Consensus practice recommendations for management of gastrointestinal dysfunction in Parkinson disease

BACKGROUND

Gastrointestinal (GI) dysfunction is a common non-motor feature of Parkinson disease (PD). GI symptoms may start years before the onset of motor symptoms and impair quality of life. Robust clinical trial data is lacking to guide screening, diagnosis and treatment of GI dysfunction in PD.

OBJECTIVE

To develop consensus statements on screening, diagnosis, and treatment of GI dysfunction in PD.

METHODS

The application of a modified Delphi panel allowed for the synthesis of expert opinions into clinical statements. Consensus was predefined as a level of agreement of 100 % for each item. Five virtual Delphi rounds were held. Two movement disorders neurologists reviewed the literature on GI dysfunction in PD and developed draft statements based on the literature review. Draft statements were distributed among the panel that included five movement disorder neurologists and two gastroenterologists, both experts in GI dysmotility and its impact on PD symptoms. All members reviewed the statements and references in advance of the virtual meetings. In the virtual meetings, each statement was discussed, edited, and a vote was conducted. If there was not 100 % consensus, further discussions and modifications ensued until there was consensus.

RESULTS

Statements were developed for screening, diagnosis, and treatment of common GI symptoms in PD and were organized by anatomic segments: oral cavity and esophagus, stomach, small intestine, and colon and anorectum.

CONCLUSIONS

These consensus recommendations offer a practical framework for the diagnosis and treatment of GI dysfunction in PD.

[Nutrition (therapy) in gastrointestinal failure]

BACKGROUND

The presence of gastrointestinal dysfunction is an outcome-relevant complication in critically ill ICU patients.

AIMS, MATERIALS AND METHODS

The following review aims to show the importance of gastrointestinal dysfunction. Multimodal therapy for gastroparesis and paralytic ileus is discussed.

CONCLUSION

Erythromycin and metoclopramide are options for gastroparesis, while neostigmine is commonly used for paralytic ileus.

Electroacupuncture ameliorates gastrointestinal dysfunction by modulating DMV cholinergic efferent signals to drive the vagus nerve in p-MCAO rats

Background

The use of proton pump inhibitors in the acute phase of cerebral infarction may lead to adverse long-term outcomes, this study aims to explore the potential of electroacupuncture (EA) in replacing omeprazole in exerting post-stroke gastrointestinal protection.

Methods

A permanent middle cerebral artery infarction model was established using the modified Longa thread occlusion technique. Gastrointestinal motility, gastrointestinal mucosal damage, cerebral infarct volume, and alterations in choline acetyltransferase (ChAT)-positive neurons within the dorsal motor nucleus of the vagus nerve (DMV) were assessed after 7 days of EA at Zusanli (ST36) or omeprazole intervention. To evaluate the role of the vagal nerve in mitigating post-stroke gastrointestinal dysfunction, we employed subdiaphragmatic vagotomy and the ChAT-specific inhibitor α-NETA. Additionally, we utilized methyllycaconitine (MLA), a selective inhibitor of the α7-type nicotinic acetylcholine receptor (α7nAChR), and PNU282987, an agonist, to identify the target of EA.

Results

EA restored ChAT neurons lost in the DMV, activated the vagus nerve and conferred cerebroprotection while ameliorating gastrointestinal mucosal injury and gastrointestinal motility disorders. In addition, following the administration of the α7nAChR antagonist, the attenuation of gastric mucosal injury and inflammatory factors induced by EA was hindered, although gastrointestinal motility still exhibited improvement.

Conclusion

EA at ST36 promotes the restoration of cholinergic signaling in the DMV of stroke-afflicted rats, and its excitation of the vagal nerve inhibits gastrointestinal inflammation after stroke via α7nAChR, while improvement in gastrointestinal motility could be mediated by other acetylcholine receptors.

Clinical study of electroacupuncture on the recovery of gastrointestinal dysfunction after laparoscopic surgery for gastrointestinal cancer - study protocol for a randomized controlled trial

BACKGROUND

Gastrointestinal dysfunction is one of the common complaints for patient post-surgery. Acupuncture has been employed to improve gastrointestinal function and sleeping quality and has confirmed clinical efficacy for emotional problems. This study aims to evaluate the clinical effect of electroacupuncture for postoperative rapid recovery.

METHODS

This study design is a two-arm, parallel, double-blinded randomized controlled trial. 104 subjects, aged from 40 to 89 years old, diagnosed with gastrointestinal cancer undergoing laparoscopic surgery, will be divided into Interventional Group and Control Group. Patients of both groups receive perioperative care under the guidance of ERAS guidance. The Interventional Group receives electroacupuncture treatment starting from the first day post-surgery for a consecutive 5 days, whereas the Control Group receives placebo electroacupuncture treatment. The primary outcome will be the first flatus time whereas the secondary outcomes will be the first sign of borborygmus, recovery of defecation, laboratory tests and questionnaires including Self-rating anxiety scale, Ford Insomnia Response to Stress Test, TCM rating scale of Gastrointestinal symptoms and Gastrointestinal Symptoms Rating Scales.

DISCUSSION

This study aims to provide timely intervention for post-laparoscopic patients with gastrointestinal tumour using the ERAS concept combined with electroacupuncture, observe the efficacy of this therapy in treating PGID, and contribute reliable scientific evidence for postoperative rapid recovery.

TRIAL REGISTRATION

Chictr.org.cn Identifier: ChiCTR2300078710. Registered on 15th December 2023.

Prediction of mechanical ventilation outcome by early abdominal-visceral-blood-flow-and-function score in critically ill patients after cardiopulmonary bypass in the ICU: A prospective observational study

Background

Abdominal organs are important organs that sense and respond to ischemia and hypoxia, but there are few evaluation methods.We use ultrasonography to evaluate abdominal organ function and blood flow in patients with mechanical ventilation (MV) after cardiopulmonary bypass and to obtain a semiquantitative score for abdominal organ function and blood flow.

Methods

Patients with cardiopulmonary bypass in the Critical Care Department of Peking Union Medical College Hospital in China from March to July 2021 were enrolled in this prospective observational study. The correlation of the abdominal-visceral-blood-flow-and-function score (AVBFS) with the duration of MV, number of days spent in the intensive care unit (ICU), acute physiology and chronic health evaluation II (APACHE-II), sequential organ failure assessment (SOFA), lactate, epinephrine, and norepinephrine use was analyzed, and the results were used to assess the predictive value of the receiver operating characteristic curve (ROC) regression analysis score for the duration of MV.

Results

Of the 92 patients who underwent cardiopulmonary bypass, 41 were finally included. The AVBFS were significantly correlated with the duration of MV, number of days spent in the ICU, APACHE-II score, SOFA score, and norepinephrine use time. The AVBFS in a group of patients using ventilators ≥36 h were significantly higher than those obtained for a group of patients using ventilators <36 h (P <0.05). The evaluation results for the AVBFS at 0-12 h after ICU admission were as follows: area under the ROC curve (AUC)=0.876 (95% confidence interval [CI]: 0.767 to 0.984), cut-off value=2.5, specificity=0.842, and sensitivity=0.773.

Conclusions

Abdominal visceral organ function and blood perfusion can be used to evaluate gastrointestinal function. It is related to early and late extubation after cardiac surgery.

Zuojin pill improves chronic unpredictable stress-induced depression-like behavior and gastrointestinal dysfunction in mice via the theTPH2/5-HT pathway

BACKGROUND

The complex bidirectional communication between the gastrointestinal tract and the brain is associated with mental disorders such as depression; serotonin, as a crucial neurotransmitter in the communication system between the central nervous system and the gastrointestinal tract, has effects on regulating gastrointestinal motility and sensation and improving psychosomatic status. Zuojin pill is used as a traditional Chinese medicine formula for the treatment of gastrointestinal disorders. This study explored the effects of Zuojin pill on the improvement of depression and gastrointestinal function in CUMS mice via TPH2 and its mechanism.

PURPOSE

The aim of this study was to investigate whether Zuojin pill could improve depression and concomitant gastrointestinal dysfunction, and to reveal whether Zuojin pill could work through the regulation of the tryptophan hydroxylase 2 (TPH2) pathway.

METHODS

The CUMS model was established to observe the effects of Zuojin pill on depression-like behavior and gastrointestinal function in mice. Nissler staining and HE staining were used to observe the structure of hippocampal neurons and intestinal mucosa respectively. 5-HT levels in serum, hippocampus, and intestinal tissues were measured by ELISA, and TPH2 expression in hippocampus and intestinal nerves was observed by WB and immunofluorescence. In order to investigate the protective effect and mechanism of Zuojin pill on PC12 cells, CORT used an in vitro model to produce PC12 cell damage.

RESULTS

Our study showed that Zuojin pill ameliorated depression-like behavior and gastrointestinal dysfunction in CUMS mice, elevated BDNF, 5-HT, and TPH2 expression in the hippocampus, and restored the ratio of dopaminergic and GABAergic neurons between intestinal muscles. In vitro experiments showed that Zuojin pill exerted a protective effect on neurons by regulating TPH2 ubiquitination and thus inhibiting CORT-induced apoptosis of PC12 cells.

CONCLUSION

Zuojin pill improves chronic unpredictable stress-induced depression-like behavior and gastrointestinal dysfunction in mice via the TPH2/5-HT pathway. Therefore, TPH2 may be a potential therapeutic target for depression with gastrointestinal dysfunction.

International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction

INTRODUCTION AND HYPOTHESIS

This manuscript from Chapter 2 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature involving the clinical evaluation of a patient with POP and associated bladder and bowel dysfunction.

METHODS

An international group of 11 clinicians performed a search of the literature using pre-specified search MESH terms in PubMed and Embase databases (January 2000 to August 2020). Publications were eliminated if not relevant to the clinical evaluation of patients or did not include clear definitions of POP. The titles and abstracts were reviewed using the Covidence database to determine whether they met the inclusion criteria. The manuscripts were reviewed for suitability using the Specialist Unit for Review Evidence checklists. The data from full-text manuscripts were extracted and then reviewed.

RESULTS

The search strategy found 11,242 abstracts, of which 220 articles were used to inform this narrative review. The main themes of this manuscript were the clinical examination, and the evaluation of comorbid conditions including the urinary tract (LUTS), gastrointestinal tract (GIT), pain, and sexual function. The physical examination of patients with pelvic organ prolapse (POP) should include a reproducible method of describing and quantifying the degree of POP and only the Pelvic Organ Quantification (POP-Q) system or the Simplified Pelvic Organ Prolapse Quantification (S-POP) system have enough reproducibility to be recommended. POP examination should be done with an empty bladder and patients can be supine but should be upright if the prolapse cannot be reproduced. No other parameters of the examination aid in describing and quantifying POP. Post-void residual urine volume >100 ml is commonly used to assess for voiding difficulty. Prolapse reduction can be used to predict the possibility of postoperative persistence of voiding difficulty. There is no benefit of urodynamic testing for assessment of detrusor overactivity as it does not change the management. In women with POP and stress urinary incontinence (SUI), the cough stress test should be performed with a bladder volume of at least 200 ml and with the prolapse reduced either with a speculum or by a pessary. The urodynamic assessment only changes management when SUI and voiding dysfunction co-exist. Demonstration of preoperative occult SUI has a positive predictive value for de novo SUI of 40% but most useful is its absence, which has a negative predictive value of 91%. The routine addition of radiographic or physiological testing of the GIT currently has no additional value for a physical examination. In subjects with GIT symptoms further radiological but not physiological testing appears to aid in diagnosing enteroceles, sigmoidoceles, and intussusception, but there are no data on how this affects outcomes. There were no articles in the search on the evaluation of the co-morbid conditions of pain or sexual dysfunction in women with POP.

CONCLUSIONS

The clinical pelvic examination remains the central tool for evaluation of POP and a system such as the POP-Q or S-POP should be used to describe and quantify. The value of investigation for urinary tract dysfunction was discussed and findings presented. The routine addition of GI radiographic or physiological testing is currently not recommended. There are no data on the role of the routine assessment of pain or sexual function, and this area needs more study. Imaging studies alone cannot replace clinical examination for the assessment of POP.

Understanding the potential causes of gastrointestinal dysfunctions in multiple system atrophy

Multiple system atrophy (MSA) is a rare, progressive neurodegenerative disorder characterised by autonomic, pyramidal, parkinsonian and/or cerebellar dysfunction. Autonomic symptoms of MSA include deficits associated with the gastrointestinal (GI) system, such as difficulty swallowing, abdominal pain and bloating, nausea, delayed gastric emptying, and constipation. To date, studies assessing GI dysfunctions in MSA have primarily focused on alterations of the gut microbiome, however growing evidence indicates other structural components of the GI tract, such as the enteric nervous system, the intestinal barrier, GI hormones, and the GI-driven immune response may contribute to MSA-related GI symptoms. Here, we provide an in-depth exploration of the physiological, structural, and immunological changes theorised to underpin GI dysfunction in MSA patients and highlight areas for future research in order to identify more suitable pharmaceutical treatments for GI symptoms in patients with MSA.

Involvement of Abnormal p-α-syn Accumulation and TLR2-Mediated Inflammation of Schwann Cells in Enteric Autonomic Nerve Dysfunction of Parkinson's Disease: an Animal Model Study

The study was designed to investigate the pathogenesis of gastrointestinal (GI) impairment in Parkinson's disease (PD). We utilized 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP, 20 mg/kg) and probenecid (250 mg/kg) to prepare a PD mice model. MPTP modeling was first confirmed. GI motility was measured using stool collection test and enteric plexus loss was also detected. Intestinal phosphorylated α-synuclein (p-α-syn), inflammation, and S100 were assessed using western blotting. Association between Toll-like receptor 2(TLR2) and GI function was validated by Pearson's correlations. Immunofluorescence was applied to show co-localizations of intestinal p-α-syn, inflammation, and Schwann cells (SCs). CU-CPT22 (3 mg/kg, a TLR1/TLR2 inhibitor) was adopted then. Success in modeling, damaged GI neuron and function, and activated intestinal p-α-syn, inflammation, and SCs responses were observed in MPTP group, with TLR2 related to GI damage. Increased p-α-syn and inflammatory factors were shown in SCs of myenteron for MPTP mice. Recovered fecal water content and depression of inflammation, p-α-syn deposition, and SCs activity were noticed after TLR2 suppression. The study investigates a novel mechanism of PD GI autonomic dysfunction, demonstrating that p-α-syn accumulation and TLR2 signaling of SCs were involved in disrupted gut homeostasis and treatments targeting TLR2-mediated pathway might be a possible therapy for PD.

Association between Gastrointestinal Dysfunction Score (GIDS) and disease severity and prognosis in critically ill patients: A prospective, observational study

OBJECTIVES

Recently, the Gastrointestinal Dysfunction Score (GIDS) was developed for use with critically ill patients. This study evaluated the association of GIDS with disease severity and clinical outcomes to assess the technical feasibility of using GIDS to reflect the severity and short-term prognosis of critically ill patients.

METHODS

Association between Gastrointestinal Dysfunction Score (GIDS) and disease severity and prognosis in critically ill patients: A prospective, observational study. This was a prospective observational study involving adult patients in two Intensive Care Units (ICUs). During the first seven days of ICU admission, GIDS, acute gastrointestinal injury (AGI), Acute Physiology and Chronic Health Evaluation II (APACHE II), and Sequential Organ Failure Assessment (SOFA) scores were assessed daily.

RESULTS

A total of 276 patients from two centers were enrolled in this study. Patients were divided into GIDS 0-1 (121, 43.8%) and GIDS 2-4 (155, 56.2%). The ICU length of stay and 28-day mortality in the GIDS 2-4 group were significantly higher than the GIDS 0-1 group (P = 0.032, P = 0.001, respectively). The APACHE II and SOFA scores in the GIDS 2-4 group were also significantly higher (P < 0.001). The ROC curves of GIDS, AGI, APACHE II, and SOFA scores on the first day of ICU admission for the prediction of 28-day mortality showed that the AUC of GIDS was 0.702 (95%CI 0.628, 0.775; P < 0.001). The AUC for GIDS + SOFA was 0.719 (95%CI 0.648, 0.790; P < 0.001), compared with SOFA alone (AUC = 0.703), showing improved predictive power for 28-day mortality.

CONCLUSIONS

GIDS represents a step toward a reliable clinical tool for GI dysfunction to assess disease severity and short-term prognosis in critically ill patients. In addition, combining GIDS with SOFA score may better predict mortality risk compared to SOFA score alone.

Sex differences in gastrointestinal dysfunction among patients with Parkinson’s disease

BACKGROUND AND OBJECTIVE

Sex differences in gastrointestinal dysfunction have not been systematically analyzed in patients with Parkinson's disease (PD). This study was aimed to investigate the sex differences in gastrointestinal dysfunctions among the patients with PD using a multicenter trial dataset.

METHODS

We analyzed the baseline data of prospectively enrolled set of patients with gastrointestinal dysfunctions. Possible sex differences in gastrointestinal symptoms assessed on the Nepean Dyspepsia Index-Korean Version (NDI-K), gastrointestinal symptom diary, and Bristol stool scale were analyzed in association with clinical PD severity and antiparkinsonian drug dosages by multiple linear regression models. We also performed post hoc analysis of the dyspepsia symptom sub-items, adjusting for multiple comparisons.

RESULTS

Sixty-six of the 144 participants were female (45.8%). There were no differences in age, PD duration, Hoehn and Yahr stage, and daily dopaminergic medication dosages between sexes. NDI-K symptom and dyspepsia scores were correlated with the activity of daily living in females but not in males. In the multiple regression analysis controlling for all possible variables, female patients were shown to have worse gastrointestinal symptoms than males. When we performed post hoc analysis of the dyspepsia symptoms, inability to finish a regular meal and nausea were significantly worse in female patients. Gastrointestinal symptom diary supported that female patients more frequently complained of early fullness and bloating in the upper abdomen after meals than males, and burning pain in upper abdomen was more severe in female patients.

CONCLUSION

Gastrointestinal dysfunctions may differentially affect female and male PD patients.

Gastrointestinal dysfunction is associated with mortality in severe burn patients: a 10-year retrospective observational study from South China

BACKGROUND

Data on severe and extensive burns in China are limited, as is data on the prevalence of a range of related gastrointestinal (GI) disorders [such as stress ulcers, delayed defecation, opioid-related bowel immotility, and abdominal compartment syndrome (ACS)]. We present a multicentre analysis of coincident GI dysfunction and its effect on burn-related mortality.

METHODS

This retrospective analysis was conducted on patients with severe [≥ 20% total burn surface area (TBSA)] and extensive (> 50% TBSA or > 25% full-thickness TBSA) burns admitted to three university teaching institutions in China between January 1, 2011 and December 31, 2020. Both 30- and 90-day mortality were assessed by collating demographic data, burn causes, admission TBSA, % full-thickness TBSA, Baux score, Abbreviated Burn Severity Index (ABSI) score, and Sequential Organ Failure Assessment (SOFA) score, shock at admission and the presence of an inhalation injury. GI dysfunction included abdominal distension, nausea/vomiting, diarrhoea/constipation, GI ulcer/haemorrhage, paralytic ileus, feeding intolerance and ACS. Surgeries, length of intensive care unit (ICU) stay, pain control [in morphine milligram equivalents (MME)] and overall length of hospital stay (LOHS) were recorded.

RESULTS

We analyzed 328 patients [75.6% male, mean age: (41.6 ± 13.6) years] with a median TBSA of 62.0% (41.0-80.0%); 256 (78.0%) patients presented with extensive burns. The 90-day mortality was 23.2% (76/328), with 64 (84.2%) of these deaths occurring within 30 d and 25 (32.9%) occurring within 7 d. GI dysfunction was experienced by 45.4% of patients and had a significant effect on 90-day mortality [odds ratio (OR) = 14.070, 95% confidence interval (CI) 5.886-38.290, P < 0.001]. Multivariate analysis showed that GI dysfunction was associated with admission SOFA score and % full-thickness TBSA. Overall, 88.2% (67/76) of deceased patients had GI dysfunction [hazard ratio (HR) for death of GI dysfunction = 5.951], with a survival advantage for functional disorders (diarrhoea, constipation, or nausea/vomiting) over GI ulcer/haemorrhage (P < 0.001).

CONCLUSION

Patients with severe burns have an unfavourable prognosis, as nearly one-fifth died within 90 d. Half of our patients had comorbidities related to GI dysfunction, among which GI ulcers and haemorrhages were independently correlated with 90-day mortality. More attention should be given to severe burn patients with GI dysfunction.

应用近红外光谱技术监测脓毒症患儿胃肠功能障碍的前瞻性研究

OBJECTIVES

To investigate the incidence and mortality of gastrointestinal dysfunction in children with sepsis, the application of near-infrared spectroscopy (NIRS) in monitoring mesenteric regional tissue oxygen saturation (rSO₂), and the association between rSO₂ and gastrointestinal dysfunction.

METHODS

In this prospective study, 79 children with sepsis in the pediatric intensive care unit (sepsis group) and 40 children who underwent physical examination in the Department of Child Healthcare (healthy control group) from January to December, 2021 were enrolled as subjects. The related medical data were collected, including general information on admission and at discharge, treatment during hospitalization, and laboratory examination results. NIRS was used to measure mesenteric rSO₂. Clinical characteristics were compared between the patients with and without gastrointestinal dysfunction.

RESULTS

For the 79 children with sepsis, the incidence rate of gastrointestinal dysfunction was 49% (39/79), and the mortality rate of the children with gastrointestinal dysfunction was 26% (10/39). The children with gastrointestinal dysfunction had a longer duration of mechanical ventilation and a higher 28-day mortality rate (P<0.05). The children with gastrointestinal dysfunction had a significantly lower median rSO₂ (64%) than the children without gastrointestinal dysfunction (72%) and the healthy control group (78%) (P<0.05).

CONCLUSIONS

There are high incidence and mortality rates of gastrointestinal dysfunction in children with sepsis, and the reduction in rSO₂ may be associated with the development of gastrointestinal dysfunction.

A systematic review of the impact of post-operative oral fluid intake on ileus following elective colorectal surgery

INTRODUCTION

Ileus (delayed return of bowel function after surgery) is one of the highest priority research questions in modern day colorectal practice. Current Enhanced Recovery After Surgery (ERAS) guidance either does not include a specific recommendation for volume of postoperative oral fluids/foodstuffs or suggests ad-lib fluids. It is unclear if the volume of intake affects ileus rates. This systematic review aimed to determine the optimal fluid volume for patients to consume day one after elective colorectal surgery.

METHODS

The literature was searched across seven databases, 23/09/2020. Randomised controlled trials of adults undergoing elective colorectal surgery, comparing oral intake postoperatively were eligible for inclusion. Two blinded reviewers assessed papers with disagreements resolved by a third independent reviewer. Main outcomes were resolution of postoperative ileus and length of hospital stay. Secondary outcomes included vomiting, mortality and complications.

RESULTS

Of 2175 screened papers, eight were eligible for inclusion. All studies gave a clear liquid diet postoperatively. The comparison groups followed a traditional nil-by-mouth approach. All studies showed a minor reduction in postoperative ileus and hospital stay in the intervention group, but we are unable to determine the optimal postoperative oral fluid volume. The low number and poor quality of studies was a significant limitation. None of the trials were conducted within an ERAS protocol: only 883 patients were included in total.

CONCLUSIONS

From the current literature it is unclear how postoperative oral fluid volume intake affects gastrointestinal function and ileus in elective colorectal surgical patients. This remains an important area for further research.

Nursing experience of abdominal massage intervention for gastrointestinal dysfunction after lung transplantation

BACKGROUND

Lung transplantation is the only effective way to treat end-stage lung disease. Severe gastrointestinal complications are common after lung transplantation and are associated with increased mortality. Early identification and active intervention are necessary to avoid treatment delays. Abdominal massage belongs to the category of external treatment of traditional Chinese medicine (TCM), which is often used in the treatment of internal diseases. It has an excellent effect in treating stomachache, bloating, anorexia, and constipation.

CASE PRESENTATION

The patient developed gastrointestinal dysfunction 16 days after lung transplantation. Through the implementation of abdominal massage intervention, symptoms were significantly relieved, weight gain occurred, and the curative effect was good.

CONCLUSION

Abdominal massage can relieve gastrointestinal symptoms and promote the recovery of gastrointestinal function after lung transplantation and has good curative effects. This method is worth promoting in patients who have had lung transplantation.

The Underestimated and Overlooked Burden of Diarrhea and Constipation in Cancer Patients

PURPOSE OF REVIEW

This review aims to summarize and discuss the diverse causes of two major gastrointestinal dysfunction symptoms, diarrhea and constipation, in cancer patients. We also discuss short- and long-term clinical, economic, and humanistic consequences, including the impact on cancer treatment regimens and patient quality of life, highlighting the limitations of the literature.

RECENT FINDINGS

Diarrhea and constipation as a result of cancer and its treatment can risk the success of anti-cancer therapies by requiring treatment delay or withdrawal, and imposes a substantial humanistic burden in patients with cancer. Despite its importance and frequency, gastrointestinal side effects may be overlooked due to the focus on cancer treatment, and the impact on patients may be underestimated. Additionally, the burden reported may not fully reflect current cancer management, particularly the true impact of economic consequences. A full understanding of the burden of diarrhea and constipation in patients with cancer is required, including broad evaluation of clinical considerations, the patient experience, and an updated assessment of economic burden. This would improve caregivers' appreciation of the impact of gastrointestinal dysfunction and aid the prioritization of future research efforts.

A guide to enteral nutrition in intensive care units: 10 expert tips for the daily practice

The preferential use of the oral/enteral route in critically ill patients over gut rest is uniformly recommended and applied. This article provides practical guidance on enteral nutrition in compliance with recent American and European guidelines. Low-dose enteral nutrition can be safely started within 48 h after admission, even during treatment with small or moderate doses of vasopressor agents. A percutaneous access should be used when enteral nutrition is anticipated for ≥ 4 weeks. Energy delivery should not be calculated to match energy expenditure before day 4–7, and the use of energy-dense formulas can be restricted to cases of inability to tolerate full-volume isocaloric enteral nutrition or to patients who require fluid restriction. Low-dose protein (max 0.8 g/kg/day) can be provided during the early phase of critical illness, while a protein target of > 1.2 g/kg/day could be considered during the rehabilitation phase. The occurrence of refeeding syndrome should be assessed by daily measurement of plasma phosphate, and a phosphate drop of 30% should be managed by reduction of enteral feeding rate and high-dose thiamine. Vomiting and increased gastric residual volume may indicate gastric intolerance, while sudden abdominal pain, distension, gastrointestinal paralysis, or rising abdominal pressure may indicate lower gastrointestinal intolerance.

Clinical evaluation of the effect of Zataria multiflora Boiss and Trachyspermum copticum (L.) on the patients with irritable bowel syndrome

BACKGROUND AND AIM

Irritable Bowel Syndrome (IBS) is the most common gastrointestinal dysfunction characterized by abdominal pain or discomfort, as well as changes in bowel movements and stool shape. Given the global trend towards the increased use of complementary and alternative medicine (CAM), the high prevalence of IBS, the lack of a standard treatment for all IBS subtypes, and patients' willingness to use CAM treatments, investigations into CAM treatments are needed. Accordingly, the present study aimed to investigate the effect of a mix of two herbal medicines (Zataria-Trachyspermum, ZT) on the clinical symptoms of patients with IBS.

EXPERIMENTAL PROCEDURE

The present study was performed on 3 groups including the positive control, experimental, and placebo groups. The sample size was calculated as 150 participants. Fifty patients were assigned to one of three parallel groups (ZT capsule, placebo, and mebeverine capsule) by block randomization. All three groups were treated for 4 weeks. The patients were monitored in the follow-up stage for 2 additional weeks.

RESULTS

After the fourth week of intervention, symptoms of pain, bloating, and reflux showed a significant decrease in the ZT group compared to the placebo and mebeverine groups (P <0.05). Moreover, the participants in the ZT group reported a significant decrease in fatigue compared to the other two groups (P <0.05).

CONCLUSION

This study confirmed the positive effect of ZT on IBS symptoms, especially pain, bloating, constipation, and bowel movements.

The intensivist's assessment of gastrointestinal function: A pilot study

Gastrointestinal dysfunction/failure (GDF) is a common cause of concern in critically ill patients. Although the gut plays an important role in the genesis of organ failure, its exclusion from organ severity scoring systems has made it challenging for intensivists to score it sufficiently at the bedside. We aimed to survey intensive care specialists about their perceptions, attitudes, and approaches towards the assessment of the gut in Australia and New Zealand intensive care units (ICUs). An electronic (online) questionnaire was used to survey intensive care specialists from the Australia and New Zealand Intensive Care Society (ANZICS). The survey comprised 10 questions focused on four key areas: (i) the extent of the problem with GDF in ICUs, (ii) the use and reliability of the current gut scoring tools, (iii) personal approaches and practices associated with GDF assessment, and (4) potential value of a novel GDF scoring system and its incorporation into an organ severity score. Our results showed that GDF was a significant concern amongst ICUs in Australia and New Zealand intensivists (84%; 66/79), with a small number of participants (14%; 3/79) using a gut scoring tool in their ICUs. Despite this, we have no established objective scoring tool for its assessment. The survey highlighted the need for developing a novel scoring tool to assess the gut was considered important amongst majority of the intensivists (92%; 72/78), which would prove useful in clinical practice and potentially lead to incorporation into an organ severity score in the future.

Clinical effects of Lactobacillus acidophilus combined with mosapride in treatment of gastrointestinal dysfunction after craniocerebral injury

BACKGROUND

Most patients with severe craniocerebral injury have gastrointestinal motility deficiency. When the body is exposed to external mechanical trauma, infection, vomiting, and gastric content reflux tend to occur, which causes early gastrointestinal dysfunction, affects nutrient intake, aggravates brain edema, delays wound healing, and is not conducive to the prognosis of patients. Mosapride is a commonly used gastrointestinal motility agent, which can improve gastrointestinal motility and speed up gastric emptying. Lactobacillus acidophilus can regulate the intestinal flora, protect the intestinal mucosal barrier, maintain intestinal balance, and relieve gastric motility. The purpose of this study was to investigate the effects of Lactobacillus acidophilus combined with mosapride treatment on the time to reach enteral nutrition standards, intestinal flora, rehabilitation process, and other aspects of patients with gastrointestinal dysfunction after craniocerebral injury, and to evaluate its clinical effects.

AIM

To observe the clinical effects of Lactobacillus acidophilus combined with mosapride in the treatment of gastrointestinal dysfunction after craniocerebral injury.

METHODS

A total of 92 patients with gastrointestinal dysfunction after craniocerebral injury at our hospital from February 2018 to February 2021 were selected and divided into a study group and a control group at a ratio of 1:1 using a random number table, with 46 cases in each group. On the basis of conventional treatment, the control group was given mosapride, and the study group was given Lactobacillus acidophilus combined with mosapride for 1 wk. The clinical efficacy, time to reach enteral nutrition standards, recovery progress, 28-d mortality rate, gastric motility indexes [intra-abdominal pressure (IAP) and residual gastric volume (GRA)], and intestinal motility before treatment and after 3 d and 1 wk of treatment were compared between the two groups. Intestinal barrier function indexes [D-lactic acid (D-LA) and diamine oxidase (DAO)] and intestinal flora (Bifidobacterium, Lactobacillus, Enterococcus, and Enterobacter) were also compared.

RESULTS

The total effective rate of the study group was higher than that of the control group (93.48% vs 78.26%, P < 0.05). The time to reach enteral nutrition standards, time to mechanical ventilation, and the length of ICU stay in the study group were shorter than those of the control group (P < 0.05). There was no significant difference in the 28-d mortality rate between the two groups (P > 0.05). The APACHE II and SOFA scores of the study group were lower than those of the control group after 3 d and 1 wk of treatment, and the Glasgow Coma scale scores were higher than those of the control group (P < 0.05). The levels of IAP, GRA, D-LA, and DAO in the study group were lower than those of the control group after 3 d and 1 wk of treatment (P < 0.05). The numbers of Bifidobacterium and Lactobacillus in the study group were more than those of the control group after 3 d and 1 wk of treatment, and the numbers of Enterococcus and Enterobacter were less than those of the control group (P < 0.05).

CONCLUSION

Lactobacillus acidophilus and mosapride are effective in treating gastrointestinal dysfunction after craniocerebral injury. They can shorten the time to reach enteral nutrition standards, adjust the intestinal flora, protect the intestinal mucosal barrier, promote the recovery of the gastrointestinal tract and nerve function, and accelerate the recovery process of patients.

Duodenal perforation after organophosphorus poisoning: A case report

BACKGROUND

Organophosphorus poisoning (OP) is one of the common critical conditions in emergency departments in China, which is usually caused by suicide by taking oral drugs. Patients with severe OP have disturbance of consciousness, respiratory failure, toxic shock, gastrointestinal dysfunction, and so on. As far as we know, the perforation of the duodenum caused by OP has not been reported yet.

CASE SUMMARY

A 33-year-old male patient suffered from acute severe OP, associated with abdominal pain. Multiple computed tomography scans of the upper abdomen showed no evidence of intestinal perforation. However, retrograde digital subtraction angiography, performed via an abdominal drainage tube, revealed duodenal perforation. After conservative treatment, the symptoms eased and the patient was discharged from hospital.

CONCLUSION

Clinicians should pay close attention to gastrointestinal dysfunction and abdominal signs in patients with severe OP. If clinical manifestation and vital signs cannot be explained by common complications, stress duodenal ulcer or perforation should be highly suspected.

Novel compound FLZ alleviates rotenone-induced PD mouse model by suppressing TLR4/MyD88/NF-κB pathway through microbiota-gut-brain axis

Parkinson's disease (PD) is the second most common neurodegenerative disease, but none of the current treatments for PD can halt the progress of the disease due to the limited understanding of the pathogenesis. In PD development, the communication between the brain and the gastrointestinal system influenced by gut microbiota is known as microbiota-gut-brain axis. However, the explicit mechanisms of microbiota dysbiosis in PD development have not been well elucidated yet. FLZ, a novel squamosamide derivative, has been proved to be effective in many PD models and is undergoing the phase I clinical trial to treat PD in China. Moreover, our previous pharmacokinetic study revealed that gut microbiota could regulate the absorption of FLZ in vivo. The aims of our study were to assess the protective effects of FLZ treatment on PD and to further explore the underlying microbiota-related mechanisms of PD by using FLZ as a tool. In the current study, chronic oral administration of rotenone was utilized to induce a mouse model to mimic the pathological process of PD. Here we revealed that FLZ treatment alleviated gastrointestinal dysfunctions, motor symptoms, and dopaminergic neuron death in rotenone-challenged mice. 16S rRNA sequencing found that PD-related microbiota alterations induced by rotenone were reversed by FLZ treatment. Remarkably, FLZ administration attenuated intestinal inflammation and gut barrier destruction, which subsequently inhibited systemic inflammation. Eventually, FLZ treatment restored blood-brain barrier structure and suppressed neuroinflammation by inhibiting the activation of astrocytes and microglia in the substantia nigra (SN). Further mechanistic research demonstrated that FLZ treatment suppressed the TLR4/MyD88/NF-κB pathway both in the SN and colon. Collectively, FLZ treatment ameliorates microbiota dysbiosis to protect the PD model via inhibiting TLR4 pathway, which contributes to one of the underlying mechanisms beneath its neuroprotective effects. Our research also supports the importance of microbiota-gut-brain axis in PD pathogenesis, suggesting its potential role as a novel therapeutic target for PD treatment.

Development of the Gastrointestinal Dysfunction Score (GIDS) for critically ill patients - A prospective multicenter observational study (iSOFA study)

BACKGROUND & AIMS

To develop a five grade score (0-4 points) for the assessment of gastrointestinal (GI) dysfunction in adult critically ill patients.

METHODS

This prospective multicenter observational study enrolled consecutive adult patients admitted to 11 intensive care units in nine countries. At all sites, daily clinical data with emphasis on GI clinical symptoms were collected and intra-abdominal pressure measured. In five out of 11 sites, the biomarkers citrulline and intestinal fatty acid-binding protein (I-FABP) were measured additionally. Cox models with time-dependent scores were used to analyze associations with 28- and 90-day mortality. The models were estimated with stratification for study center.

RESULTS

We included 540 patients (224 with biomarker measurements) with median age of 65 years (range 18-94), the Simplified Acute Physiology Score II score of 38 (interquartile range 26-53) points, and Sequential Organ Failure Assessment (SOFA) score of 6 (interquartile range 3-9) points at admission. Median ICU length of stay was 3 (interquartile range 1-6) days and 90-day mortality 18.9%. A new five grade Gastrointestinal Dysfunction Score (GIDS) was developed based on the rationale of the previously developed Acute GI Injury (AGI) grading. Citrulline and I-FABP did not prove their potential for scoring of GI dysfunction in critically ill. GIDS was independently associated with 28- and 90-day mortality when added to SOFA total score (HR 1.40; 95%CI 1.07-1.84 and HR 1.40; 95%CI 1.02-1.79, respectively) or to a model containing all SOFA subscores (HR 1.48; 95%CI 1.13-1.92 and HR 1.47; 95%CI 1.15-1.87, respectively), improving predictive power of SOFA score in all analyses.

CONCLUSIONS

The newly developed GIDS is additive to SOFA score in prediction of 28- and 90-day mortality. The clinical usefulness of this score should be validated prospectively.

TRIAL REGISTRATION

NCT02613000, retrospectively registered 24 November 2015.

Gastrointestinal dysfunction in Parkinson's disease: molecular pathology and implications of gut microbiome, probiotics, and fecal microbiota transplantation

Gastrointestinal symptoms and gut dysbiosis may occur before the onset of motor symptoms in Parkinson's disease (PD). Prediagnostic and prodromal features, such as constipation and α-synuclein pathology, can be detected several years before the clinical diagnosis of PD and have the potential to develop as early PD biomarkers. Environmental toxins and gut dysbiosis may trigger oxidative stress and mucosal inflammation, and initiate α-synuclein accumulation in the enteric nervous system, early in PD. Chronic gut inflammation can lead to a leaky gut and systemic inflammation, neuro inflammation, and neuro degeneration via gut-vagus-brain signaling or through blood-brain barrier permeability. Concepts regarding the gut-brain signaling in PD pathogenesis are changing rapidly and more investigation is required. The gut microbiota interacts with the human body by modulating the enteric and central nervous systems, and immune activity. Understanding the immune responses between gut microbiota and human body might help in elucidating the PD pathogenesis. As changes in gut microbiota composition might be associated with different clinical phenotypes of PD, gut microbiota-modulating interventions, such as probiotics and fecal microbiota transplantation (FMT), have the potential to restore the gut dysbiosis, reduce inflammation, and possibly modulate the clinical PD phenotype.

Preliminary study on theory of spleen injury caused by exogenous cold and dampness based on intestinal microecology

Exogenous cold and dampness is most likely to damage spleen Yang, which affects the spleen's function of governing transportation and dispersing essence. Human intestinal flora is widely involved in the regulation of gastrointestinal digestive functions. Therefore, based on the general understanding of the correlation between intestinal microecology and the spleen in modern research, this paper discusses the response mechanism of intestinal microflora to random exposure to cold and dampness environment in the process of gastrointestinal digestive dysfunction, and suggests that intestinal microecology imbalance may be one of the mechanisms of spleen injury caused by exogenous cold and dampness in traditional Chinese medicine.

Gastrointestinal dysfunction in movement disorders

PURPOSE OF REVIEW

This article provides an overview of the clinical presentation, investigations, and treatment options for gastrointestinal tract (GIT) dysfunction in patients with Parkinson's disease (PD) and other movement disorders.

RECENT FINDINGS

GIT dysfunction commonly appears as constipation and fecal incontinence (mostly overflow, accompanied with sphincter failure in multiple system atrophy [MSA]). Bowel dysfunction (underactive) occurs irrespectively from the site of the neurologic lesion, which is in contrast to site-dependent bladder dysfunction (brain, overactive; periphery, underactive). GI emergencies may arise, including intestinal pseudo-obstruction, intussusception, volvulus, and stercoral ulcer (ulcer of the colon due to pressure and irritation resulting from severe, prolonged constipation). Bowel function tests in neurologic patients often show a combination of slow transit and anorectal dysfunction. Management for slow transit constipation includes bulking agents, softening agents, yogurt/probiotics, and prokinetic agents. Suppositories, botulinum toxin injections, and transanal irrigation are options for managing anorectal constipation.

CONCLUSIONS

Function of the bowel is commonly affected in PD and other movement disorders. Neurologists play an important role in assessing bowel symptoms in their patients and planning treatment strategies, often in collaboration with specialist teams.

The effect of different dietary structure on gastrointestinal dysfunction in children with cerebral palsy and epilepsy based on gut microbiota

BACKGROUND

Gastrointestinal (GI) difficulties are very common among children with cerebral palsy (CP) and comorbid epilepsy. GI function is influenced by dietary structure on gut microbiota. The aim of this study was to compare gut microbiota differences in two dietary groups of this population and examine whether such differences are related to GI dysfunction.

METHODS

Forty children with CP and epilepsy were recruited from a social welfare center, including 23 consuming a fluid diet (liquid diet group) and 17 consuming a normal diet (general diet group). Bacterial DNA was extracted from feces, the V3-V4 region of the 16S rRNA gene was amplified from the DNA, and high-throughput sequencing of the amplified sequences was performed. Microbe prevalence levels were compared on multiple phylogenic levels.

RESULTS

Gut microbial populations differed substantially between the liquid diet group and general diet group. The only two phyla that differed significantly between the two groups were Bacteroidetes (p = 0.034) and Actinobacteria (p = 0.013). Regarding representation of genera, Prevotella species were selectively predominant in the general diet group (25.849% vs. 3.612% in the liquid diet group, p < 0.001), while Bifidobacterium species were selectively predominant in the liquid diet group (24.929% vs. 12.947% in the general diet group, p = 0.013). The gut microbiota of children in the general diet group contained more butyric acid-producing microbiota which was also common in healthy people (e.g. Lachnoclostridium, Dorea, Ruminococcus, Faecalibacterium, Roseburia, and Coprococcus). The gut microbiota of children in liquid diet group however, were rich in symbiotic pathogenic bacteria (e.g. Collinsella, Alistipes, and Eggerthella).

CONCLUSION

The gut microbiota of children with CP and epilepsy consuming a liquid diet had elevated levels of symbiotic pathogens and diminished intestinal barrier protection bacteria, relative to a general diet group. These differences in bacterial microbiota were associated with GI dysfunction symptoms.

Genetic variants of TAS2R38 bitter taste receptor associate with distinct gut microbiota traits in Parkinson's disease: A pilot study

The non-tasting form of the bitter taste receptor, TAS2R38, has been shown as a genetic risk factor associated with the development of Parkinson's disease (PD). Specific taste receptors that are expressed in the lower gastrointestinal tract may respond to alteration in gut microbiota composition, detecting bacterial molecules, and regulate immune responses. Given the importance of brain-gut-microbiota axis and gene-environment interactions in PD, we investigate the associations between the genetic variants of TAS2R38 and gut microbiota composition in 39 PD patients. The results confirm that the majority of PD patients have reduced sensitivity to 6-n-propylthiouracil (PROP) and are carriers of at least one non-functional TAS2R38 AVI haplotype. Moreover, we found this correlation to be associated with a reduction in bacteria alpha-diversity with a predominant reduction of Clostridium genus. We hypothesised that the high frequency of the non-taster form of TAS2R38 associated with a diminuition of Clostridium bacteria in PD might determine a reduction in the activation of protective signalling-molecules useful in preserving gut homeostasis. This pilot study, by identifying a decrease in specific bacteria associated with a reduced sensitivity to PROP, adds essential information that opens new avenues of research into the association of PD microbiota composition and sensory modification.

Gastrointestinal dysfunction in the critically ill: a systematic scoping review and research agenda proposed by the Section of Metabolism, Endocrinology and Nutrition of the European Society of Intensive Care Medicine

BACKGROUND

Gastrointestinal (GI) dysfunction is frequent in the critically ill but can be overlooked as a result of the lack of standardization of the diagnostic and therapeutic approaches. We aimed to develop a research agenda for GI dysfunction for future research. We systematically reviewed the current knowledge on a broad range of subtopics from a specific viewpoint of GI dysfunction, highlighting the remaining areas of uncertainty and suggesting future studies.

METHODS

This systematic scoping review and research agenda was conducted following successive steps: (1) identify clinically important subtopics within the field of GI function which warrant further research; (2) systematically review the literature for each subtopic using PubMed, CENTRAL and Cochrane Database of Systematic Reviews; (3) summarize evidence for each subtopic; (4) identify areas of uncertainty; (5) formulate and refine study proposals that address these subtopics; and (6) prioritize study proposals via sequential voting rounds.

RESULTS

Five major themes were identified: (1) monitoring, (2) associations between GI function and outcome, (3) GI function and nutrition, (4) management of GI dysfunction and (5) pathophysiological mechanisms. Searches on 17 subtopics were performed and evidence summarized. Several areas of uncertainty were identified, six of them needing consensus process. Study proposals ranked among the first ten included: prevention and management of diarrhoea; management of upper and lower feeding intolerance, including indications for post-pyloric feeding and opioid antagonists; acute gastrointestinal injury grading as a bedside tool; the role of intra-abdominal hypertension in the development and monitoring of GI dysfunction and in the development of non-occlusive mesenteric ischaemia; and the effect of proton pump inhibitors on the microbiome in critical illness.

CONCLUSIONS

Current evidence on GI dysfunction is scarce, partially due to the lack of precise definitions. The use of core sets of monitoring and outcomes are required to improve the consistency of future studies. We propose several areas for consensus process and outline future study projects.

Prognostic capability of the Maximum Acute Gastrointestinal Injury Score and of caloric intake in patients requiring vasopressors: A multicenter prospective cohort study

PURPOSE

Our main objective was to use the Maximum Acute Gastrointestinal Injury Score (AGI_max) to evaluate the prognostic capability of gastrointestinal dysfunction (GID), on hospital mortality in patients on mechanical ventilation (MV) requiring vasopressors. A secondary goal was to analyze the relationship between AGI_max and vasopressor dosage with increasing caloric intake.

MATERIALS AND METHODS

Prospective multicenter cohort study in ten ICUs across Argentina. Consecutive adult patients on MV, requiring vasopressors and receiving enteral nutrition (EN) were included. AGI_max was identified (I-IV) using a modified AGI score. Comparisons of clinical and outcome variables were performed in 3 predetermined EN-groups: <10 kcal/kg/d, ≥10 to <20 kcal/kg/d, or ≥ 20 kcal/kg/d.

RESULTS

A total of 494 patients met all inclusion criteria. Forty-four percent of patients had severe AGI_max and 17% received <10 kcal/kg/day, indicating more severity and higher mortality. Notable independent predictors of mortality were AGI_max, vasopressors, and caloric intake. PN was the only factor which had an inverse relationship to mortality.

CONCLUSIONS

In this population, patients with AGI_max III-IV were significantly associated with lower caloric intake and greater hospital mortality, highlighting the importance of AGI as a prognostic tool. As PN was linked with lower mortality, it could be an option to explore in further studies.

Severity of acute gastrointestinal injury grade is a good predictor of mortality in critically ill patients with acute pancreatitis

BACKGROUND

Gastrointestinal (GI) dysfunction is a common and important complication of acute pancreatitis (AP), especially in patients with severe AP. Despite this, there is no consensus means of obtaining a precise assessment of GI function.

AIM

To determine the association between acute gastrointestinal injury (AGI) grade and clinical outcomes in critically ill patients with AP.

METHODS

Patients with AP admitted to our pancreatic intensive care unit from May 2017 to May 2019 were enrolled. GI function was assessed according to the AGI grade proposed by the European Society of Intensive Care Medicine in 2012, which is mainly based on GI symptoms, intra-abdominal pressure, and feeding intolerance in the first week of admission to the intensive care unit. Multivariate logistic regression analysis was performed to assess the association between AGI grade and clinical outcomes in critically ill patients with AP.

RESULTS

Among the 286 patients included, the distribution of patients with various AGI grades was 34.62% with grade I, 22.03% with grade II, 32.52% with grade III, and 10.84% with grade IV. The distribution of mortality was 0% among those with grade I, 6.35% among those with grade II, 30.11% among those with grade III, and 61.29% among those with grade IV, and AGI grade was positively correlated with mortality (χ² = 31.511, P < 0.0001). Multivariate logistic regression analysis showed that age, serum calcium level, AGI grade, persistent renal failure, and persistent circulatory failure were independently associated with mortality. Compared with the Acute Physiology and Chronic Health Evaluation II score (area under the curve: 0.739 vs 0.854; P < 0.05) and Ranson score (area under the curve: 0.72 vs 0.854; P < 0.01), the AGI grade was more useful for predicting mortality.

CONCLUSION

AGI grade is useful for identifying the severity of GI dysfunction and can be used as a predictor of mortality in critically ill patients with AP.

Gastrointestinal dysfunction in Parkinson's disease

BACKGROUND

Gastrointestinal (GI) dysfunction is prevalent in Parkinson's disease (PD). Symptoms are evident throughout the disease course, affect the length of the GI tract and impact on patient quality of life and management. We clarify real-life differences in the frequency and severity of GI symptoms in a cohort of PD and healthy control (HC) subjects.

METHODS

103 PD patients were compared to 81 HC subjects. Outcome measures collected from validated questionnaires included constipation severity, upper and lower GI symptoms and physical activity.

RESULTS

PD patients were three-times more likely to experience constipation than HC subjects, (78.6% vs 28.4%), exhibited a fourfold increase in constipation severity and formed harder stools. PD patients also reported increased symptoms of indigestion, nausea, excessive fullness and bloating, compared to the HCs. A higher mean Leeds Dyspepsia Questionnaire score for PD patients (8.3 (standard deviation (SD) 7.7) vs 4.6 (SD 6.1), p = 0.001)) indicated increased symptom severity. Chronic pain was more frequently reported and correlated with constipation and upper GI dysfunction, being more prevalent and severe in women. Physical activity was notably decreased in the PD cohort (1823.6 (± 1693.6) vs 2942.4 (± 2620.9) metabolic equivalent-minutes/week, p = 0.001) and correlated with constipation severity. PD therapies were associated with increased fullness and bloating and harder stools.

CONCLUSIONS

PD patients report more prevalent and severe GI dysfunction, although our cohort comprised of many later-stage participants. Earlier recognition of GI dysfunction in PD provides the opportunity to direct treatment for chronic pain and constipation, promote physical activity and rationalise PD therapies for optimal patient care.

Sclerosing angiomatoid nodular transformation of the spleen, a rare cause for splenectomy: Two case reports

BACKGROUND

Sclerosing angiomatoid nodular transformation (SANT) is a rare benign disease of the spleen with unknown origin. Clinical symptoms are inhomogeneous, and suspicious splenic lesion often found incidentally, leading to splenectomy, as malignancy cannot securely be ruled out. Diagnosis is made histologically after resection.

CASE SUMMARY

Two cases of German, white, non-smoking, and non-drinking patients of normal weight are presented. The first one is a 26-year-old man without medical history who was exhibiting an undesired weight loss of 10 kg and recurring vomiting for about 18 mo. The second one is a 65-year-old woman with hypertension who had previously undergone gynecological surgery, suffering from a lasting feeling of abdominal fullness. Both showed radiologically an inhomogeneous splenic lesion leading to splenectomy approximately 6 and 9 wk after surgical presentation. Both diagnoses of SANT were made histologically. Follow-up went well, and both were treated according to the recommendation for asplenic patients.

CONCLUSION

SANT is a rare cause of splenectomy and an incidental histological finding. Further research should focus on clinical and radiological diagnosis of SANT as well as on treatment of patients with asymptomatic and small findings.

Dietary Approaches to the Management of Autism Spectrum Disorders

This chapter reviews the literature surrounding autism spectrum disorders (ASD) and their relation to gastrointestinal (GI), behavioral, neurological, and immunological functioning. Individuals with ASD often have poor GI health, including bowel motility issues, autoimmune and/or other adverse responses to certain foods, and lack of necessary nutrient absorption. These issues may be caused or exacerbated by restrictive behavioral patterns (e.g., preference for sweet and salty foods and/or refusal of healthy foods). Those individuals with GI issues tend to demonstrate more behavioral deficits (e.g., irritability, agitation, hyperactivity) and also tend to have an imbalance in overall gut microbiome composition, thus corroborating several studies that have implicated brain-gut pathways as potential mediators of behavioral dysfunction.We examine the literature regarding dietary approaches to managing ASDs, including elimination diets for gluten, casein, or complex carbohydrates, a ketogenic diet, and a low oxalate diet. We also explore the research examining dietary supplements such as fatty acids, pro- and prebiotics, vitamins, minerals, glutathione, phytochemicals, and hormones. The research on dietary approaches to managing ASDs is limited and the results are mixed. However, a few approaches, such as the gluten-free/casein-free diet, fatty acid supplementation, and pre/probiotics have generally demonstrated improved GI and associated behavioral symptoms. Given that GI issues seem to be overrepresented in ASD populations, and that GI issues have been associated with a number behavioral and neurological deficits, dietary manipulation may offer a cheap and easily implemented approach to improve the lives of those with ASD.

Gastrointestinal failure affects outcome of intensive care

PURPOSE

Goal of this study was to describe incidence and outcome of gastrointestinal failure (GIF) in ICU patients, evaluate its additive role to SOFA score in mortality prediction and describe GIF according to etiology.

MATERIALS AND METHODS

A retrospective study with prospective data collection was conducted in mixed adult ICU patients admitted 2004-2015. GIF was considered present if ≥3 of following 6 symptoms occurred in 1 day: maximum gastric residual volume ≥ 500 mL; absent bowel sounds; vomiting or regurgitation; diarrhea; suspected or radiologically confirmed bowel distension; gastrointestinal bleeding. Division into primary (gastrointestinal pathology causing GIF) and secondary (due to other conditions) GIF was made based on origin of syndrome.

RESULTS

GIF developed in 413 (10.4%) of 3959 patients. Primary GIF occurred in 61.3% and secondary GIF in 38.7% of patients. Development of GIF was associated with longer mechanical ventilation, ICU stay and higher ICU, 30-day and 90-day mortality. Outcomes of patients with primary and secondary GIF were similar. All SOFA sub-scores and number of gastrointestinal symptoms on admission day independently predicted 90-day mortality.

CONCLUSIONS

Gastrointestinal failure, independent of origin, is associated with worse ICU outcome. Similar to other organ failures included in SOFA score, GIF independently predicts mortality.

Constipation, deficit in colon contractions and alpha-synuclein inclusions within the colon precede motor abnormalities and neurodegeneration in the central nervous system in a mouse model of alpha-synucleinopathy

Background

Gastrointestinal dysfunction can affect Parkinson’s disease (PD) patients long before the onset of motor symptoms. However, little is known about the relationship between gastrointestinal abnormalities and the development of PD. Contrary to other animal models, the human A53T alpha-synuclein (αS) transgenic mice, Line G2–3, develops αS-driven neurological and motor impairments after 9 months of age, displaying a long presymptomatic phase free of central nervous system (CNS) dysfunction.

Methods

To determine whether this line can be suitable to study constipation as it occurs in prodromal PD, gastrointestinal functionality was assessed in young mice through a multidisciplinary approach, based on behavioral and biochemical analysis combined with electrophysiological recordings of mouse intestinal preparations.

Results

We found that the A53T αS mice display remarkable signs of gastrointestinal dysfunction that precede motor abnormalities and αS pathology in the CNS by at least 6 months. Young αS mice show a drastic delay in food transit along the gastrointestinal tract, of almost 2 h in 3 months old mice that increased to more than 3 h at 6 months. Such impairment was associated with abnormal formation of stools that resulted in less abundant but longer pellets excreted, suggesting a deficit in the intestinal peristalsis. In agreement with this, electrically evoked contractions of the colon, but not of the ileum, showed a reduced motor response in both longitudinal and circular muscle layers in αS mice already at 3 months of age, that was mainly due to an impaired cholinergic transmission of the underlying enteric nervous system. Interestingly, the presence of insoluble and aggregated αS was found in enteric neurons in both myenteric and submucosal plexi only in the colon of 3 months old αS mice, but not in the small intestine, and exacerbated with age, mimicking the increase in transit delay and the contraction deficit showed by behavioral and electrical recordings data.

Conclusions

Gastrointestinal dysfunction in A53T αS mice represents an early sign of αS-driven pathology without concomitant CNS involvement. We believe that this model can be very useful to study disease-modifying strategies that could extend the prodromal phase of PD and halt αS pathology from reaching the brain.

Electronic supplementary material

The online version of this article (10.1186/s40035-019-0146-z) contains supplementary material, which is available to authorized users.

[Clinical trials of acupuncture of Jiaji (EX-B2) for treatment of gastrointestinal dysfunction in sepsis patients]

OBJECTIVE

To observe the clinical therapeutic effect of acupuncture of Huatuo Jiaji (EX-B2) in the treatment of gastrointestinal dysfunction in sepsis patients, aiming at providing new clinical approach and evidence for improving septic gastrointestinal activity.

METHODS

A total of 40 patients with septic gastrointestinal dysfunction who met our inclusive criteria were randomly divided into control group and treatment group (n＝20 cases in each). Patients in the control group received routine treatment of nasogastric mosapride citrate (5 mg/time, three times a day) and tifidobacterium triple viable capsules (420 mg, twice a day), intravenous infusion of omeprazole (40 mg, twice a day), rational dose of antibiotics, maintenance treatment of functions of the heart, lung, brain, kidney and other important organs and water electrolyte balance, as well as symptomatic treatment. Patients of the treatment group were treated by acupuncture of EX-B2 on the basis of routine treatment mentioned above in the control group. The acupuncture needle was inserted into EX-B2, twirled for a while and retained for 30 min, once a day for 10 successive days. The acute physiology and chronic health evaluation (APACHE II) score was given according to Knaus and colleagues' method, the intra-abdominal pressure was detected by using a manometer which was connected to an inserted canal in the urinary bladder, and the intragatric residul volume detected by using an injection syriange pumping via a nasal feeding tube.

RESULTS

After the treatment, the APACHE II score, intra-abdominal pressure and intragastric residual volume on day 10 were significantly decreased in both groups in comparison with their own pre-treatment (P<0.05), while the borborygmus levels on day 10 were considerably increased in both groups relevant to their own pre-treatment (P<0.05). The APACHE II scores, intra-abdominal pressure and intragastric residual volume on day 3, 6 and 10 were significantly lower in the treatment group than those in the control group (P<0.05), whereas the borborygmus levels at the 3^rd , 6^th and 10^th day in the treatment group were apparently higher than those of the control group (P<0.05)．.

CONCLUSION

Acupuncture stimulation of EX-B2 has a good curative effect in improving gastrointestinal dysfunction in sepsis patients.

Melatonin and Comorbidities in Children with Autism Spectrum Disorder

PURPOSE OF REVIEW

Melatonin is used to treat sleep difficulties associated with autism spectrum disorder (ASD). There are growing evidence that melatonin could have an effect on other symptoms than sleep, such as anxiety, depression, pain, and gastrointestinal dysfunctions. Interestingly, these symptoms frequently are found as comorbid conditions in individuals with ASD. We aimed to highlight the potential effect of melatonin on these symptoms.

RECENT FINDINGS

Animal and human studies show that melatonin reduces anxiety. Regarding the effect of melatonin on pain, animal studies are promising, but results remain heterogeneous in humans. Both animal and human studies have found that melatonin can have a positive effect on gastrointestinal dysfunction.

SUMMARY

Melatonin has the potential to act on a wide variety of symptoms associated with ASD. However, other than sleep difficulties, no studies exist on melatonin as a treatment for ASD comorbid conditions. Such investigations should be on the research agenda because melatonin could improve a multitude of ASD comorbidities and, consequently, improve well-being.

Thiamine Deficiency: An Important Consideration in Critically Ill Patients

Thiamine is an essential cofactor for 4 enzymes involved in the production of energy (ATP) and the synthesis of essential cellular molecules. The total body stores of thiamine are relatively small, and thiamine deficiency can develop in patients secondary to inadequate nutrition, alcohol use disorders, increased urinary excretion and acute metabolic stress. Patients with sepsis are frequently thiamine deficient, and patients undergoing surgical procedures can develop thiamine deficiency. This deficiency can cause congestive heart failure, peripheral neuropathy, Wernicke's encephalopathy, Korsakoff's syndrome and gastrointestinal beriberi. In addition, thiamine deficiency can contribute to the development of intensive care unit complications, such as heart failure, delirium, critical care neuropathy, gastrointestinal dysfunction and unexplained lactic acidosis. Consequently, clinicians need to consider thiamine deficiency in patients admitted to intensive care units and the development of thiamine deficiency during the management of critically ill patients. Intravenous thiamine can correct lactic acidosis, improve cardiac function and treat delirium.

Oral Nigella sativa oil and thymoquinone administration ameliorates the effect of long-term cisplatin treatment on the enzymes of carbohydrate metabolism, brush border membrane, and antioxidant defense in rat intestine

We have previously shown that oral administration of Nigella sativa oil (NSO) ameliorates the deleterious gastrointestinal effects of cisplatin (CP), administered as a single dose. Since a typical clinical CP dosing regimen involves multiple cycles of CP administration in lower doses, in the present study we investigate the protective efficacy of NSO and its major bioactive constituent, thymoquinone (TQ), against multiple-dose CP treatment-induced deleterious biochemical and histological changes in rat intestine. Rats were divided into six groups, viz., control, CP, CP+NSO, CP+TQ, NSO, and TQ. Animals in CP+NSO and CP+TQ groups were pre-administered NSO (2 ml/kg bwt, orally) and TQ (1.5 mg/kg bwt, orally), respectively, daily for 14 days and were then treated with five repeated doses of CP (3 mg/kg bwt, i.p.), every fourth day for 20 days while still receiving NSO/TQ. CP treatment alone led to a significant decline in specific activities of brush border membrane (BBM) enzymes while NSO or TQ administration to CP-treated rats significantly prevented the decline in BBM enzyme activities in the isolated brush border membrane vesicles (BBMV) as well as in mucosal homogenates. Furthermore, both NSO and TQ administration markedly ameliorated CP-induced alterations on carbohydrate metabolism enzymes and the enzymatic and non-enzymatic parameters of antioxidant defense system in the intestinal mucosa. However, NSO appeared to be more efficacious than TQ in protecting against CP-induced gastrointestinal dysfunction. Histopathological findings corroborated the biochemical results. Thus, NSO and TQ may prove clinically useful in amelioration of the intestinal toxicity associated with long-term CP chemotherapy.

Microbes Tickling Your Tummy: the Importance of the Gut-Brain Axis in Parkinson's Disease

Purpose of Review

Patients suffering from Parkinson's disease (PD) are known to experience gastrointestinal dysfunction that might precede the onset of motor symptoms by several years. Evidence suggests an important role of the gut-brain axis in PD pathogenesis. These interactions might be essentially influenced by the gut microbiota. Here, we review recent findings supporting that changes in the gut microbiota composition might be a trigger for inflammation contributing to neurodegeneration in PD.

Recent Findings

Recent research revealed that PD patients exhibit a pro-inflammatory microbiota profile in their intestinal tract that might increase gut permeability, allowing leakage of bacterial products and inflammatory mediators from the intestines. Evidence in literature indicates that alpha-synuclein deposition might start in the enteric nervous system by pro-inflammatory immune activity and then propagates to the CNS. Alternatively, the peripheral inflammatory response could impact the brain through systemic mechanisms.

Summary

A better understanding of the gut-brain interactions and the role of the intestinal microbiota in the regulation of immune responses might bring new insights in PD pathological progression and might lead to novel diagnostics and therapeutic approaches.

Acute autonomic neuropathy with severe gastrointestinal symptoms in children: a case series

Background

Acute autonomic neuropathy (AAN) is rare disorder with anecdotal report, especially for childhood onset patients. Misdiagnosis or delays in treatment can always be found in clinical practice. We conducted this study to give a description of the manifestations and treatment of AAN in children and therefore help clinicians to make the accurate diagnosis early so that the prognosis of the patients can be improved.

Methods

A systematic record from 3 clinical centers was used to identify 11 subject, 3 males and 8 females, with clinical diagnosed AAN.

Result

The age ranged from 2 years and 4 months to 14 years and 6 months (mean, 9 ± 3.6 years old) and the course from onset to diagnosis ranged from 7 days to 8 months. All children shared prominent initial symptoms, 7 with frequent vomiting and 4 with motor dysfunctions. The condition of 9 patients improved after treatment of IVIg and intravenous glucocorticoid.

Conclusion

The clinical manifestations of AAN are diverse, generalized, and non-specific. Gastrointestinal disorders were the most common initial symptoms. Symptoms of gastrointestinal system and abnormal secretion of glands were severe and more common than other symptoms. The mechanism of AAN remains unknown. Although IVIg and intravenous glucocorticoid can be used in clinical practice, there is still no treatment recommendation and further study is needed.

Pilot cohort study of endoscopic botulinum neurotoxin injection in Parkinson's disease

BACKGROUND

Gastrointestinal symptoms, such as dysphagia, postprandial bloating, and defecatory straining are common in Parkinson's Disease (PD) and they impact quality of life. Endoscopic botulinum neurotoxin (BoNT) injection has been used in the treatment of dysphagia, gastroparesis and chronic anismus.

AIMS

To examine the feasibility, safety and efficacy of endoscopically delivered BoNT injection to distal esophagus, pylorus or anal canal aiming at relieving regional gastrointestinal symptoms in patients with PD.

METHODS

This is a retrospective open cohort pilot study to assess the clinical response to endoscopic BoNT injection on selected PD patients with symptoms and identifiable abnormalities on high-resolution manometry and wireless motility capsule, to generate early uncontrolled data on feasibility, tolerability, safety and efficacy. Baseline symptoms and response to therapy were assessed by questionnaires.

RESULTS

Fourteen PD patients (10 M:4 F), mean age 73 (range: 62-93) were treated. Three patients had esophageal Botox for ineffective esophageal motility (IEM) (n = 1), esophago-gastric junction outlet obstruction (EGJOO) & IEM (n = 1), and diffuse esophageal spasm (DES) (n = 1). Nine patients were treated with pyloric BoNT injection for gastroparesis with mean gastric transit time of 21.2 h; range 5.2-44.2 h. Two patients received anal Botox for defecatory dyssynergia ((Type I) (n = 1) and overlap (slow-transit and dyssynergic) constipation (n = 1). Endoscopic BoNT injection (100-200 units) was well tolerated and there were no significant adverse events.

CONCLUSIONS

Endoscopic BoNT injection to esophagus, pylorus or anal canal is safe, well-tolerated and leads to symptomatic improvement that lasts up to several months. The procedure can be repeated as needed and combined with other therapies.

Modified Sanxiang Xiaopi decoction improves gastrointestinal dysfunction in patients after surgery for colon cancer

AIM

To observe the clinical effects of modified Sanxiang Xiaopi decoction in treating gastrointestinal dysfunction in patients after surgery for colon cancer.

METHODS

Eighty patient with gastrointestinal dysfunction after surgery for colon cancer were randomly divided into a treatment group and a control group, with 40 cases for each group. Both groups were administered with enhanced anti-infection and nutrition support and other therapies, and patients in the treatment group were additionally given 80 mL of water-dissolved modified Sanxiang Xiaopi decoction through a stomach tube. Both groups were treated for 14 d. They were evaluated in terms of times to recovery of bowel sound and anal exhaust and improvement of syndromes and main symptoms.

RESULTS

The total effective rates in improving syndromes, abdominal fullness and distention, abdominal pain and loss of appetite were 90%, 90%, 95% and 90%, respectively, in the treatment group, all of which were significantly superior to those in the control group (52.5%, 52.5%, 65% and 50%, respectively; P < 0.01). Times to recovery of bowel sound and anal exhaust in the treatment group were significantly shorter than those of the control group (P < 0.01).

CONCLUSION

Modified Sanxiang Xiaopi decoction has a definite curative effect in treating gastrointestinal dysfunction in patients after surgery for colon cancer.

Using Animal Models to Study the Role of the Gut-Brain Axis in Autism

PURPOSE OF REVIEW

Individuals with autism spectrum disorders (ASD) commonly also suffer from gastrointestinal (GI) dysfunction; however, few animal model studies have systematically examined both ASD and GI dysfunction. In this review, we highlight studies investigating GI dysfunction and alterations in gut microbiota in animal models of ASD with the aim of determining if routinely used microbiology and enteric neurophysiology assays could expand our understanding of the link between the two.

RECENT FINDINGS

Gut-brain axis research is expanding, and several ASD models demonstrate GI dysfunction. The integration of well-established assays for detecting GI dysfunction into standard behavioural testing batteries is needed.

SUMMARY

Advances in understanding the role of the gut-brain axis in ASD are emerging; however, we outline standard assays for investigating gut-brain axis function in rodents to strengthen future phenotyping studies. Integrating these findings to the field of animal behaviour is one of the next major challenges in autism research.

Type 1 diabetic patients with peripheral neuropathy have pan-enteric prolongation of gastrointestinal transit times and an altered caecal pH profile

AIMS/HYPOTHESIS

We hypothesised that type 1 diabetic patients with established diabetic sensorimotor polyneuropathy (DSPN) would have segmental and/or pan-enteric dysmotility in comparison to healthy age-matched controls. We aimed to investigate the co-relationships between gastrointestinal function, degree of DSPN and clinical symptoms.

METHODS

An observational comparison was made between 48 patients with DSPN (39 men, mean age 50 years, range 29-71 years), representing the baseline data of an ongoing clinical trial (representing a secondary analysis of baseline data collected from an ongoing double-blind randomised controlled trial investigating the neuroprotective effects of liraglutide) and 41 healthy participants (16 men, mean age 49 years, range 30-78) who underwent a standardised wireless motility capsule test to assess gastrointestinal transit. In patients, vibration thresholds, the Michigan Neuropathy Screening Instrument and Patient Assessment of Upper Gastrointestinal Symptom questionnaires were recorded.

RESULTS

Compared with healthy controls, patients showed prolonged gastric emptying (299 ± 289 vs 179 ± 49 min; p = 0.01), small bowel transit (289 ± 107 vs 224 ± 63 min; p = 0.001), colonic transit (2140, interquartile range [IQR] 1149-2799 min vs 1087, IQR 882-1650 min; p = 0.0001) and whole-gut transit time (2721, IQR 1196-3541 min vs 1475 (IQR 1278-2214) min; p < 0.0001). Patients also showed an increased fall in pH across the ileocaecal junction (-1.8 ± 0.4 vs -1.3 ± 0.4 pH; p < 0.0001), which was associated with prolonged colonic transit (r = 0.3, p = 0.001). Multivariable regression, controlling for sex, disease duration and glycaemic control, demonstrated an association between whole-gut transit time and total GCSI (p = 0.02).

CONCLUSIONS/INTERPRETATION

Pan-enteric prolongation of gastrointestinal transit times and a more acidic caecal pH, which may represent heightened caecal fermentation, are present in patients with type 1 diabetes. The potential implication of delayed gastrointestinal transit on the bioavailability of nutrition and on pharmacotherapeutic and glycaemic control warrants further investigation.

TRIAL REGISTRATION

EUDRA CT: 2013-004375-12.

Prevalence of small intestinal bacterial overgrowth in Chinese patients with Parkinson's disease

Parkinson's disease (PD) is associated with gastrointestinal motility abnormalities that could favor the occurrence of small intestinal bacterial overgrowth (SIBO). The aim of the study was to assess the prevalence of SIBO in Chinese patients with PD and the potential impact of SIBO on gastrointestinal symptoms and motor function. 182 consecutive Chinese patients with PD patients and 200 sex, age, and BMI-matched subjects without PD were included. All participants underwent the glucose breath test to assess SIBO. We examined the associations between factors and SIBO with logistic regression using SPSS. Fifty-five of the 182 PD patients were SIBO positive (30.2 %; 95 % CI 23.5-36.9 %) compared with 19 of 200 in the control group (9.5 %; 95 % CI 5.4-13.6 %); the difference was statistically significant (P < 0.0001; OR 4.13; 95 % CI 2.34-7.29). Motor fluctuations present was higher in the PD patients with SIBO than in the patients without SIBO (70.9 vs. 45.7 %; P = 0.002). Multivariate analysis showed that disease duration, Hoehn and Yahr stage, Unified PD Rating-III score, Unified PD Rating-IV score, and Non-Motor Symptoms Scale score were the factors associated with the SIBO-positive status in PD patients. SIBO was highly prevalent in PD, and nearly one-third was detected. SIBO was associated with worse gastrointestinal symptoms and worse motor function. Further studies are needed to specify the reasons underlying SIBO and worse motor function in PD.

Dietary habits and neurological features of Parkinson's disease patients: Implications for practice

BACKGROUND & AIMS

Parkinson's disease (PD) patients can benefit considerably from appropriate nutritional care, particularly from diet. However, there is limited evidence on the eating habits of PD patients and their relationship with the features of the disease.

METHODS

We conducted a large case-control study. Consecutive PD patients (N = 600) receiving systematic nutritional care and healthy controls (N = 600) matched (1:1) for age, gender, education, physical activity level and residence were studied using a 66-item food frequency questionnaire. The relationship between dietary habits and the following features of PD were investigated in patients: body weight, energy balance, constipation, and levodopa therapy (dose) and its related motor complications.

RESULTS

PD patients had lower BMI and reported higher food intake than controls. BMI was found to be inversely associated with disease duration and severity, and levodopa-related motor complications, whereas energy intake was positively associated with these variables. An increase in protein intake by 10 g over physiological requirements (0.8 g/kg/day) corresponded to a mean increase in levodopa dose of 0.7 mg/kg/day. Constipation was also associated with higher levodopa requirements. Finally, protein intake and its distribution throughout the day influenced levodopa-related motor complications.

CONCLUSION

The management of protein intake and the treatment of constipation should be considered to be an integral part of the care of PD patients. Attention should always be focused on energy intake also. This would result in the maintenance of nutritional status, the optimization of levodopa-therapy and the minimization of its related motor complications.