Effect of liquid bolus consistency and delivery method on aspiration and pharyngeal retention in dysphagia patients.

There is no empirically derived consensus as to what food consistency types and method of food delivery (spoon, cup, straw) should be included in the videofluoroscopic swallowing (VFSS) studies. In the present study, we examine the rates of aspiration and pharyngeal retention in 190 dysphagic patients given thin (apple juice) and thick (apricot nectar) liquids delivered by teaspoon and cup and ultrathick (pudding-like) liquid delivered by teaspoon. Each patient was tested with each of the bolus/delivery method combinations. The fractions of patients exhibiting aspiration for each bolus/method of delivery combination were (1) thick liquids (cup), 13.2%; (2) thick liquids (spoon), 8.9%; (3) thin liquids (cup), 23.7%; (4) thin liquids (spoon), 15.8%, (5) ultrathick liquids (spoon), 5.8%. In each comparison [thick liquid (cup) vs. thick liquid (spoon), thin liquid (cup) vs. thin liquid (spoon), thick liquid (cup) vs. thin liquid (cup), thick liquid (spoon) vs. thin liquid (spoon), and thick liquid (spoon) vs. ultrathick liquid (spoon)], the p value for chi 2 was < 0.001. These results suggest that utilizing thin, thick, and ultrathick liquids and delivery by cup and spoon during a VFSS of a patient with mild or moderate dysphagia can increase the chances of identifying a consistency that the patient can swallow without aspirating and without pharyngeal retention after swallowing.

Intra- and interrater variation in the evaluation of videofluorographic swallowing studies.

The objective of this study was to determine the inter- and intrarater reliability in evaluating videofluoroscopic swallowing studies (VFSS). Participants included 4 physicians (3 physiatrists and 1 internist) and 5 speech-language pathologists with at least 5 years experience in evaluating VFSS. The main outcomes of the study were reliability ratios of positive and negative tests in inter- and intrarater evaluations. Raters independently rated each of 20 VFSS on two separate occasions. Traits evaluated included oral stage impairment, aspiration, pharyngeal retention, and several functional components: timing of swallow onset, adequacy of velopharyngeal apposition, laryngeal elevation, epiglottic tilt, pharyngeal contraction, and pharyngoesophageal (PE) segment opening. Reliability varied widely depending on food type and the trait under evaluation. Inter- and intrarater reliability ratios did not differ widely. Reliability ratios values typically were highest (greater than 90%) for aspiration, especially with solid food, and lowest for the functional components. It was concluded that inter- and intrarater reliability in VFSS are adequate for evaluating oral stage, laryngeal penetration, and aspiration and pharyngeal retention, but questionable for functional components.

Cervical pain: a comparison of three pillows.

OBJECTIVE: To compare three pillows with regard to pain intensity, pain relief, quality of sleep, disability, and overall satisfaction in subjects with benign cervical pain. The three pillows evaluated were the subjects' usual pillow, a roll pillow, and a water-based pillow. STUDY DESIGN: Subjects used their usual pillows for the first week of this 5-week randomized crossover design study. They were subsequently randomly assigned to use each of the other two pillows for 2-week periods. SETTING: Outpatient neurology and physiatry clinics. PATIENTS: Forty-one subjects with benign cervical pain syndromes and free of cognitive impairments. MAIN OUTCOME MEASURES: Visual analog scale (VAS), Sleep Questionnaire, Sickness Impact Profile (SIP), and a satisfaction scale rating the pillows. RESULTS: The water-based pillow was associated with reduced morning pain intensity, increased pain relief, and improved quality of sleep. The duration of sleep was significantly shorter for the roll pillow. Overall SIP findings showed a significant advantage for the water-based pillow over the roll pillow and standard pillow. CONCLUSIONS: Proper selection of a pillow can significantly reduce pain and improve quality of sleep but does not significantly affect disability outcomes measured by the SIP.

Racial disparities in severity of cerebrovascular events.

BACKGROUND AND PURPOSE: This study was conducted to determine if blacks hospitalized for cerebrovascular events had more severe cerebrovascular events than whites similarly hospitalized. METHODS: Data from the Maryland Health Services Cost Review Commission were used to determine incidence of coma, death rates, age at death of those who died, and length of stay for acute hemorrhagic and occlusive stroke in hospitalized blacks and whites after adjusting for sex and, if appropriate, age. RESULTS: With a single exception (number of patients with hemorrhagic stroke who died during short-term hospitalization), all indices indicated that blacks incurred more severe cerebrovascular events than whites (P < .05 or less). CONCLUSIONS: Maryland state data from hospitalized patients indicate that blacks had more severe strokes than whites.

Epidemiology and dysphagia.

With few exceptions, epidemiology of dysphagia is unexplored, particularly with regard to risk and protective factors, and underutilized. The range of incidence of dysphagia in selected primary diagnoses often associated with dysphagia is summarized.

The probability of correctly predicting subglottic penetration from clinical observations.

It is difficult to predict from clinical signs and symptoms which patients suffer from subglottic penetration of foods. Most investigators attempting to predict aspiration have used small numbers of patients and relatively unsophisticated statistical techniques. In this study, we utilized 249 patients to examine the predictive value of several clinical factors thought to be suggestive of subglottic penetration with discriminant analysis. Using this approach we were able to correctly predict about 2/3 of both those who aspirate and those who do not aspirate. This is better than others have reported but still inadequate for clinical purposes.

A protocol for the videofluorographic swallowing study.

This paper presents a detailed protocol for performing the videofluorographic swallowing study (VFSS), and describes how it evolved from its antecedents. The objectives of the VFSS are both diagnostic and therapeutic. Preparing for the VFSS is described, including the equipment, food preparation, and a brief discussion of the clinical evaluation. The detailed description of the VFSS procedure covers the position of the patient, the foods presented, the views obtained, modifications of feeding and swallowing that are commonly employed, the standardized set of observations, and reporting the results. Criteria for deviating from the protocol or aborting the study are presented. The VFSS does not necessarily end when a patient aspirates. Indeed, the complete evaluation of aspiration, and the effects of maneuvers designed to reduce it, is a major purpose of the VFSS. Modifications of feeding and swallowing are tested empirically during the study. The modifications include therapeutic and compensatory techniques that may improve the safety and efficiency of swallowing. A rationale for deciding which modifications to test in a given patient is discussed. The protocol has been used successfully in more than 350 patients. It has improved the efficiency and quality of our videofluorographic examinations.

Impact of the journal Plastic and Reconstructive Surgery.

The "impact" of Plastic and Reconstructive Surgery was evaluated by bibliometric analysis. This technique considers the average frequency with which journal authors refer to articles published in Plastic and Reconstructive Surgery. The impact of Plastic and Reconstructive Surgery was compared with that of journals most commonly referred to within Plastic and Reconstructive Surgery as well as with that of journals read most commonly by Plastic and Reconstructive Surgery subscribers, such as the Annals of Plastic Surgery and the Journal of Hand Surgery (both American and British editions). The impact factor for Plastic and Reconstructive Surgery was at least twice as great as for any other journal related to this surgical subspecialty. With regard to other surgical subspecialties, while the impact factor for Plastic and Reconstructive Surgery was less than that of the Journal of Neurosurgery, Journal of Urology, and Journal of Ophthalmology, it was greater than those for orthopedics, otolaryngology, hand surgery, and dermatologic surgery.

A bibliometric analysis of the Archives of Physical Medicine and Rehabilitation.

A bibliometric analysis based on the Journal Citation Reports distributed by the Institute of Scientific Information was made of the Archives of Physical Medicine and Rehabilitation and related journals to determine the relative ranking of the Archives in several bibliometric categories. It was hoped that this process would yield objective evidence for the strengths and weaknesses of the Archives. Bibliometric indices that were compared included the impact factor (a reflection of how often a journal's articles are cited) and the cited half-life and immediacy (both of which deal with the timeliness of a journal's articles). The overall rankings of the Archives in 1988 compared to all journals indexed were 1,887 of 4,020 for impact factor, 2,633 of 2,683 for cited half-life and 1,793 of 4,020 for immediacy. In general, the Archives ranked higher in most of these indices than most rehabilitation journals but lower than other journals widely cited in the Archives, including general journals, other specialty journals, and a basic science journal.

Scintigraphy for the detection and quantification of subglottic aspiration: preliminary observations.

Eleven patients with previously documented aspiration underwent a radioisotopic swallowing study to detect and quantify airway penetration. In those subjects able to complete a rapid-acquisition phase during swallowing, no laryngotracheal penetration was seen despite previous evidence of aspiration. However, sequential static pulmonary imaging showed significant aspiration in three individuals. Attempts were made to measure the percentage of ingested material aspirated and the clearance rate from the airways. Eight patients (73%) failed to show definite evidence of aspiration on scintigrams. It is hypothesized that the lack of scintigraphic detection in previously proven aspirators was due either to interval improvement of the dysphagia or to difficult-to-detect laryngotracheal aspiration. Isotopic imaging during swallowing appears to have little utility; however, after ingestion, the technique can demonstrate more distal penetration not detected on videofluoroscopy. More studies are suggested to better define the sensitivity and specificity of scintigraphy in aspiration detection and to determine whether these techniques have prognostic value that could alter patient management.

Nutritional status during the acute stage of spinal cord injury.

This study was designed to help clinicians establish objective guidelines for meeting the nutritional requirements of spinal cord injury (SCI) patients during their initial hospitalizations. The nutritional status of 51 SCI patients treated between 1983 and 1986 was assessed at two, four, and eight weeks after injury. Nutrient deficiencies such as albumin (100% of patients), carotene (62%), transferrin (37%), ascorbate (25%), thiamine (24%), folate (20%), and copper (11%) were documented most frequently at two weeks postinjury. There was an average of 2.0, 1.6, and 1.2 nutrient abnormalities per patient at two, four, and eight weeks postinjury, respectively. Although most depressed nutrient parameters improved with time, diet-dependent plasma proteins such as albumin and transferrin remained low throughout the entire eight-week period. Mean body weight declined 1.3 +/- 3.9 kg during the first two weeks, 2.0 +/- 4.4 kg between two and four weeks, and 0.4 +/- 2.0 kg between four and eight weeks after injury. Significant findings also included a strong correlation between plasma albumin, ascorbate, and carotene levels and maximal inspiratory and expiratory pressure (p less than .05). Although nutrient status usually improved with time and was not definitely associated with an increased risk of secondary medical complications, prudence dictates that these deficiencies should be prevented by appropriate intervention.

Prediction of pyelocaliectasis in follow-up of patients with spinal cord injury.

Two hundred and fifty spinal cord injury patients were studied on each of two occasions, 12 to 24 months apart, to determine which urological findings could be used to predict the subsequent development of clinically significant pyelocaliectasis. An equation was developed which correctly classified 90% of the patients who remained free of clinically significant pyelocaliectasis and 82% of the patients who subsequently developed clinically significant pyelocaliectasis. The statistically significant risk factors were renal calculi, bladder diverticula and a decrease in effective renal plasma flow. This study suggests that the presence of these risk factors warrants careful monitoring of renal function in these patients and appropriate management of bladder dysfunction.

Year-to-year changes in effective renal plasma flow in asymptomatic spinal cord injury patients.

Year-to-year variations in effective renal plasma flow (ERPF) measurements were determined in 78 patients with spinal cord injury who had no urologic complications or surgery or bouts of chills and fever between consecutive annual follow-up examinations. The effects of age, gender, level and degree of lesion, and time since injury on the degree of variability were also determined. None of the factors considered had a statistically significant effect (P greater than 0.05) on year-to-year variations in ERPF. About 90 per cent of the individual kidney ERPF measurements were within 100 ml/min of the measurement made in the previous year, and 90 per cent of the total ERPF measurements were within 175 ml/min of the previous year's measurement. Follow-up of patients whose year-to-year variability exceeded these limits showed that most subsequently regressed toward the mean spontaneously. These data suggest that kidney blood flow varies considerably from year to year in otherwise healthy patients with spinal cord injury and that changes of 100 ml/min or more for an individual kidney or 175 ml/min or more for both kidneys together are common, but probably of little clinical significance, provided the absolute levels of ERPF remain within normal limits.

Clinical significance of minimal changes on intravenous urography after spinal cord injury.

Evidence is given to support the thesis that minimal pyelocaliectasis and ureterectasis are of little clinical significance in spinal cord injured patients. Such renal changes almost always improve or remain stable on sequential examinations. Since moderate or severe pyelocaliectasis is usually detected by renal scintillation procedures, these findings support its use as a urinary tract screening examination along with an abdominal radiograph to detect calculi. The need for long-term serial examination of the urinary tract in spinal cord injury is emphasised.

Initial bladder management in spinal cord injury: does it make a difference?

We classified 204 patients with acute spinal cord injury into 1 of 5 groups according to the initial form of urological management. Group A patients were placed on an intermittent catheterization program within 36 hours of injury, group B received a suprapubic trocar within 36 hours of injury, group C had urethral catheters in place for more than 36 hours before intermittent catheterization was begun, group D was on indwelling urethral catheter drainage throughout the hospitalization and discharged from the hospital with indwelling catheters, and group E was placed on intermittent catheterization in a community hospital. There were no statistically significant differences among the groups in the incidence of chills and fever, rate of urinary infections (excluding group D), incidence of upper tract changes, genitourinary complications or frequency of urological procedures at 1 year after injury. We conclude that the method of initial bladder management is relatively unimportant in determining the urological prognosis after spinal cord injury.

Iatrogenic dilatation of the upper urinary tract during radiographic evaluation of patients with spinal cord injury.

Patients with upper and lower motor neuron spinal cord injuries were observed to determine whether cystography immediately before excretory urography induced iatrogenic dilatation of the upper urinary tract that was indistinguishable from true pathological dilatation. Evidence is given that such dilatation occurs. This iatrogenic dilatation is not seen in patients with normally innervated urinary tracts and appears to be caused by exaggerated bladder reflexes in patients with upper motor neuron lesions. Bladder spasms precipitated by cystographic contrast material also may create vesicoureteral obstruction and lead to dilatation of the upper urinary tract. Consequently, it is suggested that cystography should not immediately precede excretory urography. When such a sequence is necessary, room or body temperature contrast medium should be used for the cystogram, the bladder should be emptied before the excretory urogram is started and a 1-hour interval should be allowed between the 2 procedures. The findings also suggest that any factors that induce repeated or continuing bladder spasms may contribute to progressive dilatation of the upper urinary tract.

Prophylactic antibacterial therapy for preventing urinary tract infections in spinal cord injury patients.

We conducted 202 trials in 161 male hospital patients to determine if prophylactic administration of ascorbic acid or antibacterials (trimethoprim-sulfamethoxazole, nalidixic acid, methenamine hippurate or nitrofurantoin macrocrystals) would prevent bacteriuria infections in spinal cord injury patients who had had at least 1 bout of bacteriuria. None of the drugs tested appeared to be statistically effective in the doses used in preventing bacteriuria in these patients. Moreover, sensitivities were lost to several drugs other than those used prophylactically. We conclude that use of prophylactic doses of ascorbic acid or antibacterials has not proved to be beneficial in spinal cord injury patients free of indwelling catheters.

Long-term followup of renal function after spinal cord injury.

Effective renal plasma flow was measured in acute spinal cord injury patients for up to 10 years after injury to determine the extent of renal deterioration in these patients and to identify the factors associated with a loss of renal function. The over-all mean decrease in effective renal plasma flow for all patients as a whole was 4.5 ml. per year. Factors associated with a statistically significant reduction in effective renal plasma flow included age, gender, renal calculi, quadriplegia, and a history of chills and fever. Other factors examined but not found to be statistically significant included years since injury, presence of severe decubiti, bladder calculi, bacteriuria and extent of injury. This study suggests that renal function usually can be preserved in spinal cord injury patients if the treatable risk factors are managed properly.

Effective renal plasma flow: clinical significance after spinal cord injury.

We conducted a study to determine if effective renal plasma flow routinely measured by hippurate clearance during a comprehensive renal scintillation procedure is a relevant measure for assessing renal function in spinal cord injury patients. All subjects had spinal cord injury and had had contemporaneous comprehensive renal scintillation procedures and excretory urograms on 2 occasions 24 months or less apart. Each of the 469 kidneys was placed into 1 of 5 quintiles on the basis of its effective renal plasma flow at the first examination. The percentage of the kidneys that had clinically significant pyelocaliectasis or in which the pyelocaliectasis significantly worsened was 20.4 per cent in the lowest (first) quintile and 9.3, 2.2, 5.4 and 3.2 per cent in the second, third, fourth and fifth quintiles, respectively. Analogous data for ureterectasis were 16.1, 8.2, 2.2, 3.3 and 3.2 per cent. There was a significant (p less than 0.01) correlation between effective renal plasma flow and renal parenchymal thickness. Kidneys with renal calculi averaged effective renal plasma flows about 25 per cent lower than those of kidneys free of calculi. We conclude that effective renal plasma flow is a relevant measure for assessing renal function in spinal cord injury patients.