Gastroesophageal reflux disease: recent advances and its association with sleep

Association between obstructive sleep apnea and gastroesophageal reflux disease: A systematic review and meta-analysis

BACKGROUND AND AIM

We aim to conduct a systematic review and determine the association between obstructive sleep apnea (OSA) and gastroesophageal reflux disease (GERD).

METHODS

Literature search for eligible studies was performed across major databases. The main endpoint was to assess the association between GERD and OSA. Subgroup analyses were performed to determine this strength of the association stratified by the diagnostic tools used for OSA (nocturnal polysomnogram or Berlin questionnaire) and GERD (validated reflux questionnaire or esophagogastroduodenoscopy). We also compared sleep efficiency, apnea hypopnea index, oxygen desaturation index, and Epworth Sleepiness Scale in OSA patients with or without GERD. Results were pooled together using Reviewer Manager 5.4.

RESULTS

Six studies involving 2950 patients with either GERD or OSA were included in the pooled analysis. Our findings suggest that there was a statistically significant unidirectional association between GERD and OSA (odds ratio [OR] = 1.53, P = 0.0001). Subgroup analyses redemonstrated an OSA-GERD association irrespective of the tools used for diagnosing either GERD or OSA (P = 0.24 and P = 0.82, respectively). Sensitivity analyses demonstrated the same association after controlling for gender (OR = 1.63), BMI (OR = 1.81), smoking (OR = 1.45), and alcohol consumption (OR = 1.79). In patients with OSA, there were no statistically significant differences between patients with or without GERD in terms of apnea hypopnea index (P = 0.30), sleep efficiency (P = 0.67), oxygen desaturation index (P = 0.39), and Epworth Sleepiness Scale (P = 0.07).

CONCLUSION

There exists an association between OSA and GERD that is independent of the modalities used for screening or diagnosing both disorders. However, the presence of GERD did not affect the severity of OSA.

Causal analysis between gastro-oesophageal reflux disease and obstructive sleep apnoea

Background

Based on evidence from existing observational research, clarifying the causal relationship between gastro-oesophageal reflux disease (GORD) and obstructive sleep apnoea (OSA) is challenging. Here, Mendelian randomisation, a method based on genetics, was used to provide new evidence for causality.

Methods

Summary statistics from two publicly available genome-wide association studies were used to evaluate the causal relationship between GORD and OSA (the GORD database was used as an exposure variable and the OSA database as an outcome). Inverse variance weighting was used as the main analytical tool in Mendelian randomisation to estimate causal effects. The robustness of the results was evaluated by sensitivity analysis. Possible mediators were evaluated using multivariate Mendelian randomisation.

Results

A statistically significant causal relationship was observed between GORD and OSA (OR 1.597, 95% CI 1.401-1.821, p<0.001), and similar results were observed in weighted median and Mendelian randomisation-Egger regression analyses. No bias was found in the sensitivity analysis of Mendelian randomisation estimation. Multivariate Mendelian randomisation showed that GORD significantly increased the risk of developing OSA, even when the possible mediator was excluded (OR 1.107, 95% CI 1.101-1.212, p<0.001).

Conclusion

Our study confirmed a causal relationship between GORD and OSA and suggests that intervention measures should be taken for patients with GORD to prevent the occurrence of OSA.

TRPV1 is a risk factor for sleep disturbance in patients with gastro-oesophageal reflux disease: a case control study

BACKGROUND/AIMS

Gastro-oesophageal reflux disease (GORD) is a chronic high-morbidity disease with a bidirectional relationship with sleep disturbance (SD) that may occur via the transient receptor potential vanilloid type 1 receptor (TRPV1) in the oesophageal mucosa. Yet the related mechanism was still unclear, the aim of this study is to investigate whether TRPV1 is associated with the presence of SD in GORD patients.

METHODS

A case-control study was performed. After the screening, A total of 88 subjects were assigned to GORD without sleep disturbance (GORD + NOSD, n = 28), GORD comorbid sleep disturbance (GORD + SD, n = 30) and matched healthy controls (n = 30). Mucosal tissue was obtained from the participants by digestive endoscopy, the levels of TRPV1 expressed in the oesophageal mucosa were detected via RT-qPCR and western blot in different groups, and the correlation between GORD and SD were also analysed.

RESULTS

In this study, we found that the Gastroesophageal Reflux Disease Diagnostic Questionnaire (GerdQ) scores was positively correlated with Pittsburgh Sleep Quality Index (PSQI) scores but negatively correlated with total sleep time (TST). We also found that the level of TRPV1 expressed in the oesophageal mucosa of GORD + SD was significantly higher than GORD + NOSD patients, and they were all higher than healthy controls.

CONCLUSION

The current study suggested a closer link exists between GORD and sleep disturbance, and TRPV1 in oesophageal mucosa may be a crucial factor affecting sleep in GORD patients.

Sleep traits, fat accumulation, and glycemic traits in relation to gastroesophageal reflux disease: A Mendelian randomization study

Background

Sleep traits, fat accumulation, and glycemic traits are associated with gastroesophageal reflux disease (GERD) in observational studies. However, whether their associations are causal remains unknown. We performed a Mendelian randomization (MR) study to determine these causal relationships.

Methods

Independent genetic variants associated with insomnia, sleep duration, short sleep duration, body fat percentage, visceral adipose tissue (VAT) mass, type 2 diabetes, fasting glucose, and fasting insulin at the genome-wide significance level were selected as instrumental variables. Summary-level data for GERD were derived from a genome-wide association meta-analysis including 78,707 cases and 288,734 controls of European descent. Inverse variance weighted (IVW) was used for the main analysis, with weighted median and MR-Egger as complements to IVW. Sensitivity analyses were performed using Cochran's Q test, MR-Egger intercept test, and leave-one-out analysis to estimate the stability of the results.

Results

The MR study showed the causal relationships of genetically predicted insomnia (odds ratio [OR] = 1.306, 95% confidence interval [CI] 1.261 to 1.352; p = 2.24 × 10^-51), short sleep duration (OR = 1.304, 95% CI: 1.147 to 1.483, p = 4.83 × 10^-5), body fat percentage (OR = 1.793, 95% CI 1.496 to 2.149; p = 2.68 × 10^-10), and visceral adipose tissue (OR = 2.090, 95% CI 1.963 to 2.225; p = 4.42 × 10^-117) with the risk of GERD. There was little evidence for causal associations between genetically predicted glycemic traits and GERD. In multivariable analyses, genetically predicted VAT accumulation, insomnia, and decreased sleep duration were associated with an increased risk of GERD.

Conclusion

This study suggests the possible roles of insomnia, short sleep, body fat percentage, and visceral adiposity in the development of GERD.

Genetic estimation of correlations and causalities between multifaceted modifiable factors and gastro-oesophageal reflux disease

BACKGROUND

Gastro-oesophageal reflux disease (GORD) is a common gastrointestinal dysfunction that significantly affects the quality of daily life, and health interventions are challenging to prevent the risk of GORD. In this study, we used Mendelian randomization framework to genetically determine the causal associations between multifaceted modifiable factors and the risk of GORD.

MATERIALS AND METHODS

Sixty-six exposures with available instrumental variables (IVs) across 6 modifiable pathways were included in the univariable MR analysis (UVMR). Summary-level genome-wide association studies (GWAS) datasets for GORD were retrieved from the Neale Lab (GORD _Neale , Ncases = 29975, Ncontrols = 390556) and FinnGen (GORD _Finn , Ncases = 13141, Ncontrols = 89695). Using the METAL software, meta-analysis for single nucleotide polymorphisms (SNPs) from GORD _Neale and GORD _Finn was conducted with an inverse variance weighted (IVW) fixed-effect model. Moreover, we leveraged partition around medoids (PAM) clustering algorithm to cluster genetic correlation subtypes, whose hub exposures were conditioned for multivariable MR (MVMR) analyses. P-values were adjusted with Bonferroni multiple comparisons.

RESULTS

Significant causal associations were identified between 26 exposures (15 risk exposures and 11 protective exposures) and the risk of GORD. Among them, 13 risk exposures [lifetime smoking, cigarette consumption, insomnia, short sleep, leisure sedentary behavior (TV watching), body mass index (BMI), body fat percentage, whole body fat mass, visceral adipose tissue, waist circumference, hip circumference, major depressive disorder, and anxious feeling], and 10 protective exposures (leisure sedentary behavior (computer use), sitting height, hand grip strength (left and right), birth weight, life satisfaction, positive affect, income, educational attainment, and intelligence) showed novel significant causal associations with the risk of GORD. Moreover, 13 exposures still demonstrated independent associations with the risk of GORD following MVMR analyses conditioned for hub exposures (educational attainment, smoking initiation and BMI). In addition, 12 exposures showed suggestive causal associations with the risk of GORD.

CONCLUSION

This study systematically elucidated the modifiable factors causally associated with the risk of GORD from multifaceted perspectives, which provided implications for prevention and treatment of GORD.

Gastroesophageal reflux disease and oral health: A narrative review

Gastroesophageal reflux disease (GERD) is a clinical condition in which stomach contents leak backward into the esophagus. It affects millions of people worldwide and has a detrimental effect on quality of life. Heartburn and acid regurgitation are typical GERD symptoms, while atypical manifestations include noncardiac chest pain, cough and laryngitis. The oral and maxillofacial manifestations of GERD may include dental erosion, xerostomia, mucositis, aphthous like ulcerations, sour taste, burning mouth, hyperesthesia, bruxism, and/or temporomandibular disorder (TMD). This narrative review provides oral health care professionals with an update to medical aspects of GERD, recognition and management of oral and maxillofacial manifestations of the condition and provision of appropriate dental care for this patient population.

The Relationship Between Obstructive Sleep Apnea (OSA) and Gastroesophageal Reflux Disease (GERD) in Inpatient Settings: A Nationwide Study

Introduction: Several studies identified a link between gastroesophageal reflux disease (GERD) and obstructive sleep apnea (OSA). GERD is a condition in which acid reflux from the stomach to the esophagus causes troublesome symptoms. On the other hand, OSA is defined as a sleep-related breathing disorder in which airflow significantly decreases or ceases due to upper airway obstruction, leading to arousal from sleep. OSA was found to be associated with GERD. In this study, we aim to study the characteristics and concurrent risk factors associated with GERD and OSA in a large population-based study.

Methods: Patients with the diagnosis of GERD were extracted from the National Inpatient Database (NIS) for the years 2016 to 2019. Patients' age, gender, race, and hospital information, including region and bed size, were extracted and considered as baseline characteristics. The comorbidities included are hypertension (HTN), atrial fibrillation (AFib), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), pulmonary hypertension (PHTN), obesity, and smoking. Patients younger than 18 years old were excluded from this study. 

Results: Out of 22,677,620 patients with the diagnosis of GERD, 12.21% had a concurrent diagnosis of OSA (compared to 4.79% in patients without GERD, p-value <0.001). The mean age of patients with GERD and OSA was 64.47 years vs 65.42 years in patients without OSA (p-value <0.001). The GERD and OSA group had almost identical gender distribution compared to the GERD only group, as it was predominantly female patients. The white and black races were slightly more prevalent in the GERD and OSA group compared to the GERD only group. Regarding comorbidities, the prevalence of obesity was more clear in the GERD and OSA group. It was noted that the group of patients who carry a diagnosis of GERD and OSA have more prevalence of diabetes (DM), hypertension (HTN), obesity, atrial fibrillation (Afib), congestive heart failure (CHF), and pulmonary hypertension (PHTN). Patients with GERD and OSA were 21% less likely to be older than 65 years rather than younger (95% CI: 0.79-0.8, p-value <0.001), 35% less likely to be females (95% CI: 0.65-0.65, p-value <0.001), and 22% less likely to be non-white (95% CI: 0.77-0.8, p-value <0.001). Obesity was found to be the strongest association with this population, followed by PHTN, CHF, DM, HTN, Afib, and lastly smoking.

Conclusion: Patients with GERD and OSA were found more likely to be female, white, living in the southern part of the United States, obese, diabetes mellitus type 2, and being active smokers. 

Association between Sleep Quality and Gastroesophageal Reflux in Medical Students

BACKGROUND

Due to stressful occupational conditions, irregular dietary and sleep schedules, medical students are at increased risk of developing gastrointestinal disorders, gastroesophageal reflux (GERD) in particular, as well as sleep disturbances. Therefore, for the first time, we aimed to assess the correlation between GERD and sleep disturbances among medical students.

METHODS

The current cross-sectional study was done on 290 medical students at different study periods in Iran during 2018-2019. Age, sex, stage of studying, residence, and body mass index were gathered. The frequency scale for the symptoms of gastroesophageal reflux (FSSG) was utilized to assess gastrointestinal symptoms among them and the Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality. Eventually, the association of sleep disturbances with demographic factors and gastrointestinal symptoms was evaluated.

RESULTS

Living in the dormitory (p = 0.048; OR: 1.73; 95%CI: 1.01-2.99) and being overweight (p < 0.001; OR: 3.09; 95%CI: 1.58-6.06) were independently correlated with impaired sleep quality. GERD presented either by heartburn (p < 0.001) or regurgitation (p < 0.001) was associated with a lower quality of life.

CONCLUSION

GERD was correlated with poor sleep quality among medical students. In addition, residence in dormitory and being overweight were correlated with poor sleep quality.

Asthma and Three Colinear Comorbidities: Obesity, OSA, and GERD

Asthma is a complex disease with heterogeneous phenotypes and endotypes that are incompletely understood. Obesity, obstructive sleep apnea, and gastroesophageal reflux disease co-occur in patients with asthma at higher rates than in those without asthma. Although these diseases share risk factors, there are some data suggesting that these comorbidities have shared inflammatory pathways, drive the development of asthma, or worsen asthma control. This review discusses the epidemiology, pathophysiology, management recommendations, and key knowledge gaps of these common comorbidities.

The Influence of Gastroesophageal Reflux Disease on Daytime Sleepiness and Depressive Symptom in Patients With Obstructive Sleep Apnea

Background/Aims

As there is insufficient evidence for a relationship between gastroesophageal reflux disease (GERD) and obstructive sleep apnea (OSA), we investigated whether OSA diagnosed by polysomnography (PSG) is related to GERD.

Methods

A total of 402 subjects was evaluated. Overnight PSG was performed and a few questionnaires on GERD, anxiety, depression, and daytime sleepiness were administered. An apnea-hypopnea index < 5 was the classification criterion for subjects without OSA. Subjects with heartburn or acid regurgitation at least once a week were classified as having GERD.

Results

Among the 402 subjects, 318 had OSA and 84 did not. The prevalence of GERD was 12.9% among patients with OSA and 10.7% among those without (P = 0.590). The prevalence of GERD did not correlate with OSA severity (P = 0.474). Patients with OSA with GERD had higher Stanford Sleepiness Scale (P = 0.004), Epworth Sleepiness Scale (P = 0.001), and depression (P < 0.001) scores than patients with OSA without GERD. Subjects with nocturnal gastroesophageal reflux symptoms had a higher body mass index, waist-to-height ratio, and waist circumference-to-height index than those without symptoms. Multiple logistic regression showed that higher Epworth Sleepiness Scale and depression scores were independent factors associated with GERD in patients with OSA.

Conclusions

The prevalence of GERD in patients with OSA was 12.9%. The prevalence of GERD did not correlate with OSA severity. Daytime sleepiness and depression seem to be associated with GERD in patients with OSA, while nocturnal reflux symptoms seem to be related to obesity in OSA.

Severe reflux, sleep disturbances, and health-related quality of life after esophageal cancer surgery

PURPOSE

Esophagectomy for cancer is an extensive procedure often followed by severe complications. This study investigated whether patients with severe symptoms of reflux are more likely to have sleep disturbances and reduced health-related quality of life (HRQL) after esophagectomy.

METHODS

This Swedish nationwide prospective cohort study encompassed all patients who had undergone esophagectomy for cancer between 2013 and 2018. One year after surgery, the patients responded to three questionnaires on reflux (EORTC QLQOG25), sleep disturbances (KSQ), and HRQL (EORTC QLQ-C30). Multivariable logistic regression provided odds ratios (OR) with 95% confidence intervals (CI) for sleep disturbance/reduced HRQL between patients with and without reflux, adjusted for potential confounders.

RESULTS

Among 241 esophagectomy patients, 66 (27%) reported severe reflux. Patients with reflux had an increased risk of sleep disturbances (OR 2.3, 95% CI: 1.3-4.3) compared to patients without reflux. More specifically, these patients were more likely to suffer from poor sleep quality (OR 4.9, 95% CI: 1.9-12.4). Patients with reflux and sleep disturbances reported reductions in global quality of life, role function, emotional function, social function, and more symptoms in all scales, except for dyspnea.

CONCLUSIONS

This study suggests that patients with severe symptoms of reflux after esophagectomy have an increased risk of sleep disturbances and poor sleep quality, which in turn are associated with reduced HRQL.

IMPLICATIONS FOR CANCER SURVIVORS

Alleviating reflux after oesophageal cancer surgery is important, since this common symptom might reduce HRQL and well-being.

Interstitial lung disease and obstructive sleep apnea

Obstructive sleep apnea (OSA) is one of the most common comorbidities in patients with interstitial lung disease (ILD). Growing evidence highlights the significance of sleep disturbance on health outcomes in this population. The relationships between ILD and OSA are complex and possibly bidirectional, with multiple mechanisms postulated for the pathogenic and physiologic links. This review synthesizes current evidence and hypotheses regarding different aspects of the relationships between ILD and OSA, emphasizing the interactions between epidemiology, pathogenesis, and pathophysiology.

Expression of FFAR3 and FFAR4 Is Increased in Gastroesophageal Reflux Disease

Background: The negative impact of a high-fat diet on the course of gastroesophageal reflux disease (GERD) has been previously reported. Free fatty acid receptors (FFARs) may be mediators of this phenomenon. The aim of this study was to characterize the role of FFARs in the course of nonerosive (NERD) and erosive (ERD) reflux disease. Methods: Collectively, 73 patients (62 with GERD and 11 healthy controls (HCs)) were recruited to the study. Esophageal biopsies were drawn from the lower third of the esophagus and kept for further experiments. Quantitative, real-time polymerase chain reaction was used to assess the expression of FFAR1, FFAR2, FFAR3, and FFAR4 in biopsies. Histological evaluation of dilated intracellular spaces (DISs) was also performed. Results: FFAR3 exhibited the highest expression, and FFAR4 exhibited the lowest expression in all esophageal samples. Higher relative expression of FFAR1 and FFAR2 and significantly higher expression of FFAR3 (p = 0.04) was noted in patients with GERD compared to respective HCs. Patients with nonerosive GERD (NERD) presented higher expression of all FFARs compared to patients with erosive GERD (ERD) and respective HCs. Interestingly, in patients with ERD, the expression of FFAR3 was lower than in HCs. Significant, weak, positive correlation was found for FFAR3 and FFAR4 expression and DIS scores (r = 0.36, p < 0.05 for FFAR 3, and r = 0.39, p < 0.05 for FFAR4). Conclusions: In this study, we show that FFARs may play a role in GERD pathogenesis, particularly in the NERD type. It may be assumed that FFARs, in particular FFAR3 and FFAR4, may have diagnostic and therapeutic potential in GERD.

Automated feature extraction from population wearable device data identified novel loci associated with sleep and circadian rhythms

Wearable devices have been increasingly used in research to provide continuous physical activity monitoring, but how to effectively extract features remains challenging for researchers. To analyze the generated actigraphy data in large-scale population studies, we developed computationally efficient methods to derive sleep and activity features through a Hidden Markov Model-based sleep/wake identification algorithm, and circadian rhythm features through a Penalized Multi-band Learning approach adapted from machine learning. Unsupervised feature extraction is useful when labeled data are unavailable, especially in large-scale population studies. We applied these two methods to the UK Biobank wearable device data and used the derived sleep and circadian features as phenotypes in genome-wide association studies. We identified 53 genetic loci with p<5×10-8 including genes known to be associated with sleep disorders and circadian rhythms as well as novel loci associated with Body Mass Index, mental diseases and neurological disorders, which suggest shared genetic factors of sleep and circadian rhythms with physical and mental health. Further cross-tissue enrichment analysis highlights the important role of the central nervous system and the shared genetic architecture with metabolism-related traits and the metabolic system. Our study demonstrates the effectiveness of our unsupervised methods for wearable device data when additional training data cannot be easily acquired, and our study further expands the application of wearable devices in population studies and genetic studies to provide novel biological insights.

MECHANISMS OF AUTONOMIC DYSFUNCTION REALIZATION DURING COMORBID GASTROESOPHAGEAL REFLUX DISEASE AND NEUROCIRCULATORY DYSTONIA WITH INSOMNIA AMONG YOUNG PEOPLE

The aim of the study: to optimize diagnostics and treatment of comorbid gastroesophageal reflux disease (GERD) and concomitant neurocirculatory dystonia (NCD) with insomnia among young people by studying autonomic dysfunction and mechanisms of its realization. Methods. The study was conducted in three groups of patients, homogeneous by gender and age. The first group included patients with GERD and insomnia, the second group counted those with NCD and insomnia, and the third group consisted of GERD with NCD and insomnia. We studied the quality of life (SF-36), quality of sleep (PSQI), the presence and severity of depression (PHQ-9), psychosomatic condition (Spielberger-Khanin scale), and determined the presence and severity of autonomic dysfunction syndrome (Wayne questionnaire), acidity of the stomach, ultrasound examination of the esophagus and stomach. Results. The first group revealed sympathicotonia and increase of gastric juice aggression (in the stomach body 0.89±0.05) and reactive (47.2 points) and personal anxiety (52.7 points), which suggests the advisability of use PPI (omeprazole 20 mg 2 times a day for 5 weeks), and melatonin 3 mg per night during 3 weeks. The second group showed parasympathicotonia predominant, a more pronounced decrease in vitality scale (31.5±4.2), and a moderate increase in indicators of reactive (44.0 points) and personal anxiety (46.5 points), which suggests the advisability of use 3 mg of melatonin per night during 3 weeks. The third group demonstrated predominance of parasympathicotonia, motor disorders, a decrease in alkalizing function of antrum (5.4±0.17), depression (81.8 %), and the greatest decrease in indicators of sleep quality (11.7) and quality of life, which suggests the advisability of use PPI (omeprazole 20 mg 2 times per day during 5 weeks), with prokinetics (domperidone 10 mg 3 times per day during 5 weeks), and melatonin 3 mg per night during 3 weeks. Conclusions. Autonomic dysfunction has a key influence on the main pathogenetic factors in the formation of both GERD and NCD and insomnia, and the type of autonomic tone determines the features of the clinical course of both isolated and combined pathology.

Stretta radiofrequency treatment vs Toupet fundoplication for gastroesophageal reflux disease: a comparative study

Background

Outcomes of gastroesophageal reflux disease (GERD) using Toupet fundoplication (TF) and Stretta radiofrequency (SRF) have not been compared and this study was conducted to compare therapeutic efficacy of the two methods.

Methods

This retrospective study analyzed a total of 230 patients undergoing TF or SRF at our hospital. Baseline data, reflux symptoms, the DeMeester scores, lower esophageal sphincter (LES) pressure and adverse events were compared over 1 year period.

Results

A total of 226 patients were included in the study. The time and frequency of reflux and percentage of reflux time before and 12 months after therapy were not significantly different. There were significantly interactions between the therapy method and follow-up time on the DeMeester score and LES pressure. Twelve months post therapy, the DeMeester score was significantly higher in SRF than in TF group, while the LES pressure was lower. At 12 months after therapy, multivariate Cox proportional regression analysis showed that reflux frequency, the DeMeester score and LES pressure were risk factors for poor prognosis in TF group, while reflux frequency and the DeMeester score, and LES pressure were risk factors for poor prognosis in SFR group.

Conclusions

Compared with TF, SFR can significantly improve the esophageal pH and pressure in GERD patients without increasing the risk of poor prognosis.

Ankylosing Spondylitis Is Associated With Risk of New-Onset Obstructive Sleep Apnea: A Nationwide Population-Based Cohort Study

Objectives: Investigating the risk of obstructive sleep apnea(OSA) among ankylosing spondylitis (AS) patients based on administrative healthcare databases.

Methods: We conducted a nationwide cohort study by using the Taiwan National Health Insurance Research Database with 1997–2013 claim records. The AS cohort included 2,210 patients who were newly diagnosed between 2003 and 2013. Randomly selected non-AS controls were matched at a 1:4 ratio. The endpoint was set as OSA occurrence or the end of 2013. Cumulative incidences, hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated after adjusting for age, gender, comorbidities, and co-medication. Multivariate analyses were performed using the Cox proportional hazards model. Due to the violation of the proportionality assumption, landmark analysis was conducted to explore the risk of OSA during specific follow-up periods.

Results: The adjusted HR (aHR) of OSA in the AS group was 2.826 (95% C.I. = 1.727–4.625) compared to the control group. On landmark analysis, aHR was 7.919 (95% C.I. = 3.169–19.792) for the AS group 0–24 months from the index date and decreased to 1.816 (95% C.I. = 0.944–3.494) at ≥ 24 months from the index date. The increased risks of OSA in the AS group compared to the control group were found for both males and females (aHRs were 4.533 and 2.672). On age-stratified analysis, a significant risk only for the 40–59 age group with aHR of 3.913 (95% C.I. = 1.890–8.102).

Conclusions: A higher risk of developing OSA was found among newly diagnosed AS cohort during the maximum 11-year follow-up period, especially within 2 years after newly diagnosed AS and in the 40–59 age group.

Updates in the field of non-esophageal gastroesophageal reflux disorder

Introduction: Gastroesophageal reflux disease (GERD) is one of the most prevalent conditions in Western Countries, normally presenting with heartburn and regurgitation. Extra-esophageal (EE) GERD manifestations, such as asthma, laryngitis, chronic cough and dental erosion, represent the most challenging aspects from diagnostic and therapeutic points of view because of their multifactorial pathogenesis and low response to proton pump inhibitors (PPIs). In fact, in the case of EE, other causes must by preventively excluded, but instrumental methods, such as upper gastrointestinal endoscopy and laryngoscopy, have low specificity and sensitivity as diagnostic tools. In the absence of alarm signs and symptoms, empirical therapy with a double-dose of PPIs is recommended as a first diagnostic approach. Subsequently, impedance-pH monitoring could help to define whether the symptoms are GERD-related. Areas covered: This article reviews the current literature regarding established and proposed EE-GERD, reporting on all available options for its correct diagnosis and therapeutic management. Expert opinion: MII-pH could help to identify a hidden GERD that causes EE. Unfortunately, standard MII-pH analysis results are often unable to define this association. New parameters such as the mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index may have an improved diagnostic yield, but prospective studies using impedance-pH are needed.

The relationship between obstructive sleep apnea hypopnea syndrome and gastroesophageal reflux disease: a meta-analysis

BACKGROUND

Obstructive sleep apnea hypopnea syndrome (OSAHS) means apnea and hypopnea caused by partial or complete obstruction of upper airway collapse during sleep. Gastroesophageal reflux disease (GERD) is believed to be associated with various manifestations in the otorhinolaryngology and has been found to be an additional risk factor for OSAHS.

AIM

A meta-analysis was performed to identify the association between obstructive sleep apnea hypopnea syndrome and gastroesophageal reflux disease.

METHODS

To identify eligible original articles, we searched a series of computerized databases, including Medline via PubMed, EMBASE, Web of Science, and CNKI with a systematic searching strategy. The characteristics of each article and pooled odds ratios (ORs) with corresponding confidence intervals (CIs) were calculated and subgroup analysis was performed to analyze the source of heterogeneity.

RESULTS

A total of 2699 patients from seven articles were included in the meta-analysis. We identified a significant relationship between obstructive sleep apnea syndrome and gastroesophageal reflux disease, with a pooled OR of 1.75 (95% CI 1.18-2.59, P < 0.05). The pooled data was calculated under the random-effects model as a significant moderate heterogeneity was found among the meta-analysis.

CONCLUSIONS

The meta-analysis showed that there was a significant correlation between obstructive sleep apnea hypopnea syndrome and gastroesophageal reflux disease.

Gravitational forces, negative pressure and facial structure in the genesis of airway dysfunction during sleep: a review of the paradigm

The recent and distant literature has extensive discussion of how sleep apnea, adeno-tonsillar growth, and facial structural deformity are related. Conventionally, the order of cause and effect is as follows: (1) Inflammatory/infectious process→tonsillar/adenoid tissue growth→(2) airway obstruction and mouth breathing/Obstructive Sleep Apnea (OSA)→(3) altered facial structure (adenoid facies). Using this same reasoning, adenotonsillectomy is the first line of treatment in the prevention of structural abnormalities. However, through a lifetime of clinical research Christian Guilleminault and his colleagues have challenged this paradigm. Through multiple articles and studies, Guilleminault et al., teach that even slight (subclinical) facial structure/muscle tone variations may be the inciting event triggering mouth-breathing and the eventual adenotonsillar growth in most patients. Essentially, this is the reverse of the conventional paradigms. Initial treatments therefore shift from simplified removal of inflammatory tissue to limiting mouth-breathing via musculo-skeletal modification. The purpose of this paper is to synthesize and analyze the recent (and distant) relevant literature to provide support for, and provide a potential anatomic mechanism for Guilleminault et al.'s paradigm-questioning clinical observations.

Wake-up Call to Clinicians: The Impact of Sleep Dysfunction on Gastrointestinal Health and Disease

Sleep dysfunction is an epidemic affecting a large portion of the adult population. Recent studies have linked sleep dysfunction with an upregulation of proinflammatory cytokines (eg, tumor necrosis factor-α, interleukin-1 and interleukin-6), the implications of which can have a profound impact on a variety of gastrointestinal disease. In particular, sleep dysfunction seems to accelerate disease states characterized by inflammation (eg, gastroesophageal reflux disease, irritable bowel syndrome and functional dyspepsia, chronic liver disease, inflammatory bowel disease, and colorectal cancer). This article evaluates the complex interplay between sleep dysfunction and gastrointestinal health and disease.

Evaluation of treatment pattern and symptom control in patients with gastroesophageal reflux disease: multihospital questionnaire survey on the current situation in Korea

Proton pump inhibitors (PPIs) are the most effective treatment for gastroesophageal reflux disease (GERD); however, a considerable number of patients fail to respond to PPI therapy and complain of nocturnal heartburn and sleep disturbance. The aims of this study are to evaluate the treatment pattern of GERD-related medications and their efficacy in relieving nocturnal heartburn. A total of 334 patients with GERD receiving PPI therapy within 6 months were enrolled in a multihospital questionnaire survey from January, 2014 to March, 2015. GERD symptoms and patients' satisfaction were assessed by patient questionnaires, and treatment patterns of GERD-related medications were assessed by investigators. Among the 334 patients, 95.8% used PPI once daily and 58.6% used a half-dose of PPI. The PPI treatment pattern was changed in 26.6% of all patients, of those, 54% of the patients doubled the PPI dose, and 29.2% of the patients switched to another PPI. Approximately 60.3% of all patients were prescribed more than three GERD-related medications. The overall satisfaction rate was 61.8%, and 32.2% of patients experienced nocturnal heartburn and sleep disturbance. In the extended-release PPI group, there were fewer nocturnal symptoms compared with the conventional PPI group (10% vs. 33.7%, respectively, P = 0.027). The use of more than three medications was inversely associated with patients' satisfaction (OR = 0.355, 95% CI; 0.197-0.642, P = 0.001). Most patients were prescribed adjunctive medications other than PPIs; however, patients' satisfaction was inversely associated with multiple drugs. Patients' satisfaction was superior in extended-release PPIs than conventional PPIs for the relief of nocturnal heartburn in Korean patients.