designated as RUQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and left lower quadrant (LLQ) are shown.
<img alt="Figure 2" src="/files/ftp_upload/10120/10120fig2.jpg" /> 
Figure 2. Nine abdominal regions. Midclavicular lines and subcostal and intertubercular planes separate abdomen into nine regions: epigastric region, right hypochondriac region, left hypochondriac region, umbilical region, right lumbar region, left lumbar region, hypogastric region, right inguinal region, and left inguinal region.
<img alt="Figure 3" src="/files/ftp_upload/10120/10120fig3.jpg" /> 
Figure 3. Visualizing a clock face over the abdomen for thinking about the underlying anatomy while performing the exam.

Source: Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT
Abdominal pain is a frequent presenting concern in ...

Physical Examinations II

Gastroesophageal Reflux Disease II: Clinical Features and Management

Gastroesophageal reflux disease, or GERD, is a persistent medical condition that affects many individuals worldwide. Its clinical manifestations can vary greatly, making diagnosis and management challenging for healthcare professionals. The following is a comprehensive overview of the clinical manifestations, assessment, and management strategies for GERD.
Clinical Manifestations
GERD presents itself in a multitude of ways, with symptoms varying from person to person. The hallmark symptoms are heartburn, medically known as pyrosis, and regurgitation. However, the absence of these hallmark symptoms does not necessarily exclude the diagnosis of GERD. It is particularly true in cases of non-erosive reflux disease (NERD), where individuals experience the typical symptoms of GERD but do not have visible esophageal mucosal injuries seen during endoscopy.
In NERD, patients may have symptoms such as a chronic cough, laryngitis, asthma-like symptoms, or a sensation of a lump in the throat, which are considered extra-esophageal manifestations of GERD. These atypical or &#34;silent&#34; symptoms can occur without the classic symptoms of heartburn or regurgitation.
Heartburn is a burning sensation felt intermittently beneath the lower sternum, radiating upwards to the throat or jaw. Regurgitation is often characterized as a hot, bitter, or sour liquid entering the throat or mouth.
Gastroesophageal reflux disease (GERD)-related chest pain can often be mistaken for angina. The discomfort experienced is typically characterized by a burning, squeezing, or radiating sensation that may start in the chest and then spread to the back, neck, jaw, or arms.
Furthermore, patients may also experience dyspepsia, a discomfort centered in the upper abdomen, or dysphagia, difficulty swallowing. Respiratory symptoms such as wheezing, coughing, dyspnea, and otolaryngologic symptoms, including hoarseness, sore throat, and a sense of a lump in the throat, may also be present.
Assessment and Diagnostic Findings
Accurate diagnosis relies on thoroughly assessing the patient&#39;s comprehensive medical history. It includes gathering detailed information on the frequency and severity of symptoms, dietary habits, and lifestyle factors that may contribute to the condition. During physical examination, healthcare providers may look for signs such as unintended weight loss, regurgitation, and evidence of esophageal irritation, which can provide valuable clues.
To further aid in diagnosis, various diagnostic tests may be conducted. One such test is ambulatory pH monitoring, which involves measuring acid levels in the esophagus over 24 hours. This test helps assess the extent of acid reflux and its impact on the patient&#39;s symptoms.
In addition, endoscopy or barium swallow may be performed to evaluate any damage to the esophageal mucosa and rule out strictures or hernias. These procedures include inserting a flexible tube or ingesting barium contrast to visualize the esophagus effectively and identify any potential abnormalities.
Management
The management of GERD primarily involves lifestyle modifications and drug therapy; however, surgery may be required in some cases. Patients are educated to avoid factors that trigger symptoms, such as certain foods and drinks that decrease esophageal sphincter pressure or irritate the esophagus. Lifestyle changes include tobacco cessation, limiting alcohol intake, weight loss, avoiding eating before bed, and elevating the head of the bed.
Drug therapy includes medications like proton pump inhibitors (PPIs) and histamine (H2) receptor blockers, which aim to decrease the volume and acidity of reflux, improve LES function, increase esophageal clearance, and protect the esophageal mucosa. Antacids and prokinetic drugs can also be used as adjunctive treatments.
When conservative therapies fail to produce the desired results, surgical intervention may become necessary. One such procedure is Nissen fundoplication, a technique that involves wrapping a portion of the gastric fundus around the sphincter area of the esophagus. This surgical approach aims to enhance the integrity of the lower esophageal sphincter (LES) and effectively reduce reflux symptoms.

Choroba refluksowa przełyku II: cechy kliniczne i leczenie

GERD manifests with the following symptoms: Heartburn, or pyrosis, is an intermittent burning sensation that occurs from the sternum to the throat due to ...

JoVE Core

Medical-Surgical Nursing

Unit 1

Disorders of the Esophagus

KEY TERMS AND CONCEPTS

Gastritis III: Clinical Manifestations and Management

The clinical manifestations of gastritis can vary depending on the cause and type of gastritis, but some common symptoms may include the following.
Clinical manifestations of acute gastritis
The patient with acute gastritis may have a rapid onset of symptoms, such as epigastric pain or discomfort, dyspepsia, anorexia, hiccups, or nausea and vomiting, which can last from a few hours to a few days. Erosive or hemorrhagic gastritis may cause bleeding, which may manifest as blood in vomit or as melena or hematochezia.
Clinical manifestations of chronic gastritis
The patient with chronic gastritis may complain of fatigue, pyrosis after eating, belching, a sour taste in the mouth, halitosis, early satiety, anorexia, or nausea and vomiting. Some patients may have only mild epigastric discomfort or report intolerance to spicy or fatty foods or slight pain relieved by eating. Patients with chronic gastritis may be unable to absorb vitamin B12 because of diminished production of intrinsic factors by the stomach&#39;s parietal cells due to atrophy, which may lead to pernicious anemia.
Diagnostic evaluation
Diagnosing acute gastritis involves evaluating the patient&#39;s symptoms and considering any risk factors present. Sometimes, an endoscopic examination with a biopsy may be necessary to confirm the diagnosis. Various tests may be conducted to evaluate for H. pylori infection, including breath, urine, serum, stool, and gastric tissue biopsy. A complete blood count can also indicate anemia resulting from blood loss or lack of intrinsic factor, while stool tests can detect occult blood. Serum tests for intrinsic factor and antibodies to parietal cells may also be performed. Lastly, a tissue biopsy can effectively rule out the presence of gastric cancer.
Management
Managing gastritis involves addressing the underlying cause, alleviating symptoms, and promoting the healing of the gastric mucosa. Here are some commonly used methods for managing gastritis.
Drug therapy aims to alleviate irritation of the gastric mucosa and provide symptomatic relief. Commonly prescribed drugs are antacids, histamine-2 receptor antagonists, or H2 blockers, for instance, famotidine and cimetidine, proton pump inhibitors like omeprazole or lansoprazole, and intravenous fluids. Severe cases may require emergency surgery to remove gangrenous or perforated tissue. While not directly caused by gastritis, these complications can occur secondary to worsening conditions.
Chronic gastritis management involves dietary modification, including the avoidance of spicy and fatty foods, rest, stress reduction, and abstaining from smoking, alcohol, and NSAIDs. H. pylori is treated with drug combinations, typically including a proton pump inhibitor, antibiotics, and sometimes bismuth salts. This comprehensive approach aims to improve symptoms, promote healing, and address the underlying factors contributing to gastritis.

Zapalenie błony śluzowej żołądka III: objawy kliniczne i leczenie

Acute gastritis manifests with a sudden onset of symptoms, including epigastric pain, dyspepsia, anorexia, hiccups, nausea, and vomiting.
Hematemesis and ...

Gastric and Duodenal Disorders

Peptic Ulcer Disease III: Clinical Manifestations and Diagnostic Studies

Peptic ulcer disease (PUD) presents with diverse symptoms depending on the location and severity of the ulcer. Clinical manifestations of peptic ulcer include dull pain and a burning sensation in the mid-epigastric region.
Few clinical manifestations differentiate gastric ulcers from duodenal ulcers. Distinctions in the location, timing, and pain relief are crucial for healthcare providers in differentiating between gastric and duodenal ulcers during clinical assessments.
<ol>
	<li>Location of Pain: Gastric ulcers cause burning or gaseous discomfort in the epigastrium. Conversely, duodenal ulcers result in burning or cramp-like pain in the mid-epigastric region.</li>
	<li>Timing of Pain: Gastric ulcer pain often occurs shortly after eating when the stomach is full, as food can increase the amount of acid in the stomach and exacerbate the pain. In contrast, pain from duodenal ulcers typically manifests when the stomach is empty, usually 2-3 hours after meals, particularly between meals or nighttime. This discomfort arises when stomach acid directly interacts with the ulcer, causing a sensation of pain.</li>
	<li>Relief of Pain: Consuming antacids or having a meal can alleviate discomfort caused by duodenal ulcers. These actions aid in neutralizing stomach acid and promoting faster stomach emptying, thereby reducing irritation of the ulcer. However, in the case of gastric ulcers, eating might not provide relief and could potentially exacerbate the condition, as it stimulates increased acid production by the stomach.</li>
</ol>
Other nonspecific symptoms of PUD vary among individuals. These may include sour eructation or burping, bloating, early satiety, heartburn (pyrosis), constipation or diarrhea, and episodes of bleeding. Additionally, vomiting can result from gastric outlet obstruction caused by pyloric muscle spasms, mechanical obstruction from scarring, or acute swelling around the ulcer. The sudden onset of intense upper abdominal pain radiating to the shoulder, accompanied by extreme tenderness in the abdomen, can indicate a perforated peptic ulcer.
The diagnostic evaluation for PUD involves a multifaceted approach, including physical examination, endoscopy, barium contrast studies, and specific tests for identifying H. pylori infection and detecting gastrinoma (such as Zollinger-Ellison syndrome). A physical examination may reveal pain, tenderness in the upper abdomen (epigastric tenderness), or abdominal distention. Endoscopy is a valuable tool for directly visualizing inflammatory changes and identifying the location of the ulcer. In cases where endoscopy is not feasible, a barium contrast study can be used to diagnose gastric outlet obstruction or detect ulcers.
For H. pylori infection, a biopsy of the antral mucosa and rapid urease testing can be performed, as urea is a byproduct of the metabolism of the bacteria H. pylori. Various other tests are available for identifying H. pylori infection, including serologic testing for antibodies, stool antigen testing, and urea breath tests.

Choroba wrzodowa III: objawy kliniczne i badania diagnostyczne

Peptic ulcer disease, or PUD, exhibits various manifestations based on ulcer location and severity.
Gastric ulcers cause burning or gaseous discomfort in ...

Peptic Ulcer Disease IV: Management

Medical treatment strategies for peptic ulcers encompass various methods. The primary goal of treatment is to diminish gastric acidity and strengthen mucosal defense mechanisms.
The therapeutic approach involves ensuring adequate rest, implementing drug therapy, promoting smoking cessation, making dietary modifications, and emphasizing long-term follow-up care.
Pharmacological management
The prevailing therapy for peptic ulcers involves a combination of managing the patient&#39;s current medication regime, antibiotics, PPIs, and sometimes bismuth salts to suppress or eradicate H. pylori.
For patients on aspirin and nonselective NSAIDs, a pause of 4 to 6 weeks is recommended. When aspirin continuation is essential, co-administration with a proton pump inhibitor (PPI), H2 receptor blocker, or misoprostol may be advised.
Antibiotic therapy: The recommended combination drug therapy for peptic ulcers is commonly administered over 10 to 14 days. It may involve triple therapy, incorporating two antibiotics (metronidazole or amoxicillin and clarithromycin) and a proton pump inhibitor (For example, omeprazole or rabeprazole). Alternatively, quadruple therapy may be prescribed, including two antibiotics (metronidazole and tetracycline), a proton pump inhibitor, and bismuth salts. This strategic combination effectively aims to combat Helicobacter pylori and promote healing within a specified treatment period.
Cytoprotective drug therapy: Sucralfate is a cytoprotective drug therapy for short-term ulcer treatment. It offers mucosal protection to the esophagus, stomach, and duodenum. Unlike antacids, sucralfate does not neutralize acid. To maximize its effectiveness at a low pH, administer sucralfate at least 60 minutes before or after taking an antacid.
Adjunct drugs: H2 receptor blockers and antacids may be adjunct therapy to promote ulcer healing. Antacids increase gastric pH by neutralizing hydrochloric acid. As a result, they reduce the acid content of chyme reaching the duodenum. Some antacids (aluminum hydroxide) can bind to bile salts, decreasing the damaging effects of bile on the gastric mucosa.
Synthetic prostaglandin analog: Misoprostol is a synthetic prostaglandin analog prescribed to prevent gastric ulcers caused by NSAIDs and LDA. People who need chronic NSAID therapy, such as those with osteoarthritis, may benefit from its use.
In cases of Zollinger-Ellison Syndrome (ZES), characterized by gastrin hypersecretion, proton pump inhibitors effectively control gastric acid release, while octreotide, a medication suppressing gastrin levels, may be prescribed.
Lifestyle management
Smoking cessation is crucial, as it reduces pancreatic bicarbonate secretion into the duodenum, contributing to increased acidity and delayed ulcer healing.
Dietary modification advises against acid oversecretion and hypermotility, with specific caution about irritating foods and beverages, such as pepper, carbonated drinks, broth, spicy foods, and caffeine-containing items. Patients are educated to avoid stress and abstain from alcohol.
This comprehensive approach ensures a thorough and effective management strategy for peptic ulcers, addressing symptomatic relief and underlying causes.