Oral Intake Research Articles

ETWST: An Extension to the Timed Water Swallow Test for Increased Dysphagia Screening Accuracy

AbstractWe aimed to fine-tuning the Timed Water Swallow Test (TWST) screening procedure to provide the most reliable prediction of the Flexible Endoscopic Evaluation of Swallowing (FEES) assessment outcomes, with age, sex, and the presence of clinical signs of dysphagia being considered in the assessment. Participants were healthy people and patients with suspected dysphagia. TWST performance and participants’ reported dysphagia symptoms were assessed in terms of their utility in predicting the outcome of a FEES assessment the same day. The FEES assessors were blinded to the nature of the TWST performance. The water swallowing capacity levels and clinical observations during a screening performance that were indicative of dysphagia/no symptoms in FEES were determined. Convergent validity was assessed as the agreement with the Functional Oral Intake Scale (FOIS) in the FEES assessment. TWST predicted FEES findings (aspiration and dysphagia) with a sensitivity of 72 and 45% and a specificity of 75% and 80%, respectively. Extended analysis of the TWST procedure (eTWST) identified aspiration (sensitivity = 92%, specificity = 62%) and dysphagia (sensitivity = 70%, and specificity = 72%) more accurately and showed a high correlation with FOIS (ɸ = 0.37). Excellent inter-rater reliability was further observed (Kw = 0.83). The extended evaluation of TWST performance has superior criterion validity to that of TWST. eTWST displayed high convergent validity and excellent interrater reliability. We therefore believe that eTWST can be highly relevant for clinical dysphagia screening.

Radiation‐Induced Pharyngeal Necrosis and Cervical Spine Osteoradionecrosis in Patients With Oropharyngeal Squamous Cell Carcinoma

ABSTRACTBackgroundRadiation therapy with or without chemotherapy is commonly used as an adjunct or alternative to surgery for treating head and neck cancer (HNC). In rare cases, radiation‐induced side effects such as posterior pharyngeal wall necrosis, fistula formation, and osteoradionecrosis (ORN) can lead to dangerous complications of the cervical spine (C‐spine).MethodsWe conducted a literature review on C‐spine ORN in HNC, and we reported four additional cases following the treatment of oropharyngeal carcinoma.ResultsWe identified 26 reported cases of C‐spine ORN following radiation for HNC. Of the four cases from our institution, two were treated with surgical management and two with conservative measures. Two patients were able to resume oral intake. The median time to diagnosis was 121.5 (range: 22–194) months after completion of radiation.ConclusionLate complications of radiation can be devastating, severely limiting functional status and quality of life. C‐spine ORN is related to total radiation dose and should be discussed with patients as a rare but serious side‐effect.

Agreement and comparative accuracy of instability criteria at discharge for predicting adverse events in patients with community-acquired pneumonia

ObjectiveFive definitions of clinical instability have been published to assess the appropriateness and safety of discharging patients hospitalised for pneumonia. This study aimed to quantify the level of agreement between...

Management of inoperable malignant bowel obstruction using the 4-step BOUNCED diet.

Malignant bowel obstruction (MBO) presents with multiple symptoms. The 4-step BOUNCED diet educates patients to self-manage oral intake according to symptoms. It includes clear fluids, thin liquids, purée and soft, sloppy foods, which are low in fibre. This mixed methods single-arm feasibility study aimed to establish if the diet could reduce MBO symptoms in patients with inoperable colorectal and gynaecological malignancies. The secondary objectives were to investigate if it was easily followed, improved quality of life (QOL) and reduced hospital admissions. Patients able to tolerate an oral diet with one or more symptoms (pain, bloating, early satiety, nausea and vomiting) were eligible. Following informed consent, an oncology dietitian took a diet history and determined which step of the diet they needed to follow using a detailed patient information leaflet. Patients remained on the trial for 28 days. Symptom and QOL data were collected on Days 1 and 28 using the Memorial Symptom Assessment Scale and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30) questionnaires. Thirty patients (24 female, 6 male) aged 18-85 years consented from March 2021 to November 2022. Twenty-six participants completed the trial and 25 found the diet very easy or easy to understand. There was a significant reduction in pain from 96% on Day 1 to 63% on Day 28 (p = 0.004). The mean increase of EORTC global health status/QOL was 23.5 points, 95% CI (12.4-32.5) (p ≤ 0.001). There was a significant difference between number of admissions (p = 0.018) and bed days (p = 0.004) in the 28 days prior to consent compared to the trial period. A modified consistency low-fibre diet is easily followed, may reduce symptoms of MBO, admissions to hospital and improve QOL.

Long-term treatment outcomes of complicated acute diverticulitis in immunocompromised patients

PurposeThe main aim of this study was to determine the short- and long-term outcomes of the non-operative management of acute left-sided complicated diverticulitis (ALCD) in severely immunocompromised patients (IMS group) and compare them with immunocompetent patients (IC group). The secondary aim was to assess the necessity of an elective surgery following a successful prior non-operative management in the IMS group after a non-operative management of the first episode of ALCD.MethodsPatients presented with their first episode of ALCD between 2012 and 2018 were retrospectively reviewed. Only severely immunosuppressed patients were considered for the analysis, including the following: long-term oral or intravenous steroid intake, current malignancy undergoing chemotherapy, chronic kidney disease on hemodialysis, or solid organ transplant with immunosuppressive medication. For each group, demographic data, severity of the episode, management decisions (conservative or operative), and short- and long-term outcomes were recorded and compared. A sub-analysis of patients with ALCD associating and abscess (modified Hinchey classification Ib/II) was performed.ResultsA total of 290 patients were included in the study: 50 among the IMS and 240 among the IC group. The rate of emergent surgery was higher in the IMS group (50.0% vs. 22.5%, p < 0.001) and was associated with increased morbidity (72.4% vs. 50.0%, p = 0.041) and mortality (24.1% vs. 4.3%, p = 0.003). The duration of the hospital stay was significantly longer in the IMS group (15 vs. 8 days, p < 0.001). The final stoma rate was significantly higher in the IMS group (82.1% vs. 22.9, p < 0.001), with a median follow-up of 51.4 months. A total of 141 patients presented ALCD with an abscess; 25 in the IMS and 116 in the IC group. There was a higher rate of surgical intervention among the IMS group as the initial treatment approach (24.0% vs. 5.2%, p = 0.002), even though the conservative treatment had a similar rate of success (81.3% vs. 92.0%, p = 0.178). The recurrence rate following a non-operative approach was similar (IMS: 31.2% vs. 35.4% in the IC group, p = 0.169). Furthermore, 81.2% of non-operatively managed IMS patients (13 out of 16) did not require a surgical intervention at the end of the follow-up, with similar findings in the IC group (78/96, 81.2%, p = 0.148).ConclusionMedical treatment of immunosuppressed patients during their first ALCD episode associated with an abscess is feasible, with a high success rate and results comparable with the IC group. Moreover, taking into account the readmission rates, the need for emergent surgery of the recurrence, and the perioperative mortality and morbidity in the IMS group, conservative management with no differed scheduled surgery seems to be a safe option in this subgroup of patients.

The long lost denture: a rare case of an acquired, non-malignant tracheo-oesophageal fistula

BackgroundIngested dental prosthesis are susceptible to impaction in the gastrointestinal tract due to their sharp edges, size and contour. Delays in presentation arise from the lack of clear history of ingestion and misdiagnosis occurs due to the radiolucency of denture material on plain radiography. An acquired, non-malignant tracheo-oesophageal fistula (TOF) may develop from a chronically impacted denture. Surgical management of a TOF secondary to denture is a challenging clinical problem that is rarely reported in the literature and no previous case reports have described the two-staged reconstruction approach that we present here.Case presentationWe report a case of a male in his early 60s who presented to an acute general hospital with symptoms ongoing for over one year of dysphagia, recurrent chest infections and weight loss. Barium swallow and computed tomography identified an ingested dental prosthesis (denture) that had caused a TOF. He was transferred to our specialist thoracic surgery unit where an attempt to remove the foreign body endoscopically was abandoned due to firm impaction and risk of further injury. The subsequent multi-disciplinary management of this complex case required a two-staged reconstruction approach. The first procedure involved extracting the foreign body, repairing the underlying defects with tracheal resection and anastomosis, and creating an oesophageal diversion with cervical oesophagostomy. The second procedure achieved continuity of the gastrointestinal tract with gastric pull-up and pharyngo-gastric anastomosis. Following rehabilitation, the patient was discharged on oral intake alongside percutaneous jejunostomy feeding.ConclusionsEarly recognition and removal of impacted dental prosthesis is essential to prevent morbidity and mortality. Delayed diagnosis can lead to acquired TOF with associated consequences such as recurrent pulmonary infection, mediastinitis and nutritional deficit. Challenges we encountered, such as failed attempts at endoscopic retrieval and the difficult dissection of fibrotic tissue, were directly due to the delayed identification of the denture. We highlight the importance of holding a high index of clinical suspicion of foreign body ingestion in dental prosthesis wearers who present with recurrent chest infections and ongoing dysphagia. We also promote the need for a collaborative multi-disciplinary approach in the surgical management of complex cases.

Long-term Assessment of Speech and Swallowing Function in Laryngopharyngeal Cancer Patients After J-Flap Reconstruction.

A novel J-shaped anterolateral thigh (ALT) flap reconstruction technique had been developed to simultaneously restore swallowing and speech functions in patients following total laryngopharyngectomy. This study aimed to assess the outcomes and surgical complications in patients who underwent J-flap reconstruction over time. Patients who underwent J-shaped ALT flap phonatory tube reconstruction were enrolled. Surgical morbidities and outcomes were evaluated every 3 months postsurgery for 12 months or death. Of the 36 patients, 13 underwent circumferential pharyngeal wall resection (circumferential defect group, CD group), and 23 underwent partial resection (partial defect group, PD group). After 12 months, 97% of the patients resumed oral intake without reliance on a nasogastric tube (NG tube), and 50% achieved fluent speech using the reconstructed phonatory tube. The CD group showed a higher rate of delayed healing (30.77% vs. 0%, p=0.005). The PD group exhibited significantly greater percentages of individuals consuming solid food at both the 3- and 12-month intervals than the CD group (81.0% vs. 23.1% and 78.9% vs. 40%, respectively). : This study examined the evolution of speech and swallowing functions over time following J-flap voice tube reconstruction. Regardless of whether the defect was circumferential or partial, using a J-shaped ALT flap phonatory tube effectively restored both speech and swallowing functions, offering long-lasting benefits.

Effects of Losartan and Fisetin on Microfracture-Mediated Cartilage Repair of Ankle Cartilage in a Rabbit Model.

Microfracture is one surgical treatment strategy for osteochondral lesions of the talus (OLTs) but results in fibrocartilage repair tissue, which has inferior mechanical properties to native hyaline cartilage. Biological regulation of microfracture has been suggested to improve the quality of cartilage repair in patients. To determine if administration of losartan, fisetin, or losartan and fisetin combined can enhance microfracture-mediated cartilage repair of OLTs in a rabbit model. Controlled laboratory study. Four-month-old female rabbits were divided into the following groups (8 rabbits per group): microfracture only (microfracture), microfracture plus losartan (losartan), microfracture plus fisetin (fisetin), and microfracture plus losartan and fisetin (losartan+fisetin). A 2.7-mm osteochondral defect and 4 microfracture holes were created in the talar dome cartilage. The rabbits were administered losartan (10 mg/kg/day), fisetin (20 mg/kg/day), or losartan and fisetin orally until euthanized 12 weeks after surgery. Gross evaluation, micro-computed tomography, histology, and immunohistochemistry evaluations of the osteochondral defects were performed as well as quantitative polymerase chain reaction of capsule tissue and enzyme-linked immunosorbent assay of serum. The losartan and fisetin groups had increased International Cartilage Regeneration & Joint Preservation Society macroscopic scores with improved cartilage repair and enhanced subchondral bone healing compared with the microfracture group. However, the losartan+fisetin group did not show a synergistic effect. O'Driscoll histology scores were higher in the losartan and fisetin groups compared with the microfracture group, while the losartan+fisetin group had a lower score than the losartan, fisetin, and microfracture groups. Collagen type 2 staining revealed organized chondrocytes in the losartan and fisetin groups, but the losartan+fisetin group did not show improvement when compared with other groups. Fisetin treatment decreased catalase and transforming growth factor-β1-activated kinase 1 expression in capsular tissue. Concomitant microfracture and biological regulation, using oral administration of either losartan or fisetin, may improve cartilage healing of OLTs; however, losartan and fisetin combined in the current drug administration regimen does not appear to provide synergistic effects. Oral intake of losartan or fisetin may result in beneficial effects on microfracture-mediated cartilage repair of OLTs.

Prophylactic Swallowing Exercises in Patients with Laryngeal Cancer Who Underwent Total Laryngectomy—A Randomized Trial

Objectives: This study aims to determine the efficacy of prophylactic swallowing exercises on swallowing function in patients undergoing total laryngectomy for laryngeal cancer. Methods: The design was a randomized controlled trial set in one tertiary care academic medical center. A total of 92 patients undergoing total laryngectomy for stages III and IV laryngeal cancer performed five targeted swallowing exercises for a period of three months after their surgery, starting two weeks after the surgery. Weekly swallowing therapy sessions were held with the patients in order to encourage adherence and proper technique. The controls received no preventive exercise and were referred for swallowing treatment following the surgery, as well as radiation therapy if necessary. The Functional Oral Intake Scale (FOIS) and the Performance Status Scale for Head and Neck Cancer Patients (PSS-H&amp;N) were used to measure swallowing function at the baseline, one week following the surgery, and three, six, nine, and twelve months following the surgery. Results: Right after the surgery, there were no statistically significant variations between the intervention and control groups in the FOIS scores (p value = 0.64), the Eating in Public subscale scores (p value = 1) and Normalcy of Diet subscale scores (p = 0.33) of the PSS-H&amp;N. The scores were significantly better among the intervention patients at months 3, 6, 9, and 12 for all the scores, with p values smaller than 0.000. Conclusions: Although not immediately following the surgery, the patients who engaged in prophylactic swallowing exercises showed improvements in their ability to swallow at 3, 6, 9, and 12 months following their procedure.

Face recognition-driven video game for dysphagia rehabilitation in stroke patients: a pilot randomized controlled trial

ObjectiveTo explore the feasibility and effectiveness of face recognition-driven video game (FR-VG) swallowing training for stroke patients with dysphagia. DesignA single-blind pilot randomized controlled trial. SettingA rehabilitation center. ParticipantsStroke patients with dysphagia (N=26). InterventionsParticipants in the intervention group were trained using FR-VG, while the control group used the conventional method (i.e. lip exercise, tongue exercise, and lower jaw exercise). The training was conducted five days a week over four weeks. Outcome MeasuresThe swallowing function and swallowing-related quality of life between the two groups were observed before and after the intervention. The acceptance of FR-VG in the intervention group and the adherence of the patients in the two groups after the intervention were analyzed. ResultsA total of 26 stroke patients with dysphagia were included. The results showed that after the intervention, both groups exhibited significant improvements in swallowing function and swallowing-related quality of life compared to the pre-intervention (p < 0.05). Patients in the intervention group demonstrated better swallowing function than the control group on the Gugging swallowing screen (p = 0.015) and functional oral intake scale (p = 0.004). The intervention group had high acceptance of the FR-VG training and had significantly better adherence compared to the control group (p = 0.032). ConclusionsFR-VG rehabilitation training can help improve swallowing function, swallowing-related quality of life, and training adherence in stroke patients with dysphagia. Patients have a high acceptance of FR-VG rehabilitation training, which can be used as an adjunctive method to conventional rehabilitation.

Modified Double-Tract Reconstruction in Gastrointestinal Reconstruction after Proximal Gastrectomy.

To determine the clinical efficacy and safety of modified double-channel anastomosis for digestive tract reconstruction in proximal gastrectomy for early gastric cancer (EGC). Case series. Place and Duration of the Study: Department of Gastrointestinal Surgery, Heji Hospital, Changzhi Medical College, Shanxi, China, from January to November 2022. Based on inclusion and exclusion criteria, this study included a total of 21 patients with oesophagogastric junction cancer or proximal gastric cancer who underwent laparoscopic proximal gastrectomy with modified double-channel anastomosis. After resection of the proximal stomach, the remaining stomach was shaped into a tube. The distal end of the oesophagus was anastomosed to the jejunum. The jejunum was anastomosed 10-15 cm from the oesophagojejunostomy site laterally to the anterior wall of the stomach 3 cm from the gastric remnant. General data including operative time, anastomosis time, intraoperative blood loss, time to oral intake, length of hospital stay, and postoperative complications were evaluated. Postoperative gastroscopy and gastrointestinal imaging were performed to assess the residual stomach motility and anti-reflux effect. All twenty-one patients underwent modified double-channel anastomosis. The mean operation time was 254 (211 - 297) minutes. Mean reconstruction time was 65 (60 - 70) minutes. A mean of 19 (15 - 29) lymph nodes were cleared. Mean intraoperative blood loss was 86 (78.5-105ml). Mean time to oral intake was 6 (5 - 6.5) days. Postoperatively, there were two cases of pulmonary infection. There was no occurrence of anastomotic stenosis, anastomotic bleeding, or leakage. Gastrointestinal contrast study at 6 months postoperatively revealed reduced gastrointestinal motility in three cases and good residual gastric motility observed in the remaining patients. Gastroscopic examination at 6 months postoperatively revealed only one case of reflux oesophagitis. Modified double-channel anastomosis for proximal gastrectomy is safe and feasible. It provides a good anti-reflux effect and gastric emptying function without increasing the risk of postoperative complications. Adenocarcinoma of the oesophagogastric junction, Upper gastric carcinoma, Proximal gastrectomy, Double-tract reconstruction.

Interventions and evaluation to improve oral health in patients with stroke: a scoping review

Objectives: This scoping review aimed to identify and analyze intervention strategies and assessment methods for oral hygiene management (OHM) and oral function management (OFM) in patients with stroke admitted to general wards, with the goal of providing directions for future research. Methods: We conducted a comprehensive literature search on studies published over the past 10 years across databases, including Cochrane, Embase, Medline, PubMed, and ProQuest. A total of 18 studies met the inclusion and exclusion criteria. Results: In the OHM studies (N=7), oral hygiene care was primarily provided by nurses, dental assistants, and nursing care aides. Oral hygiene was assessed using plaque and gingival bleeding indices with products such as electronic toothbrushes and mouth rinses. In the OFM studies (N=11), care was provided by speech-language pathologists, occupational therapists, and dental hygienists. Assessment tools included the Functional Oral Intake Scale, the PenetrationAspiration Scale, and Video Fluoroscopic Swallowing Studies. Conclusions: Improving the oral health of patients with stroke requires both hygiene and functional management. Therefore, it is necessary to develop a method that provides specialized oral care tailored to the hospitalization environment and the specific conditions of patients with stroke.

Clinical outcomes of edoxaban treatment without parenteral anticoagulation therapy for acute venous thromboembolism: Insight from the COMMAND VTE Registry-2

Abstract Background Direct oral anticoagulants (DOACs) including edoxaban are currently widely used all over the world. Each DOAC has a specific usage for the treatment and second prevention of venous thromboembolism (VTE) in the acute phase as well as in the chronic phase. Edoxaban is recommended to be administered after an appropriate initial treatment including parenteral anticoagulation therapy such as heparin. However, because of the rapid anticoagulant effect of edoxaban after oral intake, some physicians could administer edoxaban initially without parenteral anticoagulation therapy in the daily clinical practice, which has not been investigated so far. Purpose The purpose of this study is to explore the effectiveness and safety of edoxaban treatment for VTE without initial parenteral anticoagulation therapy. Methods The COMMAND VTE Registry-2 is a multicenter registry enrolling 5,197 consecutive acute symptomatic VTE patients among 31 centers in Japan between January 2015 and August 2020. Of those, 1842 patients received edoxaban including 848 patients with pulmonary embolism (PE) and 994 patients with deep vein thrombosis (DVT) alone, who were divided into 2 groups based on the presence or absence of initial parenteral anticoagulation therapy with heparin. Propensity score matching (PSM) was performed to adjust for potential baseline differences in the 2 groups. Results PE and DVT patients with initial parenteral anticoagulation therapy with heparin accounted for 623 (73.5%) and 244 (24.5%), respectively. After the PSM, 195 pairs of PE patients and 226 pairs of DVT patients were matched. In PE patients, those matched by the PSM were relatively mild cases compared to the unmatched cases (simplified PESI score=0: 25.9% vs. 12.4%, P&amp;lt;0.001). Whereas, in DVT patients, those matched were relatively severe cases compared to unmatched cases (isolated distal DVT: 24.1% vs. 71.0%, P&amp;lt;0.001). In the matched cohort, there was no significant difference in baseline characteristics between the 2 groups, including simplified PESI score in PE patients and thrombus location profile in DVT patients. In both PE patients and DVT patients, the 30-day cumulative incidences of all-cause death were not significantly different between the 2 groups (PE patients: 3.7% vs. 2.6%, P=0.56; DVT patients: 2.7% vs. 4.5%, P=0.31). Similarly, the 30-day cumulative incidences of recurrent VTE and major bleeding were not significantly different between the 2 groups (recurrent VTE: PE patients: 0% vs. 0.5%, P=0.32; DVT patients: 0.6% vs. 0.9%, P=0.99; major bleeding: PE patients: 1.5% vs. 3.2%, P=0.32; DVT patients: 2.2% vs. 3.2%, P=0.54) Conclusion In this current real-world VTE registry, a certain number of patients received edoxaban without parenteral anticoagulation therapy, who did not show a signal of worse clinical outcomes.

Neonatal hypoglycemia: A review with focus on practical challenges and recent updates on management

At birth, a neonate undergoes a transition from the continuous maternal supply of glucose to a variable and intermittent oral glucose intake, which is regulated by the interplay of hormones and metabolic enzyme induction. Because low plasma glucose concentrations are common in the neonatal period, it may be difficult to identify those who have pathologic hypoglycemia. Hence, it is important to formally evaluate such babies by drawing critical samples. Here, we present two cases of neonatal hypoglycemia where the presentation had some similarities, but the comprehensive evaluation revealed a varied etiological spectrum necessitating lifelong management. Through these case studies, authors discuss practical challenges in the diagnosis, management, and follow-up of neonates with endocrine causes of hypoglycemia.

Tongue Pressure and Grip Strength as Indicators of Persistent Dysphagia After Acute Stroke.

This study aimed to identify the independent predictors of postacute stroke dysphagia at discharge using sarcopenia-related parameters. This single-center prospective observational study assessed consecutive inpatients diagnosed with cerebral infarction or cerebral hemorrhage upon admission to the stroke unit. Tongue pressure, grip strength, and body composition were evaluated within 48h. Dysphagia was defined by a functional oral intake scale of ≤ 5. Patient characteristics were compared between non-dysphagia and dysphagia groups using Mann-Whitney or chi-squared tests. Logistic regression analysis was performed using age, sex, tongue pressure, grip strength, skeletal muscle mass index (SMI), and National Institutes of Health Stroke Scale (NIHSS) scores as explanatory variables, with dysphagia at discharge as the objective variable. A total of 302 patients (mean age: 69.4 ± 13.8 years, 67.5% male) were analyzed, with 64 having dysphagia at discharge (21.2%). The dysphagia group was significantly older (p<0.001), had higher NIHSS scores on admission (p<0.001), lower SMI (p = 0.002), lower grip strength (p<0.001), and lower tongue pressure (p<0.001) than the non-dysphagia group. Logistic regression revealed that age (OR: 1.042, p = 0.018), tongue pressure (OR: 0.954, p = 0.010), and grip strength (OR: 0.943, p = 0.048) on admission were independent predictors of dysphagia at discharge, while NIHSS scores (OR: 1.403, p = 0.106), sex, and SMI (OR: 1.403, p = 0.150) were not. Older age, reduced tongue pressure, and reduced grip strength are strong predictors of persistent poststroke dysphagia at discharge. Thus, muscle strength is a more valuable parameter than muscle mass in predicting persistent poststroke dysphagia.

Hemodynamic effects of vericiguat in symptomaticHFrEF patients: insights from right heart catheterization study

Abstract Background Vericiguat is recommended in the guidelines as Class IIb for patients with heart failure with reduced ejection fraction (HFrEF) who continue to have persistent symptoms despite receiving standard therapy. However, the precise effects of vericiguat on pulmonary and systemic hemodynamics and cardiac performance remain unclear. Purpose This study aimed to investigate the hemodynamic impact of vericiguat in 12 symptomatic HFrEF patients who experienced worsening HF despite receiving standard therapy with the four foundational heart failure medications, using right heart catheterization (RHC). Methods On day 1, RHC was performed via the right internal jugular vein and a balloon-tripped pulmonary artery thermodilution catheter was placed. On day 2 and 3, RHC data were measured at 15min before and 30min, 1hr, 2hr, 3hr and 5hr after intake of 2.5mg vericiguat. RHC data on day 2 and 3 were averaged and the catheter was removed after the RHC measurements on day 3. RHC was repeated on a median day of 105(quartiles 37,168). The acute hemodynamic effects of vericiguat were assessed using a comparison of six RHC measures, including pulmonary artery wedge pressure (PAWP), mean pulmonary artery pressure (MPAP), mean arterial blood pressures (MABP), pulmonary (PVR) and systemic vascular resistances (SVR) and cardiac index (CI), at 15minutes before intake of vericiguat 2.5mg with those at 30minutes to 5hours after that. The chronic hemodynamic effects of vericiguat were evaluated by comparing the six RHC measures on day 1 with those on day 105(37,168). Results Participant characteristics on day 1 were age 63.5(53.5,70)yrs., 16.7%(N=2) women, height 164.3(155,171.3)cm, weight 64.6(54.8,75.1)kg, body mass index 23.8(20,26.3), systolic 101.5(90.5,111.5)mmHg and diastolic blood pressures 60.2(53.5,65)mmHg, heart rate 65.5(56,72)bpm, New York Heart Association functional class Ⅱ 50%(N=6), Ⅲ 16.7%(N=2) and Ⅳ 33.3%(N=4), estimated glomerular filtration rate 44.5(34.5,53.5)mL/min/1.73m2, left-ventricular ejection fraction 19.9(14.5,24.5)% and diastolic diameter 68(60.5,72.5)mm, left-atrial diameter 45(36.5,50.5)mm and brain natriuretic peptide level 419(254,479)pg/mL. Oral intake of vericiguat 2.5mg decreased PAWP (11[7.5,15]mmHg) and MPAP (19.3[14.3,26.8]mmHg) before the intake to PAWP (9.3[6.8,14]mmHg) and MPAP (17.5[12.5,24]mmHg) at 30min after that (both P&amp;lt;0.05[crude P&amp;lt;0.0017])(Figure A) while comparable changes in MABP, PVR, SVR and CI and the other timepoints (all P&amp;gt;0.05[crude P&amp;lt;0.0017]). Vericiguat was titrated to 2.5mg 25% (N=3), 5mg 50% (N=6) and 10mg 25% (N=3) on day 105 (37,168), in which PAWP (9.5[6.5,12.5]mmHg) was decreased from PAWP (14.5[9.5,19.5]mmHg) on day 1 (P&amp;lt;0.05[crude P&amp;lt;0.0083])(Figure B) while comparable changes in the other RHC parameters (all P&amp;gt;0.05[crude P&amp;lt;0.0083]). Conclusions The consistent reduction in PAWP underscores vericiguat's well-tolerated nature and potential to enhance cardiac performance in patients with HFrEF.

Estimation of salt intake from urinalysis as a prognostic indicator in patients with heart failure

Abstract Background Restricting sodium consumption by reducing salt intake is crucial in heart failure management. The average salt intake in Japan is approximately 10 g/day, which is significantly higher than that in other countries. Therefore, the Japanese guidelines for heart failure recommend a target salt intake of less than 6 g/day. Purpose Excessive salt intake is a well-known risk factor for heart failure, but it has also been reported that excessive salt restriction does not affect clinical outcomes in patients with heart failure. Moreover, although previous reports have mainly focused on clinically stable patients with chronic heart failure, appropriate salt intake management in patients with unstable heart failure immediately after hospital discharge remains unexplored. Therefore, this study aimed to investigate the effect of salt intake management on patients with heart failure in the early post-discharge period. Methods The study was conducted between April 2015 and March 2023, and included 395 of 4,292 patients (mean age: 72 y; sex: 63% male) who were hospitalized owing to heart failure and whose salt intake was measured at early post-discharge. Salt intake was estimated via the Tanaka Method, using spot urine samples. The patients were divided into four groups based on the estimated salt intake: very low (&amp;lt; 4 g/day) (n = 24), low (≥ 4 and &amp;lt; 7 g/day) (n = 109), high (≥ 7 and &amp;lt; 10 g/day) (n = 149), and very high (≥ 10 g/day) (n = 113). The primary endpoint was all-cause rehospitalization within 1 year of discharge. Results During a median follow-up period of 303 days, 153 rehospitalization occurred. 96 were heart failure rehospitalization; others included infection, arrhythmia, dehydration etc. Spline curve analysis for estimated salt intake and rehospitalization (Fig. 1) showed a significant nonlinear curve (P = 0.017). Cox regression analysis (Fig. 2) revealed a significantly higher number of rehospitalization in the very low group (hazard ratio [HR]: 2.29; 95% confidence interval [CI]: 1.24–4.25; P = 0.009), compared with the low group, and a similar trend was also observed in the very high group (HR: 1.51; 95% CI: 0.99–2.31; P = 0.056). Subgroup analysis (Fig. 3) showed that the impact of estimated salt intake on rehospitalization, as represented by a U-shaped curve, was more pronounced in patients who were not treated with loop or thiazide diuretics. Conclusion The results of this study suggest that both excessive salt intake and excessive restriction may increase the risk of rehospitalization in patients with heart failure during the early post-discharge period. Additionally, the results indicate that estimation of salt intake using the Tanaka method may be particularly useful for patients not undergoing diuretic treatment. Conversely, patients with very low salt intake, potentially indicative of inadequate oral intake due to an impaired general condition, may require careful follow-up.

Transcatheter closure of atrial septal defect (ASD) in adult and paediatric population without transoesophageal echocardiography/general anaesthesia

Abstract Background Transcatheter device closure is the preferred therapeutic option for ostium secundum atrial septal defect(OS-ASD). Standard practice is to perform it under transoesophageal echocardiography(TEE) guidance. However, TEE is performed under general anaesthesia (GA) and leads to increases in cost, procedural duration, ICU stay, total hospital stays, risk of oesophageal injury and complications of GA. Transthoracic echocardiography(TTE) is an excellent alternative and prior studies have shown it to be a safe alternative in paediatric population. In current study we analysed safety and efficacy of TTE-guided device closure of OS-ASD in all comer population irrespective of age, weight, defect size. Methods The study enrolled all patients who underwent device closure of OS-ASD between March 2017 and December 2023. All procedures were performed under LA for adults and conscious sedation for children. The device was placed under fluoroscopy guidance and position were confirmed on TTE. Procedural success, device, defect size ratio, procedural time, fluoroscopy time, complications, intensive care unit/hospital stay duration were analysed and compared with our own experience of 125 patients with TEE-guided closures before switching to complete TTE-guided procedure(before 2017). Results 340 patients underwent TTE-guided device closure of ASD. Procedure success was 97.4% with acceptable risk of major complications. Three(0.8%) had embolization into pulmonary artery, successfully operated surgically. Two had tamponade requiring drainage. In 9 patients, device could not be deployed despite multiple attempts and approaches. All of these had defect size of &amp;gt; 34mm and deficient IVC rim along with shorter (other than aortic) rim. Findings were compared with our own previous experience of TOE guided closure (practised before 2017). Compared to TOE group, TTE group had significantly lower total procedural duration (75±4 vs. 28 ±1 min; p &amp;lt; 0.01), intensive care unit stay (24±10 vs. 10.5±1 h; p &amp;lt; 0.01), and hospital (48±12 vs. 25.5±4h; p &amp;lt; 0.01) stay duration. Fluoroscopic time was similar in both. There was no mortality in either group. Major complications were comparable, TTE-guided group had less post-procedure complications of vomiting and headache. Additional findings of less pre-procedure fasting duration and early commencement of post procedure oral intake were noted in TTE group. Conclusion TTE-guided device closure of OS-ASD is a safe and feasible in all-comer population in experienced hands. It can definitely negate the use of TEE except in very poor echo window. The added advantages include utilization of physiological variations in PV/LV pressure during cough, Valsalva manoeuvres in awake patients. It definitely reduces the procedural duration, cost of procedure and dependence on GA and trained transoesophageal echocardiographer.

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.

The post ICU trajectory: Post acute and post ICU nutritional care

ICU survivors are growing but a persistent physical and mental disability may occur. The patients discharged from ICU are frequently malnourished and their medical nutritional support is impaired by oral intake limitation due to respiratory support such as non invasive ventilation or high flow nasal cannula oxygen therapy, dysphagia and difficulties to determine energy and protein targets. ICU acquired weakness must be recognized and could be minimized by better energy intake determined by indirect calorimetry, optimal protein intake and physical activity. Early physical activity has become a pivotal element of the improvement of the physical and cognitive condition in the post ICU.