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

Nutritional assessment in acute stroke patients: A systematic review of guidelines and systematic reviews

INTRODUCTION

Dysphagia and malnutrition are major contributors to mortality in patients with acute stroke. An early assessment of nutritional status upon hospital admission is crucial to enhance clinical outcomes by reducing the associated high-risk complications. However, the fragmented nature of the existing literature makes it difficult to optimize clinical practices.

OBJECTIVE

This study aims to identify the best clinical practices that nurses and other healthcare professionals can employ for the immediate assessment of nutritional risk in patients diagnosed with acute stroke.

DESIGN

Systematic review of clinical practice guidelines and systematic reviews.

DATA SOURCES

Comprehensive bibliographic searches were conducted up to May 2024 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines across the databases Cochrane Library, PubMed, Embase, CINAHL, and Scopus, and three recognized guideline repositories.

REVIEW METHODS

The quality of clinical practice guidelines was ascertained using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument, and the quality of systematic reviews was assessed through A MeaSurement Tool to Assess Systematic Reviews (AMSTAR 2). The evidence quality was appraised based on the classifications by the European Society of Cardiology.

RESULTS

Out of 2534 identified records, 15 were incorporated into this review. Predominantly, the selected clinical practice guidelines and systematic reviews exhibited high methodological quality. Notably, the Gugging Swallowing Screen and the Malnutrition Universal Screening Tool were pinpointed as primary tools for initial screenings. Most studies recommended that these assessments, ideally conducted within the first 24 h of patient admission, should be carried out by specially trained professionals, highlighting the pivotal role of nurses. Deviations in screening outcomes necessitate complementary specialist evaluations.

CONCLUSIONS

This systematic review offers a consolidation of current insights, proposing an innovative and integrated approach to assess nutritional needs of high-risk patients. It underscores the importance of nurses in the screening process, emphasizing their pivotal role in the nutritional management of patients with acute stroke, and advocates for further research endeavors to standardize intervention protocols to elevate patient clinical outcomes.

PROTOCOL REGISTRATION NUMBER

PROSPERO CRD42023425140.

Factors associated with oropharyngeal dysphagia and unsuccessful nasogastric tube removal after endovascular thrombectomy for anterior circulation stroke

PURPOSE

To identify the predictive variables for post-stroke dysphagia (PSD) among anterior circulation large vessel occlusion (LVO) stroke patients who underwent endovascular thrombectomy (EVT).

METHODS

This retrospective cohort study enrolled hospitalized patients with anterior LVO stroke who underwent EVT between January 1, 2018 and October 31, 2022. PSD was defined as the unsuccessful removal of the nasogastric (NG) tube. Factors, such as premorbid characteristics, laboratory results, EVT, rehabilitation-related parameters, and neuro-imaging, were analyzed for correlations to PSD at 4 and 12 weeks.

RESULTS

The study enrolled 136 patients, with a mean age of 72.9 ± 13.0 years, and 59 patients (43.4%) were male. At 4 weeks, 47.1% of the patients needed an NG tube, and at 12 weeks, 16.2% still required an NG tube. We found that lower albumin, lower body mass index (BMI), higher initial and 24-h post-EVT National Institute of Health Stroke Scale (NIHSS) scores, stroke-associated pneumonia, poor initial sitting balance and ability to sit up, insula or frontal operculum lesions, and bilateral hemisphere involvement were all associated with PSD at both 4 and 12 weeks in the univariate logistic regression. Multivariate analysis revealed that significant predictors of unsuccessful NG tube removal at 4 weeks included lower BMI (adjusted OR [aOR] 0.73, p = 0.005), hemorrhagic transformation (aOR 4.01, p = 0.0335), higher NIHSS scores at 24 h post-EVT (aOR 1.13, p = 0.0288), poor initial sitting ability (aOR 0.52, p = 0.0231), insular cortex ischemia (aOR 7.26, p = 0.0056), and bilateral hemisphere involvement (aOR 41.19, p < 0.0001). At 12 weeks, lower BMI (aOR 0.78, p = 0.0098), poor initial sitting balance (aOR 0.57, p = 0.0287), insular cortex lesions (aOR 4.83, p = 0.0092), and bilateral hemisphere involvement (aOR 4.07, p = 0.0139) remained significant predictors.

CONCLUSIONS

In patients with anterior LVO following EVT, PSD was associated with lower BMI, higher NIHSS scores, poor initial sitting balance and sitting ability, insular lesions, and bilateral hemisphere involvement.

Exploring facilitators and barriers associated with oral care for inpatients with dysphagia post-stroke

OBJECTIVE

To explore the attitudes, facilitators and barriers in providing oral care for inpatients with dysphagia post-stroke as perceived by healthcare professionals.

BACKGROUND

Dysphagia is a common complication of stroke and is associated with a higher incidence of aspiration pneumonia, malnutrition and dehydration. In the acute phase of stroke recovery, a dental professional is not usually part of the multidisciplinary team caring for the patient and oral care is the responsibility of the healthcare professionals in the stroke unit. There is a lack of high-quality evidence to demonstrate the most effective method of providing oral care for patients with dysphagia post-stroke.

MATERIALS AND METHODS

This was a single-site study conducted with healthcare professionals working in the Stroke Unit of Cork University Hospital in Ireland, using focus groups and a qualitative thematic analysis approach.

RESULTS

A total of three focus groups were conducted in the Stroke Unit with 17 healthcare professionals. The focus groups included representation from all healthcare professional groups providing direct clinical care to patients on the Stroke Unit including geriatric medicine, dietetics, speech and language therapy, healthcare assistance, nursing, occupational therapy and physiotherapy. A qualitative thematic analysis was carried out and seven overarching themes emerged from the data. Three themes related to facilitators to providing oral care for this patient group: (i) a focus on oral care in both policy and practice, (ii) expanding professional roles in the provision of oral care, (iii) perceived importance of oral care in recovery and rehabilitation. Four themes related to barriers to the provision of oral care for this patient group: (i) lack of confidence and concerns related to the perceived risk for patients with dysphagia, (ii) unique challenges of patient and stroke-related factors, (iii) lack of resources and time and (iv) perceived importance of oral care in recovery and its relative importance with competing demands.

CONCLUSION

Members of the stroke multidisciplinary team believe that they all have a part to play in the delivery of oral care for patients with dysphagia post-stroke. Opportunities exist for the development of multidisciplinary interventions to improve the oral cavity assessment and oral care provided in the Stroke Unit.

Screening for optimal parameters for modified pharyngeal electrical stimulation for the treatment of dysphagia after stroke in rats

Pharyngeal electrical stimulation (PES), a novel noninvasive peripheral nerve stimulation technique, can effectively improve neurogenic dysphagia and increase the safety and effectiveness of swallowing in the clinic. However, the lack of animal models for dysphagia has limited the mechanistic research on PES, which affects its wide application. Therefore, determining optimal parameters for PES in rats is needed to enable mechanistic studies. Modified PES (mPES), which has different waves and pulse widths from PES, was used; in previous studies mPES was found to have a neurological mechanism like that of PES. A poststroke dysphagia (PSD) model was established, and rats with dysphagia were grouped into three different intensities (0.1 mA, 0.5 mA, and 1 mA) for the selection of optimal intensity and three different frequencies (1 Hz, 2 Hz, and 5 Hz) for the selection of optimal frequency based on a stimulation duration of 10 min in the clinic. A Videofluroscopic Swallow Screen (VFSS) was used to assess swallowing function in rats before and after mPES treatment. The results showed that the 1 mA group had better swallowing function (p < 0.05) than the model group. Compared with the model group, the 1 Hz and 5 Hz groups had the same improvement in swallowing function (p < 0.05). However, the increase in excitatory signals in the sensorimotor cortex was more pronounced in the 5 Hz group than in the other frequency stimulation groups (p < 0.05). Combining the clinical findings with the above results, we concluded that the optimal stimulation parameter for mPES in rats is "frequency: 5 Hz, current intensity: 1 mA for 10 min/day", which provides a basis for future basic experimental studies of mPES in animals.

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

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

"The association between HALP score and infection in acute ischemic stroke patients"

BACKGROUND AND PURPOSE

Stroke-associated infection (SAI) is related to increased mortality in acute ischemic stroke (AIS) cases. The HALP index is used to evaluate nutrition and inflammation. Our research aimed to assess the relation between HALP scores and infection risk in AIS cases.

MATERIALS AND METHODS

132 cases of acute ischemic stroke were registered. 77 cases were male and 55 cases were female. The median age of the attending cases was 66 (35-104) years. Laboratory variables were assessed within 24 h after hospitalization in the neurology care unit. The HALP score is evaluated utilizing the formula "Hemoglobin (g/dL) × Albumin (g/dL) × Lymphocyte (/10^3/uL) / Platelet (/10^3/uL)".

RESULTS

Cases were separated into two groups according to their corresponding HALP score. Group-1 cases have a low HALP score (HALP score ≤ 18227,93). Group-2 cases have a high HALP score (HALP score > 18227,93). 26 (19.6 %) cases were diagnosed with various infections after hospitalization in the neurology care unit. Urinary tract infections were frequent infection causes in AIS cases (13 cases, 50 %). Pneumonia was observed in 8 cases, making up 30 % of the total cases. Another infection was seen in 5 (20 %) of the cases. The frequently encountered bacteria were Escherichia coli ESBL + (n = 7, 27 %) and Staphylococcus aureus (n = 6, 23 %). The mortality ratio was higher in Group-1 cases than in Group-2 cases (34 % vs 7 %).

CONCLUSIONS

This investigation has suggested a relationship between infection and HALP score in AIS patients.

Current state of research on acupuncture for the treatment of post-stroke dysphagia: a scoping review

Objective

Post-stroke dysphagia (PSD) is a common complication of stroke. Acupuncture as one of the traditional therapies in traditional Chinese medicine (TCM), can change the excitability of cerebral cortical nerve cells, and promote the recovery of neurological and swallowing functions. Several clinical primary studies (including RCTs, cohort studies, etc.) and systematic reviews have demonstrated its efficacy and safety in patients with PSD. The positive effects of acupuncture on PSD are also mentioned in international clinical and treatment guidelines, while there is no synthesis of this evidence. This scoping review aims to summarize the evidence from clinical primary studies, reviews, systematic reviews, and guidelines on acupuncture for the treatment of PSD and explore the breadth of this evidence, provide an overview of the range and characteristics of existing evidence, research gaps, and future research priorities in treating PSD with acupuncture.

Method

PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, SinoMed, Wan Fang Data, and VIP databases were searched from inception until June 12, 2024. The relevant data were presented through bubble diagrams, line graphs, and structured tables along with descriptive statistics and analysis. This scoping review was conducted based on the PRISMA-ScR Checklist.

Results

A total of 1,130 studies were included. Most of the studies were conducted in China, with the number increasing over time. The studies included 254 reviews, 815 clinical studies (678 RCTs,107 nRCTs, 12 case reports, 14 cohort studies, and four case series), 51 systematic reviews, and 10 guidelines. Acupuncture interventions included manual acupuncture (MA), electroacupuncture (EA), and MA/EA combined with acupuncture-related methods (such as scalp acupuncture, auricular acupuncture, warm acupuncture, etc.). The most frequently used acupoint was RN23. Acupuncture is often applied in combination with other treatments, such as herbal medicine, Western medicine, rehabilitation training, swallowing training, or catheter balloon dilatation. Effective rates and WTS were the most frequently used outcomes. Most studies reported significant efficacy and only a few studies explicitly reported adverse events. Acupuncture received positive recommendations in nine guidelines for the treatment of PSD.

Conclusion

As a convenient and safe traditional Chinese medicine therapy with its characteristics, acupuncture can improve different stages and types of dysphagia without causing serious adverse reactions. In the future, more standardized international cooperative clinical research is needed to identify the influence of different acupuncture intervention times on the curative effect and dose-effect relationship of acupuncture; standardize the clinical acupoint selection scheme of acupuncture; develop a COS with TCM characteristics to improve the quality of outcome reporting, This will enable different research data to be summarized and compared, reduce resource waste, and provide more high-quality evidence.

Swallowing muscle mass contributes to post-stroke dysphagia in ischemic stroke patients undergoing mechanical thrombectomy

BACKGROUND

Neurogenic dysphagia is a frequent complication of stroke and is associated with aspiration pneumonia and poor outcomes. Although ischaemic lesion location and size are major determinants of the presence and severity of post-stroke dysphagia, little is known about the contribution of other acute stroke-unrelated factors. We aimed to analyse the impact of swallowing and non-swallowing muscles measurements on swallowing function after large vessel occlusion stroke.

METHODS

This retrospective study was based on a prospective registry of consecutive ischaemic stroke patients. Patients who underwent mechanical thrombectomy between July 2021 and June 2022 and received a flexible endoscopic evaluation of swallowing (FEES) within 5 days after admission were included. Demographic, anthropometric, clinical, and imaging data were collected from the registry. The cross-sectional areas (CSA) of selected swallowing muscles (as a surrogate marker for swallowing muscle mass) and of cervical non-swallowing muscles were measured in computed tomography. Skeletal muscle index (SMI) was calculated and used as a surrogate marker for whole body muscle mass. FEES parameters, namely, Functional Oral Intake Scale (FOIS, as a surrogate marker for dysphagia presence and severity), penetration aspiration scale, and the presence of moderate-to-severe pharyngeal residues were collected from the clinical records. Univariate and multivariate ordinal and logistic regression analyses were performed to analyse if total CSA of swallowing muscles and SMI were associated with FEES parameters.

RESULTS

The final study population consisted of 137 patients, 59 were female (43.1%), median age was 74 years (interquartile range 62-83), median baseline National Institutes of Health Stroke Scale score was 12 (interquartile range 7-16), 16 patients had a vertebrobasilar occlusion (11.7%), and successful recanalization was achieved in 127 patients (92.7%). Both total CSA of swallowing muscles and SMI were significantly correlated with age (rho = -0.391, P < 0.001 and rho = -0.525, P < 0.001, respectively). Total CSA of the swallowing muscles was independently associated with FOIS (common adjusted odds ratio = 1.08, 95% confidence interval = 1.01-1.16, P = 0.029), and with the presence of moderate-to-severe pharyngeal residues for puree consistencies (adjusted odds ratio = 0.90, 95% confidence interval = 0.81-0.99, P = 0.036). We found no independent association of SMI with any of the FEES parameters.

CONCLUSIONS

Baseline swallowing muscle mass contributes to the pathophysiology of post-stroke dysphagia. Decreasing swallowing muscle mass is independently associated with increasing severity of early post-stroke dysphagia and with increased likelihood of moderate-to-severe pharyngeal residues.

Acupuncture for stroke: A bibliometric analysis of global research from 2000 to 2022

Objective

This study aimed to explore the global and future research trends in acupuncture interventions for stroke between 2000 and 2022 using bibliometric analysis.

Method

A bibliometric analysis of literature from 2000 to 2022 in the Web of Science Core Collection was conducted in this study. The analysis utilized CiteSpace, VOSviewer, and Scimago Graphica software to identify the major contributors to publications, including authors, countries, institutions, journals, references, and keywords.

Results

The bibliometric analysis yielded a total of 860 publications. There was a gradual increase in the number of publications over the study period. China published the most articles. Evidence-Based Complementary and Alternative Medicine was the journal with the greatest number of publications. The most frequently used keywords were "acupuncture," "stroke," and "electroacupuncture."

Conclusion

These analysis uncovers the research trends in acupuncture for stroke spanning 2000 to 2022 and points to prospective research frontiers. This study provides a deeper and more thorough understanding of the connotations of acupuncture for stroke and guidance and support for future research in this field.

Dysphagia management by nurses in Spanish intensive care units

INTRODUCTION/PURPOSE

Dysphagia is a disorder that presents with specific signs and symptoms in critically ill patients. Intensive care unit (ICU) nurses are responsible for monitoring and detecting abnormalities in critically ill patients, so they must be trained to assess swallowing and the complications that may arise. The aim of this research is to analyse the dynamics of the detection and assessment of dysphagia by ICU nurses.

METHOD

Cross-sectional descriptive study using an electronic questionnaire to nurses from different Spanish ICUs. The survey was adapted from previous research and consisted of 6 sections with 30 items of qualitative questions. The collection period was between December 2022 and March 2023. Statistical analysis was performed using frequencies and percentages, and the Chi-Square test was used for bivariate analysis.

OUTCOMES

43 nurses were recruited. Dysphagia is considered an important problem (90,7%) but in 50,3% of the units there is no standard or care protocol for this disorder. The most common technique is the swallowing test (32,6%). There is a consensus in our sample that aspiration pneumonia is the main problem; however, nurses in the busiest care units consider sepsis to be a frequent complication (p = ,029). The most common treatment is modification of food consistency (86,0%).

CONCLUSION

The findings of this research show a low systematisation of dysphagia screening in the units included. There is a need for greater implementation of interventions and clinical protocols for monitoring complications as well as for compensatory and rehabilitative management.

Mapping research trends regarding the mechanism of dysphagia from 1993 to 2023: a bibliometrics study and visualization analysis

As a common consequence of various neurogenic disorders, dysphagia has a significant impact on the quality of life for patients. To promote the development the field of swallowing, it will be helpful to clarify the pathological and therapeutic mechanisms of dysphagia. Through visual analysis of related papers from 1993 to 2023 in the Web of Science Core Collection (WoSCC) database, the research status and development trend of the pathogenesis of dysphagia were discussed. The co-occurrence study was finished using CiteSpace 6.2 R4 software, including keywords, countries, institutions, and authors. Finally, 1,184 studies satisfied the inclusion requirements. The findings of the visualization analysis suggested that aspiration and gastroesophageal reflux disease would be the areas of greatest interest for researchers studying the mechanism of dysphagia. As for the latest occurred research trends, fMRI, signals and machine learning emerging into the field of view of researchers. Based on an analysis of country co-occurrence, United States, Japan and China rank the top three, in terms of the number of publications on dysphagia. University System of Ohio is the organization that has published the most amount of articles regarding the mechanism of dysphagia. Other highly published schools in the top three include State University System of Florida and Northwestern University. For the prolific authors, German, Rebecca Z published the most articles at present, whose own research team working closely together. Several closely cooperating research teams have been formed at present, including the teams centered around German, Rebecca Z, Warnecke, Tobias and Hamdy Shaheen. This study intuitively analyzed the current research status of the mechanism of dysphagia, provided researchers with research hotspots in this field.

Factors influencing speech pathology practice in dysphagia after stroke: A qualitative focus group study

BACKGROUND

Dysphagia affects over half of adults after stroke. Dysphagia rehabilitation aims to improve swallowing and reduce negative outcomes for these adults. However, significant variability exists in dysphagia rehabilitation. Research is needed to explore the underlying clinician-specific and workplace factors that contribute to variability in dysphagia rehabilitation after stroke.

AIM

To explore factors influencing speech pathology practice in dysphagia rehabilitation after stroke.

METHODS & PROCEDURES

We used a phenomenological approach with an interpretivist perspective. Twenty speech pathologists working in dysphagia rehabilitation participated from different workplace settings around Australia. Five semi-structured focus groups were conducted online. Data were inductively analysed using thematic analysis with a coding reliability method.

OUTCOMES & RESULTS

Four themes were discussed within focus groups: (1) relationship between experienced and less experienced clinicians: 'Following what other people have done', (2) need for collaborative learning: 'A safe space to share and train', (3) variation between settings impacts on continuity of care: 'There's a difference between community and acute', and (4) working effectively with multidisciplinary teams (MDT): 'An MDT which can listen to the voice of speech pathology'.

CONCLUSIONS & IMPLICATIONS

Relationships between senior and junior speech pathologists, within speech pathology and MDT, and across inpatient and community settings influenced speech pathology practice. Flattened hierarchies in speech pathology, collaborative learning in workplaces, mutual respect within teams and connection across inpatient and community settings could improve the quality and consistency of dysphagia rehabilitation after stroke.

WHAT THIS PAPER ADDS

What is already known on this subject Dysphagia rehabilitation can improve swallowing after a stroke. However, dysphagia rehabilitation is characterised by variability in clinical practice. Clinician-specific and workplace factors influence clinical practice and may contribute to variability in dysphagia rehabilitation. What this study adds Professional relationships influence speech pathologists' clinical practice, including relationships between senior and junior clinicians, between inpatient and community settings and with peers and multidisciplinary teams. Workplace norms and hierarchies, poor continuity of care between settings and competing priorities from other disciplines can hinder dysphagia rehabilitation. However, collaborative learning, positive workplace cultures and respectful transdisciplinary care can improve the quality and consistency of clinical practice. What are the clinical implications of this work? Flattening hierarchies in the workplace can foster a safe learning space. Further, questioning workplace norms and seeking out peer learning within and across settings can build clinical skills and confidence. Developing positive workplace cultures that support continuous development may be key for empowering speech pathologists to provide high-quality and consistent dysphagia rehabilitation.

Effect of acupuncture on post-stroke dysphagia: a randomized controlled trial

Introduction

Post-stroke dysphagia (PSD) is associated with various complications that increase morbidity and mortality rates. Acupuncture has been used extensively in China to treat these complications; however, its therapeutic efficacy remains uncertain. We therefore aimed to study the clinical effects of acupuncture on PSD.

Methods

Patients (n = 101) were randomly divided into acupuncture (n = 50) and rehabilitation training control (n = 51) groups based on the treatment used. Both groups were treated once daily, 6 days a week, for a total of 4 weeks. Pulse oxygen saturation (SpO2) and standardized swallowing assessment (SSA) were performed before the intervention, 2 weeks into treatment, after the intervention (4 weeks post-intervention), and at a 6-month follow-up (28 weeks). The levels of hemoglobin (Hb) and albumin (ALB), and 5-hydroxytryptamine (5-HT) and dopamine (DA) were measured before the intervention, 2 weeks into treatment, and after the intervention (4 weeks), as nutrition and swallowing function indices, respectively.

Results

Following the intervention, significant differences were observed between the acupuncture and control groups. The acupuncture group exhibited considerably superior enhancements in SpO2 and SSA scores at 4 weeks (p < 0.001). Moreover, this group demonstrated significantly greater improvements in Hb, ALB, 5-HT, and DA values 4 weeks post-treatment (p < 0.001). However, sex-based differences were not observed (P > 0.005).

Conclusion

Acupuncture treatment can improve the swallowing function and nutritional status of patients with PSD, and increase the levels of 5-HT and DA. These findings strongly support the efficacy of acupuncture as a therapeutic intervention in patients with PSD.Clinical trial registration: identifier, ChiCTR2100052201. (https://www.chictr.org.cn/).

Nil per os in the management of oropharyngeal dysphagia-exploring the unintended consequences

Nil per os (NPO), also referred to as Nil by Mouth (NBM), is a health-related intervention of withholding food and fluids. When implemented in the context of a person with dysphagia, NPO aims to mitigate risks of aspiration. However, evidence demonstrating that NPO is beneficial as an intervention for people with dysphagia is lacking. This paper explores the theoretical and empirical evidence relating to the potential benefits and adverse effects of NPO and asserts that NPO is not a benign intervention. This paper argues for applying an ethics framework when making decisions relating to the use of NPO as an intervention for dysphagia, in particular addressing informed consent and a person's right to self-determination.

A systematic review and meta-analysis of acupuncture in aspiration caused by post-stroke dysphagia

Objective

This systematic review and meta-analysis aims to systematically evaluate the effectiveness and safety of acupuncture in the treatment of aspiration caused by post-stroke dysphagia.

Methods

A computer search was conducted in nine databases, including the China National Knowledge Infrastructure (CNKI), China Science and Technology Journal (VIP), Wan-fang Database, China Biomedical Literature Database (CBM), PubMed, Web of Science, Cochrane Library, Embase, and Chinese Clinical Trial Registry (ChiCTR), from their inception until April 2024. Clinical randomized controlled trials comparing acupuncture combined therapy or single therapy with control interventions for the treatment of aspiration caused by post-stroke dysphagia were included. The primary outcome measure was the Penetration Aspiration Scale (PAS), and secondary outcome measures included the overall effective rate, video fluoroscopic swallowing study (VFSS), and hyoid bone displacement. The statistical analysis was performed using RevMan 5.3 and Stata 16.0.

Results

A total of 16 articles involving 1,284 patients were included. The meta-analysis results showed that acupuncture combined therapy or single therapy was more effective in improving PAS scores compared to conventional rehabilitation therapy or balloon dilation of the catheter [WMD = -1.05, 95% CI (-1.30, -0.80), Z = 0.82, p = 0.00 < 0.05]. It was also more effective in improving VFSS scores [WMD = 1.32, 95% CI (0.08, 2.55), Z = 2.09, p = 0.04 < 0.05] and hyoid bone displacement [WMD = 2.02, 95% CI (0.86, 3.18), Z = 3.41, p = 0.00 < 0.05]. Additionally, acupuncture had a higher overall effective rate [WMD = 1.21, 95% CI (1.14, 1.29), Z = 5.76, p = 0.00 < 0.05] and a lower incidence of adverse events. Sensitivity analysis indicated that the literature had minimal impact on the results, and bias tests showed no publication bias.

Conclusion

Acupuncture combined therapy and acupuncture single therapy can effectively improve aspiration caused by post-stroke dysphagia with a low incidence of adverse events. However, due to the low quality of the included literature, more high-quality randomized controlled trials are still needed to confirm the effectiveness and safety of acupuncture in the treatment of aspiration caused by post-stroke dysphagia.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023462707, identifier CRD42023462707.

The randomized study of enteral nutrition with rapid versus conventional administration in acute stroke patients; the protocol of rapid EN trial

Rationale

Enteral nutrition is beneficial for stroke patients with oral intake difficulties. However, it is time consuming and may interfere with routine medical care. Therefore, there is a clinical benefit if enteral nutrition can be safely administered in a short time. Although our retrospective study showed the safety of rapid administration, it remains unclear whether rapid administration of enteral nutrition is as safe as conventional administration.

Aim

The randomized study of Enteral Nutrition with Rapid versus conventional administration in acute stroke patients (Rapid EN trial) aims to clarify the safety of rapid feeding of enteral nutrition compared with conventional feeding.

Methods and design

This is an investigator-initiated, multicenter, prospective, randomized, open-label, blinded end-point clinical trial. Eligible criteria include acute stroke patients who have difficulty with oral intake defined as severe altered consciousness (Japan Coma Scale 10-300) or modified water swallowing test <4. The target enrollment is 700 patients, with 350 patients receiving rapid enteral nutrition at a rate of 100 mL in 5 min (Rapid EN group) and 350 patients receiving conventional enteral nutrition at a rate of 100 mL in 30 min (Conventional EN group).

Study outcome

The primary outcome is the incidence of one or more complications of vomiting or diarrhea or pneumonia within 7 days would be non-inferior in the rapid EN group compared to the conventional EN group. Secondary outcomes were total time spent on enteral nutrition within 7 days from enteral nutrition, the incidence of vomiting, diarrhea and pneumonia within 3 or 7 days, and the rate of favorable clinical outcome.

Discussion

Since no previous reports have focused on the speed of administration, we felt it was necessary to prove the safety of rapid administration. If this study shows positive results, it will not only benefit patients, but also reduce the burden of medical care. We believe this study is novel and will be useful in clinical practice.

Clinical trial registration

https://rctportal.niph.go.jp/s/detail/um?trial_id=UMIN000046610 Identifier UMIN000046610.

"One of the biggest grey areas": A focus group study exploring dosage of swallowing exercises from speech-language pathologist perspectives

Purpose: To explore the perspectives and practices of speech-language pathologists on dosage of swallowing exercises in stroke rehabilitation.Method: Online focus groups involved 20 speech-language pathologists working in various settings across Australia. Focus group data were recorded, deidentified, and analysed using inductive thematic analysis guided by an interpretivist phenomenological approach.Result: Analysis resulted in four main themes: (1) "Getting the most bang for your buck": Importance of dosage in swallowing, (2) "No patient is identical": Personalising swallowing exercise dosage to the patient, (3) "You've got what you should do, and then what you can do": Gap between recommendations and practical application, and (4) "Not much guidance out there about dosage": More research needed to guide dosage. Speech-language pathologists agreed that dosage was theoretically important for swallowing exercises, but practical application of dosage was impacted by patient factors, limited access to resources, and lack of research-based guidelines.Conclusion: Speech-language pathologists reported trying to provide optimal care despite multiple barriers to prescribing dosages of swallowing exercises in practice. Personalising exercise dosage to the patient, creative clinician strategies, improved and equitable access to resources, and research-based guidelines on swallowing exercise dosages are needed to address these barriers.

Neuromuscular Electrical Stimulation for Post-Stroke Dysphagia Treatment: A Systemic Evaluation and Meta-Analysis of Randomized Controlled Trials

Neuromuscular electrical stimulation (NMES) is a novel treatment method that stimulates patients' swallowing functions. This systemic review was designed to evaluate the impact of NMES on dysphagia in stroke patients. Databases including PubMed, Embase, Web of Science, and Cochrane Library were searched from the date of establishment to January 28th, 2022. Two investigators identified all included studies and compared the swallowing function after NMES treatment with traditional therapy (TT). The Cochrane risk bias assessment tool was utilized to analyze the quality of included studies. Research outcomes included Swallowing Quality of Life (SWAL-QoL), Penetration-Aspiration Scale (PAS), Functional Oral Intake Scale (FOIS), Dysphagia Outcomes and Severity Scale (DOSS), the Repeat Salivary Swallowing Test (RSST), and Water Swallowing Test (WST). We extracted the mean and standard deviation of specific outcomes at the baseline level and after the treatment in both NMES and TT groups for subsequent meta-analysis. 9 randomized controlled trials (RCTs) and quasi-RCTs were included, and remarkable differences were found between patients treated with or without NMES in respect of FOIS scores (SMD = 0.48; 95% CI 0.26-0.70, P < 0.0001), PAS scores (SMD = - 0.56; 95% CI 1.01-0.10, P = 0.02), and SWAL-QoL scores (SMD = 0.57; 95% CI 0.00-1.14, P = 0.05). No significant difference was manifested in WST, RSST, and DOSS (SMD: - 0.02; 95% CI  0.38-0.35, P = 0.93). Evidence suggests that NMES is more effective for post-stroke dysphagia patients than treatment without NMES.

Research hotspot and frontiers in post-stroke dysphagia: A bibliometric study and visualisation analysis

BACKGROUND

Dysphagia, a common complication after stroke, significantly hampers the recovery process of patients, both due to dysphagia itself and the additional complications it causes. Although a large number of articles have been published on post-stroke dysphagia (PSD), bibliometric analysis in this field is still lacking. This study aimed to provide a comprehensive understanding of the research hotspots and trends in PSD, thereby guiding future research efforts.

METHODS

The Web of Science Core Collection (WoSCC) database was searched for articles related to PSD from 2003 to 2022. Data were visualised and analysed using CiteSpace and VOSviewer.

RESULTS

A total of 3102 publications were included in the scientometric analysis, with a gradual increase in the number of papers published each year. The United States emerged as the country with the highest number of publications (625 articles), while the University of Manchester led with the most publications among institutions (67 articles). Notably, Dysphagia was both the most published (254 articles) and the most cited journal (11,141 citations). Among authors, Hamdy S emerged as the most prolific (52 articles), with Martino R being the most cited (1042 citations).

CONCLUSION

Based on our findings, we anticipate that research hotspots in PSD will mainly focus on complications due to PSD such as stroke-associated pneumonia, stroke-related sarcopenia. Additionally, exploration into the mechanisms and parameters of noninvasive brain stimulation techniques for the treatment of PSD, as well as the rehabilitation needs of patients with PSD, are expected to be key focal points in future research endeavours.

Comparative global analysis of stroke rehabilitation recommendations across income levels

OBJECTIVE

Successful implementation of stroke rehabilitation guidelines demands high-quality practice standards tailored to targeted sociodemographic contexts. The primary objective is to determine the quality differences in post-stroke rehabilitation practice guidelines (PGs), when comparing high-income countries (HIC) and low or middle-income countries (LMIC).

STUDY DESIGN AND SETTING

We conducted a scoping review of PGs in English or Spanish, published between 2012 and 2021, and providing recommendations on post-stroke rehabilitation. We used Search engines, databases, guideline libraries, gray literature, and references from previous reviews on post-stroke rehabilitation as sources of evidence. Quality assessment of PGs was performed using 6P's, ELSE, IOM, and AGREE II instruments. We evaluated each item using a scale between 0 to 3, based on the confidence of adherence to the standard. For AGREE II, we followed the instruction manual for scoring. At least two reviewers were independently involved in every step of the process. A cloud-based spreadsheet was used to chart data. We compared the results of PGs originating from HIC with those from LMIC.

RESULTS

The inclusion criteria were met by 35 documents, which were subjected to evaluation. The study included 21 documents from HIC and 14 from middle-income countries (MIC). No manuscripts from low-income countries were available for inclusion in the study. The quality of PGs from MIC was found to be lower, in terms of methodological rigor and adherence to international recommendations for guidelines development. PGs from both groups of countries failed to include all target audiences and stakeholders (according to the 6P's criteria) and integration of ethical, legal, social, and economic considerations.

CONCLUSION

There are gaps in the quality and availability of stroke rehabilitation guidelines worldwide, especially in LMIC. Designing and providing financial support for the implementation of high-quality guidelines will contribute to more effective implementation strategies in stroke rehabilitation programs and lead to improved patient outcomes.

A simple nomogram for predicting aspiration associated with dysphagia in hospitalized patients after stroke

BACKGROUND

Aspiration is a common complication of poststroke dysphagia (PSD) and is associated with poor prognosis and mortality. There is no uniform criterion for determining aspiration associated with dysphagia. The aim of this study was to identify early predictors of aspiration, leading to the development of a simple nomogram for identifying aspiration risk associated with dysphagia in hospitalized patients after stroke.

METHODS

Demographic information and clinical characteristics of 330 patients with PSD in the training cohort were utilized to develop a nomogram. The LASSO regression method was used to screen variables, and logistic regression was used to construct the nomogram. Internal validation was performed with bootstrap in the training cohort, and external validation was performed in the validation cohort of another 82 patients. The area under the curve (AUC), calibration curves, and decision curve analysis (DCA) were used to evaluate the performance of the nomogram.

RESULTS

Seven variables were selected based on LASSO and multivariate logistic regression. The AUC of the nomogram was 0.834 (95% CI, 0.790-0.878) in the training cohort, 0.806 (95% CI, 0.791-0.880) in the internal validation cohort, and 0.882 (95% CI, 0.810-0.954) in the external validation cohort, which indicated that the model had good discrimination. The calibration and DCA curves showed that the nomogram had good accuracy and clinical utility.

CONCLUSIONS

In this study, we established a nomogram that can be used to identify the risk of aspiration associated with dysphagia after stroke, and patients may benefit from early screening and preventive care.

Exploring the rules of related parameters in acupuncture for post-stroke dysphagia based on data mining

Background

Post-stroke dysphagia (PSD) affects the efficacy and safety of swallowing, causing serious complications. Acupuncture is a promising and cost-effective treatment for PSD; however, as the number of randomized controlled trials increases, scientific analysis of the parameters and acupoint prescription is required. Therefore, this study aimed to explore the effects of acupuncture on parameters related to post-stroke dysphagia (PSD).

Methods

We searched the Cochrane Library, PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang Database, Chinese Biomedical Literature, and Chongqing VIP Database for randomized controlled trials of acupuncture for PSD in the last 15 years and relevant parameters were analyzed using data mining techniques.

Results

In total, 3,205 records were identified, of which 3,507 patients with PSD were included in 39 studies. The comprehensive analysis demonstrated that the closest parameter combinations of acupuncture on PSD were 0.25 mm × 40 mm needle size, 30 min retention time, five treatments per week, and a 4-week total course of treatment. Additionally, the gallbladder and nontraditional meridians, crossing points, and head and neck sites are the most commonly used acupoint parameters. The core acupoints identified were GB20, RN23, EX-HN14, Gongxue, MS6, SJ17, EX-HN12, EX-HN13, and the commonly used combination of EX-HN12, EX-HN13, GB20, and RN23.

Conclusion

This study analyzed the patterns of PSD-related needling and acupoint parameters to provide evidence-based guidelines for clinical acupuncturists in treating PSD, potentially benefitting affected patients.

Nomogram to predict ventilator-associated pneumonia in large vessel occlusion stroke after endovascular treatment: a retrospective study

Background

Ventilator-Associated Pneumonia (VAP) severely impacts stroke patients' prognosis after endovascular treatment. Hence, this study created a nomogram to predict the occurrence of VAP after endovascular treatment.

Methods

The individuals with acute ischemic stroke and large vessel occlusion (AIS-LVO) who received mechanical ventilation and endovascular therapy between July 2020 and August 2023 were included in this retrospective study. The predictive model and nomogram were generated by performing feature selection optimization using the LASSO regression model and multifactor logistic regression analysis and assessed the evaluation, verification and clinical application.

Results

A total of 184 individuals (average age 61.85 ± 13.25 years, 73.37% male) were enrolled, and the rate of VAP occurrence was found to be 57.07%. Factors such as the Glasgow Coma Scale (GCS) score, duration of stay in the Intensive Care Unit (ICU), dysphagia, Fazekas scale 2 and admission diastolic blood pressure were found to be associated with the occurrence of VAP in the nomogram that demonstrating a strong discriminatory power with AUC of 0.862 (95% CI, 0.810-0.914), and a favorable clinical net benefit.

Conclusion

This nomogram, comprising GCS score, ICU duration, dysphagia, Fazekas scale 2 and admission diastolic blood pressure, can aid clinicians in predicting the identification of high-risk patients for VAP following endovascular treatment in large vessel occlusion stroke.

Systematic approach to contextualize findings of flexible endoscopic evaluation of swallowing in neurogenic dysphagia- towards an integrated FEES report

Flexible endoscopic evaluation of swallowing (FEES) is one of the most important methods for instrumental swallowing evaluation. The most challenging part of the examination consists in the interpretation of the various observations encountered during endoscopy and in the deduction of clinical consequences. This review proposes the framework for an integrated FEES-report that systematically moves from salient findings of FEES to more advanced domains such as dysphagia severity, phenotypes of swallowing impairment and pathomechanisms. Validated scales and scores are used to enhance the diagnostic yield. In the concluding part of the report, FEES-findings are put into the perspective of the clinical context. The potential etiology of dysphagia and conceivable differential diagnoses are considered, further diagnostic steps are proposed, treatment options are evaluated, and a timeframe for re-assessment is suggested. This framework is designed to be adaptable and open to continuous evolution. Additional items, such as novel FEES protocols, pathophysiological observations, advancements in disease-related knowledge, and new treatment options, can be easily incorporated. Moreover, there is potential for customizing this approach to report on FEES in structural dysphagia.

Collet-Sicard syndrome caused by a paraganglioma in the region of the jugular foramen on one side: A case report and review

Collet-Sicard syndrome is a rare neurological disorder caused by injury to the cranial nerve pairs IX, X, X, and XII. The author reports on a previously fit 27-year-old man who presented with dysphagia, choking on drinking water, hoarseness, weakness when turning the neck and shrugging the shoulders, and unexplained weight loss. Enhanced magnetic resonance imaging indicated a space-occupying lesion at the right jugular foramen. After surgical resection, the pathologic findings suggested a paraganglioma of the right jugular foramen and confirmed the diagnosis of Collet-Sicard syndrome. After postoperative treatment with a combination of acupuncture and modern medicine, the patient's symptoms significantly improved. This article analyzes previous literature regarding Collet-Sicard syndrome etiology and reports the case of a patient with a rare etiology, whose prognosis improved significantly after treatment with a combination of acupuncture and modern medicine.

How Much Does Dysphagia Cost? Understanding the Additional Costs of Dysphagia for New Zealand in Patients Hospitalised with Stroke

INTRODUCTION

Dysphagia (i.e., disordered swallowing) is a consequence of stroke. Existing literature on the marginal cost of dysphagia after stroke is limited and ignores long-term impacts. Our aim was to determine the marginal 12-month cost attributable to dysphagia, including health-related quality of life (HRQoL) impacts, among patients hospitalised with stroke in New Zealand.

METHODS

Secondary analysis of observational data from the REGIONS Care study, a national study from New Zealand of consecutively hospitalised patients with acute stroke between May 1, 2018, and October 30, 2018, including an outcome survey at 12 months among those who provided consent. Patients were identified as dysphagic if they received a swallow screen in hospital resulting in a speech language therapist review. Patients that required a nasogastric feeding tube in hospital were classified as "severe." Optimal linear propensity score matching was utilised to provide a group of patients to compare with stroke and dysphagia. All costs were converted to 2021NZD.

RESULTS

Overall, of the 2,379 patients in the REGIONS cohort (51% male, median age: 78), 40% (944/2,379) were dysphagic (52% male, median age: 78), and 5% (111/2,379) were classified as severely dysphagic. Within 12 months of hospital discharge, dysphagia reduced HRQoL overall by 0.06 index points (95% CI: 0.028-0.100), and severe dysphagia by 0.12 index points (95% CI: 0.03-0.20). The estimated marginal 12-month cost attributable to stroke-related dysphagia was NZD 24,200 on average per patient. This estimate includes the additional hospitalisation costs (NZD 16,100), community rehabilitation services (NZD 570), hospital level aged residential care (NZD 4,030), and reduced HRQoL (NZD 3,470) over a 12-month period post-hospital discharge. The overall total marginal cost for those with severe dysphagia was NZD 34,000 per patient.

CONCLUSION

We report cost estimates to 12 months from a national perspective on the additional costs and HRQoL outcomes of dysphagia for people hospitalised with stroke in New Zealand. Findings provide a novel contribution internationally since few prior studies have extended beyond the acute hospital phase of care. By quantifying the economic burden, we provide information to decision makers to improve dysphagia management strategies and ultimately enhance the overall HRQoL for people with stroke and dysphagia.

Quality of early stroke care and long-term mortality in patients with acute stroke: A nationwide follow-up study

INTRODUCTION

High quality of early stroke care is essential for optimizing the chance of a good patient outcome. The quality of care may be monitored by process performance measures (PPMs) and previous studies have found an association between fulfilment of PPMs and short-term mortality. However, the association with long-term mortality remains to be determined. We aimed to evaluate the association between fulfilment of PPMs and long-term mortality for patients with acute stroke in Denmark.

PATIENTS AND METHODS

We used data from Danish health care registers between 2008 and 2020 to identify all patients admitted with incident stroke (haemorrhagic (ICH) or ischaemic stroke). The quality of early stroke care was assessed using 10 PPMs. Mortality was compared using Cox proportional hazard ratios, risk ratios computed using Poisson regression, and standardized relative survival.

RESULTS

We included 102,742 patients; 9804 cases of ICH, 88,591 cases of ischaemic stroke, and 4347 cases of unspecified strokes. The cumulative 10-year mortality risk was 56.8%. Fulfilment of the individual PPMs was associated with adjusted hazard rate ratios of death between 0.76 and 0.96. Patients with 100% fulfilment of all PPMs had a lower 10-year post-stroke mortality (adjusted risk ratio 0.90) compared to the patients with 0%-49% fulfilment and a standardized relative survival of 81.3%, compared to the general population.

CONCLUSION

High quality of early stroke care was associated with lower long-term mortality following both ICH and ischaemic stroke, which emphasizes the importance of continued attention on the ability of stroke care providers to deliver high quality of early care.

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.

Comparison of the efficacy and tolerability of different repetitive transcranial magnetic stimulation modalities for post-stroke dysphagia: a systematic review and Bayesian network meta-analysis protocol

INTRODUCTION

Up to 78% of patients who had a stroke develop post-stroke dysphagia (PSD), a significant consequence. Life-threatening aspiration pneumonia, starvation, and water and electrolyte abnormalities can result. Several meta-analyses have shown that repeated transcranial magnetic stimulation (rTMS) improves swallowing in patients who had a stroke; however, the optimum model is unknown. This study will be the first Bayesian network meta-analysis (NMA) to determine the best rTMS modalities for swallowing of patients who had a stroke.

METHODS AND ANALYSIS

PubMed, Web of Science, Embase, Google Scholar, Cochrane, the Chinese National Knowledge Infrastructure, the Chongqing VIP Database and WanFang Data will be searched from their creation to 2 September 2023. All randomised controlled trials associated with rTMS for PSD will be included. Only Chinese or English results will be studied. Two researchers will independently review the literature and extract data, then use the Cochrane Collaboration's Risk of Bias 2.0 tool to assess the included studies' methodological quality. The primary outcome is swallowing function improvement, whereas secondary outcomes include side effects (eg, paraesthesia, vertigo, seizures) and quality of life. A pairwise meta-analysis and NMA based on a Bayesian framework will be conducted using Stata and R statistical software. The Grading of Recommendations Assessment, Development, and Evaluation system will assess outcome indicator evidence quality.

ETHICS AND DISSEMINATION

As all data in this study will be taken from the literature, ethical approval is not needed. We will publish our work in peer-reviewed publications and present it at academic conferences.

PROSPERO REGISTRATION NUMBER

CRD42023456386.

Dysphagia after stroke: research advances in treatment interventions

After a stroke, most patients have dysphagia, which can lead to aspiration pneumonia, malnutrition, and adverse functional outcomes. Protective interventions aimed at reducing these complications remain the cornerstone of treatment. Dietary adjustments and oral hygiene help mitigate the risk of aspiration pneumonia, and nutritional supplementation, including tube feeding, might be needed to prevent malnutrition. Rehabilitative interventions aim to enhance swallowing function, with different behavioural strategies showing promise in small studies. Investigations have explored the use of pharmaceutical agents such as capsaicin and other Transient-Receptor-Potential-Vanilloid-1 (TRPV-1) sensory receptor agonists, which alter sensory perception in the pharynx. Neurostimulation techniques, such as transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and pharyngeal electrical stimulation, might promote neuroplasticity within the sensorimotor swallowing network. Further advancements in the understanding of central and peripheral sensorimotor mechanisms in patients with dysphagia after a stroke, and during their recovery, will contribute to optimising treatment protocols.

Temporal Characteristics of Penetration and Aspiration in Patients with Severe Dysphagia Associated with Lateral Medullary Syndrome

To assess the severity and timing of penetration and aspiration (PA) of severe dysphagia after lateral medullary syndrome (LMS) and its association with temporal characteristics. We performed videofluoroscopic swallowing studies (VFSS) in 48 patients with LMS and severe dysphagia and 26 sex- and age-matched healthy subjects. The following temporal measures were compared between groups: velopharyngeal closure duration (VCD); hyoid bone movement duration (HMD); laryngeal vestibular closure duration (LCD); upper esophageal sphincter (UES) opening duration (UOD); stage transition duration (STD) and the interval between laryngeal vestibular closure and UES opening (LC-UESop). The association between temporal measures and Penetration-Aspiration Scale (PAS) scores was analyzed. Differences in timing measures were compared between subgroups (safe swallows, and swallows with PA events during and after the swallow). PAS scores ≥ 3 were seen in 48% of swallows (4% occuring before, 35% occurred during and 61% after the swallow) from the LMS patients. Significantly longer STD and LC-UESop were found in the patients compared to the healthy subjects (p < 0.05). Significant negative correlations with PA severity were found for HMD, LCD, and UOD. Short UOD was the strongest predictor with an area under the receiver-operating-characteristic curve of 0.66. UOD was also significantly shorter in cases of PA after the swallow (p < 0.01). Patients with LMS involving severe dysphagia exhibit a high frequency of PA (mostly during and after swallowing). PA events were associated with shorter UOD, HMD, and LCD. Notably, shortened UOD appears to be strongly associated with PA.

Dysphagia in patients with sickle cell disease: An understudied problem

Dysphagia which is defined as disordered swallowing is well known as one of the most common and dangerous symptoms of many diseases, including neurological disorders such as Parkinson's disease, amyotrophic lateral sclerosis, myasthenia gravis, and most commonly, stroke. Strokes are a potentially devastating complication of sickle cell disease (SCD), the most common genetic hemoglobinopathy worldwide, yet little is known about dysphagia as it relates to SCD. Thus, the purposes of this article are to review briefly the primary causes and health consequences of dysphagia, to highlight the relevance of dysphagia to SCD, to review what little is known about dysphagia in SCD, to recommend, based on our consensus and the available literature, when to screen, evaluate, and monitor dysphagia in patients with SCD, and to outline unanswered questions where research on dysphagia in SCD might improve health outcomes.

Effect of thickened water swallow training in tube-feeding and dysphagia patients in the acute and early subacute phases of stroke: A quasi-experimental study

BACKGROUND

Thickened water has been widely used in patients with dysphagia who receive oral feeding, but there is little evidence for tube-feeding patients.

OBJECTIVE

To explore the effects of thickened water swallow training in tube-feeding and dysphagia patients in the acute and early subacute phases of stroke.

METHODS

A quasi-experimental study. Hospitalised patients with acute and early subacute stroke who received tube feeding due to dysphagia were recruited from March to December 2021. Patients assigned to the intervention group (n = 23) received thickened water swallow training three times daily until the feeding tube was removed or they were discharged, and patients in the control group (n = 23) received usual care. The main outcomes were duration of tube feeding and rates of weaning at discharge.

RESULTS

Patients in the intervention group had a shorter tube-feeding duration (p = .046) and a higher rate of weaning at discharge (p = .017) than those in the control group. Significant interaction effects between time and group were detected regarding quality of life except for the swallowing burden dimension.

CONCLUSIONS

Thickened water swallow training is feasible and effective for stroke patients with tube feeding and can shorten the duration of tube feeding and improve the rates of weaning and quality of life. Healthcare providers in nonrehabilitation units should actively conduct swallowing function intervention training to maximise the potential for acute and early subacute phase rehabilitation.

Graded nutritional interventions in patients with dysphagia after stroke: an assessment of the effectiveness of therapeutic strategies for different swallowing functions

OBJECTIVE

To evaluate the efficacy of graded nutrition intervention strategy in improving patients with different degrees of impaired swallowing function after stroke.

METHODS

According to the way of nursing, the patients were divided into two group. The main outcome measure was Kota swallowing index (WSI) score, and the secondary outcome was complications during the intervention. SF-36 scale was used to evaluate the improvement of quality of life before and intervention.

RESULTS

The WSI score in the control group was 62.34 ± 10.23 at 1 week after treatment, 70.52 ± 13.45 at 6 weeks after treatment, and 80.48 ± 9.87 at 12 weeks after treatment, while that in the intervention group was 71.45 ± 9.68 at 1 week after treatment, 75.81 ± 11.78 at 6 weeks after treatment, and 84.12 ± 14.32 at 12 weeks after treatment. The WSI scores of the intervention group were significantly higher than those of the control group (t = 5.634, p < 0.001), suggesting better swallowing function of the patients The incidence of pulmonary infection, malnutrition and gastroesophageal reflux in the intervention group was significantly lower than that in the control group (p < 0.05). There was no significant difference in throat inflammation and dehydration between the two groups (p > 0.05). In addition, graded nutrition interventions significantly improved patients' quality of life, including dimensions of physical functioning, role physics, physical pain, and social functioning.

CONCLUSION

Compared with conventional treatment, personalized graded nutrition intervention can significantly improve the swallowing function and reduce the pulmonary infection rate in patients with swallowing disorders after stroke.

Early flexible endoscopic evaluation of swallowing after mechanical thrombectomy in stroke patients

OBJECTIVE

The aims of the study were to (1) characterize the findings of flexible endoscopic evaluation of swallowing (FEES) in stroke patients undergoing mechanical thrombectomy (MT); (2) analyse the screening performance of the Standardized Swallowing Assessment (SSA); and (3) study the impact of FEES-defined dysphagia on 3-month outcomes.

METHODS

This single-centre study was based on a local registry of consecutive acute ischaemic stroke patients undergoing MT during a 1-year period. Patients received FEES within 5 days of admission regardless of the result of dysphagia screening. We compared baseline demographic and clinical characteristics of patients with and without FEES-defined dysphagia. We collected 3-month modified Rankin Scale (mRS) and individual index values of the European Quality of Life 5 Dimensions (EQ-5D-iv). Using univariable and multivariable regression analyses we predicted 3-month outcomes for presence of dysphagia and for FEES-defined dysphagia severity.

RESULTS

We included 137 patients with a median age of 74 years, 43.1% were female, median NIHSS was 12 and successful recanalization was achieved in 92.7%. Stroke-associated pneumonia occurred in 8% of patients. FEES-defined dysphagia occurred in 81% of patients. Sensitivity of the SSA as a dysphagia screening was 67%. Presence of dysphagia and increasing severity of dysphagia were independently associated with increasing 3-month mRS score. Increasing dysphagia severity dysphagia was independently associated with lower EQ-5D-iv.

INTERPRETATION

Early FEES-defined dysphagia occurs in four in every five patients undergoing MT. SSA has a suboptimal dysphagia screening performance. Presence of dysphagia and increasing dysphagia severity predict worse functional outcome and worse health-related quality-of-life.

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

AIM

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

DESIGN

Cross-sectional study.

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL AND PROTOCOL REGISTRATION

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

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

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

IMPACT

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

REPORTING METHOD

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

Implications for respiratory muscle training in patients with stroke-associated pneumonia: a meta-analysis

PURPOSE

To evaluate the effect of respiratory muscle training on improving lung function in patients with stroke-associated pneumonia.

MATERIALS AND METHODS

A systematic retrieval was conducted using the databases of the Cochrane Library, PubMed, the Web of Science, Embase, ProQuest, and others. Studies involving patients who received respiratory muscle training with/without a breathing trainer and those who adopted routine post-stroke rehabilitation training were included in the systematic review. The statistical analysis was performed using RevMan 5.3 software.

RESULTS

Fourteen studies were included involving 850 patients with stroke. According to the results of the meta-analysis, compared with the control group, there were statistically significant differences in forced vital capacity (FVC) measurements (mean difference (MD) = 0.93, p < 0.0001) and improvement values for FEV1/FVC (MD = 0.65, p < 0.00001) in the experimental group. The FEV1 value was higher in the experimental group than in the control group (MD = 5.89, p < 0.0001). Furthermore, respiratory muscle training was superior to routine rehabilitation training for improving the PImax of patients with stroke (MD = 9.20, p < 0.0001). The patients had better respiratory tolerance after respiratory muscle training intervention (MD = 73.40, p < 0.0001).

CONCLUSIONS

The implementation of respiratory muscle training can improve FVC and FEV lung function indicators, inspiratory muscle strength and the 6-min walk test results in patients with stroke.

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

Background

Dysphagia is a common complication of stroke that can result in serious consequences. In recent years, more and more papers on post-stroke dysphagia have been published in various journals. However, there is still a lack of bibliometric analysis of post-stroke dysphagia. This study visually analyzes the global research situation of post-stroke dysphagia from 2013 to 2022, aiming to explore the current research status, frontier trends, and research hotspots in this field.

Methods

Articles and reviews relevant to post-stroke dysphagia were obtained and retrieved from the Web of Science core collection database in the last 10 years (from 2013 to 2022). CiteSpace and Microsoft Excel 2019 were used for bibliographic analysis.

Results

A total of 1,447 articles were included in the analysis. The number of publications showed an overall upward trend, from 72 in 2013 to 262 in 2022. The most influential authors, institutions, journals, and countries were Hamdy S, University of London, Dysphagia, and the People's Republic of China. An analysis of keywords and the literature indicated that current studies in the field of post-stroke dysphagia focused on dysphagia and aspiration, dysphagia classification, dysphagia rehabilitation, and daily living.

Conclusion

This bibliometric analysis reveals the latest advancements and emerging trends in the field of post-stroke dysphagia, spanning the years 2013 to 2022. It highlights the paramount importance of conducting large-scale randomized controlled trials examining the efficacy of dysphagia screening protocols and non-invasive intervention techniques in improving the quality of life for these patients. Such research efforts hold significant academic implications for the development of evidence-based treatment strategies in this field.

Management of swallowing disorders in ICU patients - A multinational expert opinion

BACKGROUND

Dysphagia is common in intensive care unit (ICU) patients, yet it remains underrecognized and often unmanaged despite being associated with life-threatening complications, prolonged ICU stays and hospitalization.

PURPOSE

To propose an expert opinion for the diagnosis and management of dysphagia developed from evidence-based clinical recommendations and practitioner insights.

METHODS

A multinational group of dysphagia and critical care experts conducted a literature review using a modified ACCORD methodology. Based on a fusion of the available evidence and the panel's clinical experience, an expert opinion on best practice management was developed.

RESULTS

The panel recommends adopting clinical algorithms intended to promote standardized, high-quality care that triggers timely systematic dysphagia screening, assessment, and treatment of extubated and tracheostomized patients in the ICU.

CONCLUSIONS

Given the lack of robust scientific evidence, two clinical management algorithms are proposed for use by multidisciplinary teams to improve early systematic detection and effective management of dysphagia in ICU patients. Additionally, emerging therapeutic options such as neurostimulation have the potential to improve the quality of ICU dysphagia care.

Treatment of Post-stroke Dysphagia With Interferential Current: Three Case Reports and a Review of the Literature

Stroke is damage to the central nervous system due to vascular pathology. Stroke causes many complications. One of the most important of these complications is dysphagia. Dysphagia is a major cause of morbidity and mortality. In recent years, the benefits of using interferential current (IFC) stimulation in the treatment of dysphagia due to various etiologies have been demonstrated. However, there are significant gaps in the literature regarding patient populations, treatment procedures, and evaluation of treatment response. Here, we report the treatment of three cases of dysphagia after ischemic stroke with IFC stimulation and review the current literature. The patients had no previous treatment for dysphagia and were using only compensatory methods. This case report highlights the benefit of IFC stimulation in the treatment of post-stroke dysphagia both clinically and videofluoroscopically. It should be kept in mind that IFC stimulation may be an important alternative in the treatment of post-stroke dysphagia.

Dysphagia screening post-stroke: systematic review

BACKGROUND/SCOPE

Stroke is one of the main causes of death, especially when associated with dysphagia. Hence, the assessment of nutritional status and aspiration risk is important to improve clinical outcomes. The aim of this systematic review is to identify which are the most suitable dysphagia screening tools in chronic post-stroke patients.

METHODOLOGY

A systematic literature search was conducted for articles published from 1 January 2000 to 30 November 2022 in the Cochrane Library, PubMed, Embase, CINAHL, Scopus and Web of Science databases, including primary studies providing quantitative or qualitative data. Additionally, a manual search was conducted scanning the reference lists of relevant articles and Google Scholar was searched to retrieve additional records. The process of screening, selection and inclusion of the articles, as well as the assessment of risk of bias and methodological quality, were conducted by two reviewers.

RESULTS

Out of the 3672 records identified, we included 10 studies, mostly (n=9) cross-sectional, evaluating screening for dysphagia in 1653 chronic post-stroke patients. Volume-Viscosity Swallow Test was the only test applied in multiple studies with adequate sample size, demonstrating high diagnostic accuracy (sensitivity=96.6%-88.2%; specificity=83.3%-71.4%) compared with the videofluoroscopic swallowing study.

CONCLUSIONS

Dysphagia is an important complication in chronic post-stroke patients. Early identification of this condition through screening tools with adequate diagnostic accuracy is of paramount importance. The limited number of studies available and their small sample sizes may be a limitation to this study.

PROSPERO REGISTRATION NUMBER

CRD42022372303.

Complications and outcomes of hospitalizations for patients with and without Parkinson disease

Objective

To examine complications and outcomes of hospitalizations for common indications for hospitalization among patients with Parkinson disease (PD).

Methods

We identified and selected the ten most common indications for hospitalization among individuals ≥65 years of age using principal diagnoses from the California State Inpatient Database, 2018-2020. Patients with comorbid PD were identified using secondary diagnosis codes and matched one-to-one to patients without PD based on principal diagnosis (exact matching), age, gender, race and ethnicity, and Elixhauser comorbidity index (coarsened exact matching). We identified potentially preventable complications based on the absence of present on admission indicators among secondary diagnoses. In the matched cohort, we compared inpatient complications, early Do-Not-Resuscitate (DNR) orders (placed within 24 h of admission), use of life-sustaining therapies, new nursing facility requirement on discharge, and death or hospice discharge for patients with and without PD.

Results

We identified 35,457 patients with PD among the ten leading indications for hospitalization in older adults who were matched one-to-one to patients without PD (n = 70,914 in total). Comorbid PD was associated with an increased odds of developing aspiration pneumonia (OR 1.17 95% CI 1.02-1.35) and delirium (OR 1.11 95% CI 1.02-1.22) during admission. Patients with PD had greater odds of early DNR orders [placed within 24 h of admission] (OR 1.34 95% CI 1.29-1.39). While there was no difference in the odds of mechanical ventilation (OR 1.04 95% CI 0.98-1.11), patients with PD demonstrated greater odds of tracheostomy (OR 1.41 95% CI 1.12-1.77) and gastrostomy placement (OR 2.00 95% CI 1.82-2.20). PD was associated with greater odds of new nursing facility requirement upon discharge (OR 1.58 95% CI 1.53-1.64). Patients with PD were more likely to die as a result of their hospitalization (OR 1.11 95% CI 1.06-1.16).

Conclusion

Patients with PD are at greater risk of developing aspiration pneumonia and delirium as a complication of their hospitalization. While patients with PD more often have early DNR orders, they have greater utilization of life-sustaining therapies and experience worse outcomes of their hospitalization including new nursing facility requirement upon discharge and greater mortality.

Enteral tube nutrition for geriatric post-stroke dysphagia evaluation (ENGE) score to evaluate the risk of dysphagia after acute ischemic stroke

BACKGROUND

Post-stroke dysphagia (PSD) is a common complication after stroke. Early PSD prediction is essential for patient stratification for intensive oral intake rehabilitation. We aimed to develop a PSD prediction score using clinical data obtained at admission.

METHODS

We examined consecutive patients with acute ischemic stroke between 2018 and 2019. The dysphagia status 14 days after admission was assessed using the Functional Oral Intake Scale (FOIS). PSD was defined as FOIS 1-3, which represents tube-dependent nutrition. Using multivariable logistic regression analysis, we constructed the Enteral tube Nutrition for Geriatric post-stroke dysphagia Evaluation (ENGE) score. The discriminative performance of the ENGE score was analyzed by receiver operating curve analysis. The reproducibility of the ENGE score was validated using patient data in 2020.

RESULTS

PSD developed in 84 of 488 patients (median age 78 years; 57% males). The ENGE score ranged from 0 to 6, with 1 point assigned for older age (≥78 years), 1 for high premorbid modified Rankin Scale (mRS) (≥1), 3 for high NIHSS score (≥12), and 1 for low serum albumin (<3.0 mg/dl). The area under the curve (AUC) of the ENGE score for discriminating PSD was 0.88 (95% confidence interval [CI] 0.83-0.92), and a score of 3 or more had a higher positive likelihood ratio. In the validation cohort, the AUC of the ENGE score for PSD was 0.85 (95% CI 0.78-0.91), which was similar to the derivation cohort (p = 0.491).

CONCLUSIONS

The ENGE score predicts severe PSD after acute ischemic stroke with good reproducibility.

Research trends and hotspots of post-stroke dysphagia rehabilitation: a bibliometric study and visualization analysis

Background

Post-stroke dysphagia (PSD) is one of the most prevalent stroke sequelae, affecting stroke patients' prognosis, rehabilitation results, and quality of life while posing a significant cost burden. Although studies have been undertaken to characterize the pathophysiology, epidemiology, and risk factors of post-stroke dysphagia, there is still a paucity of research trends and hotspots on this subject. The purpose of this study was to create a visual knowledge map based on bibliometric analysis that identifies research hotspots and predicts future research trends.

Methods

We searched the Web of Science Core Collection for material on PSD rehabilitation research from its inception until July 27, 2023. We used CiteSpace, VOSviewer, and Bibliometrix R software packages to evaluate the annual number of publications, nations, institutions, journals, authors, references, and keywords to describe present research hotspots and prospective research orientations.

Results

This analysis comprised 1,097 articles from 3,706 institutions, 374 journals, and 239 countries or regions. The United States had the most publications (215 articles), and it is the most influential country on the subject. "Dysphagia" was the most published journal (100 articles) and the most referenced journal (4,606 citations). Highly cited references focused on the pathophysiology and neuroplasticity mechanisms of PSD, therapeutic modalities, rehabilitation tactics, and complications prevention. There was a strong correlation between the terms "validity" and "noninvasive," which were the strongest terms in PSD rehabilitation research. The most significant words in PSD rehabilitation research were "validity" and "noninvasive brain stimulation," which are considered two of the most relevant hotspots in the field.

Conclusion

We reviewed the research in the field of PSD rehabilitation using bibliometrics to identify research hotspots and cutting-edge trends in the field, primarily including the pathogenesis and neurological plasticity mechanisms of PSD, complications, swallowing screening and assessment methods, and swallowing rehabilitation modalities, and this paper can provide in the follow-up research in the field of PSD rehabilitation. The results of this study can provide insightful data for subsequent studies in the field of PSD rehabilitation.

Quality appraisal of clinical practice guidelines for the management of Dysphagia after acute stroke

Objectives

Dysphagia is a common complication in stroke patients, widely affecting recovery and quality of life after stroke. The objective of this systematic review is to identify the gaps that between evidence and practice by critically assessing the quality of clinical practice guidelines (CPGs) for management of dysphagia in stroke.

Methods

We systematically searched academic databases and guideline repositories between January 1, 2014, and August 1, 2023. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was used by two authors to independently assess CPG quality.

Results

In a total of 14 CPGs included, we identified that three CPGs obtained a final evaluation of "high quality," nine CPGs achieved "moderate quality" and two CPGs received "low quality." The domain of "scope and purpose" achieved the highest mean score (91.1%) and the highest median (IQR) of 91.7% (86.1, 94.4%), while the domain of "applicability" received the lowest mean score (55.8%) and the lowest median (IQR) of 55.4% (43.2, 75.5%).

Conclusion

The CPG development group should pay more attention to improving the methodological quality according to the AGREE II instrument, especially in the domain of "applicability" and "stakeholder involvement;" and each item should be refined as much as possible.

Efficacy of Transcranial Direct Current Stimulation Combined with Conventional Swallowing Rehabilitation Training on Post-stroke Dysphagia

To observe the clinical effects of transcranial direct current stimulation (tDCS) combined with conventional swallowing rehabilitation training on post-stroke dysphagia and explore its long-term efficacy. A total of 40 patients with dysphagia after the first stroke were randomly divided into a treatment group (n = 20) and a conventional group (n = 20). The treatment group received tDCS combined with conventional swallowing rehabilitation training, while the conventional group only received conventional swallowing rehabilitation training. The Standardized Swallowing Assessment (SSA) Scale and the Penetration-Aspiration Scale (PAS) were used to assess dysphagia before and after treatment, at the end of 10 treatments, and at the 3-month follow-up. The changes in infection indicators [the white blood cell (WBC), C-reactive protein (CRP) and procalcitonin (PCT)], the oxygenation indicator [arterial partial pressure of oxygen (PaO2)] and nutrition-related indicators [hemoglobin (Hb) and serum prealbumin (PAB)] were compared before and after treatment. The SSA and PAS scores were lower in both groups after treatment than before treatment, and the difference was statistically significant (P < 0.01). The SSA and PAS scores of the treatment group were lower than those of the conventional group before and after treatment and during follow-up, and the difference was statistically significant (P < 0.05, P < 0.01). A within-group comparison showed that WBC, CRP and PCT after treatment were lower than those before treatment, and the difference was statistically significant (P < 0.05). The PaO2, Hb and serum PAB were higher after treatment than before treatment, with a statistically significant difference (P < 0.05). The WBC, CRP and PCT of the tDCS group were lower than those of the conventional group, and PaO2, Hb and serum PAB were higher in the treatment group than in the conventional group, with a statistically significant difference (P < 0.01). The tDCS combined with conventional swallowing rehabilitation training can improve dysphagia with a better effect than conventional swallowing rehabilitation training and has a certain long-term efficacy. In addition, tDCS combined with conventional swallowing rehabilitation training can improve nutrition and oxygenation and reduce infection levels.

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.

A Dentist-Led Oral Care System Can Prevent Stroke-Associated Pneumonia: The Effects of Early Intervention by Dental Team

Background

Our facility's dental team consists of a full-time dentists and dental hygienists who work exclusively in the wards to implement best practices in oral healthcare. We executed the dental care system (DCS) that includes lectures and practical training for nurses conducted by dentists and dental hygienists, the introduction to oral assessment, standardization of oral care procedures, a process for nurses to request the dental team, and early bedside oral screening conducted by the dental team. This study investigated the DCS's effects on the incidence of stroke-associated pneumonia (SAP).

Methods

This single-center retrospective cohort study included 2,771 acute stroke patients who were newly hospitalized between April 1, 2012, and March 31, 2020. The 8-year period was divided into four phases at two-year intervals as follows: Pre (N=632), Post-1 (N=642), Post-2 (N=716), and Post-3 (N=781). Pre was prior to DCS practice. Post-1 was an early introduction to DCS. Post-2 simplified dental team requests from nurses, and Post-3 added bedside oral screening within 72 hours of admission by the dental team. Statistical analysis was performed using the Cochran-Armitage trend test, followed by multivariate logistic regression.

Results

A decrease in SAP rates was observed across the four groups (P<0.0001). Logistic regression analysis revealed a significant difference for respiratory disease (odds ratio 7.74, 95% confidence interval 5.49-10.90), hypertension (2.28, 1.39-3.73), cardiac failure (1.72, 1.04-2.85), and diabetes (1.59, 1.11-2.26), 3-digit code on the Japan coma scale (3.57, 2.53-5.05 [reference ≤2-digit code]), age ≥90 years (2.34, 1.15-4.77 [reference 18-59 years]), male (1.86, 1.31-2.67), and the Post-1 (0.49, 0.31-0.76 [reference Pre]), Post-2 (0.38, 0.25-0.61 [reference Pre]), and Post-3 (0.24, 0.15-0.40 [reference Pre]) periods.

Conclusion

The suppression of SAP is effectively achieved through early intervention and education of nurses by dental professionals.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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