The Effect of Ramelteon on Heartburn Symptoms of Patients With Gastroesophageal Reflux Disease and Chronic Insomnia: A Pilot Study.

BACKGROUND: There is a bidirectional relationship between gastroesophageal reflux disease (GERD) and sleep. It has been demonstrated that antireflux treatment can improve sleep quality in GERD patients with nighttime reflux. MATERIALS AND METHODS: Patients with heartburn and/or regurgitation ≥3 times/week and insomnia for ≥3 months were included. Patients were assessed at baseline with the demographic, GERD symptom assessment scale, Epworth sleepiness scale, Berlin sleep apnea, Pittsburgh sleep quality index, and the Insomnia severity index questionnaires. Subjects underwent an upper endoscopy followed by pH testing. Subsequently, subjects were randomized, in a double-blind, placebo-controlled trial, to receive either ramelteon 8 mg or placebo before bedtime for 4 weeks. During the last week of treatment, subjects completed a daily GERD symptom and sleep diary and underwent actigraphy. RESULTS: Sixteen patients completed the study, 8 in each arm (mean age and M/F were 48.5 vs. 57.8 y, and 8/0 vs. 6/2, respectively). Patients who received ramelteon demonstrated a statistically significant decrease in symptom score as compared with those who received placebo for daytime heartburn (-42% vs. -29%), nighttime heartburn (-42% vs. 78%), 24-hour heartburn (-42% vs. -3%), and 24-hour acid regurgitation (-26% vs. 19%) (all P<0.05). Insomnia severity index score was significantly reduced in patients receiving ramelteon as compared with placebo (-46% vs. -5%, P<0.05). Ramelteon group also demonstrated a significant improvement in sleep efficiency and sleep latency, as compared with placebo, P<0.05). No significant adverse events were observed with ramelteon. CONCLUSIONS: Ramelteon significantly improved symptoms in patients with GERD. In addition, ramelteon significantly improved patients' sleep experience. Further studies are needed in the future (NCT01128582).

Naps are associated more commonly with gastroesophageal reflux, compared with nocturnal sleep.

BACKGROUND & AIMS: Acid reflux during nighttime sleep has been associated with more severe gastroesophageal reflux disease (GERD). Napping is common, especially after lunch time, in many cultures. We aimed to compare reflux characteristics between nighttime sleep and naps in patients with GERD. METHODS: We performed a study of 15 patients (mean age, 58.5 ± 18.4 y; 10 men) with heartburn and/or regurgitation at least 3 times/week for the past 3 months, who experienced a nap in addition to regular nighttime sleep. All were evaluated using the demographics and GERD Symptoms Checklist questionnaires. Patients underwent pH testing concomitantly with actigraphy when they were not receiving antireflux treatment; only patients with abnormal results from pH tests were included in the study. Raw data from actigraphy analyses were superimposed over those collected from pH monitoring, matched by time. Integrative software was used to determine recumbent-awake, recumbent-asleep, and naps alongside pH monitoring data. RESULTS: The mean duration of nocturnal sleep time and nap time were 446.0 ± 100.7 minutes and 61.9 ± 51.8 minutes, respectively. The mean number of reflux events per hour was significantly greater during nap than nocturnal sleep time (40.1 ± 69.9/h vs 3.5 ± 4.2/h; P < .05). The mean duration of reflux events was longer during nap than nocturnal sleep time (1.9 ± 2.8 min vs 1.5 ± 2.7 min). The percentage of time spent at a pH less than 4 was significantly greater during naptime than nocturnal sleep time (36.2% ± 38.8% vs 8.9% ± 11.6%; P < .05). Arousals from naps were rare, compared with nocturnal sleep (mean, 0.7 ± 1.1 vs 4.2 ± 2.9; P < .05). Patients also experienced more acid reflux associated with symptoms during nap than nocturnal sleep (mean, 8.08% vs 0.45%; P < .05). CONCLUSIONS: We associated naps with significantly greater numbers of, and duration of, esophageal acid exposure and symptoms, compared with nocturnal sleep. Naps therefore might have important effects on disease severity.

Nonalcoholic fatty liver disease as a risk factor for cytomegalovirus hepatitis in an immunocompetent patient: A case report.

BACKGROUND: Almost 80 percent of adults in the United States have had cytomegalovirus (CMV) infection by age 40. The number of symptomatic CMV hepatitis cases has been increasing along with non-alcoholic fatty liver disease (NAFLD) cases in the United States that is estimated to be 25 percent of the population. In this paper, we try to link these two entities together. CASE SUMMARY: In this case report, we describe a young female who presented with fever, nausea, and vomiting who was found to have NAFLD and CMV hepatitis that was treated supportively. CONCLUSION: In this case report, we describe NAFLD as a risk factor for CMV hepatitis and discuss the possible impact on clinical practice. We believe, it is essential to consider NAFLD and it's disease mechanisms' localized immu-nosuppression, as a risk factor of CMV hepatitis and severe coronavirus disease 2019 infection.

Drug-Induced Liver Failure Requiring Liver Transplant: Report and Review of the Role of Albendazole in Managing Echinococcal Infection.

Albendazole is often used as adjunctive therapy in the treatment of echinococcal infection to reduce cyst viability before and prevent recurrence after surgical treatment. In this report, we present a 38-year-old Iraqi woman with Echinococcus initiated on albendazole therapy who developed acute liver failure 6 weeks after treatment. Investigation for common viral and autoimmune causes of liver injury was unremarkable, and a liver biopsy revealed changes consistent with severe, drug-induced liver injury. Despite discontinuation of albendazole, liver function continued to deteriorate, prompting rescue with an orthotopic liver transplant. Often used perioperatively in the management of Echinococcus infection, albendazole can induce idiosyncratic severe liver injury, mandating close monitoring for hepatotoxicity.