Predicting the Activation States of the Muscles Governing Upper Esophageal Sphincter Relaxation and Opening

Copyright © 2016 the American Physiological SocietyThe swallowing muscles that influence upper esophageal sphincter (UES) opening are centrally controlled and modulated by sensory information. Activation and deactivation of neural inputs to these muscles, including the intrinsic cricopharyngeus (CP) and extrinsic submental (SM) muscles, results in their mechanical activation or deactivation, which changes the diameter of the lumen, alters the intraluminal pressure, and ultimately reduces or promotes flow of content. By measuring the changes in diameter, using intraluminal impedance, and the concurrent changes in intraluminal pressure, it is possible to determine when the muscles are passively or actively relaxing or contracting. From these “mechanical states” of the muscle, the neural inputs driving the specific motor behaviors of the UES can be inferred. In this study we compared predictions of UES mechanical states directly with the activity measured by electromyography (EMG). In eight subjects, pharyngeal pressure and impedance were recorded in parallel with CP- and SM-EMG activity. UES pressure and impedance swallow profiles correlated with the CP-EMG and SM-EMG recordings, respectively. Eight UES muscle states were determined by using the gradient of pressure and impedance with respect to time. Guided by the level and gradient change of EMG activity, mechanical states successfully predicted the activity of the CP muscle and SM muscle independently. Mechanical state predictions revealed patterns consistent with the known neural inputs activating the different muscles during swallowing. Derivation of “activation state” maps may allow better physiological and pathophysiological interpretations of UES function

Modulation of Upper Esophageal Sphincter (UES) Relaxation and Opening During Volume Swallowing

“The final publication is available at Springer via http://dx.doi.org/10.1007/s00455-016-9744-4". This author accepted manuscript is made available following 12 month embargo from date of publication (17 Aug 2016) in accordance with the publisher's copyright policy.UES opening occurs following cricopharyngeus deactivation and submental muscle contraction causing hyolaryngeal elevation and UES distraction. During impedance manometry, the inverse of impedance (admittance) can be used to measure bolus presence and infer UES opening. We hypothesized that the temporal relationship between UES relaxation, opening and hyolaryngeal elevation would change with increasing bolus volume. Simultaneous intramuscular cricopharyngeal (CP) electromyography (EMG), surface submental EMG (SM-EMG), and high-resolution impedance manometry were recorded in eight (aged 27 ± 7 years, 5 M) healthy volunteers, while swallowing 0.9 % saline boluses of 2, 5, 10, and 20 ml. Data were exported and analyzed via Matlab. Statistical analysis comprised repeated measures one-way ANOVA and Pearson correlation. A P value of <0.05 was considered significant. Duration of CP deactivation increased at 20 ml volume (P < 0.001). UES relaxation and opening increased with increasing bolus volume (P < 0.001); however, overall duration of SM activation did not change. As UES opening occurs progressively earlier with increasing volumes, peak SM-EMG activity occurs relatively later (P < 0.001) and shifts from occurring before to following peak UES distention. During healthy swallowing, there is sensory modulation of cricopharyngeal and submental muscle activity. Intrabolus pressures, transmitted from the tongue base and pharynx, play a progressively more important role in sphincter opening with increasing volume. The findings may explain why some healthy elderly and patients with oropharyngeal dysphagia have difficulty swallowing larger while tolerating smaller bolus volumes

The Conceptualization and Measurement of Comorbidity: A Review of the Interprofessional Discourse

Copyright © 2013 Salimah H. Meghani et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Background. Chronic medical conditions often occur in combination. Understanding underlying mechanisms causing diseases and their interactions may make it possible to address multiple complex conditions with single or consolidated treatment approaches and improve patients’ health outcomes while reducing costs. Objectives. We present a synthesis of the current interprofessional discourse on the issues surrounding comorbidities. Methods. A targeted review of the literature was conducted using published editorials, commentaries, and review articles. Results. Errors in conceptualization and measurement plague our current understanding of comorbidities. Two potential paths to generating knowledge involve the use of etiological or epidemiological approach. An etiological approach investigates the risk factors and underlying mechanisms potentially leading to consolidation of diagnosis and treatments. Because of the rudimentary stage of knowledge development in this area, this approach will require time and significant research investments. In contrast, the epidemiological approach relies on statistical identification of disease entities that cooccur beyond random chance; this approach carries an accompanying risk of diagnostic and treatment proliferation. Discussion. The concept of comorbidity, its nature, and measurement is in need of meaningful debate by the scientific and clinical communities. Recommendations in the domains of conceptualization, research, and measurement are discussed

Honoring the Legacy: an Exhibition of Works Presented by ART CART: SAVING THE LEGACY

The story of ART CART: SAVING THE LEGACY is one of tenacity, resilience and positive aging where art, education, health, and aging intersect to provide a model for society (www.artsandcultureresearch.org/artcart ). In the mid-2000s the Research Center for Arts and Culture (RCAC) conducted the only research on professional visual artists age 62 and over in the New York City metro area. ABOVE GROUND1 found that 61% of professional visual artists age 62+ have made no preparation for their work after their death; 95% have not archived their work; 97% have no estate plan; 3 out of every 4 artists have no will and 1 in 5 have no documentation of their work at all.2 Yet, in many respects they are a model for society, maintaining strong social networks and an astonishing resilience as they age. ART CART is a response to this research, begun by six women faculty in higher education from the arts, education, health and aging. We all valued interdisciplinary, inter-generational education and saw too little of it in our practice. We saw advantages for our students to gain a grounding in both creativity and aging, learn basic health prevention principles, and take these lessons back to a variety of disciplines from social work and occupational therapy to art education, art history, arts administration, museum studies, art therapy, oral history, and dance education. We saw a model of experiential learning where students could put what they learned into immediate practice. For artists, we saw a way to keep their work from their greatest fear: the dumpster. We saw a mechanism to help them get organized, urge them to sign, date, and document their work, archive their digital records at Columbia University, obtain wills and estate plans,3 while participating fully in an inter-generational team where an artist, an artist-selected working partner and student fellows worked together towards the same goals. ART CART began with six artists and twelve students at Columbia University in 2010. By 2016, it operates both in New York City and Washington, DC, with 18 artists and 18 fellows. Alumni artists post-ART CART have secured lifetime achievement awards, grants, studio space, sales, gallery representation, exhibitions and a rejuvenated appreciation of their work across generations. And they are still documenting their work

Precision health: A nursing perspective

Precision health refers to personalized healthcare based on a person's unique genetic, genomic, or omic composition within the context of lifestyle, social, economic, cultural and environmental influences to help individuals achieve well-being and optimal health. Precision health utilizes big data sets that combine omics (i.e. genomic sequence, protein, metabolite, and microbiome information) with clinical information and health outcomes to optimize disease diagnosis, treatment and prevention specific to each patient. Successful implementation of precision health requires interprofessional collaboration, community outreach efforts, and coordination of care, a mission that nurses are well-positioned to lead. Despite the surge of interest and attention to precision health, most nurses are not well-versed in precision health or its implications for the nursing profession. Based on a critical analysis of literature and expert opinions, this paper provides an overview of precision health and the importance of engaging the nursing profession for its implementation. Other topics reviewed in this paper include big data and omics, information science, integration of family health history in precision health, and nursing omics research in symptom science. The paper concludes with recommendations for nurse leaders in research, education, clinical practice, nursing administration and policy settings for which to develop strategic plans to implement precision health

Trajectories of Fasting Blood Glucose in Autologous Hematopoietic Cell Transplantation

BackgroundPatients who receive autologous hematopoietic cell transplantation (HCT) for the treatment of hematologic malignancies are at risk of serious adverse outcomes including infections and death. Hyperglycemia following the HCT is associated with increased risk of these adverse outcomes. However, limited information is available on demographic and clinical characteristics that contribute to changes in blood glucose levels following HCT.ObjectiveThe objective of this study was to determine the trajectories of fasting blood glucose (FBG) levels as well as the demographic and clinical characteristics that predicted interindividual differences in these FBG trajectories.MethodsA sample of adult patients with hematologic malignancies who were scheduled to receive autologous HCT (n = 53) was enrolled in the study. Patients with preexisting diabetes were excluded. Demographic and clinical characteristics were abstracted from electronic medical records. Morning fasting laboratory tests (ie, FBG and absolute neutrophil counts) were obtained. Data were analyzed using hierarchical linear modeling from the day of HCT (day 0) through 14 days post-HCT.ResultsAmong 8 characteristics evaluated, pre-HCT FBG was associated with variability in both the initial levels and the trajectories of FBG. Body mass index was only associated with initial levels of FBG.ConclusionsThe large amount of interindividual variability in the trajectories of FBG levels following autologous HCT suggests that glucose control in these patients warrants ongoing assessments and preemptive tailoring.Implications for practiceFasting blood glucose monitoring is warranted. Additional research with larger samples is warranted to identify additional modifiable and nonmodifiable characteristics associated with interindividual variability in FBG levels

Hyperglycemia and Cancer: A State-of-the-Science Review

Problem Identification: Hyperglycemia can increase the risk for adverse events and outcomes in patients undergoing treatment for cancer. The purposes of this state-of-the-science review were to explore the complexity of hyperglycemia in patients with cancer and to analyze physiologic mechanisms and outcomes in individuals with or at risk for cancer. Literature Search: PubMed® and the Cochrane Library databases were searched, and 95 articles were included. Findings were evaluated for their methods and analyses. Studies assessed as methodologically flawed were not included. Data Evaluation: The synthesis of the articles provided the evidence for describing normal and glycemic pathways. Hyperglycemia in patients with cancer was explored through chronic inflammatory mechanisms that lead to increased risks for adverse events and outcomes. Synthesis: This article discusses normal glucose regulation and hyperglycemic pathways, hyperglycemia in patients with cancer, hyperglycemia and cancer-related inflammation, and outcomes (e.g., infections, mortality, symptoms). Implications for Research: Understanding the contributors to and consequences of hyperglycemia can guide the development of screening tools to predict which individuals are at the greatest risk for hyperglycemic episodes prior to starting cancer therapies. Research can lead to glycemic guidelines specific to patients with cancer for better outcomes

Differential expression of genes and differentially perturbed pathways associated with very high evening fatigue in oncology patients receiving chemotherapy.

PurposeFatigue is the most common symptom associated with cancer and its treatment. Investigation of molecular mechanisms associated with fatigue in oncology patients may identify new therapeutic targets. The objectives of this study were to evaluate the relationships between gene expression and perturbations in biological pathways and evening fatigue severity in oncology patients who received chemotherapy (CTX).MethodsThe Lee Fatigue Scale (LFS) and latent class analysis were used to identify evening fatigue phenotypes. We measured 47,214 ribonucleic acid transcripts from whole blood collected prior to a cycle of CTX. Perturbations in biological pathways associated with differential gene expression were identified from public data sets (i.e., Kyoto Encyclopedia Gene and Genomes, BioCarta).ResultsPatients were classified into Moderate (n&nbsp;=&nbsp;65, mean LFS score 3.1) or Very High (n&nbsp;=&nbsp;195, mean LFS score 6.4) evening fatigue groups. Compared to patients with Moderate fatigue, patients with Very High fatigue exhibited differential expression of 29 genes. A number of the perturbed pathways identified validated prior mechanistic hypotheses for fatigue, including alterations in immune function, inflammation, neurotransmission, energy metabolism, and circadian rhythms. Based on our findings, energy metabolism was further divided into alterations in carbohydrate metabolism and skeletal muscle energy. Alterations in renal function-related pathways were identified as a potential new mechanism.ConclusionsThis study identified differential gene expression and perturbed biological pathways that provide new insights into the multiple and likely inter-related mechanisms associated with evening fatigue in oncology patients

Advances in Conceptual and Methodological Issues in Symptom Cluster Research

Two conceptual approaches are used to evaluate symptom clusters: "clustering" symptoms (ie, variable-centered analytic approach) and "clustering" patients (ie, person-centered analytic approach). However, these methods are not used consistently and conceptual clarity is needed. Given the emergence of novel methods to evaluate symptom clusters, a review of the conceptual basis for older and newer analytic methods is warranted. Therefore, this article will review the conceptual basis for symptom cluster research; compare and contrast the conceptual basis for using variable-centered versus patient-centered analytic approaches in symptom cluster research; review their strengths and weaknesses; and compare their applications in symptom cluster research