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Based on current scientific literature, gastrostomy tube (G-tube) placement or other long-term enteral access devices should be withheld in patients with advanced dementia or other near end-of-life conditions. In many instances healthcare providers are not optimally equipped to implement this recommendation at the bedside. Autonomy of the patient or surrogate decision maker should be respected, as should the patient's cultural, religious, social, and emotional value system. Clinical practice needs to address risks, burdens, benefits, and expected short-term and long-term outcomes in order to clarify practice changes. This paper recommends a change in clinical practice and care strategy based on the results of a thorough literature review and provides tools for healthcare clinicians, particularly in the hospital setting, including an algorithm for decision making and a checklist to use prior to the placement of G-tubes or other long-term enteral access devices. Integrating concepts of patient-centered care, shared decision making, health literacy, and the teach-back method of education enhances the desired outcome of ethical dilemma prevention. The goal is advance care planning and a timely consensus among health team members, family members, and significant others regarding end-of-life care for patients who do not have an advance directive and lack the capacity to advocate for themselves. Achieving this goal requires interdisciplinary collaboration and proactive planning within a supportive healthcare institution environment.

Introduction: Nutritional disturbances in patients with chronic obstructive pulmonary disease (COPD) are very common. Symptomatology and functionality in chronic diseases could be related with the nutrition. Malnutrition could aggravate the disease. Objectives: Therefore, the aims of this study were 1) to evaluate the profile of the patient with COPD and malnutrition, and 2) to determine the relationship between the nutritional status with functionality and symptomatology in COPD patients. Methods: An observational study was conducted in patients with severe COPD. The independence levels, quality of life was evaluated, comorbidities and anxiety and depression were evaluated. Respiratory function was assessed with spirometry, forced expiratory volume in 1 second (FEV 1) was recorded, and Borg modified scale was used to determine de dyspnea perception. The Mini Nutritional Assessment questionnaire (MNA) evaluated the nutritional status. Finally, the simptomatology was assessed with Leicester Cough Questionnaire, and with London Chest Activity of Daily Living Scale. Results: A sample of 154 subjects was included in this study, 98 of them were males. A group of 71 subjects showed malnutrition and a group of 83 patients a normal nutritional status. The comparison between the groups showed significant differences in the clinical characteristics (p < 0.05). The analysis showed significant differences in dyspnea (p = 0.043), and the subscales of functionality related to respiratory symptoms self-care (p = 0.040) and leisure (p = 0.019) and the total score (p = 0.031). The worst results were shown in the patients with malnutrition. Conclusion: Our investigation shows that patients with COPD and malnutrition have worse results in symptomatology and functionality than patients with COPD without malnutrition.

Gastrocutaneous fistulas are infrequent after gastrostomy tube removal. However, if the fistulous tract remains permeable, even low-volume output can produce significant cutaneous burns. The use of biodegradable adhesives has been described, where fibrin glue is applied directly over the fistulous tract or under the guidance of procedures such as upper or lower gastrointestinal endoscopy or fistuloscopy. We studied the use of fibrin glue in five consecutive adult patients with gastrocutaneous fistulas after gastrostomy tube removal, with no complications that might impede spontaneous closure. A comparison group included seven patients treated during the preceding 2 years with conservative medical management, who were not treated with fibrin glue. There was no difference between the two groups with regard to age and gender, nor with regard to type of gastrostomy (surgical or endoscopic). The mean output volume from the fistulas was 151.4 +/- 146.1 ml/24 h in the study group and 115.0 +/- 42.7 ml/24 h in the control group, which was not significantly different ( P = 0.80). The duration of previous conservative treatment was 93.8 +/- 85.1 days for the study group and 95.8 +/- 80.7 days for the control group and this also did not differ significantly ( P = 0.93). The time to achieve total fistula closure was 7.0 +/- 3.1 days in the study group and 32.7 +/- 15.7 days in the control group. This difference was statistically significant ( P < 0.004). The time required before oral feeding could be recommenced after spontaneous or induced closure was similar in the two groups, at 2.8 +/- 1.3 days and 4.71 +/- 2.36 days, respectively. Endoscopic guidance allows direct instillation of fibrin glue via the external opening through the whole fistulous tract. This procedure reduces the time required for the closure of gastrocutaneous fistulas.

Central vein catheterization is frequently employed for monitoring, administration of drugs and parenteral nutrition in a variety of medical and surgical illnesses. Despite the widespread use of central vein access, both catheter-related infections and mechanical complications remain unacceptably common. In the last few years, data have become available to show that technical innovations and catheter maintenance protocols can reduce both catheter related bloodstream infections as well as mechanical complications. Future developments should be aimed at both educational intervention and biomaterials research. The former incorporates case-based instruction, problem-solving examination, and database analysis; while the latter will probably lead to a new set of catheters that are more resistant to infection and thrombosis.

Rationale: Gastrointestinal fistulas (GIF) represent a severe and potentially lethal complication in hospital surgical patients. However, evidences are lacking about prognosis and outcomes of GIF in Latin America (LATAM) hospitals. Objective: To describe the prognosis and outcomes GIF in LATAM hospitals. Study design: Prospective, longitudinal, cohort-type study. The cohort fostered three cross-sectional examinations: First examination: On admission of the patient in the study; Second examination: Thirty days later; and Third (and last) examination: Sixty days after patient's admission. Study serie: One hundred seventy-seven patients (Males: 58.2 %; Average age: 51.0 ± 16.7 years; Ages ≥ 60 years: 36.2 %) diagnosed with, and assisted for, GIF (ECF: Enterocutaneous: 64.9 % vs. EAF: Enteroathmospheric: 35.1 %) in 76 LATAM (13 countries) and Europe (4) hospitals. Methods: Condition (Alive vs. Deceased) and hospital status (Hospitalized vs. Discharged) of the patient, and the GFI patency (Closed vs. Non closed) were recorded in each of the cohort's examination. Indicators of GFI prognosis thus constructed were correlated demographical, sanitary, surgical and nutritional characteristics of the patients. Results: On conclusion of the study indicators of GIF prognosis behaved as follows: Mortality: 14.7 %; Prolonged hospitalization: 46.3 %; Spontaneous closure of GIF: 36.2 %. Only the type of GIF influenced upon patient's survival: ECF: 87.0 % vs. EAF: 82.3 % (Δ = +4.7 %; χ2 = 6.787; p < 0.05). Similarly, in each examination of the cohort, the number of surviving subjects was always greater among those with ECF: After 30 days: ECF: 92.1 % vs. EAF: 83.9 % (Δ = +8.2 %); After 60 days: ECF: 98.1 % vs. EAF: 90.4 % (Δ = +7.7 %; χ2 = 13.764; p < 0.05). Conclusions: Currently, only the type of GIF influences upon survival of the patient.

SUMMARYRationalePrognosis and outcomes of gastrointestinal fistulas (GIF) might depend upon the operational characteristics of the hospital containing and caring for the patients.ObjectiveTo assess how selected operational characteristics of the hospital participating in the exercises of the “Fistula Day” Project (FDP) influence upon prognosis and outcomes of GIF.Study designCohort-type study. Enrolled patients were followed for 60 days. Three cross-sectional examinations were made during the completion of the exercises of the FDP, namely, upon admission of the patient in the study, and 30 and 60 days after admission.Study serieSeventy-six hospitals of Latin America (13 countries) and Europe (4).MethodsAssociations between survival of the patient, prolongation of hospital stay, and (likely) spontaneous closure of the fistula, on one hand; and selected operational characteristics of the participating hospital, on the other; were assessed.ResultsSpecialties hospitals prevailed. Most of the hospitals assisted between 1 – 2 GIF patients a month. Participating hospitals distributed evenly regarding the number of beds. Most of the hospitals had an intensive care unit. Similarly, three-quarters of the hospitals had a multidisciplinary unit dedicated to clinical and hospital nutrition. However, a unit dedicated to the management of intestinal failure and/or postoperative fistulas was present only in a fifth of them. Experience of the physician attending GIF was rated between “Expert” and “High” in one third of the hospitals. Number of hospitals beds associated with increased survival of GIF patients (χ2 = 5.997; p = 0.092), prolonged hospital stay (χ2 = 7.885; p < 0.05), and higher rate of spontaneous closure of the fistula (χ2 = 11.947; p < 0.05). In addition, rate of spontaneous closure of the fistula was (marginally) higher among patients assisted by a hospital unit specialized on intestinal failure (χ2 = 3.610; p = 0.0574). On the other hand, survival of the patient was dependent (also marginally) upon the number of patients assisted in a month (χ2 = 5.934; p = 0.0514).ConclusionsIt is likely number of hospital beds to determine prognosis and outcomes of GIF. Other operational characteristics of the hospital might exert a marginal influence upon survival of the patient and the likely spontaneous closure of the fistula.

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