Neonatal enteral feeding tubes as loci for colonisation by members of the Enterobacteriaceae

Background The objective of this study was to determine whether neonatal nasogastric enteral feeding tubes are colonised by the opportunistic pathogen Cronobacter spp. (Enterobacter sakazakii) and other Enterobacteriaceae, and whether their presence was influenced by the feeding regime. Methods One hundred and twenty-nine tubes were collected from two neonatal intensive care units (NICU). A questionnaire on feeding regime was completed with each sample. Enterobacteriaceae present in the tubes were identified using conventional and molecular methods, and their antibiograms determined. Results The neonates were fed breast milk (16%), fortified breast milk (28%), ready to feed formula (20%), reconstituted powdered infant formula (PIF, 6%), or a mixture of these (21%). Eight percent of tubes were received from neonates who were 'nil by mouth'. Organisms were isolated from 76% of enteral feeding tubes as a biofilm (up to 107 cfu/tube from neonates fed fortified breast milk and reconstituted PIF) and in the residual lumen liquid (up to 107 Enterobacteriaceae cfu/ml, average volume 250 µl). The most common isolates were Enterobacter cancerogenus (41%), Serratia marcescens (36%), E. hormaechei (33%), Escherichia coli (29%), Klebsiella pneumoniae (25%), Raoultella terrigena (10%), and S. liquefaciens (12%). Other organisms isolated included C. sakazakii (2%),Yersinia enterocolitica (1%),Citrobacter freundii (1%), E. vulneris (1%), Pseudomonas fluorescens (1%), and P. luteola (1%). The enteral feeding tubes were in place between < 6 h (22%) to > 48 h (13%). All the S. marcescens isolates from the enteral feeding tubes were resistant to amoxicillin and co-amoxiclav. Of additional importance was that a quarter of E. hormaechei isolates were resistant to the 3rd generation cephalosporins ceftazidime and cefotaxime. During the period of the study, K. pneumoniae and S. marcescens caused infections in the two NICUs. Conclusion This study shows that neonatal enteral feeding tubes, irrespective of feeding regime, act as loci for the bacterial attachment and multiplication of numerous opportunistic pathogens within the Enterobacteriaceae family. Subsequently, these organisms will enter the stomach as a bolus with each feed. Therefore, enteral feeding tubes are an important risk factor to consider with respect to neonatal infections.

Stressors, mediators, and health care outcomes of home enteral nutrition in family caregivers and their older adult care recipients

Family caregivers manage home enteral nutrition (HEN) for over 77% of an estimated 1 of every 400 Medicare recipients. Increasing usage of HEN in older adults combined with reliance on family caregivers raises concerns for the quality, outcomes, and costs of care. These concerns are relevant in light of Medicare limitations on nursing assistance and non-reimbursement for nutrition services, despite annual costs of over $600 million. This study applied stress process theories to assess stressor, mediator, and outcome variables salient to HEN and caregiving. In-home structured interviews occurred with a multi-ethnic sample of 30 caregiving dyads at 1–3 months after discharge on HEN. Care recipients were aged ≥60 (M = 68.4 years) and did not have dementia. Caregivers were aged ≥21, unpaid, and lived within 45 minutes of care recipients. Caregivers performed an average of 19.7 tasks daily for 61.9 hours weekly. Training needs were identified for 33 functional, care management, technical, and nutritional tasks. Preparedness scores were low (M = 1.73/4.0), and positively correlated with competence, self-rated quality of care and positive feelings, and negatively with overload, role captivity, and negative feelings (Ps < .05). Caregivers had multiple changes in lifestyle and dietary behaviors. Lifestyle changes positively correlated with overload, and negatively with preparedness and positive feelings. Dietary changes positively correlated with number of tasks, overload, role captivity and negative feelings, and negatively with preparedness (Ps < .01). Fifty-seven percent of caregivers aged >50 were at nutrition risk. Care recipients fared worse. Average weight change was −4.35 pounds (P < .001). Physical complications interrupted daily enteral infusions. Water intake was half of fluid need and associated with signs of dehydration (P < .001). Physical and social function was poor, with older subjects more impaired ( P < .04). Those with better prepared or less overloaded caregivers had higher functionality and QOL (P < .002). Complications, type of feeding tube, and caregiver preparedness correlated with frequency of health care utilization (Ps < .05). Efficacy of HEN in older adults requires specialized caregiver training, attention to caregivers' needs, and frequent monitoring from a highly skilled multidisciplinary team including dietitians. ^

A dosimetry and radiobiological model for intravascular brachytherapy treatment planning with radioisotope emitting stents

The aim of this study was to develop a practical, versatile and fast dosimetry and radiobiological model for calculation of the 3D dose distribution and radiobiological effectiveness of radioactive stents. The algorithm was written in Matlab 6.5 programming language and is based on the dose point kernel convolution. The dosimetry and radiobiological model was applied for evaluation of the 3D dose distribution of 32P, 90Y, 188Re and 177Lu stents. Of the four, 32P delivers the highest dose, while 90Y, 188Re and 177Lu require high levels of activity to deliver a significant therapeutic dose in the range of 15-30 Gy. Results of the radiobiological model demonstrated that the same physical dose delivered by different radioisotopes produces significantly different radiobiological effects. This type of theoretical dose calculation can be useful in the development of new stent designs, the planning of animal studies and clinical trials, and clinical decisions involving individualized treatment plans.

Modélisation des stents en chirurgie cardiaque

Mémoire numérisé par la Direction des bibliothèques de l'Université de Montréal.

Modélisation des stents en chirurgie cardiaque

Mémoire numérisé par la Direction des bibliothèques de l'Université de Montréal.

Serum copper evolution in patients that underwent endoscopic gastrostomy for long term enteral feeding

Background and aims: Copper (Cu) is a well studied trace element but little is known about Cu evolution in long term endoscopic gastrostomy (PEG) feeding. We aimed to evaluate the evolution serum Cu since the gastrostomy until 12 weeks after the procedure in PEG patients fed with homemade meals. Methods: A prospective observational study was performed evaluating serum copper, albumin, transferrin and body mass index (BMI) at the time of the gastrostomy, 4 weeks and 12 weeks after. Data also included age, gender, NRS 2002 and nature of the underlying disease causing dysphagia: head and neck cancer (HNC) or neurological dysphagia (ND). After gastrostomy, patients were fed with homemade PEG meals. Results: One hundred and forty-six patients enrolled, 89 men, aged 21-95 years, 90 with neurologic dysphagia (ND), and 56 with head and neck cancer (HNC). 78 (53%) showed low BMI. Initially, Cu ranged 42-160 μg/dl (normal: 70-140 μg/dl); 130 patients (89%) presented normal Cu, 16 (11%) presented hypocupremia, 53% low albumin (n = 77), and 94 (65%) low transferrin. After 4 weeks, 93% presented normal Cu, 7% presented hypocupremia, low albumin was present in 34%, and low transferrin in 52%. After 12 weeks, 95% presented normal Cu, 5% presented hypocupremia, low albumin was present in 25%, and low transferrin in 32%. Comparing age, gender, underlying disease, BMI, albumin and transferrin, there were no significant differences on serum Cu. Conclusions: Most patients present normal serum Cu when gastrostomy is performed. For patients presenting hypocupremia before gastrostomy, homemade meals are effective for normalizing serum Cu.

Selenium in dysphagic patients who underwent endoscopic gastrostomy for long term enteral feeding

Background and aims - Endoscopic gastrostomy (PEG) patients usually present protein-energy malnutrition, but little is known about selenium deficiency. We aimed to assess serum selenium evolution when patients underwent PEG, after 4 and 12 weeks. We also evaluated the evolution of albumin, transferrin and Body Mass Index and the influence of the nature of the underlying disease. Methods - A blood sample was obtained before PEG (T0), after 4 (T1) and 12 (T3) weeks. Selenium was assayed using GFAAS (Furnace Atomic Absorption Spectroscopy). The PEG patients were fed through homemade meals. Patients were studied as a whole and divided into two groups: head and neck cancer (HNC) and neurological dysphagia (ND). Results - We assessed 146 patients (89 males), between 21-95 years old: HNC-56; ND-90. Normal values of selenium in 79% (n=115); low albumin in 77, low transferrin in 94, low values for both serum proteins in 66. Low BMI in 78. Selenium has slow evolution, with most patients still displaying normal Selenium at T3 (82%). Serum protein levels increase from T0 to T3, most patients reaching normal values. The nature of the underlying disease is associated with serum proteins but not with selenium. Conclusions - Low serum selenium is uncommon when PEG is performed, after 4 and 12 weeks of enteral feeding and cannot be related with serum proteins levels or dysphagia cause. Enteral nutrition using customized homemade kitchen meals is satisfactory to prevent or correct Selenium deficiency in the majority of PEG patients.

Serum trace elements in dysphagic patients that underwent endoscopic gastrostomy for long term enteral feeding

Patients who underwent endoscopic gastrostomy (PEG) present protein-energy malnutrition, but little is known about Trace Elements (TE), Zinc (Zn), Copper (Cu), Selenium (Se), Iron (Fe), Chromium (Cr). Our aim was the evaluation of serum TE in patients who underwent PEG and its relationship with serum proteins, BMI and nature of underlying disorder.

New clinical practice guideline on enteral feeding in very low birth weight infants: first part

Introduction: The nutrition of very low birth weight (VLBW) infants is aimed at promoting a similar growth to that occurring in the uterus. However, in practice this is difficult to achieve and extrauterine growth restriction is frequent. The current tendency is to avoid this restriction by means of early parenteral and enteral nutrition. Nonetheless, uncertainty about many of the practices related with nutrition has resulted in a great variation in the way it is undertaken. In 2009 and 2011 in our hospital there was an unexpected increase in necrotizing enterocolitis. To check to see whether our nutrition policy was involved, we undertook a systematic review and drew up clinical practice guidelines (CPG) about enteral feeding in VLBW infants. New considerations about the duration of the fortification and the use of probiotics have led to an update of these CPG. Methods: A total of 21 clinical questions were designed dealing with the type of milk, starting age, mode of administration, rate and volume of the increments, fortification, use of probiotics and protocol. After conducting a systematic search of the available evidence, the information was contrasted and summarized in order to draw up the recommendations. The quality of the evidence and the strength of the recommendations were determined from the SIGN scale Comment: These CPG aim to help physicians in their decision making. The protocolized application of well-proven measurements reduces the variation in clinical practice and improves results.

New clinical practice guideline on enteral feeding in very low birth weight infants: second part

Introduction: The nutrition of very low birth weight (VLBW) infants is aimed at promoting a similar growth to that occurring in the uterus. However, in practice this is difficult to achieve and extrauterine growth restriction is frequent. The current tendency is to avoid this restriction by means of early parenteral and enteral nutrition. Nonetheless, uncertainty about many of the practices related with nutrition has resulted in a great variation in the way it is undertaken. In 2009 and 2011 in our hospital there was an unexpected increase in necrotizing enterocolitis. To check to see wether our nutrition policy was involved, we underlook a systematic review and drewup clinical practice guidelines (CPG) about enteral feeding in VLBW infants. New considerations about the duration of the fortification and the use of probiotics have led to an update of these CPG. Methods: A total of 21 clinical questions were designed dealing with the type of milk, starting age, mode of administration, rate and volume of the increments, fortification, use of probiotics and protocol. Afete conducting a systematic search of the available evidence, the information was contrasted and summarized in order to draw up the recommendations. The quality of the evidence and the strength of the recommendations were determined from the SIGN scale. Comment: These CPG aim to help physicians in their decision making. The protocolized application of well-proven measurements reduces the variation in clinical practice and improves results.

Interactions between drugs and drug-nutrient in enteral nutrition: a review based on evidences

Introduction: Enteral nutrition (EN) provides calories, macronutrients and micronutrients in adequate quantity and quality to meet the patient's needs. Some drugs when crushed and diluted may have their properties altered, including the reduction of bioavailability causing the reduction of the serum concentration of the drug; tube obstruction; drug-drug interaction or drug-nutrient interaction. Methods: The study was conducted through review of submitted articles in the databases of the Virtual Health Library (VHL): MEDLINE (National Library of Medicine, USA), Lilacs (Latin American and Caribbean Literature on Health Sciences) PUBMED - NCBI (National Center for Biotechnology Information) and COCHRANE. Results: For this survey, 42 articles were identified during database searching. After applying the inclusion and exclusion criteria, 08 articles were selected, obtained from the MEDLINE and Lilacs. Discussion: Some interactions were found such as the aluminium hydroxide and lactulose with the enteral nutrition, which may result in a precipitation and reduction of drug bioavailability. Mineral oil will alter the absorption of fat-soluble vitamins and reduces the tube light. Others results were found as phenytoin, warfarin, captopril and furosemide with enteral nutrition may reduce the maximum serum concentration. Conclusion: Drug interactions are more common in day-to-day activities than health professionals may suppose. Knowledge on the matter may also assist in reducing cases of obstruction of tubes, through which enteral nutrition and medications are administered. Thus, the multidisciplinary team, acting together, may have more beneficial effects to the patient.