Gender differences in symptoms in partial responders to proton pump inhibitors for gastro-oesophageal reflux disease

BACKGROUND

Gender differences may exist in the symptom experience of patients with gastro-oesophageal reflux disease (GERD) who have a partial response to proton pump inhibitors (PPIs).

OBJECTIVE

The purpose of this study was to analyse gender differences in partial responders to PPIs.

METHODS

Patients with GERD who responded partially to PPIs (n = 580; NCT00703534) completed the Reflux Symptom Questionnaire 7-day recall (RESQ-7) and the Gastrointestinal Symptom Rating Scale (GSRS). Anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale.

RESULTS

Women had significantly higher RESQ-7 domain scores than men for Heartburn (frequency: 4.3 vs 3.9; intensity: 3.1 vs 2.8), Burping (frequency: 4.9 vs 4.4; intensity: 3.1 vs 2.8) and Hoarseness, cough and difficulty swallowing (frequency: 2.6 vs 2.2; intensity: 1.8 vs 1.5), and had higher GSRS domain discomfort scores than men for Abdominal pain (3.51 vs 3.23), Indigestion (3.80 vs 3.45) and Constipation (2.69 vs 2.17) (all p < 0.05). Anxiety and depression were significantly more prevalent in women than in men.

CONCLUSION

In this population of partial responders, women had more frequent/intense heartburn and extra-oesophageal symptoms and more discomfort from abdominal pain, indigestion and constipation than men. Comorbid anxiety and depression may contribute to the increased symptom burden in women.

Predictors of either rapid healing or refractory reflux oesophagitis during treatment with potent acid suppression

BACKGROUND

Little is known regarding patient characteristics that influence the speed of reflux oesophagitis (RO) healing.

AIM

To investigate patient characteristics that may influence RO healing rates.

METHODS

A post hoc analysis of clinical trial data for potent acid suppression treatment of RO (esomeprazole or AZD0865) was conducted. Group A underwent endoscopy at baseline, week 2 and 4, and group B at baseline, week 4 and 8. Group A patients were sub-grouped as 'rapid' (healed at 2 weeks) or unhealed at 2 weeks. Group B patients were sub-grouped as 'slow' (healed at 8 weeks, not at 4 weeks) or 'refractory' (not healed at 8 weeks). Logistic regression analysis was performed only for comparisons within group A.

RESULTS

At 2, 4 and 8 weeks, RO had healed in 68%, 65% and 61% of patients unhealed at previous endoscopy, respectively. Low-grade [vs. high-grade (C or D)] RO was the only independent predictor of rapid healing in group A after logistic regression analysis. Significantly more rapid healers had low grade RO (A or B) at baseline than patients with refractory RO (84% vs. 49%; P < 0.001), and significantly more refractory patients had frequent regurgitation at baseline than slow healers (80% vs. 63%; P = 0.039).

CONCLUSIONS

Low- (vs. high-) grade RO determines the most rapid benefit from acid suppression. Roughly two-thirds of patients healed with each time increment of potent acid suppression therapy. This suggests that some unhealed patients may still heal with continued therapy and that truly refractory RO is rare. (ClinicalTrials.gov: NCT00206245).

Diacylglycerol acyltransferase 1 inhibition with AZD7687 alters lipid handling and hormone secretion in the gut with intolerable side effects: a randomized clinical trial

AIM

Inhibition of diacylglycerol acyltransferase 1 (DGAT1) is a potential treatment modality for patients with type 2 diabetes mellitus and obesity, based on preclinical data suggesting it is associated with insulin sensitization and weight loss. This randomized, placebo-controlled, phase 1 study in 62 overweight or obese men explored the effects and tolerability of AZD7687, a reversible and selective DGAT1 inhibitor.

METHODS

Multiple doses of AZD7687 (1, 2.5, 5, 10 and 20 mg/day, n = 6 or n = 12 for each) or placebo (n = 20) were administered for 1 week. Postprandial serum triacylglycerol (TAG) was measured for 8 h after a standardized 45% fat meal. Glucagon-like peptide-1 (GLP-1) and peptide YY (PYY) were measured and a paracetamol challenge was performed to assess gastric emptying.

RESULTS

Dose-dependent reductions in postprandial serum TAG were demonstrated with AZD7687 doses ≥5 mg compared with placebo (p < 0.01). Significant (p < 0.001) increases in plasma GLP-1 and PYY levels were seen at these doses, but no clear effect on gastric emptying was demonstrated at the end of treatment. With AZD7687 doses >5 mg/day, gastrointestinal (GI) side effects increased; 11/18 of these participants discontinued treatment owing to diarrhoea.

CONCLUSIONS

Altered lipid handling and hormone secretion in the gut were demonstrated during 1-week treatment with the DGAT1 inhibitor AZD7687. However, the apparent lack of therapeutic window owing to GI side effects of AZD7687, particularly diarrhoea, makes the utility of DGAT1 inhibition as a novel treatment for diabetes and obesity questionable.

Impact of persistent, frequent regurgitation on quality of life in heartburn responders treated with acid suppression: a multinational primary care study

BACKGROUND

In gastro-oesophageal reflux disease (GERD), heartburn responds well to acid suppression, but regurgitation is a common cause of incomplete treatment response.

AIM

To assess the prevalence and burden of persistent, frequent regurgitation in primary care patients with GERD treated with acid suppression.

METHODS

We analysed observational data from 134 sites across six European countries in patients diagnosed with GERD. Within 3 months of the index visit, symptoms were assessed using the Reflux Disease Questionnaire, and their impact on sleep and work productivity with the Quality of Life in Reflux and Dyspepsia questionnaire and the Work Productivity and Activity Impairment Questionnaire, respectively. Patients provided information on concomitant over-the-counter (OTC) GERD medication use.

RESULTS

Persistent, frequent (3-7 days/week) regurgitation was reported by 13.2% (153/1156) of GERD patients with no heartburn on acid suppression; the prevalence was very similar for patients with up to 2 days/week of ongoing mild heartburn. Among patients without heartburn, sleep disturbance of any type was reported by 50.7-60.1% with persistent, frequent regurgitation, compared with 38.1-51.1% and 14.4-19.2% of those with less frequent or no regurgitation respectively. Persistent, frequent regurgitation was associated with increased use of OTC medication and more hours of work missed, whether mild, infrequent heartburn was present or not.

CONCLUSIONS

Frequent regurgitation, which persisted in 12-13% of patients with no or infrequent, mild heartburn on acid suppression, negatively affected sleep and work productivity, and increased use of OTC medication. Persistent, frequent regurgitation is problematic for primary care patients with GERD.

Clinical risk factors, bone density and fall history in the prediction of incident fracture among men and women

The FRAX(tr) algorithm uses clinical risk factors (CRF) and bone mineral density (BMD) to predict fracture risk but does not include falls history in the calculation. Using results from the Hertfordshire Cohort Study, we examined the relative contributions of CRFs, BMD and falls history to fracture prediction. We studied 2299 participants at a baseline clinic that included completion of a health questionnaire and anthropometric data. A mean of 5.5years later (range 2.9-8.8years) subjects completed a postal questionnaire detailing fall and fracture history. In a subset of 368 men and 407 women, bone densitometry was performed using a Hologic QDR 4500 instrument. There was a significantly increased risk of fracture in men and women with a previous fracture. A one standard deviation drop in femoral neck BMD was associated with a hazards ratio (HR) of incident fracture (adjusted for CRFs) of 1.92 (1.04-3.54) and 1.77 (1.16-2.71) in men and women respectively. A history of any fall since the age of 45years resulted in an unadjusted HR of fracture of 7.31 (3.78-14.14) and 8.56 (4.85-15.13) in men and women respectively. In a ROC curve analysis, the predictive capacity progressively increased as BMD and previous falls were added into an initial model using CRFs alone. Falls history is a further independent risk factor for fracture. Falls risk should be taken into consideration when assessing whether or not to commence medication for osteoporosis and should also alert the physician to the opportunity to target falls risk directly.

Proof of mechanism for the DGAT1 inhibitor AZD7687: results from a first-time-in-human single-dose study

AIMS

Inhibition of diacylglycerol acyltransferase 1 (DGAT1), which catalyses the final step in triacylglycerol (TAG) assembly, is suggested as a treatment for type 2 diabetes and obesity based on animal data indicating insulin sensitization and weight reduction. This first-time-in-human single ascending dose study explored the safety, tolerability, pharmacokinetics and pharmacodynamics of the selective DGAT1 inhibitor AZD7687.

METHODS

Eighty healthy male subjects were enrolled. In each of 10 cohorts, six subjects received the same dose of AZD7687 orally (range across cohorts 1-60 mg) and two placebo. Plasma AZD7687 exposure was measured repeatedly. Postprandial serum TAG excursion was measured during 8 h after a standardized mixed meal with fat energy content of 60% (SMM 60%; five cohorts, 1-20 mg), before (baseline) and after dosing, to assess effects on gut DGAT1 activity.

RESULTS

AZD7687 markedly reduced postprandial TAG excursion with a steep concentration-effect relationship. Incremental TAG AUC (area under the serum concentration vs. time curve) following SMM 60% was decreased >75% from baseline at doses ≥5 mg (p < 0.0001 vs. placebo). Serum levels of diacylglycerol, specifically measured with mass spectrometry, did not increase after AZD7687 administration. Nausea, vomiting and diarrhoea were reported with increasing doses and they limited dose escalation. Lowering of SMM fat content to 45 or 30% in five cohorts gradually reduced the frequency of gastrointestinal symptoms at a given dose of AZD7687.

CONCLUSIONS

The attenuating effect of AZD7687 on postprandial TAG excursion provides proof of mechanism with respect to gut DGAT1 inhibition. However, dose and diet-related gastrointestinal side effects may impact further development of DGAT1 inhibitors.

Carbohydrate-deficient transferrin in vitreous humour: a marker of possible withdrawal-related death in alcoholics

The possibility of performing reliable post-mortem analysis of carbohydrate-deficient transferrin (CDT) concentration in vitreous humour (VH) by using a commercial assay designed for serum analysis (CDTect(TM)) as well as the usefulness of VH-CDT as a marker of alcohol misuse and possible withdrawal-related death were evaluated in a forensic sample. Detectable VH-CDT was found in 20 of 21 alcoholic subjects and in two of seven controls. By using the detection limit of the CDTect(TM) method (VH-CDT = 5 U/l) as cut-off level for a positive test, the alcoholic group was significantly separated from the control group (P = 0.0024, Fisher's exact test). The sensitivity and specificity of the test was 95% and 71%, giving a positive and a negative predictive value of 91% and 83%, respectively. Time-dependent changes of VH-CDT in the dead body could not unequivocally be excluded, which must be considered when selecting cases suitable for VH-CDT analysis. We conclude that adding VH-CDT analysis to ordinary alcohol tests may become useful in forensic medicine for establishing the so-called 'alcoholic state', which may provide a tool in research dealing with the relation between alcohol withdrawal and various causes of death in alcoholics.

[Structured care program yielded good results in severe anorexia nervosa]

Between 1994 and 1998, 19 patients averaging 21 years of age (range 17-24) with severe anorexia nervosa were treated according to a special protocol including enteral nutrition by the nasogastric route, firmly implemented supervisory strategies and simultaneous psychiatric support. Mean body mass index increased from 13.8 (10.4-16.3) at admission to 15.2 (13.0-18.2) at discharge after an average hospital stay of 24 days. No serious complications occurred. At a follow-up in 1999, a questionnaire concerning the protocol was answered by 13 of the patients. Most of them experienced the hospital stay as trying, but retrospectively perceived the tube feeding and supervisory strategies as necessary.

The significance of coronary death for the excess mortality in alcohol-dependent men

General and validated cause-specific mortality, especially regarding coronary disease, was studied in a population-based cohort of 1049 alcohol-dependent (DSM-III-R) men, who were discharged from a detoxification ward. The observed and expected numbers of deaths were 140 and 23.2, respectively (P < 0.001). The estimated risk quotient of death was 6.0 (95% confidence interval 5.1-7.1). The concordance between revised and official causes of death was approximately 50%, but the resulting variation of risk quotients of cause-specific deaths generally remained within the statistical uncertainty. Coronary disease contributed to 19% of the total excess mortality in cases with a validated definite death diagnosis. The risk of coronary death tended to be augmented during the first 2 years of discharge (P = 0.05). Thus, coronary death contributed significantly to the excess mortality in alcohol-dependent men, and an increased vulnerability for sudden coronary death seemed to persist for a considerable time after discharge from detoxification.

Identification of critical positive charges in XIP, the Na/Ca exchange inhibitory peptide

The peptides XIP (RRLLFYKYVYKRYRAGKQRG) and C28R2 (LRRGQILWFRGLNRIQTQIRVVKAFRSS) correspond to the autoinhibitory domains of the Na-Ca exchanger and the plasma membrane Ca pump, respectively. An increase of ionic strength reduced the inhibition of exchange activity by XIP and C28R2, consistent with an important role for electrostatic interactions. Sulfosuccinimidyl acetate (SNA)-modified XIP did not inhibit Na-Ca exchange. Because SNA modifies lysines, we conclude that at least one of the positive charges at the XIP lysine positions (7, 11, or 17) is important for inhibition. 2CK-XIP (RRLLFYRYVYRCYCAGRQKG) has cysteines at 12 and 14 and only one lysine (at 19).2CK-XIP inhibited Na-Ca exchange; thus positive charges at 12 and 14 are not essential. SNA-modified 2CK-XIP did not inhibit; thus a positive charge at 19 is important. Iodoacetic acid-modified 2CK-XIP inhibits the Na-Ca exchanger but not the PM Ca pump. These results show that the structural determinants for inhibition of the Na-Ca exchanger and the PM Ca pump are different, that positive charges at 7, 11, or 17 (or some combination) are more important than positive charges at 12 and 14 for inhibition by XIP of the Na-Ca exchanger.

ST-segment changes and catecholamine-related myocardial enzyme release during alcohol withdrawal

ST-segment changes and biochemical signs of myocardial injury, and their relation to sympatho-adrenergic activation and cardiac function, were studied in a case series of 19 alcohol-dependent (DSM-III-R) men undergoing in-hospital treatment for alcohol withdrawal. No patient had any clinically apparent heart disease. Analyses of ST-segment depressions > or = 0.1 mV from 24 h ambulatory electrocardiographic recordings revealed horizontal or downsloping ST-segment depressions in seven of the patients. The serum concentration of creatine kinase (CKMB) the day after admission correlated with the urinary excretion of adrenaline (r = 0.74, P < 0.001) and noradrenaline (r = 0.71, P < 0.001). In the two patients with the highest adrenaline excretion and the highest serum concentrations of CKMB and cardiac troponin T, horizontal ST-segment depressions were detected as well. The left ventricular ejection fraction was > or = 0.65 (range 0.65-0.79) in all of the 17 alcoholic men who were examined by echocardiography. Our study shows that alcohol withdrawal is frequently associated with ST-segment abnormalities in men without impairment of heart function and that sympatho-adrenergic activation during withdrawal seems to influence the release of myocardial enzymes. Alcohol withdrawal should thus be considered a condition in which acute cardiac complications may be expected in susceptible individuals.

Ischemic heart disease and epilepsy: two major causes of out-hospital natural death in male alcoholics

The objectives of this research were to study the distribution of in- and out-hospital deaths and causes of death in male alcoholics and in particular to analyze obscure cases. In a population-based sample of 1123 men treated in one detoxification unit during 1986-1989, 97 patients with alcohol dependence (DSM-III-R) died < or = 1 year after in-hospital detoxification. In each case, the cause and the manner of death were assessed by scrutiny of information in hospital and autopsy records, toxicological examinations, and police reports. The results were that 71 of the 97 men died outside hospital. The overall autopsy rate was 89%. Ischemic heart disease accounted for 18 out of 41 evaluable natural out-hospital deaths. Epileptic seizures were judged to be the cause of death in five cases and could also have contributed to seven out of eight obscure out-hospital deaths. Ethanol in blood or urine was detected in 19 of the 23 deaths attributed to trauma or intoxication, whereas only four out of the 18 out-hospital deaths from ischemic heart disease were ethanol-positive. It was concluded that early detection and adequate treatment of ischemic heart disease and epilepsy might improve prognosis in patients with alcohol dependence. The use of clinical information could be of crucial importance in evaluating possible causes of death, especially in obscure cases.

The prevalence of alcoholism and its relation to cause of hospitalization and long-term mortality in male somatic inpatients

OBJECTIVE

To investigate the prevalence of alcoholism in patients hospitalized because of somatic disorders, and to analyse morbidity, mortality, and causes of death in those alcoholics.

DESIGN

Inception cohort, 7-year follow-up.

SETTING

Primary and secondary care clinics at a community hospital in Göteborg, Sweden.

PATIENTS AND CONTROLS

A convenience sample of all 205 men hospitalized at a medical, surgical, and orthopaedic clinic at a random time-point. The diagnosis of alcoholism was stated or rejected by means of structured interviews about drinking habits and by scrutiny of records from the hospital, psychiatric clinics, and social authorities. In the study of morbidity pattern and mortality in the alcoholics (n = 52), age-matched, non-alcoholic controls were recruited from the same sample.

MAIN OUTCOME MEASURES

Prevalence of alcoholism; distribution of somatic disorders as cause of hospitalization at inclusion; mortality and risk ratio of death using the death hazard function of the groups compared with that of men of the same age-distribution in the Swedish population; causes of death during a 7-year follow-up.

MAIN RESULTS

Fifty-two of the 205 hospitalized men (25%) were alcoholics and 16 of these men (31%) were treated for an alcohol-related disorder. During follow-up, the mortality rate was about 50% both in the alcoholic and in the control groups. The risk of death ratio was 5.0 [95% confidence interval (CI), 2.9 to 8.3] in the alcoholics and 3.9 (95% CI, 2.2 to 6.4) in the controls. Death from trauma, intoxication, and liver failure occurred exclusively in the alcoholics and accounted for almost one-third of the deaths after discharge.

CONCLUSIONS

Alcoholism was found in every fourth male somatic inpatient, and an alcohol-related disorder was the cause of hospitalization in one-third of these men. The long-term prognosis did not differ from that in non-alcoholic patients. In the treatment of alcoholics with somatic disorders, it is important to take measures against alcoholism as well.

Influence of increased adrenergic activity and magnesium depletion on cardiac rhythm in alcohol withdrawal

OBJECTIVE

To investigate the prevalence of arrhythmias in alcoholic men during detoxification and its relation to neuroendocrine activation and electrolyte disturbances.

DESIGN

Consecutive case-control study.

SETTING

Primary and secondary care, detoxification ward.

PATIENTS AND CONTROLS

19 otherwise healthy alcoholic men (DSM-III-R) with withdrawal symptoms necessitating detoxification in hospital. 19 age matched, healthy non-alcoholic men as controls for Holter recordings.

INTERVENTIONS

Treatment with chlomethiazole; additional treatment with carbamazepine in patients with previous seizures.

MAIN OUTCOME MEASURES

Computer based analyses of mean heart rate and arrhythmias from 24 hour Holter recordings, 24 hour urinary excretion of adrenaline and noradrenaline, magnesium retention measured by means of intravenous loading test, and serum concentrations of electrolytes.

RESULTS

The 24 hour mean heart rate was higher in the alcoholic men (97.4 beats/minute, 95% confidence interval (CI) 91.2 to 103.6) than in the controls (69.6 beats/minute, 95% CI 65.4 to 73.8, P < 0.001). However, there was no difference in diurnal heart rate variation. The prevalence of premature supraventricular depolarisations was lower in the alcoholic men (P < 0.05). Neither atrial fibrillation nor malignant ventricular arrhythmias occurred. The sinus tachycardia in the alcoholic men correlated with the concomitant urinary excretion of catecholamines (P < 0.05). The mean serum magnesium concentration was 0.78 mmol/l (95% CI 0.73 to 0.83) in the alcoholic men and 0.83 mmol/l (95% CI 0.81 to 0.85) in a reference population of 55 men aged 40. Magnesium depletion (defined as magnesium retention > 30%) was detected in 10 alcoholic men (53%). Three alcoholic men had serum potassium concentrations < or = 3.3 mmol/l on admission.

CONCLUSION

Increased adrenergic activity, magnesium depletion, and hypokalaemia are often seen after heavy drinking, but in alcoholic men without clinical heart disease these changes were not accompanied by arrhythmias other than sinus tachycardia during detoxification in hospital.

Bacterial overgrowth after high-dose corticosteroid treatment

A 63-year-old man with systemic lupus erythematosus and selective IgA deficiency developed intractable diarrhoea the day after treatment with prednisone, 50 mg daily, was started. The diarrhoea was considered to be caused by bacterial overgrowth and was later successfully treated with doxycycline. Although IgA deficiency is a risk factor for bacterial overgrowth, a further predisposing condition is necessary for development of this disorder but was not present in this case. We therefore suppose that high-dose treatment with corticosteroids might be a hitherto undescribed risk factor for bacterial overgrowth in vulnerable patients.

Diagnosis of pyogenic liver abscess via liver scanning with indium-111 labelled granulocytes

An 82-year-old man presented with a history indicating cancer or a developing pyogenic abscess in the liver. The latter diagnosis was established by a liver scan with indium-111 labelled granulocytes, whereas ultrasonography, computed tomography and percutaneous liver puncture were inconclusive.

Paracetamol medication and alcohol abuse: a dangerous combination for the liver and the kidney

The clinical pattern of paracetamol-induced acute liver damage was studied with regard to whether the intoxication was acute or due to continuous use. This condition was found to be caused almost as often by accidental chronic medication as by acute intoxication, with annual incidences per 100,000 of 0.8 and 1.2 cases, respectively. The liver damage found in 18% of the cases of acute intoxication was generally mild, probably due to an early antidote treatment. In contrast, in the chronic intoxicated cases the liver damage was more pronounced and often accompanied by a severe renal dysfunction. Since all these patients were alcohol abusers, and the reported paracetamol intake was not remarkably high, it seems reasonable to recommend that paracetamol should be prescribed with great caution to alcoholics, and absolutely not for continuous use.