Development of a new dyspepsia impact scale: the Nepean Dyspepsia Index

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).

Randomised clinical trial: an assessment of acupuncture on specific meridian or specific acupoint vs. sham acupuncture for treating functional dyspepsia

BACKGROUND

Functional dyspepsia (FD) is a common disease without an established optimal treatment.

AIM

To determine (i) the effect of acupuncture in relieving FD symptoms and improving life quality; (ii) the effect difference between acupoint and non-acupoint; and (iii) the effect difference among different acupoints.

METHODS

A total of 712 eligible patients were included and randomly assigned to six groups (Group A: specific acupoints of the stomach meridian; Group B: non-specific acupoints of the stomach meridian; Group C: specific acupoints of alarm and transport points; Group D: specific acupoints of the gallbladder meridian; Group E: sham acupuncture of non-acupoints; and Group F: itopride). A treatment period of 4 weeks (continuous five sessions per week), and a follow-up period of 12 weeks were arranged. The outcomes were the (i) patients' response, (ii) symptoms improvement measured using the Symptom Index of Dyspepsia and (iii) quality-of-life improvement based on Nepean Dyspepsia Index.

RESULTS

All groups had an improvement in dyspepsia symptoms and the QoL at the end of treatment, and the improvement was sustained for 4 weeks and 12 weeks. The overall response rate was significantly higher in acupuncture group A (70.69%), and lower in sham acupuncture group (34.75%), compared with itopride and other acupuncture groups. Similarly, the difference in symptoms and QoL improvement was significant between group A and the other acupuncture groups.

CONCLUSIONS

Acupuncture is effective in the treatment of functional dyspepsia, and is superior to non-acupoint puncture. The benefit of acupuncture relies on acupoint specificity.

Assessment of quality of life in patients with chronic pancreatitis

BACKGROUND

Quality of life (QOL) has increasingly become a factor in management decisions in patients with chronic diseases. Chronic pancreatitis (CP) is a debilitating disorder that causes not only pain and endo/exocrine insufficiency but is also connected with some social issues. The aim of this study was to assess QOL in patients with chronic pancreatitis in correlation with the disease activity or the environmental/social factors that can influence their well-being.

MATERIAL/METHODS

The study group comprised 43 patients with CP: M/F 37/6; mean age 47.9 ± 8.6; range: 30-74 yrs. The control group consisted of 40 healthy volunteers of comparable demographics. Different degrees of CP activity were defined using the Cambridge classification. Pain intensity and frequency were assessed using a pain index. QOL was assessed using the Short-Form-36 questionnaire.

RESULTS

Mean QOL scores in CP were lower compared to the control group in all SF-36 domains, particularly in general health perception, physical functioning, role-physical (p<0.001) and vitality (p<0.05). We observed correlation of QOL results and pain index in all domains, and number of the disease relapses and body weight in 5 out of 8 domains (p<0.001 and p<0.05, respectively). The worst QOL scores were obtained in retired patients, as well as in unemployed persons in almost all SF-36 domains (p<0.001).

CONCLUSIONS

Chronic pancreatitis significantly impairs patients' quality of life. Severity of abdominal pain, low body weight, and loss of work were the factors most closely associated with poor health status perception.

Development and psychometric evaluation of a diabetes-specific quality-of-life (D-QOL) scale

AIMS

The aims of this study were to develop a diabetes-specific quality-of-life (D-QOL) scale and to determine its psychometric properties.

METHODS

An initial pool of items was generated based on a conceptual construct and attributes of health-related quality of life. The items were reviewed by experts, and a pilot test was conducted. A content-validated preliminary D-QOL scale was verified for use with psychometric tests on 402 patients who were recruited from 3 hospitals in Korea. The data were analyzed using exploratory and confirmatory factor analyses, Cronbach's alpha, generalizability coefficients, ANOVA, and Pearson's correlations.

RESULTS

From exploratory analyses, a total of sixteen items clustered four factors were extracted. The four-factor structure was supported by confirmatory factor analysis. Concurrent validity was established with the 36-item Short-Form Health Survey. As hypothesized, the D-QOL scores were worse in severely or moderately depressed patients than in those who were either less depressed or not depressed, implying satisfactory known-groups validity. The reliability of the D-QOL scale was supported by Cronbach's alpha and generalizability coefficients.

CONCLUSIONS

The D-QOL scale is a simple and brief scale, the use of which is feasible in practice. It demonstrated excellent psychometric properties, and so may also be used in clinical research.

The dopaminergic system in patients with functional dyspepsia analysed by single photon emission computed tomography (SPECT) and an alpha-methyl-para-tyrosine (AMPT) challenge test

Purpose

Functional dyspepsia (FD) is a chronic condition characterized by upper abdominal symptoms without an identifiable cause. While the serotonergic system is thought to play a key role in the regulation of gut physiology, the role of the dopaminergic system, which is important in the regulation of visceral pain and stress, is under-studied. Therefore, this study investigated the dopaminergic system and its relationship with drinking capacity and symptoms in FD patients.

Methods

In FD patients and healthy volunteers (HV) the dopaminergic system was investigated by in-vivo assessment of central dopamine D2 receptors (D2Rs) with [¹²³I]IBZM SPECT and by an acute, but reversible, dopamine depletion alpha-methyl-para-tyrosine (AMPT) challenge test. A nutrient drink test was performed to investigate the association between maximal ingested volume, evoked symptoms, and D2Rs.

Results

The HV subjects comprised 12 women and 8 men (mean age 31 ± 3 years), and the FD patients comprised 5 women and 3 men (mean age 39 ± 5 years). The FD patients had a lower left plus right average striatal binding potential (BP_NP) for the caudate nucleus (p = 0.02), but not for putamen (p = 0.15), which in the FD patients was correlated with maximal ingested volume (r = 0.756, p = 0.03). The D2R BP_NP in the putamen was correlated with nausea (r = 0.857, p = 0.01). The acute dopamine depletion test, however, failed to reveal differences in prolactin release between the FD patients and the HV subjects.

Conclusion

These preliminary data suggest that chronic rather than acute alterations in the dopaminergic system may be involved in the pathogenesis of FD. Further studies are required to reproduce our novel findings and to evaluate to what extent the dopaminergic changes may be secondary to abnormalities in serotonergic pathways.

Electronic supplementary material

The online version of this article (doi:10.1007/s00259-011-2015-6) contains supplementary material, which is available to authorized users.

Randomised clinical trial: the effects of amitriptyline on drinking capacity and symptoms in patients with functional dyspepsia, a double-blind placebo-controlled study

BACKGROUND

Functional dyspepsia is one of the most prevalent (15-40%) functional gastrointestinal disorders. Antidepressants such as amitriptyline are often used in these patients, but clinical studies are currently lacking.

AIM

To evaluate the effect of 8 weeks of treatment with amitriptyline on drinking capacity, symptoms evoked by a standardised drink test (primary endpoint) and clinical symptoms (secondary endpoint).

METHODS

Patients meeting the Rome III criteria for functional dyspepsia (FD) were invited to participate in a double blind, randomised, placebo-controlled trial and were treated with either amitriptyline (12.5-50 mg) or placebo during 8 weeks. All included patients underwent a nutrient drink test before and after treatment. Drinking capacity and evoked symptoms were recorded. In addition, dyspeptic symptoms were weekly assessed using PAGI SYM (patient assessment of upper gastrointestinal symptom severity index) questionnaire.

RESULTS

Thirty-eight patients (amitriptyline n=18, placebo n=20; age 41±2year, 61% F) completed the study. The drinking capacity of liquid meal was not affected by either amitriptyline or placebo treatment. Postprandial symptoms were not significantly different between amitriptyline and placebo. During the entire treatment, total symptom score (0.47 points, P=0.02) and nausea (0.86 points, P=0.004) on PAGI SYM were significantly reduced by amitriptyline compared with placebo.

CONCLUSIONS

Amitriptyline did not affect drinking capacity and postprandial symptoms evoked by the drink test in FD patients. However, total clinical symptom score and nausea were reduced during 8 weeks of treatment. Our data suggest that amitriptyline particularly improves nausea in functional dyspepsia, but larger clinical trials are needed to further confirm our findings.

Screening for celiac disease in a North American population: sequential serology and gastrointestinal symptoms

OBJECTIVES

The prevalence of diagnosed celiac disease is <1 in 2,000 in the United States, but screening studies undertaken in European and other populations have revealed a much higher prevalence. The objective of this study was to determine the prevalence of celiac disease and the utility of screening in the general adult population of a geographically isolated area.

METHODS

Serum tissue transglutaminase antibodies (tTG-IgA) were measured in volunteer health-care participants aged ≥ 18 years at the annual Casper, Wyoming, Blue Envelope Health Fair blood draw. Subjects with positive tTG-IgA tests had their endomysial IgA antibodies checked. Double positives were offered endoscopy with small bowel biopsy. All subjects completed a short gastrointestinal (GI) symptom questionnaire.

RESULTS

A total of 3,850 residents of the Natrona County had serologic evaluation for celiac disease, 34 of whom tested positive for both tTG and endomysial antibody (EMA) IgA. Excluding three individuals with previous diagnosis of celiac disease, the overall prevalence of positive celiac serology in this community sample was 0.8%. All 31 subjects were offered a small bowel biopsy. Of the 18 biopsied subjects, 17 (94%) had at least partial villous atrophy. Symptoms that were reported by the fair attendees did not predict positivity.

CONCLUSIONS

Screening for celiac disease was widely accepted in this preventative health-care setting. Undiagnosed celiac disease affects 1 in 126 individuals in this Wyoming community. Most were asymptomatic or had atypical presentations. Serologic testing can readily detect this disease in a general population.

Health related quality of life in functional gastrointestinal disorders in Asia

The importance of health-related quality of life (HRQOL) continues to grow, as clinicians and clinical researchers have recognized the impact of the functional gastrointestinal disorders. Limited information is available on the performance of HRQOL questionnaires in Asia. Furthermore, the effect across different cultural settings of functional gastrointestinal disorders on HRQOL has been little studied in Eastern countries. We summarized recent studies on HRQOL in Korean patients with functional gastrointestinal disorders as well as other Asian literatures. Functional gastrointestinal disorders-related symptoms had a great effect on the HRQOL of Korean patients. These results and their considerable prevalence in Korea indicate that functional gastrointestinal disorders have a substantial social impact in this country.

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.

Association between clinical manifestations of complicated and uncomplicated peptic ulcer and visceral sensory dysfunction

BACKGROUND AND AIMS

Peptic ulcer disease (PUD) usually manifests as either dyspepsia or less commonly with complications such as bleeding. Patients with bleeding ulcers are often asymptomatic until the bleeding occurs. A lack of dyspeptic symptoms might be explained by impaired visceral sensory function. The aim of this study was to assess symptom profiles and compare visceral sensory thresholds in patients with bleeding peptic ulcer (BPU) and uncomplicated PUD.

METHODS

A total of 30 patients with BPU, 25 with uncomplicated PUD and 32 healthy controls (HC) without dyspeptic symptoms were recruited. In ulcer patients after at least 8 weeks of ulcer treatment and an 8-hr fast, visceral sensitivity was tested using a standardized nutrient challenge with an enteral feeding solution. Five key symptoms (fullness, abdominal pain, retrosternal/abdominal burning, nausea, and regurgitation) were assessed using visual analog scales (0-100).

RESULTS

Twenty-five of the 30 (83%, 95% confidence interval 65-94%) patients with BPU had no dyspeptic symptoms compared with none of the 25 uncomplicated PUD patients. Patients with BPU and HC had significantly lower symptom responses (BPU 127.6 +/- 24.6, HC 89.8 +/- 13.9) to the nutrient challenge than uncomplicated PUD patients (338.4 +/- 56.2, P < 0.0001). Patients with dyspeptic symptoms (30/55) had significantly higher symptom responses (327.3 +/- 47.8) than the 25/55 patients without symptoms (98.9 +/- 23.4, P < 0.0001).

CONCLUSION

Most patients with BPU present without dyspeptic symptoms. Even after healing of the ulcer, patients with uncomplicated PUD have a significantly augmented symptom response to a standardized nutrient challenge compared to patients with complicated ulcers and HC. Differences in the processing of upper gastrointestinal visceral afferents may play a major role in the clinical presentation (complicated vs uncomplicated) of PUD.

Clinical, emotional and social factors associated with quality of life in chronic pancreatitis

BACKGROUND

In chronic pancreatitis (CP), a debilitating, progressive and incurable disease, patients' wellbeing is considerably impaired, but the different factors affecting quality of life (QoL), have not been identified yet.

METHODS

69 patients with CP were evaluated (M/F 55/14; mean age 46.6 +/- 10.05 years). Different degrees of pancreatic damage were defined using the Cambridge classification; pain intensity and frequency were assessed using pain index. QoL was measured using EORTC QLQ-C30 and the PAN26 questionnaire. Although developed for pancreatic cancer, the C30/PAN26 has been validated for chronic pancreatitis.

RESULTS

Digestive symptoms, financial difficulties, fear of future health and general pain scales showed considerable effects of CP on QoL. We observed significant negative correlation between mean QoL scores and pain index in almost all domains (p < 0.001, p < 0.05). Pain intensity affects QoL scales more often than pain frequency. BMI correlated positively with QoL in global health status, altered bowel habits, body image and satisfaction with health care domains (p < 0.01, p < 0.05).

CONCLUSION

Pain index, BMI, Cambridge classification and disease duration are the most important factors adversely affecting QoL in CP. Measurement of QoL is essential in the disease management and improves the knowledge of psychosocial functioning of these patients. and IAP.

Mental and physical quality of life in actual living liver donors versus potential living liver donors: a prospective, controlled, multicenter study

In a quasi-experimental design, we investigated the quality of life (QOL) in actual liver donors (n = 43) and potential liver donors (n = 33) before and 3 months after liver transplantation. This is the first study in this field combining a prospective design with an adequate control group. Potential donors served as a control group because they also had a relative in need of a liver transplant and were as emotionally involved with the recipient as actual donors, but they were not subjected to the donor operation. Groups did not differ in age, gender, marital status, donor-recipient relationship, urgency of transplantation, or recipient group (adult versus child). Actual donors showed decreased physical QOL, whereas potential donors were not affected. However, for both groups, a decrease in anxiety was found. Furthermore, actual donors showed a better mental QOL postoperatively than potential donors. The recipients of these 2 groups did not differ with respect to postoperative complications. Furthermore, the groups did not report a different caregiver burden, but actual donors showed higher self-esteem. Because of the surgery, the worsening of physical symptoms in actual donors was expected. It is remarkable, however, that although actual donors still showed a limited physical QOL 3 months after the operation, in both groups, a similar reduction in anxiety could be observed, and actual donors even demonstrated a better mental QOL postoperatively than potential donors. The latter might be due to a psychological benefit that actual donors derived from the fact that they were able to help the recipients.

Evaluation of manual acupuncture at classical and nondefined points for treatment of functional dyspepsia: a randomized-controlled trial

PURPOSE

Acupuncture has been used traditionally as a treatment for functional dyspepsia (FD). The goal of this trial was to examine the efficacy of acupuncture at classical points and nondefined points as a treatment for functional dyspepsia.

METHODS

Sixty-eight (68) patients with functional dyspepsia, as defined by Rome-II criteria, were randomized into two groups: classical six-point acupuncture and nondefined-point acupuncture. Acupuncture was conducted three times per week for 2 weeks in a single-blind setting. To assess the effects of acupuncture, symptoms and quality of life were scored according to the Nepean Dyspepsia Index before and after acupuncture treatments.

RESULTS

Acupuncture treatment significantly decreased the dyspepsia symptoms and improved the quality of life. There was no statistical difference between the acupuncture groups treated at classical and nondefined points.

CONCLUSIONS

Our data show that both acupunctures at classical points and nondefined points improved the symptoms of patients with FD. However, we cannot rule out the possibilities of placebo effect in this trial.

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.

Patients with physiological acid exposure and positive symptom association scores: a distinct group within the GORD spectrum

Studies comparing pH-metrically well-characterized gastro-oesophageal reflux disease (GORD) patients with physiological reflux to GORD patients with pathological reflux, with regard to clinical and epidemiological data, are lacking. We included 273 GORD patients with pathological 24-h pH-monitoring (pH+), defined as pH<4 > or = 6% of time. A symptom index (SI) > or = 50% was considered positive, as well as a symptom association probability (SAP) > or = 95%. We included 84 GORD patients with physiological acid exposure (pH-) and a positive SI and/or SAP. Manometry and endoscopy reports were reviewed. Subjects completed questionnaires about demographics and medical history, functional dyspepsia and irritable bowel syndrome, the Nepean Dyspepsia Index symptom score and the RAND-36 quality of life scale. pH- patients were younger (45 vs 50 years, P = 0.003), more often female (60%vs 39%, P = 0.001), smoked more (31%vs 19%, P = 0.021) and reported proton pump inhibition failure more often (47%vs 32%, P = 0.027). A hypotensive lower oesophageal sphincter was less common in pH- patients (18%vs 34%, P = 0.008) and distal oesophageal contraction amplitude was higher (11 vs 9.5 kPa, P = 0.045). pH- patients had hiatal hernia and oesophagitis less often (48%vs 73%, P < 0.0005; 36%vs 54%, P = 0.012 respectively). pH- patients less often reported no other symptoms besides GORD (20%vs 34%, P = 0.015). pH- patients scored worse at the Nepean (reflux 19 vs 12 out of 39, P < 0.0005; dyspepsia 54 vs 38 out of 156, P < 0.0005). In the subgroup of patients who have physiological oesophageal acid exposure the enhancement of the perceived symptom burden appears to be the most important mechanism in GORD pathogenesis.

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.

Prolonged recording of duodenal acid exposure in patients with functional dyspepsia and controls using a radiotelemetry pH monitoring system

INTRODUCTION

Increased duodenal acid exposure (DAE) is associated with ulcer and dyspeptic symptoms but our understanding is limited by cumbersome recording methods. We have recently shown that prolonged radiotelemetry pH monitoring (RpHM) in the duodenum is feasible. This study compared DAE in controls and patients with functional dyspepsia (FD) using RpHM.

METHODS

FD and controls underwent 48-hour recording of DAE using endoclip-secured RpHM capsules in the distal duodenal bulb. Subjects were nil per os except for meals eaten twice daily. FD completed a 14-item symptom checklist. Sleep periods were determined from diaries. Meal periods were defined as the 3-hour period after meal initiation.

RESULTS

Thirty-four FD and 25 controls were studied. Prolonged recordings were obtained in 32/34 FD and 17/25 controls. Reasons for incomplete recordings were capsule dislodgement (7), procedural complication (1), and suspected gastric prolapse of capsule (2). Within groups, pH values for recording periods did not differ. Between groups, FD had significantly lower mean pH values [median (25th to 75th percentile)] during meals [5.11 (4.44 to 5.59) vs. 5.63 (5.17 to 6.10); P=0.003] and upright periods [4.69 (3.92 to 5.64) vs. 5.35 (4.55 to 6.31); P=0.01] but not during sleep. Duodenal pH values did not correlate with symptoms except for complaints of inability to finish a meal with meal (r=-0.341; P=0.05) and sleep (r=-0.383; P=0.03) pH.

CONCLUSIONS

RpHM allows for prolonged recording of DAE. FD have l greater DAE than controls during daytime and meal periods. DAE and symptoms are poorly associated. The association of DAE with inability to finish a meal is consistent with prior studies demonstrating impaired proximal stomach function after duodenal acidification.

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 of patients with irritable bowel syndrome in Korea

OBJECTIVE

The impact of irritable bowel syndrome (IBS) on HRQOL has been widely studied in the West. However, there are few data from Asian countries. The aim of this study was to assess the health-related quality of life (HRQOL) of patients suffering from IBS in Korea.

METHODS

Consecutive patients from six secondary and six tertiary medical centers in Korea were enrolled and completed self-administered questionnaires on sociodemographics and IBS-associated symptoms. HRQOL was assessed using the generic Short Form 36 (SF-36) and the disease-specific IBS-QOL questionnaires.

RESULTS

Of the 932 patients with abdominal pain and bowel symptoms, 664 IBS patients who fulfilled the Rome II criteria were analyzed. On all eight SF-36 scales, IBS patients had a significantly worse HRQOL than the general population (P < 0.01). The overall score for the IBS-QOL was 74.2. The health concern domain was most affected (mean score 64.2), and the sexual domain (mean score 86.7) was least affected in the IBS-QOL. Significant impairment of HRQOL was only observed in patients with severe symptoms both in the generic and specific HRQOL measurement, whereas patients with mild and moderate symptoms showed only mild impairment (P < 0.01). Female patients reported a significantly lower HRQOL than male patients (P < 0.05), but the difference was minimal. The IBS-QOL was significantly associated with female gender, total symptom score, self-reported symptom severity, and level of education in the multivariate analysis.

CONCLUSIONS

IBS-related symptoms had a great effect on the HRQOL of Korean patients. These results and the considerable prevalence of IBS in Korea indicate that IBS has a substantial social impact in this country.

Gastric hypersensitivity induced by oesophageal acid infusion in healthy volunteers

Distal oesophageal acid exposure has been shown to increase visceral sensitivity of the proximal oesophagus via central sensitization. Here we evaluated whether acidification of the distal oesophagus also affects the sensorimotor function of the proximal stomach. A gastric barostat study combined with a 30-min acid (HCl 0.15 mol L(-1)) or saline infusion in the distal oesophagus was performed in 18 healthy volunteers. Gastric and cutaneous sensitivity was assessed before and up to 2 h after the start of infusion. Directly after acid infusion, but not after saline, the threshold for discomfort decreased (-6.4 +/- 1.7 vs 0.4 +/- 0.4 mmHg; P = 0.028) and distension-induced symptoms increased significantly compared with the baseline (122 +/- 49% vs -3 +/- 9%). Cutaneous sensitivity remained unaffected by acid infusion. In contrast, when the infused liquid was aspirated 3 cm more distally, at the level of the lower oesophageal sphincter, the effect of acid infusion on gastric sensitivity was abolished and the increase in distension-induced symptoms was reduced (61 +/- 24%). Distal oesophageal acid infusion induces visceral hypersensitivity without affecting somatic sensitivity arguing against a similar mechanism of central sensitization as observed in non-cardiac chest pain. As reduction of the acid load to the stomach prevented this effect, our findings indicate that either gastric and/or duodenal acidification is involved. It should be emphasized though that aspiration from distal oesophagus may have attenuated the effect by reducing the acid-exposed area or by reducing the contact time.

Recurrent symptoms after fundoplication with a negative pH study--recurrent reflux or functional heartburn?

INTRODUCTION

A small cohort of patients present after antireflux surgery complaining of recurrent heartburn. Over two thirds of these patients will have a negative 24-h pH study. The aim of our study is to determine whether these patients have an associated functional disorder or abnormal cytokine activity and to examine the reproducibility of pH testing.

METHODS

A prospective analysis was carried out on a cohort of patients who had undergone a fundoplication and postoperative pH testing for recurrent heartburn: group A--patients with recurrent heartburn and a negative 24-h pH study and group B (control group)--patients with recurrent heartburn and a positive pH study. Questionnaires, a blood sample, and repeat pH testing were completed.

RESULTS

Sixty-nine patients were identified. Group A's depression score (8.6 +/- 4.1) was significantly higher than group B's (5.9 +/- 4.2; P = 0.03). Cytokine levels were similar in both groups. Forty-seven of 49 (96%) patients who underwent repeat pH testing had a negative study. Symptom-reflux correlation was highly significant (P < 0.001).

CONCLUSION

Some patients with recurrent heartburn and a negative pH study have associated functional or psychiatric comorbidities such as depression. Reproducibility of 24-h pH testing in these patients is excellent.

Functional dyspepsia affects women more than men in daily life: a case-control study in primary care

BACKGROUND

Little is known about possible gender differences among patients with functional dyspepsia (FD). Few studies have measured health-related quality of life (HRQoL) in patients with FD using a population-based control group as a reference.

OBJECTIVES

This study aimed to determine the degree of HRQoL impairment among patients with FD, to assess the self-reported health impact resulting from the disease, and to analyze any gender differences.

METHODS

A questionnaire that included the HRQoL Short Form 36 (SF-36) Health Survey, Hospital Anxiety and Depression Scale, and other measurements was mailed to patients with FD identified from medical records. The control group was randomly selected from the general population in the same geographical area. Responses to the SF-36 were transferred to a standard scale ranging from 0 (the worst possible score) to 100 (the best possible score).

RESULTS

Responders were assigned to 2 gender-specific subgroups, each with 88 patients with FD and 344 randomly matched controls, all aged 18 to 65 years. Compared with the controls, the HRQoL of patients with FD was impaired in all SF-36 dimensions except one -- role limitations caused by emotional problems. Female patients with FD had a significantly lower SF-36 score in the physical functioning dimension than did male patients (82.4 vs 90.5, respectively; P < 0.01). Both groups of patients with FD had impaired HRQoL compared with their respective control group in the dimensions of bodily pain (women: 69.3 vs 80.6, P < 0.001; and men: 75.8 vs 84.8, P < 0.001) and general health (women: 62.0 vs 75.6, P < 0.001; and men: 70.6 vs 78.6, P < 0.001). Additionally, women with FD had significant impairment compared with their respective control group in the dimensions of physical functioning (82.4 vs 89.3; P < 0.01) and physical role limitations (72.1 vs 85.9; P < 0.001). Depression was significantly more common among male patients with FD than among male controls (6.8% vs 2.0%, respectively; P < 0.05). More gastrointestinal comorbidity was reported among patients of both sexes compared with controls.

CONCLUSIONS

This population-based case-control study reported HRQoL impairment overall among patients with FD. This impairment was more apparent in female patients than in female controls. Females with FD tended to be more negatively affected in their daily life than their male counterparts. These gender differences should be investigated further in future studies.

Visceral hypersensitivity and impaired accommodation in refractory diabetic gastroparesis

The pathophysiology of persistent gastrointestinal (GI) symptoms in patients with diabetic gastroparesis is poorly understood. Our aim was to evaluate gastric sensation and accommodation to a meal in patients with diabetic gastroparesis and refractory symptoms. We performed intermittent, phasic balloon distensions of the stomach using a gastric barostat device in 18 patients with diabetes and gastroparesis unresponsive to prokinetic therapy and in 13 healthy volunteers. We assessed the biomechanical, sensory and accommodation responses of the stomach, during fasting and after liquid meal. During balloon distension, the sensory thresholds for discomfort were lower (P < 0.02) in patients with diabetes than those in controls, in both the fasting and the postprandial states. The accommodation response to a meal was significantly impaired (P = 0.01) in patients with diabetes when compared to controls, although fasting gastric tone was similar (P = 0.08). Patients with diabetic gastroparesis and refractory GI symptoms demonstrate sensori-motor dysfunction of the stomach, comprising either impaired accommodation, gastric hypersensitivity or both. An objective evaluation of these biomechanical and sensory properties may provide valuable mechanistic insights that could guide therapy.

Predictors and non-predictors of symptom relief in dyspepsia consultations in primary care

OBJECTIVE

We aimed to evaluate if the course of dyspepsia is influenced by medical consultation in primary care.

DESIGN, SETTING AND PATIENTS

Australian general practitioners (n = 27) recruited 157 dyspeptic patients, of whom 94 were eligible for follow-up. Dyspepsia, comorbidity, quality of life, emotional status, locus of control and consultation satisfaction were measured at baseline and follow-up (mean 3 months).

MAIN OUTCOME MEASURE

Response was defined as improvement of dyspepsia over time on the Nepean Dyspepsia Index score.

RESULTS

Dyspepsia improved in 82% (n = 77). There was no significant change in non-gastrointestinal symptoms. Half were worried or stressed by their symptoms, and 85% wanted reassurance, a need that (univariately) differentiated responders from non-responders (p = 0.02). Most patients seen in primary care with dyspepsia improved. If the doctor believed it was likely that the patient would follow their recommendations, the patient was nearly five times as likely to be a responder (OR 4.9, 95% CI 1.2-19.0). The only other significant predictor was acid suppression therapy (OR 3.5, 95% CI 1.1-10.9).

CONCLUSION

Most primary care visits for dyspepsia are followed by improvement, which may be predicted in part by indicators of patient compliance. Prescription of acid suppression therapy may also improve outcome in dyspepsia.

Laparoscopic paraesophageal hernia repair: quality of life outcomes in the elderly

Paraesophageal hernias (PEH) occur when there is herniation of the stomach through a dilated hiatal aperture. These hernias occur more commonly in the elderly, who are often not offered surgery despite the failure of medical treatment to address mechanical symptoms and life-threatening complications. The aim of this study was to assess the impact of laparoscopic repair of PEH on quality of life in an elderly population. Data were collected prospectively on 35 consecutive patients aged >70 years who had laparoscopic repair of a symptomatic PEH between December 2001 and September 2005. The change in quality of life was assessed using a validated questionnaire, the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD), and by patient interviews. Patients were assessed preoperatively, and at 6 weeks, 6 months, 12 months, 1 year, and 2 years postoperatively. Mean patient age was 77 years (range 70-85); mean American Society of Anesthesiologists class was 2.7 (range 1-3). There were 28 women and 7 men. There was one readmission for acute reherniation, which required open revision. Total complication rate was 17.1%. All complications were treated without residual disability. There was no 30-day mortality, and median hospital stay was 3 days (range 2-14). Completed questionnaires were obtained in 30 of 35 patients (85.7%). There was a significant improvement in quality of life, as measured with QOLRAD, at all postoperative time points (P < 0.001). Laparoscopic PEH repair can be performed with acceptable morbidity in symptomatic patients refractory to conservative treatment and is associated with a significant improvement in quality of life. Our data support elective repair of symptomatic PEH in the elderly, a population who may not always be referred for a surgical opinion.

Validation of a disease-specific quality-of-life questionnaire in a large sample of Dutch achalasia patients

The aim of this study was to validate a translated version of an achalasia-specific quality-of-life questionnaire (achalasia-DSQoL) by examining its psychometric properties in a Dutch cohort of achalasia patients. The achalasia-DSQoL was administered to 171 treated achalasia patients together with a clinical symptom score and the RAND-36. Validation methods included factor analysis, known-group techniques, Cronbach's alpha and Spearman rank correlation with other questionnaires and feasibility. About 72.5% of the achalasia patients completed the questionnaires. The achalasia-DSQoL showed evidence of an underlying construct and seems reliable with a Cronbach's alpha of 0.77. The question concerning heartburn did not correlate with the other items on the questionnaire. Known-group techniques demonstrated that the achalasia-DSQoL discriminates between achalasia patients in clinical remission and patients who are not. There was a moderate correlation between the achalasia-DSQoL and the RAND-36 subscales. The questionnaire was easy in use. The translated version of the achalasia-DSQoL is a valid and reliable instrument to compare groups of achalasia patients although the question concerning heartburn should be excluded.

Cholesterol reduction using psyllium husks - do gastrointestinal adverse effects limit compliance? Results of a specific observational study

PURPOSE

Despite known cholesterol lowering effects the use of psyllium husk (Plantaginis ovatae testa) in Germany for hypercholesterolemia is limited compared to their use as a laxative. To investigate whether use in hypercholesterolemia is limited due to adverse effects on the gastrointestinal system, a prospective observational study was conducted.

METHODS

Sixty-two outpatients with documented hypercholesterolemia and complaints of constipation were identified from an academic clinical center. Treatment with 3.5g psyllium husk preparation administered three times daily was initiated and patients were monitored at weekly intervals. Gastrointestinal symptoms were quantified using a validated Nepean Dyspepsia Index modified to identify both upper and lower abdominal symptoms. Diaries and study medication records were used to evaluate compliance.

RESULTS

Fifty-four of 62 patients enrolled in the study completed the study protocol with 4 subjects discontinuing due to adverse reactions associated with psyllium husks. Total cholesterol was significantly decreased from 252+/-39mg/dl before treatment to 239+/-37mg/dl after 3 weeks of treatment. Similarly, low density lipoprotein (LDL)-cholesterol decreased from 174+/-34 to 162+/-31mg/dl during the study. Triglycerides and high density lipoprotein (HDL) were unchanged. Gastrointestinal symptoms were rated lower at the end than at the beginning of the study. In week 1 most of the patients reported gastrointestinal symptoms and also gastrointestinal adverse reactions, which however, showed a decrease from week 1 to weeks 2 and 3 in the diaries. Patient response to study medication was positive for patients completing the study.

CONCLUSIONS

Psyllium husk preparations may be a therapeutic option for patients with mild to moderately elevated cholesterol levels. Adverse gastrointestinal symptoms associated with the preparation appear to be transient in some of the patients. Compliance may be optimized with adequate patient counseling.

Reliability and validity of the Gastrointestinal Symptom Rating Scale (GSRS) and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire in dyspepsia: a six-country study

BACKGROUND

Symptoms of dyspepsia significantly disrupt patients' lives and reliable methods of assessing symptom status are important for patient management. The aim of the current study was to document the psychometric characteristics of the Gastrointestinal Symptom Rating Scale (GSRS) and the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD) in Afrikaans, German, Hungarian, Italian, Polish and Spanish patients with dyspepsia.

METHODS

853 patients with symptoms of dyspepsia completed the GSRS, the QOLRAD, the 36-item Short-Form Health Survey (SF-36) and the Hospital Anxiety and Depression scale.

RESULTS

The internal consistency reliability of the GSRS was 0.43-0.87 and of the QOLRAD 0.79-0.95. Test-retest reliability of the GSRS was 0.36-0.75 and of the QOLRAD 0.41-0.82. GSRS Abdominal pain domain correlated significantly with all QOLRAD domains in most language versions, and with SF-36 Bodily pain in all versions. QOLRAD domains correlated significantly with the majority of SF-36 domains in most versions. Both questionnaires were able to differentiate between patients whose health status differed according to symptom frequency and severity.

CONCLUSION

The psychometric characteristics of the different language versions of the GSRS and QOLRAD were found to be good, with acceptable reliability and validity. The GSRS and QOLRAD were found to be useful for evaluating dyspeptic symptoms and their impact on patients' daily lives in multinational clinical trials.

Impaired drinking capacity in patients with functional dyspepsia: intragastric distribution and distal stomach volume

The water drink test is a good tool to evoke dyspeptic symptoms. To what extent these symptoms are related to altered gastric distribution is not clear. Therefore, we determined gastric volumes after a drink test using SPECT. After a baseline scan 20 healthy volunteers (HV) and 18 patients with functional dyspepsia (FD) underwent a drink test (100 mL min(-1)) followed by five scans up to 2 h. Dyspeptic symptoms were scored before every scan. A Wilcoxon signed rank test (P < 0.05) and a mixed effects model were used for statistical analyses. Fasting volumes were significantly higher in FD compared to HV for total, proximal and distal stomach (P < 0.001). Functional dyspeptic patients ingested significantly less water (P < 0.001) and had an impaired filling of the distal part of the stomach (P = 0.001) after the drink test. In FD, bloating (prox. 80%, dist. 56%), pain (prox. 87%, dist. 62%) and fullness (prox. 80%, dist. 59%) were determined more by proximal stomach volume rather than distal stomach volume. These data suggest that drinking capacity is mainly determined by antral volume, with a reduced antral filling in FD compared to HV. The persisting symptoms of bloating, pain and fullness in FD are predominantly associated with proximal stomach volume.

Internet-based assessment of bowel symptoms and quality of life

OBJECTIVES

We wished to determine the value of an open-access internet questionnaire for assessment of upper and lower gastrointestinal symptoms and health-related quality of life.

METHODS

Between January 2002 and June 2005, a symptom scale for upper gastrointestinal and lower gastrointestinal symptoms was placed on a genuine website (www.gesundheits-umfrage.de) and linked to the website of the German irritable bowel syndrome patient group (www.Reizdarmselbsthilfe.de). Patients were asked to report gastrointestinal symptoms that had occurred during the last month. Patients who finished this symptoms questionnaire and acknowledged more than two of a total of eight upper gastrointestinal symptoms and/or more than two of 16 lower gastrointestinal symptoms were immediately offered the assessment of their health-related quality of life by a validated general quality of life scale--the patient general well-being inventory--a 22-item scale with six subscales (anxiety, depression, general well-being, self-control, health, and vitality) and a global scale. Total patient general well-being inventory scores and subscale values were correlated to upper gastrointestinal and lower gastrointestinal symptom scores including the Rome I definition of the irritable bowel syndrome, and to social variables.

RESULTS

Five thousand two hundred and fifty-six individuals completed symptom assessment. Out of these, 4431 had three or more upper gastrointestinal symptoms, the mean number of upper gastrointestinal symptoms reported was 3.2+/-2.0; 4456 had three or more lower gastrointestinal symptoms (mean: 10.3+/-3.3), and 3187 met the Rome I criteria for irritable bowel syndrome. A total of 3316 individuals completed the patient general well-being inventory assessment (1156 men, 2160 women, mean age: 37.7+/-12.3 years). Upper gastrointestinal, lower gastrointestinal, and total symptom score were higher in women than in men (P < 0.001), and significantly correlated to the global quality of life assessment. Family status affected the symptom scores (higher in singles) and quality of life scores (lower in people living in partnership for health, but higher for vitality and depression). Age correlated negatively with upper gastrointestinal, lower gastrointestinal, and with total symptom scores as well as with some patient general well-being inventory scores.

CONCLUSION

Symptom and quality of life assessment using an open internet questionnaire is feasible and generates data which are, in large, comparable to those from other sources of assessment, despite the fact that the population addressed is, on average, moderately younger than previously studied cohorts.

Prevalência de dispepsia e fatores sociodemográficos

OBJETIVO: Medir a prevalência e distribuição de dispepsia e dispepsia freqüente por subtipos na população com 20 anos ou mais segundo características socioeconômicas e demográficas. MÉTODOS: Estudo transversal, de base populacional, com 3.934 indivíduos moradores na cidade de Pelotas (RS), entrevistados em seus domicílios, de outubro de 1999 a janeiro de 2000. Dispepsia foi definida como dor ou desconforto no andar superior do abdome e/ou náuseas no ano anterior à entrevista (conforme critérios Roma I e II). Dispepsia freqüente incluiu o registro de dispepsia mais de seis vezes e/ou náuseas, uma vez por mês ou mais. Esses desfechos foram analisados por idade, sexo, cor da pele, escolaridade, renda e estado civil. Os dados foram analisados por meio do teste qui-quadrado de Pearson de associação para variáveis categóricas e teste de tendência linear, quando aplicável. RESULTADOS: A prevalência de dispepsia foi de 44,4% e de dispepsia freqüente, 27,4%. A prevalência de dispepsia tipo refluxo, úlcera, dismotilidade e não especificada foi, respectivamente, 19,4%, 6,3%, 13,9% e 16,6%; para dispepsia freqüente foram 14,7%, 4,9%, 11,2% e 6,8%, respectivamente. As mulheres apresentaram cerca de 50% mais dispepsia freqüente. Indivíduos mais jovens e de menor renda apresentaram maiores prevalências de dispepsia e dispepsia freqüente. Análise de acordo com critérios de Roma II mostrou prevalências de 15,9% e 7,5% para dispepsia e dispepsia freqüente, respectivamente. CONCLUSÕES: A dispepsia constitui um problema prevalente na população estudada. A maioria dos indivíduos apresentaram mais de um subtipo de dispepsia.

Predictors of the placebo response in functional dyspepsia

BACKGROUND

Trials in functional dyspepsia report placebo response rates of 30% to 40%.

AIM

We aimed to identify predictors of the placebo response.

METHODS

Patients from primary, secondary and tertiary practices with functional dyspepsia defined by Rome II criteria were enrolled into one of four clinical trials; 220 patients were randomized to receive placebo. Scintigraphic assessment of gastric emptying at baseline was repeated at the end of the treatment in those with delayed emptying. After a 2 week run-in period, patients were followed for 8 weeks on placebo. Response was assessed on a weekly basis and a responder was defined as satisfactory relief of meal-related symptoms on at least 50% of weeks.

RESULTS

The mean age was 44 years (range 18-82) and 74% were female; 76 (35%) were placebo responders. The predominant symptom was an unstable measure over the trial. Independent predictors of a lower placebo response were lower body mass index and a more consistent predominant symptom pattern (both P < 0.05). No association was seen with age, gender, centre type, baseline symptom score, baseline or change in gastric emptying, or baseline quality of life.

CONCLUSION

In functional dyspepsia, a consistent predominant symptom pattern and lower body mass index may be associated with a lower placebo response rate.

A placebo-controlled trial of itopride in functional dyspepsia

BACKGROUND

The treatment of patients with functional dyspepsia remains unsatisfactory. We assessed the efficacy of itopride, a dopamine D2 antagonist with anti-acetylcholinesterase [corrected] effects, in patients with functional dyspepsia.

METHODS

Patients with functional dyspepsia were randomly assigned to receive either itopride (50, 100, or 200 mg three times daily) or placebo. After eight weeks of treatment, three primary efficacy end points were analyzed: the change from baseline in the severity of symptoms of functional dyspepsia (as assessed by the Leeds Dyspepsia Questionnaire), patients' global assessment of efficacy (the proportion of patients without symptoms or with marked improvement), and the severity of pain or fullness as rated on a five-grade scale.

RESULTS

We randomly assigned 554 patients; 523 had outcome data and could be included in the analyses. After eight weeks, 41 percent of the patients receiving placebo were symptom-free or had marked improvement, as compared with 57 percent, 59 percent, and 64 percent receiving itopride at a dose of 50, 100, or 200 mg three times daily, respectively (P<0.05 for all comparisons between placebo and itopride). Although the symptom score improved significantly in all four groups, an overall analysis revealed that itopride was significantly superior to placebo, with the greatest symptom-score improvement in the 100- and 200-mg groups (-6.24 and -6.27, vs. -4.50 in the placebo group; P=0.05). Analysis of the combined end point of pain and fullness showed that itopride yielded a greater rate of response than placebo (73 percent vs. 63 percent, P=0.04).

CONCLUSIONS

Itopride significantly improves symptoms in patients with functional dyspepsia. (ClinicalTrials.gov number, NCT00272103.).

Development and validation of a functional dyspepsia-related quality of life (FD-QOL) scale in South Korea

BACKGROUND

Quality of life (QOL) in patients with functional dyspepsia in South Korea has never been studied, mostly due to the lack of a psychometrically validated disease-specific instrument for measuring the QOL. The aim of the present study was to develop and validate a QOL scale for patients with functional dyspepsia.

METHODS

A Functional Dyspepsia-Related QOL (FD-QOL) scale was developed and validated as follows: item generation, pilot test, and psychometric test. Patients with functional dyspepsia (n = 220) were recruited from seven university hospitals. The participants were asked to complete the preliminary item-generated FD-QOL, the Short Form-36 (SF-36), and the Index of Dyspepsia Symptoms-Korean (IDS-K). The data were analyzed using factor analysis, correlation, anova, and Cronbach's alpha.

RESULTS

Twenty-three items were generated based upon content validity. Factor analysis extracted a four-factor solution, and two items were deleted because they were not loaded significantly on any factor. The FD-QOL was correlated with the SF-36 subscales, of which scores were differentiated according to the levels of dyspepsia symptoms. Cronbach's alpha of the FD-QOL was 0.94.

CONCLUSIONS

The FD-QOL scale is a rapid and easily applicable instrument with excellent psychometric properties of content, factorial, convergent, and known-groups validity, and internal consistency reliability in Korean patients with functional dyspepsia.

Management of functional dyspepsia: Unsolved problems and new perspectives

The common characteristic criteria of all functional gastrointestinal (GI) disorders are the persistence and recurrence of variable gastrointestinal symptoms that cannot be explained by any structural or biochemical abnormalities. Functional dyspepsia (FD) represents one of the important GI disorders in Western countries because of its remarkably high prevalence in general population and its impact on quality of life. Due to its dependence on both subjective determinants and diverse country-specific circumstances, the definition and management strategies of FD are still variably stated. Clinical trials with several drug classes (e.g., proton pump inhibitors, H2-blockers, prokinetic drugs) have been performed frequently without validated disease-specific test instruments for the outcome measurements. Therefore, the interpretation of such trials remains difficult and controversial with respect to comparability and evaluation of drug efficacy, and definite conclusions can be drawn neither for diagnostic management nor for efficacious drug therapy so far. In view of these unsolved problems, guidelines both on the clinical management of FD and on the performance of clinical trials are needed. In recent years, increasing research work has been done in this area. Clinical trials conducted in adequately diagnosed patients that provided validated outcome measurements may result in better insights leading to more effective treatment strategies. Encouraging perspectives have been recently performed by methodologically well-designed treatment studies with herbal drug preparations. Herbal drugs, given their proven efficacy in clinical trials, offer a safe therapeutic alternative in the treatment of FD which is often favored by both patients and physicians. A fixed combination of peppermint oil and caraway oil in patients suffering from FD could be proven effective by well-designed clinical trials.

Validation of the gastrointestinal symptom score for the assessment of symptoms in patients with functional dyspepsia

AIM

To validate the gastrointestinal symptom score as an outcome measure for functional dyspepsia.

METHODS

In focus groups, 10 dyspepsia-specific items including nausea, sickness, vomiting, bloating, abdominal cramps, early satiety, acidic eructation/heartburn, loss of appetite, retrosternal discomfort, epigastric pain/upper abdominal pain were identified. Ninety-five patients with functional dyspepsia and 56 healthy controls were recruited and responsiveness evaluated by analysing gastrointestinal symptom score data from 357 patients from previous placebo-controlled trials. Gastrointestinal symptom score response data were correlated with the patient's global assessments of efficacy. Convergent validity was assessed by correlating the gastrointestinal symptom score with the results obtained by the Nepean Dyspepsia Index.

RESULTS

Sensitivity: In patients and healthy controls gastrointestinal symptom score yielded consistently different scores (all P < 0.0001). TEST-RETEST RELIABILITY: Gastrointestinal symptom score determined at the two time points were significantly correlated (r-values ranging from 0.842 to 0.901). CONVERGENCE VALIDITY: Gastrointestinal symptom score of both rating groups were significantly correlated with the symptom-specific component of the Nepean Dyspepsia Index (r-vales ranging from 0.666 to 0.764, P < 0.01). RESPONSIVENESS: Responses of gastrointestinal symptom score during treatment were different for patients with a global self assessment as responders compared with non-responders (all P < 0.0055).

CONCLUSION

The gastrointestinal symptom score is a valid and reliable instrument to assess symptom intensities in patients with functional dyspepsia.

Symptom reporting by functional dyspeptics during the water load test

INTRODUCTION

Reporting of symptoms and visceral sensations in functional dyspepsia is subjective and influenced by such factors as somatization and depression. To better understand the role of these factors in symptom reporting, somatization, somatosensory amplification, alexithymia, and depression were evaluated in patients with functional dyspepsia undergoing a water load test.

METHODS

Sixty-seven controls and 103 patients with functional dyspepsia underwent a 5-min water load. Participants both recalled dyspeptic symptoms from the previous 2 wk and rated symptoms of nausea, fullness, and bloating during water load. Participants also completed the symptom checklist-90-R, somatosensory amplification scale, and the Toronto alexithymia scale.

RESULTS

Compared with controls, patients with dyspepsia had greater psychiatric distress and higher scores for somatosensory amplification and alexithymia. Patients with dyspepsia also reported fullness at significantly lower volumes of water and experienced greater symptoms during water load than controls. Receiver operator characteristics of water load volume and provoked symptoms suggested that water load (WL) volume was a better discriminator of patients with dyspepsia from controls. Patients with dyspepsia recalled significantly more symptoms in the 2 wk prior to study. Symptoms provoked during WL were not associated with measured psychiatric constructs in either controls or patients with dyspepsia whereas recalled symptoms in patients with functional dyspepsia were significantly associated with several measured psychiatric constructs.

CONCLUSIONS

Patients with functional dyspepsia report fullness at lower volumes of ingested water and develop more symptoms than do controls. Water load volume better discriminates patients with dyspepsia from controls than does symptoms provoked during water load. Provoked symptoms in dyspepsia are not associated with measured psychiatric constructs but recalled symptoms are.

Development and psychometric evaluation of the patient assessment of upper gastrointestinal symptom severity index (PAGI-SYM) in patients with upper gastrointestinal disorders

OBJECTIVE

Describe the development and evaluation of a new self-report instrument, the patient assessment of upper gastrointestinal disorders-symptom severity index (PAGI-SYM) in subjects with gastroesophageal reflux disease (GERD), dyspepsia, or gastroparesis.

METHODS

Recruited subjects with GERD (n=810), dyspepsia (n = 767), or gastroparesis (n = 169) from the US, France, Germany, Italy, the Netherlands, and Poland. Subjects completed the PAGI-SYM, SF-36, a disease-specific HRQL measure (PAGI-QOL), and disability day questions. Two-week reproducibility was evaluated in 277 stable subjects. We evaluated construct validity by correlating subscale scores with SF-36, PAGI-QOL, disability days, and global symptom severity scores.

RESULTS

The final 20-item PAGI-SYM has six subscales: heartburn/regurgitation, fullness/early satiety, nausea/vomiting, bloating, upper abdominal pain, and lower abdominal pain. Internal consistency reliability was good (alpha = 0.79-0.91); test-retest reliability was acceptable (Intraclass correlation coefficients alpha=0.60-0.82). PAGI-SYM subscale scores correlated significantly with SF-36 scores (all p < 0.0001), PAGI-QOL scores (all p < 0.0001), disability days (p < 0.0001), and global symptom severity (p < 0.0001). Mean PAGI-SYM scores varied significantly in groups defined by disability days (all p < 0.0001), where greater symptom severity was associated with more disability days.

CONCLUSIONS

Results suggest the PAGI-SYM, a brief symptom severity instrument, has good reliability and evidence supporting construct validity in subjects with GERD, dyspepsia, or gastroparesis.

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.

Alexithymia and somatosensory amplification in functional dyspepsia

Somatosensory amplification is the tendency to report somatic sensations as intense and disturbing. Alexithymia is a personality construct characterized by difficulty recognizing emotions and a tendency to focus on external events and bodily sensations. The association of somatosensory amplification and alexithymia with functional symptoms was assessed in 111 patients with functional dyspepsia and 53 healthy comparison subjects. The subjects completed several assessment instruments, including the Somatosensory Amplification Scale and the 20-Item Toronto Alexithymia Scale. The patients with dyspepsia had modestly higher scores on measures of alexithymia (especially difficulty identifying feelings) and somatosensory amplification. Alexithymia and somatosensory amplification may play important roles in symptom generation and perception in a subset of patients with functional dyspepsia, but the importance of these constructs in this patient population appears less than previously reported.

Measuring dyspepsia: a new severity index validated in Bologna

BACKGROUND

Measurement of the severity of dyspepsia symptoms before and after treatment and determining what is a significant change is a major problem in designing dyspepsia treatment studies.

OBJECTIVES

To assess the reproducibility, validity and responsiveness to treatment of a dyspepsia questionnaire to be used in clinical and population-based studies.

METHODS

Seventy-three dyspeptic patients (35 male, 38 female; mean age 52 years) and 75 healthy volunteers (32 male, 43 female; mean age 52 years) were included. Subjects were interviewed for the presence/absence and severity/frequency of 19 gastrointestinal symptoms. Severity was measured on a 5-point scale. Frequency was also recorded on a 5-point scale. A global symptom index (severity x frequency) was calculated for the eight most severe symptoms; a mean global symptom index (8-MGSI) was considered for the evaluation of the instrument. To evaluate intra-observer variation, one author interviewed subjects (T0) and then repeated the interview 1 week later (T1). For inter-observer variation, two authors interviewed patients. VALIDITY was measured by comparing 8-MGSI of the dyspepsia patients to those of healthy volunteers. Responsiveness was assessed by comparing mean global symptom index before and 1 month after appropriate therapy.

RESULTS

Reproducibility: The mean 8-MGSI was 4.5 at T0 and 3.7 at T1 with a correlation coefficient of 0.62. As for inter-observer variation, the average 8-MGSI was 4.8 by the first author and 3.9 by the second with a correlation coefficient of 0.60.

VALIDITY

The mean 8-MGSI was, respectively, 1.4 in healthy volunteers and 4.8 in dyspeptic patients (p = 0.001). Responsiveness: After treatment, a significant improvement in 8-MGSI was detected (p = 0.001).

CONCLUSIONS

This questionnaire is a reliable, valid and responsive instrument for measuring the presence, severity and frequency of dyspepsia.

Symptoms, gastric function, and psychosocial factors in functional dyspepsia

INTRODUCTION

The classification of functional dyspepsia into meaningful subgroups remains an important goal. The aim of this investigation was to determine correlations between dyspeptic symptoms with gastric physiology and psychologic distress.

METHODS

Consecutive patients with functional dyspepsia were evaluated with electrogastrography (EGG), drink test, and solid phase gastric emptying. Subjects also completed the Nepean Dyspepsia Index, Psychologic General Well-Being Index, SCL-90R, and SF-36.

RESULTS

Eighty-one patients were evaluated. Gastric emptying was performed in 29 of 81 patients and was abnormal in 21%, but no correlation existed between symptoms and T1/2 or TLAG. EGG was abnormal in 42% and drink test was abnormal in 40% of patients. Both were significantly associated with nausea but not with other symptoms. Significant correlations existed with 10 of 15 assessed symptoms and various subscales of the SCL-90R. Somatization was associated with abdominal burning, chest pain, abdominal pressure, abdominal discomfort, bad breath, chest burning, excessive fullness, bloating, abdominal pain, and regurgitation. Anxiety was associated with abdominal burning, chest pain, abdominal pressure, and abdominal discomfort. Anger-hostility was associated with abdominal burning and abdominal pressure. Increased interpersonal sensitivity was associated with abdominal burning and chest burning. SCL-90R Global Symptom Score was associated with abdominal burning, chest pain, abdominal discomfort, and bad breath.

CONCLUSIONS

Abnormal gastric physiology as measured in this study was not associated with symptoms other than nausea. Significant associations existed between measures of psychiatric distress and digestive symptoms. Symptoms in functional dyspepsia had greater associations with psychologic distress than with commonly employed tests of gastric physiology.

Factors associated with health-related quality of life in chronic pancreatitis

OBJECTIVES

Chronic pancreatitis may lead to considerable reduction in health-related quality of life, but factors associated with a poor perceived health status have not been investigated.

METHODS

We recruited 265 patients with chronic pancreatitis from a tertiary care gastroenterology clinic. Health-related quality of life was assessed using the Short Form-36 Health Survey. Data were compared with age- and gender-adjusted values from the German general population (6964 adults). Factors associated with poor perceived health status were identified by logistic regression.

RESULTS

All domains of health-related quality of life were reduced in chronic pancreatitis. Decrements were most pronounced in role limitations caused by physical (-25%) and emotional health problems (-15%), and general health perceptions (-19%). Severity of abdominal pain, chronic pancreatic diarrhea, low body weight, and loss of work independently contributed to the physical component score of the Short Form-36 (adjusted R2= 33.8%) and were the factors most closely associated with poor health status perception. The etiology and duration of the disease or changes in pancreatic morphology had no impact on health-related quality of life.

CONCLUSIONS

Patients with chronic pancreatitis experience substantial impairments in health-related quality of life. The severity of chronic pancreatitis-related symptoms is directly associated with patient function and well-being. These data offer further insight into the impact of chronic pancreatitis on patient health status and may serve as the basis for the development of disease-specific instruments, which are needed to measure the effect of therapeutic interventions on patient-derived health outcomes.

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.

Proposals to enhance the quality of observational cohort studies

For herbal medicinal products the methodology of observational cohort studies (observational studies, drug monitoring studies, Anwendungsbeobachtung) represents a useful addition to clinical trials. The key objectives are the documentation of efficacy in particular under conditions of everyday medical practice in authentic patients and the documentation of the safety profile. Supplementary to earlier activities, members of the "Clinical Trials of Herbal Medicinal Products" Working Party of the German Society for Phytotherapy have therefore again addressed the issue of observational cohort studies for to enhance the informative value and importance of this clinical research methodology. Recommendations were developed on quality aspects, methodological approaches of observation parameters, and for the reporting of the study's results. Properly planned and conducted observational cohort studies may contribute to the documentation and proof of well-established medicinal use according the EU Directive 2001/83/EC.

Health-related quality of life in chronic pancreatitis: a psychometric assessment

BACKGROUND

Measurement properties of a generic instrument to assess health-related quality of life in patients with chronic pancreatitis have not been described.

METHODS

We assessed the health-related quality of life in 314 patients with chronic pancreatitis using the generic Medical Outcomes Study Short Form-36 Health Survey. Data were compared with age- and gender-matched general population norms and the psychometric properties of the instrument were evaluated.

RESULTS

Patients with chronic pancreatitis reported considerably worse scores on all Short Form-36 scales compared with the general population. Decrements were most pronounced in role limitations caused by physical (-29%) and emotional health problems (-20%), and general health perceptions (-19%). Test-retest reliability coefficients were > or = 0.82 for all subscales and internal consistency coefficients ranged from 0.78 to 0.92. Floor effects were negligible for all but the two role subscales, but there were substantial ceiling effects for five of the eight subscales. Construct validity was supported by the findings that the Short Form-36 discriminated well between patients of different age, burden of chronic illness and severity of symptoms.

CONCLUSIONS

Patients with chronic pancreatitis experience substantial deteriorations in health-related quality of life compared with the general population. The Short Form-36 proved to be a feasible, reliable and valid measure for descriptive studies of patients with chronic pancreatitis, but ceiling effects may limit its usefulness as an outcome measure in the assessment of treatment effects.

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.

The water load test: observations from healthy controls and patients with functional dyspepsia

Gastric sensation and accommodation are studied by barostat, but this is invasive. The drink test is noninvasive and may provide similar information. We evaluated relationships between drink test, gastric function, symptoms, and psychiatric distress. Controls (73) and functional dyspeptics (FD) (92) were studied using a 5-min water load test (WL5), gastric emptying, and electrogastrography (EGG). Symptoms, quality of life, and psychiatric distress were measured using standardized measures. Controls underwent test-retest of WL5 and comparison of WL5 with 100 ml/min water-based drink test (WL100) or nutrient drink. Controls, FD, and gastroparetics estimated drinking capacity before WL5 using a visual analog scale. WL5 correlated with WL100 (r = 0.7929) but not nutrient drink test (r = 0.1995). WL5 was significantly less in FD than controls, and abnormal WL5 was seen in 46%. In FD, volume to fullness inversely correlated with symptom severity (r =-0.29; P = 0.0154) and WL5 produced more symptoms, particularly nausea. Gastric function was not different between FD with normal or abnormal WL5. Symptoms and psychiatric distress were similar between normal and abnormal WL5 groups, but the abnormal group had significantly poorer quality of life. Controls and gastroparetics had good correlation of estimated and ingested volumes, but FD did not. Versus FD with normal WL5 capacity, FD with impaired drinking capacity have normal gastric function and similar symptoms but poorer quality of life. FD are less able to predict drinking capacity. These data suggest that WL5 identifies FD with intact gastric function but abnormal visceral perception.