Modified Helicobacter test using a new test meal and a 13C-urea breath test in Helicobacter pylori positive and negative dyspepsia patients on proton pump inhibitors

AIM

To determine the sensitivity and specificity of the ¹³C-urea breath test (UBT) in patients taking proton pump inhibitors (PPIs), using a new test meal Refex.

METHODS

One hundred and fourteen consecutive patients with dyspepsia, 53 Helicobacter pylori (H. pylori) positive, 49 H. pylori negative, were included in the study. The patients were then given esomeprazole 40 mg for 29 consecutive days, and the ¹³C-UBT with the new test meal was performed the next morning.

RESULTS

The sensitivity of the ¹³C-UBT with a cut off 2.5‰ was 92.45% (95%CI: 81.79%-97.91%) by per-protocol (PP) analysis and 78.13% (95%CI: 66.03%-87.49%) by intention-to-treat (ITT) analysis. The specificity of the ¹³C-UBT test was 96.00% in the ITT population (95%CI: 86.29%-99.51%) and 97.96% in the PP population (95%CI: 89.15%-99.95%).

CONCLUSION

The new test meal based ¹³C-UBT is highly accurate in patients on PPIs and can be used in those unable to stop their PPI treatment.

Efficacy and safety of Xiangsha Liujunzi granules for functional dyspepsia: A multi-center randomized double-blind placebo-controlled clinical study

AIM

To assess the efficacy and safety of a Chinese herbal medicine (CHM), Xiangsha Liujunzi granules, in the treatment of patients with functional dyspepsia (FD).

METHODS

We performed a randomized, double-blind, placebo-controlled trial with patients from three centers. Two hundred and sixteen subjects diagnosed with FD according to ROME III criteria and confirmed by upper gastrointestinal endoscopy and spleen-deficiency and Qi-stagnation syndrome were selected to receive Xiangsha Liujunzi granules or placebo for 4 wk in a 2:1 ratio by blocked randomization. The subjects also received follow-up after the 4-wk intervention. Herbal or placebo granules were dissolved in 300 mL of water. Participants in both groups were administered 130 mL (45 °C) three times a day. Participants were evaluated prior to and following 4 wk of the intervention in terms of changes in the postprandial discomfort severity scale (PDSS) score, clinical global impression (CGI) scale score, hospital anxiety and depression scale (HADS) score, traditional Chinese medicine symptoms score (SS), scores of various domains of the 36-item short form health survey (SF-36), gastric emptying (GE) and any observed adverse effects.

RESULTS

Compared with the placebo group, patients in the CHM group showed significant improvements in the scores of PDSS, HADS, SS, SF-36 and CGI scale (P < 0.05 or P < 0.01). They also showed the amelioration in the GE rates of the proximal stomach and distal stomach (P < 0.05 or P < 0.01).

CONCLUSION

Xiangsha Liujunzi granules offered significant symptomatic improvement in patients with FD.

Antidepressants for chronic non-cancer pain in children and adolescents

BACKGROUND

Pain is a common feature of childhood and adolescence around the world, and for many young people, that pain is chronic. The World Health Organization guidelines for pharmacological treatments for children's persisting pain acknowledge that pain in children is a major public health concern of high significance in most parts of the world. While in the past pain was largely dismissed and was frequently left untreated, views on children's pain have changed over time and relief of pain is now seen as important.We designed a suite of seven reviews on chronic non-cancer pain and cancer pain (looking at antidepressants, antiepileptic drugs, non-steroidal anti-inflammatory drugs, opioids, and paracetamol) in order to review the evidence for children's pain utilising pharmacological interventions.As the leading cause of morbidity in the world today, chronic disease (and its associated pain) is a major health concern. Chronic pain (that is pain lasting three months or longer) can arise in the paediatric population in a variety of pathophysiological classifications (nociceptive, neuropathic, or idiopathic) from genetic conditions, nerve damage pain, chronic musculoskeletal pain, and chronic abdominal pain, as well as for other unknown reasons.Antidepressants have been used in adults for pain relief and pain management since the 1970s. The clinical impression from extended use over many years is that antidepressants are useful for some neuropathic pain symptoms, and that effects on pain relief are divorced and different from effects on depression; for example, the effects of tricyclic antidepressants on pain may occur at different, and often lower, doses than those on depression. Amitriptyline is one of the most commonly used drugs for treating neuropathic pain in the UK.

OBJECTIVES

To assess the analgesic efficacy and adverse events of antidepressants used to treat chronic non-cancer pain in children and adolescents aged between birth and 17 years, in any setting.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online, MEDLINE via Ovid, and Embase via Ovid from inception to 6 September 2016. We also searched the reference lists of retrieved studies and reviews, and searched online clinical trial registries.

SELECTION CRITERIA

Randomised controlled trials, with or without blinding, of any dose and any route, treating chronic non-cancer pain in children and adolescents, comparing any antidepressant with placebo or an active comparator.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for eligibility. We planned to use dichotomous data to calculate risk ratio and number needed to treat for one additional event, using standard methods. We assessed the evidence using GRADE and created three 'Summary of findings' tables.

MAIN RESULTS

We included four studies with a total of 272 participants (6 to 18 years of age) who had either chronic neuropathic pain, complex regional pain syndrome type 1, irritable bowel syndrome, functional abdominal pain, or functional dyspepsia. All of the studies were small. One study investigated amitriptyline versus gabapentin (34 participants), two studies investigated amitriptyline versus placebo (123 participants), and one study investigated citalopram versus placebo (115 participants). Due to a lack of available data we were unable to complete any quantitative analysis.Risk of bias for the four included studies varied, due to issues with randomisation and allocation concealment (low to unclear risk); blinding of participants, personnel, and outcome assessors (low to unclear risk); reporting of results (low to unclear risk); and size of the study populations (high risk). We judged the remaining domains, attrition and other potential sources of bias, as low risk of bias. Primary outcomesNo studies reported our primary outcomes of participant-reported pain relief of 30% or greater or 50% or greater (very low-quality evidence).No studies reported on Patient Global Impression of Change (very low-quality evidence).We rated the overall quality of the evidence (GRADE rating) as very low. We downgraded the quality of the evidence by three levels to very low because there was no evidence to support or refute. Secondary outcomesAll studies measured adverse events, with very few reported (11 out of 272 participants). All but one adverse event occurred in the active treatment groups (amitriptyline, citalopram, and gabapentin). Adverse events in all studies, across active treatment and comparator groups, were considered to be a mild reaction, such as nausea, dizziness, drowsiness, tiredness, and abdominal discomfort (very low-quality evidence).There were also very few withdrawals due to adverse events, again all but one from the active treatment groups (very low-quality evidence).No serious adverse events were reported across any of the studies (very low-quality evidence).There were few or no data for our remaining secondary outcomes (very low-quality evidence).We rated the overall quality of the evidence (GRADE rating) for these secondary outcomes as very low. We downgraded the quality of the evidence by three levels to very low due to too few data and the fact that the number of events was too small to be meaningful.

AUTHORS' CONCLUSIONS

We identified only a small number of studies with small numbers of participants and insufficient data for analysis.As we could undertake no meta-analysis, we are unable to comment about efficacy or harm from the use of antidepressants to treat chronic non-cancer pain in children and adolescents. Similarly, we cannot comment on our remaining secondary outcomes: Carer Global Impression of Change; requirement for rescue analgesia; sleep duration and quality; acceptability of treatment; physical functioning; and quality of life.There is evidence from adult randomised controlled trials that some antidepressants, such as amitriptyline, can provide some pain relief in certain chronic non-cancer pain conditions.There is no evidence from randomised controlled trials to support or refute the use of antidepressants to treat chronic non-cancer pain in children or adolescents.

Development and validation of a simple and multifaceted instrument, GERD-TEST, for the clinical evaluation of gastroesophageal reflux and dyspeptic symptoms

AIM

To evaluate the psychometric properties of a newly developed questionnaire, known as the gastroesophageal reflux and dyspepsia therapeutic efficacy and satisfaction test (GERD-TEST), in patients with GERD.

METHODS

Japanese patients with predominant GERD symptoms recruited according to the Montreal definition were treated for 4 wk using a standard dose of proton pump inhibitor (PPI). The GERD-TEST and the Medical Outcome Study Short Form-8 Health Survey (SF-8) were administered at baseline and after 4 wk of treatment. The GERD-TEST contains three domains: the severity of GERD and functional dyspepsia (FD) symptoms (5 items), the level of dissatisfaction with daily life (DS) (4 items), and the therapeutic efficacy as assessed by the patients and medication compliance (4 items).

RESULTS

A total of 290 patients were eligible at baseline; 198 of these patients completed 4 wk of PPI therapy. The internal consistency reliability as evaluated using the Cronbach's α values for the GERD, FD and DS subscales ranged from 0.75 to 0.82. The scores for the GERD, FD and DS items/subscales were significantly correlated with the physical and mental component summary scores of the SF-8. After 4 wk of PPI treatment, the scores for the GERD items/subscales were greatly reduced, ranging in value from 1.51 to 1.87 and with a large effect size (P < 0.0001, Cohen's d; 1.29-1.63). Statistically significant differences in the changes in the scores for the GERD items/subscales were observed between treatment responders and non-responders (P < 0.0001).

CONCLUSION

The GERD-TEST has a good reliability, a good convergent and concurrent validity, and is responsive to the effects of treatment. The GERD-TEST is a simple, easy to understand, and multifaceted PRO instrument applicable to both clinical trials and the primary care of GERD patients.

Efficacy of Mentha pulegium extract in the treatment of functional dyspepsia: A randomized double-blind placebo-controlled clinical trial

ETHNOPHARMACOLOGICAL EVIDENCE

Mentha pulegium L. leaves are used in the Iranian traditional medicine for the treatment of functional dyspepsia.

AIM OF STUDY

To study the efficacy and safety of M. pulegium in the treatment of functional dyspepsia patients fulfilling the Rome III criteria.

MATERIALS AND METHODS

The efficacy and safety of a standardized Mentha pulegium leaf extract (drug extract ratio: 15.9:1, extraction solvent: 70% v/v aqueous ethanol) (330mg three times daily taken for 2 months) as add-on to one famotidine 40mg tablet per day in the treatment of 50 functional dyspepsia patients were compared with those of a parallel placebo group (n =50).

RESULTS

The extract significantly decreased the total dyspepsia score measured by the Hong Kong dyspepsia index compared to the placebo and baseline (P=0.011 and P<0.001 respectively). The stomach pain, upper abdominal bloating, upper abdominal dull ache, belching and total dyspepsia scores were decreased from baseline in the extract group significantly compared to the placebo (P<0.001, P<0.001, P=0.003, P<0.001 and P<0.001 respectively). However, the decreases of other dyspepsia symptoms scores from baseline in the extract group were not significant compared to the placebo (P>0.05). The extract improved the quality of life measured by the SF-36 questionnaire significantly compared to the placebo and baseline (P=0.003 and P<0.001 respectively). Moreover, the extract lowered the rate of H. pylori infection determined by the urease test significantly compared to the placebo and baseline (P=0.001 and P<0.001 respectively). The extract did not significantly affect the complete blood count and liver and kidney function tests (P>0.05). The patients did not experience any adverse drug effect.

CONCLUSIONS

M. pulegium extract (genuine drug extract ratio: 19.4:1; extraction solvent: 70% v/v aqueous ethanol) 270mg three times daily taken for 2 months as adjunct to one famotidine 40mg tablet per day seems safe, improves dyspeptic symptoms and quality of life and eradicates H. pylori in functional dyspepsia patients.

Prokinetics for the treatment of functional dyspepsia: Bayesian network meta-analysis

BACKGROUND

Controversies persist regarding the effect of prokinetics for the treatment of functional dyspepsia (FD). This study aimed to assess the comparative efficacy of prokinetic agents for the treatment of FD.

METHODS

Randomized controlled trials (RCTs) of prokinetics for the treatment of FD were identified from core databases. Symptom response rates were extracted and analyzed using odds ratios (ORs). A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method in WinBUGS and NetMetaXL.

RESULTS

In total, 25 RCTs, which included 4473 patients with FD who were treated with 6 different prokinetics or placebo, were identified and analyzed. Metoclopramide showed the best surface under the cumulative ranking curve (SUCRA) probability (92.5%), followed by trimebutine (74.5%) and mosapride (63.3%). However, the therapeutic efficacy of metoclopramide was not significantly different from that of trimebutine (OR:1.32, 95% credible interval: 0.27-6.06), mosapride (OR: 1.99, 95% credible interval: 0.87-4.72), or domperidone (OR: 2.04, 95% credible interval: 0.92-4.60). Metoclopramide showed better efficacy than itopride (OR: 2.79, 95% credible interval: 1.29-6.21) and acotiamide (OR: 3.07, 95% credible interval: 1.43-6.75). Domperidone (SUCRA probability 62.9%) showed better efficacy than itopride (OR: 1.37, 95% credible interval: 1.07-1.77) and acotiamide (OR: 1.51, 95% credible interval: 1.04-2.18).

CONCLUSIONS

Metoclopramide, trimebutine, mosapride, and domperidone showed better efficacy for the treatment of FD than itopride or acotiamide. Considering the adverse events related to metoclopramide or domperidone, the short-term use of these agents or the alternative use of trimebutine or mosapride could be recommended for the symptomatic relief of FD.

Proton pump inhibitors for functional dyspepsia

BACKGROUND

Functional dyspepsia (FD or non-ulcer dyspepsia) is defined as continuous or frequently recurring epigastric pain or discomfort for which no organic cause can be found. Acid suppressive therapy, including proton pump inhibitors (PPIs), has been proposed as a therapeutic option in FD, but its efficacy remains controversial. While PPIs are generally considered safe and well tolerated, they have been associated with adverse events, especially in the long term. For this reason, decisions on whether to initiate or continue PPI therapy should be made based on an appropriate clinical indication. Therefore, we conducted a systematic review to evaluate whether PPI therapy provides symptomatic relief in FD.

OBJECTIVES

To determine the efficacy of proton pump inhibitors in the improvement of global symptoms of dyspepsia and quality of life compared to placebo, H2 receptor antagonists or prokinetics, in people with functional dyspepsia.

SEARCH METHODS

We searched in the following electronic databases: the Cochrane Library (to January 2016), MEDLINE (OvidSP; to February 2016), Embase (OvidSP; to February 2016), and SIGLE grey literature (up to February 2016) and clinical trial registries; we handsearched abstracts from conferences up to February 2016. We screened non-systematic reviews, systematic reviews and guidelines to identify any additional trials. We contacted trialists to obtain missing information.

SELECTION CRITERIA

All randomized controlled trials (RCTs) comparing any PPI with placebo, H2 receptor antagonists (H2RAs) or prokinetics for the treatment of FD. Participants were adults (aged 16 years or greater) with an adequate diagnosis of FD (any validated criteria such as Rome I, II, III or Lancet Working Group).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, trial quality and extracted data. We collected data on dyspeptic symptoms, quality of life and number of overall adverse events. Specific adverse events were beyond the scope of this review.

MAIN RESULTS

We identified 23 RCTs from 22 papers (with 8759 participants) studying the effect of PPIs versus placebo, H2RAs or prokinetics for improvement of global symptoms of dyspepsia and quality of life in people with FD. Low-dose PPIs had similar efficacy as standard-dose PPIs, therefore we combined these subgroups for the analysis. Two to eight weeks of therapy with PPI was slightly more effective than placebo at relieving overall dyspepsia symptoms in people with FD (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.82 to 0.94; participants = 5968; studies = 16; number needed to treat for an additional beneficial outcome (NNTB) 13; moderate quality evidence). PPIs may be slightly more effective than H2RAs (RR 0.88, 95% CI 0.74 to 1.04; participants = 740; studies = 2, NNTB 13; low quality evidence), and slightly more effective than prokinetics (RR 0.90, 95% CI 0.81 to 1.00; participants = 892; studies = 4; NNTB 20; low quality evidence) at relieving overall dyspepsia symptoms in people with FD. PPIs plus prokinetics were possibly slightly more effective than PPIs alone at relieving overall dyspepsia symptoms (RR 0.85, 95% CI 0.68 to 1.08; participants = 407; studies = 2; NNTB 18; moderate quality evidence).The was no difference when subgrouped by Helicobacter pylori status, country of origin, or presence of reflux or Rome III subtypes. There were no differences in the number of adverse events observed between PPIs and any of the other treatments.

AUTHORS' CONCLUSIONS

There is evidence that PPIs are effective for the treatment of FD, independent of the dose and duration of treatment compared with placebo. PPIs may be slightly more effective than H2RAs for the treatment of FD; however, the evidence is scarce. The trials evaluating PPIs versus prokinetics are difficult to interpret as they are at risk of bias. Although the effect of these drugs seems to be small, the drugs are well tolerated.

Effect of Chinese patent medicine Si-Mo-Tang oral liquid for functional dyspepsia: A systematic review and meta-analysis of randomized controlled trials

Background

Si-Mo-Tang oral liquid (SMT) has been widely used to treat functional dyspepsia (FD), but the effectiveness is still controversial. A systematic review and meta-analysis of randomized controlled trials (RCTs) were performed to assess the efficacy and adverse effects of SMT for FD.

Methods

Investigators searched for articles with publication dates to June 21, 2016, from 9 English and Chinese electronic databases. Comparisons were SMT alone or SMT in combination with western medicine as experimental intervention, and western medicine or placebo as the control. We used the Cochrane collaboration tool for assessing risk of bias to evaluate methodologies. Data were synthesized with RevMan 5.3 software. (PROSPERO Registration #CRD42016042003)

Results

Twenty-seven RCTs were included in the review, involving 2,713 participants: 1,383 subjects were in the experimental group and 1,330 in the control group. SMT showed a significant improvement in clinical efficacy (RR 1.14; 95% CI 1.09, 1.20; P<0.00001), but the heterogeneity was also significant (P = 0.0002, I² = 56%). Because of the different interventions in the 2 groups, we performed subgroup and sensitivity analyses to investigate potential sources of heterogeneity. The heterogeneity was smaller after subgroup analysis and the exclusion of a study by Zhu from 2009. The corresponding pooled RR has no obvious change (RR 1.17; 95% CI 1.13, 1.21; P<0.00001). Subgroup analysis by age and drugs administered in control interventions between SMT and western medicine also showed improvement in the efficacy rate. But a data synthesis that excluded high risk of bias in the blinding of participants and personnel showed no significant difference (RR 1.14; 95% CI 0.97, 1.35; P = 0.12). Three studies measured gastric emptying. Two of these studies reported no significant difference between the experimental and control groups, while 1 study showed that SMT reduced the time of gastric emptying. The relapse rate and adverse effects had no difference between 2 groups.

Conclusions

This meta-analysis suggests that SMT is an effective and safe therapy option for patients with FD. However, because of the high clinical heterogeneity, poor quality, high risk of bias and small sample size of some included studies, further standardized large-scale and strictly designed studies are needed.

Gut microbial diversity analysis using Illumina sequencing for functional dyspepsia with liver depression-spleen deficiency syndrome and the interventional Xiaoyaosan in a rat model

AIM

To investigate gut microbial diversity and the interventional effect of Xiaoyaosan (XYS) in a rat model of functional dyspepsia (FD) with liver depression-spleen deficiency syndrome.

METHODS

The FD with liver depression-spleen deficiency syndrome rat model was established through classic chronic mild unpredictable stimulation every day. XYS group rats received XYS 1 h before the stimulation. The models were assessed by parameters including state of the rat, weight, sucrose test result and open-field test result. After 3 wk, the stools of rats were collected and genomic DNA was extracted. PCR products of the V4 region of 16S rDNA were sequenced using a barcoded Illumina paired-end sequencing technique. The primary composition of the microbiome in the stool samples was determined and analyzed by cluster analysis.

RESULTS

Rat models were successfully established, per data from rat state, weight and open-field test. The microbiomes contained 20 phyla from all samples. Firmicutes, Bacteroidetes, Proteobacteria, Cyanobacteria and Tenericutes were the most abundant taxonomic groups. The relative abundance of Firmicutes, Proteobacteria and Cyanobacteria in the model group was higher than that in the normal group. On the contrary, the relative abundance of Bacteroidetes in the model group was lower than that in the normal group. Upon XYS treatment, the relative abundance of all dysregulated phyla was restored to levels similar to those observed in the normal group. Abundance clustering heat map of phyla corroborated the taxonomic distribution.

CONCLUSION

The microbiome relative abundance of FD rats with liver depression-spleen deficiency syndrome was significantly different from the normal cohort. XYS intervention may effectively adjust the gut dysbacteriosis in FD.

Evaluating Community Pharmacists' Dyspepsia Knowledge: A Crosssectional Study in Tehran, Iran

BACKGROUND

Dyspepsia is one of the most frequent ailments in the Iranian community. Fuelled by a growing interest in understanding drugs and self-medication for common conditions such as dyspepsia, the public increasingly seeks health advice from professionals such as community pharmacists. The purpose of our study was to assess dyspepsia-related knowledge of pharmacists in Iran.

METHODS

This cross-sectional study has been done among 200 community pharmacists working in Tehran, Iran, and conducted through a survey questionnaire, which consisted of questions about demographic information and knowledge of dyspepsia. The validity and reliability of the questionnaire were also evaluated. The main results estimated the knowledge of pharmacists about dyspepsia, and the relationship between pharmacists' demographic and practice characteristics and their knowledge of dyspepsia.

RESULTS

The mean (± SD) age of participants was 41.56 ± 13.90 years, and the mean score of knowledge was 9.32 ± 2.13 out of 17 points. Our results showed a statistically significant negative relationship between knowledge levels and both age and years of experience (p = 0.002 and p = 0.033, respectively).

CONCLUSION

According to the research, the mean knowledge level of Iranian pharmacists, in terms of correct responses for dyspepsia questions, was just over half of the possible points. Thus it was concluded that improvement in the knowledge of dyspepsia among pharmacists would improve the quality of patient services, especially because of the high prevalence of dyspepsia among the public and their frequent referral to community pharmacists for taking over-the-counter medication.

The appropriate use of proton pump inhibitors (PPIs): Need for a reappraisal

The advent of powerful acid-suppressive drugs, such as proton pump inhibitors (PPIs), has revolutionized the management of acid-related diseases and has minimized the role of surgery. The major and universally recognized indications for their use are represented by treatment of gastro-esophageal reflux disease, eradication of Helicobacter pylori infection in combination with antibiotics, therapy of H. pylori-negative peptic ulcers, healing and prophylaxis of non-steroidal anti-inflammatory drug-associated gastric ulcers and control of several acid hypersecretory conditions. However, in the last decade, we have witnessed an almost continuous growth of their use and this phenomenon cannot be only explained by the simple substitution of the previous H2-receptor antagonists, but also by an inappropriate prescription of these drugs. This endless increase of PPI utilization has created an important problem for many regulatory authorities in terms of increased costs and greater potential risk of adverse events. The main reasons for this overuse of PPIs are the prevention of gastro-duodenal ulcers in low-risk patients or the stress ulcer prophylaxis in non-intensive care units, steroid therapy alone, anticoagulant treatment without risk factors for gastro-duodenal injury, the overtreatment of functional dyspepsia and a wrong diagnosis of acid-related disorder. The cost for this inappropriate use of PPIs has become alarming and requires to be controlled. We believe that gastroenterologists together with the scientific societies and the regulatory authorities should plan educational initiatives to guide both primary care physicians and specialists to the correct use of PPIs in their daily clinical practice, according to the worldwide published guidelines.

The efficiency of Levofloxacin Containing Sequential Therapy with or without Bismuth, in Helicobacter Pylori Eradication, in Non-ulcer Dyspepsia

INTRODUCTION

The aim of this study is to determine the efficiency of levofloxacin containing sequential therapy with or without bismuth in Helicobacter pylori (Hp) eradication in nonulcer dyspepsia.

MATERIALS AND METHODS

One hundred and ninety Hp-positive patients with the pre-diagnosis of nonulcer dyspepsia were included in this study. Patients were randomized into 2 groups and 95 individuals were included in each group. The first group was administered levofloxacin containing sequential therapy with bismuth, whereas the second group was administered only levofloxacin containing sequential therapy. Rates of therapy discontinuation and eradication success were compared between the 2 groups. Furthermore, symptomatic healing rates were com-pared between patients in whom Hp eradication was achieved and in whom it was not achieved.

RESULTS

Ninety-one patients from each group applied for follow-up after treatment. It was found that 7/91(7.6%) patients from the first group and 5/91(5.4%) patients from the second group did not complete the therapy (p >0.05). In patients who completed therapy, Hp eradication was achieved in 72 out of the 84 patients (85.2%) from the first group and 71 out of 86 patients (82.6%) from the second group (p > 0.05). In addition, symptomatic healing occurred in 125 out of 143 patients (87.4%) in whom Hp was eradicated and 12 out of 27 (44.4%) patients in whom Hp was not eradicated (p < 0.001).

CONCLUSION

Levofloxacin containing sequential therapy for 14 days is quite effective and well-tolerated choice for Hp eradication. However, adding bismuth to sequential therapy does not significantly improve Hp eradication success rates. Therefore, Hp eradication is beneficial and necessary in patients with nonulcer dyspepsia.

Helicobacter pylori infection in Greenlandic patients with dyspepsia

OBJECTIVES

The aim was to evaluate the incidence of Helicobacter pylori (HP) infection in Greenland, to assess the value of the test "Helicobacter antigen in faeces" as a diagnostic tool and to determine the level of antibiotic resistance.

STUDY DESIGN

100 consecutive patients with dyspepsia who visited for endoscopic gastric examination were included. The patients had to be born in Greenland and to be > or = 18 years old.

METHODS

Samples for HP antibody in blood, HP antigen in faeces, urease test on biopsies were collected from the patients. Gastric biopsies were cultured for HP bacteria, and antibiotic resistance was tested. Patients with positive urease test and/or antigen in faeces and/or positive culture were treated simultaneously with Amoxicillin, Metronidazole and Esomeprazole for 1 week. Patients with duodenal or gastric ulcer were endoscopically re-examined 8 weeks later. Patients with proven HP infection but without ulcer submitted a faeces sample 8 weeks after the eradication.

RESULTS

77 patients were considered HP infected, and received treatment. Only 32% of them were eradicated sufficiently.

CONCLUSION

HP antigen in faeces test is useful as a diagnostic tool and for control of therapy. A change in strategy of HP treatment in Greenland is a must, presumably preceded by an elucidation of microbial sensitivity.

Pattern of psychotropic medications use in a cohort of patients with uninvestigated dyspepsia undergoing upper endoscopy: A retrospective study

The prevalence of psychotropic drugs usage is growing in the general population. Moreover, patients with dyspeptic symptoms are increasingly referred to the use of psychiatric and antianxiety drugs in addition to the primary medical treatment. The focus of this observational retrospective study was to investigate the burden of psychotropic drugs usage in a cohort of patients with uninvestigated dyspepsia scheduled for esophagogastroduodenoscopy.Medical records of 11,275 patients (4377 men and 6898 women, age range 18-96 years) referred to the Gastroenterology Unit of the University of Sassari, Sardinia, between January 1995 and December 2013 were reviewed. Information regarding any taken medications including psychiatric and antianxiety drugs was collected. Age- and gender-specific frequency of drug usage was calculated, and their association with marital status, smoking habits, place of residence, socioeconomical status, and polypharmacy was investigated by multiple logistic regression analysis.Psychiatric drugs usage was detected in 531 out of 11,275 (4.7%) patients, with preponderance of women (6.1% vs 2.6%, P < 0.0001). The most prescribed drug categories were selective serotonin-reuptake inhibitors and tricyclic antidepressants.The frequency of antianxiety medication use was 9.8% (1009/11,275) and increased with aging, whereas psychiatric drugs reached the plateau in the fifth decade. The cohort effect was remarkable for psychiatric drugs usage in patients born after 1950 compared to those born before (odds ratio: 1.47), whereas it was absent for antianxiety drugs. Conditions significantly associated with psychotropic drugs usage were assumption of more than 2 nonpsychotropic drugs, aging, female gender, smoking, marriage, widowhood, divorce, and socioeconomic status. In contrast, place of residence did not increase the consumption of psychotropic drugs. The influence of marriage and widowhood disappeared after adjusting for all covariates.Our study confirmed the frequent use of psychotropic medications with uninvestigated dyspepsia. However, the pattern of consumption was different for antianxiety and psychiatric drugs.

Randomized clinical trial comparing ten day concomitant and sequential therapies for Helicobacter pylori eradication in a high clarithromycin resistance area

BACKGROUND

Currently only a few studies compare sequential and concomitant non-bismuth Helicobacter pylori therapies referring to high antibiotic resistance populations.

MATERIALS AND METHODS

This multicenter prospective randomized clinical trial included 353 H. pylori positive, treatment naïve, patients. All patients had positive CLO-test and/or histology and culture. They received sequential (esomeprazole 40mg, amoxicillin 1g/bid for 5days, followed by 5days of esomeprazole 40mg, clarithromycin 500mg and metronidazole 500mg bid), or concomitant treatment (all drugs taken concomitantly bid for 10days). Eradication was confirmed by (13)C-urea breath test or histology 4-6weeks after treatment. Adverse events and adherence were evaluated.

RESULTS

Allocated to concomitant were 175 (72F/103M, mean 52.3years, 38.3% smokers, 25.7% ulcer disease) and 178 (87F/91M, mean 52years, 31% smokers, 19.1% ulcer disease) patients to sequential treatment. There were 303/353 (85.8%) positive cultures, with the following resistances: 34% metronidazole, 27.7% clarithromycin, and 7.9% dual. Eradication rates were, respectively, 89.1% (156/175) vs. 78.7% (140/178) by intention to treat (p=0.01, 95% CI=2.7-18) and 93.4%(156/167) vs. 82.8% (140/169) per protocol (p=0.004, 95% CI=3.6-17.6). Overall, adherence was (98.9%, 95% CI=97-100). Eradication rates according to resistance were the following: dual susceptible strains 67/69 (97.1%), 62/67 (92%) (p=0.4), metronidazole single resistant 38/39 (97.4%), 31/39 (79.5%) (p=0.03, 95% CI=3.5-33), clarithromycin single resistant 25/28 (89.3%), 26/31 (83.9%) (p=0.8), and dual resistant 9/12 (75%), 4/11 (36.4%) (p=0.1) for concomitant and sequential regimens, respectively. Side effects were comparable among regimens, except from diarrhea being more frequent among patients treated with concomitant treatment.

CONCLUSIONS

Concomitant treatment eradication rate overcomes 90% per protocol and has a significant advantage over sequential therapy. This is probably due to its better efficacy on metronidazole resistant strains. Both regimens were well tolerated and safe.

Antidepressants in the Treatment of Functional Dyspepsia: A Systematic Review and Meta-Analysis

BACKGROUND

Antidepressants have been empirically used in the treatment of functional dyspepsia (FD). However, results from recent clinical trials investigating their efficacy are conflicting. The aim of this study is to evaluate the efficacy of antidepressants in the management of FD in adults.

METHODS

Databases of MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and BIOSIS Previews were searched for all randomized controlled trials (RCT) investigating efficacy of antidepressants in the management of FD in adult patients. Data of overall symptom unimproved and adverse events were compared between the antidepressants and placebo group.

RESULTS

The search strategy identified 432 citations. Of those, eight RCTs met the inclusion criteria and were included in the meta-analysis. The pooled relative risk (RR) of symptom unimproved with tricyclic antidepressants (TCAs) versus placebo was 0.76 (95% CI: 0.62 to 0.94, P = 0.01; I2 = 0%, P = 0.39). By contrast, selective serotonin reuptake inhibitors (SSRIs) did not show a benefit over placebo (RR = 1.00, 95% CI: 0.86 to 1.17, P = 0.95; I2 = 0%, P = 0.82). Adverse events were significantly more frequent among patients receiving antidepressants than those receiving placebos (RR = 1.64, 95% CI: 1.14 to 2.35, P = 0.007).

CONCLUSION

TCAs but not SSRIs, are effective in the treatment of FD, but antidepressants were also associated with more adverse events compared with placebo.

Beneficial effects of antidepressant mirtazapine in functional dyspepsia patients with weight loss

AIM: To explore the effects and mechanism of action of antidepressant mirtazapine in functional dyspepsia (FD) patients with weight loss.

METHODS: Sixty depressive FD patients with weight loss were randomly divided into a mirtazapine group (MG), a paroxetine group (PG) or a conventional therapy group (CG) for an 8-wk clinical trial. Adverse effects and treatment response were recorded. The Nepean Dyspepsia Index-symptom (NDSI) checklist and the 17-item Hamilton Rating Scale of Depression (HAMD-17) were used to evaluate dyspepsia and depressive symptoms, respectively. The body composition analyzer was used to measure body weight and fat. Serum hormone levels were measured by ELISA.

RESULTS: (1) After 2 wk of treatment, NDSI scores were significantly lower for the MG than for the PG and CG; (2) After 4 or 8 wk of treatment, HAMD-17 scores were significantly lower for the MG and PG than for the CG; (3) After 8 wk of treatment, patients in the MG experienced a weight gain of 3.58 ± 1.57 kg, which was significantly higher than that observed for patients in the PG and CG. Body fat increased by 2.77 ± 0.14 kg, the body fat ratio rose by 4%, and the visceral fat area increased by 7.56 ± 2.25 cm²; and (4) For the MG, serum hormone levels of ghrelin, neuropeptide Y (NPY), motilin (MTL) and gastrin (GAS) were significantly upregulated; in contrast, those of leptin, 5-hydroxytryptamine (5-HT) and cholecystokinin (CCK) were significantly downregulated.

CONCLUSION: Mirtazapine not only alleviates symptoms associated with dyspepsia and depression linked to FD in patients with weight loss but also significantly increases body weight (mainly the visceral fat in body fat). The likely mechanism of mirtazapine action is regulation of brain-gut or gastrointestinal hormone levels.

Helicobacter pylori eradication effect on patients with functional dyspepsia symptoms

BACKGROUND

Dyspepsia is a common symptom with a broad differential diagnosis and complex pathophysiology which annually affect about 25% of the general population. Results of Helicobacter pylori eradication in the patients with dyspepsia symptoms in the different studies are controversy. Aim of the study was to evaluate the effect of Helicobacter pylori eradication in the patients with functional dyspepsia.

METHODS

In order to doing the clinical trial study, demographic and clinical symptoms of the patients that referred to the gastroenterology center of the Ilam County from 1391 to 1392 was recorded in a standard questionnaire (including criteria of ROM III). Overall 120 patients with dyspepsia were selected and divided into two groups of "control" and "treatment". Helicobacter pylori presence was confirmed by stool antigen test in all of the patients. Selected patients were randomly divided into two groups. Standard therapy for the Helicobacter pylori eradication was done for two weeks periods in the one group. Then in this group antacid medication (morning and night) was continued. Four weeks treatment with antacid medication (morning and night) was performed for second group (control) and then both groups were treated with antacid for three month and both groups were finally evaluated with same questionnaire.

RESULTS

The mean age of patients was 32 years; 55.8% of the patients were female. The most prevalent symptoms of functional dyspepsia (25.7%) were in the age groups of 16-34 years and 35-43 years. All of dyspepsia symptoms in the both groups of cases (Helicobacter pylori standard treated) and control (treated with antacid) decreased after treated. However, this reduction in all symptoms was not significant except for epigastric pain and vomiting.

CONCLUSIONS

Helicobacter pylori eradication has a little effect in improving of the functional dyspepsia syndrome and the effect was justly seen in the symptoms of epigastric pain and vomiting.

Changes in patients’ symptoms and gastric emptying after Helicobacter pylori treatment

AIM: To investigate the changes in clinical symptoms and gastric emptying and their association in functional dyspepsia (FD) patients.

METHODS: Seventy FD patients were enrolled and divided into 2 groups Helicobacter pylori (H. pylori)-negative group (28 patients), and H. pylori-positive group (42 patients). Patients in the H. pylori-positive group were further randomly divided into groups: H. pylori-treatment group (21 patients) and conventional treatment group (21 patients). Seventy two healthy subjects were selected as the control group. The proximal and distal stomach area was measured by ultrasound immediately after patients took the test meal, and at 20, 40, 60 and 90 min; then, gastric half-emptying time was calculated. The incidence of symptoms and gastric half-emptying time between the FD and control groups were compared. The H. pylori-negative and conventional treatment groups were given conventional treatment: domperidone 0.6 mg/(kg/d) for 1 mo. The H. pylori-treatment group was given H. pylori eradication treatment + conventional treatment: lansoprazole 30 mg once daily, clarithromycin 0.5 g twice daily and amoxicillin 1.0 g twice daily for 1 wk, then domperidone 0.6 mg/(kg/d) for 1 mo. The incidence of symptoms and gastric emptying were compared between the FD and control groups. The relationship between dyspeptic symptoms and gastric half-emptying time in the FD and control groups were analyzed. Then total symptom scores before and after treatment and gastric half-emptying time were compared among the 3 groups.

RESULTS: The incidence of abdominal pain, epigastric burning sensation, abdominal distension, nausea, belching, and early satiety symptoms in the FD group were significantly higher than in the control group (50.0% vs 20.8%; 37.1% vs 12.5%; 78.6% vs 44.4%; 45.7% vs 22.2%; 52.9% vs 15.3%; 57.1% vs 19.4%; all P < 0.05). The gastric half-emptying times of the proximal end, distal end, and the whole stomach in the FD group were slower than in the control group (93.7 ± 26.2 vs 72.0 ± 14.3; 102.2 ± 26.4 vs 87.5 ± 18.2; 102.1 ± 28.6 vs 78.3 ± 14.1; all P < 0.05). Abdominal distension, belching and early satiety had an effect on distal gastric half-emptying time (P < 0.05). Abdominal distension and abdominal pain had an effect on the gastric half-emptying time of the whole stomach (P < 0.05). All were risk factors (odds ratio > 1). The total symptom score of the 3 groups after treatment was lower than before treatment (P < 0.05). Total symptom scores after treatment in the H. pylori-treatment group and H. pylori-negative group were lower than in the conventional treatment group (5.15 ± 2.27 vs 7.02 ± 3.04, 4.93 ± 3.22 vs 7.02 ± 3.04, All P < 0.05). The gastric half-emptying times of the proximal end, distal end, and the whole stomach in the H. pylori-negative and H. pylori-treatment groups were shorter than in the conventional treatment group (P < 0.05).

CONCLUSION: FD patients have delayed gastric emptying. H. pylori infection treatment helps to improve symptoms of dyspepsia and is a reasonable choice for treatment in clinical practice.

Functional dyspepsia: new insights into pathogenesis and therapy

One in 10 people suffer from functional dyspepsia (FD), a clinical syndrome comprising chronic bothersome early satiety, or postprandial fullness, or epigastric pain or burning. Postprandial distress syndrome (PDS, comprising early satiety and/or postprandial fullness) and epigastric pain syndrome (EPS) are increasingly accepted as valid clinical entities, based on new insights into the pathophysiology and the results of clinical trials. Diagnosis is based on the clinical history, and exclusion of peptic ulcer and cancer by endoscopy. Evidence is accumulating FD and gastroesophageal ref lux disease are part of the same disease spectrum in a major subset. The causes of FD remain to be established, but accumulating data suggest infections and possibly food may play an important role in subsets. FD does not equate with no pathology; duodenal eosinophilia is now an accepted association, and Helicobacter pylori infection is considered to be causally linked to dyspepsia although only a minority will respond to eradication. In those with EPS, acid suppression therapy is a first line therapy; consider a H2 blocker even if proton pump inhibitor fails. In PDS, a prokinetic is preferred. Second line therapy includes administration of a tricyclic antidepressant in low doses, or mirtazapine, but not a selective serotonin reuptake inhibitor.

[Effect of Shuwel Decoction on Enteric Nervous System-Interstitial Cells of Cajal-Smooth Muscle Network Structure Injury in Deep Muscle Nerve Plexus of Functional Dyspepsia Rats]

OBJECTIVE

To observe morphological changes of enteric nervous system (ENS)-interstitial cells of Cajal (ICC)-smooth muscle cell (SMC) structure injury in deep muscle nerve plexus offunctional dyspepsia (FD) rats, and the repair of Shuwei Decoction (SD) on it, and to explore its effecton FD.

METHODS

Totally 72 rats were randomly divided into the control group, the model group, the lowdose SD group, the medium dose SD group, and the high dose SD group, the Mosapride group, 12 ineach group. Rats in the low dose SD group, the medium dose SD group, and the high dose SD group were intragastrically fed with SD at 0.767, 1.534, 3.068 g/mL, respectively. Rats in the Mosapride group were intragastrically fed with Mosapride (1.37 mg/kg). FD rat model with Gan depression Pi deficiency syndrome (GDPDS) was established using complex pathogenic factors. Corresponding liquors were respectively administered to rats in corresponding groups from the 3rd day after modeling. Distilled water(10 mL/kg) was administered to rats in the control group and the model group, once per day for 14 successive days. Rats were sacrificed and small intestine tissues collected for observing ENS-ICC-SMC structure injury using immunofluorescence double labeling, laser scanning confocal microscope, and transmission electron microscope at day 15. Repair of SD on it was also observed.

RESULTS

ENS-ICC SMC structure was incomplete, with obvious injury in mutual link of ICC, ICC, SMC, and connecting structure. ENS-ICC-SMC structure was more complete in high, medium, and low dose SD groups, with close link of ICC and SMO. Their connecting structures were in good conditions.

CONCLUSION

SD could keep the integrity of ENS-ICC-SMC structure by promoting regeneration and morphology of ICC, thereby, improving gastrointestinal movement disorder and showing therapeutic effect on FD.

Helicobacter pylori eradication therapy for functional dyspepsia: Systematic review and meta-analysis

AIM: To evaluate whether Helicobacter pylori (H. pylori) eradication therapy benefits patients with functional dyspepsia (FD).

METHODS: Randomized controlled trials (RCTs) investigating the efficacy and safety of H. pylori eradication therapy for patients with functional dyspepsia published in English (up to May 2015) were identified by searching PubMed, EMBASE, and The Cochrane Library. Pooled estimates were measured using the fixed or random effect model. Overall effect was expressed as a pooled risk ratio (RR) or a standard mean difference (SMD). All data were analyzed with Review Manager 5.3 and Stata 12.0.

RESULTS: This systematic review included 25 RCTs with a total of 5555 patients with FD. Twenty-three of these studies were used to evaluate the benefits of H. pylori eradication therapy for symptom improvement; the pooled RR was 1.23 (95%CI: 1.12-1.36, P < 0.0001). H. pylori eradication therapy demonstrated symptom improvement during long-term follow-up at ≥ 1 year (RR = 1.24; 95%CI: 1.12-1.37, P < 0.0001) but not during short-term follow-up at < 1 year (RR = 1.26; 95%CI: 0.83-1.92, P = 0.27). Seven studies showed no benefit of H. pylori eradication therapy on quality of life with an SMD of -0.01 (95%CI: -0.11 to 0.08, P = 0.80). Six studies demonstrated that H. pylori eradication therapy reduced the development of peptic ulcer disease compared to no eradication therapy (RR = 0.35; 95%CI: 0.18-0.68, P = 0.002). Eight studies showed that H. pylori eradication therapy increased the likelihood of treatment-related side effects compared to no eradication therapy (RR = 2.02; 95%CI: 1.12-3.65, P = 0.02). Ten studies demonstrated that patients who received H. pylori eradication therapy were more likely to obtain histologic resolution of chronic gastritis compared to those who did not receive eradication therapy (RR = 7.13; 95%CI: 3.68-13.81, P < 0.00001).

CONCLUSION: The decision to eradicate H. pylori in patients with functional dyspepsia requires individual assessment.

Women and functional dyspepsia

Functional dyspepsia is relatively common yet poorly understood. The best accepted diagnostic criteria are the Rome III criteria. The epidemiology, healthcare seeking rates, impact and pathophysiology are reviewed with a focus on women. Treatment is limited with no clearly established regimen currently recommended. Duodenal eosinophilia may be found in a subset. Proton pump inhibitors and prokinetic agents represent the standard therapeutic regimen after Helicobacter pylori infection has been eliminated. Some novel agents such as the prokinetic acotiamide appear promising; however, the need for a safe and efficacious treatment remains largely unmet. This review also describes the currently available management options for functional dyspepsia.