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Development of gastroesophageal reflux disease (GERD) after gastrostomy remains debatable. Therefore, this study aimed to evaluate whether laparoscopy-aided gastrostomy (LAG) influence on the occurrence of GERD in neurologically impaired (NI) patients. Furthermore, we investigated whether preoperatively excluding NI patients with GERD can reduce the number of patients requiring subsequent anti-reflux surgery (ARS) after LAG. This retrospective study included 35 NI patients (median age: 11.0; interquartile range 5.0–23.5 years) who underwent LAG according to our criterion from October 2012 to June 2020 and MII-pH before and after LAG. MII-pH parameters were compared in all patients and among three age groups between before and after LAG. There were no significant differences in MII-pH parameters before and 1 year after LAG in all patients, and no patient underwent subsequent ARS. Only one paediatric patient with 64 number of reflux episodes before LAG required subsequent ARS 3 years after LAG. Generally, LAG did not influence the postoperative GERD at 1 year after LAG, and our criteria could reduce the number of patients requiring subsequent ARS. However, paediatric NI patients with higher number of reflux episodes in preoperative MII-pH study may need careful long-term follow-up after LAG.

Objective An important part of laparoscopic Nissen's fundoplication (LNF) is a proper wrap, which may only be possible with proper dissection of esophagus and hiatus. However, too much dissection of esophagus and hiatus to gain sufficient length of esophagus increases morbidity. The aim of this study is to analyze the effect of minimal esophagus dissection in LNF on recurrence and post-operative hiatal hernia. Methods The present study includes the children (0-18 years) who underwent LNF with minimal esophagus dissection and without hiatal closure between 2008 and 2016. The charts of the patients analyzed retrospectively and evaluated in terms of recurrence and post-operative hiatal hernia. Results There were 143 children. Mean age was 4.5±4.6 year (20 days-17 years). About 54% of the children (n=78) were neurologically impaired. There were two temporary intestinal obstructions which did not require surgery, one esophageal tightness which resolved with one dilatation session and one recurrence with hiatal hernia which required reoperation. Conclusion Minimal esophagus dissection without hiatal closure in LNF avoids dysphagia with no increase in the rate of recurrence and complications.

Purpose To evaluate the necessity of preoperative screening for gastroesophageal reflux (GER) prior to gastrostomy in neurologically impaired children. Methods Medical records of neurologically impaired children, who have undergone laparoscopic gastrostomy between January, 2004 and June, 2018, were retrospectively reviewed. Before the year of 2014, all patients who required gastrostomy had been routinely screened for GER pre-operatively, but after the year of 2014, only the ones with GER-related symptoms were tested. The characteristics and outcomes of Routine Screening (RS) and Selective Screening (SS) periods were compared. Results There were 55 and 54 patients in the RS and SS periods, respectively. Demographics, primary pathologies, and mean follow-up durations (> 2 years) were similar. The rate of GER screening was significantly lower in the SS period (29.6% vs. 63.6%). The rate of Laparoscopic Nissen Fundoplication (LNF) combined with gastrostomy was significantly lower in the SS period (14.8% vs. 38.2%). During follow-up, the rates of new-onset GER symptoms (13% vs. 11.7%) and LNF requirement later on (6.5% vs. 8.8%) were statistically similar between the two periods. Conclusion Routine screening for GER is not necessary prior to gastrostomy in neurologically impaired children. Symptom-selective screening algorithm is safe and efficient in the long term.

Evaluate health-related quality-of-life (HRQoL) measures in noncommunicative, neurologically impaired, developmentally delayed (NCNIDD) children compared to normally developing children (ND) who undergo cochlear implantation (CI).Cross-sectional survey of parents of NCNIDD and ND children who underwent CI.Two tertiary care medical centers.Questions comprising the Children With Cochlear Implants: Parental Perspectives survey were used in analysis. Average responses were calculated within 8 domains (communication, general functioning, self-reliance, well-being and happiness, social relationships, education, effects of implantation, and support the child). Groups were compared using Wilcoxon rank-sum test. Impact of individual and collective socioeconomic/family covariates was assessed using analysis of variance.Surveys were returned from 17 of 42 (40%) patients with NCNIDD and 35 of 131 (27%) patients with ND. There were no statistically significant differences between groups in survey response rate, age, sex, age at implantation, current age, or duration of implant use. Overall, parents of children with ND responded more favorably in all domains vs children with NCNIDD. Parents of children with NCNIDD answered neutrally or favorably in all domains, except "support the child" and "self-reliance" domains. Differences between groups in mean domain scores, univariably and almost universally when adjusting for socioeconomic and family variables individually and collectively, were statistically significant.This study suggests that HRQoL benefits of CI are perceived in most domains by parents of children with NCNIDD, albeit less strongly than children with ND. A survey sensitive to challenges of children with NCNIDD may better capture benefits that may not be apparent in this study.

OBJECTIVES The best surgical option to treat drooling in neurodisabilities is still under debate. The aim of this study was to describe the technique of subtotal functional sialoadenectomy (SFS) (ie four-duct ligation (4-DL) together with bilateral sublingual gland excision) and its long-term outcomes, in comparison with 4-DL. DESIGN Retrospective observational cohort study. SETTING Unit of Pediatric Surgery of Bambino Gesu Children's Hospital (Rome). PARTICIPANTS Seventy-five patients surgically treated for drooling between 2002 and 2012, with at least five years of follow-up, divided into two groups: 4-DL group (19 patients) underwent four-duct ligation, and SFS group (56 patients) underwent subtotal functional sialoadenectomy. MAIN OUTCOME MEASURES Primary end points were the evaluation of drooling improvement after surgery (parameters: Drooling Severity and Frequency Scale, DSFS; no of bibs/day; no of shirts/day; no of pneumonia/year; use of antidrooling drugs) and the comparison between two different surgical techniques. RESULTS Median age at surgery was 10 years (1-35). Long-term outcomes showed significant improvement in DSFS and in no of shirts/day in both groups. Significantly better results were found in the SFS group than in the 4-DL group as far as DSFS (P value .045), no of bibs/day (P value .041), no of shirts/day (P value .032) are concerned. Reoperation rate for recurrence was 42% in the 4-DL group and 0% in the SFS group (P value

Background: Activity-based therapy (ABT) for the upper extremity (UE) enables neurologic recovery with tasks that are functional, intense, and highly repetitive. A large proportion of rehabilitation occurs in the home and there is a gap in literature on the application of ABT within the home. The objective of this scoping review was to describe ABT in the home-setting for the neurologically-impaired UE. Methods: A systematic scoping review included searches of: MEDLINE, CINAHL, Cochrane, and OTSeeker. Results: A systematic search yielded 51 final studies. About 61% of ABT studies were exclusively within the home, others included outpatient visits (37%). Telerehabilitation was used in 37% of the studies with live-video and store forward techniques equally represented. ABT supported by technology was used in 61% of studies. Dosing of intervention ranged from 7 to 120 hours, with a mean of 34.5 hours of practice. Adherence with intended dosing was reported in 27% of studies and subjects completed a mean of 86% of the intended practice time. Sixty-seven percent of studies reported some degree of practice without therapist supervision. Conclusions: The results showed wide variability in the intervention methods, dosing and technology used in homebased settings. The high rate of adherence with dosing is encouraging for the application of homebased neurologic UE interventions. This scoping review highlights feasibility of UE ABT within the home and need for further research.

Children with intellectual disability/neurodevelopmental delay (ID-ND) commonly ingest foreign bodies (FB) and often present complications due to peculiar aspects of their condition. The aim of this paper is to report the experience of two centers in the management of ID-ND patients after FB ingestion and to discuss a possible algorithm for clinical practice. We retrospectively evaluated data of patients managed for FB ingestion (period: 2017–2021), focusing on those with ID-ND, specifically demographics and baseline diagnosis, elements related to the event, symptoms, time to endoscopy, FB location, endoscopic details, and follow-up. A total of 457 patients were managed in the study period and 19 had ID-ND (mean age 9.8 ± 3.5 years, 15 males). A total of 16/19 (84.2%) were symptomatic and required an operative approach. Recurrent ingestions and multiple FB were found in 2 and 11 patients, respectively. Endoscopy (mean time 65.6 ± 41 min) was effective in 14 cases (73.6%) and 6 patients (31.6%) developed a complication. FB ingestion in ID-ND patients represents a challenging condition for the clinician and a potentially dangerous situation. It should be addressed specifically by a multidisciplinary team considering a tailored diagnostic and management protocol.

Assessment of discomfort as a sign for early postoperative complications in neurologically impaired (NI) children is challenging. The necessity of early routine upper gastrointestinal (UGI) contrast studies following laparoscopic Nissen fundoplication in NI children is unclear. We aimed to evaluate the role of scheduled UGI contrast studies to identify early postoperative complications following laparoscopic Nissen fundoplication in NI children. Data for laparoscopic Nissen fundoplications performed in NI children between January 2004 and June 2021 were reviewed. A total of 103 patients were included, with 60 of these being boys. Mean age at initial operation was 6.51 (0.11–18.41) years. Mean body weight was 16.22 (3.3–62.5) kg. Mean duration of follow up was 4.15 (0.01–16.65 years) years. Thirteen redo fundoplications (12.5%) were performed during the follow up period, eleven had one redo and two had 2 redos. Elective postoperative UGI contrast studies were performed in 94 patients (91%). Early postoperative UGI contrast studies were able to identify only one complication: an intrathoracal wrap herniation on postoperative day five, necessitating a reoperation on day six. The use of early UGI contrast imaging following pediatric laparoscopic Nissen fundoplication is not necessary as it does not identify a significant number of acute postoperative complications requiring re-intervention.

Among the various cochlear implant systems approved by the Food and Drug Administration, current labeling for pediatric usage encompasses (1) bilateral profound bilateral sensorineural hearing loss in children aged 9 to 24 months and bilateral severe to profound sensorineural hearing loss in children older than 2 years; (2) use of appropriately fitted hearing aids for 3 months (this can be waived if there is evidence of ossification); and (3) demonstration of limited progress with auditory, speech, and language development. Pediatric guidelines require children to have significantly worse speech understanding before qualifying for cochlear implantation. The early years of life have been shown to be critical for speech and language development, and auditory deprivation is especially detrimental during this crucial time.Level of evidence: 2.

Background The costs and benefits of full lockdown measures are debated. Neurologically impaired children are a vulnerable population with specific needs in terms of protection against infection and access to health services. Objectives We investigated the effects of lockdown on the health of children with neurological disorders and on their access to care during lockdown. Methods Data from 514 children (282 males – 232 females) were collected through physician-administered interviews to investigate: the occurrence of viral-like physical symptoms, the correlation between the risk of developing such symptoms and several demographic and clinical variables, the occurrence of any worsening of the children's neurological conditions during lockdown, and their access to care services during this period. Results 49.1% experienced at least one symptom during the study period, but no child developed severe complications. The prevalence of symptoms was significantly lower during lockdown than during the previous two months. The underlying neurological condition worsened in 11.5% of the patients. Children who regularly left the home during lockdown were greater risk of exhibiting symptoms. During lockdown, 67.7% had a specialist appointment cancelled, 52.6% contacted their paediatrician, and 30.9% contacted their child neuropsychiatrist. Among patients who usually receive rehabilitation, 49.5% continued remotely. Conclusion Lockdown protected children from infections. Telemedicine and telerehabilitation constituted a valid alternative for the care and treatment of these children, but they should not become a widespread and definitive model of care. COVID-19 and other emergency response plans must take into account the specific needs of children with disabilities.

Adhesions and fibrosis following failed primary surgery for severe gastro-oesophageal reflux (GOR) in neurologically impaired children (NI) can render mobilization of the lower oesophagus and oesophago-jejunal anastomosis a technically demanding exercise both at open surgery and laparoscopy. This paper presents the Modified Oesophago-Gastric Dissociation (M-OGD) as a less complex technical modification of the original Total Oesophago-Gastric Dissociation (TOGD). The stomach is detached from the oesophago-gastric junction with an articulated 5-mm stapler, leaving a 5-mm strip of stomach attached to the oesophagus. An end-to-side isoperistaltic oesophago-jejunostomy is created between the gastric stump and the isoperistaltic jejunal Roux loop. A jejuno-jejunal anastomosis restores bowel continuity. Between May 2018 and February 2020, M-OGD was performed on 3 NI patients with a weight of 9–27.3 kg (median = 14 kg). Median age at surgery was 60 months (18–180), median surgical time 170 min (146–280), median re-feeding time was 3 days (2–5), and median length of stay was 20 days (11–25). All patients healed primarily and after a median follow-up of 3 months, there were no problems related to the oesophago-jejunal anastomosis. M-OGD reduces the difficulties of redo oesophageal surgery following failed anti-reflux procedures, with a safer oesophago-jejunal anastomosis and a good long-term outcome.

ObjectiveTo review the outcome of children with severe neurological impairment (NI) and intestinal failure (IF) referred to our specialist multidisciplinary IF rehabilitation service and to discuss implications.DesignCase report series, descriptive analysis.SettingIF rehabilitation programme at a tertiary children’s hospital in the UK.PatientsChildren with severe NI referred to our IF rehabilitation programme from 2009 to 2019.Main outcome measuresDemographic and social data, diagnosis, clinical condition, use of home parenteral nutrition (HPN), complications, ethics review outcome and advance care plans.ResultsSix patients with severe NI were referred to our IF rehabilitation service. Consent for publication was obtained from five families. After thorough medical review and clinical ethics committee assessment, three children started HPN, one had intravenous fluids in addition to enteral feed as tolerated and one intravenous fluids only. The HPN children survived 3–7.08 years (median 4.42 years) on treatment. Objective gastrointestinal signs, for example, bleeding improved without excessive HPN-related complications. Symptomatic improvement was less clear. Analgesia was reduced in three of the five children. All cases had detailed symptom management and advance care plans regularly updated.ConclusionsHPN can play a role in relieving gastrointestinal signs/symptoms in children with severe NI and IF. HPN can be conceptualised as part of good palliative care if judged to be in the child’s best interests. However, given its risks and that HPN has the potential to become inappropriately life-sustaining, a thorough ethics review and evaluation should be performed before it is initiated, withheld or withdrawn in children with severe NI.

Gastroesophageal reflux disease (GERD) especially in neurologically impaired children remains the main indication for anti-reflux surgery in children. Laparoscopic fundoplication is the treatment of choice. Several techniques have been described such as Nissen, Toupet, Boix-Ochoa, and Thal. This chapter summarizes the technique, pitfalls and useful tips of laparoscopic Thal fundoplication.

High-cost situations need to be avoided. However, occasionally, cost may only be learned by experience. Here, we tested whether an artificially induced unstable and invisible high-cost region, a "limit-push" force field, might reshape people's motion distributions. Healthy and neurologically impaired (chronic stroke) populations attempted 600 interceptions of a projectile while holding a robot handle that could render forces to the hand. The "limit-push," in the middle of the study, pushed the hand outward unless the hand stayed within a box-shaped region. Both healthy and some stroke survivors adapted through selection of safer actions, avoiding the high-cost regions (outside the box); they stayed more inside and even kept a greater distance from the box's boundaries. This was supported by other measures that showed subjects distributed their hand movements within the box more uniformly. These effects lasted a very short time after returning to the no-force condition. Although most robotic teaching approaches focus on shifting the mean, this limit-push treatment demonstrates how both mean and variance might be reshaped in motor training and neurorehabilitation.

We sought to investigate the reliability of standard conventional perimetry (SCP) in neurologically impaired (NI) children using the examiner-based assessment of reliability scoring system and to determine the difference in time to diagnosis of a visual field defect between SCP and a behavioural visual field (BVF) test. Patient records of 115 NI children were retrospectively analysed. The full field peritest (FFP) had best reliability with 44% ‘good’ scores versus 22% for Goldmann perimetry (p

Aim: To evaluate the long-term effects of nutritional improvement following percutaneous endoscopic gastrostomy (PEG) tube feeding stratified by previous feeding method and to assess the impact of underlying muscle tone on the outcomes of the nutritional intervention. Methods: Neurologically impaired children who underwent PEG tube insertion and nutritional intervention provided by a pediatric nutritional support team were enrolled. We measured anthropometric variables, laboratory parameters, and nutritional intake at baseline, 6 months after PEG insertion, and the last visit. We evaluated the percent ideal body weight (PIBW), body mass index (BMI)-for-age z-score, and percentiles and calculated the ratios of calorie intake compared to required requirement (CIR) and protein intake compared to recommended requirement (PIR). Results: The PIBW and BMI-for-age z-score improved during the first 6 months (p = 0.003 and p = 0.005, respectively). The CIR (p = 0.015) and PIR (p = 0.004) increased during the study period. The baseline BMI and PIBW of the previous nasogastric tube feeding group were better than those of the oral feeding group (p = 0.02 and p = 0.03, respectively). The BMI-for-age z-score, PIBW, CIR, and PIR improved in the hypertonic group (p = 0.03, 0.02, 0.03, and 0.01, respectively). Conclusion: PEG tube feeding and active nutritional intervention improved the nutritional status of neurologically impaired children immediately after PEG insertion. The nutritional requirements might vary by the muscle tonicity.

The benefits of exercising are well-recognized–experts and governmental health agencies agree that regular endurance training ...

Introduction: During cyclical steady state ambulation, such as walking, variability in stride intervals can indicate the state of the system. In order to define locomotor system function, observed variability in motor patterns, stride regulation and gait complexity must be assessed in the presence of a perturbation. Common perturbations, especially for military populations, are load carriage and an imposed locomotion pattern known as forced marching (FM). We examined the interactive effects of load magnitude and locomotion pattern on motor variability, stride regulation and gait complexity during bipedal ambulation in recruit-aged females. Methods: Eleven healthy physically active females (18–30 years) completed 1-min trials of running and FM at three load conditions: no additional weight/bodyweight (BW), an additional 25% of BW (BW + 25%), and an additional 45% of BW (BW + 45%). A goal equivalent manifold (GEM) approach was used to assess motor variability yielding relative variability (RV; ratio of “good” to “bad” variability) and detrended fluctuation analysis (DFA) to determine gait complexity on stride length (SL) and stride time (ST) parameters. DFA was also used on GEM outcomes to calculate stride regulation. Results: There was a main effect of load (p = 0.01) on RV; as load increased, RV decreased. There was a main effect of locomotion (p = 0.01), with FM exhibiting greater RV than running. Strides were regulated more tightly and corrected quicker at BW + 45% compared (p < 0.05) to BW. Stride regulation was greater for FM compared to running. There was a main effect of load for gait complexity (p = 0.002); as load increased gait complexity decreased, likewise FM had less (p = 0.02) gait complexity than running. Discussion: This study is the first to employ a GEM approach and a complexity analysis to gait tasks under load carriage. Reduction in “good” variability as load increases potentially exposes anatomical structures to repetitive site-specific loading. Furthermore, load carriage magnitudes of BW + 45% potentially destabilize the system making individuals less adaptable to additional perturbations. This is further evidenced by the decrease in gait complexity, which all participants demonstrated values similarly observed in neurologically impaired populations during the BW + 45% load condition.

Event-related potentials (ERPs) can provide important insights into underlying language processes in both unimpaired and neurologically impaired populations and may be particularly useful in aphasia. This scoping review was conducted to provide a comprehensive summary of how ERPs have been used with people with aphasia (PWA), with the goal of exploring the potential clinical application of ERPs in aphasia assessment and treatment. We identified 117 studies that met inclusionary criteria, reflecting six thematic domains of inquiry that relate to understanding both unimpaired and aphasic language processing and the use of ERPs with PWA. In these studies, a wide variety of ERP components were reported. Inconsistencies in reporting of participant characteristics and study protocols limit our ability to generalize beyond the individual studies and understand implications for clinical applicability. We discuss the potential roles of ERPs in aphasia management and make recommendations for further developing ERPs for clinical utility in PWA.

Liver retraction during laparoscopic fundoplication is important for obtaining an optimal space. Several methods have been developed, but the risks and benefits are unclear. We compared three different approaches and evaluated their safety and utility. Forty-three neurologically impaired patients who underwent laparoscopic fundoplication between 2005 and 2018 were classified into three groups: A, snake retractor method, n = 18; B, crural suture method, n = 13; C, needle grasper method, n = 12. Patients’ characteristics and outcomes were reviewed. The liver retraction time was significantly shorter in group C than in A or B (p

Background Neurologically impaired (NI) children are at increased risk of malnutrition due to several nutritional and non-nutritional factors. Under nutrition, growth failure, overweight, micronutrient deficiencies, and osteopenia are nutritional comorbidities that can affect them. Patients and Methods A case control study,302 patients were recruited from Children’s Hospital Ain Shams University with age range from 6 months to 16 years. They were divided into (group 1) 151 neurologically impaired children and (group 2) 151 age and sex matched healthy controls, group 1 was further classified into 4 subgroups according to motor or mental deficit. All patients were subjected to detailed History, dietetic history (3 day food diary), Feeding assessment questionnaire and Complete anthropometric measurements Results majority of studied patients (47.6%) had motor and mental affection ,feeding difficulties were high where Gagging occurred in (44.37%) Choking (39.47%)( Vomiting 21%) Limited volume(50%) Limited variety(40.4%) aspiration ( 51.66%) and food retention (41%) NI patients had significant lower values of recommended dietary allowance of calories, protein ,CHO ,fat ,iron, vitamin B1 and vitamin B2(p Conclusion feeding difficulties were significantly high in NI Children they suffered from restricted daily caloric intake required for their energy needs, resulting in a decrease of linear growth and a serious risk of malnutrition. Micronutrients deficiency is common in younger children with neurological disorders.

Provide an approach to the management of problems that children with medical complexity experience in the hospital, with particular attention to children with severe neurologic impairment. Children with medical complexity account for an increasing number of bed days and admissions in children’s hospitals and utilize resources far out of proportion to their numbers. They are often neurologically impaired and may be technology dependent. This group of children, however, are often excluded from studies, leaving the clinician with a limited evidence base to make treatment decisions. Although the causes of severe neurologic impairment are varied, the clinical problems these children encounter are similar and include respiratory infections, problems with secretions, dysphagia, feeding intolerance, constipation, gastroesophageal reflux, scoliosis, hip dysplasia, irritability, seizures, osteopenia, and bladder dysfunction, among others. Children with medical complexity due to severe neurological impairment are high utilizers of inpatient resources. Familiarity with the common and predictable problems they experience can assist the clinician in providing care for this population.

The problems of speech and language disorders on children with central nervous system disorders are dealt with in the literature of the subject from the perspective of various disciplines – medicine, linguistics, pedagogy, psychology and speech therapy. However, there are no clear definitions in the literature of semantic terms, the clinical picture, the substance of the disorder and their etiopathogenesis. Diagnosis of raised disorders in neurologically impaired children is a structured and multi‑specialist procedure using neurological, linguistic and psychological data, further impeded by ambiguity in the criteria for their description. In practice, a variety of approaches to naming and defining these disorders often stumbles on the discrepancies in the diagnosis, which leads to errors in communication between specialists. This article discusses the case of a four‑year‑old child with intrauterine hypothyroidism and second‑degree intraventricular haemorrhage with speech and language disorders, the example of which is terminological discrepancies. Problematyka zaburzeń mowy i języka u dzieci z uszkodzeniami centralnego układu nerwowego rozpatrywana jest w literaturze przedmiotu z perspektywy różnych dyscyplin naukowych – medycyny, językoznawstwa, pedagogiki, psychologii i logopedii. Jednakże w piśmiennictwie brak jest jednoznacznych rozstrzygnięć co do zakresów znaczeniowych terminów, obrazu klinicznego, istoty zaburzeń oraz ich etiopatogenezy. Diagnozowanie omawianych zaburzeń u dzieci obciążonych neurologicznie jest ustrukturyzowaną i wielospecjalistyczną procedurą wykorzystującą dane neurologiczne, lingwistyczne oraz psychologiczne, dodatkowo utrudnioną niejednoznacznością w kryteriach ich opisu. Wobec różnorodnych ujęć w nazewnictwie i definiowaniu omawianych zaburzeń w praktyce logopedycznej często natrafia się na rozbieżności w zakresie diagnozy, co prowadzi do błędów w komunikacji między specjalistami. W artykule omówiono przypadek dziecka czteroletniego z hipotrofią wewnątrzmaciczną i krwawieniem dokomorowym II stopnia, z występującymi zaburzeniami mowy i języka. Na jego przykładzie wskazano rozbieżności terminologiczne. Wydane przez Wydawnictwo Uniwersytetu Łódzkiego ze środków finansowych Zakładu Dialektologii Polskiej i Logopedii UŁ

Background/Aims The aim of this study is to investigate the degree of delayed gastric emptying (DGE) and evaluate how the severity of DGE affects gastroesophageal reflux disease (GERD) in neurologically impaired (NI) patients utilizing 24-hour multichannel intraluminal impedance pH measurements (pH/MII) and 13C-acetate breath test (13C-ABT) analyses. Methods 13C-ABT and pH/MII were conducted in 26 NI patients who were referred to our institution due to suspected GERD. At first, correlation analyses were performed to investigate the correlation between the 13C-ABT parameters and the clinical or pH/MII parameters. Thereafter, all patients were divided into 2 groups (DGE and severe DGE [SDGE] group) according to each cut off half emptying time (t1/2, 90-170 minutes). Each pH/MII parameter was compared between the 2 groups in each set-up cutoff t1/2. Results The mean t1/2 of all patients was 215.5 ± 237.2 minutes and the t1/2 of 24 (92.3%) patients were > 100 minutes. Significant moderate positive correlations were observed between both t1/2 and lag phase time and the non-acid reflux related parameters. Furthermore, the patients in the SDGE group demonstrated higher non-acid reflux related parameters than those of the DGE groups when the cutoff was t1/2 ≥ 140 minutes. Conclusion The present study demonstrated that GE with t1/2 ≥ 140 minutes was related to an increase of non-acid exposure reaching up to the proximal esophagus in NI patients, and indicating that NI patients with SDGE might have a high risk of non-acid GERD. (J Neurogastroenterol Motil 2017;23:533-540)

The present study aimed to evaluate the characteristics associated with a number of reflux episodes (NoRE) of 70 by comparing the clinical and multichannel intraluminal impedance pH measurements (pH/MII) and pH index (pHI) in neurologically impaired (NI) children.NI children (1-16 years of age) in whom pH/MII had been measured for GERD study were enrolled in this study. All children were divided into NoRE 70 or ≤70 and pHI 4.0 or ≤4.0,5.0 or ≤5.0 or7.0 or ≤7.0. In addition, the NI children with pHI 4.0, 5.0 and 7.0 were subdivided into NoRE 70 and ≤70 groups. The clinical and pH/MII measurements were compared between each of the two groups. The cutoff values of pHI and baseline impedance (BI) (Z6) were calculated to discriminate NoRE 70 and ≤70.A total of 61 NI children were enrolled in this study. There was a significant difference in the acid-related parameters, the NoRE (nonacid) and BI between NoRE 70 and ≤70, acid-related parameters and BI between pHI 4.0 and ≤4.0, 5.0 and ≤5.0 and7.0 and ≤7.0 groups. Furthermore, a significant difference was still observed in the BI between NoRE70 and ≤70 groups among patients with pHI4.0, 5.0 or 7.0. The cutoff values of pHI and BI (Z6) for discriminating NoRE70 and ≤70 were 9.2 and 1049Ω, respectively.The present study indicates that NoRE 70 corresponds to GERD in which patients suffer severe acid exposure with pH of around 9% and esophageal mucosal damage with low BI value in NI children.

Neural coupling between the central nervous system and the periphery is essential for the neural control of movement. Corticomuscular coherence is a popular linear technique to assess synchronised oscillatory activity in the sensorimotor system. This oscillatory coupling originates from ascending somatosensory feedback and descending motor commands. However, corticomuscular coherence cannot separate this bidirectionality. Furthermore, the sensorimotor system is nonlinear, resulting in cross‐frequency coupling. Cross‐frequency oscillations cannot be assessed nor exploited by linear measures. Here, we emphasise the need of novel coupling measures, which provide directionality and acknowledge nonlinearity, to unveil neural coupling in the sensorimotor system. We highlight recent advances in the field and argue that assessing directionality and nonlinearity of neural coupling will break new ground in the study of the control of movement in healthy and neurologically impaired individuals.