Normative High-Resolution Pharyngeal Manometry: Impact of Age, Size of System, and Sex on Primary Metrics and Pressure Stability

There have been many reports of normative pharyngeal swallowing pressures using high-resolution pharyngeal manometry, but there is a fair amount of between-subject variance in reported pressure parameters. The purpose of this study was to put forward normative pharyngeal high-resolution manometry measures across the lifespan and investigate the effects of age, size of system, and sex. High-resolution pharyngeal manometry was performed on 98 healthy adults (43 males) between the ages 21 and 89. Pressure duration, maxima, integral, and within-individual variability metrics were averaged over 10 swallows of 10-ml thin liquid. Multiple linear and logistic regressions with model fitting were used to examine how pharyngeal pressures relate to age, pharyngeal size, and sex. Age was associated with tongue base maximum pressure, tongue base maximum variability, and upper esophageal sphincter-integrated relaxation pressure (F3,92 = 6.69; p < 0.001; adjusted R2 = 0.15). Pharyngeal area during bolus hold was associated with velopharynx integral (F1,89 = 5.362; p = 0.02; adjusted R2 = 0.05), and there was no significant model relating pharyngeal pressures to C2-C4 length (p < 0.05). Sex differences were best described by tongue base integral and hypopharynx maximum variability (χ2 = 10.27; p = 0.006; pseudo R2 = 0.14). Normative data reveal the distribution of swallow pressure metrics which need to be accounted for when addressing dysphagia patients, the importance of pressure interactions in normal swallow, and address the relative stability of swallow metrics with normal aging.

The Manometric Representation of the Upper Esophageal Sphincter During the Resting State: A Descriptive Study

The upper esophageal sphincter (UES) is the high-pressure zone marking the transition between the hypopharynx and esophagus. There is limited research surrounding the resting UES using pharyngeal high-resolution manometry (HRM) and existing normative data varies widely. This study describes the manometric representation of the resting UES using a clinically accessible method of measurement. Data were obtained from 87 subjects in a normative database of pharyngeal HRM with simultaneous videofluoroscopy. The resting UES manometric region was identified and ten measurement segments of this region were taken throughout the duration of the study using the Smart Mouse function within the manometry software. Intraclass correlation coefficients (ICC) were used to analyze within-subject reliability across measurements. Linear mixed-effects regression models were used to analyze how subject characteristics and manometric conditions influence resting UES pressure. There was excellent within-subject reliability between resting UES mean pressures (ICC = 0.96). In bivariate analysis, there were significant effects of age, number of sensors contained within the resting UES, and preceding swallow volume on mean resting UES pressure. For every 1 unit increase in age, there was a 0.19 unit decrease in resting UES pressure (p = 0.008). For every 1 unit increase in number of sensors contained within the resting UES, there was a 3.71 unit increase in resting UES pressure (p < 0.001). This study presents normative data for the resting UES, using a comprehensive and clinically accessible protocol that can provide standard comparison for the study of populations with swallowing disorders, particularly UES dysfunction, and provides support for UES-directed interventions.

CT pulmonary angiography: optimising acute thoracic imaging by fixed-timing contrast medium delivery with a modified breathing instruction

AIM

To compare the thoracic vascular opacification achieved using the standard bolus-tracking protocol (BTP) with a fixed-timing protocol (FTP) with a modified breathing instruction during computed tomography pulmonary angiography (CTPA) examinations.

MATERIALS AND METHODS

A single-centre review of CTPA examinations performed between July 2018 and January 2019 using the BTP or FTP and weight-based contrast dosing of 20 mg iodine/kg body weight/s for 20 seconds at 100 kV tube potential. Radiodensity (in Hounsfield units) was analysed in the right ventricle, main pulmonary artery (MPA), left atrium, left ventricle, and ascending and descending thoracic aorta (DTA). A p-value of <0.05 was considered significant.

RESULTS

Of 782 examinations, 88 BTP and 90 FTP examinations were included. Mean attenuation of the MPA was similar in the FTP (396 ± 106 HU) and BTP (362 ± 119 HU; p=0.06); however, good-quality (≥250 HU) MPA opacification was achieved in more FTP examinations (87/90, 96.7%) compared to the BTP (73/88, 82.9%; p=0.002). Mean attenuation of the DTA was better in the FTP (325 ± 72 HU) than the BTP (228 ± 75 HU; p <0.0001), with good-quality opacification (≥250 HU) in 76/90 (84.4%) FTP examinations compared with 36/88 (40.9%) BTP examinations (p <0.001).

CONCLUSION

The FTP achieves better opacification of the MPA and DTA compared to the BTP.

The Natural Swallow: Factors Affecting Subject Choice of Bolus Volume and Pharyngeal Swallow Parameters in a Self-selected Swallow

Predetermined volumes are used extensively throughout clinical assessment of swallowing physiology, but bolus volumes selected by an individual in their natural swallow can vary greatly from those used in structured assessment. This study aims to identify factors influencing self-selected volume and how the mechanics of self-selected volume swallows differ from predetermined volume swallows. We used pharyngeal high-resolution manometry (HRM) with simultaneous videofluoroscopy to measure swallowing pressures in the velopharynx, hypopharynx, and upper esophageal sphincter (UES). Data were collected from 95 healthy adults during thin liquid swallows of 10 mL and a self-selected comfortable volume. An intraclass correlation coefficient (ICC) was calculated to analyze within-subject self-selected volume reliability. Linear mixed effects regression models were used to examine the association of subject characteristics with self-selected swallow volume and of self-selected volumes on pharyngeal swallowing pressures and timing events. Mean self-selected volume was 16.66 ± 7.70 mL. Increased age (p = 0.002), male sex (p = 0.021), and increased pharyngeal hold area (p = 0.007) were significantly associated with increase in self-selected bolus volume. There was good reliability between subjects' individual swallow volumes (ICC = 0.80). Velopharyngeal maximum pressure and pressure integral, tongue base duration and maximum pressure, UES pre- and post-swallow maximum pressure, and overall pharyngeal contractile integral decreased significantly with self-selected boluses. Understanding a patient's natural swallow volume, and how their natural swallow functions, will be important for designing clinical evaluations that place stress on the patient's natural swallowing mechanics in order to assess for areas of dysfunction.

A-05 Retrospective Comparison of Concussion Recovery Between School and All Star Cheerleaders

Purpose: Though often categorized together, All Star and school cheerleading are vastly different in concussion risk due to competitiveness and skill difficulty. The purpose of the current study was to compare concussion rate and recovery in school and All Star cheerleaders diagnosed with sports-related concussions (SRC). Methods: This study was a retrospective comparison of cheerleaders (aged 8–18 years) who were evaluated in a specialty concussion clinic and diagnosed with SRC from 2020–2022. A total of 64 female cheerleaders were included (33 school and 31 All Star). We compared days to clinic, prior history of concussion, Post-Concussion Symptom Scale (PCSS) total score, symptom provocation on the Vestibular Ocular Motor Screen, and recovery time in days for each group. Results: Reports of at least one prior concussion were higher in All Star cheerleaders (61%) compared to school cheerleaders (39%). Initial evaluation occurred an average of 4.0 ± 5.8 days post injury for All Star cheerleaders, with recovery occurring in 23.6 ± 17.4 days compared to school cheerleaders who were evaluated for initial evaluation an average of 4.2 ± 4.3 days post injury and recovered in 27.6 ± 19.7 days (P &gt; 0.05). All Star cheerleaders experienced greater symptom provocation (P = 0.05) on horizontal vestibular-ocular reflex compared to school cheerleaders. There was no difference in symptom reporting on the PCSS (P = 0.23). Conclusions: Higher rates of prior concussion were reported in All Star cheerleaders. This may be a function of the more difficult skills being performed. Future research should investigate the impact of skill level and mechanism of injury on SRCs in All Star Cheerleading.

A-36 Tracking Compliance To A Home Exercise Program For Concussion Using Ecological Momentary Assessment: A Pilot Study

Purpose: The management of pediatric concussions creates a clinical challenge due to unknown patient compliance with prescribed therapies and interventions. The purpose of this pilot study was to describe the logistical use of ecological momentary assessment (EMA) to track compliance to a physical therapy facilitated vestibular/ocular motor home exercise program (HEP) in patients diagnosed with concussion. Methods: A convenience sample of 20 concussed patients (aged 13–18 years [mdn = 14.5, IQR = 14.0–16.8]) was included in this initial pilot study. All participants were evaluated within seven days of injury. Participants were instructed to complete one daily HEP compliance log until medical clearance on their parent or guardians’ mobile device using an EMA application. Results: Participants were evaluated a median 3.5 (IQR = 1.3–6.5) days post injury, recovered in a median 15.5 (IQR = 11.0–25.0) days, and completed a mean 5.85 (SD = 3.9) total EMA logs representing a 47% completion rate. Participants reported completing a mean 1.21 (SD = 0.77) HEPs per day with a range of 0.0 to 3.0. Self-reported HEP compliance did not significantly correlate with recovery time in days (P = 0.26). Conclusions: The overall response rate for EMA logs was 47% and participants reported completing 1.2 HEPs per day. Analysis of this preliminary data did not reveal a correlation between HEP compliance and recovery time in days. Participants reported the primary barrier to completing daily questionnaires was access to their parent or guardians’ mobile device at the time of the prompt. Overall, the data derived from EMA appears useful for tracking the progression of this heterogenous injury.

Choosing Wisely Canada: Canadian fertility and andrology society’s list of top items physicians and patients should question in fertility medicine

Purpose

To create a Choosing Wisely Canada list of the top 5 diagnostic and therapeutic interventions that should be questioned in Reproductive Endocrinology and Infertility in Canada.

Methods

The Canadian Fertility and Andrology Society (CFAS) National Working Group developed an initial list of recommendations of diagnostic and therapeutic interventions that are commonly used, but are not supported by evidence, and could expose patients to unnecessary harm. These were chosen based on their prevalence, cost, potential for harm, and quality of supporting evidence. A modified Delphi consensus was used over 5 rounds to generate ideas, review supporting evidence, assess clinical relevance, estimate recommendation impact and narrow the recommendations list to 5 items.

Results

Fifty unique ideas were first proposed by the working group, and after 5 rounds including a survey of Canadian Fertility and Andrology Society (CFAS) members, the final list of recommendations was created, including topics related to unnecessary investigations and interventions for patients with infertility and recurrent pregnancy loss, and those undergoing IVF. In this article, we describe not only the Delphi process used to determine the list, but also provide a summary of the evidence behind each of the final recommendations.

Conclusions

The list of five recommendations highlights opportunities to initiate conversations between clinicians and patients about the risks, benefits, harms and costs of unnecessary fertility treatments and procedures in a Canadian context.

Pharyngeal Pressure Variability During Volitional Swallowing Maneuvers

PURPOSE

Within-individual pharyngeal swallowing pressure variability differs among pharyngeal regions in healthy individuals and increases with age. It remains unknown if pharyngeal pressure variability is impacted by volitional swallowing tasks. We hypothesized that pressure variability would increase during volitional swallowing maneuvers and differ among pharyngeal regions depending on the type of swallowing task being performed.

METHOD

Pharyngeal high-resolution manometry was used to record swallowing pressure data from 156 healthy participants during liquid (5 cc) or saliva swallows, and during volitional swallowing tasks including effortful swallow, Mendelsohn maneuver, Masako maneuver, or during postural adjustments. The coefficient of variation was used to determine pressure variability of velopharynx, tongue base, hypopharynx, and upper esophageal sphincter regions. Repeated-measures analysis of variance was used on log-transformed data to examine effects of pharyngeal region and swallowing tasks on swallow-to-swallow variability.

RESULTS

There was a significant main effect of task with greater pressure variability for the effortful swallow (p = .002), Mendelsohn maneuver (p < .001), Masako maneuver (p = .002), and the head turn (p = .006) compared with normal effort swallowing. There was also a significant main effect of region (p < .01). In general, swallowing pressure variability was lower for the tongue base and upper esophageal sphincter regions than the hypopharynx. There was no significant interaction of task and region (effortful, p = .182; Mendelsohn, p = .365; Masako, p = .885; chin tuck, p = .840; head turn, p = .059; and inverted, p = .773).

CONCLUSIONS

Pharyngeal swallowing pressure variability increases in healthy individuals during volitional swallowing tasks. Less stable swallow patterns may result when tasks are less automatic and greater in complexity. These findings may have relevance to swallowing motor control integrity in healthy aging and individuals with neurogenic dysphagia.

Age-Related Functional Reserve Decline Is Not Seen in Pharyngeal Swallowing Pressures

Purpose Functional reserve represents the difference between an individual's ability to produce a maximum output function and the ability to perform a functional task. Several studies have documented an age-related decrease in functional reserve with oral tongue pressure generation. Whether this pattern is seen in pharyngeal swallowing pressures is unknown. The aim of this study was to investigate pharyngeal functional reserve using high-resolution manometry during normal-effort and effortful swallows. Method Pharyngeal high-resolution manometry was performed on 38 younger healthy individuals (≤ 40 years) and 18 older healthy individuals (≥ 60 years) during normal-effort and effortful water swallows. Pressure metrics included maximum pressure in the velopharynx, tongue base, and hypopharynx, as well as pharyngeal contractile integral and minimum pressure in the upper esophageal sphincter (UES). Repeated-measures analysis of variance was used to determine the effects of swallow task, age, and pharyngeal region on pressure generation. Results Maximum pharyngeal pressures and pharyngeal contractile integral were significantly increased during the effortful swallows compared to normal-effort swallows (p < .001), but there were no interactions between task and age in pharyngeal pressures. In the UES, minimum pressures were significantly elevated in older individuals during effortful swallows compared to normal-effort swallows (p = .007) but did not follow a pattern consistent with reduced functional reserve. Conclusions Healthy individuals increase pharyngeal driving pressures during effortful swallows, without an age-related reduction in the magnitude of pressure increase. Thus, this study did not find evidence for an age-related reduction in pharyngeal functional reserve. The preserved ability to increase pharyngeal pressures during effortful swallowing in aging may support the use of behavioral swallowing interventions in older individuals without neuromuscular conditions. Supplemental Material https://doi.org/10.23641/asha.16606709.

Spectral arc length as a method to quantify pharyngeal high-resolution manometric curve smoothness

BACKGROUND

Pharyngeal high-resolution manometry (HRM) has emerged over the last decade as a valuable assessment tool for oropharyngeal dysphagia. Data analysis thus far has focused primarily on measures of pressure and duration within key anatomic regions. We apply spectral arc length (SPARC), a dimensionless metric for quantifying smoothness felt to indirectly reflect neuromuscular coordination, as a new method of describing manometric curves. We then use it to distinguish swallows from healthy subjects and those with dysphagia related to stroke.

METHODS

Previously collected pharyngeal HRM data from eight subjects with history of stroke and eight age- and sex-matched controls were reviewed. Receiver operating characteristic (ROC) analysis was used to optimize SPARC inputs. SPARC was then computed for the velopharynx, tongue base, hypopharynx, and upper esophageal sphincter (UES), and the values were compared between the two subject groups.

RESULTS

Optimized parameter settings yielded an ROC curve with area under the curve (AUC) of 0.953. Mean SPARC values differed between control and stroke subjects for the velopharynx (t = 3.25, p = 0.0058), tongue base (t = 4.77, p = 0.0003), and hypopharynx (t = 2.87, p = 0.0124). Values were similar for the UES (t = 0.43, p = 0.671).

CONCLUSIONS

In this preliminary study, SPARC analysis was applied to distinguish control from post-stroke subjects. Considering alternative methods of analyzing pharyngeal HRM data may provide additional insight into the pathophysiology of dysphagia beyond what can be gleaned from measures of pressure and duration alone.

Measurement of Pharyngeal Air Pressure During Phonation Using High-Resolution Manometry

Purpose The study of air pressure in the vocal tract is essential to understanding vocal function. Changes in vocal tract shape during different phonatory gestures are hypothesized to produce nonuniform air pressure across lower vocal tract locations. Current methods of air pressure measurement, however, are limited to a single location in the anterior oral cavity. The purposes of this study were (a) to assess the feasibility of a novel method of simultaneously measuring phonatory air pressure at multiple locations across the lower vocal tract using high-resolution pharyngeal manometry (HRM) and (b) to compare pressure across locations and among phonatory tasks. Method Two subjects underwent HRM while performing phonatory tasks. A catheter was passed transnasally and air pressure was measured simultaneously at five locations between the velopharyngeal port and the upper esophageal sphincter. Descriptive statistics were calculated for each location by task, and for each task averaged across locations. Results HRM was well tolerated, and air pressures from multiple locations in the lower vocal tract were able to be obtained simultaneously. During vocal tract semi-occlusion tasks, air pressures differed by location. Pressures averaged across locations demonstrated a pattern of increasing pressure with increasing semi-occlusion. Conclusions HRM is feasible for measuring air pressure simultaneously at multiple locations in the lower vocal tract during phonation with high spatial and temporal resolution, providing rich data to augment understanding of vocal function. The high spatial and temporal resolution yielded by this new method, paired with preliminary evidence that pressures change by location as a function of phonatory task, may be useful in future assays exploring differences in lower vocal tract air pressures between normal and disordered populations.

Post-stroke Dysphagia: Recent Insights and Unanswered Questions

PURPOSE OF REVIEW

We explored themes in recent post-stroke dysphagia literature, focusing on the following questions: (1) What does post-stroke dysphagia look like?; (2) Who gets post-stroke dysphagia?; (3) What are the consequences of post-stroke dysphagia?; and (4) How can we improve treatment of post-stroke dysphagia?

RECENT FINDINGS

There have been several improvements in quantitative descriptions of swallowing physiology using standard and new evaluation techniques. These descriptions have been correlated with lesion locations, and several factors can predict development of post-stroke dysphagia and its sequelae. Novel treatment paradigms have leveraged post-stroke neuroplastic improvements using neurostimulation and biofeedback techniques. Despite recent findings, the field is limited by lack of standardization and unanswered questions on rehabilitation variables. Our improved understanding of post-stroke dysphagia will enhance our ability to prevent, identify, and treat it. Future work should be grounded in swallowing physiology and continue refining treatments, particularly in the acute stage.

Perceived Professional and Institutional Factors Influencing Clinical Adoption of Pharyngeal High-Resolution Manometry

Purpose We assessed experienced clinicians' perceptions of benefits and drawbacks to the clinical adoption of pharyngeal high-resolution manometry (HRM). This article focuses on the professional and institutional factors that influence the clinical adoption of pharyngeal HRM by speech-language pathologists (SLPs). Method Two surveys (closed- and open-ended questions) and a series of focus groups were completed with SLP members of both the American Speech-Language-Hearing Association and the Dysphagia Research Society (DRS). Transcripts were inductively coded for emergent themes. Results Thirteen SLPs were recruited to attend focus group sessions at the American Speech-Language-Hearing Association. Eighty-seven SLPs responded to the DRS open-set response survey. Two additional focus groups of 11 SLPs were convened at the DRS meeting. Conventional content analysis revealed overall SLP enthusiasm for the clinical use of HRM, with some concerns about the technology adoption process. The following themes related to the professional and institutional factors influencing clinical adoption were identified: (a) scope of practice, (b) access, (c) clinical workflow, and (d) reimbursement. Conclusion These data serve to elucidate the most salient factors relating to the clinical adoption of pharyngeal HRM into routine speech-language pathology clinical practice. While enthusiasm exists, a variety of systems-level issues must be addressed to support this process.

Pressure abnormalities in patients with Zenker's diverticulum using pharyngeal high-resolution manometry

OBJECTIVES

Zenker's diverticulum is associated with reduced cricopharyngeal compliance and abnormal intrabolus pressure. However, it is unclear how the pharynx compensates for these deficits. Developments in manometric technology have improved our ability to capture pharyngeal pressure events. This study aims to describe the pharyngeal-upper esophageal sphincter (UES) pressure profile during swallowing in patients with Zenker's diverticulum.

METHODS

High-resolution manometry was performed on 11 patients with symptomatic Zenker's diverticulum and 11 age- and sex-matched healthy controls during 10 mL liquid swallowing tasks. Pharyngeal and UES pressure magnitudes, durations, and integrals were compared between patients and controls using independent t tests. Other manometric parameters, including residual UES pressure at the time of maximum tongue base pressure and pharyngeal-UES pressure gradient, were also evaluated. A case example using three-dimensional high-resolution manometry is presented.

RESULTS

Compared with healthy controls, patients with Zenker's diverticulum exhibited pressure abnormalities in the UES region. While baseline and pre-opening maximum pressures were not different, residual pressures were elevated (P = .001). Pharyngeal-UES pressure gradients did not differ between the two groups.

CONCLUSION

This study used high-resolution manometry to characterize pharyngeal pressure dynamics in patients with Zenker's diverticulum. The changes occurring at the cricopharyngeus appear to result in persistent UES pressurization during UES opening, rather than high tonic resting pressure. Pharyngeal-UES pressure gradients, critical to bolus passage, were also preserved in this patient population.

LEVEL OF EVIDENCE

3b.

Practical Implications for Strength and Conditioning of Older Pre-Frail Females

Approaches to and benefits from resistance training for non-compromised older adults are well known. Less is understood about resistance training with pre-frail older adults, and even less information is available on the practical approaches to delivery. Herein, we describe an approach in pre-frail females who undertook a multi-component exercise intervention, inclusive of high-intensity, free-weight, functional resistance training. Capitalizing on the principle of overload is possible and safe for pre-frail females through constant reassurance of ability and adjustments in technique. Making exercise functionally relevant, for example, a squat is the ability to get on and off a toilet, resonates meaning. Older pre-frail females are affected by outside (clinical) influences. The exercise participant, and extraneous persons need to be educated on exercise approaches, to increase awareness, debunk myths, and enhance support for participation. Identification of individuality in a group session offers ability to navigate barriers for successful implementation.

Swallowing Pressure Variability as a Function of Pharyngeal Region, Bolus Volume, Age, and Sex

OBJECTIVES

Within-individual movement variability occurs in most motor domains. However, it is unknown how pharyngeal swallowing pressure varies in healthy individuals. We hypothesized that: 1) variability would differ among pharyngeal regions; 2) variability would decrease with increased bolus volume; 3) variability would increase with age; and 4) there would be no sex differences.

STUDY DESIGN

Case series.

METHODS

We used pharyngeal high-resolution manometry to measure swallowing pressure in the following regions: velopharynx, tongue base, hypopharynx, and upper esophageal sphincter. Data were collected from 97 healthy adults (41 male) aged 21 to 89 years during thin liquid swallows: 2 mL, 10 mL, and participant-selected comfortable volume. Pressure variability was measured using coefficient of variation. Repeated measures analysis of variance was used to assess impacts of region, bolus volume, age, and sex on pressure variability.

RESULTS

There was a significant region × volume interaction (P < .001) and significant main effect of age (P = .005). Pressures in the hypopharynx region were more variable than all other regions (P ≤ .028), and pressures in the tongue base region were less variable than all other regions (P ≤ .002) except at 2 mL volumes (P = .065). Swallowing pressure variability was significantly different in the velopharynx and upper esophageal sphincter regions, with comfortable volume and 2 mL swallows having greater variability than 10 mL swallows (P ≤ .026). Pressure variability significantly increased with increasing age (P = .002). There were no effects of sex on pressure variability (P ≥ .15).

CONCLUSION

Pharyngeal swallowing pressure variability differs according pharyngeal region, volume, and age but not sex. Abnormal swallowing pressure variability may reflect deviations in motor control in persons with swallowing impairment, and results from this study can be used as normative data for future investigations evaluating swallowing pressure generation.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E52-E58, 2021.

Multi-Component Exercise with High-Intensity, Free-Weight, Functional Resistance Training in Pre-Frail Females: A Quasi-Experimental, Pilot Study

BACKGROUND

No study has performed an exercise intervention that included high-intensity, free-weight, functional resistance training, and assessed frailty status as an inclusion criteria and outcome measure via original, standardized tools, in pre-frail females.

OBJECTIVES

Determine if the intervention strategy is not only feasible and safe, but can also improve frailty status, functional task performance, and muscle strength.

DESIGN

Pilot, quasi-experimental.

SETTING

Community.

PARTICIPANTS

20 older-adults with pre-frailty characteristics.

INTERVENTION

12-weeks (3 days/week, 45-60 minutes/session) of multi-component exercise, inclusive of aerobic, resistance, balance and flexibility exercises. The crux of the program was balance and resistance exercises, the latter utilized high-intensity, free-weight, functional resistance training. The control group maintained their usual care.

MEASUREMENTS

1) Feasibility and safety (dropout, adherence, and adverse event); 2) Frailty (Frailty Phenotype, Clinical Frailty Scale, and gait speed); 3) Functional task performance (grip strength and sit-to-stand time); and 4) Isometric and isotonic strength of the knee extensors and elbow flexors.

RESULTS

No participants dropped out of the intervention or experienced an adverse event, and adherence averaged 88.3%. The exercise group became less frail, whereas the control group became more frail. There was a significant within-group improvement in exercise participants gait speed (p ≤ 0.01, +0.24 m/sec), grip strength (p ≤ 0.01, +3.9 kg), and sit-to-stand time (p ≤ 0.01, -5.0 sec). There was a significant within-group improvement in exercise participants knee extension isometric torque (p ≤ 0.05, +7.4 Nm) and isotonic velocity (p = ≤ 0.01, +37.5 ˚/sec). Elbow flexion isotonic velocity significantly declined within the control group (p ≤ 0.01, -20.2 ˚/sec) and demonstrated a significant between-group difference (p ≤ 0.05, 40.73 ˚/sec) post-intervention.

CONCLUSIONS

The intervention strategy appears to be feasible and safe, and may also improve frailty status, functional task performance, and muscle strength. These results help calculate effect size for a future randomized controlled trial.

The use of cannabis and perceptions of its effect on fertility among infertility patients

STUDY QUESTION

What is the prevalence of cannabis use and the perceptions of its impact on fertility among infertility patients?

SUMMARY ANSWER

A total of 13% of infertility patients used cannabis within the last year, and current usage is associated with patient perceptions of negative effects of cannabis on fertility and pregnancy.

WHAT IS KNOWN ALREADY

Cannabis use is increasing among the general population and pregnant women, particularly in places where cannabis use is legal despite having known and potential negative effects on fertility and pregnancy.

STUDY DESIGN, SIZE, DURATION

A cross-sectional patient survey study was performed between July 2017 and September 2017. Patients attending a university-affiliated hospital-based fertility clinic (n = 290) were invited to complete a written survey. Inclusion criteria were limited to the ability to read English. There were no exclusion criteria.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Of the 290 patients approached, 270 (93%) agreed to participate. The questions covered demographics, cannabis usage, perceptions of the effect of cannabis on fertility and pregnancy, cessation of use due to infertility and personal history of disclosing cannabis use to healthcare providers (HCP).

MAIN RESULTS AND THE ROLE OF CHANCE

The results showed that 13% of respondents disclosed use of cannabis in the past year (past year users) and 38% had not used cannabis in the past year but had previously used cannabis (>1 year users) while 49% had never used cannabis (never users). Baseline demographics were similar for the three groups, but across four measures of fertility and pregnancy health, past-year users perceived less of a negative effect compared to >1 year users, and never users (P values of 0.02, 0.03, 0.01, <0.001 for questions on pregnancy, offspring health, male fertility and female fertility, respectively). Of past year users, 72% said they had or would disclose use to their HCP, but only 9.4% reported that their HCP had actually instructed them to discontinue use.

LIMITATIONS, REASONS FOR CAUTION

Self-reported patient surveys are subject to reporting bias and may not reflect actual use and perceptions.

WIDER IMPLICATIONS OF THE FINDINGS

This study suggests that cannabis use is common among infertility patients. Given the known negative impacts of cannabis on pregnancy, the authors would have expected informed infertility patients to cease cannabis use as part of their efforts to conceive. As the prevalence of cannabis use in the last year among infertility patients is similar to that in the general Canadian population, it is unclear whether the prevalence of cannabis use in the sample population merely reflects the average usage in society or, after taking into account those who reduced their usage to improve their fertility, is a factor contributing to infertility and thus prompting fertility referral. Given concern about the potential negative impact of cannabis use on fertility, and that only 9% of past year users had been instructed by an HCP to cease cannabis use, HCPs should consider the benefits of counselling about cannabis cessation for patients who are attempting to conceive. Future research should focus on analysing the effects of cannabis use on female fertility and determining whether a reduction in use among patients with infertility can improve conception rates.

STUDY FUNDING/COMPETING INTEREST(S)

Michelle Shin, Clinical Research Associate, is supported by the University of Toronto GREI Fellowship Fund, which is sponsored by unrestricted research grants from EMD Serono, Merck Canada and Ferring Pharmaceuticals. The authors have no potential conflicts of interest to disclose.

AGE-RELATED FUNCTIONAL RESERVE DECLINE IS NOT SEEN IN PHARYNGEAL SWALLOWING PRESSURES

Age-related decline in functional reserve has been described in tongue strength: tongue pressure during swallowing does not change with age, but maximal-effort isometric tongue pressure decreases with age. Healthy persons show a slight increase in pharyngeal swallowing pressure with age, but it is unknown if there is a similar decline in functional reserve. Fifty-six healthy adults (n=38 60 years) underwent pharyngeal high-resolution manometry during effortful and normal-effort thin liquid swallows. Repeated measures ANOVAs were performed on maximum pressures, pharyngeal contractile integral (PCI), pharyngeal pressure gradients, and upper esophageal sphincter minimum pressures. We hypothesized that older individuals would generate a less-robust pressure increase with effortful swallowing than younger individuals. Maximum pressures, PCI, and gradients increase during effortful swallowing (p&lt;0.001), but there was no interaction effect with age, suggesting a lack of age-related functional reserve decline. Older individuals had greater UES minimum pressures than younger individuals in the effortful swallowing task (p=0.03), which may stem from reduced muscular compliance in this area. These findings do not align with those reported in tongue pressures, suggesting that muscle properties and pressure generation may be fundamentally different between the pharynx and the oral tongue. Alternatively, the effortful swallowing task may not elicit maximum contractility of the pharyngeal musculature. The preserved ability to increase pharyngeal pressure during effortful swallowing may support the use of the effortful swallow exercise in older adults with swallowing disorders.

P2665An observational study assessing the impact of a cardiac arrest centre on patient outcome

Background

Out-of-hospital cardiac arrest (OHCA) is a major cause of death in Europe and the United States. There has been recent literature to suggest that the centralisation of OHCA services may benefit patient outcomes. In 2015, two major tertiary cardiac centres in the UK agglomerated to form a large dedicated tertiary cardiac centre. The previous centre had strict criteria on which OHCA patients could be admitted, with the vast majority of cases being STEMI-related. After the agglomeration, admission criteria were relaxed to include all OHCA cases within geographic range with a suspected cardiac cause.

Purpose

This study aimed to compare the short-term mortality of patients admitted with an OHCA to a tertiary cardiac centre before-and-after a major agglomeration of services had taken place and admission criteria had been relaxed.

Methods

We retrospectively analysed the data of patients admitted before and after agglomeration (2015) with OHCA who were resuscitated via conventional cardiopulmonary resuscitation. Baseline demographic characteristics were recorded, along with factors relating to the cardiac arrest. Primary endpoint was in-hospital mortality.

Results

A total of 650 patients (189 before and 461 after the agglomeration) with an OHCA between 2013 and 2018 were analysed. Patients admitted pre merger were older (67.7 vs 62.4 years, p=0.022), otherwise there were similar baseline demographic characteristics between patients admitted before and after the agglomeration (pre vs post) in terms of gender (74.4% vs 75.9% male, p=0.827), ethnicity (66.7% vs 58.9% Caucasian, p=0.588) and existing coronary artery disease (22.8% vs 22.7%, p=0.432). There were also similar peri-arrest characteristics, with a comparable number of patients having a non-shockable rhythm (15.4% vs 25.4%, p=0.164) and similar total downtimes between the groups (33 vs 32.3 mins, p=0.883). Interestingly there was a decrease in those with cardiogenic shock on arrival (92.3% vs 57.0%, p=0.0001) and fewer patients with an ejection fraction <30% (63.2 vs 38.7%, p=0.0003) post-agglomeration.

There was a greater proportion of non-ACS-related OHCA admission after the agglomeration (16.9% vs 24.1%, p=0.047) and a corresponding decrease in those admitted with a STEMI (81.5% vs 62.3%, p=0.032) and those treated with PCI (77.8% vs 54.0%, p=0.034). Despite this, in-hospital mortality was lower after the agglomeration (69.7% vs 47.1%, p=0.019), which persisted after adjustment for the previously described demographic and arrest-related characteristics using stepwise logistic regression (p=0.036) between the two groups.

Conclusion

Despite an increase in non-ACS-related-OHCA cases, the formation of a centralised invasive heart centre was associated with improved survival in OHCA patients. This suggests there may be a benefit for an out-of-hospital cardiac arrest-centre model of care, supporting a centralised strategy for immediate post-resuscitation care in OHCA patients.

Acknowledgement/Funding

None

A theory-based, task-oriented, outdoor walking programme for older adults with difficulty walking outdoors: protocol for the Getting Older Adults Outdoors (GO-OUT) randomised controlled trial

INTRODUCTION

A theory-based, task-oriented, community walking programme can increase outdoor walking activity among older adults to optimise functional independence, social participation and well-being. The study objective is to determine if there is a difference in the change in outdoor walking activity from baseline to 10 weeks, 5.5 months and 12 months after receiving a 1-day interactive workshop and outdoor walking programme (Getting Older Adults Outdoors (GO-OUT)) compared with the workshop and weekly reminders (WR) in older adults with difficulty walking outdoors.

METHODS AND ANALYSIS

A randomised controlled trial is being conducted in four urban Canadian communities. We will stratify 240 individuals by site and participant type (ie, individual vs spousal/friend pair) and randomise to either the GO-OUT or WR intervention. The GO-OUT intervention involves a 1-day workshop, where participants complete eight interactive stations to build knowledge and skills to walk outside, followed by a 10-week group outdoor walking programme (two 1-hour sessions/week) led by a physiotherapist or kinesiologist in parks. The WR intervention consists of the same workshop and 10 weekly telephone reminders to facilitate outdoor walking. The primary outcome measure is mean outdoor walking time in minutes/week derived from accelerometry and global positioning system data. GO-OUT is powered to detect an effect size of 0.4, given α=0.05, β=0.20, equal number of participants/group and a 20% attrition rate. Secondary outcomes include physical activity, lifespace mobility, participation, health-related quality of life, balance, leg strength, walking self-efficacy, walking speed, walking distance/endurance and mood.

ETHICS AND DISSEMINATION

GO-OUT has received ethics approval at all sites. A Data Safety Monitoring Board will monitor adverse events. We will disseminate findings through lay summaries, conference presentations and journal articles.

TRIAL REGISTRATION NUMBER

NCT03292510 (Pre-results).

A Markov Multi-State model of lupus nephritis urine biomarker panel dynamics in children: Predicting changes in disease activity

BACKGROUND

A urine 'biomarker panel' comprising alpha-1-acid-glycoprotein, ceruloplasmin, transferrin and lipocalin-like-prostaglandin-D synthase performs to an 'excellent' level for lupus nephritis identification in children cross-sectionally. The aim of this study was to assess if this biomarker panel predicts lupus nephritis flare/remission longitudinally.

METHODS

The novel urinary biomarker panel was quantified by enzyme linked immunoabsorbant assay in participants of the United Kingdom Juvenile Systemic Lupus Erythematosus (UK JSLE) Cohort Study, the Einstein Lupus Cohort, and the South African Paediatric Lupus Cohort. Monocyte chemoattractant protein-1 and vascular cell adhesion molecule-1 were also quantified in view of evidence from other longitudinal studies. Serial urine samples were collected during routine care with detailed clinical and demographic data. A Markov Multi-State model of state transitions was fitted, with predictive clinical/biomarker factors assessed by a corrected Akaike Information Criterion (AICc) score (the better the model, the lower the AICc score).

RESULTS

The study included 184 longitudinal observations from 80 patients. The homogeneous multi-state Markov model of lupus nephritis activity AICc score was 147.85. Alpha-1-acid-glycoprotein and ceruloplasmin were identified to be the best predictive factors, reducing the AICc score to 139.81 and 141.40 respectively. Ceruloplasmin was associated with the active-to-inactive transition (hazard ratio 0.60 (95% confidence interval [0.39, 0.93])), and alpha-1-acid-glycoprotein with the inactive-to-active transition (hazard ratio 1.49 (95% confidence interval [1.10, 2.02])). Inputting individual alpha-1-acid-glycoprotein/ceruloplasmin values provides 3, 6 and 12 months probabilities of state transition.

CONCLUSIONS

Alpha-1-acid-glycoprotein was predictive of active lupus nephritis flare, whereas ceruloplasmin was predictive of remission. The Markov state-space model warrants testing in a prospective clinical trial of lupus nephritis biomarker led monitoring.

SLP-Perceived Technical and Patient-Centered Factors Associated with Pharyngeal High-Resolution Manometry

High-resolution manometry (HRM) objectively measures swallowing-related pressures in the pharynx and esophagus. It has been used in many research applications, but it is unclear how HRM is perceived amongst speech-language pathologists (SLP) as it enters into clinical practice. The purpose of this study was to explore SLP perceptions of clinical HRM use. Based on qualitative data collected at four focus groups held at two national conferences and a survey based on open-ended questions, we found broad consensus among those queried regarding how HRM's objective and targeted data could enhance diagnosis and drive treatments. However, we found less consensus among SLPs regarding which patients may and may not benefit, as well as when in the clinical process HRM would best supplement existing technologies, showing a need for further research. These findings highlight how SLPs can be motivated to adopt new clinical technologies if they see a patient-centered benefit and underscore the need for continued SLP education on pharyngeal HRM.

Methods for measuring swallowing pressure variability using high-resolution manometry

Any movement performed repeatedly will be executed with inter-trial variability. Oropharyngeal swallowing is a complex sensorimotor action, and swallow-to-swallow variability can have consequences that impact swallowing safety. Our aim was to determine an appropriate method to measure swallowing pressure waveform variability. An ideal variability metric must be sensitive to known deviations in waveform amplitude, duration, and overall shape, without being biased by waveforms that have both positive and sub-atmospheric pressure profiles. Through systematic analysis of model waveforms, we found a coefficient of variability (CV) parameter on waveforms adjusted such that the overall mean was 0 to be best suited for swallowing pressure variability analysis. We then investigated pharyngeal swallowing pressure variability using high-resolution manometry data from healthy individuals to assess impacts of waveform alignment, pharyngeal region, and number of swallows investigated. The alignment that resulted in the lowest overall swallowing pressure variability was when the superior-most sensor in the upper esophageal sphincter reached half its maximum pressure. Pressures in the tongue base region of the pharynx were least variable and pressures in the hypopharynx region were most variable. Sets of 3 - 10 consecutive swallows had no overall difference in variability, but sets of 2 swallows resulted in significantly less variability than the other dataset sizes. This study identified variability in swallowing pressure waveform shape throughout the pharynx in healthy adults; we discuss implications for swallowing motor control.

Vocalization development in common marmosets for neurodegenerative translational modeling

Objectives In order to facilitate the study of vocalizations in emerging genetic common marmoset models of neurodegenerative disorders, we aimed to analyze call-type changes across age in a translational research environment. We hypothesized that acoustic parameters of vocalizations would change with age, reflecting growth of the vocal apparatus and a maturation of control needed to make adult-like calls. Methods Nineteen developing common marmosets were longitudinally video- and audio-recorded between the ages of 1-149 days in a naturalistic setting without any vocalization elicitation protocol. Vocalizations were coded for call type (cry, tsik, trill, phee, and trill-phee) and analyzed for duration (sec), minimum and maximum frequency (Hz), and bandwidth (Hz). Mixed model linear regressions were performed to assess the effects of age on call parameters listed above for each call type. Results Cries decreased in duration (P = 0.038), maximum frequency (P = 0.047), and bandwidth (P = 0.023) with age. Tsik calls decreased in duration (P = 0.002) and increased in minimum frequency (P = 0.004) and maximum frequency (P = 0.005) with age. Trill calls increased in duration (P = 0.003), and trillphee bandwidth (P = 0.031) decreased with age. Discussion Our results demonstrate that development of common marmoset vocalizations is call type dependent and that changes in acoustic parameters can be detected without complex vocalization elicitation paradigms or specialized audio recording equipment. Thus, we demonstrate the feasibility of a naturalistic protocol to collect and objectively analyze marmoset vocalizations longitudinally. This approach may be useful for studying vocal communication deficits in genetic models of neurodegenerative disorders.

Development of quality indicators for hip and knee arthroplasty rehabilitation

OBJECTIVE

To develop quality indicators (QIs) reflecting the minimum acceptable standard of rehabilitation care before and after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis (OA).

METHODS

Informed by high quality evidence and using a modified RAND-UCLA Delphi approach, an 18-member Canadian panel of clinicians, researchers and patients considered 81 proposed QIs (40 for THA, 42 for TKA) addressing rehabilitation before and after elective THA and TKA. Panelists rated QIs for their importance and validity on a 9-point Likert scale through two rounds of online rating interspersed with a moderated and anonymous online discussion forum. Those QIs with median ratings of ≥7 for importance and validity with no disagreement based on the inter-percentile range adjusted for symmetry were included in the final sets.

RESULTS

Fifteen panelists from seven provinces and varied practice settings completed the Delphi process. Of the 81 plus one additional QIs (total of 82), 67 (82%) were rated as both important and valid (31 for THA, 36 for TKA). For THA, 14 pre-op, six acute and eight post-acute QIs were accepted. For TKA, 16 pre-op, 10 acute and eight post-acute indicators were accepted. Two of three 'across-continuum' QIs were rated appropriate for both procedures.

CONCLUSION

This work represents the first QIs with which to measure, report and benchmark quality of care in patients receiving rehabilitation before and after THA/TKA surgery. The QIs will be further tested for reliability and feasibility before being widely disseminated in clinical settings and used to assess care gaps.

Effect of Body Position on Pharyngeal Swallowing Pressures Using High-Resolution Manometry

The effect of body position and gravitational pull on the complex pressure-driven process of pharyngeal swallowing remains unknown. Using high-resolution manometry (HRM), this study aims to identify positional adaptations of pharyngeal physiology by evaluating swallowing pressure patterns in a series of inverted body positions. Ten healthy adults each underwent swallowing tasks with pharyngeal HRM at six body positions using an inversion table (0°[upright], 45°, 90°[supine], 110°, 135°, and 180°[fully inverted]). Repeated measures ANOVA was used to assess impact of position on pressure parameters, and pharyngeal-UES pressure gradients translate. Velopharyngeal pressures varied by position (P < 0.001), with significantly higher pressures generated with inversion ≥90°, compared with upright and 45°. Change in position did not significantly affect common mesopharyngeal pressures or swallowing pressure durations. UES valving mechanisms were preserved during inversion, with subtle variations observed in integral pressures (P = 0.011). Pharyngeal-UES pressure gradients changed with position (P < 0.01), increasing with inversion > 90° compared to upright and 45°. Mechanisms of deglutition may differ with position and relative direction of gravity, particularly when at > 45° inclination. Increased palatal pressure is generated in the upside-down position to achieve nasopharyngeal closure and prevent regurgitation. While other classically measured pressures may not consistently differ with positioning, many individuals exhibit adaptations in pressure gradients when inverted, likely due to a combination of changes in pharyngeal driving force and UES opening mechanisms. Identification of these changes, relative to position, further builds on our understanding of the adaptability of the pharyngeal swallowing system.

Pharyngeal swallowing pressures in the base-of-tongue and hypopharynx regions identified with three-dimensional manometry

OBJECTIVES

This study aims to use three-dimensional (3D) high-resolution manometry to identify circumferential pressure patterns generated within the asymmetrical base-of-tongue and hypopharynx regions of the pharynx during deglutition.

STUDY DESIGN

Case series.

METHODS

Radial pressures in the regions of interest were evaluated during swallowing events in 12 healthy subjects using 3D high-resolution manometry.

RESULTS

Repeated measures analysis of variance revealed asymmetrical pharyngeal clearance pressures in the base-of-tongue and hypopharynx regions during swallowing. A significant main effect of direction on pressure was found at the time point of average maximum pressure (P < 0.001) and for pressure integral (P < 0.001), with pressure primarily generated from the posterior direction. An interaction was noted between direction and location when comparing maximum directional pressures, regardless of time (P =0.045), highlighting the differences in anterior pressure production between regions. In contrast to the high posterior pressures produced in the base-of-tongue region, an anteroposterior dominant pressure pattern was observed in the hypopharynx. Pressure waveform complexity in the hypopharynx also is likely attributed to activity in the anterior and posterior directions. Symmetrical pressure generation was observed during intrabolus flow within the hypopharynx.

CONCLUSION

This study shows that pressure is asymmetrically generated in the base-of-tongue and hypopharynx regions during swallowing of a 10-mL bolus, reflecting the complex anatomy within the pharynx. Understanding of these complex pressure patterns aids in the interpretation of high-resolution manometry and can help guide further study in the clinical assessment and treatment of pharyngeal pathology.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1989-1995, 2017.

Multimodal Swallowing Evaluation with High-Resolution Manometry Reveals Subtle Swallowing Changes in Early and Mid-Stage Parkinson Disease

BACKGROUND

Parkinson disease (PD) has detrimental effects on swallowing function. Treatment options are largely behavioral; thus, patients would benefit from an earlier start to therapy. Early swallowing changes in PD are not well-known, so patients do not typically receive swallowing treatment until later in the progression of PD.

OBJECTIVE

We used predictive modeling to determine what quantitative swallowing variables best differentiate individuals with early to mid-stage PD from healthy controls.

METHODS

Participants included twenty-six individuals with early to mid-stage PD and 26 healthy, age- and sex-matched controls. Swallowing was evaluated by simultaneous high-resolution manometry and videofluoroscopy as well as the Sydney Swallow Questionnaire (SSQ). Binomial logistic regression was performed on 4 sets of data: 1) high-resolution manometry only; 2) videofluoroscopy only; 3) SSQ only; and 4) all data combined.

RESULTS

A model from a combined data set had the highest accuracy in differentiating individuals with PD from controls. The model included maximum pressure in the velopharynx (soft palate), pressure variability in the velopharynx, and the SSQ item concerning difficulty with swallowing saliva. No significant models could be generated using the videofluoroscopy data.

CONCLUSIONS

Individuals with PD show quantitative changes in pressure generation and are able to self-assess aspects of swallowing function in the early and mid-stages of PD, even in the absence of swallowing changes seen on videofluoroscopy. A multimodal approach for the assessment of swallowing may be more accurate for determining subtle swallowing changes that occur in the early stages of PD.

Expiratory muscle strength training evaluated with simultaneous high-resolution manometry and electromyography

OBJECTIVE

To examine feasibility of a simultaneous high-resolution pharyngeal manometry (HRM) and electromyography (EMG) experimental paradigm to detect swallowing-related patterns of palatal, laryngeal, and pharyngeal muscle activity during expiratory training.

STUDY DESIGN

Technical report.

METHODS

Simultaneous HRM, surface submental, and intramuscular EMG were acquired in two healthy participants during five tasks: 10-cc water swallow, maximum expiratory pressure (MEP) testing, and expiratory muscle strength training (EMST) at three pressure levels (sham, 50%, and 75% MEP).

RESULTS

Experimental conditions were feasible. Velopharyngeal closing pressure, palate EMG activity, and pharyngeal EMG activity increased as expiratory load increased. In contrast, thyroarytenoid EMG activity was low during the expiratory task, consistent with glottic opening during exhalation. Submental EMG patterns were more variable during expiratory tasks. Intraluminal air pressures recorded with HRM were correlated with measured expiratory pressures and target valve-opening pressures of the EMST device.

CONCLUSION

Results suggest that a simultaneous HRM/EMG/EMST paradigm may be used to detect previously unquantified swallowing-related muscle activity during EMST, particularly in the palate and pharynx. Our approach and initial findings will be helpful to guide future hypothesis-driven studies and may enable investigators to evaluate other muscle groups active during these tasks. Defining mechanisms of action is a critical next step toward refining therapeutic algorithms using EMST and other targeted treatments for populations with dysphagia and airway disorders.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:797-804, 2017.

Pharyngeal Pressure and Timing During Bolus Transit

Determining intrabolus pressure (IBP) at the upper esophageal sphincter (UES) and in the esophagus has given compelling evidence that IBP can be a predictor for swallowing dysfunction. Studies have looked most superiorly at the low hypopharynx region but there has been no inquiry into what IBP measures throughout the entire pharynx can tell us. We present a study to describe the pressures within and surrounding the moving bolus throughout the pharynx and into the UES. Simultaneous high-resolution manometry (HRM) and videofluoroscopy were performed in ten healthy subjects swallowing ten 10 mL thin-liquid barium boluses. Three events surrounding bolus movement were tracked via videofluoroscopy, and two additional events were found using manometric measures. As the bolus passes through the pharynx, low pressure is created at and below the head of the bolus. A modest pressure increase is seen as the bolus passes through the pharynx, and finally, high pressure is observed at the bolus tail, followed by an even larger pressure generation of a clearance event. HRM allows for greater resolution in data collection in the pharynx and in this study, aided in identifying semi-unique characteristics around the hypopharynx and the UES which are consistent with the complex anatomy of the regions and the transition of the UES from active closure to relaxed opening. In the future, additional studies designed to look at aged and diseased populations may lead to better understanding of disease etiology, and treatment options.

Modulation of Upper Esophageal Sphincter (UES) Relaxation and Opening During Volume Swallowing

UES opening occurs following cricopharyngeus deactivation and submental muscle contraction causing hyolaryngeal elevation and UES distraction. During impedance manometry, the inverse of impedance (admittance) can be used to measure bolus presence and infer UES opening. We hypothesized that the temporal relationship between UES relaxation, opening and hyolaryngeal elevation would change with increasing bolus volume. Simultaneous intramuscular cricopharyngeal (CP) electromyography (EMG), surface submental EMG (SM-EMG), and high-resolution impedance manometry were recorded in eight (aged 27 ± 7 years, 5 M) healthy volunteers, while swallowing 0.9 % saline boluses of 2, 5, 10, and 20 ml. Data were exported and analyzed via Matlab. Statistical analysis comprised repeated measures one-way ANOVA and Pearson correlation. A P value of <0.05 was considered significant. Duration of CP deactivation increased at 20 ml volume (P < 0.001). UES relaxation and opening increased with increasing bolus volume (P < 0.001); however, overall duration of SM activation did not change. As UES opening occurs progressively earlier with increasing volumes, peak SM-EMG activity occurs relatively later (P < 0.001) and shifts from occurring before to following peak UES distention. During healthy swallowing, there is sensory modulation of cricopharyngeal and submental muscle activity. Intrabolus pressures, transmitted from the tongue base and pharynx, play a progressively more important role in sphincter opening with increasing volume. The findings may explain why some healthy elderly and patients with oropharyngeal dysphagia have difficulty swallowing larger while tolerating smaller bolus volumes.

Dysphagia Practice in 2035: Beyond Fluorography, Thickener, and Electrical Stimulation

Dysphagia evaluation and management has rapidly become the primary practice area of medical speech pathologists since its adoption in our field less than three decades ago. As a specialty, swallowing and swallowing disorders comprise the largest represented discipline with 10,059 specialty interest group members within the American Speech-Language-Hearing Association and 298 board-certified specialists in the American Speech Hearing Association. There are national and international organizations, such as the Dysphagia Research Society and its interdisciplinary journal Dysphagia, that provide continuing education for clinicians and a platform for dysphagia researchers. Despite this rapid growth, herein we identify some significant needs for improving the science and practice of dysphagia clinical care, including a deeper understanding of physiology and neurophysiology, standardization of evaluation, consensus on core sets of dysphagia parameters for clinical and research reporting, personalized algorithms for implementation of evidenced-based practice, metrics for therapy efficacy, and increased buy-in and funding from agencies. The goals of this article are to summarize the status quo of dysphagia research, evaluation, and treatment as well as to make predictions about the future. Medical trends that we speculate will influence dysphagia research and care in the future include, among others, imaging advances, personalized medicine, regenerative medicine, and telehealth.

Risk factors for revision of total knee arthroplasty: a scoping review

Background

In spite of the increasing incidence of total knee arthroplasties (TKA), evidence is limited regarding risk factors for revision. The objective of this scoping review was to identify and assess demographic, surgical and health services factors that may increase the risk for revision surgery following TKA.

Methods

A scoping review was undertaken following an electronic search in MEDLINE (1990 to December 2013), CINAHL (to December 2013), EMBASE (1990 to December 2013) and Web of Science (1990 to December 2013).

Results

Of the 4460 articles screened, 42 were included of which 26 articles were based on registry data. Increased risk of revision was associated with demographic factors (younger age, African American), surgical factors related to the primary TKA (uncemented components, implant malalignment, increased surgery duration), and health services (low volume hospitals).

Conclusions

Identifying emerging trends in characteristics of those requiring revision following TKA can help identify those at risk and allocate appropriate resources. Further primary clinical articles on risk factors for revision of TKA are necessary to ensure maximal function and lifespan following TKAs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1025-8) contains supplementary material, which is available to authorized users.

Three-dimensional manometry of the upper esophageal sphincter in swallowing and nonswallowing tasks

Objectives/Hypothesis

High‐resolution manometry (HRM) is useful in identifying disordered swallowing patterns and quantifying pharyngeal and upper esophageal sphincter (UES) physiology. HRM is limited by unidirectional sensors and circumferential averaging of pressures, resulting in an imperfect understanding of pressure from asymmetrical pharyngeal anatomy. This study aims to evaluate UES pressures simultaneously from different axial directions.

Study Design

Case series.

Methods

Three‐dimensional HRM was performed on eight healthy subjects to evaluate circumferential UES pressure patterns at rest, during the Valsalva maneuver, and during water swallowing.

Results

Multivariate analysis of the variance revealed a significant main effect of circumferential direction on pressure while at rest (P < .001); pressure was greater in the anterior and posterior portions of the UES versus lateral portions. A significant main effect of direction on pressure was not found during the Valsalva maneuver. During swallowing of a 5‐mL water bolus, circumferential direction had a significant main effect on pressure immediately before UES pressure dropped (P = .001), while the UES was open (P = .01) and at UES closure (P < .001). There was also a significant main effect of sensor level along the vertical axis on pressure immediately before UES pressure dropped (P = .032) and at UES closure (P < .001). Anterior and posterior pressures were again greater than lateral pressures at all swallowing events.

Conclusions

These results confirm that UES pressures vary significantly based on their circumferential origin, with the majority of the total pressure generated in anterior and posterior regions. Improved understanding of UES pressure in a three‐dimensional space can lead to more sophisticated treatments for pharyngeal and UES dysfunction.

Level of Evidence

4. Laryngoscope, 126:2539–2545, 2016

Predicting the activation states of the muscles governing upper esophageal sphincter relaxation and opening

The swallowing muscles that influence upper esophageal sphincter (UES) opening are centrally controlled and modulated by sensory information. Activation and deactivation of neural inputs to these muscles, including the intrinsic cricopharyngeus (CP) and extrinsic submental (SM) muscles, results in their mechanical activation or deactivation, which changes the diameter of the lumen, alters the intraluminal pressure, and ultimately reduces or promotes flow of content. By measuring the changes in diameter, using intraluminal impedance, and the concurrent changes in intraluminal pressure, it is possible to determine when the muscles are passively or actively relaxing or contracting. From these "mechanical states" of the muscle, the neural inputs driving the specific motor behaviors of the UES can be inferred. In this study we compared predictions of UES mechanical states directly with the activity measured by electromyography (EMG). In eight subjects, pharyngeal pressure and impedance were recorded in parallel with CP- and SM-EMG activity. UES pressure and impedance swallow profiles correlated with the CP-EMG and SM-EMG recordings, respectively. Eight UES muscle states were determined by using the gradient of pressure and impedance with respect to time. Guided by the level and gradient change of EMG activity, mechanical states successfully predicted the activity of the CP muscle and SM muscle independently. Mechanical state predictions revealed patterns consistent with the known neural inputs activating the different muscles during swallowing. Derivation of "activation state" maps may allow better physiological and pathophysiological interpretations of UES function.

Consensus guidelines for the investigation and management of encephalitis in adults and children in Australia and New Zealand

Encephalitis is a complex neurological syndrome caused by inflammation of the brain parenchyma. The management of encephalitis is challenging because: the differential diagnosis of encephalopathy is broad; there is often rapid disease progression; it often requires intensive supportive management; and there are many aetiologic agents for which there is no definitive treatment. Patients with possible meningoencephalitis are often encountered in the emergency care environment where clinicians must consider differential diagnoses, perform appropriate investigations and initiate empiric antimicrobials. For patients who require admission to hospital and in whom encephalitis is likely, a staged approach to investigation and management is preferred with the potential involvement of multiple medical specialties. Key considerations in the investigation and management of patients with encephalitis addressed in this guideline include: Which first-line investigations should be performed?; Which aetiologies should be considered possible based on clinical features, risk factors and radiological features?; What tests should be arranged in order to diagnose the common causes of encephalitis?; When to consider empiric antimicrobials and immune modulatory therapies?; and What is the role of brain biopsy?

Preliminary Evaluation of Functional Swallow After Total Laryngectomy Using High-Resolution Manometry

INTRODUCTION

Understanding of swallowing pressures after total laryngectomy (TL) and what constitutes a "functional" swallow are limited. Mobile structures are altered or removed after TL, with consequent effects on pressure profiles. High-resolution manometry (HRM) can characterize these pressures.

METHODS

Six TL subjects without dysphagia and 6 controls underwent pharyngeal HRM. Timing and pressure variables for the velopharynx, mesopharynx, and upper esophageal sphincter (UES) were compared. Changes in variables due to bolus volume were evaluated in TL subjects.

RESULTS

The TL subjects had increased duration of velopharyngeal pressure (P = .012). Maximum mesopharyngeal pressure was lower versus controls (P = .003). Maximal and total pre-opening (P = .002, P = .002) and post-closure (P = .001, P = .002) UES pressures were lower. Maximum mesopharyngeal pressure (P = .032) decreased with increasing bolus volume.

CONCLUSIONS

Increased velopharyngeal pressure duration and total swallow duration reflect separation of the pharynx into distinct conduits for air and food, thus ensuring successful bolus passage without the need for respiration. Decreased UES pressure highlights the effects of disrupting the cricopharyngeal and rostral esophageal muscle fibers from their attachments to the larynx and performing a cricopharyngeal myotomy. Additional studies including subjects with dysphagia could further characterize the functional TL swallow and identify aspects susceptible to dysfunction.

Increased concentration of plasma TNFR1 and TNFR2 in paediatric lupus nephritis

BACKGROUND

Juvenile-onset systemic lupus erythematous (JSLE) is a debilitating condition that frequently involves the kidneys (lupus nephritis; LN). Tumour necrosis factor alpha (TNF-α), an important pro-inflammatory cytokine, is expressed locally in the kidney and correlates with LN disease activity. The aim of this study was to ascertain whether soluble receptors for TNF-α (sTNFR1/sTNFR2) are significantly increased in children with LN.

METHODS

Plasma samples were collected from JSLE patients at routine review. Concentrations of sTNFR1 and sTNFR2 were measured (median; interquartile range, IQR) using enzyme-linked immunosorbent assay (ELISA) in 25 JSLE patients (seven LN) and 20 healthy controls (HCs).

RESULTS

sTNFR2 concentration was significantly increased in JSLE (5149 pg/dl, 3413-8561) compared to HCs (3858 pg/dl, 2254-5165; p = 0.049). sTNFR1 concentration was significantly increased in active LN (n = 7, 1765 pg/dl, IQR 1133-4167) compared to inactive LN (n = 18, 1104 pg/dl, 886-1272; p = 0.018). There was a non-significant increase in sTNFR2 concentration in active LN (9829 pg/dl, 3298-21271) compared to inactive LN (4595 pg/dl, 3345-6993; p = 0.146). sTNFR1 concentration correlated moderately with sTNFR2 (r = 0.66, p < 0.001). sTNFR2 demonstrated strong positive correlations with ESR (r = 0.941, p < 0.01) and anti-dsDNA antibodies (r = 0.998, p = 0.041). Both receptors also positively correlated with creatinine (TNFR1 r = 0.81, p < 0.001; TNFR2 r = 0.50, p = 0.015) and urinary albumin creatinine ratio (TNFR1 r = 0.64, p < 0.01; TNFR2 r = 0.63, p < 0.01).

CONCLUSIONS

These data indicate that sTNFR1 and sTNFR2 concentrations are elevated in LN and may reflect renal activity. These results provide basis for further investigation into the pathological pathways underlying LN.

Measuring Activity Performance of Continuing Care Residents Using the activPAL: An Exploratory Study

Few studies have measured the activity patterns of continuing care residents using objective, uniaxial, accelerometers such as the activPAL. This exploratory study described the activity performance of continuing care residents and explored the correlation of activity performance with grip strength, falls and mobility. Data were gathered from 24 continuing care residents. Participants (82.3 ± 5.8 years of age), wore the activPAL an average of 12.60 hours per day (SD = 0.96) and were stepping for a median of 0.47 hours (25th and 75th percentiles = 0.31, 0.81) with a median step count of 1906 steps (25th and 75th percentiles = 1216, 3420). Participants were inactive (sitting/lying/standing) for a mean 11.99 hours (SD = 1.03). No statistically significant correlations were identified between activity performance (active time, inactive time or step count) and grip strength, falls or mobility. Ambulatory older adults in continuing care centres were more sedentary compared to community-dwelling older adults or older adults with cancer.

A multisensor approach to improve manometric analysis of the upper esophageal sphincter

OBJECTIVES/HYPOTHESIS

High-resolution manometry (HRM) improves on previous manometric systems by including a greater number of sensors that are more densely placed. Due to deglutitive movement of the HRM catheter and upper esophageal sphincter (UES), it is unclear which HRM sensors capture pressure in the UES. To address this issue, we present two complementary studies to describe UES pressure patterns using HRM + videofluoroscopy and HRM + electromyography (EMG).

STUDY DESIGN

Case series involving a new analysis method.

METHODS

Study 1: Simultaneous HRM + videofluoroscopy were performed in 11 healthy subjects swallowing five 10-mL thin-liquid boluses. HRM catheter and UES movement were tracked to identify UES pressure patterns over multiple HRM sensors. Study 2: Simultaneous HRM + cricopharyngeal EMGs were performed in six healthy subjects swallowing five 10-mL water boluses. HRM and EMG outputs were correlated over individual and multiple HRM sensors.

RESULTS

HRM sensors move prior to UES movement (P < .001) and to a lesser extent in rostral and ventral directions (P ≤ .01) than the UES. UES closure pressure is captured with two distinct patterns: 1) a rostral UES pattern with short durations and fast rate of pressure release, depicting UES descent along the catheter as it closes; and 2) a caudal UES pattern with tonic pressures at baseline and a deglutitive nadir. The HRM + EMG multisensor correlation (r = 0.88) was significantly stronger than the single-sensor correlation (r = 0.80; P = .02).

CONCLUSIONS

During deglutition, the HRM catheter and the UES rise above baseline positions and create a distinctive, multisensor manometric trace. Accurate deglutitive UES pressure evaluation must include multiple manometric sensors.

LEVEL OF EVIDENCE

4 Laryngoscope, 126:657-664, 2016.

Development of postgraduate research supervisors within a teaching hospital setting

The recent trend to embed medical research at point of care has created a need for postgraduate research supervisors in hospitals who are practising clinicians and lab-based researchers. We explored the training needs of supervisors to inform the design and evaluation of a hospital-based development programme. We found that if hospital-based supervisors are to improve their practice, the programme needs to be on-site to ensure access and relevance to local issues.

Anesthetic management of super-morbidly obese parturients for cesarean delivery with a double neuraxial catheter technique: a case series

Parturients with super-morbid obesity, defined as body mass index greater than 50kg/m(2), represent a growing segment of patients who require anesthetic care for labor and delivery. Severe obesity and its comorbid conditions place the parturient and fetus at greater risk for pregnancy complications and cesarean delivery, as well as surgical and anesthetic complications. The surgical approach for cesarean delivery in these patients may require a supra-umbilical vertical midline incision due to a large pannus. The dense T4-level of spinal anesthesia can cause difficulties with ventilation for the obese patient during the procedure, which can be prolonged. Patients also may have respiratory complications in the postoperative period due to pain from the incision. We describe the anesthetic management of three parturients with body mass index ranging from 73 to 95kg/m(2) who had a cesarean delivery via a supra-umbilical vertical midline incision. Continuous lumbar spinal and low thoracic epidural catheters were placed in each patient for intraoperative anesthesia and postoperative analgesia, respectively. Continuous spinal catheters were dosed with incremental bupivacaine boluses to achieve surgical anesthesia. In one case, the patient required respiratory support with non-invasive positive pressure ventilation. Two cases were complicated by intraoperative hemorrhage. All patients had satisfactory postoperative analgesia with a thoracic epidural infusion. None suffered postoperative respiratory complications or postdural puncture headache. The use of a continuous lumbar spinal catheter and a low thoracic epidural provides several advantages in the anesthetic management of super-morbidly obese parturients for cesarean delivery.

Quantifying contributions of the cricopharyngeus to upper esophageal sphincter pressure changes by means of intramuscular electromyography and high-resolution manometry

OBJECTIVES

We sought to determine whether the association between cricopharyngeus muscle activity and upper esophageal sphincter pressure may change in a task-dependent fashion. We hypothesized that more automated tasks related to swallow or airway protection would yield a stronger association than would more volitional tasks related to tidal breathing or voice production.

METHODS

Six healthy adult subjects underwent simultaneous intramuscular electromyography of the cricopharyngeus muscle and high-resolution manometry of the upper esophageal sphincter. Correlation coefficients were calculated to characterize the association between the time-linked series.

RESULTS

Cricopharyngeus muscle activity was most strongly associated with upper esophageal sphincter pressure during swallow and effortful exhalation tasks (r = 0.77 and 0.79, respectively; P < .01). The association was also less variable during swallow and effortful exhalation.

CONCLUSIONS

These findings suggest a greater coupling for the more automatic tasks, and may suggest less coupling and more flexibility for the more volitional, voice-related tasks. These findings support the important role of central patterning for respiratory- and swallow-related tasks.

Evaluating the tongue-hold maneuver using high-resolution manometry and electromyography

The tongue-hold maneuver is a widely used clinical technique designed to increase posterior pharyngeal wall movement in individuals with dysphagia. It is hypothesized that the tongue-hold maneuver results in increased contraction of the superior pharyngeal constrictor. However, an electromyographic study of the pharynx and tongue during the tongue-hold is still needed to understand whether and how swallow muscle activity and pressure may change with this maneuver. We tested eight healthy young participants using simultaneous intramuscular electromyography with high-resolution manometry during three task conditions including (a) saliva swallow without maneuver, (b) saliva swallow with the tongue tip at the lip, and (c) saliva swallow during the tongue-hold maneuver. We tested the hypothesis that tongue and pharyngeal muscle activity would increase during the experimental tasks, but that pharyngeal pressure would remain relatively unchanged. We found that the pre-swallow magnitude of tongue, pharyngeal constrictor, and cricopharyngeus muscle activity increased. During the swallow, the magnitude and duration of tongue and pharyngeal constrictor muscle activity each increased. However, manometric pressures and durations remained unchanged. These results suggest that increased superior pharyngeal constrictor activity may serve to maintain relatively stable pharyngeal pressures in the absence of posterior tongue movement. Thus, the tongue-hold maneuver may be a relatively simple but robust example of how the medullary swallow center is equipped to dynamically coordinate actions between tongue and pharynx. Our findings emphasize the need for combined modality swallow assessment to include high-resolution manometry and intramuscular electromyography to evaluate the potential benefit of the tongue-hold maneuver for clinical populations.

Reliability of an automated high-resolution manometry analysis program across expert users, novice users, and speech-language pathologists

PURPOSE

The purpose of this study was to investigate inter- and intrarater reliability among expert users, novice users, and speech-language pathologists with a semiautomated high-resolution manometry analysis program. We hypothesized that all users would have high intrarater reliability and high interrater reliability.

METHOD

Three expert users, 15 novice users, and 5 speech-language pathologists participated in this study. Following a 20-min training session, users analyzed 30 high-resolution manometry plots using an automated analysis program. Output parameters included 2- and 3-dimensional pressure integrals over 5 anatomical regions of interest. Intraclass correlations were used to examine inter- and intrarater reliability. An analysis of variance was also performed to determine any differences in mean output parameter values.

RESULTS

Within-group interrater reliability ranged from 0.54 to 0.99, and intergroup reliability ranged from 0.92 to 0.99. Intrarater reliability ranged from 0.67 to 1.00 across all groups. There were no significant differences of output parameters among groups.

CONCLUSIONS

The high reliability observed after a short training session demonstrates that individuals with little to no prior knowledge of swallowing physiology can perform at a similar level as those with expertise. Given the quickness and ease of training in the use of this program, it has the potential for research and clinical utility.

Speech pathologist practice patterns for evaluation and management of suspected cricopharyngeal dysfunction

Speech pathologists are often the first professionals to identify signs of a cricopharyngeal (CP) dysfunction and make recommendations for further care. There are many care options for patients with CP dysfunction, but it is unclear how certain interventions are used in practice. A paper-based survey employing two clinical cases involving suspected CP dysfunction (Case 1 with adequate pharyngeal strength and Case 2 with coexisting pharyngeal weakness) was sent to members of American Speech-Language Hearing Association's Special Interest Group 13. Respondents ranked the order of management approaches (swallowing therapy, further evaluation, and referral to another medical professional) and selected specific interventions under each approach that they would recommend for each case. Completed surveys from 206 respondents were entered into analysis. The majority of the respondents recommended swallowing therapy as a first approach for each case (Case 1: 64 %; Case 2: 88 %). The most prevalent swallowing exercises recommended were the Shaker (73 %), effortful swallow (62 %), and Mendelsohn maneuver (53 %) for Case 1 and effortful swallow (92 %), Shaker (84 %), and tongue-hold swallow (73 %) for Case 2. 76 % of respondents recommended a referral for Case 1, while 38 % recommended the same for Case 2. Respondents with access to more types of evaluative tools were more likely to recommend further evaluation, and those with access to only videofluoroscopy were less likely to recommend further evaluation. However, the high degree of variability in recommendations reflects the need for best practice guidelines for patients with signs of CP dysfunction.

Early identification and treatment of communication and swallowing deficits in Parkinson disease

Parkinson disease (PD) is a complex, progressive, neurodegenerative disorder that leads to a wide range of deficits including fine and gross sensorimotor impairment, autonomic dysfunction, mood disorders, and cognitive decline. Traditionally, the focus for diagnosis and treatment has been on sensorimotor impairment related to dopamine depletion. It is now widely recognized, however, that PD-related pathology affects multiple central nervous system neurotransmitters and pathways. Communication and swallowing functions can be impaired even in the early stages, significantly affecting health and quality of life. The purpose of this article is to review the literature on early intervention for communication and swallowing impairment in PD. Overarching themes were that (1) studies and interpretation of data from studies in early PD are limited; (2) best therapy practices have not been established, in part due to the heterogeneous nature of PD; and (3) as communication and swallowing problems are pervasive in PD, further treatment research is essential.

Classification of high-resolution manometry data according to videofluoroscopic parameters using pattern recognition

OBJECTIVE

To determine if pattern recognition techniques applied to high-resolution manometry (HRM) spatiotemporal plots of the pharyngeal swallow can identify features of disordered swallowing reported on the Modified Barium Swallow Impairment Profile (MBSImP).

STUDY DESIGN

Case series evaluating new method of data analysis.

SETTING

University hospital.

SUBJECTS AND METHODS

Simultaneous HRM and videofluoroscopy was performed on 30 subjects (335 swallows) with dysphagia. Videofluoroscopic studies were scored according to the MBSImP guidelines while HRM plots were analyzed using a novel program. Pattern recognition using a multilayer perceptron artificial neural network (ANN) was performed to determine if 7 pharyngeal components of the MBSImP as well as penetration/aspiration status could be identified from the HRM plot alone. Receiver operating characteristic (ROC) analysis was also performed.

RESULTS

MBSImP parameters were identified correctly as normal or disordered at an average rate of approximately 91% (area under the ROC curve ranged from 0.902 to 0.981). Classifications incorporating two MBSImP parameters resulted in classification accuracies over 93% (area under the ROC curve ranged from 0.963 to 0.989).

CONCLUSION

Pattern recognition coupled with multiparameter quantitative analysis of HRM spatiotemporal plots can be used to identify swallowing abnormalities, which are currently assessed using videofluoroscopy. The ability to provide quantitative, functional data at the bedside while avoiding radiation exposure makes HRM an appealing tool to supplement and, at times, replace traditional videofluoroscopic studies.