Solid Bolus Research Articles

BN SO18 - Considering Physiology Surveillance in Patients with Oesophageal Atresia

Abstract Background Oesophageal atresia (OA) is a congenital malformation found between one in every 2,400 to 4,500 new-borns per year world-wide [1] who require immediate oesophageal surgery and lifelong endoscopic surveillance for complications of gastroesophageal reflux, oesophagitis, Barrett's oesophagus, anastomotic strictures, oesophageal dysmotility and dysphagia [2, 3]. This study investigates whether ad-hoc oesophageal physiology surveillance would be clinically beneficial for patients with post OA surgical history. Method Retrospective study was conducted on patients with surgical history for OA and undergone oesophageal physiology studies between 2010 and 2023. 11 patients were found (6 females) who had oesophageal physiology at mean age of 29 years (95% CI 26.7 to 35.3 years) or correspondingly post-surgery for OA. Standard high-resolution manometry assessment was re-interpreted with reference Chicago Classification(version 4.0)[4]. This followed by stimulation with multiple water swallowing and solid bolus swallows as adjunctive testing [5, 6, 7]. This project was approved by the NHS institution and the local research ethics committee (REC 18/NW/0120)(IRAS 333800). Results Major dysmotility was observed in 7 patients (63.6%)(achalasia 3, absent contractility(AC) 4) and minor dysmotility was apparent in 4 patients (ineffective oesophageal motility [IOM]). Development of major dysmotility was at a later onset post-surgery to minor dysmotility (30.4 years vs 26.5 years, p=0.214). As was achalasia to AC (32.3 years vs 29.0 years, p=0.379). Adjunctive testing augmented oesophageal smooth muscle contractility in all patients with IOM and invoked remaining neuromuscular functioning in 2 patients with AC. The achalasia diagnosis in the 3 patients remained unchanged during the adjunctive testing. Conclusion Oesophageal physiology surveillance in patients with post OA surgery would enable identifying the staging of the motility disorder and which may direct further surgical management. This study revealed patients were still suitable for partial fundoplication post OA surgery (54.5%) and surgical myotomy for achalasia (27.3%). The prevalence of achalasia (27.3%) and absent contractility (36.4%) in post OA surgery observed this study are significantly higher compared to the non-OA treatment-naïve patients found in the general population living with achalasia and absent contractility disorders.

The test of masticating and swallowing solids (ToMaSS): An investigation of applicability and clinical utility in children with orofacial myofunctional disorders.

Orofacial myofunctional disorders (OMD) are often associated with limitations of oral ingestion of solid food. The Test of Masticating and Swallowing Solids (ToMaSS) is a simple diagnostic tool to assess and quantify oropharyngeal efficiency while eating a standardised cracker. The objective of this study was to investigate the applicability and clinical utility of the ToMaSS in children with OMD. In this case-control study, data were collected from 18 children between 4 and 11 years with confirmed OMD. Inter-rater reliability and age effects on the ToMaSS parameters were investigated and the specific performance profile of the OMD children was identified. Inter-rater reliability was excellent for the ToMaSS parameters 'bites' (ICC = .999), 'masticatory cycles' (ICC = .961), 'time'(ICC≧ .999) and good for 'number of swallows' (ICC = .810). 'Masticatory cycles' and 'time' decreased as a function of age with a significant difference in the 'number of masticatory cycles' between the youngest (4-6 years) and oldest (10-14 years) participants (p = .006, Z = -2.739). Deviations from normative data in at least one of the four ToMaSS parameters were found in 90% of the OMD children with 'bites', and 'masticatory cycles' predominantly corresponding to the performances expected in typically-developing children in younger age groups. The ToMaSS is a reliable diagnostic instrument and clinically useful to detect limited efficiency of oral solid bolus intake and specific impairments in chewing function and duration of food intake in children with OMD. Our data suggest that OMD is associated with delayed development of efficient solid bolus preparation.

Normal values for swallow events during endoscopic evaluation of swallowing: a preliminary study.

The current investigation aimed to establish preliminary normative data for endoscopic swallow studies (FEES). The investigators collected data for three timing measures (time to whiteout, duration of whiteout, and total swallow time), three swallowing outcomes (safety, efficiency, and number of swallows per bolus), and one physiologic event (glottal response), for both healthy young and older adults using two liquid volumes, one pureed bolus and a solid bolus. Blinded raters retrospectively analyzed 65 randomly selected, deidentified videos of endoscopic swallowing examinations from a pool of 163 young and older adults with typical swallowing abilities. Timing measures and analysis of airway invasion, amount of residue, number of swallows, and glottal response were obtained. Preliminary means and quartiles were established for healthy adults in two age groups (young and old), for time to whiteout (WO), number of swallows per bolus, glottal response, Yale Residue Rating Scale Scores, Penetration-Aspiration Scale scores, duration of WO, and total swallow duration. Differences were found between the older and younger groups. The current study represents a preliminary attempt to provide quantitative and normative values for FEES. These data represent reference values to which other bolus presentations and populations can be compared. The data represents proof of concept and merits additional investigation. 1756246-2: Approved 2022/06/06. Study does not meet criteria. DATA REPOSITORY: https://doi.org/10.6084/m9.figshare.25800025 .

A Preliminary Study of Vallecular Bolus Aggregation in Healthy Swallowing of Solid Food Boluses.

The pharyngeal swallow typically begins within 400 ms following the arrival of a liquid bolus in the pharynx. By contrast, processed food particles aggregate in the valleculae prior to swallow initiation. With solid foods, swallow reaction time (SRT), the interval between bolus passing the ramus of mandible and hyoid burst onset (HYB) can be subdivided into components of vallecular aggregation time (VAT) and the subsequent end of aggregation to hyoid burst interval (EOA-to-HYB). However, expected durations of these timing measures remain unclear. We aimed to study bolus aggregation in healthy swallowing for International Dysphagia Diet Standardisation Initiative Food Levels 5 (minced and moist [MM5]), 6 (soft and bite-sized [SB6]), and 7 (regular [RG7]). Understanding typical patterns and durations of vallecular aggregation with solids in healthy swallowing will inform the identification of impaired swallow timing in patient populations. Twenty healthy adults (10 males, Mage = 28 years, range: 23-55 years) swallowed two boluses each of MM5, SB6, and RG7 foods in videofluoroscopy. Blinded duplicate ratings determined bolus location at swallow onset, SRT, VAT, and EOA-to-HYB. Texture-based differences were measured using Friedman's tests. Bolus location was at/above the valleculae at swallow onset for 85% of boluses, with no differences by texture. SRT, VAT, and EOA-to-HYB did not vary by texture, with overall median values (interquartile range) of 99 ms (-66 to 743 ms) for SRT, 347 ms (66 to 891 ms) for VAT, and -132 ms (-231 to -83 ms) for EOA-to-HYB. These data corroborate prior evidence that it is not unusual for food particles to aggregate in the valleculae prior to swallow initiation in healthy swallowing. However, durations of vallecular aggregation are typically < 1 s in healthy adults.

Characterization of selected additive manufacturing materials for synchrotron monochromatic imaging and broad-beam radiotherapy at the Australian synchrotron-imaging and medical beamline

Objective. This study aims to characterize radiological properties of selected additive manufacturing (AM) materials utilizing both material extrusion and vat photopolymerization technologies. Monochromatic synchrotron x-ray images and synchrotron treatment beam dosimetry were acquired at the hutch 3B and 2B of the Australian Synchrotron-Imaging and Medical Beamline. Approach. Eight energies from 30 keV up to 65 keV were used to acquire the attenuation coefficients of the AM materials. Comparison of theoretical, and experimental attenuation data of AM materials and standard solid water for MV linac was performed. Broad-beam dosimetry experiment through attenuated dose measurement and a Geant4 Monte Carlo simulation were done for the studied materials to investigate its attenuation properties specific for a 4 tesla wiggler field with varying synchrotron radiation beam qualities. Main results. Polylactic acid (PLA) plus matches attenuation coefficients of both soft tissue and brain tissue, while acrylonitrile butadiene styrene, Acrylonitrile styrene acrylate, and Draft resin have close equivalence to adipose tissue. Lastly, PLA, co-polyester plus, thermoplastic polyurethane, and White resins are promising substitute materials for breast tissue. For broad-beam experiment and simulation, many of the studied materials were able to simulate RMI457 Solid Water and bolus within ±10% for the three synchrotron beam qualities. These results are useful in fabricating phantoms for synchrotron and other related medical radiation applications such as orthovoltage treatments. Significance and conclusion. These 3D printing materials were studied as potential substitutes for selected tissues such as breast tissue, adipose tissue, soft-tissue, and brain tissue useful in fabricating 3D printed phantoms for synchrotron imaging, therapy, and orthovoltage applications. Fabricating customizable heterogeneous anthropomorphic phantoms (e.g. breast, head, thorax) and pre-clinical animal phantoms (e.g. rodents, canine) for synchrotron imaging and radiotherapy using AM can be done based on the results of this study.

SEMG-based automatic characterization of swallowed materials

Monitoring of ingestive activities is critically important for managing the health and wellness of individuals with various health conditions, including the elderly, diabetics, and individuals seeking better weight control. Monitoring swallowing events can be an ideal surrogate for developing streamlined methods for effective monitoring and quantification of eating or drinking events. Swallowing is an essential process for maintaining life. This seemingly simple process is the result of coordinated actions of several muscles and nerves in a complex fashion. In this study, we introduce automated methods for the detection and quantification of various eating and drinking activities. Wireless surface electromyography (sEMG) was used to detect chewing and swallowing from sEMG signals obtained from the sternocleidomastoid muscle, in addition to signals obtained from a wrist-mounted IMU sensor. A total of 4675 swallows were collected from 55 participants in the study. Multiple methods were employed to estimate bolus volumes in the case of fluid intake, including regression and classification models. Among the tested models, neural networks-based regression achieved an R2 of 0.88 and a root mean squared error of 0.2 (minimum bolus volume was 10 ml). Convolutional neural networks-based classification (when considering each bolus volume as a separate class) achieved an accuracy of over 99% using random cross-validation and around 66% using cross-subject validation. Multiple classification methods were also used for solid bolus type detection, including SVM and decision trees (DT), which achieved an accuracy above 99% with random validation and above 94% in cross-subject validation. Finally, regression models with both random and cross-subject validation were used for estimating the solid bolus volume with an R2 value that approached 1 and root mean squared error values as low as 0.00037 (minimum solid bolus weight was 3 gm). These reported results lay the foundation for a cost-effective and non-invasive method for monitoring swallowing activities which can be extremely beneficial in managing various chronic health conditions, such as diabetes and obesity.

Natural history of symptoms and prognostic information of the rapid drink challenge and solid bolus swallows in esophagogastric junction outflow obstruction defined by manometry.

Esophagogastric junction outflow obstruction (EGJOO) is a condition characterized by poor relaxation of the lower esophageal sphincter (LES), which can manifest as dysphagia and chest pain. The best treatment of EGJOO is unknown as some patients improve without any specific therapy, whereas some patients undergo invasive therapy. Currently, prognostic factors are lacking. We aimed to assess the long-term prognosis and predictors of dysphagia and chest pain by the rapid drink challenge and solid bolus swallows in EGJOO. We retrospectively assessed high-resolution esophageal manometries (HRM) performed at our center between 2015 and 2018. The patients completed a dysphagia and chest pain questionnaire a median of 34 months after the HRM/baseline assessment, including the Impaction dysphagia questionnaire-10 (IDQ-10) complemented with questions regarding chest pain and esophageal treatments. Symptoms were compared with HRM findings. In all, 980 HRMs were analyzed and 66 (6.5%) were identified as having HRM findings compatible with EGJOO. Of these, 27 patients with EGJOO (41%) completed the follow-up questionnaires and had no exclusion criteria, and 70% of these patients had dysphagia and 44% chest pain at least once a week. Dysphagia at follow-up was more common in patients with elevated integrated relaxation pressure (IRP) on all three HRM metrics (water swallows, solid bolus swallows, and rapid drink challenge) (p = 0.03, odds ratio: 8.4 (95% CI: 1.2-56.0)), but this was not seen for chest pain (p = 0.45). Abnormal motility patterns on rapid drink challenge or solid bolus swallows were not associated with dysphagia or chest pain at follow-up. Having a high IRP on three HRM metrics-water swallows, solid bolus swallows, and rapid drink challenge-is associated with a worse prognosis in patients with EGJOO and could potentially be used to select candidates suitable for invasive procedures.

OGBN P18 Surgical Intervention in Patient with Oesophageal Absent Contractility

Abstract Background Absent contractility (AC) is a major motility disorder with poor prognosis. Surgical management for associated comorbidities of AC are often challenging such as in GORD patients where antireflux surgery may be contraindicated or undiagnosed achalasia manifesting with normotensive integrated relaxation pressure would be deprived of surgical myotomy. Thus, it’s crucial to explore potential surgical interventions for patients with AC from both ends of the spectrum. This study will investigate the two extremes of AC and seek to determine suitable strategies for patient selection and offer insights into the management of AC through surgical intervention. Methods This is a retrospective study of patients undergone high-resolution manometry (HRM) between January 2022 to June 2023 and were diagnosed with AC based on ten 5ml water swallows. Patients were followed-up with provocative multiple water swallowing (MWS) and solid bolus swallow (SBS) assessments. Peristalsis invoked by MWS with Distal Contractile Integral (DCI) &amp;gt;100mmHgscm or SBS with DCI &amp;gt;405mmHgscm are adequate peristaltic vigour for consideration of floppy Nissen fundoplication. Patients with absolute AC on provocative stimulation and without peristaltic remnants during the HRM recording underwent oesophageal transit testing in consideration for Heller’s myotomy. Results Total of 115 patients were included (female:male=59:56, mean age 56 years old) with 43 patients (37.4%) demonstrating peristalsis on adjunctive testing (SBS assessment provoking peristalsis was greater by 3.2 folds to MWS [p=0.0004]). In 72 patients with failed adjunctive testing, 6 patients (8.3%) invoked peristalsis (DCI&amp;gt;100mmHgscm) from dry swallows (largest DCI observed: 1000) and 29 patients (40.2%) demonstrated peristaltic remnants (DCI&amp;lt;100mmHgscm). 37 patients (32.2%) had absolute AC with 21/37 patients (56.7%) were diagnosed with achalasia on transit testing (7 patients are still pending tests). AC in 9 patients originate from aetiologies where surgery would not benefit the patients. Conclusions Approximately 37.4% of patients with AC were suitable for floppy Nissen fundoplication, while 32.2% required Heller's myotomy. Surgical intervention was postponed if peristaltic remnants was observed and pending complete diminishment or recovery with prokinetic therapy. Overall, surgical intervention may be considered in nearly 70% of patients with AC.

Efficacy of High-Intensity Training in Patients with Moderate to Severe Dysphagia after Glossectomy.

Dysphagia is the main impairment arising from glossectomy for tongue cancer treatment. The study aimed to determine if an eight-week training protocol paired with accuracy tasks and swallowing exercises is effective and can improve tongue strength and swallowing in patients after tongue resection. Maximum isometric pressures, tongue endurance, swallowing pressures, mealtime duration, and oropharyngeal swallow function were studied in patients with moderate to severe dysphagia after glossectomy. Twenty-five (25) patients and thirty-one (31) healthy participants were enrolled in the study. The therapy group (TG) consisted of seventeen (17) patients who followed an 8-week treatment protocol and had multiple measurements. The follow-up control group (FUG) consisted of eight non-treated patients who had a baseline and an 8-week follow-up examination. Healthy participants served as the reference group (RF). Maximum isometric pressures, endurance, and swallowing pressures increased significantly in the TG versus the FUG. Significant improvement was documented in the TG regarding the EAT-10 questionnaire, the Penetration-Aspiration Scale scores at thickened and solid boluses, and post-swallow residues at thickened and solid boluses. The treatment protocol with tongue strength exercises combined with accuracy tasks and swallowing exercises improves the post-operative swallowing function in patients after glossectomy. Patients in the TG had more significant and quicker improvement in pressures and endurance compared to FUG.

Feasibility of using a realistic food bolus for semi-dynamic in vitro gastric digestion of hard cheese with pH-stat monitoring of protein hydrolysis

Oral processing of solid foods leads to boluses made of a human saliva and particles distributed in the size range ∼ 0 to 5 mm. However, studies on the release of nutrients from realistic solid food boluses during digestion are scarce because such mechanisms are difficult to investigate in vivo, and in vitro experiments generally recommend to extensively mince solid foods during the oral stage. Similarly, it has previously been shown that the peptic hydrolysis of protein solutions during in vitro gastric digestion can be monitored by acid titration in both static and dynamic pH conditions, but such approach has never been evaluated in the presence of particles of several millimetres in size. The first objective of the study was therefore to test the feasibility of using a realistic food bolus for gastric digestion studies with a pH-stat monitoring of proteolysis, using Emmental cheese as a solid food and with consideration of gastric acidifying kinetics. Degree of hydrolysis (DH) of proteins was monitored from two series of experiments performed in the presence and absence of pepsin. Other DH measurements, estimated from an independent approach based on the amount of free NH2 groups (OPA method) contained by peptides released in the supernatant (UV absorbance) validated the pH-stat results. A second objective of this work was to test the possible influence of human saliva on gastric proteolysis (in comparison with a water-based bolus). Results showed that saliva slightly delayed initiation of proteolysis, which could be explained by the slightly higher initial pH of the saliva-based bolus, but had no statistical effects on pepsin activity. We conclude that acid titration with a pH-stat system can be a valuable approach to monitor the gastric in vitro proteolysis of realistic solid food boluses in dynamic pH conditions.

Evaluating the impact of position, volume, and consistency on high-resolution esophageal manometry outcomes.

The Chicago classification primarily utilizes ten 5 mL liquid swallows in a supine position as the standard high-resolution esophageal manometry (HRM) protocol. HRM can be performed with varying volumes and consistencies and in an upright position. We aimed to determine the impact on HRM results by (1) position, (2) swallows of differing volume and consistency, and (3) perception of bolus passage. HRM was performed in healthy volunteers (HV) with the following protocol of swallows: liquids 10 × 5 mL, 5 × 10 mL, and 3 × 10 mL multiple rapid swallows; applesauce 5 × 5 mL and 5 × 10 mL; and bread 5 × 2 × 2 cm and 5 × 4 × 4cm. HV rated difficulty of each swallow on a 5-point Likert scale. All HVs performed the protocol in supine position first and then in "semi-upright" (sitting 70 degrees in a bed) and "upright" (sitting in a chair) in a randomized order. Thirty-seven HVs, median age 27 years, 64% female completed this study. Median distal contractile integral (DCI) and integrated relaxation pressure 4 s (IRP4) of 5 mL liquid swallows significantly differed (all p < 0.01) between position performed. Large volume swallows resulted in higher DCI and lower IRP4. IRP4 results were significantly increased for 2 × 2 cm pieces of bread compared to 5 mL water swallows. DCI results were higher for 2 × 2 cm pieces of bread compared to 5 mL water swallows. Distal latency was shorter in more upright positions. Among this cohort of HV, perceived difficulty of bolus passage was more likely to occur with solid boluses. The volume and consistency of a swallow and the position it is performed in, significantly alter HRM metrics. Interpretation of HRM studies should incorporate different normative values which are specific to the position and bolus type.

The heat is on: Consumers modify their oral processing behavior when eating spicy foods

Food texture properties and consumer characteristics influence oral processing behaviors. Little is known about oral processing behavior of pungent spicy foods. In two experiments, we investigated how adding ground dried chilies to tomato soup or beef patties and curried rice altered oral processing behaviors. In Experiment One, tomato soups differing in concentration of added ground dried chilies (0.01, 0.03, 0.20 or 0.40% w/w) were consumed (n = 23). In Experiment Two, lunch meals that differed in added ground dried chilies consisting of beef patties (0.0, 0.6 or 1.2% w/w) and curried rice (0.0, 0.4 or 1.0% w/w) were consumed (n = 49). Sip/bite sizes were determined using hidden balances. Oral processing behavior was quantified using video recordings followed by post hoc annotations of specific behaviors. When eating tomato soup, increasing oral burn was associated with increasing number of water sips, water intake and total time between sips. For the solid meals (beef patties and curried rice), increasing oral burn was associated with increased time between bites and total sips of water; conversely, total oral exposure time, total number of chews and number of chews per bite all decreased with greater burn. Saliva content and rate of saliva incorporation into the solid food bolus increased with added ground dried chilies while oral exposure time decreased. We conclude consumers adapt their oral processing behaviors to oral burn of solid foods by reducing oro-sensory exposure time, chewing bites less, increasing time between bites, and consuming more water, potentially to mitigate the discomfort associated with the burn imparted by ground dried chilies.

EndoFLIP Topography: Motor Patterns in an Obstructed Esophagus

EndoFLIP Topography: Motor Patterns in an Obstructed Esophagus

A mechanistic approach to model the breakdown of solid food during chewing

Chewing food prepares it for safe swallowing which, by reducing particle size and exposing new surface and blending it with saliva, benefits both digestion and the sensory experience of consumers, the latter through flavour and aroma release and textural changes. A multitude of rate processes are at play and it is the role of feed technologists to enhance their outcomes. Particle size reduction is due to subsequent selection and breakage in each chewing cycle. To develop a model based on mechanistic principles for predicting the Particle Size Distribution (PSD) of solid food bolus during chewing, it was examined which existing mathematical descriptions for selection and breakage that are most suitable for an integrated model. The application of the model is demonstrated by using peanuts as a working example. • Mechanistic selection and breakage models were applied to a real food for the first time. • A combined one-way and two-way models to account selection gave the best fit. • The models developed here have the potential to reduce the time needed for food design. • The models can be adapted to a wider range of food systems in future studies.

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.

Turkish normative data for the Test of Masticating and Swallowing Solids (TOMASS)

Purpose: Swallowing is a complex neuromuscular process requiring the integrity of many muscles and nerves. The natural aging process can result in deterioration of the swallowing structures and result in functional changes in healthy older adults. The Test of Masticating and Swallowing Solids is the only non-instrumental test that provides quantitative measures for solid food ingestion. This study aimed to establish normative data for the Test of Masticating and Swallowing Solids in healthy Turkish adults to potentially serve as a standard in dysphagia evaluation.&#x0D; Materials and Methods: A total of 144 healthy Turkish adults (ages 20-80+ years) grouped by age and gender participated in this study. The test required participants to eat a regional cracker. Per the protocol, the number of masticatory cycles, number of swallows, number of bites, and total duration to eat the cracker were recorded.&#x0D; Results: Normative data were obtained for the Test of Masticating and Swallowing Solids from 144 healthy adults, stratified by age and gender. Younger participants took fewer bites (2.00 versus 2.65), chewed less (34.50 versus 51.02), swallowed less (2.06 versus 3.39), and swallowed quicker (30.14 versus 49.20) than older participants. In terms of gender, males took fewer bites (1.94 versus 2.59), chewed less (40.98 versus 45.83), and swallowed quicker (36.72 versus 41.23) than females.&#x0D; Conclusion: The Test of Masticating and Swallowing Solids is a quick, sensitive, and objective measure of solid bolus ingestion that may be useful for identifying dysphagic patients at bedside and for tracking the efficiency of the oral phase of swallowing.

Chicago classification version 4.0© technical review: Update on standard high-resolution manometry protocol for the assessment of esophageal motility.

The Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). A key feature of CCv.4.0 is the more rigorous and expansive protocol that incorporates single wet swallows acquired in different positions (supine, upright) and provocative testing, including multiple rapid swallows and rapid drink challenge. Additionally, solid bolus swallows, solid test meal, and/or pharmacologic provocation can be used to identify clinically relevant motility disorders and other conditions (eg, rumination) that occur during and after meals. The acquisition and analysis for performing these tests and the evidence supporting their inclusion in the Chicago Classification protocol is detailed in this technical review. Provocative tests are designed to increase the diagnostic sensitivity and specificity of HRM studies for disorders of esophageal motility. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification, decrease the proportion of HRM studies that deliver inconclusive diagnoses and increase the number of patients with a clinically relevant diagnosis that can direct effective therapy. Another aim in establishing a standard manometry protocol for motility laboratories around the world is to facilitate procedural consistency, improve diagnostic reliability, and promote collaborative research.

The Test of Masticating and Swallowing Solids (TOMASS): Reliability and validity in patients with dysphagia.

The Test of Masticating and Swallowing Solids (TOMASS) is an international standardized swallowing assessment tool. However, its psychometric characteristics have not been analysed in patients with dysphagia. To analyse TOMASS's (1) inter- and intra-rater reliability in a clinical population of patients with dysphagia, (2) known-group validity, (3) concurrent validity and (4) correlation with meal duration. Two age- and gender-matched groups of 39 participants each were recruited: A group of patients with dysphagia and a control group with no history of dysphagia. The TOMASS was carried out in both populations, video-recorded and scored offline by two speech and language therapists (SLT 1 and SLT 2) (inter-rater reliability) and twice by the same SLT (intra-rater reliability). In the clinical group, the TOMASS was carried out three times: (1) to verify understanding of the required tasks, (2) performed concurrently during fibreoptic endoscopic evaluation of swallowing (FEES) to assess validity and (3) during clinical assessment to assess reliability. TOMASS under endoscopic control was recorded and the number of white-out events was counted to compare with the number of observed swallows per cracker during standard TOMASS as a measure of concurrent validity. As additional measures of TOMASS validity, oral dental status, classified as 'functional' or 'partially functional', and duration of a standard meal were assessed by an SLT (SLT 1 or SLT 2), and then correlated with TOMASS. TOMASS's inter- and intra-rater reliability were high (intraclass correlation coefficient (ICC) > 0.95) in both the clinical and the control groups. The number of masticatory cycles (p = 0.020), swallows (p = 0.013) and total time (p = 0.003) of TOMASS were significantly lower in the control group than in the clinical group. Patients with 'partially functional' oral dental status showed a significantly higher number of masticatory cycles per cracker and a longer duration of ingestion than patients with a 'functional' one. Concurrent validity suggested a substantial agreement between TOMASS and FEES in defining the number of swallows per cracker. The mean difference of the two measures was -0.02 (95% confidence interval (CI) = -1.7 to 1.2). Meal duration significantly correlated with the 'number of swallows per cracker' (r = 0.49; p = 0.002) and 'total time' (r = 0.41; p = 0.011). Preliminary psychometric analysis of TOMASS in a clinical sample of outpatients with dysphagia suggests that it is a reliable and valid (specifically related to the number of swallows per cracker) tool. TOMASS's application in clinical practice to quantitatively measure solid bolus ingestion is recommended. What this paper adds What is already known on the subject The Test of Masticating and Swallowing Solids (TOMASS) is an international standardized swallowing assessment tool to evaluate oral preparation and oral phase of solids. The TOMASS' reliability and validity were tested on healthy subjects and normative data were gained. What this paper adds to existing knowledge The study provides the first data on the validity and reliability of the TOMASS in a clinical population. The TOMASS was proved to be a reliable and valid tool also in patients with dysphagia and to distinguish between patients with dysphagia and healthy subjects. What are the potential or actual clinical implications of this work? The use of the TOMASS in clinical practice is recommended as a valid and reliable tool to quantitatively measure the ingestion of solid in patients with dysphagia.

The Test of Masticating and Swallowing Solids (TOMASS): Reliability, Validity and Normative Data for the Adult Indian Population.

The Test of Masticating and Swallowing Solids (TOMASS) is a reliable and well-validated tool to assess the effectiveness of solid bolus ingestion. Previous studies have established normative values for 4 to 80+ years across a range of commercially available crackers and countries. The current study aimed to establish normative data for the TOMASS across age and gender groups for a commercially available biscuit (cracker) for the adult Indian population. A total of 300 typical individuals in the age range of 21 to 80years grouped by age and sex participated in the study. Participants were instructed to eat a commercially (locally) available biscuit 'as quickly and comfortably as possible,' and the task was video recorded. The recorded video samples were analyzed to obtain measures of the number of bites, number of masticatory cycles, number of swallows, and total time taken to complete the ingestion of biscuit. Cronbach's α values revealed a moderate to good (0.71 to 0.82) test-retest reliability; ICC values were suggestive of a high level (> 0.76) of interrater reliability for all the measures of TOMASS. The results of the one-way ANOVA revealed a significant main effect of age (F = 3.12, p < 0.01) and gender (F = 4.37, p < 0.01), but not an interaction between the two. Normative data stratified by age and gender were also generated. The TOMASS assessment procedure was feasible, reliable, and valid. In the current study, we observed that males took fewer bites, took less time, chewed less, and swallowed fewer times than females. A definitive age effect was observed for the number of bites, masticatory cycles, and total time. The normative data generated by the current study can serve as clinical benchmarks to assess the ingestion of solid bouls in the adult Indian population.

Codeine induces increased resistance at the esophagogastric junction but has no effect on motility and bolus flow in the pharynx and upper esophageal sphincter in healthy volunteers: A randomized, double-blind, placebo-controlled, cross-over trial.

Chronic opioid use can induce esophageal dysfunction with symptoms resembling achalasia and a manometric pattern of esophagogastric junction-outflow obstruction (EGJ-OO). However, the effect of opioids in acute setting on pharyngeal function and esophageal body contractility has not been investigated. After positioning the high-resolution impedance manometry (HRiM) catheter, codeine (60mg) or placebo (glucose syrup) was infused intragastrically. Forty-five minutes post-infusion, participants received liquid, semi-solid, and solid boluses to assess esophageal and pharyngeal function. HRiM analysis was performed adhering to the Chicago classification v3.0. (CC v3.0). Pressure flow analysis (PFA) for the esophageal body and the pharynx was performed using the SwallowGateway™ online platform. Nineteen healthy volunteers (HV) [5 male; age 38.3] were included. After codeine administration, higher integrated relaxation pressure 4s values resulted in significantly reduced deglutitive EGJ relaxation and distal latency was significantly shorter. Distal contractility was similar in both conditions. Bolus flow resistance at the EGJ and distention pressures increased significantly after codeine infusion. Based on CC v3.0, acute infusion of codeine induced EGJ-OO in six HV (p=0.0003 vs. placebo). Codeine administration induced no significant alterations in any of the pharyngeal PFA metrics. In HV, acute administration of codeine increased bolus resistance at the EGJ secondary to induced incomplete EGJ relaxation leading to major motility disorders in a subset of subjects including EGJ-OO. However, an acute single dose of codeine did not affect motility or bolus flow in pharynx and UES. ClinicalTrials.gov number, NCT03784105.