Aspiration Pneumonia

Dental Care to Reduce Aspiration Pneumonia Recurrence: A Prospective Cohort Study

BACKGROUND

Aspiration pneumonia has a high recurrence rate, and oral care by dentists has been found effective in preventing its onset; however, this has not been evaluated using prospective studies. Therefore, we conducted a prospective study to evaluate the effectiveness of professional oral care by dentists in reducing aspiration pneumonia recurrence in older adult patients.

METHODS

In this prospective cohort study, we evaluated a dental oral care intervention, using a historical control group (control group). It was conducted at a single-centre regional core hospital in Japan that serves a large number of patients aged older than 80 years. Patients who were hospitalised for aspiration pneumonia were included in this study. During the study period (1 April 2021 to 31 March 2022), the clinical group received weekly professional cleaning by a dentist and the control group received standard oral care by a nurse as usual from 1 April 2020 to 31 March 2021. The dentist oral care group received weekly professional oral care from a dentist and was followed prospectively for 1 year. A Kaplan-Meier analysis was used to evaluate the timing of recurrent aspiration pneumonia or death. A Cox proportional hazards model was used to obtain a hazard ratio and determine the 95% confidence intervals.

RESULTS

There were 91 participants in the clinical group and 94 in the control group. The mean age of participants was 85 years, and 75 (40.5%) were female. The recurrence rate was 27.5% in the clinical group and 44.7% in the control group (P = .005). Professional cleaning by a dentist reduced the risk of recurrence of aspiration pneumonia by approximately 50% (adjusted hazard ratio, 0.465; 95% confidence interval, 0.278-0.78).

CONCLUSIONS

Professional cleaning by a dentist was associated with a lower rate of aspiration pneumonia recurrence than nurse-provided conventional oral care.

Investigating in VigiBase over 6000 cases of pneumonia in clozapine-treated patients in the context of the literature: focus on high lethality and the association with aspiration pneumonia

BACKGROUND

The literature associates clozapine with pneumonia/aspiration pneumonia.

RESEARCH DESIGN AND METHODS

The international pharmacovigilance database (VigiBase™) uses the information component (IC) as statistical signal. VigiBase clozapine reports were analyzed for pneumonia/aspiration pneumonia from introduction to 10 May 2023.

RESULTS

There were 6392 cases of all types of pneumonia (5572 cases of pneumonia, 775 of aspiration pneumonia, and 45 combined). The IC was 3.52 for aspiration pneumonia, introduced as a VigiBase label in 2003, and 1.91 for pneumonia. Patients were reclassified as 3628 with no signs of aspiration and 1533 with signs. Signs of aspiration were strongly associated with some co-medications: olanzapine, odds ratio (OR) = 23.8, 95% confidence interval (CI), 14.9-38.0; risperidone OR = 18.6, CI, 11.4-30.4; valproic acid, OR = 5.5, CI, 4.5-6.6; and benzodiazepines OR = 5.5, CI, 4.5-6.6. In 2415 cases with completed data, fatal outcomes made up 45% (signs of aspiration made no difference), but there was wide variability from 0% (females <45 years of age; duration ≤30 days) to 76% (males >64 years of age; duration >1 year). During the first week, pneumonia was associated with 1) very high titration doses, 2) very small doses in Parkinson's disease, and 3) Japan vs other countries.

CONCLUSIONS

In clozapine-treated patients: 1) at least 30% of pneumonia cases may be aspiration pneumonia, 2) stopping some co-medications may decrease the risk of aspiration pneumonia, 3) average lethality in pneumonia was 45% but may be around 75% in geriatric patients with long-term treatment, and 4) safer titrations may sometimes require 5-mg tablets.

Anaerobic Antibiotic Coverage in Aspiration Pneumonia and the Associated Benefits and Harms: A Retrospective Cohort Study

BACKGROUND

Antibiotics with extended anaerobic coverage are used commonly to treat aspiration pneumonia, which is not recommended by current guidelines.

RESEARCH QUESTION

In patients admitted to hospital for community-acquired aspiration pneumonia, does a difference exist between antibiotic therapy with limited anaerobic coverage (LAC) vs antibiotic therapy with extended anaerobic coverage (EAC) in terms of in-hospital mortality and risk of Clostridioides difficile colitis?

STUDY DESIGN AND METHODS

We conducted a multicenter retrospective cohort study across 18 hospitals in Ontario, Canada, from January 1, 2015, to January 1, 2022. Patients were included if the physician diagnosed aspiration pneumonia and prescribed guideline-concordant first-line community-acquired pneumonia parenteral antibiotic therapy to the patient within 48 h of admission. Patients then were categorized into the LAC group if they received ceftriaxone, cefotaxime, or levofloxacin. Patients were categorized into the EAC group if they received amoxicillin-clavulanate, moxifloxacin, or any of ceftriaxone, cefotaxime, or levofloxacin in combination with clindamycin or metronidazole. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included incident C difficile colitis occurring after admission. Overlap weighting of propensity scores was used to balance baseline prognostic factors.

RESULTS

The LAC and EAC groups included 2,683 and 1,316 patients, respectively. In hospital, 814 patients (30.3%) and 422 patients (32.1%) in the LAC and EAC groups died, respectively. C difficile colitis occurred in five or fewer patients (≤ 0.2%) and 11 to 15 patients (0.8%-1.1%) in the LAC and EAC groups, respectively. After overlap weighting of propensity scores, the adjusted risk difference of EAC minus LAC was 1.6% (95% CI, -1.7% to 4.9%) for in-hospital mortality and 1.0% (95% CI, 0.3%-1.7%) for C difficile colitis.

INTERPRETATION

We found that extended anaerobic coverage likely is unnecessary in aspiration pneumonia because it was associated with no additional mortality benefit, only an increased risk of C difficile colitis.

Is polypharmacy a risk factor for aspiration pneumonia in older adults? A case-control study

INTRODUCTION

The incidence of aspiration pneumonia and the number of medicines prescribed increase with older age. Many medicines pose a risk for aspiration pneumonia, especially those that decrease swallowing function. Older adults with polypharmacy often receive a combination of these medicines. This study aimed to clarify whether polypharmacy is a risk factor for aspiration pneumonia.

METHODS

Older adults aged ≥ 65 years receiving oral medicines were included in this case-control study. Patients hospitalized for pneumonia served as the case group, and other age-matched hospitalized patients served as the control group. Patient data were collected retrospectively, and logistic regression analysis was performed using items that showed significant differences in the univariate analysis as explanatory variables.

RESULTS

Logistic regression analysis revealed that the number of medicines was not a risk factor for aspiration pneumonia; however, it was associated with the Functional Oral Intake Scale score, male sex, body mass index, and number of comorbidities.

CONCLUSION

Although polypharmacy is often defined only by the number of medicines, it is not a risk factor for aspiration pneumonia. A detailed comparison of prescription medicines between the pneumonia and non-pneumonia groups is necessary.

Thick Liquids and Clinical Outcomes in Hospitalized Patients With Alzheimer Disease and Related Dementias and Dysphagia

Importance

Oropharyngeal dysphagia is common in hospitalized patients with Alzheimer disease and related dementias (ADRD). Although the use of thick liquids in patients with dysphagia has been shown to reduce aspiration on direct visualization, there is no clear evidence that this practice translates into improved clinical outcomes.

Objectives

To determine whether a diet of thick liquids compared with thin liquids is associated with improved outcomes in hospitalized patients with ADRD and dysphagia.

Design, Setting, and Participants

This cohort study included adults aged 65 years and older with ADRD who were admitted to the medicine service across 11 diverse hospitals in New York between January 1, 2017, and September 20, 2022, with clinical suspicion of dysphagia during hospitalization and survival for at least 24 hours after hospital arrival. Patients were grouped according to whether at least 75% of their hospital diet consisted of a thick liquid diet or a thin liquid diet. Propensity score matching was used to balance covariates across the 2 groups for the following covariates: demographics (eg, age, sex), baseline clinical characteristics (eg, Charlson Comorbidity Index), and acute presentation (eg, respiratory diagnosis, illness severity, delirium).

Main Outcomes and Measures

Hospital outcomes included mortality (primary outcome), respiratory complications (eg, pneumonia), intubation, and hospital length of stay (LOS).

Results

Of 8916 patients with ADRD and dysphagia included in the propensity score matched analysis, the mean (SD) age was 85.7 (8.0) years and 4829 were female (54.2%). A total of 4458 patients receiving a thick liquid diet were matched with 4458 patients receiving a thin liquid diet. There was no significant difference in hospital mortality between the thick liquids and thin liquids groups (hazard ratio, 0.92; 95% CI, 0.75-1.14]; P = .46). Compared with patients receiving thin liquids, patients receiving thick liquids were less likely to be intubated (odds ratio [OR], 0.66; 95% CI, 0.54-0.80), but they were more likely to have respiratory complications (OR, 1.73; 95% CI, 1.56-1.91).

Conclusions and Relevance

This cohort study emphasizes the need for prospective studies that evaluate whether thick liquids are associated with improved clinical outcomes in hospitalized patients with ADRD and dysphagia.

Treatment strategy for older patients with pneumonia independent of the risk of drug resistance in the world's top country for longevity

The number of older people with impaired swallowing function increases with aging population. Aspiration pneumonia is one of the most cases of pneumonia developing among older people. As aspiration pneumonia may develop as a result of age-related deterioration, it is crucial to consider it as an unavoidable event with aging. While pneumonia is diagnosed based on respiratory symptoms and radiological features, the lung involvement of aspiration pneumonia may be undetectable via a frontal chest radiograph in some cases. Bacterial profiles show the predominance of drug-resistant bacteria, such as Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA), but isolated bacteria from respiratory samples do not necessarily indicate causative pathogens. Furthermore, there is no evidence regarding treatment superiority using broad-spectrum antibiotics compared with narrow-spectrum antibiotics. Even if isolated pathogens are a causative factor for pneumonia among older patients, the use of broad-spectrum antibiotics covering the bacteria may not improve their outcomes. Therefore, we propose a treatment strategy independent of the risk of drug resistance focusing on the discrimination of patients who are unlikely to respond to broad-spectrum antibiotics. An aspiration risk is associated with increased in-hospital mortality in patients with pneumonia, which could also lead to a greater risk of poor long-term outcomes with increased 1-year mortality. Advance care planning is now recognized as a process for communication and medical decision-making across the life course. This approach would be widely recommended for older people with aspiration risk.

Risk of pneumonia-related hospitalization after initiating angiotensin-converting enzyme inhibitors compared with angiotensin II receptor blockers: a retrospective cohort study using LIFE Study data

There is insufficient evidence that angiotensin-converting enzyme inhibitors (ACEIs) can reduce pneumonia by inducing a dry cough that confers a protective effect on the airway. To increase the evidence base on the clinical use of ACEIs for pneumonia prevention, this retrospective cohort study aimed to comparatively examine the risk of pneumonia-related hospitalization between ACEI initiators and angiotensin II receptor blocker (ARB) initiators using claims data from two Japanese municipalities. We identified persons who were newly prescribed any ACEI or ARB as their first antihypertensive agent between April 2016 and March 2020. The Fine-Gray method was applied to a Cox proportional hazards model to estimate the subdistribution hazard ratio (HR) of ACEI use (reference: ARB use) for pneumonia-related hospitalization, with death treated as a competing risk. Sex, age, comorbidities, medications, and pneumococcal immunization were included as covariates. The analysis was conducted on 1421 ACEI initiators and 9040 ARB initiators, and the adjusted subdistribution HR of ACEI use was estimated to be 1.21 (95% confidence interval: 0.89-1.65; P = 0.22). ACEI initiation did not demonstrate any significant preventive effect against pneumonia-related hospitalization relative to ARB initiation. There remains a lack of strong evidence on the protective effects of ACEIs, and further research is needed to ascertain the benefits of their use in preventing pneumonia. We conducted a large-scale retrospective cohort study using real-world healthcare data from a Japanese population. In this study, ACEI initiation did not indicate a significant preventive effect against pneumonia-related hospitalization.

Pulmonary granulomas and Mendelson syndrome in an immunocompromised patient

Granuloma formation is generally correlated with infection. Pulmonary granulomas caused by foreign bodies aspiration are uncommon. The clinical and radiologic features of such cases often lack specificity, which makes it difficult to distinguish from malignancy. Aspiration is usually not considered in the differential diagnosis of patients presenting with mass-like abnormalities on chest imaging. Occult aspiration history, diverse clinical manifestations, atypical imaging findings, and limited availability of pathogen detection techniques make the precise diagnosis a substantial challenge. Herein, we describe an older patient presenting with chest pain and worrisome lung masses/nodules that proved to be pulmonary granulomas caused by foreign matters aspiration. In addition, the patient developed Mendelson syndrome due to acute macroaspiration. Lung tissue metagenomics next-generation sequencing (mNGS) revealed Streptococcus intermedius, a normal flora of the oropharynx. The aim of this case was to underscore the importance of considering aspiration as a potential differential diagnosis of patients presenting with pulmonary granulomas, especially in patients with recurrent pneumonia or predisposing factors. In addition, mNGS act as a potential, rapid, and effective technique for diagnosing aspiration-related syndrome, showing satisfactory performance in identifying pathogens.

Hypotussic cough in persons with dysphagia: biobehavioral interventions and pathways to clinical implementation

Cough is a powerful, protective expulsive behavior that assists in maintaining respiratory health by clearing foreign material, pathogens, and mucus from the airways. Therefore, cough is critical to survival in both health and disease. Importantly, cough protects the airways and lungs from both antegrade (e.g., food, liquid, saliva) and retrograde (e.g., bile, gastric acid) aspirate contents. Aspiration is often the result of impaired swallowing (dysphagia), which allows oral and/or gastric contents to enter the lung, especially in individuals who also have cough dysfunction (dystussia). Cough hyposensitivity, downregulation, or desensitization- collectively referred to as hypotussia- is common in individuals with dysphagia, and increases the likelihood that aspirated material will reach the lung. The consequence of hypotussia with reduced airway clearance can include respiratory tract infection, chronic inflammation, and long-term damage to the lung parenchyma. Despite the clear implications for health, the problem of managing hypotussia in individuals with dysphagia is frequently overlooked. Here, we provide an overview of the current interventions and treatment approaches for hypotussic cough. We synthesize the available literature to summarize research findings that advance our understanding of these interventions, as well as current gaps in knowledge. Further, we highlight pragmatic resources to increase awareness of hypotussic cough interventions and provide support for the clinical implementation of evidence-based treatments. In culmination, we discuss potential innovations and future directions for hypotussic cough research.

Impaired oral health: a required companion of bacterial aspiration pneumonia

Laryngotracheal aspiration has a widely-held reputation as a primary cause of lower respiratory infections, such as pneumonia, and is a major concern of care providers of the seriously ill orelderly frail patient. Laryngeal mechanical inefficiency resulting in aspiration into the lower respiratory tract, by itself, is not the cause of pneumonia. It is but one of several factors that must be present simultaneously for pneumonia to develop. Aspiration of oral and gastric contentsoccurs often in healthy people of all ages and without significant pulmonary consequences. Inthe seriously ill or elderly frail patient, higher concentrations of pathogens in the contents of theaspirate are the primary catalyst for pulmonary infection development if in an immunocompromised lower respiratory system. The oral cavity is a complex and ever changing eco-environment striving to maintain homogeneity among the numerous microbial communities inhabiting its surfaces. Poor maintenance of these surfaces to prevent infection can result inpathogenic changes to these microbial communities and, with subsequent proliferation, can altermicrobial communities in the tracheal and bronchial passages. Higher bacterial pathogen concentrations mixing with oral secretions, or with foods, when aspirated into an immunecompromised lower respiratory complex, may result in bacterial aspiration pneumonia development, or other respiratory or systemic diseases. A large volume of clinical evidence makes it clear that oral cleaning regimens, when used in caring for ill or frail patients in hospitals and long-term care facilities, drastically reduce the incidence of respiratory infection and death. The purpose of this narrative review is to examine oral health as a required causative companionin bacterial aspiration pneumonia development, and the effectiveness of oral infection control inthe prevention of this disease.

Hydrochloric Acid-Induced Acute Lung Injury Models: Dynamic Change and Quantitative Analysis of Modified Lung Ultrasound Scoring System and High-Resolution Computed Tomography

OBJECTIVE

Acute lung injury (ALI) has become a research hotspot due to its significant public health impact. To explore the value of the use of modified lung ultrasound (MLUS) scoring system for evaluating ALI using a rabbit model of ALI induced by hydrochloric acid (HCl) and investigate its correlation with high-resolution computed tomography (HRCT) and histopathological scores.

METHODS

Twenty New Zealand laboratory rabbits were randomly assigned to control group (N = 5) and 3 experimental groups (N = 5 each). The control group received instillation of physiological saline, while the 3 experimental groups received 2 mL/kg of different doses of HCl instillation (mild group: pH 1.5, moderate group: pH 1.2, and severe group: pH 1.0) through the trachea under ultrasound guidance. Pulmonary ultrasound (using Mindray Reason9 linear array probes with frequency of 6-15 mHz) and HRCT examinations were performed before modeling (0H) and at 1H, 2H, 4H, 8H, 12H after modeling. The experimental rabbits were sacrificed at 12H for examination of gross lung morphology and hematoxylin-eosin-stained histopathological sections. The correlation of MLUS scores with HRCT/histopathological scores was assessed.

RESULTS

All rabbits in the experimental groups showed oxygenation index PaO₂/FiO₂<300. Successful establishment of ALI model was proven by autopsy (successful modeling rate: 100%). The pathological damage increased with increase in HCl dosage. MLUS scores showed a positive correlation with HRCT scores/pathological severity. There was a strong positive correlation between MLUS scores and histopathological scores (r = 0.963, p < 0.05) as well as between HRCT scores and histopathological scores (r = 0.932, p < 0.05).

CONCLUSION

Transtracheal injection of different dosages of HCl under ultrasound guidance induced different degrees of ALI. The MLUS scoring system can be used for semiquantitative evaluation of ALI, and is suitable as a screening tool.

Development and validation of a risk prediction model for aspiration in patients with acute ischemic stroke

BACKGROUND

Aspiration is a frequently observed complication in individuals diagnosed with acute ischemic stroke, leading to potentially severe consequences. However, the availability of predictive tools for assessing aspiration probabilities remains limited. Hence, our study aimed to develop and validate a nomogram for accurately predicting aspiration probability in patients with acute ischemic stroke.

METHODS

We analyzed 30 potential risk factors associated with aspiration in 359 adult patients diagnosed with acute ischemic stroke. Advanced statistical techniques, such as Least absolute shrinkage and selection operator (LASSO) and Multivariate Logistic regression, were employed to identify independent predictors. Subsequently, we developed a nomogram prediction model based on these predictors, which underwent internal validation through 1000 bootstrap resampling. Two additional cohorts (Cohort A n = 64; Cohort B, n = 105) were included for external validation. The discriminatory power and calibration performance of the nomogram were assessed using rigorous methods, including the Hosmer-Lemeshow test, area under the receiver operating characteristic curve (AUC), calibration curve analyses, and decision curve analyses (DCA).

RESULTS

The nomogram was established based on four variables: sputum suction, brain stem infarction, temporal lobe infarction, and Barthel Index score. The predictive model exhibited satisfactory discriminative ability, with an area under the receiver operating characteristic curve of 0.853 (95 % confidence interval, 0.795-0.910), which remained consistent at 0.852 (95 % confidence interval, 0.794-0.912) during the internal validation. The Hosmer-Lemeshow test (P = 0.394) and calibration curve demonstrated favorable consistency between the predicted and observed outcomes in the development cohort. The AUC was 0.872 (95 % confidence interval, 0.783-0.962) in validation cohort A and 0.877 (95 % confidence interval, 0.764-0.989) in validation cohort B, demonstrating sustained accuracy. DCA showed a good net clinical benefit of the nomogram.

CONCLUSIONS

A nomogram for predicting the probability of aspiration in patients with acute ischemia has been successfully developed and validated.

Physiologically based pharmacokinetic model for predicting the biodistribution of albumin nanoparticles after induction and recovery from acute lung injury

The application of nanomedicine in the treatment of acute lung injury (ALI) has great potential for the development of new therapeutic strategies. To gain insight into the kinetics of nanocarrier distribution upon time-dependent changes in tissue permeability after ALI induction in mice, we developed a physiologically based pharmacokinetic model for albumin nanoparticles (ANP). The model was calibrated using data from mice treated with intraperitoneal LPS (6 mg/kg), followed by intravenous ANP (0.5 mg/mouse or about 20.8 mg/kg) at 0.5, 6, and 24 h. The simulation results reproduced the experimental observations and indicated that the accumulation of ANP in the lungs increased, reaching a peak 6 h after LPS injury, whereas it decreased in the liver, kidney, and spleen. The model predicted that LPS caused an immediate (within the first 30 min) dramatic increase in lung and kidney tissue permeability, whereas splenic tissue permeability gradually increased over 24 h after LPS injection. This information can be used to design new therapies targeting specific organs affected by bacterial infections and potentially by other inflammatory insults.

Snoring-generated fluid droplets as a potential mechanistic link between sleep-disordered breathing and pneumonia

The soft palate and back of the throat represent vulnerable early infection sites for SARS-CoV-2, influenza, streptococci, and many other pathogens. We demonstrate that snoring causes aerosolization of pharyngeal fluid that covers these surfaces, which previously has escaped detection because the inspired airstream carries the micron-sized droplets into the lung, inaccessible to traditional aerosol detectors. While many of these droplets will settle in the lower respiratory tract, a fraction of the respirable smallest droplets remains airborne and can be detected in exhaled breath. We distinguished these exhaled droplets from those generated by the underlying breathing activity by using a chemical tracer, thereby proving their existence. The direct transfer of pharyngeal fluids and their pathogens into the deep lung by snoring represents a plausible mechanistic link between the previously recognized association between sleep-disordered breathing and pneumonia incidence.

Microbiological Profile of Patients with Aspiration Pneumonia Identified by Combined Detection Methods

Purpose

Aspiration pneumonia (AP) challenges public health globally. The primary aim of this study was to ascertain the microbiological profile characteristics of patients with AP evaluated by combined detection methods, including conventional microbiological tests (CMTs), chips for complicated infection detection (CCID), and metagenomic next-generation sequencing (mNGS).

Patients and Methods

From June 2021 to March 2022, a total of thirty-nine patients with AP or community-acquired pneumonia with aspiration risk factors (AspRF-CAP) from 3 hospitals were included. Respiratory specimens, including bronchoalveolar lavage fluid (BALF), sputum, and tracheal aspirate, were collected for microorganism detection.

Results

Patients with AP were more inclined to be older, to have a shorter duration from illness onset to admission, to have a higher prevalence of different underlying diseases, particularly diabetes mellitus, chronic heart disease, and cerebrovascular disease, and to have a higher CURB-65 score (all P < 0.05). A total of 213 and 31 strains of microorganisms were detected in patients with AP and AspRF-CAP, respectively. The most common pathogens in AP were Corynebacterium striatum (17/213, 7.98%), Pseudomonas aeruginosa (15/213, 7.04%), Klebsiella pneumoniae (15/213, 7.04%), and Candida albicans (14/213, 6.57%). Besides, the most common pathogens in AspRF-CAP were Candida albicans (5/31, 16.13%), Pseudomonas aeruginosa (3/31, 9.68%) and Klebsiella pneumoniae (3/31, 9.68%). Moreover, Klebsiella pneumoniae (7/67, 10.45%) and Candida glabrata (5/67, 7.46%) were the most common pathogens among the 9 non-survived patients with AP.

Conclusion

The prevalent pathogens detected in cases of AP were Corynebacterium striatum, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Candida albicans. Early combined detection methods for patients with AP enhance the positive detection rate of pathogens and potentially expedites the initiation of appropriate antibiotic therapeutic strategies.

Glucagon-Like Peptide-1 Receptor Agonists Do Not Increase Aspiration During Upper Endoscopy in Patients With Diabetes

BACKGROUND & AIMS

Glucagon-like peptide-1-receptor agonists (GLP1-RAs) have been associated with greater retention of gastric contents, however, there is minimal controlled, population-based data evaluating the potential adverse effects of GLP1-RA in the periprocedural setting. We aimed to determine if there is increased risk of aspiration and aspiration-related complications after upper endoscopy in patients using GLP1-RAs.

METHODS

We used a nationwide commercial administrative claims database to conduct a retrospective cohort study of patients aged 18 to 64 with type 2 diabetes who underwent outpatient upper endoscopy from 2005 to 2021. We identified 6,806,046 unique upper endoscopy procedures. We compared claims for aspiration and associated pulmonary adverse events in the 14 days after upper endoscopy between users of GLP1-RAs, dipeptidyl peptidase 4 inhibitors (DPP4is), and chronic opioids. We adjusted for age, sex, Charlson Comorbidity score, underlying respiratory disease, and gastroparesis.

RESULTS

We found that pulmonary adverse events after upper endoscopy are rare, ranging from 6 to 25 events per 10,000 procedures. When comparing GLP1-RAs with DPP4i, crude relative risks of aspiration (0.67; 95% CI, 0.25-1.75), aspiration pneumonia (0.95; 95% CI, 0.40-2.29), pneumonia (1.07; 95% CI, 0.62-1.86), or respiratory failure (0.75; 95% CI, 0.38-1.48) were not higher in patients prescribed a GLP1-RA. When comparing GLP1-RAs with opioids, crude relative risks were 0.42 (95% CI, 0.15-1.16) for aspiration, 0.60 (95% CI, 0.24-1.52) for aspiration pneumonia, 0.30 (95% CI, 0.19-0.49) for pneumonia, and 0.24 (95% CI, 0.13-0.45) for respiratory failure. These results were consistent across several sensitivity analyses.

CONCLUSIONS

GLP1-RA use is not associated with an increased risk of pulmonary complications after upper endoscopy compared with DPP4i use in patients with type 2 diabetes.

Optimizing Diagnosis and Management of Community-acquired Pneumonia in the Emergency Department

Pneumonia is split into 3 diagnostic categories: community-acquired pneumonia (CAP), health care-associated pneumonia, and ventilator-associated pneumonia. This classification scheme is driven not only by the location of infection onset but also by the predominant associated causal microorganisms. Pneumonia is diagnosed in over 1.5 million US emergency department visits annually (1.2% of all visits), and most pneumonia diagnosed by emergency physicians is CAP.

Recommendations of good practice to prevent aspiration pneumonia in older adults at risk of oropharyngeal dysphagia living in nursing homes: A modified e-Delphi study protocol

BACKGROUND

Aspiration pneumonia (AP) is a subset of pneumonia caused by the aspiration of food and fluids to the lungs and is highly prevalent in the older population. Oropharyngeal dysphagia (OD) is one of the risk factors for AP and it is also associated with malnutrition, dehydration and poor functional outcomes. As pneumonia is the second most common infection in nursing homes (NHs) and OD represents a major concern to NH staff, good practices for the prevention of AP in older adults at risk of OD are needed.

PURPOSE

The aim of this modified e-Delphi study is to build consensus among a panel of experts regarding a set of recommendations for NH staff on good practices to prevent AP in older adults at risk of OD living in NHs. The objective of this paper is to establish the methodology inherent to the Delphi study.

METHODS

An online modified Delphi study will be developed in three rounds. Criteria for the Delphi panel participants include holding a master's or doctoral degree in OD or speech and language therapy; or having 10 or more years of experience in OD; or having at least one scientific publication related to OD. A previously described modified Delphi methodology will be used to achieve consensus (75% agreement). An additional round will be performed to collect the experts' perspectives regarding the priority for application of each recommendation previously validated.

DISCUSSION

This protocol aimed to describe the methodology of a future Delphi study on the prevention of AP, seeking to fulfil the gap in the literature regarding this topic. The modified Delphi technique is a widely used method for collecting experts' opinion in health sciences, but the absence of standardised guidelines allows some heterogeneity between studies with the same aim.

WHAT THIS PAPER ADDS

What is already known on the subject Aspiration pneumonia (AP) is related to three main risk factors: impaired safety of swallow, impaired nutritional status and poor oral health. It is known that being dependent for feeding is one of the main risk factors for AP and around 50% of nursing home (NH) residents need feeding assistance. Thus, it is important to promote specialised intervention and care by the NH staff for preventing AP. What this paper adds to existing knowledge It is hypothesised that increasing the knowledge of NH staff regarding the best practices for preventing AP in older adults at risk of oropharyngeal dysphagia (OD) will improve outcomes such as quality of life, incidence of AP and mortality. What are the potential or actual clinical implications of this work? The recommendations resulting from this study will address a current gap in healthcare practice of NH staff regarding older adults at increased risk for OD and, consequently, for AP.

Melatonin-induced upregulation of telomerase activity interferes with macrophage mitochondrial metabolism and suppresses NLRP3 inflammasome activation in the treatment of Pneumonia

Objective

This study aims to investigate the effects of melatonin-induced upregulation of telomerase activity on mitochondrial metabolism and NLRP3 inflammasome activation in macrophages, with the ultimate goal of elucidating potential therapeutic implications for pneumonia treatment.

Materials and methods

Macrophages were treated with melatonin to assess its impact on telomerase activity. Mitochondrial function was evaluated through the measurement of reactive oxygen species (ROS) levels and cellular energy production. NLRP3 inflammasome activation was assessed by examining the production of inflammatory cytokines, such as interleukin-1β (IL-1β). The expression levels of key proteins involved in mitochondrial metabolism and NLRP3 inflammasome signaling were also analyzed.

Results

Our findings demonstrated that melatonin treatment significantly upregulated telomerase activity in macrophages. This was associated with a reduction in ROS levels and enhanced cellular energy production, indicating improved mitochondrial function. Moreover, melatonin treatment suppressed NLRP3 inflammasome activation, resulting in reduced secretion of IL-1β. The expression levels of proteins involved in mitochondrial metabolism and NLRP3 inflammasome signaling were modulated by melatonin.

Conclusion

These results suggest that melatonin-induced upregulation of telomerase activity can interfere with mitochondrial metabolism and inhibit NLRP3 inflammasome activation in macrophages. This indicates a potential therapeutic role for melatonin in the treatment of pneumonia. Understanding the molecular mechanisms underlying these effects may lead to the development of novel therapeutic strategies targeting mitochondria and NLRP3 inflammasome activation for the management of pneumonia. Further investigations are warranted to fully uncover the therapeutic potential of melatonin and its implications for pneumonia treatment.

Incidence and characteristics of aspiration pneumonia in the Nagasaki Prefecture from 2005 to 2019

BACKGROUND

Aspiration pneumoniae remains a major health concern, particularly in the older population and has poor prognosis; however, the concept itself remains vague worldwide. This study aimed to determine the actual situation and characteristics of aspiration pneumonia from 2005 to 2019 in Nagasaki Prefecture, Japan.

METHODS

Cases of aspiration pneumonia that occurred in the Nagasaki Prefecture between 2005 and 2019 were analyzed using emergency transportation records. The number of occurrences and incidence were analyzed according to age, sex, month, day of the week, and recognition time to clarify the actual situation of aspiration pneumonia.

RESULTS

The total number of new aspiration pneumonia cases was 8,321, and the mean age of the patients was 83.0 years. Annual incidence per 100,000 population increased from 12.4 in 2005 to 65.1 in 2019, with the most prominent increase in the ≥ 80-year-old stratum. Males (55.1%) were more commonly affected than females (44.9%), and 82.2% of the cases involved patients aged ≥ 70 years. No significant correlations were observed between the incidence of aspiration pneumonia and season, month, or day of the week. Aspiration pneumonia occurred frequently in houses (39.8%) and facilities for elderly individuals (40.8%). At 7 days after admission, 80.9% of patients were still hospitalized and 6.5% had died.

CONCLUSIONS

The incidence of aspiration pneumonia with risks of severity and mortality is increasing among elderly individuals. Valid preventive measures are urgently needed based on the findings that the disease occurs in both household and elderly care facility settings, regardless of the season.

Clinical features of plastic bronchitis in children after congenital heart surgery

BACKGROUND

Plastic bronchitis (PB) can occur in patients who have undergone congenital heart surgery (CHS). This study aimed to investigate the clinical features of PB in children after CHS.

METHODS

We conducted a retrospective cohort study using the electronic medical record system. The study population consisted of children diagnosed with PB after bronchoscopy in the cardiac intensive care unit after CHS from May 2016 to October 2021.

RESULTS

A total of 68 children after CHS were finally included in the study (32 in the airway abnormalities group and 36 in the right ventricular dysfunction group). All children were examined and treated with fiberoptic bronchoscopy. Pathogens were detected in the bronchoalveolar lavage fluid of 41 children, including 32 cases in the airway abnormalities group and 9 cases in the right ventricular dysfunction group. All patients were treated with antibiotics, corticosteroids (intravenous or oral), and budesonide inhalation suspension. Children with right ventricular dysfunction underwent pharmacological treatment such as reducing pulmonary arterial pressure. Clinical symptoms improved in 64 children, two of whom were treated with veno-arterial extracorporeal membrane oxygenation (ECMO) due to recurrent PB and disease progression.

CONCLUSIONS

Children with airway abnormalities or right ventricular dysfunction after CHS should be alerted to the development of PB. Pharmacological treatment such as anti-infection, corticosteroids, or improvement of right ventricular function is the basis of PB treatment, while fiberoptic bronchoscopy is an essential tool for the diagnosis and treatment of PB. ECMO assistance is a vital salvage treatment for recurrent critically ill PB patients.

Dysphagia in Ischaemic Stroke Patients: One Centre Retrospective Study

The aim of this study was to examine the frequency of dysphagia in patients with ischaemic stroke. It was crucial to evaluate the relationship between swallowing disorders and selected demographic and clinical indicators. Additionally, the association between various patient feeding methods and selected demographic and clinical factors was assessed. Based on the analysis of medical documentation, we identified the most important clinical parameters, including demographic data, the frequency of stroke risk factors, the location of the ischaemic lesion, cortical involvement, stroke severity as measured by the NIHSS (Nationale Institutes of Health Stroke Scale), and the methods of feeding post-stroke patients. Dysphagia was observed in 65.9% of the patients in the study group. Hypertension was the most common chronic illness in the studied population of ischemic stroke patients (91.8% of patients). Diet modification (35.7%) and PEG (25%) were the frequent methods of feeding in patients with confirmed dysphagia. Age played a significant role in determining the feeding methods in patients with dysphagia. Patients with a PEG (Percutaneous Endoscopic Gastrostomy) tube were the oldest (79.37 ± 10.80) and 75% of them had pneumonia. Early identification of swallowing difficulties in stroke patients is critical in determining an appropriate and safe feeding plan, as well as initiating logopedics therapy to improve swallowing efficacy and minimize pulmonary complications.

Antibiotics for the treatment of lower respiratory tract infections in children with neurodisability: Systematic review

AIM

Determine the optimal antibiotic choice for lower respiratory tract infection (LRTI) in children with neurodisability.

METHODS

Embase, Ovid Emcare and MEDLINE were searched for studies from inception to January 2023. All studies, except case reports, focusing on the antibiotic treatment of LRTI in children, with neurodisabilities were included. Outcomes included length of stay, intensive care admission and mortality.

RESULTS

Nine studies met the inclusion criteria (5115 patients). All the studies were of low quality. The shortest length of stay was with anaerobic and gram-positive cover. Five studies used anaerobic, gram-positive and gram-negative cover (e.g., amoxicillin-clavulanic acid), which was frequently adequate. In one large study, it was better than gram-positive and gram-negative cover alone (e.g. ceftriaxone). Those unresponsive or more unwell at presentation improved faster on Pseudomonas aeruginosa cover (e.g., piperacillin-tazobactam).

CONCLUSION

In this context, anaerobic, gram-positive and gram-negative cover is just as effective as P. aeruginosa cover, supporting empiric treatment with amoxicillin-clavulanic acid. If there is a failure to improve, broadening to include P. aeruginosa could be considered. This is consistent with a consensus statement on the treatment of LRTI in children with neurodisability. An accepted definition for what constitutes LRTI in this cohort is required before designing prospective randomised trials.

Measuring the prevalence of aspiration pneumonia in view of improving the relevance of antibiotic prescription of antibiotics: A retrospective, observational study

PURPOSE

Aspiration pneumonia (AP) has significant incidence and impact on mortality. However, data about clinical diagnosis criteria are scarce. We aimed to evaluate according to predefined criteria the prevalence of true AP and its impact on antibiotic stewardship.

METHODS

Retrospective study of patients whose main diagnosis was AP hospitalized at Amiens University Hospital in 2018. We first defined diagnostic criteria of certainty for pneumonia and aspiration. AP was then classified according to degree of certainty.

RESULTS

Among 862 cases of AP, its diagnosis was certain, likely, probably in excess, certainly in excess or absent in 2 % (n = 17), 3 % (n = 26), 50.5 % (n = 433), 23.1 % (n = 198) and 21.4 % (n = 183) respectively. Irrelevant use of amoxicillin-clavulanic acid and metronidazole was found in 27 % and 13 % of cases, respectively.

CONCLUSIONS

The diagnosis of AP is frequently excessive, and diagnostic tools are urgently needed to improve antibiotic stewardship.

New Guidelines for Severe Community-acquired Pneumonia

In 2023, the new European guidelines on severe community-acquired pneumonia, providing clinical practice recommendations for the management of this life-threatening infection, characterized by a high burden of mortality, morbidity, and costs for the society. This review article aims to summarize the principal evidence related to eight different questions covered in the guidelines, by also highlighting the future perspectives for research activity.

Migraine and the microbiota. Can probiotics be beneficial in its prevention? - a narrative review

Migraine is a recurrent disease of the central nervous system that affects an increasing number of people worldwide causing a continuous increase in the costs of treatment. The mechanisms underlying migraine are still unclear but recent reports show that people with migraine may have an altered composition of the intestinal microbiota. It is well established that the gut-brain axis is involved in many neurological diseases, and probiotic supplementation may be an interesting treatment option for these conditions. This review collects data on the gastrointestinal and oral microbiota in people suffering from migraine and the use of probiotics as a novel therapeutic approach in its treatment.

Safety profile of hypnotics or sedatives on community-dwelling older adults aged 75 or older in Japan: A retrospective propensity-matched cohort study

OBJECTIVE

The purpose of the study is to assess if daily use of hypnotics increases mortality, aspiration pneumonia and hip fracture among relatively healthy individuals aged 75 years or older who lead independent lives in the community.

METHOD AND PATIENTS

Of the adults aged 75 years or older residing in Hokkaido prefecture of Japan (n = 705,538), those who did not meet several exclusion criteria were eligible for generating propensity score-matched cohorts (n = 214,723). Exclusion criteria included co-prescribed medications acting on the central nervous system, diagnoses of malignant neoplasm, dementia, depression, etc. We compared 33,095 participants who were prescribed hypnotics for daily use (hypnotic group) with a propensity score-matched cohort without a prescription (control group). Participants were followed for more than 42 months.

RESULTS

During the 42-month follow-up period, the incidence of the three outcome measures in the hypnotics group was significantly higher than that in the control group (aspiration pneumonia p < 0.001, hip fracture p = 0.007, and all-cause mortality p < 0.001). Sensitivity analyses utilizing inverse probability weighting demonstrated hazard ratios of 1.083 [1.023-1.146] for mortality, 1.117 [1.014-1.230] for aspiration pneumonia, and 1.720 [1.559-1.897] for hip fracture. Meanwhile, the attribute risk differences were 2.7, 1.5, and 1.0 per 1000 patient-years, respectively.

CONCLUSIONS

Although daily use of hypnotics increased the risk of three events, their attribute risk differences were fewer than 3.0 per 1000 patient-years. The results will help provide guidance on whether it is reasonable to prescribe hypnotics to geriatric population aged 75 or older leading independent lives in the community.

CLINICAL TRIAL REGISTRATION

UMIN-CTR UMIN000048398.

Aspiration Pneumonia

Aspiration pneumonia is a lower respiratory tract infection that results from inhalation of foreign material, often gastric and oropharyngeal contents. It is important to distinguish this from a similar entity, aspiration with chemical pneumonitis, as treatment approaches may differ. An evolving understanding of the human microbiome has shed light on the pathogenesis of aspiration pneumonia, suggesting that dysbiosis, repetitive injury, and inflammatory responses play a role in its development. Risk factors for aspiration events involve a complex interplay of anatomical and physiological dysfunctions in the nervous, gastrointestinal, and pulmonary systems. Current treatment strategies have shifted away from anaerobic organisms as leading pathogens. Prevention of aspiration pneumonia primarily involves addressing oropharyngeal dysphagia, a significant risk factor for aspiration pneumonia, particularly among elderly individuals and those with cognitive and neurodegenerative disorders.

Challenges for a broad international implementation of the current severe community-acquired pneumonia guidelines

Severe community-acquired pneumonia (sCAP) remains one of the leading causes of admission to the intensive care unit, thus consuming a large share of resources and is associated with high mortality rates worldwide. The evidence generated by clinical studies in the last decade was translated into recommendations according to the first published guidelines focusing on severe community-acquired pneumonia. Despite the advances proposed by the present guidelines, several challenges preclude the prompt implementation of these diagnostic and therapeutic measures. The present article discusses the challenges for the broad implementation of the sCAP guidelines and proposes solutions when applicable.

Effects of Cerebellar Repetitive Transcranial Magnetic Stimulation in the Treatment of Post-Stroke Dysphagia: A Meta-Analysis and Systematic Review of Randomized Controlled Trials

INTRODUCTION

This study aimed to comprehensively evaluate the therapeutic efficacy of cerebellar repetitive transcranial magnetic stimulation (rTMS) in the rehabilitation of post-stroke dysphagia (PSD).

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically searched PubMed, Cochrane Library, Embase, and Web of Science to identify relevant randomized controlled trials (RCTs) investigating the application of cerebellar rTMS in the treatment of PSD. Inclusion and exclusion criteria were rigorously applied during the screening process, and pertinent characteristics of the included RCTs were meticulously extracted. The I2 statistic was employed to assess heterogeneity, and meta-analysis was conducted using Stata 17 software. The Cochrane Risk of Bias 2 tool and PEDro scale were utilized to evaluate bias risk and literature quality.

RESULTS

Our analysis encompassed a total of 5 RCTs involving 673 patients with dysphagia who met the inclusion criteria. The findings indicated a significant positive impact of cerebellar rTMS when combined with traditional swallowing exercises on PSD, demonstrating superior efficacy compared to conventional swallowing exercises in isolation. Furthermore, the study revealed no statistically significant differences based on stimulation site (unilateral vs. bilateral cerebellum), stimulation mode (rTMS vs. intermittent theta-burst stimulation), and stimulation frequency (5 Hz vs. 10 Hz).

CONCLUSION

The amalgamation of cerebellar rTMS with conventional swallowing exercises demonstrates notable efficacy, surpassing the outcomes achievable with traditional exercises alone. The sustained effectiveness observed underscores the potential of cerebellar rTMS as an innovative avenue in the field of neurorehabilitation for PSD. This study contributes valuable insights into the prospect of utilizing cerebellar rTMS as an adjunctive therapeutic strategy in the management of PSD, emphasizing its relevance for further exploration and clinical application.

Prevalence of Oropharyngeal Dysphagia and Its Value as a Prognostic Factor in Community-Acquired Pneumonia: A Prospective Case-Control Study

BACKGROUND

Although oropharyngeal dysphagia (OD) is a common finding in patients with community-acquired pneumonia (CAP), specific recommendations are not provided in the current clinical guidelines.

OBJECTIVES

To estimate the prevalence of OD and its associated factors among patients hospitalized for CAP and to assess one-year outcomes according to the presence or absence of OD.

METHODS

We studied 226 patients hospitalized for CAP and 226 patients hospitalized for respiratory conditions other than CAP. We screened the risk of OD using the Eating Assessment Tool-10 (EAT-10), followed by the volume-viscosity swallow test (V-VST).

RESULTS

A total of 122 (53.9%) patients with CAP had confirmed OD compared with 44 (19.4%) patients without CAP. Patients with CAP and OD were older (p < 0.001; 1.02-1.07) and had less familial/institutional support (p = 0.036; 0.12-0.91) compared to patients with CAP and no OD. OD was more prevalent as the CURB-65 score increased (p < 0.001). Patients with OD spent more time in the hospital (14.5 vs. 11.0 days; p = 0.038) and required more visits to the emergency room (ER). Twenty (16.4%) patients with CAP and OD died after discharge vs. one (0.8%) patient with CAP and no OD (p < 0.001; CI = 2.24-42.60).

CONCLUSIONS

The prevalence of OD in hospitalized patients with CAP is higher than in patients hospitalized for other respiratory diagnoses. Advanced age, lower familial/institutional support, and increased CAP severity are associated with OD. Patients with CAP and OD are more frequent ER visitors after discharge and have a higher mortality. In patients with CAP and OD, aspiration pneumonia is likely underestimated.

Impact of Antibiotics Used for Acute Aspiration Bronchitis on the Prevention of Pneumonia

BACKGROUNDS

It remains unclear if antibiotics should be used for the treatment of acute aspiration bronchitis to prevent the development of pneumonia. This study aimed to assess the associations between the use of antibiotics and the development of pneumonia among patients with acute aspiration bronchitis.

METHODS

We retrospectively reviewed consecutive patients with acute aspiration bronchitis aged ≥75 years. Acute aspiration bronchitis was defined as a condition with aspiration risk, high fever (body temperature, ≥37.5 °C), respiratory symptoms, and the absence of evidence of pneumonia.

RESULTS

There was no significant difference in the incidence of pneumonia between patients treated with and without antibiotics for acute aspiration bronchitis (6/44, 14% vs. 31/143, 22%; p = 0.242). Lower estimated glomerular filtration rate (adjusted odds ratio, 0.956; 95% confidence interval, 0.920-0.993) was significantly associated with the development of pneumonia.

CONCLUSIONS

Antibiotic administration should not be routinely recommended to prevent pneumonia following acute aspiration bronchitis, and patients with decreased renal function should be closely monitored. A randomized controlled trial is necessary to validate these results.

Factors Associated with Hospitalized Community-Acquired Pneumonia among Elderly Patients Receiving Home-Based Care

(1) Background: Pneumonia stands as a prevalent infectious disease globally, contributing significantly to mortality and morbidity rates. In Taiwan, pneumonia ranks as the third leading cause of death, particularly affecting the elderly population (92%). This study aims to investigate factors associated with community-acquired pneumonia (CAP) among elderly individuals receiving home-based care. (2) Methods: Conducted between January 2018 and December 2019, this retrospective study involved a medical chart review of elderly patients under home-based care. A multiple logistic regression model was employed to identify factors associated with CAP in this demographic. (3) Results: Analysis encompassed 220 elderly patients with an average age of 82.0 ± 1.1 years. Eighty-five patients (38.6%) were hospitalized for CAP. Predominant diagnoses included cancer (32.3%), stroke (24.5%), and dementia (23.6%). Significant predictors of CAP for elderly patients under home-based care included male gender (odds ratio [OR] = 4.10, 95% confidence interval [CI]: 1.95-8.60, p < 0.001), presence of a nasogastric (NG) tube (OR = 8.85, 95% CI: 3.64-21.56, p < 0.001), and a borderline negative association with the use of proton pump inhibitors (PPIs) (OR = 0.37, 95% CI: 0.13-1.02, p = 0.0546). End-of-life care indicators for these patients with CAP included an increased number of hospital admission days in the last month of life (OR = 1.13, 95% CI: 1.08-1.18, p < 0.001) and a higher likelihood of hospital death (OR = 3.59, 95% CI: 1.51-8.55, p = 0.004). (4) Conclusions: In the current study, significant predictors of CAP among elderly patients receiving home-based care included the presence of an NG tube and male gender, while the use of PPIs was borderline inversely associated with the risk of CAP. Notably, more admission days in the last month of life and death in the hospital were found to be associated with end-of-life care for this group.

Development and validation of a novel nomogram model to assess the risk of gastric contents in outpatients undergoing elective sedative gastrointestinal endoscopy procedures

BACKGROUND

Gastric contents may contribute to patients' aspiration during anesthesia. Ultrasound can accurately assess the risk of gastric contents in patients undergoing sedative gastrointestinal endoscopy (GIE) procedures, but its efficiency is limited. Therefore, developing an accurate and efficient model to predict gastric contents in outpatients undergoing elective sedative GIE procedures is greatly desirable.

METHODS

This study retrospectively analyzed 1501 patients undergoing sedative GIE procedures. Gastric contents were observed under direct gastroscopic vision and suctioned through the endoscope. High-risk gastric contents were defined as having solid content or liquid volume > 25 ml and pH < 2.5; otherwise, they were considered low-risk gastric contents. Univariate analysis and multivariate analysis were used to select the independent risk factors to predict high-risk gastric contents. Based on the selected independent risk factors, we assigned values to each independent risk factor and established a novel nomogram. The performance of the nomogram was verified in the testing cohort by the metrics of discrimination, calibration, and clinical usefulness. In addition, an online accessible web calculator was constructed.

RESULTS

We found BMI, cerebral infarction, cirrhosis, male, age, diabetes, and gastroesophageal reflux disease were risk factors for gastric contents. The AUROCs were 0.911 and 0.864 in the development and testing cohort, respectively. Moreover, the nomogram showed good calibration ability. Decision curve analysis and Clinical impact curve demonstrated that the predictive nomogram was clinically useful. The website of the nomogram was https://medication.shinyapps.io/dynnomapp/.

CONCLUSIONS

This study demonstrates that clinical variables can be combined with algorithmic techniques to predict gastric contents in outpatients. Nomogram was constructed from routine variables, and the web calculator had excellent clinical applicability to assess the risk of gastric contents accurately and efficiently in outpatients, assist anesthesiologists in assessment and identify the most appropriate patients for ultrasound.

"Diagnose, Treat, and SUPPORT". Clinical competencies in the management of older adults with aspiration pneumonia: a scoping review

BACKGROUND

Aspiration pneumonia in older adults is increasingly common, with a high care burden and morbidity. However, clinical competencies in its management have not been developed, and healthcare professionals struggle on how to care for these patients with multimodal treatment needs. Therefore, we conducted a scoping review to investigate what is known about the desired clinical competencies for the management of older adults with aspiration pneumonia, to utilise in clinical practice, education, and future research.

METHODS

First, we defined aspiration pneumonia according to a preliminary search. We then searched the literature on MEDLINE and CINAHL, focusing on studies involving patients aged 65 years old and older diagnosed with aspiration pneumonia. All settings were included, with the exception of intensive care units. Publication dates were limited to January 2011 to July 2022 and languages to English and Japanese. The extracted data were used to refine the preliminary competency framework developed by the Japan Aspiration pneumonia inter-Professional team Educational Program (JAPEP) in preparation of this study.

RESULTS

Ninety-nine studies were included. Following data extraction from these studies, 3 competencies were renamed, and 3 new competencies were added, to create a list of 12 competencies. These were Diagnosis, Treatment, Swallow Assessment, Underlying condition management, Nutrition, Oral management, Rehabilitation, Multidisciplinary team, Decision making, Prevention, Prognosis, and Palliative care.

CONCLUSIONS

Our scoping review identified 12 clinical competencies required in the management of older adults with aspiration pneumonia, outlined in the phrase 'Diagnose, Treat and SUPPORT'. We encourage healthcare professionals to share these competencies as a team to identify areas of unmet need and improve their patient care, with an emphasis on supportive care.

Factors associated with changes in activities of daily living from admission to discharge among older patients with pneumonia

INTRODUCTION

It has not been fully elucidated that nutritional parameters affect the change of activities of daily living (ADL) during pneumonia treatment. This study assessed the impact of nutritional status, including erector spinae muscle (ESM) size on ADL changes from admission to discharge among older patients with community-acquired pneumonia (CAP).

METHODS

We retrospectively included patients (age: ≥65 years) who were admitted to the hospital for CAP and underwent chest computed tomography (CT) on admission. ADL was evaluated using the Barthel index, and patients were divided into the maintained or improved ADL group and the declined ADL group from admission through discharge. The ESM cross-sectional area was measured on a single-slice CT image. Logistic regression models were applied for assessing factors associated with changes in ADL.

RESULTS

A total of 523 patients hospitalized for CAP (median age 86 years) were evaluated. The declined group had significantly higher ADL levels on admission, a greater frequency of smoking history and malignancy, and a lower frequency of cerebrovascular disease and dementia. No significant difference in ESM size was observed between the groups. Multivariate analysis revealed that higher ADL levels on admission (odds ratio 1.034, interquartile range 1.026-1.043) and malignancy (3.002, 1.150-7.836) were associated with a decline in ADL, whereas cerebrovascular disease (0.579, 0.373-0.900) was related to improvement or maintenance of ADL.

CONCLUSIONS

Although nutritional status might not affect the change of ADL among older patients hospitalized with pneumonia, a cerebrovascular disease history may be a good predictor for ADL improvement.

Pneumonia detection based on RSNA dataset and anchor-free deep learning detector

Pneumonia is a highly lethal disease, and research on its treatment and early screening tools has received extensive attention from researchers. Due to the maturity and cost reduction of chest X-ray technology, and with the development of artificial intelligence technology, pneumonia identification based on deep learning and chest X-ray has attracted attention from all over the world. Although the feature extraction capability of deep learning is strong, existing deep learning object detection frameworks are based on pre-defined anchors, which require a lot of tuning and experience to guarantee their excellent results in the face of new applications or data. To avoid the influence of anchor settings in pneumonia detection, this paper proposes an anchor-free object detection framework and RSNA dataset based on pneumonia detection. First, a data enhancement scheme is used to preprocess the chest X-ray images; second, an anchor-free object detection framework is used for pneumonia detection, which contains a feature pyramid, two-branch detection head, and focal loss. The average precision of 51.5 obtained by Intersection over Union (IoU) calculation shows that the pneumonia detection results obtained in this paper can surpass the existing classical object detection framework, providing an idea for future research and exploration.

Early swallowing rehabilitation and promotion of total oral intake in patients with aspiration pneumonia: A retrospective study

OBJECTIVES

To investigate the impact of early swallowing assessment and rehabilitation on the total oral intake and in-hospital mortality in patients with aspiration pneumonia.

METHODS

We retrospectively analyzed the data of patients with aspiration admitted between September 1, 2015, and October 31, 2016. The inclusion criterion was total oral intake before admission. A new protocol-based intervention for appropriate early oral intake was implemented on April 1, 2016. The protocol consisted of two steps. First, a screening test was conducted on the day of admission to detect patients who were not at high risk of dysphagia. Second, patients underwent a modified water swallowing test and water swallowing test. Patients cleared by these tests immediately initiated oral intake. The primary outcome, the composite outcomes of no recovery to total oral intake at discharge, and in-hospital mortality were compared between the patients admitted pre- and post protocol intervention.

RESULTS

A total of 188 patients were included in the analysis (pre-, 92; post-, 96). The primary outcome did not differ between the pre- and post-intervention periods (23/92 [25.0%] vs. 18/96 [18.8%], p = 0.30). After adjusting for other variables, the intervention was significantly associated with a lower risk of composite outcomes (odds ratio, 0.22, 95%CI, 0.08-0.61, p = 0.004).

CONCLUSION

The new protocol for early swallowing assessment, rehabilitation, and promotion of oral intake in patients admitted with aspiration pneumonia may be associated with the lower risk for the composite outcomes of in-hospital mortality and no recovery to total oral intake.

Routine Metagenomics Service for ICU Patients with Respiratory Infection

Rationale: Respiratory metagenomics (RMg) needs evaluation in a pilot service setting to determine utility and inform implementation into routine clinical practice. Objectives: Feasibility, performance, and clinical impacts on antimicrobial prescribing and infection control were recorded during a pilot RMg service. Methods: RMg was performed on 128 samples from 87 patients with suspected lower respiratory tract infection (LRTI) on two general and one specialist respiratory ICUs at Guy's and St Thomas' NHS Foundation Trust, London. Measurements and Main Results: During the first 15 weeks, RMg provided same-day results for 110 samples (86%), with a median turnaround time of 6.7 hours (interquartile range = 6.1-7.5 h). RMg was 93% sensitive and 81% specific for clinically relevant pathogens compared with routine testing. Forty-eight percent of RMg results informed antimicrobial prescribing changes (22% escalation; 26% deescalation) with escalation based on speciation in 20 out of 24 cases and detection of acquired-resistance genes in 4 out of 24 cases. Fastidious or unexpected organisms were reported in 21 samples, including anaerobes (n = 12), Mycobacterium tuberculosis, Tropheryma whipplei, cytomegalovirus, and Legionella pneumophila ST1326, which was subsequently isolated from the bedside water outlet. Application to consecutive severe community-acquired LRTI cases identified Staphylococcus aureus (two with SCCmec and three with luk F/S virulence determinants), Streptococcus pyogenes (emm1-M1uk clone), S. dysgalactiae subspecies equisimilis (STG62647A), and Aspergillus fumigatus with multiple treatments and public health impacts. Conclusions: This pilot study illustrates the potential of RMg testing to provide benefits for antimicrobial treatment, infection control, and public health when provided in a real-world critical care setting. Multicenter studies are now required to inform future translation into routine service.

Necroptosis in Pneumonia: Therapeutic Strategies and Future Perspectives

Pneumonia remains a major global health challenge, necessitating the development of effective therapeutic approaches. Recently, necroptosis, a regulated form of cell death, has garnered attention in the fields of pharmacology and immunology for its role in the pathogenesis of pneumonia. Characterized by cell death and inflammatory responses, necroptosis is a key mechanism contributing to tissue damage and immune dysregulation in various diseases, including pneumonia. This review comprehensively analyzes the role of necroptosis in pneumonia and explores potential pharmacological interventions targeting this cell death pathway. Moreover, we highlight the intricate interplay between necroptosis and immune responses in pneumonia, revealing a bidirectional relationship between necrotic cell death and inflammatory signaling. Importantly, we assess current therapeutic strategies modulating necroptosis, encompassing synthetic inhibitors, natural products, and other drugs targeting key components of the programmed necrosis pathway. The article also discusses challenges and future directions in targeting programmed necrosis for pneumonia treatment, proposing novel therapeutic strategies that combine antibiotics with necroptosis inhibitors. This review underscores the importance of understanding necroptosis in pneumonia and highlights the potential of pharmacological interventions to mitigate tissue damage and restore immune homeostasis in this devastating respiratory infection.

Perspectives of oral health therapists on the barriers to oral care provision in nursing homes in Singapore: A qualitative analysis

INTRODUCTION

Oral health therapists (OHTs) are a valuable resource for increasing access to dental care for the frail elderly in nursing homes (NHs). However, OHTs face several barriers and their skill-set continues to be under-utilized.

AIMS

To evaluate the perceptions of OHTs regarding the barriers towards oral care provision for the elderly residents in NHs.

METHODOLOGY

Semi-structured interviews were conducted with 11 OHTs to discuss the factors that may hinder them from providing oral health services in NHs. An inductive thematic analysis directed by the grounded theory approach was performed.

RESULTS

Four major themes emerged: (i) lack of opportunity, (ii) lack of adequate education and training, (iii) limited work scope and registration status, and (iv) lack of adequate financial remuneration and adequate equipment. OHTs also raised the lack of awareness among OHTs and the various stakeholders, of how the skill-set of OHTs may be relevant for oral care provision in NHs.

CONCLUSION

Findings revealed underlying educational and regulatory barriers which need to be addressed in tandem. Addressing these barriers can be impactful in informing future strategies for the greater utilization of the skill-set of OHTs in Singapore.

Reviving Consciousness: A Neurophysiotherapy Triumph in Decompressive Craniotomy Recovery

This case report presents a 54-year-old male with a history of type-2 diabetes mellitus who experienced sudden unconsciousness and vomiting, leading to aspiration and subsequent diagnosis of a hemorrhagic stroke. The patient underwent an immediate decompressive craniotomy, revealing a sizable intraparenchymal hematoma in the right basal ganglia and corona radiata. Postoperatively, the patient exhibited left-sided weakness, hyporeflexia, and cognitive impairment. A comprehensive neurophysiotherapy intervention addressed impaired mobility, strength, balance, coordination, respiratory complications, pain management, and other associated challenges. The rehabilitation protocol involved diverse strategies such as passive and active exercises, sensory stimulation, and the application of neurophysiotherapeutic approaches. The patient's progress was assessed using various outcome measures. Neurophysiotherapy plays a crucial role in the recovery of decompressive craniotomy.

Practical Utility of a Clinical Pathway for Older Patients with Aspiration Pneumonia: A Single-Center Retrospective Observational Study

Introduction: Clinical pathways (CPWs) are patient management tools based on a standardized treatment plan aimed at improving quality of care. This study aimed to investigate whether CPW-guided treatment has a favorable impact on the outcomes of hospitalized older patients with aspiration pneumonia. Method: This retrospective study included patients with aspiration pneumonia, aged ≥ 65 years, and hospitalized at a community hospital in Japan. CPW implementation was arbitrarily determined by the attending physician upon admission. Outcomes were compared according to with or without the CPW (CPW-group and non-CPW groups). Propensity score (PS)-based analyses were used to control for confounding factors. Logistic regression analyses were conducted to evaluate the impact of CPW on the clinical course and outcomes. Results: Of 596 included patients, 167 (28%) received the CPW-guided treatment. The mortality rate was 16.4%. In multivariable model, CPW implementation did not increase the risk for total and 30-day mortality, and resulted in shorter antibiotic therapy duration (≤9 days) (PS matching (PSM): odds ratio (OR) 0.50, p = 0.001; inverse provability of treatment weighting (IPTW): OR 0.48, p < 0.001) and length of hospital stay (≤21 days) (PSM: OR 0.67, p = 0.05; IPTW: OR 0.66, p = 0.03). Conclusions: This study support CPW utility in this population.

Usefulness of barium sulfate and iohexol as contrast agents for VFSS in visualizing components of swallowing predictable of poor outcomes

Barium sulfate and iohexol are commonly used as contrast agents for videofluoroscopic swallowing study (VFSS). This study compared their usefulness as contrast agents in visualizing components of swallowing predictable of subsequent pneumonia and unintentional weight loss after VFSS. This was a randomized, controlled, crossover trial. The two contrast agents were alternately used in the same participants, and the order in which the contrast agent was tested first was randomly assigned. After VFSS, we followed the participants for 3 months and the association between VFSS findings of each contrast agent and the subsequent pneumonia and unintentional weight loss were analyzed. A total of 30 participants were included in the analysis. We recorded 11 cases of subsequent pneumonia and 13 of unintentional weight loss. Regarding the risk of subsequent pneumonia after VFSS, only the oral transit time and number of swallows tested with barium sulfate indicated significant differences between participants with and without subsequent pneumonia. For unintentional weight loss, oral transit time and pharyngeal wall coating after swallowing tested with barium sulfate, as well as oral transit time, nasal penetration, residue in the valleculae, PAS scores, and number of swallows when testing with iohexol demonstrated significant differences between those with and without unintentional weight loss.

High throughput sequencing technology reveals alteration of lower respiratory tract microbiome in severe aspiration pneumonia and its association with inflammation

BACKGROUND

Aspiration pneumonia is a common and severe clinical condition. The microbiome present in the lower respiratory tract plays a crucial role in regulating human inflammatory response. However, the relationship between the altered lower respiratory tract microbiome and inflammation in aspiration pneumonia remains inadequately explored.

PURPOSE

To investigate the alteration of the lower respiratory tract microbiome in severe aspiration pneumonia patients and explore the potential correlation between microbiome components and inflammatory response.

METHOD

Patients in the severe aspiration pneumonia group and control group were enrolled from the intensive care unit of Jinshan Hospital, Fudan University between December 31, 2020 and August 19, 2021. Sputum specimens were collected from all participants and subsequently subjected to 16S rDNA high throughput sequencing technology. The concentration of inflammatory cytokines in serum was measured using enzyme-linked immunosorbent assay (ELISA) kits, and collected data including patients' demographic information, clinical data, and laboratory examination results were recorded for further analysis.

RESULTS

Alteration in the lower respiratory tract microbiome was observed in severe aspiration pneumonia. Compared to the control group, a significant decrease in the relative abundance of Firmicutes was found at the phylum level (P < 0.01). At the family level, the relative abundance of Corynebacteriaceae, Enterobacteriaceae and Enterococcaceae increased significantly (P < 0.001, P < 0.05, P < 0.01). There were no significant differences in community diversity of the lower respiratory tract between the two groups. Patients in the severe aspiration pneumonia group exhibited significantly higher levels of inflammation compared to those in the control group. Correlation analysis showed that the relative abundance of Corynebacteriaceae was positively correlated with the expression level of IL-1β and IL-18 (P = 0.002, P = 0.02); the relative abundance of Enterobacteriaceae was negatively correlated with IL-4 (P = 0.011); no other significant correlations have been identified between microbiome and inflammatory indicators thus far (P > 0.05).

CONCLUSIONS

Alteration of the lower respiratory tract microbiome is critically involved in inflammation and disease progression in severe cases of aspiration pneumonia. The potential inflammation regulation properties of the microbiome hold promising value for developing novel therapeutic approaches aimed at mitigating the severity of the disease.

Saliva culture as a predictive indicator for current blood infections and antimicrobial resistance in the ICU setting

Antimicrobial resistance is a worldwide health problem and patients in intensive care are more vulnerable, requiring strict control measures and early identification. Currently, clinical culture materials are used to identify the bacterial agent, but saliva culture is not validated, which has great clinical relevance because it participates in several pathophysiological processes. The aim of this study was to validate saliva culture in an intensive care unit environment, determining its diagnostic value for infection. For this purpose, the results of the 39-month surveillance cultures, from the database of a private hospital were evaluated. A total of 323 cultures were paired between saliva, tracheal secretions, blood and urine from patients who were hospitalized for more than 5 days. The search for correlations between the results was performed using the Spearman correlation test. Severity and evolution data were also correlated. It was possible to correlate the presence of Klebsiella spp. between blood culture and saliva culture in 25% of the results (r = 0.01) and the correlation between saliva and tracheal secretion was 33% (r = 0.33447) with p < 0.0001. In conclusion, saliva can be an excellent discriminator of systemic infections, and can be considered a useful culture in clinical practice.

Dysphagia following cerebellar stroke: analyzing the contribution of the cerebellum to swallowing function

Swallowing is essential for human health, and the cerebellum is crucial for motor movement regulation. Cerebellar strokes may cause dysphagia, but their exact effects remain unexplored in swallowing function. Therefore, the aim of this study was to analyze the precise clinical characteristics of the oral and pharyngeal phases of swallowing after cerebellar stroke and to critically discuss the cerebellum's contribution to swallowing. The study involved 34 participants with cerebellar strokes, gathered through convenience sampling. Neurologists diagnosed isolated strokes, and a speech and language pathologist examined swallowing ability using the Mann Assessment of Swallowing Ability. The study found that 52.9% of people experienced dysphagia after a cerebellar stroke. Dysphagia was significantly associated with a higher risk of aspiration. Age was also significantly correlated with dysphagia. No significant correlation was found between swallowing ability and sex. In conclusion, this study suggests isolated cerebellar stroke can adversely affect the motor and non-motor aspects of swallowing and cause severe dysphagia and aspiration risk. Thus, early diagnosis and timely management of dysphagia following a cerebellar stroke can help prevent serious consequences.