Paralytic ileus is a failure of intestinal propulsion that appears acutely in the absence of mechanical obstruction; it is secondary to various causes and affects intestinal contractility. Therefore, parenteral administration is necessary.

In a hospitalized patient who is unable to feed orally for more than 6 days, in which of the following clinical situations are we necessarily to use parenteral nutrition?

Cardioembolic stroke with complete neurologic dysphagia.

Cachexia due to chronic empyema in immunocompromised patient.

Advanced Alzheimer's disease with severe risk of bronchial aspiration.

[Percutaneous endoscopic gastrostomy--a possibility for enteral feeding of patients with severe cerebral dysfunctions].

Patients who are unable to be adequately nourished owing to cerebral dysfunction do not tolerate nasogastric tubes for enteral nutrition well. They are threatened by active or passive dislocation of the tube into the oesophagus with subsequent aspiration. Although these risks are minimized by percutaneous gastrostomy (PEG), aspiration cannot be completely prevented even when this method of feeding is employed. Enteral nutrition was provided by PEG in 33 patients with different cerebral disorders. PEG was indicated when adequate oral intake of food and fluids proved impossible 8 to 12 days after an acute hypoxaemic cerebrovascular event. 3 of 23 patients who had suffered a stroke, 2 of 8 patients with hypoxaemic brain damage and 3 of 5 patients with decompensated cerebral sclerosis regained the ability to eat between the 21st and 50th day of treatment, so that the gastrostomy could be dispensed with. The other patients died of their severe underlying disease. 6 patients aspirated. In 2 cases this complication occurred during acute aggravation of the underlying disease after several weeks of satisfactory enteral tube feeding. 2 patients aspirated after returning to oral nutrition, whereby feeding was certainly implicated in 1 patient and probable in the other patient. PEG enables adequate enteral nutrition of patients with severe neurological impairment. The advantages of PEG over parenteral nutrition are fewer complications, lower costs and, above all, its superiority in meeting physiological requirements.

Assessment of the risk of malnutrition due to aspiration pneumonia and oral feeding difficulty.

Introduction: many patients with acute-phase swallowing disorders experience malnutrition, which can be caused by oral intake difficulties. Many diseases can cause swallowing difficulties such as aspiration pneumonia, and it is, therefore, necessary to consider the risk of malnutrition during oral feeding therapy in patients with aspiration pneumonia. Objectives: we aimed to evaluate the risk of malnutrition in patients with aspiration pneumonia and other diseases. Methods: the participants comprised 62 patients (45 males, 17 females) with acute-phase swallowing disorders who underwent speech therapy (ST) for swallowing rehabilitation. The patients were divided into four groups: 1) oral feeding with pneumonia, 2) parenteral feeding with pneumonia, 3) oral feeding without pneumonia, and 4) parenteral feeding without pneumonia. The serum albumin and total protein levels were measured to evaluate malnutrition, and swallowing ability was assessed using the Fujishima grade. Results: at the time of ST initiation, serum albumin levels were significantly higher in the oral feeding with pneumonia and oral feeding without pneumonia groups than in the parenteral feeding with pneumonia and parenteral feeding without pneumonia groups. The Fujishima grades differed significantly between the pneumonia/parenteral feeding group and the non-pneumonia/parenteral feeding group. Conclusions: patients with difficulty in swallowing due to aspiration pneumonia were at higher risk of malnutrition than were those without these difficulties. These findings suggest that the nutritional status of parenterally fed patients who developed pneumonia may be inherently poorer than that of orally fed patients.

Aspiration pneumonia

Dysphagia clinicians often recommend alteration of dietary regimens, altered head positioning, or removal of all oral intake. While studies have suggested that thickening liquids can decrease aspiration through slowed pharyngeal transit time, they have also demonstrated increased pharyngeal residues with risk for delayed aspiration. The ability of clinical interventions to reduce pneumonia incidence is relatively unknown. Dietary modifications or nothing-by-mouth status also have no effect on a patient's ability to handle their own secretions. A patient's individual vigor may impact the development of pulmonary infections more than aspiration. Also increased pneumonia risk exists in patients with esophageal dysphagia when compared to stroke patients because patients with stroke will improve as they recover from their acute injury, whereas esophageal dysphagia is likely to worsen with time. In one cohort of aspiration pneumonia patients, overall three-year mortality was 40%.

Indications for percutaneous endoscopic gastrostomy insertion: ethical aspects.

Percutaneous endoscopic gastrostomy (PEG) is a popular technique for long-term enteral nutrition. However it is not beneficial in all cases, and may even prolong the process of dying. The present article discusses the main indications for PEG insertion, and the ethical considerations involved. Three main questions need to be answered: (1) for what purposes should PEG be used; (2) for what type of patients, and (3) when should PEG be inserted in the natural history of the patient's illness? PEG is used in patients unable to maintain sufficient oral intake. It has been found to improve quality of life and/or to increase survival in patients with head and neck cancer, acute stroke, neurogenic and muscle dystrophy syndrome, growth failure (children) and gastric decompression. It led to no improvement in nutritional or functional status in patients with cachexia, anorexia, aspiration (and aspiration pneumonia), and cancer with a short life expectancy. Several court decisions have stipulated that PEG need be offered in patients in a persistent vegetative state or patients with senile dementia who have lost the ability for self-determination. Since the 30-day mortality after PEG insertion is very high for patients hospitalized in a general medical center, a 'cooling off' period of 30-60 days should be scheduled from the time of the PEG request to actual insertion.

[Nutritional support in stroke patients].

Stroke is a public health problem of the first order. In developed countries is one of the leading causes of death, along with cardiovascular disease and cancer. In addition, stroke is the leading cause of permanent disability in adulthood. Many of the patients who survive do so with significant sequelae that limit them in their activities of daily living. Most strokes (80-85%) are due to ischemia, while the rest are hemorrhagic. We have identified many modifiable risk factors, some with an important relationship with dietary factors or comorbidities in wich the diet has a significant impact. The incidence of malnutrition in stroke patients is not well known, but most likely impacts on patient prognosis. Furthermore, the nutritional status of patients admitted for stroke often deteriorates during hospitalization. It is necessary to perform a nutritional assessment of the patient in the early hours of admission, to determine both the nutritional status and the presence of dysphagia. Dysphagia, through alteration of the safety and efficacy of swallowing, is a complication that has an implication for nutritional support, and must be treated to prevent aspiration pneumonia, which is the leading cause of mortality in the stroke patient. Nutritional support should begin in the early hours. In patients with no or mild dysphagia that can be controlled by modifying the texture of the diet, they will start oral diet and oral nutritional supplementation will be used if the patient does not meet their nutritional requirements. There is no evidence to support the use of nutritional supplements routinely. Patients with severe dysphagia, or decreased level of consciousness will require enteral nutrition. Current evidence indicates that early nutrition should be initiated through a nasogastric tube, with any advantages of early feeding gastrostomy. Gastrostomy will be planned when the enteral nutrition support will be expected for long-term (4 weeks). Much evidence points to the importance of glycemic control during hospitalization for stroke. Hyperglycemia at diagnosis and during the first hours of admission impact on patient prognosis. The goal of glycemic control necessary to modify this bad prognosis without adding risk by iatrogenic hypoglycemia is still matter of debate.

Endoscopic evaluation of neurological dysphagic patients.

Dysphagia is a frequent finding in neurological patients and is a symptom related to the severity of the clinical picture. The swallowing impairments, in these patients, increase the risk of aspiration pneumonia, that leads to death, in at least 6% of patients, within the first year. Therefore, evaluation of the swallowing status is essential in patients with dysphagia and videofluoroscopic study of swallowing (VFSS) is the method of choice. It cannot be performed in all patients on account of the complexity of the procedure and since they must be brought to the Radiology Unit. In the 1980, a new bedside method was introduced, namely: fiber-optic endoscopic study of swallow (FESS) which is easy, low-cost, well-tolerated and repeatable. We use this bedside technique to assess swallowing function in patients with dysphagia admitted to acute care units, neurological and internal medicine units. The evaluation aims to indicate the safer nutritional method (oral intake, feeding tube or percutaneous gastrostomy) and, consequently, reducing the risk of aspiration pneumonia during hospitalization. We found that more than 50% of the dysphagic patients present cerebrovascular injuries and in 2% of the population, the first diagnostic hypothesis of Myasthenia Gravis can be made with the FESS technique. In 60%, we indicate a change in nutritional method: in 20% we indicate percutaneous endoscopic gastrostomy (PEG). With these indications, none of those patients had aspiration pneumonia. Our protocol for the bedside fiberoptic study of neurological patients with dysphagia has demonstrated its efectiveness by eliminating the incidence of aspiration pneumonia.

[Progress Report on Cases of Peripherally Inserted Central Catheter (PICC) Management in Our Hospital, Including Elderly Patients].

In our hospital, the number of cases in which peripherally inserted central catheters (PICCs) are used has increased; these patients include elderly people who cannot take medications orally, patients with low levels of awareness, and patients with dysphagia. We report the situation at this time mainly with regard to the number of days on which PICCs were used. Fifteen elderly patients (male, n=7; female, n=8; average age, 89.3±5.3 years) underwent PICC insertion at our hospital from August 2016 to October 2018. Among these patients, 6 had cerebrovascular disorders, 5 had aspiration pneumonia, 2 had Parkinson's syndrome, 1 had consciousness disorder resulting from asphyxia caused by foreign body aspiration, and 1 had interstitial pneumonia. Seven patients received home management. In each patient, we measured the length of time that the PICC was in place. The average duration for which a PICC was in place was 92.9±25.4 days (in cases of home care management, 159.5±48.3 days). The longest duration was 342 days, in a patient with aspiration pneumonia. The endpoints were death and discharge from hospital. Complications/accidents occurred as a result of catheter infection in 2 cases (both patients recovered after catheter removal) and as a result of self-extraction in 1 case. These results suggest that PICC is useful and does not cause serious adverse effects, even in elderly patients who require central parenteral nutrition management.

Enteral nutrition in patients with chronic neurological diseases.

Malnutrition is commonly considered an important risk factor that can produce a negative influence on the prognosis of patients with chronic neurological diseases. The reduced caloric or proteic intake due to the motor or cognitive dysfunction, the hypercatabolic state due to infections, the abnormal gastrointestinal motility are the main mechanisms responsible for a state of malnutrition. Between January and December 1999 fourteen patients with chronic neurological diseases were treated. Ten of them had had a stroke, four due to Amyotrophic Lateral Sclerosis (ALS). After the evaluation of nutritional status the patients received enteral nutrition (EN) by placement of a nasointestinal feeding tube or a Bengmark tube. Glycaemia, blood urea nitrogen, serum creatinine, electrolytes, glycosuria, glutamic-oxalacetic and glutamic pyruvic transaminase were monitored in all patients. Polymeric enteral feeding was administered by an infusion pump. Standard nourished patients (7/14) received a 30 Kcal/kg/day support, the undernourished ones (6 low, 1 moderate malnutrition) received a 35-40 Kcal/kg/day support. The complete caloric supply was reached in three-four days. Both of the groups received continuous feeding infusion during hospitalization. For the patients who continued the nutritional support at home (3/14) refeeding was performed only during night-time. In the patients with stroke the optimal/standard weight was reached within one month. In these patients oral nutrition was started within 45 days of treatment taking into account the restored swallowing function. In the patients with ALS the improvement of nutritional standards was reached within the first month and complete restoration within the second/third month. On the basis of our experience enteral nutrition represents an effective refeeding procedure in patients with chronic neurological diseases.

Aspiration pneumonia

Elderly Aging increases the risk of dysphagia. The prevalence of dysphagia in nursing homes is approximately 50%, and 30% of the elderly with dysphagia develop aspiration. For individuals older than 75, the risk of pneumonia due to dysphagia, is six times greater than those 65. Owing to multiple factors, such as frailty, impaired efficacy of swallowing, decreased cough reflex and neurological complications, dysphagia can be considered as a geriatric syndrome. Atypical presentation is common in the elderly. Older patients may have impaired T cell function and hence, they may be unable to mount a febrile response. The mucociliary clearance of older people is also impaired, resulting in diminished sputum production and cough. Therefore, they can present non-specifically with different geriatric syndromes.

Nasogastric tube feeding at home: a method for adjunctive nutritional support of malnourished patients.

Many patients with chronic diseases develop malnutrition. Force feeding with either enteral tube of parenteral infusions often succeeds in ameliorating this problem in hospitalized patients. However, after discharge many patients are incapable of sustaining adequate dietary intake. As a consequence, malnutrition may persist or recur. The authors' previous experience using nocturnal enteral tube feedings in patients with glycogen storage disease suggested that malnourished patients also might benefit from enteral tube feedings at home. Fourteen undernourished patients selected for domestic enteral tube feedings clearly demonstrated a tolerance, which included adequate gastric emptying, to the infusions during their hospitalization. They ranged in age from 2 months to 68 yr. Infusion pumps delivered the feedings continuously. At home, 12 patients experienced substantial weight gains. Two maintained their weight while they received intensive chemotherapy for malignancies. Except for the two patients with short bowel syndrome, all patients were weaned successfully to oral feedings after 1 to 3 months. The only apparent complication was possible aspiration pneumonia in a patient with neurological dysfunction. This further experience with domestic enteral tube alimentation indicates that selected patients can be managed effectively, safely and economically with nasogastric nutritional support on an outpatient basis.

A comparison of survival, pneumonia, and hospitalization in patients with advanced dementia and dysphagia receiving either oral or enteral nutrition.

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. An observational, prospective, non-randomized, and unblinded study, with a minimum follow up of 6 months. Inpatient wards as well as ambulatory and emergency units run by a Brazilian university. 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. 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. 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). 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.

Aspiration pneumonia

Risk factors Impaired swallowing: Conditions that cause dysphagia worsen the ability of people to swallow, causing an increased risk of entry of particles from the stomach or mouth into the airways. While swallowing dysfunction is associated with aspiration pneumonia, dysphagia may not be sufficient unless other risk factors are present. Neurologic conditions that can directly impact the nerves involved in the swallow mechanism include stroke, neurodegenerative diseases (such as Parkinson's disease), and multiple sclerosis. Anatomical changes in the chest can also disrupt the swallow mechanism. For example, patients with advanced COPD tend to develop enlarged lungs, resulting in compression of the esophagus and thus regurgitation.

Parenteral nutrition

There are physical, physiological, or mental differences in the geriatric population that could potentially lead to poor nutrient intake that would require them to have nutrition therapy. Geriatric patients are more inclined to have delayed muscle restoration compared to the younger population. Additionally, older patients are observed to have greater cardiac and renal impairment, insulin resistance, and to have deficiencies in vitamins and crucial elements. Patients who require nutrition therapy but have contraindications for or cannot tolerate enteral nutrition are appropriate candidates for parenteral nutrition. In the geriatric population, it is indicated if oral or enteral nutrition is impossible for 3 days or when oral or enteral nutrition is likely insufficient for more than 7 to 10 days. While there are no complications of parenteral nutrition specific to the geriatric population, complications are more prevalent in this population due to increased comorbidities.

[Two cases of home parenteral nutrition in which home care was difficult].

Home parenteral nutrition (HPN) is usually conducted after hospital training and home trials, but in more than a few cases self-care is virtually impossible or the ability of carers is insufficient. We investigated the problem points in the cases of two HPN patients from our hospital. Patient 1 was a 76-year-old man who had undergone surgery for esophageal cancer. He was rehospitalized with passage disorders due to eating difficulties such as dysmasesis and dysphagia and an insufficient ability to comprehend meals. Self-care was virtually impossible owing to his lack of understanding of the disease and his dementia. Even if subcutaneous leakage of the subcutaneously implanted port occurred or the connecting portion became dislocated, the patient would not be able to alert others to this by himself. His wife, the key person in his care, could not undergo hospital training because of her advanced age. She received instruction on the techniques for the completion of IVH for one month from the visiting carer, but handling the syringe and needle and the clamp maneuver were difficult for her, and she later developed an infection and was hospitalized. Upon consultation with the primary physician, a change was made to a Groshong catheter, which reduced the maneuver burden, but the prepared checklist was not used and there were problems in the handling of the catheter and management during the period when the maneuvers were being carried out. In addition, discord arose in the family relations, so a grandchild who was a university student rather than the daughter-in-law received instruction according to the manual in order to care for the patient on the nurse's days off. Currently, HPN is being carried out 3/week with meal instructions adjusted to the patient's dysphagia and contact with the family on the nurse's days off. An issue remaining for the future is the use of informal resources in terms of both micro-intervention, including selection of a catheter with consideration of care ability and meal instruction matched to his eating function, and macro-intervention with consideration of the family environment and interpersonal relationships. Patient 2 was a 41-year-old woman with SLE. She was a former nurse, but self-care was not possible due to steroid myopathy. Her main carer was her mother, but due to Alzheimer's-type dementia her mother had difficulty with sterile maneuvers, and sometime allowed the syringe, needle, and set to get dirty or refused to administer the medication or change the batteries on the pump. A visiting nurse and helper visit twice/week each and another volunteer provides daily support, but to continue home care in the future it will be essential to further train the helper and deepen the cooperation between all related.

Multiple system atrophy

Causes of death The most common causes of death are sudden death and death caused by infections, which include urinary catheterization infections, feeding tube infections, and aspiration pneumonia. Some deaths are caused by cachexia, also known as wasting syndrome. Epidemiology Multiple system atrophy is estimated to affect approximately 5 per 100,000 people. At autopsy, many patients diagnosed during life with Parkinson’s disease are found actually to have MSA, suggesting that the actual incidence of MSA is higher than that estimate. While some suggest that MSA affects slightly more men than women (1.3:1), others suggest that the two sexes are equally likely to be affected. The condition most commonly presents in persons aged 50–60. Research Mesenchymal stem cell therapy may delay the progression of neurological deficits in patients with MSA-cerebellar type.

Parenteral nutrition

In cancer Patients who are diagnosed with cancer, whether as outpatient undergoing treatment or hospitalized, are at a greater risk of malnutrition and cachexia. Cancer-related malnutrition can be attributed to the decrease in food intake, increase in the need for energy, and the alteration of metabolism. Patients should be assessed early on in their cancer treatment for any nutritional risk, such as by taking routine weights and BMI. Parenteral nutrition is indicated in cancer patients when it is not possible to access the digestive tract or if the tract is ineffective. In advanced cancer patients, the use of PN should be discussed in context of the risks and benefits, such as if the approximate survival rate is longer than 3 months and if PN would be expected to greatly improve the patients' quality of life. It is uncertain whether home parenteral nutrition improves survival or quality of life in people with malignant bowel obstruction.

Risk factors for nosocomial pneumonia in the elderly.

Elderly patients have a disproportionate incidence of nosocomial pneumonia (NP) and a higher mortality rate, yet few studies have focused on this high-risk population. We undertook a study to examine risk factors for NP in elderly inpatients and to describe how these patients differ from younger patients with NP. In a public teaching hospital, all cases of NP in patients aged 65+ were ascertained by prospective surveillance during a 2-year period (n = 59). These elderly cases were compared with 59 cases of NP in patients aged 25 to 50 to describe differences in risk factors and outcomes. Elderly cases were then matched to elderly control subjects who were admitted to the same hospital service but did not develop NP. Data were collected on known risk factors and on the potential risk factors of poor nutrition, neuromuscular disease, and dementia. Significant differences in risk factors were analyzed using univariate and multivariate comparisons of cases and controls. Elderly patients had twice the incidence of NP (RR = 2.1) as younger patients. Onset of infection was earlier for young than for older cases (6 versus 11 days, p less than or equal to 0.02), but mortality following NP was equal for the two age groups (42% versus 44%). No significant differences in risk factors were found for old and young cases, although older cases tended to have higher rates of poor nutrition, neuromuscular disease, and aspiration preceding their pneumonias. Comparison of elderly cases and elderly controls revealed significantly increased frequencies of poor nutrition, neuromuscular disease, pharyngeal colonization, aspiration, depressed level of alertness, intubation, intensive care unit admission, nasogastric tube use, and antacid use among cases. Cases were more severely ill on admission and had more pre-existing risk factors (2.8 versus 1.3, p less than or equal to 0.001) and more in-hospital risk factors (4.7 versus 1.6, p less than or equal to 0.001). Logistic regression analysis revealed low albumin, diagnosis of neuromuscular disease, and tracheal intubation to be strong independent predictors of risk for NP among elderly inpatients. We conclude that the specific risk factors of poor nutrition, neuromuscular disease, and tracheal intubation may prove useful to target future clinical interventions to prevent NP in the elderly.

Parenteral nutrition

Medical uses Total parenteral nutrition (TPN) is provided when the gastrointestinal tract is nonfunctional because of an interruption in its continuity (it is blocked, or has a leak – a fistula) or because its absorptive capacity is impaired. It has been used for comatose patients, although enteral feeding is usually preferable, and less prone to complications. Parenteral nutrition is used to prevent malnutrition in patients who are unable to obtain adequate nutrients by oral or enteral routes. The Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition recommends waiting until the seventh day of hospital care. Absolute indications for TPN Diseases that would require use of TPN include:

[Life-threatening airway obstruction accompanied by vocal cord paralysis due to indwelling nasogastric tube in malnourished elderly patients: a report of four cases].

We report 4 cases of elderly patients with abrupt onset of serious airway obstruction that is presumed to be due to indwelling nasogastric tube. 2 cases are patients of cerebral infarction and 2 cases are patients of Parkinson disease. The average number of days until NGTS is 17.8 days. In all cases, fiber-optic examination revealed complete loss of adduction in both vocal cords. Infection in the posterior cricoid region caused by ulcerative lesions at the upper end of the esophagus has been implicated as a pathophysiological mechanism of this syndrome, but it was not possible to confirm in the 4 cases. Because it is difficult to exactly diagnose with NGTS in clinical practice, there is a need to consider the inducing factor and response. Body mass index is very low in each of the 4 cases, ranging from 14.2 to 18.0, implying a severely malnourished or immunocompromised state, and may represent a high risk factor for this syndrome. Whenever this life-threatening syndrome is suspected, direct vocal cord examination and removal of the tube are recommended. In addition, the clinicians should not hesitate about doing intubation or tracheotomy in emergency.

Prospective audits of quality of PEM recognition and nutritional support in critically ill elderly patients.

Undereating is a frequent concern in acute care geriatric settings and is supposed to worsen the outcomes of the underlying diseases, while the quality of nutritional support could be improved. Two consecutive and prospective audits (A and B) with team training over a 1 year period investigated the quality of malnutrition recognition and nutritional support and outcomes in immobilized, critically ill elderly subjects. Audit A included 170 patients (86.3+/-6.1 years old) and audit B, 232 patients (86.3+/-6.3), respectively 20.6% and 31.4% of the hospitalized population. Misclassifications occurred in A in 54.0% compared to 34.05% in B (P < 0.001). 32.6% in A versus 86.9% in B adequately received oral supplements (P = 0.02). Significant risk factors for the adverse outcomes in the combined two audits were: dementia (RR: 1.8, 95%CI: 1.0 to 3.0, P= 0.04) and dehydration (RR: 2.0, 95%CI:1.0 to 4.1, P= 0.05) for pressure ulcer incidence; stroke (RR: 8.8, 95%CI: 4.8 to 16.0, P < 0.001) for pressure ulcer prevalence at discharge; neoplasms (RR: 1.1, 95%CI: 1.0 to 1.2, P = 0.02) for nosocomial infections; bladder indwelling for urinary tract infections (RR: 4.8, 95%CI: 2.9 to 7.7, P<< 0.001); swallowing problems for pulmonary infections (RR: 5.4, 95%CI: 2.8 to 10.5, P < 0.001); venous indwelling for septicaemia (RR: 5.4, 95%CI: 1.3 to 23. 3, P= 0.02). However, after adjustment on significant risk factors, the outcome rate was similar in audit B: death rate: A (15.6%), B (14.2%); length of stay: A (17.3+/-10.4 days), B (17.4+/-10.0); pressure ulcer incidence: A (26.4%), B (20.2%), (83% were erythema); pressure ulcer prevalence at discharge: A (14.7%), B (10.3%), (40% were erythema); nosocomial infections: A (26.4%), B (19.0%). The improvement of malnutrition recognition and nutritional support was not followed by a perceptible decrease in adverse outcome rate, this latter being mainly related to the underlying conditions of these critically ill elderly patients.

[Role of the nutritional support team in the management of dysphagia].

Dysphagia is a highly prevalent symptom, which may be due to multiple disease processes, both structural and functional, and located at the oropharyngeal or esophageal level. Oropharyngeal dysphagia can cause malnutrition even in 1/3 of patients as a result of alterations in the efficiency of swallowing and cause changes in the security of swallowing (penetration and aspiration) in up to 2/3 of the patients who present it, with high risk of aspiration pneumonia and respiratory infections. In neurological, elderly or institutionalized patients its prevalence may range from 30 to 60%, with different degrees of severity that may become necessary artificial nutrition. It is also related to greater disability, prolonged hospital stays and increased mortality. Therefore, early diagnosis is critical and the establishment of an effective treatment that includes postural exercises, nutritional support and rehabilitation. All this wouldn't be possible without a nutritional team that takes part of the multidisciplinary team patients with dysphagia required. It is the only way to ensure a longterm care to these patients in order to decrease the morbidity and mortality.

Oral manifestations of systemic disease

Dysphagia is defined as a difficulty in swallowing. Structurally it worsens when eating solids and neurologically it is worse with fluids. Structural problems may include malignancy, stricture and pharyngeal pouching which can lead to halitosis, regurgitation of undigested food and high feeling of dysphagia. Neurological problems may be related to the patient having multiple sclerosis, motor neuron disease, or having suffered from a stroke. Dysphagia may present as a barrier to care in the dental setting as the patient may require high volume suction in order to maintain patient comfort and reduce the risk of aspiration of dental material/ fluids.

[Rethinking of about the artificial hydration and nutrition for the end-stage Alzheimer's disease patients from the bioethical point of view--evidence based ethics].

Due to an increase in the number of patients suffering from Alzheimer's disease, issues relating to withholding and withdrawing of life-prolonging treatment (artificial hydration and nutrition) are in urgent need of discussion. In the ethical thinking, not only patient's autonomy (Value) but also scientific evidence (Fact) is important (= evidence based ethics). There are evidences in foreign countries that indicate tube feeding does not prevent aspiration pneumonia, does not prolong survival and does not reduce the risk of infection. In Japan, we do not have objective data on the efficacy of tube feeding. Artificial hydration and nutrition is implemented just for improving malnutrition without ethical thinking. To implement tube feeding appropriately for the end-stage Alzheimer's disease patients, an identification of objective evidence and prevalence of advanced directive in Japan are important.

[Clinical features and prognosis of terminally ill patients in a geriatric long-term care hospital with particular regard to the implications of artificial nutrition].

To clarify the clinical features of terminally ill patients in our hospital and elucidate the implications of administering artificial nutrition. Between April 2004 and March 2005, we assessed 155 patients who died in Nishimaruyama Hospital--a geriatric long-term care facility in Sapporo. We analyzed their clinical backgrounds on admission, the clinical course up to the terminal stage of the illness, and the outcome of patients who received artificial nutrition. In 95 patients, the main cause of the terminal illness was infection. The symptoms of these patients, such as cerebral infarction and cognitive dysfunction, deteriorated progressively, and eventually, eating became difficult. At this point, alternative methods for providing nutrition were discussed. For 60 patients (41 died of acute disease and 19, of advanced cancers), artificial nutrition was not considered. Artificial nutrition was administered to 63 patients; tube feeding was carried out in 30 patients. Because of repeated aspiration pneumonia, 14 of these 30 patients eventually underwent intravenous hyperalimentation (IVH). Thirty-three patients directly underwent IVH. Thirty-two patients did not undergo any feeding course. The mean survival times of the tube feeding and non-artificial nutrition groups were 827 and 60 days, respectively. The difference in the survival times was statistically significant. The outcome of patients who were placed on tube feeding was good. This may be because we selected those patients considered most suitable for tube feeding or IVH. The criteria that were used to select an appropriate method for providing nutrition varied, although the patients in our hospital requested palliative care.

Nutritional neuroscience

Treatment Prognosis of deficiency is excellent with treatment. Without, pellagra will gradually progress and lead to death within 4–5 years, often a result of malnutrition from prolonged diarrhea, or complications as caused by concurrent infections or neurological symptoms. Symptoms of pellagra can be cured with exogenous administration of nicotinic acid or nicotinamide. Flushing occurs in many patients treated therapeutically with nicotinic acid, and as a result, nicotinamide holds more clinical value as it is not associated with the same uncomfortable flushing. The adult dose of nicotinamide is 100 mg taken orally every 6 hours until resolution of major acute symptoms, followed with oral administration of 50 mg every 8–12 hours until skin lesions heal. For children, treatment involves oral ingestion of 10–15 mg of nicotinamide, depending on weight, every 6 hours until signs and symptoms are resolved. Severe cases require 1 gram every 3–4 hours, administered parenterally.

The clinical case against tube feeding in palliative care of the elderly.

The terminal stages of many neurological illnesses occurring in the elderly produce feeding and swallowing problems. These difficulties lead to ethical, religious, philosophical, and medico-legal conflicts when decisions about starting or stopping tube feedings are considered. We present the case against all forms of tube feeding in a particular subset of elderly palliative patients. These are individuals who are in the end-stage of a progressive neurological disease who are noncommunicative, and spend all or most of their time in a recumbent position. We discuss the physiological phenomena existing in these patients that make the probability of aspiration pneumonia as great or possibly greater than with careful spoon feeding. If tube feeding results in the outcome that it is thought to prevent (ie, aspiration pneumonia) then decisions regarding nutritional support in these patients become clinically clearer.

Dysphagia following chemoradiation for locally advanced head and neck cancer.

To assess the prevalence, severity and morbidity of dysphagia following concurrent chemoradiation for head and neck cancer. Patients who underwent chemotherapy and radiation for head and neck malignancies were evaluated for their ability to resume oral feeding following treatment. Modified barium swallow (MBS) studies were performed if the patients complained of dysphagia or if there was clinical suspicion of aspiration. The severity of dysphagia was graded on a scale of 1-7. If significant abnormalities were found, swallowing studies were repeated until resolution of dysphagia. Between March 1999 and May 2002, 55 patients with locally advanced head and neck cancer underwent concurrent chemotherapy and radiation. Aspiration pneumonia was observed in eight patients, three during treatment and five following treatment. Five patients died from pneumonia. Two patients developed respiratory failure requiring intubation as a complication of pneumonia. At a median follow-up of 17 months (range 6-48 months), 25 patients (45%) developed severe dysphagia requiring prolonged tube feedings for more than 3 months (22 patients) or repeated dilatations (three patients). Among 33 patients who underwent MBS following treatment, 12 patients (36%) had silent aspiration (grade 6-7 dysphagia). Thirteen patients (39%) developed grade 4-5 dysphagia which required prolonged enteral nutritional support to supplement their oral intake. Most patients had severe weight loss (0-21 kg) during treatment, likely due in part to mucositis in the orodigestive tube. Dysphagia is a common, debilitating and potentially life-threatening sequela of concurrent chemoradiation for head and neck malignancy. Physicians should be aware that the clinical manifestations of aspiration may be unreliable and insidious, because of the depressed cough reflex. Modified and traditional barium swallows should be performed following treatment to assess the safety of oral feeding and the structural integrity of the pharynx and esophagus. Patients with severe dysphagia may benefit from rehabilitation. Tube feeding should be continued for those with aspiration.

[Enteral nutrition in the elderly].

Elderly is particularly at risk of malnutrition: he is not able to feed himself adequately, it is then important to attain correct intakes using also artificial enteral nutritional techniques (nasogastric tube, gastrostomy, etc.). These techniques may lead to complications (ab ingestis pneumonia, metabolic complications, alvus disorders): the use of artificially nutrition in the elderly must be carefully evaluated. 257 patients (M = 180, F = 77) aged 65 or more, mainly affected by neoplastic diseases (n 195) and by neurological and vascular diseases (n 62). The feeding route were evaluated in this study: 74% by nasogastric tube, 13% by gastrostomy, 11% by jejunostomy. In a group of 55 patients similar concerning clinical and nutritional conditions we evaluated at the beginning of enteral feeding and four months later, caloric/protein intake, body weight and plasmatic albumin. In patients fed by nasogastric tube a mean intake of 1300 +/- 365 Kcal n.p./die, with a protein rate of 58.5 +/- 16.9 g/die was attained; by gastrostomy 1450 +/- 324 Kcal n.p./die and 65.5 +/- 16 g/die; by jejunostomy 1219 +/- 398 Kcal n.p./die and 53.3 +/- 21 g/die. The compliance to enteral nutrition was well in 37% of patients night administration was performed. Clinical complications: nausea and vomiting were observed in 9 patients with nasogastric tube, in 1 patient with gastrostomy and in 3 patients with jejunostomy; diarrhea has been noticed in 6 patients with nasogastric tube and in 1 patient with jejunostomy. Mechanical complications; nasogastric tube (n 189): 35 displacements, 7 breakages, 4 obstructions; pharyngostomy (n 6): 2 displacements and 1 obstruction; gastrostomy (n 33): 3 displacements; jejunostomy (n 29): 2 misplacements.(ABSTRACT TRUNCATED AT 250 WORDS)

[Is older age a limit factor when considering health resources? The case of home parenteral nutrition].

Some bioethicists consider older age as a limiting factor for receiving special medical care. Older adults comprise the majority of home enteral nutrition patients (neoplams of the head, neck, and upper gastrointestinal tract neuromuscular swallowing disorders, dementia, etc) On the contrary, there are very few data on Home Parenteral Nutrition (HPN) in the elderly. We report these of a 75 years old man affected from a severe short bowel syndrome due to mesenteric thrombosis. After a hospital stay of two months he was sent home on HPN. His current caregiver was her wife, a 72 year old woman suffering from incipient Parkinson's disease. HPN lasted for 11 years and was stopped because of clinical deterioration. During this time he presented 5 catheter- related infections (1.3 episodes/1,000 days). 5 catheters were used (average length 788 days). He was hospitalized four times because of HPN complications. Functional status was maintained along almost all the length of HPN. The rate of complications in this patient was similar to other groups of age receiving HPN. The technique was not burdensome for the family. Older age cannot be consider, by itself a limiting factor when receiving long term nutritional support.

Parenteral nutrition

Absolute indications for TPN Diseases that would require use of TPN include: Short bowel syndrome Small bowel obstruction Active gastrointestinal bleeding Pseudo-obstruction with complete intolerance to food High-output (defined as > 500ml/day) enteric-cutaneous fistulas (unless a feeding tube can be passed distal to the fistula) Gastrointestinal disorders TPN may be the only feasible option for providing nutrition to patients who do not have a functioning gastrointestinal tract or who have disorders requiring complete bowel rest, including bowel obstruction, short bowel syndrome, gastroschisis, prolonged diarrhea regardless of its cause, very severe Crohn's disease or ulcerative colitis, and certain pediatric GI disorders including congenital GI anomalies and necrotizing enterocolitis.

Aspiration syndromes: 10 clinical pearls every physician should know.

Aspiration syndromes are clinically and pathologically classified into three sets of disorders: (i) large airway mechanical obstruction caused by foreign bodies; (ii) aspiration pneumonitis; and (iii) aspiration pneumonia. In this article, we discuss the common clinical presentations, risk factors, radiographic features and methods of management of these disorders. We highlight recent recommendations and controversies surrounding the prevention of aspiration pneumonia in the critically ill patient. Finally, we review ethical dilemmas surrounding feeding and aspiration risk concerns in debilitated and demented patients.

Percutaneous endoscopic gastrostomy

PEG administration of enteral feeds is the most commonly used method of nutritional support for patients in the community. Many stroke patients, for example, are at risk of aspiration pneumonia due to poor control over the swallowing muscles; some will benefit from a PEG performed to maintain nutrition. PEGs may also be inserted to decompress the stomach in cases of gastric volvulus. Indications Gastrostomy may be indicated in numerous situations, usually those in which normal (or nasogastric) feeding is impossible. The causes for these situations may be neurological (e.g. stroke), anatomical (e.g. cleft lip and palate during the process of correction) or other (e.g. radiation therapy for tumors in head & neck region).


Chancroid is a solitary lesion.

Chancroid is a solitary lesion. Secondary syphilis usually occurs as a generalized rash or as characteristic lesions on palms and soles (syphilitic nails) with a longer latency period. Trichomonas balanitis is always associated with urethritis, which is not referred to in the question. Therefore, the answer is 1. However, the clinical picture suggests herpes simplex rather than candidiasis and 5 also refers to fungi (although dermatophytes do not cause balanitis).... from our point of view, even if we consider 1 to be correct, the question is misleading and could be open to challenge. Moreover, genital candidiasis is not necessarily sexually transmitted.

Chancroid is a solitary lesion. Secondary syphilis usually occurs as a generalized rash or as characteristic lesions on palms and soles (syphilitic nails) with a longer latency period. Trichomonas balanitis is always associated with urethritis, which is not referred to in the question. Therefore, [HIDDEN]. However, the clinical picture suggests herpes simplex rather than candidiasis and [HIDDEN] (although dermatophytes do not cause balanitis).... from our point of view, even if we consider [HIDDEN], the question is misleading and could be open to challenge. Moreover, genital candidiasis is not necessarily sexually transmitted.

A 24-year-old young man who 3 days after a risky sexual contact presents numerous pustular lesions, small, very pruritic and evolving to tiny erosions affecting the entire glans and the inner face of the foreskin. Which of the following is the most likely diagnostic approach?

Primary syphilis without chancre - A case report of rare syphilitic balanitis of Follmann.

Syphilitic balanitis of Follmann (SBF) is a rare condition of primary syphilis which is characterized by any kind of balanitis with or without chancre on the penis combined with the presence of swollen inguinal lymph nodes confirmed by the finding of Treponema pallidum in the lesions or by the positive serological syphilitic testing. Timely identification of the SBF is very important in properly treating the disease stopping the spread of syphilis. A 42year-old heterosexual male patient came to our clinic and complained of a painless, hard erythema nodule with a whitish scale in his coronal sulcus of the penis for about a week. The dermatologic examination revealed an infiltrative, hard erythematous lesion surrounding the coronal sulcus of the patient's penis, with mild erosion and a small amount of exudation. There was a whitish pseudomembrane-like covering on the surface of the erythematous lesion in the coronal sulcus, which is mimicked as candidal balanitis. The result of the fungus microscopic examination was negative, while the laboratory findings showed positive results in serologic syphilitic testing. The patient was diagnosed with primary syphilis and intramuscularly treated with a dose of benzylpenicillin of 2.4 million units. The patient's skin lesions disappeared completely 60 days after penicillin treatment. To our knowledge, this is the first SBF case reported in China. Syphilitic balanitis of Follmann may have variable clinical appearances. We emphasize that when balanitis with risky sexual activities or with sexually transmitted diseases, the diagnosis of SBF should be kept in mind.

Chancroid

Differential diagnosis Despite many distinguishing features, the clinical spectrums of following diseases may overlap with chancroid: Primary syphilis Genital herpes Practical clinical approach for this STI as Genital Ulcer Disease is to rule out top differential diagnosis of Syphilis and Herpes and consider empirical treatment for Chancroid as testing is not commonly done for the latter. Comparison with syphilis There are many differences and similarities between the conditions syphilitic chancre and chancroid: Similarities Both originate as pustules at the site of inoculation, and progress to ulcerated lesions Both lesions are typically 1–2 cm in diameter Both lesions are caused by sexually transmissible organisms Both lesions typically appear on the genitals of infected individuals Both lesions can be present at multiple sites and with multiple lesions

Common skin disorders of the penis.

Diseases of the male genitalia range from infectious lesions to inflammatory and neoplastic conditions, including many genital manifestations of more general skin diseases. This review highlights the clinical features, diagnosis and treatment of the most common dermatoses of the male genitalia. Herpes genitalis and infections caused by human papillomavirus (HPV) are increasing, particularly in young sexually active people. Herpes simplex virus infection is the commonest infectious cause of genital ulceration, with evidence that many infections are asymptomatic. HPV infection may be latent, subclinical and clinical. The most common causal agents for condyloma acuminatum are low-risk HPV 6 and 11; high-risk HPV types 16 and 18 are associated with premalignant and malignant lesions. Treatment for genital warts remains unsatisfactory; recurrences are common. Imiquimod, a new topical immunotherapeutic agent, which induces interferon and other cytokines, has the potential to be a first-line therapy for genital warts. Scabies and pediculosis are transmitted by skin-to-skin contact and sexual transmission is common, with the penis and scrotum favourite locations for scabious lesions. Oral ivermectin, a highly active antiparasitic drug, is likely to be the treatment of choice, but until approval is granted it should be reserved for special forms of scabies. Common skin diseases, e.g. psoriasis and lichen planus, may have an atypical appearance in the genital area. The typical psoriatic scale is usually not apparent because of moisture and maceration. Allergic contact dermatitis of the genital area may result from condoms, lubricants, feminine hygiene deodorant spray and spermicides. More often, contact dermatitis is irritant, resulting from persistent moisture and maceration. Lichen sclerosus is a chronic inflammatory disease that occurs as atrophic white patches on the glans penis and foreskin. The penile form is a common cause of phimosis in uncircumcised men; involvement of the urethral meatus may lead to progressive meatal stenosis. Plasma cell balanitis is a benign, idiopathic condition presenting as a solitary, smooth, shiny, red-orange plaque of the glans and prepuce of a middle-aged to older man. Squamous cell carcinoma (SCC) in situ, e.g. erythroplasia of Queyrat and Bowen's disease, cannot be excluded clinically; their apparent clinical benignity may lead to lengthy periods of misdiagnosis and biopsy is required to confirm the diagnosis. SCC is the most common malignancy of the penis and the role of oncogenic HPV-types has been also established in SCC of the penis. Prevention of SCC of the penis presupposes an identification of risk factors, early detection of all pre-cancerous lesions and treatment of phimosis.

[Syphilis in the context of HIV-infection--a complex disease].

A 39-year-old man complained about a slightly reddish non-itching rash evolving on his body during the last few weeks without any general symptoms. Physical examination revealed trunk-dominated roseola, papules, a few nodules with haemorrhagic crust on top, and round hyperkeratotic clavus-like lesion on the left plantar foot. In his mouth, he had a few up to 1.5 cm large erosions, and on his capillitium a diffuse alopecia. Serologic testing for syphilis was positive with Treponema-pallidum-particle-agglutination test at 1:163840, VDRL 1:64, positive IgG-FTA-ABS and 19S-IgM-FTA-ABS tests, and a pleocytosis of the liquor. In addition, there were a co-infection with mycoplasma hominis and first diagnosis of HIV infection (CDC-stadium A1). The patient was diagnosed as having secondary syphilis with suspicion of neurologic involvement and was therefore treated with 6x5 Mio. I.E. Penicillin G i.v. per day for 14 days after the initial application of 40 mg methylprednisolone. Under this regimen complete resolution of the skin lesions was noted over a 4 week period as well as slow re-growth of the hair. HIV infection at stadium A1 did not require antiretroviral treatment. A non-pruritic rash should always point to the differential diagnosis of syphilis. If syphilis is diagnosed, any other sexually transmitted disease including HIV should be excluded as possible co-infection. In case of HIV, neurosyphilis can develop at an earlier stage of common syphilis.

Genital ulcer

The most common cause of genital ulcers in the North America and Western Europe are the result of HSV or syphilis infections, while the most common cause in other parts of the world is chancroid. Most sexually active adolescents with genital ulcers have a herpes simplex virus infection, more commonly type 2. Meanwhile, according to 2017 CDC reports, syphilis is more common in men who have sex with men populations although rates of syphilis have been rising in heterosexual men and women in the United States. Following syphilis and genital herpes infections, a chancroid is the third most common cause but tends to occur in focused outbreaks over time. While rates of H. ducreyi infection seem to be declining according to a 2017 report, it is possible this may be due to lack of testing since H. ducreyi requires a very specialized culture medium which is not commonly available. Less common causes include lymphogranuloma venereum, which is more common in men who have sex with men, and

Genital ulcer

A genital ulcer is an open sore located on the genital area, which includes the vulva, penis, perianal region, or anus. Genital ulcers are most commonly caused by infectious agents (fungal infections, secondary bacterial infections, or sexually transmitted diseases such as genital herpes, syphilis or chancroid). However, this is not always the case, as a genital ulcer may have noninfectious causes as well.

Pattern of sexually transmitted infections in a Muslim majority region of North India.

Changing trends of sexually transmitted infections (STI) and HIV/AIDS has been noted in the literature over years, depending to some extent on the geographical and cultural factors of the region. In Kashmir Valley also, the pattern of STI may be different from the rest of the country. The aim was to present the experience with patterns of STI in Kashmir. Retrospective hospital-based study carried out by detailed analysis of case records of 5-year period. A total of 184 patients, 100 males and 84 females, had specific STI. Genital ulcer disease was the presentation in 54 patients (29.35%), out of which herpes genitalis was found in 27 patients (50%), followed by chancroid in 13 (24.07%) and syphilis in 10 (18.52%) patients. 42 female patients (22.83%) presented with vaginal discharge, out of which, 24 (57.14%) had vaginal candidiasis. 24 males (13.04%) presented with urethral discharge, out of which, 15 (62.5%) had nongonococcal and 9 (37.5%) gonococcal urethritis. Genital molluscum contagiosum (MC) was found in 19 patients (10.33%), and warts in 15 (8.15%). HIV positive serology was detected in 3 patients (1.63%). The most common STI encountered in our study was genital ulcer, followed by vaginal discharge, urethritis, genital MC, and genital warts. Herpes genitalis was the commonest genital ulcer; candidiasis was the most common cause of vaginal discharge and nongonococcal urethritis the most common cause of urethritis. These findings are by and large similar to those noted in other parts of our country.

[Chancroid].

Chancroid (also known as soft chancre and ulcus molle) is a sexually transmitted disease (STD) due to the Ducrey's bacillus (or Haemophilus ducreyi) characterized by chancre at the site of ulcerated inoculation associated with lymphadenopathy. The disease manifests as a small pinkish papule at the site of penetration of the bacterium. After an incubation period ranging from 24 hours to 15 days (on average 5 days). The lesion rapidly evolves into a more or less extended pinkish, painful, deep ulcer with very inflamed and sharp edges and a ragged appearance. The lymphadenopathies usually occur 2-3 weeks after the contact. They are often unilateral and can evolve into ulcers with pus discharge at the level of the skin. Some complications can occur: penile gangrene, extended gangrene of the skin, local superinfection, association with other sexually transmitted diseases. Bacterium can be identified by microscopic examination of a smear of the chancre-like ulcer, more rarely by fine-needle puncture biopsy of a lymphadenopathy. Giemsa or Pappenheim coloration allows identification of the germ. Treatment is based on azithromycin (1 g per os in a single dose) or ceftriaxone (250 mg administered intramuscularly in a single dose). We report the case of a 30-year old man with well-defined deep scrotum ulcer with necrotic center which occurred 1 week after unprotected sexual intercourse. Haemophilus ducrey has been detected by culture and the patient underwent Azithromycin therapy with good outcome.

Syphilis

Primary syphilis is typically acquired by direct sexual contact with the infectious lesions of another person. Approximately 2–6 weeks after contact (with a range of 10–90 days) a skin lesion, called a chancre, appears at the site and this contains infectious spirochetes. This is classically (40% of the time) a single, firm, painless, non-itchy skin ulceration with a clean base and sharp borders approximately 0.3–3.0 cm in size. The lesion may take on almost any form. In the classic form, it evolves from a macule to a papule and finally to an erosion or ulcer. Occasionally, multiple lesions may be present (~40%), with multiple lesions being more common when coinfected with HIV. Lesions may be painful or tender (30%), and they may occur in places other than the genitals (2–7%). The most common location in women is the cervix (44%), the penis in heterosexual men (99%), and anally and rectally in men who have sex with men (34%). Lymph node enlargement frequently (80%) occurs around the

[Lentigines].

Chancroid (also known as soft chancre and ulcus molle) is a sexually transmitted disease (STD) due to the Ducrey's bacillus (or Haemophilus ducreyi) characterized by chancre at the site of ulcerated inoculation associated with lymphadenopathy. The disease manifests as a small pinkish papule at the site of penetration of the bacterium. After an incubation period ranging from 24 hours to 15 days (on average 5 days). The lesion rapidly evolves into a more or less extended pinkish, painful, deep ulcer with very inflamed and sharp edges and a ragged appearance. The lymphadenopathies usually occur 2-3 weeks after the contact. They are often unilateral and can evolve into ulcers with pus discharge at the level of the skin. Some complications can occur: penile gangrene, extended gangrene of the skin, local superinfection, association with other sexually transmitted diseases. Bacterium can be identified by microscopic examination of a smear of the chancre-like ulcer, more rarely by fine-needle puncture biopsy of a lymphadenopathy. Giemsa or Pappenheim coloration allows identification of the germ. Treatment is based on azithromycin (1g per os in a single dose) or ceftriaxone (250mg administered intramuscularly in a single dose). We report the case of a 30-year old man with well-defined deep scrotum ulcer with necrotic center which occurred 1 week after unprotected sexual intercourse. Haemophilus ducrey has been detected by culture and the patient underwent Azithromycin therapy with good outcome.

InternalMed_Harrison

Other Candida skin infections include paronychia, a painful swelling at the nail-skin interface; onychomycosis, a fungal nail infection rarely caused by this genus; intertrigo, an erythematous irritation with redness and pustules in the skin folds; balanitis, an erythematouspustular infection of the glans penis; erosio interdigitalis blastomycetica, an infection between the digits of the hands or toes; folliculitis, with pustules developing most frequently in the area of the beard; perianal candidiasis, a pruritic, erythematous, pustular infection surrounding the anus; and diaper rash, a common erythematous-pustular perineal infection in infants. Generalized disseminated cutaneous candidiasis, another form of infection that occurs primarily in infants, is characterized by widespread eruptions over the trunk, thorax, and extremities. The diagnostic macronodular lesions of hematogenously disseminated candidiasis (Fig. 240-1) indicate a high probability of dissemination to multiple

Balanitis -- Introduction

Balanitis is an inflammation of the glans penis (head of the penis); it is fairly common and affects approximately 3-11% of males during their lifetime. Posthitis is an inflammation of the foreskin (prepuce). Balanoposthitis involves both the glans and the foreskin and occurs in approximately 6% of uncircumcised males. Balanoposthitis occurs only in uncircumcised males. [1] [2] However, balanitis and balanoposthitis often occur together, and the terms are commonly used interchangeably.  Infectious etiologies of balanitis include certain fungi like yeast and certain bacteria or viruses (including those that cause STDs such as gonorrhea). Balanitis is not a sexually transmitted infection. The actual disease is not transferable from one person to another; however, the transfer of organisms that cause balanitis is possible.  Recurrent episodes of balanoposthitis should raise the concern for occult diabetes. Patients with recurrent episodes should undergo blood glucose screening for diabetes and evaluation by a urologist.

Psoriasiform lesions of glans and palms: A rare presentation in secondary syphilis.

Erythematous scaly papules on the palms and soles are a common manifestation of secondary syphilis. We report a case of 19-year-old male who presented with erythematous, scaly, psoriasiform lesions over the palms and glans penis. The papules over the palms showed tenderness on blunt vertical pressure. There was a history of sexual contact and ulcer over the glans around 2 months back, which resolved on its own. Venereal Disease Research Laboratory test was positive in 1:32 dilution. <iTreponema pallidum</i hemagglutination test was also positive. This case highlights the atypical presentation of secondary syphilis.

Chancroid

Complications Extensive lymph node inflammation may develop. Large inguinal abscesses may develop and rupture to form draining sinus or giant ulcer. Superinfection by Fusarium and Bacteroides. These later require debridement and may result in disfiguring scars. Phimosis can develop in long-standing lesion by scarring and thickening of foreskin, which may subsequently require circumcision. Sites For Chancroid Lesions Males Internal and external surface of prepuce. Coronal sulcus Frenulum Shaft of penis Prepucial orifice Urethral meatus Glans penis Perineum area Females Labia majora is most common site. "Kissing ulcers" may develop. These are ulcers that occur on opposing surfaces of the labia. Labia minora Fourchette Vestibule Clitoris Perineal area Inner thighs

Chancroid

Pregnant and lactating women, or those below 18 years of age regardless of gender, should not use ciprofloxacin as treatment for chancroid. Treatment failure is possible with HIV co-infection and extended therapy is sometimes required. Prognosis Prognosis is excellent with proper treatment. Treating sexual contacts of affected individual helps break cycle of infection. Follow-up Within 3–7 days after commencing treatment, patients should be re-examined to determine whether the treatment was successful. Within 3 days, symptoms of ulcers should improve. Healing time of the ulcer depends mainly on size and can take more than two weeks for larger ulcers. In uncircumcised men, healing is slower if the ulcer is under the foreskin. Sometimes, needle aspiration or incision and drainage are necessary.

Pustular secondary syphilis: report of three cases and review of the literature.

Pustular syphilis is an extremely rare manifestation of secondary syphilis. Failure to recognize the disease can have devastating consequences. We present three patients with pustular syphilis as the primary manifestation of secondary syphilis. Patient 1 was initially diagnosed by Venereal Disease Research Laboratory (VDRL) test (titers 1 : 32) and confirmed by enzyme immunoassay (EIA) for Treponema pallidum. Patient 2 was screened for syphilis by VDRL (titers 1 : 64), yielding a positive result, and tested negative for HIV. Secondary syphilis was confirmed by EIA. In Patient 3, a diagnosis of secondary syphilis was established by VDRL (titers 1 : 128) and EIA. Treponema pallidum was detected by dark field microscopy in three patients. Testing for HIV infection was negative in all patients. Diagnosis in secondary syphilis remains challenging because of the diversity of clinical presentations. The most commonly observed cutaneous presentation is a generalized, non-pruritic, papulosquamous eruption varying from pink to violaceous to brown, with mucous membrane involvement. The diagnostic methods used to identify secondary syphilis are the same as those used to diagnose other stages of syphilitic infection. The persistence of syphilis in both developed and underdeveloped regions highlights the importance of considering syphilitic infection in the setting of a cutaneous pustular eruption, especially one that fails to respond to standard therapy. Testing for other sexually transmitted diseases, including HIV, should be performed in all patients diagnosed with syphilis.

Sexually Transmitted Infections -- History and Physical -- Chancroid

Females and males: Signs and symptoms: Often occurs in the 20 to 30-year-old age group, frequently among sex workers and their clients. The areas most often affected include the distal portion of the penis in men, while in women, the vagina, labia, and perianal regions are involved. The most significant symptom is the extremely high pain level noted when the lesion reaches the ulcerative stage. [6] Physical Exam: The lesion starts as a reddish papule which rapidly progresses to a pustule followed by an extremely painful ulcer. The ulcer sometimes called a "soft chancre," will have soft and irregular margins with a friable base and a grayish-yellowish exudate. It tends to bleed easily. The ulcers are typically 1 cm to 2 cm in diameter and usually resolve spontaneously within three months, even if left untreated. Close to half of the affected individuals will develop regional lymphadenopathy, which may be tender. A minority (about 25%) of these patients will progress to infected bulla or abscesses, which can rupture and become superinfected leading to significant tissue destruction and damage to the genitalia. It is estimated that 10% of affected individuals will also have syphilis or genital herpes as well.

Circumcision

Although genital warts are caused by a type of HPV, there is no statistically significant relationship between being circumcised and the presence of genital warts. Other infections Studies evaluating the effect of circumcision on the rates of other sexually transmitted infections have generally, found it to be protective. A 2006 meta-analysis found that circumcision was associated with lower rates of syphilis, chancroid and possibly genital herpes. A 2010 review found that circumcision reduced the incidence of HSV-2 (herpes simplex virus, type 2) infections by 28%. The researchers found mixed results for protection against trichomonas vaginalis and chlamydia trachomatis, and no evidence of protection against gonorrhea or syphilis. It may also possibly protect against syphilis in men who have sex with men.

Venereology

Venereology is a branch of medicine that is concerned with the study and treatment of sexually transmitted diseases (STDs). The name derives from Roman goddess Venus, associated with love, beauty and fertility. A physician specializing in venereology is called a venereologist. In many areas of the world, the specialty is usually combined with dermatology. The venereal diseases include bacterial, viral, fungal, and parasitic infections. Some of the important diseases are HIV infection, syphilis, gonorrhea, candidiasis, herpes simplex, human papillomavirus infection, and genital scabies. Other sexually transmitted infections studied in the field include chancroid, lymphogranuloma venereum, granuloma inguinale, hepatitis B, and cytomegalovirus infection.

Genital ulcer

Overview A genital ulcer may be located on the vulva, penis, perianal region, or anus. Globally, the incidence of genital ulcers is estimated to be approximately 20 million cases annually. The most likely cause of a genital ulcer varies depending on the characteristics of a population and location. The most common cause of genital ulcers in the United States is herpes simplex infections, with syphilis the second most common cause, and chancroid the third. These common causes of genital ulcer disease (HSV-1, HSV-2 and treponema pallidum) can all be efficiently transmitted through oral sex. Important signs associated with genital ulcers that may assist in the diagnosis of the cause of the genital ulcer may include the presence of tender or non-tender enlarged lymph nodes in the groin area, a painful or non-painful genital ulcer, or the presence of vesicular lesions, which are small, painful, elevated blisters.

Penile Granuloma Annulare.

A 50-year-old man presented to the genitourinary medicine clinic with a 3-year history of skin-colored circular papules over the shaft and glans of the penis. There were multiple lesions that were initially small, around 0.3 cm in diameter, and gradually enlarged. Physical examination revealed five nodules over the glans and shaft of the penis, with the largest lesion measuring 3×1 cm over the lateral aspect of the shaft (Figure 1). There were no similar lesions elsewhere. There was no lymphadenopathy and the rest of the examination was unremarkable. The patient complained of discomfort during sexual intercourse but the lesions were otherwise asymptomatic and nontender. There was no history of trauma to the area and no dermatological history. He had had the same sexual partner for the past 22 years, no significant medical history, and was not taking any medication. He was a smoker with a 32-pack-year history. His family history did not include any dermatological diseases. His father was diagnosed with type II diabetes at 65 years of age and his mother had hypertension since age 60 years. He had consulted his general practitioner regarding the penile eruption a year earlier and was treated for a presumed fungal infection with clotrimazole cream for 1 month with no effect. Results from genitourinary investigations for sexually transmitted diseases including syphilis were all negative.

Pattern of sexually transmitted infections in males in interior Sindh: a 10-year-study.

Sexually transmitted infections (STIs) are widespread in Pakistan and have not been fully documented particularly in Sindh Province. The aim of this study is to determine the number and clinical pattern of various types of STIs in general population of Larkana division and its surrounding cities. A hospital based prospective study was carried out at Male-STD-Clinic in the Department of Dermatology, Shaheed Muhtarma Benazir Bhutto Medical University Hospital Larkana from January 2000 to December 2009. Among 4,288 patients, 3,947 (92.04%) had the history of extra marital sexual contact and simultaneously had developed the clinical signs of STIs; 341 (7.95%) had history of extra marital sexual contact but did not have the manifestation of STIs. Majority of the patients (3,860, 90.01%) had the history of heterosexual contact with different partners, but only few 171 (3.98%) of them had the history of homosexual contact. According the syndromic diagnosis 1930 (45.00%) patients had genital ulcer (including herpes genitals) with or without skin manifestations, 690 (16.09%) had urethral discharge, 431 (10.05%) had genital warts, 349 (8.14%) had lesions other than STIs related, 304 (7.08%) had more than one syndrome, 193 (4.50%) had scrotal swelling, 46 (1.07%) had inguinal bubo, 3 (0.06%) were human immunodeficiency virus (HIV) positive, and 1 (0.02%) had ophthalmia neonatorum. Based on the clinical and etiological grounds: 2560 (59.70%) had syphilis, 640 (14. 92%) had gonorrhoea, 399 (9.30%) had mixed infections, 40 (0.93%) had chancroid, 431 (10.05%) had genital warts, 40 (0.93%) had lymphogranuloma venerum (LGV) and granuloma inguinale (GI), 3 (0.06%) were HIV positive, 208 (4.85%) had genital herpes, 120 (2.79%) had orchitis, 56 (1.30%) had non gonococcal urethritis (chlamydia were 19), and 1 (0.02%) had ophthalmia neonatorum. Mode of transmission of STIs in this region is mainly by heterosexual contact and syphilis is the commonest followed by gonorrhoea.

[Generalized exanthematous pustular dermatophytid, a rare clinical presentation of dermatophytid reaction].

Dermatophytids are immunologically mediated dermatologic presentations secondary to sensitization to a dermatophyte infection. They are most frequently associated with toe-web intertrigo and usually present as localized, palmar, pruriginous vesicular eruptions. We report three original cases of generalized exanthematous pustular dermatophytid associated with kerions. Two boys aged 11 and 6 years, and one girl aged 6 years initially presented with kerion secondary to Trichophyton tonsurans (case 1), Trichophyton soudanense (case 2) and Trichophyton mentagrophytes (case 3), respectively. Two to three days after initiation of griseofulvin treatment, all patients presented with a pustular eruption extending from the head to the trunk, associated in one case with fever of 39°C and inflammatory chondritis. Samples obtained from the pustular lesions were sterile, serum inflammatory markers were within the normal range and skin lesions resolved on oral corticosteroid treatment (prednisone 0.75 mg/kg, case 1) or high-potency topical steroids (cases 2 and 3) given as an adjunct to griseofulvin treatment (19 to 23 mg/kg/d). Dermatophytids occur during the acute phase of infection or within a few days of treatment initiation. Lesions are remote from the infection site, contain no dermatophyte, and resolve after treatment of the infection. We report three original cases of generalized exanthematous pustular dermatophytid, associated in one case with fever and inflammatory chondritis. The main differential diagnosis is acute generalized exanthematous pustulosis secondary to antifungal drugs. Differences in clinical presentation between the two enable the appropriate diagnosis to be made as well as continued use of the antifungal medication needed to cure the patient. General or topical steroids may also be used in combination.

Plasma cell balanitis presenting in a patient with a history of syphilis.

Plasma cell balanitis (PCB), also knows as Zoon balanitis, is a benign asymptomatic but chronic and erosive inflammatory condition of the glans penis and prepuce that generally affects uncircumcised men in later years. Clinical presentation involves a single, shiny, well defined reddish patch. We describe the first case of PCB ever reported in a patient with a previous history of syphilis, and include a review of the current literature. A 57-year-old Hispanic man with a remote history of syphilis presented with a 6-month nonhealing, granulating ulcer of the foreskin and glans penis that had been repeatedly mistaken for syphilis and treated unsuccessfully with circumcision 3 weeks previously. Biopsy of the glans penis demonstrated sections with denuded chronic granulation tissue showing a fibrotic stroma with numerous blood vessels and a mixed inflammatory infiltrate including scattered plasma cells. It is important to differentiate PCB from a syphilitic chancre in a patient presenting with a nonhealing penile lesion. This case report demonstrates that these entities may be seen in the same patient at different times.

Penoscrotal porokeratosis: A distinct entity.

A 26-year-old man presented with five months history of redness associated with itching and burning over the scrotum and shaft of the penis with a persistent rash on those sites. There had been no response to topical steroid and antifungal creams. Clinical examination revealed a large well-circumscribed erythematous plaque with a thready raised border with a tiny groove at its summit that involved almost two-thirds of the ventral part of the shaft of the penis. Ill-defined erythema with a granular surface was seen over the anterior scrotal skin. A 4 mm punch biopsy of the plaque on the penile shaft revealed multiple cornoid lamellae located adjacent to one another. The patient was treated with topical emollients. Follow up after four months revealed almost complete resolution of the plaque on the penile shaft. Penoscrotal porokeratosis appears to be a distinct entity in the family of porokeratotic diseases, described only in young males in their twenties with involvement of the penile shaft and anterior scrotum with severe burning and itching and histologically associated with multiple cornoid lamellae. It may represent an unusual epidermal porokeratotic reaction pattern and may be a self-resolving condition.

[Zoon's balanitis in circumcised and HIV infected man, at Cotonou (Benin)].

Balanitis of Zoon (BZ) characterized by an important plasma cell infiltration occurs exclusively in uncircumcised men aged between 40-80 years. We report here a case of BZ in an HIV infected patient who was circumcised since birth. A 43-year old man consulted in 2009 for itchy and not painful glans erosion evolving for one year. He is HIV1 infected and has been under didanosine, lamiduvine and nelfinavir for three years. Under this treatment, his CD4 count increased from 26 cells/mm(3) in 2007 to 206 cells/mm(3) at the time of the consultation. We noted after examination clean burgeoning erosion, red in places, pink in other places, with fuzzy boundary, sitting on the glans and extending into the preputial sulcus. Histopathology showed infiltration by sheets of plasma cells with perivascular topography in the dermis. The bacterial cultures and syphilis serology were negative. We noted a good outcome after four weeks of application of 3% oxytetracycline ointment. This observation suggests that the BZ can occur on a HIV infected patient whether he was circumcised or not. Thus, it appears fair to think of BZ faced with a chronic erosion of the glans in HIV infected patient.

Mycotic infections of the penis.

Balanitis/balanoposthitis caused by Candida albicans is the most frequent mycotic infection of the penis. Its incidence is increasing and it seems to be primarily transmitted by sexual intercourse. Although the groin is a common site for tinea, dermatophytic infections of the penis are rare. Penile involvement in systemic mycosis is usually a sign of severe disease. In immunocompromised individuals, nearly every fungal agent may cause the disease. It normally presents as ulceration, and biopsy and culture can help to confirm the diagnosis. In most cases, superficial infections of the penis respond satisfactorily to local antifungal treatment, especially if provovatice factors and the possibility of sexual transmission are considered. Systemic treatment is recommended in cases of widespread dermatophytic infection, candidosis or systemic mycosis.

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Tinea capitis occurs most commonly in children 3–7 years old. Children with tinea capitis usually present with well-demarcated scaly patches in which hair shafts are broken off right above the skin; alopecia can result. Tinea corporis is manifested by well-demarcated, annular, pruritic, scaly lesions that undergo central clearing. Usually one or several small lesions are present. In some cases, tinea corporis can involve much of the trunk or manifest as folliculitis with pustule formation. The rash should be differentiated from contact dermatitis, eczema, and psoriasis. Tinea cruris is seen almost exclusively in men. The perineal rash is erythematous and pustular, has a discrete scaly border, is without satellite lesions, and is usually pruritic. The rash must be differentiated from intertriginous candidiasis, erythrasma, and psoriasis.

Dermatologically challenging syphilis presentation.

An atypical early primary syphilis case presentation with multiple umbilicated papular lesions on the penis and a nonreactive syphilis serology was misdiagnosed as molluscum contagiosum. Over a period of eight weeks, prior to dermatologic consultation, the papules enlarged, ulcerated, and healed. New plaque and patch formation on the penis and scrotum led to a differential diagnosis of inverse psoriasis vs. syphilis. Histological examination of a shave biopsy specimen revealed numerous Treponema pallidum organisms and repeat syphilis serological test results confirmed a syphilis diagnosis. Lesions responded to treatment with benzathine penicillin. One must keep a high index of suspicion for syphilis in light of its diverse presentation and increasing incidence.

Dorsal longitudinal foreskin cut is associated with reduced risk of HIV, syphilis and genital herpes in men: a cross-sectional study in Papua New Guinea.

Various forms of penile foreskin cutting are practised in Papua New Guinea. In the context of an ecological association observed between HIV infection and the dorsal longitudinal foreskin cut, we undertook an investigation of this relationship at the individual level. We conducted a cross-sectional study among men attending voluntary confidential HIV counselling and testing clinics. Following informed consent, participants had a face-to-face interview and an examination to categorize foreskin status. HIV testing was conducted on site and relevant specimens collected for laboratory-based Herpes simplex type-2 (HSV-2), syphilis, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) testing. Overall, 1073 men were enrolled: 646 (60.2%) were uncut; 339 (31.6%) had a full dorsal longitudinal cut; 72 (6.7%) a partial dorsal longitudinal cut; and 14 (1.3%) were circumcised. Overall, the prevalence of HIV was 12.3%; HSV-2, 33.6%; active syphilis, 12.1%; CT, 13.4%; NG, 14.1%; and TV 7.6%. Compared with uncut men, men with a full dorsal longitudinal cut were significantly less likely to have HIV (adjusted odds ratio [adjOR] 0.25, 95%CI: 0.12, 0.51); HSV-2 (adjOR 0.60, 95%CI: 0.41, 0.87); or active syphilis (adjOR 0.55, 95%CI: 0.31, 0.96). This apparent protective effect was restricted to men cut prior to sexual debut. There was no difference between cut and uncut men for CT, NG or TV. In this large cross-sectional study, men with a dorsal longitudinal foreskin cut were significantly less likely to have HIV, HSV-2 and syphilis compared with uncut men, despite still having a complete (albeit morphologically altered) foreskin. The protective effect of the dorsal cut suggests that the mechanism by which male circumcision works is not simply due to the removal of the inner foreskin and its more easily accessible HIV target cells. Exposure of the penile glans and inner foreskin appear to be key mechanisms by which male circumcision confers protection.Further research in this unique setting will help improve our understanding of the fundamental immunohistologic mechanisms by which male circumcision provides protection, and may lead to new biomedical prevention strategies at the mucosal level.

Nine male cases of tinea genitalis.

Nine cases of tinea genitalis observed in Siena and Terni (Italy) between 1988 and 2003 are reported because of their infrequency. The patients were males ranging in age from 23 to 45 years. The lesions, situated on the penis, glans and scrotum, were preceded by dermatophytosis in other sites (groin five cases; feet two cases; toenails two cases; hands in one; beard in another). Mycological examination consisting of direct microscopy and culture led to isolation of Trichophyton rubrum in five cases, Epidermophyton floccosum in two and T. mentagrophytes var. interdigitalis in the others. Clinical diagnosis is not always easy. In three cases the lesions had been misdiagnosed as eczema.

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associated with candidal infection. In addition, candidal infections have an affinity for sites that are chronically wet and macerated, including the skin around nails (onycholysis and paronychia), and in intertriginous areas. Intertriginous lesions are characteristically edematous, erythematous, and scaly, with scattered “satellite pustules.” In males, there is often involvement of the penis and scrotum as well as the inner aspect of the thighs. In contrast to dermatophyte infections, candidal infections are frequently painful and accompanied by a marked inflammatory response. Diagnosis of candidal infection is based upon the clinical pattern and demonstration of yeast on KOH preparation or culture.