Test of mastication and swallowing solids in healthy individuals aged 6 to 20 years: A normative study in an Indian context

BACKGROUND

The Test of Mastication and Swallowing Solids (TOMASS) is a reliable tool for assessing chewing and swallowing in healthy adults, using commercially available crackers. TOMASS-Children (TOMASS-C) is the paediatric version of TOMASS.

OBJECTIVE

The present study aimed to establish normative data for TOMASS-C using a validated regional commercial cracker among healthy individuals aged between 6-20 years of India.

METHODS

327 healthy individuals between 6-20 years were recruited in a cross-sectional study design following a convenient sampling procedure. Participants consumed one validated regional cracker and the procedure was video recorded. Data were stratified according to age groups (6-7, 8-9, 10-13, 14-17 and 18-20 years) and sex (boys and girls). Two Speech Language Pathologists independently analysed the video recordings to derive discrete bites, masticatory cycles, swallows and total swallow time indices. Using them, time/swallow, masticatory cycles/bite, swallows/bite and time/bite were calculated.

RESULTS

All parameters of TOMASS-C had moderate to good (0.6-0.85) test-retest reliability and moderate to excellent (0.69-0.99) inter-rater reliability at p > .000. Younger participants took more bites, chewed more times and swallowed more frequently with longer chewing and swallowing time. Boys exhibited a lower number of swallows, shorter swallow time and reduced total masticatory time at p > .05. Additionally, girls demonstrated fewer bites and chewing cycles compared to boys at p > .05.

CONCLUSION

TOMASS-C using a validated regional cracker was feasible and reliable. Normative data established for healthy boys and girls between 6-20 years offers much-needed quantitative data to objectively delineate individuals with and without chewing and swallowing solid food difficulties.

A Survey of Speech-Language Pathologists' Applications of Motor Learning Principles in Dysphagia Therapy in Adults in India

PURPOSE

In the study, we investigated whether speech-language pathologists (SLPs) in India use practice and feedback conditions of motor learning principles (MLPs), including biofeedback, in dysphagia therapy in adults using a problem-solution approach.

METHOD

Based on a literature review and clinical experience, we developed and validated a hypothetical case involving an adult with dysphagia (representing the problem) and a purpose-built 22-item questionnaire (representing the solution). We distributed the questionnaire electronically by sending an e-mail to 2,069 SLPs and also published a flyer on the dysphagia special interest group of India.

RESULTS

A total of 107 SLPs anonymously submitted their responses. In practice conditions, most of the SLPs reported following massed over distributed, small over large, blocked over random, whole over part, variable over constant, and internal over external practice strategies. In feedback conditions, most of the participants reported using knowledge of results over performance, high over low, immediate over delayed, and self over therapist feedback strategies. Lastly, more than two thirds of SLPs did not use biofeedback devices for dysphagia therapy.

CONCLUSION

The findings from our study indicate that SLPs in India do not adhere uniformly to the recommended practices of MLPs for dysphagia therapy in adults.

Immunosuppression for the treatment of pulmonary hypertension in patients with systemic lupus erythematosus: A systematic review

PURPOSE

To conduct a systematic review with meta-analysis to determine the effects of immunosuppression on Group 1 Pulmonary Arterial Hypertension in patients with systemic lupus erythematosus (SLE).

METHODS

We searched Medline, Embase, Web of Science, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials (CENTRAL) with a search strategy developed by a medical librarian. We included retrospective, cross-sectional, case-control, prospective studies, and randomized controlled trials (RCTs) in our analysis and only included studies that contained data for patients with SLE. We included any immunosuppressive agents (including but not limited to cyclophosphamide, glucocorticoids, mycophenolate mofetil, azathioprine, and rituximab) We assessed for risk of bias and certainty of evidence. Outcomes included hemodynamics (as measured by pulmonary arterial hypertension), functional status, 6 minute walk test (6MWT), quality of life, mortality, and serious adverse events.

RESULTS

We included three studies. One RCT and two single-arm interventional observational studies. The RCT had a high risk of bias whereas the two single-arm interventional studies were graded as fair quality. Meta-analysis could not be conducted because of insufficient data. The RCT showed significant improvements in hemodynamics (as measured by pulmonary arterial pressures) and functional status. One observational study showed improvements in hemodynamics, functional status, and 6MWT. There were insufficient data for serious adverse events, mortality, and quality of life.

CONCLUSIONS

Despite a high prevalence and with a poor prognosis, there is a paucity of data for the role of immunosuppression in the treatment of Group 1 Pulmonary Arterial Hypertension in SLE. More high-quality studies are needed, especially to investigate serious adverse events and quality of life.

Improving the breast MRI process: A longitudinal QI project at the Houston VA

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Background: The number of female veterans is increasing by more than 18,000 per year, and 700 veterans enrolled in VA healthcare are diagnosed with breast cancer each year. The American Cancer Society recommends screening MRI in women with 20-25% or greater lifetime risk of breast cancer, and primary care physicians and oncologists order breast MRIs regularly. The Michael E. DeBakey Veteran’s Affairs Medical Center (MEDVAMC) performs mammograms and ultrasounds on site, but breast MRI is not currently available. Care in the Community arranges for veterans to obtain these studies at outside facilities. This is a complex process, requiring coordination among multiple departments at the MEDVAMC, outside MRI facilities, and patients. Methods: We created a comprehensive process map for the current breast MRI ordering process to determine areas for improvement. We reviewed all breast MRI orders from 1/2019 to 5/2021 at the MEDVAMC and determined the cancellation rate and the rate of benign (BIRADS 1-2) vs non benign (BIRADS 0, 3-5) screening outcomes. We created a Pareto analysis of cancellation reasons. Our process measures were percentage of placed breast MRI orders that were cancelled and delay from MRI order to MRI performed. Our outcome measures were percentage of order cancellations due to incorrect or incomplete orders and delay from MRI order placement to results uploaded. Results: Of the 434 orders that were placed for breast MRIs, 64% were cancelled. Only 117 of the 167 patients that had MRIs ordered ultimately received one. Of the 104 patients without known malignancy who competed an MRI, 45% had non-benign findings requiring follow-up. Our pareto analysis showed that the top cancellation reason was incorrect orders, usually contrast or side verbiage. In June 2021, the CITC order set for MRI was changed from a free text box to discrete, clickable options for side and contrast. In December 2021, we held educational interventions on how to avoid delay or cancellation. Our p-chart of percentage of cancellations due to incorrect ordering shows an extremely promising decrease, with the last seven consecutive subgroups of 15 patients below the mean. The order cancellation percentage is also decreasing. The average delay pre-intervention from MRI order placement to results uploaded was 67 days. In January 2022, we implemented a breast MRI nurse navigator to help acquire results and expedite scheduling. Post-intervention, the average delay has decreased to 38.5 days. Using XmR and S charts, we have also shown an increase in precision. Conclusions: Providing discrete, clickable options within the MRI order set reduced the number of cancellations due to incorrect verbiage. Early data suggests that the educational intervention improved the cancellation rate. Instituting a nurse navigator decreased both the delay and variability for the time from order placement to results received, which will reduce the delay to follow-up of non-benign findings.

Improving the process of obtaining screening and diagnostic breast MRI: A quality improvement project at an urban VA hospital

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Background: There are two million female veterans across the United States, a number increasing by more than 18,000 per year. 1 in 8 women will be diagnosed with breast cancer in their lifetime, and studies have shown that servicewomen are 40% more likely to get breast cancer than civilians. The American Cancer Society (ACS) recommends screening MRI in women with 20-25% or greater lifetime risk of breast cancer, and both primary care physicians and oncologists are now ordering these more frequently. The Michael E. DeBakey Veteran’s Affairs Medical Center (MEDVAMC) performs screening mammograms and ultrasounds, but breast MRI is not currently available at the facility. Care in the Community arranges for veterans to obtain these studies at outside facilities. This is a complex process, requiring coordination among multiple departments, the outside MRI facility, and the patient. There are a significant number of MRI order cancellations per month, which can lead to delays in diagnosis or treatment. Methods: We created a comprehensive process map for the current breast MRI ordering process to determine areas for improvement. We looked at all breast MRI orders starting in 12/2020 at the MEDVAMC and determined the rate of cancellation and the rate of benign (BIRADS 1-2) vs non benign (BIRADS 0, 3-5) screening outcomes. We created a Pareto analysis to determine the most common cancellation reasons and p-charts of the percent of cancelled MRI orders per month and a run chart of the percent due to incorrect verbiage. Results: Of the 243 orders placed for MRI for 124 patients from 12/2020 to 1/2022, 64.2% were cancelled. Of the 57% of patients (71/124) with complete MRIs, 35.2% had non-benign findings requiring follow up, excluding known malignancies. Our Pareto analysis showed that most cancellations were due to incorrect verbiage in the order. An intervention in 6/2021 changed the MRI order from a free text box to clickable options, followed by an educational intervention in 12/2021. Cancellations due to incorrect verbiage decreased overall after June, however it has not yet reached significance. It is too early to determine if the educational intervention caused a significant change, however the cancellation rate has decreased. Conclusions: Providing discrete, clickable options within the MRI order has reduced the number of cancellations due to incorrect verbiage, though we have not yet reached significance. Early data suggests that the educational intervention has improved the cancellation rate. Fewer cancellations will lead to more timely studies, which will in turn lead to faster follow up of non-benign findings. Further directions include using a nurse navigator to reduce confusion and delays, further simplifying the ordering process, checking patient phone numbers in clinic, and sending patients home with information on the importance of screening MRI to reduce veteran cancellation.

Blood Indices In Adult Acute Burn: A Window Into Milieu Interieur - The Future Biomarkers?

Optimal treatment of sepsis in burned patients depends on early diagnosis and includes prompt administration of antimicrobials as well as management of hemodynamic alterations and other organ dysfunctions. The role of red blood cell distribution width (RDW) and platelet indices in prognosticating and identifying sepsis in acute burn patients is studied. This study was done as a prospective study over 18 months, including patients in the age group >18 or <60 years, with burns >20% and <70% TBSA, burn time to resuscitation time 24 hours or less and with thermal and scald burns. Data of 157 patients were analyzed and the following observations were made. The mean age of the study population was 31.36 years (18-59 years). RDW values were higher in the non-survivor group. Platelet count and plateletcrit were higher in the survivor group and the no sepsis group. Positive rising trends of platelet count and plateletcrit were seen in the survivor group. Day 1, 3, 7 values of RDW, platelet count and plateletcrit were significant in determining the outcome of the patient on mortality and sepsis related morbidity of the patient. RDW, platelet count and plateletcrit in combination can predict mortality and sepsis as early as the third day, thus giving a clinical advantage of initiating targeted treatment to the at-risk burn population before sepsis is detected clinically. This could better the outcomes in treatment of burn patients.

Blood Lactate And Lactate Clearance: Refined Biomarker And Prognostic Marker In Burn Resuscitation

Adequate resuscitation of acute burn patients is important to ensure end organ perfusion and oxygenation. The ideal marker to the endpoint of burn resuscitation is still not established. We aimed to evaluate the role of blood lactate and lactate clearance in burn resuscitation and their association with mortality and sepsis in burn patients. The retrospective study included patients (18-50 years) with thermal and scald burns with total body surface area of 30% to 60% over a period of 9 months who had achieved target urine output of at least 0.5ml/kg/hr within 24 hours of resuscitation. Patients were divided based on their admission blood lactate levels (Group A < 2 mmol/L and Group B > 2 mmol/L). Group B was further subdivided into Group B1 in whom blood lactate levels reached less than 2 mmol/L within 24 hours of burn resuscitation and Group B2 in whom it did not. Total patients included were 203. Mortality (M) and sepsis (S) rates in subgroup B2 were higher (M=57.9%; S=43.5%) and rates in subgroup B1 (M=25.8%; S=27.4%) were comparable to Group A (M=27.8%; S=26.4%). Persistent lactic acidosis at 24 hours was independently associated with significantly increased mortality and sepsis. Our data suggests a correlation of blood lactate levels and lactate clearance within 24 hours of admission with mortality and sepsis related to burn injury.

The Role of Systemic Therapy in the Management of Stage I Large Cell Neuroendocrine Carcinoma of the Lung

INTRODUCTION

The optimal treatment strategy for resected stage I large cell neuroendocrine carcinoma of the lung (LCNEC) remains unknown. In this analysis, we evaluate the impact of systemic chemotherapy on patients with stage I LCNEC who have undergone surgical resection.

METHODS

The study population included patients who underwent surgical resection for LCNEC and had pathologic stage I disease. We compared overall survival between patients who underwent surgical resection alone and those who underwent surgical resection plus chemotherapy. Overall survival was estimated by the Kaplan-Meier method, and comparisons were analyzed by using multivariable Cox models and propensity score-matched analyses.

RESULTS

From 2004 to 2013, 1232 patients underwent surgical resection for stage I LCNEC in the National Cancer Database, including 957 patients (77.7%) who underwent surgical resection alone and 275 (22.3%) who received both surgery and systemic chemotherapy. Five-year survival was significantly improved in patients who received chemotherapy (64.5% versus 48.4% [hazard ratio =0.54, 95% confidence interval: 0.43-0.68, p < 0.001]). Multivariable Cox modeling confirmed the survival benefit from chemotherapy for patients with resected stage I LCNEC (hazard ratio = 0.54, 95% confidence interval: 0.43-0.68, p <0.0001). The survival benefit was further confirmed by propensity-matched analysis. In addition, older (age >70 years), comorbid white patients who underwent sublobar resections for tumors larger than 20 mm had worse survival outcomes.

CONCLUSION

In this largest-reported retrospective study of patients with resected stage I LCNEC, survival was improved in patients who received chemotherapy in both stage IA and stage IB LCNEC.

The role of adjuvant therapy in the management of resected large cell neuroendocrine carcinoma (LCNEC) of the lung: A National Cancer Database (NCDB) analysis

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Background: Large cell neuroendocrine carcinoma (LCNEC) is characterized by aggressive behavior and poor outcomes compared with other non-small cell lung cancers (ONSCLC). Methods: The National Cancer Database (NCDB) was used to identify patients diagnosed with early stage NSCLC (pathologic stage I, II, IIIA) from 2004-2012 who underwent surgical resection. Patients were divided into two groups: LCNEC and ONSCLC. One-way ANOVA was used to compare continuous variables, and chi-squared testing was used to compare categorical variables. Multivariate logistic regression analyses were used to obtain hazard ratios. Results: We identified 1672 patients with resected LCNEC and 134139 with resected ONSCLC. A higher proportion of patients with ONSCLC had a Charlson-Deyo co-morbidity score of 0 compared to LCNEC patients (50.6% vs. 43.8%; p < 0.001). No other significant differences in clinical and demographic characteristics were identified. Overall survival was lower for LCNEC patients across all stages when compared to patients with resected ONSCLC (46 months versus 74 months; 5-year survival 45% versus 57%; p <0.001). Multivariate analysis confirmed the survival benefit for adjuvant chemotherapy in resected LCNEC across all stages, including stage IA, although it did not reach statistical significance (hazard ratio 0.72 (0.51-1.02), p= 0.64; Table). Conclusions: Adjuvant chemotherapy significantly improves survival for stage IB, II and IIIA LCNEC compared to surgery alone. Patients with stage IA LCNEC appear to benefit from adjuvant chemotherapy although it did not reach statistical significance. The overall magnitude of benefit from adjuvant chemotherapy appears to be higher for patients with LCNEC compared to ONSCLC. [Table: see text]