Swallowing Research Articles

Effect of visiting time on clinical outcomes in patients with esophageal foreign bodies

Objective To investigate the effect of visiting time on the incidence of complications, hospital expenses and stays, and to provide theoretical basis for the timely treatment of patients with esophageal foreign bodies. Methods Data of 130 patients with diagnosis of esophageal foreign bodies in the Drum Tower Hospital from June 2010 to June 2017 were retrospectively studied. The patients were divided into two groups(Group A, visiting time≤24 hours; Group B, visiting time>24 hours)according to duration from ingestion to effective treatment. Clinical features including gender, age, locations and types of foreign bodies, complications, therapeutic methods, hospitalization stays and costs were analyzed. Results The most common foreign bodies that were swallowed were fish bones in both groups [40.0% (20/50), 50.0% (40/80)], followed by pig and chicken bones, dentures and jujube pips. Foreign bodies commonly blocked the upper and middle esophageal tract [98.0% (49/50), 96.3% (77/80)], but rarely the lower esophageal tract. Compared with group A, the incidence of complications [61.3% (49/80) VS 36.0% (18/50)], hospitalization expenses (1.28±1.14 thousand yuan VS 0.77±0.92 thousand yuan), and stays (9.06±10.08 d VS 5.22±3.32 d) of group B were significantly higher (all P<0.05). Conclusion Treatment within 24 hours results in fewer complications, less costs and shorter postoperative hospitalization stays for patients with esophaged foreign bodies. Key words: Esophagus; Foreign bodies; Endoscopes; Intraoperative complications; Prognosis

PHAryngeal electrical STimulation for early decannulation in TRACheotomised stroke patients with neurogenic dysphagia (PHAST-TRAC): a prospective randomised single-blinded trial

Background Dysphagia after stroke is common, especially in severely affected, tracheotomised patients. In a pilot trial, pharyngeal electrical stimulation (PES) improved swallowing function in this group of patients. The PHAryngeal electrical STimulation for early decannulation in TRACheotomised stroke patients with neurogenic dysphagia trial (PHAST-TRAC) was designed to replicate and extend this single-centre experience. Methods Patients with recent stroke who required tracheotomy were randomised to receive three days of PES or sham. All patients had the stimulation catheter inserted; sham treatment was applied by connecting the base station to a simulator box instead of the catheter. Randomisation was done via a computerised interactive system with randomisation (stratified by site) in blocks of 4 patients per site. Patients and investigators applying PES were not masked. The primary-endpoint was assessed blinded to treatment assignment by a separate investigator at each site. The primary outcome was readiness for decannulation 24-72 hours post-treatment, assessed using fiberoptic endoscopic evaluation of swallowing and based on a standardised protocol including absence of massive saliva, presence of spontaneous swallows and laryngeal sensation. We planned a sequential statistical analysis of superiority for the primary endpoint. Interim analyses were to be performed after primary outcome data were available for 50 patients (futility), 70 patients, and every additional 10 patients thereafter up to 140. Analysis was by intention-to-treat. The trial was registered as ISRCTN18137204. Findings From 29th May 2015 to 5th July 2017, 69 patients (PES 35, sham 34) from 9 sites (7 acute care hospitals, 2 rehabilitation facilities) in Germany, Austria and Italy were included: PES group mean age 61.7 (SD 13.0) years, 8 (23%) patients with haemorrhagic stroke, median time onset to randomisation 28.0 [IQR 20, 49] days; sham group age 66.8 (10.3) years, 12 (35%) patients with haemorrhagic stroke, onset to randomisation 28.0 [18, 40] days). The Independent Data & Safety Monitoring Board recommended to stop the trial early for efficacy after 70 patients had been recruited and primary endpoint data of 69 patients were available. This decision was approved by the steering committee. PES was associated with more patients being ready for decannulation as compared to sham: 17 (49%) vs. 3 (9%), odds ratio (OR) 7.00 (2.41-19.88), p=0.00082). No patient required recannulation within 48 hours or during their documented follow-up period up to 30 days or hospital discharge. Adverse events (AEs) were reported in 24 patients (69%) of the PES group and 24 patients (71%) of the sham group. The number of patients with at least one serious adverse event (SAE) did not differ between the groups: 10 (29%) vs. 8 (23%), OR 1.3 (0.44-3.83), p=0.7851). 7 patients (20%) from the PES group and 3 patients (9%) from the sham group died during the study period. None of the patient deaths or SAEs reported were judged to be PES-treatment- or investigational device-related. Interpretation PES increased the proportion of patients with stroke and subsequent tracheotomy who were ready for decannulation in this study population, many of whom received PES within a month of their stroke. Future trials should confirm whether PES is beneficial in tracheostomised patients who receive stimulation similarly early after stroke and explore its effects in other cohorts.

A Tough DISH to Swallow

A 70-year-old male was referred to the Gastroenterology clinic for evaluation of chronic dysphagia of solid food at the cervical level. Upper endoscopy showed a hypopharygeal prominence with overlying endoscopically normal, smooth mucosa (Figure A). The prominence was associated with partial obstruction and some resistance to traversing the hypopharynx with the adult gastroscope. Intubation of the esophagus was eventually successful and the exam was otherwise normal. Biopsies of the distal and proximal esophagus were normal. CT of the neck showed florid flowing ossification at the anterior aspect of C2 to C7 vertebrae (Figure B), suggestive of diffuse idiopathic skeletal hyperostosis (DISH). This caused indentation of the posterior pharyngeal wall and was deemed by the Radiologist as possible to contribute to dysphagia.Retrospective review of a cervical X-ray performed 5 years previously showed accumulation of amorphous bone formation at the anterior aspect of the cervical spine and over-bridging the disc spaces, consistent with DISH (Figure C). The patient was referred to the orthopedic spine surgical service. The patient opted for conservative management with diet modification. DISH is a non-inflammatory disease, with the principal manifestation being calcification and ossification of spinal ligaments and of peripheral entheses. The etiology is uncertain although the prevalence is particularly high in certain ethnic groups. It is more common in men than women and less common in blacks and Caucasians. The prevalence increases with age. While pain and stiffness of the thoracic spine are the most common symptoms, dysphagia sometimes results from impingement of cervical osteophytes upon the pharynx. The radiographic findings are distinctive, showing flowing linear calification along the anterolateral aspects of the vertebral bodies. The bony changes are better visualized on CT than plain films. Treatment of DISH is usually symptomatic. Surgery is occasionally required for dysphagia due to cervical spurs. Surgery is sometimes also required for cervical myelopathy and for other rare neurologic manifestations. Gastroenterologists may benefit from increased awareness of this non-gastrointestinal cause of dysphagia that may occasionally be apparent on upper endoscopic evaluation.1790_A Figure 1. Upper endoscopy shows a hypopharygeal prominence with overlying endoscopically normal, smooth mucosa.1790_B Figure 2. CT shows ossification at the anterior aspect of the cervical vertebrae.1790_C Figure 3. Plain cervical film shows accumulation of amorphous bone formation at the anterior aspect of the cervical spine.

An endogeous defensive concept, renewed cytoprotection/adaptive cytoprotection: intra(per)-oral/intragastric strong alcohol in rat. Involvement of pentadecapeptide BPC 157 and nitric oxide system.

With intra(per)-oral strong alcohol application at the tongue, swallowed, we renewed Robert's stomach cytoprotection/adaptive cytoprotection concept. We assessed strong (96%) alcohol-induced severe or minute lesions in stomach, tongue-esophagus-stomach-duodenum lesions, and sphincter pressure (lower esophageal and pyloric) upon administration intragastrically (at 1 h) or intra(per)-orally at the tongue, and swallowed (at 1, 5, 15, 30 min; and 1, 2, 24 h). The assessment also included combined administrations (intra(per)-oral at the tongue, swallowed and intragastric (at 1 h)). Immediate post-alcohol intraperitoneal medication (mg/kg) was the stable gastric pentadecapeptide BPC 157 (0.01, 0.00001; a Robert's cytoprotection mediator; with a therapeutic effect), NOS-blocker L-NAME (5), and NOS-substrate L-arginine (100 mg), (NO-system involvement). After intragastric strong alcohol administration, severe stomach ulcerations appeared along with widespread tongue, esophagus, duodenum redness, and minimal sphincter pressures. By contrast, a particular syndrome (immediate overlapping of cytoprotection/adaptive cytoprotection) (minute gastric lesion or largely attenuated hemorrhagic ulceration, tongue affected, minute esophageal and duodenal lesions, but with intact mucosa; sphincters pressures lowered) appeared after intra(per)-oral administration (1 min-24 h) as well as after combined administrations (intra(per)-oral + intragastric). BPC 157 apparently cured all alcohol-lesions, amplified the spontaneously initiated strong mucosal beneficial effect, rescued sphincter pressures; NO-agents (L-arginine (slight mucosal amelioration) and L-NAME (aggravation)) showed NO-system involvement, but no comparable effects on dropped sphincters pressures. In conclusion, minute gastric lesions (with oral application of strong alcohol at the tongue and swallowed, without, or with intragastric application of strong alcohol) renew and revise Robert's stomach cytoprotection/adaptive cytoprotection concept. The tongue becomes a new initial target, resulting in spontaneous reversal of strong alcohol-stomach lesions. BPC 157 therapy functions also within the redirected complexity of Robert's stomach cytoprotection/adaptive cytoprotection concept.

It's hard to swallow—which test is best?

It's hard to swallow—which test is best?

Metronidazole-induced encephalopathy in a patient with pyogenic spondylitis: a case report

BackgroundMetronidazole is an antimicrobial agent commonly used in the treatment of several protozoal and anaerobic infections. Neurotoxicity associated with metronidazole has been rarely reported, and the incidence of metronidazole-induced encephalopathy is unknown. Therefore, the accurate diagnosis of metronidazole-induced encephalopathy is often difficult because of the rarity of the disease.Case presentationAn 86-year-old woman suffered from pyogenic spondylitis of the lumbar spine. Parvimonas micra, a gram-positive anaerobic bacterial species and a resident of the flora of the oral cavity, was identified in the biopsy specimens. Oral administration of metronidazole (1500 mg/day) was initiated. Forty-four days after initiating metronidazole (total intake of 66 g), she complained of tingling sensations in the upper limbs. After 4 days, she complained of additional symptoms including sensory disturbance of the tongue, dysarthria, and deglutition disorder. Characteristic brain magnetic resonance imaging findings on T2-weighted fluid-attenuated inversion recovery and diffusion-weighted imaging led to the diagnosis of metronidazole-induced encephalopathy. Metronidazole was discontinued, and her neurological symptoms improved 10 days after discontinuation. At 14 days after discontinuation of oral metronidazole, abnormal findings on diffusion-weighted imaging almost disappeared.ConclusionsWith the possibility of needing to prescribe metronidazole in the orthopedic field for the treatment of various infections, orthopedic surgeons are likely to encounter cases of metronidazole-induced encephalopathy. Thus, they should be able to recognize the condition and its potential complications. With increased awareness, early diagnosis with magnetic resonance imaging and discontinuation of metronidazole may become feasible when such patients are referred. Our report presents a detailed account of such a case, which may help in the early diagnosis and treatment of patients with metronidazole-induced encephalopathy. Furthermore, we recommend that patients treated with metronidazole should undergo careful and constant surveillance after starting antibiotic therapy.

Research progress of swallowing function assessment among patients after partial laryngectomy

Swallowing function rehabilitation has great significance in improving life quality of patients partial laryngectomy. This paper summarized the main causes, methods of subjective and objective assessment as well as its advantages and disadvantages of patients with dysphagia after partial laryngectomy to set up measurement standard so as to provide a basis for rehabilitation nursing of impaired swallowing. Key words: Review; Deglutition; Partial laryngectomy; Assessment

Current status and related factors of dysphagia among community elderly

Objective To understand the current status of dysphagia among community elderly of Dongcheng District of Beijing Municipality and to explore its related factors. Methods From May 2016 to February 2017, the International Resident Assessment Instrument Home Care (InterRAI HC) was used for data of home care needs assessment of community elderly (≥60 years old) to carry out the focused analysis of dysphagia. The evaluation result of the term nutrition intake patterns of InterRAI HC was taken as the standard to determine whether to be with or without dysphagia. The chi-square test and Logistic regression were used to analyze the influencing factors of dysphagia among community elderly. Results Among 229 community elderly, there were 49 cases with dysphagia with 21.4% for the incidence. The related factors of dysphagia among community elderly included the impaired balanced capacity (OR=4.913, 95%CI: 1.772-13.618, P=0.002) , yield of drinking water<1 000 ml/d (OR=2.600, 95%CI: 1.253-5.396, P=0.010) , ages (OR=1.048, 95%CI: 1.004-1.095, P=0.024) , body mass index<18.5 kg/m2 (OR=4.576, 95%CI: 1.220-17.172, P=0.024) and history of Parkinson's disease (OR=2.505, 95%CI: 1.015-6.180, P=0.046) . Conclusions The current status of dysphagia in community elderly of Dongcheng District of Beijing Municipality is worth attaching importance to. The dysphagia of the aged should be prevented, discovered and treated early by active measures such as paying close attention to related factors and effective screening. Key words: Aged; Deglutition disorders; Community; Related factors

Effect of deglutition aids on the inhibitory effect of orally disintegrating tablets of voglibose on the postprandial elevation of blood glucose levels: a case investigating the interaction between xanthan gum and voglibose.

In this study, we first performed a disintegration test of the voglibose orally disintegrating (V-OD) tablet immersed in jelly-wafer (JW, V-ODims/jw) for 10min and compared it with the disintegration time of V-OD that was not immersed in JW. We then orally administered the V-ODims/jw tablet to 7 healthy adults and compared the shift in blood glucose levels (BGLs), after loading with a sucrose solution (Suc-sol, 100g/150mL), with that after administration of the non-immersed V-OD tablet. The disintegration time of V-ODims/jw tablet was shorter than that of V-OD. When administered to healthy adults, the BGL after loading with Suc-sol was higher with V-ODims/jw tablet administration than with V-OD tablet. We predict that the expression of the efficacy of voglibose is reduced as a result of the interaction between voglibose and the polysaccharide, xanthan gum (XG), since it is a common additive in JW. This study shows that deglutition aids with additives that do not affect pharmacokinetics must be carefully selected for administering along with pharmaceuticals, because of a suggested possibility that the interaction between these pharmaceuticals and the additives in the deglutition aids weaken the drug efficacy. A more careful selection of deglutition aids from the wide selection of medication is especially important when administered to patients who use these deglutition aids often, such as elderly individuals or individuals with a deglutition disorder.

The Relationships among Objective Measures of Tongue Strength and Risk of Aspiration

Objective: The objective measures of tongue strength can predict the risk of aspiration. Isometric tongue pressure and endurance have been reported to be lower in patients who have premature spillage, penetration and/or aspiration on endoscopic evaluation. We aimed to study the relationships between the objective measures of tongue strength and risk of aspiration in our population. Methods: Seventy-five participants were enrolled to the study. The mean age of the participants was 58.3 ±13.6 years old. They were divided into three groups (25 participants in each group). The first group was normal participants who have had no history of swallowing problem with normal flexible endoscopic evaluation of swallowing (FEES). The second group was symptomatic patients who have had history of dysphagia and/or aspiration but normal FEES. The third group was patients who have had history of dysphagia and/or aspiration with evidence of premature spillage or laryngeal penetration or aspiration by FEES. All participants underwent objective measurements of the tongue strength including maximal isometric pressure (MIP) and endurance by Iowa Oral Performance Instrument (IOPI). The quantitative data between groups were compared using ANOVA and chi-square test was used for qualitative data. The optimal cut-off points were determined by Receiver Operating Characteristic (ROC) curve. Results: MIP and endurance were significantly lower in patients who have had premature spillage, penetration and/or aspiration on endoscopic evaluation. The appropriate cut-off points for high risk group are 35 and 25 kPa for the anterior and posterior tongue pressure respectively. Conclusion: The tongue pressure can be used to screen patients who are at risk of aspiration, which will lead to early investigation and intervention for the management of these patients.

Factors Influencing SWAL-QOL (Swallowing-Quality of Life) of Elders

Purpose According to a survey of older people in 2014, 54.6% of survey participants reported feeling uncomfortable in their daily life because of swallowing disorders. The purpose of this study was to identify factors that influence swallowing quality of life in community dwelling elders. Methods A cross-sectional descriptive study was conducted with a sample of 150 community dwelling older people. Data were collected using self-administered questionnaires consisting of the MMSE-K(Mini-Mental State Examination-Korean), GDSSF-K (Geriatric Depression Scale Short Form Korea Version), Life Stress, and SWAL-QOL (Swallowing-Quality of Life). For data analysis, descriptive statistics, t-test, one-way ANOVA, Pearson correlation coefficients, and multiple regression were performed using SPSS/WIN 21.0 for Windows. Results There was a significant correlation between swallowing quality of life and mental state (r=.27, p=.001), depression (r=-.47, p<.001) and life stress (r=-.60, p<.001). The factors influencing swallowing quality of life were having experienced aspiration (β=.29, p<.001), and life stress (β=-.38, p<.001). These variables explained 43.0% of swallowing quality of life. Conclusion The findings indicate that the experiencing aspiration and life stress are variables that influence swallowing quality of life. Based on these results, nurses should educate older people about chronic disease management and eating habits to prevent aspiration. 주요어: 인지기능, 우울, 생활 ìŠ¤íŠ¸ë ˆìŠ¤, 삼킴 곤란, 삶의 질 Key Words: Cognition, Depression, Psychological stress, Deglutition disorders, Quality of life

Management and Treatment of Patients with Dysphagia

Dysphagia occurs when food or liquid is prevented from moving from the mouth to the stomach. The normal aging process and age-related disease contribute to the prevalence of dysphagia as do acquired acute and chronic progressive diseases. This paper will define compensatory techniques and discuss research that has led to evidence-based rehabilitative approaches in the treatment of deglutitive disorders. The multidisciplinary science of deglutology has advanced in evaluation including the use of high-resolution manometry and computed tomography to compliment radiographic techniques in evaluation and to better understand the changes that occur with management and treatment. We now understand the physiologic change that can occur with swallowing exercise and how both compensatory and rehabilitative techniques are not a one size fits all scenario. Evidence-based research allows clinicians to confidently provide better care and outcomes for patients with dysphagia.

Risk factors of dysphagia in patients with cardiac surgery

Objective To explore the risk factors of dysphagia in patients with cardiac surgery, so as to provide a basis for clinical nursing. Methods From January 2014 to June 2016, we collected data from 158 patients with cardiac surgery in Heping Hospital Affiliated of Changzhi Medical College. All of the patients were divided into the group of dysphagia (n=60) and the group of normal deglutition (n=98) . We compared the sexes, ages, body mass index (BMI) , smoking history, time of tracheal intubation, types of surgery, family history of heart disease, previous history of cardiac surgery, New York Heart Association (NYHA) classification, European System for Cardiac Operative Risk Evaluation (EuroSCORE) , bed and oxygen uptake after surgery, intra-operative transesophageal echocardiography, natriuretic peptide application and mechanical assistance after surgery between two groups. Multiple Logistic was used to analyze the risk factors of dysphagia after surgery. Results There were no statistical differences in the BMI, smoking history, family history of heart disease, bed and oxygen uptake after surgery, intra-operative transesophageal echocardiography, natriuretic peptide application and mechanical assistance after surgery as well as of previous history of cardiac surgery of patients between the group of dysphagia and the group of normal deglutition (P>0.05) ; however, there were significant differences among patients with different ages, gender, NYHA classification, EuroSCORE, time of tracheal intubation (P<0.05) . Multiple logistic analysis showed that the risk factors of dysphagia after cardiac surgery included the ages equal or greater than 70 years old, Ⅲ-Ⅳfor the NYHA classification, 3-6 for the score of EuroSCORE, time of tracheal intubation equal or greater than 12 hours (P<0.05) . Conclusions Health care providers should pay attention to the influencing factors of dysphagia after cardiac surgery involving ages, NYHA classification, score of EuroSCORE, time of tracheal intubation. Key words: Deglutition disorders; Cardiac surgery; Risk factors

Application of safety swallowing management in senile alzheimer disease patients with feeding difficulty

Objective To explore the effects of safety swallowing management based on swallowing functional grading in senile Alzheimer disease patients with feeding difficulty. Methods From November 2016 to April 2017, a total of 72 Alzheimer disease patients in Wuxi Second People's Hospital of Jiangsu Province were selected. All of the patients were randomly divided into observation group and control group according to the singular, dual numbers of sequences being admitted to hospital, 36 cases in each group. Patients of control group received conventional diet nursing. Patients of observation group were treated with appropriate safety swallowing management on the basis of assessment level. The effect of feeding, nutrition and feeding safety of patients between two groups were compared. Results Three months after intervention, the food-intake each meal of patients was (251.20±24.37) g in observation group, water-intake each meal was (141.50±12.27) ml higher than those in control group with significant differences (t=6.324, 8.817; P<0.01) . The serum prealbumin of observation group and control group was (202.44±12.56) mg/L and (186.94±14.80) mg/L respectively with a significant difference (t=4.611, P<0.01) . The incidence of unsafe feeding events of observation group and control group was 8.33% and 30.55% respectively with a significant difference (χ2=5.675, P<0.05) . Conclusions Application of safety swallowing management based on swallowing functional grading in senile Alzheimer disease patients is favorable for improving food-intake and supplementing nutrition. Key words: Aged; Alzheimer disease; Deglutition disorders; Safety swallowing management

The Amphibious Mudskipper: A Unique Model Bridging the Gap of Central Actions of Osmoregulatory Hormones Between Terrestrial and Aquatic Vertebrates.

Body fluid regulation, or osmoregulation, continues to be a major topic in comparative physiology, and teleost fishes have been the subject of intensive research. Great progress has been made in understanding the osmoregulatory mechanisms including drinking behavior in teleosts and mammals. Mudskipper gobies can bridge the gap from aquatic to terrestrial habitats by their amphibious behavior, but the studies are yet emerging. In this review, we introduce this unique teleost as a model to study osmoregulatory behaviors, particularly amphibious behaviors regulated by the central action of hormones. Regarding drinking behavior of mammals, a thirst sensation is aroused by angiotensin II (Ang II) through direct actions on the forebrain circumventricular structures, which predominantly motivates them to search for water and take it into the mouth for drinking. By contrast, aquatic teleosts can drink water that is constantly present in their mouth only by reflex swallowing, and Ang II induces swallowing by acting on the hindbrain circumventricular organ without inducing thirst. In mudskippers, however, through the loss of buccal water by swallowing, which appears to induce buccal drying on land, Ang II motivates these fishes to move to water for drinking. Thus, mudskippers revealed a unique thirst regulation by sensory detection in the buccal cavity. In addition, the neurohypophysial hormones, isotocin (IT) and vasotocin (VT), promote migration to water via IT receptors in mudskippers. VT is also dipsogenic and the neurons in the forebrain may mediate their thirst. VT regulates social behaviors as well as osmoregulation. The VT-induced migration appears to be a submissive response of subordinate mudskippers to escape from competitive and dehydrating land. Together with implications of VT in aggression, mudskippers may bridge the multiple functions of neurohypophysial hormones. Interestingly, cortisol, an important hormone for seawater adaptation and stress response in teleosts, also stimulates the migration toward water, mediated possibly via the mineralocorticoid receptor. The corticosteroid system that is responsive to external stressors can accelerate emergence of migration to alternative habitats. In this review, we suggest this unique teleost as an important model to deepen insights into the behavioral roles of these hormones in relation to osmoregulation.

Early gastrostomy associated with speech therapy in patients with amyotrophic lateral sclerosis

Amyotrophic Lateral Sclerosis (ALS) is a degenerative disease that occurs with the deterioration of motor neurons. The beginning of clinical impairment may be bulbar with the average life time, after the first symptoms, between 2 to 5 years, presenting serious swallowing, speech and breathing disorders. Deglutition disorders can lead to malnutrition, dehydration, aspiration, displeasure, and more serious complications such as aspiration pneumonia and death. With the evolution of the disease, the patient needs procedures that generate doubts in the professionals and family, as the correct moment of indication of the use of alternative long-term feeding routes called gastrostomies (GTT). The objective of this article is to analyze the impact of dysphagias and the most favorable moment for the placement of gastrostomies. Early GTT placement may help prevent the patient from clinically debilitating more quickly, respond better to multidisciplinary team therapeutics, and feel more comfortable.Key-words: dysphagia, enteral nutrition, gastrostomy, deglutition disorders, motor neuron disease, amyotrophic lateral sclerosis.

PB3. Pharyngeal Electrical Stimulation in neurointensive care patients suffering from severe post-stroke dysphagia – Post stimulation increase of salivary substance P level may indicate treatment success

Introduction Dysphagia is one of the most important and prognostically relevant complications of acute stroke. Pharyngeal Electrical Stimulation (PES) is a treatment device that enhances cortical reorganization for the restoration of swallowing function after cerebral injury. Furthermore, it was shown that PES leads to a temporary increase of Substance P (SP) level in saliva but not serum in healthy adults. The neuropeptide SP likely acts as a neurotransmitter in the pharyngeal mucosa and enhances the swallow and cough reflex. Post-stroke dysphagia may be related to reduced SP-levels. Here, we investigated the association of PES treatment in neurointensive care patients suffering from severe post-stroke dysphagia and salivary SP level, as well as a possible link between SP level and decannulation success after PES. Material and methods In this prospective single-center study, 23 tracheotomized stroke patients from our neurological intensive care unit were included. Due to severe and persisting dysphagia and according to the protocol for standardized endoscopic evaluation of tracheotomy decannulation in critically ill neurologic patients, participants could not be decannulated. Comorbidities that are known to likely cause dysphagia were not an exclusion criterion in contrast to other studies investigating on PES. 10 min of PES were applied on three consecutive days (= one treatment cycle). Three patients received multiple stimulation cycles. Saliva samples were collected prior to and directly after each treatment. To determine SP concentration, Enzyme-linked immunosorbent assay (ELISA) was performed. Results After the first treatment cycle 60% (n = 14) of all participants, respectively 73% (n = 7) of patients without comorbidities that likely cause dysphagia were decannulated. There was a close relation between increase of SP directly after the treatment and stimulation success (= decannulation). In 89% (n = 9) of patients without clinical improvement of dysphagia, SP levels remained stable or even decreased; 79% (n = 11) of successfully treated patients showed a post-stimulation increase of SP. Applying logistic regression analysis, increased SP level showed to be independently predictive of improved swallowing function after PES (p Conclusion The increase of salivary SP level following PES may indicate treatment success and SP therefore possibly acts as a biomarker of an improved swallowing function following PES.

Etiology and prognosis of children and adolescents with situational syncope

Objective To retrospectively analyze the etiology and prognosis of the children and adolescents with situational syncope in a single center. Methods There were 4 274 cases of children and adolescents [aged from 2 to 18 years old, the average age being (10.82 ± 3.13) years old], male 2 208 cases, female 2 066 cases with orthostatic intolerance syndromes, such as unexplained syncope or symptoms of presyncope, etc, who were treated at Children′s Syncope Outpatient Department or Inpatient Department in the Second Xiangya Hospital, Central South University from January 2000 to November 2017.All subjects underwent detailed history investigation, careful physical examinations, routine 12-lead electrocardiogram, Holter electrocardiogram(ECG), chest X-ray, echocardiography, electroencephalogram(EEG) and head computerized tomography(CT) or magnetic resonance imaging(MRI), blood biochemical examination (including fasting glucose, myocardial enzymes) and organic diseases in the heart, brain, blood vessels were excluded, but the cause of syncope was still not clear.The head-up tilt table test (HUTT) was performed after the patients or/and the families wrote the informed consent agreement. Results A total of 177 (4.14%) patients with situational syncope were diagnosed among 4 274 cases.Etiology included the abdominal musecle exercise (35.59%, 63/177 cases), urination (24.29%, 43/177 cases), bathing (9.60%, 17/177 cases), defecation (7.34%, 13/177 cases), singing (5.08%, 9/177 cases), rides (4.52%, 8/177 cases), blood-injection-injury phobia (3.95%, 7/177 cases), swallowing (3.39%, 6/177 cases), and hair-grooming (2.82%, 5/177 cases), syncope during acupuncture treatment (2.26%, 4/177 cases), and cough (1.13%, 2/177 cases). The common positions were upright position (84.18%, 149/177 cases), squatting to standing position (8.47%, 15/177 cases), sitting position (5.08%, 9/177 cases), and squatting position (2.26%, 4/177 cases). HUTT positive rate was 69.49% (123/177 cases), common type of hemodynamic were the vasodepressive type of vasovagal syncope (45.20%, 80/177 cases), mixed type of vasovagal syncope (19.77%, 35/177 cases), postural orthostatic tachycardia syndrome (3.39%, 6/177 cases) and the cardiac suppressive type of vasovagal syncope (1.13%, 2/177 cases). In 35 cases of situational syncope, the number of children and adolescents with syncope was significantly reduced by health education and upstanding training.By the first follow-up review, the cases were reduced from (2.69 ±1.81) times to (0.59 ± 0.96) times after healthy education of 2-16 weeks [(4.97±3.16) weeks]. By the second follow-up review, 3 out of 8 cases did not faint, 3 cases fainted 1 time, 1 case fainted 2 times, and 1 case fainted 4 times.The outcomes of the first reexamination of HUTT in 16 cases were negative, and other 3 cases were negative by twice visit. Conclusions The etiology of children and adolescents are flag-raising(abdominal muscle exercise), urination, bathing, defecation, singing, riding, blood-injection-injury phobia, swallowing, hair-grooming, syncope during acupuncture treatment and coughing.Healthy education is good for situational syncope. Key words: Situational syncope; Head-up tilt table test; Etiology; Healthy education; Prognosis; Child; Adolescent

EVALUATION OF ESOPHAGEAL ACHALASIA: FROM SYMPTOMS TO THE CHICAGO CLASSIFICATION.

ABSTRACT Introduction: The diagnosis of achalasia may be suggested by clinical features but a complete work-up is required not only to confirm the diagnosis but also to grade the disease by severity or clinical subtype. Objective: To review the current evaluation of esophageal achalasia and its correct comprehension. Method: The literature review was based on papers published on Medline/Pubmed, SciELO and Lilacs, crossing the following headings: “esophageal achalasia”; “deglutition disorders”; “diagnostic techniques”, “digestive system”; “endoscopy, digestive system”; “manometry”. Results: The diagnosis of achalasia is suggested by clinical features but is not sufficient to distinguish this from other esophageal disease. It must be confirmed by further diagnostic tests, such as esophagogastroduodenoscopy, barium swallow and manometry. Recent advances in diagnostic methods, including high resolution manometry might even help predicting outcome or selected more appropriate procedures to treat the disease. Conclusion: A detailed and systematic study of achalasia patients allows not only a correct diagnosis but also contributes to therapeutic decision making and prognosis.

Conservative orthodontic management of an adult cleft lip and palate patient

Clefts of the upper lip and palate are the most common congenital deformities affecting the orofacial complex in humans and are associated with many problems, including cosmetic deformities, dental abnormalities, and difficulties in speech and swallowing. As the public awareness of availability of treatment for this anomaly is minimal, the age of the patients reaching for primary treatment varies from few days to late forties. Although the aim and aspiration is to provide holistic multidisciplinary care, the priority is getting treatment for all cleft patients. This paper reports successful orthodontic management of an adult female with unilateral cleft lip and palate (CL/P) who denied surgery for her alveolar defect, so conventional orthodontic treatment was carried out with the initial expansion of maxillary arch followed by alignment of teeth to achieve stable occlusion. The final defect was covered with an obturator which also replaced the missing tooth.