Main recommendationsESGE recommends the “pull” technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer (“push”) technique for PEG placement in cases where the “pull” method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed “blindly” at the patient’s bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 – 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 – 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence.

Cytotoxic CD4 (CD4CTX) T cells are emerging as an important component of antiviral and antitumor immunity, but the molecular basis of their development remains poorly understood. In the context of human cytomegalovirus infection, a significant proportion of CD4 T cells displays cytotoxic functions. We observed that the transcriptional program of these cells was enriched in CD8 T cell lineage genes despite the absence of ThPOK downregulation. We further show that establishment of CD4CTX-specific transcriptional and epigenetic programs occurred in a stepwise fashion along the Th1-differentiation pathway. In vitro, prolonged activation of naive CD4 T cells in presence of Th1 polarizing cytokines led to the acquisition of perforin-dependent cytotoxic activity. This process was dependent on the Th1 transcription factor Runx3 and was limited by the sustained expression of ThPOK. This work elucidates the molecular program of human CD4CTX T cells and identifies potential targets for immunotherapy against viral infections and cancer.

Main recommendationsESGE recommends considering the following indications for enteral tube insertion: (i) clinical conditions that make oral intake impossible (neurological conditions, obstructive causes); (ii) acute and/or chronic diseases that result in a catabolic state where oral intake becomes insufficient; and (iii) chronic small-bowel obstruction requiring a decompression gastrostomy.Strong recommendation, low quality evidence.ESGE recommends the use of temporary feeding tubes placed through a natural orifice (either nostril) in patients expected to require enteral nutrition (EN) for less than 4 weeks. If it is anticipated that EN will be required for more than 4 weeks, percutaneous access should be considered, depending on the clinical setting.Strong recommendation, low quality evidence.ESGE recommends the gastric route as the primary option in patients in need of EN support. Only in patients with altered/unfavorable gastric anatomy (e. g. after previous surgery), impaired gastric emptying, intolerance to gastric feeding, or with a high risk of aspiration, should the jejunal route be chosen.Strong recommendation, moderate quality evidence.ESGE suggests that recent gastrointestinal (GI) bleeding due to peptic ulcer disease with risk of rebleeding should be considered to be a relative contraindication to percutaneous enteral access procedures, as should hemodynamic or respiratory instability.Weak recommendation, low quality evidence.ESGE suggests that the presence of ascites and ventriculoperitoneal shunts should be considered to be additional risk factors for infection and, therefore, further preventive precautions must be taken in these cases.Weak recommendation, low quality evidence.ESGE recommends that percutaneous tube placement (percutaneous endoscopic gastrostomy [PEG], percutaneous endoscopic gastrostomy with jejunal extension [PEG-J], or direct percutaneous endoscopic jejunostomy [D-PEJ]) should be considered to be a procedure with high hemorrhagic risk, and that in order to reduce this risk, specific guidelines for antiplatelet or anticoagulant use should be followed strictly.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with advanced dementia.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with a life expectancy shorter than 30 days.Strong recommendation, low quality evidence*.

All patients with COVID-19 are at nutritional risk, and 1/3 of them are malnourished. This study assessed the nutritional status and outcome of the subgroup who may require intensive care management (12%). FINDINGS: Malnutrition and low muscle mass are present in the majority of patients after prolonged ICU stay with mechanical ventilation. IMPLICATIONS FOR PATIENT CARE Standardized medical nutrition therapy allows improvement of nutritional parameters. Nutritional support with adequate protein intake (> 1.5gr/kg/day) remains crucial even after hospital discharge during rehabilitation.

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Background and study aims: Saliva, bubbles, or mucus can limit gastric mucosal visualization (GMV), increasing the risk of missed lesions such as gastric cancer. Several studies using endoscopy photodocumentation-based scores have reported increased quality of GMV when mucolytic and/or defoaming agents are administered. This single-centre, prospective, double-blind, randomized, placebo-controlled trial aimed to evaluate whether simethicone administration could improve GMV. Patients and methods: Patients were randomly assigned (1:1) to receive either 200 mg of simethicone (Group A) or placebo (Group B). Two independent endoscopists reviewed the entire video recording from each examination to assess the quality of GMV. The primary outcome was the rate of adequate GMV, defined as the percentage of patients in each group with a video score scale <7 based on gastric visualization of five gastric landmarks. Secondary outcomes included procedure duration, patient satisfaction, and side effects. Results: A total of 110 consecutive outpatients were randomly assigned to one of the two study groups (11 were excluded for various reasons). For the primary endpoint, 32 (61.5%) patients in group A achieved adequate GMV compared to 1/47 (2.1%) in group B (OR [95%CI]: 73.6 [9.4-576.6]; p<0.001). Median procedure time did not differ between the groups (p=0.55), and no differences were detected in patient satisfaction (p=0.18) or side effects (p=0.58). No serious adverse events were documented. Conclusions: Premedication with simethicone before upper GI endoscopy significantly improves the quality of gastric mucosal visualisation without affecting the duration of the examination, patient satisfaction, and the rate of side effects.

Cytotoxic CD4 (CD4 CTX ) T cells are emerging as an important component of antiviral and antitumor immunity, but the molecular basis of their development remains poorly understood. In the context of human cytomegalovirus infection, a significant proportion of CD4 T cells displays cytotoxic functions. We observed that the transcriptional program of these cells was enriched in CD8 T cell lineage genes despite the absence of ThPOK downregulation. We further show that establishment of CD4 CTX -specific transcriptional and epigenetic programs occurred in a stepwise fashion along the Th1-differentiation pathway. In vitro, prolonged activation of naive CD4 T cells in presence of Th1 polarizing cytokines led to the acquisition of perforin-dependent cytotoxic activity. This process was dependent on the Th1 transcription factor Runx3 and was limited by the sustained expression of ThPOK. This work elucidates the molecular program of human CD4 CTX T cells and identifies potential targets for immunotherapy against viral infections and cancer.

Background Immune-mediated inflammatory diseases (IMID) including inflammatory bowel diseases (IBD) and inflammatory arthritides are commonly treated with biological therapies, in particular anti-TNF. Patients on anti-TNF have impaired protective immunity following pneumococcal, influenza and viral hepatitis. However, the serological response to COVID-19 vaccination is still under-studied. Recent studies demonstrated that serologic response is attenuated in IMID patients on immunosuppressive therapy. In this study, the primary outcome is to describe the antibody response in IMID patients according to baseline patient characteristics, type of inflammatory disease, treatment and disease activity. Secondary outcome is to compare antibody response in patients treated with anti-TNF, versus other biologic therapies. Methods This study is a monocentric retrospective study, including 265 IMID patients followed at CHU Saint Pierre, Belgium, between 2021 and 2022. Respective baseline patient characteristics, vaccination status, treatment type, disease activity and SARS-CoV-2 antibody titers (IgG) after first, second and third vaccination were collected and analyzed. Results A total of 265 patients were enrolled (mean age 47 years old, 35% males, 67% IBD patients). Of these, 217 patients (82%) completed the 2 doses of vaccination and 130 patients (49%) the 3 doses, while 40 patients (15%) remained unvaccinated. Antibody titers after 2 doses of vaccination were available for 50 patients. In this group, the median antibody titer was 93 AU/mL [26-421] after first vaccination, raised up to 640 AU/mL [271-800] after the second vaccination (Δ85%, p&lt;0.0001). Similarly, a statistically significant increase was noted in the subgroup of patients with available serologic data after 3 vaccination doses (N=18). The median antibody titer after the first vaccination in anti-TNF subgroup (N=15) was lower than that in other biotherapies subgroup (N=23); 34 AU/mL [6-145] versus 131 AU/mL [34-704] respectively. However, after the second vaccination, higher antibody titers were found in the anti-TNF subgroup, 686 AU/mL [321-800] versus 400 AU/mL [250-800] (p&lt;0.388). Conclusion In our cohort of IMID patients, followed at CHU Saint Pierre, Belgium, there was a statistically significant raise in antibody titers after the second and third dose of COVID-19 vaccination, regardless of the type of inflammatory disease, disease activity, type of treatment and vaccine type. The antibody titers in this particular immunocompromised population were comparable to that found in the literature for the general population. More prospective observational studies are needed with a larger sample size to determine the characteristics of patients with sub-optimal serological response.