RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1

.

NAME OF THE CANDIDATE AND

ADDRESS

Ms .Jipsy p James1st Year M .Sc. NursingSarvodaya College Of Nursing,11/2, Agrahara Dasarahalli, near raheja park, Bangalore-79.

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.

NAME OF THE INSTITUTION Sarvodaya College of Nursing Bangalore- 79.

3

.

COURSE OF STUDY AND SUBJECT 1st Year M .Sc. Nursing,Medical Surgical Nursing

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.

DATE OF ADMISSION OF THE

COURSE

1-6-2011

5

.

TITLE OF THE TOPIC “A study to assess the prevalence and knowledge regarding gastro esophageal reflux disease(GERD) among adults in selected hospitals in Bangalore, with a view to develop an information booklet”

6 BRIEF RESUME OF THE WORK6.0 INTRODUCTION Enclosed

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

SUBMITTED BY:

Ms JIPSY P JAMES,

1st yr. M. Sc. (Nursing)

MEDICAL SURGICAL

NURSING,

2011-2013 BATCH,

SARVODAYA COLLEGE OF

NURSING,

BANGALORE -79.

. 6.1 NEED FOR THE STUDY6.2 REVIEW OF LITERATURE6.2.1 STATEMENT OF THE STUDY6.3 OBJECTIVES OF THE STUDY6.3.1 OPERATIONAL DEFINITIONS6.3.2 ASSUMPTION6.3.3 HYPOTHESIS6.3.4 SAMPLING CRITERIA

EnclosedEnclosedEnclosedEnclosedEnclosedEnclosedEnclosedEnclosed

7

.

MATERIALS AND METHODS

7.1 Sources of data: Data will be collected from selected rural area of Bangalore.7.2 Method of data collection: structured interview.7.3 Does the study require any investigations of interventions to be conducted

on the patients or other human being or animals? yes.7.4 Has ethical clearance been obtained from your institution?

YES. Ethical committee’s report is here with enclosed.

8 LIST OF REFERENCES

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. NAME OF THE CANDIDATE AND

ADDRESS

Ms. Jipsy p James

1st Year M .Sc. Nursing

Sarvodaya College Of Nursing,

11/2, AgraharaDasrahalli, near raheja

park, Bangalore-79.

NAME OF THE INSTITUTION Sarvodaya College Of Nursing,

Bangalore- 79.

3. COURSE OF STUDY AND

SUBJECT

1st Year M. Sc. Nursing,

Medical Surgical Nursing

4. DATE OF ADMISSION OF THE

COURSE

1-06-2011

1

5. TITLE OF THE STUDY “A study to assess the prevalence and knowledge regarding gastro esophageal reflux disease(GERD) among adults in selected hospitals in Bangalore, with a view to develop an information booklet”

2

6. BRIEF RESUME OF INTENDED WORK.

6. 0. INTRODUCTION

"Why do I have Gastro reflux disease now when I’ve never had it before?”1

- Biogher

“Health is a large word. It embraces not the body only, but the mind and spirit as

well;…..and not today’s pain or pleasure alone, but the whole being and outlook of a

man”.1 - James H.West

In normal circumstances, at the junction of the food pipe (esophagus) and the

stomach is a muscular gateway (LES), the sphincter remains contracted so that no content

of the stomach can go back into esophagus .But when the sphincter released due to any

reason or weakness, it may allow the content of the stomach to flow back into esophagus.

Gastro-esophageal reflux disease or acid-reflux disease is a condition in which

the contents of the stomach reflux backwards into the food pipe. Since the stomach

contents are acidic in nature, this damages the inner lining of the food pipe and causes

symptom of heartburn, pain, etc.2

According to American physician’s journal, Gastroesophageal reflux disease

(GERD) is a chronic, relapsing condition with associated morbidity and an adverse

impact on quality of life. The disease is common, with an estimated lifetime prevalence

of 25 to 35 percent in the U.S. population. GERD can usually be diagnosed based on the

clinical presentation alone. In some patients, however, the diagnosis may require

endoscopy and, rarely, ambulatory pH monitoring. Management includes lifestyle

modifications and pharmacologic therapy and refractory disease requires surgery. The

therapeutic goals are to control symptoms, heal esophagitis and maintain remission so

that morbidity is decreased and quality of life is improved.3

Gastro esophageal reflux is a normal physiologic event that may occur as often as

once in an hour.1 The causes for the transformation of this normal process into a chronic,

relapsing illness have not been well defined, but numerous factors are thought to be involved.

The symptoms of gastro esophageal reflux disease (GERD) vary from patient to patient, and

multiple diagnostic tests and treatments are available. The variability of symptoms and the

prevalence of GERD, family physicians need to understand the presentations, diagnosis and

treatments of this illness.3

The disease is common with an estimated lifetime prevalence of 25 to 35 percent

in the U.S. population. 20% of people had frequent symptoms of Gastro esophageal

reflux disease (GERD), but very few of them sought help for the condition. People at all

ages are susceptible to GERD, mostly it affect males than females due to the

consumption of tobacco, smoking, alcohol and also present dietary habits.4

Hiatus hernia is also associated with Gastro esophageal reflux disease (GERD) it

is the bulging of upper part of stomach in to the chest cavity through a tear or weakness

in diaphragm. Stomach exudates can also reach the upper esophagus and trachea, causing

a variety of condition such as asthma, chronic cough, sinusitis, pneumonia, obesity, body

mass index, recurrent ear infection etc. GERD may lead to Barrett esophagus. 20% of

Barrett esophagus may lead to dysplasia .5

1

A study was conducted on long term complications of Gastro esophageal Reflux

Disease (GERD). A minority of patients develop complications of Gastro esophageal

reflux Disease (GERD). One complication is an inflammation of the esophagus from

stomach acid which can lead to bleeding, ulcers or breaks in the lining of the esophagus,

called esophageal erosions or esophagitis. Another complication is a narrowing of the

esophagus, called esophageal strictures. These strictures can trap food and cause

difficulty with swallowing. In some patients, the normal esophageal lining, or epithelium,

may be replaced with abnormal epithelium. This condition is called Barrett's esophagus,

and has been linked to cancer of the esophagus. Lung (pulmonary) aspiration, asthma and

inflammation of the vocal cords or throat may also be caused by GERD.6

6. 1.NEED FOR THE STUDY:

Globally, the incidence of gastro esophageal reflux disease is very high, range

from 10% to 44% in western countries. However there is an emerging suggestion that the

prevalence of gastro esophageal reflux disease might be on the rise in Asia. The exact

reason for these changes in the prevalence of gastro esophageal reflux disease is difficult

to determine. Gastro esophageal reflux disease is a chronic relaxing condition with

associated morbidity and an adverse impact on quality of life. The disease is common

with an estimated life time prevalence of 25 to 35% in the US population7

An article from gastroenterology department America suggested that more than

60 million Americans suffering from heart burn at least once a month. An estimated 15

million American have symptoms every day, more than 35% of Americans are thought to

have Gastro esophageal reflux disease (GERD). Although GERD can affect people of all

2

ages, statistics show that it increases as you ages and tend to rise dramatically after age

of 40.8

The study was conducted in All India Institute of Medical Sciences, New Delhi,

to determine the prevalence of gastro esophageal disease by using interview -based

observational method. The subjects were asked about the frequency and severity of

heartburn and regurgitation experienced by them in the previous year. Association of

GERD with factors like age, sex, BMI, Kuppuswamy social class index, smoking,

alcohol, NSAID use, and comorbid illness was analyzed. A total of 4079 employees

were interviewed in person on a 29-item questionnaire from June 2003 to January 2005.

Of the 4039 eligible subjects, 653 (16.2% ) had GERD; 3.6% had heartburn on daily

basis and 5.9% on a weekly basis. The corresponding prevalence’s for regurgitation were

3.3% and 5.0%, respectively. One hundred and eight of 4039 (2.7%) had severe GERD

symptoms. Higher BMI (OR=1.90, 95% CI: 1.4–2.6 for BMI ≥25), current smoking

(OR=1.48, 95% CI: 1.19–1.83), asthma (OR=3.13, CI: 2.06–4.76) and hypertension

(OR=1.71, 95% CI: 1.16–2.50) were associated with the presence of GERD symptoms. 9

An article from Medscape reported that, Indian community is having less

knowledge regarding the signs and symptoms of Gastro esophageal reflux disease

(GERD). Education is needed to improve the awareness regarding the condition.

Education should include identification, risk factors, dietary and lifestyle modification for

reducing the severity and frequency of symptoms. Article reflects a need for education

about Gastro esophageal reflux disease. For general population, the lack of knowledge

regarding GERD may delay their seeking treatment until symptoms are severe. Education

must be provided in the community10.

3

The Indian Society of Gastroenterology formed a task force to study the

prevalence of GERD and its risk factors. The study by Bhatia is a multi-center

prospective questionnaire-based study of 3,224 urban and rural patients and reports the

findings of this task force. This study reports a weekly prevalence of 7.6% in the Indian

population. This journal also reports other questionnaire based cross-sectional studies,

which also show a high prevalence of GERD (16.2% to 18.7%). These studies emphasize

that the prevalence of GERD in India is likely to be between 8% and 19%, which is

comparable to GERD prevalence rates published in western countries. Additionally, these

studies highlight that the risk factors for GERD are related to diet and lifestyle choice;

which are both modifiable risk factors. 11

Traditionally, GERD has been thought to be a disease of the western world.

Prevalence rates have been estimated to be lower in Asia when compared to that of the

western countries (<5% vs. 10% to 20%). The current articles on GERD in this Journal

demonstrate that contrary to previous belief, the prevalence of GERD in India is in fact

much higher and similar to that reported in the Western countries, very little is known

about GERD in India. The prevalence of GERD in India is higher than previously

estimated and appears to be similar to that of the western countries. Several factors such

as increasing obesity change in diet and lifestyle and smoking use of specific food types

can affect the prevalence of GERD in this rapidly progressing society. With better

understanding of the risk factors, it may be possible to target an intervention directed at

the main cause of this rapid increase of GERD in India. Furthermore, future studies

should perform physiological studies and endoscopically evaluate GERD to gain a better

understanding of its cause and complications.11

4

The estimation of prevalence of GERD in India marks the first step in enhancing

our understanding of GERD. Despite the numerous studies on GERD worldwide, there

are several gaps in our knowledge of this disease. Future studies on GERD in India

should attempt to address several of these gaps while avoiding the pitfalls that have

limited the interpretation of the previous studies. The true population-based prevalence of

GERD and risk factors should be assessed.12

In addition to all above mentioned facts about GERD , the incidence rate and

the own clinical side experience in hospital during postings, many cases of Gastro

esophageal reflux disease were seen they were not aware about complications which lead

to dangerous consequences and importance of prevention of Gastro esophageal reflux

disease. So that it motivated the researcher to choose this problem. Through this study the

subjects will be able to attain the awareness and learn the preventive measures of GERD.

6. 2.REVIEW OF LITERATURE.

The review of literature is a summary of current knowledge about a particular

practice problem and includes what is known and not known about the problem. The

literature is reviewed to summarize knowledge for use in practices or to provide a basis

for conducting a study. Review of literature refers to activities involved in identifying and

researching for information on a topic and developing an understanding of the state of

knowledge on that topic.

5

The literatures are classified under following headings:

1) Prevalence of GERD

2) Etiology and risk factors of GERD

3) Clinical manifestations of GERD.

4) Adults knowledge regarding GERD.

1) Prevalence of GERD

A study published in American journal regarding prevalence and impact of

Gastro esophageal reflux disease, Shows that the prevalence of gastro esophageal reflux

disease appears to be highest in India and North America. It is also associated with huge

economic burden, direct medical costs exceed 10billion dollar per year in us. Indirect

costs 75 billion dollar per year. A recent view identified 10-20% prevalence of gastro

esophageal reflux disease; at least weekly .It has been suggested that there is an increased

trend in prevalence over the last two decade13

A cohort study was conducted by Community Medicine in Singapore, on

prevalence of gastro esophageal reflux in year 1999, 237 of the original cohort of 696

persons who were interviewed in 1994, were re-interviewed using a validated

Gastrointestinal Symptoms Questionnaire. The original cohort was a race-stratified

random sample of residents in a Singaporean town. Reflux was defined as heartburn and

or acid regurgitation occurring at least once a month. Result shows that among the 237

respondents reflux was reported by 25 respondents, giving a prevalence of 10.5 +/- 2.0%.

This compared with the prevalence of 5.5 +/- 1.5% among the same 237 respondents in

6

the 1994 survey. Of the 25 subjects who reported reflux in the current survey, 22 did not

complain of reflux symptoms in the 1994 survey. The ethnic-adjusted prevalence of

reflux in 1999 was estimated to be 9.9 +/- 1.9%. This was an increase above the

prevalence in 1994 of 1.6 +/- 1.0%. The upward trend in the prevalence of reflux was not

related to age, smoking, alcohol consumption, or increase in bodyweight.14

A study was conducted in India, about prevalence of GERD among asthmatic

adults. This study had 86 asthmatic adults which include both males and females in age

group of 20-65 years. The prevalence of GERD is estimated to be around 30-80%. The

overall prevalence of GERD in asthmatic adult was 51%.15

A study was conducted about the prevalence and risk factors among urban and

rural population in ladakh, 905 subjects analyzed, in that 469 are from rural and 722 from

urban areas. Symptomatic GERD was present in 169 subjects. Regurgitations occurred

once a week in 34.8% and heart burn in 42.9%. 16 had moderate severe disease. 153 had

mild disease .388 and 315 subjects had symptoms of heart burn, regurgitation (at least

once a week). Risk factors for GERD are age 95%, sedentary life style 95%, lower intake

of salt and tea 95%. This study suggested that there is a high prevalence of 18.7% of

GERD in India.16

An article from gastroenterology India published that the endoscopic studies will

under estimate the prevalence of Gastro esophageal reflux disease by almost 50%. The

people seek medical care whose symptoms were more severe. Some people believe the

word heartburn refers to cardiac condition and thus they may deny these symptoms on a

questionnaire because they do not have any problem with their heart. Most studies of the

7

prevalence of the Gastro esophageal reflux disease have measured the prevalence of

heartburn. They questioned 385 hospitals employees and found that 7% experience daily

14% weekly 15% one month 36%heart burn at least monthly 55-63%report at least one of

the symptom like dysphagia chest pain, coughed are associated with Gastro esophageal

reflux disease.17

2) Etiology and risk factors of GERD

A study was conducted by Indian society of gastroenterology task force on

Epidemiology and symptom, profile of gastro esophageal reflux disease data were

obtained using a questionnaire from 3224 subjects regarding the frequency, severity and

duration of heartburn, regurgitation and other symptoms of GERD, findings showed that

245 of 3224 subjects had heartburn and regurgitation at least once a week. On univariate

analysis, older age consumption of non-vegetarian and fried foods, aerated drinks,

tea/coffee was associated with GERD. Body mass index was similar in subjects with and

without GERD. On multivariate analysis, consumption of non-vegetarian food was

independently associated with GERD symptoms. Overlap with symptoms of irritable

bowel syndrome was not uncommon; 21% reported difficulty in passage of stool and 9%

had mucus in stools. About 25% of patients had consulted a doctor previously for their

gastro esophageal reflux disease.18

A study was conducted among Asian population, identified that a number of risk

factors and morbidities are associated with GERD. The disease is more common in Asia

and it also high light the need for global consensus on a symptoms based definition of

GERD. The study of epidemiology of GERD is restricted by the lack of consensus over

8

the basic definition of the disease. Symptoms experienced by a large proportion of

population, which are sufficient to impair the individuals health related quality of life.19

3)) Clinical manifestations of GERD

A study was conducted at Dow medical college in Karachi to assess the typical

and atypical manifestation of GERD, among student in terms of discomfort, 22.18%

heart burn weekly, 14.8% dysphagia, 11.92% suffered from breathing problem. It

concludes that weekly episodes of heart burn are significantly higher than that in Asian

population20.

A study was conducted among people in Indian village to assess prevalence,

care, and knowledge of the people like GERD occur as commonly in village people as in

large town and cities. The medical officer examined the villager for their complaints. The

study had 560 person .Symptoms of GERD was heart burn mostly about 15-30minute

after food. At first all of them were treated with antacid and H2 blocker which gave

temporarily relief but all of them return with recurrent symptoms. Stool examination of

20 % was carried out showed presence of entamoeba histolytic a in 10 adults.21

4. Adults knowledge regarding GERD

An article from gastroenterology department shows a survey conducted among

adult population for gastro esophageal reflux disease symptoms in Israel. The survey

included 2027 subjects. In that 8.4% subjects experience twice daily, 12.5% subjects once

weekly and 21.5% subjects monthly. 12.5% of the Israel adult population experience

GERD symptoms weekly. Heart burn regurgitation is the most common symptoms

reported by patient with GERD. Studies shown that there is an association between

9

GERD and several demographic and behavioral factors such as gender age, lack of

education, socio economic status, and also due to a different life style habit.22

A randomized control study was conducted in Ohio state university ‘Columbus,

OH, USA, to assess patient’s behaviors associated with GERD management before and

after an educational intervention. The results obtained say that the awareness among the

GERD was less and the teaching program improved patient knowledge and some

behavior made in GERD management and symptom reduction. 23

A randomized controlled study was conducted in Trondheim, Norway, to

investigate the effects of a group based education program for patients with gastro

esophageal reflux disease (GERD) on disease knowledge and the association between

knowledge and QoL (quality of life). A group based education program for patients with

GERD designed as a structured dialogue increased patients' disease knowledge, which

was retained after 1 year. Changes in GERD knowledge were not associated with change

in QoL(quality of life).24

6. 2.1. STATEMENT OF THE PROBLEM:

“A study to assess the prevalence and knowledge regarding Gastro esophageal reflux

(GERD) among adults in selected hospitals Bangalore, with a view to develop an

information booklet”

10

6. 3. OBJECTIVES OF THE STUDY:

1) To assess the prevalence and knowledge regarding GERD among

2) To find out the association between the level of knowledge and selected

Socio-demographic variables.

3) To develop an information booklet

6.3.1 OPERATIONAL DEFINITIONS

Knowledge: It refers to the verbal responses of the participants regarding Gastro

esophageal reflux, as measured by self-administered knowledge questionnaire

Gastro esophageal reflux (GERD): Is a gastrointestinal disorder characterized by

backward flowing of gastric contents into the esophagus.

Information booklet: It refers to organized information regarding the meaning, causes,

symptoms, investigations, treatment and preventive measures of GERD.

Adult: Both males and females of age group between 25-65 years.

Selected hospitals: Sarvodaya, BGS and West of Chord Road Hospital, Bangalore.

6. 3. 2 ASSUMPTIONS:

It is assumed that the adult may have some knowledge regarding GERD.

It is assumed that there is a great prevalence of GERD among adults

11

6. 3. 3. HYPOTHESIS:

H0 -There will be no significant association between level of knowledge and the selected

variable

6. 3.4. SAMPLING CRITERIA:

INCLUSION CRITERIA --- Adults who are:

present at the time of data collection.

able to read and understand Kannada or English.

willing to participate

EXCLUSION CRITERIA -- Adults who are:

already under treatment for GERD.

who have attended any awareness program about Gastro esophageal reflux

disease

7. MATERIALS AND METHODS:

7.1 SOURCE OF DATA:

Data will be collected among the adult in a selected hospital.

7.2 METHOD OF DATA COLLECTION

Research Approach : Survey approach

12

Research Design : Descriptive design.

Setting : Selected hospital, Bangalore.

Population : The population of the present study comprises of

adult adults in a selected hospital.

Sample : Adult in the selected hospitals who meet the

inclusive inclusion criteria, Bangalore.

Sample size : 200

Sampling technique: convenient sampling technique

Method of data collection : self administered questionnaire

Tool for data collection : Structured knowledge Questionnaires.

Method of data analysis and interpretation:

The researcher will use descriptive and inferential statics for analysis

Descriptive statistics:

1) The demographic variables will be analyzed by frequency and percentage

distribution.

2) Association between level of knowledge of adult regarding GERD and

selected variables will analyzed by chi-square test.

Duration of study : 4 weeks.

13

Research Variables : Knowledge of the adult regarding GERD

Demographic Variables : Age, education, marital status, religion, income per

month, annual medical checkup, occupation, previous history of diseases like asthma,

bronchiectasis ,COPD,

Projected outcomes: The study will help to determine the level of knowledge of adults

regarding GERD and help them to know more about the risk factors which in turn helps

them to lead a healthy life style, modifying it by after reading the information booklet.

7.3. Does the study require any investigations or interventions to be conducted on

patients or other humans or animals?

NO

7.4. Has ethical clearance been obtained from your institution?

Yes, ethical committee report is here with enclosed.

14

LIST OR REFERENCES

1. WWW. The shine on health .com.

2 Lemone Burke, A “Text book of medical and surgical nursing”, Critical thinking in

client.Care; 3rd edition 226-227.

3. Scott M, Gel hot et.al;GERD:Diagnosis and management, 1999 march 159(5):1161-

1199. http://www.aafp.org/afp/990301ap/1161.html 4

4. The Aalyst, Heart burn|GERD .www.digitalnaturopath.com|cond/c373737.htm

5. Jonathan E,Jenson; July 9 ,2000. www Indian surgeon.com|gerd.htm.

6. Sharon Gillson, Updated October 17, 2009

http://heartburn.about.com/od/gerdacidrefluxdisease/a/gerdcomplicate.htm

. 7. Mark Scott,Almeer,et.al;GERD;Diagnosis and management,March 1,1999

http;//ww.aafp.org|afp|990301ap|1161.html

8. Elizabeth Scherer. How common is GERD.

http://health.howstuffworks.com/diseases-conditions/digestive/how-common-is-gerd.htm

15

9. Praveen Kumar Sharma & Vineet Ahuja et. al. Indian J Gastroenterol (May–June

2011) 30(3):128–134

http://indianjgastro.com/IJG_pdf/may2011/30_3_5.pdf

10. Medscape TodayNews; GERD;Prevalance, knowledge and care pattern in U.S

Minority population.Alimantry pharmacologytherapeutics.2010; 32(5):645-654.

http://www.medicinenet.com/endoscopy/kingsport-tn_city.htm

11. Srinivas Gaddam and Prateek Sharma. Shedding light on the epidemiology of

gastroesophageal reflux disease in India—a big step forward Indian J

Gastroenterol (May–June 2011) 30(3):105–107

http://indianjgastro.com/IJG_pdf/may2011/30_3_2.pdf

12. Marco G pattiJulian Katz ;GERD 2011 aug 19

http://emedicine.medscape.com/article/176595

13.Prateek SharmaM D et.al; American journal of Gastroenterology

2008; 3(11)

http://www.nature.com/ajg/journal/v105/n2/abs/ajg2009684a.html

14. LimSL ,GohWT,et.al;Changing prevalence of gerd with changing time

Community medicine GI study group

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http://www.ncbi.nlm.nih/gov/pubmed/9772037

15. P Kumar, R Padmavati,et.al; The prevalence of gerd in asthmatics

Journal of diagnostic researcher 2011 5(4) ;711-713

http://www.jcdr.net/articles//1461/6-%202735.pdf

16. Sushil kumar, sourabh et.al,To asses prevalence and risk factors of gerd in a high

Attitude area. Indian j gastroenterol (may-jun2011)30(3);135-143

http://indianjgastro.com/ijg-pdf/may 2011/30-3

17. GR. Lockell,Rochester.prevelence of gerd

http://www.hon.choeso/books/volume5-esso junctionarticles/art126html

18. Shobna Bhatia,et.al;Epidemiology and symptoms profile of gerd in

India population. Indian J Gastroenterol(may-June2011)30(3);

118-127

www.ncbi.nlm.nih.gov/pubmed/21792655

19. J Dent1, H B El-Serag2, M-A Wallander. Epidemiology of gastro-oesophageal reflux disease: a systematic review: 2004.051821

http://gut.bmj.com/content/54/5/710.full

20. Haris Riqz et.al;The typical and atypical manifestation of gerd in Terms of

frequency,and lifestyle changes,(jan-jun 2010)

17

21. .J C Patel,et.al; Improvement of rural health, 2002;56(8)371-372

http;//www.indianmedsci.org|text.asp?2002|56|8|371|11994

22. Menachen moshkowitzm. Epidemiology of GERD disease, World j gastro enteral.

2011 march 14:17(10).

23. Finley,et.al; Assessing the impact of life style modification Education on knowledge

and behavior changes in gerd Patient. J AM Pharm Assoc(Jul-Aug 2009)49(4)544-548.

24. Urnes J; Patient education in GERD; A randomized control-

led trial,EUR J GastroenteroHepatol.2007Dec;19(2);1104-1110.

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