Nutritional Aspects of Dysphagia Management

Comparative analysis of videofluoroscopy and pulse oximetry for aspiration identification in patients with dysphagia after stroke and non-dysphagics

PURPOSE

Dysphagia is a prevalent symptom observed in acute stroke. Several bedside screening tests are employed for the early detection of dysphagia. Pulse oximetry emerges as a practical and supportive method to augment the existing techniques utilized during bedside swallowing assessments. Desaturation levels, as measured by pulse oximetry, are acknowledged as indicative of aspiration by certain screening tests. However, the predictive capability of pulse oximetry in determining aspiration remains a subject of controversy. The objective of this study was to compare aspiration and oxygen desaturation levels by time and aspiration severity in dysphagic patients compared to healthy controls. It also aimed to evaluate the accuracy of pulse oximetry by comparing it with VFSS findings in detecting aspiration in both liquid (IDDSI-0) and semi-solid (IDDSI-4) consistencies.

MATERIALS AND METHODS

Eighty subjects (40 healthy and 40 acute stroke patients) participated. Patients suspected of dysphagia underwent videofluoroscopy as part of the stroke unit's routine procedure. Baseline SpO2 was measured before VFSS, and stabilized values were recorded. Sequential IDDSI-0 and IDDSI-4 barium tests were conducted with 5 ml boluses. Stabilized SPO2 values were recorded during swallowing and 3-min post-feeding. Patients with non-dysphagia received equal bolus monitoring. Changes in SPO2 during, before, and after swallowing were analyzed for each consistency in both groups.

RESULTS

The study revealed a statistically significant difference in SPO2 between patients with dysphagia and controls for IDDSI-4 and IDSSI-0. In IDDSI-4, 20% of patients experienced SpO2 decrease compared to 2.5% in control group (p = 0.013). For IDDSI-0, 35% of patients showed SpO2 decrease, while none in the control group did (p = 0.0001). Aspiration rates were 2.5% in IDDSI-4 and 57.5% in IDDSI-0. In IDDSI-0, SpO2 decrease significantly correlated with aspiration (p = 0.0001). In IDDSI-4, 20.5% had SpO2 decrease without aspiration, and showing no significant difference (p = 0.613). Penetration-Aspiration Scale scores had no significant association with SpO2 decrease (p = 0.602). Pulse oximetry in IDDSI-4 had limited sensitivity (0%) and positive predictive value, (0%) while in IDDSI-0, it demonstrated acceptable sensitivity (60.9%) and specificity (100%) with good discrimination capability (AUC = 0.83).

CONCLUSIONS

A decrease in SPO2 may indicate potential aspiration but is insufficient alone for detection. This study proposes pulse oximetry as a valuable complementary tool in assessing dysphagia but emphasizes that aspiration cannot be reliably predicted based solely on SpO2 decrease.

Nutritional Issues in Children with Dysphagia

(1) Background: Pediatric dysphagia presents significant nutritional challenges, often impacting growth and development due to reduced oral intake, increased nutritional needs, and gastrointestinal complications; (2) Methods: This prospective quasi-experimental study assessed 117 children under 14 years old (20 patients were under 1 year old, 80 were aged 1-7 years, and 17 were older than 7 years), diagnosed with swallowing disorders, to analyze their caloric, macro-, and micronutrient intake and identify potential deficiencies. The severity of dysphagia was established using functional oral intake scales, and dietary records were reviewed over a 3-day period; (3) Results: The study revealed that 39.8% of participants did not meet their total energy expenditure (TEE), highlighting a high prevalence of malnutrition among these children. Furthermore, patients using feeding devices exhibited a significantly lower caloric intake, and over half required significantly modified food textures. After individualized speech therapy and nutritional rehabilitation, participants showed significant improvements in caloric intake, with their energy coverage increasing from 958% to 1198% of the daily requirement. Rehabilitation also improved tolerance to a broader range of food textures; (4) Conclusions: This research underscores the importance of multidisciplinary, individualized nutritional strategies to address the specific challenges of pediatric dysphagia, emphasizing the role of enteral nutrition and therapeutic interventions in improving the quality of life and nutritional outcomes of these children. Further studies are recommended to assess the long-term impact of such strategies.

A Knowledge-based Decision Support System for recommending safe recipes to individuals with dysphagia

BACKGROUND

Dysphagia is a disorder that can be associated to several pathological conditions, including neuromuscular diseases, with significant impact on quality of life. Dysphagia often leads to malnutrition, as a consequence of the dietary changes made by patients or their caregivers, who may deliberately decide to reduce or avoid specific food consistencies (because they are not perceived as safe), and the lack of knowledge in how to process foods are critics. Such dietary changes often result in unbalanced nutrients intake, which can have significant consequences for frail patients. This paper presents the development of a prototypical novel ontology-based Decision Support System (DSS) to support neuromuscular patients with dysphagia (following a per-oral nutrition) and their caregivers in preparing nutritionally balanced and safe meals.

METHOD

After reviewing scientific literature, we developed in collaboration with Ear-Nose-Throat (ENT) specialists, neurologists, and dieticians the DSS formalizes expert knowledge to suggest recipes that are considered safe according to patient's consistency limitations and dysphagia severity and also nutritionally well-balanced.

RESULTS

The prototype can be accessed via digital applications both by physicians to generate and verify the recommendations, and by the patients and their caregivers to follow the step-by-step procedures to autonomously prepare and process one or more recipe. The system is evaluated with 9 clinicians to assess the quality of the DSS's suggested recipes and its acceptance in clinical practice.

CONCLUSIONS

Preliminary results suggest a global positive outcome for the recipes inferred by the DSS and a good usability of the system.

[Protocol of action in the dietary and nutritional approach in patients with dysphagia]

Introduction

Introduction: dysphagia is classified under "symptoms and signs involving the digestive system and abdomen" in the International Classification of Diseases (ICD-10, code R13). It is defined as obstruction in the region of the pharynx, sternum or xiphoid because of obstruction of the passage of food from the mouth to the stomach or cardia, and has become one of the most important causes affecting the adequate intake of energy and nutrients. An optimal dietary and nutritional approach plays a crucial role in the management of dysphagia. The main goal of such an approach is to ensure safe and sufficient nutrition to prevent malnutrition and complications associated with dysphagia. Objectives: to establish an action protocol for an effective dietary and nutritional approach in patients with dysphagia based on the existing scientific evidence. Methods: a review of the scientific literature on the dietary-nutritional approach to dysphagia was carried out. Results: the dietary and nutritional approach in patients with dysphagia requires a multidisciplinary and personalized approach and is essential to improve the quality of life of patients with dysphagia. Through the implementation of an evidence-based action protocol, it is possible to guarantee preventing aspiration and ensuring safe swallowing and modification of textures of different foods (thus promoting adequate intake of nutrients and fluids to avoid malnutrition and dehydration). Conclusion: adequate and protocolized management, from a dietary and nutritional point of view, can have a significant impact on the quality of life of patients, improving their well-being and preventing complications associated with this condition.

Oral diet management for carcinoma at the base of tongue with radiotherapy and chemotherapy associated dysphagia: a case report

Introduction

Tongue cancer is one of the common malignancy of the head and neck, and directly impacts chewing, swallowing, and other eating activities. Based on the evidence-based guidelines and clinical management, this paper presents nutrition management experience of a patient with tongue cancer who had a dysphagia and feeding reflux while undergoing radiotherapy and chemotherapy.

Methods

Nutritional risk screening and comprehensive nutritional assessment were performed based on the patient's medical history, and personalized nutritional programs were developed under the guidance of the clinical pharmaceutical consensus of parenteral nutrition and nutritional treatment guidelines for patients with tumors during radiotherapy. For the management of oral feeding, the patient's swallowing function was evaluated to manage oral feeding. Thickening powders were used to improve the consistency of the patient's food, which successfully achieved oral feeding of the patient.

Results

The patient finally ate five meals a day by mouth, and energy requirements were met using industrialized nutritional supplements, and homogenized food was added in between the meals. The energy provided by enteral nutrition can reached approximately 60-75%. The patient's weight and albumin levels had increased significantly at the time of discharge.

Discussion

The nutritional management of patients with dysphagia should be jointly managed by clinicians, nurses, nutritionists, and family members to effectively improve the quality of life (QOL) and nutritional status of patients. To ensure adequate nutritional supply, appropriate swallowing training may delay the deterioration of the chewing function and improve the eating experience of such patients.

Hospital management of the patient with dysphagia. Survey and recommendations of SEEN nutrition area

INTRODUCTION

The prevalence of dysphagia in hospitalized patients is extraordinarily high and little known. The goal of care should be to assess the efficacy and safety of swallowing, to indicate personalized nutritional therapy. The development of Dysphagia Units, as a multidisciplinary team, facilitates comprehensive care for this type of patient.

MATERIAL AND METHODS

A observational, cross-sectional, web-based survey-type study, focused on Spanish Society of Endocrinology and Nutrition department heads, was conducted in September-October 2021. The following data were analyzed: size and type of center, existence of a dysphagia unit, dysphagia screening, dietary and nutritional therapy, education and training of professionals and patients, codification, and quality of life evaluation.

RESULTS

65 responses (39% of the total Endocrinology and Nutrition departments). 37% of hospitals have a Dysphagia Unit and 25% are developing it. 75.4% perform screening, with MECV-V in 80.6%, and VED (61.4%) and VFS (54.4%) are performed as main complementary tests. The centers have different models of oral diet, thickeners and nutritional oral supplements adapted to dysphagia. In 40% of the centers, no information is offered on dysphagia, nor on the use of thickeners, dysphagia is coded in 81%, 52.3% have specific nursing protocols and only 8% have scales for quality-of-life evaluation.

CONCLUSIONS

The high prevalence and the risk of serious complications require early and multidisciplinary management at the hospital level. The information received by the patient and caregiver about the dietary adaptations they need, is essential to minimize risks and improve quality of life.

Shear-Viscosity-Dependent Effect of a Gum-Based Thickening Product on the Safety of Swallowing in Older Patients with Severe Oropharyngeal Dysphagia

Fluid thickening is a valid therapeutic strategy for patients with oropharyngeal dysphagia (OD). The main aim of this study was to determine the therapeutic effect of the xanthan-gum-based thickener Tsururinko Quickly (TQ, Morinaga Milk Co., Tokyo, Japan) in older patients with severe OD. A total of 85 patients (83.32 ± 6.75 y) with OD and a penetration-aspiration score (PAS) of n ≥ 3 were studied by videofluoroscopy while swallowing duplicate 10 mL boluses at <50 mPa·s, 100, 200, 400, 800, and 1600 mPa·s, to assess the safety and efficacy of swallowing and the biomechanics of a swallowing response at each viscosity level. At <50 mPa·s, only 16.25% patients swallowed safely, 45% had penetrations (PAS 3-5), and 38.75% had aspirations (PAS 6-8). Fluid thickening with TQ greatly increased the prevalence of patients with safe swallowing from 62.90% at 100 mPa·s to 95.24% at 1600 mPa·s in a shear-viscosity-dependent manner. The penetrations and aspirations were significantly reduced to 3.60% and 1.19%, respectively, at 1600 mPa·s. The threshold viscosity was 100 mPa·s and the increasing viscosity above 800 mPa·s did not further improve the therapeutic effect significantly. Increasing the shear viscosity significantly reduced the time to laryngeal vestibule closure (-16.70%), increased the time to upper oesophageal sphincter opening (+26.88%), and reduced the pharyngeal bolus velocity (-31.62%) without affecting the pharyngeal residue. TQ has a strong shear-viscosity-dependent effect on the safety of swallowing in older patients with severe OD without increasing the pharyngeal residue. The therapeutic range for TQ is 100-800 mPa·s, with 200 and 800 mPa·s being the optimal doses to cover the needs of older patients with OD.

Perioperative nutritional risk and its influencing factors in patients with oral cancer: a longitudinal study

Introduction

We aimed to investigate the nutritional risk status and dynamic changes in patients with perioperative oral cancer at different stages and analyze the factors influencing nutritional risk and the correlation among body mass index, nutrition-related symptoms, and nutritional risk.

Methods

In total, 198 patients with oral cancer who were hospitalized in the Head & Neck Surgery Departments of a tertiary cancer hospital in Hunan Province, China, from May 2020 to January 2021, were selected as participants. The Nutritional Risk Screening 2002 scale and Head and Neck Patient Symptom Checklist were used to assess patients on admission day, 7 days post-surgery, and 1 month post-discharge. Multivariate analysis of variance, paired t-test, and generalized estimating equation were used to analyze the trajectory and influencing factors of nutritional risk in patients with perioperative oral cancer. Spearman's correlation analysis was used to explore the correlation among body mass index, symptoms, and nutritional risk.

Results

The nutritional risk scores of patients with oral cancer at the three time points were 2.30 ± 0.84, 3.21 ± 0.94, and 2.11 ± 0.84, respectively, and the differences were significant (p < 0.05). The incidences of nutritional risk were 30.3, 52.5, and 37.9%, respectively. The factors influencing nutritional risk included education level, smoking status, clinical stage, flap repair, and tracheotomy (β = -0.326, 0.386, 0.387, 0.336, and 0.240, respectively, p < 0.05). Nutritional risk was negatively correlated with body mass index (r_s = -0.455, p < 0.01) and positively correlated with pain, loss of appetite, sore mouth, bothersome smells, swallowing difficulty, taste changes, depression, chewing difficulty, thick saliva, and anxiety (r_s = 0.252, 0.179, 0.269, 0.155, 0.252, 0.212, 0.244, 0.384, 0.260, and 0.157, respectively, p < 0.05).

Conclusion

The incidence of nutritional risk in patients with perioperative oral cancer was high, and the trajectory of nutritional risk changed over time. Strengthening the nutritional monitoring and management of postoperative patients or those with low education level, advanced-stage cancer, flap repair, tracheotomy, and low body mass index; strengthening tobacco control management; and controlling nutrition-related discomfort symptoms in perioperative oral cancer patients are necessary.

Development and validation of a nomogram for predicting dysphagia in long-term care facility residents

BACKGROUND

Dysphagia is a common problem that can seriously affect the health of elderly residents in long-term care facilities. Early identification and targeted measures can significantly reduce the incidence of dysphagia.

AIM

This study aims to establish a nomogram to evaluate the risk of dysphagia for elderly residents in long-term care facilities.

METHODS

A total of 409 older adults were included in the development set, and 109 were included in the validation set. Least absolute shrinkage selection operator (LASSO) regression analysis was used to select the predictor variables, and logistic regression was used to establish the prediction model. The nomogram was constructed based on the results of logistic regression. The performance of the nomogram was evaluated by receiver operating characteristic (ROC) curve, calibration, and decision curve analysis (DCA). Internal validation was performed using tenfold cross-validation with 1000 iterations.

RESULTS

The predictive nomogram included the following variables: stroke, sputum suction history (within one year), Barthel Index (BI), nutrition status, and texture-modified food. The area under the curve (AUC) for the model was 0.800; the AUC value for the internal validation set was 0.791, and the AUC value for the external validation set was 0.824. The nomogram showed good calibration in both the development set and validation set. Decision curve analysis (DCA) demonstrated that the nomogram was clinically valuable.

DISCUSSION

This predictive nomogram provides a practical tool for predicting dysphagia. The variables included in this nomogram were easy to assess.

CONCLUSIONS

The nomogram may help long-term care facility staff identify older adults at high risk for dysphagia.

Nutrition in Acute Pancreatitis: From the Old Paradigm to the New Evidence

The nutritional management of acute pancreatitis (AP) patients has widely changed over time. The "pancreatic rest" was the cornerstone of the old paradigm, and nutritional support was not even included in AP management. Traditional management of AP was based on intestinal rest, with or without complete parenteral feeding. Recently, evidence-based data underlined the superiority of early oral or enteral feeding with significantly decreased multiple-organ failure, systemic infections, surgery need, and mortality rate. Despite the current recommendations, experts still debate the best route for enteral nutritional support and the best enteral formula. The aim of this work is to collect and analyze evidence over the nutritional aspects of AP management to investigate its impact. Moreover, the role of immunonutrition and probiotics in modulating inflammatory response and gut dysbiosis during AP was extensively studied. However, we have no significant data for their use in clinical practice. This is the first work to move beyond the mere opposition between the old and the new paradigm, including an analysis of several topics still under debate in order to provide a comprehensive overview of nutritional management of AP.

Dysphagia in older patients admitted to a rehabilitation setting after an acute hospitalization: the role of delirium

INTRODUCTION

Dysphagia is a swallowing disorder that affects 8% of the world population. However, data are lacking on its prevalence in a heterogeneous group of older patients. The aim of this study is to evaluate the prevalence of dysphagia at admission and at discharge, and its related factors, in particular delirium, in older patients admitted to a rehabilitation setting.

METHODS

Retrospective cohort study of patients 65 years and older admitted to a rehabilitation ward after an acute hospitalization. The presence of dysphagia at admission was screened with the 3OZ Test and confirmed by a speech-therapist. The association between clinical factors and dysphagia was investigated with a multivariate logistic regression analysis.

RESULTS

We included 1040 patients, (65% females, mean age 81.9 ± 7.2 years). The prevalence of dysphagia at admission was 14.8% and 12.8% at discharge, while the prevalence of delirium among patients with dysphagia was of 31.2% vs 6.4% among patients without dysphagia. The severity of dysphagia was moderate. In the multivariate logistic regression, delirium was associated with dysphagia at admission (OR 2.06; Confidence Interval, CI 1.08-3.23) along with a pre-hospital impairment in the Instrumental-Activities-of-Daily-Living (OR-1.26; CI - 1.1; - 1.10), a change in Barthel Index from pre-hospital to hospital admission (OR-1.02; CI - 1.01 to 1.04), comorbidity (OR 1.12; CI 0.94;1.29) and the number of antibiotics (OR-1.63; CI - 1.01;2.62).

CONCLUSION

Delirium was the main factor associated with dysphagia at rehabilitation admission. The study underlines the importance of screening dysphagia in delirious patients and warrants future studies to determine the changes in dysphagia prevalence according to delirium resolution.

Rheological Issues on Oropharyngeal Dysphagia

There is an increasing proof of the relevance of rheology on the design of fluids for the diagnosis and management of dysphagia. In this sense, different authors have reported clinical evidence that support the conclusion that an increase in bolus viscosity reduces the risks of airway penetration during swallowing. However, this clinical evidence has not been associated yet to the definition of objective viscosity levels that may help to predict a safe swallowing process. In addition, more recent reports highlight the potential contribution of bolus extensional viscosity, as elongational flows also develops during the swallowing process. Based on this background, the aim of this review paper is to introduce the lecturer (experts in Dysphagia) into the relevance of Rheology for the diagnosis and management of oropharyngeal dysphagia (OD). In this sense, this paper starts with the definition of some basic concepts on Rheology, complemented by a more extended vision on the concepts of shear viscosity and elongational viscosity. This is followed by a short overview of shear and elongational rheometrical techniques relevant for the characterization of dysphagia-oriented fluids, and, finally, an in-depth analysis of the current knowledge concerning the role of shear and elongational viscosities in the diagnosis and management of OD (shear and elongational behaviors of different categories of dysphagia-oriented products and contrast fluids for dysphagia assessment, as well as the relevance of saliva influence on bolus rheological behavior during the swallowing process).

Application of HPP for the Development of a Dessert Elaborated with Casein and Cocoa for a Dysphagia Diet

In this study, the application of high-pressure processing (HPP) for optimizing the texture of a cocoa dessert rich in casein and developed for people with dysphagia was investigated. Different treatments (250 MPa/15 min; 600 MPa/5 min) and protein concentrations (10-15%) were combined and evaluated for choosing the optimum combination leading to an adequate texture. The selected formulation was a dessert containing 4% cocoa and 10% casein and subjected to 600 MPa for 5 min. It showed a high nutritional value (11.5% protein) and high antioxidant capacity, which was slightly affected by the HPP processing. The rheological and textural properties showed that HPP had a clear effect on the dessert structure. The loss tangent decreased from 2.692 to 0.165, indicating the transition from a liquid to a gel-like structure, which is in a suitable range for dysphagia foods. During storage (14 and 28 days at 4 °C), progressive significant changes in the structure of the dessert were observed. A decrease in all rheological and textural parameters occurred, except for the loss of tangent, which increased its value. In any case, at 28 days of storage, samples maintained the weak gel-like structure (0.686 loss tangent) that is acceptable for dysphagia management.

Patients with dysphagia: How to supply nutrition through non-tube feeding

OBJECTIVE

Dysphagia has become one of the important factors that cause malnutrition in the whole age group. At present, tube feeding is still the mainstream means to solve the problem of dysphagia. However, tube feeding has physical and mental harm to people, and the ways of non-tube feeding are relatively diversified. The significance of the thickening mechanism described in some articles to solve the problem of dysphagia is not clear.

SETTING AND PARTICIPANTS

All patients with dysphagia worldwide, including oropharyngeal dysphagia (OD) and non-oropharyngeal dysphagia.

METHODS

We searched the literature in Pubmed, Web of Science and Cochrane Library and initially browsed the titles and abstracts. We reviewed the full text of the articles that met our topic, and the language of the article was limited to English.

RESULTS

We found that food thickening to a certain degree (350-1,750 cP) can reduce the complications of choking, aspiration, reflux, and other complications in patients with dysphagia, and reduce the social disorder, anxiety, and other psychological problems caused by catheterization and surgery. Significantly, food science engineers should invite clinicians to intervene in the development of specialty foods from different perspectives such as clinical pathophysiology and fluid mechanics.

CONCLUSION AND IMPLICATIONS

It is necessary to develop special foods for patients with dysphagia, which requires scientists from different disciplines to work together.

Proposal for a Standard Protocol to Assess the Rheological Behavior of Thickening Products for Oropharyngeal Dysphagia

Increasing shear viscosity (ShV) in thickening products (TP) is a valid therapeutic strategy for oropharyngeal dysphagia (OD). However, salivary amylase in the oral phase and shear rate in the pharyngeal phase of swallowing can change the viscosity of TPs when swallowed. This study aims to design and validate a rheological protocol to reproduce the oral and pharyngeal factors that affect the therapeutic effect of TPs and report the viscosity measurements in a standardized scientific and precise manner. We measured (a) the variability of the ShV measurements across several laboratories; (b) the in vitro and ex vivo properties of TPs and (c) the impact of the X-ray contrast Omnipaque, temperature and resting time on the rheological properties of TPs. A common protocol was applied in four international laboratories to assess five ShV values (100, 200, 400, 800 and 1600 mPa·s) for the xanthan-gum TP Tsururinko Quickly (TQ). The protocol included the dose (g/100 mL water), stirring procedure and standing time before measurement. Each value was characterized at the shear rate of 50 and 300 s^-1 pre- and post-oral incubation in eight volunteers. The effect of temperature, standing time and Omnipaque was assessed. The main results of the study were: (a) The mean intra-laboratory variability on the ShV at all levels was very low: 0.85%. The mean inter-laboratory variability was higher: 9.3%; (b) The shear thinning of TQ at 300 s^-1 was 75-80%. Increasing the temperature or standing time did not affect the ShV, and oral amylase caused a small decrease; (c) Omnipaque slightly decreased the dose of TP and hardly affected the amylase resistance or shear thinning. This study showed that different laboratories can obtain very accurate and similar ShV measurements using this protocol which uses scientific, universal SI units (mPa·s). Our protocol accurately reproduces oral and pharyngeal factors affecting the therapeutic effect of TPs. The addition of X-ray contrast did not produce significant changes.

Oral functional impairment may cause malnutrition following oral cancer treatment in a single-center cross-sectional study

Oral dysfunction and dysphagia after oral cancer treatment are linked to altered nutritional status. We aimed to identify specific oral functions related to nutritional status. We conducted a cross-sectional study from September 2019 to December 2021, recruited 75 participants (median age: 72.0 years), including 52 males and 23 females, collected background data, and evaluated oral function. The Mini Nutritional Assessment-Short Form (MNA-SF) scores were divided into three groups (normal nutritional status, at risk of malnutrition, and malnourished), and a multi-group comparison was conducted for each oral function measurement (microorganisms, oral dryness, occlusal force, tongue pressure, masticatory function, and Eating Assessment Tool [EAT-10]). The primary tumor site was the tongue in 31 patients (41.3%), gingiva in 30 (40.0%), and others in 14 (18.7%). Multiple comparisons revealed significant differences in occlusal force, tongue pressure, masticatory function, and EAT-10 levels, categorized as Type I (Transport type) and Type III (Occlusion type) postoperative oral dysfunctions, between each MNA-SF group. Multiple regression analysis showed a statistically significant association with MNA-SF in terms of masticatory function and EAT-10 levels, categorized as Type I. Type I and Type III are risk factors for malnutrition, confirming that different types of postoperative oral dysfunction require unique nutritional guidance.

Rheological Properties and Stability of Thickeners for Clinical Use

The adaptation of liquids for patients with dysphagia requires precision and individualization in the viscosities used. We describe the variations of viscosity in water at different concentrations and evolution over time of the three compositions of commercial thickeners that are on the market (starch, starch with gums, and gum). By increasing the concentration in water, the viscosity of gum-based thickeners increases linearly, but it did not reach pudding texture, whereas the viscosity of the starch-based thickeners (alone or mixed with gums) rapidly reaches very thick textures. We modeled the viscosity at different concentrations of the four thickeners using regression analysis (R2 > 0.9). We analyzed viscosity changes after 6 h of preparation. The viscosity of gum-based thickeners increased by a maximum of 6.5% after 6 h of preparation, while starch-based thickeners increased by up to 43%. These findings are important for correct handling and prescription. Gum-based thickeners have a predictable linear behavior with the formula we present, reaching nectar and honey-like textures with less quantity of thickener, and are stable over time. In contrast, starch thickeners have an exponential behavior which is difficult to handle, they reach pudding-like viscosity, and are not stable over time.

Protein and Sport: Alternative Sources and Strategies for Bioactive and Sustainable Sports Nutrition

Nutrition and sport play an important role in achieving a healthy lifestyle. In addition to the intake of nutrients derived from the normal diet, some sport disciplines require the consumption of supplements that contribute positively to improved athletic performance. Protein intake is important for many aspects related to health, and current evidence suggests that some athletes require increased amounts of this nutrient. On the other hand, society's demand for more environmentally friendly products, focus on the search for alternative food sources more sustainable. This review aims to summarize the latest research on novel strategies and sources for greener and functional supplementation in sport nutrition. Alternative protein sources such as insects, plants or mycoproteins have proven to be an interesting substrate due to their high added value in terms of bioactivity and sustainability. Protein hydrolysis has proven to be a very useful technology to revalue by-products, such as collagen, by producing bioactive peptides beneficial on athletes performance and sport-related complications. In addition, it has been observed that certain amino acids from plant sources, as citrulline or theanine, can have an ergogenic effect for this target population. Finally, the future perspectives of protein supplementation in sports nutrition are discussed. In summary, protein supplementation in sports nutrition is a very promising field of research, whose future perspective lies with the search for alternatives with greater bioactive potential and more sustainable than conventional sources.

The Hydration Status of Adult Patients with Oropharyngeal Dysphagia and the Effect of Thickened Fluid Therapy on Fluid Intake and Hydration: Results of Two Parallel Systematic and Scoping Reviews

BACKGROUND

The effect of oropharyngeal dysphagia (OD) and thickened fluid (TF) therapy on hydration status has not been well defined in the literature. We aimed to assess the hydration status in patients with OD and the effect TF therapy has on it.

METHODS

Two literature reviews following PRISMA methodology (each one including a systematic and a scoping review) were performed: (R1) hydration status in adult patients with OD; (R2) effect of TF therapy on fluid intake and dehydration. Narrative and descriptive methods summarized both reviews. Quality assessment was assessed by Joanna Briggs Institute tools and GRADE.

RESULTS

(R1) Five out of twenty-two studies using analytical parameters or bioimpedance showed poorer hydration status among OD and 19-100% prevalence of dehydration; (R2) two high quality studies (total of 724 participants) showed positive effects of TF on hydration status. Among the articles included, nine out of ten studies that evaluated fluid intake reported a reduced TF intake below basal water requirements.

CONCLUSIONS

Dehydration is a highly prevalent complication in OD. There is scientific evidence on the positive effect of TF therapy on the hydration status of patients with OD. However, strict monitoring of fluid volume intake is essential due to the low consumption of TF in these patients.

Advances in 3D printing of food and nutritional products

The main advantage of both 3D printing (3DP) and 3D food printing (3DFP) over other technologies is the enormous capacity of both techniques for customization. Its use makes it possible to obtain products without planning and implementing a complex and costly manufacturing process. This makes 3DFP a technology of choice for the preparation of food products that meet specific needs, such as controlled nutritional or rheological properties. However, further technological developments are still needed before 3DFP can be considered fully useful for innovative and demanding applications. If both preparation and post-processing of materials based on 3D printing are optimized, aiming to reduce production time and/or complication for non-expert users, this would open a whole new range of possibilities. It is in this sense that the development of advanced 3DFP systems becomes a must. This chapter reviews current advances in extrusion-based 3D food printing systems, with in situ gelation and mixing as key aspects to better exploit the potential of 3DFP. On one hand, 3DFP systems based on in situ gelation (G3DFP) provide greater control over the final properties of the printed products, as the selection of adequate printing parameters gives the possibility of influencing the gelation process. On the other hand, mixing is indispensable for true 3DFP automation, so that the formulations do not have to be prepared by the user. Different innovative 3DFP systems based on gelling and/or mixing are presented in this chapter. Finally, the status and future of extrusion-based 3DFP, and its application in the production of customized foods for specific needs, are also overviewed.

Complete nutrition drink with retrograded starch is low glycemic, and the individual glucose response to the low glycemic complete nutrition drink depends on fasting insulin levels and HOMA-IR in a randomized cross-over control trial

Complete nutrition drinks with a low glycemic index (GI) provide nutritional support and prevent hyperglycaemia. The present study identified GI and factors predicting individual glucose response to a new complete nutrition drink. A randomised cross-over controlled trial was conducted in eighteen healthy volunteers (FPG < 100 mg/dl). Complete nutrition drinks containing retrograded starch, glucose solution and white bread were assigned in a random sequence with 14-day wash-out intervals. Plasma glucose and insulin levels were measured from baseline to 180 min after consuming each food. Results show the adjusted GIs of the drink was 48.2 ± 10.4 and 46.7 ± 12.7 with glucose and white bread as the reference, respectively. While the drink has low GI (<55), the individual glucose responses varied (GI: 7–149). Comparing characters in individual GI < 55 (n = 12) and GI ≥ 55 (n = 6) groups revealed significantly higher baseline insulin in the low GI group (14.86 ± 16.51 μIU/ml v. 4.9 ± 3.4 μIU/ml, P < 0·05). The correlation matrix confirms only two predictive factors for having individual GI <55 were baseline insulin (r = 0·5, P = 0·03) and HOMA-IR (r = 0·55, P = 0·02). ROC curve reveals fasting insulin above 1.6 μIU/ml and HOMA-IR above 1.05 as the cut-off values. The findings suggest that the complete nutrition drink has a low GI, but there was wide variability in individual responses partly explained by fasting insulin levels and HOMA-IR. Screening for fasting insulin and HOMA-IR may be encouraged to maximise the functional benefit of the drink.

Identifying Dysphagia and Demographic Associations in Older Adults Using Electronic Health Records: A National Longitudinal Observational Study in Wales (United Kingdom) 2008-2018

Dysphagia is increasingly being recognised as a geriatric syndrome (giant). There is limited research on the prevalence of dysphagia using electronic health records. To investigate associations between dysphagia, as recorded in electronic health records and age, frailty using the electronic frailty index, gender and deprivation (Welsh index of multiple deprivation). A Cross-sectional longitudinal cohort study in over 400,000 older adults was undertaken (65 +) in Wales (United Kingdom) per year from 2008 to 2018. We used the secure anonymised information linkage databank to identify dysphagia diagnoses in primary and secondary care. We used chi-squared tests and multivariate logistic regression to investigate associations between dysphagia diagnosis and age, frailty (using the electronic Frailty index), gender and deprivation. Data indicated < 1% of individuals were recorded as having a dysphagia diagnosis per year. We found dysphagia to be statistically significantly associated with older age, more severe frailty and individuals from more deprived areas. Multivariate analyses indicated increased odds ratios [OR (95% confidence intervals)] for a dysphagia diagnosis with increased age [reference 65-74: aged 75-84 OR 1.09 (1.07, 1.12), 85 + OR 1.23 (1.20, 1.27)], frailty (reference fit: mild frailty 2.45 (2.38, 2.53), moderate frailty 4.64 (4.49, 4.79) and severe frailty 7.87 (7.55, 8.21)] and individuals from most deprived areas [reference 5. Least deprived, 1. Most deprived: 1.10 (1.06, 1.14)]. The study has identified that prevalence of diagnosed dysphagia is lower than previously reported. This study has confirmed the association of dysphagia with increasing age and frailty. A previously unreported association with deprivation has been identified. Deprivation is a multifactorial problem that is known to affect health outcomes, and the association with dysphagia should not be a surprise. Research in to this relationship is indicated.

Predictors of severe dysphagia following radiotherapy for head and neck cancer

OBJECTIVE

To investigate if severe dysphagia following radiotherapy for head and neck cancer (HNC) could be predicted by patient and tumor characteristics, feeding tube use, weight factors, jaw opening function, and saliva secretion.

METHODS

Data was collected from 94 HNC patients 6 to 36 months post radiotherapy. Swallowing function was assessed by videofluroscopy (VFS). Severe dysphagia was defined by Penetration Aspiration Scale (PAS) as PAS≥5 or a total score ≤60 on the M. D. Anderson Dysphagia Inventory (MDADI).

RESULTS

Thirty-three patients (35%) had PAS ≥5 and 19 (20%) a MDADI ≤60, that is, presented with severe dysphagia. Univariable logistic regression analysis (UVA) gave that tumor of the tonsil, overweight at time of VFS and each unit increase in Body Mass Index (BMI) predicted less risk of PAS ≥5. Dependency of feeding tube at time of VFS and each month's continued use and weight loss ≥7.5% since treatment to time of VFS predicted increased risk of PAS ≥5. Predictive variables from the UVA of PAS ≥5 (tumor of the tonsil, overweight, and total duration of feeding tube), were analyzed by multivariate logistic regression analysis. All retained power as independent predictors. UVA for MDADI showed that use of feeding tube at time of VFS predicted MDADI ≤60 with the risk increasing each month. Each increasing unit of BMI decreased risk of MDADI ≤60.

CONCLUSION

Long time users of feeding tube and higher weight-loss are at risk of severe dysphagia. This makes collaboration between professionals working with dysphagia an important step in detecting severe dysphagia.Level of Evidence: 3.

Institutionalized elderly are able to detect small viscosity variations in thickened water with gum-based thickeners: should texture classifications be reviewed?

BACKGROUND

The prevalence of dysphagia is very high in institutionalized elderly. Knowledge of the rheological and sensory characteristics of the various thickeners in elderly is limited, although it has been seen that there are differences between the rheological behaviors of gum-based thickeners with different composition. Moreover, we have not found sensory studies of viscosity in institutionalized elderly. Our hypothesis was that viscosity ranges established by the scientific societies, such as the National Dysphagia Diet Task Force (NDD), seem to be very wide and individuals might be able to detect small differences within the same texture range. The objectives of our study were 1) comparing the rheological characteristics of two commercial gum-based thickeners with different composition, dissolved in water under standard conditions, and 2) perform a sensory analysis (with both adults and institutionalized elderly) to detect different viscosities within the same texture (nectar and honey).

METHODS

Two commercial thickeners based on gums (NC and RC) were studied analyzing their viscosity in water with different concentrations (shear rate: 50 s^- 1; temperature: 22-25 °C). A sensory analysis involving 26 elderly and 29 adult controls was carried out to evaluate whether differences within nectar and honey textures among gum-based thickeners could be distinguished.

RESULTS

As the shear rate increases, viscosity decreases (non-Newtonian and pseudoplastic behavior). At the same concentration, each thickener produces a different viscosity (p < 0.05). Institutionalized elderly detected viscosity differences in nectar range of 49.9 (2.5) mPa·s (p < 0.05) and 102.2 (4.7) mPa·s (p < 0.0001). They also detected viscosity differences in honey texture range of 134.6 (9.7) mPa·s (p < 0.05) y 199.3 (9.2) mPa·s (p < 0.0001). Their caregivers also detected viscosity differences in both viscosity ranges (p < 0.0001) and with greater intensity than the elderly in honey texture (p: 0.016).

CONCLUSIONS

Our results suggest that the accepted viscosity ranges by NDD for the different textures might be too wide because institutionalized elderly and their caregivers are able to discern small differences in viscosity in nectar and honey textures. Gum-based thickeners with different composition showed differences in viscosity capacity, so they are not interchangeable.

Dysphagia, reflux and related sequelae due to altered physiology in scleroderma

Systemic sclerosis is a connective tissue disease that presents with significant gastrointestinal involvement, commonly in the esophagus. Dysphagia is a common clinical manifestation of systemic sclerosis and is strongly related to esophageal dysmotility. However, there are multiple other contributing factors in each step in the physiology of swallowing that may contribute to development of severe dysphagia. The oral phase of swallowing may be disrupted by poor mastication due to microstomia and poor dentition, as well as by xerostomia. In the pharyngeal phase of swallowing, pharyngeal muscle weakness due to concurrent myositis or cricopharyngeal muscle tightening due to acid reflux can cause disturbance. The esophageal phase of swallowing is most commonly disturbed by decreased peristalsis and esophageal dysmotility. However, it can also be affected by obstruction from chronic reflux changes, pill-induced esophagitis, or Candida esophagitis. Other contributing factors to dysphagia include difficulties in food preparation and gastroparesis. Understanding the anatomy and physiology of swallowing and evaluating systemic sclerosis patients presenting with dysphagia for disturbances in each step can allow for development of better treatment plans to improve dysphagia and overall quality of life.

Onigiri esophagography as a screening test for esophageal motility disorders

Background/Aims

No screening test for esophageal motility disorder (EMD) has been established, the objective of this study is to examine the potential usefulness of our newly developed “Onigiri esophagography” combined with an obstruction level (OL) classification system in screening for EMD.

Methods

A total of 102 patients with suspected EMDs who underwent both high-resolution manometry (HRM) and Onigiri esophagography between April 2017 and January 2019 were examined. The EMD diagnosis was performed based on the Chicago classification version 3.0 by HRM. Onigiri esophagography was performed using a liquid medium (barium sulfate) followed by a solid medium, which consisted of an Onigiri (a Japanese rice ball) with barium powder. The extent of medium obstruction was assessed by the OL classification, which was defined in a stepwise fashion from OL0 (no obstruction) to OL4 (severe obstruction).

Results

The patients with OL0 (32.3%), OL1 (50.0%), OL2 (88.0%), OL3 (100.0%), and OL4 (100.0%) were diagnosed EMDs by HRM. The area under the curve, as determined by a receiver operating characteristic analysis, for the OL classification was 0.86. Using the cutoff value of OL1, the sensitivity and specificity were 87.3% and 61.3%, respectively, while using a cutoff value of OL2, the sensitivity and specificity were 73.2% and 90.3%, respectively.

Conclusion

In conclusion, Onigiri esophagography combined with the OL classification system can be used as a screening test for EMDs with a cutoff value of OL1.

Exploring Tools for Designing Dysphagia-Friendly Foods: A Review

Dysphagia is a medical condition that affects normal swallowing. To prevent the risk of aspiration or choking, thickened fluids and texture-modified foods have been used for dysphagia management with the goal of slowing down the flow of liquids and protecting the airway. This article summarizes the available information about the rheological and textural parameters, the characterization of the most-used thickeners and the application of alternative texture modification technologies that are crucial to developing safe dishes for people who suffer from swallowing difficulties. Regarding rheological and textural measurements, fundamental and empirical methods are described.

A Systematic Review of Oropharyngeal Dysphagia Models in Rodents

Oropharyngeal dysphagia is a condition characterized by swallowing difficulty in the mouth and pharynx, which can be due to various factors. Animal models of oropharyngeal dysphagia are essential to confirm the cause-specific symptoms, pathological findings, and the effect of treatment. Recently, various animal models of dysphagia have been reported. The purpose of this review is to organize the rodent models of oropharyngeal dysphagia reported to date. The articles were obtained from Medline, Embase, and the Cochrane library, and selected following the PRISMA guideline. The animal models in which oropharyngeal dysphagia was induced in rats or mice were selected and classified based on the diseases causing oropharyngeal dysphagia. The animal used, method of inducing dysphagia, and screening methods and results were collected from the selected 37 articles. Various rodent models of oropharyngeal dysphagia provide distinctive information on atypical swallowing. Applying and analyzing the treatment in rodent models of dysphagia induced from various causes is an essential process to develop symptom-specific treatments. Therefore, the results of this study provide fundamental and important data for selecting appropriate animal models to study dysphagia.

Rheological and Nutritional Assessment of Dysphagia-Oriented New Food Preparations

Dysphagia that involves difficulty swallowing food and liquids is a symptom of different diseases. In some cases, patients who experience this symptom should be fed with modified consistency foods. Dysphagia is often accompanied by malnutrition and dehydration and an interesting approach to dealing with these conditions is to provide patients with nutrient-rich foods. In this study, two new food formulations for dysphagia patients are proposed: a cereal-based protein meal and a vegetable cream. The nutritional and rheological characteristics of the two innovative preparations were assessed and compared with those of commercial products. The proposed protein meal formulations meet the criteria for the “high protein” claim and the vegetable cream meets those of the “source of fiber” claim. The rheological investigation revealed that the flow properties of the innovative formulations were comparable to those of the commercial ones. Based on these preliminary outcomes, this investigation represents an interesting perspective potentially valuable to enlarge the offer of possibilities for people suffering from swallowing disorders.

Rheological and Textural Properties of Apple Pectin-Based Composite Formula with Xanthan Gum Modification for Preparation of Thickened Matrices with Dysphagia-Friendly Potential

Modifying the consistency of a given edible fluid matrix by incorporating food thickeners is a common nursing remedy for individuals with dysphagia when adequate water consumption is a concern. As apple pectin (AP) offers nutraceutical benefits, properly formulated apple pectin (AP)-based thickeners featuring xanthan gum (XG) can be superior candidates for preparation of dysphagia-friendly matrices (DFMs). Our recruited DFMs exhibit fluid-like behavior (loss modulus > storage modulus, G" > G') at lower AP concentrations (2 and 5%, w/w); they turn into weak/critical gels (G' ≈ G") as the concentration becomes higher (9%). In contrast, XG-DFMs display gel-like attributes with G' > G", even at rather low concentrations (<1%) and become more resistant to sugar, Na+, and Ca2+ modifications. The composite matrix of AP1.8XG0.2 (constraint at 2%) exhibits a confined viscosity of 278 ± 11.7 mPa∙s, which is considered a DFM, in comparison to only AP- or XG-thickened ones. The hardness measurements of XG0.6 and AP1.2XG0.8 are 288.33 ± 7.506 and 302.00 ± 9.849 N/m2, respectively, which potentially represent a promising formulation base for future applications with DFMs; these textural values are not significantly different from a commercially available product (p > 0.05) for dysphagia nursing administrations.

Nutrition in adult patients with selected lysosomal storage diseases

Lysosomal storage disorders (LSDs) are a group of clinically heterogeneous disorders affecting the function of lysosomes and are characterized by an accumulation of undigested substrates within several cell types. In recent years there have been substantial advances in supportive care and drug treatment for some LSDs, leading to improved patient survival, as seen in Gaucher, Pompe and Fabry disease and some Mucopolysaccharidoses; however, many symptoms still persist. Thus it is now even more important to improve patients' quality of life and reduce symptoms and comorbidities. One potential way of achieving this goal is through adjunct nutritional therapy, which is challenging as patients may be overweight with associated consequences, or malnourished, or underweight. Furthermore, drugs used to treat LSDs can modify the metabolic status and needs of patients. There are currently not enough data to make specific dietary recommendations for individual LSDs; however, suggestions can be made for managing clinical manifestations of the diseases, as well as treatment-associated adverse events. The metabolic and nutritional status of adult patients must be regularly assessed and individualized dietary plans may be created to cater to a patient's specific needs. Damage to the autophagic process is a common feature in LSDs that is potentially sensitive to dietary manipulation and needs to be assessed in clinical studies.

Nutritional Assessment in Adult Patients with Dysphagia: A Scoping Review

Malnutrition negatively affects the quality of life of patients with dysphagia. Despite the need for nutritional status assessment in patients with dysphagia, standard, effective nutritional assessments are not yet available, and the identification of optimal nutritional assessment items for patients with dysphagia is inadequate. We conducted a scoping review of the use of nutritional assessment items in adult patients with oropharyngeal and esophageal dysphagia. The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched to identify articles published in English within the last 30 years. Twenty-two studies met the inclusion criteria. Seven nutritional assessment categories were identified: body mass index (BMI), nutritional screening tool, anthropometric measurements, body composition, dietary assessment, blood biomarkers, and other. BMI and albumin were more commonly assessed in adults. The Global Leadership Initiative on Malnutrition (GLIM), defining new diagnostic criteria for malnutrition, includes the categories of BMI, nutritional screening tool, anthropometric measurements, body composition, and dietary assessment as its required components, but not the blood biomarkers and the “other” categories. We recommend assessing nutritional status, including GLIM criteria, in adult patients with dysphagia. This would standardize nutritional assessments in patients with dysphagia and allow future global comparisons of the prevalence and outcomes of malnutrition, as well as of appropriate interventions.

Efficacy and safety of a modified method for blind bedside placement of post-pyloric feeding tube: a prospective preliminary clinical trial

Objective

To compare the efficacy and safety of a new modified method of bedside post-pyloric feeding tube catheterization with the Corpak protocol versus electromagnetic-guided catheterization.

Materials and Methods

We conducted a single-center, single-blinded, prospective clinical trial. Sixty-three patients were treated with a non-gravity type gastrointestinal feeding tube using different procedures: modified bedside post-pyloric feeding tube placement (M group), the conventional Corpak protocol (C group), and standard electromagnetic-guided tube placement (EM group).

Results

The success rate in the M group, C group, and EM group was 82.9% (34/41), 70.7% (29/41), and 88.2% (15/17), respectively, with significant differences among the groups. The time required to pass the pylorus was significantly shorter in the M group (26.9 minutes) than in the C group (31.9 minutes) and EM group (42.1 minutes). The proportion of pylorus-passing operations completed within 30 minutes was significantly higher in the M group than in the C group and EM group. No severe complications occurred.

Conclusion

This modified method of bedside post-pyloric feeding tube catheterization significantly shortened the time required to pass the pylorus with no severe adverse reactions. This method is effective and safe for enteral nutrition catheterization of patients with dysphagia and a high risk of aspiration pneumonia.

Physical properties of a model set of solid, texture-modified foods

Those suffering from swallowing disorders, or dysphagia, require texture-modified foods for safe swallowing. The texture is modified according to the severity of the disorder, as maintained by the guidelines outlining classes of texture-modified foods, ranging from viscous soups to soft, solid foods. As a basis for studies of bolus rheology and oral response of solid texture-modified foods, a set of well-defined, solid foods has been identified and characterized regarding texture and physical properties. Gelled food is compared to both the firmer timbale class and to the corresponding regular food. Foods eaten at room temperature were chosen to avoid temperature effects: bread, cheese, tomato, and the combination into a sandwich. All foods were tested as gel, timbale, and regular food. The texture was determined by compression and penetration tests, thereby showing a decrease in strength (compression stress), stiffness (modulus), and penetration force for increased degree of modification. The moisture content increased with increased degree of modification. The structural change from room to oral temperature was monitored by the complex shear modulus that showed a decrease with increasing temperature. Cheese and the gelatine-based tomato gel showed a distinct melting when the temperature was increased to 37°C. The texture-modified foods were softer and moister in all aspects as compared to the regular foods, which follows the intended modification. The classes for the texture-modified foods were qualitatively comparable to other national classification systems with regard to solid foods, but there is a lack of objective, physics-based classification of texture, especially for solid, texture-modified foods.

Impact of rehabilitation treatment on swallowing during adjuvant radiotherapy following surgery in patients with oral and oropharyngeal cancer

BACKGROUND

Patients with advanced oral or oropharyngeal cancer sometimes require surgery and adjuvant postoperative radiotherapy (PORT), which may cause dysphagia. However, the efficacy of rehabilitation treatment for PORT-induced dysphagia remains unclear. This study aimed to determine whether rehabilitation treatment during PORT after surgery is effective for dysphagia.

METHODS

We retrospectively studied 55 patients with oral or oropharyngeal cancer who received PORT. Of these, 25 received rehabilitation treatment for swallowing during PORT. The Functional Oral Intake Scale (FOIS) score at 6 months after treatment was used as the swallowing outcome. We performed multivariate linear regression and stratified analyses using the FOIS score (poor oral intake group: FOIS score <5, good oral intake group: FOIS score ≧5) before PORT.

RESULTS

The median (interquartile range) FOIS scores at 6 months post-PORT were 6 (5-6) and 6 (4-7) in the non-rehabilitation and rehabilitation groups, respectively. Multivariate linear regression revealed that rehabilitation treatment was a significant independent factor for a better FOIS score. Stratified analysis of the changes in the FOIS score from pre-PORT values to those obtained 6 months after treatment showed a significant difference in the good oral intake group between the rehabilitation and non-rehabilitation groups. There was no significant difference in the FOIS score from pre-PORT values to those obtained 6 months after treatment between the rehabilitation and non-rehabilitation groups in the poor oral intake group.

CONCLUSION

Rehabilitation treatment during PORT may achieve better swallowing outcomes in patients with advanced oral or oropharyngeal cancer.

European white paper: oropharyngeal dysphagia in head and neck cancer

Purpose

To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe.

Methods

Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion.

Results

Twenty-four sections on HNC-specific OD topics.

Conclusion

This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Cardiac and Metabolic Impact of Functional Foods with Antioxidant Properties Based on Whey Derived Proteins Enriched with Hemp Seed Oil

The impaired ability to feed properly, evident in oncologic, elderly, and dysphagic patients, may result in malnutrition and sarcopenia. Increasing the consumption of dietary proteins by functional foods and enriching their composition by adding beneficial nutrients may represent an adjuvant therapy. We aimed to evaluate the safety and the positive effects of a standard diet (SD) supplemented with whey-derived protein puddings (WDPP), with appropriate rheological properties, and hemp seed oil (HSO), rich in polyphenols. Rats were assigned to SD, WDPP, WDPP plus hemp seed oil (HSOP), and HSO supplemented diets for eight weeks. “Anthropometric”, metabolic, and biochemical variables, oxidative stress, tissue injury, liver histology, and cardiac susceptibility to ischemia/reperfusion were analyzed. All the supplementations did not induce significant changes in biochemical and metabolic variables, also in relation to glucose tolerance, and livers did not undergo morphological alteration and injury. An improvement of cardiac post-ischemic function in the Langendorff perfused heart model and a reduction of infarct size were observed in WDPP and HSOP groups, thanks to their antioxidant effects and the activation of Akt- and AMPK-dependent protective pathways. Data suggest that (i) functional foods enriched with WDPP and HSOP may be used to approach malnutrition and sarcopenia successfully under disabling conditions, also conferring cardioprotection, and that (ii) adequate rheological properties could positively impact dysphagia-related problems.

Simultaneous double balloon dilatation using double channel therapeutic endoscope in patients with cricopharyngeal muscle dysfunction: An observative study

The role of endoscopic balloon dilatation (EBD) using double-balloon catheters in patients with cricopharyngeal muscle dysfunction (CPD) is still unclear. Thus, the aim of this study was to compare the functional outcomes between patients receiving EBD and rehabilitative balloon swallowing (RBS).A total of 36 patients with CPD, who visited a teaching hospital from February 2014 to June 2017, were included in the study. Among them, 12 patients with severe dysphagia underwent EBD. After propensity score matching, 24 patients who underwent RBS were selected for comparison. We compared the effects of EBD and RBS using 4 functional swallowing parameters: functional dysphagia scale score, penetration-aspiration scale score, pharyngeal transit time, and percentage of pharyngeal remnant (PR) at baseline and after the first and second treatments. Using simple and multiple regression, we examined the associations between EBD/RBS and changes of 4 parameters after the treatments since the baselineAll functional parameters significantly decreased after RBS and EBD (P < .05). After the first therapy session, significant differences in the pharyngeal transit time (P = .034), percentage of PR (P = .008), and penetration-aspiration scale score (P = .014) were observed in the EBD group, compared with those in the RBS group. The regression analysis showed significant improvements in the PR after EBD compared with that after RBS (β = 0.95, SE = 0.31, P = .005).EBD may be an alternative treatment for patients with severe CPD. A significant improvement would be expected in such patients with PR.

Paediatric dysphagia within the context of South Africa's quadruple burden of disease, seen at a tertiary level hospital

Purpose: To inform service provision, this study explored feeding and swallowing difficulties in children within the context of South Africa's quadruple burden of disease (BOD) (i.e. conditions characterised as communicable, non-communicable, maternal and/or perinatal and trauma).Method: A retrospective chart review of 1432 paediatric inpatients (under 12 years of age) who met the inclusion criteria of presenting with dysphagia and being referred for speech-language pathology services was conducted.Result: Participants with diagnoses within the maternal and/or perinatal BOD category were noted most frequently (61.2%), followed by non-communicable (59.7%), communicable (43.4%) and trauma (4.2%). The majority of participants were under 1 year of age (82.2%) and 56.2% presented with comorbidities in multiple BOD categories. Mortality was 5.9%, with a higher rate (67.7%) in more complex cases. Mortality was associated with non-communicable BOD (p = 0.001), and maternal and/or perinatal BOD (p = 0.003). Pharyngeal phase swallowing difficulties were a significant risk for mortality (OR = 2.96; 95% CI: 1.01-8.65, p = 0.047).Conclusion: The majority of children with dysphagia presented with multiple comorbidities and were at high risk for mortality. Education and service delivery models should be designed to improve health outcomes and reduce mortality rates.

Therapeutic Effect, Rheological Properties and α-Amylase Resistance of a New Mixed Starch and Xanthan Gum Thickener on Four Different Phenotypes of Patients with Oropharyngeal Dysphagia

Thickened fluids are a therapeutic strategy for oropharyngeal dysphagia (OD). However, its therapeutic effect among different phenotypes of OD patients has not yet been compared. We aimed to assess the therapeutic effect and α-amylase resistance of a mixed gum/starch thickener [Fresubin Clear Thickener^® (FCT)] on four phenotypes of OD patients: G1) 36 older; G2) 31 head/neck cancer (HNC); G3) 30 Parkinson’s disease; and G4) 31 chronic post-stroke. Therapeutic effect of FCT was assessed during videofluoroscopy using the Penetration-Aspiration Scale (PAS), for 5/20 mL boluses, at four levels of shear-viscosity (<50, 250, 1000 and 2000 mPa·s). The effect of α-amylase was assessed after 30 s of oral incubation. Patients had high prevalence of VFS signs of impaired efficacy (98.44%) and safety (70.31%) of swallow with a severe PAS score (4.44 ± 0.20). Most severe OD was in HNC (80.6% unsafe swallows). FCT showed a strong therapeutic effect on the safety of swallow at a range between 250–1000 mPa·s (74.19–96.67%, safe swallows in G1, G3, G4, and 58.06% in G2), without increasing pharyngeal residue. Viscosity was unaffected by α-amylase. Increasing shear-viscosity with FCT causes a strong viscosity-dependent therapeutic effect on the safety of swallow. This effect depends on the phenotype and is similar among older, Parkinson’s and post-stroke patients.