Impact and Management of Dysphagia in Inflammatory Myopathies

Caregivers' Knowledge and Experiences in Recognizing and Managing Dysphagia in Patients with Myopathy

Background: Dysphagia is a common complication in myopathy, significantly impacting patients' quality of life (QoL) and overall health. Caregivers play a critical role in identifying and addressing swallowing difficulties in this population. The main purpose of this study was to assess the knowledge and experiences of professional caregivers of patients with myopathy regarding the recognition and management of dysphagia in Cyprus. Methods: The study was designed as an anonymous, cross-sectional descriptive survey and involved 10 professional caregivers of patients with myopathy in Cyprus. Results: The most common dysphagia symptoms reported in myopathy patients were coughing, chewing difficulties, choking on fluids, and challenges with swallowing boluses. Only one caregiver reported difficulty managing swallowing issues, particularly in cases of reluctance to eat. Approximately 60% had received relevant training, primarily through workplace programs. Overall, caregivers did not perceive dysphagia as a significant burden. Conclusions: Dysphagia is a prevalent phenomenon in myopathy. The study reveals that caregivers of myopathy patients, regardless of their professional backgrounds, face hidden challenges in managing complex neurogenic dysphagia. They often misjudge the severity of the condition and overestimate their own competencies. Providing caregivers of patients with myopathy with targeted education would help them effectively manage swallowing difficulties associated with the condition. Encouragingly, our study also suggests that focused dysphagia education could reduce caregiver stress and enhance their overall well-being. Future efforts should concentrate on ensuring access to well-trained professionals, establishing specialized clinics, and promoting education to enhance MND-related dysphagia management and patient care.

Idiopathic inflammatory myopathies related lung disease in adults

Interstitial lung disease (ILD) is common in idiopathic inflammatory myopathies in adults, especially in patients with antisynthetase syndrome and anti-MDA5 antibody-associated dermatomyositis. Pulmonary manifestations can range from subclinical ILD to rapidly progressive respiratory failure. Coexistent myositis, characteristic skin lesions, arthritis, and Raynaud's phenomenon are common. However, 16-65% of patients present with isolated lung disease. Detection of myositis-specific and myositis-associated antibodies can aid in diagnosis and disease characterisation. Chest imaging and pathology most commonly show non-specific interstitial pneumonia and organising pneumonia patterns. Immunosuppression is the mainstay of management with aggressive combination treatment for rapidly progressive disease and incremental escalation as needed for chronic ILD. The addition of antifibrotic agents is an option in progressive fibrotic disease, and lung transplantation can be considered in severe, end-stage disease. Most patients respond to treatment, but short-term mortality remains high for patients with rapidly progressive disease associated with anti-MDA5 antibody ILD.

Cine-MRI of Deglutition: A Systematic Review

Videofluoroscopy, recognized as the gold standard for dysphagia exploration, has inherent limitations, including poor soft tissue discrimination, radiation exposure, and aspiration risk. In response to these challenges, cine-MRI of swallowing has evolved over the past three decades, yielding diverse methodologies and results across various studies.This systematic review, conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, meticulously outlines cine-MRI protocols, applications, advantages, and limitations. Our qualitative analysis encompasses 36 studies involving 715 subjects from 2001 to 2023. Cine-MRI, a promising alternative, provides safe application for dysphagic patients, offering insights into the intricacies of deglutition mechanisms and eliminating the necessity for oral contrast material. Notably, this approach is adaptable to both 1.5 and 3T MRI scanners with specific image acceleration protocols.Despite these merits, a crucial gap remains, as no non-inferiority prospective study has yet been conducted to compare cine-MRI with the gold standard. Additionally, the lack of uniform swallowing assessment criteria and the uncertain impact of the supine position underscore the need for further investigation. In conclusion, while cine-MRI of deglutition emerges as a compelling tool for dysphagia exploration, its precise indications and role in the diagnostic approach to swallowing disorders necessitate comprehensive evaluation in future studies.

Update on the evaluation and management of dysphagia in sporadic inclusion body myositis

PURPOSE OF REVIEW

Dysphagia is a common symptom of sporadic inclusion body myositis (IBM), affecting disease trajectory and patient quality-of-life. Despite this, it is considerably understudied. The purpose of this review is to summarize current evidence related to the evaluation and management of dysphagia in IBM. We highlight a patient case involving a multidisciplinary management approach, and we encourage continued exploration of exercises for delaying progression and improving impairments in patients with IBM and dysphagia.

RECENT FINDINGS

Recent investigations confirm that dysphagia in IBM is a debilitating and complex symptom that warrants timely evaluation and management. Further, they highlight the lack of validation of standardized swallowing-related metrics specifically for IBM and the limited evidence supporting a consensus of management approaches. Small scale research and clinical anecdotal data support a multidisciplinary and multipronged patient-centered approach, including rehabilitative exercise protocols, for dysphagia management in IBM.

SUMMARY

A paucity exists in the literature to effectively guide clinical decision-making for patients with IBM and dysphagia. Given this, it is our belief that a careful multidisciplinary and multipronged patient-centered approach is critical for dysphagia management in IBM. Prospective, longitudinal research on the underlying mechanisms of swallowing dysfunction using advanced and validated swallowing-related outcome measures is urgently needed.

Clinical features of dermatomyositis patients with anti-TIF1 antibodies: A case based comprehensive review

BACKGROUND AND OBJECTIVES

Dermatomyositis is chronic autoimmune disease primarily affecting skin and muscles. Antibodies are key players of pathogenesis and are in strong correlation with distinct clinical phenotypes. We present a case and a comprehensive review of the literature on dermatomyositis patients with Anti TIF1 antibodies.

METHODS

PubMed and Web of Science databases were reviewed. 166 articles were identified; 95 of them were evaluated; 79 of them included to the study. 45 of the included articles were case reports 9 were case series and 25 were research articles. In total 1065 patients were identified but number of patients with available information for different clinical features varied.

RESULTS

69.6% of the patients with Anti TIF1-γ were female. Prevalence of malignancy was 42.6% among patients with Anti TIF1-γ. Muscle weakness (83%), Gottron sign (82.2%), heliotrope rash (73.7%), nailfold capillary changes (67.7%), dysphagia (38.4%), and joint involvement (31.1%) were the most common clinical features seen in patients with Anti TIF1-γ. Interstitial lung disease (ILD) was reported among 8.7% of patients with Anti TIF1-γ. Advanced age, male gender, dysphagia, and V-neck rash were significant risk factors for malignancy, whereas juvenile age, ILD, TIF1-β antibodies and joint involvement were associated with a decreased risk for malignancy. Advanced age, malignancy, dysphagia, and muscle involvement were associated with an increased risk for mortality.

CONCLUSIONS

Patients with advanced age, male gender, dysphagia, and V-neck rash require strict cancer screening. Patients with advanced age, malignancy, dysphagia, and muscle involvement have poor prognosis and should receive aggressive treatment.

Implementation of Esophageal Screening in an Outpatient Hospital-Based Setting: A Quality Improvement Project

PURPOSE

Despite evidence supporting interconnectivity of oropharyngeal and esophageal swallowing, evaluation and treatment are dichotomized. When the videofluoroscopic swallowing study (VFSS) only considers oropharyngeal swallowing, the full scope of swallowing impairment may be missed. A lower rate of esophageal screening in an outpatient hospital setting may result from lack of speech-language pathologist (SLP) training and understanding of screening feasibility. This project was an internal quality improvement project (QIP) at Mayo Clinic in Arizona to (a) educate and train SLPs on conducting the Robust Esophageal Screening Test (REST) and (b) determine the feasibility of REST protocol implementation in a multidisciplinary swallow clinic.

METHOD

Fishbone analysis was used to identify potential causes of the gap in quality. Six Sigma methodology was used to outline the QIP. SLPs were trained in the REST protocol. To ensure adequate training, reliability ratings were assessed with the Cohen's kappa statistic. Esophageal screening via REST was implemented as an adjunct to the standard protocol during VFSS over a 3-month period for referred patients with dysphagia. Clinical findings were recorded.

RESULTS

All clinical rater SLPs reached the threshold of κ = .8 to ensure adequate rater reliability. Among 136 outpatients who underwent esophageal screening via REST, 100 patients completed the full REST screening and 36 completed a partial REST screening. Of the 100 full screenings, 80 patients had a failed screening, which indicated a potential esophageal swallowing impairment. Findings were discussed by members of the multidisciplinary dysphagia care team.

CONCLUSIONS

The results of this QIP show that focusing on assessment of dysfunction and interplay across the swallowing continuum can substantially improve patient care by expediting and specifying next steps of the multidisciplinary dysphagia care team.

Autoimmune Dysphagia Related to Rheumatologic Disorders: A Focused Review on Diagnosis and Treatment

Autoimmune dysphagia is defined as dysphagia caused by autoimmune processes affecting various components of the swallowing process such as muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. These autoimmune causes can be classified into gastroenterological, dermatological, rheumatologic, and neurologic. Rheumatological disorders, such as scleroderma, Sjogren's syndrome, systemic lupus erythematosus, rheumatoid arthritis, sarcoidosis, Behcet's disease, anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, or granulomatosis with polyangiitis, have been associated with dysphagia. Autoimmune dysphagia in the context of rheumatological disorders is particularly significant because it can occur as a sole manifestation or as part of a symptom complex associated with the underlying disorder and often responds to immunosuppressive therapies. However, diagnosing autoimmune dysphagia can be challenging as it requires the exclusion of structural and primary motility disorders through procedures such as endoscopy and manometry. Early diagnosis is important to improve the quality of life and prevent significant mortality and morbidity. Management focuses on treating the underlying disease activity, and a multidisciplinary approach involving various medical specialties may be necessary to achieve success. This article aims to review the autoimmune rheumatological conditions that can lead to dysphagia and discuss the associated pathophysiological mechanisms. We also outline the clinical clues and laboratory testing methods that facilitate early diagnosis, with the goal of improving patient outcomes through timely intervention and appropriate management.

[Myositis: from diagnosis to treatment]

BACKGROUND

Inflammatory diseases of the skeletal muscle are important, often severe diseases with a considerable impact on the quality of life. In addition to muscle weakness there is often involvement of other organs, such as the heart, lungs and esophagus with symptoms such as dyspnea or dysphagia.

PURPOSE

A fast and effective treatment is only possible by an early and reliable diagnosis according to current national and international standards.

METHODS

The diagnostic repertoire includes autoantibody testing, imaging, muscle biopsy, detection of extramuscular manifestations, e.g., by high-resolution lung computed tomography (CT) and an individualized tumor search. An optimal treatment and the avoidance of irreversible damage, such as a loss of walking ability, are only possible through a good interdisciplinary cooperation including neurology or pediatrics, rheumatology, dermatology, neuropathology, pulmonology and cardiology.

RESULTS

In addition to standard immunosuppression with glucocorticosteroids, azathioprine or methotrexate, escalation treatment with rituximab is now well established. Interdisciplinary treatment according to national and international standards, such as guidelines on myositis, should be coordinated at qualified centers of excellence.

DISCUSSION

Helpful resources are the MYOSITIS NETZ ( www.myositis-netz.de ) and the International Myositis Society (iMyoS; www.imyos.org ).

Prevalence of co-morbidity and history of recent infection in patients with neuromuscular disease: A cross-sectional analysis of United Kingdom primary care data

BACKGROUND

People with neuromuscular disease (NMD) experience a broader range of chronic diseases and health symptoms compared to the general population. However, no comprehensive analysis has directly quantified this to our knowledge.

METHODS

We used a large UK primary care database (Clinical Practice Research Datalink) to compare the prevalence of chronic diseases and other health conditions, including recent infections between 23,876 patients with NMD ever recorded by 2019 compared to 95,295 age-sex-practice matched patients without NMD. Modified Poisson regression estimated Prevalence Ratios (PR) to summarise the presence of the disease/condition ever (or for infections in 2018) in NMD patients versus non-NMD patients.

RESULTS

Patients with NMD had significantly higher rates for 16 of the 18 conditions routinely recorded in the primary care Quality and Outcomes Framework (QOF). Approximately 1-in-10 adults with NMD had ≥4 conditions recorded (PR = 1.39, 95%CI 1.33-1.45). Disparities were more pronounced at younger ages (18-49). For other (non-QOF) health conditions, significantly higher recorded levels were observed for rarer events (pulmonary embolism PR = 1.96 95%CI 1.76-2.18, hip fractures PR = 1.65 95%CI 1.47-1.85) as well as for more common primary care conditions (constipation PR = 1.52 95%CI 1.46-1.57, incontinence PR = 1.52 95%CI 1.44-1.60). The greatest co-morbidity burden was in patients with a myotonic disorder. Approximately 1-in-6 (17.1%) NMD patients had an infection recorded in the preceding year, with the risk of being hospitalised with an infection nearly double (PR = 1.92, 95%CI 1.79-2.07) compared to non-NMD patients.

CONCLUSION

The burden of chronic co-morbidity among patients with NMD is extremely high compared to the general population, and they are also more likely to present in primary and secondary care for acute events such as infections.

Prevention of Adverse Outcomes and Treatment Side Effects in Patients with Neuromuscular Disorders

In this article, we review prevention of serious adverse clinical outcomes and treatment side effects in patients with neuromuscular disorders including myopathies and myasthenia gravis. While neither of these entities is preventable, their course can often be modified, and severe sequelae may be prevented, with the identification of risk factors and proactive attention toward treatment planning.

Improvement in Tongue Pressure Precedes Improvement in Dysphagia in Dermatomyositis

Dysphagia is known to occur in patients with dermatomyositis. However, the sudden-onset dysphagia without other symptoms can make diagnosis and treatment challenging. Two patients who did not have a severe muscle weakness complained of the sudden inability to swallow solids and liquids. The muscle biopsy results showed the perifascicular atrophy, and the patients were diagnosed with dermatomyositis. Videofluoroscopy revealed an inadequate pharyngeal contraction and a decreased upper esophageal sphincter opening with silent aspiration. Both patients showed low tongue pressures. Patient 1 received intravenous and oral methylprednisolone, and patient 2 received intravenous immunoglobulin in addition to intravenous and oral methylprednisolone. Several months after the onset of the dysphagia, the swallowing function of both patients improved. The improvement in tongue pressure preceded an improvement in the subjective and objective measurements of dysphagia. In conclusion, tongue pressure may be useful for predicting early improvement in swallowing function.

Impact of dysphagia and its severity on long-term survival and swallowing function outcomes in patients with idiopathic inflammatory myopathies other than inclusion body myositis

OBJECTIVE

To investigate the impact of dysphagia on long-term survival and swallowing function outcomes in patients with idiopathic inflammatory myopathy other than inclusion body myositis.

METHODS

We retrospectively evaluated consecutive patients with idiopathic inflammatory myopathy other than inclusion body myositis to investigate the impact of dysphagia and its severity assessed using the Food Intake LEVEL Scale on survival and swallowing function outcomes. Time-to-event analyses were used, including Kaplan-Meier curves with log-rank (trend) test, cumulative incidence with Gray's test, and Cox proportional hazards models.

RESULTS

Of the 254 patients, 26 were dysphagic, including eight severe (Food Intake LEVEL Scale [FILS] score 2, 3) and six most severe (FILS score 1) cases; 210 were non-dysphagic, and 18 were indeterminate cases. During the 5 years after myositis diagnosis, 15 (57.7%) dysphagic and 31 (14.8%) non-dysphagic patients died, and dysphagic patients had significantly shorter survival. However, multivariate analysis showed that shorter survival was significantly associated with baseline age-adjusted Charlson Comorbidity Index (hazard ratio [HR] 1.57, 95% confidence interval [CI] 1.36-1.82]), but not with dysphagia (HR 1.46, 95% CI 0.69-3.10). Dysphagia severity was significantly associated with delayed recovery of dysphagia. In 20 non-severe or severe dysphagic cases, 19 restored swallowing function within 1 year. The most severe cases had a significantly higher cumulative probability of death before recovery from dysphagia than severe cases.

CONCLUSION

The poor survival of dysphagic myositis patients was largely confounded by advanced age and comorbid malignancies. However, patients with the most severe dysphagia had a significantly worse swallowing function and survival prognosis than those with milder dysphagia.

[Myositis]

The S2e guidelines on myositis were completely updated and revised under the leadership of the German Society for Neurology and the participation of many other specialist societies. Immune-mediated necrotizing myopathy and antisynthetase syndrome are now regarded as independent entities in the classification of myositis. With respect to the diagnostics, the guidelines provide concrete recommendations on dysphagia screening, especially for inclusion body myositis and for cancer diagnostics in certain forms of myositis. Following the positive ProDERM study, the use of intravenous immunoglobulins (Octagam®) is available for treatment as an approved substance. Based on the INBUILD study, antifibrotic treatment with nintedanib is available for progressive fibrosing pulmonary involvement. For rheumatologists, the updated guidelines represent a document relevant for daily practice with many recommendations for the treatment of patients with myositis.

Autoimmune Neurogenic Dysphagia

Autoimmune neurogenic dysphagia refers to manifestation of dysphagia due to autoimmune diseases affecting muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. Dysphagia is either part of the evolving clinical symptomatology of an underlying neurological autoimmunity or occurs as a sole manifestation, acutely or insidiously. This opinion article reviews the autoimmune neurological causes of dysphagia, highlights clinical clues and laboratory testing that facilitate early diagnosis, especially when dysphagia is the presenting symptom, and outlines the most effective immunotherapeutic approaches. Dysphagia is common in inflammatory myopathies, most prominently in inclusion body myositis, and is frequent in myasthenia gravis, occurring early in bulbar-onset disease or during the course of progressive, generalized disease. Acute-onset dysphagia is often seen in Guillain–Barre syndrome variants and slowly progressive dysphagia in paraneoplastic neuropathies highlighted by the presence of specific autoantibodies. The most common causes of CNS autoimmune dysphagia are demyelinating and inflammatory lesions in the brainstem, occurring in patients with multiple sclerosis and neuromyelitis optica spectrum disorders. Less common, but often overlooked, is dysphagia in stiff-person syndrome especially in conjunction with cerebellar ataxia and high anti-GAD autoantibodies, and in gastrointestinal dysmotility syndromes associated with autoantibodies against the ganglionic acetyl-choline receptor. In the setting of many neurological autoimmunities, acute-onset or progressive dysphagia is a potentially treatable condition, requiring increased awareness for prompt diagnosis and early immunotherapy initiation.

Expert Perspective: Management of Refractory Inflammatory Myopathy

The idiopathic inflammatory myopathies (IIMs) are chronic disorders characterized by inflammation in skeletal muscle but also in other organs such as the skin, lungs, joints, gastrointestinal tract, and heart. The effect of immunosuppressive treatment varies between individual patients and between organ manifestations within the same individual. Many patients respond poorly to first-line treatment with glucocorticoids and other immunosuppressive agents such as methotrexate or azathioprine, with symptoms persisting in the muscles, skin, and lungs, leading to refractory disease. Management of refractory IIM is a clinical challenge, and a systematic approach is proposed to better understand the lack of treatment response, in order to guide disease management. The first step in the management of refractory IIM is to recognize whether remaining symptoms are caused by persistent inflammation in the affected tissue or whether the symptoms may be attributable to damage preceding inflammation. Thus, a second diagnostic examination is recommended. Second, in particular for patients with remaining muscle weakness, it is important to ascertain whether the diagnosis of myositis is correct or whether another underlying muscle disorder could explain the symptoms. Third, with confirmation of remaining inflammation in the tissues, a strategy to change treatment needs to be undertaken. Few controlled trials are available to guide our treatment strategies. Furthermore, different subgroups of patients may benefit from different therapies, and different organ manifestations may respond to different therapies. In this context, subgrouping of patients with IIM based on autoantibody profile may be helpful, as there are emerging data from open studies and case series to support the notion of a varying treatment response in different autoantibody-defined subgroups of IIM patients.