Sleep-disordered breathing in patients with stroke-induced dysphagia.

This study examined the nature and characteristics of sleep-disordered breathing, including obstructive sleep apnea and central sleep apnea, in patients with post-stroke dysphagia, to determine the demographic, anthropometric and clinical variables that were associated with sleep-disordered breathing. Thirty-nine patients diagnosed with acute stroke (28 males and 11 females with a mean age of 72.3 ± 10.0 years) underwent overnight polysomnography (within 3.9 ± 1.6 days after admission). Sleep-disordered breathing was described by the apnea-hypopnea index and its obstructive and central components by the obstructive apnea-hypopnea index and central apnea-hypopnea index, respectively. Severity of dysphagia was assessed using the Mann Assessment of Swallowing Ability score. Severity of stroke and functional dependence were assessed by the National Institute of Health Stroke Scale and the modified Barthel index, respectively. Most of the cohort (87%) had moderate-to-severe dysphagia (Mann Assessment of Swallowing Ability of 143.2 ± 19.9). Sleep-disordered breathing (apnea-hypopnea index ≥ 5 events/hr) was present in 38 participants (97%) with a mean apnea-hypopnea index of 37.5 ± 24.4 events/hr. Sleep-disordered breathing was predominantly obstructive in nature, with a mean obstructive apnea-hypopnea index and central apnea-hypopnea index of 19.6 ± 15.7 and 11.4 ± 17.6 events/hr, respectively. Multivariate linear regression analyses showed that the apnea-hypopnea index was associated with sex (p = .0001), body mass index (p = .029) and the modified Barthel index (p = .006); the obstructive apnea-hypopnea index was associated with the Mann Assessment of Swallowing Ability (p = .006), sex (p = .004) and body mass index (p = .015) and had a nonlinear relationship with the modified Barthel index (p = .019); and the central apnea-hypopnea index was associated with sex (p = .027) and the modified Barthel index (p = .019). The present study showed that dysphagia severity was associated with obstructive sleep apnea severity and this association was independent of sex, modified Barthel index and body mass index. However, stroke-induced dysphagia was not associated with central sleep apnea or overall sleep-disordered breathing.

Emergency management of neck stoma patients during the coronavirus pandemic: a national nurse survey.

BACKGROUND: Neck stoma patient care involves significant clinical complexity. Inadequate staff training, equipment provision and infrastructure have all been highlighted as causes for avoidable patient harm. AIMS: To establish the perception of knowledge and confidence levels relating to the emergency management of neck stomas among UK nurses during the COVID-19 pandemic. METHOD: A nationwide prospective electronic survey of both primary and secondary care nurses via the Royal College of Nursing and social media. FINDINGS: 402 responses were collated: 81 primary care and 321 secondary care; the majority (n=130) were band 5. Forty-nine per cent could differentiate between a laryngectomy and a tracheostomy; ENT nurses scored highest (1.56; range 0-2) on knowledge. Fifty-seven per cent could oxygenate a tracheostomy stoma correctly and 54% could oxygenate a laryngectomy stoma correctly. Sixty-five per cent cited inadequate neck stoma training and 91% felt inclusion of neck stoma training was essential within the nursing curriculum. CONCLUSION: Clinical deficiencies of management identified by nurses can be attributed to a lack of confidence secondary to reduced clinical exposure and education.

Cluster of invasive Mycobacteria chimaera infections following cardiac surgery demonstrating novel clinical features and risks of aortic valve replacement.

There is a global outbreak of infections due to Mycobacterium chimaera associated with cardiac surgery. The most serious infections involve prosthetic material implantation, and all have followed surgical procedures involving cardiopulmonary bypass. We describe a cluster of four cases following cardiac surgery at a tertiary referral centre in Sydney, Australia. We report novel clinical findings, including haemolysis and kidney rupture possibly related to immune reconstitution inflammatory syndrome. The positive effect of corticosteroids on haemodynamic function in two cases and the failure of currently recommended antimicrobial therapy to sterilise prosthetic valve material in the absence of surgery despite months of treatment are also critically examined. Positron emission tomography was positive in two cases despite normal transoesophageal echocardiograms. The proportion of cases with M. chimaera infection after aortic valve replacement (4/890, 0.45%; 95% confidence interval 0.18-1.15%) was significantly higher than after all other cardiothoracic surgical procedures (0/2433, 0%; 95% confidence interval 0-0.16%).

Dysphagia and factors associated with respiratory infections in the first week post stroke.

BACKGROUND: Dysphagia occurs in approximately half of the stroke patients and is associated with respiratory infections; however, it is unclear what other factors contribute to an increased risk. This study aimed to provide evidence on factors associated with respiratory infections in the very acute stroke period. METHODS: Retrospective review of 536 stroke patients admitted to Australian Hospitals in 2010. Data were collected on 37 clinical and demographic parameters. Univariable and multivariable logistic regression was performed. RESULTS: The overall incidence of respiratory infection was 11%. On admission, requiring full assistance with mobility [OR 6.48, 95% CI 1.35, 31.16] and urinary incontinence [OR 3.21, 95% CI 1.16, 8.87] were associated with respiratory infections. During the first week post stroke nasogastric tubes (NGT) [OR 3.91, 95% CI 1.73, 8.80] and Nil By Mouth (NBM) [OR 5.62, 95% CI 1.54, 20.46] were associated with respiratory infections. Impaired GCS, ischaemic stroke and significantly impaired mobility were associated with swallowing difficulties. CONCLUSION: This study of a large cohort of acute stroke patients supports research indicating aspiration pneumonia is multifactorial in nature. NGT were associated with increased risk of respiratory infections and may contribute to infections by promoting oropharyngeal colonisation. Patients with severely impaired mobility were also at very high risk of respiratory infection.

Respiratory infections in acute stroke: nasogastric tubes and immobility are stronger predictors than dysphagia.

Swallowing problems occur in 37-78 % of stroke patients. Evidence points to multiple factors contributing to the development of pneumonia in the first week post stroke, of which the presence of dysphagia is one. A heightened understanding of the very acute phase (first 7 days post stroke) is required to improve management of this population. We conducted a retrospective review of 536 stroke patients admitted to Australian hospitals in 2010. Data were collected on 37 clinical and demographic parameters. Descriptive statistics and univariate and multivariate logistic regression analyses were performed. Dysphagia was present in 58.5 % of admissions. For those patients remaining in the study for the full week there was a recovery rate from dysphagia of 30.5 %. Overall incidence of respiratory infection was 11 %. Respiratory infections developed in 17 % of patients with dysphagia. Impaired Glasgow Coma Scale, ischemic stroke, and significantly impaired mobility were associated with swallowing difficulties. Being nil by mouth and insertion of a nasogastric tube were significant predictors for respiratory infections. This study of a large cohort of acute stroke patients supports research indicating that aspiration pneumonia is multifactorial in nature and the incidence of respiratory infection is significant in the very acute stroke period.

TrkB Regulates N-Methyl-D-Aspartate Receptor Signaling by Uncoupling and Recruiting the Brain-Specific Guanine Nucleotide Exchange Factor, RasGrf1.

Brain-derived neurotrophic factor (BDNF) facilitates multiple aspects of neuronal differentiation and cellular physiology by activating the high-affinity receptor tyrosine kinase, TrkB. While it is known that both BDNF and TrkB modulate cellular processes involved in learning and memory, exactly how TrkB cross-talks and modulates signaling downstream of excitatory ionotropic receptors, such as the NMDA receptor (NMDAR), are not well understood. A model that we have investigated involves the signaling molecule RasGrf1, a guanine nucleotide exchange factor for both Ras and Rac. We previously identified RasGrf1 as a novel Trk binding partner that facilitates neurite outgrowth in response to both nerve growth factor (NGF) (Robinson et al. in J Biol Chem 280:225-235, 2005) and BDNF (Talebian et al. in J Mol Neurosci 49:38-51, 2013); however, RasGrf1 can also bind the NR2B subunit of the NMDAR (Krapivinsky et al. in Neuron 40:775-784, 2003) and stimulate long-term depression (LTD) (Li et al. in J Neurosci 26:1721-1729, 2006). We have addressed a model that TrkB facilitates learning and memory via two processes. First, TrkB uncouples RasGrf1 from NR2B and facilitates a decrease in NMDA signaling associated with LTD (p38-MAPK). Second, the recruitment of RasGrf1 to TrkB enhances neurite outgrowth and pERK activation and signaling associated with learning and memory. We demonstrate that NMDA recruits RasGrf1 to NR2B; however, co-stimulation with BDNF uncouples this association and recruits RasGrf1 to TrkB. In addition, activation of TrkB stimulates the tyrosine phosphorylation of RasGrf1 which increases neurite outgrowth (Talebian et al. in J Mol Neurosci 49:38-51, 2013), and the tyrosine phosphorylation of NR2B (Tyr1472) (Nakazawa et al. in J Biol Chem 276:693-699, 2001) which facilitates NMDAR cell surface retention (Zhang et al. in J Neurosci 28:415-24, 2008). Collectively, these data demonstrate that TrkB alters NMDA signaling by a dual mechanism that uncouples LTD and, in turn, stimulates neuronal growth and the signaling pathways associated with learning and memory.

Role theory: a framework to investigate the community nurse role in contemporary health care systems.

Nurses' perceptions of their role are influenced by societal attitudes, government policies and trends in professional issues. Dynamic factors in contemporary health environments challenge traditional nursing roles, in particular those of community nurses. Role theory is a conceptual framework that defines how individuals behave in social situations and how these behaviours are perceived by external observers. This paper reviews the role theory literature as a conceptual framework to explore community nurses' perceptions of their role. Three theoretical perspectives of role theory have emerged from the literature review: 1. social structuralism 2. symbolic interactionism and 3. the dramaturgical perspective. These philosophical perspectives provide a useful framework to investigate the role of community nurses in the contemporary health care system.

Can't swallow, can't transfer, can't toilet: factors predicting infections in the first week post stroke.

Post stroke infections are a significant clinical problem. Dysphagia occurs in approximately half of stroke patients and is associated with respiratory infections; however it is unclear what other factors contribute to an increased risk. This study aimed to determine which factors are most strongly predictive of infections in the first 7 days post stroke admission. A retrospective review of 536 stroke patients admitted to Australian hospitals in 2010 was conducted. Data were collected on 37 clinical and demographic parameters. Univariate and multivariate logistic regression analysis was performed. The overall incidence of infection was 21%. Full assistance with mobility and incontinence on admission were associated with increased odds of general infection. Nil by mouth and presence of a nasogastric tube were significantly associated with patients developing respiratory infections. Urinary incontinence was a significant predictor for a urinary tract infection. Incidence of infection was highest on day two post admission. This study found enteral feeding, requiring full assistance with mobility and incontinence were significantly associated with developing infections in acute stroke. It contributes valuable new data from a large cohort of stroke patients demonstrating a period of susceptibility to infection in the very acute post stroke period.

Community health nursing in Australia: a critical literature review and implications for professional development.

BACKGROUND: Increasing emphasis on community-based mandates an examination of the community health nurse (CHN). AIM: A critical literature review of the CHN role internationally, with an emphasis on Australia, was undertaken in order to understand historical precedents and inform policy and strategic directions for the CHN. METHOD: A search of the CINAHL, EMBASE, and COCHRANE electronic data-bases from 1982 to June 2002 using community' and 'nursing' as key words and hand searching of books and government reports was undertaken. FINDINGS: This search strategy revealed a lack of literature compared with other areas of nursing. Key themes emerging from this review are: (1) an absence of clear role definitions and lack of clarity of roles; (2) variability in educational requirements for CHNs; (3) diminished CHN power in policy decision making; (3) conflicting role expectations between different facets of the health care system; (4) underutilisation and untapped potential of the role of the CHN in the contemporary health care system; (5) the emerging influence of specialist nurses in community based-care; (6) uptake of traditional nursing roles by non-nurses and (7) an absence of a cohesive model of professional development of CHN that is able to articulate with contemporary social, political and economic trends in health care delivery. CONCLUSIONS: Community health nursing in Australia has a low professional profile when compared to other nursing specialties. An emerging issue, gleaned from the literature review is the tension and debate between specialist and generalist services. It is apparent from this review that CHN have to more actively participate in research and peer reviewed debate in order to have their voice heard and promote their unique and valuable contribution to the nursing profession and the health care system.

Ras guanine nucleotide releasing factor 1 (RasGrf1) enhancement of Trk receptor-mediated neurite outgrowth requires activation of both H-Ras and Rac.

We previously demonstrated that the guanine nucleotide exchange factor, RasGrf1, binds nerve growth factor (NGF)-activated TrkA and facilitates neurotrophin-induced neurite outgrowth in PC12 cells. RasGrf1 can activate both Ras and Rac, via intrinsic Cdc25 and DH domains, respectively, suggesting that the activation of both could contribute to this process. Previous studies have assayed constitutive neurite outgrowth following RasGrf1 over-expression in PC12 cells, in either the absence or presence of ectopic H-Ras, and have suggested an essential role for either Ras or Rac depending on the presence of H-Ras over-expression. In contrast, in this study, we have addressed the mechanism of how RasGrf1 facilitates neurite outgrowth in response to the neurotrophins, NGF and BDNF. Using Ras/Rac activation assays and site-directed RasGrf1 mutants, we find that both Ras and Rac are essential to neurotrophin-induced neurite outgrowth. Moreover, we find that H-Ras over-expression rescues the loss of neurite outgrowth observed with a Rac minus mutant and that RasGrf1 differentially stimulates NGF-dependent activation of Rac or Ras, depending on cell type. Collectively, these studies clarify the mechanism of how RasGrf1 expression facilitates neurotrophin-induced neurite outgrowth. Moreover, they suggest that H-Ras over-expression should be used with caution to measure phenotypic responses.