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Original article
Exploratory study on gastrostomy in patients with neurological diseases: usefulness and impact
Estudio exploratorio sobre gastrostomía en pacientes con enfermedades neurológicas: utilidad e impacto
D. Pineda-Cortésa,b, F. Paz-Rodríguezc, Z. Trujillo-de Los Santosa,
Corresponding author
draztrujillo@gmail.com

Corresponding author.
, M.A. Sánchez-Guzmánd, M.G. Nava-Galáne, E. Santana-Aguilara,b, J. Rosas-Uríasb
a Programa de Cuidados Paliativos, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, Mexico
b Servicio Social de Cuidados Paliativos, Universidad Nacional Autónoma de México, Mexico
c Departamento de Neuropsicología y Grupos de Apoyo, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, Mexico
d Laboratorio de Violencia y Género, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, Mexico
e Enfermería Cuidados Paliativos, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, Mexico
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            "entidad" => "Departamento de Neuropsicolog&#237;a y Grupos de Apoyo&#44; Instituto Nacional de Neurolog&#237;a y Neurocirug&#237;a&#44; Ciudad de M&#233;xico&#44; Mexico"
            "etiqueta" => "c"
            "identificador" => "aff0015"
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            "entidad" => "Laboratorio de Violencia y G&#233;nero&#44; Instituto Nacional de Neurolog&#237;a y Neurocirug&#237;a&#44; Ciudad de M&#233;xico&#44; Mexico"
            "etiqueta" => "d"
            "identificador" => "aff0020"
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            "entidad" => "Enfermer&#237;a Cuidados Paliativos&#44; Instituto Nacional de Neurolog&#237;a y Neurocirug&#237;a&#44; Ciudad de M&#233;xico&#44; Mexico"
            "etiqueta" => "e"
            "identificador" => "aff0025"
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          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
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    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Estudio exploratorio sobre gastrostom&#237;a en pacientes con enfermedades neurol&#243;gicas&#58; utilidad e impacto"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Percutaneous endoscopic gastrostomy &#40;PEG&#41;&#44; which was developed during the 1980s&#44; has facilitated feeding of patients with oral intake difficulties but normal gastrointestinal function&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The procedure consist of the insertion of a feeding tube directly into the stomach through a small incision in the abdominal wall&#44; guided by an endoscope reaching the stomach via the oesophagus&#46; General anaesthesia is not required in the majority of cases&#59; complications are scarce&#44; of little clinical relevance&#44; and easy to treat&#59; and the procedure is relatively inexpensive&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> This has contributed to the fast development and extensive use of the technique in a great variety of situations in which swallowing is impaired&#44; especially in patients who need enteral feeding for long periods or indefinitely&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The most frequent reason for PEG &#40;90&#37; of cases&#41; is impaired feeding ability&#44; as occurs in neurological diseases causing dysphagia&#58; cerebrovascular disease &#40;CVD&#41;&#44; amyotrophic lateral sclerosis &#40;ALS&#41;&#44; advanced stages of Alzheimer disease&#44; multiple sclerosis&#44; anoxic-ischaemic encephalopathy&#44; advanced Parkinson&#8217;s disease&#44; brain tumours&#44; and neck&#44; larynx&#44; and oesophageal cancer&#44; among other diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">PEG feeding may improve the nutritional status of patients requiring prolonged hospitalisation due to their condition&#44; for example&#44; patients with CVDs and oropharyngeal cancer&#46; Up to 70&#37; of patients with acute CVD present dysphagia&#59; while approximately half of them sufficiently recover swallowing function&#44; enabling them to meet their caloric requirements&#44; the other half will present swallowing dysfunction in the long term&#44; and their recovery is unpredictable&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">PEG is of unquestionable value&#44; as shown by several studies conducted in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Brazil&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> the United States&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and Mexico&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> where researchers observed a high survival rate&#44; few complications associated with the procedure&#44; and improved functional status&#46; Furthermore&#44; PEG is associated with less discomfort and lower risk of nasogastric bleeding or tube obstruction or dislodgement&#44; as compared to nasogastric or nasojejunal tubes&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8&#44;9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The use of PEG in irreversible neurological processes and terminal illnesses is debatable&#59; placing a PEG tube may unnecessarily prolong the lives of functionally disabled individuals with a life expectancy of only a few days or weeks&#44; while increasing patient discomfort and caregiver burden and incurring high costs&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">At the Instituto Nacional de Neurolog&#237;a y Neurocirug&#237;a Manuel Velasco Su&#225;rez &#40;INNN&#41;&#44; the use of PEG is frequent&#59; over the past 3 years&#44; approximately 100 procedures per year were performed&#46; However&#44; we do not fully know which factors may have an impact on the usefulness of PEG &#40;eg&#44; survival time&#44; functional status&#44; and the socioeconomic status of the patient&#8217;s family&#41;&#44; although we aim to provide sufficient information on the procedure&#8217;s risks and benefits&#46; This study is intended to describe the usefulness of PEG&#44; its impact on survival&#44; and the associated complications and financial costs&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Population and design</span><p id="par0035" class="elsevierStylePara elsevierViewall">We conducted an observational retrospective study by reviewing patients&#8217; clinical histories&#44; using quota sampling&#46; We included 70 patients hospitalised between 2015 and 2017&#44; who underwent PEG tube placement and were discharged home&#46; We only obtained data from 51 patients &#40;we were unable to find an informant caregiver or patient in 19 cases&#41;&#46; PEG was indicated due to swallowing impairment in all cases&#46; We collected data on the following variables&#58; patient&#8217;s sociodemographic profile&#44; diagnosis&#44; date of PEG tube placement&#44; functional status according to the Karnofsky Performance Status Scale&#44; comorbidities&#44; blood count and serum albumin data &#40;pre- and post-PEG&#41;&#44; socioeconomic status&#44; and caregiver&#8217;s data&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We administered a telephone survey to caregivers to determine their experience with PEG&#58; did they know the diagnosis&#63;&#44; were the benefits and risks of the procedure explained&#63;&#44; were they trained to provide care&#63;&#44; did they find it difficult to provide PEG-related care&#63;&#44; how long did the PEG tube remain in place&#63;&#44; why was the PEG tube removed&#63;&#47;did the patient recover swallowing ability&#63;&#44; how long did the patient survive with PEG&#63;&#44; what complications did the patient present&#63;&#44; and how much did it cost to feed the patient by PEG per month&#44; including care expenses&#63;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Data were analysed using the SPSS statistical software &#40;version 22&#46;0&#41;&#46; We conducted a retrospective analysis using absolute values and percentages for categorical variables and means and standard deviations for continuous variables&#46; We used the chi square test or the Fisher test to compare proportions when any cell presented a value below 5&#37;&#46; Significant differences between pre- and post-PEG values for serum albumin and blood count data were assessed with the Mann&#8211;Whitney U test&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">Of the 51 patients&#44; 62&#46;7&#37; were women and 37&#46;3&#37; men&#59; mean age &#40;SD&#41; was 54&#46;4 &#40;18&#46;6&#41; years &#40;range&#44; 18&#8211;86&#41;&#46; The most frequent diagnoses were brain tumours&#44; in 37&#46;3&#37; of patients &#40;n&#160;&#61;&#160;19&#41;&#44; CVD in 33&#46;3&#37; &#40;n&#160;&#61;&#160;17&#41;&#44; demyelinating disease&#47;ALS&#47;Guillain&#8211;Barr&#233; syndrome in 17&#46;6&#37; &#40;n&#160;&#61;&#160;9&#41;&#44; and other neurological disease &#40;hydrocephalus&#44; leukoencephalopathy&#44; encephalopathy&#44; metabolic myopathy&#44; severe head trauma&#44; pontine myelinolysis&#41; in 11&#46;8&#37; &#40;n&#160;&#61;&#160;6&#41;&#46; The PEG tube generally remained in place for 9&#46;14 months&#46; It was removed due to improvement or tolerated oral intake in 52&#46;9&#37; of patients &#40;10 patients with CVD&#44; 9 with other neurological disease&#44; and 7 with brain tumour&#41;&#44; after a mean period of 5&#46;1 &#40;4&#46;4&#41; months&#46; Functional status&#44; as measured with the Karnofsky Performance Status Scale at the time of PEG&#44; was a mean of 51&#46;8 points&#46; Regarding survival&#44; 66&#46;7&#37; of patients &#40;n&#160;&#61;&#160;34&#41; were still alive at the time of the study &#40;14 patients with CVD&#44; 8 with brain tumour&#44; and 12 with other neurological disease&#41;&#46; The mortality rate amounted to 33&#46;3&#37; &#40;n&#160;&#61;&#160;16&#41;&#59; we should mention that of the deceased patients&#44; 3 died within 24&#160;hours of PEG tube placement&#44; due to sepsis in one patient with leukoencephalopathy and due to intracranial hypertension with uncal herniation in 2 patients diagnosed with meningioma&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The comparative analysis of serum albumin results revealed no significant differences &#40;Z&#160;&#61;&#160;&#8211;0&#46;548&#59; <span class="elsevierStyleItalic">P</span>&#160;&#61;&#160; &#46;548&#41; between pre-PEG &#40;mean of 3&#46;37 &#91;0&#46;57&#93;&#41; and post-PEG determinations &#40;mean of 2&#46;84 &#91;1&#46;58&#93;&#41;&#46; The comparative analysis of blood count results revealed no significant differences &#40;Z&#160;&#61;&#160;&#8211;0&#46;743&#59; <span class="elsevierStyleItalic">P</span>&#160;&#61;&#160;&#46;458&#41; between pre-PEG &#40;mean of 11&#46;52 &#91;2&#46;26&#93;&#41; and post-PEG determinations &#40;mean of 10&#46;16 &#91;5&#46;75&#93;&#41;&#46; When comparing survival rates&#44; we observed no statistically significant differences overall &#40;&#967;<span class="elsevierStyleSup">2</span> &#91;12&#44; N&#160;&#61;&#160;51&#93;&#160;&#61;&#160;16&#46;116&#59; <span class="elsevierStyleItalic">P</span>&#160;&#61;&#160;&#46;186&#41;&#46; However&#44; we did observe higher survival rates in patients with CVD &#40;82&#37;&#41; as compared with other conditions&#58; tumours &#40;53&#37;&#41;&#44; demyelinating disease&#47;ALS&#47;Guillain-&#8211;Barr&#233; syndrome &#40;78&#37;&#41;&#44; and other neurological diseases &#40;67&#37;&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Regarding the telephone interviews with caregivers and patients&#44; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the demographic characteristics and responses of the participants&#59; 62&#46;7&#37; were women and primary caregivers were most frequently patients&#8217; children&#44; in 39&#46;2&#37; of cases&#46; Of all respondents&#44; 92&#46;2&#37; knew the patient&#8217;s diagnosis&#44; and were informed about the procedure and its risks and benefits&#46; Three respondents were patients &#40;5&#46;9&#37;&#59; 2 with Guillain-Barr&#233; syndrome and one with hydrocephalus&#41;&#44; who had a PEG tube in place for a mean period of 3 months&#59; PEG tubes were removed due to tolerance to the oral route&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the perceived benefits&#58; 78&#46;4&#37; reported a significant benefit&#59; 43&#46;1&#37; considered care for the PEG tube to be difficult&#44; and 52&#46;9&#37; considered that general care for the PEG tube was complicated&#47;very complicated&#46; The mean monthly cost of maintaining the PEG tube was &#8364;175&#46;78 &#40;range&#44; &#8364;38&#46;38 to &#8364;293&#46;45&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">This first exploratory study at the INNN shows that PEG was correctly indicated in patients with neurological diseases&#44; such as CVD and resectable brain tumours&#46; Indication of PEG is even clearer in these cases than in other conditions with poorer prognosis&#44; such as malignant tumours associated with short survival times and located in inaccessible areas&#44; or advanced diseases with no possibility of functional recovery&#44; as is the case with degenerative dementias&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12</span></a> In our patients&#44; rates of functional recovery were comparable to rates of tolerance to oral route and removal of the PEG tube&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As a national reference centre&#44; the INNN provides care to the highest number of patients from all over the country&#59; brain tumours became the leading cause of in-hospital morbidity and mortality during the first semester of 2017&#46; In line with these data&#44; the most frequent disease in our series was brain tumours&#44; in 37&#46;3&#37; of patients&#46; In terms of mortality&#44; CVD represents the third leading cause of death in the general population&#44; and was the second cause of death in our study &#40;33&#46;3&#37;&#41;&#59; CVD is a frequent condition in the literature reviewed&#46; A study conducted in Indiana &#40;USA&#41;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> reported a mortality rate of 41&#37;&#44; whereas a Brazilian study reported 39&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and research conducted at a Mexican general hospital described a rate of 48&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">It is important to note that patients undergoing PEG placement present few complications &#40;tube dislodgement and migration&#44; and local irritation or infection&#41;&#44; which is consistent with our results&#46; The most severe complications were one case of infection and another case of haemoperitoneum&#46; Also&#44; a Spanish study reported only one case of peritonitis&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> whereas the other Mexican study reviewed described 2 cases of intestinal perforation&#44; confirming the low rate of complications associated with the procedure&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In similar studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5&#8211;7</span></a> mortality was associated with the underlying comorbidity&#59; however&#44; we observed that the mortality rate was low&#44; and directly associated with a complication unrelated to the procedure &#40;sepsis in one patient with leukoencephalopathy and 2 patients with uncal herniation due to meningioma expansion&#41;&#46; In terms of survival&#44; percentages were similar&#58; 53&#37; in Spain&#44; 57&#37; in Brazil&#44; 40&#37; in Indiana&#44; and 67&#37; in our study&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">PEG may facilitate the discharge of patients with neurological diseases with poor prognosis and long hospital stays due to dysphagia secondary to neuromotor disorders&#44; as is the case with patients with brain tumours&#44; who present impairment of the lower cranial nerves&#44; or such upper motor neuron diseases as ALS&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> Patients with acute CVD and presenting impaired swallowing are more likely to recover if we ensure adequate feeding by PEG on a temporary basis&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">None of the studies reviewed mentions the costs associated with the procedure or caregiver burden&#44; a situation that we did analyse&#44; as our patients have limited resources and are attended at a public hospital that is unable to provide equipment or to follow up patients outside the hospital or at their homes&#46; Therefore&#44; it would be beneficial to establish selection criteria such as survival time&#44; functional status&#44; family members&#8217; availability to care for the patients&#44; and income level&#44; as well as improving caregivers&#8217; training and information&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In terms of quality of life&#44; PEG offers clear benefits&#44; as nutrition and well-being are improved&#59; furthermore&#44; PEG may be even more tolerable for patients as it avoids the need for insertion of a nasal tube&#44; and is less likely to be accidentally removed&#44; with subsequent re-insertion&#46; It is also associated with higher survival rates in the short term&#44; but not in the long term&#44; as patients frequently die due to underlying conditions&#59; this supports the use of the technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;15</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Despite its significant benefits&#44; caregivers reported that care in general was complex&#44; difficult&#44; and costly&#59; the technique therefore increases caregiver burden&#46; However&#44; this perception may be improved with proper clinical follow-up&#44; and the consideration of the patient&#8217;s financial status and support network&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In summary&#44; we consider PEG to be useful in patients with a neurological disease affecting swallowing&#44; whether temporarily or in the long term&#59; however&#44; it is important to consider clinical and prognostic status&#44; to provide appropriate explanation of the risks and benefits to patients and their families&#44; and to be mindful of the needs&#44; context&#44; and wishes of the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;16</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0115" class="elsevierStylePara elsevierViewall">PEG is a safe technique of great clinical relevance for long-term enteral feeding&#44; due to the low rate of complications when proper follow-up and caregiver training are provided&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">At the INNN&#44; PEG is used frequently&#44; and the reasons for its use are similar to those reported in the studies reviewed&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5&#44;6&#44;9</span></a> The role of clinical follow-up of patients who are discharged home has not yet been analysed in the literature&#46; Other factors yet to be examined include the impact of gastrostomy&#44; at-home management&#44; treatment planning&#44; resource distribution&#44; availability of services in the event of complications&#44; and hospital readmission&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In line with the findings of Kurien et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the decision to place a PEG tube should be made on an individual basis&#44; considering the patient&#8217;s needs&#44; diagnosis&#44; and life expectancy&#46; The aim of the procedure is not only to improve patient survival and nutritional status&#44; but also quality of life&#44; which is not necessarily correlated with nutritional status&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The patient&#8217;s social context should also be considered in any clinical intervention&#44; as it helps to ensure that clinical practice is complete&#44; coherent&#44; and efficient&#46; Our study provides a comprehensive view of the procedure&#44; which is of practical interest to healthcare professionals who may provide care to these patients&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Percutaneous endoscopic gastrostomy &#40;PEG&#41; is a useful intervention for patients with impaired swallowing and a functional gastrointestinal system&#46; Neurological diseases that cause neuromotor dysphagia&#44; brain tumors&#44; and cerebrovascular disease are the most frequent indications&#59; complications are rare&#44; and morbidity and mortality rates are low&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">To describe the usefulness of PEG in patients with neurological diseases&#44; and its impact on care&#44; survival&#44; and costs and benefits&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material and methods</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective observational study&#44; reviewing clinical files of patients hospitalised at the National Institute of Neurology and Neurosurgery &#40;years 2015-2017&#41; who underwent PEG placement&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The sample included 51 patients&#58; 62&#46;7&#37; were women and the mean &#40;SD&#41; age was 54&#46;4 &#40;18&#46;6&#41; years &#40;range&#44; 18-86&#41;&#46; Diagnosis was tumor in 37&#46;3&#37; of cases and cerebrovascular disease in 33&#46;3&#37;&#46; Sixteen patients &#40;33&#46;3&#37;&#41; died and 11 presented minor complications&#46; The PEG tube remained in place for a mean of 9&#46;14 months&#59; in 52&#46;9&#37; of patients it was removed due to lack of improvement and&#47;or tolerated oral intake&#44; with removal occurring after a mean of 5&#46;1 &#40;4&#46;4&#41; months&#46; Among patients&#8217; family members&#44; 78&#46;4&#37; reported a great benefit&#44; 43&#46;1&#37; reported difficulty caring for the PEG&#44; and 45&#46;1&#37; reported complicated care in general&#46; The monthly cost of maintaining the PEG was &#8364;175&#46;78 on average &#40;range&#44; 38&#46;38-293&#46;45&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion and conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">This preliminary study reveals that PEG was well indicated in patients with neurological diseases&#44; with survival rates similar to those reported in other studies with long follow-up periods&#46; In patients with cerebrovascular disease&#44; the PEG tube remained in place a mean of 9&#46;14 months&#44; during recovery of swallowing function&#59; however&#44; the cost is high for our population&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
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            "titulo" => "Objective"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Material and methods"
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            "identificador" => "abst0020"
            "titulo" => "Results"
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            "titulo" => "Discussion and conclusions"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La Gastrostom&#237;a Endosc&#243;pica Percut&#225;nea &#40;GEP&#41; es &#250;til para personas con problemas de la v&#237;a oral con viabilidad de la v&#237;a g&#225;strica&#46; Las enfermedades neurol&#243;gicas que producen disfagia neuromotora&#44; tumores cerebrales&#44; enfermedad vascular cerebral&#44; son las que tienen mayor indicaci&#243;n&#59; las complicaciones son escasas y baja morbimortalidad&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Describir la utilidad de la GEP en pacientes con enfermedades neurol&#243;gicas y el impacto en el cuidado&#44; sobrevida y costo-beneficio&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Material y m&#233;todos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional retrospectivo&#44; mediante revisi&#243;n de expedientes cl&#237;nicos de pacientes hospitalizados en el Instituto Nacional de Neurolog&#237;a y Neurocirug&#237;a &#40;a&#241;os 2015&#8211;2017&#41; que se realiz&#243; GEP&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 51 pacientes&#58; 62&#46;7&#37; mujeres&#44; edad promedio 54&#46;4&#160;&#177;&#160;18&#46;6 a&#241;os &#40;Rango&#59; 18 a 86&#41;&#46; Diagn&#243;sticos&#58; tumor del SNC 37&#46;3&#37;&#44; y EVC 33&#46;3&#37;&#46; Mortalidad 33&#46;3&#37; &#40;16 pacientes&#41;&#58; 11 presentaron complicaciones menores&#46; Permanencia de la GEP&#58; promedio 9&#46;14 meses&#46; Al 52&#46;9&#37; se le retir&#243; por mejor&#237;a y&#47;o toler&#243; VO&#44; con tiempo promedio 5&#46;1&#160;&#177;&#160;4&#46;4 meses&#46; 78&#46;4&#37; de los familiares reportaron gran beneficio&#44; 43&#46;1&#37; percibi&#243; dif&#237;cil el cuidado de la GEP y 45&#46;1&#37; refiri&#243; complicado el cuidado en general&#46; El costo de mantener la GEP mensual fue de 175&#46;78 &#8364; en promedio &#40;rango de 38&#46;38 a 293&#46;45 &#8364;&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discusi&#243;n y conclusiones</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Este primer estudio revela que la GEP fue bien indicada en pacientes con patolog&#237;as neurol&#243;gicas&#44; con sobrevida similar a la reportada en otras investigaciones con seguimiento prolongado&#46; En pacientes con EVC la permanencia de la GEP fue de 9&#46;14 meses en promedio&#44; por recuperaci&#243;n de la v&#237;a oral&#44; sin embargo&#44; el costo es elevado para nuestra poblaci&#243;n&#46;</p></span>"
        "secciones" => array:5 [
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            "identificador" => "abst0030"
            "titulo" => "Introducci&#243;n"
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            "titulo" => "Objetivo"
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          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Material y m&#233;todos"
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          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
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          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Discusi&#243;n y conclusiones"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Pineda-Cort&#233;s D&#44; Paz-Rodr&#237;guez F&#44; Trujillo-de Los Santos Z&#44; S&#225;nchez-Guzm&#225;n MA&#44; Nava-Gal&#225;n MG&#44; Santana-Aguilar E&#44; et al&#46; Estudio exploratorio sobre gastrostom&#237;a en pacientes con enfermedades neurol&#243;gicas&#58; utilidad e impacto&#46; Neurolog&#237;a&#46; 2022&#59;37&#58;428&#8211;433&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Demographic characteristics</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&#160;&#61;&#160;51&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Women&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">32&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">62&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Men&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">37&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Son&#47;daughter&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">39&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Spouse&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">19&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Father&#47;mother&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">13&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Brother&#47;sister&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Uncle&#47;nephew&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Daughter-&#47;son-&#47;sister-&#47;brother-in-law&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">47&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">The PEG procedure was explained</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">PEG risks and benefits were explained</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Complications reported by the caregiver</span><a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Monthly expenditure &#40;&#8364;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">175&#46;78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&#160;&#61;&#160;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Difficulty in PEG care</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No answer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">General care</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Simple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Complicated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Very complicated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No answer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Beneficial</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Very much&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fairly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Scarcely&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No benefit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Survival</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;&#8239;3 months&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3-6 months&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6 months-1 year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1-2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alive &#40;at the time of study&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">66&#46;7&nbsp;\t\t\t\t\t\t\n
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ISSN: 21735808
Original language: English
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es en pt

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