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Thickening products (TPs) are a valid therapeutic strategy in patients with oropharyngeal dysphagia, their effect is mainly related to the bolus viscosity achieved. The aim of the study was to compare the information on the labels of 10 TPs of different thickening agents (hydrocolloids): modified starch-based, gum-based and mixtures. Viscosity was measured in SI units (mPa·s), using a rotational viscometer at 50 s−1 and 300 s−1, and the effect of oral amylase (α-SA) and shear thinning on the viscosity levels recommended by each manufacturer were assessed. Results were classified according to 3 textural classifications: National Dysphagia Diet (NDD), International Dysphagia Diet System (IDDSI) and Japanese Dysphagia Diet (JDD2013). Results are also presented in SI units (mPa·s) following a new proposed scientific labelling system developed in our laboratory at Hospital de Mataro and endorsed by eleven medical and scientific societies. The effect of α-SA was assessed after 30 s oral incubation of the thickened bolus. All TPs fulfil Food for Special Medical Purposes labelling regulations, use 3 thickness levels, and 70% use the NDD descriptors. Viscosities at 50 s−1 ranged between 75 and 350 mPa s for level 1, 256–1280 for level 2 and 377–6205 for level 3. α-SA caused 98–99% decrease in viscosity for modified starch-based TPs (MS) and 16% or even an increment for gum-based TPs. Shear thinning decreased viscosity from 40 to 60% for MS-based TPs and 70–75% for gum-based TPs. This study showed that TPs are commercialised using the same descriptors for very different viscosities when measured in mPa·s. Shear rate and α-SA strongly affect viscosity but this is not described on the labels. We claim labels should include viscosity in SI Units (mPa·s at 50 s−1) and the effect of α-SA and shear thinning as main factors affecting the therapeutic effect and mode of action of thickening agents.

Oropharyngeal dysphagia (OD) is a condition recognized by the World Health Organization and defined as the difficulty or inability to move a bolus safely and effectively from the oral cavity to the esophagus, and can include aspirations, choking, and residue. OD is pandemic among different phenotypes of older people, affecting between 27% and 91% of the population 70 years or older. Although OD can be diagnosed by well-defined clinical methods and complementary explorations, in the clinical setting OD is seldom systematically screened and treated, and awareness among the medical/geriatric community is scarce. The etiology of OD in this population includes many concomitant risk factors with neurogenic and neurodegenerative processes, muscular weakness, and sarcopenia. The pathophysiology includes mechanical deficits in the swallow response (mainly delayed laryngeal vestibule closure time and weak tongue thrust), reduced pharyngeal sensitivity, and sensory/motor central nervous system impairments. Recently, OD has been recognized as a geriatric syndrome due to its high prevalence and its relationship with many comorbidities and their poor outcomes, including malnutrition, respiratory infections and aspiration pneumonia, functional disability and frailty, institutionalization and increased readmissions, and mortality. There is an evidence-based and effective treatment for OD in the elderly mainly oriented to compensating swallow impairments through adaptation of fluid viscosity and solid food textures to avoid aspiration and choking, and improving nutritional status and oral health to avoid respiratory infections. This has been defined as the minimal effective treatment to be provided to this population. New treatments aiming at recovering the swallowing function are under research with promising results, and the near future will provide us with methods to stimulate the swallow response with pharmacological or physical stimuli.

Rationale: COVID-19 may manifest with a wide range of symptoms and its degree of severity may be from mild to severe Our aim was to assess the prevalence and pathophysiology of oropharyngeal dysphagia (OD), malnutrition (MN), nutritional risk, and the needs of compensatory treatments in patients admitted due to COVID-19 at the Consorci Sanitari del Marseme (CSdM), Catalonia, Spain Methods: Prospective observational study with clinical assessment of OD (clinical symptoms, clinical observation and Volume-Viscotisy Swallowing Test) and nutritional screening with NRS2002 and GLIM criteria in consecutive COVID-19 patients admitted at the Hospital de Mataro (CSdM) during 2020 Covid-19 pandemics Patient’s clinical characteristics and their needs of compensatory treatments for OD and MN were assessed at baseline and will be followed up at 3 and 6 months Here we present the baseline data Results: We included 268 hospitalized patients, 52 2% men, with a mean age of 70 2±17 0 yr, severity of disease was moderate-severe in 34% At hospital admission prevalence of OD was 52 4% (49 4% had impaired efficacy and 44 9% impaired safety of swallow) Pathophysiology of OD includes ICU and post-extubating factors (16%), neurological factors (32%), respiratory insufficiency (42%) and interstitial pneumonia (74%) Up to 43 7% of patients needed thickeners to be safely hydrated (38 7% with 250mPa·s and 5 2% with 800mPa·s of Xanthan Gum thickeners) and 54 5% had mastication impairments needing texture-modified diets (27 7% easy mastication and 28 8% puree) 74 2% of patients presented a NRS2002>3 and were at risk of MN, 46% had MN and 73 8% of patients received ONS Conclusion: Prevalence of OD, nutritional risk and MN in patients with COVID-19 at admission in a General Hospital is very high Pathophysiology is multifactorial and not limited to ICU factors Early treatment includes fluid thickening, texture modified foods and nutritional support References: 10 Basic procedures to assess and treat oropharyngeal dysphagia in patients with COVID-19 (SARS-CoV-2) infection Disclosure of Interest: O Ortega: None declared, V Arreola: None declared, W Nascimento: None declared, A Martin: None declared, A Costa: None declared, M Arus: None declared, M Roca: None declared, P Vinas: None declared, S Carrion: None declared, P Clave Grant / Research Support from: Nutricia Danone Advanced Nutrition

Oropharyngeal dysphagia and malnutrition are prevalent conditions in the older. The aim of this study was to explore the relationship between oropharyngeal dysphagia, nutritional status and clinical outcome in older patients admitted to an acute geriatric unit.We studied 1662 patients ≥70 years consecutively hospitalized with acute diseases, in whom dysphagia could be clinically assessed by the volume-viscosity swallow test and nutritional status with the Mini Nutritional Assessment(®). Anthropometric and laboratory measurements were taken and mortality recorded during hospital stay, at 6 months and one year after discharge was recorded.47.4% (95% CI 45-49.8%) patients presented oropharyngeal dysphagia and 30.6% (95% CI 27.9%-33.3%), malnutrition. Both conditions were associated with multimorbidity, multiple geriatric syndromes and poor functional capacity (p0.001). However, patients with dysphagia presented increased prevalence of malnutrition (MNA(®)17 45.3% vs 18%, p0.001) regardless of their functional status and comorbidities (OR 2.31 (1.70-3.14)) and lower albumin and cholesterol levels. Patients with malnutrition presented an increased prevalence of dysphagia (68.4% (95% CI 63.3-73.4)). Patients with dysphagia and patients with malnutrition presented increased intrahospital, 6-month and 1-year mortality rates (p0.05). The poorest outcome was for patients with both conditions (1-year mortality was 65.8%).Prevalence of dysphagia was higher than malnutrition in our older patients. Dysphagia was an independent risk factor for malnutrition, and both conditions were related to poor outcome.

Oropharyngeal dysphagia is a common condition among the elderly but not systematically explored. Oropharyngeal dysphagia is a highly prevalent clinical finding in elderly patients with pneumonia and is an indicator of disease severity in older patients with pneumonia. Dysphagia may cause a decrease in deglutition safety, leading to tracheobronchial aspiration which results in aspiration pneumonia. Clinical screening methods should be used to identify older people with oropharyngeal dysphagia and to identify those patients who are at risk of aspiration. Videofluoroscopy (VFS) is the gold standard to study the oral and pharyngeal mechanisms of dysphagia in older patients. Diagnosis and management of oropharyngeal dysphagia need a multidisciplinary approach. There are two kinds of specific preventive interventions: the first focuses on reducing the colonization of bacteria in the mouth and nasopharynx, and the second on preventing aspiration.

Objectives The objective of this study was to assess the pathophysiology of oropharyngeal dysphagia (OD) in patients with dementia, specifically in those taking antipsychotics (APs). Design A cross-sectional study was performed from January 2011 to May 2017 in a general hospital. Setting and Participants We included 114 patients with dementia, of which 39 (34.2%) were taking APs (82.5 ± 7.8 years, Barthel Index 52.28 ± 30.42) and 29 patients without dementia (82.4 ± 6.7 years, Barthel Index 77.71 ± 24.7) and OD confirmed by a videofluoroscopy. Measures Demographical and clinical factors as well as swallowing function of patients with dementia with OD were compared with older patients without dementia with OD. We also compared patients with dementia taking and not taking APs. Impaired efficacy during videofluoroscopy was defined as the presence of oral and/or pharyngeal residue, and impaired safety (unsafe swallow) was defined as aspiration or penetration. Receiver operating characteristic curves were drawn for laryngeal vestibule closure (LVC) time to predict unsafe swallow. Results 87.7% of patients with dementia presented impaired efficacy of swallow and 74.6% impaired safety [penetration-aspiration scale (PAS) 3.94 ± 1.94]. 86.2% of patients without dementia presented impaired efficacy and 44.8% impaired safety (PAS 2.21 ± 1.92). Time to LVC was significantly delayed in patients with dementia taking APs in comparison with patients without dementia (LVC 0.377 ± 0.093 vs 0.305 ± 0.026, P = .003). In contrast, there were no differences in the PAS and LVC time in patients with dementia taking and not taking APs (PAS 3.96 ± 0.26 vs 3.88 ± 0.22, LVC 0.398 ± 0.117 vs 0.376 ± 0.115, NS). LVC time ≥0.340 seconds predicted unsafe swallow in patients with dementia with an accuracy of 0.71. Conclusions/Implications Patients with dementia presented high prevalence and severity of videofluoroscopy signs of impaired efficacy and safety of swallow and a more severe impairment in airway protection mechanisms (higher PAS and LVC delay). Clinical practice should implement specific protocols to prevent OD and its complications in these patients. AP treatment did not significantly worsen swallowing impairments.

Background: Ghrelin and cholecystokinin (CCK) are among the peripheral signals that regulate hunger and satiety. Objective: The objective was to assess whether ghrelin and CCK responses to a standard nutritional load are related to age and frailty. Design: Ghrelin, CCK, insulin, glucose, and 4-h visual analog hunger scale curves after a standard nutritional load test (380 kcal) were described and compared between 3 groups: old (.75 y) and frail persons (group A), old (.75 y) but nonfrail persons (group B), and young (25–65 y) adults (group C). Results: Frail persons showed no postprandial ghrelin suppression, and old subjects, frail and nonfrail, showed no significant postprandial ghrelin recovery compared with young adults. Frailty was also associated with lower fasting ghrelin concentrations. No differences in fasting CCK were observed between young and old persons; however, postprandial CCK concentrations were enhanced in young persons, whereas no frailty effect on the CCK curve was observed in the old subjects. No correlations between mean ghrelin and hunger values over time were found, but strong negative correlations were shown between CCK and hunger (group A: rs ¼ 20.88, P ¼ 0.009; group B: rs ¼ 20.86, P ¼ 0.014; group C: rs ¼ 20.71, P ¼ 0.071) and insulin and hunger (group A: rs ¼ 20.901, P ¼ 0.006; group B: rs ¼ 20.964, P , 0.001; group C: rs ¼ 20.929, P ¼ 0.003). Conclusions: Advanced age determines a poorer ghrelin postprandial recuperation phase, a reduced CCK postprandial response, and an exaggerated postprandial insulin release. A loss of ghrelin prandial rhythm is present in old frail persons. The impaired response of these hunger regulatory hormones with age might contribute to the mechanisms of anorexia associated with aging. Am J Clin Nutr 2009;89:1–8.

Digestive surgeons should form part of the multidisciplinary team managing patients with oropharyngeal dysphagia. These patients can be diagnosed through clinical methods and complementary investigations such as videofluoroscopy and pharyngoesophageal manometry. These techniques also allow specific treatment to be selected. Up to one-third of patients with dysphagia suffer from malnutrition as a result of alterations in food bolus transport. Furthermore, up to two-thirds show alterations in swallowing safety (penetrations and aspirations, especially when swallowing liquids), as well as a high risk of respiratory infections and aspiration pneumonia. Increasing food bolus viscosity to 3500-4000 mPas (pudding viscosity) improves the effectiveness of swallowing and reduces the risk of aspirations. Botulinic toxin injection in the upper esophageal sphincter is indicated in patients with spasticity of neuromuscular origin. Cricopharyngeal myotomy is the basis of treatment for Zenker's diverticulum and is also indicated in patients with alterations in the upper esophageal sphincter and preserved oropharyngeal motor response.

Background & Aims: Exogenous cholecystokinin (CCK) decreases lower esophageal sphincter (LES) pressure and increases transient LES relaxations (TLESRs) in humans. The aims of this study were to determine whether endogenous CCK increases gastroesophageal reflux in humans and whether this is a direct effect on the LES. Methods: Esophageal pH, LES pressure, and gallbladder volume were measured in 8 healthy volunteers after ingestion of a 181-kcal meal alone or adding 12 g cholestyramine to increase endogenous CCK release. In 7 additional volunteers, the effect of cholestyramine was studied during intravenous perfusion of saline or the CCK-A receptor antagonist loxiglumide. In circular LES strips from 9 transplant donors, we measured the effect of CCK-8 (10−11 to 3 × 10−8 mol/L) on basal tension and on electrical field–induced relaxation. Results: Cholestyramine increased gallbladder emptying, reflux episodes, TLESRs, and time of esophageal pH of

Rationale: Oropharyngeal dysphagia (OD) is a major contributor to malnutrition. Starch-based thickeners improve safety of deglutition but increase residue. We aimed to evaluate the therapeutic effect of a xanthan gum-based thickener, Resource®ThickenUp Clear (RTUC, Nestle Health Science). Methods: We studied 120 patients with OD with videofluoroscopy while swallowing a series of 5 20mL liquid boluses at nectar, thin and extreme spoon-thick (EST) viscosities measured at 50/s 20oC and obtained with a hydrosoluble X-Ray contrast (50/50 vol with water) and RTUC. We assessed prevalence of penetrations and aspirations for impaired safety, oropharyngeal residue for impaired efficacy, bolus velocity, timing of the swallow response, and the nutritional risk (MNASF, NRS 2002). Results: Prevalence of malnutrition or risk of malnutrition was 71% according to MNA-SF and 76% according to NRS 2002. Increasing bolus viscosity: a) improved safety of swallow as 24% of patients with OD presented safe swallow at thin, 55% at nectar (P< 0.001) and 85% at EST (P< 0.001). Prevalence of aspiration was 16% at thin, 9% at nectar (P< 0.01) and 5% at EST (P< 0.01). The score of the penetration-aspiration scale was 3.3±0.2 (thin), 2.2±0.2 (P< 0.001, nectar) and 1.5±0.1 (P< 0.001, EST); b) did not enhance oropharyngeal residue; c) did not affect timing of swallow response; d) reduced bolus velocity from 0.25±0.01m/s at thin to 0.21±0.01m/s at EST (P< 0.05). Conclusion: Prevalence of malnutrition among neurological and older patients with OD is very high. Increasing bolus viscosity with RTUC exerts a strong therapeutic effect by improving the safety of swallow without increasing oropharyngeal residue, an advantage of new generation versus conventional thickening agents. This effect might help to improve the nutritional treatments for these patients. Disclosure of Interest: L. Rofes: None Declared, V. Arreola: None Declared, R. Mukherjee: None Declared, P. Clave Grant/Research Support from: Nestec Ltd

Rationale: To determine the relationship between oropharyngeal dysphagia (OD), nutritional status and clinical outcome in elderly patients with acute diseases admitted to a general hospital. Methods: Prospective observational study of 1662 patients over 70 years of age consecutively hospitalized in an acute geriatric unit (AGU) in a general hospital. Dysphagia was clinically assessed with the volumeviscosity swallow test (V-VST) and nutritional status with the Mini Nutritional Assessment. Other measurements taken during admission were anthropometry and laboratory values, comorbidities (Charlson index), cognitive status (Pfeiffer) and functional capacity (Barthel index). Mortality during admission, referral to nursing homes and mortality at 12 months after discharge were also monitored. Results: Up to 52.6% patients admitted to the AGU presented clinical signs of OD and a) more comorbidities (2.42+1.6 vs 2.02+1.6 p < 0.001), poorer functionality both pre-admission and at discharge (p < 0.001), more geriatric syndromes (93.3% vs 72.5% p < 0.001) and poorer outcome (1 year mortality 48.7 vs 25.1%) (p < 0.001) and b) higher prevalence of malnutrition (MNA< 17 45.3% vs 18%, p < 0.001; BMI 25.5 vs 26.8, p < 0.001) and albumin

Rationale: Recent literature suggests that diabetes is a risk factor for Parkinson’s disease (PD). We investigated the clinical features of idiopathic PD (IPD) patients in whom the onset of diabetes came first. Methods: We designed a case-control study. From the cohort of all new IPD patients free of vascular disease (n = 783) admitted and evaluated at our Institute over a 3-year period (2007 2010) we included all the patients with a diagnosis of diabetes prior to PD onset (n = 89) and a control group (n = 89) matched (1:1) for gender, body mass index (±1 kg/m2) and duration of PD (±1 year). The Unified PD Rating Scale (UPDRS) motor score was the primary endpoint. Results: At study entry, patients with diabetes were similar to controls in terms of most demographic, lifestyle and general medical features with exception of statins (18% vs. 3.4%; P= 0.003). However, diabetes was associated with higher UPDRS motor (22.3±9.0 vs. 19.3±7.9; P= 0.019) and activities of daily living (9.7±5.1 vs. 8.3±4.3; P= 0.049) scores, more severe Hoehn-Yahr staging (P= 0.009) and higher treatment doses of levodopa (mg/day, 448±265 vs. 300±213; P< 0.0001; mg/kg/day, 5.8±4.0 vs. 3.8±2.9; P< 0.0001). Conclusion: Onset of diabetes before the onset of PD appears to be a risk factor for more severe PD symptoms. These findings support the hypothesis that diabetes has a role in the etiopathogenesis of PD. Neurologists should be aware of the potential impact of diabetes on overall PD patient management.