The effect of aspirated barium sulfate, iodixanol, and diatrizoic acid on survival and lung injury in a lagomorph model

Usefulness of barium sulfate and iohexol as contrast agents for VFSS in visualizing components of swallowing predictable of poor outcomes

Barium sulfate and iohexol are commonly used as contrast agents for videofluoroscopic swallowing study (VFSS). This study compared their usefulness as contrast agents in visualizing components of swallowing predictable of subsequent pneumonia and unintentional weight loss after VFSS. This was a randomized, controlled, crossover trial. The two contrast agents were alternately used in the same participants, and the order in which the contrast agent was tested first was randomly assigned. After VFSS, we followed the participants for 3 months and the association between VFSS findings of each contrast agent and the subsequent pneumonia and unintentional weight loss were analyzed. A total of 30 participants were included in the analysis. We recorded 11 cases of subsequent pneumonia and 13 of unintentional weight loss. Regarding the risk of subsequent pneumonia after VFSS, only the oral transit time and number of swallows tested with barium sulfate indicated significant differences between participants with and without subsequent pneumonia. For unintentional weight loss, oral transit time and pharyngeal wall coating after swallowing tested with barium sulfate, as well as oral transit time, nasal penetration, residue in the valleculae, PAS scores, and number of swallows when testing with iohexol demonstrated significant differences between those with and without unintentional weight loss.

Omission of intraoperative pyloric procedures in minimally invasive esophagectomy: assessing the impact on patients

Pyloroplasty or pyloromyotomy is often undertaken during esophagectomy to aid gastric emptying postoperatively. Minimally invasive esophagectomy (MIE) frequently omits a pyloric procedure. The impact on perioperative outcomes and the need for subsequent interventions is unclear. This study assesses the requirements for endoscopic balloon dilation of the pylorus (EPD) following MIE. Patients undergoing MIE from 2016 to 2020 were reviewed. Patients undergoing open resection, or an intraoperative pyloric procedure were excluded. Demographic, clinical and pathological data were reviewed. Univariable and multivariable analysis were performed as appropriate. In total, 171 patients underwent MIE. There were no differences in age (median 65 vs. 65 years, P = 0.6), pathological stage (P = 0.10) or ASA status (P = 0.52) between those requiring and not requiring endoscopic pyloric dilation (EPD). Forty-three patients (25%) required EPD, with a total of 71 procedures. Twenty-seven patients (16%) had EPD on their index admission. Seventy-five patients (43%) had a postoperative complication. Higher ASA status was associated with increased requirement for EPD (odds ratio 10.8, P = 0.03). On multivariable analysis, there was no association between the need for a pyloric procedure and overall survival (P = 0.14). Eight patients (5%) required insertion of a feeding jejunostomy in the postoperative period, with no difference between those with or without EPD (P = 0.11). Two patients required subsequent surgical pyloromyotomy for delayed gastric emptying. Although pyloroplasty or pyloromyotomy can safely be excluded during MIE, a quarter of patients will require postoperative EPD procedures. The impact of excluding pyloric procedures on gastric emptying requires further study.

Hydrogen-rich and hyperoxygenate saline inhibits lipopolysaccharide-induced lung injury through mediating NF-κB/NLRP3 signaling pathway in C57BL/6 mice

BACKGROUND

Background: Acute lung injury (ALI) is one kind of frequently occurred emergency in Intensive Care Unite with a high mortality. The underlying causes are uncontrolled inflammatory reactions and intractable hypoxemia, which are difficult to control and improve. In the past 10 years, gas medical studies have found that both hydrogen molecules and oxygen molecules have protective effects on acute lung injury by improving inflammatory reactions and hypoxia, respectively. Oxygen is an oxidant and hydrogen is an antioxidant. In this study, we investigated the combined effect of above two-gas molecular on lipopolysaccharide (LPS) -induced acute lung injury.

METHODS

To clarify whether the combination of hydrogen and oxygen could increase or cancel out the protective effect, an ALI mice model induced by intraperitoneal injection of LPS was established, and the degree of lung tissue and mitochondria damage was evaluated based on the pathological sections, inflammatory factors, wet-dry ratio, bronchoalveolar lavage fluid (BALF). Immunohistochemistry, electron microscopy, western blotting and other detection methods also used to evaluate the therapeutic effect on acute lung injury model.

RESULTS

We observed that the combined protective effect of hydrogen and oxygen was superior to their respective protective effects, and the specific molecular mechanisms of the two therapies might be different.

CONCLUSION

Hydrogen plays a more important role in the inflammatory and anti-apoptosis mechanisms, while oxygen improves hypoxia of the body, and thus, its molecular mechanism may be closely associated to the hypoxia pathways.

Effects of a barium-based additive on gaseous and particulate emissions of a diesel engine

The addition of barium-based additives is one of the main methods used to suppress smoke emissions in non-road diesel engines. Herein, a commercial barium-based additive was added to diesel fuel at the manufacturer's recommended concentration and used in a non-road four-cylinder supercharged diesel engine, without an after-treatment system, in bench experiments. Regulated emissions of the diesel engine were measured, volatile organic compounds (VOCs) and particulate matter (PM) were sampled. The carbonaceous fraction, water-soluble ions and inorganic elements in the PM were analyzed. Results indicated that the additive effectively reduced carbon monoxide (CO), hydrocarbon (HC) and smoke emissions from the engine. A 71% reduction in smoke was observed at the rated working condition, which was the maximum reduction of the three tested conditions. The additive produced a 36% reduction of VOCs at the rated working condition. The proportion of high carbon number hydrocarbons in the VOCs increased while the atmospheric reactivity of the VOCs decreased. The additive suppressed the concentration of organic carbon (OC) and elemental carbon (EC) emissions with a maximum reduction (40%) of total carbon achieved under the rated working condition. After the application of the additive, the concentration of water-soluble ions (Cl^-, SO₄^2-, NO₃^-, Na⁺, K⁺, Ca²⁺, NH₄⁺) and elements (Fe, Mn, S, Ca, Ba) in the PM increased. A trend of increasing Barium content in the PM matched a similar trend of decreasing smoke.

Imaging of postoperative complications following Ivor-Lewis esophagectomy

Postoperative imaging plays a key role in the identification of complications after Ivor-Lewis esophagectomy (ILE). Careful analysis of imaging examinations can help identify the cause of the presenting symptoms and the mechanism of the complication. The complex surgical procedure used in ILE results in anatomical changes that make imaging interpretation challenging for many radiologists. The purpose of this review was to make radiologists more familiar with the imaging findings of normal anatomical changes and those of complications following ILE to enable accurate evaluation of patients with an altered postoperative course. Anastomotic leak, gastric conduit necrosis and pleuropulmonary complications are the most serious complications after ILE. Computed tomography used in conjunction with oral administration of contrast material is the preferred diagnostic tool, although it conveys limited sensitivity for the diagnosis of anastomotic fistula. In combination with early endoscopic assessment, it can also help early recognition of complications and appropriate therapeutic management.

Protective effect of Chrysanthemum morifolium Ramat. ethanol extract on lipopolysaccharide induced acute lung injury in mice

BACKGROUND

To evaluate the effect of Chrysanthemum morifolium Ramat. ethanol extract (CEE) on lipopolysaccharide induced acute lung injury in mice.

METHODS

The ninety C57BL/6 J male mice randomly divided into five groups: control, model and CEE (50, 100, 200 mg/kg) groups for 7 days oral administration. At the last administration, all mice except control were intratracheal instilled with lipopolysaccharide (LPS, 3 mg/kg) for establish the acute lung injury. Then lung histopathologic, lung wet/dry weight, white blood cells, lymphocytes, neutrophils were detected. The pro-inflammation cytokine tumor necrosis factor-α (TNF-α), interleukin (IL)-6, anti-inflammatory cytokine transforming growth factor-β1 (TGF-β1), IL-10 and the marker of antioxides ability total-antioxidant capacity (T-AOC), malondialdehyde (MDA) in lung tissue were measured.

RESULTS

The result showed that CEE could improve lung histopathological injury, reduce the ratio of wet/dry lung weight and lung index, inhibit the increased number of white blood cells, lymphocytes and neutrophils, and reduce the increased levels of TNF-α and IL-6. While CEE also significantly increased the levels of TGF-β1 and IL-10. Furthermore, CEE also markedly increased the activity of T-AOC, and decreased the contents of MDA with a dose-dependent manner.

CONCLUSIONS

The study exhibited that CEE has a potential protective effect on lipopolysaccharide induced acute lung injury in mice, the action mechanism of CEE may through balance of the pro-inflammatory and anti-inflammatory factors, and the oxygen free radicals inhibition.

The Landscape of Videofluoroscopy in the UK: A Web-Based Survey

Videofluoroscopy (VFS) is considered one of the gold-standard assessments of swallowing. Whilst guidelines for the application and conduct of VFS exist, their translation into clinical practice remain challenging. To build a greater understanding on how VFS clinics operate in the UK. A web-based survey was shared with speech and language therapists (SLTs) working in VFS clinics via professional networks and social media from October 2018 to January 2019. 101 responses were received. Two thirds of clinics were SLT-led, with the majority of clinics being run by two SLTs (73.6%) and a radiographer (95.5%) also known as radiologic technologists, diagnostic radiographers and medical radiation technologists. Less than 50% of radiographers had received specialist training. Around half of the clinics used a standard assessment or analysis protocol and 88.1% a rating scale. Set recipes for a range of textures were used in 53.4% of VFS clinics. Barium and water soluble contrasts were used, but only 15.8% knew the concentration of contrast used. The most commonly reported VFS pulse and frame rate was 15 per second. There was evidence of a lack of SLT knowledge regarding technical operation of VFS. Screening times varied from 0.7–10 min (median 3 min, IQR 2.5–3.5). Around 50% of respondents reported quality issues affecting analysis. In a survey of UK SLTs, translation of VFS guidance into practice was found to be limited which may impact on the quality of assessment and analysis. Collaboration with radiology, strengthening of guidelines and greater uptake of specialist training is deemed essential.

Chronic inflammatory response in the rat lung to commonly used contrast agents for videofluoroscopy

Objectives

Contrast agents (CAs) are essential for upper gastrointestinal and videofluoroscopic swallow studies (VFSSs). Recently, we reported that small amounts of Ba aspiration caused severe acute lung inflammation in a rodent model. However, the underlying molecular biological mechanisms of chronic response to CA aspiration remain unclear. The aims of this study were to explore the underlying molecular biological mechanisms of the chronic response to three kinds of CA aspiration on the lung.

Study Design

Animal model.

Methods

Eight‐week‐old male Sprague Dawley rats were divided into five groups (n = 6, each group). Three groups underwent tracheal instillation of one of three CAs: barium sulfate (Ba), ionic iodinated contrast agent (ICA), and nonionic iodinated contrast agent (NICA). A sham group was instilled with air and a control group was instilled with saline. All animals were euthanized 30 days after treatment and histological and gene analyses were performed.

Results

No animal died after CA or sham/control aspiration. Ba particles remained after 30 days and caused histopathologic changes and inflammatory cell infiltration. Iodinated ICA and NICA did not result in perceptible histologic change. Expression of Tnf, an inflammatory cytokine was increased in only Ba aspirated rats (P = .0076). Other inflammatory cytokines and fibrosis‐related genes did not alter between groups.

Conclusion

Aspirated Ba particles did not clear from the lung within a month and caused mild chronic pulmonary inflammation. ICA and NICA did not cause any inflammatory responses in the lungs, suggesting that ICA and NICA may be safer CAs for VFSS than Ba.

Level of Evidence

NA

Delayed emptying of the gastric conduit after esophagectomy

With increasing survival after esophagectomy for cancer, a growing number of individuals living with the functional results of a surgically altered anatomy calls for attention to the effects of delayed gastric conduit emptying (DGCE) on health-related quality of life and nutritional impairment. We here give an overview of the currently available literature on DGCE, in terms of epidemiology, pathophysiology, diagnostics, prevention and treatment. Attention is given to controversies in the current literature and obstacles related to general applicability of study results, as well as knowledge gaps that may be the focus for future research initiatives. Finally, we propose that measures are taken to reach international expert agreement regarding diagnostic criteria and a symptom grading tool for DGCE, and that functional radiological methods are established for the diagnosis and severity grading of DGCE.

Acute inflammatory response to contrast agent aspiration and its mechanisms in the rat lung

Objectives/Hypothesis

Contrast agent (CA) aspiration is an established complication of upper gastrointestinal and videofluoroscopic swallow studies. The underlying molecular biological mechanisms of acute response to CA aspiration in the respiratory organs remain unclear. The aims of this study were to elucidate the histological and biological influences of three kinds of CAs on the lung and to clarify the differences in acute responses.

Study Design

Animal model.

Methods

Eight‐week‐old male Sprague Dawley rats were divided into five groups (n = 6 in each group). Three groups underwent tracheal instillation of one of three different CAs: barium (Ba) sulfate, nonionic contrast agents (NICAs), and ionic contrast agents (ICAs). A control group was instilled with saline and a sham group was instilled with air. All animals were euthanized on day 2 after treatment and histological and gene analysis was performed.

Results

No animal died after CA or control/sham aspiration. Ba caused severe histopathologic changes and more prominent inflammatory cell infiltration in the lungs compared with the two other iodinated contrast agents. Increases in expressions of inflammatory cytokines (tumor necrosis factor [Tnf], interleukin‐1β [Il1b], and interferon‐γ [Ifng]) were observed in Ba aspiration rats, and upregulation of Il1b was seen in ICA aspiration rats. NICA did not cause obvious histologic changes or expressions of inflammatory cytokines and fibrosis‐related genes in the lungs.

Conclusions

Ba caused significantly more acute lung inflammation in a rodent model than did ioinic and nonionic iodinated CAs. Nonionic contrast did not cause any discernible inflammatory response in the lungs, suggesting that it may be the safest contrast for videofluoroscopic swallow studies.

Level of Evidence

NA

Laryngoscope, 129:1533–1538, 2019

An Esophagogram or Tracheobronchogram? A Review of Barium Sulfate Aspiration

The barium swallow is an important radiological investigation used for the diagnosis of upper gastrointestinal anatomical disorders like esophageal cancer, diverticulum, achalasia, foreign body, among others. Generally, it is believed to be a safe technique with rare complications, but few cases of barium sulfate aspiration have been reported in the literature with multiple complications. We are reporting a case of an elderly male who underwent esophagogram for the workup of chronic dysphagia, aspirated barium sulfate, and went into respiratory failure and circulatory shock several hours later. Moreover, we also did a systematic literature search and reviewed all available articles on aspiration of barium sulfate and its potential complications. We focused on predisposing factors for aspiration, clinical presentation, complications after aspiration, and prognosis with the aim to better understand and manage this condition.

A case report and literature review of barium sulphate aspiration during upper gastrointestinal examination

RATIONALE

Even though barium sulphate aspiration during upper gastrointestinal examination is a well-known phenomenon, complication such as long-term lung injury and death may still occur. This may depend upon the concentration, amount, anatomy, or certain predisposing factors.

PATIENT CONCERNS

A 47-year-old woman who had a barium swallow to screen for foreign body in esophagus.

DIAGNOSES

Chest radiographs demonstrated massive barium sulphate depositions in her trachea and inferior lobe of right lung.

INTERVENTIONS

A chest x-ray was done that revealed massive barium sulphate depositions in her trachea and lower lobe of right lung. As the patient did not have further complaints, she requested a transfer to West China Hospital of Sichuan University, the hospital being near her residence, for further treatment. She eventually recovered and was discharged after 1 week.

OUTCOMES

There were 23 articles (22 English and 1 Chinese with 17 men and 11 women) included in the study. The risk factors of barium sulphate aspiration are dysphagia (10/28, 35.71%) followed by esophageal obstruction caused by tumor (5/28, 17.86%) and foreign body in esophagus (3/28, 10.71%). Infants (5/28, 17.86%) are also one of the high-risk population. Both the lungs were affected in most of the patients (21/28, 75%). Majority of the presentation in patients (21/28, 75%) were dyspnea, hypoxemia, acute respiratory distress syndrome (ARDS), or respiratory failure. Few patients (7/28, 25%) showed no symptoms or mild symptoms such as cough and fever. Barium sulphate aspiration can be life-threatening with a high risk of death (nearly 40%).

LESSONS

When performing an upper gastrointestinal examination with barium sulphate, careful consideration of concentration and amount of barium sulphate and that of risk factors should be undertaken so as to avoid life-threatening aspiration.