Large variations in atrial fibrillation screening practice after ischemic stroke and transient ischemic attack in Sweden: a survey study.

BACKGROUND: Atrial fibrillation (AF) screening after ischemic stroke or transient ischemic attack (TIA) is given high priority in clinical guidelines. However, patient selection, electrocardiogram (ECG) modality and screening duration remains undecided and current recommendations vary. METHODS: The aim of this study was to investigate the clinical practice of AF screening after ischemic stroke or TIA at Swedish stroke units. In collaboration with the stakeholders of the Swedish Stroke Register (Riksstroke) a digital survey was drafted, then tested and revised by three stroke consultants. The survey consisted of 17 multiple choice/ free text questions and was sent by e-mail to the medical directors at all stroke units in Sweden. RESULTS: All 72 stroke units in Sweden responded to the survey. Most stroke units reported that ≥ 75% of ischemic stroke (69/72 stroke units) or TIA patients (67/72 stroke units), without previously known AF, were screened for AF. Inpatient telemetry ECG was the method of first-choice in 81% of the units, but 7% reported lack of access. A variety of standard monitoring durations were used for inpatient telemetry ECG. The second most common choice was Holter ECG (17%), also with considerable variations in monitoring duration. Other AF screening modalities were used as a first-choice method (handheld and patch ECG) but less frequently. CONCLUSIONS: Clinical practice for AF screening after ischemic stroke or TIA differed between Swedish stroke units, both in choice of AF screening methods as well as in monitoring durations. There is an urgent need for evidence and evidence-based recommendations in this field. TRIAL REGISTRATION: Not applicable.

Validity and Reliability of the Swedish Version of the Gugging Swallowing Screen for use in Acute Stroke Care.

The purpose of this study was to cross-culturally validate the Swedish version of the Gugging Swallowing Screen (GUSS-S) for use in the acute phase of stroke. Further, to evaluate the inter-rater reliability between different healthcare professionals. GUSS was translated into Swedish using a forward-backward method followed by expert rating to obtain content validity. For criterion validity, the GUSS-S score was compared with Flexible Endoscopic Evaluation of Swallowing (FEES) assessed with the Penetration-Aspiration Scale (PAS) in acute stroke patients (≤ 96 h after stroke onset). Convergent validity was calculated by comparison with the Functional Oral Intake Scale (FOIS) as per the comprehensive FEES assessment, the Standardized Swallowing Assessment (SSA), and the National Institutes of Health Stroke Scale (NIHSS). To evaluate inter-rater reliability, a nurse and a speech-language pathologist (SLP) independently assessed 30 patients. In total, 80 patients (32 women, median age 77 years (range 29-93) were included, mean 1.7 ± 0.9 days after admission. With a cut-off value of 14 points, the GUSS-S identified aspiration with a sensitivity of 100% and a specificity of 73% (area under the curve: 0.87, 95% CI 0.78-0.95). Spearman rank correlation showed very strong correlation between the GUSS-S and PAS (rs=-0.718, P = < 0.001) and FOIS (rs=0.720, P = 0.001) and strong correlation between the GUSS-S and SSA (rs=0.545, P = < 0.001) and NIHSS (rs=-0.447, P = 0.001). The inter-rater agreement for GUSS-S was substantial (Kw=0.67, P = < 0.001). The results indicate that the GUSS-S is a valid and reliable tool for the assessment of dysphagia in acute stroke patients by different healthcare professionals.

Early Versus Delayed Non-Vitamin K Antagonist Oral Anticoagulant Therapy After Acute Ischemic Stroke in Atrial Fibrillation (TIMING): A Registry-Based Randomized Controlled Noninferiority Study.

BACKGROUND: There are no evidence-based recommendations on the optimal time point to initiate non-vitamin K antagonist oral anticoagulants (NOACs) after acute ischemic stroke in patients with atrial fibrillation. We aimed to investigate the efficacy and safety of early versus delayed initiation of NOAC in these patients. METHODS: TIMING (Timing of Oral Anticoagulant Therapy in Acute Ischemic Stroke With Atrial Fibrillation) was a registry-based, randomized, noninferiority, open-label, blinded end-point study at 34 stroke units using the Swedish Stroke Register for enrollment and follow-up. Within 72 hours from stroke onset, patients were randomized to early (≤4 days) or delayed (5-10 days) NOAC initiation, with choice of NOAC at the investigators' discretion. The primary outcome was the composite of recurrent ischemic stroke, symptomatic intracerebral hemorrhage, or all-cause mortality at 90 days. The prespecified noninferiority margin was 3%. Secondary outcomes included the individual components of the primary outcome. RESULTS: Between April 2, 2017, and December 30, 2020, 888 patients were randomized to either early (n=450) or delayed (n=438) initiation of NOAC. No patient was lost to 90-day follow-up. Mean age was 78.3 years (SD, 9.9 years); 46.2% were women; 49.1% had previously known atrial fibrillation; and 17.5% prior stroke. The primary outcome occurred in 31 patients (6.89%) assigned to early initiation and in 38 patients (8.68%) assigned to delayed NOAC initiation (absolute risk difference, -1.79% [95% CI, -5.31% to 1.74%]; Pnoninferiority=0.004). Ischemic stroke rates were 3.11% and 4.57% (risk difference, -1.46% [95% CI, -3.98% to 1.07%]) and all-cause mortality rates were 4.67% and 5.71% (risk difference, -1.04% [95% CI, -3.96% to 1.88%]) in the early and delayed groups, respectively. No patient in either group experienced symptomatic intracerebral hemorrhage. CONCLUSIONS: Early initiation was noninferior to delayed start of NOAC after acute ischemic stroke in patients with atrial fibrillation. Numerically lower rates of ischemic stroke and death and the absence of symptomatic intracerebral hemorrhages implied that the early start of NOAC was safe and should be considered for acute secondary stroke prevention in patients eligible for NOAC treatment. REGISTRATION: URL: http://www. CLINICALTRIALS: gov; Unique identifier: NCT02961348.

Editor's Choice - Nationwide Outcome Analysis of Primary Carotid Endarterectomy in Symptomatic Patients Depending on Closure Technique and Patch Type.

OBJECTIVE: Current European guidelines recommend both eversion carotid endarterectomy (CEA) and conventional CEA with routine patch closure, rather than routine primary closure. Polyester and polytetrafluoroethylene (PTFE) have been used as patch material for a long time. More recently, bovine pericardium has been used; however, there are few studies comparing long term results between bovine pericardium and other patch types. The aim of this study was to investigate the short and long term results after CEA depending on surgical technique and patch material. METHODS: A registry based study on all primary CEAs (n = 9 205) performed for symptomatic carotid artery stenosis in Sweden from July 2008 to December 2019, cross linked with data from the Swedish stroke registry, Riksstroke, and chart review for evaluation of any events occurring during follow up. The primary endpoint was ipsilateral stroke < 30 days. Secondary endpoints included re-operations due to neck haematoma and < 30 day ipsilateral stroke, > 30 day ipsilateral stroke, all stroke > 30 days, and all cause mortality. RESULTS: 2 495 patients underwent eversion CEA and 6 710 conventional CEA for symptomatic carotid stenosis. The most commonly used patch material was Dacron (n = 3 921), followed by PTFE (n = 588) and bovine pericardium (n = 413). A total of 1 788 patients underwent conventional CEA with primary closure. Two hundred and seventy-three patients (3.0%) had a stroke < 30 days. Primary closure was associated with an increased risk of ipsilateral stroke and stroke or death <30 days: odds ratio 1.7 (95% confidence interval [CI] 1.2 - 2.4, p = .002); and 1.5 (95% CI 1.2 - 2.0), respectively. During follow up (median 4.2 years), 592 patients had any form of stroke and 1 492 died. There was no significant difference in long term risk of ipsilateral stroke, all stroke, or death depending on surgical technique or patch material. CONCLUSION: There was an increased risk of ipsilateral stroke < 30 days in patients operated on with primary closure compared with eversion CEA and patch angioplasty. There was no difference between primary closure, different patch types, or eversion after the peri-operative phase.

Risk of Stroke Recurrence After Intravenous Thrombolysis in Patients with Symptomatic Carotid Stenosis.

OBJECTIVE: To assess if intravenous thrombolysis (IVT) affects the risk of recurrent preoperative cerebrovascular events before carotid surgery or stenting in patients with symptomatic ≥ 50% carotid stenosis. METHODS: Three cohorts of symptomatic ≥ 50% carotid stenosis patients were merged. To make the control group relevant, we excluded patients not presenting with stroke on the day of symptom onset. The risk of preoperative cerebrovascular events up to 30 days was compared between the IVT-treated and non-IVT-treated. RESULTS: In total, 316 patients were included, 64 (20%) treated with IVT. Those treated with IVT had similar risk of recurrent ipsilateral ischemic stroke or retinal artery occlusion (12% at day 7, 12% at day 30) as those not treated (9% at day 7, 15% at day 30; adjusted HR 0.9, 95% CI 0.4-2.2). There was a tendency (p = 0.09) towards time-dependency in the data where the recurrence risk was higher in IVT-treated at day 0 (6% in IVT-treated, 1% in non-IVT-treated, OR 5.5, 95% CI 1.2-25.4, p = 0.03). This was not significant when adjusting for co-factors (adjusted OR 4.4, 95% CI 0.9-21.8, p = 0.07) and was offset by a later risk decrease, with no remaining risk difference between IVT-treated and non-IVT-treated at day 7. CONCLUSIONS: Intravenous thrombolysis treatment does not seem to affect the risk of recurrent ipsilateral ischemic stroke in patients with symptomatic ≥50% carotid stenosis: The risk is high in both IVT-treated and non-IVT-treated. However, there might be a risk increase on the day of IVT treatment that is offset by a risk decrease during the first week.

Interframe Echo Intensity Variation of Subregions and Whole Plaque in Two-Dimensional Carotid Ultrasonography: Simulations and In Vivo Observations.

OBJECTIVES: The risk of cardiovascular disease is associated with the echo intensity of carotid plaques in ultrasound images and their cardiac cycle-induced intensity variations. In this study, we aimed to 1) explore the underlying origin of echo intensity variations by using simulations and 2) evaluate the association between the two-dimensional (2D) spatial distribution of these echo intensity variations and plaque vulnerability. METHODS: First, we analyzed how out-of-plane motion and compression of simulated scattering spheres of different sizes affect the ultrasound echo intensity. Next, we propose a method to analyze the features of the 2D spatial distribution of interframe plaque echo intensity in carotid ultrasound image sequences and explore their associations with plaque vulnerability in experimental data. RESULTS: The simulations showed that the magnitude of echo intensity changes was similar for both the out-of-plane motion and compression, but for scattering objects smaller than 1 mm radius, the out-of-plane motion dominated. In experimental data, maps of the 2D spatial distribution of the echo intensity variations had a low correlation with standard B-mode echo intensity distribution, indicating complementary information on plaque tissue composition. In addition, we found the existence of ∼1 mm diameter subregions with pronounced echo intensity variations associated with plaque vulnerability. CONCLUSIONS: The results indicate that out-of-plane motion contributes to intra-plaque regions of high echo intensity variation. The 2D echo intensity variation maps may provide complementary information for assessing plaque composition and vulnerability. Further studies are needed to verify this method's role in identifying vulnerable plaques and predicting cardiovascular disease risk.

Endovascular thrombectomy for acute ischemic stroke.

This review describes the evolution of endovascular treatment for acute ischemic stroke, current state of the art, and the challenges for the next decade. The rapid development of endovascular thrombectomy (EVT), from the first attempts into standard of care on a global scale, is one of the major achievements in modern medicine. It was possible thanks to the establishment of a scientific framework for patient selection, assessment of stroke severity and outcome, technical development by dedicated physicians and the MedTech industry, including noninvasive imaging for patient selection, and radiological outcome evaluation. A series of randomized controlled trials on EVT in addition to intravenous thrombolytics, with overwhelmingly positive results for anterior circulation stroke within 6 h of onset regardless of patient characteristics with a number needed to treat of less than 3 for any positive shift in outcome, paved the way for a rapid introduction of EVT into clinical practice. Within the "extended" time window of 6-24 h, the effect has been even greater for patients with salvageable brain tissue according to perfusion imaging with a number needed to treat below 2. Even so, EVT is only available for a small portion of stroke patients, and successfully recanalized EVT patients do not always achieve excellent functional outcome. The major challenges in the years to come include rapid prehospital detection of stroke symptoms, adequate clinical and radiological diagnosis of severe ischemic stroke cases, enabling effective recanalization by EVT in dedicated angiosuites, followed by personalized post-EVT stroke care.

Carotid Atherosclerosis in Predicting Coronary Artery Disease: A Systematic Review and Meta-Analysis.

[Figure: see text].

Low Incidence of Late Ipsilateral Ischaemic Stroke After Treatment for Symptomatic Carotid Stenosis in Sweden 2008-2017: Increased Risk in the Elderly and After Carotid Stenting.

OBJECTIVE: Carotid stenosis is a major risk factor for stroke and surgical treatment is key in preventing recurrent ischaemic events. Previous randomised trials have demonstrated the net benefit of surgery for significant symptomatic carotid stenosis but, with present day medical treatment, there is limited evidence on the risk of late ipsilateral ischaemic stroke (IS) and its main risk factors. METHOD: Ipsilateral IS after the peri-operative period (≤ 30 days) was investigated in a nationwide, registry based cohort study of patients treated for symptomatic carotid stenosis in Sweden between 2008 - 2017. The Swedish National Registry for Vascular Surgery (Swedvasc) was used to establish the cohort, and the Swedish stroke registry (Riksstroke), combined with hospital records, was used to determine outcome. Stroke of any type and all cause mortality after the peri-operative period were studied as secondary outcomes. Cox regression was used to analyse associations between clinical factors and outcomes. RESULTS: In total, 7 589 patients (mean age 72 ± 8 years, 68% men) were followed for 4.2 ± 2.6 years. Ipsilateral IS occurred in 232 patients corresponding to a yearly incidence of 0.73%. Age above 80 years compared with 65 - 79 years was associated with an increased risk of ipsilateral IS (adjusted HR 1.94, 95% CI 1.43 - 2.65). Carotid artery stenting (CAS) compared with carotid endarterectomy (CEA) was also associated with increased risk (adjusted HR 3.20, 95% CI 2.03 - 5.03). Stroke of any type occurred in 7.7% of patients, and 19.6% of patients died during the follow up period. CONCLUSION: The incidence of ipsilateral IS after treatment for symptomatic carotid stenosis in Sweden 2008-2017 was low, demonstrating the effectiveness and durability of surgery in a real world setting. Only age above 80 years and CAS compared with CEA were associated with increased risk of ipsilateral IS.

Maintained acute stroke admission during the first wave COVID-19 pandemic in Sweden, a register-based study.

OBJECTIVES: Clinicians and researchers have addressed concerns about the negative impact of COVID-19 outbreaks on the ability of health care systems to provide timely assessment and acute therapies to patients with stroke. The aim of this study is to describe stroke care during the first wave of the COVID-19 pandemic compared to the same period the year before at an acute care hospital in Sweden. MATERIALS AND METHODS: In this cohort study data were collected from March 1st to August 31st in 2019 and 2020 on all patients diagnosed with stroke and TIA and registered at Danderyd Hospital in the national quality registry (Riksstroke). Data were completed with information from the hospital record. Sweden had no lockdown during 2020. RESULTS: During the study period in year 2019 there were 426 registered stroke patients at Danderyd hospital, compared to 403 registered stroke patients the same period during 2020 (p = 0.483). The number of minor stroke and TIA during the period in 2019 compared to 2020 were 468 versus 453 respectively (minor stroke p = 0.475 versus TIA p = 0.50). CONCLUSIONS: There were no difference in the number of patients diagnosed with stroke and TIA during the first wave of the COVID-19 pandemic.

Effects of Fluoxetine on Outcomes at 12 Months After Acute Stroke: Results From EFFECTS, a Randomized Controlled Trial.

Background and Purpose: The EFFECTS (Efficacy of Fluoxetine­a Randomised Controlled Trial in Stroke) recently reported that 20 mg fluoxetine once daily for 6 months after acute stroke did not improve functional outcome but reduced depression and increased fractures and hyponatremia at 6 months. The purpose of this predefined secondary analysis was to identify if any effects of fluoxetine were maintained or delayed over 12 months. Methods: EFFECTS was an investigator-led, randomized, placebo-controlled, double-blind, parallel group trial in Sweden that enrolled adult patients with stroke. Patients were randomized to 20 mg oral fluoxetine or matching placebo for 6 months and followed for another 6 months. The primary outcome was functional outcome (modified Rankin Scale), at 6 months. Predefined secondary outcomes for these analyses included the modified Rankin Scale, health status, quality of life, fatigue, mood, and depression at 12 months. Results: One thousand five hundred patients were recruited from 35 centers in Sweden between 2014 and 2019; 750 were allocated fluoxetine and 750 placebo. At 12 months, modified Rankin Scale data were available in 715 (95%) patients allocated fluoxetine and 712 (95%) placebo. The distribution of modified Rankin Scale categories was similar in the 2 groups (adjusted common odds ratio, 0.92 [95% CI, 0.76­1.10]). Patients allocated fluoxetine scored worse on memory with a median value of 89 (interquartile range, 75­100) versus 93 (interquartile range, 82­100); P=0.0021 and communication 93 (interquartile range, 82­100) versus 96 (interquartile range, 86­100); P=0.024 domains of the Stroke Impact Scale compared with placebo. There were no other differences in secondary outcomes. Conclusions: Fluoxetine after acute stroke had no effect on functional outcome at 12 months. Patients allocated fluoxetine scored worse on memory and communication on the Stroke Impact Scale compared with placebo, but this is likely to be due to chance. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02683213.

Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA): a pragmatic, open-label, randomised controlled trial.

BACKGROUND: Primary prevention of cardiovascular disease often fails because of poor adherence among practitioners and individuals to prevention guidelines. We aimed to investigate whether ultrasound-based pictorial information about subclinical carotid atherosclerosis, targeting both primary care physicians and individuals, improves prevention. METHODS: Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA) is a pragmatic, open-label, randomised controlled trial that was integrated within the Västerbotten Intervention Programme, an ongoing population-based cardiovascular disease prevention programme in northern Sweden. Individuals aged 40, 50, or 60 years with one or more conventional risk factors were eligible to participate. Participants underwent clinical examination, blood sampling, and ultrasound assessment of carotid intima media wall thickness and plaque formation. Participants were randomly assigned 1:1 with a computer-generated randomisation list to an intervention group (pictorial representation of carotid ultrasound plus a nurse phone call to confirm understanding) or a control group (not informed). The primary outcomes, Framingham risk score (FRS) and European systematic coronary risk evaluation (SCORE), were assessed after 1 year among participants who were followed up. This study is registered with ClinicalTrials.gov, number NCT01849575. FINDINGS: 3532 individuals were enrolled between April 29, 2013, and June 7, 2016, of which 1783 were randomly assigned to the control group and 1749 were assigned to the intervention group. 3175 participants completed the 1-year follow-up. At the 1-year follow-up, FRS and SCORE differed significantly between groups (FRS 1·07 [95% CI 0·11 to 2·03, p=0·0017] and SCORE 0·16 [0·02 to 0·30, p=0·0010]). FRS decreased from baseline to the 1-year follow-up in the intervention group and increased in the control group (-0·58 [95% CI -0·86 to -0·30] vs 0·35 [0·08 to 0·63]). SCORE increased in both groups (0·13 [95% CI 0·09 to 0·18] vs 0·27 [0·23 to 0·30]). INTERPRETATION: This study provides evidence of the contributory role of pictorial presentation of silent atherosclerosis for prevention of cardiovascular disease. It supports further development of methods to reduce the major problem of low adherence to medication and lifestyle modification. FUNDING: Västerbotten County Council, the Swedish Research Council, the Heart and Lung Foundation, the Swedish Society of Medicine, and Carl Bennet Ltd, Sweden.

Oral neuromuscular training in patients with dysphagia after stroke: a prospective, randomized, open-label study with blinded evaluators.

BACKGROUND: Oral and pharyngeal swallowing dysfunction are common complications in acute stroke patients. This primary aim of this study was to determine whether oral neuromuscular training improves swallowing function in participants with swallowing dysfunction after stroke. A secondary aim was to assess how well results of the timed water-swallow test (TWST) correspond with swallowing dysfunction diagnosed by videofluoroscopy (VFS). METHODS: This was an intention-to-treat two-centre prospective randomized open-label study with blinded-evaluators (PROBE) design. At 4 weeks after stroke onset, participants with swallowing dysfunction were randomized to 5 weeks of continued orofacial sensory-vibration stimulation with an electric toothbrush or additional oral neuromuscular training with an oral device (Muppy®). Participants were examined with TWST, a lip-force test, and VFS before (baseline), after 5 weeks' treatment (the end-of-treatment), and 12 months after treatment (follow-up). The baseline VFS results were compared with the TWST results. The primary endpoint was changes in swallowing rate assessed using TWST, from baseline to the end of training and from baseline to follow-up based on intention-to-treat analyses. The secondary endpoint was the corresponding changes in lip-force between baseline, the end of treatment, and follow-up. RESULTS: The participants were randomly assigned as controls (n = 20) or for intervention with oral neuromuscular training (n = 20). After treatment, both groups had improved significantly (intervention, P < 0.001; controls, P = 0.001) in TWST but there was no significant between-group difference in swallowing rate. At the 12-month follow-up, the intervention group had improved further whereas the controls had deteriorated, and there were significant between-group differences in swallowing rate (P = 0.032) and lip force (P = 0.001). A TWST < 10 mL/sec at baseline corresponded to VFS-verified swallowing dysfunction in all assessed participants. CONCLUSION: The 5-week oral neuromuscular training improved swallowing function in participants with post-stroke dysphagia compared with the controls 12 months after intervention, but there was no between-group difference in improvement immediately after treatment. TWST results corresponded with VFS results, making TWST a feasible method for identifying persons with swallowing dysfunction after stroke. Larger randomized controlled trials are required to confirm our preliminary positive long-term results. TRIAL REGISTRATION: Retrospectively registered at ClinicalTrials.gov : NCT04164420 . Registered on 15 November 2019.

Validation of the Simplified Modified Rankin Scale Questionnaire.

INTRODUCTION: The modified Rankin scale (mRS) is the most common assessment tool for measuring overall functional outcome in stroke studies. The traditional way of using mRS face-to-face is time- and cost-consuming. The aim of this study was to test the validity of the Swedish translation of the simplified modified Rankin scale questionnaire (smRSq) as compared with the mRS assessed face-to-face 6 months after a stroke. METHODS: Within the ongoing EFFECTS trial, smRSq was sent out to 108 consecutive stroke patients 6 months after a stroke. The majority, 90% (97/108), of the patients answered the questionnaire; for the remaining 10%, it was answered by the next of kin. The patients were assessed by face-to-face mRS by 7 certified healthcare professionals at 4 Swedish stroke centres. The primary outcome was assessed by Cohen's kappa and weighted kappa. RESULTS: There was good agreement between postal smRSq, answered by the patients, and the mRS face-to-face; Cohen's kappa was 0.43 (CI 95% 0.31-0.55), weighted kappa was 0.64 (CI 95% 0.55-0.73), and Spearman rank correlation was 0.82 (p < 0.0001). In 55% (59/108), there was full agreement, and of the 49 patients not showing exact agreement, 44 patients differed by 1 grade and 5 patients had a difference of 2 grades. DISCUSSION/CONCLUSION: Our results show good validity of the postal smRSq, answered by the patients, compared with the mRS carried out face-to-face at 6 months after a stroke. This result could help trialists in the future simplify study design and make multicentre trials and quality registers with a large number of patients more feasible and time-saving.

Effect of early supported discharge after stroke on patient reported outcome based on the Swedish Riksstroke registry.

BACKGROUND: The efficacy of early supported discharge (ESD) has not been tested in current stroke care setting, which provide relatively short hospital stays, access to hyper-acute therapies and early carotid stenosis interventions. This study aimed to compare patient-reported outcome measures (PROM) among patients with stroke that received modern stroke unit care with or without ESD. METHODS: Observational study of 30,232 patients with first-ever stroke registered in the Riksstroke registry in Sweden, between 1 January 2010 and 31 December 2013. Patient characteristics were collected from the Riksstroke and Statistics Sweden databases. The primary outcome was satisfaction with the rehabilitation at 3 months after discharge. Secondary outcome were information about stroke provided, tiredness/fatigue, pain, dysthymia/depression, general health status and dependence in activities of daily living (mobility, toileting and dressing) at 3 months after the stroke. We used separate multivariable logistic regression models for each PROM variable to analyze associations between PROMs and ESD/no ESD. RESULTS: The ESD group comprised 1495 participants: the control group comprised 28,737 participants. Multivariable logistic regression models of PROMs showed that, compared to controls, the ESD group was more satisfied with rehabilitation after discharge (OR: 1.78, 95% CI: 1.17-2.49), experienced less dysthymia/depression (OR: 0.68, 95% 0.55-0.84) and showed more independence in mobility (OR: 1.50, 95% CI: 1.17-1.92), toileting (OR: 1.30, 95%CI: 1.05-1.61), and dressing (OR: 1.23, 95%CI: 1.02-1.48). CONCLUSION: In the setting of modern stroke unit care, ESD appeared to have positive effects on stroke rehabilitation, in the subacute phase.

Bilateral vessel-outlining carotid artery calcifications in panoramic radiographs: an independent risk marker for vascular events.

BACKGROUND: In odontology, panoramic radiographs (PRs) are regularly performed. PRs depict the teeth and jaws as well as carotid artery calcifications (CACs). Patients with CACs on PRs have an increased risk of vascular events compared to healthy controls without CACs, but this association is often caused by more vascular events and risk factors at baseline. However, the risk of vascular events has only been analyzed based on the presence of CACs, and not their shape. Thus, this study determined if the shape of CACs in PRs affects the risk of future vascular events. METHODS: The study cohort included 117 consecutive patients with CACs in PRs and 121 age-matched controls without CACs. CAC shape in PRs was dichotomized into bilateral vessel-outlining CACs and other CAC shapes. Participants were followed prospectively for an endpoint of vascular events including myocardial infarction, stroke, and vascular death. RESULTS: Patients with bilateral vessel-outlining CACs had more previous vascular events than those with other CAC shapes and the healthy controls (p < 0.001, χ2). The mean follow-up duration was 9.5 years. The endpoint was reached in 83 people. Patients with bilateral vessel-outlining CACs had a higher annual risk of vascular events (7.0%) than those with other CAC shapes (4.4%) and the controls (2.6%) (p < 0.001). In multivariate analysis, bilateral vessel-outlining CACs (hazard ratio: 2.2, 95% confidence interval: 1.1-4.5) were independent risk markers for the endpoint. CONCLUSIONS: Findings of bilateral vessel-outlining CACs in PRs are independent risk markers for future vascular events.

Effects of oral neuromuscular training on swallowing dysfunction among older people in intermediate care-a cluster randomised, controlled trial.

OBJECTIVES: this prospective, cluster randomised, controlled trial investigated the effect of oral neuromuscular training among older people in intermediate care with impaired swallowing. METHODS: older people (≥65 years) with swallowing dysfunction were cluster randomised according to care units for 5 weeks of neuromuscular training of the orofacial and pharyngeal muscles or usual care. The primary endpoint was the change in swallowing rate (assessed with a timed water swallow test) from baseline to the end-of-treatment and 6 months post-treatment. The secondary endpoints were changes in signs of aspiration during the water swallow test, and swallowing-related quality of life (QOL). An intention-to-treat principle was followed, and mixed-effects models were used for data analysis with the clustered study design as a random factor. RESULTS: in total, 385 participants from 36 intermediate care units were screened, and 116 participants were randomly assigned to oral neuromuscular training (intervention; n = 49) or usual care (controls; n = 67). At the end of treatment, the geometric mean of the swallowing rate in the intervention group had significantly improved 60% more than that of controls (P = 0.007). At 6 months post-treatment, the swallowing rate of the intervention group remained significantly better (P = 0.031). Signs of aspiration also significantly reduced in the intervention group compared with controls (P = 0.01). No significant between-group differences were found for swallowing-related QOL. CONCLUSIONS: oral neuromuscular training is a new promising swallowing rehabilitation method among older people in intermediate care with impaired swallowing. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02825927.

Swallowing dysfunction as risk factor for undernutrition in older people admitted to Swedish short-term care: a cross-sectional study.

BACKGROUND: Swallowing dysfunction and risk of undernutrition increase the risk of pneumonia, morbidity, and mortality. Short-term care is an unexplored care context, where many older people stay yearly. AIM: This cross-sectional study aimed to describe and analyze the relationship between swallowing dysfunction and risk of undernutrition among older people in short-term care, including potential gender-related differences. METHODS: In total, 391 people (209 women), aged ≥ 65 years (median age 84 years) and admitted to short-term care in five Swedish counties participated. They went through a timed water swallow test to assess swallowing dysfunction, including abnormal swallowing capacity and signs of aspiration (i.e., cough and voice change). Risk for undernutrition was assessed using the Minimal Eating Observation and Nutrition Form-version II. RESULTS: Swallowing dysfunction was observed in 248 of 385 (63%) participants, including abnormal swallowing capacity in 213 of 385 (55%) and aspiration signs in 127 of 377 (34%). Abnormal swallowing capacity was more frequent among women (p = 0.030), whereas men with normal swallowing capacity exhibited signs of aspiration more frequently (cough p = 0.038, voice change p = 0.004). Risk of undernutrition was found in 91 of 390 (23%) participants, more frequently among women (p = 0.007). A logistic regression model revealed an increased risk of undernutrition among older people with abnormal swallowing capacity (OR 1.74, 95% CI 1.04-2.92, p = 0.034). CONCLUSIONS: The high prevalence of swallowing dysfunction and risk of undernutrition highlight the need for a systematic screening program and feasible treatment to improve swallowing function for adequate and safe food intake among older people in short-term care. CLINICAL TRIAL REGISTRATION: This study was registered with ClinicalTrials.gov on July 4, 2016, under NCT02825927.

Carotid near-occlusion frequently has high peak systolic velocity on Doppler ultrasound.

PURPOSE: Carotid near-occlusion is a tight atherosclerotic stenosis of the internal carotid artery (ICA) resulting in decrease in diameter of the vessel lumen distal to the stenosis. Near-occlusions can be classified as with or without full collapse, and may have high peak systolic velocity (PSV) across the stenosis, mimicking conventional > 50% carotid artery stenosis. We aimed to determine how frequently near-occlusions have high PSV in the stenosis and determine how accurately carotid Doppler ultrasound can distinguish high-velocity near-occlusion from conventional stenosis. METHODS: Included patients had near-occlusion or conventional stenosis with carotid ultrasound and CT angiogram (CTA) performed within 30 days of each other. CTA examinations were analyzed by two blinded expert readers. Velocities in the internal and common carotid arteries were recorded. Mean velocity, pulsatility index, and ratios were calculated, giving 12 Doppler parameters for analysis. RESULTS: Of 136 patients, 82 had conventional stenosis and 54 had near-occlusion on CTA. Of near-occlusions, 40 (74%) had high PSV (≥ 125 cm/s) across the stenosis. Ten Doppler parameters significantly differed between conventional stenosis and high-velocity near-occlusion groups. However, no parameter was highly sensitive and specific to separate the groups. CONCLUSION: Near-occlusions frequently have high PSV across the stenosis, particularly those without full collapse. Carotid Doppler ultrasound does not seem able to distinguish conventional stenosis from high-velocity near-occlusion. These findings question the use of ultrasound alone for preoperative imaging evaluation.

Carotid IM-GSM is better than IMT for identifying patients with multiple arterial disease.

OBJECTIVE: Atherosclerosis is a systemic inflammatory disease that can affect more than one arterial bed simultaneously. The aim of this study was to determine the relationship between ultrasound markers of atherosclerosis and multiple arterial disease. DESIGN: We have included 87 currently asymptomatic carotid disease patients (mean age 69 ± 6 year, 34% females) in this study. Intima media thickness (IMT) and intima media-grey scale median (IM-GSM) were measured in the common carotid artery (CCA), and correlated with previous and/or current atherosclerotic vascular disease in the coronary, carotid and lower extremities. Patients were divided into three groups: (1) asymptomatic, (2) previous symptoms in one arterial territory and (3) previous symptoms in multiple arterial territories. RESULTS: Patients with previous disease in the coronary arteries had higher IMT (p = .034) and lower IM-GSM (p < .001), and those with prior stroke had lower IM-GSM (p = .007). Neither IMT nor IM-GSM was different between patients with and without previous lower extremity vascular disease. IM-GSM was significantly different between groups, it decreased significantly with increasing number of arterial territories affected (37.7 ± 15.4 vs. 29.3 ± 16.4 vs. 20.7 ± 12.9) p < .001, for asymptomatic, symptoms in one and in multiple arterial systems, respectively. Conventional IMT was not significantly different between groups p = .49. CONCLUSION: Carotid IMT was higher and IM-GSM lower in patients with symptomatic nearby arterial territories but not in those with peripheral disease. In contrast to conventional IMT, IM-GSM can differentiate between numbers of arterial territories affected by atherosclerosis, suggesting that it is a better surrogate for monitoring multiple arterial territory disease.