Raed A. Joundi

Predictors and Outcomes of Dysphagia Screening After Acute Ischemic Stroke

Background and Purpose— Guidelines advocate screening all acute stroke patients for dysphagia. However, limited data are available regarding how many and which patients are screened and how failing a swallowing screen affects patient outcomes. We sought to evaluate predictors of receiving dysphagia screening after acute ischemic stroke and outcomes after failing a screening test. Methods— We used the Ontario Stroke Registry from April 1, 2010, to March 31, 2013, to identify patients hospitalized with acute ischemic stroke and determine predictors of documented dysphagia screening and outcomes after failing the screening test, including pneumonia, disability, and death. Results— Among 7171 patients, 6677 patients were eligible to receive dysphagia screening within 72 hours, yet 1280 (19.2%) patients did not undergo documented screening. Patients with mild strokes were significantly less likely than those with more severe strokes to have documented screening (adjusted odds ratio, 0.51; 95% confidence interval [CI], 0.41–0.64). Failing dysphagia screening was associated with poor outcomes, including pneumonia (adjusted odds ratio, 4.71; 95% CI, 3.43–6.47), severe disability (adjusted odds ratio, 5.19; 95% CI, 4.48–6.02), discharge to long-term care (adjusted odds ratio, 2.79; 95% CI, 2.11–3.79), and 1-year mortality (adjusted hazard ratio, 2.42; 95% CI, 2.09–2.80). Associations were maintained in patients with mild strokes. Conclusions— One in 5 patients with acute ischemic stroke did not have documented dysphagia screening, and patients with mild strokes were substantially less likely to have documented screening. Failing dysphagia screening was associated with poor outcomes, including in patients with mild strokes, highlighting the importance of dysphagia screening for all patients with acute ischemic stroke.

Antibiotics "Just-In-Case" in a Patient With Aspiration Pneumonitis

Story From the Front Lines A 50-year-old man with cerebral palsy presented to the emergency department with a witnessed generalized tonic-clonic seizure. He had a known seizure disorder that previously had been well controlled with valproate sodium. On transfer, he had multiple seizures, which eventually terminated with intravenous lorazepam in the emergency department. His blood pressure was 70/40 mm Hg, and his Glasgow Coma Scale was 6. He was intubated to protect his airway. A chest radiograph demonstrated extensive airspace opacities at the bases bilaterally, causing concern for aspiration, and he was started on treatment with piperacillin-tazobactam. The following day, he was more alert, his blood pressure improved to 110/70 mm Hg, and he remained afebrile. He required minimal pressure support ventilation. His valproic acid dose was increased, and he completed 7 days of treatment with piperacillintazobactam for the possibility of aspiration pneumonia. He was extubated and transferred to the medical unit in stable condition and ultimately back to his chronic care home 10 days later. A week later, he presented again to the hospital with a 2-day history of lethargy, decreased oral intake, and frequent watery bowel movements. He was tachycardic, hypotensive, and had a serum white blood cell count of 30 400/μL (30.4 × 109/L). A computed tomographic scan of the abdomen revealed pancolitis, and a stool specimen was positive for Clostridium difficile. He was treated with oral vancomycin and intravenous metronidazole for severe C difficile infection. His substitute decision maker, in discussion with the general surgery team, declined a colectomy. Despite medical treatment, he experienced persistent diarrhea and progressive anasarca with hypoalbuminemia level as low as 16 g/L. On day 18 of hospitalization he died of unresolving C difficile colitis.

Visual Aid Tool to Improve Decision Making in Anticoagulation for Stroke Prevention

BACKGROUND The management of stroke prevention among patients with atrial fibrillation (AF) has changed in the last few years. Despite the benefits of new oral anticoagulants (NOACs), decisions about the optimal agent remain a challenge. We provide a visual aid tool to guide clinicians and patients in the decision process of selecting oral anticoagulants for stroke prevention. METHODS We created visual plots representing benefits of warfarin versus NOACs from a meta-analysis comprising 58,541 participants. Visual plots (Cates plots) were created using software available at nntonline.net. The primary outcome was stroke or systemic embolism during the study period. RESULTS In the chosen meta-analysis, 29,312 participants received a NOAC and 29,229 participants received warfarin. For every 1000 patients with AF, 38 would have a stroke or systemic embolic event in the warfarin group compared to 31 in the NOAC group (RR .81; 95% CI .73-.91). Fifteen patients would develop an intracranial hemorrhage in the warfarin group compared to 7 in the NOAC group (RR .48; 95% CI .39-.59). Conversely, 25 patients would develop gastrointestinal bleeding in the NOAC group compared to 20 in the warfarin group (RR 1.25; 95% CI 1.01-1.55). CONCLUSION For every 1000 treated individuals with AF, NOACs would prevent stroke or systemic embolism in 7 additional patients and cerebral hemorrhage in 8 additional patients compared to warfarin. On the other hand, 5 more patients would develop gastrointestinal bleeding with NOACs compared to warfarin. These data are visually shown in Cates plots, facilitating conversations with patients regarding anticoagulation decisions.

Outcomes among patients with direct enteral vs nasogastric tube placement after acute stroke

Objective To compare complications, disability, and long-term mortality of patients who received direct enteral tube vs nasogastric tube feeding alone after acute stroke. Methods We used the Ontario Stroke Registry to identify patients who received direct enteral tubes (DET; gastrostomy or jejunostomy) or temporary nasogastric tubes (NGT) alone during hospital stay after acute ischemic stroke or intracerebral hemorrhage from July 1, 2003, to March 31, 2013. We used propensity matching to compare groups from discharge and evaluated discharge disability, institutionalization, complications, and mortality, with follow-up over 2 years, and with cumulative incidence functions used to account for competing risks. Results Among 1,448 patients with DET placement who survived until discharge, 1,421 were successfully matched to patients with NGT alone. Patients with DET had reduced risk of death within 30 days after discharge (9.7% vs 15.3%; hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.49–0.75), but this difference was eliminated after matching on length of stay and discharge disability (HR 0.90, 95% CI 0.70–1.17). Patients with DET had higher rates of severe disability at discharge (modified Rankin Scale score 4–5; 89.6% vs 78.4%), discharge to long-term care (38.0% vs 16.1%), aspiration pneumonia (14.4% vs 5.1%) and other complications, and mortality at 2 years (41.1% vs 35.9%). Conclusions Patients with DET placement after acute stroke have more severe disability at discharge compared to those with NGT placement alone, and associated higher rates of institutionalization, medical complications, and long-term mortality. These findings may inform goals of care discussions and decisions regarding long-term tube feeding after acute stroke.

Cardiac Arrest in Acute Ischemic Stroke: Incidence, Predisposing Factors, and Clinical Outcomes

BACKGROUND Cardiac arrest is a devastating complication of acute ischemic stroke, but little is known about its incidence and characteristics. We studied a large ischemic stroke inpatient population and compared patients with and without cardiac arrest. METHODS We studied consecutive patients from the Ontario Stroke Registry who had an ischemic stroke between July 2003 and June 2008 at 11 tertiary care stroke centers in Ontario. Multivariable analyses were used to determine independent predictors of cardiac arrest and associated outcomes. Adjusted survival curves were computed, and hazard ratios for mortality at 30 days and 1 year were determined for cardiac arrest and other major outcomes. RESULTS Among the 9019 patients with acute ischemic stroke, 352 had cardiac arrest, for an overall incidence of 3.9%. In a sensitivity analysis with palliative patients removed, the incidence of cardiac arrest was 2.5%. Independent predictors of cardiac arrest were as follows: older age, greater stroke severity, preadmission dependence, and a history of diabetes, myocardial infarction, congestive heart failure, and atrial fibrillation. Systemic complications associated with cardiac arrest were as follows: myocardial infarction, pulmonary embolism, sepsis, gastrointestinal hemorrhage, and pneumonia. Patients with cardiac arrest had higher disability at discharge, and a markedly increased 30-day mortality of 82.1% compared with 9.3% without cardiac arrest. CONCLUSIONS Cardiac arrest had a high incidence and was associated with poor outcomes after ischemic stroke, including multiple medical complications and very high mortality. Predictors of cardiac arrest identified in this study could help risk stratify ischemic stroke patients for cardiac investigations and prolonged cardiac monitoring.

Response to Letter Regarding Article, "Ischemic Stroke Risk in Patients With Atrial Fibrillation and CHA2DS2-VASc Score of 1: Systematic Review and Meta-Analysis".

We thank Nielsen et al for their positive comments regarding our meta-analysis and for highlighting the hurdles in designing studies to estimate the risk of stroke in patients with atrial fibrillation and a CHA2DS2-VASc score of 1. Among people with nonvalvular atrial fibrillation, CHA2DS2-VASc score of 1 is estimated to comprise 12.4% of patients not treated and 14.9% of patients treated with oral anticoagulation therapy.1 This large cohort poses a therapeutic dilemma regarding …

Predictors of Direct Enteral Tube Placement After Acute Stroke

OBJECTIVE To determine predictors of direct enteral tube (DET) placement after acute stroke. METHODS We used the Ontario Stroke Registry to identify patients who received direct enteral tubes (gastrostomy or jejunostomy) during hospital stay after acute ischemic stroke or intracerebral hemorrhage from July 1, 2003 to March 31, 2013. We used multivariable logistic regression to identify predictors of receiving DET after stroke. RESULTS Among 38,192 patients with acute stroke who met inclusion criteria, 1851 (4.9%) had DET placement during admission. We identified multiple variables significantly associated with DET placement, spanning patient demographics, comorbid illnesses, clinical, and hospital factors. The strongest predictors of receiving DET were stroke severity (adjusted odds ratio [aOR] 4.77 for severe versus mild stroke, 95% confidence interval [CI] 4.20-5.41), receiving a swallowing test within 72 hours (aOR 3.46, 95% CI 3.0-3.99), and in-hospital stroke (aOR 2.07, 95% CI 1.57-2.72). CONCLUSIONS There are a number of predictors of DET placement within multiple domains. These findings may facilitate discussions around the possibility of requiring DET during admission. Further work is required to improve patient selection and timing of DET placement after acute stroke.

Dysphagia screening after intracerebral hemorrhage

Background Dysphagia screening is recommended after acute stroke to identify patients at risk of aspiration and implement appropriate care. However, little is known about the frequency and outcomes of patients undergoing dysphagia screening after intracerebral hemorrhage (ICH). Methods We used the Ontario Stroke Registry from 1 April 2010 to 31 March 2013 to identify patients hospitalized with acute stroke and to compare dysphagia screening rates in those with ICH and ischemic stroke. In patients with ICH we assessed predictors of receiving dysphagia screening, predictors of failing screening, and outcomes after failing screening. Results Among 1091 eligible patients with ICH, 354 (32.4%) patients did not have documented dysphagia screening. Patients with mild ICH were less likely to receive screening (40.4% of patients were omitted, adjusted odds ratio (aOR) 0.40, 95% confidence interval (CI) 0.26–0.63). Older age, greater stroke severity, speech deficits, lower initial level of consciousness, and admission to intensive care unit were predictive of failing the screening test. Failing screening was associated with poor outcomes, including pneumonia (aOR 5.3, 95% CI 2.36–11.88), severe disability (aOR 4.78, 95% CI 3.08–7.41), and 1-year mortality (adjusted hazard ratio 2.1, 95% CI 1.38–3.17). When compared to patients with ischemic stroke, patients with ICH were less likely to receive dysphagia screening (aOR 0.64, 95% CI 0.54–0.76) and more likely to fail screening (aOR 1.98, 95% 1.62–2.42). Conclusion One-third of patients with ICH did not have documented dysphagia screening, increasing to 40% in patients with mild clinical severity. Failing screening was associated with poor outcomes. Patients with ICH were less like to receive screening and twice as likely to fail compared to patients with ischemic stroke, and thus efforts should be made to include ICH patients in dysphagia screening protocols whenever possible.