Effect of a texture-modified and controlled bolus volume diet on all-cause mortality in older persons with oropharyngeal dysphagia: Secondary analysis of a randomized controlled trial

BACKGROUND

Oropharyngeal dysphagia (OD) is common among older adults. Some studies have evaluated the efficacy of a texture-modified diet on mortality but with short-term follow-up. We aimed to evaluate the effect of a texture-modified diet and controlled bolus volume on all-cause mortality after 12 months in older persons with OD.

METHODS

This secondary analysis of a randomized clinical trial included patients aged ≥60 years with a diagnosis of OD. They were concurrently and randomly assigned to receive either a texture-modified food diet and controlled bolus volume (intervention group) or standard treatment (control group) with 12 months of follow-up. Secondary outcomes were oral intake, weight, handgrip strength, phase angle, and aspiration pneumonia. Kaplan-Meier analysis and the Cox proportional hazards model were used for mortality analysis.

RESULTS

A total of 127 participants (intervention group: 64 and control group: 63) were recruited, with a mean age of 76 years. The probability of all-cause mortality was significantly lower in the intervention group (n = 8, 12%) than in the control group (n = 18, 29%) (hazard ratio = 0.36 [95% CI = 0.16-0.86]; P = 0.01). There were 5 (7.9%) and 10 (16.1%) aspiration pneumonia events in the intervention and control groups, respectively (not significant) in 12 months of follow-up. Changes were observed in protein consumption (P = 0.01), body weight (P = 0.04), body mass index (P = 0.004), handgrip strength (P = 0.02), and phase angle (P = 0.04) between the treatment groups.

CONCLUSION

Compared with the standard treatment, the dietary intervention improved efficacy by limiting nutrition complications, aspiration pneumonia, and all-cause mortality.

Recommendations of good practice to prevent aspiration pneumonia in older adults at risk of oropharyngeal dysphagia living in nursing homes: A modified e-Delphi study protocol

BACKGROUND

Aspiration pneumonia (AP) is a subset of pneumonia caused by the aspiration of food and fluids to the lungs and is highly prevalent in the older population. Oropharyngeal dysphagia (OD) is one of the risk factors for AP and it is also associated with malnutrition, dehydration and poor functional outcomes. As pneumonia is the second most common infection in nursing homes (NHs) and OD represents a major concern to NH staff, good practices for the prevention of AP in older adults at risk of OD are needed.

PURPOSE

The aim of this modified e-Delphi study is to build consensus among a panel of experts regarding a set of recommendations for NH staff on good practices to prevent AP in older adults at risk of OD living in NHs. The objective of this paper is to establish the methodology inherent to the Delphi study.

METHODS

An online modified Delphi study will be developed in three rounds. Criteria for the Delphi panel participants include holding a master's or doctoral degree in OD or speech and language therapy; or having 10 or more years of experience in OD; or having at least one scientific publication related to OD. A previously described modified Delphi methodology will be used to achieve consensus (75% agreement). An additional round will be performed to collect the experts' perspectives regarding the priority for application of each recommendation previously validated.

DISCUSSION

This protocol aimed to describe the methodology of a future Delphi study on the prevention of AP, seeking to fulfil the gap in the literature regarding this topic. The modified Delphi technique is a widely used method for collecting experts' opinion in health sciences, but the absence of standardised guidelines allows some heterogeneity between studies with the same aim.

WHAT THIS PAPER ADDS

What is already known on the subject Aspiration pneumonia (AP) is related to three main risk factors: impaired safety of swallow, impaired nutritional status and poor oral health. It is known that being dependent for feeding is one of the main risk factors for AP and around 50% of nursing home (NH) residents need feeding assistance. Thus, it is important to promote specialised intervention and care by the NH staff for preventing AP. What this paper adds to existing knowledge It is hypothesised that increasing the knowledge of NH staff regarding the best practices for preventing AP in older adults at risk of oropharyngeal dysphagia (OD) will improve outcomes such as quality of life, incidence of AP and mortality. What are the potential or actual clinical implications of this work? The recommendations resulting from this study will address a current gap in healthcare practice of NH staff regarding older adults at increased risk for OD and, consequently, for AP.

Respiratory symptoms due to a twisted nasogastric tube: A case report

Insertion of a nasogastric tube (NGT) is generally considered safe; however, it is not without risk, and in cases of misplacement, complications and even death may occur. In this article, we reported a case of NGT misplacement in a 75-year-old male, which resulted in aspiration pneumonia. We also reviewed published cases of NGT misplacement. Clinicians should pay enough attention to the confirmation of the proper placement of an NGT. A systematic approach for NGT insertion and confirmation is required to prevent misplacement.

Oropharyngeal dysphagia in children with multiple disabilities

OBJECTIVE

This study aimed to investigate the prevalence of oropharyngeal dysphagia among institutionalised children with multiple disabilities, a topic with limited literature coverage.

METHODS

The study employed a questionnaire, specifically the F-PEDI-EAT-10, to screen for dysphagia in children. Trained nurses administered the questionnaire to the participants.

RESULTS

The study included 117 children with multiple disabilities (51.3 per cent boys and 48.7 per cent girls) with an average age of 14 ± 4.7 years. The questionnaire revealed that 53 per cent (n = 62) of the children had a positive score and, surprisingly, 29 per cent of them (n = 18) did not have a confirmed diagnosis of oropharyngeal dysphagia. Notably, children with a positive F-PEDI-EAT-10 score had a significantly higher prevalence of pneumopathy and undernutrition compared with those with a negative score.

CONCLUSION

This study underscores the high prevalence of oropharyngeal dysphagia among children with multiple disabilities, a condition that is often underdiagnosed.

Lack of Physician-Dentist Collaboration in Aspiration Pneumonia Prevention

This opinion paper addresses the challenges and future directions for preventing aspiration pneumonia in Japan's rapidly aging population. It highlights the increasing proportion of elderly individuals and the associated rise in health issues like decreased swallowing function, a risk factor for aspiration pneumonia. The paper emphasizes the effectiveness of dentist-provided oral care in preventing this condition but notes the lack of collaboration between dentists and physicians in Japan's clinical practice. Key challenges identified include the scarcity of full-time hospital dentists, insufficient communication between physicians and dentists, limited patient understanding and motivation regarding oral care, and a lack of training in geriatric dentistry. The paper advocates for enhanced awareness among healthcare professionals and patients, increased hospital dentists, and improved collaboration mechanisms, particularly in light of recent positive changes in insurance reimbursement policies for elderly oral care.

Retrograde transgastric jejunostomy for nutritional management and aspiration prevention in cases with severe malignant esophageal strictures

Locally advanced esophageal cancer often presents with dysphagia and can be complicated by aspiration pneumonia. Therefore, nutritional management is important to prevent pneumonia. Enteral nutrition via gastrostomies is common in esophageal cancer patients. Here, we describe the efficacy of nutritional management using a gastrojejunostomy tube retrogradely inserted in the esophagus through gastrostomy to simultaneously drain accumulated fluid on the proximal side of a malignant stricture. We performed this procedure for two cases with severe malignant strictures using two types of endoscope insertion. A 57-year-old male patient (Case 1) underwent a retrograde insertion of a gastrojejunostomy tube for severe esophageal malignant stricture with severe nausea and salivary reflux. After a narrow endoscope was inserted through the gastrostomy fistula, a gastrojejunostomy tube was inserted alongside a guidewire allowing the patient to undergo definitive chemoradiotherapy without symptoms. An 82-year-old male patient (Case 2) was scheduled for a minimally invasive esophagectomy following neoadjuvant chemotherapy after gastrostomy. However, the patient developed aspiration pneumonia due to salivary reflux; before surgery, a narrow nasal endoscope was inserted and passed through the strictures. The percutaneous endoscopic transgastric jejunostomy catheter was retrogradely inserted alongside the guidewire. In patients with malignant strictures and salivary reflux, retrograde insertion of gastrojejunostomy tubes can simultaneously provide enteral nutrition and saliva drainage.

The Potential Role of Angiotensin-Converting Enzyme Inhibitors and Beta-Blockers in Reducing Pneumonia Severity in Older Adults

Background Understanding the impact of pharmacological therapy on pneumonia severity is crucial for effective clinical management. The impact of angiotensin-converting enzyme inhibitors (ACEis) and beta-blockers (BBs) on pneumonia severity remains unknown, warranting further investigation. Methodology This retrospective study examined the hospital records of inpatients (≥75 years) admitted with community-acquired pneumonia in 2021. Pneumonia severity associated with the use of pre-established ACEi and BB therapy was documented using CURB-65 (confusion, uraemia, respiratory rate, blood pressure, age ≥65 years) and pneumonia severity index (PSI) scores. Descriptive statistics and multivariable linear regression were used to analyse differences across BB therapy, ACEi therapy, their combination, or neither (control group). Results A total of 803 patient records were examined, of whom 382 (47.6%) were male and 421 (52.4%) were female. Sample sizes for each group were as follows: control (n = 492), BB only (n = 185), ACEi only (n = 68), and BB + ACEi (n = 58). Distribution of aspiration pneumonia (AP) versus non-AP for each group, respectively, was control (21.1% vs. 78.9%), BB only (9.7% vs. 90.3%), ACEi only (7.3% vs. 92.7%), and ACEi + BB (12.1% vs. 87.9%). No significant differences in PSI and CURB-65 scores were found between intervention groups even after controlling for patient characteristics and irrespective of AP or non-AP aetiology. Patients with AP had significantly higher CURB-65 (p = 0.026) and PSI scores (p = 0.044) compared to those with non-AP. Conclusions Pre-prescribed ACEi or BB therapy did not appear to be associated with differences in pneumonia severity. There were no differences in pneumonia severity scores with ACEi and BB monotherapy or combined ACEi and BB therapy.

Safety profile of hypnotics or sedatives on community-dwelling older adults aged 75 or older in Japan: A retrospective propensity-matched cohort study

OBJECTIVE

The purpose of the study is to assess if daily use of hypnotics increases mortality, aspiration pneumonia and hip fracture among relatively healthy individuals aged 75 years or older who lead independent lives in the community.

METHOD AND PATIENTS

Of the adults aged 75 years or older residing in Hokkaido prefecture of Japan (n = 705,538), those who did not meet several exclusion criteria were eligible for generating propensity score-matched cohorts (n = 214,723). Exclusion criteria included co-prescribed medications acting on the central nervous system, diagnoses of malignant neoplasm, dementia, depression, etc. We compared 33,095 participants who were prescribed hypnotics for daily use (hypnotic group) with a propensity score-matched cohort without a prescription (control group). Participants were followed for more than 42 months.

RESULTS

During the 42-month follow-up period, the incidence of the three outcome measures in the hypnotics group was significantly higher than that in the control group (aspiration pneumonia p < 0.001, hip fracture p = 0.007, and all-cause mortality p < 0.001). Sensitivity analyses utilizing inverse probability weighting demonstrated hazard ratios of 1.083 [1.023-1.146] for mortality, 1.117 [1.014-1.230] for aspiration pneumonia, and 1.720 [1.559-1.897] for hip fracture. Meanwhile, the attribute risk differences were 2.7, 1.5, and 1.0 per 1000 patient-years, respectively.

CONCLUSIONS

Although daily use of hypnotics increased the risk of three events, their attribute risk differences were fewer than 3.0 per 1000 patient-years. The results will help provide guidance on whether it is reasonable to prescribe hypnotics to geriatric population aged 75 or older leading independent lives in the community.

CLINICAL TRIAL REGISTRATION

UMIN-CTR UMIN000048398.

Should We Stop Glucagon-Like Peptide-1 Receptor Agonists Before Surgical or Endoscopic Procedures? Balancing Limited Evidence With Clinical Judgment

The American Society of Anesthesiologists (ASA) Task Force recently recommended discontinuing glucagon-like peptide-1 receptor agonist (GLP-1 RA) agents before surgery because of the potential risk of pulmonary aspiration. However, there is limited scientific evidence to support this recommendation, and holding GLP-1 RA treatment may worsen glycemic control in patients with diabetes. As we await further safety data to manage GLP-1 RA in the perioperative period, we suggest an alternative multidisciplinary approach to manage patients undergoing elective surgery. Well-conducted observational and prospective studies are needed to determine the risk of pulmonary aspiration in persons receiving GLP-1 RA for the treatment of diabetes and obesity, as well as the short-term impact of discontinuing GLP-1 RA on glycemic control before elective procedures in persons with diabetes.

Effectiveness of Drip Infusion of Lascufloxacin, a Novel Fluoroquinolone Antibiotic, for Patients with Pneumonia Including Chronic Lung Disease Exacerbations and Lung Abscesses

Background

Lascufloxacin (LSFX), a novel fluoroquinolone antibacterial agent, has recently been used as a drip infusion for treating pneumonia, apparently with good effectiveness against various bacteria, including anaerobes, and good intrapulmonary penetration.

Methods

The clinical effectiveness of LSFX was retrospectively investigated for the 55 patients admitted to our hospital with pneumonia, including chronic lung disease exacerbations and lung abscesses, from May 2021 to July 2023.

Results

The median age of the 55 patients was 76.1 (34.1-93.1) years, 45 (81.8%) were male, and 48 (87.5%) patients had underlying disease. Community-acquired pneumonia was seen in 47 (85.5%) patients, including 9 (16.4%) with lung abscess, and the other 8 (14.5%) had nursing and healthcare-associated pneumonia/hospital-acquired pneumonia. Moderate pneumonia was present in 33 (61.8%) of 55 patients, and LSFX was used as a second-line treatment for 28 (50.9%) patients in whom first-line antibiotics were ineffective. The median duration of intravenous LSFX administration was 9 (2.0-49) days. Streptococcus pneumoniae and methicillin-susceptible Staphylococcus aureus were isolated from 3 (7.1%) and 2 (4.8%) patients, respectively. Of the 55 patients, 45 (81.5%) improved clinically with intravenous LSFX administration; 20 (95.2%) of 21 community-acquired pneumonia cases, including 9 (100.0%) of 9 bacterial pneumonia cases, were improved by LSFX as first-line treatment, and 8 (88.9%) of 9 lung abscess patients also showed clinical improvement with LSFX as a second-line treatment. There were no severe adverse effects in any of the 55 patients.

Conclusion

Based on these data, intravenous administration of LSFX seems effective for bacterial pneumonia, including chronic lung disease exacerbations and lung abscesses, and it appears to have broad antimicrobial activity and good tissue penetration into the lung.

Complications of oropharyngeal dysphagia in older individuals and patients with neurological disorders: insights from Mataró hospital, Catalonia, Spain

Background

Oropharyngeal dysphagia (OD) significantly impacts older individuals and neurologically compromised patients, hindering safe ingestion of food and liquids. Despite its prevalence, OD remains underdiagnosed and undertreated, leading to severe complications such as malnutrition, dehydration, respiratory infections, and aspiration pneumonia (AP), and increases hospital readmissions.

Objectives

This study analyzes the intricate relationship between OD and various clinical complications in older individuals and patients with neurological disorders.

Methods

Utilizing retrospective analysis and narrative review, our work consolidates findings from prior studies on Hospital de Mataro's dysphagia patient cohort. Revisiting OD's intricate association with clinical complications, it presents data via odds ratios (OR), incidence ratios (IR), and hazard ratios (HR) from univariate and multivariate analyses.

Results

Five studies (2001-2014) involving 3,328 patients were scrutinized. OD exhibited independent and significant associations with various complications among older patients. Older individuals with OD faced heightened 1-month (ODDS 3.28) and 1-year (OR 3.42) mortality risks post-pneumonia diagnosis. OD correlated with a 2.72-fold risk of malnutrition, 2.39-fold risk of lower respiratory tract infections, 1.82-fold pneumonia readmissions (IR), and 5.07-fold AP readmissions (IR). Post-stroke OD is linked to neurological impairment (OR 3.38) and respiratory (OR 9.54) and urinary infections (OR 7.77), alongside extended hospital stays (beta coefficient 2.11).

Conclusion

Oropharyngeal dysphagia causes and significantly exacerbates diverse clinical complications in older and post-stroke patients, emphasizing the urgent need for proactive identification, comprehensive assessment, and tailored management. Acknowledging OD's broader implications in general medical practice is pivotal to improving patient outcomes and healthcare quality.

Long‑term survival prognosis of function‑preserving curative gastrectomy for early gastric cancer

Segmental gastrectomy, mini-distal gastrectomy and local resection of the stomach are function-preserving curative gastrectomies (FPGs), which are used to treat gastric cancer in specialized centers. These surgical options are less invasive and can alleviate postgastrectomy symptoms more than standard gastrectomy; however, their association with prognosis remains to be fully elucidated. The present study aimed to compare the survival prognosis of patients diagnosed as node-negative by sentinel node biopsy (SNB) treated via FPG with reduced lymph node dissection with that of patients who underwent guideline gastrectomy (GL). This retrospective study was conducted between April 1999 and March 2016. The inclusion criteria were a diagnosis of gastric cancer type 0, of ≤5 cm, located in L or M areas, and pT1N0. Patients who underwent distal gastrectomy and pylorus-preserving gastrectomy were included as controls in the GL group. Among the 146 and 300 patients in the FPG and GL groups, respectively, only 1 patient in the GL group experienced recurrence. The overall survival (OS) of the FPG group was 96.6% at 5 years and 92.5% at 10 years, which was significantly higher than that of the GL group (P<0.05). In addition, the cumulative incidence of non-cancer-related deaths, especially pulmonary diseases, was lower in the FPG group than that in the GL group (P<0.05). Notably, the OS and non-cancer death rate in the FPG group remained significantly better after propensity score-matching analysis. In conclusion, for early gastric cancer located in M or L areas, patients treated via FPG guided by SNB have a better prognosis and fewer deaths caused by respiratory disease than those treated via GL. The present clinical trial was registered under the following trial registration numbers: UMIN000010154 (2013/3/4), UMIN000023828 (2016/8/29), jRCTs041180006 (2018/10/9).

Impact of Antibiotics Used for Acute Aspiration Bronchitis on the Prevention of Pneumonia

BACKGROUNDS

It remains unclear if antibiotics should be used for the treatment of acute aspiration bronchitis to prevent the development of pneumonia. This study aimed to assess the associations between the use of antibiotics and the development of pneumonia among patients with acute aspiration bronchitis.

METHODS

We retrospectively reviewed consecutive patients with acute aspiration bronchitis aged ≥75 years. Acute aspiration bronchitis was defined as a condition with aspiration risk, high fever (body temperature, ≥37.5 °C), respiratory symptoms, and the absence of evidence of pneumonia.

RESULTS

There was no significant difference in the incidence of pneumonia between patients treated with and without antibiotics for acute aspiration bronchitis (6/44, 14% vs. 31/143, 22%; p = 0.242). Lower estimated glomerular filtration rate (adjusted odds ratio, 0.956; 95% confidence interval, 0.920-0.993) was significantly associated with the development of pneumonia.

CONCLUSIONS

Antibiotic administration should not be routinely recommended to prevent pneumonia following acute aspiration bronchitis, and patients with decreased renal function should be closely monitored. A randomized controlled trial is necessary to validate these results.

Anaerobic Antibiotic Coverage in Aspiration Pneumonia and the Associated Benefits and Harms: A Retrospective Cohort Study

BACKGROUND

Antibiotics with extended anaerobic coverage are used commonly to treat aspiration pneumonia, which is not recommended by current guidelines.

RESEARCH QUESTION

In patients admitted to hospital for community-acquired aspiration pneumonia, does a difference exist between antibiotic therapy with limited anaerobic coverage (LAC) vs antibiotic therapy with extended anaerobic coverage (EAC) in terms of in-hospital mortality and risk of Clostridioides difficile colitis?

STUDY DESIGN AND METHODS

We conducted a multicenter retrospective cohort study across 18 hospitals in Ontario, Canada, from January 1, 2015, to January 1, 2022. Patients were included if the physician diagnosed aspiration pneumonia and prescribed guideline-concordant first-line community-acquired pneumonia parenteral antibiotic therapy to the patient within 48 h of admission. Patients then were categorized into the LAC group if they received ceftriaxone, cefotaxime, or levofloxacin. Patients were categorized into the EAC group if they received amoxicillin-clavulanate, moxifloxacin, or any of ceftriaxone, cefotaxime, or levofloxacin in combination with clindamycin or metronidazole. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included incident C difficile colitis occurring after admission. Overlap weighting of propensity scores was used to balance baseline prognostic factors.

RESULTS

The LAC and EAC groups included 2,683 and 1,316 patients, respectively. In hospital, 814 patients (30.3%) and 422 patients (32.1%) in the LAC and EAC groups died, respectively. C difficile colitis occurred in 5 or fewer patients (≤ 0.2%) and 11 to 15 patients (0.8%-1.1%) in the LAC and EAC groups, respectively. After overlap weighting of propensity scores, the adjusted risk difference of EAC minus LAC was 1.6% (95% CI, -1.7% to 4.9%) for in-hospital mortality and 1.0% (95% CI, 0.3%-1.7%) for C difficile colitis.

INTERPRETATION

Extended anaerobic coverage likely is unnecessary in aspiration pneumonia because it is associated with no additional mortality benefit, only an increased risk of C difficile colitis.

The importance of taste on swallowing function

The world's population is aging. Pneumonia is the leading cause of death among the older adults, with aspiration pneumonia being particularly common. Aspiration pneumonia is caused by a decline in swallowing function. Causes can include age-related sarcopenia of swallowing muscles, cognitive decline, cerebrovascular and other diseases or even changes in individual taste preference. Currently, the main treatment approach for dysphagia is resistance training of swallowing-related muscles. This approach has not been effective and establishment of novel methods are required. In this review, we introduce and discuss the relationship between taste, taste preference, carbonation and swallowing function. Taste and preference improve swallowing function. Recently, it has been shown that a carbonated beverage that combines the functionality of a thickening agent, the appeal of taste, and the stimulation of carbonation improves swallowing function. This may be very useful in the recovery of swallowing function. It is important to note that deliciousness is based not only on taste and preference, but also on visual information such as food form. Umami taste receptors are expressed not only in taste buds but also in skeletal muscle and small intestine. These receptors may be involved in homeostasis of the amino acid metabolic network, i.e., the process of amino acid ingestion, intestine absorption, and storage in skeletal muscle. Proper stimulation of umami receptors in organs other than taste buds may help maintain nutritional status and muscle mass. Umami receptors are therefore a potential therapeutic target for dysphagia.

Navigating Complexity: A Rare Case of Down Syndrome With Dural Venous Thrombosis in a Neonate

This case report presents a unique clinical scenario of a 2 kg male neonate with Down syndrome complicated by dural venous thrombosis. Born via normal vaginal delivery, the infant exhibited syndromic features characteristic of Down syndrome, necessitating admission to the neonatal intensive care unit (NICU) for respiratory distress. Confirmatory karyotyping established the diagnosis. Subsequent complications included germinal matrix haemorrhage, hypoxic-ischemic encephalopathy, and aspiration pneumonia. An MRI revealed dural venous thrombosis in the left transverse sinus, an uncommon manifestation in neonates with Down syndrome. Multidisciplinary management involved respiratory support, antibiotic therapy, and neurophysiotherapy. Infectious complications, including Klebsiella pneumoniae growth, required tailored antibiotic intervention. Despite intubation and CO2 retention challenges, the neonate improved and was ultimately discharged with favourable anthropometric measurements. This case underscores the importance of a comprehensive approach to neonatal care in the context of Down syndrome, emphasising the need for early recognition and management of rare complications such as venous thrombosis. The positive outcome highlights the efficacy of a multidisciplinary strategy in addressing complex neonatal conditions.

Evaluation of a rapid sequence induction technique in dogs with or without rocuronium

OBJECTIVE

To determine, using a rapid sequence induction (RSI) technique, whether rocuronium improves the quality and speed of endotracheal intubation in healthy dogs.

STUDY DESIGN

Randomized, crossover, experimental study.

ANIMALS

Six adult intact male Beagles (12.3 ± 0.4 kg).

METHODS

Dogs were premedicated with intravenous acepromazine (0.03 mg kg-1) and hydromorphone (0.1 mg kg-1). Ten minutes later, anesthesia was induced with intravenous propofol (2 mg kg-1 over 5 seconds), followed by saline (0.06 mL kg-1, CT group) or rocuronium (0.6 mg kg-1, RT group), with orotracheal intubation attempted after 45 seconds. Intubation time (IT) and conditions (IC) were assessed. PaO2, PaCO2, arterial blood pH and serum cortisol were obtained before and after RSI. After endotracheal intubation, saline (0.04 mL kg-1) or sugammadex (4 mg kg-1) were administered intravenously in CT or RT groups, respectively. Spontaneous ventilation restoration was noted.

RESULTS

The IT was 54.3 ± 6.9 (mean ± SD) and 57.8 ± 5.2 seconds for CT and RT, respectively (p = 0.385). All laryngoscopies indicated good IC in both treatment groups. Heart rate was lower in CT group than in RT group (66 ± 16 versus 103 ± 39 beats minute-1, p = 0.016). PaCO2, pH, PaO2 and cortisol did not differ between treatments. Compared with baseline, PaCO2 increased from 47.7 ± 6.2 to 58.8 ± 5.8 (p < 0.001) and pH decreased from 7.35 ± 0.04 to 7.28 ± 0.04 (p = 0.003), independent of treatment. Dogs in both treatment groups returned to spontaneous ventilation within 30 seconds of RSI.

CONCLUSIONS AND CLINICAL RELEVANCE

RSI resulted in respiratory acidosis without hypoxemia or increased cortisol. Rocuronium did not improve IT or IC. Spontaneous ventilation was observed immediately after administering saline or sugammadex. The co-administration of rocuronium showed no clinical benefits over propofol alone in RSI in healthy dogs.

Practical Utility of a Clinical Pathway for Older Patients with Aspiration Pneumonia: A Single-Center Retrospective Observational Study

Introduction: Clinical pathways (CPWs) are patient management tools based on a standardized treatment plan aimed at improving quality of care. This study aimed to investigate whether CPW-guided treatment has a favorable impact on the outcomes of hospitalized older patients with aspiration pneumonia. Method: This retrospective study included patients with aspiration pneumonia, aged ≥ 65 years, and hospitalized at a community hospital in Japan. CPW implementation was arbitrarily determined by the attending physician upon admission. Outcomes were compared according to with or without the CPW (CPW-group and non-CPW groups). Propensity score (PS)-based analyses were used to control for confounding factors. Logistic regression analyses were conducted to evaluate the impact of CPW on the clinical course and outcomes. Results: Of 596 included patients, 167 (28%) received the CPW-guided treatment. The mortality rate was 16.4%. In multivariable model, CPW implementation did not increase the risk for total and 30-day mortality, and resulted in shorter antibiotic therapy duration (≤9 days) (PS matching (PSM): odds ratio (OR) 0.50, p = 0.001; inverse provability of treatment weighting (IPTW): OR 0.48, p < 0.001) and length of hospital stay (≤21 days) (PSM: OR 0.67, p = 0.05; IPTW: OR 0.66, p = 0.03). Conclusions: This study support CPW utility in this population.

Prospective cross-organ analysis for the causes of fever and increased inflammatory response after endoscopic resection

OBJECTIVES

Fever and increased inflammatory responses sometimes occur following endoscopic resection (ER). However, the differences in causes according to the organ are scarcely understood, and several modified ER techniques have been proposed. Therefore, we conducted a comprehensive prospective study to investigate the cause of fever and increased inflammatory response across multiple organs after ER.

METHODS

We included patients who underwent gastrointestinal endoscopic submucosal dissection (ESD) and duodenal endoscopic mucosal resection at our hospital between January 2020 and April 2022. Primary endpoints were fever and increased C-reactive protein (CRP) levels following ER. The secondary endpoints were risk factors for aspiration pneumonia. Blood tests and radiography were performed on the day after ER, and computed tomography was performed if the cause was unknown.

RESULTS

Among the 822 patients included, aspiration pneumonia was the most common cause of fever and increased CRP levels after ER of the upper gastrointestinal tract (esophagus, 53%; stomach, 48%; and duodenum, 71%). Post-ER coagulation syndrome was most common after colorectal ESD (38%). On multivariate logistic regression analysis, lesions located in the esophagus (odds ratio [OR] 3.57; P < 0.001) and an amount of irrigation liquid of ≥1 L (OR 3.71; P = 0.003) were independent risk factors for aspiration pneumonia.

CONCLUSIONS

Aspiration pneumonia was the most common cause of fever after upper gastrointestinal ER and post-ER coagulation syndrome following colorectal ESD. Lesions in the esophagus and an amount of irrigation liquid of ≥1 L were independent risk factors for aspiration pneumonia.

Aspiration pneumonia in enteral feeding: A review on risks and prevention

Enteral feeding plays a critical role in the management of hospitalized patients, especially in intensive care units. In addition to delivering important nutrients, it also maintains the integrity of the gut and microbiota. Enteral feeding is also associated with complications and adverse events, some are related to access placement, metabolic and electrolytes disturbances, and aspiration pneumonia. In tube-fed patients, aspiration pneumonia has a prevalence ranging from 4% to 95% with a mortality rate of 17%-62%. Our review has not showed any significant difference in the incidence of aspiration pneumonia between gastric and postpyloric feeding and, given the ease of gastric access, we therefore suggest using gastric feeding as an initial strategy for the delivery of nutrition unless postpyloric access is otherwise indicated for other clinical reasons.

Infant Pneumonitis Due to a Tracheoesophageal Fistula: A Presentation of Two Autopsy Cases

Both esophageal atresia (EA) and tracheoesophageal fistula (TEF) represent a rather uncommon congenital abnormality that is the result of abnormal tracheoesophageal organogenesis. Although EA, with or without TEF, is relatively uncommon, it represents the most common upper gastrointestinal birth defect. Esophageal atresia and tracheoesophageal fistula are anatomically classified into five types according to the Gross classification (types A, B, C, D, E/H). As in type E/H, the continuity of the esophagus is not interrupted, the symptom onset is consequently delayed, and therefore diagnosis is difficult. Aspiration pneumonitis is a chemical injury caused by inhaled sterile gastric contents, while aspiration pneumonia is, in part, an infectious process because the inhaled oropharyngeal secretions are rich in bacteria. This paper aims to report two infant autopsy cases of aspiration pneumonitis with TEF involvement. The main histopathological finding was interstitial pneumonitis. Upon histopathological examination, lymphocytes, plasma cells, and macrophages were discovered on the alveolar walls, which were compatible with the chemical origin of interstitial pneumonitis. No eosinophils were detected; therefore, hypersensitivity-originating interstitial pneumonitis was ruled out. The cause of death in both cases was interstitial pneumonitis.

Impact of low pharyngeal/esophageal pressure associated with sarcopenia on postendoscopic submucosal dissection pneumonia in patients with superficial esophageal cancer

OBJECTIVES

The aging population, including patients with superficial esophageal cancer, encounters critical dysphagia- and postoperative pneumonia-related issues. Although endoscopic submucosal dissection (ESD) provides advantages over other modalities, older patients are at higher risk of postoperative pneumonia. Furthermore, the etiologies of pneumonia are complex and include patient- (such as sarcopenia) and treatment- (including ESD) related factors. Therefore, this study evaluated swallowing function in patients with superficial esophageal cancer and identified post-ESD pneumonia-associated factors.

METHODS

Comprehensive swallowing function and sarcopenia were evaluated in patients pre-ESD and 2 months post-ESD using high-resolution manometry and several swallowing studies by multiple experts. The effects of mucosal resection and sarcopenia on swallowing function changes post-ESD, the relationship between preoperative swallowing function and sarcopenia, and the factors influencing postoperative pneumonia were investigated.

RESULTS

Twenty patients were included in the study. Patients with preoperative sarcopenia had significantly lower pharyngeal/upper esophageal sphincter and tongue pressures than those without sarcopenia. However, ESD did not worsen pharyngeal or upper esophageal pressure. Post-ESD pneumonia incidence tended to be higher in patients with sarcopenia than in those without sarcopenia. The lower upper esophageal sphincter-integrated relaxation pressure (UES-IRP) was a significant factor in pneumonia development. Furthermore, the receiver operating characteristic curve for UES-IRP in pneumonia yielded an area under the curve of 0.82.

CONCLUSIONS

Sarcopenia is associated with preoperative dysphagia, which increases post-ESD pneumonia risk. Therefore, postoperative pneumonia incidence is expected to increase with an aging population, making preoperative sarcopenia and swallowing function evaluation crucial.

Comparative Analysis of the Prevalence of Dysphagia in Patients with Mild COVID-19 and Those with Aspiration Pneumonia Alone: Findings of the Videofluoroscopic Swallowing Study

Background and Objectives: Patients recovering from mild coronavirus disease (COVID-19) reportedly have dysphagia or difficulty in swallowing. We compared the prevalence of dysphagia between patients diagnosed with mild COVID-19 and those diagnosed with aspiration pneumonia alone. Materials and Methods: A retrospective study was conducted from January 2020 to June 2023 in 160 patients referred for a videofluoroscopic swallowing study (VFSS) to assess for dysphagia. The cohort included 24 patients with mild COVID-19 and aspiration pneumonia, 30 with mild COVID-19 without aspiration pneumonia, and 106 with aspiration pneumonia alone. We reviewed the demographic data, comorbidities, and VFSS results using the penetration-aspiration scale (PAS) and functional dysphagia scale (FDS). Results: In a study comparing patients with mild COVID-19 (Group A) and those with aspiration pneumonia alone (Group B), no significant differences were observed in the baseline characteristics, including the prevalence of dysphagia-related comorbidities between the groups. Group A showed milder dysphagia, as evidenced by lower PAS and FDS scores, shorter oral and pharyngeal transit times (p = 0.001 and p = 0.003, respectively), and fewer residues in the vallecula and pyriform sinuses (p < 0.001 and p < 0.03, respectively). When Group A was subdivided into those with COVID-19 with (Group A1) and without aspiration pneumonia (Group A2), both subgroups outperformed Group B in terms of specific VFSS metrics, such as oral transit time (p = 0.01), pharyngeal transit time (p = 0.04 and p = 0.02, respectively), and residue in the vallecula (p = 0.04 and p = 0.02, respectively). However, Group B showed improved triggering of the pharyngeal swallowing reflex compared with Group A2 (p = 0.02). Conclusion: Mild COVID-19 patients showed less severe dysphagia than those with aspiration pneumonia alone. This finding was consistent across VFSS parameters, even when the COVID-19 group was subdivided based on the status of aspiration pneumonia.

Dysphagia and aspiration during a Parkinson's hospitalization: a care partner's perspective and recommendations for improving standards of care

People with Parkinson's disease have a significantly increased incidence and risk of aspiration pneumonia when compared to those without. Aspiration pneumonia associated with dysphagia (swallowing issues), which is the leading cause of death among people with Parkinson's disease, accounting for 25% of Parkinson's deaths. There is relatively limited evidence of the most effective strategies to balance the competing needs of each Parkinson's patient as providers aim to prevent, diagnose, and manage dysphagia. Exacerbated, and in part caused, by the intricacies of dysphagia and Parkinson's disease, there is still limited understanding among hospital providers and the Parkinson's community regarding the most appropriate measures to prevent and manage dysphagia in Parkinson's disease. The Parkinson's Foundation Hospital Care Recommendations identified the prevention and management of dysphagia as a care standard necessary to eliminate harm and attain higher reliability in care. This article discusses key components of dysphagia management in the hospital, provides a case example to demonstrate the challenges that people with PD and their care partners experience in the hospital related to dysphagia, and offers recommendations on how to better manage dysphagia and involve care partners in PD hospital care.

Factors Associated With Swallowing Function Among Physicians in Their 50s and 60s: A Cross-Sectional Study

BACKGROUND

Individuals with swallowing dysfunction in their 50s and 60s may be at risk for aspiration pneumonia as they age. The association of background and lifestyle with swallowing dysfunction for those in their 50s and 60s has not been fully studied. This study aimed to clarify the relationship between lifestyle and swallowing function in this group.

PATIENTS AND METHODS

We targeted physicians in their 50s and 60s as participants. The repetitive saliva swallowing test (RSST) was used to evaluate swallowing function, and self-reported questionnaires about their lifestyle were administered. The associations between RSST scores and participants' backgrounds and lifestyles were analyzed.

RESULTS

This study included 310 participants, who were divided into two groups: 162 in the low RSST group and 148 in the high RSST group. The low RSST group had significantly shorter daily conversation times and a lower incidence of hyperlipidemia than the high RSST group. On multivariate analysis, less than three hours of daily conversation time was independently related to lower RSST scores (adjusted odds ratio: 1.863; 95% confidence interval: 1.167-2.974).

CONCLUSIONS

Shorter conversation time may serve as a predictor of impaired swallowing function, potentially increasing the risk of aspiration pneumonia in the future.

Evaluation of a three-axial acceleromyography monitor in dogs compared with mechanomyography

OBJECTIVE

To compare the ratio of the train-of-four (TOF) and double burst stimulation (DBS) obtained with three-axial acceleromyography (AMG) and mechanomyography (MMG) in dogs during recovery from a rocuronium-induced neuromuscular block.

STUDY DESIGN

Prospective, randomized, experimental study.

ANIMALS

A total of six intact healthy adult male Beagle dogs, weighing 9.1 ± 1.9 kg and aged 3-5 years.

METHODS

Dogs were anesthetized with intravenous (IV) dexmedetomidine and propofol, and isoflurane in oxygen. Neuromuscular function was measured with AMG and MMG in the contralateral thoracic limbs. Rocuronium (0.5 mg kg-1) was administered IV, and the TOF and DBS ratios measured. During neuromuscular block offset, MMG values were recorded when AMG first reached ratios of 0.9 and 1.0. True recovery from neuromuscular block was determined as MMG ratio ≥ 0.9. The false-positive (AMG ≥ 0.9 or 1.0, and MMG ratio < 0.9) rate was determined. Paired values were compared, and bias and limits of agreement were calculated. Receiver operating characteristic (ROC) curves were created.

RESULTS

When AMG first reached 0.9 and 1.0 during recovery, MMG values were lower (p < 0.040). When AMG reached 0.9, the false-positive rate was 29% with TOF and 27% with DBS. It decreased to 12% (TOF) and 11% (DBS) when a ratio of 1.0 was used. AMG values were higher than paired MMG values (p < 0.001). The AMG overestimated MMG by 24% and 22% for TOF and DBS, respectively. Areas under the ROC curves (95% confidence interval) were 0.91 (0.89, 0.94) and 0.86 (0.81, 0.94) for TOF and DBS, respectively.

CONCLUSIONS

and clinical relevance The three-axial AMG monitor overestimated neuromuscular function and, in some cases, indicated adequate recovery despite the MMG ratio being < 0.9. A TOF or DBS ratio of at least 1.0 should be considered when monitoring recovery of neuromuscular block with this AMG device.

Clinical Outcomes of Radiotherapy for Stage 1 Glottic Carcinoma: Comparing Accelerated Hyperfractionation and Once-daily Fractionation

BACKGROUND/AIM

Accelerated hyperfractionation (AHF) is used in head and neck cancer to improve the local control (LC) rate, but reports of outcomes for early-stage GC are limited. The outcomes of radiotherapy (RT) for stage 1 glottic carcinoma (GC) were retrospectively analyzed, comparing AHF and once-daily fractionation (ODF) using 2.0-2.4 Gy.

PATIENTS AND METHODS

A total of 102 patients with stage 1 GC underwent RT alone between 2007 and 2021, with 43 in the AHF group and 59 in the ODF group. A p-value less than 0.05 was considered to indicate a significant difference.

RESULTS

The 5-year LC rate was 98% in the AHF group and 91% in the ODF group (p=0.19). During RT, significantly more patients in the AHF group required opioids due to mucositis than in the ODF group (74% vs. 25%, p<0.001), and the rate of aspiration pneumonia tended to be higher in the AHF group than in the ODF group (7% vs. 0%, p=0.072).

CONCLUSION

There was no difference in the LC rate between AHF and ODF for stage 1 GC. Moreover, the AHF group required opioids at a higher rate and tended to have a higher risk of developing aspiration pneumonia.

Cardio-vocal syndrome - How 'benign' condition can turn 'malignant'?

Cardio-vocal syndrome (also called as Ortner's syndrome) is hoarseness of voice due to compression of left recurrent laryngeal nerve secondary to enlarged cardiac chambers and structures. We present two cases of Ortner's syndrome secondary to atrial fibrillation causing enlargement of left atrium compressing the left recurrent laryngeal nerve, and their clinical outcomes.

Impacts of body positions on the geniohyoid muscle contraction and swallowing difficulty in healthy adults

BACKGROUND

Body positions affect swallowing and gastroesophageal reflux. Swallowing impairment is one of the main causes of aspiration pneumonia. To prevent pneumonia, evaluation of body positions on gastroesophageal reflux recommended 30 degrees or higher semi-recumbent positions. The geniohypoid muscle and tongue play central roles in swallowing. However, the effects of body positions on contracting rates in the geniohyoid muscle and tongue pressure are unclear. Moreover, correlations between geniohyoid muscle contracting rates and subjective swallowing difficulties are unclear.

AIMS

This study aimed to identify the proper body positions on contracting rates in the geniohyoid muscle, tongue pressure, and subjective swallowing difficulties.

MATERIALS & METHODS

Twenty healthy adults swallowed 15- or 50 ml of water at 90 degrees sitting, 60- and 30 degrees semi-recumbent, and 0 degrees supine positions. We scored the subjective swallowing difficulties and measured the tongue pressure and the number of swallows. An ultrasound evaluated the geniohyoid muscle size and contracting rates.

RESULTS

At sitting and 60 degrees semi-recumbent positions, the geniohyoid muscle showed greter contracting rates than at 30 degrees semi-recumbent and supine postions (P < 0.05), which resulted in easier swalloiwng. Greater tongue pressure was weakly correlated with fewer swallows (r = -0.339, P = 0.002), whereas the body positions did not affect.

CONCLUSION

Considering swallowing and gastroesophageal reflux together, a trunk angle of 60 degrees or more might be beneficial for reducing the risk of aspiration.

Evaluation of the Effectiveness and Use of Anti-Methicillin-Resistant Staphylococcus aureus Agents for Aspiration Pneumonia in Older Patients Using a Nationwide Japanese Administrative Database

Studies indicated potential harm from empirical broad-spectrum therapy. A recent study of hospitalizations for community-acquired pneumonia suggested that empirical anti-methicillin-resistant Staphylococcus aureus (MRSA) therapy was associated with an increased risk of death and other complications. However, limited evidence supports empirical anti-MRSA therapy for older patients with aspiration pneumonia. In a nationwide Japanese database, patients aged ≥65 years on admission with aspiration pneumonia were analyzed. Patients were divided based on presence of respiratory failure and further sub-categorized based on their condition within 3 days of hospital admission, either receiving a combination of anti-MRSA agents and other antibiotics, or not using MRSA agents. An inverse probability weighting method with estimated propensity scores was used. Out of 81,306 eligible patients, 55,098 had respiratory failure, and 26,208 did not. In the group with and without respiratory failure, 0.93% and 0.42% of the patients, respectively, received anti-MRSA agents. In patients with respiratory failure, in-hospital mortality (31.38% vs. 19.03%, p < 0.001), 30-day mortality, and 90-day mortality were significantly higher, and oxygen administration length was significantly longer in the anti-MRSA agent combination group. Anti-MRSA agent combination use did not improve the outcomes in older patients with aspiration pneumonia and respiratory failure, and should be carefully and comprehensively considered.

Vascular ring anomaly with a right patent ductus arteriosus and a left aortic arch in a juvenile cat

This paper reports the clinical findings and surgical treatment of feline right patent ductus arteriosus (RPDA) with a left aortic arch. A two-month-old female Maine Coon was referred for an investigation of regurgitation after weaning. RPDA with a left aortic arch was diagnosed based on the echocardiographic and computed tomography (CT) findings. A right-fourth intercostal thoracotomy was found to be an appropriate approach to the duct. Preoperative diagnosis is crucial and diagnostic imaging, including radiography, echocardiography, and cardiac CT examination, is essential for determining if the aortic arch is right or left.

Esophageal cancer operation in the COVID-19 era: are the outcomes different from its past in an observational cohort study?

COVID-19 spread rapidly and potentially affected every medical profession, including surgery. This study aims to compare the postoperative outcomes of oesophageal cancer surgeries in COVID-19 age and a year before.

Methods

This retrospective cohort study was performed as a single-centred study from March 2019 to March 2022 at Cancer institute, Tehran, Iran. Demographic data, cancer type, surgical procedures, and postoperative outcomes and complications were compared between the two groups pre-COVID-19 and during the COVID-19 pandemic.

Results

Totally, 120 patients enroled in the study, of which 57 underwent surgery before the COVID-19 pandemic, and 63 during the COVID-19 pandemic. The mean age in these groups was 56.9 (±12.49) and 58.11 (±11.43), respectively. Females included 50.9% and 43.5% of individuals who underwent surgery before and during the COVID-19 pandemic. The interval between admission and surgery was significantly shorter in patients underwent surgery during the COVID-19 pandemic (5.17 vs. 7.05; P=0.013). However, there was no significant difference between time interval between surgery and discharge [11.68 (7.81) vs. 12 (6.92); P=0.689]. Aspiration pneumonia was the most common complication in both groups. There was no significant difference between postoperative complications in both groups.

Conclusion

Outcomes of oesophageal cancer surgeries in COVID-19 age in our institution were comparable with the year before the pandemic. The decrease in the time interval between surgery and discharge did not lead to an increase in postoperative complications and could be noted for post-COVID-19 era policymaking, too. This study suggests not postponing any of the surgical treatments for oesophageal cancer in the COVID-19 era.

Reversible Dysphagia Associated With Risperidone Presenting With a Choking Episode

Dysphagia has been associated with antipsychotic drug use. This case report describes the management of dysphagia in a psychiatric patient who presented to the emergency department from a psychiatric facility after choking on a hot dog. The patient was on risperidone 4 mg, initiated a month prior to treat acute psychosis. Foreign body removal from the distal trachea was performed by bronchoscopy, followed by a swallow evaluation by the speech and swallow team. The patient exhibited severe oropharyngeal dysphagia, leading to aspiration pneumonia and subsequent enteral feeding through a nasojejunal tube. Changes in medication from risperidone to aripiprazole, along with a short course of benztropine and dietary modifications, were implemented, with gradual improvement in swallowing function observed during the hospital stay. The patient's complex medical and psychiatric history contributed to a prolonged hospital stay.

Computer-aided screening of aspiration risks in dysphagia with wearable technology: a Systematic Review and meta-analysis on test accuracy

Aspiration caused by dysphagia is a prevalent problem that causes serious health consequences and even death. Traditional diagnostic instruments could induce pain, discomfort, nausea, and radiation exposure. The emergence of wearable technology with computer-aided screening might facilitate continuous or frequent assessments to prompt early and effective management. The objectives of this review are to summarize these systems to identify aspiration risks in dysphagic individuals and inquire about their accuracy. Two authors independently searched electronic databases, including CINAHL, Embase, IEEE Xplore^® Digital Library, PubMed, Scopus, and Web of Science (PROSPERO reference number: CRD42023408960). The risk of bias and applicability were assessed using QUADAS-2. Nine (n = 9) articles applied accelerometers and/or acoustic devices to identify aspiration risks in patients with neurodegenerative problems (e.g., dementia, Alzheimer's disease), neurogenic problems (e.g., stroke, brain injury), in addition to some children with congenital abnormalities, using videofluoroscopic swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) as the reference standard. All studies employed a traditional machine learning approach with a feature extraction process. Support vector machine (SVM) was the most famous machine learning model used. A meta-analysis was conducted to evaluate the classification accuracy and identify risky swallows. Nevertheless, we decided not to conclude the meta-analysis findings (pooled diagnostic odds ratio: 21.5, 95% CI, 2.7-173.6) because studies had unique methodological characteristics and major differences in the set of parameters/thresholds, in addition to the substantial heterogeneity and variations, with sensitivity levels ranging from 21.7% to 90.0% between studies. Small sample sizes could be a critical problem in existing studies (median = 34.5, range 18-449), especially for machine learning models. Only two out of the nine studies had an optimized model with sensitivity over 90%. There is a need to enlarge the sample size for better generalizability and optimize signal processing, segmentation, feature extraction, classifiers, and their combinations to improve the assessment performance. Systematic Review Registration: (https://www.crd.york.ac.uk/prospero/), identifier (CRD42023408960).

Laryngeal Penetration and Risk of Aspiration Pneumonia in Children with Dysphagia-A Systematic Review

This study was a systematic review and meta-analysis that assessed the risk of aspiration pneumonia in children with laryngeal penetration or tracheal aspiration via a video-fluoroscopic study (VFSS) and compared the results to those for children with neither condition. Systematic searches were conducted using databases, including PubMed, Cochrane Library, and Web of Science. Meta-analysis was used to obtain summary odds ratios (OR) and 95% confidence intervals (CI). The overall quality of evidence was assessed using the grading of recommendations, assessment, development, and evaluation (GRADE) criteria. In total, 13 studies were conducted with 3159 participants. Combined results from six studies showed that laryngeal penetration on VFSS may be associated with aspiration pneumonia compared to no laryngeal penetration; however, the summary estimate was imprecise and included the possibility of no association (OR 1.44, 95% CI 0.94, 2.19, evidence certainty: low). Data from seven studies showed that tracheal aspiration might be associated with aspiration pneumonia compared to no tracheal aspiration (OR 2.72, 95% CI 1.86, 3.98, evidence certainty: moderate). The association between aspiration pneumonia and laryngeal penetration through VFSS seems to be weaker than that for tracheal aspiration. Prospective cohort studies with clear definitions of laryngeal penetration and that measure clinical and patient reported outcomes are needed to further define the association between laryngeal penetration and aspiration pneumonia.

Clinical Features and Outcomes of VAP Due to Multidrug-Resistant Klebsiella spp.: A Retrospective Study Comparing Monobacterial and Polybacterial Episodes

VAP due to multidrug-resistant (MDR) bacteria is a frequent infection among patients in ICUs. Patient characteristics and mortality in mono- and polybacterial cases of VAP may differ. A single-centre, retrospective 3-year study was conducted in the four ICUs of a Lithuanian referral university hospital, aiming to compare both the clinical features and the 60-day ICU all-cause mortality of monobacterial and polybacterial MDR Klebsiella spp. VAP episodes. Of the 86 MDR Klebsiella spp. VAP episodes analyzed, 50 (58.1%) were polybacterial. The 60-day mortality was higher (p < 0.05) in polybacterial episodes: overall (50.0 vs. 27.8%), in the sub-group with less-severe disease (SOFA < 8) at VAP onset (45.5 vs. 15.0%), even with appropriate treatment (41.7 vs. 12.5%), and the sub-group of extended drug-resistant (XDR) Klebsiella spp. (46.4 vs. 17.6%). The ICU mortality (44.0 vs. 22.5%) was also higher in the polybacterial episodes. The monobacterial MDR Klebsiella spp. VAP was associated (p < 0.05) with prior hospitalization (61.1 vs. 40.0%), diabetes mellitus (30.6 vs. 5.8%), obesity (30.6 vs. 4.7%), prior antibiotic therapy (77.8 vs. 52.0%), prior treatment with cephalosporins (66.7 vs. 36.0%), and SOFA cardiovascular ≥ 3 (44.4 vs. 10.0%) at VAP onset. Patients with polybacterial VAP were more likely (p < 0.05) to be comatose (22.2 vs. 52.0%) and had a higher SAPS II score (median [IQR] 45.0 [35.25-51.1] vs. 50.0 [40.5-60.75]) at VAP onset. Polybacterial MDR Klebsiella spp. VAP had distinct demographic and clinical characteristics compared to monobacterial, and was associated with poorer outcomes.

Successful Continuation of Oral Intake in a Dysphagic and Tetraplegic Patient With Alternate Right and Left Complete Lateral Decubitus Positions in Rehabilitation

Cervical spinal cord injury can result in dysphagia and tetraplegia. Dysphagia therapy can be required to avoid aspiration pneumonia during oral intake for persons with cervical spinal cord injury. Complete lateral decubitus position may be a specific position for safe swallowing. However, the literature on dysphagia therapy in complete lateral decubitus position for persons with tetraplegia and dysphagia is limited. We present the case of a 76-year-old man with dysphagia and tetraplegia secondary to cervical cord injury. As the patient wished for oral intake, swallowing training in an elevated position of the head at 60° was already initiated. Two days after admission, aspiration pneumonia occurred. As the spasticity increased continuously, the patient could not comfortably undertake swallowing training in an elevated head position of 60°. The flexible endoscopic evaluation of swallowing (FEES) was performed for the patient. The patient did not swallow water or jelly safely in an elevated head position. However, the patient swallowed jelly safely in the right complete lateral decubitus position. Two months after the initiation of oral intake in the right complete lateral decubitus position, the second FEES revealed that the patient swallowed jelly and food in the form of paste safely in the left complete lateral decubitus position. To relieve the pain of the right shoulder induced by continuous right complete lateral decubitus position, the patient retained oral intake in the left or right complete lateral decubitus position alternately for six months without recurrent aspiration pneumonia. Right and left complete lateral decubitus positions when alternately performed in swallowing training can be useful and safe for a patient with dysphagia and tetraplegia secondary to cervical spinal cord injury.

Does Dysphagia Predict Inpatient Morbidity and Mortality in Geriatric Patients Admitted for Aspiration Pneumonia?

Background Aspiration pneumonia is common in older adults admitted for community-acquired pneumonia and is associated with significant morbidity and mortality. Factors that put this population at higher risk of aspiration include cognitive impairment, neuromuscular dysfunction, and dysphagia. This study aimed to determine whether a concurrent diagnosis of dysphagia conferred a higher risk of complications in the elderly admitted for aspiration pneumonia. Methods The National Inpatient Sample 2001-2013 database was queried for patients, aged 65 or older, with a diagnosis of aspiration pneumonia using International Classification of Diseases, Ninth Revision (ICD-9) codes. Sepsis, respiratory failure, and intubation were identified with their respective ICD-9 codes. A chi-square test and binary logistic regression analysis were used to examine socio-demographic and complication variables, with a significance level of α <0.001. Results A total of 1,097,325 patients were admitted for aspiration pneumonia, of which 349,861 (24.2%) had dysphagia. After incorporating socio-demographic variables, the dysphagia group had a significantly lower likelihood of having sepsis (OR=0.72), respiratory failure (OR=0.92), intubation (OR=0.52), and inpatient mortality (OR = 0.59). Patients with dysphagia had a significantly higher likelihood of increased length of stay (OR=1.24). Conclusions Elderly patients admitted with aspiration pneumonia with a co-diagnosis of dysphagia were less likely to have inpatient morbidity and mortality compared to their counterparts. This may be due to improved speech evaluation and treatment in patients with dysphagia allowing for better control of macro and micro aspiration. Future research is needed to examine if universal speech therapy can reduce hospitalization and long-term mortality for such patients.

Severe Hypercalcemia due to Drowning in an Onsen (Hot Spring)

Hypercalcemia is generally caused by primary hyperparathyroidism, malignancies, and drugs. Herein, we report a case of severe hypercalcemia due to drowning in hot springs. A 55-year-old woman was found floating in a public bath at a hotel and was admitted to a nearby hospital. The patient was intubated because of hypoxia and shock, and noradrenaline was titrated. Computed tomography revealed bilateral aspiration pneumonia. Blood tests revealed hypercalcemia (serum total calcium [Ca]: 18.7 mg/dL). Hyperparathyroidism, malignancy, and drug-related factors were ruled out as the causes of hypercalcemia. In addition, the public bath in which the patient drowned contained high concentrations of Ca. We concluded that the reason for hypercalcemia was accidental ingestion of the hot spring water containing a high concentration of Ca through the gastrointestinal tract. In the case of drowning and hypercalcemia, the cause may be clarified by examining the components that were accidentally swallowed.

Dysphagia in hospitalized patients: Prevalence, related factors and impact on aspiration pneumonia and mortality

BACKGROUND

Oropharyngeal dysphagia can be highly concerning in hospitalized patients, increasing morbidity and mortality, making its early identification essential. We aimed to characterize dysphagia and its association with aspiration pneumonia and mortality in a tertiary hospital in Barcelona, Spain.

METHODS

Using data from all hospital discharges during the period 2018-2021, we identified the characteristics of patients with dysphagia and their distribution among hospital departments through the minimum data set, which codifies patients' diagnoses according to the International Classification of Diseases 10th Revision (ICD-10). We used logistic regression models to assess the association between dysphagia, aspiration pneumonia and mortality.

RESULTS

Dysphagia was present in 2.4% of all hospital discharges and was more frequent in older patients and in men. The diagnoses most frequently associated with dysphagia were aspiration pneumonia (48.2%) and stroke (14%). Higher prevalence of dysphagia was found in the acute geriatric unit (10.3%), neurology (7.6%) and internal medicine (7.5%) wards. Dysphagia was associated with aspiration pneumonia, aOR = 8.04 (95%CI, 6.31-10.25), and independently increased the odds of death among hospitalized patients, aOR = 1.43 (95%CI, 1.19-1.73).

CONCLUSIONS

We conclude that dysphagia is a prevalent and transversal condition, increasing the risk of mortality in all patients, and efforts should be intensified to increase its early detection and correct management.

Clinical decision-making using an assessment protocol of swallowing function after aspiration pneumonia: a comparative retrospective study

Objective: Aspiration pneumonia is a challenge in Japan, with many elderly citizens; however, there are insufficient experts on swallowing. Non-expert doctors may suspend oral intake for an overly long period because of the fear of further aspiration. We devised and modified an assessment protocol for swallowing function with reference to the Japanese and American practical guidelines for dysphagia. This study aimed to demonstrate clinical decision-making using the protocol by reporting the results of decisions on the safe and timely restart of adequate food intake for patients with aspiration pneumonia. Patients and Methods: This comparative retrospective study included 101 patients hospitalized with aspiration pneumonia between April 2015 and November 2017. We compared the parameters of patients for whom decisions on resumption of oral intake were aided by our protocol against those of patients from the previous year when the protocol was not used. We counted the days until either resumption of oral intake or events of aspiration/choking. Results: The duration of days until oral intake in the two groups was 1.64 ± 2.34 days in the protocol group (56 patients) and 2.09 ± 2.30 days in the control group (45 patients) (P=0.52). The adverse events of aspiration/choking were less frequent in the protocol group (5 vs. 15, odds ratio (OR) 0.32, P<0.001) as compared to the control group. The protocol group showed a significant reduction in aspiration/choking (OR 0.19, P<0.01). Conclusion: Clinical decision-making based on the protocol seems to help non-expert doctors make informed decisions regarding resuming oral intake after aspiration pneumonia.

Thyroid Cancer Presenting as Aspiration Pneumonia: A Tale of Retrosternal Goiters

Abnormal enlargement of the thyroid gland is called goiter. Structurally, it can be nodular or diffuse. Usually, it presents as an anterior cervical mass; however, less commonly, it presents as a retrosternal mass causing symptoms of compression on the surrounding structures. Most patients with goiter are asymptomatic due to the euthyroid nature of the disease. However, sometimes they can be hypo or hyperthyroid depending on the etiology of the goiter. Here, we present the case of a patient without any previously known goiter who presented to the hospital with shortness of breath and was found to have hypoxic respiratory failure as his first noticed sign of thyroid disease. Diagnostic workup revealed retrosternal goiter causing compression effect on the esophagus and trachea resulting in dysphagia and aspiration. The patient was treated with feeding tube placement, followed by surgical resection of the mediastinal mass.

The Kuchi-kara Taberu index as a predictive marker of oral intake recovery in patients with aspiration pneumonia

AIM

In recent years, the Kuchi-kara Taberu (KT) index has been used as a new tool for the evaluation of dysphagia; however, its predictive ability remains unknown. This study was conducted to examine the validity of oral intake recovery prediction using the KT index in patients with aspiration pneumonia.

METHODS

The subjects were older inpatients admitted to an acute-care hospital for the treatment of aspiration pneumonia. A logistic regression analysis was conducted to clarify factors significantly associated with oral intake recovery. In addition, cut-off values of the predictors were calculated using a receiver operating characteristic curve analysis with the area under the curve (P < 0.05).

RESULTS

A total of 124 patients (mean age 84.3 ± 7.9 years old, 70 males, 54 females) were enrolled in this study and divided into two groups at discharge: the oral intake group (62.1%) and the non-oral intake group (37.9%). The significant predictors of the recovery of oral intake were the pre-treatment period, treatment period, and the total score of the KT index; the respective odds ratios were 1.082 (95% confidence interval [CI] 1.013-1.156), 1.018 (1.003-1.033) and 0.850 (0.780-0.927), and the respective areas under the curve were 0.407 (95% CI 0.300-0.515), 0.304 (0.208-0.399), and 0.732 (0.640-0.824). The cut-off value of the total score of the KT index was 30. The model showed 85.7% sensitivity and 57.4% specificity.

CONCLUSION

The KT index is suggested to be a valid variable for predicting whether or not a patient with aspiration pneumonia can recover their oral intake ability during acute-care hospitalization. Geriatr Gerontol Int 2023; 23: 221-226.

Press needle for aspiration pneumonia prevention in older adults: Study protocol for a randomized double-blind placebo-controlled trial

BACKGROUND

Pneumonia is the fifth most common cause of death among the Japanese population, with 97% of the deaths occurring among older adults aged ≥65 years. The incidence ratio of aspiration pneumonia is high among the older adults. Therefore, its prophylaxis is important in geriatric medicine. In our previous studies, we reported that stimulation of acupoints at stomach meridian 36 and kidney meridian 3 of the lower limbs with a press needle improved the swallowing function of patients with dysphagia. Improvements in swallowing function may prevent aspiration pneumonia. This study aims to investigate the protective efficacy of press needle stimulation in the lower limbs for aspiration pneumonia.

METHODS/DESIGN

This is a multicenter, randomized, double-blind, placebo-controlled trial. A total of 140 patients with cerebrovascular disorder and a history of aspiration pneumonia will be recruited from 6 centers and randomly assigned to either the real or sham press needle group in a 1:1 ratio. The press needle will be replaced twice a week. The treatment will be administered bilaterally at acupoints stomach meridian 36 and kidney meridian 3. The primary outcome is the frequency of aspiration pneumonia onset. The secondary outcome is the improvement of the latent time of the swallowing reflex. The study period is of 12-month. The primary outcome will be evaluated throughout the study period, while the secondary outcomes will be assessed at baseline, 1st month, 6th month, and at the end of the investigation period.

DISCUSSION

This study will evaluate the effects of press needle on the prevention of aspiration pneumonia and the improvement of swallowing function in patients. The results of this study will help support the prophylaxis of aspiration pneumonia.

The Association between Party Horn Use and Respiratory Function in Patients with Dementia: An Experimental Study

Background and Objectives: Respiratory diseases account for 55.5% and 33.1% of all mortality rates in patients with Alzheimer’s disease and vascular dementia, respectively. However, the widespread use of spirometers is often difficult due to challenges in performing the procedure. Therefore, the use of spirometers is usually unfeasible in patients with dementia and hinders the provision of preventive measures for aspiration pneumonia. The party horn is a common toy in many countries and can potentially be used as a novel tool. This study was conducted to analyze the usefulness of the party horn as an assessment tool for respiratory function, and to detect eating-related behavioral problems in patients with dementia. Materials and Methods: A total of 62 inpatient participants with dementia (34 males, 28 females; age, mean ± SD, 80.4 ± 7.59 years) were included in the study. The respiratory functions of patients were assessed using a party horn and a spirometer. Assessment items pertaining to cognitive function, mental and behavioral disorders, eating-related behavioral problems, and the required dietary modifications were evaluated to compare between patient groups stratified by respiratory function. Results: Significant differences between groups were noted in length of hospital stay, cognitive functions, mental and behavioral disorders, eating-related behavioral problems, and dietary modifications. Forced expiratory volume in 1 s, peak expiratory flow, and eating-related behavioral problems were significantly associated with the party-horn-integrated value (p < 0.05). Conclusions: Party-horn-based evaluation can facilitate the screening and evaluation of older dementia patients for eating-related behavioral problems and aspiration risk.

[Predicting the development of aspiration pneumonia in patients with ischemic stroke and neurogenic dysphagia]

OBJECTIVE

To determine the prognostic aspects of the development of pneumonia in patients with ischemic stroke of various pathogenetic subtypes.

MATERIAL AND METHODS

The study enrolled 110 patients (64 men and 46 women), aged 44-95 years, with dysphagia during the acute period of ischemic stroke (IS). The TOAST criteria were used to diagnose the pathogenetic subtype, and the MASA scale was used to determine the presence and severity of dysphagia. To predict the probability of switching to self-feeding from the severity of dysphagia, a non-linear regression method was used using the least squares method.

RESULTS

In patients with swallowing disorders in the acute period of IS, pneumonia often developed after 5 days from the onset of clinical manifestations of stroke. In the cardioembolic subtype of IS, the probability of pneumonia in groups with dysphagia severity from 90 to 120 points on the MASA was higher than in the atherothrombotic subtype of IS (p<0.05).

CONCLUSION

Patients with cardioembolic stroke subtype are characterized by a worse prognosis for the developing pneumonia compared to patients with atherothrombotic stroke subtype.

Early platelet level reduction as a prognostic factor in intensive care unit patients with severe aspiration pneumonia

Introduction: This study investigates risk factors underlying the prognosis of severe aspiration pneumonia (SAP) in intensive care unit (ICU) patients and attempts to provide early prognosis reference for clinical tasks. Methods: Patients diagnosed with SAP and admitted to the ICU of Jinshan Hospital, Fudan University, Shanghai, China, between January 2021 and December 2021 were recruited in this retrospective cohort study. Clinical data on a patient's general condition, underlying diseases, laboratory indicators, and 90-day outcomes (survival or death) were recorded. Results: Multivariate logistic regression analysis showed that a low platelet count was an independent risk factor affecting the prognosis of death (OR = 6.68, 95% CI:1.10-40.78, β = 1.90, P = 0.040). Receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive value of variables; cut-off values were calculated and the area under the curve was 0.7782 [(95% CI:0.686-0.871), p < 0.001] for the prediction of death at 90 days in all patients. The Kaplan-Meier curve used for survival analysis showed that, compared with the normal platelet group, the overall survival rate of patients with low platelet levels was significantly lower, and the difference was statistically significant [HR = 2.11, (95% CI:1.47-3.03), p = 0.0001, z = 4.05, X ² = 14.89]. Cox regression analysis, used to further verify the influence of prognostic risk factors, showed that a concurrent low platelet count was the most important independent risk factor affecting the prognosis of SAP (HR = 2.12 [95% CI:1.12-3.99], X² = 50.95, p = 0.021). Conclusion: These findings demonstrate an association between SAP mortality and platelet levels on admission. Thus, platelet level at admission may be used as a readily available marker for assessing the prognosis of patients with SAP.