Complications and outcome after acute stroke. Does dysphagia matter?

Tongue Pressure and Grip Strength as Indicators of Persistent Dysphagia After Acute Stroke

This study aimed to identify the independent predictors of postacute stroke dysphagia at discharge using sarcopenia-related parameters. This single-center prospective observational study assessed consecutive inpatients diagnosed with cerebral infarction or cerebral hemorrhage upon admission to the stroke unit. Tongue pressure, grip strength, and body composition were evaluated within 48 h. Dysphagia was defined by a functional oral intake scale of ≤ 5. Patient characteristics were compared between non-dysphagia and dysphagia groups using Mann-Whitney or chi-squared tests. Logistic regression analysis was performed using age, sex, tongue pressure, grip strength, skeletal muscle mass index (SMI), and National Institutes of Health Stroke Scale (NIHSS) scores as explanatory variables, with dysphagia at discharge as the objective variable. A total of 302 patients (mean age: 69.4 ± 13.8 years, 67.5% male) were analyzed, with 64 having dysphagia at discharge (21.2%). The dysphagia group was significantly older (p<0.001), had higher NIHSS scores on admission (p<0.001), lower SMI (p = 0.002), lower grip strength (p<0.001), and lower tongue pressure (p<0.001) than the non-dysphagia group. Logistic regression revealed that age (OR: 1.042, p = 0.018), tongue pressure (OR: 0.954, p = 0.010), and grip strength (OR: 0.943, p = 0.048) on admission were independent predictors of dysphagia at discharge, while NIHSS scores (OR: 1.403, p = 0.106), sex, and SMI (OR: 1.403, p = 0.150) were not. Older age, reduced tongue pressure, and reduced grip strength are strong predictors of persistent poststroke dysphagia at discharge. Thus, muscle strength is a more valuable parameter than muscle mass in predicting persistent poststroke dysphagia.

Predictors of Hospital Stay After Acute Ischemic Stroke in Hospitalized Patients: Retrospective-Cohort Study

Background: The length of hospital stay (LOS) is frequently recognized as an indicator of hospital management efficiency and the quality of care. Patients with acute ischemic stroke (AIS) who experience prolonged LOS are at a higher risk of developing complications such as hospital-acquired infections and gastrointestinal bleeding. These complications can adversely affect clinical outcomes, acting as a primary determinant of poor functional outcomes. However, evidence regarding predictors of the LOS after AIS in Ethiopia is lacking. Objective: Therefore, the objective of this study was to assess clinical predictors of the LOS after AIS among patients admitted to Tibebe Ghion and Felege Hiwot Comprehensive Specialized Hospitals. Methods: A retrospective cohort study was conducted among patients diagnosed with AIS and treated at Tibebe Ghion and Felege Hiwot hospitals from November 2018 to November 2021. Multivariate linear regression analysis was employed to explore predictors of LOS. The slope of regression line (β) with its 95% CI is used to declare statistical significance. Results: Of the 278 patients with AIS, 59.7% were male. Stroke-related complications (aspiration pneumonia and urinary tract infections occurred in the hospital in 57 (20.5%), and 12 (4.3%), patients, respectively. The most common neurological deficit observed during hospital admission was limb weakness, affecting 268 patients (96%). The median LOS was 5 days. Among the clinical characteristics, atrial fibrillation (β = 7.337, 95% CI: 1.226, 13.448), Limp weakness (β = 4.831, 95% CI: 2.330, 7.332), aspiration pneumonia (β = 2.089, 95%CI: 1.178, 3.000) and Male sex (β = 1.696, 95% CI: 0.851, 2.542), were significant predictors of LOS. Conclusion: In this study, the presence of AF and stroke-related complications, such as aspirational pneumonia, were found to be significant predictors of LOS. Therefore, implementing efficient prevention strategies targeting potentially modifiable risk factors is essential to mitigate the impact of these factors.

Translation and Validation of the TOR-BSST Into Turkish for Stroke Patients

PURPOSE

The most common cause of death in Turkey is attributed to vascular diseases, including stroke. Dysphagia stands out as one of the prevalent and life-threatening complications that often follow a stroke. Within the Turkish context, the availability of validated bedside screening tests for assessing dysphagia remains limited. The primary objective of this study was to undertake the translation of the TOR-BSST into Turkish and subsequently validate this newly translated Turkish version.

METHOD

Once the translation of the TOR-BSST into Turkish was accomplished, 60 stroke patients were consecutively enroled in the validation process. The enroled patients were evaluated using the TOR-BSST-TR, administered by a speech and language pathologist (SLP) trained in TOR-BSST screener training. On the screening day, each patient underwent a videofluoroscopic swallowing study (VFSS), administered by another SLP blinded to the patient's medical information and TOR-BSST-TR results. The VFSS images were recorded for independent analysis by the second SLP who conducted the VFSS, and a third SLP, also blinded to the TOR-BSST-TR findings, using the Penetration Aspiration Scale (PAS) to measure airway invasion severity, and Dysphagia Severity Rating Scale (DSRS) to measure overall dysphagia severity. The reliability of the gold standard VFSS ratings was assessed using the intra-class correlation coefficient (ICC). The accuracy of the new TOR-BSST-TR was assessed using sensitivity, specificity, predictive values and likelihood ratios.

RESULTS

Of all the 60 patients, 35 (58.3%) failed the TOR-BSST-TR, and 33 (55%) were identified with some degree of dysphagia from VFSS imaging scores. The overall inter-rater reliability (in ICC, 95% CI) for the gold standard ratings were as follows: PAS semi-solids (0.98, 0.95-0.99), PAS liquids (0.75, 0.58-0.85) and overall DSRS (0.70, 0.32-0.85). Based on the total screening score of the TOR-BSST-TR, the sensitivity, specificity, positive and negative predictive values along with positive likelihood ratio were as follows: 93.9%, 85.2%, 90.5%, 90.4% and 6.34, respectively.

CONCLUSION

The TOR-BSST was successfully translated into Turkish, and the resulting TOR-BSST-TR demonstrated high accuracy in the acute stroke phase using videofluoroscopy as the gold standard. Specifically, the new TOR-BSST-TR screening tool yielded excellent sensitivity, specificity and predictive values in this patient population. The clinical implementation of this validated screening tool has the potential to enhance early detection of dysphagia, thereby triggering early management and ultimately improving patient outcomes and reducing the burden of complications from vascular diseases, such as stroke. Further research and widespread adoption of the TOR-BSST-TR could contribute to more standardized and effective dysphagia assessment protocols in clinical practice.

WHAT THIS PAPER ADDS

What is already known on the subject Dysphagia, prevalent in over half of stroke survivors, poses severe complications, including aspiration pneumonia. While Turkey faces high stroke mortality, limited validated dysphagia screening tools exist. Recent cultural adaptation studies focus on tools like The Barnes-Jewish Hospital Stroke Dysphagia Screen, The Gugging Swallowing Screen Test and The Mann Assessment of Swallowing Ability. The Toronto Bedside Swallow Screening Test (TOR-BSST), a water-swallowing test for stroke patients, demonstrates accuracy. Adapting it to Turkish is crucial for effective bedside screening and managing dysphagia, offering significant benefits. This study translated TOR-BSST into Turkish, aiming to evaluate its validity and reliability in acute stroke patients, addressing a critical need in the Turkish stroke population. What this paper adds to the existing knowledge This study addresses the pressing issue of dysphagia, a life-threatening complication following strokes in Turkey, where validated bedside screening tests are limited. The research translates and validates the TOR-BSST into Turkish, involving 60 stroke patients. The TOR-BSST-TR form, administered by trained speech-language pathologists, demonstrated high sensitivity (93.9%) and good specificity (85.2%) in comparison to videofluoroscopy, the gold standard. Inter-rater reliability was satisfactory, showcasing the tool's effectiveness in identifying dysphagia. The study contributes valuable insights into dysphagia assessment, offering a reliable and culturally adapted screening tool for stroke patients in Turkey. What are the potential or actual clinical implications of this work? The clinical implications of this study are significant for stroke patients in Turkey facing dysphagia. The successful translation and validation of the TOR-BSST into Turkish offer healthcare professionals a culturally adapted and reliable bedside screening tool. This tool demonstrates high sensitivity and good specificity in identifying dysphagia, providing a valuable resource for early detection and effective management. The study's findings imply that the TOR-BSST-TR can be a practical and accurate instrument for clinicians, aiding in timely intervention, reducing complications and improving patient outcomes. Incorporating this tool into routine clinical practice may enhance dysphagia screening, leading to better patient care and quality of life.

[Postextubation dysphagia in intensive care unit : Epidemiology, clinical course, and management]

Postextubation dysphagia (PED) is common in intensive care units (ICU), affecting about 20% of patients of mixed medical surgical ICU populations. PED is an independent risk factor for increased 28-day and 90-day mortality in both neurological and nonneurological ICU patients (28-day mortality: plus 9%). The increased mortacity risk can be demonstrated for up to approximately one year after the ICU stay. Due to the consequences of PED, all ICU patients should undergo systematic dysphagia screening after extubation/decannulation (e.g., water swallow test) and fiberoptic endoscopic evaluation of the swallowing (FEES) to confirm the diagnosis. Treatment is interdisciplinary with nutrition adaptation/nutrition introduction or food restriction, physical/speech therapy and, if necessary, interventional procedures in the future.

A survey of current practice for post-acute stroke patients with cognitive impairment requiring nasogastric feeding-A proposed management pathway

BACKGROUND

Dysphagia is a common complication of stroke, and enteral feeding is often necessary. If present, cognitive impairment can complicate the process of reintroducing oral intake. There is limited evidence concerning the outcomes of enteral feeding with this particular patient group and decision-making can be challenging when considering long-term feeding options.

AIMS

To consolidate best practice and begin working towards developing a pathway for patients with cognitive impairment and dysphagia.

METHODS & PROCEDURES

A survey was conducted among post-acute stroke units in Wales to determine current practices and identify variations in the management of this patients group. We invited all stroke rehabilitation units that were part of a stroke-specific pathway in Wales to participate (n = 9).

OUTCOMES & RESULTS

Of the seven units that provided data, we identified great variety in experience and practice. Conversion to oral intake varied from 21.3% to 81.8% and to eating and drinking with acknowledged risk varying from 0.0% to 66.7%. Only one centre had a pathway specifically tailored to cognitively impaired nasogastric (NG)-fed patients.

CONCLUSIONS & IMPLICATIONS

This heterogeneity in practice and experience highlights a need to develop formal pathways for the weaning of NG feeding with these patients. Any variation in patient outcomes for those with both cognitive impairment and dysphagia compared with those unaffected need to be explored. We present a model pathway for conversion from NG feeding for patients with cognitive impairment. We also propose future work to develop a patient-centred evidence base to inform practice for patients with dysphagia and cognitive impairment post-stroke.

WHAT THIS PAPER ADDS

What is already known on the subject There is limited research on how to achieve the best outcome for patients with stroke and coexistent cognitive impairment. Clinical experience of the authors would suggest that the dated evidence around appetite and NG feeding might need to be updated to allow the prospect of swallowing recovery in this group to be optimized. What this paper adds to the existing knowledge There is often uncertainty in cases of post-stroke survivors who have cognitive impairment about how best to approach the scenario of feeding if dysphagia exists. This pathway incorporates the current guidance and recommendations in a structured way with a practical approach to the weaning of parenteral feeding to allow those guidelines to implemented as intended. What are the potential or actual clinical implications of this work? There is a possibility that the implementation of this pathway in to clinical practice will ensure that healthcare professionals working with post-stroke survivors who have cognitive impairment can offer a patient-centred, holistic management plan.

Analysis of Patients' Dietary Status/Restrictions Following Instrumental Swallow Evaluations in Skilled Nursing Facilities

Many residents in Skilled Nursing Facilities (SNFs) present with dysphagia and receive altered diets or liquids to minimize the risk of complications. Limited access to timely instrumental evaluations of swallow may impede the best management of these dysphagic residents. De-identified FEES reports completed by a mobile FEES company during a single month, January 2019, were reviewed. Descriptive statistics were used to summarize the pre-study diet/liquid levels and the post-study diet/liquid recommendations. FEES reports (n = 952) were reviewed. Before the FEES evaluation, 209 residents were receiving only non-oral nutrition. After the FEES evaluation, 76% of these residents were recommended to receive oral nutrition. Before the FEES evaluation, 442 (46%) residents were receiving thickened liquids, after the FEES evaluation, 244 (26%) were recommended to have a less restrictive liquid level. Before the FEES evaluation, 576 (60%) residents were receiving altered food texture, after the FEES evaluation, 413 (43%) were recommended to have a less restrictive food texture. The percentage of residents recommended to receive thin liquids increased from 32 to 68% and those recommended to receive a regular diet increased from 18 to 34%. These data indicate that access to instrumental swallow evaluations in the SNF setting generally resulted in lifting liquid and diet restrictions for many residents in the cohort reviewed and potentially improved their quality of life.

Continuous Estimation of Swallowing Motion With EMG and MMG Signals

Oropharyngeal dysphagia (OD) is a symptom of swallowing dysfunction that is associated with aspiration, severe respiratory complications, and even death. OD is a highly prevalent condition in populations including the elderly and patients with neurological diseases (e.g., stroke and Parkinson's disease (PD)). Assessment of swallow function is crucial for managing OD, yet depends on devices for long-term monitoring during daily life and relevant methods for accurately assessing swallow function. The videofluoroscopic swallowing study (VFSS) is usually considered a gold standard method. However, it has several limitations, such as radiation exposure, the need for technical experts, high cost, and clinical use only. This study investigates the performances of electromyography (EMG) and mechanomyography (MMG) signals, which can be easily measured using wearable sensors, to continuously estimate swallowing movement. Meanwhile, three methods, i.e., Gaussian process regression (GPR), LSTM, and random forest (RF), are used for swallowing motion estimation based on EMG/MMG signals measured from six healthy subjects and a patient with PD, respectively. Moreover, a depth camera-based approach is proposed to provide the reference laryngeal displacement (i.e., the swallowing movement). The experimental results show that EMG models with three machine learning methods can accurately estimate swallowing movement. For the healthy subjects, the mean correlation coefficient (CC) is about 0.90 and the normalized root mean square error (NRMSE) is less than 0.15. For the PD patient, the CC is 0.804 and the NRMSE is 0.205 when using RF. The performance of the MMG model is comparable to that of EMG: CC/NRMSE of the LSTM model is 0.844/0.150 (healthy subjects); CC/NRMSE of RF model is 0.727/0.204 (PD patient). To the best of our knowledge, this is the first study proving that both EMG and MMG are two effective means for an accurate continuous estimation of swallowing motion, enabling the possibility of a safe and convenient evaluation and management of OD.

Fiberoptic Endoscopy Evaluation of Swallowing (FEES) Findings Associated with High Pneumonia Risk in a Cohort of Patients at Risk of Dysphagia

Aspiration detected in the fiberoptic endoscopy evaluation of swallowing (FEES) has been inconsistently associated with pneumonia, with no evidence of the risk of pneumonia from other alterations in swallowing safety detected in FEES. We conducted a dynamic, ambidirectional cohort study involving 148 subjects at risk of dysphagia in a tertiary university hospital. Our aim was to determine the risk of pneumonia attributed to alterations in swallowing safety detected during FEES. We used multivariate negative binomial regression models to adjust for potential confounders. The incidence density rate (IR) of pneumonia in patients with tracheal aspiration of any consistency was 26.6/100 people-years (RR 7.25; 95% CI: 3.50-14.98; P < 0.001). The IR was 19.7/100 people-years (RR 7.85; 95% CI: 3.34-18.47; P < 0.001) in those with laryngeal penetration of any consistency and 18.1/100 people-years (RR 6.24; 95% CI: 2.58-15.09; P < 0.001) in those with pharyngeal residue of any consistency. When adjusted for aspiration, the association of residue and penetration with pneumonia disappeared, suggesting that their risk of pneumonia is dependent on the presence of aspiration and that only aspiration is independently associated with pneumonia. This increased risk of pneumonia was significant in uni- and multivariate negative binomial regression models. We found an independently increased risk of pneumonia among patients with dysphagia and aspiration detected during FEES. Alterations in the oral and pharyngeal phases of swallowing, without aspiration, did not increase the risk of pneumonia.

The Influence of Strength and Skill Parameters on the Evolution of Dysphagia Post Stroke: A Prospective Study

The role of pathophysiological deficits in the evolution of dysphagia post-stroke is unclear. This observational, longitudinal study aimed to document the evolution and relationship between strength and precision of submental contraction, and swallowing outcomes at six months. Participants were recruited from a tertiary acute hospital after a first acute stroke. Sociodemographic data and stroke typology were documented. Outcome measures were collected five times across six months. These included: oral diet (FOIS, IDDSI), functional ingestion (TOMASS, TWST), self-reported swallowing-related quality of life (SWAL-QOL), and submental muscle strength and precision contraction as assessed using surface electromyography coupled with biofeedback during saliva swallowing and jaw-opening tasks. Mixed effects models and multiple regressions analyses were conducted. Participants (N = 22, mean age 73.9 ± 14.4 years, 9 males) were recruited at a mean time of 2.8 ± 1.5 days after stroke. Strength parameters (effortful swallow hit rate) improved between ten days and one month post-stroke (p = 0.04). Swallowing temporal precision improved significantly between one and six months (p < 0.01). At six months, participants with decreased swallowing precision also had decreased quality of life (p = 0.04) and increased ingestion time of fluids (p = 0.002). This study is a novel step in exploring the nature and evolution of strength and precision parameters of swallowing muscle activation, and their impact on dysphagia recovery. As swallowing precision was associated with poorer functional outcomes, further studies are warranted to improve early differential diagnosis of patients at risk of chronic dysphagia.

Effect of Oral Screen Training After Stroke-A Randomised Controlled Trial

OBJECTIVE

To assess the effects of oral screen training in patients with dysphagia post-stroke.

BACKGROUND

Oral screen training has been identified as an effective method for improving orofacial and oropharyngeal motor functions. However, the evidence supporting a positive transfer effect on swallowing capacity post-primary stroke rehabilitation is still unclear. The aim of this randomised controlled trial was to investigate the effect of a 12-week oral screen training programme using a prefabricated oral screen, with swallowing capacity as the primary outcome.

MATERIALS AND METHODS

In a randomised trial, stroke survivors with residual dysphagia post-rehabilitation were randomised into intervention group (n = 12) and control group (n = 12). The intervention group underwent 12 weeks of oral screen training. The main outcome was swallowing capacity, with lip force as a training indicator. Secondary outcomes were assessed by the Eating Assessment Tool, Masticatory performance, Nordic Orofacial Test-Screening, Life Satisfaction Questionnaire and the Edmonton Symptom Assessment System.

RESULTS

At the 3-month follow-up, the group that trained with an oral screen showed a significantly greater increase in lip force than the control group (mean lip force increase 10.2 N vs. 3.1 N; p = 0.02). There was no significant improvement in swallowing capacity (mean increase 0.7 mL/min vs. 0.8 mL/min; p = 0.43), or in any of the secondary variables in the intervention group relative to the control group.

CONCLUSION

The findings from this study showed that oral screen training initiated after completion of regular rehabilitation post-stroke can increase lip force. However, there was no indication of any transfer effect on swallowing capacity.

TRIAL REGISTRATION

Clinicaltrial.gov identifier: NCT03167892.

A multicenter study on the sex difference of dysfunctions among rehabilitation outpatients in China

Dysfunction is a common clinical symptom among rehabilitation patients; however, whether there are sex differences in dysfunctions remains unclear. Therefore, this study aimed to explore this issue by examining a large sample of the population with dysfunctional problems. A multi-stage sampling scheme was used to select the rehabilitation outpatients as study participants. A total of 3415 participants from 21 medical institutions in seven cities in China were included in the final analysis. The measurement included general characteristics (age, sex, educational level, marital status, and household income) and disease-related characteristics (dysfunctions, self-care ability, vital signs, disease status, and disease course). The logistic regression was used to analyse the sex difference in dysfunctions among rehabilitation outpatients. Among 3415 rehabilitation outpatients, the mean age of participants was 45.3 years (SD:24.9), and more than half (54.0%) were male. The male patients were more likely to have cognitive impairment (OR = 1.74; 95% CI = 1.42, 2.13), speech disorders (OR = 2.00; 95% CI = 1.62, 2.48), dysphagia (OR = 1.55; 95% CI = 1.12, 2.16), and multiple dysfunctions (OR = 2.00; 95% CI = 1.57, 2.54) than female. Female patients were more likely to have motor dysfunctions (OR = 0.63; 95% CI = 0.50, 0.78). There are sex differences in dysfunctions among rehabilitation outpatients. This sex difference may provide potential clinical value for the treatment of rehabilitation patients.

The relationship between swallowing oral hesitation and cognition in frontal lobe stroke

BACKGROUND & OBJECTIVE

Oral stage dysphagia mostly caused by frontal lobe lesions. We investigated the relationship between oral hesitation and cognitive impairment after frontal lobe stroke.

METHODS

We consecutively collected 946 patients with stroke from January 2016 to December 2020. Among them, 38 patients had only frontal lobe lesions. Video fluoroscopic swallowing study (VFSS) was performed in 5 stages from water to solid food. Patients who progressed to solid food are very rare, so we focused on liquid and soft food. Diagnosis of stroke was limited to cases in which cerebral infarction or haemorrhage had been verified by magnetic resonance imaging (MRI). Cognitive impairment was evaluated by MMSE in patients with frontal lobe lesions.

RESULT

Of the total 946 patients, 35 patients with frontal lobe lesions were enrolled in the study. Of them, 22 were judged to have cognitive impairment. The oral hesitation of the liquid component was analysed, and a conclusion was drawn that the group with cognitive impairment showed significant oral hesitation than the group without cognitive impairment. On the other hand, in the case of soft food, it was found that there was no correlation between cognition and oral hesitation.

CONCLUSION

It was confirmed that oral hesitation during swallowing in patients with frontal lobe stroke had a meaningful relationship with cognition, and oral hesitation during swallowing was significantly higher in liquid swallowing rather than soft food.

Prevalence and Management of Oral Intake Restrictions in Critically Ill Patients: Insights from a Multicenter Point Prevalence Study

Oral intake restrictions due to dysphagia in the intensive care unit (ICU) can increase morbidity, mortality, and negatively impact quality of life. The current oral intake practice and clinical management strategies for addressing dysphagia in the ICU are not well-defined. This study aimed to elucidate the clinical practices surrounding oral intake restrictions due to dysphagia and its management strategies in the ICU. A multicenter, prospective, cross-sectional, 2-day point prevalence study was conducted in Japan. Relevant data on the clinical circumstances surrounding oral intake practice and the implementation of strategies to prevent dysphagia for patients admitted to the ICU on November 1, 2023, and December 1, 2023, were collected. The primary outcome was the prevalence of oral intake restrictions in patients, defined by a Functional Oral Intake Scale score of less than 7 among eligible patients for oral intake. Out of 326 participants, 187 were eligible for the final analysis after excluding 139 patients who were not eligible for oral intake, primarily due to tracheal intubation. Among those eligible, 69.0% (129/187) encountered oral intake restrictions. About 52.4% (98/187) of patients underwent swallowing screenings; 36.7% (36/98) of these were suspected of having dysphagia. Compensatory and behavioral swallowing rehabilitation were provided to 21.9% (41/187) and 10.6% (20/187) of patients, respectively, from ICU admission to the survey date. Only 27.4% (14/51) of post-extubation and 9.3% (3/32) of post-stroke patients received swallowing rehabilitation. Notably, no ICUs had dedicated speech and language therapists, and most (85.7%, 18/21) lacked established swallowing rehabilitation protocols. This 2-point prevalence survey study revealed that oral intake restrictions due to dysphagia are common in ICUs, but few patients are screened for swallowing issues or receive rehabilitation. More clinical studies are needed to develop effective protocols for identifying and managing dysphagia, including screenings and rehabilitation in the ICU.

Automatic Clinical Assessment of Swallowing Behavior and Diagnosis of Silent Aspiration Using Wireless Multimodal Wearable Electronics

Dysphagia is more common in conditions such as stroke, Parkinson's disease, and head and neck cancer. This can lead to pneumonia, choking, malnutrition, and dehydration. Currently, the diagnostic gold standard uses radiologic imaging, the videofluoroscopic swallow study (VFSS); however, it is expensive and necessitates specialized facilities and trained personnel. Although several devices attempt to address the limitations, none offer the clinical-grade quality and accuracy of the VFSS. Here, this study reports a wireless multimodal wearable system with machine learning for automatic, accurate clinical assessment of swallowing behavior and diagnosis of silent aspirations from dysphagia patients. The device includes a kirigami-structured electrode that suppresses changes in skin contact impedance caused by movements and a microphone with a gel layer that effectively blocks external noise for measuring high-quality electromyograms and swallowing sounds. The deep learning algorithm offers the classification of swallowing patterns while diagnosing silent aspirations, with an accuracy of 89.47%. The demonstration with post-stroke patients captures the system's significance in measuring multiple physiological signals in real-time for detecting swallowing disorders, validated by comparing them with the VFSS. The multimodal electronics can ensure a promising future for dysphagia healthcare and rehabilitation therapy, providing an accurate, non-invasive alternative for monitoring swallowing and aspiration events.

Dysphagia in the Aging Population

Older adults are projected to outnumber children aged under 18 years for the first time in United States history by 2034, according to Census Bureau projections. This will lead to significant increase in age-related disorders. One of the most important disorders that will increase in prevalence is dysphagia, as it leads to malnutrition, dehydration, aspiration pneumonia, and death. In this article, the physiology of dysphagia in the elderly, as well as the management options is discussed.

Improving swallowing function with thickening agents in post-stroke oropharyngeal dysphagia: a real-world experience

INTRODUCTION

Post-stroke dysphagia (PSD) is a widely prevalent and possibly life-threatening consequence that may lead to aspiration pneumonia, malnutrition, dehydration, and higher mortality risk. Recommending thickened fluids (TF) is a longstanding practice in the management of dysphagia. Augmenting liquid viscosity with a xanthan gum-based thickener benefits patients with PSD by aiding in the enhancement of bolus control, facilitating improved coordination in the swallowing mechanism, and lowering the risk of aspiration. Despite the widespread use of TF, limited high-quality evidence supports its benefits in PSD.

CASE REPORT

This manuscript presents the clinical experience with four varied cases of PSD. A comprehensive approach to management with TF decreased the risk of aspiration pneumonia and facilitated effective management of dietary recommendations both during hospitalization and after discharge (all Cases). In addition, TF maintained nutrition and hydration in patients with multiple hospital admissions (Case 2), maintained hydration in those unable to engage in swallow rehabilitation due to complex medical conditions (Cases 2, 3, and 4), and those who needed slow and longer recovery due to long-term risk of silent aspiration (Cases 2, 3, and 4). In one case (Case 4), the use of TF was extended for more than two years post-stroke with no reported incidence of chest infection.

CONCLUSION

In routine clinical practice, a comprehensive management approach with xanthan gum-based TFs reduces the risk of aspiration and aspiration pneumonia in patients with PSD while maintaining nutritional and hydration and improving swallowing function based on formal instrumental assessments. This clinical experience highlights the pivotal role of instrumental assessment, patient education, and informed decision-making to optimize outcomes with TF.

Understanding Dysphagia Care in Pakistan: A Survey of Current Speech Language Therapy Practice

Dysphagia affects individuals across all ages and has pervasive and potentially life-threatening consequences. Individuals with dysphagia are assessed and treated by speech and language therapists (SLTs), however, little attention has been paid to their practices in Pakistan. This study aimed to explore SLTs practices for dysphagia assessment, signs and symptoms observed during evaluation, and management strategies, alongside barriers and facilitators to service delivery in Pakistan. A 45-item survey was distributed to SLTs online. Responses were received from 101 participants and analyzed descriptively, and open-text responses were analyzed using content analysis. Results revealed that 65.3% SLTs worked across the lifespan, and most (79.4%) had dysphagia-related experience of five years or less. SLTs were an active workforce engaged with varying ages, disorders, and settings, yet dysphagia contributed to a small caseload percentage for most. Analyses found informal clinical exams were more frequently used than instrumental assessments. A variety of service provision facilitators were described, such as supportive teams and accessible resources, and responses about barriers revealed gaps in awareness, education, and guidance. This exploratory study presents novel and unexplored data which provides a deeper understanding of dysphagia-related care in Pakistan.

Comparison of Two Types of Electrodes for Measuring Submental Muscle Activity During Swallowing

PURPOSE

This study aimed to investigate the potential of a newly developed small electrode to accurately record muscle activity during swallowing.

MATERIAL AND METHODS

This study included 31 healthy participants. The participants underwent swallowing trials with three types of material. The recordings involved the following conditions: 1) swallowing saliva, 2) swallowing 3 mL water, and 3) swallowing 5 mL water. Two types of electrodes, a conventional electrode (CE) and a newly developed small electrode (NE), were symmetrically positioned on the skin over the suprahyoid muscle group, starting from the center. From the surface electromyography data, the swallowing duration (s), peak amplitude, and rising time (duration from swallowing onset to peak amplitude: s) were measured. Additionally, the equivalence of characteristics of the waveform of muscle activities was calculated by using the variance in both the upper and lower confidence limits in duration and rising time.

RESULTS

No significant differences in baseline, swallowing duration or rising time between the CE and NE were observed for any swallowing material. The peak amplitude was significantly higher for the NE than for the CE for all swallowing materials. The CE and NE displayed no significant difference in the equivalence of characteristics of the waveform of muscle activities for any swallowing material.

CONCLUSIONS

The gold-plated small electrodes utilized in this study indicated the ability to record the same characteristics of muscle activity as conventional electrodes. Moreover, it was able to capture the muscle activity of each muscle group with improved sensitivity in a narrow area, such as under the submandibular region, with more precision than that of conventional electrodes.

The effect of behavioral therapy on dysphagia of acute ischemic stroke patients feeding with a nasogastric tube

This prospective observational study aimed to assess the impact of behavioral therapy on dysphagia in patients with acute ischemic stroke undergoing nasogastric tube feeding. The study was conducted between June 2020 and May 2022 at the Neurological Center of Bach Mai Hospital, Vietnam, with a sample size of 230 patients divided into two groups: a normal and a behavioral therapy group. The normal therapy group received routine care and treatment based on standard protocols, while the behavioral therapy group underwent daily swallowing exercises for approximately 60 minutes. The Gugging Swallowing Screen (GUSS) was utilized to screen individuals with dysphagia, and the difference-in-differences (DID) method was adopted to estimate the effect of behavioral therapy on dysphagia patients. The study concluded that behavioral therapy improved dysphagia in patients with acute ischemic stroke undergoing nasogastric tube feeding. This study highlights the potential of behavioral therapy as an effective intervention for dysphagia rehabilitation in stroke patients.

Self-Reported Voice and Swallow Questionnaires' Alignment with Unified Parkinson's Disease Rating Scale Questions: A Preliminary Study

PURPOSE

The purpose of this manuscript was twofold: to investigate how clinical voice and swallow questionnaires align with self-reports from speech/voice and swallow domains of the Unified Parkinson's Disease Rating Scale (UPDRS), and how decline in self-reported speech/voice measures predict decline in self-reported swallowing measures.

METHODS

This observational, preliminary cross-sectional study included 15 people diagnosed with Idiopathic Parkinson's Disease. Participants completed the Voice Related Quality of Life (V-RQOL), Sydney Swallow Questionnaire (SSQ), and cognitive screening (Montreal Cognitive Assessment; MoCA) to account for cognitive impairment during self-reported speech/voice and swallow measures. They also completed the speech/voice and swallow components of the UPDRS.

RESULTS

There were significant associations between the SSQ and UPDRS question 2.3 (chewing/swallowing) (P < 0.001), but not between UPDRS question 2.1 (speech/voice) and V-RQOL. However, the MoCA was significantly and directionally associated with V-RQOL scores (P = 0.01). Finally, the V-RQOL was significantly associated with SSQ scores in a multiple regression model (P = 0.02).

CONCLUSIONS

Speech/voice and swallow-related questions from the UPDRS may be viable initial screening tools to facilitate faster and earlier laryngeal function testing. Substantially more research should be undertaken to assess how well these UPDRS question domains are indicative of underlying speech/voice or swallow dysfunction.

The relationship between dysphagia and the localisation of brain lesion in stroke: is the involvement of the pons and medulla important?

OBJECTIVES

The presence of dysphagia in stroke is associated with mortality and morbidity. The aim of this retrospective study is to present the relationship between dysphagia and the demographic characteristics of the patient, and the type and localisation of brain lesion in the acute period in stroke patients with dysphagia.

MATERIALS AND METHODS

The data of 284 patients who had stroke-related dysphagia, had a disease duration 1-3 months, had no history of swallowing dysfunction before the event, and had their brain MRI/CT reports in the hospital were included.

RESULTS

The rate of tube-dependent oral areas was higher in the lesions located in the pons and the medulla than in the lesions located in the MCA cortex, the basal ganglia, and the cerebellum (p ˂ 0.001, p = 0.032 and p = 0.011, respectively) and the percentage of those fed with NG + TPN + PEG was statistically significantly higher (p = 0.002, p = 0.032 and p = 0.011, respectively). History of pneumonia was found to be statistically significantly higher in the lesions located in the pons and the medulla than in the lesions located in the MCA cortex, ACA cortex, PCA cortex, the basal ganglia, periventricular white matter, the thalamus, the cerebellum, and the midbrain (p ˂ 0.001, p = 0.005, p = 0.023, p ˂ 0.001, p = 0.023, p = 0.001, p = 0.011 and p = 0.023, respectively).

CONCLUSION

In conclusion, although lesion localisation in the acute period in patients with dysphagia varied in terms of clinical swallowing evaluation findings, weight loss, pneumonia history, the rate of tube-dependent intake, were shown to be higher in patients who had lesions in the pons and the medulla, which is a finding that should be considered in the clinical follow-up of acute stroke patients with lesions in the pons and the medulla.

Prospective Observational Study for the Comparison of Screening Methods Including Tongue Pressure and Repetitive Saliva Swallowing With Detailed Videofluoroscopic Swallowing Study Findings in Patients With Acute Stroke

BACKGROUND

Simple, noninvasive, and repeatable screening methods are essential for assessing swallowing disorders. We focused on patients with acute stroke and aimed to assess the characteristics of swallowing screening tests, including the modified Mann Assessment of Swallowing Ability score, tongue pressure, and repetitive saliva swallowing test (RSST), compared with detailed videofluoroscopic swallowing study (VFSS) findings to contribute as a helpful resource for their comprehensive and complementary use.

METHODS AND RESULTS

We enrolled first-ever patients with acute stroke conducting simultaneous assessments, including VFSS, modified Mann Assessment of Swallowing Ability score, tongue pressure measurement, and RSST. VFSS assessed aspiration, laryngeal penetration, oral cavity residue, vallecular residue, pharyngeal residue, and swallowing reflex delay. Screening tests were compared with VFSS findings, and multiple logistic analysis determined variable importance. Cutoff values for each abnormal VFSS finding were assessed using receiver operating characteristic analyses. We evaluated 346 patients (70.5±12.6 years of age, 143 women). The modified Mann Assessment of Swallowing Ability score was significantly associated with all findings except aspiration. Tongue pressure was significantly associated with oral cavity and pharyngeal residue. The RSST was significantly associated with all findings except oral cavity residue. Receiver operating characteristic analyses revealed that the minimum cutoff value for all VFSS abnormal findings was RSST ≤2.

CONCLUSIONS

The modified Mann Assessment of Swallowing Ability is useful for broadly detecting swallowing disorders but may miss mild issues and aspiration. The RSST, with a score of ≤2, is valuable for indicating abnormal VFSS findings. Tongue pressure, especially in oral and pharyngeal residues, is useful. Combining these tests might enhance accuracy of the swallowing evaluation.

Inter-rater and Intra-rater Reliability of the Videofluoroscopic Dysphagia Scale with the Standardized Protocol

This study aimed to develop a standardized protocol for the assessment of videofluoroscopic dysphagia scale (VDS) and to demonstrate the inter-rater and intra-rater reliability of the VDS by applying the new standard protocol. A standardized protocol for the VDS was developed by dysphagia experts, including the original developer. To identify the reliability of the VDS using the protocol, 60 patients who underwent videofluoroscopic swallowing study (VFSS) for various etiologies were recruited retrospectively from three tertiary medical centers. Ten randomly selected cases were duplicated to evaluate the intra-rater reliability. Six physicians evaluated the VFSS data sets. Intraclass correlation coefficients were calculated for inter-rater and intra-rater reliability of the VDS score, and Gwet's kappa values for each VDS item were calculated. The inter-rater and intra-rater reliability of the total VDS score was 0.966 and 0.896, respectively. Notably, the evaluators' experience did not appear to have a significant impact on the reliability (physiatrists: 0.933/0.869, residents: 0.922/0.922). The reliability was consistent across different centers and dysphagia etiologies. The inter-rater and intra-rater reliability of the oral and pharyngeal sub-scores were 0.953/0.861 and 0.958/0.907, respectively. The inter-rater agreement of individual items ranged from 0.456 to 0.929, and nine items demonstrated good to very good level of agreement. Assessment of dysphagia using the VDS with the standard protocol showed excellent inter-rater and intra-rater reliabilities regardless of the evaluator's experience, VFSS equipment, and dysphagia etiologies. The VDS can be a useful assessment scale in the quantitative analysis of dysphagia based on VFSS findings.

Clinical practice patterns of speech-language pathologists for screening and identifying dysphagia

PURPOSE

To identify how speech-language pathologists (SLPs) in the United States are screening for and identifying dysphagia. To do this, we examined the approaches most often used to screen for dysphagia and the influence of contextual factors such as setting, continuing education and means of staying up to date with the most current literature on screening approaches.

METHOD

A web-based survey composed of 32 questions was developed and field tested for content, relevance and workflow. The survey was distributed online, via social media, online SLP forums and through the American Speech-Language-Hearing Association's Special Interest Group 13 (swallowing disorders). One hundred and thirty-seven clinicians from the United States completed the survey and were included for analysis using descriptive statistics and linear regression modelling to assess associations of continuing education and years practicing with screening protocols and consumption of evidence.

RESULTS

Respondents worked in a variety of settings, including acute care, skilled nursing facilities, and inpatient rehabilitation. Most respondents worked with adult populations (88%). The most common screening protocols reported were a volume-dependent water swallow test (74%), subjective patient report (66%), and trials of solids/liquids (49%). Twenty-four percent (24%) reported using a questionnaire, the Eating Assessment Tool (80%) being most common. How clinicians consume their evidence was significantly associated with the types of screening approaches used. Continuing education hours were significantly associated with dysphagia screening protocol choice (p < 0.001) and how clinicians stayed up to date with evidence (p < 0.001).

CONCLUSIONS

Results from this study provide an in-depth look at the choices clinicians are making in the field regarding how to effectively screen patients for the presence of dysphagia. Contextual factors such as evidence base consumption patterns should serve researchers to continue seeking alternative ways to share evidence with clinicians, accessibly. Associations between continuing education and protocol choice show the need for continued evidence-based and high-quality continuing education opportunities.

WHAT THIS PAPER ADDS

This study provides an in-depth look at the choices clinicians are making in the field regarding effective dysphagia screening practices. Clinician screening choices are examined with contextual factors such as evidence base consumption patterns and continuing education. This paper increases knowledge of the most used dysphagia screening practices and context for clinicians and researchers to improve use, evidence and dissemination of best practices.

The Impact of Nutritional Therapy on Gastrointestinal Motility in Older Adults

Japan is becoming a superaged society, and nutrition therapy for the elderly population is very important. Elderly individuals often have multiple diseases and are prone to malnutrition. Furthermore, functional constipation, diarrhoea, faecal incontinence, etc., may occur despite no organic abnormality of digestive tract function. Due to these disabilities, the resulting malnutrition, and the slow recovery, it is often difficult for elderly individuals to reintegrate into society. Secondary or incorrect nutritional management increases complications, decreases physical function and worsens the prognosis. Previous statistical research suggests that in-hospital mortality is significantly higher among hospitalised patients aged ≥65 years who ingest less than half of their caloric needs. Therefore, appropriate nutritional management from an early stage is essential for elderly individuals. Moreover, functional excretion disorders, dementia, and sarcopenia (muscle-wasting disease) are attracting attention as pathological conditions unique to elderly individuals, and it is essential to undergo rehabilitation early with nutritional management. Being elderly does not preclude nutritional management, and it is necessary to reconsider appropriate nutritional therapy even in the terminal stage and in advanced physical and mental illnesses. This review explores the relationship between dietary intake and FGIDs, with a focus on elderly adults.

Dysphagia and pulmonary complications in acute cerebrovascular disease: A retrospective observational study

INTRODUCTION

Dysphagia is a common post-stroke complication, which may result in serious pulmonary sequelae. Early detection of dysphagia and aspiration risk can reduce morbidity, mortality and length of hospitalization.

OBJECTIVES

This study aims to identify association between dysphagia and acute cerebrovascular disease, and evaluate the prevalence and impact of pulmonary complications on readmissions and mortality.

MATERIAL AND METHODS

Retrospective observational study based on 250 clinical records of patients with acute cerebrovascular disease: clinical history, neurological examination, imaging and Gugging Swallowing Screen in the first 48h. Patients were followed for 3 months via medical records to estimate 3-month mortality and readmissions.

RESULTS

Out of 250 clinical records analyzed, 102 (40.8%) were evaluated for dysphagia. The prevalence of dysphagia was 32.4%. The risk was higher in older patients (p<0.001), in severe stroke (p<0.001) and in the hemorrhagic subtype (p=0.008). An association was found with dysarthria and aphasia (p=0.003; p=0.017). Respiratory tract infections occurred in 14.4% of all patients (GUSS group 11.8% versus no GUSS group 16.2%), and in 75% of those with severe dysphagia (p<0.001). Mortality at 3 months was 24.2% in dysphagic patients, especially high in the severe dysphagia group (75%, p<0.001).

CONCLUSIONS

The type of cerebrovascular disease, NIHSS and GCS scores, age, dysarthria, and aphasia were significant associated factors to dysphagia. The prevalence of respiratory tract infections was higher in patients with no GUSS record, and no statistical significance was observed in related readmissions. Mortality at 3 months was superior in the severe dysphagia group.

One-Year Survival of Ischemic Stroke Patients Requiring Mechanical Ventilation

BACKGROUND

The outcome of patients with acute ischemic stroke who require mechanical ventilation has been poor. Intubation due to a reversible condition could be associated with better 1-year survival.

METHODS

All adult patients treated in Helsinki University Hospital in 2016-2020 who were admitted because of an ischemic stroke (either stroke or thrombosis seen on imaging) and needed mechanical ventilation were included in this retrospective cohort study. Data on demographics, medical history, index stroke, and indication for intubation were collected. The primary outcome was 1-year mortality. Secondary outcomes were modified Rankin Scale (mRS) score at 3 months and living arrangements at 1 year.

RESULTS

The mean age of the cohort (N = 121) was 66 ± 11 (mean ± SD) years, and the mean admission National Institutes of Health Stroke Scale score was 17 ± 10. Forty-four (36%) patients were male. The most common indication for intubation was unconsciousness (51%), followed by respiratory failure or airway compromise (28%). One-year mortality was 55%. Three-month mRS scores were available for 114 (94%) patients, with the following distribution: 0-2, 18%; 3-5, 28%; and 6 (dead), 54%. Of the 1-year survivors, 72% were living at home. In the multivariate analysis, only age over 75 years and intubation due to unconsciousness, respiratory failure, or cardiac arrest remained significantly associated with mortality.

CONCLUSIONS

The indication for intubation seems to significantly affect outcome. Functional outcome at 3 months is often poor, but a great majority of 1-year survivors are able to live at home.

Dysphagia after ischemic and hemorrhagic stroke: A propensity-matched 20-year analysis of the national inpatient sample

OBJECTIVE

Dysphagia is a common symptom of acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH), but little is known surrounding national trends of this post-stroke condition. Hence, this study aimed to identify the risk factors for dysphagia following AIS and ICH and evaluate in-hospital outcomes in these patients.

METHODS

The 2000-2019 Nationwide Inpatient Sample was queried for patients admitted with AIS (ICD9 433, 43401, 43411, 43491, ICD-10 I63) and ICH (ICD9 431, 432.9, ICD-10 I61, I62.9). Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 were used in multivariable regression to generate adjusted odds ratios (AOR)/β-coefficients for the presence of dysphagia on outcomes.

RESULTS

Of 10,415,286 patients with AIS, 956,662 (9.2%) had in-hospital dysphagia. Total of 2,000,868 patients with ICH were identified; 203,511 (10.2%) had in-hospital dysphagia. Patients with dysphagia after AIS were less likely to experience in-hospital mortality (OR 0.61;95%CI: 0.60-0.63) or be discharged home (AOR 0.51;95%CI: 0.51-0.52), had increased length of stay (Beta-coefficient = 0.43 days; 95%CI: 0.36-0.50), and had increased hospital charges ($14411.96;95%CI: 13565.68-15257.44) (all p < 0.001). Patients with dysphagia after ICH were less likely to experience in-hospital mortality (AOR 0.39;95%CI: 0.37-0.4), less likely to be discharged home (AOR 0.59,95%CI:0.57-0.61), have longer hospital stay (Beta-coefficient = 1.99 days;95%CI: 1.78-2.21), and increased hospital charges ($28251.93; 95%CI: $25594.57-30909.28)(all p < 0.001).

CONCLUSION

This is the first study to report on national trends in patients with dysphagia after AIS and ICH. These patients had longer hospital LOS, worse functional outcomes at discharge, and higher hospital costs.

The Timed Water Swallow Test (TWST): Normative data on swallowing capacity for healthy people aged 60 years and older

PURPOSE

To provide normative data on swallowing capacity (mL/s) in people older than 60 years using the Timed Water Swallow Test (TWST), stratified by sex. Intra- and inter-rater reliability for swallowing time in TWST was further investigated.

METHOD

A total of 165 participants, aged 60 years and above, were included in the study. The time taken to consume 150 mL of tap water and the swallowing capacity (mL/s) was observed in a clinical context using the TWST. Video recordings of the performances were collected for 118 of the 165 participants for inter-rater reliability testing, of which a random set of 25 performances were assessed for intra-rater reliability. Analysis of the agreement between TWST rated by an in-person clinician and rated from a video recording was further evaluated.

RESULT

There were significant age and sex effects observed for swallowing capacity. The average reduction in swallowing capacity in the investigated age range (60-92 years) was 8.8 and 7.3 mL/s, for women and men respectively. The results showed high inter-and intra-rater reliability and agreement between the clinical assessment and the video recording.

CONCLUSION

The presented measurements indicate a clear effect of age on swallowing capacity and that women may be expected to have lower capacity scores than men when tested using TWST. The provided norms can be used as reference points in the clinical identification of people at risk of dysphagia in the older population.

Clinical Predictors of Dysphagia Recovery After Stroke: A Systematic Review

Oropharyngeal dysphagia is common post-stroke and can have serious consequences for patients. Understanding dysphagia recovery is critically important to inform prognostication and support patients and professionals with care planning. This systematic review was undertaken to identify clinical predictors of dysphagia recovery post-stroke. Online databases (EMBASE, Scopus, Web of Science, PubMed, CINAHL, and Cochrane) were searched for studies reporting longitudinal swallowing recovery in adults post-stroke. Dysphagia recovery was defined as improvement measured on a clinical swallowing scale or upgrade in oral and/or enteral feeding status by the end of the follow-up period. The search strategy returned 6598 studies from which 87 studies went through full-text screening, and 19 studies were included that met the eligibility criteria. Age, airway compromise identified on instrumental assessment, dysphagia severity, bilateral lesions, and stroke severity were identified as predictors of persistent dysphagia and negative recovery in multiple logistic regression analysis. The available literature was predominated by retrospective data, and comparison of outcomes was limited by methodological differences across the studies in terms of the choice of assessment, measure of recovery, and period of follow-up. Future prospective research is warranted with increased representation of haemorrhagic strokes and uniform use of standardized scales of swallowing function.

Spontaneous Swallowing Frequency in Post-Stroke Patients with and Without Oropharyngeal Dysphagia: An Observational Study

Oropharyngeal dysphagia (OD) is a frequent complication after stroke (PSOD) that increases morbidity and mortality. Early detection of PSOD is essential to reduce morbidity and mortality in patients with acute stroke. In recent years, an association between reduced spontaneous swallowing frequency (SSF) and OD has been described. Likewise, the reduction of saliva substance P (SP) concentration has been associated with an increased risk of aspiration and a decrease in SSF. In this study we aimed to compare SSF, salivary SP concentration, hydration and nutritional status in post-stroke (PS) patients with and without OD. We included 45 acute PS patients (4.98 ± 2.80 days from stroke onset, 62.22% men, 71.78 ± 13.46 year). The Volume-Viscosity Swallowing Test (V-VST) was performed for clinical diagnosis of OD. SSF/minute was assessed through 10-min neurophysiological surface recordings including suprahyoid-electromyography and cricothyroid-accelerometry. Saliva samples were collected with a Salivette® to determine SP by ELISA. Hydration status was assessed by bioimpedance. Nutritional status was evaluated by Mini Nutritional Assessment Short Form (MNA-sf) and blood analysis. Twenty-seven PS patients (60%) had OD; 19 (40%), impaired safety of swallow. SSF was significantly reduced in PSOD, 0.23 ± 0.18 and PSOD with impaired safety, 0.22 ± 0.18 vs 0.48 ± 0.29 swallows/minute in PS without OD (PSnOD); (both p < 0.005). Nutritional risk was observed in 62.92% PSOD vs 11.11% PSnOD (p = 0.007) and visceral protein markers were also significantly reduced in PSOD (p < 0.05). Bioimpedance showed intracellular dehydration in 37.50% PSOD vs none in PSnOD. There were no differences for saliva SP concentrations. SSF is significantly reduced in PSOD in comparison with PSnOD. Acute PSOD patients present poor nutritional status, hydropenia, and high risk for respiratory complications.

Effect of Oral Apraxia on Dysphagia in Patients with Subacute Stroke

Aim of this study was to investigate the effect of post-stroke oral apraxia on dysphagia in patients with subacute stroke. We retrospectively analyzed the clinical data of 130 supratentorial stroke patients from January 2015 to February 2021 who underwent a formal limb and oral apraxia test and videofluoroscopic swallowing study (VFSS), and we compared the patients in two groups: the apraxia and non-apraxia (oral apraxia score > 45 and ≤ 45 points, respectively). All the patients participated in the standardized testing battery. The test variables were videofluoroscopic dysphagia scale (VDS), oral transit time (OTT), pharyngeal delay time (PDT), pharyngeal transit time, and penetration-aspiration scale (PAS); we conducted multivariable regression analysis with those parameters to confirm the significance of oral apraxia as a clinical determinant of post-stroke dysphagia. The mean oral apraxia scores were 38.4 and 47.6 points in the apraxia and non-apraxia groups, respectively (p < 0.001). The apraxia group had a higher proportion of delayed OTT for the 2-mL-thick liquid than the non-apraxia group (17.6% and 4.2%, respectively; p = 0.011). Oral apraxia was a significant determinant of VDS (p < 0.001), delayed OTT of 2-mL-thick liquids (p = 0.028), delayed PDT of cup drinking for thin liquid (p = 0.044), and PAS scores (p = 0.003). The presence of oral apraxia was significantly associated with dysphagia, especially with the VFSS parameters of the oral phase (thick liquid), pharyngeal phase (cup drinking for thin liquid) of swallowing, and increased risk of aspiration in subacute stroke patients. Thus, a formal assessment of oral apraxia is needed for stroke patients with dysphagia.

Dosage consideration for transcranial direct current stimulation in post-stroke dysphagia: A systematic review and network meta-analysis

Objective

This systematic review and network meta-analysis sought to determine the efficacy of different intensities of transcranial direct current stimulation (tDCS) in patients with dysphagia after stroke to improve swallowing function.

Methods

Randomized-controlled trials (RCTs) of tDCS in post-stroke dysphagia were searched from Pubmed, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Service System (SinoMed), Wanfang database, and Chinese Scientific Journals Database (VIP) from databases' inception to June 22, 2022. Article screening, data extraction, and article quality evaluation were completed by 2 independent researchers. Network meta-analysis was performed using Stata.

Results

A final total of 20 studies involving 838 stroke patients were included. The included control interventions were sham tDCS and conventional therapy (CT). Network meta-analysis showed that 20 min of 1.2, 1.4, 1.5, 1.6, and 2 mA anodal tDCS and 30 min of 2 mA anodal tDCS significantly improved post-stroke dysphagia compared with CT (all P < 0.05). In addition, 20 min of 1, 1.4, 1.6, and 2 mA anodal tDCS also significantly improved post-stroke dysphagia compared with sham tDCS (all P < 0.05). Our results demonstrated that 20 min of stimulation at 1.4 mA was the optimal parameters for anodal tDCS and exhibited superior efficacy to CT [SMD = 1.08, 95% CI (0.46, 1.69)] and sham tDCS [SMD = 1.45, 95% CI (0.54, 2.36)].

Conclusion

Different durations and intensities of anodal tDCS are effective in improving post-stroke dysphagia. However, 20 min of tDCS at 1.4 mA may be the optimal regimen.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier CRD42022342506.

Effects of chin tuck against resistance exercise on post-stroke dysphagia rehabilitation: A systematic review and meta-analysis

Background

Chin tuck against resistance (CTAR) exercise was introduced to substitute for the commonly used Shaker exercise for dysphagia rehabilitation. The effects of CTAR exercise in stroke survivors needs to be validated.

Objective

To investigate the effects of Chin tuck against resistance (CTAR) exercise on the swallowing function and psychological condition in stroke survivors compared to no exercise intervention and the Shaker exercise.

Materials and methods

The Cochrane Library, PubMed, Web of Science, EMBASE, CINAHL and four Chinese databases were searched for randomized controlled trails (RCTs) and quasi-RCTs from inception to February 2022.

Results

After screened and assessed the methodological quality of the studies, nine studies with 548 stroke survivors were included in the systematic review. 8 studies were included in the meta-analysis using RevMan 5.4 software. The mean difference (MD) or standardized mean difference (SMD) with 95% confidence intervals (CIs) were calculated. The results revealed that CTAR exercise is effective in improving swallowing safety (MD, -1.43; 95% CI, -1.81 to -1.06; P < 0.0001) and oral intake ability (SMD, -1.82; 95% CI, -3.28 to -0.35; P = 0.01) compared with no exercise intervention, CTAR exercise is superior to Shaker exercise in improving swallowing safety (MD, -0.49; 95% CI, -0.83 to -0.16; P = 0.004). The psychological condition in CTAR group is significant better than the control group (MD, -5.72; 95% CI, -7.39 to -4.05; P < 0.00001) and Shaker group (MD, -2.20; 95% CI, -3.77 to -0.64; P = 0.006).

Conclusions

Our findings support CTAR exercise as a superior therapeutic exercise for post-stroke dysphagia rehabilitation than Shaker exercise. More high-qualities RCTs from larger multicenter are needed to analysis the effects of CTAR exercise in patients with different type and phase of stroke and explore the optimal training dose.

The Effects of Adding Di-Tan Decoction (DTD) and/or Electroacupuncture (EA) to Standard Swallowing Rehabilitation Training (SRT) for Improving Poststroke Dysphagia (PSD): A Pilot, Single-Centred, Randomized Trial

OBJECTIVES

To evaluate the effect of adding Di-tan decoction (DTD) and/or electroacupuncture (EA) to standard swallowing rehabilitation training (SRT) on improving PSD.

METHODS

In total, 80 PSD patients were enrolled and randomly assigned to the DTD, EA, DTD + EA or control group at a 1 : 1 : 1 : 1 ratio. All patients received basic treatment and standard SRT. The DTD group received DTD orally, the EA group received EA, the DTD + EA group received both DTD and EA simultaneously, and the control group received only basic treatment and standard SRT. The interventions lasted for 4 weeks. The outcome measurements included the Standardized Swallowing Assessment (SSA) and Swallowing-Quality of Life (SWAL-QOL), performed and scored from baseline to 2, 4, and 6 weeks after intervention, and the Videofluoroscopic Dysphagia Scale (VDS), scored at baseline and 4 weeks after intervention. Scores were compared over time by repeated-measures analysis of variance (ANOVA) among all groups. Interactions between interventions were explored using factorial design analysis.

RESULTS

(1) The effective rates (ERs) for PSD treatment were higher in the DTD, EA and DTD + EA groups than in the control group (all P < 0.05). The ER was higher in the DTD + EA group than in the DTD or EA group (both P < 0.05). (2) There were significant group effects, time effects and interactions for the SSA and SWAL-QOL scores (all P < 0.05). All groups showed decreasing trends in SSA scores and increasing trends in SWAL-QOL scores over time from baseline to 6 weeks after intervention (all P < 0.01). (3) Factorial design analysis for ΔVDS showed that there was a significant main effect for DTD intervention (F = 11.877, P < 0.01) and for EA intervention (F = 29.357, P < 0.01). However, there was no significant interaction effect between DTD and EA (F = 0.133, P = 0.717). Multiple comparisons showed that the DTD, EA and DTD + EA groups all had higher ΔVDS values than the control group (P < 0.05). The DTD + EA group had a higher ΔVDS than the DTD or EA group (both P < 0.05). (4) Most adverse reactions were mild and transient.

CONCLUSIONS

Adding DTD or EA to SRT can better improve PSD than applying SRT alone. Adding DTD and EA simultaneously can accelerate and amplify the recovery of swallowing function versus DTD or EA alone, and both are effective and safe treatments, alone or jointly, for PSD and are a powerful supplement to routine treatments.

Fiberoptic endoscopic validation of a clinical screening test of swallowing function in critically ill patients performed within 24 h after extubation

BACKGROUND

A bedside screening tool of swallowing dysfunction (SD) (BSSD) after extubation would be useful to identify patients who are at risk of SD. We aimed to evaluate the accuracy of our BSSD in comparison with fiberoptic endoscopic evaluation of swallowing (FEES) in critically ill patients after extubation.

METHODS

We conducted a 1-year prospective monocentric study to evaluate the accuracy of our BSSD to diagnose SD following endotracheal intubation in comparison with FEES (gold standard). Patients intubated for longer than 48 h were included. Both tests were assessed within 24 h after extubation. Primary endpoint was the accuracy of the BSSD. Secondary endpoint was to assess risk factors of SD.

RESULTS

Seventy-nine patients were included in the study. Thirty-three patients (42%) presented with a SD. The BSSD showed a sensitivity of 88% (95% CI 0.72-0.97) and a specificity of 91% (95% CI 0.79-0.98), a positive predictive value of 88% (95% CI 0.72-0.97) and a negative predictive value of 91% (95% CI 0.79-0.97). The AUC reached 0.83 (95% CI 0.74-0.92).

CONCLUSION

Our study describes an accurate clinical screening tool to detect SD after extubation in critically ill patients. Screening-positive cases should be confirmed by instrumental tests, ideally using FEES.

The Incidence of Aphasia, Cognitive Deficits, Apraxia, Dysarthria, and Dysphagia in Acute Post Stroke Persian Speaking Adults

Stroke is a major cause of serious disabilities in adults. While communication deficits post stroke are prevalent and disabling, early detection of them is important during acute phase. There is limited data published on the incidence of communication disorders in Persian speaking adults following post stroke to our knowledge. The present study aims to determine the incidence and associated factors of aphasia, cognitive deficits, motor speech disorders (apraxia and dysarthria) as well as dysphagia following acute post stroke in Persian speaking adults. 100 stroke patients were assessed using P-WAB, MMSE, Oral Apraxia test, Informal Dysarthria assessment, and MASA. The data was collected from 2 hospitals in Tehran using convenient sampling for the duration of 1 year. Based on our findings, the incidence of aphasia, cognitive deficits, oral apraxia, dysarthria, and dysphagia was in respectively 61.8%, 76%, 30%, 61%, and 39% of stroke patients during the acute phase. Patients with aphasia were significantly older (mean age, 59.29 vs. 64.95), and had fewer education years (9.21 vs. 5.45) compared to individuals without aphasia (p < .05). Co-occurrence of aphasia and dysarthria, dysphasia, cognitive deficits, and apraxia was in respectively 40%, 31%, 55%, and 25%. Due to the high incidence of neurogenic communication disorders and dysphagia during the acute post stroke, especially in the elderly and the less educated patients, prompt and rapid detection of these deficits and rehabilitation is essential to ameliorate patients' quality of life and social participation, and reduce the comorbidities risk.

The Effect of Sensory Level Versus Motor Level Electrical Stimulation of Pharyngeal Muscles in Acute Stroke Patients with Dysphagia: A Randomized Trial

Dysphagia is a serious cause of morbidity and mortality in stroke survivors. Electrical stimulation is often included as part of the treatment plan for dysphagia and can be applied at a sensory or motor level intensity. However, evidence to support these different modes of stimulation is lacking. This study compared the effectiveness of sensory and motor level stimulation on post-stroke dysphagia. This is a randomized trial conducted in an inpatient rehabilitation facility. Thirty-one participants who had dysphagia caused by stroke within 6 months prior to enrolment were included. Participants were excluded if they had a contraindication for electrical stimulation, previous stroke, psychiatric disorder, contraindications for modified barium swallow study (MBSS), or pre-morbid dysphagia. Each patient received ten sessions that included 45 min of anterior neck sensory or motor level electrical stimulation in addition to traditional dysphagia therapy. Motor stimulation was administered at an intensity sufficient to produce muscle contractions. Sensory stimulation was defined as the threshold at which the patient feels a tingling sensation on their skin. Swallow functional assessment measure (FAM), dysphagia outcome severity scale (DOSS), national outcome measurement system (NOMS), penetration aspiration scale (PAS), diet change, and the swallowing quality of life questionnaire (SWAL-QOL). Clinical outcomes were analyzed using a Wilcoxon signed-rank test, Mann–Whitney U test, RM ANOVA, or chi-square analysis. There was no significant difference in age, length of stay, or initial swallow FAM between groups. Patients in the sensory group showed significant improvement on swallow FAM, DOSS, and NOMS, while those in the motor group did not (Sensory: Swallow FAM (S = 48, p = 0.01), DOSS (S = 49.5, p = 0.001), NOMS (S = 52.5, p = 0.006); Motor: Swallow FAM (S = 20.5, p = 0.2), DOSS (S = 21, p = 0.05), NOMS (S = 29.5, p = 0.2)). When the groups were combined, there was statistically significant improvement on all measures except the PAS (Swallow FAM (S = 138.5, p = 0.003), DOSS (S = 134.5, p < 0.001), NOMS (S = 164, p = 0.0004)). When comparing motor to sensory NMES, there was no significant difference between groups for Swallow FAM (p = .12), DOSS (p = 0.52), or NOMS (p = 0.41). There was no significant difference in diet change for solid food or liquids among the groups, although 50% more participants in the sensory group saw improvement in diet. This study supports the use of electrical stimulation as part of the treatment plan for post-stroke dysphagia. Sensory-level stimulation was associated with greater improvement on outcome measures compared to motor level stimulation.

Research progress on transcranial magnetic stimulation for post-stroke dysphagia

Dysphagia is one of the most common manifestations of stroke, which can affect as many as 50–81% of acute stroke patients. Despite the development of diverse treatment approaches, the precise mechanisms underlying therapeutic efficacy remain controversial. Earlier studies have revealed that the onset of dysphagia is associated with neurological damage. Neuroplasticity-based transcranial magnetic stimulation (TMS), a recently introduced technique, is widely used in the treatment of post-stroke dysphagia (PSD) by increasing changes in neurological pathways through synaptogenesis, reorganization, network strengthening, and inhibition. The main objective of this review is to discuss the effectiveness, mechanisms, potential limitations, and prospects of TMS for clinical application in PSD rehabilitation, with a view to provide a reference for future research and clinical practice.

High-Frequency Cerebellar rTMS Improves the Swallowing Function of Patients with Dysphagia after Brainstem Stroke

Objective

To explore the efficacy of high-frequency repetitive transcranial magnetic stimulation (rTMS) of the swallowing motor area of the cerebellum in patients with dysphagia after brainstem stroke.

Methods

A total of 36 patients with dysphagia after brainstem stroke were recruited and divided into 3 groups. Before stimulation, single-pulse transcranial magnetic stimulation (TMS) was used to determine the swallowing dominant cerebellar hemisphere and the representation of the mylohyoid muscle. The three groups of patients received bilateral cerebellar sham stimulation, dominant cerebellar rTMS + contralateral sham stimulation, or bilateral cerebellar rTMS. The stimulus plan for each side was 10 Hz, 80% resting movement threshold (rMT), 250 pulses, 1 s per stimulus, and 9 s intervals. Sham rTMS was performed with the coil held at 90° to the scalp. The changes in the motor evoked potential (MEP) amplitude and the clinical swallowing function scales of the patients after stimulation were compared among the three groups.

Results

34 patients were finally included for statistical analysis. The scores of penetration aspiration scale (PAS) and functional dysphagia scale (FDS) of the patients after 2 weeks of rTMS in the unilateral stimulation group and bilateral stimulation group were better than that in the sham stimulation group, and there was no significant difference between the two groups. The increase in the MEP amplitude of the cerebral hemisphere in the bilateral stimulation group was higher than that in the other two groups, and the increase in the MEP amplitude in the unilateral stimulation group was higher than that in sham stimulation group. There was no correlation between the improvement in patients' clinical swallowing function (PAS scores and FDS scores) and the increase in MEP amplitude in either the unilateral stimulation group or the bilateral stimulation group.

Conclusion

High-frequency rTMS in the cerebellum can improve swallowing function in PSD patients and increase the excitability of the representation of swallowing in the bilateral cerebral hemispheres. Compared with unilateral cerebellar rTMS, bilateral stimulation increased the excitability of the cerebral swallowing cortex more significantly, but there was no significant difference in clinical swallowing function.

Profiles of Swallowing Impairment in a Cohort of Patients With Reduced Tongue Strength Within 3 Months of Cerebral Ischemic Stroke

PURPOSE

Patients with poststroke dysphagia may experience inefficient bolus clearance or inadequate airway protection. Following a stroke, impairments in lingual pressure generation capacity are thought to contribute to oropharyngeal dysphagia. The goal of our study was to determine whether similar profiles of swallowing impairment would be seen across a cohort of patients with reduced tongue strength within 3 months after cerebral ischemic stroke.

METHOD

The sample comprised six adults with reduced tongue strength (i.e., maximum anterior isometric pressure < 40 kPa). Participants underwent a videofluoroscopy according to a standard protocol. Post hoc blinded ratings were completed using the Analysis of Swallowing Physiology: Events, Kinematics and Timing Method and coded as "typical" versus "atypical" (i.e., within vs. outside the healthy interquartile range) in comparison to published reference values.

RESULTS

The videofluoroscopies suggested that having reduced tongue strength did not translate into a common profile. Of the six participants, two showed Penetration-Aspiration Scale (PAS) scores of ≥ 3 on thin liquids, associated with incomplete laryngeal vestibule closure (LVC). Another two participants displayed PAS scores of 2 (transient penetration), but these were not associated with incomplete LVC. Pharyngeal residue, above the healthy 75th percentile, was seen for three participants. Five participants presented with atypical reductions in hyoid XY peak position.

CONCLUSIONS

In this cohort of adults within 3 months of cerebral ischemic stroke, reductions in tongue strength presented alongside a variety of changes in swallowing physiology. There was no straightforward relationship linking reduced tongue strength to particular patterns of impairment on videofluoroscopy.

Altered Brain Function Activity in Patients With Dysphagia After Cerebral Infarction: A Resting-State Functional Magnetic Resonance Imaging Study

Objective

Dysphagia after cerebral infarction (DYS) has been detected in several brain regions through resting-state functional magnetic resonance imaging (rs-fMRI). In this study, we used two rs-fMRI measures to investigate the changes in brain function activity in DYS and their correlations with dysphagia severity.

Method

In this study, a total of 22 patients with DYS were compared with 30 patients without dysphagia (non-DYS) and matched for baseline characteristics. Then, rs-fMRI scans were performed in both groups, and regional homogeneity (ReHo) and fractional amplitude of low-frequency fluctuation (fALFF) values were calculated in both groups. The two-sample t-test was used to compare ReHo and fALFF between the groups. Pearson's correlation analysis was used to determine the correlations between the ReHo and fALFF of the abnormal brain regions and the scores of the Functional Oral Intake Scale (FOIS), the Standardized Bedside Swallowing Assessment (SSA), the Videofluoroscopic Swallowing Study (VFSS), and the Penetration-Aspiration Scale (PAS).

Results

Compared with the non-DYS group, the DYS group showed decreased ReHo values in the left thalamus, the left parietal lobe, and the right temporal lobe and significantly decreased fALFF values in the right middle temporal gyrus and the inferior parietal lobule. In the DYS group, the ReHo of the right temporal lobe was positively correlated with the SSA score and the PAS score (r = 0.704, p < 0.001 and r = 0.707, p < 0.001, respectively) but negatively correlated with the VFSS score (r = −0.741, p < 0.001). The ReHo of the left parietal lobe was positively correlated with SSA and PAS (r = 0.621, p = 0.002 and r = 0.682, p < 0.001, respectively) but negatively correlated with VFSS (r = −0.679, p = 0.001).

Conclusion

The changes in the brain function activity of these regions are related to dysphagia severity. The DYS group with high ReHo values in the right temporal and left parietal lobes had severe dysphagia.

The Hydration Status of Adult Patients with Oropharyngeal Dysphagia and the Effect of Thickened Fluid Therapy on Fluid Intake and Hydration: Results of Two Parallel Systematic and Scoping Reviews

BACKGROUND

The effect of oropharyngeal dysphagia (OD) and thickened fluid (TF) therapy on hydration status has not been well defined in the literature. We aimed to assess the hydration status in patients with OD and the effect TF therapy has on it.

METHODS

Two literature reviews following PRISMA methodology (each one including a systematic and a scoping review) were performed: (R1) hydration status in adult patients with OD; (R2) effect of TF therapy on fluid intake and dehydration. Narrative and descriptive methods summarized both reviews. Quality assessment was assessed by Joanna Briggs Institute tools and GRADE.

RESULTS

(R1) Five out of twenty-two studies using analytical parameters or bioimpedance showed poorer hydration status among OD and 19-100% prevalence of dehydration; (R2) two high quality studies (total of 724 participants) showed positive effects of TF on hydration status. Among the articles included, nine out of ten studies that evaluated fluid intake reported a reduced TF intake below basal water requirements.

CONCLUSIONS

Dehydration is a highly prevalent complication in OD. There is scientific evidence on the positive effect of TF therapy on the hydration status of patients with OD. However, strict monitoring of fluid volume intake is essential due to the low consumption of TF in these patients.

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.

Effects of pharmacological agents for neurogenic oropharyngeal dysphagia: A systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to evaluate the effects of pharmacological agents for neurogenic oropharyngeal dysphagia based on evidence from randomized controlled trials (RCTs).

METHODS

Electronic databases were systematically searched between January 1970 and March 2021. Two reviewers independently extracted and synthesized the data. The outcome measure was changed in (any) relevant clinical swallowing-related characteristics.

KEY RESULTS

Data from 2186 dysphagic patients were collected from 14 RCT studies across a range of pharmacotherapies. The pooled effect size of transient receptor potential (TRP) channel agonists was large compared to placebo interventions (SMD[95%CI] =1.27[0.74,1.80], p < 0.001; I2  = 79%). Data were limited for other pharmacological agents and the overall pooled effect size of these agents was non-significant (SMD [95% CI] =0.25 [-0.24, 0.73]; p = 0.31; I2  = 85%). When analyzed separately, large effect sizes were observed with Nifedipine (SMD[95%CI] =1.13[0.09,2.18]; p = 0.03) and Metoclopramide (SMD[95%CI] =1.68[1.08,2.27]; p < 0.001). By contrast, the effects of angiotensin-converting enzyme (ACE) inhibitors (SMD[95%CI] = -0.67[-2.32,0.99]; p = 0.43; I2  = 61%), Physostigmine (SMD[95%CI] = -0.05[-1.03,0.93]; p = 0.92) and Glyceryl Trinitrate (GTN) (SMD [95% CI] = -0.01 [-0.11, 0.08]; p = 0.78) were non-significant. Within stroke patients, subgroup analysis showed that TRP channel agonists had a moderate pooled effect size (SMD[95%CI] =0.74[0.10,1.39]; p = 0.02; I2  = 82%) whereas the effects of other agents were non-significant (SMD[95%CI] =0.40[-0.04,0.84]; p = 0.07; I2  = 87%).

CONCLUSIONS & INFERENCES

Our results showed that TRP channel agonists, Nifedipine and Metoclopromide may be beneficial for neurogenic dysphagic patients. Large scale, multicenter clinical trials are warranted to fully explore their therapeutic effects on swallowing.

Transesophageal echocardiography and risk of respiratory failure in patients who had ischemic stroke or transient ischemic attack: an IDEAL phase 4 study

Objective

Transesophageal echocardiography (TEE) is sometimes used to search for cardioembolic sources after ischemic stroke or transient ischemic attack (TIA). TEE visualizes some sources better than transthoracic echocardiography, but TEE is invasive and may cause aspiration. Few data exist on the risk of respiratory complications after TEE in patients who had stroke or TIA. Our objective was to determine whether TEE was associated with increased risk of respiratory failure in patients who had ischemic stroke or TIA.

Design

This is a retrospective cohort study using administrative data from inpatient and outpatient insurance claims collected by the US federal government’s Centers for Medicare and Medicaid Services.

Setting

Hospitals and outpatient clinics throughout the USA.

Participants

99 081 patients ≥65 years old hospitalized for out-of-hospital ischemic stroke or TIA, defined by validated International Classification of Disease-9/10 diagnosis codes and present-on-admission codes, using claims data from 2008 to 2018 in a random 5% sample of Medicare beneficiaries.

Main outcome measures

Acute respiratory failure, defined as endotracheal intubation and/or mechanical ventilation, starting on the first day after admission through 28 days afterward.

Results

Of 99 081 patients included in this analysis, 73 733 (74.4%) had an ischemic stroke and 25 348 (25.6%) a TIA. TEE was performed in 4677 (4.7%) patients and intubation and/or mechanical ventilation in 1403 (1.4%) patients. The 28-day cumulative risk of respiratory failure after TEE (1.4%; 95% CI 0.8% to 2.7%) was similar to that seen in those without TEE (1.4%; 95% CI 1.4% to 1.5%) (p=0.84). After adjustment for age, sex, race, Charlson comorbidities, diagnosis of stroke versus TIA, intravenous thrombolysis, and mechanical thrombectomy, TEE was not associated with an increased risk of respiratory failure (HR, 0.9; 95% CI 0.6 to 1.2).

Conclusions

In a cohort of older patients who had ischemic stroke or TIA, TEE was not associated with an increased risk of subsequent respiratory failure.

Predictive value of the videofluoroscopic swallowing study for long-term mortality in patients with subacute stroke

To investigate the usefulness of the videofluoroscopic swallowing study (VFSS) for subacute stroke in predicting long-term all-cause mortality, including not only simple parameters obtained from VFSS results, but also recommended dietary type as an integrated parameter.This was a retrospective study of patients with subacute (<1 month) stroke at a university hospital between February 2014 and September 2019. The independent risk factors were investigated using stepwise Cox regression analysis, which increased the all-cause mortality of patients with stroke among VFSS parameters.A total of 242 patients with subacute stroke were enrolled. The significant mortality-associated factors were age, history of cancer, recommended dietary type (modified dysphagia diet; adjusted hazard ratio [HR], 6.971; P = .014; tube diet, adjusted HR: 10.169; P = .019), and Modified Barthel Index. In the subgroup survival analysis of the modified dysphagia diet group (n = 173), the parameters for fluid penetration (adjusted HR: 1.911; 95% confidence interval, 1.086-3.363; P = .025) and fluid aspiration (adjusted HR: 2.236; 95% confidence interval, 1.274-3.927; P = .005) were significantly associated with mortality.The recommended dietary type determined after VFSS in subacute stroke was a significant risk factor for all-cause mortality as an integrated parameter for dysphagia. Among the VFSS parameters, fluid penetration and aspiration were important risk factors for all-cause mortality in patients with moderate dysphagia after stroke. Therefore, it is important to classify the degree of dysphagia by performing the VFSS test in the subacute period of stroke and to determine the appropriate diet and rehabilitation intervention for mortality-related prognosis.

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.