Navigating dementia feeding decisions in Asia: a mixed methods study of caregivers.

BACKGROUND: Tube feeding is discouraged among older adults with advanced dementia; nevertheless, caregivers often find feeding decisions challenging to navigate. AIM: This study aims to gain a comprehensive understanding of tube feeding among community-dwelling older adults with advanced dementia in Singapore and its relationship to older adult quality of life (QoL) and caregiver psychological distress. METHODS: We use a convergent mixed-methods design, synthesising analysis of qualitative caregiver interviews (n = 25) and two-year prospective, longitudinal cohort survey data (n = 215, 1018 observations). RESULTS: Findings from the qualitative interviews revealed caregivers' expectations of reduced QoL for older adults with feeding tubes and their own distress related to making feeding decisions and fears prompting plans to tube-feed. Sixteen percent of community-dwelling older adults with advanced dementia relied on feeding tubes during the two-year study period. Adjusting for potential confounding and using instrumental variables estimation, tube feeding was associated with reduced older adult QoL (P < .05) and increased caregiver anxiety and depression (P < .10). CONCLUSION: Consistent with expert guidelines, we found that tube feeding was associated with significantly reduced QOL among older adults living with dementia and increased distress among caregivers relative to those of older adults without feeding tubes. Despite caregivers' recognition of reduced QOL associated with older adult use of feeding tubes, many expressed angst related to feeding choices. Our findings suggest the need for decision tools to support caregivers in making informed decisions concordant with their values.

Top Tips for Direct Percutaneous Endoscopic Jejunostomy (DPEJ) Tube Placement.

Direct percutaneous endoscopic jejunostomy (DPEJ) provides post-pyloric enteral access in patients unable to meet long-term nutritional needs per os in situations where gastric feeding is neither tolerated nor feasible. Specific conditions associated with feeding intolerance due to due to nausea, vomiting, or ileus include gastric outlet obstruction, gastroparesis, or complications of acute or chronic pancreatitis; infeasibility may be due to high aspiration risk or prior gastric surgery. Since performing DPEJ is not an ACGME requirement for GI fellows or early career gastroenterologists, not all trainees are taught this technique. Hence, provider expertise for teaching and performing this technique varies widely across centers. In this article, we provide top tips for successful performance of DPEJ.

Development and clinical feasibility of a reduced-dose radiograph in children for feeding tube placement.

BACKGROUND: Temporary feeding tubes are commonly used but may lead to complications if malpositioned. Radiographs are the gold standard for assessing tube position, but clinician concern over radiation risks may curtail their use. OBJECTIVE: We describe development and use of a reduced dose feeding tube radiograph (RDFTR) targeted for evaluation of feeding tube position. MATERIALS AND METHODS: Age-based abdominal radiograph was adapted to use the lowest mAs setting of 0.32 mAs with field of view between carina and iliac crests. The protocol was tested in DIGI-13 line-pair plates and anthropomorphic phantoms. Retrospective review of initial clinical use compared dose area product (DAP) for RDFTR and routine abdomen, chest, or infant chest and abdomen. Review of RDFTR reports assessed tube visibility, malpositioning, and incidental critical findings. RESULTS: Testing through a line-pair phantom showed loss of spatial resolution from 2.2 line pairs to 0.6 line pairs but preserved visibility of feeding tube tip in RDFTR protocol. DAP comparisons across 23,789 exams showed RDFTR reduced median DAP 72-93% compared to abdomen, 55-78% compared to chest, and 76-79% compared to infant chest and abdomen (p<0.001). Review of 3286 reports showed tube was visible in 3256 (99.1%), malpositioned in airway 8 times (0.2%) and in the esophagus 74 times (2.3%). The tip was not visualized in 30 (0.9%). Pneumothorax or pneumoperitoneum was noted seven times (0.2%) but was expected or spurious in five of these cases. CONCLUSION: RDFTR significantly reduces radiation dose in children with temporary feeding tubes while maintaining visibility of tube tip.

Unraveling medication errors in enteral tube administration: A cross-sectional study in geriatric patients receiving home health care.

Background: Medication administration through enteral feeding tubes requires careful consideration, as several medications are unsuitable for such administration due to interactions with feeding formulas or adverse effects when crushed. These errors can lead to feeding tube obstruction, reduced drug efficacy, or drug toxicity. Objective: This study aimed to assess medication errors in geriatric patients using enteral feeding tubes who were enrolled in a home health care program. Method: This was a cross-sectional observational study conducted at the Ministry of Health Government Hospital in Makkah City, Saudi Arabia. Medication errors related to chronic oral drugs in geriatric patients using enteral feeding tubes were evaluated, including inappropriate medications for enteral tube administration, inappropriate preparation, drug-nutrient interaction, and availability of liquid formulation, following established guidelines. Results: Of the total 233 medications prescribed to 46 patients receiving enteral tube feeding at home, 49.3% exhibited at least one form of medication error, totaling 135 errors. Medication errors were highly prevalent among the patients (93.4%), with the leading cause being the administration of medications unsuitable for enteral feeding tubes (33.3%), predominantly due to the use of controlled release or enteric-coated formulations. Conclusion: This study underscores the high prevalence of medication errors in older patients receiving enteral feeding at home. To ensure patient safety and optimal outcomes, healthcare professionals should utilize available resources and seek expert advice when selecting medications and dosage forms for tube-fed patients. Pharmacists play a critical role in promoting safe drug use and can greatly contribute by educating patient caregivers on proper medication preparation and administration techniques, thus preventing harm to patients.

Evaluation of community nurse-led traumatic tube displacements.

Home enteral tube feeding (HEF) has many benefits and is largely safe practice. Some complications have historically required intervention in the acute setting, including traumatic displacement of feeding tubes (i.e. internal bumper/balloon removed intact), and evidence to support the safe replacement of these tubes in the community is lacking. To address this, a service enabling community homecare nurses (CHN) to replace traumatically displaced feeding tubes was designed and evaluated. Adult patients presenting with a traumatically displaced feeding tube over 29 months were included in the service evaluation. Baseline characteristics and outcomes at day 1, 7 and 6 months post-replacement were recorded. A total of 71 tube replacements were performed by CHNs in 60 patients. No clinical complications were recorded at any follow-up points. A simple cost analysis estimated savings of £235 754.40. These results suggest that nurse-led replacement of traumatically displaced feeding tubes in adults in the community is low-risk and offers potential cost savings.

Extemporaneous compounding of dabrafenib and trametinib for cancer patients with feeding tubes.

INTRODUCTION: Dabrafenib and trametinib are oral targeted agents indicated for BRAF mutated non-small cell lung cancer and melanoma. There is little data to support the administration of these two agents via enteral feeding tube. This case series describes three patients who received compounded dabrafenib and trametinib suspensions through enteral feeding tubes. CASE REPORT: We present three patients who required dabrafenib and trametinib to be prepared as a non-standard compound for the medications to be administered via feeding tube. The patients were diagnosed with with BRAF mutated cancers including melanoma, non-small-cell lung carcinoma, and anaplastic thyroid cancer. In all three cases, there was evidence of initial disease response on imaging, and there were no unexpected toxicities secondary to dabrafenib and trametinib. DISCUSSION: There are patients that are unable to tolerate medications by mouth due to dysphagia, anatomical malfunctions, or other digestive disorders. There is limited literature that describes preparation of trametinib and dabrafenib into an enteral suspension. Identifying a safe and efficacious method of administering these two medications via feeding tube ensures that these patients continue to be able to receive them as part of their anti-cancer therapy. CONCLUSION: Despite the lack of available data, compounding of dabrafenib and trametinib may be clinically appropriate when benefits outweigh the risk of unconventional administration. Further studies are warranted to assess for the pharmacokinetics, pharmacodynamics, stability, and storage for these liquid medications.

A Randomized Clinical Trial to Compare Three Different Methods for Estimating Orogastric Tube Insertion Length in Newborns: A Single-Center Experience in China.

Background: Orogastric (OG) and nasogastric (NG) tubes are frequently used in the NICU. Obtaining a relatively accurate estimated length before insertion could significantly reduce complications. While previous studies have mainly focused on the NG tube, OG tubes are more commonly used in China. Purpose: The objective was to determine whether there were differences in the rate of accurate placement among the adapted nose-ear-xiphoid (NEX) method, nose-ear-midway to the umbilicus (NEMU) method, and weight-based (WB) equation in estimating the OG tube insertion distance. Methods: A randomized, controlled, open-label clinical trial to compare the three methods was conducted in a single center. After enrollment, newborns were randomly assigned into three groups. By radiological assessment, the anatomical region for OG tube placement was analyzed. The primary metric was the tip within the gastric body, and the second metric was strictly accurate placement defined as the tube was not looped back within the stomach and the end was located more than 2 cm but less than 5 cm into the stomach, referred to as T10. Results: This study recruited 156 newborns with the majority being preterm infants (n = 96; 61.5 percent), with an average birth weight of 2,200.8 ± 757.8 g. For the WB equation, 96.2 percent (50 cases) of the OG tubes were placed within the stomach, and the rates were 78.8 percent (41 cases) in the adapted NEX and NEMU methods. The strictly accurate placement rates were highest for the WB equation at 80.8 percent (42/52), followed by the adapted NEX method at 65.4 percent (34/52), and the NEMU method at 57.7 percent (30/52). Conclusion: The WB equation for estimating the insertion depth of the OG tube in newborn infants resulted in more precise placement compared to the adapted NEX and NEMU methods.

When Is It Safe to Feed After Surgical Feeding Tube Placement? A Survey of EAST Members.

INTRODUCTION: Many critically ill trauma and surgical patients require nutritional support. Patients needing long-term enteral access often undergo placement of surgical feeding tubes, including percutaneous endoscopic gastrostomy tube, laparoscopic gastrostomy tube, and open gastrostomy tube. This study was performed to determine national practice patterns for feeding after feeding tube placement. METHODS: A 16-question online survey was administered to members of the Eastern Association for the Surgery of Trauma via Qualtrics about feeding practices after placement of the feeding tube. Questions included demographics, training, current practice, annual procedural volume, timing to resume feeds: <2, 6, 12, or 24 h, methods to advance feeds, and reasons behind management decisions. For comparison, responses were grouped into "early" (≤6 h) and "late" (18-24 h) groups. The chi-square test was used, and P < 0.05 was significant. RESULTS: Five hundred sixteen Eastern Association for the Surgery of Trauma members completed the survey. Most (95%) respondents worked at a level 1 or 2 trauma center, and 68% are in academic practice. The most common feeding tube placement was percutaneous endoscopic gastrostomy (median = 25/y, interquartile range = 15-40). Responses showed variability in timing of when feeds were resumed after procedure. Early feeding was not affected by age (≤42 y), trauma center designation, volume, or training programs at the respondent's hospital. Graduates of surgical critical care fellowship were less likely to feed early (P = 0.043). CONCLUSIONS: There is wide variability in feeding practices after surgical feeding tube placement. Given the large quantity of procedures performed, a randomized controlled trial should be performed to determine the optimal timing to resume feeds in critically ill patients.

Actual and Potential Impact of a Home Nasogastric Tube Feeding Program for Infants Whose Neonatal Intensive Care Unit Discharge Is Affected by Delayed Oral Feedings.

OBJECTIVE: To compare healthcare use and parent health-related quality of life (HRQL) in 3 groups of infants whose neonatal intensive care unit (NICU) discharge was delayed by oral feedings. STUDY DESIGN: This was a prospective, single-center cohort of infants in the NICU from September 2018 to March 2020. After enrollment, weekly chart review determined eligibility for home nasogastric (NG) feeds based on predetermined criteria. Actual discharge feeding decisions were at clinical discretion. At 3 months' postdischarge, we compared acute healthcare use and parental HRQL, measured by the PedsQL Family Impact Module, among infants who were NG eligible but discharged with all oral feeds, discharged with NG feeds, and discharged with gastrostomy (G) tubes. We calculated NICU days saved by home NG discharges. RESULTS: Among 180 infants, 80 were orally fed, 35 used NG, and 65 used G tubes. Compared with infants who had NG-tube feedings, infants who had G-tube feedings had more gastrointestinal or tube-related readmissions and emergency encounters (unadjusted OR 3.97, 95% CI 1.3-12.7, P = .02), and orally-fed infants showed no difference in use (unadjusted OR 0.41, 95% CI 0.1-1.7, P = .225). Multivariable adjustment did not change these comparisons. Parent HRQL at 3 months did not differ between groups. Infants discharged home with NG tubes saved 1574 NICU days. CONCLUSIONS: NICU discharge with NG feeds is associated with reduced NICU stay without increased postdischarge healthcare use or decreased parent HRQL, whereas G-tube feeding was associated with increased postdischarge healthcare use.

Stylostome formation by parasitic larvae of Allothrombium fuliginosum (Trombidiformes: Trombidiidae): morphology of feeding tubes and factors affecting their size.

The morphology and formation of stylostomes (feeding tubes) in hosts' body during the parasitic phase of Allothrombium fuliginosum (Hermann) larvae were studied for the first time with light microscopy (LM) and transmission electron microscopy (TEM). The stylostomes were observed in three aphids species-Acyrthosiphon pisum (Harris), Elatobium abietinum (Walker), and Macrosiphum rosae (L.)-parasitized by mites under laboratory conditions. They consisted of 2-6 main branches, preliminarily unbranched, then producing secondary and sometimes also tertiary branches as finally formed structures. Their walls were uniformly electron-dense, without any longitudinal and transverse stratifications and showed rather irregular outlines. Distally, the stylostome branches revealed transparent pores and cavities in their walls, connecting the stylostome canal with surrounding haemocoelic space. The total length of stylostomes at the end of the parasitic phase was on average 16× greater than that recorded in the youngest stylostomes. No differences in the overall shape of feeding tubes between host species were stated. The stylostomes formed in different host species did not differ significantly, except their total length, which attained the highest value in tissues of Ac. pisum.

Impact of Design Changes in Gastrostomy Tube (G-tube) Devices for Patients Who Rely on Home-Based Blenderized Diets for Enteral Nutrition.

OBJECTIVE: Blenderized diets are gaining increasing popularity among enteral tube users. Connectors in gastrostomy tubes (G-tubes) are undergoing standardization to reduce misconnections. These standardized G-tubes are referred to as ENFit G-tubes. This study was performed to quantify the in vitro performance of existing (legacy) G-tubes and compare them with ENFit G-tubes for blenderized diets. METHOD: Patient blenderized diet recipes and practices were obtained through patient advocacy groups. Different blenders and blending times were studied. Five legacy G-tube brands and three corresponding ENFit brands, sized between 14 Fr and 24 Fr, were studied under gravity and push modes of feeding. RESULTS: Considering both thin and thick blenderized gravity mode diets, an average increase in feeding time from 20 minutes to 32 ± 18 minutes in transitioning from legacy to ENFit was observed with standard G-tubes, compared to 22 ± 3.5 minutes for low profiles. For push-mode diets, a 60-second push with standard ENFit G-tubes was easier compared to standard legacy G-tubes (61% ± 21% as much force), but faster 5-second pushes required considerably more effort for ENFit standard G-tubes (167% ± 96%). Low-profile ENFit G-tubes required slightly less effort compared to low-profile legacies for both 60-second and 5-second pushes (72% ± 22% and 90% ± 19%, respectively). Clogging was common in both legacy and ENFit devices, particularly under gravity mode. CONCLUSIONS: For a push mode of feeding, patients will largely be unimpacted after the transition to ENFit. For a gravity mode of feeding, some ENFit users may need higher-powered blenders and should expect increased feeding times.

Short-term evaluation of immune levels and nutritional values of EN versus PN in gastric cancer: a systematic review and a meta-analysis.

BACKGROUND: Postsurgical patients' oral feeding begins with clear fluids 1-3 days after surgery. This might not be sufficiently nutritious to boost the host immune system and provide sufficient energy in gastric neoplastic patients to achieve the goal of enhanced recovery after surgery (ERAS). Our objective was to analyze the significance of early postoperative feeding tubes in boosting patients' immunity and decreasing incidence of overall complications and hospital stay in gastric cancer patients' post-gastrectomy. METHODS: From January 2005 to May 24, 2019, PubMed and Cochrane databases were searched for studies involving enteral nutrition (EN) feeding tubes in comparison to parenteral nutrition (PN) in gastric cancer patients undergoing gastrectomy for gastric malignancies. Relative risk (RR), mean difference (MD), or standard mean difference (SMD) with 95% confidence interval (CI) were used to estimate the effect sizes, and heterogeneity was assessed by using Q and χ2 statistic with their corresponding P values. All the analyses were performed with Review Manager 5.3 and SPSS version 22. RESULTS: Nine randomized trials (n = 1437) and 5 retrospective studies (n = 421) comparing EN feeding tubes and PN were deemed eligible for the pooled analyses, with a categorized time frame of PODs ≥ 7 and PODs < 7. Ratio of CD4+/CD8+ in EN feeding tubes was the only outcome of PODs < 7, which showed significance (MD 0.22, 95% CI 0.18-0.25, P < 0.00001). Regarding other immune indicators, significant outcomes in favor of EN feeding tubes were measured on POD ≥ 7: CD3+ (SMD 1.71; 95% CI 0.70, 2.72; P = 0.0009), CD4+ (MD 5.84; 95% CI 4.19, 7.50; P < 0.00001), CD4+/CD8+ (MD 0.28; 95% CI 0.20; 0.36, P < 0.00001), NK cells (SMD 0.94; 95% CI 0.54, 1.30; P < 0.00001), nutrition values, albumin (SMD 0.63; 95% CI 0.34, 0.91; P < 0.001), prealbumin (SMD 1.00; 95% CI 0.52, 1.48; P < 0.00001), and overall complications (risk ratio 0.73 M-H; fixed; 95% CI 0.58, 0.92; P = 0.006). CONCLUSION: EN feeding tube support is an essential intervention to elevate patients' immunity, depress levels of inflammation, and reduce the risk of complications after gastrectomy for gastric cancer. Enteral nutrition improves the innate immune system and nutrition levels but has no marked significance on certain clinical outcomes. Also, EN reduces the duration of hospital stay and cost, significantly.

Predictors of Direct Enteral Tube Placement After Acute Stroke.

OBJECTIVE: To determine predictors of direct enteral tube (DET) placement after acute stroke. METHODS: We used the Ontario Stroke Registry to identify patients who received direct enteral tubes (gastrostomy or jejunostomy) during hospital stay after acute ischemic stroke or intracerebral hemorrhage from July 1, 2003 to March 31, 2013. We used multivariable logistic regression to identify predictors of receiving DET after stroke. RESULTS: Among 38,192 patients with acute stroke who met inclusion criteria, 1851 (4.9%) had DET placement during admission. We identified multiple variables significantly associated with DET placement, spanning patient demographics, comorbid illnesses, clinical, and hospital factors. The strongest predictors of receiving DET were stroke severity (adjusted odds ratio [aOR] 4.77 for severe versus mild stroke, 95% confidence interval [CI] 4.20-5.41), receiving a swallowing test within 72 hours (aOR 3.46, 95% CI 3.0-3.99), and in-hospital stroke (aOR 2.07, 95% CI 1.57-2.72). CONCLUSIONS: There are a number of predictors of DET placement within multiple domains. These findings may facilitate discussions around the possibility of requiring DET during admission. Further work is required to improve patient selection and timing of DET placement after acute stroke.

Timing of Direct Enteral Tube Placement and Outcomes after Acute Stroke.

BACKGROUND: Direct enteral feeding tube (DET) placement for dysphagia after stroke is associated with poor outcomes. However, the relationship between timing of DET placement and poststroke mortality and disability is unknown. We sought to determine the risk of mortality and severe disability in patients who receive DET at different times after stroke. METHODS: We used the Ontario Stroke Registry and linked administrative databases to identify patients with acute ischemic stroke or intracerebral hemorrhage between 2003 and 2013 who received DET (gastrostomy or jejunostomy) during their hospital admission. We grouped patients by week of DET placement and evaluated mortality at 30 days and 6 months after DET insertion, and disability at discharge. We used Cox proportional hazard models and multiple logistic regression to determine the association between time from admission to DET placement and outcomes, adjusting for patient and hospital factors. RESULTS: In the study sample of 1367 patients, the median time from admission to DET placement was 17 days. After adjustment, each week of delay to DET placement was associated with lower mortality at 30 days (adjusted hazard ratio [aHR] .88, 95% confidence interval [CI] .79-.98), but not at 6 months (aHR .98, 95% CI .91- 1.05), and a higher likelihood of severe disability at discharge (adjusted odds ratio 1.35, 95% CI 1.13- 1.60). CONCLUSIONS: Later DET placement after stroke was associated with lower 30-day mortality but higher severe disability at discharge. Further research is needed to understand the reasons for these observations and to optimize patient selection and timing of DET.

Carers' experiences of home enteral feeding: A survey exploring medicines administration challenges and strategies.

WHAT IS KNOWN AND OBJECTIVES: The use of enteral tube feeding at home is becoming more widespread, with patients ranging in age and diseases. Dysphagia and swallowing difficulties can compromise nutritional intake and the administration of oral medications, affecting therapeutic outcomes negatively. Carers' experiences of medicines administration and medicines optimization have not been explored fully. The objectives of this study were to identify issues carers experience in medicines administration; the strategies they have developed to cope; and suggestions to improve the medicines administration process. METHODS: An online survey was promoted nationally; 42 carers completed it. Descriptive statistical analysis was applied, as well as thematic analysis of open-ended responses. Results were compared against the 4 principles of medicines optimization. RESULTS AND DISCUSSION: 93% of respondents administered medications with enteral feeding tubes, but only 62% had received advice from healthcare professionals and only 8% had received written information on how to do so. Responses identified 5 medicines administration issues experienced by carers; 4 strategies they developed to cope; and 3 main areas of suggestions to improve medicines administration via enteral feeding at home. WHAT IS NEW AND CONCLUSION: The 4 principles of medicines optimization have not previously been applied to enteral feeding. We present a novel account of carers' experiences, for example coping with ill-suited formulations and a lack of training and support, which should inform better practice (Principle 1). Carers sometimes experience suboptimal choice of medicines (Principle 2). Carers' practices are not always well-informed and may affect therapeutic outcomes and safety (Principle 3). There is scope for improvement in carer training, education and support to better support medicines optimization (Principle 4).

Using tube feeding and levodopa-carbidopa intestinal gel application in advanced Parkinson's disease.

The inability to achieve adequate nutrition and weight loss are serious problems for patients with advanced Parkinson's disease (PD). To ensure the optimal intake of nutrition and fluids and to administer levodopa-carbidopa intestinal gel (LCIG) (which patients need to increase or maintain their mobility as long as possible), different artificial feeding tubes can be used. Although percutaneous endoscopic gastrostomy (PEG) tubes are frequently used in medical practice, there is little research that addresses key questions, including if and when to administer artificial fluids, nutrition and/or LCIG via tubes. Weight gain through tube feeding is only possible for some patients; nurses should keep in mind that tube insertion and feeding may lead to frequent adverse events. Administering LCIG via tubes is usually advisable as it seems to enhance patients' mobility and therefore has positive outcomes in terms of the quality of life of patients and their families ( Lim et al, 2015 ). The authors aimed to examine the use and consequences of providing nutrition and LCIG via gastrostomy tubes in PD patients with advanced disease.

Clinical predictors for reactive tube feeding in patients with advanced oropharynx cancer receiving radiotherapy ± chemotherapy.

Enteral feeding is often required for nutrition support in head and neck cancer patients when oral intake is inadequate. When to initiate the insertion of a feeding tube continues to be a debated issue in our institution. We investigated the use of reactive feeding tubes (RFTs) in patients with advanced stage oropharynx cancer (OPC). Data were retrospectively collected on 131 patients who had radiotherapy (RT) ± chemotherapy from 2005 to 2015. Predictors for RFT insertion were investigated. Weight loss during RT was compared between those with RFT versus prophylactic tubes (PFTs) versus no tube, and survival outcomes evaluated. RFTs were more likely to be needed in patients who had bilateral neck node irradiation (p = 0.001) and concurrent chemoradiotherapy (CRT) (p = 0.038). Patients with RFTs had significantly higher mean percentage weight loss during RT (9.5 ± 3.4%) (p < 0.001) when compared to those with a PFT (5.2 ± 4.7%) and those with no tube (5.4 ± 3.1%). No difference was seen in 5-year survival rates in patients who did not have a feeding tube to those who required a RFT. RFT use is frequent in OPC, although difficult to predict. CRT and bilateral neck node irradiation were found to be associated with the need for the insertion of a feeding tube during RT. These patients also experience significantly higher weight loss, therefore, prophylactic tubes may need to be considered more often in this population.

Clinical utility of topiramate extended-release capsules (USL255): Bioequivalence of USL255 sprinkled and intact capsule in healthy adults and an in vitro evaluation of sprinkle delivery via enteral feeding tubes.

OBJECTIVE: The objectives of these two studies were to determine if beads from extended-release topiramate capsules sprinkled onto soft food are bioequivalent to the intact capsule and if beads from the capsule can be passed through enteral gastrostomy (G-) and jejunostomy (J-) feeding tubes. METHODS: Bioequivalence of 200-mg USL255 (Qudexy XR [topiramate] extended-release capsules) sprinkled onto soft food (applesauce) versus the intact capsule was evaluated in a phase 1, randomized, single-dose, crossover study (N=36). Pharmacokinetic evaluations included area under the curve (AUC), maximum plasma concentration (Cmax), time to Cmax (Tmax), and terminal elimination half-life (t1/2). If 90% confidence intervals (CI) of the ratio of geometric least-squares means were between 0.80 and 1.25, AUC and Cmax were considered bioequivalent. In separate in vitro experiments, 100-mg USL255 beads were passed through feeding tubes using gentle syringe pressure to develop a clog-free bead-delivery method. Multiple tube sizes (14- to 18-French [Fr] tubes), dilutions (5 mg/15 mL-25 mg/15 mL), and diluents (deionized water, apple juice, Ketocal, sparkling water) were tested. RESULTS: Area under the curve and Cmax for USL255 beads sprinkled onto applesauce were bioequivalent to the intact capsule (GLSM [90% CI]: AUC0-t 1.01 [0.97-1.04], AUC0-∞ 1.02 [0.98-1.05]; Cmax 1.09 [1.03-1.14]). Median Tmax was 4h earlier for USL255 sprinkled versus the intact capsule (10 vs 14 h; p=0.0018), and t1/2 was similar (84 vs 82 h, respectively). In 14-Fr G-tubes, USL255 beads diluted in Ketocal minimized bead clogging versus deionized water. Recovery of USL255 beads diluted in deionized water was nearly 100% in 16-Fr G-, 18-Fr G-, and 18-Fr J-tubes. SIGNIFICANCE: For patients with difficulty swallowing pills, USL255 sprinkled onto applesauce offers a useful once-daily option for taking topiramate. USL255 beads were also successfully delivered in vitro through ≥14-Fr G- or J-tubes, with tube clogging minimized by portioning the dose and using glidant diluents for smaller tubes.

Is tube feeding futile in advanced dementia?

It is controversial whether tube feeding in people with dementia improves nutritional status or prolongs survival. Guidelines published by several professional societies cite observational studies that have shown no benefit and conclude that tube feeding in patients with advanced dementia should be avoided. However, all studies on tube feeding in dementia have major methodological flaws that invalidate their findings. The present evidence is not sufficient to justify general guidelines. Patients with advanced dementia represent a very heterogeneous group, and evidence demonstrates that some patients with dementia benefit from tube feeding. However, presently available guidelines make a single recommendation against tube feeding for all patients. Clinicians, patients, and surrogates should be aware that the guidelines and prior commentary on this topic tend both to overestimate the strength of evidence for futility and to exaggerate the burdens of tube feeding. Shared decision making requires accurate information tailored to the individual patient's particular situation, not blanket guidelines based on flawed data. Lay Summary: Many doctors believe that tube feeding does not help people with advanced dementia. Scientific studies suggest that people with dementia who have feeding tubes do not live longer or gain weight compared with those who are carefully hand fed. However, these studies are not very helpful because of flaws in design, which are discussed in this article. Guidelines from professional societies make a blanket recommendation against feeding tubes for anyone with dementia, but an individual approach that takes each person's situation into account seems more appropriate. Patients and surrogates should be aware that the guidelines on this topic tend both to underestimate the benefit and exaggerate the burdens of tube feeding.

More than just crushing: a prospective pre-post intervention study to reduce drug preparation errors in patients with feeding tubes.

WHAT IS KNOWN AND OBJECTIVES: Incorrect drug preparation for patients with feeding tubes can result in harm for the patient and the preparing person. Combined intervention programs are effective tools to reduce such preparation errors. However, to date, intervention programs have been mostly tested in hospitals with computerized physician order entry (CPOE), unit-dose systems, or ward-based clinical pharmacists. Hence, the primary objective of this study was to develop and evaluate an intervention program tailored to hospitals without such preconditions. METHODS: We conducted a prospective pre-/post-intervention study on a gastroenterological intensive care unit (ICU) and a surgical ward for oral, dental and maxillofacial diseases (surgical ward). During the study periods, observers documented and evaluated drug preparation processes of all peroral drugs for patients with feeding tubes. The primary endpoint was the rate of inappropriately crushed and/or suspended solid peroral drugs in regards to all solid peroral drugs. RESULTS AND DISCUSSION: Altogether, we evaluated 775 drug preparation processes of solid peroral drugs on the ICU and 975 on the surgical ward. The intervention program significantly reduced incorrect crushing and/or suspending of solid peroral drugs for administration to patients with feeding tubes from 9·8% to 4·2% (P < 0·01) on the ICU and from 5·7% to 1·4% (P < 0·01) on the surgical ward. WHAT IS NEW AND CONCLUSION: The implementation of the newly developed intervention program significantly reduced the rate of inappropriately prepared solid peroral drugs, suggesting that it is an effective measure to enable safe drug administration for inpatients with feeding tubes.