Ruth E. England

Complications and Outcome After Acute Stroke Does Dysphagia Matter

BACKGROUND AND PURPOSE The published data on the relationship between dysphagia and both outcome and complications after acute stroke have been inconclusive. We examined the relationship between these, using bedside assessment and videofluoroscopic examination. METHODS We prospectively studied 121 consecutive patients admitted with acute stroke. A standardized bedside assessment was performed by a physician. We performed videofluoroscopy blinded to this assessment within 3 days of stroke onset and within a median time of 24 hours of the bedside evaluations. The presence of aspiration was recorded. Mortality, functional outcome, lengthy of stay, place of discharge, occurrence of chest infection, nutritional status, and hydration were the main outcome measures. RESULTS Patients with an abnormal swallow (dysphagia) on bedside assessment had a higher risk of chest infection (P=.05) and a poor nutritional state (P=.001). The presence of dysphagia was associated with an increased risk of death (P=.001), disability (P=.02), length of hospital stay (P<.001), and institutional care (P<.05). When other factors were taken into account, dysphagia remained as an independent predictor of outcome only with regard to mortality. The use of videofluoroscopy in detecting aspiration did not add to the value of bedside assessment. CONCLUSIONS Bedside assessment of swallowing is of use in identifying patients at risk of developing complications. The value of routine screening with videofluoroscopy to detect aspiration is questioned.

The Natural History of Dysphagia following a Stroke

Abstract. To assess the frequency and natural history of swallowing problems following an acute stroke, 121 consecutive patients admitted within 24 hours of the onset of their stroke were studied prospectively. The ability to swallow was assessed repeatedly by a physician, a speech and language therapist, and by videofluoroscopy. Clinically 51% (61/121) of patients were assessed as being at risk of aspiration on admission. Many swallowing problems resolved over the first 7 days, through 28/110 (27%) were still considered at risk by the physician. Over a 6-month period, most problems had resolved, but some patients had persistent difficulties (6, 8%), and a few (2, 3% at 6 months) had developed swallowing problems. Ninety-five patients underwent videofluoroscopic examination within a median time of 2 days; 21 (22%) were aspirating. At 1 month a repeat examination showed that 12 (15%) were aspirating. Only 4 of these were persistent; the remaining 8 had not been previously identified. This study has confirmed that swallowing problems following acute stroke are common, and it has been documented that the dysphagia may persist, recur in some patients, or develop in others later in the history of their stroke.

Expandable Metal Stents for the Palliation of Malignant Gastroduodenal Obstruction

AbstractPurpose: Gastric outlet obstruction is a debilitating complication of upper gastrointestinal malignancy. We present our experience with insertion of self-expanding metal stents (SEMS). Methods: Twenty-eight patients were referred, stenting being attempted in 23. Two patients had esophageal Wallstents inserted through a gastrostomy; 21 had an endoscopic approach with enteral Wallstents. Results: One stent insertion failed, ten patients (45%) returned to a normal diet, ten patients (45%) managed semi-solid food and two patients (9%) had no significant improvement. No immediate complications were seen. One patient subsequently developed pancreatitis. Reintervention (4 stents, 1 jejunostomy, 1 gastrojejunostomy) was required in six of 22 patients (27%) for inadequate stent expansion (1), second stricture (2), stent migration (1), and tumor ingrowth (2). The mean survival was 95.4 days (SD 78.8 days, range 3–230 days). The mean follow-up time was 98.9 days (SD 86.7 days, range 3–309 days). Conclusions: SEMS are effective in palliating malignant gastric outlet obstruction. A combined endoscopic/fluoroscopic approach allows the most complete assessment of the stricture and removes the need for gastrostomy insertion. Careful assessment of the gastrointestinal tract distal to the lesion is important.

Aspiration following stroke: is it related to the side of the stroke?

Objective: To investigate the relationship between the side of stroke and the presence of aspiration on videofluoroscopy. Design: Observational prospective study. Subjects: Eighty-seven patients (50% female) admitted with an acute stroke to the University Hospital of South Manchester. Methods: Patients admitted to the study underwent brain CT scanning and repeated videofluoroscopy. Results: CT scanning was performed within a median three days (interquartile range 2-4 days) following stroke and videofluoroscopic (VF) examination (median 2, interquartile range 1-4 days following stroke) of their swallow. Seventeen (19.5%) patients were noted to be aspirating. There were no significant relationships at this time between side or site of lesion and the presence of aspiration. A second assessment was carried out at a median time of 29 days (interquartile range 26-45) following acute stroke. Nine of 69 (13.5%) patients were noted to be aspirating, seven of whom had right hemisphere lesions (p < 0.01). Conclusions: Continuing aspiration may be related to the side of the cerebral lesion.

Endoscopic and Percutaneous Intervention in Malignant Obstructive Jaundice

Most patients with malignant obstructive jaundice have inoperable disease at presentation. There is debate regarding the best approach to palliate these patients, i.e., surgical versus endoscopic versus percutaneous drainage. The purpose of this article is to review the current literature in an unbiased fashion, and to present a rationale for management.A multi-disciplinary approach is needed if we are to provide the best care for patients with standardization of definitions, complications, and outcomes between specialities such that meaningful comparisons can be made between studies. The need for prospective randomized trials is clear from the currently deficient literature.

Endovascular Aneurysm Repair with the Talent Stent-Graft

PURPOSE Evaluation of the Talent endovascular aortic stent graft in the management of abdominal aortic aneurysms. MATERIALS AND METHODS Thirty-eight patients with suitable abdominal aortic aneurysms were treated over an 18-month period using the modular Talent stent graft. The suprarenal Talent device was deployed in 31 cases. Clinical follow-up of all patients has been performed by clinical examination, contrast-enhanced CT, and Duplex ultrasound for a mean period of 12.5 months. RESULTS Graft placement was successful in all 38 patients. The immediate exclusion rate was 84%, the 1-month primary exclusion rate was 92.1%, and the 3-month exclusion rate was 97%. There were no deaths in the first 30 days, one death at 3 months due to a presumed rupture, and one other death at 1 year due to carcinomatosis. There have been no migrations or renal complications in the suprarenal group. CONCLUSIONS Our short- and medium-term results are comparable with other published Talent stent-graft series. Suprarenal graft fixation is a safe procedure that may aid in preventing graft migration. Long-term follow-up is required to assess the durability of the suprarenal Talent device.