A comparison of survival, pneumonia, and hospitalization in patients with advanced dementia and dysphagia receiving either oral or enteral nutrition.

OBJECTIVES: This study aimed to evaluate the survival rate, pneumonia incidence, and hospital admissions among elderly patients with advanced dementia and to compare these outcomes between patients receiving enteral and oral nutrition. DESIGN: An observational, prospective, non-randomized, and unblinded study, with a minimum follow up of 6 months. SETTING: Inpatient wards as well as ambulatory and emergency units run by a Brazilian university. PARTICIPANTS: Dysphagic elderly patients aged ≥ 60 years with advanced dementia (classified as at least 7A according to the Functional Assessment Staging [FAST]). Both patients with gastrostomies and nasogastric feeding tubes were included in the alternative feeding group. MEASUREMENTS: Following informed consent, a complete clinical examination was performed upon recruitment, and the primary caregiver was interviewed. Data concerning the major outcomes described above, as well as other demographic and clinical information, were recorded at admission and during follow-up phone calls. Survival analysis was performed using a Kaplan-Meier curve and a stepwise Cox regression analysis. RESULTS: Sixty-seven elderly patients were recruited: 36 (53,7%) for oral feeding and 31 for alternative feeding (n = 28 nasogastric tube). Of these, 57 (85.1%) were classified as at least FAST 7C. They were, on average, 84.79 years old, mostly women (85.1%), and with a low level of education (2.9 years). Mortality at 3 months was 11.1% among the oral feeding group and 41.9% among the alternative feeding group (p = 0.004). At 6 months, the mortality rate increased to 27.8% and 58.1%, respectively (p = 0.012). The following variables persisted in the regression model at the end of the analysis: feeding route (p = .018; RR = 2.33; CI: 1.158-4.667), duration of dementia (p = .014; RR = .88; CI: .786-.974) and number of pressure ulcers (p = .007; RR = 1.250; CI: 1.063-1.470). A higher incidence of aspiration pneumonia was observed in the alternative feeding group (p = 0.006), but no difference in the number of hospital admissions was detected between the groups (p = 0.365). CONCLUSION: The use of alternative feeding, along with the number of pressure ulcers were associated with an increased risk of death in elderly patients with advanced dementia. A higher incidence of aspiration pneumonia was also observed in the alternative feeding group. The number of hospital admissions was not different between the feeding routes.

South American rattlesnake bite (Crotalus durissus SP) without envenoming: insights on diagnosis and treatment.

A South American rattlesnake bite without clinical manifestations of envenoming (termed 'dry-bite') has not been recognized to occur by the Brazilian Ministry of Health, which recommends the administration of antivenom to all bitten patients. During 36 months of an observational study on South American rattlesnake bites in Minas Gerais, Brazil, 12% of 41 patients with fang marks at the bite-site did not present clinical or laboratory features of envenoming and had no plasma venom detected before specific serotherapy, fulfilling the criteria for the diagnosis of true 'dry-bite'. Data from these preliminary observations suggest that these patients should be correctly diagnosed since they should not be treated with unnecessary and sometimes hazardous and expensive serotherapy.

Is the severity of Tityus serrulatus scorpion envenoming related to plasma venom concentrations?

Plasma venom concentrations were measured by enzyme-linked immunosorbent assay at the time of hospital admission in 56 patients stung by the scorpion Tityus serrulatus. According to clinical and laboratory manifestations patients were classified into two groups: patients with only local pain at the site of the sting (n = 37), and patients with systemic manifestations of envenoming (n = 19). Circulating venom concentrations of these two groups of patients were cross-tabulated and the results showed that patients with systemic manifestations of envenoming had significantly higher plasma venom concentrations than patients with only local pain at the site of the sting.

Efficacy of antivenom therapy for neutralizing circulating venom antigens in patients stung by Tityus serrulatus scorpions.

Enzyme-linked immunosorbent assays for detection of Tityus serrulatus venom antigen and of horse anti-T. serrulatus venom antibodies were carried out before antivenom treatment and at 1, 6, 12, and 24 hr after antivenom therapy in 18 patients with systemic manifestations following T. serrulatus scorpion sting. Increased levels of circulating venom antigens were detected in the patients before antivenom treatment, but were no longer detected 1 hr after specific antivenom therapy. High titers of antivenom persisted for at least 24 hr after treatment with antivenom. The evolution of clinical and laboratory manifestations of envenoming showed that vomiting and local pain decreased within 1 hr and hyperglycemia was no longer detected 12 hr after antivenom therapy. The cardiorespiratory manifestations disappeared 6-24 hr after the administration of antivenom and all patients recovered completely. This study demonstrates the efficacy of antivenom therapy in neutralizing circulating venom antigens and supports the prompt administration of a potent antivenom to patients with systemic manifestations of envenoming.

Standardization of an enzyme linked immunosorbent assay (ELISA) for detecting circulating toxic venom antigens in patients stung by the scorpion Tityus serrulatus.

The sensitivity and specificity of an enzyme-linked immunosorbent assay (ELISA) for the detection of circulating antigens from toxic components of Tityus serrulatus scorpion venom was determined in patients stung by T. serrulatus before antivenom administration. Thirty-seven patients were classified as mild cases and 19 as moderate or severe cases. The control absorbance in the venom assay was provided by serum samples from 100 individuals of same socioeconomic group and geographical area who had never been stung by scorpions or treated with horse antisera. The negative cutoff value (mean + 2 SD) corresponded to a venom concentration of 4.8 ng/ml. Three out of the 100 normal sera were positive, resulting in a specificity of 97%. The sensitivity of the ELISA when all cases of scorpion sting were included was 39.3%. When mild cases were excluded, the sensitivity increased to 94.7%. This study showed that this ELISA can be used for the detection of circulating venom toxic antigens in patients with systemic manifestations following. T. serrulatus sting but cannot be used for clinical studies in mild cases of envenoming since the test does not discriminate mild cases from control patients.

Scorpion sting-induced pulmonary oedema: evidence of increased alveolocapillary membrane permeability.

A 16-year-old boy died with acute pulmonary oedema and shock after Tityus serrulatus scorpion sting. The patient showed evidence of cardiac dysfunction and damage, an increase in tracheobronchial aspirate/plasma protein concentration, light microscopic features of the lung compatible with the adult respiratory distress syndrome and electron microscopic findings compatible with acute lung injury and increased alveolocapillary membrane permeability.

Children with adrenergic manifestations of envenomation after Tityus serrulatus scorpion sting are protected from early anaphylactic antivenom reactions.

The incidence of early anaphylactic reactions to scorpion antivenom given i.v. after Tityus serrulatus scorpion sting was evaluated in 103 children aged up to 15 years in Belo Horizonte, Brazil. Patients without adrenergic manifestations (Group 1, n = 28) were compared with those who presented systemic involvement that included adrenergic manifestations (Group 2, n = 75). Data were recorded on a proforma and the presence or absence of early anaphylactic reaction was cross-tabulated according to clinical features, sex, age and volume of antivenom used in the treatment. Unpaired Student's t-test was used to calculate significance of differences in age and volume of antivenom used. Multivariate logistic regression was used to determine the effects of clinical features and volume of antivenom as predictors of early anaphylactic reaction to antivenom treatment. Twelve (42.9%) of 28 children included in Group 1 presented early anaphylactic reactions compared with 6 (8%) of 75 children of Group 2 (OR = 8.63; 95% CI: 2.88, 25.7). The reactions were more severe in Group 1. There were no significant differences with respect to age and sex. After adjusting for clinical form, volume of antivenom was not significantly associated with presence of reactions (OR = 1.11; 95% CI: 0.70, 2.80 for each 5.0 ml of antivenom administered). The results show that children with adrenergic manifestations after T. serrulatus scorpion sting had significantly lower anaphylactic reactions to antivenom than those without these manifestations.

[Respiratory involvement secondary to crotalid ophidian bite (Crotalus durissus)]. / Comprometimento respiratório secundário a acidente ofídico crotálico (Crotalus durissus).

Three patients presented respiratory abnormalities following Crotalus durissus snakebite. These abnormalities appeared in the first 48 h after the snake bite and consisted of dyspnea, tachypnea, use of accessory muscles of respiration (cases 1 and 2) and flaring of the nostrils (case 2). Cases 1 and 2 developed acute respiratory failure. Case 2, 24 h after the snakebite presented difficult breathing and periods of apnea. He was intubated in the emergency room and transferred to the intensive case unit where he arrive with spontaneous breathing. His respiratory pattern worsened and measurement of arterial pH and blood gases showed metabolic and respiratory acidosis with partial carbon dioxide pressure increasing from 40 to 50.3 mmHg compatible with acute ventilatory failure. Both patients needed mechanical ventilation. Weaning from the ventilator was accomplished after 33 days in case 1 and after 15 days in case 2. Both patients also presented acute renal failure treated with peritoneal dialysis with full recovery of the renal function. Measurements of forced vital capacity (FVC) and forced expiratory volume in the first second (FEV 1.0) was carried out 58 hours after the snakebite in case 3. Both FVC and FEV 1.0 were reduced in relation to the predicted values (60 and 67% respectively) but the ratio FEV 1.0/FVC was in the normal range. These findings were compatible with a restrictive pattern of ventilatory failure. Serial measurements showed progressive increase of both FVC and FEV 1.0 reaching 72 and 79% of the predicted values, respectively, in the 10th day after the snakebite.(ABSTRACT TRUNCATED AT 250 WORDS)