Prevalence, risk factors and complications of oropharyngeal dysphagia in stroke patients: A cohort study

Prevalence, risk factors, and outcomes of dysphagia after stroke: a systematic review and meta-analysis

Background

Dysphagia is a common complication after stroke, which not only brings adverse outcomes but also greatly affects the quality of life of patients. At present, there is no systematic review or meta-analysis to comprehensively evaluate the epidemiological characteristics of post-stroke dysphagia (PSD). A systematic review of the prevalence, risk factors, and prognosis of PSD is essential.

Methods

Through 31 December 2022, a comprehensive literature search was performed for observational studies related to PSD. Five databases were retrieved. Random-effects models were used to estimate the pooled prevalence, odds ratio (OR), and 95% CIs.

Results

A total of 34 studies were included, and the results showed that the overall prevalence of PSD was 46.6% (95% CI, 0.405-0.528). The prevalence of dysphagia in ischemic stroke and hemorrhagic stroke was 43.6% (95% CI 0.370-0.501) and 58.8% (95% CI 0.519-0.654), respectively. The prevalence of PSD in Africa was 49.4% (95% CI, 0.196-0.792), in Asia was 40.1% (95% CI, 0.348-0.454), in Europe was 45.8% (95% CI, 0.327-0.590), in North America was 44.3% (95% CI, 0.370-0.517), in South America was 57.5% (95% CI, 0.441-0.708), and in Oceania was 64.1% (95%CI, 0.558, 0.724). In risk factor analysis, hypertension, previous stroke, and atrial fibrillation were significantly associated with the occurrence of PSD, pooled OR = 1.179 [(95% CI, 1.002-1.386), p < 0.05], pooled OR = 1.514 [(95% CI, 1.204-1.905), p < 0.001], and pooled OR = 1.980 [(95% CI, 1.580-2.481), p < 0.001]. In outcome studies, the prevalence of aphasia and dysarthria in PSD was 35.6% (95% CI, 0.213-0.499) and 54.5% (95% CI, 0.293-0.798), respectively. The prevalence of respiratory tract infection was 27.1% (95%CI, -0.038-0.579), and the prevalence of pneumonitis was 32.1% (95% CI, 0.224-0.418). Persistence of dysphagia at discharge and at 1 month was 74.5% (95% CI, 0.621-0.869) and 50.9% (95% CI, 0.142-0.876), respectively. Mortality rates for PSD patients during admission and discharge at 1 month, 3 months, and 1 year were 11.8% (95% CI, 0.083-0.152), 26.5% (95% CI, 0.170-0.359), 25.7% (95% CI, 0.19-0.324), and 31.3% (95% CI, 0.256-0.369), respectively.

Conclusion

This study found that the overall prevalence of PSD was 46.6%. Prevalence is most influenced by the diagnosis method. Hypertension, history of stroke, atrial fibrillation, patient age, and stroke severity were risk factors significantly associated with PSD. The prevalence of aphasia, dysarthria, respiratory tract infection, and pneumonitis in PSD patients is 2-4 times that of patients without PSD.Systematic review registration: www.crd.york.ac.uk/PROSPERO, PROSPERO, CRD42021252967.

The effect of underlying diseases on pneumonia risk in patients with neurogenic or tumor-related dysphagia: a retrospective cohort study

OBJECTIVE

To analyze the association of neurological disorders (ND) and head and neck cancer (HNC) with dysphagia severity and aspiration pneumonia occurrence.

METHOD

Retrospective cohort study conducted at a university dysphagia center) for two consecutive years. Patients with ND or HNC were included if they had undergone a flexible endoscopic swallowing evaluation (FEES) at the dysphagia center, and at least one food consistency had been sampled and recorded. Outcomes of interest were swallowing safety, highest penetration-aspiration-score (PASmax), way of food intake, presence of a tracheal tube, and occurrence of pneumonia within the past two years.

RESULTS

Of 257 consecutive patients, 199 were enrolled in the study and classified according to their underlying diagnosis into ND (120 patients) or HNC (79 patients). Forty-three HNC patients (54.4%) and 54 ND patients (45%) showed critical dysphagia in FEES (PAS ≥ 6). Binary logistic regression comparing both groups showed patients with ND to be 2.31 times more likely to develop pneumonia. However, if the 32 stroke patients were excluded from the calculation, PASmax remains the only significant variable affecting pneumonia risk in both groups. Liquids were the main challenge for ND patients, while aspirating HNC patients struggled with all consistencies.

CONCLUSIONS

The study shows that patients with HNC and ND differ in pneumonia risk only if stroke patients are included in the ND group. If they are excluded, the PAS score is the only remaining risk factor for pneumonia. Thickening liquids may not be suitable for all dysphagic patients; individually tailored measures might be more helpful, especially for HNC patients.

Identifying High-Quality Non-Instrumental Dysphagia Screening Tools for Detection of Adult Dysphagia Case in Acute-Care Settings: A Systematic Review

INTRODUCTION

As patients nowadays tend to have multiple diseases and complex medical histories, our aim was to identify high-quality, non-instrumental dysphagia screening tools used for the detection of adult dysphagia cases in all disease categories in acute-care settings.

METHOD

A literature search was conducted in five databases from each database's earliest inception to 31 July 2021 and guided by five keywords: 'dysphagia', 'deglutition', 'screening', 'test' and 'measure'. Without limiting the search in any specific disease category, reviewers assessed original studies and identified tools if they had been validated against instrumental evaluations and if they had been designed as a pass-fail procedure to screen whether dysphagia is absent or present. We further excluded any tool if it was (1) for pediatric focus, or (2) a patient self-report questionnaire. All final tool candidates underwent a methodological quality appraisal using the Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2).

RESULT

Out of 195 studies with 165 tools identified, 20 tool candidates underwent QUADAS-2 review. We found six high-quality, non-instrumental screening tools for detecting adult dysphagia cases in acute-care settings, including the Yale Swallow Protocol, Gugging Swallowing Screen, Toronto Bedside Swallowing Screening Test (both English and Portuguese versions), Sapienza Global Bedside Evaluation of Swallowing and Two-Step Thickened Water Test. These high-quality tools were developed primarily for patients with stroke. Only Yale Swallow Protocol was originally tested for heterogeneous populations with stroke, multiple sclerosis, traumatic brain injury, oesophageal surgery, neurosurgery and head-and-neck cancer.

CONCLUSIONS

The results highlight the gap in the unavailability of high-quality dysphagia screening tool in several emerged high-risk populations including elderly inpatients, or patients following endotracheal extubation. Further research is needed to determine whether these six tools can be effectively applied across different high-risk populations in acute-care settings to screen for cases finding.

Effect of a systemic intervention combined with a psychological intervention in stroke patients with oropharyngeal dysfunction

BACKGROUND

Stroke frequently results in oropharyngeal dysfunction (OD), leading to difficulties in swallowing and eating, as well as triggering negative emotions, malnutrition, and aspiration pneumonia, which can be detrimental to patients. However, routine nursing interventions often fail to address these issues adequately. Systemic and psychological interventions can improve dysphagia symptoms, relieve negative emotions, and improve quality of life. However, there are few clinical reports of systemic interventions combined with psychological interventions for stroke patients with OD.

AIM

To explore the effects of combining systemic and psychological interventions in stroke patients with OD.

METHODS

This retrospective study included 90 stroke patients with OD, admitted to the Second Affiliated Hospital of Qiqihar Medical College (January 2022-December 2023), who were divided into two groups: regular and coalition. Swallowing function grading (using a water swallow test), swallowing function [using the standardized swallowing assessment (SSA)], negative emotions [using the self-rating anxiety scale (SAS) and self-rating depression scale (SDS)], and quality of life (SWAL-QOL) were compared between groups before and after the intervention; aspiration pneumonia incidence was recorded.

RESULTS

Post-intervention, the coalition group had a greater number of patients with grade 1 swallowing function compared to the regular group, while the number of patients with grade 5 swallowing function was lower than that in the regular group (P < 0.05). Post-intervention, the SSA, SAS, and SDS scores of both groups decreased, with a more significant decrease observed in the coalition group (P < 0.05). Additionally, the total SWAL-QOL score in both groups increased, with a more significant increase observed in the coalition group (P < 0.05). During the intervention period, the total incidence of aspiration and aspiration pneumonia in the coalition group was lower than that in the control group (4.44% vs 20.00%; P < 0.05).

CONCLUSION

Systemic intervention combined with psychological intervention can improve dysphagia symptoms, alleviate negative emotions, enhance quality of life, and reduce the incidence of aspiration pneumonia in patients with OD.

Development and validation of a risk prediction model for aspiration in patients with acute ischemic stroke

BACKGROUND

Aspiration is a frequently observed complication in individuals diagnosed with acute ischemic stroke, leading to potentially severe consequences. However, the availability of predictive tools for assessing aspiration probabilities remains limited. Hence, our study aimed to develop and validate a nomogram for accurately predicting aspiration probability in patients with acute ischemic stroke.

METHODS

We analyzed 30 potential risk factors associated with aspiration in 359 adult patients diagnosed with acute ischemic stroke. Advanced statistical techniques, such as Least absolute shrinkage and selection operator (LASSO) and Multivariate Logistic regression, were employed to identify independent predictors. Subsequently, we developed a nomogram prediction model based on these predictors, which underwent internal validation through 1000 bootstrap resampling. Two additional cohorts (Cohort A n = 64; Cohort B, n = 105) were included for external validation. The discriminatory power and calibration performance of the nomogram were assessed using rigorous methods, including the Hosmer-Lemeshow test, area under the receiver operating characteristic curve (AUC), calibration curve analyses, and decision curve analyses (DCA).

RESULTS

The nomogram was established based on four variables: sputum suction, brain stem infarction, temporal lobe infarction, and Barthel Index score. The predictive model exhibited satisfactory discriminative ability, with an area under the receiver operating characteristic curve of 0.853 (95 % confidence interval, 0.795-0.910), which remained consistent at 0.852 (95 % confidence interval, 0.794-0.912) during the internal validation. The Hosmer-Lemeshow test (P = 0.394) and calibration curve demonstrated favorable consistency between the predicted and observed outcomes in the development cohort. The AUC was 0.872 (95 % confidence interval, 0.783-0.962) in validation cohort A and 0.877 (95 % confidence interval, 0.764-0.989) in validation cohort B, demonstrating sustained accuracy. DCA showed a good net clinical benefit of the nomogram.

CONCLUSIONS

A nomogram for predicting the probability of aspiration in patients with acute ischemia has been successfully developed and validated.

Prevalence and Risk Factors of Poststroke Dysphagia: A Meta-Analysis

INTRODUCTION

In patients with stroke, poststroke dysphagia (PSD) is a common complication that plays an important role in morbidity and mortality. The aim of this paper was to assess the prevalence and risk factors of PSD using a systemic review and meta-analysis.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched for potentially eligible studies published until September 2023. Further, the pooled incidence and risk factors for PSD were determined using a random-effects model. Overall, 58 studies involving 37,404 patients with acute stroke were selected for the meta-analysis.

RESULTS

The pooled incidence of PSD in patients with acute stroke was 42% (95% confidence interval [CI]: 36-48%), which is the highest in South America (47%) and lowest in Asia (37%). Notably, older age (odds ratio [OR]: 2.13; 95% CI: 1.53-2.97; p < 0.001), hypertension (OR: 1.23; 95% CI: 1.06-1.44; p = 0.007), diabetes mellitus (OR: 1.22; 95% CI: 1.04-1.44; p = 0.014), stroke history (OR: 1.26; 95% CI: 1.04-1.53; p = 0.019), and atrial fibrillation (OR: 1.58; 95% CI: 1.02-2.44; p = 0.039) were found to be associated with an increased risk of PSD. Conversely, sex differences, smoking, alcoholism, obesity, hyperlipidemia, ischemic heart disease, stroke type, and the hemisphere affected were not associated with the risk of PSD.

CONCLUSION

The abstract reports the prevalence of PSD in patients with acute stroke and identified potential risk factors for PSD, including older age, hypertension, diabetes mellitus, stroke history, and atrial fibrillation.

The Prevalence of Oropharyngeal Dysphagia in Adults: A Systematic Review and Meta-analysis

To determine the global prevalence of oropharyngeal dysphagia (OD) in adults. Six electronic databases (Embase, LILACS, LIVIVO, PubMed/Medline, Scopus, and Web of Science) were searched, in addition to gray literature (ASHA, Google Scholar, ProQuest Dissertation, and Theses). A random-effects model for meta-analysis of proportions was conducted, and heterogeneity was evaluated according to the moderator variable through subgroup analysis and meta-regression. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist and the certainty of the evidence was assessed using the GRADE tool. Thirty papers were included for qualitative and quantitative synthesis. The combined prevalence estimate was 60% [CI 95% = 50%-70%; I2 = 95%], accounting for different baseline conditions. However, the wide variation that exists between the different baseline conditions (underlying disease or risk factor) tended to overestimate this prevalence when considering the general population. Only one study evaluated healthy individuals, which showed a prevalence of 31% [CI95% = 27%-36%]. The risk of bias was considered low for all studies. None of the variables were considered predictors for the observed variance between the effect sizes of the included studies. For the prevalence of OD, the GRADE rating was considered very low. Despite the high prevalence observed, with over half of the individuals affected, the evidence regarding this outcome remains uncertain due to an overestimation of the generated estimates caused by the baseline condition of the sample.

Complications of oropharyngeal dysphagia in older individuals and patients with neurological disorders: insights from Mataró hospital, Catalonia, Spain

Background

Oropharyngeal dysphagia (OD) significantly impacts older individuals and neurologically compromised patients, hindering safe ingestion of food and liquids. Despite its prevalence, OD remains underdiagnosed and undertreated, leading to severe complications such as malnutrition, dehydration, respiratory infections, and aspiration pneumonia (AP), and increases hospital readmissions.

Objectives

This study analyzes the intricate relationship between OD and various clinical complications in older individuals and patients with neurological disorders.

Methods

Utilizing retrospective analysis and narrative review, our work consolidates findings from prior studies on Hospital de Mataro's dysphagia patient cohort. Revisiting OD's intricate association with clinical complications, it presents data via odds ratios (OR), incidence ratios (IR), and hazard ratios (HR) from univariate and multivariate analyses.

Results

Five studies (2001-2014) involving 3,328 patients were scrutinized. OD exhibited independent and significant associations with various complications among older patients. Older individuals with OD faced heightened 1-month (ODDS 3.28) and 1-year (OR 3.42) mortality risks post-pneumonia diagnosis. OD correlated with a 2.72-fold risk of malnutrition, 2.39-fold risk of lower respiratory tract infections, 1.82-fold pneumonia readmissions (IR), and 5.07-fold AP readmissions (IR). Post-stroke OD is linked to neurological impairment (OR 3.38) and respiratory (OR 9.54) and urinary infections (OR 7.77), alongside extended hospital stays (beta coefficient 2.11).

Conclusion

Oropharyngeal dysphagia causes and significantly exacerbates diverse clinical complications in older and post-stroke patients, emphasizing the urgent need for proactive identification, comprehensive assessment, and tailored management. Acknowledging OD's broader implications in general medical practice is pivotal to improving patient outcomes and healthcare quality.

The Role of Perineuronal Nets in the Contralateral Hemisphere in the Electroacupuncture-Mediated Rehabilitation of Poststroke Dysphagia Mice

Acupuncture at Lianquan (CV23) acupoint has been shown to improve swallowing function in poststroke dysphagia (PSD). This improvement is supposed to be associated with the regulation of neuronal activity in the contralateral primary motor cortex (M1), while the underlying mechanism still needs to be elucidated. Perineuronal nets (PNNs) are well-known to be involved in the regulation of neuronal activity. Thus, we here aimed to detect the role of PNNs in the contralateral M1 hemisphere in the electroacupuncture (EA)-mediated effect in male mice. The results were obtained from a combination of methods, including in vitro slice electrophysiological recording, in vivo electrophysiological recording, and immunofluorescent staining in male mice. These results showed a decrease of the excitatory postsynaptic currents (sEPSCs) and no alteration of the inhibitory postsynaptic currents (sIPSCs) in the GABAergic neurons and the tonic inhibition in the excitatory neurons in the contralateral M1 after stroke induction, and EA recovered the impaired sEPSCs in the GABAergic neurons. We further found that the effect of EA-induced increase of c-Fos expression, enhancement of spike firing, potentiation of sEPSCs in the excitatory neurons, and improvement of swallowing function were all blocked by the removal of PNNs in the contralateral M1. In conclusion, the PNNs in the contralateral M1 was suggested to be participated in stroke pathogenesis and might be associated with the EA-mediated swallowing function rehabilitation of PSD in male mice. Our study provides insight into how PNNs might be involved in the mechanism of EA treatment for stroke rehabilitation.

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.

The Therapeutic Effect of Swallow Training with a Xanthan Gum-Based Thickener in Addition to Classical Dysphagia Therapy in Chinese Patients with Post-Stroke Oropharyngeal Dysphagia: A Randomized Controlled Study

Objective

In patients with post-stroke oropharyngeal dysphagia (PSOD), classical dysphagia therapy (CDT) continues to provide unsatisfactory outcomes and makes it challenging for them to remove the nasal feeding tube. Increasing bolus viscosity helps prevent aspiration in PSOD. However, conventional starch thickeners enhance post-digestion residue. This study aims to evaluate the efficacy of swallow training with xanthan gum-based thickener (XGT) (Softia G, NUTRI Co., Ltd., Yokkaichi, Japan) additional to CDT in Chinese PSOD patients with a nasogastric tube when compared to CDT alone.

Methods

Patients with PSOD who had a nasogastric tube were randomly assigned to either the experimental group (E-group) or the control group (C-group) in this randomized controlled, single-blind, parallel-group study. Both groups received CDT for 4 weeks. The E-group cases received additional swallow training with a Softia G-prepared hydrogel training material. The Functional Oral Intake Scale (FOIS) and modified volume-viscosity swallow test (M-VVST) for swallowing safety and efficacy according to adjusted Chinese dietary habits were administered before and after treatment. Post-training, both groups' nasogastric tube removal rates were calculated.

Results

One hundred sixty-seven participants (E-group: 82 and C-group: 85) completed the study. The E-group's median score of FOIS improved significantly than the C-group after training (median = 5 vs. 3, P < 0.001). The incidence of coughing, voice changes, oxygen desaturation of 3% or more, pharyngeal residue and piecemeal deglutition in the E-group was significantly lower than that in the C-group (P < 0.05). The E-group had 100% nasogastric tube removal, while the C-group had 28.24% (P < 0.001).

Conclusion

Swallow training with XGT Softia G in addition to CDT can promote swallowing safety and efficacy in Chinese patients with PSOD more effectively than CDT alone.

The assessment of dysphagia after stroke: state of the art and future directions

Dysphagia is a major complication following an acute stroke that affects the majority of patients. Clinically, dysphagia after stroke is associated with increased risk of aspiration pneumonia, malnutrition, mortality, and other adverse functional outcomes. Pathophysiologically, dysphagia after stroke is caused by disruption of an extensive cortical and subcortical swallowing network. The screening of patients for dysphagia after stroke should be provided as soon as possible, starting with simple water-swallowing tests at the bedside or more elaborate multi-consistency protocols. Subsequently, a more detailed examination, ideally with instrumental diagnostics such as flexible endoscopic evaluation of swallowing or video fluoroscopy is indicated in some patients. Emerging diagnostic procedures, technical innovations in assessment tools, and digitalisation will improve diagnostic accuracy in the future. Advances in the diagnosis of dysphagia after stroke will enable management based on individual patterns of dysfunction and predisposing risk factors for complications. Progess in dysphagia rehabilitation are essential to reduce mortality and improve patients' quality of life after a stroke.

Prognostic value of blood urea nitrogen to serum albumin ratio for acute kidney injury and in-hospital mortality in intensive care unit patients with intracerebral haemorrhage: a retrospective cohort study using the MIMIC-IV database

OBJECTIVE

We sought to evaluate the prognostic ability of blood urea nitrogen to serum albumin ratio (BAR) for acute kidney injury (AKI) and in-hospital mortality in patients with intracerebral haemorrhage (ICH) in intensive care unit (ICU).

DESIGN

A retrospective cohort study using propensity score matching.

SETTING

ICU of Beth Israel Deaconess Medical Center.

PARTICIPANTS

The data of patients with ICH were obtained from the Medical Information Mart for Intensive Care IV (V.1.0) database. A total of 1510 patients with ICH were enrolled in our study.

MAIN OUTCOME AND MEASURE

The optimal threshold value of BAR is determined by the means of X-tile software (V.3.6.1) and the crude cohort was categorised into two groups on the foundation of the optimal cut-off BAR (6.0 mg/g). Propensity score matching and inverse probability of treatment weighting were performed to control for confounders. The predictive performance of BAR for AKI was tested using univariate and multivariate logistic regression analyses. Multivariate Cox regression analysis was used to investigate the association between BAR and in-hospital mortality.

RESULTS

The optimal cut-off value for BAR was 6.0 mg/g. After matching, multivariate logistic analysis showed that the high-BAR group had a significantly higher risk of AKI (OR, 2.60; 95% confidence index, 95% CI, 1.86 to 3.65, p<0.001). What's more, a higher BAR was also an independent risk factor for in-hospital mortality (HR, 2.84; 95% confidence index, 95% CI, 1.96 to 4.14, p<0.001) in terms of multivariate Cox regression analysis. These findings were further demonstrated in the validation cohort.

CONCLUSIONS

BAR is a promising and easily available biomarker that could serve as a prognostic predictor of AKI and in-hospital mortality in patients with ICH in the ICU.

Strategies of Screening and Treating Post-Extubation Dysphagia: An Overview of the Situation in Greek-Cypriot ICUs

Post-extubation dysphagia (PED) can lead to serious health problems in critically ill patients. Contrasting its high incidence rate of 12.4% reported in a recent observational study, many ICUs lack routine bedside screening, likely due to limited awareness. This study aimed to establish baseline data on the current approaches and the status of perceived best practices in PED screening and treatment, as well as to assess awareness of PED. A nationwide cross-sectional, online survey was conducted in all fourteen adult ICUs in the Republic of Cyprus in June 2018, with a 100% response rate. Over 85% of ICUs lacked a standard screening protocol for PED. The most commonly reported assessment methods were cough reflex testing and the water swallow test. Treatment approaches included muscle strengthening exercises without swallowing and swallowing exercises. Only 28.6% of ICUs acknowledged PED as a common issue. The study identified significant gaps in awareness and knowledge regarding PED screening and treatment in Greek-Cypriot ICUs. Urgent implementation of comprehensive dysphagia education programs within the units is necessary, and interdisciplinary collaboration among nurses, intensivists, and speech and language therapists is crucial to improve the quality of care provided.

Risk factors independently associated with the maintenance of severe restriction of oral intake and alternative feeding method indication at hospital outcome in patients after acute ischemic stroke

BACKGROUND AND AIMS

From a clinical point of view, post-stroke patients present difficulties in swallowing management. The purpose of this research was to identify risk factors that were independently related to the maintenance of a severe restriction of oral intake in patients affected by acute ischemic stroke.

METHODS

The authors conducted a prospective observational cohort study of patients with dysphagia post-acute ischemic stroke who were admitted to an Emergency Room (ER). Demographic and clinical data were collected at ER admission. Swallowing data was based on The Functional Oral Intake Scale (FOIS) and was collected at two distinct moments: initial swallowing assessment and at the patient outcome. Patients were divided into two groups according to their FOIS level assigned on the last swallowing assessment (at hospital outcome): G1 with severe restriction of oral intake and indication of feeding tube - patients with FOIS levels 1 to 4; G2 without restriction of food consistencies in oral intake - patients with FOIS levels 5 to 7.

RESULTS

One hundred and six patients were included in our study. Results of the multivariate logistic regression model for the prediction of maintenance of a severe restriction of oral intake at hospital outcome in patients post-acute ischemic stroke indicated that increasing age (p = 0.006), and dysarthria (p = 0.003) were associated with higher chances of presenting severe restriction of oral intake at hospital outcome.

CONCLUSIONS

Patients with acute ischemic stroke in an Emergency Room may experience non-resolved severe dysphagia, indicating the need to prepare for the care/rehabilitation of these patients.

Geriatric nutrition risk index predicts prolonged post-stroke dysphagia in acute ischemic stroke

BACKGROUND

Post-stroke dysphagia (PSD) is a common complication after stroke. Malnutrition inhibits stroke recovery and is associated with stroke mortality. However, no studies have investigated the effects of nutritional state at admission on prolonged PSD.

METHODS

We retrospectively analyzed ischemic stroke patients in our institute from January 2018 to December 2020. Swallowing function was assessed using the Food Oral Intake Scale; prolonged PSD was defined as levels 1-3 at 14 days after admission. The Geriatric Nutritional Risk Index (GNRI) was used to assess nutritional risks, which were classified as follows: >98, no nutritional risk; 92-98, mild nutritional risk; 82-92, moderate nutritional risk; and <82, severe nutritional risk. The association between GNRI and prolonged PSD was assessed.

RESULTS

Of 580 patients (median age, 81 years; male, 53%), prolonged PSD was detected in 117 patients. Patients with severe dysphagia had older age, higher pre-stroke modified Rankin Scale score, lower GNRI, and higher National Institutes of Health Stroke Scale score. Logistic regression analysis revealed that lower GNRI was independently associated with prolonged PSD (continuous value; adjusted odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00-1.05). In addition, when "severe" and "moderate" nutritional risk was analyzed as a single class, moderate or severe nutritional risk (GNRI < 92) was independently associated with prolonged PSD (adjusted OR 2.50, 95% CI 1.29-4.87), compared with no nutritional risk patients (GNRI > 98).

CONCLUSIONS

In acute ischemic stroke, lower GNRI at admission was independently associated with prolonged PSD, suggesting that GNRI at admission might identify patients at risk of prolonged PSD.

Gastrointestinal Dysfunction in Stroke

Gastrointestinal (GI) complications are seen in over 50% of ischemic stroke survivors; the most common complications are dysphagia, constipation, and GI bleeding. The bidirectional relationship of the gut-brain axis and stroke has recently gained traction, wherein stroke contributes to gut dysbiosis (alterations in the normal host intestinal microbiome) and gut dysbiosis perpetuates poor functional neurologic outcomes in stroke. It is postulated that the propagation of proinflammatory cells and gut metabolites (including trimethylamine N-oxide and short-chain fatty acids) from the GI tract to the central nervous system play a central role in gut-brain axis dysfunction. In this review, we discuss the known GI complications in acute ischemic stroke, our current knowledge from experimental stroke models for gut-brain axis dysfunction in stroke, and emerging therapeutics that target the gut-brain axis.

How Valid and Reliable Is the International Dysphagia Diet Standardisation Initiative (IDDSI) When Translated into Another Language?

Swallowing difficulties are estimated to affect 590 million people worldwide and the modification of food and fluids is considered the cornerstone of dysphagia management. Contemporary practice uses the International Dysphagia Diet Standardisation Initiative (IDDSI), however, the validity and reliability of IDDSI when translated into another language has not been investigated. This study describes the translation process and confirms the validity and reliability of IDDSI when translated into another language (Swedish). The translation used a 12-step process based on the World Health Organization recommendations. Validity was tested using Content Validity Index (CVI) based on three ratings by a panel of 10-12 experts (Dietitians and Speech-Language Pathologists [SLPs]). The translation was rated for linguistic correlation as well as understandability and applicability in a Swedish context. Inter-rater reliability was calculated using Intraclass Correlation Coefficient (ICC) from 20 SLP assessments of 10 previously published patient cases. Significant improvement (p < 0.05) of CVI between Expert Panel assessments was shown for linguistic correlation (improvement from 0.74-0.98) and understandability/applicability (improvement from 0.79-0.93 across ratings). Excellent validity (Item-CVI > 0.78 and Scale-CVI/Average > 0.8) and very high inter-rater reliability (ICC > 0.9) were demonstrated. Results show that, when using a multi-step translation process, a translated version of IDDSI (into Swedish) demonstrates high validity and reliability. This further contributes to the evidence for use of IDDSI.

Economic Evaluation of Clinical, Nutritional and Rehabilitation Interventions on Oropharyngeal Dysphagia after Stroke: A Systematic Review

Background: Post-stroke oropharyngeal dysphagia (PS-OD) and its complications increase healthcare costs, suggesting that its appropriate management is cost-effective. We aimed to assess the efficiency of healthcare interventions in PS-OD management. Methods: A systematic review was conducted following PRISMA recommendations. Four databases were searched from inception through 30 June 2021. Outcome measures were cost-effectiveness and cost-savings of healthcare interventions. English and Spanish literature were included. Narrative and tables were used to present and synthesise evidence. Quality was evaluated using the CHEERS Statement. Results: A total of 244 studies were identified, and 10 were included. Screening and diagnosis of PS-OD studies found: (1) adjusted reduction in hospitalisation costs when assessed during the first admission day; (2) non-significant reduction in hospitalisation costs with OD management after thrombolysis; and (3) videofluoroscopy as the most cost-effective screening method (compared to bedside evaluation and a combination of both). Two studies showed cost-effective rehabilitation programmes, including OD management. Pelczarska et al. showed an incremental cost–utility ratio of texture-modified diets using a gum-based thickener of 20,977 PLN (4660€) following a dynamic model, and Kotecki et al. commercially prepared thickened fluids that were 44% to 59% less expensive than in situ prepared fluids. Elia et al. showed home enteral nutrition was cost-effective (£12,817/QALY), and Beavan et al. showed higher nutrient intake and low increase in hospitalisation costs using looped-nasogastric tubes (£5.20 for every 1% increase). Heterogeneity between studies precluded a quantitative synthesis. Conclusions: Included studies suggest that healthcare interventions aiming to prevent OD complications are cost-effective. However, studies assessing novel strategies are needed.

The effects of intermittent theta burst stimulation of the unilateral cerebellar hemisphere on swallowing-related brain regions in healthy subjects

Objective

We aimed to investigate the effects and mechanisms of swallowing-related brain regions using resting-state functional magnetic resonance imaging (rs-fMRI) in healthy subjects who underwent intermittent theta burst stimulation (iTBS) on dominant or non-dominant cerebellar hemispheres.

Methods

Thirty-nine healthy subjects were randomized into three groups that completed different iTBS protocols (dominant cerebellum group, non-dominant cerebellum group and sham group). Before iTBS, the resting motor threshold (rMT) was measured by single-pulse transcranial magnetic stimulation (sTMS) on the cerebellar representation of the suprahyoid muscles, and the dominant cerebellar hemisphere for swallowing was determined. Forty-eight hours after elution, iTBS protocols were completed: in the dominant cerebellum group, iTBS was administered to the dominant cerebellar hemisphere, and the non-dominant cerebellar hemisphere was given sham stimulation; in the non-dominant cerebellum group, iTBS was administered to the non-dominant cerebellar hemisphere, and sham stimulation was delivered to the dominant cerebellar hemisphere; in the sham group, sham stimulation was applied to the cerebellum bilaterally. Rs-fMRI was performed before and after iTBS stimulation to observe changes in the fractional amplitude of low-frequency fluctuation (fALFF) in the whole brain.

Results

Compared with baseline, the dominant cerebellum group showed increased fALFF in the ipsilateral cerebellum, and decreased fALFF in the ipsilateral middle temporal gyrus and contralateral precuneus after iTBS; the iTBS of the non-dominant cerebellum group induced increased fALFF in the ipsilateral superior frontal gyrus, the calcarine fissure and the surrounding cortex, and the contralateral inferior parietal lobule; and in the sham group, there was no significant difference in fALFF. Exploring the effects induced by iTBS among groups, the dominant cerebellum group showed decreased fALFF in the contralateral calcarine fissure, and surrounding cortex compared with the sham group.

Conclusion

Intermittent theta burst stimulation of the dominant cerebellar hemisphere for swallowing excited the ipsilateral cerebellum, and stimulation of the non-dominant cerebellar hemisphere increased the spontaneous neural activity of multiple cerebrocortical areas related to swallowing. In conclusion, regardless of which side of the cerebellum is stimulated, iTBS can facilitate part of the brain neural network related to swallowing. Our findings provide supporting evidence that cerebellar iTBS can be used as a potential method to modulate human swallowing movement.

Electroacupuncture improves swallowing function in a post-stroke dysphagia mouse model by activating the motor cortex inputs to the nucleus tractus solitarii through the parabrachial nuclei

As a traditional medical therapy, stimulation at the Lianquan (CV23) acupoint, located at the depression superior to the hyoid bone, has been shown to be beneficial in dysphagia. However, little is known about the neurological mechanism by which this peripheral stimulation approach treats for dysphagia. Here, we first identified a cluster of excitatory neurons in layer 5 (L5) of the primary motor cortex (M1) that can regulate swallowing function in male mice by modulating mylohyoid activity. Moreover, we found that focal ischemia in the M1 mimicked the post-stroke dysphagia (PSD) pathology, as indicated by impaired water consumption and electromyographic responses in the mylohyoid. This dysfunction could be rescued by electroacupuncture (EA) stimulation at the CV23 acupoint (EA-CV23) in a manner dependent on the excitatory neurons in the contralateral M1 L5. Furthermore, neuronal activation in both the parabrachial nuclei (PBN) and nucleus tractus solitarii (NTS), which was modulated by the M1, was required for the ability of EA-CV23 treatment to improve swallowing function in male PSD model mice. Together, these results uncover the importance of the M1-PBN-NTS neural circuit in driving the protective effect of EA-CV23 against swallowing dysfunction and thus reveal a potential strategy for dysphagia intervention.

Predicting Failure to Recover Swallowing in Patients with Severe Post-stroke Dysphagia: The DIsPHAGIc Score

In post-stroke dysphagia, early identification of patients at highest risk of failing swallowing recovery (SR) would be useful to decide which of them should undergo percutaneous endoscopic gastrostomy. The studies on this subject were numerous but generally based on small statistical samples. In this retrospective study, 1232 patients with ischemic or hemorrhagic stroke (73.7 ± 13.0 years, 51% men) were assessed: 593 non-dysphagic, 351 partially dysphagic and 288 totally dysphagic. Among the latter, 45.1% could not recover oral intake. A score to assess the risk of failing SR was obtained from the group with total dysphagia, and further 210 patients with total post-stroke dysphagia were utilized for validation. A regular progression of stroke severity markers, complications and mortality was observed from non-dysphagic, to partially dysphagic, up to totally dysphagic patients. Among the latter, seven variables were independently associated with failure of SR, and formed the "DIsPHAGIc score": cerebral lesion Diameter ≥ 6 cm (+ 1), left frontal Ischemia (- 1), Partial anterior circulation syndrome (- 1), Hypoxia (+ 1), Antiplatelet drug (+ 1), GCS verbal reaction < 4 (+ 1), Internal capsule ischemia (- 1). The area under the ROC curve was 0.79 (95% CI 0.74-0.85). For total scores ≥ 2 there was a high risk of failing SR, with specificity 76.9%, sensitivity 72.1% and accuracy 74.7%. The application of the DIsPHAGIc score to the validation sample provided almost identical results. The evolution of post-stroke dysphagia towards irreversibility can be predicted by a simple, reproducible and robust scoring system based on 7 variables commonly available during hospitalization.

Prevalence of Oropharyngeal Dysphagia in Adults in Different Healthcare Settings: A Systematic Review and Meta-analyses

Oropharyngeal dysphagia (OD) is prevalent in the elderly and persons with complex medical conditions, resulting in considerable medical and psychosocial consequences and reduced quality of life. Many prevalence studies regard OD in relation to age or diagnosis. Knowledge on the prevalence of OD in different healthcare settings is lacking. This systematic review aimed to estimate the prevalence of OD in adults admitted to hospitals, rehabilitation facilities, nursing homes, and palliative care facilities through meta-analyses. A systematic literature search was completed including all dates up to March 30, 2021. The methodology and reporting were based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Forty-four out of 1,956 screened articles were deemed eligible. Considerable heterogeneity in definitions of OD and type and quality of selected outcome measures were observed. Overall within-group pooled prevalence estimates for OD determined by meta-analysis were 36.5% (95% CI 29.9 - 43.6) in the hospital setting, 42.5% (95% CI 35.8 - 49.5) in the rehabilitation setting, and 50.2% (95% CI 33.3-67.2) in nursing homes. No OD prevalence data were identified for palliative care facilities. Results for between-group analyses of OD prevalence estimates in the hospital setting were non-significant for type of assessment method, diagnostic group, and type of hospital ward, but indicated significantly higher prevalence estimates in nursing homes when using screening compared to patient-report. Future research should provide OD prevalence data for palliative care, achieve consensus in OD-related terminology when performing prevalence studies, and use screening and assessments with optimal diagnostic performance and psychometric properties.

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

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

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

Objective

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

Methods

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

Results

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

Conclusion

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

Systematic review registration

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

Evident lower blood levels of multiple nutritional compounds and highly prevalent malnutrition in sub-acute stroke patients with or without dysphagia

Introduction

Malnutrition is prevalent after stroke, particularly if post-stroke oropharyngeal dysphagia (OD) reduces nutritional intake. To further understand stroke-related malnutrition, a thorough nutritional assessment was performed in ischemic stroke patients with or without OD during sub-acute inpatient rehabilitation.

Methods

In this exploratory, observational, cross-sectional, multi-center study in Germany (NTR6802), ischemic stroke patients with (N = 36) or without (N = 49) OD were age- and sex-matched to healthy reference subjects. Presence of (risk of) malnutrition (MNA-SF), blood concentration of stroke-relevant nutritional compounds and metabolites, nutritional intake, quality of life (EQ-5D-5L), and activities of daily living (Barthel index) were assessed.

Results

More than half of the stroke patients displayed (risk of) malnutrition, with higher prevalence in patient with OD vs. without OD. Fasted blood concentrations of vitamins B1, B2, B6, A, D, and E, selenium, choline, coenzyme Q10, albumin, pre-albumin, transferrin, docosahexaenoic acid, and eicosapentaenoic acid were all lower in stroke patients compared to their matched healthy reference subjects, irrespective of OD status. Reported energy, macronutrient, and water intake were lower in stroke patients vs. healthy reference subjects. As expected, quality of life and activities of daily living scores were lower in stroke vs. healthy reference subjects, with OD scoring worse than non-OD patients.

Discussion

This study shows that malnutrition is highly prevalent in sub-acute stroke patients during rehabilitation. Even though patients with OD were more likely to be malnourished, blood levels of specific nutritional compounds were similarly lower in stroke patients with or without OD compared to healthy reference subjects. Furthermore, subgroup analysis showed similarly lower blood levels of specific nutritional compounds in patients that are normal nourished vs. patients with (risk of) malnutrition. This might imply disease-specific changes in blood levels on top of overall protein-energy malnutrition. The results of the current study underline that it is important to screen for nutritional impairments in every stroke patient, either with or without OD.

Status of knowledge, attitude and practice of poststroke dysphagia in neurological nurses in China: A cross-sectional study

OBJECTIVES

To explore the status and related factors of knowledge, attitude, and practice (KAP) of poststroke dysphagia among neurological nurses in China.

METHODS

Neurological nurses from 40 tertiary hospitals in Southwest China were invited to complete a survey on the knowledge, attitude, and practice of the nursing of poststroke dysphagia. We used a questionnaire to collect the participants' information including the basic characteristics and the KAP Questionnaire on poststroke dysphagia in the neurological ward. A sample of 707 participants completed the survey.

RESULTS

The knowledge, attitude, and practice scores for the nursing of poststroke dysphagia were 12.00±4.09, 71.99±11.00, 52.22±9.08, respectively. The total score of knowledge towards the nursing of poststroke dysphagia was significantly different among nurses with different ages, working time of nursing, working time of nursing in neurology, the highest level of education, professional title, position, the method of training, the number of dysphagia-related nursing trainings, the total length of dysphagia nursing training, and the nursing basis of patients with dysphagia. The total score of attitudes towards the nursing of poststroke dysphagia was significantly different among nurses with the way they were trained, and the nursing basis for patients with dysphagia. The total score of practice towards poststroke dysphagia was significantly different among nurses with the number of dysphagia-related nursing trainings, the total length of dysphagia nursing training, the training method, and the basis of nursing patients with dysphagia.

CONCLUSION

Neurological nurses' knowledge score in poststroke dysphagia is relatively low, and the knowledge level needs improvement. The attitude and practice score of neurological nurses in dysphagia after stroke was much better than the knowledge score. Managers and nursing researchers should develop and offer effective training for neurological nurses to improve their knowledge, attitude and practice towards poststroke dysphagia, and then improve patients' health outcomes.

A Systematic and Universal Artificial Intelligence Screening Method for Oropharyngeal Dysphagia: Improving Diagnosis Through Risk Management

Oropharyngeal dysphagia (OD) is underdiagnosed and current screening is costly. We aimed: (a) to develop an expert system (ES) based on machine learning that calculates the risk of OD from the electronic health records (EHR) of all hospitalized older patients during admission, and (b) to implement the ES in a general hospital. In an observational, retrospective study, EHR and swallowing assessment using the volume-viscosity swallow test for OD were captured over 24 months in patients > 70 yr admitted to Mataró Hospital. We studied the predictive power for OD of 25,000 variables. ES was obtained using feature selection, the final prediction model was built with non-linear methods (Random Forest). The database included 2809 older patients (mean age 82.47 ± 9.33 yr), severely dependent (Barthel Index 47.68 ± 31.90), with multiple readmissions (4.06 ± 7.52); 75.76% had OD. The psychometrics of the ES built with a non-linear model were: Area under the ROC Curve of 0.840; sensitivity 0.940; specificity, 0.416; Positive Predictive Value 0.834; Negative Predictive Value 0.690; positive likelihood ratio (LH), 1.61 and negative LH, 0.146. The ES screens in 6 s all patients admitted to a 419-bed hospital, identifies patients at greater risk of OD, and shows the risk for OD in the clinician's workstation. It is currently in use at our institution. Our ES provides accurate, systematic and universal screening for OD in real time during hospital admission of older patients, allowing the most appropriate diagnostic and therapeutic strategies to be selected for each patient.

Ischemic stroke and concomitant gastrointestinal complications- a fatal combination for patient recovery

Stroke is primarily a neurodegenerative disease but can also severely impact the functions of other vital organs and deteriorate disease outcomes. A malfunction of the gastrointestinal tract (GIT), commonly observed in stroke patients, is often characterized by severe bowel obstruction, intestinal microbiota changes and inflammation. Over-activated immune cells after stroke are the major contributors to endorse intestinal inflammation and may induce damage to single-layer epithelial cell barriers. The post-stroke leakage of intestinal barriers may allow the translocation and dissemination of resident microflora to systemic organs and cause sepsis. This overshooting systemic immune reaction fuels ongoing inflammation in the degenerating brain and slows recovery. Currently, the therapeutic options to treat these GIT-associated anomalies are very limited and further research is required to develop novel treatments. In this mini-review, we first discuss the current knowledge from clinical studies and experimental stroke models that provide strong evidence of the existence of post-stroke GIT complications. Then, we review the literature regarding novel therapeutic approaches that might help to maintain GIT homeostasis and improve neurological outcomes in stroke patients.

Accuracy of Dysphagia Standard Assessment (DSA®) bedside screening test: a flowchart for patient eligibility

Background

Oropharyngeal dysphagia (OD) screening tests have improved patient management; however, the complex applicability and high percentage of false negatives do not allow these tests to be considered completely reliable if not supported by an instrumental investigation. The aim of the present study is to evaluate an OD screening test, the Dysphagia Standard Assessment (DSA®) with different volumes and viscosities.

Materials and methods

Prospective study of 72 patients evaluated for suspected OD through a double-blind methodology conducted by two operators. All patients underwent fiberoptic endoscopic evaluation of swallowing (FEES) as a reference test and a separate DSA® test. DSA® was performed by administering boluses with different viscosities, with the signal of interruption of the test being: onset of the cough reflex, wet voice after swallowing, and/or desaturation of O2 ≥ 5%. The Penetration-Aspiration Scale (PAS) was evaluated by FEES. The cut-off identified to diagnose OD was PAS ≥ 3.

Results

The test showed an accuracy of 82%, a sensitivity of 0.93 (95% C.I. 0.84–0.97), and a specificity of 0.78 (95% C.I. 0.67–0.87); positive predictive value 0.55 (95% C.I. 0.43–0.67); negative predictive value 0.97 (95% C.I. 0.90–0.99), positive likelihood ratio 4.37 (95% C.I. 3.6–5.2); likelihood negative ratio 0.08 (95% C.I. 0.06–0.09).

Conclusions

According to the preliminary results, the test showed good outcomes in determining the presence or absence of OD with a wide spectrum of applicability with some limitations that could be overcome by the selection of a target population. For this reason, a flowchart to address patient eligibility was developed.

The Impact of Periventricular Leukoaraiosis in Post-stroke Oropharyngeal Dysphagia: A Swallowing Biomechanics and MRI-Based Study

Oropharyngeal dysphagia is a highly prevalent post-stroke complication commonly associated with topographically specific gray-matter damage. In contrast, the role of damage to the extensive white matter brain network (leukoaraiosis) in post-stroke oropharyngeal dysphagia has not yet been clarified. We aim to assess the role of leukoaraiosis in post-stroke oropharyngeal dysphagia. We designed a cross-sectional study and retrospectively collected from our database patients with dysphagia affected by a recent stroke and on whom both a brain 1.5 T-MRI and a videofluoroscopy had been performed. Leukoaraiosis was assessed in brainstem and in cerebral regions (periventricular or deep) with Fazekas scale. Penetration-Aspiration-Scale and time to laryngeal vestibule closure and to upper esophageal sphincter opening were analyzed. Study population (n = 121; 57% men, 75.5 ± 9.4y) presented mostly supratentorial ischemic PACI-type strokes. Of the patients, 86% had unsafe swallows (PAS = 3.97 ± 2.04); 94.2% had cerebral leukoaraiosis (Fazekas = 3.36 ± 1.7) and 42.1% had brainstem-leukoaraiosis, hypertension being the main risk factor. We found both significant positive associations between degree of periventricular-leukoaraiosis and total-leukoaraiosis and presence of risk of aspirations (p = 0.016 and p = 0.023, respectively); and a correlation between periventricular-leukoaraiosis and PAS scale severity (r = 0.179, p = 0.049). No correlations/associations were found between stroke volume and dysphagia in this study. Our study supports a role for leukoaraiosis in the pathophysiology of dysphagia. Stroke is associated with chronic short-connection/circuit injury and damage to periventricular white matter long connections is a relevant neuro-pathophysiological mechanism contributing to impaired safety of swallow in post-stroke oropharyngeal dysphagia patients.

The Quality of Life in Citizens with Oropharyngeal Dysphagia—A Cross-Sectional Study

Dysphagia is a risk factor that impaires an individual’s experience of mealtimes. Few studies contribute to the knowledge on the health-related quality of life (HRQoL) of citizens with oropharyngeal dysphagia (OD) living independently. The aim of this study involves evaluating the HRQoL in citizens living independently and suffering from OD. This cross-sectional study was performed in seven municipalities in Denmark between March 2019 and December 2020. The 90 citizens included (54% female, mean age 76.6 years (SD 0.8)) were ≥18 years, as well as diagnosed with OD using the volume-viscosity swallow test and Minimal Eating Observation Form version II. The Dysphagia Handicap Index-DK, Barthel 20, and European Quality of Life-5 Dimensions were fulfilled. Of the participating citizens, 66% of them needed additional time to eat, 64% coughed while eating, and 58% coughed while drinking. Additionally, 60% reported having a dry mouth, 62% needed to drink to succeed with swallowing foods, and 57% had to swallow multiple times. About one-third felt embarrassed when eating with others. They could not enjoy eating in the same manner as they had previously, and/or felt handicapped or limited. OD was shown to have had a high impact on the QoL in citizens with OD living independently. Focus is needed on xerostomia, as well as on the psychological aspects pertainings to mealtimes for citizens with OD.

Predictors of complete oral feeding resumption after feeding tube placement in patients with stroke and dysphagia: A systematic review

AIMS

The aim was to synthesise and discuss predictors of complete oral feeding resumption after feeding tube placement in stroke patients with dysphagia.

DESIGN

This was a systematic review, following the PRISMA 2020 checklist.

DATA SOURCES

Eight databases (PubMed, Web of Science, Embase, Cochrane, CINAHL, CNKI, WanFang and Vip) were searched for eligible studies from inception up to June 2021.

REVIEW METHODS

The JBI Manual for Evidence Synthesis was used to guide this systematic review. Any cross-sectional survey, longitudinal study, cohort study or case-control study that explored the recovery from tube feeding to complete oral feeding in patients with dysphagia after stroke was included. Qualitative studies, review articles, case reports and conference abstracts were excluded. Two reviewers independently screened and appraised the studies. The Newcastle-Ottawa scale was used for quality assessment. Content analysis was used to categorise factors predicting feeding tube removal in stroke patients with dysphagia.

RESULTS

This review included a total of 15 studies consisting of 1746 participants, of which 2 were case-control studies and 13 were cohort studies. Four studies were rated as having low risk of bias, and the other 11 had high risk of bias. The factors examined in the studies were categorised into demographic characteristics (age and sex), swallowing function (instrumental assessments and non-instrumental assessments), stroke characteristics (stroke severity, past stroke history and location of the stroke), functional status (cognitive function and physical function) and clinical measures (body mass index, geriatric nutritional risk index, white blood cell count and C-reactive protein level).

CONCLUSIONS

The major limitation of this review is the failure to identify predictors of different tube feeding types. Although the current evidence is insufficient to support or oppose the predictive effect of any single factor, these factors are still valuable data for clinical staff that provide information that researchers can use in developing prognostic models. Rigorously designed and high-quality research is needed to further explore the predictive value of these factors.

REGISTRATION

This review was registered prospectively with PROSPERO [CRD42021272552].

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers should strengthen the monitoring of swallowing function in patients with stroke to promote complete oral feeding resumption. As the predictive value of the identified factors is still uncertain, large, well-designed, studies are needed to better clarify the importance of these predictors.

NO PATIENT OR PUBLIC CONTRIBUTION

No patient or public was involved in the design, analysis, preparation or writing of this review.

Economic evaluations of health care interventions in oropharyngeal dysphagia after stroke: protocol for a systematic review

BACKGROUND AND PURPOSE

Oropharyngeal dysphagia (OD) affects 40-81% of patients after stroke. A recent systematic review on the costs of OD and its main complications showed higher acute and long-term costs for those patients who developed OD, malnutrition and pneumonia after stroke. These results suggest that appropriate management of post-stroke OD could reduce clinical complications and costs. The purpose of this systematic review is to assess the available literature for healthcare interventions that are efficient or cost-effective in the management of OD.

METHODS

A systematic review on economic evaluations of health care interventions will be performed on post-stroke patients with OD following PRISMA recommendations. Four bibliographic databases will be searched and a subsequent reference check will be done. English and Spanish literature will be included without date restrictions. Studies will be included if they refer to economic evaluations or in which cost savings were reported in post-stroke patients suffering OD. Studies will be excluded if they are partial economic evaluation studies, if they refer to esophageal dysphagia, or if OD is caused by causes different from stroke. Evidence will be presented and synthetised with a narrative method and using tables. Quality evaluation will be done using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement.

DISCUSSION

The protocol for this systematic review is the first step to assess the cost-effectiveness of the healthcare interventions that have been described as potential treatments for post-stroke OD. This systematic review will summarise the current evidence on the relation between cost and benefits associated with the appropriate management of OD in post-stroke patients.

TRIAL REGISTRATION

PROSPERO CRD42020136245.

Prevalence of dysphagia and risk of pneumonia and mortality in acute stroke patients: a meta-analysis

Background

Post-stroke dysphagia (PSD) has been associated with high risk of aspiration pneumonia and mortality. However, limited evidence on pooled prevalence of post-stroke dysphagia and influence of individual, disease and methodological factors reveals knowledge gap. Therefore, to extend previous evidence from systematic reviews, we performed the first meta-analysis to examine the pooled prevalence, risk of pneumonia and mortality and influence of prognostic factors for PSD in acute stroke.

Methods

Our search was conducted in CINAHL, Cochrane Library, EMBASE, Ovid-Medline, PubMed, and Web of Science an initial search in October 2020 and a follow-up search in May 2021. Data synthesis was conducted using the Freeman-Tukey double-arcsine transformation model for the pooled prevalence rate and the DerSimonian-Lard random-effects model for prognostic factors and outcomes of PSD.

Results

The pooled prevalence of PSD was 42% in 42 studies with 26,366 participants. PSD was associated with higher pooled odds ratio (OR) for risk of pneumonia 4.08 (95% CI, 2.13–7.79) and mortality 4.07 (95% CI, 2.17–7.63). Haemorrhagic stroke 1.52 (95% CI, 1.13–2.07), previous stroke 1.40 (95% CI, 1.18–1.67), severe stroke 1.38 (95% CI, 1.17–1.61), females 1.25 (95% CI, 1.09–1.43), and diabetes mellitus 1.24 (95% CI, 1.02–1.51) were associated with higher risk of PSD. Males 0.82 (95% CI, 0.70–0.95) and ischaemic stroke 0.54 (95% CI, 0.46–0.65) were associated with lower risk of PSD. Haemorrhagic stroke, use of instrumental assessment method, and high quality studies demonstrated to have higher prevalence of PSD in the moderator analysis.

Conclusions

Assessment of PSD in acute stroke with standardized valid and reliable instruments should take into account stroke type, previous stroke, severe stroke, diabetes mellitus and gender to aid in prevention and management of pneumonia and thereby, reduce the mortality rate.

Trial registration

https://osf.io/58bjk/?view_only=26c7c8df8b55418d9a414f6d6df68bdb.

Supplementary information

The online version contains supplementary material available at 10.1186/s12877-022-02960-5.

Acoustic characteristics associated with liquid swallowing sounds of different bolus consistencies in young healthy adults

BACKGROUND

Cervical auscultation has been used clinically as an augmentative procedure for swallow examination. Despite its frequent use for screening and preliminary assessment of swallowing, the usefulness of cervical auscultation is controversial due to a lack of sufficient research, particularly in quantifying swallowing sounds.

AIMS

To document the acoustic characteristics of normal swallowing sound associated with swallowing bolus of different consistencies among younger healthy adults.

METHODS & PROCEDURES

A total of 30 healthy young adult participants swallowed 5 ml thickened liquids of four different consistencies (slightly thick, mildly thick, moderately thick and extremely thick) prepared using a starch-based commercial thickener, and the corresponding swallowing sounds were recorded using a wireless accelerometric stethoscope. An array of acoustic measures including duration of swallowing sound (DSS), duration to peak intensity (DPI), frequency at peak intensity (FPI), peak intensity (PI), average intensity (AI), and difference between peak and average intensity (DPAI) values associated with the swallowing signals were obtained.

OUTCOMES & RESULTS

In general, increased durational measures of the swallowing sounds were associated with an increase in bolus consistency. Intensity measures including PI, AI and DPAI were found to be stable across different consistencies. The change in FPI did not appear to be particularly meaningful due to its high variability. In addition, no significant differences were observed between men and women.

CONCLUSIONS & IMPLICATIONS

Swallow sounds associated with different bolus consistencies could be quantified and used to differentiate consistencies. The present findings could serve as a reference for future swallowing research of normal and dysphagic population.

WHAT THIS PAPER ADDS

What is already known on the subject Cervical auscultation using traditional stethoscope has been used as part of an informal clinical swallow examination by practitioners. Validity of cervical auscultation is controversial, possibly due to the lack of normative data on swallow sounds. What this paper adds to existing knowledge The present study explored the possibility of using wireless accelerometric stethoscopy for cervical auscultation for dysphagia screening. Acoustic profiles of swallow sounds associated with boluses of different consistencies in healthy individuals were examined. What are the potential or actual clinical implications of this work? Findings contribute to our knowledge about the acoustic characteristics of swallow sounds of boluses of different consistencies in healthy young individuals. The study provides normative clinical data on cervical auscultation using wireless accelerometric stethoscope for normal swallow.

Do Thickening Agents Used in Dysphagia Diet Affect Drug Bioavailability?

Swallowing oral solid dosage forms is challenging in patients with dysphagia who are at risk of aspiration or choking. The most common method to facilitate drug administration in dysphagia patients is to mix the powdered drug with a small amount of thickened water, however little is known about the effects of this method on in vivo bioavailability of drugs. This study aimed to evaluate the impact of thickened liquids on dissolution rate and bioavailability of levetiracetam as a model drug. Powdered commercial tablets of levetiracetam, carbamazepine, atenolol and cefixime were mixed with water thickened with two commercial thickeners, modified maize starch (MS) and xanthan gam (XG), at three thickness levels: nectar, honey and pudding in test groups, and mixed with only water in the control group. At the first stage, the effects of thickened water on in vitro drug release of 4 drugs (levetiracetam, carbamazepine, atenolol and cefixime) were tested by using dialysis membrane method. Addition of both thickeners significantly reduced the release of three drugs compared to the control group, except carbamazepine. Levetiracetam which had the highest solubility was chosen as the model drug for in vivo experiments. In the second stage, New Zealand albino female rabbits (n=24) were divided into two groups as: control group (water+drug, n=6) and test group (thickened water+drug, n=18). Powdered levetiracetam tablets were mixed with water thickened with XG (n=9, 1.2 %, 2.4 %, 3.6 %) and MS (n=9, 4 %, 6%, 8 %) at three thickness levels and administered to the rabbits by intragastric gavage. Blood samples were collected at 9 time points following administration. After two-weeks of wash-out, test groups were crossed over and sample collection was repeated. Blood samples were analysed using liquid chromatography with tandem mass spectrometry (LC-MS/MS). An in vitro-in vivo correlation (IVIVC) model was developed using in vitro drug dissolution (%) and in vivo plasma concentrations of levetiracetam for control group and test groups. The peak plasma concentration (C_max) was lower and time to reach C_max (t_max) was relatively higher in test groups compared to control group. The lowest C_max was detected at the highest thickness level, however, the differences between groups were not statistically significant (p=0.117 and p=0.495 for C_max and t_max, respectively). No significant difference in total amount of levetiracetam absorbed (AUC) was found between groups (p=0.215 and p=0.183 for AUC_infinity and AUC_last, respectively). The comparisons according to the type of thickener also revealed that pharmacokinetic parameters did not significantly differ between groups, except for a significantly lower C_max when drug was mixed with MS-thickened water at nectar consistency (1.2 %) compared to drug mixed with XG (4 %) at the same thickness level (p=0.038). A good correlation was observed between in vitro and in vivo data, which was characterized by higher r² values as the concentration of the thickening agents was increased, but not for all thickness levels studied, indicating an inability of this in vitro model to fully predict the in vivo response. These results suggest that regardless of the thickness level, the administration of levetiracetam with two commercial thickening agents commonly used in dysphagia for safe swallowing, do not affect the pharmacokinetic efficiency and thus, the bioavailability of the drug.

Correlation between a Bedridden Status and the Long-term Outcome in Hemodialysis Patients after Intracerebral Hemorrhaging

Objective The quality of life and activities of daily living (ADL) are generally poor among dialysis patients after intracerebral hemorrhaging, and their precise clinical course remains unclear. In addition, the association between the severity of cerebral hemorrhaging and the long-term prognosis in these patients has not been fully elucidated. This study aimed to evaluate the subsequent prognosis of hemodialysis patients who survived the acute phase of intracerebral hemorrhaging. Methods We included hemodialysis patients who were admitted to Nagasaki University Hospital between 2007 and 2015 for intracerebral hemorrhaging treatment. After excluding cases of in-hospital death, survivors were classified using the 5-point modified Rankin Scale (mRS), which specifically measures the ADL in patients with cerebrovascular diseases. The patients were followed up at the medical facilities to which they were transferred in the same medical zone until 2017. Results Out of 91 patients with cerebral hemorrhaging (65±11 years old, 66% men, hemodialysis duration 108±91 months), 62 survived until discharge. Twenty-one patients died during observation, largely due to infectious diseases, such as sepsis and pneumonia (n=16, 76%). Compared to patients with mRS 0-4 (n=31), those with mRS 5 (n=31) showed a significantly poorer prognosis. The hazard ratio adjusted for age and antiplatelets was 13.7 (95% confidence interval: 3.88-63.7, p<0.001). Conclusion Hemodialysis patients with intracerebral hemorrhaging who were bedridden showed poor outcomes. The major causes of death were infections. Therefore, these patients should be carefully monitored for infections in order to improve their prognosis.

The global prevalence of oropharyngeal dysphagia in different populations: a systematic review and meta-analysis

Background

Oropharyngeal dysphagia (OD) refers to any abnormality in the physiology of swallowing in the upper gastrointestinal tract, which leads to the related clinical complications, such as malnutrition, dehydration, and sever complication, such as aspiration pneumonia, suffocation, and eventually, premature death. The previous studies indicated a various range of prevalence of OD. The present systematic review and meta-analysis aimed to standardize the global prevalence of OD in different populations.

Methods

A systematic literature review was conducted using Embase, Scopus, PubMed, Web of Science (WoS) databases, and Google Scholar motor engine using related MeSH/Emtree and Free Text words, with no time limitation until November 2021. The heterogeneity among studies was quantified using I² index and the random effects model was used, due to the high heterogeneity among the results of studies included in the meta-analysis.

Results

The systematic literature search retrieved 2092 studies. After excluding the irrelevant studies, ultimately 27 articles with a sample size of 9841 were included in the meta-analysis. After combining the studies, the overall estimate of the global prevalence rate of OD was 43.8% (95% CI 33.3–54.9%) and the highest prevalence rate was estimated in Africa with 64.2% (95% CI 53.2–73.9%). Given the subgroup analysis based on the study population, the highest prevalence of OD was related to Dementia with 72.4% (95% CI 26.7–95.0%). The results of meta-regression indicated that the prevalence of OD has an increasing trend with the enhancement of year of publication and mean age.

Conclusion

The results of the present systematic review and meta-analysis revealed that the prevalence of OD is high in different populations and its trend has been increasing in recent years. Therefore, the appropriate strategies should be applied to reduce the prevalence of OD by finding its causation and monitoring at all levels, as well as providing feedback to hospitals.

Swallowing Ability in Stroke Patients: A Case Study in Tasikmalaya Hospital, Indonesia

BACKGROUND: Dysphagia is one of the problems that stroke patients often experience. Stroke patients who experience dysphagia often do not get attention because of the lack of early screening, which will cause delays in treatment. To overcome this, nurses have an essential role from the initial screening phase to independent nursing interventions. In screening for dysphagia, nurses can use various methods: Gugging Swallowing Screen (GUSS). AIM: The purpose of the study was to identify and explain association between respondent characteristics and the GUSS method of swallowing ability scores in stroke patients. METHODS: This research was a descriptive study, with a total sample of 20 people. The sampling technique used was consecutive sampling. RESULTS: The results showed that based on the results of the screening test for swallowing ability using the GUSS method, it was found that most of the respondents (75%) belonged to the category of severe dysphagia. Dysphagia was associated with age (p < 0.001), gender (p = 0.000), type of stroke (p < 0.001), comorbidities (p < 0.001), and the frequency of stroke attacks (p < 0.001). CONCLUSION: This study concludes that there is association between respondent characteristics: Age, gender, type of stroke, comorbidities, and frequency of attacks with the score of swallowing ability of stroke patients.

[Atrial fibrillation and cognitive impairment: features of the relationship, developmental and prevention mechanisms]

The article discusses the development of cognitive deficit in patients with atrial fibrillation (AF) and provides data on mechanisms of the development of cognitive disorders in AF. Under discussion are a possibility of reducing the risk of cognitive disorders with the anticoagulant therapy for prevention of stroke in AF and different properties of different anticoagulants, which may be important for patients. Thus, patients with cognitive disorders are more prone to missing the dose, which may entail serious, possibly fatal consequences. Therefore, the convenience of dosing may be essential. The drug rivaroxaban that has once-a-day dosing schedule and a calendar package, may help the patient better adhere to the doctor's recommendations. Therefore, rivaroxaban may help improving the compliance, which is the major condition for comprehensive, necessary protection of an elderly patient with AF, including the protection, with high safety, from stroke, from the risk of coronary complications, and from the impairment of kidney function.

Best Practice Recommendations for Dysphagia Management in Stroke Patients: A Consensus from a Portuguese Expert Panel

Dysphagia is frequent after stroke, and it increases the risk of respiratory infection, dehydration and malnutrition, resulting in worse outcomes. Different clinical guidelines present recommendations for the assessment and management of dysphagia in stroke patients in a scattered way. These best practice recommendations address seven clinical questions on the assessment and management of dysphagia in stroke patients, gathering the best-updated evidence. A systematic literature review using the PICO strategy was performed. The recommendations draft was then appraised by a multidisciplinary panel of experts (nutritionists, physiatrists, speech-language pathologists and rehabilitation nurses) in a total of 3 Delphi rounds. A minimum of 80% consensus was established, and the final version offers a total of 21 recommendations for use in clinical practice for stroke patients. These clinical recommendations are an overview of the most recent evidence combined with experts’ consensus and translated into clinically relevant statements. In implementing recommendations at the local level, health professionals should identify facilitators and barriers to evidence-based practice within their contexts and determine the best strategies to address local needs. Where the change is needed, initial and continuing training on all recommendations is essential and relevant.

Systematic Review and Meta-Analysis of Dysphagia and Associated Pneumonia in Patients With Stroke From India: A Call to Arms

OBJECTIVES

This study aimed to determine the prevalence of reported dysphagia and associated pneumonia risk among patients with stroke in India.

METHOD

We carried out a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome of interest was dysphagia and pneumonia among patients with stroke in India. Two review authors independently assessed the quality of studies using the Newcastle-Ottawa Scale and extracted related data. Meta-analysis was performed for frequency of dysphagia, associated pneumonia, and its relative risk using a random-effects model. Statistical heterogeneity was computed using the I² index.

RESULTS

A total of 3,644 titles were screened, and only eight studies met our inclusion criteria. Based on data from these studies, we calculated the pooled prevalence of dysphagia (47.71%; 95% confidence interval [CI] [20.49%, 70.92%], p < .001) and pneumonia (20.43%; 95% CI [10.73%, 30.14%], p < .001) for patients with stroke in India. We found that the relative risks of pneumonia in patients with stroke and dysphagia versus those patients with stroke and no dysphagia was 9.41 (95% CI [5.60, 15.80], p < .001). Data on length of hospital stay and rates of mortality secondary to pneumonia are also presented.

CONCLUSIONS

Despite the high incidence of dysphagia and associated pneumonia, the methodological quality of studies is fair and there is little research focused on epidemiological data. We call to arms to those SLPs working with patients with stroke in India to become proactive in both clinical practice and research domains. Supplemental Material https://doi.org/10.23641/asha.17701022.

Total magnetic resonance imaging of cerebral small vessel disease burden predicts dysphagia in patients with a single recent small subcortical infarct

Background

This study was performed to identify the association between the total magnetic resonance imaging burden of small vessel disease and the occurrence of post-stroke dysphagia in patients with a single recent small subcortical infarct (RSSI).

Methods

We retrospectively identified all patients with a magnetic resonance imaging-confirmed single RSSI. The water-swallowing test and volume-viscosity swallow test were performed within the first 24 h following admission to assess swallowing. Demographic and clinical data were extracted from our stroke database. Based on brain magnetic resonance imaging, we independently rated the presence of cerebral microbleeds, lacunes, white matter hyperintensities and enlarged perivascular spaces. The presence of each small vessel disease feature was summed to determine the total small vessel disease burden, ranging from 0 to 4.

Results

In total, 308 patients with a single RSSI were enrolled. Overall, 54 (17.5%) were diagnosed with post-stroke dysphagia. The risk factors related to post-stroke dysphagia included the following: older age, higher National Institute of Health Stroke Scale scores, higher C-reactive protein level and higher fibrinogen level. Based on multiple logistic regression, National Institute of Health Stroke Scale scores and total small vessel disease burden were independent risk factors of post-stroke dysphagia in patients with a single RSSI, after adjusting for age, gender, history of hypertension, C-reactive protein level and fibrinogen level.

Conclusions

Dysphagia in patients with a single RSSI was associated with a more severe total small vessel disease burden as reflected by MRI. Total MRI of cerebral small vessel disease burden may predict dysphagia in these patients. Furthermore, more severe total small vessel disease burden was associated with systemic inflammation.

Unfolding and characterizing the barriers and facilitators of scaling-up evidence-based interventions from the stakeholders' perspective: a concept mapping approach

INTRODUCTION AND AIMS

Much attention has been paid to scaling-up evidence-based interventions (EBIs) in previous implementation science studies. However, there is limited research on how stakeholders perceive factors of the scaling-up of EBIs. This study aimed to identify the barriers and facilitators of scaling-up the nurse-led evidence-based practice of post-stroke dysphagia identification and management (EBP-PSDIM) from the stakeholders' perspective, and to assess their importance and feasibility.

METHODS

This study was conducted using concept mapping. Through purposive sampling, 18 stakeholders were recruited for brainstorming in which they responded to the focus prompt. Here, statements regarding perceived barriers and facilitators to EBI scaling-up were elicited and then sorted by similarity before being rated based on the importance and feasibility. Cluster analysis, multidimensional scaling, and descriptive statistics were utilized to analyze the data.

RESULTS

Ultimately, 61 statements perceived to influence the scaling-up were grouped into four primary clusters, that is, community-related factors, resource team-related factors, evidence-based practice program-related factors, and scaling-up strategy-related factors. The 'perceived needs of the community' was rated as the most important and feasible factor to address, whereas 'costs/resource mobilization' was rated as the least important and feasible one.

CONCLUSION

From the stakeholders' perspective, factors involved in the EBP-PSDIM program scaling-up were initially validated as being multidimensional and conceptually distinct; The importance and feasibility ratings of the barriers and facilitators could be used to help decision-makers to prioritize the most appropriate factors to be considered when developing implementation strategies.

Predictive Model of Dysphagia and Brain Lesion-Symptom Mapping in Acute Ischemic Stroke

Background and purpose: Early recognition and management of post-stroke dysphagia (PSD) based on MRI may reduce the incidence of complications. Combining clinical symptoms with applications of MRI, we aimed to identify the risk factors of PSD, develop a prediction scale with high accuracy and map key dysphagia brain areas.

Methods: A total of 275 acute ischemic stroke patients were enrolled in this study, and 113 (41.1%) patients were diagnosed with PSD. All patients underwent the water-swallowing test (WST) and volume-viscosity swallow test (V-VST) within first 24 h following admission to assess swallowing. Vascular factors were evaluated and MRI brain scans were obtained within 3 days after symptom onset for each participant admitted to the hospital. T-test, chi-squared test and Fisher’s exact test were used to investigate the associations of various patient characteristics with dysphagia, and multivariable logistic regression models were used to construct a prediction scale. Scale accuracy was assessed using receiver operating characteristic (ROC) analysis. We extracted white matter hyperintensities for each patient as potential brain lesions. Voxel-based lesion-symptom mapping (VLSM) was used to identify key brain areas for dysphagia.

Results: Risk factors related with PSD were older age, history of atrial fibrillation, higher fasting blood glucose, NIH stroke scale, TOAST classification, progressive stroke, middle cerebral artery lesion and anterior cerebral artery lesion. Three variables with most significant associations, including NIH stroke scale, TOAST classification and progressive stroke, combined with age and gender, were used to construct a dysphagia prediction scale with high accuracy (AUC = 0.86). VLSM identified left inferior parietal gyrus as a key brain region for PSD.

Conclusion: Risk factors of PSD were identified and a predictive model of dysphagia was constructed intelligently and automatically. The left inferior parietal gyrus was identified as a key brain area for dysphagia, which provides a new symptom-based treatment target for early rehabilitation in the future.

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.

A Systematic and a Scoping Review on the Psychometrics and Clinical Utility of the Volume-Viscosity Swallow Test (V-VST) in the Clinical Screening and Assessment of Oropharyngeal Dysphagia

(1) Background: The volume-viscosity swallow test (V-VST) is a clinical tool for screening and diagnosis of oropharyngeal dysphagia (OD). Our aims were to examine the clinical utility of the V-VST against videofluoroscopy (VFS) or fiberoptic endoscopic evaluation of swallow (FEES) and to map the V-VST usage with patients at risk of OD across the years since it was described for the first time, carrying a systematic and a scoping review. (2) Methods: We performed both a systematic review (SR) including studies that look at the diagnostic test accuracy, and a scoping review (ScR) with articles published from September 2008 to May 2020. Searches were done in different databases, including PubMed and EMBASE from September 2008 until May 2020, and no language restrictions were applied. A meta-analysis was done in the SR to assess the psychometric properties of the V-VST. Quality of studies was assessed by Dutch Cochrane, QUADAS, GRADE (SR), and STROBE (ScR) criteria. The SR protocol was registered on PROSPERO (registration: CRD42020136252). (3) Results: For the diagnostic accuracy SR: four studies were included. V-VST had a diagnostic sensitivity for OD of 93.17%, 81.39% specificity, and an inter-rater reliability Kappa = 0.77. Likelihood ratios (LHR) for OD were 0.08 (LHR-) and 5.01 (LHR+), and the diagnostic odds ratio for OD was 51.18. Quality of studies in SR was graded as high with low risk of bias. In the ScR: 34 studies were retrieved. They indicated that V-VST has been used internationally to assess OD's prevalence and complications. (4) Conclusions: The V-VST has strong psychometric properties and valid endpoints for OD in different phenotypes of patients. Our results support its utility in the screening and clinical diagnosis and management of OD.