Feeding Tube Placement Research Articles

Racial Disparities in High- and Low-Value Healthcare Services Received in the Final Year of Life for Medicare Beneficiaries with Neurodegenerative Diseases (P4-9.001)

<h3>Objective:</h3> To determine if receipt of high- and low-value healthcare services in the final year of life differ by race for patients with neurodegenerative diseases (NDD), defined as any form of dementia or Parkinson’s disease. <h3>Background:</h3> Prior studies have shown substantial racial disparities in care received by patients with NDD. However, no studies have evaluated disparities in the value (defined as the ratio of benefit to cost) of care received in the last year of life, a time period that is important to patients and families and is associated with high healthcare expenditures. <h3>Design/Methods:</h3> This was a retrospective cohort study of Medicare beneficiaries in North and South Carolina from 2013–2017. Low-value healthcare services were selected from the Choosing Wisely initiative and included contraindicated cancer screening, peripheral artery stenting, and feeding tube placement. High-value healthcare services included receipt of physical or occupational therapy, hospice care, or cost-effective medications indicated to treat NDD. <h3>Results:</h3> Among 70,650 decedents, 13,753 were Black, 55,765 were White, 93.1% had dementia, and 7.7% had Parkinson’s disease. Adjusting for age, sex, Medicaid dual enrollment status, rural vs urban location, state (NC, SC), and comorbidities, Black decedents were more likely to receive low-value care including colorectal cancer screening (adjusted hazard ratio (aHR) 1.46 [1.32–1.61]), peripheral artery stenting (aHR 1.72 [1.43, 2.08]), and feeding tube placement (aHR 2.96 [2.70–3.24]) and less likely to receive physical therapy (aHR 0.73 [0.64, 0.85)], dementia medications (aHR 0.90 [0.86, 0.95]), or Parkinson’s disease medications (aHR 0.88 [0.75, 1.02]) within the last year of life, and were less likely to be admitted to hospice (aHR 0.82 [0.79–0.85]). <h3>Conclusions:</h3> Complex, systemic dynamics beyond healthcare access alone may drive racial disparities in end-of-life care for patients with NDD. Interventions to improve health equity in end-of-life settings are desperately needed. <b>Disclosure:</b> Mr. Lusk has received research support from American Heart Association. Dr. Ford has nothing to disclose. Ms. Greiner has nothing to disclose. An immediate family member of Dr. Clark has received personal compensation for serving as an employee of Blue Cross Blue Shield of NC. Dr. Johnson has nothing to disclose. The institution of Brystana Kaufman has received research support from AstraZeneca. The institution of Brystana Kaufman has received research support from NIH. The institution of Brystana Kaufman has received research support from 199. Dr. Mantri has received personal compensation in the range of $0-$499 for serving as a Consultant for Deep Brain Innovations, LLC. Dr. Mantri has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Grey Matter Technology. The institution of Dr. Mantri has received research support from The Michael J Fox Foundation for Parkinson Research. Dr. Xian has nothing to disclose. Dr. O’Brien has nothing to disclose. Dr. O’Brien has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Boehringer Ingelheim. The institution of Dr. O’Brien has received research support from Pfizer. The institution of Dr. O’Brien has received research support from BMS. Dr. Goetz has nothing to disclose.

Rapidly Progressive AIDP Secondary To Waldenström’s Macroglobulinemia, A Rare Cause With Fatal Respiratory Depression And Autonomic Instability (P10-5.001)

<h3>Objective:</h3> To report a rare case of AIDP secondary to Waldenström’s Macroglobulinemia <h3>Background:</h3> Acute inflammatory demyelinating polyneuroradiculopathy (AIDP) is a rare complication of Waldenström’s Macroglobulinemia (WM). Typical findings are a slowly progressive neuropathy, thought to be mediated through autoantibodies. Anti-myelin-associated glycoprotein (MAG) antibodies are found in 50% of patients with WM and neuropathy. A rapidly progressing course can result in fatal respiratory depression and cardiac arrhythmias. <h3>Design/Methods:</h3> Information regarding patient obtained via retrospective review of electronic medical records. <h3>Results:</h3> This is a 77 year-old male with chronic WM presenting with rapidly progressive appendicular weakness over several days. Neurologic exam was notable for diffuse areflexia, appendicular weakness (MRC Grade 1–2 of 5), and globally reduced sensation. Initially, no bulbar weakness was noted but as symptoms progressed patient required intubation on hospital day #2. MRI brain was unremarkable, however, MRI lumbosacral spine showed enhancement of nerve. Plasma levels of Anti-MAG IgM antibody (1:102400) were substantially elevated. CSF analysis showed elevated protein (55), glucose (40), and 76 nucleated cells (70% lymphocytes). Electromyography and nerve conduction studies revealed temporal dispersion, reduced motor unit recruitment and rapid firing in all muscles. Patient was treated with intravenous immunoglobulins (IVIG) 2g/kg over 5 days followed by plasma exchange when IVIG had no effect. The patient’s hospital course was complicated by severe autonomic instability with periods of bradycardia necessitating atropine and percutaneous pacing. The patient also suffered pneumonia and eventually required tracheostomy and feeding tube placement. After a prolonged ICU course, the family eventually decided to change code status to do not resuscitate and patient expired on Hospital Day #19 following an episode of bradycardia refractory to atropine. <h3>Conclusions:</h3> Waldenström’s Macroglobulinemia is an unusual etiology of AIDP. This case revealed the treatment challenges of AIDP including respiratory depression and autonomic instability. <b>Disclosure:</b> Dr. Yu has nothing to disclose. Dr. Munir has nothing to disclose. The institution of Dr. Mohney has received research support from NIH.

Nutritional and metabolic characteristics of critically ill patients admitted for severe toxidermia

Drug-induced toxidermia is an idiosyncratic adverse skin reaction that may become life-threatening in a small portion of patients, requiring intensive care unit (ICU) admission. The treatment recommendations are extrapolated from those of major burns, while prospective data remain sparse. The objective was to observe the application of these recommendations in patients treated in a burn ICU. Retrospective cohort study including patients requiring ICU between 2006 and 2020 in a tertiary university hospital. Age >18 years. Patients were categorized as Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN), or other toxidermia. severity scores, body surface area (BSA) involvement, nutritional and metabolic variables, trace element status, outcome variables. Descriptive statistics: median [IQR]. Altogether 35 patients were included (27 SJS/TEN and 8 "other"), aged 58 [48; 69] years. Skin involvement was 45% [30; 60] of body surface, 17 patients required mechanical ventilation, and length of ICU stay was 16 [6.5; 26] days. Hospital mortality was 23%. Fluid resuscitation requirements were moderate, despite intense inflammation (admission CRP (144 [89; 218] mg/L). The first 2 weeks' energy and protein intakes were below recommendations (p<0.0001), lowest with oral feeding. Indirect calorimetry showed high energy expenditure in 11 patients (30.4 [23.9; 35.5] kcal/kg) resulting in negative energy balances (mean-245 kcal/day). Copper and zinc levels were below reference range during the first week, the low copper values being a novel finding. Trace elements should be monitored. The cohort was underfed with intakes lower than our ICU protocols, partly explained by short intubation times, and mucocutaneous involvement complicating the management and placement of feeding tubes. Oral feeding was least efficient and may become an indication for supplemental parenteral nutrition in the absence of an enteral feeding tube. gov Identifier: NCT05320653.

Efficacy of ketamine mouthwash in the management of oral and pharyngeal toxicity associated with head and neck chemoradiotherapy: protocol for a phase II, Simon’s two-stage trial

IntroductionCurative intent treatment of head and neck cancer (HNC) is frequently radiation therapy over 7 weeks with concurrent chemotherapy. This regimen is effective but carries a burden of toxicity leading...

Remote Activity Monitoring and Electronic Patient-Reported Outcomes Collection During Radiotherapy for Head and Neck Cancer: A Pilot Study.

Modern wearable devices provide objective and continuous activity data that could be leveraged to enhance cancer care. We prospectively studied the feasibility of monitoring physical activity using a commercial wearable device and collecting electronic patient-reported outcomes (ePROs) during radiotherapy (RT) for head and neck cancer (HNC). Patients planned for a course of external beam RT with curative intent for HNC were instructed to use a commercial fitness tracker throughout the RT course. During weekly clinic visits, physician-scored adverse events were recorded during using Common Terminology Criteria for Adverse Events version 4.0, and patients completed ePRO surveys using a clinic tablet or computer. Feasibility of activity monitoring was defined as collection of step data for at least 80% of the RT course for at least 80% of patients. Exploratory analyses described associations between step counts, ePROs, and clinical events. Twenty-nine patients with HNC were enrolled and had analyzable data. Overall, step data were recorded on 70% of the days during patients' RT courses, and there were only 11 patients (38%) for whom step data were collected on at least 80% of days during RT. Mixed effects linear regression models demonstrated declines in daily step counts and worsening of most PROs during RT. Cox proportional hazards models revealed a potential association between high daily step counts and both reduced risk of feeding tube placement (hazard ratio [HR], 0.87 per 1,000 steps, P < .001) and reduced risk of hospitalization (HR, 0.60 per 1,000 steps, P < .001). We did not achieve our feasibility end point, suggesting that rigorous workflows are required to achieve continuous activity monitoring during RT. Although limited by a modest sample size, our findings are consistent with previous reports indicating that wearable device data can help identify patients who are at risk for unplanned hospitalization.

Influence of mild cognitive impairment on patient and care partner decision-making for acute ischemic stroke

GoalsEvidence suggests that patients with mild cognitive impairment (MCI) receive fewer treatments for acute ischemic stroke and other cardiovascular diseases than patients with normal cognition. Little is known about how patient and care partner preferences for ischemic stroke treatment differ between the patient population with MCI and the population with normal cognition. This study aimed to understand how patient MCI diagnosis influences patient and care partner decision-making for acute ischemic stroke treatments. MethodsMulti-center qualitative study using in-person semi-structured interviews with 20 MCI and normal cognition patient-care partner dyads using a standard guide. The present study reports results on patient and care partner preferences for a clinical vignette patient to receive three non-invasive treatments (intravenous tissue plasminogen activator, inpatient rehabilitation, and secondary preventive medications) and two invasive treatments (feeding tube and carotid endarterectomy) after acute ischemic stroke. We used qualitative content analysis to identify themes. FindingsWe identified three major themes: (1) Patients with MCI desired non-invasive treatments after stroke, similar to patients with normal cognition and for similar reasons; (2) Patients with MCI expressed different preferences than patients with normal cognition for two invasive treatments after stroke: carotid endarterectomy and feeding tube placement; and (3) Patients with MCI expressed more skepticism of the stroke treatment options and less decisiveness in decision-making than patients with normal cognition. ConclusionsThese results suggest that patient MCI diagnosis may contribute to differences in patient and care partner preferences for invasive treatments after stroke, but not for non-invasive treatments.

Prophylactic High-Dose Gabapentin Reduces Opiate Use during Radiation Therapy for Head and Neck Squamous Cell Carcinoma.

The role of prophylactic high-dose gabapentin for the management of oral mucositis during radiation therapy for head and neck squamous cell carcinoma (HNSCC) remains controversial. A retrospective cohort analysis was performed on primary HNSCC patients treated at our institution. Kruskal-Wallis and Fisher's exact tests were used to compare the patients' baseline characteristics. Multivariate competing risk and logistic regressions were performed to evaluate time to first opioid use and feeding tube placement. In total, 480 consecutive HNSCC patients were included. Within this cohort, 186 patients received 3600 mg gabapentin, 182 received 300 to 3200 mg gabapentin, and 112 received no gabapentin. The time to first opioid use was greater in the 3600 mg group compared with the no gabapentin group (34.3 vs. 23.9 days, p < 0.001) and to the 300 to 3200 mg group (28.0 days, p < 0.001). The proportion of patients requiring opioids at any point during RT was lower in the 3600 mg gabapentin group compared with the no gabapentin group (31.8% vs. 60.1%, p < 0.001) and with the 300 to 3200 mg group (63.8%, p < 0.001). Prophylactic use of 3600 mg gabapentin was well tolerated, halved overall opioid use, and delayed the time to first opioid use during radiation therapy.

Choosing wisely: Enteral feeding tube selection, placement, and considerations before and beyond the procedure room.

When an enteral feeding tube (EFT) is placed, it is not always known how long this nutrition support intervention will be needed. As a result, the type of device the patient originally has placed may not match the function it is required to serve or the lifestyle needs of the patient throughout their enteral nutrition journey. Medicare considers an EFT a prosthetic device, as it is replacing a permanently inoperable or nonfunctioning organ. If we think about an EFT the same way we think about a prosthetic limb, one that needs to be customized to meet all of the patient's functional and lifestyle needs, we can also begin to think beyond the procedure room and carefully consider a variety of factors that impact the patient at home receiving enteral nutrition. Proper fit, function, and style is essential in order for the patient to have a positive relationship with their EFT, contributing to their successful home enteral nutrition experience. Clinicians who care for these patients in any setting and in any capacity would benefit from enhancing their understanding of available EFT options, their design components, and available methods of placement. Many home care and outpatient clinicians adopt the role of patient advocate as it relates to a patient's enteral nutrition journey, and this expanded knowledge could be used to benefit the patient by improving their overall enteral nutrition experience and ultimately their relationship with their "prosthetic."

Mortality and morbidity following gastrojejunal feeding tube placement in children and adolescents, does the technique matter? Systematic review

Mortality and morbidity following gastrojejunal feeding tube placement in children and adolescents, does the technique matter? Systematic review

Effect of jejunal feeding tube placement on complications after laparoscopic radical surgery in patients with incomplete pyloric obstruction by gastric antrum cancer

Objective: To assess the effect of jejunal feeding tube placement on early complications of laparoscopic radical gastrectomy in patients with incomplete pyloric obstruction by gastric cancer. Methods: This was a retrospective cohort study. Perioperative clinical data of 151 patients with gastric antrum cancer complicated by incomplete pyloric obstruction who had undergone laparoscopic distal radical gastrectomy from May 2020 to May 2022 in the First Affiliated Hospital of Nanchang University were collected. Intraoperative jejunal feeding tubes had been inserted in 69 patients (nutrition tube group) and not in the remaining 82 patients (conventional group). There were no statistically significant differences in baseline characteristics between the two groups (all P>0.05). The operating time, intraoperative bleeding, time to first intake of solid food, time to passing first flatus, time to drainage tube removal, and postoperative hospital stay, and early postoperative complications (occurded within 30 days after surgery) were compared between the two groups. Results: Patients in both groups completed the surgery successfully and there were no deaths in the perioperative period. The operative time was longer in the nutritional tube group than in the conventional group [(209.2±4.7) minutes vs. (188.5±5.7) minutes, t=2.737, P=0.007], whereas the time to first postoperative intake of food [(2.7±0.1) days vs. (4.1±0.4) days, t=3.535, P<0.001], time to passing first flatus [(2.3±0.1) days vs. (2.8±0.1) days, t=3.999, P<0.001], time to drainage tube removal [(6.3±0.2) days vs. (6.9±0.2) days, t=2.123, P=0.035], and postoperative hospital stay [(7.8±0.2) days vs. (9.7±0.5) days, t=3.282, P=0.001] were shorter in the nutritional tube group than in the conventional group. There was no significant difference between the two groups in intraoperative bleeding [(101.1±9.0) mL vs. (111.4±8.7) mL, t=0.826, P=0.410]. The overall incidence of short-term postoperative complications was 16.6% (25/151). Postoperative complications did not differ significantly between the two groups (all P>0.05). Conclusion: It is safe and feasible to insert a jejunal feeding tube in patients with incomplete outlet obstruction by gastric antrum cancer during laparoscopic radical gastrectomy. Such tubes confer some advantages in postoperative recovery.

Introduction to interventional oncology: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper.

Interventional radiology (IR) is a valuable resource when caring for pediatric solid tumor patients. As minimally invasive, image-guided procedures become more relied upon to answer challenging diagnostic questions and provide alternative therapeutic options, IR is poised to become a contributing member of the multidisciplinary oncology team. Improved imaging techniques allow for better visualization during biopsy procedures, transarterial locoregional treatments have the potential to deliver targeted cytotoxic therapy while limiting systemic side effects, and percutaneous thermal ablation can be used to treat chemo-resistant tumors of various solid organs. Additionally, interventional radiologists are able to perform routine, supportive procedures for oncology patients that include central venous access placement, lumbar punctures, and enteric feeding tube placements with high levels of technical success and excellent safety profiles.

Low skeletal muscle mass is predictive of dose-limiting toxicities in head and neck cancer patients undergoing low-dose weekly cisplatin chemoradiotherapy.

The dose-limiting effect of CT-assessed low skeletal muscle mass (LSMM) measured at the level of the third cervical vertebra has been found in head and neck cancer patients receiving high-dose cisplatin chemoradiotherapy. The aim of this study was to investigate the predictive factors for dose-limiting toxicities (DLTs) using low-dose weekly chemoradiotherapy. Head and neck cancer patients receiving definite chemoradiotherapy with weekly 40 mg/m2 body surface area (BSA) cisplatin or paclitaxel 45 mg/m2 BSA and carboplatin AUC2 were consecutively included and retrospectively analysed. Skeletal muscle mass was assessed using the muscle surface at the level of the third cervical vertebra in pretherapeutic CT scans. After stratification for LSMM DLT, acute toxicities and feeding status during the treatment were examined. Dose-limiting toxicity was significantly higher in patients with LSMM receiving cisplatin weekly chemoradiotherapy. For paclitaxel/carboplatin, no significance regarding DLT and LSMM could be found. Patients with LSMM had significantly more dysphagia before treatment, although feeding tube placement before treatment was equal in patients with and without LSMM. LSMM is a predictive factor for DLT in head and neck patients treated with low-dose weekly chemoradiotherapy with cisplatin. For paclitaxel/carboplatin, further research must be carried out.

Bedside naso-jejunal placement is more difficult, but successful in patients with COVID-19 in critical care: A retrospective service evaluation of a dietitian-led service.

The COVID-19 pandemic presented clinical and logistical challenges in the delivery of adequate nutrition in the critical care setting. The use of neuromuscular-blocking drugs, presence of maxilla-facial oedema, strict infection control procedures, and patients placed in a prone position complicated feeding tube placement. We audited the outcomes of dietitian-led naso-jejunal tube (NJT) insertions using the IRIS® (Kangaroo, USA) device, before and during the COVID-19 pandemic. NJT placement was successful in 78% of all cases (n = 50), and 87% of COVID-19 cases. Anaesthetic support was only required in COVID-19 patients (53%). NJT placement using IRIS was more difficult but achievable in patients with COVID-19.

Efficacy of Prophylactic High-Dose Gabapentin and Venlafaxine on Reducing Oral Mucositis Pain Among Patients Treated With Chemoradiation for Head and Neck Cancer: A Single-Institution, Phase 2, Randomized Clinical Trial

Given the paucity of level 1 evidence, the optimal regimen to control oral mucositis pain remains unclear. Although national guidelines allow consideration of prophylactic gabapentin, prior trials showed improved pain control with venlafaxine among patients with diabetic neuropathy. We sought to investigate the role of prophylactic high-dose gabapentin with venlafaxine to reduce oral mucositis pain among patients with head and neck cancer. We performed a single-institution, phase 2 randomized trial on nonmetastatic squamous cell carcinoma of the head and neck treated with chemoradiation. Patients were randomized to either prophylactic gabapentin (3600 mg daily) with or without venlafaxine (150 mg daily). Primary endpoint was differences in pain levels at the end of chemoradiation. Secondary endpoint was toxicity profiles, quality of life changes, opioid use, and feeding tube placement. Differences between the 2 arms at multiple time points were evaluated using a generalized linear mixed regression model with Sidak correction. Between May 2018 and March 2021, a total of 62 patients were enrolled and evaluable for analysis (n=32 for the gabapentin alone arm, n=30 for the gabapentin+venlafaxine arm). Over 90% of patients tolerated gabapentin well. Head and neck pain level showed a mean value of 45 (standard deviation, 23) and 43 (standard deviation, 21) for the gabapentin alone and the gabapentin+venlafaxine arms, respectively (P=.65). No statistically significant differences were observed in adverse events, opioid use, feeding tube placement, or quality of life. The addition of venlafaxine to prophylactic gabapentin did not result in improvements in pain control and quality of life among patients with head and neck cancer.

Using an Electromagnetic Guidance System for Placement of Small-Bowel Feeding Tubes to Reduce Feeding Start Times.

Cardiothoracic surgery patients have an increased risk for aspiration and may require enteral access for nutrition. In a cardiothoracic intensive care unit, feeding start times were delayed because of scheduling conflicts with support services. An electromagnetic device (Cortrak 2 Enteral Access System, Avanos Medical) was introduced to allow advanced practice providers (nurse practitioners and physician assistants) to independently establish postpyloric access and reduce dependence on ancillary services. A quality improvement study was performed. Pre- and postimplementation data included order time, service arrival, tube placement time, tube positioning, and feeding start times for 207 placements. Pre- and postimplementation surveys were conducted to evaluate advanced practice provider satisfaction with enteral tube placement practices. Feeding start time for initial placement decreased by 35.5% (15.6 hours to 10 hours); for subsequent placement, by 55.2% (15.5 hours to 7.0 hours). Assistance by support services decreased by 80.4% (before implementation, 100 of 100 placements [100%]; after implementation, 21 of 107 placements [19.6%]; P < .001; ϕ = 0.815). Overall, advanced practice provider satisfaction increased. Most participants said that using the electromagnetic device was faster, nutrition was delivered sooner, and implementation was a valuable practice change. Using an electromagnetic device decreased feeding start times, reduced the need for support services, and increased advanced practice provider satisfaction with small-bowel feeding tube placement practices.

What is the efficacy and safety of electromagnetic-guided placement of postpyloric nasoenteral feeding tubes compared to endoscopic-guided placement?

What is the efficacy and safety of electromagnetic-guided placement of postpyloric nasoenteral feeding tubes compared to endoscopic-guided placement?

Enteral Nutrition Simulation Workshop Enhances Knowledge and Skills of Graduate Nutrition Students

Registered dietitian nutritionists are integral to the health care team, especially in delivering and managing parenteral or enteral nutrition (EN). 1 Corrigan ML Bobo E Rollins C Mogensen KM. Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: revised 2021 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in nutrition support. Nutr Clin Pract. 2021; 36: 1126-1143 Google Scholar The training and education of future registered dietitian nutritionists are necessary to promote and advance the skill set of the practitioner. The Accreditation Council for Education in Nutrition and Dietetics (ACEND) is the accrediting agency for nutrition and dietetics education programs which provides the required standards and learning elements that train students to become dietitians. 2 ACEND. Future Education Model Standards and Templates v2022.https://www.eatrightpro.org/acend/accreditation-standards-fees-and-policies/future-education-model-standards-and-templates-v2022. Accessed December 22, 2022. Google Scholar The ACEND standards require learning activities in the curriculum to ensure the full scope of the competencies is met. 2 ACEND. Future Education Model Standards and Templates v2022.https://www.eatrightpro.org/acend/accreditation-standards-fees-and-policies/future-education-model-standards-and-templates-v2022. Accessed December 22, 2022. Google Scholar In 2022, ACEND added required elements and learning experiences for all nutrition and dietetics programs. The ACEND Accreditation Standards for Nutrition and Dietetics Graduate Degree Programs (Future Education Model) 2 ACEND. Future Education Model Standards and Templates v2022.https://www.eatrightpro.org/acend/accreditation-standards-fees-and-policies/future-education-model-standards-and-templates-v2022. Accessed December 22, 2022. Google Scholar specify faculty must prepare students to become competent in this skill: “Element 3.2e-3: Explain the steps involved and observe the placement of nasogastric (NG) or nasoenteric feeding tubes; if available, assist in the process of placing NG or nasoenteric feeding tubes.” 2 ACEND. Future Education Model Standards and Templates v2022.https://www.eatrightpro.org/acend/accreditation-standards-fees-and-policies/future-education-model-standards-and-templates-v2022. Accessed December 22, 2022. Google Scholar

Early Enteral Feeding in Severe Acute Pancreatitis: A Randomized Clinical Trial Between Gastric vs Distal Jejunal Feeding

Background and AimsSevere acute pancreatitis is one of the most catabolic illnesses. Meta-analyses have shown that enteral nutrition is safer and more effective than parenteral nutrition in suppressing these losses. However, there is intense debate about how the enteral nutrition should be delivered. MethodsThe design was a randomized controlled trial of early nasogastric (NG) vs distal jejunal (DJ) tube feeding with a semi-elemental diet during the first 4 weeks of severe acute pancreatitis. The setting involved multiple national tertiary care centers. Two hundred and twenty-eight patients were screened, and 26 met the inclusion criteria for new onset severe acute pancreatitis based on an APACHE II score >8, computed tomography evidence of >30% necrosis or computed tomography score >8, and/or a Marshall score >2. The intervention was a randomized allocation to either feeding tube bedside placement by NG or transnasal endoscopy for DJ. The primary endpoint was “feeding failure” to tolerate a rate of >10% of the goal for a 48-hour period. ResultsTwenty-six eligible patients were randomized, 12 to NG and 14 to DJ, 20 of 26 from the Pittsburgh center. Most were obese (BMI 31.5 kg/m2). Feeding failure occurred in 0 of 14 in the DJ group and in 6 of 11 (55%) in the NG group (P = 0.0026). NG failures were crossed over to DJ feeding with good tolerance and eventual recovery. As a result, the quantity of feed delivered was significantly higher in the DJ group (P < 0.05). Serious adverse events (cardiorespiratory arrests, unrelated to endoscopy) occurred in 2 of the DJ and none of the NG group; 3 patients from the DJ group died of progressive organ failure, 2 with associated compartment syndrome. ConclusionThis randomized controlled trial indicates that in patients with acute pancreatitis of this level of severity, NG feeding will be ineffective. Although this is a common indication for parenteral nutrition, a safer alternative would be endoscopic-assisted DJ feeding tube placement to bypass the usually dysfunctional or obstructed upper gastrointestinal tract.

Sociodemographic Differences of Hospitalization and Associations of Resource Utilization for Failure to Thrive.

This study examines the sociodemographic differences between elective and nonelective admissions for failure to thrive (FTT). We investigate associations between admission type and hospital resource utilization, including length of stay and feeding tube placement. We included children <2 years old with FTT in the nationwide Kids' Inpatient Database. We described differences between elective and nonelective admissions using Fisher exact and t tests. To assess associations of admission type and hospital resource utilization, we used negative binomial and logistic regression for length of stay and feeding tube placement, respectively. In this study of 45,920 admissions (37,224 nonelective vs 8696 elective), we found differences by race and ethnicity, income, and insurance type, among other factors. Compared to elective admissions, nonelective admissions had higher proportions of infants who were Black, Hispanic, and of lower-income. Nonelective admissions were associated with longer lengths of stay (incidence rate ratio 1.46; 95% CI: 1.37-1.55), independent of child age, sex, neighborhood income, insurance, admission day, chronic conditions, and location. Nonelective admissions were associated with lower odds of feeding tube placement compared to elective admissions (adjusted odds ratio 0.62; 0.56-0.68). In the stratified analyses, children of racial and ethnic minority groups admitted nonelectively versus electively had relatively higher odds of feeding tube placement, while White children had relatively lower odds of feeding tube placement. There are various sociodemographic differences between elective and nonelective FTT admissions. Future research is warranted to elucidate drivers of these differences, particularly those related to racial and ethnic disparities and structural racism.

Innovative strategy to improve enteral nutrition in prone positioning with patients with COVID-19.

Enteral nutrition is essential to improve outcomes in patients who are critically ill. Patients in the prone position, including those diagnosed with coronavirus disease 2019 (COVID-19) present additional challenges for enteral nutrition initiation. A novel technique for placing feeding tubes while in the prone position was developed using an electromagnetic placement device and specialty trained clinical nurse specialists. Data were assessed retrospectively to determine effectiveness of this new practice. Sixty-eight patients had feeding tubes placed while in the prone position; 75% were able to be placed through the postpyloric route, 22% were placed through the gastric route, and 3% unable to be placed. Use of this technique facilitated earlier initiation of feedings by 2 days from time of admission and almost half a day from intubation to feeding. There was no additional radiation exposure from using this technique. Ability to place feeding tubes early while patients were prone reduced delays for starting enteral nutrition. Patients with COVID-19 in the prone position were able to receive effective nutrition support earlier with no additional complications.