Rumination Syndrome Research Articles

21 Exploring the clinical presentation and health service utilization in autistic children and adolescents diagnosed with avoidant / restrictive food intake disorder: A descriptive study

Abstract Background Avoidant/restrictive food intake disorder (ARFID) is an eating disorder with much clinical variability, negatively impacting growth, nutrition, psychosocial functioning and overall well-being. ARFID is more frequently reported in neurotypical populations than in neurodivergent populations. Little is known about the clinical presentation and healthcare utilization of autistic individuals with ARFID. Objectives The purpose of this study was to understand the clinical presentation, laboratory abnormalities and health system utilization amongst autistic individuals diagnosed with ARFID within the community. Design/Methods We completed a comprehensive multidisciplinary assessment on autistic individuals less than18 years of age who were diagnosed with ARFID by their community physician. Recruitment period: June 2020-June 2021. Results Nineteen autistic individuals completed a comprehensive multidisciplinary assessment; of these, 42.1% (8/19) met criteria for Autism Spectrum Disorder (ASD) severity level 1. The onset of restrictive eating manifested at M(SD)= 2.5 (0.7) years, and the age of ASD diagnosis was 4.2 (3.8) years. Of these, 78.9% (15/19) had the onset of feeding difficulties either prior to or at the time of their ASD diagnosis (Figure 1). Dependence on enteral feeding or nutritional supplements (74%), psychosocial impairment (68%), and nutritional deficiencies (42%) were the criteria commonly met for ARFID. Sensory-based avoidance (100%) and lack of interest in food (89%) were the two most reported potential drivers for the dysfunctional feeding behaviour based on the Pica , ARFID, and Rumination Disorder Interview-AR-Q. Neurodevelopment disorder comorbidities included ADHD (26.3%), Anxiety (21.1%), and Intellectual Developmental Disability (15.8%). Constipation (68.4%) and nutritional deficits (63.15%) were the most common medical comorbidities recorded. Nutritional profile revealed Vitamin D deficit in 50% (8/16), Anaemia 21% (4/19), Vitamin B1 deficit 20% (2/10). Additionally, three participants (17.7%, 3/17) had deficits in Vitamin B12, Zinc, Vitamin C and low ferritin levels. Four autistic individuals (21.1%, 4/19) were hospitalized because of their restrictive eating. 68.4% (13/19) autistic individuals had involvement of at least one allied health professional (OT or SLP or BT). No participants had a prior multidisciplinary feeding assessment or intervention to address restrictive eating. Conclusion ARFID is an eating disorder observed within autistic individuals. Evidence suggests food related sensory sensitivities and lack of interest in food are potential drivers of ARFID in the context of ASD. A comprehensive multidisciplinary assessment is needed to elucidate factors driving restrictive eating to inform targeted evidence-based interventions.

Gastric vs. supragastric belching, singultus, aerophagia, and differential diagnoses : An interdisciplinary perspective for otorhinolaryngologists

Belching is the act of expelling air from the stomach or esophagus into the pharynx. Although the process is regarded as physiological, excessive belching might be associated with asignificant burden for affected patients in the sense of abelching disorder. Diagnosis of abelching disorder is often challenging, and its differentiation from other conditions such as rumination syndrome, singultus, or aerophagia can be difficult. Treatment of these disorders also represents a challenge for otorhinolaryngologists. Hence, the aim of this review is to provide an interdisciplinary overview of these clinical syndromes and provide practical guidance for their diagnosis and treatment.

Current state of rumination syndrome.

Rumination syndrome (RS) is an underdiagnosed behavioral disorder of recurrent regurgitation. Regurgitation occurs in RS due to increased gastric pressure achieved by subconscious contraction of the abdominal musculature wall, reversing the pressure gradient between the esophagus and the stomach. RS is mainly diagnosed clinically by the Rome Criteria with symptoms of regurgitation without retching of recently ingested food into the mouth and subsequent spitting or re-mastication. When the diagnosis is unable to be made clinically, supportive testing including fed impedance manometry can be considered. RS occurs worldwide, affecting patients of all ages, races, and genders with a prevalence of 3.1-5.8%. There is significant overlap with RS and disorders of a gut-brain interaction and upright gastroesophageal reflux driven by aerophagia and supragastric belching. There is also an association with mood disorder, fibromyalgia, and eating disorders. RS may be misdiagnosed as a variety of other syndromes including gastroesophageal reflux disease, gastroparesis, achalasia, and bulimia nervosa. Once RS is diagnosed, the mainstay of treatment is diaphragmatic breathing to lower the intragastric pressure and increase the lower esophageal pressure. Diaphragmatic breathing can be supported with biofeedback and cognitive behavioral therapy as well as medication options for more refractory cases. Response to therapy overtime and changes in symptoms overtime can now be tracked with a validated questionnaire.

Delay in diagnosis is associated with decreased treatment effectiveness in children with rumination syndrome.

Rumination syndrome (RS) is challenging to diagnose, which can lead to diagnostic delays. Our objective was to evaluate the length of time from RS symptom onset to diagnosis in patients referred to our institution and to examine whether this duration predicts treatment outcomes. We conducted a review of patients with RS evaluated at our institution. Data were collected from chart review and patient/family reported questionnaires. We evaluated the time from symptom onset to diagnosis over time and whether it was associated with symptom resolution. We included 247 patients with RS (60% female, median age of 14 years, interquartile range [IQR]: 9-16 years). The median age at symptom onset was 11 years (IQR: 5-14 years) and median age at diagnosis was 13 years (IQR: 9-15 years) for a median duration of 1 year (IQR: 0-3 years) between symptom onset and diagnosis. Length of time between symptom onset and diagnosis did not change significantly at our institution from 2016 to 2022. Among the 164 children with outcome data, 47 (29%) met criteria for symptom resolution after treatment. A longer time to diagnosis was associated with a lower likelihood of symptom resolution after treatment (p = 0.01). In our experience, the time to RS diagnosis after symptom onset is shorter than previously described. A longer delay in diagnosis is associated with lower likelihood of symptom resolution after treatment, emphasizing the importance of a prompt recognition of rumination symptoms and a timely diagnosis.

Pilot Case Series Studying a Psychoeducational and Motivational Treatment for Children With Low-Weight Avoidant Restrictive Food Intake Disorder.

Research on treatments for children with avoidant restrictive food intake disorder (ARFID) is needed. This pilot case series describes outcome data for 20 children ages 6-12 years old with a diagnosis of ARFID and who are low-weight. Participants were recruited nationwide as part of an ongoing randomized clinical trial. All participants in this study received a 14-session psychoeducational and motivational treatment (PMT) protocol. Parents completed measures of ARFID severity (the Pica, ARFID, Rumination Disorder Interview) and parental self-efficacy (Parents vs. ARFID scale). Height and weight were self-reported by parents and percent of estimated body weight (%EBW) was calculated. Assessments occurred at baseline, 1-month within treatment, 2-months within treatment, end-of-treatment (EOT), and 6-month follow-up. Twenty children (10.34 ± 1.76 years; 85% Non-Hispanic; 75% White; 70% female; 84.16 ± 4.66% EBW) with low-weight ARFID and their parents received PMT-ARFID with a clinician specializing in eating disorders. By EOT, PARDI severity scores decreased (large effect size) parental self-efficacy increased (medium effect size), but %EBW remained unchanged. Additional research evaluating PMT in adequately powered clinical trials for youth with ARFID is needed.

RTMS as a Next Step in Antidepressant Nonresponders: A Randomized Comparison With Current Antidepressant Treatment Approaches.

Although repetitive transcranial magnetic stimulation (rTMS) is an effective treatment for depression, little is known about the comparative effectiveness of rTMS and other treatment options, such as antidepressants. In this multicenter randomized controlled trial, rTMS was compared with the next pharmacological treatment step in patients with treatment-resistant depression. Patients with unipolar nonpsychotic depression (N=89) with an inadequate response to at least two treatment trials were randomized to treatment with rTMS or to a switch of antidepressants, both in combination with psychotherapy. Treatment duration was 8 weeks and consisted of either 25 high-frequency rTMS sessions to the left dorsolateral prefrontal cortex or a switch of antidepressant medication following the Dutch treatment algorithm. The primary outcome was change in depression severity based on the Hamilton Depression Rating Scale (HAM-D). Secondary outcomes were response and remission rates as well as change in symptom dimensions (anhedonia, anxiety, sleep, rumination, and cognitive reactivity). Finally, expectations regarding treatment were assessed. rTMS resulted in a significantly larger reduction in depressive symptoms than medication, which was also reflected in higher response (37.5% vs. 14.6%) and remission (27.1% vs. 4.9%) rates. A larger decrease in symptoms of anxiety and anhedonia was observed after rTMS compared with a switch in antidepressants, and no difference from the medication group was seen for symptom reductions in rumination, cognitive reactivity, and sleep disorders. Expectations regarding treatment correlated with changes in HAM-D scores. In a sample of patients with moderately treatment-resistant depression, rTMS was more effective in reducing depressive symptoms than a switch of antidepressant medication. In addition, the findings suggest that the choice of treatment may be guided by specific symptom dimensions.

Ruminal acidosis and its definition: A critical review

Ruminal acidosis occurs as a continuum of disorders, stemming from ruminal dysbiosis and disorders of metabolism, of varying severity. The condition has a marked temporal dynamic expression resulting in cases expressing quite different rumen concentrations of VFA, lactic acid, ammonia, and rumen pH over time. Clinical ruminal acidosis is an important condition of cattle and subclinical ruminal acidosis (SRA) is very prevalent in many dairy populations with estimates between 10 to 26% of cows in early lactation. Estimates of the duration of a case suggest the lactational incidence of the condition may be as high as 500 cases per 100 cows in the first 100 d of lactation. Historical confusion about the etiology and pathogenesis of ruminal acidosis led to definitions that are not fit for purpose as acidic ruminal conditions solely characterized by ruminal pH determination at a single point fail to reflect the complexity of the condition. Use of a model, based on integrated ruminal measures including VFA, ammonia, lactic acid, and pH, for evaluating ruminal acidosis is fit for purpose, as indicated by meeting postulates for assessing metabolic disease, but requires a method to simplify application in the field. While it is likely that this model, that we have termed the Bramley Acidosis Model (BAM), will be refined, the critical value in the model is that it demonstrates that ruminal acidosis is much more than ruminal pH. Disease, milk yield and milk composition are more associated with the BAM than rumen pH alone. Two single VFA, propionate and valerate are sensitive and specific for SRA, especially when compared with rumen pH. Even with the use of such a model, astute evaluations of the condition whether in experimental or field circumstances will be aided by ancillary measures that can be used in parallel or in series to enhance diagnosis and interpretation. Sensing methods including rumination detection, behavior, milk analysis, and passive analysis of rumen function have the potential to improve the detection of SRA; however, these may advance more rapidly if SRA is defined more broadly than by ruminal pH alone.

An overview of digestive disorders of forestomach in cattles and buffaloes

Disorders affecting the forestomach in large ruminants pose significant challenges to livestock health and productivity, warranting comprehensive understanding and management strategies. This review explores the multifactorial etiology, clinical manifestations, diagnostic approaches, and therapeutic interventions for forestomach disorders in large ruminants, including rumen acidosis, bloat, ruminal impaction and traumatic reticuloperitonitis. Emphasis is placed on the role of nutrition, microbial flora imbalance, management practices, and environmental factors in predisposing animals to these conditions. Diagnostic modalities, ranging from clinical examination to advanced imaging laboratory techniques, are discussed for accurate diagnosis and timely intervention. Furthermore, therapeutic option, including dietary adjustments, rumenotomy and supportive care, are elucidated, along with preventive measures aimed at minimizing the occurrence and impact of forestomach disorders in large ruminants A holistic approach encompassing proper nutrition, herd management, and veterinary oversight is imperative for mitigating the economic and welfare implication associated with these disorders.

Seroprevalence and risk factors of Toxoplasma gondii infection among goats in Algeria

Toxoplasmosis is one of the most common zoonotic parasitic diseases worldwide and is caused by Toxoplasma gondii. It is implicated in reproductive disorders in small ruminants. This study aims to determine, for the first time in Algeria, the seroprevalence and associated factors of T. gondii infection in goats. The study was conducted in four regions, Ghardaia, Laghouat and Djelfa, southern Algeria, and Jijel region, northern Algeria. A total of 92 blood samples were collected including 74 females and 18 males. All sera were tested using an enzyme-linked immunosorbent assay (ELISA) to detect the T. gondii antibodies. The presence of anti-T. gondii antibodies was detected in 35 out of 92 goats (38.04%) (95% CI: 31.64%–44.44%) and in all flocks (100%). Risk factors that have a significant influence on the seroprevalence of T. gondii infection are breed, regions, production system, presence of cats, clinics and abortion history. However, variables such as age and gender were note significantly associated with toxoplasma infection in goats. The highest seroprevalences of infection was observed in saanen (52.94%) (p<0.001) and cross-breed race (44%) (p<0.01) in comparison with other breeds. Regarding regions, Jijel and Laghouat were most infected with seroprevalences of 50% (p<0.001) and 40.91% (p<0.01), respectively. Animals in intensive production systems were most infected, showing a seroprevalence of 51.85%, in comparison with extensive (28.13%) and semi-intensive systems (36.36%) (p<0.001). The presence of cats in farms was significantly associated with high seroprevalence (44.64%) (p<0.001). The infection was more prevalent in previously aborted females (50%) than females that had never aborted (3.35%) (p<0.001)and animals that have diarrhoea or poor health (41.67%) were significantly more infected than healthy animals (37.50%) (p<0.01). Seroprevalence in males (38.89%) was very close to those in females (37.84%) (p>0.05). Age-related seroprevalence did not vary significantly (ranged from 36.37% to 40%) between the three age classes. These results indicate that goat toxoplasmosis is widespread in Algeria, and goats may represent a high risk of contamination for humans. This requires more attention during consumption of goat meat.

Lyophilized rumen fluid as a ruminal fermentation modifier in high grain-fed acidotic goats.

Rumen cud transfaunation re-establishes rumen micro environment and improves fermentation in recipient animals affected with digestive disorders. Preserving rumen cud or fluid will increase its availability for the treatment of rumen fermentation disorders, without having to maintain donor animals. Rumen fluid collected from healthy goats, fed standard ration having roughage 70% and concentrate 30%, was lyophilized (prefreezing -80°C, 48h; lyophilization -45°C, 32h) using 5% glycerol as cryoprotectant. The 16 S metagenome analysis of the lyophilized rumen fluid (LRF) revealed an abundance of Prevotella (33.2%). Selenomonas ruminantium (1.87%) and Megasphaera elsdenii (0.23%) were also present. Twenty-four goats having history of high grain feeding and exhibiting clinical symptoms of rumen fermentation disorders were randomly distributed into either one of the two treatment groups viz., T1 = oral administration of LRF 31g/animal/day and T2 = oral administration of sodium bicarbonate (SB) 15g/animal/day. Post intervention LRF and SB, improved animal body condition, feed intake, fecal consistency, elevated the ruminal pH at 48h, reduced propionate and lactate at 48h, reduced total volatile fatty acids (TVFA) and ammonia nitrogen at 24h. Significant reduction in serum blood urea nitrogen (BUN) and urea levels were observed even from 24h post intervention irrespective of the treatments. LRF significantly improved acetate and decreased propionate production compared to SB. LRF at 7.5% (v/v) can thus be used to counteract ruminal fermentation disorders in goats sequel to high grain ration.

Multiple paths to rumination within a network analytical framework

Theories of rumination have proposed different psychological factors to place one at risk for repetitive negative thinking. A comprehensive empirical test that captures the most relevant contributors to rumination is lacking. Building on influential self-regulatory and metacognitive frameworks, we modeled how key constructs in this context relate to ruminative thinking. 498 participants completed online questionnaires including indicators of rumination, metacognition, promotion goal orientation, effortful control, and depression. We estimated regularized partial correlation networks to investigate unique associations between the different constructs and followed these analyses up with directed acyclic graphs to identify potential pathways towards rumination. Results demonstrated that: (1) both self-regulatory and metacognitive factors were directly linked to rumination, amongst these were (2) positive beliefs, negative beliefs about uncontrollability and harm, cognitive self-consciousness, depression, effortful control, perfectionism, and (lack of) cognitive confidence, and (3) we identified multiple directed pathways, suggesting three direct contributors to rumination while controlling for the influence of all other variables: diminished effortful control, positive beliefs, and cognitive self-consciousness. This study is the first to comprehensively assess metacognitive and self-regulatory frameworks of rumination in a data-driven manner. Our findings suggest that there are multiple pathways towards rumination, which should be incorporated in clinical case conceptualization of rumination and related disorders.

Prospective 2-Year Course and Predictors of Outcome in Avoidant/Restrictive Food Intake Disorder

To evaluate the 2-year course and outcomes of full and subthreshold avoidant/restrictive food intake disorder (ARFID) in youth aged 9 to 23 at baseline using a prospective longitudinal design to characterize the remission and persistence of ARFID, evaluate diagnostic crossover, and identify predictors of outcome. Greater severity in each ARFID profile-sensory sensitivity, fear of aversive consequences, and lack of interest-was hypothesized to predict greater likelihood of illness persistence, controlling for age, sex, body mass index percentile, ARFID treatment status, and baseline diagnosis. Participants (N= 100; age range, 9-23 years; 49% female; 91% White) were followed over 2 years. The Pica, ARFID, and Rumination Disorder Interview was used across 3 time points (baseline, year 1, year 2) to measure the severity of each ARFID profile and evaluate illness persistence or remission, and the Eating Disorder Assessment for DSM-5 was used to evaluate diagnostic crossover. Across the 2-year follow-up period, half the participants persisted with their original diagnosis, and 3% of participants experienced a diagnostic shift to anorexia nervosa. Greater severity in the sensory sensitivity and lack of interest profiles was associated with higher likelihood of ARFID persistence at year 1 only; greater severity in the fear of aversive consequences profile was associated with higher likelihood of ARFID remission at year 2 only. Findings underscore the distinctiveness of ARFID from other eating disorders and emphasize its persistence over 2 years. Results also highlight the predictive validity and prognostic value of ARFID profiles (ie, sensory sensitivity, fear of aversive consequences, lack of interest).

Isolation and identification of &lt;i&gt;Brucella abortus&lt;/i&gt; and &lt;i&gt;B. melitensis&lt;/i&gt; in ruminants with a history of abortion: the first report from Eritrea

Brucella species have never been isolated or documented in Eritrea. The present study was initiated to isolate and identify Brucella species that infect livestock in Eritrea. A total of 316 blood sera, 137 milk, 71 vaginal swabs, a placental cotyledon, and a fetal stomach content were sampled from 208 goat, 102 sheep, and 6 cattle. Series testing protocol starting with Rose Bengal plate test, followed by c-ELISA, culturing, and then multiplex AMOS-PCR was followed. The purpose-sampling strategy was applied, and animals with a history of abortion in the last three weeks were sampled to increase the probability of capturing Brucella species. Isolation was conducted on Burcella media agar, and Brucella broth was added with Brucella selective supplement containing 2,500IU polymyxin B, 12,500IU bacitracin, 50.0 mg cycloheximide, 2.5mg nalidixic acid, 50,000 IU nystatin, and 10.0 mg vancomycin. Accordingly, 41 animals were positive for a series of serological tests. The overall Brucella seropositive detection proportion was 13.0%, and goats constituted the majority 78% (n=32). The highest number of positive samples were from the Maekel region. Six Brucella organisms were successfully isolated from two milk samples, two vaginal swabs, one placental cotyledon, and one fetal stomach content obtained from seropositive animals. Among the Brucella isolates, five were B. melitensis, while the remaining one was B. abortus as per the multiplex AMOS- PCR assay. The present study documented the first B. abortus and B. melitensis isolates in Eritrea. Milk, vaginal discharges, placental cotyledon, and aborted fetus were identified as sources of Brucella for livestock and livestock keepers. Besides, the findings highlight a reasonable proportion of the reproductive disorders in cattle and small ruminants could be due to brucellosis. This calls for public sector intervention to control the diseases in animals and to enhance community awareness of good practices such as drinking boiled milk and avoiding contact with infected tissues and body discharges to prevent potential public health risks from zoonosis.

The role of high-resolution impedance manometry to identify rumination syndrome in children with unexplained foregut symptoms.

Diagnosis of rumination syndrome (RS) relies on Rome IV criteria. Oesophageal high-resolution impedance manometry (HRIM) can objectively demonstrate the episodes of rumination, but its role in the diagnostic pathway is not yet established. We aimed to demonstrate the clinical contribution of this tool for the timely diagnosis of RS and diagnostic work-up of children with unexplained foregut symptoms deemed to be due to other conditions. HRIMs performed between 2012 and 2021 were searched to retrieve all diagnoses of RS. Medical records were reviewed for clinical data. Out of 461 HRIMs performed, 76 children had manometric diagnosis of RS (35 male, median age: 13 years). Of them, 47% were not clinically suspected as the symptoms did not fulfil clinical criteria for RS. The indications for HRIM in these cases were investigation of unexplained foregut symptoms (37%), suspected refractory gastroesophageal reflux disease (8%) and dysphagia (2%). Among all HRIMs performed for investigations of unexplained foregut symptoms (n = 80), 35% demonstrated rumination episodes. Identification of characteristic patterns of rumination on HRIM in children with unexplained foregut symptoms enables the immediate diagnosis of RS. Thus, in situations of diagnostic uncertainty, the use of HRIM at early stages of the diagnostic pathway would reduce unnecessary investigations and treatments.

Questionnaire for diagnosis and response to therapy in rumination syndrome.

Rumination is a behavioral disorder characterized by regurgitation of food without retching. It is diagnosed clinically by the Rome Criteria and treated primarily by diaphragmatic breathing. Despite diagnosis and follow-up being based on symptomatic responses to therapies, there are no published or validated questionnaires. To address this care-gap, a rumination questionnaire was developed and reviewed by two expert esophagologists and five patients diagnosed with rumination. Ultimately, an eight-point questionnaire with scoring ranging from -1 to 10 was finalized. This newly developed questionnaire was implemented on five additional patients diagnosed clinically with rumination syndrome with improvement after interventions noted.

Screening for functional gastrointestinal disorders in preterm infants up to 12 months of corrected age: a prospective cohort study

Functional gastrointestinal disorders (FGIDs) are characterized by a variety of symptoms that are frequently age-dependent, chronic, or recurrent and are not explained by structural or biochemical abnormalities. There are studies in the literature reporting different results regarding the relationship between prematurity and FGIDs. The main objective of this study was to compare the frequency of FGIDs between preterm and term infants. The secondary objective was to evaluate whether there was any association between neonatal characteristics and development of FGIDs. A multicenter prospective cohort study that included preterm infants born before 37 weeks of gestation and healthy term infants was carried out. At 1, 2, 4, 6, 9, and 12 months of age, infants were assessed for the presence of FGIDs using the Rome IV criteria. In preterm infants, an additional follow-up visit was made at 12 months corrected age. 134 preterm and 104 term infants were enrolled in the study. Infantile colic, rumination syndrome, functional constipation, and infant dyschezia were more common in preterm infants. Incidence of other FGIDs (infant regurgitation, functional diarrhea and cyclic vomiting syndrome) were similar among preterm and term infants. Preterm infants who are exclusively breastfeed in the first 6 months of life have a lower incidence of infantile colic (18.8% vs 52.1%, p = 0.025). In terms of chronological age, FGIDs symptoms started later in preterm infants; this difference was statistically significant for infantile colic and regurgitation (median age 2 months vs 1 month, p < 0.001). Conclusions: Preterm infants have a higher prevalence of FGIDs compared with term controls. Therefore, especially if they have gastrointestinal complaints, they should be screened for FGIDs. Possibly due to maturational differences, the time of occurrence of FGIDs may differ in preterm infants. Infantile colic incidence decreases with exclusive breastfeeding.What is Known:• The functional gastrointestinal disorders are a very common in infancy.• Data on preterm infants with FGIDs are currently very limited.What is New:• Preterm infants have a higher incidence of infantile colic, rumination syndrome, functional constipation and infant dyschezia when compared to term infants.• Preterm infants who are exclusively breastfed during the first 6 months of life experience a lower incidence of infantile colic.

Early childhood-onset rumination syndrome is clinically distinct from adolescent-onset rumination syndrome.

Rumination syndrome (RS) beginning in early childhood or infancy is understudied and challenging to treat. Our objective is to compare the characteristics and outcomes of early-onset (EO) and adolescent-onset (AO) patients with RS. We conducted an ambidirectional cohort study of children diagnosed with RS at our institution. Patients were included in two groups: EO (RS symptom onset ≤5 years and diagnosis ≤12 years) and AO (onset >12 years). Patient characteristics, severity, and outcomes were compared between the groups. We included 49 EO and 52 AO RS patients. The median ages of symptom onset and diagnosis in EO were 3.5 and 6 years, respectively; AO, 14.5 and 15 years. EO RS had a slight male predominance while AO was predominantly female (p = 0.016). EO patients were more likely to have developmental delay (24% vs. 8%, p = 0.029) and less likely to have depression (0% vs. 23%, p < 0.001) or anxiety (14% vs. 40%, p = 0.004). At baseline, EO RS was less severe than AO RS: EO RS had greater regurgitation frequency (p < 0.001) but lower vomiting frequency (p = 0.001), resulting in less meal skipping (p < 0.001), reliance on tube feeding or parenteral nutrition (p < 0.001), and weight loss (p = 0.035). EO RS symptoms improved over time: at follow-up, patients had lower regurgitation (p < 0.001) and vomiting frequency (p < 0.001) compared to baseline. EO RS is clinically distinct from AO RS, with differences in sex distribution, comorbid conditions, and severity of initial presentation. The pathogenesis and natural history of EO RS may be distinct from that of AO RS.

Ruminal Acidosis Part II: Diagnosis, Prevention and Treatment

Ruminal acidosis is presented as the most significant nutritional disorder of ruminants with severe impact on animal health, welfare and considerable economics losses in ovine and bovine herds. The disease is presented in two forms Acute Ruminal Acidosis (ARA) and Sub-Acute Ruminal Acidosis (SARA). This second part of the Ruminal Acidosis review focuses on the diagnosis, prevention, and treatment. The diagnosis of SARA presents several difficulties due to the non- clinically patent symptoms. Prevention and treatment are based on the amelioration of nutrition including the use of dietary supplements, and antimicrobial administration as well as the improvement of management practices.&#x0D;

The relationship between the severity of intellectual and developmental disabilities (IDDs) in adults with IDDs and eating and drinking problems and nutritional status.

Adults with intellectual and developmental disabilities (IDDs) experience eating, drinking and swallowing problems, such as chewing problems, choking, gagging, coughing during eating, aspiration and rumination syndrome, which may lead to poor nutritional status. This study aimed to determine the relationship between IDD levels, eating, drinking and swallowing problems and nutritional status in adults with IDDs. The sample consisted of 71 participants (37 men and 34 women) with a mean age of 22.5±7years (range 18-60years). Professionals classified intellectual disability as mild, moderate or severe. The Screening Tool of Feeding Problems scale was applied to the caregivers of adults with IDDs to identify eating, drinking and swallowing problems. Dietary intake was assessed using a 24-h dietary recall and a food and nutrition photograph catalogue. The researchers measured body weight, height and middle upper arm circumference. Body mass index was calculated. Four body mass index categories were determined: underweight (<18.5kg/m2 ), normal weight (18.5-24.9kg/m2 ), overweight (25.0-29.9kg/m2 ) and obese (≥30kg/m2 ). Chi-squared tests were used to detect the relationship between IDD levels and eating and drinking problems, and analysis of variance tests were conducted to detect the relationship between IDD levels with anthropometric measurements and dietary intake. Participants had mild (42.3%; n=30), moderate (29.6%; n=21) or severe IDD (28.2%; n=20). They were underweight (12.7%; n=9), normal weight (59.2%; n=42) or overweight and/or obese (28.2%; n=20). Participants with severe IDD had significantly higher Screening Tool of Feeding Problems 'nutrition-related behaviour' and 'eating and drinking skill deficit problem' sub-scale scores than those with mild IDD. However, the groups had no significant difference in 'food refusal and selectivity' sub-scale scores. Participants with severe IDD also had anorexia prevalence similar to those with mild IDD. The groups did not significantly differ in anthropometric measurements, daily energy intake and macronutrient and micronutrient intake. While adults with severe IDD had more eating and drinking skill deficits (e.g. chewing problems and independent eating difficulties) and nutrition-related behaviour problems than those with mild IDD, the eating, drinking and swallowing problems, which may critically affect their food intake, were similar to adults with mild IDD. The anthropometric measurements and energy and nutrient intakes of adults with severe IDD were not significantly different from those with mild IDD consistently. Findings indicate that nutritional deficiencies and nutritional behaviour problems may be avoidable in adults with IDDs.

When symptoms are more than reflux.

45 year-old male patient with history of heartburn and regurgitation of non-acid food in the immediate postprandial period, with no symptomatic improvement after anti-acid treatment. The patient underwent an upper endoscopy that was unremarkable. A high-resolution impedance manometry (HRIM) was performed according to Chicago Protocol 4.0, as well as an additional solid test meal, with findings of rumination syndrome (RS) (figure 1). The study was completed with a 24-hour impedance pH monitoring that showed, in the immediate postprandial period, episodes of reflux that reached the proximal sensor followed by a normal swallow (figure 2). Abdominophrenic biofeedback was started with clinical improvement and anti-acid treatment was maintained at once a day. Discussion: RS is diagnosed by a complete clinical history, using the Rome IV or DSM-5 criteria (figure 3). Due to lack of knowledge of the disease and the fact that regurgitation can be present in other conditions including gastroesophageal reflux disease and achalasia, most patients undergo multiple tests and visit several physicians before reaching the diagnosis1. The gold standard investigation for RS, in cases where there are diagnostic doubts, is HRIM with solid meal administration, that shows a sudden increase in intragastric pressure > 30 mmHg concurrent with a drop in impedance and both simultaneous lower and upper esophageal sphincter relaxation, that may or may not be followed by re-swallowing food2. Rumination episodes can appear spontaneously (type 1) or may be preceded by a reflux episode (type 2) or a supragastric belch (type 3)3. 24-hour impedance pH monitoring cannot confirm de diagnosis, but during rumination, in the majority of episodes, the refluxed material reaches the proximal esophagus2.