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Kobylecki C, Chelban V, Goh YY, Michou E, Fumi R, Theilmann Jensen M, Mohammad R, Costantini A, Vijiaratnam N, Pavey S, Pavese N, Leigh PN, Rowe JB, Hu MT, Church A, Morris HR, Houlden H. Frequency and outcomes of gastrostomy insertion in a longitudinal cohort study of atypical parkinsonism. Eur J Neurol 2024; 31:e16258. [PMID: 38407533 PMCID: PMC11235814 DOI: 10.1111/ene.16258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/21/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Multiple system atrophy (MSA), progressive supranuclear palsy (PSP) and corticobasal syndrome (CBS) show a high prevalence and rapid progression of dysphagia, which is associated with reduced survival. Despite this, the evidence base for gastrostomy is poor, and the optimal frequency and outcomes of this intervention are not known. We aimed to characterise the prevalence and outcomes of gastrostomy in patients with these three atypical parkinsonian disorders. METHOD We analysed data from the natural history and longitudinal cohorts of the PROSPECT-M-UK study with up to 60 months of follow-up from baseline. Survival post-gastrostomy was analysed using Kaplan-Meier survival curves. RESULTS In a total of 339 patients (mean age at symptom onset 63.3 years, mean symptom duration at baseline 4.6 years), dysphagia was present in >50% across all disease groups at baseline and showed rapid progression during follow-up. Gastrostomy was recorded as recommended in 44 (13%) and performed in 21 (6.2%; MSA 7, PSP 11, CBS 3) of the total study population. Median survival post-gastrostomy was 24 months compared with 12 months where gastrostomy was recommended but not done (p = 0.008). However, this was not significant when correcting for age and duration of symptoms at the time of procedure or recommendation. CONCLUSIONS Gastrostomy was performed relatively infrequently in this cohort despite the high prevalence of dysphagia. Survival post-gastrostomy was longer than previously reported, but further data on other outcomes and clinician and patient perspectives would help to guide use of this intervention in MSA, PSP and CBS.
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Affiliation(s)
- Christopher Kobylecki
- Division of Neuroscience, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
- Department of Neurology, Manchester Centre for Clinical NeurosciencesNorthern Care Alliance NHS Foundation TrustSalfordUK
| | - Viorica Chelban
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
- Neurobiology and Medical Genetics Laboratory“Nicolae Testemitanu” State University of Medicine and PharmacyChisinauRepublic of Moldova
| | - Yee Yen Goh
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Emilia Michou
- Division of Diabetes, Endocrinology and GastroenterologyUniversity of ManchesterManchesterUK
- Department of Speech and Language Therapy, School of Health Rehabilitation SciencesUniversity of PatrasPatrasGreece
| | - Riona Fumi
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Marte Theilmann Jensen
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Rahema Mohammad
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Alyssa Costantini
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Nirosen Vijiaratnam
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | | | - Nicola Pavese
- Clinical Ageing Research UnitNewcastle UniversityNewcastleUK
| | - P. Nigel Leigh
- Department of NeuroscienceBrighton and Sussex Medical SchoolBrightonUK
| | - James B. Rowe
- Department of Clinical Neurosciences, Cambridge Centre for Parkinson‐Plus, Cambridge University Hospitals NHS TrustUniversity of CambridgeCambridgeUK
| | - Michele T. Hu
- Division of Neurology, Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
| | | | - Huw R. Morris
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Henry Houlden
- Department of Neuromuscular Diseases, Queen Square Institute of NeurologyUniversity College LondonLondonUK
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Charles L, Kothavade U, Brémault-Phillips S, Chan K, Dobbs B, Tian PGJ, Polard S, Parmar J. Outcomes of a Decision-Making Capacity Assessment Model at the Grey Nuns Community Hospital. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031560. [PMID: 35162581 PMCID: PMC8835045 DOI: 10.3390/ijerph19031560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/20/2022] [Accepted: 01/28/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND. With an increasing elderly population, the number of persons with dementia is expected to increase and, consequently, the number of persons needing decision-making capacity assessments (DMCA) is too. However, many healthcare professionals do not feel ready to provide DMCAs. Since 2006, we implemented a DMCA Model that includes a care pathway, worksheets, education, and mentoring. The objective of this study was to assess the impact of the utilization of this patient-centered DMCA model on the need for Capacity Interviews. METHODS. This was a retrospective quality assurance chart review of patients referred for DMCA to the Geriatric Service at the Grey Nuns Community Hospital from 2006–2020. The Geriatric Service is run by Family Physicians with extra training in Care of the Elderly. We extracted patient demographics, elements of the DMCA process, and whether Capacity Interviews were performed. We used descriptive statistics to summarize the data. RESULTS. Eighty-eight patients were referred for DMCAs, with a mean age of 76 years (SD = 10.5). Dementia affected 43.2% (38/88) of patients. Valid reasons for conducting a DMCA were evident in 93% (80/86) of referrals, and DMCAs were performed in 72.6% (61/84). 85.3% (58/68) of referrals identified the need for DMCA in two to four domains, most commonly accommodation, healthcare, and finances. Two to three disciplines, frequently social workers and occupational therapists, were involved in conducting the DMCAs for 67.2% (39/58) of patients. The Capacity Assessment Process Worksheet was used 63.2% of the time. Capacity Interviews were conducted in only 20.7% of referrals. Following the DMCAs, 48.2% (41/85) of those assessed were deemed to lack capacity. CONCLUSION. This study suggests that the DMCA Model implemented has decreased the need for Capacity Interviews while simultaneously respecting patient autonomy. This is an important finding as DMCAs carried out following this process reduced the need for both a Capacity Interview and declarations of incapacity while simultaneously respecting patient autonomy and supporting patients in their decisions in accordance with the legislation.
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Affiliation(s)
- Lesley Charles
- Division of Care of the Elderly, Department of Family Medicine, University of Alberta, Edmonton, AB T6G 2T4, Canada; (U.K.); (K.C.); (B.D.); (P.G.J.T.); (J.P.)
- Correspondence:
| | - Utkarsha Kothavade
- Division of Care of the Elderly, Department of Family Medicine, University of Alberta, Edmonton, AB T6G 2T4, Canada; (U.K.); (K.C.); (B.D.); (P.G.J.T.); (J.P.)
| | | | - Karenn Chan
- Division of Care of the Elderly, Department of Family Medicine, University of Alberta, Edmonton, AB T6G 2T4, Canada; (U.K.); (K.C.); (B.D.); (P.G.J.T.); (J.P.)
| | - Bonnie Dobbs
- Division of Care of the Elderly, Department of Family Medicine, University of Alberta, Edmonton, AB T6G 2T4, Canada; (U.K.); (K.C.); (B.D.); (P.G.J.T.); (J.P.)
| | - Peter George Jaminal Tian
- Division of Care of the Elderly, Department of Family Medicine, University of Alberta, Edmonton, AB T6G 2T4, Canada; (U.K.); (K.C.); (B.D.); (P.G.J.T.); (J.P.)
| | - Sharna Polard
- Library Services, Covenant Health, Edmonton, AB T6L 5X8, Canada;
| | - Jasneet Parmar
- Division of Care of the Elderly, Department of Family Medicine, University of Alberta, Edmonton, AB T6G 2T4, Canada; (U.K.); (K.C.); (B.D.); (P.G.J.T.); (J.P.)
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Boeykens K, Duysburgh I. Prevention and management of major complications in percutaneous endoscopic gastrostomy. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000628. [PMID: 33947711 PMCID: PMC8098978 DOI: 10.1136/bmjgast-2021-000628] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/24/2021] [Accepted: 03/28/2021] [Indexed: 12/17/2022] Open
Abstract
Background Percutaneous endoscopic gastrostomy is a commonly used endoscopic technique where a tube is placed through the abdominal wall mainly to administer fluids, drugs and/or enteral nutrition. Several placement techniques are described in the literature with the ‘pull’ technique (Ponsky-Gardener) as the most popular one. Independent of the method used, placement includes a ‘blind’ perforation of the stomach through a small acute surgical abdominal wound. It is a generally safe technique with only few major complications. Nevertheless these complications can be sometimes life-threatening or generate serious morbidity. Method A narrative review of the literature of major complications in percutaneous endoscopic gastrostomy. Results This review was written from a clinical viewpoint focusing on prevention and management of major complications and documented scientific evidence with real cases from more than 20 years of clinical practice. Conclusions Major complications are rare but prevention, early recognition and popper management are important.
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Affiliation(s)
- Kurt Boeykens
- AZ Nikolaas, Nutrition Support Team, Sint-Niklaas, Oost-Vlaanderen, Belgium
| | - Ivo Duysburgh
- AZ Nikolaas, Nutrition Support Team, Sint-Niklaas, Oost-Vlaanderen, Belgium
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Bond A, Conley T, Fiske J, Raymond V, Young A, Collins P, Dibb M, Smith P. Reducing 30-day post gastrostomy insertion mortality with a feeding issues multidisciplinary team meeting. Clin Nutr ESPEN 2020; 40:282-287. [DOI: 10.1016/j.clnesp.2020.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/03/2020] [Accepted: 09/06/2020] [Indexed: 12/24/2022]
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Mulkerrin S, Edwards V, Roberts R. Management of people with swallowing difficulties in late-stage neurodegenerative disease. ACTA ACUST UNITED AC 2018. [DOI: 10.12968/npre.2018.16.4.176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Síofra Mulkerrin
- Speech and language therapist, Addenbrooke's Hospital, Cambridge
| | - Victoria Edwards
- Speech and language therapist, Addenbrooke's Hospital, Cambridge
| | - Rhys Roberts
- Consultant neurologist, Addenbrooke's Hospital, Cambridge
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Hvas CL, Farrer K, Blackett B, Lloyd H, Paine P, Lal S. Reduced 30-day gastrostomy placement mortality following the introduction of a multidisciplinary nutrition support team: a cohort study. J Hum Nutr Diet 2017; 31:413-421. [DOI: 10.1111/jhn.12520] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- C. L. Hvas
- Department of Hepatology and Gastroenterology; Aarhus University Hospital; Aarhus C Denmark
- Intestinal Failure Unit; Salford Royal NHS Foundation Trust; Mancheter UK
| | - K. Farrer
- Intestinal Failure Unit; Salford Royal NHS Foundation Trust; Mancheter UK
| | - B. Blackett
- Nutrition Support Team; Salford Royal NHS Foundation Trust; Manchester UK
| | - H. Lloyd
- Nutrition Support Team; Salford Royal NHS Foundation Trust; Manchester UK
| | - P. Paine
- Department of Gastroenterology; Salford Royal NHS Foundation Trust; Manchester UK
- The University of Manchester; Manchester UK
| | - S. Lal
- Intestinal Failure Unit; Salford Royal NHS Foundation Trust; Mancheter UK
- The University of Manchester; Manchester UK
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Clarke G, Galbraith S, Woodward J, Holland A, Barclay S. Eating and drinking interventions for people at risk of lacking decision-making capacity: who decides and how? BMC Med Ethics 2015; 16:41. [PMID: 26062801 PMCID: PMC4462006 DOI: 10.1186/s12910-015-0034-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 05/29/2015] [Indexed: 11/12/2022] Open
Abstract
Background Some people with progressive neurological diseases find they need additional support with eating and drinking at mealtimes, and may require artificial nutrition and hydration. Decisions concerning artificial nutrition and hydration at the end of life are ethically complex, particularly if the individual lacks decision-making capacity. Decisions may concern issues of life and death: weighing the potential for increasing morbidity and prolonging suffering, with potentially shortening life. When individuals lack decision-making capacity, the standard processes of obtaining informed consent for medical interventions are disrupted. Increasingly multi-professional groups are being utilised to make difficult ethical decisions within healthcare. This paper reports upon a service evaluation which examined decision-making within a UK hospital Feeding Issues Multi-Professional Team. Methods A three month observation of a hospital-based multi-professional team concerning feeding issues, and a one year examination of their records. The key research questions are: a) How are decisions made concerning artificial nutrition for individuals at risk of lacking decision-making capacity? b) What are the key decision-making factors that are balanced? c) Who is involved in the decision-making process? Results Decision-making was not a singular decision, but rather involved many different steps. Discussions involving relatives and other clinicians, often took place outside of meetings. Topics of discussion varied but the outcome relied upon balancing the information along four interdependent axes: (1) Risks, burdens and benefits; (2) Treatment goals; (3) Normative ethical values; (4) Interested parties. Conclusions Decision-making was a dynamic ongoing process with many people involved. The multiple points of decision-making, and the number of people involved with the decision-making process, mean the question of ‘who decides’ cannot be fully answered. There is a potential for anonymity of multiple decision-makers to arise. Decisions in real world clinical practice may not fit precisely into a model of decision-making. The findings from this service evaluation illustrate that within multi-professional team decision-making; decisions may contain elements of both substituted and supported decision-making, and may be better represented as existing upon a continuum.
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Affiliation(s)
- Gemma Clarke
- Palliative and End of Life Care Group, Department of Public Health and Primary Care, Institute of Public Health Forvie Site, University of Cambridge School of Clinical Medicine, Box 113 Cambridge Biomedical Campus, CB2 0SR, Cambridge, UK.
| | - Sarah Galbraith
- Department of Palliative Care, Box 63, Addenbrooke's Hospital, Hills Road, CB2 0QQ, Cambridge, UK.
| | - Jeremy Woodward
- Department of Gastroenterology, Box 133, Addenbrooke's Hospital, Hills Road, CB2 0QQ, Cambridge, UK.
| | - Anthony Holland
- Cambridge Intellectual & Developmental Disabilities Research Group, Department of Psychiatry, University of Cambridge, Douglas House, 18B Trumpington Road, CB2 8AH, Cambridge, UK.
| | - Stephen Barclay
- Palliative and End of Life Care Group, Department of Public Health and Primary Care, Institute of Public Health Forvie Site, University of Cambridge School of Clinical Medicine, Box 113 Cambridge Biomedical Campus, CB2 0SR, Cambridge, UK.
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Abstract
PURPOSE OF REVIEW This review addresses current controversies regarding appropriate indications for percutaneous endoscopic gastrostomy (PEG) insertion. We address specific indications, namely, dementia, stroke, aspiration, motor neurone disease/amyotrophic lateral sclerosis, and head and neck cancer. We recommend practical strategies for improving patient selection. RECENT FINDINGS There is now a general consensus in the United States that PEG feeding does not benefit patients with advanced dementia. 'Early' PEG insertion following stroke is similarly of no benefit. It is currently unclear whether patients with amyotrophic lateral sclerosis and head and neck tumors should have PEG or radiologically inserted gastrostomy. SUMMARY Decisions relating to PEG insertion remain difficult. The gastroenterologist, working as a member of a multidisciplinary nutrition team, needs to take a lead role in this regard, rather than functioning as a technician.
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Affiliation(s)
- Carthage Moran
- aDepartment of Medicine bDepartment of Gastroenterology, Cork University Hospital, Wilton, Cork, Ireland
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