Background: Gastric fluid volume has been used as a surrogate marker for pulmonary aspiration risk in studies evaluating fasting protocol safety. This study measured residual gastric fluid volume in children using a protocol in which diluted oral contrast medium was administered up until one hour before anesthesia. Methods: This was a single-center prospective observational cohort trial of 70 children for elective abdominal/pelvic computed tomography (CT). Imaging was performed after diluted enteral contrast medium administration, beginning two hours before and ending at least one hour before induction. For each patient, gastric fluid volume was calculated using an image region of interest. The primary outcome measure was gastric fluid volume measured using the computed tomography image. Results: The median time from the end of contrast administration to imaging was 1.5 h (range: 1.1 to 2.2 h). Residual gastric volume, measured using CT was <0.4 mL/Kg in 33%; ≥0.4 mL/Kg in 67%; and ≥1.5 mL/Kg in 44% of patients. Residual gastric volumes measured using CT and aspiration were moderately correlated (Spearman\'s correlation coefficient = 0.41, p = 0.0003). However, the median residual gastric volume measured using CT (1.17, IQR: 0.22 to 2.38 mL/Kg) was higher than that of aspiration (0.51, IQR: 0 to 1.58 mL/Kg, p = 0.0008 on differences in paired measures). Three cases of vomiting were reported. No evidence of pulmonary aspiration was identified. Conclusions: Children who receive large quantities of clear fluid up to one hour before anesthesia can have a significant gastric residual volume.

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OBJECTIVE: Research suggests that clinical decision making for assessing and treating patients with swallowing dysfunction varies significantly, and decisions may harm patients. The study aimed to investigate clinical practice of speech-language pathologists (SLPs) assessing and treating swallowing in skilled nursing facilities (SNFs).
METHODS: Retrospective review of 120 medical records of patients recommended for a flexible endoscopic evaluation of swallowing (FEES).
METHODS: 120 SNF patients.
METHODS: Records from 25 SNFs were reviewed to determine which patients were receiving swallowing therapy, their diet level pre- and post-FEES, and if they received prior imaging studies. Recordings of FEES were assigned severity ratings based on the Dynamic Imaging Grade of Swallowing Toxicity-FEES scores to determine the relationship between diet and liquid recommendations before and after FEES, how often patients consume a modified diet in the absence of dysphagia, percentage of patients without dysphagia receiving swallowing treatment, percentage of patients receiving alternative means of nutrition without dysphagia, and the percentage of patients with a feeding tube without an imaging assessment.
RESULTS: Chi-square tests revealed no agreement between pre- and postimaging diet levels. Ordinal regressions indicated preimaging diets did not fit the DIGEST severity rating model; however, investigators found a good fit with postimaging diet recommendations. Descriptive statistics indicated that 67% of the patients receiving a modified solid and/or liquid did not have dysphagia. Treatment was provided to 100% of the patients without dysphagia. Sixty-one percent of patients with feeding tubes had no dysphagia. Forty-five percent of NPO (nothing by mouth) patients had imaging during their acute stay.
CONCLUSIONS: The results strongly suggest that the practice of continuing acute care diet recommendations in a SNF increases cost and may negatively impact patient quality of life. The practice may also lead to negative health consequences. A new imaging assessment is required to inform treatment when medical status changes.

Although practice guidelines recommend resuming oral feeding immediately after gastrointestinal surgery, many practitioners remain reluctant to order early oral feeding (EOF). Therefore, this review aimed to clarify the tolerance to and postoperative outcomes with EOF among patients undergoing bowel surgery. A systematic review of the literature published between January 1990 and July 2022 with the time of oral intake (early or delayed until resolution of ileus) as the exposure variable was conducted using PubMed and Scopus databases. Outcomes of interest included tolerance to EOF and postoperative adverse effects or complications. After screening 1,667 research articles, 18 randomized control trials, six prospective case series, and four cohort studies met our inclusion criteria, collectively representing data from 2,647 patients in eleven countries. These studies indicate that while most patients tolerate EOF, 5-25% may not tolerate EOF until the fourth postoperative day (POD). Moreover, EOF, at best, has no advantage over delayed feeding in terms of vomiting, nausea, nasogastric tube requirement, or other postoperative complications. In addition, early return of bowel function, lower risk of diarrhea, and lower pain score with EOF are inconsistently reported, and shorter hospitalization with EOF may be limited to those who tolerate oral feeding on POD 0 or 1. Nevertheless, shorter hospitalization with EOF could reduce the cost of hospitalization. A substantial number of patients may not be able to tolerate oral feeding after bowel surgery until POD 4, and in patients who tolerate EOF, the only clear benefit is a shorter length of hospitalization.

BACKGROUND: Starvation ketoacidosis (SKA) is a rare cause of ketoacidosis in the general population but can be seen with malignancy. Patients often respond well to treatment, but some rarely develop refeeding syndrome (RFS) as their electrolytes drop to dangerous levels causing organ failure. Typically, RFS can be managed with low-calorie feeds, but sometimes patients require a halt in feeds until their electrolyte imbalances are managed.
METHODS: We discuss a woman with synovial sarcoma on chemotherapy who was diagnosed with SKA and then developed severe RFS after treatment with intravenous dextrose. Phosphorus, potassium, and magnesium levels dropped precipitously and remained fluctuant for 6 days. She also developed normal sinus ventricular tachycardia, premature ventricular beats, and bigeminy. She could not tolerate calorie supplementation at that time. She was managed with electrolyte repletions until clinically stable and then progressed to a liquid diet.
CONCLUSIONS: We present a unique case of severe SKA that resulted in RFS requiring nihil per orem (NPO) treatment for 6 days. There are no specific guidelines for SKA or RFS management. Patients with pH < 7.3 may benefit from baseline serum phosphorus, potassium, and magnesium levels. Clinical trials are needed to further study which patients may benefit from starting at a low-calorie intake versus those that require holding nutrition until clinically stable.
CONCLUSIONS: Completely stopping caloric intake until a patient\'s electrolyte imbalance improves is an important management aspect of RFS to underscore and study, as grave complications can occur even with cautious refeeding regimens.

Eosinophilic esophagitis (EoE), an eosinophil predominant, TH2-mediated condition increasing in prevalence in pediatric and adult populations, is typically treated with dietary manipulations to avoid triggering antigens. However, identifying specific dietary causes remains a persistent challenge, and restrictive diets are burdensome. Total dietary modification using amino acid-based formula does not always produce symptomatic or histologic resolution, suggesting that exposure to ingested aeroallergens drives their disease. EoE patients demonstrate symptomatic exacerbation from July to September correlating with higher grass and ragweed pollen counts. We present a 7-year-old tracheostomy- and gastrostomy-dependent girl who was found on surveillance endoscopy to have profound eosinophilic infiltration throughout the esophagus with inflammatory changes including basal cell hyperplasia on histology. She responded partially to topical corticosteroid therapy with fluticasone and had complete resolution of esophageal eosinophilic infiltrate with subcutaneous dupilumab.

BACKGROUND: Endoscopy with sedation is a common inpatient procedure. \"NPO after midnight\" remains the prevailing fasting practice despite ASA guidelines indicating specific fasting times. This quality improvement project aims to assess patient discomfort with the \"NPO after midnight\" order versus implementation of specific NPO times.
METHODS: Patients in the inpatient wards scheduled for endoscopy after 1 pm the following day were recruited. The gastroenterology services designated specific NPO times per ASA guidelines for the post-intervention group. Each participant completed a survey qualifying hunger, thirst, and discomfort levels. Pearson\'s chi-squared analysis was performed.
RESULTS: NPO duration was reduced in the post-intervention group with significant improvement in thirst, hunger, and discomfort levels. A shortened preoperative fasting period did not lead to increase in procedural complications.
CONCLUSIONS: Despite ASA guidelines, the practice of keeping patients NPO after midnight remains pervasive, resulting in unnecessarily prolonged fasting and patient discomfort. Implementing specific diet recommendations reduces duration of NPO and improves patient comfort and overall satisfaction.

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We report our experience with topiramate rectal suspensions in a single center case series of three patients <1 year of age from 2017 to 2020 who received topiramate per rectum after being placed nil per os (NPO) status at a free standing children\'s hospital. The objective was to describe the compounding methods and clinical outcomes of three of the youngest patients to receive topiramate rectal suspensions. All three patients received topiramate per rectum for 2-4 days. No adverse effects or increase in seizure frequency were noted. For patients placed on NPO status, there is currently no alternative to oral topiramate. No studies describe per rectum topiramate use in pediatrics. Rectal administration of topiramate is not only useful in times when patients are NPO, but may also be useful when patients on topiramate experience status epilepticus. The formulation of topiramate suppositories should be explored in the future. Until further information is available, dose substitution should be done carefully with close supervision by a healthcare provider.

This study contributes to our understanding of organizational identity through dichotomous motivations of altruism and egoism in non-profit organizations (NPO). By applying an empirical analysis of NPO members, organizational identity is found to be well explained by altruistic motivation and egoistic motivation. More importantly, this study finds that collectivism positively moderates the relationship between altruistic motivation and organizational identity, and negatively moderates the relationship between egoistic motivation and organizational identity. It is noticeable that altruistic motivations have a stronger impact on organizational identity when collectivism is high, while egoistic motivations have a stronger impact on organizational identity when collectivism is low. Finally, this study generates helpful management implications based on research findings. It is suggested that the managers of NPOs could enhance members\' organizational identity by taking motivations and collectivism into consideration, that is to say, in order to build up organizational identity of NPO members, both righteousness and shared interests matter simultaneously.