Postextubation dysphagia (PED) is a common problem in critically ill patients with recent intubation. Although several risk factors have been identified, most of them are nonmodifiable preexisting or concurrent conditions. Early extubation, small endotracheal tube size, and small bore of nasogastric tube potentially decrease the risk of PED. The majority of patients receive treatment based on only bedside swallow evaluations, which has an uncertain diagnostic accuracy as opposed to gold standard instrumental tests. Therefore, the treatment decision for patients may not be appropriately directed for each individual. Current treatments are mainly focused on dietary modifications and postural changes/compensatory maneuvers rather than interventions, but recent studies have shown limited proven benefits. Direct therapies in oromotor control, such as therapeutic exercises and neuromuscular stimulations, should be considered as potential effective treatments. P ostextubation dysphagia (PED) is defi ned as the difficulty or inability to eff ectively and safely transfer food and liquid from the mouth to the stomach after extubation. It is commonly seen in trauma and critical care patients requiring endotracheal intubation for mechanical ventilation, especially after cardiac surgery (1, 2). PED may result in aspiration and its ensuing complications, such as aspiration pneumonia, chemical pneumonitis, transient hypoxemia, bronchospasm, or mechanical obstruction with atelectasis. As a result, malnutrition, prolonged hospital stays, fi nancial burden, and increased mortality occur (3, 4). Understanding the treatment modalities and screening tests is essential to minimize complications, improve quality of treatment, and develop standard screening guidelines. INCIDENCEOf 220,000 survivors of acute respiratory failure requiring mechanical ventilation each year in the US (5), 3% to 62% develop PED. Th e wide range of incidence could be explained by the diff erences in the population studied, diff erences in the sensitivity of diagnostic methods and the timing of the assessment, and the duration of intubation. Th e patients who required prolonged intubation from all diagnosis subtypes were found to have a higher incidence of PED compared to postoperative patients with a shorter duration of intubation (6). MECHANISMSTh e mechanisms of PED are multifactorial and include mechanical causes, cognitive disturbances, and residual eff ects of narcotics and anxiolytic medications (7). Mechanical causes are directly related to the duration of intubation and endotracheal tube size, since these tubes cause mucosal infl ammation leading to loss of architecture, oropharyngeal muscle atrophy from disuse during intubation, diminished proprioception, decreased laryngeal sensation, and laryngeal injury (edema, granuloma, and vocal cord paralysis) (6). Traumatic brain injury or critical illness may also cause PED by damaging peripheral and bulbar nerves, altering cognition, or causing the dysregulation of the swallowing refl ex (8). RISK FACTORSP...
Background: Opisthorchis viverrini infection is still one of the public health problems in Thailand. Our recent cohort study conducted in a rural community in central Thailand showed that the incidence rate of O. viverrini infection in 2002-2004 was 21.6/100 person-years. Conventional control activities including case diagnosis and treatment, hygienic defecation promotion and health education focusing on avoiding raw fish consumption was implemented. This study aimed to re-assess the status of infection after implementation of intervention programs, using both quantitative and qualitative methods in [2007][2008][2009]. Methods: A prospective cohort study was conducted to evaluate the incidence and risk factors of O. viverrini infection. Stool examination methods including wet preparation, Kato and formalin-ethyl acetate concentration technique were performed for the detection of O. viverrini eggs. A standardized questionnaire was used to assess risk behavior. In addition, qualitative information was collected from both O. viverrini negative and positive villagers using focus group discussions. Results: The incidence of O. viverrini infection was 21.4/100 person-years. Consumption of chopped raw fish salad, Koi pla and age 60 years and older were independently associated with O. viverrini infection, similar to our previous study. Findings from the qualitative study, indicated that inadequate knowledge, misbeliefs, and social and cultural mores were important factors leading to the maintenance of risk behaviors. Moreover, unhygienic defecation and insufficient diagnosis and treatment were found to facilitate O. viverrini transmission.
Background: Recent studies suggested that fragmented (fQRS) is associated with poor clinical outcomes in heart failure with reduced ejection fraction (HFrEF) patients. However, no systematic review or meta-analysis has been done. We conducted a systematic review and meta-analysis to assess the association between baseline fQRS and all-cause mortality in HFrEF. Methods:We comprehensively reviewed the databases of MEDLINE and EMBASE from inception to February 2018. Published studies of HFrEF that reported fQRS and outcome of all-cause mortality and major arrhythmic event (sudden cardiac death, sudden cardiac arrest, ventricular fibrillation, or sustained ventricular tachycardia) were included. Data were integrated using the random-effects, generic inverse-variance method of DerSimonian and Laird.Results: Ten studies from 2010 to 2017 were included. Baseline fQRS was associated with increased all-cause mortality (risk ratio [RR] 1.63, 95% confidence interval [CI] 1.22-2.19, p < 0.0001, I 2 = 73%) as well as major arrhythmic events (RR = 1.74, 95% CI 1.09-2.80, I 2 = 89%). Baseline fQRS increased all-cause mortality in both Asian and Caucasian cohorts (RR = 2.17 with 95% CI 1.33-3.55 and RR = 1.45 with 95% CI 1.05-1.99, respectively) as well as increased major arrhythmic events in Asian cohort (RR = 1.50, 95% CI 1.05-2.13). Baseline fQRS also increased all-cause mortality in patients who had not received implantable cardioverter-defibrillator, significantly more than in patients who had received implantable cardioverter-defibrillator
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