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Background: Liquid nutrition delivered through a tube is often used amid difficulty swallowing. Tube feeding has been shown to have a relationship to pneumonia and mortality. Aim: Researchers investigated the relationship of feeding route (oral or tube) to patient outcomes. Design: Data were collected on outcomes (pneumonia, depression, mortality), feeding route, presence/absence of dysphagia, and covariates (chronic obstructive pulmonary disease [COPD], stroke, mortality risk, illness severity, sex, age). Researchers collected data over a 45-month period to ensure an adequate sample size for matching. The method of sampling was retrospective, archival data analysis. Propensity score analysis resulted in 94 matched, balanced pairs. Covariates were isolated from the treatment effect. Participants: The records of 2,180 inpatients treated by Palliative Medicine were considered, and 292 met the inclusion criteria. Results: Results revealed 10.14 times greater odds of pneumonia (OR = 10.14; p <.001) with tube feeding compared to oral feeding in patients with dysphagia and end-stage COPD or end-stage stroke. Results also revealed increased odds of depression (OR = 2.79; p =.01) and mortality (OR = 3.02; p <.01) with tube feeding compared to oral feeding. Conclusion: Study findings should encourage consideration of oral nutrition at the end of life. [ABSTRACT FROM AUTHOR]

Communication is fundamental to mental health services for every patient, caregiver and clinician interaction. Without adequate communication skills, the aspiration to inclusion, engagement and recovery is likely to fail. Speech and language therapists provide specialist knowledge directly with patients, and indirectly via clinicians and caregivers. The objective of this study was to explore current UK provision and practice of speech and language therapists supporting working age adults with mental health conditions. A ten question online survey was shared on social media and sent to a network of speech and language therapists interested in mental health services in September 2019. Responses were analysed using descriptive statistics supported by free text survey responses. From survey closing in March 2020, 96 responses were received from across the four UK nations describing widely varying services. Respondents reported concerning gaps in SLT provision, other professions not understanding the SLT role, but over 75% of respondents reported multidisciplinary ways of working. Risks associated with communication impairment are often overlooked. The understanding of mental health professionals about the role of speech and language therapists is patchy. Highlighting awareness amongst the mental health workforce about communication impairment will improve access to treatment and care for all patients. [ABSTRACT FROM AUTHOR]

Purpose: The intervention of thickened liquids (TL) is commonly used to reduce aspiration in people with dysphagia. Speech-language pathologists (SLPs) have traditionally believed it is an effective intervention. Recent articles highlight limited evidence, poor acceptance, and a variety of unintended consequences. This study explores if current debates have been reflected in SLP practices and perspectives. Method: An e-survey was developed. Participants were recruited via professional associations in Australia, New Zealand, Ireland, the United Kingdom, and the United States. Descriptive and inferential statistics were used to explore the data. Principal component analysis was used to summarize SLP practices and perspectives. Results: The 370 respondents represented mainly experienced, confident, hospital-based clinicians. While 20% of respondents frequently recommend TL, 61% believe it to be a burdensome treatment. "Best treatment" and "It works" beliefs continue to underpin decision making. Those who recommend TL most often are most influenced by penetration, coughing, and their own clinical experience. They are more likely to believe TL is evidence based and effective, reduces aspiration, and improves hydration. Person-centeredness is important among all respondents, although significant numbers would implement TL against patient wishes. Improvements in aspiration status and quality of life rank highly as reasons to discontinue TL. Conclusions: The results of this study suggest that fewer respondents are regularly using TL. Divergent groups are evident with those frequently employing and believing in the efficacy of TL and those who do not. While current debates are influencing practice, there clearly remains a significant number of SLPs continuing to recommend TL. This study's findings highlight both alterations and preservations in the discipline's approach to TL and calls for SLPs to reframe our thinking regarding this intervention as well as consider alternative options in this treatment space. [ABSTRACT FROM AUTHOR]

Background: Use of modified texture diets—thickening of liquids and modifying the texture of foods—in the hope of preventing aspiration, pneumonia and choking, has become central to the current management of dysphagia. The effectiveness of this intervention has been questioned. We examine requirements for a valid informed consent process for this approach and whether the need for informed consent for this treatment is always understood or applied by practitioners. Main text: Valid informed consent requires provision of accurate and balanced information, and that agreement is given freely by someone who knows they have a choice. Current evidence, including surveys of practitioners and patients in different settings, suggests that practice in this area is often inadequate. This may be due to patients' communication difficulties but also poor communication—and no real attempt to obtain consent—by practitioners before people are 'put on' modified texture diets. Even where discussion occurs, recommendations may be influenced by professional misconceptions about the efficacy of this treatment, which in turn may poison the well for the informed consent process. Patients cannot make appropriate decisions for themselves if the information provided is flawed and unbalanced. The voluntariness of patients' decisions is also questionable if they are told 'you must', when 'you might consider' is more appropriate. Where the decision-making capacity of patients is in question, inappropriate judgements and recommendations may be made by substitute decision makers and courts unless based on accurate information. Conclusion: Research is required to examine the informed consent processes in different settings, but there is ample reason to suggest that current practice in this area is suboptimal. Staff need to reflect on their current practice regarding use of modified texture diets with an awareness of the current evidence and through the 'lens' of informed consent. Education is required for staff to clarify the importance of, and requirements for, valid informed consent and for decision making that reflects people's preferences and values. [ABSTRACT FROM AUTHOR]

Purpose: Medications can produce side effects that negatively impact swallowing and cognition. Speech-language pathologists (SLPs) who know which medications their patients are taking are able to consider the potential impact of medication side effects on their patient's swallow function and progress in therapy. The goal of this investigation was to gain preliminary information on how often SLPs report that they review a patient's medications as part of their standard practice, as well as the most common reasons for not reviewing patient medications. Method: A 10-item online questionnaire was distributed to practicing SLPs to collect information regarding their clinical experience, patient caseload, and whether they routinely review patient medications. Logistic regression analysis was used to determine which variables were associated with medication review. Results: Responses were received from 205 SLPs. Approximately half reported "always" reviewing patient medications (n = 116). The most frequent reason given for not reviewing medications was lack of pharmacology training. The results indicated that SLPs with 15 years or more of experience were nearly 3 times more likely to review medications than SLPs with less experience. Not all Special Interest Groups participated in the distribution of the survey. Conclusions: Many SLPs reported that they did not consistently check patient medications as part of a patient evaluation. Of concern is the possibility that SLPs do not realize the importance of medication knowledge. Clinicians may gain familiarity with the medications and understanding of the impact that medications have on their patients as they accrue clinical experience. Future research should investigate the best ways to promote knowledge of this topic in new clinicians. [ABSTRACT FROM AUTHOR]

Purpose: Dysphagia prevalence in younger community dwelling adults and across nations is sparse. We investigated the prevalence of swallowing problems in an unselected cohort of people aged 18–65 years. Methods: The EAT-10 Assessment Tool was converted into an anonymized online survey. Invitations were e-mailed to author contacts and onwards dispersal encouraged. Analysis was performed using non-parametric test for group comparison (Mann–Whitney U) and Spearman's rho correlation. Results: From March 2014 to October 2017: 2054 responses (32 reported ages outside of 18–65 or undeclared) from Africa, Asia, Australasia/Oceania, Europe, and North and South America. Responses: 1,648 female, 364 male, (10 reported as both), median age 34, (range 18–65, mean 37.12, SD 12.40) years. Total EAT-10 scores: median 0 (range 0–36, mean 1.57, SD 3.49). EAT-10 score ≥ 3 (337) median 5 (range 3–36, mean 7.02 SD 5.91). Median age 36 (range 19–65, mean 37.81, SD 13.21) years. Declared sex was not statistically significantly associated with non-pathological vs. pathological EAT-10 score (p = 0.665). Female scores (median 0.00, mean 1.56, SD 3.338) were significantly higher than for males (median 0.00, mean 1.62, SD 4.161): U (Nfemale = 1648, Nmale = 364) = 275,420.000, z = − 2.677, p = 0.007. Age and EAT-10 score were not associated: females rs = − 0.043, p = 0.079, N = 1648, males rs = − 0.003, p = 0.952, N = 364. Considerable impact on people: "I take ages to eat a main course ... This is embarrassing and I often leave food even though I am still hungry." (no diagnosis, EAT-10 = 17). Conclusion: Concerns regarding swallowing exist in people undiagnosed with dysphagia, who may feel uncomfortable seeking professional help. Dysphagia may be under reported resulting in a hidden population. Subtle changes are currently seen as subtle markers of COVID-19. Further work is required to ensure that what is an essentially normal swallow does not become medicalized. [ABSTRACT FROM AUTHOR]

Purpose: Working with patients and families with different cultural backgrounds is now commonplace in all areas of speech-language pathology. This includes supporting those with eating, drinking, and swallowing problems. Becoming more culturally sensitive as clinicians requires us to think less of them versus us, and instead what matters to them, and how best for us to provide expert care. Our starting point for this important topic is not how we tweak our clinical recommendations to fit someone's "culture." Rather, let us examine what is culture and how should it factor into our professional work? We need to understand how our patients and families view health and well-being, or lack thereof, in general. This will enable us to frame our support and offer optimal care to all stakeholders. This leads naturally to a consideration of the concepts of autonomy, informed consent, and how these factor into person-centered care, and shared decision making. Conclusions: As well as gaining an understanding of the frameworks of health and illness, we consider how food and drink are much more than mere nutrition and hydration. Foods signal our individual and collective identities. Thus, to be a respectful and professional clinician, we need to appreciate our role as a cultural guest with all whom we serve. We propose that there is no such thing as being "culturally competent." Expert clinicians possess a respect for the patient and their expertise-by-experience of health and illness. Such respect is founded in the position of cultural humility, to be a guest of someone's world view, in the same way that we respect being a guest in a patient's physical home. [ABSTRACT FROM AUTHOR]

Purpose: This article discusses the complexities of caring for individuals with dementia with an interdisciplinary team approach. The overlap and potential conflict between speech-language pathologists (SLPs) and occupational therapists (OTs) are addressed. SLPs and OTs have potentially similar roles when caring for people with dementia, so it can be difficult to decipher whose job it is to implement similar therapy techniques. However, there are ways health care professionals can prepare themselves to work collaboratively and potentially avoid conflict among team members, such as overstepping their professional boundaries and scopes of practice. This article discusses three beneficial techniques for interprofessional collaboration: acquiring sufficient knowledge about the scopes of practice of both SLPs and OTs, developing effective communication skills, and identifying the intentions of each therapeutic technique. Conclusions: There is no straightforward or universal answer to the question "Whose job is it?" when considering SLPs and OTs in caring for people with dementia. Deciding whether an SLP or an OT should implement certain aspects of therapy depends on the roles of each professional and how they can benefit the patient. Interdisciplinary team members must work together to identify how their roles interact and overlap. SLPs and OTs must have a solid knowledge base about each other's scopes of practice, develop effective communication skills, and be able to identify the intentions of their therapy. Developing these skills allows SLPs and OTs to work harmoniously in interprofessional teams. [ABSTRACT FROM AUTHOR]

Traditional point-based grading is failing students entering a competency-based workforce: Employers require concrete skills and knowledge, not "high" grades. In the specifications approach, learning outcomes are explicitly linked to the grading system. The basic components of the approach include clear alignment of learning outcomes to certification standards, bundled sequences of assessments tied to basic and advanced competency/learning outcomes, pass/fail grading with no partial credit, opportunities to revise unacceptable work, and detailed expectations of performance on assessments. This article describes the specifications approach and provides examples highlighting how to (1) align course learning objectives with a grading system, (2) implement a pass/fail approach even for complex assessment, (3) define specifications, (4) create and sequence bundles of assessments, and (5) provide instructor support through feedback and tokens. [ABSTRACT FROM AUTHOR]

Dysphagia management is complex and requires balancing individuals' preferences, quality of life, and medical consequences. Ethical challenges are not uncommon given the complexity of dysphagia. Professionals must engage in ethical reflection and shared decision-making when managing dysphagia. Recognizing one's own presuppositions and beliefs may be fundamental to ensuring an ethical approach. The goal of this article is to apply principles of ethics using hypothetical case studies of dysphagia. To this end, we will describe the challenges of working with the disorder of dysphagia; the influence of culture on decision-making about eating and feeding; the importance of information disclosure and respect for individuals' refusal of recommendations; and the interplay of ethical reflection, evidence, and clinical judgment when making complex dysphagia management decisions. These concepts should be kept in mind to ensure compassionate and competent care of the person with eating, drinking, or swallowing problems and their family caregivers. [ABSTRACT FROM AUTHOR]

Billions of health care dollars go towards caring for older adults. Medicare per-person spending rises steadily with age and doubles between ages 70 and 95 (Neuman, Cubanski, Huang, & Damico, 2015). The baby boomers, born between 1946 and 1965, represent a large wave of older patients entering the United States health care system today. The boomer demographic is significant for its size and longevity, thereby adding pressure to an already strained health care system. Of critical importance to the boomers is where they expect to live until they die and how they expect to be cared for. Aging in place has become a common phrase and signals the boomers' overwhelming desire to remain at home until the end (Lai, 2008). According to the United Nations, by 2025 Japan will be the country with the highest proportion of individuals aged 75 or over, followed by Sweden and then Italy (Ogawa & Matsukura, 2007). What can we learn from Japan about graceful aging? This article discusses multiple factors responsible for longevity in Japan, ranging from perceptions of aging to government policy. [ABSTRACT FROM AUTHOR]

Purpose: Speech-language pathologists routinely assess physical tension during evaluation of those who stutter. If speakers experience tension that is not visible to clinicians, then judgments of severity may be inaccurate. This study addressed this potential discrepancy by comparing judgments of tension by people who stutter and expert clinicians to determine if clinicians could accurately identify the speakers’ experience of physical tension. Method: Ten adults who stutter were audio-video recorded in two speaking samples. Two board-certified specialists in fluency evaluated the samples using the Stuttering Severity Instrument-4 and a checklist adapted for this study. Speakers rated their tension using the same forms, and then discussed their experiences in a qualitative interview so that themes related to physical tension could be identified. Results: The degree of tension reported by speakers was higher than that observed by specialists. Tension in parts of the body that were less visible to the observer (chest, abdomen, throat) was reported more by speakers than by specialists. The thematic analysis revealed that speakers’ experience of tension changes over time and that these changes may be related to speakers’ acceptance of stuttering. Conclusion: The lack of agreement between speaker and specialist perceptions of tension suggests that using self-reports is a necessary component for supporting the accurate diagnosis of tension in stuttering. [ABSTRACT FROM AUTHOR]

Purpose: This study surveyed didactic and clinical education in fluency disorders at undergraduate and graduate institutions in the United States that provide education in speech-language pathology to determine whether a previously observed reduction in requirements has continued since prior surveys (Yaruss, 1999; Yaruss & Quesal, 2002). Method: The study involved a detailed questionnaire that was sent to 282 communication science and disorders departments. Questions examined didactic and clinical education, as well as faculty knowledge about fluency disorders. Results: Comparisons with prior surveys revealed several findings, including (a) on average, programs have increased academic coursework and incorporated more practical sessions and competency-based testing in the classroom; (b) the number of faculty who possess extensive clinical experience with fluency disorders has decreased; and (c) although an increase in clinical requirements in fluency disorders was detected, the number of programs providing minimal education about fluency disorders remains high. Conclusion: Given an expanding scope of practice, many programs have continued to try to provide adequate education about fluency disorders. Still, direct clinical experiences are limited, and faculty expertise in this area has continued to decrease. To raise students’ confidence and competence in fluency disorders, efforts beyond graduate work—or systemic changes in the profession— may be necessary. [ABSTRACT FROM AUTHOR]

The replacement of fluids (usually water), may be undertaken in one of three ways: * orally: People may drink it or it may be administered via an enteral tube; * intravenously where fluid is provided via a cannula into a vein; or * subcutaneously, where fluids are administered between the subcutaneous layer of the skin and fat. This is called hypodermoclysis. As speech-language pathologists (SLPs) monitor the ability to swallow, they are in an ideal position, particularly in community settings, to identify problems with hydration. People with dysphagia may require a modification to their diet. Fluids are frequently thickened, which then results in reduction of fluid (water) intake. When the amount of water drunk is exceeded by the amount of water lost (e.g., urine, feces, sweat, and breath) dehydration may result. Clinically, dehydration may present as agitation, dry skin and tongue (mouth), and reduced skin elasticity. Hypodermoclysis is a simple technique that can be used in the community with minimal training and can be used to supplement oral intake. The SLP is ideally placed to suggest this to the physician caring for the patient. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis The association between extraesophageal reflux (EER) and symptoms of gastroesophageal reflux disease (GERD) is inadequately understood. We used the Comprehensive Reflux Symptom Scale (CReSS) to evaluate EER and reflux-symptom prevalence in gastroenterology and otolaryngology outpatients and symptom awareness among UK gastroenterologists. Study Design Cross-sectional cohort survey. Methods Six hundred thirty-nine participants were surveyed: 103 controls, 359 patients undergoing esophagogastroduodenoscopy (EGD), and 177 otolaryngology clinic patients with throat symptoms. Participants completed the CReSS questionnaire. The study was undertaken in the Endoscopy Unit and the Department of Otolaryngology-Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle-upon-Tyne, United Kingdom. Registered members of the British Gastroenterology Society were asked to rate how frequently reflux patients might complain of each CReSS item. Results The median CReSS total in volunteers (4) was significantly lower ( P < .002) than in ear, nose, and throat (ENT) patients (26) or EGD patients with (42) or without (32) esophageal inflammation. All items were scored as ≥1 by >15% of ENT patients and 28% of EGD patients. Three major, robust CReSS factors: esophageal, pharyngeal, and upper airway emerged. Of 259 gastroenterologists, >20% scored 8 of the 34 symptoms as never being reported by reflux patients. Conclusions Endorsement of each EER CReSS item by 28% to 58% of patients with endoscopic evidence of GERD supports the Montreal consensus on an EER-GERD continuum. Gastroenterologists vary considerably in their appreciation of EER symptom relevance. The advantages of CReSS include standardized, comprehensive capture of patient experience; discriminant validity of ENT and GERD patients from volunteers; and discrete esophageal, pharyngeal, and upper airway subscales. Level of Evidence 4 Laryngoscope, 125:424-430, 2015 [ABSTRACT FROM AUTHOR]

People with life-limiting disease are among the most vulnerable groups accessing healthcare. Given this vulnerability, polarized views have been expressed in the literature regarding such individuals' involvement in research studies. This is further compounded when the research is focused on rehabilitation, the concept of which is often misunderstood by patients, carers, and medical professionals. A number of factors can affect how we conduct research to elicit the needs of people with life-limiting disease, including social, historical, and cultural influences. Despite advances in palliative care research, challenges remain for those working across the specialism. In this review, we discuss the challenges of conducting rehabilitation research in this distinct clinical specialism and important considerations when involving patients and carers. We highlight the opportunities for understanding patient rehabilitation needs through mixed methods research design for studies involving those undergoing potentially complex rehabilitation interventions across settings. Note People with life-limiting disease will be referred to as 'patients' in the context of their being involved with the healthcare system and receiving care from a clinician. [ABSTRACT FROM AUTHOR]

This paper contributes to our understanding of participation in the Eucharist by examining the swallow. The paper begins with a thick description of the swallow as act, as phenomenon, and as symbol. This description reveals the swallow's interstitial nature, which is then examined for its implications on the meaning of participation in the sacrament. The paper then recommends approaches to the Eucharist for Catholics for whom swallowing is difficult or impossible. The paper finally incorporates these findings with the ex opere operato doctrine, demonstrating participation as efficacious interaction. [ABSTRACT FROM AUTHOR]

The article describes a case of a speech-language pathologist (SPL) who is faced with an ethical dilemma concerning her job. The pathologist was sent by her employer on a course to be trained in Therapy X. She queries the use of such therapy as there is no research evidence to support it. Some ideas based on American Speech-Language-Hearing Association (ASHA) publications are presented to help clarify what is and is not appropriate practice.

Hersh (2010) raises important issues regarding the ending of the therapeutic relationship. In this paper, we will explore this concept in relation to speech-language pathology (SLP) and palliative care. Palliative care aims to affirm life and minimize the complications of life limiting disease. Speech-language pathologists (SLPs) work with people with progressive and life limiting disease as rehabilitation experts but often work independently of specialist palliative care teams. Rehabilitation may seem incongruent with palliation but SLPs have a vital role in the empowerment of patients with communication difficulties and symptom reduction through specialist dysphagia management and communication therapy. This is vital in the last months and weeks of life. Starting and closing episodes of care remains a challenging area for therapists. SLP membership of palliative care multidisciplinary teams is limited and there may be a lack of understanding between professionals regarding the SLP role. In this paper we will use case studies and the palliative care literature to define a role for rehabilitation and the transition from supportive to palliative rehabilitation and closing episodes of care. [ABSTRACT FROM AUTHOR]

Feeding difficulties are common in preterm infants. These may be associated with inadequate dietary intake, poor growth, and parental anxiety. Oral-motor dysfunction has been observed in preterm infants during sucking and the early stages of weaning but has not been rigorously studied in later infancy when eating a range of food consistencies. We aimed to establish if oral-motor dysfunction during feeding occurs in preterm infants in later infancy and to explore the relationships with specific neonatal risk factors: gestational age at birth, prolonged supplementary oxygen requirement, and delay in establishing full oral feeding. Infants born less than 37 weeks gestational age were evaluated once at 10 months corrected gestational age using a validated feeding assessment (Schedule for Oral Motor Assessment). Fifteen infants were enrolled (9 males, 6 females; median gestational age at birth = 33 weeks, range = 25–36 weeks; median birth weight = 1890 g, range = 710–2950 g). Oral-motor dysfunction was observed in three infants all born after 31 weeks gestation. No relationship was found with the neonatal risk factors. This study indicates that oral-motor dysfunction may occur in later infancy and is not easily predicted from specific neonatal risk factors. Further study is required to evaluate the true prevalence and the health implications of oral-motor dysfunction in this population in later infancy. [ABSTRACT FROM AUTHOR]

This original pilot study was conducted to explore and understand the factors that influence a patient’s decision-making when considering percutaneous endoscopic gastrostomy placement for nonoral nutrition and hydration supplementation. Seven patients living with progressive dysphagic symptoms who had made a decision about percutaneous endoscopic gastrostomy placement were interviewed and their responses analyzed using the constant comparison method. All participants felt they had no option other than to accept the percutaneous endoscopic gastrostomy. The impact of visible physical deterioration and medical opinion were the most powerful influences on patients’ decisions. Patients’ perception of their involvement in the decision varied. This was linked to the amount and timing of information supplied and support they felt they received. Few patients have prior knowledge of tube feeding and rely heavily on medical advice. Effective communication by healthcare professionals can promote an environment that is supportive of patients’ involvement in decisions. Adequate preparation time is vital if patients are to stop feeling uninvolved or peripheral to the decision-making process. Multidisciplinary teams need to address their working practices so that they do not intimidate patients, but rather empower patients in their decision-making. [ABSTRACT FROM AUTHOR]

There have been questions about the reliability of subjective rating scales used to assess valleculae residue from fluoroscopic images. The aim of this study was to assess interrater agreement on one such scale, and compare it with agreement using a new objective measurement scale. Five speech and language therapists rated 100 valleculae residue still images from 20 consecutive patients using standard clinical practice (i.e., subjective visual grading of the videofluoroscopy still and rating as none, mild, moderate, or severe). The images were rerated by the same clinicians using Picture Archiving Communication System measurement tools. The valleculae residue ratio relates the residue size to the size of an individual's valleculae. A valleculae residue ratio scale was devised using a linear classifier, which defines the cutoff between grades of valleculae residue (none, mild, moderate, and severe). The new method proved at least as reliable as the traditional method; for interrater reliability, kappa = 0.73 vs. 0.73; for intrarater reliability, kappa = 0.87 vs. 0.85. The valleculae residue ratio is proposed as a new quick reliable method of quantifying residue where the Picture Archiving Communication System is available. We now wish to test the impact of this method where poor inter- and intrarater reliability exists. [ABSTRACT FROM AUTHOR]

There have been questions about the reliability of subjective rating scales used to assess valleculae residue from fluoroscopic images. The aim of this study was to assess interrater agreement on one such scale, and compare it with agreement using a new objective measurement scale. Five speech and language therapists rated 100 valleculae residue still images from 20 consecutive patients using standard clinical practice (i.e., subjective visual grading of the videofluoroscopy still and rating as none, mild, moderate, or severe). The images were rerated by the same clinicians using Picture Archiving Communication System measurement tools. The valleculae residue ratio relates the residue size to the size of an individual’s valleculae. A valleculae residue ratio scale was devised using a linear classifier, which defines the cutoff between grades of valleculae residue (none, mild, moderate, and severe). The new method proved at least as reliable as the traditional method; for interrater reliability, kappa = 0.73 vs. 0.73; for intrarater reliability, kappa = 0.87 vs. 0.85. The valleculae residue ratio is proposed as a new quick reliable method of quantifying residue where the Picture Archiving Communication System is available. We now wish to test the impact of this method where poor inter- and intrarater reliability exists. [ABSTRACT FROM AUTHOR]

Background: Difficulty swallowing is a well-documented symptom in head and neck cancer and oesophageal malignancy. The frequency of oropharyngeal swallowing difficulties in the palliative phase of other malignancies is less reported. Aim: 1) To describe the patient experience of swallowing and associated difficulties while receiving specialist palliative care for malignancies other than those affecting the head and neck and 2) to identify the quality of life issues for the participants with dysphagia and compare with normative and dysphagic data provided by SWAL-QOL. Design: Four month prospective pilot study - questionnaire design. Setting: Acute teaching hospital. Participants: Eleven patients receiving specialist palliative care. Methods: Participants were interviewed using a modified version of the SWAL-QOL, a validated quality of life assessment tool for use specifically with people with oropharyngeal dysphagia. Eight quality of life domains were explored as well as fourteen dysphagic symptoms. Results: Seven of the 11 participants had dysphagic symptoms detailed in the SWAL-QOL and a further two patients reported transient dysphagic symptoms since diagnosis of their disease. Nine participants reported an impact on their quality of life and three reported a considerable impact in four or more domains. Eight of the 11 participants had self-selected softer textured foods. A notable group were three patients with lung cancer and one with lung metastases with a history of vocal fold motion impairment, all of who had experienced dysphagic symptoms since diagnosis. Conclusions: Patients with cancers not affecting the head and neck are at risk of developing symptoms of oropharyngeal dysphagia and subsequently, compromized nutrition, hydration and quality of life. Areas for further research are suggested. [ABSTRACT FROM AUTHOR]

Cervical auscultation is the use of a listening device, typically a stethoscope in clinical practice, to assess swallow sounds and by some definitions airway sounds. Judgments are then made on the normality or degree of impairment of the sounds. Listeners interpret the sounds and suggest what might be happening with the swallow or causing impairment. A major criticism of cervical auscultation is that there is no evidence on what causes the sounds or whether the sounds correspond to physiologically important, health-threatening events. We sought to determine in healthy volunteers (1) if a definitive set of swallow sounds could be identified, (2) the order in which swallow sounds and physiologic events occur, and (3) if swallow sounds could be matched to the observed physiologic events. Swallow sounds were computer recorded via a Littmann stethoscope from 19 healthy volunteers (8 males, 11 females, age range = 18–73 years) during simultaneous fiberoptic laryngoscopy and respiration monitoring. Six sound components could be distinguished but none of these occurred in all swallows. There was a wide spread and a large degree of overlap of the timings of swallow sounds and physiologic events. No individual sound component was consistently associated with a physiologic event, which is a clinically significant finding. Comparisons of groups of sounds and events suggest associations between the preclick and the onset of apnea; the preclick and the start of epiglottic excursion; the click and the epiglottis returning to rest; the click and the end of the swallow apnea. There is no evidence of a causal link. The absence of a swallow sound in itself is not a definite sign of pathologic swallowing, but a repeated abnormal pattern may indicate impairment. At present there is no robust evidence that cervical auscultation of swallow sounds should be adopted in routine clinical practice. There are no data to support the inclusion of the technique into clinical guidelines or management protocols. More evaluation using imaging methods such as videofluoroscopy is required before this subjective technique is validated for clinical use by those assessing swallowing outside of a research context. [ABSTRACT FROM AUTHOR]

Health risks associated with dysphagia in adults with intellectual impairment are well documented. There is little research into compliance with dysphagia recommendations in environments where care is provided for adults with intellectual impairment. This is a pilot study into carer compliance with Speech-Language Pathology recommendations. We aimed to investigate the level of compliance with dysphagia recommendations in day centers and the factors that might affect compliance using a questionnaire. Twenty-seven clients were observed. Results showed an overall high level of compliance with recommendations (82%), with figures ranging from 64% compliance with appropriate utensils to 100% with direct support recommendations. Areas of noncompliance were evident, with level of dependence of clients and training of carers being key issues. Implications for practitioners are discussed. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: We aimed to investigate whether the type of dysphagia examination (fiberoptic endoscopic evaluation of swallowing [FEES] or videofluoroscopy) influences the scoring of penetration and aspiration. Study Design: Prospective, single-blind study. Methods: Fifteen dysphagic participants were recruited and underwent one FEES and one videofluoroscopy examination, performed and recorded simultaneously. Fifteen independent raters from 12 centers scored penetration and aspiration from recordings using the Penetration Aspiration Scale. Raters were blind to participant details, the pairing of the FEES and videofluoroscopy recordings, and the other raters' scores. Interrater and intrarater reliability were analyzed using weighted kappa. Results: The Penetration Aspiration Scale scores were significantly higher for the FEES recordings than for the videofluoroscopy recordings (ANOVA P < .001). The mean difference between the FEES and videofluoroscopy penetration aspiration scores for the same swallows was 1.15 points. Interrater and intrarater reliability ranged from 0.64 to 0.79 (weighted kappa). Conclusions: Penetration aspiration is perceived to be greater (more severe) from FEES than videofluoroscopy images. The clinical implications are discussed. [ABSTRACT FROM AUTHOR]

This is the first study to examine dysphagia assessment practices of UK/Ireland speech and language therapists. The aims were to (1) examine practice patterns across clinicians, (2) determine levels of consistency in practice, and (3) compare practices of clinicians in the UK/Ireland with those previously reported of clinicians in the United States. A questionnaire, developed for earlier U.S. research, was adapted following a pilot study. The resulting email survey was completed by 296 speech and language therapists working with dysphagic adults. Respondents were asked to rate how frequently they use 31 components of a clinical dysphagia examination. Consistency was determined by calculating the percentage of respondents who agreed on frequency of use. Low frequency of use was reported for four components: trials with compensatory techniques, obtain patient’s drug history, assessment of speech articulation/intelligibility, and screening/assessment of mental abilities. Variability among clinicians was high, with inconsistency observed for 6/31 components (19%) and high consistency for only 10/31 (32%). Results were compared with data from the earlier U.S. study. Notable differences in practice were observed for five components: cervical auscultation, trials with compensatory techniques, gag reflex, assessment of sensory function, and screening/assessment of mental abilities. Inconsistency among UK/Ireland clinicians was higher than in the comparator U.S. study. The clinical implications of these findings are discussed. [ABSTRACT FROM AUTHOR]

Background: Assessment referrals are increasing for unexpected dysphagia, particularly for older people. It is unclear if this is due to more impaired swallows or healthy age-related changes. Swallow respiration coordination prevents aspiration, and may deteriorate with age. Nonpathological features of the swallow in healthy aging and the factors that influence an individual's ability to eat and drink safely need greater understanding. Some changes might predispose an older person to dysphagic complications in the event of an insult such as a stroke. We investigated the effects of healthy aging on resting and swallow respiratory patterns.Methods: Fifty healthy volunteers (aged 20-78 years) were recruited to have swallow respiration patterns recorded on a computer. Bolus volume and consistency variations were studied: 5 and 20 ml of water and 5 ml of yogurt.Results: Measurable swallows significantly decreased with age for water boluses. Swallow apnea increased with age (5 ml of water r = 0.433, p = .002; 5 ml of yogurt r = 0.367, p = .023). Independent of age were: breathing out (occurred after 98% of boluses); multiple swallowing (occurred with all bolus types); post-swallow respiration reset pattern (more irregular after yogurt, Wilcoxon signed rank Z = -2.236, p = .025); and resting respiration.Conclusions: Subtle changes occur in swallow respiration coordination with age. These changes may be compensatory protective mechanisms rather than the result of decreased muscle mobility or reaction times, and not indicative of impairment. Misattributing healthy age-related changes to impairment affects patient care and the use of healthcare resources. [ABSTRACT FROM AUTHOR]

Cervical auscultation is experiencing a renaissance as an adjunct to the clinical swallowing assessment. It is a controversial technique with a small evidence base. We have aimed to establish whether cervical auscultation interpretation is based on the actual sounds heard or, in practice, influenced by information gleaned from other aspects of the clinical assessment, medical notes, or previous knowledge. We sought to determine (a) rater reliability and its impact on the clinical value of cervical auscultation and (b) how judgments compare with the “gold standard”: videofluoroscopy. Swallow sounds were computer recorded via a Littmann stethoscope. Sounds were sampled from 10 healthy control swallows with no aspiration/penetration and 10 patient swallows with aspiration/penetration, all recorded during simultaneous videofluoroscopy. The system generated sound quality similar to “live” bedside listening, a feature rarely seen in cervical auscultation studies. The 20 sound clips were classified as “normal” or “abnormal” by 19 volunteer speech-language pathologists with experience in cervical auscultation. After at least four weeks, 11 of these judges rated the sounds rerandomized on a new CD. Intrarater reliability kappa ranged from -0.12 to 0.71. Individual reliability did not correlate with years of experience, practice pattern, or frequency of use. Interrater reliability kappa?=?0.17. Comparison with radiologically defined aspiration/penetration yielded 66% specificity, 62% sensitivity, and majority consensus gave 90% specificity, 80% sensitivity. There was a significant relationship between individual reliability and true positive rate (rs?=?0.623,p?=?0.040). The reliability of individual judges varied widely and thus, inevitably, agreement between judges was poor. Validity is dependent upon reliability: Improving the poor raters would improve the overall accuracy of this technique in predicting abnormality in swallowing. The group consensus correctly identified 17 of the 20 clips so we may speculate that the swallow sound contains audible cues that shouldin principlepermit reliable classification. [ABSTRACT FROM AUTHOR]

Summarizes the incidence, causes, and risks of dysphagia and provides a detailed update on investigation and management, including the need for a multidisciplinary approach in treatment. Discussion of how dysphagia impairs swallowing; Causes of dysphagia; Symptoms of dysphagia and examination findings; Investigation of the condition with upper gastrointestinal endoscopy or barium swallow; Strategy for a treatment plan.

The aim of this study was to examine respiration characteristics at rest in healthy volunteers and patients with poststroke dysphagia, using a simple notebook computer-based system. Eighteen patients (age range=51–82 years) with dysphagia poststroke and 50 healthy volunteers (age range=20–78 years) were recruited. The patient group had a wide range of stroke severity as assessed using the Scandinavian Stroke Score (SSS 6–51) and Barthel Index (BI 2–20). Length of breathing cycle, rate, and a measure of the variability of the cycle length were examined. The patient group had a shorter mean cycle length (2.93 s compared with 3.91 s, p < 0.01) and hence faster respiration rate (0.35 Hz compared with 0.26 Hz, p < 0.01). The control group showed greater variability in the cycle length (10.78% compared with 6.56%, p = 0.01). There was no correlation between the SSS and BI and resting respiration variables. This suggests that it is not stroke severity alone that affects breathing. The differences observed in resting respiratory rate suggest that respiratory monitoring as a useful adjunct to the clinical bedside assessment warrants further investigation. [ABSTRACT FROM AUTHOR]

The aim of this study was to examine swallow respiratory characteristics using a notebook computer system. A relatively simple system assessing easily identifiable features is more likely to be incorporated into everyday clinical practice. Eighteen patients (age range = 51–82 years) with dysphagia poststroke and 50 healthy volunteers (age range = 20–78 years) were recruited. The patient group was less likely to always breathe out postswallow on water (9/15 cf 46/49), and some did not breathe out immediately postswallow at all (3/15 cf 0/49, p < 0.01). The pattern was similar with yogurt. Multiple swallowing was identified in the patient group and surprisingly with a large number of the volunteers for all bolus types but was more common in the patient group (p < 0.01). This trait is usually attributed to impaired swallows; that it is prevalent in the normal population has implications for using it as a dysphagia marker in clinical assessments. Yogurt has intrinsic features that increase multiple swallowing and caution should be used when identifying an impairment based on multiple swallowing with such a test substance. In the control group there was a high correlation of swallow apnea on 5 mL of water compared with 20 mL of water (r = 0.759, p < 0.01) and 5 mL of yogurt (r = 0.871, p < 0.01), indicating a possible individual swallow respiration pattern. This was also evident in the patient group. No significant difference in length of swallow apnea was found between the two groups. No evidence was found to link swallow respiration characteristics with aspiration as identified on simultaneous videofluoroscopy. The patient group had a wide range of impairments which suggests that stroke severity is not the sole determinant of swallow respiratory changes. [ABSTRACT FROM AUTHOR]

The authors discuss the controversies concerning tube feeding and gastrotomies in patients with dementia. They explore the most common questions concerning tube feeding and gastrotomies with respect to dementia as well as the lack of evidences on outcomes of various studies regarding the issue. The authors suggest the need for clinicians to establish interventions that will include an option of gastrostomy and to conduct further study to clarify the effectiveness of the procedure.

Videofluoroscopy has become an increasingly important armament in the investigation and assessment of swallowing disorders. However, very little work has been published on the radiation dose used in such examinations and currently there is no national diagnostic reference level in the United Kingdom. Videofluoroscopy in our hospital is performed predominantly by one radiologist (IZM) in a single fluoroscopy room. We recorded the screening times of 230 patients over a 45-month period. Screening time ranged from 18 to 564 s (median = 171 s) associated with a median dose-area product of 1.4 Gy cm2. This is below the third quartile level of 2.7 Gy cm2 for all such examinations performed across the northern England. The effective dose associated with a typical videofluoroscopy dose-area product is 0.2 mSv. Videofluoroscopy is the most appropriate instrumental examination for assessing oropharyngeal swallow biomechanics and intervention strategies. This data set is based on the largest number of videofluoroscopy swallow studies published to date. Our results show that videofluoroscopy can be performed using minimal radiation doses. [ABSTRACT FROM AUTHOR]