Risk of dysphagia in a population of infants born preterm: characteristic risk factors in a tertiary NICU

Abstract Objective: To examine the prevalence and characteristics of dysphagia and suck-swallow-breath incoordination as phenotypes of oral feeding difficulties. Method: A cross-sectional study with secondary data collected consecutively over 2 years from October 2020 to October 2022 to measure the prevalence of swallowing and oral feeding difficulty in preterm infants using Flexible endoscopic evaluation of swallowing examination at the tertiary Integrated Dysphagia Clinic. Results: The prevalence of swallowing disorders was 25 % and the prevalence of suck-swallow-breath incoordination was 62.5 %. The significant risk factor that may show a possible correlation with oral feeding difficulty was mature post-menstrual age (p = 0.006) and longer length of stay (p = 0.004). The dominant percentage of upper airway abnormality and disorder were retropalatal collapse (40 %), laryngomalacia (42.5 %), paradoxical vocal cord movement (12.5 %), and gastroesophageal reflux disease (60 %). The dominant characteristic of oral motor examination and flexible endoscopic evaluation of swallowing examination was inadequate non-nutritive sucking (45 %), inadequate postural tone (35 %), and inadequate nutritive sucking (65 %). Conclusion: Dysphagia in preterm infants is mostly observed in those with mature post-menstrual age, longer length of stay, and the presence of gastroesophageal reflux disease with inadequate non-nutritive sucking and nutritive sucking abilities. Suck-swallow-breath incoordination is primarily observed in those with immature post-menstrual age, a higher prevalence of cardiopulmonary comorbidity, and a higher prevalence of upper airway pathologies (laryngomalacia, paradoxical vocal cord movement) with inadequate nutritive sucking ability.

Risk of dysphagia in a population of infants born pre-term: characteristic risk factors in a tertiary NICU.

OBJECTIVE: To examine the prevalence and characteristics of dysphagia and suck-swallow-breath incoordination as phenotypes of oral feeding difficulties. METHOD: A cross-sectional study with secondary data collected consecutively over 2 years from October 2020 to October 2022 to measure the prevalence of swallowing and oral feeding difficulty in preterm infants using Flexible endoscopic evaluation of swallowing examination at the tertiary Integrated Dysphagia Clinic. RESULTS: The prevalence of swallowing disorders was 25 % and the prevalence of suck-swallow-breath incoordination was 62.5 %. The significant risk factor that may show a possible correlation with oral feeding difficulty was mature post-menstrual age (p = 0.006) and longer length of stay (p = 0.004). The dominant percentage of upper airway abnormality and disorder were retropalatal collapse (40 %), laryngomalacia (42.5 %), paradoxical vocal cord movement (12.5 %), and gastroesophageal reflux disease (60 %). The dominant characteristic of oral motor examination and flexible endoscopic evaluation of swallowing examination was inadequate non-nutritive sucking (45 %), inadequate postural tone (35 %), and inadequate nutritive sucking (65 %). CONCLUSION: Dysphagia in preterm infants is mostly observed in those with mature post-menstrual age, longer length of stay, and the presence of gastroesophageal reflux disease with inadequate non-nutritive sucking and nutritive sucking abilities. Suck-swallow-breath incoordination is primarily observed in those with immature post-menstrual age, a higher prevalence of cardiopulmonary comorbidity, and a higher prevalence of upper airway pathologies (laryngomalacia, paradoxical vocal cord movement) with inadequate nutritive sucking ability.

Development of clinical-based scoring system to diagnose tuberculous meningitis in children.

OBJECTIVE: Diagnosing tuberculous meningitis (TBM) in children is challenging due to the low sensitivity with time delay of bacterial culture techniques and the lack of brain imaging facilities in many low- and middle-income settings. This study aims to establish and test a scoring system consisting of clinical manifestations on history and examination for diagnosing TBM in children. DESIGN: A retrospective study was conducted using a diagnostic multivariable prediction model. PARTICIPANTS: 167 children diagnosed with meningitis (tuberculous, bacterial, viral and others) aged 3 months to 18 years who were hospitalised from July 2011 until November 2021 in a national tertiary hospital in Indonesia. RESULTS: Eight out of the 10 statistically significant clinical characteristics were used to develop a predictive model. These resulted in good discrimination and calibration variables, which divided into systemic features with a cut-off score of ≥3 (sensitivity 78.8%; specificity 86.6%; the area under the curve (AUC) value 0.89 (95% CI 0.85 to 0.95; p<0.001)) and neurological features with a cut-off score of ≥2 (sensitivity 61.2%; specificity 75.2%; the AUC value 0.73 (95% CI 0.66 to 0.81; p<0.001)). Combined together, this scoring system predicted the diagnosis of TBM with a sensitivity, specificity and positive predictive value of 47.1%, 95.1% and 90.9%, respectively. CONCLUSION: The clinical scoring system consisting of systemic and neurological features can be used to predict the diagnosis of TBM in children with limited resource setting. The scoring system should be assessed in a prospective cohort.

Classifying atopic dermatitis: a systematic review of phenotypes and associated characteristics.

Atopic dermatitis is a heterogeneous disease, accompanied by a wide variation in disease presentation and the potential to identify many phenotypes that may be relevant for prognosis and treatment. We aimed to systematically review previously reported phenotypes of atopic dermatitis and any characteristics associated with them. Ovid EMBASE, Ovid MEDLINE and Web of Science were searched from inception till 12 February 2021 for studies attempting to classify atopic dermatitis. Primary outcomes are atopic dermatitis phenotypes and characteristics associated with them in subsequent analyses. A secondary outcome is the methodological approach used to derive them. In total, 8511 records were found. By focussing only on certain clinical phenotypes, 186 studies were eligible for inclusion. The majority of studies were hospital-based (59%, 109/186) and cross-sectional (76%, 141/186). The number of included patients ranged from seven to 526 808. Data-driven approaches to identify phenotypes were only used in a minority of studies (7%, 13/186). Ninety-one studies (49%) investigated a phenotype based on disease severity. A phenotype based on disease trajectory, morphology and eczema herpeticum was investigated in 56 (30%), 22 (12%) and 11 (6%) studies respectively. Thirty-six studies (19%) investigated morphological characteristics in other phenotypes. Investigated associated characteristics differed between studies. In conclusion, we present an overview of phenotype definitions used in literature for severity, trajectory, morphology and eczema herpeticum, including associated characteristics. There is a lack of uniform and consistent use of atopic dermatitis phenotypes across studies.

Effects of short-term energy restriction on liver lipid content and inflammatory status in severely obese adults: Results of a randomized controlled trial using 2 dietary approaches.

Short-term very-low-energy diets (VLEDs) are used in clinical practice prior to bariatric surgery, but regimens vary and outcomes of a short intervention are unclear. We examined the effect of 2 VLEDs, a food-based diet (FD) and a meal-replacement plan (MRP; LighterLife UK Limited, Harlow, UK), over the course of 2 weeks in a randomized controlled trial. We collected clinical and anthropometric data, fasting blood samples, and dietary evaluation questionnaires. Surgeons took liver biopsies and made a visual assessment of the liver. We enrolled 60 participants of whom 54 completed the study (FD, n = 26; MRP, n = 28). Baseline demographic features, reported energy intake, dietary evaluation and liver histology were similar in the 2 groups. Both diets induced significant weight loss. Perceived difficulty of surgery correlated significantly with the degree of steatosis on histology. There were reductions in the circulating inflammatory mediators C-reactive protein, fetuin-A and interleukin-6 between baseline (pre-diet) and post-diet. The diets achieved similar weight loss and reduction in inflammatory biomarkers. There were no significant differences in perceived operative difficulty or between patients' evaluation of diet satisfaction, ease of use or hunger frequency. Non-alcoholic fatty liver disease histology assessments post-diet were also not significantly different between diets. The results of this study show the effectiveness of short-term VLEDs and energy restriction, irrespective of macronutrient composition, although the small sample size precluded detection of subtle differences between interventions.

The expression of inhibitor of nuclear factor kappa-B kinase epsilon (IKKe) in human aortic aneurysm.

BACKGROUND: Aortic aneurysm (AA) is one of the most common causes of sudden death among elderly people. Although AA can be detected by non-invasive imaging techniques, there are no pharmacological treatments currently available to prevent progression at any stage of the disease. In this study we will explore the expression of inhibitor of nuclear factor kappa-B kinase epsilon (IKKe) in AA and its potential underlying molecular mechanism in AA. MATERIALS AND METHODS: Human aortic tissue was taken from 14 patients who underwent surgical repair of AA for the AA group and another 11 patients with normal aorta who underwent aortic valve replacement surgery for the control group. After excision, we used haematoxylin-eosin staining, Masson staining, immunohistochemistry analysis and Western blot analysis to observe the expres-sion, location and morphological changes of the IKKe, P50 and the extracellular matrix within the AA. RESULTS: In the AA group, haematoxylin-eosin staining revealed a loss of medial integrity and inflammatory cell infiltration. Masson staining confirmed the degradation of the extracellular matrix in the AA group. Immunohistochemistry analysis showed increased infiltration of inflammatory cells and up-regulation of proinflammatory cytokines in the AA group when compared to the control group. Based on immunohistochemistry and Western blot analysis, there was clearly over-expression of IKKe, P50 and MMP2 in AA group, mainly in the intrinsic aortic cells of the media. CONCLUSIONS: The over-expression of IKKe may play an important role in the ori-gination and progression of AA and might be a vital target for their treatment.

Impact on the pharyngeal airway space of different orthognathic procedures for the prognathic mandible.

The study objective was to evaluate, through a meta-analysis, the impact on the pharyngeal airway space (PAS) of different orthognathic surgeries for the treatment of the prognathic mandible. An electronic search of three databases and hand searches were carried out up to December 2014. The inclusion criteria were clinical human studies, including randomized controlled trials (RCTs), controlled clinical trials (CCTs), and retrospective studies, with the aim of comparing bilateral sagittal split osteotomy (BSSO) to intraoral vertical ramus osteotomy (IVRO), or one-jaw to two-jaw surgery for the treatment of the prognathic mandible. The PAS changes (anterior-posterior dimensions and cross-sectional area) at the level of the nasopharynx, oropharynx, and hypopharynx were analyzed. A statistically significant difference was found between BSSO and IVRO groups and one-jaw surgery and two-jaw surgery with regard to PAS changes after the treatment of mandibular prognathism. The results of this meta-analysis indicate that BSSO presents less change in the PAS after mandibular setback surgery compared to IVRO. Furthermore, the results of this study suggest that bimaxillary surgery is superior to mandibular setback surgery alone for the correction of the prognathic mandible, particularly in patients with factors predisposing them to the development of breathing problems.

Reevaluation of acetylcholinesterase staining for the diagnosis of Hirschsprung disease and allied disorders.

OBJECTIVES: Acetylcholinesterase (AChE) staining has become the gold standard for definitively diagnosing Hirschsprung disease (HD), although some pitfalls have been reported. We reevaluated a large series at our institute in order to validate the accuracy of AChE staining for detecting HD. METHODS: A retrospective study of the rectal mucosal specimens of all of the children with suspected HD during a 13-year period was performed. The specimens were stained according to the modified Karnovsky-Roots method for AChE staining. The final diagnosis, prognosis, and management after the histopathological diagnosis were analyzed with a questionnaire sent to the patient's original hospital. RESULTS: Three hundred and fifty-eight specimens were collected. One hundred twenty-two (34%) specimens were diagnosed as HD, 198 (55%) as nonHD, 25 (7%) as "undetermined," and 13 (4%) as "inappropriate." The non-HD group contained 190 (96%) specimens with a normal appearance and 8 (4%) specimens with suspected intestinal neuronal dysplasia (IND). Three hundred and six of 358 questionnaires were returned. The final diagnosis showed that no specimens first diagnosed as HD were identified as non-HD and vice versa, for a sensitivity and specificity of 100%. Four cases were finally diagnosed as chronic idiopathic intestinal pseudo-obstruction (CIIP) in the non-HD group. All of the patients with HD underwent radical surgery. Most non-HD patients were managed conservatively, although some continued to have constipation. CONCLUSIONS: AChE staining is an accurate tool for differentiating between HD and non-HD with high sensitivity and specificity. CIIP can be included in cases of non-HD; therefore, careful follow-up is mandatory.

Pre-operative dietary restriction for patients undergoing bariatric surgery in the UK: observational study of current practice and dietary effects.

BACKGROUND: Bariatric surgery is effective at achieving weight loss in the severely obese, with the majority of procedures performed laparoscopically. A short-term pre-operative energy restrictive diet is widely adopted to enable surgery by reducing liver size and improving liver flexibility. However, the dietary approach is not standardised. This observational study reports on pre-operative restrictive diets in use across bariatric services in the UK. METHODS: Between September and November 2012, information was collected from bariatric services on current or past pre-operative diets, and any research providing evidence for the use or modification of their diets. RESULTS: Around one third of bariatric services (28) in the UK responded, with a total of 49 diets in current use. Types of diet include low energy, low carbohydrate and liquid, with 59 % offering low energy/low carbohydrate food-based, 21 % milk/yoghurt, 18 % meal replacement (liquid) and 2 % clear liquid. Diet duration varies between 7 and 42 days. Limited anecdotal evidence was provided by services evaluating the pre-operative diet, and its alternative approaches, with dietary choice primarily clinician-led. CONCLUSIONS: This study has highlighted variability and lack of consensus in the form of pre-bariatric surgery diet used across different centres. Further research comparing outcomes for alternative diets would support best practice in the future.

Retrospective analysis of abnormal 24-h urinary free catecholamine concentration in screening for phaeochromocytoma.

BACKGROUND: Patients with hypertension often have increased 24-h excretion of urinary free catecholamines (UFCA) compared with normotensive patients, but the extent to which beta-blockade and other antihypertensive agents affect 24-h UFCA concentrations remains unclear. Consequently, many patients with slightly elevated 24-h UFCA concentrations are not adequately investigated for the presence of phaeochromocytoma. METHOD: We undertook a retrospective study on patients with at least one abnormal 24-h urinary collection of adrenaline (Adr), noradrenaline (NA) or dopamine (DA) between July 1997 and December 1999 to assess these issues. RESULTS: Of the 168 patients identified with raised 24-h UFCA concentrations, 106 with hospital notes were audited. Of the 46 patients whose values were more than twice the upper reference limit, 24 had their result confirmed with a repeat sample and only 10 underwent computed tomography or m-iodobenzylguanidine scanning. Two patients of these 10 had a phaeochromocytoma. We observed that hypertension correlated with significantly increased NA excretion compared with normotensive patients (median value 490+/-222 nmol per 24 h versus 304+/-229 nmol per 24 h, P<0.005). Patients on beta-blockers showed a trend towards significantly increased NA excretion (P=0.08). CONCLUSIONS: Many patients with abnormal 24-h UFCA excretion are not thoroughly investigated for the presence of phaeochromocytoma. NA concentration is significantly raised above the reference limit for patients with hypertension, and the use of beta-blockers showed a trend towards a further elevation in NA concentrations. Care must therefore be taken when interpreting abnormal NA concentrations in patients with hypertension or in those taking beta-blockers.

Activity of mushroom tyrosinase on catechol and on a catechol estrogen in an organic solvent.

A suspension of tyrosinase-coated glass beads in butanol effectively oxidizes catechol substrate. The enzyme is not soluble in the organic solvent and activity can be stopped by removal of the solid state enzyme after low-speed centrifugation or decantation. The product was assayed by HPLC and by its reactivity towards Besthorn's reagent, which gave a reaction typical for o-quinones. Addition of water to the extent of 0.5 to 4% raised the rate of substrate utilization but the accumulation of quinone first increased and then began to decrease. It is suggested that the product in dry butanol is prevented from reacting further by lack of water, which is necessary to promote secondary reactions causing free radical formation and leading ultimately to polymerization to melanin. Successive washes of the solid state enzyme with butanol increased enzyme activity, indicating presence of a butanol extractable inhibitor in the tyrosinase preparation. The enzyme on glass beads in butanol suspension was stabilized by the presence of substrate. 2-Hydroxyestradiol acted as an inhibitor of the tyrosinase-catalyzed oxidation of catechol. The data obtained can be interpreted to mean that the oxidation of the estrogen in the presence of tyrosinase, as previously reported, may be dependent upon the enzyme-catalyzed oxidation of catechol. The oxidation product of catechol, the o-quinone, is likely to function as oxidant towards 2-hydroxyestradiol.

C-reactive protein in semen and serum of men with chronic prostatitis.

Qualitative determination of C-RP in semen and serum of men with and without prostatitis showed that, the protein is present mostly in semen only in cases with prostatitis and with a significantly higher percentage incidence in the infertile than the fertile.