Receiving Tube Feeding Research Articles

P-P14 A multi-centre retrospective cohort study exploring weight loss and nutritional interventions in severe acute pancreatitis

Abstract Background Acute pancreatitis is among the most common acute gastrointestinal diseases. Severe acute pancreatitis (SAP) develops in up to 20% of patients and is associated with increased morbidity and mortality. Patients may have long and complex hospital admissions; nutritional support is a cornerstone of management. Due to increased metabolic demands and development of pancreatic exocrine insufficiency (PEI) patients frequently endure excessive weight loss. There has been little research into the effect of SAP on nutritional status and necessary nutritional interventions. This project aimed to characterise weight loss in SAP, routes of feeding, and PEI - including pancreatic enzyme replacement therapy (PERT). Methods Participating centres were recruited via the Nutrition Interest group of PSGBI and were required to retrospectively recruit 5-10 consecutive patients admitted following January 1st 2018 using a predefined data collection tool. Inclusion criteria included; age ≥18 years and diagnosed SAP of any aetiology (defined by organ failure of > 48hrs). The exclusion criterion was where death occurred during hospital admission. Data were collected regarding, weight changes, anthropometric measures, nutritional interventions used, PERT administration and diabetic status, including insulin use. All analyses were performed with IBM SPSS 22 (IBM Corp. Armonk, NY), with p < 0.05 considered statistically significant. Results 34 patients (22 male) from five centres met the inclusion criteria and were included in data analysis. Most common aetiologies were gallstones (13/34) and alcohol (11/34). A mean weight reduction of 12.6% (SD ± 10.77) (p < 0.001) was observed. Multivariate analyses showed that higher premorbid weight (p = 0.02) and PERT administration with tube feeding (p = 0.005) were associated with weight loss. Most patients (29/34) received tube feeding; mean duration 56.8 (SD ± 58.29) days. There was a significant increase in patients with diabetes requiring insulin therapy from admission (n = 3) to discharge (n = 9) (p = 0.03). Most (29/31) patients required oral PERT prescription on discharge. Conclusions Patients with SAP lost significant weight during the course of their illness despite aggressive, extended nutritional support and the correction of PEI with PERT. The significant increase in insulin dependence among patients with diabetes, and the number of patients requiring PERT on discharge, reflects the destructive effect SAP has on pancreatic function. These multicentre findings could be used as a baseline for determining effectiveness of nutritional interventions in SAP and may provide a basis for further prospective research in this area.

Blenderized food tube feeding in patients with head and neck cancer

BackgroundPatients with headand neck cancer (HNC) are at high risk for malnutrition before and during chemoradiation treatment. Many will also require tube feeding to address declines in energy intake, weight, and quality of life (QOL) caused by the impact of treatment on gastrointestinal (GI) symptoms. Blenderized tube feeding (BTF) may ameliorate these adverse conditions.MethodsIn this open‐label, prospective pilot study, 30 patients with HNC who required feeding tube placement were recruited to switch from standard commercial formula after 2 weeks to a commercially prepared BTF formula. Weight, body mass index (BMI), GI symptoms, and QOL scores were tracked for 6 weeks from the first week of feeding tube placement.ResultsOf the 16 patients who completed the 6‐week assessment period, weights and BMI scores for 15 patients trended upward. For most patients, QOL and oral intake increased and GI symptoms decreased over the 6‐week period, particularly during weeks 3 and 4, when the impact of treatment is particularly exacting on patients with HNC.ConclusionBTF effectively mitigated weight loss, GI symptoms, QOL scores, and total energy intake in this group of patients with HNC who received tube feeding for 6 weeks.

Association between Domperidone Administered via Feeding Tube and Feeding Success in Critically Ill Patients with Enteral Feeding Intolerance.

One nutritional challenge in critically ill patients is enteral feeding intolerance (EFI), but current prokinetic agents have uncertain efficacy and safety profiles. We conducted a longitudinal, single-center, retrospective study to evaluate the efficacy and safety of domperidone administered via the feeding tube versus intravenous (IV) metoclopramide among adult patients with EFI. The primary outcome was feeding success, defined as the proportion of patients with average percentage of daily protein prescription >80% of the target dose. The secondary outcomes were safety endpoints. Among 28,814 intensive care unit (ICU) admissions, 552 patients with EFI were included, 38 receiving IV metoclopramide and 514 receiving tube feeding domperidone. The proportion of feeding success in patients receiving tube feeding domperidone and IV metoclopramide was 42.02% and 21.05%, respectively. After 1:2 matching (IV metoclopramide to tube feeding domperidone), the proportion of feeding success was 40.79% in patients receiving tube feeding domperidone. Basically, after matching, there were no differences in any safety endpoints (mortality and length of stay during ICU and hospitalization, organ-support-treatment free days) or adverse events (recurrence of EFI, electrolyte disturbance, abdominal and other symptoms) between the two groups (p > 0.05). A logistic regression analysis in the matched cohort indicated that domperidone administered via the feeding tube was independently associated with feeding success. We found that tube feeding domperidone was efficient in increasing enteral nutrition delivery performance among critically ill adult patients with EFI.

Retrospective study on growth in infants with isolated Robin sequence treated with the Tuebingen Palate Plate

BackgroundChildren with Robin sequence (RS) are at risk of growth failure, mainly due to their increased work of breathing and feeding difficulties. Various conservative and surgical treatment approaches exist, but their impact on weight gain has not yet been adequately addressed. A functional treatment concept, used in our center for > 20 years, includes a pre-epiglottic baton plate (Tuebingen palatal plate) and intensive feeding training.ObjectiveTo investigate the effect of the Tuebingen treatment protocol on growth and weight trajectories during infancy.MethodsThis retrospective study analyzed longitudinal data from infants with isolated RS admitted to Tuebingen University Children’s Hospital, Germany between 1998 and 2019. Through our electronic patient database, we evaluated anthropometric parameters until reaching 1-year follow-up. Results are shown as median (IQR).ResultsIn 307 infants analyzed, median Z-score for weight decreased from − 0.28 at birth to − 1.12 upon admission to our center at a median age of 22 days. Z-score then remained largely unchanged until discharge (Z-score difference, − 0.08), while the proportion of infants receiving tube feedings decreased from 55.1 to 13.7%. Z-score subsequently increased from − 1.17 at discharge to − 0.44 at the 1-year follow-up (p < 0.001).ConclusionBased on a comparatively large cohort, this functional treatment was associated with better weight gain and improved feeding. As RS infants often show postnatal growth failure, weight monitoring may be a valuable parameter for monitoring treatment effectiveness.Clinical Trial Registration Not necessary due to the retrospective design.

Effectiveness of fibreoptic endoscopic evaluation of swallowing and dietary intervention during home-visit dental care in older individuals.

Currently, patients with dysphagia are receiving dietary management that deviates from their original swallowing function. To evaluate the clinical significance of fibreoptic endoscopic evaluation of swallowing (FEES) and dietary intervention (DI) by multi-professional collaboration during visit care for determining the actual oral intake status in patients with dysphagia. Five hundred and eighteen patients with dysphagia underwent FEES, focusing on the penetration-aspiration scale, and DI. Oral intake status was categorised using the functional oral intake scale (FOIS). FOIS scores at the first visit, after FEES, and at the reassessment were compared. At the first visit, 34.7% of the patients had an FOIS score of level 1 (no oral intake) and 65.3% had a score of level 2 or higher (capable of oral intake). Following FEES, 7.1% of patients had an FOIS score of level 1, and 44.4% had a score of level 2 with resumption of oral intake. At the reassessment, 489 patients (94.4%) were capable of oral ingestion (FOIS level 2 or higher). There were significant differences between the distributions of FOIS scores at the first visit and following FEES (P<.01) and between those at the first visit and at the reassessment (P<.01). Regarding tube feeding, 17 (5.9%) of 289 patients, who had received tube feeding at the first visit, were completely capable of oral intake following FEES and at the reassessment. Appropriate evaluation of swallowing function using FEES and DI helps to understand the definite swallowing function in patients with dysphagia.

Prednisone-Responsive Hypercalcemia in a Patient With IgG4 Disease and Elevated Serum PTHrP Levels

Background: Ninety percent of hypercalcemia cases are related to either primary hyperparathyroidism or malignancy (1). This case presents one of the atypical etiologies of hypercalcemia. Clinical Case: A 53-year-old man with past medical history of nephrectomy was admitted for acute respiratory distress syndrome secondary to SARS-CoV-2. Hospital stay was complicated by septic shock and acute kidney injury requiring hemodialysis. Three months post hospital admission, the patient developed non-parathyroid (PTH) mediated hypercalcemia. Lab work results showed elevated serum calcium of 12.7 mg/dl (8.6–10.6), ionized calcium 6.8 mg/dl (4.2–5.4), albumin 2.6 g/dl (3.4–5.4), serum creatinine of 3.5 mg/dl (0.5–1.5), eGFR of 18.4 ml/min, and a PTH of 4 pg/ml (12–88). Liver profile - total bilirubin of 10.5 mg/dl (0–1.2), direct bilirubin of 5.9 mg/dl (0–0.2), GGTP 2055 U/L (6–60), alkaline phosphatase of 936 u/L (40–125), bone fractionated alkaline phosphatase 216 u/L (0–55), 25-OH Vitamin D of 11 ng/nl (20–80), 1,25 OH vitamin D of <5 pg/ml (19–79), TSH of 3.56 mciu/mL (0.35–4.0), CPK of 20 u/L (21–232) and a normal SPEP and immune-electrophoresisTreatment for hypercalcemia was initiated with calcitonin and oral steroids (prednisone 40mg/day for 4 days, 20mg/day for 1 day, and 10mg/day for 2 days), resulting in normalization of serum calcium. Patient received tube feedings that contained 2192 mcg retinol activity equivalents of vitamin A daily, which is associated with vitamin A intoxication in the presence of renal insufficiency. Vitamin A returned 0.78 mg/L (0.3–1.2). Serum Parathyroid hormone-related peptide (PTHrP) was elevated at 12.4 pmol/L (0.0–2.0). There was no obvious malignancy on various imaging studies. A magnetic resonance cholangiopancreatography (MRCP) showed biliary stricturing suggestive of primary sclerosing cholangitis (PSC), however, liver biopsy was not consistent with PSC. Serum IgG4 level was found to be elevated to 142 mg/dl (range: 1–123) which raised suspicion for autoimmune cholangiopathy. Discussion: Patient presented with non-PTH mediated hypercalcemia with low serum 1,25 OHD levels and elevated serum PTHrP level. Although most cases of elevated PTHrP associated with hypercalcemia are due to solid tumors, increased PTHrP levels have been seen in hypercalcemic patients with hematological malignancies and rare benign causes such as pneumonia (5). Association of elevated hypercalcemia with elevated IgG4 levels and PTHrP levels has not been previously reported. MRCP findings and abnormal morphology detailed in liver biopsy are suggestive of IgG4-related disease (IgG4RD) (3). The responsiveness in hypercalcemia to prednisone also supports this diagnosis. IgG4RD is associated with multi-organ autoimmune involvement. This case report highlights another complication of IgG4RD (i.e. hypercalcemia) associated with elevated PTHrP levels.

Fluid Needs in the Older Adult Receiving Tube Feedings.

Fluid imbalance can occur quickly in older adults and in others who cannot express thirst or are in a setting where fluid status is not closely monitored. In tube-fed individuals receiving inadequate calories, severe malnutrition may occur in weeks to months, but improper water intake may lead to critical fluid imbalances in a matter of days. Simplistic equations frequently used to determine fluid needs in adults include milliliters per kilogram of body weight and milliliters per energy (kilocalories) consumed or per energy (kilocalories) need and variations of the Holliday-Segar formula. None of these fluid-requirement equations have been validated through evidenced-based science, and research investigations have revealed that they can grossly overestimate or underestimate fluid needs in the older adult. Clinicians need guidance to better estimate initial fluid needs for the older adult receiving tube feedings and to provide proper close monitoring afterward to avert preventable fluid imbalance-related hospital readmissions, morbidities, and mortalities in this patient population.

Analysis of risk factors for multidrug-resistant pathogens and appropriate treatment indications for pneumonia in children with neurologic impairment

IntroductionThe features of pneumonia in children with neurologic impairment (NI) resemble those of healthcare-associated pneumonia is defined as pneumonia occurring in the community associated with healthcare risk factors. There are currently no guidelines for the treatment of pneumonia in children with NI. Here, we assessed whether the guidelines applicable for treating pneumonia in adults could be applied to children with NI. MethodsBetween 2008 and 2019, we enrolled children with NI who developed pneumonia and were treated in the pediatric ward of Kawasaki Medical School Hospital. We evaluated patient characteristics, the frequency of isolation of multidrug-resistant (MDR) pathogens, and clinical outcomes. ResultsMDR pathogens were more frequently isolated from patients receiving tube feeding (TF) and/or with tracheostomy than from patients without these risk factors. Other risk factors, including a history of antibiotic therapy and methicillin-resistant Staphylococcus aureus isolation, recent hospitalization, residence in a nursing home or extended care facility, and low-dose, long-term macrolide therapy, did not significantly affect the frequency of MDR pathogen isolation. In patients receiving TF and/or with tracheostomy, treatment success was achieved in all cases treated with broad-spectrum antibiotics and 72.2% of cases treated with non-broad-spectrum antibiotics (P = 0.007). Conversely, among patients without these risk factors, no such difference was observed. ConclusionsOur findings indicate that the guideline to select antibiotics for treating pneumonia in children with NI should be simpler and more useful than the current guidelines for adult pneumonia, based on risk factor assessment for MDR pathogens.

Prevalence and risk factors of dysphagia among nursing home residents in eastern China: a cross-sectional study.

BackgroundDysphagia is a common health care problem and poses significant risks including mortality and hospitalization. China has many unsolved long-term care problems, as it is a developing country with the largest ageing population in the world. The present study aimed to identify the prevalence and risk factors of dysphagia among nursing home residents in China to direct caregivers towards preventative and corrective actions.MethodsData were collected from 18 public or private nursing homes in 9 districts of Nanjing, China. A total of 775 older adults (aged 60 ~ 105 years old; 60.6% female) were recruited. Each participant underwent a standardized face-to-face interview by at least 2 investigators. The presence of risk of dysphagia was assessed using the Chinese version of the EAT-10 scale. The Barthel Index (BI) was used to evaluate functional status. Additionally, demographic and health-related characteristics were collected from the participants and their medical files. Univariate analyses were first used to find out candidate risk factors, followed by binary logistic regression analyses to determine reliable impact factors after adjusting for confounders.ResultsOut of 775 older adults, the prevalence of dysphagia risk was calculated to be 31.1%. A total of 85.0% of the older adults reported at least one chronic disease, and diseases with the highest prevalence were hypertension (49.5%), stroke (40.4%), diabetes (25.5%) and dementia (18.2%). Approximately 11.9% of participants received tube feeding. The mean BI score was 56.2 (SD = 38.3). Risk factors for dysphagia were texture of diet (OR = 2.978, p ≤ 0.01), BI level (OR = 1.418, p ≤ 0.01), history of aspiration, pneumonia and heart attack (OR = 22.962, 4.909, 3.804, respectively, p ≤ 0.01), types of oral medication (OR = 1.723, p ≤ 0.05) and Parkinson disease (OR = 2.566, p ≤ 0.05).ConclusionsA serious risk of dysphagia was observed among Chinese nursing home residents. Overall, nursing home residents were moderately dependent, according to the BI level. The risk for dysphagia increased with thinner diet texture, worse functional status, history of aspiration, pneumonia and heart attack, more oral medications and Parkinson disease. The findings of our study may serve to urge nursing home staff to pay more attention to the swallowing function of all residents and to take more actions in advance to prevent or reduce dysphagia.

Risk factors of malnutrition in children with severe motor and intellectual disabilities

BackgroundChildren with severe motor and intellectual disabilities (SMID) are at a high risk of malnutrition and often require tube feeding to maintain their nutritional status. However, determining their energy requirements is difficult since inadequate dietary intake, severe neurological impairment, respiratory assistance, and cognitive impairment are all factors that affect malnutrition in SMID. AimThis study investigated the factors affecting malnutrition and identified problems affecting the nutritional status of children with SMID. MethodsForty-two children with SMID with oral motor dysfunction who were receiving home medical care at one of four hospitals were enrolled. Their nutritional status was assessed using a 3-day dietary record, anthropometric measurements, and laboratory tests. The clinical findings associated with malnutrition were compared, and a body mass index (BMI) z-score less than −2SD was defined as malnutrition. The relationship between BMI z-score and other potential predictors was also investigated. ResultsThirty-three (79%) children received tube feeding, and 20 (48%) experienced malnutrition. The median age of the malnourished children was older than that of non-malnourished children. Respiratory assistance was significantly correlated with higher BMI z-score, independent of other potential confounders such as nutrition method, muscle tonus, and energy intake. Cholesterol levels were significantly higher in children receiving a standard infant formula beyond 3 years of age than in those who switched to enteral formula before 3 years of age. ConclusionsMalnutrition in children with SMID was mainly associated with age or respiratory condition. Energy requirements should be regularly re-evaluated with considering these factors.

Age Predicts Whether Tube-fed Patients Will Require Tube Feeding on Discharge: Results of a Pilot Toward Developing a Predictive Model

Abstract Objectives There is currently no model to predict the need for long-term tube-feeding. A predictive model may reduce unnecessary feeding tube placement. This study is a pilot effort toward developing a model to predict whether patients need tube feeding on hospital discharge. Methods All adult patients with tube feeding orders at any time during their hospitalization at the New York Presbyterian, Milstein Hospital during the period January 1st, 2018 to December 31st,2018 were evaluated. A student t-test was performed on the difference in average age between the subjects receiving tube feeding at discharge and the subjects discharged without tube feeding. Results The mean age of the subjects requiring tube feeding at discharge (66.2 ± 18 years) is 2.6 years higher than that in the group without tube feeding at discharge (63.6 + 17.2 years, P = 0. 0014). The distribution of age in both groups is left-skewed. The age of the subjects requiring tube feeding at discharge is fairly more dispersed compared the age of subjects without tube feeding at discharge. Conclusions We found that age is significantly higher in subjects requiring tube feeding at discharge. The actual difference in age is small, and its contribution to predicting tube feeding is unknown. The next step toward building a predictive model will be to apply appropriate regression analysis to assess the predictive value of 10 preliminarily identified to determine how and whether they predict which subjects need tube feeding at discharge. These are age, sex, insurance status, race, smoking status, BMI, head or neck cancer, tracheotomy, stroke severity, and dysphasia severity. Funding Sources None.

Specific Quality of Life Assessment by the NutriQoL® Questionnaire Among Patients Receiving Home Enteral Nutrition.

BackgroundHome enteral nutrition (HEN), including tube feeding and oral supplementation, can improve or worsen quality of life (QoL). The specific assessment of factors affecting QoL may identify the inherent problems associated with HEN. The aim of this study was to evaluate whether the validated NutriQoL® questionnaire is useful for assessing the QoL and the factors influencing it in patients receiving HEN.MethodsA total of 78 patients receiving HEN completed both the NutriQoL and the SF‐12 questionnaires during their routine visits to nutrition service at the hospital.ResultsNinety percent of patients receiving HEN had cancer, 58% received oral supplements, and 42% received tube feeding. At recruitment, the mean score ± SD of the NutriQoL was 66 ± 14, whereas that of the SF‐12 was 40 ± 9. A positive correlation between NutriQoL and SF‐12 scores (ρ = 0.5; P < .001) was found. Multivariate analysis showed that HEN type (oral vs tube) (odds ratio [OR], 5.6; 95% CI 2.0–15.3; P = .001) and the absence of secondary effects (OR, 3.0; 95% CI, 1.2–7.9; P = .024) were both variables explaining NutriQoL results adjusted by sex and age. The SF‐12 results did not show associations with nutrition factors. On visit 2, we observed significant improvements in NutriQoL results.ConclusionThe NutriQoL questionnaire identifies specific problems that affect the QoL of patients receiving HEN, whereas SF‐12 does not. The route of entry and the occurrence of complications influence specific QoL. NutriQoL is a useful tool to identify the factors that worsen the QoL in patients receiving HEN.

Between Choice, Necessity, and Comfort: Deciding on Tube Feeding in the Acute Phase After a Severe Stroke.

This is an ethnographic study of decision-making concerning tube feeding in the acute phase after a severe stroke. It is based on 6 months of ethnographic research in three stroke units in the Netherlands, where the decision-making on life-sustaining treatment was studied in 16 cases of severe stroke patients. Data were collected through participant observation and interviews. For this article, the analysis was narrowed down to the decision whether or not the patient should receive tube feeding. The data on tube feeding were assembled and coded according to different modes of dealing with this decision in clinical practice, which we refer to as “repertoires.” We discerned three different repertoires: choice, necessity, and comfort. Each repertoire structures clinical practice differently: It implies distinctive ethical imperatives, central concerns, sources of information, and temporalities. We hope our findings can improve decision-making by uncovering its underlying logics in clinical practice.

Nutritional management of patients with oesophageal cancer throughout the treatment trajectory: benchmarking against best practice.

Oesophageal cancer (OC) impacts nutritional status and outcomes. This study aims to benchmark the current nutrition management of patients with OC against best practice recommendations, identify critical points in the treatment trajectory where nutritional status is compromised, service gaps and opportunities for improvement. A retrospective audit collected demographic, medical and nutritional data from medical records of patients who received curative treatment for OC at a tertiary referral hospital in Sydney, Australia. Thirty-seven patient records were audited over the time period. Twenty-nine patients underwent nutrition screening on admission to the service. Eighteen out of 25 patients receiving neoadjuvant radiation therapy, all patients during surgical admission, and only 19 patients at postsurgical discharge were seen by a dietitian. All patients received tube feeding post-operatively; however, initiation within 24h only occurred for 14 patients. Weight significantly declined over the course of treatment (p < 0.001), whilst malnutrition during surgical admission (p = 0.004) and postsurgical discharge (p = 0.038) were both associated with significantly higher unplanned readmissions. Best practice recommendations were met for aspects of the immediate post-operative period; however, service gaps remain during pre-operative and post-discharge care. Findings from this study indicate that nutritional care is inconsistent across different treatment stages, and malnutrition impacts negatively on unplanned readmission. Research is needed to address evidence-practice gaps, assess appropriateness of recommendations and provide evidence for models of care during multimodality treatments and across different services.

Osteoporosis pathology in people with severe motor and intellectual disability

ObjectivesWe assessed the severity and pathology of osteoporosis in children and adults with severe motor and intellectual disabilities (SMID) by evaluating bone enzymes, by which we aimed to determine adequate treatment approaches for preventing fractures. MethodsNinety patients (44 men, 46 women; mean age, 34.5 years) underwent bone quality assessment. Quantitative ultrasonography (QUS) was used to measure the T-score and Z-score of the calcaneus, and blood tests were used to measure bone-specific alkaline phosphatase and tartrate-resistant acid phosphatase 5b levels as bone formation and resorption markers, as well as calcium, phosphorous, and parathyroid hormone levels as routine examination. ResultsBone formation and resorption marker levels were within normal ranges in adults, although they were high during the growth period in children and adolescents and in elderly women. Patients receiving tube feeding showed a significantly lower Z-score than those without tube feeding. Tube feeding was a significant factor for the Z-score, whereas age, vitamin supplements, and anti-epileptic drugs were not. ConclusionsThe severity of osteoporosis in SMID started during the growth period and seems to be caused by a lack of an effective increase in bone mineral density. Any treatment should be started during the growth period. More study about tube feeding is needed.

Aspiration: Should It Be Tested or Treated?

Research Article| September 01 2019 Aspiration: Should It Be Tested or Treated? AAP Grand Rounds (2019) 42 (3): 32. https://doi.org/10.1542/gr.42-3-32 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Aspiration: Should It Be Tested or Treated?. AAP Grand Rounds September 2019; 42 (3): 32. https://doi.org/10.1542/gr.42-3-32 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: aspirations (psychology), endotracheal aspiration, inspiration, pulmonary aspiration Source: Tanaka N, Nohara K, Ueda A, et al. Effect of aspiration on the lungs in children: a comparison using chest computed tomography findings. BMC Pediatr. 2019; 19(1): 162; doi: https://doi.org/10.1186/s12887-019-1531-6Google Scholar Investigators from multiple institutions in Osaka, Japan, conducted a retrospective study to assess the relationship between food aspiration and/or saliva aspiration and pneumonia in children and young adults with severe motor disturbances and/or developmental delay. Patients who were receiving care for dysphagia at the Osaka Developmental Rehabilitation Center, Osaka, Japan, were enrolled in the study. Chest CT was performed to detect signs of aspiration pneumonia in study participants. CT scans were evaluated by 2 of the authors who used a standardized method to classify specific radiographic signs of aspiration pneumonia, including parenchymal bands, bronchiolectasis, bronchial wall thickening, bronchiectasis, atelectasis, tree-in-bud pattern, intraluminal airway debris, fibrosis, and air trapping. If any of these findings were present, the patient was classified as having pneumonia. Within 1 week of CT, study participants underwent fiberoptic endoscopic evaluation of swallowing (FEES). The presence of food and/or saliva aspiration was categorized using the penetration-aspiration scale (PAS); PAS scores of 5–6 were classified as aspiration, and scores of 1–4 were classified as no aspiration. Food aspiration and saliva aspiration were categorized separately. The primary outcome was pneumonia at CT. The secondary outcome was a history of pneumonia in the past year based on medical record review. The associations between food or saliva aspiration and these outcomes were assessed with chi-square tests. Data were analyzed on 85 participants with a mean (standard deviation) age of 11.2 (7.2) years (range, 11 months to 26 years). All patients received nutrition orally, with 49.4% also receiving tube feedings. Among study participants, 48 (56.5%) had food aspiration, 26 (30.6%) had saliva aspiration, and 20 (23.5%) had both. Signs of pneumonia were found at CT in 34 (70.8%) patients with food aspiration compared to 20 (54.1%) patients with no food aspiration (P=.11). There was also no statistically significant association between food aspiration and a history of pneumonia in the previous year; 41.7% of those with food aspiration had a history of pneumonia compared to 35.1% of patients with no food aspiration (P=.55). However, among those with saliva aspiration, 88.5% had CT findings of pneumonia versus 52.5% of those without saliva aspiration (P=.002). There was no statistical association between saliva aspiration and a history of pneumonia. The authors conclude that saliva aspiration may be an indicator of aspiration pneumonia risk in contrast to the presence of food aspiration at FEES. Dr Bratton has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. The relationship of aspiration to both acute and chronic pulmonary injury remains poorly understood. The concept that aspiration of food contents causes lung injury is based on the observation of respiratory distress and fever developing within hours after an... You do not currently have access to this content.

Healthcare utilization at the end of life in people dying from amyotrophic lateral sclerosis: A retrospective cohort study using linked administrative data

BackgroundALS is an incurable neurodegenerative disorder, with the recommendation that symptom management and palliative care start immediately or soon after diagnosis. However, little is known about healthcare utilization at the end of life in this patient group. AimTo describe healthcare utilization at the end of life in patients who died from ALS. DesignWe performed a retrospective cohort study using population-level administrative databases. The description of healthcare utilization was based on (1) validated quality indicators for end-of-life care, and (2) the European Federation of Neurological Societies guidelines on the clinical management of ALS. SettingWe included all people who died from ALS in Belgium between 2010 and 2015 (using ICD-10 code G12.2). Results1636 people died from ALS in Belgium between 2010 and 2015. The mean age at death was 71 years (SD11.3), and 56% were men. Specialized palliative care was used by 44% at some point in the last two years of life. In the last month of life, 13% received tube feeding, 48% received diagnostic testing, 41% were admitted to a hospital, and 25% were admitted to an emergency department. Medications were used mainly to treat pain (43%), insomnia and fatigue (33%) and thrombosis (32%); 39% used riluzole. Non-invasive ventilation was used by 18%. 39% died at home. ConclusionAdministrative data provide a valuable source to describe healthcare utilization in small populations such as ALS, but more clinical evidence is needed on the advantages and disadvantages initiating or terminating treatments at the end of life.

Mesh erosion after hiatal hernia repair: the tip of the iceberg?

Primary repair of large hiatal hernia is associated with a high recurrence rate, which has led to the use of mesh for crural repair. However, severe mesh-related complications, including esophageal or gastric erosion, have been observed. In the present study, we made a thorough identification of all published reports on the esophageal or gastric mesh erosion or migration after hiatal hernia repair. The incidence, site, mesh type, latent interval, consequence and treatment methods of mesh erosion were summarized and analyzed. A total of 50 cases of esophageal or gastric mesh erosion or migration after hiatal hernia repair were reported since 1998. A higher erosion rate was observed in recurrent hiatal hernia repair. The most common erosion site was esophagus (50%), followed by stomach (25%) and gastric-esophageal junction (GEJ) (23%). The most common mesh types reported in this series were PTEF andpolypropylene. The duration from the hernia repair to the identification of erosion varied greatly, and 79% of the erosion occurred within 2years after the hernia repair. Various treatment methods were reported, including endoscopic mesh retrieval (15.7%), laparoscopic mesh removal (11.8%), surgical mesh removal (19.6%); however, distal esophageal resection and gastric resection were reported in 19.6% and 5.9%, respectively. Some patients had to receive tube feeding. The true incidence of mesh erosion after hiatal hernia repair may be higher than previously reported, and the erosion is more prone to occur after recurrent hiatal hernia repair. Mesh erosion can result in severe morbidity and sometimes require complex organ resection. Different kinds and shapes of prosthetic meshes can cause erosion; therefore, mesh should be used very selectively for hiatal hernia repair. The patient should be informed about the mesh placement and the possible mesh-related complications.

P3B.16: The Overload Gut Syndrome

Introduction: Short bowel syndrome (SBS) is the main cause for intestinal failure in children. Parenteral nutrition allows survival and growth while physiological intestinal adaptation occurs. Most patients can be weaned off PN after two to three years. In some cases, although adaptation was successful and PN was weaned without difficulty, intestinal symptoms such as abdominal pain, discomfort, abdominal distension and diarrhea occur, along with a decrease in growth rate requiring the resumption of PN - defining the overload gut syndrome (OGS). The aim of this study was to describe the natural history, the clinical and biological characteristics and the management of OGS. Methods: this retrospective study included all children referred to our center with a history of SBS weaned off PN who needed to return to PN between 2013 and 2018. All children were evaluated in our ward before resuming PN. Clinical history, examination and biological testings, including plasma citrulline levels were collected. A stool balance analysis was performed using the duplicate meal technique and bomb calorimetry. Results: Nine children were included in the study. Mean age at PN resumption was 10 years and 10 months. PN discontinuation lasted six and a half years (mean). All patients presented with stunting which was more important on height than on weight (loss of 1.5 SD and 1.3 SD respectively). All patients were hyperphagic, five of them received tube feeding on top of oral feeding, with mean ingested calories of 2336 kcalories/day, with a ratio of ingested calories over resting energy expenditure of 205%. Mean number of stools was 4.4 per day, with a mean stool weight of 1400g/day (52g/kg/d). One patient presented with recurrent episodes of D-lactic acidosis. Four patients had bicarbonates concentration under 21mmol/l. Mean total absorption rate was 69%. After PN start, the intestinal symptoms resolved, weight increased by 1.4 SD and height by 0.8 SD at 12 months follow-up. Biological parameters all improved. Mean citrulline plasma levels remained stable (26mmol/l at PN re-start - 24mmol/l at 12 months follow-up). Conclusion: Overload gut syndrome is a rare complication of SBS in children. It occurs in children with high enteral intake and low absorption rate: the remnant intestine cannot face the calorie load and becomes overwhelmed. Symptoms should be recognized early in order to resume PN in time to avoid consequences on final stature.

The impact of body mass index on resource utilization and outcomes of children admitted to a pediatric intensive care unit.

Introduction:Obesity is associated with poor health outcomes but may be protective in intensive care unit patients. The objective of this study is to describe the characteristics of underweight, normal weight, and obese children, and to compare their length of stay, resource utilization, and mortality.Methods:The charts of 1447 patients who were admitted to a tertiary-level pediatric intensive care unit during 1 calendar year were reviewed. Patients were divided into three groups: underweight (<5th percentile), normal (5th–95th percentiles), and obese (>95th percentile). Body mass index for age percentile was used for children older than age 2 years, and weight-for-height percentile was used for children younger than age 2 years. Demographic data, Pediatric Index of Mortality 2 score, Pediatric Index of Mortality 2 risk of mortality, hospital mortality, hospital length of stay, the use and duration of ventilator support, hemodynamic support, and dialysis were determined.Results:Fifteen percent of children were underweight, while 61.5% were normal weight and 23.5% were obese; 54.9% of the patients were male. The overall mortality was 1.87%, with no significant difference between the three weight groups. The racial distribution, prevalence, and duration of invasive and noninvasive ventilation, and the use of vasopressors, central venous lines, and dialysis were similar between three groups. Tube feeding and parenteral nutrition were used more often in the underweight group. Pediatric intensive care unit and hospital lengths of stays were higher in underweight children. Underweight children were younger when compared to normal or obese children. Pediatric Index of Mortality 2 scores and Pediatric Index of Mortality 2 risk of mortality scores were higher in underweight children.Conclusion:There were no significant differences between the three weight groups in mortality. Underweight children were younger and sicker, and received tube feeding and parenteral nutrition more frequently.