Changes in retro-odontoid mass after upper cervical spine surgery.

A non-neoplastic mass posterior to the dens is termed a retro-odontoid mass (R-OM). This retrospective study evaluated radiographic and clinical outcomes and R-OM changes after upper cervical spine surgery. This study included 69 patients who underwent upper cervical spine surgery, including atlantoaxial fusion, occipitocervical fusion, or decompression. All patients underwent preoperative magnetic resonance imaging (MRI). Six-month follow-up MRI examinations were performed in 30 patients who had preoperative R-OMs. Radiographic outcomes of the anterior and posterior atlantodental intervals were measured using X-rays and computed tomography. The R-OM and space available for the cord (SAC) were measured using MRI. Clinical outcomes were evaluated using neck and arm pain visual analog scales, the Japanese Orthopedic Association score, the neck disability index, and the patient-reported subjective improvement rate. The anterior atlantodental interval decreased, while the posterior atlantodental interval and SAC increased postoperatively. Among the clinical outcomes, the neck and arm pain and the neck disability index decreased postoperatively, while the Japanese Orthopedic Association score increased. All clinical and radiographic outcomes improved postoperatively. The R-OM either decreased in size or disappeared after fusion surgery in all cases, except in one patient who underwent decompression surgery. In conclusion, stabilization through fusion surgery is essential for treating R-OM.

Thickened liquids for dysphagia management: A call to action in the development of educational and instructional strategies.

This article is a "call to action" in the service delivery of thickened liquids. We discuss the importance of staff education and further development of educational resources in dysphagia management involving the use of thickened liquids, particularly as related to inadequacies in staff education and training. We discuss the use of contemporary instructional strategies to promote accuracy in preparation and knowledge about the thickening process.

Gravity flow test comparisons for mildly thick consistency.

Simple measurement tools that provide objective information about the consistency of thickened liquids have received increasing attention given possible application to clinical practice for dysphagia. The International Dysphagia Diet Standardization Initiative (IDDSI) advocates the use of the IDDSI Flow Test for measuring thickness and verifying a prescribed level of consistency. This study compares gravity flow test measurements taken with two 10-ml syringes of starch and gum-thickened samples prepared to a mildly thick consistency using product label information. One of the 10-ml syringes met IDDSI specification and the other 10-ml syringe did not. Thickened samples also were measured using the line spread apparatus. The results showed that two syringes yielded significantly different gravity flow test measurements, often resulting in changes to the classification level of thickness. There was no effect of thickening agent. Line spread measurements did not vary from one another. Study findings indicate the importance of continued testing with the IDDSI Flow Test and education/awareness about the use of the IDDSI reference syringe. An essential aspect about the use of thickened liquids in dysphagia management is that beverage preparations represent their prescribed level of modification. The findings of this study indicate the importance of following syringe specifications when conducting gravity flow testing using the IDDSI methodology. The implication is that the wrong 10-ml syringe could result in errant clinical decisions in determining the accuracy of texture modifications, resulting in care providers who are more likely to over or under thicken modifications to achieve a targeted level of thickness.

Incremental Adjustments to Amount of Thickening Agent in Beverages: Implications for Clinical Practitioners Who Oversee Nutrition Care Involving Thickened Liquids.

This study examined the changes in viscosity in response to small alterations in the amount of a thickening agent mixed with three commonly thickened beverages. A total of 11 incremental adjustments in the amount of a starch-based thickening agent (5.0 g to 7.0 g) were made. The results showed that the incremental increases resulted in systematic changes to the liquid thickness, reflecting modifications that ranged from a nectar (mildly thick) to a honey-like (moderately thick) level of consistency. The findings emphasize the importance of the proper preparation of thickened beverages, highlighting the need for standards in training practices and the use of simple measurement tools for assuring the prescribed levels of consistency.

Modifying Food Textures: Practices and Beliefs of Staff Involved in Nutrition Care.

Purpose: Modifying food texture is an important part of dysphagia management, yet less is known about the day-to-day practices that might impact the nutritional well-being of patients. This study surveyed staff involved in the service delivery of texture-modified foods with the objectives to gain information about roles and responsibilities, instruction and knowledge about modifying foods, and beliefs about the use of texture-modified foods in nutrition care. Method: We created a 21-item survey about texture-modified foods. Recruitment efforts focused on both professional and frontline staff involved in service delivery. Practice groups and organizations provided the means of recruiting professionals from different disciplines. Because frontline staff (e.g., certified nursing assistants, cooks) do not have similar membership groups, we recruited them through direct contacts with health care agencies. Results: A total of 175 individuals completed the survey. Respondents included 107 professionals (primarily certified dietary managers, registered dietitians, speech-language pathologists) and 68 frontline staff (mostly certified nursing assistants/home health aides). Although the frontline and professional staff showed generally similar patterns of opinions and beliefs about modified food textures, differences emerged in reported experiences, roles, and responsibilities in service delivery. Conclusions: Survey respondents conveyed generally positive attitudes and opinions about the use of texture-modified foods, and respondents perceived them to be easy to execute and beneficial to the nutritional well-being of patients. Survey findings clearly highlight the contributions of frontline staff in the service delivery of modified food textures. Consideration must be given to continued reliance on informal, limited instruction about texture-modified foods and possible implications for safe nutrition care. Both professional and frontline staff convey a willingness to customize or alter food textures and the belief that patients should be able to choose the level of texture modification that they want to eat.

Visualizing the Consistency of Thickened Liquids With Simple Tools: Implications for Clinical Practice.

Purpose: Accurate texture modifications to thin liquids are a critical aspect of patients' nutritional health and well-being. This study explored the use of 3 tools (2 distance- and 1 time-measuring devices) to characterize texture-modified liquids. The objectives were to use the tools to measure modified liquids, to determine if measurements differentiated nectar and honey levels of modification, and to compare measurements with other published reports. Method: We measured the flow distance of 33 prethickened water samples in centimeters (cm) using a line spread apparatus and a Bostwick Consistometer (Christison Particle Technologies). We selected a Zahn viscosity cup to measure the stream time of each prethickened liquid in seconds. Results: The 2 distance-measuring devices (line spread and Bostwick Consistometer) showed that thinner (nectar-thick) modifications spread or flowed a farther distance in comparison to thicker (honey-like) modifications. Testing with the line spread indicated that an average spread distance of 4.5 cm differentiated nectar-thick and honey-like consistencies. A flow distance of greater than 15 cm differentiated nectar from honey consistency measured with a Bostwick Consistometer. We were not successful in using the Zahn viscosity cup to determine the stream time of modified liquids. Conclusions: Two of the tools provided objective information about levels of liquid modification, which has implications for day-to-day preparation. Measurement tools that are accurate and easy to use have the potential to provide quick and dependable feedback to verify a prescribed level of liquid modification. Further efforts are needed to standardize the application of simple measurement tools in the management of patients who consume thickened liquids.

Sensory texture analysis of thickened liquids during ingestion.

Practitioners support the use of thickened liquids for many patients with disordered swallowing. Although physical measures have highlighted differences among products there are questions about the ability of the measures to fully explain the sensory texture effects during swallowing of thickened liquids. This study used a trained sensory panel to describe the textural aspects of liquids during ingestion and swallowing. The lexicon was able to characterize differences in beverages, thickeners, and thickness levels with the most important attribute being viscosity, which loaded heavily in the almost one-dimensional space that resulted from the sensory analysis of these beverages. Other effects, such as slipperiness provided some minimal additional information on the products. PRACTICAL APPLICATIONS: Trained sensory panelists were shown to be useful in the measurement of differences in thickened liquid products prescribed for patients with dysphagia. They were able to differentiate products based on perceived differences related to flow speed, viscosity, and other parameters suggesting their use in further studies of swallowing behavior and for development of products for disordered swallowing should be considered. Understanding how these variables might relate to clinical decision making about product selection or modification to best meet the nutritional needs of a person with disordered swallowing could be helpful. This is especially true given the difficulties in measuring texture instrumentally in these products.

Evaluation of malnutrition in orthopaedic surgery.

Malnutrition can increase the risk of surgical site infection in both elective spine surgery and total joint arthroplasty. Obesity and diabetes are common comorbid conditions in patients who are malnourished. Despite the relatively high incidence of nutritional disorders among patients undergoing elective orthopaedic surgery, the evaluation and management of malnutrition is not generally well understood by practicing orthopaedic surgeons. Serologic parameters such as total lymphocyte count, albumin level, prealbumin level, and transferrin level have all been used as markers for nutrition status. In addition, anthropometric measurements, such as calf and arm muscle circumference or triceps skinfold, and standardized scoring systems, such as the Rainey-MacDonald nutritional index, the Mini Nutritional Assessment, and institution-specific nutritional scoring tools, are useful to define malnutrition. Preoperative nutrition assessment and optimization of nutritional parameters, including tight glucose control, normalization of serum albumin, and safe weight loss, may reduce the risk of perioperative complications, including infection.

Line spread as a visual clinical tool for thickened liquids.

PURPOSE: Preparing modified liquids to a target level of consistency is critical to patients' nutritional care. This study examined the relationship of line spread (i.e., the distance a liquid flows) to viscometer measurements for a variety of product/liquid combinations and determined if flow distance visually differentiated nectar-thick versus honey-like consistency. METHOD: Combinations of 4 thickening products (3 starch-based and 1 gum-based thickener) prepared with 6 serving-temperature liquids that had various levels of fat, fiber, and added nutrients were tested. A total of 32 product/liquid combinations tested within the target range of 80-800 centipoise (cP). Measurements were recorded using line spread and a Brookfield RVDV-II+ viscometer. RESULTS: Nectar-thick and honey-like consistencies significantly differed in their degree of line spread. Using our line spread apparatus, a value of 4.5 cm differentiated between nectar-thick and honey-like consistencies. There was an inverse correlation (-.75) between viscometer data and line spread results. That is, high viscosity values represented samples with less flow distance (line spread), and low viscosity values represented samples with more flow distance. CONCLUSION: Line spread appears to be a quick, objective, and visual method that might be used to help patients and their caregivers achieve more accurate and consistent thickened liquid preparation.

Managing dysphagia through diet modifications.

OVERVIEW: Dysphagia can lead to malnutrition, dehydration, aspiration pneumonia, and even death. The condition has diverse causes and symptoms vary widely. Nurses are likely to encounter patients with dysphagia in various settings, including acute care medical units, rehabilitation centers, and skilled nursing facilities. Dietary modification--altering the consistency of foods and liquids--is a fundamental aspect of dysphagia management. This article describes normal and impaired swallowing, discusses several types and levels of dietary modification, and offers readers a concise list of nursing considerations.

Quality of care issues for dysphagia: modifications involving oral fluids.

AIMS AND OBJECTIVES: This study examined practices of health care providers who thicken oral fluids for patients with impaired swallowing (dysphagia). It contrasts viscosity (thickness) of nectar-like and honey-thick consistencies prepared and measured in a laboratory setting to actual practices in health care settings and to guidelines of the National Dysphagia Diet. BACKGROUND: The care plans for many patients include changes to fluid thickness to maintain safe intake of oral fluids. Serving patients improperly prepared beverages may contribute to medical complications such as dehydration if patients consume less fluid, or aspiration of overly thin or thickened liquids, which may increase the risk of pneumonia. DESIGN: Descriptive analysis of group trends for viscosity measurements of liquids prepared by health care providers in four care settings to laboratory measurements and the National Dysphagia Diet. METHODS: Forty-two health care providers participated. Each prepared thickened samples in their natural work environment using typical procedures. RESULTS: Viscosity measurements of modified liquids prepared by health care providers did not compare favourably to published findings of laboratory viscosity measures or to the ranges of the National Dysphagia Diet. Participants who prepared overly thick or overly thin nectar-like liquids followed a similar pattern with honey-like samples. Many participants failed to use product label information in sample preparation. CONCLUSIONS: Results suggest that many patients are served modified liquids that are too thick or too thin in relation to their target level of thickness, possibly increasing risk of further medical complications for those who consume them. Product directions that are too vague or general also may contribute to inaccurate results. RELEVANCE TO CLINICAL PRACTICE: The patient's nursing staff typically oversees nutritional care plans that may include modifications to oral fluids to enable their patients to safely drink by mouth. Additional consideration should be given to training procedures and possible noncompliance with preparation guidelines.

Comparisons of thickened beverages using line spread measurements.

Concerns about the preparation of thickened beverages for patients with dysphagia highlight the need for objective measurements with application to clinical settings. This cross-sectional study examined the line spread test (distance a liquid flows) to determine reproducibility of the measurements and whether specific line spread measurements can differentiate nectar- and honey-like thickness levels in the National Dysphagia Diet. Two common thickeners were tested in three different beverages. Replication of preparation procedures allowed comparison of product/beverage line spread results to viscometer-determined viscosity measured at a similar temperature and time to thicken. Analysis of variance showed a significant two-way interaction for both levels of thickness, indicating that line spread measurements differentiated products mixed with different beverages. Standard deviations and confidence intervals confirmed that measurements were highly repeatable. Line spread distance (cm) and viscosity measured in centipoise (cP) for a similar product/beverage statistically correlated with one another, suggesting that line spread and viscometry provided some similar information about thickness across the six product/beverage combinations tested.

Serving temperature viscosity measurements of nectar- and honey-thick liquids.

This study reports the viscosity (thickness) of nectar- and honey-thick liquids measured at a typical serving temperature. Centipoise (cP) measurements were compared for three products (two starch and one gum-based thickener) mixed with five beverages that set for three time intervals (manufacturer-recommended time to thicken, 10 min, and 30 min). The serving temperature of the cold beverages was 4 degrees C (water, apple juice, orange juice, and milk), and the hot beverage (coffee) was measured at 70 degrees C. Statistical analysis showed that all factors interacted with one another, meaning that the viscosity of a nectar- or honey-like liquid varies greatly depending on the type of thickening agent and beverage combination in relation to the amount of time it thickens. Simply Thick, the gum-based thickener, typically produced samples that were the least viscous but they maintained a more consistent level of thickness over time. Serving temperature results are contrasted with viscosity measurements collected at room temperature, showing variable thickening patterns especially related to the type of thickening agent.

Interventions to support diabetes self-management: the key role of the patient in diabetes care.

More so than most other diseases, effective control of type 2 diabetes (DM) requires that patients are actively engaged in the self-management of their health. In this paper we define and characterize the elements of self-management and review the published literature for the evidence of the benefit of interventions that support patient self-management.

Sensory characteristics of beverages prepared with commercial thickeners used for dysphagia diets.

OBJECTIVE: To describe and compare sensory characteristics of six beverages prepared with four commercial thickeners used in dysphagia diets. DESIGN: The study used a completely randomized design within a test of each beverage. SUBJECTS/SETTING: Five highly trained descriptive sensory analysis panelists conducted the testing in a laboratory environment. INTERVENTION: Coffee, milk, apple juice, orange juice, Ensure (Abbott Laboratories, Abbott Park, IL), and water were thickened using two starch-based and two gum-based commercial thickeners according to manufacturers' instructions to achieve nectar-like and honey-like consistencies. MAIN OUTCOME MEASURES: Sensory attributes of the original beverages and the thickened samples were defined and scored. STATISTICAL ANALYSES PERFORMED: Sensory scores were analyzed by analysis of variance using general linear models and Fisher's least significant difference test to determine specific differences. RESULTS: All thickeners suppressed the main flavors of the base beverages and imparted slight off-flavors (bitter, sour, metallic, or astringent) in some beverages. Starch-based thickeners imparted a starchy flavor and grainy texture, whereas gum-based thickeners gave added slickness to the beverages. Although thickeners mixed well with some beverages, they were difficult to disperse in others, making some thickened beverages lumpy. CONCLUSIONS: All thickeners added either a starchy, grainy, or slick flavor or texture and tended to suppress the base flavor of beverages, especially at honey-like consistencies. Thus, individual decisions about which characteristics are more negative (eg, slick vs grainy texture) for specific patients must be made. Additional development of thickening agents seems necessary for improved sensory properties. Information from this article should help professionals and their patients with dysphagia better understand the sensory issues associated with the use of commercial thickening agents in various beverages.

Inclusion of immigrant families in U.S. health coverage expansions.

This paper examines federal and state restrictions on immigrants and the negative impact of these restrictions on local efforts to serve the uninsured. It examines a health coverage program offered to low-income residents in Alameda County, California from 2000 to 2005, illustrating local efforts to expand health coverage to both adults and children, regardless of immigration status. After five years of operating the pilot program, leaders of Alameda County's health care safety net conclude that local health coverage programs are unsustainable over a long period of time without significant federal and state support. The financial resources that federal, state, and local governments are patching together for health coverage could be used more efficiently if consolidated. Stabilizing the federal tax base and recognizing the phenomenal amount of federal, state, and local funding that is already spent on medical care for the uninsured are the first steps towards achieving meaningful health care reform.

Midazolam más fentanil como coadyuvantes en la anestesia epidural en pacientes sometidos a hernioplastias inguinales en el Hospital Antonio Lenín Fonseca octubre 2005- enero 2006 / Midazolam more fentanil like helping in the anesthesia epidural in subjected patients to hernioplastias inguinales in the Hospital Antonio Lenín Fonseca October 2005 - January 2006

Se realizó un estudio ensayo clínico controlado, ciego, con el fin de comprobar la pontenciación del uso combinado del Midazolam con el Fentanil en la prolongación de la analgesia postoperatoria al ser administrados por vía epidural como fármacos coadyuvantes en la anestesia epidural. Setenta y cinco pacientes conformaron el estudio, distribuyéndose en tres grupos de veinticinco cada uno, a todos se les administró Bupivacaina al 0.5 por ciento más epinefrina 75 mg como anestésico local, con la diferencia en el fármaco coadyuvante, en el grupo A se administró Midazolam 3 mg más Fentanil 100 mcg, en el grupo B Midazolam 3 mg y en el grupo C Fentanil 100 mcg. La duración de la analgesia postoperatoria fue mayor en el grupo de Midazolam más Fentanil con 344.35 minutos y por último los del grupo de Midazolam con 317.69 minutos. El grupo de Midazolam más Fentanil presentó a su vez mejor nivel de sedación seguido del grupo de Midazolam. En conclusión el grupo de Midazolam más Fentanil cómo farmacos coadyuvantes resultaron ser mejor que utilizándose de forma separadas, al prolongar la analgesia posoperatoria así como el nivel de sedación en los pacientes...

Thickened liquids: practice patterns of speech-language pathologists.

This study surveyed the practice patterns of speech-language pathologists in their use of thickened liquids for patients with swallowing difficulties. A 25-item Internet survey about thickened liquids was posted via an e-mail list to members of the American Speech-Language-Hearing Association Division 13, Swallowing and Swallowing Disorders (Dysphagia). Responses of 145 professionals who primarily manage adult dysphagia are reported. Although the majority affirmed that thickening thin liquids was an effective intervention strategy, opinions about effectiveness were more favorable for nectar-thick versus honey-like and spoon-thick consistencies. Respondents also acknowledged that their patients had little liking for thickened liquids. Results highlight issues related to products and staff training, as well as perceptions concerning the factors that might affect patients' acceptance of and compliance with use of the products.

Viscosity measurements of nectar- and honey-thick liquids: product, liquid, and time comparisons.

This study compared the viscosity (thickness) of five different liquids thickened to nectar- or honey-like consistencies with a variety of thickening products. Samples were prepared using manufacturer guidelines and viscosity was measured at the recommended time to thicken (standard) and also after 10 and 30 min. Centipoise (cP) measurements of the samples were compared across products and within product lines for each level of thickness at all three time periods. Statistical analysis showed that the viscosity of a nectar- or honey-like liquid was highly dependent on the type of thickening product and the time it was allowed to thicken. Variability in viscosity measurements also was noted within a product line for thickening various liquids. Results are discussed in relation to the National Dysphagia Diet guidelines for nectar- and honey-like consistencies.