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Stoica A, Lionte C, Palaghia MM, Gîrleanu I, Şorodoc V, Ceasovschih A, Sîrbu O, Haliga RE, Bologa C, Petriş OR, Nuţu V, Trofin AM, Bălan GG, Catana AN, Coman AE, Constantin M, Puha G, Morăraşu BC, Şorodoc L. Severe Intentional Corrosive (Nitric Acid) Acute Poisoning: A Case Report and Literature Review. J Pers Med 2023; 13:987. [PMID: 37373976 DOI: 10.3390/jpm13060987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/02/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Despite being one of the most debilitating conditions encountered in the field of toxicology, there is a lack of neutralization measures for the toxins involved in acute corrosive poisoning, and this promotes progressive contact injury of deep tissues after poisoning has occurred. Multiple controversies still surround management strategies during the acute phase of poisoning and the long-term follow-up of the patient. Here, we report a severe case of intentional poisoning with nitric acid complicated by extensive injury of the upper digestive tract, multiple stricture formation, and complete dysphagia. Serial endoscopic dilation and insertion of a jejunostomy feeding tube were necessary, and underlying psychiatric illness negatively affected the outcome of the patient. We conclude that an interdisciplinary approach is necessary to properly reduce the extent of lesions and sequelae induced by corrosion. Early endoscopic mapping of injuries is of major importance to better predict the evolution and possible complications of poisoning. Interventional and reconstructive surgical procedures may significantly improve the life expectancy and quality of life of patients following intoxication with corrosive substances.
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Affiliation(s)
- Alexandra Stoica
- Internal Medicine Department, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Cătălina Lionte
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Mădălina Maria Palaghia
- General Surgery Department, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- First General Surgery Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Irina Gîrleanu
- Internal Medicine Department, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Gastroenterology Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Victoriţa Şorodoc
- Internal Medicine Department, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Alexandr Ceasovschih
- Internal Medicine Department, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Oana Sîrbu
- Internal Medicine Department, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Raluca Ecaterina Haliga
- Internal Medicine Department, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Cristina Bologa
- Internal Medicine Department, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Ovidiu Rusalim Petriş
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
- Nursing Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Vlad Nuţu
- General Surgery Department, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- First General Surgery Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Ana Maria Trofin
- General Surgery Department, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Second General Surgery Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Gheorghe G Bălan
- Internal Medicine Department, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Gastroenterology Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Andreea Nicoleta Catana
- Infectious Diseases Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Adorata Elena Coman
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
- Preventive Medicine and Interdisciplinary Team Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Mihai Constantin
- Internal Medicine Department, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Gabriela Puha
- Internal Medicine Department, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Bianca Codrina Morăraşu
- Internal Medicine Department, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Laurenţiu Şorodoc
- Internal Medicine Department, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
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Wang DH, Tsai FT, Tu HF, Yang CC, Hsu ML, Huang LJ, Lin CT, Hsu WE, Lin YC. Profiles of oral microbiome associated with nasogastric tube feeding. J Oral Microbiol 2023; 15:2200898. [PMID: 37063979 PMCID: PMC10101675 DOI: 10.1080/20002297.2023.2200898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Background Dysbiosis of oral microbiome causes chronic diseases including dental caries and periodontitis, which frequently affect older patient populations. Severely disabled individuals with impaired swallowing functions may require nutritional supply via nasogastric (NG) tubes, further impacting their oral condition and possibly microbial composition. However, little is known about the effect of NG tube on oral microbes and its potential ramification. Methods By using 16S rRNA amplicon sequencing, we characterized the tongue microbiome of 27 patients fed with NG tubes and 26 others fed orally. Results The microbial compositions of NG-tube and oral-feeding patients were substantially different, with more Gram-negative aerobes enriched in the presence of NG tube. Specifically, NG-tube patients presented more opportunistic pathogens like Pseudomonas and Corynebacterium associated with pneumonia and lower levels of commensal Streptococcus and Veillonella. Co-occurrence analysis further showed an inverse relationship between commensal and pathogenic species. Conclusion We present a systematic, high-throughput profiling of oral microbiome with regard to long-term NG tube feeding among the older patient population.
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Affiliation(s)
- Ding-Han Wang
- Department of Dentistry, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fa-Tzu Tsai
- Department of Dentistry, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsi-Feng Tu
- Department of Dentistry, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Dentistry, National Yang Ming Chiao Tung University Hospital, Yilan County, Taiwan
| | - Cheng-Chieh Yang
- Department of Dentistry, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Stomatology, Oral & Maxillofacial Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Lun Hsu
- Department of Dentistry, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Lin-Jack Huang
- Department of Dentistry, National Yang Ming Chiao Tung University Hospital, Yilan County, Taiwan
| | - Chiu-Tzu Lin
- Department of Dentistry, National Yang Ming Chiao Tung University Hospital, Yilan County, Taiwan
| | - Wun-Eng Hsu
- Department of Dentistry, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Yu-Cheng Lin
- Department of Dentistry, National Yang Ming Chiao Tung University, Taipei, Taiwan
- CONTACT Yu-Cheng Lin Department of Dentistry, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Cao Y, Liu C, Lin J, Ng L, Needleman I, Walsh T, Li C. Oral care measures for preventing nursing home-acquired pneumonia. Cochrane Database Syst Rev 2022; 11:CD012416. [PMID: 36383760 PMCID: PMC9668328 DOI: 10.1002/14651858.cd012416.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pneumonia in residents of nursing homes can be termed nursing home-acquired pneumonia (NHAP). NHAP is one of the most common infections identified in nursing home residents and has the highest mortality of any infection in this population. NHAP is associated with poor oral hygiene and may be caused by aspiration of oropharyngeal flora into the lung. Oral care measures to remove or disrupt oral plaque might reduce the risk of NHAP. This is the first update of a review published in 2018. OBJECTIVES To assess effects of oral care measures for preventing nursing home-acquired pneumonia in residents of nursing homes and other long-term care facilities. SEARCH METHODS An information specialist searched CENTRAL, MEDLINE, Embase, one other database and three trials registers up to 12 May 2022. We also used additional search methods to identify published, unpublished and ongoing studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) that evaluated the effects of oral care measures (brushing, swabbing, denture cleaning mouthrinse, or combination) in residents of any age in nursing homes and other long-term care facilities. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed search results, extracted data, and assessed risk of bias in the included studies. We contacted study authors for additional information. We pooled data from studies with similar interventions and outcomes. We reported risk ratios (RRs) for dichotomous outcomes, mean differences (MDs) for continuous outcomes, and hazard ratios (HRs) or incidence rate ratio (IRR) for time-to-event outcomes, using random-effects models. MAIN RESULTS We included six RCTs (6244 participants), all of which were at high risk of bias. Three studies were carried out in Japan, two in the USA, and one in France. The studies evaluated one comparison: professional oral care versus usual oral care. We did not include the results from one study (834 participants) because it had been stopped at interim analysis. Consistent results from five studies, with 5018 participants, provided insufficient evidence of a difference between professional oral care and usual (simple, self-administered) oral care in the incidence of pneumonia. Three studies reported HRs, one reported IRRs, and one reported RRs. Due to the variation in study design and follow-up duration, we decided not to pool the data. We downgraded the certainty of the evidence for this outcome by two levels to low: one level for study limitations (high risk of performance bias), and one level for imprecision. There was low-certainty evidence from meta-analysis of two individually randomised studies that professional oral care may reduce the risk of pneumonia-associated mortality compared with usual oral care at 24 months' follow-up (RR 0.43, 95% CI 0.25 to 0.76, 454 participants). Another study (2513 participants) reported insufficient evidence of a difference for this outcome at 18 months' follow-up. Three studies measured all-cause mortality and identified insufficient evidence of a difference between professional and usual oral care at 12 to 30 months' follow-up. Only one study (834 participants) measured the adverse effects of the interventions. The study identified no serious events and 64 non-serious events, the most common of which were oral cavity disturbances (not defined) and dental staining. No studies evaluated oral care versus no oral care. AUTHORS' CONCLUSIONS Although low-certainty evidence suggests that professional oral care may reduce mortality compared to usual care when measured at 24 months, the effect of professional oral care on preventing NHAP remains largely unclear. Low-certainty evidence was inconclusive about the effects of this intervention on incidence and number of first episodes of NHAP. Due to differences in study design, effect measures, follow-up duration, and composition of the interventions, we cannot determine the optimal oral care protocol from current evidence. Future trials will require larger samples, robust methods that ensure low risk of bias, and more practicable interventions for nursing home residents.
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Affiliation(s)
- Yubin Cao
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Chang Liu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Jie Lin
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral Anaesthesiology and Intensive Care Unit, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Linda Ng
- School of Nursing and Midwifery, The University of Queensland, South Brisbane, Australia
| | - Ian Needleman
- Unit of Periodontology and International Centre for Evidence-Based Oral Health, UCL Eastman Dental Institute, London, UK
| | - Tanya Walsh
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Chunjie Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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ESPEN practical guideline: Clinical nutrition and hydration in geriatrics. Clin Nutr 2022; 41:958-989. [DOI: 10.1016/j.clnu.2022.01.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 11/15/2022]
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Brock M, Bahammam S, Sima C. The Relationships Among Periodontitis, Pneumonia and COVID-19. FRONTIERS IN ORAL HEALTH 2022; 2:801815. [PMID: 35128525 PMCID: PMC8813972 DOI: 10.3389/froh.2021.801815] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/27/2021] [Indexed: 12/23/2022] Open
Abstract
Periodontitis is a chronic inflammatory disease of the supporting structures of the teeth that affects approximately half of adults 30 years and older. There is increasing interest in the direct and indirect relationships between periodontitis and systemic diseases, including respiratory diseases. The aim of this study was to assess the evidence on links among periodontitis, pneumonia, and COVID-19. Oral and periodontal bacteria may be linked to respiratory disease directly by aspiration of pathogens into the lungs causing pneumonia. As SARS-CoV-2 began to spread worldwide in 2020, questions have arisen of how periodontal disease may also be connected to SARS-CoV-2 infection and severity, including potential replication and dissemination of the virus from periodontal pockets. Some proposed mechanisms include the oral cavity acting as a reservoir or point of entry for SARS-CoV-2, overgrowth of periodontal pathogens, and increased production of proinflammatory cytokines. Due to potential links between periodontal disease and respiratory infections like pneumonia and SARS-CoV-2, oral hygiene and management of periodontitis remain essential to help reduce infection and transmission of SARS-CoV-2.
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Affiliation(s)
- Mikaela Brock
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA, United States
| | - Shaima Bahammam
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA, United States
- Department of Dentistry, King Fasial Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Corneliu Sima
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA, United States
- *Correspondence: Corneliu Sima
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Palmer PM, Padilla AH. Risk of an Adverse Event in Individuals Who Aspirate: A Review of Current Literature on Host Defenses and Individual Differences. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2022; 31:148-162. [PMID: 34731584 DOI: 10.1044/2021_ajslp-20-00375] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE The presence of oropharyngeal dysphagia increases the likelihood of prandial aspiration, and aspiration increases the likelihood of a dysphagia-related pulmonary sequelae such as aspiration pneumonia, acute respiratory distress syndrome, pulmonary fibrosis, and even death. Although these outcomes are unfortunate, it is important to point out that these consequences are not solely determined by the presence of aspiration. The purpose of this tutorial is to provide current information on pulmonary defenses and the variables that increase risk of an adverse outcome in individuals who aspirate. METHOD This tutorial reviews the basics of lung defenses and summarizes the literature to make the case that the host is a central theme in dysphagia management. Case studies are employed to highlight the key variables. RESULTS Based on a literature review, a series of questions are proposed for consideration in dysphagia management. These questions, which take the focus away from the presence of aspiration and toward the associated risks within an individual, are then applied to two case studies. CONCLUSIONS A guiding framework is proposed to encourage clinicians to assess more than the presence of aspiration and consider the individual's ability to cope with the aspirated material. In the presence of aspiration, clinicians are urged to focus on the risk factors that can lead to a negative consequence, identify which factors are modifiable, and determine when a level of risk is acceptable.
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Affiliation(s)
- Phyllis M Palmer
- Department of Speech and Hearing Sciences, The University of New Mexico, Albuquerque
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Cheng W, Chen L, Yu H, Lu D, Yu R, Chen J. Value of Combining of the NLR and the Fibrinogen Level for Predicting Stroke-Associated Pneumonia. Neuropsychiatr Dis Treat 2021; 17:1697-1705. [PMID: 34093013 PMCID: PMC8169056 DOI: 10.2147/ndt.s311036] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 05/14/2021] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To evaluate the value of the NLR (neutrophil-to-lymphocyte ratio) and the fibrinogen level in predicting stroke-associated pneumonia (SAP) in acute ischemic stroke (AIS) patients. PATIENTS AND METHODS In total, we enrolled 734 medical-ward patients with AIS in this retrospective study. Patients were divided into SAP (n=52) and non-SAP (n=682) groups according to the diagnostic criteria of SAP. Binary logistic regression analysis was used to analyze the relationship between the NLR, serum fibrinogen concentration and SAP. Receiver operating characteristic (ROC) curves were generated to identify the optimal cutoff points and assess the diagnostic value of the NLR, serum fibrinogen and the combination of NLR and fibrinogen in predicting SAP. RESULTS SAP occurred in 52 (7.08%) patients among the enrolled AIS patients. Binary logistic regression analysis showed that the NLR (odds ratio [OR]: 2.802, 95% confidence interval [CI]: 1.302-6.032, P=0.008) and serum fibrinogen concentration (OR: 7.850, 95% CI: 3.636-16.949, P=0.000) were independently associated with a higher risk of SAP incidence after adjusting for age, sex, ASPECT score, atrial fibrillation, nasogastric tube feeding, LDL-C and TC, temperature at admission and mechanical ventilation. The optimal cutoff points of the NLR and serum fibrinogen to distinguish SAP among AIS patients were 3.603 (AUC, 0.690; NPV, 95.78; PPV, 19.01) and 4.595 (AUC, 0.727; NPV, 95.60; PPV, 24.49), respectively. When the combination of NLR and fibrinogen was used to predict SAP, the optimal cutoff points were >2.436 for NLR and >3.24 for fibrinogen (AUC, 0.758; NPV, 98.50; PPV, 11.80). CONCLUSION The NLR and serum fibrinogen might have greater negative diagnostic value in predicting SAP among AIS patients. Combining the NLR and serum fibrinogen showed an increased AUC for predicting SAP among AIS patients.
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Affiliation(s)
- Wei Cheng
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Lichang Chen
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Huapeng Yu
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Dongzhu Lu
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Rong Yu
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Jian Chen
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, People's Republic of China
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Shiraishi O, Kato H, Iwama M, Hiraki Y, Yasuda A, Peng YF, Shinkai M, Kimura Y, Imano M, Yasuda T. Simplified percutaneous endoscopic transgastric conduit feeding jejunostomy for dysphagia after esophagectomy. Dis Esophagus 2020; 33:5487254. [PMID: 31069391 DOI: 10.1093/dote/doz042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/13/2019] [Accepted: 04/05/2019] [Indexed: 12/11/2022]
Abstract
Unexpected dysphagia is an important problem affecting life prognosis in patients who have undergone an esophagectomy for esophageal cancer. For nutritional support in patients suffering from dysphagia after a previous esophagectomy, a simplified percutaneous endoscopic transgastric conduit feeding jejunostomy approach was developed that can be performed regardless of the patient's condition. The feasibility of this procedure in 25 patients with esophageal cancer who underwent three-stage esophagectomy with retrosternal gastric conduit reconstruction from April 2009 to December 2016 was evaluated retrospectively. Under fluoroscopy, a percutaneous endoscopic transgastric conduit feeding jejunostomy catheter (9 French) was introduced into the jejunum in the epigastric region using the Seldinger's technique. The following patient data were analyzed retrospectively: operating time, complications, reasons for oral intake difficulty, and clinical data describing patients' nutritional status before and 1 month after percutaneous endoscopic transgastric conduit jejunostomy treatment, such as serum albumin and clinical course. Median patients' age was 68 years (range 50-76 years). Indications for the procedure were late swallowing dysfunction (n = 12), early swallowing dysfunction secondary to surgical complication (n = 8), anastomotic leakage (n = 3), and anorexia (n = 2). Causes of late swallowing dysfunction were radiation injury (n = 8), advanced age (n = 2), or cerebral infarction (n = 2). The median operating time was 29 minutes (range 14-82 minutes). Four patients developed mild erosions at the stoma secondary to bile reflux along the side of the catheter. No patient experienced severe complications such as ileus and peritonitis. Patients were treated for a median of 160 days (range 18-3106 days) with percutaneous endoscopic transgastric conduit jejunostomy. Patient's serum albumin significantly increased from 2.8 to 3.3 g/dl in 1 month. Of the eight patients with early swallowing dysfunction, six successfully regained sufficient oral nutrition after receiving enteral feeding nutritional management. Although all except one late swallowing dysfunction patient could not discontinue tube feeding, five patients were long-term survivors at the time this report was written. This jejunostomy procedure is simple, safe, and useful for patients with unexpected dysphagia and accompanying malnutrition after esophagectomy.
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Affiliation(s)
- Osamu Shiraishi
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Hiroaki Kato
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Mituru Iwama
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Yoko Hiraki
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Atsushi Yasuda
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Ying-Feng Peng
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Masayuki Shinkai
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Yutaka Kimura
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Motohiro Imano
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Takushi Yasuda
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
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Katagiri S, Shiba T, Tohara H, Yamaguchi K, Hara K, Nakagawa K, Komatsu K, Watanabe K, Ohsugi Y, Maekawa S, Iwata T. Re-initiation of Oral Food Intake Following Enteral Nutrition Alters Oral and Gut Microbiota Communities. Front Cell Infect Microbiol 2019; 9:434. [PMID: 31956606 PMCID: PMC6951430 DOI: 10.3389/fcimb.2019.00434] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/05/2019] [Indexed: 11/22/2022] Open
Abstract
Stroke is associated with multiple forms of disability, including dysphagia. Post-stroke dysphagia increases the risks of pneumonia and mortality and often results in cessation of oral feeding. However, appropriate rehabilitation methods can eventually lead to resumption of oral food intake. This study tried to clarify that re-initiating oral food intake could modify the composition of oral/gut microbial communities in patients with dysphagia. From 78 patients with sub-acute stage of stroke, 11 complete tube feeding subjects without taking antibiotics were enrolled and received rehabilitation for re-initiation of oral food intake, and 8 subjects were brought back to complete oral feeding. Oral and gut microbiota community profiles were evaluated using 16S rRNA sequencing of the saliva and feces samples before and after re-initiation of oral food intake in patients recovering from enteral nutrition under the same nutrient condition. Standard nutrition in the hospital was 1,840 kcal, including protein = 75 g, fat = 45 g, and carbohydrates = 280 g both for tube and oral feeding subjects. Oral food intake increased oral and gut microbiome diversity and altered the composition of the microbiome. Oral and gut microbiome compositions were drastically different; however, the abundance of family Carnobacteriaceae and genus Granulicatella was increased in both the oral and gut microbiome after re-initiation of oral food intake. Although oral microbiota showed more significant changes than the gut microbiota, metagenome prediction revealed the presence of more differentially enriched pathways in the gut. In addition, simpler co-occurrence networks of oral and gut microbiomes, indicating improved dysbiosis of the microbiome, were observed during oral feeding as compared to that during tube feeding. Oral food intake affects oral and gut microbiomes in patients recovering from enteral nutrition. Rehabilitation for dysphagia can modify systemic health by increasing the diversity and altering the composition and co-occurrence network structure of oral and gut microbial communities.
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Affiliation(s)
- Sayaka Katagiri
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takahiko Shiba
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Haruka Tohara
- Gerodontology and Oral Rehabilitation, Department of Gerontology and Gerodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohei Yamaguchi
- Gerodontology and Oral Rehabilitation, Department of Gerontology and Gerodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Koji Hara
- Gerodontology and Oral Rehabilitation, Department of Gerontology and Gerodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuharu Nakagawa
- Gerodontology and Oral Rehabilitation, Department of Gerontology and Gerodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Keiji Komatsu
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuki Watanabe
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yujin Ohsugi
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shogo Maekawa
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takanori Iwata
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Tube Feeding in Individuals with Advanced Dementia: A Review of Its Burdens and Perceived Benefits. J Aging Res 2019; 2019:7272067. [PMID: 31929906 PMCID: PMC6942829 DOI: 10.1155/2019/7272067] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/06/2019] [Indexed: 01/02/2023] Open
Abstract
Background Dementia remains a growing concern for societies globally, particularly as people now live longer. About 90% of individuals with advanced dementia suffer from eating problems that lead to general health decline and ultimately impacts upon the physical, psychological, and economic wellbeing of the individuals, caregivers, and the wider society. Objective To evaluate the burdens and perceived benefits of tube feeding in individuals with advanced dementia. Design Narrative review. Methods Computerized databases, including PubMed, Embase, Medline, CINAHL, PsycInfo, and Google Scholar were searched from 2000 to 2019 to identify research papers, originally written in or translated into English language, which investigated oral versus tube feeding outcome in individuals with advanced dementia. Results Over 400 articles were retrieved. After quality assessment and careful review of the identified articles, only those that met the inclusion criteria were included for review. Conclusion Tube feeding neither stops dementia disease progression nor prevents imminent death. Each decision for feeding tube placement in individuals with advanced dementia should be made on a case-by-case basis and involve a multidisciplinary team comprising experienced physicians, nurses, family surrogates, and the relevant allied health professionals. Careful considerations of the benefit-harm ratio should be discussed and checked with surrogate families if they would be consistent with the wishes of the demented person. Further research is required to establish whether tube feeding of individuals with advanced dementia provides more burdens than benefits or vice-versa and evaluate the impacts on quality of life and survival.
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Huang GQ, Lin YT, Wu YM, Cheng QQ, Cheng HR, Wang Z. Individualized Prediction Of Stroke-Associated Pneumonia For Patients With Acute Ischemic Stroke. Clin Interv Aging 2019; 14:1951-1962. [PMID: 31806951 PMCID: PMC6844226 DOI: 10.2147/cia.s225039] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 10/15/2019] [Indexed: 12/21/2022] Open
Abstract
Background Stroke-associated pneumonia (SAP) is a serious and common complication in stroke patients. Purpose We aimed to develop and validate an easy-to-use model for predicting the risk of SAP in acute ischemic stroke (AIS) patients. Patients and methods The nomogram was established by univariate and multivariate binary logistic analyses in a training cohort of 643 AIS patients. The prediction performance was determined based on the receiver operating characteristic curve (ROC) and calibration plots in a validation cohort (N=340). Individualized clinical decision-making was conducted by weighing the net benefit in each AIS patient by decision curve analysis (DCA). Results Seven predictors, including age, NIHSS score on admission, atrial fibrillation, nasogastric tube intervention, mechanical ventilation, fibrinogen, and leukocyte count were incorporated to construct the nomogram model. The nomogram showed good predictive performance in ROC analysis [AUROC of 0.845 (95% CI: 0.814-0.872) in training cohort, and 0.897 (95% CI: 0.860-0.927) in validation cohort], and was superior to the A2DS2, ISAN, and PANTHERIS scores. Furthermore, the calibration plots showed good agreement between actual and nomogram-predicted SAP probabilities, in both training and validation cohorts. The DCA confirmed that the SAP nomogram was clinically useful. Conclusion Our nomogram may provide clinicians with a simple and reliable tool for predicting SAP based on routinely available data. It may also assist clinicians with respect to individualized treatment decision-making for patients differing in risk level.
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Affiliation(s)
- Gui-Qian Huang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, People's Republic of China
| | - Yu-Ting Lin
- Department of Pulmonary Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, People's Republic of China
| | - Yue-Min Wu
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, People's Republic of China
| | - Qian-Qian Cheng
- School of Mental Health, Wenzhou Medical University, Wenzhou 325000, Zhejiang, People's Republic of China
| | - Hao-Ran Cheng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, People's Republic of China
| | - Zhen Wang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, People's Republic of China
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Mohandas N, Kumar R, Leelakrishnan V, Sharma S, Aparanji K. International Survey of Physicians' Perspectives on Percutaneous Endoscopic Gastrostomy Tube Feeding in Patients with Dementia and Review of Literature. Cureus 2019; 11:e4578. [PMID: 31281761 PMCID: PMC6605970 DOI: 10.7759/cureus.4578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Percutaneous endoscopic gastrostomy (PEG) tube often remains to be used as a primary modality for feeding in patients with advanced dementia, perhaps due to misconceptions regarding the outcomes. Physicians' perceptions regarding the PEG tubes could be a significant contributing factor globally. A multidisciplinary approach involving the ethics committee can help address the issue. Our survey is focused on gauging physicians' perceptions regarding PEG tube utilization and its global impact on outcomes in dementia.
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Affiliation(s)
- Naveen Mohandas
- Gastroenterology, Mid Cheshire Hospitals National Health Service Foundation Trust, Crewe, GBR
| | - Raghu Kumar
- Gastroenterology, Flinders Medical Centre, Adelaide, AUS
| | | | - Sudeep Sharma
- Miscellaneous, University of Illinois, Springfield, USA
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Liu C, Cao Y, Lin J, Ng L, Needleman I, Walsh T, Li C. Oral care measures for preventing nursing home-acquired pneumonia. Cochrane Database Syst Rev 2018; 9:CD012416. [PMID: 30264525 PMCID: PMC6513285 DOI: 10.1002/14651858.cd012416.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pneumonia occurring in residents of long-term care facilities and nursing homes can be termed 'nursing home-acquired pneumonia' (NHAP). NHAP is the leading cause of mortality among residents. NHAP may be caused by aspiration of oropharyngeal flora into the lung, and by failure of the individual's defence mechanisms to eliminate the aspirated bacteria. Oral care measures to remove or disrupt oral plaque might be effective in reducing the risk of NHAP. OBJECTIVES To assess effects of oral care measures for preventing nursing home-acquired pneumonia in residents of nursing homes and other long-term care facilities. SEARCH METHODS Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 November 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 10), MEDLINE Ovid (1946 to 15 November 2017), and Embase Ovid (1980 to 15 November 2017) and Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1937 to 15 November 2017). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. We also searched the Chinese Biomedical Literature Database, the China National Knowledge Infrastructure, and the Sciencepaper Online to 20 November 2017. SELECTION CRITERIA We included randomised controlled trials (RCTs) that evaluated the effects of oral care measures (brushing, swabbing, denture cleaning mouthrinse, or combination) in residents of any age in nursing homes and other long-term care facilities. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed search results, extracted data, and assessed risk of bias in the included studies. We contacted study authors for additional information. We pooled data from studies with similar interventions and outcomes. We reported risk ratio (RR) for dichotomous outcomes, mean difference (MD) for continuous outcomes, and hazard ratio (HR) for time-to-event outcomes, using random-effects models. MAIN RESULTS We included four RCTs (3905 participants), all of which were at high risk of bias. The studies all evaluated one comparison: professional oral care versus usual oral care. We did not pool the results from one study (N = 834 participants), which was stopped at interim analysis due to lack of a clear difference between groups.We were unable to determine whether professional oral care resulted in a lower incidence rate of NHAP compared with usual oral care over an 18-month period (hazard ratio 0.65, 95% CI 0.29 to 1.46; one study, 2513 participants analysed; low-quality evidence).We were also unable to determine whether professional oral care resulted in a lower number of first episodes of pneumonia compared with usual care over a 24-month period (RR 0.61, 95% CI 0.37 to 1.01; one study, 366 participants analysed; low-quality evidence).There was low-quality evidence from two studies that professional oral care may reduce the risk of pneumonia-associated mortality compared with usual oral care at 24-month follow-up (RR 0.41, 95% CI 0.24 to 0.72, 507 participants analysed).We were uncertain whether or not professional oral care may reduce all-cause mortality compared to usual care, when measured at 24-month follow-up (RR 0.55, 95% CI 0.27 to 1.15; one study, 141 participants analysed; very low-quality evidence).Only one study (834 participants randomised) measured adverse effects of the interventions. The study identified no serious events and 64 non-serious events, the most common of which were oral cavity disturbances (not defined) and dental staining.No studies evaluated oral care versus no oral care. AUTHORS' CONCLUSIONS Although low-quality evidence suggests that professional oral care could reduce mortality due to pneumonia in nursing home residents when compared to usual care, this finding must be considered with caution. Evidence for other outcomes is inconclusive. We found no high-quality evidence to determine which oral care measures are most effective for reducing nursing home-acquired pneumonia. Further trials are needed to draw reliable conclusions.
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Affiliation(s)
- Chang Liu
- West China Hospital of Stomatology, Sichuan UniversityDepartment of Oral and Maxillofacial Surgery, State Key Laboratory of Oral DiseasesNO.14, 3rd Section of Ren Min Nan RoadChengduSichuanChina610041
| | - Yubin Cao
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan UniversityDepartment of Head and Neck OncologyNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
| | - Jie Lin
- West China Hospital of Stomatology, Sichuan UniversityDepartment of Oral Anaesthesiology and Intensive Care UnitNo 14, Section 3, South Renmin RoadChengduSichuanChina610041
| | - Linda Ng
- The University of QueenslandSchool of Nursing and MidwiferyMater Campus: JP Kelly BuildingSouth BrisbaneQueenslandAustralia4101
| | - Ian Needleman
- UCL Eastman Dental InstituteUnit of Periodontology and International Centre for Evidence‐Based Oral Health256 Gray's Inn RoadLondonUKWC1X 8LD
| | - Tanya Walsh
- The University of ManchesterDivision of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Chunjie Li
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan UniversityDepartment of Head and Neck OncologyNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
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ESPEN guideline on clinical nutrition and hydration in geriatrics. Clin Nutr 2018; 38:10-47. [PMID: 30005900 DOI: 10.1016/j.clnu.2018.05.024] [Citation(s) in RCA: 652] [Impact Index Per Article: 108.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 05/29/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats. AIM To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons. METHODS This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process. RESULTS We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counseling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach. CONCLUSION A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used.
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Celik GG, Eser I. Examination of intensive care unit patients' oral health. Int J Nurs Pract 2017; 23. [PMID: 28960619 DOI: 10.1111/ijn.12592] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 07/24/2017] [Accepted: 08/14/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Oral health problems are common complications that most intensive care unit patients experience. There are many factors that affect oral health negatively and nurses have important responsibilities in this regard. AIM The aim of this study was assessment of the intensive care unit patients' oral health and risk factors. METHODS This study was planned as a descriptive study and conducted between December 2015 and June 2016, with 202 patients in 20 intensive care units of 6 hospitals in Turkey. Data were collected via Data Collection Form and Bedside Oral Exam guide. Oral health assessment of patients was made using a source of light and a tongue depressor. RESULTS We observed a significant difference in score of the Bedside Oral Exam guide by age, consciousness, type of respiration and feeding, the frequency of oral health, the total number of drugs, and technique of oral care (P < 0.05). None of the intensive care units were using the oral assessment guide. CONCLUSION The result of this study shows that there are various risk factors that adversely affect the oral health of intensive care unit patients. Nurses should undertake assessments on the basis of oral care protocols for patients at risk and carry out evidence-based individualized oral care applications.
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Affiliation(s)
| | - Ismet Eser
- Ege University Nursing Faculty, İzmir, Turkey
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16
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Ewan V, Hellyer T, Newton J, Simpson J. New horizons in hospital acquired pneumonia in older people. Age Ageing 2017; 46:352-358. [PMID: 28338911 DOI: 10.1093/ageing/afx029] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Indexed: 02/07/2023] Open
Abstract
Approximately 1.5% of hospital patients develop hospital acquired pneumonia. Aspiration is the major risk factor for pneumonia and is associated with reduced ability to mechanically clear respiratory pathogens into the stomach. Currently non-invasive methods of diagnosing hospital acquired pneumonia are less robust than invasive methods, and lead to over-diagnosis. Accurate diagnosis is key to surveillance, prevention and treatment of HAP, and also to improving outcomes; newer imaging modalities such as phase contrast X-ray imaging and nanoparticle enhanced magnetic resonance imaging may help. Potential preventative strategies such as systematic swallowing assessment in non-stroke patients, and interventions such as improving oral hygiene need further, robust randomised controlled trials. Antibiotics are likely to continue to be the mainstay of treatment, and new antibiotics such as ceftobiprole are likely to have a role in treating hospital acquired pneumonia. Given the spread of antimicrobial resistance, alternative treatment strategies including bacteriophages, peptides and antibodies are under investigation. Reducing the incidence of hospital acquired pneumonia could decrease length of hospital stay, reduce inappropriate antibiotic use, and both improve functional outcomes and mortality in our increasingly aged population.
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Affiliation(s)
- Victoria Ewan
- Newcastle University, Institute of Cellular Medicine, Newcastle upon Tyne, Tyne and Wear , United Kingdom
| | - Thomas Hellyer
- Newcastle University, Institute of Cellular Medicine, Newcastle upon Tyne, Tyne and Wear , United Kingdom
| | - Julia Newton
- Newcastle University, Clinical Academic Office, Newcastle upon Tyne, Tyne and Wear, United Kingdom
| | - John Simpson
- Newcastle University, Institute of Cellular Medicine, Newcastle upon Tyne, Tyne and Wear , United Kingdom
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Li C, Zhang Q, Ng L, Needleman I, Jie L, Walsh T. Oral care measures for preventing nursing home-acquired pneumonia. Cochrane Database Syst Rev 2016. [DOI: 10.1002/14651858.cd012416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Chunjie Li
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University; Department of Head and Neck Oncology; No. 14, Section Three, Ren Min Nan Road Chengdu Sichuan China 610041
| | - Qi Zhang
- State Key Laboratory of Oral Diseases, West China College of Stomatology, Sichuan University; Department of Oral Implantology; No. 14, Section Three, Ren Min Nan Road Chengdu Sichuan China 610041
| | - Linda Ng
- University of Queensland; School of Nursing and Midwifery; Mater Campus: JP Kelly Building South Brisbane Queensland Australia 4101
| | - Ian Needleman
- UCL Eastman Dental Institute; Unit of Periodontology and International Centre for Evidence-Based Oral Health; 256 Gray's Inn Road London UK WC1X 8LD
| | - Lin Jie
- West China Hospital of Stomatology, Sichuan University; Department of Oral Anaesthesiology and Intensive Care Unit; No 14, Section 3, South Renmin Road Chengdu China 610041
| | - Tanya Walsh
- The University of Manchester; Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health; JR Moore Building Oxford Road Manchester UK M13 9PL
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Lin LF. Transnasal versus conventional peroral insertion of percutaneous endoscopic gastrostomy using pull method. ADVANCES IN DIGESTIVE MEDICINE 2015. [DOI: 10.1016/j.aidm.2014.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Rosen R, Amirault J, Liu H, Mitchell P, Hu L, Khatwa U, Onderdonk A. Changes in gastric and lung microflora with acid suppression: acid suppression and bacterial growth. JAMA Pediatr 2014; 168:932-7. [PMID: 25133779 PMCID: PMC5101185 DOI: 10.1001/jamapediatrics.2014.696] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE The use of acid suppression has been associated with an increased risk of upper and lower respiratory tract infections in the outpatient setting but the mechanism behind this increased risk is unknown. We hypothesize that this infection risk results from gastric bacterial overgrowth with subsequent seeding of the lungs. OBJECTIVES To determine if acid-suppression use results in gastric bacterial overgrowth, if there are changes in lung microflora associated with the use of acid suppression, and if changes in lung microflora are related to full-column nonacid gastroesophageal reflux. DESIGN, SETTING, AND PARTICIPANTS A 5-year prospective cohort study at a tertiary care center where children ages 1 to 18 years were undergoing bronchoscopy and endoscopy for the evaluation of chronic cough. Acid-suppression use was assessed through questionnaires with confirmation using an electronic medical record review. MAIN OUTCOMES AND MEASURES Our primary outcome was to compare differences in concentration and prevalence of gastric and lung bacteria between patients who were and were not receiving acid-suppression therapy. We compared medians using the Wilcoxon signed rank test and determined prevalence ratios using asymptotic standard errors and 95% confidence intervals. We determined correlations between continuous variables using Pearson correlation coefficients and compared categorical variables using the Fisher exact test. RESULTS Forty-six percent of patients taking acid-suppression medication had gastric bacterial growth compared with 18% of untreated patients (P = .003). Staphylococcus (prevalence ratio, 12.75 [95% CI, 1.72-94.36]), Streptococcus (prevalence ratio, 6.91 [95% CI, 1.64-29.02]), Veillonella (prevalence ratio, 9.56 [95% CI, 1.26-72.67]), Dermabacter (prevalence ratio, 4.78 [95% CI, 1.09-21.02]), and Rothia (prevalence ratio, 6.38 [95% CI, 1.50-27.02]) were found more commonly in the gastric fluid of treated patients. The median bacterial concentration was higher in treated patients than in untreated patients (P = .001). There was no difference in the prevalence (P > .23) of different bacterial genera or the median concentration of total bacteria (P = .85) in the lungs between treated and untreated patients. There were significant positive correlations between proximal nonacid reflux burden and lung concentrations of Bacillus (r = 0.47, P = .005), Dermabacter (r = 0.37, P = .008), Lactobacillus (r = 0.45, P = .001), Peptostreptococcus (r = 0.37, P = .008), and Capnocytophagia (r = 0.37, P = .008). CONCLUSIONS AND RELEVANCE Acid-suppression use results in gastric bacterial overgrowth of genera including Staphylococcus and Streptococcus. Full-column nonacid reflux is associated with greater concentrations of bacteria in the lung. Additional studies are needed to determine if acid suppression-related microflora changes predict clinical infection risk; these results suggest that acid suppression use may need to be limited in patients at risk for infections.
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Affiliation(s)
- Rachel Rosen
- Aerodigestive Center, Department of Gastroenterology, Boston Children’s Hospital, Boston, Massachusetts
| | - Janine Amirault
- Aerodigestive Center, Department of Gastroenterology, Boston Children’s Hospital, Boston, Massachusetts
| | - Hongye Liu
- Clinical Research Center, Boston Children’s Hospital, Boston, Massachusetts
| | - Paul Mitchell
- Clinical Research Center, Boston Children’s Hospital, Boston, Massachusetts
| | - Lan Hu
- Center for Computational Cancer Biology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Umakanth Khatwa
- Aerodigestive Center, Department of Pulmonary Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Andrew Onderdonk
- Department of Microbiology, Brigham and Women’s Hospital, Boston, Massachusetts
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Cunha-Correia AS, Neto AH, Pereira AF, Aguiar SMHCÁ, Nakamune ACDMS. Enteral nutrition feeding alters antioxidant activity in unstimulated whole saliva composition of patients with neurological disorders. RESEARCH IN DEVELOPMENTAL DISABILITIES 2014; 35:1209-1215. [PMID: 24685936 DOI: 10.1016/j.ridd.2014.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 03/07/2014] [Accepted: 03/07/2014] [Indexed: 06/03/2023]
Abstract
Patients with neurological disorders have an increased risk of oral and systemic diseases due to compromised oral hygiene. If patients lose the ability to swallow and chew food as a result of their disorder, enteral nutrition is often utilized. However, this type of feeding may modify salivary antioxidant defenses, resulting in increased oxidative damage and the emergence of various diseases. The aim of this study was to evaluate the effects of enteral nutrition on biochemical parameters in the unstimulated whole saliva composition of patients with neurological disorders. For this, enzymatic (superoxide dismutase - SOD; glutathione peroxidase - GPx) and non-enzymatic (uric acid; ferric ion reducing antioxidant power - FRAP) antioxidant activity, as well as a marker for oxidative damage (thiobarbituric acid reactive substances - TBARS) were analyzed. Unstimulated whole saliva was collected from 12 patients with neurological disorders and tube-feeding (tube-fed group - TFG), 15 patients with neurological disorders and normal feeding via the mouth (non-tube-fed group - NTFG), and 12 volunteers without neurological disorders (control group - CG). The daily oral hygiene procedures of TFG and NTFG patients were similar and dental care was provided monthly by the same institution's dentist. All patients exhibited adequate oral health conditions. The salivary levels of FRAP, uric acid, SOD, GPx, TBARS, and total protein were compared between studied groups. FRAP was increased (p<0.05) in the NTFG (4,651 ± 192.5 mmol/mL) and the TFG (4,743 ± 116.7 mmol/mL) when compared with the CG (1,844 ± 343.8 mmol/mL). GPx values were lower (p<0.05) in the NTGF (8.24 ± 1.09 mmol/min/mg) and the TFG (8.37 ± 1.60 mmol/min/mg) than in the CG (15.30 ± 2.61 mmol/min/mg). Uric acid in the TFG (1.57 ± 0.23 mg/dL) was significantly lower than in the NTFG (2.34 ± 0.20mg/dL) and the CG (3.49 ± 0.21 mg/dL). Protein was significantly lower in the TFG (5.35 ± 0.27 g/dL) than in the NTFG (7.22 ± 0.57 g/dL) and the CG (7.86 ± 0.54 g/dL). There was no difference in the salivary flow rate and SOD between groups. Enteral nutrition in patients with neurological disorders was associated with lower oxidative damage, resulting in increased salivary antioxidant capacity. These results emphasize the importance of oral care for this population to prevent oral and systemic diseases.
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Affiliation(s)
| | - Antonio Hernandes Neto
- Division of Biochemistry, Department of Basic Sciences, School of Dentistry of Araçatuba, UNESP - Univ Estadual Paulista, Araçatuba, SP, Brazil
| | - Ariana Ferreira Pereira
- Graduate Studies Program in Physiological Sciences, Brazilian Physiological Society, UNESP - Univ Estadual Paulista, Araçatuba, SP, Brazil
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Huang K, Wu B, Ding X, Xu Z, Tang H. Post-esophagectomy tube feeding: a retrospective comparison of jejunostomy and a novel gastrostomy feeding approach. PLoS One 2014; 9:e89190. [PMID: 24658763 PMCID: PMC3962330 DOI: 10.1371/journal.pone.0089190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 01/15/2014] [Indexed: 01/26/2023] Open
Abstract
Background McKeown-type esophagectomy combined with retrosternal reconstruction is a common surgical treatment for esophageal cancer. Various enteral feeding options are available post-esophagectomy, but no definitive preference exists. Method “Retrosternal Route Gastrostomy Feeding (RGF)” was developed as an alternative enteral feeding approach that requires few additional surgical interventions. RGF is based on McKeown-type esophagectomy. We retrospectively compared RGF (n = 121) to jejunostomy feeding (JF) (n = 153) in 274 patients at the Department of Cardiothoracic Surgery in Changzheng Hospital (Shanghai, China) between June 2008 and Sept. 2012. Data pertaining to efficacy and procedural complications were compared among patients. Results RGF had a significantly shorter postoperative hospital stay (11 vs. 15 days, p<0.001) and time to removal of the feeding tube (9 vs. 14 days, p<0.001) compared to JF. Bowel obstruction (0.0% vs. 7.2% p = 0.003), abdominal distension (9.1% vs. 19% p = 0.022), and the occurrence of pneumonia (11.6% vs. 26.1% p = 0.003) were significantly lower in the RGF group. Feeding tube related complications and the associated morbidity rate were reduced in the RGF group. The two groups had similar tolerance to surgery. Conclusion Our data suggests that RGF is a safe post-esophagectomy enteral feeding alternative to JF.
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Affiliation(s)
- Kenan Huang
- Department of Thoracic and Cardiovascular Surgery, Shanghai Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Bin Wu
- Department of Thoracic and Cardiovascular Surgery, Shanghai Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Xinyu Ding
- Department of Thoracic and Cardiovascular Surgery, Shanghai Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Zhifei Xu
- Department of Thoracic and Cardiovascular Surgery, Shanghai Changzheng Hospital, The Second Military Medical University, Shanghai, China
- * E-mail: (ZX); (HT)
| | - Hua Tang
- Department of Thoracic and Cardiovascular Surgery, Shanghai Changzheng Hospital, The Second Military Medical University, Shanghai, China
- * E-mail: (ZX); (HT)
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Allewelt M. Aspiration pneumonia and primary lung abscess: diagnosis and therapy of an aerobic or an anaerobic infection? Expert Rev Respir Med 2014; 1:111-9. [DOI: 10.1586/17476348.1.1.111] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Brogan E, Langdon C, Brookes K, Budgeon C, Blacker D. Dysphagia and Factors Associated with Respiratory Infections in the First Week Post Stroke. Neuroepidemiology 2014; 43:140-4. [DOI: 10.1159/000366423] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/31/2014] [Indexed: 11/19/2022] Open
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Horie N, Yamaguchi T, Chida S, Kato T, Kaneko T, Shimoyama T. The associations between functional and nutritional factors for oral opportunistic infections in a long-term hospital. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY MEDICINE AND PATHOLOGY 2013. [DOI: 10.1016/j.ajoms.2013.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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25
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Cardin F. Special considerations for endoscopists on PEG indications in older patients. ISRN GASTROENTEROLOGY 2012; 2012:607149. [PMID: 23227352 PMCID: PMC3512294 DOI: 10.5402/2012/607149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 10/31/2012] [Indexed: 01/29/2023]
Abstract
Undernutrition in frail elderly people is a pathological condition that needs to be recognized and addressed early. Neurological dysphagia is among the most frequent causes of this condition in the elderly but should be considered a terminal event in Alzheimer-type dementias. Tube feeding is an important resource for facilitating metabolic recovery in cachectic patients and is particularly successful in "bridging" and stabilizing therapies prior to major treatment able to cure the patient. Clinical management of tube feeding in "incurable" conditions is complex and becomes part of the palliative care and comfort provided in the terminal stages of illness. Non-specialized physicians are often unfamiliar with the theory and practice of end-of-life interventions, and the resulting decisions are in many cases actually contrary to patient comfort. These problems deserve to be more carefully addressed when the patient is unable to cooperate or express his/her preferences and needs. The success of percutaneous endoscopic gastrostomy has led to increasingly frequent referrals for placement in critically ill elderly patients. Endoscopists therefore become a key figure in stimulating rational, correct treatment of these patients.
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Affiliation(s)
- Fabrizio Cardin
- Geriatric Surgery Unit, Geriatric Department, Padova University and General Hospital, Via Giustiniani 1, 35100 Padova, Italy
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Abstract
The frailty syndrome is defined as unintentional weight and muscle loss, exhaustion, and declines in grip strength, gait speed, and activity. Evidence with respect to the clinical definition, epidemiology, mechanisms, interactions, assessment, prevention, and treatment of frailty in the older adult is reviewed.
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Affiliation(s)
- Roschelle A Heuberger
- Department of Human Environmental Studies, Central Michigan University, Mt. Pleasant, Michigan 48859, USA.
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Enteral tube feeding alters the oral indigenous microbiota in elderly adults. Appl Environ Microbiol 2011; 77:6739-45. [PMID: 21821752 DOI: 10.1128/aem.00651-11] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Enteral tube feeding is widely used to maintain nutrition for elderly adults with eating difficulties, but its long-term use alters the environment of the oral ecosystem. This study characterized the tongue microbiota of tube-fed elderly adults by analyzing the 16S rRNA gene. The terminal restriction fragment length polymorphism (T-RFLP) profiles of 44 tube-fed subjects were compared with those of 54 subjects fed orally (average age, 86.4 ± 6.9 years). Bar-coded pyrosequencing data were also obtained for a subset of the subjects from each group (15 tube-fed subjects and 16 subjects fed orally). The T-RFLP profiles demonstrated that the microbiota of the tube-fed subjects was distinct from that of the subjects fed orally (permutational multivariate analysis of variance [perMANOVA], P < 0.001). The pyrosequencing data revealed that 22 bacterial genera, including Corynebacterium, Peptostreptococcus, and Fusobacterium, were significantly more predominant in tube-fed subjects, whereas the dominant genera in the subjects fed orally, such as Streptococcus and Veillonella, were present in much lower proportions. Opportunistic pathogens rarely detected in the normal oral microbiota, such as Corynebacterium striatum and Streptococcus agalactiae, were often found in high proportions in tube-fed subjects. The oral indigenous microbiota is disrupted by the use of enteral feeding, allowing health-threatening bacteria to thrive.
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Puri V, Hu Y, Guthrie T, Crabtree TD, Kreisel D, Krupnick AS, Patterson GA, Meyers BF. Retrograde Jejunogastric Decompression After Esophagectomy Is Superior to Nasogastric Drainage. Ann Thorac Surg 2011; 92:499-503. [DOI: 10.1016/j.athoracsur.2011.03.082] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 03/14/2011] [Accepted: 03/15/2011] [Indexed: 11/17/2022]
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Abstract
SummaryThis review provides an update on current evidence surrounding epidemiology, treatment and prevention of lower respiratory tract infection, with special reference to pneumonia and influenza, in care home residents. The care home sector is growing and provides a unique ecological niche for infections, housing frail older people with multiple co-morbidities and frequent contact with healthcare services. There are therefore considerations in the epidemiology and management of these conditions that are specific to care homes. Opportunities for prevention, in the form of vaccination strategies and improving oral hygiene, may reduce the burden of these diseases in the future. Work is needed to research these infections specifically in the care home setting, and this article highlights current gaps in our knowledge.
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30
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Clinical Update on Nursing Home Medicine: 2009. J Am Med Dir Assoc 2009; 10:530-53. [DOI: 10.1016/j.jamda.2009.08.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 08/04/2009] [Indexed: 12/25/2022]
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31
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Segal R, Dan M, Eger G, Lubart E, Leibovitz A. Staphylococcus aureus colonization in the nasopharynx of nasogastric tube-fed patients in a long-term care facility. Eur J Clin Microbiol Infect Dis 2009; 28:1147-9. [PMID: 19437051 DOI: 10.1007/s10096-009-0747-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2008] [Accepted: 04/15/2009] [Indexed: 10/20/2022]
Abstract
The purpose of this paper is to investigate whether the presence of a nasogastric tube (NGT) for feeding has an impact on the nasal colonization by Staphylococcus aureus. Three groups of frail elderly were examined: 76 patients fed by NGTs and 52 orally fed patients in skilled nursing wards, and 33 orally fed patients in regular nursing wards. Samples from the nasal and oral cavities were cultured for S. aureus and susceptibility testing for oxacillin was performed. The prevalence of S. aureus (either oxacillin-susceptible or oxacillin-resistant) in the NGT-fed group was not significantly different to that in the two orally fed groups nor the nostril in which the NGT was placed. A significant correlation in colonization was found between the two nares and between the nares and oral cavity in the same patient (r > 0.45, P < 0.005) for both oxacillin-susceptible and oxacillin-resistant S. aureus. The presence of NGTs for feeding in elderly frail patients is not associated with higher rates of S. aureus colonization in the nares or oral cavity.
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Affiliation(s)
- R Segal
- Shmuel Harofeh Geriatric Medical Center, Beer Yaacov 70350, Israel.
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33
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Dougall A, Fiske J. Access to special care dentistry, part 9. Special care dentistry services for older people. Br Dent J 2009; 205:421-34. [PMID: 18953303 DOI: 10.1038/sj.bdj.2008.891] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This article looks at three common neurological conditions associated with later years: stroke, Parkinson's disease and dementia. All of them impact on oral health, access to dental services and delivery of dental care, and treatment goals need to be adapted to take into account patients' changing needs, medical status, pattern of recovery or the stage of dementia that they have reached. The article concludes by considering the topic of elder abuse. The dental team may have a role both in identifying abuse and ensuring appropriate action is taken.
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Affiliation(s)
- A Dougall
- Division One/Special Care Dentistry, Dublin Dental School and Hospital, Lincoln Place, Dublin 2, Ireland
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Abstract
Dysphagia, the impairment of any part of the swallowing process, increases the risk of aspiration. Dysphagia and aspiration are associated with the development of aspiration pneumonia. While some changes in swallowing may be a natural result of aging, dysphagia is especially prevalent among older adults with neurologic impairment or dementia, leading to an increased risk of aspiration and aspiration pneumonia. This article discusses best practices for assessment and prevention of aspiration among older adults who are being hand-fed or fed by tube. To view an accompanying online video, go to http://links.lww.com/A226.
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Langdon PC, Lee AH, Binns CW. Dysphagia in acute ischaemic stroke: severity, recovery and relationship to stroke subtype. J Clin Neurosci 2007; 14:630-4. [PMID: 17434310 DOI: 10.1016/j.jocn.2006.04.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2006] [Revised: 04/12/2006] [Accepted: 04/27/2006] [Indexed: 11/28/2022]
Abstract
Dysphagia in stroke is linked with increased risk of pneumonia, increased length of stay and poorer outcomes. This study followed a cohort of 88 acute ischaemic stroke patients admitted to hospitals in Perth, Western Australia, over 30 days. There were 8/88 deaths (9%). Infections were treated in 25/80 survivors (31%). Presence and severity of dysphagia were measured at 2 and 7 days post-stroke. Respiratory tract infections occurred at significantly higher rates for dysphagics (p<0.05). At 2 days post-stroke, the odds ratio (OR) of chest infection for dysphagics was 1.45 (95% CI=1.07-1.98). Survivors who were "nil by mouth" 2 days post-stroke were significantly more likely to develop pneumonia (p=0.01). At 7 days post-stroke, dysphagics were again more likely to develop pneumonia (p=0.014) with OR=1.77 (95% CI=1.26-2.49). The total anterior circulation infarcts demonstrated more severe and prolonged dysphagia than other stroke subtypes.
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Affiliation(s)
- P Claire Langdon
- School of Public Health, Curtin University of Technology, Perth, WA, Australia.
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Segal R, Dan M, Pogoreliuk I, Leibovitz A. Pathogenic Colonization of the Stomach in Enterally Fed Elderly Patients: Comparing Percutaneous Endoscopic Gastrostomy with Nasogastric Tube. J Am Geriatr Soc 2006; 54:1905-8. [PMID: 17198497 DOI: 10.1111/j.1532-5415.2006.00964.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare the gastric juice microbiota of older people fed through a percutaneous endoscopic gastrostomy tube (PEG) with that of those fed through a nasogastric tube (NGT). DESIGN Prospective comparative study. SETTING Nursing and skilled nursing wards. PARTICIPANTS Fifty-four elderly PEG-fed and 52 NGT-fed patients. MEASUREMENTS Cultures from the oropharynx and the gastric juice. RESULTS Pathogenic bacteria were isolated from the oropharynxes of 44% of the PEG-fed patients and 54% of the NGT-fed patients. The most frequent gram-negative bacilli isolated from the oropharynx were Proteus spp. (13-21%) and Pseudomonas aeruginosa (13-18%), with no significant difference between the groups. Isolation rates from the gastric juice were significantly more frequent in the NGT-fed patients than in the PEG-fed patients for Proteus spp. (4% vs 23%), Escherichia coli (6% vs 21%), and mixed flora (11% vs 27%). Significant correlation was found between high gastric pH and the isolation of bacteria in both groups (correlation coefficient = 0.58, P < .001). CONCLUSION Gastric juice of PEG-fed patients harbors pathogenic bacteria in significant numbers. No significant difference was noted with respect to the rate of isolation of pathogenic bacteria from the oropharynx between the groups. Major bacterial pathogens, such as P. aeruginosa and Proteus spp., were isolated significantly more from the gastric juice of NGT-fed patients. These results support the view that a bidirectional spread pattern of pathogens may take place in NGT-fed patients.
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Affiliation(s)
- Refael Segal
- Shmuel Harofeh Geriatric Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Beer-Yaakov, Israel
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38
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39
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Segal R, Pogoreliuk I, Dan M, Baumoehl Y, Leibovitz A. Gastric microbiota in elderly patients fed via nasogastric tubes for prolonged periods. J Hosp Infect 2006; 63:79-83. [PMID: 16516342 DOI: 10.1016/j.jhin.2005.11.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Accepted: 11/09/2005] [Indexed: 01/15/2023]
Abstract
Aspiration of oropharyngeal contents is a constant threat for elderly patients fed via a nasogastric tube (NGT). Colonization of the oropharynx of these patients by pathological flora and the development of biofilms on the feeding tube has been documented recently. In addition, the presence of the NGT may interfere with the gastro-oesophageal sphincter, leading to gastro-oesophageal reflux. Thus, the passage of pathogenic bacteria in both directions is facilitated. The purpose of this study was to explore the microbiota of the gastric juice and the oropharynx in NGT-fed elderly patients. Samples of gastric juice were drawn after an overnight fast, and microbial cultures and direct pH measurement were performed. Concomitant cultures were obtained from the oropharynx. Overall, 107 gastric and oropharyngeal cultures were obtained from 52 subjects. Pathogenic flora (Gram-negative bacteria or Staphylococcus aureus) were isolated from 74% of stomach samples and from 69% of oropharynx samples. Proteus spp. (26%) and Escherichia coli (22%) were the most common isolates in the gastric juice, and Proteus spp. (24%) and Pseudomonas spp. (21%) were the most common isolates in the oropharynx. Similarity in the composition of the oropharynx and gastric flora was observed in most cases. The gastric pH was relatively high (4.57 +/- 0.65 at 3 h after feeding and 4.2 +/- 0.9 at 12 h after feeding) and was highly correlated with the isolation of pathogenic bacteria (r = 0.58, P < 0.01). These results support the view that in addition to the oropharynx, the stomach of NGT-fed elderly patients constitutes a reservoir of pathogens that could be associated with the risk of aspiration pneumonia. The cause of the high gastric pH and its relation to pathogenic bacteria warrants further study.
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Affiliation(s)
- R Segal
- Shmuel Harofeh, Geriatric Medical Centre, Beer-Yaakov, Israel.
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40
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Leibovitz A, Carmeli Y, Segal R. Effect of various antibacterial preparations on the pathogenic oral flora in elderly patients fed via nasogastric tube. Antimicrob Agents Chemother 2005; 49:3566-8. [PMID: 16048986 PMCID: PMC1196244 DOI: 10.1128/aac.49.8.3566-3568.2005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Oropharyngeal colonization by pathogenic gram-negative bacilli (GNB) and Staphylococcus aureus is associated with aspiration pneumonia. Decolonization in high-risk populations may be important. We prospectively evaluated six antiseptic compounds in nasogastric tube-fed frail elderly patients; only polymixine reduced oropharyngeal colonization with GNB. None had an effect on S. aureus colonization.
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Affiliation(s)
- Arthur Leibovitz
- Shmuel-Harofeh Hospital, Geriatric Medical Center, POB 2, Be'er-Ya'akov, 70350, Israel
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41
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Abstract
• Background Comprehensive oral care is an evidence-based prevention strategy to reduce the risk of ventilator-associated pneumonia in patients receiving mechanical ventilation. Until recently, no comprehensive guidelines or standards existed to define necessary tasks, methods, and frequency of oral care to provide patients with optimal results.
• Objectives To observe current practice of, define best practice for, and measure compliance with standardized comprehensive oral care.
• Methods This observational study was part of a larger research study performed at 5 acute care hospitals. Time blocks of 4 hours were randomized over 8 intensive care units and the 7 days of the week. Baseline data were collected before implementation of multifaceted education on an oral-cleansing protocol; interventional data were collected afterward.
• Results Oral care practices were observed for 253 patients. During the baseline period, oral cleansing was primarily via suction swabs. Toothbrushing and moisturizing of the oral tissues were not observed. Only 32% of the patients had suctioning to manage oral secretions. During the interventional period, 33% of patients had their teeth brushed, 65% had swab cleansing, and 63% had a moisturizer applied to the oral mucosal tissues. A total of 61% had management of oral secretions; 38% had oropharyngeal suctioning via a special catheter.
• Conclusions Implementation of an evidence-based oral cleansing protocol improved the care of patients receiving mechanical ventilation. Multifaceted education and implementation strategies motivated staff to increase oral care practices.
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Affiliation(s)
- Constance J. Cutler
- Clinical Excellence Department, Advocate Health Care, Oak Brook, Ill (cjc), and Medical Education and Research, Advocate Health Care, Park Ridge, Ill (nd)
| | - Nancy Davis
- Clinical Excellence Department, Advocate Health Care, Oak Brook, Ill (cjc), and Medical Education and Research, Advocate Health Care, Park Ridge, Ill (nd)
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Abstract
PURPOSE OF REVIEW Review of recent studies (2003 and 2004) concerning pneumonia in the very old. RECENT FINDINGS Hospitalisation for community-acquired pneumonia (CAP) in the elderly is associated with a high mortality and with a high rate of readmission within the following year. Functional status, altered mental status, number of comorbidities, aspiration pneumonia, renal failure, and nutritional status are all indicators of adverse prognosis. Although Streptococcus pneumoniae, Haemophilus influenzae, Enterobacteriacae, and Staphylococcus aureus are the most frequently identified causative microorganisms, viruses account for up to 26% of hospital admissions for CAP. Chlamydia pneumoniae is also implicated in CAP and in nursing-home-acquired pneumonia (NHAP), with recent reports of outbreaks in nursing homes. Aspiration pneumonia is frequent in the elderly and occurs with increased frequency in patients with nasogastric tubes or percutaneous enterogastric tubes. In severe aspiration pneumonia, 20% of organisms implicated are anaerobic and 80% aerobic, most of which are gram-negative Enterobacteriaceae. Poor oral hygiene increases subsequent risk of pneumonia: dental plaque may act as a reservoir for pathogenic organisms implicated in CAP or NHAP. Prevention of CAP and NHAP relies on the combined use of influenza and pneumococcal vaccination, which decreases hospital admissions and in-hospital mortality for CAP. SUMMARY Recent studies stress the importance of aspiration as a frequent mechanism of CAP, provide new insights as to causative organisms in this setting, and underline the contribution of combined vaccination in reducing morbidity and mortality.
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Affiliation(s)
- Jean-Paul Janssens
- Division of Lung Diseases, Geneva University Hospital, Geneva, Switzerland.
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Leibovitz A, Nagler R, Plotnikov G, Habot B, Segal R. Biochemical, immunological and enzymatic components of saliva in prolonged naso-gastric-fed elderly patients. Aging Clin Exp Res 2004; 16:457-60. [PMID: 15739596 DOI: 10.1007/bf03327401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIMS We have previously shown that naso-gastric tube (NGT)-fed patients harbor pathogenic flora in their oropharynx. The purpose of this study was to examine comparatively the biochemical, immunological and enzymatic components of the saliva of these patients with that of orally-fed counterparts. METHODS The study group consisted of 19 elderly NGT-fed patients and 18 comparable patients on oral feeding. Unstimulated whole saliva was collected and analyzed according to accepted methods for sodium, potassium, chloride, uric acid, total protein, albumin, amylase, lysozyme, and immunoglobulins, IgM, IgG, IgA, as well as secretory IgA. RESULTS None of the above tested salivary components significantly differed between the two groups. Only uric acid levels were significantly lower (50%, p < 0.05) in NGT-fed patients. CONCLUSIONS Uric acid is the main antioxidant component of saliva and, as such, it may be related to pathogenic bacterial colonization of the oropharynx in NGT-fed patients, with the risk of aspiration pneumonia.
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Affiliation(s)
- Arthur Leibovitz
- Geriatric Medical Center Shmuel Harofe, Sackler Faculty of Medicine, Tel-Aviv University, Beer Yaacov, Israel.
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Abstract
Pneumonia is a major medical problem in the very old. The increased frequency and severity of pneumonia in the elderly is largely explained by the ageing of organ systems (in particular the respiratory tract, immune system, and digestive tract) and the presence of comorbidities due to age-associated diseases. The most striking characteristic of pneumonia in the very old is its clinical presentation: falls and confusion are frequently encountered, while classic symptoms of pneumonia are often absent. Community-acquired pneumonia (CAP) and nursing-home acquired pneumonia (NHAP) have to be distinguished. Although there are no fundamental differences in pathophysiology and microbiology of the two entities, NHAP tends to be much more severe, because milder cases are not referred to the hospital, and residents of nursing homes often suffer from dementia, multiple comorbidities, and decreased functional status. The immune response decays with age, yet pneumococcal and influenza vaccines have their place for the prevention of pneumonia in the very old. Pneumonia in older individuals without terminal disease has to be distinguished from end-of-life pneumonia. In the latter setting, the attributable mortality of pneumonia is low and antibiotics have little effect on life expectancy and should be used only if they provide the best means to alleviate suffering. In this review, we focus on recent publications relative to CAP and NHAP in the very old, and discuss predisposing factors, microorganisms, diagnostic procedures, specific aspects of treatment, prevention, and ethical issues concerning end-of-life pneumonia.
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Affiliation(s)
- Jean-Paul Janssens
- Division of Lung Diseases and Department of Geriatrics, Geneva University Hospitals, Geneva, Switzerland.
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Leibovitz A, Dan M, Zinger J, Carmeli Y, Habot B, Segal R. Pseudomonas aeruginosa and the oropharyngeal ecosystem of tube-fed patients. Emerg Infect Dis 2003; 9:956-9. [PMID: 12967493 PMCID: PMC3020605 DOI: 10.3201/eid0908.030054] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We evaluated whether elderly patients fed with nasogastric tubes (NGT) are predisposed to Pseudomonas aeruginosa colonization in the oropharynx. Fifty-three patients on NGT feeding and 50 orally fed controls with similar clinical characteristics were studied. The tongue dorsum was swabbed and cultured. P. aeruginosa was isolated in 18 (34%) of the NGT-fed group but in no controls (p<0.001). Other gram-negative bacteria were cultured from 34 (64%) of NGT-fed patients as compared with 4 (8%) of controls (p<0.001). Antibiotic susceptibility of the oropharyngeal P. aeruginosa isolates was compared with that of isolates from sputum cultures obtained from our hospital's bacteriologic laboratory. The oropharyngeal isolates showed a higher rate of resistance; differences were significant for amikacin (p<0.03). Scanning electron microscope studies showed a biofilm containing P. aeruginosa organisms. The pulsed-field gel electrophoresis profile of these organisms was similar to that of P. aeruginosa isolates from the oropharynx. NGT-fed patients may serve as vectors of resistant P. aeruginosa strains.
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