Search

Clinical reasoning, the application of medical knowledge to a patient’s problem, requires training in a safe environment. Learning tasks based on Virtual Patients (VP-tasks) simulate the clinical setting in a save way and integrate well into blended-learning environments, as synchronous tasks (face-to-face or online) or as asynchronous online tasks. The article presents the editorial process for developing VP-based self-study quizes (SSQ) and field-study results on students’ learning experiences and study habits. The editorial process initially only involved experienced clinical, educational and technical experts. To better match the tasks’ difficulty to students’ knowledge, junior doctors and advanced medical students joined in a later stage. Students (n = 351) rated the SSQs (n = 10) produced by the expanded team to match their knowledge better as compared to the SSQs (n = 13) developed by the initial expert editorial team. Students rated the online SSQs as more helpful as compared to similar face-to-face VP-tasks. Students’ free comments indicate their high acceptance of the SSQ-format. The SSQ-format is feasible for providing systematic online training in clinical reasoning, especially when working with a multi-level-educational editorial team and when a systematically structured blueprint of topics and learning goals drives the editorial work.

Since the World Health Organization declared the COVID-19 pandemic a Global Public Health Emergency, experts in swallowing are seeking guidance on service delivery and clinical procedures. The European Society for Swallowing Disorders provides considerations to support experts in swallowing disorders in clinical practice. During the COVID-19 pandemic, assessment and treatment of patients with oropharyngeal dysphagia should be provided, while at the same time balancing risk of oropharyngeal complications with that of infection of patients and healthcare professionals involved in their management. Elective, non-urgent assessment may be temporarily postponed and patients are triaged to decide whether dysphagia assessment is necessary; instrumental assessment of swallowing is performed only if processing of the instruments can be guaranteed and clinical assessment has not provided enough diagnostic information for treatment prescription. Assessment and management of oropharyngeal dysphagia is a high-risk situation as it must be considered an aerosol-generating procedure. Personal protective equipment (PPE) should be used. Telepractice is encouraged and compensatory treatments are recommended. ispartof: DYSPHAGIA vol:36 issue:4 pages:764-767 ispartof: location:United States status: published

To compare the results of a simultaneously performed videofluoroscopic swallowing study and fiberendoscopic evaluation of swallowing in patients with dysphagia after surgery and radiotherapy for oropharyngeal or laryngeal cancer. This prospective study included 31 patients who were examined simultaneously with a standardized protocol. The fiberendoscopic and videofluoroscopic swallowing loops were independently scored by two otorhinolaryngologists/phoniatricians and two radiologists. The presence of penetration/aspiration, the amount of pharyngeal residues and the position of the bolus head when triggering of pharyngeal swallow begins were evaluated. Generalized linear models were used to model the impact of rater, method, bolus and quantities as well as specified moderation effects on scorings. In addition, post hoc Wilcoxon tests were used. Rater agreement was assessed using weighted kappas and their 95% confidence intervals. A total of 202 swallow sequences in 29 patients was evaluated. Interrater agreement was substantial to excellent for both methods (weighted k = 0.979–0.613). Significant differences between both methods were found when assessing the penetration-aspiration scale (p = 0.001, tendency of higher scores by videofluoroscopic (median = 2.59) as opposed to fiberendoscopic (median = 2.14) and the residue severity scores in the valleculae (p = 0.029) and the sinus piriformes (p = 0.002) with larger residues scored by fiberendoscopic evaluation of swallowing. No significant differences were found regarding the time point of triggering (p = 0.273). Simultaneous evaluation of swallowing with FEES and VFSS showed significantly different results in symptomatic patients after tumor operation and radiotherapy. Electronic supplementary material The online version of this article (10.1007/s00455-019-09979-8) contains supplementary material, which is available to authorized users.

Introduction Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies. Recommendations This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with. Conclusions The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf).

Benigne Osophaguserkrankungen stellen aufgrund einer oftmals unspezifischen Klinik eine diagnostische Herausforderung dar. Die Durchleuchtungsuntersuchung als mehrphasiger Test mit Videoaufzeichnung ist eine wertvolle bildgebende Methode, um strukturelle und funktionelle Anomalien der Speiserohre zu erkennen und den klinischen Symptomen korrekt zuzuordnen. Neben der Primardiagnostik liefert sie als Wegweiser fur weitere zielgerichtete diagnostische Masnahmen auch wichtige Informationen fur die postoperative Nachsorge. Die multiplanare Computertomografie und die Magnetresonanztomografie erlauben hingegen die morphologische Beurteilung der Wanddicke und einer eventuellen Beteiligung umgebender Strukturen und konnen, bei speziellen Fragestellungen gezielt eingesetzt, eine weitere invasive Diagnostik uberflussig machen. In diesem Kapitel werden neben einem Einblick in die Durchleuchtungsuntersuchung des Osophagus die bildgebenden Befunde und klinischen Besonderheiten der fur die Chirurgie relevanten benignen Pathologien der Speiserohre behandelt. Dabei ist ein multidisziplinares Dysphagiemanagement unter zentraler Einbindung der Radiologie von groser Bedeutung.

The problems and symptoms of patients are at the heart of medicine and pertinent to information, communication, and education. Patients present their problems to health professionals looking for relief and a cure, while institutions collect data about symptoms of patients and the way health professionals treated them to support society's care providers in administrating and managing care. The information on the problems of patients and the way health professionals treated them, which is gathered and stored in patient files, is valuable as educational material in the field of medicine. Driven by the fast developments of new technical tools case-based information, communication and education starts to enter educational domains beyond the field of medicine, such as school systems and public health services. In our discussion we seek to understand and outline how to use the material gathered and stored in patient files to educate health professionals. Additionally, this paper gives examples of case-based education for all members of society. ispartof: ANNALS OF THE NEW YORK ACADEMY OF SCIENCES vol:1434 issue:1 pages:27-34 ispartof: location:United States status: published

Purpose Clinical assessment of swallowing disorders (dysphagia) requires accurate and comprehensive medical history-taking to further tailor the diagnostic work-up, but functional health care questionnaires show a large variability and various limitations. The aim of this study was to assess the way in which international swallowing experts from various disciplines asses swallowing problems in order to improve the radiologist´s ability to take a thorough medical history in this specific patient group. Methods A two-step Delphi method was used to collect swallowing experts’ ways of taking the medical history in patients with swallowing disorders. The questions obtained in a first interview round were pooled and structured by dividing them into general and specific questions, including several subcategories, and these were scored by the experts in a second step based on to their clinical relevance. Results Eighteen experts provided 25 different questions categorized as general questions and 34 dimension-specific questions (eight attributed to ‘suspicion of aspiration,’ 13 to ‘dysphagia,’ six to ‘globus sensation,’ four to ‘non-cardiac chest pain,’ and three to ‘effect of life.’) In the second interview round, the experts´ average predictive values attributed to those questions showed the varying importance of the presented items. Seven general and 13 specific questions (six of them attributed to ‘effect on life’ and seven ‘others’) were also added. Conclusions This collection of questions reflects the fact that a multidisciplinary approach when obtaining the medical history in patients with swallowing disorders may contribute to an improved technique for performing a symptom-oriented medical history-taking for radiologists of all training levels.

Keeping up to date with the increasing amount of health-related knowledge and managing the increasing numbers of patients with more complex clinical problems is a challenge for healthcare professionals and healthcare systems. Health IT applications, such as electronic health records or decision-support systems, are meant to support both professionals and their support systems. However, for physicians using these applications, the applications often cause new problems, such as the impracticality of their use in clinical practice. This review adopts a social sciences perspective to understand these problems and derive suggestions for further development. Indeed, humans use tools to remediate the brain's weaknesses and enhance thinking. Available health IT tools have been shaped to fit administrative needs rather than physicians' needs. To increase the beneficial effect of health IT applications in health care, clinicians' style of thinking and their learning needs must be considered when designing and implementing such systems. New health IT tools must be shaped to fit health professionals' needs. To further ease the integration of new health IT tools into clinical practice, we must also consider the effects of implementing new tools on the wider social framework.

Radiological fluoroscopic evaluation remains the primary imaging modality of choice to evaluate patients with swallowing disorders, despite the increasing availability and technical advantages of nonradiological techniques and the current radiological focus on cross-sectional imaging studies, such as computed tomography and magnetic resonance imaging. The radiological swallowing evaluation should be tailored to assess the entire upper gastrointestinal tract, including the lower esophageal sphincter. Fluoroscopy enables the simultaneous assessment of esophageal motility disorders, as well as structural pathologies, including strictures, webs, rings, diverticula, and tumors. Mono- and double-contrast esophagrams and solid bolus tests together allow assessment of lower esophageal sphincter function and complement other methods, such as endoscopy, manometry, or impedance planimetry. Here we review the role of radiological studies for correct assessment of structural and functional pathologies at the level of the lower esophageal sphincter.

Swallowing problems may be due to an abnormal transportation of food and drinks from the mouth to the stomach. The esophagram aims to monitor this and to reveal abnormalities in the morphodynamic process. It is important to analyze the patient’s symptom before the examination in order to custom-tailor the radiologic approach and to be able to explain the patients symptoms. Lower motor-neuron disease causes a global weakness in the pharyngeal musculature with lack of elevation of the pharynx during swallowing. This may cause major aspiration. Upper motor neuron disease affects the oral stage as well as an incoordination in the pharyngeal stage.

OBJECTIVES To compare videofluoroscopy that included a tablet test with impedance planimetry (EndoFLIP(®)) for the evaluation of oesophageal stenosis in patients with dysphagia. METHODS In 56 patients, videofluoroscopic examinations following the transit of a 14-mm tablet were retrospectively reviewed and correlated with impedance planimetry findings, a catheter-based method using impedance planimetry to display the oesophageal diameter estimates. Additional findings assessed were the occurrence of symptoms during tablet passage and evaluation of oesophageal motility. RESULTS Impaction of the tablet occurred in 31/56 patients; nine showed a moderate delay (2-15 s), three a short delay (

The lower esophageal sphincter and gastric fundus are challenging anatomical areas to evaluate radiologically. By visualizing the esophagogastric region and the stomach in mono- and double-contrast technique and recording it on videotape, it is an excellent method for evaluating patients with suspected abnormalities or noncharacteristic swallowing disorders. Additionally, in patients after antireflux procedures or bariatric surgery, swallowing studies and CT have proven to be workhorses for the radiological diagnosis of postoperative complications. Examinations should be tailored according to the individual anatomical situation and the patients’ symptoms.

Radiologie ist ein Fachgebiet mit einem hohen Informationsfluss. Neben klassischen sind elektronische Medien in groser Vielfalt verfugbar. Asynchrones und synchrones E-Learning als stetig wachsendes Angebot unterstutzen die Radiologie in Form diverser Fallsammlungen, Webinaren oder Onlinetexten. Etabliert sind diverse Internetressourcen, Social Media und Onlinekurse. Dynamische Webseiten bieten eine neue Vielfalt an Interaktionen. Der Zugang zu grosen Datenmengen ist zunehmend einfacher, schnell verfugbar und voller neuer Anwendungsmoglichkeiten. Soziale Medien zeigen exponentiell wachsende Nutzerzahlen, ermoglichen eine effiziente, ortsubergreifende Zusammenarbeit und fordern die Bildung fachlicher Netzwerke. Massive Open Online Courses (MOOCs) erganzen das Bildungsangebot und steigern die Zugangsmoglichkeiten zu Bildungsressourcen. Trotz der Vielfalt kommt nach wie vor der kritischen Auswahl gegenuber der unkritischen Nutzung dieser Medien eine zentrale Bedeutung zu. Elektronische Medien sind jedoch nicht fur eine einseitige Nutzung gedacht, sondern viel mehr als Erganzung oder Kombination mit klassischen Medien sinnvoll einsetzbar. Jedenfalls wird der radiologische Arbeitsplatz dadurch bereichert. So dynamisch der Fortschritt im Bereich radiologischer Medien und Tools ist, den direkten Personenkontakt sollen die Radiological Media nie ersetzen.

This paper reporting on techniques for esophageal evaluation and imaging and drugs for esophageal disease includes commentaries on endoscopy techniques including dye-based high-resolution and dye-less high-definition endoscopy; the shift from CT to MRI guidance in tumor delineation for radiation therapy; the role of functional lumen imaging in measuring esophageal distensibility; electrical stimulation of the lower esophageal sphincter (LES) as an alternative to fundoduplication for treatment of gastroesophageal reflux disease (GERD); the morphological findings of reflux esophagitis and esophageal dysmotility on double-contrast esophagography; the value of videofluoroscopy in assessing protecting mechanisms in patients with chronic reflux or swallowing disorders; targeting visceral hypersensitivity in the treatment of refractory GERD; and the symptoms and treatments of nighttime reflux and nocturnal acid breakthrough (NAB).

Oropharyngeal dysphagia (OD) is a swallowing disorder caused by congenital abnormalities and structural damage and disease-associated damage of the oral cavity, pharynx, and upper esophageal sphincter. Patients with OD lack the protective mechanisms necessary for effective swallowing, exhibiting difficulty controlling food in the mouth and initiating a swallow, leading to choking, coughing, and nasal regurgitation. OD is a major risk factor for malnutrition, dehydration, and aspiration pneumonia. The following on OD includes commentaries on the application of simulation of oropharyngeal transient receptor potential vanilloid 1 (TRPV1) and maneuvers like the Shaker exercise to improve the safety and efficacy of swallow in OD patients; the prevalence of esophageal pathologies in OD patients and the need to evaluate the esophagus, esophagogastric junction, and stomach; and strategies for clinical screening to detect OD and aspiration among high-risk patients and to improve oral health care, maintain nutrition and hydration, and prevent aspiration pneumonia.

The following discussion of upper esophageal sphincter dysfunction includes commentaries on the role of the cricopharyngeus muscle in reflux disease; the etiology and treatment of Zenker diverticulum; the use of videofluoroscopy in patients with dysphagia, suspicion of aspiration, or globus; the role of pH-impedance monitoring in globus evaluation; and treatment for reflux-associated globus.

The following on the treatments of adenocarcinomas in Barrett's esophagus contains commentaries on endo mucosal resection; choice between other ablative therapies; the remaining genetic abnormalities following stepwise endoscopic mucosal resection and possible recurrences; the Fotelo-Fotesi PDT; the CT TNM classification of early stages of Barrett's carcinoma; the indications of lymphadenectomy in intramucosal cancer; the differences in lymph node yield in transthoracic versus transhiatal dissection; video-assisted lymphadenectomy; and the importance of the length of proximal esophageal resectipon; and indications of sentinel node dissection.

Magnetic resonance imaging (MRI), mammography and ultrasonography were performed in 44 consecutive women (mean age 45 [29-70] years) with a total of 73 silicone breast implants. The implant had been inserted after mastectomy for cancer in 15 patients, for cosmetic breast augmentation in 29. MRI proved to be superior to the other two imaging modalities with respect to assessing implant content, capsule and surrounding tissues. In 39 patients MRI clearly demarcated the implant from the residual breast tissue. But in four patients the lateral MRI assessment was impaired by phase artefact and in one other by movement artefacts in a restless patient. Implant thickness was underestimated by mammography and ultrasonography compared with MRI. In nine cases mammography showed retromammary parenchyma, while MRI did so in 20. The posterior wall of the implant was visualized by mammography in only one patient, but in all of them by MRI. Ultrasonography failed in all patients to show the entire implant circumference. In three cases MRI was the only imaging method which revealed a defect in the implant capsule with extrusion of silicone.

Acute colonic pseudo-obstruction (Ogilvie's syndrome) is a clinical entity characterized by massive nontoxic dilatation of the colon in the absence of mechanical obstruction and is associated with increased morbidity and mortality in the immunosuppressed patient. We present a case of a kidney transplant recipient developing a life-threatening condition with acute colonic pseudo-obstruction associated with radiologic findings of a linear pneumatosis intestinalis (PI). Urgent laparotomy and resection of the dilated cecum, colon ascendens and transversum was performed because of bowel necrosis with multiple serosal defects. Stool cultures and special stains for microorganisms were all negative, and there was no evidence for viral or fungal infection. The patient was discharged 31 days after transplantation with normal renal function. In conclusion, this steroid-induced ileus (pseudo-obstruction) is a potentially malignant early form of colonic dysmotility rarely reported in transplant recipients. Awareness and early recognition of the condition are critical for a successful outcome. Colonoscopic decompression can achieve reversal of colonic dilatation in most cases, but in some patients prophylactic laparotomy is indicated for prevention of the catastrophic consequences of perforation.

Purpose: To evaluate the functional disorders of the oral and pharyngeal phases of deglutition after repair of esophageal atresia in children. Material and Methods: 19 children (10 girls, 9 boys, mean age 22 months) underwent videofluoroscopy of deglutition after repair of esophageal atresia. The videofluoroscopic studies were assessed according to functional and morphological changes in the oral, pharyngeal and esophageal phases. The persistence of radiologic findings on videofluoroscopy was determined. Results: The oral phase was normal in all patients. The main functional disorder of the pharyngeal phase was aspiration in 7 (37%) children. A completely normal deglutition in the pharyngeal and esophageal phases was not seen in any patient. Conclusion: Videofluoroscopy after repair of esophageal atresia is helpful in differentiation of functional and morphological disorders that can lead to prandial aspiration and have an influence on the decision about continued therapy.

This study evaluated the clinical significance of pharyngeal retention to predict aspiration in patients with dysphagia.At videofluoroscopy, pharyngeal retention was found in 108 (28%; 73 males, 35 females; mean age, 60 years) of 386 patients with a suspected deglutition disorder. Swallowing function was assessed videofluoroscopically. The amount of residual contrast material in the valleculae or piriform sinuses was graded as mild, moderate, or severe. The frequency, type, and grade of aspiration were assessed.Pharyngeal retention was caused by pharyngeal weakness or paresis in 103 (95%) of 108 patients. In 70 patients (65%) with pharyngeal retention, postdeglutitive overflow aspiration was found. Aspiration was more often found in patients who had additional functional abnormalities such as incomplete laryngeal closure or impaired epiglottic tilting (p0.05). Postdeglutitive aspiration was diagnosed in 25% patients with mild, in 29% with moderate, and in 89% with severe pharyngeal retention (p0.05).Postdeglutitive overflow aspiration is a frequent finding in patients with pharyngeal retention, and the risk of aspiration increases markedly with the amount of residue. Functional abnormalities other than pharyngeal weakness, such as impaired laryngeal closure, may contribute to aspiration.

The aim of this study was to assess the role of videofluoroscopy in the detection of structural abnormalities of the pharynx and esophagus in patients with different symptoms of impaired deglutition. Dynamic radiographic recording of deglutition was performed in 3193 consecutive patients (1578 men, 1615 women; mean age 54 years) suffering from dysphagia, suspicion of aspiration, globus sensation, and non-cardiac chest pain. We assessed different structural lesions from the oral cavity to the esophagus and classified them into eight categories. Their frequency and association with the different clinical symptoms were evaluated. Videofluoroscopy revealed 1040 structural abnormalities in 833 patients (26%) including mass lesions from the oral cavity to hyoid/larynx ( n=66), pharyngeal diverticula ( n=181), pharyngeal masses ( n=78), other pharyngeal narrowings ( n=71), webs ( n=98), masses ( n=39), and other narrowings ( n=73) of the upper esophageal sphincter, esophageal diverticula ( n=80), esophageal webs, rings and strictures ( n=194), and intrinsic and extrinsic esophageal lesions ( n=160). There was a considerable variance of findings for different symptoms. In a large proportion of symptomatic patients videofluoroscopy detects morphological abnormalities along pharynx and esophagus often combined with functional disorders. This fact underlines the role of videofluoroscopy as a diagnostic test for function as well as morphology.

AIM: The goal of our study was to evaluate findings in mammography and sonography in male patients with pathohistologically proven diseases of the breast. MATERIAL AND METHODS: Mammographies and sonographies, which were obtained in 41 male patients in a 6-year period, were retrospectively evaluated in accordance with the BI-RADS(R) classification. RESULTS: Histologically 13 carcinomas, 21 gynecomastias, 3 pseudogynecomastias, 2 epithelial inclusion cysts and 2 other benign lesions were diagnosed. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of mammography in differentiation of benign versus malignant disease were 92 %, 89 %, 80 %, 96 % and 90 %, respectively. Additional sonography did not change these results. However, sonography increased diagnostic confidence in 18.2 % (2/11) of suspicious lesions. CONCLUSION: In our study the invasive ductal carcinoma of male patients was a predominantly lobulated, ill-defined lesion in mammography and sonography. The differentiation of carcinoma to pseudogynecomastia and diffuse or dendritic gynecomastia was securely feasible. However, we could not reliably distinguish between carcinoma and some benign mass lesions. In cases of mammographically diagnosed masses or unclear mammography, additional sonography should be performed to increase the diagnostic confidence.

AIM: Videofluoroscopic assessment of the spectrum and incidence of swallowing complications after state-of-the-art laryngeal cancer surgery. MATERIALS AND METHODS: We retrospectively studied videofluoroscopic examinations of 120 patients (94 men, 26 women; mean age, 58 years) with suspected complications after laryngeal resection (partial laryngectomy, 65; total laryngectomy, 55). Swallowing function (i.e., oral bolus control, laryngeal elevation and closure, presence of pharyngeal residue, aspiration) and structural abnormalities such as strictures, fistulas and tumour recurrence were assessed by videofluoroscopy. RESULTS: Abnormalities were found in 110 patients, including strictures in nine, fistulas in six and mass lesions in 13 patients. Aspiration was found in 63 patients overall (partial laryngectomy, 61/65; total laryngectomy, 2/55), occurring before swallowing in five, during swallowing in 34, after swallowing in nine and at more than one phase in 15 patients. Pharyngeal paresis was detected in three and pharyngeal weakness in 19 patients. Pharyngo-oesophageal sphincter dysfunction was observed in 10 cases. CONCLUSION: Aspiration is a very common complication after partial laryngeal resection. It is mainly caused by incomplete laryngeal closure, sphincter dysfunction or pharyngeal pooling. Videofluoroscopy is the only radiological technique able to identify both disordered swallowing function and structural changes after laryngeal resection. Detection of these complications is crucial for appropriate further therapy.Kreuzer, S. H. (2000). Clinical Radiology 55 , 775–781.

Inflammatory bowel disease (IBD) comprises the two disorders ulcerative colitis (UC) and Crohn's disease (CD). Although the etiology is still unclear, initiation and aggravation of the inflammatory processes seem to be due to a massive local mucosal immune response. An increased number of greatly activated macrophages seems to contribute to the onset of IBD by expressing upregulated costimulatory molecules (e.g., CD80/CD86) and a cytokine profile favouring a type I proinflammatory response. The release of interleukin 2 (IL-2) and Interferon-gamma (IFN-gamma) by naive T lymphocytes predominantly stimulates cytotoxic T lymphocytes, macrophages, and natural killer (NK) cells and increases the antigen-presenting potential of all these cell types. Opposite this proinflammatory immune reaction a compensatory type II antiinflammatory response has been suggested in the inflamed mucosa, involving mainly interleukin 4 and interleukin 10. Both cytokines are able to down-regulate inflammatory mediators including tumor necrosis factor-alpha (TNF-alpha) and interleukin 1 and favor a humoral immune response. The main goal of this clinical trial is the local liposome-mediated gene transfer of these two antiinflammatory cytokines, interleukin 4 and interleukin 10, in patients with severe IBD of the rectum. This local administration of antiinflammatory cytokines will avoid toxic systemic side effects, prevents blocking of the beneficial effects of proinflammatory cytokines, e.g., TNF-alpha in other tissue compartments and increases the local concentration of interleukin 4 and interleukin 10 over a prolonged period of time. The combined effects of IL-4 and IL-10 have been shown to shift the Th1/Th2 cell activation in favor of a Th2 immune response which seems to be essential for fighting against the inflammation and ultimative healing.

Hintergrund. Der Pharynx reprasentiert, durch seine Funktion als Luft- und Speiseweg einerseits sowie durch seine Topographie in der komplexen Zervikalregion andererseits, ein auserst differenziertes Organsystem. Bildgebungsverfahren. Neben den, in den letzten Jahren und Jahrzehnten einer rasanten Entwicklung unterworfenen, und in der Kopf-Hals-Radiologie unerlasslichen Schnittbildverfahren, spielen, gerade bei der Bildgebung des Pharynx, konventionelle Rontgenverfahren, welche eine dynamische Beurteilung der Funktion erlauben, weiterhin eine wichtige Rolle in der Diagnostik. Die Methoden der Bildgebung stellen somit heute, erganzend zur klinischen Untersuchung, unumstritten das 2. Standbein in der Abklarung von Pathologien am Pharynx dar. Resumee. Dieses Zusammenwirken bietet dem Radiologen, entsprechend der Fragestellung nach funktionellen oder strukturellen Pathologien, ein vielfaltiges Betatigungsfeld, erfordert gleichzeitig aber das grundlegende Verstandnis der normalen Anatomie und Physiologie sowie die Kenntnis der spezifischen Vor- und Nachteile der zur Verfugung stehenden bildgebenden Verfahren.

Radiologic evaluation of patients with dysphagia relies on a meticulous and standardized technique. For assessment of function video recording is mandatory. A systematic approach for the description of function and dysfunction is necessary. The following describes such an approach focused on an easy and reproducible technique and a comprehensive description of radiologic events and morphology.

Purpose: To evaluate the prevalence and clinical significance of associated oesophageal motor disorders in patients with midoesophageal diverticula. Material and Methods: We retrospectively reviewed videofluoroscopic and, if available, manometric studies of 30 patients with midoesophageal diverticula. The type of diverticulum and the presence and nature of oesophageal motor disorders were assessed. Results: Videofluoroscopy showed that 24 patients had 26 pulsion-type diverticula and 6 patients had 7 traction-type diverticula. Oesophageal motor disorders were demonstrated in 21 of the 24 patients with pulsion-type diverticula and in 3 of the 6 with traction-type diverticula. Nineteen patients had nonspecific motor disorders, 5 had achalasia, and 5 had gastrooesophageal reflux or oesophagitis. Conclusion: Midoesophageal diverticula are most often of the pulsion-type and tend to be associated with an oesophageal motor disorder. Motor disorders are predominantly nonspecific, but achalasia may be encountered as well.

Oropharyngeal dysphagia (OD) is a swallowing disorder caused by congenital abnormalities and structural damage and disease-associated damage of the oral cavity, pharynx, and upper esophageal sphincter. Patients with OD lack the protective mechanisms necessary for effective swallowing, exhibiting difficulty controlling food in the mouth and initiating a swallow, leading to choking, coughing, and nasal regurgitation. OD is a major risk factor for malnutrition, dehydration, and aspiration pneumonia. The following on OD includes commentaries on the application of simulation of oropharyngeal transient receptor potential vanilloid 1 (TRPV1) and maneuvers like the Shaker exercise to improve the safety and efficacy of swallow in OD patients; the prevalence of esophageal pathologies in OD patients and the need to evaluate the esophagus, esophagogastric junction, and stomach; and strategies for clinical screening to detect OD and aspiration among high-risk patients and to improve oral health care, maintain nutrition and hydration, and prevent aspiration pneumonia.

Pharyngo-oesophageal abnormalities are found in a high proportion of patients with globus sensation. This study compares the diagnostic value of static single- and double-contrast radiography of the pharynx and oesophagus with videofluoroscopy and with videofluoroscopy combined with static radiography in these patients. Pharyngeal and oesophageal morphology and motor function were studied in 130 consecutive patients with globus sensation (46 males, 84 females; mean age, 47 years) by means of static single and double-contrast radiography and by videofluoroscopy. Videofluoroscopy revealed significantly more functional and structural abnormalities compared to static radiography. Pharyngeal and/or oesophageal disorders were found in 89 vs. 47 patients (chi2 [1] = 19.82, P = 0.0001), pharyngeal abnormalities in 54 vs. 27 patients (chi2 [1] = 13.5, P0.0002), and oesophageal abnormalities in 72 vs. 27 patients (chi2 [1] = 28.13, P0.0001). Videofluoroscopy combined with static radiography revealed significantly more abnormalities than videofluoroscopy alone (chi2 [1] = 4.23, P0.05), and assessed mucosal details more reliably than videofluoroscopy alone. The most frequent abnormalities found were nonspecific oesophageal motor disorders, pharyngo-oesophageal sphincter dysfunction, pharyngeal stasis, achalasia, and laryngeal penetration or aspiration of barium. In most patients with globus sensation, pharyngeal and/or oesophageal abnormalities can be detected radiographically. Videofluoroscopy revealed significantly more functional but not morphological abnormalities than did static radiography. Videofluoroscopic studies combined with static radiography had a higher diagnostic value than videofluoroscopic studies alone.

PURPOSE The purpose of this study was to test a scoring system and its utility for the assessment of the clinical significance of radiological examinations. MATERIAL AND METHODS The reports of all diagnostic studies obtained in patients with a clinical suspicion of pancreatitis, urinary tract obstruction, biliary or gallbladder diseases, ileus and gastrointestinal perforation were scored prospectively in 4 categories from 0 to 3. These categories were related to the ability to establish a definite diagnosis, to exclude suspected disease, to influence further diagnostic work-up and therapeutic decision-making. RESULTS This scoring system showed significant differences of the efficacy of different imaging modalities in these 5 clinical settings. CONCLUSION This scoring system was helpful to determine the clinical significance of radiological examinations.

In laryngectomized patients a tracheo-esophageal artificial fistula can be used to achieve air flow from the trachea to the esophagus during speech. A one-way plastic valve is often used for the fistula. A free jejunal graft between the trachea and the esophagus can also be used. To avoid aspiration the transplant is attached to the submental area giving the graft a siphon-like shape. We performed 23 videoradiographic examinations using high-density barium in 14 such patients. The aim was to evaluate the protective function of these grafts against aspiration. Penetration of the bolus and a small amount of residual contrast material in the ascending limb of the graft was a normal finding. If the standard barium bolus reached the descending limb at any time during the examination, this was a sign of aspiration hazard. To avoid aspiration, the vertex of the speech siphon should be higher than the level of the hypopharyngeal anastomosis.

To evaluate students' overall assessment and effectiveness of the web-based blended learning conception "Unified Patient Project" (UPP) for medical students rotating on their otolaryngology internship (ear, nose, and throat [ENT] tertiary).Prospective comparison group design of the quasiexperimental type.Medical education.The experimental group (preintervention test [pretest], intervention, and postintervention test [posttest]) comprised 117 students, and the comparison group (pretest, alternative intervention, and posttest), 119.In the experimental group, lecturing of case studies was replaced by the blended learning concept UPP. A standardized questionnaire evaluated students' overall assessment of teaching otolaryngology. A pretest and posttest using multiple choice questions was administered to clarify whether the UPP has led to a knowledge gain.The comparison group was more satisfied with their teaching; however, this was not statistically significant (P = .26) compared with the UPP. Students with higher preknowledge benefitted from the UPP, while students with lower preknowledge did not (P = .01). On average, posttest results in the experimental group exceeded those of the comparison group by 8.7 percentage points for a 75% preknowledge of the maximum attainable score, while they fell below those of the comparison group by 8.1 percentage points for a 25% preknowledge.Students' satisfaction with the blended learning concept UPP was lower than in the face-to-face teaching, although this was not statistically significant. The new web-based UPP leads to an improved knowledge in clinical otolaryngology for all students. Students with lower preknowledge benefitted more from face-to-face teaching than from the UPP, while students with higher preknowledge benefitted more from the UPP. This implies students with poor preknowledge need special promotion programs.

The intention of this chapter is to introduce a multi-disciplinary diagnostic work-up and, in particular, to present a practical and structured radiological approach. Swallowing disorders are common. U.S. statistics indicate that more than 5 % of the population has swallowing difficulties, and in hospitals up to 50% (Logemann 1995). The swallowing tract crosses many anatomic regions. Liquid and solid foods have to be transported properly from the oral cavity into the pharynx and through the esophagus into the stomach. Thus, a wide variety of diseases may affect deglutition, resulting in a multidisciplinary work-up of dysphagic patients. Videofluoroscopy (VF) of deglutition is the method of choice to investigate the whole swallowing tract in a ‘‘one-stop-shopping’’ fashion. VF can depict patho- logic findings of morphology and function as a basis to decide on a further specialized work-up.

Successful allogeneic bone marrow transplantation (BMT) for hematologic disorders may be complicated by graft-versus-host-disease (GVHD). Chronic GVHD is a systemic disease, involving, among other organs, the skin, mouth, liver, and esophagus. Esophageal involvement results in mucosal inflammation, leading to submucosal fibrosis and, occasionally, formation of webs and strictures. We investigated 25 allogeneic BMT recipients (17 with and eight without chronic GVHD). All patients had a videofluoroscopic study of the pharynx and esophagus to determine the radiographic abnormalities characteristic of chronic GVHD. Oropharyngeal abnormalities (poor bolus control, pharyngeal retention, or excessive mucous secretions) were found in five patients with and three patients without GVHD. Only one patient with GVHD had a pharyngo-esophageal stricture. There was no significant difference between the two groups with regard to pharyngo-esophageal radiographic abnormalities and esophageal symptoms. Radiographic evidence of esophageal motility disorder is not specific for GVHD involvement. In the absence of specific radiographic features, endoscopy is the most accurate method for the diagnosis of esophageal involvement by GVHD.

The purpose of this study was to evaluate the efficacy of a new automatic biopsy device (Autovac, Angiomed, Karlsruhe, Germany) in ultrasound (US) guided biopsies of focal abdominal lesions. 50 consecutive patients with focal abdominal lesions underwent US guided biopsies. In the first 24 patients, needle passes were performed with the Autovac system (outer diameter 0.95 mm) as well as with the Biopty gun (outer diameter 0.9 mm) (Bard Covington, USA). The size and the quality of the histologic and the cytologic material obtained by both systems were evaluated by histopathologists blinded to the system used. Autovac yielded significantly more material (defined as the area of the obtained tissue cores) and a significantly higher quality score than did the Biopty system. 96% of the histologic specimen and 100% of the cytologic smears obtained with Autovac were diagnostic, compared to 70 and 81% with Biopty, respectively. With the exception of a short-time elevation of the blood pressure in one patient, no complications occurred. The results indicate an advantage of the automatic full-cut type system Autovac over the tru-cut type Biopty gun in US-guided biopsies of focal abdominal lesions.

The following on the treatments of adenocarcinomas in Barrett's esophagus contains commentaries on endo mucosal resection; choice between other ablative therapies; the remaining genetic abnormalities following stepwise endoscopic mucosal resection and possible recurrences; the Fotelo-Fotesi PDT; the CT TNM classification of early stages of Barrett's carcinoma; the indications of lymphadenectomy in intramucosal cancer; the differences in lymph node yield in transthoracic versus transhiatal dissection; video-assisted lymphadenectomy; and the importance of the length of proximal esophageal resectipon; and indications of sentinel node dissection.

Grundlagen: Neben der klassisch-chirurgischen Therapie des Zenker-Divertikels, der offenen Abtragung und Myotomie, gibt es transorale, minimal invasive Verfahren. Diese haben als gemeinsames Prinzip eine Spaltung der Schwelle zwischen zervikalem Osophagus und dem dorsal abgehenden Divertikel. Dies bewirkt eine suffiziente Drainage des Divertikels in den Osophagus bei gleichzeitiger Myotomie des M. cricopharyngeus.

Acute epiglottitis is a rare but life-threatening disease that commonly occurs in children, and also rarely in adults. The symptoms may be mild and non-specific before a rapid onset of airway obstruction occurs. Early diagnosis is essential, as delayed treatment is associated with a high rate of complications including death. We present the clinical and radiological findings of this unusual condition in an adult.

The goal of imaging, when investigating the postoperative stomach and duodenum, is to rule out or to detect early and late postoperative complications. Clinical and laboratory findings, as well as endoscopy and imaging have to be considered in an interdisciplinary setting. Fluoroscopy and CT represent the basic imaging modalities which provide specific information on the evaluation of the normal postoperative state, as well as the detection of leaks, fistulas, haematomas, abcesses, obstruction, malignant disease and functional disorders.

Multislice CT offers new opportunities for the imaging of gastrointestinal organs. With thin collimation, excellent imaging of the stomach becomes possible and allows for high-quality multiplanar reformations and 3D visualization. Adequate distension of the stomach using water as a negative contrast agent (hydro-CT) is a prerequisite for assessing the stomach wall. While such techniques have already been used with single-slice spiral CT to improve staging of gastric malignancies, single slice suffers substantially from relatively large slice thickness (Fishman et al. 1996; Baert et al. 1989; Merino et al. 1999). The much faster speed of multislice CT means that optimal contrast material injection techniques are essential (Fleischmann et al. 2000) in order to improve delineation of tumour from normal tissue. Indeed, the combination of hydro-CT with near isotropic multislice imaging offers improved diagnosis to a large variety of gastric diseases. Compared with endosonography, multislice CT is able not only to visualize the immediate vicinity of the stomach, but also more distant regions, such as para-aortic lymph nodes or abdominal organs.

Multidetector computed tomography (CT) offers new opportunities in imaging of the gastrointestinal tract. When thin collimation is used, near-isotropic imaging of the stomach is possible, allowing high-quality multiplanar reformation and three-dimensional reconstruction of gastric images. Proper distention of the stomach and optimally timed administration of intravenous contrast material are required to detect and characterize disease. In contrast to gastroscopy and double-contrast studies of the stomach, CT provides information about both the gastric wall and the extragastric extent of disease. Preoperative staging of gastric carcinoma appears to be the main clinical indication for multidetector CT. In addition, multidetector CT allows detection of other gastric malignancies (lymphoma, carcinoid tumors, metastases, gastrointestinal stromal tumors) and benign gastric tumors (neural tumors, polyps). Gastric inflammation (gastritis, ulcers, Menetrier disease) and miscellaneous gastric conditions (emphysema, gastric outlet obstruction, varices) can also be visualized with multidetector CT. Multidetector CT is a valuable tool for the evaluation of gastric wall disease and serves as an adjunct to endoscopy.

The aim of this study was to evaluate the types of swallowing abnormalities that occur in symptomatic patients who have undergone cardiovascular surgery.From 1994 to 2001, 22 patients (17 males and five females; age range, 4-89 years; mean age, 64 years) who had swallowing abnormalities after cardiovascular surgery were referred for a videofluoroscopic swallowing study. Each study was analyzed for functional abnormalities of the tongue, soft palate, epiglottis, hyoid and larynx, pharynx, upper esophageal sphincter, and esophagus. Also, the performance of transesophageal echocardiography, long-term intubation, or both was noted.Swallowing abnormalities were present in 18 patients (81.8%) (range, one to eight functional abnormalities; mean, 3.9 functional abnormalities). The distribution of abnormalities across the functional units statistically significantly deviated (chi(2) = 14.4; df = 6; p = 0.025) from uniform distribution, with abnormalities most commonly involving the hyoid and larynx (13 patients [59.1%]) and the pharynx (10 patients [45.5%]). Aspiration was found in 13 patients (59.1%) (predeglutitive, n = 1; intradeglutitive, n = 4; postdeglutitive, n = 3; and mixed, n = 5). In the 14 patients (63.6%) who underwent transesophageal echocardiography, long-term intubation, or both, we frequently found incomplete tilting of the epiglottis, pharyngeal weakness, and postdeglutitive aspiration.Most patients with swallowing problems after cardiovascular surgery present with multiple abnormalities that most commonly affect the hyoid and larynx and the pharynx and result predominantly in intra- or postdeglutitive aspiration. The performance of transesophageal echocardiography and long-term intubation may influence the types of swallowing abnormalities.

The negative influence of obesity on the detection rate of the appendix for US in adults has been reported. It has been assumed that obesity is a limiting factor in the detection of the appendix with US in children as well, but this has not yet been proven. The aim of our study was to evaluate whether nutritional condition (defined by the body mass index-for-age percentiles: BMI-FAP) influences the detection of the appendix in children on US. One hundred twenty-six children (65 girls and 61 boys) with a mean age of 11.4 years with clinically suspected acute appendicitis underwent ultrasound on a commercially available high-end machine (HDI 5000, ATL, Bothell, Wash.). The BMI was calculated, and children were divided in three weight groups in accordance with the BMI-FAP, and were correlated with US findings. Evaluation of the three weight groups in accordance with the BMI-FAP demonstrated significant differences ( p=0.04) in the detection of the appendix. There was no statistical significance for the BMI, weight, height, and age solely for the detection of the appendix. In children there is a correlation between the nutritional condition as defined by the BMI-FAP and the detection of the appendix.

Background: Zenker's diverticulum is associated with characteristic symptoms of progressive dysphagia and regurgitation. As most patients are elderly, the perioperative risk is usually high. We report our clinical experience with the transoral endoscopic staple-assisted method, including a thorough assessment of the symptomatic relief achieved by the procedure. Methods: 46 consecutive patients (29 m, 17 f) with a median age of 61 years (range, 37–96 years) were treated between 1997 and 2002. The symptoms and their frequency were registered. The follow-up consisted of clinical and radiographic investigations. Results: The median size of the diverticulum was 4 cm (range, 2–12 cm). Transoral treatment was successful in 39 patients; in 7 cases (15.2%) a switch to open surgery was required. The median operating time was 30 min (range, 10–150 min). Mortality rate was nil, while morbidity was 7.7%. The median duration of the postoperative hospital stay was 5 days (range, 1–65 days). After a median follow-up of 11 months (range, 1–40 months), 5 patients had been reoperated on endoscopically due to clinical recurrence. Clinical symptoms were significantly reduced (dysphagia of liquids p ? 0.0001, dysphagia of solids p ? 0.001, regurgitation p ? 0.001). Conclusion: Our results confirm that minimal invasive treatment of Zenker's diverticulum is a safe method and provides significant symptomatic relief.

Orthotopic liver transplantation (OLT) has been shown to be an effective treatment of hepatocellular carcinoma (HCC) in certain stages. 1 However, in patients with advanced tumors, the oncologic outcome after surgery is disappointing. 2 In early stages OLT seems to be the treatment of choice, especially in patients with cirrhosis. 1,2 In the light of limited donor resources, resection still is important. Palliative procedures such as chemoembolization, cryotherapy, thermoablation, and ethanol injection are frequently used in advanced disease 3–5 because the surgical death rate is enhanced in these situations. 2 Above all, adequate patient selection based on accurate staging is a crucial precondition for an appropriate treatment decision. In terms of preoperative staging, multiphasic helical computed tomography (HCT) has become the standard tool for the detection of nodular lesions in liver cirrhosis. 6,7 Most radiologic studies dealing with the value of several staging modalities based their gold standard either on intraoperative examination and the findings after partial resection or on follow-up studies with or without biopsy confirmation. 8–12 Besides detection of hepatic metastases, intraoperative ultrasound (IOUS) evolved into an indispensable tool in hepatic resection or intraoperative intervention for HCC. 13–16 Due to the lack of a more precise method, the diagnostic value of IOUS was frequently assessed by examination of resected liver segments or by follow-up studies of the liver remnant after hepatic resection. 17–19 Radiologic studies on liver imaging in patients scheduled for OLT are rare and generally are limited by a long interval between imaging and OLT. 20–24 To our knowledge, until now there has been no report dealing with the evaluation of triphasic HCT performed within 3 weeks before OLT and IOUS in staging HCC in transplant patients. The present study is an attempt to reveal the true value of multiphasic HCT and IOUS of the liver in patients with HCC in cirrhosis. Lesion-by-lesion analysis and segment-by-segment analysis were performed to evaluate sensitivity, specificity, predictive value of a positive value, and predictive value of a negative result as well as the overall accuracy of these methods.

Guidelines can be regarded as special forms of algorithms and have been shown to be useful tools for supporting medical decision making. With the Council Directive 97/43/Euratom recommendations concerning referral criteria for medical exposure have to be implemented into national law of all EU member states. The time- and cost-consuming efforts of developing, implementing, and updating such guidelines are balanced by the acceptance in clinical practice and eventual better health outcomes. Clearly defined objectives with special attention drawn on national and regional differences among potential users, support from organisations with expertise in evidence-based medicine, separated development of the evidence component and the recommendations component, and large-scale strategies for distribution and implementation are necessary. Editors as well as users of guidelines for referral criteria have to be aware which expectations can be met and which cannot be fulfilled with this instrument; thus, dealing with guidelines requires a new form of "diagnostic reasoning" based on medical ethics.