Vocal Fold Motion Impairment in Neurodegenerative Diseases.

Vocal fold motion impairment (VFMI) is the inappropriate movement of the vocal folds during respiration, leading to vocal fold adduction and/or abduction problems and causing respiratory and vocal impairments. Neurodegenerative diseases (NDDs) are a wide range of disorders characterized by progressive loss of neurons and deposition of altered proteins in the brain and peripheral organs. VFMI may be unrecognized in patients with NDDs. VFMI in NDDs is caused by the following: laryngeal muscle weakness due to muscular atrophy, caused by brainstem and motor neuron degeneration in amyotrophic lateral sclerosis; hyperactivity of laryngeal adductors in Parkinson's disease; and varying degrees of laryngeal adductor hypertonia and abductor paralysis in multiple system atrophy. Management of VFMI depends on whether there is a presence of glottic insufficiency or insufficient glottic opening with/without severe dysphagia. VFMI treatment options for glottic insufficiency range from surgical interventions, including injection laryngoplasty and medialization thyroplasty, to behavioral therapies; for insufficient glottic opening, various options are available based on the severity and underlying cause of the condition, including continuous positive airway pressure therapy, botulinum toxin injection, tracheostomy, vocal fold surgery, or a combination of interventions. In this review, we outline the mechanisms, clinical features, and management of VFMI in NDDs and provide a guide for physicians who may encounter these clinical features in their patients. NDDs are always progressive; hence, timely evaluation, proper diagnosis, and appropriate management of the patient will greatly affect their vocal, respiratory, and swallowing functions as well as their quality of life.

[A Questionnaire Survey of Nurses on Pharmacist Services in the Emergency Rooms at Tokushukai Medical Group].

We conducted a multicenter survey of emergency room nurses to obtain information that would be useful for the establishment of pharmacist services in emergency rooms. Notably, 199 valid responses were obtained from 12 hospitals. The most common expectation from pharmacists in the emergency room was "drug management" (70.9%), followed by "providing information to physicians regarding the patient's medication history" (59.3%), and "auditing of dosage and interaction" (57.3%). The working arrangements that the survey respondents wanted regarding pharmacists in emergency rooms were: 24 h pharmacist (41.7% wanted this arrangement), day-shift pharmacist (24.6% wanted this arrangement), 24 h on-call (17.1% wanted this arrangement), day-shift on-call (5.0% wanted this arrangement), telephone support (11.1% wanted this arrangement), and 0.5% said that there was no need for pharmacists. In the analysis of factors affecting nurse satisfaction, day-shift pharmacist was a significant factor. We hope that the results of this survey will be used as a guide for the development of emergency room pharmacist services tailored to the unique characteristics and actual working conditions of each hospital.

Swallowing improvement surgeries.

PURPOSE: To discuss the different swallowing improvement surgeries that address one or more dysfunctional pharyngolaryngeal structures causing dysphagia. These surgeries reduce the risk of aspiration without sacrificing vocal function. METHODS: We searched the PubMed database and used Google Scholar search engine to find studies discussing the different swallowing improvement surgeries. A manual search of references in selected articles and reviews was done as well. No chronologic limitation was set for the studies; however, only articles written in English and Japanese were considered. Due to the nature of this article, no particular inclusion or exclusion criteria were set when searching for studies to be used as references; however, all relevant studies were reviewed and agreed upon by the authors for inclusion in this review article. RESULTS/DISCUSSION: Surgeries to improve swallowing function can be categorized into those that reinforce nasopharyngeal closure or pharyngeal contraction, improve laryngeal elevation or pharyngoesophageal segment opening, and those that improve vocal fold closure to protect the airway during swallowing. They are an effective alternative treatment that may significantly improve these patients' quality of life. Swallowing rehabilitation with the altered pharyngolaryngeal structures is required post-operatively to significantly improve patients' dysphagia. CONCLUSIONS: Surgeries to improve swallowing function address specific dysfunctional sites involved in the swallowing mechanism. Choosing the most appropriate surgery for each patient requires knowledge of the pathophysiology for their dysphagia and detailed pre-operative work-up.

Two cases of systemic capillary leak syndrome associated with COVID-19 in Japan.

Systemic Capillary Leak Syndrome (SCLS) is a rare disease that causes severe distributive shock provoked by infection or vaccination. SCLS is clinically diagnosed by a triad of distributive shock, paradoxical hemoconcentration, and hypoalbuminemia. SCLS associated with coronavirus disease (COVID-19) in adults has not been reported yet in Japan. Case 1: A 61-year-old woman with fever, sore throat, headache, and muscle pain was admitted to our emergency department with suspected COVID-19. She had been diagnosed with SCLS 3 years earlier. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antigen and polymerase chain reaction (PCR) tests were negative at admission. She went into shock in the emergency department and was treated for septic shock. The following day, the SARS-CoV-2 PCR test was positive. She did not respond to fluid resuscitation and catecholamine and finally died. Case 2: A 58-year-old man was admitted to our hospital for de-saturation due to COVID-19. He got into shock on day 3. SCLS was suspected, and 5 g of intravenous immunoglobulin and 5% albumin were administered for sepsis treatment. He responded to the aggressive fluid therapy within 48 h and was finally discharged. COVID-19 can trigger SCLS, and early recognition of SCLS is crucial for survival. Primary care physicians should consider SCLS when they observe distributive shock and paradoxical hemoconcentration deviations from the natural course of COVID-19.

Differences in residual volume above different tracheostomy tube cuffs depending on tube structure, tube tilt angle, and liquid viscosity.

INTRODUCTION: Proper management of aspirated material above the tracheostomy tube cuff is crucial to prevent complications, such as aspiration pneumonia. This study aimed to thoroughly examine the effects of aspirated liquid viscosity, suction port positioning, and tube tilt angle on residual volume above the cuff (RVAC). METHODS: Five types of tracheostomy tubes (approximately 9 mm outer diameter) were placed through a transparent cylinder with an inner diameter of 18 mm. The cuff was inflated to completely seal the interior of the cylinder. Four liquids with different viscosities were poured onto the cuff, and the liquid above the cuff was suctioned from the side port. The cylinder was angled at 90° and 20°, and each test was performed thrice to determine the average RVAC. RESULTS: After side-port suctioning, some liquid residue was observed on the cuff of all tracheostomy tubes. The RVAC increased with higher liquid viscosity. The tubes with a longer distance from the suction port opening to the cuff top exhibited more RVAC. Moreover, the RVAC was almost the same regardless of the cylinder angle for tubes with a suction port on the lateral side. However, tubes with backside ports showed a decreased RVAC with cylinder tilt. CONCLUSIONS: This study underscores the persistence of residual material on cuffed tracheostomy tubes even with regular subglottic secretion drainage. This emphasizes the need for specialized tracheostomy tube development aimed at reducing post-suction RVAC. Improved designs can potentially minimize complications associated with residue accumulation.

Longitudinal Analysis of Dysphagia and Factors Related to Postoperative Pneumonia in Patients Undergoing Esophagectomy for Esophageal Cancer.

Few studies have quantified longitudinal changes in swallowing in patients undergoing esophagectomy for esophageal cancer. This study longitudinally analyzed the changes in the Modified Barium Swallow Study Impairment Profile (MBSImP™) scores, swallowing kinematic measurements, and swallowing-related symptoms in patients undergoing esophagectomy. We also examined the association between identified swallowing impairment and aspiration pneumonia after surgery. We included consecutive patients who underwent esophagectomy and completed laryngoscopy and videofluoroscopy before, two weeks, and three months after surgery. We analyzed physiological impairments using the MBSImP. We also assessed the swallowing kinematics on a 5 mL thickened liquid bolus at three time points. Vocal fold mobility was assessed using a laryngoscope. Repeated measures were statistically examined for longitudinal changes in swallowing function. The association between the significant changes identified after esophagectomy and aspiration pneumonia was tested. Twenty-nine patients were included in this study. Preoperative swallowing function was intact in all participants. The timing of swallowing initiation and opening of the pharyngoesophageal segment remained unchanged after surgery. Tongue base retraction and pharyngeal constriction ratio worsened two weeks after surgery but returned to baseline levels three months after surgery. Three months after surgery, hyoid displacement and vocal fold immobility did not fully recover. Aspiration pneumonia occurred in nine patients after surgery and was associated with postoperative MBSImP pharyngeal residue scores. Decreased hyoid displacement and vocal fold immobility were observed postoperatively and persisted for a long time. The postoperative pharyngeal residue was associated with pneumonia and thus should be appropriately managed after surgery.

Seasonal pigment fluctuation in diploid and polyploid Arabidopsis revealed by machine learning-based phenotyping method PlantServation.

Long-term field monitoring of leaf pigment content is informative for understanding plant responses to environments distinct from regulated chambers but is impractical by conventional destructive measurements. We developed PlantServation, a method incorporating robust image-acquisition hardware and deep learning-based software that extracts leaf color by detecting plant individuals automatically. As a case study, we applied PlantServation to examine environmental and genotypic effects on the pigment anthocyanin content estimated from leaf color. We processed >4 million images of small individuals of four Arabidopsis species in the field, where the plant shape, color, and background vary over months. Past radiation, coldness, and precipitation significantly affected the anthocyanin content. The synthetic allopolyploid A. kamchatica recapitulated the fluctuations of natural polyploids by integrating diploid responses. The data support a long-standing hypothesis stating that allopolyploids can inherit and combine the traits of progenitors. PlantServation facilitates the study of plant responses to complex environments termed "in natura".

Effects of early local administration of high-dose bFGF on a recurrent laryngeal nerve injury model.

BACKGROUND: Research on regenerative medicine using basic fibroblast growth factor (bFGF) has recently advanced in the field of laryngology. We previously reported that local administration of bFGF 1 month after recurrent laryngeal nerve (RLN) paralysis compensated for atrophy of the thyroarytenoid muscle. The objective of this study was to elucidate the effects of early bFGF administration on the thyroarytenoid muscle after RLN transection and to investigate the underlying mechanisms. METHODS: A rat model of RLN paralysis was established in this study. One day after RLN transection, low- (200 ng) or high-dose (2000 ng) bFGF or saline (control) was administered to the thyroarytenoid muscle. The larynges were excised for histological and immunohistochemical examinations at 1, 7, 14, 28, and 56 days after administration. RESULTS: The cross-sectional thyroarytenoid muscle area was significantly larger in the high-dose group than in the saline and low-dose groups on days 28 and 56. Immunohistochemistry indicated that bFGF significantly increased the number of satellite cells in the thyroarytenoid muscle up to day 14 and that of neuromuscular junctions on days 28 and 56. CONCLUSIONS: A single, early local administration of high-dose bFGF prevented atrophic changes in the thyroarytenoid muscles by activating satellite cell proliferation and reforming neuromuscular junctions. As increased neuromuscular junctions are expected to maintain myofiber volume, bFGF administration may prevent thyroarytenoid muscle atrophy in the mid to long term.

Clinical Risk Factors for Dysphagia and Esophageal Dysmotility in Systemic Sclerosis.

Systemic sclerosis (SSc) is often associated with dysphagia and esophageal dysmotility; however, only a few clinical studies on this topic have been conducted. Patients with SSc who underwent swallowing examinations and esophagography at our institution between 2010 and 2022 were included. A retrospective evaluation of the patients' backgrounds, autoantibody positivity, swallowing function, and esophageal motility was performed using medical charts. The association between dysphagia and esophageal dysmotility in patients with SSc and respective risk factors was investigated. Data were collected from 50 patients. Anti-topoisomerase I antibodies (ATA) and anti-centromere antibodies (ACA) were detected in 21 (42%) and 11 (22%) patients, respectively. Dysphagia was present in 13 patients (26%), and esophageal dysmotility in 34 patients (68%). ATA-positive patients had a higher risk for dysphagia (p = 0.027); ACA-positive patients had a significantly lower risk (p = 0.046). Older age and laryngeal sensory deficits were identified as risk factors for dysphagia; however, no risk factors for esophageal dysmotility were identified. No correlation was found between dysphagia and esophageal dysmotility. Esophageal dysmotility is more common in patients with SSc than in those with dysphagia. Autoantibodies can be predictors of dysphagia, and dysphagia must be carefully considered in ATA-positive and elderly patients with SSc.

Promotion of antimicrobial stewardship following issuance of the antimicrobial resistance national action plan in Japan: A systematic review of 2016-2020.

BACKGROUND: Antimicrobial resistance (AMR) represents a global threat with the potential to cause a significant healthcare burden. In 2016, the Japanese Government issued the national action plan (NAP) for AMR. Since issuance of this plan, several studies on antimicrobial stewardship programmes (ASPs) have been published in Japan. This systematic review was undertaken to elucidate the current state of ASPs and the impact of the NAP. METHODS: Medline (PubMed) and EMBASE were searched for studies published between January 2016 and the end of September 2021. The Risk of Bias in Non-Randomized Studies of Intervention tool was used to assess the risk of bias in interventional studies, and the Newcastle-Ottawa Scale was used to assess the quality of cohort, case-control and cross-sectional studies. RESULTS: Eighty studies, including 30 (37.5%) interventional studies, 15 (18.8%) database-oriented studies and nine (11.3%) analytical studies (one case-control study, six cohort studies and two cross-sectional studies), were included. All of the interventional studies were before-after trials, and interrupted time series analysis was commonly used to assess changes in antimicrobial consumption per intervention. Five database-related studies demonstrated decreasing antimicrobial consumption after issuance of the NAP. CONCLUSION: Several ASP studies were published after issuance of the NAP, suggesting that the latter promoted research into ASPs. A few database-related studies showed a positive impact of the NAP on antimicrobial consumption. However, more high-quality studies, especially interventional studies using an appropriate methodology and standardized data collection, are needed.

Aspiration Prevention Surgery: Clinical Factors Associated With Improvements in Oral Status Intake and Suction Frequency.

OBJECTIVE: In recent years, the use of aspiration prevention surgery (APS) for the treatment of severe dysphagia has been on the rise. However, relevant clinical studies have included small samples, and the frequency of, and risk factors for postoperative complications have not been clarified. We investigated the clinical features of patients undergoing APS and whether oral-intake status and suction frequency could be reduced. STUDY DESIGN: A case series. SETTING: Single-institution academic center. METHODS: We retrospectively evaluated medical charts generated from 2010 to 2021. The clinical characteristics of patients undergoing APS, changes in the oral-intake status (Functional Oral Intake Scale, FOIS), suction frequency before and after surgery, risk factors for postoperative complications, and factors contributing to improvements in postoperative oral-intake status were retrieved. RESULTS: We included the data of 100 patients (median age: 65 years, 72 men). Amyotrophic lateral sclerosis was the most common primary disease (28%), and glottis closure was the most common APS (69%). Postoperatively, 78% of patients showed improvements in the FOIS score, and suction frequency decreased in 85% of cases. Postoperative complications were observed in 10 patients (10%), wound infection in 6, and bleeding in 4; all improved. Higher preoperative FOIS scores were significantly associated with postoperative complications (p = 0.02). CONCLUSION: APS contributed to improving the FOIS score and helped reduce the suction frequency in most cases. APS can be performed safely with proper perioperative management, even in patients with poor preoperative general conditions and nutritional status.

Aspiration prevention surgeries: a review.

BACKGROUND: Severe dysphagia can cause intractable pneumonia and lead to life-threatening conditions. Intractable aspiration can occur despite medical management for aspiration prevention. Surgical intervention is indicated for intractable aspiration to prevent potentially life-threatening complications. Since the 1970s, several surgical treatments to prevent aspiration have been reported, and various aspiration prevention surgeries have been introduced, but little is known about them or their benefits. This is a review of the types of aspiration prevention surgery, with the aim of increasing aspiration prevention surgery awareness and their clinical outcomes among medical professionals, which will guide the choices of aspiration prevention surgeries for patients with intractable aspiration. MAIN BODY: Aspiration prevention surgeries can be categorized into three according to their approaches: removal of the larynx, altering the structure of the trachea, and closure of the larynx. Aspiration prevention surgeries to remove the larynx include total and central-part laryngectomy. Aspiration prevention surgeries to alter the structure of the trachea include tracheoesophageal diversion, laryngotracheal separation, and the tracheal flap method. Surgeries to close the larynx can be divided into supraglottic laryngeal closure, glottic laryngeal closure, and subglottic laryngeal closure. Aspiration prevention surgeries prevent aspiration and increase oral intake in 50-80% of patients. Most patients lose vocal function after aspiration prevention surgeries; however, some patients who have undergone total laryngectomy or laryngotracheal separation restored their speech function through tracheoesophageal puncture and use of voice prosthesis. Postoperative suture failure is frequent after epiglottic flap closure and total laryngectomy but rare after central-part laryngectomy, laryngotracheal separation, glottic closure, and subglottic closure. Furthermore, aspiration prevention surgeries improve the quality of life of patients and their caregivers by decreasing suctioning frequency. CONCLUSIONS: In this review, we described the history and development of aspiration prevention surgeries. Medical professionals need to continually improve their knowledge and skills to facilitate appropriate aspiration prevention surgeries according to patient condition.

Case Report: An Imported Case of Severe Leptospirosis with Septic Cardiomyopathy Requiring Venoarterial Extracorporeal Membrane Oxygenation in Japan.

A 29-year-old Japanese man presenting with fever, joint pain, and diarrhea was admitted to the intensive care unit for cardiogenic and distributive shock. We suspected leptospirosis based on conjunctival hyperemia, skin rash, elevated bilirubin, and renal involvement; a travel history to Laos was also suggestive. We confirmed the diagnosis with blood and urine polymerase chain reaction and microscopic agglutination tests using paired serum samples. His hemodynamics were unstable, and his echocardiogram showed diffuse and severe left ventricular systolic dysfunction on day 2. He initially required venoarterial extracorporeal membrane oxygenation (V-A ECMO) support but responded and recovered on antimicrobial therapy. His cardiac function and hemodynamics improved on day 5. Severe leptospirosis may cause jaundice, renal failure, pulmonary hemorrhage, acute respiratory distress syndrome, and central nervous system involvement; however, few studies have reported severe cardiac manifestations. Herein, we report the first case of septic cardiomyopathy secondary to leptospirosis that was successfully managed with V-A ECMO. Leptospirosis should be included in the differential diagnosis when a patient returning from an endemic area presents with cardiogenic shock. Furthermore, intensive care management with prompt initiation of V-A ECMO should be considered to reverse septic cardiomyopathy.

Swallowing computed tomography and virtual reality as novel imaging modalities for the diagnosis of clicking larynx: Two case reports.

Globus sensation and pain causes are difficult to identify by conventional examination methods. With technology advances, new imaging methods including swallowing computed tomography (CT) and virtual reality (VR) have emerged and are contributing to definite diagnoses. We report two cases of cervical discomfort diagnosed as clicking larynx using swallowing CT/VR . Case 1 is a 55-year-old man. There were no findings on laryngoscopy or swallowing examinations, but swallowing CT/VR showed that the thyroid cartilage collided with the hyoid bone during swallowing, leading to the diagnosis of a clicking larynx. The patient was obese and is under observation hoping that weight loss will improve symptoms. Case 2 is a 32-year-old transgender man. He is receiving male hormones for gender identity disorder. He was diagnosed with a clicking larynx using swallowing CT/VR. Hormonal therapy may have increased the size of the thyroid cartilage, likely causing the symptoms. As they didn't choose surgical treatment, no symptomatic relief was achieved, but identifiying the cause contributed to improved patient satisfaction. Swallowing CT/VR is useful not only for evaluating the swallowing function, but also the underlying etiology of globus sensation and pain upon swallowing. Further clinical applications of this technique are expected for motion induced cervical symptoms.

Changes in intravenous and oral antimicrobial prescriptions during the coronavirus disease 2019 (COVID-19) pandemic: an experience at a tertiary-care center.

Antimicrobial use during the coronavirus disease 2019 (COVID-19) pandemic at a tertiary-care center was analyzed using interrupted time-series analysis. Among intravenous antimicrobials, the use of azithromycin and third-generation cephalosporins significantly decreased during the current pandemic. Similarly, the use of oral antimicrobials, including azithromycin and fluoroquinolones, also decreased.

Peutz-Jeghers Syndrome.

This case report describes multiple dark-brown 1- to 2-mm hyperpigmented macules on the lips, nose, and conjunctivae.

Sex-and Age-Based Etiological Analysis of 2901 Patients With Dysphonia in a Japanese Tertiary Medical Institute.

OBJECTIVES: Societal aging is a grave concern in Japan, and its impact on voice clinics has not been investigated. This study aimed to clarify recent demographic features of geriatric dysphonia at a tertiary medical institute in Japan. STUDY DESIGN: Retrospective study. METHODS: The medical records of 2901 patients newly referred to the Voice Outpatient Clinic of the University of Tokyo Hospital between 2003 and 2020 were analyzed for age, sex, and etiology. RESULTS: The mean ± standard deviation age of all patients was 53.2 ± 20.7 (median, 58; range, 0-95) years. The aging rate (ratio of patients aged ≥65 years) increased continuously during the study period, and the recent aging rate was the highest in the world (43%). However, its rate of increase has slowed over the past 10 years. The etiologies of dysphonia associated with the largest number of older patients were vocal fold immobility (32%), vocal fold atrophy (23%), and benign vocal fold lesions (11%). The highest aging rate was detected in patients with laryngeal cancer/leukoplakia, vocal tremor, vocal fold atrophy, sulcus vocalis, and vocal fold immobility. CONCLUSIONS: Societal aging substantially increased the aging rate of patients with dysphonia in a Japanese voice clinic. The incidence of vocal fold immobility and atrophy is expected to continue to increase, whereas that of benign vocal fold lesions is expected to decrease.

Safety of surgical tracheostomy under continued antithrombotic therapy: A retrospective cohort study.

OBJECTIVE: Although various guidelines have been established for the management of antithrombotic therapy during surgical treatments, surgical tracheostomy (ST) under continued antithrombotic therapy (CAT) remains challenging. Here, we investigated the risk factors for complications after ST by focusing on the application of CAT during ST. DESIGN: A retrospective cohort study with medical records from 2009 to 2020. SETTING: A single-center study. PARTICIPANTS: This study included patients who had undergone ST at the Department of Otolaryngology of our hospital MAIN OUTCOME MEASURES: The primary outcomes were the incidence of complications and blood test results. Secondary outcomes were risk factors for postoperative complications. RESULTS: We identified 288 patients (median age: 64 years; 184 men [64%]), among whom 40 (median age: 67 years; 29 men [73%]) underwent CAT. Although the patients undergoing CAT had significantly longer activated partial thromboplastin time (p=0.002) and a higher prothrombin time-international normalized ratio (p=0.006) compared to antithrombotic naïve patients, no statistically significant intergroup differences were observed for the risk of bleeding, infection, or subcutaneous emphysema. Instead, ST under local anesthesia (p=0.01) and ST for airway emergency (p=0.02) significantly increased the risk of early postoperative complications. CONCLUSION: These results suggest that ST under CAT can be safely performed without any increased risk of postoperative complications. Nevertheless, surgeons should be extra cautious about early complications after ST under local anesthesia without intubation or ST for airway emergencies.

Risk Factors for Aspiration Pneumonia After Receiving Liquid-Thickening Recommendations.

OBJECTIVE: We examined the influence of liquid thickness levels on the frequency of liquid penetration-aspiration in patients with dysphagia and evaluated the clinical risk factors for penetration-aspiration and aspiration pneumonia development. STUDY DESIGN: A case series. SETTING: Single-institution academic center. METHODS: We reviewed medical charts from 2018 to 2019. First, we evaluated whether liquid thickness levels influence the frequency of liquid penetration-aspiration in patients with dysphagia. Penetration-aspiration occurrence in a videofluoroscopic swallowing study was defined as Penetration-Aspiration Scale (PAS) scores ≥3. Second, the association between liquid thickness level and penetration-aspiration was analyzed, and clinical risk factors were identified. Moreover, clinical risk factors for aspiration pneumonia development within 6 months were investigated. RESULTS: Of 483 patients, 159 showed penetration-aspiration. The thickening of liquids significantly decreased the incidence of penetration-aspiration (P < .001). Clinical risk factors for penetration-aspiration were vocal fold paralysis (odds ratio [OR], 1.99), impaired laryngeal sensation (OR, 5.01), and a history of pneumonia (OR, 2.90). Twenty-three patients developed aspiration pneumonia while undertaking advised dietary changes, including liquid thickening. Significant risk factors for aspiration pneumonia development were poor performance status (OR, 1.85), PAS score ≥3 (OR, 4.03), and a history of aspiration pneumonia (OR, 7.00). CONCLUSION: Thickening of liquids can reduce the incidence of penetration-aspiration. Vocal fold paralysis, impaired laryngeal sensation, and history of aspiration pneumonia are significant risk factors of penetration-aspiration. Poor performance status, PAS score ≥3, and history of aspiration pneumonia are significantly associated with aspiration pneumonia development following recommendations on thickening liquids. LEVEL OF EVIDENCE: 3.