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SUMMARY Up to a third of the patients who receive proton pump inhibitor (PPI) once daily will demonstrate lack or partial response to treatment. There are various mechanisms that contribute to PPI failure and they include residual acid reflux, weakly acidic and weakly alkaline reflux, esophageal hypersensitivity, and psychological comorbidity, among others. Some of these underlying mechanisms may coincide in the same patient. Evaluation for proper compliance and adequate dosing time of PPIs should be the first management step before ordering invasive diagnostic tests. Doubling the PPI dose or switching to another PPI is the second step of management. Upper endoscopy and pH testing appear to have limited diagnostic value in patients who failed PPI treatment. In contrast, esophageal impedance with pH testing (multichannel intraluminal impedance MII-pH) on therapy appears to provide the most insightful information about the subsequent management of these patients (step 3). In step 4, treatment should be tailored to the specific underlying mechanism of patient's PPI failure. For those who demonstrate weakly acidic or weakly alkaline reflux as the underlying cause of their residual symptoms, transient lower esophageal sphincter relaxation reducers, endoscopic treatment, antireflux surgery and pain modulators should be considered. In those with functional heartburn, pain modulators are the cornerstone of therapy. [ABSTRACT FROM AUTHOR]

SUMMARY Noncardiac chest pain (NCCP) is a common and challenging clinical problem. It is estimated that more than 70 million Americans (23% of the population) suffer from this condition yearly. Patients with NCCP represent a diagnostic dilemma. Their chest pain is often indistinguishable from cardiac pain leading to extensive and expensive evaluations. Once coronary artery disease and other cardiac and pulmonary sources of chest pain are excluded, patients are frequently referred to gastroenterologists to look primarily for esophageal sources of pain. A variety of diagnostic tests are available to the practicing clinician to identify the origin of pain, including ambulatory pH testing, esophageal motility, upper endoscopy, provocative testing and even therapeutic trials. [ABSTRACT FROM AUTHOR]

Aliment Pharmacol Ther 31, 950–960 Background Optimal long-term management of symptomatic gastro-oesophageal reflux disease (sGERD) patients has not been established. Aim To determine the clinical value of maintenance intermittent treatment with rabeprazole 20 mg vs. placebo in patients with sGERD. Methods This multicentre, US study enrolled patients with sGERD (≥3-month history of GERD symptoms and ≥4 days/week of heartburn during a 2-week placebo run-in) without oesophageal erosions. Patients with complete heartburn control after 4 weeks of open-label rabeprazole 20 mg daily treatment were randomized to 6-month, double-blind, maintenance intermittent treatment (7- to 14-day courses when heartburn recurred) with rabeprazole 20 mg or placebo. Results The primary efficacy end point, mean percentage of heartburn-free days, was significantly greater with rabeprazole vs. placebo: 82.58% and 62.17% (ITT; P < 0.0001) [per protocol 86.74% rabeprazole vs. 74.93% placebo ( P < 0.0254)]. Compared with placebo group, the rabeprazole group also experienced a significantly higher percentage of heartburn-free daytime (84.06% vs. 63.39%; P < 0.0001) and nighttime (95.41% vs. 90.25%; P = 0.0021) periods, had significantly fewer discontinuations because of insufficient heartburn control (6.3% vs. 36.3%; P < 0.0001) and took fewer antacid tablets daily (0.58 vs. 1.16; P = 0.0021). Conclusion Intermittent use of rabeprazole may be an effective maintenance treatment strategy for patients with sGERD and warrants further investigation. This trial was registered with under the number NCT00165841. [ABSTRACT FROM AUTHOR]

Background Randomized, placebo-controlled studies have failed to demonstrate a significant treatment effect for laryngopharyngeal reflux (LPR) using traditional clinical endpoints. We compared the effect of esomeprazole 20 mg twice daily (b.i.d.) vs placebo on voice and acoustic-related measures in patients with LPR. Methods Patients with LPR underwent endoscopy and pH testing. Subsequently, patients underwent videostroboscopic recordings of the larynx, acoustic voice and speech analysis. A voice use and quality diary and oesophageal symptom diary were completed at baseline. Thereafter, patients were randomized to esomeprazole 20 mg twice daily vs placebo for 3 months. The voice use and quality diary and oesophageal symptom dairy were repeated during the last week of treatment. Videostroboscopy and acoustic voice and speech analysis were also performed at the end of treatment. Key Results Twenty-four patients were randomized to the esomeprazole group and 17 to the placebo group. There was no significant difference in videostroboscopic reflux finding scores from baseline to post-treatment. Acoustic measures also failed to demonstrate significant differences within the same or between groups, even when a sub-group analysis of patients with endoscopically documented oesophageal inflammation at baseline was performed. Additionally, no significant differences were found between groups when using voice use and quality diary. Conclusions & Inferences Use of more specific laryngeal functional parameters such as voice-related acoustic measures of pitch range, fundamental frequency and intensity also failed to demonstrate a significant response to proton pump inhibitor treatment as compared to placebo in patients with suspected LPR. [ABSTRACT FROM AUTHOR]

Background Oral tablet formulations of metoclopramide are effective therapies for gastroparesis and gastro-oesophageal reflux disease; however, difficulty swallowing tablets or nausea/vomiting may reduce patient adherence to therapy. Because of this, a metoclopramide orally-disintegrating tablet (ODT) has been developed. Aim To evaluate the bioequivalence of a single administration of a 10-mg metoclopramide ODT and a conventional 10-mg oral metoclopramide tablet in healthy volunteers. Methods In a randomized, single-dose, crossover study, healthy volunteers received single administration of 10-mg metoclopramide ODT and 10-mg conventional metoclopramide tablet, with a 7-day interval between treatments. Serial blood samples were collected before dosing and during 24 h post-treatment. Results Forty-one volunteers completed both treatment arms. Metoclopramide ODT was bioequivalent to conventional tablets; 90% CIs for geometric mean treatment ratios of Cmax [91.6% (90% CI, 87.7–95.8%)], AUClast [97.3% (90% CI, 94.5–100.2%)] and AUCinf [97.6% (90% CI, 94.5–100.8%)] were within the predefined range. Of the 44 volunteers included in the safety analysis, 9 (20%) reported AEs after ODT, compared with 13 (30%) after conventional tablets. Conclusion In healthy volunteers, single administration of 10-mg metoclopramide ODT was well tolerated and bioequivalent to single administration of a conventional 10-mg metoclopramide tablet. [ABSTRACT FROM AUTHOR]

Background The proportion of patients who respond to proton pump inhibitor (PPI) therapy is about 20% lower in those with non-erosive reflux disease (NERD) than in those with erosive oesophagitis. Aim To assess efficacy and safety of dexlansoprazole MR, a PPI using Dual Delayed Release technology, in NERD patients. Methods In this 4-week, double-blind, placebo-controlled study, 947 NERD patients randomly received dexlansoprazole MR 30 mg, 60 mg or placebo once daily (QD). The percentages of 24-h heartburn-free days (primary) and nights without heartburn (secondary) were assessed from patients’ daily diaries. Investigators also assessed symptoms. Patients completed validated quality of life and symptom severity questionnaires. Results Dexlansoprazole MR provided significantly greater median percentages of 24-h heartburn-free days (54.9% and 50.0% for the 30- and 60-mg doses vs. 17.5% for placebo, P < 0.00001) and nights without heartburn (80.8% and 76.9% vs. 51.7%, P < 0.00001 vs. placebo). Dexlansoprazole MR also reduced symptom severity. Quality of life improvements in patients receiving dexlansoprazole MR were consistent with clinical efficacy endpoints. Percentages of patients experiencing treatment-emergent adverse events were similar among groups. Conclusions Dexlansoprazole MR 30 and 60 mg were superior to placebo in providing 24-h heartburn-free days and nights in NERD patients. Treatment was well tolerated. [ABSTRACT FROM AUTHOR]

Proton-pump inhibitor (PPI) failure in gastro-oesophageal reflux disease (GORD) patients has become the main reason for referral of these patients to gastroenterology specialists. It is estimated that 30% of GORD patients requiring a PPI once daily will experience treatment failure. Patients with non-erosive reflux disease are the most common GORD-related group in which once-daily PPI therapy fails. Various mechanisms have been suggested to underlie PPI failure in GORD patients. The most pertinent include weakly acidic reflux, duodenogastro-oesophageal reflux, visceral hyperalgesia, delayed gastric emptying, psychological co-morbidity and concomitant functional bowel disorders, as well as others. Because of the importance of PPI failure as a target for future drug development, further understanding of the most relevant underlying mechanisms is needed. [ABSTRACT FROM AUTHOR]

Barrett's esophagus (BE) patients demonstrate a higher distal esophageal acid exposure profile than other gastroesophageal reflux disease patients. Cellular oxidative stress has been proposed to contribute to the development of BE and esophageal adenocarcinoma. However, a relationship between low esophageal pH and oxidative stress has yet to be elucidated. The aim of this study was to determine the duration of low pH exposure in the esophagus of BE patients compared to those with erosive esophagitis (EE) and to test if brief exposure to low pH leads to the induction of reactive oxygen species (ROS). Seventy-three patients with BE or EE were evaluated by 24-hour esophageal pH monitoring and the percentage of time during which there was exposure to pH ≤ 4 and pH ≤ 2 was recorded. In vitro, Seg-1 and Het-1A cells were evaluated after brief exposure to pH4 or pH2 by flow cytometry and fluorescent microscopy for the production of ROS. BE patients demonstrated a significantly higher exposure to low pH values (pH ≤ 2) than EE patients. The mean percent total time, duration and mean number of reflux episodes at pH ≤ 2 were 2.8 ± 0.53%, 28.8 ± 3.6 seconds and 79 ± 11.4 episodes in BE patients, whereas in EE patients they were significantly less, 1.16 ± 0.3%, 15.6 ± 1.2 seconds and 48.3 ± 8.8 episodes, respectively ( P < 0.05). In vitro experiments indicate that esophageal cells, when exposed to pH 2, produce ROS. In vitro studies using brief pH 2 exposure are biologically relevant to the clinical situation. Our studies indicate that such exposure induces oxidative stress. This stress may cause DNA damage, mutations and progression to cancer. [ABSTRACT FROM AUTHOR]

Non-cardiac chest pain (NCCP) is very common, affecting up to a quarter of the USA adult population. Recent studies have shown that the disorder has a profound impact on patient's quality of life and is associated with marked increase in utilization of healthcare resources. Non-cardiac chest pain is a heterogeneous disorder with gastrointestinal and non-gastrointestinal causes. After excluding a cardiac cause, most NCCP patients are treated by cardiologists or primary care physicians and only the minority are referred to a gastroenterologist for further work-up. Gastro-oesophageal reflux disease (GORD) is the most common cause for NCCP. The role of oesophageal dysmotility in NCCP has been discounted in recent years. However, visceral hyperalgesia has been shown to play an important role in symptom generation of non-GORD-related NCCP. The main therapeutic interventions in GORD-related NCCP patients are potent antireflux modalities and pain modulators in those with non-GORD-related NCCP. [ABSTRACT FROM AUTHOR]

To commemorate Edkins’ discovery of gastrin in 1905, we review a century of progress in the physiology and pathobiology of gastrin and acid secretion especially as it pertains to clinical aspects of gastro-oesophageal reflux disease. Although initially ignored, Edkins’ observations eventually led to the enthusiastic investigation of gastrin and acid regulation in peptic ulcer disease, culminating in important therapeutic advances in the management of acid peptic disease. Following the improved understanding of gastric secretory physiology, and the development of acid suppressants with increasing efficacy, the use of surgical intervention for peptic ulcer disease was almost eliminated. Surgery became obsolete with the discovery of Helicobacter pylori. Three other advances are also influencing modern practice: the gastrotoxicity of aspirin and non-steroidal anti-inflammatory drugs is now increasingly appreciated, the role of endoscopy in the diagnosis and therapy of upper gastrointestinal bleeding, and the use of intravenous acid-suppressive agents. The major issue for the future resides within the epidemic of gastro-oesophageal reflux disease. How to diagnose, categorize and treat this condition and how to identify and prevent neoplasia, are the challenges of the new century. [ABSTRACT FROM AUTHOR]

Proton-pump inhibitor failure has become a common clinical dilemma in gastrointestinal clinics and has been increasingly encountered at the primary care level as well. Underlying mechanisms are diverse and may overlap. Most patients who have proton-pump inhibitor failure are likely to originate from the non-erosive reflux disease phenotype. Currently, available diagnostic modalities provide limited clues to the exact underlying cause. Treatment relies primarily on escalating dosing of proton-pump inhibitors. However, new insights into the pathophysiology of proton-pump inhibitor failure are likely to provide alternative therapeutic options. [ABSTRACT FROM AUTHOR]

Gastro-oesophageal reflux disease (GERD) has been associated with a variety of supra-oesophageal symptoms, including asthma, laryngitis, hoarseness, chronic cough, frequent throat clearing and globus pharyngeus. GERD may be overlooked as the underlying mechanism for these symptoms because typical GERD symptoms may be absent, despite abnormal oesophageal acid exposure. Two basic mechanisms linking GERD with laryngeal symptoms have been proposed: direct contact of gastric acid with the upper airway, in some cases due to micro-aspiration, and a vagovagal reflex triggered by acidification of the distal portion of the oesophagus. Gastro-oesophageal reflux (GER) during sleep is believed to be an important mechanism for the development of supra-oesophageal complications of GERD, such as asthma and idiopathic pulmonary fibrosis (IPF). Several physiological changes during sleep, including prolonged oesophageal acid contact time, decreased upper oesophageal sphincter pressure, increased gastric acid secretion, decreased salivation, decreased swallowing and a decrease in conscious perception of acid, render an individual more susceptible to reflux-induced injury. Supra-oesophageal symptoms often improve in response to aggressive acid-suppressive therapy. However, many unanswered questions remain regarding the appropriate approach to diagnosis and treatment of patients with GERD-related supra-oesophageal symptoms. In this article we review the relationship between supra-oesophageal symptoms and GERD and, where possible, highlight the evidence supporting the role of night-time reflux as a contributing factor to these symptoms. [ABSTRACT FROM AUTHOR]

Endoscopic-negative reflux disease (ENRD) is the most common presentation of gastro-oesophageal reflux disease (GERD)—affecting up to 70% of these individuals. In the last three decades therapeutic studies have focused solely on the treatment of patients with erosive oesophagitis. However, more recent studies have shifted our attention to defining, understanding and treating those with ENRD. GERD has traditionally been approached as a spectrum with ENRD at the mild end and complicated GERD (i.e. patients with erosive oesophagitis, stricture and Barrett's oesophagus) being at the other end, suggesting that patients' disease may progress over time along the spectrum. Current data indicate that ENRD should be approached as a unique entity rather than a part of the GERD spectrum and that over time only a few patients with ENRD will develop GERD-related complications. Patients with ENRD are a heterogenous group of patients with different aetiologies for their heartburn symptoms, including motor events, reflux of acidic or nonacidic gastric contents, minute changes in intraesophageal pH (pH < 4), mucosal hypersensitivity, and emotional or psychological abnormalities. By dropping the spectrum concept, which emphasizes oesophageal mucosal injury, we can focus our attention on the specific mechanisms that lead to symptom generation in each of the three unique groups of GERD (ENRD, erosive oesophagitis and Barrett's oesophagus) and on the specific therapeutic modalities that benefit each of these individual groups. Acid suppressive therapy with proton pump inhibitors is highly effective in healing erosions and controlling symptoms in those with erosive oesophagitis. In those with ENRD the resolution or control of heartburn with proton pump inhibitor therapy is greater than that with placebo or H2 receptor antagonist, but not as consistent nor as impressive as the results observed in studies of patients with erosive oesophagitis. By considering the mechanisms involved in ENRD symptom generation, future studies that include high-dose proton pump inhibitors, promotility agents (alone or in combination with proton pump inhibitors), transient lower oesophageal sphincter reducers, or pain modulators (e.g. tricyclic antidepressant agents) may prove beneficial. [ABSTRACT FROM AUTHOR]

Discusses the clinical management of heartburn. Disease overview; Subgroups; Diagnosis; Therapeutic approaches.

Background: Comparative studies of omeprazole and lansoprazole are scarce and even scarcer are comparisons of higher doses. Most of the comparative studies have assessed the effect of the two proton pump inhibitors (PPIs) on gastric acid secretion or gastric pH. Few studies have compared clinical end-points such as oesophageal healing and symptom control. Aim: To determine the clinical efficacy of omeprazole 40 mg daily as compared to lansoprazole 30 mg twice a day in symptom control of patients with severe symptomatic GERD. Methods: Ninety-six patients who failed a standard dose of lansoprazole (30 mg once daily), were enrolled in a prospective fashion from three VA medical centres and were randomized to receive 6 weeks of either omeprazole 40 mg daily or lansoprazole 30 mg twice daily. Patients reported daily on symptom severity and frequency, antacid consumption and side-effects. Results: Forty-six patients received omeprazole and 44 lansoprazole. Although not statistically significant, there was a consistent trend of better symptom control in the omeprazole group for daytime and night-time heartburn and acid regurgitation. There was no statistical difference between the two groups in mean antacid consumption overall and at the end of each of the 6 weeks of the study. In addition, there was no significant difference in the overall frequency of side-effects between the two groups nor for each individual side-effect. Conclusion: Omeprazole 40 mg once daily is equally effective and tolerated as lansoprazole 30 mg twice daily in symptom control of patients with GERD. [ABSTRACT FROM AUTHOR]

INTRODUCTION: elderly patients appear to have a more aggressive form of gastro-oesophageal reflux disease than younger patients. Reduced pain perception with age is a possible underlying mechanism. AIMS: to compare the extent of oesophageal mucosal injury, acid exposure, symptom severity and perception thresholds for acid infusion in older (aged 60 or older) and younger patients with gastro-oesophageal reflux. METHODS: twenty-five younger and 23 older patients completed the study. We determined acid exposure and oesophageal mucosal injury by ambulatory 24-h oesophageal pH monitoring and upper endoscopy, respectively. We determined chemosensitivity by infusing 0.1 N hydrochloric acid into the mid-oesophagus for 10 min at 10 ml/min after a 2-min infusion of normal saline at a similar rate. We quantified acid perception thresholds by the lag time to initial typical symptom perception, intensity rating at the end of acid infusion and an acid perfusion sensitivity score, calculated from the fractional duration of symptom perception and intensity rating. RESULTS: mean percentage of total time with pH <4 was higher in the older (15.8+/-2.4) than in the younger patients (11.9+/-1.8; P = 0.18). Of the older group, 74% had erosive oesophagitis versus 64% in the younger group. Frequency of symptoms (heartburn, acid regurgitation and dysphagia) was lower in the elderly group. Older patients perceived heartburn and acid regurgitation as much less severe than younger patients (P < 0.05).Younger patients had a significantly shorter lag time to initial symptom perception (P < 0.05) and a higher sensory intensity rating (P < 0.08). The acid perfusion sensitivity score was significantly lower in the older group (P < 0.05). CONCLUSIONS: older patients with gastro-oesophageal reflux disease have reduced symptom severity for heartburn despite a tendency towards increased severity of oesophageal mucosal injury and acid exposure. Age-related reduction in chemosensitivity to acid is a possible underlying mechanism. [ABSTRACT FROM AUTHOR]

The prevalence and type of sexual dysfunction in patients with functional gastrointestinal (GI) disorders involving the upper (functional dyspepsia) or lower GI tract (irritable bowel syndrome) were studied in 683 patients seen at a tertiary referral center and a comparison group of 247 community volunteers. Associations between sexual dysfunction and type and severity of GI symptoms, and psychological symptoms were examined. All subjects were evaluated with a validated bowel syndrome questionnaire, which included questions about sexual function. Psychological symptom severity was assessed by SCL-90R. The prevalence of self-reported sexual dysfunction in patients with functional GI disorders was 43.3% and did not differ by gender, age stratification or disease subtype: irritable bowel syndrome (IBS); non-ulcer dyspepsia (NUD), and IBS+NUD. In the comparison subjects without IBS symptoms and those with IBS symptoms but not seeking health care (IBS non-patients), the reported sexual dysfunction prevalence was significantly lower (16.1 and 24.4%, respectively, p < 0.005). Decreased sexual drive was the symptom most commonly reported by both male (36.2%) and female (28.4%) patients. Dyspareunia was reported by 16.4% of females and 4% of males with IBS, but was rarely observed in patients with NUD. Report of sexual dysfunction was positively associated with perceived GI symptom severity, but not with psychological symptom severity. Sexual dysfunction should be incorporated into the quality-of- life assessment of patients with functional GI disorders and addressed in future outcome studies. [ABSTRACT FROM AUTHOR]

Focuses on nalidixic acid, a quinolonecarboxylic acid introduced into medical practice in 1963. Drugs produced by nalidixic acid; Gram-negative organisms that are susceptible to the quinolones; Organisms that are resistant to the quinolones.

The author reflects on a study regarding the efficacy and effectiveness of eosinophilic oesophagitis (EOE) management. Topics discussed include the use of proton pump inhibitors (PPIs), elimination diet with PPI and budesonide, the treatment guidelines for advanced erosive oesophagitis was followed, and the effectivess of diet in EOE was not established.

The author discusses a commentary on proton pump inhibitor (PPI) test's role in eosinophilic oesophagitis (EOE). Topics covered include the retrospective study design used to compare demographics, clinical and histological characteristics between EOE patients, the elusive clear definition of response to PPI treatment in EOE, and the inclusion of patients from the Swiss EOE database.

The authors discuss the results of a study which suggest that acupuncture is effective in treating functional dyspepsia using specific acupoints. They contend that the study emphasizes the importance of sticking to specific acupoints when treating patients with functional dyspepsia. They argue that the author of the study did not embark on functional assessment of the oesophagus and stomach. They suggest that sham acupuncture was significantly inferior to the other acupuncture groups.

The authors discuss pregabalin's effect on acid-induced oesophageal hypersensitivity. The authors say that functional heart burn, noncardiac chest pain, and those with refractory gastro-oesophageal reflux disease (GERD) are some of the manifestations of oesophageal hypersensitivity. They also mention that pregabalin is used to cure neuropathic pain and epilepsy.

A letter to the editor on mGluR5 inhibitor in patients with gastro-oesophageal reflux disease is presented.

A response by R. Fass to a letter to the editor about his article "Maintenance Intermittent Therapy With Rabeprazole 20 mg in Patients With Symptomatic Gastro-Oesophageal Reflux Disease: A Double-Blind, Placebo-Controlled, Randomized study" in earlier issue is presented.

A response by R. Fass and R. Dickman to a letter to the editor about their article concerning the therapeutic use of sham acupuncture is presented.

A letter to the editor is presented in response to the article "Proton pump inhibitor failure in gastro-oesophageal reflux disease--what about eosinophilic oesophagitis?," by R. Fass and M. Shapiro, in the 2006 issue of the "Alimentary Pharmacology & Therapeutics" journal.

The article discusses the role of 24-h pH testing in evaluating patients with suspected gastro-oesophageal reflux disease. Main indications for referrals for pH testing are failure of proton pump inhibitor therapy or presurgical evaluation. An important contribution of the pH test is the finding that a significant number of patients with non-erosive reflux disease have normal oesophageal acid exposure. The new position of pH test is evaluated with the introduction of novel techniques that can access non-acid-related reflux events.

A response from the author of the article "Oesophageal eosinophilia must be excluded before determining prevalence of eosinophilic oesophagitis" in the previous issue is presented.

Background: The United States Air Force currently uses AFI 36-2905 for cardiovascular fitness standards and evaluation. Regarding its fitness test, the Air Force considers waist circumference (WC) twice as important as push-ups or sit-ups. Because of this weighting, one assumes that the Air Force considers WC relatively correlated with overall fitness or at least cardiovascular fitness. To our knowledge, the Air Force has not considered on a large scale how body mass index (BMI), height-to-weight ratio (H-W), or waist-to-height ratio (WHtR) compares with WC with respect to its fitness test.Methods: Using a 5.38 million record database from the Air Force Fitness Management System, we evaluated how WC, BMI, WHtR, and H-W correlate with fitness as assessed by the 1.5-mile run in addition to total fitness, which incorporates the 1.5-mile run time, number of push-ups and sit-ups. As this previously collected data were anonymous to us, this study fell under the definition of exempt status and approved by the institutional review board overseeing Joint Base San Antonio. For each waist metric, we performed a simple ordinary least squares regression to ascertain the correlation between that particular metric and either run time or total fitness; when incorporating more than one explanatory variable or covariate (to control for age and/or sex), we performed multiple ordinary least squares regressions. Due to the large database size and to mitigate against a type I error, we used an alpha of 0.001 for all statistical hypothesis tests.Findings: Approximately 18% of the 5.38 million records belonged to women. With respect to sex differences, males appeared noticeably faster and performed more push-ups on average than females. The number of sit-ups completed was more comparable, with males having a slight advantage. Males also appeared to have larger WC, BMI, H-W, and WHtR measurements. We compared the ordinary least squares results between WC, H-W, WHtR, and BMI and ranked them by R2. Models varied in R2 from 1% to 46% depending on the covariates in the model, with sex having a greater effect than age. Whether individually or adjusting for age and sex, WHtR performed better than the other body composition variables with an average rank score of 1.1 and a median improvement of approximately 4% to the current Air Force metric of WC.Discussion: From our findings, we present a 20-point WHtR scoring system for the Air Force to use in lieu of its traditional usage of WC. We used this assessment chart to score all Airmen in our database and compared the results to their current scores on the abdominal circumference portion of the test with respect to predicting run time, after accounting for sex, age, and number of push-ups and sit-ups. The R2 value improved from 40.3 to 43.6, a relative improvement of approximately 8%, a fairly significant effect given the database consisted of over 5 million records. Future studies should investigate the longitudinal effect of varying waist metrics over time on run time or total fitness performance. [ABSTRACT FROM AUTHOR]

Eosinophilic esophagitis (EoE) is a disorder characterized by long-term chronic eosinophilic inflammation, which may predispose patients for malignant transformation. To determine if EoE is associated with an increased risk for esophageal cancer (EC) over time. This was a cross-sectional population-based study using the Explorys Platform. Data were collected from January 1999 to December 2014 and the search terms 'Eosinophlic esophagitis', gastroesophageal reflux disease, and Barrett's esophagus were used. The latter two served as comparison groups. The term 'malignant tumor of esophagus' was searched in Explorys and was accepted only if it was established after the aforementioned diagnoses. Analysis was performed using social science statistical software. A total of 27,183,310 subjects were included in the study. Of those 5,370 (0.02%) had the diagnosis of EoE, 25,610 (0.09%) BE, and 2,606,640 (9.59%) gastroesophageal reflux (GERD). In general, diagnosis of EC was rare prior to age 40. Therefore, subsequent analysis was done on subjects between 40 to 79 years of age (N = 20,257,480). The prevalence of EC was 0.05% (N = 2420), in BE (N = 19,640) 2.65%, and in GERD (N = 1,696,230) 0.22%. No cases of EC were identified among those with EoE.We found no significant difference or increased risk in the rate of EC in the EoE group (P = 0.575) when compared to the control population. In this largest study, we found no association between esophageal cancer and EoE. Further long-term prospective studies are needed to better characterize the relationship between EoE and esophageal malignancy. [ABSTRACT FROM AUTHOR]

A response by T. Hershcovici and R. Fass to a letter to the editor about his article "Night-Time Intra-Pesophageal Bile and Acid: A Comparison Between Gastro-Oesophageal Reflux Disease Patients Who Failed and Those Who Were Treated Successfully With a Proton Pump Inhibitor" in the previous issue is presented.

Background Selective serotonin reuptake inhibitors ( SSRIs) are used to treat noncardiac chest pain ( NCCP) symptoms, however, data regarding their efficacy remains inconclusive. Aim To conduct a meta-analysis of randomised controlled trials ( RCT) comparing SSRIs to placebo in patients with NCCP, and rate the quality of evidence. Methods Electronic databases were searched using the terms 'noncardiac chest pain', 'atypical chest pain' and 'selective serotonin reuptake inhibitors'. Data were extracted from RCTs of ≥8 weeks. Standardised mean differences ( SMD), weighted mean differences ( WMD) or risk ratios ( RR) were used as summary statistics for pooled outcomes. GRADE methodology was used to rate the quality of evidence. Results Four RCTs (184 patients) met the inclusion criteria. Compared to placebo, patients on SSRIs showed a nonsignificant change in chest pain of 3½ points decrease on a 100 mm visual analogue scale (184 patients, 95% CI, −9.5 to 2.5; I2 = 0%). Change in depression scores was not significantly different between the two groups (88 patients; WMD = 0.7; 95% CI, −1.81 to 3.20; I2 = 64%). Treatment discontinuations were not significantly different between groups (154 patients, RR = 2.08; 95% CI, 0.77-5.60; I2 = 0%). The quality of evidence was rated as moderate for change in chest pain symptoms, low for change in depression scores and moderate for treatment discontinuation due to adverse events. Conclusions Selective serotonin reuptake inhibitors are not superior to placebo in improving chest pain or depression symptoms in patients with noncardiac chest pain. Larger trials with longer follow-up periods are necessary to assess the benefits and drawbacks of SSRIs for the treatment of noncardiac chest pain. [ABSTRACT FROM AUTHOR]

Pain modulators have been primarily used for the management of functional esophageal disorders. Recently, these drugs have also been used for the management of other esophageal disorders, such as non-erosive reflux disease, the hypersensitive esophagus, and heartburn that is not responsive to proton pump inhibitor treatment. Several etiologies have been identified in patients with functional esophageal disorders, and these include esophageal hypersensitivity due to peripheral and/or central sensitisation, altered central processing of peripheral stimuli, altered autonomic activity, and psychological comorbidity such as depression and anxiety. Different antidepressants have been used as pain modulators and have demonstrated a beneficial effect on patients with the aforementioned esophageal disorders. Tricyclic antidepressants are the most commonly used class of drugs in clinical practice. Other antidepressants that have been used, some with more clinical success than others, include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and trazodone. Other medications that have been used as pain modulators in esophageal disorders include adenosine antagonists, serotonin agonists, antiepileptics, and medications that ameliorate peripheral neuropathy. The mechanism by which many of the pain modulators confer their visceral analgesic effect remains to be fully elucidated. Regardless, their role and value in treating esophageal disorders have markedly increased in the last decade. [ABSTRACT FROM AUTHOR]

The lower esophageal sphincters (LES) together with the crural diaphragm are the major antireflux barriers protecting the esophagus from reflux of gastric content. However, reflux of gastric contents into the esophagus is a normal phenomenon in healthy individuals occurring primarily during episodes of transient lower esophageal sphincter relaxation (TLESR), defined as LES relaxation in the absence of a swallow. Transient lower esophageal sphincter relaxation is also the dominant mechanism of pathologic reflux in gastroesophageal reflux disorder (GERD) patients. Frequency of TLESR does not differ significantly between healthy individuals and those with GERD, but TLESRs are more likely to be associated with acid reflux in GERD patients. Understanding the mechanisms responsible for elicitation of a TLESR, using recently introduced novel technology is an area of intense interest. Pharmacologic and non-pharmacologic manipulation of receptors involved in the control of TLESR has recently emerged as a potential target for GERD therapy. [ABSTRACT FROM AUTHOR]

Background A growing number of studies have shown the impact of psychological comorbidities on gastro-oesophageal reflux disease (GERD) patients’ symptom reports and healthcare-seeking behaviour. Aim To review the reported relationship between GERD and psychological comorbidity. Methods Review of the literature on GERD and psychological comorbidity. Results Psychological comorbidity is common among GERD patients and appears to afflict all GERD phenotypes. Sexual and physical abuse is also common in GERD patients. Stress enhances perception of oesophageal acid exposure. Treatment for GERD, especially in those who are not responsive to antireflux treatment, may require further evaluation for psychological comorbidity. Conclusions Psychological comorbidity is very common in GERD patients and is likely to play an important role in response, or failure of response, to proton pump inhibitor treatment. [ABSTRACT FROM AUTHOR]

Background A number of mechanisms, other than acid reflux, may be responsible for the symptoms of gastro-oesophageal reflux disease. Aim To assess the importance of non-acid reflux mechanisms. Methods This review is based on presentations and discussion at a workshop, where specialists in the field analysed data relating to these mechanisms. Results Weakly acidic reflux, pH (4–7), detected with impedance–pHmetry is associated with regurgitation and atypical gastro-oesophageal reflux disease symptoms. It is not clear whether pepsin and trypsin can elicit symptoms, but bile can elicit heartburn. The magnitude of reflux-induced oesophageal distension can be determined by high frequency ultrasonography and is not reduced by proton pump inhibition, suggesting that persisting symptoms ‘on’ a proton pump inhibitor may still be due to oesophageal distension by non-acidic reflux. Exaggerated longitudinal muscle contraction can induce non-acid-related heartburn. Preliminary studies showed a positive effect of baclofen, surgery or endoscopic procedures to reduce weakly acidic reflux. Conclusion Mechanisms other than acid reflux are involved in some of the symptoms of gastro-oesophageal reflux disease. Controlled outcome studies are needed to clarify their roles and the indications for antireflux procedures in patients with persistent symptoms whilst ‘on’ a proton pump inhibitor. [ABSTRACT FROM AUTHOR]

Background Obesity has been demonstrated to be a risk factor for the development of gastro-oesophageal reflux disease (GERD). Aim To perform a prospective cohort study to determine whether there was a difference in body mass index (BMI) between patients with GERD and patients with Barrett’s oesophagus (BE). Methods We prospectively enrolled patients undergoing endoscopic evaluation for GERD and collected information regarding BMI, tobacco and/or alcohol use, and family history of GERD. Patients with non-erosive reflux disease underwent confirmatory 24-h pH testing. Results Seven hundred and fifty one patients with GERD (mean ± s.d. age of 55.4 ± 14.2 years, 74% male) entered the study, and BE was present in 165 (22%, 90% male, 79% Caucasian) patients. The mean GERD symptom duration was 10.3 ± 0.4 years (range 1–62 years) with a mean body mass index of 27.8 ± 0.2 kg/m2 (range 15–55) Compared with patients having GERD alone, patients with BE were more likely to be older ( P = 0.001), male ( P < 0.001), current or prior tobacco users ( P = 0.002), and with greater duration of GERD symptoms ( P < 0.001). There was no significant difference in the BMI for patients with and without BE. Conclusions While obesity is a risk factor for both GERD and BMI, patients with BE did not demonstrate increased BMI compared with patients having chronic GERD. [ABSTRACT FROM AUTHOR]

Background Effects of frequent nocturnal symptoms of gastro-oesophageal reflux disease (GERD-FNS) on health-related quality of life (HRQOL) and work productivity are not well documented. Aim To assess symptom severity, production loss, and HRQOL among employed adults with and without GERD-FNS. Methods Using several validated outcome measures in a web survey design, GERD was pre-specified as GERD Symptom and Medication Questionnaire score >9, and ≥1 episode of heartburn or acid regurgitation during the preceding week. GERD-FNS patients were those reporting ≥2 symptom-nights during the previous week; their outcomes were compared with those of patients having minimal or no nocturnal symptoms (GERD-NNS) and vs. non-GERD controls. Results Data were collected from 1002 GERD patients (476 GERD-FNS, 526 GERD-NNS) and 513 controls. Severe symptoms were more common, sleep abnormalities were more frequent ( P < 0.0001) and SF-36 scores lower ( P < 0.05, all scores) among GERD-FNS patients vs. GERD-NNS patients. GERD-related work loss was greater among those with GERD-FNS vs. GERD-NNS ( P < 0.0001). Work loss and functional limitations were more pronounced when comparing GERD-FNS cases vs. non-GERD controls. Conclusion Employed adults with frequent nocturnal GERD report more severe symptoms, and are associated with impaired sleep, HRQOL and work productivity compared with controls and patients with minimal or no nocturnal symptoms. [ABSTRACT FROM AUTHOR]

Although numerous studies of people living with HIV have focused on positive social support, researchers have directed surprisingly little attention to the nature and effects of negative social interactions in this population. Based on data from a diverse sample of people with HIV (N=271), we conducted a factor analysis to develop the HIV version of the Unsupportive Social Interactions Inventory (USII). Four types of unsupportive or upsetting responses that an HIV positive person might receive from others were identified: insensitivity, disconnecting, forced optimism and blaming. In analyses with a sub-sample of 96 people with HIV, unsupportive social interactions were only moderately correlated with social support, suggesting that these constructs are relatively independent. Using hierarchical regression analysis, we found that unsupportive social interactions predicted a significant amount of the variance in depression, beyond the variance accounted for by physical functioning and positive social support. Partial correlations indicated that the relationship between unsupportive social interactions and depression was not an artifact of trait negative affectivity. Favourable evidence of the USII's reliability and validity suggests that the instrument provides a useful tool for assessing unsupportive social interactions experienced by people with HIV. Practical implications of the findings and directions for future research are discussed. [ABSTRACT FROM AUTHOR]

For fixed wing aircraft within the U.S. Air Force, Operating and Support (O&S) costs encompass a large portion of total life cycle costs. O&S costs include fuel, maintenance, and engine upgrades. To the authors' knowledge, no study to date has attempted to empirically quantify the realized effects of new aircraft engines on sustainment costs. Utilizing the Air Force Total Ownership Cost database, they focused on new engines appearing on the C-5s, C-130s, and C-135s. Although narrow in scope, results suggest newer engines have lower fuel costs. Maintenance costs for newer engines were not consistently higher or lower than the engines they replaced, although Contractor Logistics Support was not tracked by engine in this study. We found that savings from improved fuel efficiency tended to be greater than a potential increase in maintenance costs. [ABSTRACT FROM AUTHOR]

Abstract: Background: High‐resolution esophageal manometry (HREM) has become a leading tool in the assessment of esophageal motor disorders, replacing conventional manometry. However, there is limited data about the contribution of HREM as compared with conventional manometry to the assessment of esophageal motor disorders in patients with non‐cardiac chest pain (NCCP). The aim of the study was to compare the distribution of esophageal motor disorders in patients with NCCP using HREM as compared with conventional manometry and to determine if HREM improved diagnosis of these disorders. Methods: In this study, we included 300 consecutive patients with NCCP who underwent either HREM or conventional manometry over a period of 10 years. A total of 150 patients had conventional manometry and the other 150 patients HREM. The Chicago 3.0 classification and the Castell and Spechler classification were used to determine the esophageal motor disorder of NCCP patients undergoing HREM and conventional manometry, respectively. Key Results: In both HREM and the conventional manometry groups, normal esophageal motility was the most frequent finding (47% and 36%; respectively, P = .054). Hypotensive lower esophageal sphincter was the most common motility disorder identified by conventional manometry (27.3%), while ineffective esophageal motility was the most common esophageal motor disorder identified by HREM (25.3%). Conclusions & Inferences: There is a discrepancy in the type of esophageal motor disorders identified by HREM as compared with conventional manometry in NCCP patients. Hypotensive motility disorders are the most commonly diagnosed by both manometric techniques. [ABSTRACT FROM AUTHOR]

Abstract: Background: Ineffective esophageal motility (IEM) is the most common finding on high‐resolution esophageal manometry (HREM). The underlying mechanisms for IEM remain to be fully elucidated. The aim of this study was to determine if utilization of skeletal muscle relaxants is associated with IEM, and with more severe subtypes of the disorder. Methods: Patients with diagnosis of IEM were gender and age matched to patients with normal HREM. Demographic information, symptoms, endoscopic findings, medication usage and medical comorbidities were recorded. Patients with a diagnosis of IEM were divided into subgroups based on mean distal contractile integral (DCI) and percentage of ineffective swallows, and assessed for clinically significant differences among patients with varying severity of underlying IEM. Key Results: A total of 118 patients were included in each group. There were no significant clinical differences between the group of patients with IEM and the group of patients with normal manometry. Within the group of IEM patients, those with mean DCI < 250 mm Hg/s/cm were more likely to be prescribed skeletal muscle relaxants (27.8% vs 11.0%, P = .044), and those using skeletal muscle relaxants had a larger mean percentage of ineffective swallows (81.1% vs 71.5%, P = .029). There were no significant differences across mean DCI subgroups in usage of any other medication, or in any of the demographic variables or disease comorbidities examined in this study. Conclusions & Inferences: Use of skeletal muscle relaxants is associated with more severe IEM, which may suggest a causal association between this class of medications and weaker esophageal peristalsis. [ABSTRACT FROM AUTHOR]

Background Surgical fundoplication has been considered to be one of the leading therapeutic modalities for gastro-oesophageal reflux disease ( GERD) during the last several decades. Aim To determine the trend of surgical fundoplication utilisation in GERD patients during the last decade in the United States. Methods Population-based study using a large nationwide database, the Explorys database system, to identify patients diagnosed with GERD and those who underwent surgical fundoplication. Using a quadratic regression model, we determined and compared the trends of surgical fundoplication utilisation annually from 2004 to 2013. Results We identified 4 059 060 patients with the diagnosis of GERD, of whom 2343 (0.05%) underwent surgical fundoplication between 2004 and 2013. There was a significant decline in the number of surgical fundoplications performed over the last 5 years from 0.062% in 2009 to 0.047% in 2013 ( P < 0.05). Female patients accounted for the majority of those who underwent fundoplication (62.52%). Caucasian patients between the ages of 18 and 65 years were the most likely group to undergo surgical fundoplication (66.28%). The number of overweight patients undergoing surgical fundoplication has been significantly increasing over the last decade ( P < 0.05). Importantly, 80% of surgical patients were treated with a proton pump inhibitor ( PPI) post surgical fundoplication by 2013 ( P < 0.001). Conclusions Utilisation of surgical fundoplication in GERD patients has been steadily declining over the past 5 years. The vast majority of patients will resume PPI treatment after surgical fundoplication. [ABSTRACT FROM AUTHOR]

Background Non-cardiac chest pain is one of the most common functional gastrointestinal disorders. By recognising that gastro-oesophageal reflux disease (GERD), oesophageal dysmotility and oesophageal hypersensitivity are the main underlying mechanisms of NCCP, a more directed therapeutic approach has been developed. Aim To determine the value of the current therapeutic modalities for NCCP. Methods Electronic (Pubmed/Medline/Cochrane central) and manual search. Results Double-dose PPI treatment for two months is a reasonable first choice approach in patients with NCCP because GERD is the most common aetiology. Studies evaluating the role of medical therapy in NCCP patients with hypercontractile oesophageal motility suggest a limited value to muscle relaxants like calcium channel blockers (nifedipine, diltiazem), nitrates and sildenafil. While most trials evaluating pain modulators are small and many are not placebo-controlled, these type of medications appear efficacious in both patients with NCCP due to oesophageal dysmotility and those with functional chest pain. Cognitive behavioural therapy has been extensively studied in patients with functional chest pain with good results. Other psychological techniques such as hypnotherapy, group therapy or coping skills have been scarcely studied but appear to be effective in NCCP patients. Conclusion Medical, endoscopic and surgical therapeutic options are available for the treating physician, although some patients with non-cardiac chest pain may require a multimodal therapeutic approach. [ABSTRACT FROM AUTHOR]

Background Eosinophilic oesophagitis (EoE) is primarily diagnosed by clinicians. There are less than a handful of epidemiological studies in EoE that have included elderly patients (>65 years). Aim To determine the prevalence of elderly subjects among EoE patients and compare their clinical presentation, associated conditions and treatment modalities with adult and paediatric EoE patients. Methods A large nationwide database (Explorys) between January 2011 and January 2014 was used. The term 'Eosinophilic Oesophagitis' was used in the Explorys search tool. The patient population was divided into three groups, Paediatric (<18 years), Adult (18-65 years) and Elderly (>65 years). Results We identified 4840 patients coded as EoE. The total estimated prevalence was 50.6 cases per 100 000 patients (0.05%). A total of 360 cases (7.44%) were elderly patients with an estimated prevalence rate of 18.6 cases per 100 000. Across all age groups, the majority of EoE patients were Caucasians and males. A significantly greater proportion of older patients had concomitant GERD. Dysphagia was the most common symptom among elderly EoE patients as compared with the paediatric EoE patients ( P < 0.001). The proportion of elderly EoE patients with food allergies or asthma was significantly lower as compared with paediatric and adult EoE patients ( P < 0.001). Oesophageal dilation and/or proton pump inhibitor treatment were the most commonly used therapeutic modalities in elderly EoE patients. Conclusion Eosinophilic oesophagitis is uncommon in elderly subjects and the clinical presentation is markedly different as compared with adults or the paediatric population. [ABSTRACT FROM AUTHOR]

Background Up to half of gastroesophageal reflux disease ( GERD) patients report having heartburn that awakens them from sleep during the night. Recumbent-awake and conscious awakenings from sleep during the night are commonly associated with acid reflux events. The aim of the study was to assess the effect of esomeprazole 40 mg once daily on nighttime acid reflux, frequency of conscious awakenings associated with acid reflux and the recumbent-awake period. Methods Patients with heartburn and/or regurgitation at least three times a week were eligible for this study. All patients underwent upper endoscopy and were evaluated by demographic, Epworth Sleepiness scale, Berlin and GERD symptom checklist questionnaires. Subjects then underwent esophageal pH testing concomitantly with an actigraphy. All subjects were given esomeprazole 40 mg once daily for 7 days and completed a daily symptom record diary. On day 7, subjects repeated the pH test with actigraphy. Key Results Twenty patients (mean age of 48.95 ± 18.69, age range 20-81 years) were enrolled. Esophageal acid exposure parameters, during recumbent-awake, recumbent-asleep, and conscious awakenings were significantly improved on last day of treatment as compared to baseline ( p < 0.05). However, the frequency and duration of conscious awakenings and duration of recumbent-awake period did not improve as compared to baseline ( p > 0.05). Conclusions & Inferences While esomeprazole significantly reduced esophageal acid exposure during conscious awakenings and recumbent-awake and asleep periods, it did not decrease the number and duration of conscious awakening or duration of recumbent-awake period. [ABSTRACT FROM AUTHOR]

Background Length of Barrett's oesophagus ( BE) is a risk factor for oesophageal cancer. The underlying mechanisms that determine BE length are nor fully known. Aim To determine if there is a correlation between obesity and length of BE. Methods Using a population-based study, 381 patients diagnosed with Barrett's oesophagus between 1999 and 2013 were included. Body mass index ( BMI) at the time of BE diagnosis was calculated. Upper endoscopy reports were reviewed to obtain the length of BE. Spearman's correlation coefficient was performed to assess the strength of the relationship between Barrett's length and BMI. A multivariate logistic regression analysis was conducted to further examine the association between BMI and length of BE. Results The adjusted odds ratio for each five-point increase in BMI was 1.5 (95% CI 1.24-1.81, P < 0.001). The mean BMI was significantly higher in patients with long segment BE as compared to patients with short segment BE (32.7 vs. 30.3, P = 0.001). There was also a positive trend in long segment BE as patients entered into higher BMI categories (Z = 4.25, P < 0.001). There was a significant correlation between BMI and length of BE (r = 0.25, P < 0.0001). Conclusion The study demonstrated a correlation between BMI and the length of Barrett's oesophagus mucosa. Thus, increased BMI is associated with longer segment of Barrett's oesophagus. [ABSTRACT FROM AUTHOR]

SUMMARY Gastroesophageal reflux disease (GERD) can be difficult to diagnose - symptoms alone are often not enough, and thus, objective testing is often required. GERD is a manifestation of pathologic levels of reflux into the esophagus of acidic, nonacidic, and/or bilious gastric content. However, in our current evidence-based knowledge approach, we only have reasonable outcome data in regards to acid reflux, as this particular type of refluxate predictably causes symptoms and mucosal damage, which improves with medical or surgical therapy. While there are data suggesting that nonacid reflux may be responsible for ongoing symptoms despite acid suppression in some patients, outcome data about this issue are limited. Therefore, this working group believes that it is essential to confirm the presence of acid reflux in patients with 'refractory' GERD symptoms or extraesophageal symptoms thought to be caused by gastroesophageal reflux before an escalation of antireflux therapy is considered. If patients do not have pathologic acid reflux off antisecretory therapy, they are unlikely to have clinically significant nonacid or bile reflux. Patients who do not have pathologic acid gastroesophageal reflux parameters on ambulatory pH monitoring then: (i) could attempt to discontinue antisecretory medications like proton pump inhibitors and H2-receptor antagonists (which are expensive and which carry risks - i.e. C. diff, etc.); (ii) may undergo further evaluation for other causes of their esophageal symptoms (e.g. functional heartburn or chest pain, eosinophilic esophagitis, gastroparesis, achalasia, other esophageal motor disorders); and (iii) can be referred to an ear, nose, and throat/pulmonary/allergy physician for assessment of non-GERD causes of their extraesophageal symptoms. [ABSTRACT FROM AUTHOR]

Background Parietal cell H+/K+ATPase activation is essential for optimal proton pump inhibitor (PPI) activity. Succinic acid (SA) was shown to induce gastric acid secretion. VECAM is a combination of omeprazole (OMP) and SA. To compare the effect of once daily bedtime dosing of VECAM 40 and VECAM 20 without food vs OMP 20 mg administered before breakfast on gastric acidity. Methods Open label, randomized, crossover study enrolling 36 healthy subjects comparing the study treatments at steady state for 24 h intragastric pH monitoring. Key Results The median percent time intragastric pH > 4 demonstrated that VECAM 40 was superior to VECAM 20 (65.7% vs 49.1% P < 0.0001) and OMP 20 mg (65.7% vs 47.6% P = 0.005) during 24 h. VECAM 40 was superior to VECAM 20 (52.8% vs 38.8% P = 0.0079) and OMP 20 mg (52.8% vs 27.2% P < 0.0001), and VECAM 20 was superior to OMP 20 mg (38.8 vs 27.2 P = 0.0069) during the nighttime. VECAM 20 and OMP 20 mg were comparable during 24 h. Conclusions & Inferences VECAM 40 and VECAM 20 were significantly better in maintaining intragastric pH > 4 during the nighttime than OMP 20 mg. Succinic acid eliminates the need for a subsequent meal for intragastric pH control by VECAM. [ABSTRACT FROM AUTHOR]