Boykin IV 18 Apr As performance-based contracting grows and evolves, the benefits of private-sector experience and best practices provide solutions to government entities on all levels. With a General Services Administration GSA goal of 50 percent performance-based contract awards inand a similar goal from the Defense Department forthe writing is on the wall. Whether we choose to wholeheartedly embrace the change or be dragged kicking and screaming all the way, performance-based contracting is here to stay. Simply defined, performance-based contracting allows government to acquire services via contracts that define what is to be achieved, not necessarily how it is done.
Strong recommendation, high level of evidence Accelerated gastric emptying and functional dyspepsia can present with symptoms similar to those of gastroparesis; therefore, documentation of delayed gastric emptying is recommended before selecting therapy with prokinetics agents or gastric electrical stimulation GES.
Symptoms have not been well correlated with gastric emptying. Nausea, vomiting, early satiety, and postprandial fullness correlate better with delayed gastric emptying than upper abdominal pain and bloating 3,4. The epidemiology and impact of gastroparesis are reviewed elsewhere 2.
More community-based data are required to confirm or enhance the published figures. Gastroparesis significantly impacts quality of life 6,7increases direct health-care costs through hospitalizations, emergency room, or doctor visits, and is associated with morbidity and mortality 8,9.
The symptoms are often the same with the different etiologies of gastroparesis: In patients from the NIH Gastroparesis Registry, symptoms prompting evaluation more often included vomiting for diabetic gastroparesis DG and abdominal pain for idiopathic gastroparesis IG.
Patients with IG have more early satiety and abdominal pain compared with patients with DG who have more severe retching; all the patients included in these multicenter studies had documentation of delayed gastric emptying in their medical record 11, Abdominal pain is an often under-appreciated symptom in gastroparesis.
Severity ranking of abdominal pain was in the same range as other symptoms e. The presence of anxiety or depression has been associated with more severe symptoms 14, The combination of symptoms and delayed gastric emptying is required to establish the diagnosis of gastroparesis as the epidemiology, natural history, pathophysiology, and treatment of gastroparesis which are reviewed in detail elsewhere 2 are typically based on combined criteria.
Diabetes with evidence of gastroparesis on objective testing has been associated with increased health-care costs, including increased clinic visits, emergency room visits, hospitalizations, overall morbidity and mortality 8,9. Since accelerated gastric emptying and functional dyspepsia can also present with symptoms similar to gastroparesis, documentation of delayed gastric emptying 3,16 is necessary before selecting therapy with prokinetics agents or GES.
Identifying the Cause of Gastroparesis Recommendations Patients with gastroparesis should be screened for the presence of diabetes mellitus, thyroid dysfunction, neurological disease, prior gastric or bariatric surgery, and autoimmune disorders. Patients should undergo biochemical screen for diabetes and hypothyroidism; other tests are as indicated clinically.
Strong recommendation, high level of evidence A prodrome suggesting a viral illness may lead to gastroparesis postviral gastroparesis. This condition may improve over time in some patients. Clinicians should inquire about the presence of a prior acute illness suggestive of a viral infection.
Strong recommendation, high level of evidence. Optimization of glycemic control should be a target for therapy; this may improve symptoms and the delayed gastric emptying. Moderate recommendation, moderate level of evidence Medication-induced delay in gastric emptying, particularly from narcotic and anticholinergic agents and glucagon like peptide-1 GLP-1 and amylin analogs among diabetics, should be considered in patients before assigning an etiological diagnosis.
Narcotics and other medications that can delay gastric emptying should be stopped to establish the diagnosis with a gastric emptying test. Strong recommendation, high level of evidence Gastroparesis can be associated with and may aggravate gastroesophageal reflux disease GERD. Evaluation for the presence of gastroparesis should be considered in patients with GERD that is refractory to acid-suppressive treatment.
In the NIH consortium cohort, delayed gastric emptying was more pronounced in patients with type 1 DG The year incidence of gastroparesis has been reported to be 5.The study of military history at one time was reserved for the officer cast of many military organizations however with the advent of the Noncommissioned Officer Corps in the American Army, the need to understand past military events are essential.
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