How to administer a percutaneous endoscopic gastrostomy (PEG) feed

RATIONALE AND KEY POINTS

In hospitals and nursing homes, the maintenance of feeding tubes used in enteral nutrition, such as percutaneous endoscopic gastrostomy (PEG) (the placement of a feeding tube directly into the stomach through the abdominal wall), is often a nursing responsibility. Therefore, it is vital nurses understand how to care for this patient group safely and effectively. Incorrect PEG procedures, inadequate infection prevention and control practices, and a lack of appropriate stoma care, can negatively affect patient outcomes. Nurses administering enteral feeding via PEG must have the knowledge and skills required to do so safely and must work within their level of competence. • Enteral nutrition such as PEG aims to meet the nutritional requirements of patients who have an intact gastrointestinal (GI) tract but whose oral intake is inadequate. • Management of the PEG feeding tube and care of the stoma site are vital, and nurses should be able to recognise common complications of PEG feeding. • A non-touch technique should be used when administering enteral feed via PEG to reduce the risk of bacterial contamination. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of: • How this article might improve your practice when administering enteral feed via PEG. • How you could use this information to educate nursing students or colleagues about safe enteral feeding with PEG.

Prognostic nutritional index (PNI) as an influencing factor for in-hospital mortality in patients with stroke-associated pneumonia: a retrospective study

Background

Stroke-associated pneumonia (SAP) significantly increases patients' risk of death after stroke. The identification of patients at high risk for SAP remains difficult. Nutritional assessment is valuable for risk identification in stroke patients. The aim of this study was to evaluate the relationship between prognostic nutritional index (PNI) levels and in-hospital mortality in SAP patients.

Methods

A total of 336 SAP patients who visited the Third People's Hospital of Chengdu from January 2019 to December 2023 were included in this study, and PNI were calculated based on the results of admission examinations. Linear regression was used to analyze the influencing factors of baseline PNI in SAP patients. Logistic regression as well as restricted cubic splines (RCS) were used to analyze the relationship between baseline PNI levels and hospital mortality events in SAP patients. Receiver operating characteristic (ROC) curves were plotted to assess the predictive value of PNI for in-hospital mortality by area under the curve (AUC).

Results

Thirty out of 336 SAP patients presented with in-hospital mortality and these patients had significantly lower PNI levels. In our study, PNI levels were influenced by age, body mass index, and total cholesterol. Increased PNI levels are an independent protective factor for the risk of in-hospital mortality in SAP patients (OR: 0.232, 95% CI [0.096-0.561], P = 0.001). There was a nonlinear correlation between PNI and in-hospital mortality events (P for nonlinear <0.001). In terms of predictive effect, PNI levels were more efficacious in predicting in-hospital mortality in SAP patients with higher sensitivity and/or specificity compared to individual indicators (AUC = 0.750, 95% CI [0.641-0.860], P < 0.001).

Conclusion

PNI levels in SAP patients were associated with the short-term prognosis of patients, and SAP patients with elevated PNI levels had a reduced risk of in-hospital mortality.

Percutaneous Endoscopic Gastrostomy in the 21st Century-An Overview of 1415 Consecutive Dysphagic Adult Patients

Background/Objectives: Percutaneous endoscopic gastrostomy (PEG) is recommended for long-term enteral nutrition in dysphagic patients. This study aims to characterize conditions motivating PEG, assess nutritional status on the gastrostomy day, evaluate survival and search for survival predictors. Methods: Retrospective study of adult patients who underwent PEG in a tertiary hospital from 2001 to 2023. Data collected included demographics, underlying disorders, nutritional status (anthropometry/laboratory evaluation) on the day of PEG and survival recorded until death or December 2023. Multivariable analysis was performed with Cox regression to search for survival predictors. Results: A total of 1415 patients were included (61.8% males, mean age 66.9 years); 66.4% presented a neurological disorder and 31.3% head and neck or esophageal cancers (HNC/EC). The mean BMI was 20.9 kg/m2, with 49.8% underweight. Albumin, transferrin and total cholesterol were low at 43.2%, 62.2% and 50%, respectively. Median overall survival was 11.1 months; 14.1% of deaths occurred within 4 weeks. HNC/EC patients showed lower survival than neurological patients. Potentially regressive neurological conditions presented longer survival than progressive ones. Predictors of increased survival included female gender, younger age, higher albumin and higher BMI. The protective effect of BMI and albumin was more pronounced in males than in females. Conclusions: Neurological disorders were the most frequent underlying conditions. Nearly half of the patients displayed malnutrition before PEG feeding. Although PEG-fed patients displayed a considerable median survival time, some died early without benefit from PEG. Patients with potentially regressive neurological conditions presented better outcomes. Female gender, younger age, higher albumin and higher BMI were associated with longer survival.

Oropharyngeal dysphagia impact of pneumonia risk in neurological patients receiving enteral tube feeding: Insights from a gastroenterologist

BACKGROUND

Oropharyngeal dysphagia is prevalent among neurological patients, often necessitating enteral tube feeding with a nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG). These patients are at significant risk of developing aspiration pneumonia. This study aimed to assess the impact of oropharyngeal dysphagia on pneumonia risk requiring hospitalization in neurological patients on long-term enteral tube feeding.

METHODS

This retrospective observational study was conducted between 2015 and 2022. It included neurological patients who underwent upper gastrointestinal endoscopy combined with a Modified Flexible Endoscopic Evaluation of Swallowing (mFEES) for suspect dysphagia, characterized by difficulty or discomfort in swallowing. Participants were either orally fed or had been on long-term enteral tube feeding via NGT or PEG. A 2-year follow-up was conducted to monitor pneumonia cases requiring hospitalization. Multivariate analyses were conducted to identify risk factors for pneumonia requiring hospitalization.

KEY RESULTS

A total of 226 orally fed and 152 enteral tube-fed patients were enrolled. Multivariate analyses showed a significantly increased risk of pneumonia in patients with a history of pneumonia and those receiving enteral tube feeding. Subgroup analysis indicated a significantly lower risk of pneumonia among enteral tube-fed patients with oropharyngeal dysphagia who PEG-fed patients compared to NGT-fed patients (adjusted HR: 0.21, 95% CI: 0.10-0.44, p < 0.001). The cumulative incidence of pneumonia requiring hospitalization was significantly lower in the PEG group than in the NGT group (p < 0.001).

CONCLUSION

mFEES could be a screening tool for oropharyngeal dysphagia. PEG is preferred over NGT for long-term enteral feeding, as it significantly reduces the risk of pneumonia requiring hospitalization, especially in patients with oropharyngeal dysphagia.

Factors associated with oropharyngeal dysphagia and unsuccessful nasogastric tube removal after endovascular thrombectomy for anterior circulation stroke

PURPOSE

To identify the predictive variables for post-stroke dysphagia (PSD) among anterior circulation large vessel occlusion (LVO) stroke patients who underwent endovascular thrombectomy (EVT).

METHODS

This retrospective cohort study enrolled hospitalized patients with anterior LVO stroke who underwent EVT between January 1, 2018 and October 31, 2022. PSD was defined as the unsuccessful removal of the nasogastric (NG) tube. Factors, such as premorbid characteristics, laboratory results, EVT, rehabilitation-related parameters, and neuro-imaging, were analyzed for correlations to PSD at 4 and 12 weeks.

RESULTS

The study enrolled 136 patients, with a mean age of 72.9 ± 13.0 years, and 59 patients (43.4%) were male. At 4 weeks, 47.1% of the patients needed an NG tube, and at 12 weeks, 16.2% still required an NG tube. We found that lower albumin, lower body mass index (BMI), higher initial and 24-h post-EVT National Institute of Health Stroke Scale (NIHSS) scores, stroke-associated pneumonia, poor initial sitting balance and ability to sit up, insula or frontal operculum lesions, and bilateral hemisphere involvement were all associated with PSD at both 4 and 12 weeks in the univariate logistic regression. Multivariate analysis revealed that significant predictors of unsuccessful NG tube removal at 4 weeks included lower BMI (adjusted OR [aOR] 0.73, p = 0.005), hemorrhagic transformation (aOR 4.01, p = 0.0335), higher NIHSS scores at 24 h post-EVT (aOR 1.13, p = 0.0288), poor initial sitting ability (aOR 0.52, p = 0.0231), insular cortex ischemia (aOR 7.26, p = 0.0056), and bilateral hemisphere involvement (aOR 41.19, p < 0.0001). At 12 weeks, lower BMI (aOR 0.78, p = 0.0098), poor initial sitting balance (aOR 0.57, p = 0.0287), insular cortex lesions (aOR 4.83, p = 0.0092), and bilateral hemisphere involvement (aOR 4.07, p = 0.0139) remained significant predictors.

CONCLUSIONS

In patients with anterior LVO following EVT, PSD was associated with lower BMI, higher NIHSS scores, poor initial sitting balance and sitting ability, insular lesions, and bilateral hemisphere involvement.

A Single-Center Retrospective Study of Bacterial Infections After Acute Ischemic Stroke: The Prevalence Before and During the COVID-19 Pandemic

Background and Objectives: The management of ischemic stroke involves care that is integrated and comprehensive, including the prevention of infection complications. This study aimed to investigate the prevalence and profile of bacterial infections after acute ischemic stroke both before and during the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: A retrospective cross-sectional study examined the medical records of hospitalized acute ischemic stroke patients who had microbiological cultures taken at the National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Jakarta, Indonesia, from 1 January 2018 to 31 December 2021. The percentage of positive bacterial growth in the microbiological cultures was used to determine the prevalence of bacterial infection after acute ischemic stroke. Results: A total of 519 patients met the study criteria, including 48 and 471 patients with infections before and during the COVID-19 pandemic. The prevalence of bacterial infection after acute ischemic stroke was 17.9%. There were significant differences in the prevalence of bacterial infection after acute ischemic stroke before and during the COVID-19 pandemic (87.5% vs. 10.8%). Staphylococcus sp. and Klebsiella sp. were the most frequently observed. The risk factors that influenced bacterial infection after acute ischemic stroke were intensive care stay (OR 0.22; 95%CI 0.13-0.39, p-value < 0.001), sepsis (OR 1.99; 95%CI 1.12-3.53, p-value = 0.019), COVID-19 infection (OR 4.81; 95%CI 2.64-8.76, p-value < 0.001), the use of steroids (OR 0.31; 95%CI 0.14-0.67, p-value = 0.003), and the use of TPN (OR 0.34; 95%CI 0.13-0.86, p-value = 0.022). Conclusions: Following the start of the COVID-19 pandemic, there was a decrease in the prevalence of bacterial infections after AIS. Patients with bacterial infections had different profiles before and during the COVID-19 pandemic.

Effect of Intermittent Oro-Esophageal Tube Feeding in Bulbar Palsy After Ischemic Stroke: A Randomized Controlled Study

BACKGROUND

Nasogastric tube feeding (NG) has been widely used in patients with bulbar palsy after ischemic stroke but is associated with a significant risk of complications including malnutrition and pneumonia. Intermittent oro-esophageal tube feeding (IOE) can help alleviate these concerns. This study explored the clinical effect of IOE versus NG on nutritional status, swallowing function, stroke-associated pneumonia, and depression in patients with bulbar palsy after ischemic stroke.

METHODS

This randomized controlled study included 148 patients with bulbar palsy after ischemic stroke who underwent routine treatment and swallowing rehabilitation training in the Department of Rehabilitation Medicine between July 2017 and July 2019 in China. The participants were randomly divided into the IOE group (n=74) and NG group (n=74) with IOE and NG as nutritional supports, respectively. The primary outcome was nutritional status including (1) body mass index (kg/m2), (2) serum ALB (albumin, g/L), and (3) PA (prealbumin, mg/L). The secondary outcomes were (1) swallowing function including (i) Functional Oral Intake Scale (FOIS) and (ii) Penetration-Aspiration Scale, (2) pneumonia, (3) depression, and (4) adverse events. Statistical analyses for continuous outcomes were performed using t test, Mann-Whitney U test and Wilcoxon signed-rank test and categorical variables using χ2 test. SPSS 21.0 was used for all analysis.

RESULTS

There were no significant baseline differences between the 2 groups. After the treatment, the IOE group demonstrated significantly better results compared with the NG group in ALB ([32.71±0.94] versus [32.28±0.81] g/L; P=0.003), PA ([278.15±13.81] versus [270.31±15.08] mg/L; P=0.001], body mass index ([19.77±1.03] versus [19.41±0.98] kg/m2; P=0.002], FOIS (P<0.001), Penetration-Aspiration Scale (P<0.001), stroke-associated pneumonia ([1, 4.05%] versus [26, 35.14%]; P<0.001), depression ([1, 1.35%] versus [44, 59.46%]; P<0.001) and overall less adverse events (reflux, fever, discomfort in the throat; P<0.001).

CONCLUSIONS

In patients with dysphagia with bulbar palsy after ischemic stroke who received routine treatment and swallowing rehabilitation training, IOE is safer and more conducive to the improvement of nutritional status, swallowing function, stroke-associated pneumonia, and depression than NG.

REGISTRATION

URL: https://www.chictr.org.cn; Unique identifier: ChiCTR-INC-17011741.

When a gastrostomy tube goes missing, acute bowel obstruction due to a migrated Foley catheter

A gastrostomy is a common procedure for patients with swallowing problems or inability to maintain regular oral nutrition. These gastrostomy tubes need special attention, as complications can occur if the tubes are left unattended. In rare scenarios, these tubes can migrate and cause severe life-threatening difficulties such as bowel obstruction and pancreatitis. We present the case of a 76-year-old quadriplegic woman who had a gastrostomy tube. Suddenly, the tube was missing, and after urgent medical care, the gastrostomy tube was found within her bowel. After successful surgery, she recovered from this incident.

Acute Dysphagia Following Reperfusion Therapies: A Prospective Pilot Cohort Study

Dysphagia is a well-documented sequela of stroke. Recent advancements in medical treatments for stroke include reperfusion therapies (endovascular thrombectomy (EVT) and thrombolysis). As outcomes following reperfusion therapies are typically measured via general functional scales, the pattern and progression of acute dysphagia following reperfusion therapies is less known. To determine the progression of acute dysphagia (0-72 h) following reperfusion therapies and relationships between various stroke parameters and dysphagia, twenty-six patients were prospectively recruited across two EVT and thrombolysis centres in Brisbane, Australia. Dysphagia was screened via the Gugging Swallowing Screen (GUSS) at the bedside at three timepoints: 0-24 h, 24-48 h, and 48-72 h post-reperfusion therapies. Across three groups (EVT only, thrombolysis only, or both), the incidence of any dysphagia within the first 24 h of reperfusion therapy was 92.31% (n = 24/26), 91.30% (n = 21/23) by 48 h, and 90.91% (n = 20/22) by 72 h. Fifteen patients presented with severe dysphagia at 0-24 h, 10 at 24-48 h, and 10 at 48-72 h. Whilst dysphagia was not significantly correlated to infarct penumbra/core size, dysphagia severity was significantly related to the number of passes required during EVT (p = 0.009).Dysphagia continues to persist in the acute stroke population despite recent advancements in technology aimed to reduce morbidity and mortality post-stroke. Further research is required to establish protocols for management of dysphagia post-reperfusion therapies.

Diagnostic value of coagulation index and serum inflammatory cytokines in hemorrhagic stroke patients with pulmonary infection in the sequelae stage

BACKGROUND

Stroke is the second reason for global deaths and a major reason for disabilities.

OBJECTIVE

To unravel the clinical value of the coagulation index and serum inflammatory cytokines in hemorrhagic stroke patients with pulmonary infection in the sequelae stage.

METHODS

Altogether, 130 hemorrhagic stroke patients who received treatment in Hebei General Hospital from April 2019 to December 2020 were selected. Patients were classified into the infection group (n= 65) and non-infection group (n= 65) according to whether they had a pulmonary infection in the sequelae stage of hemorrhagic stroke. Levels of coagulation index and serum inflammatory cytokines of patients in two groups were compared. Multiple linear regression analysis was used to analyze pulmonary infection-related factors of hemorrhagic stroke patients. The diagnostic value of the coagulation index and serum inflammatory cytokines in pulmonary infection was analyzed by the receiver operating characteristic (ROC) curve.

RESULTS

Prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB), D-dimer (D-D), platelet (PLT) related to coagulation function levels and interleukin 1β (IL-1β), interleukin 17 (IL-17) related to serum inflammatory cytokines levels of patients in the infection group were higher than those in non-infection groups (p< 0.05). Multiple linear regression analysis uncovered that FIB, D-D, PLT, and IL-17 were influencing factors of pulmonary infection in the sequelae of patients with hemorrhagic stroke (p< 0.05). Area under the curve (AUC) values of pulmonary infection in the sequelae stage of patients with hemorrhagic stroke diagnosed by FIB, D-D, PLT, and IL-17 were 0.823, 0.758, 0.660, and 0.755, respectively.

CONCLUSION

FIB, D-D, PLT, and IL-17 levels could be used for pulmonary infection diagnosis in the sequelae stage of hemorrhagic stroke patients.

Complications of percutaneous endoscopic gastrostomy in intensive care patients with dysphagia associated with neurological disorders

OBJECTIVE

To develop an effective method for percutaneous endoscopic gastrostomy using gastropexy technology.

MATERIAL AND METHODS

We retrospectively analyzed 260 ICU patients with dysphagia associated with neurological disorders between 2010 and 2020. All patients were divided into two groups: the main group (n=50) - percutaneous endoscopic gastrostomy with gastropexy, control group (n=210) - surgery without fixing the anterior wall of the stomach to the abdominal wall.

RESULTS. G

Astropexy significantly reduced the incidence of postoperative complications (p=0.045) and severe complications (grade IIIa and higher) (χ2=3.701, p=0.055). Early postoperative complications occurred in 20 (7.7%) patients. Surgery and subsequent treatment were associated with normalization of leukocyte count (p=0.041), C-reactive protein (p=0.024) and serum albumin (p=0.0012). Mortality was similar in both groups. Overall 30-day mortality rate in both groups was 20.8% that was associated with clinical severity of patients. Percutaneous endoscopic gastrostomy was not the direct cause of death in any case. However, complications of endoscopic gastrostomy aggravated the underlying disease in 2.9% of cases.

CONCLUSION

Percutaneous endoscopic gastrostomy with gastropexy reduces the incidence of postoperative complications.

Comparison Between Percutaneous Endoscopic Gastrostomy and Nasogastric Feeding in 160 Patients with Swallowing Disturbances: A Two-Year Follow-Up Study

Purpose

We retrospectively compared the complications, blood biochemical indexes and outcomes in patients with swallowing disturbances receiving nasogastric tube (NGT) feeding and percutaneous endoscopy gastrostomy (PEG).

Methods

Among 160 patients, 72 cases received PEG and 88 cases received NGT. All patients were followed up for two years. We collected their clinical data from the medical records. Indicators, such as body mass index (BMI), white blood cell (WBC), hemoglobin (HGB), complications, including recurrent aspiration pneumonia, gastrointestinal bleeding, reflux esophagitis, and outcomes (survival or death) were compared between the two groups semi-annually.

Results

SAt both six months and one year after receiving treatment, there was no statistical difference between the two groups in indicators, complications and outcomes, with all P >0.05. It can be seen that, when the patients were followed up for one and a half years18 months, ALB was lower in the NGT group (33.81±0.46) compared with the PEG group (36.14±0.50) (P <0.05). After two years of follow-up, differences between the NGT and PEG group could be seen in a variety of indicators, including BMI (20.08±0.27 vs 21.03±0.25), WBC (9.12±0.56 vs 7.08±0.29), ALB (33.11±0.43 vs 35.75±0.49), creatinine (55.07±1.83 vs 63.21±2.94), and the complications, such as aspiration pneumonia, gastrointestinal bleeding, reflux esophagitis, and electrolyte disorder, in the PEG group were significantly reduced compared to the NGT groupthan that in its counterpart, P <0.05. In the two-year follow-up period, there were 13 and 22 patients died in the PEG group and NGT group, respectively.

Conclusion

Both techniques are safe and effective in the short term. However, on a longer-term basis, PEG is shown to be superior to NGT feeding in improving nutrition and preventing common complications for patients with swallowing disturbances.

Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes

BACKGROUND

Percutaneous Endoscopic Gastrostomy (PEG) tubes are often placed for dysphagia following a stroke in order to maintain sufficient caloric intake. The 2011 ASGE guidelines recommend delaying PEG tube placement for two weeks, as half of patients with dysphagia improve within 2 wk. There are few studies comparing outcomes based on timing of PEG tube placement, and there is increasing demand for early PEG tube placement to meet requirements for timely discharge to rehab and skilled nursing facilities.

AIM

To assess the safety of early (≤ 7 d post stroke) vs late (> 7 d post stroke) PEG tube placement and evaluate whether pre-procedural risk factors could predict mortality or complications.

METHODS

We performed a retrospective study of patients undergoing PEG tube placement for dysphagia following a stroke at two hospitals in Saint Louis, MO between January 2011 and December 2017. Patients were identified by keyword search of endoscopy reports. Mortality, peri-procedural complication rates, and post-procedural complication rates were compared in both groups. Predictors of morbidity and mortality such as protein-calorie malnutrition, presence of an independent cardiovascular risk equivalent, and presence of Systemic inflammatory response syndrome (SIRS) criteria or documented infection were evaluated by multivariate logistic regression.

RESULTS

154 patients had a PEG tube placed for dysphagia following a stroke, 92 in the late group and 62 in the early group. There were 32 observed deaths, with 8 occurring within 30 d of the procedure. There was an increase in peri-procedural and post-procedural complications with delayed PEG placement which was not statistically significant. Hospital length of stay was significantly less in patients with early PEG tube placement (12.9 vs 22.34 d, P < 0.001). Protein calorie malnutrition, presence of SIRS criteria and/or documented infection prior to procedure or having a cardiovascular disease risk equivalent did not significantly predict mortality or complications.

CONCLUSION

Early PEG tube placement following a stroke did not result in a higher rate of mortality or complications and significantly decreased hospital length of stay. Given similar safety outcomes in both groups, early PEG tube placement should be considered in the appropriate patient to potentially reduce length of hospital stay and incurred costs.

Palato-Pharyngo-Laryngeal Rhythmic Myoclonus in Neuro-Bechet Syndrome: A Case Report

OBJECTIVE

Behcet's syndrome (BS) is a chronic, relapsing multisystemic inflammatory perivasculitis and can affect any tissue, including the nervous system. Neuro-Bechet's syndrome (NBS) most commonly affects the CNS parenchyma and presents with a subacute brainstem syndrome that includes cranial neuropathies. Here we describe a rare case of palato-pharyngo-laryngeal myoclonus as a manifestation of NBS and discuss it from a laryngology perspective.

METHODS

Case report at tertiary care center. Informed consent was obtained from patient. IRB approved as non-human subjects research.

RESULTS

A 52-year-old male presented with a progressive history of ataxia, fatigue, apathy, dysphagia, depressed mood, dizziness, poor appetite, subjective fever and recurrent orogenital lesions. He was diagnosed with NBS and treated with methylprednisolone, followed by infliximab and methotrexate. Despite treatment, his severe spastic dysarthria, dysphagia, and aspiration worsened over the next few months, necessitating a gastrotomy tube. With concern for laryngospasm, he was referred to otolaryngology and found to have synchronous and symmetric palatal, pharyngeal, and laryngeal rhythmic myoclonus bilaterally at a frequency of 2 Hz with inappropriate vocal cord closure. Treatment with baclofen and a scopolamine patch improved his breathing and reduced choking events.

CONCLUSIONS

Palato-pharyngo-laryngeal rhythmic myoclonus can be a presentation of brainstem NBS in the otolaryngology clinic. We theorize perivascular disease in NBS results in a brainstem lesion in the denato-rubro-olivary tract, which results in hypertrophic olivary degeneration and subsequent activation of the inferior olives oscillatory activity, causing palato-pharyngo-laryngeal rhythmic myoclonus. Common symptoms include significant dysarthria, dysphonia, and dysphagia with concern for obstructive sleep apnea and airway compromise. Treatments include pharmacologic therapy, laryngeal botox, and tracheostomy in cases of significant airway compromise.

The Role of the Pharmacist in Selecting the Best Choice of Medication Formulation in Dysphagic Patients

Usually, the administration of drugs by feeding tube in dysphagic patients involves handling of marketing licenses outside their term, due to the lack of suitable formulations. This circumstance has put health professionals in the dilemma of choosing the formulation whose manipulation possibly does not alter the effectiveness of the drug. In this regard, a practical guide providing indications on the prescription, handling, and administration of drugs through enteral feeding tube could be of paramount utility. For this purpose, we have considered the 1047 solid oral pharmaceutical forms included in the formulary of San Paolo Hospital (Savona, Italy). From our analysis, it emerges that 95% of medicinal products are worryingly used off-label and 40% have to be managed by the hospital pharmacists without having suitable indications by either the manufacturers or by literature studies. To fill this gap, we have compiled a detailed table containing missing indications derived from pharmacist expertise and evidence-based practices, with the aim that the sharing of our procedures will contribute to make uniform pharmacological therapies from one hospital to another. This study will allow doctors to have easy access to information on drugs that can be prescribed and nurses to become familiar only with the pharmaceutical forms that can be administered.

Bibliometric analysis of global research trends on post-stroke pneumonia: Current development status and research Frontiers

Background

As one of the most common complications of stroke, post-stroke pneumonia significantly increases the incidence of adverse outcomes, mortality, and healthcare costs for patients with stroke. As the field of post-stroke pneumonia has gained interest in the recent years, there has been an increasing number of publications on post-stroke pneumonia research worldwide. Therefore, a more comprehensive understanding of the field is needed now. This paper is intended to analyze the research status and detect the research frontiers in this field.

Methods

VOS viewer, CiteSpace, and the online scientometric platform (https://bibliometric.com/) were the main visualization tools used in this paper. They were used to perform citation analysis of countries/institutions, co-citation analysis of authors/journals/references, co-authorship analysis of authors, co-occurrence analysis of keywords, and citation bursts analysis of references.

Results

The number of publications in this field has increased rapidly since 2010 and is expected to continue to increase in the next few years. The countries contributing most to post-stroke pneumonia research were the USA, China, and Germany. The most productive institution was Harvard University, followed by Humboldt University of Berlin, Charité Universitätsmedizin Berlin, and Free University of Berlin from Germany. Meanwhile, the German authors Meisel A, Meisel C, and Dirnagl U, who have contributed significantly to this field, were all associated with these three German institutions. The high-quality and high output journal was STROKE. In the coming years, the hot topic keywords “risk & risk-factors,” “outcome & impact,” “management & guidelines,” and “predictors” will gain more attention in this field. Finally, hot keywords were grouped into four clusters in this paper: cluster 1 (risk-factors studies of post-stroke pneumonia), cluster 2 (clinically relevant studies of post-stroke pneumonia), cluster 3 (mechanism studies of post-stroke pneumonia), and cluster 4 (care studies of post-stroke pneumonia).

Conclusion

This study shows the knowledge structure and evolution of the field of post-stroke pneumonia research and predicts research trends through visualization analysis. The future trend of post-stroke pneumonia research will gradually shift from clinical and mechanistic studies to treatment and prevention studies.

Evaluation of Oropharyngeal Dysphagia in Older Patients for Risk Stratification of Pneumonia

Objective

Nasogastric tube (NGT) and percutaneous endoscopic gastrostomy (PEG) are widely used techniques to feed older patients with oropharyngeal dysphagia. Aspiration pneumonia is the most common cause of death in these patients. This study aimed to evaluate the role of oropharyngeal dysphagia in older patients on long-term enteral feeding for risk stratification of pneumonia requiring hospitalization.

Methods

We performed modified flexible endoscopic evaluation of swallowing to evaluate oropharyngeal dysphagia in older patients and conducted prospective follow-up for pneumonia requiring hospitalization. A total of 664 oral-feeding patients and 155 tube-feeding patients were enrolled. Multivariate Cox analysis was performed to identify risk factors of pneumonia requiring hospitalization.

Results

Multivariate analyses showed that the risk of pneumonia requiring hospitalization significantly increased in older patients and in patients with neurological disorders, tube feeding, and oropharyngeal dysphagia. Subgroup analysis revealed that the risk of pneumonia requiring hospitalization was significantly lower in patients with PEG than in those with NGT among the patients with oropharyngeal dysphagia (adjusted hazard ratio 0.26, 95% confidence interval: 0.11–0.63, P = 0.003).

Conclusions

For older patients with oropharyngeal dysphagia requiring long-term enteral tube feeding, PEG is a better choice than NGT. Further research is needed to elucidate the role of oropharyngeal dysphagia in enteral feeding in older patients.

An investigation into the effect of nasogastric intubation on markers of autonomic nervous function

BACKGROUND

Nasogastric (NG) intubation for esophageal manometry can be traumatic and may be associated with a temporary reduction/absence in esophageal peristalsis. This study explored the prevalence and effect on esophageal motor function. We also hypothesized that baseline anxiety as well as markers of autonomic nerve function were correlated to attenuated esophageal peristalsis.

METHODS

Twenty-seven patients with esophageal symptoms referred for esophageal manometry investigation (mean age 56.8 ± 16.7 years, range 23-85 years) reported baseline anxiety score (Likert scale) preintubation. Patients had continuous heart rate and blood pressure measured prior to intubation and until 10 min after catheter withdrawal. Quality of motility was assessed for each 5 ml water swallow using standard Chicago Classification metrics.

KEY RESULTS

Nasogastric-intubation elicited a significant increase in heart rate (p < 0.001), systolic (p < 0.001) and diastolic (p < 0.001) blood pressure, which was in part anticipatory. The median time taken for patients' first hypotensive peristalsis (Distal Contractile Integral; DCI ≥100 mmHg s cm) was 130 s (Interquartile range; 47-242 s) and for their first normal peristalsis (DCI ≥450 mm Hg s cm) was 150 s (IQR 61-320 s), with improvement and consistent stabilization in DCI there onward. This corresponded closely to the time for initial recovery of heart rate and systolic and diastolic blood pressure postintubation.

CONCLUSIONS AND INFERENCES

Nasogastric intubation resulted in heightened sympathetic responses and/or dampened parasympathetic responses, and an associated temporary reduction or absence in esophageal peristalsis.

Best Practice Recommendations for Dysphagia Management in Stroke Patients: A Consensus from a Portuguese Expert Panel

Dysphagia is frequent after stroke, and it increases the risk of respiratory infection, dehydration and malnutrition, resulting in worse outcomes. Different clinical guidelines present recommendations for the assessment and management of dysphagia in stroke patients in a scattered way. These best practice recommendations address seven clinical questions on the assessment and management of dysphagia in stroke patients, gathering the best-updated evidence. A systematic literature review using the PICO strategy was performed. The recommendations draft was then appraised by a multidisciplinary panel of experts (nutritionists, physiatrists, speech-language pathologists and rehabilitation nurses) in a total of 3 Delphi rounds. A minimum of 80% consensus was established, and the final version offers a total of 21 recommendations for use in clinical practice for stroke patients. These clinical recommendations are an overview of the most recent evidence combined with experts' consensus and translated into clinically relevant statements. In implementing recommendations at the local level, health professionals should identify facilitators and barriers to evidence-based practice within their contexts and determine the best strategies to address local needs. Where the change is needed, initial and continuing training on all recommendations is essential and relevant.

The effects of endovascular clot retrieval and thrombolysis on dysphagia in an Australian quaternary hospital: A retrospective review

Dysphagia (impaired swallowing) is known to contribute to decreased quality of life, and increased length of hospital stay and mortality post-stroke. Despite the advancements in stroke treatment with the introduction of thrombolysis and endovascular clot retrieval (ECR), patients continue to present with high rates of dysphagia. Speech and language therapists and stroke teams should consider the presence of haemorrhagic transformation, success of reperfusion and presence of communication deficits as risk factors for dysphagia post-ECR and/or thrombolysis.

PURPOSE

To establish incidence rates and patterns of dysphagia following the administration of reperfusion therapies in acute ischaemic stroke management.

METHOD

A retrospective review of 193 patients admitted with acute ischaemic stroke to a quaternary stroke unit in Australia over a three year period was completed. Clinical information extracted included demographics, type (thrombolysis and/or endovascular clot retrieval) and success of reperfusion therapy, and the progression of dysphagia and related factors.

RESULTS

Over half of all patients treated with reperfusion therapies presented with dysphagia on initial assessment by speech-language pathology (SLP). The type of reperfusion therapy administered was not significantly correlated with the presence of dysphagia. Dysphagia on initial assessment was significantly correlated with the presence of aphasia on initial assessment, the presence of haemorrhagic transformation, and the success of reperfusion. Increased rates of enteral feeding were also found in this study compared to figures reported in literature.

CONCLUSION

This study identified ongoing high rates of dysphagia amongst this patient population regardless of treatment type, demonstrating the need for ongoing SLP management post stroke. Further research is required in this area to develop an evidence-base for SLPs and the wider medical team and to inform clinical practice guidelines.

WHAT THIS PAPER ADDS

What is already known on the subject Stroke is one of the leading causes of disability and death internationally. Dysphagia (impaired swallowing), a common sequalae of stroke, is known to contribute to decreased quality of life, increased length of hospital stay and mortality. With advancements in technology, treatments for acute ischaemic stroke (endovascular clot retrieval and thrombolysis) are increasing in popularity. However, limited research exists exploring the impact of these therapies on dysphagia. What this paper adds Despite the advancements in stroke treatment, patients continue to present with high rates of dysphagia. Dysphagia following thrombolysis and/or ECR was found to be significantly correlated to the presence of aphasia, haemorrhagic transformation, and the success of reperfusion (regardless of treatment type). Additionally, increased rates of enteral feeding were found amongst this patient population compared to figures reported in the literature for patients following traditional stroke management. Clinical implications of this study Speech-language pathologists and the wider medical team should consider dysphagia as an ongoing consequence of stroke following reperfusion therapies, with consideration for success of reperfusion and adverse outcomes i.e., haemorrhagic transformation. Further research is required to provide an evidence-base and specific guidelines for the management of dysphagia post reperfusion therapies, including use of enteral feeding.

Endoscopic gastrostomy for nutritional support in post-stroke dysphagia

Introduction

Introduction: persistent dysphagia affects 15 % of stroke patients and contributes to malnutrition, aspiration, and death. This study aimed to characterize patients with post-stroke dysphagia who underwent percutaneous endoscopic gastrostomy (PEG), and to assess the impact of PEG feeding on nutritional status and outcome. Methods: an observational and retrospective study using records from patients with post-stroke dysphagia who underwent PEG. Body mass index (BMI), serum albumin, transferrin, and cholesterol were recorded at the time of PEG insertion (T0) and 3 months later (T3). The evolution of these parameters was analyzed and compared to survival. Results: we obtained data from 158 patients (53.2 % males) with a median age of 75 years. Most strokes were ischemic (n = 135, 85.4 %). Median time between stroke and PEG was 2 months. Median survival after gastrostomy was 16 months. At admission, 41.6 % of patients had low BMI, 62.3 % low albumin, 68.6 % low transferrin, and 59.6 % low cholesterol levels. The prevalence of low albumin and low transferrin was higher in the patients who underwent PEG more than 2 months after stroke. A significant increase in albumin and transferrin, and a normalization of cholesterol levels was observed after 3 months of PEG feeding. Mortality was 12.9 %, 27.7 %, and 40 % at 1, 3, and 12 months, respectively. Survival was lower in patients with low albumin, transferrin or total cholesterol at admission. Conclusions: the prevalence of malnutrition is high among patients with post-stroke dysphagia. PEG feeding improves albumin, transferrin, and cholesterol levels. Early post-PEG mortality is high and must be considered on an individual basis.

Enteral nutrition ameliorates the symptoms of Crohn's disease in mice via activating special pro-resolving mediators through innate lymphoid cells

Crohn's disease activates the inflammatory reactions to induce intestinal disorders. Enteral nutrition (EN) could exert general immunomodulatory effects. Cecal ligation and perforation (CLP) surgery was utilized to establish Crohn's disease mice models. Survival analysis, hematoxylin-eosin staining, flow cytometry, ELISA, Western blot and liquid chromatography-tandem MS were applied. Baicalein was added to inhibit lipoxygenases. The survival rate was restored and inflammatory injury, exudate neutrophils in peritoneal lavage and serum levels of IL-6 and TNF-α were ameliorated by EN treatment as compared with CLP treatment. EN also increased ILC-3 content, 5/15-LOX level and RvD1-RvD5 in peritoneal lavage. Baicalein reversed all the detected effects of EN except ILC-3 content. EN could activate special pro-resolving mediators (SPMs) through ILCs to mitigate injuries of Crohn's disease.

Safety and Feasibility of Percutaneous Gastrostomy Placement in Patients on Antiplatelet Therapy

Background: Guidelines recommend the discontinuation of clopidogrel prior to gastrostomy tube placement. The aim of this study was to examine the safety and feasibility of performing radiologically inserted gastrostomy (RIG) tube placement in patients taking clopidogrel and/or aspirin. Methods: We performed an institutional review board-approved retrospective analysis of the medical records for 237 consecutive patients following RIG tube placement secondary to dysphagia from August 2017 to January 2019. Antiplatelet medications and RIG type placement techniques (push vs pull) were compared with bleeding complications. Complications were categorized based on the Society of Interventional Radiology clinical practice guidelines. Of the 237 patients with RIG tubes placed, 77 patients were on antiplatelet therapy: 55 on single antiplatelet therapy and 22 on dual antiplatelet therapy. Of the 55 patients on single antiplatelet therapy, 26 were taking clopidogrel and 29 were taking aspirin. Results: A total of 9 bleeding complications were observed. The most common complication was minimal bleeding or hematoma around the incision site (n=7). No statistically significant increase was seen in bleeding rates when comparing patients on any antiplatelet therapy regimen vs none (P=0.15), single antiplatelet therapy vs none (P=0.13), clopidogrel vs none (P=0.71), or dual antiplatelet therapy vs none (P=0.61). No significant increase in the bleeding complication rate was noted when comparing the aspirin-only regimen vs clopidogrel alone (P=0.34). Conclusion: These findings suggest that the risk of bleeding complications is not increased in patients taking clopidogrel and/or aspirin prior to RIG tube placement.

Efficacy of speech therapy in post-intubation patients with oropharyngeal dysphagia: a randomized controlled trial

PURPOSE

to verify the efficacy of speech therapy in the early return of oral intake in patients with post-orotracheal intubation dysphagia.

METHODS

It was a double-blinded randomized controlled trial for two years with patients of intensive care units of a hospital. Study inclusion criteria were orotracheal intubation>48hours, age≥18 years old, clinical stability, and dysphagia. Exclusion criteria were tracheotomy, score 4 to 7 in the Functional Oral Intake Scale (FOIS), neurological disorders. Patients were randomized into speech treatment or control group (ten days of follow-up). The treated group (TG) received guidance, therapeutic techniques, airway protection and maneuvers, orofacial myofunctional and vocal exercises, diet introduction; the control group (CG) received SHAM treatment. Primary outcomes were oral intake progression, dysphagia severity, and tube feeding permanence.

RESULTS

In the initial period of study, 240 patients were assessed and 40 (16.6%) had dysphagia. Of this, 32 patients met the inclusion criteria, and 17 (53%) received speech therapy. Tube feeding permanence was shorter in TG (median of 3 days) compared to CG (median of 10 days) (p=0.004). The size effect of the intervention on tube feeding permanence was statistically significant between groups (Cohen's d=1.21). TG showed progress on FOIS scores compared to CG (p=0.005). TG also had a progression in severity levels of Dysphagia protocol (from moderate to mild dysphagia) (p<0.001).

CONCLUSION

Speech therapy favors an early progression of oral intake in post-intubation patients with dysphagia. Clinical Trial Registration: RBR-9829jk.

Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part II: Rehabilitation

Dysphagia is one of the most common and important complications of stroke. It is an independent marker of poor outcome following acute stroke and it continues to be effective for many years. This consensus-based guideline is not only a good address to clinical questions in practice for the clinical management of dysphagia including management, diagnosis, follow-up, and rehabilitation methods, but also includes detailed algorithms for these topics. The recommendation paper has been written by a multidisciplinary team and offers 117 recommendations for stroke patients with dysphagia. While focusing on management principles, diagnosis, and follow-up in the 1st part (45 items), rehabilitation details were evaluated in the 2nd part (72 items).

Dysphagia in neurological diseases: a literature review

Dysphagia is defined as an impairment of this complex and integrated sensorimotor system. It is estimated that 400,000 to 800,000 individuals worldwide develop neurogenic dysphagia per year. Neurogenic dysphagia is typically occurring in patients with neurological disease of different etiologies. A correct and early diagnosis and an appropriate management of dysphagia could be useful for improving patient’s quality of life and may help to prevent or delay death. In the present review, we discuss thoroughly the anatomy and physiology of swallowing and also the pathophysiological mechanisms involved in impaired swallowing, as well as the diagnosis, management, and potential treatments of neurogenic dysphagia. Assessment of neurogenic dysphagia includes medical history, physical exam, and instrumental examinations (fiberoptic endoscopic evaluation of swallowing, videofluoroscopic swallowing study, electromyography). Pharmacological treatment of these problems includes oral anticholinergic drugs. Surgical myotomy of the cricopharyngeal muscle showed an important improvement of oropharyngeal dysphagia associated to upper esophageal sphincter hyperactivity. Chemical myotomy of the upper esophageal sphincter by local injections of botulinum toxin type A into the cricopharyngeal muscle has been proposed as an alternative less invasive and less unsafe than surgical myotomy.

Predictors and associating factors of nasogastric tube removal: Clinical and brain imaging data analysis in post-stroke dysphagia

BACKGROUND/PURPOSE

Post-stroke dysphagia is a frequent complication. Although most patients with dysphagia recover after the acute phase, some patients require long-term enteral feeding, either through a nasogastric (NG) or gastrostomy tube; the effectiveness of using either tube is still under debate. This study elucidated the natural course of NG tube installation and removal and examined the predictors and associating factors based on clinical and brain imaging data.

METHODS

This retrospective cohort study with medical record reviews recruited patients received NG tube installation after their acute stroke events between January 1, 2016, and December 31, 2016. Inclusion criteria were subjects above 20 years of age and with a diagnosis of a newly onset stroke except SAH whose comprehensive clinical and imaging data were available. Survival analysis was performed for the right-censored data because some patients were lost to follow-up after discharge or transferal.

RESULTS

In total we recruited 135 patients. Among these patients, the timing of their NG tube removal reached a plateau at 12-16 weeks after stroke. The modified Rankin score on discharge, representing the overall subacute disease status, was the most significant factor. Other clinical variables could be divided into 2 categories: baseline patient characteristics and stroke event severity. Moreover, semi-quantitative brain imaging scores corresponding to the aforementioned 3 categories were correlated significantly.

CONCLUSION

In Taiwan, the NG tube removal rate reached a plateau at around 12-16 weeks after stroke onset. Variables related to long-term NG tube use were divided into baseline characteristics of patient and stroke event severity.

Percutaneous Endoscopic Gastrostomy versus Nasogastric Tube Feeding: Oropharyngeal Dysphagia Increases Risk for Pneumonia Requiring Hospital Admission

Background: Aspiration pneumonia is the most common cause of death in patients with percutaneous endoscopic gastrostomy (PEG) and nasogastric tube (NGT) feeding. This study aimed to compare PEG versus NGT feeding regarding the risk of pneumonia, according to the severity of pooling secretions in the pharyngolaryngeal region. Methods: Patients were stratified by endoscopic observation of the pooling secretions in the pharyngolaryngeal region: control group (<25% pooling secretions filling the pyriform sinus), pharyngeal group (25–100% pooling secretions filling the pyriform sinus), and laryngeal group (pooling secretions entering the laryngeal vestibule). Demographic data, swallowing level scale score, and pneumonia requiring hospital admission were recorded. Results: Patients with NGT (n = 97) had a significantly higher incidence of pneumonia (episodes/person-years) than those patients with PEG (n = 130) in the pharyngeal group (3.6 ± 1.0 vs. 2.3 ± 2.1, P < 0.001) and the laryngeal group (3.8 ± 0.5 vs. 2.3 ± 2.2 vs, P < 0.001). The risk of pneumonia was significantly higher in patients with NGT than in patients with PEG (adjusted hazard ratio = 2.85, 95% CI: 1.46–4.98, P < 0.001). Cumulative proportion of pneumonia was significantly higher in patients with NGT than with PEG for patients when combining the two groups (pharyngeal + laryngeal groups) (P = 0.035). Conclusion: PEG is a better choice than NGT feeding due to the decrease in risk of pneumonia requiring hospital admission, particularly in patients with abnormal amounts of pooling secretions accumulation in the pyriform sinus or leak into the laryngeal vestibule.

The Effect of Enteral Tube Feeding on Patients' Health-Related Quality of Life: A Systematic Review

Patients with functional gastrointestinal tract who are unable to meet their nutritional requirements may benefit from the use of enteral nutrition via feeding tubes which could be nasogastric, percutaneous endoscopic gastrostomy and jejunostomy. Although enteral tube feeding has been shown to promote nutritional status, improve wound healing, and enhance patients’ quality of life (QoL), evidence of tube and feed complications and reduced QoL has also been reported. Despite the increasing prevalence of patients on enteral tube feeding, no systematic review examining the role of enteral tube feeding on patients’ QoL appears to have been published. Aim: The aim of this systematic review is to evaluate the effect of enteral tube feeding on patients’ QoL. Method: Three databases (EMBASE, Pubmed, and PsycINFO) plus Google Scholar were searched for relevant articles based on the Population, Intervention, Comparator, Outcomes (PICO) framework. The review was in line with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines and involved the use of synonyms and medical subject headings. In addition, search terms were combined using Boolean operators (AND/OR) and all the articles retrieved were exported to EndNote for de-duplication. Results: Fourteen articles which met the criteria were included and three distinct areas were identified: the effect of early versus late enteral tube feeding on QoL; the QoL of patients on gastrostomy versus standard care, and the effect of enteral tube feeding on QoL. Overall, nine studies reported improvement in the QoL of patients on enteral tube feeding, while five studies demonstrated either no significant difference or reduction in QoL. Some factors which may have influenced these outcomes are differences in types of gastrostomy tubes, enteral feeding methods (including time patients spent connected to enteral feed/pump), and patients’ medical conditions, as well as the generic and/or type of QoL measuring instrument used. Conclusion: Most reviewed studies suggest that enteral tube feeding is effective in improving patients’ QoL. The use of enteral tube feeding-specific QoL measuring instruments is recommended for future research, and improved management strategies including use of mobile enteral feeding pumps should further enhance patients’ QoL. More studies on the effect of delivery systems/enteral feeding pumps on QoL are needed as research in this area is limited.

Effects of Neuromuscular Electrical Stimulation for Masseter Muscle on Oral Dysfunction After Stroke

Objective

To determine positive effect of neuromuscular electrical stimulation (NMES) in conventional dysphagia therapy on masseter muscle oral dysfunction of patients after subacute stroke.

Methods

Among subacute stroke patients who were diagnosed as oropharyngeal dysphagia by videofluoroscopy swallowing study (VFSS), those with oral dysfunction were enrolled. They were randomly assigned to a study group or a control group. The study group received NMES on masseter muscle and suprahyoid muscle simultaneously, while the control group received NMES only on suprahyoid muscle. NMES therapy session as applied 30 minutes each time, two times per day for a total of 20 sessions. Both groups received conventional dysphagia therapy for 2 weeks. All enrolled patients were evaluated by VFSS after 2 weeks. Oropharyngeal swallowing function was evaluated by Penetration-Aspiration Scale, Functional Dysphagia Scale (FDS), and American Speech-Language-Hearing Association National Outcome Measurement System swallowing scale based on results of VFSS.

Results

Patients were randomly assigned to the study group (n=20) or the control group (n=20). There were no significant differences in baseline characteristics or initial values between the two groups. After 2 weeks of NMES, both groups showed improvement in scores of total FDS and pharyngeal phase FDS. Additionally, the study group showed improvement in oral phase FDS. Changes in all measurements were similar between the two groups.

Conclusion

In this preliminary study, NMES for masseter muscle has a therapeutic effect on oral dysfunction of patients after subacute stroke.

Cilostazol is Effective to Prevent Stroke-Associated Pneumonia in Patients Receiving Tube Feeding

Stroke-associated pneumonia (SAP) is a frequent complication in acute ischemic stroke (IS) patients, especially those receiving tube feeding (TF). In this retrospective study, we investigated whether or not cilostazol, a pluripotent phosphodiesterase III-specific inhibitor with anti-platelet and vasculogenic effects, can prevent SAP in these patients and reduce their duration of stay in intensive care unit/hospitalization. We recruited 158 IS patients receiving TF. Patients' characteristics (including age, gender, past history), National Institute of Health Stroke Scale and serum albumin level on admission, concomitant medications associated with SAP prevention (including cilostazol), and stroke characteristics (bilateral subcortical white matter lesion, brainstem involvement, large infarction, and asymptomatic hemorrhagic infarction) were compared between the SAP(-) and SAP(+) groups. Cilostazol was more frequently used in the SAP(-) group (20.8% vs. 6.1%, p < 0.05). Duration of intensive care unit was longer in patients with SAP (9 ± 8 vs. 6 ± 6 days, p < 0.05). However, the length of stay in an intensive care unit and duration of hospitalization were not reduced due to the prevention of SAP by cilostazol treatment. Cilostazol administration was associated with reduced SAP incidence in acute IS patients receiving TF.

Changes in the dysphagia and nutritional status of patients with brain injury

AIMS AND OBJECTIVES

To evaluate the degree of improvement in the dysphagia and nutritional status of patients with brain injuries after removal of the nasogastric tube.

BACKGROUND

The nurse should assess patients' dysphagia, after removal of the nasogastric tube, and immediately reflect the changes in patient care. Accordingly, the critical roles of nurses in caring for patients with dysphagia involve providing appropriate nutritional therapy as well as preventing aspiration pneumonia and nutritional imbalance. Assessment of the patient's dysphagia on a regular basis and analysis of nutritional status according to the degree of dysphagia are necessary to determine the appropriate timing for providing nursing interventions and to develop protocols for the provision of a therapeutic diet.

DESIGN

Prospective observational study.

METHODS

This study was conducted on 56 patients with dysphagia after a brain injury. Data were collected using the Gugging Swallowing Screen (GUSS) test and Swallowing Symptom Questionnaire (SSQ). Descriptive statistics, chi-square tests, t tests, and MANOVA were analysed using SPSS 22.0.

RESULTS

Patient's dysphagia was observed over the course of 2 weeks. After 14 days, the severity of dysphagia decreased from 91.1%-35.7%, while the number of participants with normal swallowing increased from 1.8%-58.9%. Dysphagia in patients with brain injury improved gradually over time. A significant difference was observed in the serum albumin level of patients with dysphagia (F = 9.51, p = .003, Wilk's λ = .034).

CONCLUSIONS

Most of the patients with brain injury developed moderate dysphagia immediately after removal of the nasogastric tube. However, after 14 days had elapsed, the percentage of patients recovering from dysphagia increased to 58.9%. Proper dietary patterns were not adequately provided depending on the degree of patient's dysphagia after removal of the nasogastric tube. Assessing the degree of dysphagia using the GUSS test and providing appropriate diet prevent malnutrition in patients with dysphagia.

RELEVANCE TO CLINICAL PRACTICE

This study was conducted in patients who developed complications of dysphagia after a brain injury. Using the Gugging Swallowing Screen (GUSS) test, the changes in the degree of dysphagia were repeatedly measured at different times: 4, 7 and 14 days after the removal of the nasogastric tube. Provision of appropriate diet and changes in the nutritional status were analysed to determine the proper timing for nursing intervention in patients with dysphagia. The data obtained from this study could serve as a basis for developing diet provision protocols for patients with dysphagia.

Anterior Superior Iliac Spine to the Tibial Tuberosity Length: An Easier, Accurate, and Faster Method for Predicting Orogastric Tube Length in Neonates-An Observational Study

Orogastric tube (OGT) procedures are done in 20% of newborn unit cases. This study was contemplated to work out a formula to predict OGT length in terms of femur length in neonates and its agreement to existing standards. In this observational study, OGT length was estimated using NEMU (nose-ear-mid umbilicus) in 53 consecutive newborns. Their anterior superior iliac spine to tibial tuberosity length (AS-TT) was measured and equated using linear regression analysis in Stata. We further verified the accuracy of the new formula and comparison of time taken by both the methods. Strong positive correlation was seen between OGT and AS-TT (r = .88). OGT length was 10.14 + 0.88 AS-TT, which can be used in neonatal intensive care unit newborns with greater accuracy and with lesser time than the classical method. Strong agreement levels were seen. AS-TT closely relates to the femur length and can be chosen as a guide as it is faster when compared to other methods.

Factors Predicting Recovery of Oral Intake in Stroke Survivors with Dysphagia in a Convalescent Rehabilitation Ward

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.

The Use of Enteral Nutrition in the Management of Stroke

This article discusses the use of enteral nutrition in the management of stroke. Stroke is a major source of disability, including dysphagia. The clinical manifestation of swallowing difficulties in stroke patients may lead to malnutrition which has implications for health status and clinical outcomes including morbidity, mortality and cost to the health service. The prevalence of malnutrition following an acute stroke could range from 8% to 34%. Therefore, the need to develop and implement the use of enteral nutrition support in stroke patients becomes pertinent. A range of enteral feeding tubes and feeding methods may be used to support stroke patients who are unable to meet their nutritional requirements through oral intake alone, although each of these approaches has its merits and limitations. Based on this review, there is evidence that enteral nutrition support is a useful method of providing nutrition for patients with dysphagia following a stroke in order to enhance their nutritional status and promote their health. However, there are challenges in the use of enteral tube feeding in these patients.

Recent Advances in Enteral Nutrition

There have been significant advances in the provision of enteral nutrition support in the acute and community healthcare settings.[...].

The challenges of home enteral tube feeding: a global perspective

The aim of this review is to provide a global perspective of Home Enteral Tube Feeding (HETF) and to outline some of the challenges of home enteral nutrition (HEN) provisions. It is well established that the number of patients on HETF is on the increase worldwide due to advances in technology, development of percutaneous endoscopic gastrostomy techniques, and the shift in care provisions from acute to community settings. While the significance of home enteral nutrition in meeting the nutritional requirements of patients with poor swallowing reflexes and those with poor nutritional status is not in doubt, differences exist in terms of funding, standards, management approaches and the level of infrastructural development across the world. Strategies for alleviating some of the challenges militating against the effective delivery of HETF including the development of national and international standards, guidelines and policies for HETF, increased awareness and funding by government at all levels were discussed. Others, including development of HEN services, which should create the enabling environment for multidisciplinary team work, clinical audit and research, recruitment and retention of specialist staff, and improvement in patient outcomes have been outlined. However, more research is required to fully establish the cost effectiveness of the HEN service especially in developing countries and to compare the organization of HEN service between developing and developed countries.