Hyponatraemia in older people as a sign of adrenal insufficiency: a case-control study.

BACKGROUND: Hyponatraemia is a common cause of hospitalisation in older adults. Adrenal insufficiency (AI) can result in hyponatraemia. AIM: The aim of our study was to determine the frequency and characteristics of AI in elderly patients with hyponatraemia. METHODS: Thirty patients ≥65 years with Na(+) ≤130 mmol/L and 30 age-matched control subjects, all hospitalised, were included in the study. Plasma cortisol levels were determined before and after intravenous administration of 1 µg synthetic adrenocorticotropin hormone. A peak cortisol >550 nmol/L was considered to exclude AI. RESULTS: Sodium levels were 125 ± 5 and 139.8 ± 2 mmol/L in the hyponatremic and control groups respectively. Baseline cortisol <550 nmol/L was found in a half of hyponatremic patients. However, stimulated cortisol levels were compatible with AI in only one case (3%) and none of the controls. The mean cortisol levels were significantly higher in hyponatremic compared with control subjects, both in the basal state (585 ± 215 and 381 ± 135 nmol/L, respectively, P < 0.001) and after stimulation (933 ± 254 and 781 ± 160 nmol/L, P < 0.05). However, the incremental increase in cortisol levels after stimulation was similar in the two groups (361 ± 196 and 403 ± 155 nmol/L) CONCLUSIONS: AI is an uncommon cause of hyponatraemia in older age. Based on this small cohort, AI may be present in 3% of elderly patients with hyponatraemia. AI cannot be excluded by baseline cortisol in a significant minority of hyponatremic patients and further testing with adrenocorticotropin hormone stimulation is needed.

Severe hyponatraemia in elderly hospitalized patients: prevalence, aetiology and outcome.

BACKGROUND: Hyponatraemia is the commonest electrolyte disorder in the elderly. Data on severe hyponatraemia and the prevalence of cerebral salt wasting syndrome (CSWS) in elderly hospitalized patients are lacking. We studied the incidence, frequency of various aetiologies, outcome and the possible role of CSWS in severe hyponatraemia in elderly medical patients. METHODS: A prospective, observational, non-interventional study conducted over a 5-month period in medical wards. Eighty-six patients aged over 65 years with serum sodium levels < or =125 mEq/L were included. All patients were examined by one of the authors, who also evaluated potential contributing factors. Demographic, clinical and outcome data were extracted from the medical records. RESULTS: The mean age of the patients was 82.1 + 8.7 years. The prevalence of hyponatraemia was 6.2% (8.1% women and 4.0% men (P < 0.001)). There was no increase in incidence of hyponatraemia with age. The leading cause of hyponatraemia was the syndrome of inappropriate antidiuretic hormone secretion (SIADH), whose aetiology could be determined in only 46% of cases. Aetiology was multifactorial in 51% of patients (1.7 aetiological factors per patient). All patients with thiazide-induced hyponatraemia had other contributing factors. Hyperglycaemia and hypoalbuminaemia were predictors of neurological manifestations of hyponatraemia. Overall in-hospital mortality was 19%. Only hypoalbuminaemia was found as an independent risk factor for death. In none of the patients was the hyponatraemia due to CSWS. CONCLUSION: Severe hyponatraemia in elderly hospitalized medical patients is more frequent in women and of multifactorial aetiology in 50% of cases. It is most commonly caused by SIADH; CSWS is an unlikely cause.

Giant cell arteritis: intensity of the initial systemic inflammatory response and the course of the disease.

OBJECTIVE: Giant cell arteritis (GCA) has a variable course. We assessed whether intensity of initial systemic inflammatory response (ISIR) can predict the course of GCA. METHODS: Charts of 130 GCA patients were reviewed. ISIR intensity at presentation was determined by 5 parameters of inflammation: sedimentation rate >100 mm/h, thrombocytosis >400,000/microl, hemoglobin <11 g/dl, leukocytosis >11000/microl, and fever >37.5 degrees C. Patients were divided into 3 groups according to ISIR intensity: strong (4-5 parameters present, n=24), moderate (2-3 parameters, n=55) and weak ISIR (0-1 parameter, n=51). RESULTS: There were no significant differences between these groups regarding mean age, female:male ratio and the initial prednisone dose. At 1 year, 75% of patients in the strong ISIR group required >5 mg/d of prednisone, compared to 54% and 37% of patients with moderate or weak ISIR, respectively (p=0.015). Disease flares were more common in patients with strong ISIR during a 3-year period, compared to patients with moderate or weak ISIR (77%, 67% and 43%, respectively, p=0.013). Only 33% of patients with strong ISIR were able to discontinue steroids after 3 years, compared to 49% and 77% of patients with moderate and weak ISIR, respectively (p=0.003). CONCLUSION: GCA Patients with strong ISIR have prolonged disease course with more flares, requiring higher steroid doses. ISIR intensity should be taken into consideration when planning studies evaluating potential steroid-sparing agents, as response to treatment may vary in patients with different ISIR intensities.

The incidence of giant cell arteritis in Jerusalem over a 25-year period: annual and seasonal fluctuations.

OBJECTIVE: Giant-cell arteritis (GCA) incidence is reported to be rising. A cyclic pattern of annual incidence rates and seasonal variations were reported by several groups. However, such fluctuations were not observed by others. We examined both annual and seasonal rates of GCA over a period of 25 years in Jerusalem. METHODS: Charts of all patients diagnosed as GCA between 1980-2004 were reviewed. In 170 cases GCA was biopsy-proven. Thirty-six additional cases were included as they met the American College of Rheumatology GCA classification criteria. Data on the Jerusalem population throughout the study period was collected from the annual publications of the Israel Bureau of Statistics. Age- and sex-specific incidence rates per 100000 population aged>or=50 were calculated. RESULTS: For the whole period, the average age-adjusted incidence rate was 11.3 per 100000, and 9.5 for the biopsy-positive cases. The female: male ratio was 1.4:1. Cyclic fluctuations of GCA incidence with 3 distinctive peaks, 8-10 years apart, were observed. Altogether, there was no apparent increase in GCA incidence during this period. Seasonal variations were observed: in 192 patients we were able to estimate the time of onset of GCA symptoms. It showed a peak in the months of May and June, with the number of patients being twice as expected for this period (p<0.001). CONCLUSION: GCA onset was more common in late spring and early summer, and fluctuations in GCA annual incidence with 3 distinctive peaks were observed during a 25-year period. These suggest infectious or other environmental etiology, however thus far no such agents were proven.

Demographic and clinical characteristics of patients admitted to medical departments.

INTRODUCTION: The significant changes, which have affected departments of medicine over the last two decades, have been much editorialized. Surprisingly few data have been published that document these changes. We describe the demographic and clinical characteristics of patients admitted to one hospital's departments of internal medicine. METHODS: During a 3 months prospective study, 1039 patients (46% of all 2277 new admissions to the departments of medicine, consisting of +/- 175 beds) were randomized for inclusion. Information was extracted from the medical records regarding demography; functional capacity; clinical data and outcome. RESULTS: The mean age of the patients was 72 +/- 16 years (mean +/- SD); 51% were male, 56% were married, and 83% lived at home. Although 293 patients (28%) were defined as dependent, the majority lived at home (170, 58%). Cognition was normal in only 74%. The four most common disease categories leading to admission were infections (383 patients, 37%), cardiovascular disorders (372, 36%), respiratory conditions (284, 27%) and genito-urinary problems (90, 9%). Overall, 98 persons died (9%). Independent risk factors for death were: mechanical ventilation; a 'do not resuscitate' order; a high APACHE-II score; a low serum albumin level; higher age; and not being married (P < 0.01). CONCLUSIONS: Geriatric patients occupy a central position in our medical wards. These data are relevant for allocation of special resources for departments with high proportions of geriatric patients; for the design of employment conditions that ascertains continuing job satisfaction; as well as for the planning of teaching opportunities for residents and students.

The effect of chromium on established atherosclerotic plaques in rabbits.

Twenty-three rabbits were fed for 8 weeks with standard diet to which was added a 1.5% cholesterol supplement. After this the cholesterol supplement was discontinued, but 11 rabbits received a daily intraperitoneal injection of 20 micrograms of potassium chromate while the remaining 12 received distilled water. The aortas were examined after a further 30 weeks; their mean weight per unit length was 1.27 g (SE +/- 0.17) in the control group and 0.81 g (SE +/- 0.08) in the chromium treated group (t = 2.36; P < 0.05). The percentage area of intimal surface covered by plaques was 94.8% (SE +/- 1.7) and 62.6% (SE +/- 10.4), respectively (t = 3.53; P < 0.005), and the total cholesterol content per unit length of aorta was 729 mg/100 ml (SE +/- 44.0) and 457.8 mg/100 ml (SE +/- 117.1), respectively (t = 23; P < 0.05). The results show a significant effect of chromium on the regression of cholesterol-induced atherosclerotic plaques in rabbits.

The action of chromium on serum lipids and on atherosclerosis in cholesterol-fed rabbits.

Eight rabbits, fed on a 1% cholesterol diet for 30 days, were injected daily with potassium chromate for a further 60 days. A 50% reduction in aortic intimal plaque area and in aortic total cholesterol content was observed. However, although levels of serum cholesterol and triglycerides were consistently lower and levels of high density lipoprotein fractions consistently higher in the chromium-treated as compared to the control rabbits, these differences did not reach statistical significance. A further 6 rabbits were injected with potassium chromate and fed on a 1% cholesterol diet for 12 weeks. Mean aortic cholesterol content (+/-SEM) was 40.23 mg/10 cm aortic length (+/-7.50) as compared to 66.24 mg/10 cm (+/- 7.89) in a control group (P less than 0.05), whereas the area of aortic intima covered by macroscopic plaques was 67.5% (+/-2.79) and 81.1% (+/-3.14) (P less than 0.01) respectively.

The effect of chromium on cholesterol-induced atherosclerosis in rabbits.

Rabbits fed on a 1% cholesterol diet for 30 days were injected daily with potassium chromate for a further 60 days. A 50% reduction in aortic intimal plaque area and in aortic total cholesterol content was observed. Control rabbits treated with chromium showed a significant increase in the chromium concentration of their aortas, liver and kidneys but not of the myocardium. Cholesterol-fed rabbits treated with chromium showed a significant increase in chromium concentrations in the liver and kidneys only. Serum cholesterol levels were consistently lower in the chromium-treated animals, although the differences did not reach significant levels.

Cardiotoxicity of interferon. A review of 44 cases.

Cardiovascular complications have occurred in clinical trials of interferon. We review herein experience to date of cardiotoxicity with all types of interferons in cancer patients. The most common presentations of cardiotoxicity were cardiac arrhythmia, dilated cardiomyopathy, and symptoms of ischemic heart disease, including myocardial infarction and sudden death. The cardiac effects were not related to the daily dose, cumulative total dose, or period of therapy. Some of the patients in whom interferon has caused cardiovascular sequelae have had a history of coronary heart disease or have previously been given chemotherapy with drugs known to be cardiotoxic. In most of the patients, cardiac toxicity was reversible following the cessation of the drug therapy.

Positive radionuclide myocardial infarction pattern after ventricular fibrillation and direct current countershock.

A patient is presented in whom direct current counter-shock was applied for primary ventricular fibrillation. He recovered uneventfully and no evidence was found of a myocardial infarction; however, a positive 99m technetium stannous diphosphate scan obtained four days after the defibrillation showed positive findings. This positive scintigram was most probably due to myocardial or skeletal muscular damage consequent to counter-schock, but myocardial necrosis induced by ventricular fibrillation may be another cause. This case demonstrates again that a transmural or subendocardial infarction is not the only circumstance under which an abnormal scintigram can be obtained.

Body positional effect on gas exchange in unilateral pleural effusion.

The positional effect on gas exchange was studied in eight patients who had unilateral pleural fluid without clinical or radiologic evidence of parenchymal lung disease. In all eight patients, PaO2 values were higher when the lung with the pleural fluid was uppermost. The mean PaO2 in this position was 71.9 +/- 9.3 mm Hg (mean +/- SE) compared with 66.7 +/- 8.7 mm Hg in the lateral decubitus position with the pleural fluid lowermost. The mean difference in PaO2 between the two positions was 5.1 +/- mm Hg (p less than 0.005). Larger positional differences were found in the patients with the smallest pleural effusions. These results are probably due to perfusion of areas of unventilated lung, accentuated by gravity with a consequent increase in shunting. A large effusion also causes a decrease in perfusion, so that ventilation-perfusion mismatching is decreased and the positional effect on gas exchange diminished.

Diuretic-induced severe hyponatremia. Review and analysis of 129 reported patients.

Thiazides were responsible for severe diuretic-induced hyponatremia (serum sodium level < 115 mEq/L) in 94 percent of 129 cases reported in the literature between 1962 and 1990. The hyponatremia developed within 14 days in most of the patients receiving thiazides but in none of the patients who were treated with furosemide. Diuretic-induced hyponatremia was four times more common in women than in men. Advanced age was not associated with a higher tendency for hyponatremia. In the majority of the patients who received thiazides, excess antidiuretic hormone activity, hypokalemia, and excess water intake were accompanying findings which, singly or together, appeared to contribute to the development of hyponatremia. In 12 patients, mortality was directly related to hyponatremia. Rapid average correction of hyponatremia and a relatively high total correction (over 20 mEq/L) in the first 24 h were significantly associated with higher mortality or demyelinating syndrome. The presence of neurologic signs is an indication for active sodium replacement. The onset of thiazide-induced hyponatremia may in some cases occur within 1 day and therefore needs to be corrected rapidly, but within a total elevation of 20 mEq/L in the first 24 h. Where the onset is judged to have been slow (over several days), the level should be corrected at a slow rate, up to a total of 12 to 15 mEq/L in 24 h.

Dissociation between the wishes of terminally ill parents and decisions by their offspring.

OBJECTIVE: To assess the attitude and factors affecting decision-making by offspring for life-sustaining measures toward their elderly terminally ill parents. DESIGN: Survey SETTING: Acute geriatric department of a university-affiliated teaching hospital. PATIENTS AND PARTICIPANTS: 108 offspring of 48 terminally ill elderly patients were interviewed. MEASUREMENTS: The attitude of offspring regarding life-sustaining measures based on a comprehensive questionnaire, administered by face-to-face interview, that included clinical, social, and religious information for each patient and social, religious, demographic, and educational information for each family member. RESULTS: A significant majority requested the continuation of fluid, nutrition, and medication (78%, 66%, 73%, respectively). A minority of 25%-29% requested the initiation of resuscitation, mechanical ventilation, and dialysis. Active euthanasia was requested by seven offspring. Factors that significantly affected offspring's decisions were the degree of religious observance and close relationship. Approximately 50% of offspring believed they knew their parents' wishes, but most of them did not comply with the parents' wishes. The offspring's preferences for themselves differed in important aspects from the requests for their parents. The great majority stated that a family member and/or the responsible physician should be involved in the decision-making process (76% and 79%, respectively). Only 2.0% suggested the participation of an ethics committee, and the court was rejected by all. CONCLUSIONS: Basic life-sustaining measures are requested for the terminally ill parents by most of the offspring. A significant minority even requested aggressive life-sustaining measures. The degree of religiosity and closeness of relationship influenced offspring's request most strongly.

Primary lymphosarcoma of the breast: review of the literature on occurrence in elderly patients.

A case of primary lymphocytic lymphosarcoma of the breast in a 74-year-old woman is presented, together with a review of the literature on 23 cases of primary breast lymphosarcoma in patients aged 60 or older. In this age group, simple local excision or mastectomy is probably sufficient.

Occult elevation of CK as a manifestation of rhabdomyolysis in the elderly.

OBJECTIVE: To evaluate the incidence, etiology and clinical course of rhabdomyolysis in hospitalized elderly patients. DESIGN: Retrospective case series. SETTING: Acute geriatric department of a university-affiliated teaching hospital. PATIENTS: Twenty-three patients who fulfilled our criteria of rhabdomyolysis. Criteria for inclusion were the finding of elevated serum creatine kinase of five-fold or greater above the upper reference limit and greater than 97% MM isoenzyme. RESULTS: In a 3-year period 23 patients out of 2,870 admissions fulfilled the criteria for rhabdomyolysis, an incidence rate of 0.8%. Diseases or insults associated with rhabdomyolysis were, in order of frequency, acute immobilization, infectious disease, cerebrovascular accident, hyperosmolar state, hyponatremia, hypernatremia, hypothermia, and a fall. Twenty-two patients recovered from the acute illness; one patient died from respiratory failure. Seventeen patients had renal failure (serum creatinine greater than 180 mumol/L), none necessitating dialysis. Serum creatinine always declined following recovery. CONCLUSION: Elevation of CK with few other clinical features of rhabdomyolysis is common in admissions to a geriatric service. It is due to complete immobilization resulting from acute illness. Renal failure is mild and reversible, and the prognosis for recovery is excellent.

Hypoglycemia in hospitalized nondiabetic older patients.

OBJECTIVES: To analyze the clinical characteristics, associated risk factors, and outcome of hypoglycemia in nondiabetic hospitalized older patients. DESIGN: A retrospective case control study. PARTICIPANTS: Sixty patients, aged 65 years and older, in the acute medical and geriatric wards who developed hypoglycemia. A control group was composed of 83 older patients, sex and age matched, in orthopedic and surgery wards who were undergoing corrective surgery for hip fracture or hernioplasty. MEASUREMENTS: For all patients, data for the following variables were abstracted from the charts: age, sex, degree of hypoglycemia, clinical presentation of hypoglycemia, number and duration of hypoglycemia episodes, nutritional state, and blood chemistry analysis. Risk factors were defined as nutritional state, heart failure, renal or liver disease, malignancy, and infection or sepsis. RESULTS: Mean blood glucose in hypoglycemic cases was 38.9 +/- 7 mg/dL. Symptoms and signs of hypoglycemia were noted in only 38.4% (23/60) of patients. All identified risk factors except cachexia were found significantly more frequently in the hypoglycemic patients than in the control group. Mean total number of risk factors was greater in the hypoglycemic group than in the control group, 2.97 +/- 1.1 versus 1.64 +/- .8, respectively (P < .001). In a multivariant logistic model, low plasma albumin level, liver disease, malignancy, and congestive heart failure were significant predictors of hypoglycemia. In-hospital mortality rate was higher among the hypoglycemic patients, 48% versus 18.1% (P < .001), and was independent of the degree of hypoglycemia or the number of hypoglycemic episodes. Mortality was correlated significantly with the number of risk factors (3.4 +/- 1.1 vs 2.5 +/- 1.1; P = .006). Hypoglycemia remained a significant predictor of mortality (OR = 3.67; 95% CI, 1.2-11.2) even after the adjustment for other risk factors. CONCLUSIONS: Hypoglycemic episodes occur even among nondiabetic hospitalized older patients. Symptoms and signs of hypoglycemia were noted in only two-fifths of the patients. Albumin less than 3.0 g%, liver disease, renal insufficiency, malignancy, congestive heart failure, and sepsis were statistically significant predictors of developing hypoglycemia. The overall mortality rate was significantly higher among the hypoglycemic patients and was independent of hypoglycemia levels. Mean total number of risk factors was significantly higher among those who died compared with hypoglycemic patients who survived. Based on the present study, the estimated odds of mortality in an older patient with hypoglycemia were 3.67 times higher than in those without hypoglycemia.

Acute renal failure in the elderly treated by one-time peritoneal dialysis.

To determine the factors affecting outcome of acute renal failure (ARF) in the elderly, we retrospectively studied 44 patients over the age of 65 who had undergone acute peritoneal dialysis. Thirteen patients (29%) survived 2 months or longer after dialysis treatment ("survivors"). Thirty-one patients (71%) died within this period ("nonsurvivors"). The main factor distinguishing survivors was the frequency of sepsis (none of 13 survivors vs 17 of 31 nonsurvivors). Preexisting malignancy and total number of acute insults to renal function were significantly less frequent, and immediate clinical and biochemical outcome of dialysis significantly better in survivors. The overall complication rate of dialysis was high (31 of 44 patients), but was significantly lower in survivors. Acute peritoneal dialysis is a useful procedure in the management of ARF in the elderly. However, we suggest that elderly patients in whom sepsis is a contributory factor to the development of ARF do not benefit from peritoneal dialysis therapy.

Longitudinal changes in attitudes of offspring concerning life-sustaining measures for their terminally ill parents.

OBJECTIVES: To define longitudinal changes in the attitudes of offspring concerning life-sustaining measures for their older, terminally ill parents and to determine whether experience of a "life event" influences such decisions. DESIGN: An attitudinal survey of three groups. SETTING: The geriatric department of a university-affiliated general hospital. PARTICIPANTS: Fifty-one subjects who had been interviewed regarding life-sustaining treatment for their terminally ill parents were reinterviewed 6 years later. In addition, a control group composed of 116 participants was generated from patients visiting hospital outpatient clinics. The control group had no prior experience involving hospitalization of a first-degree relative as a result of a life-threatening situation. INTERVENTIONS: Each subject took part in a personal interview. MAIN OUTCOME MEASURES: Attitudes regarding life-sustaining measures were assessed, and the subjects' sociodemographic and religious characteristics were noted. RESULTS: The attitudes of offspring in the acute phase situation and after the passage of 6 years were strikingly consistent. Twenty-one percent had requested the initiation of resuscitation in the acute phase ("real time"), and 27.4% said the same 6 years later. The provision of nutrition and medication was requested by approximately 70% of participants both at the acute phase and 6 years later. When comparing each individual's personal views at the interviews with all others, consistency in attitude was found among answers to most questions. When comparing the acute phase group with the control group, a significantly higher percentage of the former requested the initiation of resuscitation (48.3% vs 25%), whereas a smaller percentage preferred that the decision be made by the physician (3.5% vs 21.3%). Active euthanasia was requested by 6.5% of the acute phase group and 12.9% of the control group. CONCLUSIONS: The decisions made by offspring regarding life-sustaining measures for their terminally ill parent at real time remain unchanged 6 years after the event. Exposure to a life event significantly affects the decision-making of the offspring of a terminally ill parent. However, the subject's attitude toward extreme solutions--opposing active euthanasia and requesting the administration of nutrition and medication--was not influenced by the fact that the subject had undergone a life event.

Risk factors for nephrotoxicity in elderly patients receiving once-daily aminoglycosides.

BACKGROUND: There remain concerns about the safety of once-daily dosing of aminoglycosides (AGs) in the elderly. AIM: To assess the safety of once-daily AGs in elderly patients and evaluate possible risk factors for nephrotoxicity. DESIGN: Prospective, non-interventional surveillance study. METHODS: All patients receiving AGs were monitored over 4 months. Clinicians determined the AG dose for each patient after estimating patient weight and calculating creatinine clearance (CrCl) using the Cockcroft-Gault formula. Parallel figures were calculated by the investigators using measured weight. Clinicians obtained an AG trough level 24 h after initiation of treatment, and, if non-toxic, every 5-7 days thereafter. AG toxicity was defined as an increase in serum creatinine of > or =50%. RESULTS: In the study period, 249 consecutive patients received an AG: 116 (47%) males, mean+/-SD age 75+/-16 years. Forty-two (17%) received amikacin and 207 (83%) gentamicin. An increase of > or =50% in serum creatinine was detected in 31/249 (12.4%); maximal creatinine was < or =177 micromol/l in 16/249 (6.4%), 186-265 micromol/l in nine (3.6%), and >265 micromol/l in six (2.4%). None developed oliguric renal failure. Renal damage correlated with a high AG trough level (>1.1 microg/ml) (p<0.001); haemoglobin level <10 g/dl (p<0.05); hospital admission >7 days prior to AG treatment (p<0.005); and AG treatment > or =11 days (p<0.05). Mean CrCl based on estimated weight was 52+/-18 ml/min; that based on actual weight was 71+/-37 ml/min. Despite this, mean AG dose was 1.3+/-0.6 higher than optimal. CONCLUSIONS: Oliguric and/or lasting renal toxicity is rare in elderly patients receiving once-daily aminoglycosides for <11 days, if regular trough drug levels are monitored.

A prospective comparison of the use of nasogastric and percutaneous endoscopic gastrostomy tubes for long-term enteral feeding in older people.

OBJECTIVE: To compare the indications for and the outcome of long-term enteral feeding by nasogastric tube (NGT) with that of percutaneous endoscopic gastrostomy (PEG) tube. DESIGN: A prospective, multicenter cohort study. SETTING: Acute geriatric units and long-term care (LTC) hospitals in Jerusalem, Israel. PARTICIPANTS: 122 chronic patients aged 65 years and older for whom long-term enteral feeding was indicated as determined by the treating physician. Patients with acute medical conditions at the time of tube placement were excluded. MEASUREMENTS: We examined the indications for enteral feeding, nutritional status, outcome and complications in all subjects. Subjects were followed for a minimum period of six months. RESULTS: Although the PEG patients were older and had a higher incidence of dementia, there was an improved survival in those patients with PEG as compared to NGT (hazard ratio (HR)=0.41; 95% confidence interval (CI) 0.22-0.76; P=0.01). Also, the patients with PEG had a lower rate of aspiration (HR=0.48; 95% CI 0.26-0.89) and self-extubation (HR=0.17; 95% CI 0.05-0.58) than those with NGT. Apart from a significant improvement in the serum albumin level at the 4-week follow-up assessment in the patients with PEG compared to those with NGT (adjusted mean 3.35 compared to 3.08; F=4.982), nutritional status was otherwise similar in both groups. CONCLUSION: In long-term enteral feeding, in a selected group of non-acute patients, the use of PEG was associated with improved survival, was better tolerated by the patient and was associated with a lower incidence of aspiration. A randomized controlled study is needed to determine whether PEG is truly superior to NGT.