Nicholas E. Diamant

Dysphagia After Stroke: Incidence, Diagnosis, and Pulmonary Complications

Objective— To determine the incidence of dysphagia and associated pulmonary compromise in stroke patients through a systematic review of the published literature. Methods— Databases were searched (1966 through May 2005) using terms “cerebrovascular disorders,” “deglutition disorders,” and limited to “humans” for original articles addressing the frequency of dysphagia or pneumonia. Data sources included Medline, Embase, Pascal, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Selected articles were reviewed for quality, diagnostic methods, and patient characteristics. Comparisons were made of reported dysphagia and pneumonia frequencies. The relative risks (RRs) of developing pneumonia were calculated in patients with dysphagia and confirmed aspiration. Results— Of the 277 sources identified, 104 were original, peer-reviewed articles that focused on adult stroke patients with dysphagia. Of these, 24 articles met inclusion criteria and were evaluated. The reported incidence of dysphagia was lowest using cursory screening techniques (37% to 45%), higher using clinical testing (51% to 55%), and highest using instrumental testing (64% to 78%). Dysphagia tends to be lower after hemispheric stroke and remains prominent in the rehabilitation brain stem stroke. There is increased risk for pneumonia in patients with dysphagia (RR, 3.17; 95% CI, 2.07, 4.87) and an even greater risk in patients with aspiration (RR, 11.56; 95% CI, 3.36, 39.77). Conclusions— The high incidence for dysphagia and pneumonia is a consistent finding with stroke patients. The pneumonia risk is greatest in stroke patients with aspiration. These findings will be valuable in the design of future dysphagia research.

Cognitive-behavioral therapy versus education and desipramine versus placebo for moderate to severe functional bowel disorders

BACKGROUND & AIMS Studies of antidepressants and psychological treatments in functional bowel disorders (FBD) are methodologically limited. The aim of this study was to assess the clinical efficacy and safety of cognitive-behavioral therapy (CBT) against education (EDU) and desipramine (DES) against placebo (PLA) in female patients with moderate to severe FBD (irritable bowel syndrome, functional abdominal pain, painful constipation, and unspecified FBD). We also evaluated the amenability of clinically meaningful subgroups to these treatments. METHODS This randomized, comparator-controlled, multicenter trial enrolled 431 adults from the University of North Carolina and the University of Toronto with moderate to severe symptoms of FBD. Participants received psychological (CBT vs. EDU) or antidepressant (DES vs. PLA) treatment for 12 weeks. Clinical, physiologic, and psychosocial assessments were performed before and at the end of treatment. RESULTS The intention-to-treat analysis showed CBT as significantly more effective than EDU (P = 0.0001; responder rate, 70% CBT vs. 37% EDU; number needed to treat [NNT ], 3.1). DES did not show significant benefit over PLA in the intention-to-treat analysis (P = 0.16; responder rate, 60% DES vs. 47% PLA; NNT, 8.1) but did show a statistically significant benefit in the per-protocol analysis (P = 0.01; responder rate, 73% DES vs. 49% PLA; NNT, 5.2), especially when participants with nondetectable blood levels of DES were excluded (P = 0.002). Improvement was best gauged by satisfaction with treatment. Subgroup analyses showed that DES was beneficial over PLA for moderate more than severe symptoms, abuse history, no depression, and diarrhea-predominant symptoms; CBT was beneficial over EDU for all subgroups except for depression. CONCLUSIONS For female patients with moderate to severe FBD, CBT is effective and DES may be effective when taken adequately. Certain clinical subgroups are more or less amenable to these treatments.

Cortical activation during human volitional swallowing : an event-related fMRI study

Functional magnetic resonance imaging (fMRI) provides a safe, noninvasive method for studying task-related cortical neuronal activity. Because the cerebral cortex is strongly implicated in the control of human swallowing, we sought to identify its functional neuroanatomy using fMRI. In 10 healthy volunteers, a swallow event-related paradigm was performed by injecting 5 ml water bolus into the oral cavity every 30 s. Whole brain functional magnetic susceptibility[Formula: see text]-weighted spiral imaging data were simultaneously acquired over 600 s on a 1.5-T magnetic resonance scanner, utilizing the blood oxygenation level-dependent technique, and correlation maps were generated using both >99% percentile rank and spatial extent thresholding. We observed areas of increased signal change consistently in caudal sensorimotor cortex, anterior insula, premotor cortex, frontal operculum, anterior cingulate and prefrontal cortex, anterolateral and posterior parietal cortex, and precuneus and superiomedial temporal cortex. Less consistent activations were also seen in posterior cingulate cortex and putamen and caudate nuclei. Activations were bilateral, but almost every region, particularly the premotor, insular, and frontal opercular cortices, displayed lateralization to one or the other hemisphere. Swallow-related cortical activity is multidimensional, recruiting brain areas implicated in processing motor, sensory, and attention/affective aspects of the task.

Further validation of the IBS-QOL: a disease-specific quality-of-life questionnaire

Abstract OBJECTIVE: There has been growing interest in the investigation of health-related quality of life (HRQOL) among patients with gastrointestinal (GI) disorders. We recently reported on the development and preliminary validation of the IBS-QOL, a specific quality-of-life measure for irritable bowel syndrome (IBS). The aim of this study was to determine the longitudinal construct validity (responsiveness) of the IBS-QOL. METHODS: Female patients enrolled in a multicenter treatment trial for functional bowel disorders were studied pre- and posttreatment with the IBS-QOL and other health status measures. Based on the response to treatment for several variables (pain/14-day score, daily function, and days in bed/3 months), patients were stratified into Responders, Partial Responders, and Nonresponders. Change scores in the IBS-QOL were then statistically compared with changes in the other variables to determine their correlation and whether Responders were significantly different from non- and Partial Responders on the IBS-QOL. RESULTS: There was a significant correlation between change scores on the IBS-QOL and the other measures of treatment effect (Pain/14 days, r = 0.25, p CONCLUSION: The IBS-QOL is responsive to treatment in a referral-based clinical population of patients with functional bowel disorders.

Functional disorders of the anus and rectum

In this report the functional anorectal disorders, the etiology of which is currently unknown or related to the abnormal functioning of normally innervated and structurally intact muscles, are discussed. These disorders include functional fecal incontinence, functional anorectal pain, including levator ani syndrome and proctalgia fugax, and pelvic floor dyssynergia. The epidemiology of each disorder is defined and discussed, their pathophysiology is summarized and diagnostic approaches and treatment are suggested. Some suggestions for the direction of future research on these disorders are also given.

Effect of age, gender, and parity on anal canal pressures: contribution of impaired anal sphincter function to fecal incontinence

The contribution of the resting anal canal pressure (RAP) and the maximal squeeze pressure (MSP) to the problem of fecal incontinence was assessed by comparing 143 incontinent patients to a control population of 157 healthy subjects. These parameters were determined using a multilumen continuously perfused catheter and a mechanized rapid pull-through technique. In 10 male volunteers both RAP and MSP were determined using catheters that varied from 3 mm to 18 mm in diameter. In the control population, the RAP was significantly lower in females 40 years of age and over as compared to males. MSP values were significantly lower in females at virtually all ages. In women, parity did not correlate with RAP (coefficient=−0.099, P>0.05) and MSP (coefficient=−0.123, P>0.05) and any decrease in pressures was related to aging. Aging in women was associated with a consistent reduction in RAP (coefficient=−0.614, P<0.0005) and MSP (coefficient=−0.372, P=0.0006). In males, there was a similar but less impressive age-related reduction for the RAP (coefficient=−0.333, P=0.006) but not for the MSP (coefficient=−0.196, P>0.05). Nine percent of the volunteer population were essentially unable to increase the RAP with maximal squeeze efforts. A linear increase in anal pressures was recorded as catheter diameter increased from 3 to 12 mm. Normative data for the RAP and MSP (mean ±2sd) were constructed for each sex on a decade basis and showed a wide range of pressures for each age grouping. In the group with fecal incontinence (FI) 39% of females and 44% of males fell within the “normal” range for both the RAP and MSP. For all patients with FI, 41% and 17% had impairment of one or both parameters, respectively. It is concluded that: (1) aging affects the RAP in both sexes but to a greater degree in women. The MSP is related to aging in women only; (2) child bearing has no effect upon these parameters; (3) clinical problems of bowel control can occur when sphincter pressure measurements are within the low “normal” range; and (4) recording instrument diameter consistently affects RAP and MSP.

Minimum standards of anorectal manometry

Functional disorders of the anus and rectum affect 10–20% of the population. Tests of anorectal function can provide useful information regarding the pathophysiology of disorders that affect continence and defecation or those that cause anorectal pain. Currently, several tests are available for evaluating anorectal function (Table 1). Often, they complement each other, but among the various tests that are available, the two most commonly performed tests are: (i) anorectal manometry and (ii) the balloon expulsion test. Recent studies suggest that manometric tests can be useful in the management of defecation disorders. The diagnostic potential and yield of these tests have been described previously. However, there is lack of uniformity with regard to the methods of performance and interpretation of the tests. There is also a relative lack of normative data stratified for age and gender. Individual laboratories are therefore encouraged to either consult published data or establish their own normative data. Purpose

The Toronto Bedside Swallowing Screening Test (TOR-BSST): Development and Validation of a Dysphagia Screening Tool for Patients With Stroke

Background and Purpose— Dysphagia occurs in 55% of all acute stroke patients. Early identification of dysphagia from screening can lead to earlier treatments and thereby reduce complications. We designed and validated a new bedside dysphagia screening tool—the Toronto Bedside Swallowing Screening Test (TOR-BSST) for stroke survivors in acute and rehabilitative settings. Methods— The TOR-BSST initially contained 5 items with proven high predictive ability for dysphagia. Trained screeners administer and score the TOR-BSST in less than 10 minutes. Trained nurses from 2 acute and 2 rehabilitation facilities administered the TOR-BSST to consecutively admitted stroke inpatients. A positive screen identified patients at risk for dysphagia. Blinded repeat screenings were conducted within 24 hours. Test-retest reliability was established with the first 50 administrations at an ICC=0.92 (CI, 0.85 to 0.96). Items were eliminated if they contributed ≤5% to the total score and were judged clinically impractical. 20% of all enrolled patients were randomly allocated to gold standard videofluoroscopic assessment of swallowing and findings rated independently by 4 blinded experts. Adequate validity was set at sensitivity ≥90% and negative predictive value ≥90%. Results— 311 stroke inpatients were enrolled; 103 acute and 208 rehabilitation. Screening was positive in 59.2% acute and 38.5% rehabilitation patients. The pharyngeal sensation item did not meet inclusion criteria and was eliminated. The TOR-BSST demonstrated excellent validity with sensitivity at 91.3% (CI, 71.9 to 98.7), and negative predictive values at 93.3% in acute and 89.5% in rehabilitation settings. Conclusion— The TOR-BSST is a simple accurate tool to identify stroke patients with dysphagia regardless of severity and setting.

Altered Brain Structure in Irritable Bowel Syndrome: Potential Contributions of Pre-Existing and Disease-Driven Factors

BACKGROUND & AIMS Brain imaging studies have identified abnormal rectal-evoked responses and cortical thinning in patients with irritable bowel syndrome (IBS). However, it is not known whether these abnormalities are pre-existing or develop as result of long-term IBS. Therefore, we tested whether abnormal structural gray matter integrity in IBS correlates with individual disease symptoms, duration of the IBS, or the personality characteristic of pain catastrophizing. METHODS Eleven IBS patients and 16 age-matched healthy subjects underwent structural magnetic resonance imaging. Voxel-based morphometry and cortical thickness analysis were used to identify abnormalities in subcortical and cortical regions, respectively, and their correlation to individual characteristics. RESULTS The IBS group showed increased hypothalamic gray matter and cortical thinning in the anterior midcingulate cortex compared with controls, a strong negative correlation between dorsolateral prefrontal cortex thickness and pain catastrophizing, and a positive correlation between anterior insula thickness and pain duration. In the insula, there was cortical thinning in patients with short-term IBS, but long-term IBS pain was associated with a more normal insula thickness. CONCLUSIONS Our findings provide new insight into IBS and chronic pain through evidence for structural changes that could fit with functional abnormalities. We report that patients with IBS have increased hypothalamic gray matter, which may be related to the association among IBS, stress, and the hypothalamic-pituitary-adrenal axis. Furthermore, we have identified some supraspinal abnormalities that may be pre-existing and contribute to vulnerability, and others that may develop over time, possibly because of chronic abnormal inputs.

What determines severity among patients with painful functional bowel disorders

OBJECTIVE: For patients with painful functional bowel disorders (FBD), physicians frequently make diagnostic and treatment decisions based on the severity of the pain reported; patients with severe painful complaints may receive extensive diagnostic tests and treatments. Therefore, it would be important to determine what clinical factors contribute to the judgment of severity among patients with FBD. The aim of this study was to identify the psychosocial, behavioral, and physiological (visceral sensitivity) factors that predicted severity in patients with moderate to severe FBD. METHODS: Two hundred eleven female patients with moderate or severe FBD, as determined by the Functional Bowel Disorder Severity Index, entered a multicenter treatment trial at the University of North Carolina and the University of Toronto. Patients filled out diary cards and were given questionnaires and physiological testing (rectal sensitivity using barostat). Analysis of covariance and logistic regression adjusting for demographic factors were performed to determine which factors distinguished patients at study entry with moderate from those with severe FBD. RESULTS: Patients with severe FBD were characterized by greater depression and psychological distress, poorer physical functioning and health-related quality of life, more maladaptive coping strategies, and greater health care utilization. There was a trend for patients with severe FBD to have lower rectal sensation thresholds. Regression analysis indicated that severity was best predicted by behavioral features: poorer daily physical function, difficulties related to eating, more phone calls to the physician, and more days in bed for GI symptoms. CONCLUSIONS: We conclude that patient illness behaviors are best correlated with severity in FBD. The use of psychopharmacological agents (e.g., antidepressants) and psychological treatments to treat psychiatric comorbidity and to improve behavioral coping styles is recommended. Training to help medical physicians identify and respond to psychosocial and behavioral features of these conditions is likely to improve patient satisfaction with their care and the clinical outcome.