慢性卒中后吞咽障碍中神经功能严重程度和全身生化标志物与向经口进食过渡的关系

文献信息

中文摘要

背景： 卒中后吞咽障碍与吸入性肺炎、营养不良和功能结局不良相关。尽管卒中后全身生化异常常见，但其对吞咽恢复和向经口进食过渡的贡献仍不清楚。本研究探讨了慢性卒中后吞咽障碍患者全身生化标志物与经口进食过渡及吞咽相关功能改善之间的关联。方法：这项回顾性单中心研究纳入了2023年2月至2025年12月期间接受肠内营养的89例慢性卒中后吞咽障碍患者。回顾性分析生化参数和吞咽结局，吞咽结局采用功能性经口摄入量表（FOIS）和渗透-误吸量表（PAS）评估。计算基线（T0）与随访（T1）之间的变化（Δ = T1 - T0）。采用多变量logistic和线性回归分析，以确定向经口进食过渡和误吸严重程度改善的独立预测因素。结果：89例患者中，52例（58.4%）实现了经口进食。康复后观察到吞咽功能显著改善，表现为FOIS评分升高以及PAS-软食和PAS-液体评分降低（均p < 0.001），同时CRP（C反应蛋白）、D-二聚体、白细胞计数和中性粒细胞计数降低（均p < 0.05）。实现经口进食的患者表现出更大的PAS评分改善（均p < 0.001），并且维生素B12水平变化呈分化趋势（过渡者下降，而仍接受肠内喂养者升高）（p = 0.049）。在探索性多变量分析中，较高的NIHSS（美国国立卫生研究院卒中量表）评分和较低的基线25-羟基维生素D水平与向经口进食过渡的可能性较低相关（NIHSS OR = 0.78，p = 0.031；维生素D OR（比值比）= 1.12，p = 0.001），而基线PAS-液体评分不是过渡的独立预测因素。在误吸严重程度的线性回归分析中，基线PAS-液体评分是ΔPAS-液体的最强预测因素（B = -0.527，p = 0.001），而较低的基线25-羟基维生素D与改善较少相关（B = -0.021，p = 0.047）。鉴于样本量有限且未进行多重比较校正，这些生化关联应解释为探索性。结论：在慢性卒中后吞咽障碍患者中，向经口进食过渡主要与神经功能严重程度相关，而误吸严重程度的改善与基线误吸负担关系最强。较低的基线25-羟基维生素D与这两种结局均显示出探索性关联。由于25-羟基维生素D在随访期间没有显著变化，且模型把握度不足，这种关联应被视为产生假设，而非临床已确立。这些生化发现需要在更大规模的前瞻性研究中得到证实。

英文摘要

Background: Post-stroke dysphagia is associated with aspiration pneumonia, malnutrition, and poor functional outcomes. Although systemic biochemical abnormalities are common after stroke, their contribution to swallowing recovery and transition to oral feeding remains unclear. This study investigated the association of systemic biochemical markers with oral feeding transition and swallowing-related functional improvement in patients with chronic post-stroke dysphagia. Methods: This retrospective single-center study included 89 patients with chronic post-stroke dysphagia who received enteral nutrition between February 2023 and December 2025. Biochemical parameters and swallowing outcomes, assessed using the Functional Oral Intake Scale (FOIS) and Penetration-Aspiration Scale (PAS), were retrospectively analyzed. Changes between baseline (T0) and follow-up (T1) were calculated (Δ = T1 - T0). Multivariable logistic and linear regression analyses were performed to identify independent predictors of transition to oral feeding and improvement in aspiration severity. Results: Of the 89 patients, 52 (58.4%) achieved oral feeding. Significant improvements in swallowing function were observed following rehabilitation, as reflected by increased FOIS scores and decreased PAS-soft and PAS-liquid scores (all p < 0.001), together with reductions in CRP (C-reactive protein), D-dimer, white blood cell count, and neutrophil count (all p < 0.05). Patients who achieved oral feeding demonstrated greater improvements in PAS scores (both p < 0.001) and a divergent change in vitamin B12 levels (a decrease among those who transitioned versus an increase among those who remained enterally fed) (p = 0.049). In exploratory multivariable analyses, higher NIHSS (National Institutes of Health Stroke Scale) scores and lower baseline 25-hydroxyvitamin D levels were associated with a lower likelihood of transition to oral feeding (NIHSS OR = 0.78, p = 0.031; vitamin D OR (Odds ratio) = 1.12, p = 0.001), whereas baseline PAS-liquid score was not an independent predictor of transition. In the linear regression analysis of aspiration severity, baseline PAS-liquid score was the strongest predictor of ΔPAS-liquid (B = -0.527, p = 0.001), while lower baseline 25-hydroxyvitamin D was associated with less improvement (B = -0.021, p = 0.047). Given the limited sample size and the absence of correction for multiple comparisons, the biochemical associations should be interpreted as exploratory. Conclusions: In patients with chronic post-stroke dysphagia, transition to oral feeding was primarily associated with neurological severity, whereas improvement in aspiration severity was most strongly related to baseline aspiration burden. Lower baseline 25-hydroxyvitamin D showed exploratory associations with both outcomes. Because 25-hydroxyvitamin D did not change significantly during follow-up and the models were underpowered, this association should be regarded as hypothesis-generating rather than clinically established. These biochemical findings require confirmation in larger prospective studies.