The association of swallowing dysfunction and aspiration pneumonia

A Pluridisciplinary Tracheostomy Weaning Protocol for Brain-Injured Patients, Outside of the Intensive Care Unit and Without Instrumental Assessment: Results of Pilot Study

Concurrently to the recent development of percutaneous tracheostomy techniques in the intensive care unit (ICU), the amount of tracheostomized brain-injured patients has increased. Despites its advantages, tracheostomy may represent an obstacle to their orientation towards conventional hospitalization or rehabilitation services. To date, there is no recommendation for tracheostomy weaning outside of the ICU. We created a pluridisciplinary tracheostomy weaning protocol relying on standardized criteria but adapted to each patient's characteristics and that does not require instrumental assessment. It was tested in a prospective, single-centre, non-randomized cohort study. Inclusion criteria were age > 18 years, hospitalized for an acquired brain injury (ABI), tracheostomized during an ICU stay, and weaned from mechanical ventilation. The exclusion criterion was severe malnutrition. Decannulation failure was defined as recannulation within 96 h after decannulation. Thirty tracheostomized ABI patients from our neurosurgery department were successively and exhaustively included after ICU discharge. Twenty-six patients were decannulated (decannulation rate, 90%). None of them were recannulated (success rate, 100%). Two patients never reached the decannulation stage. Two patients died during the procedure. Mean tracheostomy weaning duration (inclusion to decannulation) was 7.6 (standard deviation [SD]: 4.6) days and mean total tracheostomy time (insertion to decannulation) was 42.5 (SD: 24.8) days. Our results demonstrate that our protocol might be able to determine without instrumental assessment which patient can be successfully decannulated. Therefore, it may be used safely outside ICU or a specialized unit. Moreover, our tracheostomy weaning duration is very short as compared to the current literature.

Nil per os in the management of oropharyngeal dysphagia-exploring the unintended consequences

Nil per os (NPO), also referred to as Nil by Mouth (NBM), is a health-related intervention of withholding food and fluids. When implemented in the context of a person with dysphagia, NPO aims to mitigate risks of aspiration. However, evidence demonstrating that NPO is beneficial as an intervention for people with dysphagia is lacking. This paper explores the theoretical and empirical evidence relating to the potential benefits and adverse effects of NPO and asserts that NPO is not a benign intervention. This paper argues for applying an ethics framework when making decisions relating to the use of NPO as an intervention for dysphagia, in particular addressing informed consent and a person's right to self-determination.

Prevalence of oropharyngeal dysphagia symptoms in community-dwelling older adults: A community survey

BACKGROUND

Dysphagia is a common clinical condition in older adults with significant implications for health and quality of life (QOL). However, its prevalence and associated factors in the Indian community-dwelling older adults remain understudied. The present study aims at identifying the prevalence of oropharyngeal dysphagia symptoms in Indian community-dwelling older adults and identifying the age-related comorbid variables associated with an increased risk of oropharyngeal dysphagia in this population.

METHODS

Total 384 community-dwelling older adults (60 years of age or older) who were independent in performing daily activities were included in the present study. The Malayalam version of the Eating Assessment Tool-10 (EAT-10) questionnaire was used to assess individuals at risk for dysphagia. Additionally, they also completed a self-report questionnaire addressing age-related comorbid variables associated with an increased risk of oropharyngeal dysphagia.

RESULT

Using the Malayalam version of the EAT-10, the present study identified the prevalence of oropharyngeal dysphagia symptoms in 9.9% of community-dwelling older adults. Among the EAT-10 symptoms, cough while/after swallowing, difficulty swallowing solids and difficulty swallowing liquids were the most prevalent symptoms reported by participants. Increase in age and age-related comorbidities such as tooth loss, history of heart failure and digestive diseases were found to be significantly associated with the reporting of risk for dysphagia symptoms.

CONCLUSION

As dysphagia symptoms significantly impact the social, psychological and QOL of community-dwelling older adults, it is important to develop awareness about these symptoms among older adults, caretakers and physicians. Early detection and appropriate management of community-dwelling older adults at risk for dysphagia can contribute to better health outcomes and improved QOL.

Development of cooking method for senior-friendly food using fruits suitable for older adults with masticatory dysfunction

BACKGROUND/OBJECTIVES

The purpose of this study was to establish a fruit-cooking method suitable for older adults with masticatory dysfunction.

MATERIALS/METHODS

Five types of fruits were selected to make fruit jelly and puree: apple, sweet persimmon, mandarin, Korean melon, and watermelon. Recipes were selected based on the Korean Industrial Standard (KS) for senior-friendly foods (KS H 4897), which classifies foods into 3 levels (L1-L3) based on their hardness and viscosity.

RESULTS

In South Korea, senior-friendly foods are classified into 3 stages based on their hardness. Stage 1 is for foods that are able to eat with teeth (hardness greater than 50,000 N and less than 500,000 N), Stage 2 is for foods that are able to eat with gums (hardness greater than 20,000 N and less than 50,000 N), and Stage 3 is for foods that are able to eat with the tongue (hardness less than 20,000 N). As a result of measuring the hardness by varying the shape of the fruit, it was found that nearly all fruits could be eaten fresh by chewing with the teeth (L1) but did not meet the KS for mastication using the gums (L2) or tongue (L3), so the cooking method was selected as fruit jelly and fruit puree. Only sweet persimmon, which had a hardness of 61,624-496,393 N, was not suitable for consumption in fresh fruit, unprocessed form. Based on their hardness measurements, fruit jellies (27,869 to 36,343 N) and fruit purees (315 to 1,156 N) met the L2 and L3 requirements, respectively. The viscosity results of all fruit purees met the L3 requirement.

CONCLUSION

These results offer a simple cooking method to prepare texture-modified fruits suitable for safe consumption by older adults living with masticatory difficulties in general households and nursing facilities.

Development and validation of a novel nomogram model to assess the risk of gastric contents in outpatients undergoing elective sedative gastrointestinal endoscopy procedures

BACKGROUND

Gastric contents may contribute to patients' aspiration during anesthesia. Ultrasound can accurately assess the risk of gastric contents in patients undergoing sedative gastrointestinal endoscopy (GIE) procedures, but its efficiency is limited. Therefore, developing an accurate and efficient model to predict gastric contents in outpatients undergoing elective sedative GIE procedures is greatly desirable.

METHODS

This study retrospectively analyzed 1501 patients undergoing sedative GIE procedures. Gastric contents were observed under direct gastroscopic vision and suctioned through the endoscope. High-risk gastric contents were defined as having solid content or liquid volume > 25 ml and pH < 2.5; otherwise, they were considered low-risk gastric contents. Univariate analysis and multivariate analysis were used to select the independent risk factors to predict high-risk gastric contents. Based on the selected independent risk factors, we assigned values to each independent risk factor and established a novel nomogram. The performance of the nomogram was verified in the testing cohort by the metrics of discrimination, calibration, and clinical usefulness. In addition, an online accessible web calculator was constructed.

RESULTS

We found BMI, cerebral infarction, cirrhosis, male, age, diabetes, and gastroesophageal reflux disease were risk factors for gastric contents. The AUROCs were 0.911 and 0.864 in the development and testing cohort, respectively. Moreover, the nomogram showed good calibration ability. Decision curve analysis and Clinical impact curve demonstrated that the predictive nomogram was clinically useful. The website of the nomogram was https://medication.shinyapps.io/dynnomapp/.

CONCLUSIONS

This study demonstrates that clinical variables can be combined with algorithmic techniques to predict gastric contents in outpatients. Nomogram was constructed from routine variables, and the web calculator had excellent clinical applicability to assess the risk of gastric contents accurately and efficiently in outpatients, assist anesthesiologists in assessment and identify the most appropriate patients for ultrasound.

Quantitative Analysis of Temporal Parameters Correlated with Aspiration and Lesion Location in Stroke Patients

The purpose of this study was to identify differences in temporal parameters correlating to the presence of aspiration and the severity of penetration-aspiration scale (PAS) in patients with dysphagia after stroke. We also investigated whether there was a significant difference in temporal parameters based on the location of the stroke lesion. A total of 91 patient videofluoroscopic swallowing study (VFSS) videos of stroke patients with dysphagia were retrospectively analyzed. Various temporal parameters including oral phase duration, pharyngeal delay time, pharyngeal response time, pharyngeal transit time, laryngeal vestibule closure reaction time, laryngeal vestibule closure duration, upper esophageal sphincter opening duration and upper esophageal sphincter reaction time were measured. Subjects were grouped by the presence of aspiration, PAS score, and location of the stroke lesion. Pharyngeal response time, laryngeal vestibule closure duration, and upper esophageal sphincter opening duration were significantly prolonged in the aspiration group. These three factors showed positive correlation with PAS. In terms of stroke lesion, oral phase duration was significantly prolonged in the supratentorial lesion group, while upper esophageal sphincter opening duration was significantly prolonged in the infratentorial lesion group. We have demonstrated that quantitative temporal analysis of VFSS can be a clinically valuable tool identifying dysphagia pattern associated with stroke lesion or aspiration risk.

Application of deep learning technology for temporal analysis of videofluoroscopic swallowing studies

Temporal parameters during swallowing are analyzed for objective and quantitative evaluation of videofluoroscopic swallowing studies (VFSS). Manual analysis by clinicians is time-consuming, complicated and prone to human error during interpretation; therefore, automated analysis using deep learning has been attempted. We aimed to develop a model for the automatic measurement of various temporal parameters of swallowing using deep learning. Overall, 547 VFSS video clips were included. Seven temporal parameters were manually measured by two physiatrists as ground-truth data: oral phase duration, pharyngeal delay time, pharyngeal response time, pharyngeal transit time, laryngeal vestibule closure reaction time, laryngeal vestibule closure duration, and upper esophageal sphincter opening duration. ResNet3D was selected as the base model for the deep learning of temporal parameters. The performances of ResNet3D variants were compared with those of the VGG and I3D models used previously. The average accuracy of the proposed ResNet3D variants was from 0.901 to 0.981. The F1 scores and average precision were 0.794 to 0.941 and 0.714 to 0.899, respectively. Compared to the VGG and I3D models, our model achieved the best results in terms of accuracy, F1 score, and average precision values. Through the clinical application of this automatic model, temporal analysis of VFSS will be easier and more accurate.

Inhibitory Synaptic Influences on Developmental Motor Disorders

During development, GABA and glycine play major trophic and synaptic roles in the establishment of the neuromotor system. In this review, we summarise the formation, function and maturation of GABAergic and glycinergic synapses within neuromotor circuits during development. We take special care to discuss the differences in limb and respiratory neuromotor control. We then investigate the influences that GABAergic and glycinergic neurotransmission has on two major developmental neuromotor disorders: Rett syndrome and spastic cerebral palsy. We present these two syndromes in order to contrast the approaches to disease mechanism and therapy. While both conditions have motor dysfunctions at their core, one condition Rett syndrome, despite having myriad symptoms, has scientists focused on the breathing abnormalities and their alleviation-to great clinical advances. By contrast, cerebral palsy remains a scientific quagmire or poor definitions, no widely adopted model and a lack of therapeutic focus. We conclude that the sheer abundance of diversity of inhibitory neurotransmitter targets should provide hope for intractable conditions, particularly those that exhibit broad spectra of dysfunction-such as spastic cerebral palsy and Rett syndrome.

Fiberoptic endoscopic validation of a clinical screening test of swallowing function in critically ill patients performed within 24 h after extubation

BACKGROUND

A bedside screening tool of swallowing dysfunction (SD) (BSSD) after extubation would be useful to identify patients who are at risk of SD. We aimed to evaluate the accuracy of our BSSD in comparison with fiberoptic endoscopic evaluation of swallowing (FEES) in critically ill patients after extubation.

METHODS

We conducted a 1-year prospective monocentric study to evaluate the accuracy of our BSSD to diagnose SD following endotracheal intubation in comparison with FEES (gold standard). Patients intubated for longer than 48 h were included. Both tests were assessed within 24 h after extubation. Primary endpoint was the accuracy of the BSSD. Secondary endpoint was to assess risk factors of SD.

RESULTS

Seventy-nine patients were included in the study. Thirty-three patients (42%) presented with a SD. The BSSD showed a sensitivity of 88% (95% CI 0.72-0.97) and a specificity of 91% (95% CI 0.79-0.98), a positive predictive value of 88% (95% CI 0.72-0.97) and a negative predictive value of 91% (95% CI 0.79-0.97). The AUC reached 0.83 (95% CI 0.74-0.92).

CONCLUSION

Our study describes an accurate clinical screening tool to detect SD after extubation in critically ill patients. Screening-positive cases should be confirmed by instrumental tests, ideally using FEES.

Beyond Laryngeal Clefts: Interarytenoid Injection Augmentation to Predict Success of Suture Augmentation in Children

OBJECTIVE

To assess the efficacy of interarytenoid injection augmentation (IAIA) and the ability of IAIA to predict response to interarytenoid suture augmentation (IASA) based on diet advancement on video fluoroscopic swallow studies (VFSS).

METHODS

Retrospective cohort analysis of patients with persistent pharyngeal dysphagia at a tertiary children's hospital with VFSS pre- and post-IAIA were included between March 2011 and June 2019.

RESULTS

Median age of the 229 patients was 2.2 years (5.8 months-19 years). Interarytenoid mucosal height (IAMH) was found to be above the false vocal folds in 112 patients (53.4%) and at true vocal folds in 10 (4.9%) patients. On VFSS post-IAIA, 95 (41.5%) patients were successfully advanced in recommended diet consistency, 115 (50.2%) were stable, and 19 (8.3%) needed thicker consistency. Paired t-tests on pre- and post-operative consistency scores showed significant improvement, p-value of <0.0001, 95% confidence interval (CI; 0.50-0.85). Poisson regression found no covariates with significant association with improvement on IAIA. For IASA patients, 35/60 (58.3%) improved on post-op VFSS. Paired t-tests on pre- and post-operative consistency scores showed significant improvement, p-value of <0.0001, 95% CI (0.63-1.33). Positive predictive value for IAIA predicting response to IASA was 77% with positive likelihood ratio of 2.3. The response to IAIA versus no response to IAIA likelihood ratios were found to have a statistically significant difference (p < 0.05).

CONCLUSIONS

Our study suggests IAIA yields objective improvement in swallow function on VFSS in nearly half of our patients and may be a reliable diagnostic tool to predict response to IASA in patients with persistent pharyngeal dysphagia with or without a laryngeal cleft.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 2022.

Single Nucleotide Polymorphisms May Increase the Risk of Aspiration Pneumonia in Post-Stroke Patients with Dysphagia

This study aimed to evaluate whether genetic polymorphism is associated with an increased risk of infection, specifically post-stroke aspiration pneumonia. Blood samples were obtained from a total of 206 post-stroke participants (males, n = 136; mean age, 63.8 years). Genotyping was performed for catechol-O-methyltransferase (rs4680, rs165599), dopamine receptors (DRD1; rs4532, DRD2; rs1800497, DRD3; rs6280), brain-derived neurotrophic factor (rs6265), apolipoprotein E (rs429358, rs7412), and the interleukin-1 receptor antagonist gene (rs4251961). The subjects were stratified into two groups, aged < 65 (young) and ≥ 65 (elderly). Functional parameters and swallowing outcomes were measured at enrollment and at 3 months post-onset. The primary outcome was the incidence of aspiration pneumonia. Analysis of the association between genetic polymorphisms and aspiration pneumonia history showed that a minor C rs429358 allele was associated with the occurrence of aspiration pneumonia in the young group, both in the additive and the dominant models (odds ratio: 4.53; 95% CI: 1.60−12.84, p = 0.004). In the multivariable analysis, the minor C rs429358 allele increased the risk of post-stroke aspiration pneumonia in young stroke patients by 5.35 (95% CI: 1.64−20.88). In contrast, no such association was observed in the elderly group. Apolipoprotein E polymorphism may affect the risk of post-stroke aspiration pneumonia.

Implementation of a pneumonia prevention protocol to decrease the incidence of postoperative pneumonia in patients after hip fracture surgery

OBJECTIVE

Postoperative pneumonia is among the most common complications in elderly patients after hip fracture surgery. We implemented a proactive postoperative pneumonia prevention protocol and analyzed the incidence of postoperative pneumonia in elderly patients (≥70 years of age) receiving this protocol after hip fracture surgery versus those receiving usual care before the protocol's implementation at our institution.

MATERIALS AND METHODS

From November 2018 to October 2019, the proactive postoperative pneumonia prevention protocol was implemented. The treatment included intensified physical therapy, postoperative pulmonary exercises and oral care, in addition to the usual surgical treatment for elderly patients with hip fracture. The intervention cohort data were compared with a historical control cohort treated from July 2017 to June 2018. The primary outcome of this study was the incidence of postoperative pneumonia in both groups, diagnosed according to the presence of two of three of the following: elevated infection parameters, radiologic examination confirmation of pneumonia of the chest or clinical suspicion.

RESULTS

A total of 494 patients (n= 249 in the historical control cohort and n=245 in the intervention cohort) were included. A total of 69 patients developed postoperative pneumonia. The incidence of postoperative pneumonia was significantly lower (6.7 percentage points) in the group receiving the proactive postoperative pneumonia prevention protocol (17.3% in the historical control cohort vs 10.6% in the intervention cohort; p=0.033).

DISCUSSION AND CONCLUSION

A proactive postoperative pneumonia prevention protocol showed promise in decreasing the occurrence of postoperative pneumonia after hip fracture surgery in elderly patients.

Flourishing in head and neck cancer survivors

Background

There is a growing cohort of head and neck cancer (HNC) patients affected by late‐ and long‐term posttreatment side effects. Our study evaluates the relationship between the demographics, clinical characteristics, and posttreatment symptom burden with the subjective sense of flourishing among HNC survivors.

Methods

A cross‐sectional, single‐center study of adult survivors of squamous cell cancer of the oral cavity, oropharynx, and larynx/hypopharynx who completed the Secure Flourishing Index (SFI) and patient‐reported outcomes related to depression, anxiety, swallowing dysfunction, neck disability, and insomnia between November 2020 and April 2021.

Results

A total of 100, predominantly male (86%), survivors with an average age of 63.0 ± 9.6 were included in the study. Univariable analysis showed a significant association between higher flourishing scores and advanced age (95% CI: [0.011, 0.84], p = 0.0441), normal diet (95% CI: [5.79, 31.18], p = 0.0149), employment (95% CI: [1.24, 17.20], p = 0.0239), higher income (95% CI: [7.30, 27.72], p = 0.0248), and decreased reported difficulty paying for needs (95% CI: [−33.46, −18.88], p < 0.001). Flourishing was inversely associated with higher symptoms of depression (95% CI: [−2.23, −1.15], p < 0.001), anxiety (95% CI: [−1.92,‐0.86], p < 0.001), swallowing dysfunction (95% CI: [−0.77, −0.26], p < 0.001), neck disability (95% CI: [−1.05, −0.35], p < 0.001), and insomnia (95% CI: [−1.12, −0.22], p = 0.004) in the multivariable analysis.

Conclusions

Common late‐ and long‐term side effects of HNC treatment and financial hardship are associated with lower levels of flourishing or a more negative perception of life after treatment. Results highlight the importance of symptom burden for survivors' overall evaluation of their quality of life.

Higher Activity and Quality of Life Correlates with Swallowing Function in Older Adults with Low Activities of Daily Living

INTRODUCTION

The aim of this study was to clarify the relationship among swallowing function, activity, and quality of life (QOL) in older adults with low activities of daily living (ADL).

MATERIALS AND METHODS

We conducted a cross-sectional study. In total, 271 Japanese adults aged over 65 years who underwent medical intervention at their residence (male: n = 107; female: n = 164; mean age = 84.6 ± 8.3 years) participated. We collected data regarding age, sex, body mass index (BMI), residence (their house/nursing home), activity status, consciousness level (eye response), history of aspiration pneumonia, other medical history, number of medication types, frequency of going out, and time spent away from bed. We judged consciousness level (eye response) using the Glasgow Coma Scale (GCS), calculated the Charlson comorbidity index, measured QOL using the short version of the Quality of Life Questionnaire for Dementia (short QOL-D), and assessed swallowing function using the Functional Oral Intake Scale (FOIS). To examine the relationship between scores for the FOIS and the other variables, we used the Spearman rank correlation coefficient and ordinal logistic regression analysis.

RESULTS

The FOIS was strongly correlated with BMI (ρ = 0.47), activity status (ρ = -0.60), GCS (ρ = -0.41), time spent away from bed (ρ = 0.56), scores for the short QOL-D (ρ = 0.40), weakly correlated with history of aspiration pneumonia (ρ = -0.27), and frequency of going out (ρ = 0.39). Results for the ordinal logistic regression analysis showed that the FOIS was associated with activity status, frequency of going out, time spent away from bed, and scores for the short QOL-D.

CONCLUSION

The swallowing function of older adults with low ADL was related to their QOL and activities, such as time spent away from bed and home. Thus, in rehabilitation programs for swallowing function in older adults, not only functional but also psychological approaches may prove effective.

Predictors of Aspiration Pneumonia and Mortality in Patients with Dysphagia

OBJECTIVES/HYPOTHESIS

To identify risk factors for pneumonia incidence in patients with dysphagia undergoing a videofluoroscopic swallow study (VFSS) in an outpatient tertiary-care center.

STUDY DESIGN

Historical cohort study.

METHODS

All individuals undergoing a VFSS between 10/02/13 and 07/30/15 were identified and followed historically for 2 years. Demographic information, medical history, and fluoroscopic data were collected. The 2-year incidence of pneumonia was obtained from the medical records and telephone interview. The incidence of pneumonia and death were calculated and risk factors for pneumonia and mortality were ascertained.

RESULTS

689 patients were followed for 2 years. The mean age (±standard deviation) of the cohort was 65 (±15.5) years. 49% (338/689) were female. The most common causes of dysphagia were cricopharyngeus muscle dysfunction (270/689), head and neck cancer (175/689), and neurodegenerative disease (56/689). The incidence of pneumonia was 22% (153/689). The incidence of death was 11%. Multivariable logistic regression revealed that chronic obstructive pulmonary disorder [COPD] (odds ratio [OR] = 2.36, 95% confidence interval [CI]: 1.33-4.19), hypertension (OR = 1.82, 95% CI: 1.23-2.73), tracheotomy status (OR = 2.96, 95% CI: 1.09-7.99), and vallecular residue (OR = 1.88, 95% CI: 1.24-2.85) were all significantly associated with an elevated risk of pneumonia. Kidney disease (OR = 1.27, 95% CI: 1.02-9.9), COPD (OR = 3.27, 95% CI: 1.65-6.49), vallecular residue (OR = 2.35, 95% CI: 1.35-4.1), male gender (OR = 2.21, 95% CI: 1.25-3.92), and low body mass index (OR: 1.12, 95% CI: 1.06-1.19) were independent adjusted risk factors for death.

CONCLUSIONS

The incidence of aspiration pneumonia (22%) and death (11%) within 2-years of a VFSS was high. The greatest adjusted risk factors for incident pneumonia were tracheotomy (OR = 3.0), COPD (OR = 2.4) and vallecular residue (OR = 1.9). The greatest adjusted risk factors for death were COPD (OR = 3.3), vallecular residue (OR = 2.3), and male gender (OR = 2.2).

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Potential Prognostic Impact of Dopamine Receptor D1 (rs4532) Polymorphism in Post-stroke Outcome in the Elderly

Background: Single-nucleotide polymorphisms (SNPs) may affect post-stroke motor recovery, and some SNPs have been implicated in swallowing disturbances after stroke. Certain SNPs may also have altered influences according to different age. Objective: This post-hoc study investigated whether SNPs have different effects on dysphagia recovery between the elderly vs. young stroke patients. Methods: Analysis was conducted from a previous study including 218 stroke subjects with dysphagia. They were stratified into two groups, aged <65 and aged ≥65 years. The primary outcome was persistence of nil per mouth (NPM) at 3 months post-stroke onset. Association between outcome and nine different SNPs were investigated. Results: The elderly group (50%, n = 103) showed poorer swallowing outcomes than the young group. The minor allele of the dopamine receptor D1 (DRD1, rs4532) polymorphism showed potential association (p = 0.022) with an increased risk of NPM at 12 weeks post-stroke in the elderly, both in the additive (OR, 2.94; 95% CI, 1.17-7.37) and dominant models (OR, 2.93; 95% CI, 1.04-8.23) but did not reach statistical significance after Bonferonni correction. Logistic regression analysis showed that in those aged ≥65 years, models including the minor allele of rs4532 predicted the risk of the poor outcome with good accuracies even after adjustment of clinical factors, such as previous pneumonia episodes (AUROC, 0.86; 95% CI, 0.79-0.93) or the National Institutes of Health Stroke Scale (AUROC, 0.82; 95% CI, 0.67-0.92). In contrast, those aged <65 years seemed not to be affected by the presence of the rs4532 polymorphism, and models that included intubation history (AUROC, 0.81; 95% CI, 0.73-0.90) or previous pneumonia episodes (AUROC, 0.77; 95% CI, 0.68-0.87) showed modest levels of accuracies in predicting NPM at 12 weeks poststroke. Conclusions: Our study suggests a possible association between the rs4532 and post-stroke swallowing recovery, primarily in those aged ≥65 years. Certain SNPs may lead to less favorable outcomes in the elderly. The gene-age interaction should be considered in post-stroke swallowing recovery. Clinical Trial Registration: https://www.clinicaltrials.gov, Unique identifier [NCT03577444].

Respiratory-swallow coordination and swallowing impairment in head and neck cancer

BACKGROUND

The aim of the study was to determine the link between frequency of optimal respiratory-swallow coordination, swallowing impairment, and airway invasion in head and neck cancer (HNC) patients.

METHOD

A cross-sectional study of a heterogeneous group of HNC patients (49), precancer (N = 30) or postcancer treatment (N = 29), participated in a single Modified Barium Swallow Study (MBSS) with synchronized respiratory data.

RESULTS

Spearman correlation coefficients revealed significant negative correlations between optimal respiratory-swallow phase pattern and objective measures of swallowing impairment: penetration-aspiration scale max, pharyngeal total, and oral total scores with Spearman correlation coefficients of -0.53 (z .001), -0.50 (P < .001), and -0.43 (P = .002), respectively. Optimal respiratory-swallow pattern was significantly decreased (P = .03) in patients after cancer treatment compared with another patient group before cancer treatment.

CONCLUSION

These findings indicate that as the percentage of optimal respiratory-swallow phase patterns increase, swallowing impairment decreases in the HNC patient population.

Development of the Pediatric Dysphagia Risk Screening Instrument (PDRSI)

OBJETIVO

Desenvolver um instrumento de rastreio para a identificação de crianças com risco para disfagia, em ambiente hospitalar.

MÉTODO

O Instrumento de Rastreio para o Risco de Disfagia Pediátrica (IRRD-Ped), constituído por 23 questões, foi desenvolvido por fonoaudiólogos, após revisão da literatura. Ele foi proposto para ser aplicado aos responsáveis por crianças em internação hospitalar. O IRRD-Ped foi enviado a juízes para análise, tendo sido também realizado um estudo piloto. Para verificar a validade de critério, aplicou-se o IRRD-Ped aos responsáveis por crianças internadas e, posteriormente, realizou-se, com estas crianças, avaliação clínica da deglutição, através do Protocolo de Avaliação da Disfagia Pediátrica (PAD-PED). Os responsáveis assinaram o Termo de Consentimento Livre e Esclarecido. Os sujeitos foram separados em dois grupos (com disfagia e com deglutição normal), sendo verificada a associação entre as questões do IRRD-Ped e o resultado do PAD-PED, através do teste qui-quadrado de Person ou exato de Fisher. Definiu-se o ponto de corte para presença de risco para disfagia através da Curva ROC. A confiabilidade do IRRD-Ped foi verificada pelo coeficiente α de Cronbach.

RESULTADOS

A amostra foi constituída por 40 crianças com mediana de idade de 3,7 meses. Verificou-se associação estatisticamente significativa em oito itens do instrumento. A consistência interna do IRRD-Ped foi de 0,828. O ponto de corte para o risco de disfagia foi de cinco pontos (sensibilidade = 100% e especificidade = 80%).

CONCLUSÃO

Devido aos satisfatórios resultados encontrados, deve-se dar prosseguimento ao processo de validação do IRRD-Ped.

The Pathophysiology of Rett Syndrome With a Focus on Breathing Dysfunctions

Rett syndrome (RTT), an X-chromosome-linked neurological disorder, is characterized by serious pathophysiology, including breathing and feeding dysfunctions, and alteration of cardiorespiratory coupling, a consequence of multiple interrelated disturbances in the genetic and homeostatic regulation of central and peripheral neuronal networks, redox state, and control of inflammation. Characteristic breath-holds, obstructive sleep apnea, and aerophagia result in intermittent hypoxia, which, combined with mitochondrial dysfunction, causes oxidative stress-an important driver of the clinical presentation of RTT.

Swallowing dysfunction after minimally invasive oesophagectomy

OBJECTIVES

Patients undergoing oesophagectomy frequently experience malnutrition, which in combination with the catabolic effects of surgery can result in loss of muscle mass and function. Safe swallowing requires preservation of muscle mass. Swallowing dysfunction puts postoperative patients at risk for aspiration and pneumonia. Modified Barium Swallow Study (MBSS) enables assessment of postoperative swallowing impairments. The current study assessed incidence and risk factors associated with swallowing dysfunction and restricted diet at discharge in patients after oesophagectomy in a high-volume surgical centre.

METHODS

Patients with an MBSS after oesophagectomy were identified between March 2015 to April 2020 at a high-volume surgical centre. Swallowing was quantitatively evaluated on MBSS with the Rosenbek Penetration-Aspiration Scale (PAS). Muscle loss was evaluated clinically with preoperative hand grip strength (HGS). Univariable and multivariable logistic and linear regression analyses were performed.

RESULTS

129 patients (87% male; median age 66 years) underwent oesophagectomy with postoperative MBSS. Univariate analysis revealed older age, preoperative feeding tube, lower preoperative HGS and discharge to non-home were associated with aspiration or penetration on MBSS. Age and preoperative feeding tube remained as independent predictors in the multivariable analysis. Both univariate and multivariable analyses revealed increased age and preoperative feeding tube were associated with diet restrictions at discharge.

CONCLUSIONS

Swallowing dysfunction after oesophagectomy is correlated with increased age and need for preoperative enteral feeding tube placement. Further research is needed to understand the relationship between muscle loss and aspiration with the goal of enabling preoperative physiological optimisation and patient selection.

Neck Disability and Swallowing Function in Posttreatment Head and Neck Cancer Patients

Objective

To examine the relationship between symptoms of neck disability and swallowing dysfunction among head and neck cancer (HNC) survivors.

Study Design

Cross-sectional analysis.

Setting

Single-center, university-affiliated HNC survivorship clinic.

Subjects and Methods

Survivors’ patient-reported symptoms of neck disability and swallowing dysfunction were prospectively collected from March 2017 to May 2018. Neck disability and swallowing dysfunction were measured using the Neck Disability Index and Eating Assessment Tool (EAT-10), respectively. Linear regression was used to analyze the association between neck disability and swallowing dysfunction.

Results

A total of 179 survivors, predominantly male (n = 130, 72.6%) with an average age of 64.64 ± 9.91 years, were included in the analysis. Primary cancer sites were oropharynx (n = 85, 47.5%), oral cavity (n = 59, 33.0%), and larynx/hypopharynx (n = 35, 19.5%). Mean EAT-10 score was 10.07 ± 10.89 (range = 0-40; >2 indicative of swallowing dysfunction). Survivors treated for early stage cancer had lower EAT-10 scores than those with advanced stage (early = 3.55 ± 7.46; advanced = 11.95 ± 11.02, P < .001). After controlling for age, time since treatment, American Joint Committee on Cancer stage, and treatment modality, the EAT-10 score for patients with mild neck disability was 6.88 (95% confidence interval [CI], 3.71-10.06; P < .001) points higher than those without neck disability, and the score for those with moderate-complete neck disability was 13.65 (95% CI, 9.47-17.83; P < .001) points higher than those without neck disability.

Conclusions

Swallowing dysfunction is a commonly recognized effect of HNC treatment. The prevalence and burden of neck disability are shown to be highly correlated with swallowing dysfunction. These results support the need for comprehensive, multidisciplinary rehabilitation interventions for patients with HNC.

Effects of Tongue Exercise Frequency on Tongue Muscle Biology and Swallowing Physiology in a Rat Model

Age-related changes in muscle composition and function are often treated using exercise, including muscles of the tongue to treat swallowing impairments (dysphagia). Although tongue exercise is commonly prescribed, optimal tongue exercise doses have not been determined. The purpose of this study was to evaluate effects of varying tongue exercise frequency on tongue force, genioglossus muscle fiber size, composition and metabolism, and swallowing in a rat model. We randomized 41 old and 40 young adult Fischer 344/Brown Norway rats into one of four tongue exercise groups: 5 days/week; 3 days/week; 1 day/week; or sham. Tongue force was higher following all exercise conditions (vs sham); the 5 day/week group had the greatest change in tongue force (p < 0.001). There were no exercise effects on genioglossus (GG) fiber size or MyHC composition (p > 0.05). Significant main effects for age showed a greater proportion of Type I fibers in (p < 0.0001) and increased fiber size of IIa fibers (p = 0.026) in old. There were no significant effects of citrate synthase activity or PGC-1α expression. Significant differences were found in bolus speed and area (size), but findings were potentially influenced by variability. Our findings suggest that tongue force is influenced by exercise frequency; however, these changes were not reflected in characteristics of the GG muscle assayed in this study. Informed by findings of this study, future work in tongue dose optimization will be required to provide better scientific premise for clinical treatments in humans.

Association of Opioid Use in the Week Before Death Among Patients With Advanced Lung Cancer Having Sepsis

Opioid use can induce immunosuppression; however, it is unclear whether opioid use increases infections in patients with advanced cancers. This study assessed the association between opioid use in the week before death and mortality among patients with advanced lung cancer having sepsis. Data on opioid usage in the week before death, general information, and clinical information of the patients were collected retrospectively. The primary outcome was the association between opioid use in the week before death and mortality after sepsis. The study included 980 patients who died of advanced lung cancer between January 2003 and June 2017 (sepsis related: 413, unrelated to sepsis: 567). The average morphine equivalent daily dose in the final week was higher in the sepsis group (313.5 ± 510.5 mg) than in the nonsepsis group (125.2 ± 246.9 mg, P < .001). A significant association was found between the average morphine equivalent daily dose in the final week and mortality due to sepsis (odds ratio: 1.02, 95% confidence interval: 1.01-1.02, P < .001). This was especially evident when the dose was increased by 10 mg in the final week. Furthermore, older age, male sex, and a lower body mass index were associated with an increased risk of mortality after developing sepsis. Opioid use in the week before death may be associated with mortality for patients with advanced lung cancer having sepsis.

Aerodigestive disorders in dogs evaluated for cough using respiratory fluoroscopy and videofluoroscopic swallow studies

Aerodigestive diseases, hybrid disorders representing a pathologic link between respiratory and alimentary tracts, may manifest with respiratory signs without gastrointestinal signs. These are underdiagnosed in dogs due to poor clinical recognition and diagnostic limitations. We hypothesize that a subset of dogs presenting for cough without gastrointestinal signs would have occult aerodigestive disorders identified using videofluoroscopic swallow study (VFSS). Data were retrospectively obtained from 31 client-owned dogs presenting for cough, with thoracic radiographs, and a VFSS between April 2015 and December 2017. Exclusion criteria were cough of cardiac origin or gastrointestinal signs within 6 months. Swallow study parameters included pharyngeal/esophageal motility, laryngeal obstruction/defects, penetration-aspiration, reflux, excessive aerophagia, megaesophagus (ME), lower-esophageal sphincter achalasia-like syndrome (LES-AS), and sliding hiatal hernia (HH). The median (interquartile range) duration of cough was 4 (2-8) months. Thoracic radiographs were unremarkable in 11 dogs, with aspiration pneumonia suspected in seven. In 25/31 dogs (81%), VFSS abnormalities were detected and some dogs had more than one defect: pharyngeal (n=10) or esophageal hypomotility (n=10), reflux (n=9), penetration-aspiration (n=8), excessive aerophagia (n=6), laryngeal obstruction (n=3), ME (n=3), HH (n=2), and LES-AS (n=1). A respiratory disorder causing cough was identified in 17 dogs with VFSS abnormalities (laryngeal obstruction/defect and airway disease including chronic or eosinophilic bronchitis, tracheal/mainstem bronchial collapse, bronchiectasis, and bronchomalacia). An alimentary disorder identified on VFSS in absence of a discrete respiratory disorder causing cough was diagnosed in eight dogs. In conclusion, canine aerodigestive disorders can manifest as cough without alimentary signs. VFSS is a useful diagnostic to determine the contribution of esophageal/gastrointestinal pathology in dogs with cough.

Dysphagia in the intensive care unit: epidemiology, mechanisms, and clinical management

Dysphagia may present in all critically ill patients and large-scale clinical data show that e.g. post-extubation dysphagia (PED) is commonly observed in intensive care unit (ICU) patients. Recent data demonstrate that dysphagia is mostly persisting and that its presence is independently associated with adverse patient-centered clinical outcomes. Although several risk factors possibly contributing to dysphagia development were proposed, the underlying exact mechanisms in ICU patients remain incompletely understood and no current consensus exists on how to best approach ICU patients at risk.From a clinical perspective, dysphagia is well-known to be associated with an increased risk of aspiration and aspiration-induced pneumonia, delayed resumption of oral intake/malnutrition, decreased quality of life, prolonged ICU and hospital length of stay, and increased morbidity and mortality. Moreover, the economic burden on public health care systems is high.In light of high mortality rates associated with the presence of dysphagia and the observation that dysphagia is not systematically screened for on most ICUs, this review describes epidemiology, terminology, and potential mechanisms of dysphagia on the ICU. Furthermore, the impact of dysphagia on affected individuals, health care systems, and society is discussed in addition to current and future potential therapeutic approaches.

The Association of 3-D Volume and 2-D Area of Post-swallow Pharyngeal Residue on CT Imaging

Pharyngeal residue, the material that remains in the pharynx after swallowing, is an important marker of impairments in swallowing and prandial aspiration risk. The goals of this study were to determine whether the 2D area of post-swallow residue accurately represents its 3D volume, and if the laterality of residue would affect this association. Thirteen patients with dysphagia due to brainstem stroke completed dynamic 320-detector row computed tomography while swallowing a trial of 10 ml honey-thick barium. 3D volumes of pharyngeal residue were compared to 2D lateral and anterior-posterior areas, and a laterality index for residue location was computed. Although the anteroposterior area of residue was larger than the lateral area, the two measures were positively correlated with one another and with residue volume. On separate bivariate regression analyses, residue volume was accurately predicted by both lateral (R² = 0.91) and anteroposterior (R² = 0.88) residue areas, with limited incidence of high residuals. Half of the sample demonstrated a majority of pharyngeal residue lateralized to one side of the pharynx, with no effect of laterality on the association between areas and volume. In conclusion, the area of post-swallow pharyngeal residue was associated with volume, with limitations in specific cases. Direct measurement of pharyngeal residue volume and swallowing physiology with 3D-CT can be used to validate results from standard 2D instrumentation.

Risk Factors for Dysphagia Following a Cervical Fusion in a Trauma Population

Background

Dysphagia following a cervical fusion is a known complication; however, this has not been examined in the trauma population. We sought to identify risk factors that can be optimized in this population.

Methods

We performed a retrospective chart review on consecutive trauma patients who underwent a cervical fusion from 2014 to 2017 at a single institution with multiple surgeons. We included patients more than 18-years-old who were admitted through the emergency department with a diagnosis of acute cervical injury and underwent a cervical fusion during the same admission. We excluded patients who remained intubated postoperatively or underwent a tracheostomy. The primary outcome was dysphagia as evaluated by a bedside swallow test on postoperative day one by the nursing staff. This was followed by a standardized assessment performed by a speech therapist on postoperative day two in some cases. Variables of interest included sex, age, mechanism of injury, surgical approach, cervical levels, and Charlson comorbidity index. Univariate analysis was also utilized.

Results

Sixty patients met the study criteria. Nineteen patients (31.7%) developed dysphagia postoperatively. Mechanical falls were the most common injury mechanism (80%) and most surgical procedures were performed on the subaxial cervical spine (68.3%). Comparing the dysphagia groups, there was no significant difference among the confounding variables. Patients with dysphagia had an increased length of stay (10.6 ± 6.7 vs. 7.4 ± 3.1, p = 0.056) and were more likely to have had an anterior vs. posterior cervical fusion (63.2% vs. 34.1%, p = 0.056).

Conclusions

We found no statistically significant risk factors leading to postoperative dysphagia. The objective of this pilot is to find the baseline dysphagia rate and the potential modifiable factors in this unique patient population undergoing cervical fusion procedures.

Coordination of Pharyngeal and Laryngeal Swallowing Events During Single Liquid Swallows After Oral Endotracheal Intubation for Patients with Acute Respiratory Distress Syndrome

To evaluate timing and duration differences in airway protection and esophageal opening after oral intubation and mechanical ventilation for acute respiratory distress syndrome (ARDS) survivors versus age-matched healthy volunteers. Orally intubated adult (≥ 18 years old) patients receiving mechanical ventilation for ARDS were evaluated for swallowing impairments via a videofluoroscopic swallow study (VFSS) during usual care. Exclusion criteria were tracheostomy, neurological impairment, and head and neck cancer. Previously recruited healthy volunteers (n = 56) served as age-matched controls. All subjects were evaluated using 5-ml thin liquid barium boluses. VFSS recordings were reviewed frame-by-frame for the onsets of 9 pharyngeal and laryngeal events during swallowing. Eleven patients met inclusion criteria, with a median (interquartile range [IQR]) intubation duration of 14 (9, 16) days, and VFSSs completed a median of 5 (4, 13) days post-extubation. After arrival of the bolus in the pharynx, ARDS patients achieved maximum laryngeal closure a median (IQR) of 184 (158, 351) ms later than age-matched, healthy volunteers (p < 0.001) and it took longer to achieve laryngeal closure with a median (IQR) difference of 151 (103, 217) ms (p < 0.001), although there was no significant difference in duration of laryngeal closure. Pharyngoesophageal segment opening was a median (IQR) of - 116 (- 183, 1) ms (p = 0.004) shorter than in age-matched, healthy controls. Evaluation of swallowing physiology after oral endotracheal intubation in ARDS patients demonstrates slowed pharyngeal and laryngeal swallowing timing, suggesting swallow-related muscle weakness. These findings may highlight specific areas for further evaluation and potential therapeutic intervention to reduce post-extubation aspiration.

Validation of the Choking Risk Assessment and Pneumonia Risk Assessment for adults with Intellectual and Developmental Disability (IDD)

BACKGROUND

Risk assessments are needed to identify adults with intellectual and developmental disability (IDD) at high risk of choking and pneumonia.

AIM

To describe the development and validation of the Choking Risk Assessment (CRA) and the Pneumonia Risk Assessment (PRA) for adults with IDD.

METHODS

Test items were identified through literature review and focus groups. Five-year retrospective chart reviews identified a positive choking group (PCG), a negative choking group (NCG), a positive pneumonia group (PPG), and a negative pneumonia group (NPG). Participants were tested with the CRA and PRA by clinicians blind to these testing conditions.

RESULTS

The CRA and PRA differentiated the PCG (n=93) from the NCG (n=526) and the PPG (n=63) from the NPG (n=209) with high specificity (0.91 and 0.92 respectively) and moderate to average sensitivity (0.53 and 0.62 respectively). Further analyses revealed associations between clinical diagnoses of dysphagia and choking (p=0.043), and pneumonia (p<0.001).

CONCLUSIONS

The CRA and PRA are reliable, valid risk indicators for choking and pneumonia in adults with IDD. Precautions for mitigating choking and pneumonia risks can be applied selectively thus avoiding undue impacts on quality of life and unnecessary interventions for low risk individuals.

Development of a Dysphagia Screening Test for Preterm Infants (DST-PI)

OBJECTIVE

To explore both the early prediction and diagnosis of dysphagia in preterm infants as an important developmental aspect as well as the prevention of respiratory complications, we developed the simple and-easy-to-apply Dysphagia Screening Test for Preterm Infants (DST-PI) to predict supraglottic penetration and subglottic aspiration.

METHODS

Fifty-two infants were enrolled in a videofluoroscopic swallowing study (VFSS) due to clinical suspicions of dysphagia. Thirteen items related to supraglottic penetration or subglottic aspiration were initially selected from previous studies for the DST-PI. Finally, 7 items were determined by linear logistic regression analysis. Cutoff values, sensitivity, specificity, and the area under the ROC curve (AUC) of the DST-PI for predicting supraglottic penetration or subglottic aspiration were calculated using a ROC curve. For inter-rater reliability, the kappa coefficient was calculated.

RESULTS

Seven items were selected: 'gestational age,' 'history of apnea,' 'history of cyanosis during feeding,' 'swallowing pattern,' 'coughs during or after feeding,' 'decreased oxygen saturation within 3 minutes of feeding,' and 'voice change after feeding.' The Spearman correlation coefficient between the DST-PI and the penetration-aspiration scale (PAS) was 0.807 (p<0.001). The sensitivity and specificity at different cutoff values for detecting supraglottic penetration and subglottic aspiration were 96.6% and 76.9% at 3.25, and 88.9% and 75.8% at 6.25, respectively.

CONCLUSION

The DST-PI is a valid and reliable dysphagia screening test for supraglottic penetration or subglottic aspiration in preterm infants that is easy to apply in a clinical context.

Age-related effect of cell death on fiber morphology and number in tongue muscle

INTRODUCTION

Multiple pathways may exist for age-related tongue muscle degeneration. Cell death is one mechanism contributing to muscle atrophy and decreased function. We hypothesized with aging, apoptosis, and apoptotic regulators would be increased, and muscle fiber size and number would be reduced in extrinsic tongue muscles.

METHODS

Cell death indices, expression of caspase-3 and Bcl-2, and measures of muscle morphology and number were determined in extrinsic tongue muscles of young and old rats.

RESULTS

Significant increases in cell death, caspase-3, and Bcl-2 were observed in all extrinsic tongue muscles along with reductions in muscle fiber number in old rats.

DISCUSSION

We demonstrated that apoptosis indices increase with age in lingual muscles and that alterations in apoptotic regulators may be associated with age-related degeneration in muscle fiber size and number. These observed apoptotic processes may be detrimental to muscle function, and may contribute to degradation of cranial functions with age. Muscle Nerve 57: E29-E37, 2018.

PEG Insertion in Patients With Dementia Does Not Improve Nutritional Status and Has Worse Outcomes as Compared With PEG Insertion for Other Indications

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tubes are commonly utilized as a method of enteral feeding in patients unable to obtain adequate oral nutrition. Although some studies have shown improved mortality in select populations, the safety and effectiveness of PEG insertion in patients with dementia compared with those with other neurological diseases or head and neck malignancy remains less well defined.

OBJECTIVE

To evaluate the nutritional effectiveness, rate of rehospitalization, and risk of mortality among patients with dementia compared with patients with other neurological diseases or head and neck cancers who undergo PEG placement.

MATERIALS AND METHODS

We conducted a retrospective analysis from a prospective database of patients who underwent PEG placement at an academic tertiary center between 2008 and 2013. The following data were collected: indication for PEG, patient demographics, biochemical markers of nutritional status rehospitalization, and survival rates.

RESULTS

During the study period, 392 patients underwent PEG tube placement. Indications for PEG were dementia (N=165, group A), cerebrovascular accident (N=124, group B), and other indications such as oropharyngeal cancers and motor neuron disease (N=103, group C). The mean follow-up time after PEG was 18 months (range, 3 to 36 mo). No differences in baseline demographics were noted. PEG insertion in the dementia (group A) neither reduced the rehospitalization rate 6 months' postprocedure compared with groups B and C (2.45 vs. 1.86 and 1.65, respectively; P=0.05), nor reduced the mortality rate within the first year post-PEG placement (75% vs. 58% and 38% for groups A, B, and C, respectively, P=0.001), as well, it did not improve survival at 1 month after the procedure (15% vs. 3.26% and 7.76%, for groups A, B, C, respectively, P<0.01). The presence of dementia was also associated with shorter mean time to death (7.2 vs. 8.85 and 8 mo for groups A, B, C, respectively, P<0.05). The rate of improvement of the nutritional biomarker albumin was lower in the dementia group [3.1. to 2.9 vs. 3.2 to 3.3 and 3 to 3.3 g/dL for groups A, B, and C, respectively (P<0.02)]. Multivariate regression analysis showed that the presence of dementia was an independent predictor for mortality rate within the first year and 1-month mortality rate in patients undergoing PEG insertion with odds ratio 3.22 (95% confidence interval, 1.52-4.32) and odds ratio 2.52 (95% confidence interval, 1.22-3.67).

CONCLUSIONS

PEG insertion in patients with dementia neither improve both short-term and long-term mortality nor rehospitalization rate as compared with patients who underwent PEG placement for alternate indications such as other neurological diseases or head and neck malignancy and even was associated with shorter time to death. Furthermore, PEG insertion in patients with dementia did not improve albumin. Therefore, careful selection of patients with dementia is warranted before PEG placement weighing the risks and benefits on a personalized basis.

Soft Electronics Enabled Ergonomic Human-Computer Interaction for Swallowing Training

We introduce a skin-friendly electronic system that enables human-computer interaction (HCI) for swallowing training in dysphagia rehabilitation. For an ergonomic HCI, we utilize a soft, highly compliant ("skin-like") electrode, which addresses critical issues of an existing rigid and planar electrode combined with a problematic conductive electrolyte and adhesive pad. The skin-like electrode offers a highly conformal, user-comfortable interaction with the skin for long-term wearable, high-fidelity recording of swallowing electromyograms on the chin. Mechanics modeling and experimental quantification captures the ultra-elastic mechanical characteristics of an open mesh microstructured sensor, conjugated with an elastomeric membrane. Systematic in vivo studies investigate the functionality of the soft electronics for HCI-enabled swallowing training, which includes the application of a biofeedback system to detect swallowing behavior. The collection of results demonstrates clinical feasibility of the ergonomic electronics in HCI-driven rehabilitation for patients with swallowing disorders.

Geriatric oral and maxillofacial dysfunctions in the context of geriatric syndrome

OBJECTIVES

To propose the application of the concept of geriatric syndrome for common geriatric oral and maxillofacial dysfunctions and to suggest the necessity of developing effective evaluation methods for oral and maxillofacial frailty.

DESIGN

The concepts of frailty and geriatric syndrome based on multi-morbidity and polypharmacy were applied to five common geriatric oral medicinal dysfunctional problems: salivary gland hypofunction (dry mouth), chronic oral mucosal pain disorders (burning mouth symptoms), taste disorders (taste disturbances), swallowing disorders (dysphagia), and oral and maxillofacial movement disorders (oromandibular dyskinesia and dystonia).

RESULTS

Each of the dysfunctions is caused by various kinds of diseases and/or conditions and medications, thus the concept of geriatric syndrome could be applied. These dysfunctions, suggested as components of oral and maxillofacial geriatric syndrome, are associated and interacted with each other in a complexity of vicious cycle. The resulting functional impairments caused by this syndrome can cause oral and maxillofacial frailty.

CONCLUSIONS

Geriatric oral and maxillofacial dysfunctions could be better appreciated in the context of geriatric syndrome. The development of effective methods for evaluating the severity of these dysfunctions and the resulting frailty is essential.

Both pharyngeal and esophageal phases of swallowing are associated with recurrent pneumonia in pediatric patients

INTRODUCTION

One of the underlying causes of recurrent pneumonia in children is swallowing dysfunction, with aspiration syndrome. Swallowing dysfunction should be considered not only a problem of the oropharyngeal phase but also a problem of the esophageal phase.

OBJECTIVES

This study aimed to determine the relationship between findings from a swallowing study and a history of recurrent pneumonia in pediatric patients.

METHODS

A videofluroscopic swallowing study of 274 pediatric patients who had swallowing dysfunction was conducted. Information on a history of recurrent pneumonia during a 1-year period was obtained from hospital files.

RESULTS

The median age of the participants was 33 months (min =10, max = 180), of whom 51.8% were females. In the study, 83.2% of the patients had cerebral palsy, 7.7% had syndromic symptoms, 3.6% had muscular dystrophy, and 5.5% were classified as "other." During the 1-year period, 67.9% of the participants had a history of recurrent pneumonia history. Furthermore, 66.4% had oral dysfunction, 32.5% had laryngeal penetration, 46.4% had aspiration, 45.3% had abnormal esophageal body function, and 35.8% had reflux symptoms. There was no correlation between oral dysfunction and recurrent pneumonia (P = .902), but there was a positive correlation between recurrent pneumonia and laryngeal penetration (P < .001, r = .26), aspiration (P < .001, r =.49), abnormal esophageal body function (P = .002, r = .18), and reflux (P < .001, r = .22).

CONCLUSION

Both pharyngeal swallowing disorders, such as penetration and aspiration, and esophageal disorders and reflux may result in recurrent pneumonia in pediatric patients. Thus, all phases of deglutition should be considered and followed up during swallowing evaluation.

Respiratory-swallowing coordination in normal subjects: Lung volume at swallowing initiation

This study was designed to investigate the significance of bolus types and volumes, delivery methods and swallowing instructions on lung volume at swallowing initiation in normal subjects in a single experiment using a multifactorial approach. Our broad range goal was to determine optimal lung volume range associated with swallowing initiation to provide training targets for dysphagic patients with disordered respiratory-swallow coordination. Our hypothesis was that swallows would be initiated within a limited range of quiet breathing lung volumes regardless of bolus volume, consistency or task. Results confirmed this hypothesis and revealed that swallows were initiated at mean lung volume=244ml. Cued swallows were initiated at lower quiet breathing volumes than un-cued swallows (cued=201ml; un-cued=367ml). Water boluses were initiated at slightly higher quiet breathing volumes than solids. Data suggest that swallows occur within a restricted range of lung volumes with variation due to instructions, bolus type and other experimental variables.

Alterations in oropharyngeal sensory evoked potentials (PSEP) with Parkinson's disease

Movement of a food bolus from the oral cavity into the oropharynx activates pharyngeal sensory mechanoreceptors. Using electroencephalography, somatosensory cortical-evoked potentials resulting from oropharyngeal mechanical stimulation (PSEP) have been studied in young healthy individuals. However, limited information is known about changes in processing of oropharyngeal afferent signals with Parkinson's disease (PD). To determine if sensory changes occurred with a mechanical stimulus (air-puff) to the oropharynx, two stimuli (S1-first; S2-s) were delivered 500ms apart. Seven healthy older adults (HOA; 3 male and 4 female; 72.2±6.9 years of age), and thirteen persons diagnosed with idiopathic Parkinson's disease (PD; 11 male and 2 female; 67.2±8.9 years of age) participated. Results demonstrated PSEP P1, N1, and P2 component peaks were identified in all participants, and the N2 peak was present in 17/20 participants. Additionally, the PD participants had a decreased N2 latency and gated the P1, P2, and N2 responses (S2/S1 under 0.6). Compared to the HOAs, the PD participants had greater evidence of gating the P1 and N2 component peaks. These results suggest that persons with PD experience changes in sensory processing of mechanical stimulation of the pharynx to a greater degree than age-matched controls. In conclusion, the altered processing of sensory feedback from the pharynx may contribute to disordered swallow in patients with PD.

EMG Activity of Masseter Muscles in the Elderly According to Rheological Properties of Solid Food

Objective

To assess the impact of aging on masticatory muscle function according to changes in hardness of solid food.

Methods

Each of fifteen healthy elderly and young people were selected. Subjects were asked to consume cooked rice, which was processed using the guidelines of the Universal Design Foods concept for elderly people (Japan Care Food Conference 2012). The properties of each cooked rice were categorized as grade 1, 2, 3 and 4 (5×10³, 2×10⁴, 5×10⁴, and 5×10⁵ N/m²) respectively. Surface electromyography (sEMG) was used to measure masseter activity from food ingestion to swallowing of test foods. The raw data was normalized by the ratio of sEMG activity to maximal voluntary contraction and compared among subjects. The data was divided according to each sequence of mastication and then calculated within the parameters of EMG activities.

Results

Intraoral tongue pressure was significantly higher in the young than in the elderly (p<0.05). Maximal value of average amplitude of the sequence in whole mastication showed significant positive correlation with hardness of food in both young and elderly groups (p<0.05). In a comparisons between groups, the maximal value of average amplitude of the sequence in whole mastication and peak amplitude in whole mastication showed that mastication in the elderly requires a higher percentage of maximal muscle activity than in the young, even with soft foods (p<0.05).

Conclusion

sEMG data of the masseter can provide valuable information to aid in the selection of foods according to hardness for the elderly. The results also support the necessity of specialized food preparation or products for the elderly.

Adding Endoscopist-Directed Flexible Endoscopic Evaluation of Swallowing to the Videofluoroscopic Swallowing Study Increased the Detection Rates of Penetration, Aspiration, and Pharyngeal Residue

BACKGROUND/AIMS

Currently, the videofluoroscopic swallowing study (VFSS) is the standard tool for evaluating dysphagia. We evaluated whether the addition of endoscopist-directed flexible endoscopic evaluation of swallowing (FEES) to VFSS could improve the detection rates of penetration, aspiration, and pharyngeal residue, compared the diagnostic efficacy between VFSS and endoscopist-directed FEES and assessed the adverse events of the FEES.

METHODS

In single tertiary referral center, a retrospective analysis of prospectively collected data was conducted. Fifty consecutive patients suspected of oropharyngeal dysphagia were enrolled in this study between January 2012 and July 2012.

RESULTS

The agreement in the detection of penetration and aspiration between VFSS and FEES of viscous food (κ=0.34; 95% confidence interval [CI], 0.15 to 0.53) and liquid food (κ=0.22; 95% CI, 0.02 to 0.42) was "fair." The agreement in the detection of pharyngeal residue between the two tests was "substantial" with viscous food (κ=0.63; 95% CI, 0.41 to 0.94) and "fair" with liquid food (κ=0.37; 95% CI, 0.10 to 0.63). Adding FEES to VFSS significantly increased the detection rates of penetration, aspiration, and pharyngeal residue. No severe adverse events were noted during FEES, except for two cases of epistaxis, which stopped spontaneously without requiring any packing.

CONCLUSIONS

This study demonstrated that the addition of endoscopist-directed FEES to VFSS increased the detection rates of penetration, aspiration, and pharyngeal residue.

Relationship between removable prosthesis and some systemics disorders

This article reviews the dental literature concerning the potential impact of the removable prosthesis (RP) on the health status of patients with certain systemic diseases. Literature was surveyed using Medline/PubMed database resources, as well as a manual search, up to 2015 to identify appropriate articles that addressed the aim of this review. The research used keywords about associations between RP and six pathologies: Human immunodeficiency virus infection, diabetes mellitus, pulmonary diseases, gastric-Helicobacter pylori, cancer, and cardiovascular diseases. Analysis of literature showed that in patients with dentures having one or more of the six general conditions listed, Candida albicans organism is more frequently found in the oral flora compared to healthy denture wearer. Although causality has not been established and pending further research on this topic, the hygienic practices necessary to minimize the risk of numerous pathologies should be strengthened in the case of these patients, all the more in the presence of physical or psychological disability. The relationship between the general diseases and increasing of oral candidiasis denture patients is not explained. Therefore, attention to oral hygiene and professional care for removing C. albicans may be beneficial in these medically compromised patients.

Implementing oral care to reduce aspiration pneumonia amongst patients with dysphagia in a South African setting

Oral care is a crucial routine for patients with dysphagia that, when completed routinely, can prevent the development of aspiration pneumonia. There is no standardised protocol for oral care within government hospitals in South Africa. This study aimed to investigate the outcome of an oral care protocol. Participants were patients with oropharyngeal dysphagia, with either stroke or traumatic brain injury as the underlying medical pathology, and nurses. All participants were recruited from one tertiary level government hospital in Gauteng, South Africa. 139 nurses participated in the study and received training on the oral care protocol. There were two groups of participants with oropharyngeal dysphagia. Group one (study group, n = 23) was recruited by consecutive sampling, received regular oral care and were not restricted from drinking water; however, all other liquids were restricted. Group two (comparison group, n = 23) was recruited via a retrospective record review, received inconsistent oral care and were placed on thickened liquids or liquid restricted diets. Results showed that a regimen of regular oral care and free water provision when combined with dysphagia intervention did prevent aspiration pneumonia in patients with oropharyngeal dysphagia. The article highlights two key findings: that regular and routine oral care is manageable within an acute government hospital context and a strict routine of oral care can reduce aspiration pneumonia in patients with oropharyngeal dysphagia. An implication from these findings is confirmation that teamwork in acute care settings in developing contexts must be prioritised to improve dysphagia management and patient prognosis.

A muscle stem cell for every muscle: variability of satellite cell biology among different muscle groups

The human body contains approximately 640 individual skeletal muscles. Despite the fact that all of these muscles are composed of striated muscle tissue, the biology of these muscles and their associated muscle stem cell populations are quite diverse. Skeletal muscles are affected differentially by various muscular dystrophies (MDs), such that certain genetic mutations specifically alter muscle function in only a subset of muscles. Additionally, defective muscle stem cells have been implicated in the pathology of some MDs. The biology of muscle stem cells varies depending on the muscles with which they are associated. Here we review the biology of skeletal muscle stem cell populations of eight different muscle groups. Understanding the biological variation of skeletal muscles and their resident stem cells could provide valuable insight into mechanisms underlying the susceptibility of certain muscles to myopathic disease.

The Effect of Stroke on Pharyngeal Laterality During Swallowing

Objective

To investigate whether patterns of dysphagia and swallowing laterality differ according to the location of brain lesions in patients with stroke.

Methods

Patients with stroke >20 years of age were enrolled in this study. A videofluoroscopic swallowing study (VFSS) including the anterior-posterior view was used to assess swallowing. Patterns of swallowing were classified into three types according to the width of barium sulfate flow while passing the pharyngoesophageal segment: right-side-dominant flow, left-side-dominant flow, and no laterality in flow. Laterality was defined when the width of one side was twice or more the width of the other side.

Results

A total of 92 patients who underwent swallowing function evaluations by VFSS were enrolled from Sep-tember 2012 to May 2013. Of these, 72 patients had supratentorial lesions (group I) and 20 patients had infratento-rial lesions (group II). Only 10 patients (13.9%) in group I and three patients (15.0%) in group II showed laterality. Of these 13 patients, laterality occurred on the left side regardless of the side of the brain lesion. No relationships were found between swallowing laterality and location of stroke or motor weakness.

Conclusion

The results suggest that swallowing laterality was not prevalent among patients with stroke and that lesion side, location of the brain lesion, or motor weakness did not influence swallowing laterality. Although stroke can cause symptoms of dysphagia, it is difficult to conclude that stroke has a crucial impact on swallowing laterality.

Respiratory-swallow training in patients with head and neck cancer

OBJECTIVE

To test a novel intervention to train swallowing to occur in the midexpiratory to low expiratory phase of quiet breathing to improve swallowing safety and efficiency.

DESIGN

Safety and efficacy nonrandomized controlled trial with 1-month follow-up.

SETTING

Ambulatory clinics.

PARTICIPANTS

Patients (N=30) with head and neck cancer (HNC) and chronic dysphagia completed the intervention. Fifteen of these patients participated in a 1-month follow-up visit.

INTERVENTIONS

Training protocol based on hierarchy of motor skill acquisition to encourage autonomous and optimal respiratory-swallowing coordination. Visual feedback of respiratory phase and volume for swallowing initiation was provided by nasal airflow and rib cage/abdomen signals.

MAIN OUTCOME MEASURES

Respiratory-swallow phase pattern, Modified Barium Swallow Impairment Profile (MBSImP) scores, Penetration-Aspiration Scale (PAS) scores, and MD Anderson Dysphagia Inventory scores.

RESULTS

Using visual feedback, patients were trained to initiate swallows during the midexpiratory phase of quiet breathing and continue to expire after swallowing. This optimal phase patterning increased significantly after treatment (P<.0001). Changes in respiratory-swallowing coordination were associated with improvements in 3 MBSImP component scores: laryngeal vestibular closure (P=.0004), tongue base retraction (P<.0001), and pharyngeal residue (P=.01). Significant improvements were also seen in PAS scores (P<.0001). Relative to pretreatment values, patients participating in 1-month follow-up had increased optimal phase patterning (P<.0001), improved laryngeal vestibular closure (P=.01), tongue base retraction (P=.003), and pharyngeal residue (P=.006) MBSImP scores and improved PAS scores (P<.0001).

CONCLUSIONS

Improvements in respiratory-swallowing coordination can be trained using a systematic protocol and respiratory phase-lung volume-related biofeedback in patients with HNC and chronic dysphagia, with favorable effects on airway protection and bolus clearance.