Impact of Coronavirus disease 2019 pandemic in children with functional abdominal pain disorders: Data from long-term follow-up

OBJECTIVE

We aimed to compare symptom frequency and severity in children with functional abdominal pain disorders (FAPDs) and to evaluate anxiety, quality of life (QoL) and global health during Coronavirus disease 2019 (COVID-19) related quarantine and after 17 months.

METHODS

Children diagnosed with FAPDs between October 2019 and February 2020 at 5 different centers were enrolled and prospectively interviewed during the COVID-19 quarantine and 17 months later when schools, hospital services, and routine activities had re-opened to the public. The patients were asked to complete the Rome IV questionnaire, the Pediatric Quality of Life Inventory 4.0 (PedsQL 4.0) Generic Core Scale, the Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and global health questionnaires. Data about COVID-19 infection and its clinical outcome were also collected.

RESULTS

Ninety-nine out of 180 (55%) children completed the follow-up. The number of patients reporting a worsening of their symptoms was significantly higher at follow-up when compared to the quarantine period (24/99 [24.2%] vs. 12/99 [12.1%]; p = 0.04). The PedsQL 4.0 subtotal score at follow-up significantly decreased at 17 months of follow-up (65.57 [0-100]) when compared to the quarantine (71 [0-100], p = 0.03). Emotional functioning was the most significantly reduced (Follow-up: 64.7 [0-100] vs. Quarantine: 75 [0-100]; p = 0.006). We did not identify significant differences in symptoms and QoL between COVID-19 infected children and the remaining cohort at the two time points.

CONCLUSIONS

An improvement of symptoms and QoL was observed during the quarantine, followed by a worsening at-follow-up. These findings reinforce the hypothesis that the nest effect overweighted COVID-19 fears during the quarantine and highlight the importance of psychological factors in symptom exacerbation.

Meta-analysis: Intestinal ultrasound to evaluate colonic contents and constipation

BACKGROUND

Constipation can be diagnosed clinically using the Rome criteria. Ultrasound (US), which lacks the radiation exposure of conventional X-ray, holds promise as a non-invasive tool to evaluate colonic contents and constipation.

AIM

To examine the role of US in the assessment of constipation.

METHODS

We performed a systematic search of Embase (OVID, 1984), Medline (Ovid, 1946), Cochrane Central, ClinicalTrials.gov and Australia New Zealand Clinical Trials Registry from database inception to 26 January 2024 according to PRISMA guidelines and prospectively registered with PROSPERO. All studies using US to assess constipation or colonic contents in either adults or children were included. Rectal diameter measurements were pooled in meta-analysis. Risk of bias was assessed using the Newcastle Ottawa Scales and Joanna Briggs Institute checklists.

RESULTS

Of 12,232 studies screened, 51 articles (6084 patients; 3422 children) describing US to assess symptoms in patients with constipation were included. Most studies used Rome criteria to diagnose constipation. Rectal diameter was associated with clinical constipation in 29 paediatric studies (3331 patients). Meta-analysis showed the mean rectal diameter of constipated patients was significantly higher than controls (mean difference 12 mm, 95% confidence intervals (CI): 6.48, 17.93, p < 0.0001, n = 16 studies). Other features of constipation on US included posterior acoustic shadowing and echogenicity of luminal contents.

CONCLUSION

US is an appealing imaging modality to assess luminal contents and constipation. Further well-designed studies are required to validate US metrics that accurately identify constipation.

Self-Perception Profile, Body Image Perception and Satisfaction in Relation to Body Mass Index: An Investigation in a Sample of Adolescents from the Campania Region, Italy

(1) Background: Body image dissatisfaction has been commonly reported in adolescents with overweight/obesity and has been related to a lack of motivation to change lifestyle behaviors. Plus, a better perception of physical fitness has been related to a higher self-perception in physical aspect and social items in youths. (2) Methods: A total of 120 (59.2% males, mean age of 12.3 ± 0.9 years) middle-school adolescents participated in the present study. Anthropometric measurements were assessed following the standard procedures. Body weight perception and body image satisfaction were assessed using the Silhouette Figure Body Images Test. Self-perception profile, perceived physical fitness, and perceived difficulties in conducting physical tasks were assessed by using structured questionnaires. (3) Results: Overweight was present in 27.5% adolescents and obesity in 32.5%. A total of 89.7% of adolescents with obesity did not have a real perception of his/her weight status and 84.6% of adolescents with obesity were not satisfied with his/her body image. The self-perception of physical appearance, perceived difficulties in running, perceived overall fitness, and perceived speed/agility were lower in adolescents who were unsatisfied with their body image. Body image satisfaction was positively associated with the self-perception of physical appearance and overall fitness and negatively associated with perceived difficulties in running, independently of sex, age, and BMI. (4) Conclusions: Adolescents with obesity did not have a real perception of their weight status and were unsatisfied with their body image. The positive association between body satisfaction, a better perception of overall fitness, and less difficulties in conducting physical tasks suggests the protective role of the components of physical activity and health-related fitness on body acceptance in a critical period of life.

Nutritional and exercise interventions to improve conception in women suffering from obesity and distinct nosological entities

Infertility among women, particularly those living with obesity, presents a multifaceted challenge with implications for reproductive health worldwide. Lifestyle interventions, mainly focusing on weight loss, have emerged as promising strategies to improve fertility outcomes in this population. This review aims to explore the effectiveness of various lifestyle interventions, encompassing dietary modifications and exercise regimens, in enhancing fertility outcomes among women with obesity and associated conditions such as polycystic ovary syndrome, congenital adrenal hyperplasia, type 2 diabetes mellitus, premenopause, hypothyroidism and eating disorders. Methodology of study search encompass a broad spectrum, ranging from interventions targeting weight management through slow or rapid weight loss to dietary approaches emphasizing whole food groups, specific nutrients, and dietary patterns like low-carbohydrate or ketogenic diets, as well as the Mediterranean diet. By synthesizing existing findings and recommendations, this review contributes to the understanding of lifestyle interventions in addressing infertility, with an emphasis on the population of women of reproductive age with excess weight and known or unknown infertility issues, while promoting their integration into clinical practice to optimize reproductive health and overall well-being.

Comparison of long-term outcomes after laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass for morbid obesity

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the two most bariatric procedures in Asia. However, a comparison of long-term outcomes is still limited.

OBJECTIVES

To compare the degree of long-term weight loss, remission of comorbidities and complication rates after LRYGB and LSG procedures.

METHODS

A retrospective analysis was conducted for all patients who underwent LSG or LRYGB between May 2005 and May 2018 at a single institute with at least 1-5 years of follow up. Demographic data were collected.

RESULTS

Of the total 342 patients, 159 underwent primary LSG and 183 patients underwent LRYGB. Preoperative BMI in the LSG group was significantly higher than the LRYGB group (54.7 ± 12.6 kg/m2 vs 48.2 ± 8.2 kg/m2, P = 0.001). Comorbidities between LSG and LRYGB groups were similar. Mean percentage of total weight loss (%TWL) at 5 years after was 23.6 ± 1.7 % in the LSG group vs. 29.9 ± 1.3 % in the LRYGB group (P = 0.005) and LRYGB resulted in greater weight loss than LSG at all time points. The remission of comorbidities were similar in both groups, except that dyslipidemia was significantly better in the LRYGB group. Overall complications were 35.2 % in the LSG group vs. 20.8 % in the LRYGB group (P = 0.003).

CONCLUSIONS

Our center revealed that LRYGB had better results than LSG in terms of percentage total weight loss at all time points. In the long term, LSG showed a higher overall complication rate compared to LRYGB.

A Comprehensive Review of Hepatitis B Vaccine Nonresponse and Associated Risk Factors

Hepatitis B virus (HBV) infection remains a significant global health concern worldwide, contributing to high rates of mortality and morbidity, including chronic hepatitis B, cirrhosis, and hepatocellular carcinoma (HCC). Universal vaccination programs have significantly reduced the rate of HBV transmission; however, a subset of individuals fail to develop a protective immune response following vaccination and are termed nonresponders. A comprehensive search strategy using the PubMed, Google Scholar, and Web of Science databases was employed to search for relevant studies using keywords including "hepatitis B vaccine", "vaccine nonresponse", "immunogenicity", "immune response to the hepatitis B vaccine", and "associated risk factors". Factors influencing the vaccine's response include demographic factors, such as age and sex, with increased nonresponse rates being observed in older adults and males. Obesity, smoking, and alcohol consumption are lifestyle factors that decrease the vaccine response. Medical conditions, including diabetes, chronic kidney and liver diseases, HIV, celiac disease, and inflammatory bowel disease, affect the vaccine response. Major histocompatibility complex (MHC) haplotypes and genetic polymorphisms linked to immune regulation are genetic factors that further influence the vaccine's effectiveness. To reduce the global burden of hepatitis B infection, it is essential to understand these factors to improve vaccine effectiveness and develop individualized vaccination strategies.

Anemia and iron metabolism disorders after single anastomosis sleeve ileal (SASI) bypass. Is it a real problem?

PURPOSE

SASI (single anastomosis sleeve ileal) bypass can lead to nutritional deficiencies, including disorders of iron metabolism and anemia. This study aims to evaluate the effect of SASI bypass on weight loss, anemia, and iron deficiency in patients with obesity during the follow-up period.

METHODS

This study is a retrospective analysis of prospectively collected data from patients who underwent SASI bypass at our hospital between January 2020 and February 2022.

RESULTS

The mean age of the patients was 42 years (range 22-58). The average duration of the follow-up period was 26 months. The mean percentage of excess weight loss (%EWL) was 90.1%, and total weight loss (%TWL) was 30.5%. During the postoperative observation period, anemia was identified in ten patients (25%), comprising 70% with normocytic anemia, 10% with microcytic anemia, and two macrocytic anemia cases (20%). Iron deficiency was observed in two patients (5%).

CONCLUSION

SASI bypass is an effective bariatric procedure in weight loss outcomes. However, there may be an increased risk of anemia and iron metabolism disruptions associated with this procedure. The common limb length (250 vs. 300 cm) did not significantly impact hemoglobin, iron, TIBC, ferritin levels, or anemia incidence among patients undergoing SASI bypass. The decrease in postoperative ferritin levels signifies a depletion in tissue iron reserves, thereby emphasizing the necessity for surveillance of iron homeostasis parameters following SASI bypass.

Comment on Salazar et al. Weight Regain after Metabolic Surgery: Beyond the Surgical Failure. J. Clin. Med. 2024, 13, 1143

I read the article by Salazar J. [...].

Prebiotics, Probiotics and Postbiotics: The Changing Paradigm of Functional Foods

The rampant use of antibiotics has led to the emergence of multidrug resistance and is often coupled with gut dysbiosis. To circumvent the harmful impact of antibiotics, probiotics have emerged as an effective intervention. However, while the new probiotics are being added to the list, more recently, the nature and role of their counterparts, viz. prebiotics, postbiotics and parabiotics have also drawn considerable attention. As such, intricate relationships among these gut-biotics vis-à-vis their role in imparting health benefits is to be delineated in a holistic manner. Prebiotic dietary fibers are selectively fermented by probiotics and promote their colonization in the gut. The proliferation of probiotics leads to production of fermentation by-products (postbiotics) which affect the growth of enteropathogens by lowering the pH and producing inhibitory bacteriocins. After completing life-cycle, their dead remnants (parabiotics e.g. exopolysaccharides and cell wall glycoproteins) also inhibit adhesion and biofilm formation of pathogens on the gut epithelium. These beneficial effects are not just endemic to gut but a systemic response is witnessed at different gut-organ axes. Thus, to decipher the role of probiotics, it is imperative to unravel the interdependence between these components. This review elaborates on the recent advancements on various aspects of these gut-biotics and the mechanism of potential attributes like anti-oxidant, anti-inflammatory, anti-neoplastic, anti-lipidemic and anti-hyperglycemic benefits.

Assessment of Helicobacter pylori cytotoxin-associated Gene A (Cag A) protein and its association with ferritin and vitamin B12 deficiencies among adult healthy asymptomatic residents in Sharjah, United Arab Emirates

The United Arab Emirates (UAE) serves as an effective epidemiological site for assessing Helicobacter pylori (H. pylori) infection due to its diverse population. However, comprehensive studies on the prevalence of H. pylori in the UAE are notably scarce. In depth prevalence studies are needed as a preventive measure against gastric cancer and other emerging extra gastric diseases associated with H. pylori infection. Aim: This study aimed to assess H. pylori infection and its virulent oncoprotein, the Cytotoxin-Associated Gene (Cag A) and its association with ferritin and vitamin B12 deficiencies. Methods: The study was conducted on 1094 healthy asymptomatic volunteers residents in the Sharjah Emirate, UAE. Enzyme-linked immunosorbent assay (ELISA) was performed to assess H. pylori infection using H. pylori antibodies (IgG), and detection of CagA protein using Cag A antibody (IgG) in the human serum. Ferritin and vitamin B12 serum levels were assessed and correlated to H. pylori infection. Results: This study focuses mainly on the assessment of H. pylori and its virulent factor CagA, in relation to vitamin B12 and ferritin deficiencies. Remarkably, 49.6 % of the participants were detected positive for H. pylori, with over half of these cases involving CagA positive strains. Notably, among Emirati participants, 76.11 % of those with H. pylori infection were CagA positive. Statistical analysis revealed a significant correlation between H. pylori, CagA level, and ferritin/vitamin B12 deficiencies. Conclusion: These findings emphasize the importance of timely detection and eradication of H. pylori not only as a preventive strategy against gastric cancer but also as an effective strategy to rescue the adverse effects from ferritin and vitamin B12 deficiencies, thereby improving the overall health outcomes of individuals affected by H. pylori infection.

Effects of Pea (Pisum sativum) Prebiotics on Intestinal Iron-Related Proteins and Microbial Populations In Vivo (Gallus gallus)

Iron deficiency remains a public health challenge globally. Prebiotics have the potential to improve iron bioavailability by modulating intestinal bacterial population, increasing SCFA production, and stimulating expression of brush border membrane (BBM) iron transport proteins among iron-deficient populations. This study intended to investigate the potential effects of soluble extracts from the cotyledon and seed coat of three pea (Pisum sativum) varieties (CDC Striker, CDC Dakota, and CDC Meadow) on the expression of BBM iron-related proteins (DCYTB and DMT1) and populations of beneficial intestinal bacteria in vivo using the Gallus gallus model by oral gavage (one day old chicks) with 1 mL of 50 mg/mL pea soluble extract solutions. The seed coat treatment groups increased the relative abundance of Bifidobacterium compared to the cotyledon treatment groups, with CDC Dakota seed coat (dark brown pigmented) recording the highest relative abundance of Bifidobacterium. In contrast, CDC Striker Cotyledon (dark-green-pigmented) significantly increased the relative abundance of Lactobacillus (p < 0.05). Subsequently, the two dark-pigmented treatment groups (CDC Striker Cotyledon and CDC Dakota seed coats) recorded the highest expression of DCYTB. Our study suggests that soluble extracts from the pea seed coat and dark-pigmented pea cotyledon may improve iron bioavailability by affecting intestinal bacterial populations.

Carcinogenic Risk from Lead and Cadmium Contaminating Cow Milk and Soya Beverage Brands Available in the Portuguese Market

Our previous work demonstrated the presence of lead (Pb) and cadmium (Cd) contamination in cow milk (CM) and soy beverages (SBs) in Portugal. These metals share carcinogenic mechanisms, suggesting at least additive effects. Our goals were to assess carcinogenic risks from Pb and Cd intake detected in various CM and SB brands on the Portuguese market and to determine the relative contributions of Pb and Cd. Furthermore, we modeled different consumption scenarios for various age/body weight groups to estimate cumulative Excess Lifetime Carcinogenic Risk (ELCR). ELCR was computed by multiplying chronic daily intake by a cancer slope factor for each metal, with an ELCR > 1 × 10-4 indicating carcinogenic risk. Five CM and three SB brands posed cancer risks in children, with the highest values at 1.75 × 10-4 and 9.12 × 10-5, respectively; Pb had mean relative contributions of 87.8 ± 3.1% in CM and 54.9 ± 12.1% in SB. Carcinogenic risks were observed for children, adolescents, and adults in several CM or SB consumption scenarios, albeit at levels above typical Portuguese intakes. Strict monitoring of metal levels, such as Pb and Cd, is advised because CM is a component of many foods, including baby food.

A superior approach? The role of robotic sleeve gastrectomy in patients with super super obesity using the 2019-2022 MBSAQIP database

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) in patients with BMI ≥ 60 presents technical challenges, that might be overcome by robotic surgery, but its effectiveness has not been rigorously evaluated. We compared the 30-day outcomes of LSG and robotic sleeve gastrectomy (RSG) in patients with BMI < 60 versus ≥ 60 and between LSG and RSG in patients with BMI ≥ 60.

METHODS

Patients aged 18-65 years who underwent sleeve gastrectomy were included using the 2019-2022 MBSAQIP database. We performed a Propensity Score Matching analysis, with 21 preoperative characteristics. We compared 30-day postoperative outcomes for patients with BMI < 60 versus ≥ 60 using either a laparoscopic (Analysis 1) or robotic approach (Analysis 2) and compared LSG versus RSG in patients with BMI ≥ 60 (Analysis 3).

RESULTS

297,250 patients underwent LSG and 81,008 RSG. Propensity-matched¸ outcomes in analysis 1 (13,503 matched cases), showed that patients with BMI ≥ 60 had higher rates of mortality (0.1% vs. 0.0%, p = 0.014), staple line leak (0.3% vs. 0.2%, p = 0.035), postoperative bleeding (0.2% vs 0.1%, p = 0.028), readmissions (3.5% vs. 2.4%, p < 0.001), and interventions (0.7% vs. 0.5%, p = 0.028) when compared to patients with BMI < 60. In analysis 2 (4350 matched cases), patients with BMI ≥ 60 demonstrated longer operative times, length of stay, and higher rates of unplanned ICU when compared to patients with BMI < 60. In analysis 3 (4370 matched cases), patients who underwent RSG had fewer readmissions (2.9% vs. 3.7%, p = 0.037), staple line leaks (0.1% vs. 0.3%, p = 0.029), and postoperative bleeding (0.1% vs. 0.3%, p = 0.045), compared to LSG. Conversely, a longer operative time (92.74 ± 38.65 vs. 71.69 ± 37.45 min, p < 0.001) was reported.

CONCLUSION

LSG patients with BMI ≥ 60 have higher rates of complications compared to patients with a BMI < 60. Moreover, some outcomes may be improved with the robotic approach in patients with BMI ≥ 60. These results underscore the importance of considering a robotic approach in this super super obese population.

Associations between Celiac Disease, Extra-Gastrointestinal Manifestations, and Gluten-Free Diet: A Narrative Overview

Millions of children and adults worldwide suffer from undiagnosed and untreated celiac disease (CeD). The clinical picture of CeD is highly heterogeneous and comprises manifestations that can affect almost the whole body. This narrative overview is aimed at characterizing diseases and complaints that are associated with unrecognized CeD and that frequently involve sites other than the gastrointestinal (G.I.) tract, i.e., dental, otorhinolaryngological, and ocular complications; skin and hair abnormalities; afflictions of the bones, joints, and muscles; cardiovascular affectations; kidney diseases; neuro-psychiatric disorders; and gynecological-obstetrical manifestations. The association between CeD and extra-GI manifestations is frequently overlooked, which leads to a delay in diagnosis. Most CeD-mediated disorders can be treated with a strict gluten-free diet (GFD), but some of them are irreversible unless CeD is diagnosed in time. Some manifestations can be classified as risk factors for CeD, and CeD screening tests for affected patients should be selectively considered. Apart from gastroenterologists, specialists in other medical disciplines can play an important role in identifying people with unrecognized CeD and may help prevent its progress and long-term complications. Further comprehensive investigations are necessary to clarify the pathogenesis of extra-GI manifestations and the effect of a GFD.

New-Onset Type 2 Diabetes after Bariatric Surgery: A Matched Cohort Study

INTRODUCTION

The objective of this study is to determine the difference in rates of new-onset type 2 diabetes (T2D) for individuals who have had metabolic and bariatric surgery (MBS) and similar individuals who did not have MBS, and to determine whether differences in new-onset T2D differ depending on whether the individual had prediabetes at baseline.

METHODS

This study used data from a large United States employer-based retrospective claims database from 2016 to 2021 (analysis completed in 2023). Individuals who did and did not have MBS were matched 1:1 on index year, sex, age, health plan type, region, body mass index, baseline healthcare costs, other obesity-related comorbidities, prediabetes diagnosis, and inpatient admissions in the year before the index date. New-onset T2D was examined at 1 (18,752 matches) and 3 (5,416 matches) years after the index date and stratified by baseline prediabetes.

RESULTS

Among the full cohort of individuals with and without prediabetes at baseline, 0.1% and 2.7% of individuals who had did and did not have MBS developed T2D within 1 year after the index date, respectively (difference=2.6, 95% CI 2.4-2.8), and 0.3% and 8.4% of individuals who did and did not have MBS developed T2D within 3 years after the index date, respectively (difference=8.1, 95% CI 7.3-8.8). The difference in new-onset T2D was greatest among individuals with prediabetes at baseline.

CONCLUSIONS

This study demonstrated patients with obesity and without T2D who undergo MBS are significantly less likely to develop new-onset T2D compared to matched non-MBS patients.

Vitamin D: An Essential Nutrient in the Dual Relationship between Autoimmune Thyroid Diseases and Celiac Disease-A Comprehensive Review

Autoimmune thyroid diseases (AITD) are among the most frequent autoimmune disorders, with a multifactorial etiology in which both genetic and environmental determinants are probably involved. Celiac disease (CeD) also represents a public concern, given its increasing prevalence due to the recent improvement of screening programs, leading to the detection of silent subtypes. The two conditions may be closely associated due to common risk factors, including genetic setting, changes in the composition and diversity of the gut microbiota, and deficiency of nutrients like vitamin D. This comprehensive review discussed the current evidence on the pivotal role of vitamin D in modulating both gut microbiota dysbiosis and immune system dysfunction, shedding light on the possible relevance of an adequate intake of this nutrient in the primary prevention of AITD and CeD. While future technology-based strategies for proper vitamin D supplementation could be attractive in the context of personalized medicine, several issues remain to be defined, including standardized assays for vitamin D determination, timely recommendations on vitamin D intake for immune system functioning, and longitudinal studies and randomized controlled trials to definitely establish a causal relationship between serum vitamin D levels and the onset of AITD and CeD.

The real occurrence of gastroesophageal reflux disease after sleeve gastrectomy - a prospective pH-monitoring study

Introduction

Sleeve gastrectomy (SG) is currently the most frequently performed bariatric procedure in the world. However, the occurrence of gastroesophageal reflux disease (GERD) after SG remains controversial and questionable.

Aim

To determine the occurrence of GERD after SG using a pH-monitoring study.

Material and methods

This is a prospective study involving patients undergoing SG in one surgical centre. Inclusion criteria were eligibility for bariatric surgery, no symptoms of GERD, normal gastroscopy, and pH-monitoring before the surgery. Postoperative examinations were performed 6 months after surgery.

Results

A total of 38 patients were analysed in the study. The mean age was 44.9 years, and the mean preoperative BMI was 42.6 kg/m2. Before surgery, all patients had normal pH values. After surgery, mean acid exposure time (AET), number of refluxes, and DeMeester score increased statistically significantly (p < 0.001). 27 (71.1%) patients each had AET > 6%, but only 9 (23.7%) reported GERD symptoms and the need for PPIs. The correlation between AET and %TWL was moderate positive, and the correlation between DeMeester score and %TWL was low positive (p = 0.011, p = 0.014, respectively).

Conclusions

GERD after SG seems to be a significant problem. More than two-thirds of patients had de novo GERD after SG in pH-monitoring, but only one-quarter of them required PPIs.

Does the presence of an esophageal motor disorder influence the response to anti-reflux mucosectomy (ARMS) for refractory GERD?

INTRODUCTION

The prevalence of esophageal motor disorders (EMD) in PPI-refractory gastroesophageal reflux disease (GERD) is substantial. However, limited data exist on their impact on the efficacy of endoscopic treatments like anti-reflux mucosectomy (ARMS). This study aimed to evaluate the influence of EMD on ARMS efficacy in patients with PPI-refractory GERD.

METHOD

This single-center retrospective study enrolled patients with refractory GERD treated with ARMS-b (anti-reflux mucosectomy band-ligation). High-resolution esophageal manometry (HREM) was conducted before the procedure to identify EMD presence. The primary endpoint was treatment efficacy, defined as >50% improvement in GERD-HRQL score at 1 year. Secondary endpoints included PPI intake, symptom control, ARMS complications, and overall patient satisfaction at 12 months.

RESULTS

The study included 65 patients, with 41 (63.1%) showing EMD on HREM. Treatment efficacy was achieved by 33.8% (22) of patients, with 8 without EMD, 11 having isolated LES hypotonia, and 3 with both LES hypotonia and esophageal body motor disorder. No significant differences were observed between patients with and without EMD regarding the primary endpoint, PPI use, symptom control, or complications. Dysphagia developed in 52.3% (34) within 6 months, leading to esophageal dilatation in 15.3% (10). Two patients experienced acute hemorrhage, and one had perforation.

CONCLUSION

The presence of esophageal motor disorders does not seem to impact ARMS response, suggesting the technique's consideration in this population. Larger studies are essential for confirming these results and exploring treatment response and post-operative predictors.

Predictors of Length of Hospital Stay After Reduction of Internal Hernia in Patients With a History of Roux-en-Y Gastric Bypass

BACKGROUND

Postoperative internal hernias after Roux-en-Y gastric bypass (RYGB) have an incidence of 2%-9% and are a surgical emergency. Evidence on factors associated with length of stay (LOS) after emergent internal hernia reduction in RYGB patients is limited.

METHODS

This is a retrospective review of patients who underwent internal hernia reduction after RYGB at our tertiary care center over a 5 year period from 2015 to 2020. Demographics, comorbidities, and intra- and postoperative hospital course were collected. Univariate and multivariate linear regressions were used to investigate factors associated with LOS.

RESULTS

We identified 38 patients with internal hernia after RYGB. These patients with mean age 44.1 years were majority female (71.1%) and white race (60.5%). Of the 24 patients where the RYGB was done at our institution, the mean RYGB to IH interval was 43 months. Petersen's defect (57.8%) followed by jejuno-jejunal mesenteric defect (31.6%) were the most common locations for IH. Both Petersen's and jejuno-jejunal mesenteric hernias were found in 4 cases (10.5%). Revision of bypass and small bowel resection were required in 13.2% and 5.3% of cases, respectively. The median (interquartile range) length of stay (LOS) was 2 days. On the multivariate analysis, male sex (P = .019), conversion to exploratory laparotomy (P = .005), and resection of small bowel (P < .001) were independent risk factors for increased LOS.

CONCLUSION

The most common location of IH after RYGB is Petersen's defect, followed by jejuno-jejunal mesenteric defect. LOS was significantly associated with male sex, exploratory laparotomy, and resection of small bowel.

Management of Pain Medication in Patients With a History of Bariatric Surgery: A Systematic Review

CONTEXT

Obesity prevalence is persistently increasing worldwide. Among surgical therapeutic procedures, bypass surgery and sleeve gastrectomy have shown the best results regarding weight loss, prevention, and treatment of secondary complications. However, these surgeries are associated with an increased risk of malabsorption and metabolic changes that could further affect the pharmacokinetics of drugs. On the other hand, patients with a history of such surgeries are more likely to experience pain and request analgesic initiation or adaptation. The question of how to manage pain medication in these patients is challenging due to their narrow therapeutic indexes.

OBJECTIVES

To summarize the current literature on the impact of bariatric surgery on the subsequent pharmacokinetics of analgesics and propose a multidisciplinary therapeutic attitude to optimize pain management in these patients.

METHODS

We conducted a systematic review that included all pharmacological studies published after 2000.

RESULTS

Unexpectedly, these surgeries seem to increase the bioavailability of drugs by long-term improvement of hepatic function. Yet, the medical community drastically lacks robust guidelines for pain management in those patients. This systematic review aims to bring together pharmacological studies related to the use of pain treatments in patients who underwent bypass surgery or sleeve gastrectomy.

CONCLUSIONS

Caution should be exercised regarding the risk of overdose in every circumstance: treatment initiation, change of doses, or change of molecule. More prospective trials comparing the pharmacokinetics of medications in obese patients with and without prior bariatric surgery are needed.

Late marginal ulcer perforation after Roux-en-Y Gastric bypass - A case report with two-step management

INTRODUCTION

Marginal ulcers are an acid-related complication of laparoscopic Roux-en-Y gastric bypass. Few cases of acute perforation have been described, and there are few reports on viable surgical management. This case report demonstrates a two-step surgical procedure for treating a perforated late marginal ulcer in a patient with sepsis.

PRESENTATION OF CASE

A 39-year-old smoker presented to the emergency department six years after undergoing a Roux-en-Y gastric bypass. Diagnostic findings revealed ascites and changes in intestinal calibre, indicating the need for surgery. Intraoperatively, a perforated marginal ulcer covered by the liver was observed. Given the extent of the perforation and the patient's increased instability, discontinuity resection was performed. After stabilisation and improvement in the nutritional status, the gastrojejunostomy was restored nine weeks later.

DISCUSSION

Treatment of Marginal ulcers is controversial, with no clear guidelines. However, severe complications require endoscopic or surgical treatment. The literature considers three main surgical treatment options for perforated marginal ulcers: surgical repair, surgical anastomotic revision, and gastric bypass reversal. Complicated situations, significant intraoperative findings, and unstable patients require tailored approaches.

CONCLUSION

A two-step procedure with discontinuity resection for damage control surgery, patient stabilisation, and improvement of nutritional status, followed by elective continuity restoration with a new gastrojejunostomy, is considered feasible in critically ill patients.

The Milan score: A novel manometric tool for a more efficient diagnosis of gastro-esophageal reflux disease

OBJECTIVE

A definitive diagnosis of gastroesophageal reflux disease (GERD) depends on endoscopic and/or pH-study criteria. However, high resolution manometry (HRM) can identify factors predicting GERD, such as ineffective esophageal motility (IEM), esophago-gastric junction contractile integral (EGJ-CI), evaluating esophagogastric junction (EGJ) type and straight leg raise (SLR) maneuver response. We aimed to build and externally validate a manometric score (Milan Score) to stratify the risk and severity of the disease in patients undergoing HRM for suspected GERD.

METHODS

A population of 295 consecutive patients undergoing HRM and pH-study for persistent typical or atypical GERD symptoms was prospectively enrolled to build a model and a nomogram that provides a risk score for AET > 6%. Collected HRM data included IEM, EGJ-CI, EGJ type and SLR. A supplemental cohort of patients undergoing HRM and pH-study was also prospectively enrolled in 13 high-volume esophageal function laboratories across the world in order to validate the model. Discrimination and calibration were used to assess model's accuracy. Gastroesophageal reflux disease was defined as acid exposure time >6%.

RESULTS

Out of the analyzed variables, SLR response and EGJ subtype 3 had the highest impact on the score (odd ratio 18.20 and 3.87, respectively). The external validation cohort consisted of 233 patients. In the validation model, the corrected Harrel c-index was 0.90. The model-fitting optimism adjusted calibration slope was 0.93 and the integrated calibration index was 0.07, indicating good calibration.

CONCLUSIONS

A novel HRM score for GERD diagnosis has been created and validated. The MS might be a useful screening tool to stratify the risk and the severity of GERD, allowing a more comprehensive pathophysiologic assessment of the anti-reflux barrier.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier: NCT05851482).

A Nationwide Report on Metabolic and Bariatric Surgery in 2019-2022: Utilizing the Korean Society of Metabolic and Bariatric Surgery Database Registry

Purpose

The introduction of insurance coverage in Korea has led to a rise in the number of bariatric and metabolic surgeries. This study aims to provide a comprehensive report on the nationwide status of these surgeries from 2019 to 2022, utilizing data from the Korean Society of Metabolic and Bariatric Surgery (KSMBS) database registry.

Materials and Methods

This study analyzed data from the KSMBS registry, collected from 68 certified surgeons across 58 institutions from January 2019 to December 2022. After excluding non-relevant cases, the final analysis included 7,377 patients.

Results

Annually, data for 1,869, 1,934, 1,782, and 1,792 patients were collected from 2019 to 2022, respectively. The rate of revisional operations accounted for 7.1%, 8.2%, 4.6%, and 4.5% of the total cases each year. The most common primary surgery was Sleeve Gastrectomy (SG, ranging from 71.1% to 78.9%), followed by Roux-en-Y Gastric Bypass (RYGB, ranging from 9.6% to 13.4%). The surgeries demonstrated a high safety profile, with a low morbidity rate (0.5% to 0.9%) and a zero mortality rate over the 4 years. Within 2 years post-operation, the Total Weight Loss Percentage was similar among patients who underwent SG, RYGB, and Sleeve Plus procedures.

Conclusion

The number of bariatric and metabolic surgeries in Korea has increased significantly since the introduction of national insurance coverage. SG was the most performed primary procedure. All surgical procedures showed safe short-term outcomes and yielded reasonable results upon follow-up, indicating a positive impact of insurance coverage on the accessibility and safety of surgeries.

Galactooligosaccharides: Synthesis, metabolism, bioactivities and food applications

Prebiotics are non-digestible ingredients that exert significant health-promoting effects on hosts. Galactooligosaccharides (GOS) have remarkable prebiotic effects and structural similarity to human milk oligosaccharides. They generally comprise two to eight sugar units, including galactose and glucose, which are synthesized from substrate lactose by microbial β-galactosidase. Enzyme sources from probiotics have received particular interest because of their safety and potential to synthesize specific structures that are particularly metabolized by intestinal probiotics. Owing to advancements in modern analytical techniques, many GOS structures have been identified, which vary in degree of polymerization, glycosidic linkage, and branch location. After intake, GOS adjust gut microbiota which produce short chain fatty acids, and exhibit excellent biological activities. They selectively stimulate the proliferation of probiotics, inhibit the growth and adhesion of pathogenic bacteria, alleviate gastrointestinal, neurological, metabolic and allergic diseases, modulate metabolites production, and adjust ion storage and absorption. Additionally, GOS are safe and stable, with high solubility and clean taste, and thus are widely used as food additives. GOS can improve the appearance, flavor, taste, texture, viscosity, rheological properties, shelf life, and health benefits of food products. This review systemically covers GOS synthesis, structure identifications, metabolism mechanisms, prebiotic bioactivities and wide applications, focusing on recent advances.

Treatment of dyspeptic symptoms with YamatoGast. A non-interventional study of a registered traditional herbal Rikkunshito extract product from Japanese Kampo Medicine in routine practice in Germany

INTRODUCTION

Dyspeptic symptoms belong to the most frequent reasons to seek medical advice and are a burden both for the individual affected and the healthcare system. In Japan, the traditional herbal Kampo prescription rikkunshito has proven benefit for this indication.

METHODS

In a prospective, multicentre, non-interventional study (NIS), the effectiveness, safety, and tolerability of a two-week treatment with the registered rikkunshito extract product YamatoGast was assessed in German patients with an acute episode of dyspeptic symptoms of functional origin under real-world conditions. The primary endpoint was the responsiveness to treatment assessed by the overall treatment effect (OTE) score. Secondary endpoints were the change in severity of dyspeptic symptoms and the change in quality of life (QoL). Safety evaluation was based on reported adverse drug reactions, drug compliance, and ratings of tolerability by physicians and patients.

RESULTS

Sixty-six patients were enrolled (mean age 48.9 years, 74% females). The treatment was well tolerated and highly beneficial, as expressed by pronounced responder rates of 78.9% for the primary endpoint OTE. All secondary endpoints were also met. The severity of dyspeptic symptoms significantly improved by 62-77% compared to baseline, confirmed by a remarkable improvement of QoL. Significant symptom relief started from the third day of treatment onwards.

CONCLUSION

In this non-interventional study, two-week treatment with YamatoGast resulted in a significant improvement of dyspeptic symptoms and was associated with high patient response and satisfaction. YamatoGast was confirmed as a safe and clinically relevant therapeutic option for patients suffering upper gastrointestinal complaints in routine practice.

Alpha-Gal syndrome as a novel food allergy: a case report study

Introduction and importance

Alpha-Gal syndrome (AGS), a distinct form of mammalian meat allergy, presents unique characteristics that set it apart from typical IgE-mediated food hypersensitivities. AGS induces an allergic response typically 3-6 h post-ingestion of mammalian meat, such as beef, pork, or lamb. This prolonged reaction time differentiates AGS from other food allergies, which usually provoke a more immediate response.

Case presentation

The authors present a case of a 35-year-old male patient who, unbeknownst to him, had been experiencing symptoms consistent with Alpha-Gal allergy for several years. His symptoms only subsided upon the complete elimination of mammalian meat from his diet. It was only then that the possibility of AGS was considered. Complete abstinence from mammalian meat, meat by-products, and other α-Gal containing foods is the most effective preventative strategy for AGS. No definitive cure for AGS has been established as of now. Treatment protocols for hypersensitivity reactions are contingent upon the severity of the reaction, with therapies ranging from antihistamine medications to the administration of epinephrine.

Conclusion

There is considerable variability among AGS patients concerning the consumption of dairy products. Some individuals with AGS can safely consume dairy products without any adverse reactions, while others are advised to abstain due to potential allergenic responses. This variability in dairy tolerance among AGS patients warrants further investigation.

Percutaneous Removal of Migrated Gastrointestinal Stents Using Gastrostomy Access

This report describes the experience of removing migrated gastrointestinal (GI) stents using a gastrostomy (G) access. Four male patients aged 23-62 years (mean, 42 years) had 6 migrated stents removed using an existing (n = 3) or new (n = 1) G access. Removed stents included 5 covered esophageal stents that migrated into the stomach and 1 distal noncovered duodenal stent that migrated into the proximal duodenum. One patient had 2 stents removed during the same session. All stents were removed successfully without adverse events. Techniques used included the folding technique using a wire in 3 stents and forceps in 2 stents. Eversion technique was used in the duodenal stent. The G or gastrojejunostomy tubes were replaced after stent removal and used for enteral feedings. In conclusion, removing migrated GI stents using an existing or new G access was technically successful and safe.

Effects of Vertical Sleeve Gastrectomy on Weight Loss, Eating Behaviors, and Weight Concern Eight Months Postsurgery

OBJECTIVES

Following vertical sleeve gastrectomy (VSG), the role of eating behaviors in weight regain remains unclear. This study aimed to examine the effects of VSG on excess weight loss (EWL) and five eating-related variables (food addiction, disinhibition, susceptibility to hunger, dietary restraint, and weight concern) while exploring their associations before and eight months post-surgery.

MATERIALS AND METHODS

A sample of 76 participants who underwent VSG was recruited from a healthcare center in Quebec, Canada. Measurements included body mass index (BMI), the Eating Disorder Examination (weight concern), the Yale Food Addiction Scale (food addiction), and the Three-Factor Eating Questionnaire (disinhibition, susceptibility to hunger, and dietary restraint). T-tests were conducted between pre-surgery (T0) and eight-month post-surgery (T8), and correlations were examined between T0 and T8, within T0, and within T8.

RESULTS

The mean EWL was 63.43% ± 13.14 at T8. Comparisons between T0 and T8 showed a significant decrease in food addiction, disinhibition, and susceptibility to hunger (p = 0.001-0.005). No significant differences were observed for dietary restraint and weight concerns. BMI at T0 was negatively correlated with EWL at T8 (r = -0.45). Within T0, a negative correlation was observed between food addiction and dietary restraint (r = -0.42), which changed from negative to positive within T8 (r = 0.35).

CONCLUSIONS

This study confirmed that VSG is effective for weight loss and associated with a reduction in maladaptive eating behaviors. Postsurgery, individuals with greater food addiction exhibited more dietary restraint, suggesting a need for restraint among those experiencing a strong drive toward food. However, weight concerns remained high even after significant weight loss, indicating that weight loss alone may not be sufficient for change. A postsurgery medical follow-up focusing on overall well-being and lifestyle adaptation would be a crucial complement.

Pharmacotherapeutic advances in fibromyalgia: what's new on the horizon?

INTRODUCTION

This review delves into Fibromyalgia Syndrome (FMS), a chronic pain condition demanding thorough understanding for precise diagnosis and treatment. Yet, a definitive pharmacological solution for FMS remains elusive.

AREAS COVERED

In this article, we systematically analyze various pharmacotherapeutic prospects for FMS treatment, organized into sections based on the stage of drug development and approval. We begin with an overview of FDA-approved drugs, discussing their efficacy in FMS treatment. Next, we delve into other medications currently used for FMS but still undergoing further study, including opioids and muscle relaxants. Further, we evaluate the evidence behind medications that are currently under study, such as cannabinoids and naltrexone. Lastly, we explore new drugs that are in phase II trials. Our research involved a thorough search on PUBMED, Google Scholar, and clinicaltrials.gov. We also discuss the action mechanisms of these drugs and their potential use in specific patient groups.

EXPERT OPINION

A focus on symptom-driven, combination therapy is crucial in managing FMS. There is also a need for ongoing research into drugs that target neuroinflammation, immunomodulation, and the endocannabinoid system. Bridging the gap between benchside research and clinical application is challenging, but it holds potential for more targeted and effective treatment strategies.

Gastrointestinal diagnoses in patients with eating disorders: A retrospective cohort study 2010-2020

BACKGROUND AND AIMS

Gastrointestinal (GI) disorders are common in patients with eating disorders. However, the temporal relationship between GI and eating disorder symptoms has not been explored. We aimed to evaluate GI disorders among patients with eating disorders, their relative timing, and the relationship between GI diagnoses and eating disorder remission.

METHODS

We conducted a retrospective analysis of patients with an eating disorder diagnosis who had a GI encounter from 2010 to 2020. GI diagnoses and timing of eating disorder onset were abstracted from chart review. Coders applied DSM-5 criteria for eating disorders at the time of GI consult to determine eating disorder remission status.

RESULTS

Of 344 patients with an eating disorder diagnosis and GI consult, the majority (255/344, 74.2%) were diagnosed with an eating disorder prior to GI consult (preexisting eating disorder). GI diagnoses categorized as functional/motility disorders were most common among the cohort (57.3%), particularly in those with preexisting eating disorders (62.5%). 113 (44.3%) patients with preexisting eating disorders were not in remission at GI consult, which was associated with being underweight (OR 0.13, 95% CI 0.04-0.46, p < 0.001) and increasing number of GI diagnoses (OR 0.47 per diagnosis, 95% CI 0.26-0.85, p = 0.01).

CONCLUSIONS

Eating disorder symptoms precede GI consult for most patients, particularly in functional/motility disorders. As almost half of eating disorder patients are not in remission at GI consult. GI providers have an important role in screening for eating disorders. Further prospective research is needed to understand the complex relationship between eating disorders and GI symptoms.

A Bibliometric Analysis of the 50 Most Cited Articles on Body Contouring Surgery After Massive Weight Loss

BACKGROUND

Body contouring surgery after massive weight loss has emerged a safe and reliable option to improve self-esteem, social life, work ability, physical activity, and sexual activity, and it is considered as an essential step in the multidisciplinary approach to morbid obesity. In this study, we aim to provide a comprehensive overview of the current state of literature on body contouring after massive weight loss, identifying research trends and areas for future investigation.

METHODS

The Web of Science Core Collection was used to identify the 50 most cited publications on post-massive weight loss surgery. Data collected from each article included: title, journal, publication year, total citations, average citations per year, authors, study type, study topic, country, and institution of origin.

RESULTS

The top 50 most-cited articles include 44 original articles and 6 review articles. The most cited article, published by Lockwood in 1991, received a total of 224 citations. The research areas included surgical outcomes and complications (n=19, 38%), psychological aspects such as body image, quality of life and desire for body contouring procedures (n=18, 36%), surgical techniques (n=11, 22%), an anatomical study (n=1, 2%), and a classification system (n=1; 2%). Plastic and Reconstructive Surgery journal published most (44%) of the papers identified. The University of Pittsburgh was the single institution that contributed the most (n=11; 22%).

CONCLUSION

This bibliometric analysis provides insights and research trends for clinicians interested in body contouring after massive weight loss, facilitating the understanding and evolution of post-bariatric surgery and elucidating the rationale behind current practice.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Celiac Disease-Related Conditions: Who to Test?

Celiac disease (CeD) is a chronic immune-mediated condition triggered by gluten consumption in genetically predisposed individuals. Approximately 1% of the general population is affected by the disorder. Disease presentation is heterogeneous and, despite growing awareness among physicians and the public, it continues to be underestimated. The most effective strategy for identifying undiagnosed CeD is proactive case finding through serologic testing in high-risk groups. We reviewed the most recent evidence on the association between CeD and more than 20 conditions. In light of this review, CeD screening is recommended in individuals with (1) autoimmune disease and accompanying symptoms suggestive of CeD; (2) diseases that may mimic CeD (eg, irritable bowel syndrome [IBS], inflammatory bowel disease [IBD], and microscopic colitis); and (3) among patients with conditions with a high CeD prevalence: first-degree relatives, idiopathic pancreatitis, unexplained liver enzyme abnormalities, autoimmune hepatitis, primary biliary cholangitis, hyposplenism or functional asplenia with severe bacterial infection, type 1 diabetes mellitus, Hashimoto's thyroiditis and Graves' disease, Sjögren's syndrome, dermatitis herpetiformis, recurrent aphthous syndrome and enamel defects, unexplained ataxia, peripheral neuropathy, delayed menarche or premature menopause, Down syndrome, Turner syndrome, Williams syndrome, chronic fatigue syndrome, IgA nephropathy, and IgA deficiency. CeD serology should be the initial step in the screening process. However, for patients with any of the aforementioned disorders who are undergoing upper endoscopy, biopsies should be performed to rule out CeD.

Bariatric surgery stigma from the perspective of patients: A scoping review

AIMS

To explore the experiences and consequences of bariatric surgery stigma from the perspective of bariatric surgery patients and to identify knowledge gaps in the literature.

DESIGN

A scoping review.

DATA SOURCES

Studies published between December 2002 and January 2022 were identified from the following databases: PubMed, Web of Science, PsycINFO and MEDLINE.

REVIEW METHODS

We screened 3092 records and included 28 studies. Findings were grouped thematically using the health stigma discrimination framework.

RESULTS

Patients experienced several types of stigmas, including perceived, experienced, anticipated and internalized stigma, related to undergoing bariatric surgery. Patients were confronted with negative comments and judgement from others when they disclosed their decision to have surgery or when they revealed that they had undergone surgery. These experiences led to conflicts in the decision-making process, such as delaying the choice for surgery, seeking surgery abroad or opting out. Patients who internalized stigma often reported feelings of shame and embarrassment for choosing surgery and felt the need for secrecy or selective disclosure. Stigma experiences were influenced by gender and differed between different subgroups of patients.

CONCLUSION

The stigma surrounding bariatric surgery has detrimental consequences for eligible individuals and bariatric surgery patients. However, the evidence from patients' perspective remains limited. More research into patient's experiences is needed to improve patient care and further educate healthcare professionals. In addition, to better understand the nature and implications of bariatric surgery stigma, future research should be founded on stigma theories and distinguish between the different types of stigmas.

IMPACT

This scoping review contributes to a better understanding of the implications the stigma surrounding bariatric surgery has for bariatric surgery patients before and after surgery. The knowledge generated by this review can inform improvements in the education and management of people living with obesity and bariatric surgery patients.

REPORTING METHOD

The scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews checklist.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

PROTOCOL REGISTRATION

A protocol was not registered for this scoping review.

Utilizing Telemedicine Applications in Celiac Disease and Other Gluten-Free-Diet-Dependent Conditions: Insights from the COVID-19 Pandemic

BACKGROUND

Globally, approximately 1.4% of people have celiac disease (CD), induced by gluten sensitivity. If left untreated, it causes small intestinal inflammation and villous atrophy, which can result in failure to thrive, anemia, osteoporosis, malabsorption, and even malignancy. The only treatment option available is a gluten-free diet (GFD). Few studies have looked at the role and perception of telehealth in relation to CD and selective nutrition both before and after the COVID-19 pandemic.

AIM

Our goal was to screen and investigate the research conducted both before and after the COVID-19 pandemic concerning the utilization of telehealth applications and solutions in CD and other GFD-dependent circumstances.

METHODS

We employed a narrative review approach to explore articles that were published in scholarly journals or organizations between the years 2000 and 2024. Only English-language publications were included. PubMed and Google Scholar searches were mainly conducted using the following keywords: telemedicine, telehealth, telecare, eHealth, m-health, COVID-19, SARS-CoV-2, celiac disease, and gluten-free diet (GFD). Manual searches of the references in the acquired literature were also carried out, along with the authors' own personal contributions of their knowledge and proficiency in this field.

RESULTS

Only a few studies conducted prior to the COVID-19 outbreak examined the viewpoints and experiences of adult patients with CD with relation to in-person clinic visits, as well as other options such as telehealth. The majority of patients believed that phone consultations were appropriate and beneficial. Video conferencing and telemedicine became more popular during the COVID-19 pandemic, demonstrating the effectiveness of using these technologies for CD on a global basis. In recent years, urine assays for gluten identification have become accessible for use at home. These tests could be helpful for CD monitoring with telemedicine assistance.

CONCLUSIONS

The extended knowledge gathered from the COVID-19 pandemic is expected to complement pre-COVID-19 data supporting the usefulness of telemedicine even after the emergent pandemic, encouraging its wider adoption in standard clinical practice. The monitoring and follow-up of CD patients and other GFD-dependent conditions can greatly benefit from telemedicine.

The role of pediatricians in the diagnosis and management of IgE-mediated food allergy: a review

Importance

Food allergy can often cause a significant burden on patients, families, and healthcare systems. The complexity of food allergy management requires a multidisciplinary approach involving different types of healthcare providers, including allergists, dieticians, psychologists, nurses, family practitioners and, of particular relevance for this article, pediatric primary caretakers. Pediatricians may be the first-line healthcare providers for food allergy: strategies for management and guideline adherence have been highlighted.

Observations

This review article summarizes the up-to-date recommendations on the role of pediatricians in the diagnosis, management, and prevention of IgE-mediated food allergy. Early introduction of allergenic foods like peanut is known to be of importance to reduce the development of peanut allergy in infants, and pediatricians are essential for educating and supporting parents in this decision. In scenarios of limited allergist availability, as is often the case among rural, Medicaid and minority populations, pediatricians can assist in the evaluation and management of food allergy, and provide action plans, education and counselling for patients and families.

Conclusions and relevance

Pediatric primary caretakers play a key role in the diagnosis, management, and prevention of IgE-mediated food allergy. As more diagnostic tools and therapies in food allergy become available, the need for a multidisciplinary team is paramount to optimize patient care.

The Saudi Gastroenterology Association consensus on the clinical care pathway for the diagnosis and treatment of GERD

ABSTRACT

Gastroesophageal reflux disease (GERD) is one of the most common problems encountered in outpatient general medicine and gastroenterology clinics. GERD may present with classic esophageal symptoms, extraesophageal symptoms, or mixed symptoms. The diagnosis and treatment of GERD are challenging due to the variety of symptoms and multifactorial pathophysiology. Since there is no consensus on the diagnosis and treatment of GERD in Saudi Arabia, the Saudi Gastroenterology Association established an expert group to formulate a consensus on the clinical care pathway for the diagnosis and treatment of GERD to update health-care providers in Saudi Arabia. The expert group reviewed the literature including recently published international guidelines, clinical trials, and expert opinion and conducted virtual and in-person meetings. A total of 22 statements on the definition, diagnosis, and treatment of GERD were formulated, and three algorithms for the clinical care of GERD were developed with a detailed description for each step. The expert group endorsed the new definition of GERD, the practical principles of interpretation of the diagnostic GERD evaluation, and the practical guidance for GERD treatment including medical, surgical, and endoscopic therapy. The expert group recommends further studies to investigate local data on the diagnosis and treatment of GERD.

IgE to wheat, prick test, and Patch test among children with celiac disease

INTRODUCTION AND AIM

Celiac disease is one of the most common autoimmune disorders. This study aimed to evaluate the relationship between celiac disease and wheat sensitization.

SUBJECTS AND METHODS

In the current study, children aged < 18 years with confirmed celiac disease were included. Data were analyzed using SPSS.

RESULTS

Gastrointestinal problems were the most common indication for evaluation in terms of celiac disease. Prick and patch tests were positive in 43.4% and 34% respectively.

CONCLUSION

Prick test and patch test for wheat sensitization were positive in about 30-45% of the children for celiac disease.

Diabetes Is Associated with Worse Postoperative Mortality and Morbidity in Bariatric Surgery, Regardless of the Procedure

Background/Objectives: Bariatric surgery is a central cornerstone in obesity treatment. We aimed to assess the impact of diabetes on the postoperative outcomes of bariatric surgery and compare three techniques: sleeve gastrectomy, Roux-en-Y, and gastric banding. Methods: We extracted data from the National Inpatient Sample (2015-2019) using ICD codes. The primary outcome was postoperative mortality. Secondary outcomes were major bleeding, atrial fibrillation, and acute renal failure. Results: Among patients who underwent sleeve gastrectomy, diabetes was associated with a higher adjusted risk of mortality (aOR 2.07 [1.36-3.16]), atrial fibrillation, and acute renal failure, but a similar risk of bleeding. Among patients who underwent Roux-en-Y, diabetes did not increase mortality and bleeding risk. Still, it was associated with a higher risk of atrial fibrillation and acute renal failure. Among patients who underwent gastric banding, diabetes was only associated with a higher risk of bleeding. When comparing the three techniques in diabetes patients, Roux-en-Y was significantly associated with higher mortality and acute renal failure risk when compared to the other procedures. Bleeding was more common in Roux-en-Y than in Sleeve. Conclusions: In total, diabetes is associated with worse postoperative outcomes in bariatric surgery, regardless of the technique. Among diabetes patients, Roux-en-Y was associated with the highest mortality and morbidity.

Latent profile analysis reveals overlapping ARFID and shape/weight motivations for restriction in eating disorders

BACKGROUND

DSM-5 differentiates avoidant/restrictive food intake disorder (ARFID) from other eating disorders (EDs) by a lack of overvaluation of body weight/shape driving restrictive eating. However, clinical observations and research demonstrate ARFID and shape/weight motivations sometimes co-occur. To inform classification, we: (1) derived profiles underlying restriction motivation and examined their validity and (2) described diagnostic characterizations of individuals in each profile to explore whether findings support current diagnostic schemes. We expected, consistent with DSM-5, that profiles would comprise individuals endorsing solely ARFID or restraint (i.e. trying to eat less to control shape/weight) motivations.

METHODS

We applied latent profile analysis to 202 treatment-seeking individuals (ages 10-79 years [M = 26, s.d. = 14], 76% female) with ARFID or a non-ARFID ED, using the Nine-Item ARFID Screen (Picky, Appetite, and Fear subscales) and the Eating Disorder Examination-Questionnaire Restraint subscale as indicators.

RESULTS

A 5-profile solution emerged: Restraint/ARFID-Mixed (n = 24; 8% [n = 2] with ARFID diagnosis); ARFID-2 (with Picky/Appetite; n = 56; 82% ARFID); ARFID-3 (with Picky/Appetite/Fear; n = 40; 68% ARFID); Restraint (n = 45; 11% ARFID); and Non-Endorsers (n = 37; 2% ARFID). Two profiles comprised individuals endorsing solely ARFID motivations (ARFID-2, ARFID-3) and one comprising solely restraint motivations (Restraint), consistent with DSM-5. However, Restraint/ARFID-Mixed (92% non-ARFID ED diagnoses, comprising 18% of those with non-ARFID ED diagnoses in the full sample) endorsed ARFID and restraint motivations.

CONCLUSIONS

The heterogeneous profiles identified suggest ARFID and restraint motivations for dietary restriction may overlap somewhat and that individuals with non-ARFID EDs can also endorse high ARFID symptoms. Future research should clarify diagnostic boundaries between ARFID and non-ARFID EDs.

Effects of single-anastomosis duodenal-ileal bypass with sleeve gastrectomy on gut microbiota and glucose metabolism in rats with type 2 diabetes

Background

Bariatric and metabolic surgery often leads to significant changes in gut microbiota composition, indicating that changes in gut microbiota after bariatric and metabolic surgery might play a role in ameliorating type 2 diabetes (T2D). However, the effects of single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) on gut microbiota in T2D remain unclear.

Objectives

To investigate the effects of SADI-S on gut microbiota and glucose metabolism in T2D rats.

Methods

Nineteen T2D rats were randomly divided into the SADI-S group (n = 10) and the sham operation with pair-feeding group (sham-PF, n = 9). Fecal samples were collected to analyze the gut microbiota composition with 16S ribosomal DNA gene sequencing. The fasting blood glucose and glycated hemoglobin were measured to evaluate the effects of SADI-S on glucose metabolism.

Results

The Chao and ACE index results indicated the richness of the gut microbial community. The ACE and Chao index values were significantly lower in the SADI-S group than in the sham-PF group, indicating that indicating that species richness was significantly lower in the SADI-S group than in the sham-PF group (p < 0.05). Shannon and Simpson indices were used to estimate the species diversity of the gut microbiota. Compared with the sham-PF group, the SADI-S group showed significantly lower Shannon index and higher Simpson index values, indicating that the species diversity was significantly lower in the SADI-S group than in the sham-PF group (p < 0.05). At the genus level, SADI-S significantly changed the abundances of 33 bacteria, including the increased anti-inflammatory bacteria (Akkermansia and Bifidobacterium) and decreased pro-inflammatory bacteria (Bacteroides). SADI-S significantly decreased the fasting blood glucose and glycated hemoglobin levels. The blood glucose level of rats was positively correlated with the relative abundances of 12 bacteria, including Bacteroides, and negatively correlated with the relative abundances of seven bacteria, including Bifidobacterium.

Conclusion

SADI-S significantly altered the gut microbiota composition of T2D rats, including the increased anti-inflammatory bacteria (Akkermansia and Bifidobacterium) and decreased pro-inflammatory bacteria (Bacteroides). The blood glucose level of rats was positively correlated with the abundances of 12 bacteria, including Bacteroides, but negatively correlated with the relative abundance of 7 bacteria, including Bifidobacterium. These alternations in gut microbiota may be the mechanism through which SADI-S improved T2D. More studies should be performed in the future to validate these effects.

Revision of restrictive bariatric procedures in elderly patients: results at a 5-year follow-up

Revisional Bariatric Surgery (RBS) is increasing in popularity. Elderly patients (> 65 years old) are sometimes referred for RBS evaluation. The aim of this study is to evaluate outcomes of elderly patients undergoing RBS. A retrospective analysis of a cohort from a single-tertiary bariatric center. All elderly patients undergoing RBS after restrictive procedures between 2012 and 2022 were included. Thirty Nine patients undergoing RBS were included in the comparative analysis - 23 patients (57.5%) after adjustable gastric banding (s/p LAGB) and 16 patients (40%) after Sleeve Gastrectomy (s/p SG). The mean age and body mass index (BMI) of patients were comparable (67.2 ± 2.8 years and 38.3 ± 7.4, respectively). There was no difference in associated medical problems except reflux which was higher in s/p SG (68% vs. 13%; p < 0.001). The mean time interval between surgeries was 8.7 ± 5.1 years. The surgeries included One anastomosis gastric bypass (n = 22), SG (n = 8) and Roux-en-y gastric bypass (n = 9). Early major complication rates were comparable (4.3% and 12.5%; p = 0.36), and readmission rate was higher in patients s/p SG (p = 0.03). Ninety percent of patients were available to a follow-up of 59.8 months. The mean BMI and total weight loss was 29.2 and 20.3%, respectively with no difference between groups. The rate of patients with associated medical problems at last follow-up was significantly reduced. Five patients (12.5%) underwent revisional surgery due to complications during follow-up. In conclusion, RBS in the elderly is associated with a reasonable complication rate and is effective in terms of weight loss and improvement of associated medical problems in a 5-year follow-up.

Challenges of Revisional Metabolic and Bariatric Surgery: A Comprehensive Guide to Unraveling the Complexities and Solutions of Revisional Bariatric Procedures

Revisional metabolic and bariatric surgery (RMBS) presents unique challenges in addressing weight loss failure or complications arising from initial bariatric procedures. This review aims to explore the complexities and solutions associated with revisional bariatric procedures comprehensively, offering insights into the evolving terrain of metabolic and bariatric surgery. A literature review is conducted to identify pertinent studies and expert opinions regarding RMBS. Methodological approaches, patient selection criteria, surgical techniques, preoperative assessments, and postoperative management strategies are synthesized to provide a comprehensive overview of current practices and advancements in the field, including institutional protocols. This review synthesizes key findings regarding the challenges encountered in RMBS, including the underlying causes of primary procedure failure, anatomical complexities, technical considerations, and assessments of surgical outcomes. Additionally, patient outcomes, complication rates, and long-term success are presented, along with institutional approaches to patient assessment and procedure selection. This review provides valuable insights for clinicians grappling with the complexities of RMBS. A comprehensive understanding of patient selection, surgical techniques, preoperative management, and postoperative care is crucial for enhancing outcomes and ensuring patient satisfaction in the field of metabolic bariatric surgery.

Long-Term Differential Effects of Gastric Bypass and Sleeve Gastrectomy on Bone Mineral Density

Context

The association of obesity with bone fragility fractures is complex and non-linear. Despite good efficacy on weight loss, bariatric surgery (BS) is also associated with bone loss. However, we lack information on risk factors of the long-term deleterious effects of BS on the skeleton.

Objective

We aimed to assess the factors associated with low bone mineral density (BMD) performed a long time after Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG).

Methods

This cross-sectional study involved patients at a long distance from their BS that underwent dual-energy x-ray absorptiometry (DXA) with biological factors (vitamins, micronutrients, bone and inflammation biomarkers). Simple and multiple linear models (stepwise and parsimony approach) were developed.

Results

A total of 131 patients (91 RYGB, 40 SG) underwent DXA (51.8 ± 11.08 years, 87.8% women). At a mean of 6.8 ± 3.7 years after surgery, the mean weight loss was -28.6 ± 9.6%, and only 6 patients (5.7%) had a T-score less than or equal to -2.5. On univariate analysis, BMD was lower in the RYGB than in the SG group (P < .001) at all sites, despite similar fat and fat-free mass and weight loss. Serum parathyroid hormone and phosphate levels were higher in RYGB than SG patients. A total of 10.1% of patients showed vascular calcifications. On multivariable analysis, BMD remained different between surgery groups after adjustment for age, body mass index, ethnicity, and sex. The model-adjusted R 2 values were 0.451 for the total hip; 0.462 the femoral neck, and 0.191 the lumbar spine for the inflammation model; 0.458, 0.462, and 0.254, respectively, for the bone marker model; and 0.372, 0.396, and 0.142 for the vitamin model. Serum zinc, ferritin, and uric acid levels were the markers associated with BMD to a low extent.

Conclusion

BMD differed depending on the BS procedure. A few biological markers may be associated weakly with BMD well after the surgery.

Understanding preferences of patients with obesity for metabolic bariatric surgery: a comprehensive adaptive choice-based conjoint analysis

BACKGROUND

Patient preferences toward metabolic bariatric surgery (MBS) remain inadequately explored.

OBJECTIVE

This study aims to identify and analyze the key factors influencing the decision-making process of patients considering MBS.

SETTING

The research was conducted at the metabolic bariatric surgery clinic of the Medical Research Institute Hospital, Alexandria University, Egypt.

METHOD

Patients with obesity were recruited at the clinic before MBS. The surgical profiles were characterized by attributes including treatment method, recovery and reversibility, treatment tenure, expected weight loss, impact on associated medical problems, risk of complication, side effects, dietary changes, and out-of-pocket costs. Patients engaged in an online survey comprising sociodemographic data, Build Your Own (BYO) section, screening section, and choice tournament section. Adaptive choice-based conjoint analysis was employed to discern the preferences.

RESULTS

Of the 299 respondents, the surgical profiles with the highest preference involved a loss of 80% of excess weight without any recurrence (14.67 [95% CI, 14.10-15.23]), 0% risk of complication (13.74 [95% CI, 13.03-14.45]), and absence of adverse effects (11.32 [95% CI, 10.73-11.91]). K-mean cluster analysis identified 2 distinct groups: "patients prioritize weight loss" group prioritized excess weight loss, surgery availability, and diet change, whereas "patients prioritize avoidance of complications" group focused on the risk of complication, adverse effects, and the surgery mechanism.

CONCLUSIONS

MBS candidates predominantly value weight loss without recurrence, followed by minimization of complication risks and adverse effects, within 3 years postsurgery. Conversely, initial out-of-pocket costs and resolution of medical conditions were deemed the least influential attributes.

Sensitization to Food and Aero-Allergens in Children with Coeliac Disease Assessed with the Use of a Multiplex Molecular Diagnostic Technique

(1) Background. Coeliac disease (CD) often co-occurs with autoimmune conditions or genetic syndromes, but there are few studies on the co-existence of CD and immunoglobulin E (IgE)-mediated allergies. The purpose of this study was to assess sensitization to food and aero-allergens in pediatric patients with CD. (2) Methods. A multiplex ALEX®2 test was used to determine specific IgEs (sIgEs). (3) Results. The study included 108 children newly diagnosed with CD. Allergen extract- and/or allergen molecule-sIgEs were detected in 49.1% of children. Most children (41.5%) were sensitized to both inhalant and food allergens. The three most common aero-allergens (timothy pollen, ryegrass, silver birch) were molecules Phl p 1, Lol p 1, and Bet v 1. The most common food allergens (hazelnut, apple, and peanut) were Cor a 1, Mal d 1, and Ara h 8 molecules of the PR-10 subfamily. Patients were not sensitized to cereal allergens containing gluten. Spearman's rank correlation analysis of sensitized patients showed a significant positive relationship (r = 0.31) between the patients' age and the occurrence of positive sIgEs (≥0.3 kUA/L) for inhalant allergen molecules (p = 0.045). In sensitized patients, mainly symptoms of inhalant allergy were observed, such as hay fever, conjunctivitis, and bronchial asthma. (4) Conclusions. The current study indicates the co-occurrence of IgE sensitization to food and inhalant allergens in children with CD. The study highlights the need to take a closer look at the diagnosis of IgE-mediated allergy in patients with CD, which may help in their care and lead to a better understanding of the relationship between CD and IgE-mediated allergy.

The Efficacy and Safety of Endoscopic Balloon Dilatation in the Treatment of Functional Post-Sleeve-Gastrectomy Stenosis

Background and Objectives: Functional gastric stenosis, a consequence of sleeve gastrectomy, is defined as a rotation of the gastric tube along its longitudinal axis. It is brought on by gastric twisting without the anatomical constriction of the gastric lumen. During endoscopic examination, the staple line is deviated with a clockwise rotation, and the stenosis requires additional endoscopic manipulations for its transposition. Upper gastrointestinal series show the gastric twist with an upstream dilatation of the gastric tube in some patients. Data on its management have remained scarce. The objective was to assess the efficacy and safety of endoscopic balloon dilatation in the management of functional post-sleeve gastrectomy stenosis. Patients and Methods: Twenty-two patients with functional post-primary-sleeve-gastrectomy stenosis who had an endoscopic balloon dilatation between 2017 and 2023 were included in this retrospective study. Patients with alternative treatment plans and those undergoing endoscopic dilatation for other forms of gastric stenosis were excluded. The clinical outcomes were used to evaluate the efficacy and safety of balloon dilatation in the management of functional gastric stenosis. Results: A total of 45 dilatations were performed with a 30 mm balloon in 22 patients (100%), a 35 mm balloon in 18 patients (81.82%), and a 40 mm balloon in 5 patients (22.73%). The patients' clinical responses after the first balloon dilatation were a complete clinical response (4 patients, 18.18%), a partial clinical response (12 patients, 54.55%), and a non-response (6 patients, 27.27%). Nineteen patients (86.36%) had achieved clinical success at six months. Three patients (13.64%) who remained symptomatic even after achieving the maximal balloon dilation of 40 mm were considered failure of endoscopic dilatation, and they were referred for surgical intervention. No significant adverse events were found during or following the balloon dilatation. Conclusions: Endoscopic balloon dilatation is an effective and safe minimally invasive procedure in the management of functional post-sleeve-gastrectomy stenosis.

National trends in nine key minerals intake (quantity and source) among U.S. adults, 1999 to march 2020

BACKGROUND

Changes in economy and dietary guidelines brought a great shock to diet quality and meal behaviors, but if these transformations have extended to minerals intake and their sources was still poorly understood. It is essential to evaluate time trends in minerals intake and their sources to inform policy makers.

OBJECTIVE

To investigate trends in minerals intake and their sources among U.S. adults.

METHODS

This analysis used dietary data collected by 24-h recalls from U.S. adults (≥ 20 years) in NHANES (1999-March 2020). Minerals intake, age-adjusted percentage of participants meeting recommendations, and minerals sources were calculated among all participants and by population subgroups in each NHANES survey cycle. Weighted linear or logistic regression models were used to examine the statistical significance of time trends.

RESULTS

A total of 48223 U.S. adults were included in this analysis. From 1999 to March 2020, intake of calcium (from 0.94 to 1.02 g/day), magnesium (from 308.07 to 321.85 mg/day), phosphorus (from 1.24 to 1.30 g/day), and sodium (from 3.24 to 3.26 mg/day) from food and beverages (FB) and dietary supplements (DSs) significantly increased, and intake of iron (from 19.17 to 16.38 mg/day), zinc (from 16.45 to 14.19 mg/day), copper (from 1.79 to 1.38 mg/day), and potassium (from 2.65 to 2.50 g/day) from FB + DSs decreased (all FDR < 0.05). Additionally, age-adjusted percentage of participants meeting recommendations for calcium, phosphorus, sodium, and selenium significantly increased, that for iron, potassium, zinc, and copper decreased (all FDR < 0.05). Minerals intake and time trends in minerals intake were highly variable depending on age, gender, race/ethnicity, education, and income. For example, white, higher socioeconomic status participants had a higher minerals intake (e.g. iron, zinc, and copper), but had a greater decrease in minerals intake. Furthermore, the percentage of minerals from milks and DSs decreased, and that from beverages increased.

CONCLUSION

From 1999 to March 2020, both minerals intake and their sources experienced a significant alteration among U.S. adults. Many differences in minerals intake and their food sources across sociodemographic characteristics appeared to narrow over time. Although some improvements were observed, important challenges, such as overconsumption of sodium and underconsumption of potassium, calcium, and magnesium, still remained among U.S. adults.

Establishment of a novel weight reduction model after laparoscopic sleeve gastrectomy based on abdominal fat area

In light of ongoing research elucidating the intricacies of obesity and metabolic syndrome, the role of abdominal fat (especially visceral fat) has been particularly prominent. Studies have revealed that visceral adipose tissue can accelerate the development of metabolic syndrome by releasing various bioactive compounds and hormones, such as lipocalin, leptin and interleukin. A retrospective analysis was performed on the clinical data of 167 patients with obesity. Among them, 105 patients who satisfied predefined inclusion and exclusion criteria were included. The parameters evaluated included total abdominal fat area (TAFA), laboratory indicators and anthropometric measurements. Weight reduction was quantified through percent total weight loss (%TWL) and percent excess weight loss (%EWL) postoperatively. Binary logistic regression analysis and receiver operating characteristic (ROC) curve analysis were employed to identify predictors of weight loss. Binary logistic regression analysis emphasized that total abdominal fat area was an independent predictor of %EWL ≥75% (p < 0.001). Total abdominal fat area (p = 0.033) and BMI (p = 0.003) were independent predictors of %TWL ≥30%. In our cohort, %TWL ≥30% at 1 year after surgery was closely related to the abdominal fat area and BMI. Based on these results, we formulated a novel model based on these factors, exhibiting superior predictive value for excellent weight loss.