P = 0.012). Other endpoints, including cardiovascular and all-cause mortalities, were similar between the two groups. The changes in cardiovascular parameters did not differ between HDx with an MCO membrane and online-HDF. However, attention may be needed in patients with high CAC scores or scores with an increasing tendency when online-HDF is replaced with HDx with an MCO membrane.Expanded hemodialysis (HDx) with medium cutoff (MCO) membranes, which remove middle-to-large molecules well, may be a good option to replace online hemodiafiltration (online-HDF). To provide more evidence, this randomized controlled trial compared several cardiovascular parameters between patients undergoing HDx and online-HDF. Eighty patients undergoing thrice-weekly hemodialysis were randomly assigned to receive either HDx with a Theranova membrane (n = 43) or online-HDF (n = 37). The primary endpoints were changes in brachial-ankle pulse wave velocity (baPWV), echocardiographic parameters, and coronary artery calcium (CAC) scores over 1 year, and the secondary endpoints included blood cardiovascular biomarkers, mortality, and patient-reported outcomes. A linear mixed model and log-rank test were used to estimate the group differences. 65 patients had completed the trial. The changes in baPWV and echocardiographic parameters did not differ between the two groups. The CAC scores remained stable in the online-HDF group, whereas an increasing trend was shown in the HDx group ( In addition to traditional cardiovascular risk factors, nontraditional factors, including uremic toxins, electrolyte and fluid imbalance, anemia, and inflammation, contribute to worsening cardiovascular outcomes in ESRD5. In particular, uremic toxins induce oxidative stress and vascular inflammation and remodeling9. Furthermore, uremic conditions induce platelet activation and aggregation, which leads to thrombus formation8. All of these factors can explain the high risk of cardiovascular diseases in patients with ESRD.Cardiovascular disease is a leading cause of morbidity and mortality in patients with end-stage renal disease (ESRD)10. Given the potential association of middle-to-large uremic molecules but not small molecules with a high risk of cardiovascular disease12, the goal of treatment has been to enhance removal of these uremic toxins via HD membranes with increased permeability14. The technique used to increase the removal rate of middle-to-large molecules includes the use of high-flux membranes plus high dialysis intensity and alternative hemofiltration15. Although high-flux membranes improve the clearance of smaller middle molecules , larger middle solutes  may not be the target10. An increase in dialysis intensity has less effect on the plasma levels of potential cardiovascular toxins, which ultimately cannot improve patient survivals17. Online hemodialfiltration (online-HDF) is a great option for removing middle-to-large molecules with the help of ultrafiltration and subsequent convection. The online-HDF seems to represent the gold standard in removing uremic toxins among hemodialysis types18. This dialysis technique was related to improved cardiovascular outcomes in some studies20, although others did not show cardiovascular benefits related to online-HDF26. Despite the enhanced removal of middle-to-large molecules, it is difficult to make wide use of online-HDF due to the high cost, technical burden, and simultaneous risk of albumin loss15.Uremic toxins are removed by hemodialysis (HD), but diffusion-based approaches in the conventional mode are limited in their ability to completely remove these toxins27. This novel HD method has shown greater removal of middle-to-large molecules than conventional HD31. However, it is unknown whether the use of MCO membranes confers cardiovascular benefits compared with other dialysis techniques. Because online-HDF was associated with improved cardiovascular survival compared with a high-flux dialyzer in some pooled analyses20, this randomized, controlled study tried to address the noninferiority of HDx with an MCO membrane to online-HDF in terms of cardiovascular outcomes. For this purpose, several cardiovascular parameters, such as brachial-ankle pulse wave velocity (baPWV), echocardiography, and blood markers, were traced over a one-year study period.Expanded HD (HDx) is a treatment in which diffusion and convection are integrated inside a dialyzer equipped with a medium cutoff (MCO) membranehttps://cris.nih.go.kr/cris; ID, KCT0003188; date of registration, September 19th, 2018). The protocol was registered at Clinicaltrials.gov (ID: NCT03448887). All patients were recruited between April 2018 and May 2019 and signed an informed consent form to participate in the study. No changes were made to the procedures or study outcomes after trial commencement.The study was a multicenter, prospective, open-label, randomized trial with prevalent HD patients from the dialysis units of four tertiary referral hospitals in South Korea. The study was approved by the review boards of all hospitals  and was conducted in accordance with the principles of the Declaration of Helsinki. The study was registered at Clinical Research Information Service  in the study group or online-HDF  with a high-flux dialyzer  in the control group using a web-based randomization system. Randomization was stratified by the participating center and patient age (≥ 65 or < 65 years old). HD was conducted in three 4-h sessions per week, and the postdilution volume-controlled mode with a target convective ultrafiltration volume of ≥ 19 L and a dialysate flow rate of ≥ 500 mL/min was used in online-HDF. Adverse events during the study period were noted whether or not they were related to the treatments.Baseline clinical information was collected, such as age, sex, dialysis vintage, type of vascular access, comorbidities including diabetes mellitus, and previous history of myocardial infarction, cerebrovascular disease, congestive heart failure, peripheral vascular disease, and kidney transplantation. Kt/V was calculated by the second-generation formula for single-pool values to determine the appropriate level of HD.32. Using pulsed-wave spectral Doppler tissue images, the early transmitral inflow (E) and early diastolic mitral annular peak (e′) velocities were calculated to display E/e′ as an indicator of LV diastolic function. Noncontrast cardiac computed tomography was performed to obtain the CAC score. The Agatston score was used to calculate the CAC scores, which ranged from 0 to several thousand, indicating extensive coronary atherosclerosis33. The CAC scores were available in 41 patients in the HDx group and 35 patients in the online-HDF group, because 4 patients had stents in coronary arteries. Blood cardiovascular biomarkers, such as troponin I and T, brain natriuretic peptide (BNP), and N-terminal prohormone of BNP (NT-proBNP), were measured using electrochemiluminescence immunoassays. Plasma interleukin (IL)-6 was measured using an enzyme-linked immunosorbent assay kit . Other blood markers, such as albumin, calcium, phosphate, and high-sensitivity C-reactive protein, were also recorded by immunoturbidimetry and colorimetric assays.All cardiovascular parameters were recorded at baseline and 6 and 12 months after enrollment. The primary endpoints were the changes in cardiovascular parameters, such as baPWV, echocardiographic parameters, and coronary artery calcium (CAC) scores, from baseline to 12 months after enrollment. baPWV was measured using a noninvasive vascular testing device . The values were obtained from the arm contralateral to the patient’s vascular access. Transthoracic two-dimensional echocardiography was conducted to estimate the left ventricular ejection fraction (LVEF) and left ventricular mass index (LVMI)34, the degree of fatigue35, and the recovery time after dialysis36, were collected as secondary endpoints. The DSI contained 30 items targeting specific and common physical and emotional symptoms of HD patients. The degree of fatigue after dialysis ranged from 0 to 10, with high degrees indicating worse fatigue. The patients were requested to respond to a single open-ended question, “How long does it take you to recover from a dialysis session?” The recovery time was scored at five levels as follows: 1, within minutes; 2, upon arriving home; 3, by bedtime; 4, by the next morning; and 5, by the next dialysis session. Mortality and its causes were also evaluated based on prospective monitoring.Patient-reported outcomes, such as the Dialysis Symptom Index (DSI)37, a total of 74 patients were needed to provide 80% power at a two-sided alpha level of 0.05, to detect a mean difference of 0.3 m/s between the effect of the two modalities. We had added approximately 10% more participants to account for potential dropouts, resulting in a final enrollment goal of 80 participants (40 per group).The sample size was driven by the primary endpoint, baPWV. When standard deviations of 0.5 m/s and 0.4 m/s in the online-HDF and conventional HD, respectively, from the best estimates were assumedU test for continuous variables and with the chi-square test for categorical variables. Linear mixed-effects models were used to assess changes from baseline and differences between groups in primary and secondary endpoints with treatment assignment and time as fixed effects and patients as random effects. The estimated changes at 6 and 12 months in each group and the differences between groups  are presented with means and 95% confidence intervals. Because there was no prespecified plan to adjust for multiple comparisons, P values and their corresponding 95% confidence intervals were not adjusted for multiple tests, and a Bonferroni-adjusted significance of 0.025  was applied to account for two tests for between-group differences at 6 and 12 months. Kaplan–Meier survival curves were drawn to evaluate the all-cause and cardiovascular mortalities. The log-rank test was used to compare survival curves. Cox proportional hazard ratio models were conducted to calculate hazard ratios of the mortality risk. A P value less than 0.05 was considered significant in other analyses. All of the analyses were performed using STATA software  and GraphPad Prism .All analyses were conducted based on the intention-to-treat principle. Categorical and continuous variables are expressed as proportions and the means ± standard deviations for normally distributed variables and as the median with interquartile range for nonnormally distributed variables. A comparison of baseline characteristics was performed with the unpaired t-test or Mann–Whitney Eighty-six patients were initially assessed for eligibility for the study between April 2018 and May 2019. Six patients were excluded because they refused to participate in the study. Finally, a total of 80 patients were randomized, and 65 patients were followed up until the end of the study  were further adjusted, the overall results remained unaltered .The changes in blood biomarkers, including troponins I and T, BNP, NT-proBNP, high-sensitivity C-reactive protein, and IL-6, did not differ between the two groups Table . When adThere were 6 deaths  during the study period Table . Of themThe baseline DSI scores, degree of fatigue, and recovery time after dialysis were not different between the two groups Table . The chaUremic toxin, a result of ESRD, is associated with high cardiovascular risk. However, conventional HD may not be enough to remove all uremic toxins, particularly middle-to-large molecules. This prospective, open-label, multicenter, randomized, controlled trial indicated that HDx with an MCO membrane was not inferior to online-HDF in terms of cardiovascular risk according to the change trends in the values of baPWV, LVEF, LVMI, E/e′, and other blood biomarkers. Additionally, the changes in patient-reported outcomes did not differ between the two groups. However, compared with the online-HDF group, the HDx group had an increasing trend in CAC scores, although this endpoint was not followed in some patients.38. A representative randomized, controlled trial wherein 86 patients received HDx with a Theranova membrane and 86 other patients received conventional high-flux dialyzer identified a great reduction in middle-to-large molecules such as free light chains, complements, and cytokines when using HDx, but serum albumin levels were maintained similarly between the two groups30. However, there are no studies that address the effects of HDx on cardiovascular endpoints, such as surrogate markers and mortality, and this clinical trial was the first to compare cardiovascular parameters between HDx and online-HDF.Previous studies have shown the superiority of HDx with a Theranova membrane to conventional HD in removing middle-to-large molecules while ensuring retention of albumin26. Of them, the Estudio de Supervivencia de Hemodiafiltración On-Line trial was the only one to show a reduction in all-cause and cardiovascular mortalities for the online-HDF arm compared with the high-flux HD arm. None of the others showed elevated cardiovascular survival, although the clearance of middle-to-large molecules improved in online-HDF. Corresponding meta-analyses reported survival and cardiovascular benefits for online-HDF compared with conventional HD41. Post hoc and pooled analyses suggest that a high convection volume may be needed to show better outcomes in online-HDF than in conventional HD25. European regulatory authorities have allowed online-HDF to be used in patients with uncontrolled hyperphosphatemia and those suffering from complications such as amyloidosis42, but this issue may not be similarly accepted in other countries because of limitations in setting up online-HDF. Before conducting online-HDF, new machines, quality control in substituting fluids, and trained staff are needed, all of which limit its utilization, particularly in primary clinics or developing countries43. The present results may support the interchangeability of HDx with an MCO membrane when online-HDF is recommended in terms of cardiovascular benefit.Five randomized, controlled trials have been conducted in different European countries to determine the benefits for survival and other outcomes  in online-HDF44. The CAC, a marker of vascular remodeling in ESRD patients46, seemed to be worsening in the HDx group compared with the online-HDF group. However, not only were these results based on subgroup analysis because of missing data in some patients, but the normal aging process might mask the changes caused by uremia-related calcification, particularly in elderly patients9. Nevertheless, the choice of HD modality between HDx with an MCO membrane and online-HDF may be affected, particularly when CAC scores are aggravated along with HD.In terms of uremic status, vascular remodeling, characterized by a high degree of both intimal and medial calcifications, is promoted via bone-related proteins and transformation of vascular smooth muscle cells into osteoblastic-like cells48, but one randomized, controlled trial  did not demonstrate a benefit of online-HDF using the Kidney Disease Quality of Life-Short form survey49. In the case of HDx with an MCO membrane, a randomized, controlled trial  demonstrated the benefit of HDx in quality of life, although another randomized, controlled trial  showed no difference between groups50. The present trial measured three different patient-reported outcomes, because these are more predictive of outcomes than the Kidney Disease Quality of Life-Short form52, and found no difference between HDx and online-HDF. Based on these results, HDx with an MCO membrane may be a good alternative to online-HDF in patients receiving conventional HD who want to use the latter in order to improve their quality of life.Previous studies have shown that patients on online-HDF had better quality of life than patients on conventional HDAlthough the trial results are informative, there are some issues that need to be discussed. The trial was conducted only in Korean patients, and thus, the dialysis settings or the risk of cardiovascular disease may be different in other populations. The study duration and sample size were relatively short and low, respectively. Most of the measurements were conducted in the individual hospitals, not in a central laboratory, which might increase the measurement variability, although the same protocol was used. Other important parameters were not examined, such as residual kidney function, intradialytic hemodynamic stability, and nutritional status.HDx with an MCO membrane was not inferior to online-HDF in terms of cardiovascular parameters. Accordingly, the former can be a good alternative to the latter. This issue may be more important in clinics where online-HDF is not available. However, when online-HDF is replaced with HDx with an MCO membrane, attention may be needed in patients with a high CAC score or a CAC score with an increasing trend. Large clinical trials with other populations and long-term follow-up durations are needed to confirm the present results.Supplementary Information.


Previous studies from the developed countries showed that children born very low birth weight have a higher risk of hypertension compared with that of the normal birth weight controls. However, studies regarding the prevalence of hypertension in such children from the developing countries are scarce. This study aimed to identify the perinatal and postnatal factors associated with hypertension in children born very low birth weight.p = 0.045) and a greater proportion of current obesity  compared to those in the normotensive group. Multivariate analysis revealed that current obesity was associated with hypertension . Among 36 children with normal office blood pressure, four children (11.1%) had high blood pressure uncovered by ABPM, called “masked hypertension”. Office systolic blood pressure at the 85th percentile was the greatest predictor for masked hypertension with a sensitivity of 75% and a specificity of 81.2%.Forty-six children aged ≥ 6 years from the VLBW cohort of Ramathibodi Hospital, Bangkok, Thailand underwent the ambulatory blood pressure monitoring. The prevalence of hypertension was 15.2% (7/46). The hypertension group had a significant higher BMI z-score at 3 years of age (0.90 ± 1.44 vs − 0.45 ± 1.47,  The World Health Organization estimated the prevalence of preterm birth to be 5–18% across 184 countries and the preterm birth rates have been increasing in almost all countries . In pretPatients who have normal office blood pressure but elevated out-of-office blood pressure are called having “masked hypertension” . CompareChildren aged ≥ 6 years from the cohort of children born VLBW (< 1500 g) at Ramathibodi Hospital, Bangkok, Thailand were enrolled. Children who had chronic diseases that may contribute to the development of hypertension e.g. known kidney diseases, etc., or who were not contactable at the time of recruitment were excluded. Detailed perinatal data were collected including gestational age, birth weight, maternal hypertension during pregnancy, antenatal steroid therapy, umbilical catheter insertion, and other perinatal problems such as respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, etc. The birth weight z-score was calculated according to the Fenton growth for preterm infants , 17. BeiMeasurements of office blood pressure were performed by oscillometric method using Dinamap™ V100 . The device was applied in the right arm with a corrected cuff size after being rest for 5 min in the sitting position with feet on the floor and arm and back supported. Readings were taken three times after resting for five minutes between measurements and the average of the three measurements was used for analysis. Z-scores of office blood pressure were calculated based on the normative pediatric BP tables of normal-weight children by the American Academy of Pediatrics . Office ABPM was performed with the A&D TM-2430 device , which has been validated for use in children and adolescents . Measure® software version 22 was used for analysis. Data were presented as percentages, mean and standard deviation or median and interquartile range (IQR), as appropriate. Categorical data were compared using the chi-square test or Fisher’s exact test, as appropriate. Student’s t-test or Mann–Whitney U test was used for comparison of continuous data between the two groups, as appropriate. Factors associated with hypertension were analyzed by univariate logistic regression and the potential significant parameters (p ≤ 0.2) were selected to be analyzed with multivariate analysis. The receiver operating characteristic (ROC) curve was used to analyze the performance of the parameters for detecting masked hypertension. A p ≤ 0.05 was considered statistically significant.The IBM SPSSThe data of all patients born VLBW in the pediatric department during the years 2004 and 2012 were reviewed. From this population (402 patients), only 110 patients were contactable at the time of recruitment due to changes in the address and telephone numbers. Of these, 37 patients were living in the other regions and 10 patients refused to participate in this study. Seventeen patients were excluded from the study due to severe BPD (1), obstructive sleep apnea (4), known chronic kidney diseases (3), central nervous system anomalies (2), and attention deficit hyperactivity disorder who received psychostimulants (7). Therefore, 46 patients  participated in this study. Baseline characteristics of all participants were summarized in Table Office blood pressure and ABPM were performed in all participants. Regarding office blood pressure, 10 patients of 46 participants (21.7%) had office hypertension. Among patients with office hypertension, 3 patients had hypertension confirmed by ABPM so-called “sustained hypertension”, while another 7 patients had normal ambulatory blood pressure so-called “white-coat hypertension”. Regarding 36 patients with normal office blood pressure, 4 children (11.1%) had masked hypertension uncovered by ABPM. Therefore, the overall prevalence of hypertension was 15.2% (7/46).p = 0.045). Comparisons of the current anthropometric parameters and laboratory investigation between the groups with and without hypertension were presented in Table p < 0.01) and higher WHR  compared to those in the normotensive group. Multivariate analysis adjusted for birth weight and antenatal steroid exposure and birth weight showed that current obesity was a significant factor associated with hypertension  as shown in Table Comparisons of perinatal parameters and postnatal growth between patients with and without hypertension were presented in Table p = 0.01). The ROC analysis showed that SBP z-score was the best predictor of masked hypertension with the area under the curve of 0.85. The office SBP cutoff level at the 85th percentile had a sensitivity of 75% and a specificity of 81.2%.Regarding 36 children with normal office blood pressure, 4 patients with masked hypertension had a significantly higher mean office SBP z-score than that of the group without masked hypertension  and specificity (81.2%) to predict masked hypertension. Hamdani G et al. reported that the 85th percentile of SBP had a sensitivity of 86.8% and a specificity of 57.4% to diagnose ambulatory hypertension in healthy adolescents . As sameThe prevalence of hypertension was 15.2% in this cohort of children born VLBW. The current obesity was an independent factor associated with hypertension during the childhood period.The present study had some limitations. The sample size was small, especially the proportion of children with masked hypertension. This might not have enough power to detect some differences of the parameters between the groups with and without hypertension. Due to a retrospective design with a cross-sectional survey, incomplete data existed. Office BP was measured on only one visit, therefore it might not correctly define office hypertension. Lastly, there was no available standard ambulatory blood pressure tables for Thai children, so the authors used a normogram reported by the European investigators .


We studied the relationship between exhaled H2 and diarrhea in KTR, and explored potential clinical and dietary determinants. Methods: Clinical, laboratory, and dietary data were analyzed from 424 KTR participating in the TransplantLines Biobank and Cohort Study (NCT03272841). Fasting exhaled H2 concentration was measured using a model DP Quintron Gas Chromatograph. Diarrhea was defined as fast transit time  of 3 or more episodes per day. We studied the association between exhaled H2 and diarrhea with multivariable logistic regression analysis, and explored potential determinants using linear regression. Results: KTR  had a median exhaled H2 of 11 (5.0–25.0) ppm. Signs of small intestinal bacterial overgrowth  were present in 31.6% of the KTR, and 33.0% had diarrhea. Exhaled H2 was associated with an increased risk of diarrhea . Polysaccharide intake was independently associated with higher H2 , and a trend for an association with proton-pump inhibitor use was observed (std. β 0.16 p = 0.05). Conclusion: Higher exhaled H2 is associated with an increased risk of diarrhea in KTR. Our findings set the stage for further studies investigating the relationship between dietary factors, small bowel dysbiosis, and diarrhea after kidney transplantation.Background: Diarrhea is common among kidney transplant recipients (KTR). Exhaled hydrogen (H Kidney transplantation is the preferred treatment for end-stage kidney disease (ESKD) . Given t2), carbon dioxide (CO2), and methane (CH4) [2) can be used as a non-invasive surrogate marker for small intestinal bacterial overgrowth [2 is associated with the risk of diarrhea in KTR is currently unknown, and the role of post-kidney transplant medication regimens  and diet composition as potential determinants of exhaled H2 have not been investigated.It has recently been shown that KTR are commonly affected by an unbalanced gut microbiome, i.e., gut dysbiosis, characterized by a diminished microbial diversity ,8. Emergne (CH4) . Exhaledergrowth . Whether2 in a large KTR cohort, to study its relationship with diarrhea and to investigate its potential clinical and dietary determinants.Therefore, in the current study we assessed exhaled HThis is a cross-sectional study based on data from the TransplantLines Biobank and Cohort Study , conducted at the outpatient clinic of the University Medical Centre Groningen , which investigates all different types of solid organ transplant recipients [2). Body surface area (BSA) was calculated using the formula of Du Bois and Du Bois [Clinical data were collected according to a detailed protocol, as described elsewhere . Patient Du Bois . Estimat Du Bois . Body co Du Bois .2 results were automatically corrected for CO2 in order to reduce the chance of dilution by environmental air. A fasting basal  exhaled H2 concentration above 20 parts per million (ppm) was considered suggestively positive for small intestinal bacterial overgrowth (SIBO) as suggested elsewhere [Breath samples were collected in a 50 cc syringe with a hole of 6 mm at approximately 40 cc with a 3-way-stopcock. Patients were fasting (and therefore did not ingest any carbohydrates) for at least eight hours and were not allowed to smoke for at least one hour before the sample collection . The stulsewhere ,9,10,11.One day before the study visit, participants had collected a stool sample at home with a FaecesCatcher  . The samEquation: Percentage of dry matter stool samples.The stool form and consistency were graded using the Bristol Stool Form Scale (BSFS) . The scaDietary intake was assessed using a validated self-administered food frequency questionnaire (FFQ) . A trainp < 0.05 was considered significant. Variable distribution was evaluated by Kolmogorov–Smirnov test. Categorical variables are presented as n (%), normally distributed variables as mean ± standard deviation (SD), and non-normally distributed variables as median (interquartile range). We divided patients into three groups according to exhaled hydrogen. The highest group was defined as >20 ppm  with Bonferroni post hoc tests for normally distributed variables and the Kruskal–Wallis test for non-normal distribution. Possible determinants of exhaled H2 were studied using univariable linear regression. Since we aimed to explore the potential relevance of any clinical or nutritional factor as potential determinant of exhaled H2, we tested all available variables in individual univariable regression analysis. Subsequently, all variables with a p < 0.05 were included in a multivariable linear regression model to identify independent determinants of exhaled H2 production. Residuals were checked for normality and variables were natural log-transformed when appropriate. Multivariable logistic regression was performed to determine the potential relationship between exhaled H2 and diarrhea. Variables of known clinical importance for diarrhea in KTR, such as age, sex, eGFR, transplant vintage, immunosuppressive use [2 determinants, such as use of PPI and polysaccharides intake, were used in the model.Statistical analyses were performed using IBM SPSS version 23.0 . In all analyses, for SIBO ,9,10,11)sive use ,20, and 2. According to the BSFS, 33% of KTR had diarrhea. Further clinical and laboratory characteristics are shown in 2 concentration . One-hundred thirty-four (134) out of 424 patients (31.6%) were considered positive for small intestinal bacterial overgrowth (H2 ≥ 20 ppm). KTR in the highest H2 group had lower BMI  and body fat percentage  when compared to the lowest H2 group. Patients in the highest H2 group also had lower waist circumference when compared to both the lowest and intermediate group .A total of 424 KTR  male) were included in the study. The median transplant vintage was 1.8 (1.0–7.2) years, and 16.3% had a history of allograft rejection. With respect to comorbidities, 19.3% and 73.3% of patients had diabetes and hypertension, respectively. The mean eGFR was 49.8 ± 19.1 mL/min/1.73 m2 group had significantly higher levels of tacrolimus when compared to the lowest H2 group, and a trend when compared to the intermediate group . KTR in the intermediate  and highest  H2 groups more commonly used proton-pump inhibitors when compared to the lowest group , p = 0.01, while use of statins and antihypertensive drugs were similar among the groups. Nutritional data  and higher intake of polysaccharides  when compared to the lowest and intermediate groups, respectively.The immunosuppressive regimen consisted mostly of triple therapy including prednisolone  and mycophenolate mofetil (MMF) (73.3%) in combination with the calcineurin inhibitor tacrolimus (78.5%) or cyclosporine (9.0%). Alternatively, regimens could contain azathioprine (5.7%) or everolimus (2.4%). When comparing the groups, we did not find statistical differences regarding immunosuppressive regimens. When comparing immunosuppressive trough blood concentrations, the highest Hnal data  showed n2. Associations were explored for all factors shown in 2 and mono/disaccharides  and vitamin C intake , as well as a positive association with polysaccharide intake . Other possible influencing factors, such as waist circumference (WC), total cholesterol, low-density lipoprotein (LDL)-cholesterol, tacrolimus trough blood, and use of proton-pump inhibitors were also significant in univariable analyses. In multivariable linear regression analyses, only polysaccharide intake remained independently associated with exhaled H2 , while a trend for an association with proton-pump inhibitor use was observed .We subsequently performed linear regression to investigate possible clinical, laboratory and dietary factors determinants of exhaled H2 and the use of MMF were significantly associated with diarrhea according to BSFS , while adjusting for potential confounders including age, sex, eGFR, transplant vintage, tacrolimus use, and polysaccharides intake. Although individuals with higher stool water content also had a higher number of evacuation episodes , the number of evacuation episodes was not associated with H2 .2 group displayed a trend towards higher percentage of water stool content when compared to the lowest group . Linear regression analysis disclosed a trend for an association between exhaled H2 and stool water content .Feces samples of 75 KTR were available for the analysis of water content. Patients in the highest H2 higher than 20 ppm. In multivariable-adjusted analyses, exhaled H2 was associated with an increased risk of diarrhea in KTR. We identified polysaccharide intake as an independent dietary determinant of exhaled H2. The present data suggest a relationship between small bowel dysbiosis, diarrhea, and diet after kidney transplantation.Diarrhea is a common complication after kidney transplantation ,22, withAs a frequent GI symptom after kidney transplantation, diarrhea may be related to infections, antibiotics, or immunosuppressive drugs . In the 2 and MMF use with the presence of diarrhea. MMF use has consistently been implicated in posttransplant diarrhea [2 and diarrhea is in line with previous data outside the transplant population [2 in both fasting state and following ingestion of a substrate [We observed independent associations between both exhaled Hdiarrhea . Our finpulation . In irriubstrate .2 and diarrhea, we hypothesize that lipopolysaccharide (LPS) present in Gram-negative bacteria, the most common microorganisms related to SIBO, may promote local inflammation, causing mucosal lesions and increasing intestinal permeability, disabsorption syndrome, and increased nutrient fermentation [2 in humans only occurs through microbial anaerobic fermentation of unabsorbed carbohydrates [2 is generally considered a marker for alterations in small bowel microbiota composition. Since higher levels of exhaled H2 can be caused either by slow transit or by bacterial overgrowth with a delayed return of exhaled H2 to baseline levels, Romagnuolo et al. [2 levels ≥20 ppm can be representative of SIBO. In agreement, Corazza et al. [2 values were significantly higher than in healthy volunteers  [2 of 2.0 ± 2.5 ppm after a dinner meal in healthy subjects, with no value exceeding 11.0 ppm, whereas exhaled H2 after an identical meal in patients with bacterial overgrowth exceeded 48 ppm [2 can be considered suggestive of SIBO, potentially connecting higher exhaled H2 with the observed increased risk of diarrhea.Although our study did not reveal potential mechanisms underlying the association between exhaled Hentation . Becausehydrates , higher o et al.  states ta et al.  have dem< 0.001) . Perman < 0.001)  observedd 48 ppm . These s2 tended to have higher stool water content and the percentage of stool water content was positively associated with both exhaled H2 and the number of evacuation episodes. An experimental study has disclosed that greater gastro-intestinal H2 content shortened colonic transit time by 47% in the proximal colon, and by 10% in the distal colon [2 production.In addition, patients with higher exhaled Hal colon . These d2, with a trend for an association with H2 in multiple linear regression, which is in line with the notion that exhaled H2 is associated with small intestinal microbiota overgrowth.A recent meta-analysis suggested that the use of proton-pump inhibitors (PPI) can moderately increase the risk of SIBO . Since g2. Polysaccharides are complex carbohydrates that can be divided into starch and non-starch [2 groups, we assume higher starch intake as the main cause of higher polysaccharide intake. Some starch, known as resistant starch (RS), escapes digestion in the small intestine and, upon reaching the large intestine, acts similarly to dietary fiber, fermenting and incorporating water [A complex interplay exists between diet, GI transit, and gut microbiota . In the n-starch . Since tng water . Our finng water . In the ng water ,40. At tBacteroides and various Firmicutes [Ruminococcus, Coprococcus, and Dorea, were significantly reduced in fecal specimens from patients with diarrhea [RS and other types of starch that escape digestion in the small intestine may be quantitatively more important as substrates of fermentation than non-starch polysaccharides in the colon . While trmicutes . A studydiarrhea ,45. Thes2 produced by bacterial fermentation depends significantly on methanogenic and sulfate-reducing bacteria that convert H2 to methane and hydrogen sulfide [Methanobrevibacter smithii, which plays an important role upon removing the end-product H2 from bacterial fermentation, was reduced in KTR [2 metabolization, also contributing to a rise in the gas levels in the breath test.Another important fact to be highlighted is that the elimination of the H sulfide . We reced in KTR . These f2 and diarrhea in a large-scale cohort of KTR. The breath test we used is widely available, safe, inexpensive, and noninvasive, advantages that make it ideal for daily clinical practice employment. Limitations of the present study include the cross-sectional nature, precluding conclusions on causality, the single H2 measurement, which does not necessarily reflect the entire post-transplant period, and the lack of information regarding the course and duration of diarrhea (acute or chronic). Since our study population consisted almost entirely of Caucasians, our results cannot be extrapolated to different populations. The purpose of performing the breath test was to investigate exhaled H2 in KTR under fasting basal conditions . Although some investigators suggest that the use of fasting hydrogen is insufficient for SIBO diagnosis [To the best of our knowledge, this is the first study to evaluate the relationship between exhaled Hiagnosis , fastingiagnosis ,10,32,332 higher than 20 ppm was present in 31.6% of KTR, which was associated with increased risk of diarrhea. Polysaccharide intake was an independent determinant of exhaled H2. The present results suggest that diarrhea in KTR may reflect an altered small bowel gut microbial composition, at least partly under dietary control. These data encourage future studies to validate our findings; to further investigate the associations between the diet, small bowel dysbiosis, and post-kidney transplant diarrhea; and to explore whether lowering polysaccharide intake or correction of SIBO may reduce diarrhea in KTR. Characterizing small intestinal bacterial overgrowth in post-transplant patients with GI symptoms could support more focused antibacterial or dietary therapeutic approaches.In conclusion, a fasting exhaled H


The effectiveness of pulmonary rehabilitation (PR) has not yet been established in patients with asthma – chronic obstructive pulmonary disease overlap (ACO) depending on their nutritional status. We aimed to evaluate the effectiveness of a short-term PR program in patients with comorbid asthma, chronic obstructive pulmonary disease (COPD), and obesity. We included 40 ACO patients and divided them into 3 groups according to body mass index (BMI) and then subdivided them into PR (n=21) and control (n=19) groups. The COPD Assessment Test (CAT), the Asthma Control Test (ACT), and the modified Medical Research Council dyspnea scale (mMRS) were used to evaluate symptoms levels. BODE index  was used to evaluate the effectiveness of pulmonary rehabilitation. In addition, spirometry and bioimpedansometry were performed. All measurements were done before and after a 6-month PR program. A significantly lower decline in the BODE index was observed in overweight patients (decreased by 43.6% compared to baseline and lower by 40.7% compared to the control group). The six-minute walking test (6MWT) significantly increased in all groups (p<0.001). There was a decrease in total CAT score by 25.4% and by 31.2% in the overweight group (p<0.001). The BMI decreased more in the obese group (by 9.4% compared to baseline). Our study result showed that early use of PR program significantly improves functional capacity and BODE index, leads to dyspnea and CAT scores reduction and improvement in pulmonary function, cause a decrease in BMI, body fat percentage, and visceral fat level, and an increase in muscle mass in overweight and obese patients with ACO. There has been increasing recognition of the clinical overlap between asthma and chronic obstructive pulmonary disease (COPD) in recent years, known as asthma-COPD overlap (ACO). Patients with ACO have more respiratory symptoms, more frequent exacerbations and hospital admissions, lower quality of life, a more noticeable decline in lung function, and a higher mortality rate than those with asthma or COPD alone –4. CurreA total of 40 ACO patients (mean age 64.86±9.81 years) were recruited into the study, and following baseline assessment were divided into three groups: normal body mass index (BMI 18.5–24.9) – n=13, overweight (BMI<25–29.9) – n=13, and obese patients (BMI≥30) n=14. Patients in all 3 groups were additionally subdivided into the PR group, which included 7 patients from each group . The effectiveness of PR was evaluated compared with the control group (n=19). There were no significant differences in baseline demographic and clinical characteristics between PR and control groups. All subjects included were previously prescribed long-acting bronchodilators in combination with inhaled corticosteroids (ICS). The study was conducted from October 15, 2018, until February 10, 2020. All patients were included at the time of hospital admission due to exacerbation and received written and oral information about the study and their right to withdraw. The inclusion criteria were as follows: diagnosis of asthma, COPD, age more than 40 years, and spirometry with persistent airflow limitation, not fully reversible, but with current or historical variability. ACO was defined as the presence of features shared with both diseases and a similar number of features for asthma and COPD, according to the Global Initiative for Asthma (GINA)/ the Global Initiative for Obstructive Lung Disease (GOLD) criteria [e.g., unstable angina, unstable arrhythmias), BMI<18.5, severe renal impairment. The PR program included combined strength and endurance training five times a week for 30 minutes, education, breathing techniques, psychological consulting, and dietetic support for obese patients. All patients were interviewed with a series of questionnaires, including the COPD Assessment Test (CAT), the Asthma Control Test (ACT), and the modified Medical Research Council dyspnoea scale (mMRS) for evaluation of the symptom level. Spirometry testing was performed using a computer spirograph “BTL-08 SpiroPro” (Great Britain). To evaluate the effectiveness of PR, the BODE index  (performed in accordance with the American Thoracic Society/European Respiratory Society statement) was used. Weight and body composition variables were measured using a segmental body composition monitor . All measurements were done before and after a 6-month PR program. Data are presented as mean±standard deviation. The Mann-Whitney U test was used to compare differences between normal weight and obesity groups, normal weight and overweight groups, and overweight and obesity groups. Wilcoxon signed-rank test was used to compare the outcome variables in the PR and control groups at baseline and after six months. All statistical analyses were performed using SPSS Statistics 23.0.The exclusion criteria were clinically significant orthopedic or cognitive impairment, any previous history of thoracic surgical intervention, history of myocardial infarction, unstable cardiovascular disease (Baseline forced expiratory volume in 1 second (FEV1) was lower in patients with normal BMI by 5.4% compared to patients with obesity and 12.2% compared to overweight patients, but the difference was not significant (p>0.05) . Overweiet al. suggested using the BODE index to assess the effectiveness of rehabilitation programs [The coexistence of asthma and COPD features increases the burden of disease and challenges current diagnostic and therapeutic strategies, making the ACO a significant clinical entity. The GINA  and the programs . We founprograms . Simultaprograms . ConsequTherefore, the analysis of the obtained data confirmed the effectiveness of the PR program in patients with comorbid asthma, COPD, and obesity. However, key limitations in the current study were the small number of participants and that our study design did not allow us to assess the optimal duration of the PR program. Therefore, future research is needed, and it is important to examine the effect of long-term PR in the ACO population, especially in the precision medicine era.Early use of PR program significantly improves functional capacity and BODE index, leading to dyspnoea and CAT score reduction and improvement in pulmonary function, causing a decrease in BMI, body fat percentage, and visceral fat level and an increase in muscle mass in overweight and obese patients with ACO.The study is a fragment of the planned research work of the Department of Propedeutics of Internal Diseases of the Bukovinian State Medical University– Medicamentic correction of metabolic and immunological disorders, intensity of systemic inflammation and endothelial dysfunction in patients with comorbid cardiovascular and broncho obstructive diseases, musculoskeletal disorders and chronic dermatoses (state registration number 0120U101550).The authors declare no conflict of interest.This study was approved by the Committee on Bioethics of Higher State Educational Establishment of Ukraine, Bukovinian State Medical University, (No 2/2019).Written informed consent was obtained from the participants in the study.OH and HS contributed to conceptualizing, OF and AB contributed to the methodology, OH contributed to writing the original draft, HS and OF contributed to editing the manuscript, OH and AB contributed to data collection, OH and HS contributed to data analysis.


We consider that acupuncture to the abdomen could be an alternative antispasmodic method during upper gastrointestinal endoscopic procedure.A prospective study was conducted in patients with early-stage gastric cancer to determine the efficacy and safety of acupuncture stimulation as an antispasmodic compared with conventional medication during the procedure of endoscopic submucosal dissection (ESD) of the upper gastrointestinal tract. This study was a prospective single blinded quasi-randomized controlled trial. Seventy-three patients who were scheduled to undergo ESD for gastric cancer at Aizu Medical Center between 19 February 2016 and 30 June 2016 were assessed for eligibility for the study. Sixty out of 73 patients were included in the study and assigned into two intervention groups: medication group (MG) and acupuncture group (AG). Ease of the procedure was evaluated using modified NIWA classification (MNC) by endoscopist considering the frequency and amplitude of the upper gastrointestinal peristalsis. For the statistical analysis, Mann–Whitney test was used to compare the differences of MNC values (baseline and end of procedure) between two groups. The difference of MNC found in the AG (−2.00 (−3.0 to −2.0)) was significantly greater than that in the MG (−1.00 (−2.0 to −1.0),  Endoscopic submucosal dissection (ESD) is a procedure that enables en bloc resection of gastric neoplastic lesions, and ESD is the first-line treatment for early-stage gastrointestinal cancer ,2.Adverse events during ESD procedure such as perforation and bleeding may be caused by poor visualization of the resection area besides fibrosis or scars ,4,5. As Normally, antispasmodic agents such as “anticholinergics” and “glucagon” are used, but for patients with underlying diseases such drugs may be contraindicated or require careful administration. According to a nationwide survey on the adverse events during gastroendoscopy in Japan, cases of accidental events due to the use of antispasmodic agents were observed . FurtherAcupuncture is a non-pharmacological treatment with less adverse events than that observed in conventional medicine. Of various effects of acupuncture on the upper and lower gastrointestinal organ reported , acupuncOur purpose is to verify whether acupuncture stimulation to CV12 can be an alternative treatment for antispasmodic agents in ESD procedure.We prospectively compared acupuncture with conventional antispasmodic agent in terms of the antispasmodic effect on the stomach and the safeness during ESD procedure for early-stage gastric cancer patients. The study design is quasi-randomized parallel group study. It was shown in the detailed protocol of this study ).Patients who were scheduled to undergo ESD for gastric cancer at Aizu Medical Center between 24 February 2016 and 30 June 2016 were screened for eligibility for the study. H. pylori infection. Early-stage gastric cancer was pathologically diagnosed using endoscopy prior to ESD . Af. Af13]. The patients were not informed in advance which group they were going to be assigned in but were informed about it after ESD. In addition, the endoscopist and the operator knew in advance about which procedure (acupuncture or medication) was to be taken. On the other hand, the biostatisticians performed the analysis with the patient assignment information masked.The ease of procedure according to the state of the upper gastrointestinal peristalsis during ESD was evaluated by the endoscopist using the Modified NIWA classification (MNC)  12,14].,14.12,14Visual analogue scale (VAS) was also utilized in order to evaluate the ease of the procedure. VAS is a 100 mm horizontal scale of which the left end (0 mm) represents “the easiest” and the right end (100 mm) “the most difficult”. MNC and VAS were evaluated twice for each procedure. The first was after inserting an endoscope and marking the tumor (baseline), and the second was when the procedure was completed (endpoint). The primary outcome measures and secondary outcome measures were obtained by independent evaluators.Bleeding (intraoperative and postoperative), perforation (intraoperative and delay) due to ESD. Here, bleeding during the procedure is defined as when bleeding continued even after coagulation with normal hemostats, and when clipping or alcohol local injection had to be performed. Bleeding after treatment is defined as when hemostasis at the excised site had to be performed by upper gastrointestinal endoscopy because hematemesis, melena, or shock was observed.Perforation was defined as when a perforation was clearly confirmed during the operation and endoscopic clip closure was performed. Delayed perforation was defined as when peritonitis was suspected, and free air was found by abdominal X-ray or CT scan.Additionally, blood pressure fluctuation was monitored during procedure. Blood pressure fluctuations were defined as greater than 30% increase or decrease from the baseline value  and such increase or decrease last for 3 min or more within 5 min after intervention with antispasmodics or acupuncture.Presence or absence of aspiration pneumonia after treatment was evaluated comprehensively by not only respiratory symptoms , and fever, but also findings by images of chest X-ray or chest CT, and sputum examination and blood culture.In accordance with the ASA Physical Status Classification System (ASA-PS) , the opeOther outcome measures related to complications were:Statistical analysis of this study was conducted by independent two biostatisticians . In order to avoid bias, the biostatisticians performed the statistical analysis with grouping information masked.The sample size of this study was computed based on the expected value of the primary outcome, which is the change in the MNC at the end of the ESD. Previous studies have reported that gastric peristalsis was suppressed by about 1.8 points in MNC when acupuncture was applied to the abdomen (CV12) during upper gastrointestinal endoscopy procedure. Furthermore, the difference of MNC change between the acupuncture group and the medication group was 0.2 points . As the Thus, the required sample size was calculated to be 46 patients (MG 23 and AG 23) to detect a minimal difference of MNC means = 1 with SD = 1 at a significance level of 0.05 (α = 0.05) with a power of 0.9 (β = 0.1). In this study, 30 patients per group were recruited in anticipation of a certain dropout.This study was conducted with the full analysis set (FAS), therefore participants who were not able to complete the study were excluded from the analysis. All the data were made into a dataset by an independent data entry operator.The measured continuous and ordinal variables were presented as Medians and interquartile ranges (IQR), and count variables as numbers and percentages. Clinical baseline characteristics data were compared between the two groups by the Mann–Whitney test for continuous variables, and the chi-square test for count variables whenever appropriate. The main analysis, the difference between baseline and endpoint was compared using Mann–Whitney test for ordinal variables and continuous variables, and the chi-square test for count variables whenever appropriate. All statistical analyses were performed using STATA software, version 15 .During the period from 24 February 2016 to 30 June 2016, 73 patients with the clinically diagnosed early-stage gastric cancer were found to meet the inclusion criteria. Among them, 13 people were excluded: four cases had a history of subtotal excision of gastric cancer in the past and 9 cases did not consent to the clinical trial. Sixty patients out of these 73 agreed to participate in the study. Of those participants, 14 were unable to complete the study because there was no peristalsis in the stomach (7 in the MG and 7 in the AG) . The baseline characteristics of the patients in each group are shown .p < 0.0001) (The MNC decreased from 4.00 (3.0 to 4.0) unit at the baseline to 1.00 (1.0 to 1.0) unit after ESD in the AG, and 4.00 (3.0 to 4.0) unit to 2.00 (2.0 to 3.0) unit in the MG, respectively. The difference in the MNC in the AG (−2.00 (−3.0 to −2.0)) unit was significantly greater than that in the MG (−1.00 (−2.0 to −1.0) unit; by Mann–Whitney test,  0.0001) A.p < 0.0001). (The difference of VAS in the AG −73.00 (−87.0 to −59.0) mm was significantly greater than that in the MG −41.00 (−65.0 to −29.0) mm . B The mai0.0001). ).The procedure time and anesthesia time were significantly longer in the AG than in the MG, but the resected area was also greater in the AG. On the one hand, the amount of anesthetic used during procedure was not significantly different between the two groups .The numbers of complications such as bleeding, perforation, emergency surgery, and aspiration pneumonia were few in both groups and were not significantly different. p = 0.001 ) than in the MG (14 (60.86%)),  = 0.001 . The median (IRQ) amount of glucagon used in the MG was 0.5 (0.5 to 1.0) ml. Additionally, the number of patients who received additional administration of glucagon due to recurrence of peristalsis during the procedure was seven. No serious adverse events due to acupuncture stimulation were reported.This is the first study that evaluated the usefulness of acupuncture for suppressing gastric peristalsis during ESD procedure. For patients, successful gastric cancer surgery is of paramount importance. For that purpose, it is important to minimize troubles during the operation, and suppression of gastric peristalsis is one of them. In this study, we found that acupuncture stimulation on the abdomen, by its gastric relaxation effect, suppressed the gastric peristalsis and made the procedure easier than with the antispasmodic agent. The antispasmodic agent used in this study was glucagon, of which the gastrointestinal motility-suppressing effect was first reported by Stunkard et al. in 1972. AS Chernish et al. confirmed its usefulness as a pretreatment for gastrointestinal examination ,18, it hIn this study, more frequent adverse events were observed in the MG than in the AG, and most of them were blood pressure fluctuations. The increase in the blood pressure is considered as a result of elevated activity in the sympathetic nervous system due to hypoglycemia as a reaction to the hyperglycemic effect of glucagon. This is considered as a result of overreaction of the parasympathetic nerve activity to the elevated sympathetic activity. In the AG, few patients had blood pressure fluctuations and it is considered that the burden on the endoscopist due to blood pressure fluctuation was lowered. The migrating motor complex (MMC), which is a cyclical phenomenon of gastric motility of human in fasted state, consists of four phases: Phase I is a quiescent period with no contractions; phase II has intermittent, irregular low-amplitude contractions; phase III has short burst of regular high-amplitude contractions; and phase IV is a short transition period back to phase I. Contractions occur every 90–120 min periodically ,20. In oAcupuncture stimulates the skin and muscle sensory nerves and communicates through branch projections to the medulla oblongata, the cerebral aqueduct, and the hypothalamus via the spinal thalamus. Based on such nerve pathway it exerts a regulating action, an analgesic action, and an anti-stress action of the autonomic nerve .The following mechanisms are considered to work when gastric motility is suppressed by acupuncture stimulation to the abdomen: The peristalsis inhibitory effect of acupuncture is a somatic visceral reflex caused by mechanically noxious stimuli to the skin and muscles of the abdomen which through afferent pathways are transmitted to the spinal cord segmentally .As the rIn the acupuncture stimulation to CV12 that we performed in this study, as the depth of the acupuncture reached the white line of the abdominal muscle, and the fascia and white line were strongly stimulated by the acupuncture, it was considered that gastric motility was suppressed by the sympathetic nervous system via reflex and RVML.We also would like to mention that this study has some limitations. Firstly, this study was a quasi-randomized controlled trial. This pilot study was conducted as an unprecedented attempt to develop a complementary medicine for antispasmodics in ESD. As it was not clear how much antispasmodic effects in the upper gastrointestinal tract to be caused by acupuncture, we planned this quasi-randomization by assigning the first 10 cases to the acupuncture group with acupuncture stimulation and confirmed its antispasmodic effect. Therefore, confounding factors may not be adjusted because it is not a normal RCT, and the results should be considered conservatively.Secondly, although subjects and the statisticians were not aware of the assignment, the endoscopists and the acupuncture practitioners were not masked. In particular, as the endoscopists knew which group each case was in, the possibility of introducing information bias cannot be denied. However, as the relaxation effect of the stomach caused by acupuncture was obvious, we consider that the sufficiently correct evaluation was performed. If acupuncture could serve as an alternative to upper gastrointestinal antispasmodics, non-inferiority studies should be done in the future.We devised a usage of acupuncture to the abdomen as an alternative to antispasmodic drugs used during ESD of early gastric cancer. Acupuncture stimulation to the abdomen produced a relaxing action on the stomach and an antispasmodic effect was confirmed. In addition, compared to the drug, acupuncture stimulation to the abdomen was found to be significantly better in ease of surgery score and to have less fluctuation of blood pressure during the operation. It was considered that acupuncture to the abdomen could be an alternative to drugs. To extend our research, we may consider the idea that acupuncture stimulation could be used as an antispasmodic agent for duodenum or colon during endoscopic retrograde cholangiopancreationography (ERCP) or colon ESD.


Firmicutes, Actinobacteria, and Bacteroidetes, colonize the surface of the respiratory mucosa of healthy people. They interact and coexist with the local mucosal immune system of the human airway, maintaining the immune stability and balance of the respiratory system. While suffering from chronic respiratory diseases, the microbial population in the airway changes and the proportion of Proteobacteria is increased in patients with asthma. The abundance of the microbial population in patients with chronic obstructive pulmonary disease (COPD) is decreased, and conversely, the proportion of Firmicutes and Proteobacteria increased. The diversity of airway microorganisms in cystic fibrosis (CF) patients is decreased, while pathogenic bacteria and conditional pathogenic bacteria are proliferated in large numbers. The proportion of Firmicutes and Proteobacteria is increased in patients with upper airway cough syndrome (UACS), which replaces the dominance of Streptococcus and Neisseria in the pharynx of a normal population. Therefore, a clear understanding of the immune process of the airway flora and the immune dysfunction of the flora on the pathogenesis of chronic respiratory diseases can provide new ideas for the prevention and treatment of human respiratory diseases.Large quantities of bacteria, including  The human body carries a huge group of microbial populations, which constitutes a complex and delicate ecosystem. The complex interaction between microbes and the human immune system determines the health of the human body. The airway is an open cavity connecting the human body with the outside world. It is always invaded by external microbes, so it has strong local immunity. For example, the airway contains not only motile cilia, strong secretory goblet cells, and secretory IgA on the mucosal surface but also abundant mucosal-associated lymphoid tissue under the mucosa, which is sufficient to cope with the invasion of external pathogens . Once thFirmicutes, Actinobacteria, Bacteroidetes, Proteobacteria, and Fusobacteria [Large quantities of bacteria colonize the surface of the respiratory mucosa of healthy people, of which the main groups are bacteria . Bacteribacteria . This isbacteria , 14. Howbacteria .Streptococcus pneumoniae and Chlamydia pneumoniae infections were common during acute asthma attacks [Proteobacteria in the flora was significantly different from that of healthy people [Moraxella catarrhalis, Haemophilus influenzae, or Streptococcus pneumoniae, were increased significantly, which were related to the severity and acute exacerbation of asthma [Proteobacteria, including Haemophilus influenzae, Pseudomonas aeruginosa, Klebsiella pneumonia, and other respiratory pathogens, in respiratory specimens of asthma patients was higher than that of the normal population. The increase in these pathogens was also found in patients with irregular inhaled hormone therapy, suggesting that this feature of respiratory flora was a characteristic of asthma itself and not simply a result of immunosuppression caused by inhaled hormones. In contrast, the proportion of Prevotella of Bacteroidetes in the airways of asthma patients was lower than that of the normal population [Asthma is a kind of disease that is well-recognized as immune dysfunction of the respiratory system, which is defined as a clinical syndrome of intermittent respiratory symptoms caused by viral upper respiratory infections, environmental allergens, or other stimuli, characterized by nonspecific bronchial hyperresponsiveness and airway inflammation , 17. Due attacks . Analysiy people . Throughf asthma , 22. Thepulation –25.Haemophilus influenzae and Haemophilus parainfluenza were impaired in response to dexamethasone, which was found in some patients with hormone-resistant asthma [The distribution of different bacterial communities is also related to the features of asthma. Airway microbes and asthma patients also have certain effects on the responsiveness of glucocorticoids. In vitro studies have shown that monocytes and macrophages cocultured with t asthma . Studiest asthma , 28. Thet asthma .These studies indicated that changes in respiratory flora would increase types of pathogenic bacteria but reduce types of normal flora and biomass in asthma patients, suggesting that the immune dysregulation of the respiratory flora may be one of the causes of asthma attacks.COPD is a highly heterogeneous disease that seriously affects human health. It is characterized by persistent airflow obstruction and increasing airway chronic inflammatory response to harmful particles or gases. Exposure to noxious smoke and particles is a major driver for the progression of COPD. At the same time, other factors also play a part, such as genetic predisposition, nutritional status, and respiratory infection . The rolProteobacteria such as Pseudomonadaceae, Burkholderiaceae, and Enterobacteriaceae was increased, and the relative abundance of Firmicutes was decreased [Firmicutes and Actinobacteria were the dominant flora in the lungs of COPD patients. By sampling and sequencing the BALF of patients with moderate and severe COPD, Pragman et al. found that the structure of the flora in the lungs of these two groups of patients was changed and that Firmicutes, Proteobacteria, and Actinobacteria were abundant in the lower airways of these patients [Unlike the early changes in the microbiota of patients with asthma, there is no significant difference in respiratory flora between mild and moderate COPD patients and normal people . Changesecreased . Howeverpatients . Microbipatients .Firmicutes before the colonization of the dominant bacteria. This finding also supported the clinical features of acute exacerbation in both types. Taking into account the different microbial modes, different therapeutic measures are required. Although the composition of respiratory flora in patients with COPD has been clear through microbiological analysis, the role of respiratory flora in the pathogenesis of the disease remains to be further explored.Microbiological studies showed that, at the acute exacerbation stage of COPD, there was no significant difference in respiratory microbes compared with the stationary phase . The resCF is a familial autosomal recessive inherited congenital disease, which is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR), resulting in the structural and functional alterations of the transmembrane protein in pulmonary CF, thereby causing chronic pulmonary infection and pulmonary function deterioration in patients, leading to early deaths . CF is cPseudomonas aeruginosa and Burkholderiaceae. Although antibiotic treatment and species richness declined slightly, the microbial community structure hardly changed. Moreover, the microbial composition in acute exacerbation was highly similar to that in the stationary phase, suggesting that exacerbations may be due to the spread of infection in the lungs, rather than changes in the composition of the microbial community.Fodor et al. used massive pyrosequencing technology to identify changes in the airway microbial community structure of 23 CF patients during CF exacerbations and stabilities and obtained more than 350,000 sequences, representing nearly 170 distinct microbial floras . ApproxiPseudomonas aeruginosa, Haemophilus influenzae, and Staphylococcus aureus. Meanwhile, other strains such as Burkholderia, Stenotrophomonas maltophilia, and Achromobacteria xyloxydans were also present in elderly patients [Bacteroidetes and Fusobacteria were the dominant strains in healthy individuals while Actinobacteria accounted for a larger proportion in CF patients. The structure of pulmonary florae was destroyed, pathogenic bacteria and conditional pathogens were multiplied, and florae were out of balance, which may be one of the causes of CF.The research through in vitro bacterial culture of the patients' sputa revealed that the predominant pathogenic bacteria were patients , 43. TheUACS, formerly known as postnasal drip syndrome (PNDS), is a syndrome of chronic cough caused by the reflux of allergic or nonallergic inflammatory secretions from the nasal cavity and nasopharynx into the pharynx . It can Firmicutes and Proteobacteria are the dominant flora in UACS that are different from the normal flora. Among these, Lactobacillus of Firmicutes and Pseudomonas aeruginosa of Proteobacteria have significantly increased and replaced the dominant position of original Streptococcus and Neisseria in the pharynx of normal people. Moreover, TRPV1 and TGF-β2 were increased significantly in UACS patients [β1 and β2 in mammary secretions of dairy cows infected with Pseudomonas aeruginosa compared to those uninfected, demonstrating the correlation between Pseudomonas aeruginosa and TGF-β1 and β2. Meanwhile, Pseudomonas aeruginosa could also stimulate airway inflammation through a variety of known inflammatory pathways, leading to an increase in the prevalence of UACS [There is a slight difference in the types of pharyngeal flora between healthy people and patients with UACS. patients . TRPV1 ipatients . TRPV1 i of UACS .Fungal colonization in the human body refers to the presence of a large number of fungi growing in the form of spores at a site where the human body communicates with the outside world, such as the alimentary canal, the upper airway, and urogenital tract, but without local tissues damage or symptoms . ColonizCandida and Aspergillus in the upper airway are very common [Candida was the most common fungus colonizing in the lower airway, among which the infection rate of Candida albicans was the highest (37.91%), followed by Aspergillus (16.99%) [Aspergillus fumigatus and Candida albicans being the most common [Contamination and colonization with y common . The res(16.99%) . Systemit common .Glucocorticoid has a potent anti-inflammatory and immunosuppression function, which eliminates most pathogenic bacteria and improves the airway microenvironment by effectively reducing the levels of proinflammatory cytokines and airway inflammation. Inhaled corticosteroids, without obvious systemic side effects, can easily form an effective concentration in the airway and work directly, which is quickly destroyed by enzymes in alveoli and inactivated by the liver after entering the blood circulation.α and leukotrienes by promoting the production of enzyme-linked protein I, resulting in the decrease of phospholipase A2-α; (2) inhibiting the production of inflammatory protein and its phospholipase A2-α by inactivating MAPK; (3) inhibiting the expression of cytokines, chemokines, cell adhesion factors, and their receptors by activating NF-κB pathway [Candida infection in the oral and pharyngeal [pneumonia and mycobacterial disease). Thus, rationally controlling the time of using hormones may reduce the incidence of adverse reactions.Glucocorticoids can enter into the nucleus by binding with glucocorticoid receptor in the cytoplasm through the cell membrane and form hormone-hormone receptor complex, which combines with special DNA sequence to produce biological effect through the following three ways: (1) inhibiting the release of inflammatory factors such as TNF- pathway . Glucoco pathway . Howeveraryngeal . Furtherfirmicutes and Bacteroidetes was increased in normal obese children [In addition, previous studies have proved that the diversity of oral microflora was decreased, while the proportion of children . Becausechildren .Although ICSs have been widely used in the clinical treatment of respiratory diseases because of the strong anti-inflammatory activities, they could not effectively improve the inflammatory response of airway remodeling and proliferation. Most clinical reports have shown that excessive inhalation of ICSs may cause drug dependence or resistance and other adverse reactions, especially in children with asthma in the early stage, which will affect children's immune system and result in hormone-dependent. Therefore, exploring new anti-inflammatory drugs to combine or even replace hormones is the leading direction of drug development.Lactobacillus rhamnosus and Lactobacillus plantarum. This supplement inhibits the expression of inflammatory factors in the lung by activating TLR3 and RIG-1 signaling pathways in alveolar macrophages to promote IFN-β and also regulates lung flora and intestinal flora to alleviate respiratory syncytial virus (RSV) infection. Over-the-counter probiotics have been used in clinical trials to investigate their potential effects in various disease conditions, but it is required more stringent quality control to ensure the purity and efficacy of products. The challenge of detecting unwanted microbial contaminants is that the sensitivity of detection may be reduced in the presence of the required probiotic microorganisms. One of the strategies under study was to reduce or eliminate the growth of bacteria in the product for improving the sensitivity of detecting the contaminating microbes. FDA scientists developed and used recombinant phage lysine as a reagent to improve LBP purity detection through “mock” purity assays (“test-tube” studies) where Lactobacillus jensenii represented the probiotic's product strain. However, the type of strains, dosage, and course of probiotic can affect the outcome of clinical application, and even the same flora will have different effects at different ages. Therefore, the prevention and treatment of respiratory infection with probiotics deserves further research.Probiotic refers to live biotherapeutic products (LBP) containing enough viable organisms with well-defined composition. It can change the composition of the flora at a certain site of the host through colonization, thereby improving the microecological balance of the host and playing a beneficial role . On the Candida albicans and Staphylococcus aureus, which was correlated with the concentration of baicalin, that is, the DNA synthesis of Candida albicans was decreased with the increase of drug concentration [Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa [Streptococcus pneumoniae, Staphylococcus aureus, etc.) activities of the agents, but few considered the antibacterial effect in vivo. And due to the complexity of pharmacodynamics, it is difficult to draw the conclusion whether antibacterial effects of drugs or anti-inflammatory effects play the decisive role in airway inflammation.Natural products or traditional Chinese medicine have been reported to improve airway immunity, ameliorate the function of the blood-air barrier, inhibit inflammation, and reduce growth of pathogenic bacteria due to its advantages of multicomponent, multichannel, and multitarget , which hntration , 67. Cryntration . The Yinruginosa . Xiaocharuginosa . It can There is still a lack of robust research on pharmacological mechanisms. Therefore, further efforts are needed to elucidate the underlying mechanism in germ-free mice.Changes in the immunity of respiratory flora play an important role in the development of multiple chronic respiratory diseases. In recent years, with the application of various new techniques in the detection of microbes in respiratory specimens, growing evidence showed that respiratory microbial population and its related local mucosal immunity were associated with the clinical manifestations, acute exacerbation, and prognosis of chronic respiratory immune disorders, such as asthma and COPD. Through studying the microbiological basis of the progression of human respiratory diseases, we can make a better understanding of the local immunological mechanism of the progression of these diseases, facilitate the judgment of disease types, predict the responsiveness to treatment, and evaluate the therapeutic effect. It provided a new idea for the clinical diagnosis, treatment, prediction, and prognosis of respiratory diseases.


Results. We enrolled 707 outpatients. Overall, 157 (22.2%) patients had CKD at baseline. Patients with CKD were older, with higher serum uric acid (UA) levels, and lower FEV1. During a mean follow-up of 52.3 ± 30.2 months, 100 patients developed CKD, and 200 patients showed a rapid reduction of eGFR. Multivariable Cox regression analysis displayed that UA (hazard ratio (HR) 1.148, p < 0.0001) and diabetes  were predictors of incident CKD. The independent predictors of rapidly declining renal function were represented by an increase of 1 mg/dL in UA (odds ratio (OR) 2.158, p < 0.0001)), an increase of 10 mL/min/1.73 m2 in baseline eGFR  and the presence of diabetes . Conclusions. This study shows that COPD patients have a significant worsening of renal function over time and that UA and diabetes were the two strongest predictors. Optimal management of these risk factors may reduce the incidence of CKD in this population thus probably improving clinical outcome.Background. Chronic obstructive pulmonary disease (COPD) patients have multiple comorbidities which may affect renal function. Chronic kidney disease (CKD) is a risk factor for adverse outcomes in COPD patients. The predictors of CKD in COPD are not well investigated. Methods. A multicenter observational cohort study including patients affected by COPD (GOLD stages 1 and 2) was carried out. Principal endpoints were the incidence of CKD, as defined by an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m Chronic obstructive pulmonary disease (COPD) is a widespread systemic inflammatory disorder, characterized by persistent respiratory symptoms and airflow limitation, which often is not fully reversible . COPD reIn particular, COPD patients have a higher risk of developing CKD than the general population , with ag1) [Indeed, among COPD patients the concomitant occurrence of CKD exerts a negative impact on both global health status and overall mortality ,17,18. I1) . Consist1) . Finally1) . It is tIn light of the above considerations, the main purpose of our study was to investigate the predictive factors of CKD development in COPD patients, with particular regard to the role of UA. The secondary aim focused on the search, in the same study population, for factors associated with the rapid decline of eGFR.2-adrenergic agonist (LABA), long-acting muscarinic receptor antagonist (LAMA) or inhaled corticosteroid (ICS) therapy because COPD had just been diagnosed. However, patients with active cancer, advanced hepatic disease, severe renal failure (baseline eGFR < 30 mL/min/1.73 m2), and acute kidney injury were excluded from the study. Furthermore, other exclusion criteria were the presence of chronic inflammatory or systemic autoimmune diseases, treatment with xanthine oxidase inhibitors, as well as use of hormone replacement therapy in female patients within the past 3 months.In the present multicenter prospective observational study, 707 Caucasian subjects  with COPD were recruited at the Geriatrics (558 patients) and Respiratory (68 patients) Units of “Magna Graecia” University Hospital of Catanzaro, Italy, and at the First Internal Medicine Unit (81 patients) of Sapienza University of Rome, Italy. The diagnosis of COPD was made according to the current Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations . SpiromeAll enrolled patients underwent anamnestic data collection and medical examination. A full anthropometric assessment was performed with measurement of body weight, height and body mass index (BMI). All subjects had different cardiovascular risk factors, but none of them had developed clinical events. Patients with a systolic blood pressure (SBP) ≥140 mmHg and/or diastolic blood pressure (DBP) ≥90 mmHg were considered to be hypertensive according to current guidelines . We alsoAll laboratory tests were carried out after a fasting period of at least 12 h. Glycemia was measured by the glucose oxidation method . The concentrations of triglycerides, total cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL), were measured by enzymatic method . Plasma concentration of insulin was determined by an assay based on chemiluminescence (Roche Diagnostics). Insulin sensitivity was estimated using the homeostasis model assessment (HOMA) index. Serum levels of high-sensitivity C-reactive protein (hs-CRP) levels were measured by turbidimetric immunoassay . Serum creatinine and UA levels were determined by an automated technique based on the Jaffé chromogen measurement and by the URICASE/POD method , combined in an automated analyzer. eGFR was calculated using the equation proposed by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) .2, stage G1), mild reduction of eGFR , moderate reduction of eGFR , and severe reduction of renal function eGFR . Within an outpatient context, a second measurement of serum creatinine was performed at follow-up in a time window ranging from 3 to 5 years with respect to baseline.Patients were stratified according to the classification of “Kidney Disease: Improving Global Outcomes” (KDIGO) clinical practice guidelines , based oThis multicenter study satisfied the standards of good clinical practice (GCP) and the principles of the Declaration of Helsinki. All enrolled participants signed a written informed consent. The present observational investigation was approved by the local Ethical Committee of Calabria Region (code protocol number 2012.63).t-test for unpaired data was used to compare continuous variables between groups and χ2 test was used for nominal data. The annual deterioration of eGFR, expressed as the difference between eGFR measurements at follow-up and baseline, divided by the number of years of follow-up, was calculated. Study population was subdivided according to the presence of CKD at baseline, and on the basis of either presence or absence of a rapid decline of eGFR (>5 mL/min/1.73 m2/year), with the aim of evaluating the features of subjects with renal function decline. Moreover, we carried out a multivariate logistic regression analysis to define the adjusted odds ratio (OR) of variables affecting the annual rapid deterioration in renal function. In the multivariate analysis, all factors potentially influencing kidney function were included . In addition, the occurrence of CKD (eGFR < 60 mL/min/1.73 m2) at follow-up was measured as number of cases per 100 patient-year. Moreover, considering that the second serum creatinine value was not measured at the same time for all subjects in the follow-up, a regression analysis based on the Cox proportional hazard model was used to calculate the relative corrections of the factors associated with eGFR <60 mL/min/1.73 m2. We consecutively performed univariate and multivariate Cox regression analyses to calculate the hazard ratio (HR) of risk factors associated with the incidence of CKD. The multivariate analysis was carried out including all the variables that were significant according to univariate testing.Data were expressed as mean ± standard deviation (SD) for continuous variables, and as frequencies and percentages for nominal data. Because the distribution of the studied variables was normal, Student’s A p value lower than 0.05 was considered to be statistically significant. All analyses were performed using the SPSS 20.0 statistical program for Windows .2 and 157 (22.2%) patients had renal dysfunction at baseline (eGFR <60 mL/min/1.73 m2). The anthropometric, hemodynamic, and biohumoral characteristics of the entire study population according to the presence or absence of renal dysfunction at baseline are reported in 1 . Moreover, the mean baseline FVC and FEV1/FVC values were 91.4 ± 26.7% pred. and 0.61 ± 0.07, respectively. Among the 707 patients (48.1% women) enrolled in this study, the mean age was 61.8 ± 9.9 years, the mean e-GFR values were 79.7 ± 26.1 mL/min/1.73 mted in 1 . The mea2, during follow-up one hundred patients developed CKD (2.38%/100 patient-year). In particular, the percentage of patients with eGFR >90 mL/min/1.73 m2 decreased from 29.3% (baseline) to 19.4% (follow-up). The percentage of patients with eGFR between 60 and 89 mL/min/1.73 m2 changed from 48.5 to 44.3%. Moreover, the proportion of patients with eGFR between 30 and 59 mL/min/1.73 m2 increased from 22.2 to 34.9%. At follow-up, 1.41% of patients developed severe renal failure <30 mL/min/1.73 m2  and diabetes  were the strongest predictors of CKD occurrence in COPD patients . Overall, 200 (28.2%) patients showed a reduction of eGFR >5 mL/min/1.73 m2/year. No statistically significant differences were found for BMI, DBP, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, and hs-CRP. In contrast, there was a significantly higher prevalence of females among the patients with a rapid decline in eGFR, they were older and presented significantly higher values of SBP, PP, fasting glucose, insulin and HOMA, uric acid, baseline eGFR and lower values of FEV1 ( of FEV1 .2/year), is shown in The prevalence of different cardiovascular risk factors and current therapies, according to the rapid decline of renal function (>5 mL/min/1.73 m2/year) was performed (p = 0.001). In addition, the presence of diabetes was associated with a 10.2% increased risk of rapid renal function decline while a 10 mL/min/1.73 m2 increase in baseline eGFR was associated with a 5.5% risk. Finally, a 10 mmHg of PP increase justified a 2.3 higher risk of rapid renal function deterioration. No statistically significant associations were found with regard to age, BMI, smoking, HOMA, hs-CRP, therapy with RAAS-inhibiting drugs, calcium channel blockers, diuretics, other antihypertensive drugs, statins, antiplatelet agents, and baseline FEV1 . Diabetes and baseline eGFR were also significantly retained in the model (This last analysis documented that, even if the association was attenuated, UA was the strongest predictor of rapid decline in renal function. In particular, an increase of 1 mg/dL of UA was associated with a double risk of rapid deterioration of renal function (OR 2.158, he model —Panel B.2. Similar to our findings, 20% and 31% of COPD patients recruited in previous studies complained of overt CKD [The present study shows that UA is associated with a rapid decline in kidney function and with an enhanced risk of incident kidney disease in COPD patients included within GOLD stages 1 and 2. A baseline renal dysfunction was quite common in the COPD patients enrolled in our study. Indeed, 77.8% exhibited normal renal function, whereas 22.2% of the recruited participants had an eGFR < 60 mL/min/1.73 mvert CKD ,33, whervert CKD . Howeververt CKD . Howeververt CKD . Anyway,vert CKD ,6. The dvert CKD ,17,18. Ivert CKD ,20,21.In COPD patients, the association between high serum UA levels and CKD incidence can be explained by several pathophysiological mechanisms, that correlate UA with inflammation and endothelial dysfunction . For insIn COPD subjects, a significant increase in chronic oxidative stress levels was observed , togetheOn the basis of such considerations, the enhanced mortality rate observed by Zhang et al. in hyperuricemic patients with COPD, could be attributable to a reduction of eGFR, which is known to increase the global cardiovascular risk . In COPDThe limitations of this study include its observational design and the lack of data during follow-up with regard to glycemic control, as well as to some relevant COPD severity assessments such as CAT score, lung function decline and DLCO. Another relevant limitation of our study regards the lack of proteinuria levels. Furthermore, the renal function impairment was assessed by using only a second measurement of serum creatinine during the follow-up period, whereas the monitoring of creatinine serum concentrations more than twice would be better for the detection of renal function deterioration. Moreover, we included only adult Caucasian patients, so that the generalizability of our results to other cardiovascular clinical settings or to other ethnicity groups is uncertain. Finally, we excluded patients with severe COPD.In conclusion, the interesting findings of our present study, referring to a large number of COPD patients, suggests that UA represents an independent predictor of CKD occurrence and rapidly progressive decline in renal function. Overall, the disease association including COPD, hyperuricemia and kidney failure persists even after correction for the known risk factors involved in renal damage . Therefo


Effective therapies for reflux hypersensitivity are lacking. Endoscopic radiofrequency ablation may reduce the sensitivity of the distal esophagus through direct interference with nociceptors or vagal afferent fibers and thus may be useful in reflux hypersensitivity. The aim of this study is to assess the effectiveness and possible mechanisms of endoscopic radiofrequency ablation in reflux hypersensitivity patients.  Patients with reflux hypersensitivity who fulfilled the Rome IV criteria and who wished to receive further treatment were recruited. Endoscopic radiofrequency ablation was delivered to the gastroesophageal junction. Data were collected by questionnaire using a 6-point Likert scale. The primary outcome measure was effect on symptoms including heartburn, regurgitation, and chest pain. The secondary outcomes were degree of satisfaction, medication use, acid exposure time (AET), low esophageal sphincter (LES) pressure, and total reflux episodes. We also assessed positive cell density of transient receptor potential vanilloid type 1 receptor (TRPV1) and calcitonin gene-related peptide (CGRP), both of which are biomarkers of afferent fibers, in biopsies obtained from esophageal mucosa 0.5 cm-1 cm above the Z line. These scales will be administered at baseline, 3-month follow-up, 6-month follow-up, and 12-month follow-up. P < 0.001). Satisfaction with life increased to 72.7% (16/22), 72.7% (16/22), and 68.2% (15/22) at 3, 6, and 12 mo, respectively, compared with baseline (P < 0.001). Nineteen patients reduced their medication use after treatment. Of these, 22.7% (5/22), 31.8% (7/22), and 40.9% (9/22) subjects stopped medication use at 3 mo, 6 mo, and 12 mo, respectively. No statistical differences were noted in AET, LES pressure, or total reflux episodes from preoperation to 12 mo postoperation. After treatment, the positive cell density of both TRPV1 and CGRP decreased significantly; however, only TRPV1 had a positive correlation with heartburn  and chest pain .  A total of 22 reflux hypersensitivity patients were enrolled . A significant improvement in symptom scores  was noted at 3 months, 6 months, and 12 months ( Endoscopic radiofrequency ablation was an effective and safe therapeutic option in reflux hypersensitivity patients. Further studies with large sample size are required to validate the role of radiofrequency in reflux hypersensitivity. Reflux hypersensitivity refers to patients with esophageal symptoms who lack evidence of reflux on endoscopy or abnormal acid exposure on reflux monitoring, but the symptoms are related to physiologic reflux . Pain moEndoscopic radiofrequency ablation of the lower esophageal sphincter (LES) is an effective treatment for GERD, which can improve GERD symptoms by delivering radiofrequency energy to the LES, leading to increased basal pressure and reduced compliance –7. It haWe therefore recruited a prospectively followed cohort of reflux hypersensitivity patients to investigate the efficacy of radiofrequency ablation in reflux hypersensitivity and to determine the potential role of TRPV1 and CGRP in the development and treatment of reflux hypersensitivity.We conducted a single-arm cohort study of radiofrequency energy to the gastroesophageal junction for the treatment of patients with reflux hypersensitivity from July 2018 to April 2020. The study protocol was approved by the Ethics Committee of Tongji Hospital, and all patients signed an informed consent.A total of 22 reflux hypersensitivity patients were enrolled in this study. The trial flow diagram is presented in Participants with coagulation disorders, cardiogenic chest pain, prominent dysphagia, previous esophageal or gastric surgery, psychiatric disorders, or unstable disorders were excluded.Before ablation, one biopsy was taken from 0.5 cm to 1 cm above the gastroesophageal junction. A Chinese self-developed radiofrequency ablation device, MER-200GA, was used to perform the therapeutic procedures . During Data were collected by questionnaire using a 6-point Likert scale. The frequency was graded as 0 (none), 1 (less than once a week), 2 (once or twice a week), 3 (three or four times a week), 4 (five or six times a week), and 5 (more than six times a week). The severity was graded as 0 (none), 1 (slight), 2 (mild), 3 (moderate), 4 (severe), and 5 (extremely severe). The total of the frequency score and the severity score for each of these measures were designated as the symptom score.The primary outcomes were symptoms which include heartburn, regurgitation, and chest pain. The secondary outcomes were degree of satisfaction with life quality , medication use (using a questionnaire), and the indicators of 24-h pH-impedance monitoring and esophageal manometry including AET, LES pressure, total reflux episodes, and positive cell density of TRPV1 and CGRP, both of which are biomarkers of afferent fibers, in biopsies obtained from esophageal mucosa 0.5 cm-1 cm above the gastroesophageal junction.At 3, 6, and 12 mo after treatment, the symptoms, satisfaction with radiofrequency treatment, and medication use were evaluated and compared with pretreatment. At 12 mo, 24-h pH-impedance monitoring, esophageal manometry, and EGD with biopsies were also performed. The biopsies obtained from distal esophageal mucosa were immune-stained with the primary antibody against TRPV1 and CGRP. The AET, LES, pressure, total reflux episodes, and positive cell density of TRPV1 and CGRP at 12 mo after treatment were compared with those pretreatment.We compared 2 different methods for evaluating missing data. The complete method evaluated only subjects with complete data for a given outcome. The carryforward method evaluated all subjects after carrying forward the last available value for missing data.t-test. For variables without normal distribution, we reported median values and performed comparisons using the Wilcoxon-matched pairs signed-rank test.For variables with normal distribution, we reported mean ± standard deviation (SD) and performed comparisons using the paired Student Pearson's correlation test was used to evaluate the relationship between symptoms and density of afferent fibers in the distal esophagus. For all correlation analyses, we considered an absolute value of the coefficient below 0.3 as a weak correlation, 0.3 to 0.5 as a moderate correlation, and above 0.5 as a strong correlation, as recommended by Cohen.P values were two-sided with P < 0.05 defined as statistically significant. All analyses were performed using R .All reported A total of 22 reflux hypersensitivity patients were enrolled in the study; the baseline characteristics of the patients are outlined in P < 0.001; mean decrease in regurgitation, −4.4 ± 1.2, P < 0.001; mean decrease in chest pain, −3.5 ± 1.1, P < 0.001; at 6 mo: mean decrease in heartburn, −5.6 ± 1.3, P < 0.001; mean decrease in regurgitation, −4.8 ± 1.5, P < 0.001; mean decrease in chest pain, −3.7 ± 1.4, P < 0.001; and at 12 mo: mean decrease in heartburn, −5.3 ± 1.3, P < 0.001; mean decrease in regurgitation, −4.9 ± 1.4, P < 0.001; mean decrease in chest pain, −3.5 ± 1.0, P < 0.001)  .P < 0.001). The ratio of satisfaction with life quality increased to 72.7% (16/22), 72.7% (16/22), and 68.2% (15/22) at 3, 6, and 12 mo, respectively. In total, 86.4% (19/22) subjects reduced their PPIs consumption after treatment. Of these, 22.7% (5/22), 31.8% (7/22), and 40.9% (9/22) subjects stopped medication use at 3 mo, 6 mo, and 12 mo, respectively , which indicated that radiofrequency energy might effectively damage the afferent fibers and block visceral sensation in the distal esophagus  and chest pain , respectively. These findings indicated that higher density of TRPV1+ afferent fibers could lead to more severe symptoms of heartburn and chest pain, which partially explained the refractory symptoms with no change in AET, LES pressure, and total reflux episodes in reflux hypersensitivity patients. In addition, the correlation tests also provided evidence that the improvement in symptoms after radiofrequency ablation was strongly associated with the downregulation of TRPV1 , transient nausea/vomiting (9 cases), retrosternal discomfort (7 cases), mild fever (5 cases), belching (3 cases), and transient dysphagia (1 case).Although seldom studied in reflux hypersensitivity, endoscopic radiofrequency ablation is one of the popular options for treating GERD. Several mechanisms have been proposed to explain radiofrequency ablation effects in GERD, including inhibition of transient LES relaxations and increasing LES pressure, and this might contribute to a decrease in reflux events –7. HowevAlthough the reflux is “physiological”, it occurs predominately in the distal esophagus, so the procedure is performed near the gastroesophageal junction with reference to GERD. Among the 22 reflux hypersensitivity patients in the present study, 81.8%, 77.3%, and 50% complained of heartburn, regurgitation, and noncardiac chest pain, respectively, and at least two of these symptoms were present in each patient at baseline. The Likert score of these three typical symptoms decreased 3 to 12 mo after the procedure. In addition, improvement in satisfaction was evident at 3 mo after the procedure and was sustained over the entire observational period of 1 year. In agreement with most previous studies on reflux diseases , we alsoThis is the first study to evaluate the role of TRPV1 and CGRP in the distal esophageal mucosa of reflux hypersensitivity patients. TRPV1 and CGRP are often co-exist in the esophagus ; they arThe present study has some notable limitations that reduce the strength of our conclusions. First, the sample size in this single-center study was small, and the follow-up period was short. In addition, we did not include a sham-controlled group to eliminate the placebo effect. Furthermore, several patients were unable to undergo repeated invasive examinations such as ambulatory, 24-h pH-impedance monitoring, and esophageal biopsy during the follow-up period, which resulted in incomplete critical information when determining the mechanism of treatment. Further sham-controlled research on the long-term therapeutic values of radiofrequency ablation in a large population of reflux hypersensitivity patients is required.In summary, our research first confirmed the value of endoscopic radiofrequency ablation in the management of reflux hypersensitivity regarding symptom relief, satisfaction, and PPIs consumption. The dramatically reduced TRPV1 and CGRP in the distal esophageal mucosal after radiofrequency ablation as well as the obvious correlation between TRPV1 and the severity of heartburn or chest pain suggested that altered TRPV1 in the distal esophagus may be an important pathophysiological factor and a therapeutic target in the treatment of reflux hypersensitivity.