Review article: Functional dyspepsia and pregnancy-Effects and management in a special population.

BACKGROUND: Around 10% of Americans meet the Rome IV criteria for functional dyspepsia (FD), with a significantly higher rate in women. FD also has a higher prevalence in women below the age of 50, suggesting that women who are affected are likely to be of reproductive age. Unfortunately, there is a lack of research or evidence-based guidelines on managing FD in pregnancy. AIMS AND METHODS: To address this issue, we aimed to perform a systematic review of the interactions between FD and pregnancy and managing pre-existing FD in the peripartum and post-partum phases using current lifestyle, pharmacological, non-pharmacological and alternative medicine interventions. RESULTS: Due to the lack of Rome IV FD-specific data in pregnancy, we instead performed a narrative review on how existing FD interventions could be extrapolated to the pregnant population. Where possible we use the highest level of available evidence or official guidelines to answer these questions, which often involves synthesising treatment and safety evidence of these interventions in other diseases during pregnancy. Finally, we highlight current substantial knowledge gaps requiring further research for the safe management of a pregnant patient with pre-existing FD. CONCLUSIONS: Overall, despite the paucity of knowledge of treating FD during pregnancy, providers can mitigate this uncertainty by planning ahead with the patient. Patients should ideally minimise treatment until after breastfeeding. However, interdisciplinary resources are available to ensure that minimal-risk interventions are maximised, while interventions with more risks, if necessary, are justifiable by both the patient and the care team. Future investigations should continue to elicit the mechanistic relationship between FD and pregnancy while cautiously expanding prospective research on promising and safe therapies in pregnant patients with pre-existing FD.

ROLE OF SPOUSAL INVOLVEMENT IN CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) ADHERENCE IN PATIENTS WITH OBSTRUCTIVE SLEEP APNEA (OSA).

INTRODUCTION: Little is known about the impact of spousal involvement on continuous positive airway pressure (CPAP) adherence. The aim of this study was to determine whether spouse involvement affects adherence with CPAP therapy, and how this association varies with gender. METHODS: 194 subjects recruited from Apnea Positive Pressure Long Term Efficacy Study (APPLES) completed the Dyadic Adjustment Scale (DAS). The majority of participants were Caucasian (83%), and males (73%), with mean age of 56 years, mean BMI of 31 kg/m2. & 62% had severe OSA. The DAS is a validated 32-item self-report instrument measuring dyadic consensus, satisfaction, cohesion, and affectional expression. A high score in the DAS is indicative of a person's adjustment to the marriage. Additionally, questions related to spouse involvement with general health and CPAP use were asked. CPAP use was downloaded from the device and self-report, and compliance was defined as usage ≥ 4 h per night. RESULTS: There were no significant differences in overall marital quality between the compliant and noncompliant subjects. However, level of spousal involvement was associated with increased CPAP adherence at 6 months (p=0.01). After stratifying for gender these results were significant only among males (p=0.03). Three years after completing APPLES, level of spousal involvement was not associated with CPAP compliance even after gender stratification. CONCLUSION: Spousal involvement is important in determining CPAP compliance in males in the 1st 6 months after initiation of therapy but is not predictive of longer-term adherence. Involvement of the spouse should be considered an integral part of CPAP initiation procedures. SUPPORT: HL068060.

Comparison of the different characteristics of sensed reflux events among different heartburn groups.

BACKGROUND AND AIM: Presently, there are no studies comparing sensed acid reflux event (SARE) characteristics among different heartburn groups. Our aim was to compare the different esophageal acid reflux characteristics of an SARE among the different heartburn groups. METHODS: Patients with heartburn underwent endoscopy and pH testing and were stratified into 3 groups: erosive esophagitis (EE), nonerosive reflux disease (NERD), and functional heartburn (FH). Patients underwent esophageal pH testing using a 4-sensor pH probe, with the most distal pH sensor positioned 1 cm> lower esophageal sphincter (LES). RESULTS: Twenty-two patients had EE, 15 NERD, and 13 FH (M/F: 20/2, 12/3, 5/8, mean age: 51.5+/-3.7, 50.1+/-4.2, 50.3+/-3.8, respectively). The percentage of SAREs at 1 cm>LES that had reached 16 cm>LES was significantly higher in the FH group compared with NERD and EE (P<0.05). EE demonstrated the lowest nadir during an SARE and NERD the most acid reflux events before an SARE (up to 4 h). CONCLUSIONS: Patients with FH demonstrated the most SAREs that reached the proximal esophagus. EE patients demonstrated the lowest nadir pH during an SARE and NERD patients the most acid reflux events before an SARE, as compared with the other heartburn groups.

The effect of auditory stress on perception of intraesophageal acid in patients with gastroesophageal reflux disease.

BACKGROUND & AIMS: Most patients with gastroesophageal reflux disease (GERD) report that stress exacerbates their symptoms, yet mechanisms underlying this association remain unknown. We sought to determine the effect of an acute laboratory stressor on perceptual and emotional responses to intraesophageal acid perfusion in healthy controls and patients with GERD. METHODS: Forty-six patients with heartburn and 10 healthy controls underwent upper endoscopy and, if negative, pH monitoring. Assessment of psychologic factors and health-related quality of life was done by a questionnaire. Perceptual and emotional responses to intraesophageal acid at baseline, during auditory stress, and during an auditory control condition were determined using a randomized crossover design. Plasma levels of norepinephrine, adrenocorticotropic hormone, and cortisol were assessed. RESULTS: Twenty-nine subjects were identified as nonerosive reflux disease and 17 as erosive esophagitis. Quality of life, psychologic profile, and personality assessment variables were similar among the 2 patient groups and the controls. There was a significant reduction in mean lag time to initial symptom perception and an increase in mean intensity rating and mean acid perfusion sensitivity score in the 2 patient groups during the stress period, which was not seen during the control condition. Healthy controls demonstrated lack of a significant change in all parameters of stimulus response functions to acid, regardless of condition. CONCLUSIONS: Acute auditory stress can exacerbate heartburn symptoms in GERD patients by enhancing perceptual response to intraesophageal acid exposure. This greater perceptual response is associated with greater emotional responses to the stressor.

Relationships between sleep quality and pH monitoring findings in persons with gastroesophageal reflux disease.

BACKGROUND: Nighttime reflux has been shown to be associated with esophageal mucosal injury, complications, and extra-esophageal manifestations. However, few studies have assessed the impact of gastroesophageal reflux on reported quality of sleep and quality of sleep on gastroesophageal reflux. AIMS: The aims of this study were (1) to determine the correlation between the severity of gastroesophageal reflux disease (GERD) symptoms and esophageal acid contact time and subjects' perceived quality of sleep; (2) to investigate the correlation between reported quality of sleep of the night prior and severity of GERD symptoms and esophageal acid contact time the following day; and (3) to define in a sleep laboratory the correlation between acid reflux events and sleep architecture. METHODS: Subjects with typical GERD symptoms > or =3 times a week underwent upper endoscopy and pH monitoring. These subjects subsequently completed the GERD Symptom Assessment Score (GSAS), and the Sleep Heart Health Study Sleep Habits (SHHS) Questionnaire to assess baseline sleep symptoms and GERD symptoms, including an index of GERD symptom severity (GERD symptom index). Before and after the pH test, the patients completed a different instrument, the Sleep Quality Questionnaire, utilized specifically to assess the quality of each subject's sleep before and after pH testing. Fifteen randomly selected subjects also underwent a polysomnographic study during the pH test. RESULTS: Forty-eight (33 males/15 females, mean age 48.8 +/- 17.1 y) subjects were prospectively recruited. Using data from the GSAS and SHHS questionnaires, disorders of initiating and maintaining sleep were found to be positively associated with greater severity of the GERD symptom index (r = 0.33, p <0.05). More frequent awakenings also correlated with a higher GERD symptom index (r = 0.4, p <0.01). Correlations between the Sleep Quality Questionnaire on the night before sleep testing and pH monitoring data showed that subjects with poorer sleep quality had longer acid reflux events (r=-0.34, p<0.05). More perceived awakenings also were correlated with the number of supine acid reflux events > 5 min (r=0.31, p<0.05) and the duration of the longest supine acid reflux event (r = 0.28, p = 0.05). Inverse correlations were observed between overall sleep quality on the pH testing night and a higher percentage of time spent with pH<4 supine (r=-0.432, p <0.002), and the duration of the longest acid reflux event during the entire night (r = -0.38, p <0.01) and supine (r=-0.37, p<0.02). CONCLUSIONS: Persons with worse GERD symptoms report poorer subject sleep quality. Poor sleep quality on the night prior to pH testing was associated with more acid exposure the following day. Greater acid exposure at night was related to a worse perception of sleep quality the next day. These findings suggest important interactions between GERD and sleep quality.