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In elderly patients in the chronic phase of ischemic stroke, the risk for death from aspiration pneumonia remains high 10 , Because dysphagia influences outcomes in elderly persons after stroke, straightforward techniques that can accurately evaluate swallowing ability are needed.

Various techniques have been developed 5—16 , although most screening tests for dysphagia evaluate the ability to swallow water.

However, some tests fail to identify mild dysphagia or subclinical aspiration 24 , To overcome the problems of conventional methods, Smithard and colleagues 5 developed a bedside test to assess swallowing ability.

This test consists of two stages, can be performed easily at the bedside, and evaluates swallowing ability at multiple time points.

We wanted to determine whether this method was useful for diagnosing dysphagia and predicting outcomes in patients with ischemic stroke.

An important feature of this method is inclusion of a pretest evaluation of laryngeal function, palate movement, gag reflex, and voluntary cough, in addition to level of consciousness and control of the head and trunk.

Speech, the ability to repeatedly swallow saliva, and voluntary cough also can be assessed as baseline values for bedside swallowing assessments.

When our patients performed water-swallowing tests after such evaluations, we observed high incidences of repeated movements, stridor on swallowing, and abnormal laryngeal function after swallowing.

Repeated movements refer to laryngeal movement two or more times on attempts to swallow 5 ml of water. Such repeated movements suggest problems in the oral or laryngeal phases of swallowing 5 , 6.

Stridor on swallowing and abnormal laryngeal function after swallowing suggest decreased laryngeal perception or swallowing reflex, or the presence of aspiration 11 , Because repeated episodes of pneumonia were probably caused by aspiration, we excluded data from group 4 when we evaluated the utility of the Smithard method for risk screening.

We followed groups 1 and 3 for as long as 2. In contrast, accuracy for predicting risk for death from pneumonia based on the presence or absence of a history of pneumonia was 0.

These results suggest that this method is useful for identifying patients with a history of ischemic stroke who are at increased risk for aspiration pneumonia odds ratio, In addition, the mortality rate from aspiration pneumonia increased at a similar pace in groups 3 and 4.

We found no difference in the mortality rate from aspiration pneumonia in groups 3 and 4. Perhaps this lack of difference was related to the fact that many patients in group 3 and all patients in group 4 received gastrostomy tubes after evaluation for dysphagia.

Despite this procedure, however, outcomes based on annual mortality rates in groups 3 and 4 were poorer than in group 1. One of the reasons for the poor outcomes would be gastroesophageal reflux phenomenon and oral hygiene, so meticulous attention must be focused on food processing and oral hygiene care These findings indicate that the Smithard method is helpful for predicting the risk for aspiration pneumonia in patients with ischemic stroke.

The study by Smithard and colleagues 5 of outcomes in patients with acute stroke who had dysphagia on bedside swallowing assessment and were followed for 6 months showed high rates of pneumonia, poor nutritional status, and mortality 5.

Furthermore, the diagnostic accuracy of the bedside swallowing assessment to detect dysphagia seemed similar to that of videofluoroscopy, the most accurate diagnostic procedure available, based on a comparison of diagnostic accuracy between the two methods 5.

In the current study, we show the utility of the bedside swallowing assessment as a screening procedure for dysphagia.

In addition to the validity, the convenience of bedside assessment, the use of water volumes, and evaluation variables similar to those of other water-swallowing tests 7 , 8 further enhance the value of this technique as a screening evaluation for dysphagia.

Patients who display even one abnormal finding according to the Smithard method should be followed carefully for aspiration pneumonia.

After ischemic stroke, patients should be evaluated carefully and retested at regular intervals, because the results of the bedside swallowing assessment may become positive during follow-up.

We evaluated swallowing ability 3—12 months after the last acute ischemic stroke, regardless of recurrence or the interval after the first stroke.

The interval from the first stroke to the time of testing, therefore, varied considerably. This variation in interval between the first stroke and testing was probably related to the incidence of pneumonia or cerebrovascular diseases, perhaps indicating selection bias.

Groups 3 and 4 showed a high incidence of bilateral hemispheric infarction, suggesting that these groups may have had frequent recurrence of ischemic stroke during an extended period, or that stroke may have occurred after the development of unrecognized lesions.

This was corroborated by the high incidences of impaired activities of daily living and disturbed consciousness in groups 3 and 4. Background differences in the presence of disturbed consciousness and dementia between the groups could introduce bias in the study and influence prognosis.

Furthermore, it is unclear whether episodes of aspiration pneumonia during follow-up were caused by aspiration during meals or during sleep 24 , Finally, the diagnosis of pneumonia is often attributed to aspiration pneumonia, particularly in patients after stroke, because the diagnosis apparently depends on clinical findings 18 , Our results indicate that the bedside swallowing assessment in elderly patients after initial recovery from stroke is useful for identifying those at greatest risk for pneumonia and death.

Decision Editor: John E. Morley, MB, BCh. We thank Professors Raoul Breugelmans and J. Long-term prognosis of patients with initial cerebral thrombosis and the MRI findings.

Jpn J Geriatr. Dementia and disability after initial cerebral thrombosis evaluated by MRI and their clinical course.

The association of swallowing dysfunction and aspiration pneumonia. Predictors of aspiration pneumonia: How important is dysphagia? Complications and outcome after acute stroke: Does dysphagia matter?

Aspiration following stroke: clinical correlates and outcome. Barer DH. The natural history and functional consequences of dysphagia after hemispheric stroke.

J Neurol Neurosurg Psychiatry. Validation of the 3-oz water swallow test for aspiration following stroke.

Arch Neurol. Aspiration in acute stroke: a clinical study with videofluoroscopy. Q J Med. Aspiration and the elderly. Longemann JA. Evaluation and Treatment of Swallowing Disorders.

San Diego: College-Hill Press; Ekberg O, Wahlgren L. Dysfunction of pharyngeal swallowing: a cineradiographic investigation in dysphagial patients.

Acta Radiol Diagn. Does pulse oximetry reliably detect aspiration in dysphagic stroke patients? Ann Otol Rhinol Laryngol. Mechanisms of dysphagia in suprabulbar palsy with lacunar infarct.

Using the Fleming index of dysphagia to establish prevalence. World Medical Association Declaration of Helsinki. Recommendations guiding physicians in biomedical research involving human subjects.

Aspiration pneumonia: a review. Am Fam Physician. Epinephrine adrenaline is the first-line treatment for severe allergic reactions anaphylaxis.

If administered in a timely manner, epinephrine can reverse its effects. Epinephrine relieves airway swelling and obstruction, and improves blood circulation; blood vessels are tightened and heart rate is increased, improving circulation to body organs.

Epinephrine is available by prescription in an autoinjector. Antihistamines can alleviate some of the milder symptoms of an allergic reaction, but do not treat all symptoms of anaphylaxis.

Histamine also causes itchiness by acting on sensory nerve terminals. The most common antihistamine given for food allergies is diphenhydramine.

Glucocorticoid steroids are used to calm down the immune system cells that are attacked by the chemicals released during an allergic reaction.

This treatment in the form of a nasal spray should not be used to treat anaphylaxis, for it only relieves symptoms in the area in which the steroid is in contact.

Another reason steroids should not be used is the delay in reducing inflammation. Steroids can also be taken orally or through injection, by which every part of the body can be reached and treated, but a long time is usually needed for these to take effect.

For reasons not entirely understood, the diagnosis of food allergies has apparently become more common in Western nations recently.

Therefore, reduced exposure to these organisms, particularly in developed countries, could have contributed towards the increase. Peanut and tree nut allergies are less likely to be outgrown, although evidence now [ when?

In Japan, allergy to buckwheat flour, used for soba noodles, is more common than peanuts, tree nuts or foods made from soy beans.

In the United States, an estimated 12 million people have food allergies. Whether rates of food allergy are increasing or not, food allergy awareness has definitely increased, with impacts on the quality of life for children, their parents and their caregivers.

The Culinary Institute of America, a premier school for chef training, has courses in allergen-free cooking and a separate teaching kitchen.

Despite all these precautions, people with serious allergies are aware that accidental exposure can easily occur at other peoples' houses, at school or in restaurants.

There is an increased occurrence of bullying, which can include threats or acts of deliberately being touched with foods they need to avoid, also having their allergen-free food deliberately contaminated.

After many public protests, Sony Pictures and the director apologized for making light of food allergies.

In response to the risk that certain foods pose to those with food allergies, some countries have responded by instituting labeling laws that require food products to clearly inform consumers if their products contain priority allergens or byproducts of major allergens among the ingredients intentionally added to foods.

There are no labeling laws mandating declaration of the presence of trace amounts in the final product as a consequence of cross-contamination, except in Brazil.

In the United States, the Food Allergen Labeling and Consumer Protection Act of FALCPA requires companies to disclose on the label whether a packaged food product contains any of these eight major food allergens, added intentionally: cow's milk, peanuts, eggs, shellfish, fish, tree nuts, soy and wheat.

These products are regulated by the Food Safety and Inspection Service FSIS , which requires that any ingredient be declared in the labeling only by its common or usual name.

Neither the identification of the source of a specific ingredient in a parenthetical statement nor the use of statements to alert for the presence of specific ingredients, like "Contains: milk", are mandatory according to FSIS.

In the United States, there is no federal mandate to address the presence of allergens in drug products. The value of allergen labeling other than for intentional ingredients is controversial.

This concerns labeling for ingredients present unintentionally as a consequence of cross-contact or cross-contamination at any point along the food chain during raw material transportation, storage or handling, due to shared equipment for processing and packaging, etc.

Argentina decided to prohibit precautionary allergen labeling since , and instead puts the onus on the manufacturer to control the manufacturing process and label only those allergenic ingredients known to be in the products.

South Africa does not permit the use of PAL, except when manufacturers demonstrate the potential presence of allergen due to cross-contamination through a documented risk assessment and despite adherence to Good Manufacturing Practice.

This threshold reference dose for foods such as cow's milk, egg, peanut and other proteins will provide food manufacturers with guidance for developing precautionary labeling and give consumers a better idea of might be accidentally in a food product beyond "may contain.

In Brazil, since April , the declaration of the possibility of cross-contamination is mandatory when the product does not intentionally add any allergenic food or its derivatives, but the Good Manufacturing Practices and allergen control measures adopted are not sufficient to prevent the presence of accidental trace amounts.

These allergens include wheat, rye, barley, oats and their hybrids, crustaceans, eggs, fish, peanuts, soybean, milk of all species of mammalians, almonds , hazelnuts , cashew nuts , Brazil nuts , macadamia nuts , walnuts , pecan nuts , pistachios , pine nuts , and chestnuts.

There are concerns that genetically modified foods , also described as foods sourced from genetically modified organisms GMO , could be responsible for allergic reactions, and that the widespread acceptance of GMO foods may be responsible for what is a real or perceived increase in the percentage of people with allergies.

National Academy of Sciences report concluded that there is no relationship between consumption of GM foods and the increase in prevalence of food allergies.

One concern is that genetic engineering could make an allergy-provoking food more allergic, meaning that smaller portions would suffice to set off a reaction.

However, for the soybean proteins known to trigger allergic reactions, there is more variation from strain to strain than between those and the GMO varieties.

Research on an attempt to enhance the quality of soybean protein by adding genes from Brazil nuts was terminated when human volunteers known to have tree nut allergy reacted to the modified soybeans.

Prior to a new GMO food receiving government approval, certain criteria need to be met. These include: Is the donor species known to be allergenic?

Does the amino acid sequence of the transferred proteins resemble the sequence of known allergenic proteins? Are the transferred proteins resistant to digestion - a trait shared by many allergenic proteins?

In Starlink brand corn restricted to animals was detected in the human food supply, leading to first a voluntary and then a FDA mandated recall.

In the US, the FDA Food Code states that the person in charge in restaurants should have knowledge about major food allergens, cross-contacts, and symptoms of food allergy reactions.

Restaurant staff, including wait staff and kitchen staff, may not be adequately informed about allergenic ingredients, or the risk of cross-contact when kitchen utensils used to prepare food may have been in previous contact with an allergenic food.

The problem may be compounded when customers have a hard time describing their food allergies or when wait staff have a hard time understanding those with food allergies when taking an order.

There exists both over-reporting and under-reporting of the prevalence of food allergies. Self-diagnosed perceptions of food allergy are greater than the rates of true food allergy because people confuse non-allergic intolerance with allergy, and also attribute non-allergy symptoms to an allergic response.

Conversely, healthcare professionals treating allergic reactions on an out-patient or even hospitalized basis may not report all cases.

Recent increases in reported cases may reflect a real change in incidence or an increased awareness on the part of healthcare professionals. A number of desensitization techniques are being studied.

The benefits of allergen immunotherapy for food allergies is unclear, thus is not recommended as of [update]. There is research on the effects of increasing intake of polyunsaturated fatty acids PUFAs during pregnancy, lactation, via infant formula and in early childhood on the subsequent risk of developing food allergies during infancy and childhood.

From two reviews, maternal intake of omega-3, long-chain fatty acids during pregnancy appeared to reduce the risks of medically diagnosed IgE-mediated allergy, eczema and food allergy per parental reporting in the first 12 months of life, [] [] but the effects were not all sustained past 12 months.

There is research on probiotics , prebiotics and the combination of the two synbiotics as a means of treating or preventing infant and child allergies.

From reviews, there appears to be a treatment benefit for eczema, [] [] [] but not asthma, wheezing or rhinoconjunctivitis. The Food Standards Agency, in the United Kingdom, are in charge of funding research into food allergies and intolerance.

From Wikipedia, the free encyclopedia. Hypersensitivity reaction to a food. Archived from the original PDF on 5 March J Allergy Clin Immunol.

December Journal of Allergy and Clinical Immunology. The Journal of Allergy and Clinical Immunology. Archived from the original on 17 June Retrieved 15 June Sense About Science.

Archived from the original PDF on 18 June Retrieved 7 June November J Pediatr Rio J. World Allergy Organ J. Retrieved 12 January Archived from the original on 29 April Retrieved 7 April Food Allergy Initiative.

Accessed 27 Mar Asthma and Allergy Foundation of America. Archived from the original on 7 December Retrieved 15 March Food Additives and Ingredients Association.

Archived from the original on 13 February Retrieved 8 June Archived from the original on 12 December Retrieved 8 December Archived from the original on 23 May Retrieved 26 October Archived from the original on 20 November Retrieved 19 November Biocompatibility of Dental Materials.

Archived from the original on 18 May Retrieved 5 March Habif Clinical Dermatology. Elsevier Health Sciences. Archived from the original on 8 September Retrieved 6 March Bope; Rick D.

Kellerman Conn's Current Therapy Expert Consult. Archived from the original on 5 May Journal of Investigative Dermatology.

Adverse Effects of Vaccines: Evidence and Causality. Institute of Medicine. Archived from the original on 30 September American Academy of Pediatrics.

Archived from the original on 16 January Retrieved 26 January Allergo J Int. Archived from the original on 16 June Retrieved 12 June NHS Choices.

Retrieved 31 January Allergies Archived at the Wayback Machine. Kent, England. Accessed 27 Apr Causes of Food Allergies. Archived at the Wayback Machine April By the time he collected himself and walked out, the Dallas Stars were celebrating an overtime victory to send them to the Stanley Cup Final.

Whitecloud had flipped the puck over the glass for an automatic delay of game penalty, Dallas scored on the power play and Vegas lost the game and the Western Conference final.

Just for that type of penalty to decide a game, it doesnt make sense to me, Golden Knights coach Peter DeBoer said. Gone are the days that you have to mug somebody to get a penalty late in regulation or in overtime of a playoff game because referees swallow their whistles not to have too big an influence.

Those are penalties regardless. Its not a judgement call by any means. I dont know if the fans not being there affect anything at all, but you know when youre taking penalties, you try not to take them because they can be so costly at the end of a game.

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