Symptoms associated with gastroesophageal reflux disease: development of a questionnaire for use in clinical trials

Prevalence and severity of abdominal bloating in patients with gastroesophageal reflux disease

Abdominal bloating (AB) is a common symptom among patients with gastroesophageal reflux disease (GERD); however, in clinical practice, its prevalence is likely underestimated due to the lack of objective tools to measure its frequency and severity. It is associated with dissatisfaction and worse quality of life, but data on its prevalence before and after mechanical control of GERD (i.e. fundoplication, magnetic sphincter augmentation, and antireflux mucosectomy) are lacking. To assess and determine the pre- and postoperative prevalence and severity of AB among patients with GERD, we conducted a structured literature search using MeSH and free-text terms in MEDLINE (via Pubmed), EMBASE, and Taylor & Francis Online between January 1977 and October 2022. Fifteen articles reporting the prevalence or severity of AB using quality-of-life questionnaires before or after antireflux surgery (ARS) were included. Overall, a high prevalence of AB before ARS was found. A decline in the prevalence and severity of AB was documented postoperatively in most cases independent of the surgical approach. Among surgical approaches, a complete fundoplication had the highest reported postoperative AB. Overall, patients reported less severe and less frequent AB after ARS than before. The traditional belief that postoperative bloating is a sequela of ARS should be reevaluated.

Objective ambulatory pH monitoring and subjective symptom assessment of gastroesophageal reflux disease show type of carbohydrate and type of fat matter

Background

Rising prevalence of gastroesophageal reflux disease (GERD) in US Veterans is concurrent with increasing excess body weight.

Objective

The objective of this cross-sectional study is to examine relationships between dietary macronutrients, gastrointestinal hormones, and GERD status.

Methods

Ninety-eight veterans with overweight/obesity and empiric proton pump inhibitor (PPI) treatment were enrolled from the Tennessee Valley Healthcare System. Subjects had esophageal manometry and 24-h pH monitoring. Subjective symptoms were assessed with Gastroesophageal Reflux Disease Questionnaire (GERDQ) and Symptom Assessment Scale (GSAS). The primary outcomes, total acid exposure time (AET) and number of reflux episodes, enabled categorizing subjects as either pathologic GERD or inconclusive GERD. Data analysis included independent T-tests, Spearman Rho correlations, and multivariable linear regression modeling.

Results

Higher intake of sugar-sweetened beverages (sugar-sweetened tea, soda, and fruit juice) associated with higher AET. Higher saturated-to-unsaturated fat intake is associated with higher AET and number of reflux episodes. Overall, sugar-sweetened beverage intake, saturated-to-unsaturated fat ratio, tomato-based food items, glucagon-like polypeptide 1 (GLP-1) level, time of first meal, and education status accounted for a significant amount of the variability in AET. Pathologic GERD subjects reported more heartburn (p = 0.006), regurgitation (p = 0.01), acid taste (0.001), and nausea severity (p = 0.04). GERDQ score associated with AET (r = 0.31, p = 0.005), but GSAS did not (r = 0.12, p = 0.28).

Conclusion

Of the many foods and nutrients tested, the type (not amount) of carbohydrate (simple sugars) and the type (not amount) of fat (saturated vs unsaturated fat) consumed associated with objective and/or subjective GERD testing. These novel findings contribute to the evidence base guiding specific dietary recommendations in the clinical management of GERD.

'Persistent throat symptoms' versus 'laryngopharyngeal reflux': a cross-sectional study refining the clinical condition

Objective

Many patients are assessed for chronic symptoms including: dysphonia, ‘globus’, throat clearing, postnasal secretions and cough; commonly grouped together and attributed to ‘laryngopharyngeal reflux’. This study aimed to explore a clinical trial’s baseline dataset for patterns of presenting symptoms, which might provide a more rational basis for treatment.

Design

Baseline data were analysed for participants entering the Trial Of Proton-Pump Inhibitors in Throat Symptoms: age, body mass index, Reflux Symptom Index, Comprehensive Reflux Symptom Score, Laryngopharyngeal Reflux-Health-related Quality of Life questionnaire and Reflux Finding Score (RFS-endoscopic examination). The relationships between the questionnaires and demographic factors were assessed. Exploratory factor analysis (EFA) was conducted on individual symptom items in the combined questionnaires. The EFA factors were applied to a Cluster Analysis of participants, to explore the presence of identifiable patient.

Results

Throat clearing and globus were the highest ranked scores in the 344 participants. Increasing age was inversely associated with symptom severity (p<0.01). There was no relationship between the RFS and any of the three questionnaires. EFA resulted in a seven-factor model with clinically meaningful labels: voice, cough, gastrointestinal symptoms, airway symptoms and dysphagia, throat clearing, lump in throat, and life events. Cluster analysis failed to demonstrate any clinically meaningful clusters of patients.

Conclusion

This study offers a framework for future research and demonstrates that individual symptoms cannot be used to group patients. The analysis supports the use of a broad ‘umbrella’ term such as persistent throat symptoms.

Trial registration number

ISRCTN38578686.

Beyond the Eckardt Score: Patient-Reported Outcomes Measures in Esophageal Disorders

PURPOSE OF REVIEW

To provide an overview of patient reported outcome measures (PROMs) and summarize their role in assessing undifferentiated dysphagia and common esophageal disorders, including achalasia, eosinophilic esophagitis (EoE), and gastroesophageal reflux disease (GERD).

RECENT FINDINGS

Given the subjective nature of swallowing disorders, accurate diagnoses often rely on capturing the patient experience. As a result, the number of PROMs used to characterize esophageal symptoms is increasing with a recent particular emphasis on EoE. Overall, esophageal-focused PROMs are used to interpret patient symptoms and quality of life, diagnosis, and symptom changes over time. There are limitations with each instrument, including factors affecting validity, reliability, accessibility, patient participation, and logistical implementation. PROM instruments can be helpful tools in the diagnosis and treatment of esophageal disorders. Instruments should be chosen based on factors such as target population and setting, including research, clinical, and quality improvement efforts. Future research should address how best to implement PROMs and integrate the obtained data with patient care.

Lansoprazole for persistent throat symptoms in secondary care: the TOPPITS RCT

BACKGROUND

Persistent throat symptoms are commonly attributed to 'laryngopharyngeal reflux'. Despite a limited evidence base, these symptoms are increasingly being treated in primary care with proton pump inhibitors.

OBJECTIVE

To assess the value of proton pump inhibitor therapy in patients with persistent throat symptoms.

DESIGN

This was a double-blind, placebo-controlled, randomised Phase III trial.

SETTING

This was a multicentre UK trial in eight UK ear, nose and throat departments.

PARTICIPANTS

A total of 346 participants aged ≥ 18 years with persistent throat symptoms and a Reflux Symptom Index score of ≥ 10, exclusive of the dyspepsia item, were recruited.

INTERVENTION

Random allocation (1 : 1 ratio) to either 30 mg of lansoprazole twice daily or matched placebo for 16 weeks.

MAIN OUTCOME MEASURE

Symptomatic response (i.e. total Reflux Symptom Index score after 16 weeks of therapy).

RESULTS

A total of 1427 patients were screened and 346 were randomised. The mean age was 52 years (standard deviation 13.7 years, range 20-84 years); 150 (43%) participants were male and 196 (57%) were female; 184 (53%) participants had a mild Reflux Symptom Index minus the heartburn/dyspepsia item and 162 (47%) had a severe Reflux Symptom Index minus the heartburn/dyspepsia item. A total of 172 patients were randomised to lansoprazole and 174 were randomised to placebo.

MAIN OUTCOMES

A total of 267 participants completed the primary end-point visit (lansoprazole, n = 127; placebo, n = 140), of whom 220 did so between 14 and 20 weeks post randomisation ('compliant' group); 102 received lansoprazole and 118 received placebo. The mean Reflux Symptom Index scores at baseline were similar [lansoprazole 22.0 (standard deviation 8.0), placebo 21.7 (standard deviation 7.1), overall 21.9 (standard deviation 7.5)]. The mean Reflux Symptom Index scores at 16 weeks reduced from baseline in both groups [overall 17.4 (standard deviation 9.9), lansoprazole 17.4 (standard deviation 9.9), placebo 15.6 (standard deviation 9.8)]. Lansoprazole participants had estimated Reflux Symptom Index scores at 16 weeks that were 1.9 points higher (worse) than those of placebo participants (95% confidence interval -0.3 to 4.2; padj = 0.096), adjusted for site and baseline severity.

SECONDARY OUTCOMES

Ninety-five (43%) participants achieved a Reflux Symptom Index score in the normal range (< 12) at 16 weeks: 42 (41%) in the lansoprazole group and 53 (45%) in the placebo group. A total of 226 participants completed the end-of-trial follow-up visit (lansoprazole, n = 109; placebo, n = 117), of whom 181 were 'compliant'. The mean Reflux Symptom Index scores at 12 months reduced from baseline in both groups [lansoprazole 16.0 (standard deviation 10.8), placebo 13.6 (standard deviation 9.6), overall 14.7 (standard deviation 10.2)]. A total of 87 (48%) participants achieved a Reflux Symptom Index score in the normal range at 12 months: 33 (40%) in the lansoprazole group and 54 (55%) in the placebo group. Likewise, the Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life total scores and subscales all showed very similar changes in the lansoprazole and placebo cohorts at both 16 weeks and 12 months.

LIMITATIONS

Drop-out rate and compliance are issues in pragmatic clinical trials. The Trial Of Proton Pump Inhibitors in Throat Symptoms (TOPPITS) aimed to detect clinically relevant difference with 90% power. The 346 randomised participants reduced to 283 at the primary end point; 267 completed the primary outcome measure, 220 within the protocol time scale. Despite this, the powers to detect the clinically relevant difference in Reflux Symptom Index score at 16 weeks were 82% (compliant comparison) and 89% (pragmatic comparison). The lack of difference between lansoprazole and placebo is generalisable across NHS clinics.

CONCLUSIONS

Participants on lansoprazole did not report significantly better outcomes than participants on placebo on any of the three patient-reported outcome tools (Reflux Symptom Index, Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life). This multicentre, pragmatic, powered, definitive Phase III trial found no evidence of benefit for patients by treating persistent throat symptoms with lansoprazole.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38578686 and EudraCT number 2013-004249-17.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 3. See the NIHR Journals Library website for further project information.

Risk assessment of obstructive sleep apnea among gastroesophageal reflux disease patients in Taif, Saudi Arabia

Background:

Previous studies have reported the association between gastroesophageal reflux disease (GERD) and obstructive sleep apnea (OSA).

Objectives:

The aim of the present study was to assess the prevalence of GERD among Saudi population, and to determine the risk of OSA among those diagnosed with GERD in Taif city of Saudi Arabia.

Materials and Methods:

A cross-sectional online survey was done among 843 Saudi participants using a questionnaire by collecting demographic data, weight, height, blood group, and having a previous nose or throat surgery. The GERD questionnaire and the sleep apnea symptom index were used to determine GERD and OSA prevalence.

Results:

The prevalence of GERD and OSA was 17.6% and 2.4%, respectively. A significantly higher prevalence of GERD was found among males, those with age >50 years, employees and obese participants, and those having OSA. Participants with an age >50 years and males, had a significantly higher prevalence of OSA. Being a male and older age were predictors for GERD, and the presence of GERD was an independent predictors for OSA.

Conclusion:

Future population-based studies including a representative sample of the population should be done to confirm the revealed association between GERD and OSA. It is necessary to assess GERD in patients with OSA in clinical practice.

Evaluation of treatment pattern and symptom control in patients with gastroesophageal reflux disease: multihospital questionnaire survey on the current situation in Korea

Proton pump inhibitors (PPIs) are the most effective treatment for gastroesophageal reflux disease (GERD); however, a considerable number of patients fail to respond to PPI therapy and complain of nocturnal heartburn and sleep disturbance. The aims of this study are to evaluate the treatment pattern of GERD-related medications and their efficacy in relieving nocturnal heartburn. A total of 334 patients with GERD receiving PPI therapy within 6 months were enrolled in a multihospital questionnaire survey from January, 2014 to March, 2015. GERD symptoms and patients' satisfaction were assessed by patient questionnaires, and treatment patterns of GERD-related medications were assessed by investigators. Among the 334 patients, 95.8% used PPI once daily and 58.6% used a half-dose of PPI. The PPI treatment pattern was changed in 26.6% of all patients, of those, 54% of the patients doubled the PPI dose, and 29.2% of the patients switched to another PPI. Approximately 60.3% of all patients were prescribed more than three GERD-related medications. The overall satisfaction rate was 61.8%, and 32.2% of patients experienced nocturnal heartburn and sleep disturbance. In the extended-release PPI group, there were fewer nocturnal symptoms compared with the conventional PPI group (10% vs. 33.7%, respectively, P = 0.027). The use of more than three medications was inversely associated with patients' satisfaction (OR = 0.355, 95% CI; 0.197-0.642, P = 0.001). Most patients were prescribed adjunctive medications other than PPIs; however, patients' satisfaction was inversely associated with multiple drugs. Patients' satisfaction was superior in extended-release PPIs than conventional PPIs for the relief of nocturnal heartburn in Korean patients.

Patient-Reported Outcome Measures Related to Laryngopharyngeal Reflux: A Systematic Review of Instrument Development and Validation

OBJECTIVES

Patient-reported outcome (PRO) measures are often used to diagnose laryngopharyngeal reflux (LPR) and monitor treatment outcomes in clinical and research settings. The present systematic review was designed to identify currently available LPR-related PRO measures and to evaluate each measure's instrument development, validation, and applicability.

DATA SOURCES

MEDLINE via PubMed interface, CINAHL, and Health and Psychosocial Instrument databases were searched with relevant vocabulary and key terms related to PRO measures and LPR.

REVIEW METHODS

Three investigators independently performed abstract review and full text review, applying a previously developed checklist to critically assess measurement properties of each study meeting inclusion criteria.

RESULTS

Of 4947 studies reviewed, 7 LPR-related PRO measures (publication years, 1991-2010) met criteria for extraction and analysis. Two focused on globus and throat symptoms. Remaining measures were designed to assess LPR symptoms and monitor treatment outcomes in patients. None met all checklist criteria. Only 2 of 7 used patient input to devise item content, and 2 of 7 assessed responsiveness to change. Thematic deficiencies in current LPR-related measures are inadequately demonstrated: content validity, construct validity, plan for interpretation, and literacy level assessment.

CONCLUSION

Laryngopharyngeal reflux is often diagnosed according to symptoms. Currently available LPR-related PRO measures used to symptomatically identify suspected LPR patients have disparate developmental rigor and important methodological deficiencies. Care should be exercised to understand the measurement characteristics and contextual relevance before applying these PRO measures for clinical, research, or quality initiatives.

Efficacy and Safety of a Natural Remedy for the Treatment of Gastroesophageal Reflux: A Double-Blinded Randomized-Controlled Study

Gastroesophageal reflux (GER) is a common, chronic, relapsing symptom. Often people self-diagnose and self-treat it even though health-related quality of life is significantly impaired. In the lack of a valid alternative approach, current treatments focus on suppression of gastric acid secretion by the use of proton pump inhibitors (PPIs), but people with GER have a significantly lower response rate to therapy. We designed a randomized double-blinded controlled clinical study to evaluate the efficacy and the safety of a formulation based on sodium alginate/bicarbonate in combination with extracts obtained from Opuntia ficus-indica and Olea europaea associated with polyphenols (Mucosave®; verum), on GER-related symptoms. Male/female 118 (intention to treat) subjects with moderate GER and having at least 2 to 6 days of GER episodes/week were treated with verum (6 g/day) or placebo for two months. The questionnaires Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQoL) and Gastroesophageal Reflux Disease Symptom Assessment Scale (GSAS) were self-administered by participants before the treatment and at the end of the treatment. Verum produced statistically significant reduction of GERD-HRQoL and GSAS scores, −56.5% and −59.1%, respectively, in comparison to placebo. Heartburn and acid regurgitation episodes for week were significantly reduced by verum (p < 0.01). Results indicate that Mucosave formulation provides an effective and well-tolerated treatment for reducing the frequency and intensity of symptoms associated with gastroesophageal reflux.

Influence of everyday bolus consistencies in different body positions on high-resolution esophageal pressure topography (HREPT) parameters

The standard protocol for esophageal manometry involves placing the patient in the supine position with head turned to left (supine head left [SHL]) while evaluating liquid bolus swallows. Routinely, semisolid or solid boluses are not evaluated. Currently, the daily American diet includes up to 40% solid or semisolid texture. Thus far, the data on the effect of different bolus on high-resolution esophageal pressure topography (HREPT) parameters are scarce. This study aims to evaluate the effect of every day bolus consistencies in different body positions on HREPT variables. HREPT was performed on healthy volunteers with a modified protocol including liquid swallows in the SHL position followed by applesauce (semisolid), cracker (solid), and marshmallow (soft solid) in three different positions (SHL, sitting, and standing). A total of 38 healthy adult subjects (22 males and 16 females, median age = 27, and mean body mass index = 25) were evaluated. The resting upper esophageal sphincter pressure was significantly different while subjects swallowed crackers, applesauce, and marshmallows in most positions compared with liquid SHL (P < 0.05). The lower esophageal sphincter, contractile front velocity, and distal contractile integral pressures did not differ in all different consistencies compared with SHL. The integrated relaxation period was significantly higher with solid bolus compared with liquid bolus only in SHL position. The intrabolus pressure was significantly different with solid and soft solid boluses in all postures compared to liquid SHL. The American diet consistency affects upper esophageal sphincter pressure and partially integrated relaxation period and intrabolus pressure in various positions. Semisolid bolus swallows do not cause substantial pressure changes and are safe for evaluation and maintaining adequate caloric intake in patients with dysphagia who cannot tolerate solids.

Gastroesophageal reflux disease and laparoscopic sleeve gastrectomy: a physiopathologic evaluation

OBJECTIVE

To evaluate the effect of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) in morbidly obese patients.

BACKGROUND

Symptomatic GERD is considered by many a contraindication to LSG. However, studies evaluating the relationship between LSG and GERD by 24-hour pH monitoring are lacking.

METHODS

Consecutive morbidly obese patients selected for LSG were included in a prospective clinical study. Gastroesophageal function was evaluated using a clinical validated questionnaire, upper endoscopy, esophageal manometry, and 24-hour pH monitoring before and 24 months after LSG. This trial is registered with ClinicalTrials.gov (no. NCT02012894).

RESULTS

From June 2009 to September 2011, a total of 71 patients were enrolled into the study; 65 (91.5%) completed the 2-year protocol. On the basis of preoperative 24-hour pH monitoring, patients were divided into group A (pathologic, n=28) and group B (normal, n=37). Symptoms improved in group A, with the Gastroesophageal Reflux Disease Symptom Assessment Scale score decreasing from 53.1±10.5 to 13.1±3.5 (P<0.001). The DeMeester score and total acid exposure (% pH<4) decreased in group A patients (DeMeester score from 39.5±16.5 to 10.6±5.8, P<0.001; % pH<4 from 10.2±3.7 to 4.2±2.6, P<0.001). Real "de novo" GERD occurred in 5.4% group B patients. No significant changes in lower esophageal sphincter pressure and esophageal peristalsis amplitude were found in both groups.

CONCLUSIONS

LSG improves symptoms and controls reflux in most morbidly obese patients with preoperative GERD. In obese patients without preoperative evidence of GERD, the occurrence of "de novo" reflux is uncommon. Therefore, LSG should be considered an effective option for the surgical treatment of obese patients with GERD.

Consumer use of over-the-counter proton pump inhibitors in patients with gastroesophageal reflux disease

OBJECTIVES

Optimal administration of proton pump inhibitor (PPI) for the treatment of gastroesophageal reflux disease (GERD) requires consideration of meal timing. Since becoming available over the counter (OTC), no studies have assessed treatment patterns and symptom control in OTC consumers. The objective of this study was to survey dosing patterns and symptom control in OTC and prescription PPI users.

METHODS

Patients at five clinics were surveyed regarding diagnosis of GERD, use of OTC or prescription PPIs, information on time of day dosing, demographics, and Gastroesophageal Reflux Disease Symptom Assessment Scale (GSAS; 2001, Johnson & Johnson).

RESULTS

Of the 1,959 patients surveyed, 610 (31%) used PPIs for GERD. Of these, 190 (31%) and 223 (37%) received prescriptions from gastroenterologists (GIs) and primary care physicians (PCPs), respectively; 197 (32%) purchased OTC PPIs. Of the patients prescribed PPIs by GIs, 71% were optimal users, whereas 47% of patients receiving prescriptions from PCPs and 39% of consumers used PPIs optimally (P<0.001 compared with GIs). GSAS symptom, frequency, and severity scores were significantly better in patients prescribed PPIs by GIs (all P<0.001, GI compared with PCP and consumer). GSAS symptom, frequency, and severity scores were also significantly better in patients using PPIs optimally (P<0.001 for all parameters) compared with those taking PPIs suboptimally or excessively.

CONCLUSIONS

Patients receiving prescription PPI from a GI are more likely to be optimal users with better symptom control. Conversely, consumers are more likely to be suboptimal users with inadequate symptom control.

Development of an online library of patient-reported outcome measures in gastroenterology: the GI-PRO database

OBJECTIVES

Because gastrointestinal (GI) illnesses can cause physical, emotional, and social distress, patient-reported outcomes (PROs) are used to guide clinical decision making, conduct research, and seek drug approval. It is important to develop a mechanism for identifying, categorizing, and evaluating the over 100 GI PROs that exist. Here we describe a new, National Institutes of Health (NIH)-supported, online PRO clearinghouse-the GI-PRO database.

METHODS

Using a protocol developed by the NIH Patient-Reported Outcome Measurement Information System (PROMIS(®)), we performed a systematic review to identify English-language GI PROs. We abstracted PRO items and developed an online searchable item database. We categorized symptoms into content "bins" to evaluate a framework for GI symptom reporting. Finally, we assigned a score for the methodological quality of each PRO represented in the published literature (0-20 range; higher indicates better).

RESULTS

We reviewed 15,697 titles (κ>0.6 for title and abstract selection), from which we identified 126 PROs. Review of the PROs revealed eight GI symptom "bins": (i) abdominal pain, (ii) bloat/gas, (iii) diarrhea, (iv) constipation, (v) bowel incontinence/soilage, (vi) heartburn/reflux, (vii) swallowing, and (viii) nausea/vomiting. In addition to these symptoms, the PROs covered four psychosocial domains: (i) behaviors, (ii) cognitions, (iii) emotions, and (iv) psychosocial impact. The quality scores were generally low (mean 8.88 ± 4.19; 0 (min)-20 (max). In addition, 51% did not include patient input in developing the PRO, and 41% provided no information on score interpretation.

CONCLUSIONS

GI PROs cover a wide range of biopsychosocial symptoms. Although plentiful, GI PROs are limited by low methodological quality. Our online PRO library (www.researchcore.org/gipro/) can help in selecting PROs for clinical and research purposes.

Systematic review: questionnaires for assessment of gastroesophageal reflux disease

Numerous questionnaires with a wide variety of characteristics have been developed for the assessment of gastroesophageal reflux disease (GERD). Four well-defined dimensions are noticeable in these GERD questionnaires, which are symptoms, response to treatment, diagnosis, and burden on the quality of life of GERD patients. The aim of this review is to develop a complete overview of all available questionnaires, categorized per dimension of the assessment of GERD. A systematic search of the literature up to January 2013 using the Pubmed database and the Embase database, and search of references and conference abstract books were conducted. A total number of 65 questionnaires were extracted and evaluated. Thirty-nine questionnaires were found applicable for the assessment of GERD symptoms, three of which are generic gastrointestinal questionnaires. For the assessment of response to treatment, 14 questionnaires were considered applicable. Seven questionnaires with diagnostic purposes were found. In the assessment of quality of life in GERD patients, 18 questionnaires were found and evaluated. Twenty questionnaires were found to be used for more than one assessment dimension, and eight questionnaires were found for GERD assessment in infants and/or children. A wide variety of GERD questionnaires is available, of which the majority is used for assessment of GERD symptoms. Questionnaires differ in aspects such as design, validation and translations. Also, numerous multidimensional questionnaires are available, of which the Reflux Disease Questionnaire is widely applicable. We provided an overview of GERD questionnaires to aid investigators and clinicians in their search for the most appropriate questionnaire for their specific purposes.

DASH for asthma: a pilot study of the DASH diet in not-well-controlled adult asthma

This pilot study aims to provide effect size confidence intervals, clinical trial and intervention feasibility data, and procedural materials for a full-scale randomized controlled trial that will determine the efficacy of Dietary Approaches to Stop Hypertension (DASH) as adjunct therapy to standard care for adults with uncontrolled asthma. The DASH diet encompasses foods (e.g., fresh fruit, vegetables, and nuts) and antioxidant nutrients (e.g., vitamins A, C, E, and zinc) with potential benefits for persons with asthma, but it is unknown whether the whole diet is beneficial. Participants (n = 90) will be randomized to receive usual care alone or combined with a DASH intervention consisting of 8 group and 3 individual sessions during the first 3 months, followed by at least monthly phone consultations for another 3 months. Follow-up assessments will occur at 3 and 6 months. The primary outcome measure is the 7-item Juniper Asthma Control Questionnaire, a validated composite measure of daytime and nocturnal symptoms, activity limitations, rescue medication use, and percentage predicted forced expiratory volume in 1 second. We will explore changes in inflammatory markers important to asthma pathophysiology (e.g., fractional exhaled nitric oxide) and their potential to mediate the intervention effect on disease control. We will also conduct pre-specified subgroup analyses by genotype (e.g., polymorphisms on the glutathione S transferase gene) and phenotype (e.g., atopy, obesity). By evaluating a dietary pattern approach to improving asthma control, this study could advance the evidence base for refining clinical guidelines and public health recommendations regarding the role of dietary modifications in asthma management.

Patient-reported outcomes in gastroenterology: clinical and research applications

Patient-generated reports, also known as Patient-Reported Outcomes (PROs), capture the patients' illness experience in a structured format and may help bridge the gap between patients and providers. PROs measure any aspect of patient-reported health (e.g., physical, emotional or social symptoms) and can help to direct care and improve clinical outcomes. When clinicians systematically collect patient-reported data in the right place at the right time, PRO measurement can effectively aid in detection and management of conditions, improve satisfaction with care and enhance the patient-provider relationship. This review article summarizes the latest approaches to PRO measuring for clinical trials and clinical practice, with a focus on use of PROs in gastroenterology.

Systematic review of patient-reported outcome instruments for gastroesophageal reflux disease symptoms

Gastroesophageal reflux disease (GERD) symptoms are best assessed using patient-reported outcome (PRO) instruments. Guidance on developing well-defined and reliable instruments that capture optimal information from the patient's perspective was recently published by the US Food and Drug Administration and the European Medicines Agency. The aim of this systematic review was to identify and evaluate existing PRO instruments for GERD symptoms with regard to regulatory requirements. Systematic literature searches were conducted in PubMed and Embase to identify PRO instruments for GERD symptoms that have undergone psychometric evaluation. Content, construct and test-retest reliability, internal consistency, and responsiveness were evaluated in relation to regulatory recommendations. Supplementary searches were conducted to assess whether identified instruments had been used as clinical trial endpoint measures. The systematic literature searches identified 15 PRO instruments for GERD symptoms that have undergone psychometric evaluation. Eight were designed to evaluate GERD symptoms, two were to diagnose GERD, four were designed for both evaluative and diagnostic purposes, and one was designed for screening purposes. Five instruments were developed and reported to include most steps recommended by the Food and Drug Administration and European Medicines Agency, and have also been used as endpoint measures in clinical trials: the GERD Symptom Assessment Scale, the Nocturnal Gastro-oesophageal Reflux Disease Symptom Severity and Impact Questionnaire, the Reflux Questionnaire, the Reflux Disease Questionnaire, and the Proton pump inhibitor Acid Suppression Symptom test. Existing PRO instruments for GERD do not meet all the regulatory requirements for an outcome instrument in reflux trials and may need further validation.

Systematic review: symptom assessment using patient-reported outcomes in gastroesophageal reflux disease and dyspepsia

OBJECTIVE

The importance of symptom assessment using patient-reported outcomes (PROs) is becoming increasingly recognized in the management of upper gastrointestinal (GI) disease. The authors aimed to review systematically the methodological aspects of PRO instrument development and use in the GERD or dyspepsia literature, and to assess these instruments' properties in light of the Food and Drug Administration's (FDA) guidance.

MATERIAL AND METHODS

Systematic PubMed and Embase searches (using terms based on the FDA guidance) identified studies that reported methodological aspects in developing or using PRO instruments for GERD or dyspepsia symptom measurement.

RESULTS

Ten studies were identified (six systematically and four from citation lists). Studies reported the development or use of a relevant PRO instrument, with a focus on methodological aspects that the FDA guidance describes as important for patient understanding. Studies demonstrated heterogeneity of recall periods, symptoms and response options. Two studies demonstrated that a lack of consistent vocabulary may contribute to discrepancy in symptom reporting between investigators and patients. Two studies indicated that symptoms must be described in a manner that is relevant to patients. One study described the development of a PRO instrument separately in two languages, acknowledging linguistic and cultural differences between populations. One study demonstrated changes in symptom severity based on the recall period.

CONCLUSIONS

There is considerable heterogeneity in the methodology used to develop PRO instruments for upper GI disease. Adherence to best practices in PRO development and validation may improve the quality and utility of these measures, leading to improved communication in clinical practice.

The measurement of symptoms and side effects in clinical trials of chronic pain

Clinical trials in chronic pain have used various methods to assess the effect of medications. In addition to measuring symptom relief, researchers must also address adverse events (AEs) associated with the medication to evaluate overall therapeutic results. This paper reviews methods of measuring symptoms and AEs, including passive capture, scripted prompting, prospective assessments of side effects of interest, and prospective comprehensive symptom checklists. Methods of measuring therapeutic results have advantages and disadvantages. Although passive AE capture (unscripted, open-ended questions about symptoms) is not constrained by preconceptions of potential AEs, it sometimes fails to capture clinically significant AEs. Scripted prompting (prespecified, scripted, open-ended questions about symptoms) is likely to address the latter problem but preclude consistency across trials. Prospective assessments (prespecified symptom inventories) can offer greater sensitivity and consistency in detecting side effects of specific treatments. Comprehensive symptom distress inventories can be more sensitive measures of overall treatment benefit, which may be important when efficacy, passive AE capture, and comprehensive quality of life (QOL) batteries fail to differentiate between treatments. In cancer populations these inventories have been statistically correlated with survival and other important clinical outcomes, even after controlling for disease status, global QOL, psychological state, and performance status. Other important considerations are patient perceptions of the importance of symptoms, the correlations between QOL and symptom distress, and the usefulness of global ratings, in which patients integrate any perceived benefits of the medication with tolerability and other factors, such as convenience and cost.

Esophageal symptoms questionnaire for the assessment of dysphagia, globus, and reflux symptoms: initial development and validation

Esophageal symptoms often co-occur. A validated self-report measure encompassing multiple esophageal symptoms is necessary to determine their frequency and severity both independently and in association with each other. Such a questionnaire could streamline the diagnostic process and guide patient management. We aimed to develop an integrative measure that provides a clinical 'snapshot' of common esophageal symptoms. Internal reliability and content validity of a 38-item self-report Esophageal Symptoms Questionnaire (ESQ), measuring the frequency and severity of typical esophageal symptoms using Likert-rating scales were assessed in 211 patients presenting to gastroenterology and ENT outpatient tertiary care clinics. Reproducibility, concurrent and predictive validity were evaluated using the reduced-item ESQ. The 38-item ESQ had high internal reliability. Principal component analyses and item reduction methods identified three components, to which 30 of 38 items contributed significantly, providing 59% of total variance. The test-retest correlations were moderate-to-strong for 24 of 30 new items (r(s) ≥ 0.44, P < 0.05). The resultant subscales measuring dysphagia (ESQ-D), globus (ESQ-G), and reflux (ESQ-R) compared well against concurrent physician's 'working' diagnosis (odds ratio 1.04-1.09). The receiver operating characteristics were adequate-to-good for ESQ-D (area under the curve [AUC]= 0.87) and ESQ-G (AUC = 0.74), but poor for ESQ-R (AUC = 0.61) although it matched the content of the validated Reflux Disease Questionnaire. The brief 30-item ESQ shows good internal reliability and content validity as a summary of the extent of dysphagia, globus and reflux symptoms. As a tool measuring more than one esophageal symptom, ESQ could guide patient management by indicating which of the coexisting symptoms needs to be addressed first.

Insights into gastroesophageal reflux disease-associated dyspeptic symptoms

BACKGROUND & AIMS

Patients with GERD frequently report dyspeptic-like symptoms, including nausea, vomiting, early satiety, bloating, and belching. The purpose of this review was to define the epidemiology and underlying mechanisms for dyspeptic symptoms in GERD patients.

METHODS

We performed a systematic literature review to identify the prevalence of dyspeptic symptoms in GERD patients. We identified 2057 studies, and 37 studies (2%) met the entry criteria, including 17 articles describing the prevalence of dyspeptic symptoms in GERD subjects, 7 studies describing mechanistic evaluation of dyspeptic symptoms in GERD, 7 studies describing questionnaires used to measure dyspeptic symptoms, and 6 studies assessing the role of proton pump inhibitor therapy for dyspeptic symptoms associated with GERD. We used an evidence-based approach to assess the literature.

RESULTS

The median (± standard deviation) prevalence of GERD in 30,384 subjects from 8 studies conducted in Western countries was 30% ± 8% (range, 20%-40%). Dyspeptic symptoms were present in 38% ± 14% (range, 21%-63%) and were more frequent in patients with frequent GERD symptoms, compared with patients with intermittent or no GERD symptoms [Evidence B]. Patients with nonerosive disease had a higher prevalence of dyspeptic symptoms [Evidence B] in addition to a lower response to proton pump inhibitor therapy [Evidence A], compared with patients with erosive esophagitis. Epigastic pain, belching, bloating, and early satiety demonstrated improvement on PPI therapy [Evidence A], compared with symptoms of nausea and vomiting that did not improve [Evidence A]. Patients with dyspepsia were at risk for a subsequent new diagnosis of GERD [Evidence B]. Dyspeptic symptoms contributed significantly to the decrement in health-related quality of life associated with GERD.

CONCLUSIONS

Dyspeptic symptoms are common in GERD patients and impact health-related quality of life.

Questionnaire based gastroesophageal reflux disease (GERD) assessment scales

Questionnaire based assessment scales for gastroesophageal reflux disease (GERD) have been utilized for assessment of the patient's symptomatology, assessment of symptom severity and frequency, assessment of health-related quality of life and for assessment of response to treatment. A multitude of unidimensional and multidimensional questionnaires exist for making symptom assessment and monitoring quality of life in GERD. Many of the scales meet some of the parameters of an ideal evaluative GERD specific assessment instrument. Yet, there are certain shortcomings and challenges which are faced in development of GERD questionnaires. This review discusses the features of an ideal symptom assessment instrument, examines the strengths and weaknesses of currently available questionnaires.

Relationship between gastroesophageal reflux symptoms and dietary factors in Korea

Background/Aims

The incidence of gastroesophageal reflux disease (GERD) is increasing in Korea. The aim of this study was to evaluate the relationship between GERD symptoms and dietary factors in Korea.

Methods

From January 2007 to April 2008, 162 subjects were enrolled (81 in GERD group and 81 in control group). They were asked to complete the questionnaires about GERD symptoms and dietary habits. The symptom severity score was recorded by visual analogue scale.

Results

Subjects with overweight or obesity had an increased risk for GERD (OR, 2.52; 95% CI, 1.18-5.39). Irregular dietary intake was one of the risk factors for GERD (OR, 2.33; 95% CI, 1.11-4.89). Acid regurgitation was the most suffering (2.85 ± 2.95 by visual analogue scale) and frequent reflux-related symptom (57.5%) in GERD. Noodles (OR, 1.22; 95% CI, 1.12-1.34), spicy foods (OR, 1.09; 95% CI, 1.02-1.16), fatty meals (OR, 1.20; 95% CI, 1.09-1.33), sweets (OR, 1.42; 95% CI, 1.00-2.02), alcohol (OR, 1.16; 95% CI, 1.03-1.31), breads (OR, 1.17; 95% CI, 1.01-1.34), carbonated drinks (OR, 1.69; 95% CI, 1.04-2.74) and caffeinated drinks (OR,1.41; 95% CI, 1.15-1.73) were associated with symptom aggravation in GERD. Among the investigated noodles, ramen (instant noodle) caused reflux-related symptoms most frequently (52.4%).

Conclusions

We found that noodles, spicy foods, fatty meals, sweets, alcohol, breads, carbonated drinks and caffeinated drinks were associated with reflux-related symptoms.

Randomised clinical trial: high-dose acid suppression for chronic cough - a double-blind, placebo-controlled study

BACKGROUND

Cough may be a manifestation of gastro-oesophageal reflux disease (GERD). The utility of acid suppression in GERD-related cough is uncertain.

AIM

To assess the impact of high-dose acid suppression with proton pump inhibitors (PPI) on chronic cough in subjects with rare or no heartburn.

METHODS

Subjects were nonsmokers without history of asthma, with chronic cough for >8 weeks. All subjects underwent a baseline 24-h pH/impedance study, methacholine challenge test and laryngoscopy. Subjects were randomised to either 40 mg of esomeprazole twice daily or placebo for 12 weeks. The primary outcome measure was the Cough-Specific Quality of Life Questionnaire (CQLQ). Secondary outcomes were response on Fisman Cough Severity/Frequency scores and change in laryngeal findings.

RESULTS

Forty subjects were randomised (22 PPI, 18 placebo) and completed the study. There was no difference between PPI and placebo in CQLQ (mean improvement 9.8 vs. 5.9 respectively, P = 0.3), or Fisman Cough Severity/Frequency scores. Proportion of patients who improved by >1 s.d. on the CQLQ was 27.8% (five of 18) and 31.8% (seven of 22) in the placebo and PPI groups respectively.

CONCLUSION

In subjects with chronic cough and rare or no heartburn, high-dose proton pump inhibitor does not improve cough-related quality of life or symptoms.

A pragmatic symptom-based approach

Symptoms are the main cause of morbidity and a significant impairment of quality of life in reflux disease. The majority of patients report their symptoms to primary care physicians, and do not have objective evidence of reflux oesophagitis. Thus symptom evaluation is the primary method of diagnosis, assessment of severity, and determining the choice of therapy. Symptoms are not currently judged to cause reflux disease until they occur on at least two days a week; at this level, they lead to significant impairment of quality of life. Heartburn and regurgitation and general considered to be the cardinal symptoms of reflux. However, these often occur in the setting of other upper gastrointestinal symptoms, particularly epigastric pain, which patients often have difficulty in distinguishing from heartburn. Questionnaires have been developed in order to standardise and improve symptom-based diagnosis, and perform as well as primary care clinicians. These have yet to become mainstream practise but offer great potential.

Characteristics of gastroesophageal reflux in adults with cystic fibrosis

BACKGROUND

Gastroesophageal reflux (GER) in adults with cystic fibrosis (CF) is poorly characterized. This study examines the frequency and predictors of GER symptoms and their relationship to lung function in adults with CF.

METHODS

Cross-sectional study of adults at the University of Minnesota CF Clinic using two validated self report surveys: The Mayo GER questionnaire and the GERD Symptom Assessment Scale (GSAS).

RESULTS

Of 274 invited patients, 201 (73%) completed the surveys and 173 performed spirometry at the same visit. Frequent symptoms (at least weekly) were reported by 24% of the patients and an additional 39% experienced occasional symptoms. Heartburn, acid regurgitation and dysphagia were the most common symptoms and 18% reported that GER symptoms worsened their respiratory condition. Females and patients reporting weight loss had more symptoms (mean GSAS symptom score 4.9 vs. 4.0, p=0.025 and 5.3 vs. 4.2, p=0.04) and more severe symptoms (mean GSAS distress score 5.6 vs. 3.8, p=0.005 and 6.8 vs. 4.0, p=0.01) compared to males and those who did not report weight loss. Patients on acid suppression (n=122, 61%) continued to report heartburn (n=80, 66%) and acid regurgitation (n=47, 23%). GER symptoms and severity of symptoms were not predictive of FEV(1) or FVC.

CONCLUSIONS

GER symptoms were present in a majority of patients. Females and patients with weight loss require special attention to their GER symptoms. Many patients on acid suppression continued to be report symptoms.

Brief Questioning by Nursing Staffs before Endoscopic Examination May Not Always Pick Up Clinical Symptoms of Endoscopic Reflux Esophagitis

The clinical features of patients reflux esophagitis without any symptoms have not been clearly demonstrated. This study evaluated the clinical features of patients with endoscopy-positive reflux esophagitis, who did not complain of symptoms, as detected by brief questioning by nursing staffs. Eight thousand and thirty-one patients not taking medication for gastrointestinal disease, were briefly asked about the presence of heartburn, dysphagia, odynophagia and acid regurgitation by nursing staffs before endoscopy for assessment of esophagitis utilizing the Los Angeles Classification. Endoscopically, 1199 (14.9%) patients were classified as positive for reflux esophagitis. The endoscope positive subjects who complain heartburn were 539/1199 (45.0%).The endoscope positive subjects who do not complain symptoms were 465 in 1199 positive reflux esophagitis (38.8%). We compared endoscopic positive subjects without any complain by brief question by nursing staffs to endoscopic positive subjects with heartburn. Male gender, no obesity, absence of hiatus hernia, and low-grade esophagitis were associated with endoscopy-positive patients who do not complain of symptoms. The results of this study indicated correct detection of clinical symptoms of reflux esophagitis might be not easy with brief questioning by nursing staffs before endoscopic examination.

The Breathe Easier through Weight Loss Lifestyle (BE WELL) Intervention: a randomized controlled trial

BACKGROUND

Obesity and asthma have reached epidemic proportions in the US. Their concurrent rise over the last 30 years suggests that they may be connected. Numerous observational studies support a temporally-correct, dose-response relationship between body mass index (BMI) and incident asthma. Weight loss, either induced by surgery or caloric restriction, has been reported to improve asthma symptoms and lung function. Due to methodological shortcomings of previous studies, however, well-controlled trials are needed to investigate the efficacy of weight loss strategies to improve asthma control in obese individuals.

METHODS/DESIGN

BE WELL is a 2-arm parallel randomized clinical trial (RCT) of the efficacy of an evidence-based, comprehensive, behavioral weight loss intervention, focusing on diet, physical activity, and behavioral therapy, as adjunct therapy to usual care in the management of asthma in obese adults. Trial participants (n = 324) are patients aged 18 to 70 years who have suboptimally controlled, persistent asthma, BMI between 30.0 and 44.9 kg/m2, and who do not have serious comorbidities (e.g., diabetes, heart disease, stroke). The 12-month weight loss intervention to be studied is based on the principles of the highly successful Diabetes Prevention Program lifestyle intervention. Intervention participants will attend 13 weekly group sessions over a four-month period, followed by two monthly individual sessions, and will then receive individualized counseling primarily by phone, at least bi-monthly, for the remainder of the intervention. Follow-up assessment will occur at six and 12 months. The primary outcome variable is the overall score on the Juniper Asthma Control Questionnaire measured at 12 months. Secondary outcomes include lung function, asthma-specific and general quality of life, asthma medication use, asthma-related and total health care utilization. Potential mediators (e.g., weight loss and change in physical activity level and nutrient intake) and moderators (e.g., socio-demographic characteristics and comorbidities) of the intervention effects also will be examined.

DISCUSSION

This RCT holds considerable potential for illuminating the nature of the obesity-asthma relationship and advancing current guidelines for treating obese adults with asthma, which may lead to reduced morbidity and mortality related to the comorbidity of the two disorders.

TRIAL REGISTRATION

NCT00901095.

[Health-related quality of life issues in gastroesophageal reflux disease]

Several studies have reported significant Health-Related Quality of life (HRQOL) impairment in gastroesophageal reflux disease (GERD) patients compared with the general population. The evaluation of quality of life is important as a parameter for the treatment. Because GERD has diverse symptoms such as esophageal and extraesophageal syndromes, HRQOL of GERD should be determined by both disease and non-disease related factors. The purpose is to overview the HRQOL instruments used in the evaluation of GERD, published reports regarding HRQOL in GERD, and the effects of medical treatments on GERD.

Power spectral analysis of the sleep electroencephalogram in heartburn patients with or without gastroesophageal reflux disease: a feasibility study

GOALS

Determine the feasibility of using power spectrum of the sleep electroencephalogram (EEG) as a more sensitive tool than sleep architecture to evaluate the relationship between gastroesophageal reflux disease (GERD) and sleep.

BACKGROUND

GERD has been shown to adversely affect subjective sleep reports but not necessarily objective sleep parameters.

STUDY

Data were prospectively collected from symptomatic patients with heartburn. All symptomatic patients underwent upper endoscopy. Patients without erosive esophagitis underwent pH testing. Sleep was polygraphically recorded in the laboratory. Spectral analysis was performed to determine the power spectrum in 4 bandwidths: delta (0.8 to 4.0 Hz), theta (4.1 to 8.0 Hz), alpha (8.1 to 13.0 Hz), and beta (13.1 to 20.0 Hz).

RESULTS

Eleven heartburn patients were included in the GERD group (erosive esophagitis) and 6 heartburn patients in the functional heartburn group (negative endoscopy, pH test, response to proton pump inhibitors). The GERD patients had evidence of lower average delta-power than functional heartburn patients. Patients with GERD had greater overall alpha-power in the latter half of the night (3 hours after sleep onset) than functional heartburn patients. No significant differences were noted in conventional sleep stage summaries between the 2 groups.

CONCLUSIONS

Among heartburn patients with GERD, EEG spectral power during sleep is shifted towards higher frequencies compared with heartburn patients without GERD despite similar sleep architecture. This feasibility study demonstrated that EEG spectral power during sleep might be the preferred tool to provide an objective analysis about the effect of GERD on sleep.

Laryngopharyngeal reflux: a prospective analysis of a 34 item symptom questionnaire

OBJECTIVES

Laryngopharyngeal reflux is increasingly diagnosed, but both its symptoms and relationship to gastro-oesophageal reflux disease remain confused.

AIMS

(i) To assess symptoms in potential laryngopharyngeal reflux patients according to a comprehensive symptom list based on both a gastro-oesophageal reflux questionnaire and a laryngopharyngeal reflux questionnaire. (ii) To assess whether there are statistically discrete symptom clusters which might map to specific syndromes e.g. globus pharynges.

DESIGN

Prospective single cohort questionnaire survey.

METHODS

A 34-item questionnaire comprising all symptoms identifiable on (i) the original 25-item Gastroesophageal Symptom Assessment Scale (GSAS) and (ii) the nine Reflux Symptom Index (RSI) items, 'unbundled' as necessary, were administered to 62 ENT clinic attenders. Descriptive, correlation and cluster analysis was performed.

RESULTS

All but two of the combined 34-symptom list were endorsed by at least 20% of 62 patients. Certain symptoms which the Reflux Symptom Index groups as a single item were only weakly correlated. No specific symptom clusters were identified.

CONCLUSIONS

Neither the most popular 'lower' oesophageal (GSAS) nor the 'throat' reflux (RSI) questionnaire adequately captures the full range of potential reflux symptoms regularly encountered in otolaryngology patients: inadequate evaluation of patients' symptoms may have contributed to the ongoing uncertainty about the role of acid or pepsin suppression. A more comprehensive reflux questionnaire is needed to characterise the true reflux correlations of laryngopharyngeal symptoms, and offer a symptom-specific measure of response to placebo and anti-reflux therapy.

Multiple preoperative endoscopic interventions are associated with worse outcomes after laparoscopic Heller myotomy for achalasia

BACKGROUND

The effect of preoperative pneumatic dilation or botulinum toxin injection on outcomes after laparoscopic Heller myotomy (LHM) for achalasia is unclear. We compared outcomes in patients with and without multiple preoperative endoscopic interventions.

METHODS

This cohort study categorized achalasia patients undergoing first-time LHM by the number of preoperative endoscopic interventions: zero or one intervention vs. two or more interventions. Outcomes of interest included surgical failure (defined as the need for re-intervention), gastrointestinal symptoms, and health-related quality of life. Logistic regression modeling was performed to determine the independent effect of multiple preoperative endoscopic interventions on the likelihood of surgical failure.

RESULTS

One hundred thirty-four patients were included; 88 (66%) had zero to one preoperative intervention, and 46 (34%) had multiple (more than one) interventions. The incidence of surgical failure was 7% in the zero to one intervention group and 28% in the more than one intervention group (p < 0.01). Greater improvements in gastrointestinal symptoms and health-related quality of life were seen in the zero to one intervention group. On logistic regression modeling, the likelihood of surgical failure was significantly higher in the more than one intervention group (odds ratio = 5.1, 95% confidence interval 1.6-15.8, p = 0.005).

CONCLUSIONS

Multiple endoscopic treatments are associated with poorer outcomes and should be limited to achalasia patients who fail surgical therapy.

Impact of PPIs on patient focused symptomatology in GERD

About half of patients with gastroesophageal reflux disease (GERD) have a normal endoscopy, so symptom assessment is the only appropriate outcome measure for these persons. Symptom assessment is also of great importance in persons with erosive esophagitis. There is currently no fully validated questionnaire to compare symptom response to treatment of patients with GERD. The aim of this review is to consider ReQuest^™ assessment tool to evaluate esophageal, supra-esophageal, and infra-esophageal symptoms, as well as any modification of the patient’s quality of life. The ReQuest^™ may be combined with the Los Angeles classification of esophagitis (LA A–D), to include the normal endoscopic finding in normal endoscopy reflux disease. The ReQuest^™ score declines rapidly towards normal with patient treatment with a proton pump inhibitor. A proportion of patients need more than the usual 8 weeks of therapy. For example, in GERD patients with Los Angeles B–D, the ReQuest^™ score falls more with pantoprazole 40 mg than with esomoprazole 40 mg after 12 weeks of therapy. Now that the simplified ReQuest in Practice^™ is available, this validated brief questionnaire has potential as an instrument for use in GERD patients seen in everyday clinical practice.

Clinical trial design in adult reflux disease: a methodological workshop

BACKGROUND

The development of well-tolerated acid suppressant drugs has stimulated substantial growth in the number of trials assessing therapy options for gastro-oesophageal reflux disease (GERD).

AIM

To develop consensus statements to inform clinical trial design in adult patients with GERD.

METHODS

Draft statements were developed employing a systematic literature review. A modified Delphi process including three rounds of voting was used to reach consensus. Between voting, statements were revised based on feedback from the Working Group and additional literature reviews. The final vote was at a face-to-face meeting that included discussion time. Voting was conducted using a six-point scale.

RESULTS

At the last vote, 93% of the final 102 statements achieved consensus (defined a priori as being supported by >or=75% of the votes). The Working Group strongly supported the development of validated patient-reported outcome instruments. Symptom assessments carried out by the investigator were considered unacceptable. There was agreement that exclusion from clinical trials should be minimized to improve generalizability, that prospective evaluation ideally requires electronic timed/dated methods and that endoscopists should be blinded to patient symptom status.

CONCLUSIONS

Implementation of the consensus statements will improve the quality and comparability of trials, and make them compatible with regulatory requirements.

Systematic review: health-related quality of life (HRQOL) questionnaires in gastro-oesophageal reflux disease

BACKGROUND

Although gastro-oesophageal reflux disease (GERD) has a well-established pathophysiology, the impact of GERD symptoms on the patients' quality of life can be profound. Therefore, health-related quality of life (HRQOL) questionnaires have become standard instruments to evaluate the effect of treatment in clinical trials.

AIM

To evaluate the reliability, validity and responsiveness of available GERD-specific HRQOL.

METHODS

A systematic literature search using the Medical Subject Headings terms: 'Gastro-oesophageal reflux', 'Heartburn' and 'Oesophagitis' with 'quality of life' and 'questionnaires' was preformed to identify the available HRQOL questionnaires. To analyse the psychometric properties of the respective tools, the actual guidelines for the use of patient-reported outcomes in clinical trials were applied.

RESULTS

We identified five GERD-specific HRQOL questionnaires but none of them fulfilled all quality criteria; either they did not meet the actual standards for psychometric properties (HBQOL, GERD-HRQL, Jasani et al.Aust Fam Physician 1999; 28: 515), or were impracticable to use in clinical trials. The generic and hybrid instruments lack specificity and sensitivity and were not designed for treatment evaluation in GERD patients.

CONCLUSION

There is need for a new evaluative tool in the assessment of HRQOL during GERD therapy.

Effect of proton-pump inhibitor treatment on symptoms and quality of life in GERD patients depends on the symptom-reflux association

BACKGROUND

Gastroesophageal reflux disease patients demonstrate various pathophysiologic backgrounds. Therefore, a heterogeneous response to proton-pump inhibitor (PPI) treatment can be expected. We investigated the effect of short-term PPI treatment on symptoms and quality of life (QOL) in primary care patients with and without pathologic esophageal acid exposure and in presence or absence of a positive association between symptoms and reflux episodes.

STUDY

Seventy-four heartburn patients were categorized into 4 groups according to positive or negative symptom-reflux association, as expressed in symptom index, symptom sensitivity index, and symptom association probability (SAP) and presence or absence of pathologic reflux, defined as esophageal pH<4%>6% of the time (pH+/pH-). Overall and specific reflux symptoms were assessed 1 week before and the last week during a 2-week course of 40-mg esomeprazole daily. The QOL was scored by the Quality of Life in Reflux and Dyspepsia questionnaire 2 weeks before treatment and directly after.

RESULTS

Using the SAP to assess symptom-reflux associations, the 4 groups [SAP+pH+(n=40); SAP+pH-(n=12); SAP-pH+(n=10); SAP-pH-(n=10)] had similar demographic characteristics. The SAP-pH- subgroup had the least overall symptom reduction (P<0.01) and in the SAP+pH+ subgroup the greatest heartburn symptom reduction was found (P<0.02). The residual symptom scores on treatment were lowest in SAP+pH+ and highest in SAP-pH- subgroups and relatively high in the SAP+pH-. QOL was severely reduced and SAP-pH- patients had the lowest QOL overall. Similar findings were made using symptom index and symptom sensitivity index.

CONCLUSIONS

Symptomatic reflux patients without evidence of reflux disease on a 24-hour pH recording responded less favorably to PPI treatment than patients with a positive symptom-reflux association or with pathologic reflux.

Maintenance treatment of gastroesophageal reflux disease: an evaluation of continuous and on-demand therapy with rabeprazole 20 mg

OBJECTIVE

To evaluate continuous therapy (COT) and on-demand therapy (ODT) with rabeprazole 20 mg for maintenance in uninvestigated gastroesophageal reflux disease (GERD).

METHODS

This randomized, open-label study enrolled 331 GERD (heartburn-predominant) patients with a pre-existing proton pump inhibitor history of one month or longer, to an acute four-week trial with 20 mg rabeprazole daily for heartburn management. Patients who achieved satisfactory heartburn control during the acute phase (three days or less of heartburn, with no more than one episode rated as moderate, and heartburn rated satisfactorily or completely controlled with minimal rescue antacid use in the seven days preceding randomization) were randomly assigned to six months of rabeprazole 20 mg given as either daily COT or daily ODT, which was initiated upon symptom recurrence and stopped upon symptom resolution. Rescue antacid usage was permitted and tracked. Primary efficacy was measured as the proportion of heartburn-free days over six months.

RESULTS

For the 268 patients, the mean percentage of heartburn-free days for the COT group and for the ODT group were 90.3%+/-14.8% and 64.8%+/-22.3%, respectively (P<0.0001). COT was associated with an increased number of medication intake days (154+/-40.2) versus ODT (68+/-46.1), with less heartburn episodes observed with COT versus ODT, respectively (n=7, n=26, P<0.0001). Ninety-two per cent of COT patients and 79% of ODT patients were either 'satisfied' or 'very satisfied' with treatment. The mean usage of antacids was low and similar in both groups. COT and ODT regimens were safe and well-tolerated, with a similar incidence of adverse events.

CONCLUSION

Results based on symptom assessments favour COT with rabeprazole 20 mg for maintenance therapy in patients with uninvestigated GERD; however, both therapy types are safe and acceptable treatment options for selected patients.

Failures in a proton pump inhibitor therapeutic substitution program: lessons learned

The pathogenesis of patient dissatisfaction following involuntary therapeutic substitutions involving proton pump inhibitors (PPIs) is poorly understood. The aim of this study was to describe the patient population experiencing therapeutic failure and investigate whether failure was related to individual differences in response to the different PPIs. Treatment failures in a lansoprazole-rabeprazole therapeutic substitution program were compared to switch successes. A subgroup was randomized in a double-blind, double-dummy, crossover study to four 2-week periods of lansoprazole-rabeprazole-lansoprazole-rabeprazole or vice versa. Measures included overall rating of gastrointestinal reflux disease (GERD) symptoms for the past week as well as the frequency and distress scales of the GERD Symptom Assessment Scale. One hundred fifteen nonresponders were compared with 54 successful responders. Nonresponders consisted primarily of patients with GERD (74%, vs. 44% of responders; P = 0.005) who had undergone upper gastrointestinal endoscopy (50%, vs. 31% of responders; P = 0.02). Twelve patients completed the randomized treatment study. The interrater kappa coefficient for responder status was estimated to be 0.80 for lansoprazole and 0.21 for rabeprazole. The majority of PPI nonresponders had a clinical diagnosis of GERD and were receiving >/=40 mg of rabeprazole daily. This pilot study provides new insights into the design of subsequent studies of nonresponders in PPI therapeutic substitution programs.

Gastro-esophageal reflux disease symptoms are more common in general practice in Japan

AIM: To accurately assess the prevalence of GERD symptoms in general practice.

METHODS: 4139 consecutive patients (2025 men and 2114 women with a mean age of 43 years), who first attended the Outpatient Department of General Medicine and Emergency Care at Toho University Omori Hospital, were asked to respond to the F-scale questionnaire regardless of their chief complaints. The questionnaire is a self-report instrument, written in a simple and easy-to-understand language, containing 12 questions.

RESULTS: Of 4139 subjects, 1554 patients (37.6%) were identified as GERD according to their F-scale score (> 7). However, there were only 45 consultations (1.1%) for typical GERD symptoms. Although GERD symptoms are common in adults of all ages, the prevalence of GERD was highest in the 20-29 years age group and the age group 70-79 years had the lowest prevalence for both males and females.

CONCLUSION: Although there was a high rate indicating GERD in our primary care population, only 1.1% of outpatients attended our hospital with a chief complaint of GERD symptoms. Since about one-third of GERD patients are affected by atypical symptoms, general physicians need to be cautious about extrapolating these results to patients with a chief complaint other than typical GERD symptoms.

Applying data mining techniques in the development of a diagnostics questionnaire for GERD

Gastroesophageal reflux disease (GERD) is a common condition, managed mostly in primary care practice. Heartburn and acid regurgitation are considered primary symptoms, and are usually highly specific. However, the symptom spectrum is much wider and in many cases it is difficult to determine whether the patient has GERD or dyspepsia from another origin. The aim of this study is to develop a symptom score and rule for the diagnosis of GERD, using data mining techniques, to provide a clinical diagnostic tool for primary care practitioners in the evaluation and management of upper gastrointestinal symptoms. A diagnostic symptom questionnaire consisting of 15 items and based on the current literature was designed to measure the presence and severity of reflux and dyspepsia symptoms using a 5-point Likert-type scale. A total of 132 subjects with uninvestigated upper abdominal symptoms were prospectively recruited for symptom evaluation. All patients were interviewed and examined, underwent upper gastrointestinal endoscopy, and completed the questionnaire. Based on endoscopic findings as well as the medical interview, the subjects were classified as having reflux disease (GERD) or non-reflux disease (non-GERD). Data mining models and algorithms (neural networks, decision trees, and logistic regression) were used to build a short and simple new discriminative questionnaire. The most relevant variables discriminating GERD from non-GERD patients were heartburn, regurgitation, clinical response to antacids, sour taste, and aggravation of symptoms after a heavy meal. The sensitivity and specificity of the new symptom score were 70%-75% and 63%-78%, respectively. The area under the ROC curve for logistic regression and neural networks were 0.783 and 0.787, respectively. We present a new validated discriminative GERD questionnaire using data mining techniques. The questionnaire is useful, friendly, and short, and therefore can be easily applied in clinical practice for choosing the appropriate diagnostic workup for patients with upper gastrointestinal complaints.

Tradução e validação para a língua portuguesa (Brasil) de instrumentos específicos para avaliação de qualidade de vida na doença do refluxo gastroesofágico

INTRODUÇÃO: Estudos têm demonstrado ser a doença do refluxo gastroesofágico capaz de alterar a qualidade de vida e a produtividade no trabalho dos doentes por ela acometidos. Instrumentos para esse tipo de avaliação são provenientes, em sua maioria, de países de língua inglesa e/ou francesa. A utilização desses instrumentos em nosso meio demanda criterioso processo de tradução e validação. OBJETIVOS: Traduzir para língua portuguesa os questionários GERD-HRQL (Gastroesophageal Reflux Disease - Health Related Quality of Life), HBQOL (Heartburn Specific Quality of Life Instrument) e GSAS (Gastroesophageal Reflux Disease Symptom Assessment Scale) específicos para avaliação de qualidade de vida na doença do refluxo gastroesofágico. Testar suas propriedades psicométricas de confiabilidade e validade. MÉTODOS: Cento e trinta e dois pacientes com doença do refluxo gastroesofágico (idade média 54,9 anos, ± DP 13,9) atendidos no ambulatório de motilidade digestiva da Universidade Federal de São Paulo, SP, e de gastrocirurgia da Faculdade de Medicina de São José do Rio Preto, SP, aceitaram participar do presente estudo, fornecendo termo de consentimento pós-esclarecimento. Destes, 40 pacientes participaram da fase de pré-teste (28 do sexo feminino e 12 do sexo masculino, com idade média de 55,3 anos, ± DP 14,7) e 92 da fase de validação (64 do sexo feminino e 28 sexo masculino, com idade média 54,7 anos e ± DP 13,7). A tradução e adaptação cultural foi realizada de acordo com o método de GUILLEMIN et al., sendo a validação dos questionários traduzidos (GERD-HRQL, HBQOL e GSAS) realizada em relação aos instrumentos genérico SF-36 e sintomático ESDRGE (SQGERD). RESULTADOS: A adaptação cultural implicou na troca de quatro palavras no GERD-HRQL, seis no HBQOL e nove no GSAS. Posteriormente a esta fase, o questionário GSAS foi abandonado por problemas no cálculo do escore, sendo as propriedades de medidas testadas nos dois questionários remanescentes, esses se mostraram reprodutíveis para uso inter e intra-observador com valores de 0,980 e 0,968, respectivamente, para o GERD-HRQL, e valores que variaram de 0,868 a 0,972, respectivamente, para o HBQOL. O questionário HBQOL demonstrou alta consistência interna (>0,70) para três das quatro dimensões avaliadas (aspecto físico, dor, sono). Os resultados encontrados na fase de validação apresentaram bons níveis de correlação com os questionários SF-36 e ESDRGE (SQGERD). CONCLUSÕES: As versões para a língua portuguesa (Brasil) dos instrumentos GERD-HRQL e HBQOL, adaptadas ao padrão cultural brasileiro, configuram-se em opções válidas, confiáveis, com baixo nível de desgaste do paciente e de fácil aplicação para avaliação de qualidade de vida na DRGE em nosso meio. O instrumento HBQOL é a única opção de avaliação multidimensional de qualidade de vida atualmente disponível para uso no Brasil. A versão em português do instrumento GSAS mostrou-se inadequada para avaliação de qualidade de vida na DRGE em nosso meio.

Symptom assessment tools for gastroesophageal reflux disease (GERD) treatment

Relief of symptoms, both typical and atypical, is the mainstay of therapy for patients with gastroesophageal reflux disease (GERD); however, evaluation of GERD symptoms' response to treatment has been hampered by the lack of a questionnaire that meets all the criteria of an ideal evaluative GERD symptom assessment tool. These criteria are: sensitivity in GERD patients, covering all symptom dimensions (multidimensional construct), assessment of frequency and intensity of "typical" and "atypical" GERD symptoms, practical and economical, easy to understand, responsive over short time intervals, use as a patient self-assessment tool, amenable to daily use, psychometrically validated, and translation into many languages with cross-cultural adaptation. Thus far, 14 instruments have been developed to assess GERD symptoms and potentially can be used to evaluate treatment response during a therapeutic trial in GERD patients. However, comparison of the different evaluative tools is needed.

GERD evaluation: time for a new paradigm?

In the past there has been reliance on heartburn and acid regurgitation as the cardinal symptoms of gastro-esophageal reflux. Now it is recognized that diverse additional symptoms including extraesophageal manifestations are essential components of gastroesophageal reflux disease (GERD). Furthermore, previous reliance in mucosal damage at endoscopy as evidence of therapeutic success in the management of GERD has proven of only limited value in the diverse world of GERD symptoms. Indeed is now apparent that the relationship between symptoms and lesions is modest at best. Most patients with GERD have no overt erosions or ulceration at endoscopy and they frequently suffer from a wide array of complaints other than heartburn that contribute to their diminished perception of life's quality. To address these problems, multidimensional questionnaires designed to encompass the diverse symptomatology of GERD have been investigated, principally, to provide a reproducible metric of change in the subjective response to pharmacologic therapy during trials for patients with nonerosive reflux disease. The most promising of these instruments is The ReQuest questionnaire, because it has been extensively validated in multiple patient groups and cultures, appears highly promising in this regard and for erosive disease too and may ultimately prove to be of value for the initial evaluation of patients with GERD. We propose that accurate symptom delineation complemented with endoscopy performed in selected groups of patients will become the mainstay in diagnosis of GERD and the assessment of therapy efficacy.