Effect of Early Enteral Nutrition Support on Nitrogen Balance and Nihss Score in Elderly Patients With Acute Cerebral Stroke and Dysphagia

Gieseg S., Baxter-Parker G., Lindsay A.

Konecny P., Elfmark M.

Lin W., Chou C., Chang M., Chung Y., Lin F., Tsai P.

Stroke involving the brainstem (SBS) causes severe oropharyngeal dysphagia (OD). Research on the therapeutic efficacy of vagus nerve modulation (VNM) by using repetitive transcranial magnetic stimulation (rTMS) in SBS patients with OD has been limited thus far. We aimed to assess the effect of VNM by using rTMS in improving swallowing function after SBS.We conducted a sham-controlled, double-blinded, parallel pilot study in 28 SBS patients with OD randomly allocated to a real rTMS group (n = 13; TMSreal) or a sham group (n = 15; TMSsham). For VNM, 5-Hz rTMS was applied to the left mastoid in 10 sessions. We evaluated all patients for swallowing function before and after rTMS conditioning, assessed on the 8-point Penetration-Aspiration Scale (PAS) through videofluoroscopy and the Australian Therapy Outcome Measures-Swallowing scale (AusTOMs). We measured the amplitude and latency of cricopharyngeal motor evoked potentials (CP-MEPs) as the neurophysiological parameters.TMSreal exhibited significant improvement in all swallowing outcomes-neurophysiological, radiological, and functional-compared with TMSsham: We noted higher CP-MEP amplitude (p = 0.004), shorter CP-MEP latency (p = 0.004), a lower PAS score (p = 0.001), and a higher AusTOMs score (p < 0.001) following rTMS in TMSreal. Moreover, the neurophysiological improvements were significantly correlated with the functional outcomes (p < 0.05).Our results encourage the application of VNM by using rTMS for improving swallowing function after SBS. The immediate therapeutic effects suggest that this novel intervention can be an effective complementary therapy to traditional oropharyngeal rehabilitation.URL: https://www.clinicaltrials.gov. Unique identifier: NCT02893033.

Teuschl Y., Trapl M., Ratajczak P., Matz K., Dachenhausen A., Brainin M.

Background and purpose While formal screening for dysphagia following acute stroke is strongly recommended, there is little evidence on how multi-consistency screening and dietary modifications affect the rate of stroke-associated pneumonia (SAP). This observational study reports which factors affect formal screening on a stroke-unit and how dietary recommendations relate to SAP. Method Analyses from a database including 1394 patients admitted with acute stroke at our stroke-unit in Austria between 2012 and 2014. Dietary modifications were performed following the recommendations from the Gugging Swallowing Screen (GUSS). Patients evaluated with GUSS were compared to the unscreened patients. Results Overall, 993 (71.2%) patients were screened with GUSS; of these 50 (5.0%) developed SAP. In the 401 unscreened patients, the SAP rate was similar: 22 (5.5%). Multivariable analysis showed that either mild to very mild strokes or very severe strokes were less likely to undergo formal screening. Older age, pre-existing disability, history of hypertension, atrial fibrillation, stroke severity, cardiological and neurological complications, nasogastric tubes, and intubation were significant markers for SAP. Out of 216 patients, 30 (13.9%) developed SAP in spite of receiving nil per mouth (NPO). Conclusion The routine use of GUSS is less often applied in either mild strokes or very severe strokes. While most patients with high risk of SAP were identified by GUSS and assigned to NPO, dietary modifications could not prevent SAP in 1 of 7 cases. Other causes of SAP such as silent aspiration, bacteraemia or central breathing disturbances should be considered.

Lee M., Ovbiagele B.

The past year saw advances in endovascular treatment for acute stroke, speech therapy for aphasia after stroke, and cardiac disease management to prevent stroke. These treatments were characterized by more intensive or more extensive effects than standard care, necessitating thoughtful translation of the clinical trial findings into routine clinical practice.

Oh D., Park J., Kim W.

Abubakar S., Jamoh B.

Wada A., Kawakami M., Otsuka T., Aoki H., Anzai A., Yamada Y., Liu F., Otaka E., Akaboshi K., Liu M.

In highly invasive diseases, metabolism commonly changes. Hypercatabolism is frequent in acute stroke, and nitrogen balance tends to be negative. However, there has been no study describing nitrogen balance in subacute and chronic stroke patients. The present study aimed to examine nitrogen balance in the subacute and chronic phases and to identify the factors related to it.Nitrogen balance was calculated from the collected urine of 56 patients with subacute stroke [mean (SD) 53.8 (18.4) days post-stroke] who were admitted for rehabilitation for their first-ever ischaemic or nonsurgical haemorrhagic stroke. In the first experiment, their nitrogen balance was measured during the rehabilitation phase, and factors (type, severity of hemiparesis, activities of daily living, dysphagia and malnutrition status) related to it were evaluated. The second experiment was performed to describe the time course of nitrogen balance in 31 consecutive patients, with assessments made at admission and at discharge.Nitrogen balance was positive in all patients in the subacute phase. A significant difference was seen in nitrogen balance between high and low fat-free mass in male patients. In the chronic phase, nitrogen balance was positive in 96% of the patients. There was no significant difference in nitrogen balance between discharge and admission.In the subacute and chronic phases of stroke, it was confirmed that hypercatabolism had resolved and that intensive rehabilitation is possible in the convalescent period of stroke.

Hägg M.K., Tibbling L.I.

Most patients with post-stroke dysphagia are also affected by facial dysfunction in all four facial quadrants. Intraoral stimulation can successfully treat post-stroke dysphagia, but its effect on post-stroke facial dysfunction remains unknown.This study aimed to investigate whether intraoral stimulation after stroke has simultaneous effects on facial dysfunction in the contralateral lower facial quadrant and in the other three facial quadrants, on lip force, and on dysphagia.Thirty-one stroke patients were treated with intraoral stimulation and assessed with a facial activity test, lip force test, and swallowing capacity test at three time-points: before treatment, at the end of treatment, and at late follow-up (over one year after the end of treatment).Facial activity, lip force, and swallowing capacity scores were all improved between baseline and the end of treatment (P < 0.001 for each), with these improvements remaining at late follow-up. Baseline and treatment data did not significantly differ between patients treated short and late after stroke.Treatment with intraoral stimulation significantly improved post-stroke dysfunction in all four facial quadrants, swallowing capacity, and lip force even in cases of long-standing post-stroke dysfunction. Furthermore, such improvement remained for over one year after the end of treatment.

Lindsay A., Lewis J., Scarrott C., Draper N., Gieseg S.P.

Rugby union is a sport governed by the impacts of high force and high frequency. Analysis of physiological markers following a game can provide an understanding of the physiological response of an individual and the time course changes in response to recovery. Urine and saliva were collected from 11 elite amateur rugby players 24 h before, immediately after, and at 17, 25, 38, 62 and 86 h post-game. Myoglobin, salivary immunoglobulin A and cortisol were analysed by ELISA, whereas neopterin and total neopterin were analysed by high-performance liquid chromatography. There was a significant post-game increase of all four markers. The increases were cortisol 4-fold, myoglobin 2.85-fold, neopterin 1.75-fold and total neopterin 2.3-fold when corrected with specific gravity. All significant changes occurred post-game only, with markers returning to and remaining at baseline within 17 h. The intensity of the game caused significant changes in key physiological markers of stress. They provide an understanding of the stress experienced during a single game of rugby and the time course changes associated with player recovery. Neopterin provides a new marker of detecting an acute inflammatory response in physical exercise, while specific gravity should be considered for urine volume correction post-exercise.

Lindsay A., Janmale T., Draper N., Gieseg S.P.

Abstract Body building is a sport where ultrastructual damage to muscle fibres aids the development of dense muscle layers. Using a new strong cation exchange (SCX) based chromatography technique to measure neopterin and 7,8-dihydroneopterin, we investigated whether this muscle damage caused increased levels of inflammation. Urine samples were collected over eight consecutive mornings from 10 natural competitive body builders. Samples were analysed using SCX high performance liquid chromatography (HPLC) with urine volume corrected for creatinine and specific gravity (SG). The majority of subjects showed large changes in both neopterin and total neopterin (7,8-dihydroneopterin+neopterin) levels, though the mean data for the group showed no significant change over the week. There was no evidence of the high intensity resistance training causing an accumulation of inflammation as the values for all the body builders returned to close to the starting values after 2 days rest. The SCX analysis had an intra-specific viability of 3.04% and the inter-specific viability was 5.42%. Urine volume correction with SG was found to give the same values as using creatinine. Creatinine and specific gravity are both reliable methods for correcting for urine volume while SCX HPLC provides a new means of measuring urinary neopterin and total neopterin.

Kwah L.K., Diong J.

Drury P., Levi C., D'Este C., McElduff P., McInnes E., Hardy J., Dale S., Cheung N.W., Grimshaw J.M., Quinn C., Ward J., Evans M., Cadilhac D., Griffiths R., Middleton S.

Background Our randomized controlled trial of a multifaceted evidence-based intervention for improving the inpatient management of fever, hyperglycemia, and swallowing dysfunction in the first three-days following stroke improved outcomes at 90 days by 15%. We designed a quantitative process evaluation to further explain and illuminate this finding. Methods Blinded retrospective medical record audits were undertaken for patients from 19 stroke units prior to and following the implementation of three multidisciplinary evidence-based protocols (supported by team-building workshops, and site-based education and support) for the management of fever (temperature ≥37·5°C), hyperglycemia (glucose >11 mmol/l), and swallowing dysfunction in intervention stroke units. Results Data from 1804 patients (718 preintervention; 1086 postintervention) showed that significantly more patients admitted to hospitals allocated to the intervention group received care according to the fever ( n = 186 of 603, 31% vs. n = 74 of 483, 15%, P < 0·001), hyperglycemia ( n = 22 of 603, 3·7% vs. n = 3 of 483,0·6%, P = 0·01), and swallowing dysfunction protocols ( n = 241 of 603, 40% vs. n = 19 of 483, 4·0%, P ≤ 0·001). Significantly more patients in these intervention stroke units received four-hourly temperature monitoring ( n = 222 of 603, 37% vs. n = 90 of 483, 19%, P < 0·001) and six-hourly glucose monitoring (194 of 603, 32% vs. 46 of 483, 9·5%, P < 0·001) within 72 hours of admission to a stroke unit, and a swallowing screen (242 of 522, 46% vs. 24 of 350, 6·8%, P ≤ 0·0001) within the first 24 hours of admission to hospital. There was no difference between the groups in the treatment of patients with fever with paracetamol (22 of 105, 21% vs. 38 of 131, 29%, P = 0·78) or their hyperglycemia with insulin (40 of 100, 40% vs. 17 of 57, 30%, P = 0·49). Interpretation Our intervention resulted in better protocol adherence in intervention stroke units, which explains our main trial findings of improved patient 90-day outcomes. Although monitoring practices significantly improved, there was no difference between the groups in the treatment of fever and hyperglycemia following acute stroke. A significant link between improved treatment practices and improved outcomes would have explained further the success of our intervention, and we are still unable to explain definitively the large improvements in death and dependency found in the main trial results. One potential explanation is that improved monitoring may have led to better overall surveillance of deteriorating patients and faster initiation of treatments not measured as part of the main trial.

Lin H., Tsai T., Liu C., Lu C., Chang W., Chen S., Huang C., Huang C., Tsai N., Huang C., Liou C., Lin T., Lan M., Yip H.

We hypothesized that serum level of neopterin is significantly predictive of prognostic outcome in patients after acute ischemic stroke (IS). Between November 2008 and May 2010, serum levels of neopterin were prospectively collected at 48 h after acute IS in 157 patients. Serum neopterin levels were substantially higher in patients with severe neurological impairment [National institutes of Health Stroke Scale (NIHSS) score ≥ 12] than in those with NIHSS < 12 (p < 0.008). Furthermore, Spearman's test showed a strongly positive correlation between neopterin level and NIHSS (p = 0.003). Multiple logistic regression analysis demonstrated that serum neopterin level was strongly and independently predictive of NIHSS ≥ 12 (p = 0.002) at 48 h after acute IS and 90-day major adverse clinical outcome (defined as NIHSS ≥ 12, recurrent stroke or death) (p = 0.003). Serum level of neopterin was notably increased after acute IS. This biomarker was strongly and independently predictive of 90-day unfavorable clinical outcome in patients after acute IS. ► Serum neopterin level was notably increased after acute ischemic stroke (IS). ► Serum neopterin level predicted severity of extra-cranial carotid artery stenosis. ► Serum neopterin level independently predicted NIHSS ≥ 12 at 48 h after acute IS. ► Neopterin level independently predicted 90-day major adverse clinical outcome.

Baroni A.F., Fábio S.R., Dantas R.O.

CONTEXT: Stroke is a frequent cause of dysphagia. OBJECTIVE: To evaluate in a tertiary care hospital the prevalence of swallowing dysfunction in stroke patients, to analyze factors associated with the dysfunction and to relate swallowing dysfunction to mortality 3 months after the stroke. METHODS: Clinical evaluation of deglutition was performed in 212 consecutive patients with a medical and radiologic diagnosis of stroke. The occurrence of death was determined 3 months after the stroke. RESULTS: It was observed that 63% of the patients had swallowing dysfunction. The variables gender and specific location of the lesion were not associated with the presence or absence of swallowing dysfunction. The patients with swallowing dysfunction had more frequently a previous stroke, had a stroke in the left hemisphere, motor and/or sensitivity alterations, difficulty in oral comprehension, alteration of oral expression, alteration of the level of consciousness, complications such as fever and pneumonia, high indexes on the Rankin scale, and low indexes on the Barthel scale. These patients had a higher mortality rate. CONCLUSIONS: Swallowing evaluation should be done in all patients with stroke, since swallowing dysfunction is associated with complications and an increased risk of death.

Zhang Y., Gong Z., Cai J., Yu W., Dai Y., Wang H.

Xie Y., Xiong Y., Sun M., Zhao Y., Wu M.

BackgroundOver the past 23 years, there has been a thorough analysis of literature concerning nutritional interventions, nutrients, and feeding approaches related to stroke. Furthermore, a scientific knowledge map was established, elucidating the current state of research, examining its development and trends, and offering new research viewpoints for the future. This study aimed to investigate global and emerging research trends in nutritional interventions for stroke from 2000 to 2023 through bibliometric analysis.MethodsA bibliometric analysis of literature from the Core Collection of Scientific Networks for the years 2000–2022 was conducted. CiteSpace, VOSviewer, and bibliometric graphical software were used to identify major contributors to publications, including authors, countries, institutions, journals, references, and keywords.ResultsThe bibliometric analysis yielded a total of 464 publications. This is a gradually increasing number in terms of the number of publications during the study period. China had the highest number of publications. Clinical Nutrition” was the journal with the highest number of relevant publications, and the most commonly used keywords were “stroke,” “nutrition” and “malnutrition.”ConclusionThese analyses reveal research trends in nutritional therapy for stroke from 2000 to 2023 and point to prospective research frontiers. This study provides a deeper understanding of what nutritional treatment of stroke entails and provides guidance and support for future research in this area.