Translation and transcultural adaptation of the Modified Swallowing Assessment (MSA) to Brazilian Portuguese. / Tradução e adaptação transcultural do Modified Swallowing Assessment (MSA) para o português brasileiro.

PURPOSE: To translate and adapt the Modified Swallowing Assessment (MSA) protocol for post-stroke patients into Brazilian Portuguese. METHODS: This is an initial stage of the Brazilian Portuguese Modified Swallowing Assessment validation process. Translation was performed by two bilingual speech therapists and the translations synthesis evaluations by two external dysphagia experts. The synthesis version in the target language (Portuguese) was back-translated into the source language (English). After the synthesis of the translated versions, the instrument was applied to 22 post-stroke individuals. RESULTS: Health professionals discussed all the results of the study stages considering the instrument concept and the target population. The semantic, linguistic and conceptual equivalences found in the translation and adaptation process were adequate, not requiring modifications since the items were consistent with the Brazilian culture. CONCLUSION: MSA was translated and adapted to Brazilian Portuguese (MSA-BR). The translation and cross-cultural adaptation process included all the items of the original protocol and maintained the standards and characteristics of the instrument.

OBJETIVO: Traduzir e adaptar para o português brasileiro o protocolo Modified Swallowing Assessment (MSA) para pacientes pós-acidente vascular cerebral. MÉTODO: Trata-se de uma etapa inicial do processo de validação do Modified Swallowing Assessment para o português brasileiro. Foi realizada a tradução por dois fonoaudiólogos bilíngues e a síntese das traduções por dois avaliadores externos, especialistas em disfagia. A versão síntese no idioma alvo (português) foi retrotraduzida para o idioma fonte (inglês). Após a síntese das versões traduzidas, o instrumento foi aplicado em 22 indivíduos com acidente vascular cerebral. RESULTADOS: Os avaliadores debateram sobre todos os resultados das etapas do estudo considerando o conceito do teste e o público alvo. As discrepâncias semânticas, linguísticas e conceituais encontradas no processo de tradução e adaptação foram adequadas, para que os itens fossem compatíveis com a cultura brasileira. CONCLUSÃO: O MSA foi traduzido e adaptado para o português brasileiro (MSA-BR). O processo de tradução e adaptação transcultural manteve todos os itens do protocolo original, preservando-se os padrões e as características do instrumento original.

Tradução e adaptação transcultural do Modified Swallowing Assessment (MSA) para o português brasileiro / Translation and transcultural adaptation of the Modified Swallowing Assessment (MSA) to Brazilian Portuguese

RESUMO Objetivo Traduzir e adaptar para o português brasileiro o protocolo Modified Swallowing Assessment (MSA) para pacientes pós-acidente vascular cerebral. Método Trata-se de uma etapa inicial do processo de validação do Modified Swallowing Assessment para o português brasileiro. Foi realizada a tradução por dois fonoaudiólogos bilíngues e a síntese das traduções por dois avaliadores externos, especialistas em disfagia. A versão síntese no idioma alvo (português) foi retrotraduzida para o idioma fonte (inglês). Após a síntese das versões traduzidas, o instrumento foi aplicado em 22 indivíduos com acidente vascular cerebral. Resultados Os avaliadores debateram sobre todos os resultados das etapas do estudo considerando o conceito do teste e o público alvo. As discrepâncias semânticas, linguísticas e conceituais encontradas no processo de tradução e adaptação foram adequadas, para que os itens fossem compatíveis com a cultura brasileira. Conclusão O MSA foi traduzido e adaptado para o português brasileiro (MSA-BR). O processo de tradução e adaptação transcultural manteve todos os itens do protocolo original, preservando-se os padrões e as características do instrumento original.

ABSTRACT Purpose To translate and adapt the Modified Swallowing Assessment (MSA) protocol for post-stroke patients into Brazilian Portuguese. Methods This is an initial stage of the Brazilian Portuguese Modified Swallowing Assessment validation process. Translation was performed by two bilingual speech therapists and the translations synthesis evaluations by two external dysphagia experts. The synthesis version in the target language (Portuguese) was back-translated into the source language (English). After the synthesis of the translated versions, the instrument was applied to 22 post-stroke individuals. Results Health professionals discussed all the results of the study stages considering the instrument concept and the target population. The semantic, linguistic and conceptual equivalences found in the translation and adaptation process were adequate, not requiring modifications since the items were consistent with the Brazilian culture. Conclusion MSA was translated and adapted to Brazilian Portuguese (MSA-BR). The translation and cross-cultural adaptation process included all the items of the original protocol and maintained the standards and characteristics of the instrument.

Flexible endoscopic evaluation of swallowing (FEES) for neurogenic dysphagia: training curriculum of the German Society of Neurology and the German stroke society.

BACKGROUND: Neurogenic dysphagia is one of the most frequent and prognostically relevant neurological deficits in a variety of disorders, such as stroke, parkinsonism and advanced neuromuscular diseases. Flexible endoscopic evaluation of swallowing (FEES) is now probably the most frequently used tool for objective dysphagia assessment in Germany. It allows evaluation of the efficacy and safety of swallowing, determination of appropriate feeding strategies and assessment of the efficacy of different swallowing manoeuvres. The literature furthermore indicates that FEES is a safe and well-tolerated procedure. In spite of the huge demand for qualified dysphagia diagnostics in neurology, a systematic FEES education has not yet been established. RESULTS: The structured training curriculum presented in this article aims to close this gap and intends to enforce a robust and qualified FEES service. As management of neurogenic dysphagia is not confined to neurologists, this educational programme is applicable to other clinicians and speech-language therapists with expertise in dysphagia as well. CONCLUSION: The systematic education in carrying out FEES across a variety of different professions proposed by this curriculum will help to spread this instrumental approach and to improve dysphagia management.

Using routine data for quality assessment in NeuroNet telestroke care.

BACKGROUND: Systematic clinical trials are often unavailable to evaluate and optimize operational telestroke networks. In a complementary approach, readily available routine clinical data were analyzed in this study to evaluate the effect of a telestroke network over a 4-year period. METHODS: Routine clinical data from the HELIOS hospital information system were compared before and after implementation of the NeuroNet concept, including neurologic acute stroke teleconsultations, standard operating procedures, and peer review quality management in 3 hospital cohorts: 5 comprehensive stroke centers, 5 NeuroNet hospitals, and 5 matched control hospitals. RESULTS: During the study period, the rate of thrombolytic therapy increased by 4.8% in NeuroNet hospitals, while ischemic stroke in-hospital mortality decreased (relative risk reduction ~29% in NeuroNet and control hospitals). The odds ratio for thrombolytic therapy in comprehensive stroke centers compared to NeuroNet hospitals was reduced from 3.7 to 1.3 between 2006 and 2009. Comprehensive stroke care coding according to German Diagnosis Related Groups definitions increased by 45% in NeuroNet (P < .0001) and by 18% in control hospitals. CONCLUSIONS: Routine clinical data on in-hospital mortality, the rate of thrombolytic therapy, and comprehensive stroke care coding reflect different aspects of acute stroke care improvement related to the implementation of the telemedical NeuroNet concept and unified quality management (standard operating procedure teaching concept, peer review process). Similar evaluation processes could contribute to quality monitoring in other telestroke networks.

Static posturography in aging and Parkinson's disease.

INTRODUCTION: In clinical practice, evaluation of postural control is based on the neurological examination, including Romberg's test, examination of gait and performance of pull test as part of the Unified Parkinson's Disease Rating Scale (UPDRS). The goal of our study was to identify posturographic parameters since quantitative technical methods for the measurement of postural control are not established in clinical routine yet. METHODS: In this cross-sectional study design we examined patients with Parkinson's disease (PD) (Hoehn and Yahr < 3; PD n = 12) on a static posturographic platform (eyes open and eyes closed), performing a standard Romberg's test during neurological examination and compared the results with an age-matched healthy adult control (HAC n = 10) and a healthy young control (HYC n = 21). RESULTS: In the platform Romberg's test with open eyes, the patients with PD showed a significantly greater mean sway [PD: 14.98 vs. HAC: 8.77 (mm), p < 0.003 vs. HYC 7.80 (mm)], greater mean radius [PD: 28.31 vs. HAC: 16.36 (mm), p < 0.008 vs. HYC: 14.19 (mm)] and greater marked area [PD: 2.38 vs. HAC: 0.88 (cm(2)), p < 0.016 vs. HYC: 0.78 (cm(2))] compared to the HAC. The Romberg's test with closed eyes revealed a significantly greater mean sway [PD: 13.83 vs. HAC: 10.12 (mm), p < 0.033 vs. HYC: 5.82 (mm)] and greater mean radius [PD: 25.03 vs. HAC: 18.15 (mm), p < 0.045 vs. HYC: 9.11 (mm)] compared to both groups. CONCLUSIONS: The platform Romberg-test with closed eyes detected significant differences in elderly people and patients with Parkinson's disease, which could be objectively quantified with static posturography testing. Age alone showed significant changes, only detectable with closed eyes. Therefore, balance testing with a new computerized approach could help to identify balance problems in a geriatric assessment in clinical routine, especially with the parameters marked area and mean sway.

Prediction of outcome in neurogenic oropharyngeal dysphagia within 72 hours of acute stroke.

BACKGROUND: Stroke is the most frequent cause of neurogenic oropharyngeal dysphagia (NOD). In the acute phase of stroke, the frequency of NOD is greater than 50% and, half of this patient population return to good swallowing within 14 days while the other half develop chronic dysphagia. Because dysphagia leads to aspiration pneumonia, malnutrition, and in-hospital mortality, it is important to pay attention to swallowing problems. The question arises if a prediction of severe chronic dysphagia is possible within the first 72 hours of acute stroke. METHODS: On admission to the stroke unit, all stroke patients were screened for swallowing problems by the nursing staff within 2 hours. Patients showing signs of aspiration were included in the study (n = 114) and were given a clinical swallowing examination (CSE) by the swallowing/speech therapist within 24 hours and a swallowing endoscopy within 72 hours by the physician. The primary outcome of the study was the functional communication measure (FCM) of swallowing (score 1-3, tube feeding dependency) on day 90. RESULTS: The grading system with the FCM swallowing and the penetration-aspiration scale (PAS) in the first 72 hours was tested in a multivariate analysis for its predictive value for tube feeding-dependency on day 90. For the FCM level 1 to 3 (P < .0022) and PAS level 5 to 8 (P < .00001), the area under the curve (AUC) was 72.8% and showed an odds ratio of 11.8 (P < .00001; 95% confidence interval 0.036-0.096), achieving for the patient a 12 times less chance of being orally fed on day 90 and therefore still being tube feeding-dependent. CONCLUSIONS: We conclude that signs of aspiration in the first 72 hours of acute stroke can predict severe swallowing problems on day 90. Consequently, patients should be tested on admission to a stroke unit and evaluated with established dysphagia scales to prevent aspiration pneumonia and malnutrition. A dysphagia program can lead to better communication within the stroke unit team to initiate the appropriate diagnostics and swallowing therapy as soon as possible.

Thrombolysis for stroke in the elderly.

INTRODUCTION: Systemic thrombolysis with intravenous recombinant tissue plasminogen activator (rt PA) for acute ischemic stroke had been licensed for patients up to 75 years in age in many European countries and was recently extended to 80 years. This age restriction results from the potential higher risk of cerebral bleeding in the elderly. The major rt PA trials included only 42 patients above 80 years showing a potential benefit from treatment. Further data is still rare. METHODS: Using our stroke database we identified all patients beyond 75 years with middle cerebral artery ischemia treated with intravenous rt PA in our stroke unit from 02/1999 until 07/2004. Clinical course and outcome until day 5 in addition to mortality after 3 and 6 months were analysed. RESULTS: Twenty-nine patients (80.8+/-4 years, 16 of them over 80 years old) met the inclusion criteria representing 21.2% of those receiving thrombolytic therapy. The median NIH-SS score on admission was 14 points. On day 5 after thrombolysis, 13/29 showed a good recovery (NIH-SS improvement >or=4 pts). The remaining exhibited only small or no benefit (n=11), deterioration (n=3) or died (n=2). A total of 3/29 patients developed non-symptomatic parenchymal hemorrhage or hemorrhagic transformation. One patient died due to space-occupying cerebral hemorrhage. Extracerebral bleeding was found in 3/29 requiring substitution in one. One other died for primary cardiac reasons. Median NIH-SS on day 5 was 10 points. Mortality after 3 and 6 months was 20.7%. We did not find factors predicting clinical outcome. Most importantly, there was no significant difference regarding outcome in patients 76--80 vs. 81--87 years old. DISCUSSION: Intravenous rt PA resulted in good neurological in-hospital outcome in almost 45% and six-months survival of almost 80% of the patients beyond 75 years. In 10.3% non-symptomatic and in 3.4% symptomatic cerebral bleeding was found. Thus, seniors beyond 75 and even beyond 80 years in good medical condition may benefit from systemic treatment with rt PA. Prospective studies are needed to clarify which part of the senior population might be most eligible for systemic thrombolysis.

The use of telemedicine in combination with a new stroke-code-box significantly increases t-PA use in rural communities.

BACKGROUND: The benefit of tissue plasminogen activator (t-PA) is strongly associated with the time to treatment. In Bavaria, Germany, only half of the population has the opportunity to be transferred to 1 of the 19 stroke units within the critical time window of less than 3 hours. The aim of this study was to investigate the benefit of a new stroke-code-box for t-PA thrombolysis combined with a telemedicine network system to increase the use of acute stroke thrombolysis. METHODS: Two specialized stroke centers in Germany established a 24-hour telemedicine network (Telemedicine Pilot Project of an Integrated Stroke Care [TEMPiS]) to advise 12 community hospitals in eastern Bavaria. These clinics are linked via telemedicine in a 24-hour/7-day service network that allows patients to be examined by experts via a videoconference system Additionally, a special stroke-code-box for acute t-PA thrombolysis was designed to reduce time in the application and documentation process. RESULTS: In the 12-month period before implementation of the TEMPiS network system, 10 patients had received systemic thrombolysis. In our 6-month study period (from July to December 2003) and after implementation of a stroke-code-box for t-PA thrombolysis within the telestroke network, 164 patients with acute stroke were presented with t-PA treatment indications. Of this patient population, 27.4% (45 of 164) received t-PA. CONCLUSIONS: Stroke care, including t-PA thrombolysis in non-urban areas, is feasible using a modern stroke unit concept within a telestroke network. With the expertise of specialized stroke centers accessed via telemedicine and the design of a stroke-code-box for t-PA thrombolysis, nearly one-third of patients presented with a possible indication for systemic thrombolysis can be treated with t-PA, thereby increasing the options for a successful stroke treatment.

Predictors of survival after severe dysphagic stroke.

BACKGROUND AND PURPOSE: Dysphagia is estimated to occur in up to 50% of the stroke neurorehabilitation population. Those patients with severe neurogenic oropharyngeal dysphagia (NOD) may receive feeding gastrostomy tubes (FGT) if noninvasive therapies prove ineffective in eliminating aspiration or sustaining adequate nutritional intake. Our aim was to quantify the recovery of swallowing function, and to identify variables predictive of survival after dysphagic stroke requiring FGT placement. METHODS: We identified consecutive stroke patients with severe dysphagic stroke requiring FGT placement admitted to a rehabilitation hospital between May 1998 and October 2001. The medical records were reviewed, and demographic, clinical, videofluoroscopic (VSS) and neuroimaging information were abstracted. A follow-up telephone interview was performed to determine whether the FGT was still in use, had been removed,or if the patient had died. State death certificate records were reviewed to ascertain date of death for subjects who had expired by the time of follow-up. Univariate and multivariate analyses were performed. RESULTS: 11.6 % (77/664) of stroke patients admitted during the study period had severe dysphagic stroke with FGT insertion. Follow-up was available for 66 (85.7 %) of these individuals at a mean of two years after acute stroke. On follow-up 64% (42/66) of the patients were alive and 45 % had had the FGT removed and resumed oral diets. On univariate analysis patients who were alive at the time of follow-up had received FGT feeding for a shorter period of time (p < 0.0003), showed no signs of aspiration on the Clinical Assessment of Feeding & Swallowing (CAFS,p < 0.020) and on the Videofluoroscopic Swallowing Study (VSS, 0.001), had a better discharge FIM-Score (Functional Independence Measure) for eating (p < 0.0002) and cognitive function (p < 0.002) as well as better discharge FCM-Score (Functional Communication Measure) for swallowing (p < 0.0001). On multivariate analysis we developed a model consisting of FGT removal at discharge from the rehabilitation hospital (p < 0.011) and non-aspiration during VSS (p < 0.040) that was significantly associated with longer survival time during follow-up. CONCLUSIONS: Severe dysphagia requiring FGT is common in patients with stroke referred for neurorehabilitation. Patients who had a FGT in place at the time of discharge from the stroke rehabilitation unit or aspirated during VSS were substantially more likely to have died by the time of follow-up compared to those who had had the FGT removed and had no signs of aspiration on VSS. However functional outcome measurements (FIM, FCM) including the cognitive function (attention, concentration etc.) could play an important role for prediction of swallowing regeneration and survival in neurorehabilitation. These findings may have practical utility in guiding physicians and speech language pathologists when advising patients and families about prognosis in stroke survivors with severe dysphagia.

The relationship between plasma D-dimer concentrations and acute ischemic stroke subtypes.

Elevated concentrations of D-dimers (DDs) in patients with acute ischemic stroke may cause differential diagnostic problems with regard to pulmonary or deep venous thrombosis. The true relationship between plasma DDs and acute ischemic stroke remains uncertain. We studied acute stroke patients admitted to a single acute neurology department with a specialized stroke unit. As part of our clinical protocol, blood samples of each patient had been taken within the first 24 hours after the onset of stroke symptoms and before anticoagulant treatment had been started, to evaluate the coagulation profile. Each patient's medical record was reviewed, and demographic, clinical, laboratory and neuroimaging information was abstracted. Univariate and multivariate statistical analyses were performed. A total of 59 patients admitted to our stroke unit between October 2003 and March 2004 with different stroke subtypes according to the TOAST criteria were evaluated to characterize the impact of stroke category on DD concentration. Family members (n = 23) served as controls in this study. Multivariate regression analysis revealed that patients who sustained cardioembolic stroke had significantly higher DD concentrations than controls and patients who sustained transient ischemic attacks. We identified a correlation between plasma DD levels and different acute ischemic stroke subtypes before any stroke treatment was started. Thus DD concentrations may be considered a direct consequence of marked cerebral infarction and may be useful for physicians when making decisions on treatment for acute ischemic stroke.

Telemedicine for safe and extended use of thrombolysis in stroke: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria.

BACKGROUND AND PURPOSE: Systemic thrombolysis represents the only proven therapy for acute ischemic stroke, but safe treatment is reported only in established stroke units. One major goal of the ongoing Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria is to extend the use of tissue plasminogen activator (tPA) treatment in nonurban areas through telemedic support. METHODS: The stroke centers in Munich-Harlaching and in Regensburg established a telestroke network to provide consultations for 12 local hospitals in eastern Bavaria. The telemedic system consists of a digital network that includes a 2-way video conference system and CT/MRI image transfer with a high-speed data transmission up to 2 Mb/s. Each network hospital established specialized stroke wards in which qualified teams treat acute stroke patients. Physicians in these hospitals are able to contact the stroke centers 24 hours per day. RESULTS: A total of 106 systemic thrombolyses were indicated via teleconsultations between February 1, 2003, and April 7, 2004. During the first 12 months, the rate of thrombolyses was 2.1% of all stroke patients. Mean age was 68 years, and median National Institutes of Health Stroke Scale score was 13. Mean delay between onset and hospital admission was 65 minutes, and door-to-needle time was on average 76 minutes, which included 15 minutes for the teleconsultation. Symptomatic hemorrhage occurred in 8.5% of patients, and in-hospital mortality was 10.4%. CONCLUSIONS: The present data suggest that systemic thrombolysis indicated via stroke experts in the setting of teleconsultation exhibits similar complication rates to those reported in the National Institute of Neurological Disorders and Stroke trial. Therefore, tPA treatment is also safe in this context and can be extended to nonurban areas.

Predictors of feeding gastrostomy tube removal in stroke patients with dysphagia.

Dysphagia is a common consequence of stroke, estimated to be present in 25% to 50% of the stroke rehabilitation population. Relatively few data exist concerning outcome following insertion of feeding gastrostomy/jejunostomy tubes (FGT) in stroke patients with dysphagia. Our aim was to identify variables predictive of FGT removal. We studied stroke patients admitted to a single rehabilitation hospital and identified consecutive stroke patients with FGT placement. Each patient's medical records were reviewed, and demographic, clinical, and neuroimaging information were abstracted. Follow-up status was obtained by telephone interviews and review of state death certificates. Univariate and multivariate analyses were performed. Seventy-seven of the 664 (11.1%) stroke patients admitted in the 42-month study period had FGT insertion for dysphagia. Multivariate regression analysis revealed that bilateral stroke (bilateral vs unilateral; P < .022), aspiration during videofluoroscopic swallowing study (VSS; P < .012), and age greater than 52 years (P < .001) were negative predictors of FGT removal prior to discharge from the rehabilitation hospital. We identified three independent variables (bilateral stroke, aspiration during VSS, and age > 52) in stroke patients with severe dysphagia requiring FGT placement that are negative predictors of FGT removal prior to discharge from rehabilitation. These findings may help physicians and speech language pathologists predict who is likely to have a FGT removed before rehabilitation hospital discharge.