Construction and validation of an educational booklet on care for children with gastrostomy.

OBJECTIVES: to describe the process of construction and validation of an educational booklet on care for children with gastrostomy, directed to caregivers. METHODS: a methodological study developed in five stages: bibliographic survey; situational diagnosis; illustration, layout, design and text construction; expert validation and Flesch-Kincaid Readability calculation; validation with the target audience. Content Validity Index and Suitability Assessment of Materials were applied for expert analysis. RESULTS: the Content Validity Index obtained overall score of 0.93. In the Suitability Assessment of Materials score, the booklet scored 85.2%. It presented a satisfactory readability percentage, with an overall score of 72%, and was consistent with caregivers' assessment in the validation with the target audience, considering the explanatory technology, important and adequate. CONCLUSIONS: the developed educational booklet was considered valid for use by caregivers, thus contributing to the maintenance of best practices in care for children with gastrostomy.

Factors associated with failure of Enhanced Recovery After Surgery (ERAS) in colorectal and gastric surgery.

Background: The Enhanced Recovery After Surgery (ERAS) pathway is widely applied in the perioperative period of stomach and colorectal surgery, and can decrease the length of hospital stay of the patients without compromising the safety of the patients. However, some patients are removed from this pathway for various reasons. Here we found some factors that taking the patients out from the procedures. Methods: A retrospective analysis of collected data of 550 patients over a 3-year period was conducted, with 292 in the ERAS group and 258 in the conventional care group. Then various basic elements were analyzed to explore the reasons for the failure to complete the ERAS program. Results: Total length of hospital stay after surgery was significantly shorter in the ERAS group, and a similar incidence of complication rates were observed in the two groups. In this study, the significant factors that associated with complications were advanced age (OR 2.18; p = .031), history of abdominal surgery (OR 2.03; p = .04), incomplete gastrointestinal obstruction (OR 3.42; p < .001), laparoscopic surgery (OR 0.39; p = .004) and intraoperative neostomy (OR 2.37; p = .006). Conclusions: We found that advanced age (>80 years old), history of abdominal surgery, gastrointestinal obstruction and stoma formation were the risk factors. We anticipated to design a risk assessment system upon the high-risk patients from the present ERAS pathway, and make a modified ERAS pathway for those patients.

Gastrostomy Tube Weaning and Treatment of Severe Selective Eating in Childhood: Experience in Israel Using an Intensive Three Week Program.

BACKGROUND: Children dependent on gastrostomy tube feeding and those with extremely selective eating comprise the most challenging groups of early childhood eating disorders. We established, for the first time in Israel, a 3 week intensive weaning and treatment program for these patients based on the "Graz model." OBJECTIVES: To investigate the Graz model for tube weaning and for treating severe selective eating disorders in one center in Israel. METHODS: Pre-program assessment of patients' suitability to participate was performed 3 months prior to the study, and a treatment goal was set for each patient. The program included a multidisciplinary outpatient or inpatient 3 week treatment course. The major outcome measures were achievement of the target goal of complete or partial tube weaning for those with tube dependency, and expansion of the child's nutritional diversity for those with selective eating. RESULTS: Thirty-four children, 28 with tube dependency and 6 with selective eating, participated in four programs conducted over 24 months. Their mean age was 4.3 ± 0.37 years. Of all patients, 29 (85%) achieved the target goal (24 who were tube-dependent and 5 selective eaters). One patient was excluded due to aspiration pneumonia. After 6 months follow-up, 24 of 26 available patients (92%) maintained their target or improved. CONCLUSIONS: This intensive 3 week program was highly effective in weaning children with gastrostomy tube dependency and ameliorating severe selective eating. Preliminary evaluation of the family is necessary for completion of the program and achieving the child's personal goal, as are an experienced multidisciplinary team and the appropriate hospital setup, i.e., inpatient or outpatient.

Outcome of Rehabilitation and Swallowing Therapy after Percutaneous Endoscopic Gastrostomy in Dysphagia Patients.

The objective of this study was to investigate the outcomes of rehabilitation (with swallowing therapy) after percutaneous endoscopic gastrostomy (PEG) in patients with neurogenic dysphagia. Forty-seven patients (29 males and 18 females) who were transferred to the rehabilitation ward of our hospital after receiving PEG tube placements during a 5-year period were enrolled in this study. Patients' demographic data, comorbidities, nutritional statuses, and laboratory biomarkers before the PEG procedure were collected. Rehabilitation (with swallowing therapy) outcomes such as changes in Functional Independence Measure (FIM) and dysphagia grade (using Fujishima's classification) were evaluated. Significant improvements in FIM scores and dysphagia grades after rehabilitation therapy were observed. Twenty-seven patients (57.4 %) were discharged with some oral intake and 10 patients (21.3%) were discharged PEG-free (defined as the PEG tube not being used or removed). Factors associated with being discharged with some oral intake were increase in FIM score (adjusted OR 1.10, 95 % CI 1.02-1.19) and higher baseline dysphagia grade (adjusted OR 1.88, 95 % CI 1.04-3.39). Factors associated with being discharged PEG-free were longer rehabilitation period (OR 1.03, 95 % CI 1.01-1.04), absence of respiratory disorders (OR 0.12, 95 % CI 0.03-0.35), and increase in FIM score (OR 1.17, 95 % CI 1.08-1.28). Changes in dysphagia grade were significantly correlated with changes in FIM score (r 2 = 0.46, p < 0.0001), indicating that improvement of FIM scores through general rehabilitation therapy may play an important role in the treatment of dysphagia.

Serum copper evolution in patients that underwent endoscopic gastrostomy for long term enteral feeding / Evolución del cobre sérico en pacientes sometidos a gastrostomía endoscópica para nutrición enteral a largo plazo

Background and aims: Copper (Cu) is a well studied trace element but little is known about Cu evolution in long term endoscopic gastrostomy (PEG) feeding. We aimed to evaluate the evolution serum Cu since the gastrostomy until 12 weeks after the procedure in PEG patients fed with homemade meals. Methods: A prospective observational study was performed evaluating serum copper, albumin, transferrin and body mass index (BMI) at the time of the gastrostomy, 4 weeks and 12 weeks after. Data also included age, gender, NRS 2002 and nature of the underlying disease causing dysphagia: head and neck cancer (HNC) or neurological dysphagia (ND). After gastrostomy, patients were fed with homemade PEG meals. Results: One hundred and forty-six patients enrolled, 89 men, aged 21-95 years, 90 with neurologic dysphagia (ND), and 56 with head and neck cancer (HNC). 78 (53%) showed low BMI. Initially, Cu ranged 42-160 µg/dl (normal: 70-140 µg/dl); 130 patients (89%) presented normal Cu, 16 (11%) presented hypocupremia, 53% low albumin (n = 77), and 94 (65%) low transferrin. After 4 weeks, 93% presented normal Cu, 7% presented hypocupremia, low albumin was present in 34%, and low transferrin in 52%. After 12 weeks, 95% presented normal Cu, 5% presented hypocupremia, low albumin was present in 25%, and low transferrin in 32%. Comparing age, gender, underlying disease, BMI, albumin and transferrin, there were no significant differences on serum Cu. Conclusions: Most patients present normal serum Cu when gastrostomy is performed. For patients presenting hypocupremia before gastrostomy, homemade meals are effective for normalizing serum Cu (AU)

Introducción y objetivos: el cobre (Cu) es un oligoelemento muy estudiado, pero poco se sabe de su evolución en los pacientes alimentados por gastrostomía endoscópica (GEP). Pretendemos evaluar la evolución del Cu sérico desde la gastrostomía hasta 12 semanas después de la intervención en estos pacientes alimentados con preparaciones domésticas. Métodos: realizamos un estudio observacional prospectivo para evaluar el Cu sérico, la albúmina, la transferrina y el índice de masa corporal (IMC) en el momento de la GEP, tras 4 semanas y 12 semanas después de la intervención. Los datos incluyen edad, género, NRS 2002 y enfermedad subyacente: cánceres de cabeza y cuello (CCC) y disfagia neurológica (DN). Después de la intervención, estos pacientes fueron alimentados con preparaciones domésticas. Resultados: 146 enfermos (89 hombres), entre 21-95 años: CCC-56, DN-90. Valores de Cu entre 42-160 µg/dl (normal: 70-140 µg/dl); normales 89% (n = 130); bajos 11% (n = 16), albúmina baja: 53% (n = 77), transferrina baja: 65% (n = 94), IMC bajo: 53% (n = 78). Después de 4 semanas: valores normales de Cu en 93% y bajos en 7%, albúmina baja en 34%, transferrina baja en 52%. Tras 12 semanas: valores normales de Cu en 95% y bajos en 5%, albúmina baja en 25%, transferrina baja en 32%. No encontramos diferencias significativas en el Cu sérico cuando se compara edad, género, enfermedad subyacente, IMC, albúmina y transferrina. Conclusiones: la mayoría de los enfermos presentan Cu sérico normal en el momento de la gastrostomía. Para los enfermos con Cu sérico bajo antes del procedimiento, la alimentación con preparaciones domésticas parece suficiente para su normalización progresiva (AU)

La opinión del paciente cuenta: Experiencia en la atención nutricional en un equipo multidisciplinar de ELA / The patient’s opinion matters: experience in the nutritional care in an ALS multidisciplinary team

La Esclerosis Lateral Amiotrófica (ELA) es una enfermedad neurodegenerativa que carece de tratamiento curativo por lo que el tratamiento será sintomático en Unidades Multidisciplinares. Éstas estarán compuestas por los profesionales expertos necesarios para la atención del enfermo con una visión interdisciplinar que actúe de una forma coordinada ante las diferentes situaciones que puedan surgir a lo largo de la evolución de la enfermedad. En este sentido existen diferentes estudios que demuestran una mayor supervivencia en los pacientes tratados en el marco de un equipo multidisciplinar comparado con el tratamiento por especialidades aisladas. En el Hospital Universitario de Bellvitge desde 2004 se ha creado una Unidad Multidisciplinar de ELA que integra neurólogo, neumólogo, nutricionista, endocrinólogo, rehabilitador, fisioterapeuta, psicólogo, trabajador social, enfermera gestora, logopeda, administrativo. Para evaluar el impacto de la atención multidisciplinar de nuestro programa se evaluaron 418 pacientes diagnosticados de ELA, 84 pacientes habían recibido atención por consultas de neurología general y 334 tratados bajo un modelo de atención multidisciplinar. Los pacientes que fueron tratados en la unidad de atención multidisciplinar tuvieron una mediana de supervivencia de 1246 días (IC 1109 - 1382), 104 días superior a la mediana de 1148 días de aquellos seguidos en la consulta de neurología general (IC 998 - 1297). Esta diferencia fue estadísticamente significativa (log-rank10,8, p 0,008). Este beneficio fue independiente del hecho de haber recibido tratamiento con riluzole, ventilación mecánica no invasiva o gastrostomía percutánea. La valoración nutricional se realizará desde la primera visita y en todos los controles posteriores. Es importante realizar las medidas antropométricas y detectar la pérdida de peso involuntaria y las posibles causas desencadenantes para establecer el tratamiento nutricional adecuado. La exploración de la disfagia permite establecer el consejo dietético adecuado, la introducción de espesantes para adecuar la textura de los alimentos o la suplementación nutricional con fórmulas hipercalóricas para evitar o corregir la pérdida de peso. En el caso que estas medidas no sean suficientes o bien existe el riesgo de fracaso de la función respiratoria se indicará la colocación precoz de gastrostomía. El análisis de 140 pacientes con ELA (92 controles y 48 con gastrostomía radiológica percutánea), no mostró diferencias en el tiempo de supervivencia media entre los grupos (32 vs 33,9 meses, log Rank 1,86 p= 0,39). Ningún paciente presentó complicaciones mayores. A pesar de no evidenciar cambios en la supervivencia, el uso de la gastrostomía debe ser entendido como un tratamiento destinado a mejorar la calidad de vida y el bienestar del paciente. El apoyo psicosocial a la persona y al entorno familiar es fundamental para poder integrar todos los cambios y situaciones que surgirán en la evolución de la enfermedad. Debe iniciarse desde el diagnóstico ya que la atención temprana contribuye a su mejor formación, prevenir situaciones de deterioro y afrontar el proceso de dependencia. Además existe la posibilidad de utilizar la tecnología y las redes sociales para complementar el modelo asistencial clásico. En el caso concreto de la Unidad Funcional de ELA del HUB, las personas afectadas y sus familias cuentan con los recursos del Aula Paciente y el blog ELA, creados con el objetivo de ofrecer espacios de diálogo entre pacientes, familiares y cuidadores. El grado de satisfacción del paciente con la atención recibida por la Unidad Multidisciplinar de ELA sobre la accesibilidad al servicio, la información recibida y la calidad de la atención, globalmente fue valorada cómo buena en el 52,8% o muy buena en el 29,2 % de los pacientes. Conclusión: La atención a la persona afectada de ELA debe ser contemplada en el marco de un equipo multidisciplinar integrado por todos los profesionales que vayan a intervenir a lo largo del proceso de su enfermedad para ofrecer una mayor supervivencia con la mejor atención y calidad de vida (AU)

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Avaliação de famílias de crianças e adolescentes submetidos à gastrostomia / Family evaluation of children and adolescents submitted to gastrostomy

O estudo objetivou conhecer a estrutura, funcionamento e desenvolvimento da família, identificar redes de apoio social no cuidado à criança e ao adolescente gastrostomizado, e descrever dificuldades e facilidades enfrentadas nessa experiência. Utilizou-se o Modelo Calgary de Avaliação Familiar, como referencial teórico, tendo sido acrescido da entrevista semiestruturada como instrumento de pesquisa; a Análise de Narrativa foi o método seguido. O uso do dispositivo tecnológico afeta os cuidadores e sua rotina, e estabelece relacionamento de renúncia e doação para com o gastrostomizado. Existe dificuldade em aceitar que os filhos não se alimentam normalmente. Os principais contratempos foram referentes à falta de conhecimento e treinamento para os cuidados específicos no domicílio. Os apoios são limitados. Este estudo possibilitou compreender melhor a experiência dessas famílias e evidenciou que o uso de um dispositivo tecnológico traz melhoras à saúde da criança, porém é um processo difícil de ser aceito inicialmente.

The study aimed to understand the structure, operation and development families, to identify social support networks for the care of the child and adolescent submitted to gastrostomy, and to describe difficulties and facilities faced in this experience. We used the Calgary Family Assessment Model as theoretical reference, we added it to the semi-structured interview as research instrument; and we used Narrative Analysis as method. The uses of the technological device affect caregivers and their routines, and establish a relationship of renounce and donation with the gastrectomy patient. Difficulty was found to accept that their children are not fed normally. The main setbacks referred to the lack of knowledge and training for specific homecare. Support is limited. This study allowed better comprehension of experiences from families and showed that the use of a technological device brings benefits to the child's health, thus, it is a difficult process to be accepted at first.

ESPGHAN position paper on management of percutaneous endoscopic gastrostomy in children and adolescents.

OBJECTIVES: This European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) position statement provides a comprehensive guide for health care providers to manage percutaneous endoscopic gastrostomy tubes in a safe, effective, and appropriate way. METHODS: Relevant literature from searches of PubMed, CINAHL, and recent guidelines was reviewed. In the absence of evidence, recommendations reflect the expert opinion of the authors. Final consensus was obtained by multiple e-mail exchange and during 3 face-to-face meetings of the gastroenterology committee of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. RESULTS: Endoscopically placed gastrostomy devices are essential in the management of children with feeding and nutritional problems. The article focuses on practical issues such as indications and contraindications. CONCLUSIONS: The decision to place an endoscopic gastrostomy has to be made by an appropriate multidisciplinary team, which then provides active follow-up and care for the child and the device.

As práticas de cuidado da família à criança com gastrostomia no contexto domiciliar / Family care practices toward children with gastrostomy in the home context

O desenvolvimento tecnológico permitiu o aumento da expectativa de vida de crianças com necessidades especiais de saúde. Neste contexto, a gastrostomia vem sendo utilizada com maior frequência em crianças que apresentam dificuldades e risco para se alimentar por via oral. O cuidado a crianças com gastrostomia exige demandas de cuidados peculiares e imprescindíveis à sobrevida que serão realizados pelos familiares cuidadores no domicílio. Neste sentido, esse estudo teve como objeto de investigação,o cuidado do familiar cuidador à criança com gastrostomia no contexto domiciliar. Como objetivos: conhecer como o familiar cuidador realiza os cuidados à criança com gastrostomia no cenário domiciliar; desvelar os desafios enfrentados pelo familiar cuidador na prática de cuidar da criança com gastrostomia no domicílio; e analisar as estratégias que mediaram às práticas de cuidar do familiar cuidador com crianças gastrostomia no domicílio. Os alicerces teóricos estiveram pautados nas concepções de cuidado de Collière e na educação problematizadora de Paulo Freire. Metodologia: pesquisa qualitativa desenvolvida por meio do método criativo sensível, com a implementação da dinâmica Corpo Saber no domicílio de crianças com gastrostomia com 16 familiares cuidadores. Para a análise dos resultados, utilizou-se a análise de discurso em sua corrente francesa. Os discursos dos familiares no processo de alimentar a criança com gastrostomia revelaram a necessidade de triturar os alimentos de modo a torná-lo mais liquefeito e assim administrá-lo com maior facilidade pela sonda, a preocupação com valor nutricional e o volume do alimentoa ser administrado. Acerca da administração dos medicamentos, apontaram a necessidade de triturar os medicamentos sólidos, a preocupação comos horários e a forma de administrá-los. Quanto aos cuidados com higienização abordaram questões relacionadas aos utensílios, dispositivo e à pele periestomal.

Technological development has led to an increase in life expectancy of children with special health care needs. Therefore, the gastrostomy has been used most often in children who have difficulties and risk to feed orally. The care for children with gastrostomy requires peculiar care demands essential to survival that will be carried out by family caregivers at home. Therefore, this study had as subject the care of caregivers to children with gastrostomy in the home context. Objectives: To know how the family caregiver performs the care of children with gastrostomy in a home scenario, reveal the challenges faced by family caregivers while taking care of children with gastrostomy at home and analyze strategies for that. The theoretical foundations were guided in the Colliére care concepts and the problem-based education of Paulo Freire. Methodology: qualitative research developed through the sensitive creative method, with the implementation of the dynamic "Corpo Saber" in the domicile, of children with gastrostomy, with 16 family caregivers. To analyze the results we used the speech analysis in its French chain. The speeches of the family in the process of feeding the children with gastrostomy revealed the need to grind food in order to make it more liquid and thus manage it more easily by the probe, the concern about nutritional value and food volume to be administered. About the drug administration identified the need to grind the solid drug, the concern about schedules and how to manage them. Thus, in caring for hygiene, discussed issues related to tools, device and the peristomal skin.

Gastrostomía endóscopica percutánea en esclerosis lateral amiotrófica; experiencia en un hospital de tercer nivel / Percutaneous endoscopic gastrostomy in amyotrophic lateral sclerosis, experience in a district general hospital

Introducción: La Esclerosis Lateral Amiotrófica (ELA) es una enfermedad degenerativa neurológica con afectación de la vía piramidal, produciendo trastornos motores progresivos que evolucionan hasta la parálisis. Estos pacientes pueden asociar disfagia, precisando soporte nutricional a través de de sonda nasogástrica o Gastrostomía Endoscópica Percutánea (PEG). La PEG está asociada con aumento de la supervivencia, sin embargo la evidencia acerca del momento óptimo para su colocación es escasa. Objetivo: Analizar las características de los pacientes con ELA en el momento de colocación de la PEG y su evolución. Material y métodos: Estudio descriptivo retrospectivo. Se incluyeron pacientes con diagnóstico de ELA y PEG valorados durante los años 2005-2014 en nuestro hospital. Se analizaron parámetros nutricionales y respiratorios, y evolución de los pacientes. Los resultados se analizaron en el programa SPSS15. Resultados: 37 pacientes fueron incluidos (56,8% hombres, 43,2% mujeres) con una edad media al diagnóstico 60 años, y edad media de colocación de PEG de 63,1 años, el 48,6% debutó con afectación espinal y el 51,4%, con bulbar. El 43,2% de los pacientes recibieron suplementos previa colocación de PEG durante un promedio de 11,3 meses. La capacidad vital forzada (CVF) media al diagnóstico fue del 65,45±13,67%, evolucionando desfavorablemente hasta un 39,47±14,69% en el momento de colocación de la PEG. El 86,5% de los pacientes precisaron soporte respiratorio con ventilación mecánica no invasiva (VMNI). El 86,5% presentaron disfagia, el 64,9% pérdida de peso > 5-10% de su peso habitual, el 8,1% IMC bajo, el 27% parámetros bioquímicos de desnutrición y el 73% empeoramiento de función respiratoria, por tanto, el 100% cumplían criterios de colocación de PEG según nuestro protocolo. La duración de la nutrición enteral fue de 10,1 meses con una mortalidad del 50% en los primeros 6 meses de la colocación de la PEG. Conclusiones: Evidenciamos una demora de 3 años entre el diagnóstico y la colocación de la PEG, con una supervivencia del 50% a los 6 meses de la realización de la misma. Más estudios son necesarios para determinar si una colocación más precoz podría aumentar la supervivencia (AU)

Background: Amyotrophic Lateral Sclerosis (ALS) is a degenerative disorder that affects the pyramidal tract, producing progressive motor dysfunctions leading to paralysis. These patients can present with dysphagia, requiring nutritional support with a nasogastric tube or Percutaneous Endoscopic Gastrostomy (PEG). PEG is associated with increased survival rates. However, the timing of PEG placement remains a significant issue for clinicians. Objective: To analyse the characteristics of ALS patients at the moment of PEG placement and their progression. Methods and materials: Descriptive retrospective study including patients diagnosed with ALS and PEG who were assessed during the 2005-2014 period in our hospital. Nutritional parameters and respiratory function were assessed for all patients, as well as their progression. The data was analysed using SPSS15. Results: 37 patients were included (56.8% men, 43.2% women) with an average age of 60 at diagnosis, and an average age of 63.1 at PEG placement. 48.6% started with spinal affection and 51.4%, with bulbar affection. 43.2% of the patients received oral nutritional supplements prior to PEG placement for a mean period of 11.3 months. The mean forced vital capacity at diagnosis was 65.45±13.67%, with a negative progression up to 39.47±14.69% at the moment of PEG placement. 86.5% of patients required non-invasive positive-pressure ventilation. 86.5% presented with dysphagia, 64.9% with weight loss > 5-10% from their usual weight, 8.1% with low Body Mass Index, 27% with malnutrition and 73% with aworsened breathing function; therefore, 100% met the criteria for PEG placement according to our protocol. The period on enteral feeding was extended for 10.1 months with a mortality of 50% during the first 6 months from PEG placement. Conclusions: There is evidence of a 3-year delay between diagnosis and PEG placement, with a survival rate of 50% at 6 months from PEG insertion. Further studies are required to establish whether an earlier placement might increase survival rates (AU)

Feasibility of implementing fast-track surgery in pancreaticoduodenectomy with pancreaticogastrostomy for reconstruction--a prospective cohort study with historical control.

INTRODUCTION: Fast track programmes have been introduced in pancreatic surgery, but the data are sparse. The aim of this prospective study was to analyse the feasibility of implementing fast track rehabilitation protocol in PD with pancreaticogastrostomy, using historical control for comparison. MATERIALS AND METHODS: Between April 2012 and December 2012, twenty patients who underwent PD (with pancreaticogastrostomy) were managed by a fast-track rehabilitation protocol. These patients were compared with an equal number of historical controls treated according to the traditional protocol. RESULTS: Patients in the fast track group were able to tolerate liquid (p = 0.0005) and solid diet (p = 0.0001) earlier, and they passed stools earlier (p = 0.02). Delayed gastric emptying (DGE) was significantly reduced in the fast track group (p = 0.02). There was no difference in the rates of pancreatic fistula (PF), post pancreatectomy haemorrhage (PPH) and mortality between the two groups. Length of hospital stay was reduced in the fast track group (median 14 vs 18.5, p = 0.007). CONCLUSION: Fast track programme appears to be feasible in PD, even with pancreatico-gastric anastomosis. It is associated with early recovery, reduced DGE and reduced hospital stay.

El autocuidado en pacientes portadores de gastrostomía radiológica percutánea / Self-care in patients with radiological percutaneous gastrostomy

El paciente afectado de disfagia puede alimentarse mediante la gastrostomía radiológica percutánea (GRP).Objetivos: determinar el nivel de dependencia para las actividades básicas de la vida diaria (ABVD) de los pacientes portadores de GRP, describir el perfil del cuidador y evaluar la capacidad para la realización del autocuidado y la relación existente entre estos factores. Material y métodos: estudio descriptivo mediante encuesta de 48 pacientes sometidos a recambio de sonda de GRP, entre el 1 de enero y el30 de septiembre de 2010. Se recogieron características del paciente: edad, sexo, patología causante de la disfagia, complicaciones relacionadas con la GRP y número de recambios de sonda e índice de Barthel(IB) y realización del autocuidado del estoma, la sonda y la administración de la nutrición enteral. Características del cuidador: formal o informal, sexo, edad y relación de parentesco con el paciente. Para el análisis de los datos se utilizó la estadística descriptiva, el test exacto de Fisher, la prueba U Mann-Whitney, y para el análisis multivariante la regresión lineal múltiple. Resultados: población de 65,81 años de media, femenina (60,41%) y afectados de disfagia neurológica (85,41%), con tasa de complicaciones mayores del 4,1% y media de recambios de 9,52. IB medio de 25,94.Cuidador formal en 14 pacientes e informal en 20 (familiar directo, mujer y de edad superior a los 50 años). 13/48 pacientes han realizado el autocuidado. El 77,8% del número de recambios de sonda se explica por un modelo de regresión lineal múltiple, relacionándose positivamente(X2= 48,00, p< 0,01) con los meses que la gastrostomía permanece colocada y la realización del autocuidado, y negativamente con el IB. Conclusiones: el desarrollo del autocuidado repercute sobre el número de recambios de sonda de GRP (AU)

A patient with dysphagia may be fed through Percutaneous Radiologic Gastrostomy (PRG)Objectives: to determine the level of dependence for basic activities of daily life (BADLs) of patients with PRG, to describe their caretaker profile, and to assess the ability to conduct self-care and the relationship existing between these factors. Materials and methods: descriptive study through survey, on 48 patients subject to PRG catheter replacement, between January, 1st and September,30th, 2010. Patient characteristics were collected: age, gender, condition causing dysphagia, complications associated with PRG, and number of catheter replacements and Barthel Index (BI), and conduction of self-care regarding stoma, catheter, and enteral nutrition administration; and caretaker characteristics: formal or informal, gender, age, and family relationship with the patient. Descriptive statistics was used for data analysis, as well as Fisher’s Exact Test and U Mann-Whitney Test; and multiple linear regression was used for multivariate analysis Results: a population with an average age of 65.81, female (60.41%) and suffering neurological dysphagia (85.41%), with a major complication rate of 4.1% and a median of 9.52 replacements. Median BI of 25.94. Formal caretaker in 14 patients and informal in 20 (direct relative, female and over 50-year-old). 13/48 patients have conducted self-care. The77.8% of catheter replacements is explained through a multiple linear regression model, being positively associated (X2=48.00, p<0.01) with the months during which the gastrostomy remains placed and self-careis conducted, and negatively with BI. Conclusions: conducting or not conducting self-care has an impact on the number of PRG catheter replacements (AU)

Nutritional and psychosocial outcomes of gastrostomy tube-dependent children completing an intensive inpatient behavioral treatment program.

OBJECTIVES: Limited published data describe the long-term effects of behavioral strategies to wean children from gastrostomy tube (GT) feeding dependence. This study presents data relating to nutritional and psychosocial outcomes observed during a 1-year period in medically complex GT feeding-dependent patients who completed an inpatient behavioral-based tube weaning protocol. METHODS: This was a retrospective study of prospectively and retrospectively collected data associated with a clinical cohort of 77 children diagnosed as having a feeding disorder, GT feeding dependence (>1 year), and an inability to maintain acceptable growth via oral feeding completing an inpatient tube weaning protocol. Nutritional data (percentage of ideal body weight, and oral energy intake as percent ofenergy goal) and psychosocial data (mealtime behavior problems, quality of caregiver and child interactions, and parenting stress) were assessed pre- and post-hospitalization. Nutritional data were also monitored longitudinally at 1, 3, 6, and 12 months postreatment. Data were grouped for retrospective analysis. RESULTS: Mealtime environment and feeding behaviors significantly improved, and all of the patients demonstrated reductions in tube dependence aside from 1 treatment failure. Fifty-one percent of patients were fully weaned from tube feeding after 2 weeks and an additional 12% completed weaning in the outpatient follow-up clinic within 1 year. Patients maintained nutritional stability at the 1-year posttreatment follow-up appointment. CONCLUSIONS: Inpatient behavioral interventions are highly effective and safe for transitioning long-term tube feeding children to oral feeding.

Increased likelihood of long-term gastrostomy tube dependence in head and neck cancer survivors without partners.

BACKGROUND: We evaluated factors associated with long-term dependence on percutaneous endoscopic gastrostomy (PEG) tubes. METHODS: One hundred fifty-four patients receiving treatment at the University of Alabama at Birmingham between 2002 and 2004 who underwent PEG tube placement were identified through retrospective review of medical records. Using binary logistic regression, we evaluated the association of various factors on long-term dependence on PEG tubes. RESULTS: A total of 25.3% of survivors remained PEG tube-dependent at 12 months. The odds of long-term PEG tube-dependence were greater for those who did not have partners compared with those who had partners (odds ratio [OR], 3.33; p = .004), for patients who received radiation therapy (OR, 6.21; p = .018), and for those who had a tracheotomy in place for longer than 30 days (OR, 4.328; p = .035). CONCLUSION: Data suggest that interventions targeted at reducing long-term dependence on PEG tubes take into account not only treatment-related factors, but also the important role that social support plays.

Prolonged duodenal paralysis after PEG placement in a patient with traumatic brain injury: a case report.

Percutaneous endoscopic gastrostomy (PEG) has recently become a usual procedure for patients with prolonged disorders of consciousness after brain injuries. Despite a high rate of success and a very low procedure-related mortality, morbidity associated to PEG placement reaches 9.4% in a recent large meta-analysis. This case report describes an uncommon complication of PEG placement in a patient with vegetative state after traumatic brain injury: the development of prolonged duodenal paralysis. This patient was treated by placement of a transient jejunostomy until recovery of duodenal functional activity, to permit adequate nutrition. This procedure-related complication is previously unreported in scientific literature.

Rehabilitation team disagreement: guidelines for resolution.

Rehabilitation care is provided by interdisciplinary teams including physicians, nurses, therapists, social workers, psychologists, and others. When there is disagreement or miscommunication among team members, progress toward patient goals can be thwarted. This paper will discuss differing models by which teams function, and what happens when a nonphysician member of the team disagrees with the plan of care. An analysis of the ethical issues embedded in two cases will be presented, and suggestions for resolution of team disagreement will be recommended.

[The role of a multidisciplinary approach in geriatric care and rehabilitation from the acute to the chronic stage].

A multidisciplinary team for bed sores consisted of 10 members including 3 dermatologists, 3 nurses, 1 physical therapist (PT), 1 pharmacist, 1 dietician, and 1 medical clerk. The incidence of new bed sores after admission was significantly decreased from 3.31% in 2003 to 1.04% in 2005 (P < 0.01). A total of 324 percutaneous endoscopic gastrostomy (PEG) procedures were performed from 2001 to January 2006. Among those, the survival of 172 elderly patient (aged 65 years or older at the time of PEG) was calculated by the Kaplan-Meier method. The 30-day mortality rates was 11%, and the 1-year, and 5-year survival rates were 61.2%, and 34.4% respectively. After discharge, 40 patients were followed up at the PEG clinic in our hospital whose staff consisted of 1 expert surgeon, 5 nurses and 1 dietician. When compared with 67 patients transferred to other hospitals or nursing homes, the patients in the PEG clinic showed a significantly longer survival (P < 0.01, 44 versus 29 months). A full-time integrated treatment (FIT) program for stroke rehabilitation was developed in the Nanakuri-Sanatorium of our university in 2000. Eighty-one stroke patients were on the FIT program during their hospital stay and achieved significantly higher activities of daily living (ADL) scores (P < 0.01) at discharge assessed by functional independence measure (FIM) compared to 41 patients on previous rehabilitation program. In addition, their ADL scores were maintained significantly higher (P < 0.05) even at 18 month after discharge, which might help them to stay home independently or with less care burden. These results suggest the important role of multidisciplinary approach for geriatric care and rehabilitation.

Prospective, randomized, controlled, single-blind trial of the costs and consequences of systematic nutrition team follow-up over 12 mo after percutaneous endoscopic gastrostomy.

OBJECTIVES: We assessed the economic and clinical implications of systematic long-term nutrition team follow-up of patients after percutaneous endoscopic gastrostomy. METHODS: We designed a prospective, randomized, controlled, single-blind trial in a large district hospital and its catchment area. All adult patients referred for a gastrostomy were eligible and randomized into two groups. The intervention group had regular follow-up by the nutrition team (weekly in hospital, monthly after discharge) with appropriate support and advice for patient, carer, and primary care professionals. The control group had no specific nutrition team input (as is often current practice). Endpoints to the study were 12 mo, elective removal of tube, or death. The primary outcome was total health care costs. Secondary outcomes were complications, length of stay, readmissions, nutritional status, and quality of life. RESULTS: One hundred twelve patients were recruited. Eleven died before the start of the trial, leaving 47 in the intervention group and 54 in the control group. They were well matched for age, sex, and underlying diagnosis. Overall, the health care costs were 13,330 sterlings per patient in the intervention group compared with 16,858 pound sterlings in the control group (two-tailed, P = 0.27), a saving of 21% per patient. The intervention group had shorter lengths of stay, fewer and briefer readmissions, earlier removal of gastrostomy (where appropriate), shorter duration of feeding, and less demand for general practitioners and district nurse inputs. Nutritional status and quality of life were similar. CONCLUSIONS: Regular systematic nutrition team follow-up for gastrostomy-fed patients does not increase costs and may improve quality of care.