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López-Fernández MD, Fernández-Lao C, Ruíz-Martínez AM, Fernández-Gualda MÁ, Lozano-Lozano M, Ortiz-Comino L, Galiano-Castillo N. Exploring predictors of dysphagia in survivors of head and neck cancer: A cross-sectional study. Support Care Cancer 2024; 32:162. [PMID: 38366091 PMCID: PMC10873441 DOI: 10.1007/s00520-024-08358-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 02/07/2024] [Indexed: 02/18/2024]
Abstract
PURPOSE To evaluate the prevalence of dysphagia in survivors of head and neck cancer (sHNC) and to identify the predictors contributing to the development of dysphagia. METHODS We enrolled 62 sHNC in a cross-sectional study to check the prevalence of dysphagia in sHNC and to evaluate which factors were influencing the presence of this side effect. Besides dysphagia, sociodemographic and clinical characteristics, oral symptoms, maximal mouth opening (MMO), sleep quality and physical condition were evaluated, and a linear regression analysis was performed to verify which of these outcomes impact dysphagia. RESULTS Among all the sHNC, 85.5% presented dysphagia. The linear regression analysis confirmed that 44.9% of the variance in dysphagia was determined by coughing, MMO and sleep quality, being MMO the most powerful predictor, followed by coughing and sleep quality. CONCLUSION Dysphagia affected the great majority of sHNC. Moreover, symptoms as coughing, reduced MMO and sleep disorders may act as predictors contributing to the development of dysphagia. Our results emphasize the importance of an early and proper identification of the symptoms as well as an adequate treatment strategy to address the cluster of symptoms that sHNC undergo.
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Affiliation(s)
- María Dolores López-Fernández
- UGC Medicina Física y Rehabilitación, Hospital de Neurotraumatología y Rehabilitación, Hospital Universitario Virgen de Las Nieves, Instituto de Investigación Biosanitaria Ibs, Granada, Spain
| | - Carolina Fernández-Lao
- Biomedical Group (BIO277), Department of Physical Therapy, Health Sciences Faculty, University of Granada, Sport and Health Research Center (IMUDs), Instituto de Investigación Biosanitaria Ibs, Granada, Spain.
| | - Alba María Ruíz-Martínez
- Department of Radiation Oncology, Hospital Universitario Vírgen de Las Nieves, Instituto de Investigación Biosanitaria Ibs, Granada, Spain
| | - Miguel Ángel Fernández-Gualda
- Biomedical Group (BIO277), Department of Physical Therapy, Health Sciences Faculty, University of Granada, Instituto de Investigación Biosanitaria Ibs, Granada, Spain
| | - Mario Lozano-Lozano
- Biomedical Group (BIO277), Department of Physical Therapy, Health Sciences Faculty, University of Granada, Sport and Health Research Center (IMUDs), Instituto de Investigación Biosanitaria Ibs, Granada, Spain
| | - Lucía Ortiz-Comino
- Biomedical Group (BIO277), Department of Physical Therapy, Health Sciences Faculty (Melilla), University of Granada, Sport and Health Research Center (IMUDs), Instituto de Investigación Biosanitaria Ibs, Granada, Spain
| | - Noelia Galiano-Castillo
- Biomedical Group (BIO277), Department of Physical Therapy, Health Sciences Faculty, University of Granada, Sport and Health Research Center (IMUDs), Instituto de Investigación Biosanitaria Ibs, Granada, Spain
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Mootassim-Billah S, Schoentgen J, De Bodt M, Roper N, Digonnet A, Le Tensorer M, Van Nuffelen G, Van Gestel D. Acoustic Analysis of Voluntary Coughs, Throat Clearings, and Induced Reflexive Coughs in a Healthy Population. Dysphagia 2023; 38:1467-1486. [PMID: 37245187 PMCID: PMC10225042 DOI: 10.1007/s00455-023-10574-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 03/31/2023] [Indexed: 05/29/2023]
Abstract
Cough efficacy is considered a reliable predictor of the aspiration risk in head and neck cancer patients with radiation-associated dysphagia. Currently, coughing is assessed perceptually or aerodynamically. The goal of our research is to develop methods of acoustic cough analysis. In this study, we examined in a healthy population the acoustical differences between three protective maneuvers: voluntary cough, voluntary throat clearing, and induced reflexive cough. Forty healthy participants were included in this study. Voluntary cough, voluntary throat clearing, and reflexive cough samples were recorded and analyzed acoustically. Temporal acoustic features were the following: the slope and curvature of the amplitude contour, as well as the average, slope, and curvature of the sample entropy and kurtosis contours of the recorded signal. Spectral features were the relative energy in the frequency bands (0-400 Hz, 400-800 Hz, 800-1600 Hz, 1600 Hz-3200 Hz, > 3200 Hz) as well as the weighted spectral energy. Results showed that, compared to a voluntary cough, a throat clearing starts with a weaker onset pulse and involves oscillations from the onset to the offset (concave curvature of the amplitude contour, p < 0.05), lower average (p < 0.05), and slope (p < 0.05) as well as lower convex curvature (p < 0.05) of the kurtosis contour. An induced reflexive cough starts with a higher and briefer onset burst and includes higher frication noise (larger convexity of the curvature of the amplitude and kurtosis contours (p < 0.05)) compared to a voluntary cough. The conclusion is that voluntary coughs are acoustically significantly different from voluntary throat clearings and induced reflexive coughs.
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Affiliation(s)
- Sofiana Mootassim-Billah
- Department of Radiation Oncology, Speech Therapy, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium.
| | - Jean Schoentgen
- Department of Biomechatronics, Université Libre de Bruxelles, Brussels, Belgium
| | - Marc De Bodt
- Department of Otolaryngology and Head and Neck Surgery, University Rehabilitation Center for Communication Disorders, Antwerp University Hospital, Antwerp, Belgium
- Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Logopaedics and Audiological Sciences, Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Nicolas Roper
- Department of Oto-Rhino-Laryngology and Head & Neck Surgery, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Antoine Digonnet
- Department of Surgical Oncology, Head and Neck Surgery Unit, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Mathilde Le Tensorer
- Speech Therapy Unit, Institut Jules Bordet, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Gwen Van Nuffelen
- Department of Otolaryngology and Head and Neck Surgery, University Rehabilitation Center for Communication Disorders, Antwerp University Hospital, Antwerp, Belgium
- Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Logopaedics and Audiological Sciences, Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Dirk Van Gestel
- Department of Radiation Oncology, Head and Neck Unit, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
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Mootassim-Billah S, Van Nuffelen G, Schoentgen J, De Bodt M, Van Gestel D. Assessment of radio(chemo)therapy-related dysphagia in head and neck cancer patients based on cough-related acoustic features: a prospective phase II national clinical trial (ACCOUGH-P/A trial). Trials 2023; 24:619. [PMID: 37773172 PMCID: PMC10540417 DOI: 10.1186/s13063-023-07660-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Radiation-associated dysphagia is defined as impaired swallowing efficiency/safety following (chemo)radiotherapy in head and neck cancer patients. In a dysphagia framework, impaired coughing may lead to lung aspiration and fatal lung infection. Although cough efficacy is a predictor of the risk of aspiration, cough investigation is minimal in patients with radiation-associated dysphagia. Because cough is a transient signal, existing software for speech analysis are not appropriate. The goal of our project is to develop an assessment method using acoustic features related to voluntary and reflexive coughs as biomarkers of the risk of penetration/aspiration in patients with radiation-associated dysphagia. METHODS Healthy subjects and head and neck cancer patients with and without dysphagia will produce voluntary coughs, throat clearings and reflexive coughs. Recordings will be made using an acoustic microphone and a throat microphone. The recorded signals will be manually segmented and subsequently analysed with a software under development. Automatic final segmentation enables to measure cough duration. The first method of analysis includes temporal features: the amplitude contour, the sample entropy and the kurtosis. These features report respectively the strength, the unpredictability (turbulence noise due to the air jet) and the impulsive quality (burst) of the signal. The second method of analysis consists of a spectral decomposition of the relative cough signal energy into several frequency bands (0-400 Hz, 400-800 Hz, 800-1600 Hz, 1600-3200 Hz, > 3200 Hz). The primary outcome of this exploratory research project is the identification of a set of descriptive acoustic cough features in healthy subjects as reference data (ACCOUGH). The secondary outcome of this research in head and neck cancer patients with radiation-associated dysphagia includes the identification of (1) a set of descriptive acoustic cough features as biomarkers of penetration-aspiration (ACCOUGH-P/A), (2) swallowing scores, (3) voice features and (4) aerodynamic cough features. DISCUSSION This study is expected to develop methods of acoustic cough analysis to enhance the assessment of radiation-associated dysphagia in head and neck cancer patients following (chemo)radiation. TRIAL REGISTRATION International Standard Randomized Controlled Trials Number (ISRCTN) registry ISRCTN16540497. Accepted on 23 June 2023.
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Affiliation(s)
- Sofiana Mootassim-Billah
- Department of Radiation Oncology, Speech Therapy, Institut Jules Bordet, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium.
| | - Gwen Van Nuffelen
- Department of Otolaryngology and Head and Neck Surgery, University Rehabilitation Center for Communication Disorders, Antwerp University Hospital, Antwerp, Belgium
- Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Logopaedics and Audiological Sciences, Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Jean Schoentgen
- Department of Biomechatronics, Université Libre de Bruxelles, Brussels, Belgium
| | - Marc De Bodt
- Department of Otolaryngology and Head and Neck Surgery, University Rehabilitation Center for Communication Disorders, Antwerp University Hospital, Antwerp, Belgium
- Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Logopaedics and Audiological Sciences, Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Dirk Van Gestel
- Department of Radiation Oncology, Head and Neck Unit, Institut Jules Bordet, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
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Lv G, Wu X, Wang Z, Wu K, Ang G, Cui S, Shi Y, Wang Y, Liu D. Higher radiation doses after partial laryngectomy may raise the incidence of pneumonia: A retrospective cohort study. Front Oncol 2022; 12:1072474. [PMID: 36636552 PMCID: PMC9831674 DOI: 10.3389/fonc.2022.1072474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/05/2022] [Indexed: 12/28/2022] Open
Abstract
Background Currently, studies have shown that a high dose of radiotherapy to the throat have various harmful and adverse effects on the patients' laryngeal function, resulting in the development of pneumonia. This study aimed to explore how radiotherapy dose affected the probability of pneumonia following laryngeal cancer surgery. Materials and methods A retrospective analysis was done on patients diagnosed with laryngeal cancer between 2010 and 2020 and were treated surgically and with postoperative radiotherapy in the same institution. This study included 108 patients in total, 51 of who were in the low-dose group and 57 of whom were in the high-dose group. Age, gender, the location of laryngeal cancer, the presence or absence of lymph node metastasis, and other demographic and clinical characteristics were collected, and the prevalence of postoperative pneumonia was compared between the two groups. Results The total prevalence of postoperative pneumonia was 59.3%, but there was a significant difference between the two groups(high-dose group 71.9% VS low-dose group 45.1%; p=0.005). A total of 9.3% (10/108) of the patients had readmission due to severe pneumonia, and the rate of readmission due to pneumonia was significantly different between the two groups (high-dose group 15.8% VS low-dose group 2.0%, p=0.032). Additionally, the high-dose group's prevalence of Dysphagia was significantly higher than the low-dose group's. According to multivariate logistic modeling, high-dose radiation was a risk factor for pneumonia (OR=4.224, 95%CI =1.603-11.131, p=0.004). Conclusion Pneumonia risk could increase with radiotherapy doses > 50 Gy in the treatment of laryngeal cancer. Therefore, we recommend that when the radiation dose surpasses 50Gy, doctors should pay particular attention to the lung health of patients with laryngeal cancer.
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Affiliation(s)
- Guoqi Lv
- Department of Otorhinolaryngology Head and Neck Surgery, Dalian Municipal Central Hospital, Dalian, Liaoning, China,Dalian Medical University, Dalian, Liaoning, China
| | - Xiuling Wu
- Department of Otorhinolaryngology Head and Neck Surgery, Dalian Municipal Central Hospital, Dalian, Liaoning, China,Dalian Medical University, Dalian, Liaoning, China
| | - Zhengying Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Dalian Municipal Central Hospital, Dalian, Liaoning, China,China Medical University, Shenyang, Liaoning, China
| | - Kanglong Wu
- Dalian Medical University, Dalian, Liaoning, China,The Second Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Geer Ang
- Department of Otorhinolaryngology Head and Neck Surgery, Dalian Municipal Central Hospital, Dalian, Liaoning, China,Dalian Medical University, Dalian, Liaoning, China
| | - Shulin Cui
- Department of Otorhinolaryngology Head and Neck Surgery, Dalian Municipal Central Hospital, Dalian, Liaoning, China,Dalian Medical University, Dalian, Liaoning, China
| | - Yuqi Shi
- Department of Otorhinolaryngology Head and Neck Surgery, Dalian Municipal Central Hospital, Dalian, Liaoning, China,Dalian Medical University, Dalian, Liaoning, China
| | - Yu Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Dalian Municipal Central Hospital, Dalian, Liaoning, China,Dalian Medical University, Dalian, Liaoning, China
| | - Delong Liu
- Department of Otorhinolaryngology Head and Neck Surgery, Dalian Municipal Central Hospital, Dalian, Liaoning, China,*Correspondence: Delong Liu,
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Zhou J, Heng Y, Yang Y, Zhu X, Zhou L, Gong H, Xu C, Tao L. Survival outcomes in patients with T3-4aN0M0 glottic laryngeal squamous cell carcinoma and evaluation of postoperative radiotherapy. Oncol Lett 2022; 24:434. [PMID: 36311684 PMCID: PMC9608082 DOI: 10.3892/ol.2022.13554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022] Open
Abstract
This study aimed to evaluate the clinical outcomes of patients with T3-4aN0M0 glottic laryngeal squamous cell carcinoma (LSCC) treated with laryngectomy, and to assess the postoperative radiotherapy (PORT) results in terms of the survival of T3-T4aN0M0 patients with negative margins. This was a retrospective review of 369 T3-4aN0M0 glottic LSCC cases. The 5-year cancer-specific survival (CSS) and overall survival (OS) rates were 67.5 and 66.7%, respectively. Patients who received total laryngectomy had worse survival [5-year CSS, 62.5%; disease-free survival (DFS), 56.2%] than those who underwent partial laryngectomy (5-year CSS, 79.3%; DFS, 65.4%). More advanced-stage cancer is a predictor of poor survival. There was no significant difference in CSS or DFS between patients with positive margins following rescue therapy and those with negative margins. Furthermore, no difference in the survival rates was observed between patients with negative margins who received PORT and those who did not (5-year DFS: 59.1 vs. 63.8%, P=0.057 and CSS: 62.5 vs. 69.5%, P=0.074). For T3-4aN0M0 glottic LSCC patients, surgical treatment remained a good option, as it can achieve satisfactory oncological outcomes. However, PORT did not increase survival in surgically managed pT3-4aN0M0 LSCC patients with negative margins.
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Affiliation(s)
- Jian Zhou
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University, Shanghai 200031, P.R. China
| | - Yu Heng
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University, Shanghai 200031, P.R. China
| | - Yue Yang
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University, Shanghai 200031, P.R. China
| | - Xiaoke Zhu
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University, Shanghai 200031, P.R. China
| | - Liang Zhou
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University, Shanghai 200031, P.R. China
| | - Hongli Gong
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University, Shanghai 200031, P.R. China
| | - Chengzhi Xu
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University, Shanghai 200031, P.R. China
| | - Lei Tao
- Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Fudan University, Shanghai 200031, P.R. China
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Mootassim‐Billah S, Van Nuffelen G, Schoentgen J, De Bodt M, Dragan T, Digonnet A, Roper N, Van Gestel D. Assessment of cough in head and neck cancer patients at risk for dysphagia-An overview. Cancer Rep (Hoboken) 2021; 4:e1395. [PMID: 33932152 PMCID: PMC8551981 DOI: 10.1002/cnr2.1395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/22/2021] [Accepted: 03/26/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND This literature review explores the terminology, the neurophysiology, and the assessment of cough in general, in the framework of dysphagia and regarding head and neck cancer patients at risk for dysphagia. In the dysphagic population, cough is currently assessed perceptually during a clinical swallowing evaluation or aerodynamically. RECENT FINDINGS Recent findings have shown intra and inter-rater disagreements regarding perceptual scoring of cough. Also, aerodynamic measurements are impractical in a routine bedside assessment. Coughing, however, is considered to be a clinically relevant sign of aspiration and dysphagia in head and cancer patients treated with concurrent chemoradiotherapy. CONCLUSION This article surveys the literature regarding the established cough assessment and stresses the need to implement innovative methods for assessing cough in head and neck cancer patients treated with concurrent chemoradiotherapy at risk for dysphagia.
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Affiliation(s)
- Sofiana Mootassim‐Billah
- Department of Radiation Oncology, Speech Therapy, Institut Jules BordetUniversité Libre de BruxellesBrusselsBelgium
| | - Gwen Van Nuffelen
- Department of Otolaryngology and Head and Neck Surgery, University Rehabilitation Center for Communication DisordersAntwerp University HospitalAntwerpBelgium
- Department of Translational Neurosciences, Faculty of Medicine and Health SciencesUniversity of AntwerpAntwerpBelgium
- Department of Logopaedics and Audiological Sciences, Faculty of Medicine and Health SciencesUniversity of GhentGhentBelgium
| | - Jean Schoentgen
- BEAMS (Bio‐, Electro‐ And Mechanical Systems)Université Libre de BruxellesBrusselsBelgium
| | - Marc De Bodt
- Department of Otolaryngology and Head and Neck Surgery, University Rehabilitation Center for Communication DisordersAntwerp University HospitalAntwerpBelgium
- Department of Translational Neurosciences, Faculty of Medicine and Health SciencesUniversity of AntwerpAntwerpBelgium
- Department of Logopaedics and Audiological Sciences, Faculty of Medicine and Health SciencesUniversity of GhentGhentBelgium
| | - Tatiana Dragan
- Department of Radiation Oncology, Head and Neck Unit, Institut Jules BordetUniversité Libre de BruxellesBrusselsBelgium
| | - Antoine Digonnet
- Department of Surgical Oncology, Head and Neck Surgery Unit, Institut Jules BordetUniversité Libre de BruxellesBrusselsBelgium
| | - Nicolas Roper
- Department of Oto‐Rhino‐Laryngology and Head & Neck Surgery, Erasme HospitalUniversité Libre de BruxellesBrusselsBelgium
| | - Dirk Van Gestel
- Department of Radiation Oncology, Head and Neck Unit, Institut Jules BordetUniversité Libre de BruxellesBrusselsBelgium
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Reflex vs. volitional cough differences amongst head and neck cancer survivors characterized by time since treatment and aspiration status. Respir Physiol Neurobiol 2021; 293:103702. [PMID: 34033947 DOI: 10.1016/j.resp.2021.103702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study was to investigate differences in reflexive and volitional cough airflows in advanced stage head and neck cancer survivors as it relates to aspiration status and time since treatment. The hypothesis is that those who aspirate several years after treatment completion would demonstrate reduced airflows for all cough parameters compared to those recently status post treatment completion given the known progressive deterioration associated with radiotherapy. METHODS Demographic and airflow data during both reflexive and volitional cough tasks and aspiration status as determined during fiberoptic endoscopic evaluation of swallow function were collected from 33 Head and Neck Cancer (HNC) survivors. RESULTS Omnibus MANOVA for dependent airflow variables and independent variables aspiration status, time since treatment and cough type (reflex or volitional) was significant (F(3,1) = 184, p < 0.000) indicating that peak expiratory flow rates (PEFR) were reduced under reflex (mean PEFR 1.88 SD 0.7) versus volitional (mean PEFR 2.3, SD 0.7) cough types; reduced for aspirators versus non-aspirators (F(2,1) = 4.1, p = 0.04) and reduced for those in the subacute versus chronic phase status post Intensity Modulated Radiotherapy (IMRT) (F(2,1) = 10.05, p = 0.002). CONCLUSION Findings of reduced reflexive compared to volitional cough airflows in head and neck cancer survivors are consistent with those from both healthy and other diseased populations. Additional findings that aspirators demonstrate reduced cough airflows compared to non-aspirators supports the hypothesis. Surprisingly, those recently status post treatment completion show worse cough airflows compared to those remotely status post treatment completion.
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Ohkoshi A, Kato K, Ogawa T, Nakanome A, Ishii R, Katori Y. Improvement of a delayed swallowing reflex following treatment for advanced head and neck cancer. CANCERS OF THE HEAD & NECK 2020; 5:8. [PMID: 32514387 PMCID: PMC7265250 DOI: 10.1186/s41199-020-00055-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/05/2020] [Indexed: 11/10/2022]
Abstract
Background The latency of the swallowing reflex is an important factor causing dysphagia in head and neck cancer patients. Although there are many reports comparing voluntary swallowing function before and after treatment, few studies have focused on the latency of the swallowing reflex, which is a risk factor for pneumonia due to silent aspiration. The aim of this retrospective study was to clarify the changes in the latency of the swallowing reflex before and after treatment. Methods The latency of the swallowing reflex was quantified using the time from the injection of 1 ml of distilled water into the pharynx through a nasal catheter to the onset of swallowing. Results The latency time of the swallowing reflex was significantly decreased 3 months after treatment compared to before treatment. A significant reduction was also observed in patients with pharyngeal cancer who underwent chemoradiation therapy. Conclusions This retrospective study showed that a delayed swallowing reflex improved with treatment in advanced head and neck cancer patients. Trial registration The Institutional Review Board of Tohoku University Hospital (Number 2014-1-274).
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Affiliation(s)
- Akira Ohkoshi
- Department of Otorhinolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Sendai, 980-8575 Japan
| | - Kengo Kato
- Department of Otorhinolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Sendai, 980-8575 Japan
| | - Takenori Ogawa
- Department of Otorhinolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Sendai, 980-8575 Japan
| | - Ayako Nakanome
- Department of Otorhinolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Sendai, 980-8575 Japan
| | - Ryo Ishii
- Department of Otorhinolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Sendai, 980-8575 Japan
| | - Yukio Katori
- Department of Otorhinolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Sendai, 980-8575 Japan
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Strojan P, Hutcheson KA, Eisbruch A, Beitler JJ, Langendijk JA, Lee AWM, Corry J, Mendenhall WM, Smee R, Rinaldo A, Ferlito A. Treatment of late sequelae after radiotherapy for head and neck cancer. Cancer Treat Rev 2017; 59:79-92. [PMID: 28759822 PMCID: PMC5902026 DOI: 10.1016/j.ctrv.2017.07.003] [Citation(s) in RCA: 163] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 06/05/2017] [Accepted: 07/09/2017] [Indexed: 12/21/2022]
Abstract
Radiotherapy (RT) is used to treat approximately 80% of patients with cancer of the head and neck. Despite enormous advances in RT planning and delivery, a significant number of patients will experience radiation-associated toxicities, especially those treated with concurrent systemic agents. Many effective management options are available for acute RT-associated toxicities, but treatment options are much more limited and of variable benefit among patients who develop late sequelae after RT. The adverse impact of developing late tissue damage in irradiated patients may range from bothersome symptoms that negatively affect their quality of life to severe life-threatening complications. In the region of the head and neck, among the most problematic late effects are impaired function of the salivary glands and swallowing apparatus. Other tissues and structures in the region may be at risk, depending mainly on the location of the irradiated tumor relative to the mandible and hearing apparatus. Here, we review the available evidence on the use of different therapeutic strategies to alleviate common late sequelae of RT in head and neck cancer patients, with a focus on the critical assessment of the treatment options for xerostomia, dysphagia, mandibular osteoradionecrosis, trismus, and hearing loss.
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Affiliation(s)
- Primož Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia.
| | - Katherine A Hutcheson
- Department of Head and Neck Surgery, Section of Speech Pathology and Audiology, MD Anderson Cancer Center, Houston, TX, USA
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Jonathan J Beitler
- Departments of Radiation Oncology, Otolaryngology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anne W M Lee
- Center of Clinical Oncology, University of Hong Kong - Shenzhen Hospital, Shenzhen, China
| | - June Corry
- Radiation Oncology, GenesisCare, St. Vincents's Hospital, Melbourne, Victoria, Australia
| | | | - Robert Smee
- Department of Radiation Oncology, The Prince of Wales Cancer Centre, Sydney, NSW, Australia
| | | | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, Italy
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Zecha JAEM, Raber-Durlacher JE, Nair RG, Epstein JB, Elad S, Hamblin MR, Barasch A, Migliorati CA, Milstein DMJ, Genot MT, Lansaat L, van der Brink R, Arnabat-Dominguez J, van der Molen L, Jacobi I, van Diessen J, de Lange J, Smeele LE, Schubert MM, Bensadoun RJ. Low-level laser therapy/photobiomodulation in the management of side effects of chemoradiation therapy in head and neck cancer: part 2: proposed applications and treatment protocols. Support Care Cancer 2016; 24:2793-805. [PMID: 26984249 DOI: 10.1007/s00520-016-3153-y] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 03/07/2016] [Indexed: 12/19/2022]
Abstract
PURPOSE There is a large body of evidence supporting the efficacy of low-level laser therapy (LLLT), more recently termed photobiomodulation (PBM) for the management of oral mucositis (OM) in patients undergoing radiotherapy for head and neck cancer (HNC). Recent advances in PBM technology, together with a better understanding of mechanisms involved and dosimetric parameters may lead to the management of a broader range of complications associated with HNC treatment. This could enhance patient adherence to cancer therapy, and improve quality of life and treatment outcomes. The mechanisms of action, dosimetric, and safety considerations for PBM have been reviewed in part 1. Part 2 discusses the head and neck treatment side effects for which PBM may prove to be effective. In addition, PBM parameters for each of these complications are suggested and future research directions are discussed. METHODS Narrative review and presentation of PBM parameters are based on current evidence and expert opinion. RESULTS PBM may have potential applications in the management of a broad range of side effects of (chemo)radiation therapy (CRT) in patients being treated for HNC. For OM management, optimal PBM parameters identified were as follows: wavelength, typically between 633 and 685 nm or 780-830 nm; energy density, laser or light-emitting diode (LED) output between 10 and 150 mW; dose, 2-3 J (J/cm(2)), and no more than 6 J/cm(2) on the tissue surface treated; treatment schedule, two to three times a week up to daily; emission type, pulsed (<100 Hz); and route of delivery, intraorally and/or transcutaneously. To facilitate further studies, we propose potentially effective PBM parameters for prophylactic and therapeutic use in supportive care for dermatitis, dysphagia, dry mouth, dysgeusia, trismus, necrosis, lymphedema, and voice/speech alterations. CONCLUSION PBM may have a role in supportive care for a broad range of complications associated with the treatment of HNC with CRT. The suggested PBM irradiation and dosimetric parameters, which are potentially effective for these complications, are intended to provide guidance for well-designed future studies. It is imperative that such studies include elucidating the effects of PBM on oncology treatment outcomes.
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Affiliation(s)
- Judith A E M Zecha
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Judith E Raber-Durlacher
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.,Department of Medical Dental Interaction and Department of Periodontology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University, P.O. Box 22660 1100 DD, Amsterdam, the Netherlands
| | - Raj G Nair
- Oral Medicine Oral Pathology and Human Diseases, Menzies Health Institute Queensland and Oral Medicine Consultant, Department of Haematology and Oncology/Cancer Services, Gold Coast University Hospital, Queensland Health, Queensland, Australia
| | - Joel B Epstein
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.,Division of Otolaryngology and Head and Neck Surgery, City of Hope, Duarte, CA, 91010, USA
| | - Sharon Elad
- Division of Oral Medicine, Eastman Institute for Oral Health, and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, 14620, USA
| | - Michael R Hamblin
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, 02114, USA.,Department of Dermatology, Harvard Medical School, Boston, MA, 02115, USA.,Harvard-MIT Division of Health Science and Technology, Cambridge, MA, 02139, USA
| | - Andrei Barasch
- Division of Oncology, Weill Cornell Medical Center, New York, NY, USA
| | - Cesar A Migliorati
- Department of Diagnostic Sciences and Oral Medicine, Director of Oral Medicine, College of Dentistry, University of Tennessee Health Science Center, 875 Union Ave. Suite N231, Memphis, TN, 38163, USA
| | - Dan M J Milstein
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Marie-Thérèse Genot
- Laser Therapy Unit, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles, Brussels, Belgium
| | - Liset Lansaat
- Antoni van Leeuwenhoek Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Ron van der Brink
- Division of Otolaryngology and Head and Neck Surgery, City of Hope, Duarte, CA, 91010, USA
| | | | - Lisette van der Molen
- Antoni van Leeuwenhoek Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Irene Jacobi
- Antoni van Leeuwenhoek Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Judi van Diessen
- Antoni van Leeuwenhoek Department of Radiation Oncology, Amsterdam, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Jan de Lange
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Ludi E Smeele
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.,Antoni van Leeuwenhoek Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Mark M Schubert
- Seattle Cancer Care Alliance (SCCA), Oral Medicine, 825 Eastlake Ave E Ste G6900, Seattle, WA, 98109, USA
| | - René-Jean Bensadoun
- World Association for Laser Therapy (WALT) Scientific Secretary, Centre de Haute Energie (CHE), 10 Bd Pasteur, 06000, Nice, France.
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Feasibility of intensity-modulated and image-guided radiotherapy for functional organ preservation in locally advanced laryngeal cancer. PLoS One 2012; 7:e42729. [PMID: 22916151 PMCID: PMC3423414 DOI: 10.1371/journal.pone.0042729] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2012] [Accepted: 07/11/2012] [Indexed: 11/19/2022] Open
Abstract
Purpose The study aims to assess the feasibility of intensity-modulated and image-guided radiotherapy (IMRT, and IGRT, respectively) for functional preservation in locally advanced laryngeal cancer. A retrospective review of 27 patients undergoing concurrent chemoradiation for locally advanced laryngeal cancers (8 IMRT, 19 IGRT) was undertaken. In addition to regular clinical examinations, all patients had PET imaging at 4 months and 10 months after radiotherapy, then yearly. Loco-regional control, speech quality and feeding-tube dependency were assessed during follow-up visits. Results At a median follow-up of 20 months (range 6–57 months), four out of 27 patients (14.8%) developed local recurrence and underwent salvage total laryngectomy. One patient developed distant metastases following salvage surgery. Among the 23 patients who conserved their larynx with no sign of recurrence at last follow-up, 22 (95%) reported normal or near normal voice quality, allowing them to communicate adequately. Four patients (14.8%) had long-term tube feeding-dependency because of severe dysphagia (2 patients) and chronic aspiration (2 patients, with ensuing death from aspiration pneumonia in one patient). Conclusions and Clinical Relevance Functional laryngeal preservation is feasible with IMRT and IGRT for locally advanced laryngeal cancer. However, dysphagia and aspiration remain serious complications, due most likely to high radiation dose delivery to the pharyngeal musculatures.
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Raber-Durlacher JE, Brennan MT, Verdonck-de Leeuw IM, Gibson RJ, Eilers JG, Waltimo T, Bots CP, Michelet M, Sollecito TP, Rouleau TS, Sewnaik A, Bensadoun RJ, Fliedner MC, Silverman S, Spijkervet FKL. Swallowing dysfunction in cancer patients. Support Care Cancer 2012; 20:433-43. [PMID: 22205548 PMCID: PMC3271214 DOI: 10.1007/s00520-011-1342-2] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 11/29/2011] [Indexed: 01/08/2023]
Abstract
PURPOSE Dysphagia (swallowing dysfunction) is a debilitating, depressing, and potentially life-threatening complication in cancer patients that is likely underreported. The present paper is aimed to review relevant dysphagia literature between 1990 and 2010 with a focus on assessment tools, prevalence, complications, and impact on quality of life in patients with a variety of different cancers, particularly in those treated with curative chemoradiation for head and neck cancer. METHODS The literature search was limited to the English language and included both MEDLINE/PubMed and EMBASE. The search focused on papers reporting dysphagia as a side effect of cancer and cancer therapy. We identified relevant literature through the primary literature search and by articles identified in references. RESULTS A wide range of assessment tools for dysphagia was identified. Dysphagia is related to a number of factors such as direct impact of the tumor, cancer resection, chemotherapy, and radiotherapy and to newer therapies such as epidermal growth factor receptor inhibitors. Concomitant oral complications such as xerostomia may exacerbate subjective dysphagia. Most literature focuses on head and neck cancer, but dysphagia is also common in other types of cancer. CONCLUSIONS Swallowing impairment is a clinically relevant acute and long-term complication in patients with a wide variety of cancers. More prospective studies on the course of dysphagia and impact on quality of life from baseline to long-term follow-up after various treatment modalities, including targeted therapies, are needed.
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Affiliation(s)
- Dysphagia Section, Oral Care Study Group, Multinational Association of Supportive Care in Cancer (MASCC)/International Society of Oral Oncology (ISOO)
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Oral Medicine, Carolinas Medical Center, Charlotte, NC USA
- Department of Otorhinolaryngology, Head and Neck Surgery, VU University Medical Center, Amsterdam, the Netherlands
- School of Medical Sciences, University of Adelaide, Adelaide, South Australia Australia
- The Nebraska Medical Center and University of Nebraska Medical Center, Omaha, NE USA
- Institute of Preventive Dentistry and Oral Microbiology School of Dental Medicine, University of Basel, Basel, Switzerland
- Department of Oral Biochemistry, Academic Centre for Dentistry Amsterdam (ACTA), and Centre for Special Care in Dentistry (SBT), Amsterdam, the Netherlands
- Department of Oral Oncology, FUNDALEU (Foundation for the Fight Against Leukemia), Buenos Aires, Argentina
- Clinical Oral Medicine, Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, 3400 Spruce Street, Philadelphia, PA USA
- Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
- Radiation Oncology Department, Poitiers University Hospital and Faculty of Medicine, Poitiers, France
- ANP Oncology, Bern University Hospital, Bern, Switzerland
- Department of Orofacial Sciences, University of California San Francisco, School of Dentistry, San Francisco, CA USA
- Department Oral & Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Section Preventive Dentistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Gustav Mahlerlaan 3004, 1081 LA Amsterdam, the Netherlands
| | - Judith E. Raber-Durlacher
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
- Section Preventive Dentistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Gustav Mahlerlaan 3004, 1081 LA Amsterdam, the Netherlands
| | - Mike T. Brennan
- Department of Oral Medicine, Carolinas Medical Center, Charlotte, NC USA
| | - Irma M. Verdonck-de Leeuw
- Department of Otorhinolaryngology, Head and Neck Surgery, VU University Medical Center, Amsterdam, the Netherlands
| | - Rachel J. Gibson
- School of Medical Sciences, University of Adelaide, Adelaide, South Australia Australia
| | - June G. Eilers
- The Nebraska Medical Center and University of Nebraska Medical Center, Omaha, NE USA
| | - Tuomas Waltimo
- Institute of Preventive Dentistry and Oral Microbiology School of Dental Medicine, University of Basel, Basel, Switzerland
| | - Casper P. Bots
- Department of Oral Biochemistry, Academic Centre for Dentistry Amsterdam (ACTA), and Centre for Special Care in Dentistry (SBT), Amsterdam, the Netherlands
| | - Marisol Michelet
- Department of Oral Oncology, FUNDALEU (Foundation for the Fight Against Leukemia), Buenos Aires, Argentina
| | - Thomas P. Sollecito
- Clinical Oral Medicine, Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, 3400 Spruce Street, Philadelphia, PA USA
| | - Tanya S. Rouleau
- Department of Oral Medicine, Carolinas Medical Center, Charlotte, NC USA
| | - Aniel Sewnaik
- Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rene-Jean Bensadoun
- Radiation Oncology Department, Poitiers University Hospital and Faculty of Medicine, Poitiers, France
| | | | - Sol Silverman
- Department of Orofacial Sciences, University of California San Francisco, School of Dentistry, San Francisco, CA USA
| | - Fred K. L. Spijkervet
- Department Oral & Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Effectiveness of image-guided radiotherapy for laryngeal sparing in head and neck cancer. Oral Oncol 2010; 46:283-6. [DOI: 10.1016/j.oraloncology.2010.01.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 01/15/2010] [Accepted: 01/15/2010] [Indexed: 11/22/2022]
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Abstract
PURPOSE OF REVIEW Chemotherapy has been found to result in comparable survival rates to surgery for head and neck cancer. However, toxicity can often be worse after chemoradiotherapy, with impairment in voice, swallowing, nutrition, and quality of life. Investigators are attempting to modify radiotherapy treatment regimens to spare organs that have an impact on swallowing. This review will highlight voice and swallowing impairment seen after chemoradiotherapy, as well as treatment for voice and swallowing disorders in this population. Results of newer radiotherapy regimens will also be highlighted. RECENT FINDINGS Specific oropharyngeal swallowing motility disorders after chemoradiotherapy have been identified. Damage to specific structures has been correlated with specific pharyngeal phase swallow impairment. Swallowing function and quality of life have been examined over time, with improvement seen in both. Preventive/prophylactic swallow exercise programs have been encouraging. Chemoradiotherapy effects on voice have been identified in terms of acoustic, aerodynamic, and patient and clinician-rated perception of function. Improvement in voice has also been observed over time after chemoradiotherapy. Voice therapy has been found to have a positive impact on voice and perceptual measures in this population. SUMMARY Current studies show some improvement in swallow function after swallow and voice therapy in patients treated with chemoradiotherapy. Further, there is a suggestion of improved swallow function with sparing of organs with specific radiotherapy protocols. Future research needs to focus on specific voice and swallow treatment regimens in the head and neck cancer patient treated with chemoradiotherapy, specifically, timing, frequency, duration, and specific treatment types.
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Lazarus CL. Effects of Chemoradiotherapy on Tongue Function in Patients With Head and Neck Cancer. ACTA ACUST UNITED AC 2009. [DOI: 10.1044/sasd18.2.55] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
In this review article, the effects of radiotherapy ± chemotherapy on tissues and on oropharyngeal swallowing are reviewed. In addition, normal tongue function for swallowing is reviewed, as are the effects of tongue exercise programs designed to improve tongue strength and swallow functioning. Current literature on swallow exercise programs for head and neck cancer patients is provided. Also discussed are potential new avenues for research in this population.
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Affiliation(s)
- Cathy L. Lazarus
- Department of Otolaryngology, New York University School of MedicineNew York, NY
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16
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Abstract
Patients who have cancers of the oral cavity, pharynx, or larynx may be treated with surgery, radiotherapy, chemotherapy, or a combination of these modalities. Each treatment type may have a negative impact on posttreatment swallowing function; these effects are presented in this article. A number of rehabilitative procedures are available to the clinician to reduce or eliminate swallowing disorders in patients treated for cancer of the head and neck. The various procedures-including postures, maneuvers, modifications to bolus volume and viscosity, range-of-motion exercises, and strengthening exercises-and their efficacy in patients treated for head and neck cancer are discussed.
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Affiliation(s)
- Barbara R Pauloski
- Communication Sciences and Disorders, Northwestern University, 2240 Campus Drive, Suite 3-331, Evanston, IL 60208-3540, USA.
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17
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Current World Literature. Curr Opin Otolaryngol Head Neck Surg 2008; 16:175-82. [DOI: 10.1097/moo.0b013e3282fd9415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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