Oropharyngeal Secretions Research Articles

Risk factors for aspiration pneumonia in geriatric patients with dementia and prolonged dysphagia

Background: Dysphagia is an obvious risk factor for aspiration pneumonia in old age patients, especially those who are having dementia. The study aimed to determine the risk factors responsible for the development of aspiration pneumonia in geriatric patients with dementia and dysphagia in order to enable the development of a particular preventive program accordingly. Patients and Methods: The study recruited 98 patients diagnosed with dementia and dysphagia classified into patient and control groups according to the presence of aspiration pneumonia. Data collected included demographic and medical assessment data. Dementia severity was assessed with the clinical dementia rating (CDR) scale. According to the results of bedside clinical swallowing assessment and the Fiberoptic endoscopic evaluation of swallowing (FEES) results, the severity of swallowing impairment was determined by using the functional oral intake scale (FOIS), oropharyngeal secretion collection, penetration aspiration scale (PAS), and pharyngeal stasis scale. Results: Patients with aspiration pneumonia were of longer hospital stay duration, with more percentage of malnutrition, recent stroke, and comorbidities with RR (risk ratio) of 3.22, 1.59 and 3.8 respectively. FEES outcome revealed significant differences between the two groups in all measures of dysphagia severity. The risk factors of aspiration pneumonia were severe penetration aspiration, combined tube, and oral feeding, malnutrition, comorbidities, and severe dementia. Conclusion: The predictive risk factors for the development of aspiration pneumonia in dementia patients with dysphagia were malnutrition, comorbidities, severe dementia, and severe aspiration scale and tube feeding. These findings should be integrated into clinical practice to prevent aspiration pneumonia.

Relationship Between Obesity and Ventilator-Associated Pneumonia: A Post Hoc Analysis of the NUTRIREA2 Trial

Patients with obesity are at higher risk for community-acquired and nosocomial infections. However, no study has specifically evaluated the relationship between obesity and ventilator-associated pneumonia (VAP). Is obesity associated with an increased incidence of VAP? This study was a post hoc analysis of the Impact of Early Enteral vs Parenteral Nutrition on Mortality in Patients Requiring Mechanical Ventilation and Catecholamines (NUTRIREA2) open-label, randomized controlled trial performed in 44 French ICUs. Adults receiving invasive mechanical ventilation and vasopressor support for shock and parenteral nutrition or enteral nutrition were included. Obesity was defined as BMI≥ 30kg/m2 at ICU admission. VAP diagnosis was adjudicated by an independent blinded committee, based on all available clinical, radiologic, and microbiologic data. Only first VAP episodes were taken into account. Incidence of VAP was analyzed by using the Fine and Gray model, with extubation and death as competing risks. A total of 699 (30%) of the 2,325 included patients had obesity; 224 first VAP episodes were diagnosed (60 and 164 in obese and nonobese groups, respectively). The incidence of VAP at day 28 was 8.6%vs10.1%in the two groups (hazard ratio, 0.85; 95%CI 0.63-1.14; P= .26). After adjustment on sex, McCabe score, age, antiulcer treatment, and Sequential Organ Failure Assessment at randomization, the incidence of VAP remained nonsignificant between obese and nonobese patients (hazard ratio, 0.893; 95%CI, 0.66-1.2; P= .46). Although no significant difference was found in duration of mechanical ventilation and ICU length of stay, 90-day mortality was significantly lower in obese than in nonobese patients (272 of 692 [39.3%] patients vs718 of 1,605 [44.7%]; P= .02). In a subgroup of patients (n= 123) with available pepsin and alpha-amylase measurements, no significant difference was found in rate of abundant microaspiration of gastric contents, or oropharyngeal secretions between obese and nonobese patients. Our results suggest that obesity has no significant impact on the incidence of VAP.

Is COPD associated with increased risk for microaspiration in intubated critically ill patients?

BackgroundAlthough COPD patients are at higher risk for aspiration when breathing spontaneously, no information is available on the risk for microaspiration in invasively ventilated COPD patients. The aim of our study was to determine the relationship between COPD and abundant microaspiration in intubated critically ill patients.MethodsThis was a retrospective analysis of prospectively collected data, provided by 3 randomized controlled trials on microaspiration in critically ill patients receiving invasive mechanical ventilation for more than 48 h. Abundant microaspiration was defined as the presence of pepsin and or alpha-amylase at significant levels in tracheal aspirates. In all study patients, pepsin and alpha-amylase were quantitatively measured in all tracheal aspirates collected during a 48-h period. COPD was defined using spirometry criteria.ResultsAmong the 515 included patients, 70 (14%) had proven COPD. Pepsin and alpha-amylase were quantitatively measured in 3873 and 3764 tracheal aspirates, respectively. No significant difference was found in abundant microaspiration rate between COPD and non-COPD patients (62 of 70 patients (89%) vs 366 of 445 (82%) patients, p = 0.25). Similarly, no significant difference was found in abundant microaspiration of gastric contents (53% vs 45%, p = 0.28), oropharyngeal secretions (71% vs 71%, p = 0.99), or VAP (19% vs 22%, p = 0.65) rates between the two groups. No significant difference was found between COPD and non-COPD patients in duration of mechanical ventilation, ICU length of stay, or ICU mortality.ConclusionsOur results suggest that COPD is not associated with increased risk for abundant microaspiration in intubated critically ill patients.

New aspects of rapid sequence induction including treatment of pulmonary aspiration

Pulmonary aspiration of solid components leads to displacement of the tracheobronchial tree, the aspiration of acidic gastric juices to chemical pneumonitis (Mendelson's syndrome) and the aspiration of oropharyngeal secretions or gastrointestinal pathogens to aspiration pneumonia. Principally, pulmonary aspiration can occur at any stage of anesthesia. In the clinical routine the aim must therefore be to identify those patients who have an increased risk of aspiration. When this is successful, measures can be taken to reduce the risk; these can be regional anaesthesia or the performance of general anaesthesia as rapid sequence induction (RSI). If severe pulmonary aspiration occurs despite all preventive measures, mostly during induction of anaesthesia, extensive experience and rapid action are necessary. This can only be achieved if the induction to RSI is performed by three persons with supervision of the trainee anaesthetist by a consultant anaesthetist.

Microscopic imaging of bronchoalveolar fluids of COVID-19 positive intubated patients reveals the different level of SARS-CoV-2 infection on oral squamosal epithelial cells

COVID-19 pandemic has been a global health emergency due to its association with severe pneumonia and high rate of mortality. In the current study, we reported the direct evidence for the variable level of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus infection on several types of oral epithelial cells isolated from the aspirated oropharyngeal and bronchoalveolar secretions of severely infected and intubated patients using cytology, confocal based immunofluorescence imaging (IF), scanning electron microscope (SEM) and transmission electron microscopic (TEM) studies. Cytological analysis showed the presence of keratinised and non-keratinised oral epithelial cells with viral inclusion bodies in stratum granulosum and intermedium cells. IF imaging using SARS-CoV-2 spike protein specific antibody confirmed the presence of virus inside the stratum spinosum/granulosum (keratinised) and stratum intermedium/superficial cells (non-keratinised). No SARS-CoV-2 viruses were seen in stratum corneum cells. SEM analysis also confirms the absence of virus like structure on stratum corneum surface while viruses like structure were seen on the stratum spinosum/granulosum/stratum/intermedium and stratum superficial cells. This advanced microscopic study confirms directly that the virus tends to infect and multiply in the metabolically active or sub-basal cells of oral epithelium and absent in the inactive keratinised stratum corneum from shedding zones of oral mucosa.

Human Papillomavirus in Sinonasal Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis.

Simple SummaryThe causative role of human papillomavirus (HPV) in sinonasal squamous cell carcinoma (SNSCC) remains unclear and is hindered by small studies using variable HPV detection techniques. This meta-analysis aims to provide an updated overview of HPV prevalence in SNSCC stratified by detection method, anatomic subsite, and geographic region. From 60 eligible studies, an overall HPV prevalence was estimated at 26%. When stratified by detection method, HPV prevalence was lower when using multiple substrate testing compared to single substrate testing. Anatomic subsite HPV prevalence was higher in subsites with high exposure to secretion flow compared to low exposure subsites. HPV prevalence in SNSCC followed the global distribution of HPV+ oropharyngeal squamous cell carcinoma. Taken together, this meta-analysis further supports a role for HPV in a subset of SNSCCs.Human papillomavirus (HPV) drives tumorigenesis in a subset of oropharyngeal squamous cell carcinomas (OPSCC) and is increasing in prevalence across the world. Mounting evidence suggests HPV is also involved in a subset of sinonasal squamous cell carcinomas (SNSCC), yet small sample sizes and variability of HPV detection techniques in existing literature hinder definitive conclusions. A systematic review was performed by searching literature through March 29th 2020 using PubMed, Embase, and Web of Science Core Collection databases. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed by two authors independently. A meta-analysis was performed using the random-effects model. Sixty studies (n = 1449) were eligible for statistical analysis estimating an overall HPV prevalence of 25.5% (95% CI 20.7–31.0). When stratified by HPV detection method, prevalence with multiple substrate testing (20.5%, 95% CI 14.5–28.2) was lower than with single substrate testing (31.7%, 95% CI 23.6–41.1), highest in high-exposure anatomic subsites (nasal cavity and ethmoids) (37.6%, 95% CI 26.5–50.2) vs. low-exposure (15.1%, 95% CI 7.3–28.6) and highest in high HPV+ OPSCC prevalence geographic regions (North America) (30.9%, 95% CI 21.9–41.5) vs. low (Africa) (13.1, 95% CI 6.5–24.5)). While small sample sizes and variability in data cloud firm conclusions, here, we provide a new reference point prevalence for HPV in SNSCC along with orthogonal data supporting a causative role for virally driven tumorigenesis, including that HPV is more commonly found in sinonasal subsites with increased exposure to refluxed oropharyngeal secretions and in geographic regions where HPV+ OPSCC is more prevalent.

Transesophageal echocardiography-associated tracheal microaspiration and ventilator-associated pneumonia in intubated critically ill patients: a multicenter prospective observational study

BackgroundMicroaspiration of gastric and oropharyngeal secretions is the main causative mechanism of ventilator-associated pneumonia (VAP). Transesophageal echocardiography (TEE) is a routine investigation tool in intensive care unit and could enhance microaspiration. This study aimed at evaluating the impact of TEE on microaspiration and VAP in intubated critically ill adult patients.MethodsIt is a four-center prospective observational study. Microaspiration biomarkers (pepsin and salivary amylase) concentrations were quantitatively measured on tracheal aspirates drawn before and after TEE. The primary endpoint was the percentage of patients with TEE-associated microaspiration, defined as: (1) ≥ 50% increase in biomarker concentration between pre-TEE and post-TEE samples, and (2) a significant post-TEE biomarker concentration (> 200 μg/L for pepsin and/or > 1685 IU/L for salivary amylase). Secondary endpoints included the development of VAP within three days after TEE and the evolution of tracheal cuff pressure throughout TEE.ResultsWe enrolled 100 patients (35 females), with a median age of 64 (53–72) years. Of the 74 patients analyzed for biomarkers, 17 (23%) got TEE-associated microaspiration. However, overall, pepsin and salivary amylase levels were not significantly different between before and after TEE, with wide interindividual variability. VAP occurred in 19 patients (19%) within 3 days following TEE. VAP patients had a larger tracheal tube size and endured more attempts of TEE probe introduction than their counterparts but showed similar aspiration biomarker concentrations. TEE induced an increase in tracheal cuff pressure, especially during insertion and removal of the probe.ConclusionsWe could not find any association between TEE-associated microaspiration and the development of VAP during the three days following TEE in intubated critically ill patients. However, our study cannot formally rule out a role for TEE because of the high rate of VAP observed after TEE and the limitations of our methods.

ACTINOMYCOSIS MIMICKING LUNG CANCER: A CASE REPORT

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary actinomycosis is a rare disease that can be challenging to diagnose and is associated with multiple risk factors such as poor oral hygiene, alcoholism, and chronic underlying lung diseases. Actinomycosis can often be misdiagnosed as lung abscess, tuberculosis, or malignancy with radiologic findings that might be misleading. Here we present a case with initial chest CT finding concerning neoplasm but diagnosed as pulmonary actinomycosis on further evaluation. CASE PRESENTATION: 55-year-old male with past medical history of HTN presented with right sided upper back pain and 6 pounds of unintentional weight for 4 weeks. He did not report any symptoms of cough, hemoptysis, shortness of breath, or chest pain. He was a heavy smoker with 45 pack years of smoking and a history of chronic alcoholism with 30 ml of 3-4 vodka shots twice a week for the last 30 years. Patient’s laboratory studies were pertinent for WBC count of 19.6 X 10 3. CT of the chest showed 4.6 x 3.4 cm thick-walled cavitary mass in the right lower lobe concerning for neoplasm with the extension of mass to the right paravertebral region and diffuse right pleural metastases, pathologic lymphadenopathy, and trace right pleural effusion. He underwent BAL with bronchial brushing which showed significant endobronchial inflammation. Microbiological examination of samples obtained from BAL showed Gram-positive filamentous bacteria. Treatment was given with IV clindamycin and he was discharged home on PO Clindamycin for 4 weeks with a repeat chest X-ray in 2 weeks. He was readmitted after 2 weeks with worsening shortness of breath, was found to be hypoxic with SpO2 of 65% on RA and RR of 40/min, he was intubated. Repeat CT chest showed diffuse right pleural thickening and ground-glass opacity of the right upper and middle lung. He was started on broad-spectrum antibiotics with IV vancomycin, IV Zosyn and IV Penicillin but he remained critically ill and a decision was made by the family to withdraw care. The patient was terminally extubated. DISCUSSION: Actinomycosis is a chronic, granulomatous disease mostly caused by A. israelii which is a normal commensal of human oropharynx, GI tract, and female genitalia. Pulmonary actinomycosis accounts for 15% of total disease burden and is usually caused by aspiration of the oropharyngeal or gastrointestinal secretion especially in patients with chronic alcoholism and poor dentition, facial or dental trauma1. CONCLUSIONS: Diagnosis of actinomycosis can be challenging given that presentation and radiologic findings might resemble various other conditions. Pulmonary actinomycosis if diagnosed and treated early has an excellent prognosis, the clinician should have high levels of suspicion in patients with risk factors such as chronic alcoholism, poor dental hygiene, prompting further evaluation with radiology and confirmation of diagnosis with histology and microbiology. Reference #1: 1. Mabeza GF, Macfarlane J. Pulmonary actinomycosis. Eur Respir J. 2003;21(3):545-551. doi:10.1183/09031936.03.00089103 DISCLOSURES: No relevant relationships by Sotirios Doukas, source=Web Response No relevant relationships by Leena Kavali, source=Web Response No relevant relationships by Shashank Nuguru, source=Web Response

Anti-inflammatory mechanisms in the action of the antiseptic drug lizak (clinical and immunological study)

Topicality: In recent years, ideas about the mechanisms of action of a local lysozyme containing antiseptic have been significantly expanded. Data on the availability of antiviral drugs and a positive effect on regeneration processes have been obtained. Objective: In order to further study the properties of the drug, its effect on the mechanisms of inflammation in a clinical setting and model of inflammation in an animal experiment was investigated. Material and methods: Clinical and immunological studies were conducted in 22 children aged 9-12 years, of which 10 people represented a group of healthy donors. 12 people with exacerbation of chronic catarrhal pharyngitis received the drug Lizak in the form of monotherapy according to the instructions. The oropharyngeal secretion was studied, where the pro-inflammatory cytokine interleukin-1β (Cytokine, RF), lactoferrin (Vector Best, RF), as well as the macrophage inflammatory protein MIP-1b (Hucaltbiotecknolgy, Netherlands) were determined by the ELISA method. As an analyzer, a Lab line reader (Austria) was used. The studies were carried out at two points: before the start of therapy and a day after its completion. Under the experimental conditions, a model of caraginan edema of rat paws was used, which, prior to the introduction of phlogogen, received per os drug lizak. The degree of edema was determined using a special installation with an installed micrometer for measuring the thickness of the feet in the time interval from 0 to 24 hours. In addition, the levels of proinflammatory cytokine interleukin-1β and anti-inflammatory interleukin-10 were determined in the blood serum of animals at the same time intervals. Statistics were carried out using the ‘t’ –Student criterion. Results: Under monotherapy with the drug Lysak in children with acute pharyngitis, a decrease in the content of proinflammatory factors, interleukin-1β and Mip-1b, in the oropharyngeal secretion is shown. When studying the effect of the drug on the development of aseptic inflammation (stage of exudation) in the foot of rats, it was found that the drug Lizak had an inhibitory effect on the development of edema in the range of 1-4 hours, after which its effect was not detected (24 hours). In the control group and the “pure” control group, inflammatory edema was detected compared to the initial level (p=0.02) at 4 hours and was not detected after 24 hours. The drug Lysac has the ability to inhibit the development of aseptic local inflammation in the initial stages of its development. Confirmation of the systemic nature of the action of the drug is to reduce the level of pro-inflammatory cytokine-interleukin-1 in the blood serum of animals by 4 hours from the onset of the inflammatory process. Conclusions: The drug Lizak actively reduces the levels of pro-inflammatory cytokines both systemically and with local use and has a pronounced decongestant effect.

The importance of oral hygiene for patients on mechanical ventilation.

The importance of oral hygiene for patients on mechanical ventilation.

The Triangular Relationship Among Swallowing Disorders, Aspiration Pneumonia, and Poor Oral Hygiene

Persons with dysphagia have difficulties chewing and swallowing food because of functional, structural, or psychological reasons. Dysphagia may cause choking or the inhalation of food into the trachea and lungs. Patients with dysphagia often induce the coughing reflex when drinking water and brushing teeth and tend to suffer from gum bleeding. As a result, their caregivers tend to reduce the frequency of or discontinue teeth brushing, which promotes the spread of periodontal disease, dental caries, and oropharyngeal secretions colonizing in the oral cavity or throat. When a patient suffers a choking attack or aspiration, bacteria is inhaled into the trachea and lungs, causing aspiration pneumonia. Furthermore, patients with choking issues are often be fitted with nasogastric tubes to facilitate the delivery of nutrients and water. Long-term use of nasogastric tubes also significantly increases the risk of aspiration pneumonia. Adjusting eating posture, improving food texture, conducting swallowing rehabilitation, providing training, and practicing proper oral care are an effective approach to preventing the onset of chewing and swallowing disorders and aspiration pneumonia.

Guidance for resumption of routine electrodiagnostic testing during the COVID-19 pandemic.

As the world accommodates to the coronavirus disease 2019 (COVID‐19) pandemic, routine in‐person medical services are resuming. The resumption of non urgent electrodiagnostic (EDX) testing faces unique challenges due to the long duration of the procedure and direct close contact with patients, including studies with risk of exposure to oropharyngeal secretions. We provide consensus guidance for resumption of EDX testing, addressing scheduling, patient arrival and registration, use of personal protective equipment, COVID‐19 screening and testing, the performance of EDX testing in outpatient and inpatient settings, cleaning and maintenance of the EDX equipment and laboratory, balancing trainee safety and training requirements, and patient care issues. These are broad recommendations that need to be adapted to local COVID‐19 risks, institutional guidelines and policies, and changing federal, state, and local regulations, and to changes in the pandemic over time.

Oropharyngeal Secretion as Alternative for SARS-CoV-2 Detection

This study aimed to determine if sampling of oropharyngeal secretions (OSs) helps improves detection of SARS-CoV-2 RNA by nucleic acid amplification testing of potential patients with COVID-19. The first prospective study consisted of 75 patients with COVID-19 who were ready for discharge and who had 2 consecutive negative results per nucleic acid amplification testing (NAAT) of viral samples retrieved with nasopharyngeal swabs (NPSs). Because of detection of potential false negatives in that cohort, the NAAT results of paired OS and NPS samples from 50 additional recruits with COVID-19 during their recovery stage were used in a second prospective study to compare the diagnostic values of the 2 viral RNA sampling methods. For identification of the frequency of inconsistency between the sampling methods, the McNemar’s test was used for difference analysis and the kappa statistic for consistency analysis. OSs obtained from 2 of the 75 participants in the first study yielded positive results for SARS-CoV-2 nucleic acid. Both were male and aged >60 y. Subsequent chemiluminescence enzyme immunoassays indicated that they were positive for the SARS-CoV-2 IgM and IgG antibodies. For parallel NAAT of OS and NPS samples in the second study, McNemar’s test indicated that the difference between the frequencies of inconsistent parts of OS and NPS was statistically significant (P = 0.021). Cohen’s kappa coefficient for OS and NPS was 0.244, which is indicative of fair consistency. The NPS test has a risk of sending home more patients (59%) who still have the infection, while the OS test will make such an error in fewer patients (14%). Although OS sampling improves the accuracy of SARS-CoV-2 nucleic acid testing, it has to be emphasized that this conclusion is based on a very small sample size. Detection of viral RNA from a patient’s secretions is not confirmative of viral infectivity.

Death by cat bite: Pasteurella multocida: Autopsy findings and review of the literature

Pasteurella multocida, a gram-negative bacillus, is present in the oropharyngeal secretions of livestock, wild animals, and domesticated pets and can cause infection in humans. The most common route of entry has been shown to be via an animal bite, but a significant portion of cases of human infection lack evidence of such a wound. Review of the literature reveals that patients with a history of an animal bite tend to have a less aggressive clinical course than patients without an animal source of infection. We present a case, however, of Pasteurella multocida bacteremia which resulted in the death of an immunocompromised 80-year old woman in which the route of infection was found at autopsy to be a cat bite. This case highlights the importance of educating patients, particularly those with underlying immunocompromised conditions, of the possible lethal complications that can result from animal inflicted wounds and the importance of seeking medical assistance should a bite occur.

COVID-19 and gastrointestinal endoscopies: Current insights and emergent strategies.

A new coronavirus emerged in December 2019 in Wuhan city of China, named as the severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2), and the disease was called coronavirus disease‐2019 (COVID‐19). The infection due to this virus spread exponentially throughout China and then spread across >205 nations, including the United States (US). Gastrointestinal (GI) endoscopies are routinely performed in the US and globally. Previous reports of isolated infection outbreaks were reported with endoscopes acting as potential vectors. While multidrug‐resistant organisms have been reported to be spread by endoscopes, few cases of viruses such as hepatitis B and C are noted in the literature. COVID‐19 is predominately spread by droplet transmission, although recent evidence has showed that shedding in feces and feco‐oral transmission could also be possible. It is unclear if COVID‐19 could be transmitted by endoscopes, but it could theoretically happen due to contact with mucous membranes and body fluids. GI endoscopies involve close contact with oral and colonic contents exposing endoscopy staff to respiratory and oropharyngeal secretions. This can increase the risk of contamination and contribute to virus transmission. Given these risks, all major GI societies have called for rescheduling elective non‐urgent procedures and perform only emergent or urgent procedures based on the clinical need. Furthermore, pre‐screening of all individuals prior to endoscopy is recommended. This article focuses on the risk of COVID‐19 transmission by GI shedding, the potential role of endoscopes as a vector of this novel virus, including transmission during endoscopies, and prevention strategies including deferral of elective non‐urgent endoscopy procedures.

US CDC Real-Time Reverse Transcription PCR Panel for Detection of Severe Acute Respiratory Syndrome Coronavirus 2.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified as the etiologic agent associated with coronavirus disease, which emerged in late 2019. In response, we developed a diagnostic panel consisting of 3 real-time reverse transcription PCR assays targeting the nucleocapsid gene and evaluated use of these assays for detecting SARS-CoV-2 infection. All assays demonstrated a linear dynamic range of 8 orders of magnitude and an analytical limit of detection of 5 copies/reaction of quantified RNA transcripts and 1 x 10−1.5 50% tissue culture infectious dose/mL of cell-cultured SARS-CoV-2. All assays performed comparably with nasopharyngeal and oropharyngeal secretions, serum, and fecal specimens spiked with cultured virus. We obtained no false-positive amplifications with other human coronaviruses or common respiratory pathogens. Results from all 3 assays were highly correlated during clinical specimen testing. On February 4, 2020, the Food and Drug Administration issued an Emergency Use Authorization to enable emergency use of this panel.

The genetic and clinical characteristics of aromatic L-amino acid decarboxylase deficiency in mainland China

Aromatic L-amino acid decarboxylase deficiency (AADCD) is a rare neurotransmitter metabolic disorder caused by DDC gene mutations, which leads to the metabolic disturbance of dopamine and serotonin. Most of the reported cases came from Taiwan China, but patients from mainland China were seldomly reported. The current study was the largest AADCD patient cohort from mainland China. Twenty-three patients with clinical features of AADCD and DDC gene variants were recruited. A total of 16 DDC variants were identified in this study, of which four variants (c.2T>C, c.277A>G, c.1021+1G>A, c.565G>T) were never reported previously. The intronic variant c.714+4A>T was the most common one, with an allele frequency of 45.7%. And patients carried this intronic variant presented with severe clinical manifestations, all of whom were bedridden. In this study, the average onset age was 3.61 ± 1.28 months and the average age of diagnosis was 12.91 ± 5.62 months. Early onset hypotonia, oculogyric crises, and autonomic symptoms such as excessive sweating, nasal congestion and profuse nasal, and oropharyngeal secretions, were common in our patients. Eighteen patients (78.3%) got various degree of improvement after using pyridoxine monotherapy or different combination of pyridoxine, dopamine agonists, and monoamine oxidase (MAO) inhibitors.

Evaluation of prevention of ventilator-associated infections in four Australian intensive care units.

Effective approaches to practice improvement require development of tailored interventions in collaboration with knowledge users. To explore critical care nurses' knowledge and adherence to best practice guidelines for management of patients with an artificial airway to minimise development of ventilator-associated pneumonia. A cross-sectional study was undertaken across four intensive care units that involved three phases: (1) survey of critical care nurses regarding their current practice; (2) observation of respiratory care delivery; and (3) chart audit. Key care processes evaluated were: (1) technique and adherence to standard precautions when performing endotracheal suction, cuff pressure checks and extubation; and (2) frequency of endotracheal suctioning and mouth care. Observational and chart audit data on the provision and documentation of respiratory care were collected for 36 nurse/patient dyads. Forty-six nurses were surveyed and the majority responded that endotracheal suctioning and mouth care should be performed 'as required' or every 2 hours (h). During observations of practice, no patient received mouth care every 2 h, nor had documentation of such. Inconsistent adherence to standard precautions and hand hygiene during respiratory care provision was observed. Chart audit indicated that nurses varied in the frequency of suctioning consistent with documented clinical assessment findings. Although nurses had good knowledge for the management of artificial airways, this was not consistently translated into practice. Gaps were identified in relation to respiratory related infection prevention, the prevention of micro-aspiration of oropharyngeal secretions and in the provision of mouth care.

Various surgical techniques influence on the local immunity state in the postoperative period in children's tonsils hypertrophy

Topicality: There are many conflicting opinions in the literature regarding the best surgical technique for the treatment of OSAS related to palatine hypertrophy – partial (tonsillotomy) or complete (tonsillectomy) removal of lymphoid tissue of the tonsils. Also, there are many opinions about the use of a variety of traditional and modern surgical instruments to reduce the volume of the tonsils, including using a laser, a radiofrequency knife, an ultrasonic knife, a shaver (microdebrider) and a coblator. Aim of the study: The aim of the study was to compare the surgical methods effectiveness of tonsils hypertrophy treatment which the based on the restoration of the mucous membrane's local immunity function. Materials and methods: Children who undergoing surgical treatment for palatine tonsils hypertrophy 2-3 degrees according to the Brodsky classification and the presence of OSAS took part in the study. The patients were randomized and divided into four comparison groups using different surgical techniques. The first group, which used the surgical technique of classical tonsillotomy (TT) included 28 patients, the second group, which used the surgical technique of intracapsular shavertonsillotomy(STT) included 18 patients, the third group, which used surgical technique of intracapsular coblationtonsillotomy (CTT), and groups which using surgical technique of tonsilloplasty included 12 patients (TP). Determined the state of local immunity before surgery and 1 month after surgery by concentration levels of sIgA, α-IFN, IL-1β, TGF-1β and general-purpose immune complexes. Results: Recovery of the concentration of the major marker of local immunity sIgA occurs significantly (P<0.05) faster when using the surgical technique of CTT and STT. Recovery of the concentration of the major marker of antiviral immunity α-IFN occurs significantly (P <0.05) faster when using the surgical technique of CTT, STT and TP. Recovery of the concentration of the anti-inflammatory cytokine IL-1β occurs significantly (P<0.05) faster with the use of the surgical technique of STT and TP. Indicators of the regeneration factor TGF-1β are significantly the highest when using the surgical techniques of STT, TT and TP. The concentration of immune complexes in the oropharyngeal secretions of patients with tonsil hypertrophy at 1 month after surgery significantly decreased with the use of surgical techniques TT and TP. Significant (P <0.05) increase in IgG level was de- termined in all comparison groups except the group where tonsilloplasty was used. Conclusions: The safety surgical technique of palatine tonsils volume reduction – TP and STT promotes significantly (P<0,05) faster restoration of concentration of the main mucous membrane's local immunity markers.

Prone Positioning for Acute Respiratory Distress Syndrome in Adults.

Prone Positioning for Acute Respiratory Distress Syndrome in Adults.