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M.Tech. / Homoeopathy is considered to be a safe and effective modality of treatment for various ailments commonly encountered during pregnancy, such as constipation, exhaustion, pyrosis, backache, haemorrhoids, and varicose veins (Castro, 2004; Rothenberg, 2004). Pyrosis is defined as a burning sensation in the epigastric and sub-sternal region, which may radiate to the neck, throat, back and even the face, with rising of acid liquid from the stomach (Beers & Berkow, 1999; O’Toole, 2003). Pyrosis affects up to 85% of pregnant woman, the aetiology being complex and multi-factorial (Broussard & Richter, 1998; Page & Percival, 2000; Richter, 2005). The aim of the study was to determine the effect of homoeopathic similimum treatment on the frequency and severity of pyrosis during pregnancy, and also on the frequency which other antacid medication was taken. A qualitative, interventive, and descriptive study was conducted monitoring twelve participants over a period of five weeks. Non-probability purposive sampling was employed to select twelve pregnant women between 12-34 weeks gestation, suffering from pyrosis, and met the inclusion criteria for the study. Participants were recruited through referrals from midwives and advertisements placed in pharmacies and health stores. The participants evaluated their own symptoms on a daily questionnaire, recording how often they suffered from pyrosis, and also rating the severity of their discomfort. The questionnaire was completed for one week prior to treatment, and then for four weeks during which the participant received homoeopathic similimum treatment. The researcher interviewed each participant during three consultations. A thorough homoeopathic case history was taken during the initial consultation, capturing the totality of the participants’ symptoms on a case study form. After evaluation of the symptoms and repertorisation, a homoeopathic similimum remedy was prescribed. The choice of dosage and potency was individualized to the participant according to homoeopathic principles. A follow-up consultation was conducted after two weeks of treatment. During the follow-up consultation the participants’ symptoms were recorded on a follow-up sheet and their response to the treatment was evaluated. Where indicated the treatment was continued as before, the similimum remedy changed if indicated by a change in symptoms, or treatment stopped when no longer necessary. A final consultation was conducted after another two weeks. The symptoms were again recorded on a follow-up sheet, and the effectiveness of the similimum treatment was then evaluated. The data from the consultations were used to write in-depth case studies representing a qualitative evaluation of the study, based on the subjective experience of symptoms by the participants. Quantitative data was obtained from the daily questionnaires, and represented graphically. The means for all twelve cases, relating to the frequency and severity of pyrosis during the time of the study, were obtained from this data, and represented on bar graphs. From the case studies and questionnaires it was determined that there was an improvement in all twelve of the cases studied. All the participants, except for case five, eight, and nine, experienced improvement in the frequency that pyrosis was experienced. There was improvement of the severity of the symptoms in all twelve case studies. In case five, eight, and nine, the frequency of the symptoms of pyrosis didn’t decrease, but there was amelioration of the severity of the symptoms. In several cases there was also improvement of other concomitant symptoms and participants reported an overall improvement of their health. In case three the symptoms were no longer present after the first two weeks of treatment. No further treatment was required, and the participant remained symptom free for the remainder of her pregnancy. In all of the other cases the participants still continued to experience symptoms, but less frequently and suffered less discomfort. The symptoms were typically ameliorated when the prescribed remedy was taken. Provisional findings suggest that homoeopathic similimum treatment may be effective in managing pyrosis during pregnancy.

Background: 20 to 30% of patients with GORD respond inadequately to conventional therapy. Most of these patients belong to the non-­‐erosive reflux disease group. Despite not having oesophagitis, in these patients oesophageal mucosal integrity appears to be impaired. Aims: To study the dynamic in vitro and in vivo properties of oesophageal mucosal integrity in patients with non-­‐erosive reflux disease, and to test the feasibility of a topical mucosal protectant therapy. Methods: In vitro studies of mucosal integrity were done on human oesophageal biopsies using Ussing chambers. Change in transepithelial electrical resistance (TER) on exposure to acidic solutions was measured. Integrity was assessed in vivo by measuring impedance change and subsequent recovery after oesophageal acid perfusion in symptomatic patients. Proximal and distal oesophageal mucosal integrity was assessed in vitro and in vivo. The effect of in vitro topical application of an alginate-­‐based solution on acid-­‐induced changes in mucosal integrity was tested. Results: In vitro exposure of biopsies to acidic and weakly acidic solutions caused a greater impairment of integrity in symptomatic patients than in controls. In vivo oesophageal acid perfusion causes a profound drop in distal oesophageal impedance that is slow to recover. Recovery is slower in patients with non-­‐erosive reClux disease than in patients with functional heartburn, and a low baseline impedance is associated with painful perception of acid. Proximal oesophageal sensitivity appears unrelated to impaired mucosal integrity, but rather to a distinct sensory afferent nerve distribution. Topical pre-­‐treatment with an alginate solution is able to prevent acid-­‐induced changes in integrity in vitro. Conclusion: Patients with non-­‐erosive reClux disease have a distinct mucosal vulnerability to acidic and weakly acidic solutions that may underlie persistent symptoms. A topical therapeutic approach may be a feasible add-­‐on strategy to treat GORD in the future.

abstract: Drinking vinegar is a popularly discussed remedy for relieving heartburn symptom, as can be read on many websites; however, there has been no scientific research or theory to support its efficacy. This randomized, placebo-controlled, double-blind, cross-over research study tested the efficacy of the organic apple cider vinegar, with mother, on alleviation of the heartburn symptom related to Gastro-esophageal reflux disease (GERD). A minimum of one week separated the four trial arms: chili (placebo), antacid after chili meal (positive control), vinegar added to chili, and diluted vinegar after chili meal. Twenty grams of vinegar were used in both vinegar treatments, and 10 grams of liquid antacid were used in the antacid trial. A five-point Likert scale and a 10-cm visual analogue scale (VAS) were used to assess heartburn severity during a 120 minutes testing time. Seven of 15 recruited subjects' data was usable for statistical analysis (age: 39.6 ± 12.2 y, body mass index (BMI): 29.4 ± 4.2 kg/m2, waist circumference: 36.4 ± 4.1 inch). There was no statistically significant difference among the mean and incremental area-under-the-curve (iAUC) heartburn scores among different trials (Likert scale questionnaire p= .259, VAS questionnaire p= .659, iAUC Likert scale p= .184, iAUC VAS p= .326). Seven participants were further divided into antacid responder (n=4) and antacid non-responder groups (n=3). Likert scale mean heartburn score and iAUC data in antacid responder group had significant finding (p= .034 and p= .017 respectively). The significance lay between antacid and 'vinegar added to chili' trials. Effect size was also used to interpret data due to the small sample size: Likert scale: mean heartburn score= .444, iAUC= .425; VAS mean heartburn score= .232, iAUC .611. Effect size for antacid responder group was Likert scale: mean heartburn score= .967, iAUC= .936. Future research is needed to examine whether ingesting organic vinegar benefits alleviation of heartburn symptom related to GERD for people who do not respond well to antacid. / Dissertation/Thesis / Masters Thesis Nutrition 2016

Introdução: O tratamento cirúrgico da doença do refluxo gastroesofágico (DRGE) possui excelente resultado na maioria dos pacientes. Porém, um grupo significante de indivíduos apresenta complicações ou recidiva dos sintomas, com impacto na qualidade de vida. Objetivos: Avaliar o grau de satisfação dos pacientes submetidos à fundoplicatura laparoscópica à Nissen, e comparar os resultados da aplicação do questionário GERD-HRQL de qualidade de vida pessoalmente e por via telefônica. Identificar fatores pré e pós-operatórios associados ao resultado do tratamento cirúrgico. Métodos: Foram selecionados 178 pacientes operados entre 2005 e 2009, no serviço de cirurgia do esôfago do HCFMUSP. Os pacientes foram convocados para consulta ambulatorial. Foram levantados os prontuários médicos para obtenção de dados pré-operatórios. No estudo foi feita a análise de dados epidemiológicos, cirúrgicos, endoscópicos e manométricos. Os pacientes foram divididos em grupos, e foi aplicado o questionário de qualidade de vida GERD- HRQL. Foi avaliada também a nota de melhora dos sintomas de 0 a 10, a intenção de fazer novamente a cirurgia e o uso atual de omeprazol. Os pacientes que não puderam comparecer ao ambulatório foram entrevistados por telefone. Resultados: 90 pacientes foram incluídos no estudo, 45 no grupo A (entrevista ambulatorial) e 45 no grupo B (entrevista telefônica). Houve diferença significante entre a pontuação média no questionário GERD-HRQL dos pacientes do grupo A (6,29) e B (14,09), p=0,002. Esse resultado também foi significante quando separados homens (p=0,018) e mulheres (p=0,049) de ambos os grupos. Porém, a nota de melhora dos sintomas (p=0,642) e a intenção de fazer novamente a cirurgia (p=0,714) foram iguais. Analisando-se somente os pacientes do grupo A, a correlação linear de Pearson não mostrou diferença estatística entre a pontuação no questionário GERD-HRQL e idade (p=0,953), IMC pré-operatório (p=0,607), IMC pós-operatório (p=0,498), pressão do esfíncter inferior do esôfago (PEM, p=0,651; PRM, p>0,999) e amplitude média de contração do esôfago distal (p=0,997). A correlação da pontuação média no questionário GERD-HRQL com número de pontos na hiatoplastia (p=0,857), presença de esofagite erosiva pré-operatória (p=0,867), tamanho da hérnia hiatal (p=0,867) e presença de distúrbio motor do esôfago (p=0,207) também não mostrou significância estatística. A presença de esôfago de Barrett maior que 1cm correlacionou-se com menor pontuação no questionário GERD-HRQL (p=0,035). O uso rotineiro de omeprazol foi marcador de menor satisfação com a cirurgia (p=0,034). Conclusões: A satisfação dos pacientes com o tratamento cirúrgico é de forma geral elevada. A aplicação do questionário GERD-HRQL mostrou pior qualidade-de-vida dos pacientes entrevistados por telefone, em comparação aos pacientes entrevistados pessoalmente no ambulatório. O uso rotineiro de omeprazol após a cirurgia esteve associado à menor satisfação com o tratamento cirúrgico da DRGE Não foram identificados fatores pré-operatórios que possam determinar pior resultado da fundoplicatura laparoscópica à Nissen, porém a presença de esôfago de Barrett no pré-operatório foi um marcador de maior satisfação dos pacientes operados / Introduction: The surgical treatment of gastroesophageal reflux disease (GERD) has excellent results in most patients. However, a significant group develops complications or recurrence of symptoms, with impact on quality-of- life. Objectives: Evaluate the satisfaction of patients submitted to laparoscopic Nissen fundoplication, and compare the results of the GERD-HRQL quality of life questionnaire applied in person and by telephone. Identify pre and postoperative factors associated with the outcome of the surgical treatment.. Methods: 178 patients operated by the esophageal surgery division at Hospital das Clínicas da Faculdade de Medicina da USP, between 2005 and 2009, were selected. Patients were invited to an ambulatory interview. Charts were reviewed, and preoperative data was obtained. Epidemiological, surgical, endoscopic, and manometric parameters were studied. Patients were divided in groups, and the GERD-HRQL questionnaire was used. We also evaluated the score of symptom improvement between 0 and 10, if the patient would do the surgery again and current use of omeprazole. Patients who could not come to the ambulatory were interviewed by telephone. Results: 90 patients were enrolled in the study, 45 in group A (ambulatory interview) and 45 in group B (telephonic interview). There was significant statistical difference between the average score in the GERD-HRQL questionnaire in groups A (6,29) and B (14,09), p=0,002. This result was also significant among men (0,018) and women (0,049) in both groups. However, the score of symptom improvement (p=0,642) and the intention of doing the surgery again (p=0,714) were equivalent. In group A patients, Pearson\'s linear correlation did not show statistical difference between the GERD-HRQL score and age (p=0,953), preoperative BMI (p=0,607), postoperative BMI (p=0,997), inferior esophageal sphincter pressure (PEM, p=0,651; PRM, p>0,999) and distal esophageal contraction pressure (p=0,997). The correlation between GERD-HRQL score and number of stitches in hiatoplasty (p=0,857), presence of preoperative erosive esophagitis (p=0,867), size of hiatal hernia (p=0,867) and presence of motor esophageal disturbances (p=0,207) did not show statistical significance. The presence of Barrett\'s esophagus larger than 1cm correlated with a lower score on GERD-HRQL questionnaire (p=0,035). The routine use of omeprazole was a marker of lower satisfaction with the surgical treatment (p=0,034). Conclusions: Patient satisfaction with surgical treatment is generally high. The GERD-HRQL questionnaire showed poorer quality-of-life of patients interviewed by telephone, compared to patients interviewed at the ambulatory. The routine use of omeprazole after surgery was associated with lower satisfaction with the surgical treatment. No preoperative factors were identified that could determine worst outcome after laparoscopic Nissen fundoplication, but the presence of Barrett\'s esophagus preoperatively was a marker of increased patient\'s satisfaction

Introdução: O tratamento cirúrgico da doença do refluxo gastroesofágico (DRGE) possui excelente resultado na maioria dos pacientes. Porém, um grupo significante de indivíduos apresenta complicações ou recidiva dos sintomas, com impacto na qualidade de vida. Objetivos: Avaliar o grau de satisfação dos pacientes submetidos à fundoplicatura laparoscópica à Nissen, e comparar os resultados da aplicação do questionário GERD-HRQL de qualidade de vida pessoalmente e por via telefônica. Identificar fatores pré e pós-operatórios associados ao resultado do tratamento cirúrgico. Métodos: Foram selecionados 178 pacientes operados entre 2005 e 2009, no serviço de cirurgia do esôfago do HCFMUSP. Os pacientes foram convocados para consulta ambulatorial. Foram levantados os prontuários médicos para obtenção de dados pré-operatórios. No estudo foi feita a análise de dados epidemiológicos, cirúrgicos, endoscópicos e manométricos. Os pacientes foram divididos em grupos, e foi aplicado o questionário de qualidade de vida GERD- HRQL. Foi avaliada também a nota de melhora dos sintomas de 0 a 10, a intenção de fazer novamente a cirurgia e o uso atual de omeprazol. Os pacientes que não puderam comparecer ao ambulatório foram entrevistados por telefone. Resultados: 90 pacientes foram incluídos no estudo, 45 no grupo A (entrevista ambulatorial) e 45 no grupo B (entrevista telefônica). Houve diferença significante entre a pontuação média no questionário GERD-HRQL dos pacientes do grupo A (6,29) e B (14,09), p=0,002. Esse resultado também foi significante quando separados homens (p=0,018) e mulheres (p=0,049) de ambos os grupos. Porém, a nota de melhora dos sintomas (p=0,642) e a intenção de fazer novamente a cirurgia (p=0,714) foram iguais. Analisando-se somente os pacientes do grupo A, a correlação linear de Pearson não mostrou diferença estatística entre a pontuação no questionário GERD-HRQL e idade (p=0,953), IMC pré-operatório (p=0,607), IMC pós-operatório (p=0,498), pressão do esfíncter inferior do esôfago (PEM, p=0,651; PRM, p>0,999) e amplitude média de contração do esôfago distal (p=0,997). A correlação da pontuação média no questionário GERD-HRQL com número de pontos na hiatoplastia (p=0,857), presença de esofagite erosiva pré-operatória (p=0,867), tamanho da hérnia hiatal (p=0,867) e presença de distúrbio motor do esôfago (p=0,207) também não mostrou significância estatística. A presença de esôfago de Barrett maior que 1cm correlacionou-se com menor pontuação no questionário GERD-HRQL (p=0,035). O uso rotineiro de omeprazol foi marcador de menor satisfação com a cirurgia (p=0,034). Conclusões: A satisfação dos pacientes com o tratamento cirúrgico é de forma geral elevada. A aplicação do questionário GERD-HRQL mostrou pior qualidade-de-vida dos pacientes entrevistados por telefone, em comparação aos pacientes entrevistados pessoalmente no ambulatório. O uso rotineiro de omeprazol após a cirurgia esteve associado à menor satisfação com o tratamento cirúrgico da DRGE Não foram identificados fatores pré-operatórios que possam determinar pior resultado da fundoplicatura laparoscópica à Nissen, porém a presença de esôfago de Barrett no pré-operatório foi um marcador de maior satisfação dos pacientes operados / Introduction: The surgical treatment of gastroesophageal reflux disease (GERD) has excellent results in most patients. However, a significant group develops complications or recurrence of symptoms, with impact on quality-of- life. Objectives: Evaluate the satisfaction of patients submitted to laparoscopic Nissen fundoplication, and compare the results of the GERD-HRQL quality of life questionnaire applied in person and by telephone. Identify pre and postoperative factors associated with the outcome of the surgical treatment.. Methods: 178 patients operated by the esophageal surgery division at Hospital das Clínicas da Faculdade de Medicina da USP, between 2005 and 2009, were selected. Patients were invited to an ambulatory interview. Charts were reviewed, and preoperative data was obtained. Epidemiological, surgical, endoscopic, and manometric parameters were studied. Patients were divided in groups, and the GERD-HRQL questionnaire was used. We also evaluated the score of symptom improvement between 0 and 10, if the patient would do the surgery again and current use of omeprazole. Patients who could not come to the ambulatory were interviewed by telephone. Results: 90 patients were enrolled in the study, 45 in group A (ambulatory interview) and 45 in group B (telephonic interview). There was significant statistical difference between the average score in the GERD-HRQL questionnaire in groups A (6,29) and B (14,09), p=0,002. This result was also significant among men (0,018) and women (0,049) in both groups. However, the score of symptom improvement (p=0,642) and the intention of doing the surgery again (p=0,714) were equivalent. In group A patients, Pearson\'s linear correlation did not show statistical difference between the GERD-HRQL score and age (p=0,953), preoperative BMI (p=0,607), postoperative BMI (p=0,997), inferior esophageal sphincter pressure (PEM, p=0,651; PRM, p>0,999) and distal esophageal contraction pressure (p=0,997). The correlation between GERD-HRQL score and number of stitches in hiatoplasty (p=0,857), presence of preoperative erosive esophagitis (p=0,867), size of hiatal hernia (p=0,867) and presence of motor esophageal disturbances (p=0,207) did not show statistical significance. The presence of Barrett\'s esophagus larger than 1cm correlated with a lower score on GERD-HRQL questionnaire (p=0,035). The routine use of omeprazole was a marker of lower satisfaction with the surgical treatment (p=0,034). Conclusions: Patient satisfaction with surgical treatment is generally high. The GERD-HRQL questionnaire showed poorer quality-of-life of patients interviewed by telephone, compared to patients interviewed at the ambulatory. The routine use of omeprazole after surgery was associated with lower satisfaction with the surgical treatment. No preoperative factors were identified that could determine worst outcome after laparoscopic Nissen fundoplication, but the presence of Barrett\'s esophagus preoperatively was a marker of increased patient\'s satisfaction

Ziel der vorliegenden Arbeit ist die Untersuchung der gesundheitsbezogenen Lebensqualität bei Patienten mit gastroösophagealer Refluxerkrankung (GERD) unter „usual care“ Bedingungen über einen Zeitraum von zwei Jahren. Insgesamt wurden 6215 Patienten mit GERD in die Studie eingeschlossen und vier bis acht Wochen mit einem Protonenpumpenhemmer behandelt. Danach begann die Beobachtungsphase, in der keine weiteren Vorgaben zur Behandlung gemacht wurden. Die Lebensqualität wurde mit dem Short Form 36 (SF-36) und dem Quality of Life in Reflux and Dyspepsia (QOLRAD) zu Studienbeginn, nach zwei Wochen und im Anschluss daran einmal jährlich erhoben. Die Ergebnisse zeigen, dass die Lebensqualität von Patienten mit GERD im Vergleich zur Normpopulation deutlich eingeschränkt war. Nach zweiwöchiger Behandlung mit einem PPI stieg die Lebensqualität deutlich in allen gemessenen Bereichen. Nach 12 und 24 Monaten lag die Lebensqualität unter den Werten unmittelbar nach der Behandlungsphase, aber noch immer deutlich über den Ausgangswerten. Die Verbesserung der Lebensqualität war vor allem abhängig von einer Verbesserung der Symptome. Mit dem krankheitsspezifischen Messinstrument QOLRAD konnte die Veränderungen in der Lebensqualität der Patienten genauer erfasst werden als mit dem SF-36. Daher sollte bei Studien zur Lebensqualität bei GERD, insbesondere wenn Therapieeffekte gemessen werden sollen, möglichst ein krankheitsspezifisches Messinstrument zum Einsatz kommen. / The aim of this study is to analyse the health-related quality of life in patients with gastro-eosophageal reflux disease (GERD) under routine over a period of two years. 6215 patients with physician diagnosed GERD have been recruited. All patients received treatment with a proton pump inhibitor for four to eight weeks. Afterwards they entered the follow-up, and their treatment is at the discretion of their physicians. Quality of life was assessed with the questionnaires Short Form 36 (SF-36) and Quality of Life in Reflux and Dyspepsia (QOLRAD) at baseline, two weeks, and after one and two years. At baseline, quality of life in patients with GERD was lower than in the norm population. After two weeks treatment with PPI, quality of life improved in all dimensions. After 12 and 24 months, quality of life was lower than after two weeks, but significantly better than at baseline. The improvement of quality of life was particulary correlated with symptom improvement. Changes in quality of life could be more accurately described with the QOLRAD than with the SF-36. Therefore, studies on health related quality of life in GERD patients should include a disease specific questionnaire.