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BACKGROUND/OBJECTIVES To evaluate the nutritional status and prevalence of malnutrition in hospitalized children at admission and during hospitalization in South Korea. SUBJECTS/METHODS This first cross-sectional nationwide "Pediatric Nutrition Day (pNday)" survey was conducted among 872 hospitalized children (504 boys, 368 girls; 686 medical, 186 surgical) from 23 hospitals in South Korea. Malnutrition risk was screened using the Pediatric Yorkhill Malnutrition Score (PYMS) and the Screening Tool Risk on Nutritional status and Growth. Nutritional status was assessed by z-scores of weight-for-age for underweight, weight-for-height for wasting, and height-for-age for stunting as well as laboratory tests. RESULTS At admission, of the 872 hospitalized children, 17.2% were underweight, and the prevalence of wasting and stunting was 20.2% and 17.3%, respectively. During hospitalization till pNday, 10.8% and 19.6% experienced weight loss and decreased oral intake, respectively. During the aforementioned period, fasting was more prevalent in surgical patients (7.5%) than in medical patients (1.6%) (P < 0.001). According to the PYMS, 34.3% and 30% of the children at admission and on pNday, respectively, had a high-risk of malnutrition, requiring consultation with the nutritional support team (NST). However, only 4% were actually referred to the NST during hospitalization. CONCLUSIONS Malnutrition was prevalent at admission and during hospitalization in pediatric patients, with many children experiencing weight loss and poor oral intake. To improve the nutritional status of hospitalized children, it is important to screen and identify all children at risk of malnutrition and refer malnourished patients to the multidisciplinary NST for proper nutritional interventions.

Children with biliary atresia, particularly infants, are at high risk for malnutrition due to a multitude of factors including poor oral intake and intolerance of enteral feeding, fat malabsorption, abnormal nutrient metabolism, and increased caloric demand. Malnutrition and sarcopenia negatively impact outcomes in biliary atresia, leading to higher pre- and post-transplant morbidity and mortality. This review summarizes factors contributing to nutritional deficiencies in biliary atresia and offers an organized approach to the assessment and management of malnutrition in this vulnerable population.

Primary hyperoxaluria type 1 is a rare genetic condition characterized by oxalate deposition in the kidneys. We report findings of an 8-month old female presenting with failure to thrive, poor oral intake, and kidney stones resulting in the diagnosis of primary hyperoxaluria type 1. The patient exhibits a unique presentation without renal failure at the time of diagnosis suggesting a previously unreported comorbidity in early stages of disease.

Background Postoperative pain in children is often poorly managed at home, leading to slower functional recovery, poor oral intake, sleep disturbances, and behavioral changes. Panda is a smartphone application (app) designed to support parents in assessing their child's pain and managing medications. Aims The aim of this study was to evaluate the Panda app's usability and feasibility in hospital prior to testing the app at home. Methods The study comprised two phases. Phase I evaluated Panda's usability with nurses, parents, and adolescents using simulated scenarios. Usability was measured by task completion rate, user error rates, and the Computer Systems Usability Questionnaire. Phase II evaluated Panda's feasibility by observing parents/guardians of pediatric patients using the app on the postsurgical ward. Feasibility was measured using response frequency and delay following app notifications from an audit trail of app function, and parental satisfaction from an interview. Feedback was used to guide iterative app improvements. Results In Phase I, 13 nurses, 12 parents, and 5 adolescents evaluated the app. A total of 103 usability issues were identified, analyzed, and addressed. In Phase II, 29 parents responded to a total of 151 app notifications, with 84% responding within 1 hour in the final round of testing; 93% of participants reported the app was easy to use, and rated the app with a median [interquartile range] Computer Systems Usability Questionnaire score of 2 [1-4]. Significant barriers to use included lack of flexibility in the medication scheduling, low volume of alert sounds, and the extra time spent on medication safety checks. Conclusion Panda's usability was improved and its feasibility demonstrated in the controlled hospital environment. The next step is to evaluate its feasibility for use at home.

Summary Objective To investigate post-operative intravenous fluid administration and length of stay in a single site cleft centre. Previous publications have linked increased length of stay following primary cleft surgery to the administration of intravenous fluids post-operatively. Materials and Methods One hundred and ten primary cleft operations were conducted from May 2015 to April 2016 on non-syndromic infants. At West Midlands Cleft Centre, there are three cleft surgeons and 20 paediatric anaesthetists. This observational study compares classification of cleft type and surgical procedure with intravenous fluid administration, time taken to tolerate oral feeding, and length of stay. Results Cleft lip repair infants had the shortest length of stay in hospital, 25 h 8 min (median) and 33% had intravenous fluids. The palate repair only and lip and palate repair children had a median length of stay of 29 h 20 min and 29 h 0 min respectively, A total of 79% and 76% of these groups had intravenous fluids administered. Cleft lip repair infants fed in significantly less time than palate alone or lip and palate operations (p values 0.00 and 0.03, respectively). Conclusion Cleft lip repair only infants feed well post-operatively and rarely require intravenous fluids. Infants having cleft repair involving the palate are slower to feed orally, and may require fluids due to poor oral intake. Intravenous fluids following lip repair is associated with longer hospital stay. We suggest intravenous fluids may not be needed routinely following cleft lip repair, but should always be considered following repair involving the palate.

A 78-year-old male, originally from China, was brought to the hospital for weakness, urinary incontinence, confusion, and poor oral intake. He was started on empiric antibiotics, which were narrowed when blood cultures produced gram-negative bacteremia speciating to Klebsiella pneumoniae, sensitive to ceftriaxone. Computed tomography scan of the abdomen and pelvis demonstrated a large cystic region with air-fluid level in the left lobe of the liver. Suspecting this to be the source of the patient’s bacteremia, the lesion was percutaneously drained and the fluid cultured, which also revealed ceftriaxone-sensitive Klebsiella pneumoniae. While a stool ova and parasite examination on the patient was negative, further workup was positive for Entamoeba histolytica antibody in the serum, detected via enzyme-linked immunosorbent assay and indicative of either current or past infection. This suggested possible prolonged subclinical infection with bacterial superinfection, especially given that Klebsiella pneumoniae is one of the most common organisms cultured from these abscesses. In patients with liver abscesses who immigrated from developing and/or endemic regions or have a relevant recent travel history, an underlying amoebic etiology of an abscess should be considered.

This study aimed to elucidate the effects of a liquid polymeric formula containing alginate, a source of water- soluble dietary fiber, on stool form, intestinal microbiota, and the production of short-chain fatty acid production. Participants were 11 elderly patients with malnutrition and poor oral intake, who required enteral feeding. The alginate-containing liquid formula, which characteristically changes state from liquid to semi-solidified depending on pH, was administered for 4 weeks. This variable-viscosity liquid formula significantly improved the values of nutritional indices and stool form. Analysis of fecal specimens revealed significant decreases in pH. The concentrations of short-chain fatty acids did not change significantly in stool samples, but acetic acid and propionic acid were significantly increased in blood samples. The proportion of Clostridium cluster XI in fecal microbiota was also significantly increased. The alginate-containing variable-viscosity liquid formula significantly improved stool form, lowered fecal pH, and short-chain fatty acid concentrations in blood.

Background At three weeks of age, a previous 34 weeks' gestation male infant (twin A) was transferred to our regional perinatal center (RPC) with complaints of poor oral feeding and intermittent tachypnea. Twin B was discharged at 37 weeks with an uneventful course. Case Twin A briefly required respiratory support but continued to have difficulty transitioning from gavage to oral feeding. Initially, his inability to feed orally was thought to be secondary to nasal congestion and prematurity, but with worsening respiratory distress he was transferred for further evaluation and management. Diagnosis & Conclusion On admission to RPC, the examination prompted a cardiac assessment which revealed a large aortic-pulmonary window type II. After surgery, the infant quickly improved and went home on-demand oral feeds. Cardiac lesions are more common in monochorionic twins but should be suspected in dichorionic twins especially if one twin has a normal course.

Introduction Besides the causes we know including adhesive ileus, it is not uncommon for poor oral intake (POI) in patients after distal pancreatectomy (DP). This study investigated the occurrence of POI and identify the risk factors of POI in patients after DP. Methods In this retrospective study, prospectively collected data of patients who received DP in National Cancer Center, Korea between April 2013 and December 2020 were reviewed. The diet protocol after DP in our institution as follows; sips of water (SOW) on postoperative day (POD) 1, soft blended diet (SBD) on POD 2 or 3, and normal regular diet (NRD) after POD 5, if the patient was tolerable on diet protocol. POI after distal pancreatectomy was defined as the delay of postoperative diet protocol after DP or the reverse of postoperative diet progression sequence. Results A total of 148 patients received open distal pancreatectomy during the study period. Patients who were diagnosed adhesive ileus were excluded (n = 14), and finally 134 patients were enrolled. Including 7 patients with postoperative delayed gastric emptying, 39.2 (52/134)% patients experienced POI after distal pancreatectomy. multi-visceral resection (HR 2.901, 95% CI 1.041-8.085, p = 0.042), celiac axis resection (HR 12.369, 95% CI 1.113-137.451, p = 0.041), operation time > 180 minutes (HR 3.146, 95% CI 1.265-7.822, p = 0.014), and postoperative major complication (HR 3.778, 95% CI 1.205-11.847, p = 0.023), clinically significant POPF (HR 3.642, 95% CI 1.065-12.451, p = 0.039) were independent risk factors for POI after DP. Conclusions Therefore, especially in patients with these risk factors.

Background Ketotic Hypoglycaemia (Blood sugar 2.5) is common in children with acute gastroenteritis and other common illnesses with poor oral intake. Untreated hypoglycaemia can lead to serious neurological sequelae. Some metabolic disorders can present with ketotic hypoglycaemia, the presenting illness unmasking the underlying metabolic problem, despite the presence of ketones. We looked specifically at cases of ketotic hypoglycaemia in children with a history of diarrhoea and vomiting or acute illness with inadequate oral intake. Aims To compare screening and management of ketotic hypoglycaemia in association with acute illness with the local guidelines. Methods Patients were identified through HIPE code ‘’E-16-2’’. A retrospective chart review was done on patients presenting with hypoglycaemia from Feb 2016 to May 2017 to compare the screening and management of patients with the local guidelines. As per audit recommendation the local hospital guideline was reviewed and an Algorithm along with ‘’Hypoglycaemia pack’’ was made available in the acute assessment unit. Staff education session was arranged A re-audit was performed on patients presenting with hypoglycaemia from January 2018 to December 2018 to see the adherence to the recommendations. Results The following table shows comparison of initial audit and re-audit results Conclusion Re audit showed marked improvement in lab glucose monitoring ,rechecking blood glucose timing and taking samples for urinary organic acids.However there is still room for improvement in sampling serum Amino acids. All patients got treatment as per guildelines. Recommendations Algorithmic approach,staff education and availability of ‘’Hypoglycaemia Packs’’ did improve the outcome however there is continued need for staff education to adhere to the guidelines

In acute pancreatitis, the most crucial aspect of management falls within the first 48-72 hours, which should be approached in a step-wise order. When steps are skipped or rushed, such as the early use of computed tomography (CT) with contrast in the setting of poor oral intake, the risk of morbidity increases. This is a case when the deleterious effects of contrast worsened the severity of the clinical course, resulting in a higher rate of mortality and longer hospital stay, and escalated the healthcare cost burden.

Children are at risk for malnutrition in hospital, and a contributing factor may be poor oral intake. Barriers to intake have been studied in adults, but there is a lack of research in children. The purpose of this study was to identify the potential barriers to oral intake for children in hospital. Patients and families (n = 58) admitted to surgery and medicine units at the Stollery Children’s Hospital completed a survey on barriers to oral food intake. Barriers were classified into 6 domains and major barriers were those identified by at least 30% of the population. On average each patient was affected by 22% of the barriers. Within each domain, the proportion of patients identifying at least 1 barrier was as follows: organization (74%), hunger (67%), quality (60%), effects of illness (53%), choice (38%), and physical limitations (29%). Having food brought in from home due to hunger, not wanting what was ordered once it arrives, food quality, decreased appetite, sickness, fatigue, and pain were identified as major barriers. Children have unique barriers to oral food intake in hospital which have not been previously identified. Food service models should consider these barriers to better meet the needs of this population.

Wernicke's encephalopathy (WE) is an acute neurological disorder, potentially fatal if untreated, caused by thiamine deficiency. A 15-year-old female patient with choledocholithiasis, cholecystitis and abdominal tuberculosis on antitubercular therapy presented with poor oral intake, bilious vomiting and encephalopathy. A prompt diagnosis of WE was made and confirmed by brain magnetic resonance imaging. The patient recovered completely after the administration of thiamine.

Mucocutaneous Manifestations of Scurvy A 72-year-old woman with poor oral intake presented with gingival bleeding, petechiae on both legs, and corkscrew hairs. A diagnosis of scurvy was made.

1. Giovanna Manzano, MD* 2. Rohini Shantharam, MD† 3. Elke Webb, MD‡ 4. Nika Finelt, MD† 5. Kyle Hengel, MD‡ 1. *Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 2. †Department of Dermatology, Northwell Health, New Hyde Park, NY 3. ‡Department of Pediatrics, Cohen Children’s Medical Center at Northwell Health, New Hyde Park, NY A previously healthy 11-month-old boy born at full-term presents with a rash for 3 days. It began as a single purpuric lesion on his right ear and progressed over 2 days to involve his face (Fig 1) and all extremities. On the day of presentation, mom reports swelling of his face, hands, and feet; nasal congestion; cough; bilateral conjunctivitis; and “red tears.” He has poor oral intake and urine output, worsening fussiness, is difficult to console, but has no tactile fever. Two weeks ago he completed 10 days of amoxicillin for acute otitis media. His medical, surgical, travel, allergic, and family histories are otherwise unremarkable. His vaccines are up to date. He takes no prescribed or over-the-counter medications. Figure 1. Characteristic targetoid lesions present on the patient's left ear and face. On physical examination he is crying and appears uncomfortable. He is afebrile, and tachycardic to 158 beats/min with normal blood …

Preoperative malnutrition because of poor oral intake significantly increases the risk of adverse events after surgery and leads to increased length of stay. While immunonutrition has been utilized in the non-ERAS setting, its utility in both minimally invasive surgery and ERAS pathway procedures remain poorly defined. There are at least ten meta-analyses regarding the assessment of immunonutrition, but virtually, all of these were performed in an era prior to minimally invasive surgery, adoption of enhanced recovery protocols, and an understanding of the assessment and physiology of sarcopenia. In terms of immunonutrition within an ERAS pathway, the few studies that have been published have severe flaws in design and sample, bringing their overall conclusion into question. Furthermore, the optimal components of immunonutrition have yet to be adequately determined and may vary for patients based on comorbidities as well as the proposed procedures. Risk stratification based on markers of nutritionally deficient states such as image assessed sarcopenia, Glasgow Prognostic Score, prognostic nutrition index, or assessment of methylarginines are needed prior to the initiation of any such immunotherapy. Lastly, there is a need for properly designed randomized control trials that stratify patients appropriately and determine the optimal timing, composition, and duration of immunotherapy.

Background and Aim Self-expandable metallic stents (SEMS) have been widely accepted as palliation therapy for malignant gastric outlet obstruction (GOO). However, the factors predictive of poor oral intake after SEMS placement have not been elucidated sufficiently. We aimed to clarify both the patient and stent-related predictive factors. Methods We retrospectively reviewed 126 consecutive patients who underwent uncovered SEMS placement for malignant GOO between April 2010 and March 2013 at a university hospital and two tertiary care referral centers. Results Technical success of SEMS placement was achieved in all 126 (100%) patients. Improved oral intake was observed in 111 (88.1%) patients. A Karnofsky performance status ≤ 40 (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.02–1.28; P = 0.041), peritoneal dissemination (OR, 1.20; 95% CI, 1.01–1.26; P = 0.038), and under-expansion of the SEMS on the procedure day (OR, 1.55; 95% CI, 1.26–1.62; P

Iron deficiency is found frequently in patients with inflammatory bowel disease (IBD) and can have a significant effect on their quality of life. The causes of iron deficiency are gastrointestinal blood loss, poor oral intake of iron, malabsorption, and inflammation. Previous studies have highlighted the correlation between higher iron stores and quality of life as well as the under diagnosis and treatment of iron deficiency in IBD by medical professionals. This article analyses the diagnosis and treatment of iron deficiency in the authors' local IBD cohort. The authors compared their findings to guidance developed by the British Society of Gastroenterology (BSG) and reviewed similar studies, comparing management options that use different iron preparations.

Background: The purpose of this study was to identify variables that may preoperatively predict successful outcomes in ambulatory cleft lip repair and to quantify the potential cost savings. Methods: A retrospective chart review of all patients who underwent cleft lip repair at a tertiary cleft care center from January of 2010 to May of 2013 was performed. Because inpatient stay is the authors’ current practice, overnight desaturations, poor oral intake, and failure to stop intravenous narcotics during the first day were considered indicators of a poor candidate. Charge data were also collected. Results: Twenty-nine of 111 patients were deemed likely to fail ambulatory surgery. American Society of Anesthesiologists score greater than 2 (p = 0.019), low birth weight (p = 0.022), bilateral cleft lip–cleft palate (p = 0.003), central nervous system or neurologic diagnosis (p = 0.046), syndromic and/or multiple congenital abnormalities (p = 0.024), prior emergency room visits (p = 0.021), failure to thrive (p = 0.046), and age older than 7 months (p = 0.028) were associated with poor candidacy. A diagnosis of cleft lip was protective (p = 0.015). Fifty-five patients had no risk factors for a poor ambulatory outcome and did not stay more than 1 day. The average savings per patient who met the authors’ criteria was $4261. Conclusions: The authors found that 49.5 percent of children may be safely eligible for ambulatory cleft lip repair. Patients with risk factors may be best served by a short hospital admission. This would lead to a national savings of $8,765,183 per year.

Vertical banded gastroplasty (VBG) was once a common operation for surgical weight loss. Though the operation has lost favor, there are patients that are having complications and symptoms related to the surgery. A case involving a patient with severe regurgitation, vomiting, and poor oral intake is presented. The surgical technique for reversing the VBG is detailed, including technical points of interest.

The risk of dying from a pulmonary embolism (PE) is estimated to be about 30% if inotropic support is required and no cardiopulmonary arrest occurs. Fibrinolysis in massive PE is regarded as a life-saving intervention, unless there is a high risk of bleeding following the use of the fibrinolytic therapy. Rivaroxaban is an oral factor Xa inhibitor, however its anticoagulation effects before or after administration of fibrinolytics in massive PE are still unknown. Two patents were admitted: 61-year-old woman with repeated syncope, and a 73-year-old woman was admitted with dyspnea and poor oral intake. Systemic arterial hypotension with radiologic confirmation led to a diagnosis of massive PE in both patients. Rivaroxaban was administered before in one, and after firbrinolytic therapy in the other. One showed similar efficacy of rivaroxaban with currently used anticoagulants after successful fibrinolysis, and the other one without antecedent administration of the fibrinolytic agent showed unfavorable efficacy of rivaroxaban.

We report the successful treatment of idiopathic intractable hiccups with cisatracurium under intravenous general anesthesia. The patient had a history of hiccups for 19 years that were refractory to a variety of treatments. When his hiccups were accompanied by vomiting, insomnia, shortness of breath, and poor oral intake for 9 days, he sought relief. We administered a nondepolarizing muscle relaxant, cisatracurium, during total intravenous anesthesia, to stop the hiccups. The duration of the anesthetic was determined by the time it took for the patient to recover from the neuromuscular blockade without reversal the cisatracurium. On emergence he had no hiccups. When the hiccups recurred 2 weeks later after a big meal, we repeated the procedure with success. He has now been hiccup free for at least 6 months.

A 47-year-old Malay man who presented with fever, poor oral intake and loss of weight for 1 month duration. Further work-up revealed evidence of disseminated Salmonella infection that was further complicated with pericardial and pleural empyema. Cultures from pericardial and pleural fluids grew Salmonella species with negative serial blood cultures. Contrast enhanced CT thorax showed pleural effusion with large pericardial effusion. The patient was treated with antibiotics and drainage of pericardial and pleural empyema was done and he was discharged well.

90 Background: Patients with peritoneal dissemination of gastric cancer have poor oral intake caused by bowel obstruction. Palliative surgery has often been undertaken to improve quality of life (QoL), but there is no prospective study on palliative surgery. Methods: We prospectively examined the significance of palliative surgery for patients with poor oral intake caused by peritoneal dissemination of gastric cancer using a patient-reported QoL measures. Eligibility criteria included histologically proven primary gastric adenocarcinoma presenting with bowel obstruction caused by peritoneal dissemination; presence of non-curable factors; extremely poor or no oral intake requiring parenteral nutrition. Patients underwent palliative surgery by small intestine/colon resection, small intestine/colon bypass or ileostomy/colostomy for bowel obstruction. The primary endpoint was change in QoL assessed at baseline, 14 days, 1 month and 3 months following surgical palliation by means of the Euro QoL Five Dimensions (EQ-5D) questionnaire and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire gastric cancer module (QLQ-STO22). Secondary endpoints were postoperative improvement in oral intake and surgical complications. Results: Between May 2013 and March 2018, 63 patients (33 bypass and 28 stoma, 3 exploratory laparotomy) were enrolled from 14 institutions. The mean EQ-5D utility index baseline score of 0.6 remained consistent. Gastric-specific symptoms mostly showed statistically significant improvement from baseline. 42 patients (67%) were able to eat solid food 2 weeks after palliative surgery and 36 patients (57%) tolerated it for 3 months. The rate of overall morbidity of grade III or more according to the Clavien–Dindo classification was 15.8 per cent (10 patients) and the 30-day postoperative mortality rate was 3.2 per cent (2 patients). Conclusions: In patients with bowel obstruction caused by peritoneal dissemination of gastric cancer, palliative surgery maintained QoL while improving solid food intake, with acceptable operative morbidity and mortality rate. Clinical trial information: 000023495.

Submassteric abscess is a rare head and neck abscess. It may mimic a parotid abscess due to very close anatomical relationship. We present a 14-month-old child presented with fever, poor oral intake, irritability, and left-sided cheek swelling. Contrast-enhanced computed tomography of the neck showed an abscess formation in left submasseteric space. Intraoral drainage of abscess was successfully performed under general anesthesia. Patient recovered well and was discharged on day three post operatively. Subsequent follow up at one-week post operatively showed no recollection of the abscess.International Journal of Human and Health Sciences Vol. 03 No. 02 April’19. Page: 123-125

This is a case report of an 8-month-old girl who presented to the pediatric emergency department with vesicular rash and fever. She was diagnosed with eczema herpeticum (EH). EH is an acute, rapidly progressive rare dermatologic disease, and if it is not treated promptly, it can cause life-threatening complications. It often occurs in a patient with an underlying skin disorder, such as atopic dermatitis or other erosive dermatoses. Diagnosis is mainly made by clinical examination usually presented as many very similar shaped and sized eroded vesicles. It is important for clinicians to recognize the sign and symptoms of EH and have a high suspicion for patients with atopic dermatitis who present with rapidly disseminating blisters. Treatment is with oral or intravenous acyclovir. If the patient has widespread eruptions or systemic symptoms such as fever, malaise, and poor oral intake, the patient should be admitted for intravenous acyclovir.

Purpose: Oral mucositis can be occurred very often in cancer patients w ho are undergoing chemotherapy. It is very troublesome to cancer patients because it causes pai n, gingival bleeding, nutritional imbalance due to poor oral intake, and sometimes leads to longer hospital stay and poor quality of life. However, it can be prevented or ameliorated by active oral care. This study was designed to improve chemotherapy-induced oral mucositis by means of active education and communication activity according to a standardized protocol for self-oral care. Methods: Seventy cancer patients who were admitted to hospital for chem otherapy and had grade I oral mucositis were enrolled. These patients were educated with one to one method for self-oral care including concept of mucositis along with the importance of self-oral care, and the method of brushing teeth and gargling, etc. Communication activity for it was performed by nurses and physician together, giving feedback and reeducation to patients. The effect of education and communicat ion activity was assessed by the survey from patients. Results: The survey showed that the level of awareness for oral mucositis, the method of brushing and gargling were improved significantly after education and communication activity. The rate of oral mucositis was also reduced after these activity. Conclusion: We conclude that education and communication activity enable cancer patients to do more effective self-oral care and to reduce oral mucositis.

Objectives We present a rare case of absolute dysphagia after adenotonsillectomy due to a forgotten gauze pack impacted in the esophagus. Case report A 9 year old girl was presented with absolute dysphagia 15 days after adenotonsillectomy. The parents reported postoperative poor oral intake for semisolids which became absolute for both solids and fluids 4 days after surgery. Clinically, the only positive finding was pooling of saliva in the hypopharynx detected by flexible nasopharyngoscopy. Computerized tomography revealed a retropharyngo-esophageal well defined lesion which was suggested to be localized neck space infection. Rigid esophagoscopy under general anesthesia was done before planned neck exploration to surprisingly reveal an impacted gauze pack surrounded by severe esophageal inflammatory reaction. Conclusion Because dysphagia was attributed to adenotonsillectomy itself in this case, the diagnosis was delayed for about 15 days. A systematic approach for the management of progressive dysphagia should be considered from non-invasive to more invasive maneuvers and foreign body option should always be borne in mind.

Disuse atrophy of swallowing-related organs due to an excessive decrease in swallowing frequency is suspected to occur in patients with poor oral intake, especially elderly people. However, swallowing frequency in daily life has not previously been examined in the elderly. This study examined swallowing frequency in elderly people and compared these findings to those in a younger population and differences in the degree of activity in daily life. (i) We compared swallowing frequency in 20 elderly people (82·0 ± 8·3 year) and 15 healthy young people (26·5 ± 3·5 year). (ii) 20 elderly people were divided into two groups according to the degree of activity in daily life: a semi-bedridden group and bedridden group; the swallowing frequency was compared between these groups. (i) The swallowing frequency in the elderly people was 2-19 times per hour and the mean was 9·4 ± 4·9, and that in the healthy young people was 16-76 times per hour and the mean was 40·7 ± 19·5. Swallowing frequency in elderly people was significantly lower than that in young healthy people (P < 0·0001). (ii) The swallowing frequency in bedridden group was 2-11 times per hour and the mean was 6·8 ± 3·3, and that in semi-bedridden group was 3-19 times per hour and the mean was 11·9 ± 5·1. Swallowing frequency in bedridden group was significantly lower than that in semi-bedridden group (P < 0·05). These results indicate that in daily life, elderly people tend to swallow less frequently than young people. In addition, swallowing frequency was lower in elderly subjects with a low degree of activity in daily life.

Lingual tonsillar hypertrophy is recognized as a cause of persistent obstructive sleep apnea (OSA) after adenotonsillectomy in children. However, little has been reported regarding the complications, postoperative course and effectiveness of lingual tonsillectomy (LT). Our objective was to review the safety and effectiveness of LT in children.Retrospective review of children undergoing LT from January 2009 to December 2015 at a tertiary children's hospital. Complications, postoperative course and polysomnographic (PSG) outcomes were recorded for all patients.We identified 92 children (mean age = 8.6 years, 50% female) who underwent LT; 43.5% had a syndromic diagnosis. The most common complications were emergency department presentation for bleeding (4.4%) and poor oral intake (3.3%). The readmission rate was 4.4% including 2 children (2.2%) who required operative control of hemorrhage. No children required unplanned reintubation or ICU admission. In children with PSG data (n = 18), the median apnea-hypopnea index (AHI) decreased from 8.5 to 3.8 events/hour (p = 0.022) and the median obstructive AHI (oAHI) decreased from 8.3 to 3.1 events/hour (p = 0.021). In addition, the oxygen saturation nadir increased from 83.8% to 89.0% (p = 0.0007). After surgery the percentage of patients with oAHI5 events/hour increased from 27.8% to 61.1% (p = 0.08).Readmission and bleeding rates after lingual tonsillectomy in children were similar to that seen with tonsillectomy. Polysomnographic data showed that lingual tonsillectomy resulted in a significant reduction of both AHI and oAHI with a postoperative oAHI5 achieved in 61% of patients.

Purpose: Intestinal dysfunction is a major problem after gastroschisis repair, and causes poor oral intake and poor body weight gain in infants with gastroschisis. Dai-kenchu-to (DKT) is often used in the treatment of gastrointestinal dysfunction in Japan. The purpose of this study was to analyze the effect of DKT on infants with uncomplicated gastroschisis. Methods: In this retrospective cohort study from 1991 to 2009, we assessed 16 infants with uncomplicated gastroschisis. Eight infants received 0.3 g/kg/day of DKT for 12 months (group 1) and 8 infants did not receive DKT (group 2). We analyzed their body weight as an indicator of the effect of DKT. Results: There were no significant differences in the background characteristics. The body weight of group 1 was significantly increased at the ages of 9 months (p = 0.0348) and 12 months (p = 0.0097), compared with group 2. Multivariate analyses revealed that only DKT administration had a significant impact on body weight gain at the ages of 9 months (p = 0.0201) and 12 months (p = 0.0111). No side effects related to DKT were reported. Conclusion: DKT administration might work safely and effectively for improving the body weight gain in infants with uncomplicated gastroschisis.

A 65-year-old female with a history of mitral valve repair with a 30-mm Physio Ring underwent transcatheter valve-in-ring implantation of a 26-mm Sapien XT prosthesis for severe mitral regurgitation. After the procedure, patient complained of recurrent pre-syncopal episodes. She admits to poor oral intake since the …

This article describes the radiologic techniques to obtain upper gastrointestinal access in children with poor oral intake and inadequate nutrition. Our goal is to provide a simple guide of radiologic gastrostomy and gastrojejunostomy procedures, their technical success, and long-term outcomes. Potential complications will be discussed as well as their management. It is important to emphasize that a multidisciplinary approach (pediatrician, dietitian, interventional radiologist, pediatric surgeon) is paramount for appropriate indications and management of patients with gastrostomies and gastrojejunostomies.

We established a promising new experimental animal model with an orthotopic xenograft of esophageal cancer that successfully represents poor oral intake, a major clinical feature of esophageal cancer. The advantage of this model is that no surgical technique is required, only the injection of a cell suspension by a needle and syringe via the esophageal lumen from the mouth, which provides a high reproducibility of tumor implantation and a rapid progress of outcome. We propose that this model is useful to study cancer-related outcomes and for developing new therapies for esophageal cancer, and we expect it to make a contribution to clinical practice.

In this issue of the Journal, we are publishing a review article by Belle et al1 demonstrating that undernutrition in nursing homes is extremely common. Using the Minimum Data Set 2.0 definition of weight loss of 5% or more in 1 month or 10% or more in 6 months had a prevalence of 6% to 15%. In the United States for the first 3 quarters of the Minimum Data Set 3.0,2e4 the national average for residents who lost too much weight was 7.2%. Studies using the MiniNutritional Assessment5,6 reported a prevalence in general of 20% to 39% of malnutrition and approximately half of the residents being at risk for malnutrition. The MiniNutritional Assessment also detects frailty, leading to a potential overestimation of undernutrition.7e10 Studies reporting poor oral intake had a range of 3% to 77%. The average prevalence of eating disabilities ranged from 11% to 36%. Also in this issue is a study from Landi et al10 finding that in a large study of Italian nursing homes, 12% suffered from anorexia. Those who were anorectic had double likelihood of death compared with those who were not anorexic. Potentially reversible problems of drugs, depression, and chewing difficulties were identified as possible causes in the group with anorexia.

We aimed to demonstrate whether enteral nutrition (EN) is feasible in daily practice of hematopoietic stem cell transplantation (HSCT).Nutritional records of 100 patients were evaluated. Patients with poor oral intake were fed by EN with tube. A total of 79 patients required nutritional support. Of them, 71 were fed by EN only. Five were fed by EN plus parenteral nutrition (PN),three were fed by PN only. Median duration of EN was 21 days. In the EN only group, 68% gained or maintained their weight. EN should be considered as a feasible option for nutrition support in children undergoing HSCT. Pediatr Blood Cancer 2012; 59: 1327–1329. © 2012 Wiley Periodicals, Inc.

Polypharmacy can refer to the prescribing of many medicines (five or more medicines are often quoted) or to the addition of inappropriate medicines to an existing regime. It appeared in medical literature more than 150 years ago and thus is not an unfamiliar term. Why is there a need to talk about polypharmacy in a general surgery population? The number of chronic medicine that patients receive has increased over the years. The following paragraphs will sought to explain why.

Invasive pulmonary aspergillosis (IPA) is an increasing cause of morbidity and mortality in patients with hematologic malignancies. A major program of construction work close to our unit prompted us to evaluate the efficacy of itraconazole prophylaxis in preventing IPA in these patients. During September 1994 to December 1995, 77 patients undergoing 96 neutropenic episodes (mean duration, 19.3 days +/- 9.1) received itraconazole as antifungal prophylaxis. All patients were treated in laminar air flow rooms. Itraconazole was administered at a loading dose of 600mg/d, (day 1 to day 3) and 400mg/d on the following days, in 87 instances. In the remaining episodes, the daily dose was 200 or 400mg. Oral doses were adjusted to reach a plasma itraconazole level (PIL) above 1000ng/l. In cases of inadequate PIL or poor oral intake, IV AmphoB was started at a 20 mg daily dose. Five cases of IPA (proven n = 2, probable n = 3) were observed. This represents an incidence of 5.2% of the total number of episodes. One out of 67 (2%) treatment episodes with adequate PIL were associated with IPA as compared to 4 of 29 (14%) episodes with inadequate PIL, (p0.02). AmphoB was added in 28 cases because of low PIL (n = 25), and/or antibiotic-resistant fever persistent pulmonary infiltrate (n = 8). These results need to be interpreted with caution, because of the absence of randomization or a control group. The efficacy of Itraconazole in neutropenic patients with high risk IPA has to be confirmed on larger and prospective studies.

A mealtime screening tool was administered to 349 residents of a home for the aged to determine the prevalence of mealtime difficulties including, but not limited to, dysphagia. Mealtime difficulties, as assessed during a single meal observation of each resident, were documented in 87% of these individuals. Though 68% exhibited signs of dysphagia, 46% had poor oral intake, 35% had positioning problems, and 40% exhibited challenging behaviors. An increased prevalence of mealtime difficulties was related to both the presence and degree of cognitive impairment. Oral intake was best among residents with severe cognitive impairment, many of whom received partial to total feeding assistance. In contrast, poor oral intake was associated with mild-moderate cognitive impairment, pointing to a need for more aggressive intervention with this group. The results clearly demonstrate that the prevalence of a wide range of eating-related problems far exceeds accepted estimates of dysphagia alone and support a multidisciplinary approach to mealtime interventions for the institutionalized elderly. Additionally, the magnitude of problems identified has implications for both resource and staff-training requirements in long-term care facilities.

Many inborn errors of intermediary metabolism present during periods of poor oral intake or intercurrent illness. Under these conditions, the body switches to a predominantly catabolic state, when glycogen, fat, and protein are mobilized as alternative energy sources. If a genetic defect already exists in any of these catabolic pathways, the problem is accentuated because the catabolic state demands a high flux of metabolite through these pathways. Therefore, a cardinal principle in the management of children who have IEM is to prevent them from lapsing into a catabolic state. This can be done through: 1) aggressive nutrition management to promote positive nitrogen balance and decrease accumulation of toxic metabolites, and 2) immunizations to minimize the possibility of viral or bacterial illness. When catabolism does occur, high-dose glucose infusion is a potent method for turning off the catabolic state. This simplistic view of the catabolic pathways neglects many details in each of the metabolic pathways and diseases cited in the article and questions. Nevertheless, it should provide a useful framework for explaining some of the clinical findings encountered in caring for this special group of patients. A partial list of more commonly encountered IEMs is contained in the Table. The different parts of the biochemical pathways discussed previously are combined into Figure 6. Hopefully, for some readers, the Figure also will lead to the affirmation that biochemistry is not so bad after all!

Objective: Tonsillectomy remains one of the most common surgeries performed in the pediatric population. Factors that are predictive of a prolonged stay after tonsillectomy are useful in planning postop care.Method: A retrospective chart review was completed inclusive of all pediatric patients who had tonsillectomy at a tertiary medical center from March 10, 2010, to January 1, 2011. Preoperative variables were analyzed to determine predictors of extended hospital stay (defined as > 24 hours).Results: A total of 210 patients were reviewed. Thirty-three patients (15.7%) had hospital stays greater than 24 hours. Indications for tonsillectomy included obstructive sleep apnea (69.5%), tonsillitis (9.5%), and asymmetry (1.9%). Twenty-eight (84.8%) patients had extended stays for poor oral intake. Fever and respiratory complications accounted for 0.06% respectively. Patients with extended stays were younger (P < .001), weighed less (P < .001), and had higher apnea-hypopnea indices (P = .043). Patients with a hi...

Low vitamin D status is recognized as a prevalent disorder in certain high-risk groups. The greatest prevalence has been reported in the institutionalized elderly. The goal of this article is to review the literature pertaining to vitamin D deficiency in the institutionalized elderly and to highlight the need for treatment in this high-risk group. A computer search for English language articles from 1980 to February 2007 was conducted using the PubMed database and key words vitamin D, hyperpar-athyroidism, elderly, institutionalization, and nursing home. Several risk factors have been noted, which are more prominent in the institutionalized elderly, including decreased sun exposure, poor oral intake, and multiple comorbidities. Long-term care residents should be prescribed higher doses of calcium and vitamin D for adequate bone mineral density and fracture prevention.

Objectives: The aim of this study was to review the literature regarding the measures to reduce post tonsillectomy pain. Data sources: They included medical text books, medical journals, and medical websites (PubMed, Medscape, Science Direct and EMF-Portal) and all materials available in the internet from 2000 to 2015. Study selection. The initial search presented 170 articles. The articles studied different tools and techniques in tonsillectomy, pharmacological and non pharmacological methods for reducing post operative pain. Data extraction: Web search was performed on the medical databases and the full text of the relevant paper was critically analyzed and interpreted. Data synthesis: Comparisons were made by a structured review with the results, summarized and incorporated into the review article’s main text. Findings: Pain is the most significant obstacle to the rehabilitation of a patient following tonsillectomy. Inadequate analgesia causes poor oral intake, which leads to lassitude, delayed recovery of strength and well being and occasionally requires overnight hospitalization in day case surgical practice. Conclusion: The advances in new surgical tools and techniques make this surgery a safe procedure with less post operative pain. The pain can be managed also in a more effective manner with the combination of pharmacological and non-pharmacological therapies.

Objective: To evaluate the safety of ambulatory adenotonsillectomy in children younger than 3 years. Materials and Methods: The records of 102 children younger than 3 years who underwent adenotonsillectomy as an outpatient procedure were reviewed during a 3-year period. Results: Ten patients (10%) required overnight hospital admission for an average of 1.4 days. Nine patients were admitted directly from the day-stay unit and 1 patient was admitted 48 hours after surgery. The reason for hospital admission was poor oral intake. None of the patients had postoperative bleeding or respiratory problems or required intensive care unit admission. Conclusion: The safety of ambulatory adenotonsillectomy depends on judicious selection criteria and can be performed in children younger than 3 years. Arch Otolaryngol Head Neck Surg. 1997;123:681-683