Quality of life in functional dyspepsia: responsiveness of the Nepean Dyspepsia Index and development of a new 10-item short form

Acupuncture for functional dyspepsia: study protocol for a two-center, randomized controlled trial

Background

Functional dyspepsia (FD) is a common health problem currently without any optimal treatments. Acupuncture has been traditionally sought as a treatment for FD. The aim of this study is to investigate whether acupuncture treatment helps improve symptoms of FD.

Methods/design

A two-center, randomized, waitlist-controlled trial will be carried out to evaluate whether acupuncture treatment improves FD symptoms. Seventy six participants aged 18 to 75 years with FD as diagnosed by Rome III criteria will be recruited from August 2013 to January 2014 at two Korean Medicine hospitals. They will be randomly allocated either into eight sessions of partially individualized acupuncture treatment over 4 weeks or a waitlist group. The acupuncture group will then be followed-up for 3 weeks with six telephone visits and a final visit will be paid at 8 weeks. The waitlist group will receive the identical acupuncture treatment after a 4-week waiting period. The primary outcome is the proportion of responders with adequate symptom relief and the secondary outcomes include Nepean dyspepsia index, EQ-5D, FD-related quality of life, Beck’s depression inventory, state-trait anxiety inventory questionnaire, and level of ghrelin hormone. The protocol was approved by the participating centers’ Institutional Review Boards.

Discussion

Results of this trial will help clarify not only whether the acupuncture treatment is beneficial for symptom improvement in FD patients but also to elucidate the related mechanisms of how acupuncture might work.

Trial registration

ClinicalTrials.gov Identifier: NCT01921504.

Changes in the symptom pattern and the densities of large-intestinal endocrine cells following Campylobacter infection in irritable bowel syndrome: a case report

Background

Irritable bowel syndrome (IBS) is a common chronic functional gastrointestinal disorder. Post-infectious IBS (PI-IBS) is a subset of IBS that accounts for a large proportion of IBS patients. The PI-IBS symptoms meet the Rome criteria for IBS with diarrhoea (IBS-D) or IBS with mixed bowel habits (IBS-M). A low-grade inflammation has been reported to occur in PI-IBS. Abnormalities in intestinal endocrine cells have been reported in both sporadic IBS and PI-IBS.

Case presentation

A 20-year-old female with a diagnosis of IBS with constipation (IBS-C), according to Rome III criteria, contracted Campylobacter-induced gastroenteritis, after which her symptom pattern changed to IBS-M. She showed an intestinal low-grade inflammation that was manifested by an increase in the number of intraepithelial and lamina propria leucocytes and lymphocytes and an increase in the density of mast cells in lamina propria. There was also an increase in the density of intestinal serotonin and peptide YY (PYY) cells and a decrease in the density of rectal somatostatin cells. Follow-up of the patient at 4-months post-infection revealed reduction of IBS symptoms and an improvement in her quality of life. However, 6 months following the Campylobacter infection, the patient switched back from IBS-M to IBS-C, probably due to recovery from PI-IBS. The patient was treated with prucalopride, which is serotonin 5HT₄ receptor agonist. Six months later following this treatment, the symptoms were reduced and the quality of life improved in the reported patient.

Conclusions

Gastroenteritis in patients with IBS-C causes a post-infectious, low-grade inflammation. Interaction between immune-cells and intestinal endocrine cells increases the density of certain endocrine cells, which in turn might be responsible for the change in the symptom pattern, the milder symptoms and the improvement in the quality of life seen in the reported patient. The findings in this case raise the question as to whether intestinal infections are responsible for the previously reported switching of IBS from one subtype to another over time.

[Practical aspects for minimizing errors in the cross-cultural adaptation and validation of quality of life questionnaires]

BACKGROUND

The development and validation of questionnaires for evaluating quality of life (QoL) has become an important area of research. However, there is a proliferation of non-validated measuring instruments in the health setting that do not contribute to advances in scientific knowledge.

AIMS

To present, through the analysis of available validated questionnaires, a checklist of the practical aspects of how to carry out the cross-cultural adaptation of QoL questionnaires (generic, or disease-specific) so that no step is overlooked in the evaluation process, and thus help prevent the elaboration of insufficient or incomplete validations.

METHODS

We have consulted basic textbooks and Pubmed databases using the following keywords quality of life, questionnaires, and gastroenterology, confined to «validation studies» in English, Spanish, and Portuguese, and with no time limit, for the purpose of analyzing the translation and validation of the questionnaires available through the Mapi Institute and PROQOLID websites.

RESULTS

A checklist is presented to aid in the planning and carrying out of the cross-cultural adaptation of QoL questionnaires, in conjunction with a glossary of key terms in the area of knowledge. The acronym DSTAC was used, which refers to each of the 5 stages involved in the recommended procedure. In addition, we provide a table of the QoL instruments that have been validated into Spanish.

CONCLUSIONS

This article provides information on how to adapt QoL questionnaires from a cross-cultural perspective, as well as to minimize common errors.

Chronic fatigue in patients with unexplained self-reported food hypersensitivity and irritable bowel syndrome: validation of a Norwegian translation of the Fatigue Impact Scale

BACKGROUND

Patients with unexplained self-reported food hypersensitivity and irritable bowel syndrome (IBS) suffer from several health complaints, including fatigue. The aim of the present study was to validate a Norwegian translation of the Fatigue Impact Scale (FIS), and to assess the impact of fatigue in patients with self-reported food hypersensitivity and IBS, as compared with healthy controls.

METHODS

Thirty-eight patients with unexplained self-reported food hypersensitivity and IBS, who participated in the validation of the FIS completed the following additional questionnaires: the Short Form of Nepean Dyspepsia Index for assessment of quality of life, the Subjective Health Complaint Inventory, and questionnaires for diagnosis and severity of IBS. Impact of fatigue was studied in 43 patients with unexplained self-reported food hypersensitivity, 70% diagnosed with IBS, and 42 healthy controls.

RESULTS

Cronbach's α for the FIS was 0.98, indicating excellent agreement between individual items. Scores on the FIS correlated with scores on the Short Form of Nepean Dyspepsia Index (r = 0.50, P = 0.001), indicating good convergent validity, and were higher in patients (median 85.0, interquartile range 36.8-105.3) than in controls (median 14.0, interquartile range 3.0-29.0, P ≤ 0.0001).

CONCLUSION

The Norwegian translation of the FIS performed excellently in patients with unexplained self-reported food hypersensitivity and IBS, with patients reporting significantly more impact of chronic fatigue than healthy controls.

Effects of dietary guidance on the symptoms, quality of life and habitual dietary intake of patients with irritable bowel syndrome

Diet is important in triggering the symptoms of irritable bowel syndrome (IBS). This study investigated the impact of dietary guidance on the symptoms, quality of life and habitual diet of patients with IBS. Forty-six patients who fulfilled the Rome III criteria for the diagnosis of IBS were included. Of these patients, 17 completed the entire study. Each patient attended three sessions (~45 min in duration) and received individual guidance on their dietary management. The patients were asked to complete the following questionnaires prior to receiving the dietary guidance, and at least 3 months subsequently: The Birmingham IBS symptom score questionnaire, the IBS Quality of Life (IBS-QOL) questionnaire, the Short-Form Nepean and Dyspepsia Index (SF‑NDI) and the MoBa Food Frequency Questionnaire (MoBa FFQ). The time at which patients completed the questionnaires following dietary guidance ranged from 3-9 months (median, 4 months). The total IBS symptom scores were reduced once the patients had received dietary guidance (P=0.001). The total score for the quality of life, as assessed by the IBS‑QOL and the SF-NDI, increased significantly following the dietary guidance sessions (P=0.003 and P=0.002, respectively). There were no statistical differences in the intake of calories, carbohydrate, fiber, protein, fat or alcohol in the patients with IBS following dietary guidance. There were increases in the consumption of dairy products, β-carotene, retinol equivalents, riboflavin, vitamin B12 and calcium, although only the increase in vitamin B12 consumption was statistically significant. There was a significant reduction in the consumption of certain fruits and vegetables that were rich in highly fermentable short-chain carbohydrates, disaccharides, monosaccharides and polyols, as well as insoluble fibers. In conclusion, three 45-min dietary guidance sessions, administered by a nurse, reduced the symptoms and improved the quality of life of patients with IBS, and resulted in an adequate intake of vitamins and minerals. Individual dietary guidance is a cost-effective option for the management of IBS.

Whole-brain functional connectivity identification of functional dyspepsia

Recent neuroimaging studies have shown local brain aberrations in functional dyspepsia (FD) patients, yet little attention has been paid to the whole-brain resting-state functional network abnormalities. The purpose of this study was to investigate whether FD disrupts the patterns of whole-brain networks and the abnormal functional connectivity could reflect the severity of the disease. The dysfunctional interactions between brain regions at rest were investigated in FD patients as compared with 40 age- and gender- matched healthy controls. Multivariate pattern analysis was used to evaluate the discriminative power of our results for classifying patients from controls. In our findings, the abnormal brain functional connections were mainly situated within or across the limbic/paralimbic system, the prefrontal cortex, the tempo-parietal areas and the visual cortex. About 96% of the subjects among the original dataset were correctly classified by a leave one-out cross-validation approach, and 88% accuracy was also validated in a replication dataset. The classification features were significantly associated with the patients' dyspepsia symptoms, the self-rating depression scale and self-rating anxiety scale, but it was not correlated with duration of FD patients (p>0.05). Our results may indicate the effectiveness of the altered brain functional connections reflecting the disease pathophysiology underling FD. These dysfunctional connections may be the epiphenomena or causative agents of FD, which may be affected by clinical severity and its related emotional dimension of the disease rather than the clinical course.

Functional Dyspepsia Treatment Trial (FDTT): a double-blind, randomized, placebo-controlled trial of antidepressants in functional dyspepsia, evaluating symptoms, psychopathology, pathophysiology and pharmacogenetics

BACKGROUND

Functional dyspepsia (FD) is a common problem affecting up to 10-25% of individuals. FD accounts for significant health care costs and affects quality of life but has no definitive treatment.

OBJECTIVES

The Functional Dyspepsia Treatment Trial (FDTT) aims to test whether treatment with an antidepressant (amitriptyline or escitalopram) leads to improvement of symptoms in patients with moderate to severe FD.

DESIGN

The FDTT is an international multicenter, parallel group, randomized, double-blind, placebo-controlled trial to evaluate whether 12 weeks of treatment with escitalopram or amitriptyline improves FD symptoms compared to treatment with placebo. Secondly, it is hypothesized that acceleration of solid gastric emptying, reduction of postprandial satiation, and enhanced gastric volume change with a meal will be significant positive predictors of short- and long-term outcomes for those on antidepressants vs. placebo. The third aim is to examine whether polymorphisms of GNβ3 and serotonin reuptake transporter influence treatment outcomes in FD patients receiving a tricyclic antidepressant, selective serotonin reuptake inhibitor therapy, or placebo.

METHODS

The FDTT enrollment began in 2006 and is scheduled to randomize 400 patients by the end of 2012 to receive an antidepressant or placebo for 12 weeks, with a 6-month post-treatment follow-up. The study incorporates multiple validated questionnaires, physiological testing, and specific genetic evaluations. The protocol was approved by participating centers' Institutional Review Boards and an independent Data Safety Monitoring Board was established for monitoring to ensure patient safety and a single interim review of the data in December 2010 (ClinicalTrials.gov number NCT00248651).

An Extract of Glycyrrhiza glabra (GutGard) Alleviates Symptoms of Functional Dyspepsia: A Randomized, Double-Blind, Placebo-Controlled Study

A randomized, double-blind, placebo-controlled study was conducted to evaluate the efficacy of GutGard, an extract of Glycyrrhiza glabra, in patients with functional dyspepsia. The primary outcome variables of the study were the change in the severity symptoms and the global assessment of efficacy. The quality of life was evaluated as a secondary outcome measure. The patients received either placebo or GutGard (75 mg twice daily) for 30 days. Efficacy was evaluated in terms of change in the severity of symptoms (as measured by 7-point Likert scale), the global assessment of efficacy, and the assessment of quality of life using the short-form Nepean Dyspepsia Index. In comparison with placebo, GutGard showed a significant decrease (P ≤ .05) in total symptom scores on day 15 and day 30, respectively. Similarly, GutGard showed marked improvement in the global assessment of efficacy in comparison to the placebo. The GutGard group also showed a significant decrease (P ≤ .05) in the Nepean dyspepsia index on day 15 and 30, respectively, when compared to placebo. GutGard was generally found to be safe and well-tolerated by all patients. GutGard has shown significant efficacy in the management of functional dyspepsia.

Anxiety, depression and quality of life differences between functional and organic dyspepsia

OBJECTIVE AND BACKGROUND

The role of psychological disturbance in the pathogenesis of functional dyspepsia is uncertain. We aimed to examine for differences in anxiety, depression and health-related quality of life (HRQOL) between adults with organic (OD) and functional dyspepsia (FD).

METHODOLOGY

A prospective, cross-sectional study of Malaysian adults undergoing oesophago-gastro-duodenoscopy (OGDS) for the primary indication of dyspepsia was conducted. Prior to OGDS, locally translated and validated versions of the Hospital Anxiety and Depression Scale (HADS), Nepean Dyspepsia Index (NDI) and Leeds Dyspepsia Questionnaire (LDQ) were administered.

RESULTS

839 patients (mean age 49.6 ± 15.8 years, 55.7% female, ethnic division: Malays 30.5% , Chinese 38.4%, Indians 29.4%) were studied between June 2008 and March 2009. 472 (56.3%) and 367 (43.7%) patients had FD and OD respectively. There was no difference in the mean LDQ score between FD and OD patients (18.6 vs 18.1, P = 0.4). Moderate/severe anxiety was more prevalent in FD compared to OD patients (28.5% vs 23.1%, P = 0.05) but there was no significant difference in depression. Summary scores for the NDI revealed a lower mean value in FD patients compared to OD patients (68.6 ± 19.5 vs 71.4 ± 19.6, P = 0.04).

CONCLUSION

Patients with FD have a lower HRQOL compared to those with OD, but this could not be attributed to differences in anxiety nor depression between both groups.

Review article: endpoints used in functional dyspepsia drug therapy trials

BACKGROUND

The measurement of patient-reported outcomes (PRO) in treatment trials for functional gastrointestinal disorders is a matter of controversy.

AIM

To focus on instruments and endpoints that have been used to evaluate the efficacy of therapeutic agents in functional dyspepsia (FD) trials, also considering the newly defined Rome III FD criteria.

METHODS

A Medline search was conducted to identify relevant studies pertaining to FD treatment, with particular emphasis on the studies to date which have used validated outcome measures.

RESULTS

Currently available outcome measures are heterogeneous across studies. They include global binary endpoints, analogue or categorical scoring scales, uni- or multi-dimensional disease specific questionnaires, global outcome evaluations and quality of life questionnaires. Across the available outcome measures, substantial heterogeneity is found, not only in the type of endpoint measure, but also in the number and types of symptoms that are considered to be part of the FD symptom complex. Especially based on content validity, none of the existing questionnaires or endpoints can be considered sufficiently validated to be recommended unequivocally as the primary outcome measure for FD trials according to the Rome III criteria. On the other hand, existing well-validated multi-dimensional questionnaires that include many non-FD symptoms can be narrowed down to evaluate only the cardinal symptoms according to Rome III.

CONCLUSIONS

There is an urgent need to develop Rome III-based patient-reported outcomes for functional dyspepsia. Well-validated multi-dimensional questionnaires may serve as a guidance for this purpose, and could also be considered for use in ongoing clinical trials.

Longitudinal and cross-sectional factors associated with long-term clinical course in functional dyspepsia: a 5-year follow-up study

OBJECTIVES

Functional dyspepsia (FD) is a heterogeneous disorder with different pathophysiological mechanisms underlying the symptom pattern, but little is known about its clinical course. The aims of this study were to study the long-term evolution of symptoms in a clinical FD population and to identify factors associated with outcome.

METHODS

FD patients who previously underwent gastric function testing and filled out a dyspepsia symptom score (DSS) were contacted. At follow-up, patients indicated whether symptoms had worsened, remained unchanged, improved, or disappeared. Anxiety and depression, DSS, chronic fatigue symptoms, irritable bowel syndrome (IBS) comorbidity, and FD-specific quality of life (QoL) were assessed using mailed questionnaires. Bivariate associations between different patient characteristics and DSS and QoL at follow-up were tested; multiple linear regression was used to identify factors associated with the outcomes, both longitudinally and cross-sectionally.

RESULTS

Data were obtained from 253 patients (84.9% of the eligible and consenting population (n=298) and 53.2% of the original population (n=476)). The mean duration of follow-up was 68±2 months. Disappeared, improved, unchanged, and worsened symptoms were reported by 17.4, 38.3, 30.8, and 13.4% of the patients, respectively. Correlations between dyspepsia symptoms at initial visit and follow-up were small to moderate in magnitude. DSS at initial visit and trait anxiety were longitudinally associated with DSS at follow-up, with a trend found for weight loss; depression, chronic fatigue, and IBS at follow-up were cross-sectionally associated with DSS. Trait anxiety, weight loss, and DSS at initial visit were independently associated with QoL at follow-up; depression as well as DSS and chronic fatigue at follow-up were cross-sectionally associated.

CONCLUSIONS

About half of FD patients reported disappeared or improved symptoms after a mean follow-up of 5 years. Although stability of symptom levels is low to moderate, DSS at initial visit, trait anxiety, and initial weight loss are more strongly associated with outcome than gastric sensorimotor function.

Duodenal administered seal oil for patients with subjective food hypersensitivity: an explorative open pilot study

Short-term duodenal administration of n-3 polyunsaturated fatty acid (PUFA)-rich seal oil may improve gastrointestinal complaints in patients with subjective food hypersensitivity, as well as joint pain in patients with inflammatory bowel disease (IBD). The aim of the present explorative pilot study was to investigate whether 10-day open treatment with seal oil, 10 mL self-administrated via a nasoduodenal tube 3 times daily, could also benefit nongastrointestinal complaints and quality of life (QoL) in patients with subjective food hypersensitivity. Twenty-six patients with subjective food hypersensitivity, of whom 25 had irritable bowel syndrome (IBS), were included in the present study. Before and after treatment and 1 month posttreatment, patients filled in the Ulcer Esophagitis Subjective Symptoms Scale (UESS) and the Gastrointestinal Symptom Rating Scale (GSRS) for gastrointestinal symptoms and subjective health complaints (SHC) inventory for nongastrointestinal symptoms in addition to short form of the Nepean dyspepsia index (SF-NDI) for evaluation of QoL. Compared with baseline, gastrointestinal, as well as nongastrointestinal, complaints and QoL improved significantly, both at end of treatment and 1 month posttreatment. The consistent improvements following seal oil administration warrant further placebo-controlled trials for confirmation of effect.

Long-term tegaserod treatment for dysmotility-like functional dyspepsia: results of two identical 1-year cohort studies

BACKGROUND

Functional dyspepsia (FD) is a chronic disorder that adversely affects health-related quality of life (HRQoL). Published information on its long-term management is minimal and treatment options are limited.

AIM

The aim of this study was to evaluate safety, efficacy and HRQoL with tegaserod 6 mg twice daily over 1 year in women with FD who completed one of two 6-week, randomized, placebo-controlled, double-blind studies.

METHODS

About 780 patients received tegaserod 6 mg twice daily in two identical 1-year extension studies. Scheduled assessments included adverse events, the Short-Form Nepean Dyspepsia Index (SF-NDI), Work Productivity and Activity Impairment-Dyspepsia (WPAI-Dyspepsia) questionnaire, and patient perceptions of treatment efficacy.

RESULTS

Mean tegaserod treatment duration in the two studies was 236 and 222 days. Most adverse events occurred in the first 6 months, were similar to previous reports (commonly diarrhea), and were transient and well tolerated. SF-NDI, WPAI-Dyspepsia scores and perceived symptom relief improved from baseline over the 1-year evaluation.

CONCLUSIONS

The long-term safety profile of tegaserod in women with FD was consistent with that of short-term treatment and accompanied by improvements in HRQoL, work productivity and symptom relief. These long-term results add to the clinical experience with FD and support the potential value of a 5-HT(4) agonist in the management of FD.

Acupuncture as a treatment for functional dyspepsia: design and methods of a randomized controlled trial

BACKGROUND

Acupuncture is widely used in China to treat functional dyspepsia (FD). However, its effectiveness in the treatment of FD, and whether FD-specific acupoints exist, are controversial. So this study aims to determine if acupuncture is an effective treatment for FD and if acupoint specificity exists according to traditional acupuncture meridians and acupoint theories.

DESIGN

This multicenter randomized controlled trial will include four acupoint treatment groups, one non-acupoint control group and one drug (positive control) group. The four acupoint treatment groups will focus on: (1) specific acupoints of the stomach meridian; (2) non-specific acupoints of the stomach meridian; (3) specific acupoints of alarm and transport points; and (4) acupoints of the gallbladder meridian. These four groups of acupoints are thought to differ in terms of clinical efficacy, according to traditional acupuncture meridians and acupoint theories. A total of 120 FD patients will be included in each group. Each patient will receive 20 sessions of acupuncture treatment over 4 weeks. The trial will be conducted in eight hospitals located in three centers of China. The primary outcomes in this trial will include differences in Nepean Dyspepsia Index scores and differences in the Symptom Index of Dyspepsia before randomization, 2 weeks and 4 weeks after randomization, and 1 month and 3 months after completing treatment.

DISCUSSION

The important features of this trial include the randomization procedures (controlled by a central randomization system), a standardized protocol of acupuncture manipulation, and the fact that this is the first multicenter randomized trial of FD and acupuncture to be performed in China. The results of this trial will determine whether acupuncture is an effective treatment for FD and whether using different acupoints or different meridians leads to differences in clinical efficacy.

TRIAL REGISTRATION NUMBER

Clinical Trials.gov Identifier: NCT00599677.

Translation and validation of the Nepean Dyspepsia Index for functional dyspepsia in China

AIM: To assess the reliability and validity of the translated version of Nepean Dyspepsia Index (NDI) in Chinese patients with documented functional dyspepsia (FD).

METHODS: The translation process included forward translation, back translation, pretest and cross-cultural adaptation. Reliability and validity of the translated version were examined by asking 300 subjects to complete the Chinese version of the NDI. The mean age of subjects was 39.24 years and 68.7% of the subjects were women. Internal consistency analysis with Cronbach’s α was performed to test the reliability. Correlation analysis was used to assess the content validity. Factor analysis and structural equation models were used to assess the construct validity.

RESULTS: The Cronbach’s α coefficients ranged 0.833-0.960, well above the acceptable level of 0.70. Correlation analysis showed that each item had a strong correlation with the corresponding domain, but a weak correlation with other domains. Confirmatory factor analysis indicated that the comparative fit index was 0.94, higher than the acceptable level of 0.90.

CONCLUSION: The Chinese version of the NDI is a reliable and valid scale for measuring health-related quality of life and disease severity in Chinese patients with FD.

Minimum clinically important difference for the Nepean Dyspepsia Index, a validated quality of life scale for functional dyspepsia

OBJECTIVES

The Nepean Dyspepsia Index (NDI) was specifically developed for trials in functional dyspepsia, but the smallest change on the total or subscale scores, which corresponds to a clinically meaningful change (minimal clinically important difference, MCID), has not been established. An MCID has been established for the SF-36 (> or =5 points on physical or mental health subscales); such information is critical for understanding clinical trial data. We aimed at calculating an MCID for the NDI to help guide the interpretation of future clinical trials.

METHODS

Comprehensive clinical data were collected in outpatients (n=101) and community subjects (n=460), and the MCID for the NDI total score was examined in three ways. The first estimated the average change (over a 2-week period) in the NDI corresponding to a five-point change in the SF-36 mental and physical subscales, and the second repeated this using a 1-s.d. change in symptom level, whereas the third calculated Cohen's d effect size among individuals changing by at least five points on the SF-36 subscales. A separate cross-sectional study was used to obtain the receiver-operator characteristic curve for discriminating between dyspepsia and non-dyspepsia subjects.

RESULTS

Among individuals improving by at least 1 s.d. on the patient-reported symptom score, the corresponding improvement in NDI quality of life (QoL) was an average of 18 points (s.d.=12) compared with only 7 points (s.d.=15) in those with no/minimal change in symptoms, yielding a Cohen d of 1.0 and a proposed MCID of 10 points. Although the same pattern was found using the SF-36 physical scale, the effect size was smaller (Cohen's d=0.25). Smaller effect sizes were also obtained using the SF-36 mental subscale (Cohen's d=0.1) and the physician global assessment (Cohen's d=0.33). In a separate cross-sectional community study, the NDI-QoL score was shown to provide good discrimination between individuals meeting and not meeting the Rome criteria for functional dyspepsia, with an area under the receiver-operator characteristic curve of 0.80 (95 % confidence interval: 0.75, 0.85).

CONCLUSIONS

A change of at least 10 points on the NDI total scale corresponds to a clinically meaningful change in patient status.

Quality of life in South East Asian patients who consult for dyspepsia: validation of the short form Nepean Dyspepsia Index

Background

Treatment objectives for dyspepsia include improvements in both symptoms and health-related quality of life (HRQoL). There is a lack of disease-specific instruments measuring HRQoL in South East Asian dyspeptics.

Objectives

To validate English and locally translated version of the Short-Form Nepean Dyspepsia Index (SF-NDI) in Malaysian patients who consult for dyspepsia.

Methods

The English version of the SF-NDI was culturally adapted locally and a Malay translation was developed using standard procedures. English and Malay versions of the SF-NDI were assessed against the SF-36 and the Leeds Dyspepsia Questionnaire (LDQ), examining internal consistency, test-retest reliability and construct validity.

Results

Pilot testing of the translated Malay and original English versions of the SF-NDI in twenty subjects did not identify any cross-cultural adaptation problems. 143 patients (86 English-speaking and 57 Malay speaking) with dyspepsia were interviewed and the overall response rate was 100% with nil missing data. The median total SF-NDI score for both languages were 72.5 and 60.0 respectively. Test-retest reliability was good with intraclass correlation coefficients of 0.90 (English) and 0.83 (Malay), while internal consistency of SF-NDI subscales revealed α values ranging from 0.83 – 0.88 (English) and 0.83 – 0.90 (Malay). In both languages, SF-NDI sub-scales and total score demonstrated lower values in patients with more severe symptoms and in patients with functional vs organic dyspepsia (known groups validity), although these were less marked in the Malay language version. There was moderate to good correlation (r = 0.3 – 0.6) between all SF-NDI sub-scales and various domains of the SF-36 (convergent validity).

Conclusion

This study demonstrates that both English and Malay versions of the SF-NDI are reliable and probably valid instruments for measuring HRQoL in Malaysian patients with dyspepsia.

Subjective health complaints and quality of life in patients with irritable bowel syndrome following Giardia lamblia infection: a case control study

OBJECTIVE

Irritable bowel syndrome (IBS) is associated with unexplained medical symptoms, and the degree of somatic comorbidity may indicate whether the aetiology of IBS is predominantly psychological or biological in origin. The purpose of this study was to examine the comorbidity and quality of life of patients with IBS following infection with Giardia lamblia.

MATERIAL AND METHODS

Sixty-seven consecutive patients with persistent abdominal symptoms, initiated by an acute infection with G. lamblia, completed questionnaires for scoring of subjective health complaints (SHC) and quality of life (Short-form Nepean Dyspepsia Index (SF-NDI)). The scores were compared with corresponding scores in persons from the general population (n=70).

RESULTS

Compared with controls, each of the two groups of patients, those with present (n=17) and those with cured (n=50) G. lamblia infection, had significantly higher scores (p<0.0001) on SHC. However, subscores on somatic comorbidity (musculoskeletal pain) were low and similar to those in the general population (OR 1.2 (0.51-2.73)). Quality of life was substantially impaired in the patients; sum scores 30.0+/-8.0 (mean+/-SD) and 31.7+/-9.3 in the patient groups and 13.5+/-6.8 in the general population (p<0.0001).

CONCLUSIONS

Patients with post-giardiasis IBS suffer very little somatic comorbidity, suggesting that the aetiology of this form of postinfective IBS is predominantly biological in origin and may thus differ from the more common, non-postinfective forms of IBS. The combination of persisting abdominal symptoms and psychological distress might be a perpetuating factor contributing to low quality of life.

The EQ-5D (Euroqol) is a valid generic instrument for measuring quality of life in patients with dyspepsia

Background

There is little information of the validity of generic instruments in measuring health-related quality of life (HRQOL) in patients with dyspepsia. We aimed to assess the reliability and validity of the EQ-5D, a brief and simple instrument, in measuring HRQOL in adult patients with dyspepsia.

Methods

Consecutive adults with dyspepsia attending the Gastroenterology clinic in a tertiary referral center were interviewed with the EQ-5D (both English and Malay versions), the short-form Nepean Dyspepsia Index (SF-NDI), the SF-36 and Leeds Dyspepsia Questionnaire (LDQ). Known-groups and convergent construct validity were investigated by testing hypotheses at attribute and overall levels. A repeat telephone interview was conducted 2 weeks later to assess test-retest reliability.

Results

A total of 113 patients (mean (SD) age: 53.7 (14) years; 49.5% male; 24.8% Malays, 37.2% Chinese; 70.8% functional dyspepsia) were recruited. Response rate was 100% with nil missing data. Known-groups validation revealed 20/26 hypotheses fulfillment. Patients with more severe dyspepsia reported more problems with their usual activity (p = 0.07) and pain (p = 0.06) and demonstrated lower median VAS scores (60 vs 70, p = 0.002) and EQ-5D utility scores (0.72 vs 0.78, p = 0.002). Those reporting problems in various EQ-5D dimensions had significantly lower scores in relevant SF-36 and SF-NDI dimensions. The overall EQ-5D utility score also demonstrated good correlation with the SF-36 summary physical and mental scores and the SF-NDI total score. Intraclass correlation coefficient for test-retest reliability was 0.66 (95% CI = 0.55 – 0.76).

Conclusion

The EQ-5D is an acceptable, valid and reliable generic instrument for measuring HRQOL in adult patients with dyspepsia.

Exploratory Study of Tegaserod for Dyspepsia in Women Receiving PPIs for Heartburn

Background and Aims

Tegaserod is a selective serotonin receptor (5-HT₄) agonist that relieves dysmotility symptoms associated with constipation. Here we explore its effects on functional dyspepsia symptoms and heartburn during continued proton pump inhibitor (PPI) treatment.

Methods

In this multicenter pilot study, following a 2-week screening/baseline period, women with functional dyspepsia and persisting heartburn treated with PPIs received add-on open-label tegaserod 6 mg twice daily (bid) for 4 weeks. Treatment responders were then randomized 1:1 to continue double-blind tegaserod or placebo therapy for 6 weeks. Efficacy variables included the proportion of days with satisfactory relief of dyspepsia symptoms (early satiety, postprandial fullness and bloating) as well as the change in individual symptom severity scores for these three cardinal dyspepsia symptoms. Health-related quality of life was evaluated using a validated questionnaire, the Nepean Dyspepsia Index. Adverse events (AEs) were monitored.

Results

Of 101 women enrolled, 71 completed open-label treatment, and 70 responders were randomized to double-blind treatment. The proportion of days with satisfactory relief of dyspepsia symptoms (least squares mean, LSM) increased with tegaserod and placebo, to 0.69 and 0.62, respectively at study end (P = 0.366). Similarly, both groups showed improvements in the composite daily symptom severity score (overall LSM change from baseline of 1.55 and 1.57, P = 0.934), and the Nepean Dyspepsia Index (overall LSM change of −39.0 and −37.8, P = 0.537). Tegaserod was well tolerated. Diarrhea was the most common AE (8.1% tegaserod, 0% placebo). There were no serious AEs or deaths.

Conclusions

A significant treatment effect was not demonstrated in this study using a treatment-withdrawal methodology. In future studies of functional dyspepsia patients with heartburn, a more rigorous parallel-group study design should be considered.

Tegaserod treatment for dysmotility-like functional dyspepsia: results of two randomized, controlled trials

OBJECTIVES

Therapies for dysmotility-like functional dyspepsia (FD) are limited. We studied tegaserod, a selective serotonin type 4 receptor agonist, in patients with FD.

METHODS

Two identical multicenter, double-blind, randomized, placebo-controlled trials enrolled women >/=18 yr with recurring mid-upper abdominal discomfort characterized by postprandial fullness, early satiety, and/or bloating. Patients were randomized to tegaserod 6 mg b.i.d. or placebo. Two patient-reported primary variables were assessed: percentage of days with satisfactory symptom relief, and symptom severity using the composite average daily severity score (CADSS).

RESULTS

In total, 2,667 women were randomized with no differences between trials in terms of recruitment method, Helicobacter pylori status, heartburn, or medication use. Mean percentage of days with satisfactory symptom relief for tegaserod versus placebo in Trial 1: 32.2%versus 26.6% (95% CI of treatment difference 2.82, 9.27; P < 0.01), Trial 2: 31.9%versus 29.4% (95% CI of treatment difference -0.21, 6.53; P= 0.066). Mean CADSS in Trial 1: 3.14 versus 3.35 (95% CI of treatment difference -0.29, -0.10; P < 0.0001), Trial 2: 3.15 versus 3.23 (95% CI of treatment difference -0.18, 0.01; P= 0.094). Meta-analysis showed significant benefit for both end points: increase in days with satisfactory relief 4.6% (95% CI 2.29, 6.96); decrease in CADSS 0.14 (95% CI 0.21, 0.07). Treatment effect was greater in patients with severe baseline symptoms. Diarrhea requiring study discontinuation was more common with tegaserod than placebo (4.1%vs 0.3%).

CONCLUSIONS

Some improvement in dysmotility-like FD was observed with tegaserod treatment. The clinical implication of this improvement is uncertain.

Asimadoline, a kappa-opioid agonist, and satiation in functional dyspepsia

BACKGROUND

Asimadoline, a kappa-opioid agonist, reduces visceral sensitivity in experimental animal models and may decrease satiation and postprandial fullness in healthy individuals. However, its effect on satiation in functional dyspepsia is unclear, and any symptom benefit has not been explored.

AIM

To evaluate the effects of asimadoline on satiation volume and postchallenge symptoms in functional dyspepsia.

METHODS

A randomized, double-blind trial evaluated gastric satiation and symptoms before and after 8 weeks of asimadoline 0.5 mg (n = 13) or 1.0 mg (n = 13) or placebo (n = 14) b.d. in patients with functional dyspepsia (Rome II). Gastrointestinal Symptom Rating Scale and Nepean Dyspepsia Index were used to assess symptoms during the 8-week treatment.

RESULTS

Over 8 weeks of treatment, asimadoline had no significant effect on maximum-tolerated volume or aggregate symptom score with nutrient drink challenge, and on the mean of the total daily symptom severity score compared to placebo. In a post hoc analysis, asimadoline 0.5 mg significantly increased the maximum-tolerated volume (1217 mL +/- 90.2) compared to placebo (807 mL +/- 111.8) in patients with higher postprandial fullness scores (P = 0.01).

CONCLUSION

Asimadoline overall did not significantly alter maximum-tolerated volume, symptoms postnutrient challenge or symptoms over 8 weeks in functional dyspepsia.

Clinical trial: a randomized controlled cross-over study of flupenthixol + melitracen in functional dyspepsia

BACKGROUND

Functional dyspepsia is a prevalent condition associated with diminished quality of life (QoL) and high economic burden.

AIM

To study the efficacy of a combination of flupenthixol and melitracen (F + M) with anxiolytic and antidepressant properties in functional dyspepsia using a randomized controlled cross-over design.

METHODS

Patients met the Rome III criteria for functional dyspepsia and a validated questionnaire was used to exclude those with anxiety or depression. Moreover, patients had to have failed a trial of acid-suppressive therapy and Helicobacter pylori eradication when positive. End points included subjective global symptom relief and QoL assessed by the Nepean Dyspepsia Index (NDI).

RESULTS

Twenty-five patients (14 females, 11 males; mean age = 34.3 +/- 9.9 years) were enrolled and 24 completed the 8-week study. There was a significant improvement in subjective global symptom relief with F + M vs. placebo (ITT: 73.9% vs. 26.1%, P = 0.001) and a significant drop in the NDI score vs. placebo (ITT: -9.0 +/- 11.9 vs. -2.4 +/- 8.9, P = 0.03). No difference was noted whether the initial treatment was F + M or placebo. No significant side effects were noted.

CONCLUSIONS

A combination of F and M is safe and effective in the short-term treatment of functional dyspepsia. F + M is associated with significant improvement in QoL independent of the presence of anxiety or depression.

Breathing exercises with vagal biofeedback may benefit patients with functional dyspepsia

OBJECTIVE

Many patients with functional dyspepsia (FD) have postprandial symptoms, impaired gastric accommodation and low vagal tone. The aim of this study was to improve vagal tone, and thereby also drinking capacity, intragastric volume and quality of life, using breathing exercises with vagal biofeedback.

MATERIAL AND METHODS

Forty FD patients were randomized to either a biofeedback group or a control group. The patients received similar information and care. Patients in the biofeedback group were trained in breathing exercises, 6 breaths/min, 5 min each day for 4 weeks, using specially designed software for vagal biofeedback. Effect variables included maximal drinking capacity using a drink test (Toro clear meat soup 100 ml/min), intragastric volume at maximal drinking capacity, respiratory sinus arrhythmia (RSA), skin conductance (SC) and dyspepsia-related quality of life scores.

RESULTS

Drinking capacity and quality of life improved significantly more in the biofeedback group than in the control group (p=0.02 and p=0.01) without any significant change in baseline autonomic activity (RSA and SC) or intragastric volume. After the treatment period, RSA during breathing exercises was significantly correlated to drinking capacity (r=0.6, p=0.008).

CONCLUSIONS

Breathing exercises with vagal biofeedback increased drinking capacity and improved quality of life in FD patients, but did not improve baseline vagal tone.

A single zoledronic acid infusion reduces bone resorption markers more rapidly than weekly oral alendronate in postmenopausal women with low bone mineral density

Early data suggest that an annual i.v. infusion of zoledronic acid (ZOL) might have therapeutic use in women with osteoporosis. In this randomized, double-blind, double-dummy, multicenter, 24-week trial, we evaluated the onset of action of a single infusion of ZOL 5 mg (n=69) compared with weekly oral alendronate (ALN) 70 mg (n=59) in postmenopausal women with low bone mineral density (T score< or =-2 by DXA) as assessed by reductions in urine N-telopeptide of type I collagen (NTX) at week 1. The effects of these therapies on other markers of bone turnover, patient preference for once yearly i.v. vs. oral weekly treatment, and adverse events were also assessed. At week 1, ZOL 5 mg resulted in a significantly greater reduction in mean urine NTX from baseline than ALN 70 mg (P<0.0001). Significantly greater reduction in urine NTX and serum beta-C-telopeptide of type I collagen (beta-CTX) were also observed in the ZOL 5 mg group at all post-baseline time points. Bone-specific alkaline phosphatase (BSAP) levels showed a more gradual reduction in both the ZOL 5 mg and ALN 70 mg groups, reaching premenopausal range by week 12. A comparable proportion of patients reported adverse events in each treatment group (ZOL 5 mg, 91.3%; ALN 70 mg, 86.4%). Transient, flu-like symptoms were the most common adverse events in the ZOL 5 mg group and resulted in a higher frequency of adverse events in this group during the first 3 days of treatment. After 3 days, adverse event rates were similar in the 2 groups. The majority of patients, including those experiencing flu-like symptoms, expressed a preference for annual i.v. therapy (66.4%) compared with weekly oral therapy (19.7%). We conclude that a single i.v. infusion of ZOL 5 mg reduced urine NTX levels more rapidly than weekly oral ALN 70 mg. The majority of study patients preferred an i.v. treatment regimen of ZOL 5 mg over weekly osteoporosis therapy with ALN 70 mg.

Efficacy and safety of ecabet sodium on functional dyspepsia: A prospective, double-blinded, randomized, multi-center controlled trial

AIM: To compare ecabet sodium and cimetidine in relieving symptoms of functional dyspepsia.

METHODS: We performed a multi-center, prospective, randomized, double-blinded controlled trial to compare the clinical efficacy of ecabet sodium and cimetidine in patients with functional dyspepsia. Two-hundred and seventy-two patients with dyspeptic symptoms fulfilling the Rome-II criteria were enrolled from 7 centers. In the study group (115 patients), 1.5 g ecabet sodium was given twice a day. In the control group (121 patients), 400 mg cimetidine was given twice a day. Symptoms and parameters of quality of life were analyzed at baseline, 3, 14, and 28 d after initiating the treatment.

RESULTS: Two-hundred and thirty-six patients completed the clinical trial. After 4 wk of treatment, the rates of improvement in patients with dyspeptic symptoms were not different between two groups (77.4% in the ecabet group and 79.3% in the cimetidine group, respectively, P > 0.05). Likewise, the rates of symptomatic improvement were not different at 3 d and 14 d. The parameters of quality of life did not change significantly during the study period in both groups. There was no clinically significant adverse event in both groups.

CONCLUSION: In patients with functional dyspepsia, ecabet sodium has similar clinical efficacy with cimetidine.

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

BACKGROUND

Symptom assessment using questionnaires has been recommended as the primary outcome measure in clinical gastroesophageal reflux and dyspepsia trials. Questionnaires should have proven reliability, validity, and responsiveness, and may assess the frequency and/or severity of dyspepsia symptoms. Although a number of measures have been developed, it remains unclear which of these should be used in new trials.

OBJECTIVE

To describe existing questionnaire outcome measures that assess symptoms of gastroesophageal reflux dyspepsia for use in clinical trials.

METHODS

Studies were identified from Medline, Embase, the Cochrane library, and reference lists. The inclusion criterion was that the study assessed a questionnaire, which measured the frequency or severity of dyspepsia or gastroesophageal reflux symptoms, in a sample of patients.

RESULTS

No direct comparison between questionnaires was possible due to methodological heterogeneity. Thirty-seven studies describing 26 questionnaires met the inclusion criteria. Twelve were unidimensional (assessed symptoms only) and 14 were multidimensional (also assessed quality of life). Eleven questionnaires assessed both frequency and severity of dyspepsia, and 10 had proven reliability, validity, and responsiveness. No studies compared different questionnaires.

CONCLUSIONS

Future gastroesophageal reflux and dyspepsia clinical trials should use unidimensional or multidimensional outcome measures that assess both the frequency and severity of symptoms, and have proven reliability, validity, and responsiveness. Further research is necessary to compare existing outcome measures to determine which are the most reliable, valid, and responsive instruments.

Review article: epidemiology and quality of life in functional gastrointestinal disorders

The epidemiology and health-related quality of life associated with functional gastrointestinal disorders are reviewed, with particular emphasis on irritable bowel syndrome and functional dyspepsia. The literature supports the significant world-wide prevalence of functional gastrointestinal disorders, including irritable bowel syndrome (IBS), functional dyspepsia and chronic constipation. An increased female prevalence has been demonstrated in most studies in patients with IBS and chronic constipation, but not functional dyspepsia. The female to male ratio appears to be greater in the health care-seeking population than in community populations. However, some differences in the reported general prevalence and gender-related prevalence of functional gastrointestinal disorders may be due to cultural factors and study methodology. A significant health care burden is associated with IBS, with increased out-patient services, abdominal and pelvic surgeries, and gastrointestinal- and non-gastrointestinal-related physician visits and health care costs. Health-related quality of life is impacted significantly in patients with functional gastrointestinal disorders, such as functional dyspepsia and IBS, compared with the general healthy population, as well as patients with other chronic medical conditions, such as gastro-oesophageal reflux disease and asthma. Impaired health-related quality of life has been demonstrated, in particular, in patients with moderate to severe disease seen in referral settings. The health-related quality of life appears to improve in treatment responders, or correlates with symptom improvement, with at least some treatment modalities studied in functional gastrointestinal disorders, but further studies are needed. Predictors of health-related quality of life in patients with functional gastrointestinal disorders include psychosocial factors, such as early adverse life events, and symptoms related to visceral perception, e.g. pain and chronic stress. The presence of extra-intestinal symptoms appears to have a major if not greater impact on health care visits, excess health care costs and health-related quality of life in patients with functional gastrointestinal disorders.

Development and validation of a cross-cultural questionnaire to evaluate nonulcer dyspepsia: the Porto Alegre Dyspeptic Symptoms Questionnaire (PADYQ)

Despite its high prevalence, nonulcer dyspepsia is still difficult to study, due to the lack of adequate tools to measure significant outcomes. The objective of this study was to develop and validate a symptom-focused, disease-specific questionnaire to evaluate patients with nonulcer dyspepsia. For that, the questionnaire was carefully written following widely accepted terminology, so as to facilitate translation and validation in other languages and cultures. The questionnaire was developed using Rome I terminology for symptoms, which were evaluated according to their intensity, duration, and frequency when applicable. Thirty-one patients with nonulcer dyspepsia, as well as 31 sex-and age-matched volunteers without digestive problems were used to assess the internal consistency, reproducibility, responsiveness, content validity, and discriminant validity of the questionnaire. Another 31 functional dyspeptic patients were enrolled for assessment of criterion validity. Cronbach's alpha coefficient was 0.82. The intraclass correlation coefficient for the scores obtained 7 days apart was 0.86. The mean score obtained after 3 months of treatment was 16.4, vs. 23.03 at baseline (P = 0.001). Two blinded gastroenterologists agreed that the questionnaire adequately evaluated nonulcer dyspepsia. The median symptoms score for controls was 0, vs. 22.5 for dyspeptic patients (P = 0.001). An inverse correlation was observed between quality of life and dyspeptic symptoms (R = -0.28, P = 0.026). The proposed questionnaire has high degrees of both reproducibility and responsiveness. As this questionnaire was based on Rome I International Consensus terminology, it is expected that it will be easy to translate and validate.

Dyspeptic symptoms associated with Helicobacter pylori infection are influenced by strain and host specific factors

BACKGROUND

Dyspepsia can be associated with H. pylori infection.

AIM

To assess dyspeptic symptoms and potentially influencing factors before and up to 6 months following successful H. pylori eradication therapy.

METHODS

Prospective cohort study involving H. pylori positive subjects from ambulatory or hospitalized care. Main outcome measures were symptoms during baseline and follow-up, the proportion of symptom-free patients, and symptom scores.

RESULTS

After successful eradication, the summary score of all dyspeptic symptoms decreased and during follow-up, the proportion of symptom-free patients was higher in the group with peptic ulcers (69.4% vs. 40.9%, P < 0.0001) than with functional dyspepsia (FD). Regardless of diagnosis, virulent strains of H. pylori were associated with a higher prevalence of epigastric pain before treatment: absolute risk-difference (ARD) with Oip-A: 18.2%, Odds Ratio (OR) 2.35 [1.3-4.2, 95%-CI], P = 0.01; with Cag-A: 24.6%, OR 2.81 [1.6-5], P = 0.01. Low-dose aspirin in part was a major risk factor in FD for previous weight loss bdfore study entry. Post-treatment, non-ulcer patients were more likely to suffer from distention/bloating. Likewise, alcohol induced persistence of nausea and vomiting in this population.

CONCLUSIONS

Dyspeptic symptoms in H. pylori infected patients are more common with virulent strains. Symptoms are more likely to persist despite successful eradication if patients initially harboured virulent strains or concomitant aspirin or alcohol intake are present. In one-third of peptic ulcer patients, symptoms will not be cured 3 months after therapy.

Efficacy of artichoke leaf extract in the treatment of patients with functional dyspepsia: a six-week placebo-controlled, double-blind, multicentre trial

BACKGROUND

This study aimed to assess the efficacy of artichoke leaf extract (ALE) in the treatment of patients with functional dyspepsia (FD).

METHODS

In a double-blind, randomized controlled trial (RCT), 247 patients with functional dyspepsia were recruited and treated with either a commercial ALE preparation (2 x 320 mg plant extract t.d.s.) or a placebo. The primary efficacy variable was the sum score of the patient's weekly rating of the overall change in dyspeptic symptoms (four-point scale). Secondary variables were the scores of each dyspeptic symptom and the quality of life (QOL) as assessed by the Nepean Dyspepsia Index (NDI).

RESULTS

Two hundred and forty-seven patients were enrolled, and data from 244 patients (129 active treatment, 115 placebo) were suitable for inclusion in the statistical analysis (intention-to-treat). The overall symptom improvement over the 6 weeks of treatment was significantly greater with ALE than with the placebo (8.3 +/- 4.6, vs. 6.7 +/- 4.8, P < 0.01). Similarly, patients treated with ALE showed significantly greater improvement in the global quality-of-life scores (NDI) compared with the placebo-treated patients (- 41.1 +/- 47.6 vs. - 24.8 +/- 35.6, P < 0.01).

CONCLUSION

The ALE preparation tested was significantly better than the placebo in alleviating symptoms and improving the disease-specific quality of life in patients with functional dyspepsia.

Relationships among symptom sub-groups, gastric emptying and blood gut hormones in patients with functional dyspepsia

AIM

To study the relationships among symptom subgroups, gastric emptying and gastrointestinal hormones in patients with functional dyspepsia (FD) and to explore pathogenesis of FD.

METHODS

The patients with FD were divided into 3 subgroups according to the RomeIIcriteria and 10 cases were selected randomly from each subgroup. Ten healthy subjects served as control. Thus 4 subgroups were set up, including the ulcer-like dyspepsia group (10 cases), the dysmotility-like dyspepsia group (10 cases), the unspecified dyspepsia group (10 cases) and the control group (10 healthy subjects). Changes of radionuclide gastric emptying and blood levels of relevant gastrointestinal hormones were observed synchronously. After gastric emptying was measured, the 30 cases of FD were divided into 2 groups: the normal gastric emptying group and the delayed gastric emptying group. Gastric emptying was recorded by ^99mTc-labelled solid food. Changes in motilin(MTL), somatostatin(SS), substance P(SP)and nitric oxide(NO)contents in peripheral blood were determined by radioimmunoassay and nitrate reductase technique.

RESULTS

In the ulcer-like group, 40% patients had gastric emptying delay while the half gastric emptying time (GET_1/2) and gastric emptying rate (GE%)at every time-point did not show significant changes(P<0.05)compared with control group and the other two subgroups of FD. The levels of SS in peripheral blood were increased significantly (P<0.05). However, the levels of MTL, SP, NO did not show significant changes (P<0.05) compared with control group. In the dysmotility-like group, 70% patients had gastric emptying delay, meanwhile, GET1/2 was prolonged significantly (P<0.05), and GE% was decreased significantly (15 min, P>0.05; 30 min, P>0.05; 45 min, P<0.05; 60 min, P<0.05; 90 min, P<0.01; and 120 min, P<0.01, respectively). Levels of SS in peripheral blood were increased significantly (P<0.05), whereas levels of MTL, SP, NO did not show significant changes (P>0.05). In the unspecified group, 70% of patients had gastric emptying delay, meanwhile, GET1/2 was prolonged significantly (P<0.05), and GE% was decreased significantly (15 min P>0.05; 30 min, P>0.05; 45 min, P<0.05; 60 min, P<0.05; 90 min, P<0.01; and 120 min, P<0.01, respectively). Levels of SS in peripheral blood were increased significantly (P<0.05), whereas levels of MTL, SP, NO did not show significant changes (P>0.05). In the normal gastric emptying group of FD, levels of SS in peripheral blood were increased significantly (P<0.05), whereas levels of MTL, SP, NO did not show significant changes (P>0.05). In the delayed gastric emptying group of FD, levels of SS and NO in peripheral blood were increased significantly (P<0.05), whereas levels of MTL were decreased significantly (P<0.05), meanwhile, levels of SP did not show significant changes (P>0.05).

CONCLUSION

Gastric motility disturbance plays an important role in pathogenesis of dysmotility-like dyspepsia and unspecified dyspepsia. Three subgroups of FD have different mechanisms and the Rome II criteria have practical importance in diagnosis and therapy of FD. Therefore, gastric emptying test has significance in evaluation of gastric motility function and in the treatment of FD. The increase of NO and the decrease of MTL are related to gastric emptying delay. The roles of SS and SP need to be studied further.

Health-related quality of life in functional dyspepsia

BACKGROUND

We performed a systematic review of the literature to compare the health-related quality of life (HRQOL) of patients with functional dyspepsia with either healthy controls or those with other diseases.

METHODS

Full-length published manuscripts during 1980-2002 were included if (a) patients had functional dyspepsia, but not uninvestigated dyspepsia; and (b) HRQOL was measured using a validated generic or dyspepsia-specific instruments, but not global assessment alone.

RESULTS

Twelve studies were reviewed; six fulfilled the selection criteria. None examined HRQOL among samples of the general population. None used dyspepsia-specific HRQOL instruments. Three studies contained four comparisons of HRQOL between functional dyspepsia patients and controls; two studies examined HRQOL changes in response to therapy. Two studies demonstrated a significant reduction at least in some domains of HRQOL among patients with functional dyspepsia compared to controls, while one study was negative. In general, studies that reported a decline in HRQOL Short Form-36 (SF-36) showed that changes in the physical domain were similar to those on mental domain of the SF-36.

CONCLUSIONS

There is some evidence for a decrease in HRQOL in patients with moderate to severe functional dyspepsia who seek care for their symptoms; however, more studies are needed. A therapeutic response in functional dyspepsia-related pain or discomfort might result in a corresponding improvement in HRQOL.

Diabetic gastropathy and prokinetics

The treatment of diabetic gastropathy, which here refers to a clinical syndrome of upper GI tract symptoms suggestive of an upper motility disturbance in diabetes whether or not there is delayed gastric emptying, remains suboptimal. New prokinetics and other motility-modifying agents may prove useful, but adequate clinical trials will be required to establish a role for them. However, diabetic gastropathy seems to represent a heterogenous syndrome in terms of pathophysiology, which potentially complicates the design of new randomized, controlled trials. This review aims to provide guidelines for future trials in this field. The evidence that delayed gastric emptying is a cause of symptoms in diabetic gastropathy is critically evaluated. The trial evidence supporting the short and long term efficacy of prokinetics is reviewed. Based on the available literature, it is concluded that improvement in gastric emptying does not equate with symptom relief in diabetic gastropathy. It is suggested that although gastric emptying should still be measured in clinical trials, it should not represent the primary outcome. The withdrawal treatment design applied in studies of diabetic gastropathy might be suboptimal. Double blind, parallel group studies remain the trial design of choice, but incorporation of validated outcome assessments and measurement of potential confounders of treatment response need attention in future trials.