A comparative study of disorders of gut-brain interaction in Western Europe and Asia based on the Rome foundation global epidemiology study.

OBJECTIVE: Many studies have been published on disorders of the gut-brain interaction (DGBI) in Asia and Western Europe, but no previous study has directly assessed the difference between the two regions. The aim was to compare the prevalence of DGBI in Asia and Western Europe. METHODS: We used data collected in a population-based Internet survey, the Rome Foundation Global Epidemiology Study, from countries in Western Europe (Belgium, France, Germany, Netherlands, Italy, Spain, Sweden, and the United Kingdom) and Asia (China, Japan, South Korea, and Singapore). We assessed DGBI diagnoses (Rome IV Adult Diagnostic Questionnaire), anxiety/depression (Patient Health Questionnaire-4, PHQ-4), non-GI somatic symptoms (PHQ-12), and access to and personal costs of doctor visits. RESULTS: The study included 9487 subjects in Asia and 16,314 in Western Europe. Overall, 38.0% had at least one DGBI; younger age, female sex, and higher scores on PHQ4 and PHQ12 were all associated with DGBI. The prevalence of having at least one DGBI was higher in Western Europe than in Asia (39.1% vs 36.1%, OR 1.14 [95% CI 1.08-1.20]). This difference was also observed for DGBI by anatomical regions, most prominently esophageal DGBI (OR 1.67 [1.48-1.88]). After adjustment, the difference in DGBI prevalence diminished and psychological (PHQ-4) and non-GI somatic symptoms (PHQ-12) had the greatest effect on the odds ratio estimates. CONCLUSION: The prevalence of DGBI is generally higher in Western Europe compared to Asia. A considerable portion of the observed difference in prevalence rates seems to be explained by more severe psychological and non-GI somatic symptoms in Western Europe.

Quality of life measures in irritable bowel syndrome.

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder with significant morbidity, resulting from the interaction of physiologic, psychological, social, cultural and behavioral factors. In view of this complex interaction, and in the absence of a measurable biological index of disease, health-related quality of life (HRQoL) has emerged as an ideal measure for use in clinical trials and outcome studies. This article discusses the relevance of HRQoL measurement in IBS and its definition. It then explores the research methodology in HRQoL and describes how global measures and generic HRQoL instruments have been used in IBS. Finally, the IBS-specific HRQoL measures are described in detail, with an emphasis on their development, content and validation.

Here's my phone number, don't call me: physician accessibility in the cell phone and e-mail era.

Physician accessibility, for example how available a doctor should be by cell phone or e-mail is an important issue that is not well understood. There can be large differences between the expectations of patients and the perspective of their providers. The rationale for providing accessibility has historical roots and relates to the very basis of the physician-patient relationship and the effects on patient outcomes. While patients may want this line of communication, physicians may worry about disruption from unexpected phone calls, being requested to provide advice without access to records and providing services without adequate remuneration among other concerns. Herein, we discuss the rationale for these concerns, and provide suggestions on how we might overcome them. We suggest a framework with guidelines on establishing and maintaining remote accessibility with patients in the context of a productive physician-patient relationship.

The response of Asian patients with functional dyspepsia to eradication of Helicobacter pylori infection.

OBJECTIVES/BACKGROUND: The role of Helicobacter pylori infection in functional dyspepsia (FD) remains controversial. Several randomized controlled trials involving populations in the West, observed no statistically significant advantage over placebo. However, none of these studies involved Asian populations which have high infection rates. METHODS: A double blind, randomized, placebo-controlled trial of H. pylori eradication for FD was conducted in our Singapore-based Asian population. Forty-one patients received active treatment consisting of a 1-week course of omeprazole 20 mg once daily, clarithromycin 250 mg twice daily and tinidazole 500 mg twice daily whereas another 41 patients received matching placebo tablets. A dyspepsia score was derived by grading 5 dyspeptic symptoms on a Likert scale. Symptom assessment and urea breath test were repeated at 6 weeks, 6 and 12 months from the start of treatment. The primary end point was symptom resolution, defined as a dyspepsia score of 0 or 1 at the end of 12 months follow-up. RESULTS: On intention-to-treat analyses, symptom resolution was observed in 24% of patients on active treatment and 7% on placebo; the difference in proportion of patients with symptom resolution was statistically significant (P=0.02, 95% confidence interval: 1.1-17.7). H. pylori eradication rates perprotocol and intention-to-treat were 80.0 and 68.3%, on active treatment and 5.6 and 4.9% on placebo (both P values<0.0001). Among patients with H. pylori eradicated on active treatment the symptom resolution rate was 39% (10 of 26), whereas it was 3% (one of 35) among patients in the placebo group who had persistent H. pylori infection. In multivariate analysis, posttreatment H. pylori status was the only predictor of symptom resolution. The majority of patients, 91.5%, had ulcer-like dyspepsia; heartburn and acid regurgitation were uncommon, and no increase was observed after treatment. CONCLUSION: In contrast to Western populations, our results suggest that patients with FD in Asia would benefit from treatment for H. pylori infection with as much as a 13-fold increased chance of symptom resolution following its eradication.

Validation of structured scoring using the LA classification for esophagitis and endoscopically suspected Barrett's esophagus in a tertiary Asian endoscopy center.

AIM: To determine the inter-observer agreement and validity of the LA Classification in scoring the severity of esophagitis in Asian patients. METHODS: Video endoscopy clips were selected from 45 consecutive patients participating in reflux studies. The videos were viewed by endoscopists who then independently scored the presence, severity and distribution of esophagitis, including endoscopically suspected Barrett's esophagus (ESBE). Each video was discussed and a consensus on findings reached. Kappa (k) correlation was calculated to describe inter-observer agreement. RESULTS: Thirty-five clips were scored (no esophagitis 20%, grade-A 54%, grade-B 23%, grade-C 3%, respectively and 10 clips were excluded for poor imaging). Excellent agreement was noted on the presence of esophagitis (mean k = 0.79, range 0.77-0.82). Fifteen patients (42%) had ESBE with a mean k of 0.48 (range 0.39-0.60). Inter-observer agreement on the LA grade was good (mean k = 0.58, range 0.55-0.63), whilst in agreement between endoscopists and consensus grading, the mean kappa rose to 0.77 (range 0.73-0.81). There was a trend of increasing agreement as viewings progressed, with superior kappa correlation after 16 cases. Evaluation of the extent of esophagitis showed good k values using the alternative approach of grouping by circumferential extent (mean k = 0.64, range 0.60-0.67) at the lower categories of severity. CONCLUSIONS: Scoring using the LA classification for esophagitis and the concurrence on the presence of ESBE showed moderate to strong agreement amongst Asian endoscopists. Our results also suggested that an alternative method of scoring esophagitis based on proportion of circumferential involvement was reliable. A learning effect was observed and reliable scoring was achieved after 16 patients.

A bolt out of the blue: a case of unexpected acute liver failure.

INTRODUCTION: We describe an unusual case of acute hepatitis leading rapidly to acute liver failure. CLINICAL PICTURE: Our patient had known chronic hepatitis B with a regenerating nodule confirmed on imaging and histology. He was admitted initially for abdominal discomfort after a trip to China, and investigations showed acute hepatitis with alanine transaminase (ALT) and aspartate transaminase (AST) at 678 and 557 U/L, respectively. Initial differential diagnoses were acute exacerbations of chronic hepatitis B, and viral hepatitis A or E. However, acute Budd- Chiari syndrome was diagnosed on computed tomography (CT) scan of the abdomen, which showed extensive thrombosis of the hepatic vein, all the intrahepatic branches, inferior vena cava, up to the right atrium. TREATMENT: Due to the extensive nature of the thrombus, radiological or surgical intervention could not be performed. OUTCOME: The patient was managed conservatively but progressed rapidly and died of acute liver failure 16 days after presentation. CONCLUSION: Our case highlights the rapidity of progression of acute Budd-Chiari syndrome. Diagnosis and management of Budd-Chiari syndrome are discussed.