BACKGROUND: Hospitalizations for aspiration pneumonia have doubled among older adults. Using a bedside water swallow test (WST) to screen for swallowing-related aspiration can be efficient and cost-effective for preventing additional comorbidities and mortality. We evaluated screening accuracy of bedside WSTs used to identify patients at risk for dysphagia-associated aspiration.

Sponsorship, in addition to mentorship, is critical for successful career advancement. Understanding sponsorship as a distinct professional relationship may help faculty and academic leaders make more informed decisions about using sponsorship as a deliberate career-advancement strategy.

Dysphagia affects the vast majority of acute stroke patients. Although it improves within 2 weeks for most, some face longstanding swallowing problems that place them at risk for pneumonia, malnutrition, dehydration, and significantly affect quality of life. This paper discusses the scope, the disease burden, and the tools available for screening and formal evaluation of dysphagia. The most common and recently developed treatment interventions that might be useful in the treatment of this population are discussed.

Background and Purpose-Dysphagia is a common problem after stroke associated with significant morbidity and mortality. Except for patients with brain stem strokes, particularly lateral medullary strokes, it is difficult to predict which cases are likely to develop swallowing dysfunction based on their neuroimaging. Clear models of swallowing control and integration of cortico-bulbar input have not been defined and the role of subcortical structures is unclear. The purpose of this study was to identify supratentorial regions of interest (ROIs) that might be related to clinically important dysphagia in acute stroke patients, focusing on subcortical structures. Methods-We studied 29 acute supratentorial ischemic stroke cases admitted to our institution between 2001 and 2005 diagnoses with first ischemic stroke and without history of swallowing dysfunction. Subjects had MRI within 24 hours. Cases were defined as those subjects who were diagnosed as dysphagic after clinical evaluation by a speech language pathologist (SLP) and whose dysphagia was considered clinically significant, ie, requiring treatment by diet modification. Controls were defined as those patients who: (1) passed the stroke unit's dysphagia screening, (2) had a clinical evaluation by SLP that did not result in a diagnosis of dysphagia or diet modifications, or (3) had no documented evidence of dysphagia evaluation or treatment during hospitalization and were discharged on a regular diet. A trained technician, blinded to case-control status, examined 12 ROIs for dysfunctional tissue in diffusion and perfusionweighted images. The odds ratio (OR) of dysphagia was calculated for each ROI. Logistic regression models were used to adjust for stroke severity (NIHSS) and volume. Results-Analysis of data on 14 cases and 15 controls demonstrated significant differences in the unadjusted odds of dysphagia for the following ROIs: (1) primary somatosensory, motor, and motor supplementary areas (PSSM; ORϭ10, Pϭ0.009); (2) orbitofrontal cortex (OFC; ORϭ6.5, Pϭ0.04); (3) putamen, caudate, basal ganglia (PCBG; ORϭ5.33, Pϭ0.047); and (4) internal capsule (IC; ORϭ26; Pϭ0.005). Nonsignificant differences were found in the insula and temporopolar cortex. Adjusted OR of dysphagia for subjects with strokes affecting the IC was 17.8 (Pϭ0.03). Adjusted odds ratios for the PSSM, OFC, and PCBG were not statistically significant. Conclusion-Significantly increased odds of dysphagia were found in subjects with IC involvement. Other supratentorial areas that may be associated with dysphagia include the PSSM, OFC, and PCBG. Analysis of additional areas was limited by the number of subjects in our sample. Future studies with larger sample size are feasible and will contribute to the development of a full swallowing control model. (Stroke. 2008;39:3022-3028.)

The COVID-19 pandemic is having a profound impact on the provision of medical care. As the curve progresses and patients are discharged the rehabilitation wave brings a high number of post-acute COVID-19 patients suffering from physical, mental, and cognitive impairments threatening their return to normal life. The complexity and severity of disease in patients recovering from severe COVID-19 infection require an approach that is implemented as early in the recovery phase as possible, in a concerted and systematic way. To address the rehabilitation wave, we describe a spectrum of interventions that start in the ICU and continue through all the appropriate levels of care. This approach requires organized rehabilitation teams including physical therapists, occupational therapists, speech-language pathologists, rehabilitation psychologists/neuropsychologists, and physiatrists collaborating with acute medical teams. Here, we also discuss administrative factors that influence the provision of care during the COVID-19 pandemic. The services that can be provided are described in detail to allow the reader to understand what services may be appropriate locally. We have been learning and adapting real-time during this crisis and hope that sharing our experience facilitates the work of others as the pandemic evolves. It is our goal to help reduce the potentially long-lasting challenges faced by COVID-19 survivors.

In this study, the relationship between patients' perceptions of pain control during hospitalization and their overall satisfaction with care was examined. Satisfaction data were collected from the federally mandated Hospital Consumer Assessment of Healthcare Providers and Systems survey for 4349 adult patients admitted to any surgical unit over an 18-month period. Patients' perceptions of pain control and staff's efforts to control pain were associated with their overall satisfaction scores. These perceptions varied widely among services and nursing units. Interestingly, patient satisfaction was more strongly correlated with the perception that caregivers did everything they could to control pain than with pain actually being well controlled. The odds of a patient being satisfied were 4.86 times greater if pain was controlled and 9.92 times greater if the staff performance was appropriate. Hospitals may improve their patients' satisfaction by focusing on improving the culture of pain management.

During feeding, solid food is chewed and propelled to the oropharynx, where the bolus gradually aggregates while the larynx remains open and breathing continues. The aggregated bolus in the valleculae is exposed to respiratory airflow, yet aspiration is rare in healthy individuals. The mechanism for preventing aspiration during bolus aggregation is unclear. One possibility is that alterations in the pattern of respiration during feeding could help prevent inhalation of food from the pharynx. We hypothesized that respiration was inhibited during bolus aggregation in the valleculae. Videofluorography was performed on 10 healthy volunteers eating solid foods with barium. Respiration was monitored concurrently with plethysmography and nasal air pressure. The timing of events during mastication, food transport, pharyngeal bolus aggregation, and swallowing were measured in relation to respiration. Respiratory cycle duration decreased during chewing (P < 0.001) but increased with swallowing (P < 0.001). During 66 recordings of vallecular bolus aggregation, there was inspiration in 8%, expiration in 41%, a pause in breathing in 17%, and multiple phases (including inspiration) in 35%. Out of 98 swallows, 47% started in the expiratory phase and 50% started during a pause in breathing, irrespective of bolus aggregation in the valleculae. Plethysmography was better than nasal manometry for determining the end of active expiration during feeding and swallowing with solid food. The hypothesis is rejected in that respiration was not inhibited during bolus aggregation. These findings suggest that airflow through the pharynx does not have a role in preventing aspiration during bolus aggregation in the oropharynx.

The hyoid bone and larynx elevate to protect the airway during swallowing. However, it is unknown whether hyo-laryngeal movements during swallowing can adjust and adapt to predict the presence of a persistent perturbation in a feed-forward manner (adaptive motor learning). We investigated adaptive motor learning in nine healthy adults. Electrical stimulation was administered to the anterior neck to reduce hyo-laryngeal elevation, requiring more strength to swallow during the perturbation period of this study. We assessed peak hyoid bone and laryngeal movements using videofluoroscopy across 35 5ml-water swallows. Evidence of adaptive motor learning of hyo-laryngeal movements was found when: (1) participants showed systematic, gradual increases in elevation against the force of electrical stimulation, and; (2) hyo-laryngeal elevation overshot the baseline (pre-perturbation) range of motion, showing behavioral after-effects, when the perturbation was unexpectedly removed. Hyolaryngeal kinematics demonstrate adaptive, error-reducing movements in the presence of changing and unexpected demands. This is significant because individuals with dysphagia often aspirate due to disordered hyo-laryngeal movements. Thus, if rapid motor learning is accessible during swallowing in healthy adults, patients may be taught to predict the presence of perturbations and reduce errors in swallowing before they occur.