高齢脳卒中リハビリテーション患者におけるMini Nutritional Assessment Short-FormとGeriatric Nutritional Risk Indexの併存的および予測的妥当性

Background: Malnutrition might worsen the clinical outcomes in stroke patients, although few nutritional screening tools have assessed their validity. Methods: We assessed clinical data of consecutive stroke patients aged ≥65 years in rehabilitation hospital from 2015 to 2017 using the Mini Nutritional Assessment Short-Form (MNA-SF) and the Geriatric Nutritional Risk Index (GNRI) for index testing. The European Society for Parenteral and Enteral Nutrition diagnostic criteria for malnutrition (ESPEN-DCM) was used as a reference standard. The receiver-operating characteristics curve was illustrated by the sensitivity (Se) and specificity (Sp). The Youden index was used to define the cut-off value for malnutrition detection or screening. The Functional Independence Measure (FIM) and discharge destination were compared for verifying predictive validity. Results: We enrolled 420 patients for the analysis. Of them, 125 patients were included in malnutrition group (mean age: 80 years) and 295 in non-malnutrition group (mean age: 77 years) by the ESPEN-DCM. The area under the curve of the MNA-SF and the GNRI were 0.890 and 0.865, respectively. Se and Sp cut-off values to detect or screen malnutrition were 5 (Se: 0.78; Sp: 0.85) and 7 (Se: 0.96; Sp: 0.57) for the MNA-SF and 92 (Se: 0.74; Sp: 0.84) and 98 (Se: 0.93; Sp: 0.50) for the GNRI, respectively. The GNRI were associated with discharge destination, whereas no correlation was observed between the MNA-SF and outcomes by multivariable analysis. Conclusions: The MNA-SF and GNRI have fair concurrent validity if appropriate cut-off values were used. The GNRI exhibits good predictive validity in stroke patients

ロートを用いた客観的な簡易とろみ評価方法の開発

Some patients with dysphagia are prone to aspiration of low-viscosity liquids. Thickened liquids are often used in attempts to prevent aspiration. The patients should be given thickened liquids with suitable thickness, and the thickness should be constant at all time. While rotational and cone-and-plate viscometers are used for the evaluation of thickened liquids, they are high-precision and expensive equipment. To control the thickness of liquids, a simple and objective evaluation method is thus necessary. We developed a method to evaluate thickened liquids using funnels, and verified the appropriateness of this method. We measured the outflow times of five thickened liquids through funnels. One of the thickened liquids was a commercially available nutritional supplement, another was made with a thickening agent that contained guar gum, and all others were made with a thickening agent that contained xanthan gum. Four funnels with different stem sizes were tested. We found that the outflow time of thickened liquids through a funnel depended on their viscosities at a shear rate between 10 and 50 s–1, when the average inner diameter of the stem was in the range of 5.3–9.0 mm, and the volume of the liquid poured into the funnel was 30 mL. The correlation coefficient between the value of the sensory evaluation and the outflow time of the funnel with an average stem ID of 5.3 mm was 0.946. Therefore, this method may be useful in hospital and nursing home kitchens for evaluating thickened liquids

Videofluoroscopic Swallowing Study of Esophageal Cancer Cases

Aims: To determine suitable food textures for videofluoroscopic study of swallowing (VFSS), in order to predict and prevent subsequent aspiration pneumonia in esophageal cancer patients with dysphagia after surgery. Methods: We evaluated 45 hospitalized esophageal cancer patients who underwent surgery between January 2012 and December 2013. The control group consisted of 43 patients who underwent surgery between January 2010 and December 2011 and were not examined by VFSS. Test foods, which were presented in order of increasing thickness, included thin barium sulfate (Ba) liquid (3 or 10 ml), slightly thickened Ba liquid (3 or 10 ml), a spoonful of Ba jelly, and a spoonful of Ba puree. Results: Patients could most safely swallow puree, followed by jelly. The 3-mL samples of both the thin and thick liquids put patients at risk for aspiration pneumonia, with incidence rates of 13% and 11%, respectively. While 64.4% of patients could swallow all test foods and liquids safely, 35.6% were at risk for aspiration pneumonia when swallowing liquids. Even though >30% of patients were at risk, only 1 (2.2%) in the VFSS group developed aspiration pneumonia, which occurred at the time of admission. Following VFSS, no incidence of aspiration pneumonia was observed. However, aspiration pneumonia occurred in 4 (9.3%) control patients during hospitalization. Conclusions: Postoperative esophageal cancer patients were more likely to aspirate any kind of liquid than solid foods, such as jellies. VFSS is very useful to determine suitable food textures for postoperative esophageal cancer patients

Proposal for a Standard Protocol to Assess the Rheological Behavior of Thickening Products for Oropharyngeal Dysphagia

Increasing shear viscosity (ShV) in thickening products (TP) is a valid therapeutic strategy for oropharyngeal dysphagia (OD). However, salivary amylase in the oral phase and shear rate in the pharyngeal phase of swallowing can change the viscosity of TPs when swallowed. This study aims to design and validate a rheological protocol to reproduce the oral and pharyngeal factors that affect the therapeutic effect of TPs and report the viscosity measurements in a standardized scientific and precise manner. We measured (a) the variability of the ShV measurements across several laboratories; (b) the in vitro and ex vivo properties of TPs and (c) the impact of the X-ray contrast Omnipaque, temperature and resting time on the rheological properties of TPs. A common protocol was applied in four international laboratories to assess five ShV values (100, 200, 400, 800 and 1600 mPa·s) for the xanthan-gum TP Tsururinko Quickly (TQ). The protocol included the dose (g/100 mL water), stirring procedure and standing time before measurement. Each value was characterized at the shear rate of 50 and 300 s−1 pre- and post-oral incubation in eight volunteers. The effect of temperature, standing time and Omnipaque was assessed. The main results of the study were: (a) The mean intra-laboratory variability on the ShV at all levels was very low: 0.85%. The mean inter-laboratory variability was higher: 9.3%; (b) The shear thinning of TQ at 300 s−1 was 75–80%. Increasing the temperature or standing time did not affect the ShV, and oral amylase caused a small decrease; (c) Omnipaque slightly decreased the dose of TP and hardly affected the amylase resistance or shear thinning. This study showed that different laboratories can obtain very accurate and similar ShV measurements using this protocol which uses scientific, universal SI units (mPa·s). Our protocol accurately reproduces oral and pharyngeal factors affecting the therapeutic effect of TPs. The addition of X-ray contrast did not produce significant changes

Inappropriate Timing of Swallow in the Respiratory Cycle Causes Breathing–Swallowing Discoordination

Rationale: Swallowing during inspiration and swallowing immediately followed by inspiration increase the chances of aspiration and may cause disease exacerbation. However, the mechanisms by which such breathing-swallowing discoordination occurs are not well-understood. Objectives: We hypothesized that breathing-swallowing discoordination occurs when the timing of the swallow in the respiratory cycle is inappropriate. To test this hypothesis, we monitored respiration and swallowing activity in healthy subjects and in patients with dysphagia using a non-invasive swallowing monitoring system. Measurements and Main Results: The parameters measured included the timing of swallow in the respiratory cycle, swallowing latency (interval between the onset of respiratory pause and the onset of swallow), pause duration (duration of respiratory pause for swallowing), and the breathing-swallowing coordination pattern. We classified swallows that closely follow inspiration (I) as I-SW, whereas those that precede I as SW-I pattern. Patients with dysphagia had prolonged swallowing latency and pause duration, and tended to have I-SWor SW-I patterns reflecting breathing-swallows discoordination. Conclusions: We conclude that swallows at inappropriate timing in the respiratory cycle cause breathing-swallowing discoordination, and the prolongation of swallowing latency leads to delayed timing of the swallow, and results in an increase in the SW-I pattern in patients with dysphagia

Prospective Observational Study for the Comparison of Screening Methods Including Tongue Pressure and Repetitive Saliva Swallowing With Detailed Videofluoroscopic Swallowing Study Findings in Patients With Acute Stroke

Background Simple, noninvasive, and repeatable screening methods are essential for assessing swallowing disorders. We focused on patients with acute stroke and aimed to assess the characteristics of swallowing screening tests, including the modified Mann Assessment of Swallowing Ability score, tongue pressure, and repetitive saliva swallowing test (RSST), compared with detailed videofluoroscopic swallowing study (VFSS) findings to contribute as a helpful resource for their comprehensive and complementary use. Methods and Results We enrolled first‐ever patients with acute stroke conducting simultaneous assessments, including VFSS, modified Mann Assessment of Swallowing Ability score, tongue pressure measurement, and RSST. VFSS assessed aspiration, laryngeal penetration, oral cavity residue, vallecular residue, pharyngeal residue, and swallowing reflex delay. Screening tests were compared with VFSS findings, and multiple logistic analysis determined variable importance. Cutoff values for each abnormal VFSS finding were assessed using receiver operating characteristic analyses. We evaluated 346 patients (70.5±12.6 years of age, 143 women). The modified Mann Assessment of Swallowing Ability score was significantly associated with all findings except aspiration. Tongue pressure was significantly associated with oral cavity and pharyngeal residue. The RSST was significantly associated with all findings except oral cavity residue. Receiver operating characteristic analyses revealed that the minimum cutoff value for all VFSS abnormal findings was RSST ≤2. Conclusions The modified Mann Assessment of Swallowing Ability is useful for broadly detecting swallowing disorders but may miss mild issues and aspiration. The RSST, with a score of ≤2, is valuable for indicating abnormal VFSS findings. Tongue pressure, especially in oral and pharyngeal residues, is useful. Combining these tests might enhance accuracy of the swallowing evaluation