Functional fat injection in the treatment of dysphagia following surgery

Functional fat injection under local anesthesia could be useful in the treatment of chronic dysphagia in selected patients with tissue loss secondary to laryngeal surgery

SWALLOWING, NUTRITIONAL STATUS AND HYDRATION IN ACUTE AND SUB-ACUTE CARE SETTINGS: IMPLICATIONS ON SURVIVAL AND ASPIRATION PNEUMONIA

Introduction: malnourishment, dehydration and dysphagia are common in hospitalized patients both in Acute and Sub-acute care settings. However, the relationships among these conditions have been poorly studied and with divergent results. In the absence of these information it appears very difficult to appropriate manage health-care resources in order to early identify the population at risk of developing negative outcomes and to develop a prevention program. This research project was design in order to improve the clinical management of dysphagic, malnourished and dehydrated patients admitted to the Acute and Sub-acute care Units. In particular, the project was structured into 3 different phases. In the first one the prevalence of malnutrition, dysphagia and dehydration at admission in Acute and Sub-acute care settings was analyzed. In the second phase the association between malnutrition, critical weight loss, dysphagia and dehydration and negative clinical outcomes was studied. Finally, in the third phase a statistically-based exploratory analysis (using an unsupervised clustering method) was used in order to identify the presence of similar phenotypic subgroups of patients according to objective criteria. In addition, the ability of this classification in predicting negative clinical outcomes was also assessed. Materials and methods: a total of 686 patients were recruited, 483 of them were admitted to the Acute care Unit (Stroke-Unit), while 203 were admitted to the Sub-acute care Unit. Information regarding age, gender, weight, height, presence of aphasia and dysarthria, severity of stroke (only in patients admitted to the Acute care Unit), data on functional status activity of daily living, data on oral intake, data on serum analysis (known or suspected to be related to the presence of dysphagia, dehydration and malnutrition), presence of swallowing disorders, data on hydration level, presence of undernutrition were collected at admission in all the patients. Student t test and Chi-square test were used to compare the distribution of continuous and categorical data among patients according to gender and presence of dysphagia. Correlation analysis was performed in order to evaluate the presence of significant correlations among the collected variables. Kaplan-Meier curves and Cox\u2019s proportional hazard models were used to assess the impact of malnutrition, critical weight loss, dysphagia and dehydration on clinical outcomes. Finally, Ward\u2019s minimum-variance hierarchical method was used in order to generate clusters by placing subjects into groups not defined a priori but according to the similarity of clinical characteristics. Results: Patients admitted to the Acute care Unit were found malnourished in 16.2% of cases. Dysphagia was detected in 24.2% of patients while dehydration was found in 49.7% of cases. As far as it is concerned the Sub-acute care Unit, dysphagia was reported in 22.2% of cases, malnutrition in 22.2% of cases and dehydration in 45.8% of cases. A total of 114 patients died during the follow-up period. One-hundred-two were admitted to the Acute care Unit, while 12 were admitted to the Sub-acute care Unit. In both group no significant association between malnutrition and dehydration and mortality or pulmonary complications was found. On the other hand, dysphagia significantly affected survival. In the Acute care Unit 33 out of the 117 patients with dysphagia died during the 6 months follow-up; while in the Sub-acute care Unit 8 out of the 45 patients with dysphagia died during the 6 months follow-up. In addition, the presence of dysphagia significantly increased the risk of developing pulmonary complications (Odds Ratio = 5.493; p = 0.007 in Acute care settings and Odds Ratio = 2.809; p = 0.029 in Sub-acute care settings). Also critical weight loss significantly affected survival and increased the risk of develop pulmonary complications both in Acute and in Sub-acute care settings. Patients with both critical weight loss and dysphagia had a higher mortality risk than patients with critical weight loss but without dysphagia or patients with dysphagia but without critical weight loss (Odds Ratio = 4.943; p = 0.019 in Acute care settings and Odds Ratio = 2.732; p = 0.032 in Subacute care settings). Using the clustering approach, a dendrogram was generated and a 4-cluster reduction was chosen to describe the results. Patients in different clusters demonstrated significant differences both in the results of continuous and categorical data. In addition, significant differences among clusters were also found in survival and in the risk to develop pulmonary complications. In particular, patients of cluster 2 died more frequently than patients in the other clusters (p = 0.019), while pulmonary complications were more frequently in patients of cluster 1 and 2 (p = 0.021). Discussion: the prevalence of malnutrition, dehydration and dysphagia was high, both in Acute and Subacute care settings. Interestingly, malnutrition and dehydration did not influence the occurrence of negative clinical outcomes. On the other hand, dysphagia and critical weight loss significantly affected survival and occurrence of pulmonary complications. In particular, dysphagic patients who experienced a critical weight loss had the poorest prognosis. The unsupervised statistical methods based upon hierarchical clustering was able to classify patients into 4 clusters which described patients who shared common clinical features. Even if it is unlikely that these clusters represent distinct pathophysiologies, patients in different clusters have significantly different prognoses. It is possible that the application of unsupervised clustering method in the classification of hospitalized patients could provide interesting prognostic information

Functional fat injection under local anesthesia to treat severe postsurgical dysphagia, case report

Background: In this study, we present the first application of functional fat injection performed under local anesthesia in the treatment of severe dysphagia secondary to head and neck cancer surgery. Methods: Functional fat injection was performed using a transcervical approach. Control of injection depth and site was performed through a transnasal flexible endoscope. The effect of surgery was evaluated through videofluoroscopy (VFS), Fiberendoscopic Evaluation of Swallowing (FEES), Functional Oral Intake Scale (FOIS), and Eating Assessment Tool-10 (EAT-10). Results: Before the functional fat injection, the patient was dependent on permanent tube feeding; the VFS and FEES revealed a severe impairment of swallowing abilities. The EAT-10 scored 26. Twelve months after surgery, the patient was on oral diet, the VFS demonstrated mild to moderate dysphagia, the FEES demonstrated aspiration only with liquids and the EAT-10 improved. Conclusion: Functional fat injection under local anesthesia could be useful in the treatment of chronic dysphagia in selected patients

Reliabiliy and clinical validity of the italian reflux symptom index

Currently, there is no Italian version of the Reflux Symptom Index (RSI). The aim of this study was to develop an Italian RSI and to evaluate its internal consistency, reliability, and clinical validity. The study design used was a cross-sectional survey study. Eighty patients with a Reflux Finding Score (RFS) >7, and 193 asymptomatic subjects were included in the study. For the RSI reliability analysis, the appositely developed Italian RSI was filled twice, with a week interval, by the 80 patients and 80 control subjects. The test-retest reliability was assessed through the Pearson correlation test, whereas the Cronbach's \u3b1 coefficient was used for internal consistency analysis. For the clinical validity assessment, the scores obtained in the pathological group were compared with the data from the asymptomatic individuals through the Student's t test. Finally, the correlation between RSI and RFS in the 80 patients was assessed. All of the patients filled in the entire questionnaire autonomously. The test-retest reliability in the patients, as well as in the control group, was very high (r > 0.90); the internal consistency also showed very high values (\u3b1 = 0.99). The mean RSI score in the patients was 21.1 \ub1 6.6, whereas in the control group it was 6.3 \ub1 5.6; the difference was statistically significant (P = 0.0001). The mean RFS score in the 80 patients was 9.2 \ub1 2.7 and the correlation between RFS score and RSI score was rather high (r = 0.89). The Italian RSI is easily administered, highly reproducible, and exhibits excellent clinical validity

Surgical management of a life-threatening retro-pharyngeal haematoma following trans-oesophageal echocardiography = Trattamento chirurgico di un pericoloso ematoma retrofaringeo, sviluppatosi a seguito di un\u2019ecocardiografia transesofagea

Nonostante siano state descritte complicanze potenzialmente letali, l\u2019ecocardiografia transesofagea viene considerata una procedura diagnostica sicura. Scopo del presente lavoro \ue8 sottolineare come, nei casi di voluminosi ematomi secondari a tale procedura, possa diventare indispensabile il ricorso alla chirurgia per tutelare la vita del paziente. Nel caso qui descritto, un paziente affetto da spondilosi cervicale e in terapia anticoagulante ha sviluppato, a seguito di un\u2019ecocardiografia transesofagea, un ematoma retrofaringeo tanto voluminoso da determinare un\u2019ostruzione delle vie aeree superiori. Per assicurarne la perviet\ue0 \ue8 stato necessario ricorrere a una tracheotomia, l\u2019ematoma, invece, \ue8 stato drenato per via transcervicale. Il paziente \ue8 guarito completamente in 10 giorni. Il chirurgo otorinolaringoiatrico dovrebbe essere a conoscenza, non solo di questa rara complicanza, ma anche della necessit\ue0 di un suo trattamento chirurgico.Trans-oesophageal echocardiography is generally considered a safe procedure, but occasional life-threatening complications have been reported. The aim of this clinical investigation is to outline the need of surgical management in cases of large retro-pharyngeal haematoma following trans-oesophageal echocardiography. In the case reported here, a patient with cervical spondylosis on anti-coagulant therapy was referred to the Head and Neck Department because of a retro-pharyngeal haematoma with severe upper airway obstruction following transoesophageal echocardiography. Tracheotomy was required to guarantee respiratory function, while trans-cervical surgery was performed to evacuate the haematoma. Total recovery was achieved within 10 days. In conclusion, the head and neck surgeon should consider the need of surgical management in cases of retro-pharyngeal haematoma following trans-oesophageal echocardiography

Use of proton pump inhibitors and risk of ischemic events in the general population

BACKGROUND AND AIMS: A potential increased risk of cardiovascular events has been suggested for proton pump inhibitors (PPIs), the most commonly prescribed drugs for the management of upper gastrointestinal disorders. We aimed to estimate the risk of hospitalization for cardio/cerebrovascular (CV) events in a cohort of incident PPI users. METHODS: A nested case-control study was carried out using regional healthcare utilization databases. For each case (hospitalization for non-haemorrhagic CV event), up-to-five controls randomly selected from the cohort were matched by gender, age at cohort entry, and index date. Exposure was estimated as recency of therapy (current, recent and past users) and number of days covered. Adjusted conditional logistic regression was used to estimate the association between exposure and outcome. RESULTS: Among new PPI users, we identified 17,832 cases and 89,160 controls (males 64.9%; mean age 58.9 years). Cases showed a significantly higher prevalence of use of drugs for diabetes, hypertension and hypercholesterolemia than controls. Risk of CV events was significantly higher for current (OR 1.61; 95%CI 1.55-1.68) and recent users (OR 1.15; 95%CI 1.06-1.26) compared to past users. Analogous results were found stratifying for cardiovascular (ORcurrent 1.71; 95%CI 1.63-1.81) and cerebrovascular events (ORcurrent 1.43; 95%CI 1.34-1.54). The increased risk was confirmed in subgroups by antithrombotic, statin use, or exposure duration. The same analysis for H2-antagonists use showed no significant results. CONCLUSIONS: In primary care setting, PPI use was independently associated with increased risk of first-time cardiovascular event, consistent with the evidence that PPIs adversely impact vascular function, underlying the need to promote appropriate prescribing of these drugs

Cross-cultural adaptation and validation of the voice handicap index into Italian

Objectives. To evaluate the internal consistency, reliability, and clinical validity of the Italian version of the Voice Handicap Index (VHI). Study Design. Cross-sectional survey study was carried out. Methods. One hundred and seventy-five patients with voice disorders, divided in four groups according to the etiology of the disease (neurogenic, structural, functional, and inflammatory), and 84 asymptomatic subjects were included in the study. Internal consistency was analyzed through Cronbach alpha coefficient. For the VHI test-retest reliability analysis, the Italian VHI was filled twice by 56 patients and 56 control subjects. The test-retest reliability was assessed through the Pearson correlation test. For the clinical validity assessment, the scores obtained in the pathological group were compared with those found in asymptomatic individuals through the Kruskal-Wallis test. Also, the correlation between VHI and the grade of voice disorder was assessed. Finally, the effect of age and gender on overall VHI and its three subscales was analyzed. Results. Optimal internal consistency was found (alpha = 0.93); the test-retest reliability in both groups was high (r > 0.86). Nonparametric Kruskal-Wallis analysis of variance for the overall VHI score and its three domains revealed a significant main effect for group (P = 0.000). The control group scored significantly lower than the four groups of voice-disordered patients. The overall VHI score positively correlated with the grade of voice disorder (r = 0.43). In the voice-disorder group, age and gender were not correlated to the overall VHI score and to their three domains. Conclusion. The Italian VHI is highly reproducible, and exhibits excellent clinical validity

Prognostic value of the Sinonasal Outcome Test 22 (SNOT-22) in chronic rhinosinusitis

Studi in letteratura hanno evidenziato che il punteggio basale del Sinonasal Outcome Test 22 (SNOT-22) influenza l\u2019outcome chirurgico nella rinosinusite cronica (CRS) ed hanno suggerito che un approccio SNOT-22-mediato potrebbe migliorare la comprensione delle aspettative dei pazienti dopo il trattamento. Il presente studio mirava a verificare questa ipotesi in una popolazione italiana di CRS. In 457 pazienti con CRS, trattati con chirurgia endoscopica endonasale dopo fallimento della terapia medica massimale, sono stati calcolati la percentuale di raggiungimento della differenza minima clinicamente rilevabile (MCID) e la percentuale di miglioramento relativo dopo l\u2019intervento chirurgico. Inoltre, \ue8 stato studiato l\u2019impatto di diversi fattori sul punteggio dello SNOT-22 preoperatorio e postoperatorio. Il miglioramento dei sintomi si \ue8 verificato nella maggior parte dei pazienti ed era direttamente proporzionale alla SNOT-22 basale. Il 79,7% dei pazienti ha raggiunto l\u2019MCID e la percentuale di miglioramento relativo \ue8 stata del 50,1%. Le implicazioni psicologiche e sociali hanno influenzato significativamente i punteggi dello SNOT-22. Un\u2019analisi di regressione multipla ha mostrato che la storia di precedenti interventi chirurgici, asma, score endoscopico preoperatorio e SNOT-22 basale hanno statisticamente predetto il punteggio dello SNOT-22 postoperatorio (R2 = 0,229). Sottoporre i pazienti con CRS a SNOT-22 prima dei trattamenti chirurgici potrebbe quindi aiutare ad informarli sui probabili esiti, sebbene sia fortemente influenzato dalla percezione individuale. Sono necessari ulteriori studi per identificare un set efficace di parametri soggettivi e oggettivi per la valutazione dei risultati.Previous studies have highlighted that baseline Sinonasal Outcome Test 22 (SNOT-22) score affects surgical outcomes in chronic rhinosinusitis (CRS) and suggested that a SNOT-22- based approach might ameliorate patients\u2019 understanding of expectations after treatment. Our study aimed at verifying this hypothesis in an Italian CRS population. In 457 CRS patients treated with endoscopic sinus surgery after failure of maximal medical therapy, the percentage of achieving a minimal clinically important difference (MCID) and the percentage of relative improvement after surgery were calculated. Moreover, the impact of several factors on preoperative and postoperative SNOT-22 score was investigated. Symptom improvement occurred in the majority of patients and was directly proportional to baseline SNOT-22. 79,7% of patients achieved the MCID and the percentage of relative improvement was 50,1%. Psychological and social-functioning implications significantly affected SNOT-22 scores. Multiple regression analysis showed that history of previous surgery, asthma, preoperative endoscopic and SNOT-22 scores predicted the postoperative SNOT-22 score (R2 = 0,298). Submitting CRS patients to SNOT-22 prior to surgical treatments might help to inform about probable outcomes, although it is strongly influenced by individual perception. Further studies are needed to identify an effective set of subjective and objective parameters for evaluation of outcomes