Preventing taxane-related peripheral neuropathy, pain and nail toxicity: a prospective self-controlled trial comparing hilotherapy with frozen gloves in early breast cancer

PURPOSE

The prevention of taxane-related toxicities at the extremities is highly important for patients' treatment and quality-of-life. Several studies endorse hand/foot-cooling using frozen gloves as a prophylactic intervention. Unlike frozen gloves, hilotherapy produces cooling at a constant temperature. Comparative data with frozen gloves are unavailable.

METHODS

This prospective self-controlled study explores the efficacy of hilotherapy at the right hand and foot compared to frozen gloves at the left in patients with early breast cancer treated with weekly paclitaxel 80 mg/m² or three-weekly docetaxel 75 mg/m². Patient-reported outcomes were collected at baseline, 6, 12, 18 and 24 weeks after the start of treatment. Primary and secondary endpoints were the incidence of any-grade and ≥ grade 2 side-effects (peripheral neuropathy, pain and nail toxicities), and perceived comfort of both interventions.

RESULTS

Sixty-two patients participated. The incidence of any-grade side-effects was similar on both sides, 85.5% with hilotherapy and 90.3% with frozen gloves (p = 1.000). The incidence of ≥ grade 2 side-effects at the extremities was significantly lower with hilotherapy: 43.6% compared to 61.3% with frozen gloves (p = 0.013). Perceived comfort was significantly better for hilotherapy than for frozen gloves (p < 0.0001).

CONCLUSIONS

Compared to frozen gloves, continuous cooling of hands and feet using hilotherapy produces better prevention of ≥ grade 2 patient-reported side-effects at the extremities (peripheral neuropathy, pain and nail toxicities). Perceived comfort was significantly better for hilotherapy. From a clinical and patient perspective, hilotherapy is a better alternative for preventing clinically significant taxane-related side-effects.

Scalp cooling in breast cancer patients treated with docetaxel-cyclophosphamide: patient- and nurse-reported results

PURPOSE

Recent evidence supports the efficacy of scalp cooling in preventing chemotherapy-induced alopecia in breast cancer treatments. However, efficacy largely varies between treatment regimens. The aim of this study was to explore the patient- and nurse-reported results of scalp cooling in terms of hair loss and need for a wig/head cover in patients with breast cancer treated with 3-weekly docetaxel 75 mg/m²- cyclophosphamide 600 mg/m².

METHODS

We studied nurse-reported efficacy as noted in the electronic patient files of 85 patients treated with docetaxel 75 mg/m²- cyclophosphamide 600 mg/m² between 1/1/2017 and 1/1/2020. Sixty-nine of them also self-reported on their scalp cooling results up to one year after adjuvant chemotherapy in a retrospective way.

RESULTS

Nurse- and patient-reported data showed that scalp cooling was successful (i.e., hair loss < 50%) in 47.1 and 44.9% of patients, respectively, and 55% of patients were (very) satisfied with the result of scalp cooling. Scalp cooling was perceived as (very) uncomfortable in 36.2% of patients. Regarding hair status one year after treatment, 47 patients (55.3%) reported no changes compared to their hair status before treatment.

CONCLUSIONS

Scalp cooling is successful in preventing severe chemotherapy-induced alopecia in almost half of the patients with breast cancer treated with docetaxel 75 mg/m²- cyclophosphamide 600 mg/m². Better understanding of the success rate of scalp cooling enables correct patient information and decision-making support.

Objective prediction of pharyngeal swallow dysfunction in dysphagia through artificial neural network modeling

BACKGROUND

Pharyngeal pressure-flow analysis (PFA) of high resolution impedance-manometry (HRIM) with calculation of the swallow risk index (SRI) can quantify swallow dysfunction predisposing to aspiration. We explored the potential use of artificial neural networks (ANN) to model the relationship between PFA swallow metrics and aspiration and to predict swallow dysfunction.

METHODS

Two hundred consecutive dysphagia patients referred for videofluoroscopy and HRIM were assessed. Presence of aspiration was scored and PFA software derived 13 metrics and the SRI. An ANN was created and optimized over training cycles to achieve optimal classification accuracy for matching inputs (PFA metrics) to output (presence of aspiration on videofluoroscopy). Application of the ANN returned a value between 0.00 and 1.00 reflecting the degree of swallow dysfunction.

KEY RESULTS

Twenty one patients were excluded due to insufficient number of swallows (<4). Of 179, 58 aspirated and 27 had aspiration pneumonia history. The SRI was higher in aspirators (aspiration 24 [9, 41] vs no aspiration 7 [2, 18], p < 0.001) and patients with pneumonia (pneumonia 27 [5, 42] vs no pneumonia 8 [3, 24], p < 0.05). The ANN Predicted Risk was higher in aspirators (aspiration 0.57 [0.38, 0.82] vs no aspiration 0.13 [0.4, 0.25], p < 0.001) and in patients with pneumonia (pneumonia 0.46 [0.18, 0.60] vs no pneumonia 0.18 [0.6, 0.49], p < 0.01). Prognostic value of the ANN was superior to the SRI.

CONCLUSIONS & INFERENCES

In a heterogeneous cohort of dysphagia patients, PFA with ANN modeling offers enhanced detection of clinically significant swallowing dysfunction, probably more accurately reflecting the complex interplay of swallow characteristics that causes aspiration.

Presbyfagie: de invloed van het primair verouderingsproces op de slikfunctie

PRESBYPHAGIA: THE INFLUENCE OF PRIMARY AGING ON SWALLOWING FUNCTION: Elderly often get confronted with swallowing difficulties. It is important to differentiate between presbyphagia, which describes the influence of primary aging on swallow function and dysphagia, which is a pathological swallowing disorder caused by age related diseases and their treatment. In this literature overview the focus is on presbyphagia. The influence of primary aging on the oropharyngeal swallowing function and on other body functions that are indirectly related to swallowing will be discussed. From the literature we learn that in primary aging a number of functions stay preserved, a number of functions deteriorate, and some compensatory mechanisms are evident. The swallow safety as such however, stays preserved. To conclude with we discuss some clinical implications concerning both the detection of swallowing disorders in the elderly and the establishment of preventive action for the healthy elderly.

Automatische Impedantie Manometrie (AIM): objectieve diagnostiek van oro-faryngale dysfagie

AUTOMATED IMPEDANCE MANOMETRY (AIM): OBJECTIVE DIAGNOSIS OF OROPHARYNGEAL DYSPHAGIA: This review article aims to demonstrate the clinical potential of Automated Impedance Manometry (AIM) as a new, non-radiological technique for screening and diagnosis of oro-pharyngeal dysphagia. An integrated - rather than separate - analysis of pressure and impedance patterns generated in the pharynx when swallowing a food bolus, can be a useful complement to the radiological investigations considered as gold standard today. Major advantages are the objective nature of this technique and the fully automated calculation of various swallow parameters. A global measure of swallowing function can be derived (a Swallow Risk Index, SRI) and is related to (the severity of) the risk of aspiration and the presence of pharyngeal post-swallow residue. It was shown that aspiration on videofluoroscopy was accurately detected by using AIM with a sensitivity of 0.88 and a specificity of 0.96. AIM analysis can be performed quickly and is reliable in the hands of different end users. Various parameters are sufficiently sensitive to detect changes in bolus consistency and - as was recently found - are influenced by swallowing manoeuvers. Furthermore, different patterns of deviant swallow parameters can be found in different patient populations. Whether this observation can provide specific diagnoses and - as a consequence - more targeted treatments is currently under investigation.

An impedance-manometry based method for non-radiological detection of pharyngeal postswallow residue

BACKGROUND

Postswallow residue is indicative of impaired pharyngeal bolus clearance. The integrated nadir impedance to impedance ratio (iZn/Z) is a novel functional variable that can be derived using automated impedance manometry (AIM). In this study, the postswallow pharyngeal iZn/Z was evaluated as a potential correlated postswallow residue and therefore predictor of ineffective swallowing.

METHODS

Optimal iZn/Z criteria were determine using a database of 50 randomly selected bolus swallows recorded with impedance, manometry, and videofluoroscopy. The iZn/Z was derived for a region of interest (ROI), spanning the mid-point of the pharyngeal stripping wave to the upper esophageal sphincter proximal margin, and from 0.25 to 1.25 s after the peak of the pharyngeal stripping wave. Videofluorscopy was scored by four experts using a six-point bolus residue scale (BRS) score. Optimized criteria for iZn/Z were then applied to a much larger database of 225 swallows scored for residue by one expert observer.

KEY RESULTS

Among individual database, swallows iZn/Z was significantly correlated with average expert BRS score (r = 0.748, P < 0.0001). An iZn/Z of ≥ 500 was optimally predictive of swallows with residue defined by a BRS score of 4 or more. Within the larger cohort, iZn/Z was higher in dysphagia patient swallows compared with controls [2 (1, 4) vs 1 (1, 3), P < 0.005] and swallows with an iZn/Z ≥ 500 had higher bolus residue scores [4 (1, 6) vs 2 (1, 4), P < 0.001].

CONCLUSIONS & INFERENCES

The AIM derived iZn/Z is an easily determined objective non-radiological marker of clinically relevant postswallow residue and therefore has potential diagnostic relevance as a predictor of ineffective swallowing.

Anxiety and depression after stroke: a 5 year follow-up

PURPOSE

The aim was to document the prevalence and predictors of anxiety and depression 5 years after stroke, across four European centres.

METHOD

A cohort of 220 stroke patients was assessed at 2, 4 and 6 months and 5 years after stroke. Patients were assessed on the Hospital Anxiety and Depression Scale and measures of motor function and independence in activities of daily living.

RESULTS

At 5 years, the prevalence of anxiety was 29% and depression 33%, with no significant differences between centres. The severity of anxiety and depression increased significantly between 6 months and 5 years. Higher anxiety at 6 months and centre were significantly associated with anxiety at 5 years, but not measures of functional recovery. Higher depression scores at 6 months, older age and centre, but not measures of functional recovery, were associated with depression at 5 years.

CONCLUSIONS

Anxiety and depression were more frequent at 5 years after stroke than at 6 months. There were significant differences between four European centres in the severity of anxiety and depression. Although the main determinant of anxiety or depression scores at 5 years was the level of anxiety or depression at 6 months, this accounted for little of the variance. Centre was also a significant predictor of mood at 5 years. There needs to be greater recognition of the development of mood disorders late after stroke and evaluation of variation in management policies across centres.

[Recurrent falling, osteoporosis and sarcopenia, three major problems, an integrated approach]

Falling incidents occur frequently and have many harmful side-effects. Not only is there a risk of injuries, the psychological and financial consequences can also be considerable. If these issues are to be addressed thoroughly attention will have to be paid to a reduction of the risk of falling as well as to that of fractures. The department of Gerontology and Geriatrics of the University of Louvain is actively involved in both areas. This involvement is clarified in this contribution. Firstly there is a description of the establishment of the 'Expert Centre Prevention of Falling Flanders' and its tasks. Then some research projects related to prevention of falling will be dealt with briefly, whilst the final part discusses in greater detail the research programme 'Old age related osteoporosis and sarcopenia'.

Process evaluation of a nurse-led multifactorial intervention protocol for risk screening and assessment of fall problems among community-dwelling older persons: a pilot-study

This pilot study investigated the feasibility of a nurse-led fall prevention strategy in community-dwelling older persons. The sample included 126 subjects (mean age = 76 years) who could rise from a chair and transfer independently. During a home visit, a research nurse identified individuals at risk: a history of >or= 2 falls in the previous year or difficulties in gait and/or balance. Patients not at risk received an educational leaflet. Older persons at risk received an evaluation of risk factors for falling. Whenever problems were identified, the nurses gave specific advice and subjects were referred to their general practitioner (GP). After one month, adherence to these recommendations was evaluated. Twenty-seven individuals showed an increased risk of falling (21.4%). The mean number of risk factors per person was 3.4 (SD=1.2). Noncompliance with one or more of the fall prevention recommendations was 58.3%. Differentiated by type of recommendations, a high degree of compliance was observed for recommendations related to gait and balance, use of medication, orthostatic hypotension, urge-incontinence, environment and behavior (81.8%-100%). While most individuals followed the recommendation to consult their GP (66.7%-80%), most of the GP's failed to propose any further measures to prevent falls. Screening, evaluation of risk factors, giving advice and follow-up required on average 3.1 (SD=0.8), 29.4 (SD=15.1), 15.8 (SD=11.0) and 13.1 (SD=3.9) minutes, respectively. Of those subjects who were not at risk, 76.1% had read the leaflet and 74.6% of those considered it useful. This study provides preliminary evidence for the feasibility in terms of time investment to integrate a nurse-led multifactorial fall intervention in current care for older persons living at home. However, further investigation to increase compliance with recommendations and more insight in the GP's role relating to the management of patients at risk for falls is needed.

Videomanometry reveals clinically relevant parameters of swallowing in children

OBJECTIVE

The aim of this pilot study is to demonstrate the technical and clinical feasibility of videomanometry to assess swallowing in infants and young children presenting with dysphagia.

METHODS

We performed videomanometry using a combined solid state catheter and a perfused manometric sleeve assembly in eight patients (2-28 months) presenting at a tertiary care institution with symptoms of dysphagia. Solid state sensors were positioned at the inferior margin of the valleculae and the laryngeal entrance and the upper esophageal sphincter sleeve assembly was positioned across the upper esophageal sphincter. Manometric and radiological data were digitally recorded simultaneously using a manofluoromixer. Liquid bolus swallows were recorded in each patient and different geometric parameters of deglutition were measured.

RESULTS

Placement and fixation of the catheter was well tolerated and no adverse effects occurred. The children easily swallowed test boluses as selected during clinical examination. Results indicate that pharyngeal contractility can be evaluated as well as relaxation of the upper esophageal sphincter during swallowing of wet boluses.

CONCLUSIONS

Videomanometry in young children is feasible with the limited discomfort of the placement of the catheter. It is a promising technique that will allow more accurate assessment of pediatric oropharyngeal dysphagia.

[Multidisciplinary approach to patients with persistent swallowing problems; the first experiences, 1996/'02 in Louvain]

OBJECTIVE

To inventory the experiences of a multidisciplinary team for the treatment of patients with chronic swallowing problems.

DESIGN

Descriptive, retrospective.

METHOD

Data were collected on the cause, treatment and course in 400 consecutive ambulatory patients who had had swallowing problems for at least several months. During the period from 1 October 1996 to 30 April 2002 they had been referred to a multidisciplinary team consisting of a radiologist, an otorhinolaryngologist, a thoracic surgeon, a logopaedician, a neurologist and an internist-geriatrician in the University Hospitals of the Catholic University of Louvain (Belgium).

RESULTS

The group of 4oo patients consisted of 236 men and 164 women, one-third of whom were 70 years of age or older. Half of the patients had problems swallowing solid food and more than 10% were unable to take any food by mouth. Most of the underlying conditions were neurological. The most commonly prescribed treatments were adjustments to the diet and posture (41%) and logopaedic guidance (36%). The safety and comfort of swallowing were improved in 44% of the patients, 13% were able to feed themselves orally once more after the intervention and in 11% there was still an indication for a percutaneous endoscopic gastrostomy (PEG) catheter.

Swallowing and functional outcome after partial laryngectomy: a literature review

There is a wide range of partial surgical resections for the treatment of laryngeal tumours. In addition to good cure rates, the main aim is to preserve a competent and functional larynx. Functional outcomes have proven to have a substantial effect on postoperative quality of life and are usually included in clinical studies. This article reviews reported functional outcomes after partial laryngectomies, particularly when related to swallowing. In the majority of patients, reports indicate acceptable feeding without the presence of a permanent tracheostomy. However, a wide variety of methods and variables are used to describe these functional outcomes, making the comparison of functional outcome after different treatment modalities and resections difficult. More objective evaluation procedures are needed for swallowing to reveal the exact pathophysiology, spontaneous progression and prognostic factors after well-defined laryngeal resections.

Development of the orohypopharyngeal cavity in normal infants and young children

OBJECTIVE

To study the growth of the oropharynx and hypopharynx in infants and young children by measuring the lengths of the segments between nasopharyngeal valve and tongue base, tongue base and arytenoids, and arytenoids and upper esophageal sphincter. These measurements will be used as references for developing manofluoroscopy to study deglutition in infants and young children.

PATIENTS AND METHODS

Twenty-three children (14 boys, 9 girls) between birth and 4 years of age were prospectively studied. All children had near normal growth parameters and were free of medical illnesses or other major medical conditions that are known to influence the pharyngeal cavity. Lateral videofluoroscopy was used to assess the pharyngeal structures during breathing. All images were digitally recorded and analyzed using a computer program designed specifically for this study.

RESULTS AND CONCLUSIONS

Statistically significant correlations were found between the age or height of the patient and the distance from velopharyngeal valve to tongue base and the distance from tongue base to arytenoids, showing a linear increase of the length of the oro- and hypopharynx with age and patient height. There was no significant difference in the pharyngeal distances between boys and girls. On the basis of these results, a linear regression comparison could be established to define the length of each pharyngeal segment for any age until 4 years and for the 50th percentile of height.

Dysphagia in multiple sclerosis

OBJECTIVES

(1) To determine the prevalence of swallowing problems in MS patients and its relation to the overall disability. (2) To define the most frequent symptoms suggestive of dysphagia. (3) To describe the abnormalities on manofluoroscopy (MFS).

METHODS

Three hundred and eight consecutive MS patients were asked whether they ever had swallowing problems. If so the questionnaire of the Johns Hopkins Swallowing Centre was applied to qualify the dysphagia. A MFS was performed in 30 patients with dysphagia covering the entire spectrum of MS. Overall disability was assessed using the Expanded Disability Status Scale (EDSS).

RESULTS

Seventy-three of our 309 patients had permanent dysphagia (24%). Another 5% had a history of transitory swallowing problems only. Permanent dysphagia started to be a problem in mildly impaired patients (EDSS 2-3). Prevalence increased together with rising disability to reach 65% in the most severely disabled subjects (EDSS 8-9). Two alarming symptoms of patients with swallowing problems, coughing or choking during the meal and a history of pneumonia were present in 59%, respectively, 12% of these patients. MFS showed deficiency of the oral phase in all patients, while only the patients with an EDSS higher than 7.5 showed abnormalities of the pharyngeal phase.

CONCLUSIONS

Permanent dysphagia may already develop in mildly impaired MS patients but becomes a rather frequent finding in MS patients with moderate or severe disability. MFS is a sensitive and useful ancillary examination. Important qualitative changes of the pharyngeal phase on MFS are seen in patients with an EDSS higher than 7.5.

Upper and lower gastrointestinal evaluation of elderly inpatients who are iron deficient

PURPOSE

Iron deficiency anemia is commonly caused by chronic gastrointestinal blood loss, and a thorough examination of the gastrointestinal tract has become standard practice. In contrast, iron deficiency without anemia has hardly been studied, and its causes are less certain. The aim of the present study was to determine the diagnostic value of upper and lower gastrointestinal evaluation in elderly hospitalized patients with iron deficiency, irrespective of the hemoglobin level.

PATIENTS AND METHODS

In a prospective study, 151 consecutive elderly patients with iron deficiency (serum ferritin level < 50 microg/L at two separate occasions) were investigated using esophagogastroduodenoscopy with colonoscopy (n = 90) or barium enema (n = 61).

RESULTS

A potential upper gastrointestinal tract lesion was found in 47 (49%) of the 96 anemic patients and in 31 (56%) of the 55 nonanemic patients (P = 0.38). Nonanemic patients had a greater prevalence of erosive gastritis or duodenitis. Anemic patients (72%) were more frequently investigated with a colonoscopy than nonanemic patients (38%, P = 0.001), and a lower gastrointestinal lesion was found in 32% of the anemic patients and 16% of the nonanemic patients (P = 0.03). Cancer was the most common lesion in the colon; 11 of the 18 patients were asymptomatic. Site-specific symptoms, fecal occult blood loss, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) were not associated with the detection of gastrointestinal lesions. In 9.5% of the patients with a benign upper gastrointestinal lesion, a synchronous colonic tumor was found.

CONCLUSION

Elderly patients with iron deficiency should undergo endoscopic examination, irrespective of the hemoglobin level. The presence of gastrointestinal symptoms, a positive fecal occult blood test, and the use of NSAIDs are of limited value in guiding the diagnostic procedure.

Relationship between age-associated endocrine deficiencies and muscle function in elderly women: a cross-sectional study

OBJECTIVE

Muscle receptors and selected anabolic effects have been identified for both insulin-like growth factor I (IGF-I) and 1,25-dihydroxyvitamin D (1,25(OH)2D3). The aim of the present study was to test the hypothesis that the decreasing concentrations of these endocrine factors might be involved in the decline in muscle function that characterizes normal human ageing.

DESIGN

Cross-sectional study.

STUDY PARTICIPANTS

A community-based sample of 245 healthy elderly women aged 70-90 years. Exclusion criteria were diseases or medications known to affect muscle function or the somatotrophic axis.

MEASUREMENTS

Knee extension strength was evaluated using an isokinetic dynamometer. A standardized questionnaire was used to assess habitual physical activity. IGF-I and 1,25(OH)2D3 were measured by radioimmunoassay. Vitamin D binding protein (DBP) was measured by single radial immunodiffusion and the free 1,25(OH)2D3 concentration calculated as the molar ratio of total 1,25(OH)2D3 to DBP.

RESULTS

The differences in isometric and isokinetic strength over the age range were equivalent to losses of 0.9-2.4% per year. However, no relationship was found between the somatotrophic axis or vitamin D status and knee extension strength, despite markedly decreasing concentrations of circulating IGF-I and free 1,25(OH)2D3 with age.

CONCLUSION

Levels of circulating IGF-I and free 1,25(OH)2D3 appear not to be involved in the loss of muscle function that characterizes normal human ageing.

Mechanisms involved in postdeglutition retention in the elderly

This study examines possible quantifiable causes of postdeglutition pharyngeal retention in the elderly. Manofluorography and computer processing of video images are performed. Retention in the valleculae and in the piriform sinuses is associated with a markedly reduced pharyngeal shortening, a low tongue driving force (TDF), and a diminished amplitude of the pharyngeal contraction. There is no relationship with the hypopharyngeal suction pump (HSP). Retention limited to the valleculae is associated with a low TDF, and retention restricted to the piriform sinuses is accompanied by a reduced pharyngeal shortening.

Is metabolic evidence for vitamin B-12 and folate deficiency more frequent in elderly patients with Alzheimer's disease?

BACKGROUND

It is still unclear whether there is an association between Alzheimer's disease and vitamin B-12 or folate deficiency. This study was designed to investigate whether patients with Alzheimer's disease are particularly prone to metabolically significant cobalamin or folate deficiency as compared to nondemented hospitalized controls and healthy elderly controls living at home.

METHODS

Evaluation for the diagnosis of Alzheimer's disease, routine laboratory tests, serum folate and vitamin B-12, serum methylmalonic acid (MMA), total homocysteine (tHcy), and radiological tests was performed in 52 patients with Alzheimer's disease (AD), 50 nondemented hospitalized controls, and 49 healthy elderly subjects living at home.

RESULTS

Serum vitamin B-12 and folate levels are comparable between patients with AD, hospitalized control patients, and subjects living at home. Patients with AD have the highest serum MMA and tHcy levels. The MMA levels of patients with AD and hospitalized controls are not different, but the mean tHcy level is significantly higher in patients with AD as compared to nondemented patients or subjects living at home.

CONCLUSION

The interpretation of the vitamin B-12 and folate status in patients with AD depends largely on the methodology (i.e., serum vitamin vs metabolite levels) and the selection of the control group. Although patients with AD have the highest tHcy and MMA levels, metabolically significant vitamin B-12 and folate deficiency is also a substantial problem in nondemented elderly patients.

Swallowing and the duration of the hyoid movement in normal adults of different ages

Normal swallows were examined using ultrasound imaging. Durational data of the hyoid movement were obtained from frame-by-frame analysis. The duration of the hyoid movement of three consecutive unstimulated (= dry) swallows was compared to that of stimulated (= wet) swallows in 120 subjects equally distributed among both sexes and four different age groups. Dry swallows proved to be longer than wet ones, and the duration of both types increased with age. The first dry swallow was invariably shorter than the third one; no such difference was noted with the wet swallows. With increasing age, the oral phase was more frequently accompanied by extra hyoid gestures, and the total number of swallows produced during a 10-second period was reduced in the elderly. These differences probably do not indicate pathology, but may be explained by changes in oral sensitivity, and subclinical oral-motor changes which occur in normal subjects with increasing age.

Deglutition disorder as a late sequel of radiotherapy for a pharyngeal tumor

We present the case of a 62-yr-old patient who developed severe swallowing problems 5 yr after radiotherapy for a pharyngeal carcinoma. Although peripheral and cranial nerves are thought to be relatively radioresistant, cranial nerve damage can occur many years after radiotherapy. This may result in severe deglutition disorders and lead to a complete inability to eat normally. The aim is to demonstrate how these late sequelae can cause impairment of different structures involved in the swallowing process.

Pressure-reducing effects of heel protectors

This study examined the pressure-reducing effects of 13 different heel-protecting devices. A group of 40 elderly patients (mean age 82 years, range 71-94) admitted to the Geriatric Department of the University Hospitals in Leuven, Belgium participated in this study. The pressures were registered by means of a sensitive computerized diagnostic system, which measured vertical forces. An ordinary head pillow was shown to be the most effective pressure-reducing device, followed by heel protectors based on siliconized hollow fibers.

Effect of body position on deglutition

This study examined the effects of changes in body position on different swallowing parameters derived from manofluorographic examinations. Quantitative data were obtained in a group of 12 young healthy volunteers. They were all tested in the upright position; six of them were also evaluated in the supine position, and the other six in the upside down position. In the different positions all volunteers were able to swallow a liquid bolus without aspiration or stasis. However, the dynamics of the swallow became different. Lying down resulted in a pharyngeal transit time comparable with the upright position. The tongue driving force was higher and the hypopharyngeal suction power weakened. In the upside down position, the pharyngeal transit time became longer and the tongue driving force was even more powerful. There was no apparent difference in the traditional manometric parameters; the amplitude, duration, and propagation velocity of the pharyngeal contraction on swallowing did not change obviously in the different body positions.

Manofluorographic analysis of swallowing in the elderly

This study examined the effect of aging on the mechanisms of swallowing by comparing 16 elderly subjects (80 years +/- 5) with 20 healthy volunteers. Manofluorography was used to obtain quantitative and qualitative data of the pharyngeal swallow. Aging is associated with a significant decrease in the level of negative pressure resulting from the opening of the upper esophageal sphincter and with a substantial number of incomplete relaxations of the sphincter. In addition, several qualitative changes were noted.

Aztreonam-flucloxacillin double beta-lactam treatment as empirical therapy of serious infections in very elderly patients

Aztreonam, the first monocyclic beta-lactam antibiotic with pure anti-Gram-negative activity, combined with flucloxacillin, a penicillinase resistant penicillin, was given as empirical treatment of 53 serious infections in very elderly people. Eighteen of the cases had positive blood cultures and 11 had a clinical picture of sepsis without positive blood cultures: Of 49 evaluable infections, 45 (92%) were cured. In 40% of the infections, antibiotic treatment could be narrowed after 72 hours to one antibiotic. Diarrhoea, mostly transitory, was the only side-effect. Aztreonam-flucloxacillin combination is a safe and effective empirical treatment regimen for serious infections in very elderly patients.