Aspiration and dysphagia screening in acute stroke - the Gugging Swallowing Screen revisited

Reliability, validity and normative data of the timed water swallow test accompanied by sEMG

PURPOSE

Swallowing disorders are highly interrelated with increased morbidity and mortality rates; therefore, early detection is crucial. Most screening tools rely on subjective observation, thus making objective assessment tools more vital. Timed Water Swallowing Test (TWST) is a screening tool used in the field providing quantitative data. This study aimed to investigate the swallowing parameters in a wide age range by using TWST and to expand the already existing normative data pool accordingly. It is also aimed to examine the reliability of the TWST and assess its validity in stroke survivors.

MATERIALS AND METHODS

This study had a cross-sectional design. TWST carried out simultaneously along with surface EMG and laryngeal sensor on 196 healthy subjects aged 10 to 80 for normative data. Also, TWST carried out 30 patients having a history of recent stroke. Test-retest and inter-rater scoring analysis were used for reliability purposes, while Gugging Swallowing Screen (GUSS) test was used for validity purposes. Additionally, the correlations between the participants' TWST scores and GUSS scores were examined using the Spearman correlation coefficient.

RESULTS

The normative TWST data of healthy participants are tabulated and presented and their average swallowing capacity was found 13.73 ml/s. Furthermore, the mean swallowing capacity of stroke survivors was found 4.61 ml/s. As a result of validity analyses, a statistically strong and significant relationship was found between GUSS and TWST parameters (r = 0.775, p < 0.001). Intraclass correlation coefficient (ICC) and correlation values were found between moderate to good agreement between test-retest measurement (ICC = 0.563 to 0.891, p < 0.05). Also, the agreement between the raters was found to be significant (ICC = 0.949 to 0.995, p < 0.05).

CONCLUSION

TWST is a valid and reliable screening tool to evaluate dysphagia on given population. Although the test's performance on healthy individuals is adequate, more research is still needed to confirm that it can be used as a screening tool for stroke.

Incidence and factors associated with dysphagia in intensive care unit patients 24 h after extubation

BACKGROUND

Post-extubation dysphagia deserves attention because it places patients at risk following extubation, especially critically ill patients in intensive care unit. However, there are limited studies of post-extubation dysphagia in the early stages after extubation.

AIM

To investigate the incidence and factors associated with post-extubation dysphagia among patients in intensive care unit within 24 h of extubation.

STUDY DESIGN

A prospective descriptive study was carried out with 173 adult patients in intensive care unit with tracheal extubation at a tertiary hospital in Guangzhou, China. The Gugging Swallowing Screen was used to evaluate the swallowing function of patients 1, 4 and 24 h after extubation. Demographic and clinical data were retrieved from medical records.

RESULTS

The incidence of post-extubation dysphagia in patients within 1, 4 and 24 h after extubation was 86.71% (n = 150), 63.01% (n = 109) and 43.35% (n = 75), respectively. The risk factors included older age (OR = 1.057, 95%CI [1.039, 1.072], p < .001), cardiovascular disease (OR = 0.098, 95%CI [0.082, 0.127], p = .012), thyroid dysfunction (OR = 5.042, 95%CI [1.527, 13.684], p < .001), non-post-operative admission (OR = 3.186, 95%CI [1.142, 14.422], p = .036), mechanical ventilation duration >48 h (OR = 3.558, 95%CI [1.217, 10.385], p = .020), intubation duration >24 h (OR = 0.533, 95%CI [0.278, 0.898], p = .048) and intubation model size ≤7 (OR = 0.327, 95%CI [0.158, 0.788], p < .01).

CONCLUSIONS

This study revealed a high incidence of post-extubation dysphagia in critical patients in the 24 h after extubation, with the incidence decreasing over time. Screening of early post-extubation dysphagia after extubation is needed, but the specific evaluation time point requires further investigation. Patients with older age, cerebrovascular disease, thyroid dysfunction, post-operative admission, longer mechanical ventilation time, thicker intubation models and longer intubation time have a higher risk of the occurrence of post-extubation dysphagia.

RELEVANCE TO CLINICAL PRACTICE

The incidence of post-extubation dysphagia is very high in the early stage. Within 24 h after extubation, the patient's swallowing function should be actively evaluated, and the occurrence of aspiration should be vigilant. Patients with older age, cerebrovascular disease, thyroid dysfunction, post-operative admission, longer mechanical ventilation time, thicker intubation models and longer intubation time should receive more attention.

Advancing stroke patient care: a network meta-analysis of dysphagia screening efficacy and personalization

Introduction

The increasing incidence of stroke globally has led to dysphagia becoming one of the most common complications in stroke patients, with significant impacts on patient outcomes. Accurate early screening for dysphagia is crucial to avoid complications and improve patient quality of life.

Methods

Included studies involved stroke-diagnosed patients assessed for dysphagia using bedside screening tools. Data was sourced from Embase, PubMed, Web of Science, Scopus, and CINAHL, including publications up to 10 December 2023. The study employed both fixed-effect and random-effects models to analyze sensitivity, specificity, positive predictive value (PPV), and Negative Predictive Value (NPV), each with 95% confidence intervals. The random-effects model was particularly utilized due to observed heterogeneity in study data.

Results

From 6,979 records, 21 studies met the inclusion criteria, involving 3,314 participants from 10 countries. The analysis included six assessment tools: GUSS, MASA, V-VST, BSST, WST, and DNTA, compared against gold-standard methods VFSS and FEES. GUSS, MASA, and V-VST showed the highest reliability, with sensitivity and specificity rates of 92% and 85% for GUSS, 89% and 83% for MASA, respectively. Heterogeneity among studies was minimal, and publication bias was low, enhancing the credibility of the findings.

Conclusion

Our network meta-analysis underscores the effectiveness of GUSS, MASA, and V-VST in dysphagia screening for stroke patients, with high sensitivity and specificity making them suitable for diverse clinical settings. BSST and WST, with lower diagnostic accuracy, require more selective use. Future research should integrate patient-specific outcomes and standardize methodologies to enhance dysphagia screening tools, ultimately improving patient care and reducing complications.

Systematic review registration

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

Exploring the diagnostic accuracy and applicability of the Gugging Swallowing Screen in children with feeding and/or swallowing disorders

BACKGROUND

The Gugging Swallowing Screen (GUSS) is a bedside dysphagia screening tool that has been designed to determine the risk of aspiration in acute stroke patients. There is no evidence in the literature for the GUSS for the pediatric population. The present study aimed to determine the diagnostic accuracy of GUSS as a screening tool in the Greek language for children with dysphagia.

METHODS

Eighty-Greek-Cypriot children aged 3-12 years who had dysphagia participated in this retrospective study. The translated into Greek GUSS was administered twice (pre- and post-therapy) to each patient throughout 24 sessions of dysphagia therapy.

KEY RESULTS

The GUSS showed a high internal consistency (Cronbach's α = 0.826), good test-retest reliability (rs = 0.767), convergent validity compared to the Greek Pediatric Eating Assessment tool-10 (PEDI-EAT-10) total score (rs = -0.365), and inter-rater reliability (κ = 0.863). A total cutoff points equal to 13.00 was also calculated. Aspiration was identified by the GUSS with low sensitivity and high specificity (PPV 100%, NPV 57%, LR+ NA, LR- 0.79); dysphagia/penetration was identified with high sensitivity and low specificity (PPV 33%, NPV 100%, LR+ 0.102, LR- NA).

CONCLUSIONS & INFERENCES

The pediatric version of GUSS has been found to be a valuable tool in identifying the risk of aspiration as that of adults. It proved to be used as a good screening guide for selecting and confirming the existence of dysphagia from instrumental assessments. This is the first study of the pediatric version of GUSS, and future studies on this topic are needed.

Accuracy of Dysphagia Screening by Non-clinical Research Staff in the Emergency Department

Although the emergency department (ED) is the initial care setting for the majority of older adults requiring hospital admission, there is a paucity of ED-based dysphagia research in this at-risk population. This is driven by barriers to dysphagia evaluation in this complex care environment. Therefore, we assessed the reliability of trained, non-clinical ED research staff in administering dysphagia screening tools compared to trained speech pathologists (SLPs). We also aimed to determine perceptual screening discrepancies (e.g. voice change) between clinical and non-clinical staff. Forty-two older adults with suspected pneumonia were recruited during an ED visit and underwent dysphagia (Toronto Bedside Swallow Screening Tool; TOR-BSST©) and aspiration (3-oz water swallow test; 3-oz WST) screening by trained non-clinical research staff. Audio-recordings of screenings were re-rated post-hoc by trained, blinded SLPs with discrepancies resolved via consensus. Cohen's kappa (unweighted) revealed moderate agreement in pass/fail ratings between clinical and non-clinical staff for both the TOR-BSST© (k = 0.75) and the 3 oz WST (k = 0.66) corresponding to excellent sensitivity and good specificity for both the TOR-BSST (SN = 94%, SP = 85%) and the 3 oz WST (SN = 90%, SP = 81%). Further analysis of TOR-BSST perceptual parameters revealed that most discrepancies between clinicians and non-clinicians resulted from over-diagnosis of change in vocal quality (53%). These results support the feasibility of non-clinical research staff administering screening tools for dysphagia and aspiration in the ED. Dysphagia screening may not necessitate clinical staff involvement, which may improve feasibility of large-scale ED research. Future training of research staff should focus on perceptual assessment of vocal quality.

Oral intake of solid medications in patients with post-stroke dysphagia. A challenge for nurses?

AIM

To provide a comprehensive overview of how stroke nurses manage solid medication (SM) delivery to patients with post-stroke dysphagia.

DESIGN

Cross-sectional study.

METHODS

A self-administered online survey was carried out among nurses in German-speaking countries between September and December 2021.

RESULTS

Out of a total of 754 responses, analysis was conducted on 195 nurses who reported working on a stroke unit. To identify swallowing difficulties in acute stroke care, 99 nurses indicated routinely administering standardised screenings, while 10 use unvalidated screenings, and 82 are waiting for a specialist evaluation. Regardless of whether screening methods are used or not, most preferred a non-oral route of medication administration for patients with suspected dysphagia. None of the respondents reported administering whole SMs orally to patients. If screening methods indicate dysphagia, approximately half of the respondents would modify SMs. Participants who stated to use the Gugging Swallowing Screen managed the SM intake guided by its severity levels. One-third of the group who awaited assessment by the dysphagia specialist provided modified medication before the consultation.

CONCLUSION

Most of the nurses on stroke units use swallowing screens and avoid the administration of whole SMs in post-stroke dysphagia. In addition to the non-oral administration, SMs are modified if dysphagia is suspected. Precise guidance on the administration of SM is needed, based on screening tests and prior to expert consultation.

TRIAL AND PROTOCOL REGISTRATION

ClinicalTrials.gov: Registration ID: NCT05173051/ Protocol ID: 11TS003721.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The present paper serves to alert nurses to the issue of patient safety when administering medication for acute stroke-induced dysphagia.

IMPACT

SM delivery after acute stroke-induced dysphagia is often neglected. While nurses are aware of the risk associated with dysphagia and would not give whole SMs to patients, the modification of tablets and their administration with semisolids are common.

REPORTING METHOD

This study was reported according to the Checklist for Reporting of Survey Studies (CROSS).

Effectiveness of Conventional Dysphagia Therapy (CDT), Neuromuscular Electrical Stimulation (NMES), and Transcranial Direct Current Stimulation (tDCS) in Acute Post-Stroke Dysphagia: A Comparative Evaluation

This study aims to compare the effectiveness of conventional dysphagia therapy (CDT), neuromuscular electrical stimulation (NMES), and transcranial direct current stimulation (tDCS) in the treatment of post-stroke dysphagia. A single-blind randomized controlled trial was conducted with 40 acute stroke patients - 18 females and 22 males with a mean age of 65.8 ± 11.9. The subjects were grouped into 4, with 10 individuals in each. The procedures administered to groups were as follows: the first group, sham tDCS and sham NMES; the second group, tDCS and sham NMES; the third group, NMES and sham tDCS; and the fourth group, all therapy procedures. CDT was applied to all groups either as a standalone procedure or combined with one or two of the instrumental techniques. Gugging Swallowing Screen (GUSS) and Videofluoroscopic Swallowing Study (VFSS) were employed to determine the severity of dysphagia and the effectiveness of treatment modalities. Additionally, the Penetration Aspiration Scale (PAS), Functional Oral Intake Scale (FOIS), and Dysphagia Severity Rating Scale (DSRS) were administered to interpret VFSS data. Pre- and post-treatment comparisons of all groups have revealed a statistically significant difference for all parameters except for the PAS scores at International Dysphagia Diet Standardization Initiative (IDDSI)-Level 4 consistencies. However, the differences between pre- and post-treatment scores of the fourth group across all parameters were significant - GUSS (p = 0.005), FOIS (p = 0.004), DSRS (p = 0.005), PAS IDDSI-4 (p = 0.027), PAS IDDSI-0 (p = 0.004). Inter-group comparisons, on the other hand, pointed out that the difference between pre- and post-treatment GUSS, FOIS, DSRS, and PAS scores at IDDSI Level-0 consistencies was statistically significant for all groups - GUSS (p = 0,009), FOIS (p = 0,004), DSRS (p = 0,002), PAS IDDSI-0 (p = 0,049). Closer examination of treatment groups indicated that the tDCS + CDT group, the NMES + CDT group, and the group that underwent the combination of three modalities made better progress than the one that was treated with only CDT. Though not statistically significant, the NMES + CDT group achieved better improvement than the tDCS + CDT group. This study has yielded that the group in which NMES, tDCS, and CDT were applied in combination has achieved better results than all the other groups. All treatment modalities applied to accelerate the general recovery process in acute stroke patients with dysphagia were found to be effective for the treatment of post-stroke swallowing disorders. The use of instrumental treatments such as NMES and tDCS enhanced the effectiveness of the treatment and provided more significant progress. Furthermore, combining treatment modalities such as NMES and tDCS was more effective when compared to using only conventional therapy. As a result, the most effective treatment outcomes were obtained by the group receiving CDT, NMES, and tDCS in combination. Therefore, the use of combined approaches has been recommended in appropriate patients; yet the provisional results should be tested in randomized trials with more participants.

Construction of an enteral nutrition evaluation system for critically ill patients based on the Delphi method

BACKGROUND

This study aimed to construct an enteral nutrition evaluation system for critically ill patients using the Delphi method to direct the formulation of enteral nutrition support strategies and reduce interruption to enteral feeding.

METHODS

We used domestic and foreign databases to obtain and analyze the literature and form "The Whole-Proceeding Enteral Nutrition Evaluation System for Critically Ill Patients." The Delphi method was used to conduct two rounds of expert opinion consultation, combined with the suggestions from the research group to finalize the nutrition evaluation content of the system.

RESULTS

After two rounds of expert consultation, a nutrition evaluation system was formed around three dimensions: before the start, during, and after the end of nutritional support. The effective recovery rates of the two rounds of expert consultation were 90.0% (18/20) and 100.0% (18/18), respectively. Authority coefficients were 0.865 and 0.908, while Kendall coordination coefficients were 0.108 ( P < 0.05) and 0.115 ( P < 0.001), respectively. Finally, the full enteral nutrition evaluation system for critically ill patients was constructed based on the Delphi method, including three primary items and seven secondary and 28 tertiary indicators.

CONCLUSION

The established "Whole-Proceeding Enteral Nutrition Evaluation System for Critically Ill Patients" has high consistency from expert opinions and reliability, which can provide a practical evaluation tool for the process of enteral nutrition for severe patients.

Swallowing capacity and gravity of the laryngotracheal aspiration risk in atypical cerebellar stroke: case report

This case report aimed to evaluate the swallowing capacity and the severity of the risk of laryngotracheal aspiration of a 52-year-old female patient with atypical and rare stroke, with major injury in the cerebellar pathway. In order to measure swallowing capacity and risk of aspiration a routine clinical assessment used in the speech therapy clinic was performed and two valid clinical tests were used: Massey Bedside Swallowing Screen (MBSS) and Gugging Swallowing Screen (GUSS). After evaluation with the clinical tests, it was observed that the patient had reduced swallowing capacity, performance characterized as pathological, 100% dysfunction in the water swallowing test (MBSS), presence of choking, coughing, change in vocal quality and anterior escape. In the assessment of risk of aspiration with the GUSS, the patient presented moderate dysphagia and risk of laryngotracheal aspiration.This case report demonstrated that moderate dysphagia is found in a stroke patient with lesions that affect the cerebellum. Standardized and validated clinical tests such as GUSS and MBSS should also be used to assess the risk of dysphagia after stroke at ambulatory care.

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

Background

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

Methods

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

Results

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

Conclusion

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

Concurrent and Predictive Validity of the Mann Assessment of Swallowing Ability in Belgian Acute Stroke Patients Based on a 1-Year Follow-Up Study

INTRODUCTION

The Mann Assessment of Swallowing Ability (MASA) is a standardized clinical swallowing examination, specifically developed as a diagnostic test for the presence of oropharyngeal dysphagia and aspiration in the early period after stroke onset. In the original validation study, cutoff scores of <178 and <170 points, respectively, for the identification of dysphagia and aspiration risk are reported. However, a literature search revealed that alternative cutoff scores for dysphagia and/or aspiration provide better diagnostic accuracy. The aim of this secondary data analysis study was to evaluate the concurrent and predictive validity of the MASA.

METHODS

Data were derived from a Belgian cohort study of an acute stroke population (n = 151). The MASA total score (MASA-TS), which is the sum of weighted scores on the 24 items, was evaluated against the Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) to assess concurrent validity. To assess predictive validity of the MASA-TS, pneumonia during hospitalization and over 1 year and mortality acted as a future criterion. Analyses included receiver operating characteristic curves and area under the curve (AUC).

RESULTS

Diagnostic accuracy of the MASA-TS was good for dysphagia (AUC = 0.85) and for the presence of relevant aspiration risk (AUC = 0.84). Using the original cutoff scores, the MASA-TS showed perfect sensitivity (Se = 1.00) for the identification of dysphagia and aspiration but inadequate specificity (Sp) for dysphagia (Sp = 0.16) and aspiration (Sp = 0.43). After determining new MASA cutoff scores, the optimal MASA cutoff scores were ≤146 for both dysphagia and aspiration with adequate thresholds (Se = 0.71 and Sp = 0.81 for dysphagia; Se = 0.73 and Sp = 0.80 for aspiration). The MASA-TS was a significant predictor of pneumonia during hospitalization (AUC = 0.85) and 1-year follow-up (AUC = 0.86), and of mortality (AUC = 0.79).

CONCLUSION

The MASA-TS showed good concurrent validity with the FEDSS. Furthermore, using new cutoff scores (≤146 for the identification of dysphagia and aspiration) lead in general to more accurate diagnostic indexes. The MASA-TS is a good predictor of aspiration pneumonia during hospitalization and 1-year follow-up and of mortality.

Dysphagia and daily oral fluids among cerebrovascular stroke patients: an theory-based nursing intervention protocol

Objective

To evaluate the improvement of dysphagia and the daily amounts of oral fluids served among people who had recently experienced a cerebrovascular stroke (CVS) after applying a nursing intervention protocol.

Methods

A quasi-experimental design was used to examine 60 stroke patients who were randomly and alternatively divided equally into a study group and a control group. Gugging Swallowing Screen (GUSS) and fluid balance chart were used. Within the first 24 h of a patient’s admission, expert nurses were trained in nursing intervention protocol to manage dysphagia and daily oral fluids.

Results

Post-nursing intervention, the severity of dysphagia decreased among the study group more than in the control group. Additionally, the study group began taking greater amounts of fluids by the oral route than before the nursing intervention.

Conclusions

A standardized nursing intervention protocol is needed to decrease the severity of dysphagia after CVS and increase the amount of daily oral fluids. The presence of a structured theory-based nursing intervention protocol for dysphagia management will greatly contribute to decreasing the consequences of dysphagia after CVS, and can also be expected to attenuate the effects of aspiration pneumonia, dehydration, and malnutrition; further, it also increases adherence to the protocol by both nurses and patients.

Machine learning predictive model for aspiration screening in hospitalized patients with acute stroke

Dysphagia is a fatal condition after acute stroke. We established machine learning (ML) models for screening aspiration in patients with acute stroke. This retrospective study enrolled patients with acute stroke admitted to a cerebrovascular specialty hospital between January 2016 and June 2022. A videofluoroscopic swallowing study (VFSS) confirmed aspiration. We evaluated the Gugging Swallowing Screen (GUSS), an early assessment tool for dysphagia, in all patients and compared its predictive value with ML models. Following ML algorithms were applied: regularized logistic regressions (ridge, lasso, and elastic net), random forest, extreme gradient boosting, support vector machines, k-nearest neighbors, and naïve Bayes. We finally analyzed data from 3408 patients, and 448 of them had aspiration on VFSS. The GUSS showed an area under the receiver operating characteristics curve (AUROC) of 0.79 (0.77-0.81). The ridge regression model was the best model among all ML models, with an AUROC of 0.81 (0.76-0.86), an F1 measure of 0.45. Regularized logistic regression models exhibited higher sensitivity (0.66-0.72) than the GUSS (0.64). Feature importance analyses revealed that the modified Rankin scale was the most important feature of ML performance. The proposed ML prediction models are valid and practical for screening aspiration in patients with acute stroke.

A bedside swallowing screen for the identification of post-extubation dysphagia on the intensive care unit - validation of the Gugging Swallowing Screen (GUSS)-ICU

PURPOSE

Screening for dysphagia at the intensive care unit (ICU) soon after extubation can prevent aspiration, pneumonia, lower mortality, and shorten re-feeding interval. This study aimed to modify the Gugging Swallowing Screen (GUSS), which was developed for acute stroke patients, and to validate it for extubated patients in the ICU.

METHODS

In this prospective study, forty-five patients who had been intubated for at least 24 h were recruited consecutively at the earliest 24 h after extubation. The modified GUSS-ICU was performed twice by two speech and language therapists independently. Concurrently, gold standard the flexible endoscopic evaluation of swallowing (FEES) was performed by an otorhinolaryngologist. Measurements were conducted within a three-hour period; all testers were blinded to each other's results.

RESULTS

According to FEES, 36 of 45 (80%) participants were diagnosed with dysphagia; 13 of those were severe, 12 moderate, and 11 mild. Compared to FEES, the GUSS-ICU predicted dysphagia well (area under the curve for the initial rater pair: 0.923, 95% CI 0.832-1.000 and 0.923, 95% CI 0.836 -1.000 for the second rater pair). The sensitivity was 91.7% (95% CI 77.5-98.3%) and 94.4% (95% CI 81.3-99.3%); the specificity was 88.9% (51.8-99.7%) and 66.7% (29.9-92.5%); the positive predictive values were 97.1% (83.8-99.5%) and 91.9% (81.7-96.6%), and the negative predictive values were 72.7% (46.8-89%) and 75% (41.9-92.6%) for the first and second rater pairs, respectively. Dysphagia severity classification according to FEES and GUSS-ICU correlated strongly (Spearman's rho: 0.61 for rater 1 and 0.60 for rater 2, p < 0.001). Agreement by all testers was good (Krippendorffs Alpha: 0.73). The interrater reliability showed good agreement (Cohen`s Kappa: 0.84, p < 0.001).

CONCLUSION

The GUSS-ICU is a simple, reliable, and valid multi-consistency bedside swallowing screen to identify post-extubation dysphagia at the ICU.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04532398,31/08/2020.

Assessment and treatment of neurogenic dysphagia in stroke and Parkinson's disease

PURPOSE OF REVIEW

Neurogenic dysphagia worsens quality of life and prognosis of patients with different neurological disorders. Management of neurogenic dysphagia can be challenging. This review provides a comprehensive overview of current evidence on screening, diagnosis, and treatment of neurogenic dysphagia in stroke and Parkinson's disease, suggesting clues for clinical practice.

RECENT FINDINGS

The pros and cons of diagnostic techniques are discussed in the light of updated evidence. Findings from recent meta-analyses of different treatment approaches, including traditional dysphagia therapy, peripheral and central neurostimulation techniques, and treatment with botulinum toxin, are critically discussed, emphasizing inconsistencies and controversial issues.

SUMMARY

Screening tests and clinical swallow examination should be routinely performed in neurological patients at risk for dysphagia. In patients testing positive for dysphagia, first-line instrumental investigations, represented by fiberoptic endoscopic evaluation of swallowing or videofluoroscopic swallow study, should be performed to confirm the presence of dysphagia, to assess its severity, and to inform the treatment. Second-line and third-line instrumental methods can be used in selected patients to clarify specific pathophysiological aspects of oropharyngeal dysphagia. Treatment strategies should be personalized, and combination of traditional dysphagia therapy with innovative treatment approaches may increase the chance of restoring effective and safe swallowing.

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

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

Reoralisierung nach Intubation bei Intensivaufenthalt

Die Schluckfunktion kann durch eine Intubation stark beeinträchtigt werden. Essen und Trinken, aber auch Speichelschlucken können dadurch massiv gestört werden. In diesem Fall konnten einer jungen, multimorbiden Frau durch die Zusammenarbeit des gesamten medizinischen Personals die Nahrungsaufnahme wieder ermöglicht und die Lebensqualität gesteigert werden.

Are Oropharyngeal Dysphagia Screening Tests Effective in Preventing Pneumonia?

Oropharyngeal dysphagia, a clinical condition that indicates difficulty in moving food and liquid from the oral cavity to the esophagus, has a markedly high prevalence in the elderly. The number of elderly people with oropharyngeal dysphagia is expected to increase due to the aging of the world's population. Understanding the current situation of dysphagia screening is crucial when considering future countermeasures. We report findings from a literature review including citations on current objective dysphagia screening tests: the Water Swallowing Test, Mann Assessment of Swallowing Ability, and the Gugging Swallowing Screen. Pneumonia can be predicted using the results of the screening tests discussed in this review, and the response after the screening tests is important for prevention. In addition, although interdisciplinary team approaches prevent and reduce aspiration, optimal treatment is a challenging. Intervention studies with multiple factors focusing on the elderly are needed.

Decreased Maximal Tongue Protrusion Length May Predict the Presence of Dysphagia in Stroke Patients

Objective

To investigate the relationship between maximal tongue protrusion length (MTPL) and dysphagia in post-stroke patients.

Methods

Free tongue length (FTL) was measured using the quick tongue-tie assessment tool and MTPL was measured using a transparent plastic ruler in 47 post-stroke patients. The MTPL-to-FTL (RMF) ratio was calculated. Swallowing function in all patients was evaluated via videofluoroscopic swallowing study (VFSS), PenetrationAspiration Scale (PAS), Functional Oral Intake Scale (FOIS), and Videofluoroscopic Dysphagia Scale (VDS).

Results

The MTPL and RMF values were significantly higher in the non-aspirator group than in the aspirator group (MTPL, p=0.0049; RMF, p<0.001). MTPL and RMF showed significant correlations with PAS, FOIS and VDS scores. The cut-off value in RMF for the prediction of aspiration was 1.56, with a sensitivity of 84% and a specificity of 86%.

Conclusion

There is a relationship between MTPL and dysphagia in post-stroke patients. MTPL and RMF can be useful for detecting aspiration in post-stroke patients.

Association between clinical evaluation and self perception of deglutition with motor disability scale in patients with multiple sclerosis

PURPOSE

To investigate the association between the clinical evaluation and self-perception of deglutition with the motor disability scale in patients with Multiple Sclerosis.

METHODS

It is a cross-sectional, prospective study that was conducted with individuals with Multiple Sclerosis treated by the Neuroimmunology outpatient clinic of a hospital in southern Brazil. We reviewed the electronic medical records of patients to extract the score from the last Expanded Disability Status Scale. After the analysis of the inclusion criteria, and in clinical consultation, two protocols were applied: one of self-perception for the risk of dysphagia, through the Brazilian equivalence instrument of the Eating Assessment Tool; and the clinical evaluation of swallowing, with food, through the scale Gugging Swallowing Screen. The data were analyzed through tables, descriptive statistics and the tests: Fisher's Exact Association Test and Chi-square Test to assess the association between the results of the applied scales. We considered a maximum significance level of 5% (p <0.05).

RESULTS

It was possible to observe that there was a significant association between the scores of the Gugging Swallowing Screen scales with the Expanded Disability Status Scale of the patients. In addition, there was also a relation between the results of both protocols with the Expanded Disability Status Scale.

CONCLUSION

The patients with Multiple Sclerosis in this study presented oropharyngeal dysphagia, what was confirmed by the association between the clinical evaluation of swallowing and the results of the instrument of self-perception of swallowing and the motor disability scale.

Neural correlates in the development of and recovery from dysphagia after supratentorial stroke: A prospective tractography study

•

Stroke may lead to unilateral or bilateral CBT changes regardless of dysphagia.

•

Poor fractional anisotropy of the unaffected sides relates to limited recovery.

•

Swallowing recovery may depend on the integrity of the unaffected CBT.

•

Bi-hemispheric reorganization of the CBT is associated with swallowing recovery.

Background

Methods

Results

Conclusions

Cough Sounds Recorded via Smart Devices as Useful Non-Invasive Digital Biomarkers of Aspiration Risk: A Case Report

Spirometer measurements can reflect cough strength but might not be routinely available for patients with severe neurological or medical conditions. A digital device that can record and help track abnormal cough sound changes serially in a noninvasive but reliable manner would be beneficial for monitoring such individuals. This report includes two cases of respiratory distress whose cough changes were monitored via assessments performed using recordings made with a digital device. The cough sounds were recorded using an iPad (Apple, Cupertino, CA, USA) through an embedded microphone. Cough sounds were recorded at the bedside, with no additional special equipment. The two patients were able to complete the recordings with no complications. The maximum root mean square values obtained from the cough sounds were significantly reduced when both cases were diagnosed with aspiration pneumonia. In contrast, higher values became apparent when the patients demonstrated a less severe status. Based on an analysis of our two cases, the patients’ cough sounds recorded with a commercial digital device show promise as potential digital biomarkers that may reflect aspiration risk related to attenuated cough force. Serial monitoring aided the decision making to resume oral feeding. Future studies should further explore the clinical utility of this technique.

European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia

Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD.

Screening for aspiration risk associated with dysphagia in acute stroke

BACKGROUND

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

OBJECTIVES

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Validation of the munich swallowing score (mucss) in patients with neurogenic dysphagia: A preliminary study

BACKGROUND

The Munich Swallowing Score (MUCSS) is a clinician rated scale for the assessment of the functional level of swallowing saliva/secretions, food and liquids. The MUCSS consists of two eight-point subscales, MUCSS-Saliva and MUCSS-Nutrition. In a previous article, content validity and interrater reliability were described.

OBJECTIVE

The aim of the present study was to investigate criterion validity and sensitivity to change of the MUCSS.

METHODS

The research was conducted at a tertiary care academic hospital. Data were collected retrospectively in a cohort of 100 acute and subacute neurologic patients. Criterion validity was judged by comparison to the Gugging Swallowing Screen (GUSS), the Barthel Index (BI), Early Rehabilitation Barthel Index (ERI), Extended Barthel Index (EBI) and also by comparison to three physiological scales drawn from FEES videos: The Penetration - Aspiration Scale (PAS), the Yale Pharyngeal Residue Severity Rating Scale (YPR) and the Murray Secretion Scale (MSS). Changes in oral intake and saliva swallowing were followed up for three months.

RESULTS

Between MUCSS and scores directly reflecting dysphagic symptoms (GUSS, PAS, YPR, MSS, ERI), strong to moderate correlations were found, weaker but statistically significant associations were seen with global measures of disability (BI isolated, EBI-subscale cognitive functions). MUCSS was sensitive to positive change of saliva swallowing and oral intake during the recovery period.

CONCLUSIONS

These preliminary data suggest that the MUCCS is a valid scale and may be appropriate for documenting clinical change in swallowing abilities of patients with neurogenic dysphagia.

Diagnostic accuracy of the Dysphagia Trained Nurse Assessment tool in acute stroke

BACKGROUND AND PURPOSE

Comprehensive swallow screening assessments to identify dysphagia and make early eating and drinking recommendations can be used by trained nurses. This study aimed to validate the Dysphagia Trained Nurse Assessment (DTNAx) tool in acute stroke patients.

METHODS

Participants with diagnosed stroke were prospectively and consecutively recruited from an acute stroke unit. Following a baseline DTNAx on admission, participants underwent a speech and language therapist (SLT) bedside assessment of swallowing (speech and language therapist assessment [SLTAx]), videofluoroscopy (VFS) and a further DTNAx by the same or a different nurse.

RESULTS

Forty-seven participants were recruited, of whom 22 had dysphagia. Compared to SLTAx in the identification of dysphagia, DTNAx had a sensitivity of 96.9% (95% confidence interval [CI] 83.8-99.9) and specificity of 89.5% (95% CI 75.2-97.1). Compared to VFS in the identification of aspiration, DTNAx had a sensitivity of 77.8% (95% CI 40.0-97.2) and a specificity of 81.6% (95% CI 65.7-92.3). Over 81% of the diet and fluid recommendations made by the dysphagia trained nurses were in absolute agreement compared to SLTAx. Both DTNAx and SLTAx had low diagnostic accuracy compared to the VFS-based definition of dysphagia.

CONCLUSIONS

Nurses trained in DTNAx showed good diagnostic accuracy in identifying dysphagia compared to SLTAx and in identifying aspiration compared to VFS. They made appropriate diet and fluid recommendations in line with SLTs in the early management of dysphagia.

Dysphagia Screening in Parkinson's Disease. A diagnostic accuracy cross-sectional study investigating the applicability of the Gugging Swallowing Screen (GUSS)

BACKGROUND

Simple water-swallowing screening tools are not predictive of aspiration and dysphagia in patients with Parkinson's Disease (PD). We investigated the diagnostic accuracy of a multi-texture screening tool, the Gugging Swallowing Screen (GUSS) to identify aspiration and dysphagia/penetration in PD patients compared to flexible endoscopic evaluation of swallowing (FEES).

METHODS

Swallowing function was evaluated in 51 PD participants in clinical 'on-medication' state with the GUSS and a FEES examination according to standardized protocols. Inter-rater reliability and convergent validity were determined and GUSS- and FEES-based diet recommendations were compared.

KEY RESULTS

Inter-rater reliability of GUSS ratings was high (r_s  = 0.8; p < 0.001). Aspiration was identified by the GUSS with a sensitivity of 50%, and specificity of 51.35% (PPV 28%, NPV 73%, LR+ 1.03, LR- 0.97), dysphagia/penetration was identified with 72.97% sensitivity and 35.71% specificity (PPV 75%, NPV 33.33%, LR+ 1.14, LR- 0.76). Agreement between GUSS- and FEES-based diet recommendations was low (r_s  = 0.12, p = 0.42) with consistent NPO (Nil per Os) allocation by GUSS and FEES in only one participant.

CONCLUSIONS AND INFERENCES

The multi-texture screening tool GUSS in its current form, although applicable with good inter-rater reliability, does not detect aspiration in PD patients with acceptable accuracy. Modifications of the GUSS parameters "coughing," "voice change" and "delayed swallowing" might enhance validity. The GUSS' diet recommendations overestimate the need for oral intake restriction in PD patients and should be verified by instrumental swallowing examination.

Clinical Utility of the Serum Level of Lipoprotein-Related Phospholipase A2 in Acute Ischemic Stroke With Cerebral Artery Stenosis

We aimed to study the clinical utility of serum lipoprotein-associated phospholipase A2 (Lp-PLA2) in acute ischemic stroke (AIS) with cerebral artery stenosis (CAS). We included 200 AIS patients and 90 healthy controls in this study. AIS patients were classified into three subgroups depending on the severity of CAS. They were also classified based on the stability of the carotid plaques. Spearman correlation analysis was performed to determine the correlation relationship between the level of Lp-PLA2 and neurologic injury. Binary logistic regression analysis was performed to determine the independent risk factors for AIS. Receiver operating characteristic (ROC) analysis was performed to assess the diagnostic value of Lp-PLA2 for AIS and for the degree of CAS. We found that the serum level of Lp-PLA2 in AIS patients was significantly higher than that in the control group. Lp-PLA2 was further identified as an independent risk factor for AIS (p = 0.001, OR = 1.057). In addition, serum Lp-PLA2 level was the highest in AIS patients with severe CAS or occlusion. Lp-PLA2 level was higher in AIS patients with unstable plaques and in AIS patients with moderate to severe neurological injury. Lp-PLA2 level was positively correlated with National Institutes of Health Stroke Scale (NIHSS) score (r = 0.335, p = 0.001). We found that the optimal cut-off value for Lp-PLA2 level was 123.365 ng/ml, at which the sensitivity and specificity for the diagnosis of ACI were 74.5 and 86.7%, respectively, and the area under ROC curve (AUC) was 0.892. Similarly, the optimal value for Lp-PLA2 level was 136.46 ng/ml, at which the sensitivity and specificity for the diagnosis of the presence of moderate to severe artery stenosis or occlusion were 79.6 and 95.2%, respectively, and the AUC was 0.938. The ROC curve indicated that serum Lp-PLA2 level has an excellent diagnostic value for AIS and severe stenosis. Based on these results we conclude that Lp-PLA2 could be a potential biomarker to complement the current imaging methods in the prediction and diagnosis of AIS. An elevated Lp-PLA2 level is also correlated with carotid plaque instability, severe neurological injury and cerebrovascular stenosis. Future longitudinal studies are needed to determine whether there is a causative relationship between Lp-PLA2 and AIS.

Cut-off Values of the Respiratory Muscle Power and Peak Cough Flow in Post-Stroke Dysphagia

Background and objectives: This study aimed to determine the cut-off values of the following three respiratory pressure meters; the voluntary peak cough flow (PCF), maximal expiratory pressure (MEP) and maximal inspiratory pressure (MIP); associated with post-stroke dysphagia and assess which of these parameters show good diagnostic properties associated with post-stroke dysphagia. Materials and Methods: Retrospective analysis of a prospectively maintained database. Records of patients with first-ever diagnosed dysphagia attributable to cerebrovascular disease, who had performed spirometry measurements for the PCF, MIP and MEP. Results: From a total of 237 stroke patients, 163 patients were diagnosed with dysphagia. Those with dysphagia had significantly lower PCF values than those without dysphagia (116.3 ± 75.3 vs. 219.4 ± 91.8 L/min, p < 0.001). In addition, the former group also had lower MIP (30.5 ± 24.7 vs. 41.6 ± 25.7 cmH₂O, p = 0.0002) and MEP (41.0 ± 27.9 vs. 62.8 ± 32.3 cmH₂O, p < 0.001) values than the latter group. The receiver operating characteristic curve analysis showed that the PCF cut-off value of 151 L/min (area under the receiver operating characteristic curve [AUC] 0.81; sensitivity 72%; specificity 78.8%) was associated with post-stroke dysphagia. The optimum MEP and MIP cut-off were 38 cmH₂O (AUC 0.70, sensitivity 58%; specificity 77.7%) and 20 cmH₂O (AUC 0.65, sensitivity 49%; specificity 84%). PCF showed the highest AUC results. Results from the univariate analysis indicated that PCF values of ≤151 L/min increased risk of dysphagia by 9.51-fold (4.96–18.23). Multivariable analysis showed that after controlling of other clinical factor, the PCFs at this cut-off value still showed increased risk of by 4.19 (2.02–83.69) but this was not observed with the MIPs or MEPs. Conclusions: Our study has provided cut-off values that are associated with increased risk of dysphagia. Among the three parameters, PCF showed increased association with post-stroke dysphagia.

Relationship between oral intake and severity of Acute Stroke

PURPOSE

To correlate stroke severity with oral intake level of the studied population and compare the two factors at the time of admission and after swallowing management.

METHODS

A total of 137 patients hospitalized in the cerebral vascular accident unit (CVAU) of a teaching hospital participated. During the stay at CVAU, the patients were submitted to daily neurological evaluation and application of National Institutes of Health Stroke Scale (NIHSS), to evaluate the severity of stroke, ranging from zero (without evidence of neurological deficit) to 42 (in coma and unresponsive). Functional Oral Intake Scale (FOIS), which is a marker for evolution of oral intake and ranges from level one (nothing oral) to seven (oral total restrictions). Data from the NIHSS and FOIS scales of admission and discharge were analyzed and compared to verify association between improvement of oropharyngeal dysphagia with functional improvement of individuals.

RESULTS

At admission, 63 (46.0%) patients had mild strokes, 38 (27.7%) had severe and very severe stroke; 46 (33.6%) had oral intake and need for special preparation or compensations. At discharge, there was an increase in patients with mild stroke (76 - 55.5%); oral intake without special preparation or compensations, but with food restrictions (18 - 13.1%), and oral intake without restrictions (44 - 32.1%).

CONCLUSION

The level of oral intake increased as the severity of stroke decreased. Speech and language therapy contributed to a decrease in stroke severity and improvement in oral intake.

Effect of Brain Lesions on Voluntary Cough in Patients with Supratentorial Stroke: An Observational Study

Patients with stroke are known to manifest a decreased cough force, which is associated with an increased risk of aspiration. Specific brain lesions have been linked to impaired reflexive coughing. However, few studies have investigated whether specific stroke lesions are associated with impaired voluntary cough. Here, we studied the effects of stroke lesions on voluntary cough using voxel-based lesion-symptom mapping (VLSM). In this retrospective cross-sectional study, the peak cough flow was measured in patients who complained of weak cough (n = 39) after supratentorial lesions. Brain lesions were visualized via magnetic resonance imaging (MRI) at the onset of stroke. These lesions were studied using VLSM. The VLSM method with non-parametric mapping revealed that lesions in the sub-gyral frontal lobe and superior longitudinal and posterior corona radiata were associated with a weak cough flow. In addition, lesions in the inferior parietal and temporal lobes and both the superior and mid-temporal gyrus were associated with a weak peak cough flow during voluntary coughing. This study identified several brain lesions underlying impaired voluntary cough. The results might be useful in predicting those at risk of poor cough function and may improve the prognosis of patients at increased risk of respiratory complications after a stroke.

Dysphagia and disability in minor strokes - An institutional study

BACKGROUND

Minor strokes, defined as NIHSS ≤5 are considered non-disabling, associated with a favourable outcome.

AIM

Our aim was to study prevalence and predictors of dysphagia in patients with minor stroke and its impact on functional outcome.

METHODS

Single centre retrospective study of all minor strokes admitted to Comprehensive Stroke care centre with 1 year completed follow-up were recruited. Clinical and imaging details and follow-up data were extracted from medical records.

RESULTS

We had 147 patients with minor stroke, 72.1% men with median age 61 years. 71% presented within 24 h of symptom onset. Most common etiology was lacunar .Median NIHSS at admission was 3(IQR 2). 85 patients had anterior circulation strokes and 34 had chronic infarcts in imaging.19 had significant dysphagia and 10 were discharged with nasogastric feeding tube. Admission NIHSS and white mater changes in imaging were predictive of post stroke dysphagia. Excellent recovery of dysphagia was found within 1 month post stroke in all, except one who required percutaneous gastrostomy. At 3 months 76% had excellent outcome. Presence of dysphagia and diabetes were found to be predictive of short term outcome, independent of admission stroke severity. At 12 months, post stroke dysphagia, female gender and white mater changes in imaging were predictive of unfavourable outcome.

CONCLUSIONS

Minor strokes are disabling in a small fraction of patients. Over 10% of them can have significant post stroke dysphagia necessitating nasogastric feeding short term. This patient subgroup tend to have less favourable outcome on short and long term follow-up.

The cost-effectiveness of food consistency modification with xanthan gum-based Nutilis Clear® in patients with post-stroke dysphagia in Poland

Background

Dysphagia is a well-known stroke complication characterised by difficulty in swallowing. It may affect the majority of stroke patients and increases mortality and morbidity, due to aspiration pneumonia and malnutrition. Food thickening may help patients to feed themselves, and its effectiveness was demonstrated. However, the cost-effectiveness studies are lacking. We evaluate the cost-utility of xanthan gum-based consistency modification therapy (Nutilis Clear®) in adult post-stroke patients from the public payer perspective in Poland.

Methods

Routine clinical practice was used as a comparator, as no alternative specific treatment for dysphagia is available. To verify the robustness of the results against the modelling approach, we built two models: a static (a fixed simple-equations model, 8-week time horizon of dysphagia) and a dynamic one (Markov model, with a possible dysphagia resolution over a 1-year horizon). In both models, the treatment costs, health state utilities, and clinical events (i.e. aspiration, aspiration pneumonia, death) were included. Parameters were estimated jointly for both models, except for the duration of dysphagia and the risk of aspiration pneumonia (specific to the time horizon). We only assumed Nutilis Clear® to prevent aspirations, without affecting dysphagia duration.

Results

The average cost of one quality-adjusted life year (i.e. the incremental cost-utility ratios, ICURs) amounted to 21,387 PLN (€1 ≈ 4.5 PLN), and 20,977 PLN in static and dynamic model, respectively; far below the cost-effectiveness threshold in Poland (147,024 PLN). The one-way, scenario, and probabilistic sensitivity analysis confirmed these findings.

Conclusions

Nutilis Clear® is highly cost-effective in Poland from the public payer perspective. Our approach can be used in other countries to study the cost-effectiveness of food thickening in stroke patients.

The Gugging Swallowing Screen in dysphagia screening for patients with stroke: A systematic review

BACKGROUND

Dysphagia in patients with stroke can cause serious complications, such as aspiration and pneumonia, that often lead to increase in mortality and length of hospitalization. Several screening tests for dysphagia have been developed and are used in clinical practice to prevent dysphagia complications. The Gugging Swallowing Screen is 1 such screening test. It is suggested for use in the assessment of the ability of patients to swallow fluid and non-fluid foods separately. It also promotes effective communication between healthcare providers.

OBJECTIVES

We aimed to investigate the validity and benefit of the Gugging Swallowing Screen.

DESIGN

This was a systematic review.

DATA SOURCE

We sourced data from electronic databases including Ovid MEDLINE, Ovid EMBASE, the Cochrane Library, KoreaMed, Research Information Sharing Service, and Korean studies Information Service System.

REVIEW METHODS

We conducted a systematic review of electronic databases. We included studies published in English and Korean up to November 2018 that pertained to the Gugging Swallowing Screen. We designed strategies that included Medical Subject Headings and keywords, such as "dysphagia," "swallowing," "assessment," "screening," and "GUSS," used alone or in combination.

RESULTS

Of the 297 studies that appeared in the search result, 219 articles were reviewed by 2 independent reviewers after duplicate studies were eliminated. Finally, 8 articles were included in this study. With regard to validity, the Gugging Swallowing Screen had a pooled sensitivity of 0.97 (95% confidence interval: 0.93-0.99), a pooled specificity of 0.67 (95% confidence interval: 0.59-0.74), and an area under the receiver operating characteristic curve of 0.9381. With regard to benefit, early systematic dysphagia screening using Gugging Swallowing Screen performed by nurses reduced both screening time and pneumonia rate compared to the control group (p = 0.004). The incidence of X-ray-verified pneumonia was significantly lower in the Gugging Swallowing Screen group than in the clinical screening group (p ˂ 0.01), but no significant difference was observed in the incidence of pneumonia compared to the value predicted using the 10 mL water swallowing test.

CONCLUSIONS

The Gugging Swallowing Screen is a reliable and sensitive tool for screening dysphagia. Early and systematic assessment can prevent aspiration and pneumonia. However, further studies are needed to confirm the effectiveness of this tool.

Predictive value of a novel pragmatic tool for post-stroke aspiration risk: The Functional Bedside Aspiration Screen

BACKGROUND

There is still a strong need for an optimal clinician-friendly screening tool for the identification of aspiration risk in stroke patients. In this study, we present the development of a novel, context-specific screening tool for the prediction of aspiration risk on recent stroke survivors, the Functional Bedside Aspiration Screen (FBAS), and examine its construct validity, reliability with the predictive values toward pragmatic patients' outcomes.

METHODS

We conducted a prospective validation study of 104 acute ischemic stroke patients admitted to clinical wards in a tertiary university hospital. A group of experts developed and administered the FBAS 10-point scale to all patients. Outcome measures were compared with those of the validated Yale Swallow Protocol (YSP, reference measure) and health indicators.

KEY RESULTS

A strong association was found between the FBAS cutoff criterion and the YSP (Pearson χ²  = 54.92, P < .001). A score of ≤8 on the FBAS presented with 93.3% sensitivity and 83.3% specificity in deeming patient with reduced safety for oral nutrition (AUC = 0.934, CI = 0.884-0.985). An inverse relationship was found between performance on the FBAS and in-hospital and long-term outcome indicators. Patients who failed the FBAS were 1.82 times more likely to develop aspiration pneumonia (95% CI = 1.42-2.35) and 1.35 times more likely to develop pneumonia within 3 months postonset (95% CI = 1.15-1.59).

CONCLUSIONS AND INFERENCES

The FBAS is a potentially useful tool for timely prediction of aspiration risk and health outcome in acute stroke.

[Nurse-performed screening to identify dysphagia for neurological patients]

Nurse-performed screening to identify dysphagia for neurological patients Abstract. Background: Dysphagia is often underestimated, although it can have serious consequences if it is not treated. In the literature a multidisciplinary approach is often recommended in the diagnosis of dysphagia, with care playing an increasingly major role. A quick and easy assessment of the risk of dysphagia is absolutely essential. Aim: Identification of screening tools for the detection of neurogenic dysphagia by nurses and to describe the psychometric characteristics. Method: A literature review was carried out in 2017 between June and the end of July, resulting in 14 included studies. Results: A total of seven screening tools were identified. Due to its good practicability and psychometric properties, the RBWH DST appears to be particularly suitable for the use of screening in the nursing context, especially when the studies are given differentiated consideration. Conclusion: The relevant validation of already existing tools, aimed at creating a standard for the early detection of dysphagia, is not yet available. When this is concluded, the nursing staff need to be trained in the correct use of the tools.

The Prognostic Value of Serum Cytokines in Patients with Acute Ischemic Stroke

The inflammatory response is an unavoidable process and contributes to the destruction of cerebral tissue during the acute ischemic stroke (AIS) phase and has not been addressed fully to date. Insightful understanding of correlation of inflammatory mediators and stroke outcome may provide new biomarkers or therapeutic approaches for ischemic stroke. Here, we prospectively recruited 180 first-ever AIS patients within 72 hrs after stroke onset. We used the National Institutes of Health Stroke Scale (NIHSS) to quantify stroke severity and modified Rankin scale (mRS) to assess the 3-month outcome for AIS patients. Initially, we screened 35 cytokines, chemokines, and growth factors in sera from 75 AIS patients and control subjects. Cytokines that were of interest were further investigated in the 180 AIS patients and 14 heathy controls. We found that IL-1RA, IL-1β, IL-4, IL-5, IL-6, IL-7, IL-9, IL-10, IL-13, IL-15, EGF, G-CSF, Flt-3L, GM-CSF and Fractalkine levels were significantly decreased in severe stroke patients. In particular, IL-1β, IL-4, IL-5, IL-7, IL-9, IL-10, IL-15, G-CSF and GM-CSF were significantly reduced in AIS patients with poor outcome, compared to those with good prognosis. IL-6 was notably higher in the poor outcome group. Only IL-9 level decreased in the large infarct volume group. After adjusting for confounders, we found that IL-5 was an independent protective factor for prognosis in AIS patients with an adjusted OR of 0.042 (P = 0.007), whereas IL-6 was an independent risk predictor for AIS patients with an adjusted OR of 1.293 (P = 0.003). Our study suggests the levels of serum cytokines are related to stroke severity, short-term prognosis and cerebral infarct volume in AIS patients.

Clinical Approaches to Assess Post-extubation Dysphagia (PED) in the Critically Ill

Swallowing disorders and respective consequences (including aspiration-induced pneumonia) are often observed in extubated ICU patients with data indicating that a large number of patients are affected. We recently demonstrated in a large-scale analysis that the incidence of post-extubation dysphagia (PED) is 12.4% in a general ICU population and about 18% in emergency admissions to the ICU. Importantly, PED was mostly sustained until hospital discharge and independently predicted 28- and 90-day mortality. Although oropharyngeal/laryngeal trauma, neuromuscular ICU-acquired weakness, reduced sensation/sensorium, dyssynchronous breathing, and gastrointestinal reflux, are all considered to contribute to PED, little is known about the underlying pathomechanisms and risk factors leading to PED in critically ill patients. Systematic screening of all potential ICU patients for oropharyngeal dysphagia (OD) seems key for early recognition and follow-up, as well as the design and testing of novel therapeutic interventions. Today, screening methods and clinical investigations for dysphagia differ considerably. In the context of a recently proposed pragmatic screening algorithm introduced by us, we provide a concise review on currently available non-instrumental techniques that could potentially serve for non-instrumental OD assessment in critically ill patients. Following systematic literature review, we find that non-instrumental OD assessments were mostly tested in different patient populations with only a minority of studies performed in critically ill patients. Due to little available data on non-instrumental dysphagia assessment in the ICU, future investigations should aim to validate respective approaches in the critically ill against an instrumental (gold) standard, for example, flexible endoscopic evaluation of swallowing. An international expert panel is encouraged to addresses critical illness-related definitions, screening and confirmatory assessment approaches, treatment recommendations, and identifies optimal patient-centered outcome measures for future clinical investigations.

Dysphagia in supratentorial recent small subcortical infarcts results from bilateral pyramidal tract damage

Background

Dysphagia occurs in up to 20% of patients with a recent small subcortical infarct, even when excluding brainstem infarcts.

Aim

To examine the impact of lesion topography and concomitant cerebrovascular lesions on the occurrence of dysphagia in patients with a single supratentorial recent small subcortical infarct.

Methods

We retrospectively identified all inpatients with magnetic resonance imaging-confirmed supratentorial recent small subcortical infarcts over a five-year period. Dysphagia was determined by speech-language therapists. Recent small subcortical infarcts were compiled into a standard brain model and compared using lesion probability maps. Furthermore, magnetic resonance imaging scans were reviewed for the combination of both acute and old cerebrovascular lesions.

Results

A total of 243 patients with a recent small subcortical infarct were identified (mean age 67.9 ± 12.2 years). Of those, 29 had mild and 18 moderate-to-severe dysphagia. Lesion probability maps suggested no recent small subcortical infarct location favoring the occurrence of moderate-to-severe dysphagia. However, patients with moderate-to-severe dysphagia more frequently showed combined damage to both pyramidal tracts by the recent small subcortical infarct and a contralateral old lesion (lacune: 77.8% vs. 19.9%, p < 0.001; lacune or confluent white matter hyperintensities: 100% vs. 57.7%, p < 0.001) than patients without swallowing dysfunction. Comparable results were obtained when analyzing patients with any degree of dysphagia.

Conclusions

Preexisting contralateral vascular pyramidal tract lesions are closely related to the occurrence of moderate-to-severe dysphagia in patients with supratentorial recent small subcortical infarcts.

Systematic dysphagia screening and dietary modifications to reduce stroke-associated pneumonia rates in a stroke-unit

Background and purpose

While formal screening for dysphagia following acute stroke is strongly recommended, there is little evidence on how multi-consistency screening and dietary modifications affect the rate of stroke-associated pneumonia (SAP). This observational study reports which factors affect formal screening on a stroke-unit and how dietary recommendations relate to SAP.

Method

Analyses from a database including 1394 patients admitted with acute stroke at our stroke-unit in Austria between 2012 and 2014. Dietary modifications were performed following the recommendations from the Gugging Swallowing Screen (GUSS). Patients evaluated with GUSS were compared to the unscreened patients.

Results

Overall, 993 (71.2%) patients were screened with GUSS; of these 50 (5.0%) developed SAP. In the 401 unscreened patients, the SAP rate was similar: 22 (5.5%). Multivariable analysis showed that either mild to very mild strokes or very severe strokes were less likely to undergo formal screening. Older age, pre-existing disability, history of hypertension, atrial fibrillation, stroke severity, cardiological and neurological complications, nasogastric tubes, and intubation were significant markers for SAP. Out of 216 patients, 30 (13.9%) developed SAP in spite of receiving nil per mouth (NPO).

Conclusion

The routine use of GUSS is less often applied in either mild strokes or very severe strokes. While most patients with high risk of SAP were identified by GUSS and assigned to NPO, dietary modifications could not prevent SAP in 1 of 7 cases. Other causes of SAP such as silent aspiration, bacteraemia or central breathing disturbances should be considered.

Role of sLOX-1 in intracranial artery stenosis and in predicting long-term prognosis of acute ischemic stroke

OBJECTIVE

The role of sLOX-1 in acute ischemic stroke still remains unclear. This study aims to demonstrate the value of sLOX-1 in evaluating degrees of intracranial artery stenosis and to predict prognosis in stroke.

METHODS

Two hundred and seventy-two patients were included in this study and basic data were collected within 72 hr on admission. We assessed the association between sLOX-1 levels and stroke conditions in one-year duration. After adjusting for potential confounders, regression analyses were performed.

RESULTS

We found that sLOX-1 levels were increased significantly in severe patients compared to the mild stroke group (p = .011). After adjusting confounders, sLOX-1 was associated with a poor functional outcome in patients with an adjusted OR of 2. 946 (95% CI, 1.788-4.856, p < .001). There was also positive correlation between sLOX-1 levels and the degrees of intracranial artery stenosis in the different groups (p = .029).

CONCLUSIONS

Our study demonstrated that sLOX-1 levels could be used to evaluate the severity of stroke and the degrees of intracranial artery stenosis. Furthermore, sLOX-1 could be exploited to predict the long-term functional outcome of stroke.