Dysphagia in cerebral palsy: A comparative study of the exeter dysphagia assesment technique and a multidisciplinary assessment

Eighteen children with cerebral palsy in a special school, most of whom had feeding difficulties, were studied to compare the diagnostic value of the Exeter Dysphagia Assessment Technique (EDAT) with an exhaustive clinical assessment undertaken by a multidisciplinary team experienced in the diagnosis and treatment of dysphagia of neurological origin. Four feeding skills were assessed by each method independently, viz. anticipation, intraoral sensory perception, oral-motor efficiency, and pharyngeal triggering. Comparison of the two sets of results showed agreement in at least 78% of the assessed skills. The possible reasons for the few discrepancies are discussed. The noninvasive EDAT equipment was easy to use with the children, who had a range of type and severity of cerebral palsy. The test was undertaken in their familiar surroundings and took 15 to 20 min per child. Interpretation of the results showed that EDAT provided a rapid, reliable diagnostic aid which assisted in the assessment of the degree of feeding impairment within each of the four feeding skills tested. The authors are very grateful for the financial support for this project which was provided partially by Action Research and partially by the Northcott Devon Medical Foundation     

Coexisting severe frailty and malnutrition predict mortality among the oldest old in nursing homes: A 1-year prospective study

The aim of this study was to explore the relationship of coexisting severe frailty and malnutrition with all-cause mortality among the oldest old in nursing homes. This study was conducted among all subjects (n = 160) aged 85 years and older who lived in two nursing homes of Japan. Information about the health status of participants was gathered from history, medical documentation, test assessing frailty, according to the Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) and the Mini Nutritional Assessment Short Form (MNA-SF). Seventy five residents (46.9%) were identified as affected by coexisting severe frailty and malnutrition. After a 12-month follow-up period, 42 (26.3%) residents died. In the Cox regression analysis, coexisting severe frailty and malnutrition, and heart failure were associated with mortality during the 12-month follow-up period among the oldest old nursing home residents (adjusted HR 10.89, 95% CI 4.04–29.33, p < 0.0001; and adjusted HR 7.83, 95% CI 3.25–18.88, p < 0.0001, respectively). The present study suggests that coexisting severe frailty and malnutrition are very frequent, and coexisting severe frailty and malnutrition are associated with all-cause mortality among the oldest old in nursing homes.     

Achalasia and diet: Assessment of the effect of achalasia on the diet of patients and their spouses

The effect of achalasia on the diet of patients and their spouses was investigated using a validated questionnaire. The discordance between the diet of the patients and their respective spouses was compared with matched controls. There is no statistically significant difference between the discordance of case couples and control couples. Patients with achalasia, and their spouses, eat a normal diet.     

Esophageal motility,heartburn, and gastroesophageal reflux: Variations in clinical presentation of esophageal dysphagia

Dysphagia is a potentially important symptom, often leading to the finding of an anatomical or motility disorder of the esophagus. Dysphagia and heartburn represent two of the most common symptoms associated with esophageal motility disorders. To explore the relationship of symptomatic esophageal dysphagia and heartburn and their association with primary esophageal motor disorders, we have performed a retrospective assessment of 1035 patient evaluations performed at our gastrointestinal laboratory. A clear statistical association of symptomatic dysphagia and heartburn was established; however, no pattern diagnostic of a specific motility disorder was discernible. A sizable fraction of our patient population with dysphagia demonstrated normal esophageal motility. A significant portion of dyspeptic patients exhibited both normal motility and acid exposure. The differences observed between the incidence of subjective symptoms and objective dysfunction may be explained in part by an altered or increased esophageal sensitivity of these patients.     

The effects of cold,touch, and chemical stimulation of the anterior faucial pillar on human swallowing

Cold stimulation of the oropharyngeal mucosa, including the faucial pillar region, is used as a specific technique for the treatment of swallowing disorders. The physiological mechanisms underpinning this clinical technique are unclear. Thermal (cold), chemical (saline, glucose and water), mechanical (light touch) and feigned stimulation of the faucial pillar were assessed for their effects on the latency to swallow and the repetitive frequency of swallowing. There was no significant difference between these variables following light stimulation of the faucial pillar with a metal probe warmed to body temperature compared with feigned stimulation. However, cold touch stimulation evoked a significant increase in swallowing latency and repetitive frequency compared to feigned stimulation. The results suggest the existence of thermo-sensitive receptors in the faucial pillars that evoke swallowing when stimulated by cold touch. The clinical and physiological importance of these findings are discussed.     

Communication strategies and effectiveness of early childhood obesity-related prevention programs for linguistically diverse communities: A rapid review

Children from culturally and linguistically diverse backgrounds experience higher rates of obesity and have poorer outcomes in obesity prevention studies. Interventions tailored to specific cultural groups may be limited within linguistically diverse, multicultural communities, and thus, alternative approaches to childhood obesity prevention in these communities are needed. This study aims to describe communication strategies used in interventions targeting prevention of obesity/obesity-related behaviors, among children 0–5 years, from linguistically diverse communities, and assess their effectiveness. A rapid review was conducted by systematically searching Medline, Embase, and CINAHL. The inclusion criteria are as follows: Studies reported an intervention tailored to linguistically diverse communities targeting at least one obesity-related behavior among children 0–5 years. The exclusion criteria are as follows: Interventions used simple language translations, targeted one language group, or treated obesity. A total of 4677 articles were identified with 14 studies meeting inclusion criteria. Key communication strategies included materials in multiple languages, English text written at a set readability level, and multimodal delivery. Six studies reported effectiveness data, of which five had effective primary or secondary outcomes. This is the first rapid review to identify communication strategies used in childhood obesity prevention interventions for linguistically diverse communities, highlighting a need for future research to incorporate and evaluate the communication strategies identified.     

Adding Endoscopist-Directed Flexible Endoscopic Evaluation of Swallowing to the Videofluoroscopic Swallowing Study Increased the Detection Rates of Penetration,Aspiration, and Pharyngeal Residue

Background/AimsCurrently, the videofluoroscopic swallowing study (VFSS) is the standard tool for evaluating dysphagia. We evaluated whether the addition of endoscopist-directed flexible endoscopic evaluation of swallowing (FEES) to VFSS could improve the detection rates of penetration, aspiration, and pharyngeal residue, compared the diagnostic efficacy between VFSS and endoscopist-directed FEES and assessed the adverse events of the FEES.MethodsIn single tertiary referral center, a retrospective analysis of prospectively collected data was conducted. Fifty consecutive patients suspected of oropharyngeal dysphagia were enrolled in this study between January 2012 and July 2012.ResultsThe agreement in the detection of penetration and aspiration between VFSS and FEES of viscous food (κ=0.34; 95% confidence interval [CI], 0.15 to 0.53) and liquid food (κ=0.22; 95% CI, 0.02 to 0.42) was “fair.” The agreement in the detection of pharyngeal residue between the two tests was “substantial” with viscous food (κ=0.63; 95% CI, 0.41 to 0.94) and “fair” with liquid food (κ=0.37; 95% CI, 0.10 to 0.63). Adding FEES to VFSS significantly increased the detection rates of penetration, aspiration, and pharyngeal residue. No severe adverse events were noted during FEES, except for two cases of epistaxis, which stopped spontaneously without requiring any packing.ConclusionsThis study demonstrated that the addition of endoscopist-directed FEES to VFSS increased the detection rates of penetration, aspiration, and pharyngeal residue.     

Swallowing problems after excision of tumors of the skull base: Diagnosis and management in 12 patients

Acute-onset dysphagia can be a debilitating complication of operative intervention in skull base surgery. A retrospective study performed at Baptist Hospital in vestigated the oropharyngeal deficits, compensatory swallow techniques, and diet modifications of 12 patients who had undergone excision of skull base tumors. Oropharyngeal dysfunction, reduced laryngeal elevation, and copious pharyngeal retention were the most prominent swallowing deficits. Aspiration occurred in 75% of the patients studied. The most frequently employed compensatory swallow techniques were head turns to the affected side, supraglottic swallow, double swallows, alternating liquids and solids, carbonated beverage swallows, and small bolus size. Approximately 2 weeks following skull base surgery, 58% of the patients were able to tolerate oral intake with the aid of compensatory swallow techniques and diet modifications. Only 1 patient in this group remained unable to tolerate food by mouth. This paper focuses on identification of the disordered components of the swallow and the therapeutic management techniques characteristic of the patient who has undergone excision of a skull base tumor.     

Interrater and Intrarrater Reliability of the Exeter Dysphagia Assessment Technique Applied to Healthy Elderly Adults

The purpose of this study was to evaluate the inter- and intrarater reliabilities of the Exeter Dysphagia Assessment Technique in a sample of elderly adults. This procedure uses noninvasive methods to record aspects of oral motor efficiency and synchronization of respiration during swallowing with the aid of specially developed equipment. Changes in the direction of nasal air flow, time of lip or tongue/spoon contact, and the time/frequency of swallow sounds are monitored and analyzed. Seventy records were evaluated independently by three trained assessors on three consecutive occasions. Interrater reliability was found to be good to very good for five of the respiratory variables assessed and moderate for the sixth. Interrater agreement was also very good for three of the timed oropharyngeal events assessed and moderate for the fourth. Intrarater reliability was very good for the same five respiratory variables and moderate for the sixth. Intrarater agreement was also very good for three of the timed oropharyngeal events and moderate for the fourth. Repeat evaluations of these records showed that agreement between and within raters concerning the sixth respiratory variable was improved substantially when the charts were examined in an enlarged form that provided improved resolution. We conclude that the majority of variables monitored by the Exeter Dysphagia Assessment Technique can be evaluated very reliably.     

中国结核病防治规划监控与评价指标分级研究

目的确立中国结核病防治规划监控与评价(ME)指标的相对重要性,为建立ME指标体系提供参考依据。方法于2007年7月-2008年6月采用综合评分法对ME指标的相对重要性(分级)进行评价。结果邀请30名专家,包括统计监测(10%)、实验室(10%)和结核病控制专家(80%),90%以上都在各自领域工作了10年以上,约64%来自国家级,约84%是高级职称。函询问卷回收率为100%。ME指标体系中的10类69个指标按照相对重要性被分为35个主要指标和29个次要指标,5个指标被排除。结论所选专家具有丰富的实践经验和理论知识,对指标的分级比较符合我国结核病防治工作的实际情况。     

Efficacy of population‐wide diabetes and obesity prevention programs: An overview of systematic reviews on proximal,intermediate, and distal outcomes and a meta‐analysis of impact on BMI

We conducted an overview of systematic reviews and a meta‐analysis of the impact on body mass index (BMI) of primary studies of population‐wide obesity and diabetes prevention programs, in order to evaluate their efficacy. We searched eight databases for reviews of population‐level programs reporting effect on diet, physical activity, BMI, or prevalence of obesity/overweight or type 2 diabetes mellitus (T2DM). Meta‐analysis of primary studies within reviews reporting effect on BMI. Interventions were categorized using ANGELO framework and quality assessment using AMSTAR. Fifty‐three systematic reviews were included. Primary studies were largely natural experiments or cross‐sectional studies of national data. Increased price of sugar‐sweetened beverages (SSBs) and fast food, decreased price of fruit and vegetables, food labelling, and grocery store interventions were associated with positive effects on diet. Park and playground renovations and point‐of‐choice prompts to increase stair use were associated with positive effects on physical activity. Increased price of SSBs, menu labelling, grocery store interventions, and multicomponent interventions were associated with small reductions in BMI. There was insufficient evidence of impact of any interventions on the prevalence of overweight, obesity, or T2DM. We have identified a promising suite of population‐wide actions to improve diet, increase physical activity, and reduce BMI. Impact on subsequent incidence of T2DM remains speculative.     

Intrinsic Properties of the Adult Human Mylohyoid Muscle: Neural Organization, Fiber-Type Distribution, and Myosin Heavy Chain Expression

The mylohyoid (MH) muscle plays a critical role in chewing, swallowing, respiration, and phonation. The present study was designed to test the hypothesis that the functional properties of the MH are reflected by its intrinsic specializations, including the neural organization, fiber-type distribution, and myosin heavy chain (MHC) expression. Adult human MH muscles were investigated to determine the nerve supply pattern using Sihler’s stain, banding pattern and types of motor endplates using acetylcholinesterase (AChE) staining and silver impregnation, and muscle fiber type and MHC composition using immunocytochemical and immunoblotting techniques. The adult human MH was found to have the following neuromuscular specializations. First, the muscle was innervated by several branches of the MH nerve derived from the mandibular division of the trigeminal nerve. Each of the nerve branches supplied a distinct region of the muscle, forming a segmental innervation pattern. Second, the MH had a single motor endplate band which was located in the middle of the muscle length. Both en plaque and en grappe types of motor endplates were identified on the MH muscle fibers. Finally, the adult human MH fibers expressed unusual MHC isoforms (i.e., slow-tonic, α-cardiac, embryonic, and neonatal) which coexisted with the major MHC isoforms (i.e., slow type I, fast type IIa, and fast type IIx), thus forming various major/unusual (or m/u) MHC hybrid fiber types. The m/u hybrid fibers (84% of the total fiber population) were the predominant fiber types in the adult MH muscle. Determination of the neuromuscular specializations of the MH is helpful for better understanding of the muscle functions and for development of strategies to treat MH-related upper airway disorders.     

Free Jejunal Grafts of the Pharynx: Surgical Methods, Complications, and Radiographic Evaluation

Free jejunal grafts have been used in the surgical treatment of patients with carcinoma of the pharynx and upper esophagus. Post-operative complications, including swallowing difficulty, are frequent and radiographic assessment may be required. In this pictorial paper, we describe the surgical technique of free jejunal grafting of the pharyngoesophagus, and the radiographic appearances and clinical importance of early and delayed complications following the procedure. Dysphagia after placement of a jejunal graft is a common occurrence which is often multifactorial, and may be related to functional, anatomic, or a combination of factors.     

Randomized trial of nutrition education added to internet-based information and exercise at the work place for weight loss in a racially diverse population of overweight women

Objective:

Obesity in the United States is highly prevalent, approaching 60% for black women. We investigated whether nutrition education sessions at the work place added to internet-based wellness information and exercise resources would facilitate weight and fat mass loss in a racially diverse population of overweight female employees.

Methods:

A total of 199 (average body mass index 33.9±6.3 kg m⁻²) nondiabetic women (57% black) at our institution were randomized to a 6-month program of either internet-based wellness information (WI) combined with dietitian-led nutrition education group sessions (GS) weekly for 3 months and then monthly with shift in emphasis to weight loss maintenance (n=99) or to WI alone (n=100). All were given access to exercise rooms convenient to their work site. Fat mass was measured by dual-energy X-ray absorptiometry.

Results:

WI+GS subjects lost more weight than WI subjects at 3 months (−2.2±2.8 vs −1.0±3.0 kg, P>0.001). Weight (−2.7±3.9 vs −2.0±3.9 kg) and fat mass (−2.2±3.1 vs −1.7±3.7 kg) loss at 6 months was significant for WI+GS and WI groups (both P<0.001), but without significant difference between groups (both P>0.10); 27% of the WI+GS group achieved ⩾5% loss of initial weight as did 18% of the WI group (P=0.180). Blacks and whites similarly completed the study (67 vs 74%, P=0.303), lost weight (−1.8±3.4 vs −3.3±5.2 kg, P=0.255) and fat mass (−1.6±2.7 vs −2.5±4.3 kg, P=0.532), and achieved ⩾5% loss of initial weight (21 vs 32%, P=0.189), irrespective of group assignment.

Conclusion:

Overweight women provided with internet-based wellness information and exercise resources at the work site lost weight and fat mass, with similar achievement by black and white women. Additional weight loss benefit of nutrition education sessions, apparent at 3 months, was lost by 6 months and may require special emphasis on subjects who fail to achieve weight loss goals to show continued value.