Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease

Real-world-evidence, prospective-observational study to evaluate safety and effectiveness of rabeprazole dual-delayed-release capsules in patients with gastroesophageal reflux disease

BACKGROUND

Abnormal gastric acid reflux into the esophagus causes symptoms of gastroesophageal reflux disease (GERD) such as heartburn and regurgitation and also leads to mucosal damage. This damage can further lead to complications such as Barrett's esophagus and esophagitis. Conventional proton pump inhibitors (PPIs) often fail to reduce nocturnal acid production, leaving patients with unresolved symptoms that worsen at night and decreased satisfaction. Happi ER, a novel dual delayed-release (DDR) formulation of rabeprazole, aims to address these limitations by providing both immediate and prolonged acid suppression.

AIM

To evaluate the safety and effectiveness of rabeprazole DDR 20 mg capsule in patients with GERD.

METHODS

This study involved a multicenter, real-world, prospective, observational design over an eight-week period. A total of 1022 GERD patients were treated with rabeprazole DDR 20 mg capsules (Happi ER), as prescribed by their physicians. We included adult patients with confirmed GERD and persistent heartburn symptoms despite prior PPI use. Outcome measures included heartburn severity, frequency of night-time awakenings, use of rescue medications, and overall patient satisfaction.

RESULTS

Rabeprazole DDR 20 mg capsules (Happi ER) were shown to be highly effective in treating GERD symptoms. At the end of the study, the mean heartburn score improved significantly from 2.46 ± 0.67 at baseline to 0.16 ± 0.39 (P < 0.0001). The median number of night-time awakenings decreased to 0 (P < 0.0001). More than 93% of patients rated the therapy as "excellent" or "very good", reflecting high satisfaction. No significant adverse effects were reported, and the safety profile was comparable to that of traditional PPIs.

CONCLUSION

By providing both rapid and sustained acid suppression, Happi ER effectively treats GERD, particularly with respect to night-time symptoms. Its safety and efficacy profile make it a viable option for individuals with mild-to-moderate GERD, significantly improving the quality of life and symptom management.

The relationship between intraoperative EndoFLIP™ distensibility index and manometry lower esophageal sphincter basal mean pressure in patients undergoing anti-reflux surgery

BACKGROUND

Decisions made for anti-reflux surgery can be guided by both EndoFLIP™ measurement of lower esophageal sphincter (LES) distensibility index (DI) and esophageal manometric measurement of lower esophageal function, but the exact nature of their relationship to one another is unknown despite serving similar purposes. The purpose of this study is to evaluate the relationship between pre-operative LES basal mean pressure with esophageal manometry and intraoperative gastroesophageal DI using EndoFLIP™ following crural dissection to aid in informing surgeons' decision-making during anti-reflux surgery.

METHODS

A retrospective chart review was conducted of patients with gastroesophageal reflux disease who underwent preoperative esophageal manometry evaluation and anti-reflux surgery with EndoFLIP™ intraoperatively between December 2020 and January 2024. Data collected included LES basal mean pressure from manometry and the logarithm of intraoperative EndoFLIP™ DI. Data analysis included descriptive statistics, Pearson's correlation coefficient, and independent sample t-tests.

RESULTS

A total of 147 patients were included in the study. Mean LES basal pressure was 20.3, and median DI after crural dissection was 4.6. There was a significant but weak to non-existent inverse correlation between LES basal mean pressure following crural dissection and logDI (r = - 0.243, p = 0.005). Mean LES pressures were compared with findings of significant differences at DI 5, 5.5, 6, 6,5, 7, 7.5, and 8 (p < 0.05 for all), thus, none of the analyzed DI cut-points could definitively be used to inform operative decision-making.

CONCLUSION

There is a significant but weak or non-existent inverse relationship between LES basal mean pressure measured on manometry and DI following crural dissection during anti-reflux surgery, but no specific DI can determine best fundoplication type of surgery based on LES pressures. Surgeons should take advantage of the distinct information gleaned from both manometry and EndoFLIP™, when possible, when planning and performing anti-reflux surgery.

A Paper-Based Sensor for the Detection of Gastroesophageal Reflux Disease Utilizing a Cleavable Fluorescent Polymer

Nowadays, gastroesophageal reflux disease (GERD) has emerged as one of the major hazards to the health of the upper gastrointestinal tract, and there is an urgent need for a low-cost, user-friendly, and non-invasive detection method. Herein, a paper-based sensor (CP sensor) for the non-invasive screening of GERD is proposed. The sensor is structured as a specially shaped cellulose paper strip embedded with fluorescent colloids, which are self-assembled from a cleavable synthetic fluorescent polymer (P4). Benefiting from the introduction of amide bonds and the unique assembled structure of the nanocolloids, the pepsin in the sample solution will hydrolyze the water-soluble branches in the micellar shell during detection, resulting in a corresponding output of the fluorescent signal. This responsiveness, which can be observed by the naked eye, is so sensitive with a minimum detectable concentration for pepsin as low as 0.3 ng·mL-1. Clinical trials have further demonstrates that the designed paper sensor is capable of providing improved accuracy in the early diagnosis of GERD.

Experimental drugs for erosive esophagitis: what is in the clinical development pipeline?

INTRODUCTION

Proton pump inhibitor (PPI) has revolutionized the treatment of erosive esophagitis (EE) in the past few decades. However, roughly 30-40% of the patients, especially those with severe EE (Los Angeles Grade C/D), remain poorly responsive to this medication. Novel drugs have been formulated and/or repurposed to address this problem.

AREAS COVERED

This review highlights novel drugs that have been investigated for use in EE, such as mucosal protectants, prokinetics, transient lower esophageal sphincter relaxation (TLESR) reducers, novel PPIs, and the new potassium-competitive acid blocker (PCAB). Studies have demonstrated that PCAB has promising results (efficacy and safety) compared to PPI for the healing of EE, especially in severe diseases.

EXPERT OPINION

PCAB has gained interest in recent years, with pharmacokinetics and pharmacodynamics properties surpassing PPI. Although recent data on PCABs, which comprised mainly of Vonoprazan, have shown promising results, more randomized controlled trials for other PCAB drugs are needed to elucidate and confirm the superiority of this drug class to PPI, the current first-line treatment of EE.

Comparative Efficacy of Dexlansoprazole, Pantoprazole, Esomeprazole, and Rabeprazole in Achieving Optimal 24-Hour Intragastric pH Control: A Randomized Crossover Study Using Ambulatory pH Monitoring

INTRODUCTION

Proton pump inhibitors (PPIs) regulate gastric acid reflux. Dexlansoprazole's efficacy in prolonging acid suppression compared to conventional PPIs and placebo requires evaluation.

METHODS

A prospective, randomized, placebo-controlled, five-way crossover pilot study was conducted on healthy volunteers comparing the potency of dexlansoprazole to conventional PPIs in which five patients were randomized into five treatment cohorts, including dexlansoprazole 60 mg, pantoprazole 40 mg, esomeprazole 40 mg, rabeprazole 20 mg, and placebo, assessing 24-hour intragastric pH using Z/pH Recorder (ZepHr®, Diversatek, Inc., Milwaukee, WI) and analyzing statistical differences via paired t-test.

RESULTS

Dexlansoprazole showed significantly longer durations with pH > 4.0 compared to placebo (P < 0.001) and all other PPIs (P < 0.05) over 24 hours. Although not significant in the first 0-12-hour period, dexlansoprazole maintained significantly higher pH levels in the last 12-24-hour period compared to pantoprazole (P = 0.001) and esomeprazole (P = 0.044) but not with rabeprazole (P = 0.075). Additionally, during the 24-hour pH monitoring measured at 30-minute intervals, dexlansoprazole (mean pH = 3.98 ± 0.11) consistently showed higher values than pantoprazole (mean pH = 3.48 ± 0.12), rabeprazole (mean pH = 3.66 ± 0.05), esomeprazole (mean pH = 3.66 ± 0.05), and placebo (mean pH = 2.52 ± 0.12), indicating its superior potency.

CONCLUSION

Dexlansoprazole's dual-delayed release mechanism demonstrates superior acid suppression compared to traditional PPIs and placebo in this pilot study. Larger studies are needed to further evaluate its long-term efficacy and safety.

13-Week Repeated Oral Toxicity and Toxicokinetic Studies of Rabeprazole Sodium and Sodium Bicarbonate Combination in Dogs

The subchronic toxicity and toxicokinetics of a combination of rabeprazole sodium and sodium bicarbonate were investigated in dogs by daily oral administration for 13 consecutive weeks with a 4-week recovery period. The dose groups consisted of control (vehicles), (5 + 200), (10 + 400), and (20 + 800) mg/kg of rabeprazole sodium + sodium bicarbonate, 20 mg/kg of rabeprazole sodium only, and 800 mg/kg of sodium bicarbonate only. Esophageal ulceration accompanied by inflammation was observed in only one animal in the male (20 + 800) mg/kg rabeprazole sodium + sodium bicarbonate group. However, the severity of the ulceration was moderate, and the site of occurrence was focally extensive; thus, it was assumed to be a treatment-related effect of rabeprazole sodium + sodium bicarbonate. In the toxicokinetics component of this study, systemic exposure to rabeprazole sodium (AUClast and Cmax at Day 91) was greater in males than females, suggesting sex differences. AUClast and Cmax at Day 91 were increased compared to those on Day 1 in a dose-dependent manner. A delayed Tmax and no drug accumulation were observed after repeated dosage. In conclusion, we suggest under the conditions of this study that the no-observed-adverse-effect level (NOAEL) of the combination of rabeprazole sodium + sodium bicarbonate in male and female dogs is (10 + 400) and (20 + 800) mg/kg, respectively.

Problematic anger among military personnel after combat deployment: prevalence and risk factors

BACKGROUND

Problematic anger, characterized by excessive frequency, intensity, and duration of anger which causes substantial emotional distress and functional interference, poses a marked challenge in military populations. Despite its importance, research on this topic is limited. This study contributes to the literature by exploring problematic anger in a large sample of Norwegian military personnel who served in NATO missions in Afghanistan.

METHODS

All Norwegian military personnel who deployed to Afghanistan between 2001 and 2020 were sent a link to a cross-sectional web-based survey by the Joint Medical Services of the Norwegian Armed Forces in 2020. A total of 6205 individuals (response rate: 67.7%) participated. The cross-sectional survey assessed problematic anger, mental and physical health, war zone stressor exposure, and quality of life.

RESULTS

Overall, 8.4% of participants reported problematic anger. Mental health disorders, deployment-related shame and guilt, chronic pain, and challenges with the military-to-civilian transition were independently associated with problematic anger. Both staying in service and maintaining a part-time connection with the military as a reservist mitigated the risk of problematic anger after deployment, compared to complete separation from military service.

CONCLUSION

Findings demonstrate a sizeable prevalence of problematic anger among veterans of combat deployments. Given the associations between problematic anger and mental health disorders, chronic pain, and transition challenges, interventions designed to mitigate problematic anger need to be multi-faceted, including the possibility of maintaining an ongoing connection to military service. By reducing the risk of problematic anger, occupational, interpersonal and health outcomes may be improved for service members. Future research should examine the impact of problematic anger on adjustment over time, prevention strategies, and problematic anger in other high-risk occupations.

24 h combined esophageal multichannel intraluminal impedance and pH monitoring in children with chronic cough

BACKGROUND

Chronic cough in children is closely related to gastroesophageal reflux (GER). However, this association has not been adequately studied due to a lack of diagnostic tools. Combined esophageal multichannel intraluminal impedance and pH (MII-pH) monitoring is considered the most accurate method for evaluating the association between symptoms and reflux, but data on its use in children with chronic cough are still lacking. We aimed to assess the association between chronic cough and GER in children through MII-pH monitoring.

METHODS

Children with chronic cough (> 4 weeks) who were suspected gastroesophageal reflux disease(GERD) were selected to undergo 24 h MII-pH monitoring at our hospital. Patients were divided into groups according to their age, body position, reflux index (RI) or total reflux events, and the differences between the groups were analyzed. Then the significance and value of 24 h pH and impedance monitoring in chronic cough and the relationship between chronic cough and reflux were discussed.

RESULTS

Overall, 426 patients were included. The median age was 12 months (interquartile range: 6-39.5 months), 129 (30.3%) patients had RI > 7% detected by pH-metry, and 290 (68.1%) patients had positive diagnosis based on the impedance data. GER predominantly occurred in the upright position and mostly involved weakly acidic reflux and mixed gas-liquid reflux. There were 14.1% of children in non-acid GER group were SAP positive showing no difference in acid GER group 13.2% (P = 0.88), whereas patients with SAP > 95% in MII positive group (47[16.2%]) is higher than in MII negative group (P < 0.05).

CONCLUSION

Twenty four hour MII-pH monitoring is safe, well tolerated in children, but also has a higher detection rate of gastroesophageal reflux. It can find identify weakly acidic reflux, weakly alkaline reflux and reflux events with different physical properties, which can explain the relationship between GER and chronic cough more comprehensively. It provides new approach for exploring the etiology, diagnosis and treatment of children with chronic cough.

Association Between Childhood Asthma and Gastroesophageal Reflux Disease in Children: A Systematic Review

This study aims to comprehensively investigate the association between childhood asthma and gastroesophageal reflux disease (GERD) in children. A thorough search of pertinent databases was done in order to find studies that satisfied the requirements for inclusion. A thorough search of PubMed, Web of Science, SCOPUS, and Science Direct was conducted to find pertinent literature. Twelve studies, including a total of 176,678 patients - 91,447 (51.8%) of them were males - were included in our data. The prevalence of GERD in asthmatic children ranged from 0.7% to 65.3%, with a total prevalence of 3317 (3.6%). The included studies documented that GERD increases the chance of asthma, while asthma raises the risk of GERD. Obesity in asthmatic patients was an independent risk factor for the incidence of GERD. Controlling asthma is significantly impacted by comorbidities like obesity and GRED. The findings of our comprehensive review point to a possible link between juvenile patients with asthma who are referred to secondary and tertiary care facilities and having GERD. Nevertheless, the evidence for this link is weak in a number of situations. Lack of longitudinal research establishing the proper temporal sequence, studies indicating no severity-response relationship, and insufficient data showing a treatment-response relationship all contribute to the uncertainty around the nature and direction of the association. Our findings highlight the need for additional epidemiologic research to investigate the connection between GERD and asthma, including long-term follow-up.

Management of Gastroesophageal Reflux Disease after Sleeve Gastrectomy: Effectiveness of Medical, Endoscopic, and Surgical Therapies

Introduction: Sleeve gastrectomy (SG) has become the most frequently performed bariatric operation in the United States. One of the main disadvantages of this procedure is the risk of developing gastroesophageal reflux disease (GERD) after the operation. We aimed to analyze different approaches for the treatment of GERD after SG. Methods: A literature review was performed to identify all possible treatment options for post-SG GERD. All the studies were assessed for full eligibility by manual assessment of their aims, methodology, results, and conclusions. Records were individually reviewed by the authors comparing outcomes and complications between procedures. Results: Although some studies have shown improvement or even resolution of GERD symptoms after SG, most patients develop or worsen symptoms. Lifestyle modifications along with medical therapy should be started on patients with GERD after SG. For those who are refractory to medication, endoscopic and surgical therapies can be offered. Conversion to Roux-en-Y gastric bypass (RYGB) is consistently effective in treatment of GERD and is the ideal therapy in patients with associated insufficient weight loss. Endoscopic and alternative surgical procedures are also available and have shown acceptable short-term outcomes. Conclusions: Several treatment options exist for the treatment of GERD after SG. Although conversion to RYGB remains the most effective therapy, other emerging endoscopic and surgical procedures could avoid the potential morbidity of this procedure and should be further evaluated. An evidence-based algorithm for the management of GERD after SG is proposed to guide decision making.

Gastroesophageal reflux disease in Sri Lanka: An island-wide epidemiological survey assessing the prevalence and associated factors

Gastroesophageal reflux disease (GERD) is commonly encountered in clinical practice in Sri Lanka. However, its prevalence in Sri Lanka is unknown. Our objective was to study the island-wide prevalence of GERD symptoms in Sri Lanka and its associated factors. A total of 1200 individuals aged 18-70 years (male: female 1: 1.16, mean age 42.7 years [SD 14.4 years]). were recruited from all 25 districts of the country, using stratified random sampling. An interviewer-administered, country-validated questionnaire was used to assess the GERD symptom prevalence and associated factors. Weight, height, waist, and hip circumference were measured. Heartburn and/or regurgitation at least once a week, an internationally used criterion for probable GERD was used to diagnose GERD. In this study, GERD symptom prevalence was 25.3% (male 42.1% and female 57.9%). Factors independently associated with GERD were inadequate sleep, snacking at midnight, sleeping within two hours of consuming a meal, skipping breakfast, increased mental stress, and certain medications used such as statins, and antihypertensive medications (p<0.001, univariate and logistic regression analysis). 38.4% of the study population have been using medication for heartburn and regurgitation in the past 3 months and 19.8% were on proton pump inhibitors. To conclude, the prevalence of GERD symptoms in Sri Lanka (25.3%) is higher than its estimated global prevalence of 13.8%. Several meal-related lifestyle habits, mental stress, and the use of some medications are significantly associated with GERD, indicating the importance of lifestyle modification and stress reduction in its management.

Chinese expert consensus on diagnosis and management of gastroesophageal reflux disease in the elderly (2023)

Gastroesophageal reflux disease (GERD) in the elderly is characterized by atypical symptoms, relatively severe esophageal injury, and more complications, and when GERD is treated, it is also necessary to fully consider the general health condition of the elderly patients. This consensus summarized the epidemiology, pathogenesis, clinical manifestations, and diagnosis and treatment characteristics of GERD in the elderly, and provided relevant recommendations, providing guidance for medical personnel to correctly understand and standardize the diagnosis and treatment of GERD in the elderly.

Effects of H2-Receptor Antagonists on the Exposure of Dacomitinib

Dacomitinib is an irreversible epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor indicated for the treatment of patients with advanced non-small-cell lung cancer (NSCLC) and EGFR-activating mutations. Proton-pump inhibitors decreased dacomitinib exposure. This analysis summarizes the effect of Histamine-2 receptor antagonists (H2RAs) on dacomitinib exposure. A within-patient comparison of the steady-state trough concentrations (Ctrough,ss) of dacomitinib and its active metabolite and active moiety with and without concomitant use of H2RAs was conducted using a linear mixed effects model with pooled data from 11 clinical studies in patients with NSCLC. An oral absorption physiologically based pharmacokinetic (PBPK) model was constructed and verified using clinical pharmacokinetic (PK) data after a single dose of dacomitinib in healthy volunteers to estimate the effect of gastric pH altered by an H2RA on dacomitinib's PKs. The adjusted geometric mean of the dacomitinib Ctrough,ss of the dacomitinib parent, metabolite and active moiety following co-administration with an H2RA was approximately 86%, 104% and 100% relative to that following dacomitinib 45 mg administration without an H2RA (p > 0.05). The PBPK modeling showed negligible change in dacomitinib maximum concentration (Cmax) and area under the drug concentration-time curve (AUC) over 0-24 h after H2RA administration when compared with those administered dacomitinib alone. Co-administration of an H2RA with dacomitinib is not expected to have any clinically relevant effect on dacomitinib exposure.

Neurogastroenterology and Motility Disorders of the Gastrointestinal Tract in Cystic Fibrosis

PURPOSE OF REVIEW

To discuss all the various motility disorders impacting people with Cystic Fibrosis (PwCF) and provide diagnostic and management approaches from a group of pediatric and adult CF and motility experts and physiologists with experience in the management of this disease.

RECENT FINDINGS

Gastrointestinal (GI) symptoms coexist with pulmonary symptoms in PwCF regardless of age and sex. The GI manifestations include gastroesophageal reflux disease, esophageal dysmotility gastroparesis, small bowel dysmotility, small intestinal bacterial overgrowth syndrome, distal idiopathic obstruction syndrome, constipation, and pelvic floor disorders. They are quite debilitating, limiting the patients' quality of life and affecting their nutrition and ability to socialize. This genetic disorder affects many organ systems and is chronic, potentially impacting fertility and future family planning, requiring a multidisciplinary approach. Our review discusses the treatments of motility disorders in CF, their prevalence and pathophysiology. We have provided a framework for clinicians who care for these patients that can help to guide their clinical management.

Different effects of chronic omeprazole use on osteoporotic fractures rate in the elderly

AIMS

To investigate the potential association of chronic use of omeprazole with the occurrence of osteoporotic fractures (OF) in community-dwelling elderly subjects.

METHODS

The cohort consisted of community-dwelling residents aged >65 years registered with a large health maintenance organization in Israel between January 2002 and December 2016. Data were retrospectively collected from the electronic medical files on demographics, parameters known to be associated with OF, diagnoses of osteoporotic hip, wrist, and vertebral fractures, and chronic use of omeprazole (>11 prescriptions/year). Time to OF/death/end of study was calculated from the beginning of the study (2002). The risk of fractures in the chronic users of omeprazole was analyzed by multivariate Cox proportional hazard regression model.

RESULTS

In total, 46 805 subjects were included (41% men), mean age 83.4±6.4 years, of whom 10 272 (21.9%) were chronic users of omeprazole. During 14 years of follow-up, OF were diagnosed in 414 (4.0%) omeprazole users and 1007 (2.8%) omeprazole nonusers (p < 0.001). In a Cox regression model adjusted for age and gender only, chronic use of omeprazole was associated with a 16% excess of OF. However, when parameters known to be associated with OF were entered into the multivariate Cox regression model, chronic use of omeprazole was not found to be an independent risk factor for OF, either overall (adjusted hazard ratio = 0.965, 95% confidence interval 0.86-1.08, P = .55) or specifically, in the ≥85 years age group (adjusted hazard ration = 0.780, 95% confidence interval 0.635-0.958, P < .05) in which an inverse correlation between omeprazole use and OF, was demonstrated.

CONCLUSIONS

Chronic use of omeprazole was not associated with the occurrence of OF in elders.

The Angle of His as a Measurable Element of the Anti-reflux Mechanism

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common condition, resulting from the loss of the anti-reflux barrier. Laparoscopic fundoplication is the surgical procedure of choice for treatment of GERD; however, there remains a debate on the exact mechanism through which it prevents reflux.

OBJECTIVES

Our aim was to understand the relationship between reflux, fundoplication, and the angle of His on an experimental model.

METHODS

The study was conducted on four groups of fresh explanted swine stomachs: control group, myotomy, myotomy with Nissen fundoplication, and myotomy with Toupet fundoplication. The stomachs were placed in a specially designated container on an inclinable platform which would increase the hydrostatic pressure on the esophago-gastric junction. Measurements of the angle of His using fluoroscopy and the esophago-gastric orifice area using endoscopy were performed, and the occurrence of reflux was documented.

RESULTS

Each group of the study contained nine swine stomachs. In the control and myotomy groups, the angle became wider as the incline level increased the pressure and was significantly different between the groups (p < .001). Both groups demonstrated an increase in the orifice area as the incline level increased the pressure. There was a significant correlation between the angle of His and the area of the esophago-gastric orifice (p < .001). In the control group, the reflux began at the 0°. In the myotomy group, it began at the + 15° incline (less pressure). Reflux rarely occurred in the Nissen and Toupet groups, with the breaking point being mostly defined as "beyond - 30°". A significant difference was noted in the occurrence of reflux between fundoplication and the non-fundoplication groups (p < 0.001), while there was no significant difference between the Toupet and Nissen groups (p = 0.134). Analysis showed a significant independent correlation between both the angle of His and the orifice area with the presence of reflux (p = .002 and p = .024 respectively).

CONCLUSIONS

In this study, we developed an experimental model to enable careful evaluation of the elements of the anti-reflux mechanism, of which, the angle of His has a measurable element. We demonstrated that as the angle of His becomes wider the esophago-gastric orifice area becomes larger. Additionally, a wider angle of His and a larger esophago-gastric orifice area were correlated independently with more reflux. This suggests that the fundoplication creates an acute angle of His which is correlated with a smaller area of the esophago-gastric orifice and eventually with a lower incidence of reflux.

Epidemiology, Causes, and Management of Gastro-esophageal Reflux Disease: A Systematic Review

Our comprehensive systematic review aimed to examine gastroesophageal reflux disease (GERD), a disorder that occurs when stomach contents flow back into the esophagus. It may manifest as either non-erosive reflux disease or erosive esophagitis. The activity depicts the assessment and medical management of GERD and emphasizes the interprofessional team's involvement to enhance care for people with this ailment. Data sources were PubMed/Medline and Embase. Our review investigated English-language articles (from 2014 to 2023) according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Overall, there were seven articles. Surveys and analyses of national databases were the most widely used methods (n=7). The search identified 3,730 studies, and seven were eligible for inclusion in the analysis. Further understanding of GERD and treatment protocols may help improve evaluation and management in the future. Millions of individuals worldwide suffer from GERD, a common clinical condition. Patients can be identified by symptoms that are both common and uncommon. For many GERD patients, acid suppression treatment reduces symptoms and avoids clinical complications. Our capacity to recognize and treat disease consequences has improved with the advancement of diagnostic and treatment methods. Here, we go into the etiology and consequences of GERD and offer details on the treatment strategy for this prevalent illness.

Should video laryngoscopy or direct laryngoscopy be used for adults undergoing endotracheal intubation in the pre-hospital setting? A critical appraisal of a systematic review

The safety and utility of endotracheal intubation by paramedics in the United Kingdom is a matter of debate. Considering the controversy surrounding the safety of paramedic-performed endotracheal intubation, any interventions that enhance patient safety should be evaluated for implementation based on solid evidence of their effectiveness. A systematic review performed by Hansel and colleagues (2022) sought to assess compare video laryngoscopes against direct laryngoscopes in clinical practice. This commentary aims to critically appraise the methods used within the review by Hansel et al (2022) and expand upon the findings in the context of clinical practice.

Yardstick for managing cough, part 1: In adults and adolescent patients older than 14 years of age

Nationwide statistics in the United States and Australia reveal that cough of undifferentiated duration is the most common complaint for which patients of all ages seek medical care in the ambulatory setting. Management of chronic cough is one of the most common reasons for new patient visits to pulmonologists. Because symptomatic cough is such a common problem and so much has been learned about how to diagnose and treat cough of all durations but especially chronic cough, this 2-part yardstick has been written to review in a practical way the latest evidence-based guidelines most of which have been developed from recent high quality systematic reviews on how best to manage cough of all durations in adults, adolescents, and children. In this manuscript, part 1 of the 2-part series, we provide evidence-based, and expert opinion recommendations on the management of chronic cough in adult and adolescent patients (>14 years of age).

Dietary and Nutritional Support in Gastrointestinal Diseases of the Upper Gastrointestinal Tract (I): Esophagus

The esophagus is the centerpiece of the digestive system of individuals and plays an essential role in transporting swallowed nutrients to the stomach. Diseases of the esophagus can alter this mechanism either by causing anatomical damage that obstructs the lumen of the organ (e.g., peptic, or eosinophilic stricture) or by generating severe motility disorders that impair the progression of the alimentary bolus (e.g., severe dysphagia of neurological origin or achalasia). In all cases, nutrient assimilation may be compromised. In some cases (e.g., ingestion of corrosive agents), a hypercatabolic state is generated, which increases resting energy expenditure. This manuscript reviews current clinical guidelines on the dietary and nutritional management of esophageal disorders such as severe oropharyngeal dysphagia, achalasia, eosinophilic esophagitis, lesions by caustics, and gastroesophageal reflux disease and its complications (Barrett's esophagus and adenocarcinoma). The importance of nutritional support in improving outcomes is also highlighted.

Proton Pump Inhibitor Pantoprazole Modulates Intestinal Microbiota and Induces TLR4 Signaling and Fibrosis in Mouse Liver

Proton pump inhibitors (PPIs) are one of the most prescribed drugs around the world. PPIs induce microbiota modulation such as obesity both in humans and in animal models. However, since PPIs can induce microbiota modulation despite the absence of a high-fat diet or weight gain, it is an interesting model to correlate microbiota modulation with the establishment of non-alcoholic fatty liver disease (NAFLD). We investigated the effect of pantoprazole treatment on TLR4 signaling and liver histology in C57BL/6J mice for 60 days, trying to correlate microbiota modulation with some aspects of liver injury. We performed glucose (GTT) and insulin (ITT) tolerance tests, serum lipopolysaccharide (LPS) dosage, liver histology, liver and intestine extraction for Western blot and qPCR. Fecal microbiota were investigated via metagenomics. Chronic treatment with pantoprazole induced microbiota modulation and impaired ileum barrier integrity, without an association with insulin resistance. Furthermore, increased circulating LPS and increased Toll-like receptor 4 (TLR4) and TGFβ downstream signaling may have an important role in the development of the observed liver microvesicular steatosis and fibrosis. Finally, this model of PPI-induced changes in microbiota might be useful to investigate liver microvesicular steatosis and fibrosis.

Bridge Swallowing Exercise for Gastroesophageal Reflux Disease Symptoms: A Pilot Study

Objectives

We previously reported that swallowing in the bridge position (bridge swallowing) increased distal esophageal contractions and lower esophageal sphincter pressure against gravity. Moreover, bridge swallowing had the potential to strengthen esophageal peristalsis. In this study, we sought to evaluate whether the bridge swallowing exercise could improve gastroesophageal reflux disease (GERD) symptoms and gastroscopy findings.

Methods

Seventeen subjects with scores of 8 points or higher on the Frequency Scale for Symptoms of GERD (FSSG) questionnaire participated in the study. The exercise of dry swallowing in the bridge posture lasted 4 weeks and was performed ten times per day. FSSG scores were compared before and after exercise. Three of the 17 participants underwent upper gastrointestinal endoscopy. The modified Los Angeles classification of reflux esophagitis was used for objective assessment before and after exercise.

Results

No participants dropped out of this study. FSSG scores improved significantly after exercise (from median [range] 16 [13-21] points before exercise to 5 [4-10] points after exercise, P <0.001). Upper gastrointestinal endoscopy showed improvement in the modified Los Angeles classification grade in one participant.

Conclusions

The bridge swallowing exercise significantly improves FSSG scores. This exercise can be performed easily and safely without adverse events. Further multicenter prospective studies are needed to validate that the bridge swallowing exercise is effective in improving GERD.

Efficacy and Safety of Domperidone in Combination with Proton Pump Inhibitors in Gastroesophageal Reflux Disease: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

The aims of gastroesophageal reflux disease (GERD) treatment are symptom relief and healing of oesophagitis. Besides proton pump inhibitors (PPIs), prokinetic agents are also commonly prescribed to treat GERD. Domperidone, a well-known antiemetic, is an example of a prokinetic agent. It is a dopaminergic blocker that increases lower oesophagus sphincter pressure and activates gastric motility. We carried out a systematic review and meta-analysis to explore the benefits of domperidone in addition to PPI therapy for GERD. We searched for publications comparing PPI plus domperidone to PPI monotherapy in terms of symptom improvement in GERD (until 21 April 2022) on PubMed, Scopus, Google Scholar, Web of Science, Cochrane Library, WHO’s International Clinical Studies Registry Platform, and ClinicalTrials.gov without restricting date, language, or study design. The protocol was registered in PROSPERO (CRD42021242076). This meta-analysis incorporated 11 studies with a total of 841 participants (419 in the PPI plus domperidone group and 422 in the PPI monotherapy group). The combination of a PPI and domperidone resulted in a significant reduction in global GERD symptoms. Adverse events associated with PPI plus domperidone treatment were similar to those associated with PPI monotherapy. In conclusion, the combination of domperidone and a PPI is generally safe and effective in treating GERD as compared with that of PPI alone.

Clinical significance of gastroesophageal reflux disease with minimal change: a multicenter prospective observational study

Non-erosive reflux disease (NERD) is classified into grade N (no minimal change) and grade M (minimal change) based on the Los Angeles classification. However, few reports have described the clinical characteristics of grade M. This study was performed to clarify the clinical characteristics of grade M. Among 290 consecutive patients with gastroesophageal reflux disease (GERD), 45 patients with grade M, 62 patients with grade N, and 94 patients with grade A were compared with respect to clinical differences. The degree of symptom improvement after 4 weeks of proton pump inhibitor administration was also prospectively compared among the three groups. Grades N and M showed no or little difference in the patients' backgrounds (including sex and body mass index), GERD/functional dyspepsia symptom scores, life dissatisfaction (diet, sleep, work, and mood), Short Form-8 (mental component summary) scores, and symptom improvement. In contrast, significant differences were present between grades M and A as well as between grades N and A. The overall results of our study suggest that the distinction between grade M and grade N is of little clinical significance from the viewpoint of clinical characteristics.

[French practical guidelines for the diagnosis and management of IPF - 2021 update, full version]

BACKGROUND

Since the previous French guidelines were published in 2017, substantial additional knowledge about idiopathic pulmonary fibrosis has accumulated.

METHODS

Under the auspices of the French-speaking Learned Society of Pulmonology and at the initiative of the coordinating reference center, practical guidelines for treatment of rare pulmonary diseases have been established. They were elaborated by groups of writers, reviewers and coordinators with the help of the OrphaLung network, as well as pulmonologists with varying practice modalities, radiologists, pathologists, a general practitioner, a head nurse, and a patients' association. The method was developed according to rules entitled "Good clinical practice" in the overall framework of the "Guidelines for clinical practice" of the official French health authority (HAS), taking into account the results of an online vote using a Likert scale.

RESULTS

After analysis of the literature, 54 recommendations were formulated, improved, and validated by the working groups. The recommendations covered a wide-ranging aspects of the disease and its treatment: epidemiology, diagnostic modalities, quality criteria and interpretation of chest CT, indication and modalities of lung biopsy, etiologic workup, approach to familial disease entailing indications and modalities of genetic testing, evaluation of possible functional impairments and prognosis, indications for and use of antifibrotic therapy, lung transplantation, symptom management, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis.

CONCLUSION

These evidence-based guidelines are aimed at guiding the diagnosis and the management in clinical practice of idiopathic pulmonary fibrosis.

Assessment of Laryngopharyngeal Reflux and Obstructive Sleep Apnea: A Population-Based Study

OBJECTIVES/HYPOTHESIS

To evaluate the presence of laryngopharyngeal reflux (LPR) and the potential association between presence of LPR symptoms and obstructive sleep apnea (OSA) in a representative sample from a population-based study.

STUDY DESIGN

Cross-sectional study.

METHODS

Participants of the follow-up of the Epidemiological Sleep Study were evaluated. Sleep was assessed through questionnaires and polysomnography. The presence of LPR was based on the questionnaire Reflux Score Index (RSI), and scores higher than 13 were suggestive of LPR. A general linear model test was used for comparison of continuous data and Pearson's chi-square test was used to compare categorical variables. Predictors of LPR were obtained by regression analysis.

RESULTS

701 were enrolled (54.8% female, 45.2% male; mean age, 50.2 ± 13.3 years). The mean apnea-hypopnea index score was 17 ± 18.3 events/hr, and the mean RSI score was 7.0 ± 8.1. LPR was found in 17% of the volunteers, whereas OSA was present in 38.5% of the sample. Specifically, in those patients with OSA, the prevalence of LPR was 45.4%; however, there was no statistically significant association between LPR and the presence of OSA. The severity of OSA was not associated with RSI score. The presence of LPR was associated with older age, smoking, excessive daytime sleepiness and worse quality of life and sleep scores questionnaires.

CONCLUSIONS

Age, smoking, but not body mass index, were associated with LPR. There was not statistically significant association of LPR with OSA. Individuals with symptoms of LPR had greater drowsiness and worse quality of life and sleep.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:1877-1882, 2022.

French practical guidelines for the diagnosis and management of idiopathic pulmonary fibrosis - 2021 update. Full-length version

BACKGROUND

Since the latest 2017 French guidelines, knowledge about idiopathic pulmonary fibrosis has evolved considerably.

METHODS

Practical guidelines were drafted on the initiative of the Coordinating Reference Center for Rare Pulmonary Diseases, led by the French Language Pulmonology Society (SPLF), by a coordinating group, a writing group, and a review group, with the involvement of the entire OrphaLung network, pulmonologists practicing in various settings, radiologists, pathologists, a general practitioner, a health manager, and a patient association. The method followed the "Clinical Practice Guidelines" process of the French National Authority for Health (HAS), including an online vote using a Likert scale.

RESULTS

After a literature review, 54 guidelines were formulated, improved, and then validated by the working groups. These guidelines addressed multiple aspects of the disease: epidemiology, diagnostic procedures, quality criteria and interpretation of chest CT scans, lung biopsy indication and procedures, etiological workup, methods and indications for family screening and genetic testing, assessment of the functional impairment and prognosis, indication and use of antifibrotic agents, lung transplantation, management of symptoms, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis.

CONCLUSION

These evidence-based guidelines are intended to guide the diagnosis and practical management of idiopathic pulmonary fibrosis.

The Discrepancy Between Subjective and Objective Clinical Endpoints in Gastroesophageal Reflux Disease

Therapeutic outcome in gastroesophageal reflux disease (GERD) is commonly determined by both subjective and objective clinical endpoints. Clinicians frequently use symptom improvement as a key benchmark of clinical success, in conjunction with normalization of objective parameters such as esophageal acid exposure and inflammation. However, GERD therapeutic trials have demonstrated that a substantial number of patients rendered asymptomatic, whether through medical, surgical, or endoscopic intervention, continue to have persistent abnormal esophageal acid exposure and erosive esophagitis. The opposite has also been demonstrated in therapeutic trials, where patients remained symptomatic despite normalization of esophageal acid exposure and complete resolution of esophageal inflammation. Moreover, there is no substantive evidence that symptomatic response to antireflux treatment requires complete esophageal mucosal healing or normalization of esophageal acid exposure. Thus, it appears that a certain level of improvement in objective parameters is needed to translate into meaningful changes in symptoms and health-related quality of life of GERD patients. This supports the need to reconsider the commonly used "hard" clinical endpoints to evaluate therapeutic trials in GERD.

Gastroesophageal Reflux in Children with Asthma

Background: Nowadays it is considered that a specific causal relationship exists between asthma and gastroesophageal reflux (GER), because of the aspiration of gastric refluate which leads to and maintain spasticity even real crisis of paroxystic expiratory dyspnea. This study explores this relationship and evaluates the results after treatment. Methods: 56 children diagnosed with asthma, hospitalized in a regional center of pediatric gastroenterology in Northeast Romania, underwent 24-hour continuous esophageal pH monitoring in order to establish the presence of GER. The Boix-Ochoa score was used to interpret the results. Proton pump inhibitors were administered to those with GER and the patients were reevaluated after 2 months. Results: 39 patients (69.64%) had GER, with a Boix-Ochoa score above normal (N < 11.99), and 17 patients (30.36%) had normal score. After administering proton pump inhibitors for 2 months, 7 patients still had high Boix-Ochoa score (17.95%). The result of this analysis shows that the presence of asthma increases the chance of GER by 2.86 times. Conclusions: In children with asthma we have to look for GER in order to treat, because it can help the treatment of asthma or even solve some cases resistant to standard treatment.

Endoscopic Findings of Gastro-Esophageal Reflux Disease in Elderly and Younger Age Groups

Objective: To determine and compare the clinical features and endoscopic findings of gastro-esophageal reflux disease (GERD) in elderly and younger age groups. Materials and Methods: The clinical and endoscopic features were evaluated for all patients with GERD between January 2017 and September 2020. The criteria for inclusion were being aged over 65 and under 50 years and having an upper gastrointestinal endoscopy with reflux symptoms resistant to ppi theraphy. The exclusion criteria included prior surgery, age under 18 years, and pregnancy. The diagnosis of GERD was made according to the patients' symptoms. The SPSS 11.0 for Windows pocket program was used for statistical analysis. Results: Two hundred eighty-six patients aged over 65 years and 261 patients aged below 50 years were enrolled in this study. The mean age of the older group was 68.2 ± 4.5 years and the mean age of the young group was 38 ± 7.2 years. The male/female ratio was 5/3 and 2/1 in the young and older groups, respectively. The older patients had less severe and rare typical symptoms than the young patients. However, significantly more serious endoscopic findings were noted in the older patients compared with the younger patients. Conclusion: The older and young patients with GERD were predominantly male and typical reflux problems were less common in older patients with GERD. Older patients had more important endoscopic findings such as hernia, esophagitis, and cancer.

Degree of concordance on the management of patients with gastroesophageal reflux disease. A study among specialists that are members of the Sociedad Latinoamericana de Neurogastroenterología (SLNG)

INTRODUCTION AND AIMS

Due to its different clinical manifestations, gastroesophageal reflux disease (GERD) requires diverse diagnostic and therapeutic interventions. The aim of the study was to evaluate the degree of agreement among Latin American specialists, with respect to the management of GERD.

MATERIALS AND METHODS

A cross-sectional study was conducted through a survey with 42 statements (22 related to diagnosis and 20 to treatment) applied to 56 specialists from Latin America. There were 4 possible statement responses: in complete agreement, in partial agreement, in partial disagreement, and in complete disagreement. Reproducibility, level of agreement, and concordance were measured through the Kappa statistic.

RESULTS

The response rate was 81% (47/56). General concordance was low, given that there was complete concordance in only 12 statements (28.6%). There was partial concordance in 22 statements (52.4%) and no concordance in 8 (19%). The following themes had the most disagreement: the performance of endoscopy before beginning treatment, the use of proton pump inhibitors (PPIs) in patients with extraesophageal symptoms and with no typical symptoms, and the combined use of PPIs and prokinetics.

CONCLUSIONS

In the present study, we found that there was agreement among the Latin American specialists for the diagnosis and management of GERD in less than one-third of the recommendations considered standard. The low concordance could be related to the fact that the availability of diagnostic tools and medications, as well as the prevalence of GERD phenotypes, are different in each country.

Low FODMAPs diet or usual dietary advice for the treatment of refractory gastroesophageal reflux disease: An open-labeled randomized trial

BACKGROUND

The low FODMAPs (fermentable oligo-, di-, monosaccharides, and polyols) diet improves lower gastrointestinal symptoms. Patients suffering from proton pump inhibitor (PPI) refractory gastroesophageal reflux disease (GERD) have limited treatment options. We investigated the efficacy of a low FODMAPs diet in patients with PPI refractory GERD.

METHODS

This multicenter, randomized, open-label study compared the efficacy of a 4-week low FODMAPs diet and usual dietary advice (ie, low-fat diet and head of bed elevation) in patients with symptomatic PPI refractory GERD, defined by a Reflux Disease Questionnaire (RDQ) score >3 and abnormal pH-impedance monitoring on PPIs. The primary endpoint was the percentage of responders (RDQ ≤3) at the end of the diet.

RESULTS

Thirty-one patients (55% women, median age 45 years) were included, 16 randomized in the low FODMAPs diet group and 15 in the usual dietary advice group. Adherence to the assigned diet was good, with a significant difference in the FODMAPs intake per day between the low FODMAPs diet (2.5 g) and the usual dietary advice group (13 g) (p < 0.001). There was no difference in response rates (RDQ score ≤3) between the low FODMAPs diet (6/16, 37.5%) and usual dietary advice (3/15, 20%) groups (p = 0.43). Total RDQ score and dyspepsia subscore decreased significantly over time in both groups (p = 0.002), with no difference according to the assigned diet group (p = 0.85).

CONCLUSION

Low FODMAPs diet and usual dietary advice have similar but limited beneficial effects on symptoms in patients with PPI refractory GERD.

Degree of concordance on the management of patients with gastroesophageal reflux disease. A study among specialists that are members of the Sociedad Latinoamericana de Neurogastroenterología (SLNG)

INTRODUCTION AND AIMS

Due to its different clinical manifestations, gastroesophageal reflux disease (GERD) requires diverse diagnostic and therapeutic interventions. The aim of the study was to evaluate the degree of concordance among Latin American specialists, with respect to the management of GERD.

MATERIALS AND METHODS

A cross-sectional study was conducted through a survey with 42 statements (22 related to diagnosis and 20 to treatment) applied to 56 specialists from Latin America. There were 4 possible statement responses: in complete agreement, in partial agreement, in partial disagreement, and in complete disagreement. Reproducibility, level of agreement, and concordance were measured through the Kappa statistic.

RESULTS

The response rate was 81% (47/56). General concordance was low, given that there was complete concordance in only 12 statements (28.6%). There was partial concordance in 22 statements (52.4%) and no concordance in 8 (19%). The following themes had the most disagreement: the performance of endoscopy before beginning treatment, the use of proton pump inhibitors (PPIs) in patients with extraesophageal symptoms and with no typical symptoms, and the combined use of PPIs and prokinetics.

CONCLUSIONS

In the present study, we found that there was agreement among the Latin American specialists for the diagnosis and management of GERD in less than one-third of the recommendations considered standard. The low concordance could be related to the fact that the availability of diagnostic tools and medications, as well as the prevalence of GERD phenotypes, are different in each country.

The Usefulness of the Measurement of Esophagogastric Junction Distensibility by EndoFLIP in the Diagnosis of Gastroesophageal Reflux Disease

BACKGROUND/AIMS

Increased esophagogastric junction (EGJ) relaxation is the most important mechanism involved in gastroesophageal reflux disease (GERD). An endoscopic functional luminal imaging probe (EndoFLIPⓇ) is a device used to quantify EGJ distensibility in routine endoscopy. The aim of the current study was to assess the usefulness of EndoFLIPⓇ for the diagnosis of GERD compared to normal controls.

METHODS

We analyzed EndoFLIPⓇ data from 204 patients with erosive reflux disease (ERD), 310 patients with nonerosive reflux disease (NERD), and 277 normal subjects. EndoFLIPⓇ uses impedance planimetry to measure 16 cross-sectional areas (CSAs) in conjunction with the corresponding intrabag pressure within a 4.6 cm cylindrical segment of a fluid-filled bag. The EGJ distensibility was assessed using 40 mL volume-controlled distensions.

RESULTS

The mean distensibility index values were 13.98 mm2/mm Hg in ERD patients, 11.42 mm2/mm Hg in NERD patients, and 9.1 mm2/mm Hg in normal subjects. There were significant differences in EGJ distensibility among the three groups (p<0.001). In addition, the CSAs were significantly higher in the ERD (291.03±160.77 mm2) and NERD groups (285.87±155.47 mm2) than in the control group (249.78±144.76 mm2, p=0.004). We determined the distensibility index cutoff value of EGJ as 10.95 for the diagnosis of GERD by receiver operating characteristic curve analysis.

CONCLUSIONS

The EGJ distensibilities of GERD patients were higher than those of normal subjects, regardless of the presence of reflux esophagitis. Thus, the measurement of EGJ distensibility using the EndoFLIPⓇ system could be useful in the diagnosis of GERD.

The bitter tastant denatonium benzoate has no influence on the number of transient lower esophageal sphincter relaxations in health

BACKGROUND

Administration of a bitter compound can alter the intragastric pressure (IGP) after a meal. Additionally, a negative correlation between IGP and the number of transient lower esophageal sphincter relaxations (TLESRs) has been demonstrated. However, the effect of a bitter tastant on the number of TLESRs and subsequent reflux episodes has never been investigated and it is unclear whether bitter food items should be avoided in gastro-esophageal reflux disease. We hypothesize that bitter administration in healthy volunteers (HVs) will lead to an increase in the number of TLESRs.

METHODS

After an overnight fast, 20 female HVs (36 years [21-63]) underwent a high-resolution impedance manometry (HRiM) measurement. After placement of the HRiM probe, 0.1 ml/kg of a 10 mM denatonium benzoate solution (bitter) or an identical volume of water (placebo) was administered directly into the stomach. The number of TLESRs and reflux episodes was quantified 30 min before and 2 h after consumption of a high caloric meal.

KEY RESULTS

There was no significant difference in the number of TLESRs or reflux episodes between the bitter and placebo condition. Additionally, no differences were observed in the nature (gas or liquid) and extent of reflux events. Lower esophageal sphincter pressures dropped significantly in the first postprandial hour to start recovering slowly back to baseline values during the second postprandial hour (p < 0.0001), without any difference between both conditions.

CONCLUSIONS & INTERFERENCES

Administration of the bitter tastant denatonium benzoate has no influence on the number of TLESRs or reflux episodes.

Risk factors of erosive esophagitis and barrett's esophagus in patients with reflux symptoms

Background: Gastroesophageal reflux disease (GERD) is a prevalent condition. Erosive esophagitis (EE) and Barrett’s esophagus (BE) are the two important complications of GERD. We aimed to study the prevalence of EE and BE in a group of Patients with reflux symptoms who were referred for endoscopy. The relationship between reflux symptoms and endoscopic findings was also examined.

Methods: We enrolled 139 consecutive patients with characteristic symptoms of GERD. Demographic and clinical characteristics of the patients including duration and severity of reflux symptoms, were recorded. Endoscopic findings of EE were identified and classified according to the Los Angeles classification, while BE was confirmed by histopathology examination. The Fisher’s exact test and the two-sample 𝑡-test were used to test the association of esophageal lesions (BE and/or EE) with the patients' clinical and endoscopic data.

Results: Forty seven and 13 patients were found to have EE and BE, respectively. Multivariate analysis showed that older age (p=0.001) and hiatal hernia (p=0.004) was significantly related risk factors for erosive esophagitis and BE. While an increase in BMI (p=0.004) was related to EE, patients with BE were more likely to have severe reflux symptoms than others (p=0.002).

Conclusion: In patients with GERD, the presence of hiatal hernia may be strong risk factor for erosive esophagitis and BE, as does older age. For Barrett’s esophagus, severe reflux symptoms are more likely.

The Head and Neck Survivorship Tool (HN-STAR) Trial (WF-1805CD): A protocol for a cluster-randomized, hybrid effectiveness-implementation, pragmatic trial to improve the follow-up care of head and neck cancer survivors

Survivors of head and neck cancer (HNC) can have multiple health concerns. To facilitate their care, we developed and pilot-tested a clinical informatics intervention, HN-STAR. HN-STAR elicits concerns online from HNC survivors prior to a routine oncology clinic visit. HN-STAR then presents tailored evidence-based clinical recommendations as a clinical decision support tool to be used during the visit where the oncology clinician and survivor select symptom management strategies and other actions. This generates a survivorship care plan (SCP). Online elicitation of health concerns occurs 3, 6, and 9 months after the clinic visit, generating an updated SCP each time. HN-STAR encompasses important methods of improving survivorship care (e.g., needs assessment, tailored interventions, dissemination of guidelines) and will be evaluated in a pragmatic trial to maximize external validity. This hybrid type 1 implementation-effectiveness trial tests HN-STAR effectiveness while studying barriers and facilitators to implementation in community oncology practices within the National Cancer Institute Community Oncology Research Program. Effectiveness will be measured as differences in key survivorship outcomes between HNC participants who do and do not use HN-STAR over one year after the clinic visit. The primary endpoint is HNC-specific quality of life; other outcomes include patient-centered measures and receipt of guideline-concordant care. Implementation outcomes will be assessed of survivors, providers, and clinic stakeholders. The hybrid design will provide insight into a dose-response relationship between the extent of implementation fidelity and effectiveness outcomes, as well as how to incorporate HN-STAR into standard practice outside the research setting.

Inappropriate Medication Use and Cost Comparison Analysis of Proton Pump Inhibitors: Evidence from an Indian Tertiary Care Facility

RATIONALE AND OBJECTIVE

Proton pump inhibitor (PPI) is one of the most widely prescribed medicines and commonly used in gastric related disorders and there is a huge need to analyze the irrational use of PPI in a country like India. The present study was designed to describe the rational drug use and cost comparison analysis of PPI in a rural tertiary care hospital.

METHODOLOGY

A prospective observational study was performed among 253 inpatients for a period of 9 months after getting ethical approval. Those who received the PPIs for any of its indications were included in the study without any gender or age restriction. US FDA guidelines were used to analyse the appropriateness of the drug use and cost comparison analysis of the branded versus generic PPIs was also performed.

FINDINGS

Among the 253 inpatients, the majority (62%) were male and the mean age was 46±19 years. Mean hospital stay and the number of drugs in prescription were found to be 4.0 ± 1days 4.39 ±1.16 items, respectively. Pantoprazole (76%) was the most prescribed PPI even though the majority (57%) of the patients treated outside the FDA approved indication. Drug interaction has been reported in 14% and ADR in 9% of the population. The average cost of hospital stay estimated as 207.96+149.57 INR, and potential cost saving of INR 41582 was observed with generic replacement.

CONCLUSION

The study inferred irrational drug use of PPI still prevalent, that too without considering the economic impact of it on general populations. Healthcare practitioners should be aware and cautious while prescribing the PPI to identify the actual need and to choose the most cost-effective alternative 1.

Anti-inflammatory chemoprevention attenuates the phenotype in a mouse model of esophageal adenocarcinoma

Barrett´s Esophagus (BE) is the main known precursor condition of Esophageal Adenocarcinoma (EAC). BE is defined by the presence of metaplasia above the normal squamous columnar junction and has mainly been attributed to gastroesophageal reflux disease (GERD) and chronic reflux esophagitis. Thus, the rising incidence of EAC in the Western world is likely mediated by chronic esophageal inflammation, secondary to GERD in combination with environmental risk factors such as a Western diet and obesity. However, (at present) risk prediction tools and endoscopic surveillance have shown limited effectiveness. Chemoprevention as an adjunctive approach remains an attractive option to reduce the incidence of neoplastic disease. Here, we investigate the feasibility of chemopreventive approaches in BE and EAC via inhibition of inflammatory signaling in a transgenic mouse model of BE and EAC (L2-IL1B mice), with accelerated tumor formation on a high fat diet (HFD). L2-IL1B mice were treated with the IL-1 receptor antagonist Anakinra and the nonsteroidal anti-inflammatory drugs (NSAIDs) aspirin or Sulindac. Interleukin-1b antagonism reduced tumor progression in L2-IL1B mice with or without a HFD, while both NSAIDs were effective chemoprevention agents in the accelerated HFD fed L2-IL1B mouse model. Sulindac treatment also resulted in a marked change in the immune profile of L2-IL-1B mice. In summary, anti-inflammatory treatment of HFD-treated L2-IL1B mice acted protectively on disease progression. These results from a mouse model of BE support results from clinical trials that suggest that anti-inflammatory medication may be effective in the chemoprevention of EAC.

Lifestyle Risk Factors, Quality of Life, and Intervention Preferences of Barrett's Esophagus Patients: A Prospective Cohort Study

BACKGROUND AND AIMS

Lifestyle counseling to achieve a healthy weight, quit smoking, and reduce alcohol is a cornerstone in the management of Barrett's Esophagus (BE). However, little is known about whether patients make these recommended lifestyle changes or the impact of non-adherence on their quality of life (QOL). This study characterized the lifestyle risk factors, QOL, and intervention preferences of BE patients as a first step toward developing lifestyle change interventions for this population.

METHODS

Patients with a confirmed BE diagnosis (N = 106) completed surveys at a surveillance endoscopy visit (baseline) and at 3- and 6-month follow-ups. Patients reported on lifestyle risk factors, adherence determinants (e.g., perceived benefits/barriers, risk, intentions), QOL, and intervention preferences.

RESULTS

Most patients (56%) had uncontrolled reflux, were overweight/obese (65.1%), and had low dietary fiber intake (91%). Many (45%) reported poor QOL. Patients' perceived risk of developing esophageal cancer was high, but their behavior change intentions were low. Despite receiving lifestyle counseling from physicians, there were no significant changes in patients' QOL or lifestyle risk factors over time. Nonetheless, patients indicated strong interest in internet (62.6%) and multimedia programs (57.9%) addressing acid reflux and weight control.

CONCLUSION

BE patients reported uncontrolled reflux, poor QOL, and multiple lifestyle risk factors that did not change over time. Despite low levels of intention for making lifestyle changes, patients were interested receiving more information about controlling acid reflux, suggesting a potential teachable moment and opportunity for web-based and multimedia multiple behavior interventions that seek to control acid reflux symptoms through weight loss and a high fiber diet.

The Wonderful Activities of the Genus Mentha: Not Only Antioxidant Properties

Medicinal plants and their derived compounds have drawn the attention of researchers due to their considerable impact on human health. Among medicinal plants, mint (Mentha species) exhibits multiple health beneficial properties, such as prevention from cancer development and anti-obesity, antimicrobial, anti-inflammatory, anti-diabetic, and cardioprotective effects, as a result of its antioxidant potential, combined with low toxicity and high efficacy. Mentha species are widely used in savory dishes, food, beverages, and confectionary products. Phytochemicals derived from mint also showed anticancer activity against different types of human cancers such as cervix, lung, breast and many others. Mint essential oils show a great cytotoxicity potential, by modulating MAPK and PI3k/Akt pathways; they also induce apoptosis, suppress invasion and migration potential of cancer cells lines along with cell cycle arrest, upregulation of Bax and p53 genes, modulation of TNF, IL-6, IFN-γ, IL-8, and induction of senescence phenotype. Essential oils from mint have also been found to exert antibacterial activities against Bacillus subtilis, Streptococcus aureus, Pseudomonas aeruginosa, and many others. The current review highlights the antimicrobial role of mint-derived compounds and essential oils with a special emphasis on anticancer activities, clinical data and adverse effects displayed by such versatile plants.

Association between acid-suppressive drug use and atopic dermatitis in patients with upper gastrointestinal diseases: A population-based retrospective cohort study

WHAT IS KNOWN AND OBJECTIVE

Proton-pump inhibitors (PPIs) and histamine-2-receptor antagonists (H2RAs) are two of the most widely used acid-suppressive drugs (ASDs). Some studies have reported that prenatal ASD exposure may increase the risk of asthma and other allergic diseases. This study investigated the effects of ASDs on the risk of atopic dermatitis in patients with upper gastrointestinal diseases.

METHODS

This population-based retrospective cohort study used data of 289,850 patients with at least two diagnoses of upper gastrointestinal diseases (UGIDs) between 1 January 2001 and 31 December 2005, from Taiwan's National Health Insurance Research Database. The AD risks among ASD users and nonusers were compared. Differences in sociodemographic characteristics and potential covariates were examined. AD hazard ratios were estimated, and groups were compared using Cox proportional hazards regression analysis after adjustment for age, sex and other covariates.

RESULTS AND DISCUSSION

In total, 109,980 patients were included. The adjusted hazard ratio (HR) of AD risk in ASD users relative to that in nonusers was 1.52 (95% confidence interval [CI]: 1.40-1.64, p < 0.001). For a dose-effect sub-analysis, patients were divided into four groups based on their defined daily dose. ASDs dose-dependently affected the AD risk (p for trend <0.01). Furthermore, the adjusted HR of the AD risk among ASD nonusers was 2.30 (95% CI: 2.06-2.57) relative to that in the comparison group (ASD nonusers without UGIDs). Among patients with UGIDs, ASD users had a higher AD risk than ASD nonusers. A subgroup analysis revealed only H2RA use was associated with an increased AD risk (adjusted HR 1.70, 95% CI: 1.53-1.89, p < 0.001).

WHAT IS NEW AND CONCLUSIONS

These results indicate that the use of H2RAs was associated with an increased risk of AD among patients with UGIDs, and the increase in risk appeared to be dose-dependent. ASDs should be used only in situations where clear clinical benefits can be obtained.

Effects of Deacidification on Composition of Schisandra chinensis Ethanolic Extract and Studies on Acute Toxicity in Mice

Schisandra chinensis Fructus (SCF), a well-known traditional medicinal material, is a rich source of dibenzocyclooctene type lignans and polyphenols, which are important ingredients in SCF and show various activities. SCF also contains about 18% organic acids, mainly citric acid, which makes the fruit and extract taste extremely sour and limited its application in beverages or food industries. In the present study, a chemical deacidification method was applied to defatted and non-defatted ethanol extract of SCF, and the effects on organic acid, lignans, and phenolic compounds were evaluated. Free radical scavenging activity and acute toxicity in mice before and after deacidification were also compared. Our results demonstrated that chemical deacidification significantly decreased the contents of organic acid and lignan compounds and markedly improves the safety of the ethanol extract of SCF, which will facilitate the comprehensive utilization of SCF extract in food and beverage industries.

Efficacy of DA-5204 (Stillen 2X) for patients with gastroesophageal reflux disease: A randomized, double-blind, placebo-controlled pilot study

BACKGROUND/AIM

Proton pump inhibitor (PPI) alone is not satisfactory for the treatment of gastroesophageal reflux disease (GERD). Therefore, we investigated the efficacy of DA-5204 (Stillen 2X, 90 mg of Artemisia asiatica 95% ethanol extract per tablet) and PPI combination therapy on GERD in comparison to PPI alone.

METHODS

This randomized, double-blind, placebo-controlled study randomly assigned 70 patients with endoscopically proven esophageal mucosal injury (Los Angeles classification grade A or B) into 2 groups: pantoprazole 40 mg once daily with DA-5204 twice daily (DA-5204 group) or pantoprazole 40 mg once daily with placebo twice daily (placebo group) for 4 weeks. The primary endpoint was endoscopic healing rate. The secondary endpoint was sufficient relief (≥50% reduction) of symptoms using GERD Questionnaire.

RESULTS

Final analyses included 29 patients with the DA-5204 group and 30 patients with the placebo group. At weeks 4, there was no significant difference in the endoscopic healing rate between the 2 groups (DA-5204 vs placebo; 96.6% vs 93.3%; P = 1.000). However, the rate of residual minimal change was significantly lower in the DA-5204 group (5/28, 17.9%) than in the placebo group (17/28, 60.7%) (P < .001). The rates of symptom relief were not different between the DA-5204 group and the placebo group (all P > .05).

CONCLUSION

Combined therapy with PPI and DA-5204 has no additional effect on the endoscopic healing rate compared to PPI alone. However, it may be beneficial in resolving minimal change.

Proton pump inhibitor administration in neonates and infants. Lack of consensus - An ASPO survey

OBJECTIVE

Laryngopharyngeal and Gastroesophageal reflux (LPR and GER) are distinct clinical entities that present with a range of non-specific symptoms. The exact prevalence in the pediatric population is unknown. While there has been an increase in the use of PPIs, lack of clear guidelines, conflicting evidence regarding efficacy and safety concerns with long-term use require physicians to use their own anecdotal experience and clinical judgement when treating patients. The goal of this study was to evaluate practice patterns among pediatric otolaryngologists regarding the use of proton-pump inhibitors for reflux-related conditions.

METHODS

A survey was submitted to American Society of Pediatric Otolaryngology (ASPO) members to determine practice patterns regarding use of PPIs for reflux-related conditions in the newborn and infant population. Statistical analysis using Fisher's exact test was performed.

RESULTS

37% of respondents would not prescribe PO PPIs in neonates, with 50% not prescribing IV PPIs. 60% would prescribe a PPI as second or third-line treatment for infants (10 weeks to 1-year). Only 10% would prescribe as first-line in this age group. 48% would prescribe PPIs once daily and 19% as BID. No significant practice differences exist based on years of experience, number of relevant patients seen, and setting of practice.

CONCLUSION

There was no agreement regarding dosage, frequency and duration of PPI treatment for reflux disease in neonates and infants. There was also no correlation with experience or practice setting. This emphasizes the need for a multidisciplinary approach and consensus statement to guide management of GER and LPR in this population.

Different Traditional Herbal Medicines for the Treatment of Gastroesophageal Reflux Disease in Adults

Background/Aims

Traditional Herbal Medicines (THM) have been being used for gastroesophageal reflux disease (GERD) for a long time, but clinical evidence is still scarce. We evaluated different THM prescriptions for GERD in adults.

Methods

Data added to nine online databases from their inception to November 30, 2019, were systematically searched. All relevant randomized controlled trials (RCTs) were included and were combined with Bayesian network analysis. The Cochrane Collaboration’s risk of bias tool and GRADE profiler version 3.6 were respectively employed to evaluate the quality of evidence of outcomes.

Results

Seventeen publications involving 1441 participants were retrieved. The results of our analysis suggested that Jianpi therapy+proton pump inhibitors (PPIs) and Ligan Hewei therapy respectively ranked first in overall clinical efficacy and efficacy under gastroscope; Ligan Hewei therapy+PPIs was the optimum intervention in the improvement of acid regurgitation and heartburn.

Conclusion

This research indicates that Ligan Hewei therapy and Jianpi therapy, or these therapies separately combined with PPIs, should be recommended as appropriate complementary and alternative treatments based on the specific characteristics of GERD. However, additional well-designed RCTs with high methodological quality are still needed for future research.

Long-term use of proton pump inhibitors as a risk factor for various adverse manifestations

The long-term use of proton pump inhibitors (PPIs) can lead to increased gastric pH, hypochlorhydria and in some cases to achlorhydria when compared to other acid-suppressing agents like histamine-2 (H2) receptor blockers and antacids. These consequences by the use of long-term PPIs may lead to significant vitamin (B₁₂ and C) and mineral (iron, calcium and magnesium) deficiencies which needs gastric acid for their absorption and bioavailability. Long-term use of PPIs by the pregnant patients may impose a potential risk of congenital malformations. Various studies have recommended the life style modifications and antacid use as first choice among pregnant womens by preserving PPIs (omeprazole as a safe choice of PPI) for severe conditions of gastroesophageal reflux disease. The long-term acid suppression by PPIs can also lead to enteric, respiratory and urinary tract infections. The hypochlorhydria by chronic PPIs use may induce hypergastrinemia, which ultimately mediates the gastric polyps, gastric carcinoids and gastric cancer. The concomitant use of PPIs with antiplatelet drugs like clopidogrel can impose the patients to major adverse cardiac events. This review has enlisted the comprehensive information regarding the adverse effects induced by long-term use of PPIs and their possible relations. Considerable studies like case-control, randomized trials, cohort studies and meta-analysis were reported in supporting these adverse effects. The clinicians and patients should be cautious about these effects so that they can avoid the serious outcomes. PPIs should be avoided for long-term use mainly in older adults unless there is a proper indication.

Prevalence and predictors of proton pump inhibitor partial response in gastroesophageal reflux disease in systemic sclerosis: a prospective study

Proton pump inhibitor (PPI) twice daily dosing is a standard therapy for gastroesophageal reflux disease (GERD) in systemic sclerosis (SSc) but there is no data on its response rate or the predictors of PPI-partial response GERD. Aims were to determine the prevalence of PPI-partial response GERD in SSc and to define its predictors. A prospective study was conducted in SSc patients with GERD. The patients were treated with omeprazole 20 mg bid for 4 weeks. The severity of symptom-grading by visual analogue scale (VAS) and frequency of symptoms by frequency scale for symptoms of GERD (FSSG) were assessed at baseline and 4 weeks after treatment. PPI-partial response GERD was defined as less than 50% improvement in the VAS for severity of symptom as well as acid reflux score by FSSG after treatment. According to the sample size calculation, 243 SSc-GERD patients were enrolled; of whom 166 (68.3%) had the diffuse cutaneous SSc. PPI-partial response GERD was found in 131 SSc patients (prevalence 53.9%; 95%CI 47.4–60.3). The multivariate analysis revealed that esophageal dysphagia was an only predictor the PPI-partial response GERD (OR 1.82; 95%CI 1.01–3.29) while neither SSc subset nor severity of skin tightness were significantly associated with PPI-partial response GERD. Half of the SSc patients were PPI-partial response GERD. Esophageal dysphagia was the only predictor of PPI-partial response GERD in SSc patients. Screening for dysphagia before starting GERD treatment is helpful for assessment the risk of PPI refractoriness GERD in SSc patients.