Nature,nurture, nutrition: Interdisciplinary programs to address the prevention of malnutrition and dehydration

Malnutrition and dehydration are common problems in nursing home patients. One explanation for this may be the large number of patients requiring feeding assistance. The Dysphagia Team at the Department of Veterans Affairs Medical Center in Miami, Florida served as the primary source in the expansion of a nutritionally supportive environment to assist in the prevention of malnutrition and dehydration in patients with feeding/swallowing disorders. “Silver Spoons,” a program in which volunteers provide supervised feeding, “Happy Hour,” a time each day during which an atmosphere is provided that encourages socialization and hydration, and “Second Seating,” during which lunch is provided for patients who require modification of eating style, food texture, or timing are described. Analysis of the program's outcomes show it to be timely, pleasing to patients, and cost-effective.     

Hyoid-Bolus Transit Latencies in Normal Swallow

Pharyngeal swallow delay is frequently found in dysphagic patients and is thought to be a factor in a range of swallowing problems, including aspiration. Implicit in notions of swallow “delay” is a temporal interval between two events that is longer than normal. However, there appears to be little agreement about which referent events should be considered in determining delay. A number of pharyngeal bolus transit points and various pharyngeal gestures have been used in delays determined from fluoroscopic evidence, and other referents have been used in electromyographic and manometric studies of swallow. In this study latencies between the first movement of the hyoid and several pharyngeal bolus transit points were calculated from fluoroscopic swallow studies in normal nondysphagic adults. Means and standard deviations of these latencies are provided for a 3-cc and a 20-cc bolus and for both nonelderly and elderly adults. The data may be a useful resource for relating the specific latencies investigated to concepts of pharyngeal swallow delay, in particular, when assessing videofluoroscopic studies using a similar protocol.     

A Questionnaire Study to Assess Long-Term Outcome in Patients with Abnormal Esophageal Manometry

Patients with unexplained chest pain or dysphagia are often referred for esophageal manometric studies to further investigate their symptoms. Four main manometric abnormalities have been described: achalasia, diffuse esophageal spasm, “nutcracker” (hypercontracting) esophagus, and hypocontracting esophagus. With the exception of achalasia, treatments are of limited benefit and the natural history of these conditions is largely unknown. We sent questionnaires to patients who were investigated at least three years before our study began. They repeated a DeMeester symptom questionnaire that they had completed at the time of their initial study. Questionnaires were sent to 137 patients with diffuse esophageal spasm, “nutcracker” (hypercontracting) esophagus, or hypocontracting esophagus. We also sent questionnaires to 57 patients with dysphagia or chest pain who had had normal esophageal manometry and pH studies. These patients acted as symptomatic controls. Responses were compared using the Wilcoxon signed ranks test. Seventy-two (53%) patients with diffuse esophageal spasm, “nutcracker” esophagus, or hypocontracting esophagus replied. An additional 8 (6%) patients died. Symptom scores in all three conditions had improved significantly over time (p ≤ 0.01 for each condition, Wilcoxon signed ranks test). Patients with dysphagia or chest pain but normal esophageal studies had not improved. The significance of diffuse esophageal spasm, “nutcracker” esophagus, and hypocontracting esophagus found at esophageal manometry remains uncertain. Although treatment is often ineffective, these conditions typically run a benign course. Patients can be reassured that their symptoms are likely to improve with time.     

Reliability and Validity of Cervical Auscultation: A Controlled Comparison Using Video fluoroscopy

Cervical ausculation is experiencing a renaissance as an adjunct to the clinical swallowing assessment. It is a controversial technique with a small evidence base. We have aimed to establish whether cervical ausculation interpretation is based on the actual sounds heard or, in practice, influenced by information gleaned from other aspects of the clinical assessment, medical notes, or previous knowledge. We sought to determine (a) rater reliability and its impact on the clinical value of cervical auscultation and (b) how judgments compare with the “gold standard”: videofluoroscopy. Swallow sounds were computer recorded via a Littmann stethoscope. Sounds were sampled from 10 healthy control swallows with no aspiration/penetration and 10 patient swallows with aspiration/penetration, all recorded during simultaneous videofluoroscopy. The system generated sound quality similar to “live” bedside listening, a feature rarely seen in cervical auscultation studies. The 20 sound clips were classified as “normal” or “abnormal” by 19 volunteer speech-language pathologists with experience in cervical auscultation. After at least four weeks, 11 of these judges rated the sounds rerandomized on a new CD. Intrarater reliability kappa ranged from −0.12 to 0.71. Individual reliability did not correlate with years of experience, practice pattern, or frequency of use. Interrater reliability kappa=0.17. Comparison with radiologically defined aspiration/penetration yielded 66% specificity, 62% sensitivity, and majority consensus gave 90% specificity, 80% sensitivity. There was a significant relationship between individual reliability and true positive rate (r _s=0.623,p=0.040). The reliability of individual judges varied widely and thus, inevitably, agreement between judges was poor. Validity is dependent upon reliability: Improving the poor raters would improve the overall accuracy of this technique in predicting abnormality in swallowing. The group consensus correctly identified 17 of the 20 clips so we may speculate that the swallow sound contains audible cues that shouldin principle permit reliable classification. Study performed at the Freeman Hospital, Newcastle-upon-Tyne, UK. This project was supported by the Stroke Association (grant 11/98). Presented in part at the Otorhinological Research Society, Spring Meeting, 4 April 2003, Birmingham, UK, and the ASHA Convention, 13–15 November 2003.     

Is There a Relationship Between the pH and Volume of Saliva and Esophageal pH-metry Results?

There are several implications in the buffer capacity and in the protective role of saliva in gastroesophageal reflux disease (GERD) and other digestive disorders. The lack of knowledge about the production and quality of saliva and the fact that saliva plays an important role in digestive homeostasis motivated the authors to study the relationship between reflux measured by esophageal pH-metry and the pH and volume of saliva in individuals with GERD and its laryngopharyngeal manifestations (LPR). The study was designed as a randomized clinical trial. The studied population consisted of 39 adults with GERD and LPR confirmed by a positive 24-hour double-probe esophageal pH-metry. Unstimulated whole saliva was collected and its pH and volume were compared to pH-metry results. Patients were divided into four groups according to the number of distal episodes of reflux and two groups according to the presence or absence of proximal reflux. A highly significant difference was found between the groups with distal reflux when comparing salivary volume alone and salivary volume/salivary pH. The same occurred for the presence or absence of proximal reflux. These results suggest a direct correlation between salivary volume and “salivary pH × volume” with the number of distal and proximal episodes of reflux on the esophageal pH-metry. If larger studies confirm this finding, in the future it might be possible to diagnose GERD and LPR through a simple “spit test,” avoiding more costly and invasive procedures.     

What Is the Chin-down Posture? A Questionnaire Survey of Speech Language Pathologists in Japan and the United States

The “chin-down” or “chin-tuck” maneuver is a postural technique widely used in dysphagia treatment. The posture, however, does not have a precise anatomical definition. We studied the current practice of 42 speech-language pathologists (SLPs) in Japan and the U.S. with a questionnaire survey regarding the chin-down posture. The main findings were that (1) three of five of the pictures were selected by respondents both in Japan and in the U.S. as depicting the chin-down posture; (2) 23% of Japanese and 58% of the U.S. SLPs made a distinction between chin down and chin tuck; and (3) the use of anatomical terminology by SLPs differed between the two countries. This study showed that there is poor agreement among SLPs about the meaning of the chin-down and chin-tuck postures. Developing a precise definition is important because various postures may have differing physiologic effects.     

Vertebral “clover” scintigraphic image in a vertebral metastasis misdiagnosed with Paget’s disease

The diagnosis of Paget’s bone disease (PD) is often reached fortuitously with X-ray or scintigraphy. The peculiar distribution of the bone tracer in some skeletal locations, such as vertebra, may be highly suggestive of this disorder. Indeed, there are two distinct vertebral images on the bone scan highly specific of PD: the “clover” and the “heart” images. It has been previously reported that the specificity of these images for PD diagnosis is very high, nearly 100%, then suggesting that these findings could be patognomonic of this process. We have recently observed a 55-year-old male patient with back pain secondary to a vertebral metastasis due to a hepatocellular carcinoma. Initially, the bone scan showed the characteristic “clover” image at T-12 level and he was misdiagnosed with PD. Afterwards, the MRI suggested the diagnosis of a vertebral metastasis, and a computed tomography-guided needle biopsy further confirmed the diagnosis. In view of the present data, this image cannot be considered as patognomonic of PD.     

Nutritional considerations for the pureed diet texture in dysphagic elderly

In long-term care facilities little attention is given to the nutritional density, flavor, and presentation of the pureed diet texture. Use of the food processor to puree food offers opportunities for the development of pureed meals that are flavorful and appealing. This article presents guidelines that foodservice departments can use to transform their traditional pureed meals into “cuisine puree”.     

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation

A study, comprising dissection and microscopic examination of the pectinate area with special consideration to anal glands, was performed in 29 cadavers varying from fully mature neonatal deaths to 52 years of age. At the junction of the anal canal proper with the rectal neck, an “anorectal sinus” (a submucosal anal circumferential depression) was identified in 18 specimens; in 6 specimens, the anorectal sinus was replaced by a fibroepithelial band (“anorectal band”); in 5 specimens, the anorectal sinus was absent, and in 3 of the 5 specimens only scattered epithelial cells (“epithelial debris” of the anorectal sinus) were detected. These findings suggest that the anorectal sinus is an embryonic vestige which results from hindgut “invagination” by the proctodeum. Its persistence or partial obliteration would result in the formation of tubular structures which are considered by investigators as anal glands. The sinus may be completely obliterated or may leave behind a submucosal “anorectal band” or scattered “epithelial debris”. Evidence in favor of this new concept is put forward. The role of anorectal sinus, anorectal band, and epithelial debris in the genesis of some idiopathic anal lesions is discussed.     

The use of bisphosphonate in the treatment of avascular necrosis: a systematic review

Up to now, there is no uniformly accepted treatment for avascular necrosis (AN) that alleviates pain and retards its progression. The aim of clinical and surgical treatments is usually only to improve blood support in the avascular area. The objective of the present study was to make a systematic review of the use of bisphosphonates in the treatment of AN. Studies in which bisphosphonate was used for the treatment of AN were researched through the MEDLINE databases (from 1966 to 2007) and the Cochrane Central Register of Controlled Trials and using the following terms: “avascular necrosis,” “aseptic necrosis,” “bisphosphonates,” “alendronate,” “pamidronate,” “zoledronate,” and “risedronate”. Only seven articles that met the previously established criteria were obtained from MEDLINE, and none were obtained from the Cochrane Central Register of Controlled Trials. Of these seven articles, two were randomized clinical trials and five were prospective comparative studies; one of them corresponded to an extension of a previous study. The present review demonstrates that there are no controlled and double-blind studies about the efficacy of bisphosphonates in the treatment of AN. Therefore, the data are still insufficient for justifying its use for this indication. On the other hand, noncontrolled studies appear to demonstrate favorable results, particularly in diminishing pain, improving mobility, and lowering the incidence of articular collapse, which justifies new studies being developed in this area.     

Surface Electromyography in Preoperative Evaluation and Postoperative Monitoring of Zenker’s Diverticulum

Patients with Zenker’s diverticulum (ZD) underwent surface electromyography (sEMG) evaluation to determine sEMG patterns specific for ZD. Group 1 comprised patients with proven long-standing ZD that refused surgical treatment (n = 11, age mean = 55.7 years). Group 2 comprised surgically operated on patients with ZD (n = 6, age mean = 61 years). The timing, amplitude, and graphic patterns of activity of the masseter, submental, and laryngeal strap muscles were examined during voluntary single water swallows (“normal”), single swallows of excessive amounts of water (20 ml, “stress test”), and continuous drinking of 100 cc of water. The muscle activity in pharyngeal and initial esophageal stages of swallowing was measured, and graphic records were evaluated in relation to timing and voltage. The data were compared with the previously established normative database. The main sEMG patterns of ZD are (1) duration of swallowing and drinking is longer than normal (p < 0.05), (2) electric amplitude of laryngeal strap muscles during swallowing activity is higher than normal (p < 0.05), and (3) regurgitation peaks immediately after swallow followed by secondary swallow of the regurgitated portion of a bolus as seen at the sEMG records are specific graphic patterns for the ZD. Zenker’s diverticulum has its own specific sEMG patterns. Surface EMG, being an important screening method for patients with dysphagia, is a valuable additional diagnostic tool for ZD. Because it is noninvasive and nonradiographic, it can be used for monitoring of long-standing cases of the disease as well as monitoring of postsurgical recovery.     

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation

The role of the external and internal anal sphincters in the mechanism of anal continence is presented. The external sphincter induces continence by 1) preventing internal sphincter relaxation, what I have called the “voluntary inhibition action,” and 2) mechanical compression of the rectal neck and anal canal proper. The mechanism of both actions is described. The internal sphincter plays a significant role not only in involuntary, but also in voluntary, continence. The importance of this role in the correction of anal incontinence is clarified. “Stress defecation,” a condition which follows internal sphincter damage, is discussed. A “single loop continence” theory is presented, based on the fact that each of the three loops of the external sphincter has its own innervation, attachment, and direction of muscle bundles; each loop thus acts as a separate sphincter. The clinical application of this theory is presented.     

Aerosols for systemic treatment

The development of a new group of drugs (polypeptides) have recently increased the interest of alternative administration to the enteral route because of its proteolytic activity and the catabolism of the “first-pass effect.” Aside from the “needle,” the administration in the respiratory tract via aerosol is the method with the best efficiency. But several problems prohibited its spreading: (1) the accuracy and the reproducibility of the inhaled dose (range ca. 1:4); (2) the small amount of inhaled drug in relation to the dose in the aerosol delivery system (range ca. 1%–10%); (3) the fear of allergic reactions of the respiratory system; (4) the variability of the drug transport into the systemic circulation. New approaches and data raise hopes in reducing the problems: (1) aerosol delivery systems with defined particle spectrum and storage systems; slow vital capacity inhaling maneuver; (2) delivery systems that nebulizes nearly the total amount of drug; (3) all studies with the inhalation application of insulin, heparin, ergotamin, ribavirin, aminoglycosides, and “cigarette smoke” do not reveal any relevant allergic reaction; (4) many studies were performed in the last 10 years on the influence of substances and especially of diseases on the transport of molecules through the respiratory tract. Only a few of them are relevant (exogen allergic alveolitis, active sarcoidosis, active smoking). Aerosols for systemic drug treatment seems to be a gained alternative to the “syringe.”     

Viscosity measurements of barium sulfate mixtures for use in motility studies of the pharynx and esophagus

Detailed viscosity measurements have been made of barium sulfate mixtures over a wide range of viscosities for use in radiography of the esophagus, stomach, and duodenum. A new methodology was developed for more accurate estimation of viscosity in non-Newtonian fluids in conventional cylinder-type viscometers. As base cases, the variation of viscosity with shear rate was measured for standard commercial mixes of e·z·hd (250% w/v) and a diluted mixture of liquid e·z·paque (40% w/v). These suspensions are strongly shear thinning at low shear rates. Above about 3s⁻¹ the viscosity is nearly constant, but relatively low. To increase the viscosity of the barium sulfate mixture, Knott's strawberry syrup was mixed to different proportions with e·z·hd powder. In this way viscosity was systematically increased to values 130,000 times that of water. For these mixtures the variation of viscosity with temperature, and the change in mixture density with powder-syrup ratio are documented. From least-square fits through the data, simple mathematical formulas are derived for approximate calculation of viscosity as a function of mixture ratio and temperature. These empirical formulas should be useful in the design of “test kits” for systematic study for pharyngeal and esophageal motility, and clinical analysis of motility disorders as they relate to bolus consistency.     

The Lived Experience of Mothers of Children with Chronic Feeding and/or Swallowing Difficulties

The purpose of this phenomenologic study was to describe the lived experiences of seven mothers who were providing home-based care for their children with feeding and/or swallowing difficulties. Data were collected using semistructured interviews and were analysed as per Colaizzi’s method of inductive reduction. Results suggest that the mothers’ experiences can be understood as two continuing journeys that were not mutually exclusive. The first, “Deconstruction: A journey of loss and disempowerment,” comprised three essences: (1) losing the mother dream, (2) everything changes: living life on the margins, and (3) disempowered: from mother to onlooker. The second journey was “Reconstruction: Getting through the brokenness” with the essences of (4) letting go of the dream and valuing the real, (5) self-empowered: becoming the enabler, (6) facilitating the journey, and (7) the continuing journey: negotiating balance. The phenomenon of being the mother of a child with chronic feeding and/or swallowing difficulties continued to be a transformative experience in which personal growth emerged along with chronic sorrow and periodic resurgence of struggle and loss. Implications call for healthcare professionals to incorporate maternal meanings and needs in providing appropriate family-focused intervention.

How now,brown cow,vaccine or extract?

Conclusions In summary, the word “allergen vaccine” should be used to denote FDA-approved preparations of therapeutic allergens used to treat allergic diseases. The term “allergen extract” should be used for preparations of allergens that are not yet FDA-approved, are FDA-approved but not yet incorporated into a therapeutic vaccine for an individual patient, or are used for experimental purposes. The term “diagnostic allergens”, in this case also approved by the FDA or its equivalent is appropriate when these products are used for skin testing. The use of these terms by physicians in allergy/immunology will enhance the specialty and be useful to patients who do not and never did understand the term “allergen extract”.     

Clinical implications of body image among rural African-American women

OBJECTIVE: To increase understanding of body image among rural, African-American women through open-ended interviews. DESIGN: Individuals’ perceptions of body image were investigated using open-ended, in-depth interviews that were taperecorded, transcribed, and analyzed to identify common themes and to compare thematic data across three body mass index categories (obese, overweight, and normal). SETTING: University-affiliated rural community health center. PARTICIPANTS: Twenty-four African-American women, aged 21 to 47 years. MAIN RESULTS: Respondents reported the following common themes: dissatisfaction with current weight; fluctuating levels of dissatisfaction (including periods of satisfaction); family and social pressure to be self-accepting; and social and physical barriers to weight loss. The interviews revealed ambivalence and conflicts with regard to body image and weight. Among these women, there was strong cultural pressure to be self-accepting of their physical shape, to “be happy with what God gave you,” and to make the most of their appearance. CONCLUSIONS: The pressure to be self-accepting often conflicted with these obese women’s dissatisfaction with their own appearance and weight. Although the respondents believed they could lose weight “if [they] put [their] mind to it,” those women wanting to lose weight found that they lacked the necessary social support and resources to do so. The conflicts stemming from social pressures and their own ambivalence may result in additional barriers to the prevention of obesity, and an understanding of these issues can help health care providers better address the needs of their patients. This work was supported by grant RO1HL43611 from the National Heart Lung and Blood Institute.     

The exeter dysphagia assessment technique

The Exeter Dysphagia Assessment Technique (EDAT) uses noninvasive equipment to record, simultaneously, “feeding respiratory patterns,” the time drink entered the mouth, and associated swallow sounds during feeding. The easily portable equipment enabled patients' swallowing ability to be tested, at the bedside if necessary, using a small amount of fruit-flavored drink. The results appear in chart form. EDAT findings from groups of normal subjects aged 2–90 years were compared with those from patients with dysphagia of neurologic origin and normal subjects under experimental feeding conditions. The results revealed maturation of the feeding respiratory pattern in the teenage years and remarkable consistency thereafter. Differences in the recordings between the normal and abnormal subjects were sufficiently marked to allow the findings to be used in the diagnosis of other patients with dysphagia of doubtful neurologic cause. Interpretation of the charts and recorded timings of the oral and pharyngeal stages of swallowing permitted a more accurate identification of sensory nerve, motor nerve, and functional involvement causing dysphagia of neurologic origin and may be used as a guide to the origin of the sensory deficit.     

Tissue-type plasminogen activator activity in morphologically normal tissues adjacent to gastrointestinal carcinomas is associated with the degree of tumor progression

Purpose: To investigate whether the level of plasminogen activator (PA) activity assayed in gastrointestinal carcinomas and the “morphologically normal tissues” adjacent to them is associated with the degree of tumor progression. Methods: Tumor and “normal tissues” were obtained from gastrointestinal surgical samples to assess urokinase-type (u-PA) and tissue-type plasminogen activator (t-PA) activities by radial caseinolytic assay and the expression of PA inhibitor-1 (PAI-1) by ELISA. We compared the PA system between the tumor and “normal tissues” and we investigated the existence of correlations between: (a) PA production in the tumor and “normal tissues”, (b) different components of the PA system, and (c) PA system and the degree of tumor progression. Results: (1) Total PA activity, u-PA activity and PAI-1 expression are significantly higher in tumor than in “normal tissues”, whereas t-PA activity does not differ between them. (2) Total PA activity mainly correlates with u-PA activity in tumor tissues and similarly with u-PA and t-PA activities in “normal tissues”. (3) There is a significant association between t-PA activity in tumor and “normal tissues” and the degree of tumor progression. Conclusions: “Morphologically normal tissues” adjacent to carcinomas present abnormal t-PA activity that is associated with the degree of tumor progression. Assaying of this activity could be useful as a predictive parameter.     

Esophageal Adenocarcinoma: Pseudo-Nutcracker Esophagus

Pseudoachalasia due to adenocarcinoma is well known. We report a case of nutcracker esophagus in the setting of outflow obstruction from esophageal adenocarcinoma. Endoscopy is warranted to exclude similar lesions in patients with “pseudo-nutcracker esophagus”.