Aspiration after critical illness: role of endotracheal tube, tracheostomy, swallowing disorders.

Swallowing is a complex process that involves over 50 muscles and nerves and has two critical roles: passing food from the oral cavity through the pharynx and into the esophagus and preventing contents from entering the airway. If a patient's swallowing physiology or airway protective mechanisms are disturbed, the airways and the lungs have innate defense systems to protect against injury and infection. However, critically ill patients are more likely to develop dysphagia, which is an impairment or malfunction in any aspect of the swallowing mechanism, due to the numerous interventions they undergo. When airway reflexes fail, commonly in the presence of dysphagia, aspiration can occur, which is the entry of a fluid or solid below the level of the true vocal cords. If left unmanaged, dysphagia has been associated with aspiration pneumonia, pneumonitis, airway obstruction, delayed enteral nutrition, prolonged length of ICU and hospital stay, reduced quality of life, and even death; in some cases, dysphagia is an independent risk factor for mortality. It is important to routinely assess dysphagia in all critically ill patients using a multimodal approach, including systematic assessments, scoring indices, trained specialists, and intensive care unit nurses. Several interventions are crucial for preventing and managing dysphagia and its associated problems. Further research is necessary to help determine the best ways to prevent and manage pulmonary aspiration in critically ill patients. Several interventions are essential in preventing and managing dysphagia and the sequelae of swallowing dysfunction. Further research is needed to help elucidate the best way to avoid and manage pulmonary aspiration in critically ill patients.

Sex-Based Disparities in Outcomes With Abdominal Aortic Aneurysms.

Although abdominal aortic aneurysms (AAA) are more common in men, women with AAA have increased morbidity and mortality. Additionally, there are discrepancies among professional society guidelines for AAA screening in women. In this retrospective study from the Nationwide Inpatient Sample (NIS) database from 2003 to 2014, we compared rates of AAA repair (rupture and elective) and AAA-related mortality in men vs. women to identify predictors of death among men and women with AAA. We divided the population into 1) AAA rupture 2) elective AAA repair. The main outcomes included temporal trends in AAA rupture, rupture-related death, AAA repair, in-hospital death, and predictors of AAA-related death. There were 570,253 discharge records for AAA admissions between 2003 and 2014, including 22.8% women and 77.2% men. Women had a higher proportion of rupture (18.4% vs 12.6%, p <0.01). A smaller proportion of women underwent endovascular aortic repair (EVAR) compared with men in the ruptured AAA (13.9% vs. 20.3%, p <0.01) and elective repair (55.7% vs. 67.4%, p <0.01) cohorts. Within the ruptured cohort, a higher proportion of women did not receive repair (46.4% vs. 26.1%, p <0.01). On multivariable analysis, female gender was a significant predictor of death with rupture (OR 1.39, 95% CI 1.16 to 1.66) and elective repair (OR 1.74, 95% CI 1.36 to 2.22), with both elective EVAR (OR 2.52, 95% CI 2.06 to 3.09) and elective open aortic repair (OAR; OR 1.50, 95% CI 1.33 to 1.68). Propensity score matching confirmed a higher risk of death in women in both the rupture (OR 1.19, 95% CI 1.09 to 1.30) and elective repair (OR 1.50, 95% CI 1.35 to 1.67) cohorts. In conclusion, AAA poses significant morbidity and mortality, especially in women. Women were more likely to die before repair with AAA rupture and female gender was an independent predictor of mortality in both the rupture and elective repair groups.

Tumor volume reduction evaluated by cone beam computed tomography during stereotactic body radiotherapy for early stage non-small cell lung cancer.

BACKGROUND: We hypothesized that significant tumor volume reduction (TVR) occurs over the course of stereotactic body radiotherapy (SBRT) for early stage non-small cell lung cancer (NSCLC), and that TVR correlates with clinical outcomes. METHODS: We conducted a retrospective review of patients treated with SBRT for early stage NSCLC across two academic centers. For each patient, we contoured the tumor volume (TV) on cone beam computed tomography (CBCT) images obtained before each treatment fraction. We then calculated TVR based on the TV from the first and last days of treatment. We used log-rank tests to quantify differences in overall survival (OS), progression-free survival (PFS) and recurrence based on TVR. RESULTS: Data from 69 patients and a total of 73 treated tumors were analyzed. The median follow-up for survivors was 51.8 months (range, 6.9 to 80.0 months). The median TVR for the cohort was 10.1% (range, -5.7% to 43.5%). There was no significant difference in either OS (median 33.4 vs. 29.1 months, P=0.79) or PFS (median 26.3 vs. 12.3 months, P=0.43) for those with high TVRs (≥10.1%) vs. low TVRs (<10.1%), respectively. There was a trend toward superior 2-year PFS in the high TVR group (52.2% vs. 36.7%, P=0.062), but this effect diminished on longer follow-up (4-year PFS 31.9% vs. 26.7%, P=0.15). No associations were observed between TVR and local, regional or distant recurrence. CONCLUSIONS: We were not able to demonstrate that TVR is a reliable predictive imaging marker for stage I/II NSCLC treated with SBRT. Future studies with larger sample sizes are needed to clarify a potential relationship between TVR and early outcomes.

Clinical significance of pretreatment tumor growth rate for locally advanced non-small cell lung cancer.

BACKGROUND: Locally advanced non-small cell lung cancer (NSCLC) may exhibit significant tumor growth before the initiation of definitive chemoradiation therapy (CRT). We thus investigated the prognostic value of pretreatment tumor growth rate as measured by specific growth rate (SGR). METHODS: We conducted a retrospective review of 42 patients with locally advanced NSCLC treated with definitive concurrent CRT. For each patient, we contoured the primary gross tumor volume (GTV) on the pretreatment diagnostic chest computed tomography (CT) scan and the radiation therapy (RT) planning CT scan. We then calculated SGR based on the primary GTV from each scan and the time interval between scans. We used log-rank tests and univariate Cox regression models to quantify differences in progression-free survival (PFS), overall survival (OS) and recurrence based on SGR. RESULTS: We divided patients into two groups for analysis: those with an SGR greater than or equal to the upper tercile value of 0.94%/day (high SGR) and those with SGR less than 0.94%/day (low SGR). Patients with high SGRs versus low SGRs experienced inferior PFS (median, 5.6 vs. 13.6 months, P=0.016), without a significant difference in OS. The inferior PFS in the high SGR group persisted on multivariate analysis [adjusted hazard ratio (HR) 2.37, 95% confidence interval (CI): 1.07-5.25, P=0.034]. The risk of distant recurrence was higher in the high SGR group (HR 2.62, 95% CI: 1.08-6.38, P=0.033), but there was no difference in the risk of locoregional recurrence between groups. CONCLUSIONS: Pretreatment SGR was associated with inferior PFS and distant control among patients with locally advanced NSCLC treated with concurrent CRT. Further studies in larger populations may aid in elucidating optimal SGR cut-off points for risk stratification.