Faculty Bibliography

Purpose/UNASSIGNED:The aim of this study was to investigate improvements in swallowing function and physiology in a series of healthy older adults with radiographically confirmed dysphagia, following completion of an exercise-based swallowing intervention. Patients and methods/UNASSIGNED:Nine otherwise healthy older adults (six females, mean age =75.3, SD =5.3) had confirmed impairments in swallowing safety and/or efficiency on a modified barium swallow study. Each participant completed an 8-week swallowing treatment protocol including effortful swallows, Mendelsohn maneuvers, tongue-hold swallows, supraglottic swallows, Shaker exercises and effortful pitch glides. Treatment sessions were conducted once per week with additional daily home practice. Penetration-Aspiration Scale and the Modified Barium Swallowing Impairment Profile (MBSImP) were scored in a blind and randomized fashion to examine changes to swallowing function and physiology from baseline to post-treatment. Results/UNASSIGNED:There were significant improvements in swallowing physiology as represented by improved oral and pharyngeal composite scores of the MBSImP. Specific components to demonstrate statistical improvement included initiation of the pharyngeal swallow, laryngeal elevation and pharyngeal residue. There was a nonsignificant reduction in median PAS scores. Conclusion/UNASSIGNED:Swallowing physiology can be improved using this standardized high-intensity exercise protocol in healthy adults with evidence of dysphagia. Future research is needed to examine the individual potential of each exercise in isolation and to determine ideal dose and frequency. Studies on various etiological groups are warranted.

Purpose: Despite being widely adopted in clinical practice, the rehabilitative potential of swallowing exercises is not well documented (Langmore & Pisegna, 2015). While collecting a sample of 98 videofluoroscopies (VF) from healthy individuals to serve as a control group for an unrelated study, we discovered 13 subjects with incidental findings of impaired swallowing (safety and/or efficiency deficits). Our purpose was to explore the impact of a standardized 'one-size-fits-all' treatment (tx) protocol on impaired swallowing function in this cohort of otherwise healthy individuals. Method(s): 13 healthy individuals (9 F, mean age = 71.5, SD = 11.9) completed 8 weeks of swallowing exercises. Treatment sessions (once per week) consisted of 20 repetitions of each of the following exercises: effortful swallows, tongue hold swallows, supraglottic swallows, Shaker exercises and Mendelsohn maneuvers, as well as 10 repetitions of effortful pitch glides. Subjects were also asked to complete daily homework consisting of 3 additional treatment sets per day. VF was collected pre-and post-tx with a standardized protocol and scored using the MBSimPTM method. Scores for components 1-5 and 6-16 were combined for an oral total (OT) and pharyngeal total (PT) respectively. Wilcoxon rank sum tests compared OT and PT scores from pre-to post-tx. Result(s): The pre-tx and post-tx OT median scores remained unchanged (4). The median PT score was 10 pre-tx (range 2-14) and reduced to 7 post-tx (range 3-11), though this change narrowly missed statistical significance (Z =-1.99; p = .058). Post-hoc evaluations revealed that 8 subjects demonstrated improved PT scores, 2 worsened, 3 were unchanged and that the greatest changes came from components 6 (initiation of the pharyngeal swallow), 8 (laryngeal elevation), 15 (tongue base retraction) and 16 (pharyngeal residue). Conclusions (Including Clinical Relevance): Our sample of otherwise healthy individuals with VF evidence of impaired swallowing completed a standardized 'one-size-fits-all' approach to dysphagia rehabilitation that is common place in clinical practice. The approach appeared to rehabilitate aspects of swallowing function-especially in the pharyngeal phase-for the majority of subjects. Future research should compare physiologically-targeted exercises with one-size-fits all approaches. Further investigations into dose, frequency and maintenance of exercise interventions will be vital contributions

Purpose: Non-tuberculous mycobacteria (NTM) is an intracellular microorganism that causes cavitary disease and nodular bronchiectatic disease of the lung. Common symptoms include chronic cough, sputum production and frequent pneumonias. Patients with NTM appear to have impaired swallow function as represented by impaired airway protection. Our aim is to determine bolus clearance in patients with NTM compared with a control. Method(s): Videofluoroscopy (VF) was prospectively collected from 195 patients:132 patients with NTM (90 females; ages 30-90) and 63 age-and sex-matched normal controls with normal pulmonary function tests and no pulmonary disease (39 females; ages 27-92).Two boluses of 3, 5, 10 mL thin liquid, two 5 mL puree Varibar, and cracker were analyzed per subject (N = 1,755 swallows).Outcome measures included ordinal ratings of residue in the valleculae and pyriform sinuses. The correlation between clinical information and the present of pharyngeal residue structures was analyzed by Fisher's exact test for categorical variables and Wilcoxon's rank sum test for comparisons of continuous variables between groups. Result(s): Inter-and intra-rater reliability of the ordinal ratings were assessed using two-way random intraclass correlation coefficients (ICC(2,1)) on 20% of the data with good results (intra-rater: ICC = 0.92, 95% CI 0.70-0.97 and inter-rater: ICC = 0.92, 95% CI 0.81-0.97).The ratings of residue in the valleculae were significantly higher in the NTM group compared to the control group for one of the 3 mL bolus (p = 0.008), for 5 mL boluses (p = 0.009 and p = 0.004), 10 mL boluses (p = 0.0005 and p = 0.0006), puree (p = 0.006), cracker (p = 0.005).The ratings of residue in the pyriform sinuses were also significantly higher in the NTM group for 3 mL boluses (p = 0.0002 and p = 0.01), 5 mL boluses (p = 0.0003 and p = 0.002), 10 mL boluses (p = 0.001 and p = 0.001), puree trials (p<0.0001 and p<0.0001).Wilcoxon's rank sum test determined no age difference and Fisher's exact test determined no gender difference between the NTM and control groups. Conclusions (Including Clinical Relevance): Patients with NTM appear to have reduced bolus clearance than healthy individuals with no pulmonary disease, as represented by ratings of residue in the valleculae and pyriform sinuses.Future work is needed to elucidate the interaction between the respiratory-swallowing systems and airway protection and responsiveness to swallowing treatment for patients with NTM

Introduction: Edema is a frequent clinical observation after chemoradiation treatment (CRT) for oral/oropharyngeal cancer (O/OP Ca). Our aims were to reliably quantify edema from video fluoroscopy (VF) at 3 time points (baseline 1-month (mo) and 4-mo post CRT) and to explore the relationship between edema and (a) patient-reported outcomes (EAT-10) and (b) functional impairment on VF (Dynamic Imaging Grade of Swallowing Toxicity DIGEST).
Material(s) and Method(s): 15 patients (7 M; age 38-76) with O/OP Ca received radiotherapy (70 Gy 7 weeks) and 3 weekly doses of cisplatin. VF was completed pre-CRT 1-mo and 4-mo post-CRT. Edema was captured by measuring posterior pharyngeal wall (PPW) thickness and pharyngeal area (PA) at rest. EAT-10 surveys were completed on the day of VF. DIGEST scores were rated according to published protocols. Mixed model repeated measures ANOVAs were run for each edema measure (PPW PA) to test for the effect of TIME EAT-10 and DIGEST while controlling for age and sex.
Result(s): For PPW we found a main effect of TIME but not EAT-10 or DIGEST (Table 1). Post-hoc comparisons revealed a significant worsening from mean at baseline (4.1 mm) to 4-mo post CRT (6.0 mm) but not at 1-mo post CRT (5.4 mm). For PA we found a main effect of TIME and of DIGEST grade (Table 2). Mean PA was significantly smaller at 1-mo post CRT (527 mm2) compared with baseline (716 mm2) but not different from 4-mo post CRT (652 mm2). Mean PA was significantly greater for grade 2 (751 mm2) compared with grade 0 (442 mm2) contrary to the hypothesized direction.
Conclusion(s): The data confirm that post-CRT edema can be quantified on 2D lateral VF. Patient reported outcomes (EAT-10) were not independently predictive of edema. Surprisingly worse DIGEST grades were associated with increased pharyngeal area at rest perhaps reflecting impairment associated with pharyngeal atrophy not edema. Future work should monitor patients' edema and swallow function over a longer time period and at a greater frequency

Medical innovators and regulators have increasingly recognized the importance of working with patients to design medical therapies and clinical trials that meet the needs of specific patient populations. For diseases such as Parkinson's disease (PD), a progressive, degenerative disease with few effective treatment options, traditional randomized clinical trials with a fixed statistical threshold may not reflect patients' perspectives on the trade-off between the risk of endorsing an ineffective therapy (false positive) and the risk of rejecting an effective therapy (false negative). This collaborative project, which involved academia, industry, FDA, patient-scientists and MJFF, developed and tested methods for incorporating patient preference information as explicit means to set significance levels in clinical trial design.
Method(s): With direct input from patients with PD, we developed a patient preference survey and deployed it online through Fox Insight for 6-weeks and received 2,752 complete responses (24.4%), allowing us to analyze differences in outcome priorities among various demographic groups. We then assigned weights to the consequences of errors based on identified patient preferences, and proposed a hypothetical clinical trial design optimized to maximize the values identified by patients.
Result(s): Movement symptoms, which are common endpoints in PD clinical trials, were ranked as most important, and psychological and cognitive symptoms, which are less commonly studied, were ranked as the next most important. Differences emerged from different groups within the patient population, depending upon how the disease manifested itself. Preferences from respondents with mild PD symptoms and no prior experience with deep brains stimulation (

Introduction The aims of this study are to investigate a possible correlation between the time point at which peak hydraulic pressure and peak force on the cochlear wall appears during insertion of a cochlear implant electrode and to investigate whether a difference exists in maximum hydraulic pressure and maximum force on the cochlear wall during a fast and slow insertion, a manual and automatic insertion and an electrode insertion into a narrow or wide round window (RW) opening. Material and methods Twenty fresh frozen human temporal bones were used. Intracochlear hydraulic pressure and force on the cochlear wall were recorded during round window insertions of a straight electrode array with different insertion speeds, different insertion methods and with different widths of the opening of the RW. Results A statistical signifcant correlation between the time point at which peak hydraulic pressure and peak force on the cochlear wall appears was found (r=0.91, p<0.001). Furthermore, a slow insertion speed showed a higher hydraulic pressure and a higher force on the cochlear wall compared to a fast insertion speed (p<0.001). No statistically signifcant effect of insertion method or the width of the opening of the RW was found on hydraulic pressure and on force on the cochlear wall. Conclusions Peak hydraulic pressure and peak force on the cochlear wall during electrode insertion seems to appear at approximately the same time. Furthermore, a slow insertion speed seems to result in a higher intracochlear hydraulic pressure and a higher force on the cochlear wall

Background/UNASSIGNED:Harmony is an important part of tonal music that conveys context, form and emotion. Two notes sounded simultaneously form a harmonic interval. In normal-hearing (NH) listeners, some harmonic intervals (e.g., minor 2nd, tritone, major 7th) typically sound more dissonant than others (e.g., octave, major 3rd, 4th). Because of the limited spectro-temporal resolution afforded by cochlear implants (CIs), music perception is generally poor. However, CI users may still be sensitive to relative dissonance across intervals. In this study, dissonance ratings for harmonic intervals were measured in 11 unilaterally deaf CI patients, in whom ratings from the CI could be compared to those from the normal ear. Methods/UNASSIGNED:Stimuli consisted of pairs of equal amplitude MIDI piano tones. Intervals spanned a range of two octaves relative to two root notes (F3 or C4). Dissonance was assessed in terms of subjective pleasantness ratings for intervals presented to the NH ear alone, the CI ear alone, and both ears together (NH + CI). Ratings were collected for both root notes for within- and across-octave intervals (1-12 and 13-24 semitones). Participants rated the pleasantness of each interval by clicking on a line anchored with "least pleasant" and "most pleasant." A follow-up experiment repeated the task with a smaller stimulus set. Results/UNASSIGNED:< 0.001). Ratings were similar between NH-only and NH + CI listening, with no significant binaural enhancement/interference. The follow-up tests showed that ratings were reliable for the least and most pleasant intervals. Discussion/UNASSIGNED:Although pleasantness ratings were less differentiated for the CI ear than the NH ear, there were similarities between the two listening modes. Given the lack of spectro-temporal detail needed for harmonicity-based distinctions, temporal envelope interactions (within and across channels) associated with a perception of roughness may contribute to dissonance perception for harmonic intervals with CI-only listening.