The role of psychosocial factors in peptic ulcer disease: beyond Helicobacter pylori and NSAIDs

Methodological advice for the young at heart investigator: Triangulation to build better foundations

In medicine and science, one is typically taught the main theories in a discipline or field along with standard models before receiving more instructions on how to apply certain methods. The aim of this work is not to address one method, but rather methodology, the study and evaluation of methods, by taking a philosophy of science detour. In this, a critique of biomedicine will be used as a starting point to address some positions regarding reductionism, specifying notions such as systems and mechanisms, as well as regarding the mind-body problem discussing psychosomatic medicine and psychoneuroimmunology. Some recommendations to make science more pluralistic, robust and translationally-relevant will then be made as a way to foster constructive debates on reductionism and the mind-body problem and, in turn, favor more interdisciplinary research.

Depression during the COVID-19 pandemic among older Canadians with peptic ulcer disease: Analysis of the Canadian Longitudinal Study on Aging

The COVID-19 pandemic and associated public health measures have exacerbated many known risk factors for depression that may be particularly concerning for individuals with chronic health conditions, such as peptic ulcer disease (PUD). In a large longitudinal sample of older adults with PUD, the current study examined the incidence of depression during the pandemic among those without a pre-pandemic history of depression (n = 689) and the recurrence of depression among those with a history of depression (n = 451). Data came from four waves of the Canadian Longitudinal Study on Aging (CLSA). Multivariate logistic regression analyses were conducted to identify factors associated with incident and recurrent depression. Among older adults with PUD and without a history of depression, approximately 1 in 8 (13.0%) developed depression for the first time during the COVID-19 pandemic. Among those with a history of depression, approximately 1 in 2 (46.6%) experienced depression during the pandemic. The risk of incident depression and recurrent depression was higher among those who were lonely, those with functional limitations, and those who experienced an increase in family conflict during the pandemic. The risk of incident depression only was higher among women, individuals whose income did not satisfy their basic needs, those who were themselves ill and/or those whose loved ones were ill or died during the pandemic, and those who had disruptions to healthcare access during the pandemic. The risk of recurrent depression only was higher among those with chronic pain and those who had difficulty accessing medication during the pandemic. Implications for interventions are discussed.

Anxiety symptoms in older Chinese adults in primary care settings: Prevalence and correlates

Background

Integrating mental health services into primary care is a potentially cost-effective way to decrease the treatment gap for anxiety in older adults but data on the epidemiology of anxiety symptoms in older Chinese adults in primary care settings have been very limited. This study investigated the prevalence and correlates of anxiety symptoms in Chinese older primary care patients.

Methods

A total of 753 older primary care patients (≥65 years) were consecutively recruited from 13 primary care clinics in Wuhan, China, and interviewed with the validated Chinese version of the short form of the Geriatric Anxiety Inventory (GAI-SF).

Results

The prevalence of anxiety symptoms (GAI-SF ≥ 3) in older primary care patients was 21.1%. Statistically significant correlates of anxiety symptoms were female sex (vs. male, OR = 1.85, P = 0.002), poor economic status (vs. good, OR = 2.31, P = 0.013), fair and poor family relationship (vs. good, OR = 1.85, P = 0.006), hypertension (OR = 2.01, P < 0.001), chronic gastric ulcer (OR = 6.82, P < 0.001), and Parkinson's disease (OR = 7.83, P = 0.031).

Conclusions

Anxiety symptoms are prevalent among older adults attending primary care clinics. Efforts for preventing or reducing anxiety symptoms in older primary care patients may be more useful to target those who are women, have poor financial status, don't have a good family relationship, suffer from hypertension, have chronic gastric ulcer, and suffer from Parkinson's disease.

The number of household members as a risk factor for peptic ulcer disease

Peptic ulcer disease (PUD) is caused by many sociodemographic and economic risk factors other than H. pylori infection. However, no studies reported an association between PUD and the number of household members. We showed the number of family members affected by PUD based on sex in a Korean population. This cross-sectional study used 1998–2009 data from the Korea National Health and Nutrition Examination Survey of the Korea Centers for Disease Control and Prevention. Multiple binary logistic regression models adjusted for confounders were constructed to analyze the association of PUD with the number of household members. The number of household members was associated with PUD, age, body mass index (BMI), waist circumference, systolic blood pressure, hemoglobin, glucose, location (urban/rural), income, education level, stress, current drinking, and smoking in both sexes. Men with other household members had a higher PUD risk compared to men or women living alone (reference), and the opposite was observed for women. Men with 4 household members had a higher PUD risk than men living alone in the model adjusted for age, BMI, income, location, education, and stress (OR = 2.04 [95% CI 1.28–3.27], p value = .003). Women with more than 6 household members had a lower PUD risk than women living alone in the adjusted model (OR = 0.50 [0.33–0.75], p value = .001). Women with more household members had a lower PUD risk. However, more men had PUD than women regardless of the number of household members.

Psychiatric symptoms among patients with acute abdominal pain

Background: Abdominal pain is a common cause of visits to emergency facilities. It is related to psychiatric disorders in primary care, but it is unclear if this also holds in emergency departments.Objective: Is to explore potential differences between diagnostic groups in patients with acute abdominal pain in an emergency ward regarding concurrent somatic-and psychiatric symptoms, 'Length of stay' (LOS) and perceived health.Method: The patients (N = 137) were divided into three groups; organic dyspepsia, specific abdominal diagnoses, and non-specific abdominal pain. The Prime-MD results for extra gastrointestinal symptoms (outside the gastrointestinal tract), psychiatric symptoms, frequency of symptoms, self-reported health, and LOS within the month before admittance were compared between the diagnostic groups.Results: There was a significant positive correlation between the number of physical extra gastrointestinal and psychiatric symptoms (p < .001), especially regarding anxiety (p < .001) and depression (p = .002). Patients with organic dyspepsia reported significantly more total (p = .016), extragastrointestinal (p = .026) (chest pain; p = .017, dizziness; p = .004, palpitations; p = .005, insomnia; p = .005 and worries; p = .001), and summarized anxiety and depression symptoms (p = .001-0.002) besides poorer general health (p < .001) compared to other abdominal conditions. Also, organic dyspepsia patients needed longer hospital stay than the non-specific abdominal group (p = .002) but similar to the specific abdominal disorders group.Conclusion: Organic dyspepsia is accompanied by more co-occurring physical, anxiety and depression symptoms as well as poorer perceived health than other abdominal pain conditions and comparably increased LOS. This suggests that psychiatric consultations might be beneficial for diagnosing and treating psychiatric comorbidity in emergency care.

Floating Drug Delivery Systems: An Emerging Trend for the Treatment of Peptic Ulcer

Floating drug delivery system (FDDS) is the main approach to prolonging the gastric residence time in the stomach in which the bilayer floating tablet has the main role. It is more suitable for the treatment of local infections such as peptic ulcer, gastritis, Zollinger-Ellision syndrome, indigestion, and other local infections related to the gastrointestinal tract and also used for systemic applications. FDDS provides protection for those drugs which are acid labile and have a short half-life. It also improves bioavailability, reduces drug waste, and enhances the residence time of drugs. Nowadays, various technologies are being used for the development of FDDS. Novel drug delivery systems incorporation into bilayer floating tablets have also broadened the role of FDDS. Polymers have the main role in the development of FDDS, which serve as carriers for the drug and determine the gastric retention time and drug protection. FDDS is also an easy, cheap, and more convenient method for dual drug delivery of drugs.

Increased risk of herpes zoster in patients with peptic ulcers: A longitudinal follow-up study using a national sample cohort

The purpose of this study was to investigate the association of herpes zoster infection with peptic ulcer disease in a Korean population.The Korean National Health Insurance Service selects samples directly from the entire Korean population database, and 1,125,691 participants with 114,369,638 medical claim codes were selected from the entire Korean population (50 million). A total of 127,802 peptic ulcer disease participants were matched with 127,802 control participants at a ratio of 1:1, considering age group, sex, income group, region of residence, hypertension, diabetes, and dyslipidemia. We analyzed stratified Cox proportional hazard models to calculate the hazard ratios of peptic ulcer with respect to herpes zoster. For subgroup analyses, we divided the participants by age, sex, and time periods after the index date.The rate of herpes zoster was higher in the peptic ulcer group (9.1% [11,669/127,802]) than in the control group (7.4% [9,397/127,802], P < .001). The adjusted hazard ratio of herpes zoster was 1.24 (95% CI = 1.21-1.28, P < .001). In subgroup analyses performed according to age and sex, all crude and adjusted hazard ratios of herpes zoster were higher in the peptic ulcer disease group than in the control group (each P < .05). In another subgroup analysis according to follow-up periods, the crude and adjusted hazard ratios of herpes zoster were higher in the peptic ulcer disease group than in the control group except for < 1 year periods after the index dates (each P < .001).The hazard ratios of herpes zoster were significantly increased in the peptic ulcer group compared with those in the control group in all age and sex groups.

Circadian rhythms: a regulator of gastrointestinal health and dysfunction

Circadian rhythms regulate much of gastrointestinal physiology including cell proliferation, motility, digestion, absorption, and electrolyte balance. Disruption of circadian rhythms can have adverse consequences including the promotion of and/or exacerbation of a wide variety of gastrointestinal disorders and diseases. Areas covered: In this review, we evaluate some of the many gastrointestinal functions that are regulated by circadian rhythms and how dysregulation of these functions may contribute to disease. This review also discusses some common gastrointestinal disorders that are known to be influenced by circadian rhythms as well as speculation about the mechanisms by which circadian rhythm disruption promotes dysfunction and disease pathogenesis. We discuss how knowledge of circadian rhythms and the advent of chrono-nutrition, chrono-pharmacology, and chrono-therapeutics might influence clinical practice. Expert opinion: As our knowledge of circadian biology increases, it may be possible to incorporate strategies that take advantage of circadian rhythms and chronotherapy to prevent and/or treat disease.

Cumulative exposure to nighttime environmental noise and the incidence of peptic ulcer

BACKGROUND

Exposure to noise poses auditory and non-auditory effects on health. The gastrointestinal tract is considered as the site of adverse reactions to noise-induced stress; little attention has been paid to a potential link between noise and peptic ulcers.

OBJECTIVES

The aim of this study was to investigate whether cumulative exposure to environmental noise affects the incidence of peptic ulcer in adults.

METHODS

We analyzed the data from the National Health Insurance Service-National Sample Cohort (2002-2013). The final study sample comprised 217,308 adults assessed for gastric ulcer and 249,514 adults assessed for duodenal ulcer. The diagnosis of gastric (ICD-10: K25) and duodenal (ICD-10: K26) ulcers during an 8-year follow-up (2006-2013). Environmental noise data was obtained from the National Noise Information System, a nationwide monitors system of noise.

RESULTS

During the follow-up period, gastric ulcers occurred in 32.1% subjects and duodenal ulcers occurred in 10.7% subjects. The rate of diagnosis for gastric and duodenal ulcers was increased with the increases in cumulative mean levels of nighttime environmental noise. With increases in the increase in interquartile range (IQR) of nighttime noise, the hazard ratio (HR) was significantly increased by 12% (HR = 1.12; 95% CI, 1.10-1.13) for gastric ulcer and 17% (HR = 1.17; 95% CI, 1.15-1.20) for duodenal ulcer based on the fully adjusted model.

CONCLUSION

Our finding supports previous reports on the damaging effect of environmental noise on the gastrointestinal tract and suggests that cumulative exposure to environmental nighttime noise affects the development of peptic ulcers.

Temperament and character in patients with acute abdominal pain

BACKGROUND

Several conditions presenting with abdominal pain are associated with specific personality factors although it is unclear if this is true also in emergency clinic settings.

OBJECTIVE

To study personality factors among patients with acute abdominal pain in an emergency ward.

METHODS

Consecutive patients (N = 165) with abdominal symptoms at an emergency clinic were administrated the Temperament and Character Inventory (TCI). Three main groups were identified; specific abdominal diagnoses, (N = 77), non-specific abdominal pain, (N = 67) and organic dyspepsia (N = 21). TCI results were compared between clinical groups and a control group (N = 122).

RESULTS

As compared to individuals with specific abdominal diagnoses and controls, those with organic dyspepsia were significantly more anxious (harm avoidance), (p = 0.003), and had lower ability to cooperate (cooperativeness) (p = 0.048 and p = 0.004 respectively). They were also significantly more unpretentious (self-transcendence) compared to individuals with specific abdominal diagnoses (p = 0.048), non-specific abdominal pain (p = 0.012) and controls (p = 0.004) and evidenced less mature character (sum of self-directedness and cooperativeness) compared to those with specific abdominal diagnoses and controls (p = 0.003).

CONCLUSION

Individuals seeking care at an emergency clinic with organic dyspepsia showed a distinguishable pattern of personality features that distinguished them from the other comparison groups. Therefore an evaluation of personality factors may add a new dimension to the diagnostic investigation in the emergency care of abdominal pain and contribute to the optimization of the treatment of organic dyspepsia.

A collection of the etiological theories, characteristics, and observations/phenomena of peptic ulcers in existing data

In this article, we compiled 13 etiological theories, 15 characteristics, and 81 observations/phenomena of peptic ulcers, reported in reproducible, peer-reviewed studies from the literature, to reflect the historical evolution of studies on peptic ulcers and to provide a multidisciplinary view of this disease. This data was collected during the systematic review of topics on peptic ulcers including genetics, etiology, epidemiology, psychology, anatomy, neurology, bacteriology, pathology, and clinical statistics. The data curated herein was extracted via application of recently published basic theories and methodologies.

Restructuring of a Textile Manufacturing Company and Workers' Health

Organizational restructuring is associated with greater mortality and morbidity of the workers affected by it. We examined the quality of workers' health at a textile manufacturing company after restructuring, comparing three groups of workers: workers who remained (survivors), workers who lost their jobs and later found new jobs (the reemployed), and unemployed workers. A total of 1046 workers participated in a telephonic survey. The data were processed using SPSS and the R package version 1.2 of prLogistic. The differences between groups were calculated using the chi-square test and adjusted prevalence ratios. The comparison between the three groups shows significantly poorer mental health of the unemployed, who more often than survivors and the reemployed reported depression, as well as significant differences in elevated blood pressure, cholesterol level, and cardiac disorders. The reemployed, who were nonetheless in better health compared to the unemployed, reported poor mental health or depression more often in comparison to survivors. Higher morbidity of the unemployed and reemployed could be influenced by numerous factors associated with restructuring.

Urinary incontinence is associated with the development of peptic ulcers in adult women: Data from the KNHANES IV

The aim of this study was to investigate the association between urinary incontinence (UI) and peptic ulcer (PU) and how this is related to psychological stress in Korean women by analyzing the data from the Korea National Health and Nutrition Examination Survey IV (KNHANES).A nationally representative sample of data on 7475 Korean women ≥19 years of age from the KNHANES 2008 to 2010 was included. Physician-diagnosed UI and PU were assessed using questionnaires and surveys. Psychological stress was assessed through a questionnaire using a 4-point Likert scale. Data were analyzed using logistic regression to determine the association between UI and PU according to the level of psychological stress perception.PU was found in 1.41% of the total population. Breaking this down by the existence of UI, PU was found in 3.5% of the population with UI, and 1.4% of the population without UI, which showed a significant difference. A statistically significant trend for increasing prevalence of UI and PU with increasing psychological stress perception levels was found among the study population. Multivariable logistic regression analyses for PU showed that UI was significantly associated with a higher probability of PU in an adjusted model, which means that members of the population with UI were more likely to have PU than those without UI. A higher level of psychological stress perception was also significantly associated with increased odds of PU in the adjusted model.UI could potentiate the development of PU through increasing levels of psychological stress perception.

Association of peptic ulcer disease with obesity, nutritional components, and blood parameters in the Korean population

Objectives

Peptic ulcer disease (PUD) is a common disorder, but whether an association exists between PUD and anthropometric indicators remains controversial. Furthermore, no studies on the association of PUD with anthropometric indices, blood parameters, and nutritional components have been reported. The aim of this study was to assess associations of anthropometrics, blood parameters, nutritional components, and lifestyle factors with PUD in the Korean population.

Methods

Data were collected from a nationally representative sample of the South Korean population using the Korea National Health and Nutrition Examination Survey. Logistic regression was used to examine associations of anthropometrics, blood parameters and nutritional components among patients with PUD.

Results

Age was the factor most strongly associated with PUD in women (p = <0.0001, odds ratio (OR) = 0.770 [0.683–0.869]) and men (p = <0.0001, OR = 0.715 [0.616–0.831]). In both crude and adjusted analyses, PUD was highly associated with weight (adjusted p = 0.0008, adjusted OR = 1.251 [95%CI: 1.098–1.426]), hip circumference (adjusted p = 0.005, adjusted OR = 1.198 [1.056–1.360]), and body mass index (adjusted p = 0.0001, adjusted OR = 1.303 [1.139–1.490]) in women and hip circumference (adjusted p = 0.0199, adjusted OR = 1.217 [1.031–1.435]) in men. PUD was significantly associated with intake of fiber (adjusted p = 0.0386, adjusted OR = 1.157 [1.008–1.328], vitamin B2 (adjusted p = 0.0477, adjusted OR = 1.155 [1.001–1.333]), sodium (adjusted p = 0.0154, adjusted OR = 1.191 [1.034–1.372]), calcium (adjusted p = 0.0079, adjusted OR = 1.243 [1.059–1.459]), and ash (adjusted p = 0.0468, adjusted OR = 1.152 [1.002–1.325] in women but not in men. None of the assessed blood parameters were associated with PUD in women, and only triglyceride level was associated with PUD in men (adjusted p = 0.0169, adjusted OR = 1.227 [1.037–1.451]).

Discussion

We found that obesity was associated with PUD in the Korean population; additionally, the association between nutritional components and PUD was greater in women than in men.

The association between peptic ulcer diseases and mental health problems: A population-based study: a STROBE compliant article

This study aimed to investigate the association between the prevalence of peptic ulcer disease (PUD) and mental health problems, such as severe stress, depressive mood, and suicidal ideation.The population-based cross-sectional study was comprised of 14,266 subjects participating in the fourth annual Korea National Health and Nutrition Examination survey from 2007 to 2009. The participants were divided into 2 groups according to the self-reported questionnaires: the PUD group and the non-PUD group. The association between PUD and mental health problems, such as severe stress, depressed mood, suicidal ideation, and psychological counseling history, were evaluated by using multivariate analysis and logistic regression.Among the 14,266 participants over 19-years old, 813 participants (5.6%) had PUD. Compared to the non-PUD group (n = 13,453), the PUD group had a significantly higher percentage of males, current smokers, and heavy drinkers, lower education status, lower income, and greater presence of diabetes mellitus, hypertension, metabolic syndrome and mental health problems, including severe stress, depressed mood, suicidal ideation, and psychological counseling history. After adjustment for lifestyle and medical and environmental factors, mental health problems were found to be associated with a significantly higher risk for PUD.Psychological problems, such as severe stress, depressed mood, suicidal ideation, and psychological counseling, were associated with PUD prevalence.

Selye's general adaptation syndrome: stress-induced gastro-duodenal ulceration and inflammatory bowel disease

Hans Selye in a note to Nature in 1936 initiated the field of stress research by showing that rats exposed to nocuous stimuli responded by way of a 'general adaptation syndrome' (GAS). One of the main features of the GAS was the 'formation of acute erosions in the digestive tract, particularly in the stomach, small intestine and appendix'. This provided experimental evidence for the view based on clinical data that gastro-duodenal (peptic) ulcers could be caused by stress. This hypothesis was challenged by Marshall and Warren's Nobel Prize (2005)-winning discovery of a causal association between Helicobacter pylori and peptic ulcers. However, clinical and experimental studies suggest that stress can cause peptic ulceration in the absence of H. pylori Predictably, the etiological pendulum of gastric and duodenal ulceration has swung from 'all stress' to 'all bacteria' followed by a sober realization that both factors play a role, separately as well as together. This raises the question as to whether stress and H. pylori interact, and if so, how? Stress has also been implicated in inflammatory bowel disease (IBD) and related disorders; however, there is no proof yet that stress is the primary etiological trigger for IBD. Central dopamine mechanisms seem to be involved in the stress induction of peptic ulceration, whereas activation of the sympathetic nervous system and central and peripheral corticotrophin-releasing factor appears to mediate stress-induced IBD.

Women Who Sleep More Have Reduced Risk of Peptic Ulcer Disease; Korean National Health and Nutrition Examination Survey (2008-2009)

Sleep is integral to life and sleep duration is important in sleep quality, physical, and psychological health. Disturbances in sleep duration have been associated with increased risk of metabolic disorders, hypertension, and overall mortality. Sleep disturbance has also been linked with various gastrointestinal disorders. However, the association between sleep and peptic ulcer disease (PUD) has not been evaluated. We investigated the association between sleep duration and PUD. Subjects were included from the fifth Korean National Health and Nutrition Examination Survey conducted from 2008-2009. Individuals with PUD were defined as those with a physician diagnosis of PUD. Daily sleep duration was established by asking participants the amount of time that they slept per day. Multiple logistic regression models were used to evaluate the association of PUD and sleep duration. This study included 14,290 participants (8,209 women). The prevalence of PUD was 5.7% and was higher in men (6.8%) than in women (4.9%). Women who slept ≥9 hours were significantly less likely to have PUD compared to women who slept 7 hours. In men, longer sleep duration (≥9 hours) had a tendency toward PUD prevention. Our results suggest that longer sleep duration may play a protective role for PUD development.

Pharmacological reports about gastroprotective effects of methanolic extract from leaves of Solidago chilensis (Brazilian arnica) and its components quercitrin and afzelin in rodents

Solidago chilensis Meyenmost (Asteraceae), popularly known as "Brazilian arnica" or "arnica-do-campo," is widely used in the folk medicine to treat gastric disorders. Based on this, the gastroprotective activity of S. chilensis methanolic extract was investigated. Besides, a phytochemical study allowed isolation of two flavonoids (quercitrin and afzelin). The gastroprotective effects were investigated in acute gastric ulcer models, and the antisecretory activity was assessed in vivo and in vitro. The adhered mucus levels, reduced glutathione (GSH) content and myeloperoxidase (MPO) activity were quantified in ulcerated tissues. The contribution of isolated compounds in extract effects was evaluated, and its doses were calculated according to its yield. To evaluate the in vivo healing properties of S. chilensis methanolic extract, a chronic gastric ulcer was induced in mice by 10 % acetic acid. Evaluation of tumor necrosis factor (TNF) levels was also performed at the site of the acetic acid-induced gastric ulcer. In parallel, effects on cell viability and cell proliferation of fibroblasts (L929 cells) were determined by in vitro trials. Firstly, the S. chilensis methanolic extract (100 or 300 mg/kg) reduced the ulcer area induced by ethanol/HCl in mice when compared to the vehicle group. Moreover, the S. chilensis extract (300 mg/kg) prevented the mucus depletion, the increase in MPO activity and the decrease in the GSH levels in the ulcerated gastric tissue. The S. chilensis extract also was able to decrease the indomethacin-induced gastric ulcer in rats at a dose of 100 mg/kg. The antisecretory effect of the extract (100 mg/kg, intraduodenal (i.d.)) was confirmed by the reduction in the volume and acidity in parallel to an increase in the pH of gastric content. In addition, quercitrin (1.38 mg/kg, but not 0.46 mg/kg) and afzelin (0.026 and 0.078 mg/kg) decreased the ethanol/HCl-induced gastric ulcer. In this model, quercitrin (1.38 mg/kg) prevented the depletion of gastric GSH content and both quercitrin (1.38 mg/kg) and afzelin (0.078 mg/kg) reduced the MPO activity. These compounds also inhibited the H(+),K(+)-ATPase activity at a concentration of 1-100 μg/ml. In addition, the participation of quercitrin and afzelin in these effects also was confirmed. Furthermore, after 4 days of the treatment, an oral administration of S. chilensis methanolic extract (100 mg/kg) reduced the area of the gastric ulcer induced by acetic acid and the regeneration of the gastric mucosa was accompanied by a reduction in gastric TNF levels. The healing properties of the extract also were confirmed by enhancement of proliferation and coverage of scratched wounds in a fibroblast monolayer. Together, our results confirmed the gastroprotective effect of S. chilensis methanolic extract as well as its gastric healing potential and provided some support to the traditional use of S. chilensis for prevention and treatment of gastric lesions in complementation to its known anti-inflammatory properties.

The psyche and gastric functions

Although the idea that gastric problems are in some way related to mental activity dates back to the beginning of the last century, until now it has received scant attention by physiologists, general practitioners and gastroenterologists. The major breakthrough in understanding the interactions between the central nervous system and the gut was the discovery of the enteric nervous system (ENS) in the 19th century. ENS (also called 'little brain') plays a crucial role in the regulation of the physiological gut functions. Furthermore, the identification of corticotropin-releasing factor (CRF) and the development of specific CRF receptor antagonists have permitted to characterize the neurochemical basis of the stress response. The neurobiological response to stress in mammals involves three key mechanisms: (1) stress is perceived and processed by higher brain centers; (2) the brain mounts a neuroendocrine response by way of the hypothalamic-pituitary-adrenal axis (HPA) and the autonomic nervous system (ANS), and (3) the brain triggers feedback mechanisms by HPA and ANS stimulation to restore homeostasis. Various stressors such as anger, fear, painful stimuli, as well as life or social learning experiences affect both the individual's physiologic and gastric function, revealing a two-way interaction between brain and stomach. There is overwhelming experimental and clinical evidence that stress influences gastric function, thereby outlining the pathogenesis of gastric diseases such as functional dyspepsia, gastroesophageal reflux disease and peptic ulcer disease. A better understanding of the role of pathological stressors in the modulation of disease activity may have important pathogenetic and therapeutic implications.

Associations between DSM-IV mental disorders and onset of self-reported peptic ulcer in the World Mental Health Surveys

OBJECTIVE

Recent research demonstrating concurrent associations between mental disorders and peptic ulcers has renewed interest in links between psychological factors and ulcers. However, little is known about associations between temporally prior mental disorders and subsequent ulcer onset. Nor has the potentially confounding role of childhood adversities been explored. The objective of this study was to examine associations between a wide range of temporally prior DSM-IV mental disorders and subsequent onset of ulcer, without and with adjustment for mental disorder comorbidity and childhood adversities.

METHODS

Face-to-face household surveys conducted in 19 countries (n=52,095; person years=2,096,486). The Composite International Diagnostic Interview retrospectively assessed lifetime prevalence and age at onset of 16 DSM-IV mental disorders. Peptic ulcer onset was assessed in the same interview by self-report of physician's diagnosis and year of diagnosis. Survival analyses estimated associations between first onset of mental disorders and subsequent ulcer onset.

RESULTS

After comorbidity and sociodemographic adjustment, depression, social phobia, specific phobia, post-traumatic stress disorder, intermittent explosive disorder, alcohol and drug abuse disorders were significantly associated with ulcer onset (ORs 1.3-1.6). Increasing number of lifetime mental disorders was associated with ulcer onset in a dose-response fashion. These associations were only slightly attenuated by adjustment for childhood adversities.

CONCLUSIONS

A wide range of mental disorders were linked with the self-report of subsequent peptic ulcer onset. These associations require confirmation in prospective designs, but are suggestive of a role for mental disorders in contributing to ulcer vulnerability, possibly through abnormalities in the physiological stress response associated with mental disorders.

The association between reflux esophagitis and psychosocial stress

BACKGROUND

The prevalence of reflux esophagitis is increasing in Korea. Reflux esophagitis aggravates the stress and fatigue level of daily life, but less is known about the association with stress and fatigue, which could be bi-directional.

AIM

To evaluate the impact of reflux esophagitis on stress and fatigue and to compare the stress level of people with reflux esophagitis with that of controls with peptic ulcer disease and healthy controls.

METHODS

Among a total of 9,033 subjects who underwent a comprehensive medical check-up including upper endoscopy, 6,834 subjects (75.7 %) were enrolled. Stress and fatigue scores were measured by a validated Korean version of the Brief Encounter Psychosocial Instrument and the Fatigue Severity Scale.

RESULTS

Among 6,834 subjects, 13.2 % were in the high-stress group, and reflux esophagitis was found in 6.0 %. After adjustment for confounders, reflux esophagitis was significantly associated with high stress (odds ratio 1.94, 95 % confidence interval 1.25-3.02). Subjects with reflux esophagitis had significantly higher BEPSI-K scores compared with healthy controls (p = 0.027); and however, there was no significant difference in BEPSI-K scores between reflux esophagitis group and peptic ulcer disease controls. Fatigue severity scale was highly correlated with BEPSI-K (p < 0.001); however, there was no significant difference in fatigue severity scale level between the reflux esophagitis group and controls. The severity of reflux esophagitis was significantly correlated with BEPSI-K score (p = 0.008).

CONCLUSIONS

Reflux esophagitis is significantly associated with psychosocial stress, and the severity of reflux esophagitis correlates with the degree of stress.

Antidepressant use and the risk of upper gastrointestinal bleeding in psychiatric patients: a nationwide cohort study in Taiwan

The magnitude of risk between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding (UGIB) is still unknown in patients with psychiatric diseases. The aim of this study was to quantify the risk of UGIB induced by use of antidepressants with different affinities for serotonin transporters in psychiatric patients using Taiwan's nationwide health insurance claims database. We conducted a propensity score- matched retrospective cohort study and identified 304,606 psychiatric patients who initiated antidepressant treatment during the 2005-2006 period. Antidepressants were classified as high- (HA group), intermediate- (IA group), or low-affinity (LA group) serotonin reuptake inhibitors. Patients in the LA group were matched 1:1 to those in the HA and IA groups according to their propensity scores. Subjects who were successfully matched were followed up from the date of antidepressant initiation to first hospitalization for UGIB, drug discontinuation, transition to or addition of antidepressants in another group, or the study's end (whichever occurred first). A total of 153,486 psychiatric patients were successfully matched, and 498 first UGIB events were identified. Compared with the LA group, patients in the HA group had a higher risk for UGIB (hazard ratio [HR], 1.38; 95% confidence interval [CI], 1.11-1.71). The HR (95% CI) of the IA group was 1.11 (95% CI, 0.88-1.41). The trend for elevated UGIB risk with increasing affinity of serotonin transporters was statistically significant (P < 0.01). Elderly patients and those with prior UGIB history were more susceptible to the harmful effects. Our findings suggest that the use of high-affinity serotonin reuptake inhibitors may increase the risk for UGIB in psychiatric patients.

Association between periodontal disease and peptic ulcers among Japanese workers: MY health up study

OBJECTIVE

This study aimed to investigate the association between periodontal disease and peptic ulcers in a working population.

METHODS

Self-administered questionnaires were distributed to all employees of a large insurance company in Japan. The questionnaire asked about their health status and lifestyle habits. Peptic ulcer was defined as either stomach ulcer, duodenal ulcer, or both. For the evaluation of periodontal disease, three indices were used: (a) loss of five or more teeth, (b) having been told of having periodontitis, and (c) periodontal risk score.

RESULTS

Of the eligible 28 765 subjects analyzed, peptic ulcer was present in 397 (1.4%). The results of bivariate analyses showed that a significantly higher proportion of subjects with peptic ulcer reported that they lost five or more teeth (35.3 vs. 17.4%, p&lt;0.001) or that they were told they had periodontitis (33.5 vs. 20.7%, p&lt;0.001). Moreover, the periodontal risk score was higher for those with peptic ulcer than those without (mean 0.83 vs. 0.59, p&lt;0.001). In multivariate logistic regression analyses, statistical associations were found between the presence of peptic ulcer and loss of five or more teeth (odds ratio (OR): 1.41, 95% confidence interval (CI): 1.13-1.76, p&lt;0.01), having been told of having periodontitis (OR: 1.28, 95% CI: 1.03-1.59, p&lt;0.05), and a 1-point increase in the periodontal risk score (OR: 1.17, 95% CI: 1.04-1.30, p&lt;0.01), respectively.

CONCLUSION

Modest but statistically significant associations were found between the self-reported measures of periodontal disease and peptic ulcers.

Altered physiology of acid secretion in depression-prone Flinders rats results in exacerbated NSAID and stress-induced gastric damage

BACKGROUND

Flinders Sensitive Line (FSL) rats are characterized by hypersensitivity to cholinergic stimuli and have been extensively used for studying depressive disorders. A link between depression and peptic ulcers has long been established; however, there is a lack of data from animal models.

METHODS

We studied the physiology of acid secretion in FSL and Flinders Resistant Line (FRL) rats in vivo and in vitro. We also examined the susceptibility of Flinders rats to water immersion restraint stress (WIRS) or NSAID-induced gastric damage and explored the effect of an anticholinergic agent, atropine, in reversing this effect.

KEY RESULTS

Basal acid output was more than twofold greater in FSL compared with FRL rats in vivo, 213.5 and 92.8 μEq/3 h/100 g (P = 0.02), respectively. Carbachol was a more potent secretagog in vitro, and somatostatin was a less potent inhibitory agent, while paradoxically stimulating acid secretion over and above the carbachol response in gastric glands from FSL rats. The FSL rats were more susceptible to indomethacin and WIRS-induced gastric mucosal damage compared with FRL rats. Atropine reduced acid output, which resulted in a reduction in indomethacin and stress-induced gastric damage in FSL rats.

CONCLUSIONS & INFERENCES

Our study, for the first time, demonstrates that the altered vagally mediated physiology of acid secretion in depression-prone FSL rats contributes to gastric hypersecretion and, consequently, results in exacerbated stress and NSAID-induced gastric damage. Flinders rats may be a useful animal model for studying acid-related and also gastrointestinal functional disorders in depression.

Is childhood physical abuse associated with peptic ulcer disease? Findings from a population-based study

This study investigated childhood physical abuse and ulcers in a regionally representative community sample. Age, race and sex were controlled for in addition to five clusters of potentially confounding factors: adverse childhood conditions, adult socioeconomic status, current health behaviors, current stress and marital status, and history of mood/anxiety disorders. Childhood physical abuse is associated with many negative physical and psychological adult health outcomes. Two recent studies demonstrate a potential link between childhood physical abuse and peptic ulcer disease in adulthood. The authors use regional data for the Canadian provinces of Manitoba and Saskatchewan from the 2005 Canadian Community Health Survey. Of the 13,069 respondents with complete data on abuse and ulcers, 7.3% (n = 1,020) report that they had been physically abused as a child by someone close to them and 3.0% (n = 493) report that they had been diagnosed with peptic ulcers by a health professional. The regional response rate is approximately 84%. Findings show that those reporting abuse had more than twice the prevalence of ulcers than did those not reporting abuse (6.6% vs. 2.7%). The fully adjusted odd ratio of peptic ulcers among those who had reported childhood physical abuse is 1.68 (95% CI = 1.22, 2.32). A significant and stable relationship between childhood physical abuse and peptic ulcers is found, even when taking into account five clusters of potentially confounding factors. Prospective studies that apply the biopsychosocial model are likely to be the most effective for identifying the pathways that connect childhood physical abuse and ulcer disease.

Gastroprotective Effect of Ginger Rhizome (Zingiber officinale) Extract: Role of Gallic Acid and Cinnamic Acid in H(+), K(+)-ATPase/H. pylori Inhibition and Anti-Oxidative Mechanism

Zinger officinale has been used as a traditional source against gastric disturbances from time immemorial. The ulcer-preventive properties of aqueous extract of ginger rhizome (GRAE) belonging to the family Zingiberaceae is reported in the present study. GRAE at 200 mg kg⁻¹ b.w. protected up to 86% and 77% for the swim stress-/ethanol stress-induced ulcers with an ulcer index (UI) of 50 ± 4.0/46 ± 4.0, respectively, similar to that of lansoprazole (80%) at 30 mg kg⁻¹ b.w. Increased H⁺, K⁺-ATPase activity and thiobarbituric acid reactive substances (TBARS) were observed in ulcer-induced rats, while GRAE fed rats showed normalized levels and GRAE also normalized depleted/amplified anti-oxidant enzymes in swim stress and ethanol stress-induced animals. Gastric mucin damage was recovered up to 77% and 74% in swim stress and ethanol stress, respectively after GRAE treatment. GRAE also inhibited the growth of H. pylori with MIC of 300 ± 38 μg and also possessed reducing power, free radical scavenging ability with an IC₅₀ of 6.8 ± 0.4 μg mL⁻¹ gallic acid equivalent (GAE). DNA protection up to 90% at 0.4 μg was also observed. Toxicity studies indicated no lethal effects in rats fed up to 5 g kg⁻¹ b.w. Compositional analysis favored by determination of the efficacy of individual phenolic acids towards their potential ulcer-preventive ability revealed that between cinnamic (50%) and gallic (46%) phenolic acids, cinnamic acid appear to contribute to better H⁺, K⁺-ATPase and Helicobacter pylori inhibitory activity, while gallic acid contributes significantly to anti-oxidant activity.

Evaluation of the antipeptic ulcer activity of the leaf extract of Plantago lanceolata L. in rodents

The effect of the leaf extract of Plantago lanceolata L. (Plantaginaceae) on gastric secretion and cytoprotection was evaluated using different models of gastroduodenal ulcer, including acetic acid induced chronic gastric ulcer, indomethacin induced gastric ulcer, cysteamine induced duodenal ulcer and pylorus ligation induced gastric ulcer. The aqueous extract was administered at 200 mg/kg and 400 mg/kg and 140 mg/kg and 280 mg/kg for mice and rats, respectively, and compared with vehicle or the standard, ranitidine (50 or 70 mg/kg) or misopristol (280 μg/kg). In addition, activity of the mucilage (172 mg/kg) was also evaluated in acetic acid induced chronic gastric ulcer. Administration was done orally except in pylorus ligation, where the intraduodenal route was used. In all cases, higher doses of the extract provided better protection than lower doses and the mucilage, hinting at a dose-dependent effect. Whilst higher doses of the extract showed a better healing of the ulcer as well as protection in indomethacin and pylorus ligation models, activities of lesser magnitude than ranitidine were noted in the cysteamine model. Together these findings indicate that higher doses used in the present study provided an overall better protection against gastroduodenal ulcers than the standard drugs employed through antisecretory and cytoprotective mechanisms.

Bearing grudges and physical health: relationship to smoking, cardiovascular health and ulcers

BACKGROUND

Personality traits are reported to be associated with a variety of medical comorbidities. Correlational studies report an association between 'bearing grudges' and medical conditions. We hypothesize persons reporting "bearing grudges for years" would be more likely to have medical comorbidities and test this hypothesis in an epidemiological sample.

METHODS

The National Comorbidity Survey Replication is a probability sample of the US population designed to constitute a nationally representative sample (N = 9,882). Associations were measured in odds ratios (95% CI) and adjusted using logistic regression. Confounders included: gender, age, race, and smoking status. We tested the hypothesis on 14 following medical conditions: heart disease, high blood pressure, history of heart attack, asthma, diabetes, cancer, epilepsy, arthritis, neck problems, headaches, stroke, and ulcers. Significance levels were adjusted for multiple comparisons using the Bonferoni procedure.

RESULTS

Positive and statistically significant associations were found, after adjusting for confounders and correcting for multiple comparisons, between bearing grudges and history of heart attack (odds ratio 2.1, 95% CI 1.5-2.9) and disease (1.6, 1.2-2.2); high blood pressure (1.5, 1.3-1.7), stomach ulcers (1.6, 1.3-1.9); arthritis (1.5, 1.3-1.9); back problems (1.6, 1.4-1.8); headaches (1.8, 1.6-2.1); and chronic pain (1.7, 1.4-2.1). No association was found with history of asthma, diabetes, epilepsy, allergies, stroke, and cancer.

CONCLUSIONS

In a population-based survey, bearing grudges is associated with a history of pain disorders, cardiovascular disease, and stomach ulcers. These results point to the importance of psychosomatic research in medical settings.

Meta-analysis: incidence of endoscopic gastric and duodenal ulcers in placebo arms of randomized placebo-controlled NSAID trials

BACKGROUND

The safety of NSAIDs is often evaluated by comparison with placebo in clinical trials.

AIM

To investigate the incidence of gastric and duodenal ulcers (GDU) in placebo arms in NSAID trials over the last three decades.

METHODS

Randomized placebo-controlled trials of oral NSAIDs from 1975 to 2006 were systematically reviewed. The pooled incidence of GDU in placebo arms was calculated and compared. Meta-regression was used to identify risk factors related to the incidence of the placebo ulcer at the study level.

RESULTS

Thirty-six studies met inclusion criteria (duration of 6.5 days to 24 weeks). In total, 3.29% GDUs were reported in 36 placebo arms. The incidence of GDU in placebo arms was 0, 4.20% and 3.03% in the studies from 1975-1989, 1990-1999 and 2000-2006 respectively (P > 0.05). Eligible subjects with previous GI events and eligible subjects on co-therapy with low-lose aspirin/corticosteroids were associated with the increase in placebo ulcer incidence after adjusting for other factors.

CONCLUSIONS

The incidence of GDU in placebo arms has not changed significantly over the last three decades, although has decreased in the past 10 years. Studies show that previous GI events and co-therapy with low-dose aspirin/corticosteroids were associated with increasing GDU in placebo arms.

Peptic ulcer and childhood adversities experienced by working-aged people

AIM: To study the association between self-reported peptic ulcer and childhood adversities.

METHODS: The Health and Social Support Study (HeSSup) population consisted of a stratified random sample drawn from the Finnish Population Register in four age groups: 20-24, 30-34, 40-44 and 50-54. The survey was carried out by postal questionnaire during 1998, with a response rate of 40.0%. A follow-up questionnaire was sent during 2003 to all those who responded to the first. Altogether 19 626 individuals returned the follow-up questionnaire; a response rate of 75.8%. The subjects were asked whether a doctor had told them that they have or have had peptic ulcer. The analyses covered those who responded affirmatively to both the baseline and the follow-up enquiries (n = 718). Those not reporting a peptic ulcer in either of the two questionnaires (n = 17 677) were taken as controls. The subjects were further requested (through six questions) to think about their childhood adversities.

RESULTS: The most common adversities mentioned were long-lasting financial difficulties in the family, serious conflicts in the family, and a family member seriously or chronically ill. All the adversities reported, except parental divorce, were more common among peptic ulcer patients than among controls (P values varied between < 0.001 and 0.003). Age- and sex-adjusted odds ratios (OR) of childhood adversities in the multivariate logistic analysis for self-reported peptic ulcer varied between 1.45 and 2.01. Adjusting for smoking, heavy drinking, stress and nonsteroidal anti-inflammatory drug use had no further influence (ORs between 1.22 and 1.73).

CONCLUSION: Our findings suggest that childhood adversities maintain a connection with and have a predictive role in the development of peptic ulcer.

Psychological stress downregulates epidermal antimicrobial peptide expression and increases severity of cutaneous infections in mice

The skin is the first line of defense against microbial infection, and psychological stress (PS) has been shown to have adverse effects on cutaneous barrier function. Here we show that PS increased the severity of group A Streptococcus pyogenes (GAS) cutaneous skin infection in mice; this was accompanied by increased production of endogenous glucocorticoids (GCs), which inhibited epidermal lipid synthesis and decreased lamellar body (LB) secretion. LBs encapsulate antimicrobial peptides (AMPs), and PS or systemic or topical GC administration downregulated epidermal expression of murine AMPs cathelin-related AMP and beta-defensin 3. Pharmacological blockade of the stress hormone corticotrophin-releasing factor or of peripheral GC action, as well as topical administration of physiologic lipids, normalized epidermal AMP levels and delivery to LBs and decreased the severity of GAS infection during PS. Our results show that PS decreases the levels of 2 key AMPs in the epidermis and their delivery into LBs and that this is attributable to increased endogenous GC production. These data suggest that GC blockade and/or topical lipid administration could normalize cutaneous antimicrobial defense during PS or GC increase. We believe this to be the first mechanistic link between PS and increased susceptibility to infection by microbial pathogens.

Comorbidity of depression with chronic diseases: a population-based study in Aleppo, Syria

OBJECTIVE

To assess the comorbidity and correlates of depression in chronic diseases in the community in Aleppo, Syria. This has never been previously investigated in an Arab country.

METHOD

We conducted a cross-sectional, population-based study in Aleppo on adults aged 18-65 (N = 2038). We collected data utilizing a structured interview questionnaire. Socio-demographics, general health information, and self-report of physician-diagnosed depression and chronic diseases active in the past year were obtained. We used logistic regression to estimate the odds of depression in chronic diseases and socio-demographic correlates of depression comorbid with chronic diseases.

RESULTS

Mean age (SD) was 35.3 (12.1) years, 55% were female. In women, predictors of depression were heart disease (OR = 3.95, 95% CI: 1.50-10.40), hypertension (OR = 2.92, 95% CI: 1.53-5.55), and kidney disease (OR = 2.96, 95% CI: 1.64-5.32). Depression comorbidity with any chronic disease decreased in higher socio-economic status (middle vs. low: OR = 0.28, 95% CI: 0.12-0.65; high vs. low: OR = 0.20, 95% CI: 0.05-0.81). In men, predictors of depression were rheumatism (OR = 7.10, 95% CI: 2.58-19.60) and respiratory disease (OR = 3.77, 95% CI: 1.23-11.60). Depression comorbidity decreased in residence in formal zones (OR = 0.22, 95% CI: 0.06-0.80).

CONCLUSION

Depression is associated with many chronic diseases in the community in Aleppo, a finding consistent with reports from other cultures. Potential gender-related risk factors were identified. Findings inform public mental health planning and support the delivery of depression treatment in primary care settings.

Gastroprotective effect of swallow root (Decalepis hamiltonii) extract: possible involvement of H(+)-K(+)-ATPase inhibition and antioxidative mechanism

The present study reports the antiulcer potentials of aqueous extract of swallow root (Decalepis hamiltonii Wight & Arn, SRAE) belonging to the family Asclepiadaceae. Swim stress-induced ulcers with an ulcer index (UI) of 6.0+/-0.01 was protected up to 43% and 72% at 100 and 200mg/kg b.w. of SRAE, respectively, similar to protection offered by ranitidine (79%) at 30mg/kg b.w. Depletion in antioxidant enzymes and increased Thiobarbituric Acid Reactive Substances (TBARS) were observed in ulcer-induced rats while SRAE fed rats showed normal levels. SRAE also normalized approximately 3.1 and 2.4 folds of increased H(+)-K(+)-ATPase and gastric mucin, respectively, in ulcerous animals, similar to the levels found in healthy controls. SRAE also possessed reducing power, free radical scavenging ability with an IC(50) of 0.17microg/mL gallic acid equivalent (GAE), comparable to that of BHA (IC(50)-0.08microg/mL). DNA protection up to 80% at 0.2microg was also observed. Toxicity studies indicated no lethal effects in rats fed up to 5g/kg b.w. Antioxidant, proton pump inhibition as well as boosting of gastric mucin effects of SRAE have been implicated to be responsible for antiulcer property of SRAE.

Effect of taurine on gastric ulcer in pylorus-ligated rats

AIM: To explore the effect of taurine on the pylorus ligation-induced gastric ulcer in rats and its mechanism.

METHODS: Rat model of gastric ulcer was made by pylorus ligation method. A total of 45 Wistar rats were randomly and averagely divided into 3 groups: normal control group, ulcer model group and taurine-treated group. Six hours later, all the rats were killed, and the gastric mucosal ulcer index (UI), total acidity of gastric juice, pepsin activity and H+,K+-ATPase activity in parietal cells were measured.

RESULTS: In comparison with the normal control group, the ulcer model group showed an increase in UI (35.3 ± 3.7 vs 0, P < 0.01), total acidity of gastric juice (28.56 ± 3.81 mmol/L vs 20.34 ± 4.40 mmol/L, P < 0.01), pepsin activity [7.58 ±1.58 μg/(mL·min) vs 5.83 ± 1.22 μg/(mL·min), P < 0.01] and H+, K+-ATPase activity of parietal cells (8.86 ± 1.50 U/mg vs 6.95 ± 1.03 U/mg, P < 0.01). However, in the treated group, the gastric mucosal injury was attenuated, and the value of gastric mucosal UI (15.4 ± 3.6 vs 35.3 ± 3.7, P < 0.01), total acidity of gastric juice (19.58 ± 3.68 mmol/L vs 28.56 ± 3.81 mmol/L, P < 0.01), pepsin activity [6.36 ± 1.45 μg/(mL·min) vs 7.58 ± 1.58 μg/(mL·min), P < 0.05] and H+, K+-ATPase activity of parietal cells (7.62 ± 1.46 U/mg vs 8.86 ± 1.50 U/mg, P < 0.05) were decreased significantly as compared with those in the model group.

CONCLUSION: Taurine can alleviate gastric ulcerative injury in pylorus-ligated rats, which may be related to the inhibitory effect of taurine on the secretion of gastric acid and pepsin.