Listening for Dysphagia: Voice Quality Sequelae of Material in the Airway.

PURPOSE: Postswallow voice abnormality is often assumed to indicate the presence of material in the laryngeal airway (MIA), but prior research has not shown definitive evidence of a causal relationship. This study investigated if endoscopically confirmed MIA (prandial material or secretions) generates specific voice quality attributes that can be perceptually identified by experienced listeners. METHOD: Forty-four dysphagic adults underwent endoscopic evaluation of swallowing. Time-linked audiovisual recordings of pre- and postswallow phonation were analyzed to determine the presence, amount, and location of prandial material or secretions in the larynx during phonation. Expert listeners completed auditory-perceptual ratings of phonation samples. RESULTS: Voice quality ratings did not differ significantly when there was MIA during postswallow phonation. However, judgments of voice quality abnormality for MIA samples were elevated when analyses controlled for effects of baseline dysphonia. Listeners were most likely to perceive voice quality abnormality when larger amounts of secretions were present, as compared to prandial material. Interrater reliability was variable and ranged from low to moderate across perceptual parameters. CONCLUSIONS: MIA during phonation occurred for many participants, but perception of voice quality abnormality was variable when MIA was present. Baseline dysphonia is common among individuals with dysphagia and may limit perception of voice quality abnormalities generated by MIA. Secretions in the laryngeal airway may have a greater impact on voice quality parameters.

Using Reflective Writing to Explore Resident Resilience during Global Health Electives.

Pediatric residents participating in global health electives (GHEs) report an improved knowledge of medicine and health disparities. However, GHEs may pose challenges that include cost, personal safety, or individual mental health issues. The objective of this study was to describe the use of guided reflections to understand resident resilience during GHEs. Forty-five residents enrolled in two pediatric training programs were asked to respond in writing to weekly prompts during a GHE and to complete a post-trip essay. Analysis of the reflections and essays, including an inductive thematic analysis, was completed. Two coders performed a second analysis to support classification of themes within the Flinders Student Resilience (FSR) framework. Four themes emerged from the initial analysis: 1) benefits, 2) stresses and challenges, 3) career development, and 4) high-value care. Analysis using the FSR framework revealed the following themes: acknowledgment of personal limitations, importance of relationships in coping throughout the GHE, and discernment of career focus. Reflective writing provided insight into how residents mitigate GHE challenges and develop resilience. Despite statements of initial distress, residents focused on their personal benefits and growth during the GHE. The FSR framework revealed the residents' robust self-awareness of limitations and that strong relationships on the ground and at home were associated with perceived benefits and growth. Programs should consider helping residents to identify healthy coping practices that can promote personal resilience during GHEs as part of pre-departure preparation and debriefing, as well as providing for supportive communities during the GHE.

Surgical Treatment of Acquired Velopharyngeal Insufficiency in Adults With Dysphagia and Dysphonia.

OBJECTIVES: Velopharyngeal insufficiency (VPI) is a form of velopharyngeal dysfunction caused by abnormal or insufficient anatomy. This process is known to be associated with dysphagia and dysphonia but surgical interventions for these complex patients have not been well studied. The current study characterized a small cohort of adult patients with acquired VPI, dysphonia, and dysphagia, as well as associated surgical interventions. METHODS: A retrospective descriptive case series of 22 (N = 22) adult patients over a 6-year period with acquired VPI and varying degrees of dysphagia and dysphonia was described from a multi-disciplinary voice and swallowing clinic. Perceptual assessment, nasopharyngoscopy, fluoroscopic swallowing assessment, and patient reported outcomes were reviewed to characterize the cohort. RESULTS: VPI etiologies included: stroke (n = 4), head and neck cancer (n = 5), brainstem lesions (n = 5), trauma (n = 5), and other/unknown (n = 3). All 22 patients underwent nasopharyngoscopy and were categorized as having unilateral (n = 13), central (n = 4), or no (n = 5) velopharyngeal deficits. Seventeen patients (77.2%) underwent modified barium swallow studies, revealing that soft palate elevation scored least impaired among patients with no VPI, and most impaired among patients with unilateral VPI deficits. All 22 patients underwent some form of surgical intervention for VPI, with 14 (63.6%) of those patients requiring additional surgical revision. CONCLUSION: This series is one of the first to the authors' knowledge to characterize a cohort of individuals with VPI, dysphagia, and dysphonia and associated surgical interventions.

Implementation Strategies for the International Dysphagia Diet Standardisation Initiative (IDDSI), Part I: Quantitative Analysis of IDDSI Performance Among Varied Participants.

Purpose The International Dysphagia Diet Standardisation Initiative (IDDSI) is an international standardized framework for texture-modified diets (TMDs). However, user accuracy in conducting IDDSI testing methods are unknown. The aims of this study were threefold: (a) to describe performance on two tasks (an IDDSI knowledge quiz and a TMD sample classification task), (b) to determine interrater and intrarater agreement for classification task performance, and (c) to determine predictive relationships between socioeconomic factors or prior knowledge on task performance. Method Sixty-eight participants were recruited, including health care professionals and non-health care-related individuals. A mixed between-subjects and within-subject design was used. All participants completed a baseline knowledge quiz, 30 min of self-study using the IDDSI.org curriculum, a post self-study knowledge quiz, and a TMD classification task of 21 TMD samples with representation across all IDDSI levels. Data were collected via electronic survey. Results There was a significant increase (p < .001) between pre and post self-study knowledge quiz scores. On the classification task, unmodified foods and drinks were most accurately classified with thickened liquids (IDDSI Levels 1, 2, 3) most inaccurately classified. At baseline, moderate interrater agreement was found with intrarater agreement ranging from fair to almost perfect among identical samples. No significant predictive relationships were found between classification task performance and socioeconomic status or prior experience. Conclusions Thirty minutes of self-study using the online IDDSI.org curriculum improved baseline IDDSI knowledge check performance. Overall accuracy of TMD classification was low and warrants further evaluation given potential adverse health outcomes secondary to inappropriate TMD presentation. Given no predictive relationships between socioeconomic factors and prior experience on task performance, the IDDSI curriculum and classification task appear accessible to various users, including non-health care-related participants. Future studies should more closely observe testing behavior to further characterize variation in participants' use of the testing methods.

The Influence of Culture on Teamwork and Communication in a Simulation-Based Resuscitation Training at a Community Hospital in Honduras.

STATEMENT: Communication and teamwork are important aspects of medicine and have been a recent focus of resuscitation. Culture can influence communication and teamwork, and these effects have not been studied in low-resource settings. Using a case study and the TEAM scale, we evaluated how culture influences teamwork and communication during resuscitation simulations, in addition to examining other challenges of simulation research in low-resource settings. We observed lower scores in leadership and communication skills than have been seen in other studies using the TEAM scale, which led us to evaluate the possible role of culture in influencing these skills. The high power distance and collectivism in Latin America can make communication difficult, especially during debriefing. Furthermore, in a male-biased medical hierarchy, female nurses may be less likely to voice concerns. Ultimately, this commentary provides advice for taking the influences of culture into account when planning future simulation training in low-resource settings.