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.

Strongyloides stercoralis hyperinfection syndrome after liver transplantation: case report and literature review.

Strongyloides stercoralis is an intestinal nematode that causes human infections and whose life cycle has special features, including autoinfection. Strongyloides infection may be asymptomatic for years, owing to a low parasite load. During immunosuppressive therapy, however, if cellular immunity is depressed, autoinfection can occur at a higher rate, resulting in hyperinfection syndrome. In this specific circumstance, it can become a fatal illness. We describe a case of hyperinfection syndrome in a liver transplant recipient and also review the literature.

Gut permeability to lactulose and mannitol differs in treated Crohn's disease and celiac disease patients and healthy subjects

The gut barrier monitors and protects the gastrointestinal tract from challenges such as microorganisms, toxins and proteins that could act as antigens. There is evidence that gut barrier dysfunction may act as a primary disease mechanism in intestinal disorders. The aim of the present study was to evaluate the barrier function towards sugars after the appropriate treatment of celiac disease and Crohn's disease patients and compare the results with those obtained with healthy subjects. Fifteen healthy volunteers, 22 celiac disease patients after 1 year of a gluten-free diet, and 31 Crohn's disease patients in remission were submitted to an intestinal permeability test with 6.0 g lactulose and 3.0 g mannitol. Six-hour urinary lactulose excretion in Crohn's disease patients was significantly higher than in both celiac disease patients (0.42 vs 0.15 percent) and healthy controls (0.42 vs 0.07 percent). Urinary lactulose excretion was significantly higher in celiac disease patients than in healthy controls (0.15 vs 0.07 percent). Urinary mannitol excretion in Crohn's disease patients was the same as healthy controls (21 vs 21 percent) and these values were significantly higher than in celiac disease patients (10.9 percent). The lactulose/mannitol ratio was significantly higher in Crohn's disease patients in comparison to celiac disease patients (0.021 vs 0.013) and healthy controls (0.021 vs 0.003) and this ratio was also significantly higher in celiac disease patients compared to healthy controls (0.013 vs 0.003). In spite of treatment, differences in sugar permeability were observed in both disease groups. These differences in the behavior of the sugar probes probably reflect different mechanisms for the alterations of intestinal permeability.

Efficacy of glutamine-supplemented parenteral nutrition on short-term survival following allo-SCT: a randomized study.

Fifty-three patients with hematological malignancies who underwent Allo-SCT from HLA-identical siblings were randomly assigned to receive glutamine-enriched parenteral nutrition-PN (GlPN, n=27) or standard PN (PN, n=26), in isonitrogenous solutions. Deaths (D+100 and D+180), infections, acute GVHD, length of stay, time of neutropenia and intestinal permeability (IP) were studied. Ages, gender, diagnosis, disease status and treatment variables were equally distributed between groups. Survival on D+180 was increased in GlPN (74%) vs PN (46%), P=0.03 (log-rank), as on D+100 (P=0.05). Most deaths occurred before D+100, especially in PN (10/26, 39%) vs GlPN (4/27, 15%). GVHD was the most frequent cause of death (8/21, 38%), especially in PN (n=6, five before D+100). Other outcomes were not affected. IP was affected on admission, was not affected by glutamine enrichment, but consistently worsened throughout the study. Results showed that GlPN was efficacious in increasing short-term survival after Allo-SCT. Benefits of glutamine seem to be independent of mucosal protection, as IP was not affected by its use. A trend to a lower incidence of GVHD deaths may suggest an immunomodulatory role of glutamine.

Gut permeability to lactulose and mannitol differs in treated Crohn's disease and celiac disease patients and healthy subjects.

The gut barrier monitors and protects the gastrointestinal tract from challenges such as microorganisms, toxins and proteins that could act as antigens. There is evidence that gut barrier dysfunction may act as a primary disease mechanism in intestinal disorders. The aim of the present study was to evaluate the barrier function towards sugars after the appropriate treatment of celiac disease and Crohn's disease patients and compare the results with those obtained with healthy subjects. Fifteen healthy volunteers, 22 celiac disease patients after 1 year of a gluten-free diet, and 31 Crohn's disease patients in remission were submitted to an intestinal permeability test with 6.0 g lactulose and 3.0 g mannitol. Six-hour urinary lactulose excretion in Crohn's disease patients was significantly higher than in both celiac disease patients (0.42 vs 0.15%) and healthy controls (0.42 vs 0.07%). Urinary lactulose excretion was significantly higher in celiac disease patients than in healthy controls (0.15 vs 0.07%). Urinary mannitol excretion in Crohn's disease patients was the same as healthy controls (21 vs 21%) and these values were significantly higher than in celiac disease patients (10.9%). The lactulose/mannitol ratio was significantly higher in Crohn's disease patients in comparison to celiac disease patients (0.021 vs 0.013) and healthy controls (0.021 vs 0.003) and this ratio was also significantly higher in celiac disease patients compared to healthy controls (0.013 vs 0.003). In spite of treatment, differences in sugar permeability were observed in both disease groups. These differences in the behavior of the sugar probes probably reflect different mechanisms for the alterations of intestinal permeability.

Intestinal adaptation in short bowel syndrome without tube feeding or home parenteral nutrition: report of four consecutive cases.

Because home total parenteral nutrition (TPN) is not available to most of the Brazilian population, an alternative treatment for short bowel syndrome was evaluated. Four patients ages 40-65 y (mean: 53.75 +/- 10.59), three with mesenteric thrombosis, and one with Crohn's disease were studied. The average length of the remaining small bowel in these patients was 54.5 +/- 6.4 cm; the ileocecal valve was preserved in 3 cases. A progressive step diet was used for intestinal adaptation. Administration of pectin was started at the beginning of the special oral diet (step 1), followed by medium-chain triacylglycerols (MCTs) and complex, nonfermentable sugars (step 2); coconut oil (47% MCTs) and simple sugars (step 3); and long-chain triacylglycerols and lactose (step 4). TPN was interrupted at step 3 or 4 when the energy content of the diet reached 150% of the patient's resting energy expenditure, if serum albumin and weight were stable or increasing, and if the frequency, amount, and consistency of stools remained unchanged. Nutritional follow-up showed that patients responded well to this approach; also, patients returned to their previous professional activities. Thus, enteral formulas were not essential for gastrointestinal adaptation. Home TPN should not be indicated on the basis of strict criteria, but rather when a patient fails to adapt to a progressive, special oral diet.