Timeline to dysphagia resolution after endoscopic intervention of an interarytenoid defect based on Video Fluoroscopic Swallow Study dysphagia severity

INTRODUCTION

We previously reported that endoscopic repair of a Type 1 Laryngeal Cleft (LC1) or Deep Interarytenoid Groove (DIG) improves swallowing function postoperatively. However, caregivers often ask about the timeline to resolution of the need for thickening. This study re-examines this cohort to answer this important caregiver-centered question.

METHODS

We reassessed a 3-year retrospective, single-center dataset of children with dysphagia found to have a LC-1 or DIG on endoscopic exam. The primary outcome was rate of complete resolution of dysphagia at 2, 6, and 12 months after endoscopic intervention. A sub-group analysis was made based on severity of dysphagia prior to intervention and by type of endoscopic repair.

RESULTS

Thirty-nine patients with mean age 1.35 years that had a LC-1 or DIG met criteria for inclusion. Rate of complete dysphagia resolution increased over time. Those with mild dysphagia (flow-reducing nipple and/or IDDSI consistency 1 or 2) had brisker resolution than those with moderate dysphagia (IDDSI consistency 3 or 4) at 2 months (67% vs 5%, p < 0.01) and at 6 months (80% vs 18%, p < 0.01) after endoscopic repair. There was no difference in dysphagia resolution between patients grouped by type of endoscopic repair.

CONCLUSION

Addressing an interarytenoid defect in patients will not result in immediate, complete dysphagia resolution in most patients. However, patients that only require a flow-reducing nipple and/or thickening to an IDDSI consistency 1 or 2 have brisker resolution of the need for thickening than those that require an IDSSI consistency 3 or 4 prior to intervention. These results inform pre-operative discussions of the timeline to resolution based upon severity of dysphagia and help manage caregiver expectations.

Optimal timing and technique for endoscopic management of dysphagia in pediatric aerodigestive patients

INTRODUCTION

The best strategy to manage an interarytenoid defect [Type 1 laryngeal cleft (LC-1) or deep interarytenoid groove (DIG)] in pediatric aerodigestive patients with dysphagia remains uncertain. This study compared benefit of interarytenoid augmentation (IAA) to suture repair or clinical observation alone in pediatric patients.

METHODS

A 3-year retrospective, single-center analysis of children with dysphagia undergoing endoscopic airway evaluation was performed. Physician preference guided treatment plan: suture repair with CO2 laser, IAA (carboxy methylcellulose or calcium hydroxyapatite), or observation. Primary outcome was improved post-operative diet. Significance was assumed at p < 0.05.

RESULTS

449 patients underwent diagnostic endoscopy. Mean age (±SD) at procedure was 21 ± 13 months, with nearly one fourth (28 %) of children ≤ 12 months. Eighty (18 %) had either an LC-1 (n = 55) or DIG (n = 25). Of these, 35 (42 %) underwent suture repair, 22 (28 %) IAA, and 23 (30 %) observation only. Aspiration improved overall in the interventional groups compared to observational controls (58 % vs. 9 %, p < 0.05), with no change in benefit observed by age of intervention. IAA was as effective as suture repair (59 % vs 55 %, p = 0.46). In patients with only a DIG, IAA intervention alone significantly improved swallow function (66.6 % vs. 0 %, p < 0.05).

CONCLUSION

In pediatric aerodigestive patients with dysphagia, 18 % of children have an addressable lesion. IAA or suture repair similarly improves dietary advancement. IAA improves swallow function in patients with DIG. These findings support a novel protocol to intervene in dysphagia patients with LC-1 or DIG via IAA at the initial operative evaluation.

Development and maintenance of a biospecimen repository for clinical samples derived from pulmonary patients

The Pulmonary Biospecimen Repository (PBR) at the University of Alabama at Birmingham (UAB) was launched in 2009. The purpose of the UAB PBR is to provide investigators within the pulmonary community at UAB and elsewhere with clinical samples derived from multiple lung diseases, including transplant recipients, idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease, cystic fibrosis, and asthma. Cell and fluid samples isolated from bronchoalveolar lavage (BAL), plasma, and serum are collected and stored; samples are assessed routinely for viability. Each sample is linked directly with the respective patient information via the Pulmonary Translational Research and Clinical Database, a Health Insurance Portability and Accountability Act compliant database that includes detailed information allowing for the study of specific patient cohorts. To access samples, investigators must complete a request form, which is reviewed by the UAB PBR Steering Committee. To date, more than 800 patients have provided approximately 7,000 BAL, serum and plasma fluid, and cell samples. Over the past 4 years, nearly 800 of these samples have been distributed to investigators at UAB and elsewhere. Future plans for the UAB PBR include expanding sample collection to additional pulmonary diseases, such as mycobacterial infections, increasing the number of sample users and obtaining external funding to ensure its continued sustainability.

Synthesis and evaluation of N-acetylprolinate esters - novel skin penetration enhancers

A series of N-acetylproline esters (alkyl side chain length, 5-18) were synthesized and tested for potential skin penetration enhancement activity using modified Franz diffusion cells and hairless mouse skin as the penetration barrier. Benazepril and hydrocortisone were used as model drugs and were applied as saturated solutions in propylene glycol. The enhancers were added at a concentration of 5% (w/v). Drug flux, permeability coefficient and enhancement ratios for permeability coefficient were determined. Azone was used as the positive control. While all the compounds tested increased the skin penetration of hydrocortisone, the 5- and 8- carbon esters had no significant effect on the skin penetration of benazepril. The highest fluxes were obtained with 11, 12, and 18-carbon esters and they were comparable to Azone. There was no significant difference between the fluxes obtained with 2 and 5% (w/v) concentrations of the 12-carbon ester on hydrocortisone permeation. The 16-carbon ester, where ethanol was used as a cosolvent, significantly increased the fluxes of both the drugs compared to the control. Differential scanning calorimetric studies suggested that the enhancers may be acting on the lipids of the stratum corneum and their effect was similar to that of Azone. The membrane/vehicle partition coefficient studies indicated an increase in benazepril partition coefficient with enhancer treatment compared to the control. Maximum flux increase was obtained with the 11 and 12 carbon (alkyl chain length) esters for both benazepril and hydrocortisone. The 18- carbon ester which has a cis-double bond in the alkyl side chain, also increased the flux significantly.

n-pentyl N-acetylprolinate. A new skin penetration enhancer

The activity of n-pentyl N-acetylprolinate (PNAP) as a transdermal penetration enhancer was investigated. PNAP was synthesized from L-proline by acetylation with acetic anhydride, followed by acid-catalyzed esterification with 1-pentanol. Structure confirmation was accomplished by IR and NMR spectroscopy and elemental analysis. Benzoic acid (BA) was used as a model drug, and the effect of PNAP on the flux of BA through human cadaver skin was evaluated. The central nervous system (CNS) toxicity of PNAP was evaluated by comparing the effects of intraperitoneal administration of PNAP to mice with those of laurocapram (Azone), a known penetration enhancer. Based on preliminary studies, PNAP appears to be an effective transdermal penetration enhancer, is nontoxic at low doses, and exhibits dose-related CNS toxicity at higher doses.

A study of bubbles in a rubber elastomer manipulated under clinical conditions

One hundred addition reaction silicone impressions were made by students and faculty members using two types of syringes with two syringe tip sizes. A count of the bubbles in the impressions revealed a total of 439 with only one impression completely free of bubbles in either the posterior or anterior test regions. Faculty members, presumably more experienced, confirmed the last out-fewer bubbles hypothesis developed in a previous laboratory investigation, but some students did not. A pneumatically activated syringe produced no fewer bubbles than did the conventional hand-powered syringe but most of the students and faculty members thought it was advantageous. Half believed that more practice with it would be beneficial. We recommend that practicing dentists try to minimize bubbles by extruding the first part of the syringe contents onto the mixing pad or in a distant intraoral location before injecting around the critical tooth preparations.

The microscopic appearance and effect of toothbrushing on extrinsically stained metal-ceramic restorations

To clarify the nature and longevity of the extrinsic stain layer of metal-ceramic restorations, a series of experiments were undertaken. It was found, with microscopic examination, that there is little or no diffusion of the stain into the underlying porcelain and that at a thickness of 22 microns the extrinsic stain layer is grossly evident to an observer. Using a fluoride dentifrice caused no significant loss of either stain or surface integrity with 120,000 brush strokes (equivalent to 8.5 years). At 160,000 strokes (equivalent to 11.4 years) there was evidence of loss of surface integrity.

Darmstoff analogues. 2. Ring and side-chain effects on smooth-muscle contraction

2-cis-delta 8-Heptadecenyl-4-(hydroxymethyl)-1,3-dioxolane monosodium phosphate (1b) has been shown to be present as a major component of Darmstoff in mammalian intestine and to be a potent inducer for contraction of intestinal smooth muscle. The analogous 2-pentadecyl material 1a, also found abundantly in the intestine, is inactive. In this study, synthesis of phosphorylated hydroxymethyl-1,4-dioxanes, -tetrahydrofurans, -cyclopentanes, and -oxathiolanes bearing both oleyl and palmityl side chains is reported. Of these, 2-(hydroxymethyl)-5-cis-delta 8-heptadecenyl-1,4-dioxane monosodium phosphate (2b) exhibits about 12% of the activity of 1b. Its pentadecyl analogue 2a, like 1a, is totally inactive, as are all other compounds prepared. The results indicate that Darmstoff-like compounds exhibit specific chemical requirements for activity and that where activity is encountered, the side-chain specificity noted in 1a and 1b can be preserved.

Provisional restorations for traumatically injured teeth requiring endodontic treatment

The acid-etch-composite resin technique is used to retain a provisional restoration during the course of endodontic treatment. As described, the use of a gutta percha cone during the buildup and bonding to adjacent teeth provides the following: (1) good esthetics during endodontic treatment, (2) good support for rubber dam placement, (3) good entry to the canal, (4) good coronal seal for medication within the canal, and (5) good function as required by the provisional crown.

A procedure for repairing fractured post-core restorations

Two methods have been described for dealing with fractured or underextended posts in endodontically treated teeth. They seem to be adequate in preserving teeth that might otherwise have been lost.

Conditioning dentures for problem patients

We have had considerable success with difficult patients through the use of conditioning dentures. Patients with severe gagging problems have been able to gradually accustom themselves to the presence of dentures in the privacy of their homes and at their own rate of progression. Patients without previous denture experience are given a chance to adjust to problems of speech, salivation, and taste prior to receiving their new dentures. We believe that conditioning dentures should be a part of the treatment sequence for all patients being prepared for their first dentures. Many problems are faced by the new denture patient, and anything the dentist can do to prepare him for this difficult time can increase the chances for success.