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ApSimon M, Steel C, Johnston C, Winder B, Cohen S, Reichert H, Armstrong D. Enteral nutrition on discharge from intensive care and 30-day unplanned readmission: An exploratory, retrospective study of association. Clin Nutr ESPEN 2024; 61:15-21. [PMID: 38777427 DOI: 10.1016/j.clnesp.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 01/31/2024] [Accepted: 03/05/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND & AIMS Individuals who survive critical illness are often malnourished with inadequate oral nutrient intake after leaving the intensive care unit (ICU). Enteral nutrition (EN) improves nutrient intake but there is limited evidence on the impact of maintaining EN after discharge from the ICU. The objective of this exploratory study was to understand the association between EN maintenance after ICU and 30-day unplanned hospital re-admission, to inform on future prospective research into the effects of post-ICU nutrition. METHODS This was a single-centre, retrospective study of ICU patients, requiring ventilation, who received EN for at least 3 days in ICU and were discharged to the ward. RESULTS 102 patients met the inclusion criteria; 45 (44.1%) maintained EN and 57 (55.9%) discontinued EN after ICU discharge; there were no significant differences in demographics or clinical measures at ICU admission. Reason for EN discontinuation was documented in 38 (66.7%) patients, with 27 (71%) discontinuing EN due to a routine ward practice of feeding tube removal. Unplanned 30-day hospital re-admission occurred in 17 (16.7%) patients overall, 5 (11.1%) in the EN group and 12 (21.1%) in the non-EN group (crude odds ratio [OR] 0.47, 95% CI 0.15, 1.45, p = 0.188). After adjusting for age, sex, BMI and length of stay, there was a persistent trend to lower re-admission rates in the EN group (OR 0.37, 95% CI 0.09, 1.57, p = 0.176). CONCLUSIONS EN maintenance after ICU discharge was associated with a trend to lower 30-day unplanned hospital re-admission rates. The clinically relevant reduction of about 50% in unplanned re-admission rates in this exploratory study warrants larger, prospective studies of post-ICU nutrition strategies based on clear discontinuation criteria to optimize nutrition and evaluate patient-centred outcomes.
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Affiliation(s)
| | - Cindy Steel
- Nestlé Health Science Canada, North York, ON, Canada.
| | | | - Barb Winder
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sarah Cohen
- EpidStrategies, A Division of ToxStrategies, Inc., Katy, TX, USA
| | - Heidi Reichert
- EpidStrategies, A Division of ToxStrategies, Inc., Katy, TX, USA
| | - David Armstrong
- Hamilton Health Sciences, Hamilton, ON, Canada; Division of Gastroenterology & Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
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Itoshima R, Ojasalo V, Lehtonen L. Impact of discharge criteria on the length of stay in preterm infants: A retrospective study in Japan and Finland. Early Hum Dev 2024; 193:106016. [PMID: 38663141 DOI: 10.1016/j.earlhumdev.2024.106016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/12/2024] [Accepted: 04/19/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND To shorten the hospital stay in preterm infants, it is important to understand the factors extending the length of stay. AIMS To understand how different discharge criteria affect the length of stay in preterm infants. STUDY DESIGN A retrospective comparison study. SUBJECTS Preterm infants born at 28 to 31 gestational weeks in 2020-2021 in a Level IV NICU in Japan (n = 22) and a Level III NICU in Finland (n = 49). OUTCOME MEASURES We compared the most common last discharge criteria and the postmenstrual age (PMA) between the two NICUs. The potential extending effects of each discharge criterion on the length of stay were also evaluated. The discharge criteria were classified into six categories: temperature, respiration, feeding, examination, weight limit, and family readiness. RESULTS The PMA at discharge was significantly higher in Japan than in Finland: median 40.7 (interquartile range 39.9-41.3) vs. 37.9 (36.9-39.0) weeks; r = 0.58; p < 0.001. The most common last discharge criterion was the family criterion in Japan (n = 19; 86 %) and the respiration criterion in Finland (n = 43; 88 %). In Japan, the length of stay was extended by 7.9 (standard deviation [SD] 7.0) days due to a lack of family readiness for discharge and 8.7 (SD 8.7) days due to not having discharged home with a feeding tube as a common practice. CONCLUSIONS The length of stay of preterm infants in Japan could be notably reduced by supporting the parents' earlier readiness for discharge and allowing tube feeding at home.
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Affiliation(s)
- Ryo Itoshima
- Department of Clinical Medicine, University of Turku, Turku, Finland; Division of Neonatology, Nagano Children's Hospital, Azumino, Japan; Life Science Research Center, Nagano Children's Hospital, Azumino, Japan.
| | - Venla Ojasalo
- Department of Clinical Medicine, University of Turku, Turku, Finland; Turku Bioscience Centre, University of Turku and Åbo Akademi University, Turku, Finland; InFLAMES Research Flagship Center, University of Turku, Turku, Finland
| | - Liisa Lehtonen
- Department of Clinical Medicine, University of Turku, Turku, Finland; Department of Paediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
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Mohamed Elfadil O, Velapati SR, Patel J, Hurt RT, Mundi MS. Enteral Nutrition Therapy: Historical Perspective, Utilization, and Complications. Curr Gastroenterol Rep 2024:10.1007/s11894-024-00934-8. [PMID: 38787510 DOI: 10.1007/s11894-024-00934-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE OF REVIEW Enteral nutrition (EN) therapy can provide vital nutrition support for patients with various medical conditions as long as it is indicated and supported by ethical reasoning. This review seeks to offer a detailed account of the history of EN development, highlighting key milestones and recent advances in the field. Additionally, it covers common complications associated with EN and their management. RECENT FINDINGS After years of research and development, we have reached newer generations of enteral feeding formulations, more options for enteral tubes and connectors, and a better understanding of EN therapy challenges. Given the availability of many different formulas, selecting a feeding formula with the best evidence for specific indications for enteral feeding is recommended. Initiation of enteral feeding with standard polymeric formula remains the standard of care. Transition to small-bore connectors remains suboptimal. Evidence-based practices should be followed to recognize and reduce possible enteral feeding complications early.
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Affiliation(s)
- Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Saketh R Velapati
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Janki Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA.
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Kotsia E, Chroni E, Alexandropoulou A, Mills C, Veltsista D, Kefalopoulou ZM, Michou E. Dysphagia Assessments as Criteria in the 'Decision-Making Process' for Percutaneous Endoscopic Gastrostomy Placement in People with Amyotrophic Lateral Sclerosis: A Systematic Review. Dysphagia 2024:10.1007/s00455-024-10686-2. [PMID: 38517530 DOI: 10.1007/s00455-024-10686-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/09/2024] [Indexed: 03/24/2024]
Abstract
To review the assessment methods of dysphagia as a criterion for the decision-making process for Percutaneous Endoscopic Gastrostomy (PEG) placement in patients with Amyotrophic Lateral Sclerosis (ALS). Systematic review. A search was conducted in three databases (EMBASE, CINAHL, PUBMED) in December 2022 and updated in July 2023. Two reviewers independently screened, selected, and extracted data. Study quality was appraised using the Joanna Briggs Institute Critical Appraisal Tools. Systematic review registration number in the International Prospective Register of Systematic Reviews (PROSPERO): CRD42022385461. The searches identified 240 records. The 10 eligible studies included 2 case reports, 4 retrospective studies, 3 prospective studies, and 1 cohort observational study. Study quality was low, with most studies having moderate to high risk of bias. Dysphagia is a common criterion for decision-making. Dysphagia assessment is usually in the form of either self-reports, objective instrumental assessments, or both. Dysphagia is a common criterion for the decision-making process, yet is missing in clinical guidelines. Establishing the optimal means of dysphagia assessment is important for timely decision-making procedures, so that life-threatening consequences of dysphagia are minimized.
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Affiliation(s)
- Ermioni Kotsia
- School of Medicine, Unit of Neuromuscular Diseases University Hospital of Patras, University of Patras, Patras, Greece
| | - Elizabeth Chroni
- School of Medicine, Unit of Neuromuscular Diseases University Hospital of Patras, University of Patras, Patras, Greece
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece
| | - Anna Alexandropoulou
- School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Claire Mills
- Speech and Language Therapy Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Dimitra Veltsista
- School of Medicine, Unit of Neuromuscular Diseases University Hospital of Patras, University of Patras, Patras, Greece
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece
| | | | - Emilia Michou
- School of Medicine, Unit of Neuromuscular Diseases University Hospital of Patras, University of Patras, Patras, Greece.
- Department of Speech and Language Therapy, School of Health Rehabilitation Sciences, University of Patras, Patras, Greece.
- Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK.
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Knatten CK, Dahlseng MO, Perminow G, Skari H, Austrheim AI, Nyenget T, Aabakken L, Schistad O, Stensrud KJ, Bjørnland K. Push-PEG or Pull-PEG: Does the Technique Matter? A Prospective Study Comparing Outcomes After Gastrostomy Placement. J Pediatr Surg 2024:S0022-3468(24)00199-4. [PMID: 38604831 DOI: 10.1016/j.jpedsurg.2024.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/04/2024] [Accepted: 03/17/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Push-PEG (percutaneous endoscopic gastrostomy) with T-fastener fixation (PEG-T) allows one-step insertion of a balloon tube or button, and avoids contamination of the stoma by oral bacteria. However, PEG-T is a technically more demanding procedure with a significant learning curve. The aim of the present study was to compare outcomes after PEG-T and pull-PEG in a setting where both procedures were well established. MATERIALS AND METHODS The study is a prospective cohort study including all patients between 0 and 18 year undergoing PEG-T and pull-PEG between 2017 and 2020 at a combined local and tertiary referral center. Complications and parent reported outcomes were recorded during hospital stay, after 14 days and 3 months postoperatively. RESULTS 82 (93%) of eligible PEG-T and 37 (86%) pull-PEG patients were included. The groups were not significantly different with regard to age or weight. Malignant disorders and heart conditions were more frequent in the pull-PEG group, whilst neurodevelopmental disorders were more frequent in the PEG-T group (p < 0.001). 54% in both groups had a complication within 2 weeks. Late complications (between 2 weeks and 3 months postoperatively) occurred in 63% PEG-T vs 62% pull-PEG patients (p = 0.896). More parents in the pull-PEG group (49%) reported that the gastrostomy tube restricted their child's activity, compared to PEG-T (24%) (p = 0.01). At 3 months follow-up, more pull-PEG patients (43%) reported discomfort from the gastrostomy compared to PEG-T (21%) (p = 0.03). CONCLUSION Overall complication rates were approximately similar, but pull-PEG was associated with more discomfort and restriction of activity. LEVELS OF EVIDENCE Treatment study level II.
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Affiliation(s)
| | | | - Gøri Perminow
- Department of Pediatrics, Oslo University Hospital, Norway
| | - Hans Skari
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway
| | | | - Tove Nyenget
- Department of Pediatrics, Oslo University Hospital, Norway
| | - Lars Aabakken
- Department of Gastroenterology, Oslo University Hospital, Norway; University of Oslo, Norway
| | - Ole Schistad
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway
| | - Kjetil Juul Stensrud
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway
| | - Kristin Bjørnland
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway; University of Oslo, Norway
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Oshima A, Wakabayashi M, Ikeno T, Matsuura K, Hayashi R, Higashino T. Second free jejunum transfer after flap loss does not affect oral intake: A retrospective case-control study. J Plast Reconstr Aesthet Surg 2024; 88:208-223. [PMID: 37988972 DOI: 10.1016/j.bjps.2023.10.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE Free jejunum transfer is one of the standard procedures for restoring oral intake after total pharyngo-laryngo-esophagectomy. Flap loss leading to a second free jejunum transfer rarely occurs. This study investigated the impact of a second free jejunum transfer on post-operative oral intake. METHODS A retrospective review was conducted on patients who underwent a first free jejunum transfer between July 1998 and December 2019. A total of 367 patients were included in the study. Among them, 17 patients who underwent a second free jejunum transfer because necrosis constituted the second free jejunum transfer group, whereas 350 patients who did not require a second free jejunum transfer formed the first free jejunum transfer group. The incidence of dysphagia requiring tube feeding and post-operative complications was compared between the two groups. Moreover, risk factors for dysphagia and complications were estimated. RESULTS There were no statistically significant differences in the incidence of dysphagia post-operation between the two groups. A second free jejunum transfer was a statistically significant factor for complications at 2- and 6-months post-operation; however, there were no significant differences in complication rates at the 12-month follow-up. Furthermore, there were no significant differences in the incidence of severe complications between the two groups. CONCLUSION Although a second free jejunum transfer increases early complications, it is not associated with major complications and does not negatively impact oral intake. These findings support the conclusion that free jejunum transfer is safe and helps maintain post-operative quality of life.
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Affiliation(s)
- Azusa Oshima
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Kashiwa, Japan; Course of Advanced Clinical Research of Cancer, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Masashi Wakabayashi
- Clinical Research Support Office, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takashi Ikeno
- Clinical Research Support Office, National Cancer Center Hospital East, Kashiwa, Japan
| | - Kazuto Matsuura
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Ryuichi Hayashi
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takuya Higashino
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Kashiwa, Japan
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7
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Yamamichi T, Imanishi Y, Sakai T, Yoshida M, Takayama K, Uga N, Umeda S, Usui N. Risk factors for and developmental relation of delayed oral nutrition in infants with congenital diaphragmatic hernia. Pediatr Surg Int 2023; 40:2. [PMID: 37991549 DOI: 10.1007/s00383-023-05595-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE To identify risk factors for delayed oral nutrition in infants with a congenital diaphragmatic hernia (CDH) and its impact on developmental delay at 18 months of age. METHODS This retrospective single-center cohort study compared the clinical parameters in patients with isolated CDH born and treated at our hospital between 2006 and 2020. We evaluated clinical features significantly related to delayed oral nutrition (defined as taking ≥ 30 days from weaning from mechanical ventilation to weaning from tube feeding). RESULTS Twenty-six of the 80 cases had delayed oral nutrition. Univariate analyses showed significant differences. Multivariate analyses were performed on the three items of preterm delivery, defect size (over 50% to nearly entire defect), and ventilation for ≥ 9 days. We identified the latter two items as independent risk factors. The adjusted odds ratios were 4.65 (95% confidence interval, 1.27-7.03) and 6.02 (1.65-21.90), respectively. Delayed oral nutrition was related to a significantly higher probability of developmental delay at 18 months (crude odds ratio 4.16, 1.19-14.5). CONCLUSION In patients with CDH, a large defect and ventilatory management over 9 days are independent risk factors for delayed oral nutrition, which is a potent predictor of developmental delay that requires active developmental care.
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Affiliation(s)
- Taku Yamamichi
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan.
| | - Yousuke Imanishi
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Takaaki Sakai
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
| | - Mina Yoshida
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
| | - Keita Takayama
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
| | - Naoko Uga
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
| | - Satoshi Umeda
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
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Asahina H, Ogasawara T, Akieda T, Miyahara K, Okada Y, Matsumura K, Taniguchi M, Yoshida A, Kakinoki Y. Palatal microbiota associated with membranous substances in older Japanese individuals undergoing tube feeding in long-term care: A cross-sectional study. Heliyon 2023; 9:e20401. [PMID: 37780754 PMCID: PMC10539663 DOI: 10.1016/j.heliyon.2023.e20401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 09/14/2023] [Accepted: 09/22/2023] [Indexed: 10/03/2023] Open
Abstract
Objective Tube feeders are prone to membranous substance formation on the palate, and those with membranous substances have a risk of fever, with the probable involvement of their oral bacteria. However, the palatal microbiota of those with membranous substances has not been elucidated. Therefore, we evaluated the differences in palatal microbiota between tube-fed individuals with and without membranous substances to clarify the microbiota. Materials and methods This study included 19 participants aged 65 years who required tube feeding. The participants' characteristics were collected from nursing records and oral examinations. If membranous materials were found on the palate, a specimen was collected. Membranous substances were defined as keratotic degeneration observed under a microscope. Additionally, we performed a comprehensive microbiome analysis by extracting DNA from the samples and performing 16 S rRNA gene sequencing. Finally, we compared the participant demographics and oral microbiota between patients with and without membranous substances. Results A total of 11 participants had membranous substances associated with "mouth dryness" (p < 0.001) and "constant mouth opening" (p = 0.020). Palatal microbiota differed between those with and without membranous substances. Among the bacteria with a relative abundance greater than 1.0%, the abundance of Streptococcus (p = 0.007), Fusobacterium (p = 0.041), Streptococcus agalactiae (p = 0.009), and Fusobacterium nucleatum subsp. vincentii (p = 0.026) was significantly higher in the membranous substance group than in the non-membranous substance group. Conclusions The palatal microbiota of individuals undergoing tube feeding differed depending on the presence or absence of membranous substances. Membrane substance formation associated with dry mouth purportedly alters the palatal microbiota. Streptococcus, Fusobacterium, S. agalactiae, and F. nucleatum subsp. vincentii were more abundant in the oral microbiota of patients with membranous substances. Thus, preventing this formation may help in controlling the growth of these microbes.
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Affiliation(s)
- Hironao Asahina
- Department of Oral Health Promotion, Graduate School of Oral Medicine, Matsumoto Dental University, Nagano, 399-0704, Japan
- Department of Special Care Dentistry, Hiroshima University Hospital, Hiroshima, 734-8551, Japan
| | - Tadashi Ogasawara
- Matsumoto Dental University, Nagano, 399-0704, Japan
- Yokosuna Dental Clinic, Shizuoka, 424-0035, Japan
| | | | - Kohta Miyahara
- Department of Special Care Dentistry, Hiroshima University Hospital, Hiroshima, 734-8551, Japan
| | - Yoshiyuki Okada
- Department of Special Care Dentistry, Hiroshima University Hospital, Hiroshima, 734-8551, Japan
| | | | | | - Akihiro Yoshida
- Department of Oral Microbiology, Matsumoto Dental University, Nagano, 399-0704, Japan
| | - Yasuaki Kakinoki
- Department of Special Needs and Geriatric Dentistry, Kyushu Dental University, Fukuoka, 803-8580, Japan
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Dipasquale V, Morello R, Romano C. Gastrointestinal and nutritional care in pediatric neuromuscular disorders. World J Clin Pediatr 2023; 12:197-204. [PMID: 37753494 PMCID: PMC10518748 DOI: 10.5409/wjcp.v12.i4.197] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/04/2023] [Accepted: 08/09/2023] [Indexed: 09/06/2023] Open
Abstract
Neuromuscular diseases (NMDs) affect the development and growth of the neuromuscular system in children. The pathology can occur anywhere along the neuromuscular pathway, from the brain to the nerves to the muscle fibers. These diseases have a profound impact on the quality of life not only of children but also of their families. The predominant manifestation in NMDs is hypotonia, which leads to muscle weakness and fatigue, reduced mobility, and decreased physical performance. However, multiple organ systems can be affected, with resulting orthopedic, cardiac, infectious, respiratory, and nutritional problems. Children with NMD present an increased risk for several dietary and feeding difficulties because of their neuromuscular diagnosis, presentation, and severity. These problems include chronic gastrointestinal issues (constipation, dysphagia, gastroesophageal reflux, and diarrhea), dysphagia, malnutrition, and body composition alterations. As a result, compared to the overall pediatric population, infants and children with NMD are more likely to be malnourished, ranging from failure to thrive to overweight or obesity. Disease-specific guidelines vary in level of detail and recommendations for dietary management. Overall, nutritional data available are sparse, with the exception of Duchenne muscular dystrophy, spinal muscular atrophy, and congenital muscular dystrophy. The purpose of this review is to describe the spectrum of nutritional challenges in children with NMD and to summarize the main dietary and gastrointestinal recommendations for each neuromuscular disorder to provide guidance for daily clinical practice.
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Affiliation(s)
- Valeria Dipasquale
- Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital “G. Martino”, Messina 98124, Italy
| | - Rossella Morello
- Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital “G. Martino”, Messina 98124, Italy
| | - Claudio Romano
- Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital “G. Martino”, Messina 98124, Italy
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Boeykens K, Holvoet T, Duysburgh I. Nasogastric tube insertion length measurement and tip verification in adults: a narrative review. Crit Care 2023; 27:317. [PMID: 37596615 PMCID: PMC10439641 DOI: 10.1186/s13054-023-04611-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/11/2023] [Indexed: 08/20/2023] Open
Abstract
Nasogastric feeding tube insertion is a common but invasive procedure most often blindly placed by nurses in acute and chronic care settings. Although usually not harmful, serious and fatal complications with misplacement still occur and variation in practice still exists. These tubes can be used for drainage or administration of fluids, drugs and/or enteral feeding. During blind insertion, it is important to achieve correct tip position of the tube ideally reaching the body of the stomach. If the insertion length is too short, the tip and/or distal side-openings at the end of the tube can be located in the esophagus increasing the risk of aspiration (pneumonia). Conversely, when the insertion length is too long, the tube might kink in the stomach, curl upwards into the esophagus or enter the duodenum. Studies have demonstrated that the most frequently used technique to determine insertion length (the nose-earlobe-xiphoid method) is too short a distance; new safer methods should be used and further more robust evidence is needed. After blind placement, verifying correct gastric tip positioning is of major importance to avoid serious and sometimes lethal complications.
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Affiliation(s)
- Kurt Boeykens
- Nutrition Support Team, VITAZ Hospital, Moerlandstraat 1, 9100, Sint-Niklaas, Belgium.
| | - Tom Holvoet
- Nutrition Support Team, VITAZ Hospital, Moerlandstraat 1, 9100, Sint-Niklaas, Belgium
| | - Ivo Duysburgh
- Nutrition Support Team, VITAZ Hospital, Moerlandstraat 1, 9100, Sint-Niklaas, Belgium
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Avasarala V, Aitharaju V, Encisco EM, Rymeski B, Ponsky TA, Huntington JT. Enteral access and reflux management in neonates with severe univentricular congenital heart disease: literature review and proposed algorithm. Eur J Pediatr 2023; 182:3375-3383. [PMID: 37191690 DOI: 10.1007/s00431-023-04992-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023]
Abstract
Neonates with severe congenital heart disease undergoing surgical repair may face various complications, including failure to thrive. Feeding tube placement and fundoplication are often performed to combat poor growth in neonates. With the variety of feeding tubes available and controversy surrounding when fundoplication is appropriate, there is no current protocol to determine which intervention is necessary for this patient population. We aim to provide an evidence-based feeding algorithm for this patient population. Initial searches for relevant publications yielded 696 publications; after review of these studies and inclusion of additional studies through external searches, a total of 38 studies were included for qualitative synthesis. Many of the studies utilized did not directly compare the different feeding modalities. Of the 38 studies included, five studies were randomized control trials, three studies were literature reviews, one study was an online survey, and the remaining twenty-nine studies were observational. There is no current evidence to suggest that this specific patient population should be treated differently regarding enteral feeding. We propose an algorithm to assist optimal feeding for neonates with congenital heart disease. Conclusion: Nutrition remains a vital component of the care of neonates with congenital heart disease; determining the optimal feeding strategy for these patients can be approached like other neonates.
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Affiliation(s)
- Vardhan Avasarala
- Department of Surgery, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Varun Aitharaju
- Department of Surgery, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Ellen M Encisco
- Department of Pediatric Surgery, Akron Children's Hospital, 215 West Bowery Street, Level 6, Akron, OH, 44308, USA
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Beth Rymeski
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Todd A Ponsky
- Department of Surgery, Northeast Ohio Medical University, Rootstown, OH, USA
- Department of Pediatric Surgery, Akron Children's Hospital, 215 West Bowery Street, Level 6, Akron, OH, 44308, USA
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Justin T Huntington
- Department of Pediatric Surgery, Akron Children's Hospital, 215 West Bowery Street, Level 6, Akron, OH, 44308, USA.
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Elgersma KM, Trebilcock AL, Whipple MO, Tanner LR, Pilditch SJ, Shah KM, McKechnie AC. Risk Factors for Tube Feeding at Discharge in Infants Undergoing Neonatal Surgery for Congenital Heart Disease: A Systematic Review. Pediatr Cardiol 2022. [PMID: 36404346 DOI: 10.1007/s00246-022-03049-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/07/2022] [Indexed: 11/22/2022]
Abstract
Approximately 30-50% of infants undergoing neonatal surgery for congenital heart disease (CHD) cannot meet oral feeding goals by discharge and require feeding tube support at home. Feeding tubes are associated with increased readmission rates and consequent hospital, payer, and family costs, and are a burden for family caregivers. Identification of modifiable risk factors for oral feeding problems could support targeted care for at-risk infants. Therefore, the aim of this systematic review is to determine risk factors for tube feeding at discharge in infants undergoing neonatal surgery for CHD. Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a search was conducted using MEDLINE, CINAHL, and Cochrane Database of Systematic Reviews. Studies published before 2010 were excluded. The search resulted in 607 records, of which 18 were included. Studies were primarily retrospective cohort designs and results were often inconsistent. Study quality was assessed using the Joanna Briggs Critical Appraisal Tools. As a group, the studies exhibited substantial risk for bias. Based on the findings, infants who struggle with feeding preoperatively, experience increased nil per os duration and/or low oral feeding volume postoperatively, experience increased duration of mechanical ventilation, or have vocal cord dysfunction may be at risk for tube feeding at hospital discharge. Factors warranting further examination include cardiac physiology (e.g., aortic arch obstruction) and the relationship between neurodevelopment and oral feeding. Clinicians should use caution in assuming risk for an individual and prioritize early implementation of interventions that facilitate oral feeding development.
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Dahlseng MO, Skari H, Perminow G, Kvello M, Nyenget T, Schistad O, Stensrud KJ, Bjornland K, Knatten CK. Reduced complication rate after implementation of a detailed treatment protocol for percutaneous endoscopic gastrostomy with T-fastener fixation in pediatric patients: A prospective study. J Pediatr Surg 2022; 57:396-401. [PMID: 35487796 DOI: 10.1016/j.jpedsurg.2022.03.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 03/23/2022] [Accepted: 03/26/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Percutaneous endoscopic gastrostomy with push technique (PEG-T) is increasingly used in pediatric patients. In a retrospective study of PEG-T (cohort 1) we reported frequent complications related to T-fasteners and tube dislodgment. The aim of this study was to assess complications after implementation of a strict treatment protocol, and to compare these with the previous retrospective study. MATERIALS AND METHODS The study is a prospective study of PEG-T placement performed between 2017 and 2020 (cohort 2) in pediatric patients (0-18 years). Complications were recorded during hospital stay, fourteen days and three months postoperatively, graded according to the Clavien-Dindo classification and categorized as early (<30 days) or late (>30 days). RESULTS In total 82 patients were included, of which 52 (60%) had neurologic impairments. Median age and weight were 2.0 years [6 months-18.1 years] and 13.4 kg [3.5-51.5 kg], respectively. There was a significant reduction in median operating time from 28 min [10-65 min] in cohort 1 to 15 min [6-35 min] in cohort 2 (p<0.001), number of patients with early tube dislodgement (cohort 1: 9 (10%) vs cohort 2: 1 (1%), p = 0.012), and number of patients with late migrated T-fasteners (cohort 1: 11 (13%) vs cohort 2: 1 (1%), p = 0.004). CONCLUSION We experienced less migrated T-fasteners and tube dislodgment after implementation of strict treatment protocol. LEVEL OF EVIDENCE Treatment study level III.
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Affiliation(s)
- Magnus Odin Dahlseng
- Department of Pediatrics, Oslo Universitetssykehus, Ullevål Sykehus, Barne- og Ungdomsklinikken, Oslo University Hospital, PB 4956 Nydalen, Oslo 0424, Norway.
| | - Hans Skari
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway
| | - Gøri Perminow
- Department of Pediatrics, Oslo Universitetssykehus, Ullevål Sykehus, Barne- og Ungdomsklinikken, Oslo University Hospital, PB 4956 Nydalen, Oslo 0424, Norway
| | - Morten Kvello
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway; Department of Gynecology and Obstetrics, Sørlandet Sykehus Kristiansand, Norway
| | - Tove Nyenget
- Department of Pediatrics, Oslo Universitetssykehus, Ullevål Sykehus, Barne- og Ungdomsklinikken, Oslo University Hospital, PB 4956 Nydalen, Oslo 0424, Norway
| | - Ole Schistad
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway
| | - Kjetil Juul Stensrud
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway
| | - Kristin Bjornland
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Norway; University of Oslo, Norway
| | - Charlotte Kristensen Knatten
- Department of Pediatrics, Oslo Universitetssykehus, Ullevål Sykehus, Barne- og Ungdomsklinikken, Oslo University Hospital, PB 4956 Nydalen, Oslo 0424, Norway
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14
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Osawa M, Ikeda H, Ueda A, Naito H, Nagao R, Kakimoto Y. Gastric aspiration in sudden unexpected infant death of Prader-Willi syndrome: immunohistochemical detection of feeding components. Int J Legal Med 2022; 136:1883-1888. [PMID: 36018383 PMCID: PMC9576639 DOI: 10.1007/s00414-022-02883-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 08/17/2022] [Indexed: 11/24/2022]
Abstract
Prader–Willi syndrome (PWS) in infants is characterized by hypotonia and poor sucking with feeding difficulties. Two autopsy cases of sudden unexpected death during sleep after tube feeding are described herein. For one, gastric aspiration caused by the possible milk regurgitation was suspected. Immunohistochemical examination of lung sections was performed using three antibodies to human α-lactalbumin, human gross cystic disease fluid protein 15, and cow whey β-lactoglobulin. Five cases of sudden unexpected infant death occurring earlier than at 6 months old were selected as controls. Marked immune-staining for infant formula in one PWS subject was evident within terminal bronchioles and alveoli with granular and amorphous features. However, no positive staining was apparent in the other subject, who exhibited contrasting features in milk distribution. Among control cases, one showed mild staining in the bronchiole, but the others did not. The antibody to β-lactoglobulin reacted specifically with formula, with no nonspecific background. Gastric contents in the airway can be a difficult issue because of the consequent terminal gasping. However, because of an episode of antemortem symptoms of potential regurgitation, and from findings at autopsy such as petechiae, we inferred that fatal regurgitation occurred in this PWS infant after tube feeding. Several clinical reports have described milk aspiration, but this pathological report is the first related to aspiration in PWS during tube feeding.
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Affiliation(s)
- Motoki Osawa
- Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
| | - Haruka Ikeda
- Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Atsushi Ueda
- Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Haruaki Naito
- Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Ryoko Nagao
- Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Yu Kakimoto
- Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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15
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TOMIOKA KAZUMI, NISHIYAMA MASAHIRO, TOKUMOTO SHOICHI, YAMAGUCHI HIROSHI, NOZU KANDAI, NAGASE HIROAKI. Behavioral Therapy for Children with Avoidant/Restrictive Food Intake Disorder Dependent on Tube or Oral Enteral Nutrient Formula: A Feasibility Study. Kobe J Med Sci 2022; 67:E155-E160. [PMID: 35368003 PMCID: PMC9677579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/22/2021] [Indexed: 06/14/2023]
Abstract
In children with eating disorders, nutritional status and growth may depend on enteral nutrient formula. Ultimately, its goal is to introduce or reintroduce oral feeding. Japanese research on the treatment of tube or oral formula-dependent children is scarce. This study determined the feasibility of behavioral therapy for children with avoidant/restrictive food intake disorder and dependency on the tube or oral enteral nutrient formula in Japan. Medical records of children diagnosed with this disorder, dependent on the tube or oral enteral nutrient formula and who had received behavioral therapy intervention to withdraw from the formula were retrospectively investigated. We collected their characteristics at first visit and the caloric percentage from oral food intake six months after starting the treatment. In total, four patients (age range: 2-5 years) participated in this study. The feeding routes employed before the intervention were a nasogastric tube for one patient, a gastrostomy bottom for the other patient, and oral formula for the remaining patients (i.e., two children). At the sixth month of the behavioral treatment, none of the patients needed the formula, and the caloric percentage of required nutrition from oral food intake was 100%. Our data demonstrate that this behavioral therapy is feasible for children with avoidant/restrictive food intake disorder dependent on the tube or oral formula in Japan.
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Affiliation(s)
- KAZUMI TOMIOKA
- Corresponding author: Phone: +81-78-382-6090, Fax: +81-78-382-6099, E-mail:
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16
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Remijn L, Kalsbeek CJC, Platteel V, Kindermann A. How to support parents and healthcare professionals in the decision-making process of tube feeding in children? Disabil Health J 2021;:101261. [PMID: 35022149 DOI: 10.1016/j.dhjo.2021.101261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Tube feeding in children has a severe psychosocial impact on children and their families. Parents also feel that they have limited communication with healthcare professionals (HCPs) about decision-making and the implications of tube feeding. OBJECTIVE This study focussed on the parents' experiences and expectations about tube feeding of children and a solution to improve the management and communication of it. METHODS We applied a design thinking method in two parts. First, focus groups and individual interviews were conducted with parents of children aged 0-10 years who are or had been tube fed and HCPs. Thereafter, two sounding boards with HCPs and parents were convened to discuss improvements in the management of tube feeding. RESULTS In total, 17 parents participated in the study. Two main topics derived from the focus groups and interviews: psychosocial impact and communication with HCPs. The sounding boards (five HCPs and two parents) divided the challenges of tube feeding into three stages: the moment tube feeding is considered, the insertion of the tube in the hospital, and transfer to the domestic environment and follow-up. Interview topics were used to develop a communication sheet to support the decision process of tube feeding. CONCLUSIONS The empowerment of parents in the process of tube feeding is important. More attention should be paid to alternatives, consequences, and planning for the long term. The developed communication sheet offers suggestions for issues to discuss and could support communication between parents and HCPs about tube feeding.
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17
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Willemsen ACH, Kok A, Baijens LWJ, de Boer JP, de Bree R, Devriese LA, Driessen CML, van Herpen CML, Hoebers FJP, Kaanders JHAM, Karsten RT, van Kuijk SMJ, Lalisang RI, Navran A, Pereboom SR, Schols AMWJ, Terhaard CHJ, Hoeben A. Development and external validation of a prediction model for tube feeding dependency for at least four weeks during chemoradiotherapy for head and neck cancer. Clin Nutr 2021; 41:177-185. [PMID: 34883306 DOI: 10.1016/j.clnu.2021.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/29/2021] [Accepted: 11/18/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND & AIMS Patients who receive chemoradiotherapy or bioradiotherapy (CRT/BRT) for locally advanced head and neck squamous cell carcinoma (LAHNSCC) often experience high toxicity rates interfering with oral intake, causing tube feeding (TF) dependency. International guidelines recommend gastrostomy insertion when the expected use of TF exceeds 4 weeks. We aimed to develop and externally validate a prediction model to identify patients who need TF ≥ 4 weeks and would benefit from prophylactic gastrostomy insertion. METHODS A retrospective multicenter cohort study was performed in four tertiary head and neck cancer centers in the Netherlands. The prediction model was developed using data from University Medical Center Utrecht and the Netherlands Cancer Institute and externally validated using data from Maastricht University Medical Center and Radboud University Medical Center. The primary endpoint was TF dependency ≥4 weeks initiated during CRT/BRT or within 30 days after CRT/BRT completion. Potential predictors were extracted from electronic health records and radiotherapy dose-volume parameters were calculated. RESULTS The developmental and validation cohort included 409 and 334 patients respectively. Multivariable analysis showed predictive value for pretreatment weight change, texture modified diet at baseline, ECOG performance status, tumor site, N classification, mean radiation dose to the contralateral parotid gland and oral cavity. The area under the receiver operating characteristics curve for this model was 0.73 and after external validation 0.62. Positive and negative predictive value for a risk of 90% or higher for TF dependency ≥4 weeks were 81.8% and 42.3% respectively. CONCLUSIONS We developed and externally validated a prediction model to estimate TF-dependency ≥4 weeks in LAHNSCC patients treated with CRT/BRT. This model can be used to guide personalized decision-making on prophylactic gastrostomy insertion in clinical practice.
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Affiliation(s)
- Anna C H Willemsen
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, the Netherlands; GROW-School of Oncology and Developmental Biology, Maastricht University Medical Center, the Netherlands; Department of Respiratory Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, the Netherlands
| | - Annemieke Kok
- Department of Dietetics, University Medical Center Utrecht, the Netherlands.
| | - Laura W J Baijens
- GROW-School of Oncology and Developmental Biology, Maastricht University Medical Center, the Netherlands; Department of Otorhinolaryngology, Head & Neck Surgery, Maastricht University Medical Center, the Netherlands
| | - Jan Paul de Boer
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Remco de Bree
- Department of Head and Neck Surgical Oncology, University Medical Center Utrecht, the Netherlands
| | - Lot A Devriese
- Department of Medical Oncology, University Medical Center Utrecht, the Netherlands
| | - Chantal M L Driessen
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Carla M L van Herpen
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Frank J P Hoebers
- GROW-School of Oncology and Developmental Biology, Maastricht University Medical Center, the Netherlands; Department of Radiation Oncology, MAASTRO Clinic, Maastricht, the Netherlands
| | - Johannes H A M Kaanders
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Rebecca T Karsten
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, the Netherlands
| | - Roy I Lalisang
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, the Netherlands; GROW-School of Oncology and Developmental Biology, Maastricht University Medical Center, the Netherlands
| | - Arash Navran
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Susanne R Pereboom
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Annemie M W J Schols
- Department of Respiratory Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, the Netherlands
| | - Chris H J Terhaard
- Department of Radiotherapy, University Medical Center Utrecht, the Netherlands
| | - Ann Hoeben
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, the Netherlands; GROW-School of Oncology and Developmental Biology, Maastricht University Medical Center, the Netherlands
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18
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Bischoff SC, Austin P, Boeykens K, Chourdakis M, Cuerda C, Jonkers-Schuitema C, Lichota M, Nyulasi I, Schneider SM, Stanga Z, Pironi L. ESPEN practical guideline: Home enteral nutrition. Clin Nutr 2021; 41:468-488. [PMID: 35007816 DOI: 10.1016/j.clnu.2021.10.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 10/25/2021] [Indexed: 01/12/2023]
Abstract
This ESPEN practical guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home enteral nutrition (HEN) providers in a concise way about the indications and contraindications for HEN, as well as its implementation and monitoring. This guideline will also inform interested patients requiring HEN. Home parenteral nutrition is not included but will be addressed in a separate ESPEN guideline. The guideline is based on the ESPEN scientific guideline published before, which consists of 61 recommendations that have been reproduced and renumbered, along with the associated commentaries that have been shorted compared to the scientific guideline. Evidence grades and consensus levels are indicated. The guideline was commissioned and financially supported by ESPEN and the members of the guideline group were selected by ESPEN.
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Affiliation(s)
- Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany.
| | - Peter Austin
- Pharmacy Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK, University College London School of Pharmacy, London, UK
| | - Kurt Boeykens
- AZ Nikolaas Hospital, Nutrition Support Team, Sint-Niklaas, Belgium
| | - Michael Chourdakis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Cristina Cuerda
- Hospital General Universitario Gregorio Marañón, Nutrition Unit, Madrid, Spain
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Ibolya Nyulasi
- Department of Nutrition, Department of Rehabilitation, Nutrition and Sport, Latrobe University, Department of Medicine, Monash University, Australia
| | - Stéphane M Schneider
- Gastroenterology and Nutrition, Centre Hospitalier Universitaire, Université Côte d'Azur, Nice, France
| | - Zeno Stanga
- Division of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital and University of Bern, Switzerland
| | - Loris Pironi
- Alma Mater Studiorum -University of Bologna, Department of Medical and Surgical Sciences, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Centre for Chronic Intestinal Failure, Clinical Nutrition and Metabolism Unit, Italy
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19
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Singh H, Morrison M, McIltrot K. Education Following Pediatric Gastrostomy Tube Placement: An Integrative Review. J Pediatr Nurs 2021; 61:387-393. [PMID: 34601247 DOI: 10.1016/j.pedn.2021.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 09/10/2021] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is a gap in knowledge regarding the necessary components for pediatric gastrostomy tube education. This integrative review addresses the question "What are the educational components following pediatric gastrostomy placement?" METHODS A literature search was conducted using PubMed, CINAHL, and Cochrane Library electronic databases, along with a hand search. Articles for review included those in the pediatric population, English language, and publication dates between 2010 and 2020. RESULTS Ultimately, 7 articles met the inclusion criteria for review. Articles were all pediatric focused (0-18 years), and were a mix of quantitative and qualitative designs, along with one non-research paper. Three major themes were identified from the literature including that gastrostomy tube education should be a multidisciplinary effort, that education should take a standardized approach, and that it should include psychosocial elements that enhance caregiver knowledge and empowerment. DISCUSSION This review demonstrates that while there is no consensus on a superior mode or means of education, pediatric gastrostomy discharge education must be standardized and high quality to promote the best patient and caregiver outcomes. Further research should aim to address which forms of education, if any, lead to the best outcomes, and how education can best be delivered to promote caregiver knowledge and ease.
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20
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Braun G, Mück A. [Endoscopy on the surgical intensive care unit]. Anaesthesist 2021; 70:977-990. [PMID: 34709412 DOI: 10.1007/s00101-021-01047-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 11/24/2022]
Abstract
Endoscopy is most frequently performed in intensive care units (ICU) for gastrointestinal bleeding; however, there are other indications for performing an endoscopy on the ICU. This article shows the indications for this, the background and the peri-interventional and postinterventional management. The endoscopic placement of a postpyloric feeding tube is a well-established procedure. For anastomotic leakage in the esophagus and rectum, the endoscopic vacuum therapy is the treatment of choice. Gastrointestinal motility disorders are a frequent phenomenon in critically ill patients and are associated with increased mortality. With a cecal diameter > 9-12 mm, endoscopic decompression can be performed; however, this is associated with an increased risk of perforation and should only be carried out after the failure of conservative treatment.
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Affiliation(s)
- Georg Braun
- Medizinische Klinik 3 am Universitätsklinikum Augsburg, Klinik für Anästhesiologie und Operative Intensivmedizin, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - Alexander Mück
- Medizinische Klinik 3 am Universitätsklinikum Augsburg, Klinik für Anästhesiologie und Operative Intensivmedizin, Stenglinstr. 2, 86156, Augsburg, Deutschland
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21
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Silvah JH, de Lima CMM, Nicoletti CF, Barbosa AC, Junqueira GP, da Cunha SFDC, Marchini JS. Protein provision and lower mortality in critically ill patients with COVID-19. Clin Nutr ESPEN 2021; 45:507-510. [PMID: 34620363 PMCID: PMC8282450 DOI: 10.1016/j.clnesp.2021.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) severely impacted the management of critically ill patients, including nutritional therapy. This study aimed to verify an association between mortality and the energy and protein provided to critically ill patients affected by the SARS-CoV-2 and receiving enteral nutrition support. METHODS Patients with confirmed COVID-19, with >7 days of stay in the ICU, on enteral nutrition were followed from the moment of hospitalization until discharge from the ICU or death. Data about age, gender, Simplified Acute Physiology Score III (SAPS3), intensive care unit (ICU) length of stay, days on mechanical ventilation (MV), clinical endpoint outcome (discharge or death), and daily energy and protein provision were collected from electronic medical records. Cox regression analyses and Kaplan-Meyer curves were used in statistical analysis. RESULTS Fifty-two patients (66.2 ± 13.1 years; 53.8% women) were enrolled in the present study. The mean length of hospitalizations and SAPS3 score were 17.8 ± 9.8 days and 78.7 ± 14.7, respectively; all patients needed mechanical ventilation (mean of days was 16.42 ± 9.1). For most patients (73.1%) the endpoint was death. Twenty-five percent of patients had protein supply >0.8 g/IBW/day. Survival during COVID-19 hospitalization at ICU was significantly different among patients according to protein supply (p = 0.005). Hazard Ratios (HR) for protein supply showed that a protein intake >0.8 g/IBW/day was associated with significantly lower mortality (HR 0.322, p = 0.049). CONCLUSION Our study suggests that a protein supply at least > 0.8 g/IBW/day could be related to reduced mortality in ICU patients with COVID-19.
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Affiliation(s)
- Jose Henrique Silvah
- Division of Medical Nutrition, Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil; ATN - Alimentar Terapia Nutricional, Coordination and Assistance in Nutritional Therapy, Ribeirão Preto, SP, Brazil.
| | - Cristiane Maria Martires de Lima
- Division of Medical Nutrition, Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil; ATN - Alimentar Terapia Nutricional, Coordination and Assistance in Nutritional Therapy, Ribeirão Preto, SP, Brazil
| | - Carolina Ferreira Nicoletti
- Departament of Health Science, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Ana Carolina Barbosa
- ATN - Alimentar Terapia Nutricional, Coordination and Assistance in Nutritional Therapy, Ribeirão Preto, SP, Brazil
| | - Gizela Pedroso Junqueira
- Division of Medical Nutrition, Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Selma Freire de Carvalho da Cunha
- Division of Medical Nutrition, Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Julio Sergio Marchini
- Division of Medical Nutrition, Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
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22
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Bozzetti F, Gurizzan C, Lal S, Van Gossum A, Wanten G, Golusinski W, Hosal S, Bossi P. A European survey on the practice of nutritional interventions in head-neck cancer patients undergoing curative treatment with radio(chemo)therapy. Eur Arch Otorhinolaryngol 2021. [PMID: 34146151 DOI: 10.1007/s00405-021-06920-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 05/29/2021] [Indexed: 10/25/2022]
Abstract
PURPOSE As the practice of nutritional support in patients with head and neck cancer (HNC) during curative radio(chemo)therapy is quite heterogeneous, we carried out a survey among European specialists. METHODS A 19-item questionnaire was drawn up and disseminated via the web by European scientific societies involved in HNC and nutrition. RESULTS Among 220 responses, the first choice was always for the enteral route; naso-enteral tube feeding was preferred to gastrostomy in the short term, while the opposite for period longer than 1 month. Indications were not solely related to the patient's nutritional status, but also to the potential burden of the therapy. CONCLUSION European HNC specialists contextualize the use of the nutritional support in a comprehensive plan of therapy. There is still uncertainty relating to the role of naso-enteral feeding versus gastrostomy feeding in patients requiring < 1 month nutritional support, an issue that should be further investigated.
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Flood C, Parker EK, Kaul N, Deftereos I, Breik L, Asrani V, Talbot P, Burgell R, Nyulasi I. A benchmarking study of home enteral nutrition services. Clin Nutr ESPEN 2021; 44:387-396. [PMID: 34330495 DOI: 10.1016/j.clnesp.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/16/2021] [Accepted: 05/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND & AIMS Patients receiving home enteral nutrition (HEN) via an enteral feeding tube often have complex healthcare requirements. There is limited information regarding how HEN care is provided within Australia and New Zealand. This study aimed to investigate the characteristics of HEN services and the provision of nutrition care to individuals receiving HEN within Australia and New Zealand. METHODS A cross-sectional study, surveying lead HEN dietitians for HEN services was conducted from the period 09 July 2019 to 20 September 2019 inclusive. An online survey was used to obtain data relating to the demographics, funding and clinical resources of respondents' HEN services. Services were benchmarked against a HEN service implementation checklist adapted from the Agency for Clinical Innovation (ACI). RESULTS Responses were received from 107 HEN services, with an estimated combined population of 7122 HEN patients. Services were predominantly government-funded (n = 102, 95.3%) and operated from acute hospitals (n = 57, 53.3%). The reported combined cost of all HEN equipment to the patient ranged from $0-$77 per week or $0-$341 per month. Fifty-two services were reported to have a dedicated HEN dietitian/coordinator, which was positively associated with the undertaking of quality improvement activities (p = 0.019). Mean compliance to the ACI HEN implementation checklist was 70.4% (±15.7%) with a range of 13.0-98.2%. Mean compliance was significantly higher in services with a HEN dietitian/coordinator than services without one (75.5% (±12.0%) vs 64.3% (±16.6%); p < 0.001). CONCLUSIONS This study provides detailed information regarding the characteristics of HEN services and nutrition care provided to enterally-fed patients across Australia and New Zealand. The majority of HEN services are not adhering to the ACI HEN service guidelines and there is considerable variation in cost burden for consumers indicating inequitable delivery of care to patients.
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Affiliation(s)
- Caroline Flood
- Nutrition Department, Alfred Health, Melbourne, Victoria, Australia.
| | - Elizabeth Kumiko Parker
- Department of Dietetics and Nutrition, Westmead Hospital, Sydney, New South Wales, Australia
| | - Neha Kaul
- Nutrition Department, Alfred Health, Melbourne, Victoria, Australia; Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Irene Deftereos
- Department of Surgery, Western Health, The University of Melbourne, Melbourne, Australia; Department of Nutrition and Dietetics, Western Health, Footscray, Melbourne, Australia
| | - Lina Breik
- Dietetics Department, Eastern Health, Melbourne, Victoria, Australia
| | - Varsha Asrani
- Department of Nutrition and Dietetics, Auckland City Hospital, New Zealand; Surgical and Translational Research (StaR) Centre, School of Medicine, University of Auckland, Auckland, New Zealand
| | - Peter Talbot
- Department of Dietetics and Nutrition, Westmead Hospital, Sydney, New South Wales, Australia
| | - Rebecca Burgell
- Department of Gastroenterology and Department of Hepatology, Alfred Health, Melbourne, Victoria, Australia
| | - Ibolya Nyulasi
- Nutrition Department, Alfred Health, Melbourne, Victoria, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Rehabilitation, Nutrition and Sport, La Trobe University, Bundoora, Victoria, Australia
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Barkhordari M, Jahani S, Soltani F, Molavynejad S, Maraghi E. Effect of Tubular Feeding with the Measurement of Gastric Residual Volume on Ventilator Associated Pneumonia. Tanaffos 2021; 20:319-26. [PMID: 36267927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 01/19/2021] [Indexed: 11/21/2022]
Abstract
Background Several measures have been taken to prevent the onset of ventilator-associated pneumonia (VAP), one of which is measuring the gastric residual volume. The purpose of this study is to compare the effect of two tube feeding methods with and without gastric residual volume measurement on VAP. Materials and Methods This clinical trial was performed on the study population of patients with endotracheal tubes hospitalized in Intensive Care Units 1 and 2 of Golestan hospital, Ahvaz, Iran. Overall, 70 patients who met the inclusion criteria were randomly divided into groups 1 and 2. Groups 1 and 2 were fed with and without measuring gastric residual volume, respectively. The incidence of pneumonia was assessed using the Modified Clinical Pulmonary Infection Score prior to the intervention and on the fifth day post- intervention. The data were analyzed by the SPSS software version 22. Results The incidence of VAP was 9.12% in the group with gastric residual volume measurement and 7.14% in the other group. There was no significant difference between the two groups (P=0.827) regarding VAP prevalence. Conclusion Monitoring gastric residual v olume requires aspiration and repeated measurements of gastric contents, resulting in increased nursing workload. Moreover, if the gastric residual volume is high, the patient will be deprived of calorie intake and subjected to malnutrition. As a result, removing the monitoring of gastric residual volume from the care setting and focusing on interventions proven to reduce VAP can be more helpful.
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Kunieda K, Kurata N, Yoshimatsu Y, Ohno T, Shigematsu T, Fujishima I. A Safe Way to Administer Drugs Through a Nutrition Tube-The Simple Suspension Method. Dysphagia 2021. [PMID: 33719015 DOI: 10.1007/s00455-021-10280-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 02/24/2021] [Indexed: 02/07/2023]
Abstract
The simple suspension method (SSM), developed by Kurata in 1997, is a way to suspend tablets and capsules in warm water for decay and suspension prior to their administration. This method is safe and has various advantages such as the avoidance of tube clogging and the loss of the drug. This study aimed to investigate whether a higher percentage of commonly used drugs could pass through nutrition tubes effectively using SSM, relative to that using the conventional crushing method. A tablet or capsule was inserted into a 20 mL syringe with warm water (at 55 °C). After 10 min, it was shaken in the syringe. The suspension liquid was injected into tubes of the following sizes: 8 Fr, 10 Fr, 12 Fr, 14 Fr, 16 Fr, and 18 Fr. A total of 3686 tablets and 432 capsules that are frequently used in Japan were tested. Using SSM, 3377 (91.6%) tablets and 359 (83.1%) capsules disintegrated within 10 min and passed through the tube without clogging it in the tube passage test. With the conventional crushing method, 2117 tablets (57.4%) and 272 capsules (63.0%) could be crushed. SSM reduced the risk of tube clogging and drug loss with more drugs than that with the conventional crushing method. The number of drugs indicated for administration by SSM is greater than that indicated by the conventional crushing method. Further studies are needed to consider its utility compared to conventional methods for dysphagia patients in clinical settings.
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Edwards S, Hyman PE, Mousa H, Bruce A, Cocjin J, Dean K, Fleming K, Romine RS, Davis AM. iKanEat: protocol for a randomized controlled trial of megestrol as a component of a pediatric tube weaning protocol. Trials 2021; 22:169. [PMID: 33640012 PMCID: PMC7913389 DOI: 10.1186/s13063-021-05131-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/13/2021] [Indexed: 11/10/2022] Open
Abstract
Background Although tube feeding routinely saves the lives of children who do not eat by mouth, chronic tube feeding can be a burden to patients, caregivers, and families. Very few randomized trials exist regarding the best methods for weaning children from their feeding tubes. Methods The current paper describes a randomized controlled trial of an empirically supported outpatient treatment protocol for moving children from tube to oral eating called iKanEat. Specifically, we describe the methods of randomized double-blind, placebo-controlled trial which includes a 4-week course of megestrol, the only medication used in the iKanEat protocol, to determine whether the addition of megestrol results in improved child outcomes. The primary and secondary aims are to assess the safety and efficacy of megestrol as part of the iKanEat protocol. The third aim is to provide critical information about the impact of the transition from tube to oral feeding on parent stress and parent and child quality of life. Discussion This trial will provide data regarding whether megestrol is a safe and effective component of the iKanEat tube weaning protocol, as well as important data on how the tube weaning process impacts parent stress and parent and child quality of life. Trial registration ClinicalTrials.gov NCT#03815019. Registered on January 17, 2019
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Affiliation(s)
- Sarah Edwards
- Pediatric Gastroenterology, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Paul E Hyman
- Pediatric Gastroenterology, New Orleans Children's Hospital, New Orleans, LA, USA
| | - Hayat Mousa
- Pediatric Gastroenterology, Hepatology and Nutrition, University of California San Diego/Rady Children's Hospital, San Diego, CA, USA
| | - Amanda Bruce
- Department of Pediatrics, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 4004, Kansas City, KS, 66160, USA.,Center for Children's Healthy Lifestyles & Nutrition, Kansas City, MO, USA
| | - Jose Cocjin
- Pediatric Gastroenterology, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Kelsey Dean
- Department of Pediatrics, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 4004, Kansas City, KS, 66160, USA.,Center for Children's Healthy Lifestyles & Nutrition, Kansas City, MO, USA
| | - Kandace Fleming
- Life Span Institute, University of Kansas, Lawrence, KS, USA
| | | | - Ann M Davis
- Department of Pediatrics, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 4004, Kansas City, KS, 66160, USA. .,Center for Children's Healthy Lifestyles & Nutrition, Kansas City, MO, USA.
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Sakai T, Shirai T, Oishi T. Vitamins K and D deficiency in severe motor and intellectually disabled patients. Brain Dev 2021; 43:200-7. [PMID: 33139126 DOI: 10.1016/j.braindev.2020.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES We aimed to determine serum 25-hydroxyvitamin D (25(OH)D) and undercarboxylated osteocalcin (ucOC) levels in severe motor and intellectual disabilities (SMID) patients and their association with bone turnover biomarkers. METHODS We assessed vitamin D and K levels as indicators of osteoporosis in institutionalized adults with SMID. From December 2019 to February 2020, 93 institutionalized patients (48 men, 45 women; median age, 49 years) underwent annual routine examinations. Serum ucOC, 25(OH)D, bone-specific alkaline phosphatase (BAP), and tartrate-resistant acid phosphatase A 5b (TRACP-5b) levels as bone formation and resorption markers and calcium and phosphorous levels were measured. Vitamin K deficiency was indirectly assessed based on ucOC levels. RESULTS Mean ucOC levels were higher than normal (i.e., vitamin K deficiency). Serum 25(OH)D levels were markedly diminished. Overall, 86% of patients had deficient 25(OH)D levels. These 25(OH)D-deficient patients had higher ucOC levels. Multiple linear regression analysis revealed an inverse correlation between 25(OH)D and ucOC levels. ucOC levels were significantly higher and 25(OH)D levels were significantly lower in tube feeding. TRACP-5b levels were significantly higher in elderly than in young women. BAP and TRACP-5b levels were normal in adults. No relationship existed between vitamin D and antiepileptic drug use. CONCLUSIONS Vitamin K and D co-deficiency was common in SMID patients. Vitamin K and D deficiencies were worse in tube-fed patients than in oral intake patients. SMID patients should undergo regular monitoring of vitamin D and K levels and supplementation of these vitamins.
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28
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Bager P, Olesen L, Baltzer RL, Borre M, Aagaard NK. Equal efficacy of gastric and jejunal tube feeding in liver cirrhosis and/or alcoholic hepatitis: a randomised controlled study. Br J Nurs 2020; 29:1148-1154. [PMID: 33180609 DOI: 10.12968/bjon.2020.29.20.1148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND AND AIM Malnutrition and muscle mass loss are complications in liver cirrhosis and alcoholic hepatitis (AH). Hospitalised patients who do not meet nutritional requirements are recommended to be fed enterally or parenterally, but no guidelines recommend a specific type of tube. This study aimed to compare the efficacy of jejunal versus gastric feeding. METHOD 40 inpatients with liver cirrhosis and/or AH, a nutritional risk score more than 2 and a reduced daily energy intake were included. Half were randomised to nasogastric (NG) and half to nasojejunal (NJ) tube feeding. All received Peptamen AF as a supplement to oral intake. Participants were followed up until discharge or death. FINDINGS The study evaluated the data for 33 patients for 7 days after tube insertion. Mean daily energy intake for 7 days was 6509 kJ (NG) vs 6605kJ (NJ) (P=0.90). Tubes accidently removed by patients: once (n=16); twice (n=9); three times (n=6), with no differences between NG and NJ. CONCLUSION There were no significant differences in total nutritional intake between early NG feeding and early NJ feeding 7 days after tube insertion. The number of tube replacements was similar in both groups. Choice of tubes for patients with severe liver disease will depend on individual patient characteristics and needs and local facilities.
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Affiliation(s)
- Palle Bager
- Clinical Nurse Specialist/Senior Researcher, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | - Lene Olesen
- Liver Nurse, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | - Rikke L Baltzer
- Liver Nurse, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | - Mette Borre
- Dietitian, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | - Niels K Aagaard
- Consultant, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
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29
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Miyahara K, Ogasawara T, Hasegawa H, Shinotsuka K, Shimada K, Ochiai T, Shen FC, Kakinoki Y. Pharyngeal Deposits Comprising Salivary Mucin in Tube-fed Elderly Patients: MUC2 and MUC7 Immunoreactivity. Dysphagia 2020; 36:875-881. [PMID: 33145634 DOI: 10.1007/s00455-020-10202-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 10/19/2020] [Indexed: 12/15/2022]
Abstract
Several investigators have reported that oral membranous and pharyngeal viscous deposits developed in bedridden elderly persons requiring nursing care without oral intake. Therefore, this study aimed to clarify the origin of viscous deposits on the pharyngeal mucosa based on characteristics of salivary and tracheal secretory mucin. The participants were 35 elderly people who required nursing care. All 46 collected specimens, including 30 intraoral and 16 pharyngeal specimens, were stained against specific mucins secreted from the respiratory tract and saliva gland using antibodies anti-MUC2 and anti-MUC7, respectively. Out of 35 participants, the intraoral membranous deposits and deposits on the pharyngeal mucosa developed in 17 (48.6%) and 10 persons (28.6%), respectively. The pharyngeal deposits developed in 58.8% of participants who developed intraoral deposits. All pathological specimens shared microscopic findings of various combinations of eosinophilic lamellar structure and a pale-basophilic amorphous substance. Immunohistochemically, both the 30 oral and the 16 pharyngeal specimens obtained from 17 participants were consistently positive for MUC7 but negative for MUC2. In conclusion, we clarified that the mucoid component of both oral and pharyngeal deposits comprised MUC7 salivary mucin, which revealed that both deposits originated from the oral cavity. This result strongly suggests that oral care is intimately related to oral and pharyngeal conditions.
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Affiliation(s)
- Kohta Miyahara
- Department of Special Care Dentistry, Hiroshima University, Hiroshima, Japan
| | - Tadashi Ogasawara
- Department of Oral Health Promotion, Graduate School of Oral Medicine, Matsumoto Dental University, 1780 Hirooka-Gobara, Shiojiri, Nagano, 399-0781, Japan.
| | - Hiromasa Hasegawa
- Hard Tissue Pathology Unit, Graduate School of Oral Medicine, Matsumoto Dental University, Shiojiri, Japan
| | | | - Katsumitsu Shimada
- Department of Oral Pathology, Matsumoto Dental University, Shiojiri, Japan
| | - Takanaga Ochiai
- Department of Oral Pathology, Matsumoto Dental University, Shiojiri, Japan.,Department of Oral Pathology, Division of Oral Pathognesis & Disease Control, Asahi University School of Dentistry, Mizuho, Japan
| | - Fa-Chih Shen
- Dental Department, Sijhih Cathay General Hospital, New Taipei, Taiwan
| | - Yasuaki Kakinoki
- Department of Special Needs and Geriatric Dentistry, Kyushu Dental University, Kitakyushu, Japan
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30
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Hirota K, Nishimoto K, Kumai Y, Miyamaru S, Miyamoto T, Saito H, Ise M, Murakami D, Orita Y. Swallowing dysfunction following surgery for well-differentiated thyroid cancer with extrathyroid invasion. Int J Clin Oncol 2020; 25:1921-1927. [PMID: 32683511 DOI: 10.1007/s10147-020-01748-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 07/04/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Differentiated thyroid carcinoma (DTC) can invade the surrounding aerodigestive tract. Radical surgery for locally advanced DTC will require resection of the trachea, recurrent laryngeal nerve (RLN), inferior pharyngeal constrictor muscles (IPCMs), or a part of the esophagus. The purpose of this study was to demonstrate the effect of resection of these surrounding tissues combined with total thyroidectomy and neck dissection on swallowing function following surgery. METHODS We performed total thyroidectomy combined with neck dissection and resection of the RLN in 24 patients with DTC with extrathyroidal invasion (19 unilateral, 1 bilateral), IPCMs (n = 5), or muscle layers of esophagus (n = 9). Nine patients received a tracheostomy placement due to a window resection of the trachea for tumor invasion (n = 6) and necessary upper airway management (n = 3). We used the duration of nasogastric tube feeding to evaluate swallowing function following surgery. RESULTS Patients who underwent tracheostomy or IPCM resection showed significantly longer periods of tube feeding (p = 0.0057 and 0.0017, respectively). In contrast, resection of the unilateral RLN or esophageal muscle layer showed no difference in tube feeding duration. Multiple regression analysis indicated that tracheostomy and IPCM resection were significant independent predictors of longer periods of tube feeding (p = 0.04583 and 0.00087, respectively). CONCLUSION These results indicate that tracheostomy placement and resection of the IPCMs, together with total thyroidectomy, extends the tube feeding duration in the postoperative period.
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Affiliation(s)
- Kaoruko Hirota
- Department of Otolaryngology-Head and Neck Surgery, Kumamoto University Graduate School of Medicine, Kumamoto, Japan
| | - Kohei Nishimoto
- Department of Otolaryngology-Head and Neck Surgery, Kumamoto University Graduate School of Medicine, Kumamoto, Japan
| | - Yoshihiko Kumai
- Department of Otolaryngology-Head and Neck Surgery, Kumamoto University Graduate School of Medicine, Kumamoto, Japan
| | - Satoru Miyamaru
- Department of Otolaryngology-Head and Neck Surgery, Kumamoto University Graduate School of Medicine, Kumamoto, Japan
| | - Takumi Miyamoto
- Department of Otolaryngology-Head and Neck Surgery, Kumamoto University Graduate School of Medicine, Kumamoto, Japan
| | - Haruki Saito
- Department of Otolaryngology-Head and Neck Surgery, Kumamoto University Graduate School of Medicine, Kumamoto, Japan
| | - Momoko Ise
- Department of Otolaryngology-Head and Neck Surgery, Kumamoto University Graduate School of Medicine, Kumamoto, Japan
| | - Daizo Murakami
- Department of Otolaryngology-Head and Neck Surgery, Kumamoto University Graduate School of Medicine, Kumamoto, Japan
| | - Yorihisa Orita
- Department of Otolaryngology-Head and Neck Surgery, Kumamoto University Graduate School of Medicine, Kumamoto, Japan.
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Sakai T, Honzawa S, Kaga M, Iwasaki Y, Masuyama T. Osteoporosis pathology in people with severe motor and intellectual disability. Brain Dev 2020; 42:256-263. [PMID: 31982226 DOI: 10.1016/j.braindev.2019.12.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 12/18/2019] [Accepted: 12/24/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVES We assessed the severity and pathology of osteoporosis in children and adults with severe motor and intellectual disabilities (SMID) by evaluating bone enzymes, by which we aimed to determine adequate treatment approaches for preventing fractures. METHODS Ninety patients (44 men, 46 women; mean age, 34.5 years) underwent bone quality assessment. Quantitative ultrasonography (QUS) was used to measure the T-score and Z-score of the calcaneus, and blood tests were used to measure bone-specific alkaline phosphatase and tartrate-resistant acid phosphatase 5b levels as bone formation and resorption markers, as well as calcium, phosphorous, and parathyroid hormone levels as routine examination. RESULTS Bone formation and resorption marker levels were within normal ranges in adults, although they were high during the growth period in children and adolescents and in elderly women. Patients receiving tube feeding showed a significantly lower Z-score than those without tube feeding. Tube feeding was a significant factor for the Z-score, whereas age, vitamin supplements, and anti-epileptic drugs were not. CONCLUSIONS The severity of osteoporosis in SMID started during the growth period and seems to be caused by a lack of an effective increase in bone mineral density. Any treatment should be started during the growth period. More study about tube feeding is needed.
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Affiliation(s)
- Tomoko Sakai
- Department of Rehabilitation Medicine, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Shiho Honzawa
- Department of Pediatrics, Tokyo Metropolitan Tobu Medical Center for Persons with Developmental/Multiple Disabilities, Tokyo, Japan
| | - Makiko Kaga
- Department of Pediatrics, Tokyo Metropolitan Tobu Medical Center for Persons with Developmental/Multiple Disabilities, Tokyo, Japan
| | - Yuji Iwasaki
- Department of Pediatrics, Tokyo Metropolitan Tobu Medical Center for Persons with Developmental/Multiple Disabilities, Tokyo, Japan
| | - Tatsuo Masuyama
- Department of Pediatrics, Tokyo Metropolitan Tobu Medical Center for Persons with Developmental/Multiple Disabilities, Tokyo, Japan
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Chou HH, Tsou MT, Hwang LC. Nasogastric tube feeding versus assisted hand feeding in-home healthcare older adults with severe dementia in Taiwan: a prognosis comparison. BMC Geriatr 2020; 20:60. [PMID: 32059646 PMCID: PMC7023686 DOI: 10.1186/s12877-020-1464-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 02/06/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND All individuals with severe dementia should be offered careful hand feeding. However, under certain circumstances, people with severe dementia have a feeding tube placed. In Taiwan, tube feeding rate in demented older home care residents is increasing; however, the benefits of tube feeding in this population remain unknown. We compared the clinical prognosis and mortality of older patients with severe dementia receiving nasogastric tube feeding (NGF) or assisted hand feeding (AHF). METHODS Data from the in-home healthcare system between January 1 and December 31, 2017 were analyzed to identify 169 participants over 60 years of age in this retrospective longitudinal study. All subjects with severe dementia and complete functional dependence suffered from difficulty in oral intake and required either AHF or NGF. Data were collected from both groups to analyze pneumonia, hospitalization, and mortality rates. RESULTS A total of 169 subjects (56 males and 113 females, aged 85.9 ± 7.5 years) were analyzed. 39 required AHF and 130 NGF. All subjects were bedridden; 129 (76%) showed Barthel index < 10. Pneumonia risk was higher in the NGF group (48%) than in the AHF group (26%, p = 0.015). After adjusting for multiple factors in the regression model, the risk of pneumonia was not significantly higher in the NGF group compared with the AHF group. One-year mortality rates in the AHF and NGF groups were 8 and 15%, respectively, and no significant difference was observed after adjustment with logistic regression (aOR = 2.38; 95% CI, 0.58-9.70). There were no significant differences in hospitalization rate and duration. CONCLUSIONS For older patients with dementia requiring in-home healthcare, NGF is not associated with a significantly lower risk of pneumonia than AHF. Additionally, neither mortality nor hospitalization rates decreased with NGF. On the contrary, a nonsignificant trend of increased risk of pneumonia was observed in NGF group. Therefore, the benefits of NGF are debatable in older patients with severe dementia requiring in-home healthcare. Continued careful hand feeding could be an alternative to NG feeding in patients with severe dementia. Furthermore, large-scale studies on in-home healthcare would be required to support these results.
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Affiliation(s)
- Hsiao-Hui Chou
- Department of Family Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Meng-Ting Tsou
- Department of Family Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Lee-Ching Hwang
- Department of Family Medicine, Mackay Memorial Hospital, Taipei, Taiwan. .,Department of Medicine, Mackay Medical College, Taipei, Taiwan.
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Willemsen ACH, Hoeben A, Lalisang RI, Van Helvoort A, Wesseling FWR, Hoebers F, Baijens LWJ, Schols AMWJ. Disease-induced and treatment-induced alterations in body composition in locally advanced head and neck squamous cell carcinoma. J Cachexia Sarcopenia Muscle 2020; 11:145-159. [PMID: 31536685 PMCID: PMC7015232 DOI: 10.1002/jcsm.12487] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 05/07/2019] [Accepted: 07/02/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Chemoradiation or bioradiation treatment (CRT/BRT) of locally advanced head and neck squamous cell carcinoma (LAHNSCC) comes with high toxicity rates, often leading to temporary tube feeding (TF) dependency. Cachexia is a common problem in LAHNSCC. Yet changes in body composition and muscle weakness during CRT/BRT are underexplored. Strong evidence on the effect of TF on body composition during treatment is lacking. The aim of this cohort study was to assess (i) the relationship of fat-free mass index (FFMI) and handgrip strength (HGS) with CRT/BRT toxicity and outcome, (ii) body composition in patients treated with chemoradiation (cisplatin) vs. bioradiation (cetuximab), and (iii) the effect of the current TF regime on body composition and muscle strength. METHODS Locally advanced head and neck squamous cell carcinoma patients treated with CRT/BRT between January 2013 and December 2016 were included (n = 137). Baseline measurements of body composition (bioelectrical impedance analysis) and HGS were performed. Toxicity grades (Common Terminology Criteria for Adverse Events) were scored. In a subset of 69 patients, weight loss, body composition, and HGS were additionally assessed during and after CRT/BRT. TF was initiated according to the Dutch guidelines for malnutrition. RESULTS In this cohort (68% male, mean age 59 ± 8 years), the incidence of baseline muscle wasting, defined as FFMI < P10 , was 29%. Muscle wasting was present in 23 of 100 (23%) chemoradiation patients and 17 of 37 (46%) bioradiation patients (P = 0.009). Muscle-wasted patients required more unplanned hospitalizations during CRT (P = 0.035). In the chemoradiation subset, dose-limiting toxicity was significantly higher in wasted vs. non-wasted patients (57% vs. 25%, P = 0.004). Median follow-up was 32 months. Multivariate Cox regression analysis identified muscle wasting as independent unfavourable prognostic factor for overall survival [hazard ratio 2.1 (95% CI 1.1-4.1), P = 0.022] and cisplatin as favourable prognostic factor [hazard ratio 0.3 (95% CI 0.2-0.6), P = 0.001]. Weight and HGS significantly decreased during CRT/BRT, -3.7 ± 3.5 kg (P < 0.001) and -3.1 ± 6.0 kg (P < 0.001), respectively. Sixty-four per cent of the patients required TF 21 days (range 0-59) after CRT/BRT initiation. Total weight loss during CRT/BRT was significantly (P = 0.007) higher in the total oral diet group (5.5 ± 3.7 kg) compared with the TF group (3.0 ± 3.2 kg). Loss of FFM and HGS was similar in both groups. CONCLUSIONS In LAHNSCC patients undergoing CRT/BRT, FFMI < P10 is an unfavourable prognostic factor for overall survival, treatment toxicity, and tolerance. Patients experience significant weight and FFM loss during treatment. Current TF regime attenuates weight loss but does not overcome loss of muscle mass and function during therapy. Future interventions should consider nutritional intake and additional strategies specifically targeting metabolism, loss of muscle mass, and function.
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Affiliation(s)
- Anna C H Willemsen
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands.,GROW-School of Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.,Department of Respiratory Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ann Hoeben
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands.,GROW-School of Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Roy I Lalisang
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands.,GROW-School of Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ardy Van Helvoort
- Department of Respiratory Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, The Netherlands.,Danone Nutricia Research, Nutricia Advanced Medical Nutrition, Utrecht, The Netherlands
| | - Frederik W R Wesseling
- GROW-School of Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.,Department of Radiation Oncology, MAASTRO Clinic, Maastricht, The Netherlands
| | - Frank Hoebers
- GROW-School of Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.,Department of Radiation Oncology, MAASTRO Clinic, Maastricht, The Netherlands
| | - Laura W J Baijens
- GROW-School of Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.,Department of Otorhinolaryngology, Head & Neck Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Annemie M W J Schols
- Department of Respiratory Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, The Netherlands
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Farlow JL, Birkeland AC, Hardenbergh A, Lyden T, Brenner JC, Shuman AG, Chinn SB, Stucken CL, Malloy KM, Moyer JS, Casper KA, Prince MEP, Bradford CR, Wolf GT, Chepeha DB, Rosko AJ, Spector ME. Speech and swallowing outcomes after laryngectomy for the dysfunctional irradiated larynx. Eur Arch Otorhinolaryngol 2020; 277:1459-1465. [PMID: 31989269 DOI: 10.1007/s00405-020-05809-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 01/18/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To characterize outcomes of total laryngectomy for the dysfunctional larynx after radiation. METHODS Retrospective case series of all subjects who underwent total laryngectomy for the irradiated dysfunctional larynx between 2000 and 2018 at an NCI-designated comprehensive cancer center at a single tertiary care academic medical center. Main outcomes included enteral tube feeding dependency, functional tracheoesophageal speech, and number and timing of postoperative pharyngeal dilations. RESULTS Median time from radiation to laryngectomy was 2.8 years (range 0.5-27 years). Functional outcomes were analyzed for the 32 patients with 1-year follow-up. Preoperatively, 81% required at least partial enteral tube feeding, as compared to 34% 1-year postoperatively (p = 0.0003). At 1 year, 81% had achieved functional tracheoesophageal speech, which was associated with cricopharyngeal myotomy (p = 0.04, HR 0.04, 95% CI 0.002-0.949). There were 34% of subjects who required at least one pharyngeal dilation for stricture by 1 year postoperatively. Over half (60%) of the cohort were dilated over the study period. CONCLUSIONS Laryngectomy for the dysfunctional larynx improves speech and swallowing outcomes in many patients. Cricopharyngeal myotomy is associated with improved postoperative voice. While the need for enteral feeding is decreased, persistent postoperative swallowing dysfunction is common. Careful patient selection and education regarding functional expectations are paramount.
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Affiliation(s)
- Janice L Farlow
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109-5312, USA
| | - Andrew C Birkeland
- Department of Otolaryngology, Head and Neck Surgery, University of California Davis, Sacramento, CA, 98517, USA
| | - Anna Hardenbergh
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109-5312, USA
| | - Teresa Lyden
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109-5312, USA
| | - J Chad Brenner
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109-5312, USA
| | - Andrew G Shuman
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109-5312, USA
| | - Steven B Chinn
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109-5312, USA
| | - Chaz L Stucken
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109-5312, USA
| | - Kelly M Malloy
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109-5312, USA
| | - Jeffrey S Moyer
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109-5312, USA
| | - Keith A Casper
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109-5312, USA
| | - Mark E P Prince
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109-5312, USA
| | - Carol R Bradford
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109-5312, USA
| | - Gregory T Wolf
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109-5312, USA
| | - Douglas B Chepeha
- Department of Otolaryngology, University of Toronto, Toronto, ON, Canada
| | - Andrew J Rosko
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109-5312, USA.
| | - Matthew E Spector
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109-5312, USA.
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Kurisu K, Yoshiuchi K, Ogino K, Oda T. Machine learning analysis to identify the association between risk factors and onset of nosocomial diarrhea: a retrospective cohort study. PeerJ 2019; 7:e7969. [PMID: 31687281 PMCID: PMC6825409 DOI: 10.7717/peerj.7969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 10/01/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Although several risk factors for nosocomial diarrhea have been identified, the detail of association between these factors and onset of nosocomial diarrhea, such as degree of importance or temporal pattern of influence, remains unclear. We aimed to determine the association between risk factors and onset of nosocomial diarrhea using machine learning algorithms. METHODS We retrospectively collected data of patients with acute cerebral infarction. Seven variables, including age, sex, modified Rankin Scale (mRS) score, and number of days of antibiotics, tube feeding, proton pump inhibitors, and histamine 2-receptor antagonist use, were used in the analysis. We split the data into a training dataset and independant test dataset. Based on the training dataset, we developed a random forest, support vector machine (SVM), and radial basis function (RBF) network model. By calculating an area under the curve (AUC) of the receiver operating characteristic curve using 5-fold cross-validation, we performed feature selection and hyperparameter optimization in each model. According to their final performances, we selected the optimal model and also validated it in the independent test dataset. Based on the selected model, we visualized the variable importance and the association between each variable and the outcome using partial dependence plots. RESULTS Two-hundred and eighteen patients were included. In the cross-validation within the training dataset, the random forest model achieved an AUC of 0.944, which was higher than in the SVM and RBF network models. The random forest model also achieved an AUC of 0.832 in the independent test dataset. Tube feeding use days, mRS score, antibiotic use days, age and sex were strongly associated with the onset of nosocomial diarrhea, in this order. Tube feeding use had an inverse U-shaped association with the outcome. The mRS score and age had a convex downward and increasing association, while antibiotic use had a convex upward association with the outcome. CONCLUSION We revealed the degree of importance and temporal pattern of the influence of several risk factors for nosocomial diarrhea, which could help clinicians manage nosocomial diarrhea.
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Affiliation(s)
- Ken Kurisu
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Infectious Diseases, Showa General Hospital, Tokyo, Japan
| | - Kazuhiro Yoshiuchi
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kei Ogino
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Infectious Diseases, Showa General Hospital, Tokyo, Japan
| | - Toshimi Oda
- Department of Infectious Diseases, Showa General Hospital, Tokyo, Japan
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Chen CM, Shih CK, Su YJ, Cheang KU, Lo SF, Li SC. Evaluation of white sweet potato tube-feeding formula in elderly diabetic patients: a randomized controlled trial. Nutr Metab (Lond) 2019; 16:70. [PMID: 31636690 PMCID: PMC6796455 DOI: 10.1186/s12986-019-0398-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 09/24/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Elderly people with type 2 diabetes mellitus (T2DM) have an increased risk of diabetes-related microvascular and macrovascular complications, thus diabetic patients with a functioning gastrointestinal tract but without sufficient oral intake require enteral nutrition (EN) formulas to control blood glucose. White sweet potato (WSP) was a kind of sweet potato could provide a healthy carbohydrate source to EN formula. The aim of this study was to examine at risk of malnutrition T2DM patients whether a WSP-EN would attenuate glucose response and elevate nutritional index compared to a standard polymeric formulas. METHODS In this randomized, parallel, placebo-controlled, pilot clinical trial to investigate the effects of EN with WSP on aged residents with T2DM in long-term care institutions. In total, 54 eligible participants were randomly assigned to either the non-WSP-EN or WSP-EN group. For 60 days, the WSP-EN group received a WSP formula through nasogastric tube via a stoma with a large-bore syringe. The participants received EN of standard polymeric formulas without WSP in the non-WSP-EN group. RESULTS The body weight, body mass index, Mini Nutritional Assessment score, and Geriatric Nutritional Risk Index were significantly higher in the WSP-EN group (p < 0.05). Moreover, the WSP-EN intervention reduced glycated hemoglobin levels (6.73% ± 1.47% vs. 6.40% ± 1.16%), but increased transferrin (223.06 ± 38.85 vs. 245.85 ± 46.08 mg/dL), high-density lipoprotein cholesterol (42.13 ± 10.56 vs. 44.25 ± 8.43 mg/dL), and vitamin A (2.45 ± 0.77 vs 2.74 ± 0.93 μM) levels (p < 0.05). In addition, there was no important side effects including gastrointestinal intolerance with prescribed doses in our WSP-EN treated patients when compared with control ones. CONCLUSIONS The results suggest WSP incorporated into enteral formulas can improve nutrition status and glycemic control in elderly diabetic patients. TRIAL REGISTRATION NCT02711839, registered 27 May 2015.
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Affiliation(s)
- Chiao-Ming Chen
- Department of Food Science, Nutrition, and Nutraceutical Biotechnology, Shih-Chien University, No.70, Dazhi St., Zhongshan Dist., Taipei City, 10462 Taiwan
| | - Chun-Kuang Shih
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, 250 Wu-Hsing Street, Taipei, 11031 Taiwan
| | - Yi-Jing Su
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, 250 Wu-Hsing Street, Taipei, 11031 Taiwan
| | - Kuan-Un Cheang
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, 250 Wu-Hsing Street, Taipei, 11031 Taiwan
| | - Shu-Fang Lo
- Department of Agronomy, Chiayi Agricultural Experiment Station, Taiwan Agricultural Research Institute, 2 Min-Cheng Road, Chiayi, 60044 Taiwan
| | - Sing-Chung Li
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, 250 Wu-Hsing Street, Taipei, 11031 Taiwan
- Department of Agronomy, Chiayi Agricultural Experiment Station, Taiwan Agricultural Research Institute, 2 Min-Cheng Road, Chiayi, 60044 Taiwan
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Abstract
BACKGROUND Severe protein malnutrition, with a serum albumin < 25 g/L, is one of the complications that may develop after bariatric surgery. It is associated with increased morbidity and mortality and requires timely diagnosis and appropriate treatment to prevent rapid clinical deterioration. However, evidence-based recommendations for a specific treatment approach are currently not available. The present study describes the efficacy of a newly developed treatment regimen for post-bariatric patients presenting with severe hypoalbuminemia. METHODS A single-centre, retrospective analysis of eleven post-bariatric patients presenting with severe hypoalbuminemia, treated with continuous 24 h nasal-jejunal tube feeding of a medium chain triglyceride (MCT) formulation in combination with pancreatic enzyme supplementation every 3 h. RESULTS Duration of tube feeding ranged from 25 to 156 days (median 64 days) and pancreatic enzyme was supplemented for 22-195 days (median 75 days). An increase in serum albumin levels of 5 g/L and 10 g/L was achieved after a median period of 20 (range 6-26 days) and 36 days (range 21-57 days), respectively. Albumin levels were > 35 g/L after a median period of 58 days (range 44-171 days). CONCLUSION In this case series, a continuous 24-h nasal-jejunal MCT tube feed combined with frequent pancreatic enzyme supplementation was effective in all patients presenting with severe post-bariatric hypoalbuminemia and was not associated with adverse effects.
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Affiliation(s)
- Carlijn Kuin
- Division of Human Nutrition, Wageningen University Research, Wageningen, The Netherlands
| | - Floor den Ouden
- Division of Human Nutrition, Wageningen University Research, Wageningen, The Netherlands
| | - Hans Brandts
- Department of Clinical Nutrition, Rijnstate Hospital, Arnhem, The Netherlands
| | - Laura Deden
- Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
- Vitalys Clinic, Velp, The Netherlands
| | - Eric Hazebroek
- Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
- Vitalys Clinic, Velp, The Netherlands
| | - Marcel van Borren
- Department of Clinical Chemistry, Rijnstate Hospital, Arnhem, The Netherlands
| | - Hans de Boer
- Department of Internal Medicine, Rijnstate Hospital, Wagnerlaan 55, 6800, TA, Arnhem, The Netherlands.
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Wong MKW, Haliburton B, Graham A, Lapidus-Krol E, Moraes TJ, Marcon MA, Chiu PPL. Requirement and Duration of Tube Feed Supplementation among Congenital Diaphragmatic Hernia Patients. J Pediatr Surg 2019; 54:895-8. [PMID: 30773392 DOI: 10.1016/j.jpedsurg.2019.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 01/27/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE Oral feeds pose a challenge for congenital diaphragmatic hernia (CDH) infants. Tube feed (TF) supplementation may be required to support the achievement of normal growth. The aim of this study was to determine the duration and factors associated with TF use in CDH infants at our institution. METHODS A single centre retrospective chart review was performed for CDH-born infants who underwent repair between 2000 to 2013 (REB #1000053124). Patient demographics, perinatal management, and feeding status of infants with at least 1-year follow-up were reviewed. RESULTS Of 160 CDH infants, 32 (20%) were discharged on partial or complete TF, and an additional 5 (3.1%) patients started TF post discharge. CDH infants with TF were more likely to have initial arterial blood pH < 7.25, patch repair, ECMO support, and prolonged ICU stay (p < 0.05). Time to TF discontinuation did not differ significantly between those partially or fully TF at discharge. Twelve patients (33.3%) remained TF at their last known follow-up. CONCLUSION High risk CDH patients are likely to require TF to support their nutritional intake. Parents and caregivers need to be informed and properly supported. Long-term monitoring of CDH patient oral intake, growth, and development will be required. LEVEL OF EVIDENCE/TYPE OF STUDY Level III Retrospective Study.
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Fan PEM, Tan SB, Farah GI, Cheok PG, Chock WT, Sutha W, Xu D, Chua W, Kwan XL, Li CL, Teo WQ, Ang SY. Adequacy of different measurement methods in determining nasogastric tube insertion lengths: An observational study. Int J Nurs Stud 2019; 92:73-78. [PMID: 30743198 DOI: 10.1016/j.ijnurstu.2019.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/04/2019] [Accepted: 01/04/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Distance from the tip of the nose to earlobe to xiphisternum is commonly used to determine the length of nasogastric tube to be inserted. However, it is not evidence-based and frequently leads to improper positioning. OBJECTIVES This study evaluated four formulae and the distance from the tip of the nose to earlobe to xiphisternum in estimating the internal length of nasogastric tube required for optimal positioning. DESIGN Observational Study. SETTINGS Tertiary hospital in Singapore involving patients from the medical and surgical intensive care units and a neurosurgical ward. PARTICIPANTS Inclusion criteria were patients who required a nasogastric tube insertion and age > = 21 years old and =<85 years old. Patients who required an orogastric tube insertion or did not require a chest x-ray post nasogastric tube insertion were excluded. METHODS Upon nasogastric tube insertion, the external length of the tube was measured and the corresponding internal length calculated. Several anatomical measurements were taken as required in the formulae below: 1. ((Distance from tip of nose to earlobe to xiphisternum-50 cm)/2) + 50 cm. 2. 29.38 + 4.53*gender+0.34*distance from nose to umbilicus with head flat on bed-0.06*weight (gender = 1 for male, and 0 for female). 3. Distance from xiphisternum to earlobe to nose + 10 cm. 4. Distance from earlobe to xiphisternum to umbilicus-distance from tip of the nose to earlobe. Post insertion chest x-rays were examined to evaluate the position of the nasogastric tube. For those with optimal positioning, the distance from tip of the nose to earlobe to xiphisternum and the four formulae were compared to determine which provided the least difference with the internal length of the nasogastric tube. RESULTS Ninety-two participants were recruited. The average age of the cohort was 62.9 years old with 54% being male. Twenty-five had nasogastric tubes in optimal position; 13 had it too short and 54 had it too long. For nasogastric tubes in optimal position, distance from xiphisternum to earlobe to nose + 10 cm provided the best estimate of the internal length. Average difference between the distance from xiphisternum to earlobe to nose + 10 cm and internal length of the nasogastric tubes in optimal position was only 1.8 cm which was by far the least difference compared to other formulae. CONCLUSION This study found distance from xiphisternum to earlobe to nose + 10 cm to provide the best estimate for the internal length of nasogastric tube required. However, even this formula could result in placement that is not optimal due to anatomical differences.
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Affiliation(s)
| | - Siok Bee Tan
- Nursing Division, Singapore General Hospital, Singapore
| | - Gillan Irani Farah
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Poh Gek Cheok
- Nursing Division, Singapore General Hospital, Singapore
| | | | | | - Donghui Xu
- Nursing Division, Singapore General Hospital, Singapore
| | - Weiyan Chua
- Nursing Division, Singapore General Hospital, Singapore
| | - Xiu Ling Kwan
- Nursing Division, Singapore General Hospital, Singapore
| | - Chi Ling Li
- Nursing Division, Singapore General Hospital, Singapore
| | - Wei Qin Teo
- Nursing Division, Singapore General Hospital, Singapore
| | - Shin Yuh Ang
- Nursing Division, Singapore General Hospital, Singapore
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Syrmis M, Frederiksen N, Reilly C. Characterisation of information Hospitals Provide Parents on Tube Feeding, Including Tube Weaning. J Pediatr Nurs 2019; 44:e91-7. [PMID: 30503253 DOI: 10.1016/j.pedn.2018.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 11/11/2018] [Accepted: 11/13/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of this study was to characterise the content of hospital parent guides related to pediatric tube feeding. DESIGN AND METHODS A naturalistic search strategy was used to retrieve parent guides produced by hospitals using Google. Guides were analysed and content identified as being associated with codes which were derived from previous research into the education of parents on tube feeding and the prevention and treatment of tube feeding dependency and tube weaning. RESULTS Of the 17 collected guides from Australia, New Zealand, the United Kingdom, the United States of America, and Canada, most (64.7%) were published between 2009 and 2016. The guides provided comprehensive information regarding the reasons for and types of tube feeding, details of multidisciplinary teams and the practical management of tube feeding. All guides covered common medical problems and trouble-shooting solutions. Yet there was infrequent coverage of goal setting, risks and prevention of oral aversion and tube feeding dependency, social and emotional management of tube feeding and tube exit planning including tube weaning. CONCLUSIONS A gap exists in the education of families regarding psychosocial implications of tube feeding, oral aversion and tube feeding dependency and prevention, and tube exit planning. PRACTICE IMPLICATIONS Improvements need to be implemented in the development of education materials for families of children who require tube feeding. Families need information on all aspects of tube feeding including practical, social, and emotional management as well as advice on tube exit planning including tube weaning.
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Arjaans W, Ouwehand M, Bouma G, van der Meulen T, de van der Schueren MAE. Cortrak ® duodenal tube placements: A solution for more patients? A preliminary survey to the introduction of electromagnetic-guided placement of naso-duodenal feeding tubes. Clin Nutr ESPEN 2018; 29:133-136. [PMID: 30661676 DOI: 10.1016/j.clnesp.2018.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 11/06/2018] [Indexed: 11/24/2022]
Abstract
RATIONALE The Cortrak® feeding tube, an electromagnetic (EM) guided feeding tube which is placed by a trained nurse at the patient's bedside, is reported to be a safe, patient friendly and cost effective answer to the disadvantages of endoscopic placement of naso-duodenal feeding tubes. However, this procedure requires a learning curve and regular practice. This study aims to evaluate whether introducing Cortrak® feeding tube placement would be profitable in a tertiary referral academic hospital. METHODS We re-evaluated all endoscopically placed post-pyloric feeding tubes in the years 2012-2013. Taking into consideration training for nurses to learn how to place Cortrak® feeding tubes, strict inclusion criteria were formulated for the initial retrospective analysis: age 18 years or older, normal GI anatomy and non-ICU admitted patients. As a secondary analysis we also evaluated ICU patients (age >18 and normal upper GI tract). RESULTS Patient records of 487 duodenal feeding tube placements in 331 patients were evaluated; 125 non-ICU placements (in 90 patients) and 84 ICU placements (in 75 ICU patients) fulfilled the inclusion criteria. Main reasons for exclusion were: abnormalities of the upper GI tract (n = 176) and endoscopy for diagnostic reasons (n = 74). Main indications for placements were gastroparesis (37%) or insufficient food intake (20%). For secondary analysis, 84 placements in 75 ICU patients were re-evaluated, with main indication gastroparesis (62%). CONCLUSION In our hospital, at least one quarter of the duodenal tube placements would qualify for Cortrak® placement in the initial phase. Once routine has been built up and also ICU patients could be considered, half or more patients requiring a naso-duodenal feeding tube would qualify for Cortrak® placement, adding up to 3 placements per week. The findings of this study may help to decide on the profitability of introducing this method in our own hospital. The next step will be to perform a cost-benefit analysis to study whether implementing Cortrak® in practice is cost-effective and feasible.
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Affiliation(s)
- W Arjaans
- Nutrition Support Team, Amsterdam UMC/Vrije Universiteit, Amsterdam, the Netherlands; Department of Nutrition and Dietetics, Amsterdam UMC/Vrije Universiteit, Amsterdam, the Netherlands.
| | - M Ouwehand
- Nutrition Support Team, Amsterdam UMC/Vrije Universiteit, Amsterdam, the Netherlands; Department of Nutrition and Dietetics, Amsterdam UMC/Vrije Universiteit, Amsterdam, the Netherlands
| | - G Bouma
- Department of Gastroenterology, Amsterdam UMC/Vrije Universiteit, Amsterdam, the Netherlands
| | - T van der Meulen
- Department of Gastroenterology, Amsterdam UMC/Vrije Universiteit, Amsterdam, the Netherlands
| | - M A E de van der Schueren
- Department of Nutrition and Dietetics, Amsterdam UMC/Vrije Universiteit, Amsterdam, the Netherlands; Department of Nutrition and Health, HAN University of Applied Sciences, Nijmegen, the Netherlands
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Eslamian G, Ardehali SH, Baghestani AR, Vahdat Shariatpanahi Z. Effects of early enteral bovine colostrum supplementation on intestinal permeability in critically ill patients: A randomized, double-blind, placebo-controlled study. Nutrition 2018; 60:106-111. [PMID: 30551120 DOI: 10.1016/j.nut.2018.10.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 09/27/2018] [Accepted: 10/10/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES In this study we sought to investigate the effect of early enteral bovine colostrum supplementation on intestinal permeability in intensive care unit (ICU)-hospitalized patients. METHODS A total of 70 ICU-hospitalized adult patients were randomly assigned to receive a bovine colostrum supplement or placebo according to the stratified blocked randomization by age and admission category. Plasma endotoxin and zonulin concentrations were measured on days 5 and 10 of intervention. RESULTS Out of 70 participants, 32 patients in the colostrum group and 30 patients in the control group were included in the final analysis of the outcomes. Plasma endotoxin concentration decreased significantly in the colostrum group on the 10th day (P < 0.05). Furthermore, plasma levels of zonulin reduced in the colostrum group significantly compared with the placebo group (P < 0.001).The incidence of diarrhea was significantly lower in the colostrum group than in the control group (P = 0.02). CONCLUSIONS Our results provide evidence that bovine colostrum supplementation may have beneficial effects on intestinal permeability and gastrointestinal complications in ICU-hospitalized patients. Further studies are needed to investigate the exact mechanism of action of these effects.
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Affiliation(s)
- Ghazaleh Eslamian
- Student Research Committee, Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Hossein Ardehali
- Department of Anesthesiology and Critical Care, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ahmad-Reza Baghestani
- Department of Biostatistics, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Vahdat Shariatpanahi
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Pham CH, Collier ZJ, Webb AB, Garner WL, Gillenwater TJ. How long are burn patients really NPO in the perioperative period and can we effectively correct the caloric deficit using an enteral feeding "Catch-up" protocol? Burns 2018; 44:2006-10. [PMID: 30115532 DOI: 10.1016/j.burns.2018.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/07/2018] [Accepted: 07/20/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE "NPO at midnight" is a standard preoperative practice intended to reduce aspiration risk but can result in prolonged feeding interruptions in critically ill burn patients. Postoperative hyperalimentation in the form of a "catch-up" tube feeding protocol is routine. A retrospective review of our perioperative fasting practices and "catch-up" enteral feeding protocols was performed. METHODS Patients admitted to the Burn ICU from July 1st, 2015 to August 31st, 2016 were reviewed. Patients who had a protected airway in place, prescribed enteral nutrition, and underwent surgery were included. The time from NPO to surgical start (NPO-SS), NPO to feeding restart (NPO-FR), and calories received/prescribed were quantified. The efficacy of a postoperative catch-up feeding protocol was analyzed. RESULTS There were 41 patients that fit inclusion criteria with some undergoing multiple surgeries, yielding 109 surgeries/discrete perioperative events. The average total body surface area burn (38.1±23.6%), age (38.8±20.1years), ICU days (45.0±37.3 days), and ventilator days (35.1±33.8 days) were calculated. Average fasting durations of NPO-SS and NPO-FR were 9.3±3.1 and 14.2±4.1h, respectively. The average caloric deficit to prescribed calories ratio during the NPO-SS and NPO-FR periods were 1154±629/3534±851kcal and 1765±928/3534±851kcal, respectively. A post-operative catch-up protocol completely compensated for perioperative caloric deficits 68.8% (22/32) of the time. CONCLUSIONS In critically ill burn patients, a preoperative fast resulted in an average loss of greater than 50% of prescribed calories on the day of surgery. Clinicians should re-evaluate the standard practice of making preoperative patients "NPO at midnight". An effective catch-up protocol can adequately reduce caloric deficits.
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Wesselink E, Koekkoek KWAC, Looijen M, van Blokland DA, Witkamp RF, van Zanten ARH. Associations of hyperosmolar medications administered via nasogastric or nasoduodenal tubes and feeding adequacy, food intolerance and gastrointestinal complications amongst critically ill patients: A retrospective study. Clin Nutr ESPEN 2018; 25:78-86. [PMID: 29779822 DOI: 10.1016/j.clnesp.2018.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 04/02/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Adequate nutrition is essential during critical illness. However, providing adequate nutrition is often hindered by gastro-intestinal complications, including feeding intolerance. It is suggested that hyperosmolar medications could be causally involved in the development of gastro-intestinal complications. The aims of the present study were 1) to determine the osmolality of common enterally administered dissolved medications and 2) to study the associations between nasogastric and nasoduodenal administered hyperosmolar medications and nutritional adequacy as well as food intolerance and gastro-intestinal symptoms. METHODS This retrospective observational cohort study was performed in a medical-surgical ICU in the Netherlands. Adult critically ill patients receiving enteral nutrition and admitted for a minimum ICU duration of 7 days were eligible. The osmolalities of commonly used enterally administrated medications were measured using an osmometer. Patients were divided in two groups: Use of hyperosmolar medications (>500 mOsm/kg) on at least one day during the first week versus none. The associations between the use of hyperosmolar medications and nutritional adequacy were assessed using multiple logistic regression analysis. The associations between hyperosmolar medication and food intolerance as well as gastrointestinal symptoms were assessed using ordinal logistic regression. RESULTS In total 443 patients met the inclusion criteria. Of the assessed medications, only three medications were found hyperosmolar. We observed no associations between the use of hyperosmolar medications and nutritional adequacy in the first week of ICU admission (caloric intake β -0.27 95%CI -1.38; 0.83, protein intake β 0.32 95%CI -0.90; 1.53). In addition, no associations were found for enteral feeding intolerance, diarrhea, obstipation, gastric residual volume, nausea and vomiting in ICU patients receiving hyperosmolar medications via a nasogastric tube. A subgroup analysis of patients on duodenal feeding showed that postpyloric administration of hyperosmolar medications was associated with increased risk of diarrhea (OR 138.7 95%CI 2.33; 8245). CONCLUSIONS Our results suggest that nasogastric administration of hyperosmolar medication via a nasogastric tube does not affect nutritional adequacy, development of enteral feeding intolerance and other gastro-intestinal complications during the first week after ICU admission. During nasoduodenal administration an increased diarrhea incidence may be encountered.
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Affiliation(s)
- Evertine Wesselink
- Division of Human Nutrition, Wageningen University, Stippeneng 4, 6708 WE, Wageningen, The Netherlands.
| | - Kristine W A C Koekkoek
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, Ede, The Netherlands.
| | - Martijn Looijen
- Department of Information Technology and Datawarehouse, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP, Ede, The Netherlands.
| | - Dick A van Blokland
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, Ede, The Netherlands.
| | - Renger F Witkamp
- Division of Human Nutrition, Wageningen University, Stippeneng 4, 6708 WE, Wageningen, The Netherlands.
| | - Arthur R H van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, Ede, The Netherlands.
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Takano C, Seki M, Shiihara H, Komine-Aizawa S, Kuroda K, Takahashi S, Ushijima H, Hayakawa S. Frequent isolation of extended-spectrum beta-lactamase-producing bacteria from fecal samples of individuals with severe motor and intellectual disabilities. J Infect Chemother 2018; 24:182-187. [PMID: 29398476 DOI: 10.1016/j.jiac.2017.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/20/2017] [Accepted: 10/03/2017] [Indexed: 02/06/2023]
Abstract
Extended-spectrum beta-lactamase (ESBL) producing bacteria spread worldwide and became major concern for antibiotic treatment. Although surveillance reports in general hospitals and long-term care facilities are increasing, their frequencies in individuals with severe motor and intellectual disabilities (SMID) are so far unknown. In this study, we examined the frequency of ESBL in stool samples collected from 146 asymptomatic SMID subjects hospitalized in a single institution. With their clinical information, we evaluated possible risk factors for ESBL colonization. From 146 fecal samples, ESBL-producing bacteria were isolated in 45 cases (31%). Drug sensitivity testing showed that 82% of the isolates were resistant to levofloxacin but were sensitive to tazobactam/piperacillin and cefmetazole. The most frequent genotype was CTX-M-9 detected in 36/45 (80%). A high degree of disability, antibiotic use within three months before sampling and post-tracheostomy were statistically significant risk factors. Tube feeding was also strongly correlated with ESBL colonization (p < 0.001) and associated with lower micro-organismic diversities. Our findings are the first to reveal a high prevalence of ESBL in the fecal samples of SMID individuals and suggest possible relationships between high degree disability, tube feeding and latest histories of antibiotic use.
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Affiliation(s)
- Chika Takano
- Division of Microbiology, Department of Pathology and Microbiology, Nihon University School of Medicine, 30-1, Oyaguchikamicho, Itabashi-ku, Tokyo 173-8610, Japan; Department of Pediatrics and Child Health, Nihon University School of Medicine, 30-1, Oyaguchikamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Mitsuko Seki
- Division of Microbiology, Department of Pathology and Microbiology, Nihon University School of Medicine, 30-1, Oyaguchikamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Hiroaki Shiihara
- Ashikaga-no-mori Ashikaga Hospital, 615, Onumatacho, Ashikaga-shi, Tochigi 326-0011, Japan
| | - Shihoko Komine-Aizawa
- Division of Microbiology, Department of Pathology and Microbiology, Nihon University School of Medicine, 30-1, Oyaguchikamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kazumichi Kuroda
- Division of Microbiology, Department of Pathology and Microbiology, Nihon University School of Medicine, 30-1, Oyaguchikamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Shori Takahashi
- Department of Pediatrics and Child Health, Nihon University School of Medicine, 30-1, Oyaguchikamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Hiroshi Ushijima
- Division of Microbiology, Department of Pathology and Microbiology, Nihon University School of Medicine, 30-1, Oyaguchikamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Satoshi Hayakawa
- Division of Microbiology, Department of Pathology and Microbiology, Nihon University School of Medicine, 30-1, Oyaguchikamicho, Itabashi-ku, Tokyo 173-8610, Japan.
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Wirth R. [Percutaneous endoscopic gastrostomy in geriatrics : Indications, technique and complications]. Z Gerontol Geriatr 2018; 51:237-245. [PMID: 29349584 DOI: 10.1007/s00391-017-1363-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/06/2017] [Accepted: 12/12/2017] [Indexed: 11/26/2022]
Abstract
The technique of percutaneous endoscopic gastrostomy (PEG) was introduced in 1979 as a semi-invasive approach for children with the need for a gastric fistula in order to avoid an operative intervention. The suture pull-through method was rapidly established and is now omnipresent. Because scientific evidence is broadly missing, there is some uncertainty about the indications in geriatric medicine. Guidelines do not recommend the insertion of a PEG in patients with severe dementia and malnutrition. Tube feeding is mainly recommended as a temporary method for patients who cannot take oral nutrition for more than 3 days or for whom the energy intake for more than 10 days presumably covers less than 50% of their needs, assuming that the overall prognosis is reasonable. Insertion of a PEG is only recommended if artificial nutrition is expected to be necessary for more than 3-4 weeks or if a nasogastric tube is not tolerated.
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Affiliation(s)
- Rainer Wirth
- Klinik für Altersmedizin und Frührehabilitation, Marien Hospital Herne - Universitätsklinikum der Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Deutschland.
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Schmidt SB, Kulig W, Winter R, Vasold AS, Knoll AE, Rollnik JD. The effect of a natural food based tube feeding in minimizing diarrhea in critically ill neurological patients. Clin Nutr 2018; 38:332-340. [PMID: 29358002 DOI: 10.1016/j.clnu.2018.01.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/26/2017] [Accepted: 01/03/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Diarrhea has negative consequences for patients, health care staff and health care costs when neurological patients are fed enterally over long periods. We examined the effect of tube feeding with natural foods in reducing the number of fluid stool evacuations and diarrhea in critically ill neurological patients. METHODS A multicenter, prospective, open-label and randomized controlled trial (RCT) was conducted at facilities in Germany specializing in early rehabilitation after neurological damage. Patients of the INTERVENTION group were fed by tube using a commercially available product based on real foods such as milk, meat, carrots, whereas CONTROL patients received a standard tube-feed made of powdered raw materials. All received enteral nutrition over a maximum of 30 days. The number of defecations and the consistency of each stool according to the Bristol Stool Chart (BSC) were monitored. In addition, daily calories, liquids and antibiotic-use were recorded. RESULTS 118 Patients who had suffered ischemic stroke, intracerebral hemorrhage, traumatic brain injury or hypoxic brain damage and requiring enteral nutrition were enrolled; 59 were randomized to receive the intervention and 59 control feed. There were no significant differences in clinical screening data, age, sex, observation period or days under enteral nutrition between the groups. Patients in both groups received equivalent amount of calories and fluids. In both groups antibiotics were frequently prescribed (69.5% in the INTERVENTION group and 75.7% in the CONTROL group) for 10-11 days on average. In comparison to the CONTROL group, patients in the INTERVENTION group had a significant reduction of the number of watery stool evacuations (type 7 BSC) (minus 61%, IRR = 0.39, p < 0.001). Further statistical evaluations using the following corrections: major diarrhea-associated confounders (number and duration of antibiotics); shorter observation period of 15 days; excluding patients with Clostridium difficile associated diarrhea (CDAD) and the Per Protocol Population, confirmed the primary hypothesis. The number of days with diarrhea was significantly lower in the INTERVENTION group (0.8 ± 1.60 days versus 2.0 ± 3.46 days). CONCLUSIONS Tube feeding with natural based food was effective in reducing the number of watery defecations and diarrhea in long term tube-fed critically ill neurological patients, compared to those fed with standard tube feeding.
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Affiliation(s)
- Simone B Schmidt
- Institute for Neurorehabilitation Research (InFo), BDH-Clinic Hessisch Oldendorf, Hannover Medical School, Hessisch Oldendorf, Germany.
| | - Willibald Kulig
- HiPP GmbH & Co. Vertrieb KG, Georg-Hipp-Straße 7, 85276 Pfaffenhofen, Germany
| | - Ralph Winter
- SRH Kurpfalzkrankenhaus Heidelberg gGmbH, Germany
| | - Antje S Vasold
- Medizinische Einrichtung des Bezirkes Oberpfalz KU, Klinik für Neurologische Rehabilitation, Germany
| | | | - Jens D Rollnik
- Institute for Neurorehabilitation Research (InFo), BDH-Clinic Hessisch Oldendorf, Hannover Medical School, Hessisch Oldendorf, Germany
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Takenoshita S, Kondo K, Okazaki K, Hirao A, Takayama K, Hirayama K, Asaba H, Nakata K, Ishizu H, Takahashi H, Nakashima-Yasuda H, Sakurada Y, Fujikawa K, Yokota O, Yamada N, Terada S. Tube feeding decreases pneumonia rate in patients with severe dementia: comparison between pre- and post-intervention. BMC Geriatr 2017; 17:267. [PMID: 29157223 PMCID: PMC5697435 DOI: 10.1186/s12877-017-0662-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/10/2017] [Indexed: 11/10/2022] Open
Abstract
Background It is widely supposed that there is no benefit, including extended survival and decreased rate of pneumonia, in patients with severe dementia receiving enteral tube feeding (TF). However, there have been few studies comparing the frequency of pneumonia before and after TF in severe dementia. Methods Nine psychiatric hospitals in Okayama Prefecture participated in this retrospective survey. All inpatients fulfilling the entry criteria were evaluated. All subjects suffered from difficulty in oral intake. Attending physicians thought that the patients could not live without long-term artificial nutrition, and they decided whether or not to make use of long-term artificial nutrition from January 1, 2014 to December 31, 2014. Results We evaluated 58 patients including 46 with TF and 12 without. The mean age of all patients was 79.6 ± 9.0 years old. Patients with probable Alzheimer’s disease (n = 38) formed the biggest group, and those with vascular dementia the second (n = 14). Median survival times were 23 months among patients with TF and two months among patients without TF. The start of TF decreased the frequency of pneumonia and the use of intravenous antibiotics. Conclusions TF decreased pneumonia and antibiotic use, even in patients with severe dementia. The results of this study do not necessarily indicate that we should administer TF to patients with severe dementia. We should consider the quality of life of patients carefully before deciding the use or disuse of TF for patients with severe dementia.
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Affiliation(s)
- Shintaro Takenoshita
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Keiko Kondo
- Department of Psychiatry, Sekizen Hospital, Tsuyama, Japan
| | | | - Akihiko Hirao
- Department of Psychiatry, Kawada Hospital, Okayama, Japan
| | - Keiko Takayama
- Department of Psychiatry, Kibogaoka Hospital, Tsuyama, Japan
| | | | - Hiroyuki Asaba
- Department of Psychiatry, Kohnan Hospital, Tamano, Japan
| | - Kenji Nakata
- Department of Psychiatry, Taiyo Hills Hospital, Takahashi, Japan
| | - Hideki Ishizu
- Department of Psychiatry, Zikei Hospital, Okayama, Japan
| | | | | | - Yasue Sakurada
- Department of Psychiatry, Mannari Hospital, Okayama, Japan
| | - Kengo Fujikawa
- Department of Psychiatry, Kinoko Espoir Hospital, Kasaoka, Japan
| | - Osamu Yokota
- Department of Psychiatry, Kinoko Espoir Hospital, Kasaoka, Japan
| | - Norihito Yamada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Seishi Terada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
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Fullerton BS, Hong CR, Velazco CS, Mercier CE, Morrow KA, Edwards EM, Ferrelli KR, Soll RF, Modi BP, Horbar JD, Jaksic T. Severe neurodevelopmental disability and healthcare needs among survivors of medical and surgical necrotizing enterocolitis: A prospective cohort study. J Pediatr Surg 2017; 53:S0022-3468(17)30651-6. [PMID: 29079317 DOI: 10.1016/j.jpedsurg.2017.10.029] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 10/05/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE This study characterizes neurodevelopmental outcomes and healthcare needs of extremely low birth weight (ELBW) survivors of necrotizing enterocolitis (NEC) compared to ELBW infants without NEC. METHODS Data were collected prospectively on neonates born 22-27weeks' gestation or 401-1000g at 47 Vermont Oxford Network member centers from 1999 to 2012. Detailed neurodevelopmental evaluations were conducted at 18-24months corrected age. Information regarding rehospitalizations, postdischarge surgeries, and feeding was also collected. "Severe neurodevelopmental disability" was defined as: bilateral blindness, hearing impairment requiring amplification, inability to walk 10 steps with support, cerebral palsy, and/or Bayley Mental or Psychomotor Developmental Index <70. Diagnosis of NEC required both clinical and radiographic findings. RESULTS There were 9063 children without NEC, 417 with medical NEC, and 449 with surgical NEC evaluated. Significantly higher rates of morbidity were observed among infants with a history of NEC. Those with surgical NEC were more frequently affected across all outcome measures at 18-24months corrected age: 38% demonstrated severe neurodevelopmental disability, nearly half underwent postdischarge operations, and a quarter required tube feeding at home. CONCLUSION At 18-24months, extremely low birth weight survivors of necrotizing enterocolitis were at markedly increased risk (p<0.001) for severe neurodevelopmental disability, postdischarge surgery, and tube feeding. LEVEL OF EVIDENCE II (prospective cohort study with <80% follow-up rate).
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Affiliation(s)
- Brenna S Fullerton
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Charles R Hong
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Cristine S Velazco
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | - Erika M Edwards
- University of Vermont, Burlington, VT; Vermont Oxford Network, Burlington, VT
| | | | - Roger F Soll
- University of Vermont, Burlington, VT; Vermont Oxford Network, Burlington, VT
| | - Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Jeffrey D Horbar
- University of Vermont, Burlington, VT; Vermont Oxford Network, Burlington, VT
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA.
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Abstract
Electromagnetic (EM)-guided tube placement has been successfully used to pre-empt lung misplacement, but undetected misplacements continue to occur. The authors conducted an audit to investigate whether official Cortrak or local guidance enabled differentiation of gastrointestinal (GI) from lung traces. X-ray, pH or an EM trace beyond the gastric body were used to independently confirm gastric position. The authors undertook 596 nasointestinal (NI) tube placements, of which 361 were primary GI placements and 41 lung misplacements. Official guidance that in GI traces a midline deviation is absent cannot differentiate GI from lung traces because deviation is common in both. However, when comparing a trace in the same patient, midline deviation during lung misplacement always occurred >18 cm above the horizontal line compared with only 33% of the subsequent GI deviation (p<0.0001). Official guidance could lead to aborted GI placements or undetected lung placements. EM-guided placement must have an expert-led understanding of the 3D trace pattern, artefact correction and appraised practical experience differentiating GI from lung placement. The authors invite Halyard Health to update guidance in view of these findings.
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Affiliation(s)
- Stephen J Taylor
- Research Dietitian, Department of Nutrition and Dietetics, Southmead Hospital, Bristol
| | - Rowan Clemente
- Specialist Dietitian, Department of Nutrition and Dietetics, Southmead Hospital, Bristol
| | - Kaylee Allan
- Specialist Dietitian, Department of Nutrition and Dietetics, Southmead Hospital, Bristol
| | - Sophie Brazier
- Specialist Dietitian, Department of Nutrition and Dietetics, Southmead Hospital, Bristol
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