Single Swallows Research Articles

Does a Single Swallow make it a Summer? Report of an Unusual case of Adenocarcinoma Mammary Gland type of Vulva with Neuroendocrine Differentiation

Does a Single Swallow make it a Summer? Report of an Unusual case of Adenocarcinoma Mammary Gland type of Vulva with Neuroendocrine Differentiation

383. LOSS OF PERISTALTIC RESERVE DETERMINED BY MULTIPLE RAPID SWALLOWS CORRELATES WITH DYSPHAGIA AND POOR BOLUS TRANSIT IN INEFFECTIVE ESOPHAGEAL MOTILITY

Abstract Introduction Ineffective esophageal motility (IEM) is a common finding on high resolution esophageal manometry (HRM) and is often of unclear clinical significance as its impact on dysphagia and bolus transit is variable. Multiple rapid swallow (MRS) testing is a provocative maneuver performed during HRM that assesses peristaltic reserve, documented by the presence of contractile augmentation (defined by contractile vigor after MRS greater than that seen with single swallows). Lack of augmentation after MRS is associated with dysphagia after anti-reflux surgery. To date, no studies have evaluated the impact of peristaltic reserve on dysphagia and bolus transit in IEM patients. Methods Retrospective review of 159 patients with Chicago classification 4.0 IEM. 52 patients were excluded due to prior esophageal surgery, technically inadequate MRS, or concomitant esophagogastric junction outflow obstruction. Demographics and brief esophageal dysphagia questionnaire (BEDQ) results were obtained from a prospectively maintained database. MRS and bolus transit data were analyzed using a commercially available software. Impedance analysis documented complete versus incomplete bolus transit. Augmentation was defined as the ratio of post-MRS DCI to mean single swallow DCI > 1. Fisher's exact test for continuous data and linear model ANOVA were used to assess for statistical significance. Results 107 IEM patients were included, 46 of them had loss of peristaltic reserve (no augmentation on MRS). Compared to IEM patients with augmentation, those without augmentation had more severe dysphagia documented by higher mean BEDQ score (6.8 versus 4.8, p= 0.045), and increased rates of impaired bolus transit (73% versus 55%, p-= 0.013). Discussion IEM patients without augmentation on MRS have more severe dysphagia and more frequent incomplete bolus clearance. These findings support adding MRS response to the diagnosis of IEM or using it to describe a subset of patients with more severe disease.

Integrated Relaxation Pressure and Its Diagnostic Ability May Vary According to the Conditions Used for HREM Recording.

Integrated Residual Pressure (IRP) measured under conditions alternative to supine single swallows may provide clinically useful information regarding EGJ relaxation. This study aimed to compare IRP values obtained under different situations and explore their potential clinical utility. We analyzed and compared the values of IRP obtained from healthy volunteers and patients with suspected achalasia during supine single swallows (Ssup-IRP), sitting single swallows (Ssit-IRP), supine multiple rapid swallows (Msup-IRP), and sitting multiple rapid swallows (Msit-IRP). We analyzed the HREM recordings of 40 healthy volunteers and 53 patients with suspected achalasia. The four metrics were significantly different from each other in healthy volunteers (Ssup-IRP > Msup-IRP > Ssit-IRP > Msit-IRP) and their corresponding 95th percentiles were substantially distinct (Ssup-IRP: 25.3mmHg, Ssit-IRP: 20.9mmHg, Msup-IRP: 15.9mmHg, and Msit-IRP: 11.9mm Hg, respectively). Complete agreement among the four metrics in predicting abnormal IRP was found in 39 of the 47 patients with suspected achalasia who completed the protocol. Optimal cutoffs derived from ROC curve analysis demonstrated ≥ 0.95 specificities for detection of impaired EGJ relaxation among patients with suspected achalasia. Among the eight patients with suspected achalasia with normal Ssup-IRP, five demonstrated abnormal Msit-IRP and four abnormal Ssit-IRP. Significant differences of IRP exist depending on the measurement situation, indicating that correct interpretation of IRP values requires specific cutoffs for each situation.The sensitivities of Ssit-IRP and Msit-IRP in detecting defective EGJ relaxation appear to be slightly higher than that of Ssup-IRP.

Normative Reference Values for FEES and VASES: Preliminary Data From 39 Nondysphagic, Community-Dwelling Adults.

The aim of this study was to establish preliminary reference values for the Visual Analysis of Swallowing Efficiency and Safety (VASES)-a standardized rating methodology used to evaluate swallowing safety and efficiency for flexible endoscopic evaluation of swallowing (FEES). FEES were completed in nondysphagic, community-dwelling adults using a standardized protocol of 15 swallowing trials that varied by bolus size, consistency, contrast agent, and swallowing instructions. FEES were blindly analyzed using VASES. Primary outcome measures included bolus location at swallow onset, Penetration-Aspiration Scale (PAS) scores, and percentage-based residue ratings for six anatomic landmarks. Secondary outcome measures included sip size, bite size, and number of swallows. Thirty-nine healthy adults completed the study, yielding an analysis of 584 swallows. Swallows were initiated with the bolus in the pharynx for 41.8% of trials. PAS 1 was the most common score, accounting for 75.3% of trials, followed by PAS 3, which accounted for 18.8% of trials. When residue was present (> 0%), the amount was relatively small across all anatomic landmarks, with median residue ratings of 2.0% (oropharynx), 1.5% (hypopharynx), 3.0% (epiglottis), 3.0% (laryngeal vestibule), and 3.5% (vocal folds). Five events of aspiration were observed, which were characterized by subglottic residue ratings of 1%, 3%, 10%, 24%, and 90%. The average sip size of self-selected volume cup sips of water was 19.8 ml, and the average bite size of a 3.0-g saltine cracker was 1.33 g. Moreover, 78% of the trials in this study protocol (except 90-ml trials) were completed in a single swallow. The results from this study provide preliminary norms for VASES that could be used as a reference when assessing functional swallowing outcomes during FEES. While this is an important first step in establishing norms for FEES and VASES, clinicians and researchers should be mindful that the normative reference values from this study are from a relatively small study sample (N = 39), with most people below the age of 60 years (n = 30). Future research should expand on these norms by including a greater number of people across the age continuum and with greater racial, ethnic, and gender diversity. Supplemental Material and Open Science Form: https://doi.org/10.23641/asha.23504325.

A fuzzy-based framework for diagnosing esophageal mobility disorder using high-resolution manometry

In recent years, the high-resolution manometry (HRM) technique has been increasingly used to study esophageal and colonic pressurization and has become a standard routine for discovering mobility disorders. In addition to evolving guidelines for the interpretation of HRM like Chicago standard, some complexities, such as the dependency of normative reference values on the recording device and other external variables, still remain for medical professions. In this study, a decision support framework is developed to aid the diagnosis of esophageal mobility disorders based on HRM data. To abstract HRM data, Spearman correlation is employed to model the spatio-temporal dependencies of pressure values of HRM components and convolutional graph neural networks are then utilized to embed relation graphs to the features vector. In the decision-making stage, a novel Expert per Class Fuzzy Classifier (EPC-FC) is presented that employs the ensemble structure and contains expertized sub-classifiers for recognizing a specific disorder. Training sub-classifiers using the negative correlation learning method makes the EPC-FC highly generalizable. Meanwhile, separating the sub-classifiers of each class gives flexibility and interpretability to the structure.The suggested framework is evaluated on a dataset of 67 patients in 5 different classes recorded in Shariati Hospital. The average accuracy of 78.03% for a single swallow and 92.54% for subject-level is achieved for distinguishing mobility disorders. Moreover, compared with the other studies, the presented framework has an outstanding performance considering that it imposes no limits on the type of classes or HRM data. On the other hand, the EPC-FC outperforms other comparative classifiers such as SVM and AdaBoost not only in HRM diagnosis but also on other benchmark classification problems.

Which screening tool should be used for identifying aspiration risk associated with dysphagia in acute stroke? A Cochrane Review summary with commentary.

Dysphagia is a common impairment in patients with acute stroke and is associated with an increased risk of complications such as aspiration pneumonia, malnutrition and dehydration, as well as with poor outcome and higher mortality. Therefore, immediate screening for aspiration risk is recommended, using a bedside swallow screening tool. To determine the diagnostic accuracy and the sensitivity and specificity of bedside screening tests for detecting risk of aspiration associated with dysphagia in people with acute stroke. A summary of the Cochrane Review by Boaden et al. 2021, with comments from a rehabilitation perspective. The review included 25 studies with 3953 participants and 37 screening tests. No single study demonstrated 100% sensitivity and specificity with low risk of bias for all domains. The best performing swallow screening tools were the Bedside Aspiration test (combined water swallow and instrumental tool), the Gugging Swallowing Screen (GUSS, water plus other consistencies) and the Toronto Bedside Swallowing Screening Test (TOR-BSST, water only). However, these tests were based on single studies with small sample sizes. It was not possible to explore the influence of sources of heterogeneity. No single swallow screening tool with high accuracy as well as good quality evidence could be identified, but recommendations for further high-quality research are offered.

EndoFLIP Topography: Motor Patterns in an Obstructed Esophagus

EndoFLIP Topography: Motor Patterns in an Obstructed Esophagus

The rostral brainstem's pivotal role in swallow‐breathing coordination

Respiration and swallowing are motor behaviours that require the interaction of two brainstem central pattern generators (r‐CPG, sw‐CPG). Previously we studies the interaction of swallowing and breathing in the in situ perfused brainstem preparation that identified a pivotal role of the pontine Kolliker‐Fuse nuclei for the mediation of protective glottal closure. We recently developed a computational model to further aid and test network connectivity and neural interaction between sw‐ and r‐CPGs. The model is based on a stepwise integration of synaptic connectivity between central sensory relay, sw‐ and r‐CPG neuron populations. The model is validated by experimental data obtained in situ. In the model and experimental data, stimulation of the superior laryngeal nerve (SLN, 10s) reliably triggers sequential swallowing with concomitant swallowing‐related glottal closure and suppression of inspiratory activity. Short SLN stimulation (100ms) evokes single swallows and respiratory phase resetting in the model and in situ yielding comparable phase response curves. Consistent with experiments, numerical circuit‐busting simulations show that deletion of ponto‐medullary synaptic interactions triggers apneusis and eliminates swallowing‐related glottal closure during sequential swallowing. Additionally, systematic variations of the synaptic strengths of distinct network connections predict vulnerable network connections that can mediate clinically relevant breathing‐swallowing disorders observed in the elderly and patients with neurodegenerative disease. Thus, the present model provides novel insights that can guide future experiments and the development of efficient treatments for prevalent breathing‐swallowing disorders.

Solid bolus swallows during high-resolution manometry complement multiple rapid swallows in predicting symptoms following antireflux surgery.

Solid bolus swallows (SBS) assess esophageal peristalsis on high-resolution manometry (HRM). It remains unknown if increase in contraction vigor (contraction reserve) following SBS (SBS-CR) provides information similar to that observed following multiple rapid swallows (MRS-CR). Clinical and HRM data from adult patients (n=96, age 58.2years, 61.5% female) undergoing esophageal testing prior to anti-reflux surgery (ARS) were analyzed if both MRS and SBS were available, and compared to similar data from healthy asymptomatic volunteers (n=18, age 27.5years, 55.6% female). Patients reported esophageal symptoms before and after ARS using 5-point Likert scales evaluating symptom frequency and severity; scores for each patient were averaged to determine global symptoms. Distal contractile integral (DCI) from single swallows was compared to MRS DCI and SBS DCI; the ratio of single swallow DCI to MRS DCI or SBS DCI ≥1 determined the presence of contraction reserve. Multiple rapid swallows CR was concordant with SBS CR in 55.6% of healthy volunteers, 100% of absent contractility, 100% of ineffective esophageal motility (IEM) and 56.9% without IEM. Correlation between MRS DCI and SBS DCI was highest when IEM criteria were met (Spearman's rho 0.998). While neither MRS CR nor SBS CR presence differed by presenting symptoms or global symptom score at baseline, post-ARS global symptom burden was highest in the absence of both MRS CR and SBS CR, especially in patients with esophageal hypomotility using Chicago Classification version 4.0 criteria (p=0.03). Multiple rapid swallows and SBS are complementary in predicting post-ARS symptom burden.

Screening for aspiration risk associated with dysphagia in acute stroke.

Stroke can affect people's ability to swallow, resulting in passage of some food and drink into the airway. This can cause choking, chest infection, malnutrition and dehydration, reduced rehabilitation, increased risk of anxiety and depression, longer hospital stay, increased likelihood of discharge to a care home, and increased risk of death. Early identification and management of disordered swallowing reduces risk of these difficulties. Primary objective • To determine the diagnostic accuracy and the sensitivity and specificity of bedside screening tests for detecting risk of aspiration associated with dysphagia in people with acute stroke Secondary objectives • To assess the influence of the following sources of heterogeneity on the diagnostic accuracy of bedside screening tools for dysphagia - Patient demographics (e.g. age, gender) - Time post stroke that the study was conducted (from admission to 48 hours) to ensure only hyperacute and acute stroke swallow screening tools are identified - Definition of dysphagia used by the study - Level of training of nursing staff (both grade and training in the screening tool) - Low-quality studies identified from the methodological quality checklist - Type and threshold of index test - Type of reference test SEARCH METHODS: In June 2017 and December 2019, we searched CENTRAL, MEDLINE, Embase, CINAHL, and the Health Technology Assessment (HTA) database via the Centre for Reviews and Dissemination; the reference lists of included studies; and grey literature sources. We contacted experts in the field to identify any ongoing studies and those potentially missed by the search strategy. We included studies that were single-gate or two-gate studies comparing a bedside screening tool administered by nurses or other healthcare professionals (HCPs) with expert or instrumental assessment for detection of aspiration associated with dysphagia in adults with acute stroke admitted to hospital. Two review authors independently screened each study using the eligibility criteria and then extracted data, including the sensitivity and specificity of each index test against the reference test. A third review author was available at each stage to settle disagreements. The methodological quality of each study was assessed using the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS-2) tool. We identified insufficient studies for each index test, so we performed no meta-analysis. Diagnostic accuracy data were presented as sensitivities and specificities for the index tests. Overall, we included 25 studies in the review, four of which we included as narratives (with no accuracy statistics reported). The included studies involved 3953 participants and 37 screening tests. Of these, 24 screening tests used water only, six used water and other consistencies, and seven used other methods. For index tests using water only, sensitivity and specificity ranged from 46% to 100% and from 43% to 100%, respectively; for those using water and other consistencies, sensitivity and specificity ranged from 75% to 100% and from 69% to 90%, respectively; and for those using other methods, sensitivity and specificity ranged from 29% to 100% and from 39% to 86%, respectively. Twenty screening tests used expert assessment or the Mann Assessment of Swallowing Ability (MASA) as the reference, six used fibreoptic endoscopic evaluation of swallowing (FEES), and 11 used videofluoroscopy (VF). Fifteen screening tools had an outcome of aspiration risk, 20 screening tools had an outcome of dysphagia, and two narrative papers did not report the outcome. Twenty-one screening tests were carried out by nurses, and 16 were carried out by other HCPs (not including speech and language therapists (SLTs)). We assessed a total of six studies as low risk across all four QUADAS-2 risk of bias domains, and we rated 15 studies as low concern across all three applicability domains. No single study demonstrated 100% sensitivity and specificity with low risk of bias for all domains. The best performing combined water swallow and instrumental tool was the Bedside Aspiration test (n = 50), the best performing water plus other consistencies tool was the Gugging Swallowing Screen (GUSS; n = 30), and the best water only swallow screening tool was the Toronto Bedside Swallowing Screening Test (TOR-BSST; n = 24). All tools demonstrated combined highest sensitivity and specificity and low risk of bias for all domains. However, clinicians should be cautious in their interpretation of these findings, as these tests are based on single studies with small sample sizes, which limits the estimates of reliability of screening tests. We were unable to identify a single swallow screening tool with high and precisely estimated sensitivity and specificity based on at least one trial with low risk of bias. However, we were able to offer recommendations for further high-quality studies that are needed to improve the accuracy and clinical utility of bedside screening tools.

807 ASSOCIATION OF BOLUS TRANSIT TIME ON BARIUM ESOPHAGOGRAM WITH ESOPHAGEAL PERISTALSIS

Abstract The threshold criteria for diagnosing ineffective esophageal motility (IEM) has changed over the years and is based on the proportion of failed and weak peristalses. Bolus transit time (BTT) on barium esophagogram (BE) can intuitively be the ‘gold standard' for assessing the effectiveness of esophageal peristalsis. The aim of this study was to associate upright and prone BTT with esophageal peristalsis and dysphagia in patients with normal lower esophageal sphincter (LES) parameters. Methods Patients with normal LES on high-resolution manometry (HRM) who also had a standard-protocol BE from 2017 to 2020 were included. Patients with previous foregut surgery, hiatal hernia, jackhammer esophagus, distal esophageal spasm, fragmented peristalsis, and those with < or > 10 single swallows on HRM were excluded. Based on the number of normal swallows (DCI >450 mmHg.s.cm), the patients were divided into 11 groups (10 normal to 0 normal). Upright and prone BTT were measured on BE. Fractional polynomial and logistic regression analysis were used to study association (along with rate of change) between BTT, dysphagia, and peristalsis. Results In total, 146 patients met the inclusion criteria. Prone BTT increased in tandem with a decrease in the number of normal peristalses (p < 0.001), but no difference was noted in upright BTT (p = 0.317). Two deflection points were noted on the association between peristalsis and prone BTT at 50%, 40 seconds and 30%, 80 seconds on the y and x-axes, respectively, after which declining peristaltic function was independent of prone BTT. Patients with prone BTT >40 seconds had nearly 6-fold higher odds of having zero normal peristalses (p = 0.002). Increasing prone BTT was associated with increasing dysphagia (p < 0.05). Conclusion Prone, but not upright BTT, correlates with the proportion of normal esophageal peristalses and dysphagia. The phenotype of abnormal swallows (failed, weak) appears to have minimal impact on BTT. The current perspective of manometric classification may need to be adjusted to use the proportion of normal peristalses as a criterion.

800 ASSOCIATION OF MULTIPLE RAPID SWALLOW PARAMETERS WITH SYMPTOMS IN PATIENTS WITH INEFFECTIVE AND NORMAL ESOPHAGEAL MOTILITY

Abstract Multiple rapid swallows (MRS) is a provocative test to assess inhibitory swallowing mechanisms and esophageal peristaltic reserve. MRS response has been purposed to predict post-fundoplication dysphagia and has been associated with increased acid exposure time. Recently it was added to the Chicago classification v 4.0 protocol as an adjunctive test. This study aimed to understand the association of MRS parameters with symptoms in patients within ineffective (IEM) or normal esophageal motility (NEM). Methods After IRB approval, a prospectively maintained esophageal motility database was retrospectively reviewed to identify patients with IEM and NEM who also had an MRS evaluation. Patients with previous gastroesophageal surgery, manometric hiatal hernia, or a diagnosed motility disorder (except IEM) were excluded. Patient-reported symptoms (0–4) (heartburn, regurgitation, dysphagia, and chest pain) were grouped by score: 0, 1–2, or 3–4. We compared the prevalence of normal or abnormal MRS and individual MRS parameters (distal contractile integral [DCI], integrated relaxation pressure, distal latency, adequate inhibition, and post-MRS DCI/mean single swallow DCI ratio) with patient-reported symptoms. Results From 2019–2020, a total of 531 patients (254 = IEM, 277 = NEM) met the inclusion criteria and formed the study cohort. The presence of normal or abnormal MRS results was not associated with any patient-reported symptom in either the NEM or IEM group. Furthermore, patient-reported symptoms were not associated with individual MRS parameters in either group. Conclusion In patients with IEM and NEM, adjunct assessment with MRS does not correlate with patient-reported symptoms. Further studies are needed to assess the role of MRS as an adjunctive test during routine manometry.

Normal Values of High-resolution Manometry Parameters With Provocative Maneuvers.

Background/AimsIncorporation of complementary and provocative test swallows to the high-resolution manometry (HRM) protocol offers potential to address limitations posed by HRM protocols that involve only a single swallow type. The aim of this study is to describe normal findings of a comprehensive HRM testing protocol performed on healthy asymptomatic volunteers.MethodsThirty healthy asymptomatic volunteers completed HRM with 5-mL liquid swallows in the supine position. They also completed 5-mL liquid swallows in the upright position, viscous swallows, solid test swallows, multiple rapid swallows, and a rapid drink challenge. HRM studies were analyzed via Chicago classification version 3.0.ResultsThe median (5th-95th percentiles) for integrated relaxation pressure (IRP) on supine swallows was 11 (4-16) mmHg; IRP was lower than supine on upright liquid 9 (0-17) mmHg, viscous 6 (0-15) mmHg, solid 9 (1-19) mmHg, multiple rapid swallows 3 (0-12) mmHg, and rapid drink challenge 5 (–3-12) mmHg; P < 0.005. While an “elevated” IRP value was observed on 1 to 2 test maneuvers in 8/30 (27%) subjects, all 30 subjects had an IRP value < 12 mmHg on at least one of the test maneuvers.ConclusionsNormal values and findings from a comprehensive HRM testing protocol are reported based on evaluation of 30 healthy asymptomatic volunteers. Isolated “abnormalities” of IRP and contractile parameters were observed in the majority (80%) of these asymptomatic subjects, while all subjects also had normal features observed. Thus, the definition of “normal” should be recalibrated to focus on the entirety of the study and not individual metrics.

Scoring the Penetration-Aspiration Scale (PAS) in Two Conditions: A Reliability Study.

A widely applied metric for identifying airway invasion events is the Penetration-Aspiration Scale (PAS). PAS scores are often included as primary outcome measures in clinical interventional studies, applied to characterize airway protection in a particular disease, used to establish a normal referent for control group comparisons without dysphagia, and as determinants or predictors of clinical outcomes. Despite the widespread use of the PAS, there is variability in scoring condition. One common method used in research studies includes rater scores applied to each single swallow that occurred during a modified barium swallow study (MBSS) of the same patient. A second common method includes raters scoring single swallow segments that have been spliced from full MBSS from different patients. These single swallow segments are then randomly distributed and the rater is blinded to all swallows that occurred during that patient MBSS. The potential effects of different scoring conditions on rater reliability and score accuracy have not been studied and may have high relevance for the conclusion drawn from the result. The primary aim of this investigation is to determine the impact of two scoring conditions on rater reliability and score accuracy: 1. Contextual, unblinded scoring condition and 2. Randomized, blinded condition. Results of the present study show that no statistically significant differences in PAS rater reliability and score accuracy were found between the two scoring conditions. If findings from this pilot study are reproduced in larger sample sizes, the time and intensity involved in splicing and randomizing MBSS for scoring may not be necessary.

Solid Swallow Examination During High Resolution Manometry and EGJ-Distensibility Help Identify Esophageal Outflow Obstruction in Non-obstructive Dysphagia

Single water swallow (SWS) high-resolution manometry (HRM) may miss relevant esophageal motility disorders. Solid test meal (STM) during HRM and lately the functional lumen imaging probe (FLIP) have been shown to be of diagnostic value in the assessment of motility disorders. We aimed to assess the diagnostic yield of STM and FLIP in non-obstructive dysphagia (NOD). Patients assessed for dysphagia with both HRM and FLIP between April 2016 and August 2019 were analyzed for signs of non-obstructive EGJ outflow obstruction (EGJOO) according to Chicago Classification 3.0 (CCv3) and CC adapted for the use with solid swallows (CC-S), followed by an individual group-specific analysis. Five subjects without dysphagia served as control group. Standard HRM- and FLIP-values as well as esophagograms and Eckardt Scores were analyzed. Forty-two patients were identified (male/female, 14/36, median age 62). Twenty-five (59.5%) were diagnosed with EGJOO during STM only (= SWS-negative patients; CC-S). The EGJ distensibility index (EGJ-DI) of symptomatic patients was significantly lower compared to the control group (p = 0.006). EGJ-DI was < 3mm2/mmHg in 67% and 88% of patients diagnosed according to CC-S and CCv3, respectively. The IRP during STM showed a significant association to the corresponding EGJ-DI values (p < 0.001). Seventy-six percent of patients received treatment because of additional STM evaluation with a favorable clinical response rate of 89%. STM and FLIP identify EGJOO in symptomatic patients with normal SWS during HRM. STM resembles an inexpensive and clinically meaningful option to diagnose motility disorders and helps to select patients for interventional treatment.

Eletromiografia de Superfície dos Músculos Masseter e Supra-Hióideos na Fase Oral da Deglutição em Adultos Saudáveis

Objective: to evaluate by means of electromyographic analysis of the masseter and suprahyoid muscles the oral phase of the swallowing of different volumes of saliva and liquid in healthy adult individuals. Material and Methods: the method consisted in analyzing samples of three swallowing trials: voluntary and single swallow of saliva (dry), voluntary and single swallow of 10 ml of water, and voluntary and single swallow of 20ml of water. Statistical analysis: Through Friedman’s ANOVA test we observed a significant variation in the medium potential of the right suprahyoid muscle (p=0.010) when compared to the left suprahyoid muscle (p=0.05). Other correlations were verified by using the Nemenyi test, the Wilcoxon test and the Spearman coefficient to support the different analyses of the results. Results: the analysis found a direct relation between the electrical activity of the masseter and suprahyoid muscles when swallowing 20 ml water as regards the highest potential values, irrespective of face side – left or right; i.e., when swallowing 20ml water, the higher the potential of one muscle group, the higher the expected value of its antagonist. Conclusion: the electromyographic behavior of the masseter and suprahyoid muscles during voluntary swallowing of saliva and two standardized liquid volumes showed that the electrical activity of the masseter muscles did not vary according to the type of swallowing.

A Single Swallow by Zhang Ling

0 STATEMENT OF OWNERSHIP, MANAGEMENT, AND CIRCULATION 1. Publication Title: World Literature Today 2. Publication Number: 060-680 3. Filing Date: September 1, 2021 4. Issue Frequency: Quarterly 5. Number of Issues Published Annually: Four 6. Annual Subscription Price: $35 US, $45 Canada, $65 Elsewhere, $150 US Institution, $205 International Institution 7. Complete Mailing Address of Known Office of Publication: World Literature Today / University of Oklahoma / 630 Parrington Oval, Suite 110 / Norman, OK 73019-4033 8. Complete Mailing Address of Headquarters of General Business Office of Publisher: Same as above. 9. Full Names and Complete Mailing Addresses of: Publisher: Robert Con Davis-Undiano. Assistant Director & Editor in Chief: Daniel Simon / World Literature Today / University of Oklahoma / 630 Parrington Oval, Suite 110 / Norman, OK 73019-4033 10. Owner: University of Oklahoma Board of Regents / 119 Evans Hall / Norman, OK 73019-3074 11. Known Bondholders, Mortgagees, and Other Security Holders: None 12. The purpose, function, and nonprofit status of this organization and the exempt status for federal income-tax purposes have not changed during the preceding twelve months. 13. Publication Title: World Literature Today 14. Issue Date for Circulation Data Below: Autumn 2020 15. Extent and Nature of Circulation: 2613 1200 760 1960 100 50 150 2110 503 2613 92.89% Actual no. copies of single issue published nearest to filing date Average no. copies of each issue during preceding 12 months I certify that all information furnished above is true and complete. Daniel Simon, Assistant Director Total no. of copies Paid and/or requested circulation 1. Paid subscriptions 2. Counter sales Total paid and/or requested circulation Free distribution by mail Free distribution outside the mail Total free distribution Total distribution Copies not distributed Total Percent circulation 2613 1200 760 1960 100 50 150 2110 503 2613 92.89% Zhang Ling A Single Swallow Trans. Shelly Bryant. Seattle. Amazon Crossing. 2020. 291 pages. THE STORY OF A Single Swallow follows the lives of three men, two westerners and one Chinese, who became friends during World War II in a Chinese village. One is a priest, the other two soldiers, and they must navigate the violent and tense climate of wartime China. Their collective trauma brings them together, and they agree that even after the war, they will all meet again annually in the village on a set day. This friendship even continues beyond death, as the ghost of the priest still travels to the village each year waiting for his friends. Their past slowly begins to unfold throughout the narrative via another common aspect of their lives: meeting a young girl. Stella, Wende, A Yan: the three men know her by three different names. They each refer to her by one of these names, claiming ownership over their version of her. Yan means “swallow,” and like a bird she flies into each man’s life and changes them forever. Her life was devastated when she experienced the violence of Japanese troops firsthand, and the priest, who is serving as the village doctor, shows her compassion and takes her in. Swallow shows great promise and intelligence, but the villagers, especially the men, see her as soiled from the attack by the Japanese and disregard her. Themes of gender, memory, and trauma are woven throughout the narrative. At one point, all three of these men show her kindness, and their lives are forever altered. Like the men’s posthumously binding friendship, their connection with Swallow leaves such a deep impact on them, and they remember her with fondness and guilt. Ultimately, the story is not just about friendship; it is also about one woman, a single swallow, who changes the lives of three men forever. Amy Lantrip University of California Irvine World Literature Today Print & Digital Unlimited Articles my.worldlit.org GIFT SUBSCRIPTIONS AVAILABLE! MY.WORLDLIT.ORG f “T ranslation is an aesthetic act in which the translator tries to replicate the artistry of the original , providing the reader of the translation with a similarly rich and powerful aesthetic experience.” – ANNE O. FISHER WORLDLIT.ORG 107 ...

Application of a novel straight leg raise test during high-resolution manometry can predict esophageal contractile reserve in patients with gastroesophageal reflux disease.

Increased intra-abdominal pressure from abdominal compression augments esophageal peristalsis during high-resolution manometry (HRM), and straight leg raise (SLR) while supine increases intra-abdominal pressure. We determined if water swallows performed during SLR can mimic contraction reserve seen with multiple rapid swallows (MRS). Consecutive patients evaluated for GERD symptoms completed validated GERD questionnaires, esophageal HRM, and upper endoscopy. Distal contractile integral (DCI) was analyzed during single water swallows (10×5mL), MRS (5×2mL), and during SLR (5x5mL). Peristaltic breaks were measured using software tools with a 20mmHg isobaric contour. Univariate correlational analyses were performed to compare esophageal motor patterns and DCI values during single water swallows, MRS, and SLR. Of 103 study patients (mean age: 46.7±12.3years, 56.3% female), 50 (48.5%) had ineffective esophageal motility (IEM). Contraction reserve was observed on MRS in 62% with IEM, and 35.8% with normal motility (p=0.008). DCI was significantly higher during SLR compared to mean single swallow DCI in both IEM and normal motility patients (p<0.001 for each comparison). In IEM patients, SLR significantly reduced swallows with peristaltic breaks (6.1±3.7 vs 3.6±3.6; p<0.001) and shortened the length of the largest break (4.8±3.4 vs 3.0±3.0cm; p<0.001). DCI response following MRS correlated with DCI with swallows during SLR, with a correlational coefficient (Pearson's r) of 0.70 (p<0.001). Swallowing against the resistance of increased intra-abdominal pressure from SLR improves esophageal body peristaltic performance and predicts esophageal body contraction reserve.

Multiple swallow behaviour during high resolution pharyngeal manometry: prevalence and sub-typing in healthy adults

ABSTRACT Background: Typical voluntary bolus swallowing consists of a single discrete oropharyngeal swallow. Multiple Swallow Behaviour, such as piecemeal deglutition, is also known to occur in health. We hypothesized that Multiple Swallow Behaviour can be detected and sub-typed utilizing high resolution pharyngeal manometry (HRPM) with impedance. Methods: Prevalence of Multiple Swallow Behaviour was examined in 50 healthy subjects (29 females, mean age 47years, range 19.8–79.5years). HRPM was performed using the Medical Measurement Systems motility system and 8-French pressure-impedance solid state catheter (32 × 1 cm spaced uni-directional pressure sensors, 16 × 2 cm impedance segments). Triplicate boluses of 3, 5, 10 and 20 ml of thin, mildly thick and extremely thick consistencies were tested. Multiple Swallow Behaviour was defined by a sequence of two or more swallows on the pressure topography tracing, occurring after oral bolus administration, with an inter-swallow interval of ≤5 sec. Results: Single swallows were the most common behaviour observed. However, 28 of 50 participants exhibited at least one Multiple Swallow Behaviour event. Larger bolus volumes elicited more Multiple Swallow events. Using impedance, Multiple Swallow Behaviour was further sub-typed as Secondary Dry Swallows (70%, considered normal), Preceding Dry Swallows (1%, considered abnormal), Piecemeal Swallows (25%, considered abnormal for volumes <20 ml) or Clearing Swallows (4%, considered abnormal). Conclusion: HRPM with impedance enables the detection and characterization of Multiple Swallow Behaviour and potentially improves our ability to distinguish manifestations of swallowing disorders. Further studies are required to investigate Multiple Swallow Behaviour sub-types in patients with dysphagia.

Contraction Reserve With Ineffective Esophageal Motility on Esophageal High-Resolution Manometry is Associated With Lower Acid Exposure Times Compared With Absent Contraction Reserve.

Ineffective esophageal motility (IEM) is a minor motor disorder with potential reflux implications. Contraction reserve, manifested as augmentation of esophageal body contraction after multiple rapid swallows (MRS), may affect esophageal acid exposure time (AET) in IEM. Esophageal high-resolution manometry (HRM) and ambulatory reflux monitoring studies were reviewed over 2 years to identify patients with normal HRM, IEM (≥50% ineffective swallows), and absent contractility (100% failed swallows). Single swallows and MRS were analyzed using HRM software tools (distal contractile integral, DCI) to determine contraction reserve (mean MRS DCI to mean single swallow DCI ratio >1). Univariate analysis and multivariable regression analyses were performed to determine motor predictors of abnormal AET in the context of contraction reserve. Of 191 eligible patients, 57.1% had normal HRM, 37.2% had IEM, and 5.8% had absent contractility. Contraction reserve had no affect on AET in normal HRM. Nonsevere IEM (5-7 ineffective swallows) demonstrated significantly lower proportions with abnormal AET in the presence of contraction reserve (30.4%) compared with severe IEM (8-10 ineffective swallows) (75.0%, P = 0.03). Abnormal AET proportions in nonsevere IEM with contraction reserve (32.7%) resembled normal HRM (33.0%, P = 0.96), whereas that in severe IEM with (46.2%) or without contraction reserve (50.0%) resembled absent contractility (54.5%, P ≥ 0.6). Multivariable analysis demonstrated contraction reserve to be an independent predictor of lower upright AET in nonsevere (odds ratio 0.44, 95% confidence interval 0.23-0.88) but not severe IEM. Contraction reserve affects esophageal reflux burden in nonsevere IEM. Segregating IEM into severe and nonsevere cohorts has clinical value.