Postoperative Swallowing Assessment After Lung Transplantation.

BACKGROUND: Dysphagia, aspiration, and potential pneumonia represent a major source of morbidity in patients undergoing lung transplantation. Conditions that potentiate dysphagia and aspiration include frailty and prolonged intubation. Our group of speech-language pathologists has been actively involved in performance of a bedside evaluation of swallowing, and instrumental evaluation of swallowing with modified barium swallow, and postoperative management in patients undergoing lung transplantation. METHODS: All lung transplant patients from April 2009 to September 2012 were evaluated retrospectively. A clinical bedside examination was performed by the speech-language pathology team, followed by a modified barium swallow or fiberoptic endoscopic evaluation of swallowing. RESULTS: A total of 321 patients were referred for evaluation. Twenty-four patients were unable to complete the evaluation. Clinical signs of aspiration were apparent in 160 patients (54%). Deep laryngeal penetration or aspiration were identified in 198 (67%) patients during instrumental testing. A group of 81 patients (27%) had an entirely normal clinical examination, but were found to have either deep penetration or aspiration. CONCLUSIONS: The majority of patients aspirate after lung transplantation. Clinical bedside examination is not sensitive enough and will fail to identify patients with silent aspiration. A standard of practice following lung transplantation has been established that helps avoid postoperative aspiration associated with complications.

Handgrip strength and dysphagia assessment following cardiac surgery.

OBJECTIVES/HYPOTHESIS: Prolonged intubation has been recognized as a risk factor for dysphagia following cardiac surgery. We conducted a study to determine whether those patients intubated longer than 12 hours following cardiac surgery exhibit low handgrip strength and if dysphagia is prevalent in those with low handgrip strength. STUDY DESIGN: Feasibility study. METHODS: Patients intubated more than 12 hours after cardiac surgery were enrolled. Handgrip strength was measured. If subjects were found to have low grip strength they underwent clinical swallowing exam by a speech-language pathologist followed by modified barium swallow (MBS) to assess for dysphagia. Severity of dysphagia was assessed with the Penetration-Aspiration Scale (PAS) and need for diet modification. RESULTS: Eighty-six percent (12/14) of patients tested had low handgrip strength. Eight patients with low grip strength completed the bedside swallowing exam and MBS. Four of the eight patients (50%) had deep laryngeal penetration (PAS scores 4-5) on MBS and three (38%) patients were found to have silent aspiration (PAS 8). The findings on MBS resulted in the recommendation of a swallowing strategy and/or modified diet for six of the eight (80%) patients. Nonoral feedings were recommended for two patients (25%) based on MBS results. CONCLUSIONS: A majority of patients intubated >12 hours after cardiac surgery exhibit low handgrip strength. Dysphagia is prevalent among those with low handgrip strength. The role of frailty measures in screening for dysphagia deserves further investigation. LEVEL OF EVIDENCE: 4.

Frailty measurements and dysphagia in the outpatient setting.

OBJECTIVE: Deconditioning and frailty may contribute to dysphagia and aspiration. Early identification of patients at risk of aspiration is important. Aspiration prevention would lead to reduced morbidity and health care costs. We therefore wondered whether objective measurements of frailty could help identify patients at risk for dysphagia and aspiration. METHODS: Consecutive patients (n = 183) were enrolled. Patient characteristics and objective measures of frailty were recorded prospectively. Variables tested included age, body mass index, grip strength, and 5 meter walk pace. Statistical analysis tested for association between these parameters and dysphagia or aspiration, diagnosed by instrumental swallowing examination. RESULTS: Of variables tested for association with grip strength, only age category (P = .003) and ambulatory status (P < .001) were significantly associated with grip strength in linear regression models. Whereas walk speed was not associated with dysphagia or aspiration, ambulatory status was significantly associated with dysphagia and aspiration in multivariable model building. CONCLUSION: Nonambulatory status is a predictor of aspiration and should be included in risk assessments for dysphagia. The relationship between frailty and dysphagia deserves further investigation. Frailty assessments may help identify those at risk for complications of dysphagia.

A nomenclature paradigm for benign midmembranous vocal fold lesions.

OBJECTIVES/HYPOTHESIS: There is a significant lack of uniform agreement regarding nomenclature for benign vocal fold lesions (BVFLs). This confusion results in difficulty for clinicians communicating with their patients and with each other. In addition, BVFL research and comparison of treatment methods are hampered by the lack of a detailed and uniform BVFL nomenclature. STUDY DESIGN: Clinical consensus conferences were held to develop an initial BVFL nomenclature paradigm. Perceptual video analysis was performed to validate the stroboscopy component of the paradigm. METHODS: The culmination of the consensus conferences and the video-perceptual analysis was used to evaluate the BVFL nomenclature paradigm using a retrospective review of patients with BVFL. RESULTS: An initial BVFL nomenclature paradigm was proposed utilizing detailed definitions relating to vocal fold lesion morphology, stroboscopy, response to voice therapy and intraoperative findings. Video-perceptual analysis of stroboscopy demonstrated that the proposed binary stroboscopy system used in the BVFL nomenclature paradigm was valid and widely applicable. Retrospective review of 45 patients with BVFL followed to the conclusion of treatment demonstrated that slight modifications of the initial BVFL nomenclature paradigm were required. With the modified BVFL nomenclature paradigm, 96% of the patients fit into the predicted pattern and definitions of the BVFL nomenclature system. CONCLUSIONS: This study has validated a multidimensional BVFL nomenclature paradigm. This vocal fold nomenclature paradigm includes nine distinct vocal fold lesions: vocal fold nodules, vocal fold polyp, pseudocyst, vocal fold cyst (subepithelial or ligament), nonspecific vocal fold lesion, vocal fold fibrous mass (subepithelial or ligament), and reactive lesion.

Transfection of human monocyte-derived dendritic cells with native tumor DNA induces antigen-specific T-cell responses in vitro.

OBJECTIVE: Nucleofection of genomic tumor (Tu) DNA into human monocyte-derived dendritic cells (hMoDC) was evaluated for use in producing anti-tumor vaccines able to induce effective T-cell specific immune responses. METHODS: Cultured hMoDC obtained from HLA-A2+ normal donors were nucleofected with genomic DNA extracted from an HLA-A2+gp100+ Mel 526 cell line and 3' end-labeled with biotinylated TdT nucleotides or from a genetically-modified Mel 526 expressing enhanced green fluorescent protein (EGFP). An Amaxa Nucleofector system was used for electroporation. Nucleofected hMoDC were matured in the presence of cytokines and examined in ELISPOT assays for the ability to present the gp100(209-217) epitope to epitope-specific T cells or to prime autologous naïve T cells in culture. RESULTS: The nucleofected hMoDC presented gp100 protein to HLA-A2+gp 100-specific T cells as observed in IFN-gamma ELISPOT assays. Spot formation was inhibited by anti-HLA class I and HLA-A2 but not anti-HLA class II antibodies (Abs). Tu DNA-nucleofected hMoDC also primed nasmall yi, Ukrainianve autologous peripheral blood T cells in culture to develop into Tu-reactive effector cells (CTL). These CTL recognized Tu cells which had donated genomic DNA, and these responses were MHC class I- and class II-restricted. The CTL recognized shared Tu antigens encoded in Tu-derived DNA. CONCLUSION: Nucleofection of hMoDC with genomic Tu-derived DNA is a useful strategy for Tu vaccine production: it is feasible, does not require Tu epitope isolation, can be used when few Tu cells are available, and avoids Tu-induced DC suppression.

Successful cochlear implantation in a patient with superficial siderosis.

OBJECTIVE: To define the presentation and outcome of cochlear implantation in a patient with profound sensorineural hearing loss due to superficial siderosis. STUDY DESIGN: Retrospective case review. RESULTS: Postimplantation speech reception threshold was 34 dB, and hearing in noise testing sentences were 71% demonstrating a successful outcome. These results have been maintained for 5 years after implantation. CONCLUSION: Cochlear implantation is a potentially successful rehabilitation option for certain patients with profound sensorineural hearing loss due to superficial siderosis.

Safety of uvulopalatopharyngoplasty as outpatient surgery.

OBJECTIVE: Determine the admission rate and characterize the complications in uvulopalatopharyngoplasty (UPPP) patients scheduled to have outpatient surgery. STUDY DESIGN AND SETTING: Retrospective review of patients undergoing UPPP between 2000 and 2004 in a tertiary care setting. RESULTS: UPPP alone or in conjunction with tonsillectomy, septoplasty, or supraglottoplasty was carried out in 110 patients. Average preoperative respiratory disturbance index (RDI) was 35. Admission was required in 20 (18%) patients whereas 90 (82%) were discharged on the day of surgery. Admission due to desaturation was noted in 3 (3%) patients. The most common reasons for admission included pain and nausea. There were no major complications. CONCLUSIONS: Careful preoperative selection of patients should permit many patients to undergo UPPP as outpatient surgery. Factors requiring admission may be assessed in the early postoperative period. The rate of respiratory events requiring postoperative admission after UPPP is low. SIGNIFICANCE: UPPP can be carried out safely on an outpatient basis. EBM RATING: C-4.

Multiplexed analysis of serum cytokines as biomarkers in squamous cell carcinoma of the head and neck patients.

OBJECTIVE: Our objective was to characterize cytokine profiles in the systemic circulation of patients with active squamous cell carcinoma of the head and neck (SCCHN) compared with long-term tobacco smokers as controls. Furthermore, we hypothesized that persistent immune dysregulation in patients cured of their disease may be reflected in altered cytokine profiles in the systemic circulation. STUDY DESIGN: Retrospective, case-control study. METHODS: Using three well-defined clinical cohorts of SCCHN patients and smoker controls, we analyzed 100 microL of serum for a panel of 10 cytokines to determine whether serum cytokine profiles could distinguish clinically defined groups of SCCHN patients. Statistical analysis of multiplexed cytokine profiles was applied to classify three clinically defined groups: active SCCHN patients, treated SCCHN patients with no evidence of disease for over 3 years, and matched disease-free controls. Discrimination of outcome status was accomplished using classification trees, and 10-fold cross-validation was implemented to assess classification accuracy using independent data. RESULTS: We show that multiplexed cytokine and chemokine profiling may be performed to reflect the immune status of SCCHN patients. Selected cytokine profiles indicate that immunologic responses to carcinogenesis may not normalize even in the absence of tumor for over 3 years. CONCLUSION: Multiplexed serum cytokine profiles may be applicable to early detection, for screening those at high risk for SCCHN, and as clinically predictive biomarkers of disease status in successfully treated patients.

Decreased absolute counts of T lymphocyte subsets and their relation to disease in squamous cell carcinoma of the head and neck.

PURPOSE: Apoptosis of circulating CD8+ T cells seen in patients with squamous cell carcinoma of the head and neck [SCCHN (Hoffmann T, et al. Clin Cancer Res 2002;8:2553-62)] suggested a possibility of lymphocyte imbalance. Therefore, absolute numbers and percentages of lymphocyte subsets were examined in the peripheral blood of SCCHN patients and controls. EXPERIMENTAL DESIGN: Venous blood was obtained from 146 patients with SCCHN and 54 normal volunteers. Absolute numbers of CD3+, CD4+, and CD8+ T lymphocytes were determined using fluorobeads in a flow cytometry-based technique. Percentages of T lymphocyte subsets were also evaluated by flow cytometry. The patients were grouped at the time of blood draw [active versus no evidence of disease (NED), type of therapy administered, and the length of follow-up]. RESULTS: Patients with SCCHN had significantly lower absolute numbers of CD3+ CD4+, and CD8+ T cells than normal controls. However, no differences in the percentages of T-cell subsets between patients and normal controls were observed. Patients with active disease had significantly lower CD3+ and CD4+ T-cell counts than those with NED. Patients who had NED after surgery and radiotherapy had the lowest T-cell counts among the NED cohort. Patients who had NED for >2 years did not recover their T-cell counts, and the T-cell imbalance was evident many years after curative surgery. The tumor-node-metastasis (TNM) stage or site of the disease was not related to the absolute T-cell count. Patients with recurrent disease at the time of blood draw tended to have the lowest CD4+ T-cell counts. CONCLUSIONS: Patients with SCCHN have altered lymphocyte homeostasis, which persists for months or years after curative therapies.