Presenting Symptoms and Dysphagia Screen Predict Outcome in Mild and Rapidly Improving Acute Ischemic Stroke Patients

Nomogram Model for Predicting the Functional Outcomes in Patients With Minor Ischemic Stroke Based on Clinical Characteristics and Small Vessel Disease Burden

OBJECTIVES

Our purpose is to assess the role of total small vessel disease (SVD) burden affecting the clinical outcome and develop and validate a prognostic nomogram for minor ischemic stroke (MIS) patients.

METHODS

Between January 2018 and April 2023, 454 MIS patients were enrolled. The functional outcome was the modified Rankin scale (mRS) score at 90 days. The least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression model were used to identify prognostic predictors, and then a nomogram was drawn.

RESULTS

Our nomogram comprising of systolic blood pressure (SBP), baseline National Institutes of Health Stroke Scale score (NIHSS), total SVD burden scores, coronary heart disease, disabling stroke, progressive stroke, alteplase treatment, and infarction location demonstrated a good discriminative power in both the training set (AUC=0.870; 95% CI: 0.827-0.912) and the internal validation set (AUC=0.876; 95% CI: 0.817-0.935). The calibration curve and DCA in our result showed the model's high degree of calibration and clinical value. The DeLong test was used to compare the AUCs between the nomogram and non-SVD burden score model in the training (P=0.028) and internal validation sets (P=0.013), indicating that our nomogram performs significantly better than the non-SVD burden score model.

CONCLUSIONS

The SVD burden is an important prognosis factor. Furthermore, the proposed nomogram has good discrimination, calibration, and clinical benefits and is better than the non-SVD burden score model in predicting the outcomes for MIS patients.

Identifying Paediatric Populations with Increased Risk for Oropharyngeal Dysphagia in Acute and Critical Care Settings: A Scoping Review

Dysphagia is common in hospitalised children. Clarity regarding its prevalence is required to direct service needs. This review reports oropharyngeal dysphagia prevalence in children admitted to acute and/or critical care, following acute illness, medical or surgical intervention. It also explores patient characteristics significantly associated with oropharyngeal dysphagia in these settings. Five electronic databases (EMBASE, CINAHL, Cochrane, PubMed, Scopus) were searched. Studies identified for inclusion involved children (0-16 years), in acute or critical care settings, where prevalence data for new-onset or worsening oropharyngeal dysphagia was reported. Peer reviewed journal articles, including systematic reviews were included. Data was extracted and synthesised using a purpose designed extraction tool. A total of 7,522 studies were screened and 67 studies met criteria. The most researched populations included congenital heart disease surgeries, posterior fossa tumour resections, stroke and post-extubation dysphagia. Populations with the highest documented dysphagia prevalence were children after posterior fossa tumour resection with a new tracheostomy, children using nasal continuous positive airway pressure, and children following ischemic stroke. Characteristics significantly associated with oropharyngeal dysphagia were younger age, lower weight, longer intubation, upper/middle airway dysfunction (e.g., vocal paresis), and presence of additional comorbidities. This review presents synthesised prevalence data for children in acute and critical care settings with new-onset or worsening oropharyngeal dysphagia. It highlights the broad nature of oropharyngeal dysphagia in hospitalised children and the need for more rigorous research into characteristics associated with increased risk to better support screening and early identification of oropharyngeal dysphagia in these settings.

Noninstrumental Dysphagia Assessment and Screening: A Proposed Checklist

PURPOSE

In the field of dysphagia research, there is a need to establish a framework for the critical appraisal of methodological reporting. A working group was formed to develop a tool to aid in such critical appraisal across various domains of dysphagia research (called the FRONTIERS [Framework for RigOr aNd Transparency In REseaRch on Swallowing] Framework). The goal of the current paper is to present and describe one domain of this tool: noninstrumental assessment and screening tools.

METHOD

Methods describing the development of the FRONTIERS Framework and the associated tool are detailed in the prologue of this series.

RESULTS

A set of questions specific to the critical appraisal of transparency and rigor of research involving noninstrumental screening and assessment tools was developed. This included 13 "yes/no" questions, each of which is presented with a rationale for its inclusion and an example of its implementation.

CONCLUSIONS

The use of this framework will serve researchers and those appraising the quality of research that uses noninstrumental dysphagia assessment and screening tools. More broadly, the FRONTIERS Framework will facilitate improved rigor and transparency across dysphagia research. Special considerations and future goals are discussed.

Machine learning decision support model for discharge planning in stroke patients

BACKGROUND/AIM

Efficient discharge for stroke patients is crucial but challenging. The study aimed to develop early predictive models to explore which patient characteristics and variables significantly influence the discharge planning of patients, based on the data available within 24 h of admission.

DESIGN

Prospective observational study.

METHODS

A prospective cohort was conducted at a university hospital with 523 patients hospitalised for stroke. We built and trained six different machine learning (ML) models, followed by testing and tuning those models to find the best-suited predictor for discharge disposition, dichotomized into home and non-home. To evaluate the accuracy, reliability and interpretability of the best-performing models, we identified and analysed the features that had the greatest impact on the predictions.

RESULTS

In total, 523 patients met the inclusion criteria, with a mean age of 61 years. Of the patients with stroke, 30.01% had non-home discharge. Our model predicting non-home discharge achieved an area under the receiver operating characteristic curve of 0.95 and a precision of 0.776. After threshold was moved, the model had a recall of 0.809. Top 10 variables by importance were National Institutes of Health Stroke Scale (NIHSS) score, family income, Barthel index (BI) score, FRAIL score, fall risk, pressure injury risk, feeding method, depression, age and dysphagia.

CONCLUSION

The ML model identified higher NIHSS, BI, and FRAIL, family income, higher fall risk, pressure injury risk, older age, tube feeding, depression and dysphagia as the top 10 strongest risk predictors in identifying patients who required non-home discharge to higher levels of care. Modern ML techniques can support timely and appropriate clinical decision-making.

RELEVANCE TO CLINICAL PRACTICE

This study illustrates the characteristics and risk factors of non-home discharge in patients with stroke, potentially contributing to the improvement of the discharge process.

REPORTING METHOD

STROBE guidelines.

Presenting symptoms and functional outcome of chronic subdural hematoma patients

BACKGROUND

Patients with chronic subdural hematoma (CSDH) can present with a variety of signs and symptoms. The relationship of these signs and symptoms with functional outcome is unknown. Knowledge of these associations might aid clinicians in the choice to initiate treatment and may allow them to better inform patients on expected outcomes.

OBJECTIVE

To investigate if presenting signs and symptoms influence functional outcome in patients with CSDH.

METHODS

We conducted a retrospective analysis of consecutive CSDH patients in three hospitals. Glasgow Outcome Scale Extended (GOS-E) scores were obtained from the first follow-up visit after treatment. An ordinal multivariable regression analysis was performed, to assess the relationship between the different signs and symptoms on the one hand and functional outcome on the other adjusted for potential confounders.

RESULTS

We included 1,307 patients, of whom 958 (73%) were male and mean age was 74 (SD ± 11) years. Cognitive complaints were associated with lower GOS-E scores at follow-up (aOR 0.7, 95% CI: 0.5 - 0.8) Headache and higher Glasgow Coma Scale (GCS) scores were associated with higher GOS-E scores. (aOR 1.9, 95% CI: 1.5-2.3 and aOR 1.3, 95% CI: 1.2-1.4).

CONCLUSION

Cognitive complaints are independently associated with worse functional outcome, whereas headache and higher GCS scores are associated with better outcome. The increased probability of unfavorable outcome in patients with CSDH who present with cognitive complaints favors a more prominent place of assessing cognitive status at diagnosis.

Dysphagia and disability in minor strokes - An institutional study

BACKGROUND

Minor strokes, defined as NIHSS ≤5 are considered non-disabling, associated with a favourable outcome.

AIM

Our aim was to study prevalence and predictors of dysphagia in patients with minor stroke and its impact on functional outcome.

METHODS

Single centre retrospective study of all minor strokes admitted to Comprehensive Stroke care centre with 1 year completed follow-up were recruited. Clinical and imaging details and follow-up data were extracted from medical records.

RESULTS

We had 147 patients with minor stroke, 72.1% men with median age 61 years. 71% presented within 24 h of symptom onset. Most common etiology was lacunar .Median NIHSS at admission was 3(IQR 2). 85 patients had anterior circulation strokes and 34 had chronic infarcts in imaging.19 had significant dysphagia and 10 were discharged with nasogastric feeding tube. Admission NIHSS and white mater changes in imaging were predictive of post stroke dysphagia. Excellent recovery of dysphagia was found within 1 month post stroke in all, except one who required percutaneous gastrostomy. At 3 months 76% had excellent outcome. Presence of dysphagia and diabetes were found to be predictive of short term outcome, independent of admission stroke severity. At 12 months, post stroke dysphagia, female gender and white mater changes in imaging were predictive of unfavourable outcome.

CONCLUSIONS

Minor strokes are disabling in a small fraction of patients. Over 10% of them can have significant post stroke dysphagia necessitating nasogastric feeding short term. This patient subgroup tend to have less favourable outcome on short and long term follow-up.

Inconsistent Classification of Mild Stroke and Implications on Health Services Delivery

OBJECTIVE

To conduct a scoping review on classifications of mild stroke based on stroke severity assessments and/or clinical signs and symptoms reported in the literature.

DATA SOURCES

Electronic searches of PubMed, PsycINFO (Ovid), and Cumulative Index to Nursing and Allied Health (CINAHL-EBSCO) databases included keyword combinations of mild stroke, minor stroke, mini stroke, mild cerebrovascular, minor cerebrovascular, transient ischemic attack, or TIA.

STUDY SELECTION

Inclusion criteria were limited to articles published between January 2003 and February 2018. Inclusion criteria included studies (1) with a definition of either mild or minor stroke, (2) written in English, and (3) with participants aged 18 years and older. Animal studies, reviews, dissertations, blogs, editorials, commentaries, case reports, newsletters, drug trials, and presentation abstracts were excluded.

DATA EXTRACTION

Five reviewers independently screened titles and abstracts for inclusion and exclusion criteria. Two reviewers independently screened each full-text article for eligibility. The 5 reviewers checked the quality of the included full-text articles for accuracy. Data were extracted by 2 reviewers and verified by a third reviewer.

DATA SYNTHESIS

Sixty-two studies were included in the final review. Ten unique definitions of mild stroke using stroke severity assessments were discovered, and 10 different cutoff points were used. The National Institutes of Health Stroke Scale was the most widely used measure to classify stroke severity. Synthesis also revealed variations in classification of mild stroke across publication years, time since stroke, settings, and medical factors including imaging, medical indicators, and clinical signs and symptoms.

CONCLUSIONS

Inconsistencies in the classification of mild stroke are evident with varying use of stroke severity assessments, measurement cutoff scores, imaging tools, and clinical or functional outcomes. Continued work is necessary to develop a consensus definition of mild stroke, which directly affects treatment receipt, referral for services, and health service delivery.

The Effect of Improved Dysphagia Care on Outcome in Patients with Acute Stroke: Trends from 8-Year Data of a Large Stroke Register

BACKGROUND

Early dysphagia screening and appropriate management are recommended by current guidelines to reduce complications and case fatality in acute stroke. However, data on the potential benefit of changes in dysphagia care on patient outcome are limited. Our objective was to assess the degree of implementation of dysphagia guidelines and determine the impact of modifications in dysphagia screening and treatment practices on disease complications and outcome in stroke patients over time.

METHODS

In this prospective register-based study ("Stroke Register of Northwestern Germany"), all adult stroke patients admitted to 157 participating hospitals between January, 2008 and December, 2015 were included (n = 674,423). Dysphagia incidence upon admission, the proportion of patients receiving a standardized swallowing screening, and the percentage of dysphagic patients being referred to a speech language therapist (SLT) for treatment were obtained per year. Pneumonia rate, modified Rankin Scale (mRS) at discharge, and in-hospital mortality were compared between groups of dysphagic vs. non-dysphagic patients over time.

RESULTS

Screening proportions continuously increased from 47.2% in 2008 to 86.6% in 2015. But the proportion diagnosed with dysphagia remained stable with about 19%. The number of dysphagic patients receiving SLT treatment grew from 81.6 up to 87.0%. Pneumonia incidence was higher in dysphagic stroke cases (adjusted OR 5.4 [5.2-5.5], p < 0.001), accompanied by a worse mRS at discharge (adjusted OR for mRS ≥3: 3.1 [3.0-3.1], p < 0.001) and higher mortality (adjusted OR 3.1 [3.0-3.2], p < 0.001). The order of magnitude of these end points did not change over time.

CONCLUSION

Although advances have been made in dysphagia care, prevalent screening and treatment practices remain insufficient to reduce pneumonia rate, improve functional outcome, and decrease case fatality in dysphagic stroke patients. More research is urgently needed to develop more effective swallowing therapies.