Using the National Institute of Health Stroke Scale to Predict Dysphagia in Acute Ischemic Stroke

Background and Purpose: Oropharyngeal dysphagia is a common manifestation in acute stroke. Aspiration resulting from difficulties in swallowing is a symptom that should be considered due to the frequent occurrence of aspiration pneumonia that could influence the patient's recovery as it causes clinical complications and could even lead to the patient's death. The early clinical evaluation of swallowing disorders can help define approaches and avoid oral feeding, which may be detrimental to the patient. This study aimed to create an algorithm to identify patients at risk of developing dysphagia following acute ischemic stroke in order to be able to decide on the safest way of feeding and minimize the complications of stroke using the National Institutes of Health Stroke Scale (NHISS). Methods: Clinical assessment of swallowing was performed in 50 patients admitted to the emergency unit of the University Hospital, Faculty of Medicine of Ribeirao Preto, Sao Paulo, Brazil, with a diagnosis of ischemic stroke, within 48 h after the beginning of symptoms. Patients, 25 females and 25 males with a mean age of 64.90 years (range 26-91 years), were evaluated consecutively. An anamnesis was taken before the patient's participation in the study in order to exclude a prior history of deglutition difficulties. For the functional assessment of swallowing, three food consistencies were used, i.e. pasty, liquid and solid. After clinical evaluation, we concluded whether there was dysphagia. For statistical analysis we used the Fisher exact test, verifying the association between the variables. To assess whether the NIHSS score characterizes a risk factor for dysphagia, a receiver operational characteristics curve was constructed to obtain characteristics for sensitivity and specificity. Results: Dysphagia was present in 32% of the patients. The clinical evaluation is a reliable method of detection of swallowing difficulties. However, the predictors of risk for the swallowing function must be balanced, and the level of consciousness and the presence of preexisting comorbidities should be considered. Gender, age and cerebral hemisphere involved were not significantly associated with the presence of dysphagia. NIHSS, Glasgow Coma Scale, and speech and language changes had a statistically significant predictive value for the presence of dysphagia. Conclusions: The NIHSS is highly sensitive (88%) and specific (85%) in detecting dysphagia; a score of 12 may be considered as the cutoff value. The creation of an algorithm to detect dysphagia in acute ischemic stroke appears to be useful in selecting the optimal feeding route while awaiting a specialized evaluation. Copyright (C) 2012 S. Karger AG, Basel

Rehabilitative management of swallowing and oral-motor movements in patients with tetanus of a public service in Brazil

When looking at developing countries, the prolonged intensive medical and nursing care required by many patients places extra demands on an already stretched healthcare budget. The purpose of this study was to verify the effectiveness of a systematic rehabilitative program for swallowing and oral-motor movements in intensive care unit patients with the diagnosis of tetanus. Forty-five patients who were clinically diagnosed with tetanus were included in the study. Participants were divided in two groups: Cl - consisted of 18 tetanus patients who were consecutively admitted to the infectious disease ICU from January 2002 to December 2005, prior to the existence of a systematic swallowing and oral-motor intervention: GII - consisted of 27 tetanus patients who were consecutively admitted to the infectious disease ICU from January 2006 to December 2009 and were submitted to a specific rehabilitative management of swallowing and of the oral-motor movements. Results indicate that the proposed rehabilitative program reduced by approximately 50% the time patients remained in the ICU. The significant improvement observed in patients with tetanus who were submitted to the rehabilitative program for swallowing and oral-motor movements occurred in conjunction with a reduction in the amount of time necessary to reintroduce oral feeding, to decannulate and to remove the feeding tubes. In conclusion, swallowing/muscle exercise, in patients with severe/very severe tetanus, seem to promote the remission of muscle tension and seem to maximize functional swallowing. (C) 2012 Elsevier B.V. All rights reserved.

Estudo multicêntrico sobre escalas para grau de comprometimento em disfagia orofaríngea neurogênica

OBJETIVO: Analisar a concordância entre distintas escalas para grau de comprometimento em disfagia orofaríngea neurogênica. MÉTODOS: Foi realizado estudo clínico transversal. Participaram 200 indivíduos com disfagia orofaríngea neurogênica, 108 do gênero masculino e 92 do gênero feminino, com idades de 3 meses a 91 anos. Foram aplicadas quatro escalas para classificar o grau de comprometimento da disfagia orofaríngea, sendo duas escalas clínicas e duas videofluoroscópicas. Análises estatísticas foram realizadas para verificar a concordância entre as escalas clínicas e objetivas. RESULTADOS: Os resultados mostraram concordância muito boa entre as escalas clínicas estudadas (Kappa=0,92) e concordância moderada entre as escalas objetivas (Kappa=0,52). CONCLUSÃO: Embora a concordância entre as escalas clínicas tenha sido muito boa e entre as escalas objetivas tenha sido moderada, ainda é necessária ampla discussão e possível revisão dos parâmetros que definem o grau de comprometimento da disfagia orofaríngea em pacientes neurológicos.

Food restrictions of patients who are undergoing treatment for oral and oropharyngeal cancer

Purpose: Oral squamous cell carcinoma and its treatment are associated with facial disfigurement and functional inabilities that may lead to malnutrition or under nourishment. This study assessed the incidence of food restrictions in patients undergoing treatment for oral and oropharyngeal cancer. Method: We interviewed 120 patients in two hospitals in Sao Paulo, Brazil, using a structured food frequency questionnaire comprising the most commonly consumed foods in Brazil. This questionnaire was applied twice; the first time to inform dietary patterns prior to the diagnosis of cancer and the second time to assess recent modifications of diet that were associated with the disease and its treatment. Hospital files provided information on clinical status. Multivariate Poisson regression models assessed covariates with prognostic value. Results: One third of patients suffered major food restrictions (i.e., they reduced substantially the intake of more than 50% of the most commonly consumed food items before the diagnosis); 39% suffered a less severe condition (they could not eat less than 50% of the most commonly consumed food items before the diagnosis, and they needed changes in food preparation). Larger tumour size (adjusted incidence ratio IR = 1.45), posterior location (IR = 1.33), radiotherapy (IR = 1.84), loss of tongue mobility (IR = 1.36) and loss of teeth (IR = 1.25) in the surgery were associated significantly with the study outcome. Conclusion: This study identified clinical predictors of food restrictions in patients undergoing treatment for oral and oropharyngeal cancer. This knowledge may contribute to improve patient care and management, and to develop interventions aimed at preventing nutritional depletion of these patients. (C) 2011 Elsevier Ltd. All rights reserved.

Prognostic significance of NDRG1 expression in oral and oropharyngeal squamous cell carcinoma

Human N-myc downstream-regulated gene 1 (NDRG1) is a metastasis suppressor gene with several potential functions, including cell differentiation, cell cycle regulation and response to hormones, nickel and stress. The purpose of this study was to investigate the immunoexpression of NDRG1 in oral and oropharyngeal squamous cell carcinomas searching for its role in the clinical course of these tumors. We investigated immunohistochemical expression of NDRG1 protein in 412 tissue microarray cores of tumor samples from 103 patients with oral and oropharyngeal squamous cell carcinomas and in 110 paraffin-embedded surgical margin sections. The results showed NDRG1 up-regulation in 101/103 (98.1 %) tumor samples, but no expression in any normal tissue sample. Western blot assays confirmed the immunohistochemical findings, suggesting that lower levels of NDRG1 are associated with a high mortality rate. NDRG1 overexpression was related to long-term specific survival (HR = 0.38; p = 0.009), whereas the presence of lymph-node metastasis showed the opposite association with survival (HR = 2.45; p = 0.013). Our findings reinforce the idea that NDRG1 plays a metastasis suppressor role in oral and oropharyngeal squamous cell carcinomas and may be a useful marker for these tumors.

Effects of 3-Dimensional Conformal or Intensity-modulated Radiotherapy on Dental Pulp Sensitivity during and after the Treatment of Oral or Oropharyngeal Malignancies

Introduction: Radiation therapy (RT) of malignant tumors in the head and neck area may have damaging effects on surrounding tissues. The aim of this investigation was to evaluate the effects of RI delivered by 3-dimensional conformal radiotherapy (3D-RT) or intensity-modulated radiotherapy (IMRT) on dental pulp sensitivity. Methods: Twenty patients with oral or oropharyngeal cancer receiving RT with 3D-RT or IMRT underwent cold thermal pulp sensitivity testing (PST) of 2 teeth each at 4 time points: before RT (TP1), the beginning of RT with doses between 30 and 35 Gy (TP2), the end of RT with doses between 60 and 70 Gy (TP3), and 4 to 5 months after the start of RT (TP4). Results: All 40 teeth showed positive responses to PST at TP1 (100%) and 9 at TP2 (22.5%; 3/16 [18.8%] for 3D-RT and 6/24 [25.0%] for IMRT). No tooth responded to PST at TP3 and TP4 (0%). A statistically significant difference existed in the number of positive pulp responses between different time points (TP1 through TP4) for all patients receiving RT (P <= .05), IMRT (P <= .05), and 3D-RT (P <= .05). No statistically significant differences in positive sensitivity responses were found between 3D-RT and IMRT at any time point (TP1, TP3, TP4, P = 1.0; TP2, P = .74). A statistically significant correlation existed between the location of the tumor and PST at TP2 for IMRT (P <= .05) but not for 3D-RT (P = .14). Conclusions: RT decreased the number of teeth responding to PST after doses greater than 30 to 35 Gy. The type of RT (3D-RT or IMRT) had no influence on the pulp responses to PST after the conclusion of RT. (J Endod 2012;38:148-152)

Gross morphology of rhea oropharyngeal cavity

The rhea (Rhea americana americana) is an american bird belonging to Ratite's family. Studies related to its morphology are still scarce. This study aims to describe the macroscopic structures of the oropharyngeal cavity. Five heads (2 to 6 months old) formalin preserved were anatomically dissected to expose the oropharynx. The oropharynx of the rhea was "bell-shaped" composed by the maxillary and mandibular rhamphotheca. The roof and floor presented two distinct regions different in colour of the mucosa. The rostral region was pale pink contrasting to grey coloured caudal region. The median longitudinal ridge extended rostrally from the apex of the choana to the tip of the beak in the roof and it is clearly more prominent and rigid than the homolog in the floor that appeared thin and stretched merely along the rostral portion of the regio interramalis. The floor was formed by the interramal region, (regio interramalis) tongue and laryngeal mound containing glove-shaped glottis. This study confirmed the basic morphology of the oropharinx of the rhea. However, important morphological information not previously described is highlighted and contradictory information present in the literature is clarified.

Clinical prognostic indicators of dysphagia following prolonged orotracheal intubation in ICU patients

Introduction The development of postextubation wallowing dysfunction is well documented in the literature with high prevalence in most studies. However, there are relatively few studies with specific outcomes that focus on the follow-up of these patients until hospital discharge. The purpose of our study was to determine prognostic indicators of dysphagia in ICU patients submitted to prolonged orotracheal intubation (OTI). Methods We conducted a retrospective, observational cohort study from 2010 to 2012 of all patients over 18 years of age admitted to a university hospital ICU who were submitted to prolonged OTI and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist. The prognostic factors analyzed included dysphagia severity rate at the initial swallowing assessment and at hospital discharge, age, time to initiate oral feeding, amount of individual treatment, number of orotracheal intubations, intubation time and length of hospital stay. Results After we excluded patients with neurologic diseases, tracheostomy, esophageal dysphagia and those who were submitted to surgical procedures involving the head and neck, our study sample size was 148 patients. The logistic regression model was used to examine the relationships between independent variables. In the univariate analyses, we found that statistically significant prognostic indicators of dysphagia included dysphagia severity rate at the initial swallowing assessment, time to initiate oral feeding and amount of individual treatment. In the multivariate analysis, we found that dysphagia severity rate at the initial swallowing assessment remained associated with good treatment outcomes. Conclusions Studies of prognostic indicators in different populations with dysphagia can contribute to the design of more effective procedures when evaluating, treating, and monitoring individuals with this type of disorder. Additionally, this study stresses the importance of the initial assessment ratings.

FGFR4 Profile as a Prognostic Marker in Squamous Cell Carcinoma of the Mouth and Oropharynx

Background: Fibroblast growth factor receptor 4 (FGFR4) is a member of a receptor tyrosine kinase family of enzymes involved in cell cycle control and proliferation. A common single nucleotide polymorphism (SNP) Gly388Arg variant has been associated with increased tumor cell motility and progression of breast cancer, head and neck cancer and soft tissue sarcomas. The present study evaluated the prognostic significance of FGFR4 in oral and oropharynx carcinomas, finding an association of FGFR4 expression and Gly388Arg genotype with tumor onset and prognosis. Patients and Methods: DNA from peripheral blood of 122 patients with oral and oropharyngeal squamous cell carcinomas was used to determine FGFR4 genotype by PCR-RFLP. Protein expression was assessed by immunohistochemistry (IHC) on paraffin-embedded tissue microarrays. Results: Presence of allele Arg388 was associated with lymphatic embolization and with disease related premature death. In addition, FGFR4 low expression was related with lymph node positivity and premature relapse of disease, as well as disease related death. Conclusion: Our results propose FGFR4 profile, measured by the Gly388Arg genotype and expression, as a novel marker of prognosis in squamous cell carcinoma of the mouth and oropharynx.

Consumo de alimentos de origem animal e câncer de boca e orofaringe

OBJETIVO: Avaliar a relação entre alimentos de origem animal e câncer de boca e orofaringe. MÉTODOS: Estudo caso-controle, de base hospitalar, pareado por sexo e idade (± 5 anos) com a coleta de dados realizada entre julho de 2006 e junho de 2008. A amostra foi composta por 296 pacientes com câncer de boca e orofaringe e 296 pacientes sem histórico de câncer atendidos em quatro hospitais da cidade de São Paulo (SP), Brasil. Foi aplicado um questionário semiestruturado, para a coleta de dados relativos à condição socioeconômica e aos hábitos deletérios (tabaco e bebidas alcoólicas). Para avaliação do consumo alimentar, utilizou-se um questionário de frequência alimentar qualitativo. A análise se deu por meio de modelos de regressão logística multivariada, que consideraram a hierarquia existente entre as características estudadas. RESULTADOS: Entre os alimentos de origem animal, o consumo frequente de carne bovina (OR = 2,73; IC95% = 1,27-5,87; P < 0,001), bacon (OR = 2,48; IC95% = 1,30-4,74; P < 0,001) e ovos (OR = 3,04; IC95% = 1,51-6,15; P < 0,001) estava relacionado ao aumento no risco de câncer de boca e orofaringe, tanto na análise univariada quanto na multivariada. Entre os laticínios, o leite apresentou efeito protetor contra a doença (OR = 0,41; IC95% = 0,21-0,82; P < 0,001). CONCLUSÕES: O presente estudo sustenta a hipótese de que alimentos de origem animal podem estar relacionados à etiologia do câncer de boca e orofaringe. Essa informação pode orientar políticas preventivas contra a doença, gerando benefícios para a saúde pública.

The pattern recognition receptors expressed on neutrophils and the associated cytokine profile from different aged patients with Candida-related denture stomatitis

This study evaluated the expression of pattern recognition receptors (PRRs) and activation factors associated with salivary and blood neutrophils from different aged patients diagnosed with Candida-related denture stomatitis (DS). Expression of neutrophil PRRs was determined by flow cytometry and immunofluorescence, and the levels of selected cytokines that influence immune activation were determined by ELISA. The salivary (but not the serum derived) neutrophils of individuals with DS were found to have an increased expression of CD69 regardless of the age of the patient compared to patients without DS. However, these salivary neutrophils had a lower expression of CD66b and CD64. Expression of TLR2 was lower on the salivary-and serum-derived neutrophils from elderly individuals compared to the neutrophils of younger subjects, regardless of whether the individual had DS. Salivary interleukin (IL)-4 was elevated in both of the elderly subject groups (with or without DS). Only elderly DS patients were observed to have increased serum IL-4 levels and reduced salivary IL-12 levels. Younger DS patients showed an increase in salivary IL-10 levels, and both the saliva and the serum levels of IFN-gamma were increased in all of the younger subjects. Our data demonstrated that changes in both the oral immune cells and the protein components could be associated with DS. Furthermore, changes in the blood-derived factors were more associated with age than DS status. (C) 2012 Elsevier Inc. All rights reserved.

Extracellular Matrix Composition of the Cricopharyngeus Muscle

The aim of this study was to analyze the presence and distribution of total collagen, type I and type III collagen, elastic fibers, fibronectin, and versican in the endomysium of cricopharyngeus muscles from adults of various ages. The study was a cross-sectional analysis of human cricopharyngeus muscles. Twenty-seven muscles obtained from autopsies of men and women ranging in age from 28 to 92 years were analyzed with the Picrosirius method, oxidized Weigert resorcin-fuchsin, immunohistochemistry, and image analysis. Collagen had the highest density among the analyzed components. Elastic fibers surrounded each muscle cell; they were aligned longitudinally by their long axis and associated with traversing fibers, thereby forming a fiber network with embedded muscle cells. The fibronectin and versican contents varied widely among the specimens. We found no statistically significant differences between the proportion of extracellular matrix (ECM) components and factors such as gender and race. We conclude that the higher proportion of type I and type III collagen is compatible with the cricopharyngeus muscle's sphincteric behavior, and the arrangement of the elastic fibers may also contribute to the muscle's elasticity. We found no statistically significant correlation between the ECM components and age.

Oral candidiasis mimicking an oral squamous cell carcinoma: report of a case

Oral candidiasis is a significant problem in immune-compromised patients. The most common forms of mucosal candidiasis are oropharyngeal, oesophageal and vaginal, and more than 90% of HIV positive persons will manifest at least one episode of oropharyngeal candidiasis. Local and systemic factors such as uninterrupted daily use of a prosthesis by patients, smoking habit, as well as high glucose intake may contribute to the development of the lesion. The aim of this article is to report an uncommon case of oral candidiasis presenting an aggressive clinical behaviour in a 64-year-old male patient, with a significant smoking habit and a medical history of non-controlled diabetes. The lesion affected the hard and soft palate of the right side, revealing erythematous and ulcerated areas, elevated borders and central portions resembling necrosis, mimicking the clinical features of oral squamous cell carcinoma. However, the correct diagnosis of oral candidiasis was obtained after histopathological and cytological examinations and the patient was easily treated with traditional antifungal drugs and correction of his glucose levels.

Videofluoroscopic evaluation of mastication and swallowing in individuals with TMD

To study mastication and swallowing disorders in patients with temporomanclibular disorders (TMD). Objective: To investigate mastication and swallowing disorders in patients with severe TMD referred to surgery. Materials and Methods: Clinical and experimental study involving ten individuals with TMD submitted to deglutition videofluoroscopy. These patients did not have posterior teeth, mastication pain and food replacement in favor of pasty consistence food. The assessment of the oral and pharyngeal phases approached the following aspects: side of onset and preferential side for chewing, premature escape, remains of food residues in the oral cavity or in the pharyngeal recesses, number of necessary swallowing efforts, laryngeal penetration and/or tracheal aspiration. Results: During mastication and the oral phase we observed tongue compensatory movements upon chewing (n = 7; 70%), premature escape (n = 4; 40%), food remains in the cavity after swallowing (n = 5; 50%) and an excessive number of deglutition efforts (n = 5; 50%). On the pharyngeal phase we observed food remains in the valleculae (n = 6; 60%), in the pyriform sinuses (n = 4; 40%); laryngeal penetration (n = 1; 10%) and tracheal aspiration (n = 4; 40%). Conclusion: TMD patients may have alterations in their chewing and swallowing patterns, with laryngeal penetration and/or tracheal aspiration. The study indicates the need for a multidisciplinary assessment because of dysphagia in TMD patients.

Motor Neuron Disease and Acquired Axonal Neuropathy Association in HIV Infection: Case Report and Update

Background: A possible viral etiology has been documented in the genesis of motor neuron disorders and acquired peripheral neuropathies, mainly due to the vulnerability of peripheral nerves and the anterior horn to certain viruses. In recent years, several reports show association of HIV infection with Amyotrophic Lateral Sclerosis Syndrome, Motor Neuron Diseases and peripheral neuropathies. Objective: To report a case of an association between Motor Neuron Disease and Acquired Axonal neuropathy in HIV infection, and describe the findings of neurological examination, cerebrospinal fluid, neuroimaging and electrophysiology. Methods: The patient underwent neurological examination. General medical examinations were performed, including, specific neuromuscular tests, analysis of cerebrospinal fluid, muscle biopsy and imaging studies. Results and Discussion: The initial clinical presentation of our case was marked by cramps and fasciculations with posterior distal paresis and atrophy in the left arm. We found electromyography tracings with deficits in the anterior horn of the spinal cord and peripheral nerves. Dysphagia and release of primitive reflexes were also identified. At the same time, the patient was informed to be HIV positive with high viral load. He received antiretroviral therapy, with load control but with no clinical remission. Conclusion: Motor Neuron disorders and peripheral neuropathy may occur in association with HIV infection. However, a causal relationship remains uncertain. It is noteworthy that the antiretroviral regimen may be implicated in some cases.