Symptom-based outcome measures for dyspepsia and GERD trials: a systematic review

Spanish translation and validation of a hybrid, health-related quality of life questionnaire for chronic esophageal conditions: NEQOL-S

BACKGROUND

Chronic esophageal conditions (CEC) are associated with significant disease-related burden, disability, and costs. Health-related quality of life (HRQOL) constructs are intended to capture the physical, mental, social, and emotional aspects of a patient's life and how health status impacts these domains. The Northwestern Esophageal Quality of Life (NEQOL) can be used among esophageal diseases while maintaining sensitivity to specific conditions. We aimed to translate, cross-cultural adapt, and validate the NEQOL into Spanish.

METHODS

After language and cross-cultural adaptation, the NEQOL was applied to an outpatient clinic-based population in a single tertiary center. We analyzed the internal consistency, construct, criterion validity, and test-retest reliability of the questionnaire. The criterion validity was tested against the SF-12 questionnaire.

KEY RESULTS

After completing the translation process, no item was considered problematic. A total of 385 patients were included in the validation study. The internal consistency (Cronbach's alpha) for the total NEQOL-S score was 0.89. The NEQOL-S questionnaire showed moderate test-retest reliability (ICC = 0.828; 95% CI 0.755-0.881; p < 0.001). Criterion validity showed good coherence when correlated with the SF-12 survey (R²  = 0.538; 95% CI 0.491-0.585, p < 0.001).

CONCLUSIONS AND INFERENCES

The translated and cross-culturally adapted NEQOL-S showed good psychometric properties that allow its use in Spanish-speaking patients suffering from CEC.

Effect of Dewaxed Coffee on Gastroesophageal Symptoms in Patients with GERD: A Randomized Pilot Study

Gastroesophageal Reflux Disease (GERD) is multifactorial pathogenesis characterized by the abnormal reflux of stomach contents into the esophagus. Symptoms are worse after the ingestion of certain foods, such as coffee. Hence, a randomized pilot study conducted on 40 Italian subjects was assessed to verify the effect of standard (SC) and dewaxed coffee (DC) consumption on gastroesophageal reflux symptoms and quality of life in patients with gastrointestinal diseases. The assessment of patient diaries highlighted a significant percentage reduction of symptoms frequency when consuming DC and a significant increase in both heartburn-free and regurgitation-free days. Consequentially, patients had a significant increase of antacid-free days during the DC assumption. Moreover, the polyphenolic profile of coffee pods was ascertained through UHPLC-Q-Orbitrap HRMS analysis. Chlorogenic acids (CGAs) were the most abundant investigated compounds with a concentration level ranging between 7.316 (DC) and 6.721 mg/g (SC). Apart from CGAs, caffeine was quantified at a concentration level of 5.691 mg/g and 11.091 for DC and SC, respectively. While still preliminary, data obtained from the present pilot study provide promising evidence for the efficacy of DC consumption in patients with GERD. Therefore, this treatment might represent a feasible way to make coffee more digestible and better tolerated.

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.

Effects of Osteopathic Visceral Treatment in Patients with Gastroesophageal Reflux: A Randomized Controlled Trial

Osteopathic manual treatment has been recommended as a non-pharmacological therapy for Gastroesophageal Reflux Disease (GERD). However, to date, no study has supported the effectiveness of this intervention with respect to the symptoms of the disease. Our goal was to assess the effect of an osteopathic manual technique for the lower esophageal sphincter on GERD symptoms, cervical mobility and on the C4 spinous process pressure pain threshold (PPTs).

METHODS

A randomized, double-blind placebo-controlled trial was performed. Sixty subjects suffering from GERD participated in this study and were randomly assigned to either an experimental group (EG) (n = 29), who received the osteopathic technique for the lower esophageal sphincter, or to a control group (CG) (n = 31), who received a manual contact, which mimicked the osteopathic technique without exerting any therapeutic force. Randomization was computer-generated, with allocation concealed by sequentially numbered, opaque, sealed envelopes. The GerdQ questionnaire was used to assess symptom changes the week after intervention. Cervical Range of Motion (CROM) and algometer were used to evaluate cervical mobility and PPTs before and after both treatments. Before-after between groups comparison (t-test) was used for statistical analysis of the outcome, with two measurement points (GerdQ), while repeated-measures ANOVA was used for those outcomes with four measurement points (CROM and PPT).

RESULTS

The application of the osteopathic manual treatment in subjects with GERD produced a significant improvement in symptoms one week after the intervention (p = 0.005) with a between-groups difference of 1.49 points in GerdQ score (95% CI: 0.47-2.49). PPT C4 improved in the EG after the treatment (p = 0.034; η² = 0.048) (between-groups difference 8.78 Newton/cm²; 95% CI: 0.48-17.09). CROM also increased in the EG compared to the CG (p < 0.001; η² = 0.108) (between-groups difference 33.89 degrees; 95% CI: 15.17-52.61).

CONCLUSIONS

The manual osteopathic technique produces an improvement in GERD symptoms one week after treatment, cervical mobility, and PPTs. This may mean that osteopathic treatment is useful for improving symptoms of GERD.

Systematic review: Disease-specific instruments to assess gastrointestinal symptoms in functional dyspepsia

BACKGROUND

Functional dyspepsia (FD) is a common functional gastrointestinal disorder with incompletely understood pathophysiology and heterogeneous symptom presentation. Assessment of treatment efficacy in FD is a methodological challenge as response to treatment must be assessed primarily by measuring subjective symptoms. Therefore, the use of patient-reported outcome measures (PROMs) is recommended by regulatory authorities to assess gastrointestinal symptoms in clinical trials for FD. In the last decades, a multitude of outcome measures has been developed. However, currently no PROM has been approved by the regulatory authorities, and no consensus has been reached with regard to the most relevant outcome measure in FD.

PURPOSE

This systematic review discusses the available disease-specific outcome measures for assessment of FD symptoms with psychometric validation properties, strengths, and limitations. Moreover, recommendations for use of current available outcome measures are provided, and potential areas of future research are discussed.

New psychometric data from the Spanish versions of the Glasgow Dyspepsia Severity Score and the Dyspepsia-Related Health Scale measures

BACKGROUND AND OBJECTIVE

There are no structural abnormalities in functional dyspepsia, therefore it is essential to have a viable questionnaire to measure treatment outcome according to patient perception. The aim of the study was to extensively document psychometric characteristics of the Glasgow Dyspepsia Severity Score and the Dyspepsia-Related Health Scale that are currently available in Spanish.

METHODS

Patients with functional dyspepsia (n = 158) were recruited from a randomized trial that assessed standard vs. standard and psychological treatment. Participants had completed the validation questionnaires and the Medical Outcome Study Short-form 36. Reliability (Cronbach's alpha), validity (Confirmatory Factor Analysis, convergent and known group validity) and responsiveness (minimal clinically important difference) were analyzed.

RESULTS

A Confirmatory Factor Analysis of the Glasgow Dyspepsia Severity Score showed a one-factor solution model, but a low Cronbach's alpha (0.61). With regard to the Dyspepsia-Related Health Scale, the Cronbach's alpha (0.80-0.97) and Confirmatory Factor Analysis supported a model with four inter-correlated dimensions and suggested a need to improve the "Satisfaction with dyspepsia-related health" dimension (Cronbach's alpha < 20). Finally, the global scores for both the Glasgow Dyspepsia Severity Score and the Dyspepsia-Related Health Scale were responsive at six months post-treatment, with a minimal clinically important difference of 4 and 6, respectively.

CONCLUSIONS

Our findings support the continued application of the Dyspepsia-Related Health Scale and the need to improve the "Satisfaction with dyspepsia-related health" dimension. Although the Glasgow Dyspepsia Severity Score is a promising questionnaire, further review of the content is required to eliminate and add items in order to provide greater consistency to the evaluated construct.

Histopathological Assessment of Dyspepsia in the Absence of Endoscopic Mucosal Lesions

Introduction

Dyspepsia is a common symptom with an extensive differential diagnosis. Endoscopy alone may miss serious mucosal lesions in about 15 to 30% of cases. The aim was to determine histopathological features of gastric and duodenal mucosal biopsies in patients with dyspepsia and normal looking upper gastrointestinal (GI) endoscopy.

Materials and methods

One hundred and five adult patients presenting with dyspepsia with no endoscopic mucosal lesions in the upper GI tract were included. Gastric biopsy specimens according to Sydney-Houston system for grading gastritis and biopsy from duodenum were taken. The histopathological features were graded according to the Sydney-Houston system classification for grading gastritis.

Results

The histological lesions were found in 65.7% (69 out of 105 endoscopy free dyspeptic patients). Chronic inflammation was the commonest finding. Neutrophilic activity, glandular atrophy, and mild degree of intestinal metaplasia were present in 27, 45, and 6 patients (22.8, 42.8, and 5.7% respectively). Helicobacter pylori was present in 54 patients with histopathological lesions and in 6 patients without histopathological lesions, and the difference was significant (p = 0.045).

Conclusion

The endoscopic diagnosis of dyspepsia correlated poorly with histopathological findings. The histopathological examination allowed detection and grading of gastric pathology in dyspepsia with normal endoscopy and the commonest finding was the moderate chronic gastritis.

How to cite this article

Dawod HM, Emara MW. Histopathological Assessment of Dyspepsia in the Absence of Endoscopic Mucosal Lesions. Euroasian J Hepato-Gastroenterol 2016;6(2):97-102.

Efficacy and safety of Aloe vera syrup for the treatment of gastroesophageal reflux disease: a pilot randomized positive-controlled trial

OBJECTIVE

To investigate the use of Aloe vera (A. vera) for the treatment of gastroesophageal reflux disease (GERD) symptoms and compare its effects with those of omeprazole and ranitidine.

METHODS

In this pilot, randomized controlled trial, 79 subjects were allocated to A. vera syrup (standardized to 5.0 mg polysaccharide per mL of syrup) at a dose of 10 mL/d, omeprazole capsule (20 g/d) or ranitidine tablet (150 mg in a fasted state in the morning and 150 mg 30 min before sleep at night) for a period of 4 weeks. The frequencies of eight main symptoms of GERD (heartburn, food regurgitation, flatulence, belching, dysphagia, nausea, vomiting and acid regurgitation) were assessed at weeks 2 and 4 of the trial.

RESULTS

A. vera was safe and well tolerated and reduced the frequencies of all the assessed GERD symptoms, with no adverse events requiring withdrawal.

CONCLUSION

A. vera may provide a safe and effective treatment for reducing the symptoms of GERD.

Gastroesophageal reflux disease in COPD: links and risks

COPD is a long-term condition associated with considerable disability with a clinical course characterized by episodes of worsening respiratory signs and symptoms associated with exacerbations. Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal conditions in the general population and has emerged as a comorbidity of COPD. GERD may be diagnosed by both symptomatic approaches (including both typical and atypical symptoms) and objective measurements. Based on a mix of diagnostic approaches, the prevalence of GERD in COPD ranges from 17% to 78%. Although GERD is usually confined to the lower esophagus in some individuals, it may be associated with pulmonary microaspiration of gastric contents. Possible mechanisms that may contribute to GERD in COPD originate from gastroesophageal dysfunction, including altered pressure in the lower esophageal sphincter (which normally protect against GERD) and changes in esophageal motility. Proposed respiratory contributions to the development of GERD include respiratory medications that may alter esophageal sphincter tone and changes in respiratory mechanics, with increased lung hyperinflation compromising the antireflux barrier. Although the specific cause and effect relationship between GERD and COPD has not been fully elucidated, GERD may influence lung disease severity and has been identified as a significant predictor of acute exacerbations of COPD. Further clinical effects could include a poorer health-related quality of life and an increased cost in health care, although these factors require further clarification. There are both medical and surgical options available for the treatment of GERD in COPD and while extensive studies in this population have not been undertaken, this comorbidity may be amenable to treatment.

Association Between Joint Hypermobility and Gastroesophageal Reflux Disease: An Observational Analytical Cross Sectional Study

Objectives

This study aims to assess the association between joint hypermobility (JHM) and gastroesophageal reflux disease (GERD).

Patients and methods

This cross sectional study included 100 consecutive Iraqi patients (43 males, 57 females; mean age 30±6.6 years; range 18 to 40 years) with GERD diagnosed by a gastroenterologist according to the guidelines for diagnosis and management of GERD and age and sex matched 100 healthy controls (36 males, 64 females; mean age 30±5.2 years; range 20 to 40 years). JHM was measured using Beighton score method by a blinded observer. A score of 4 or more was considered hypermobile.

Results

Joint hypermobility values were significantly higher in GERD patients than in controls [46 (71.9%) vs 18 (28.1%), p<0.001, odds ratio=3.88; 95% confidence interval=2.04-7.39]. Multiple logistic regression analysis to detect predictors of GERD in JHM patients revealed that patients with high total mobility score (7- 9) had the highest risk for developing GERD [about 41 fold compared to those with normal mobility score (<4), P model <0.001, and overall prediction accuracy of 68%].

Conclusion

There is a significant association between JHM and GERD. The high total mobility score (7-9) was associated with a significantly high risk for developing GERD, indicating that early recognition of JHM may assist in early diagnosis and treatment of GERD.

Mandarin version of the Leeds Dyspepsia Questionnaire: A valid instrument for assessing symptoms in Asians

OBJECTIVE

To develop and validate a Mandarin version of the Leeds Dyspepsia Questionnaire (M-LDQ) in Asian patients with dyspepsia.

METHODS

The M-LDQ was developed according to standardized methods. The validity, internal consistency, test-retest reliability and responsiveness of the instrument were evaluated in both primary and secondary care patients.

RESULTS

A total of 184 patients (mean age 54.0 ± 15.8 years, of whom 59% were women and 72.3% of whom had at least secondary level education) were recruited between August 2012 and March 2013, from both primary (n = 100) and secondary care clinics (n = 84). Both the internal consistency of all components of the M-LDQ (Cronbach's α 0.79) and test-retest reliability (Spearman's correlation coefficient 0.78) were good. The M-LDQ was valid in diagnosing dyspepsia in primary care (area under the receiver operating characteristics curve 0.84) and was able to discriminate between secondary and primary care patients (median cumulative LDQ score 13.0 vs 3.0, P < 0.0001). Among eight patients with organic dyspepsia, the median M-LDQ score reduced significantly from 21.0 (pretreatment) to 9.5 (4 weeks post-treatment) (P < 0.0001).

CONCLUSION

The M-LDQ is a valid and responsive instrument for assessing ethnic Chinese adults with dyspepsia.

Gastro-esophageal reflux disease and exacerbations in chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVE

We tested the hypothesis that gastro-esophageal reflux disease is a risk factor for exacerbations in individuals with chronic obstructive pulmonary disease (COPD).

METHODS

Among 9622 participants in the Copenhagen City Heart Study, we identified 1259 individuals with COPD and information on gastro-esophageal reflux disease and the regular use of acid inhibitory treatment. These individuals were followed for 5 years with regard to medically treated COPD exacerbations, which we defined as a short course treatment with oral corticosteroids alone or in combination with antibiotics. We applied a multivariable Cox regression analysis with adjustment for well-established risk factors associated with COPD exacerbations or gastro-esophageal reflux disease, including COPD severity, and symptoms.

RESULTS

Individuals with COPD and gastro-esophageal reflux disease had more chronic bronchitis (31 vs 21%, P = 0.004), more breathlessness (39 vs 22%, P < 0.001), and more of them had a history of respiratory infections (6.8 vs 1.4%, P < 0.001) than individuals with COPD but without gastro-esophageal reflux disease. Among individuals with COPD and gastro-esophageal reflux disease, those who did not use acid inhibitory treatment regularly had an increased risk of COPD exacerbations during follow-up, hazards ratio (HR): HR = 2.7 (1.3-5.4, P = 0.006). Individuals with gastro-esophageal reflux disease, using acid inhibitory treatment regularly did not have an increased risk of exacerbations, HR = 1.2 (0.6-2.7, P = 0.63).

CONCLUSIONS

Gastro-esophageal reflux disease was associated with an increased risk of medically treated exacerbations of COPD, but only in those individuals who did not use acid inhibitory treatment regularly.

Randomized controlled trial comparing the efficacy of mosapride plus omeprazole combination therapy to omeprazole monotherapy in gastroesophageal reflux disease

OBJECTIVE

We investigated whether the prokinetic activity of mosapride, a 5-hydroxytryptamine 4 receptor agonist, in combination with proton pump inhibitor (PPI) would ameliorate symptoms of gastroesophageal reflux disease (GERD) in Japanese patients.

METHODS

Patients who experienced reflux symptoms more than twice weekly were eligible for this study. In all, 60 patients were randomized to receive mosapride 5 mg thrice daily combined with omeprazole 10 mg once daily (GO group), or omeprazole alone (O group) for 4 weeks. The patients completed the frequency scale for the symptoms of GERD (FSSG) at the beginning and the end of the study. The primary outcome compared changes in the FSSG reflux-related symptom (RS) score between treatment groups during the study period.

RESULTS

The FSSG RS scores significantly decreased both in the GO group and the O group, with no differences in improvement between the groups (-5.86 for the GO group vs -4.89 for the O group, P = 0.49). In non-erosive reflux disease (NERD) patients the improvement was significantly lower than that in erosive GERD patients (-4.00 vs -7.67, P = 0.02). However, the addition of mosapride was effective in subgroup analyses of specific symptoms, such as burping.

CONCLUSIONS

Combining mosapride with PPI provided no additional amelioration of reflux symptoms compared to PPI alone. Both regimens provided less relief from reflux symptoms in NERD than in erosive GERD patients. The addition of mosapride ameliorated reflux in patients with symptoms like burping.

Clinically significant endoscopic findings in a multi-ethnic population with uninvestigated dyspepsia

INTRODUCTION

The proportion of clinically significant endoscopic findings (CSEF) in dyspepsia affects the initial management of this condition. With the changing epidemiology of organic upper gastrointestinal diseases in Asia, current data on CSEF remains uncertain.

METHODS

A cross-sectional study of consecutive adult patients attending an open access endoscopy list for the primary indication of dyspepsia was conducted. Independent epidemiological and clinical factors for CSEF were determined prospectively.

RESULTS

Data for 1167/1208 (96.6 %) adults (mean age 49.7 ± 15.9 years, 42.4 % males, ethnic distribution: 30.5 % Malays, 36.9 % Chinese and 30.8 % Indians) were analysed between January 2007 and August 2008. Three-hundred and eight (26.4 %) patients were found to have CSEF, most often those with age ≥45 years (30.3 vs 19 %, P < 0.0001), male gender (34.1 vs 20.7 % female, P < 0.0001), lower education levels (i.e. primary or no education), smoking (36.7 vs 24.9 %, P = 0.003), H. pylori infection (40.6 vs 21.8 %, P < 0.0001), and duration of dyspepsia ≤5 months (32.8 vs 24.4 %, P = 0.006). Age ≥ 45 years (OR 1.82, 95 % CI = 1.38-2.48), male gender (OR 1.84, 95 % CI = 1.53-2.59), H. pylori infection (OR 2.36, 95 % CI = 1.83-3.26), and duration of dyspepsia ≤5 months (OR 1.44, 95 % CI = 1.13-2.03) were subsequently identified as independent risk factors for CSEF.

CONCLUSION

CSEF are found in 26.4 % of Asian adults with uninvestigated dyspepsia. Duration of symptoms <5 months, among other recognised factors, is predictive of CSEF.

Pediatric patients with dyspepsia have chronic symptoms, anxiety, and lower quality of life as adolescents and adults

BACKGROUND & AIMS

Little is known about long-term health outcomes of children with dyspeptic symptoms. We studied the natural history of pediatric patients with dyspeptic symptoms, with and without histologic reflux, compared with healthy controls.

METHODS

We performed a prospective study of consecutive new patients, ages 8-16 years, who underwent evaluation for dyspepsia, including upper endoscopy. Patients were assigned to groups with histologic evidence of reflux esophagitis (n = 50), or normal histology results (n = 53). Healthy children were followed up as controls (n = 143). Patients and controls were evaluated 5-15 years later. They provided self-reports on severity of dyspeptic symptoms, use of acid suppression, quality of life, anxiety, and depression.

RESULTS

When the study began, the groups with histologic evidence of esophagitis and normal histologies did not differ in severity of dyspeptic symptoms, functional disability, or depression. After a mean 7.6-year follow-up period, each group had significantly lower quality-of-life scores and more severe dyspeptic symptoms and functional disability than controls, but did not differ significantly from each other; both groups were significantly more likely than controls to meet criteria for an anxiety disorder. At time of follow-up evaluation, use of acid-suppression medication was significantly greater in the group with histologic evidence for esophagitis, compared with patients who had normal histology findings when the study began.

CONCLUSIONS

Among pediatric patients with dyspepsia evaluated by endoscopy and biopsy, those with histologic evidence for esophagitis or normal histology findings are at increased risk for chronic dyspeptic symptoms, anxiety disorder, and reduced quality of life in adolescence and young adulthood.

Large-scale randomized clinical study on functional dyspepsia treatment with mosapride or teprenone: Japan Mosapride Mega-Study (JMMS)

BACKGROUND AND AIM

Functional dyspepsia (FD) is a common condition seen in primary gastroenterology practice. The present study was conducted to compare the clinical effectiveness of mosapride and teprenone in patients with FD.

METHODS

Prospective clinical comparative study with random allocation of open labeled medications was performed as a multicenter trial in Japan. 1042 patients presenting symptoms of FD, either with gastric stasis (GSS) and/or epigastric pain (EPS), were enrolled. After initial endoscopic evaluation, medication either with mosapride 5 mg tid or teprenone 50 mg tid was started. Severity and frequency of GSS and EPS, health-related quality of life (HR-QOL) by the SF-36 Japanese version, and patients' compliance to medication was evaluated.

RESULTS

Organic lesions were found in 90 patients (9%) in the 1027 patients examined by endoscopy. Among those without any specific lesions detected by endoscopy, gastrointestinal symptoms were resolved within one week after the endoscopy in 264 (28%) patients before initiating medication. 618 patients who remained symptomatic were randomized to medication either with mosapride (n = 311) or teprenone (n = 307). Two-week treatment with mosapride significantly improved GSS and EPS, while teprenone tended to improve only GSS. Mosapride also improved HR-QOL. 91% of patients treated with mosapride favored their medication, while only 52% of patients treated with teprenone favored their medication.

CONCLUSIONS

Endoscopic evaluation at patients' presentation was effective to find active lesions and to improve FD symptoms. Mosapride was more favorably accepted than teprenone by the patients with sufficient safety and efficacy.

Validation study of the Leeds Dyspepsia Questionnaire in a multi-ethnic Asian population

BACKGROUND AND AIM

Outcome measures for clinical trials in dyspepsia require an assessment of symptom response. There is a lack of validated instruments assessing dyspepsia symptoms in the Asian region. We aimed to translate and validate the Leeds Dyspepsia Questionnaire (LDQ) in a multi-ethnic Asian population.

METHODS

A Malay and culturally adapted English version of the LDQ were developed according to established protocols. Psychometric evaluation was performed by assessing the validity, internal consistency, test-retest reliability and responsiveness of the instruments in both primary and secondary care patients.

RESULTS

Between April and September 2010, both Malay (n=166) and Malaysian English (n=154) versions were assessed in primary and secondary care patients. Both language versions were found to be reliable (internal consistency was 0.80 and 0.74 (Cronbach's α) for Malay and English, respectively; spearman's correlation coefficient for test-retest reliability was 0.98 for both versions), valid (area under receiver operating curve for accuracy of diagnosing dyspepsia was 0.71 and 0.77 for Malay and English versions, respectively), discriminative (median LDQ score discriminated between primary and secondary care patients in Malay (11.0 vs 20.0, P<0.0001) and English (10.0 vs 14.0, P=0.001), and responsive (median LDQ score reduced after treatment in Malay (17.0 to 14.0, P=0.08) and English (18.0 to 11.0, P=0.008) to dyspepsia.

CONCLUSIONS

The Malaysian versions of the LDQ are valid, reliable and responsive instruments for assessing symptoms in a multi-ethnic Asian population with dyspepsia.

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.

Endoscopic and symptoms analysis in Mexican patients with irritable Bowel syndrome, dyspepsia, and gastroesophageal reflux disease

The aim of this study was to analyze the data of endoscopy and symptoms in 118 Mexican patients with irritable bowel syndrome (IBS), dyspepsia, non-erosive reflux disease (NERD) and erosive esophagitis (EE). IBS criteria were fulfilling for dyspepsia patients in 47%, for NERD in 48%, and for EE patients in 48% of cases. Esophagitis was present in 42% of patients with IBS and in 45% of patients with dyspepsia. A higher prevalence of hiatus hernia was found in EE vs. NERD. Heartburn and acid eructation were associated with the presence of esophagitis; acid eructation, regurgitation and nocturnal pain with duodenitis; and heartburn and regurgitation with hiatus hernia. Males more frequently reported: mucus in feces, abdominal distension, nausea and gastritis; and women more frequently reported esophagitis and duodenitis. Patients with NERD (OR 2.54, 95% CI 1.08 to 5.99, p=0.04), tenesmus and early satiety, and men had an increase risk for reporting hard or lumpy stools. In conclusion, nearly half of the Mexican patients with NERD, EE and dyspepsia fulfill criteria for IBS. A large number of symptoms were correlated with endoscopy, which can be used to improve the indication of the endoscopy and its implementation in clinical studies.

A validation study of the Italian Short-Form Leeds Dyspepsia Questionnaire

Assessment of symptoms should be one of the main outcome measures in dyspepsia clinical trials. This requires a reliable, valid and responsive questionnaire that measures the frequency and severity of dyspeptic symptoms. The Short-Form Leeds Dyspepsia Questionnaire (SF-LDQ) has been proven to fulfil these criteria in its original version in the English language. The aim of the study was to assess the internal consistency, reliability, validity and responsiveness of the Italian version of the SF-LDQ in primary and secondary care. Unselected primary and secondary care patients completed the Italian version of the SF-LDQ. Test-retest reliability was assessed after 2 days. Validity was measured by comparison with diagnosis made by physicians. Responsiveness was determined before and after treatment for endoscopically proven disease. The SF-LDQ was administered to 311 patients in primary care and 179 in secondary care patients. Internal consistency, as judged by the Cronbach's α, was 0.90. Pearson's correlation coefficient for test-retest reliability was 0.92. The SF-LDQ had a sensitivity of 80% and a specificity of 82%. A highly significant response to change was also observed (p = 0.001). The Italian SF-LDQ is a reliable, valid and responsive self-completed outcome measure for quantifying the frequency and severity of dyspeptic symptoms.

[Symptom profile in gastroesophageal reflux disease in untreated patients and those with persistent symptoms despite treatment]

AIM

1. To analyze the symptom profile of gastroesophageal reflux disease (GERD) with typical clinical manifestations (heartburn and/or regurgitation); 2. to compare untreated patients with those with persistent symptoms despite treatment; 3. to evaluate severity according to physicians' and patients' opinions; and 4. to determine the diagnostic and therapeutic approaches used.

METHODS

We performed a prospective, observational, cross-sectional study under conditions of standard clinical practice.

RESULTS

A total of 2356 patients were included. Dyspeptic symptoms were highly frequent (close to 90% in both groups) and supraesophageal symptoms were also common (50-60%). Patients with persistent symptoms despite treatment were older, and had more supraesophageal symptoms; in addition, the typical supraesophageal and dyspeptic symptoms of GERD were more severe in these patients. Severity evaluations by patients and doctors were concordant but patients considered severity to be greater. Older age was a risk factor for supraesophageal symptoms, female gender for dyspeptic symptoms and body mass index for greater severity of GERD symptoms. Endoscopy was requested in about 60% of the patients. Diet counseling was advised in most patients and postural recommendations were made in more than half. Proton pump inhibitors were prescribed in almost all patients, and were associated with prokinetics and/or antacids in many patients.

CONCLUSIONS

Dyspeptic symptoms should not be considered as independent of GERD, and typical and atypical symptoms are associated in 50% of patients. Gastroenterologists follow clinical practice guidelines fairly closely but diagnostic procedures seem to be overindicated.

WITHDRAWN: Initial management strategies for dyspepsia

BACKGROUND

This review considers management strategies (combinations of initial investigation and empirical treatments) for dyspeptic patients. Dyspepsia was defined to include both epigastric pain and heartburn.

OBJECTIVES

To determine the effectiveness, acceptability, and cost effectiveness of the following initial management strategies for patients presenting with dyspepsia (a) Initial pharmacological therapy (including endoscopy for treatment failures). (b) Early endoscopy. (c) Testing for Helicobacter pylori (H. pylori )and endoscope only those positive. (d) H. pylori eradication therapy with or without prior testing.

SEARCH STRATEGY

Trials were located through electronic searches and extensive contact with trialists.

SELECTION CRITERIA

All randomised controlled trials of dyspeptic patients presenting in primary care.

DATA COLLECTION AND ANALYSIS

Data were collected on dyspeptic symptoms, quality of life and use of resources. An individual patient data meta-analysis of health economic data was conducted

MAIN RESULTS

Twenty-five papers reporting 27 comparisons were found. Trials comparing proton pump inhibitors (PPI) with antacids (three trials) and histamine H2-receptor antagonists (H2RAs) (three trials), early endoscopy with initial acid suppression (five trials), H. pylori test and endoscope versus usual management (three trials), H. pylori test and treat versus endoscopy (six trials), and test and treat versus acid suppression alone in H. pylori positive patients (four trials), were pooled. PPIs were significantly more effective than both H2RAs and antacids. Relative risks (RR) and 95% confidence intervals (CI) were; for PPI compared with antacid 0.72 (95% CI 0.64 to 0.80), PPI compared with H2RA 0.63 (95% CI 0.47 to 0.85). Results for other drug comparisons were either absent or inconclusive. Initial endoscopy was associated with a small reduction in the risk of recurrent dyspeptic symptoms compared with H. pylori test and treat (OR 0.75, 95% CI 0.58 to 0.96), but was not cost effective (mean additional cost of endoscopy US$401 (95% CI $328 to 474). Test and treat may be more effective than acid suppression alone (RR 0.59 95% CI 0.42 to 0.83).

AUTHORS' CONCLUSIONS

Proton pump inhibitor drugs (PPIs) are effective in the treatment of dyspepsia in these trials which may not adequately exclude patients with gastro-oesophageal reflux disease (GORD). The relative efficacy of histamine H2-receptor antagonists (H2RAs) and PPIs is uncertain. Early investigation by endoscopy or H. pylori testing may benefit some patients with dyspepsia but is not cost effective as part of an overall management strategy.

Comparison of endoscopic findings with symptom assessment systems (FSSG and QUEST) for gastroesophageal reflux disease in Japanese centres

BACKGROUND AND AIM

We compared endoscopic findings of the frequency scale for the symptoms of gastroesophageal reflux disease (FSSG), a written questionnaire developed in Japan, to that for the questionnaire for the diagnosis of reflux esophagitis (QUEST) for the diagnosis of reflux esophagitis.

METHODS

We registered 475 patients with untreated symptoms of upper abdominal pain (male/female: 252/223, average age 52.4 +/- 17.8 years). Subjects were assessed first with the FSSG and QUEST questionnaires, then by endoscopy, before allocation to a gastric ulcer (GU), duodenal ulcer (DU), gastroesophageal reflux disease (GERD) or functional dyspepsia (FD) group.

RESULTS

On the basis of the endoscopic findings the diagnoses for the 475 subjects were as follows: FD 52.2%, DU 7.6%, GU 7.8%, and GERD 32.4% (Grade M 10.1%, Grade A + B 20.2%, Grade C + D 2.3%). There was no difference between the FSSG and QUEST in sensitivity, specificity or accuracy for any condition. The FSSG score rose with increasing endoscopic severity of GERD, but there was no correlation between the QUEST score and endoscopic severity. The FSSG total score was inferior to QUEST in terms of distinguishing GERD from other conditions, but when only the questions relating to reflux symptoms were used, the FSSG was able to distinguish GERD from other conditions as well as QUEST.

CONCLUSIONS

The FSSG score reflects the severity of the endoscopic findings of GERD.

Evaluation of the methodological quality of systematic reviews of health status measurement instruments

A systematic review of measurement properties of health-status instruments is a tool for evaluating the quality of instruments. Our aim was to appraise the quality of the review process, to describe how authors assess the methodological quality of primary studies of measurement properties, and to describe how authors evaluate results of the studies. Literature searches were performed in three databases. One hundred and forty-eight reviews were included. The purpose of included reviews was to identify health status instruments used in an evaluative application and to report on the measurement properties of these instruments. Two independent reviewers selected the articles and extracted the data. Reviews were often of low quality: 22% of the reviews used one database, the search strategy was often poorly described, and in many cases it was not reported whether article selection (75%) and data extraction (71%) was done by two independent reviewers. In 11 reviews the methodological quality of the primary studies was evaluated for all measurement properties, and of these 11 reviews only 7 evaluated the results. Methods to evaluate the quality of the primary studies and the results differed widely. The poor quality of reviews hampers evidence-based selection of instruments. Guidelines for conducting and reporting systematic reviews of measurement properties should be developed.

Meta-analysis: Helicobacter pylori'test and treat' compared with empirical acid suppression for managing dyspepsia

BACKGROUND

Which of Helicobacter pylori'test and treat' or empirical acid suppression should be preferred for the initial management of uncomplicated dyspepsia is controversial. Aim To conduct an individual patient data meta-analysis of randomized controlled trials (RCTs) of 'test and treat' vs. empirical acid suppression in adults with uncomplicated dyspepsia in primary care.

METHODS

Investigators provided original data sets for analysis. Effect of management strategy on symptom status and dyspepsia-related resource use at 12-month follow-up was examined by pooling symptom and cost data to obtain relative risk (RR) of remaining symptomatic at 12 months and weighted mean difference (WMD) in costs between the two strategies with 95% confidence intervals (CI).

RESULTS

We identified three eligible RCTs containing 1547 patients, 791 (51%) of whom were assigned to 'test and treat'. There was no difference detected in symptom-cure at 12 months (RR = 0.99; 95% CI: 0.95-1.03). There was a nonsignificant trend towards cost-savings with 'test and treat' (WMD in costs = - 28.91 pound; 95% CI: - 68.48 pound to 10.65 pound).

CONCLUSIONS

There was little difference in symptom-resolution or costs between the two strategies. A combination of patient and physician preference should determine the initial approach to the management of uncomplicated dyspepsia.

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.

Symptom evaluation in gastroesophageal reflux disease

The evaluation of the success of therapy for gastroesophageal reflux disease (GERD) has thus far been primarily on the basis of the endoscopic evaluation of the ability of drugs to heal esophageal mucosal breaks and to a lesser extent on their ability to decrease the diverse symptoms of acid reflux. However, because most patients with GERD have no visible esophageal lesions using conventional endoscopic methods, this paradigm requires serious reconsideration. As patients with nonerosive reflux disease (NERD) are just as symptomatic as patients with erosions and are no easier to treat the use of endoscopic end points alone, as criteria for determining healing and efficacy of therapy requires reassessment. In addition, the symptoms of GERD are now appreciated to be broad-based, including many extraesophageal symptoms that contribute to the marked reduction in quality of life for GERD patients. For this reason, and because endoscopic criteria cannot be applied to evaluating therapy in NERD, the success of GERD therapy should be judged primarily in terms of diminishment of GERD-related symptoms--a return to the traditional way that patients judge therapeutic success. To objectively determine the success of therapy in GERD, multisymptom GERD questionnaires have been developed. The most promising are those that reflect the numerous types of GERD symptoms, are patient-administered, quantitative, responsive, and have been validated in both NERD and erosive GERD patients. The ReQuest instrument is especially attractive as it records the entire range of GERD symptoms on a daily basis (including also their frequency and intensity) and is responsive to changes with time and with therapy. Symptom-based evaluative tools should greatly aid the objective evaluation of GERD symptoms, monitor precisely how patients respond to therapy and thereby lead to improvements in GERD management.

Effectiveness and costs of implementation strategies to reduce acid suppressive drug prescriptions: a systematic review

Background

Evaluation of evidence for the effectiveness of implementation strategies aimed at reducing prescriptions for the use of acid suppressive drugs (ASD).

Methods

A systematic review of intervention studies with a design according to research quality criteria and outcomes related to the effect of reduction of ASD medication retrieved from Medline, Embase and the Cochrane Library. Outcome measures were the strategy of intervention, quality of methodology and results of treatment to differences of ASD prescriptions and costs.

Results

The intervention varied from a single passive method to multiple active interactions with GPs. Reports of study quality had shortcomings on subjects of data-analysis. Not all outcomes were calculated but if so rction of prescriptions varied from 8% up to 40% and the cost effectiveness was in some cases negative and in others positive. Few studies demonstrated good effects from the interventions to reduce ASD.

Conclusion

Poor quality of some studies is limiting the evidence for effective interventions. Also it is difficult to compare cost-effectiveness between studies. However, RCT studies demonstrate that active interventions are required to reduce ASD volume. Larger multi-intervention studies are necessary to evaluate the most successful intervention instruments.

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.

The Short-Form Leeds Dyspepsia Questionnaire validation study

BACKGROUND

Assessment of symptoms should be the primary outcome measure in dyspepsia clinical trials. This requires a reliable, valid and responsive questionnaire that measures the frequency and severity of dyspepsia. The Leeds Dyspepsia Questionnaire fulfils these characteristics, but is long and was not designed for self-completion, so a shorter questionnaire was developed (the Short-Form Leeds Dyspepsia Questionnaire).

AIM

To assess the acceptability, interpretability, internal consistency, reliability, validity and responsiveness of the Short-Form Leeds Dyspepsia Questionnaire in primary and secondary care.

METHODS

Unselected primary and secondary care patients completed the Short-Form Leeds Dyspepsia Questionnaire. Test-retest reliability was assessed after 2 days. Validity was measured by comparison with general practitioners' diagnosis. Sensitivity analysis and logistic regression were employed to determine the most valid scoring system. Responsiveness was determined before and after treatment for endoscopically proven disease.

RESULTS

The Short-Form Leeds Dyspepsia Questionnaire was administered to 388 primary care and 204 secondary care patients. The Pearson coefficient for test-retest reliability was 0.93. The Short-Form Leeds Dyspepsia Questionnaire had a sensitivity of 77% and a specificity of 75%. A highly significant response to change was observed (P < 0.005).

CONCLUSIONS

The Short-Form Leeds Dyspepsia Questionnaire is a reliable, valid and responsive self-completed outcome measure for quantifying the frequency and severity of dyspepsia symptoms, which is shorter and more convenient than the Leeds Dyspepsia Questionnaire.

Digestive symptoms and their psychosocial impact: validation of a questionnaire

OBJECTIVE

Questionnaires evaluating digestive symptoms and their psychosocial impact have not been extensively validated in Norwegian populations. In this study a self-administered questionnaire developed in Norway is evaluated for this purpose.

MATERIAL AND METHODS

The questionnaire, the Digestive Symptoms and Impact Questionnaire, DSIQ, was developed by a cooperative group of general practitioners and gastroenterologists. The DSIQ contains 18 similarly structured global-type questions focusing on the patient's own judgement. The validation was based on 567 patients with dyspeptic symptoms or reflux symptoms referred to gastroscopy from general practice.

RESULTS

Eighty percent of the patients responded to all the questions. All response categories were used for all questions. Factor analysis revealed 4 subscales: abdominal pain and bowel symptoms; gastric dysfunction; health impairment and impairment of everyday life. A question about reflux symptoms was retained as a subscale on its own. Overall score was established by calculating the mean of all question responses. Test-retest reliability in stable patients (intraclass correlation coefficient, range 0.80- 0.91) and internal consistency reliability (Cronbach's alpha, range 0.65-0.91) were satisfactory. Criterion validity was supported by significant correlations to patients' globally estimated quality of life and the General Health Questionnaire (GHQ-30). Responsiveness in spontaneously improved patients or patients given effective treatment ranged from moderate to highly responsive (responsiveness statistic range from 0.54 to 2.83).

CONCLUSIONS

The DSIQ is a self-administered, simple and well-validated method for evaluating digestive symptoms and their psychosocial impact. The DSIQ shows satisfactory internal consistency reliability, test-retest reliability, responsiveness and criterion validity.

Advantages and disadvantages of lumping together gastroesophageal reflux disease and dyspepsia

PURPOSE OF REVIEW

The aim of this article is to identify and to balance the arguments in favor of and against lumping together gastroesophageal reflux disease and functional dyspepsia.

RECENT FINDINGS

In at least half of the patients diagnosed with gastroesophageal reflux disease no organic abnormalities are found. Hypersensitivity of the esophagus to various stimuli plays a key role in the genesis of symptoms in these patients. The association between symptoms and acid reflux events can be quantified by 24-h esophageal pH monitoring. It has also become possible to detect non-acid reflux, using the intraluminal impedance monitoring technique. Functional dyspepsia is still defined by a combination of symptoms for which no organic cause can be found. No positive diagnostic tools have yet become available and treatment with acid secretion inhibitors, Helicobacter pylori eradication or prokinetic drugs remains marginally effective.

SUMMARY

Gastroesophageal reflux disease is a well defined disease which can be diagnosed objectively with endoscopy or 24-h pH/impedance monitoring with symptom association analysis. Functional dyspepsia is a functional disorder for which no objective test has yet been discovered. Treatment of gastroesophageal reflux disease is based on objectively identified abnormalities and highly effective. Treatment of functional dyspepsia is empiric and marginally effective. For these reasons, the lumping together of gastroesophageal reflux disease and functional dyspepsia is not to be advised.

Design of treatment trials for functional gastrointestinal disorders

This document addresses the design of trials to assess the efficacy of new treatments for functional gastrointestinal disorders (FGID), emphasizing trials in irritable bowel syndrome and dyspepsia, because most research has been undertaken in these conditions. The double-blind, randomized, placebo-controlled, parallel group trial remains the preferred design. Randomized withdrawal designs, although encouraged by the European Agency for the Evaluation of Medicinal Products, have the same potential disadvantages as a crossover design, including carryover effects, unmasking (unblinding), and overestimation of the potential benefit for clinical practice. Innovative trial designs that evaluate intermittent (on demand) treatment are likely to become more common in the future. Investigators should include as broad a spectrum of patients as possible and should report recruitment strategies, inclusion/exclusion criteria, and attrition data. The primary analysis should be based on the proportion of patients in each treatment arm who satisfy an a priori treatment responder definition, or a prespecified clinically meaningful change in a patient-reported symptom improvement measure. Such measures of improvement are psychometrically validated subjective global assessments or a change from baseline in a validated symptom severity questionnaire. It is unethical to change the responder definition after a trial begins. Data analysis should address all patients enrolled, using an intention-to-treat principle. Reporting of results should follow the Consolidated Standards for Reporting Trials guidelines and include an analysis of harms data and secondary outcome measures to support or explain the primary outcome. Trials should be registered in a public location, prior to initiation, and should be published even if the results are negative or inconclusive.

Review article: from gastrin to gastro-oesophageal reflux disease--a century of acid suppression

To commemorate Edkins' discovery of gastrin in 1905, we review a century of progress in the physiology and pathobiology of gastrin and acid secretion especially as it pertains to clinical aspects of gastro-oesophageal reflux disease. Although initially ignored, Edkins' observations eventually led to the enthusiastic investigation of gastrin and acid regulation in peptic ulcer disease, culminating in important therapeutic advances in the management of acid peptic disease. Following the improved understanding of gastric secretory physiology, and the development of acid suppressants with increasing efficacy, the use of surgical intervention for peptic ulcer disease was almost eliminated. Surgery became obsolete with the discovery of Helicobacter pylori. Three other advances are also influencing modern practice: the gastrotoxicity of aspirin and non-steroidal anti-inflammatory drugs is now increasingly appreciated, the role of endoscopy in the diagnosis and therapy of upper gastrointestinal bleeding, and the use of intravenous acid-suppressive agents. The major issue for the future resides within the epidemic of gastro-oesophageal reflux disease. How to diagnose, categorize and treat this condition and how to identify and prevent neoplasia, are the challenges of the new century.

Validation of a 7-point Global Overall Symptom scale to measure the severity of dyspepsia symptoms in clinical trials

BACKGROUND

Currently there is no consensus on the optimal method to measure the severity of dyspepsia symptoms in clinical trials.

AIM

To validate the 7-point Global Overall Symptom scale.

METHODS

The Global Overall Symptom scale uses a 7-point Likert scale ranging from 1 = no problem to 7 = a very severe problem. Validation was performed in two randomized-controlled trials (n = 1121 and 512). Construct validity: Global Overall Symptom was compared with the Quality of Life in Reflux And Dyspepsia, Gastrointestinal Symptom Rating Scale, Reflux Disease Questionnaire and 10 specific symptoms using Spearman correlation coefficients. Test-retest reliability: The Intraclass Correlation Coefficient was calculated for patients with stable dyspepsia defined by no change in Overall Treatment Effect score over two visits. Responsiveness: effect size and standardized response mean were also calculated.

RESULTS

Construct validity: Change in Global Overall Symptom score correlated significantly with Quality of Life for Reflux And Dyspepsia, Gastrointestinal Symptom Rating Scale, Reflux Disease Questionnaire and specific symptoms (all P < 0.0002). Reliability: The Intraclass Correlation Coefficient was 0.62 (n = 205) and 0.42 (n = 270). Responsiveness: There was a positive correlation between change in Global Overall Symptom and change in symptom severity. The effect size and standardized response mean were 1.1 and 2.1, respectively.

CONCLUSION

The Global Overall Symptom scale is a simple, valid outcome measure for dyspepsia treatment trials.

Initial management strategies for dyspepsia

BACKGROUND

This review considers management strategies (combinations of initial investigation and empirical treatments) for dyspeptic patients. Dyspepsia was defined to include both epigastric pain and heartburn.

OBJECTIVES

To determine the effectiveness, acceptability, and cost effectiveness of the following initial management strategies for patients presenting with dyspepsia: (a) Initial pharmacological therapy (including endoscopy for treatment failures). (b) Early endoscopy. (c) Testing for Helicobacter pylori (H. pylori )and endoscope only those positive. (d) H. pylori eradication therapy with or without prior testing.

SEARCH STRATEGY

Trials were located through electronic searches and extensive contact with trialists.

SELECTION CRITERIA

All randomised controlled trials of dyspeptic patients presenting in primary care.

DATA COLLECTION AND ANALYSIS

Data were collected on dyspeptic symptoms, quality of life and use of resources. An individual patient data meta-analysis of health economic data was conducted

MAIN RESULTS

Twenty-five papers reporting 27 comparisons were found. Trials comparing proton pump inhibitors (PPI) with antacids (three trials) and histamine H2-receptor antagonists (H2RAs) (three trials), early endoscopy with initial acid suppression (five trials), H. pylori test and endoscope versus usual management (three trials), H. pylori test and treat versus endoscopy (six trials), and test and treat versus acid suppression alone in H. pylori positive patients (four trials), were pooled. PPIs were significantly more effective than both H2RAs and antacids. Relative risks (RR) and 95% confidence intervals (CI) were; for PPI compared with antacid 0.72 (95% CI 0.64 to 0.80), PPI compared with H2RA 0.63 (95% CI 0.47 to 0.85). Results for other drug comparisons were either absent or inconclusive. Initial endoscopy was associated with a small reduction in the risk of recurrent dyspeptic symptoms compared with H. pylori test and treat (OR 0.75, 95% CI 0.58 to 0.96), but was not cost effective (mean additional cost of endoscopy US$401 (95% CI $328 to 474). Test and treat may be more effective than acid suppression alone (RR 0.59 95% CI 0.42 to 0.83).

AUTHORS' CONCLUSIONS

Proton pump inhibitor drugs (PPIs) are effective in the treatment of dyspepsia in these trials which may not adequately exclude patients with gastro-oesophageal reflux disease (GORD). The relative efficacy of histamine H2-receptor antagonists (H2RAs) and PPIs is uncertain. Early investigation by endoscopy or H. pylori testing may benefit some patients with dyspepsia but is not cost effective as part of an overall management strategy.

Helicobacter pylori "test and treat" or endoscopy for managing dyspepsia: an individual patient data meta-analysis

BACKGROUND & AIMS

Helicobacter pylori "test and treat" has been recommended for the management of young dyspeptic patients without alarm symptoms, and trials have suggested that it is as effective as endoscopy. However, none of these trials have had sufficient sample size to confirm that "test and treat" costs less or to detect small differences in effect. A collaborative group has prospectively registered trials comparing prompt endoscopy with a "test and treat" approach, with the aim of performing an individual patient data meta-analysis of both effect and resource utilization data.

METHODS

Researchers provided data for meta-analysis, pooling effects of interventions on individual dyspepsia symptoms. Standardized unit costs were applied to resource utilization, and net benefit was calculated at patient level. Effects, costs, and net benefit were then pooled at study level.

RESULTS

Five trials were identified, containing 1924 patients (946 endoscopy [mean age, 40 years], 978 "test and treat" [mean age, 41 years]). The relative risk (RR) of remaining symptomatic after 1 year was reduced with endoscopy compared with "test and treat" (RR = 0.95; 95% confidence interval [CI]: 0.92-0.99). "Test and treat" cost 389 dollars less per patient (95% CI: 275-502 dollars). Using the net benefit approach, at no realistic level of willingness to pay per patient symptom-free did prompt endoscopy become cost-effective.

CONCLUSIONS

Prompt endoscopy confers a small benefit in terms of cure of dyspepsia but costs more than "test and treat" and is not a cost-effective strategy for the initial management of dyspepsia.