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Braun RG, Arata J, Gonzalez-Fernandez M. Dysphagia and Enteral Feeding After Stroke in the Rehabilitation Setting. Phys Med Rehabil Clin N Am 2024; 35:433-443. [PMID: 38514228 DOI: 10.1016/j.pmr.2023.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Physiatrists play a vital role in post-stroke dysphagia management not only by providing guidance on the risks, benefits, and efficacy of various treatment options but also as advocates for patients' independence and quality of life. While swallow study results are often discussed broadly by acute stroke clinicians as "pass/fail" findings, physiatrists need a more nuanced working knowledge of dysphagia diagnosis and treatment that encompasses swallow pathophysiology, targeted treatment strategies, and prognosis for recovery. To that end, this review summarizes current clinical practice guidelines on dysphagia, nutrition and oral care, risks and benefits of differing enteral access routes, prognostic factors, and approaches to rehabilitation.
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Affiliation(s)
- Robynne G Braun
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA; University of Maryland Rehabilitation and Orthopedic Institute, Baltimore, MD, USA; Brain Rehab and Recovery Lab, University of Maryland School of Medicine, Bressler Research Building, Suite 12-019, 655 West Baltimore Street, Baltimore, MD 21201, USA.
| | - Jodi Arata
- Rehabilitation Research Lab, University of Maryland Rehabilitation and Orthopedic Institute, 2200 Kernan Drive, Baltimore, MD 21207, USA
| | - Marlis Gonzalez-Fernandez
- Department of PM&R, Johns Hopkins University School of Medicine, 600 North Wolf Street, Phipps 184, Baltimore, MD 21287, USA; Outpatient PM&R Clinics, Johns Hopkins Hospital, 600 North Wolfe Street Phipps 174, Baltimore, MD 21287, USA
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Braun R, Han K, Arata J, Gourab K, Gonzalez-Fernandez M. Establishing a Clinical Care Pathway to Expedite Rehabilitation Transitions for Stroke Patients With Dysphagia and Enteral Feeding Needs. Am J Phys Med Rehabil 2024; 103:390-394. [PMID: 38112750 PMCID: PMC11031280 DOI: 10.1097/phm.0000000000002387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
OBJECTIVE The aim of the study is to evaluate the safety and efficacy of a physiatrist-led clinical pathway to expedite rehabilitation transitions for stroke patients with dysphagia requiring nasogastric tube or percutaneous endoscopic gastrostomy. DESIGN This is a retrospective single-center observational study in 426 adults with stroke and dysphagia admitted to the acute hospital. Physican Medicine and Rehabilitation (PM&R) was consulted to determine dysphagia prognosis and candidacy for rehabilitation admission with nasogastric tube or percutaneous endoscopic gastrostomy. The proportion of patients accepted with nasogastric tube versus percutaneous endoscopic gastrostomy, progression to total oral diet during rehabilitation, and lengths of stay were tracked. RESULTS The rate of recovery to total oral diet for patients accepted with nasogastric tube was 38/44 = 86.3% versus 29/75 = 38.6% with percutaneous endoscopic gastrostomy. There was a significant difference in mean time to total oral diet with nasogastric tube (20.37 days) versus percutaneous endoscopic gastrostomy (34.46 days): t (43) = 4.49, P < 0.001. The acute hospital length of stay was significantly shorter with nasogastric tube (12.9 days) versus percutaneous endoscopic gastrostomy (20.4 days): t (117) = 4.16, P < 0.001. Rehabilitation length of stay did not differ significantly between groups (26.9 vs. 32.0 days). CONCLUSION Physiatrist-led initiatives to evaluate stroke patients with dysphagia can expedite rehabilitation transitions, prevent unnecessary invasive procedures, and reduce acute hospital length of stay.
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Affiliation(s)
- Robynne Braun
- University of Maryland School of Medicine, Department of Neurology, Baltimore, MD
| | - Kenneth Han
- Midstate Medical Center, Hartford Healthcare, Meriden CT
| | - Jodi Arata
- University of Maryland Rehabilitation and Orthopedic Institute, Baltimore, MD
| | - Krishnaj Gourab
- University of Maryland Rehabilitation and Orthopedic Institute, Baltimore, MD
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Hochu G, Soule S, Lenart E, Howley IW, Filiberto D, Byerly S. Synchronous tracheostomy and gastrostomy placement results in shorter length of stay in traumatic brain injury patients. Am J Surg 2024; 227:153-156. [PMID: 37852846 DOI: 10.1016/j.amjsurg.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/31/2023] [Accepted: 10/02/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines recommend gastrostomy for patients suspected to require enteral access device for 4-6 weeks. Our hypothesis was that traumatic brain injury (TBI) patients undergoing synchronous tracheostomy/gastrostomy (SYNC) compared to tracheostomy first (DELAY) have shorter length of stay (LOS) but higher rates of unnecessary gastrostomy. METHODS Retrospective review of TBI patients requiring tracheostomy in 2017-2022 at a Level 1 trauma center was conducted. SYNC and DELAY patients were compared, and CoxPH analysis was performed for LOS. RESULTS 394 patients were included [mean age: 42 (SD:18); mortality: 9 %]. The DELAY group had longer LOS (39 vs 32 days, p < 0.001). There was no significant difference in unnecessary gastrostomy rate between groups (p = 0.1331). In adjusted hazard analysis, SYNC predicted shorter LOS (HR:1.54; 95 % CI:1.20-1.98, p < 0.001). CONCLUSIONS Synchronous gastrostomy was associated with shorter length of stay and similar rates of unnecessary gastrostomy in TBI patients.
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Affiliation(s)
- Gabrielle Hochu
- College of Medicine, University of Tennessee Health Science Center, 910 Madison Ave, Memphis, TN, 38103, USA.
| | - Sara Soule
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Memphis, TN, 38103, USA
| | - Emily Lenart
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Memphis, TN, 38103, USA
| | - Isaac W Howley
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Memphis, TN, 38103, USA
| | - Dina Filiberto
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Memphis, TN, 38103, USA
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Memphis, TN, 38103, USA
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Fabricius J, Pedersen AR. Subacute prognosis of oral nutrition (SPOON): Development of a multivariable prognostic model for complete oral intake in tube-fed subjects with acquired brain injury. Clin Nutr 2023; 42:1770-1777. [PMID: 37572580 DOI: 10.1016/j.clnu.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/16/2023] [Accepted: 07/10/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND & AIMS Enteral feeding is very common following an acquired brain injury. However, no prognostic models for oral food intake have been developed for subacute rehabilitation. The aim of this study was to develop a prognostic model and online tool, coined "subacute prognosis of oral nutrition" (SPOON), for complete oral intake in tube-fed subjects with acquired brain injury. METHODS The model was developed using routinely gathered clinical data from a cohort of 1233 adult patients who were tube-fed at admission for sub-acute inpatient rehabilitation. Candidate predictors were included based on scientific evidence and their availability in the medical records within the first days following admission. The outcome was time until achieving complete oral food intake without any tube-feeding supplements. Time until complete oral intake was analyzed by discrete time-to-event analysis with logit-link and presented as daily odds ratios (OR) with 95% confidence intervals (CI). RESULTS The following predictors of complete oral intake were included in the model: age, diagnosis, cuffed tracheostomy tube, days from injury to admission for rehabilitation, and the Early Functional Abilities (EFA) sum score. Multiple adjusted analyses were performed stratified by cuffed tracheostomy tube status. Some of the strongest predictors of complete oral intake were age 18-40 years, OR 1.99 (95%CI: 1.53; 2.59); 0-2 weeks since injury, OR 3.75 (95%CI: 2.72; 5.16); and EFA 61-100 (slight/no disturbance in function), OR 5.81 (95%CI: 4.47; 7.55). The online prognostic tool SPOON was evaluated in a usability study. Based on feedback from clinicians, the tool was further refined to enable extraction of data for prediction directly from medical records. CONCLUSIONS The objective of SPOON is to complement the planning of rehabilitation initiatives and inform discussions to determine if a percutaneous endoscopic gastrostomy (PEG) tube should be inserted. SPOON is being implemented locally, but external validation based on appropriate data modeling is warranted before further clinical implementation.
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Affiliation(s)
- Jesper Fabricius
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Voldbyvej 15, 8450, Hammel, Denmark.
| | - Asger Roer Pedersen
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Voldbyvej 15, 8450, Hammel, Denmark; University Research Clinic for Innovative Patient Pathways, Diagnostic Centre, Silkeborg, Denmark
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Wang L, Qiao J, Sun F, Wei X, Dou Z. Demographic and clinical factors associated with recovery of poststroke dysphagia: A meta-analysis. Brain Behav 2023; 13:e3033. [PMID: 37190927 PMCID: PMC10275539 DOI: 10.1002/brb3.3033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/23/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Poststroke dysphagia (PSD) recovery depends on various factors. We aimed to provide evidence concerning predictive variables for the recovery of PSD. METHODS PubMed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang Database, VIP database of Chinese periodicals, Chinese biomedical literature service system (SinoMed), and Cochrane Library databases were systematically searched up to September 21, 2022. According to the inclusion criteria, the literature searched in the database was screened. The methodological quality of included studies was assessed using the Newcastle-Ottawa Scale (NOS). Meta-analysis was performed to identify the factors prognostic for PSD. RESULTS Twenty-eight studies were eligible, and pooled analyses were allowed for 12 potential prognostic factors. We identified older age, higher National Institutes of Health Stroke Scale (NIHSS) score, lower activities of daily living (ADL) score, lower body mass index (BMI), severe dysphagia on admission, aspiration, brainstem stroke, severe cognitive impairment, and bilateral hemispheric stroke were negative factors for the recovery of PSD, while early intervention and Modified Rankin Scale (mRS) = 0 before onset were protective factors for the recovery of PSD. There was no significant association between stroke type and prognosis of PSD. CONCLUSION Prognostic factors of PSD summarized in this meta-analysis could be useful for developing reasonable treatment plan to better promote recovery of swallowing function after stroke.
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Affiliation(s)
- Lian Wang
- Department of Rehabilitation MedicineThe Third Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Jia Qiao
- Department of Rehabilitation MedicineThe Third Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Fang Sun
- Clinical Medical of Acupuncture Moxibustion and RehabilitationGuangzhou University of Chinese MedicineGuangzhouChina
| | - Xiaomei Wei
- Department of Rehabilitation MedicineThe Third Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Zulin Dou
- Department of Rehabilitation MedicineThe Third Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
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Hu X, Pu M, Wang Z, Yu J, Wu X, Cheng J, Chen C, Yin H, Yang T, Zhang Z, Zhao L, Xie P, Li Q. Clinical and imaging predictors of dysphagia and swallowing ability recovery in acute ischemic stroke. Neurol Sci 2023; 44:621-629. [PMID: 36301361 DOI: 10.1007/s10072-022-06470-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/20/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Dysphagia is one of the most common complications of acute ischemic stroke, and prediction of dysphagia is crucial for post-stroke treatment. We aimed to identify predictors of dysphagia and swallowing function recovery following ischemic stroke and to investigate dysphagia-associated lesion location. METHODS We prospectively enrolled patients with acute ischemic stroke confirmed on diffusion-weighted imaging. All patients received swallowing evaluation within 48 h after admission. Follow-up oral intake ability was measured on 7 and 30 days after stroke onset. Voxel-based lesion-symptom mapping was performed to determine locations associated with dysphagia. RESULTS Of 126 patients included in the final analysis, 23 patients (18.3%) were classified as initial dysphagia. The presence of facial palsy (P = 0.008) and larger white matter hyperintensity (WMH) volume (P = 0.003) was associated with initial dysphagia. Initial risk of aspiration assessed by Any2 score (P = 0.001) at baseline was identified as independent predictor for dysphagia at day 7. Patients with higher Any2 score (P < 0.001), aphasia (P = 0.013), and larger WMH volume (P = 0.010) were less likely to have a full swallowing function recovery at 1 month. Acute infarcts in right corona radiata and right superior longitudinal fasciculus were correlated with impaired recovery of swallowing ability at 1 month. CONCLUSIONS Initial risk of aspiration was identified as risk factor for short-term and long-term dysphagia. Aphasia and larger WMH volume were revealed to be significant predictors for swallowing function recovery at 1 month. Right corona radiata was identified as an essential brain area for dysphagia.
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Affiliation(s)
- Xiao Hu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Mingjun Pu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Zijie Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Jialun Yu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xiaofang Wu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Jing Cheng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Chu Chen
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Hao Yin
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Tiannan Yang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Zhehao Zhang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Libo Zhao
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Peng Xie
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- NHC Key Laboratory of Diagnosis and Treatment On Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
- NHC Key Laboratory of Diagnosis and Treatment On Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230000, China.
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Muscari A, Falcone R, Pirazzoli E, Faccioli L, Muscari S, Pastore Trossello M, Puddu GM, Rignanese L, Spinardi L, Zoli M. Predicting Failure to Recover Swallowing in Patients with Severe Post-stroke Dysphagia: The DIsPHAGIc Score. Dysphagia 2023; 38:290-304. [PMID: 35676540 DOI: 10.1007/s00455-022-10467-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 05/16/2022] [Indexed: 01/27/2023]
Abstract
In post-stroke dysphagia, early identification of patients at highest risk of failing swallowing recovery (SR) would be useful to decide which of them should undergo percutaneous endoscopic gastrostomy. The studies on this subject were numerous but generally based on small statistical samples. In this retrospective study, 1232 patients with ischemic or hemorrhagic stroke (73.7 ± 13.0 years, 51% men) were assessed: 593 non-dysphagic, 351 partially dysphagic and 288 totally dysphagic. Among the latter, 45.1% could not recover oral intake. A score to assess the risk of failing SR was obtained from the group with total dysphagia, and further 210 patients with total post-stroke dysphagia were utilized for validation. A regular progression of stroke severity markers, complications and mortality was observed from non-dysphagic, to partially dysphagic, up to totally dysphagic patients. Among the latter, seven variables were independently associated with failure of SR, and formed the "DIsPHAGIc score": cerebral lesion Diameter ≥ 6 cm (+ 1), left frontal Ischemia (- 1), Partial anterior circulation syndrome (- 1), Hypoxia (+ 1), Antiplatelet drug (+ 1), GCS verbal reaction < 4 (+ 1), Internal capsule ischemia (- 1). The area under the ROC curve was 0.79 (95% CI 0.74-0.85). For total scores ≥ 2 there was a high risk of failing SR, with specificity 76.9%, sensitivity 72.1% and accuracy 74.7%. The application of the DIsPHAGIc score to the validation sample provided almost identical results. The evolution of post-stroke dysphagia towards irreversibility can be predicted by a simple, reproducible and robust scoring system based on 7 variables commonly available during hospitalization.
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Affiliation(s)
- Antonio Muscari
- Stroke Unit-Medical Department of Continuity of Care and Disability, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138, Bologna, Italy.
| | - Roberta Falcone
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138, Bologna, Italy
| | - Enrico Pirazzoli
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138, Bologna, Italy
| | - Luca Faccioli
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Silvia Muscari
- Department of Rehabilitation, ASST Pini-CTO Hospital, Milan, Italy
| | - Marco Pastore Trossello
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giovanni M Puddu
- Stroke Unit-Medical Department of Continuity of Care and Disability, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Loredana Rignanese
- Stroke Unit-Medical Department of Continuity of Care and Disability, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Physical Medicine and Rehabilitation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Spinardi
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Zoli
- Stroke Unit-Medical Department of Continuity of Care and Disability, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138, Bologna, Italy
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Basagni B, Marignani S, Pancani S, Mannini A, Hakiki B, Grippo A, Macchi C, Cecchi F. Cognitive Profile in Patients Admitted to Intensive Rehabilitation after Stroke Is Associated with the Recovery of Dysphagia: Preliminary Results from the RIPS (Intensive Post-Stroke Rehabilitation) Study. Semin Speech Lang 2023; 44:15-25. [PMID: 36649702 DOI: 10.1055/s-0042-1759612] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Dysphagia represents one of the most frequent symptoms in the post-acute stroke population. Swallowing impairment and cognitive deficits can often co-occur. This study aims to investigate the relationship between cognitive impairment and the recovery of dysphagia in patients attending specific rehabilitation. Patients admitted to intensive rehabilitation units were administered the Functional Oral Intake Scale (FOIS) and Montreal Cognitive Screening Test (MoCA); when screening positive for dysphagia, they entered a rehabilitation program. Their FOIS score at discharge was the primary outcome measure. In the multivariate analysis, younger age (B = - 0.077, p = 0.017), higher MoCA (B = 0.191, p = 0.002), and higher FOIS (B = 1.251, p = 0.032) at admission were associated with higher FOIS at discharge. When executive function (EF) replaced the MoCA total score in the model, younger age (B = - 0.134, p = 0.001), higher admission EF (B = 1.451, p < 0.001), and FOIS (B = 1.348, p = 0.035) were associated with higher FOIS at discharge. Our results confirm the hypothesis that a better cognitive profile upon admission is associated with a higher probability of dysphagia recovery at discharge. EF seems to have a crucial role in dysphagia recovery. These results highlight the importance of considering the cognitive profile when assessing and treating dysphagia after stroke and of using screening tests that include executive functions.
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Affiliation(s)
| | | | | | | | - Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | | | | | - Francesca Cecchi
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Joundi RA, Saposnik G, Martino R, Fang J, Kapral MK. Development and Validation of a Prognostic Tool for Direct Enteral Tube Insertion After Acute Stroke. Stroke 2020; 51:1720-1726. [PMID: 32397928 DOI: 10.1161/strokeaha.120.028949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- We aimed to create a novel prognostic risk score to estimate outcomes after direct enteral tube placement in acute stroke. Methods- We used the Ontario Stroke Registry and linked databases to obtain clinical information on all patients with direct enteral tube insertion after ischemic stroke or intracerebral hemorrhage from July 1, 2003 to June 30, 2010 (derivation cohort) and July 1, 2010 to March 31, 2013 (validation cohort). We used multivariable regression to assign scores to predictor variables for 3 outcomes after tube placement: favorable outcome (discharge modified Rankin Scale score 0-3 and alive at 90 days), poor outcome (discharge modified Rankin Scale score 5 or death at 90 days), and 30-day mortality. Results- Variables associated with a favorable outcome were younger age, preadmission independence, ischemic stroke rather than intracerebral hemorrhage, lower stroke severity, and a shorter time between stroke and tube placement. Variables associated with a poor outcome were older age, preadmission dependence, atrial fibrillation, greater stroke severity, and tracheostomy. Age, preadmission dependence, atrial fibrillation, cancer, chronic obstructive pulmonary disease, and shorter time to tube placement were associated with increased 30-day mortality. Using these variables, we created an online calculator to facilitate estimation of individual patient risk of favorable and poor outcomes. C-statistic in the validation cohort was 0.82 for favorable outcome, 0.65 for poor outcome, and 0.62 for 30-day mortality, and calibration was adequate. Conclusions- We developed risk scores to estimate outcomes after direct enteral tube insertion for acute dysphagic stroke. This information may be useful in discussions with patients and families when there is prognostic uncertainty surrounding outcomes with direct enteral tube placement after stroke.
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Affiliation(s)
- Raed A Joundi
- From the Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary (R.A.J.).,ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.)
| | - Gustavo Saposnik
- ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.).,Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), University of Toronto, Canada.,Institute of Health Policy, Management and Evaluation (G.S.), University of Toronto, Canada
| | - Rosemary Martino
- Department of Speech-Language Pathology (R.M.), University of Toronto, Canada.,Graduate Department of Rehabilitation Science (R.M.), University of Toronto, Canada.,Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Canada (R.M.)
| | - Jiming Fang
- ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.)
| | - Moira K Kapral
- ICES, Toronto, Canada (R.A.J., G.S., J.F., M.K.K.).,Division of General Internal Medicine, Department of Medicine (M.K.), University of Toronto, Canada.,Institute of Health Policy, Management, and Evaluation (M.K.), University of Toronto, Canada
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10
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Galovic M, Stauber AJ, Leisi N, Krammer W, Brugger F, Vehoff J, Balcerak P, Müller A, Müller M, Rosenfeld J, Polymeris A, Thilemann S, De Marchis GM, Niemann T, Leifke M, Lyrer P, Saladin P, Kahles T, Nedeltchev K, Sarikaya H, Jung S, Fischer U, Manno C, Cereda CW, Sander JW, Tettenborn B, Weder BJ, Stoeckli SJ, Arnold M, Kägi G. Development and Validation of a Prognostic Model of Swallowing Recovery and Enteral Tube Feeding After Ischemic Stroke. JAMA Neurol 2020; 76:561-570. [PMID: 30742198 DOI: 10.1001/jamaneurol.2018.4858] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Predicting the duration of poststroke dysphagia is important to guide therapeutic decisions. Guidelines recommend nasogastric tube (NGT) feeding if swallowing impairment persists for 7 days or longer and percutaneous endoscopic gastrostomy (PEG) placement if dysphagia does not recover within 30 days, but, to our knowledge, a systematic prediction method does not exist. Objective To develop and validate a prognostic model predicting swallowing recovery and the need for enteral tube feeding. Design, Setting, and Participants We enrolled participants with consecutive admissions for acute ischemic stroke and initially severe dysphagia in a prospective single-center derivation (2011-2014) and a multicenter validation (July 2015-March 2018) cohort study in 5 tertiary stroke referral centers in Switzerland. Exposures Severely impaired oral intake at admission (Functional Oral Intake Scale score <5). Main Outcomes and Measures Recovery of oral intake (primary end point, Functional Oral Intake Scale ≥5) or return to prestroke diet (secondary end point) measured 7 (indication for NGT feeding) and 30 (indication for PEG feeding) days after stroke. Results In total, 279 participants (131 women [47.0%]; median age, 77 years [interquartile range, 67-84 years]) were enrolled (153 [54.8%] in the derivation study; 126 [45.2%] in the validation cohort). Overall, 64% (95% CI, 59-71) participants failed to recover functional oral intake within 7 days and 30% (95% CI, 24-37) within 30 days. Prolonged swallowing recovery was independently associated with poor outcomes after stroke. The final prognostic model, the Predictive Swallowing Score, included 5 variables: age, stroke severity on admission, lesion location, initial risk of aspiration, and initial impairment of oral intake. Predictive Swallowing Score prediction estimates ranged from 5% (score, 0) to 96% (score, 10) for a persistent impairment of oral intake on day 7 and from 2% to 62% on day 30. Model performance in the validation cohort showed a discrimination (C statistic) of 0.84 (95% CI, 0.76-0.91; P < .001) for predicting the recovery of oral intake on day 7 and 0.77 (95% CI, 0.67-0.87; P < .001) on day 30, and a discrimination for a return to prestroke diet of 0.94 (day 7; 95% CI, 0.87-1.00; P < .001) and 0.71 (day 30; 95% CI, 0.61-0.82; P < .001). Calibration plots showed high agreement between the predicted and observed outcomes. Conclusions and Relevance The Predictive Swallowing Score, available as a smartphone application, is an easily applied prognostic instrument that reliably predicts swallowing recovery. It will support decision making for NGT or PEG insertion after ischemic stroke and is a step toward personalized medicine.
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Affiliation(s)
- Marian Galovic
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland.,National Institute for Health Research University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, England.,Magnetic Resonance Imaging Unit, Chalfont Centre for Epilepsy, Chalfont St Peter, England
| | - Anne Julia Stauber
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Natascha Leisi
- Department of Otorhinolaryngology, Head and Neck Surgery, Kantonsspital St. Gallen, St Gallen, Switzerland
| | - Werner Krammer
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Florian Brugger
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Jochen Vehoff
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Philipp Balcerak
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Anna Müller
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Marlise Müller
- Department of Otorhinolaryngology, Head and Neck Surgery, Kantonsspital St. Gallen, St Gallen, Switzerland
| | - Jochen Rosenfeld
- Department of Otorhinolaryngology, Head and Neck Surgery, Kantonsspital St. Gallen, St Gallen, Switzerland
| | - Alexandros Polymeris
- Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sebastian Thilemann
- Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Thorsten Niemann
- Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Maren Leifke
- Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Philippe Lyrer
- Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Petra Saladin
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | - Timo Kahles
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland.,Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Hakan Sarikaya
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Concetta Manno
- Stroke Center, Department of Neurology, Neurocenter of Southern Switzerland, Ospedale Civico, Lugano, Switzerland
| | - Carlo W Cereda
- Stroke Center, Department of Neurology, Neurocenter of Southern Switzerland, Ospedale Civico, Lugano, Switzerland
| | - Josemir W Sander
- National Institute for Health Research University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, England.,Magnetic Resonance Imaging Unit, Chalfont Centre for Epilepsy, Chalfont St Peter, England.,Stichting Epilepsie Instellingen Nederland, Heemstede, Netherlands
| | - Barbara Tettenborn
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Bruno J Weder
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland.,Support Centre for Advanced Neuroimaging, Institute of Diagnostic and Interventional Neuroradiology, University Hospital Inselspital, University of Bern, Bern, Switzerland
| | - Sandro J Stoeckli
- Department of Otorhinolaryngology, Head and Neck Surgery, Kantonsspital St. Gallen, St Gallen, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Georg Kägi
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
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11
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Lee WH, Lim MH, Seo HG, Seong MY, Oh BM, Kim S. Development of a Novel Prognostic Model to Predict 6-Month Swallowing Recovery After Ischemic Stroke. Stroke 2019; 51:440-448. [PMID: 31884906 DOI: 10.1161/strokeaha.119.027439] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- The aim of this study was to explore clinical and radiological prognostic factors for long-term swallowing recovery in patients with poststroke dysphagia and to develop and validate a prognostic model using a machine learning algorithm. Methods- Consecutive patients (N=137) with acute ischemic stroke referred for swallowing examinations were retrospectively reviewed. Dysphagia was monitored in the 6 months poststroke period and then analyzed using the Kaplan-Meier method and Cox regression model for clinical and radiological factors. Bayesian network models were developed using potential prognostic factors to classify patients into those with good (no need for tube feeding or diet modification for 6 months) and poor (tube feeding or diet modification for 6 months) recovery of swallowing function. Results- Twenty-four (17.5%) patients showed persistent dysphagia for the first 6 months with a mean duration of 65.6 days. The time duration of poststroke dysphagia significantly differed by tube feeding status, clinical dysphagia scale, sex, severe white matter hyperintensities, and bilateral lesions at the corona radiata, basal ganglia, or internal capsule (CR/BG/IC). Among these factors, tube feeding status (P<0.001), bilateral lesions at CR/BG/IC (P=0.001), and clinical dysphagia scale (P=0.042) were significant prognostic factors in a multivariate analysis using Cox regression models. The tree-augmented network classifier, based on 10 factors (sex, lesions at CR, BG/IC, and insula, laterality, anterolateral territory of the brain stem, bilateral lesions at CR/BG/IC, severe white matter hyperintensities, clinical dysphagia scale, and tube feeding status), performed better than other benchmarking classifiers developed in this study. Conclusions- Initial dysphagia severity and bilateral lesions at CR/BG/IC are revealed to be significant prognostic factors for 6-month swallowing recovery. The prediction of 6-month swallowing recovery was feasible based on clinical and radiological factors using the Bayesian network model. We emphasize the importance of bilateral subcortical lesions as prognostic factors that can be utilized to develop prediction models for long-term swallowing recovery.
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Affiliation(s)
- Woo Hyung Lee
- From the Department of Biomedical Engineering, Seoul National University College of Medicine, Republic of Korea (W.H.L., M.H.L., S.K.)
| | - Min Hyuk Lim
- From the Department of Biomedical Engineering, Seoul National University College of Medicine, Republic of Korea (W.H.L., M.H.L., S.K.)
| | - Han Gil Seo
- Department of Rehabilitation Medicine, Seoul National University Hospital, Republic of Korea (H.G.S., M.Y.S., B.-M.O.)
| | - Min Yong Seong
- Department of Rehabilitation Medicine, Seoul National University Hospital, Republic of Korea (H.G.S., M.Y.S., B.-M.O.)
| | - Byung-Mo Oh
- Department of Rehabilitation Medicine, Seoul National University Hospital, Republic of Korea (H.G.S., M.Y.S., B.-M.O.)
| | - Sungwan Kim
- From the Department of Biomedical Engineering, Seoul National University College of Medicine, Republic of Korea (W.H.L., M.H.L., S.K.).,Institute of Bioengineering, Seoul National University, Republic of Korea (S.K.)
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12
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Affiliation(s)
- Cathy M Stinear
- From the Department of Medicine (C.M.S., M.-C.S.), University of Auckland, New Zealand.,Centre for Brain Research (C.M.S., M.-C.S., W.D.B.), University of Auckland, New Zealand
| | - Marie-Claire Smith
- From the Department of Medicine (C.M.S., M.-C.S.), University of Auckland, New Zealand.,Centre for Brain Research (C.M.S., M.-C.S., W.D.B.), University of Auckland, New Zealand
| | - Winston D Byblow
- Centre for Brain Research (C.M.S., M.-C.S., W.D.B.), University of Auckland, New Zealand.,Department of Exercise Sciences (W.D.B.), University of Auckland, New Zealand
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13
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Unsedated Outpatient Percutaneous Endoscopic Gastrostomy in Stroke Patients: Is It Feasible and Safe? Surg Laparosc Endosc Percutan Tech 2019; 29:383-388. [PMID: 31033632 DOI: 10.1097/sle.0000000000000661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Percutaneous endoscopic gastrostomy (PEG) is an established practice for long-term nutrition in dysphagia-suffering stroke patients. This study sought to determine the feasibility and safety of outpatient, unsedated PEG implementation in stroke patients. This retrospective cohort study involved stroke victims who underwent unsedated outpatient PEG insertion from 2014 to 2017 at our Surgical Endoscopy Unit. Patients were given pharyngeal anesthesia with lidocaine 10% spray, while the PEG tube was placed under local anesthesia. The incidence of intraprocedural and postprocedural complications and 30-day mortality rate were recorded. Data from 127 cases were analyzed. The procedures were performed with minor, transient complications, which resolved after rescue maneuvers. No intraprocedural and postprocedural major complications or death were observed. During the 30-day follow-up, the most important complication involved a single case of accidental PEG removal that was successfully resolved surgically. Unsedated PEG insertion appears to be a feasible, well-tolerated, and safe option for stroke-related dysphagia.
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14
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Abstract
Stroke remains the second leading cause of death in the world, and its prevalence is projected to rise in the United States and globally. The main driver for increased stroke prevalence is aging of the population; however, best evidenced-based strategies for stroke treatment and prevention are not always followed for older patients. Furthermore, considerable gaps in knowledge exist for stroke prevention and treatment in elderly and very elderly patients. In this chapter, we discuss various aspects of stroke care in the elderly, including the evidence that guides stroke prevention and treatment. We focus on the challenges in managing stroke in the very elderly including the paucity of data to guide management. The sections span the continuum of stroke care, from primary prevention to management of stroke complications. Finally, we highlight the most significant unanswered questions regarding stroke care in the elderly.
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Affiliation(s)
- Anjail Sharrief
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center, Houston, TX, United States
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX, United States.
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15
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Predictors of Direct Enteral Tube Placement After Acute Stroke. J Stroke Cerebrovasc Dis 2019; 28:191-197. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 09/10/2018] [Accepted: 09/19/2018] [Indexed: 01/22/2023] Open
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16
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Garg R, Prabhakaran S, Holl JL, Luo Y, Faigle R, Kording K, Naidech AM. Improving the Accuracy of Scores to Predict Gastrostomy after Intracerebral Hemorrhage with Machine Learning. J Stroke Cerebrovasc Dis 2018; 27:3570-3574. [PMID: 30201458 PMCID: PMC6252136 DOI: 10.1016/j.jstrokecerebrovasdis.2018.08.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/05/2018] [Accepted: 08/10/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Gastrostomy placement after intracerebral hemorrhage indicates the need for continued medical care and predicts patient dependence. Our objective was to determine the optimal machine learning technique to predict gastrostomy. METHODS We included 531 patients in a derivation cohort and 189 patients from another institution for testing. We derived and tested predictions of the likelihood of gastrostomy placement with logistic regression using the GRAVo score (composed of Glasgow Coma Scale ≤12, age >50 years, black race, and hematoma volume >30 mL), compared to other machine learning techniques (kth nearest neighbor, support vector machines, random forests, extreme gradient boosting, gradient boosting machine, stacking). Receiver Operating Curves (Area Under the Curve, [AUC]) between logistic regression (the technique used in GRAVo score development) and other machine learning techniques were compared. Another institution provided an external test data set. RESULTS In the external test data set, logistic regression using the GRAVo score components predicted gastrostomy (P < 0.001), however, with a lower AUC (0.66) than kth nearest neighbors (AUC 0.73), random forests (AUC 0.74), Gradient boosting machine (AUC 0.77), extreme gradient boosting (AUC 0.77), (P < 0.01 for all compared to logistic regression). Results from the internal test set were similar. CONCLUSIONS Machine learning techniques other than logistic regression (eg, random forests, extreme gradient boost, and kth nearest neighbors) were significantly more accurate for predicting gastrostomy using the same independent variables. Machine learning techniques may assist clinicians in identifying patients likely to need interventions.
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Affiliation(s)
- Ravi Garg
- Center for Healthcare Studies, Northwestern University, Chicago, Illinois
| | - Shyam Prabhakaran
- Center for Healthcare Studies, Northwestern University, Chicago, Illinois
| | - Jane L Holl
- Center for Healthcare Studies, Northwestern University, Chicago, Illinois
| | - Yuan Luo
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Roland Faigle
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Konrad Kording
- Department of Neuroscience, University of Pennsylvania, Pennsylvania
| | - Andrew M Naidech
- Center for Healthcare Studies, Northwestern University, Chicago, Illinois.
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17
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Brown K, Cai C, Barreto A, Shoemaker P, Woellner J, Vu K, Xavier A, Saeed U, Watkins J, Savitz S, Sharrief A. Predictors of Percutaneous Endoscopic Gastrostomy Placement in Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2018; 27:3200-3207. [PMID: 30172678 DOI: 10.1016/j.jstrokecerebrovasdis.2018.07.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 07/05/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Dysphagia is a common complication of stroke and can have a lasting impact on morbidity and mortality; yet there are no standards to guide dysphagia management in stroke patients. We assessed predictors of percutaneous endoscopic gastrostomy (PEG) placement in an ischemic stroke cohort and sought to determine the utility of an objective scale in predicting PEG placement in a high-risk sub-set. METHODS Consecutive cases of ischemic stroke were retrospectively, identified and demographic and clinical variables were collected. Penetration-Aspiration (PAS) scores (1-2 normal; 3-5 penetration; 6-8 aspiration) were calculated for patients undergoing Fiberoptic Endoscopic Evaluation of Swallowing (FEES) or Modified Barium Swallowing Studies (MBSS). Multiple logistic regression analysis was used to assess predictors of PEG placement. RESULTS Among 724 patients, 131 underwent PEG placement. In univariate analysis of the overall cohort, sex, age, insured payer status, arrival National Institute of Health Stroke Scale (NIHSS), NIHSS level of consciousness severity, NIHSS dysarthria severity, diabetes mellitus, and prior International Conference for Harmonization (ICH) were all significantly associated with PEG placement. Among 197 high-risk patients undergoing FEES or MBSS, the multivariate logistic regression analysis showed that PAS scores 6-8 versus 1-2 (odds ratio [OR] 13.2; 95% confidence interval [CI] 4.58, 38.2), PAS score 3-5 versus 1.2 (OR 33.8; 95% CI 11.6, 98.3), Hispanic race (OR, 5.73; 95% CI 1.82, 18.0), male sex (OR, 2.59; 95% CI 1.05, 6.34), and arrival NIHSS (OR, 1.11; 95% CI 1.05, 1.18) were associated with PEG placement. CONCLUSIONS Use of an objective dysphagia scale simplified the prediction model among acute ischemic stroke patients undergoing instrumental assessments of dysphagia with FEES or MBSS. Male sex and Hispanic race were also significantly associated with PEG placement in this analysis. These findings support the need for rigorously designed prospective studies to assess biological and social factors that influence PEG placement and to determine, how to best evaluate and manage patients with dysphagia.
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Affiliation(s)
- Kristin Brown
- Department of Neurology, McGovern Medical School, Houston, Texas.
| | - Chunyan Cai
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Andrew Barreto
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Paige Shoemaker
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Jade Woellner
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Kim Vu
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Andreaa Xavier
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Umair Saeed
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Jeffrey Watkins
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Sean Savitz
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Anjail Sharrief
- Department of Neurology, McGovern Medical School, Houston, Texas
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18
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Faigle R, Cooper LA, Gottesman RF. Race Differences in Gastrostomy Tube Placement After Stroke in Majority-White, Minority-Serving, and Racially Integrated US Hospitals. Dysphagia 2018; 33:636-644. [PMID: 29468269 DOI: 10.1007/s00455-018-9882-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 02/15/2018] [Indexed: 02/02/2023]
Abstract
We sought to determine individual and system contributions to race disparities in percutaneous endoscopic gastrostomy (PEG) tube placement after stroke. Ischemic stroke admissions were identified from the Nationwide Inpatient Sample between 2007 and 2011. Hospitals were categorized based on the percentage of ethnic/racial minority stroke patients (< 25% ethnic/racial minorities ["majority-white hospitals"], 25-50% ethnic/racial minorities ["racially integrated hospitals"], or > 50% ethnic/racial minorities ["minority-serving hospitals"]). Logistic regression was used to evaluate the association between ethnicity/race and PEG utilization within and between the different hospital strata. Among 246,825 stroke admissions, patients receiving care in minority-serving hospitals had higher odds of PEG compared to patients in majority-white hospitals, regardless of individual patient race (adjusted odds ratio [OR] 1.24, 95% CI 1.12-1.38). Ethnic/racial minorities had higher odds of PEG than whites in any hospital strata; however, this discrepancy was largest in majority-white hospitals (OR 1.62, 95% CI 1.48-1.76), and smallest in minority-serving hospitals (OR 1.22, 95% CI 1.11-1.33; p for interaction < 0.001). Ethnic/racial minority patients had similar odds of PEG in any hospital strata, while white patients had increasing odds of PEG in racially integrated and minority-serving compared to majority-white hospitals (OR 1.28, 95% CI 1.15-1.43 in racially integrated, and OR 1.39, 95% CI 1.23-1.57 in minority-serving, compared to majority-white hospitals, p for trend < 0.001). The likelihood of PEG after ischemic stroke was increased in minority-serving compared to majority-white hospitals. White patients had higher odds of PEG in minority-serving compared to majority-white hospitals, indicating a systemic difference in PEG placement across hospitals.
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Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA.
| | - Lisa A Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, 2024 East Monument Street, Baltimore, MD, 21287, USA
| | - Rebecca F Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA
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19
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Wilmskoetter J, Simpson AN, Logan SL, Simpson KN, Bonilha HS. Impact of Gastrostomy Feeding Tube Placement on the 1-Year Trajectory of Care in Patients After Stroke. Nutr Clin Pract 2018; 33:553-566. [DOI: 10.1002/ncp.10015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/25/2017] [Indexed: 02/06/2023] Open
Affiliation(s)
- Janina Wilmskoetter
- Department of Health Sciences and Research; College of Health Professions; Medical University of South Carolina; Charleston South Carolina USA
| | - Annie N. Simpson
- Department of Healthcare Leadership and Management; College of Health Professions; Medical University of South Carolina; Charleston South Carolina USA
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina USA
| | - Sarah L. Logan
- Department of Neurosciences; College of Medicine; Medical University of South Carolina; Charleston South Carolina USA
| | - Kit N. Simpson
- Department of Healthcare Leadership and Management; College of Health Professions; Medical University of South Carolina; Charleston South Carolina USA
| | - Heather S. Bonilha
- Department of Health Sciences and Research; College of Health Professions; Medical University of South Carolina; Charleston South Carolina USA
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina USA
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20
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Hwang DY, George BP, Kelly AG, Schneider EB, Sheth KN, Holloway RG. Variability in Gastrostomy Tube Placement for Intracerebral Hemorrhage Patients at US Hospitals. J Stroke Cerebrovasc Dis 2017; 27:978-987. [PMID: 29221969 DOI: 10.1016/j.jstrokecerebrovasdis.2017.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 10/11/2017] [Accepted: 11/01/2017] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE We sought to characterize the variability among US hospitals with regard to gastrostomy tube placement for inpatients with intracerebral hemorrhage (ICH). METHODS Using the Nationwide Inpatient Sample, we examined variations in the annual rate of gastrostomy tube placement from 2002 to 2011 for ICH patients admitted to hospitals with 30 or more annual ICH admissions. We then directly compared, among these hospitals, their individual frequencies of gastrostomy tube placement for ICH patients over the same time period. To quantify variability among hospitals, we used multilevel multivariable regression models accounting for a hospital random effect, adjusted for patient-level and hospital-level factors predictors of placement. RESULTS Gastrostomy tube placement rates did not significantly change from 2002 to 2011 (9.8 to 8.7 per 100 admissions; P trend = .57). Among 690 hospitals with 38,080 ICH hospitalizations during this period, 10.4% of patients had a gastrostomy tube placed (n = 3976). Variation in the rate of placement among individual hospitals was large, from 0% to 34.4% (interquartile range 5.7%-13.6%). For a regression model controlling for patient and hospital covariates, the median odds ratio was 1.36 (95% confidence interval 1.28-1.44), indicating that if a patient moved from one hospital to another with a higher intrinsic propensity of placement, there was a 1.36-fold median increase in the odds of receiving a gastrostomy tube, independent of patient and hospital factors. CONCLUSIONS Variation in gastrostomy tube placement rates across hospitals is large and may in part reflect differences in local practice patterns or patient and surrogate preferences.
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Affiliation(s)
- David Y Hwang
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, Connecticut; Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, Yale University, New Haven, Connecticut.
| | - Benjamin P George
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Adam G Kelly
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Eric B Schneider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kevin N Sheth
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, Connecticut; Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Robert G Holloway
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
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21
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Nobleza COS, Pandian V, Jasti R, Wu DH, Mirski MA, Geocadin RG. Outcomes of Tracheostomy With Concomitant and Delayed Percutaneous Endoscopic Gastrostomy in the Neuroscience Critical Care Unit. J Intensive Care Med 2017; 34:835-843. [PMID: 28675111 DOI: 10.1177/0885066617718492] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND In patients with severe neurologic conditions, percutaneous endoscopic gastrostomy (PEG) is typically performed either alone or with a tracheostomy. The characteristics and outcomes of patients receiving PEG concomitantly with a tracheostomy (CTPEG) and those receiving delayed PEG (DPEG) after a tracheostomy were compared. METHODS Retrospective cohort study in a 24-bed neuroscience critical care unit (NCCU) at a tertiary care hospital. Consecutive patients admitted to the NCCU from April 2007 to July 2013 who underwent percutaneous tracheostomy and gastrostomy by the percutaneous tracheostomy team were included and grouped according to the timing of PEG placement: CTPEG versus DPEG. RESULTS Of the 290 patients, 234 (81%) received CTPEG. Demographic and clinical characteristics were similar among the 2 groups except for a lower median (interquartile range [IQR]) body mass index (BMI; 27 [22.67-31.60] versus 30.8 [24.55-40.06], P = .017) and lower rate of acute respiratory distress syndrome (3.85% vs 10.71%, P = .048) in the CTPEG cohort. Furthermore, 59% of CTPEG cohort were neurology patients while 63% of DPEG were neurosurgery patients, P = .004. Primary outcomes showed shorter mean NCCU length of stay (LOS; 25 [12] vs 33 [17] days, P < .001) and median hospital LOS (32 [25-43] vs 37 [31-56] days, P = .002) for the CTPEG cohort. Secondary outcomes showed higher predischarge prealbumin levels (15.6 [7.75] vs 11.58 [5.41], P = .021) and lower median overall hospital cost (US$123 860.20 [US$99 024-US$168 713.40] vs US$159 633.50 [US$121 312-US$240 213.10], P = .0003) in the CTPEG group. Anatomic contraindications were the most common reason for DPEG (30%). CONCLUSIONS Among institutions with a tracheostomy team, the practice of tracheostomy with concomitant PEG placement may be considered as feasible as delayed PEG in carefully selected neurocritically ill patients with possible advantages of overall shorter NCCU and hospital LOS, higher predischarge prealbumin, and lower hospital costs. These findings may aid in decisions regarding the timing of PEG placement in the NCCU. Further prospective studies are warranted.
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Affiliation(s)
| | - Vinciya Pandian
- 2 Department of Acute and Chronic Care, Johns Hopkins University School of Nursing, Baltimore, MD, USA.,3 Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ravirasmi Jasti
- 4 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David H Wu
- 5 Department of Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marek A Mirski
- 4 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,5 Department of Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Romergryko G Geocadin
- 4 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,5 Department of Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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22
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Ikenaga Y, Nakayama S, Taniguchi H, Ohori I, Komatsu N, Nishimura H, Katsuki Y. Factors Predicting Recovery of Oral Intake in Stroke Survivors with Dysphagia in a Convalescent Rehabilitation Ward. J Stroke Cerebrovasc Dis 2017; 26:1013-1019. [PMID: 28108097 DOI: 10.1016/j.jstrokecerebrovasdis.2016.12.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/03/2016] [Accepted: 12/08/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy may be performed in dysphagic stroke patients. However, some patients regain complete oral intake without gastrostomy. This study aimed to investigate the predictive factors of intake, thereby determining gastrostomy indications. METHOD Stroke survivors admitted to our convalescent rehabilitation ward who underwent gastrostomy or nasogastric tube placement from 2009 to 2015 were divided into 2 groups based on intake status at discharge. Demographic data and Functional Independence Measure (FIM), Dysphagia Severity Scale (DSS), National Institutes of Health Stroke Scale, and Glasgow Coma Scale (GCS) scores on admission were compared between groups. We evaluated the factors predicting intake using a stepwise logistic regression analysis. RESULTS Thirty-four patients recovered intake, whereas 38 achieved incomplete intake. Mean age was lower, mean body mass index (BMI) was higher, and mean time from stroke onset to admission was shorter in the complete intake group. The complete intake group had less impairment in terms of GCS, FIM, and DSS scores. In the stepwise logistic regression analysis, BMI, FIM-cognitive score, and DSS score were significant independent factors predicting intake. The formula of BMI × .26 + FIM cognitive score × .19 + DSS score × 1.60 predicted recovery of complete intake with a sensitivity of 88.2% and a specificity of 84.2%. CONCLUSIONS Stroke survivors with dysphagia with a high BMI and FIM-cognitive and DSS scores tended to recover oral intake.
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Affiliation(s)
- Yasunori Ikenaga
- Department of Rehabilitation Medicine, Yawata Medical Center, Komatsu City, Japan.
| | - Sayaka Nakayama
- Department of Rehabilitation Medicine, Yawata Medical Center, Komatsu City, Japan
| | - Hiroki Taniguchi
- Department of Rehabilitation Medicine, Yawata Medical Center, Komatsu City, Japan
| | - Isao Ohori
- Department of Rehabilitation Medicine, Yawata Medical Center, Komatsu City, Japan
| | - Nahoko Komatsu
- Department of Rehabilitation Medicine, Yawata Medical Center, Komatsu City, Japan
| | - Hitoshi Nishimura
- Department of Rehabilitation Medicine, Yawata Medical Center, Komatsu City, Japan
| | - Yasuo Katsuki
- Department of Rehabilitation Medicine, Yawata Medical Center, Komatsu City, Japan
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23
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Zhang Z, Akulian J, Hong Y, Liu N, Chen Y. How should this patient with repeated aspiration pneumonia be managed and treated?-a proposal of the Percutaneous ENdoscopIc Gastrostomy and Tracheostomy (PENlIGhT) procedure. J Thorac Dis 2016; 8:3720-3727. [PMID: 28149569 PMCID: PMC5227226 DOI: 10.21037/jtd.2016.12.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Cerebrovascular accident (CVA) is commonly seen among the elderly with a substantial proportion of patients suffering from long-term dysphagia and/or an inability to protect their airway. This potentially imposes on them an increased risk of malnutrition and aspiration pneumonia. In this article, we present a patient with malnutrition and dysphagia secondary to CVA. We propose a procedure for which we will name the Percutaneous ENdoscopIc Gastrostomy and Tracheostomy (PENlIGhT) procedure for placement of percutaneous endoscopic gastrostomy (PEG) and tracheostomy tube (TT) at the same time. The medical literature was systematically reviewed for both PEG and tracheostomy, aiming to provide the state-of-the-art evidence for clinical use of the PENlIGhT procedure. In clinical practice, the PENlIGhT procedure is indicated for patients who are expected to have prolonged swallowing disturbance and mechanical ventilation. Some prediction tools and scores can be helpful to identify such groups of patients. Patients with poor neurological outcomes who require prolonged maintenance of life are also good candidates for the PENlIGhT procedure.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Jason Akulian
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Ning Liu
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Yuhao Chen
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
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24
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Wilmskoetter J, Simpson AN, Simpson KN, Bonilha HS. Practice Patterns of Percutaneous Endoscopic Gastrostomy Tube Placement in Acute Stroke: Are the Guidelines Achievable? J Stroke Cerebrovasc Dis 2016; 25:2694-2700. [PMID: 27475521 DOI: 10.1016/j.jstrokecerebrovasdis.2016.07.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 06/09/2016] [Accepted: 07/04/2016] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Our objectives were to evaluate trends in percutaneous endoscopic gastrostomy (PEG) tube placement rate and timing in acute stroke patients. We hypothesized that noncompliance with clinical practice guidelines for timing of tube placement and an increase in placement occurred because of a decrease in length of hospital stay. METHODS We conducted a retrospective observational study of archival hospital billing data from the Florida state inpatient healthcare cost and utilization project database from 2001 to 2012 for patients with a primary diagnosis of stroke. Outcome measures were timing of PEG tube placements by year (2006-2012), rate of placements by year (2001-2012), and length of hospital stay. Univariate analyses and simple and multivariable logistic regression analyses were conducted. RESULTS The timing of gastrostomy tube placement remained stable with a median of 7 days post admission from 2006 through 2012. The proportion of tubes that were placed at or after 14 days and thereby met the guideline recommendations varied from 14.09% in 2006 to 13.41% in 2012. The rate of tube placement in stroke patients during the acute hospital stay decreased significantly by 25% from 6.94% in 2001 to 5.22% in 2012 (P < .0001). The length of hospital stay for all stroke patients decreased over the study period (P < .0001). CONCLUSIONS The vast majority of PEG tube placements happen earlier than clinical practice guidelines recommend. Over the study period, the rate of tubes placed in stroke patients decreased during the acute hospital stay despite an overall reduced length of stay.
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Affiliation(s)
- Janina Wilmskoetter
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina
| | - Annie N Simpson
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina; Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Kit N Simpson
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina
| | - Heather S Bonilha
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina; Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina.
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25
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Faigle R, Bahouth MN, Urrutia VC, Gottesman RF. Racial and Socioeconomic Disparities in Gastrostomy Tube Placement After Intracerebral Hemorrhage in the United States. Stroke 2016; 47:964-70. [PMID: 26892281 DOI: 10.1161/strokeaha.115.011712] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 01/22/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Percutaneous endoscopic gastrostomy (PEG) tubes are widely used for enteral feeding of patients after intracerebral hemorrhage (ICH). We sought to determine whether PEG placement after ICH differs by race and socioeconomic status. METHODS Patient discharges with ICH as the primary diagnosis from 2007 to 2011 were queried from the Nationwide Inpatient Sample. Logistic regression was used to evaluate the association between race, insurance status, and household income with PEG placement. RESULTS Of 49 946 included ICH admissions, a PEG was placed in 4464 (8.94%). Among PEG recipients, 47.2% were minorities and 15.6% were Medicaid enrollees, whereas 33.7% and 8.2% of patients without a PEG were of a race other than white and enrolled in Medicaid, respectively (P<0.001). Compared with whites, the odds of PEG were highest among Asians/Pacific Islanders (odds ratio [OR] 1.62, 95% confidence interval [CI] 1.32-1.99) and blacks (OR 1.42, 95% CI 1.28-1.59). Low household income (OR 1.25, 95% CI 1.09-1.44 in lowest compared with highest quartile) and enrollment in Medicaid (OR 1.36, 95% CI 1.17-1.59 compared with private insurance) were associated with PEG placement. Racial disparities (minorities versus whites) were most pronounced in small/medium-sized hospitals (OR 1.77, 95% CI 1.43-2.20 versus OR 1.31, 95% CI 1.17-1.47 in large hospitals; P value for interaction 0.011) and in hospitals with low ICH case volume (OR 1.58, 95% CI 1.38-1.81 versus OR 1.29, 95% CI 1.12-1.50 in hospitals with high ICH case volume; P value for interaction 0.007). CONCLUSIONS Minority race, Medicaid enrollment, and low household income are associated with PEG placement after ICH.
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Affiliation(s)
- Roland Faigle
- From the Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Mona N Bahouth
- From the Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Victor C Urrutia
- From the Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca F Gottesman
- From the Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
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26
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Abstract
PURPOSE OF REVIEW This review addresses current controversies regarding appropriate indications for percutaneous endoscopic gastrostomy (PEG) insertion. We address specific indications, namely, dementia, stroke, aspiration, motor neurone disease/amyotrophic lateral sclerosis, and head and neck cancer. We recommend practical strategies for improving patient selection. RECENT FINDINGS There is now a general consensus in the United States that PEG feeding does not benefit patients with advanced dementia. 'Early' PEG insertion following stroke is similarly of no benefit. It is currently unclear whether patients with amyotrophic lateral sclerosis and head and neck tumors should have PEG or radiologically inserted gastrostomy. SUMMARY Decisions relating to PEG insertion remain difficult. The gastroenterologist, working as a member of a multidisciplinary nutrition team, needs to take a lead role in this regard, rather than functioning as a technician.
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Affiliation(s)
- Carthage Moran
- aDepartment of Medicine bDepartment of Gastroenterology, Cork University Hospital, Wilton, Cork, Ireland
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27
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Udd M, Lindström O, Mustonen H, Bäck L, Halttunen J, Kylänpää L. Assessment of indications for percutaneous endoscopic gastrostomy--development of a predictive model. Scand J Gastroenterol 2015; 50:245-52. [PMID: 25540954 DOI: 10.3109/00365521.2014.927914] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Percutaneous endoscopic gastrostomy (PEG) is used for long-term enteral nutrition in neurological patients with dysphagia (NEUR), in head and neck cancer patients prior to chemoradiation therapy (head and neck malignancy group [HNM]), or in cases of oropharyngeal or esophageal tumor obstruction or stricture (OBSTR). Considerable morbidity and overall mortality is reported. Aim was to analyze the complication rates and mortality with PEG and to identify subgroups with poor outcomes. MATERIAL AND METHODS Patients underwent PEG (n = 401) in a single tertiary care center. Indications, characteristics, and causes of death were recorded. RESULTS Number of patients in groups: HNM 135 (34%), OBSTR 74 (18%), and NEUR 192 (48%); follow-up time median (interquartile range): 17 (39) months; the time PEG used for feeding: 4 (7) months. A total of 91 patients (23%) had 110 complications, 31 patients (8%) had early (≤30 days) complications, and 49 patients (12%) major complications. Two deaths (0.5%, 2 peritonitis) were related to PEG. The 30-day mortality was 11% (n = 47). According to multivariate analysis, an increased 30-day mortality was associated with ≥75 years of age, American Society of Anesthesiologists (ASA) class IV, a Charlson comorbidity index (CCI) ≥4, body mass index (BMI) <18.5, and ongoing antibiotic therapy. With this model, 95% specificity was obtained in the 30-day survival figures. CONCLUSION The presented predictive model derived from our analysis may recognize patients with poor outcome when referred for PEG. The parameters in the present model (age, ASA class, CCI score, BMI, and data of ongoing antibiotic treatment) are easily measurable, and it is possible to integrate them into everyday work.
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Affiliation(s)
- Marianne Udd
- Department of Gastroenterological and General Surgery, Unit of Therapeutic Endoscopy, Helsinki University Central Hospital and Helsinki University , Helsinki , Finland
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28
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Faigle R, Marsh EB, Llinas RH, Urrutia VC, Gottesman RF. Novel score predicting gastrostomy tube placement in intracerebral hemorrhage. Stroke 2014; 46:31-6. [PMID: 25468881 DOI: 10.1161/strokeaha.114.006891] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Dysphagia after intracerebral hemorrhage (ICH) contributes significantly to morbidity, often necessitating placement of a percutaneous endoscopic gastrostomy (PEG) tube. This study describes a novel risk prediction score for PEG placement after ICH. METHODS We retrospectively analyzed data from 234 patients with ICH presenting during a 4-year period. One hundred eighty-nine patients met inclusion criteria. The sample was randomly divided into a development and a validation cohort. Logistic regression was used to develop a risk score by weighting predictors of PEG placement based on strength of association. RESULTS Age (odds ratio [OR], 1.64 per 10-year increase in age; 95% confidence interval [CI], 1.02-2.65), black race (OR, 3.26; 95% CI, 0.96-11.05), Glasgow Coma Scale (OR, 0.80; 95% CI, 0.62-1.03), and ICH volume (OR, 1.38 per 10-mL increase in ICH volume) were independent predictors of PEG placement. The final model for score development achieved an area under the curve of 0.7911 (95% CI, 0.6931-0.8892) in the validation group. The score was named the GRAVo score: Glasgow Coma Scale ≤12 (2 points), Race (1 point for black), Age >50 years (2 points), and ICH Volume >30 mL (1 point). A score >4 was associated with ≈12× higher odds of PEG placement when compared with a score ≤4 (OR, 11.81; 95% CI, 5.04-27.66), predicting PEG placement with 46.55% sensitivity and 93.13% specificity. CONCLUSIONS The GRAVo score, combining information about Glasgow Coma Scale, race, age, and ICH volume, may be a useful predictor of PEG placement in ICH patients.
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Affiliation(s)
- Roland Faigle
- From the Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Elisabeth B Marsh
- From the Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rafael H Llinas
- From the Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Victor C Urrutia
- From the Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca F Gottesman
- From the Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
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29
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George BP, Kelly AG, Schneider EB, Holloway RG. Current practices in feeding tube placement for US acute ischemic stroke inpatients. Neurology 2014; 83:874-82. [PMID: 25098538 DOI: 10.1212/wnl.0000000000000764] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE We sought to identify current US hospital practices for feeding tube placement in ischemic stroke. METHODS In a retrospective observational study, we examined the frequency of feeding tube placement among hospitals in the Nationwide Inpatient Sample with ≥30 adult ischemic stroke admissions annually with length of stay greater than 3 days. We examined trends from 2004 to 2011 and predictors using data from more recent years (2008-2011). We used multilevel multivariable regression models accounting for a hospital random effect, adjusted for patient-level and hospital-level factors to predict feeding tube placement. RESULTS Feeding tube insertion rates did not change from 2004 to 2011 (8.1 vs 8.4 per 100 admissions; p trend = 0.11). Among 1,540 hospitals with 164,408 stroke hospitalizations from 2008 to 2011, a feeding tube was placed 8.8% of the time (n = 14,480). Variation in the rate of feeding tube placement was high, from 0% to 26% between hospitals (interquartile range 4.8%-11.2%). In the subset with available race/ethnicity data (n = 88,385), after controlling for patient demographics, socioeconomics, and comorbidities, hospital factors associated with feeding tube placement included stroke volume (odds ratio [OR] 1.28 highest vs lowest quartile; 95% confidence interval [CI] 1.10-1.49), for-profit status (OR 1.13 vs nonprofit; 95% CI 1.01-1.25), and intubation use (OR 1.66 highest vs lowest quartile; 95% CI 1.47-1.87). In addition, hospitals with higher rates of black/Hispanic stroke admissions had increased risk of feeding tube placement (OR 1.28 highest vs lowest quartile; 95% CI 1.14-1.44). CONCLUSIONS Variation in feeding tube insertion rates across hospitals is large. Differences across hospitals may be partly explained by external factors beyond the patient-centered decision to insert a feeding tube.
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Affiliation(s)
- Benjamin P George
- From the Department of Neurology (A.G.K., R.G.H.), the University of Rochester School of Medicine and Dentistry (B.P.G.), NY; and the Center for Surgical Trials and Outcomes Research, Department of Surgery (E.B.S.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Adam G Kelly
- From the Department of Neurology (A.G.K., R.G.H.), the University of Rochester School of Medicine and Dentistry (B.P.G.), NY; and the Center for Surgical Trials and Outcomes Research, Department of Surgery (E.B.S.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric B Schneider
- From the Department of Neurology (A.G.K., R.G.H.), the University of Rochester School of Medicine and Dentistry (B.P.G.), NY; and the Center for Surgical Trials and Outcomes Research, Department of Surgery (E.B.S.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert G Holloway
- From the Department of Neurology (A.G.K., R.G.H.), the University of Rochester School of Medicine and Dentistry (B.P.G.), NY; and the Center for Surgical Trials and Outcomes Research, Department of Surgery (E.B.S.), Johns Hopkins University School of Medicine, Baltimore, MD.
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