Systematic review: health-related quality of life (HRQOL) questionnaires in gastro-oesophageal reflux disease

BACKGROUND

Although gastro-oesophageal reflux disease (GERD) has a well-established pathophysiology, the impact of GERD symptoms on the patients' quality of life can be profound. Therefore, health-related quality of life (HRQOL) questionnaires have become standard instruments to evaluate the effect of treatment in clinical trials.

AIM

To evaluate the reliability, validity and responsiveness of available GERD-specific HRQOL.

METHODS

A systematic literature search using the Medical Subject Headings terms: 'Gastro-oesophageal reflux', 'Heartburn' and 'Oesophagitis' with 'quality of life' and 'questionnaires' was preformed to identify the available HRQOL questionnaires. To analyse the psychometric properties of the respective tools, the actual guidelines for the use of patient-reported outcomes in clinical trials were applied.

RESULTS

We identified five GERD-specific HRQOL questionnaires but none of them fulfilled all quality criteria; either they did not meet the actual standards for psychometric properties (HBQOL, GERD-HRQL, Jasani et al.Aust Fam Physician 1999; 28: 515), or were impracticable to use in clinical trials. The generic and hybrid instruments lack specificity and sensitivity and were not designed for treatment evaluation in GERD patients.

CONCLUSION

There is need for a new evaluative tool in the assessment of HRQOL during GERD therapy.

Impact of inflammatory bowel disease on health-related quality of life

Health-related quality of life (HRQOL) has a recognized importance to evaluate, manage and follow patients. Different types of instruments for measuring HRQOL have recently been introduced to evaluate HRQOL in patients with inflammatory bowel disease. Most questionnaires suggest that inflammatory bowel disease has a significant impact in HRQOL. It seems that ulcerative colitis has less profound effects on HRQOL than Crohn's disease and that some differences in HRQOL status are related to some factors such as the severity of the disease. When patients express their concerns, most important worries are related to surgery. Effective medical treatment appears to improve HRQOL. Effects of surgery on HRQOL can probably be different depending on the type of surgical technique and if it is curative or not. Recent studies suggest that inflammatory bowel disease not only impacts on patient's HRQOL but also on their caregivers. Features such as the impact on HRQOL of different disease variables, such as complications or patient personality, the role of medical or surgical treatments on different dimensions of HRQOL, the cost-utility evaluation of therapy are some of the fields that will probably focus the protagonism in the next years.

Review article: the initial management of uninvestigated dyspepsia in younger patients-the value of symptom-guided strategies should be reconsidered

Several major management guidelines on dyspepsia (upper abdominal pain or discomfort) recommend an initial 'test-and-treat' policy (non-invasive Helicobacter pylori testing with eradication therapy if positive) in uninvestigated patients less than about 45 years old. However, the evidence that this is the optimal strategy is limited. Data from the few available randomized controlled trials provide evidence that this policy improves symptomatology more than a 'test-and-endoscope' approach (in which only H. pylori-positive patients undergo early endoscopy) in those with upper abdominal pain. The balance of cost-effectiveness data from clinical studies and decision analyses indicates that both 'test-and-treat' and empirical anti-secretory therapy approaches are more cost-effective than the 'test-and-endoscope' strategy. Therefore, given concerns about the safety of widespread H. pylori eradication, initial empirical anti-secretory therapy may be a cost-effective alternative to the 'test-and-treat' policy in some younger dyspeptic patients. The effectiveness of such an empirical approach might well be improved by symptom-guided therapy and there is growing evidence that the predominant dyspeptic symptom may provide this guide. The diagnostic, therapeutic and economic utility of this approach merits further clinical investigation.

Does cyclosporin A worsen liver function in patients with inflammatory bowel disease and total parenteral nutrition?

OBJECTIVE

inflammatory bowel disease (IBD), total parenteral nutrition (TPN) and immunosuppressive treatment with cyclosporin A (CsA) are well known factors in hepatobiliary disorders. Their association, however, has been little studied.

METHOD

we retrospectively analyzed the results of liver function tests (transaminases, AST. ALT), total bilirubin, alkaline phosphatase, and gamma-glutamyltransferase (GGT) in a consecutive series of 50 patients (29 men, 21 women, mean age 32 years, range 16-78 years) hospitalized for a severe attack of IBD between January 1992 and July 1997. Basal laboratory values in all patients were normal. Thirty-eight patients had ulcerative colitis (UC) and 12 had Crohn's disease (CD), which debuted in 28% of the patients. All patients were treated with methylprednisolone (MP) (0.75-1.0 mg/kg daily i.v., and received TPN. 42% (21/50) required additional treatment with CsA (5 mg/kg daily i.v.) at the beginning or during the first week of TPN and during 7-24 days, because on nonresponse to steroid treatment. Two study groups were defined according to treatment: Group I consisted of 29 patients given MP + TPN, and group II comprised 21 patients who received MP + TPN + CsA. The groups were otherwise similar in all other variables analyzed. Liver function tests were done weekly until the end of the study period.

RESULTS

62% of the patients (31/50) showed hepatobiliary dysfunction, defined previously as a 2-fold or greater elevation of two or more parameters. There was no statistically significant difference between the two groups in the incidence of dysfunction (15/29 vs 16/21, n.s.). The parameters that showed the greatest alterations were GGT and ALT; the greatest elevation appeared during the third week of immunosuppressive treatment, and did not exceed 6-fold the normal value. The alterations disappeared once TPN and immunosuppressive treatment were discontinued.

CONCLUSIONS

the hepatobiliary dysfunction in patients treated with both TPN and CsA was no more severe than associated with TPN alone.

Ethanol feeding aggravates morphological and biochemical parameters in experimental chronic pancreatitis

BACKGROUND AND AIMS

Instillation of trinitrobenzene sulfonic acid (TNBS) into the rat pancreatic ducts induces morphological changes resembling human chronic pancreatitis. In humans, alcoholism is commonly associated with chronic pancreatitis, but ethanol feeding fails to induce pancreatitis in experimental animals. We hypothesized that ethanol would manifest its pathogenetic effects on a duct-injured pancreas.

METHODS

Chronic pancreatitis was induced in rats by instillation of TNBS into pancreatic ducts. Thereafter, rats were fed a normal chow diet with or without ethanol supplementation. Control rats received vehicle and a normal diet. A separate group of vehicle-treated rats were also fed with ethanol. At 2 and 4 weeks pancreata were excised and processed for morphological examination or for biochemical assays. From crude homogenates, protein and hydroxyproline were quantified. After sonication, homogenates were also assayed for amylase and DNA. An oral glucose tolerance test was performed on the fourth week.

RESULTS

TNBS induced chronic fibrogenic pancreatitis that was associated with a reduction in pancreatic weight, DNA, protein and amylase as compared to control rats. Ethanol feeding to TNBS-treated animals slowed weight gain, increased fasting glucose and impaired glucose tolerance test. Larger areas of gland atrophy were observed with a striking disruption of the normal architecture of the islets. Ethanol accelerated pancreatic involution and collagen deposition as measured by total amylase, protein, DNA and hydroxyproline content.

CONCLUSIONS

In TNBS chronic pancreatitis, active fibrogenesis is associated with progressive atrophy of glandular elements. Morphological and biochemical parameters are aggravated by sustained ethanol intake.

Derangement of mucosal barrier function by bacteria colonizing the rat colonic mucosa

BACKGROUND

Interaction between gut flora and the intestinal barrier may involve changes in permeability.

METHODS

Rats with a colonic segment excluded from faecal transit were surgically prepared. Matched groups were either kept on luminal antibiotics to prevent colonization of the segment or recolonized with mixed rat flora. Permeability to low-dose trinitrobenzenesulphonic acid (TNBS) or trinitrophenol (TNP), and mucosal injury by the compounds at a high dose were tested in antibiotic and recolonized rats (the compounds differ in water solubility but share a common antigenic domain).

RESULTS

Lumen to blood clearance of the hydrophilic probe (TNBS) was faster in recolonized than in antibiotic rats. The hydrophobic compound TNP was absorbed at faster rates than TNBS, but there was no difference between antibiotic and recolonized rats. Instillation of TNBS at a high dose induced mucosal release of inflammatory mediators and tissue myeloperoxidase accumulation in recolonized rats but not in antibiotic rats. Large necrotic lesions with submucosal involvement after TNBS were only observed in recolonized rats. In contrast, TNP induced mucosal inflammation and large lesions with submucosal necrosis both in recolonized and in antibiotic rats.

CONCLUSION

Colonizing bacteria may increase intestinal permeability to hydrophilic compounds and render the mucosa susceptible to injury.

Influence of the substrate on the reproducibility of the hydrogen breath test to measure the orocecal transit time

BACKGROUND

The H2 breath test is widely used for the measurement of the orocecal transit time (OCTT). However, its clinical applicability is limited by its suboptimal reproducibility.

AIM

To investigate whether changes in the substrate for the H2 breath test improve its reliability for the measurement of the OCTT.

METHODS

72 consecutive patients referred for measurement of the OCTT were studied. The breath test was performed twice, on consecutive days. One group of patients ('lactulose + water' group) received lactulose 13.3 g in water both days. Another group ('lactulose + diet') received lactulose 13.3 g in a liquid meal of 400 kcal. A third group ('lactulose-lactitol') received 13.2 g of lactulose the first day and 10 g lactitol the following day. The fourth group ('lactitol + water') received lactitol 10 g in water both days. Alveolar breath was sampled every 10 min for the next 3 h for H2 chromatography.

RESULTS

OCTT in the first and second day test for the groups 'lactulose + water', 'lactulose + diet' and 'lactitol + water' were similar. In these three groups, the values obtained on the first and second day did not differ from 0 and were also significantly correlated. However, the correlation and the mean coefficient of variation were better in group 'lactulose + water' than in the groups 'lactulose + diet' and 'lactitol + water'. In group 'lactulose-lactitol' the results on both days were significantly correlated although the delta between matched values was different from 0 (p = 0.03).

CONCLUSION

The meal substrate influences the variability of the OCTT. However, reproducibility of the test does not improve with the addition of a liquid meal.

The search for an 111In labeled agent for the solid component of gastric emptying

111In-labeled solid meal was prepared by chelation of 111In with Chelex resin bead. The effect of grinding of normal Chelex bead on 111In chelation and retention in solid meal was evaluated in an in vitro system. The Chelex resin beads were ground in a mortar-pestle to form ground Chelex resin beads. Fine particles were removed by resuspension in distilled water and centrifugation (1000 g). One hundred to 150 microCi of 111In chloride was diluted with 0.1 N HCl and mixed with 1 g of Chelex resin beads. Unbound 111In was removed by centrifugation (1000 g). The 111In-labeled Chelex resin beads were mixed with fresh egg and 111In-labeled solid meal was prepared by heating until solid. The meals were digested with HCl-pepsin (1.2 mg/mL of pepsin in 0.1 N HCl) for 4 h in a stirrer-bath (37 degrees C). Aliquots were collected at intervals for determination of 111In loss from 111In-labeled solid meal. These results suggest that 111In Chelex resin beads were retained in solid meals at a higher level than normal Chelex resin beads and other 111In-tracers.