Kinematic and Temporal Factors Associated with Penetration–Aspiration in Swallowing Liquids

In this study we undertook careful analysis of 13 quantitative physiological variables related to oropharyngeal swallowing from a sample of 42 subacute patients referred for dysphagia assessment. Each patient underwent a videofluoroscopic swallowing examination in which they swallowed up to five boluses of 22 % w/v ultrathin liquid barium suspension administered by teaspoon. Our goal was to determine whether scores on 13 kinematic or temporal parameters of interest were independently associated with the presence of penetration–aspiration in the final compiled dataset of 178 swallows. Participants were classified as aspirators based on the presence of at least one swallow that demonstrated a Penetration–Aspiration Scale score of ≥3. The parameters of interest included six kinematic parameters for capturing hyoid position, three swallow durations [laryngeal closure duration, hyoid movement duration, and upper esophageal sphincter (UES) opening duration], and four swallow intervals (laryngeal closure to UES opening, bolus dwell time in the pharynx prior to laryngeal closure, stage transition duration, and pharyngeal transit time). Mixed-model repeated-measures ANOVAs were conducted to determine the association between each parameter and aspiration status. Only 1 of the 13 parameters tested distinguished aspirators from nonaspirators: aspirators demonstrated significantly shorter UES opening duration. In addition, a trend toward reduced maximum superior position of the hyoid was seen in aspirators. Limitations and future considerations are discussed.     

A New Method to Evaluate Linear Block at the Left Atrial Roof: Is It Reliable Without Pacing?

A New Method to Evaluate Linear Block at the Left Atrial Roof . Objective: The present study aimed to evaluate a new method for validation of complete linear block at the left atrial (LA) roof. Background: Linear lesions at the LA roof have been reported to improve the success rate of catheter ablation of atrial fibrillation (AF). Methods: Complete linear block at the LA roof was evaluated in 31 patients after complete isolation of pulmonary vein antrum (PVA) using a simple method. We hypothesized that complete linear block of the LA roof could be confirmed during sinus rhythm if (1) a continuous line of double potentials could be recorded at the LA roof, and (2) the activation sequence along the posterior wall changed to caudocranial. The results of this method were compared with standard pacing techniques. Results: Thirty‐nine lines were assessed using this method: 8 before and 31 after achievement of complete conduction block. After validation of complete linear block at the LA roof, double potentials with a mean interpotential interval of 60 ± 13 ms were recorded in 25 patients and electroanatomical mapping of the left atrium showed the activation sequence of posterior wall changed to caudocranial in all 31 patients during sinus rhythm. The sensitivity, specificity, positive and negative predictive values of this method for validating complete linear block were 100%, 88.9%, 96.8%, and 100%, respectively. Conclusion: A corridor of double potentials along the roof line and a caudocranial activation sequence along the posterior wall during sinus rhythm can indicate conduction block at the LA roof after PVA isolation. (J Cardiovasc Electrophysiol, Vol. pp. 741‐746, July 2010)     

Wet Voice as a Sign of Penetration/Aspiration in Parkinson’s Disease: Does Testing Material Matter?

Wet voice is a perceptual vocal quality that is commonly used as an indicator of penetration and/or aspiration in clinical swallowing assessments and bedside screening tests. Our aim was to describe the clinimetric characteristics of this clinical sign using various fluid materials and one solid food in the Parkinson’s disease (PD) population. Consecutive PD individuals were submitted for simultaneous fiberoptic endoscopic evaluation of swallowing (FEES) and voice recording. Speech therapists rated the presence or absence of wetness and other voice abnormalities. Two binary endpoints of FEES were selected for comparison with an index test: low penetration (LP) and low penetration and/or aspiration (LP/ASP). The accuracy of wet voice changed according to the testing material in PD patients. Overall, the specificity of this indicator was better than its sensitivity, and the wafer cookie and yogurt drink yielded the best indices. Our data show that wet voice is clearly indicative of LP or LP/ASP in PD patients in case of positive test. However, in the case of a negative result, the wet voice test should be repeated or combined with other clinical tests to include or exclude the risk of LP or LP/ASP.     

Is Liver-Specific Gadoxetic Acid-Enhanced Magnetic Resonance Imaging a Reliable Tool for Detection of Hepatocellular Carcinoma in Patients with Chronic Liver Disease?

Background

Gadoxetic acid is a recently developed hepatobiliary-specific contrast material used for magnetic resonance imaging (MRI) which enables highly sensitive detection of hepatocellular carcinoma (HCC).

Aim

We performed a meta-analysis of all available studies of the diagnostic performance of gadoxetic acid-enhanced MRI (Gd-EOB-MRI) for detection of HCC in patients with chronic liver disease.

Methods

Databases including MEDLINE and EMBASE were searched for relevant original articles published from January 2000 to April 2012. Pooled estimation and subgroup analysis data were obtained by statistical analysis.

Results

Across 10 studies of 570 patients, Gd-EOB-MRI sensitivity was 0.91 (95 % CI 0.77, 0.97) and specificity was 0.93 (95 % CI 0.85, 0.97). Overall, LR+ was 13.6 (95 % CI 5.6, 33.2), LR? was 0.10 (95 % CI 0.04, 0.27), and DOR was 140.36 (95 % CI 28, 696). Among patients with high pre-test probabilities, MRI enabled confirmation of HCC; among patients with low pre-test probabilities, MRI enabled exclusion of HCC. Worst-case-scenario (pre-test probability, 50 %) post-test probabilities were 93 and 9 % for positive and negative MRI results, respectively. In studies in which both Gd-EOB-MRI and contrast enhanced computed tomography (CE-CT) were performed, Gd-EOB-MRI was more sensitive than CE-CT (0.93 vs. 0.78; p < 0.05). Subgroup analysis suggested average lesion size (<2 vs. >2 cm) did not affect the diagnostic accuracy of the test (p > 0.05).

Conclusions

A limited number of small studies suggest Gd-EOB-MRI has good diagnostic performance in the detection of HCC among patients with chronic liver disease. It is also confirmed to be a reliable tool for evaluation of small early-stage HCC.     

Triangular Cord Sign in Detection of Biliary Atresia: Is It a Valuable Sign?

Background Early detection of biliary atresia (BA) has a vital role in prevention of liver cirrhosis in these patients. There are some evidences that triangular cord (TC) sign, i.e., triangular structure located cranial to the portal vein bifurcation on ultrasonographic examination, is suggestive of BA in suspected cases. The aim of this study is to evaluate and compare the sensitivity, specificity, and accuracy of TC sign with other methods of diagnosis such as hepatobiliary scan. Methods Fifty-eight infants referred to pediatric gastroenterology ward with diagnosis of infantile cholestasis from March 2004 to March 2008 were evaluated to find the cause of cholestasis. Diagnosis was made by means of history, clinical examination, hepatobiliary scan, and liver biopsy. Ultrasonographic examination was focused on presence of TC sign in patients. If the diagnosis was in favor of BA, patient was sent for direct cholangiography as a gold-standard test for confirmation of the diagnosis. The sensitivity, specificity, and accuracy of the tests were compared with golden standard. Results Among 58 infants with infantile cholestasis, BA was diagnosed and confirmed in 10 infants (17.2%). Hepatobiliary scintigraphy had 80% sensitivity, 72.9% specificity, and 74.1% accuracy. TC sign had 70% sensitivity, 95.8% specificity, and 91.3% accuracy. Conclusion TC sign is more accurate than hepatobiliary scan and has acceptable sensitivity and specificity for diagnosis of BA.     

Is Gluten a Cause of Gastrointestinal Symptoms in People Without Celiac Disease?

The avoidance of wheat- and gluten-containing products is a worldwide phenomenon. While celiac disease is a well-established entity, the evidence base for gluten as a trigger of symptoms in patients without celiac disease (so-called ‘non-celiac gluten sensitivity’ or NCGS) is limited. The problems lie in the complexity of wheat and the ability of its carbohydrate as well as protein components to trigger gastrointestinal symptoms, the potentially false assumption that response to a gluten-free diet equates to an effect of gluten withdrawal, and diagnostic criteria for coeliac disease. Recent randomized controlled re-challenge trials have suggested that gluten may worsen gastrointestinal symptoms, but failed to confirm patients with self-perceived NCGS have specific gluten sensitivity. Furthermore, mechanisms by which gluten triggers symptoms have yet to be identified. This review discusses the most recent scientific evidence and our current understanding of NCGS.     

Recording patient bodyweight in hospitals: are we doing well enough?

Recording patient weight is a standard practice for all hospital admissions, with this measurement influencing other daily practices that rely on the delivery of safe and effective patient care. Patient weight is important in the areas of medication prescribing, fluid balance and assessment of nutrition. In particular, prescribing narrow therapeutic index medications may result in significant harm as a potential consequence of inaccurate dosing. Despite its importance, it is evident that bodyweight measurements are recorded in only 13.5–55% of hospital patients, in a variety of settings including the emergency department, intensive care unit, medical and surgical wards. Barriers to compliance of healthcare staff include additional workload, patient handling and availability of appropriate weighing equipment. Hospitals and patients would benefit from enhancing compliance with the systematic weighing of patients, staff training and removing barriers to performing this task.     

Diagnosis of Helicobacter pylori Infection from Antral Biopsies in Pediatric Patients: Is Urease Test that Reliable?

Our objectives were to determine if the urease (CLO) test alone is a reliable diagnostic test for H. pylori gastritis in children and if the density of H. pylori influences the CLO test result. We performed a combined retrospective and prospective study reviewing the results of CLO-test and histology of gastric mucosal biopsy from 67 patients (35 females) with H. pylori gastritis. Two antral biopsies were inoculated on the CLO-test and two processed for histology to grade the severity of gastritis and H. pylori density. The mean age of patients was 11 years (sd ± 4.53). Only 50 patients tested positive for H. pylori on CLO-test, whereas all patients were positive on histology. %The sensitivity of the CLO-test was 75%. There was a significant association between CLO-test positivity and the density of H. pylori organisms on histology (P < 0.01), and with the severity of gastritis (P < 0.001) by the Pearson chi-square test. However, there was no association between the density of H. pylori and severity of gastritis. In conclusion, the CLO-test is not reliable as a sole diagnostic test for H. pylori gastritis in children because of a significant number of false negatives. Histologic examination of gastric mucosal biopsy is superior to the CLO-test in diagnosing H. pylori infection.