Pre-hospitalization dysphagia and feeding tube placement in nursing home residents with advanced dementia

BACKGROUND

Despite research demonstrating the risks of using feeding tubes in persons with advanced dementia, they continue to be placed. The natural history of dysphagia among patients with advanced dementia has not been examined. We conducted a secondary analysis of a national cohort of persons with advanced dementia staying at a nursing home stay before hospitalization to examine (1) pre-hospitalization dysphagia prevalence and (2) risk of feeding tube placement during hospitalization based on preexisting dysphagia.

METHODS

A retrospective cohort study consisting of all nursing home (NH) residents (≥66 years) with advanced dementia (Cognitive Function Scale score ≥2), a hospitalization between 2013-2017, and a Minimum Data Set (MDS) 3.0 assessment within 120 days before hospitalization. Pre-hospitalization dysphagia status and surgically placed feeding tube insertion during hospitalization were determined by MDS 3.0 swallowing items and ICD-9 codes, respectively. A multivariate logistic model clustering on hospital was used to examine the association of dysphagia with percutaneous endoscopic gastrostomy (PEG) feeding tube placement after adjustment for confounders.

RESULTS

Between 2013 and 2017, 889,983 persons with NH stay with advanced dementia (mean age: 84.5, SD: 7.5, and 63.5% female) were hospitalized. Pre-hospitalization dysphagia was documented in 5.4% (n = 47,574) and characterized by oral dysphagia (n = 21,438, 2.4%), pharyngeal dysphagia (n = 24,257, 2.7%), and general swallowing complaints/pain (n = 14,928, 1.7%). Overall, PEG feeding tubes were placed in 3529 patients (11.2%) with pre-hospitalization dysphagia, whereas 27,893 (88.8%) did not have pre-hospitalization dysphagia according to MDS 3.0 items. Feeding tube placement risk increased with the number of dysphagia items noted on the pre-hospitalization MDS (6 vs. 0 dysphagia variables: OR = 5.43, 95% CI: 3.19-9.27).

CONCLUSIONS

Based on MDS 3.0 assessment, only 11% of PEG feeding tubes were inserted in persons with prior dysphagia. Future research is needed on whether this represents inadequate assessment or the impact of potentially reversible intercurrent illness resulting in feeding tube placement.

The effects of respiratory muscle training on respiratory function and functional capacity in patients with early stroke: a meta-analysis

BACKGROUND

Respiratory muscle training is a continuous and standardized training of respiratory muscles, but the evidence of the effects on early stroke patients is not clear. This meta-analysis aimed to investigate the effects of respiratory muscle training on respiratory function and functional capacity in patients with early stroke.

METHODS

PubMed, Embase, PEDro, ScienceDirect, AMED, CINAHL, and China National Knowledge Infrastructure databases were searched from inception to December 8, 2023 for articles about studies that 1) stroke patients with age ≥ 18 years old. Early stroke < 3 months at the time of diagnosis, 2) respiratory muscle training, including inspiratory and expiratory muscle training, 3) the following measurements are the outcomes: respiratory muscle strength, respiratory muscle endurance, pulmonary function testing, dyspnea fatigue score, and functional capacity, 4) randomized controlled trials. Studies that met the inclusion criteria were extracted data and appraised the methodological quality and risk of bias using the Physiotherapy Evidence Database scale and the Cochrane Risk of Bias tool by two independent reviewers. RevMan 5.4 with a random effect model was used for data synthesis and analysis. Mean differences (MD) or standard mean differences (SMD), and 95% confidence interval were calculated (95%CI).

RESULTS

Nine studies met inclusion criteria, recruiting 526 participants (mean age 61.6 years). Respiratory muscle training produced a statistically significant effect on improving maximal inspiratory pressure (MD = 10.93, 95%CI: 8.51-13.36), maximal expiratory pressure (MD = 9.01, 95%CI: 5.34-12.69), forced vital capacity (MD = 0.82, 95%CI: 0.54-1.10), peak expiratory flow (MD = 1.28, 95%CI: 0.94-1.63), forced expiratory volume in 1 s (MD = 1.36, 95%CI: 1.13-1.59), functional capacity (SMD = 0.51, 95%CI: 0.05-0.98) in patients with early stroke. Subgroup analysis showed that inspiratory muscle training combined with expiratory muscle training was beneficial to the recovery of maximal inspiratory pressure (MD = 9.78, 95%CI: 5.96-13.60), maximal expiratory pressure (MD = 11.62, 95%CI: 3.80-19.43), forced vital capacity (MD = 0.87, 95%CI: 0.47-1.27), peak expiratory flow (MD = 1.51, 95%CI: 1.22-1.80), forced expiratory volume in 1 s (MD = 0.76, 95%CI: 0.41-1.11), functional capacity (SMD = 0.61, 95%CI: 0.08-1.13), while inspiratory muscle training could improve maximal inspiratory pressure (MD = 11.60, 95%CI: 8.15-15.05), maximal expiratory pressure (MD = 7.06, 95%CI: 3.50-10.62), forced vital capacity (MD = 0.71, 95%CI: 0.21-1.21), peak expiratory flow (MD = 0.84, 95%CI: 0.37-1.31), forced expiratory volume in 1 s (MD = 0.40, 95%CI: 0.08-0.72).

CONCLUSIONS

This study provides good-quality evidence that respiratory muscle training is effective in improving respiratory muscle strength, pulmonary function, and functional capacity for patients with early stroke. Inspiratory muscle training combined with expiratory muscle training seems to promote functional recovery in patients with early stroke more than inspiratory muscle training alone.

TRIAL REGISTRATION

Prospero registration number: CRD42021291918.

Development and validation of a nomogram for predicting pulmonary infections after Intracerebral hemorrhage in elderly people

OBJECTIVES

The purpose of this study was to develop and validate a nomogram for the prediction of pulmonary infections in elderly patients with intracerebral hemorrhage (ICH) during hospitalization in the intensive care unit (ICU).

METHODS

A total of 1183 elderly patients diagnosed with ICH were included from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database and randomly grouped into training (n=831) and validation (n=352) cohorts. Candidate predictors were identified using the least absolute shrinkage and selection operator (LASSO) regression. Meanwhile, the variables derived from the LASSO regression were included in the multivariate logistic regression analysis, the variables with P < 0.05 were included in the final model and the nomogram was constructed. The discriminatory ability was assessed by plotting the receiver operating curve (ROC) and calculating the area under the curve (AUC). The Performance of the model was assessed by calibration plots and the Hosmer-Lemeshow goodness-of-fit test (HL test). In addition, clinical decision curves assess the net clinical benefit.

RESULTS

The nomogram included chronic lung disease, dysphagia, mechanical ventilation, use of antibiotics, Glasgow Coma Scale (GCS), Logical Organ Dysfunction System (LODS), blood oxygen saturation (SpO2), white blood cell count (WBC) and prothrombin time (PT). The AUC of the predictive model was 0.905 (95 % CI: 0.877, 0.764) in the training cohort and 0.888 (95 % CI: 0.754, 0.838) in the validation cohort, which showed satisfactory discriminative ability. Second, the nomogram showed good calibration. Decision curve analysis showed that the predictive nomogram was clinically useful.

CONCLUSION

A prediction model for predicting pulmonary infections in elderly ICH patients was constructed. The model can help clinicians to identify high-risk patients as soon as possible and prevent the occurrence of pulmonary infections.

Post-stroke pneumonia: Factors associated with readmission within 90 days of stroke discharge

OBJECTIVE

The objective was to identify risk and protective factors associated with post-stroke pneumonia readmission.

METHOD

A retrospective chart review was conducted on 365 stroke patients who were admitted to Ascension Via Christi St. Francis Hospital in Wichita, Kansas from January 1, 2015 through January 30, 2020. This case control study used matching by age at a proportion of four control patients to one post-stroke pneumonia patient. Patients with and without post-stroke pneumonia readmission within 90 days of discharge were included in this study.

RESULTS

Of the 3,952 patients diagnosed with stroke, 1.8% (n=73) patients were readmitted with post-stroke pneumonia. Compared to patients who were not readmitted for post-stroke pneumonia, patients with post-stroke pneumonia readmission were more likely to: have used a nasogastric tube during index admission, have used mechanical ventilation during index admission, or have been placed on a nothing-by-mouth diet at discharge. Being placed on nothing-by-mouth for fluids was also a predictor of post-stroke pneumonia readmission. Lack of acquired infection during the index admission was a protective factor for post-stroke pneumonia readmission.

DISCUSSION

The pathophysiology of post-stroke pneumonia is multifactorial and includes consideration of dysphagia severity, bacterial colonization of the oropharynx and feeding tube, and an altered immune system.

CONCLUSION

During the index admission, patients on nothing-by-mouth were more likely to be readmitted, and infection-free patients were less likely to be readmitted with post-stroke pneumonia. By identifying at-risk patients, clinicians may be able to use this information to tailor future medical interventions to prevent post-stroke pneumonia readmissions.

Prevalence of Oropharyngeal Dysphagia in Adults in Different Healthcare Settings: A Systematic Review and Meta-analyses

Oropharyngeal dysphagia (OD) is prevalent in the elderly and persons with complex medical conditions, resulting in considerable medical and psychosocial consequences and reduced quality of life. Many prevalence studies regard OD in relation to age or diagnosis. Knowledge on the prevalence of OD in different healthcare settings is lacking. This systematic review aimed to estimate the prevalence of OD in adults admitted to hospitals, rehabilitation facilities, nursing homes, and palliative care facilities through meta-analyses. A systematic literature search was completed including all dates up to March 30, 2021. The methodology and reporting were based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Forty-four out of 1,956 screened articles were deemed eligible. Considerable heterogeneity in definitions of OD and type and quality of selected outcome measures were observed. Overall within-group pooled prevalence estimates for OD determined by meta-analysis were 36.5% (95% CI 29.9 - 43.6) in the hospital setting, 42.5% (95% CI 35.8 - 49.5) in the rehabilitation setting, and 50.2% (95% CI 33.3-67.2) in nursing homes. No OD prevalence data were identified for palliative care facilities. Results for between-group analyses of OD prevalence estimates in the hospital setting were non-significant for type of assessment method, diagnostic group, and type of hospital ward, but indicated significantly higher prevalence estimates in nursing homes when using screening compared to patient-report. Future research should provide OD prevalence data for palliative care, achieve consensus in OD-related terminology when performing prevalence studies, and use screening and assessments with optimal diagnostic performance and psychometric properties.

Effect of Pulmonary Function Training with a Respirator on Functional Recovery and Quality of Life of Patients with Stroke

A stroke is a sudden onset cerebral blood circulation disorder. It occurs in patients with cerebrovascular disease due to various predisposing factors causing stenosis, occlusion, or rupture of intracerebral arteries, which, in turn, causes acute cerebral blood circulation disturbance and clinically manifests as symptoms and signs of excessive or permanent cerebral dysfunction. It can cause serious harm to patients' physical and mental health. This study aimed to evaluate the effect of Breathe-Link breathing trainers on lung function and the ability to perform activities of daily living in patients with stroke. Sixty patients with stroke were randomly divided into two groups. One group was set as the control group and received routine breathing training. The experimental group received a Breathe-Link trainer based on regular training, with rehabilitation training for 12 weeks as the time node. Respiratory muscle strength, respiratory velocity, respiratory capacity, forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and rate in the first second (FEV1/FVC) were used to evaluate the respiratory function of patients, and the Barthel index was used to evaluate the ability to perform activities of daily living. Improvements in respiratory function and daily living ability were compared between the two groups. After 12 weeks of training, respiratory muscle strength, respiratory velocity, respiratory volume, FVC, FEV1, FEV1/FVC, and Barthel index of patients in the two groups improved compared with those before training (P < 0.05), and the improvement in the treatment group was better than that in the control group (P < 0.05). Breathe-Link breathing trainers can improve lung function and the ability to perform activities of daily living in patients with stroke, and its effect is acceptable. It can be recommended for clinical use.

Best Practice Recommendations for Dysphagia Management in Stroke Patients: A Consensus from a Portuguese Expert Panel

Dysphagia is frequent after stroke, and it increases the risk of respiratory infection, dehydration and malnutrition, resulting in worse outcomes. Different clinical guidelines present recommendations for the assessment and management of dysphagia in stroke patients in a scattered way. These best practice recommendations address seven clinical questions on the assessment and management of dysphagia in stroke patients, gathering the best-updated evidence. A systematic literature review using the PICO strategy was performed. The recommendations draft was then appraised by a multidisciplinary panel of experts (nutritionists, physiatrists, speech-language pathologists and rehabilitation nurses) in a total of 3 Delphi rounds. A minimum of 80% consensus was established, and the final version offers a total of 21 recommendations for use in clinical practice for stroke patients. These clinical recommendations are an overview of the most recent evidence combined with experts’ consensus and translated into clinically relevant statements. In implementing recommendations at the local level, health professionals should identify facilitators and barriers to evidence-based practice within their contexts and determine the best strategies to address local needs. Where the change is needed, initial and continuing training on all recommendations is essential and relevant.

European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia

Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD.

Nonventilator hospital-acquired pneumonia: A call to action

In 2020 a group of U.S. healthcare leaders formed the National Organization to Prevent Hospital-Acquired Pneumonia (NOHAP) to issue a call to action to address non-ventilator-associated hospital-acquired pneumonia (NVHAP). NVHAP is one of the most common and morbid healthcare-associated infections, but it is not tracked, reported, or actively prevented by most hospitals. This national call to action includes (1) launching a national healthcare conversation about NVHAP prevention; (2) adding NVHAP prevention measures to education for patients, healthcare professionals, and students; (3) challenging healthcare systems and insurers to implement and support NVHAP prevention; and (4) encouraging researchers to develop new strategies for NVHAP surveillance and prevention. The purpose of this document is to outline research needs to support the NVHAP call to action. Primary needs include the development of better models to estimate the economic cost of NVHAP, to elucidate the pathophysiology of NVHAP and identify the most promising pathways for prevention, to develop objective and efficient surveillance methods to track NVHAP, to rigorously test the impact of prevention strategies proposed to prevent NVHAP, and to identify the policy levers that will best engage hospitals in NVHAP surveillance and prevention. A joint task force developed this document including stakeholders from the Veterans' Health Administration (VHA), the U.S. Centers for Disease Control and Prevention (CDC), The Joint Commission, the American Dental Association, the Patient Safety Movement Foundation, Oral Health Nursing Education and Practice (OHNEP), Teaching Oral-Systemic Health (TOSH), industry partners and academia.

The role of the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke (GLOBE-3S) in the prevention of stroke-associated pneumonia (SAP)

Background and purpose

Stroke-associated pneumonia (SAP) affects 10 to 38% of patients in the acute phase of stroke. Stroke patients diagnosed with dysphagia have an 11-fold higher risk of developing SAP. Thus, identifying dysphagic patients through a highly accurate screening tool might be crucial in reducing the incidence of SAP. We present a case–control study designed to evaluate efficacy in reducing the risk of SAP between two swallowing screening tools, the classic water swallow test (WST) and a recently validated tool such as the GLOBE-3S (the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke), which is a highly sensitive swallowing screening tool particularly accurate in detecting silent aspiration as well.

Methods

We analyzed the occurrence of dysphagia in 100 acute stroke patients distributed in two groups: half were screened with WST and the other half with GLOBE-3S.

Results

Dysphagia was diagnosed in 28 patients. The main result is that, among patients who passed the dysphagia screenings, none of those screened with the GLOBE-3S method developed pneumonia compared to 31.82% in the WST group. Discriminant function analysis (DFA) showed that NIH Stroke Scale (NIHSS) score and the dysphagia screening method (i.e., GLOBE-3S vs. WST) were the two main factors in the SAP’s predicting model and the only significant ones per se.

Conclusions

The new GLOBE-3S screening test can reduce the risk of SAP compared to WST.

The Persian version of the Functional Oral Intake Scale (FOIS-P): a validation study on stroke patients with dysphagia

PURPOSE

The present study aimed to validate the Persian version of the Functional Oral Intake Scale (FOIS-P) for stroke patients.

MATERIALS AND METHODS

The current study was conducted in two phases: (1) translation and cross-cultural adaptation of the FOIS into Persian and (2) validation of the FOIS-P. Phase 1 included forward translation, synthesis, back-ward translation, expert panel, and pretesting. To validate the FOIS-P, inter-rater reliability, cross-validity, and sensitivity to change of the scale were investigated. To evaluate the inter-rater reliability of the FOIS-P, two speech-language pathologists, who were blind to the study aims and procedure, applied the FOIS-P to assess the oral intake of 60 stroke survivors. The cross-validity was assessed by investigating the correlation between the FOIS scores and the Video Fluoroscopy Swallowing Study (VFSS). Also, we applied the FOIS-P on 60 patients with stroke at three different times to investigate the sensitivity to change.

RESULTS

Inter-rater reliability of the FOIS-P was excellent according to Cohen's Kappa calculation (K = 0.89, p<.001). Investigation of cross-validity showed that there were significant correlations between the FOIS scores and presence of dysphagia, presence of aspiration, and severity of dysphagia (p<.001). The changes of the FOIS-P scores over follow-ups revealed that the FOIS-P was sensitive to the patient's oral intake changes.

CONCLUSIONS

The FOIS-P is a valid and reliable tool for assessing oral intake in stroke survivors with dysphagia. Hence, the FOIS-P may be suitable for clinical and research in the field of stroke.

Oral Health, Oral Microbiota, and Incidence of Stroke-Associated Pneumonia-A Prospective Observational Study

Stroke-associated pneumonia is a major cause for poor outcomes in the post-acute phase after stroke. Several studies have suggested potential links between neglected oral health and pneumonia. Therefore, the aim of this prospective observational study was to investigate oral health and microbiota and incidence of pneumonia in patients consecutively admitted to a stroke unit with stroke-like symptoms. This study involved three investigation timepoints. The baseline investigation (within 24 h of admission) involved collection of demographic, neurological, and immunological data; dental examinations; and microbiological sampling (saliva and subgingival plaque). Further investigation timepoints at 48 or 120 h after baseline included collection of immunological data and microbiological sampling. Microbiological samples were analyzed by culture technique and by 16S rRNA amplicon sequencing. From the 99 patients included in this study, 57 were diagnosed with stroke and 42 were so-called stroke mimics. From 57 stroke patients, 8 (14%) developed pneumonia. Stroke-associated pneumonia was significantly associated with higher age, dysphagia, greater stroke severity, embolectomy, nasogastric tubes, and higher baseline C-reactive protein (CRP). There were trends toward higher incidence of pneumonia in patients with more missing teeth and worse oral hygiene. Microbiological analyses showed no relevant differences regarding microbial composition between the groups. However, there was a significant ecological shift over time in the pneumonia patients, probably due to antibiotic treatment. This prospective observational study investigating associations between neglected oral health and incidence of SAP encourages investigations in larger patient cohorts and implementation of oral hygiene programs in stroke units that may help reducing the incidence of stroke-associated pneumonia.

A Comparative Study of Two Tube Feeding Methods in Patients with Dysphagia After Stroke: A Randomized Controlled Trial

BACKGROUND

Dysphagia is a common symptom seen in stroke patients, it not only affects patients' nutrition supply, but also causes aspiration pneumonia. To solve the problem of nutritional support for patients with dysphagia after stroke, nasogastric tubes are routinely indwelling to provide nutrition in China. However, this feeding method sometimes causes food reflux, aspiration, pneumonia, and often affects the patients' comfort and self-image acceptance.

AIM

The aim of this study was to determine whether a new feeding method called intermittent oroesophageal (IOE) tube feeding compared with continuous nasogastric tube feeding as a practical and beneficial mean of decreasing the rate of stroke associated pneumonia (SAP), and improving patients' swallowing function, comfort, psychological status.

DESIGN

This was an assessor-blinded, single-center, randomized controlled trial.

METHODS

Ninety-seven hospitalized stroke patients with dysphagia in the rehabilitation department from January to December 2018 were randomized to a control group and an intervention group. Patients in both groups received routine nursing, rehabilitation treatment and swallowing therapy. Patients in the intervention group were given IOE tube feeding, while those in the control group were fed by indwelling nasogastric tube. Outcomes were assessed at admission, discharge or the end of the tube feeding.

RESULTS

The incidence of SAP in the intervention group was 16.33% lower than that (31.25%) in the control group; the comfort score (2.08 ± .64), anxiety score (10.98 ± 2.28), depression score (7.39 ± 2.16) were lower than those (3.02 ± .70), (12.10 ± 2.18), (8.42 ± 2.34) in the control group. The improvement rate of swallowing function in the intervention group was 83.67% higher than that (66.67%) in the control group (all P < .05).

CONCLUSIONS

The IOE tube feeding compared with continuous tube feeding may reduce the incidence of SAP, and improve patients' swallowing function, comfort, psychological status in patients with dysphagia after stroke.

Individualized Prediction Of Stroke-Associated Pneumonia For Patients With Acute Ischemic Stroke

Background

Stroke-associated pneumonia (SAP) is a serious and common complication in stroke patients.

Purpose

We aimed to develop and validate an easy-to-use model for predicting the risk of SAP in acute ischemic stroke (AIS) patients.

Patients and methods

The nomogram was established by univariate and multivariate binary logistic analyses in a training cohort of 643 AIS patients. The prediction performance was determined based on the receiver operating characteristic curve (ROC) and calibration plots in a validation cohort (N=340). Individualized clinical decision-making was conducted by weighing the net benefit in each AIS patient by decision curve analysis (DCA).

Results

Seven predictors, including age, NIHSS score on admission, atrial fibrillation, nasogastric tube intervention, mechanical ventilation, fibrinogen, and leukocyte count were incorporated to construct the nomogram model. The nomogram showed good predictive performance in ROC analysis [AUROC of 0.845 (95% CI: 0.814-0.872) in training cohort, and 0.897 (95% CI: 0.860-0.927) in validation cohort], and was superior to the A²DS², ISAN, and PANTHERIS scores. Furthermore, the calibration plots showed good agreement between actual and nomogram-predicted SAP probabilities, in both training and validation cohorts. The DCA confirmed that the SAP nomogram was clinically useful.

Conclusion

Our nomogram may provide clinicians with a simple and reliable tool for predicting SAP based on routinely available data. It may also assist clinicians with respect to individualized treatment decision-making for patients differing in risk level.

Variation in Dysphagia Assessment and Management in Acute Stroke: An Interview Study

(1) Background: Patients with dysphagia are at increased risk of stroke-associated pneumonia. There is wide variation in the way patients are screened and assessed. The aim of this study is to explore staff opinions about current practice of dysphagia screening, assessment and clinical management in acute phase stroke. (2) Methods: Fifteen interviews were conducted in five English National Health Service hospitals. Hospitals were selected based on size and performance against national targets for dysphagia screening and assessment, and prevalence of stroke-associated pneumonia. Participants were purposefully recruited to reflect a range of healthcare professions. Data were analysed using a six-stage thematic process. (3) Results: Three meta themes were identified: delays in care, lack of standardisation and variability in resources. Patient, staff, and service factors that contribute to delays in dysphagia screening, assessment by a speech and language therapist, and delays in nasogastric tube feeding were identified. These included admission route, perceived lack of ownership for screening patients, prioritisation of assessments and staff resources. There was a lack of standardisation of dysphagia screening protocols and oral care. There was variability in staff competences and resources to assess patients, types of medical interventions, and care processes. (4) Conclusion: There is a lack of standardisation in the way patients are assessed for dysphagia and variation in practice relating to staff competences, resources and care processes between hospitals. A range of patient, staff and service factors have the potential to impact on stroke patients being assessed within the recommended national guidelines.

Factors Associated with Risk of Stroke-Associated Pneumonia in Patients with Dysphagia: A Systematic Review

Dysphagia is associated with increased risk of stroke-associated pneumonia (SAP). However, it is unclear what other factors contribute to that risk or which measures may reduce it. This systematic review aimed to provide evidence on interventions and care processes associated with SAP in patients with dysphagia. Studies were screened for inclusion if they included dysphagia only patients, dysphagia and non-dysphagia patients or unselected patients that included dysphagic patients and evaluated factors associated with a recorded frequency of SAP. Electronic databases were searched from inception to February 2017. Eligible studies were critically appraised. Heterogeneity was evaluated using I². The primary outcome was SAP. Eleven studies were included. Sample sizes ranged from 60 to 1088 patients. There was heterogeneity in study design. Measures of immunodepression are associated with SAP in dysphagic patients. There is insufficient evidence to justify screening for aerobic Gram-negative bacteria. Prophylactic antibiotics did not prevent SAP and proton pump inhibitors may increase risk. Treatment with metoclopramide may reduce SAP risk. Evidence that nasogastric tube (NGT) placement increases risk of SAP is equivocal. A multidisciplinary team approach and instrumental assessment of swallowing may reduce risk of pneumonia. Patients with impaired mobility were associated with increased risk. Findings should be interpreted with caution given the number of studies, heterogeneity and descriptive analyses. Several medical interventions and care processes, which may reduce risk of SAP in patients with dysphagia, have been identified. Further research is needed to evaluate the role of these interventions and care processes in clinical practice.

Predictive Factors of Swallowing Disorders and Bronchopneumonia in Acute Ischemic Stroke

BACKGROUND

In stroke patients, early complications such as swallowing disorders (SD) and bronchopneumonia (BP) are frequent and may worsen outcome. The aim of this study was to evaluate the prevalence of SD in acute ischemic stroke (AIS) and the risk of BP, as well as to identify factors associated with these conditions.

METHODS

We retrospectively studied all AISs over a 12-month period in a single-center registry. We determined the frequency of SD in the first 7 days and of BP over the entire hospital stay. Associations of SD and BP with patient characteristics, stroke features, dental status, and presence of a feeding tube were analyzed in multivariate analyses.

RESULTS

In the 340 consecutive patients, the overall frequency of SD and BP was 23.8% and 11.5%, respectively. The multivariate analyses showed significant associations of SD with NIHSS scores >4, involvement of the medulla oblongata and wearing a dental prosthesis (area under the receiver-operator curve (AUC) of 76%). BP was significantly associated with NIHSS scores >4, male sex, bilateral cerebral lesions, the presence of SD, and the use of an enteral feeding tube (AUC 84%). In unadjusted analysis, unfavorable 12-month outcome and mortality were increased in the presence of SD.

CONCLUSION

In AIS, SD and BP are associated with stroke severity and localization and wearing a dental prosthesis increases the risk of SD. Given that patients with SD have an increased risk of poor outcome and mortality, high-risk patients warrant early interventions, including more randomized trials.

EA promotes swallowing via activating swallowing-related motor neurons in the nucleus ambiguus

To observe the effect of electroacupuncture (EA) on swallowing and its underlying mechanism, 32 Sprague-Dawley (SD) rats were chose and the electrophysiology was used to detect the discharge of nucleus ambiguus (NA) after EA at CV23 (Lianquan), GV16 (Fengfu), and other acupoints. The swallowing-related motor neuron was identified by antidromic stimulation through recurrent laryngeal nerve. Meanwhile, the swallowing numbers were induced by Double-distilled water (DDW) and the neuron discharges were recorded before and after EA. Beside, 50 SD rats were used for testing the c-fos expressions in NA after EA at different acupoints and the other 80 SD rats were used for chemical damage through the microinjection to bilateral NA. 58 neurons provided complete data after histological identification. And two types of swallowing-related (SR) motor neurons were identified, named spontaneous and silent neurons. We found that the onset latency of the first swallow was shorter and the swallowing numbers were increased after EA at CV23 than the other acupoints (P < 0.01). The excitatory neuron response rates were 66.67%, 71.11%, 42.22% and 35.56% for CV23, GV16, PC6 (Neiguan), and ST36 (Zusanli), respectively. The c-fos expressions on CV23 and GV16 groups were significantly higher than the other groups (P < 0.05). After chemical damage, the swallowing numbers could not be regulated by EA, but could be regulated by EA after fake damage. The results of the present study demonstrate that EA at CV23 and GV16 could regulate swallowing function via activating swallowing-related motor neurons in NA.

Predictors of post-stroke fever and infections: a systematic review and meta-analysis

Background

Fever after stroke is common, and often caused by infections. In the current study, we aimed to test the hypothesis that pneumonia, urinary tract infection and all-cause fever (thought to include at least some proportion of endogenous fever) have different predicting factors, since they differ regarding etiology.

Methods

PubMed was searched systematically for articles describing predictors for post-stroke pneumonia, urinary tract infection and all-cause fever. A total of 5294 articles were manually assessed; first by title, then by abstract and finally by full text. Data was extracted from each study, and for variables reported in 3 or more articles, a meta-analysis was performed using a random effects model.

Results

Fifty-nine articles met the inclusion criteria. It was found that post-stroke pneumonia is predicted by age OR 1.07 (1.04–1.11), male sex OR 1.42 (1.17–1.74), National Institutes of Health Stroke Scale (NIHSS) OR 1.07 (1.05–1.09), dysphagia OR 3.53 (2.69–4.64), nasogastric tube OR 5.29 (3.01–9.32), diabetes OR 1.15 (1.08–1.23), mechanical ventilation OR 4.65 (2.50–8.65), smoking OR 1.16 (1.08–1.26), Chronic Obstructive Pulmonary Disease (COPD) OR 4.48 (1.82–11.00) and atrial fibrillation OR 1.37 (1.22–1.55). An opposite relation to sex may exist for UTI, which seems to be more common in women.

Conclusions

The lack of studies simultaneously studying a wide range of predictors for UTI or all-cause fever calls for future research in this area. The importance of new research would be to improve our understanding of fever complications to facilitate greater vigilance, monitoring, prevention, diagnosis and treatment.

Predictors of post-stroke body temperature elevation

Background

Growing evidence indicates that elevated body temperature after stroke is associated with unfavorable outcome. The aim of the current study was to investigate which factors predict temperature elevation within 48 h of stroke onset. Specifically, we hypothesized that temperature elevation would be associated with stroke symptom severity and that hemorrhagic stroke would cause a more pronounced temperature increase compared to ischemic stroke.

Methods

The medical records of 400 stroke patients were retrospectively reviewed. Multiple linear regression analysis was used to determine which factors were associated with elevated body temperature.

Results

Several factors were significantly associated with peak body temperature (the highest recorded body temperature) within 48 h of stroke onset: stroke severity measured by the National Institutes of Health Stroke Scale (NIHSS) (regression coefficient; (RC) 0.022), female gender (RC 0.157), tympanic/non-rectal temperature reading (RC −0.265), swallowing difficulties (RC 0.335), intubation (RC 0.470), antipyretic treatment (RC 0.563), and C-reactive protein > 50 or signs of infection at admission (RC 0.298). Contrary to our expectations, patients with intracerebral hemorrhage did not have higher peak body temperatures than patients with ischemic stroke.

Conclusions

In conclusion, temperature elevation within the first 48 h of stroke onset is common, can be partially predicted using information at admission and is strongly associated with stroke severity. The strong association with stroke severity may, at least partly, explain the previously described association between post-stroke temperature elevation and unfavorable outcome.

Instrumento de rastreio para disfagia orofaríngea no Acidente Vascular Encefálico - Parte I: evidências de validade baseadas no conteúdo e nos processos de resposta

RESUMO Objetivo Este estudo tem o objetivo de identificar as evidências de validade baseadas no conteúdo e nos processos de resposta de um instrumento de Rastreamento para disfagia orofaríngea no Acidente Vascular Encefálico (RADAVE). Método Os critérios para elaborar os itens do instrumento foram baseados na revisão de literatura. Um grupo de juízes com 19 profissionais distintos e da área da saúde avaliaram a relevância e representatividade das questões e o resultado foi analisado por meio do índice de validade de conteúdo (IVC). Para evidência de validade baseada nos processos de resposta, 23 profissionais da saúde aplicaram o instrumento e analisaram as questões por meio de escala estruturada e entrevista cognitiva. Resultados O RADAVE foi estruturado para ser aplicado em duas etapas. A primeira versão foi constituída por 18 questões na etapa I e 11 questões na etapa II. Oito questões da etapa I e quatro questões da etapa II não atingiram o IVC mínimo, sendo realizadas reformulações pelos autores. A entrevista cognitiva demonstrou a necessidade de novos ajustes que resultaram na versão final com 12 questões na Etapa I e seis questões na Etapa II. Conclusão Foi possível desenvolver um instrumento de rastreamento para a disfagia no Acidente Vascular Encefálico com adequadas evidências de validade baseadas no conteúdo e nos processos de resposta. As duas evidências de validade obtidas até o momento permitiram ajustar o instrumento em relação ao seu constructo. Os próximos estudos irão analisar as demais evidências de validade e as medidas de acurácia.

Effects of aspiration pneumonia on the intensive care requirements and in-hospital mortality of hospitalised patients with acute cerebrovascular disease

INTRODUCTION

In this study, we aimed to evaluate the effects of the development of aspiration pneumonia (AP) on the intensive care unit (ICU) requirements and in-hospital mortality of patients hospitalised in the neurology ward due to an acute cerebrovascular accident (CVA).

MATERIAL AND METHODS

Five hundred and three patients hospitalised in the neurology ward following an acute CVA were retrospectively analysed. The patients were divided into two groups: those with AP (group 1) and those without AP (group 2). Demographic characteristics and physical and radiological findings, including the localisation, lateralisation and aetiology of the infarction, in addition to ICU requirements and mortality, were evaluated.

RESULTS

Aspiration pneumonia was detected in 80 (15.9%) patients during the in-hospital stay. Transfer to the ICU for any reason was required in 37.5% of the patients in group 1 and 4.7% of those in group 2 (p < 0.001). In-hospital mortality occurred in 7.5% and 1.4% of the patients in group 1 and group 2, respectively (p = 0.006). The incidence of AP was highest in patients with an infarction of the medial cerebral artery (MCA) (p < 0.001). The AP was associated with older age (p < 0.001), hypertension (p = 0.007), echocardiography findings (p = 0.032) and the modified Rankin Scale (mRS) score (p < 0.001).

CONCLUSIONS

Our findings suggest that the requirement rate for transfer to the ICU and the mortality rate appear to be significantly higher in patients with a diagnosis of AP. Precautions should be taken, starting from the first day of hospitalisation, to decrease the incidence of AP in patients with acute CVA, focusing especially on older patients and those with a severe mRS score.

Histamine H2-Blocker and Proton Pump Inhibitor Use and the Risk of Pneumonia in Acute Stroke: A Retrospective Analysis on Susceptible Patients

BACKGROUND

Although histamine H2-blockers (H2B) and proton pump inhibitors (PPI) are used commonly to prevent gastrointestinal bleeding in acute stroke, they are implicated in the increased risk of pneumonia in other disease populations. In acute stroke, the presence of distinctive risk factors of pneumonia, including dysphagia and impaired consciousness, makes inclusive analysis vulnerable to confounding. Our aim was to assess whether acid-suppressive drugs increase pneumonia in acute stroke in a population controlled for confounding.

METHODS

We analyzed acute stroke patients admitted to a tertiary care hospital. To minimize confounding, we only included subjects who could not feed orally during 14 days of hospitalization. Exposure was defined as H2B or PPI, given in days; the outcome was development of pneumonia within this period. The incidence was calculated from the total number of pneumonias divided by the sum of person-days at risk. We additionally performed multivariate Poisson regression and propensity score analyses, although the restriction largely eliminated the need for multivariate adjustment.

RESULTS

A total of 132 pneumonias occurred in 3582 person-days. The incidence was 3.69%/person-day (95% confidence interval (CI); 3.03-4.37%/day). All subjects had dysphagia. Stroke severity and consciousness disturbances were well-balanced between the groups exposed to H2B, PPI, or none. The relative risk (RR) compared with the unexposed was 1.22 in H2B (95%CI; 0.83-1.81) and 2.07 in PPI (95% CI; 1.13-3.62). The RR of PPI compared with H2B was 1.69 (95%CI; 0.95-2.89). In multivariate regression analysis, the RRs of H2B and PPI were 1.24 (95% CI; 0.85-1.81) and 2.00 (95% CI; 1.12-3.57), respectively; in propensity score analyses they were 1.17 (95% CI; 0.89-1.54) and 2.13 (95% CI; 1.60-2.84).

CONCLUSIONS

The results of this study suggested that prophylactic acid-suppressive therapy with PPI may have to be avoided in acute stroke patients susceptible to pneumonia.

The Efficacy of Prophylactic Antibiotics on Post-Stroke Infections: An Updated Systematic Review and Meta-Analysis

Post-stroke infections are common complications in acute stroke patients and are associated with an unfavorable functional outcome. However, reports on the effects of prophylactic antibiotics treatment on post-stroke infections are conflicting, especially those on post-stroke pneumonia and outcomes. We searched the PubMed, Embase, and Web of Knowledge databases up through March 11^th, 2016. Seven randomized controlled trials including 4261 patients were analyzed among this systematic review and meta-analysis. We found preventive antibiotics treatment at the time of stroke onset did reduce the incidence of infections in adults with acute stroke (OR = 0.57, 95% CI: 0.38–0.85, P = 0.005), including reducing the number of urinary tract infections (OR = 0.34, 95% CI: 0.26–0.46, P < 0.001), but did not significantly decrease the rate of post-stroke pneumonia (OR = 0.91, 95% CI: 0.73–1.13, P = 0.385). Importantly, antibiotics treatment also showed no significant effect on the number of fatalities among stroke patients (OR = 1.07, 95% CI: 0.90–1.26, P = 0.743) and functional outcome scores on the modified Rankin Scale (OR = 1.76, 95% CI: 0.86–3.63, p = 0.124). Our study indicated that preventive antibiotics treatment not reduced the rate of post-stroke pneumonia or mortality, even though decreased the risk of infections, especially urinary tract infections. Thus, preventive antibiotics treatment may not be recommended for acute stroke patients.

Association between nasogastric tubes, pneumonia, and clinical outcomes in acute stroke patients

OBJECTIVE

To investigate whether nasogastric tubes (NGTs) increase poststroke pneumonia (PSP), mortality, or poor outcomes in nil-by-mouth acute stroke patients.

METHODS

This study analyzed prespecified outcomes of PSP at 14 days and mortality and function measured by the modified Rankin Scale at 90 days in 1,217 nil-by-mouth stroke patients at ≤48 hours of symptom onset in a multicenter randomized controlled trial of preventive antibiotics between April 21, 2008, and May 17, 2014. Generalized mixed models adjusted for age, comorbidities, stroke type and severity, and quality of care were used. No patients were lost to follow-up at 14 days, and 36 (3%) were lost at 90 days.

RESULTS

Patients with NGT (298 of 1,217 [24.4%]) had more severe strokes (median NIH Stroke Scale score 17 vs 14, p = 0.0001) and impaired consciousness (39% vs 28%, p = 0.001). NGT did not increase PSP (43 of 298 [14.4%] vs 80 of 790 [10.1%], adjusted odds ratio [OR] 1.26 [95% confidence interval (CI) 0.78-2.03], p = 0.35) or 14- and 90-day mortality (33 of 298 [11.1%] vs 78 of 790 [9.9%], adjusted OR 1.10 [95% CI 0.67-1.78], p = 0.71; and 79 of 298 [26.5%] vs 152 of 790 [19.2%], adjusted OR 0.95 [95% CI 0.67-1.33], p = 0.75, respectively). Ninety-day modified Rankin Scale score distribution was comparable between groups (adjusted OR 1.14 [95% CI 0.87-1.56], p = 0.08). PSP independently increased 90-day mortality (40 of 123 [32.5%] vs 191 of 965 [19.8%], adjusted OR 1.71 [95% CI 1.11-2.65], p = 0.015) and was not prevented by antibiotics in patients with NGT (adjusted OR 1.1 [95% CI 0.89-1.54], p = 0.16).

CONCLUSIONS

Early NGT does not increase PSP incidence, mortality, or poor functional outcomes and can be used safely in acute stroke patients.

Post-stroke pneumonia at the stroke unit - a registry based analysis of contributing and protective factors

BACKGROUND

To investigate prevalence and risk factors for post stroke pneumonia (PSP) in patients with acute ischemic stroke treated at stroke units (SU).

METHOD

We analysed data from the Austrian Stroke Unit registry concerning admissions from January 2003 to December 2013 and assessed the prevalence of PSP at the stroke unit. Patients with and without PSP were compared in univariate and multivariate models searching for factors associated with the occurrence of PSP at the SU.

RESULTS

Three thousand one hundred eleven patients (5.2%) of 59,558 analysed patients were diagnosed with PSP. While age and stroke severity were non-modifiable factors associated with PSP, modifiable risk factors included chronic alcohol consumption and atrial fibrillation. Patients who developed neurological, cardiac, and other infective complications showed a higher prevalence of PSP, an increased prevalence was also found in connection with the placement of nasogastric tubes or urinary catheters. Female sex, left hemispheric stroke, cryptogenic stroke pathogenesis and additionally, treatment with lipid lowering drugs were factors associated with a lower PSP prevalence.

CONCLUSION

Pneumonia in acute ischemic stroke is associated with a variety of modifiable and unmodifiable factors that allow to identify patients at high risk of developing PSP and to focus on early preventive measures at the SU. Further studies could use the results of this study to explore potential benefits of specific interventions targeted at these factors.

Risk factors for lung infection in stroke patients: a meta-analysis of observational studies

BACKGROUND

The aims of this meta-analysis were to evaluate the risk factors associated with lung infections in stroke patients and to provide evidence for prevention decisions.

METHODS

We searched the Embase, PubMed, EBSCO and Web of Science databases to collect studies from January 2000 to July 2015.

RESULTS

The meta-analysis identified 23 risk factors for lung infections in stroke patients, and the top 5, ranked by order according to odds ratio values (95% confidence interval), were as follows: multiple vertebrobasilar stroke, 22.99 (4.04, 130.83); National Institutes of Health Stroke Scale score >15 points, 14.63 (8.54, 25.08); mechanical ventilation, 10.20 (7.15, 14.57); nasogastric tube use, 9.87 (6.21, 15.70); and dysphagia, 7.50 (2.60, 21.65).

CONCLUSION

Preventive measures should be taken against these risk factors to reduce the incidence of lung infection.

Systematic review and meta-analysis of the diagnostic accuracy of the water swallow test for screening aspiration in stroke patients

AIM

The aim of this study was to determine the diagnostic accuracy of the water swallow test for screening aspirations in stroke patients.

BACKGROUND

The water swallow test is a simple bedside screening tool for aspiration among stroke patients in nursing practice, but results from different studies have not been combined before.

DESIGN

A systematic review and meta-analysis was conducted to provide a synthetic and critical appraisal of the included studies.

DATA SOURCES

Electronic literature in MEDLINE, EMBASE, CINAHL and other sources were searched systemically in this study. Databases and registers were searched from inception up to 30 April 2015.

REVIEW METHODS

This systematic review was conducted using the recommendations from Cochrane Collaboration for Systematic Reviews of Diagnostic Test Accuracy. Bivariate random-effects models were used to estimate the diagnostic accuracy across those studies. The tool named Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate the quality of the studies.

RESULTS

There were 770 stroke patients in the 11 studies for the meta-analysis. The water swallow test had sensitivities between 64-79% and specificities between 61-81%. Meta-regression analysis indicated that increasing water volume resulted in higher sensitivity but lower specificity of the water swallow test.

CONCLUSIONS

This systematic review showed that the water swallow test was a useful screening tool for aspiration among stroke patients. The test accuracy was related to the water volume and a 3-oz water swallow test was recommended for aspiration screening in stroke patients.