Effect of early rehabilitation by physical therapists on in-hospital mortality after aspiration pneumonia in the elderly.

OBJECTIVE: To clarify the effect of early rehabilitation by physical therapists on in-hospital mortality among elderly patients with aspiration pneumonia. DESIGN: A retrospective cohort study. SETTING: A total of 1161 acute-care hospitals across Japan. PARTICIPANTS: Consecutive patients (age, 70-100 y) (N=68,584) from July 2010 to March 2012 in the Japanese Diagnosis Procedure Combination inpatient database with aspiration pneumonia on admission who underwent early physical therapist-guided rehabilitation (n=16,835) and who did not undergo rehabilitation administered by physical therapists (n=51,749). INTERVENTIONS: Early rehabilitation was defined as physical rehabilitation administered by a physical therapist, initiated within 3 days of admission, and undertaken for at least 7 days. MAIN OUTCOME MEASURE: Thirty-day in-hospital mortality. RESULTS: The 30-day in-hospital mortality rates were 5.1% and 7.1% in the early rehabilitation group and the control group, respectively. The multivariable logistic regression model showed that the early rehabilitation group had a significantly lower in-hospital mortality rate (odds ratio, .71; 95% confidence interval [CI], .64-.79; P<.001). Among patients without severe pneumonia, we found no significant difference in mortality rates between patients who underwent early rehabilitation and those who did not undergo rehabilitation by physical therapists. The instrumental variable analysis confirmed that early rehabilitation was associated with a reduced risk for in-hospital mortality (risk difference, -1.9%; 95% CI, -2.3% to -1.5%; P<.001; number needed to treat, 53 [95% CI, 43-67]). CONCLUSIONS: The data suggest that early rehabilitation by physical therapists was associated with a reduction in 30-day in-hospital mortality rates in elderly patients with severe aspiration pneumonia.

[A survey about the criteria for the indication of a gastrostomy in patients with advanced dementia]. / Criterios de médicos tratantes para indicar instalación de gastrostomía en pacientes con demencia avanzada.

BACKGROUND: Decision making concerning patients with advanced dementia is complicated. The indication of a gastrostomy is among these hard decisions, especially considering that there is no consensus about its real benefit. AIM: To explore the criteria used by Chilean physicians to indicate a gastrostomy in patients with advanced dementia. MATERIAL AND METHODS: A questionnaire about the decision making to indicate a gastrostomy was delivered to 72 physicians working in public and private hospitals. RESULTS: The survey was answered by 43 physicians. Fifty one percent had indicated a gastrostomy to patients with advanced dementia in the last year, 79% believed that gastrostomy reduces the risk of aspiration pneumonia, 50% thought that gastrostomy helps in bed sore healing and 74% believed that gastrostomy improves survival. CONCLUSIONS: The majority of physicians who answered the survey think that gastrostomy will improve the health status of patients with advanced dementia.

[Modified tracheostomy management: a protocol for the application of stoma buttons in difficult decannulations]. / Modifiziertes Trachealkanülenmanagement: Platzhaltereinsatz als Option bei erschwerten Dekanülierungen (Pilotprojekt REHAB Basel).

Current approaches to decannulation management often fail to account for patients with combined swallowing and respiratory deficits. We expanded our existing weaning and decannulation protocol by adding an optional 3-day decannulation trial to evaluate readiness for decannulation. If a patient meets predefined test-decannulation criteria a tracheostomy button is inserted during a laryngoscopic examination and left in situ for up to 3 days. Before, during and after button insertion the patient's respiratory function and saliva management are closely monitored before the decision for or against permanent decannulation is made. We present evaluation criteria, protocols and flow-charts illustrating the 3-day decannulation trial as well as 2 case studies.

Effect of early rehabilitation on activities of daily living in patients with aspiration pneumonia.

AIM: To assess the effect of early rehabilitation on improving activities of daily living (ADL) in elderly patients with aspiration pneumonia. METHODS: Using the Japanese Diagnosis Procedure Combination inpatient database, we retrospectively analyzed consecutive patients with aspiration pneumonia at admission who received early rehabilitation (n = 48 201) or did not receive any rehabilitation (n = 64 357) from July 2010 to March 2013. Early rehabilitation was defined as any type of physical rehabilitation initiated within 7 days after admission. The proportions of improved ADL scores from admission to discharge were compared between the early rehabilitation group and the non-rehabilitation group using a multivariable logistic regression analysis and instrumental variable analysis. RESULTS: The proportion of improved ADL scores was higher in the early rehabilitation group than in the non-rehabilitation group (25.4% vs 33.9%; P < 0.001). The multivariable logistic regression analysis showed that the early rehabilitation group exhibited significant improvement in ADL (odds ratio 1.57; 95% confidence interval 1.50-1.64; P < 0.001). The instrumental variable analysis showed that early rehabilitation was associated with increased proportion of improved ADL (risk difference 8.2%; 95% confidence interval 6.9-9.5%; P < 0.001). CONCLUSIONS: The present results suggest that early rehabilitation might improve ADL during hospitalization in patients with aspiration pneumonia. Geriatr Gerontol Int 2016; 16: 1181-1187.

[Prognostic factors associated with community-acquired aspiration pneumonia]. / Factores pronósticos de la neumonía por aspiración adquirida en la comunidad.

BACKGROUND: Aspiration pneumonia (AP) represents about 5-24% of community-acquired pneumonias. This condition mainly affects elderly patients and causes a high mortality. Our objective was to quantify the AP mortality rate and to identify prognostic factors upon patients admission. PATIENTS AND METHOD: We underwent a retrospective observational study of a cohort of AP patients admitted to a tertiary care hospital during a 29 months period. The in-hospital mortality rate was calculated. To identify prognostic factors, basal characteristics of patients as well as their clinical presentation and complementary tests performed on admission were studied and analyzed by univariate and multivariate techniques. Odds ratios and 95% confidence intervals were estimated. RESULTS: Thirty six out of 105 admitted patients with AP died (cumulative mortality incidence rate 34%, 95% CI 25-44%). In the univariate analysis, demographic, clinical and complementary test variables were associated with mortality. Final logistic model revealed the following independent variables: living in a nursing home (OR = 3.4; 95% CI 1.1-10.9), high degree of dependence (OR = 0.3; 95% CI, 0.1-0.9), body temperature (OR = 0.5 per Celsius degree; 95% CI, 0.3-1.0), serum creatinine levels (OR = 2.2 per mg/100 ml; 95% CI, 1.2-4.1) and LDH serum concentrations (OR = 1.5 per 100 IU/L; 95% CI, 1.1-2.0). CONCLUSIONS: The mortality of community-acquired AP is very high. In addition to clinical and biological parameters on admission such as body temperature and LDH and creatinine serum concentrations, living in a nursing home and having a high degree of dependence for the basic daily activities were identified as independent prognostic factors. An in-depth knowledge of prognostic factors related to pre-admission care and assistance is needed to decrease the mortality in these patients.

[Malignant catatonia]. / Catatonía maligna.

INTRODUCTION: Malignant catatonia is thought to be due to a severely decreased central dopaminergic activity of a medical, psychiatric, toxic-pharmacologic or idiopathic origin. CLINICAL CASE: A 24 year-old man presented with a generalized tonic-clonic seizure of focal onset. Within the following 48 hours, he developed agitation and paranoid ideation, which evolved into a severe catatonic syndrome complicated by aspiration pneumonia requiring transfer to Intensive Care Unit (ICU). Complementary tests (CT scan MRI, CSF, blood and urine studies) were negative or could not provide an etiological diagnosis. Initial EEG showed theta and delta waves, originating in the right frontal regions which later generalized. He stayed in ICU for the following three months in a state of catatonic stupor with frequent medical complications. During this time, he was given 27 sessions of electroconvulsive therapy (ECT) that eventually led to a remission of the catatonic syndrome. He was discharged from hospital one month later, fully asymptomatic except for a residuary amnesia, with a final diagnosis of idiopathic malignant catatonia. CONCLUSIONS: The authors have reviewed the management of this syndrome, which can be challenging for the physician because of the wide array of possible etiologies and its potentially lethal nature. A favorable outcome can be expected when ECT is started early, provided the underlying pathological process is treatable and there are no structural lesions in the central nervous system.

[Clinical study of percutaneous endoscopic gastrostomy in neurosurgery].

We investigated the efficacy of percutaneous endoscopic gastrostomy (PEG) in neurosurgery. PEG was applied 94 feeding patients using One-Step Button. The mean age was 70.8 +/- 15.4 years old, and the mean duration between the onset of swallowing disturbance and PEG was 3 months. Minor complication associated with PEG was 8 cases (8.5%), which treated conservatively. Body weight, BMI, and biochemical data were increased one month after PEG, so nutrition was improved. Aspiration pneumonia was improved in 9/18 patients. Fourteen patients got oral intake, and PEG was extracted in 10 patients. PEG was evaluated to be superior to transnasal feeding with regard to simplicity, efficacy, improvement of good nutrition or aspiration pneumonia, and rehabilitation.

[Consequences of an accidental aspiration of petroleum in a case of a fire eating man]. / Folgen einer akzidentellen Aspiration von Petroleum bei einem Feuerspucker.

Fire-eater's pneumonitis, caused by aspiration of petroleum, is an infrequent clinical problem in our region. It is an acute inflammatory response of the lungs to the accidental aspiration of hydrocarbons, as shown in our patient. Despite the severe initial clinical und radiological presentation, fire-eater's pneumonitis usually shows a favourable evolution with "restitutio ad integrum". Acute mortality rate is less than 1%. Fire-eater's lung is a medical emergency and needs medical support and surveillance. There is no good evidence that systemic cortico-steroids and antibiotics are effective in the treatment of hydrocarbon aspiration. Concerning chronic lung injury after fire-eater's pneumonitis, there are favorable results from short observational series.

Criterios de médicos tratantes para indicar instalación de gastrostomía en pacientes con demencia avanzada / A survey about the criteria for the indication of a gastrostomy in patients with advanced dementia

Background: Decision making concerning patients with advanced dementia is complicated. The indication of a gastrostomy is among these hard decisions, especially considering that there is no consensus about its real benefit. Aim: To explore the criteria used by Chilean physicians to indicate a gastrostomy in patients with advanced dementia. Material and Methods: A questionnaire about the decision making to indicate a gastrostomy was delivered to 72 physicians working in public and private hospitals. Results: The survey was answered by 43 physicians. Fifty one percent had indicated a gastrostomy to patients with advanced dementia in the last year, 79% believed that gastrostomy reduces the risk of aspiration pneumonia, 50% thought that gastrostomy helps in bed sore healing and 74% believed that gastrostomy improves survival. Conclusions: The majority of physicians who answered the survey think that gastrostomy will improve the health status of patients with advanced dementia.

[Collagen injection for augmentation of periprosthetic leakage after tracheo-esophageal voice restoration]. / Die Kollageninjektion zur Augmentation des insuffizienten Stimmprothesenlagers.

After laryngectomy the majority of patients receive a vocal rehabilitation by tracheo-esophageal puncture and insertion of voice prosthesis. Periprosthetic leakage causing aspiration represents a well known complication and is frequently treated by temporary removal of the prosthesis with shrinkage of the shunt. Here we describe 10 patients with such a leakage treated by collagen injection for periprosthetic tissue augmentation. A mean of 1,6 injections were necessary for complete control of the leakage. The injection was well tolerated and was found effective for median period of 9,3 months. In our hands the periprosthetic collagen injection represents an effective and well tolerated procedure for temporary augmentation of tracheo-esophageal leakage in post-laryngectomy patients. However, alternative fillers without pre-testing necessity and longer augmentation intervals should be considered.

Tracheo-esophageal anastomosis in treatment of chronic aspiration pneumonitis.

A patient underwent tracheo-esophageal anastomosis following repeated episodes of aspiration pneumonia after the resection of a meningioma at foramen magnum. The surgery eliminated the intractable problem with aspiration. This procedure is reversible, and restoration of the laryngeal function can be accomplished when the patient has recovered neurologically. If adequate neurologic recovery does not occur, the anastomosis can be left intact indefinitely.