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Clavé P, Ortega O, Rofes L, Alvarez-Berdugo D, Tomsen N. Brain and Pharyngeal Responses Associated with Pharmacological Treatments for Oropharyngeal Dysphagia in Older Patients. Dysphagia 2023; 38:1449-1466. [PMID: 37145201 DOI: 10.1007/s00455-023-10578-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 04/07/2023] [Indexed: 05/06/2023]
Abstract
Impaired pharyngo-laryngeal sensory function is a critical mechanism for oropharyngeal dysphagia (OD). Discovery of the TRP family in sensory nerves opens a window for new active treatments for OD. To summarize our experience of the action mechanism and therapeutic effects of pharyngeal sensory stimulation by TRPV1, TRPA1 and TRPM8 agonists in older patients with OD. Summary of our studies on location and expression of TRP in the human oropharynx and larynx, and clinical trials with acute and after 2 weeks of treatment with TRP agonists in older patients with OD. (1) TRP receptors are widely expressed in the human oropharynx and larynx: TRPV1 was localized in epithelial cells and TRPV1, TRPA1 and TRPM8 in sensory fibers mainly below the basal lamina. (2) Older people present a decline in pharyngeal sensory function, more severe in patients with OD associated with delayed swallow response, impaired airway protection and reduced spontaneous swallowing frequency. (3) Acute stimulation with TRP agonists improved the biomechanics and neurophysiology of swallowing in older patients with OD TRPV1 = TRPA1 > TRPM8. (4) After 2 weeks of treatment, TRPV1 agonists induced cortical changes that correlated with improvements in swallowing biomechanics. TRP agonists are well tolerated and do not induce any major adverse events. TRP receptors are widely expressed in the human oropharynx and larynx with specific patterns. Acute oropharyngeal sensory stimulation with TRP agonists improved neurophysiology, biomechanics of swallow response, and safety of swallowing. Subacute stimulation promotes brain plasticity further improving swallow function in older people with OD.
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Affiliation(s)
- Pere Clavé
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Omar Ortega
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Laia Rofes
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Daniel Alvarez-Berdugo
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Noemí Tomsen
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain.
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Tomsen N, Ortega O, Alvarez-Berdugo D, Rofes L, Clavé P. A Comparative Study on the Effect of Acute Pharyngeal Stimulation with TRP Agonists on the Biomechanics and Neurophysiology of Swallow Response in Patients with Oropharyngeal Dysphagia. Int J Mol Sci 2022; 23:ijms231810773. [PMID: 36142680 PMCID: PMC9506471 DOI: 10.3390/ijms231810773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/07/2022] [Accepted: 09/13/2022] [Indexed: 11/16/2022] Open
Abstract
Fluid thickening is the main compensatory strategy for patients with oropharyngeal dysphagia (OD) associated with aging or neurological diseases, and there is still no pharmacological treatment. We aimed to compare the effects of increasing bolus viscosity with that of acute stimulation with TRPV1, TRPA1 or TRPM8 agonists on the biomechanics and neurophysiology of swallow response in patients with OD. We retrospectively analyzed seven studies from our laboratory on 329 patients with OD. The effect of increasing shear viscosity up to 3682 mPa·s was compared by videofluoroscopy and pharyngeal sensory evoked potentials (pSEP) with that of adding to the bolus: capsaicin (TRPV1, 150 μM/10 μM), piperine (TRPA1/V1, 1 mM/150 μM), menthol (TRPM8, 1 mM/10 mM), cinnamaldehyde-zinc (TRPA1, 100 ppm−70 mM), citral (TRPA1, 250 ppm) or citral-isopulegol (TRPA1-TRPM8, 250 ppm−200 ppm). Fluid thickening improved the safety of swallow by 80% (p < 0.0001) by delaying bolus velocity by 20.7 ± 7.0% and time to laryngeal vestibule closure (LVC) by 23.1 ± 3.7%. Capsaicin 150μM or piperine 1 mM significantly improved safety of swallow by 50% (p < 0.01) and 57.1% (p < 0.01) by speeding time to LVC by 27.6% (p < 0.001) and 19.5% (p < 0.01) and bolus velocity by 24.8% (p < 0.01) and 16.9% (p < 0.05), respectively. Cinnamaldehyde-zinc shortened the P2 latency of pSEPs by 11.0% (p < 0.01) and reduced N2-P2 amplitude by 35% (p < 0.01). In conclusion, TRPV1 and TRPV1/A1 agonists are optimal candidates to develop new pharmacological strategies to promote the recovery of brain and swallow function in patients with chronic OD.
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Affiliation(s)
- Noemí Tomsen
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, 08304 Mataró, Spain
- Correspondence: ; Tel.: +34-937417700 (ext. 2284)
| | - Omar Ortega
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, 08304 Mataró, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, 28029 Barcelona, Spain
| | - Daniel Alvarez-Berdugo
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, 08304 Mataró, Spain
| | - Laia Rofes
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, 08304 Mataró, Spain
| | - Pere Clavé
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, 08304 Mataró, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, 28029 Barcelona, Spain
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Arreola V, Ortega O, Álvarez-Berdugo D, Rofes L, Tomsen N, Cabib C, Muriana D, Palomera E, Clavé P. Effect of Transcutaneous Electrical Stimulation in Chronic Poststroke Patients with Oropharyngeal Dysphagia: 1-Year Results of a Randomized Controlled Trial. Neurorehabil Neural Repair 2021; 35:778-789. [PMID: 34137329 DOI: 10.1177/15459683211023187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background. Chronic poststroke oropharyngeal dysphagia (CPSOD) is associated with impaired oropharyngeal sensory/motor function. We aimed to assess effect of sensory (SES) and motor (NMES) transcutaneous electrical stimulation (TES) on safety of swallow and clinical outcomes in patients with CPSOD in a one-year follow-up randomized controlled trial. Methods. Ninety patients (74.1 ± 11.5 y, modified Rankin score 2.6 ± 1.7) with CPSOD and impaired safety of swallow were randomized to (a) compensatory treatment (CT), (b) CT + SES, and (c) CT + NMES. Patients were treated with up to two cycles (6 months apart) of 15 × 1 hour TES sessions over two weeks and followed up with 4-5 clinical and videofluoroscopic assessments during one year. Key results. Baseline penetration-aspiration scale (PAS) was 4.61 ± 1.75, delayed time to laryngeal vestibule closure (LVC) 396.4 ± 108.7 ms, and impaired efficacy signs 94.25%. Swallowing parameters significantly improved between baseline and 1-year follow-up in SES and NMES groups for prevalence of patients with a safe swallow (P < .001), mean PAS (P < .001), time to LVC (P < .01), and need for thickening agents (P < .001). Patients in the CT presented a less intense improvement of signs of impaired safety of swallow without significant changes in time to LVC. No differences between groups were observed for 1-year mortality (6.1%), respiratory infections (9.6%), nutritional and functional status, QoL, and hospital readmission rates (27.6%). No significant adverse events related to TES were observed. Conclusions and inferences. Transcutaneous electrical stimulation is a safe and effective therapy for older patients with CPSOD. After 1-year follow-up, TES greatly improved the safety of swallow and reduced the need for fluid thickening in these patients.
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Affiliation(s)
- Viridiana Arreola
- Gastrointestinal Physiology Laboratory, 16380Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - Omar Ortega
- Gastrointestinal Physiology Laboratory, 16380Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Daniel Álvarez-Berdugo
- Gastrointestinal Physiology Laboratory, 16380Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Laia Rofes
- Gastrointestinal Physiology Laboratory, 16380Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Noemí Tomsen
- Gastrointestinal Physiology Laboratory, 16380Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Christopher Cabib
- Gastrointestinal Physiology Laboratory, 16380Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - Desiree Muriana
- Neurology Unit, 16380Hospital de Mataró, Consorci Sanitari Del Maresme, Mataró, Barcelona, Spain
| | - Elisabet Palomera
- Unitat de Suport a La Recerca, Fundació Salut Del Consorci Sanitari Del Maresme, Mataró, Barcelona, Spain
| | - Pere Clavé
- Gastrointestinal Physiology Laboratory, 16380Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
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Mundet L, Rofes L, Ortega O, Cabib C, Clavé P. Kegel Exercises, Biofeedback, Electrostimulation, and Peripheral Neuromodulation Improve Clinical Symptoms of Fecal Incontinence and Affect Specific Physiological Targets: An Randomized Controlled Trial. J Neurogastroenterol Motil 2021; 27:108-118. [PMID: 33109777 PMCID: PMC7786087 DOI: 10.5056/jnm20013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/16/2020] [Accepted: 07/03/2020] [Indexed: 02/06/2023] Open
Abstract
Background/Aims Fecal incontinence (FI) is a prevalent condition among community-dwelling women, and has a major impact on quality of life (QoL). Research on treatments commonly used in clinical practice—Kegel exercises, biofeedback, electrostimulation, and transcutaneous neuromodulation—give discordant results and some lack methodological rigor, making scientific evidence weak. The aim is to assess the clinical efficacy of these 4 treatments on community-dwelling women with FI and their impact on severity, QoL and anorectal physiology. Methods A randomized controlled trial was conducted on 150 females with FI assessed with anorectal manometry and endoanal ultrasonography, and pudendal nerve terminal motor latency, anal/rectal sensory-evoked-potentials, clinical severity, and QoL were determined. Patients were randomly assigned to one of the following groups Kegel (control), biofeedback + Kegel, electrostimulation + Kegel, and neuromodulation + Kegel, treated for 3 months and re-evaluated, then followed up after 6 months. Results Mean age was 61.09 ± 12.17. Severity of FI and QoL was significantly improved in a similar way after all treatments. The effect on physiology was treatment-specific Kegel and electrostimulation + Kegel, increased resting pressure (P < 0.05). Squeeze pressures strongly augmented with biofeedback + Kegel, electrostimulation + Kegel and neuromodulation + Kegel (P < 0.01). Endurance of squeeze increased in biofeedback + Kegel and electrostimulation + Kegel (P < 0.01). Rectal perception threshold was reduced in the biofeedback + Kegel, electrostimulation + Kegel, and neuromodulation + Kegel (P < 0.05); anal sensory-evoked-potentials latency shortened in patients with electrostimulation + Kegel (P < 0.05). Conclusions The treatments for FI assessed have a strong and similar efficacy on severity and QoL but affect specific pathophysiological mechanisms. This therapeutic specificity can help to develop more efficient multimodal algorithm treatments for FI based on pathophysiological phenotypes.
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Affiliation(s)
- Lluís Mundet
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - Laia Rofes
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain.,Neos Surgery, Parc Tecnològic del Vallès, Cerdanyola del Vallès, Barcelona, Spain
| | - Omar Ortega
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - Christopher Cabib
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - Pere Clavé
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
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Cabib C, Nascimento W, Rofes L, Arreola V, Tomsen N, Mundet L, Palomeras E, Michou E, Clavé P, Ortega O. Short-term neurophysiological effects of sensory pathway neurorehabilitation strategies on chronic poststroke oropharyngeal dysphagia. Neurogastroenterol Motil 2020; 32:e13887. [PMID: 32449296 DOI: 10.1111/nmo.13887] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/20/2020] [Accepted: 04/29/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Neurorehabilitation strategies for chronic poststroke (PS) oropharyngeal dysphagia (OD) have been mainly focused on the neurostimulation of the pharyngeal motor cortex with only marginal effects. In contrast, treatments targeting the PS oropharyngeal sensory pathway dysfunction offer very promising results, but there is little knowledge on the underlying mechanisms. We aimed to explore the neurophysiological mechanisms behind the effect of three sensory neurostimulation strategies. METHODS We carried out a randomized two-blinded parallel group's crossover sham-controlled clinical trial in 36 patients with unilateral stroke and chronic unsafe swallow to investigate the effect of repetitive transcranial magnetic stimulation (rTMS) of the primary sensory cortex (A), oral capsaicin (B) and intra-pharyngeal electrical stimulation (IPES; C). The effect was evaluated immediately after the interventions with videofluoroscopy (VFS) and motor/sensory evoked potentials (MEP/SEP). KEY RESULTS Interventions induced no changes in the biomechanics of the swallow response during VFS. However, an enhancement of motor cortex excitability (latency shortening and increased size of thenar MEP) was found with active interventions (A + B + C, and B/C alone; P < .05 for all) but not with sham. Active but not sham interventions shortened pharyngeal SEP latency in the ipsilesional hemisphere (A + B + C: P2-peak, P = .039; A: N2-peak, P = .034) and antagonized the physiological habituation in pharyngeal MEP (A + B + C and A alone, P < .05 for both). CONCLUSIONS AND INFERENCES Sensory pathway neurostimulation strategies caused immediate enhancement of motor cortex excitability with peripheral strategies (capsaicin and IPES) and of pharyngeal sensory conduction with rTMS. These changes support the use of sensory neurorehabilitation strategies in promoting swallow recovery in chronic PS-OD.
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Affiliation(s)
- Christopher Cabib
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró (Universitat Autónoma de Barcelona), Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Weslania Nascimento
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró (Universitat Autónoma de Barcelona), Mataró, Spain
| | - Laia Rofes
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró (Universitat Autónoma de Barcelona), Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Viridiana Arreola
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró (Universitat Autónoma de Barcelona), Mataró, Spain
| | - Noemí Tomsen
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró (Universitat Autónoma de Barcelona), Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Lluis Mundet
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró (Universitat Autónoma de Barcelona), Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Ernest Palomeras
- Neurology Department, Hospital de Mataró (Universitat Autónoma de Barcelona), Mataró, Spain
| | - Emilia Michou
- Technological Educational Institute Western Greece, Patras, Greece
| | - Pere Clavé
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró (Universitat Autónoma de Barcelona), Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Omar Ortega
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró (Universitat Autónoma de Barcelona), Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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Tomsen N, Alvarez-Berdugo D, Rofes L, Ortega O, Arreola V, Nascimento W, Martin A, Cabib C, Bolivar-Prados M, Mundet L, Legrand C, Clavé P, Michlig S. A randomized clinical trial on the acute therapeutic effect of TRPA1 and TRPM8 agonists in patients with oropharyngeal dysphagia. Neurogastroenterol Motil 2020; 32:e13821. [PMID: 32064725 DOI: 10.1111/nmo.13821] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 01/22/2020] [Accepted: 01/28/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Oropharyngeal dysphagia (OD) treatment is moving away from compensatory strategies toward active treatments that improve swallowing function. The aim of this study was to assess the acute therapeutic effect of TRPA1/M8 agonists in improving swallowing function in OD patients. METHODS Fifty-eight patients with OD caused by aging, stroke, or neurodegenerative disease were included in a three-arm, quadruple-blind, randomized clinical trial (NCT02193438). Swallowing safety and efficacy and the kinematics of the swallow response were assessed by videofluoroscopy (VFS) during the swallow of 182 ± 2 mPa·s viscosity (nectar) boluses of a xanthan gum thickener supplemented with (a) 756.6 μmol/L cinnamaldehyde and 70 μmol/L zinc (CIN-Zn) (TRPA1 agonists), (b) 1.6 mmol/L citral (CIT) (TRPA1 agonist), or (c) 1.6 mmol/L citral and 1.3 mmol/L isopulegol (CIT-ISO) (TRPA1 and TRPM8 agonists). The effects on pharyngeal event-related potentials (ERP) were assessed by electroencephalography. KEY RESULTS TRPA1 stimulation with either CIN-Zn or CIT reduced time to laryngeal vestibule closure (CIN-Zn P = .002, CIT P = .023) and upper esophageal sphincter opening (CIN-Zn P = .007, CIT P = .035). In addition, CIN-Zn reduced the penetration-aspiration scale score (P = .009), increased the prevalence of safe swallows (P = .041), and reduced the latency of the P2 peak of the ERP. CIT-ISO had no positive effect on biomechanics or neurophysiology. No significant adverse events were observed. CONCLUSIONS AND INFERENCES TRPA1 stimulation with CIN-Zn or CIT improves the swallow response which, in the case of CIN-Zn, is associated with a significant improvement in cortical activation and safety of swallow. These results provide the basis for the development of new active treatments for OD using TRPA1 agonists.
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Affiliation(s)
- Noemí Tomsen
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Barcelona, Spain.,Gastrointestinal Motility Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain.,Institut de Neurociències, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Daniel Alvarez-Berdugo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Barcelona, Spain.,Gastrointestinal Motility Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Laia Rofes
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Barcelona, Spain.,Gastrointestinal Motility Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Omar Ortega
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Barcelona, Spain.,Gastrointestinal Motility Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Viridiana Arreola
- Gastrointestinal Motility Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Weslania Nascimento
- Gastrointestinal Motility Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Alberto Martin
- Gastrointestinal Motility Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Christopher Cabib
- Gastrointestinal Motility Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Mireia Bolivar-Prados
- Gastrointestinal Motility Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Lluís Mundet
- Gastrointestinal Motility Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | | | - Pere Clavé
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Barcelona, Spain.,Gastrointestinal Motility Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
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Miarons M, Clavé P, Wijngaard R, Ortega O, Arreola V, Nascimento W, Rofes L. Pathophysiology of Oropharyngeal Dysphagia Assessed by Videofluoroscopy in Patients with Dementia Taking Antipsychotics. J Am Med Dir Assoc 2019; 19:812.e1-812.e10. [PMID: 30149844 DOI: 10.1016/j.jamda.2018.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/19/2018] [Accepted: 04/21/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The objective of this study was to assess the pathophysiology of oropharyngeal dysphagia (OD) in patients with dementia, specifically in those taking antipsychotics (APs). DESIGN A cross-sectional study was performed from January 2011 to May 2017 in a general hospital. SETTING AND PARTICIPANTS We included 114 patients with dementia, of which 39 (34.2%) were taking APs (82.5 ± 7.8 years, Barthel Index 52.28 ± 30.42) and 29 patients without dementia (82.4 ± 6.7 years, Barthel Index 77.71 ± 24.7) and OD confirmed by a videofluoroscopy. MEASURES Demographical and clinical factors as well as swallowing function of patients with dementia with OD were compared with older patients without dementia with OD. We also compared patients with dementia taking and not taking APs. Impaired efficacy during videofluoroscopy was defined as the presence of oral and/or pharyngeal residue, and impaired safety (unsafe swallow) was defined as aspiration or penetration. Receiver operating characteristic curves were drawn for laryngeal vestibule closure (LVC) time to predict unsafe swallow. RESULTS 87.7% of patients with dementia presented impaired efficacy of swallow and 74.6% impaired safety [penetration-aspiration scale (PAS) 3.94 ± 1.94]. 86.2% of patients without dementia presented impaired efficacy and 44.8% impaired safety (PAS 2.21 ± 1.92). Time to LVC was significantly delayed in patients with dementia taking APs in comparison with patients without dementia (LVC 0.377 ± 0.093 vs 0.305 ± 0.026, P = .003). In contrast, there were no differences in the PAS and LVC time in patients with dementia taking and not taking APs (PAS 3.96 ± 0.26 vs 3.88 ± 0.22, LVC 0.398 ± 0.117 vs 0.376 ± 0.115, NS). LVC time ≥0.340 seconds predicted unsafe swallow in patients with dementia with an accuracy of 0.71. CONCLUSIONS/IMPLICATIONS Patients with dementia presented high prevalence and severity of videofluoroscopy signs of impaired efficacy and safety of swallow and a more severe impairment in airway protection mechanisms (higher PAS and LVC delay). Clinical practice should implement specific protocols to prevent OD and its complications in these patients. AP treatment did not significantly worsen swallowing impairments.
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Affiliation(s)
- Marta Miarons
- Pharmacy Department, Hospital de Mataró, Mataró, Spain.
| | - Pere Clavé
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Universitat Autónoma de Barcelona, Mataró, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Omar Ortega
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Universitat Autónoma de Barcelona, Mataró, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Viridiana Arreola
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Universitat Autónoma de Barcelona, Mataró, Spain
| | - Weslania Nascimento
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Universitat Autónoma de Barcelona, Mataró, Spain
| | - Laia Rofes
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
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Bolivar‐Prados M, Rofes L, Arreola V, Guida S, Nascimento WV, Martin A, Vilardell N, Ortega Fernández O, Ripken D, Lansink M, Clavé P. Effect of a gum-based thickener on the safety of swallowing in patients with poststroke oropharyngeal dysphagia. Neurogastroenterol Motil 2019; 31:e13695. [PMID: 31402571 PMCID: PMC6852432 DOI: 10.1111/nmo.13695] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/16/2019] [Accepted: 07/23/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Increasing viscosity with thickening agents is a valid therapeutic strategy for oropharyngeal dysphagia (OD). To assess the therapeutic effect of a xanthan gum-based thickener (Nutilis Clear® ) at six viscosities compared with thin liquid in poststroke OD (PSOD) patients. METHODS A total of 120 patients with PSOD were studied in this controlled, multiple-dose, fixed-order, and single-blind study using videofluoroscopy (VFSS). A series of boluses of 10 mL thin liquid and 2000, 1400, 800, 450, 250, and 150 mPa s viscosities were given in duplicate, interrupted in case of aspiration. We assessed the safety and efficacy of swallow and the kinematics of the swallow response. KEY RESULTS A total of 41.2% patients had safe swallow at thin liquid which significantly increased for all viscosities from 71.9% at 150 mPa s to 95.6% at 1400 mPa s (P < .001). PAS score (3.7 ± 2.3) at thin liquid was also reduced by increasing bolus viscosity (P < .001). The prevalence of patients with aspiration at thin liquid was 17.5% and decreased at all viscosities (P < .01), except at 150 mPa s. Increasing viscosity shortened time to laryngeal vestibule closure (LVC) at all viscosities (P < .01) and reduced bolus velocity at ≥450 mPa s (P < .05). The prevalence of patients with pharyngeal residue at each viscosity 37.7%-44.7% was similar to that at thin liquid (41.2%). CONCLUSIONS AND INFERENCES The prevalence of unsafe swallow with thin liquids is very high in PSOD. Increasing shear bolus viscosity with this xanthan gum-based thickener significantly increased the safety of swallow in patients with PSOD in a viscosity-dependent manner without increasing the prevalence of pharyngeal residue.
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Affiliation(s)
- Mireia Bolivar‐Prados
- Gastrointestinal Physiology LaboratoryHospital de Mataró, Universitat Autònoma de BarcelonaMataróSpain
| | - Laia Rofes
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd)BarcelonaSpain
| | - Viridiana Arreola
- Gastrointestinal Physiology LaboratoryHospital de Mataró, Universitat Autònoma de BarcelonaMataróSpain
| | - Sonia Guida
- Danone Nutricia ResearchNutricia Advanced Medical NutritionUtrechtThe Netherlands
| | - Weslania V. Nascimento
- Gastrointestinal Physiology LaboratoryHospital de Mataró, Universitat Autònoma de BarcelonaMataróSpain
| | - Alberto Martin
- Gastrointestinal Physiology LaboratoryHospital de Mataró, Universitat Autònoma de BarcelonaMataróSpain
| | - Natàlia Vilardell
- Gastrointestinal Physiology LaboratoryHospital de Mataró, Universitat Autònoma de BarcelonaMataróSpain
| | - Omar Ortega Fernández
- Gastrointestinal Physiology LaboratoryHospital de Mataró, Universitat Autònoma de BarcelonaMataróSpain
| | - Dina Ripken
- Danone Nutricia ResearchNutricia Advanced Medical NutritionUtrechtThe Netherlands
| | - Mirian Lansink
- Danone Nutricia ResearchNutricia Advanced Medical NutritionUtrechtThe Netherlands
| | - Pere Clavé
- Gastrointestinal Physiology LaboratoryHospital de Mataró, Universitat Autònoma de BarcelonaMataróSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd)BarcelonaSpain
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9
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Arreola V, Vilardell N, Ortega O, Rofes L, Muriana D, Palomeras E, Álvarez-Berdugo D, Clavé P. Natural History of Swallow Function during the Three-Month Period after Stroke. Geriatrics (Basel) 2019; 4:geriatrics4030042. [PMID: 31324004 PMCID: PMC6787737 DOI: 10.3390/geriatrics4030042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/05/2019] [Accepted: 07/06/2019] [Indexed: 02/07/2023] Open
Abstract
Oropharyngeal dysphagia is a prevalent complication following stroke (PS-OD), and one that is sometimes spontaneously recovered. This study describes the natural history of PS-OD between admission and three months post-stroke, and the factors associated with its prevalence and development. PS-OD was assessed with the volume-viscosity swallow test (V-VST) in all stroke patients on admission and at the three-month follow-up. We analyzed clinical, demographic, and neuroanatomical factors of 247 older post-stroke patients (National Institute of Health Stroke Scale (NIHSS) = 3.5 ± 3.8), comparing among those with PS-OD the ones with and without spontaneous recovery. PS-OD prevalence on admission was 39.7% (34.0% impaired safety; 30.8%, efficacy) and 41.7% (19.4% impaired safety; 39.3%, efficacy) at three months. Spontaneous swallow recovery occurred in 42.4% of patients with unsafe and in 29.9% with ineffective swallow, associated with younger age and optimal functional status. However, 26% of post-stroke patients developed new signs/symptoms of ineffective swallow related to poor functional, nutritional and health status, and institutionalization. PS-OD prevalence on admission and at the three-month follow-up was very high in the study population. PS-OD is a dynamic condition with some spontaneous recovery in patients with optimal functional status, but also new signs/symptoms can appear due to poor functionality. Regular PS-OD monitoring is needed to identify patients at risk of nutritional and respiratory complications.
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Affiliation(s)
- Viridiana Arreola
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, 08304 Mataró, Spain
| | - Natàlia Vilardell
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, 08304 Mataró, Spain
| | - Omar Ortega
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, 08304 Mataró, Spain
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, 08036 Barcelona, Spain
| | - Laia Rofes
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, 08304 Mataró, Spain
| | - Desiree Muriana
- Neurology Unit, Hospital de Mataró, Universitat Autònoma de Barcelona, 08304 Mataró, Spain
| | - Ernest Palomeras
- Neurology Unit, Hospital de Mataró, Universitat Autònoma de Barcelona, 08304 Mataró, Spain
| | - Daniel Álvarez-Berdugo
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, 08304 Mataró, Spain
| | - Pere Clavé
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, 08304 Mataró, Spain.
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, 08036 Barcelona, Spain.
- Fundació Institut d'Investigació en Ciències de la Salut, Germans Trias i Pujol, 08916 Badalona, Spain.
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10
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Mundet L, Cabib C, Ortega O, Rofes L, Tomsen N, Marin S, Chacón C, Clavé P. Defective Conduction of Anorectal Afferents Is a Very Prevalent Pathophysiological Factor Associated to Fecal Incontinence in Women. J Neurogastroenterol Motil 2019; 25:423-435. [PMID: 31177647 PMCID: PMC6657934 DOI: 10.5056/jnm18196] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/01/2019] [Accepted: 03/26/2019] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Fecal incontinence (FI) is a prevalent condition among women. While biomechanical motor components have been thoroughly researched, anorectal sensory aspects are less known. We studied the pathophysiology of FI in community-dwelling women, specifically, the conduction through efferent/afferent neural pathways. Methods A cross-sectional study was conducted on 175 women with FI and 19 healthy volunteers. The functional/structural study included anorectal manometry/endoanal ultrasound. Neurophysiological studies including pudendal nerve terminal motor latency (PNTML) and sensory-evoked-potentials to anal/rectal stimulation (ASEP/RSEP) were conducted on all healthy volunteers and on 2 subgroups of 42 and 38 patients, respectively. Results The main conditions associated with FI were childbirth (79.00%) and coloproctological surgery (37.10%). Cleveland score was 11.39 ± 4.09. Anorectal manometry showed external anal sphincter and internal anal sphincter insufficiency in 82.85% and 44.00%, respectively. Sensitivity to rectal distension was impaired in 27.42%. Endoanal ultrasound showed tears in external anal sphincter (60.57%) and internal anal sphincter disruptions (34.80%). Abnormal anorectal sensory conduction was evidenced through ASEP and RSEP in 63.16% and 50.00% of patients, respectively, alongside reduced activation of brain cortex to anorectal stimulation. In contrast, PNTML was delayed in only 33.30%. Stools were loose/very loose in 56.70% of patients. Conclusions Pathophysiology of FI in women is mainly associated with mechanical sphincter dysfunctions related to either muscle damage or, to a lesser extent, impaired efferent conduction at pudendal nerves. Impaired conduction through afferent anorectal pathways is also very prevalent in women with FI and may play an important role as a pathophysiological factor and as a potential therapeutic target.
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Affiliation(s)
- Lluís Mundet
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - Christopher Cabib
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain
| | - Omar Ortega
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - Laia Rofes
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - Noemí Tomsen
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain
| | - Sergio Marin
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain
| | - Carla Chacón
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain
| | - Pere Clavé
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
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11
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Tomsen N, Ortega O, Rofes L, Arreola V, Martin A, Mundet L, Clavé P. Acute and subacute effects of oropharyngeal sensory stimulation with TRPV1 agonists in older patients with oropharyngeal dysphagia: a biomechanical and neurophysiological randomized pilot study. Therap Adv Gastroenterol 2019; 12:1756284819842043. [PMID: 31068978 PMCID: PMC6492367 DOI: 10.1177/1756284819842043] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 03/12/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Older people with oropharyngeal dysphagia (OD) present a decline in pharyngeal sensory function. The aim of this proof-of-concept study was to assess the biomechanical and neurophysiological effects of acute and subacute oropharyngeal sensory stimulation with transient receptor potential vanilloid 1 (TRPV1) agonists (capsaicinoids) in older patients with OD. METHODS We studied the effect of a single dose versus multiple doses (2 weeks) of oral capsaicin treatment (10-5 M) or placebo in 28 older patients with OD (81.2 ± 4.6 years) using videofluoroscopy (penetration-aspiration scale [PAS], timing of swallow response) and electroencephalography (EEG) (latency and amplitude of pharyngeal event-related potential [ERP]). RESULTS Acute stimulation by capsaicinoids 10-5 M did not improve swallow function and did not produce significant changes in pharyngeal ERP. In contrast, after 10 days of treatment, patients presented a clinically relevant and statistically significant reduction in the laryngeal vestibule closure (LVC) time (22.5%, p = 0.042), and in the PAS (24.2%, p = 0.038), compared with the placebo group. EEG results showed a reduction in the latency of the N1 peak (28.6%, p = 0.007) and an increase of the amplitude of the P1-N2 (59.4%, p = 0.038) and the N2-P2 (43.6%, p = 0.050) peaks. We observed a strong and significant correlation between the reduction in the latency of the N1 peak and change in LVC time after subacute treatment (r = 0.750, p = 0.003). CONCLUSIONS After 2 weeks of treatment, oropharyngeal sensory stimulation with capsaicinoids induced cortical changes that were correlated with improvements in swallowing biomechanics in older patients with OD. These results further show that sensory stimulation by TRPV1 agonists can become a useful pharmacological treatment for older patients with OD.
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Affiliation(s)
- Noemí Tomsen
- Laboratori de Fisiologia Digestiva CIBERehd
CSdM-UAB, Hospital de Mataró, Barcelona, Spain
- Centro de Investigación Biomédica en Red de
enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos
III, Barcelona, Spain
| | - Omar Ortega
- Laboratori de Fisiologia Digestiva CIBERehd
CSdM-UAB, Hospital de Mataró, Barcelona, Spain
- Centro de Investigación Biomédica en Red de
enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos
III, Barcelona, Spain
| | - Laia Rofes
- Centro de Investigación Biomédica en Red de
enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos
III, Barcelona, Spain
| | - Viridiana Arreola
- Laboratori de Fisiologia Digestiva CIBERehd
CSdM-UAB, Hospital de Mataró, Barcelona, Spain
| | - Alberto Martin
- Laboratori de Fisiologia Digestiva CIBERehd
CSdM-UAB, Hospital de Mataró, Barcelona, Spain
| | - Lluís Mundet
- Laboratori de Fisiologia Digestiva CIBERehd
CSdM-UAB, Hospital de Mataró, Barcelona, Spain
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12
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Miarons M, Rofes L. Systematic review of case reports of oropharyngeal dysphagia following the use of antipsychotics. Gastroenterol Hepatol 2018; 42:209-227. [PMID: 30470564 DOI: 10.1016/j.gastrohep.2018.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/23/2018] [Accepted: 09/07/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of this systematic review was to examine the effect of antipsychotic medication on dysphagia based on clinical case reports. PATIENTS AND METHODS Literature searches were performed using the electronic databases PubMed and Embase. In PubMed, we used the MeSH terms "antipsychotic agents" OR "tranquilizing agents" combined with "deglutition disorders" OR "deglutition". In Embase, we used the Emtree terms "neuroleptic agents" combined with "swallowing" OR "dysphagia". Two reviewers assessed the eligibility of each case independently. RESULTS A total of 1043 abstracts were retrieved, of which 36 cases met the inclusion criteria; 14 cases were related to typical antipsychotics and 22 to atypical antipsychotics. Dysphagia occurred together with extrapyramidal symptoms in half of the cases and was the only prominent symptom in the other half. The most common strategy against dysphagia was changing to another antipsychotic (n=13, 36.1%). CONCLUSIONS The data from this review indicate that antipsychotics can increase the prevalence of dysphagia.
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Affiliation(s)
- Marta Miarons
- Pharmacy department, Mataró Hospital, Spain; Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain.
| | - Laia Rofes
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
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13
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Alvarez-Berdugo D, Rofes L, Casamitjana JF, Enrique A, Chamizo J, Viña C, Pollán CM, Clavé P. TRPM8, ASIC1, and ASIC3 localization and expression in the human oropharynx. Neurogastroenterol Motil 2018; 30:e13398. [PMID: 29971861 DOI: 10.1111/nmo.13398] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/24/2018] [Indexed: 12/06/2022]
Abstract
BACKGROUND Oropharyngeal dysphagia (OD) is a prevalent disease with poor prognosis among older people and has no pharmacological treatment. Polymodal sensory receptors like the TRP or ASIC family receptors are potential targets to treat OD. TRPM8 agonists and acidic solutions can improve the swallow response in patients with OD, but little is known about the expression of TRPM8, ASIC1, and ASIC3 in the human oropharynx. The aim of this study was to assess the expression and localization of TRPM8, ASIC1, and ASIC3 in human samples of the oropharynx to lay the basis for new pharmacological treatments for OD. METHODS Pathology-free samples from oropharyngeal regions innervated by cranial nerves V, IX, and X were obtained during major ENT surgery and processed to obtain mRNA (20 patients) or to be used in immunohistochemical assays (12 patients). TRPM8, ASIC1, and ASIC3 expression and localization were studied with RT-qPCR and fluorescent immunohistochemistry. KEY RESULTS ASIC3 was expressed in the 3 regions studied with similar levels and was localized on sensory fibers innervating the mucosa below the basal lamina of all studied regions. TRPM8 was also co-localized on the sensory fibers innervating the mucosa below the basal lamina of all studied regions. In contrast, ASIC1 was only found in the nerves innervating the tongue muscular fibers. CONCLUSIONS & INFERENCES TRPM8 and ASIC3 are found on submucosal sensory nerves in the human oropharynx. Our study lays the basis to use oropharyngeal TRPM8 and ASIC3 receptors as therapeutic targets to develop new active pharmacological treatments for OD patients.
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Affiliation(s)
- D Alvarez-Berdugo
- Gastrointestinal Motility Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Barcelona, Spain
| | - L Rofes
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Barcelona, Spain
| | - J F Casamitjana
- ENT Department, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - A Enrique
- ENT Department, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - J Chamizo
- ENT Department, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - C Viña
- ENT Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - C M Pollán
- ENT Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - P Clavé
- Gastrointestinal Motility Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Barcelona, Spain.,Fundació Institut de Investigació Germans Trias i Pujol, Badalona, Spain
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14
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Miarons M, Tomsen N, Nascimento W, Espín À, López-Faixó D, Clavé P, Rofes L. Increased levels of substance P in patients taking beta-blockers are linked with a protective effect on oropharyngeal dysphagia. Neurogastroenterol Motil 2018; 30:e13397. [PMID: 30043538 DOI: 10.1111/nmo.13397] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 05/23/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND We have recently found a potential protective effect of beta-blockers on oropharyngeal dysphagia (OD). The action mechanism by which beta-blockers could wield this protective effect is unknown, but the neurotransmitter substance P (SP) could play a key role. The aim of this study was to analyze serum and saliva SP levels in patients taking beta-blockers (TBB), and to explore its relationship with OD. METHODS Adult (>50 year) patients TBB were randomly recruited from the primary care setting and 1:1 matched by age, sex, and Barthel Index (BI) with patients not taking beta-blockers (NTBB). Serum and saliva samples were taken and analyzed for their SP levels using an enzyme-linked immunosorbent assay (ELISA). Socio-demographic and clinical variables were collected. Dysphagia was evaluated in all patients using the clinical volume-viscosity swallow test (V-VST). KEY RESULTS We studied 28 patients TBB (64.96 ± 7.31 years, 57.1% women, BI 99.6 ± 1.31, carvedilol-equivalent dose 24.11 ± 18.12 mg) and 28 patients NTBB (65.61 ± 6.43 years, 57.1% women, BI 99.6 ± 1.31). SP serum levels were significantly higher in patients TBB (260.68 ± 144.27 vs 175.46 ± 108.36 pg/mL, P = .009) as were SP saliva levels (170.34 ± 146.48 vs 102.73 ± 52.28 pg/mL, P < .001) compared with patients NTBB. The prevalence of OD was 32.1% in patients TBB and 67.9% in patients NTBB (P = .015). Moreover, patients with OD had significantly lower SP saliva levels in comparison with patients without clinical signs of OD (98.39 ± 43.25 vs 174.69 ± 147.21 pg/mL) P < .001. CONCLUSIONS & INFERENCES We have found that serum and saliva SP levels are greater in patients TBB. This increase in SP levels could be the action mechanism by which beta-blockers protect patients from OD.
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Affiliation(s)
- M Miarons
- Department of Pharmacy, Hospital de Mataró, Mataró, Spain
| | - N Tomsen
- Unitat d'Exploracions Funcionals Digestives, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - W Nascimento
- Unitat d'Exploracions Funcionals Digestives, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - À Espín
- Unitat d'Exploracions Funcionals Digestives, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - D López-Faixó
- Department of Pharmacy, Hospital de Mataró, Mataró, Spain
| | - P Clavé
- Unitat d'Exploracions Funcionals Digestives, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - L Rofes
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
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15
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Rofes L, Muriana D, Palomeras E, Vilardell N, Palomera E, Alvarez-Berdugo D, Casado V, Clavé P. Prevalence, risk factors and complications of oropharyngeal dysphagia in stroke patients: A cohort study. Neurogastroenterol Motil 2018; 30:e13338. [PMID: 29573064 DOI: 10.1111/nmo.13338] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 02/15/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Oropharyngeal dysphagia (OD) is a prevalent poststroke condition with severe complications and increased mortality. Poststroke OD prevalence varies among studies and there is little evidence of its related risk factors and associated complications. OBJECTIVE to evaluate the prevalence of OD after stroke and the risk factors and associated complications. METHODS We performed a prospective longitudinal study of stroke patients consecutively admitted to a general hospital. OD was diagnosed with the volume-viscosity swallow test (V-VST). Demographic, functional status and topographical and clinical variables of stroke were collected to assess risk factors for OD. We evaluated functional status, mortality, respiratory infections, and readmissions 3 and 12 months after stroke. A multivariate regression analysis determined associated risk factors for OD and for each outcome variable. KEY RESULTS We included 395 stroke patients with a 45.06% prevalence of OD on admission. OD was independently associated with age (OR = 1.05; CI = 1.02-1.08), previous stroke (OR = 2.40; CI = 1.00-5.79), severity using the National Institute of Health Stroke Scale (OR = 3.52; CI = 1.57-7.87) and volume of the lesion (OR = 1.02; CI = 1.01-1.03). OD after stroke was an independent risk factor for prolonged hospital stay (P = .049; β = 0.938) and institutionalization after discharge (OR = 0.47; CI = 0.24-0.92); OD was an independent risk factor for poorer functional capacity (OR = 3.00; CI = 1.58-5.68) and increased mortality (HR = 6.90; CI = 1.57-30.34) 3 months after stroke. CONCLUSIONS & INFERENCES Poststroke OD is prevalent and associated with poor short and long term prognosis. Stroke severity and patient status before stroke were more relevant to OD than lesion location. Systematic screening programs and early OD management could significantly improve poststroke patient outcome.
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Affiliation(s)
- L Rofes
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Mataró, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Mataró, Barcelona, Spain
| | - D Muriana
- Neurology Unit, Hospital de Mataró, Mataró, Barcelona, Spain
| | - E Palomeras
- Neurology Unit, Hospital de Mataró, Mataró, Barcelona, Spain
| | - N Vilardell
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Mataró, Barcelona, Spain
| | - E Palomera
- Research Unit, Hospital de Mataró, Mataró, Barcelona, Spain
| | - D Alvarez-Berdugo
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Mataró, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Mataró, Barcelona, Spain
| | - V Casado
- Neurology Unit, Hospital de Mataró, Mataró, Barcelona, Spain
| | - P Clavé
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Mataró, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Mataró, Barcelona, Spain
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Alvarez-Berdugo D, Rofes L, Arreola V, Martin A, Molina L, Clavé P. A comparative study on the therapeutic effect of TRPV1, TRPA1, and TRPM8 agonists on swallowing dysfunction associated with aging and neurological diseases. Neurogastroenterol Motil 2018; 30. [PMID: 28799699 DOI: 10.1111/nmo.13185] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 07/18/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Oropharyngeal sensory impairment is a potential target to treat swallowing dysfunction in patients with oropharyngeal dysphagia (OD). AIM To assess the therapeutic effect of stimulating oropharyngeal sensory afferents with TRPV1, TRPA1, or TRPM8 agonists vs increasing bolus viscosity in older and neurologic patients with OD by comparing four studies of similar experimental design. METHODS Swallow function of 142 older patients with impaired safety of swallow at nectar ([50-350] mPa·s) viscosity was evaluated with videofluoroscopy (VFS) while treated with TRPV1 (150 μmol/L), TRPV1/A1 (150 μmol/L and 1 mmol/L), or TRPM8 (1 mmol/L or 10 mmol/L) agonists or modified starch (MS) at spoon thick viscosity (>1750 mPa·s). RESULTS TRPV1 stimulation with capsaicinoids reduced penetrations by 50%, pharyngeal residue by 80%, and LVC time by 24.38% and increased bolus velocity by 36.51%. TRPV1/A1 stimulation with piperine reduced penetrations by 56.32%, LVC time by 25.55% and increased bolus velocity by 23.63%. TRPM8 stimulation with menthol 1 mmol/L reduced penetrations by 37.5% while 10 mmol/L reduced LVC time by 18.44%. Thickeners reduced penetrations by 77.11%, but increased pharyngeal residue by 19.89%, delayed LVC by 41.73%, and reduced bolus velocity by 13.44%. CONCLUSION Natural capsaicinoids have a stronger therapeutic effect on VFS signs and swallow response by stimulating TRPV1 than TRPV1/A1 or TRPM8 agonists. While TRP stimulants increased bolus velocity and reduced swallow response times, thickeners reduced bolus velocity and further delayed the swallow response. This study sets the bases to develop new pharmacologic strategies for older patients with OD, moving away from compensation toward the recovery of swallow function.
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Affiliation(s)
- D Alvarez-Berdugo
- GI Physiology Lab, Hospital de Mataró, Barcelona, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - L Rofes
- GI Physiology Lab, Hospital de Mataró, Barcelona, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - V Arreola
- GI Physiology Lab, Hospital de Mataró, Barcelona, Spain
| | - A Martin
- GI Physiology Lab, Hospital de Mataró, Barcelona, Spain
| | - L Molina
- Escola Superior de Ciències de la Salut Tecnocampus, Barcelona, Spain
| | - P Clavé
- GI Physiology Lab, Hospital de Mataró, Barcelona, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.,Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol (IGTP), Barcelona, Spain
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Vilardell N, Rofes L, Arreola V, Martin A, Muriana D, Palomeras E, Ortega O, Clavé P. Videofluoroscopic assessment of the pathophysiology of chronic poststroke oropharyngeal dysphagia. Neurogastroenterol Motil 2017; 29:1-8. [PMID: 28547922 DOI: 10.1111/nmo.13111] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 04/17/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Oropharyngeal dysphagia (OD) is a major complaint following stroke, associated with poor clinical outcome and high mortality rates. We aimed at characterizing the kinematics of swallow response associated with unsafe swallowing in chronic poststroke patients with OD. PATIENTS AND METHODS Consecutive poststroke patients with a positive volume-viscosity swallow test for OD 3 months following stroke were studied by videofluoroscopy (VFS). Demographical and clinical factors and kinematics of swallow response were compared between those poststroke patients with safe swallow (penetration-aspiration scale, PAS≤2) and those with unsafe swallow (PAS≥3). Receiver operating characteristic (ROC) curves were drawn for laryngeal vestibule closure (LVC) time which predicts unsafe swallow. RESULTS We studied 73 poststroke patients (76.7±9.3 years, 53.4% male) by VFS (60.4% with impaired safety, PAS=4.47±1.44, and 95.9% with impaired efficacy of swallow). Poststroke patients with unsafe swallow presented a poorer functional (Rankin 2.2±1.6 vs 1.2±1.0, P<.012) and nutritional status (MNA-sf≤11, 34.2% vs 7.4%, P<.05) than poststroke patients with safe swallow. Poststroke patients with unsafe swallow presented a significant delay in LVC time (406.4±99.5 ms vs 318.9±80.4 ms; P<.05) and weaker tongue bolus propulsion forces (0.771±0.450 mJ vs 1.638±3.212 mJ; P=.043). LVC time ≥340 ms predicts unsafe swallow in chronic poststroke patients with a diagnostic accuracy of 0.78. CONCLUSIONS Impaired safety of swallow in chronic poststroke patients is caused by specific impairments in swallow response including delayed timing of airway protection mechanisms and weak tongue propulsion forces. Treatments aiming to restore swallowing function in poststroke patients with OD should be targeted to improve these critical biomechanical events.
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Affiliation(s)
- N Vilardell
- Unitat d'Exploracions Funcionals Digestives, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - L Rofes
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - V Arreola
- Unitat d'Exploracions Funcionals Digestives, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - A Martin
- Unitat d'Exploracions Funcionals Digestives, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - D Muriana
- Neurology Unit, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - E Palomeras
- Neurology Unit, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - O Ortega
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - P Clavé
- Unitat d'Exploracions Funcionals Digestives, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain.,Fundació Institut d'Investigació en Ciències de la Salut, Germans Trias i Pujol, Badalona, Spain
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Cabib C, Ortega O, Vilardell N, Mundet L, Clavé P, Rofes L. Chronic post-stroke oropharyngeal dysphagia is associated with impaired cortical activation to pharyngeal sensory inputs. Eur J Neurol 2017; 24:1355-1362. [DOI: 10.1111/ene.13392] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 07/04/2017] [Indexed: 11/28/2022]
Affiliation(s)
- C. Cabib
- Laboratorio de Fisiología Digestiva; Hospital de Mataró; Mataró
| | - O. Ortega
- Laboratorio de Fisiología Digestiva; Hospital de Mataró; Mataró
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd); Hospital de Mataró; Mataró
| | - N. Vilardell
- Laboratorio de Fisiología Digestiva; Hospital de Mataró; Mataró
| | - L. Mundet
- Laboratorio de Fisiología Digestiva; Hospital de Mataró; Mataró
| | - P. Clavé
- Laboratorio de Fisiología Digestiva; Hospital de Mataró; Mataró
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd); Hospital de Mataró; Mataró
- Fundación Instituto de Investigación en Ciencias de la Salud; Hospital Universitario Germans Trias i Pujol; Badalona Spain
| | - L. Rofes
- Laboratorio de Fisiología Digestiva; Hospital de Mataró; Mataró
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd); Hospital de Mataró; Mataró
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Rofes L, Ortega O, Vilardell N, Mundet L, Clavé P. Spatiotemporal characteristics of the pharyngeal event-related potential in healthy subjects and older patients with oropharyngeal dysfunction. Neurogastroenterol Motil 2017; 29. [PMID: 27485487 DOI: 10.1111/nmo.12916] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 07/06/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Oropharyngeal dysphagia (OD) is a highly prevalent symptom in older people. Appropriate oropharyngeal sensory feedback is essential for safe and efficient swallowing. However, pharyngeal sensitivity decreases with advancing age and could play a fundamental role in the physiopathology of swallowing dysfunction associated with aging. We aimed to characterize pharyngeal sensitivity and cortical response to a pharyngeal electrical stimulus in healthy volunteers (HV) and older patients with and without OD. METHODS Eight young HV, eight older HV without OD, and 14 older patients with OD were studied by electroencephalography through 32 scalp electrodes. Pharyngeal event-related potentials (ERP) were assessed following electrical stimulation of the pharynx. Sensory and tolerance thresholds to the electrical stimulus and latency, amplitude, and scalp current density of each ERP component were analyzed and compared. An ERP source localization study was also performed using the sLORETA software. KEY RESULTS Older participants (with and without OD) presented an increased sensory threshold to pharyngeal electrical stimulation (10.2 ± 1.7 mA and 11.5 ± 1.9 mA respectively), compared with young HV (6.0 ± 1.2 mA). The cortical activation of older HV in response to pharyngeal electrical stimulus was reduced compared with young HV (N2 amplitude: 0.22 ± 0.79 vs -3.10 ± 0.59, P<.05). Older patients with OD also presented disturbances to the pharyngo-cortical connection together with disrupted pattern of cortical activation. CONCLUSIONS AND INFERENCES Older people present a decline in pharyngeal sensory function, more severe in older patients with OD. This sensory impairment might be a critical pathophysiological element and a potential target for treatment of swallowing dysfunction in older patients.
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Affiliation(s)
- L Rofes
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Hospital de Mataró, Mataró, Spain
| | - O Ortega
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Mataró, Spain
| | - N Vilardell
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Mataró, Spain
| | - L Mundet
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Mataró, Spain
| | - P Clavé
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Hospital de Mataró, Mataró, Spain.,Gastrointestinal Physiology Laboratory, Hospital de Mataró, Mataró, Spain
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20
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Vilardell N, Rofes L, Nascimento WV, Muriana D, Palomeras E, Clavé P. Cough reflex attenuation and swallowing dysfunction in sub-acute post-stroke patients: prevalence, risk factors, and clinical outcome. Neurogastroenterol Motil 2017; 29. [PMID: 27424849 DOI: 10.1111/nmo.12910] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 06/22/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cough and swallowing impairments in post-stroke patients (PSP) have been associated with increased risk for respiratory complications. AIMS To assess the prevalence of alterations in protective cough responses in subacute PSP and its association with oropharyngeal dysphagia (OD), clinical, and neurotopographic stroke factors and clinical outcomes. METHODS Three months after stroke, the cough reflex test (CRT) was performed by nebulizing incremental citric acid concentrations (7.8-1000 mmol L-1 ) to determine the concentration that elicited two and five coughs; OD was assessed by the volume-viscosity swallow test. Clinical and neurotopographic stroke risk factors and complications (readmissions, respiratory infections, institutionalization, and mortality) were recorded from 3 to 12 months post-stroke. RESULTS We included 225 PSP. Prevalence of impaired CRT was 5.8%, that of OD was 40.4% (20.4% with impaired safety of swallow), and of both impairments was, 1.8%. No specific risk factors associated with impaired CRT were found; however, hemorrhagic, wide circulation infarction (TACI), and brainstem strokes delayed the cough response. OD was associated with age, TACI and poor functional and nutritional status. Outcome of PSPs was unaffected by impaired CRT but OD and impaired safety of swallow increased institutionalization, respiratory infections, and mortality with the poorest outcome for those with both impairments. CONCLUSIONS Prevalence of subacute post-stroke OD and swallow safety impairments was much higher than CRT attenuation, and risk factors strongly differed suggesting that the swallow response receives a stronger cortical control than the cough reflex. OD has a greater impact on PSP clinical outcome than impaired cough, the poorest prognosis being for patients with both airway protective dysfunctions.
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Affiliation(s)
- N Vilardell
- Unitat d'Exploracions Funcionals Digestives, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - L Rofes
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - W V Nascimento
- Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - D Muriana
- Neurology Unit, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - E Palomeras
- Neurology Unit, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - P Clavé
- Unitat d'Exploracions Funcionals Digestives, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain.,Fundació Institut d'Investigació en Ciències de la Salut, Germans Trias i Pujol, Badalona, Spain
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21
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Ortega O, Rofes L, Martin A, Arreola V, López I, Clavé P. A Comparative Study Between Two Sensory Stimulation Strategies After Two Weeks Treatment on Older Patients with Oropharyngeal Dysphagia. Dysphagia 2016; 31:706-16. [DOI: 10.1007/s00455-016-9736-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/21/2016] [Indexed: 10/21/2022]
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22
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Alvarez-Berdugo D, Rofes L, Casamitjana JF, Padrón A, Quer M, Clavé P. Oropharyngeal and laryngeal sensory innervation in the pathophysiology of swallowing disorders and sensory stimulation treatments. Ann N Y Acad Sci 2016; 1380:104-120. [DOI: 10.1111/nyas.13150] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/19/2016] [Accepted: 05/25/2016] [Indexed: 02/02/2023]
Affiliation(s)
- Daniel Alvarez-Berdugo
- Gastrointestinal Motility Laboratory, Hospital de Mataró; Consorci Sanitari del Maresme; Mataró Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas; Instituto de Salud Carlos III; Barcelona Spain
| | - Laia Rofes
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas; Instituto de Salud Carlos III; Barcelona Spain
| | | | - Andreína Padrón
- Department of Pathology, Hospital de Mataró; Consorci Sanitari del Maresme; Mataró Spain
| | - Miquel Quer
- ENT and Cervicofacial Pathology Department of Hospital de la Santa Creu i Sant Pau; Barcelona Spain
| | - Pere Clavé
- Gastrointestinal Motility Laboratory, Hospital de Mataró; Consorci Sanitari del Maresme; Mataró Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas; Instituto de Salud Carlos III; Barcelona Spain
- Fundació Institut de Investigació Germans Trias i Pujol; Badalona Spain
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23
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Cabib C, Ortega O, Kumru H, Palomeras E, Vilardell N, Alvarez-Berdugo D, Muriana D, Rofes L, Terré R, Mearin F, Clavé P. Neurorehabilitation strategies for poststroke oropharyngeal dysphagia: from compensation to the recovery of swallowing function. Ann N Y Acad Sci 2016; 1380:121-138. [DOI: 10.1111/nyas.13135] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/11/2016] [Accepted: 05/19/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Christopher Cabib
- Gastrointestinal Physiology Laboratory, Department of Surgery; Hospital de Mataró, Universitat Autònoma de Barcelona; Mataró Spain
| | - Omar Ortega
- Gastrointestinal Physiology Laboratory, Department of Surgery; Hospital de Mataró, Universitat Autònoma de Barcelona; Mataró Spain
- Centro de Investigación Biomedica en Red de enfermedades hepáticas y digestivas (CIBERehd); Instituto de Salud Carlos III; Barcelona Spain
| | - Hatice Kumru
- Fundación Institut Guttmann; Institut Universitari de Neurorehabilitació, Universitat Autonoma de Barcelona; Badalona Spain
| | - Ernest Palomeras
- Neurology Department, Hospital de Mataró; Universitat Autònoma de Barcelona; Mataró Spain
| | - Natalia Vilardell
- Gastrointestinal Physiology Laboratory, Department of Surgery; Hospital de Mataró, Universitat Autònoma de Barcelona; Mataró Spain
| | - Daniel Alvarez-Berdugo
- Gastrointestinal Physiology Laboratory, Department of Surgery; Hospital de Mataró, Universitat Autònoma de Barcelona; Mataró Spain
- Centro de Investigación Biomedica en Red de enfermedades hepáticas y digestivas (CIBERehd); Instituto de Salud Carlos III; Barcelona Spain
| | - Desirée Muriana
- Neurology Department, Hospital de Mataró; Universitat Autònoma de Barcelona; Mataró Spain
| | - Laia Rofes
- Gastrointestinal Physiology Laboratory, Department of Surgery; Hospital de Mataró, Universitat Autònoma de Barcelona; Mataró Spain
- Centro de Investigación Biomedica en Red de enfermedades hepáticas y digestivas (CIBERehd); Instituto de Salud Carlos III; Barcelona Spain
| | - Rosa Terré
- Fundación Institut Guttmann; Institut Universitari de Neurorehabilitació, Universitat Autonoma de Barcelona; Badalona Spain
- Health Sciences Research Institute of the Germans Trias i Pujol Foundation; Barcelona Spain
| | - Fermín Mearin
- Fundación Institut Guttmann; Institut Universitari de Neurorehabilitació, Universitat Autonoma de Barcelona; Badalona Spain
- Health Sciences Research Institute of the Germans Trias i Pujol Foundation; Barcelona Spain
| | - Pere Clavé
- Gastrointestinal Physiology Laboratory, Department of Surgery; Hospital de Mataró, Universitat Autònoma de Barcelona; Mataró Spain
- Centro de Investigación Biomedica en Red de enfermedades hepáticas y digestivas (CIBERehd); Instituto de Salud Carlos III; Barcelona Spain
- Health Sciences Research Institute of the Germans Trias i Pujol Foundation; Barcelona Spain
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Alvarez-Berdugo D, Rofes L, Farré R, Casamitjana JF, Enrique A, Chamizo J, Padrón A, Navarro X, Clavé P. Localization and expression of TRPV1 and TRPA1 in the human oropharynx and larynx. Neurogastroenterol Motil 2016; 28:91-100. [PMID: 26530852 DOI: 10.1111/nmo.12701] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 09/08/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Previous studies have found that TRPV1 and TRPA1 receptor agonists improve swallow response in patients with oropharyngeal dysphagia (OD), but little is known about the expression of these receptors in the human oropharynx. The aim of this study was to assess the expression and localization of TRPV1 and TRPA1 in human samples from the oropharynx of healthy patients, to provide the basis for new pharmacological treatments for OD. METHODS Samples from oropharyngeal regions innervated by cranial nerves V, IX, and X (tongue, pharynx, and epiglottis) were obtained during ENT surgery and processed either for mRNA (21 patients) or for immunohistochemical assays (seven patients). The expression analysis was performed with RT-qPCR using ACTBh as reference gene. Hemotoxylin and eosin staining was used to study the histology; the immunohistochemical assay used (i) neuron-specific enolase to detect nerve fibers or (ii) fluorescent probes to locate TRPV1 and TRPA1. RESULTS TRPV1 was expressed in the three studied regions, with higher levels in CN V region (tongue) than in CN X region (epiglottis; p < 0.05), and was localized at epithelial cells and nociceptive fibers in all studied regions. TRPA1 was also expressed in all studied regions, but was always localized below the basal lamina. No immunoreactivity for TRPA1 was found on epithelial cells. CONCLUSIONS & INFERENCES TRPV1 and TRPA1 are widely expressed in the human oropharynx with two distinct patterns. Our study further confirms that TRPV1/A1 receptors are promising therapeutic targets to develop active treatments for OD patients.
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Affiliation(s)
- D Alvarez-Berdugo
- Gastrointestinal Motility Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - L Rofes
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Barcelona, Spain
| | - R Farré
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Barcelona, Spain.,Translational Research Center for Gastrointestinal Disorders, KU Leuven - University of Leuven, Leuven, Belgium
| | - J F Casamitjana
- ENT Department, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - A Enrique
- ENT Department, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - J Chamizo
- ENT Department, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - A Padrón
- Department of Pathology, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - X Navarro
- Department of Cell Biology, Physiology and Immunology, Institute of Neurosciences, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas, Bellaterra, Spain
| | - P Clavé
- Gastrointestinal Motility Laboratory, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Barcelona, Spain.,Fundació Institut de Investigació Germans Trias i Pujol, Badalona, Spain
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Vilardell N, Rofes L, Arreola V, Speyer R, Clavé P. A Comparative Study Between Modified Starch and Xanthan Gum Thickeners in Post-Stroke Oropharyngeal Dysphagia. Dysphagia 2015; 31:169-79. [DOI: 10.1007/s00455-015-9672-8] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 11/11/2015] [Indexed: 11/30/2022]
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26
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Carrión S, Cabré M, Monteis R, Roca M, Palomera E, Serra-Prat M, Rofes L, Clavé P. Oropharyngeal dysphagia is a prevalent risk factor for malnutrition in a cohort of older patients admitted with an acute disease to a general hospital. Clin Nutr 2015; 34:436-42. [DOI: 10.1016/j.clnu.2014.04.014] [Citation(s) in RCA: 200] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 02/19/2014] [Accepted: 04/22/2014] [Indexed: 11/24/2022]
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27
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Espín F, Rofes L, Ortega O, Clavé P, Gallego D. Nitrergic neuro-muscular transmission is up-regulated in patients with diverticulosis. Neurogastroenterol Motil 2014; 26:1458-68. [PMID: 25109425 DOI: 10.1111/nmo.12407] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 07/04/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Neuro-transmission impairment could be associated to motility changes observed in patients with diverticular disease. Therefore, the objective was to characterize the inhibitory neuro-muscular transmission and gene expression changes of the enteric inhibitory pathways in patients with diverticulosis (DS). METHODS Circular muscle strips from sigmoid colon of patients with DS and controls were studied using the organ bath technique to evaluate spontaneous contractility and enteric motor neurons stimulated by electrical field and qRT-PCR to assess the expression of nNOS, iNOS, P2Y1 R and PGP9.5. KEY RESULTS Patients with DS presented decreased spontaneous rhythmic contractions (SRC) that were significantly enhanced after incubation with L-NNA (1 mM) and TTX (1 μM), and unaffected by the P2Y1 antagonist MRS2500 (1 μM). Stimulation on enteric motor neurons caused an increased duration of the latency of OFF-contractions in DS group (p < 0.001), antagonized by L-NNA and slightly affected by MRS2500 (1 μM). No differences in the IC50 between controls and DS patients were observed on inhibition of SRC for the NO-donor sodium nitroprusside (SNP) and the preferential P2Y agonist ADPβS. Moreover, nNOS relative expression was also up-regulated 2.3-fold in the DS group (p < 0.05) whereas there was no significant difference in relative expression of iNOS, P2Y1 R and the neuronal marker PGP9.5 between groups. CONCLUSIONS & INFERENCES Patients with DS presented an over-expression of nNOS with increased endogenously NO-mediated responses suggesting enhanced NO-release. Up-regulation in the nitrergic pathway in early stages of the disease might play a role in colonic motor disorders associated to diverticular disease.
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Affiliation(s)
- F Espín
- Department of Surgery, Gastrointestinal Physiology Laboratory, Hospital de Mataró, Mataró, Barcelona, Spain
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Rofes L, Arreola V, Mukherjee R, Clavé P. Sensitivity and specificity of the Eating Assessment Tool and the Volume-Viscosity Swallow Test for clinical evaluation of oropharyngeal dysphagia. Neurogastroenterol Motil 2014; 26:1256-65. [PMID: 24909661 PMCID: PMC4282313 DOI: 10.1111/nmo.12382] [Citation(s) in RCA: 178] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 05/18/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Oropharyngeal dysphagia (OD) is an underdiagnosed digestive disorder that causes severe nutritional and respiratory complications. Our aim was to determine the accuracy of the Eating Assessment Tool (EAT-10) and the Volume-Viscosity Swallow Test (V-VST) for clinical evaluation of OD. METHODS We studied 120 patients with swallowing difficulties and 14 healthy subjects. OD was evaluated by the 10-item screening questionnaire EAT-10 and the bedside method V-VST, videofluoroscopy (VFS) being the reference standard. The V-VST is an effort test that uses boluses of different volumes and viscosities to identify clinical signs of impaired efficacy (impaired labial seal, piecemeal deglutition, and residue) and impaired safety of swallow (cough, voice changes, and oxygen desaturation ≥3%). Discriminating ability was assessed by the AUC of the ROC curve and sensitivity and specificity values. KEY RESULTS According to VFS, prevalence of OD was 87%, 75.6% with impaired efficacy and 80.9% with impaired safety of swallow including 17.6% aspirations. The EAT-10 showed a ROC AUC of 0.89 for OD with an optimal cut-off at 2 (0.89 sensitivity and 0.82 specificity). The V-VST showed 0.94 sensitivity and 0.88 specificity for OD, 0.79 sensitivity and 0.75 specificity for impaired efficacy, 0.87 sensitivity and 0.81 specificity for impaired safety, and 0.91 sensitivity and 0.28 specificity for aspirations. CONCLUSIONS & INFERENCES Clinical methods for screening (EAT-10) and assessment (V-VST) of OD offer excellent psychometric proprieties that allow adequate management of OD. Their universal application among at-risk populations will improve the identification of patients with OD at risk for malnutrition and aspiration pneumonia.
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Affiliation(s)
- L Rofes
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
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Rofes L, Arreola V, Mukherjee R, Clavé P. Sensitivity and specificity of the Eating Assessment Tool and the Volume-Viscosity Swallow Test for clinical evaluation of oropharyngeal dysphagia. Neurogastroenterol Motil 2014. [PMID: 24909661 DOI: 10.1111/nmo.12382.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Oropharyngeal dysphagia (OD) is an underdiagnosed digestive disorder that causes severe nutritional and respiratory complications. Our aim was to determine the accuracy of the Eating Assessment Tool (EAT-10) and the Volume-Viscosity Swallow Test (V-VST) for clinical evaluation of OD. METHODS We studied 120 patients with swallowing difficulties and 14 healthy subjects. OD was evaluated by the 10-item screening questionnaire EAT-10 and the bedside method V-VST, videofluoroscopy (VFS) being the reference standard. The V-VST is an effort test that uses boluses of different volumes and viscosities to identify clinical signs of impaired efficacy (impaired labial seal, piecemeal deglutition, and residue) and impaired safety of swallow (cough, voice changes, and oxygen desaturation ≥3%). Discriminating ability was assessed by the AUC of the ROC curve and sensitivity and specificity values. KEY RESULTS According to VFS, prevalence of OD was 87%, 75.6% with impaired efficacy and 80.9% with impaired safety of swallow including 17.6% aspirations. The EAT-10 showed a ROC AUC of 0.89 for OD with an optimal cut-off at 2 (0.89 sensitivity and 0.82 specificity). The V-VST showed 0.94 sensitivity and 0.88 specificity for OD, 0.79 sensitivity and 0.75 specificity for impaired efficacy, 0.87 sensitivity and 0.81 specificity for impaired safety, and 0.91 sensitivity and 0.28 specificity for aspirations. CONCLUSIONS & INFERENCES Clinical methods for screening (EAT-10) and assessment (V-VST) of OD offer excellent psychometric proprieties that allow adequate management of OD. Their universal application among at-risk populations will improve the identification of patients with OD at risk for malnutrition and aspiration pneumonia.
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Affiliation(s)
- L Rofes
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
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Rofes L, Arreola V, Mukherjee R, Swanson J, Clavé P. The effects of a xanthan gum-based thickener on the swallowing function of patients with dysphagia. Aliment Pharmacol Ther 2014; 39:1169-79. [PMID: 24628492 DOI: 10.1111/apt.12696] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 02/17/2014] [Accepted: 02/19/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Increasing bolus viscosity of thin liquids is a basic therapeutic strategy to protect patients with oropharyngeal dysphagia (OD) from aspiration. However, conventional starch thickeners increase post-deglutitive residue. AIM To assess the therapeutic effect of a new xanthan gum-based thickener, Resource ThickenUp Clear (Nestlé Health Science, Vevey, Switzerland) on patients with oropharyngeal dysphagia. METHODS We studied the effect of Resource ThickenUp Clear using a clinical method and videofluoroscopy on 120 patients with oropharyngeal dysphagia (66 with stroke, 41 older and 13 with neurodegenerative diseases) and 14 healthy volunteers while swallowing thin-liquid, nectar-like and spoon-thick boluses. We assessed the prevalence of signs of impaired safety and efficacy of swallow and the physiology of the swallow response. RESULTS Increasing bolus viscosity with Resource ThickenUp Clear: (i) improved safety of swallow demonstrated by a reduction in the prevalence of cough and voice changes in the clinical study and penetrations and aspirations during video fluoroscopy. Prevalence of aspirations was 12.7% with thin liquid, 7.7% with nectar-like (P < 0.01) and 3.4% with spoon-thick (P < 0.01) viscosities. Penetration-Aspiration Scale was reduced from 3.24 ± 0.18 at thin liquid to 2.20 ± 0.18 at nectar-like (P < 0.001) and to 1.53 ± 0.13 at spoon-thick (P < 0.001) viscosities; (ii) did not enhance pharyngeal residue; (iii) nectar-like viscosity did not affect bolus velocity nor timing of swallow response and (iv) spoon-thick viscosity reduced bolus velocity. CONCLUSIONS Resource ThickenUp Clear improves the safety of swallow without increasing residue providing a viscosity-dependent therapeutic effect for patients with oropharyngeal dysphagia. At nectar viscosity, the effect is due to intrinsic texture properties, spoon-thick viscosity adding changes in swallow physiology. NCT01158313.
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Affiliation(s)
- L Rofes
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
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Abstract
Oropharyngeal dysphagia (OD) is a swallowing disorder caused by congenital abnormalities and structural damage and disease-associated damage of the oral cavity, pharynx, and upper esophageal sphincter. Patients with OD lack the protective mechanisms necessary for effective swallowing, exhibiting difficulty controlling food in the mouth and initiating a swallow, leading to choking, coughing, and nasal regurgitation. OD is a major risk factor for malnutrition, dehydration, and aspiration pneumonia. The following on OD includes commentaries on the application of simulation of oropharyngeal transient receptor potential vanilloid 1 (TRPV1) and maneuvers like the Shaker exercise to improve the safety and efficacy of swallow in OD patients; the prevalence of esophageal pathologies in OD patients and the need to evaluate the esophagus, esophagogastric junction, and stomach; and strategies for clinical screening to detect OD and aspiration among high-risk patients and to improve oral health care, maintain nutrition and hydration, and prevent aspiration pneumonia.
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Affiliation(s)
- Laia Rofes
- Centro de Investigación Biomédica en Red de enfermedades hepaticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - Pere Clavé
- Gastrointestinal Physiology Lab, Hospital de Mataró, Mataró, Spain
| | - Ann Ouyang
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | | | - Peter Pokieser
- Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Natalia Vilardell
- Unitat de Proves funcionals Digestives, Hospital de Mataró, Barcelona, Spain
| | - Omar Ortega
- Unitat de Proves funcionals Digestives, Hospital de Mataró, Barcelona, Spain
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Rofes L, Arreola V, López I, Martin A, Sebastián M, Ciurana A, Clavé P. Effect of surface sensory and motor electrical stimulation on chronic poststroke oropharyngeal dysfunction. Neurogastroenterol Motil 2013; 25:888-e701. [PMID: 23937476 DOI: 10.1111/nmo.12211] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 07/20/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic poststroke oropharyngeal dysfunction (OD) is a common condition, leading to severe complications, including death. Treatments for chronic poststroke OD are scarce. The aim of our study was to assess and compare the efficacy and safety of treatment with surface electrical stimulation (e-stim) at sensory and motor intensities in patients with chronic poststroke OD. METHODS Twenty chronic poststroke patients with OD were randomly assigned to (i) sensory e-stim (treatment intensity: 75% of motor threshold) or (ii) motor e-stim (treatment intensity: motor threshold). Patients were treated during 10 days, 1 h/day. Videofluoroscopy was performed at the beginning and end of the study to assess signs of impaired efficacy and safety of swallow and timing of swallow response. KEY RESULTS Patients presented advanced age (74.95 ± 2.18), 75% were men. The mean days poststroke was 336.26 ± 89.6. After sensory stimulation, the number of unsafe swallows was reduced by 66.7% (p < 0.001), the laryngeal vestibule closure time by 22.94% (p = 0.027) and maximal vertical hyoid extension time by 18.6% (p = 0.036). After motor stimulation, the number of unsafe swallows was reduced by 62.5% (p = 0.002), the laryngeal vestibule closure time by 38.26% (p = 0.009) and maximal vertical hyoid extension time by 24.8% (p = 0.008). Moreover, the motor stimulus reduced the pharyngeal residue by 66.7% (p = 0.002), the upper esophageal sphincter opening time by 39.39% (p = 0.009), and increased bolus propulsion force by 211.1% (p = 0.008). No serious adverse events were detected during the treatment. CONCLUSIONS & INFERENCES Surface e-stim is a safe and effective treatment for chronic poststroke dysphagic patients.
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Affiliation(s)
- L Rofes
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
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Abstract
OBJECTIVE There is no pharmacological treatment for oropharyngeal dysphagia (OD). The aim of this study was to compare the therapeutic effect of stimulation of oropharyngeal transient receptor potential vanilloid type 1 (TRPV1) with that of thickeners in older patients with OD. DESIGN A clinical videofluoroscopic non-randomised study was performed to assess the signs of safety and efficacy of swallow and the swallow response in (1) 33 patients with OD (75.94 ± 1.88 years) while swallowing 5, 10 and 20 ml of liquid (20.4 mPa.s), nectar (274.4 mPa.s), and pudding (3930 mPa.s) boluses; (2) 33 patients with OD (73.94 ± 2.23 years) while swallowing 5, 10 and 20 ml nectar boluses, and two series of nectar boluses with 150 μM capsaicinoids and (3) 8 older controls (76.88 ± 1.51 years) while swallowing 5, 10 and 20 ml nectar boluses. RESULTS Increasing bolus viscosity reduced the prevalence of laryngeal penetrations by 72.03% (p < 0.05), increased pharyngeal residue by 41.37% (p < 0.05), delayed the upper esophageal sphincter opening time and the larynx movement and did not affect the laryngeal vestibule closure time and maximal hyoid displacement. Treatment with capsaicinoids reduced both, penetrations by 50.% (p < 0.05) and pharyngeal residue by 50.% (p < 0.05), and shortened the time of laryngeal vestibule closure (p < 0.001), upper esophageal sphincter opening (p < 0.05) and maximal hyoid and laryngeal displacement. CONCLUSION Stimulation of TRPV1 by capsaicinoids strongly improved safety and efficacy of swallow and shortened the swallow response in older patients with OD. Stimulation of TRPV1 might become a pharmacologic strategy to treat OD.
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Affiliation(s)
- Laia Rofes
- Centro de Investigación Biomedica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
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Abstract
Oropharyngeal Dysphagia (OD) is both underestimated and underdiagnosed as a cause of malnutrition and respiratory complications following stroke. OD occurs in more than 50% of stroke patients. Aspiration pneumonia (AP) occurs in up to 20% of acute stroke patients and is a major cause of mortality after discharge. Systematic screening for OD should be performed on every patient with stroke before starting oral feeding, followed, if appropriate by clinical and instrumental (videofluroscopy and/or fiberoptic endoscopy) assessment. Bolus modification with adaptation of texture and viscosity of solids and fluids and postural adjustments should be part of the minimal treatment protocol, but they do not change the impaired swallow physiology nor promote recovery of damaged neural swallow networks in stroke patients. To this purpose, two new neurostimulation approaches are being developed to stimulate cortical neuroplasticity to recover swallowing function: (i) those aimed at stimulating the peripheral oropharyngeal sensory system by chemical, physical or electrical stimulus; and (ii) those aimed at directly stimulating the pharyngeal motor cortex, such as repetitive transcranial magnetic stimulation (rTMS). The study of Park et al. in this issue of Neurogastroenterology and Motility evaluated the effect of rTMS in dysphagic stroke patients and showed a marked improvement in swallow physiology. Other studies also using rTMS showed plastic changes in pharyngeal motor cortical areas relevant to swallowing function. If further randomized controlled trials confirm these initial results, the neurorehabilitation strategies will be introduced to clinical practice sooner rather than later, improving the recovery of dysphagic stroke patients. Progress at last.
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Affiliation(s)
- L Rofes
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
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Rofes L, Arreola V, Clavé P. The volume-viscosity swallow test for clinical screening of dysphagia and aspiration. Nestle Nutr Inst Workshop Ser 2012; 72:33-42. [PMID: 23051998 DOI: 10.1159/000339979] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Oropharyngeal dysphagia (OD) is a major complaint among many patients with neurological diseases and in the elderly, but is often underdiagnosed. The volume-viscosity swallow test (V-VST) is a bedside method to screen patients for dysphagia. METHODS The V-VST was designed to identify clinical signs of impaired efficacy (labial seal, oral and pharyngeal residue, and piecemeal deglutition) and impaired safety of swallow (voice changes, cough and decrease in oxygen saturation ≥3%). It starts with nectar viscosity and increasing bolus volume, then liquid and finally pudding viscosity in a progression of increasing difficulty to protect patients from aspiration. RESULTS The V-VST allows quick, safe and accurate screening for OD in hospitalized and independently living patients with multiple etiologies. The V-VST presents a sensitivity of 88.2% and a specificity of 64.7% to detect clinical signs of impaired safety of swallow (aspiration or penetration). The test takes 5-10 min to complete. DISCUSSION AND CONCLUSION The V-VST is an excellent tool to screen patients for OD. It combines good psychometric properties, a detailed and easy protocol designed to protect safety of patients, and valid end points to evaluate safety and efficacy of swallowing and detect silent aspirations.
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Affiliation(s)
- Laia Rofes
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
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Almirall J, Rofes L, Serra-Prat M, Icart R, Palomera E, Arreola V, Clavé P. Oropharyngeal dysphagia is a risk factor for community-acquired pneumonia in the elderly. Eur Respir J 2012; 41:923-8. [PMID: 22835620 DOI: 10.1183/09031936.00019012] [Citation(s) in RCA: 146] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to explore whether oropharyngeal dysphagia is a risk factor for community-acquired pneumonia (CAP) in the elderly and to assess the physiology of deglutition of patients with pneumonia. In the case-control study, 36 elderly patients (aged ≥ 70 years) hospitalised with pneumonia were matched by age and sex with two independently living controls. All subjects were given the volume-viscosity swallow test to identify signs of oropharyngeal dysphagia. In the pathophysiological study, all cases and 10 healthy elderly subjects were examined using videofluoroscopy. Prevalence of oropharyngeal dysphagia in the case-control study was 91.7% in cases and 40.3% in controls (p<0.001). Adjusting for functionality and comorbidities, dysphagia showed an independent effect on pneumonia (OR 11.9, 95% CI 3.03-46.9). Among cases in the pathophysiological study, 16.7% showed safe swallow, 30.6% high penetrations, 36.1% severe penetrations and 16.7% silent aspirations during videofluoroscopy, while in the healthy elderly subjects these percentages were 80%, 20%, 0% and 0%, respectively (p<0.001). A delay in closure of the laryngeal vestibule (0.414 ± 0.029 s versus 0.200 ± 0.059 s, p<0.01) was the main mechanism of impaired airway protection. In elderly subjects, oropharyngeal dysphagia is strongly associated with CAP, independently of functionality and comorbidities. Elderly patients with pneumonia presented a severe impairment of swallow and airway protection mechanisms. We recommend universal screening of dysphagia in older persons with pneumonia.
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Affiliation(s)
- Jordi Almirall
- Intensive Care Unit, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
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Clavé P, Rofes L, Carrión S, Ortega O, Cabré M, Serra-Prat M, Arreola V. Pathophysiology, relevance and natural history of oropharyngeal dysphagia among older people. Nestle Nutr Inst Workshop Ser 2012; 72:57-66. [PMID: 23052001 DOI: 10.1159/000339986] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Oropharyngeal dysphagia (OD) is a very frequent condition among older people with a prevalence ranging from mild symptoms in 25% of the independently living to severe symptoms in more than 50% living in nursing homes. There are several validated methods of screening, and clinical assessment and videofluoroscopy are the gold standard for the study of the mechanisms of OD in the elderly. Oropharyngeal residue is mainly caused by weak bolus propulsion forces due to tongue sarcopenia. The neural elements of swallow response are also impaired in older persons, with prolonged and delayed laryngeal vestibule closure and slow hyoid movement causing oropharyngeal aspirations. OD causes malnutrition, dehydration, impaired quality of life, lower respiratory tract infections, aspiration pneumonia, and poor prognosis including prolonged hospital stay and enhanced morbidity and mortality in several phenotypes of older patients ranging from independently living older people, hospitalized older patients and nursing home residents. Enhancing bolus viscosity of fluids greatly improves safety of swallow in all these patients. We believe OD should be recognized as a major geriatric syndrome, and we recommend a policy of systematic and universal screening and assessment of OD among older people to prevent its severe complications.
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Affiliation(s)
- Pere Clavé
- Unitat d'Exploracions Funcionals Digestives, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Barcelona, Spain
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Rofes L, Arreola V, Romea M, Palomera E, Almirall J, Cabré M, Serra-Prat M, Clavé P. Pathophysiology of oropharyngeal dysphagia in the frail elderly. Neurogastroenterol Motil 2010; 22:851-8, e230. [PMID: 20529208 DOI: 10.1111/j.1365-2982.2010.01521.x] [Citation(s) in RCA: 178] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Oropharyngeal dysphagia is a major complaint among the elderly. Our aim was to assess the pathophysiology of oropharyngeal dysphagia in frail elderly patients (FEP). METHODS A total of 45 FEP (81.5 +/- 1.1 years) with oropharyngeal dysphagia and 12 healthy volunteers (HV, 40 +/- 2.4 years) were studied using videofluoroscopy. Each subject's clinical records, signs of safety and efficacy of swallow, timing of swallow response, hyoid motion and tongue bolus propulsion forces were assessed. KEY RESULTS Healthy volunteers presented a safe and efficacious swallow, faster laryngeal closure (0.157 +/- 0.013 s) upper esophageal sphincter opening (0.200 +/- 0.011 s), and maximal vertical hyoid motion (0.310 +/- 0.048 s), and stronger tongue propulsion forces (22.16 +/- 2.54 mN) than FEP. By contrast, 63.63% of FEP presented oropharyngeal residue, 57.10%, laryngeal penetration and 17.14%, tracheobronchial aspiration. Frail elderly patients with impaired swallow safety showed delayed laryngeal vestibule (LV) closure (0.476 +/- 0.047 s), similar bolus propulsion forces, poor functional capacity and higher 1-year mortality rates (51.7%vs 13.3%, P = 0.021) than FEP with safe swallow. Frail elderly patients with oropharyngeal residue showed impaired tongue propulsion (9.00 +/- 0.10 mN), delayed maximal vertical hyoid motion (0.612 +/- 0.071 s) and higher (56.0%vs 15.8%, P = 0.012) 1-year mortality rates than those with efficient swallow. CONCLUSION & INFERENCES Frail elderly patients with oropharyngeal dysphagia presented poor outcome and high mortality rates. Impaired safety of deglutition and aspirations are mainly caused by delayed LV closure. Impaired efficacy and residue are mainly related to weak tongue bolus propulsion forces and slow hyoid motion. Treatment of dysphagia in FEP should be targeted to improve these critical events.
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Affiliation(s)
- L Rofes
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
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Gallego D, Aulí M, Aleu J, Martínez E, Rofes L, Martí-Ragué J, Jiménez M, Clavé P. Effect of otilonium bromide on contractile patterns in the human sigmoid colon. Neurogastroenterol Motil 2010; 22:e180-91. [PMID: 20367799 DOI: 10.1111/j.1365-2982.2010.01495.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The mechanism of action of the spasmolytic compound otilonium bromide (OB) on human colonic motility is not understood. The aim of our study was to characterize the pharmacological effects of OB on contractile patterns in the human sigmoid colon. METHODS Circular sigmoid strips were studied in organ baths. Isolated smooth muscle cells from human sigmoid colon were examined using the calcium imaging technique. KEY RESULTS Otilonium bromide inhibited by 85% spontaneous non-neural rhythmic phasic contractions (RPCs), (IC(50) = 49.9 nmol L(-1)) and stretch-induced tone (IC(50) = 10.7 nmol L(-1)) with maximum effects at micromolar range. OB also inhibited by 50% both on- (IC(50) = 38.0 nmol L(-1)) and off-contractions induced by electrical stimulation of excitatory motor neurons. In contrast, the inhibitory latency period prior to off-contractions was unaffected by OB. OB inhibited acetylcholine-, substance P-, and neurokinin A-induced contractions. The L-type Ca(2+) channel agonist BayK8644 reversed the effects of OB on RPCs, on- and off-contractions. Hexamethonium, atropine, the NK(2) antagonist, or depletion of intracellular Ca(2+) stores by thapsigargin did not prevent the inhibitory effect of OB on RPCs and electrical contractions. KCl-induced calcium transients in isolated smooth muscle cells were also inhibited by OB (IC(50) = 0.2 micromol L(-1)). CONCLUSIONS & INFERENCES Otilonium bromide strongly inhibited the main patterns of human sigmoid motility in vitro by blocking calcium influx through L-type calcium channels on smooth muscle cells. This pharmacological profile may mediate the clinically observed effects of the drug in patients with irritable bowel syndrome.
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Affiliation(s)
- D Gallego
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Instituto de Salud Carlos III, Barcelona, Spain
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Rofes L, Bueno A, Valero J, Labad A. [Retrospective study of prodromal symptoms in schizophrenia]. Actas Esp Psiquiatr 2003; 31:35-9. [PMID: 12590371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
INTRODUCTION There are some non-psychotic symptoms that can forecast the onset of psychosis. Discovering the differences between the symptoms that lead to disease and those that do not makes it possible to identify them and permits early treatment of the disease. METHODS A sample of 689 schizophrenic patients was analyzed retrospectively. This sample was obtained from the clinical records database of the University Psychiatric Hospital Institut Pere Mata. Data were analyzed with the SPSS version 9.0 statistical package. RESULTS The most frequent prodromal symptoms of the sample were the delusional ones, the disorganized ones and the neurotic ones. The prodromal symptoms were equally distributed in both genders. In the subtypes, paranoids showed more delusional symptoms, whereas the nonparanoids presented more disorganized symptoms. Acute onsets had more delusional prodromal symptoms whereas the insidious onsets showed more disorganized ones. CONCLUSIONS In the prodromal stages of shizophrenia, we can also find the community neurotic prevalences regarding gender. The higher rate of neurotic symptoms in the nonparanoid subtype would be explained by the inclusion of the schizoaffective category, whereas the higher rate of disorganized symptoms categories would be due to the hebephrenic and simple categories. The latter would also explain the prodromal differences in the onset type.
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Affiliation(s)
- L Rofes
- Unidad de Psiquiatría y Psicologia Médica, Departamento de Medicina y Cirugía. Facultad de Medicina y Ciencias de la Salud. Universidad Rovira i Virgili. Reus (Tarragona), España.
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