Magister Scientiae (Physiotherapy) - MSc(Physio) / Dysphagia is commonly known as a swallowing disorder associated with stroke patients. Between 37% - 78% of stroke patients suffer from it initially. Complications of dysphagia include aspiration leading to chest infection and pneumonia, malnutrition, dehydration, and an increased risk of death. Its early diagnosis and management is an important prerequisite for recovery from stroke during the rehabilitation phase. As healthcare professionals, nurses play an important role in the diagnosis and management of dysphagia in stroke patients. Studies have shown that nurses display a lack of knowledge about dysphagia in stroke patients. The aim of the study was to determine the knowledge of nurses regarding dysphagia in patients with stroke, at an Intermediate Hospital, in Namibia. The objectives of the study were to determine the knowledge of nurses regarding dysphagia, the association between the knowledge and socio demographic factors and to design an intervention program based on the knowledge of the nurses. The study was carried out in a selected hospital in Namibia. All nurses, who were employed at the Intermediate Hospital at the time of the study, were invited to participate. Of the 500 employed nurses, 188 accepted the invitation to participate in the study. The study used a quantitative method consisting of a survey to determine the knowledge of the nurses. Data was collected using a self-administered questionnaire with closed-ended questions which was developed by the researcher. The quantitative data were captured and analysed using SPSS (22.0 version). Descriptive statistics was used to summarize the study findings by using means, standard deviations, frequencies and percentages. To determine the association between the knowledge of dysphagia and the socio-demographic factors, therefore inferential statistics were used to in three levels of analysis. The findings of the study shows that nurses have a moderate knowledge regarding to the signs and symptoms and complications of dysphagia. Poor knowledge was identified in management of dysphagia. Further, the results also indicated that further training and experience in caring for stroke patients was more relevant to knowledge than the position and qualification of a nurse. Training and experience in the care of dysphagia patients is a stronger predictor of knowledge than the initial qualification or years of experience of a nurse. An intervention program was designed based on the information obtained from the findings of the questionnaire and supporting literature. Permission to conduct this study was obtained from the Senate Research Grants and Study Leave Committee at the University of the Western Cape. Written permission was obtained from the Ministry of Health and Social Services, Office of the Permanent Secretary, as well from the Acting Medical Superintendent of the Intermediate Hospital Oshakati. The aim of the study, confidentiality and the participants' freedom to withdraw from the study was explained. In order to maintain anonymity, nurses were asked to place informed consent forms and questionnaires in separate boxes. The outcomes of the study could be used to offer appropriate training programs to increase nurses’ knowledge of dysphagia in stroke patients.

This thesis examines the phonetic, phonological, and social aspects of pre-aspiration in English spoken in Aberystwyth, mid Wales. Pre-aspiration refers to a period of voiceless (primarily) glottal friction occurring in the sequences of sonorants and phonetically voiceless obstruents (e.g. in mat [mahts] or mass [mahs]). Chapter 1 summarises the objectives of this thesis and where the thesis is positioned with respect to our current knowledge of the phenomenon and the relevant theoretical issues. Chapter 2 introduces the data used to address these objectives. Pre-aspiration is usually considered as consisting of a voiced glottal component, or breathiness, and a voiceless glottal component, or voiceless pre-aspiration, and these are treated as a single unit in a number of analyses (Helgason 2003; Helgason & Ringen 2008; Karlsson & Svantesson 2011; Morris 2010; Ringen & van Dommelen 2013; Stevens & Hajek 2004b, 2004c; Stevens 2010, 2011). Chapter 3 shows that this is not adequate because distinguishing the two enables us to discover patterns that would remain obscured otherwise – such as breathiness being a possible precursor to pre-aspiration. This is demonstrated through the segmental and prosodic conditioning of pre-aspiration and breathiness. Chapter 4 shows that although pre-aspiration is not an obligatory feature of Aberystwyth English (in the sense that it would occur in 100% of time where it can), it nevertheless forms two clear categories sensitive to phonological rather than phonetic vowel height. However, phonological vowel height on its own cannot explain these two categories and interacts with a number of other conditioning factors. Whilst Chapter 3 investigates the relationship between pre-aspiration and breathiness, Chapter 5 looks into that of pre-aspiration and glottalisation and demonstrates that the two can occur in the same environment, which enlightens the debates related to the historical connections between pre-aspiration and glottalisation in particular (e.g. Kortland 1988). It furthermore reveals that although it is not known why they are co-occurring for some speakers and mutually exclusive or allophonic for others, their relationship is conditioned prosodically and not segmentally. Chapter 6 illustrates that pre-aspiration is an acoustic correlate of the fortis-lenis contrast in plosives in production at least equally well as breathiness, voicing, release duration, or the duration of the preceding vowel, and better than voiceless closure duration, glottalisation, or f0 before or after the plosive in question in the word-medial (cotter [khɒhtsə] ~ codder [khɒdə]) and the word-final positions (cot ~ cod). It is therefore at least as important as the other four correlates. Chapter 7 finds that pre-aspiration also exhibits social conditioning. Females pre-aspirate more frequently than males, which is often found in pre-aspiration studies, but this difference disappears as the age decreases. Furthermore, the frequency of breathiness, and the duration of pre-aspiration and breathiness are not conditioned by gender. However, all four variables are affected by age. Pre-aspiration thus seems to be undergoing an advancing sound change according to Labov’s Principle II (2001: 292) and breathiness seems to be its precursor. Chapter 8 summarises the results and outlines questions for further research.

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The goal of antibiotic stewardship is to improve antibiotic use, often by reducing unnecessary treatment. Bedside dysphagia screening tools help identify patients at high risk of aspiration following stroke. Presence of dysphagia does not indicate a need for antibiotic treatment. Therefore, this retrospective, cohort study was developed to evaluate the association of dysphagia and antibiotic prescribing following stroke. There were 117 patients included. Patients were placed into 2 cohorts based on the results of the dysphagia screening, with 55 patients positive for dysphagia and 62 patients negative for dysphagia. Patients with dysphagia tended to be older, had higher National Institutes of Health stroke scores, and lower renal function. Patients with dysphagia were prescribed more empiric antibiotics than those without dysphagia (18.2% vs. 3.2%, p = 0.01). This resulted in 53 antibiotic days of therapy in the dysphagia cohort compared to 19 antibiotic days of therapy in the no dysphagia cohort (p = 0.1). No patients later developed pneumonia and only one patient was started antibiotics after 48 h. Two cases of Clostridioides difficile were reported. Both patients were in the dysphagia cohort and received antibiotics. Multivariable logistic regression demonstrated that positive chest x-ray findings and failed dysphagia screen were independent conditions associated with initiating antibiotics. These findings indicate that antibiotic use was higher in patients following stroke with a positive dysphagia screen. Close monitoring of stroke patients, particularly when positive for dysphagia, might be an under-recognized antibiotic stewardship opportunity.

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The aspiration of oral and gastric substances is a well-known risk for ventilator associated pneumonia (VAP) in the intubated, mechanically ventilated (MV), patient of the intensive care unit (ICU) population. The gastric biomarker pepsin and the oral biomarker salivary amylase have been identified as evidence of aspiration prior to the manifestation of acute pulmonary illness. In an effort to decrease the risk for aspiration, several evidence based nursing practices are in place. Actions include 30 degree head of the bed positioning, oral care, suctioning, and circuit change interval protocols, as well as the administration of medication with the objective of reducing acid reflux. Additional recommendations concern the type of endotracheal tube (ETT) used to ventilate the intubated patient. The continuous subglottic suctioning endotracheal tube (CSS-ETT) features an additional port which continually suctions secretions that accumulate above the inflated endotracheal cuff. Patients with standard endotracheal tubes (S-ETT) receive manual, as needed suctioning of accumulated secretions in the mouth and the oropharynx per agency protocol. Research of the critical care population has demonstrated a decreased instance of VAP using CSS-ETT as compared to S-ETT utilization. This study sought to compare the incidence of the biomarkers pepsin and salivary amylase in the suctioned oral and tracheal secretions of patients with S-ETT compared to patients with CSS-ETT. Part of the protocol of a descriptive, comparative study of the clinical indicators for suctioning established the collection of the paired suctioned oral and tracheal aspirates. Those collected aspirates were analyzed for a pilot study of pepsin and amylase analysis. This study compares the incidence of aspirates in oral and tracheal secretions by endotracheal tube type.; The intention of this study was that it would assist in demonstrating beneficial aspects of the selection of the CSS-ETT. It is considered that further investigation with a larger population group could add statistical significance.; Tracheal aspirates were obtained with a closed tracheal suction device while oral secretions were obtained with a suction catheter designed to reach the oropharynx. Biomarkers assayed were the gastric marker pepsin and the oropharyngeal marker salivary amylase. Assays of pepsin and salivary amylase were performed using standard procedures in a specialty diagnostic laboratory. Specimens were obtained from 11 subjects: 8 male and 3 female. The majority were Caucasian (n=9), had a CSS-ETT (n=8), were on mechanical ventilation in the synchronized intermittent mandatory ventilation mode, and on tube feedings (n=9) located in the stomach (n=7). The mean age was 56 years. Feeding tubes were placed in 9 patients, and the majority of the tubes were Dobbhoff. Pepsin was found in the oral secretions of 62.5% (n = 5) of the CSS-ETT subjects, while 50.0% (n = 4) had pepsin in the tracheal aspirate. Pepsin was found in the oral secretions of 66.7% (n = 2) of the S-ETT subjects, and 66.7% (n = 2) had pepsin in their tracheal aspirate. All subjects of both groups (n = 11) had oral salivary amylase detected. Salivary amylase was detected in the tracheal aspirate of 100% (n = 3) of the S-ETT subjects versus 62.5% (n = 5) in CSS-ETT group. Based on the results of this study, there was a reduction in the number of subjects who had oral compared to tracheal aspirate pepsin in the CSS-ETT group (n = 5 oral versus n = 4 tracheal) tube type. The S-ETT group had equal number of subjects with oral (n = 2) and tracheal pepsin detected (n = 2). However, the results when comparing the S-ETT and the CSS-ETT groups were not statistically significant (p = 0.898 pepsin oral and 0.621 tracheal pepsin). There may be clinical significance. It appears that the CSS-ETT was beneficial in that group; two fewer subjects had pepsin in their tracheal aspirate (n = 5 oral versus n = 4 tracheal aspirate pepsin).

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