Validation of the Spanish version of DYsphagia in MUltiple Sclerosis questionnaire (DYMUS)

BACKGROUND

Dysphagia is a common symptom in multiple sclerosis that can occur even early in the disease course and can lead to serious complications. Early recognition and treatment can promote comfort, safety and optimal nutritional status. Few dysphagia rating scales are available in Spanish. The aim of this study was to translate the Dysphagia in Multiple Sclerosis Questionnaire (DYMUS) into Spanish and to validate it.

METHODS

Forward and backward translation method was used to translate the original English version of DYMUS into Spanish. A pilot-study with 10 PwMS was carried on in order to improve the intelligibility of the instrument, comprehensibility and content validity of the questionnaire. The questionnaire was filled out by 100 PwMS who were asked a dichotomous question on their swallowing ("Do you have swallowing troubles?"). Descriptive data are presented as median and quartiles for continuous variables and frequency and percentage for categorical ones. Internal consistency reliability was estimated by Cronbach's alfa. Test-retest reliability was estimated by intraclass correlation coefficient. Concurrent validity with a speech and language therapy assessment (SLT-A) was measured with the weighted kappa statistic for the concordance for both dysphagia type and degree categories. Confirmatory factor analysis by means of structural equation models was used to verify the two-factor (solids and liquids) structure of the DYMUS questionnaire. As the goodness of fit evaluation was poor, an additional exploratory factor analysis was carried out.

RESULTS

Internal consistency was high. The globus sensation question and the weight loss questions (item 3 and 10) are the least specific with dysphagia symptomatology so they are worst correlated with the sum of the others (item-rest correlation, 0.243 and 0.248, respectively). The test-retest reliability of the DYMUS among 40 patients using ICC was 0.75 (95% CI 0.57 - 0.86). Concurrent validity with SLT-A was poor (weighted kappa 0.37 for dysphagia type and 0.38 for dysphagia degree). The DYMUS questionnaire detected three times more dysphagia (53% versus 17%) than the dichotomous question. Confirmatory factors analysis failed to confirm the bidimensional structure (solid and liquid items) often reported in other validation studies. The subsequent exploratory factor analysis also identified two factors, but with poor interpretability.

CONCLUSION

DYMUS-SP scale is not a sufficiently useful scale to detect dysphagia in PwMS due to the poor concurrent validity and the probable overdiagnosis of the condition; however, it can be helpful as a screening tool when combined with other measures.

[Oropharyngeal dysphagia in stroke: diagnostic and therapeutic aspects]

INTRODUCTION

The prevalence of oropharyngeal dysphagia is high after a stroke. Clinically, it manifests as alterations affecting swallowing efficiency and safety, with the consequent morbidity and mortality associated with nutritional and respiratory alterations.

AIM

To carry out an updated review of the diagnostic and therapeutic aspects of oropharyngeal dysphagia after a stroke that can be applied in daily clinical practice, and of the non-invasive neurostimulation techniques.

DEVELOPMENT

The process of diagnosis and treatment of oropharyngeal dysphagia aims to screen, identify and diagnose patients at risk of dysphagia, and establish the dietary and therapeutic measures that ensure proper nutrition and hydration of patients under safe conditions. The diagnosis is based on the clinical examination of swallowing and on instrumental examinations such as videofluoroscopy and fibro-endoscopy. Therapeutic measures include compensatory and rehabilitative strategies (active manoeuvres, motor control exercises, neuromuscular electrostimulation and botulinum toxin treatment). Neurostimulation techniques include non-invasive central stimulation and intrapharyngeal electrical stimulation.

CONCLUSION

The prevalence of oropharyngeal dysphagia is high after a stroke. Diagnosis should include a clinical evaluation and an instrumental examination, and thus objectively indicate the treatment, which will include compensatory and restorative measures with which to reduce the associated morbidity and mortality.

Prevalence of medication and off-label medication use in acquired brain injury at a neurorehabilitation hospital

PURPOSE

Patients who suffer acquired brain injury (ABI) require a great variety of drugs. Furthermore, the lack of evidence on the medication effects in this type of patient increases off-label prescription. The aim of this study was to describe the pattern of medication use and the practice of prescribing off-label drugs in these patients.

METHODS

A cross-sectional study was conducted in patients with ABI, of either traumatic or non-traumatic cause, admitted to a neurorehabilitation hospital for rehabilitation. Demographic and clinical data and prevalence of medication use and off-label prescription were collected.

RESULTS

The majority of the studied patients (85.2%) were considered polymedicated since they were prescribed ≥ 6 drugs concomitantly. In traumatic brain injury (TBI) patients, antidepressants (81.5%) were the Anatomical Therapeutic Chemical (ATC) group's most prescribed versus antithrombotic agents (80.5%) in non-traumatic brain injury (N-TBI) patients. Up to 37.3% of all active substances prescribed in TBI patients were off-label compared with 24.9% in N-TBI patients. The most prescribed off-label active substances in both groups were those related to the Nervous System (N) ATC group to treat neurobehavioural problems.

CONCLUSION

A multidisciplinary pharmacotherapeutic follow-up of these patients would be essential to address the high prescription rate of medications and the off-label prescription practice. In this way, medication problems related to polypharmacy could be minimised and the benefit-risk ratio of prescribed off-label drugs could be ensured according to the available medical evidence.

Botulinum toxin treatment for oropharyngeal dysphagia in patients with stroke

BACKGROUND

In a previous pilot study, we demonstrated that a single injection of botulinum toxin A (BTX-A) in the cricopharyngeus muscle is effective in patients with neurologic dysphagia with upper esophageal sphincter (UES) opening dysfunction and presence of some pharyngeal contraction (>25 mmHg). The aim of this study was to confirm the long-lasting efficacy of this procedure after stroke.

METHODS

We prospectively studied 23 patients with stroke for at least 6 months before administration of a BTX-A injection. Baseline diagnosis of UES opening dysfunction and presence of some pharyngeal contraction were assessed by videofluoroscopy (VFS) and esophageal manometry (EM). Clinical and VFS follow-up was made at 3 weeks and 3, 6, and 12 months postinjection.

KEY RESULTS

Eighteen patients (78%) were fed by gastrostomy tube prior to treatment. Videofluoroscopy showed UES relaxation impairment, residue in pyriform sinuses, and aspiration in all cases. After BTX-A, the number of patients with aspiration and pharyngeal residue decreased to 52% and 70%, respectively (p < 0.05 for both); residue was severe in only 4%. Esophageal manometry showed a mean pharyngeal amplitude 66.8 mmHg (range: 25-120 mmHg). We observed a significant improvement in feeding mode during follow-up: after 3 months, 70% of patients were eating exclusively by mouth. Lower residual pressure and minor pharyngeal delay time at baseline were all predictive factors for treatment effectiveness.

CONCLUSIONS & INFERENCES

A single injection of BTX-A is efficacious for a period of at least 12 months in improving oropharyngeal dysphagia in stroke patients with UES opening dysfunction and some pharyngeal contraction (>25 mmHg).

Pasteurella multocida bacterial meningitis caused by contact with pigs

Pasteurella multocida belongs to the normal flora of the respiratory and digestive tract of many animals. Animal exposure is a considerable risk factor for Pasteurella infection. P. multocida is the most common cause of local infection after an animal bite but is an unusual cause of meningitis. We present a case of bacterial meningitis by P. multocida in a 37-year-old man who worked in a pig farm and was bitten by a pig. The patient had a defect located in the lamina cribosa and this lesion could be the gateway of the infection, although in this case the infection could also be acquired through the pig bite. The bacteria was identified as P. multocida with the biochemical test API 20E (bioMérieux). In agreement with findings in the literature, the strain was susceptible in vitro to penicillin, ampicillin, cefotaxime, ceftriaxone ciprofloxacin, levofloxacin, imipenem and tetracycline.

Effectiveness of chin-down posture to prevent tracheal aspiration in dysphagia secondary to acquired brain injury. A videofluoroscopy study

BACKGROUND

The chin-down posture is generally recommended in patients with neurogenic dysphagia to prevent tracheal aspiration; however, its effectiveness has not been demonstrated.

AIM

To videofluoroscopically (VDF) assess the effectiveness of chin-down posture to prevent aspiration in patients with neurogenic dysphagia secondary to acquired brain injury.

METHODS

Randomized, alternating, cross-over study (with and without the chin-down posture) in 47 patients with a VDF diagnosis of aspiration [31 stroke, 16 traumatic brain injury (TBI)] and 25 controls without aspiration (14 stroke, 11 TBI).

KEY RESULTS

During the chin-down posture, 55% of patients avoided aspiration (40% preswallow aspiration and 60% aspiration during swallow). The percentage was similar in both etiologies (58% stroke and 50% TBI). Fifty-one percent of patients had silent aspiration; of these, 48% persisted with aspiration while in the chin-down posture. A statistically significant relationship was found between the existence of pharyngeal residue, cricopharyngeal dysfunction, pharyngeal delay time and bolus volume with the persistence of aspiration. The chin-down posture did not change swallow biomechanics in patients without aspiration.

CONCLUSIONS & INFERENCES

Only half the patients with acquired brain injury avoided aspiration during cervical flexion; 48% of silent aspirators continued to aspire during the maneuver. Several videofluoroscopic parameters were related to inefficiency of the maneuver. Therefore, the indication for chin-down posture should be evaluated by videofluoroscopic examination.

Evolution of tracheal aspiration in severe traumatic brain injury-related oropharyngeal dysphagia: 1-year longitudinal follow-up study

The aims of the article were to ascertain the clinical evolution and prognostic factors of aspiration recovery and feeding outcome in patients with severe traumatic brain injury (TBI) and a videofluoroscopic (VFS) diagnosis of tracheal aspiration. Twenty-six patients with severe TBI and VFS diagnosis of tracheal aspiration were prospectively evaluated. Clinical evaluation of oropharyngeal dysphagia and VFS examination were performed at admission and repeated at 1, 3, 6 and 12 months of follow-up. At admission, all patients had VFS aspiration. During follow-up, an improvement was observed in both oral and pharyngeal function, with the number of patients with aspiration decreasing progressively. The most significant change occurred in the examination made at 3 months. At 1 year, only 23% of patients had aspiration. No patient had clinically significant respiratory infections during the follow-up period. Persistent aspiration at 1 year of follow-up correlated with baseline variables: Rancho Los Amigos Level Cognitive Function Scale score, Disability Rating Scale score, tongue control alteration, velopharyngeal reflex abolition and delay in triggering swallowing reflex. Swallowing physiology in severe TBI greatly improved during follow-up and the number of aspirations decreased progressively, with the most significant reduction at between 3 and 6 months of evolution. This study revealed several prognostic factors for persisting aspiration: neurological involvement (evaluated with the Rancho Los Amigos Level Cognitive Function Scale and Disability Rating Scale), tongue control alteration, oropharyngeal reflex abolition and delay in triggering swallowing reflex at baseline.

Alteraciones de la función intestinal en pacientes con lesión medular: relación con las características neurológicas de la lesión

BACKGROUND AND OBJECTIVE

The study consisted of a clinical evaluation of bowel dysfunction and the relation with neurological patterns in spinal cord injury (SCI).

PATIENTS AND METHOD

109 patients; 30% tetraplegics and 70% paraplegics; ASIA Impairment Scale: 65% A (complete), 12% B (sensitive incomplete), 11% C (motor incomplete with muscle grade <3), 13% D (motor incomplete with muscle grade >or= 3). 83% had spinal sacral reflexes (SSR). An interview and ano-rectal examination were performed.

RESULTS

77% patients required laxatives and 68% digital stimulation; 10% had bowel movements less than thrice a week and 18% spent more than one hour; 27% presented constipation, 31% fecal incontinence, 31% had ano-rectal pathology and 18% had autonomic dysreflexia (AD). Patients ASIA A,B,C with SSR took more suppositories, evacuated less frequently and spent more time than patients without SSR. Tetraplegics ASIA A,B,C had more constipation. Only patients with high level SCI and ASIA A,B,C with SSR had AD. ASIA D patients also needed laxatives, digital stimulation and presented colo-rectal symptoms.

CONCLUSIONS

The prevalence of colo-rectal symptoms is high in SCI patients and neurogenic bowel characteristics are related to neurological patterns.

[Videofluoroscopy quantification of laryngotracheal aspiration outcome in traumatic brain injury-related oropharyngeal dysphagia]

INTRODUCTION

Swallowing impairments are frequent after severe traumatic brain injury (TBI).

OBJECTIVE

to define and prospectively quantify the videofluoroscopic symptoms in patients after TBI, and to evaluate the evolution of patients with laryngotracheal aspiration.

METHOD

We studied 10 patients with TBI, and a clinical suspicion of aspiration confirmed by means of a videofluoroscopic exploration (VDF). VDF was repeated at 1, 3, 6, and 12 months thereafter.

RESULTS

30% of patients had an impaired gag reflex, and 40% cough during oral feeding. In the first VDF exploration the following was observed: increased oral transit time (OTT) in 70% (average: 3.8 sec.; range: 0.8-15 sec.), altered lingual control in 60%, and dysfunctional palatoglossal closure in 20%. Mean pharyngeal transit time (PTT) was 0.72 sec. (range: 0.34-1.50 sec.), and time to swallowing reflex (TSR) was 0.32 sec. (range: 0.10-0.80 sec.). After one year only 3 patients had aspiration--with a normal OTT in 7 patients, a normal PTT in 9, and a normal TSR in all; 80% had an exclusively oral diet, and 20% combined oral intake and gastrostomy feeding.

CONCLUSION

Videofluoroscopic evaluation allows to confirm and quantite swallowing dysfunction in patients with severe TBI. Most frequent early findings included an increase in OTT and alterations in lingual control; aspirations were quite frequent, and more than half were silent. After one year the majority of patients showed a favorable outcome.

Oropharyngeal dysphagia after the acute phase of stroke: predictors of aspiration

Oropharyngeal dysphagia is frequent during the acute phase of stroke, but most patients recover. Dysphagia is related to higher incidence of aspiration, pneumonia and death. Frequently neither clinical history nor neurological evaluation predicts the presence of aspiration. In 64 patients not recovered from severe stroke after the acute phase with clinically suspected oropharyngeal dysphagia we investigated: (i) the correlation between clinical manifestations and videofluoroscopic findings; (ii) predictive factors of aspiration and silent aspiration. Clinical examination showed that 44% had impaired gag reflex, 47% cough during oral feeding, and 13% changes in voice after swallowing. Videofluoroscopy revealed some abnormality in 87%: 53% in the oral phase and 84% in the pharyngeal phase (aspiration in 66%; half being silent). Impaired pharyngeal safety was more frequent in posterior territory lesions and patients with a history of pneumonia (P<0.01). No correlation was found between clinical evaluation findings and presence of aspiration. Silent aspirations were more frequent in patients with previous orotracheal intubation (P<0.05) and abnormalities in velopharyngeal reflexes (P<0.05). We concluded that in patients not recovered from severe stroke after the acute phase and with suspected oropharyngeal dysphagia, clinical evaluation is of scant use in predicting aspiration and silent aspiration. Videofluoroscopic examination is mandatory in these patients.

Post-traumatic syringomyelia following complete neurological recovery

OBJECTIVE

To describe the later neurologic deterioration secondary to the appearance of a post-traumatic syringomyelic cavity, in a patient who, in the initial phase, had an incomplete spinal cord lesion (ASIA C), which improved to ASIA E.

METHODS

A 52-year-old male patient who, at the age of 19 (1965), suffered a spinal cord injury. He presented with a fracture of the sixth and seventh cervical neurological segment at the time of the lesion, evolving to ASIA E. Nine years after the traumatism, he began to feel pain accompanied by a sensory and motor deficit.

RESULTS

With the aid of myelography and MRI, the existence of a syringomyelic cavity was detected, which extended from the fourth to the seventh cervical segments. The patient was operated on, on various occasions, placing a syringo-subarachnoid shunt. The neurological status of the patient continued to deteriorate and, at present, he has a complete lesion below the fourth neurological cervical segment with a partially preserved sensitive area up to T1.

CONCLUSION

The development of the syringomyelic cavity could be one of the causes of later neurologic deterioration in patients with traumatic spinal cord injury with neurological recovery 'ad integrum' in the initial phase of spinal cord injury.

[Agitation in head injury. II. Treatment with antidepressant, sympathomimetic, beta blocker , dopaminergic and other drugs]

OBJECTIVE

To review the literature of the past 20 years, using the articles indexed in MEDLINE, on the drug treatment of agitation in traumatic head injury.

DEVELOPMENT

The treatment of agitation in traumatic head injury should be based on well-designed, randomised, placebo-controlled studies which justify any particular decision regarding drug use. However, care of the agitated traumatic head injury patient is based on the management of other related disorders, on the response of similar patient populations and clinical experience based on empirical observation. Amongst the drugs available, carbamazepine is the most widely used for post-traumatic agitation, followed by antidepressants and as a third option propranolol. We discuss other drugs which are used less frequently in post-traumatic agitation.

CONCLUSIONS

Many drugs are used and there is little agreement on the subject. However, with regard to certain characteristics of the agitation, different pharmacological treatments may be recommended.

[Agitation in head injury. I. Definition and treatment with anxiolytic neuroleptics and antiepileptic drugs]

OBJECTIVE

To carry out a bibliographic review of articles indexed in MEDLINE over the past 20 years concerning the pharmacological treatment of agitation in head injury.

DEVELOPMENT

Head injury may cause different behaviour changes, of which agitation is the most dramatic. The incidence of agitation after severe head injury varies from 11% to 50% depending on the study involved. This incidence is high enough to warrant specific management. Drug treatment has variable results. When there is imminent danger of harm to the patient himself or to others, or when aggressive behaviour makes medical management difficult, the benzodiazepines have been found useful. Antipsychotic drugs are only indicated in head injury when the agitation causes a clinical emergency, and in such a case the more potent drugs such as haloperidol are best, since they have less sedative effect. They are also effective when the clinical features are similar to those of classical schizophrenia. Antiepileptic drugs have been used successfully for treating agitation-aggressiveness, specially in paroxystic behaviour disorders. We also consider other treatments used for posttraumatic agitation.

CONCLUSION

There is no general agreement amongst doctors as to the best treatment for posttraumatic agitation in head injury. However, with regard to certain characteristics of agitation different drugs may be recommended for treatment.