Serum Zn Levels in Dysphagic Patients Who Underwent Endoscopic Gastrostomy for Long Term Enteral Nutrition

Background and aims: Dysphagic patients who underwent endoscopic gastrostomy (PEG) usually present protein-energy malnutrition, but little is known about micronutrient malnutrition. The aim of the present study was the evaluation of serum zinc in patients who underwent endoscopic gastrostomy and its relationship with serum proteins, whole blood zinc, and the nature of underlying disorder. Methods: From patients that underwent gastrostomy a blood sample was obtained minutes before the procedure. Serum and whole blood zinc was evaluated using Wavelength Dispersive X-ray Fluorescence Spectroscopy. Serum albumin and transferrin were evaluated. Patients were studied as a whole and divided into two groups: head and neck cancer (HNC) and neurological dysphagia (ND). Results: The study involved 32 patients (22 males), aged 43-88 years: HNC = 15, ND = 17. Most (30/32) had low serum zinc, 17/32 presented normal values of whole blood zinc. Only two, with traumatic brain injury, presented normal serum zinc. Serum zinc levels showed no differences between HNC and ND patients. There was no association between serum zinc and serum albumin or transferrin. There was no association between serum and whole blood zinc. Conclusions: Patients had low serum zinc when gastrostomy was performed, similar in HNC and ND, being related with prolonged fasting and unrelated with the underlying disease. Decrease serum zinc was unrelated with low serum proteins. Serum zinc was more sensitive than whole blood zinc for identifying reduced zinc intake. Teams taking care of PEG-patients should include zinc evaluation as part of the nutritional assessment, or include systematic dietary zinc supply.

Selenium in dysphagic patients who underwent endoscopic gastrostomy for long term enteral feeding

Background and aims - Endoscopic gastrostomy (PEG) patients usually present protein-energy malnutrition, but little is known about selenium deficiency. We aimed to assess serum selenium evolution when patients underwent PEG, after 4 and 12 weeks. We also evaluated the evolution of albumin, transferrin and Body Mass Index and the influence of the nature of the underlying disease. Methods - A blood sample was obtained before PEG (T0), after 4 (T1) and 12 (T3) weeks. Selenium was assayed using GFAAS (Furnace Atomic Absorption Spectroscopy). The PEG patients were fed through homemade meals. Patients were studied as a whole and divided into two groups: head and neck cancer (HNC) and neurological dysphagia (ND). Results - We assessed 146 patients (89 males), between 21-95 years old: HNC-56; ND-90. Normal values of selenium in 79% (n=115); low albumin in 77, low transferrin in 94, low values for both serum proteins in 66. Low BMI in 78. Selenium has slow evolution, with most patients still displaying normal Selenium at T3 (82%). Serum protein levels increase from T0 to T3, most patients reaching normal values. The nature of the underlying disease is associated with serum proteins but not with selenium. Conclusions - Low serum selenium is uncommon when PEG is performed, after 4 and 12 weeks of enteral feeding and cannot be related with serum proteins levels or dysphagia cause. Enteral nutrition using customized homemade kitchen meals is satisfactory to prevent or correct Selenium deficiency in the majority of PEG patients.

Serum trace elements in dysphagic patients that underwent endoscopic gastrostomy for long term enteral feeding

Patients who underwent endoscopic gastrostomy (PEG) present protein-energy malnutrition, but little is known about Trace Elements (TE), Zinc (Zn), Copper (Cu), Selenium (Se), Iron (Fe), Chromium (Cr). Our aim was the evaluation of serum TE in patients who underwent PEG and its relationship with serum proteins, BMI and nature of underlying disorder.

Variability of starch-based thickened drinks for patients with dysphagia in the hospital setting

Starch-based thickening agents may be prescribed for patients with dysphagia. Thickened fluids alter variables of the swallow reflex, allowing more time for bolus manipulation without compromising airway closure. This investigation explored the variation in viscosity and physical characteristics of thickened drinks prepared in different media under laboratory conditions and compared the results with those of thickened drinks presented to dysphagic patients in one hospital. The rheological characteristics were tested on a simple plastometer and a Bohlin CVOR rheometer (Malvern Instruments, Worcestershire, UK). Samples prepared to “syrup” consistency both in the laboratory and in the hospitalwere significantly different from each other (P < 0.0001). This was also the case for samples prepared to “custard” consistency. Differences existed not only in viscosity, but drinks prepared in different media produced different rheological matrices. This signifies different viscoelastic behaviors that may effect manipulation in the mouth. From this study, preparation of thickened drinks using starch-based instant thickening powders appears to be a highly variable practice.

The influence of sour taste and cold temperature in pharyngeal transit duration in patients with stroke

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Classification of normal swallowing and oropharyngeal dysphagia using wavelet

Oropharyngeal dysphagia is characterized by any alteration in swallowing dynamics which may lead to malnutrition and aspiration pneumonia. Early diagnosis is crucial for the prognosis of patients with dysphagia, and the best method for swallowing dynamics assessment is swallowing videofluoroscopy, an exam performed with X-rays. Because it exposes patients to radiation, videofluoroscopy should not be performed frequently nor should it be prolonged. This study presents a non-invasive method for the pre-diagnosis of dysphagia based on the analysis of the swallowing acoustics, where the discrete wavelet transform plays an important role to increase sensitivity and specificity in the identification of dysphagic patients. (C) 2008 Elsevier Inc. All rights reserved.

Which one of these is not like the others? An inter-hospital study of the viscosity of thickened fluids

Engineering This investigation examined the rheological (viscosity and yield stress) and material property (density) characteristics of the thickened meal-time and videofluorscopy fluids provided by 10 major metropolitan hospitals. Differences in the thickness of thickened fluids were considered as a source of variability and potential hazard for inter-hospital transfers of dysphagic patients. The results indicated considerable differences in the viscosity, density, and yield stress of both meal-time and videofluoroscopy fluids. In theory, the results suggest that dysphagic patients transferred between hospitals could be placed on inappropriate levels of fluid thickness because of inherent differences in the rheology and material property characteristics of the fluids provided by different hospitals. Slowed improvement or medical complications are potential worst-case scenarios for dysphagic patients if the difference between the thick fluids offered by 2 hospitals are extreme. The investigation outlines the most appropriate way to assess the rheological and material property characteristics of thickened fluids. In addition, it suggests a plan of quality improvement to reduce the variability of the thickness of fluids offered at different hospitals.

How thick is thick? Multicenter study of the rheological and material property characteristics of mealtime fluids and videofluoroscopy fluids

Objective rheological assessment of fluids given to dysphagic patients at mealtime and during videofluoroscopy was carried out using a multicenter format. Thin, quarter-thick, half-thick and full-thick fluids were examined for the degree of correlation between mealtime fluids and their allegedly matched videofluoroscopy counterparts. The study was carried out to determine whether perceived subjective differences between mealtime fluids and videofluoroscopy fluids could be quantified using the rheological parameters of viscosity, density, and yield stress. The results showed poor correlation between mealtime fluids and videofluoroscopy fluids over all parameters. In general, the videofluoroscopy fluids were more viscous, more dense, and showed higher yield stress values than their mealtime counterparts. Given these results, it is reasonable to assume that the fluids used during videofluoroscopy do not provide an accurate indication of swallowing ability at mealtime. Therefore, it is suggested that clinicians use objective methods to theologically match videofluoroscopy fluids to mealtime fluids.

Classification of normal swallowing and oropharyngeal dysphagia using wavelet

Oropharyngeal dysphagia is characterized by any alteration in swallowing dynamics which may lead to malnutrition and aspiration pneumonia. Early diagnosis is crucial for the prognosis of patients with dysphagia, and the best method for swallowing dynamics assessment is swallowing videofluoroscopy, an exam performed with X-rays. Because it exposes patients to radiation, videofluoroscopy should not be performed frequently nor should it be prolonged. This study presents a non-invasive method for the pre-diagnosis of dysphagia based on the analysis of the swallowing acoustics, where the discrete wavelet transform plays an important role to increase sensitivity and specificity in the identification of dysphagic patients. (C) 2008 Elsevier B.V. All rights reserved.

A eficácia da reabilitação em disfagia orofaríngea

TEMA: eficácia da reabilitação em disfagia orofaríngea. A atuação fonoaudiológica com disfagia orofaríngea em nosso País alcançou proporções significativas e merece neste momento atenção para que esta atuação esteja baseada em evidências científicas. As técnicas terapêuticas e a eficácia da reabilitação em disfagia orofaríngea têm sido estudadas desde a década de 70, alcançando seu ápice na década de 80 e 90. Poucos estudos têm relatado a eficácia da reabilitação em disfagia orofaríngea, sendo mais freqüente aqueles que têm se preocupado em provar os efeitos da técnica terapêutica na dinâmica da deglutição. No Brasil, as pesquisas em disfagia orofaríngea têm valorizado os procedimentos de avaliação, sendo poucos os trabalhos que tratam da reabilitação. OBJETIVO: apresentar uma análise crítica sobre a eficácia da reabilitação em disfagia orofaríngea. CONCLUSÃO: este artigo de revisão aponta que estudos não randomizados têm comprometido os resultados, uma vez que a casuística das pesquisas têm utilizado amostras muito heterogêneas, que incluem disfagias orofaríngeas mecânicas e neurogênicas ocasionadas por distintas etiologias. Além disto, os programas terapêuticos empregados são pouco descritivos comprometendo a reprodução por parte de outros pesquisadores. Tais achados sugerem a necessidade de estudos mais randomizados, talvez inicialmente por meio de estudos de casos que possam excluir as variáveis do controle da eficácia terapêutica. Outra sugestão seria empregar, assim como as pesquisas atuais têm proposto, escalas que possam medir o impacto do treinamento de deglutição nas condições nutricionais e pulmonares do indivíduo disfágico. Uma importante área da pesquisa, relacionada ao controle da eficiência e eficácia terapêutica, está nos estudos que objetivam estabelecer o grau de redução de custos hospitalares e em empresas de home care, mediante a atuação do fonoaudiólogo com a disfagia orofaríngea.

Disfagia e alterações emocionais

Swallowing function may be impaired by a number of conditions involving primary or associated emotional distress. When psychogenic dysphagia is suspected, routine investigation using radiological and manometric examination is inappropriate. These cases demand an evaluation of the individual as a whole, interesting the disease as well as the patient's personal problems and concerns. Five cases of patients complaining of swallowing difficulty and showing concurrent emotional distress were studied. Four individuals were anxious and one was depressed. Because of our approach, a close medical-patient-relationship was established. Afterwards, an explanation about the normal swallowing mechanisms and the role of the emotions on it was provided. All patients showed improvement of the symptom in the following 24 hours. Dysphagia can be found in anxiety, depression and conversion hysteria, with high incidence in the urban population of the third world countries. However, several professionals are unaware of these disorders. Our results suggest that this plain approach is an useful tool in managing dysphagic patients and it has validity even in individuals bearing dysphagia due to comproved organic disease. The results also emphasize the importance of the medical patient relationship and the utility of a hollistic evaluation of the disease.

Laryngeal mobility and dysphagia

The authors studied the utility of the physical test of laryngeal movement in swallowing disorders of the oropharyngeal region. Measurement and palpation of the larynx during deglutition were performed in the neck of 14 dysphagic patients and in two normal control groups. The normal groups were used to establish the pattern of the movement and the normal values of laryngeal elevation. Control elevation ranged from 1.80 to 2.50 cm. In eight patients laryngeal motion was defective and presented values ranging from zero to 1.50 cm. Palpation during laryngeal movement also revealed unexpected anomalous displacement such as lateral shifting and lowering of the larynx. In six patients with defective laryngeal motion, pharyngeal and upper esophageal sphincter function were also impaired. Direct measurement and palpation of laryngeal mobility during deglutition is a noninvasive method that can be used to evaluate dysphagia and the risk for aspiration. Also, it allows physical assessment of the evolution of the disorder.

Investigacao clinica da disfagia orofaringea

The accurate investigation of the oropharyngeal dysphagia demands a systematic sequence of physical examinations. The aim of the present work is to propose a practical rule to facilitate the clinical investigation and the management of dysphagic patients. After a detailed anamnesis, an endoscopic examination is carried out and several manouvers to observe the oral, pharyngeal and laryngeal functions are performed by the patient. Following, a second endoscopy is performed during swallows of several consistencies of food, to verify the impairment of the laryngeal and or pharyngeal activities. The elevation of the laryngeal cartilage is also evaluated.

O efeito do sabor azedo e da temperatura fria no tempo de trânsito faríngeo da deglutição em indivíduos após acidente vascular encefálico hemisférico isquêmico

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

New image analysis of large food particles can discriminate experimentally suppressed mastication

Objective parameters that could provide a basis for food texture selection for elderly or dysphagic patients have not been established. We, therefore, aimed to develop a precise method of measuring large particles (>2 mm in diameter) in a bolus and an analytical method to provide a scientific rationale for food selection under masticatory dysfunction conditions. We developed a new illumination system to evaluate the ability of twenty female participants (mean age, 23.4 +/- 4.3 years) to masticate carrots, peanuts and beef with full, half and one quarter of the number of masticatory strokes. We also evaluated mastication under suppressed force, regulated by 20% electromyographic of the masseter muscle. The intercept and inclination of the regression line for the distribution of large particles were adopted as coefficients for the discrimination of masticatory efficiency. Single set of coefficient thresholds of 0.10 for the intercept and 1.62 for the inclination showed excellent discrimination of masticatory conditions for all three test foods with high specificity and sensitivity. These results suggested that our method of analysing the distribution of particles >2 mm in diameter might provide the basis for the appropriate selection of food texture for masticatory dysfunction patients from the standpoint of comminution.