The use of videofluoroscopy (VFS) and fibreoptic endoscopic evaluation of swallowing (FEES) in the investigation of oropharyngeal dysphagia in stroke patients: A narrative review

OBJECTIVES

Patients with suspected acute stroke require rapid assessment of swallowing on admission. If aspiration is suspected, this takes the form of specialist assessment, using either videofluoroscopy (VFS) or fibreoptic endoscopic evaluation of swallowing (FEES). The review aim was to evaluate and compare the effectiveness of each method in stroke patients. Literature was collected from the databases Scopus, Web of Science and Medline, and articles included in the review were published within the last 10 years, in the English language.

KEY FINDINGS

Sensitivity and specificity ranged from 0.29-0.33 and 0.96-1.0 for VFS, respectively, and 0.37-1.0 and 0.65-0.87 for FEES, respectively, depending on the type of bolus utilised. VFS is the current gold-standard for the investigation of oropharyngeal dysphagia (OD), however, radiation dose and patient transport implications mean FEES may be preferred. FEES has limitations including 'whiteout' and the invasive nature of the endoscope. The NICE guidelines do not recommend a definitive protocol specifically in stroke patients. This suggests further research may be required to determine the most effective method.

CONCLUSION

FEES is a beneficial first line examination, providing limited invasiveness, and administering a high level of patient suitability, without using ionising radiation. VFS could potentially be useful following FEES to secure full visualisation, ensuring an aspiration event is not missed during FEES.

IMPLICATIONS FOR PRACTICE

Use of FEES as the first line test rather than VFS, ensures radiation dose is as low as reasonably practicable (ALARP). Ongoing research to ensure protocols follow current best practice can help ensure accurate management of oropharyngeal dysphagia in stroke patients.

Understanding and responding to COVID-19 in Wales: protocol for a privacy-protecting data platform for enhanced epidemiology and evaluation of interventions

INTRODUCTION

The emergence of the novel respiratory SARS-CoV-2 and subsequent COVID-19 pandemic have required rapid assimilation of population-level data to understand and control the spread of infection in the general and vulnerable populations. Rapid analyses are needed to inform policy development and target interventions to at-risk groups to prevent serious health outcomes. We aim to provide an accessible research platform to determine demographic, socioeconomic and clinical risk factors for infection, morbidity and mortality of COVID-19, to measure the impact of COVID-19 on healthcare utilisation and long-term health, and to enable the evaluation of natural experiments of policy interventions.

METHODS AND ANALYSIS

Two privacy-protecting population-level cohorts have been created and derived from multisourced demographic and healthcare data. The C20 cohort consists of 3.2 million people in Wales on the 1 January 2020 with follow-up until 31 May 2020. The complete cohort dataset will be updated monthly with some individual datasets available daily. The C16 cohort consists of 3 million people in Wales on the 1 January 2016 with follow-up to 31 December 2019. C16 is designed as a counterfactual cohort to provide contextual comparative population data on disease, health service utilisation and mortality. Study outcomes will: (a) characterise the epidemiology of COVID-19, (b) assess socioeconomic and demographic influences on infection and outcomes, (c) measure the impact of COVID-19 on short -term and longer-term population outcomes and (d) undertake studies on the transmission and spatial spread of infection.

ETHICS AND DISSEMINATION

The Secure Anonymised Information Linkage-independent Information Governance Review Panel has approved this study. The study findings will be presented to policy groups, public meetings, national and international conferences, and published in peer-reviewed journals.

Determination of the aryltetralin lignan content of podophyllum resins and roots/rhizomes

A simple, quantitatively reproducible method for determining the aryltetralin lignan content of the resins and roots/rhizomes of Podophyllum hexandrum and P. peltatum is described. The method confirms that P. hexandrum resins and roots/rhizomes contain approximately four times the quantity of lignans as do those of P. peltatum and also that there is a significant variation in the lignan content of P. hexandrum resins.

Papaver bracteatum Lindley: thebaine content in relation to plant development

Four thebaine-rich varieties of P. bracteatum have been grown in the open over two seasons and the thebaine distribution in aerial parts examined to determine the most suitable source material for commercial production. The leaves contained only 0-1 to 0-15%; the capsules 0-5 to 3-0% and the bled latex 28 to 53%. The maximum for the latter occurred about 3-4 weeks after petal opening and during the day, at about 15,00 h. A product 'bractium' prepared exactly as opium from P. somniferum contained up to 55% thebaine and calculations from the 1974 results gave theoretical yields up to 58 k of thebaine per hectare. However this is a very labour intensive method; furthermore bled latex only represents about 46% of the total thebaine of the capsule. In addition the pedicels contain significant amounts of thebaine, so that fruiting tops may be recommended as source material. In the capsule the thebaine content reaches a peak 3 to 4 weeks after petal opening and again two weeks later. At this fully ripe stage there is a theoretical yield of 50 kg per hectare. Two further advantages accrue from collection at this time: the ripe seeds can probably be used for similar purposes as poppy seed; and the pericarps at this stage contain no 'bound thebaine' (i;e., thebaine insoluble in MeOH; NH4OH but soluble in acetic acid--in unripe capsules bound thebaine represents 18 to 36% of the total thebaine). There is some evidence that, as this perennial plant increases in age, the capacity for thebaine production seems to continue increasing. Storage of raw material, even in ideal conditions, led to a loss of thebaine of 12 to 20% in one year.

The determination of thebaine in Papaver bracteatum Lindl by gas-liquid chromatography

Several solvents have been examined in the process of developing a convenient method for extracting powdered material and removing interfering pigments to produce an extract of Papaver bracteatum suitable for g.l.c. assay. The most suitable extracting solvent was aqueous acetic acid (5%); the assay method gave satisfactory reproducibility with a wide range of plant materials (coefficient of variation 0.63 to 3.33%). The accuracy was checked by recovery experiments with pure thebaine and by examination of exhausted marcs. The presence of other alkaloids did not interfer with the assay. There were substantial differences in the amounts of thebaine extracted from capsule and root samples by ammoniacal methanol and by aqueous acetic acid, indicating the presence of thebaine in a "bound" form. The minimum amount of thebaine that could readily be determined by the g.l.c. method was 0.3 mg in the sample of powder used for the assay.