Heather L. Flowers

The Incidence of Dysphagia Following Endotracheal Intubation: A Systematic Review

Hospitalized patients are often at increased risk for oropharyngeal dysphagia following prolonged endotracheal intubation. Although reported incidence can be high, it varies widely. We conducted a systematic review to determine: (1) the incidence of dysphagia following endotracheal intubation, (2) the association between dysphagia and intubation time, and (3) patient characteristics associated with dysphagia. Fourteen electronic databases were searched, using keywords dysphagia, deglutition disorders, and intubation, along with manual searching of journals and grey literature. Two reviewers, blinded to each other, selected and reviewed articles at all stages according to our inclusion criteria: adult participants who underwent intubation and clinical assessment for dysphagia. Exclusion criteria were case series (n < 10), dysphagia determined by patient report, patients with tracheostomies, esophageal dysphagia, and/or diagnoses known to cause dysphagia. Critical appraisal used the Cochrane risk of bias assessment and Grading of Recommendations, Assessment, Development and Evaluation tools. A total of 1,489 citations were identified, of which 288 articles were reviewed and 14 met inclusion criteria. The studies were heterogeneous in design, swallowing assessment, and study outcome; therefore, we present findings descriptively. Dysphagia frequency ranged from 3% to 62% and intubation duration from 124.8 to 346.6 mean hours. The highest dysphagia frequencies (62%, 56%, and 51%) occurred following prolonged intubation and included patients across all diagnostic subtypes. All studies were limited by design and risk of bias. Overall quality of the evidence was very low. This review highlights the poor available evidence for dysphagia following intubation and hence the need for high-quality prospective trials.

MRI-Based Neuroanatomical Predictors of Dysphagia after Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Background: Considering that the incidence of dysphagia is as high as 55% following acute stroke, we undertook a systematic review of the literature to identify lesion sites that predict its presence after acute ischemic stroke. Methods: We searched 14 databases, 17 journals, 3 conference proceedings and the grey literature using the Cochrane Stroke Group search strategy and terms for MRI and dysphagia. We evaluated study quality using the Cochrane Collaboration’s risk of bias tool and extracted individual-level data. We calculated relative risks in order to model dysphagia according to neuroanatomical lesion sites. Results: Of 964 abstracts, 84 articles met the criteria for full review. Of these 84 articles, 17 met the quality criteria. These 17 articles dealt exclusively with dysphagia after infratentorial stroke and provided MRI correlates of dysphagia for 656 patients. The incidence of dysphagia according to stroke region was 0% in the cerebellum, 6% in the midbrain, 43% in the pons, 40% in the medial medulla and 57% in the lateral medulla. Within these regions, pontine (relative risk 3.7, 95% confidence interval 1.5–7.7), medial medullary (relative risk 6.9, 95% confidence interval 3.4–10.9) and lateral medullary lesions (relative risk 9.6, 95% confidence interval 5.9–12.8) predicted an increased risk of dysphagia. Conclusions: We sought to develop a neuroanatomical model of dysphagia throughout the whole brain. However, the literature that met our quality criteria addressed the MRI correlates of dysphagia exclusively within the infratentorium. Although not surprising, these findings are a first step toward establishing a neuroanatomical model of dysphagia after infratentorial ischemic stroke and provide insight into the assessment of individuals at risk for dysphagia.

The Effect of Prophylactic Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement on Swallowing and Swallow-Related Outcomes in Patients Undergoing Radiotherapy for Head and Neck Cancer: A Systematic Review

Patients undergoing radiotherapy for head and neck cancer (HNC) often experience malnutrition and dehydration during treatment. As a result, some centres place PEG tubes prophylactically (pPEG) to prevent these negative consequences. However, recent research has suggested that pPEG use may negatively affect swallowing physiology, function and/or quality of life, especially in the long term. The purpose of this study was to systematically review the literature on pPEG use in HNC patients undergoing radiotherapy and to determine its impact on swallowing-related outcomes. The following electronic databases were searched for all relevant primary research published through February 24, 2014: AMED, CINAHL, the Cochrane Library, Embase, Healthstar, Medline, and PsycINFO. Main search terms included HNC, radiotherapy, deglutition disorders, feeding tube(s), and prophylactic or elective. References for all accepted papers were hand searched to identify additional relevant research. Methodological quality was assessed using Cochrane’s Risk of Bias. At all levels, two blinded raters provided judgments. Discrepancies were resolved by consensus. The search retrieved 181 unique citations. Twenty studies met our inclusion criteria. Quality assessment revealed that all studies were at risk for bias due to non-randomized sampling and unreported or inadequate blinding. Ten studies demonstrated selection bias with significant baseline differences between pPEG patients and controls. Results regarding the frequency and severity of dysphagia and swallowing-related outcomes were varied and inconclusive. The impact of pPEG use on swallowing and swallowing-related outcomes remains unclear. Well-controlled, randomized trials are needed to determine if pPEG places patients at greater risk for developing long-term dysphagia.

Poststroke Aphasia Frequency, Recovery, and Outcomes: A Systematic Review and Meta-Analysis

OBJECTIVES To conduct a systematic review to elucidate the frequency, recovery, and associated outcomes for poststroke aphasia over the long-term. DATA SOURCES Using the Cochrane Stroke Strategy, we searched 10 databases, 13 journals, 3 conferences, and the gray literature. STUDY SELECTION Our a priori protocol criteria included unselected samples of adult stroke patients from randomized controlled trials or consecutive cohorts. Two independent reviewers rated abstracts and articles for exclusion or inclusion, resolving discrepancies by consensus. DATA EXTRACTION We documented aphasia frequencies by stroke type and setting, and computed odds ratios (ORs) with their 95% confidence intervals (CIs) for outcomes. DATA SYNTHESIS We retrieved 2168 citations, reviewed 248 articles, and accepted 50. Median frequencies for mixed stroke (ischemic and hemorrhagic) were 30% and 34% for acute and rehabilitation settings, respectively. Frequencies by stroke type were lowest for acute subarachnoid hemorrhage (9%) and highest for acute ischemic stroke (62%) when arrival to the hospital was ≤3 hours from stroke onset. Articles monitoring aphasia for 1 year demonstrated aphasia frequencies 2% to 12% lower than baseline. Negative outcomes associated with aphasia included greater odds of in-hospital death (OR=2.7; 95% CI, 2.4-3.1) and longer mean length of stay in days (mean=1.6; 95% CI, 1.0-2.3) in acute settings. Patients with aphasia had greater disability from 28 days (OR=1.5; 95% CI, 1.3-1.7) to 2 years (OR=1.7; 95% CI, 1.6-2.0) than those without aphasia. By 2 years, they used more rehabilitation services (OR=1.5; 95% CI, 1.3-1.6) and returned home less frequently (OR=1.4; 95% CI, 1.2-1.7). CONCLUSIONS Reported frequencies of poststroke aphasia range widely, depending on stroke type and setting. Because aphasia is associated with mortality, disability, and use of health services, we recommend long-term interdisciplinary vigilance in the management of aphasia.

Coronal view ultrasound imaging of movement in different segments of the tongue during paced recital: Findings from four normal speakers and a speaker with partial glossectomy

The goal of this study was to quantitatively describe aspects of coronal tongue movement in different anatomical regions of the tongue. Four normal speakers and a speaker with partial glossectomy read four repetitions of a metronome-paced poem. Their tongue movement was recorded in four coronal planes using two-dimensional B-mode ultrasound imaging. Quantitative indicators of tongue function (total distance travelled and concavity) were calculated. In all participants, it was observed that the centre of the tongue travelled greater distances than the lateral free margins. The tongues of the female speakers F1 and F2 travelled greater distances than those of the males M1 and M2. The greatest distances travelled were observed in the speaker with partial glossectomy G. In three of the participants, the greatest cumulative distances were recorded for the anterior tongue (F1, M1, and G) and in the other two (F2 and M2) in the posterior tongue. The concavity measure illustrated that the posterior tongue showed consistent grooving during connected speech, in all speakers. Flatness or convexity of the tongue was mainly observed in the anterior tongue. The study provides the first quantitative description of coronal tongue movement in a complex speech passage. Future research will have to further examine the effects of gender and orofacial morphology on the coronal shape and movement of the tongue.

A Systematic Review of Current Clinical and Instrumental Swallowing Assessment Methods

Tests for dysphagia serve as either assessment or screening tools. To be clinically useful these tools must be reliable, validated with proper psychometric techniques, and feasible. In a previous systematic review, only two screening tools met these criteria from the studies in stroke patients. There are no such systematic reviews assessing the availability and methodological quality of bedside or instrumental diagnostic assessment tools for dysphagia. This systematic review of recent literature identified 13 articles that have targeted development of new dysphagia tools, seven of which related to screening, five to clinical assessment, and one to instrumental assessment. Across all articles, critical appraisal revealed that none of the recent articles addressing screening, clinical or instrumental assessment had sufficient methodological rigor, and therefore readiness, for implementation into clinical practice. To ensure the best in patient care, it is necessary to develop tools with methodological rigor for all patient groups with dysphagia, beyond just screening. Future studies of patients with dysphagia must use prospective controlled study designs and only available tools that are reliable, valid and feasible. The development and testing of any new tools must ensure that they are also reliable, valid and feasible.

MRI-Based Neuroanatomical Predictors of Dysphagia, Dysarthria, and Aphasia in Patients with First Acute Ischemic Stroke

Background: Due to the high post-stroke frequency of dysphagia, dysarthria, and aphasia, we developed comprehensive neuroanatomical, clinical, and demographic models to predict their presence after acute ischemic stroke. Methods: The sample included 160 randomly selected first-ever stroke patients with confirmed infarction on magnetic resonance imaging from 1 tertiary stroke center. We documented acute lesions within 12 neuroanatomical regions and their associated volumes. Further, we identified concomitant chronic brain disease, including atrophy, white matter hyperintensities, and covert strokes. We developed predictive models using logistic regression with odds ratios (OR) and their 95% confidence intervals (95% CI) including demographic, clinical, and acute and chronic neuroanatomical factors. Results: Predictors of dysphagia included medullary (OR 6.2, 95% CI 1.5–25.8), insular (OR 4.8, 95% CI 2.0–11.8), and pontine (OR 3.6, 95% CI 1.2–10.1) lesions, followed by brain atrophy (OR 3.0, 95% CI 1.04–8.6), internal capsular lesions (OR 2.9, 95% CI 1.2–6.6), and increasing age (OR 1.4, 95% CI 1.1–1.8). Predictors of dysarthria included pontine (OR 7.8, 95% CI 2.7–22.9), insular (OR 4.5, 95% CI 1.8–11.4), and internal capsular (OR 3.6, 95% CI 1.6–7.9) lesions. Predictors of aphasia included left hemisphere insular (OR 34.4, 95% CI 4.2–283.4), thalamic (OR 6.2, 95% CI 1.6–24.4), and cortical middle cerebral artery (OR 4.7, 95% CI 1.5–14.2) lesions. Conclusion: Predicting outcomes following acute stroke is important for treatment decisions. Determining the risk of major post-stroke impairments requires consideration of factors beyond lesion localization. Accordingly, we demonstrated interactions between localized and global brain function for dysphagia and elucidated common lesion locations across 3 debilitating impairments.


English adaptation, international harmonisation, and normative validation of the Language Screening Test (LAST)

Background: The Language Screening Test (LAST) is a unique bedside tool, designed to rapidly and reliably evaluate aphasia during the acute and chronic phases of stroke. Two equivalent reliable and validated versions of the LAST exist in French. Aims: Our objective was to conduct a linguistic adaptation for English (LASTen) through a process of translation, international harmonisation, and normalisation in multiple English-speaking countries. Methods & Procedures: There were four progressive stages in the adaptation of the LASTen including a series of sequential evaluations to identify problematic items, with selection of alternatives by consensus and in collaboration with the original LAST developers. First, three Canadian translators independently adapted the 29 items of the original LAST into English, resolving discrepancies by consensus to produce adaptation I. Evaluations of adaptation I involved ratings of translation difficulty and multidisciplinary expert panel review to produce adaptation II. Evaluations of adaptation II included ratings of translation quality by three different translators followed by healthy native speaker testing in Canada to produce adaptation III. Evaluations of adaptation III included expert review in Australia, Canada, England, and the USA for cultural acceptability and naturalness, followed by healthy native speaker testing in all the four countries to produce adaptation IV. Adaptation IV constituted a linguistically valid LASTen for four English dialects. We documented consensus decisions to modify or retain problematic items. We evaluated group differences using the Kruskal–Wallis test for continuous variables and chi-squared analyses for frequency variables with statistical significance of alpha ≤.05. Outcomes & Results: During the translation and the evaluations, we reconsidered 22 of the 29 items, revising 20 to produce adaptation IV of the LASTen. Normative testing in the four English-speaking countries involved 109 participants (mean age 60 years, SD ±16.1). Fifty-five percent were women, and 32% lacked postsecondary education. Fourteen participants made errors across nine items. There were no significant differences in errors for age, sex, or country. However, participants with postsecondary education made fewer errors than those without (p = .04). Conclusions: We achieved a linguistically compatible adaptation of the French LAST for English, confirming naturalness and cultural appropriateness in healthy native speakers of four English dialects. Our systematic multistep approach delineates rigorous methods for the adaptation of aphasia tools. Our normative validation of the LASTen in healthy native speakers of English provides the impetus for its validation in stroke patients within the four English-speaking countries.

09:40 AM: Multiplanar Sonography of Tongue Movement in Speech

Factor Receptor (EGFR) occurs in up to 80-90% of HNSCC, correlating negatively with survival. EGFR activates multiple signal pathways regulating gene expression, cell growth, and resistance to apoptosis. Extracellular signal regulated kinase (ERK), a member of the EGFR-activated MAPK cascade, is increased in HNSCC. The transcription factor ATF2, also constitutively activated in HNSCC, is induced through activated SAPK pathways. It is hypothesized that EGFR-related ERK signaling has an important association with downstream ATF2 activation in HNSCC. METHODS: All experiments have been performed in the well-studied cell line UM-SCC-9. ATF2, p-ATF2, ERK and p-ERK levels were determined at baseline and following stimulation with EGF through Western blot analysis and flow cytometry. In addition ATF2, p-ATF2, ERK and p-ERK levels were determined following treatment of cell lines with MEK 1/2 selective inhibitor UO126 and tyrosine kinase inhibitor AG1478. RESULTS: These experiments confirm that ERK, p-ERK, ATF2 and p-ATF are constitutively expressed in HNSCC. In addition, stimulation of cell lines with EGF results in increased p-ERK and p-ATF2 activation. Treatment of cell lines with tyrosine kinase inhibitor AG1478 and MEK 1/2 selective inhibitor modulates expression of p-ATF2. CONCLUSION: EGFR has an important association with ATF2 activation downstream of ERK in HNSCC. Further characterization of the relationship of ERK and ATF2 downstream of EGFR may assist in developing more specific molecular targets in the treatment of HNSCC. SIGNIFICANCE: Many distinct molecular signaling pathways involved in the pathogenesis and progression of HNSCC have been studied; however, more research is needed to determine how these different pathways interact. Further elucidation of these molecular pathways may help determine potential adjuvant therapies in the treatment of HNSCC.