Neurogastroenterology & Motility

Background: Gastrointestinal (GI) motility disorders are prevalent, impose a significant burden, and are associated with disrupted spatial propagation of bioelectrical gastric slow waves. High-resolution endoscopic gastric mapping (EGM) is an emerging minimally invasive technique for imaging gastric electrical activity; however, EGM is performed alongside standard gastroscopy and requires procedural sedation, which may interact with gastric electrical activity, distorting clinical insights. This study explored the influence of procedural sedation on EGM-recorded slow-wave activity. Methods: EGM was performed for {approx}7 min in 32 patients undergoing upper GI endoscopy at two New Zealand hospitals. Endoscopists administered procedural sedation (fentanyl and midazolam) according to best clinical practice. The relationship between slow-wave amplitude and patient characteristics was then investigated using a variety of statistical techniques. Key Results: Gastric slow waves were detected in 30 of 32 patients who underwent EGM. Symptom scores and demographic measures were comparable between sites. Fentanyl (A, 93.4 {+/-} 13.7 g vs B, 137.5 {+/-} 33.7 g, p[≤]0.001) and midazolam (A, 5.0 {+/-} 0.9 mg vs B, 7.4 {+/-} 1.6 mg, p[≤]0.001) doses were higher at Hospital B than Hospital A. Correspondingly, slow-wave amplitudes were lower at Hospital B than Hospital A (A, 2.33 {+/-} 1.61 mV vs B, 0.86 {+/-} 1.01 mV, p=0.004). All other slow-wave metrics were consistent between hospitals. Combined sedative dose was negatively correlated with slow-wave amplitude (p=0.037). Conclusions & Inferences: Higher procedural sedative doses are associated with lower-amplitude gastric slow-waves. Procedural sedation dose and opiate administration should be carefully considered when interpreting GI electrophysiology measurements.

Introduction: Illness perceptions, the cognitive and emotional beliefs patients hold about their condition, are key determinants of patient outcomes across a range of chronic health conditions. Although well-studied in several gastrointestinal disorders, their role remains poorly characterized within patients with functional dyspepsia (FD) and chronic nausea and vomiting syndrome (CNVS). This study examined the associations between illness perceptions, gastrointestinal symptoms, mental health, and gastric electrophysiology in these patients. Methods: Patients meeting self-reported Rome IV criteria for FD and/or CNVS underwent body surface gastric mapping (BSGM) using Gastric Alimetry (Alimetry, New Zealand). The standardized protocol included a 30-minute fasting baseline, 482 kCal meal, and a 4-hour postprandial recording, with concurrent symptom logging. From the BSGM data, patients were phenotyped using established rule-based criteria via the Auckland Classification. Illness perceptions were assessed using the Brief Illness Perceptions Questionnaire alongside validated psychological and quality of life metrics. Results: The cohort included 309 patients (80% female; median age= 36, 15-88) who reported highly negative illness perceptions, which were significantly correlated with worse symptomatology, quality of life, and mental health (medium-large effect sizes). Using multivariable analysis, perceived consequences and emotional responses emerged as the most robust predictors of these patient-reported outcomes. Additionally, illness perceptions significantly mediated the relationship between mental health and gastrointestinal symptoms, with large effect sizes. Associations with gastric electrophysiology were limited to BMI-Adjusted Amplitude, which was associated with poorer perceptions of treatment control and greater emotional response to symptoms. Furthermore, the Continuous Phenotype (normal spectral activity, with continuous symptoms) was associated with worse illness perceptions, including higher perceived consequences, symptom identity, concern, and emotional response, whilst the High Frequency Phenotype was associated with lower understanding. Discussion: The way patients perceive their condition is a quantifiable aspect of the illness experience that is associated with symptom burden, mental health, and quality of life in patients with FD and CNVS. The observed associations with gastric electrophysiology suggest that illness perceptions may also vary in relation to underlying patient physiology. These findings support the consideration of illness perceptions as part of multidisciplinary assessment and management, including targeted patient education and clinical interventions to address distressing or maladaptive illness beliefs.

Background: Functional dyspepsia (FD) is among the most common gastrointestinal disorders worldwide and is characterized by symptoms including epigastric pain, early satiety, postprandial fullness, bloating, and upper abdominal discomfort. Itopride hydrochloride is commonly administered as 50 mg three times daily (TID). To improve convenience and potentially enhance adherence, a once-daily (OD) 150 mg extended-release formulation was developed. Phase 1 studies demonstrated bioequivalent overall exposure between the OD and TID regimens, with sustained-release characteristics and no evidence of dose dumping, supporting advancement to Phase 3. This pivotal clinical study evaluated whether itopride hydrochloride 150 mg OD is non-inferior to the established 50 mg TID regimen in improving FD symptoms over 8 weeks. Methods: This Phase 3, randomized, open-label, multicenter, active-controlled study enrolled 564 participants with FD (or chronic gastritis) to compare the efficacy and safety of itopride hydrochloride 150 mg OD versus 50 mg TID over 8 weeks. The primary endpoint was change in overall FD severity from baseline to Week 8, assessed using the Leeds Dyspepsia Questionnaire (LDQ) severity score. Secondary endpoints included symptom-specific severity, disease-specific quality of life, responder rates, treatment acceptance, and safety. Results: Clinical non-inferiority in terms of overall FD severity was demonstrated with OD treatment compared to TID. LDQ severity improved by -9.60 (95% CI -10.15, -9.05) with TID and -9.76 (95% CI -10.32, -9.19) with OD, with a between-group difference of 0.16 (95% CI -0.42, 0.74). Improvements across symptom domains and quality of life measures were comparable. Treatment acceptance favored OD (mean 4.22 vs 3.83; p < 0.001). Both regimens were well tolerated, with predominantly mild adverse events. This clinical evaluation of OD was supported by the Phase 1 results confirming that both single-dose and multiple-dose administration of itopride hydrochloride 150 mg OD provided a comparable extent of exposure to the 50 mg TID regimen, demonstrated by area under the curve (AUC) values within the 80 to125% bioequivalence range and stable pharmacokinetic profiles across fed and fasted conditions. Conclusion: The study confirmed that itopride hydrochloride 150 mg OD is non-inferior to the TID regimen for improving FD (or chronic gastritis) symptoms. The OD regimen demonstrated comparable efficacy, favorable treatment acceptance, and a positive benefit-risk profile, offering a more convenient therapeutic option for patients.

Irritable bowel syndrome (IBS) is a common disorder of brain-gut interaction characterized by recurrent abdominal pain and altered bowel habits. Although music-based interventions (MBIs) have shown benefits on pain and stress, the mechanisms associated with MBI-related changes in IBS pain remain poorly understood, and the feasibility of capturing these responses using multimodal wearable monitoring in everyday settings has not been established. This protocol describes a single-arm pilot mechanistic trial examining clinical and multimodal mechanistic responses to an MBI in adults with IBS and the feasibility of extending physiological monitoring from the laboratory to home settings. Thirty-six adults aged 18-50 years with provider-confirmed IBS will be enrolled, with approximately 30 expected to complete the post-intervention laboratory visit. Participants will receive board-certified music therapist-guided laboratory sessions and complete four weeks of self-administered home practice using a standardized 20-minute MBI protocol at least five days per week. Guided by a brain-gut mechanistic framework, assessments will include patient-reported pain, stress, and IBS symptoms; quantitative sensory testing; gut microbiome profiling using 16S rRNA gene sequencing; and multimodal physiological recordings of neural, autonomic, and muscular activity. Analyses will characterize within-session and longitudinal changes in clinical and mechanistic measures and assess recruitment, retention, MBI adherence, wearable data completeness, and participant acceptability. Findings will inform the selection of candidate mechanisms and wearable monitoring approaches for evaluation in a future adequately powered randomized controlled trial.

ABSTRACT Background: The esophageal String Test (EST) is emerging as a minimally invasive alternative for assessing disease activity in eosinophilic esophagitis (EoE), yet the molecular composition of its protein content remains unknown. Objective: To comprehensively characterize the esophageal EST proteome, define an EoE-associated luminal protein signature, and evaluate its biological and clinical relevance. Methods: EST samples were obtained from patients with active EoE, healthy controls (C) and patients with gastroesophageal reflux disease (GERD). Label-free proteomic profiling was performed by liquid chromatography-tandem mass spectrometry. Differential protein accumulation, principal component analysis (PCA), pathway annotation, comparison with published esophageal tissue and salivary proteomes, receiver operating characteristic (ROC) analyses and correlations with clinical disease activity were performed. Results: More than 3,000 proteins were identified in esophageal EST samples. Global proteomic profiling clearly separated patients with EoE from both C and GERD, whereas only limited differences were observed between the latter two groups. This enabled the identification of an EoE-associated luminal protein signature comprising inflammatory, epithelial, and tissue remodeling proteins. Comparison with published proteomic datasets indicated that the EST samples a complex esophageal luminal protein microenvironment containing proteins represented in esophageal mucosa and saliva, together with inflammatory and extracellular components. Several individual proteins showed high discriminatory performance in this exploratory cohort for distinguishing EoE from non-EoE subjects, and multiple proteins correlated with eosinophil counts and endoscopic measures of disease activity. Conclusions: This study demonstrates that the EST provides access to a complex esophageal luminal protein microenvironment and establishes a molecular framework for its minimally invasive characterization in EoE. KEYWORDS: eosinophilic esophagitis, esophageal string test, esophageal luminal protein signature

Background: Sleeve gastrectomy is the most frequently performed bariatric procedure worldwide but is associated with the development of de novo gastroesophageal reflux disease (GERD). Hiatal hernia has been identified as a relevant anatomical factor in postoperative reflux, although most studies evaluate it dichotomously without analyzing whether its size influences GERD risk. The aim was to evaluate the association between preoperative hiatal hernia size and de novo GERD after sleeve gastrectomy. Methods: Retrospective, single - center, observational study of patients undergoing sleeve gastrectomy at Hospital Central Norte de Petroleos Mexicanos (2018 - 2025). Demographic and clinical characteristics, endoscopic classification of hiatal hernia size (small <2 cm, medium 2.1 - 4 cm, large >4 cm), and evidence of de novo GERD were analyzed using descriptive statistics, Fisher's exact test, odds ratio (=R) estimation with 95% confidence intervals (CI), and binary logistic regression. Statistical significance was set at p<0.05. Results: Fiftysix patients were included (mean age 48.3 {+/-} 8.1 years; 67.9% male). Hiatal hernia classification was conclusive in 46 patients (82.1%): 63.0% no hernia, 4.3% small, 30.4% medium, and 2.2% large. De novo GERD occurred in 14.0% of patients without preexisting GERD (6/43). No significant association was found between hiatal hernia size and de novo GERD (Fisher p=0.515). In the reduced logistic model, neither hiatal hernia (medium/large vs. absent/small; OR 3.47; 95% CI 0.50 - 29.43; p=0.207) nor age (OR 1.02; 95% CI 0.90 - 1.13; p=0.754) was significantly associated. No evaluated factor (sex, smoking, alcohol, age) reached significance. Conclusions: In this cohort, no statistically significant association was demonstrated between preoperative hiatal hernia size and de novo GERD after sleeve gastrectomy; however, the low number of events limits the ability to exclude a clinically relevant association. These findings are compatible with a multifactorial mechanism rather than with the isolated presence of this finding. Prospective studies with larger sample sizes and standardized reflux assessment instruments are required to confirm these results.

Background. Anaerostipes caccae CLB101TM is a next-generation probiotic that directly produces butyrate and is hypothesized to reduce gastrointestinal symptoms by strengthening intestinal barrier integrity. Clinical evidence for A. caccae in symptomatic adult populations remains limited. Methods. Ninety-three adults were randomized 1:1 to CLB101TM ( n=47) or placebo (n=46) for 28 days. The primary outcome was safety and tolerability as assessed by the number, frequency, and severity of adverse events. Secondary outcomes were focused on exploring signals of efficacy, and included change in the Gastrointestinal Symptom Rating Scale (GSRS) composite score from baseline to Week 4. Five GSRS subcategories were additionally evaluated. Exploratory endpoints included daily self-reported GI symptoms, as well as stool and blood measures of intestinal barrier function. Results. 71 participants were evaluated for the GSRS (77.5% female, aged 42.1 SD 12 years, BMI mean 31.3 SD 3.6). No adverse events were reported in the placebo arm, while three self-limiting adverse events were associated with CLB101TM administration. CLB101TM reduced GI symptom burden versus placebo on the primary GSRS composite at Week 4 (mean change: -1.60 vs -0.90; MWU p=0.040). Two secondary subscales reached significance after FDR-BH correction: Reflux (mean change: -1.26 vs -0.30; FDR-adjusted p=0.024) and Abdominal Pain (mean change: -1.86 vs -0.83; FDR-adjusted p=0.024). Daily symptom diaries showed trends toward greater reductions in abdominal discomfort, bloating, and flatulence in the active arm at the end of study. This study population did not demonstrate signs of intestinal barrier dysfunction. Product adherence averaged 97.7%. Conclusions. CLB101TM was safe and tolerable and significantly improved overall GI symptom burden, reflux, and abdominal pain after four weeks of daily supplementation in overweight symptomatic adults. Trial Registration. The trial was approved by Sterling IRB (14583-NACraft) and registered with ClinicalTrials.gov (NCT07336615).

Pediatric endoscopy is performed only when clinically indicated, limiting access to healthy duodenal tissue. Biopsies with duodenal no pathologic abnormality (NPA) are often used as controls despite the presence of symptoms or inflammatory disease found elsewhere in the gastrointestinal (GI) tract. We characterized pediatric duodenal NPA tissue across clinical, histologic, cellular, and transcriptomic domains. Methods Archival duodenal NPA biopsies were obtained with clinical metadata and hematoxylin-and-eosin whole-slide images (WSIs). Duodenal mRNA-seq data were analyzed from a subset of patients with duodenal NPA. Clinical metadata and WSIs underwent machine-learning analysis, cell populations were quantified from WSIs, and RNA-seq data underwent differential expression and pathway-enrichment analyses. Results The primary cohort included 195 patients with duodenal NPA. Comparisons between patients with non-duodenal GI disease and those with no GI disease showed differences in inflammatory biomarkers and follow-up utilization. Unsupervised clinical clustering identified three clusters with partial enrichment for IBD with colonic inflammation and Eosinophilic Esophagitis (EoE) with esophageal inflammation. Supervised clinical classification showed modest discrimination. WSI clustering showed limited disease-status discrimination, and cell quantification showed no significant group differences. In the separate RNA-seq cohort of 43 patients, differential-expression and pathway-enrichment analyses identified transcriptional and pathway-level differences between disease-status groups. Conclusions This multi-level characterization indicates that pediatric duodenal NPA tissue should not be treated as a uniform control category. Clinical metadata and transcriptomics revealed clinical and molecular heterogeneity, while histologic and cell analyses showed limited disease-status separation, supporting a refined definition of control tissue.

Gastrointestinal dysfunction is a prominent feature of neurodevelopmental disorders and contributes significantly to visceral discomfort, but the specific etiology is unclear. In particular, it is unknown which cell types within central, autonomic or enteric nervous systems, gut muscle, epithelium or immune system are the principal drivers of gut dysfunction. We report that the Mecp2 mouse model of Rett syndrome, a neurodevelopmental disorder with profound gut dysmotility, exhibits impaired whole gut transit times and constipation in vivo as well as striking alterations to propagating neurogenic contractions in ex vivo colons. Selective elimination of Mecp2 in neurons, but not glia or smooth muscle, recapitulates these dysmotility phenotypes. Bulk RNA sequencing of colonic external muscle, containing the myenteric compartment of the enteric nervous system, showed significant expression changes in specific neurochemical signaling pathways. Pharmacological modulation of one, the M1 acetylcholine receptor, modified the aberrant neurogenic contractile phenotype in mutant mice and reproduced it in wild-type mice. These results identify disruptions to neuronal muscarinic signaling in the enteric nervous system in a mouse model of Rett syndrome and provide an experimental strategy to identify translationally relevant cellular and molecular pathways underlying gastrointestinal dysmotility in neurodevelopmental disorders.

Purpose: Posterior pharyngeal wall (PPW) thickening is a common structural manifestation of treatment-related internal lymphedema in patients with head and neck cancer and can be evaluated using lateral videofluoroscopic images acquired during modified barium swallow (MBS) studies. However, no standardized method currently exists for quantitative measurement. Methods: This two-phase methodological study first conducted a scoping review to characterize existing approaches to PPW thickness measurement and identify the principal factors contributing to variation in PPW thickness measurement. Eight studies were identified with variation observed across these measurement factors. An empirical reliability study was then performed using 107 MBS studies from 93 Head and Neck Cancer patients. Two independent raters annotated 10 anatomical landmarks on pre-swallow and post-swallow resting frames, and a computer-assisted algorithm quantitatively generated seven candidate PPW thickness measurements based on different vertebral reference points and measurement directions. Reliability was assessed intraclass correlation coefficients (ICCs). Results: Inter-rater reliability was highest for the measurement originating from the midpoint of C3 and extending perpendicular to the anterior C3 surface (ICC, 0.78; 95% CI, 0.72-0.83). Among the normalization references, C2-C4 vertebral length demonstrated greater reliability than C3 vertebral length, with an ICC of 0.88 (95% CI, 0.85-0.91). No significant differences were observed between pre-swallow and post-swallow PPW thickness measurements across the evaluated approaches. Conclusions: These findings provide a methodological foundation for more standardized and reliable quantification of PPW thickness, with potential to expand the role of MBS from the functional evaluation of swallowing to include quantitative characterization of pharyngeal structural abnormalities.

Background: A major hallmark of necrotizing enterocolitis (NEC) is intestinal hypoxia, but detection of this feature is difficult. Photoacoustic imaging (PAI) is an emerging imaging method to noninvasively visualize intestinal oxygenation and microvasculature and is promising for improved NEC detection. Prior to clinical translation of PAI for NEC detection, initial studies must be performed in a pediatric population to assess safety and feasibility. Methods: Under IRB approval, eighteen healthy pediatric participants underwent PAI scans before and after eating a lipid-rich snack. PAI was acquired in each abdominal quadrant with intestinal regions-of-interest (ROI) manually drawn on each image series to measure averaged values of deoxygenated hemoglobin (Hb), oxygenated hemoglobin (HbO2), total hemoglobin (HbT), and oxygen saturation (sO2). Results: Minor temporary erythema and pressure from safety goggles in some participants were the only adverse events reported. Pre-/post-prandial changes for HbT, HbO2, Hb, and sO2 were assessed for each abdominal region and age cohort. Results showed significant post-prandial hyperemia in the intestines with no changes in bowel oxygenation. Conclusions: PAI is a safe and feasible imaging modality for evaluating intestinal blood flow in pediatric patients that detects physiological changes in bowel microvasculature and shows strong potential as a quantitative biomarker for assessment and monitoring of intestinal vascular health.

Introduction Individuals with Gastroesophageal Reflux Disease (GERD) often experience airway inflammation and bronchoconstriction as a result of reflux aspiration and/or vagally mediated reflexes. The Impulse Oscillometry System (IOS) is a sensitive, non-invasive tool that can detect subtle changes in airway resistance. While there are few studies exploring airway resistance in GERD globally, no studies have been conducted in Sri Lanka. Therefore, we aim to compare the airway resistance using IOS in medical undergraduates with and without symptomatic GERD. Methods A cross-sectional study was conducted among 811 medical undergraduates (31.1% male; mean age 22.9 years) at the Faculty of Medicine, Rajarata University of Sri Lanka. Symptomatic GERD was screened using the validated GerdQ, and a cutoff of[&ge;]8 was used to diagnose those with GERD symptoms. Of the 242 (29.8%) with GERD symptoms, 188 with chronic respiratory diseases or recent respiratory symptoms were excluded, and 50 with GERD symptoms and 50 healthy, age- and sex-matched controls were recruited. Lung function was assessed using IOS and spirometry, according to American Thoracic Society (ATS) and European Respiratory Society (ERS) guidelines. Results Prevalence of symptomatic GERD among medical undergraduates was 29.8% (242/811). The common symptoms among GERD were heartburn (89.6%, 217/242) and regurgitation (85.5%, 207/242). Oscillometry parameters including, R5-R20 Hz (15.29% vs 9.69%, p=0.002), Fres (14.95 1/s vs 13.37 1/s, p = 0.04), and AX (0.66 vs 0.48, p = 0.02) were significantly higher in students with symptomatic GERD (mean = 15.29%) than in healthy controls (mean = 9.69%; p = 0.002). However, spirometry parameters including FEV1, FVC, and PERF did not differ between the GERD-positive and control groups. Conclusion Individuals with symptomatic GERD demonstrated a higher peripheral airway resistance compared to controls, whereas no significant difference was observed in upper airway resistance. This could be due to the gastric acid stimulation of vagal nerve terminations in the lower part of the esophageal wall, leading to increased resistance in the peripheral airways through vagally mediated bronchoconstriction.

Gut-brain communication has emerged as a rapidly expanding field of research, with recent electrophysiological studies revealing rhythmic gut-brain coupling between gastric activity and brain oscillations in humans. Gut motility is a key determinant of gastrointestinal function, but it remains unclear whether individual differences in gut motility reflected by weekly bowel movements (e.g., defecation frequency) are associated with differences in gut-brain coupling. Here, we address this question by examining women with self-reported daily bowel movements (N = 38) and women with less frequent bowel movements (N = 38). We recorded simultaneous electroencephalography (EEG) and electrogastrography (EGG) at fasting state, performed cognitive assessments, and analysed faecal short-chain fatty acids (SCFAs) as markers of colonic fermentation. In a subset of participants, EEG-EGG coupling was assessed twice over an interval of at least eight weeks to assess test-retest reliability. In this group, EEG-EGG coupling showed moderate test-retest reliability (Intraclass Correlation Coefficient (ICC) = 0.50). When comparing the two groups of women, the phase-amplitude coupling (PAC) analysis between EEG and EGG signals revealed a significantly stronger gut-brain coupling in women with daily bowel movements compared to women with less frequent bowel movements (p = 0.03). We additionally found that women with daily bowel movements made less errors in the cognitive tasks and had higher levels of faecal SCFAs. A path analysis suggested that bowel movements significantly affect gut-brain phase-amplitude coupling through faecal SCFAs. However, neither faecal SCFAs nor phase-amplitude coupling significantly predicted cognitive performance, suggesting the existence of alternative pathways for the association between bowel movements and cognitive performance. Together, our findings suggest that the strength of gut-brain coupling is associated with bowel movements and cognitive performance, making EEG-EGG coupling a promising marker of human gut-brain interactions.

ObjectiveTo establish a standardized training program for endoscopic pathogen visualization literacy (EPVL) based on fluorescence rapid on-site evaluation (ROSE) technology for gastroenterologists, and to evaluate its training efficacy. MethodsA prospective quasi-experimental study was conducted. A total of 54 gastroenterology trainees were non-randomly allocated into the EPVL training group (Group A, n=28, 16-hour comprehensive training) and the control group (Group B, n=26, 3.5-hour traditional teaching). Pre- and post-training assessments included theoretical examinations, fluorescence ROSE image interpretation tests (30 parallel images per set), interpretation speed measurement, and clinical decision-making integration evaluation. The primary outcome was the change in image interpretation accuracy, analyzed by ANCOVA with pre-test scores as the covariate. ResultsBaseline characteristics were comparable between groups (P>0.05 for all demographic variables and pre-test scores). Group A showed significant improvement in image interpretation accuracy from 57.8{+/-}13.6% pre-training to 82.5{+/-}11.2% post-training (improvement of 24.7%, paired t=-12.86, P<0.001), while Group B improved from 58.5{+/-}13.0% to 71.0{+/-}13.5% (improvement of 12.5%, paired t=-5.24, P<0.001). After ANCOVA adjustment for pre-test scores, the between-group difference was significant (F(1, 51)=10.95, P=0.0017, 2=0.177), with Cohens d=0.94 (large effect size). Interpretation speed in Group A (19.2{+/-}2.8 s/image) was significantly faster than in Group B (32.5{+/-}6.0 s/image, t=-10.45, P<0.001). Clinical decision-making scores were significantly higher in Group A (80.5{+/-}8.0 vs. 65.3{+/-}11.5, t=5.60, P<0.001). The Kappa agreement with the gold standard in Group A improved from 0.56{+/-}0.18 to 0.84{+/-}0.11 (t=-8.35, P<0.001). Participant satisfaction exceeded 88%. ConclusionThe EPVL training program significantly improves gastroenterologists fluorescence ROSE image interpretation accuracy, speed, and clinical decision-making integration, providing a novel and effective standardized training paradigm for digestive endoscopy education.

Objective: Circadian rhythms are frequently disrupted in patients in the intensive care unit (ICU), potentially worsening clinical outcomes. Continuous enteral nutrition throughout the day and night is common in the ICU, but eliminates feeding-fasting cycles that serve as important timing cues for the circadian system. The objective of this study was to determine the effect of providing enteral nutrition in a cyclic daytime pattern, compared with continuous administration, on circadian rhythmicity in critically ill patients in the ICU. Design: Single-center randomized controlled trial Setting: Mixed medical-surgical tertiary intensive care unit in the Netherlands Patients: Adult ICU patients ([&ge;]18 yr) receiving enteral nutrition. Intervention: Patients were randomized to receive either continuous, or cyclic daytime enteral feeding (08:00-20:00), initiated from the start of nutritional support. Measurements and Main Results: Sixty-two ICU patients were enrolled, of whom 51 were included in the per-protocol analysis. While the amplitude of the 24-hour rhythm in core body temperature did not differ significantly between the cyclic daytime and continuous feeding groups (0.17 [interquartile range: 0.09-0.24] vs. 0.20 [0.13-0.30], p=0.182), the 24-hour rhythm in heart rate was enhanced in patients receiving cyclic daytime feeding, as reflected by significantly higher amplitudes and more synchronized peak times. No significant differences in 24-hour rhythmicity were observed between groups for the other vital signs or melatonin. Conclusions: Our findings suggest that cyclic daytime feeding may strengthen circadian rhythms in critically ill patients. Further studies are warranted to evaluate its impact on clinical outcomes.

BackgroundTranscutaneous auricular vagus nerve stimulation (taVNS) depends on activating afferent vagal pathways, leading to central and physiological (parasympathetic) modulation. Explaining how taVNS changes cardiorespiratory physiology requires systematic characterization of the effects of electrode location and stimulation waveform using rigorous experimental controls. ObjectiveTo determine the acute effects of four taVNS stimulation configurations (left unilateral 25 Hz, 100 Hz, burst, and bilateral 25 Hz) on physiological markers of parasympathetic activation compared with configuration-matched earlobe stimulation in healthy subjects at rest. MethodsCustomized 8-mm ear-clip electrodes delivered monophasic 500 s pulses (anode anterior) to the tragus or a configuration-matched earlobe control across four stimulation configurations (left unilateral 25 Hz, 100 Hz, burst, and bilateral 25 Hz). Twenty-five healthy participants completed a randomized, single-blind, within-subject crossover study, undergoing both active and control stimulation for all four configurations (200 sessions total). Each session consisted of five 60-second stimulation blocks (1,000 stimuli total). Heart rate (HR), heart rate variability (HRV; RMSSD), and respiration were recorded continuously. Linear mixed-effects models compared physiological responses between tragus and earlobe stimulation during the first stimulation block (primary analysis), across 5-second HR intervals (secondary analysis), and averaged across all five stimulation blocks (post hoc analysis). ResultsDuring the first stimulation block, HRV was significantly higher during unilateral left 25 Hz tragus stimulation than during the matched earlobe control ({beta} = -10.34, t(33) = -2.63, p = .01, 95% CI [-18.05, -2.64]), consistent with increased parasympathetic activity. No significant differences were observed for HRV with the other stimulation configurations, or for HR or respiration under any configuration. Analysis of 5-second HR intervals likewise revealed no significant temporal effects for block one. Analysis of 5-second heart rate intervals across the five blocks identified differences between tragus and earlobe at discrete time points but did not show a consistent temporal pattern across the stimulation period. Across all five stimulation blocks, unilateral left 25 Hz tragus stimulation remained associated with higher HRV ({beta} = -6.56, t(124) = -3.85, p < .01, 95% CI [-9.90, -3.22]) and also produced an increase in HR relative to earlobe stimulation ({beta} = -1.05, t(24) = -2.57, p = .01, 95% CI [-1.85, -0.24]). Respiration was unaffected throughout. ConclusionIn this systematic study, unilateral left 25 Hz tragus stimulation produced physiological modulation consistent with vagal target engagement. These findings underscore the importance of rigorous dose-specific taVNS studies to establish reproducible physiological biomarkers.

Central Amygdala neurons expressing Isl1 (CeAIsl1+) project to brainstem regions involved in control of the jaw and the stomach, including the parabrachial nucleus (PBN), the nucleus of the tractus solitary (NTS), and the parvocellular reticular nucleus (PCRt). Stimulation of CeAIsl1+ cells elicits fictive feeding, particularly biting. Activation of these neurons can rate dependently set the amplitude of bite force and inhibition dramatically reduces bite force. Findings suggest this force generation depends on modulation of a jaw closing reflex involving tooth sensory neurons in the mesencephalic trigeminal nucleus (Me5). Anatomical tracing studies show Me5 neurons receive synaptic input from CeAIsl1+ neurons. Patch clamp recordings of Me5 neurons indicate this synapse is mediated by GABA yet depolarizing. Activation of CeAIsl1+ neurons is capable of dramatically potentiating the periodontal jaw closing reflex, a reflex whereby Me5 tooth sensory neurons activate jaw closing muscles. In addition to controlling the actions of the jaw, CeAIsl1+ neuron stimulation is sufficient to reduce gastric pH. Inhibition experiments show these cells are necessary for lowering gastric pH in mice anticipating a meal. Finally, CeAIsl1+ neurons can modulate gastric motility, stimulation transiently suppresses gastric motility, an effect also observed when animals chewed food. Subdiaphragmatic vagotomy eliminated the transient suppression of gastric motility otherwise observed with CeAIsl1+ neuron stimulation or food chewing. Taken together, this molecularly and anatomically defined population generates specific motor patterns of ingestion that involve not only release of oromotor patterns, but also modulation of gastric functions.

Objective: To evaluate the added diagnostic value of immediate postpartum impedance spectroscopy (IS) when used alongside clinical assessment for obstetric anal sphincter injury (OASI), using subsequent three-dimensional endoanal ultrasound (3D EAUS) as the anatomical reference assessment. Methods: This prospective observational cohort study included women following vaginal birth with at least one predefined OASI risk factor or clinical uncertainty regarding sphincter injury. Participants underwent postpartum clinical assessment, including digital rectal examination and senior obstetric reassessment when required, followed by immediate postpartum IS. Women who subsequently completed 3D EAUS were included in the paired diagnostic analysis. Diagnostic performance, agreement with EAUS and clinically relevant discordant findings were evaluated. Results: Of 151 women enrolled, 70 completed EAUS and were included in the paired analysis; 29/70 (41.4%) were OASI-positive on the EAUS-based reference assessment. IS had a sensitivity of 86.2% (95% CI 69.4-94.5), specificity of 92.7% (95% CI 80.6-97.5) and overall accuracy of 90.0% (95% CI 80.8-95.1), compared with 75.9% (95% CI 57.9-87.8), 70.7% (95% CI 55.5-82.4) and 72.9% (95% CI 61.5-81.9), respectively, for clinical assessment. In paired analysis, IS was correct and clinical assessment incorrect in 17 women, whereas clinical assessment was correct and IS incorrect in five (McNemar P=0.017). Seven women with confirmed OASI were not identified clinically, and all seven generated an IS REFER result. Conversely, among 12 women clinically diagnosed with OASI who underwent primary repair but were subsequently classified as OASI-negative, 10 (83.3%) generated an IS PASS result. IS was performed within the first hour postpartum in 94.3% of women, and 70.0% of examinations were performed by midwives. Conclusions: Immediate postpartum IS provided additional objective information complementary to clinical assessment, particularly when clinical findings did not reliably identify or exclude sphincter injury. These findings support prospective evaluation of IS within postpartum diagnostic pathways to determine whether its use reduces diagnostic errors and improves clinically meaningful outcomes.

Background Pontocerebellar hypoplasia Type 2A (PCH2A) is a rare, autosomal recessive disorder with reduced life expectancy. Clinical features include profound developmental delay, microcephaly, and a dyskinetic movement disorder. Additional symptoms frequently observed are feeding difficulties, vomiting, dystonic attacks, and seizures. Compared to parents of typically developing children, parents of children with PCH2A experience decreased health-related quality of life. The aim of this study was to provide a follow-up on survival, symptoms, and perceived disease burden. Methods Patients were primarily recruited via the German patients' organization (PCH-Familie e.V.). Inclusion required genetic confirmation of PCH2A. Data were collected from 2020-2022 using parent questionnaires and medical reports; uncertainties were clarified during semi-standardized telephone interviews. Statistical analysis was quantitative, appropriate statistical tests were used, depending on the data distribution. Results Sixty-five patients participated, with a median age of 6.4 years and balanced gender distribution. Sixteen patients (25%) died at a median age of 5.5 years. Ten-year survival rate was 71.5%. Feeding difficulties, dyskinesia, and sleep disturbances were common and persistent symptoms. Seizures increased with age, whereas vomiting and dystonic attacks decreased over time. Perceived disease burden differed among families, but most reported overall impaired quality of life. The most burdensome symptoms were restlessness, sleep disorder, and gastrointestinal issues, while seizures/epilepsy were ranked as least impactful. With increasing age, perceived burden from feeding and swallowing disorders, gastrointestinal problems, episodic abdominal pain, and overall quality of life decreased significantly. Conclusions Life expectancy in PCH2A remains limited, but survival appears to have improved in more recent birth cohorts. Most symptoms persist with age, though a few, like reflux and dystonic attacks, improve in tendency. Conversely, respiratory symptoms and seizures tend to worsen. Notably, perceived disease burden generally decreases as patients age. Restlessness proved to be the most burdensome symptom, although it has not been clearly described before.

Background The Low Anterior Resection Syndrome (LARS) score is an internationally validated instrument for identifying bowel dysfunction following anterior resection for rectal cancer. Although widely used, it has been shown to have limited sensitivity for capturing the impact of LARS on daily-life and response to treatment. We have therefore developed a novel patient-reported outcome measure (PROM): the LARS Impact and Consequences Assessment Tool (LARS-ICAT). Methods Initial development of LARS-ICAT followed a five-stage process following established PROM development guidance. Stage one established the conceptual foundation through previously published Delphi consensus. Stage two involved item generation, followed by evaluation of content validity through patient focus groups (n=11) in stage three. Stage four comprised iterative expert review and refinement through clinical consensus with patient involvement. Stage five involved cognitive interviews with patients conducted across five rounds (n=23). Results Several items identified through the Delphi consensus were reworded as they included multiple concepts. A one-month recall period was selected, with six and four response options for symptom and consequence items respectively. Additional consequence items, including impact on sleep and transport use, were incorporated. Focus groups and clinicians emphasised the importance of capturing individual symptom burden, leading to the addition of symptom bother scales. These iterative refinements culminated in LARS-ICAT v2.6. Conclusions LARS-ICAT is a novel PROM designed to assess symptom burden and treatment response in LARS. Future studies will assess its psychometric properties. Once validated, LARS-ICAT will provide a comprehensive, patient-centred assessment of LARS, enhancing our ability to manage this challenging condition.