Predictors and Outcomes of Dysphagia Screening After Acute Ischemic Stroke

Research hotspot and frontiers in post-stroke dysphagia: A bibliometric study and visualisation analysis

BACKGROUND

Dysphagia, a common complication after stroke, significantly hampers the recovery process of patients, both due to dysphagia itself and the additional complications it causes. Although a large number of articles have been published on post-stroke dysphagia (PSD), bibliometric analysis in this field is still lacking. This study aimed to provide a comprehensive understanding of the research hotspots and trends in PSD, thereby guiding future research efforts.

METHODS

The Web of Science Core Collection (WoSCC) database was searched for articles related to PSD from 2003 to 2022. Data were visualised and analysed using CiteSpace and VOSviewer.

RESULTS

A total of 3102 publications were included in the scientometric analysis, with a gradual increase in the number of papers published each year. The United States emerged as the country with the highest number of publications (625 articles), while the University of Manchester led with the most publications among institutions (67 articles). Notably, Dysphagia was both the most published (254 articles) and the most cited journal (11,141 citations). Among authors, Hamdy S emerged as the most prolific (52 articles), with Martino R being the most cited (1042 citations).

CONCLUSION

Based on our findings, we anticipate that research hotspots in PSD will mainly focus on complications due to PSD such as stroke-associated pneumonia, stroke-related sarcopenia. Additionally, exploration into the mechanisms and parameters of noninvasive brain stimulation techniques for the treatment of PSD, as well as the rehabilitation needs of patients with PSD, are expected to be key focal points in future research endeavours.

Clinical Features and Voxel-Based-Symptom-Lesion Mapping of Silent Aspiration in Acute Infratentorial Stroke

Post-stroke dysphagia (PSD) is a severe and common complication after ischemic stroke. The role of silent aspiration as an important contributing factor in the development of a dysphagia-associated complications, in particular aspiration-associated pneumonia has been insufficiently understood. The aim of this study was to investigate the characteristics and risk factors of silent aspiration in patients with acute infratentorial stroke by FEES and to identify culprit lesions in stroke patient with a high risk of silent aspiration via voxel-based-symptom-lesion mapping (VBS/ML). This study is a retrospective observational study based on a prospectively collected FEES and stroke database. Consecutive patient cases with acute ischemic infratentorial stroke and FEES examination between 2017 and 2022 were identified. Group allocation was performed based on PAS scores. Imaging analysis was performed by manual assignment and by VBS/ML. Group comparisons were performed to assess silent aspiration characteristics. Binary logistic regression analysis was performed to determine if baseline clinical, demographic, and imaging parameters were helpful in predicting silent aspiration in patients. In this study 84 patient cases with acute infratentorial stroke who underwent FEES examination were included. Patients were moderately affected at admission (mean NIH-SS score at admission 5.7 SD ± 4.7). Most lesions were found pontine. Overall 40.5% of patients suffered from silent aspiration, most frequently in case of bilateral lesions. Patients with silent aspiration had higher NIH-SS scores at admission (p < 0.05), had a more severe swallowing disorder (p < 0.05) and were 4.7 times more likely to develop post-stroke pneumonia. Patients who underwent FEES examination later than 72 h after symptom onset were significantly more likely to suffer from silent aspiration and to develop pneumonia compared to patients who underwent FEES examination within the first 72 h (p < 0.05). A binary logistic regression model identified NIH-SS at admission as a weak predictor of silent aspiration. Neither in manual assignment of the lesions to brain regions nor in voxel-wise statistic regression any specific region was useful in prediction of silent aspiration. Silent aspiration is common in patients with infratentorial stroke and contributes to the risk for pneumonia. Patients with silent aspiration are more severely affected by stroke, but cannot reliably be identified by NIH-SS at admission or lesion location. Patients suffering from acute infratentorial stroke should been screened and examined for PSD and silent aspiration.

Predictors of dysphagia screening and pneumonia among patients with intracerebral haemorrhage in China: a cross-sectional hospital-based retrospective study

OBJECTIVES

This study aimed to investigate factors associated with undergoing dysphagia screening (DS) and developing pneumonia, as well as the relationship between DS and pneumonia in patients with intracerebral haemorrhage (ICH).

DESIGN

Our study was a cross-sectional hospital-based retrospective study.

STUDY DESIGN AND SETTINGS

We derived data from the China Stroke Centre Alliance, a nationwide clinical registry of ICH from 1476 participating hospitals in mainland China. To identify predictors for pneumonia, multivariable logistic regression models were used to identify patient characteristics that were independently associated with DS and pneumonia.

PARTICIPANTS

We included 31 546 patients in this study with patient characteristics, admission location, medical history, hospital characteristics and hospital grade from August 2015 to July 2019.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were DS and pneumonia during acute hospitalisation.

RESULTS

In total, 25 749 (81.6%) and 7257 (23.0%) patients with ICH underwent DS and developed pneumonia. Compared with patients without pneumonia, those who developed pneumonia were older and had severe strokes (Glasgow Coma Scale 9-13: 52.7% vs 26.9%). Multivariable analyses revealed that a higher pneumonia risk was associated with dysphagia (OR, 4.34; 95% CI, 4.02 to 4.68), heart failure (OR, 1.85; 95% CI, 1.24 to 2.77) and smoking (OR, 1.12; 95% CI, 1.12 to 0.20). DS was associated with lower odds of pneumonia (OR, 0.65; 95% CI, 0.44 to 0.95).

CONCLUSION

Our findings further confirm that dysphagia is an independent risk factor for pneumonia; one-fifth of patients with ICH did not undergo DS. However, comprehensive dysphagia evaluation and effective management are crucial. Nursing processes ensure the collection of complete and accurate information during evaluation of patients. There is a need to increase the rate of DS in patients with ICH, especially those with severe stroke or older. Further, randomised controlled trials are warranted to determine the effectiveness of DS on clinical outcomes.

Dysphagia screening post-stroke: systematic review

BACKGROUND/SCOPE

Stroke is one of the main causes of death, especially when associated with dysphagia. Hence, the assessment of nutritional status and aspiration risk is important to improve clinical outcomes. The aim of this systematic review is to identify which are the most suitable dysphagia screening tools in chronic post-stroke patients.

METHODOLOGY

A systematic literature search was conducted for articles published from 1 January 2000 to 30 November 2022 in the Cochrane Library, PubMed, Embase, CINAHL, Scopus and Web of Science databases, including primary studies providing quantitative or qualitative data. Additionally, a manual search was conducted scanning the reference lists of relevant articles and Google Scholar was searched to retrieve additional records. The process of screening, selection and inclusion of the articles, as well as the assessment of risk of bias and methodological quality, were conducted by two reviewers.

RESULTS

Out of the 3672 records identified, we included 10 studies, mostly (n=9) cross-sectional, evaluating screening for dysphagia in 1653 chronic post-stroke patients. Volume-Viscosity Swallow Test was the only test applied in multiple studies with adequate sample size, demonstrating high diagnostic accuracy (sensitivity=96.6%-88.2%; specificity=83.3%-71.4%) compared with the videofluoroscopic swallowing study.

CONCLUSIONS

Dysphagia is an important complication in chronic post-stroke patients. Early identification of this condition through screening tools with adequate diagnostic accuracy is of paramount importance. The limited number of studies available and their small sample sizes may be a limitation to this study.

PROSPERO REGISTRATION NUMBER

CRD42022372303.

Clinical signs to predict the severity of dysphagia in Acute Ischemic Stroke patients

OBJECTIVES

In the current era, clinicians working in areas with limited and/or without facilities are only able to manage their patients based on clinical signs to detect dysphagia. This study assesses the performance of 5 simple clinical signs for predicting the severity of dysphagia.

METHODS

We systematically documented 5 targeted bedside clinical signs within 24 h after admission in 737 consecutive patients with acute stroke. We examined the median onset of each sign and calculated their ratios associated with severe dysphagia. The performance and significance of these special clinical signs were evaluated by further computation.

RESULTS

In total, 184 of 737 AIS patients were screened positive dysphagia by the modified V-VST. The 5 targeted bedside clinical signs were differed among the patients with and without dysphagia. Patients with serious dysphagia (n = 61,33.15%) showed higher positive percentages of larynx movement disorders than those classified as moderate (73.77% [60.99%-83.50%] vs 29.27% [21.82%-38.03%], p < 0.001). Logistic regression analyses conducted in the subsets confirmed larynx movement disorders as an independent predictor of dysphagia severity.

CONCLUSIONS

Larynx movement disorders is correlated with a higher probability of severe dysphagia as measured by the modified V-VST in AIS patients.

Research hotspots and trends in post-stroke dysphagia: a bibliometric analysis

Background

Dysphagia represents one of the common complications following a stroke, and post-stroke dysphagia (PSD) can lead to aspiration, pneumonia, and malnutrition, thus prolonging hospital stay, escalating medical expenditures, and imposing a substantial economic strain on both patients and society. The utilization of bibliometric analysis offers a quantitative approach for investigating the existing literature and recognizes the current status of the research. However, bibliometric analysis on the subject of PSD remains absent. Consequently, we carried out this study to provide researchers with insights, facilitating their further exploration of PSD.

Methods

Conducting a bibliometric analysis of articles pertaining to PSD retrieved over the past two decades enables us to acquire the research hotspots and trends in this area. The publications concerning PSD were searched from the Core Collection of Web of Science, spanning the period ranging from 2003 to 2023. Articles or reviews published in English were included in this study. Subsequently, we employed CiteSpace and VOSviewer software to visualize the retrieved articles, thereby identifying the cooperative relationships of authors, institutions, and countries, as well as relevant information about journals and references.

Results

This study comprised 866 papers in total, and the number of articles published each year shows an overall growth trend. As for the analysis of the authors, Dziewas R. was the most prolific author with 21 articles. The most frequently published institutions, countries, and journals were the University of Manchester, China, and Dysphagia, with 28, 254, and 75 publications, respectively. And the co-cited authors and journals with the highest counts were Martino R and Stroke. According to the analysis of keywords and references, dysphagia screening and assessment, prevention of pneumonia, rehabilitation approaches, and nutritional management of PSD are considered research hotpots. Additionally, future research may focus on the topics of systematic review and meta-analysis, noninvasive brain stimulation, and lesion location.

Conclusion

Through the bibliometrics analysis of PSD, we can capture the research hotspots and frontiers of PSD, thereby providing inspiration and reference for subsequent studies in this field.

Comparison between healthcare quality in primary stroke centers and comprehensive stroke centers for acute stroke patients: evidence from the Chinese Stroke Center Alliance

Background

To improve stroke care quality, the guidelines for stroke center construction in China recommended establishing primary stroke centers (PSCs) and comprehensive stroke centers (CSCs). We aimed to compare stroke care quality between the two types of centers.

Methods

Data were collected from acute stroke patients admitted to PSCs or CSCs in the China Stroke Center Alliance program. Twenty-one individual guideline-recommended performance measures and two summary measures were compared between the two groups. Multivariable logistic regression models were used to examine the association between stroke center status (CSC vs. PSC) and healthcare quality.

Findings

Data from 750,594 stroke patients from 1474 stroke centers (252 CSCs and 1222 PSCs) were analyzed. For many components of healthcare performance in stroke patients, comparable levels of performance were observed between CSCs and PCSs. Nonetheless, CSCs outperformed PSCs in the areas of administering intravenous recombinant tissue plasminogen activator within 4.5 h (aOR = 1.31 [95% CI: 1.07-1.60]), rehabilitation for acute ischaemic stroke (AIS) (aOR = 1.19 [95% CI: 1.01-1.40]), and the provision of hypoglycemic medication and statin therapy upon discharge for AIS (aOR = 1.26 [95% CI: 1.00-1.59] and aOR = 1.28 [95% CI: 1.04-1.59], respectively). More patients with intracerebral haemorrhage and subarachnoid haemorrhage received neurosurgery in CSCs (14.4% vs. 10.6% and 51.0% vs. 33.9%, respectively). Additionally, CSCs had higher in-hospital mortality than PSCs (aOR = 1.33 [95% CI: 1.01-1.73]).

Interpretation

Overall PSCs provided equivalent care for many quality measures to CSCs in China with the exception of thrombolysis, rehabilitation access, and medication at discharge for AIS, whereby improvements should be directed. Nevertheless, PSCs have demonstrated lower risk-adjusted in-hospital mortality rates.

Funding

The National Key Research and Development Projects of China.

Risk factors independently associated with the maintenance of severe restriction of oral intake and alternative feeding method indication at hospital outcome in patients after acute ischemic stroke

BACKGROUND AND AIMS

From a clinical point of view, post-stroke patients present difficulties in swallowing management. The purpose of this research was to identify risk factors that were independently related to the maintenance of a severe restriction of oral intake in patients affected by acute ischemic stroke.

METHODS

The authors conducted a prospective observational cohort study of patients with dysphagia post-acute ischemic stroke who were admitted to an Emergency Room (ER). Demographic and clinical data were collected at ER admission. Swallowing data was based on The Functional Oral Intake Scale (FOIS) and was collected at two distinct moments: initial swallowing assessment and at the patient outcome. Patients were divided into two groups according to their FOIS level assigned on the last swallowing assessment (at hospital outcome): G1 with severe restriction of oral intake and indication of feeding tube - patients with FOIS levels 1 to 4; G2 without restriction of food consistencies in oral intake - patients with FOIS levels 5 to 7.

RESULTS

One hundred and six patients were included in our study. Results of the multivariate logistic regression model for the prediction of maintenance of a severe restriction of oral intake at hospital outcome in patients post-acute ischemic stroke indicated that increasing age (p = 0.006), and dysarthria (p = 0.003) were associated with higher chances of presenting severe restriction of oral intake at hospital outcome.

CONCLUSIONS

Patients with acute ischemic stroke in an Emergency Room may experience non-resolved severe dysphagia, indicating the need to prepare for the care/rehabilitation of these patients.

Incidence and Risk Factors for Dysphagia Following Cerebellar Stroke: a Retrospective Cohort Study

The cerebellum is known to play a supportive role in swallowing-related functions; however, wide discrepancies about the incidence rate of swallowing disorders following cerebellar strokes exist within the literature. This study aimed to investigate the incidence rate of dysphagia and the factors which may affect the presence of dysphagia and clinical recovery in individuals diagnosed with cerebellar stroke. A retrospective chart audit of 1651 post-stroke patients (1049 males and 602 females) admitted with a cerebellar stroke to a comprehensive tertiary hospital in China was conducted. Data on demographics, medical, along with swallowing function assessment were collected. Differences between dysphagic and non-dysphagic groups were evaluated using t-tests and Pearson's chi-square test. Univariate logistic regression analysis was performed to establish factors associated with the presence of dysphagia. A total of 11.45% of participants were identified with dysphagia during inpatient admission. Individuals with mixed types of stroke, multiple lesions in the cerebellum, and ages older than 85 years old were more likely to develop dysphagia. Moreover, the prognosis of dysphagia following a cerebellar stroke was associated with lesions in different parts of the cerebellum. The cumulative recovery rates from the best to worse were the right hemisphere group, the cerebellum vermis or peduncle group, and both the hemisphere group and the left hemisphere group, respectively.

Management of Aspiration Risk in Stroke

Managing risk for aspiration in the stroke patient will assist to decrease one of the major complications that these patients experience, which is poststroke pneumonia. Using an evidenced-based dysphagia protocol is shown to reduce mortality, morbidity, and length of stay caused by poststroke pneumonia. Physicians, nurses, speech pathologists, and dieticians will be instrumental in performing ongoing assessments and aspiration-prevention strategies to improve stroke patient outcome and reduce complications. Education, and measurement of comprehension, of the care team, patient, and family concerning dysphagia management and prevention of aspiration pneumonia will assist in achieving the aforementioned goals.

Clinical and imaging predictors of dysphagia and swallowing ability recovery in acute ischemic stroke

OBJECTIVE

Dysphagia is one of the most common complications of acute ischemic stroke, and prediction of dysphagia is crucial for post-stroke treatment. We aimed to identify predictors of dysphagia and swallowing function recovery following ischemic stroke and to investigate dysphagia-associated lesion location.

METHODS

We prospectively enrolled patients with acute ischemic stroke confirmed on diffusion-weighted imaging. All patients received swallowing evaluation within 48 h after admission. Follow-up oral intake ability was measured on 7 and 30 days after stroke onset. Voxel-based lesion-symptom mapping was performed to determine locations associated with dysphagia.

RESULTS

Of 126 patients included in the final analysis, 23 patients (18.3%) were classified as initial dysphagia. The presence of facial palsy (P = 0.008) and larger white matter hyperintensity (WMH) volume (P = 0.003) was associated with initial dysphagia. Initial risk of aspiration assessed by Any2 score (P = 0.001) at baseline was identified as independent predictor for dysphagia at day 7. Patients with higher Any2 score (P < 0.001), aphasia (P = 0.013), and larger WMH volume (P = 0.010) were less likely to have a full swallowing function recovery at 1 month. Acute infarcts in right corona radiata and right superior longitudinal fasciculus were correlated with impaired recovery of swallowing ability at 1 month.

CONCLUSIONS

Initial risk of aspiration was identified as risk factor for short-term and long-term dysphagia. Aphasia and larger WMH volume were revealed to be significant predictors for swallowing function recovery at 1 month. Right corona radiata was identified as an essential brain area for dysphagia.

A robust HD-sEMG sensor suitable for convenient acquisition of muscle activity in clinical post-stroke dysphagia

Objective.A flexible high-density surface electromyography (HD-sEMG) sensor combined with an adaptive algorithm was used to collect and analyze the swallowing activities of patients with Post-stroke dysphagia.Approach.The electrode frame, modified electrode, and bonded substrate of the sensor were fabricated using a flexible printed circuit process, controlled drop coating, and molding, respectively. The adaptation algorithm was achieved by using Laplace and Teager-Kaiser energy operators to extract active segments, a cross-correlation coefficient matrix (CCCM) to evaluate synergy, and multi-frame real-time dynamic root mean square (RMS) to visualize spatiotemporal information to screen lesions and level of dysphagia. Finally, support vector machines (SVM) were adopted to explore the classification accuracy of sex, age, and lesion location with small sample sizes.Main results.The sensor not only has a basic low contact impedance (0.262 kΩ) and high signal-to-noise ratio (37.284 ± 1.088 dB) but also achieves other characteristics suitable for clinical applications, such as flexibility (747.67 kPa) and durability (1000 times) balance, simple operation (including initial, repeated, and replacement use), and low cost ($ 15.2). The three conclusions are as follows. CCCM can be used as a criterion for judging the unbalanced muscle region of the patient's neck and can accurately locate unbalanced muscles. The RMS cloud map provides the time consumption, swallowing times, and unbalanced areas. When the lesion location involves the left and right hemispheres simultaneously, it can be used as an evidence of relatively severely unbalanced areas. The classification accuracy of SVM in terms of sex, age, and lesion location was as high as 100%.Significance.The HD-sEMG sensor in this study and the adaptation algorithm will contribute to the establishment of a larger-scale database in the future to establish more detailed and accurate quantitative standards, which will be the basis for developing more optimized screening mechanisms and rehabilitation assessment methods.

Practice Patterns and Attitudes Among Speech-Language Pathologists Treating Stroke Patients with Dysphagia: A Nationwide Survey

Dysphagia management is a core component of quality stroke care. Speech-Language Pathologists (SLPs) play a key role in the management of post-stroke dysphagia. We sought to elicit perceptions, attitudes, and practice patterns regarding post-stroke dysphagia management among SLPs in the United States. We conducted a survey among SLPs registered with the American Speech-Language-Hearing Association who indicated that they care for acute stroke patients. A total of 336 participants completed the survey. Over half of the participants (58.6%) indicated that they obtain objective swallow testing in ≥ 60% of their post-stroke dysphagia patients. Almost 1 in 5 SLPs indicated that they are often unable to perform objective dysphagia testing due to limited resources (18.8% indicated resource limitations; 78.9% indicated no resources limitations; 2.4% were unsure). SLPs in hospitals without stroke center certification had higher odds of indicating limited resources compared to SLPs in certified stroke centers (OR 2.08, 95% CI 1.11-3.87). Over 75% indicated that percutaneous endoscopic gastrostomy (PEG) tubes after stroke are placed too early. SLPs who obtain objective swallow testing in ≥ 60% of patients had higher odds of indicating that PEG tubes are placed too early (OR 1.70, 95% CI 1.13-2.56). While 19.4% indicated that the optimal timing for PEG after stroke is < 7 days after admission, 25.0% indicated that the optimal timing is > 12 days. Almost 35% indicated that health care system pressures influence their recommendations, and 47.6% indicated that ≥ 25% of PEGs could be avoided if patients were given up to 7 more days for swallowing recovery.

Characteristics of submental muscles function and hyoid bone movement in patients with dysphagia after stroke

BACKGROUND

Dysphagia is one of the common complications after stroke. Dysphagia significantly increases the probability of serious adverse consequences. The purpose of this study was to compare the characteristics of submental muscles electromyography and hyoid motion parameters between patients with dysphagia after stroke and healthy controls, and whether there is a synergistic effect between the function of the submental muscles and the movement of the hyoid.

METHODS

Fifteen patients with post-stroke dysphagia and fifteen healthy adults simultaneously underwent the videofluoroscopic and surface electromyography of the submental muscles while swallowing 5 ml of concentrated liquid barium sulphate. The electromyographic signal of the submental muscles was analysed along with parameters of hyoid movement.

FINDINGS

Stage transition duration and duration of surface electromyographic activity were extended significantly in post-stroke dysphagia patients(P < 0.05). Surface electromyography amplitude and hyoid movement were significantly reduced in patients (P < 0.05). There was a significant correlation between the maximum hyoid movement distance and the peak sEMG amplitude in healthy controls (r = 0.660, P = 0.014), but not in patients with dysphagia after stroke (r = 0.425, P = 0.148).

INTERPRETATION

Submental muscles electromyographic signal changes in patients may be the result of uncoordinated muscle contractions and decreased muscle strength. Furthermore, the reduced hyoid movement distance may be due to impaired function of the submental muscles. In addition, the submental muscles and hyoid movement or other swallowing structures functions were impaired to varying degrees, resulting in the disappearance of the correlation between the maximum movement distance of the hyoid and the peak amplitude.

Predictive Factors for Oral Intake Recovery After Acute Stroke: Analysis of a Japanese Nationwide Inpatient Database

OBJECTIVE

It remains unclear which factors contribute to dysphagia recovery after an acute stroke. This study aimed to identify factors associated with complete oral intake recovery in patients with post-stroke dysphagia.

METHODS

Data were obtained from the Diagnosis Procedure Combination database, which is a nationwide database of administrative claims and discharge abstracts in Japan. We selected patients admitted within 3 days of stroke onset and conducted multivariable logistic regression analysis. Total oral intake within 30 days of admission was the primary outcome measure.

RESULTS

A total of 151,302 patients were included, and total oral intake was observed in 48% of them within 30 days of admission. Total oral intake was significantly associated with age, sex, stroke subtype, consciousness disturbance, low body mass index, multiple comorbidities, and the modified Rankin Scale before stroke onset. In addition, males had worse outcomes than females (odds ratio, 0.75; 95% confidence interval, 0.73-0.77, p < 0.001), and intracerebral and subarachnoid hemorrhagic stroke subtypes were associated with non-recovery.

CONCLUSION

This study identified several prognostic factors for total oral intake in patients with acute stroke. These results may be useful for predicting a patient's dysphagia prognosis at the time of admission and designing a nutritional management plan for patients with acute stroke.

A Prospective Validation Study of the Functional Bedside Aspiration Screen with Endoscopy: Is It Clinically Applicable in Acute Stroke?

The purpose of this study was to investigate the reliability of the novel Functional Bedside Aspiration Screen (FBAS) to predict aspiration risk in acute stroke and to guide initial therapy needs. We conducted a prospective validation study of the FBAS 10-point scale in 101 acute ischemic stroke patients. Outcome measures were compared with the Penetration Aspiration Scale (PAS) via the Flexible Endoscopic Swallowing Study. Correlations with the Functional Oral Intake Scale (FOIS) and the Therapy Requirement Scale (TRS) were analyzed. We observed a 65.8% sensitivity and 70.2% specificity (p = 0.004) for predicting penetration risk (for PAS score ≥ 3) and a 73% sensitivity and 62% specificity for predicting aspiration risk (PAS score ≥ 6). For patients with a modified ranking scale 0-2 (n = 44) on admission, the predictive measurements of the FBAS yielded sensitivity and specificity values of 66.7% and 88.6% (p = 0.011). A significant negative correlation was found with PAS measurements, whereas a positive correlation was observed regarding FOIS. Significantly lower FBAS scores were observed in patients with high requirements for therapeutic interventions and dietary modification. FBAS may be regarded as an alternative time-efficient clinical support tool in settings in which instrumentation is not directly accessible. Further studies including a larger cohort of acute stroke patients with more severe neurological deficits are necessary.

Variation in stroke care at the hospital level: A cross-sectional multicenter study

Introduction

Stroke is one of the leading causes of mortality and disability. Improving patient outcomes can be achieved by improving stroke care and adherence to guidelines. Since wide variation in adherence rates for stroke guidelines still exists, we aimed to describe and compare stroke care variability within Belgian hospitals.

Materials and methods

An observational, multicenter study was performed in 29 Belgian hospitals. We retrospectively collected patient characteristics, quality indicators, and time metrics from the last 30 consecutive patients per hospital, diagnosed with ischemic stroke in 2019 with structured questionnaires. Mean adherence ratios (%) ± SD (minimum – maximum) were calculated.

Results

We analyzed 870 patient records from 29 hospitals. Results showed large inter- and intrahospitals variations in adherence for various indicators. Almost all the patients received brain imaging (99.7%) followed by admission at a stroke unit in 82.9% of patients. Of patients not receiving thrombolysis, 92.5% of patients were started on antithrombotic drugs. Indicators with moderate median adherence but large interhospital variability were glycemia monitoring [82.3 ± 16.7% (26.7–100.0%)], performing clinical neurological examination and documentation of stroke severity [63.1 ± 36.8% (0–100%)], and screening for activities of daily living [51.1 ± 40.3% (0.0–100.0%)]. Other indicators lacked adequate adherence: swallowing function screening [37.0 ± 30.4% (0.0–93.3%)], depression screening [20.2 ± 35.8% (0.0–100%)], and timely body temperature measurement [15.1 ± 17.0% (0.0–60%)].

Conclusion

We identified high adherence to guidelines for some indicators, but lower rates with large interhospital variability for other recommendations also based on robust evidence. Improvement strategies should be implemented to improve the latter.

Swallowing function after acute ischemic stroke: Development and validation of a novel clinical prognostic model

Background

Predicting the duration of dysphagia after acute ischemic stroke (AIS) is important for clinical treatment decisions.

Objective

The purpose of this study is to assess the swallowing function of AIS patients and to develop and validate a prognostic model for the need for nasogastric tube (NGT) in these patients.

Materials and methods

We included 554 AIS patients during 2018–2019 as the development group and had 186 AIS patients as the external validation group. The primary end point of the study was the retention of NGT in patients 1 week after admission (Functional Oral Intake Scale ≤ 4). Swallowing function and stroke-associated pneumonia (SAP) at 1 month post-onset were also the objectives of this study. The volume-viscosity swallow test (V-VST) was used to assess the patient’s impaired swallowing function. The Predictive model was built by logistic regression.

Results

Overall, a total of 104 patients required indwelling NGT at 1 week of AIS onset in development group. The final prognostic model includes 5 variables: age (OR: 1.085, 95%CI: 1.049–1.123), neutrophil-to-lymphocyte ratio (NLR) (OR: 1.332, 95%CI: 1.090–1.626), NIHSS (OR: 1.092, 95%CI: 1.025–1.164), history of drinking (OR: 2.532, 95%CI: 1.452–4.417) and stroke location (Subtentorial vs. Supratentorial, OR: 1.954, 95%CI: 1.088–3.509). The prediction model had an AUC of 0.810, while the external validation group was 0.794.

Conclusion

In stroke patients, it is very important to decide early whether to indwell a NGT. The nomogram will support decision making for NGT insertion and help these patients recover from their condition.

Can Machine Learning classifiers be used to regulate nutrients using small training datasets for aquaponic irrigation?: A comparative analysis

With the recent advances in the field of alternate agriculture, there has been an ever-growing demand for aquaponics as a potential substitute for traditional agricultural techniques for improving sustainable food production. However, the lack of data-driven methods and approaches for aquaponic cultivation remains a challenge. The objective of this research is to investigate statistical methods to make inferences using small datasets for nutrient control in aquaponics to optimize yield. In this work, we employed the Density-Based Synthetic Minority Over-sampling TEchnique (DB-SMOTE) to address dataset imbalance, and ExtraTreesClassifer and Recursive Feature Elimination (RFE) to choose the relevant features. Synthetic data generation techniques such as the Monte-Carlo (MC) sampling techniques were used to generate enough data points and different feature engineering techniques were used on the predictors before evaluating the performance of kernel-based classifiers with the goal of controlling nutrients in the aquaponic solution for optimal growth.[27–35]

Fostering eating after stroke (FEASt) trial for improving post-stroke dysphagia with non-invasive brain stimulation

Dysphagia is a serious stroke complication but lacks effective therapy. We investigated safety and preliminary efficacy of anodal transcranial direct current stimulation (atDCS) paired with swallowing exercises in improving post-stroke dysphagia from an acute unilateral hemispheric infarction (UHI). We conducted a double-blind, early phase-2 randomized controlled trial, in subjects (n = 42) with moderate-severe dysphagia [Penetration and Aspiration Scale (PAS) score ≥ 4], from an acute-subacute UHI. Subjects were randomized to Low-Dose, High-Dose atDCS or Sham stimulation for 5 consecutive days. Primary safety outcomes were incidence of seizures, neurological, motor, or swallowing function deterioration. Primary efficacy outcome was a change in PAS scores at day-5 of intervention. Main secondary outcome was dietary improvement at 1-month, assessed by Functional Oral Intake (FOIS) score. No differences in pre-defined safety outcomes or adjusted mean changes in PAS, FOIS scores, between groups, were observed. Post-hoc analysis demonstrated that 22 /24 subjects in the combined atDCS group had a clinically meaningful dietary improvement (FOIS score ≥ 5) compared to 8 /14 in Sham (p = 0.037, Fisher-exact). atDCS application in the acute-subacute stroke phase is safe but did not decrease risk of aspiration in this early phase trial. The observed dietary improvement is promising and merits further investigation.

Dysphagia screening and pneumonia after subarachnoid hemorrhage: Findings from the Chinese stroke center alliance

BACKGROUND AND PURPOSE

Dysphagia is common and is associated with aspiration pneumonia. However, little is known about the prevalence of and factors influencing dysphagia screening (DS) and pneumonia after subarachnoid hemorrhage (SAH).

METHODS

We used data on SAH patients admitted to 1476 hospitals from the China Stroke Center Alliance (CSCA) from August 2015 to July 2019 to analyze the rates of DS and pneumonia. We then conducted univariate and multivariable analyses to examine the relationship between DS and pneumonia.

RESULTS

Among 4877 SAH patients who were eligible for DS and had complete data on pneumonia status, 3527 (72.3%) underwent DS, and 1006 (20.6%) developed pneumonia. Compared with patients without pneumonia, patients with pneumonia were older (mean: 63.4 vs. 57.8 years of age), had lower Glasgow Coma Scale (GCS) scores at admission (mean: 13.5 vs. 14.3), were more likely to have dysphagia (15.2% vs. 3.3%), and were more likely to have undergone aneurysm isolation (19.1% vs. 10.0%). In multivariable analyses, factors independently associated with a higher risk of pneumonia were dysphagia [odds ratio (OR), 3.77; 95% confidence interval (CI), 2.85-4.98], age (OR, 1.50 per 10-year increase; 95% CI, 1.40-1.60), male sex (OR, 1.23; 95% CI, 1.02-1.49), arrival at the hospital by emergency medical services (OR, 1.36; 95% CI, 1.16-1.58), nimodipine treatment (OR, 1.42; 95% CI, 1.11-1.81), endovascular embolization of aneurysms (OR, 1.23; 95% CI, 1.03-1.47), cerebral ventricular shunt placement (OR, 2.24; 95% CI, 1.41-3.54), and treatment at a higher grade hospital (OR, 1.44; 95% CI, 1.21-1.71).

CONCLUSION

More than a quarter of patients with SAH did not have documented DS, while one-fifth developed pneumonia. DS performance was associated with a lower risk of pneumonia. Randomized controlled trials may be needed to determine the effectiveness of DS.

Predicting Gastrostomy Tube Placement After Intracerebral Hemorrhage: External Validation of the GRAVo Score

BACKGROUND

Dysphagia is a common consequence of intracerebral hemorrhages (ICH). It can lead to enduring impairments of dietary intake and the requirement for feeding via percutaneous gastrostomy (PEG) tubes. However, variabilities in the course of swallowing recovery after ICH make it difficult to anticipate the need for PEG placement in an individual patient. A new tool called the GRAVo score was recently developed to predict PEG tube placement after an ICH but has not been externally validated. Our study aims were to externally validate the GRAVo score in a multicenter cohort and reexamine the role of race in predicting PEG placement, given the uncertain biological plausibility for this relationship observed in the derivation cohort.

METHODS

Patients for this analysis were selected from a previously completed multicenter, randomized, double-blind futility design clinical trial, the Intracerebral Hemorrhage Deferoxamine trial, and underwent a retrospective review of prospectively collected data. The GRAVo scores were computed by using previously established methods using the following variables: Glasgow Coma Scale ≤ 12 (2 points), race (1 point for Black), age > 50 years (2 points), and ICH volume > 30 mL (1 point). Association of GRAVo scores with PEG placement were examined by using logistic regression analysis after adjustment for exposure to deferoxamine. Model performance was estimated by using area under the receiving operating characteristic curve (AUROC). Subsequently, a second model was created by excluding scores for race, and the AUROC of both models were compared.

RESULTS

A total of 291 patients with complete data points served as the study cohort; 38 (13%) underwent PEG placement. The median GRAVo score for patients in the PEG and non-PEG groups were 4 (interquartile range 3-4) versus 2 (interquartile range 2-3), respectively (p < 0.0001). External validation of the GRAVo score yielded an AUROC of 0.7008 (95% confidence interval 0.6036-0.78); the model obtained without assignment of scores for the variable race yielded an AUROC of 0.6958 (95% confidence interval 0.6124-0.7891). The receiver operating characteristic curves from both models demonstrated close overlap.

CONCLUSIONS

The results of our external validation demonstrate the validity of GRAVo scores for predicting PEG tube placement after an ICH. However, its performance was more modest compared with that of the derivation cohort. Inclusion of the race variable had no measurable effect on model performance. Differences in patient characteristics between these cohorts may have influenced our results. These findings should be taken into consideration when using the GRAVo score to assist clinical decision making on PEG placement after an ICH.

Predictors of dysphagia screening and pneumonia among patients with acute ischaemic stroke in China: findings from the Chinese Stroke Center Alliance (CSCA)

Background and purpose

Guidelines recommend dysphagia screening to identify those at high risk of pneumonia. However, little is known about the prevalence and predictors of dysphagia screening and pneumonia among patients with acute ischaemic stroke in China.

Methods

Using data from the Chinese Stroke Center Alliance, which is a multicentre, prospective, consecutive patient enrolment programme, univariate and multivariate analyses were conducted to identify patient and hospital characteristics associated with dysphagia screening and pneumonia during acute hospitalisation.

Results

Of 790 811 patients admitted to 1476 hospitals, 622 718 (78.7%) underwent dysphagia screening, and 64 398 (8.1%) developed pneumonia. Patients in stroke units were more likely to be screened for dysphagia than those not in stroke units (OR 1.50; 95% CI 1.48 to 1.52), while patients with a past history of stroke were less likely to be screened (OR 0.87; 95% CI 0.86 to 0.88). Dysphagia screening (OR 1.46; 95% CI 1.30 to 1.65), dysphagia (OR 7.31; 95% CI 7.15 to 7.46), and admission to stroke units (OR 1.17; 95% CI 1.14 to 1.19) were significantly associated with a greater risk of pneumonia.

Conclusions

Dysphagia was a critical factor in the development of pneumonia. Nearly one in five patients with acute ischaemic stroke in the Chinese Stroke Center Alliance were not screened for dysphagia. Pneumonia prevention during acute hospitalisation is dependent not only on dysphagia screening but also on the effectiveness of subsequent dysphagia management interventions. Further studies are needed to elucidate the relationship between dysphagia screening, stroke unit care and pneumonia in patients with acute ischaemic stroke.

Clinical and Imaging Features Associated with the Utilization of Comfort Measures Only in Acute Ischemic Stroke

Objectives: Up to 10% of acute ischemic stroke (AIS) patients can die in the first 30 days. Older age and a higher National Institutes of Health Stroke Scale (NIHSS) score are associated with transition to comfort measures only (CMO) in AIS. There are insufficient data on specific stroke etiology, infarct location, or vascular territory for the association of AIS with the use of CMO. We therefore evaluated the clinical and imaging factors associated with utilization of CMO and their outcomes. Methods: AIS patients seen in an academic comprehensive stroke center in the United States between July 1, 2015, and June 30, 2016, were subgrouped based on the use of CMO orders (CMO vs. non-CMO) during hospitalization. Clinical, laboratory, and imaging data were analyzed. Multivariable logistic regression analysis was performed, adjusting for pertinent covariates. Results: The study consisted of 296 patients, 27 (9%) patients were transitioned to CMO. Compared with non-CMO patients, those with CMO were older (mean ± standard deviation: 66 ± 15 vs. 75 ± 11 years, p = 0.002). Hemorrhagic transformation of AIS was more likely in CMO (17% vs. 41%, p = 0.0030) compared with non-CMO patients. On multivariate analysis, severe stroke measured by the NIHSS score (odds ratio [OR] = 1.2; 95% confidence interval [CI] = 1.1-1.4), infarction of the insular cortex (OR = 12.9; 95% CI = 1.4-118.4), and presence of cerebral edema with herniation (OR = 9.4; 95% CI = 2.5-35.5) were associated with transition to CMO. Conclusions: The presence of severe stroke, infarction of the insular cortex, and cerebral edema with herniation were associated with utilization of CMO in AIS. Impairment of multiple neurological functions served by the insular cortex could play a role in transition to CMO.

Dysphagia Management and Outcomes in Elderly Stroke Patients with Malnutrition Risk: Results from Chinese Stroke Center Alliance

Purpose

To investigate the effectiveness of dysphagia screening and subsequent swallowing rehabilitation in elderly stroke patients with malnutrition risk.

Patients and Methods

Based on the Chinese Stroke Center Alliance (CSCA) from August 1, 2015 to July 21, 2019, we compared the in-hospital adverse outcomes among stroke patients (including ischemic stroke, intracranial hemorrhage, and subarachnoid hemorrhage) over 70 years old with and without dysphagia screening. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were the composite endpoint of discharge against medical advice (DAMA) or in-hospital death.

Results

Among 365,530 stroke patients ≥ 70 years old with malnutrition risk in the CSCA, documented dysphagia screening was performed for 288,764 (79.0%) participants. Of these, 41,482 (14.37%) patients had dysphagia, and 33,548 (80.87%) patients received swallowing rehabilitation. A total of 1,694 (0.46%) patients experienced in-hospital death. After adjustment for traditional risk factors, dysphagia screening was associated with a low risk of all-cause mortality in stroke patients [adjusted odds ratio (aOR): 0.75, 95% confidence interval (CI):0.65–0.87]. Compared to patients with dysphagia who did not receive swallowing rehabilitation, patients reveiving swallowing rehabilitation had a reduced risk of in-hospital death (aOR:0.39, 95% CI: 0.33–0.46). Additionally, dysphagia screening had a lower risk for the composite endpoint of DAMA or in-hospital death (aOR:0.83,95% CI: 0.80–0.87), as did subsequent swallowing rehabilitation (aOR:0.43,95% CI: 0.40–0.47). Similar results were observed in the sensitivity analysis through inverse probability of treatment weighting, propensity score matching, and excluding patients without National Institutes of Health Stroke Scale scores. A similar association was observed between dysphagia management and adverse clinical outcomes in ischemic stroke and intracranial hemorrhage patients.

Conclusion

Dysphagia screening and swallowing rehabilitation were associated with a reduced risk of in-hospital death and composite outcome of DAMA or in-hospital death for stroke patients with malnutrition risk. Future research should concentrate on improving the quality of medical care for dysphagia management to improve patients’ outcomes.

Inpatient Management of Acute Stroke of Unknown Type in Resource-Limited Settings

Stroke is the second leading cause of death and disability worldwide, with a disproportionate burden on low- and middle-income countries. Critical elements of guideline-based stroke care developed in high-income countries are not applicable to resource-limited settings, where lack of access to neuroimaging prevents clinicians from distinguishing between ischemic stroke and intracranial hemorrhage, requiring challenging clinical decision-making, particularly in the acute setting. We discuss strategies for acute inpatient management of stroke of unknown type with a focus on blood pressure management and antiplatelet therapy when neuroimaging is unavailable, and review some of the challenges and strategies for successfully implementing stroke unit care in resource-limited health care settings.

Dysphagia is a strong predictor of death and functional dependence at three months post-stroke

BACKGROUND

Few Brazilian studies investigated risk factors for dysphagia and associated complications in a large cohort.

OBJECTIVE

To investigate frequency, predictors, and associated outcomes of dysphagia in patients up to three months post-stroke.

METHODS

Prospective cohort study of consecutively admitted patients in a specialized center for acute stroke. Patients with a transient ischemic attack, subarachnoid hemorrhage, cerebral venous thrombosis, hemorrhagic stroke with secondary cause, non-acute stroke, or those who did not consent to participate were excluded. Swallowing was evaluated by speech language pathologists using Volume-Viscosity Swallow Test. General function at three months post-stroke was assessed using the following instruments: Modified Rankin scale, Barthel Index and Functional Independence Measure.

RESULTS

A total of 831 patients were admitted and 305 patients were included according to the inclusion and exclusion criteria. The mean age of patients was 63.6±13.3 years, mean time from stroke to swallowing assessment was 4.2±4.1 days, and 45.2% of the patients had dysphagia. Age (OR=1.02; 95%CI 1.00-1.04; p=0.017), known medical history of obstructive sleep apnea (OR=5.13; 95%CI 1.74-15.15; p=0.003), and stroke severity at hospital admission (OR=1.10; 95%CI 1.06-1.15; p<0.001) were independently associated with dysphagia. Dysphagia (OR=3.78; 95%CI 2.16-6.61; p<0.001) and stroke severity (OR=1.05; 95%CI 1.00-1.09; p=0.024) were independently associated with death or functional dependence at three months.

CONCLUSIONS

Dysphagia was present in almost half of stroke patients. Age, obstructive sleep apnea, and stroke severity were predictors of dysphagia, which was independently associated with death or functional dependence at three months.

Acupuncture Reduces the Risk of Dysphagia in Stroke Patients: A Propensity Score-Matched Cohort Study

Background: Post-stroke dysphagia (PSD) affects the quality of life in stroke patients, impairs their rehabilitation ability, and causes other complications following stroke. Currently, there is currently some understanding of PSD risk factors, but its protective factors remain largely unknown. Objective: To analyze the effects of acupuncture (AP) on dysphagia in stroke patients and explore its potential as a preventive therapy. Methods: Patients with a diagnosis of stroke from 2010 to 2019 were selected and followed until 2020, utilizing factors such as age, gender, stroke location, stroke type, and baseline comorbidity. To compare the incidence of dysphagia, equal numbers of stroke patients treated with and without AP (n = 1,809) were matched by 1:1 propensity scoring. The Cox proportional hazards model and Kaplan-Meier method were used to assess the risk of dysphagia as an outcome measure. Results: The stroke patients treated with AP had a lower risk of dysphagia after adjusting for age, gender, stroke location, stroke type, and baseline comorbidity [adjusted hazard ratio (AHR) = 0.43, 95% confidence interval = 0.37-0.49] compared with those in the non-AP cohort. AP also decreased the risk of PSD among different gender groups. The risk ratios were AHR = 0.45 and AHR = 0.33 for males and females, respectively. AP also reduced the risk for PSD among different age groups. The risk ratios were AHR = 0.20, AHR = 0.37, AHR = 0.41, and AHR = 0.45 for the 18-39, 40-59, 60-79, and >80 years-old groups. Regarding stroke types (ischemic, hemorrhagic, and mixed type), patients treated with AP had a lower risk (AHR = 0.47, 0.28 and 0.17, respectively). With respect to stroke location, the risk of PSD in AP-treated patients was decreased regardless of location: brain stem (AHR = 0.41), diencephalon (AHR = 0.13), or multiple lesions (AHR = 0.40), the risk of PSD in AP-treated patients was decreased. For all baseline comorbidities, AP attenuated the risk of dysphagia. The cumulative incidence of dysphagia was remarkably lower in the AP group than in the non-AP group (log-rank test, P = 0.000). Limitations: First, this was a single-center clinical retrospective study. Second, we did not classify the severity of stroke and dysphagia. Third, all data were extracted manually. Lastly, the sample size was relatively small. Thus, future studies with larger sample sizes are warranted to verify our findings. Conclusion: Acupuncture treatment attenuates the risk of dysphagia in stroke patients. Future research should increase the sample size and elaborate further on the details of the AP protocol.

Systematic Review and Meta-Analysis of Dysphagia and Associated Pneumonia in Patients With Stroke From India: A Call to Arms

OBJECTIVES

This study aimed to determine the prevalence of reported dysphagia and associated pneumonia risk among patients with stroke in India.

METHOD

We carried out a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome of interest was dysphagia and pneumonia among patients with stroke in India. Two review authors independently assessed the quality of studies using the Newcastle-Ottawa Scale and extracted related data. Meta-analysis was performed for frequency of dysphagia, associated pneumonia, and its relative risk using a random-effects model. Statistical heterogeneity was computed using the I² index.

RESULTS

A total of 3,644 titles were screened, and only eight studies met our inclusion criteria. Based on data from these studies, we calculated the pooled prevalence of dysphagia (47.71%; 95% confidence interval [CI] [20.49%, 70.92%], p < .001) and pneumonia (20.43%; 95% CI [10.73%, 30.14%], p < .001) for patients with stroke in India. We found that the relative risks of pneumonia in patients with stroke and dysphagia versus those patients with stroke and no dysphagia was 9.41 (95% CI [5.60, 15.80], p < .001). Data on length of hospital stay and rates of mortality secondary to pneumonia are also presented.

CONCLUSIONS

Despite the high incidence of dysphagia and associated pneumonia, the methodological quality of studies is fair and there is little research focused on epidemiological data. We call to arms to those SLPs working with patients with stroke in India to become proactive in both clinical practice and research domains. Supplemental Material https://doi.org/10.23641/asha.17701022.

Total magnetic resonance imaging of cerebral small vessel disease burden predicts dysphagia in patients with a single recent small subcortical infarct

Background

This study was performed to identify the association between the total magnetic resonance imaging burden of small vessel disease and the occurrence of post-stroke dysphagia in patients with a single recent small subcortical infarct (RSSI).

Methods

We retrospectively identified all patients with a magnetic resonance imaging-confirmed single RSSI. The water-swallowing test and volume-viscosity swallow test were performed within the first 24 h following admission to assess swallowing. Demographic and clinical data were extracted from our stroke database. Based on brain magnetic resonance imaging, we independently rated the presence of cerebral microbleeds, lacunes, white matter hyperintensities and enlarged perivascular spaces. The presence of each small vessel disease feature was summed to determine the total small vessel disease burden, ranging from 0 to 4.

Results

In total, 308 patients with a single RSSI were enrolled. Overall, 54 (17.5%) were diagnosed with post-stroke dysphagia. The risk factors related to post-stroke dysphagia included the following: older age, higher National Institute of Health Stroke Scale scores, higher C-reactive protein level and higher fibrinogen level. Based on multiple logistic regression, National Institute of Health Stroke Scale scores and total small vessel disease burden were independent risk factors of post-stroke dysphagia in patients with a single RSSI, after adjusting for age, gender, history of hypertension, C-reactive protein level and fibrinogen level.

Conclusions

Dysphagia in patients with a single RSSI was associated with a more severe total small vessel disease burden as reflected by MRI. Total MRI of cerebral small vessel disease burden may predict dysphagia in these patients. Furthermore, more severe total small vessel disease burden was associated with systemic inflammation.

Structural Connectivity Affecting Aspiration After Stroke

Aspiration after stroke is associated with pneumonia and mortality. In this study, we investigated brain structural connectivity associated with aspiration after unilateral supratentorial stroke. Patients on oral feeding after stroke were divided into liquid aspiration (22 patients) and normal (18 patients) groups based on videofluoroscopic swallowing studies. Voxel-based lesion-symptom mapping and voxel-wise group comparison of fractional anisotropy, mode of anisotropy, and mean diffusivity maps were conducted. Voxel-based lesion-symptom mapping revealed no significant lesion differences between groups. The aspiration group showed significantly increased fractional anisotropy and mode of anisotropy in the anterior limb and the genu of the internal capsule in the right hemisphere. In contrast, the normal group showed significantly increased mean diffusivity, mainly in the superior longitudinal fasciculus in the right hemisphere (P < 0.05). Degeneration of the internal capsule in the right hemisphere was found to affect aspiration after stroke.

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.

Screening for aspiration risk associated with dysphagia in acute stroke

BACKGROUND

Stroke can affect people's ability to swallow, resulting in passage of some food and drink into the airway. This can cause choking, chest infection, malnutrition and dehydration, reduced rehabilitation, increased risk of anxiety and depression, longer hospital stay, increased likelihood of discharge to a care home, and increased risk of death. Early identification and management of disordered swallowing reduces risk of these difficulties.

OBJECTIVES

Primary objective • To determine the diagnostic accuracy and the sensitivity and specificity of bedside screening tests for detecting risk of aspiration associated with dysphagia in people with acute stroke Secondary objectives • To assess the influence of the following sources of heterogeneity on the diagnostic accuracy of bedside screening tools for dysphagia - Patient demographics (e.g. age, gender) - Time post stroke that the study was conducted (from admission to 48 hours) to ensure only hyperacute and acute stroke swallow screening tools are identified - Definition of dysphagia used by the study - Level of training of nursing staff (both grade and training in the screening tool) - Low-quality studies identified from the methodological quality checklist - Type and threshold of index test - Type of reference test SEARCH METHODS: In June 2017 and December 2019, we searched CENTRAL, MEDLINE, Embase, CINAHL, and the Health Technology Assessment (HTA) database via the Centre for Reviews and Dissemination; the reference lists of included studies; and grey literature sources. We contacted experts in the field to identify any ongoing studies and those potentially missed by the search strategy.

SELECTION CRITERIA

We included studies that were single-gate or two-gate studies comparing a bedside screening tool administered by nurses or other healthcare professionals (HCPs) with expert or instrumental assessment for detection of aspiration associated with dysphagia in adults with acute stroke admitted to hospital.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened each study using the eligibility criteria and then extracted data, including the sensitivity and specificity of each index test against the reference test. A third review author was available at each stage to settle disagreements. The methodological quality of each study was assessed using the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS-2) tool. We identified insufficient studies for each index test, so we performed no meta-analysis. Diagnostic accuracy data were presented as sensitivities and specificities for the index tests.

MAIN RESULTS

Overall, we included 25 studies in the review, four of which we included as narratives (with no accuracy statistics reported). The included studies involved 3953 participants and 37 screening tests. Of these, 24 screening tests used water only, six used water and other consistencies, and seven used other methods. For index tests using water only, sensitivity and specificity ranged from 46% to 100% and from 43% to 100%, respectively; for those using water and other consistencies, sensitivity and specificity ranged from 75% to 100% and from 69% to 90%, respectively; and for those using other methods, sensitivity and specificity ranged from 29% to 100% and from 39% to 86%, respectively. Twenty screening tests used expert assessment or the Mann Assessment of Swallowing Ability (MASA) as the reference, six used fibreoptic endoscopic evaluation of swallowing (FEES), and 11 used videofluoroscopy (VF). Fifteen screening tools had an outcome of aspiration risk, 20 screening tools had an outcome of dysphagia, and two narrative papers did not report the outcome. Twenty-one screening tests were carried out by nurses, and 16 were carried out by other HCPs (not including speech and language therapists (SLTs)). We assessed a total of six studies as low risk across all four QUADAS-2 risk of bias domains, and we rated 15 studies as low concern across all three applicability domains. No single study demonstrated 100% sensitivity and specificity with low risk of bias for all domains. The best performing combined water swallow and instrumental tool was the Bedside Aspiration test (n = 50), the best performing water plus other consistencies tool was the Gugging Swallowing Screen (GUSS; n = 30), and the best water only swallow screening tool was the Toronto Bedside Swallowing Screening Test (TOR-BSST; n = 24). All tools demonstrated combined highest sensitivity and specificity and low risk of bias for all domains. However, clinicians should be cautious in their interpretation of these findings, as these tests are based on single studies with small sample sizes, which limits the estimates of reliability of screening tests.

AUTHORS' CONCLUSIONS

We were unable to identify a single swallow screening tool with high and precisely estimated sensitivity and specificity based on at least one trial with low risk of bias. However, we were able to offer recommendations for further high-quality studies that are needed to improve the accuracy and clinical utility of bedside screening tools.

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 Benefit of Dysphagia Screening in Adult Patients With Stroke: A Meta-Analysis

Background Early identification of dysphagia aims to mitigate the risk of health consequences in adults poststroke; however, the evidence from experimental trials alone is inconclusive. This meta-analysis assessed dysphagia screening benefit from both trial and observational data. Methods and Results Seven electronic databases were searched to December 2019. Unique abstracts and full articles were screened for eligibility by 2 independent blinded raters using a priori criteria and discrepancies resolved by consensus. Included studies were summarized descriptively and assessed for methodological quality using Cochrane Risk of Bias Tool. Across studies, pooled estimates of health benefit were derived for homogeneous data using Review Manger 5.3. From the yield of 8860 citations, 30 unique articles were selected: 24 observational and 6 randomized trials. Across studies, comparisons varied: no screening versus screening, late versus earlier screening, informal versus formal screening, pre- versus postscreening, and pre- versus poststroke guidelines that included screening. Pooled estimates across comparisons favored experimental groups for pneumonia odds ratio (OR), 0.57 (95% CI, 0.45-0.72), mortality OR, 0.52 (95% CI, 0.35-0.77), dependency OR, 0.54 (95% CI, 0.35-0.85), and length of stay standardized mean difference, -0.62 (95% CI, -1.05 to -0.20). Conclusions Combining evidence from experimental and observational studies derived a significant protective health benefit of dysphagia screening following adult acute stroke for pneumonia, mortality, dependency, and length of stay.

Diagnosis and treatment of neurogenic dysphagia - S1 guideline of the German Society of Neurology

Introduction

Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies.

Recommendations

This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with.

Conclusions

The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf).

Tube feeding predictors after ischemic hemispheric stroke during hospitalization

PURPOSE

To verify the factors associated with the need of tube feeding (TF) during patients post-ischemic stroke hospitalization.

METHOD

This is a retrospective study with 70 adult post-ischemic hemispheric stroke adult patients hospitalized in the Neurology department at a tertiary public hospital in Santa Catarina, Brazil. We investigated associations between the need of a feeding tube during hospitalization and the variables age, gender, admission and discharge NIHSS and FOIS, length of hospital stay in days, presence of thrombolytic therapy, extensive stroke, hemisphere affected, prior stroke, pneumonia during hospitalization, presence of signs of laryngeal penetration and laryngotracheal aspiration and dysphagia in the first and last swallowing clinical evaluation.

RESULTS

A total of 33 participants used tube feeding. There was a significant relationship among tube feeding and the following parameters: NIHSS (p value .001), FOIS (p value .001), extensive stroke (p value .034), left hemisphere involvement (p value .035), pneumonia during hospitalization (p value .001), length of hospital stay in days (p value .001), signs of laryngotracheal penetration/aspiration (p value .001) and dysphagia in speech-language assessment (p value .001).

CONCLUSION

Tube feeding during patients hospitalization after ischemic hemispheric stroke was predicted by the severity of stroke and signs of airway permeation.Key pointsSwallowing difficulty is one of the most common post-stroke consequences.There are few studies on the characterization of post-stroke patients with tube feeding.Tube feeding after ischemic stroke predictors were severity of stroke and signs of airway permeation.

Care of the Patient With Acute Ischemic Stroke (Posthyperacute and Prehospital Discharge): Update to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association

In 2009, the American Heart Association/American Stroke Association published a comprehensive scientific statement detailing the nursing care of the patient with an acute ischemic stroke through all phases of hospitalization. The purpose of this statement is to provide an update to the 2009 document by summarizing and incorporating current best practice evidence relevant to the provision of nursing and interprofessional care to patients with ischemic stroke and their families during the acute (posthyperacute phase) inpatient admission phase of recovery. Many of the nursing care elements are informed by nurse-led research to embed best practices in the provision and standard of care for patients with stroke. The writing group comprised members of the Stroke Nursing Committee of the Council on Cardiovascular and Stroke Nursing and the Stroke Council. A literature review was undertaken to examine the best practices in the care of the patient with acute ischemic stroke. The drafts were circulated and reviewed by all committee members. This statement provides a summary of best practices based on available evidence to guide nurses caring for adult patients with acute ischemic stroke in the hospital posthyperacute/intensive care unit. In many instances, however, knowledge gaps exist, demonstrating the need for continued nurse-led research on care of the patient with acute ischemic stroke.

Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part I: Management, Diagnosis, and Follow-up

Dysphagia is one of the most common and important complications of stroke. It is an independent marker of poor outcome after acute stroke and may become chronic after the acute period and continues to affect all aspects of the patient's life. Patients with stroke may encounter any of the medical branches in the emergency room or outpatient clinic, and as in our country, there may not be specialists specific for dysphagia, such as speech-language pathologists (SLP), in every hospital. This study aimed to raise awareness and create a common opinion of medical specialists for stroke patients with dysphagia. This recommendation paper has been written by a multidisciplinary team and offers 45 recommendations for stroke patients with dysphagia. It was created using the eight-step Delphi round via e-mail. This study is mostly specific to Turkey. However, since it contains detailed recommendations from the perspective of various disciplines associated with stroke, this consensus-based recommendation paper is not only a useful guide to address clinical questions in practice for the clinical management of dysphagia in terms of management, diagnosis, and follow-up, but also includes detailed comments for these topics.

Knowledge and Practice of Health Professionals in the Management of Dysphagia

The aim of this study was to determine healthcare providers' knowledge and practices about dysphagia. A descriptive cross-sectional study was carried out based on a self-administered and anonymous questionnaire addressed to healthcare providers in Spain. A total of 396 healthcare providers participated in the study. Of these, 62.3% knew the definition of dysphagia as a swallowing disorder. In addition, up to 39.2% of the participants reported that they did not know whether the EatingAssessmentTool (EAT-10) dysphagia screening test was usedin their own clinical settings. Similarly, up to 49.1% of them did not know the ClinicalExaminationVolume-Viscosity (MECV-V) method. Nearly all participants (98.8%) reported that thickeners must be used forall liquids administered to patients. A higher percentage of respondents based the choice of texture on patient's tolerance (78.2%) rather than on the MECV-V result (17.3%). In addition,76.4% of the professionals had witnessed a bronchoaspiration; after it, 44.4% (n = 175) of them reported the appearance of pneumonia, and 14.5% (n = 57) the death of the patient (p = 0.005). The participants revealeda moderate/low knowledge ofthe definition, diagnosis, and clinical management of liquid dysphagia, which indicates some room for improvements.

How demographic and clinical characteristics contribute to the recovery of post-stroke dysphagia?

According to the analysis to find out how demographic and clinical characteristics influent the dysphagia outcome after stroke, furthermore, giving some insights to clinical treatment.One hundred eighty post-stroke dysphagia (PSD) patients were enrolled in this retrospective study at the stroke rehabilitation department. The outcome measurements are beside water swallow test at discharge and length of stay at hospital. Twenty-five demographic and clinical variables were collected for this study. Logistic regression and multilinear regression were utilized to estimate models to identify the risk and protect predictors of PSD outcome.Mouth-opening degree, drooling severity scale (DSS) level, mini-mental state exam (MMSE) level, Barthel index and Berg balance scale were significant different between recovered and unrecovered group. Type of stroke, MMSE degree, DSS and hemoglobin level shown significant predictive value for PSD outcome in logistic regression. In addition, obstructive sleep apnea (OSA) and DSS degree were important risk factors for PSD outcome. Gender, body mass index, drinking, hypertension, recurrent stroke, water swallow test level on admission, Berg balance scale, DSS and days between onset to admission shown significant predictive value for length of stay of PSD patients.PSD outcome was influenced by type of stroke, MMSE degree, DSS and hemoglobin level significantly and obstructive sleep apnea act as an important risk role for PSD recovery.

Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part II: Rehabilitation

Dysphagia is one of the most common and important complications of stroke. It is an independent marker of poor outcome following acute stroke and it continues to be effective for many years. This consensus-based guideline is not only a good address to clinical questions in practice for the clinical management of dysphagia including management, diagnosis, follow-up, and rehabilitation methods, but also includes detailed algorithms for these topics. The recommendation paper has been written by a multidisciplinary team and offers 117 recommendations for stroke patients with dysphagia. While focusing on management principles, diagnosis, and follow-up in the 1st part (45 items), rehabilitation details were evaluated in the 2nd part (72 items).

Defect-free care trends in the Paul Coverdell National Acute Stroke Program, 2008-2018

BACKGROUND

In an effort to improve stroke quality of care and patient outcomes, quality of care metrics are monitored to assess utilization of evidence-based stroke care processes as part of the Paul Coverdell National Acute Stroke Program (PCNASP). We aimed to assess temporal trends in defect-free care (DFC) received by stroke patients in the PCNASP between 2008 and 2018.

METHODS

Quality of care data for 10 performance measures were available for 849,793 patients aged ≥18 years who were admitted to a participating hospital with a clinical diagnosis of stroke between 2008 and 2018. A patient who receives care according to all performance measures for which they are eligible, receives "defect-free care" (DFC) (eg, appropriate medications, assessments, and education). Generalized estimating equations were used to examine the factors associated with receipt of DFC.

RESULTS

DFC among ischemic stroke patients increased from 38.0% in 2008 to 80.8% in 2018 (P < .0001), with the largest improvement seen in receipt of stroke education (relative percent change, RPC = 64%). Similarly, DFC for hemorrhagic stroke and transient ischemic attack patients increased from 46.7% to 82.6% (RPC = 76.9%) and 39.9% to 85.0% (RPC = 113.0%) (P < .001), respectively. Among ischemic stroke patients, the adjusted odds for receiving DFC were lower for women, patients aged 18 to 54 years, Medicaid or Medicare participants, and patients with atrial fibrillation (P < .05).

CONCLUSIONS

From 2008 to 2018, receipt of DFC by ischemic stroke patients significantly increased in the PCNASP; however certain subgroups were less likely to receive this level of care. Targeted quality improvement initiatives could result in even further improvements among all stroke patients and help reduce disparities in care.

Effects of cognitive and motor dual-tasks on oropharyngeal swallowing assessed with FEES in healthy individuals

Dysphagia is frequent in many neurological diseases and gives rise to severe complications such as malnutrition, dehydration and aspiration pneumonia. Therefore, early detection and management of dysphagia is essential and can reduce mortality. This study investigated the effect of cognitive and motor dual-task interference on swallowing in healthy participants, as dual-task effects are reported for other motor tasks such as gait and speech. 27 participants (17 females; 29.2 ± 4.1 years) were included in this prospective study and examined using flexible endoscopic evaluation of swallowing (FEES). Using a previously established FEES-based score, the paradigms "baseline swallowing", "cognitive dual-task" and "motor dual-task" were assessed. Scores of the three paradigms were compared using a repetitive measures ANOVA and post-hoc analysis. Mean baseline swallowing score in single task was 5 ± 3. It worsened to 6 ± 5 in the cognitive (p = 0.118), and to 8 ± 5 in the motor dual-task condition (p < 0.001). This change was driven by subclinical worsening of premature bolus spillage and pharyngeal residue. Oropharyngeal swallowing is not exclusively reflexive in nature but requires attention, which leads to motor dual-task interference. This has potential diagnostic and therapeutic implications, e.g. in the early screening for dysphagia or in avoiding dual-task situations while eating.

Nurses' knowledge of stroke-related oropharyngeal dysphagia in the Eastern Cape, South Africa

BACKGROUND

Early identification of stroke-related oropharyngeal dysphagia (OPD) using screening by nurses can prevent adverse patient outcomes in lower middle-income countries. Nurses are essential in the OPD management team and should ideally be able to screen and prioritise dysphagia management in stroke patients.

OBJECTIVE

The aim of this research was to describe nurses' practices related to identification and management of patients with stroke-related OPD.

METHODS

Qualified nurses from various healthcare levels in the Eastern Cape, South Africa were invited to complete a previously published hard copy survey on the signs and symptoms, complications and management of stroke-related OPD. A sample of 130 participants completed the survey.

RESULTS

The mean scores of correct responses for each section were: 8.7/13 (66.7%) for signs and symptoms, 4.7/10 (47.3%) for complications and 3.8/7 (54.2%) for management practices. Statistically, there were no differences between the levels of healthcare for the signs and symptoms section and the complications section. Regarding management of OPD, secondary-level (S) nurses demonstrated significantly better knowledge than primary-level (P) and tertiary-level (T) nurses (S-P: p = 0.022; S-T: p = 0.010). Secondary-level nurses also scored significantly higher across all three sections (S-P: p = 0.044; S-T: p = 0.025) than those at the other levels.

CONCLUSIONS

The study found that nurses across all levels of healthcare had only moderate knowledge regarding identification and management of stroke-related OPD. Interdisciplinary collaboration between nurses and speech-language therapists may improve nurses' knowledge in identification and management of stroke-related OPD in lower middle-income settings such as South Africa.

Temporal variations in quality of acute stroke care and outcomes in London hyperacute stroke units: a mixed-methods study

Background

Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of the day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units.

Objectives

To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units, and to identify factors influencing such variations.

Design

This was a prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. Factors influencing variations in care and outcomes were studied through interview and observation data.

Setting

The setting was acute stroke services in London hyperacute stroke units.

Participants

A total of 7094 patients with a primary diagnosis of stroke took part. We interviewed hyperacute stroke unit staff (n = 76), including doctors, nurses, therapists and administrators, and 31 patients and carers. We also conducted non-participant observations of delivery of care at different times of the day and week (n = 45, ≈102 hours).

Intervention

Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards was designed to deliver uniform access to high-quality hyperacute stroke unit care across the week.

Main outcome measures

Indicators of quality of acute stroke care, mortality at 3 days after admission, disability at the end of the inpatient spell and length of stay.

Data sources

Sentinel Stroke National Audit Programme data for all patients in London hyperacute stroke units with a primary diagnosis of stroke between 1 January and 31 December 2014, and nurse staffing data for all eight London hyperacute stroke units for the same period.

Results

We found no variation in quality of care by day and time of admission across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor in 3-day mortality nor disability at hospital discharge. Other quality-of-care measures significantly varied by day and time of admission. Quality of care was better if the nurse in charge was at a higher band and/or there were more nurses on duty. Staff deliver ‘front-door’ interventions consistently by taking on additional responsibilities out of hours, creating continuities between day and night, building trusting relationships and prioritising ‘front-door’ interventions.

Limitations

We were unable to measure long-term outcomes as our request to the Sentinel Stroke National Audit Programme, the Healthcare Quality Improvement Partnership and NHS Digital for Sentinel Stroke National Audit Programme data linked with patient mortality status was not fulfilled.

Conclusions

Organisational factors influence 24 hours a day, 7 days a week (24/7), provision of stroke care, creating temporal patterns of provision reflected in patient outcomes, including mortality, length of stay and functional independence.

Future work

Further research would help to explore 24/7 stroke systems in other contexts. We need a clearer understanding of variations by looking at absolute time intervals, rather than achievement of targets. Research is needed with longer-term mortality and modified Rankin Scale data, and a more meaningful range of outcomes.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 34. See the NIHR Journals Library website for further project information.

Development and Validation of a Prognostic Tool for Direct Enteral Tube Insertion After Acute Stroke

Background and Purpose- We aimed to create a novel prognostic risk score to estimate outcomes after direct enteral tube placement in acute stroke. Methods- We used the Ontario Stroke Registry and linked databases to obtain clinical information on all patients with direct enteral tube insertion after ischemic stroke or intracerebral hemorrhage from July 1, 2003 to June 30, 2010 (derivation cohort) and July 1, 2010 to March 31, 2013 (validation cohort). We used multivariable regression to assign scores to predictor variables for 3 outcomes after tube placement: favorable outcome (discharge modified Rankin Scale score 0-3 and alive at 90 days), poor outcome (discharge modified Rankin Scale score 5 or death at 90 days), and 30-day mortality. Results- Variables associated with a favorable outcome were younger age, preadmission independence, ischemic stroke rather than intracerebral hemorrhage, lower stroke severity, and a shorter time between stroke and tube placement. Variables associated with a poor outcome were older age, preadmission dependence, atrial fibrillation, greater stroke severity, and tracheostomy. Age, preadmission dependence, atrial fibrillation, cancer, chronic obstructive pulmonary disease, and shorter time to tube placement were associated with increased 30-day mortality. Using these variables, we created an online calculator to facilitate estimation of individual patient risk of favorable and poor outcomes. C-statistic in the validation cohort was 0.82 for favorable outcome, 0.65 for poor outcome, and 0.62 for 30-day mortality, and calibration was adequate. Conclusions- We developed risk scores to estimate outcomes after direct enteral tube insertion for acute dysphagic stroke. This information may be useful in discussions with patients and families when there is prognostic uncertainty surrounding outcomes with direct enteral tube placement after stroke.

Relationships between high comorbidity index and nutritional parameters in patients with Oropharyngeal Dysphagia

BACKGROUND & AIMS

Oropharyngeal dysphagia (OD) and comorbidities can exert an influence on nutritional status and contribute to mortality. The aim of the present study was to examine relationships between high Charlson Comorbidity Index (CCI) scores and OD outcomes, including OD severity, feeding route, nutritional status and one-year mortality rate in adults and elderly individuals.

METHODS

A longitudinal study, whose the final sample comprised 110 patients with OD and 75 of whom were evaluated for one-year mortality outcome. Swallowing (videofluoroscopy), nutritional status [body mass index (BMI)], CCI, type of feeding route, medications and hospitalization were evaluated. Multinomial logistic regression was performed to calculate the unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (95%CI).

RESULTS

Overall sample of the study were adults and elders with a median age (years) of 61.3 [interquartile range (IQR): 58.4-64.2]. The median CCI was 2.3 (IQR: 2.1-2.6) and the mortality rate was 10.8%. Hospitalization was significantly associated with underweight (p = 0.013) and number of medications (p = 0.023). After adjustment, sex/age and nº-Medications/Hospitalization (nº-M/H), CCI ≥3 was associated with nasogastric tube feeding (OR 4.57, 95%CI 1.59-13.1 and OR 3.39, 95%CI 1.21-9.51 respectively) and swallowing performance (OR 0.73, 95%CI 0.59-0.90 and OR 0.74, 95%CI 0.61-0.90 respectively).

CONCLUSIONS

A high CCI was associated with OD severity and feeding route, but not with nutritional status or mortality.