Long-term outcome of percutaneous endoscopic gastrostomy feeding in patients with dysphagic stroke.
(9/1000)
OBJECTIVE: investigation of length of survival, complications, level of dependence and recovery of swallow in patients who received percutaneous endoscopic gastrostomy (PEG) feeding for dysphagia due to stroke. DESIGN: a retrospective case note analysis of patients treated between 1991 and 1995 and telephone survey of modified Barthel index in October 1996. SETTING: Cardiff Royal Infirmary and the University Hospital of Wales in Cardiff. SUBJECTS: 126 patients who had PEG inserted after dysphagic stroke. MAIN OUTCOME MEASURES: complications of PEG, length of survival, duration of PEG feeding, recovery of swallow and modified Barthel index score. RESULTS: median length of follow-up was 31 months (range 4-71). Median duration of PEG use was 127 days (range 1-1372). For patients with PEG inserted within 2 weeks the median duration was 52 days (range 2-1478). At follow up 36 (29%) had had PEG removed, 72 (57%) had died with PEG in use, 10 (8%) still had PEG and were nil by mouth and five (4%) had PEG in use with swallow recovered. The median survival was 305 days. Thirty-five (28%) patients died in hospital. Aspiration pneumonia was the commonest complication. Thirty-three patients were alive in October 1996. The modified Barthel index for nursing home patients was 4 (range 0-13) and for patients at home 11 (range 2-20). CONCLUSION: PEG feeding is safe and well tolerated in patients with dysphagic stroke. Early PEG placement (within 2 weeks) is worthwhile with many going on to have long-term feeding. Although overall mortality is high, some patients have a long-term survival and a few attain a reasonable level of function in daily living activities. Late recovery of swallow occurs and patients should have follow-up swallowing assessment. (+info)
Medication-induced oesophageal injury leading to broncho-oesophageal fistula.
(10/1000)
Medication-induced oesophageal injury is one of the least recognised side-effects of oral medication and, in contrast to other oesophageal pathologies, is rarely considered in the differential diagnosis of chest pain. We describe a case of medication-induced oesophageal injury with a rare complication in which the diagnosis was not considered until the characteristic features were demonstrated at endoscopy. (+info)
Cervical osteoarthropathy: an unusual cause of dysphagia.
(11/1000)
PRESENTATION: A 72-year-old man complained of progressive dysphagia for solids associated with a sensation of foreign body in his throat for 2 years. A barium swallow showed a bridging osteophyte between C4 and C5 vertebrae indenting the oesophagus posteriorly and displacing it anteriorly. OUTCOME: He refused surgical intervention and was given dietary advice. After 6 months, his weight was steady and he was able to swallow semi-solid food without difficulty. (+info)
Prospective, randomised, double blind trial of prophylaxis with single dose of co-amoxiclav before percutaneous endoscopic gastrostomy.
(12/1000)
OBJECTIVE: To determine the efficacy of antibacterial prophylaxis in preventing infectious complications after percutaneous endoscopic gastrostomy. DESIGN: Prospective, randomised, placebo controlled, double blind, multicentre study. SETTING: Departments of internal medicine at six German hospitals. SUBJECTS: Of 106 randomised adult patients with dysphagia, 97 received study medication, and 84 completed the study. The median age of the patients was 65 years. Most had dysphagia due to malignant disease (65%), and many (76%) had serious comorbidity. INTERVENTIONS: A single intravenous 2.2 g dose of co-amoxiclav or identical appearing saline was given 30 min before percutaneous endoscopic gastrostomy performed by the thread pull method. MAIN OUTCOME MEASURES: Occurrence of peristomal wound infections and other infections within one week after percutaneous endoscopic gastrostomy. RESULTS: The incidence of peristomal and other infections within one week after percutaneous endoscopic gastrostomy was significantly reduced in the antibiotic group (8/41 (20%) v 28/43 (65%), P<0.001). Similar results were obtained in an intention to treat analysis. Several peristomal wound infections were of minor clinical significance. After wound infections that required no or only local treatment were excluded from the analysis, antibiotic prophylaxis remained highly effective in reducing clinically important wound infections (1/41 (2%) v 11/43 (26%), P<0.01) and non-wound infections (2 (5%) v 9 (21%), P<0.05). CONCLUSIONS: Antibiotic prophylaxis with a single dose of co-amoxiclav significantly reduces the risk of infectious complications after percutaneous endoscopic gastrostomy and should be recommended. (+info)
Phase II trial of weekly irinotecan plus cisplatin in advanced esophageal cancer.
(13/1000)
PURPOSE: To evaluate the response, toxicity, survival, and quality of life in patients with unresectable or metastatic esophageal cancer treated with weekly irinotecan and cisplatin. PATIENTS AND METHODS: Thirty-five patients with metastatic or unresectable esophageal adenocarcinoma (23 patients) or squamous cell carcinoma (12 patients) were treated. No prior chemotherapy was allowed. The majority of patients had metastatic and bidimensionally measurable disease (34 patients each [97%]). Patients were treated with cisplatin 30 mg/m(2) and irinotecan 65 mg/m(2), repeated weekly for 4 weeks, followed by a 2-week rest period. Treatment was recycled every 6 weeks. Degree of dysphagia relief was monitored, and quality of life was measured prospectively using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C-30 and Functional Assessment of Cancer Therapy-General instruments. RESULTS: Thirty-five patients were assessable for response and toxicity. Major objective responses were observed in 20 patients (57%; 95% confidence interval, 41% to 73%), including two complete responses (6%). Similar response rates were observed for adenocarcinoma (12 of 23 patients; 52%) and squamous carcinoma (eight of 12 patients; 66%). The median duration of response was 4.2 months (range, 1 to 8.8+ months). Median actuarial survival was 14.6 months (range, 1 to 15.2+ months). In 20 patients with dysphagia assessable at baseline, 18 (90%) noted either improvement or resolution of dysphagia on chemotherapy. Global quality of life improved in responding patients, primarily because of improvements in pain, emotional state, and relationships with family and friends. Toxicity was relatively mild and included only three patients (9%) with grade 4 neutropenia and four (11%) with grade 3 diarrhea. There were no treatment-related deaths. CONCLUSION: The combination of weekly cisplatin plus irinotecan had significant activity in metastatic esophageal carcinoma and resulted in significant relief of dysphagia. The regimen was well tolerated, with acceptable myelosuppression and rare treatment-related diarrhea. Further evaluation of the combination of weekly irinotecan and cisplatin, including the addition of other agents to this regimen, is indicated. (+info)
Lateralization of cortical function in swallowing: a functional MR imaging study.
(14/1000)
BACKGROUND AND PURPOSE: While functional MR imaging and other techniques have contributed to our knowledge of functional brain localization, these methods have not been extensively applied to the complex and incompletely understood task of swallowing. We used functional MR imaging to investigate motor cortex activity during swallowing in healthy human adults. METHODS: Eight subjects were imaged on a 1.5-T MR system using blood oxygen level-dependent contrast mechanisms. Subjects performed three swallowing tasks and a finger-tapping task. Areas of activation in the cortex and subcortical areas were tabulated, and a laterality index, defined as LI = [sigmas left - sigmas right]/[sigmas left + sigmas right] x 100, was computed for the three tasks. RESULTS: Activation was observed in the primary motor and sensory cortices, motor processing and association areas, and subcortical sites. This activity was dominant for one hemisphere with left hemispheric dominance more prevalent among the subjects. Right hemispheric dominance, however, showed stronger lateralization than the left hemisphere. CONCLUSION: Our data indicate that specific sites in the motor cortex and other cortical and subcortical areas are activated with swallowing tasks and that hemispheric dominance is a feature of swallowing under these conditions. In addition, we demonstrate the utility of functional MR imaging in the study of the cortical representation of swallowing and suggest a role for functional MR imaging in the diagnosis of dysphagia of cerebral origin. (+info)
Respiratory function in childhood following repair of oesophageal atresia and tracheoesophageal fistula.
(15/1000)
AIM: To determine the relation between respiratory function in infancy and at school age in children who have undergone oesophageal atresia and tracheoesophageal fistula repair, and assess the value of infant respiratory function testing; and to examine the effect of bronchodilators. METHOD: Fourteen children (6 girls, and 8 boys) who had undergone respiratory function testing in infancy were retested at school age (7-12 years). Measurements included lung volume, airways resistance, peak flow, and spirometry. Clinical problems were investigated by questionnaire. Twelve children had repeat measurements after taking salbutamol. RESULTS: Predominant complaints were non-productive cough and dysphagia, but even those children with major problems in infancy reported few restrictions at school or in sport or social activities. Respiratory function and clinical findings at school age appeared unrelated to status in infancy, such that even the patients with severe tracheomalacia requiring aortopexy did not have lung function testing suggestive of malacia at school age. Most patients showed a restrictive pattern of lung volume which would appear to result from reduced lung growth after surgery rather than being a concomitant feature of the primary congenital abnormality. Although six children reported wheeze and four had a diagnosis of asthma, only one responded to salbutamol. This suggests that a tendency to attribute all lower respiratory symptoms to asthma may have led to an overdiagnosis of this condition in this patient group. CONCLUSION: Respiratory function testing in infancy is of limited value in medium term prognosis, but may aid management of contemporary clinical signs. In children respiratory function testing is valuable in assessing suspected asthma and effects of bronchodilators. (+info)
Stroke in the very old : clinical presentation and determinants of 3-month functional outcome: A European perspective. European BIOMED Study of Stroke Care Group.
(16/1000)
BACKGROUND AND PURPOSE: The oldest old represent the fastest-growing segment of the elderly population in developed countries. Knowledge of age-specific aspects of stroke is essential to establish diagnostic and therapeutic pathways and to set up prevention and rehabilitation programs. We sought to evaluate stroke features and functional outcome in patients aged >/=80 years compared with the younger age groups. METHODS: In a European Union Concerted Action involving 7 countries, 4499 patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, and 3-month disability (Barthel Index) and handicap (Rankin Scale). RESULTS: Overall, 3141 patients (69.8%) were aged <80 years, and 1358 (30.2%) were aged >/=80 years. At baseline, female sex, prestroke institutionalization, and a worse prestroke Rankin score were significantly more frequent in the older patients, as were coma, paralysis, swallowing problems, and urinary incontinence in the acute phase (all P values <0.001). Brain imaging and other diagnostic tools were significantly less used in the older patients. Paralysis, swallowing problems, and incontinence during hospitalization independently predicted 3-month disability or handicap in both groups. For the older patients, prestroke institutionalization proved a further strong and independent determinant of 3-month disability (odds ratio, 2.33; 95% CI, 1.22 to 4.45) and handicap (odds ratio, 7.04; 95% CI, 1.62 to 30. 69). CONCLUSIONS: In the very old, both medical and sociodemographic factors may significantly influence stroke outcome, showing peculiar characteristics. Knowledge of these determinants may reduce the burden on health systems, improving quality of care. (+info)