Percutaneous Endoscopic Gastrostomy Tube Insertion in Neurodegenerative Disease: A Retrospective Study and Literature Review

Palliative Care in Parkinson's Disease

Palliative care aims to alleviate suffering from symptoms not often addressed in typical clinic visits, including nonmotor symptoms, psychosocial and caregiver burden, and advanced care planning. Palliative care is appropriate at any point in Parkinson's disease, but hospice care is an important potential therapy for end-of-life care. Palliative care remains underutilized, and work is underway on developing palliative care delivery models.

One-Year Mortality After Percutaneous Endoscopic Gastrostomy: The Prognostic Role of Nutritional Biomarkers and Care Settings

Background/Objectives: This study aimed to evaluate the clinical outcomes, complications, and one-year mortality of patients undergoing percutaneous endoscopic gastrostomy (PEG) in different care settings (hospital, nursing home, and home). Additionally, we investigated the comparative prognostic role of the prognostic nutritional index (PNI) and the CRP-to-albumin ratio (CAR) in predicting mortality among these patients. Methods: A retrospective analysis of 236 adult patients who underwent PEG placement between January 2022 and December 2023 was performed. Demographic, clinical, and laboratory data were collected. The PNI was calculated according to the following formula: PNI = 10 × (albumin) + 0.005 × (lymphocyte count). The CAR was obtained by the ratio of the CRP level to the albumin level. Patients were categorized based on their post-PEG care settings. Results: Neurologic disorders were the most common indication for PEG (69.9%). The one-year mortality was 32.2%, with a median survival of 38 weeks (95% CI: 35-41). In the multivariable model, a lower PNI (HR = 0.93, 95% CI: 0.89-0.97, p < 0.001), as well as being followed in a hospital setting, emerged as independent predictors of mortality. Patients with timely PEG tube replacement showed a reduced mortality risk. The ROC analysis showed that the PNI had a higher AUROC (0.78 ± 0.04) compared to the CAR (0.69 ± 0.04), indicating superior prognostic accuracy for predicting one-year mortality. Conclusions: Care settings significantly influence survival outcomes, with better mortality rates observed in nursing homes and home environments. The PNI was superior to the CAR in predicting one-year mortality, emphasizing its clinical utility in risk stratification for PEG patients. Proactive tube management and individualized care strategies are critical for improving the prognosis in this population.

Clinical Practices and Opinions toward Gastrostomy Use in Patients with Atypical Parkinsonian Syndromes: A National Survey in the UK

BACKGROUND

Severe dysphagia poses a significant challenge for clinicians regarding feeding tube choices, practices, and timing due to a lack of evidence-based guidance.

OBJECTIVES

To assess national clinical practices and opinions on gastrostomy use in patients with atypical parkinsonian syndromes (APS) across the UK.

METHODS

Online survey was administered to clinicians and allied health professionals regarding availability of services, current use, perceived advantages, and problems associated with gastrostomy insertion.

RESULTS

We received responses from 47 respondents across 12 UK centers, including 44 clinicians specialized in APS. Consensus was observed regarding primary indications for gastrostomy insertion and circumstances justifying avoidance of the procedure. Limitations in recommending gastrostomy due to insufficient evidence on safety and outcomes, survival and quality of life were identified. Widespread agreement on delays in gastrostomy discussions was highlighted as a challenge in optimizing patient care, together with variability in current practices and concerns over the lack of a standardized gastrostomy pathway, emphasizing the need for further research to address existing evidence gaps.

CONCLUSION

This multi-center survey highlights agreement among clinicians on key aspects of indication, challenges, and limitations such as delayed decision-making and the absence of standardized pathways regarding the timing, method, and overall approach to gastrostomy insertion in APS. This study identified next steps to facilitate a more structured approach to future research toward a consensus on best practices for gastrostomy in APS. Addressing these challenges is crucial for enhancing patient outcomes and overall care quality in APS.

Clinical Practice Guideline for Percutaneous Endoscopic Gastrostomy

With an aging population, the number of patients with difficulty swallowing due to medical conditions is gradually increasing. In such cases, enteral nutrition is administered through a temporary nasogastric tube. Long-term use of a nasogastric tube leads to various complications and a decreased quality of life. Percutaneous endoscopic gastrostomy (PEG) is the percutaneous placement of a tube into the stomach, aided endoscopically, which may be an alternative to a nasogastric tube when enteral nutritional is required for 4 weeks or more. This paper is the first Korean clinical guideline for PEG. It was developed jointly by the Korean College of Helicobacter and Upper Gastrointestinal Research and led by the Korean Society of Gastrointestinal Endoscopy. These guidelines aimed to provide physicians, including endoscopists, with the indications, use of prophylactic antibiotics, timing of enteric nutrition, tube placement methods, complications, replacement, and tubes removal for PEG based on the currently available clinical evidence.

Radiologically inserted gastrostomy tube in neurological disease: A retrospective study

Objectives

This study aimed to compare the safety and efficacy of balloon and non-balloon (or dilator) gastrostomy devices in radiologically inserted gastrostomy (RIG) for patients with neurological disease.

Material and Methods

A retrospective analysis of 152 patients was conducted at a tertiary care hospital from July 2017 to September 2020. 104 and 48 patients were included in the balloon and non-balloon groups, respectively. The frequency of complications per specific neurological indication as well as the breakdown of the different complications pertaining to each indication was recorded for analysis. The recovery time, fluoroscopy time, contrast volume, peak radiation, and pain management dosages for each procedure were all reviewed to evaluate for statistical differences between the balloon and non-balloon groups. An adjusted model odds ratio (OR) was conducted to evaluate how each of the variables (type of gastrostomy tube, body mass index [BMI], age, and gender) affected the frequency of complications within our cohort.

Results

This study included 152 patients, with an average age of 65.17 years (interquartile range [IQR] = 12.66) and an average BMI of 26.97 (IQR = 7.19). The majority of patients were male (71.1%). The most common indication for the procedure was stroke (24.3%), followed by post-intubation dysphagia (16.4%) and intracranial hemorrhage (11.8%). Amyotrophic lateral sclerosis (ALS) and altered mental status had a similar prevalence at 9.9%. The overall complication rate was 33.8%, overall mortality rate 3.3%, 30-day mortality rate of 2.6%, and no other major complications according to CIRSE criteria. Notably, patients with neurodegenerative disorders exhibited comparable rates of minor complications: 33.3% in ALS (5/15 patients), 50% in myasthenia gravis (1/2 patients), and 100% in muscular dystrophy (1/1 patient). The study compared two groups: the balloon group (104 patients) and the dilator group (48 patients). The balloon group received significantly lower preoperative sedation in the form of fentanyl (Avg = 4.46 min vs. 6.54 min, P = 0.287). The balloon group had shorter fluoroscopy time, lower radiation exposure dose, and shorter operating time compared to the dilator group, though not statistically significant. In the logistic regression model, there was no statistical difference in complication rates between the dilator and balloon groups. BMI, age, and gender did not significantly affect minor complication rates.

Conclusion

RIG tube insertions may serve as a valuable, alternative approach in providing enteral support in patients with neurological disease.

A comparison of balloon-assisted versus dilator in percutaneous gastrostomy tube placement

Objectives

This study assesses the safety and efficacy of balloon-assisted gastrostomy (BAG) compared to conventional techniques using dilators.

Material and Methods

A single-center retrospective review of all fluoroscopically-guided percutaneous gastrostomy tube insertions from July 2017 to September 2020 was performed. Two hundred and seventy-three patients were included in this study, with 183 patients and 90 patients in the BAG and dilator groups, respectively. Fluoroscopy time, peak radiation dose, pain management, days to interventional radiology (IR) reconsultation, and post-operative complications (major and minor) for each procedure were reviewed to evaluate for statistical differences.

Results

There were shorter fluoroscopy times (5.13 min vs. 7.05 min, P = 0.059) and a significantly lower radiation use (Avg = 102.13 mGy vs. 146.98 mGy, P < 0.05) in the BAG group. The BAG group required significantly lower operating time (41 min vs. 48 min, P < 0.01) and received lower pain management (fentanyl 75 mcg and midazolam 1.5 mg, P < 0.001). The mean days to IR reconsultation for the BAG group was greater (29 days vs. 26 days, P = 0.38). The overall rate of minor complications (grades 1 and 2, according to the CIRSE classification system) was higher in the dilator group (39% vs. 35% in BAG group, P = 0.53). No major complications were reported in either group.

Conclusion

BAG is a safe and efficient technique for percutaneous gastrostomy tube placement. BAG patients required significantly lesser radiation, OR time, post-operative pain management, and recorded lower postoperative complications compared to their counterparts in gastrostomies utilizing dilators.

Nutrition nurse-led outpatient 'hot' clinics are efficient and cost-effective: a retrospective single-centre evaluation

BACKGROUND

Nutrition nurses work in multidisciplinary and nurse-led outpatient clinics. The daily nutrition nurse-led 'hot' clinic in this study sees patients for enteral or home parenteral nutritional support. Appointments may be for routine procedures or emergency reviews.

AIMS

This study aimed to identify activities and procedures performed in the nutrition nurse-led clinic, identifying admission avoidance activity.

METHODS

Nurse-held records for the period from April 2018 to March 2020 were reviewed retrospectively. Data were collated in an Excel spreadsheet for analysis and results are presented using descriptive statistics.

RESULTS

Records covered a total of 590 patients, 294 men and 296 women with a median age of 59 years, and 606 procedures. Key activities were troubleshooting enteral feeding tubes (29%), insertion of fine-bore nasogastric feeding tubes (18%) and management of home parenteral nutrition issues (11%). The presenting problem or issue was resolved in 90% of patients, with no need for hospital admission or additional medical review.

CONCLUSION

The nutrition nurse-led clinic provides an efficient and cost-effective service, preventing hospital admission and emergency department attendance in most cases.

Neurological update: the palliative care landscape for atypical parkinsonian syndromes

Atypical parkinsonian syndromes are neurodegenerative conditions, characterised by rapid disease progression and shorter life expectancy compared to idiopathic Parkinson's disease. These conditions inflict substantial physical and psychosocial burden on patients and their families; hence, there is a clear rationale for a palliative care approach from diagnosis. An interdisciplinary care model has been shown to improve symptom burden, quality of life and engagement with advance care planning, in a heterogeneous group of neurodegenerative conditions. In this update, we summarise how the landscape for treating these patients has changed and the questions that still need to be resolved.

Palliative care in Parkinson disease and related disorders

Although neuropalliative care is a relatively new field, there is increasing evidence for its use among the degenerative parkinsonian syndromes, including idiopathic Parkinson disease, progressive supranuclear palsy, multiple system atrophy, dementia with Lewy bodies, and corticobasal syndrome. This chapter outlines the current state of evidence for palliative care among individuals with the degenerative parkinsonian syndromes with discussion surrounding: (1) disease burden and needs across the conditions; (2) utility, timing, and methods for advance care planning; (3) novel care models for the provision of palliative care; and 4) end-of-life care issues. We also discuss currently unmet needs and unanswered questions in the field, proposing priorities for research and the assessment of implemented care models.

Exploring Gastrostomy Care-Related Information Needs in Patients With Amyotrophic Lateral Sclerosis and Their Families

The aim of this study was to explore gastrostomy care-related information needs in amyotrophic lateral sclerosis (ALS) patients and their families. This was a quantitative content analysis. Data were collected from a major online patient community in Korea by analyzing posted free texts. A total of 173 posted free texts from January 2010 to July 2020 from the "question and answer" bulletin board were analyzed. Questions were mostly asked by the adult children of patients, and the most frequent question period was "after hospital discharge." The commonly mentioned topics related to gastrostomy and G-tube complications. Patients with ALS and their families have a high requirement for gastrostomy care and enteral feeding information. These findings indicate that there is a need to support decision-making for gastrostomy in hospitals and to provide information about G-tube care and enteral nutrition after leaving the hospital. This information and coaching/support for patients with amyotrophic lateral sclerosis and their families currently appears to be obtained mainly through online patient communities. Both hospital and home care nurses could play a greater role in providing this information.

A qualitative meta-synthesis of evidence (meta-ethnography) exploring the personal experiences of gastrostomy tube in neurodegenerative diseases: a case of motor neurone disease

PURPOSE

The lived experiences of a gastrostomy tube (GT) in adults with neurodegenerative diseases (NDDs) are not well understood. The aim of this qualitative meta-synthesis was to review and synthesise the available evidence to inform clinical practice and identify research gaps.

METHODS

Meta-ethnographic synthesis of qualitative studies was conducted with systematic searching of eight databases from inception to March 2021. Qualitative studies reporting personal experiences of GTs in adults with NDDs were identified. New theories were developed during translation of concepts from each study and combined as a "line-of-argument" synthesis. Patient and public involvement was incorporated as two of the authors are living with an NDD and a GT.

RESULTS AND CONCLUSIONS

Of 2863 unique records identified, only nine fulfilled the review criteria. All studies recruited participants with motor neurone disease (MND); no other NDDs were represented. Two main themes emerged: decision making and living with GT. Decision making was the predominant theme and data regarding living with GT were sparse. There is limited research on the lived experience of a GT in adults with NDDs. The lived experience of GT in MND is complex and individualised. Future research is indicated to inform clinical practice.Implications for rehabilitationEvidence related to the lived experiences of gastrostomy tube (GT) in neurodegenerative diseases (NDDs) is lacking especially in relation to the time after GT insertion.Decision making in relation to GT is a complex and individualised psychological process for some people, while others perceive no decisional conflict.Support from healthcare professionals is crucial during the decision-making time and should not cease after GT insertion.Support from healthcare professionals can help resolve any clinical complications and also incorporate GT into everyday routines.Healthcare professionals should be aware that their views on the benefits and problems related to GT may differ to those of individuals with a NDD.

Palliative Care in Movement Disorders: an Evolving Field

PURPOSE OF REVIEW

This review summarizes the current state of evidence for palliative care (PC) in movement disorders, describes the application of PC to clinical practice, and suggests future research directions.

RECENT FINDINGS

PC needs are common in persons living with movement disorders and their families from the time of diagnosis through end-of-life and contribute to quality of life. Early advance care planning is preferred by patients, impacts outcomes and is promoted by PC frameworks. Systematic assessment of non-motor symptoms, psychosocial needs and spiritual/existential distress may address gaps in current models of care. Several complementary and emerging models of PC may be utilized to meet the needs of this population. A PC approach may identify and improve important patient and caregiver-centered outcomes. As a relatively new application of PC, there is a need for research to adapt, develop and implement approaches to meet the unique needs of this population.

How people living with motor neurone disease and their carers experience healthcare decision making: a qualitative exploration

PURPOSE

Healthcare decision making in motor neurone disease (MND) focuses on symptom management and quality of life. Decision making may be affected by personal approach to receiving information, decision making style, and disease symptoms. This study explored decision making from the perspectives of people living with motor neurone disease (plwMND). The issues impacting engagement and involvement in healthcare decisions were investigated.

METHODS

Semi-structured interviews were conducted with 19 plwMND and 15 carers. Interview data was inductively analysed to identify and describe patterns and themes.

RESULTS

Data analysis identified six overarching themes: Dimensions of decision making; Window of opportunity for choice; Intrinsic influences on decision making; Extrinsic influences impacting decision making; Planning in uncertainty; and, Communication is core. Many participants did not identify a process of "decision-making" except if considering early gastrostomy placement. Information provision requires a balance between ensuring patients are informed but not overwhelmed. Communication impairment impacts involvement. Healthcare professionals' communication style influences engagement in decision making.

CONCLUSION

PlwMND perceive a lack of clinical decisions to make because disease symptoms and clinical phenotypes dictate necessary interventions. PlwMND describe communication impairment as a barrier to involvement in decision making and extra support is required to ensure they maintain engagement.IMPLICATIONS FOR REHABILITATIONPeople living with MND (plwMND) perceive they have few clinical decisions to make and viewed this process as "accepting a recommendation", rather than "making a decision" although early gastrostomy placement is the exception with considerable deliberation evident.Specialist multidisciplinary clinic advice is especially helpful for plwMND without dysphagia (swallowing problems) when considering early gastrostomy placement.Communication impairment may be a barrier to involvement in healthcare decisions and extra support to remain engaged is required.Some plwMND choose not to involve others in their decisions, and patients/families with medical or scientific backgrounds are more likely to collaborate with each other outside the context of clinic appointments.

Attitude and experience of neurologists towards percutaneous endoscopic gastrostomy: an Egyptian study

Background

Dysphagia is a common symptom among various neurological diseases. Guidelines recommend gastrostomy insertion for prolonged dysphagia with lower rate of intervention failure encountered with percutaneous endoscopic gastrostomy (PEG) as compared to nasogastric tube insertion.

Methods

Neurology consultants only were included and completed a self-administered questionnaire concerning their practice backgrounds and previous experience with PEG feeding during their practice.

Results

Ninety-eight percent stated that they would recommend PEG for patients with prolonged need of nasogastric feeding. However, only 88% actually referred patients to perform PEG, with the cerebrovascular disorders being the most common cases to be referred. The main barriers the surveyed neurologists faced were family resistance and financial reasons (53.5%). Interestingly, younger neurologists practicing for less than 15 years referred patient to perform PEG significantly more frequent than older ones (p = 0.01). About 18% of our sample confirmed the lack of sufficient knowledge about the benefits of PEG feeding, and only 22% previously attended scientific sessions about the benefits and indications of PEG.

Conclusion

Based on our study, we recommend that PEG should be more encouraged in indicated neurological cases. Scientific sessions targeting neurologists and public awareness about the benefits of PEG and its relatively infrequent complications are highly demanded.

Percutaneous endoscopic gastrostomy tube placement in amyotrophic lateral sclerosis: a case series with a multidisciplinary, team-based approach

Background

Amyotrophic lateral sclerosis is a progressive neurodegenerative disease that affects motor neurons. When bulbar symptoms impair oral nutritional uptake, guidelines recommend percutaneous endoscopic gastrostomy tube placement. Studies evaluating the appropriate timing and procedural method of placement of gastrostomy tubes have been published; however, no study has been published that evaluated outcomes from a team-based approach to percutaneous endoscopic gastrostomy placement.

Methods

A retrospective cohort study was performed to evaluate 26 amyotrophic lateral sclerosis patients with various respiratory statuses, who had percutaneous endoscopic gastrostomy tubes placed using a multidisciplinary approach that included neurology, anesthesia, general surgery, and gastroenterology. Preprocedural risks and postprocedural outcomes were compared with previously published studies.

Results

The mean age at percutaneous endoscopic gastrostomy placement was 66 years. The mean forced vital capacity was 54% and 18 patients (72%) were on noninvasive ventilation. There were 3 minor complications and no major complications prior to index discharge. The mean length of hospital stay was 3 days. There were no delayed complications or deaths. All patients alive at 6 months and 1 year were using their gastrostomy tubes without problems.

Conclusions

Compared to previously published studies, a multidisciplinary approach to percutaneous endoscopic gastrostomy placement had a better placement rate, fewer minor and major complications, and a comparative length of stay. These data support the effectiveness of a multidisciplinary approach to increase the success and survival rates of patients with amyotrophic lateral sclerosis.

Mortality and Institutionalization After Percutaneous Endoscopic Gastrostomy in Parkinson's Disease and Related Conditions

Background

Percutaneous endoscopic gastrostomy (PEG) can facilitate feeding and medication administration in dysphagic patients with Parkinson's disease and related disorders. Information on survival, institutionalization, and complications post PEG might inform feeding decisions.

Method

A total of 93 patients with Parkinson's disease and related disorders were identified by review of PEG registers and by searching the administrative databases in 2 large UK university hospitals (2005-2017); 83 case notes were available for retrospective review. Care processes and outcomes were assessed.

Results

The following were the diagnoses: 58 (70%) had Parkinson's disease, 10 (12%) had progressive supranuclear palsy, 5 (6%) had multiple system atrophy, 3 (4%) had dementia with Lewy bodies, and 7 (8%) had vascular parkinsonism. The median age was 78 years (interquartile range 72-82); 29 (35%) were women. Care processes included a future care plan in place prior to admission for 18 patients (22%), and PEG was placed during emergency admission in 68 patients (82%). The outcomes included median survival at 422 days; 30-day mortality rate was 6% (5 patients); and of 56 patients admitted from home, 18 (32%) were discharged to institutions (nursing or care homes). The most common complication was aspiration pneumonia for 18 (22%) of patients. Age, sex, diagnosis, admission type, comorbidities, and place of residence did not predict survival. Discharge to own home and follow-up by the home enteral feeding team were associated with longer survival.

Conclusion

We recommend markers of advanced disease should prompt advanced care planning. Discussions about PEG feeding should include information about post-PEG survival, complications, and risk of institutionalization. Further research is needed on quality-of-life post PEG and ways to reduce aspiration pneumonia. All PEG patients should have nutrition team follow-up.

Survival following the placement of gastrostomy tube in patients with multiple sclerosis

Background

Around a third of people with multiple sclerosis (MS) experience dysphagia. There is a need for disease-specific information on survival following placement of gastrostomy tube in people with MS.

Objective

We aimed to study survival following gastrostomy in patients with MS.

Methods

We reviewed medical records, home enteral feeding database and death certificates of people with MS who had gastrostomy from 2005 to 2017. Cox regression analysis was performed to identify independent predictors associated with mortality after gastrostomy.

Results

Median survival of 53 patients with MS after gastrostomy was 21.73 months. Median duration of hospital stay after gastrostomy was 14 days (IQR 5.25, 51.5). Survival at 30 days, 3 months, 1, 2, 5 and 10 years were 100% (53/53), 98.1% (52/53), 81.1% (43/53), 54.7% (29/53), 22.4% (11/49) and 6.8% (3/44), respectively. Of 53 patients, 24 died due to respiratory tract infection. Patients who had gastrostomy tube before 50 years of age survived longer (median 28.48 months) compared with those who had the gastrostomy after age 50 years (median 17.51 months) (p = 0.040).

Conclusion

Around 54% of patients with MS survived two or more years following gastrostomy. Younger patients had better survival. The most frequent cause of death was respiratory infection.

A Comprehensive Examination of Percutaneous Endoscopic Gastrostomy and Its Association with Amyotrophic Lateral Sclerosis Patient Outcomes

There is literature discord regarding the impact of percutaneous endoscopic gastrostomy (PEG), or “feeding tube”, on amyotrophic lateral sclerosis (ALS) outcomes. We assess one of the largest retrospective ALS cohorts to date (278 PEG users, 679 non-users). Kruskal–Wallis and Kaplan–Meier analysis compared cohort medians and survival duration trends. A meta-analysis determined the aggregate associative effect of PEG on survival duration by combining primary results with 7 published studies. Primary results (p < 0.001) and meta-analysis (p < 0.05) showed PEG usage is associated with an overall significant increase in ALS survival duration, regardless of onset type. Percent predicted forced vital capacity (FVC %predict) ≥50 at PEG insertion significantly increases survival duration (p < 0.001); FVC %predict ≥60 has the largest associative benefit (+6.7 months, p < 0.05). Time elapsed from ALS onset until PEG placement is not predictive (p > 0.05). ALSFRS-R survey assessment illustrates PEG usage does not slow functional ALS pathology (p > 0.05), but does stabilize weight and/or body mass index (BMI) (p < 0.05). Observed clinical impression of mood (CIM), was not impacted by PEG usage (p > 0.05). Overall results support PEG as a palliative intervention for ALS patients with ≥50 FVC %predict at PEG insertion.

[Percutaneous endoscopic gastrostomy]

Percutaneous endoscopic gastrostomy (PEG) was developed in 1980. Since that time this method has become preferable for long-term enteral nutrition. PEG is an effective and relatively safe procedure for enteral nutrition of patients with impaired enteral feeding. However, complications and mortality are also observed. Indications, contraindications and potential complications of PEG are reviewed in the article.

Predictive Factors for Early Initiation of Artificial Feeding in Patients With Sporadic Creutzfeldt-Jakob Disease

Background: Akinetic mutism has often been used as the predictor of sporadic Creutzfeldt-Jacob disease (sCJD) endpoints, but it may be difficult for general physcians to assess. Nasogastric (NG) tube insertion is indicated for many neurodegenerative diseases with a clinical course of swallowing failure, and can be more easily identified than akinetic mutism by general physicians. Therefore, the aim of this study was to identify whether there are predictive factors for early initiation of artificial feeding in patients with sCJD who require enteral nutrition due to swallowing failure.

Methods: We retrospectively reviewed the medical records of all patients diagnosed with probable sCJD who were admitted to the neurology ward at a medical center in Taiwan from January 2002 to July 2017. We used Pearson's chi-squared test to detect the correlation of initial symptoms, neurological signs, brain magnetic resonance imaging (MRI), electroencephalography (EEG), and increased levels of 14-3-3 protein in cerebrospinal fluid (CSF) analysis. The Cox proportional hazards model was used to detect prognostic factors for early initiation of NG tube insertion in sCJD patients.

Results: The onset age ranged from 51 to 83 years, and mostly ranged from 60 to 79 years. Akinetic mutism was correlated with pyramidal tract signs, myoclonus, and extrapyramidal signs. Furthermore, myoclonus was revealed to be associated with pyramidal tract signs. Multivariate Cox regression analysis showed that myoclonus and elevated CSF levels of 14-3-3 protein are predictive of early NG insertion.

Conclusions: Increased levels of 14-3-3 protein in CSF and the presence of myoclonus at diagnosis are predictive of early swallowing difficulty and indicate rapid deterioration in probable sCJD. In addition to akinetic mutism, early initiation of artificial feeding can be used to predict early deterioration in sCJD.

Nasal unsedated seated percutaneous endoscopic gastrostomy (nuPEG): a safe and effective technique for percutaneous endoscopic gastrostomy placement in high-risk candidates

OBJECTIVE

Percutaneous endoscopic gastrostomy (PEG) tube placement is associated with a high risk of cardiorespiratory complications in patients with significant respiratory compromise. This study reports a case series of high-risk patients undergoing PEG placement using a modified technique-nasal unsedated seated PEG (nuPEG) placement.

DESIGN

Retrospective review of 67 patients at high risk of complications undergoing PEG placement between September 2012 and December 2016.

SETTING

UK specialist tertiary centre for clinical nutrition support.

INTERVENTIONS

Patients underwent 'push' PEG placement using nasal endoscopy without sedation in a seated position.

MAIN OUTCOME MEASURES

Procedural success and tolerability, short term (within 24 hours), medium term (24 hours to 30 days) complications and survival were recorded.

RESULTS

67 patients underwent 68 nuPEG placements. The majority had motor neuron disease (46/67). One patient developed a lower respiratory tract infection the following day. Two patients experienced accidental displacement of their PEG within 2 weeks. One patient died within 30 days of nuPEG insertion due to reasons unrelated to the procedure. Endoscopic comfort scores of 1 or 2 (98.0%) indicated good tolerance. A failure rate of 10.5% was attributed to intrathoracic displacement of the stomach, almost certainly due to the advanced stage of the neurological disease and associated diaphragmatic weakness.

CONCLUSIONS

Our experience with the nuPEG technique suggests that it is safe and well tolerated in high-risk patients. As a result, it has now entirely supplanted radiologically inserted gastrostomy insertion in our institution and we recommend it as the method of choice for gastrostomy tube insertion in such patients.

Palliative Care for Movement Disorders

PURPOSE OF REVIEW

While care for patients with movement disorders has traditionally focused on motor symptoms, there is increasing evidence that optimal care for these disorders is more complex both in terms of the spectrum of symptoms experienced by patients (e.g., pain, depression) and the multidimensional needs of patients and their families. Palliative care is an approach to the care of patients and families affected by serious illnesses that seeks to relieve suffering by addressing complex medical symptoms, psychosocial issues, spiritual well-being, and goals of care. While traditionally associated with cancer and hospice, more recent work in palliative care has focused on integrating a palliative care approach from the time of diagnosis for patients with chronic illnesses, including movement disorders.

RECENT FINDINGS

Studies of patients with movement disorders and their family caregivers suggest that these patients have significant unmet needs under current models of care, including underrecognition and treatment of non-motor symptoms, inadequate psychosocial support, and suboptimal end-of-life care. We describe how a palliative care approach can empower clinicians, patients, and families to reduce common sources of suffering and optimize quality of life. This field recognizes the importance of primary palliative care (palliative skills useful for any clinician caring for persons caring for serious illness) as a foundation of the palliative care approach and complementary to specialist palliative care. In this article, we will focus on primary palliative care skills for movement disorder specialists including providing a diagnosis and prognosis with compassion, discussing goals of care, complex symptom management, caregiver support, spiritual and emotional well-being, and referral to hospice and specialist palliative care. A palliative care approach complements other efforts in movement disorder care. Research is needed to evaluate and develop therapeutic interventions and models of care applying a palliative care approach.

Mitochondrial dysfunction in Parkinsonian mesenchymal stem cells impairs differentiation

Sporadic cases account for 90–95% of all patients with Parkinson's Disease (PD). Atypical Parkinsonism comprises approximately 20% of all patients with parkinsonism. Progressive Supranuclear Palsy (PSP) belongs to the atypical parkinsonian diseases and is histopathologically classified as a tauopathy. Here, we report that mesenchymal stem cells (MSCs) derived from the bone marrow of patients with PSP exhibit mitochondrial dysfunction in the form of decreased membrane potential and inhibited NADH-dependent respiration. Furthermore, mitochondrial dysfunction in PSP-MSCs led to a significant increase in mitochondrial ROS generation and oxidative stress, which resulted in decrease of major cellular antioxidant GSH. Additionally, higher basal rate of mitochondrial degradation and lower levels of biogenesis were found in PSP-MSCs, together leading to a reduction in mitochondrial mass. This phenotype was biologically relevant to MSC stemness properties, as it heavily impaired their differentiation into adipocytes, which mostly rely on mitochondrial metabolism for their bioenergetic demand. The defect in adipogenic differentiation was detected as a significant impairment of intracellular lipid droplet formation in PSP-MSCs. This result was corroborated at the transcriptional level by a significant reduction of PPARγ and FABP4 expression, two key genes involved in the adipogenic molecular network. Our findings in PSP-MSCs provide new insights into the etiology of ‘idiopathic’ parkinsonism, and confirm that mitochondrial dysfunction is important to the development of parkinsonism, independent of the type of the cell.

•

PSP pathology leads to inhibition of mitochondrial respiration and decrease mitochondrial membrane potential.

•

Mitochondrial dysfunction in PSP-MSCs induces ROS generation and oxidative stress.

•

Higher rate of mitophagy reduces mitochondrial mass in PSP-MSCs.

•

PSP impairs differentiation properties in MSCs.