The Effect of Respiratory Muscle Training on Swallowing Function in Patients With Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

The improvement of swallowing function after stroke is a significant challenge faced by patients and health care professionals. However, the current evidence synthesis of the effects of respiratory muscle training (RMT) on swallowing function is limited.

OBJECTIVE

To assess the effectiveness of RMT on swallowing recovery in patients undergoing stroke.

METHODS

The CKNI, WanFang Data, PubMed, CINAHL, Web of Science, Embase, MEDLINE, and Cochrane Library databases were searched for studies evaluating RMT interventions' effect on swallowing outcomes. Risks of bias were evaluated using the approach recommended by the Cochrane Collaboration tool and a summary of findings table was generated using the GRADE approach. Outcomes were synthesized using a random-effects meta-analysis model.

RESULTS

RMT interventions reduced the risk of aspiration (SMD = 1.19; 95% CI, 0.53-1.84), the recovery process of water swallowing function (RR = 1.22; 95% CI, 1.05-1.42), and the activity of the swallowing muscles (SMD = 2.91; 95% CI, 2.22-3.61). However, there was no significant effect of RMT on the functional level of oral intake (SMD = 0.70; 95% CI, -0.03 to 1.42).

CONCLUSIONS

RMT can be regarded as an innovative, auxiliary means in the near future to better manage and improve swallowing function, given its improving effect on work outcomes in this review.

Association between a malnutrition screening tool and mealtime observation checklist items in older people receiving oral intake support: A cross-sectional study of four long-term care facilities

BACKGROUND

Multiple nutritional screening tools are available for older people; however, few screening tools include specific eating behaviours as risk factors that could lead to poor food intake. The 24-item mealtime observation checklist (MOCL), developed by the Japanese Ministry of Health, Labour and Welfare in 2015, comprises signs, symptoms and conditions during mealtime that reflect eating and swallowing functions and oral conditions.

OBJECTIVES

To examine factors associated with malnutrition among the MOCL items in older people.

METHODS

A cross-sectional study was conducted using data from a retrospective cohort study conducted at four long-term care facilities in Japan. Among the older people residing in the facilities, 198 who received oral intake support were included in the analyses. Nutritional status was assessed using the Mini Nutritional Assessment-Short Form (MNA®-SF), and comparisons were made between 'malnutrition' and 'at-risk or well-nourished'. The association between each MOCL item and malnutrition was assessed using multivariable logistic regression analysis.

RESULTS

Of the 198 participants, 98 (49.5%) were classified as 'malnutrition', 98 (49.5%) as 'at-risk' and 2 (1%) as 'well-nourished' by MNA®-SF. After adjusting for participant characteristics such as age and sex, significant associations with malnutrition were observed for four items from the 24-item MOCL: 'Has fatigue due to extended mealtime (odds ratio [OR] = 3.20, 95% confidence interval [CI]: 1.36-7.53)', 'Food residues in the oral cavity are conspicuous (OR = 2.77, 95% CI: 1.38-5.52)', 'Has difficulty swallowing food and takes time to swallow (OR = 3.78, 95% CI: 1.45-9.84)' and 'Assisted feeding is required (OR = 3.70, 95% CI: 1.73-7.91)'.

CONCLUSIONS

The four signs, symptoms and conditions during mealtime identified in this study may be associated with malnutrition in older people.

IMPLICATIONS FOR PRACTICE

These may indicate the potential eating problems that can lead to malnutrition. By incorporating them into early intervention and prevention measures, health care providers may help prevent malnutrition and improve the nutritional status of older people.

Comparison of energy intake in critical illness survivors, general medical patients, and healthy volunteers: A descriptive cohort study

BACKGROUND

Intensive care unit (ICU) survivors have reduced oral intake; it is unknown whether intake and associated barriers are unique to this group.

OBJECTIVE

To quantify energy intake and potential barriers in ICU survivors compared with general medical (GM) patients and healthy volunteers.

DESIGN

A descriptive cohort study in ICU survivors, GM patients, and healthy volunteers. Following an overnight fast, participants consumed a 200 ml test-meal (213 kcal) and 180 min later an ad libitum meal to measure energy intake (primary outcome). Secondary outcomes; taste recognition, nutrition-impacting symptoms, malnutrition, and quality of life (QoL). Data are mean ± SD, median (interquartile range [IQR]) or number [percentage]).

RESULTS

Twelve ICU survivors (57 ± 17 years, BMI: 30 ± 6), eight GM patients (69 ± 19 years, BMI: 30 ± 6), and 25 healthy volunteers (58 ± 27 years, BMI: 25 ± 4) were included. Recruitment ceased early because of slow recruitment and SARS-CoV-2. Energy intake was lower in both patient groups than in health (ICU: 289 [288, 809], GM: 426 [336, 592], health: 815 [654, 1165] kcal). Loss of appetite was most common (ICU: 78%, GM: 67%). For ICU survivors, GM patients and healthy volunteers, respectively, severe malnutrition prevalence; 40%, 14%, and 0%; taste identification; 8.5 [7.0, 11.0], 8.5 [7.0, 9.5], and 8.0 [6.0, 11.0]; and QoL; 60 [40-65], 50 [31-55], and 90 [81-95] out of 100.

CONCLUSIONS

Energy intake at a buffet meal is lower in hospital patients than in healthy volunteers but similar between ICU survivors and GM patients. Appetite loss potentially contributes to reduced energy intake.

Preoperative free access to water compared to fasting for planned cesarean under spinal anesthesia: a randomized controlled trial

BACKGROUND

Contemporary guidance for preoperative feeding allows solids up to 6 hours and clear fluids up to 2 hours before anesthesia. Clinical trial evidence to support this approach for cesarean delivery is lacking. Many medical practitioners continue to follow conservative policies of no intake from midnight to the time of surgery, especially in pregnant women.

OBJECTIVE

This study aimed to evaluate the pragmatic approach of permitting free access to water up to the call to dispatch to the operating theater vs fasting from midnight in preoperative oral intake restriction for planned cesarean delivery under spinal anesthesia on perioperative vomiting and maternal satisfaction.

STUDY DESIGN

A randomized controlled trial was conducted in the obstetrical unit of the University of Malaya Medical Centre from October 2020 to May 2022. A total of 504 participants scheduled for planned cesarean delivery were randomized: 252 undergoing preoperative free access to water up to the call to dispatch to the operating theater (intervention group) and 252 undergoing fasting from midnight (fasting arm). The primary outcomes were perioperative vomiting and maternal satisfaction. Analyses were performed using t test, Mann-Whitney U test, and chi-square test, as appropriate.

RESULTS

Of note, 9 of 252 patients (3.6%) in the intervention group and 24 of 252 patients (9.5%) in the control group had vomiting at up to 6 hours after completion of cesarean delivery (relative risk, 0.38; 95% confidence interval, 0.18-0.79; P=.007), and the maternal satisfaction scores (0-10 visual numerical rating scale) were 9 (interquartile range, 8-10) in the intervention group and 5 (interquartile range, 3-7) in the control group (P<.001). Assessed before dispatch to the operating theater, feeling of thirst was reported by 69 of 252 patients (27.4%) in the intervention group and 134 of 252 patients (53.2%) in the control group (relative risk, 0.52; 95% confidence interval, 0.41-0.65; P<.001), capillary glucose levels were 4.8±0.7 mmol/L in the intervention group and 4.9±0.8 mmol/L in the control group (P=.048), and preoperative intravenous fluid hydration was commenced in 49 of 252 patients (19.4%) in the intervention group and 76 of 252 patients (30.2%) in the control group (relative risk, 0.65; 95% confidence interval, 0.47-0.88; P=.005). In the operating theater, ketone was detected in the catheterized urine in 38 of 252 patients (15.1%) in the intervention group and 78 of 252 patients (31.0%) in the control group (relative risk, 0.49; 95% confidence interval, 0.25-0.59; P<.001), and the numbers of doses of vasopressors needed to correct hypotension were 2.3±1.7 in the intervention group and 2.7±2.2 in the control (P=.009). The recommendation rates for preoperative oral intake regimen to a friend were 95.2% (240/252) in the intervention group and 39.7% (100/252) in the control group (relative risk, 2.40; 95% confidence interval, 2.06-2.80; P<.001), in favor of free access to water. Other assessed maternal and neonatal outcomes were not different.

CONCLUSION

Compared with fasting, free access to water in planned cesarean delivery reduced perioperative vomiting and was strongly favored by women. In addition, several pre- and intraoperative secondary outcomes were improved. However, postcesarean delivery recovery and neonatal outcomes were not different.

Acute pneumonitis caused by oral intake of incense

Incense is typically burned for use, with bronchitis and pneumonia reported as potential side effects. Physicians should be cautious as inappropriate oral ingestion of incense can lead to acute pneumonitis.

Association of early oral intake after extubation and independent activities of daily living at discharge among intensive care unit patients: A single centre retrospective cohort study

PURPOSE

We investigated the association between the time to first post-extubation oral intake, barriers to oral intake, and the rate of activities of daily living (ADL) independence at discharge (Barthel Index score <70).

METHOD

Consecutive patients admitted to the intensive care unit, aged ≥18 years, and mechanically ventilated for ≥48 hr were retrospectively enrolled. The time to first oral intake, barriers to oral intake, daily changes, and clinical outcomes were assessed. Multiple logistic regression analysis adjusted for baseline characteristics was used to determine the association between time to first post-extubation oral intake and ADL independence.

RESULT

Among the 136 patients, 74 were assigned to the ADL independence group and 62 to the dependence group. The time to first post-extubation oral intake was significantly associated with ADL independence (adjusted p = < 0.001) and was a predictor of ADL independence at discharge. Respiratory and dysphagia-related factors (odds ratio [OR] 0.35; 95% confidence interval [CI] 0.15-0.82, p = 0.015 and OR 0.07; CI 0.01-0.68, p = 0.021, respectively) were significantly associated with the ADL independence at discharge.

CONCLUSION

Respiratory and dysphagia-related factors, as barriers to the initiation of oral intake after extubation, were significantly associated with ADL independence at discharge.

Factors Related to Oral Problems in Patients with Prolonged Disorders of Consciousness in Long-Term Care: A Cross-Sectional Study

Factors influencing oral problems, such as malocclusion and oral motor dysfunction, in patients with prolonged disorders of consciousness (DOC) remain unclear. This study aimed to clarify the relationship between oral problems and physical function, communication, respiration, and oral intake status, as well as related factors in patients with DOC receiving long-term care at home. A cross-sectional study was conducted in October 2018; 127 patients who developed DOC > 5 years ago were analyzed. The differences between patients with and without oral problems were examined, and a binomial logistic regression analysis was performed to examine factors associated with oral problems, with the presence of oral problems as the dependent variable, and age, the number of years since onset, drooling, oral intake status, and the presence of a family dentist as explanatory variables. A post hoc power analysis of the binomial logistic regression analysis for oral problems (odds ratio: 2.05, alpha value: 0.05, incidence of oral problems: 0.80, and total sample size: 127) demonstrated an observed power of 93.09%. Oral intake status (p = 0.010) and the number of years since onset (p = 0.046) were significantly related to oral problems. Preventive oral management and rehabilitation from the early stage after onset may be effective for oral problems in patients with DOC.

Factors Contributing to Complete Oral Intake in Dysphagic Stroke Patients with Enteral Feeding Tubes in Convalescent Rehabilitation Wards

Objectives:

This study investigated the factors contributing to complete oral intake (COI) in dysphagic stroke patients with enteral feeding tubes in the local clinical setting.

Methods:

Data of patients with percutaneous endoscopic gastrostomy (PEG) or nasogastric tube (NGT) feeding on admission to convalescent rehabilitation wards (CRWs) were extracted from the Kaga Regional Cooperation Clinical Pathway for Stroke database for multiple centers including 19 acute care hospitals and 11 hospitals with CRWs. Patients were divided into two groups based on their status regarding COI or incomplete oral intake (ICOI) at discharge. Logistic regression analysis with forced-entry variables was used to identify factors contributing to COI.

Results:

On discharge from CRWs, COI and ICOI were observed in 140 and 207 cases, respectively. The COI group was younger, had a higher rate of initial stroke, higher Functional Oral Intake Scale (FOIS) scores, higher Functional Independence Measure (FIM) motor and cognitive scores, higher Body Mass Index (BMI), lower rate of patients with PEG, and shorter stays in acute care wards. Logistic regression analysis with forced entry revealed that younger age; initial stroke; higher FOIS score, FIM cognitive score, and BMI; and shorter stay in the acute care ward contributed to COI.

Conclusions:

The primary factors contributing to COI in dysphagic stroke patients with enteral feeding tubes were younger age, initial stroke, higher swallowing and cognitive function, good nutritional status, and shorter stay in the acute care ward.

Patient-Centred Outcomes Following Tracheostomy in Critical Care

INTRODUCTION

Around 20% of intensive care unit (ICU) patients undergo tracheostomy insertion and expect high-quality care concentrating on patient-centered outcomes including communication, oral intake, and mobilization. The majority of data has focused on timing, mortality, and resource utilization, with a paucity of information on quality of life following tracheostomy.

METHODS

Single center retrospective study including all patients requiring tracheostomy from 2017 to 2019. Information collected on demographics, severity of illness, ICU and hospital length of stay (LOS), ICU and hospital mortality, discharge disposition, sedation, time to vocalization, swallow and mobilization. Outcomes were compared for early versus late tracheostomy (early = <day 10) and age category (≤ 65 vs ≥ 66 years).

RESULTS

In total, 304 patients were included and 71% male, median age 59, APACHE II score 17. Median ICU and hospital LOS 16 and 56 days, respectively. ICU and hospital mortality 9.9% and 22.4%. Median time to tracheostomy 8 days, 8.55% open. Following tracheostomy, median days of sedation was 0, time to noninvasive ventilation (NIV) 1 day (94% of patients achieving this), ventilator-free breathing (VFB) 5 days (72%), speaking valve 7 days (60%), dynamic sitting 5 days (64%), and swallow assessment 16 days (73%). Early tracheostomy was associated with shorter ICU LOS (13 vs 26 days, P < .0001), reduced sedation (6 vs 12 days, P < .0001), faster transition to level 2 care (6 vs 10 days, P < .003), NIV (1 vs 2 days, P < .003), and VFB (4 vs 7 days, P < .005). Older patients received less sedation, had higher APACHE II scores and mortality (36.1%) and 18.5% were discharged home. Median time to VFB was 6 days (63.9%), speaking valve 7 days (64.7%), swallow assessment 20.5 days (66.7%), and dynamic sitting 5 days (62.2%).

CONCLUSION

Patient-centered outcomes are a worthy goal to consider when selecting patients for tracheostomy in addition to mortality or timing alone, including in older patients.

The Kuchi-kara Taberu index as a predictive marker of oral intake recovery in patients with aspiration pneumonia

AIM

In recent years, the Kuchi-kara Taberu (KT) index has been used as a new tool for the evaluation of dysphagia; however, its predictive ability remains unknown. This study was conducted to examine the validity of oral intake recovery prediction using the KT index in patients with aspiration pneumonia.

METHODS

The subjects were older inpatients admitted to an acute-care hospital for the treatment of aspiration pneumonia. A logistic regression analysis was conducted to clarify factors significantly associated with oral intake recovery. In addition, cut-off values of the predictors were calculated using a receiver operating characteristic curve analysis with the area under the curve (P < 0.05).

RESULTS

A total of 124 patients (mean age 84.3 ± 7.9 years old, 70 males, 54 females) were enrolled in this study and divided into two groups at discharge: the oral intake group (62.1%) and the non-oral intake group (37.9%). The significant predictors of the recovery of oral intake were the pre-treatment period, treatment period, and the total score of the KT index; the respective odds ratios were 1.082 (95% confidence interval [CI] 1.013-1.156), 1.018 (1.003-1.033) and 0.850 (0.780-0.927), and the respective areas under the curve were 0.407 (95% CI 0.300-0.515), 0.304 (0.208-0.399), and 0.732 (0.640-0.824). The cut-off value of the total score of the KT index was 30. The model showed 85.7% sensitivity and 57.4% specificity.

CONCLUSION

The KT index is suggested to be a valid variable for predicting whether or not a patient with aspiration pneumonia can recover their oral intake ability during acute-care hospitalization. Geriatr Gerontol Int 2023; 23: 221-226.

Comparison of Post-Cesarean Pain Perception of General Versus Regional Anesthesia, a Single-Center Study

Background and Objectives: Pain during and after the procedure remains the leading concern among women undergoing cesarean section. Numerous studies have concluded that the type of anesthesia used during a cesarean section undoubtedly affects the intensity and experience of pain after the operation. Materials and Methods: This prospective cohort study was conducted at the Clinic for Gynecology and Obstetrics, Clinical Center "Dragisa Misovic-Dedinje", Belgrade, Serbia. Patients at term pregnancy (37-42 weeks of gestation) with an ASA I score who delivered under general (GEA) or regional anesthesia (RA) by cesarean section were included in the study. Following the procedure, we assessed pain using the Serbian McGill questionnaire (SF-MPQ), Visual Analogue Scale (VAS) and the pain attributes questionnaire at pre-established time intervals of 2, 12, and 24 h after the procedure. Additionally, time to patient's functional recovery was noted. We also recorded the time to the first independent mobilization, first oral intake, and lactation establishment. Results: GEA was performed for 284 deliveries while RA was performed for 249. GEA had significantly higher postoperative sensory and affective pain levels within intervals of 2, 12, and 24 h after cesarean section. GEA had significantly higher postoperative VAS pain levels. On pain attribute scale intensity, GEA had significantly higher postoperative pain levels within all intervals. Patients who received RA had a shorter time to first oral food intake, first independent mobilization, and faster lactation onset in contrast to GEA. Conclusions: The application of RA presented superior postoperative pain relief, resulting in earlier mobilization, shorter time to first oral food intake, and faster lactation onset in contrast to GEA.

Use of Maximum Tongue Pressure Values to Examine the Presence of Dysphagia after Extubation and Prevent Aspiration Pneumonia in Elderly Emergency Patients

Background: Tongue pressure values in patients with dysphagia are reported to be significantly lower than those in healthy controls. The aim of this study was to measure the maximum tongue pressure (MTP) values after extubation in order to assess the presence of post-extubation dysphagia for the safe initiation of oral intake in elderly patients. Methods: Data from 90 patients who were extubated after mechanical ventilation under tracheal intubation were collected retrospectively. The patients were divided into two groups as follows: normal group (those who did not develop aspiration pneumonia after extubation; median age 62 years) and aspiration group (those who developed aspiration during the evaluation period; median age 75 years). The MTP values were measured at 6 h, 24 h, 3 days, and 7 days after extubation. Results: The values were significantly increased 24 h after extubation in the normal group (p < 0.05). Alternatively, no increase was observed even after 1 week of extubation in the aspiration group, and the values were significantly lower than those in the normal group. The cutoff values at 6 and 24 h after extubation, which were measured using the receiver operator characteristic (ROC) curve, were 17.8 and 23.2 kpa, respectively; furthermore, the results of these assessments were strongly related to the development of aspiration 6 h after extubation (χ2-value: 6.125; p = 0.0133). Conclusions: The presence of post-extubation dysphagia in patients who are intubated for ≥24 h can be predicted based on age and the MTP values at 6 h after extubation.

A Novel Morphine Drinking Model of Opioid Dependence in Rats

An animal model of voluntary oral morphine consumption would allow for a pre-clinical evaluation of new treatments aimed at reducing opioid intake in humans. However, the main limitation of oral morphine consumption in rodents is its bitter taste, which is strongly aversive. Taste aversion is often overcome by the use of adulterants, such as sweeteners, to conceal morphine taste or bitterants in the alternative bottle to equalize aversion. However, the adulterants’ presence is the cause for consumption choice and, upon removal, the preference for morphine is not preserved. Thus, current animal models are not suitable to study treatments aimed at reducing consumption elicited by morphine itself. Since taste preference is a learned behavior, just-weaned rats were trained to accept a bitter taste, adding the bitterant quinine to their drinking water for one week. The latter was followed by allowing the choice of quinine or morphine (0.15 mg/mL) solutions for two weeks. Then, quinine was removed, and the preference for morphine against water was evaluated. Using this paradigm, we show that rats highly preferred the consumption of morphine over water, reaching a voluntary morphine intake of 15 mg/kg/day. Morphine consumption led to significant analgesia and hyperlocomotion, and to a marked deprivation syndrome following the administration of the opioid antagonist naloxone. Voluntary morphine consumption was also shown to generate brain oxidative stress and neuroinflammation, signs associated with opioid dependence development. We present a robust two-bottle choice animal model of oral morphine self-administration for the evaluation of therapeutic interventions for the treatment of morphine dependence.

Labelling fish diets with 15 N -Leucine for monitoring feed consumption and bio-distribution in Atlantic salmon

Feeding represents 50–70% of the cost of production in salmon farming, higher than any other animal farm. The improvement of this percentage is challenging as the food is thrown into the fish tank, there is no quantification of the amount of food that is consumed by the fish. In consequence, it is difficult to adjust the food composition making it more nutritive or promoting food consumption by fish. In this study, to investigate food consumption, bio‐distribution and food residues, leucine containing ¹⁵N (a stable isotope of nitrogen) was used to label the fish food. Atlantic salmon (Salmo salar) weighing 100–120 g were maintained in 30 L tanks at a density of 14 kg/m³. Fishes were fed daily at 1% of the fish weight with pellet labelled with ¹⁵N‐leucine. The ¹⁵N incorporation was determined 14 hours after the feeding in all the fish organs. Results showed that 14 hours after the administration of a single dose of labelled food to Atlantic salmon enables the detection of the tracer in the whole organism allowing determining the food consumption. Through the analysis of nitrogen use efficiency (NUE), we showed that the trunk, pyloric caeca and head incorporate the highest level of the marker (72.7, 8.7 and 5.7%, respectively). This methodology would permit monitoring feeding to minimize food loss, improve administration methodologies or select the preferred foods for the fish, among others to reduce production costs.

Single-centre survey of women reflecting on recent experiences and preferences of oral intake during labour

BACKGROUND

Consensus-based recommendations guiding oral intake during labour are lacking.

AIMS

We surveyed women at a tertiary women's hospital about preferences for and experiences of oral intake during labour, gastrointestinal symptoms during labour and recalled advice about oral intake.

MATERIALS AND METHODS

Women who experienced labour completed a postpartum survey with responses as free text, yes-no questions and five-point Likert scales. We identified demographic data and risk factors for surgical or anaesthetic intervention at delivery from medical records. We summarised free text comments using conventional content analysis.

RESULTS

One hundred and forty-nine women completed the survey (47% response rate). Their mean (SD) age was 31 (four) years, birthing at median gestation of 39 weeks (interquartile range: 38-40). One hundred and twenty-two (83%) and 44 (30%) women strongly agreed or agreed they felt like drinking and eating respectively during labour. Ninety women (61%) reported nausea and 47 women (32%) reported vomiting in labour. Forty-one women (28%) did not receive advice on oral intake during labour. Maternal risk factors for surgical intervention were identified in 72 (48%) women and fetal risk factors in 27 (18%) women. Thirty-one women (21%) delivered by emergency caesarean section.

CONCLUSION

Pregnant women received variable advice regarding oral intake during labour, from variable sources. Most women felt like drinking but not eating during labour. Guidelines on oral intake in labour may be beneficial to women, balancing the preferences of women with risks of surgical intervention.

FACTORS ASSOCIATED WITH ORAL INTAKE ABILITY IN PATIENTS WITH ACUTE-STAGE STROKE

OBJECTIVE

To investigate the factors predicting oral feeding ability following acute stroke.

METHODS

This retrospective study compared patients admitted to a stroke care unit in 2 groups: an oral intake group and a tube feeding group. The groups were evaluated for 28 items and initial blood investigation tests, and the results compared. Logistic regression analysis was used to identify the clinical variables significantly associated with oral feeding ability.

RESULTS

A total of 255 stroke patients (162 in the oral intake group and 93 in the tube feeding group) were admitted to the stroke care unit. Significant differences were observed between the 2 groups for 20 items. Logistic analysis found that the following variables were significant in the prediction model: age, date of initiation of oral feeding, stroke recurrence/patient deterioration during hospitalization, and date of initiation of occupational therapy.

CONCLUSION

Factors associated with achieving oral intake among stroke care unit patients were: young age at time of admission; starting oral intake early; no stroke recurrence/patient deterioration during hospitalization; and achieving rehabilitation of daily activities early during the physical function recovery stage.

Can Videofluoroscopic Swallowing Kinematic Analysis Predict Recovery of Oral Intake in Postoperative Oral Cancer Patients Requiring Nasogastric Tube Feeding?

This retrospective study determined the significant predictive factors for the number of days required to remove nasogastric tubes (NGTs) after surgery in patients with oral cancer (OC). In this study, patients underwent a videofluoroscopic swallowing study (VFSS) approximately 2 weeks after surgery. Videofluoroscopic images were analyzed, and variables such as swallowing and swallowing kinematics were measured. Patient characteristics, swallowing kinematics, and swallowing results were assessed using a Cox proportional hazards model. This study assessed 129 participants (66 men, 63 women, mean age: 69.0 ± 14.1 years) with nine types of cancer. The Cox proportional hazard ratio revealed that sex, body mass index before surgery, radiotherapy and/or chemotherapy, dysphagia before surgery, normalized pharyngeal constriction ratio, upper esophageal sphincter (UES) opening, and laryngeal vestibule disclosure (LVC) disorder were predictive factors for the removal of NGTs when adjusted for age. The study identified several predictive factors for the removal of NGTs and oral intake recovery in patients with OC. Regarding swallowing kinematics, UES opening is the most significant predictive factor. After surgery for OC, VFSS should be performed to assess safe eating methods and predict the recovery of oral intake and removal of the NGT.

Factors Related to Oral Intake of Food by Hospitalized Patients with Malnutrition under the Care of a Nutrition Support Team

This study aimed to evaluate the role of the general condition and oral health status in determining the primary nutritional route and suitable food form for oral ingestion among malnourished inpatients. This cross-sectional study included 255 inpatients referred to a nutrition support team (NST), which included dental professionals, at an acute care hospital. We assessed the participants’ basic information, and Dysphagia Severity Scale (DSS) and Oral Health Assessment Tool (OHAT) scores. The nutritional intake mode was evaluated based on the Functional Oral Intake Scale scores at the initial NST consultation (FOIS-I), and then revised by the NST based on the participants’ general condition and oral health (FOIS-R). There was a divergence between FOIS-I and FOIS-R, with FOIS-R being significantly higher than FOIS-I (p < 0.001). Logistic regression analysis of FOIS-R identified that consciousness level (odds ratio (OR): 0.448; 95% confidence interval (CI): 0.214–0.935) and DSS (OR: 3.521; 95% CI: 2.574–4.815) significantly affected the oral nutrition intake. Among participants who could ingest orally (FOIS-R ≥ 3; n = 126), FOIS score had significant negative and positive associations with the OHAT and DSS scores, respectively. These findings suggest that appropriate assessment of oral health status, including swallowing function, might contribute to high-quality nutrition management.

Examining antidepressant use in palliative care patients by risk of antidepressant discontinuation syndrome

Antidepressant drugs, which are widely used in palliative care patients for both management of psychiatric disorders and non-psychiatric symptoms, may cause a cluster of distressing symptoms on discontinuation. In dying patients, cessation of oral intake may occur either temporarily or permanently for reasons related to disease or its treatment, as well as in the days before death. We examined antidepressant use in palliative care patients by risk of antidepressant discontinuation syndrome (ADDS). Strategies for reducing the risk of ADDS, and for managing it that should occur, are discussed.

Longitudinal comparisons of a whole-mouth taste test to clinician-rated and patient-reported outcomes of dysgeusia postradiotherapy in patients with head and neck cancer and associations with oral intake

BACKGROUND

After head and neck cancer (HNC) treatment, dysgeusia may be a barrier to oral intake. In this exploratory study, we prospectively examined taste perception, clinician-rated (CRO) and patient-reported (PRO) taste changes and their effect on oral intake postradiotherapy.

METHODS

Twenty-eight patients were assessed at baseline, treatment weeks 2 and 4, and 1, 3, and 6 months post-treatment using a whole-mouth taste test and associated CRO and subjective PRO measures.

RESULTS

Greater taste impairment was reflected by subjective than by a whole-mouth taste test. The most significant and consistent decline occurred mid-treatment. The Chemotherapy-Induced Taste Alteration Scale (PRO) discomfort subscale correlated significantly with maintaining an oral diet, percent of oral intake, and appetite level from mid-treatment to 6 months post-treatment.

CONCLUSIONS

PRO results indicated ongoing oral intake issues. Whole-mouth taste tests may fail to fully reflect functional taste-loss. Dysgeusia prevention and treatment methods are needed to improve patient outcomes.

Identification of risk factors for mortality and delayed oral dietary intake in patients with open drainage due to deep neck infections: Nationwide study using a Japanese inpatient database

BACKGROUNDS

Data on risk factors for deep neck infection including descending necrotizing mediastinitis (DNM) have been limited. Using a nationwide database, the aim was identifying the factors related to patient death and delay in recovering oral intake.

METHODS

Data of 4949 patients were extracted from a Japanese inpatient database between 2012 and 2017. The main outcome was survival at discharge. In a subgroup analysis of the 4949 patients with survival, the second outcome was delay in the interval between admission and full recovery of oral intake.

RESULTS

Only a few factors (advanced-age, ventilation) were associated with both mortality and delayed oral dietary intake by logistic regression analyses. Conversely, several factors including DNM (adjusted-odds ratio [OR] 1.41) and repeated surgery (adjusted-OR 1.70) were significantly related only to delayed oral dietary intake.

CONCLUSIONS

Although DNM was not necessarily related to mortality, patients with DNM should receive careful attention to avoid delayed oral dietary intake.

Effects of Oral Management on Elderly Patients with Pneumonia

OBJECTIVES

In this study, we examined the factors influencing the presence or absence of dental intervention in patients with pneumonia in an acute-care hospital, focusing on oral intake and its status.

DESIGN

Observational study.

SETTING

Teikyo University School of Medicine, Mizonokuchi Hospital.

PARTICIPANTS

Patients ≥65 years of age who were admitted to the Teikyo University School of Medicine, Mizonokuchi Hospital between January 1, 2018 and December 31, 2019 with pneumonia who were referred to the Department of Rehabilitation with suspected dysphagia were included in the study. Fifty patients who underwent dental intervention were compared with 50 controls who had received no dental interventions prior to the opening of the dental department.

MEASUREMENTS

Time series matching was retrospectively performed using the Oral Health Assessment Tool (OHAT). From the medical records, age at admission, sex, pneumonia severity classification (age, dehydration, respiratory failure, orientation disturbance, and blood pressure [A-DROP] score), body mass index, Charlson's Comorbidity Index, OHAT, functional oral intake scale (FOIS) score at admission and discharge, and the length of hospital stay were retrieved; FOIS level ≥4 was defined as established oral intake.

RESULTS

The number of patients in the control group before matching was 179. Twelve patients with missing information and seven patients who died in the hospital were excluded from this study. Multivariable logistic regression analysis showed that dental intervention (odds ratio 3.0, p = 0.014) was associated with the establishment of oral intake at discharge. Multiple logistic regression analysis showed that dental intervention was a significant factor for FOIS at discharge (p = 0.002) and the length of hospital stay (p = 0.039).

CONCLUSION

Oral management with dental intervention was associated with establishing oral intake and reducing hospital stay in patients with pneumonia, regardless of pneumonia severity or comorbidities.

Relationship between oral intake level and oral health assessment tool scores in the convalescent ward

PURPOSE

To examine the relationship between oral intake function and oral health status in convalescent inpatients.

METHODS

Subjects were 222 patients admitted to a convalescent hospital between 1 January and 30 June 2018. Investigation items were age, sex, causative disease, body mass index, functional oral intake scale (FOIS), functional independence measure, occlusal contact, assistance with oral cleaning, and oral health assessment tool (OHAT) scores. Multiple regression analysis was performed with FOIS as the dependent variable, and investigation items were related to FOIS as independent variables.

RESULTS

Results of multiple regression analysis for all patients suggested that saliva and denture scores were significantly associated with FOIS. However, analysis excluding non-oral feeding patients did not show a significant association between FOIS and OHAT scores.

CONCLUSION

The results of this study suggest that oral health status is associated with oral intake function. In addition, the oral health status of inpatients may be strongly related to whether or not they are eating orally. Therefore, it is necessary to take good care of oral health in non-oral feeding patients in the convalescent ward.

Family mealtime behaviors in children who are tube fed and preparing to transition to oral eating: A comparison to other pediatric populations

This study examined differences in observed mealtime behaviors between children preparing to transition to oral feeding and children with various other chronic illnesses using a standardized measure of mealtime beaviors. The parent-child mealtime relationship can become strained due to problematic mealtime behaviors that limit food intake, as well as inadvertent reinforcement of disruptive behavior by caregivers. Frequency/rate of behaviors were compared between children with tube feeding (CwTF) and from previous studies of children with chronic illnesses using the Dyadic Interactive Nomenclature for Eating (DINE). Parents of CwTF used more coaxing, physical prompts, and reinforcement during meals, while parents of children with chronic illnesses used more direct commands and engaged in more parent talk. Findings support differences in parent-child mealtime interactions and eating behaviors across pediatric illness subgroups.

Prediction of oral intake recovery for inpatients with aspiration pneumonia by videoendoscopic evaluation using the Hyodo-Komagane score in Japan

OBJECTIVE

To verify the validity of the prediction of oral intake recovery for inpatients with aspiration pneumonia using the Hyodo-Komagane score.

BACKGROUND

Patients admitted for treatment of aspiration pneumonia sometimes have difficulty in resuming oral intake due to decreased swallowing function. Predicting whether the swallowing function will recover enough to achieve oral ingestion at discharge is an important factor in developing a treatment strategy. No studies have investigated the prediction of oral intake recovery using videoendoscopic examination.

METHODS

Subjects were 65 patients who were admitted to an acute care hospital for the treatment of aspiration pneumonia. The patients were divided into two groups, the oral feeding group and the tube feeding group, according to their oral intake status at discharge or transfer. Logistic regression analysis was performed using the condition that tube feeding was not required as an objective variable and the items with significant differences between the two groups as explanatory variables. Additionally, the receiver operating characteristic curve was used to identify patients who could take food orally at discharge.

RESULTS

The odds ratios for the Hyodo-Komagane score and the pharyngeal clearance score were 1.485 and 3.379, respectively. When the cut-off values of the Hyodo-Komagane score and the pharyngeal clearance score were 6 and 1, the sensitivity was 0.88 and 0.91, and the specificity was 0.64 and 0.70, respectively.

CONCLUSION

The Hyodo-Komagane score and especially the pharyngeal clearance score are useful indices to predict oral intake recovery for inpatients with aspiration pneumonia.

Aluminum reproductive toxicity: a summary and interpretation of scientific reports

Publications addressing aluminum (Al)-induced reproductive toxicity were reviewed. Key details were compiled in summary tables. Approximate systemic Al exposure, a measure of bioavailability, was calculated for each exposure, based on the Al percentage in the dosed Al species, Al bioavailability, and absorption time course reports for the exposure route. This was limited to laboratory animal studies because no controlled-exposure human studies were found. Intended Al exposure was compared to unintended dietary Al exposure. The considerable and variable Al content of laboratory animal diets creates uncertainty about reproductive function in the absence of Al. Aluminum-induced reproductive toxicity in female mice and rats was evident after exposure to ≥25-fold the amount of Al consumed in the diet. Generally, the additional daily Al systemic exposure of studies that reported statistically significant results was greater than 100-fold above the typical human daily Al dietary consumption equivalent. Male reproductive endpoints were significantly affected after exposure to lower levels of Al than females. Increased Al intake increased fetus, placenta, and testes Al concentrations, to a greater extent in the placenta than fetus, and, in some cases, more in the testes than placenta. An adverse outcome pathway (AOP) was constructed for males based on the results of the reviewed studies. The proposed AOP includes oxidative stress as the molecular initiating event and increased malondialdehyde, DNA and spermatozoal damage, and decreased blood testosterone and sperm count as subsequent key events. Recommendations for the design of future studies of reproductive outcomes following exposure to Al are provided.

Nutrition During Critical Care: An Audit on Actual Energy and Protein Intakes

INTRODUCTION

Oral nutrition is delivered frequently in intensive care units (ICUs) but rarely studied. The primary objective of this study was to quantify nutrition intakes in patients exclusively orally fed (OF) and in those receiving medical nutrition solutions or both.

METHODS

Adults who stayed in a mixed ICU for ≥3 days were studied. Nutrition deficits were calculated as the difference between estimated energy or protein targets (determined by weight-based formulas) and actual intakes (recorded on a daily basis by nurses). Total volumes of enteral or parenteral nutrition solutions, propofol, and glucose infused over 24 hours were collected and energy and protein amounts were calculated. In OF patients, food intake at each meal (breakfast, lunch, and dinner) was estimated using the "one-quarter portion" method.

RESULTS

Among the 289 included patients aged 67 (57-75.5) years, 253 were fed and received, on average, 14.3 (7.8-19) kcal/kg/d and 0.53 (0.27-0.8) g/kg/d protein. In OF patients (n = 126), intakes were 9.7 (5.8-19) kcal/kg/d and 0.35 (0.17-0.57) g/kg/d protein. In the subset of OF patients with ICU stay ≥ 7 days (n = 37), respectively, 51% and 94% never received ≥80% of their energy and protein targets.

CONCLUSION

Nutrition intakes were lower by oral feeding compared with other exclusive or combined medical nutrition. Compared with the prescribed amounts, the deficit was larger for proteins than for energy.

Factors predicting the effects of dysphagia rehabilitation on multidimensional functional status in elder outpatients: A prospective cohort study

OBJECTIVE

This study aimed to clarify the relationship between the oral intake function and functional status, as well as to determine the aspects of functional status potentially predicting the effects of dysphagia rehabilitation in the maintenance stage, in elder outpatients.

METHODS

This study was conducted in a clinic, specialised in rehabilitation of patients with dysphagia. The participants were 93 non-tube-fed patients 65 years of age or older. The participants were scheduled to undergo the initial examination for oral intake function and functional status, and then to receive dysphagia rehabilitation for 1 year. After rehabilitation period, oral intake function was re-evaluated, and the elements of functional status potentially related to the effects of dysphagia rehabilitation were determined.

RESULTS

It was found that the lower the participants' oral intake function levels, the higher the prevalence of reduced parameters of functional status. After 1-year dysphagia rehabilitation, the oral intake function was maintained or improved in 70 (75.3%) participants, but had diminished in 23 (24.7%). Our analysis revealed that participants with higher Vitality Index scores and MMSE at the time of initial examination were significantly more likely to show maintained or improved oral intake function at 1 year (odds ratio[OR], 1.76; 95% confidence interval [CI], 1.14-2.71; OR, 1.17; 95% CI, 1.06-1.28, respectively).

CONCLUSIONS

It became apparent that the lower the oral intake function level at the initial examination, the higher the prevalence of reduced multidimensional functional status. Mental function was found to predict the effects of dysphagia rehabilitation in the maintenance stage.

Effect of dysphagia rehabilitation in patients receiving enteral nutrition at home nursing care: A retrospective cohort study

Objective

We considered the effect of dysphagia rehabilitation and investigated parameters associated with the resumption of oral intake in the elderly patients receiving home nursing care who were not eating by mouth.

Methods

The participants were 116 patients aged ≥65 years (66 men and 50 women, mean age 79.7 ± 8.9 years) who were receiving home nursing care and not eating by mouth because of dysphagia. All patients underwent dysphagia rehabilitation for 6 months with the objective of resuming oral intake. After 6 months of dysphagia rehabilitation, the patients’ eating status was assessed using the Functional Oral Intake Scale (FOIS) and the associations of the post‐intervention FOIS score with age, history of pneumonia, duration of enteral nutrition, body mass index (BMI), alertness, physical function (ability to walk) and swallowing function at the initial examination.

Results

Functional Oral Intake Scale scores increased significantly after 6 months rather than those at the initial evaluation (P < .001). Eighty patients (69.0%) resumed oral intake (FOIS score ≥2), thirty patients (25.9%) of whom became capable of daily oral intake (FOIS score ≥3). Swallowing function was associated with the resumption of oral intake. In addition, physical function before dysphagia rehabilitation was an important factor to resume daily oral intake.

Conclusions

The results of the present study suggest that the resumption of oral intake by patients receiving enteral nutrition requires improvement in swallowing function. In addition, anyone who cannot walk may not recover daily oral intake.

Investigation on the status of oral intake management measures during labor in China

The World Health Organization recommended that the oral intake of low-risk pregnant women during labor should not be restricted. Hospitals in different countries take different measures to manage the intake during labor, but it is not clear about the current situation of oral intake management measures in the hospital during labor in China. Thus, the objective of this study was to investigate the current situation of oral intake management measures during labor in China, so as not only provide references for developing appropriate midwifery technology training and formulating relevant policies, but also provide a basis for exploring and implementing better oral intake management measures in the future.A cross-sectional survey was conducted. From December 2017 to November 2018, the oral intake management measures of 1213 hospitals in 22 provinces, cities, and autonomous regions in China were investigated by a self-designed questionnaire. χ test was used for statistical analysis.Different hospitals in China have adopted different oral intake management measures. Among the 1213 hospitals, 939(77.4%) hospitals took measures to allow pregnant women to bring the easily digestible food, 813(67.0%) hospitals took measures to allow pregnant women to eat what she wanted to eat. Few hospitals provide pregnant women with oral nutrition solution or provide a suitable diet for pregnant women. Thirty-four (2.8%) hospitals still restrict pregnant women's fluid intake.Oral intake management measures that are more suitable for Chinese pregnant women should be explored to better ensure the women energy needs and they safely go through childbirth.

Barriers to managing medications appropriately when patients have restrictions on oral intake

RATIONALE, AIMS, AND OBJECTIVES

Investigation of several serious adverse events in our organization highlighted that medications were managed inappropriately when patients have oral intake restrictions. The aim of this work was to identify the barriers to optimal medication management when patients have restrictions on their oral intake.

METHOD

Data were feedback and comments obtained between 2011 and 2014 from a hospital-wide quality assurance project. Data had not been purposefully collected and were in response to a general request for feedback regarding managing oral medications when patients have oral intake restrictions. Data came from a range of clinical staff and from various forums associated with the quality assurance project, including 37 presentations, 34 group meetings, and over 50 one-on-one meetings, as well as emails and other sources. Data were analysed using the thematic analysis approach. Data were coded inductively, and the domains of the Theoretical Domains Framework were used to categorize the data. Subthemes and themes were then developed.

RESULTS

Barriers could be broadly grouped into systems-level issues (organizational guidance and work environment) and the individual person-level issues (staff knowledge and beliefs). These barriers highlight the complexity of the medication management task. The lack of standardized guidance and consistent terminology regarding medication administration when patients have restrictions on oral intake, particularly when fasting or nil by mouth, were important systems factors, as were workflow issues and the "culture" of the environment in which staff practiced. Lack of knowledge about medication administration, social influences, and role interpretation were important individual person factors.

CONCLUSION

Systems- and individual person-level issues were significant contributors to inappropriate medication management when patients have oral intake restrictions. Many of the barriers may be addressed with systems approaches such as hospital-wide guidance that simplifies and standardize oral medication administration instructions, particularly regarding fasting and nil by mouth terminology.

Effect of an Oral Health Programme on Oral Health, Oral Intake, and Nutrition in Patients with Stroke and Dysphagia in Taiwan: A Randomised Controlled Trial

No previous studies have evaluated an oral health programme, before swallowing therapy, in patients with stroke and dysphagia in Taiwan. This randomised controlled trial evaluated the effect of an oral health programme (i.e., sputum assessment, Bass method-based tooth brushing, and tooth coating with fluoride toothpaste) before swallowing therapy. Sixty-six patients with stroke (23 female, 43 male) in our rehabilitation ward, who underwent nasogastric tube insertion, were assigned randomly to an oral care group (n = 33) and a control group (n = 33). Demographic data, oral health assessment, Functional Oral Intake Scale (FOIS) scores, Mini-Nutritional Assessment-Short Form (MNA-SF) scores, and nasogastric tube removal rates were compared between groups. We evaluated outcomes using generalised estimating equation analysis. Three weeks post-implementation, the oral care group had significant oral health improvements relative to the control group (95% CI =−2.69 to −1.25, Wald χ² = 29.02, p < 0.001). There was no difference in the FOIS (95% CI = −0.16 to 0.89, Wald χ² = 1.86, p > 0.05), MNA-SF (95% CI =−0.35 to 0.53, Wald χ² =−0.17, p > 0.05), and nasogastric tube removal (p > 0.05) between groups. The oral care group had a higher, but non-significant FOIS score (3.94 vs 3.52) (p > 0.05). Routine oral health programmes implemented during stroke rehabilitation in patients with dysphagia may promote oral health and maintain oral intake.

Genetic correlations between nicotine reinforcement-related behaviors and propensity toward high or low alcohol preference in two replicate mouse lines

Common genetic factors may contribute to the high comorbidity between tobacco smoking and alcohol use disorder. Here, we assessed behavioral and biological effects of nicotine in replicate mouse lines selectively bred for high (HAP2/3) or low alcohol preference (LAP2/3). In Experiment 1, free-choice (FC) oral nicotine and quinine intake were assessed in HAP2/3 and LAP2/3 mice. Effects of nicotinic acetylcholine receptor blockade by mecamylamine on nicotine intake in HAP2 mice were also examined. In Experiment 2, HAP2/3 and LAP2/3 mice were tested for differences in sensitivity to nicotine-induced taste conditioning. In Experiment 3, the effects of a single nicotine injection on nucleus accumbens (NAc) and dorsal striatum monoamine levels in HAP2/3 and LAP2/3 mice were tested. In Experiment 1, HAP2/3 mice showed greater nicotine intake and intake ratio than LAP2/3 mice. There were no line differences in quinine intake. Mecamylamine reduced nicotine intake and intake ratio in HAP2 mice. In Experiment 2, HAP2/3 mice showed weaker nicotine-induced conditioned taste aversion (CTA) compared with LAP2/3 mice. In Experiment 3, nicotine treatment increased NAc dopamine turnover across both HAP2/3 and LAP2/3 mouse lines. These results show that there is a positive genetic correlation between oral alcohol intake (high alcohol intake/preference selection phenotype) and oral nicotine intake and a negative genetic correlation between oral alcohol intake and sensitivity to nicotine-induced CTA.

Lipopolysaccharides in Food, Food Supplements, and Probiotics: Should We be Worried?

The fever-inducing effect of lipopolysaccharides (LPS) is well known, and human blood is extremely responsive to this pyrogen. Recently, the safety of LPS-containing food supplements and probiotic drugs as immune-stimulants has been questioned, although these products are orally taken and do not reach the bloodstream undigested. The concerns are understandable, as endotoxaemia is a pathological condition, but the oral uptake of probiotic products containing LPS or Gram-negative bacteria does not pose a health risk, based on the available scientific evidence, as is reviewed here. The available methods developed to detect LPS and other pyrogens are mostly used for quality control of parentally applied therapeuticals. Their outcome varies considerably when applied to food supplements, as demonstrated in a simple comparative experiment. Products containing different Escherichia coli strains can result in vastly different results on their LPS content, depending on the method of testing. This is an inherent complication to pyrogen testing, which hampers the communication that the LPS content of food supplements is not a safety concern.

Oral 5-aminolevulinic acid-mediated photodynamic diagnosis using fluorescence cystoscopy for non-muscle-invasive bladder cancer: A multicenter phase III study

OBJECTIVE

To confirm the reproducibility of the effectiveness and safety in photodynamic diagnosis of non-muscle-invasive bladder cancer using 5-aminolevulinic acid in a prospective multicenter non-randomized phase III trial.

METHODS

A total of 61 patients with primary or recurrent non-muscle-invasive bladder cancer were prospectively enrolled from five hospitals between May 2015 and March 2016. 5-Aminolevulinic acid (20 mg/kg) was orally administered 3 h before transurethral resection of bladder tumors using white light or fluorescent light. Of 60 evaluable patients, 511 specimens were obtained from tumor-suspicious lesions and normal-looking mucosa. The primary end-point was sensitivity. The secondary end-points were specificity, positive and negative predictive values, and safety.

RESULTS

The sensitivity of the fluorescent light source (79.6%) was significantly higher (P < 0.001) than that of the white light source (54.1%). In total, 25.4% (46/181) of tumor specimens were diagnosed as positive with only the fluorescent light source. In nine (15%) of 60 patients, the risk classification and recommended treatment after transurethral resection of bladder tumors were changed depending on the additional types of tumor diagnosed by the fluorescent light source. The specificity of the fluorescent light versus white light source was 80.6% versus 95.5%. No grade 4-5 adverse event was noted. Hypotension and urticaria were severe adverse events whose relationship to oral 5-aminolevulinic acid could not be excluded.

CONCLUSIONS

These findings confirm the diagnostic efficacy and safety of photodynamic diagnosis with 20 mg/kg of oral 5-aminolevulinic acid, and show that transurethral resection of bladder tumors with a fluorescent light source using oral 5-aminolevulinic acid is well tolerated.

Prediction of decannulation, oral intake recovery, overall survival and lung metastasis following oral malignant tumor resection and reconstruction

The present study investigated whether tongue base and mandibular bone defects were associated with the rate of decannulation and oral intake recovery, and survival time, including overall and lung metastasis-free survival time, in patients that underwent oral malignant tumor (OMT) resection with reconstruction. A total of 105 patients that underwent OMT resection with laryngeal preservation and reconstruction were recruited. The extent of defects was classified according to Urken's classification. The rates of decannulation and oral intake recovery were assessed with the Kaplan-Meier method. It was identified that 4-5 section segmental mandibulectomy (SM) and total glossectomy (TG) were significantly associated with a lower rate of decannulation and oral intake recovery by univariate and multivariate analysis using a Cox's proportional model. Patients in the high risk group (4-5 sections or TG) were significantly less likely to achieve decannulation and unaided oral intake. Patients in the high risk group exhibited a significantly shorter overall and lung metastasis-free survival time. Following multivariate analysis adjusted for the clinical stage (IV/I-III), past history of or postoperative radiotherapy (yes/no) and age (per year), the high risk group was associated with a significantly rate of decannulation and unaided oral intake. In conclusion, TG or wide SM is a prognostic parameter for functional and survival outcomes, including lung metastasis, in OMT.

Behavioral effects of long-term oral administration of aluminum ammonium sulfate in male and female C57BL/6J mice

Background

Aluminum (Al) is considered to be a neurotoxic metal, and excessive exposure to Al has been reported to be a potential risk factor for neurodegenerative diseases. Al ammonium sulfate is one of the Al compounds that is widely used as a food additive. However, the effects of the oral administration of Al ammonium sulfate on physical development and behavior remain to be examined.

Methods

In this study, we investigated the effects of the administration of Al ammonium sulfate 12‐water dissolved in drinking water (0.075 mg/mL) beginning in adolescence on various types of behavior in adult female C57BL/6J mice through a battery of behavioral tests (low‐dose experiment; Experiment 1). We further examined the behavioral effects of the oral administration of a higher dose of the Al compound in drinking water (1 mg/mL) beginning in the prenatal period on behavior in adult male and female mice (high‐dose experiment; Experiment 2).

Results

In the low‐dose experiment, in which females’ oral intake of Al was estimated to be 0.97 mg Al/kg/d as adults, Al‐treated females exhibited an increase in total arm entries in the elevated plus maze test, an initial decrease and subsequent increase in immobility in the forced swim test, and reduced freezing in the fear conditioning test approximately 1 month after the conditioning session compared with vehicle‐treated females (uncorrected P < .05). However, the behavioral differences did not reach a statistically significant level after correction for multiple testing. In the high‐dose experiment, in which animals’ oral intakes were estimated to be about ten times higher than those in the low‐dose experiment, behavioral differences found in the low‐dose experiment were not observed in high‐dose Al‐treated mice, suggesting that the results of the low‐dose experiment might be false positives. Additionally, although high‐dose Al‐treated females exhibited increased social contacts with unfamiliar conspecifics and impaired reference memory performance, and high‐dose Al‐treated mice exhibited decreases in prepulse inhibition and in correct responses in the working memory task (uncorrected P < .05), the differences in any of the behavioral measures did not reach the significance level after correction for multiple testing.

Conclusion

Our results show that long‐term oral exposure to Al ammonium sulfate at the doses used in this study may have the potential to induce some behavioral changes in C57BL/6J mice. However, the behavioral effects of Al were small and statistically weak, as indicated by the fact that the results failed to reach the study‐wide significance level. Thus, further study will be needed to replicate the results and reevaluate the behavioral outcomes of oral intake of Al ammonium sulfate.

Aluminum (Al) ammonium sulfate was orally administered to C57BL/6J mice (estimated dose of 0.97‐9.78 Al mg/kg/d). Behavioral effects of Al were assessed in a battery of behavioral tests in mice in adulthood. Statistically significant behavioral differences were not found between Al‐ and vehicle‐treated mice.

Association of Oral Intake and Transient Mixed Venous Oxygen Desaturation in Patients Undergoing Fast-Track Postoperative Care After Open-Heart Surgery

OBJECTIVE

The impact of early resumption of oral intake after cardiac surgery on hemodynamics has not been characterized. The authors examined the effects of early oral intake on the oxygen supply-demand relationship in patients undergoing on-pump cardiac surgery in an early recovery after surgery program.

DESIGN

Prospective data were collected in postcardiac surgical patients in a multidisciplinary intensive care unit (ICU) during an 18-month period.

SETTING

Single institution study.

PARTICIPANTS

Forty-three patients who underwent either mitral or aortic valve repair and were successfully liberated from ventilatory support within 10 hours after surgery.

INTERVENTIONS

Patients were either allowed to resume oral intake on the morning of the first postoperative day or not at the discretion of the surgical team after extubation.

MEASUREMENTS AND MAIN RESULTS

The oxygen supply-demand relationship was assessed continuously with cardiac index and mixed venous oxygen saturation (SvO₂). Among the subjects, 22 patients were allowed to eat, and transient SvO₂ decrease was noted in 13 patients. All transient SvO₂ decreases occurred in the patients with early oral intake. The hemodynamic status and oxygen supply-demand relationship did not differ between the patients with and without transient SvO₂ decrease. All the subjects were discharged successfully from the ICU on the first postoperative day, and the length of hospital stay was similar irrespective of SvO₂ decrease after early oral intake.

CONCLUSIONS

Early oral intake shortly after extubation was associated with transient but significant SvO₂ decrease in patients who underwent fast-track recovery after open-heart surgery. Because this phenomenon did not negatively affect the postoperative outcome, early oral intake may not be harmful.

The Effects of Different Isocaloric Oral Nutrient Solutions on Psychophysical, Metabolic, Cognitive, and Olfactory Function in Young Male Subjects

Food intake influences human cognition, olfaction, hunger, and food craving. However, little research has been done in this field to elucidate the effects of different nutrients. Thus, the goal of our study was to investigate the effects of oral ingestion of different nutrient solutions on olfactory, cognitive, metabolic and psychophysical function. Twenty healthy men participated in our study employing a double-blind, cross-over, repeated measurement design. Participants were tested on four different study days. Each day participants received, in randomized order, one of three isocaloric (protein, carbohydrate or fat 600 kcal, 1,500 mL) solutions or a placebo. Olfactory and cognitive tests (monitoring only) were conducted three times, i.e., 60 min before the beginning of nutrient intake, following oral ingestion of the solution and 60, and 240 min after. Psychophysical and metabolic function tests (active grehlin, desacyl ghrelin, insulin, glucagon, glucose, triglyceride, urea) were performed 7 times on each examination day (observation period: −60 min, 0 = solution intake, +60, +120, +180, +240, and +300 min). Ratings of hunger and food craving significantly differed over the observation period with lowest ratings following application of the protein solution. Highest ratings of craving were found following placebo intake. We further observed a significant positive correlation of active grehlin with hunger and fat, protein and sweets craving for each nutrient solution. Active grehlin significantly correlated with carbohydrate craving for carbohydrate and fat solution and with vegetable craving for fat solution only. Hunger hormone levels, hunger and food craving ratings demonstrated that the hierarchical order that appears in satiating efficiencies of isovolumetric-isocaloric ingested macronutrients is protein > fat > carbohydrate. Our study reveals that the type of nutrient exerts a significant influence on metabolic parameters, hunger and food craving.

Rehabilitative management for aspiration pneumonia in elderly patients

Aspiration pneumonia is a common disease that frequently occurs in elderly patients. Most patients with aspiration pneumonia have swallowing disability and develop hospital‐acquired disability. Frequently, patients have difficulty returning home, and they often require long‐term hospitalization. Recently, the effectiveness of rehabilitative management including physical, pulmonary, and dysphagia rehabilitation for aspiration pneumonia was reported. Several studies showed that early rehabilitation was associated with reduced mortality and early hospital discharge after aspiration pneumonia. Unnecessary “nil by mouth” directives associated with aspiration pneumonia at hospital admission resulted in adverse effects, including decline in swallowing ability and prolonged treatment duration. Rehabilitative management combined with appropriate nutrition is recommended to improve clinical outcomes, including physical and swallowing function in geriatric patients with aspiration pneumonia.

Detection of Fucoidan in Urine after Oral Intake of Traditional Japanese Seaweed, Okinawa mozuku (Cladosiphon okamuranus Tokida)

Seaweed has been considered an indigestible food. Fucoidan, which is found abundantly in seaweed, especially in Cladosiphon okamuranus (Okinawa mozuku), has a high molecular weight and has been long believed to be hardly absorbed in the human digestive system due to a lack of certain digestive enzymes. We previously reported that fucoidan can be detected in serum and urine after oral intake of purified fucoidan in humans and rats. However, it is unclear whether the fucoidan in mozuku can be absorbed after digestion of mozuku. Therefore, we attempted to detect fucoidan in urine before and after mozuku intake. We determined the fucoidan concentration in urine after oral intake of Okinawa mozuku and urinary fucoidan was detected in several volunteers. In conclusion, these results suggest that fucoidan in mozuku can be absorbed after ingestion of mozuku.

Weekend days are not required to accurately measure oral intake in hospitalised patients

BACKGROUND

Nutrition studies in patients admitted to hospital frequently disregard oral intake because measurement is time-intensive and logistically challenging. In free-living populations, weighed food records (WFR) are the gold-standard and are conducted on weekend and weekdays to capture variations in intake, although this may not translate during hospitalisation. The present study aimed to determine whether oral intake differs between weekends and weekdays in hospitalised patients.

METHODS

For adult patients initially admitted to the intensive therapy unit with a moderate-severe head injury over a 12-month period, WFR were conducted each week on Tuesday, Thursday and Saturday throughout hospitalisation. Meal components were weighed before and after consumption, and energy and protein intakes were calculated using specialised software. Data are reported as the mean (SD). Differences were assessed using paired t-tests and agreement using Bland-Altman plots.

RESULTS

Thirty-two patients had WFR collected on 220 days, 68% (n = 149) on weekdays and 32% (n = 71) on weekends. Overall, daily intakes were 5.72 (3.67) MJ [1367 (877) kcal] and 62 (40) g protein. There were no differences in intake across all days (P = 0.937 energy, P = 0.797 protein), nor between weekdays and weekends, in weeks 1-3 of oral intake (all P > 0.1). Limits of agreement between mean intakes across days were wide for energy [range -11.20 to 9.55 MJ (-2680 to 2283 kcal)] and protein (range -125 to 110 g).

CONCLUSIONS

Grouped energy and protein intakes from WFR in hospitalised patients are similar on weekdays and weekends, although large intra-patient variations occur. Future quantification of oral intake during hospitalisation should include as many days as feasible, although not necessarily weekend days, to reflect true intake.

The effects on plasma L-arginine levels of combined oral L-citrulline and L-arginine supplementation in healthy males

We investigated the effects of combining 1 g of l-citrulline and 1 g of l-arginine as oral supplementation on plasma l-arginine levels in healthy males. Oral l-citrulline plus l-arginine supplementation more efficiently increased plasma l-arginine levels than 2 g of l-citrulline or l-arginine, suggesting that oral l-citrulline and l-arginine increase plasma l-arginine levels more effectively in humans when combined.

Patterns of return to oral intake and decannulation post-tracheostomy across clinical populations in an acute inpatient setting

BACKGROUND

Dysphagia is often a comorbidity in patients who require a tracheostomy, yet little is known about patterns of oral intake commencement in tracheostomized patients, or how patterns may vary depending on the clinical population and/or reason for tracheostomy insertion.

AIMS

To document patterns of clinical management around the commencement of oral intake throughout hospital admission and along the decannulation pathway in patients with a new tracheostomy, and to examine the nature of variability across multiple clinical populations.

METHODS & PROCEDURES

A 12-month retrospective review of 126 patients who had undergone an acute tracheostomy was conducted. Within the cohort, patients were further classified into eight clinical populations representing specialty areas within the tertiary referral centre. Data were collected on timing of milestones and patterns of clinical management related to oral and enteral feeding and decannulation. Relationships between temporal variables were calculated, in addition to descriptive analysis of the overall cohort and by clinical population.

OUTCOMES & RESULTS

Median temporal markers of patient progression post-tracheostomy insertion for the cohort were: continuous cuff deflation after 7.5 days, commencement of oral intake after 10.5 days, decannulation after 15 days and cessation of enteral nutrition (EN) after 17 days. However, considerable individual variation and differences between clinical populations was observed. Overall, 86% of the cohort returned to oral intake, although 25% were discharged with EN via a gastrostomy. A total of 86% of the group were decannulated by hospital discharge. Oral intake was introduced at every stage of the decannulation pathway, including prior to cuff deflation, but the majority of patients commenced diet/fluids following cuff deflation or with an uncuffed tube in situ, and most patients who ceased EN did so following decannulation. Commencement of oral intake was evenly split between the intensive care unit (ICU) and the wards. Increased time to commencement of oral intake correlated with increased time to decannulation (r = .805, p = .001), and increased time to decannulation correlated with increased hospital length of stay (r = .687, p = .006). Whilst cohort patterns were observed within the heterogeneous group, sub-analysis revealed distinct patterns of oral intake management across the different clinical populations.

CONCLUSIONS & IMPLICATIONS

The data provide benchmarks enabling comparison by overall cohort as well as by specialist clinical populations, each with differing reasons for tracheostomy insertion. The data would suggest that tracheostomy patients should not be looked upon as a singular cohort; rather, evaluation of factors with specific attention made to underlying aetiology and individual clinical presentation is essential.

Early versus delayed postoperative oral hydration after general anesthesia: a prospective randomized trial

The purpose of our study was to determine the safety and tolerability of early oral hydration (EOH) compared with delayed oral hydration (DOH) after general anesthesia. One thousand anesthesiology (ASA) I to III adult patients undergoing non-gastrointestinal surgery with general anesthesia were randomized assigned into two groups: DOH (n=500, patients were given water 4 h after general anesthesia), EOH (n=500, patients were given 0.5 ml/kg water once recovered from general anesthesia.) in the postanesthesia care unit (PACU). Patients were evaluated for nausea, vomiting, drink desire, thirsty scale, oropharyngeal discomfort scale, and satisfaction scale. Statistical analysis was performed with Student's t and Chi-Square tests. Complete data were available for 983 patients (EOH=488, DOH=495). Twenty minutes after receiving water the incidence of vomiting in EOH group was very low. And there was no significant difference between the two groups at the same time point (p > 0.05). Compared with DOH group, after receiving water there was a significant decrease of patients' thirsty scales (p < 0.0001) and oropharyngeal discomfort scales (p < 0.0001) in EOH group. Significantly more patients' satisfaction were reported in EOH group (p < 0.001). No serious adverse effects were reported during the study period. For patients undergoing non-gastrointestinal surgery, early oral hydration after recovery from general anesthesia was safe, with lower thirsty scale and oropharyngeal discomfort scales, and higher satisfaction.

Nutrition care-related practices and factors affecting nutritional intakes in hospital patients at risk of pressure ulcers

BACKGROUND

Malnutrition is common in hospitals and is a risk factor for pressure ulcers. Nutrition care practices relating to the identification and treatment of malnutrition have not been assessed in patients at risk of pressure ulcers. The present study describes nutrition care practices and factors affecting nutritional intakes in this patient group.

METHODS

The study was conducted in four wards at two hospitals in Queensland, Australia. Adult patients at risk of pressure ulcers as a result of restricted mobility were observed for 24 h to determine their daily oral intake and practices such as nutrition screening, documentation and intervention. Independent samples t-tests and chi-squared tests were used to analyse dietary intake and nutrition care-related data. Predictors of receiving a dietitian referral were identified using logistic regression analyses.

RESULTS

Two hundred and forty-one patients participated in the present study. The observed nutritional screening rate was 59% (142 patients). Weight and height were documented in 71% and 34% of cases. Sixty-nine patients (29%) received a dietitian referral. Predictors of receiving a dietitian referral included lower body mass index and longer length of stay. On average, patients consumed 73% and 72% of the energy and protein provided, respectively. Between 22% and 38% of patients consumed <50% of food provided at main meals.

CONCLUSIONS

Nutrition care practices including malnutrition risk screening and documentation of nutritional parameters appear to be inadequate in patients at risk of pressure ulcers. A significant proportion of these patients eat inadequately at main meals, further increasing their risk of malnutrition and pressure ulcers.

Applicability of the two-step thickened water test in patients with poststroke dysphagia: a novel assessment tool for paste food aspiration

This study evaluated the clinical usefulness of the newly developed Two-Step Thickened Water Test (TTWT) in identifying patients with poststroke dysphagia at risk of aspiration of paste food. The study subjects were 110 poststroke patients (mean age, 73 ± 10 years). The TTWT comprises a bedside pretest (tongue protrusion, vocalization, voluntary cough, and dry swallow) and a direct swallowing test using 4 mL of thickened water. Fiberoptic endoscopic evaluation of swallowing determined the subject's ability to swallow the paste food. Based on the test results and endoscopic evaluation, we calculated the TTWT's sensitivity and specificity in identifying paste food aspiration. We also calculated these values when normal water was used instead of thickened water in a direct swallowing test. The prevalence of dysphagia for paste food was 41% in our study group. The sensitivity and specificity of the TTWT in identifying dysphagia for paste food was 93% and 88%, respectively. The specificity decreased to 78.5% when normal water was used, with no decrease in sensitivity. The test was completed in less than 10 minutes, with no adverse events in any subject. Our data suggest that the TTWT might be a useful assessment tool for evaluating the risk of paste food aspiration in patients with poststroke dysphagia.

Body weight reducing effect of oral boric acid intake

BACKGROUND

Boric acid is widely used in biology, but its body weight reducing effect is not researched.

METHODS

Twenty mice were divided into two equal groups. Control group mice drank standard tap water, but study group mice drank 0.28mg/250ml boric acid added tap water over five days. Total body weight changes, major organ histopathology, blood biochemistry, urine and feces analyses were compared.

RESULTS

Study group mice lost body weight mean 28.1% but in control group no weight loss and also weight gained mean 0.09% (p<0.001). Total drinking water and urine outputs were not statistically different. Cholesterol, LDL, AST, ALT, LDH, amylase and urobilinogen levels were statistically significantly high in the study group. Other variables were not statistically different. No histopathologic differences were detected in evaluations of all resected major organs.

CONCLUSION

Low dose oral boric acid intake cause serious body weight reduction. Blood and urine analyses support high glucose, lipid and middle protein catabolisms, but the mechanism is unclear.