We report the case of a 74-year-old woman with Parkinson\'s disease (PD) who developed acute dysphagia, dysarthria, and hoarseness. A neurological examination and nasopharyngeal fiberscopy revealed paralysis of the left glossopharyngeal, vagus, and hypoglossal nerves. No skin rash was observed. Cerebrospinal fluid testing showed lymphocytic pleocytosis, and an elevated varicella-zoster virus (VZV) IgG antibody index. She was diagnosed with zoster sine herpete unilaterally affecting multiple lower cranial nerves. Although dysphagia is common in patients with PD, acute exacerbations of dysphagia require careful investigation of various potential causes, including VZV infection.

BACKGROUND: Frailty is common in stroke, where it exerts disease- and treatment-modifying effects. However, there has been little work evaluating how frailty influences outcomes after percutaneous endoscopic gastrostomy (PEG) tube insertion. This study investigates the relationship between pre-stroke frailty and one-year mortality following PEG insertion.
METHODS: A pre-stroke frailty index (FI) was calculated for individuals with post-stroke dysphagia who underwent PEG insertion between March 2019 and February 2021. Mortality was recorded at one year, as well as instances of post-PEG pneumonia and discharge destination.
RESULTS: Twenty-nine individuals underwent PEG insertion, eleven (37.9%) of whom died in the subsequent year. The mean (SD) FI for those who survived was 0.10 (0.09), compared to 0.27 (0.19) for those who died (p = 0.02). This remained significant after adjustment for age and sex, with each 0.1 increase in the FI independently associated with an increased odds of one-year mortality (aOR 1.39, 95% CI 1.17-1.67). There was no association between frailty and post-PEG pneumonia (0.12 (0.21) in those who aspirated versus 0.11 (0.18) in those who did not, p = 0.75).
CONCLUSIONS: Pre-stroke frailty is associated with increased one-year mortality after PEG, a finding that may help inform shared clinical decision-making in complex decisions regarding PEG feeding.

UNASSIGNED: Percutaneous endoscopic gastrostomy (P.E.G.) is recommended for stroke patients with dysphagia to sustain oral nutrition.
UNASSIGNED: This study assesses the outcomes of stroke patients undergoing P.E.G. compared with those requiring nasogastric tube (N.G.T) or control group.
UNASSIGNED: We performed a thorough search across five electronic databases to gather pertinent studies. Outcomes were analyzed using relative risk (R.R.) for categorical data and mean difference (M.D.) for continuous data, each with 95% confidence intervals (C.I.). The single-arm meta-analysis results were presented as proportions or mean changes, also with 95% C.I.
UNASSIGNED: We included 22 studies consisting of 996,567 patients. Our double-arm meta-analysis (924,134 patients) revealed no significant difference in post-hospitalization or in-hospital mortality between P.E.G. and control groups. However, P.E.G. patients showed a higher risk of aspiration pneumonia than control (R.R. = 11.72[3.75, 36.62], p < 0.00001). A comparison of P.E.G. and N.G.T. in three studies involving 691 patients indicated a non-significant difference in-hospital mortality risk (R.R. = 0.59, 95% C.I. [0.2, 1.72]). The single-arm analysis of stroke patients with P.E.G. identified a 19.8% in-hospital mortality, 13.6% rate of aspiration pneumonia, and 58% rate of pneumonia.
UNASSIGNED: Stroke patients undergoing P.E.G remain at high risk for aspiration pneumonia and with an in-hospital mortality suggesting the need for identifying the best candidates and timing for the procedure.

BACKGROUND: Mitochondrial diseases (MDs) are systemic disorders that can affect multiple organs. Renal manifestations, including renal tubular acidosis, are common because kidneys are particularly vulnerable to energy deprivation. Treatment of MDs is often complex and electrolyte replacement can be difficult especially in pediatric patients, because large and repeated amounts of oral supplements are needed but are not well tolerated.
METHODS: We describe the case of a girl affected by Kearns-Sayre disease with severe renal tubular acidosis. The management of her metabolic acidosis was challenging because she showed persistent low levels of serum bicarbonates despite a progressive incrementation of oral bicarbonates. Furthermore, as a result to the ingestion of large amounts of alkali, the girl developed an aversion to oral supplementation. After positioning a percutaneous gastrostomy (PEG) and starting enteral administration of bicarbonates (with daily boluses and continuous nocturnal infusion), she finally obtained an adequate electrolyte control, with a significant increase in her quality of life.
CONCLUSIONS: In MDs, the combination of nocturnal continuous enteral administration of alkali plus diurnal boluses may represent a valid solution to correct metabolic acidosis. It can also result in an improved patients\' quality of life, particularly in pediatric settings, where compliance to oral therapy is often lacking due to the large and repeated amounts of unpalatable bicarbonates solutions required.

UNASSIGNED: Although percutaneous endoscopic gastrostomy (PEG) placement is still widely practiced in Japan, studies from Western countries report that it is less beneficial for patients in end-of-life care with cognitive decline. Decisions regarding PEG placement are largely influenced by physician judgment.
UNASSIGNED: The aim of this study was to investigate the background and perceptions of Japanese physicians regarding PEG for older adults in end-of-life care and to identify the factors associated with differences in physician judgment regarding PEG.
UNASSIGNED: The study employed a cross-sectional design.
UNASSIGNED: A questionnaire on PEG for older adults in end-of-life care was sent to Japanese physicians. Logistic regression analysis was used to calculate the odds ratios (ORs) and confidence intervals (CIs) of the association between PEG recommendations and each factor.
UNASSIGNED: PEG placement was advised for bedridden patients and older adults with cognitive decline by 26% of the physicians who responded to the survey. Differences in physician perceptions of PEG feeding were associated with the recommendation for PEG, benefits of preventing aspiration pneumonia (OR: 4.9; 95% CI: 3.1-8.2), impact on post-discharge accommodation decisions (OR: 6.1; 95% CI: 1.9-30.9), and hesitancy to recommend a PEG placement (OR: 1.9; 95% CI: 1.3-4.5). Working in a facility with PEG placement (OR: 2.0; 95% CI: 1.2-3.5) was an associated background factor.
UNASSIGNED: Differences in Japanese physicians\' attitudes toward using PEG feeding for older adults in end-of-life care were significantly associated with differences in their perceptions of the impact of PEG feeding and working in a facility with PEG placement.

Percutaneous endoscopic gastrostomy (PEG) is widely used for long-term enteral nutrition in patients unable to maintain adequate oral intake. Despite advancements in PEG techniques, complications remain a concern. We report a case of a 94-year-old bedridden man who developed significant complications after PEG placement using the pull method. Initially, minor bleeding at the puncture site was managed using traction compression. However, the patient later experienced hemorrhagic shock owing to pulsatile bleeding around the gastrostomy site. Despite attempts to control the bleeding through traction and transfusions, a pseudoaneurysm adjacent to the PEG button was identified. The patient underwent successful transcatheter arterial embolization (TAE). Post-TAE, no further bleeding or hematoma was observed, and imaging confirmed the resolution of the pseudoaneurysm and hematoma. Methicillin-resistant Staphylococcus aureus (MRSA) infection was detected at the gastrostomy site, which contributed to complications. Despite successful management of the bleeding, the patient\'s overall condition deteriorated, and he died on postoperative day 66. This case underscores the importance of vigilant monitoring and management of PEG-related complications, particularly infections that may precipitate severe vascular events.

BACKGROUND: Initiation of feeding after percutaneous endoscopic gastrostomy (PEG) placement has been debated. Randomized controlled trials (RCTs) have been performed on early feeding compared with delayed feeding after PEG placement with varying results. Therefore, a meta-analysis was conducted examining early vs delayed feeding after placement of a PEG.
METHODS: A comprehensive search of databases was conducted in January 2024. Peer-reviewed published RCTs comparing early feeding (≤4 h) with delayed feeding (>4 h) were identified and included in the meta-analysis. Meta-analysis was completed using pooled estimates of overall complications, individual complications, mortality ≤72 h, and number of day 1 significant gastric residual volumes.
RESULTS: Six RCTs (n = 467) were included in the analysis. Comparison of early feeding with delayed feeding after PEG showed no statistically significant differences for overall complications (P = 0.18), mortality ≤72 h (P = 0.3), and number of day 1 significant gastric residual volumes (P = 0.05). No differences were also noted for individual complications, including vomiting, wound infection, bleeding, or diarrhea.
CONCLUSIONS: Feeding ≤4 h after PEG have no differences in minor and major complications compared with that of delayed feeding. Early feeding ≤4 h is safe and should be recommended in future guidelines.

UNASSIGNED: When commencing enteral feeding, patients and families will want to know the likelihood of returning to an oral diet. There is a paucity of data on the prognosis of patients with gastrostomies. We describe a large dataset of patients, which identifies factors influencing gastrostomy removal and assesses the likelihood of the patient having at home enteral nutrition.
UNASSIGNED: Retrospective data was collected on patients from Sheffield Teaching Hospitals who had received a gastrostomy and had outpatient enteral feeding between January 2016 and December 2019. Demographic data, indication and outcomes were analysed.
UNASSIGNED: A total of 451 patients were assessed, median age: 67.7. 183/451(40.6%) gastrostomies were for head and neck cancer, 88/451 (19.5%) for stroke, 28/451 (6.2%) for Motor Neuron Disease, 32/451 (7.1%) for other neurodegenerative causes, 120/451 (26.6%) other. Of the 31.2% who had their gastrostomy removed within 3 years, head and neck cancer was the most common indication (58.3%) followed by stroke (10.2%), Motor Neuron Disease (7.1%) and other neurodegenerative diseases (3.1%). Gastrostomy removal was significantly influenced by age, place of residence, and having head and neck cancer (p < 0.05). There was the greatest likelihood of removal within the first year (24%). 70.5% had enteral feeding at home.
UNASSIGNED: This large cohort study demonstrates 31.2% of patients had their gastrostomy removed within 3 years. Head and neck cancer patients, younger age and residing at home can help positively predict removal. Most patients manage their feeding at home rather than a nursing home. This study provides new information on gastrostomy outcomes when counselling patients to provide realistic expectations.

BACKGROUND: Clinically assisted nutrition and hydration via percutaneous endoscopic gastrostomy (PEG) is a therapeutic option to ameliorate the difficulties associated with enhanced catabolism, weight loss, and dysphagia in Huntington\'s disease (HD).
OBJECTIVE: The objective is to provide insights into demographics, staging (Shoulson-Fahn), complications, weight trajectories, and survival rates in people with HD (pwHD) who underwent PEG.
METHODS: This retrospective study included 705 consecutive pwHD who attended our HD clinic between July 2006 and March 2024, of whom 52 underwent PEG. A control group (n = 52), comprising pwHD without PEG, were closely matched for sex, stage, age, CAG length, and disease burden score at PEG. The study was registered as a service evaluation at the National Hospital for Neurology and Neurosurgery.
RESULTS: PEG prevalence was 15.0% (n = 52/347) among manifest pwHD: 4.8% (n = 3/62) for Stage 3; 33.3% (n = 16/48) for stage 4; and 44.1% (n = 30/68) for stage 5. Commonest indications were dysphagia, weight loss, and inadequate oral intake. Complications included chest infection, tube dislodgement, and peristomal and skin infections. Modeling of weight trajectories after PEG found no difference between PEG and non-PEG groups. Mortality rate was 34.6% (n = 18/52) in the PEG and 36.5% (n = 19/52) in the non-PEG groups (P = 0.84). Treatment duration (until study endpoint or death) was 3.48 years (interquartile range = 1.71-6.02; range = 0.23-18.8), with 65.4% (n = 34/52) alive at the study endpoint.
CONCLUSIONS: PEG in pwHD at-risk for weight loss may help slow weight loss. Prospective studies are required to strengthen PEG decision-making in pwHD. PEG survival was much longer than other dementias, highlighting the need to consider PEG independently in pwHD.

BACKGROUND: Percutaneous radiological gastrostomy (PRG) and percutaneous endoscopic gastrostomy (PEG) are minimally invasive gastrostomy techniques for individuals requiring prolonged enteral feeding. Recent meta-analyses concerning their efficacy and safety mainly included retrospective studies and yielded conflicting results. This meta-analysis of randomized controlled trials (RCTs) aimed to compare efficacy, safety, and procedure time between PRG and PEG for enteral feeding.
METHODS: MEDLINE, Embase, and the Cochrane Library were searched for eligible RCTs comparing PRG and PEG for enteral feeding through February 23, 2024. The primary outcome was technical success. The secondary outcomes were (1) adverse events (AEs), (2) mortality, and (3) procedure time. We used the random-effects model to calculate pooled risk ratio (RR) and mean difference (MD) with corresponding 95% CIs for dichotomous and continuous outcomes, respectively.
RESULTS: Five RCTs with 544 patients (268 PRG and 276 PEG) were included. There was similar technical success (RR = 1.02; 95% CI = 0.98-1.05; I² = 35%; moderate certainty of evidence because of inconsistency), overall mortality (RR = 1.25; 95% CI = 0.63-2.47; I² = 47%; very low certainty of evidence because of inconsistency, indirectness, and imprecision), and overall AEs risk (RR = 1.06; 95% CI = 0.63-1.76; I² = 81%; low certainty of evidence because of inconsistency and imprecision) between the two groups. However, compared with PEG, the procedure time was longer in the PRG group (MD = 19.35 min; 95% CI = 0.95-37.75 min; I² = 98%; very low certainty of evidence because of inconsistency and imprecision).
CONCLUSIONS: PRG and PEG demonstrate similar efficacy and safety; however, the endoscopic technique may boast a shorter procedure time.