Postextubation dysphagia (PED) is a common problem in critically ill patients with recent intubation. Although several risk factors have been identified, most of them are nonmodifiable preexisting or concurrent conditions. Early extubation, small endotracheal tube size, and small bore of nasogastric tube potentially decrease the risk of PED. The majority of patients receive treatment based on only bedside swallow evaluations, which has an uncertain diagnostic accuracy as opposed to gold standard instrumental tests. Therefore, the treatment decision for patients may not be appropriately directed for each individual. Current treatments are mainly focused on dietary modifications and postural changes/compensatory maneuvers rather than interventions, but recent studies have shown limited proven benefits. Direct therapies in oromotor control, such as therapeutic exercises and neuromuscular stimulations, should be considered as potential effective treatments. P ostextubation dysphagia (PED) is defi ned as the difficulty or inability to eff ectively and safely transfer food and liquid from the mouth to the stomach after extubation. It is commonly seen in trauma and critical care patients requiring endotracheal intubation for mechanical ventilation, especially after cardiac surgery (1, 2). PED may result in aspiration and its ensuing complications, such as aspiration pneumonia, chemical pneumonitis, transient hypoxemia, bronchospasm, or mechanical obstruction with atelectasis. As a result, malnutrition, prolonged hospital stays, fi nancial burden, and increased mortality occur (3, 4). Understanding the treatment modalities and screening tests is essential to minimize complications, improve quality of treatment, and develop standard screening guidelines. INCIDENCEOf 220,000 survivors of acute respiratory failure requiring mechanical ventilation each year in the US (5), 3% to 62% develop PED. Th e wide range of incidence could be explained by the diff erences in the population studied, diff erences in the sensitivity of diagnostic methods and the timing of the assessment, and the duration of intubation. Th e patients who required prolonged intubation from all diagnosis subtypes were found to have a higher incidence of PED compared to postoperative patients with a shorter duration of intubation (6). MECHANISMSTh e mechanisms of PED are multifactorial and include mechanical causes, cognitive disturbances, and residual eff ects of narcotics and anxiolytic medications (7). Mechanical causes are directly related to the duration of intubation and endotracheal tube size, since these tubes cause mucosal infl ammation leading to loss of architecture, oropharyngeal muscle atrophy from disuse during intubation, diminished proprioception, decreased laryngeal sensation, and laryngeal injury (edema, granuloma, and vocal cord paralysis) (6). Traumatic brain injury or critical illness may also cause PED by damaging peripheral and bulbar nerves, altering cognition, or causing the dysregulation of the swallowing refl ex (8). RISK FACTORSP...

BackgroundThere are limited data about modes of death and major adverse cardiovascular events (MACEs) in patients with hypertrophic cardiomyopathy (HCM) in South East Asian population. The aim of the study was to examine modes of death and clinical outcomes in Thai patients with HCM.MethodsBetween January 1, 2009 and December 31, 2013, 166 consecutive patients with HCM diagnosed in our institution were evaluated. Five patients were excluded because of non-Thai ethnic groups (n = 3) and diagnosis of myocardial infarction at initial presentation documented by coronary angiography (n = 2). The final study population consisted of 161 patients with HCM. HCM-related deaths included: (1) sudden cardiac death (SCD) – death due to sudden cardiac arrest or unexpected sudden death; (2) heart failure – death due to refractory heart failure; or (3) stroke - death due to embolic stroke associated with atrial fibrillation. MACEs included: (1) SCD, sudden unexpected aborted cardiac arrest, fatal, or nonfatal ventricular arrhythmia (ventricular fibrillation or sustained ventricular tachycardia); (2) heart failure (fatal or non-fatal), or heart transplantation; or (3) stroke - fatal or non-fatal embolic stroke associated with atrial fibrillation.ResultsOne hundred and sixty-one Thai patients with HCM (age 66 ± 16 years, 58% female) were enrolled. Forty-two patients (26%) died over a median follow-up period of 6.8 years including 25 patients (16%) with HCM-related deaths (2%/year). The HCM-related deaths included: heart failure (52% of HCM-related deaths; n = 13), SCD (44% of HCM-related deaths; n = 11), and stroke (4% of HCM-related deaths, n = 1). The SCDs occurred in 6.8% of patients (1%/year). Eighty-four major MACEs occurred in 65 patients (41, 5%/year). The MACEs included: 40 heart failures in which 2 patients underwent heart transplants; 22 SCDs and nonfatal ventricular arrhythmias; and 22 fatal or nonfatal strokes.ConclusionsThe most common mode of death in adult patients with HCM in Thailand was heart failure followed by SCD. About one-third of the patients experiencing heart failure died during the 6.8 years of follow-up. SCDs occurred in 7% of patients (1%/year), predominantly in the fourth decade or later.

We report a 62-year-old white woman with metastatic choroidal melanoma who developed immune checkpoint inhibitor (ICI)-induced enteritis and grade 3 diarrhea refractory to steroids and infliximab. Her diarrhea quickly resolved after infusion of vedolizumab, and the patient was able to taper down steroids. Vedolizumab’s mechanism of action and its gut specificity have the potential to reverse immune-induced enterocolitis without neutralizing or reversing the therapeutic benefit of ICI on the malignancy.