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Church L, Spahr A, Marschner S, Wallace J, Chow C, King S. Evaluating the impact of oral hygiene instruction and digital oral health education within cardiac rehabilitation clinics: A protocol for a novel, dual centre, parallel randomised controlled trial. PLoS One 2024; 19:e0306882. [PMID: 38990852 PMCID: PMC11239009 DOI: 10.1371/journal.pone.0306882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 06/24/2024] [Indexed: 07/13/2024] Open
Abstract
INTRODUCTION Diseases of the periodontal tissues including gingivitis and periodontitis can affect up to 90% and 50% of the population respectively. These conditions are multifactorial inflammatory conditions involving a dysbiotic biofilm that, if left untreated, can lead to the destruction of the supporting structures of the teeth and have significant systemic implications, specifically on cardiovascular health. The elevation of inflammatory markers, particularly high-sensitive C-reactive protein (hsCRP), are strongly associated with an increased risk of atherosclerosis, a key risk factor for cardiovascular disease (CVD). HsCRP as well as other inflammatory markers can be detected in blood samples as early as 21 days after ceasing toothbrushing, due to the immune response to stagnant oral biofilm. The most effective way to ensure oral biofilm cannot remain on oral tissues, thus preventing periodontitis and reducing inflammatory CVD risk, is with good oral hygiene. The primary aim of this study is to assess whether individualised oral hygiene instruction (OHI) partnered with a digital oral health education (DOHE) package can improve the oral health of patients living with CVD. METHODS AND ANALYSIS A total of 165 participants will be recruited from the Westmead and Blacktown Mt Druitt cardiac rehabilitation out-patient clinics into this dual centre, single blind, parallel design, randomised controlled trial. A baseline oral health clinical examination will be completed, followed by a self-report questionnaire before they are randomised in a 1:1:1 ratio into one of 3 arms as follows: individualised OHI partnered with DOHE (Group A), (Group B) DOHE only (Group B), and control/usual care (no oral health education) (Group C). Groups will have their intervention repeated at the 6-week follow-up. After completing the 12-week follow-up, Group B and Group C will receive tailored OHI. Group C will also receive the DOHE package. The primary outcome is the change in approximal plaque index score between baseline and 6-week follow up. ETHICS AND DISSEMINATION The study has been approved by the Western Sydney Local Health District Human Ethics Committee 2023/ETH00516. Results will be published in peer-reviewed journals and presented at conferences. TRIAL REGISTRATION NUMBER ACTRN12623000449639p ANZCTR: https://www.anzctr.org.au/.
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Affiliation(s)
- Lauren Church
- The University of Sydney Dental School, The University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, The University of Sydney, Westmead, New South Wales, Australia
| | - Axel Spahr
- The University of Sydney Dental School, The University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, The University of Sydney, Westmead, New South Wales, Australia
| | - Simone Marschner
- Westmead Applied Research Centre, The University of Sydney, Westmead, New South Wales, Australia
| | - Janet Wallace
- School of Health Sciences, Oral Health, The University of Newcastle, Ourimbah, New South Wales, Australia
| | - Clara Chow
- Westmead Applied Research Centre, The University of Sydney, Westmead, New South Wales, Australia
- The University of Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Shalinie King
- The University of Sydney Dental School, The University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, The University of Sydney, Westmead, New South Wales, Australia
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Church LA, Robins L, Xu F, Qin L, Tran A, Wallace JP, King S. Oral health education strategies for patients living with cardiovascular disease within hospital settings: a scoping review. Front Public Health 2024; 12:1389853. [PMID: 38962771 PMCID: PMC11220159 DOI: 10.3389/fpubh.2024.1389853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 06/07/2024] [Indexed: 07/05/2024] Open
Abstract
Objective To identify and describe the impact of current oral health education programmes provided to patients in cardiology hospital wards and outpatient clinics. Methods This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews statement. Searches were conducted using electronic databases: Cochrane, Medline, and Scopus, as well as grey literature searching. Results Three eligible studies were identified. All included studies reported generalised poor oral health in their participants at baseline, with significant improvement at follow-up. They all reported significant reductions in plaque deposits and gingival bleeding. One study reported significantly less bacteria on participant tongues, as well as fewer days with post-operative atrial fibrillation in the intervention group. Furthermore, in this study, one patient in the intervention group developed pneumonia, whilst four patients in the control group did. Conclusion Oral health education for patients with cardiovascular disease is limited and many have poor oral health. Educational programmes to improve oral health behaviours in patients with cardiovascular disease can improve both oral and general health outcomes. Implications for public health Oral disease is a modifiable risk factor for cardiovascular disease. Integrating oral health education into cardiology hospital settings is a simple strategy to improve access to oral health information and improve both oral and cardiovascular outcomes.
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Affiliation(s)
- L. A. Church
- The University of Sydney Dental School, The University of Sydney, Sydney, NSW, Australia
- Westmead Applied Research Centre, The University of Sydney, Westmead, NSW, Australia
| | - L. Robins
- The University of Sydney Dental School, The University of Sydney, Sydney, NSW, Australia
| | - F. Xu
- The University of Sydney Dental School, The University of Sydney, Sydney, NSW, Australia
| | - L. Qin
- The University of Sydney Dental School, The University of Sydney, Sydney, NSW, Australia
| | - A. Tran
- The University of Sydney Dental School, The University of Sydney, Sydney, NSW, Australia
| | - J. P. Wallace
- School of Health Sciences, Oral Health, The University of Newcastle, Ourimbah, NSW, Australia
| | - S. King
- The University of Sydney Dental School, The University of Sydney, Sydney, NSW, Australia
- Westmead Applied Research Centre, The University of Sydney, Westmead, NSW, Australia
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Braun RG, Arata J, Gonzalez-Fernandez M. Dysphagia and Enteral Feeding After Stroke in the Rehabilitation Setting. Phys Med Rehabil Clin N Am 2024; 35:433-443. [PMID: 38514228 DOI: 10.1016/j.pmr.2023.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Physiatrists play a vital role in post-stroke dysphagia management not only by providing guidance on the risks, benefits, and efficacy of various treatment options but also as advocates for patients' independence and quality of life. While swallow study results are often discussed broadly by acute stroke clinicians as "pass/fail" findings, physiatrists need a more nuanced working knowledge of dysphagia diagnosis and treatment that encompasses swallow pathophysiology, targeted treatment strategies, and prognosis for recovery. To that end, this review summarizes current clinical practice guidelines on dysphagia, nutrition and oral care, risks and benefits of differing enteral access routes, prognostic factors, and approaches to rehabilitation.
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Affiliation(s)
- Robynne G Braun
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA; University of Maryland Rehabilitation and Orthopedic Institute, Baltimore, MD, USA; Brain Rehab and Recovery Lab, University of Maryland School of Medicine, Bressler Research Building, Suite 12-019, 655 West Baltimore Street, Baltimore, MD 21201, USA.
| | - Jodi Arata
- Rehabilitation Research Lab, University of Maryland Rehabilitation and Orthopedic Institute, 2200 Kernan Drive, Baltimore, MD 21207, USA
| | - Marlis Gonzalez-Fernandez
- Department of PM&R, Johns Hopkins University School of Medicine, 600 North Wolf Street, Phipps 184, Baltimore, MD 21287, USA; Outpatient PM&R Clinics, Johns Hopkins Hospital, 600 North Wolfe Street Phipps 174, Baltimore, MD 21287, USA
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Dziewas R, Michou E, Trapl-Grundschober M, Lal A, Arsava EM, Bath PM, Clavé P, Glahn J, Hamdy S, Pownall S, Schindler A, Walshe M, Wirth R, Wright D, Verin E. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J 2021; 6:LXXXIX-CXV. [PMID: 34746431 DOI: 10.1177/23969873211039721] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 07/27/2021] [Indexed: 12/30/2022] Open
Abstract
Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD.
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Affiliation(s)
- Rainer Dziewas
- Department of Neurology, University Hospital Münster, Münster, Germany.,Department of Neurology and Neurorehabilitation, Klinikum Osnabrück, Osnabrück, Germany
| | - Emilia Michou
- Department of Speech Language Therapy, School of Health Rehabilitation Sciences, University of Patras, Greece.,Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, University of Manchester and the Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | | | - Avtar Lal
- Guidelines Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Ethem Murat Arsava
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Pere Clavé
- Centro de Investigación Biomédica en Red de Enfermedades, Hepáticas y Digestivas (CIBERehd), Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - Jörg Glahn
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Hospital Ruhr-University Bochum, Germany
| | - Shaheen Hamdy
- Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, University of Manchester and the Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Sue Pownall
- Department of Speech & Language Therapy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Antonio Schindler
- Department of Biomedical and Clinical Sciences, Phoniatric Unit, Sacco Hospital Milano, University of Milano, Milan, Italy
| | - Margaret Walshe
- Department of Clinical Speech and Language Studies, Trinity College, Dublin, Ireland
| | - Rainer Wirth
- Department of Geriatric Medicine, Marien Hospital Herne, University Hospital Ruhr-University Bochum, Germany
| | - David Wright
- School of Pharmacy, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Eric Verin
- Department of Physical and Rehabilitation Medicine, Rouen University Hospital, Rouen, France
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Hashemi H, Nabovati P, Yekta AA, Agha Mirsalim M, Rafati S, Ostadimoghaddam H, Khabazkhoob M. Binocular vision disorders in a geriatric population. Clin Exp Optom 2021; 105:539-545. [PMID: 34016028 DOI: 10.1080/08164622.2021.1922065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Clinical relevance: A population-based epidemiological survey is important to help establish the frequency of binocular vision disorders in a geriatric population. Such data will be useful to clinicians and help guide diagnostic testing for this age group.Background: To determine the prevalence of binocular vision disorders and their associations with age and sex in the geriatric population.Methods: This report is a part of the Tehran Geriatric Eye study (TGES); a population-based cross-sectional study conducted on residents over 60 years of age in Tehran, Iran, using random stratified cluster sampling. A total of 165 clusters were selected (proportionally to size) from 22 strata of Tehran city. All participants underwent a complete ocular examination including the measurement of visual acuity, refraction, unilateral and alternating cover tests, and the Worth 4-dot suppression test. Strabismus was defined as the presence of constant unilateral or alternating esotropia or exotropia at either near (40 cm) or far (6 m). Distance and near exophoria were defined as more than 3Δ and 9Δ of exophoria at 6 m and 40 cm, respectively. Distance and near esophoria were defined as more than 1Δ and any amount of esophoria at 6 m and 40 cm, respectively.Results: Statistical analysis was performed on the data of 2,227 participants. The mean age of the participants was 66.6 ± 5.4 years and 59.4% were female. The prevalence of distance exophoria, esophoria, and hyperphoria was 8.9%, 0.34%, and 0.29%, respectively. The prevalence of near exophoria, esophoria, and hyperphoria was 32.4%, 0.61%, and 0.37%, respectively. The prevalence of distance exotropia and esotropia was 1.3% and 0.63%, respectively. The prevalence of near exotropia and esotropia was 4.6% and 0.59%, respectively.Conclusion: Non-strabismic binocular vision disorders were prevalent in an elderly population. Exo deviations were more prevalent than eso deviations.
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Affiliation(s)
- Hassan Hashemi
- Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran, Iran
| | - Payam Nabovati
- Rehabilitation Research Center, Department of Optometry, Iran University of Medical Sciences, Tehran, Iran
| | - Abbas Ali Yekta
- Department of Optometry, Mashhad University of Medical Sciences, Mashhad, Iran.,Translational Ophthalmology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Shokoofeh Rafati
- Rehabilitation Research Center, Department of Optometry, Iran University of Medical Sciences, Tehran, Iran
| | - Hadi Ostadimoghaddam
- Refractive Errors Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mehdi Khabazkhoob
- Department of Medical Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Dziewas R, Allescher HD, Aroyo I, Bartolome G, Beilenhoff U, Bohlender J, Breitbach-Snowdon H, Fheodoroff K, Glahn J, Heppner HJ, Hörmann K, Ledl C, Lücking C, Pokieser P, Schefold JC, Schröter-Morasch H, Schweikert K, Sparing R, Trapl-Grundschober M, Wallesch C, Warnecke T, Werner CJ, Weßling J, Wirth R, Pflug C. Diagnosis and treatment of neurogenic dysphagia - S1 guideline of the German Society of Neurology. Neurol Res Pract 2021; 3:23. [PMID: 33941289 PMCID: PMC8094546 DOI: 10.1186/s42466-021-00122-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
Introduction Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies. Recommendations This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with. Conclusions The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf).
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Affiliation(s)
- Rainer Dziewas
- Klinik für Neurologie, Universitätsklinik Münster, 48149 Münster, Germany. .,Klinik für Neurologie und Neurologische Frührehabilitation, Klinikum Osnabrück, Am Finkenhügel 1, 49076, Osnabrück, Germany.
| | - Hans-Dieter Allescher
- Zentrum für Innere Medizin, Klinikum Garmisch-Partenkirchen GmbH, Auenstraße 6, 82467, Garmisch-Partenkirchen, Germany
| | - Ilia Aroyo
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Grafenstr. 9, 64283, Darmstadt, Germany
| | | | | | - Jörg Bohlender
- Universitätsspital Zürich, ORL-Klinik, Abteilung für Phoniatrie und Klinische Logopädie, Frauenklinikstr. 24, 8091, Zürich, Schweiz
| | - Helga Breitbach-Snowdon
- Schule für Logopädie, Universitätsklinikum Münster, Kardinal-von-Galen-Ring 10, 48149, Münster, Germany
| | | | - Jörg Glahn
- Universitätsklinik für Neurologie und Neurogeriatrie, Johannes Wesling Klinikum Minden, Hans-Nolte Strasse 1, 32429, Minden, Germany
| | - Hans-Jürgen Heppner
- Private Universität Witten/Herdecke gGmbH, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany
| | - Karl Hörmann
- University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christian Ledl
- Abteilung Sprach-, Sprech- und Schlucktherapie, Schön Klinik Bad Aibling SE & Co. KG, Kolbermoorer Str. 72, 83043, Bad Aibling, Germany
| | - Christoph Lücking
- Schön Klinik München Schwabing, Parzivalplatz 4, 80804, München, Germany
| | - Peter Pokieser
- Medizinische Universität Wien, Teaching Center / Unified Patient Program, AKH Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Joerg C Schefold
- Universitätsklinik für Intensivmedizin, Inselspital, Universitätsspital Bern, 3010, Bern, Schweiz
| | | | - Kathi Schweikert
- REHAB Basel, Klinik für Neurorehabilitation und Paraplegiologie, Im Burgfelderhof 40, 4012, Basel, Schweiz
| | - Roland Sparing
- VAMED Klinik Hattingen GmbH, Rehabilitationszentrum für Neurologie, Neurochirurgie, Neuropädiatrie, Am Hagen 20, 45527, Hattingen, Germany
| | - Michaela Trapl-Grundschober
- Klinische Abteilung für Neurologie, Therapeutischer Dienst, Universitätsklinikum Tulln, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Alter Ziegelweg 10, 3430, Tulln an der Donau, Österreich
| | - Claus Wallesch
- BDH-Klinik Elzach gGmbH, Am Tannwald 1, 79215, Elzach, Germany
| | - Tobias Warnecke
- Klinik für Neurologie, Universitätsklinik Münster, 48149 Münster, Germany
| | - Cornelius J Werner
- Sektion Interdisziplinäre Geriatrie, Klinik für Neurologie, Medizinische Fakultät, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Johannes Weßling
- Zentrum für Radiologie, Neuroradiologie und Nuklearmedizin, Clemenskrankenhaus Münster, Düesbergweg 124, 48153, Münster, Germany
| | - Rainer Wirth
- Klinik für Altersmedizin und Frührehabilitation, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Katholische Kliniken Rhein-Ruhr, Hölkeskampring 40, 44625, Herne, Germany
| | - Christina Pflug
- Klinik und Poliklinik für Hör-, Stimm- und Sprachheilkunde, Universitäres Dysphagiezentrum Hamburg, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Campbell P, Bain B, Furlanetto DL, Brady MC. Interventions for improving oral health in people after stroke. Cochrane Database Syst Rev 2020; 12:CD003864. [PMID: 33314046 PMCID: PMC8106870 DOI: 10.1002/14651858.cd003864.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND For people with physical, sensory and cognitive limitations due to stroke, the routine practice of oral health care (OHC) may become a challenge. Evidence-based supported oral care intervention is essential for this patient group. OBJECTIVES To compare the effectiveness of OHC interventions with usual care or other treatment options for ensuring oral health in people after a stroke. SEARCH METHODS We searched the Cochrane Stroke Group and Cochrane Oral Health Group trials registers, CENTRAL, MEDLINE, Embase, and six other databases in February 2019. We scanned reference lists from relevant papers and contacted authors and researchers in the field. We handsearched the reference lists of relevant articles and contacted other researchers. There were no language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) that evaluated one or more interventions designed to improve the cleanliness and health of the mouth, tongue and teeth in people with a stroke who received assisted OHC led by healthcare staff. We included trials with a mixed population provided we could extract the stroke-specific data. The primary outcomes were dental plaque or denture plaque. Secondary outcomes included presence of oral disease, presence of related infection and oral opportunistic pathogens related to OHC and pneumonia, stroke survivor and providers' knowledge and attitudes to OHC, and patient satisfaction and quality of life. DATA COLLECTION AND ANALYSIS Two review authors independently screened abstracts and full-text articles according to prespecified selection criteria, extracted data and assessed the methodological quality using the Cochrane 'Risk of bias' tool. We sought clarification from investigators when required. Where suitable statistical data were available, we combined the selected outcome data in pooled meta-analyses. We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS Fifteen RCTs (22 randomised comparisons) involving 3631 participants with data for 1546 people with stroke met the selection criteria. OHC interventions compared with usual care Seven trials (2865 participants, with data for 903 participants with stroke, 1028 healthcare providers, 94 informal carers) investigated OHC interventions compared with usual care. Multi-component OHC interventions showed no evidence of a difference in the mean score (DMS) of dental plaque one month after the intervention was delivered (DMS -0.66, 95% CI -1.40 to 0.09; 2 trials, 83 participants; I2 = 83%; P = 0.08; very low-quality evidence). Stroke survivors had less plaque on their dentures when staff had access to the multi-component OHC intervention (DMS -1.31, 95% CI -1.96 to -0.66; 1 trial, 38 participants; P < 0.0001; low-quality evidence). There was no evidence of a difference in gingivitis (DMS -0.60, 95% CI -1.66 to 0.45; 2 trials, 83 participants; I2 = 93%; P = 0.26: very low-quality evidence) or denture-induced stomatitis (DMS -0.33, 95% CI -0.92 to 0.26; 1 trial, 38 participants; P = 0.69; low-quality evidence) among participants receiving the multi-component OHC protocol compared with usual care one month after the intervention. There was no difference in the incidence of pneumonia in participants receiving a multi-component OHC intervention (99 participants; 5 incidents of pneumonia) compared with those receiving usual care (105 participants; 1 incident of pneumonia) (OR 4.17, CI 95% 0.82 to 21.11; 1 trial, 204 participants; P = 0.08; low-quality evidence). OHC training for stroke survivors and healthcare providers significantly improved their OHC knowledge at one month after training (SMD 0.70, 95% CI 0.06 to 1.35; 3 trials, 728 participants; I2 = 94%; P = 0.03; very low-quality evidence). Pooled data one month after training also showed evidence of a difference between stroke survivor and providers' oral health attitudes (SMD 0.28, 95% CI 0.01 to 0.54; 3 trials, 728 participants; I2 = 65%; P = 0.06; very low-quality evidence). OHC interventions compared with placebo Three trials (394 participants, with data for 271 participants with stroke) compared an OHC intervention with placebo. There were no data for primary outcomes. There was no evidence of a difference in the incidence of pneumonia in participants receiving an OHC intervention compared with placebo (OR 0.39, CI 95% 0.14 to 1.09; 2 trials, 242 participants; I2 = 42%; P = 0.07; low-quality evidence). However, decontamination gel reduced the incidence of pneumonia among the intervention group compared with placebo gel group (OR 0.20, 95% CI 0.05 to 0.84; 1 trial, 203 participants; P = 0.028). There was no difference in the incidence of pneumonia in participants treated with povidone-iodine compared with a placebo (OR 0.81, 95% CI 0.18 to 3.51; 1 trial, 39 participants; P = 0.77). One OHC intervention compared with another OHC intervention Twelve trials (372 participants with stroke) compared one OHC intervention with another OHC intervention. There was no difference in dental plaque scores between those participants that received an enhanced multi-component OHC intervention compared with conventional OHC interventions at three months (MD -0.04, 95% CI -0.33 to 0.25; 1 trial, 61 participants; P = 0.78; low-quality evidence). There were no data for denture plaque. AUTHORS' CONCLUSIONS We found low- to very low-quality evidence suggesting that OHC interventions can improve the cleanliness of patient's dentures and stroke survivor and providers' knowledge and attitudes. There is limited low-quality evidence that selective decontamination gel may be more beneficial than placebo at reducing the incidence of pneumonia. Improvements in the cleanliness of a patient's own teeth was limited. We judged the quality of the evidence included within meta-analyses to be low or very low quality, and this limits our confidence in the results. We still lack high-quality evidence of the optimal approach to providing OHC to people after stroke.
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Affiliation(s)
- Pauline Campbell
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Brenda Bain
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Denise Lc Furlanetto
- Public Health Department, Health Sciences Faculty, University of Brasilia, Brasilia, Brazil
| | - Marian C Brady
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
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Wu J, Dai Y, Lo ECM, Qi Y, Zhang Y, Li QL, Dai R. Using metagenomic analysis to assess the effectiveness of oral health promotion interventions in reducing risk for pneumonia among patients with stroke in acute phase: study protocol for a randomized controlled trial. Trials 2020; 21:634. [PMID: 32650814 PMCID: PMC7350693 DOI: 10.1186/s13063-020-04528-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/18/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The prevalence of pneumonia complicating stroke in acute phase has a poor prognosis and higher risk for death. Oral opportunistic pathogens have been reported to be associated with pneumonia among people with compromised health. Oral health promotion is effective in reducing dental plaque among patients with stroke, which is considered as reservoirs for oral opportunistic pathogens. This study evaluates the effectiveness of oral health promotions in reducing the prevalence of pneumonia via its effects on composition and relative abundance of oral opportunistic pathogens. METHODS/DESIGN This study is a randomized, single-blind, parallel trial of 6 months duration. The study is being conducted at one of the largest medical teaching hospitals in Hefei, China. A total of 166 patients with stroke and free from any post-stroke complication will be recruited. After enrollment, patients will be randomized to one of the following groups: (1) oral hygiene instruction (OHI) or (2) OHI, 6-month use of powered tooth brushing, and 0.2% chlorhexidine gluconate mouth rinse (10 ml twice daily). The primary outcome is the prevalence of pneumonia complicating stroke. Patients will be monitored closely for any occurrence of pneumonia over the entire period of this trial. Oral rinse samples will be collected at baseline and multiple follow-up reviews (3, 5, 7 days, and 1, 3, 6 months after baseline). Next-generation sequencing will be employed to detect composition and relative abundances of the microorganism in the oral rinse samples. Questionnaire interviews and clinical oral examinations will be conducted at baseline and 1, 3, and 6 months after baseline. DISCUSSION The findings of this trial will provide evidence whether oral health promotion intervention is effective in reducing the prevalence of pneumonia complicating stroke via its effect on the oral microbiome. The analysis of the outcomes of this trial is empowered by metagenomic analysis at 16S rRNA level, which is more sensitive and comprehensive to help us detect how oral health promotion inventions affect the oral microbiome in terms of its composition, relative abundance, and interactions between species, which all may contribute to the occurrence of pneumonia complicating stroke. TRIAL REGISTRATION ClinicalTrials.gov NCT04095780 . Registered on 19 September 2019.
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Affiliation(s)
- Juncang Wu
- The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, 246 Heping Road, Hefei, China
| | - Yuanchang Dai
- The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, 246 Heping Road, Hefei, China
| | - Edward C M Lo
- Department of Dental Public Health, Faculty of Dentistry, The University of Hong Kong, 34 Hospital Road, Sai Ying Pun, Hong Kong
| | - Yinliang Qi
- The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, 246 Heping Road, Hefei, China
| | - Ya Zhang
- Key Laboratory of Oral Diseases Research of Anhui Province, Stomatological Hospital & College, Anhui Medical University, Hefei, China
| | - Quan-Li Li
- Key Laboratory of Oral Diseases Research of Anhui Province, Stomatological Hospital & College, Anhui Medical University, Hefei, China.
| | - Ruoxi Dai
- The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, 246 Heping Road, Hefei, China.
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9
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Umemoto G, Furuya H. Management of Dysphagia in Patients with Parkinson's Disease and Related Disorders. Intern Med 2020; 59:7-14. [PMID: 30996170 PMCID: PMC6995701 DOI: 10.2169/internalmedicine.2373-18] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/23/2019] [Indexed: 01/02/2023] Open
Abstract
Various methods of rehabilitation for dysphagia have been suggested through the experience of treating stroke patients. Although most of these patients recover their swallowing function in a short period, dysphagia in Parkinson's disease (PD) and Parkinson-related disorder (PRD) degenerates with disease progression. Muscle rigidity and bradykinesia are recognized as causes of swallowing dysfunction, and it is difficult to easily apply the strategies for stroke to the rehabilitation of dysphagia in PD patients. Disease severity, weight loss, drooling, and dementia are important clinical predictors. Silent aspiration is a pathognomonic sign that may lead to aspiration pneumonia. Severe PD patients need routine video fluoroscopy or video endoscopy to adjust their food and liquid consistency. Patients with PRD experience rapid progression of swallowing dysfunction. Nutrition combined with nasogastric tube feeding or percutaneous endoscopic gastrostomy feeding should be considered owing to the increased risk of aspiration and difficulty administrating oral nutrition.
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Affiliation(s)
- George Umemoto
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Fukuoka University, Japan
| | - Hirokazu Furuya
- Department of Neurology, Kochi Medical School, Kochi University, Japan
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10
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Variation in Dysphagia Assessment and Management in Acute Stroke: An Interview Study. Geriatrics (Basel) 2019; 4:geriatrics4040060. [PMID: 31731452 PMCID: PMC6960646 DOI: 10.3390/geriatrics4040060] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/20/2019] [Accepted: 10/23/2019] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Patients with dysphagia are at increased risk of stroke-associated pneumonia. There is wide variation in the way patients are screened and assessed. The aim of this study is to explore staff opinions about current practice of dysphagia screening, assessment and clinical management in acute phase stroke. (2) Methods: Fifteen interviews were conducted in five English National Health Service hospitals. Hospitals were selected based on size and performance against national targets for dysphagia screening and assessment, and prevalence of stroke-associated pneumonia. Participants were purposefully recruited to reflect a range of healthcare professions. Data were analysed using a six-stage thematic process. (3) Results: Three meta themes were identified: delays in care, lack of standardisation and variability in resources. Patient, staff, and service factors that contribute to delays in dysphagia screening, assessment by a speech and language therapist, and delays in nasogastric tube feeding were identified. These included admission route, perceived lack of ownership for screening patients, prioritisation of assessments and staff resources. There was a lack of standardisation of dysphagia screening protocols and oral care. There was variability in staff competences and resources to assess patients, types of medical interventions, and care processes. (4) Conclusion: There is a lack of standardisation in the way patients are assessed for dysphagia and variation in practice relating to staff competences, resources and care processes between hospitals. A range of patient, staff and service factors have the potential to impact on stroke patients being assessed within the recommended national guidelines.
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11
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Eltringham SA, Kilner K, Gee M, Sage K, Bray BD, Smith CJ, Pownall S. Factors Associated with Risk of Stroke-Associated Pneumonia in Patients with Dysphagia: A Systematic Review. Dysphagia 2019; 35:735-744. [PMID: 31493069 PMCID: PMC7522065 DOI: 10.1007/s00455-019-10061-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 08/27/2019] [Indexed: 12/22/2022]
Abstract
Dysphagia is associated with increased risk of stroke-associated pneumonia (SAP). However, it is unclear what other factors contribute to that risk or which measures may reduce it. This systematic review aimed to provide evidence on interventions and care processes associated with SAP in patients with dysphagia. Studies were screened for inclusion if they included dysphagia only patients, dysphagia and non-dysphagia patients or unselected patients that included dysphagic patients and evaluated factors associated with a recorded frequency of SAP. Electronic databases were searched from inception to February 2017. Eligible studies were critically appraised. Heterogeneity was evaluated using I2. The primary outcome was SAP. Eleven studies were included. Sample sizes ranged from 60 to 1088 patients. There was heterogeneity in study design. Measures of immunodepression are associated with SAP in dysphagic patients. There is insufficient evidence to justify screening for aerobic Gram-negative bacteria. Prophylactic antibiotics did not prevent SAP and proton pump inhibitors may increase risk. Treatment with metoclopramide may reduce SAP risk. Evidence that nasogastric tube (NGT) placement increases risk of SAP is equivocal. A multidisciplinary team approach and instrumental assessment of swallowing may reduce risk of pneumonia. Patients with impaired mobility were associated with increased risk. Findings should be interpreted with caution given the number of studies, heterogeneity and descriptive analyses. Several medical interventions and care processes, which may reduce risk of SAP in patients with dysphagia, have been identified. Further research is needed to evaluate the role of these interventions and care processes in clinical practice.
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Affiliation(s)
- Sabrina A Eltringham
- Speech and Language Therapy Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK. .,Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK.
| | - Karen Kilner
- Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
| | - Melanie Gee
- Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
| | - Karen Sage
- Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
| | | | - Craig J Smith
- Greater Manchester Comprehensive Stroke Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, Manchester, UK.,Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Sue Pownall
- Speech and Language Therapy Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
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12
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Zetterlund C, Lundqvist LO, Richter HO. Visual, musculoskeletal and balance symptoms in individuals with visual impairment. Clin Exp Optom 2018; 102:63-69. [PMID: 29938826 DOI: 10.1111/cxo.12806] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 05/28/2018] [Accepted: 05/30/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Visual impairment is globally among the most prevalent disabilities. Research concerning the health consequences of visual deficits is challenged by confounding effects of age, because visual impairment becomes more prevalent with age. This study investigates the influence of visual deficits on visual, musculoskeletal and balance symptoms in adults with and without visual impairment, while controlling for age effects. METHODS Thirty-nine patients with visual impairment, aged 18-72 years, were compared to 37 age-matched controls with normal vision, allocated to two age groups: < 45 and ≥ 45 years. Self-reported symptoms were measured using the Visual, Musculoskeletal and Balance Symptoms Questionnaire and compared with demographic and optometric variables. RESULTS In total, patients with visual impairment reported more symptoms than age-matched normally sighted controls. Younger adults in the control group were almost free from symptoms, whereas younger adults with visual impairment reported levels of symptoms equal to older adults with visual impairment. Multiple logistic regression modelling identified use of eyeglasses, magnifying aids and presence of anisometropia to be the most influential risk factors for reporting visual, musculoskeletal and balance symptoms, with accentuated influence on balance symptoms. CONCLUSIONS People with visual impairments and people with age-related normal visual deficits are both predisposed to report visual, musculoskeletal and balance symptoms relative to people without visual defects or need for eye-wear correction. Age-related variations in symptoms were observed in the control groups but not in the visual impairment groups, with younger visual impairment patients reporting as many symptoms as older visual impairment patients. These findings indicate a need for a wider interdisciplinary perspective on eye care concerning people with visual impairment and people with need for habitual daily use of eye wear correction.
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Affiliation(s)
- Christina Zetterlund
- Low Vision Centre, Region Örebro County, Örebro, Sweden.,University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Lars-Olov Lundqvist
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Hans Olof Richter
- Centre for Musculoskeletal Research, Department of Occupational and Public Health Science, University of Gävle, Gävle, Sweden
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13
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Lyons M, Smith C, Boaden E, Brady MC, Brocklehurst P, Dickinson H, Hamdy S, Higham S, Langhorne P, Lightbody C, McCracken G, Medina-Lara A, Sproson L, Walls A, Watkins DC. Oral care after stroke: Where are we now? Eur Stroke J 2018; 3:347-354. [PMID: 31236482 DOI: 10.1177/2396987318775206] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 04/12/2018] [Indexed: 01/25/2023] Open
Abstract
Purpose There appears to be an association between poor oral hygiene and increased risk of aspiration pneumonia - a leading cause of mortality post-stroke. We aim to synthesise what is known about oral care after stroke, identify knowledge gaps and outline priorities for research that will provide evidence to inform best practice. Methods A narrative review from a multidisciplinary perspective, drawing on evidence from systematic reviews, literature, expert and lay opinion to scrutinise current practice in oral care after a stroke and seek consensus on research priorities.Findings: Oral care tends to be of poor quality and delegated to the least qualified members of the caring team. Nursing staff often work in a pressured environment where other aspects of clinical care take priority. Guidelines that exist are based on weak evidence and lack detail about how best to provide oral care. Discussion Oral health after a stroke is important from a social as well as physical health perspective, yet tends to be neglected. Multidisciplinary research is needed to improve understanding of the complexities associated with delivering good oral care for stroke patients. Also to provide the evidence for practice that will improve wellbeing and may reduce risk of aspiration pneumonia and other serious sequelae. Conclusion Although there is evidence of an association, there is only weak evidence about whether improving oral care reduces risk of pneumonia or mortality after a stroke. Clinically relevant, feasible, cost-effective, evidence-based oral care interventions to improve patient outcomes in stroke care are urgently needed.
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Affiliation(s)
- Mary Lyons
- Faculty of Health and Wellbeing, University of Central Lancashire, UK.,Department of International Public Health, Liverpool School of Tropical Medicine, UK
| | - Craig Smith
- Division of Cardiovascular Sciences, Manchester Academic Health Science Centre, University of Manchester, UK.,Department of Neurosciences, Salford Royal NHS Foundation Trust, UK
| | - Elizabeth Boaden
- Faculty of Health and Wellbeing, University of Central Lancashire, UK
| | - Marian C Brady
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, UK
| | - Paul Brocklehurst
- North Wales Organisation for Randomised Trials in Health, Bangor Institute of Health and Medical Research and Salford Royal NHS Foundation Trust, UK
| | - Hazel Dickinson
- Faculty of Health and Wellbeing, University of Central Lancashire, UK
| | - Shaheen Hamdy
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | - Susan Higham
- Institute of Psychology, Health and Society, University of Liverpool, UK
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | | | - Giles McCracken
- Centre for Oral Health Research, School of Dental Sciences, Newcastle University, UK
| | | | - Lise Sproson
- National Institute for Health Research Devices for Dignity Healthcare Technology Cooperative, Sheffield Teaching Hospitals NHS Foundation Trust, UK
| | - Angus Walls
- Edinburgh Dental Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, UK
| | - Dame Caroline Watkins
- Faculty of Health and Wellbeing, University of Central Lancashire, UK.,Faculty of Health Sciences, Australian Catholic University, Australia
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14
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Characterisation of Cronobacter strains isolated from hospitalised adult patients. Antonie van Leeuwenhoek 2017; 111:1073-1085. [PMID: 29270766 DOI: 10.1007/s10482-017-1008-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 12/15/2017] [Indexed: 10/18/2022]
Abstract
Bacteria belonging to the genus Cronobacter are opportunistic pathogens known for causing rare but serious infections in neonates, including meningitis, necrotising enterocolitis and sepsis. Cronobacter infections occur also in adult populations, however, they generally have milder manifestations and their prevalence is uncertain. In this study, the presence of Cronobacter strains from adult patients in the University Hospital in Bratislava was investigated and overall 18 confirmed isolates from 321 patients (5.3%) were recovered. No Cronobacter positive sample was detected in 215 sputum samples from outpatients. The highest occurrence of Cronobacter strains was observed from stroke patients and this may be associated with an abnormal swallowing ability. The isolated strains belonged to the species Cronobacter sakazakii and Cronobacter malonaticus. In silico genotyping (MLST, CRISPR-cas array profiling) of whole genome sequences assigned the strains to three different MLST clones. The majority (12/18) of the isolated strains were sequence type ST513 or single locus variants ST514 and ST515, thereby being members of C. sakazakii pathovar clonal complex CC4. However, according to core genome MLST analysis the ST513-ST515 strains created a unique cluster substantially different from other CC4 strains. The isolated strains were susceptible to 18 tested antibiotics. All strains possess a genomic island encoding for increased thermal tolerance. As Cronobacter strains are frequently present in dried foods of plant origin, spread of a specific clone within a hospital may be caused by food transmission and may be facilitated by its tolerance to environmental stresses such as desiccation and temperature.
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15
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Ali AN, Howe J, Majid A, Redgrave J, Pownall S, Abdelhafiz AH. The economic cost of stroke-associated pneumonia in a UK setting. Top Stroke Rehabil 2017; 25:214-223. [PMID: 29105583 DOI: 10.1080/10749357.2017.1398482] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Introduction Stroke-associated pneumonia (SAP) is common, however, data on the economic impact of SAP are scarce. This study aimed to prospectively evaluate the impact of SAP on acute stroke care costs in a UK setting. Methods Prospective cohort study of 213 consecutive patients with stroke (196 ischemic, 17 hemorrhagic) was admitted to a UK hospital over 1 year. Socio demographic and clinical characteristics were recorded along with all treatments and rehabilitation activity. Patients were classified as having SAP if they fulfilled criteria for "probable" or "definite" respiratory tract infection according to the Centres for Disease Control and Prevention definition, within the first seven days following stroke. Resource use was calculated using a "bottom up" approach of cumulative unit costs. Univariate and multivariate regression analyses were used to establish independent predictors of direct costs. Results Probable or definite SAP occurred in 13.2% (28/213) of patients. Patients with SAP experienced greater inpatient stays (31 days vs. 9 days, p ≤ 0.001) and higher in-hospital mortality (29.2% vs. 10.2%, p = 0.007). Mean (SD) acute care costs per patient was £7035 (6767), but costs were significantly greater for patients with SAP than without [£14,371 (9484) versus £6,103 (5,735); p ≤ 0.001]. SAP was an independent predictor of costs along with increasing stroke severity (NIHSS) and age. Occurrence of SAP resulted in an adjusted incremental additional cost of £5817 (95% CI 4945-6689; p = 0.001) per patient. Conclusions SAP increased acute care costs for stroke by approximately 80%. This provides further impetus for research aimed at reducing SAP, and will inform cost-effectiveness analyses of potential therapeutic strategies.
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Affiliation(s)
- A N Ali
- a Department of Geriatrics and Stroke , Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield , UK.,b Faculty of Medicine and Dentistry , University of Sheffield , Sheffield , UK
| | - J Howe
- c Department of Neurosciences , Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield , UK
| | - A Majid
- b Faculty of Medicine and Dentistry , University of Sheffield , Sheffield , UK.,c Department of Neurosciences , Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield , UK
| | - J Redgrave
- b Faculty of Medicine and Dentistry , University of Sheffield , Sheffield , UK.,c Department of Neurosciences , Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield , UK
| | - S Pownall
- b Faculty of Medicine and Dentistry , University of Sheffield , Sheffield , UK.,d Department of Speech and Language Therapy , Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield , UK
| | - A H Abdelhafiz
- e Department of Geriatrics , Rotherham General Hospital NHS Foundation Trust , Rotherham , UK
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16
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Smithard DG. Stroke in Frail Older People. Geriatrics (Basel) 2017; 2:E24. [PMID: 31011034 PMCID: PMC6371123 DOI: 10.3390/geriatrics2030024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/20/2017] [Accepted: 06/22/2017] [Indexed: 02/01/2023] Open
Abstract
The population is ageing, with the greatest proportional increase in those >80 years of age. Many of these people will be frail and at risk of stroke. Research has shown that the very old have much to benefit from hyperacute stroke intervention, but at the same time they suffer increased mortality. Their outcome following stroke and intervention is more often predicted by the presence of frailty rather than age alone. Intervention both in primary prevention and hyperacute stroke management needs to allow for preexisting morbidity and frailty in deciding what is and what is not appropriate, rather than an arbitrary decision on age. Frail older people are more likely to develop delirium and dysphagia combined with poor mouthcare and die, yet all of these issues are managed badly. An increased awareness of these complications of stroke in the frail older person is necessary.
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Affiliation(s)
- David G Smithard
- Department of Electronic and Digital Arts, University of Kent, Canterbury CT2 7NZ, UK.
- Clinical Gerontology, King's College Hospital, London SE5 9RS, UK.
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17
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Boaden E, Lyons M, Singhrao SK, Dickinson H, Leathley M, Lightbody CE, McLoughlin A, Khan Z, Crean S, Smith C, Higham S, Watkins C. Oral flora in acute stroke patients: A prospective exploratory observational study. Gerodontology 2017; 34:343-356. [DOI: 10.1111/ger.12271] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2017] [Indexed: 01/25/2023]
Affiliation(s)
- Elizabeth Boaden
- Faculty of Health and Wellbeing; School of Nursing; University of Central Lancashire; Preston UK
| | - Mary Lyons
- Faculty of Health and Wellbeing; School of Nursing; University of Central Lancashire; Preston UK
| | - Sim K. Singhrao
- Dementia & Neurodegenerative Diseases Research Group; College of Clinical and Biomedical Sciences; School of Dentistry; University of Central Lancashire; Preston UK
| | - Hazel Dickinson
- Faculty of Health and Wellbeing; School of Nursing; University of Central Lancashire; Preston UK
| | - Michael Leathley
- Faculty of Health and Wellbeing; School of Nursing; University of Central Lancashire; Preston UK
| | - Catherine E. Lightbody
- Faculty of Health and Wellbeing; School of Nursing; University of Central Lancashire; Preston UK
| | - Alison McLoughlin
- Faculty of Health and Wellbeing; School of Nursing; University of Central Lancashire; Preston UK
| | - Zarine Khan
- Dementia & Neurodegenerative Diseases Research Group; College of Clinical and Biomedical Sciences; School of Dentistry; University of Central Lancashire; Preston UK
| | - Stjohn Crean
- Dementia & Neurodegenerative Diseases Research Group; College of Clinical and Biomedical Sciences; School of Dentistry; University of Central Lancashire; Preston UK
| | - Craig Smith
- Greater Manchester Comprehensive Stroke Centre; and University of Manchester Stroke and Vascular Centre; Manchester Academic Health Science Centre; Salford Royal NHS Foundation Trust; Salford UK
| | - Susan Higham
- Department of Health Services Research; Institute of Psychology; Health and Society; The Research Wing; School of Dentistry; University of Liverpool; Liverpool UK
| | - Caroline Watkins
- Faculty of Health and Wellbeing; School of Nursing; University of Central Lancashire; Preston UK
- Australian Catholic University; North Sydney Australia
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19
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Abstract
Dysphagia is one of the many complications of stroke. It is common and is an independent marker of outcome. Dysphagia management is important. Although the speech and language pathologist is the key worker in dysphagia management, they are supported by all members of the multi-disciplinary team. Stroke patients should be screened on admission for the presence of dysphagia and assessed by the speech and language therapist (or appropriate professional), where indicated investigation should be undertaken to understand the swallowing physiology and to guide treatment. Management, at present, is based around texture modification of food/liquids and swallowing manoeuvres. Rehabilitation of swallowing remains in its infancy, but there is a lot of promising research with neurostimulation, medication and devices to strengthen muscles involved in swallowing.
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Affiliation(s)
- David G. Smithard
- Department of Electronics and Digital Arts, University of Kent, Canterbury, UK
- Princess Royal University Hospital, King’s College Hospital, London, UK
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20
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Popper M, Gancarčíková S, Maďar M, Mudroňová D, Hrčková G, Nemcová R. Amoxicillin-clavulanic acid and ciprofloxacin-treated SPF mice as gnotobiotic model. Appl Microbiol Biotechnol 2016; 100:9671-9682. [PMID: 27695915 DOI: 10.1007/s00253-016-7855-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 08/25/2016] [Accepted: 09/13/2016] [Indexed: 12/22/2022]
Abstract
The experiment was carried out on 24 SPF BALB/c female mice and lasted for 15 days with a 5-day antibiotic (ATB) treatment and then 10 days without ATB treatment. The aim of our study was to acquire an animal model with reduced and controlled microflora and, at the same time, to ensure that the good health of these animals is maintained. Per oral administration of amoxicillin and clavulanate potassium in Amoksiklav (Sandoz, Slovenia) at a dose of 387.11 mg/kg body weight (0.2 ml of dilution per mouse) and subcutaneous administration of ciprofloxacin in Ciloxan (Alcon, Spain) at a dose of 18.87 mg/kg body weight (0.1 ml of dilution per mouse) were performed every 12 h during first 5 days of experiment. Five-day treatment with ATB led to a reduced survivability of microorganisms in faeces (28.33 ± 0.43 % on day 2) and caecum content (28.10 ± 1.56 %), where no cultivable microorganisms in faeces were present. Ten-day convalescence of decontaminated animals under gnotobiotic conditions prevented recovery of species diversity in mice gut microflora. This was reduced to two detectable cultivable species, namely Escherichia coli (GenBank KX086704) and Enterococcus sp. (GenBank KX086705) which were capable to restore its metabolic (CRL 2012) and morphological potential (Baratta et al. Histochem Cell Biol 131:713-726, 2009) within physiological range. Animals obtained under this procedure can be used in further studies. As a result, we created a mouse gnoto model with reduced and controlled microflora without alteration of the overall health status of the respective animals.
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Affiliation(s)
- Miroslav Popper
- Department of Microbiology and Immunology, University of Veterinary Medicine and Pharmacy in Košice, Košice, Slovakia.
| | - Soňa Gancarčíková
- Department of Microbiology and Immunology, University of Veterinary Medicine and Pharmacy in Košice, Košice, Slovakia
| | - Marián Maďar
- Department of Microbiology and Immunology, University of Veterinary Medicine and Pharmacy in Košice, Košice, Slovakia
| | - Dagmar Mudroňová
- Department of Microbiology and Immunology, University of Veterinary Medicine and Pharmacy in Košice, Košice, Slovakia
| | - Gabriela Hrčková
- Institute of Parasitology, Slovak Academy of Sciences, Košice, Slovakia
| | - Radomíra Nemcová
- Department of Microbiology and Immunology, University of Veterinary Medicine and Pharmacy in Košice, Košice, Slovakia
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21
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Di Pede C, Mantovani ME, Del Felice A, Masiero S. Dysphagia in the elderly: focus on rehabilitation strategies. Aging Clin Exp Res 2016; 28:607-17. [PMID: 26589905 DOI: 10.1007/s40520-015-0481-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 10/17/2015] [Indexed: 11/25/2022]
Abstract
Prevalence of oropharyngeal dysphagia among the elderly is high, but underestimated and underdiagnosed. It may give raise to relevant complications impacting on morbidity, hospital length of stay and health care costs. Dysphagia evaluation and management is a multidisciplinary task; it includes a detailed history taking, clinical and instrumental exams, and identification of the risk of aspiration. Long-standing individual abilities and impairments determine the goals of an ad hoc rehabilitation program. Currently there are no standard algorithmic approaches for the management of dysphagia in the elderly. Education of health professionals on early diagnosis and improvement of therapeutic strategies are mainstays to allow maximal recovery potential in this population. This narrative review summarizes the current rehabilitation approaches for dysphagia in the elderly. The aim is to inform the treating health care professionals, whether caring physician, physical medicine doctor, speech/swallowing therapist or nurse, on the state-of-the-art and stimulate discussion in the scientific community.
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Affiliation(s)
- C Di Pede
- Rehabilitation Unit, Department of Neurosciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - M E Mantovani
- Rehabilitation Unit, Department of Neurosciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - A Del Felice
- Rehabilitation Unit, Department of Neurosciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - S Masiero
- Rehabilitation Unit, Department of Neurosciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy.
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Smith CJ, Horne M, McCracken G, Young D, Clements I, Hulme S, Ardron C, Hamdy S, Vail A, Walls A, Tyrrell PJ. Development and feasibility testing of an oral hygiene intervention for stroke unit care. Gerodontology 2016; 34:110-120. [PMID: 27198495 DOI: 10.1111/ger.12232] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To develop an oral hygiene complex intervention and evaluate its feasibility in a single UK stroke centre. BACKGROUND Oral hygiene interventions might improve clinical outcomes after stroke but evidence-based practice is lacking. MATERIALS AND METHODS We used a sequential mixed methods approach and developed an oral hygiene complex intervention comprising: (i) web-based education and 'hands-on' practical training for stroke unit nursing staff, (ii) a pragmatic oral hygiene protocol consisting of twice-daily powered (or manual if preferred) brushing with chlorhexidine gel (or non-foaming toothpaste) ± denture care. We evaluated feasibility of (i) the staff education and training and (ii) the oral hygiene protocol in consenting inpatients with confirmed stroke, requiring assistance with at least one aspect of personal care. RESULTS The staff education and training were feasible, acceptable and raised knowledge and awareness. Several barriers to completing the education and training were identified. The oral hygiene protocol was feasible and well-tolerated. 22% of eligible patients screened declined participation in the study. Twenty-nine patients (median age = 78 year; National Institutes of Health Stroke Scale score = 8.5; 73% dentate) were recruited at a median of 7 days from stroke onset. 97% of participants chose the default chlorhexidine-based protocol; the remainder chose the non-foaming toothpaste-based protocol. The mouth hygiene protocol was administered as prescribed on 95% of occasions, over a median duration of 28 days. There were no adverse events attributed to the oral hygiene protocol. CONCLUSION Our oral hygiene complex intervention was feasible in a single UK stroke centre. Further studies to optimise patient selection, model health economics and explore efficacy are now required.
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Affiliation(s)
- Craig J Smith
- Greater Manchester Comprehensive Stroke Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, Salford, UK.,Stroke and Vascular Centre, Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Maria Horne
- Faculty of Health Studies, School of Nursing, University of Bradford, Bradford, UK
| | - Giles McCracken
- School of Dental Sciences, Newcastle University, Newcastle, UK
| | - David Young
- The Greater Manchester School for Dental Care Professionals (MANDCP), Salford, UK
| | - Ian Clements
- Patient, Carer and Public Involvement Group, North West Stroke Research Network, Salford Royal NHS Foundation Trust, Salford, UK
| | - Sharon Hulme
- Stroke and Vascular Centre, Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Claire Ardron
- Greater Manchester Comprehensive Stroke Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, Salford, UK
| | - Shaheen Hamdy
- Centre for Gastrointestinal Sciences, Institute of Inflammation and Repair, University of Manchester, Manchester, UK
| | - Andy Vail
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Angus Walls
- Edinburgh Dental Institute, University of Edinburgh, Edinburgh, UK
| | - Pippa J Tyrrell
- Greater Manchester Comprehensive Stroke Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, Salford, UK.,Stroke and Vascular Centre, Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
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Cohen DL, Roffe C, Beavan J, Blackett B, Fairfield CA, Hamdy S, Havard D, McFarlane M, McLauglin C, Randall M, Robson K, Scutt P, Smith C, Smithard D, Sprigg N, Warusevitane A, Watkins C, Woodhouse L, Bath PM. Post-stroke dysphagia: A review and design considerations for future trials. Int J Stroke 2016; 11:399-411. [PMID: 27006423 DOI: 10.1177/1747493016639057] [Citation(s) in RCA: 242] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 12/21/2015] [Indexed: 12/14/2022]
Abstract
Post-stroke dysphagia (a difficulty in swallowing after a stroke) is a common and expensive complication of acute stroke and is associated with increased mortality, morbidity, and institutionalization due in part to aspiration, pneumonia, and malnutrition. Although most patients recover swallowing spontaneously, a significant minority still have dysphagia at six months. Although multiple advances have been made in the hyperacute treatment of stroke and secondary prevention, the management of dysphagia post-stroke remains a neglected area of research, and its optimal management, including diagnosis, investigation and treatment, have still to be defined.
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Affiliation(s)
| | - Christine Roffe
- Stroke Research, University Hospital of North Midlands, Keele University, UK
| | | | | | - Carol A Fairfield
- School of Psychology and Clinical Language Sciences, University of Reading, UK
| | - Shaheen Hamdy
- Institute of Inflammation and Repair, University of Manchester, UK
| | - Di Havard
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK
| | | | | | | | - Katie Robson
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK
| | - Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK
| | - Craig Smith
- Stroke and Vascular Research Centre, University of Manchester, UK
| | - David Smithard
- Elderly Medicine, Princess Royal University Hospital, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK
| | | | - Caroline Watkins
- College of Health and Wellbeing, University of Central Lancashire, UK
| | - Lisa Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK
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24
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van de Beek D, Brouwer M, Nederkoorn P. Parenteral antibiotics are not enough to prevent pneumonia in stroke - Authors' reply. Lancet 2015; 386:653-4. [PMID: 26334158 DOI: 10.1016/s0140-6736(15)61502-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Diederik van de Beek
- Department of Neurology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, Netherlands; Centre of Infection and Immunity, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, Netherlands.
| | - Matthijs Brouwer
- Department of Neurology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, Netherlands; Centre of Infection and Immunity, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, Netherlands
| | - Paul Nederkoorn
- Department of Neurology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, Netherlands
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25
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Silvestri L, van Saene HKF, Milanese M, Ros S, Zandstra DF. Parenteral antibiotics are not enough to prevent pneumonia in stroke. Lancet 2015; 386:653. [PMID: 26334157 DOI: 10.1016/s0140-6736(15)61501-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Luciano Silvestri
- Department of Anaesthesia and Intensive Care, St John Hospital, Gorizia, 34170, Italy.
| | | | - Marco Milanese
- Department of Anaesthesia and Intensive Care, St John Hospital, Gorizia, 34170, Italy
| | - Silvia Ros
- Department of Neurology, St John Hospital, Gorizia, 34170, Italy
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26
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Brady MC, Stott D, Weir CJ, Chalmers C, Sweeney P, Donaldson C, Barr J, Barr M, Pollock A, McGowan S, Bowers N, Langhorne P. Clinical and cost effectiveness of enhanced oral healthcare in stroke care settings (SOCLE II): a pilot, stepped wedge, cluster randomized, controlled trial protocol. Int J Stroke 2015; 10:979-84. [PMID: 26079661 DOI: 10.1111/ijs.12530] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 03/29/2015] [Indexed: 11/29/2022]
Abstract
RATIONALE Stroke-associated pneumonia, a leading cause of hospital-acquired infection after stroke, affects a fifth of stroke survivors annually. Associated with increased risk of death and poorer rehabilitation outcomes, research suggests a possible relationship between stroke-associated pneumonia and patients' oral health. AIM The aim of this study is to evaluate the feasibility of a randomized controlled trial of the clinical and cost effectiveness of enhanced oral healthcare vs. usual oral healthcare for people in stroke care settings. DESIGN Our pilot, multicentered, pragmatic, stepped wedge, cluster randomized controlled trial oral healthcare [Stroke Oral healthCare pLan Evaluation (SOCLE II)] will compare enhanced oral healthcare intervention and usual oral healthcare. Over 13 months, across 4 wards, we seek to recruit 400 patients (estimating an average of 23 beds per site and a 50% recruitment rate) and 60 nursing staff (estimating an average of 20 members of staff per site and a 75% recruitment rate). Initially, control data (usual oral healthcare) will be collected from all sites. In a randomized, stepped manner, wards will convert to deliver the enhanced oral healthcare intervention. STUDY OUTCOME(S) Outcomes will be captured across dimensions of care (as recommended for evaluations of complex interventions) at baseline and weekly thereafter. Primary outcomes are pneumonia (patients), knowledge and attitudes (staff), and specialist dental referrals (service). Secondary outcomes include oral health quality of life, plaque, antibiotics, length of stay, death (patients), use of oral healthcare equipment and products, completed assessments, and documented oral healthcare plans (staff). DISCUSSION As one of the first stepped wedge, cluster randomized, controlled trials in stroke care mapping of the complex intervention, our choice of primary and secondary outcomes and choice of trial design are described.
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Affiliation(s)
- Marian C Brady
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - David Stott
- Academic Section of Geriatric Medicine, Glasgow Royal Infirmary, Glasgow, UK
| | - Christopher J Weir
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK.,Edinburgh Health Services Research Unit, Edinburgh, UK
| | | | | | - Cam Donaldson
- Yunus Centre for Social Business & Health, Glasgow Caledonian University, Glasgow, UK
| | - John Barr
- NMAHP Research Unit, Stroke Rehabilitation Research Advisory Group, Glasgow, UK
| | - Marion Barr
- NMAHP Research Unit, Stroke Rehabilitation Research Advisory Group, Glasgow, UK
| | - Alex Pollock
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Sheena McGowan
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Naomi Bowers
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Peter Langhorne
- Academic Section of Geriatric Medicine, Glasgow Royal Infirmary, Glasgow, UK
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27
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Warusevitane A, Karunatilake D, Sim J, Lally F, Roffe C. Safety and Effect of Metoclopramide to Prevent Pneumonia in Patients With Stroke Fed via Nasogastric Tubes Trial. Stroke 2015; 46:454-60. [DOI: 10.1161/strokeaha.114.006639] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Anushka Warusevitane
- From the Stoke Stroke Research Group, University Hospital of North Staffordshire (A.W., C.R.), Stroke Services, Taunton and Somerset NHS Trust (D.K.), Health Services Research Unit (J.S., C.R.), and Institute for Science and Technology in Medicine (F.L., C.R.), Keele University, Staffordshire, United Kingdom
| | - Dumin Karunatilake
- From the Stoke Stroke Research Group, University Hospital of North Staffordshire (A.W., C.R.), Stroke Services, Taunton and Somerset NHS Trust (D.K.), Health Services Research Unit (J.S., C.R.), and Institute for Science and Technology in Medicine (F.L., C.R.), Keele University, Staffordshire, United Kingdom
| | - Julius Sim
- From the Stoke Stroke Research Group, University Hospital of North Staffordshire (A.W., C.R.), Stroke Services, Taunton and Somerset NHS Trust (D.K.), Health Services Research Unit (J.S., C.R.), and Institute for Science and Technology in Medicine (F.L., C.R.), Keele University, Staffordshire, United Kingdom
| | - Frank Lally
- From the Stoke Stroke Research Group, University Hospital of North Staffordshire (A.W., C.R.), Stroke Services, Taunton and Somerset NHS Trust (D.K.), Health Services Research Unit (J.S., C.R.), and Institute for Science and Technology in Medicine (F.L., C.R.), Keele University, Staffordshire, United Kingdom
| | - Christine Roffe
- From the Stoke Stroke Research Group, University Hospital of North Staffordshire (A.W., C.R.), Stroke Services, Taunton and Somerset NHS Trust (D.K.), Health Services Research Unit (J.S., C.R.), and Institute for Science and Technology in Medicine (F.L., C.R.), Keele University, Staffordshire, United Kingdom
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28
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Livengood HM, Baker NA. The role of occupational therapy in vision rehabilitation of individuals with glaucoma. Disabil Rehabil 2014; 37:1202-8. [PMID: 25243762 DOI: 10.3109/09638288.2014.961651] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Specific to individuals with glaucoma: (1) provide an overview of the role of occupational therapists (OTs) as part of the vision rehabilitation team, (2) outline evaluation and intervention approaches provided by OTs, and (3) summarize the evidence to support those intervention approaches. METHODS Literature on vision rehabilitation and the typical practice patterns of OTs working with individuals with glaucoma are reviewed and the occupational therapy process is applied to evaluation and intervention approaches. The evidence which supports intervention approaches for individuals with glaucoma is presented. RESULTS The strength of the evidence to support common intervention approaches employed by OTs is weak or inconclusive; many studies lack quality methodological rigor. Moderate evidence supports patient education programs and strong evidence supports problem-solving and self-management strategies; this evidence is based on a limited number of studies. CONCLUSION The prevalence of eye diseases is increasing; knowledge of how visual impairment affects disability will inform resource allocation and development of rehabilitation programs that address the unique needs of individuals with glaucoma. Rehabilitation specialists are key members of the healthcare team aligned to proactively recognize and develop comprehensive rehabilitation programs to maximize individuals' function, quality of life and independence in everyday living. IMPLICATIONS FOR REHABILITATION Glaucoma is one of the four major eye diseases that may result in visual impairment leading to disability. Research supports intervention approaches and vision rehabilitation techniques used by occupational therapists to optimize the health and well-being of individuals with glaucoma. Rehabilitation specialists are key members of the healthcare team who need to be alert to subtle behaviors that may be indicative of visual impairment versus attributed to other client factors.
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Affiliation(s)
- Heather M Livengood
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh , Pittsburgh, PA , USA
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29
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Tay WY, Low LL, Tan SY, Vasanwala FF. Evidence-Based Measures for Preventing Aspiration Pneumonia in Patients with Dysphagia. PROCEEDINGS OF SINGAPORE HEALTHCARE 2014. [DOI: 10.1177/201010581402300210] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Dysphagia increases the risk of aspiration pneumonia with resultant morbidity and recurrent hospital admissions. With a rapidly ageing population and an increasing complex chronic disease burden, the prevalence of patients with dysphagia will increase. Family physicians will encounter more patients with dysphagia in various practice settings of primary, intermediate long term care and tertiary settings. We conducted a comprehensive literature review on the latest established evidence on measures to prevent aspiration pneumonia in patients with dysphagia. We found that many studies involved only small numbers of patients and lacked the methodological quality of well-conducted randomised contolled trials. Interventions that showed strongest evidence in preventing aspiration pneumonia were good oral health and the use of Angiotensin Converting Enzyme (ACE) inhibitor. We have provided a summary of key recommendations for family physicians, based on the Scottish Intercollegiate Guidelines Network (SIGN) framework in order to reflect the latest evidence-based strategies on measures to prevent aspiration pneumonia in patients with dysphagia.
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Affiliation(s)
- Wei Yi Tay
- Department of Family Medicine and Continuing Care, Singapore General Hospital, Singapore
| | - Lian Leng Low
- Department of Family Medicine and Continuing Care, Singapore General Hospital, Singapore
| | - Shu Yun Tan
- Department of Family Medicine and Continuing Care, Singapore General Hospital, Singapore
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30
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Meuleners LB, Fraser ML, Ng J, Morlet N. The impact of first- and second-eye cataract surgery on injurious falls that require hospitalisation: a whole-population study. Age Ageing 2014; 43:341-6. [PMID: 24192250 DOI: 10.1093/ageing/aft177] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND cataract is a leading cause of reversible vision impairment and may increase falls in older adults. OBJECTIVE to assess the risk of an injury due to a fall among adults aged 60+, 2 years before first-eye cataract surgery, between first-eye surgery and second-eye surgery and 2 years after second-eye surgery. DESIGN a retrospective cohort study. SETTING Western Australian Hospital Morbidity Data System and the Western Australian Death Registry. SUBJECTS there were 28,396 individuals aged 60+ years who underwent bilateral cataract surgery in Western Australia between 2001 and 2008. METHODS Poisson regression analysis based on generalised estimating equations compared the frequency of falls 2 years before first-eye cataract surgery, between first- and second-eye surgery and 2 years after second-eye cataract surgery after accounting for potential confounders. RESULTS the risk of an injurious fall that required hospitalisation doubled (risk ratio: 2.14, 95% confidence interval: 1.82 to 2.51) between first- and second-eye cataract surgery compared with the 2 years before first-eye surgery. There was a 34% increase in the number of injurious falls that required hospitalisation in the 2 years after second-eye cataract surgery compared with the 2 years before first-eye surgery (risk ratio: 1.34, 95% confidence interval: 1.16-1.55). CONCLUSIONS there was an increased risk of injurious falls after first- and second-eye cataract surgery which has implications for the timely provision of second-eye surgery as well as appropriate refractive management between surgeries.
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Affiliation(s)
- Lynn B Meuleners
- School of Public Health, Curtin-Monash Accident Research Centre, Curtin University, Perth, Western Australia, Australia
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31
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Pohl P, Ahlgren C, Nordin E, Lundquist A, Lundin-Olsson L. Gender perspective on fear of falling using the classification of functioning as the model. Disabil Rehabil 2014; 37:214-22. [PMID: 24786969 PMCID: PMC4364267 DOI: 10.3109/09638288.2014.914584] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Purpose: To investigate associations between fear of falling (FOF) and recurrent falls among women and men, and gender differences in FOF with respect to International Classification of Functioning (ICF). Methods: Community-dwelling people (n = 230, 75–93 years, 72% women) were included and followed 1 year regarding falls. Data collection included self-reported demographics, questionnaires, and physical performance-based tests. FOF was assessed with the question “Are you afraid of falling?”. Results were discussed with a gender relational approach. Results: At baseline 55% women (n = 92) and 22% men (n = 14) reported FOF. During the follow-up 21% women (n = 35) and 30% men (n = 19) experienced recurrent falls. There was an association between gender and FOF (p = 0.001), but not between FOF and recurrent falls (p = 0.79), or between gender and recurrent falls (p = 0.32). FOF was related to Personal factors and Activity and Participation. The relationship between FOF and Personal factors was in opposite directions for women and men. Conclusions: Results did not support the prevailing paradigm that FOF increases rate of recurrent falls in community-dwelling people, and indicated that the answer to “Are you afraid of falling?” might be highly influenced by gendered patterns. Implications for Rehabilitation The question “Are you afraid of falling?” has no predictive value when screening for the risk of falling in independent community-dwelling women or men over 75 years of age. Gendered patterns might influence the answer to the question “Are you afraid of falling?” Healthcare personnel are recommended to be aware of this when asking older women and men about fear of falling.
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Affiliation(s)
- Petra Pohl
- Department of Community Medicine and Rehabilitation, Physiotherapy and
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32
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Wirth R, Smoliner C, Jäger M, Warnecke T, Leischker AH, Dziewas R. Guideline clinical nutrition in patients with stroke. EXPERIMENTAL & TRANSLATIONAL STROKE MEDICINE 2013; 5:14. [PMID: 24289189 PMCID: PMC4176491 DOI: 10.1186/2040-7378-5-14] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 11/22/2013] [Indexed: 01/04/2023]
Abstract
Stroke is regularly accompanied by dysphagia and other factors associated with decreased nutritional intake. Dysphagia with aspiration pneumonia and insufficient nutritional intake lead to worse outcome after stroke. This guideline is the first chapter of the guideline “Clinical Nutrition in Neurology” of the German Society for Clinical Nutrition (DGEM) which itself is one part of a comprehensive guideline about all areas of Clinical Nutrition. The thirty-one recommendations of the guideline are based on a systematic literature search and review, last updated December 31, 2011. All recommendations were discussed and consented at several consensus conferences with the entire DGEM guideline group. The recommendations underline the importance of an early screening and assessment of dysphagia and give advice for an evidence based and comprehensive nutritional management to avoid aspiration, malnutrition and dehydration.
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Affiliation(s)
- Rainer Wirth
- Department of Internal Medicine and Geriatrics, St, Marien-Hospital Borken, Am Boltenhof 7, D-46325 Borken, Germany.
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Sensorimotor Adaptation Training’s Effect on Head Stabilization in Response to a Lateral Perturbation in Older Adults. J Aging Phys Act 2013; 21:272-89. [DOI: 10.1123/japa.21.3.272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The goal of this study was to determine if exposure to sensorimotor adaptation training improved head stabilization in older adults. Sixteen participants, age 66–81 yr, were assigned at random to the control group (n= 8) or the experimental group (n= 8). Both groups first completed 6 trials of walking a foam pathway consisting of a moveable platform that induced a lateral perturbation during walking. Head-in-space and trunk-in-space angular velocities were collected. Participants from both groups then trained twice per week for 4 wk. Both groups walked on a treadmill for 20 min. The control group viewed a static scene. The experimental group viewed a rotating visual scene that provided a perceptual-motor mismatch. After training, both groups were retested on the perturbation pathway test. The experimental group used a movement strategy that preserved head stabilization compared with the controls (p< .05). This training effect was not retained after 4 wk.
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Hannawi Y, Hannawi B, Rao CPV, Suarez JI, Bershad EM. Stroke-associated pneumonia: major advances and obstacles. Cerebrovasc Dis 2013; 35:430-43. [PMID: 23735757 DOI: 10.1159/000350199] [Citation(s) in RCA: 220] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 02/14/2013] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Stroke-associated pneumonia (SAP) has been implicated in the morbidity, mortality and increased medical cost after acute ischemic stroke. The annual cost of SAP during hospitalization in the United States approaches USD 459 million. The incidence and prognosis of SAP among intensive care unit (ICU) patients have not been thoroughly investigated. We reviewed the pathophysiology, microbiology, incidence, risk factors, outcomes and prophylaxis of SAP with special attention to ICU studies. METHODS To determine the incidence, risk factors and prognosis of acute SAP, PubMed was searched using the terms 'pneumonia' AND 'neurology intensive unit' and the MeSH terms 'stroke' AND 'pneumonia'. Non-English literature, case reports and chronic SAP studies were excluded. Studies were classified into 5 categories according to the setting they were performed in: neurological intensive care units (NICUs), medical intensive care units (MICUs), stroke units, mixed studies combining more than one setting or when the settings were not specified and rehabilitation studies. RESULTS The incidences of SAP in the following settings were: NICUs 4.1-56.6%, MICUs 17-50%, stroke units 3.9-44%, mixed studies 3.9-23.8% and rehabilitation 3.2-11%. The majority of NICU and MICU studies were heterogeneous including different neurovascular diseases, which partly explains the wide range of SAP incidence. The higher incidence in the majority of ICU studies compared to stroke units or acute floor studies is likely explained by the presence of mechanical ventilation, higher stroke severity causing higher rates of aspiration and stroke-induced immunodepression among ICU patients. The short-term mortality of SAP was increased among the mixed and stroke unit studies ranging between 10.1 and 37.3%. SAP was associated with worse functional outcome in the majority of stroke unit and floor studies. Mortality was less consistent among NICU and MICU studies. This difference could be due to the heterogeneity of ICU studies and the effect of small sample size or other independent risk factors for mortality such as the larger neurological deficit, mechanical ventilation, and age, which may simultaneously increase the risk of SAP and mortality confounding the outcomes of SAP itself. The pathophysiology of SAP is likely explained by aspiration combined with stroke-induced immunodepression through complex humeral and neural pathways that include the hypothalamic-pituitary-adrenal axis, parasympathetic and sympathetic systems. CONCLUSIONS A unified definition of SAP, strict inclusion criteria, and the presence of a long-term follow-up need to be applied to the future prospective studies to better identify the incidence and prognosis of SAP, especially among ICU patients.
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Affiliation(s)
- Yousef Hannawi
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA. yousefhannawi @ yahoo.com
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35
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Geeganage C, Beavan J, Ellender S, Bath PMW. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev 2012; 10:CD000323. [PMID: 23076886 DOI: 10.1002/14651858.cd000323.pub2] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Dysphagia (swallowing problems) are common after stroke and can cause chest infection and malnutrition. Dysphagic, and malnourished, stroke patients have a poorer outcome. OBJECTIVES To assess the effectiveness of interventions for the treatment of dysphagia (swallowing therapy), and nutritional and fluid supplementation, in patients with acute and subacute (within six months from onset) stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (February 2012), MEDLINE (1966 to July 2011), EMBASE (1980 to July 2011), CINAHL (1982 to July 2011) and Conference Proceedings Citation Index- Science (CPCI-S) (1990 to July 2011). We also searched the reference lists of relevant trials and review articles, searched Current Controlled Trials and contacted researchers (July 2011). For the previous version of this review we contacted the Royal College of Speech and Language Therapists and equipment manufacturers. SELECTION CRITERIA Randomised controlled trials (RCTs) in dysphagic stroke patients, and nutritional supplementation in all stroke patients, where the stroke occurred within six months of enrolment. DATA COLLECTION AND ANALYSIS Two review authors independently applied the inclusion criteria, assessed trial quality, and extracted data, and resolved any disagreements through discussion with a third review author. We used random-effects models to calculate odds ratios (OR), 95% confidence intervals (95% CI), and mean differences (MD). The primary outcome was functional outcome (death or dependency, or death or disability) at the end of the trial. MAIN RESULTS We included 33 studies involving 6779 participants.Swallowing therapy: acupuncture, drug therapy, neuromuscular electrical stimulation, pharyngeal electrical stimulation, physical stimulation (thermal, tactile), transcranial direct current stimulation, and transcranial magnetic stimulation each had no significant effect on case fatality or combined death or dependency. Dysphagia at end-of-trial was reduced by acupuncture (number of studies (t) = 4, numbers of participants (n) = 256; OR 0.24; 95% CI 0.13 to 0.46; P < 0.0001; I(2) = 0%) and behavioural interventions (t = 5; n = 423; OR 0.52; 95% CI 0.30 to 0.88; P = 0.01; I(2) = 22%). Route of feeding: percutaneous endoscopic gastrostomy (PEG) and nasogastric tube (NGT) feeding did not differ for case fatality or the composite outcome of death or dependency, but PEG was associated with fewer treatment failures (t = 3; n = 72; OR 0.09; 95% CI 0.01 to 0.51; P = 0.007; I(2) = 0%) and gastrointestinal bleeding (t = 1; n = 321; OR 0.25; 95% CI 0.09 to 0.69; P = 0.007), and higher feed delivery (t = 1; n = 30; MD 22.00; 95% CI 16.15 to 27.85; P < 0.00001) and albumin concentration (t = 3; n = 63; MD 4.92 g/L; 95% CI 0.19 to 9.65; P = 0.04; I(2) = 58%). Although looped NGT versus conventional NGT feeding did not differ for end-of-trial case fatality or death or dependency, feed delivery was higher with looped NGT (t = 1; n = 104; MD 18.00%; 95% CI 6.66 to 29.34; P = 0.002). Timing of feeding: there was no difference for case fatality, or death or dependency, with early feeding as compared to late feeding. Fluid supplementation: there was no difference for case fatality, or death or dependency, with fluid supplementation. Nutritional supplementation: there was no difference for case fatality, or death or dependency, with nutritional supplementation. However, nutritional supplementation was associated with reduced pressure sores (t = 2; n = 4125; OR 0.56; 95% CI 0.32 to 0.96; P = 0.03; I(2) = 0%), and, by definition, increased energy intake (t = 3; n = 174; MD 430.18 kcal/day; 95% CI 141.61 to 718.75; P = 0.003; I(2) = 91%) and protein intake (t = 3; n = 174; MD 17.28 g/day; 95% CI 1.99 to 32.56; P = 0.03; I(2) = 92%). AUTHORS' CONCLUSIONS There remains insufficient data on the effect of swallowing therapy, feeding, and nutritional and fluid supplementation on functional outcome and death in dysphagic patients with acute or subacute stroke. Behavioural interventions and acupuncture reduced dysphagia, and pharyngeal electrical stimulation reduced pharyngeal transit time. Compared with NGT feeding, PEG reduced treatment failures and gastrointestinal bleeding, and had higher feed delivery and albumin concentration. Nutritional supplementation was associated with reduced pressure sores, and increased energy and protein intake.
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Affiliation(s)
- Chamila Geeganage
- Clinical Pharmacology and Pharmacy, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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Silvestri L, de la Cal MA, van Saene HKF. Selective decontamination of the digestive tract: the mechanism of action is control of gut overgrowth. Intensive Care Med 2012; 38:1738-50. [PMID: 23001446 DOI: 10.1007/s00134-012-2690-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 08/03/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE Gut overgrowth is the pathophysiological event in the critically ill requiring intensive care. In relation to the risk of developing a clinically important outcome, gut overgrowth is defined as ≥10(5) potential pathogens including 'abnormal' aerobic Gram-negative bacilli (AGNB), 'normal' bacteria and yeasts, per mL of digestive tract secretion. Surveillance samples of throat and gut are the only samples to detect overgrowth. Gut overgrowth is the crucial event which precedes both primary and secondary endogenous infection, and a risk factor for the development of de novo resistance. Selective decontamination of the digestive tract (SDD) is an antimicrobial prophylaxis designed to control overgrowth. METHODS There have been 65 randomised controlled trials of SDD in 15,000 patients over 25 years and 11 meta-analyses, which are reviewed. RESULTS AND CONCLUSIONS These trials demonstrate that the full SDD regimen using parenteral and enteral antimicrobials reduces lower airway infection by 72 %, blood stream infection by 37 %, and mortality by 29 %. Resistance is also controlled. Parenteral cefotaxime which reaches high salivary and biliary concentrations eradicates overgrowth of 'normal' bacteria such as Staphylococcus aureus in the throat. Enteral polyenes control 'normal' Candida species. Enteral polymyxin and tobramycin, eradicate, or prevent gut overgrowth of 'abnormal' AGNB. Enteral vancomycin controls overgrowth of 'abnormal' methicillin-resistant S. aureus. SDD controls overgrowth by achieving high antimicrobial concentrations effective against 'normal' and 'abnormal' potential pathogens rather than by selectivity.
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Affiliation(s)
- Luciano Silvestri
- Department of Emergency, Unit of Anesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Via Fatebenefratelli 34, 34170, Gorizia, Italy
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Salat D, Campos M, Montaner J. [Advances in the pathophysiology and management of infections in the acute phase of stroke]. Med Clin (Barc) 2012; 139:681-7. [PMID: 22652018 DOI: 10.1016/j.medcli.2012.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 03/14/2012] [Accepted: 03/22/2012] [Indexed: 11/18/2022]
Abstract
Infection in the acute phase of stroke has been identified as an independent predictor of poor outcome, both in the short and intermediate term. Various factors raising the risk of developing an infection (exposure to multiple pathogens, disruption of the protective function of the mucous membranes and a state of relative immunosuppression) coexist during the acute phase of stroke. Several risk factors have been identified for their development (especially increasing age and stroke severity). It has been proposed that infection contributes to a worse prognosis through different mechanisms, notably the development of an inflammatory response to brain tissue (with a potential to add secondary damage to that caused by the ischemic insult). Clinical trials evaluating the prophylactic and early administration of antibiotics to reduce the incidence of infection in the acute phase of stroke have yielded inconsistent results. Immunomodulating strategies, which may provide therapeutic alternatives in the future, are currently being evaluated.
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Affiliation(s)
- David Salat
- Laboratorio de Investigación Neurovascular, Unidad Neurovascular, Departamento de Neurología, Hospital Vall d'Hebron, Barcelona, España
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Silvestri L, van Saene HKF, Petros AJ. Selective digestive tract decontamination in critically ill patients. Expert Opin Pharmacother 2012; 13:1113-29. [PMID: 22533385 DOI: 10.1517/14656566.2012.681778] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Selective decontamination of the digestive tract (SDD) has been proposed to prevent endogenous and exogenous infections and to reduce mortality in critically ill patients. Although the efficacy of SDD has been confirmed by randomized controlled trials (RCTs) and systematic reviews, SDD has been the subject of intense controversy, based mainly on an insufficient evidence of efficacy and on concerns about resistance. AREAS COVERED This article reviews the philosophy, the current evidence on the efficacy of SDD and the issue of emergence of resistance. All SDD RCTs were searched using Embase and Medline, with no restriction of language, gender or age. Personal archives were also explored, including abstracts from major scientific meetings; references in papers and published meta-analyses on SDD were crosschecked. Up-to-date evidence of the impact of SDD on carriage, infections and mortality is presented, and the efficacy of SDD in selected patient groups was investigated, along with the problem of the emergence of resistance. EXPERT OPINION SDD significantly reduces the number of infections of the lower respiratory tract and bloodstream, multiple organ failure and mortality. It also controls resistance, particularly when the full protocol of parenteral and enteral antimicrobials is used.
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Affiliation(s)
- Luciano Silvestri
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Via Fatebenefratelli 34, 34170 Gorizia, Italy.
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Comparison of outcomes before and after implementation of a water protocol for patients with cerebrovascular accident and dysphagia. J Neurosci Nurs 2012; 43:165-71. [PMID: 21796034 DOI: 10.1097/jnn.0b013e3182135adf] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to investigate the impact of a water protocol on the incidence of aspiration pneumonia in persons with cerebrovascular accident and dysphagia admitted to an acute neurologic rehabilitation setting. Retrospective chart review and cohort matching of persons with dysphagia admitted before and after the implementation of a water protocol were carried out. The incidence of aspiration pneumonia was higher in the cohort control group-those patients admitted during the years before the implementation of a water protocol. No persons with dysphagia who received water, even if known aspirators of thin liquids, developed aspiration pneumonia. Our findings support the premise that even in known thin liquid aspirators, offering water does not increase incidence of aspiration pneumonia.
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Westendorp WF, Vermeij JD, Vermeij F, Den Hertog HM, Dippel DWJ, van de Beek D, Nederkoorn PJ. Antibiotic therapy for preventing infections in patients with acute stroke. Cochrane Database Syst Rev 2012; 1:CD008530. [PMID: 22258987 DOI: 10.1002/14651858.cd008530.pub2] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Stroke is the main cause of disability in high income countries and ranks second as a cause of death worldwide. Infections occur frequently after stroke and may adversely affect outcome. Preventive antibiotic therapy in the acute phase of stroke may reduce infections and improve outcome. OBJECTIVES 1. To assess whether preventive antibiotic therapy in patients with acute stroke reduces the risk of dependency and death at follow-up. 2. To assess whether preventive antibiotic therapy in patients with acute stroke reduces infection rate. SEARCH METHODS We searched the Cochrane Stroke Group's Trials Register (October 2010); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 3); MEDLINE (1950 to October 2010) and EMBASE (1980 to October 2010). In an effort to identify further published, unpublished and ongoing trials we searched trials and research registers, scanned reference lists and contacted authors, colleagues and researchers in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) of preventive antibiotic therapy versus control (placebo or open control) in patients with acute ischaemic or haemorrhagic stroke. DATA COLLECTION AND ANALYSIS Two authors independently selected articles and performed data extraction; we discussed and resolved discrepancies in a consensus meeting with a third observer. We contacted the study authors to obtain missing data when required. An independent observer assessed methodological quality. We calculated relative risks (RRs) for dichotomous outcomes, assessed heterogeneity amongst included studies and performed subgroup analyses on study quality. MAIN RESULTS We included five studies involving 506 patients. Study population, study design, type of antibiotic and definition of infection differed considerably. The number of patients who died in the preventive antibiotic group was non-significantly reduced (33/248 (13%) versus 38/258 (15%), RR 0.85, 95% confidence interval (CI) 0.47 to 1.51); the number of dependent patients in the preventive antibiotic therapy group was also non-significantly reduced (97/208 (47%) versus 127/208 (61%), RR 0.67, 95% CI 0.32 to 1.43). Preventive antibiotic therapy did reduce the incidence of infections in patients with acute stroke from 36% to 22% (36/166 (22%) versus 61/169 (36%), RR 0.58, 95% CI 0.43 to 0.79). No major side-effects of preventive antibiotic therapy were reported. AUTHORS' CONCLUSIONS In this meta-analysis, preventive antibiotic therapy seemed to reduce the risk of infection, but did not reduce the number of dependent or deceased patients. However, the included studies were small and heterogeneous. Large randomised trials are urgently needed.
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Westendorp WF, Nederkoorn PJ, Vermeij JD, Dijkgraaf MG, van de Beek D. Post-stroke infection: a systematic review and meta-analysis. BMC Neurol 2011; 11:110. [PMID: 21933425 PMCID: PMC3185266 DOI: 10.1186/1471-2377-11-110] [Citation(s) in RCA: 474] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 09/20/2011] [Indexed: 11/10/2022] Open
Abstract
Background stroke is the main cause of disability in high-income countries, and ranks second as a cause of death worldwide. Patients with acute stroke are at risk for infections, but reported post-stroke infection rates vary considerably. We performed a systematic review and meta-analysis to estimate the pooled post-stroke infection rate and its effect on outcome. Methods MEDLINE and EMBASE were searched for studies on post-stroke infection. Cohort studies and randomized clinical trials were included when post-stroke infection rate was reported. Rates of infection were pooled after assessment of heterogeneity. Associations between population- and study characteristics and infection rates were quantified. Finally, we reviewed the association between infection and outcome. Results 87 studies were included involving 137817 patients. 8 studies were restricted to patients admitted on the intensive care unit (ICU). There was significant heterogeneity between studies (P < 0.001, I2 = 97%). The overall pooled infection rate was 30% (24-36%); rates of pneumonia and urinary tract infection were 10% (95% confidence interval [CI] 9-10%) and 10% (95%CI 9-12%). For ICU studies, these rates were substantially higher with 45% (95% CI 38-52%), 28% (95%CI 18-38%) and 20% (95%CI 0-40%). Rates of pneumonia were higher in studies that specifically evaluated infections and in consecutive studies. Studies including older patients or more females reported higher rates of urinary tract infection. Pneumonia was significantly associated with death (odds ratio 3.62 (95%CI 2.80-4.68). Conclusions Infection complicated acute stroke in 30% of patients. Rates of pneumonia and urinary tract infection after stroke were 10%. Pneumonia was associated with death. Our study stresses the need to prevent infections in patients with stroke.
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Greater amount of visual information exacerbates force control in older adults during constant isometric contractions. Exp Brain Res 2011; 213:351-61. [PMID: 21800256 DOI: 10.1007/s00221-011-2777-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 06/16/2011] [Indexed: 10/17/2022]
Abstract
The purpose of this study was to compare control of force and modulation of agonist muscle activity of young and older adults when the amount of visual feedback was varied at two different force levels. Ten young adults (25 years ± 4 years, 5 men and 5 women) and ten older adults (71 years ± 5 years, 4 men and 6 women) were instructed to accurately match a constant target force at 2 and 30% of their maximal isometric force with abduction of the index finger. Each trial lasted 35 s, and the amount of visual feedback was varied by changing the visual angle at 0.05, 0.5, and 1.5°. Each subject performed three trials for each visual angle condition. Force variability was quantified as the standard deviation and coefficient of variation (CV) of force. Modulation of the agonist muscle activity was quantified as the normalized power spectrum density of the EMG signal recorded from two pairs of bipolar electrodes placed on the first dorsal interosseus muscle. The frequency bands of interest were between 5 and 100 Hz. There were significant age-associated differences in force control with changes in the amount of visual feedback. The CV of force did not change with visual angle for young adults, whereas it increased for older adults. Although older adults exhibited similar CV of force to young adults at 0.05° (5.95 ± 0.67 vs. 5.47 ± 0.5), older adults exhibited greater CV of force than young adults at 0.5° (8.49 ± 1.34 vs. 5.05 ± 0.5) and 1.5° (8.23 ± 1.12 vs. 5.49 ± 0.6). In addition, there were age-associated differences in the modulation of the agonist muscle activity. Young adults increased normalized power in the EMG signal from 13 to 60 Hz with an increase in visual angle, whereas older adults did not. These findings suggest that greater amount of visual information may be detrimental to the control of a constant isometric contraction in older adults, and this impairment may be due to their inability to effectively modulate the motor neuron pool of the agonist muscle.
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Brady MC, Stott DJ, Norrie J, Chalmers C, St George B, Sweeney PM, Langhorne P. Developing and evaluating the implementation of a complex intervention: using mixed methods to inform the design of a randomised controlled trial of an oral healthcare intervention after stroke. Trials 2011; 12:168. [PMID: 21729277 PMCID: PMC3155479 DOI: 10.1186/1745-6215-12-168] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Accepted: 07/05/2011] [Indexed: 11/26/2022] Open
Abstract
Background Many interventions delivered within the stroke rehabilitation setting could be considered complex, though some are more complex than others. The degree of complexity might be based on the number of and interactions between levels, components and actions targeted within the intervention. The number of (and variation within) participant groups and the contexts in which it is delivered might also reflect the extent of complexity. Similarly, designing the evaluation of a complex intervention can be challenging. Considerations include the necessity for intervention standardisation, the multiplicity of outcome measures employed to capture the impact of a multifaceted intervention and the delivery of the intervention across different clinical settings operating within varying healthcare contexts. Our aim was to develop and evaluate the implementation of a complex, multidimensional oral health care (OHC) intervention for people in stroke rehabilitation settings which would inform the development of a randomised controlled trial. Methods After reviewing the evidence for the provision of OHC following stroke, multi-disciplinary experts informed the development of our intervention. Using both quantitative and qualitative methods we evaluated the implementation of the complex OHC intervention across patients, staff and service levels of care. We also adopted a pragmatic approach to patient recruitment, the completion of assessment tools and delivery of OHC, alongside an attention to the context in which it was delivered. Results We demonstrated the feasibility of implementing a complex OHC intervention across three levels of care. The complementary nature of the mixed methods approach to data gathering provided a complete picture of the implementation of the intervention and a detailed understanding of the variations within and interactions between the components of the intervention. Information on the feasibility of the outcome measures used to capture impact across a range of components was also collected, though some process orientated uncertainties including eligibility and recruitment rates remain to be further explored within a Phase II exploratory trial. Conclusions Complex interventions can be captured and described in a manner which facilitates evaluation in the form of exploratory and subsequently definitive clinical trials. If effective, the evidence captured relating to the intervention context will facilitate translation into clinical practice.
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Affiliation(s)
- Marian C Brady
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK.
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van Saene HKF, Petros AJ, Sarginson RE, Gordon AC, Bion JF. Is Selective Decontamination of the Digestive Tract a Solution to the Antimicrobial Resistance Problem in the UK? J Intensive Care Soc 2009. [DOI: 10.1177/175114370901000202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Hendrick KF van Saene
- Consultant/Reader Medical Microbiology, School of Clinical Sciences, University of Liverpool
| | - Andy J Petros
- Consultant Intensivist, Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children
| | - Richard E Sarginson
- Consultant Anaesthetist & Intensive Care Medicine, Intensive Care Unit, Royal Liverpool Children's NHS Trust
| | - Anthony C Gordon
- Consultant and Honorary Senior Lecturer, Critical Care Medicine, Charing Cross Hospital, Imperial College NHS Trust
| | - Julian F Bion
- Professor of Intensive Care Medicine, University Dept Anaesthesia and Intensive Care Medicine, Queen Elizabeth Hospital, Birmingham
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Buccello-Stout RR, Bloomberg JJ, Cohen HS, Whorton EB, Weaver GD, Cromwell RL. Effects of sensorimotor adaptation training on functional mobility in older adults. J Gerontol B Psychol Sci Soc Sci 2008; 63:P295-300. [PMID: 18818444 DOI: 10.1093/geronb/63.5.p295] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The goal of this study was to determine if prolonged exposure to perceptual-motor mismatch increased adaptability and retention of balance in older adults. Sixteen adults, aged 66 to 81 years, were randomized to one of two groups: either the control group (n=8) or the experimental group (n=8). Both groups first completed six trials of walking an obstacle course. Participants then trained twice a week for 4 weeks. In the training, the control group walked on a treadmill for 20 minutes while viewing a static visual scene and the experimental group walked on a treadmill for 20 minutes while viewing a rotating visual scene that provided a perceptual-motor mismatch. Following training, both groups were post-tested on the obstacle course. The experimental group moved faster through the obstacle course with fewer penalties. This training effect was retained for 4 weeks. Exposure to perceptual-motor mismatch induced an adaptive training effect that improved balance and locomotor control in older adults.
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Affiliation(s)
- Regina R Buccello-Stout
- Division for Flight Analogs, Universities Space Research Association, NASA Johnson Space Center, 2101 NASA Parkway, Mail Code SK37, Houston, TX 77058, USA.
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To review or not to review: that is the question. J Hosp Infect 2008. [DOI: 10.1016/j.jhin.2008.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Silvestri L, Van Saene HKF, Casarin A, Berlot G, Gullo A. Impact of Selective Decontamination of the Digestive Tract on Carriage and Infection Due to Gram-Negative and Gram-Positive Bacteria: A Systematic Review of Randomised Controlled Trials. Anaesth Intensive Care 2008; 36:324-38. [PMID: 18564793 DOI: 10.1177/0310057x0803600304] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Meta-analyses of randomised controlled trials of selective digestive decontamination have clinical outcome measures, mainly pneumonia and mortality. This meta-analysis has a microbiological endpoint and explores the impact of selective digestive decontamination on Gram-negative and Gram-positive carriage and severe infections. We searched electronic databases, Cochrane Register of Controlled Trials, previous meta-analyses and conference proceedings with no language restrictions. We included randomised controlled trials which compared the selective digestive decontamination protocol with no treatment or placebo. Three reviewers independently applied selection criteria, performed the quality assessment and extracted the data. The outcome measures were carriage and severe infection due to Gram-negative and Gram-positive bacteria. Odds ratios were pooled with the random effect model. Fifty-four randomised controlled trials comprising 9473 patients were included; 4672 patients received selective digestive decontamination and 4801 were controls. Selective digestive decontamination significantly reduced oropharyngeal carriage (odds ratio [OR] 0.13, 95% confidence interval [CI] 0.07 to 0.23), rectal carriage (OR 0.15, 95% CI 0.07 to 0.31), overall infection (OR 0.17, 95% CI 0.10 to 0.28), lower respiratory tract infection (OR 0.11, 95% CI 0.06 to 0.20) and bloodstream infection (OR 0.35, 95% CI 0.21 to 0.67) due to Gram-negative bacteria. Reduction in Gram-positive carriage was not significant. Gram-positive lower airway infections were significantly reduced (OR 0.52, 95% CI 0.34 to 0.78). Gram-positive bloodstream infections were not significantly increased (OR 1.03, 95% CI 0.75 to 1.41). The association of parenteral and enteral antimicrobials was superior to enteral antimicrobials in reducing carriage and severe infections due to Gram-negative bacteria. This meta-analysis confirms that selective digestive decontamination mainly targets Gram-negative bacteria; it does not show a significant increase in Gram-positive infection.
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Affiliation(s)
- L. Silvestri
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Head, Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
| | - H. K. F. Van Saene
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Department of Medical Microbiology, University of Liverpool and Department of Clinical Microbiology and Infection Control, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - A. Casarin
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Department of Critical Care, St. Michael's Hospital, Toronto, Ontario, Canada
| | - G. Berlot
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Head, Unit of Anesthesia, Intensive Care and Pain Therapy, University Hospital, Trieste, Italy
| | - A. Gullo
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Head, Unit of Anaesthesia and Intensive Care, Policlinico University Hospital, Catania, Italy
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Foley N, Teasell R, Salter K, Kruger E, Martino R. Dysphagia treatment post stroke: a systematic review of randomised controlled trials. Age Ageing 2008; 37:258-64. [PMID: 18456790 DOI: 10.1093/ageing/afn064] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND dysphagia is common following stroke and is associated with the development of pneumonia. Many dysphagia treatment options are available, some still experimental and others already rooted in common practice. Previous reviews of these treatments were limited due to a dearth of available studies. Recently, more trials have been published warranting a re-examination of the evidence. OBJECTIVE a systematic review of all randomised controlled trials (RCTs), updating previous work and evaluating a broader range of therapeutic interventions intended for use in adults recovering from stroke and dysphagia. METHODS using multiple databases, we identified RCTs published between the years 1966 and August 2007 examining the efficacy of dysphagia therapies following stroke. Across studies, results of similar treatments and outcomes were compared and evaluated. RESULTS fifteen articles were retrieved assessing a broad range of treatments that included texture-modified diets, general dysphagia therapy programmes, non-oral (enteral) feeding, medications, and physical and olfactory stimulation. Across the studies there was heterogeneity of the treatments evaluated and the outcomes assessed that precluded the use of pooled analyses. Descriptively these findings present emerging evidence that nasogastric tube feeding is not associated with a higher risk of death compared to percutaneous feeding tubes; and general dysphagia therapy programmes are associated with a reduced risk of pneumonia in the acute stage of stroke. CONCLUSIONS dysphagia is known to be a common and potentially serious complication of stroke. Despite the recent newly published RCTs, few utilise the same treatment and outcomes thereby limiting the evidence to support the medical effectiveness of common dysphagia treatments used for patients recovering from stroke.
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Affiliation(s)
- Norine Foley
- Lawson Health Research Institute, Parkwood Hospital, Rm B-3019b, 801 Commissioner's Rd. E. London, ON N6C 5J1, Canada.
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Silvestri L, van Saene HKF, Thomann C, Perić M. Selective decontamination of the digestive tract reduces pneumonia and mortality without resistance emerging. Am J Infect Control 2007; 35:354-7. [PMID: 17577486 DOI: 10.1016/j.ajic.2006.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Accepted: 07/05/2006] [Indexed: 11/29/2022]
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