Enteral Feeding Research Articles

Development and validation of an LC-MS/MS method for highly concentrated tacrolimus and cyclosporine samples prepared from pharmaceutical products to assess drug loss from feeding tubes

IntroductionTacrolimus and cyclosporine are common immunosuppressants utilized post-organ transplantation to manage allograft rejection. Both have narrow therapeutic indices and are frequently measured to support dose adjustments. Although nasogastric tubes are commonly used to provide nutritional support and serve as a route for immunosuppressant administration, they were never validated for such purposes. ObjectiveTo develop and validate a liquid chromatography – tandem mass spectrometry (LC-MS/MS) method for highly concentrated tacrolimus and cyclosporine samples prepared from pharmaceutical products to support the validation of feeding tube administration of these immunosuppressants. MethodsThe method involved stepwise dilutions with dimethyl sulfoxide before analysis using online sample preparation and LC-MS/MS. It was validated in a CLIA-certified clinical laboratory that measures immunosuppressants by LC-MS/MS and is designed to support clinical studies evaluating drug loss from feeding tubes. ResultsThe method was linear between 6.8 µg/mL and 75 µg/mL for tacrolimus, and between 0.9 mg/mL and 10 mg/mL for cyclosporine, with r2 > 0.99 and total precision <5 % at all QC levels. The method demonstrated good recovery using certified cyclosporine reference material, European pharmacopeia reference standard tacrolimus, and prepared pharmaceutical products. Minimal matrix effects were observed. ConclusionAn analytical method was developed and validated for in vitro studies with simulated administration of tacrolimus or cyclosporine to assess loss during drug administration using feeding tubes.

Tissue-Engineered Implant for Hemilaryngectomy Reconstruction with Recurrent Laryngeal Nerve Injury.

Laryngeal cancer resections often require excision of portions of the larynx along with sacrifice of the ipsilateral recurrent laryngeal nerve (RLN). In such cases, there are no reconstructive options that reliably restore laryngeal function, rendering patients with severe functional impairment. To address this unmet clinical need, we extend our evaluation of a 3-implant mucosal, muscle, cartilage reconstruction approach aimed at promoting functional laryngeal restoration in a porcine hemilaryngectomy model with ipsilateral RLN transection. Six Yucatan mini-pigs underwent full-thickness hemilaryngectomies with RLN transection followed by transmural reconstruction using fabricated collagen polymeric mucosal, muscle, and cartilage replacements. To determine the effect of adding therapeutic cell populations, subsets of animals received collagen muscle implants containing motor-endplate-expressing muscle progenitor cells (MEEs) and/or collagen cartilage implants containing adipose stem cell (ASC)-derived chondrocyte-like cells. Acoustic vocalization and laryngeal electromyography (L-EMG) provided functional assessments and histopathological analysis with immunostaining was used to characterize the tissue response. Five of six animals survived the 4-week postoperative period with weight gain, airway maintenance, and audible phonation. No tracheostomy or feeding tube was required. Gross and histological assessments of all animals revealed implant integration and regenerative remodeling of airway mucosa epithelium, muscle, and cartilage in the absence of a material-mediated foreign body reaction or biodegradation. Early voice and L-EMG data were suggestive of positive functional outcomes. Laryngeal reconstruction with collagen polymeric mucosa, muscle, and cartilage replacements may provide effective restoration of function after hemilaryngectomy with RLN transection. Future preclinical studies should focus on long-term functional outcomes. NA Laryngoscope, 134:4604-4613, 2024.

Effect of different tube feeding methods on gastroesophageal reflux features in preterm infants: a pH-impedance monitoring study.

Continuous feeding and boluses may have a different impact on pH-MII GER features in symptomatic tube-fed preterm infants, whereas the permanence of the feeding tube across LES did not seem to worsen GER indexes. • Due to the functional and anatomical immaturity of the gastrointestinal tract, gastroesophageal reflux (GER) is common in preterm infants. • A stepwise therapeutical approach which firstly undertakes conservative strategies is the most advisable choice to avoid potentially harmful pharmacological overtreatments in the preterm population. • Continuous feeding and boluses may have a different impact on GER features assessed by pH-MII monitoring in tube-fed preterm infants. • The permanence of the feeding tube during or after the feeding period did not seem to worsen GER occurrence. • By reducing GER features, especially acid GER, continuous feeding may potentially contribute to limit the need for antiacid medications in this population.

Wearable smart glasses for first‐person video analysis to evaluate nursing skills: A pilot study with a mixed method design

AbstractBackgroundComprehensive assessment of skills and performance are necessary to improve the quality of care in nursing education. Various factors pose challenges to accurate assessments, including high student–teacher ratio and observer bias.ObjectivesTo establish an assessment system based on first‐person video of smart glasses and validate its usability and feasibility.MethodsWe used two cameras (smart glasses for first‐person perspective and a web cam) to perform video analysis for skill and performance assessments. Usability tests were conducted using quantitative and qualitative questionnaires for the usefulness and acceptability of the current assessment system. Data from standardised checklists for three clinical nursing skills (intramuscular injection, endotracheal suction, and Levin tube feeding) were used to analyse the inter‐rater reliability in addition to Fleiss' Kappa coefficient analysis. A total of 22 participants (18 students and 4 reviewers) were recruited. They completed the study. Apart from physical discomfort component, the proposed smart glasses‐based first‐person video assessment system achieved good usability scores from both students and reviewers.Results and ConclusionsFleiss' Kappa values for individual items ranged from 0.450 to 0.808, with an overall average value of 0.592. Results of this study validated the potential of smart glasses‐based assessment system where a set of beneficial mechanisms may meaningfully support the formative learning process. However, issues regarding upgrading the device and need for guidelines for roles of raters and students still remain.

Efficacy and Safety of Orogastric vs. Nasogastric Tube Feeding in Preterm Infants: A Systematic Review and Meta-Analysis

Background: Enteral nutrition can be delivered to the stomach using nasogastric or orogastric tubes, with each route having advantages and disadvantages. This meta-analysis aimed to compare the effects of these methods on growth, development, and the incidence of adverse outcomes. Methods: This analysis included studies that enrolled preterm infants who received nasogastric or orogastric tube feeding. We searched databases including PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. Only randomized controlled trials were selected. We used version 2 of the Cochrane tool to assess the risk of bias in randomized trials and Review Manager 5.4 software to perform the meta-analysis. Results: Six studies involving 265 preterm infants were included. The meta-analysis showed that orogastric tube feeding took significantly longer to establish full enteral tube feeding compared to nasogastric tube feeding (MD = 1.62, 95% confidence interval [CI]: 0.99–2.26, Z = 5.02, p &lt; 0.01). However, no significant difference was observed between the two groups regarding time to regain birth weight (MD = −0.38, 95% CI: −2.2–1.44, Z = 5.02, p = 0.68). Data on adverse events were insufficient to perform a combined analysis. Conclusions: Preterm infants fed via nasogastric tubes took less time to reach full enteral feeding than those fed via orogastric tubes. Further research is required to evaluate the effect of feeding routes on adverse outcomes.

The effect of blended tube feeding compared to conventional formula on clinical outcomes in adults: A systematic review.

To explore the effect of blended tube feeding compared to conventional formulas on nutritional status, quality of life, anthropometry, diarrhoea and tube blockages in adults receiving tube feeding. The protocol was registered (PROSPERO CRD42022372443). Five databases (MEDLINE, EMBASE, CINAHL, Scopus, CENTRAL) were searched from commencement of database to 14th June 2023 to identify studies comparing blended tube feeding to conventional formulas in adults receiving tube feeding. Certainty assessment was conducted using the Cochrane Risk of Bias Tools and the Grading of Recommendations, Assessment, Development and Evaluations framework, and a narrative synthesis of results is provided. From 4227 studies screened, eight were included (total n = 763 patients, 9-215 patients). Three studies were hospital-based and five were home-based with duration from 8 days-8 months. Blended tube feeding and conventional formulas were nutritionally equivalent in only three studies; energy and protein concentration of formulas ranged from 1.7-7.1 kJ/mL and 21-68.5 g/L for the blended tube feeding groups, and 4.2-6.7 kJ/mL and 39-100 g/L for the conventional groups. No studies assessed nutrition status or quality of life using validated measures. Blended tube feeding was associated with a clinically relevant reduction in diarrhoea with a low level of certainty. For remaining outcomes, there were inconclusive findings and an overall very low certainty of evidence for each. The effect of blended tube feeding compared to conventional formulas on all outcomes remains uncertain. Blended tube feeding may reduce the incidence of diarrhoea. Future research using nutritionally equivalent comparisons and validated outcome measures is required.

Percutaneous endoscopic gastrostomy helped to normalise feeding problems and gastrointestinal symptoms in Silver-Russell syndrome.

This study evaluated feeding problems and gastrointestinal symptoms in children with Silver-Russell syndrome (SRS), which is a rare epigenetic disorder. It also compared the symptoms experienced during different feeding methods, including percutaneous endoscopic gastrostomy (PEG). The national expert team for children with SRS at Queen Silvia Children's Hospital, Gothenburg, studied 46 referrals (63% male) who were born with SRS in Sweden from 1984 to 2018. Patient data were extracted from the Paediatric National Growth Hormone Registry. The medical records covered a median of 68% of the time of the patients' childhood, with a median follow-up of 9 years. Their symptoms were most prevalent during infancy and decreased when they were toddlers. Feeding problems and gastrointestinal symptoms were reported in 91% of the 46 patients, with vomiting in 57% and constipation in 46%. There were 19 children who relied on enteral feeding for their nutrition and 13 of those received PEG. Their body mass index (BMI) increased significantly 2 years after PEG started (p = 0.005). Feeding problems and gastrointestinal symptoms were very common in children with SRS, but partly disappeared during childhood. Providing treatment, such as PEG, normalised the BMIs of children with SRS and reduced their symptoms.

Association between nasogastric tube feeding and discharge outcomes in patients aged 80 and older with aspiration pneumonia: A propensity score‐matched retrospective cohort study

AbstractBackgroundThis study investigated the association between nasogastric tube feeding (NGF) and discharge rate to previous residences with oral intake in patients aged 80+ with aspiration pneumonia.MethodsA retrospective cohort study included 256 hospitalized patients with aspiration pneumonia from 2012 to 2022, which could not start oral intake within 48 h due to dysphagia. Using 1:2 matched‐pair analysis, the association of interest was examined using logistic regression analysis.ResultsNGF was associated with a lower discharge rate (odds ratio: 0.15; 95% CI: 0.05–0.46).ConclusionPatients with NGF had a lower discharge rate to previous residences with oral intake.

Blended diets for children and young people: applying the evidence to nursing practice.

Enteral tube feeding is commonly used for children and young people with complex health and care needs. Blended diets are becoming more widely used and there is increasing evidence to show the benefits of a blended diet for children, young people and their families. This article aims to collate recent evidence on blended diets and describe the implications for nursing practice. Studies exploring blended diets have identified benefits such as improved gastrointestinal symptoms, positive engagement with families around food and mealtimes and the normalisation of enteral tube feeding. Research has also explored the nutritional and microbial content of food blends as well as the viscosity and risk of tube blockage. These are key considerations when supporting families to make informed decisions and use blended diets safely. Nurses play an important role in supporting the safe and effective use of blended diets as part of a wider multidisciplinary team. It is necessary that they have an understanding of the evidence underpinning nursing practice in this area.

Is Outpatient Supraglottoplasty Possible? Examination of Perioperative Comorbidities and Outcomes.

Supraglottoplasty (SGP) is necessary in approximately 10% to 15% of infants with congenital laryngomalacia (LM). Postoperative management strategies vary and this study examines outcomes and readmission rates. This is a retrospective chart review. A single tertiary care institution's patients undergoing SGP from 2012 to May 2022. Patients were assigned to 1 of 3 groups based on length of stay (LOS) including 0, 1, or 2+ days. Preoperative data included age, prevailing symptoms, and comorbidities at the time of surgery. Postoperative data included level of care, perioperative complications, readmission rates, and SGP failure. Descriptive statistics were used to evaluate differences between the 3 groups. Following SGP in 975 patients, 23.8% were discharged the same day (Group 0), 63.2% were observed overnight (Group 1), and 13.0% required 2+ days (Group 2). Four of the 616 patients in Group 1 were admitted to an intensive care unit (ICU) setting, and 11 patients in Group 2. The patients in Group 2 had a higher incidence of Pepcid use, previous intubation, cardiac anomalies, prior gastrostomy tube (G tube), subglottic stenosis, cyanosis, failure to thrive, and prematurity. The significant differences in the group admitted to the ICU were those admitted for airway, cerebral palsy, prior G tube, PSG, prior intubation, or cardiac anomaly (P = <.05). Readmission rates from Group 0 versus 1 were 1.3% and 2.9%, respectively, though this was not statistically significant. SGP is a safe procedure that can be performed in the outpatient setting in select patients.

Comparison of microbiological loads of enteral products at two different ambient room temperatures.

Despite the high risk of bacterial contamination, no studies have been found that evaluate the optimal hanging time of open-system enteral sets under room temperature and intensive care conditions. This study aims to determine the differences in microbial loads of solutions taken from open-system enteral feeding sets hanging for 24 h under room temperature and intensive care conditions. This study is a descriptive type of research. The study sample consisted of a total of 40 samples, with 20 samples under room temperature (25.2-23.3°C) and 20 samples under intensive care conditions (21.1-24.2°C). A simple random sampling method was used for sample selection. The assessment of microbial quality was based on the US Food and Drug Administration online Bacteriological Analytical Manual. In this study, it was determined that 5% of the samples taken from intensive care and 15% of the samples taken at room temperature exceeded the accepted limit for aerobic mesophilic bacteria count. The count of catalase and coagulase-negative Staphylococcus spp was 5% in intensive care samples and 40% in room temperature samples. The total coliform count was not detected in intensive care samples but was 35% in room temperature samples. Escherichia coli was not detected in either group. Differences in microbial loads were observed when commercial enteral solutions were administered using open-system enteral feeding sets under room and intensive care conditions for 24 h. Therefore, large-scale studies are needed to determine the safe use of open-system enteral feeding sets under room temperature conditions.

Association of time to start of enteral nutrition and outcome in cats with hepatic lipidosis.

Enteral nutrition (EN) is essential for management of hepatic lipidosis (HL) in cats. To determine if time to start of EN and other clinicopathologic variables are associated with outcome in cats with HL. Forty-eight cats with HL. Retrospective study. Information retrieved from medical records and client communications included clinicopathologic findings, time to start of EN, initial % of resting energy requirements provided, type of feeding tube, duration of hospitalization, and 3-month survival. Variables were compared between surviving and nonsurviving cats and between cats fed ≤12 hours and >12 hours after hospital admission. Multivariable statistical testing was performed to further investigate variables of interest. Seventeen of 25 (68%) cats fed ≤12 hours and 13 of 23 (57%) of cats fed >12 hours after hospital admission survived (P = .55). Only increasing age (odds ratio [OR], 1.313; 95% confidence interval [CI], 1.032-1.671; P = .03) and the presence of ascites (OR, 6.415; 95% CI, 1.354-30.395; P = .02) were associated with death in multivariable analysis. Hospitalization duration (median, interquartile range [IQR]) was shorter in cats fed >12 hours (2.8 days; IQR, 2.1-3.8 days) as compared with cats fed ≤12 hours (4.8 days; IQR, 3.6-6.2 days) after hospital admission (P < .001). An initial stabilization period before EN introduction does not decrease survival or increase duration of hospitalization in cats with HL.

17 Caregiver experiences with enteral feeding transitions

Abstract Background Children with medical complexity (CMC) are an expanding group within paediatrics due to advances in medical care, often including a dependence on medical technology. Issues such as oromotor swallowing dysfunction and feeding difficulties are common in this population. As a result, many CMC require the use of enteral tubes for feeding. While evidence does support improved nutritional status with the use of enteral feeding tubes, there is limited literature discussing how these interventions impact other patient centered outcomes, such as quality of life for the child, changes in parental caregiving, and logistical implications for the family. A comprehensive understanding of the positive and negative outcomes associated with selection and transition between different feeding tube options is needed. Objectives To describe and explore the caregiver and patient experience with different feeding tubes, with a focus on the experience of transitioning between different enteral feeding modalities. Design/Methods We conducted semi-structured interviews with 16 participants, including both caregivers and two patients. Reflexive thematic analysis was utilized to identify preliminary themes from interviews. Themes were further refined by the study team. Results The themes identified through interviews included: A) the pros and cons with each type of enteral feeding modality, B) the emotional impacts on patients and caregivers, C) logistical impacts on day-to-day life for families, and D) the experience of transitioning between feeding tubes. Globally, participants spoke positively about their transition from nasogastric feeding to either gastrostomy or gastrojejunal feeding tubes. Caregivers also felt that they were integral to the decision-making process, though some felt in hindsight the transition process was too slow. Conclusion This study highlights both the complexity and heterogeneity of the caregiver experience with different feeding tubes. It found that most families consistently viewed their transitions with enteral feeding tubes positively, as this was seen as a significant milestone in helping their child both nutritionally and with their quality of life. Finally, further research could be done to explore experiences with gastrojejunal and jejunal feeding, as this patient population is not well elucidated within the literature.

Feculent Drainage from Percutaneous Endoscopic Gastrostomy Tube due to Gastrocolocutaneous Fistula Found in Emergency Department: A Case Report

Introduction Percutaneous endoscopic gastrostomy (PEG) placement is a common procedure for patients requiring non-oral feeding. One rare complication of PEG placement is the formation of a gastrocolocutaneous fistula that develops when bowel is caught between the stomach and abdominal wall during placement. This report explores an elderly patient's gastrocolocutaneous fistula development months post-PEG placement who presented with malodorous leakage from the gastrostomy tube to the Emergency Department (ED). Case Report A 73-year-old male on hospice presented to the ED with malodorous leakage from his PEG tube. He had received the PEG tube four months prior to this presentation and had it replaced once at an outside hospital due to blockages. In the ED, his PEG tube was found to have a deflated balloon stopper. The PEG tube was replaced, but the feculent discharge persisted. Imaging showed the tube's position in the transverse colon. The patient underwent non-surgical management, with PEG tube removal and nutritional support via nasogastric tube. He was discharged with improvement of PEG site. Conclusion Gastrocolocutaneous fistula should be considered in patients experiencing unexpected PEG tube drainage or feeding-related complications such as diarrhea. Careful replacement techniques after dislodgement or blockage are important. Radiologic confirmation should be considered after replacement of tubes with feculent drainage. The rarity of gastrocolocutaneous fistula cases in literature explains the lack of standardized management approaches. Clinical signs such as feculent leakage through PEG tube site should prompt recognition and diagnosis by the ED clinician.

21 Exploring the clinical presentation and health service utilization in autistic children and adolescents diagnosed with avoidant / restrictive food intake disorder: A descriptive study

Abstract Background Avoidant/restrictive food intake disorder (ARFID) is an eating disorder with much clinical variability, negatively impacting growth, nutrition, psychosocial functioning and overall well-being. ARFID is more frequently reported in neurotypical populations than in neurodivergent populations. Little is known about the clinical presentation and healthcare utilization of autistic individuals with ARFID. Objectives The purpose of this study was to understand the clinical presentation, laboratory abnormalities and health system utilization amongst autistic individuals diagnosed with ARFID within the community. Design/Methods We completed a comprehensive multidisciplinary assessment on autistic individuals less than18 years of age who were diagnosed with ARFID by their community physician. Recruitment period: June 2020-June 2021. Results Nineteen autistic individuals completed a comprehensive multidisciplinary assessment; of these, 42.1% (8/19) met criteria for Autism Spectrum Disorder (ASD) severity level 1. The onset of restrictive eating manifested at M(SD)= 2.5 (0.7) years, and the age of ASD diagnosis was 4.2 (3.8) years. Of these, 78.9% (15/19) had the onset of feeding difficulties either prior to or at the time of their ASD diagnosis (Figure 1). Dependence on enteral feeding or nutritional supplements (74%), psychosocial impairment (68%), and nutritional deficiencies (42%) were the criteria commonly met for ARFID. Sensory-based avoidance (100%) and lack of interest in food (89%) were the two most reported potential drivers for the dysfunctional feeding behaviour based on the Pica , ARFID, and Rumination Disorder Interview-AR-Q. Neurodevelopment disorder comorbidities included ADHD (26.3%), Anxiety (21.1%), and Intellectual Developmental Disability (15.8%). Constipation (68.4%) and nutritional deficits (63.15%) were the most common medical comorbidities recorded. Nutritional profile revealed Vitamin D deficit in 50% (8/16), Anaemia 21% (4/19), Vitamin B1 deficit 20% (2/10). Additionally, three participants (17.7%, 3/17) had deficits in Vitamin B12, Zinc, Vitamin C and low ferritin levels. Four autistic individuals (21.1%, 4/19) were hospitalized because of their restrictive eating. 68.4% (13/19) autistic individuals had involvement of at least one allied health professional (OT or SLP or BT). No participants had a prior multidisciplinary feeding assessment or intervention to address restrictive eating. Conclusion ARFID is an eating disorder observed within autistic individuals. Evidence suggests food related sensory sensitivities and lack of interest in food are potential drivers of ARFID in the context of ASD. A comprehensive multidisciplinary assessment is needed to elucidate factors driving restrictive eating to inform targeted evidence-based interventions.

68 Feasibility of applying synchronized and proportional negative pressure ventilation in preterm infants with respiratory distress (NeoVest)

Abstract Background In preterm infants, application of negative pressure ventilation (NPV) may offer advantages to traditional methods of nasal continuous positive airway pressure (nCPAP). In a pre-clinical model, we recently described the “NeoVest”, a system consisting of a sealed abdominal interface and a ventilator that applies NPV in synchrony and in proportion to the diaphragm electrical activity (Edi) (Beck 2022). In animals with loaded breathing, the Neovest allowed a 50% reduction in Edi, and demonstrated specific diaphragm unloading, without hemodynamic effects. The NeoVest system, and its interface, have yet to be evaluated in human infants. Objectives The aim of the study was to evaluate the feasibility of applying synchronized and proportional NPV with an abdominal interface in infants with respiratory distress. Design/Methods This is a prospective feasibility trial. The inclusion criteria were admission to the Neonatal Intensive Care Unit with respiratory distress, birthweight&amp;gt;1.5kg, &amp;lt;6 weeks of age, FiO2 &amp;lt;0.35, clinically stable with no recent apneas and bradycardias, nCPAP &amp;lt;8 cm H2O and at least 48 hrs old, or post-extubation. After parental consent, the feeding tube was exchanged for a 6F “Edi catheter” (for feeding and measuring Edi), and sensors were placed (heart rate, oxygen saturation, transcutaneous CO2, and non-invasive blood pressure (BP)). Figure 1 shows the Neovest interface on a manikin. The five protocol steps were: nCPAP ON/NeoVest OFF (10 min), nCPAP ON/NeoVest ON (10 min), NO ASSIST (1 min), NeoVest only medium (10 min), NeoVest high (5 min), NeoVest low (5 min). Results Eight babies have been included to this point. The principal diagnoses were Respiratory Distress Syndrome and/or Transient Tachypnea of the Newborn. Mean weight was 2186±480g and age 10±8 days old. All babies tolerated the physical application of the vest. As shown in Figure 2, there was no significant difference in Edipk when the vest was placed (12.4±5.5 vs. 11.1±3.5 uV). During the period of no assist, Edipk was higher (18.8 ±7.3 uV) than nCPAP or NeoVest periods (p= 0.012), which were not significantly different from each other. Neural respiratory rate was the same for all periods tested. As per its design, the Neovest system delivered negative pressure in synchrony and in proportion to the Edi. Negative pressures applied (□PVEST) were -9±4, -11±4, and -7±5 cmH2O (Figure 2) for the three NeoVest periods. All infants were clinically stable with no disruptions to vital signs. Conclusion Applying synchronized and proportional negative pressure with the NeoVest system was feasible and showed promise with regards to diaphragm unloading. Future studies are required to evaluate the NeoVest utility for longer periods and compared to other methods of respiratory support.

Case Report: A delicate equilibrium of exocrine pancreatic recovery and hepatotoxicity with elexacaftor/tezacaftor/ivacaftor therapy in a pediatric patient with cystic fibrosis

This case report presents a comprehensive evaluation of the complex balance of therapeutic benefits and potential risks associated with the cystic fibrosis transmembrane conductance regulator (CFTR) modulator elexacaftor/tezacaftor/ivacaftor (ETI) therapy in managing an eight-year-old male with cystic fibrosis (CF) and exocrine pancreatic insufficiency (EPI). While ETI therapy significantly enhanced exocrine pancreatic function, it led to hepatotoxicity, necessitating therapy discontinuation. Attempts to restart ETI at reduced doses were unsuccessful due to persistent hepatic dysfunction. Reduced ETI dosing frequency, implemented due to hepatic dysfunctions, did not result in substantial therapeutic benefits. Clinical markers showed a resurgence of severe EPI and sustained need for gastrostomy tube feeds, with only modest improvement in hepatic function compared to the period following ETI cessation or during prior use of CFTR modulator therapy with lumacaftor/ivacaftor. This case underscores the importance of personalized therapeutic approaches, biomarker-guided monitoring, and multidisciplinary insights to optimize CF management while also highlighting the ongoing need for research to mitigate hepatotoxicity risks and ensure long-term therapeutic efficacy.

Advancing Digital Education Technologies by Empowering Nurses With Point-of-Care Ultrasound: Protocol for a Mixed Methods Study.

Bedside ultrasonography, also known as point-of-care ultrasound (PoCUS), is a promising technological tool that enhances clinical assessment, enriching diagnostic capabilities and clinical reasoning. Its use in nursing spans various patient populations and health care settings, providing nurses with a valuable health assessment tool to improve care quality and patient safety. Despite its growing integration into clinical practice, PoCUS training has mainly focused on physicians, leaving a gap for trained nurses who demonstrate similar proficiency in conducting scans and interpreting images. Previous research highlights the value of digital tools in PoCUS training, showing their role in improving professionals' and students' knowledge, image interpretation skills, and clinical acumen. This study aimed to (1) establish an assessment instrument gauging nurses' competency milestones in PoCUS and evaluate its content and appearance validity, (2) develop a series of 5 educational videos focused on PoCUS and assess their content and appearance validity, and (3) construct an online learning environment tailored to nurses' PoCUS training needs and evaluate its content and appearance validity. We will conduct a methodological study of technological production guided by Rogers' diffusion of innovations theory. Subproject 1 will design and validate a comprehensive assessment tool for evaluating nurses' competency milestones in PoCUS use. For this purpose, a scoping review will be conducted. The review will be based on JBI Collaboration guidelines and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extended for Scoping Reviews (PRISMA-ScR) checklist. Subproject 2 involves an evaluation of content and appearance validity for a series of 5 educational videos on PoCUS, designed specifically for nurses about applying peripherally inserted central catheter lines, inserting nasogastric feeding tubes, assessing gastric residual volume, assessing pressure injuries and soft tissue conditions, and assessing muscle mass to monitor patient nutritional status. In subproject 3, a comprehensive online learning environment dedicated to PoCUS training for nurses will be developed and validated. The launch of an online learning environment represents a cornerstone of our dissemination strategy, scheduled to coincide with the inaugural Brazilian PoCUS symposium for nurses, an event organized by the project members. This platform will serve as a pivotal resource for continuous learning and professional development. Subproject 1 will start in the second half of 2024 and is expected to be completed by mid-2025. Subproject 2 is currently ongoing and is expected to be completed in early 2026. Subproject 3 is set to begin in early 2025 and is planned to be completed by 2026. Through these concerted efforts, the project aims to bridge the existing gap in PoCUS training for nurses, thereby fostering their proficiency and enhancing patient care outcomes. PRR1-10.2196/58030.

Features Associated With the Presence of Specific Bacterial Strains in Pediatric Tracheostomy.

Tracheostomy bypasses physical barriers that decrease microbial access to the lower airway, which can lead to changes to the lung microbiota. Patients often become chronically colonized with potential pathogens. This study described the incidence and prevalence of specific organisms in a 5-y cohort of children with tracheostomy. This retrospective cohort of children aged 0-18 y with tracheostomy identified associations between microbial species and subject characteristics including reason for tracheostomy, gastrostomy tube (G-tube), fundoplication, and ventilator use using chi-square test or Fisher exact test. Of 113 eligible patients, 79 (57% male) met study inclusion criteria. Reasons for tracheostomy included airway obstruction secondary to craniofacial anomalies in 16 children (20%), upper-airway obstruction in 14 subjects (17.3%), neuromuscular disorder in 19 subjects (24%), bronchopulmonary dysplasia with or without pulmonary hypertension in 17 subjects (21%), and congenital heart disease in 13 subjects (16%). Most (69%) used a ventilator for at least 6 h/d; 63% had a G-tube; 41% also had a Nissen fundoplication. Of the 20% with upper-airway obstruction, one third were ventilator dependent, unlike other diagnoses where 57% used a ventilator. Staphylococcus aureus (52/113), Pseudomonas aeruginosa (43/113), and Stenotrophomonas species (39/113) were the most frequently identified bacterial species. Most microbes identified were not associated with subjects underlying diagnoses, ventilator use, or feeding type. However, there was a significant association between upper-airway obstruction and group B Streptococcus species and G-tube with P. aeruginosa. This retrospective single-site descriptive cohort analysis of pediatric subjects with long-term tracheostomy identified trends in microbial prevalence. The presence of specific bacterial strains was more likely to follow individual subject trajectories than sequential appearance of species. P. aeruginosa was associated with G-tube and Streptococcus species with upper-airway obstruction. Ventilator dependence was not associated with specific microbial profiles.

Changes of the microbiome as a predictor of comorbidity in gastrostomy patients

Dysphagia as a symptom of dysfunction of the digestive system occurs in patients with various pathologies and in severe cases requires the formation of a nutrient fistula. The presence of a stoma is a source of additional pathological changes. Changes in the microbiota of gastrostomy patients is an issue that is practically not covered in the scientific literature. The purpose of the study is to determine characteristic changes in the microbiota of the oral cavity, stomach and intestines caused by nutritional stoma and their clinical significance. Materials and methods. The study included 20 children fed through a gastrostomy tube and 10 children fed by mouth. Group 1 consisted of patients with a gastrostomy installed in less than 1 year, group 2 - in periods of more than 1 year, group 3 - children without gastrostomy. All patients underwent a standard examination in a gastroenterological hospital and 16S rRNA sequencing of aspirates from 3 biotopes - mouth, stomach and intestines. An assessment of physical development and bioimpedance measurements was carried out, and a group of patients with sarcopenia was identified. Results. In all three biotopes of patients with gastrostomies, a pronounced disturbance of microbiological homeostasis was found. In the oral cavity, the number of anti-carious microorganisms is reduced and, on the contrary, the level of periodontogenic strains is increased. This fact is the cause of the occurrence of comorbid conditions and requires the appointment of local therapy with probiotic strains approved for use. Changes in the gastric microbiome after gastrostomy placement are characterized by a high degree of H. pylori contamination against the background of a decrease in anti-inflammatory protection. Determining the level of bacteria of the genera Prevotella, Parabacteroides, Porphyromonas in the stomach can become a marker of concomitant chronic inflammatory changes in the mucous membrane of the upper gastrointestinal tract, a high risk of developing peptic ulcers and its complications. The state of the gut microbiome correlates with underweight, BMI, proportion of fat mass and active cell mass. The development of sarcopenia in gastrostomy patients is one of the possible dangerous comorbid conditions, one of the diagnostic criteria of which is a decrease in the level of Phylum Fusobacteriota bacteria.