Drooling in Parkinson's Disease: Evidence of a Role for Divided Attention

Drooling is a frequently reported symptom in Parkinson's Disease (PD) with significant psychosocial impact and negative health consequences including silent aspiration of saliva with the associated risk of respiratory infections. It is suggested that in PD drooling is associated with inefficient oropharyngeal swallowing which reduces the effective clearance of saliva rather than hyper-salivation. This is compounded by unintended mouth opening and flexed posture increasing anterior loss of saliva. It is reported to occur most frequently during cognitively distracting concurrent tasks suggesting an impact from divided attention in a dual-task situation. However, this supposition has not been systematically examined. This study assessed whether frequency of saliva swallows reduced, and drooling severity and frequency increased, when people with PD engaged in a cognitively distracting task. 18 patients with idiopathic PD reporting daytime drooling on the Unified Parkinson's Disease Rating Scale (UPDRS) were recruited. They completed the Radboud Oral Motor Inventory for PD saliva questionnaire and the Montreal Cognitive Assessment. UPDRS drooling score, disease stage, duration, gender, and age were recorded. Swallow frequency and drooling severity and frequency were measured at rest and during a distracting computer-based language task. There was no significant difference between drooling severity at rest and during distraction (Wilcoxon signed rank test z = - 1.724, p = 0.085). There was a significant difference between at rest and distraction conditions for both drooling frequency (Wilcoxon signed rank test z = - 2.041, p = 0.041) and swallow frequency (Wilcoxon signed rank test z = - 3.054, p = 0.002). Participants swallowed less frequently and drooled more often during the distraction task. The frequency of saliva swallows and drooling are affected by divided attention in a dual-task paradigm. Further studies are needed to explore the exact role of attention in saliva management and the clinical applications in assessment and treatment.

Abstract P4-15-05: The presence of one or multiple foci of microinvasion is not associated with an increased risk of local recurrence in women with ductal carcinoma in situ treated with breast conserving therapy

Background: Ductal Carcinoma in Situ (DCIS) is a non-invasive breast cancer often treated with breast-conserving surgery (BCS) with or without radiotherapy (RT). It is unclear if the presence of microinvasion (MI) (invasion ≤1mm) is associated with an increased risk of LR (DCIS or invasive) or invasive LR compared to women with pure DCIS. In addition, the impact of multiple foci (>2) of MI compared to pure DCIS is also unknown; therefore, it is unclear if some women with MI require more aggressive treatment. We evaluated the impact of the presence of MI and the number of foci of MI on the risks of any LR and invasive LR in a population of women with DCIS with and without MI treated with BCS.

Methods: The cohort includes all women diagnosed with pure DCIS or DCIS with MI in Ontario from 1994-2003 treated with BCS +/- RT. All cases had systematic pathology review to confirm the presence and number of foci of MI. Treatment and outcomes were ascertained through administrative databases and validated by chart review. Cox proportional hazards model was used to evaluate the impact of MI and the number of foci of MI (1 vs >2 foci) on the development of any LR and invasive LR compared to cases with pure DCIS. The 10-yr local recurrence-free survival (LRFS) and invasive LRFS rates were calculated using the Kaplan-Meier approach with differences compared using the log-rank test.

Results: The population cohort includes 2,988 women with DCIS treated by BCS (N=2,721 pure DCIS, N= 267 DCIS with MI). Median follow-up (12 years; p=.23) and median age at diagnosis (58 years; p=.17) were similar in both groups. RT was given in 58% of cases with MI and 51% of cases with pure DCIS (p=.03). Hormonal therapy was utilized in 7.1% of women with MI and 5.3% of women with pure DCIS (p=.22). LR developed in 59 (22.1%) cases with MI and 530 (19.6%) cases of pure DCIS. Women with MI were more likely to have high nuclear grade (p<.001), and larger tumor size (p<.001) compared to those without MI. On multivariable analyses adjusted for age, the presence of 1 focus of MI(HR=.92, 95% CI: .64-1.33) or ≥2 foci of MI (HR=1.26, 95% CI: .85-1.85) was not associated with an increased risk of any LR compared to cases with pure DCIS. Factors associated with any LR were age <50 years at diagnosis, RT, multifocality and high nuclear grade. The presence of 1 focus of MI (HR=.86, 95% CI: .52-1.40) or > 2 foci of MI (HR=1.45, 95% CI: .90-2.32) was also not associated with an increased risk of invasive LR compared to cases of pure DCIS. Among women treated with BCS alone, the 10 year LRFS rates were 80%, 75% and 73% for women with pure DCIS, 1 focus, >2 foci of MI (p=.10). The invasive LRFS rates were 89%, 91% and 85% (p=.26). Among women treated with BCS+RT, the 10 year LRFS rates were 87%, 88% and 80% (p=0.32) for women with pure DCIS, 1 focus or ≥2 foci of MI. The invasive LRFS rates were 93%, 90% and 86% (p=.44). There was no interaction between the presence of MI and RT.

Conclusions: Women with DCIS with one or multiple foci of microinvasion (<1mm) treated by breast conserving therapy do not have an increased risk of LR or invasive LR compared to women with pure DCIS.

Citation Format: Lalani N, Paszat L, Sutradhar R, Gu S, Fong C, Nofech-Mozes S, Hanna W, Tuck A, Youngson B, Miller N, Done SJ, Chang MC, Sengupta S, Elavathil L, Jani PA, Bonin M, Rakovitch E. The presence of one or multiple foci of microinvasion is not associated with an increased risk of local recurrence in women with ductal carcinoma in situ treated with breast conserving therapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-15-05.

Abstract P2-12-02: Is breast-conserving therapy effective in women with large ductal carcinoma in situ (DCIS) lesions? A population-based analysis

Background: Most women diagnosed with DCIS will be treated by breast-conserving surgery (BCS) with or without radiotherapy (RT). Data on outcomes following breast-conserving therapy are predominantly based on women with small (<25mm) lesions. The paucity of data on outcomes of women with larger (>40mm) DCIS lesions leads to uncertainty of the appropriateness of breast-conserving therapy for women with larger lesions. Specifically, it is unclear if women with large tumors experience higher risks of local recurrence (LR) and invasive LR after BCS+/-RT that would preclude recommendations of breast-conserving therapy. We report the outcomes and evaluate the impact of large tumor size (>40mm) on recurrence risk in a population of women with pure DCIS treated by BCS alone or with RT.

Methods: The cohort includes all women diagnosed with DCIS in Ontario from 1994-2003 treated with BCS +/- RT; 82% had pathology review. Treatment and outcomes were ascertained through administrative databases and validated by chart review. Cox proportional hazards model was used to evaluate the impact of tumor size (≤10mm,11-25mm, 26-39mm, ≥40mm) on the development of any LR (DCIS or invasive) and invasive LR. The 10 and 15-year LR-free survival (LRFS) and invasive LRFS rates were calculated using the Kaplan-Meier method with differences compared using the log-rank test.

Results: The cohort includes 3262 women with DCIS treated by BCS (N=1635 had RT). Median age at diagnosis was 59 years (IQR 50-68 years). Median follow-up was 13 years (IQR 8-15 years). Distribution of tumor size: 707 (22%) ≤10mm, 524 (16%) 11-25mm, 107 (3%) 26-39mm, 84 (3%) ≥40mm, unable to determine in 1840 (56%). Women with lesions ≥ 40mm were more likely to be ≤50 years of age at diagnosis (p=.02), have high nuclear grade (p<.001), multifocality (p<.001), and positive margins (p<.001) compared to women with smaller lesions. On multivariable analyses adjusted for age and year of diagnosis, tumor size ≥40mm was significantly associated with an increased risk of LR compared to size ≤10mm (HR=2.5, 95%CI:1.64-3.81). Other factors associated with LR were age <50 years (p<.001), omission of RT (p<.001), high nuclear grade (p=.002), and multifocality (p=.0008). Tumor size ≥40mm was not significantly associated with an increased risk of invasive LR (HR=1.68, 95%CI:.94-3.04). Women with tumour size ≥40mm treated with BCS alone had lower 10 and 15 year LRFS (53% and 41%) and invasive LRFS rates (78% and 75%) compared to women with smaller lesions. However, women with larger lesions treated with RT had significantly higher LRFS and invasive LRFS rates

Outcomes by tumour size for women with DCIS treated with BCS with or without RT  ≤10mm N=70711-25mm N=52426-39mm N=107≥40mm N=84p-valueBCS AloneLRFS (%)      10 yr85797053<0.001 15 yr81746741  Invasive LRFS (%)      10 yr928786780.03 15 yr89838375 BCS + RTLRFS (%)      10 yr928874850.01 15 yr86847079  Invasive LRFS (%)      10 yr959492910.27 15 yr90918789 

. There was a significant interaction between tumor size ≥40mm and RT (p=.02).

Conclusions: Women with DCIS lesions ≥40mm treated by BCS alone experience significantly higher risks of LR and invasive LR compared to smaller lesions but this risk can be mitigated with the addition of RT.

Citation Format: Lalani N, Paszat L, Nofech-Mozes S, Sutradhar R, Gu S, Hanna W, Fong C, Miller N, Youngson B, Done SJ, Tuck A, Chang MC, Sengupta S, Jani PA, Bonin M, Rakovitch E. Is breast-conserving therapy effective in women with large ductal carcinoma in situ (DCIS) lesions? A population-based analysis [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-12-02.

Vocal tract characteristics in Parkinson's disease

PURPOSE OF REVIEW

Voice tremor is strongly linked to the Parkinson's disease speech-voice symptom complex. Little is known about the underlying anatomic source(s) of voice tremor when it occurs. We review recent literature addressing this issue. Additionally we report findings from a study we conducted employing rating of vocal tract structures viewed using nasolaryngoscopy during vocal and nonspeech tasks.

RECENT FINDINGS

In Parkinson's disease, using laryngeal electromyography, tremor has not been identified in muscles in the vocal folds even when perceived auditorily. Preliminary findings using nasolaryngoscopy suggest that Parkinson's disease voice tremor is not associated with the vocal folds and may involve the palate, the global larynx, and the arytenoids. Tremor in the vertical larynx on /a/, and tremor in the arytenoid cartilages on /s/ differentiated patients with Parkinson's disease from neurologically healthy controls. Visual reliable detection of tremor when it is absent or borderline present, is challenging.

SUMMARY

Parkinson's disease voice tremor is likely to be related to oscillatory movement in structures across the vocal tract rather than just the vocal folds. To progress clinical practice, more refined tools for the visual rating of tremor would be beneficial. How far voice tremor represents a functionally significant factor for speakers would also add to the literature.

Is there an order of loss of sounds in speakers with Parkinson's disease?

Influential reports on speech changes in people with Parkinson's disease (PD; Logemann et al., 1978, 1981) reported a posterior to anterior pattern of loss of speech sound accuracy. These claims have never been examined. In a partial replication of Logemann et al.'s work, we examined whether posterior lingual sounds are most affected in people with Parkinson's disease, followed by anterior lingual sounds and then labial sounds. Ninety-nine people with PD (age: mean 70.7, SD 8.46; time since diagnosis: mean 6.97, SD 6.2) with mild to severe overall motor symptoms (Hoehn and Yahr stages 1-5, median 2.5) completed a diagnostic intelligibility test. This was scored by 60 listeners unfamiliar with PD and dysarthric speech. We calculated the proportion of posterior versus anterior lingual versus labial sounds misrecognized by the listeners. We compared profiles of misperceived sounds within and across Hoehn and Yahr stages of severity and in relation to Unified Parkinson's Disease Rating Scale (UPDRS) and speech intelligibility scores. Speech accuracy declined significantly in relation to overall motor impairment for labial and anterior lingual sounds but not for velar sounds. Speech sound accuracy was strongly associated with intelligibility outcomes (p = < 0.01). Contrary to previous assertions, there was no evidence supporting the existence of a posterior to anterior order of 'loss' of oral speech sounds in people with PD, nor an interaction of anterior-posterior speech profile changes with Hoehn and Yahr stage. Findings support the notion that a common underlying impairment of movement downscaling affects all sounds similarly and simultaneously in PD from the start.

Acoustic changes in the speech of children with cerebral palsy following an intensive program of dysarthria therapy

BACKGROUND

The speech intelligibility of children with dysarthria and cerebral palsy has been observed to increase following therapy focusing on respiration and phonation.

AIMS

To determine if speech intelligibility change following intervention is associated with change in acoustic measures of voice.

METHODS & PROCEDURES

We recorded 16 young people with cerebral palsy and dysarthria (nine girls; mean age 14 years, SD = 2; nine spastic type, two dyskinetic, four mixed; one Worster-Drought) producing speech in two conditions (single words, connected speech) twice before and twice after therapy focusing on respiration, phonation and rate. In both single-word and connected speech we measured vocal intensity (root mean square-RMS), period-to-period variability (Shimmer APQ, Jitter RAP and PPQ) and harmonics-to-noise ratio (HNR). In connected speech we also measured mean fundamental frequency, utterance duration in seconds and speech and articulation rate (syllables/s with and without pauses respectively). All acoustic measures were made using Praat. Intelligibility was calculated in previous research.

OUTCOMES & RESULTS

In single words statistically significant but very small reductions were observed in period-to-period variability following therapy: Shimmer APQ -0.15 (95% CI = -0.21 to -0.09); Jitter RAP -0.08 (95% CI = -0.14 to -0.01); Jitter PPQ -0.08 (95% CI = -0.15 to -0.01). No changes in period-to-period perturbation across phrases in connected speech were detected. However, changes in connected speech were observed in phrase length, rate and intensity. Following therapy, mean utterance duration increased by 1.11 s (95% CI = 0.37-1.86) when measured with pauses and by 1.13 s (95% CI = 0.40-1.85) when measured without pauses. Articulation rate increased by 0.07 syllables/s (95% CI = 0.02-0.13); speech rate increased by 0.06 syllables/s (95% CI = < 0.01-0.12); and intensity increased by 0.03 Pascals (95% CI = 0.02-0.04). There was a gradual reduction in mean fundamental frequency across all time points (-11.85 Hz, 95% CI = -19.84 to -3.86). Only increases in the intensity of single words (0.37 Pascals, 95% CI = 0.10-0.65) and reductions in fundamental frequency (-0.11 Hz, 95% CI = -0.21 to -0.02) in connected speech were associated with gains in intelligibility.

CONCLUSIONS & IMPLICATIONS

Mean reductions in impairment in vocal function following therapy observed were small and most are unlikely to be clinically significant. Changes in vocal control did not explain improved intelligibility.

Investigating the association of rs2910164 with cancer predisposition in an Irish cohort

INTRODUCTION

MicroRNAs (miRNAs) are small noncoding RNA molecules that exert post-transcriptional effects on gene expression by binding with cis-regulatory regions in target messenger RNA (mRNA). Polymorphisms in genes encoding miRNAs or in miRNA-mRNA binding sites confer deleterious epigenetic effects on cancer risk. miR-146a has a role in inflammation and may have a role as a tumour suppressor. The polymorphism rs2910164 in the MIR146A gene encoding pre-miR-146a has been implicated in several inflammatory pathologies, including cancers of the breast and thyroid, although evidence for the associations has been conflicting in different populations. We aimed to further investigate the association of this variant with these two cancers in an Irish cohort.

METHODS

The study group comprised patients with breast cancer (BC), patients with differentiated thyroid cancer (DTC) and unaffected controls. Germline DNA was extracted from blood or from saliva collected using the DNA Genotek Oragene 575 collection kit, using crystallisation precipitation, and genotyped using TaqMan-based PCR. Data were analysed using SPSS, v22.

RESULTS

The total study group included 1516 participants. This comprised 1386 Irish participants; 724 unaffected individuals (controls), 523 patients with breast cancer (BC), 136 patients with differentiated thyroid cancer (DTC) and three patients with dual primary breast and thyroid cancer. An additional cohort of 130 patients with DTC from the South of France was also genotyped for the variant. The variant was detected with a minor allele frequency (MAF) of 0.19 in controls, 0.22 in BC and 0.27 and 0.26 in DTC cases from Ireland and France, respectively. The variant was not significantly associated with BC (per allele odds ratio = 1.20 (0.98-1.46), P  = 0.07), but was associated with DTC in Irish patients (per allele OR = 1.59 (1.18-2.14), P = 0.002).

CONCLUSION

The rs2910164 variant in MIR146A is significantly associated with DTC, but is not significantly associated with BC in this cohort.

Intonation patterns in older children with cerebral palsy before and after speech intervention

PURPOSE

This paper examined the production of intonation patterns in children with developmental dysarthria associated with cerebral palsy (CP) prior to and after speech intervention focussing on respiration and phonation. The study further sought to establish whether intonation performance might be related to changes in speech intelligibility.

METHOD

Intonation patterns were examined using connected speech samples of 15 older children with moderate to severe developmental dysarthria due to CP (9 females; age range: 11-18). Recordings were made prior to and after speech intervention based on a systems approach. Analyses are focussed on the use of intonation patterns, pitch accentuation and phrasing.

RESULT

Group analyses showed a significant increase in the use of rising intonation patterns after intervention. There were also some indications that this increase might have been related to gains in speech intelligibility for some of the children. No changes were observed regarding pitch accentuation and phrasing following intervention.

CONCLUSION

The findings highlight that changes can occur in the use of intonation patterns in children with dysarthria and CP following speech systems intervention. It is hypothesised that the emergence of the rising pattern in some of the children's intonational inventories possibly reflected improved breath support and control of laryngeal muscles.

Swallowing in Parkinson's disease: clinical issues and management

Changes to swallowing affect most people with Parkinson's disease (PD). Changes may not initially exercise a decisive impact, but can later pose significant threats to nutritional, hydration and respiratory health and psychosocial quality of life. This review, from a largely clinical viewpoint, outlines the nature of changes in PD and considers the issue of how many people are affected and in what ways. It outlines main approaches to assessment and management, with an emphasis on aspects relevant to PD. Dysphagia contributes to drooling in PD. The review therefore also touches on the nature and management of this condition that has its own set of health and psychosocial quality-of-life issues.

Utility and accuracy of perceptual voice and speech distinctions in the diagnosis of Parkinson’s disease, PSP and MSA-P

Aim: To determine if perceptual speech measures distinguish people with Parkinson’s disease (PD), multiple system atrophy with predominant parkinsonism (MSA-P) and progressive supranuclear palsy (PSP). Methods: Speech–language therapists blind to patient characteristics employed clinical rating scales to evaluate speech/voice in 24 people with clinically diagnosed PD, 17 with PSP and 9 with MSA-P, matched for disease duration (mean 4.9 years, standard deviation 2.2). Results: No consistent intergroup differences appeared on specific speech/voice variables. People with PD were significantly less impaired on overall speech/voice severity. Analyses by severity suggested further investigation around laryngeal, resonance and fluency changes may characterize individual groups. Conclusion: MSA-P and PSP compared with PD were distinguished by severity of speech/voice deterioration, but individual speech/voice parameters failed to consistently differentiate groups.

Abstract P3-17-01: Long-term rates of breast preservation after breast-conserving therapy for ductal carcinoma in situ

Background: Despite evidence that radiotherapy (RT) after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) halves the risk of recurrence, the benefit of RT in the management of DCIS continues to be a matter of controversy. One argument against the use of RT after BCS is that patients who develop ipsilateral local recurrence (LR) can be salvaged with further breast-conserving surgery such that the omission of RT will lead to high rates of breast preservation while minimizing exposure to RT. Breast preservation is an important determinant of quality of life for women with early stage breast cancer and DCIS. Yet the management of LR and the impact of RT on the resultant long-term risks of bilateral breast preservation in a population of women with DCIS are unclear. We assessed the treatment of LR, the impact of RT on the use of salvage mastectomy and the long-term risks of bilateral breast preservation achieved in a population of women with DCIS treated with BCS alone or BCS+RT.

Methods: A population-based analysis of women diagnosed with DCIS from 1994-2003 treated with BCS alone or BCS+RT with pathology review. Treatment and outcomes, including the development of LR and contralateral breast events, were determined by administrative databases with validation by review of operative or pathology reports. Median follow-up was 10.2 years for cases treated by BCS alone, 11.6 years for those treated by BCS+RT. We used a propensity-adjusted Cox proportional hazards model to evaluate factors associated with the use of salvage mastectomy for LR and to evaluate factors associated with any mastectomy. We assessed the risk of long-term breast preservation by calculating the KM 10-year risk of ipsilateral mastectomy and any mastectomy.

Results: The population cohort includes 3303 women with pure DCIS;1649 (50%) were treated by BCS alone, 1654 (50%) received BCS+RT. Women treated with RT had more high risk features of DCIS than those treated by BCS alone. LR developed in 343 (21%) women treated by BCS alone and in 257 (15.5%) women treated by BCS+RT (p&lt;0.01). Most women who developed LR received salvage mastectomy, irrespective of age at diagnosis and histology. Salvage mastectomy was used in 57.4% (197/343) of cases that recurred after BCS alone and in 67.6% (173/257) that recurred after BCS+RT. The likelihood of receiving salvage mastectomy for LR was similar in patients initially treated by BCS+RT vs. those initially treated BCS alone. Most (90%) of mastectomies were performed for a LR. Overall, individuals initially treated by BCS+RT had a 29% lower probability of having a mastectomy at 10 years compared to those treated by BCS alone (HR=0.71, 95%CI: 0.60,0.84,p&lt;0.0001). The 10 year mastectomy-free survival rates are 82.7% for women initially treated by BCS alone and 87.3% for those treated by BCS+RT (p=0.0096).

Conclusion: Women who received RT after BCS for DCIS experience a greater likelihood of long-term bilateral breast preservation. This is attributable to the lower risks of LR and that most local recurrences after breast-conserving therapy are treated by salvage mastectomy. Long-term breast preservation should be considered in discussions weighing the benefits and risks of RT after conservative surgery for DCIS.

Citation Format: Rakovitch E, Nofech-Mozes S, Hanna W, Gu S, Fong C, Tuck A, Sengupta S, Elavathil L, Jani P, Done S, Miller N, Youngson B, Bonin M, Chang M, Paszat L. Long-term rates of breast preservation after breast-conserving therapy for ductal carcinoma in situ [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-17-01.