Dysphagia Days as an Assessment of Clinical Treatment Outcome in Eosinophilic Esophagitis.

INTRODUCTION: The aim of this study was to evaluate Dysphagia Days as a measure of symptom improvement in patients with eosinophilic esophagitis from the HEROES study. METHODS: Dysphagia Days, defined as a yes answer to the following question: During any meal today, did food go down slowly or get stuck in your throat or chest? was assessed for cendakimab vs placebo. RESULTS: A statistically significant reduction in the mean number of Dysphagia Days experienced was observed with cendakimab 360 mg vs placebo at week 16 (-4.67 vs -1.83; P = 0.0115); an even greater improvement was observed in steroid-refractory patients vs placebo (-4.48 vs -0.04; P = 0.0079). DISCUSSION: Dysphagia Days represents a relevant clinical end point to capture dysphagia-related symptoms.

Impact of local steroid application on dysphagia after anterior cervical spine surgery: a meta-analysis.

INTRODUCTION: Dysphagia is one of the most common complications of anterior cervical spine surgery. Local steroid was widely used to reduce the postoperative swallowing pain. However, the effect of local steroid application on dysphagia after anterior cervical spine surgery was still uncertain. MATERIALS AND METHODS: We searched Medline (PubMed), Embase and the Cochrane Library on July 27, 2021 for studies investigating the effect of local steroid application on dysphagia after anterior cervical spine surgery from their date of inception to 2021. The relative risk or weighted mean difference with 95% confidence interval was recorded as a summary statistic consist of postoperative dysphagia, swallowing VAS scores, SWAL-QOL scores, PSTSI, and steroid related complications. RESULTS: This meta-analysis included 7 RCT studies involving 254 patients in the steroid group and 232 patients in the placebo group. Results showed local steroid group had less patients with dysphagia, lower swallowing VAS scores and less severe of prevertebral soft-tissue edema on the fourth day after surgery. No significant difference in non-fusion rate between the two groups was observed. And all included studies had no serious steroid related complications reported. CONCLUSIONS: The use of local steroid in anterior cervical spine surgery could reduce the early postoperative dysphagia without serious steroid related complication. However, the safety of local steroid application still need further studies with larger samples.

The effect of local intraoperative corticosteroid application on postoperative dysphagia following anterior cervical spine surgery.

Dysphagia is a common complication following anterior cervical spine surgery (ACSS). Although several literatures have reported the potential benefit of local corticosteroid application on dysphagia, its safety and efficacy are still unclear. A systematic review was performed aiming to evaluate the evidence of local corticosteroid application in prevention or treatment of postoperative dysphagia following ACSS. A systematic search was performed in September 2018 in PubMed and Embase database. The following information was extracted: study investigator, year of publication, number of patients, study design, inclusion/exclusion criteria, administration protocol of steroid, type of surgical procedure, number of levels performed, assessment methodology of dysphagia, radiologic assessment of prevertebral soft tissue swelling (PSTS), follow-up time points, outcome of dysphagia, and corticosteroid-related complications. Qualitative synthesis was performed. Finally, 5 studies met the inclusion/exclusion criteria. Four studies found that local corticosteroid application could decrease the incidence and magnitude of postoperative dysphagia while 1 study showed no effect on dysphagia significantly at 6 weeks and 3 months follow-up time. A total of 2325 patients received local corticosteroid intraoperatively; no early corticosteroid-related complication was reported. Totally, 4 adverse events occurred in long-term follow-up time, including 2 bone nonunion at 1.5 and 2.5 years postoperatively, 2 esophageal perforation at 2 months and 11 months of follow-up, respectively. Local corticosteroid application can reduce the incidence and severity of dysphagia following ACSS without increasing early corticosteroid-related complications. But further high-quality study is necessary to analyze potential delayed complications.

Comparative clinical evaluation on herbal formulation Pepsil, Safoof-e-Katira and Omeprazole in gastro esophageal reflux disease.

This study was conducted to evaluate the role of Unani herbal drugs Pepsil and Safoof-e-katira on the gastro esophageal reflux disease (GERD). This was multicentre randomized case control study conducted at Matab Hakeem Muhammad Noor-ud-din, Burewala; Aziz Muhammad din Medical and Surgical Centre, Burewala and Shifa-ul-mulk Memorial Hospital, Hamdard University Karachi. The patients were selected according to inclusion and exclusion criteria. In test group-1 the male female ratio was 40%, 60%; test group-2 was 42%, 58% and in control group was 44%, 56% respectively. The observed symptoms in the study were increased appetite (TG-1-95%, TG-2-95% and CG-89%), difficulty in swallowing (TG-1-93%, TG-2-96% and TC-94%), belching/burping (TG-1-97%, TG-2-97% and CG-95%), vomiting (TG-1-90%, TG-2-96% and CG-89%), heart burn (TG-1-100%, TG-2-100% and CG-98%), palpitation (TG-1-100%, TG-2-100% and CG-97%), epigastric pain (TG-1-97%, TG-2-97% and CG-90%), abdominal cramps (TG-1-97%, TG-2-98% and CG-95%), tenesmus (TG-1-100%, TG-2-100% and CG-97%), flatulence (TG-1-100%, TG-2-75% and CG-95%), wakeup during sleep (TG-1-94%, TG-2-87% and CG-94%). The p-value of the results of the symptoms was 0.000 except flatulence where the value was 0.001. The statistical results of the study prescribed that all the drugs studied (Pepsil, Safoof-e-katira and Omeprazole) are highly significant. The herbal coded drug Pepsil showed no side effects and unani herbal drug safoof-e-katira showed minimum result of 75% in the patients while Omeprazole resulted with some side effects. In the result it can be concluded that the herbal coded drug Pepsil is a potent herbal drug for gastro esophageal reflux disease.

Safety of botulinum toxin for dysphagia in oculopharyngeal muscular dystrophy.

INTRODUCTION: Despite multiple studies reporting marked benefit of botulinum toxin (BTX) for treatment of cricopharyngeal dysphagia, little is known about its safety for this indication. We examined the safety of cricopharyngeal BTX for dysphagia in oculopharyngeal muscular dystrophy (OPMD). METHODS: We reviewed records of patients with OPMD who received cricopharyngeal BTX. RESULTS: Twenty-four patients underwent 66 procedures. Overall adverse event frequency was 44%. The most common adverse events were dysphonia (24%) and worsened dysphagia (14%). Logistic regression demonstrated that dose was a significant predictor of worsened dysphagia (P = 0.036) and of the composite event of dysphonia or worsened dysphagia (P = 0.009). There was a nonsignificant trend for dose as a predictor of dysphonia (P = 0.073). 59% of procedures were associated with symptomatic improvement. CONCLUSIONS: While BTX appears to be beneficial for treatment of dysphagia in OPMD, caution is warranted when injecting the cricopharyngeus muscle due to dose-related risk of dysphonia or worsened dysphagia.

Diagnosis and evaluation of elderly-onset myasthenia gravis: A case report.

RATIONALE: Patients with elderly-onset myasthenia gravis can have a good prognosis with appropriate diagnosis and response, although it is difficult to differentiate between exacerbations of myasthenia gravis in elderly patients and age-related changes. Therefore, it is important for physicians to understand the clinical characteristics and safe assessment methods for patients with elderly-onset myasthenia gravis. PATIENT CONCERNS: An 82-year-old male diagnosed with myasthenia gravis 6 months prior had no difficulty in daily living. After falling on a golf course, he was diagnosed with a right femoral neck fracture on the 1st day and underwent right total hip replacement surgery on the 12th day, being transferred to our hospital for rehabilitation therapy on the 32nd day. However, immediately after transfer, the patient showed fatigability during training and difficulty swallowing food. DIAGNOSES: This case was diagnosed as an exacerbation of myasthenia gravis. INTERVENTIONS: Pyridostigmine was initiated with the expectation of immediate effect on the 54th day. OUTCOMES: His symptoms and physical functions improved immediately, and walking distance and food intake increased. From this clinical course, it was judged that immunosuppressive therapy was indicated as a transition to generalized myasthenia gravis. For this reason, he was discharged after arranging postdischarge visits to the department of neurology, accordingly. LESSONS: A better understanding of the characteristics of elderly-onset myasthenia gravis may allow for relatively safe assessment of the condition and improve its diagnosis and treatment.

High dosage of aripiprazole-induced dysphagia.

BACKGROUND: Dysphagia as a main manifestation of extrapyramidal symptoms is an uncommon adverse effect of second-generation antipsychotics. METHOD: We present a 54-year-old drug-naïve patient with schizophrenia, who developed dysphagia with aripiprazole 30 mg daily treatment. RESULTS: This is the first case report on aripiprazole-induced dysphagia. We discuss the risk factors that led to dysphagia in this case. CONCLUSION: Aripiprazole-induced dysphagia is rare, and it is important to be aware that it does occur with high-dosage treatment.

Botulinum Toxin Injection for the Treatment of Upper Esophageal Sphincter Dysfunction.

Dysphagia associated with upper esophageal sphincter (UES) dysfunction remarkably affects the quality of life of patients. UES injection of botulinum toxin is an effective treatment for dysphagia. In comparison with skeletal muscles of the limb and trunk, the UES is a special therapeutic target of botulinum toxin injection, owing to its several anatomical, physiological, and pathophysiological features. This review focuses on (1) the anatomy and function of the UES and the pathophysiology of UES dysfunction in dysphagia and why the entire UES rather than the cricopharyngeal muscle before/during botulinum toxin injection should be examined and targeted; (2) the therapeutic mechanisms of botulinum toxin for UES dysfunction, including the choice of injection sites, dose, and volume; (3) the strengths and weaknesses of guiding techniques, including electromyography, ultrasound, computed tomography, and balloon catheter dilation for botulinum toxin injection of the UES.

Ultrasonography-guided botulinum toxin injection to the cricopharyngeus muscle: a case report and technical notes.

Dysphagia associated with the cricopharyngeus muscle (CPm) dysfunction negatively influences the quality of life. This high-pressure region must relax and the lumen must open for smooth food passage. The CP muscle is therefore a common target of chemodenervation with botulinum toxin (BTX). Here we presented a patient with severe left lateral medullary syndrome and non-relaxation of the CPm. We described how to localize the CPm in the transverse and longitudinal views under ultrasonography and offered a video demonstrating ultrasonography-guided BTX injection. Ultrasonography-guided CPm injection with BTX may serve as a reliable, rapid, and effective choice for treatment of cricopharyngeal dysphagia.

Phase 2: a dose-escalation study of OncoGel (ReGel/paclitaxel), a controlled-release formulation of paclitaxel, as adjunctive local therapy to external-beam radiation in patients with inoperable esophageal cancer.

OncoGel, a novel injectable formulation of paclitaxel in a biocompatible biodegradable gel (ReGel), provides controlled release of paclitaxel at the injection site, resulting in high intralesional paclitaxel concentrations and continuous radiosensitization without attendant systemic toxicities. This dose-escalation study evaluated the toxicity, pharmacokinetics, and preliminary antitumor activity of OncoGel injected intralesionally in patients with inoperable esophageal cancer who were candidates for palliative external-beam radiotherapy (RT). Eleven patients with inoperable advanced esophageal cancer received a single administration of OncoGel into the primary tumor using conventional endoscopic techniques. Three cohorts received approximately one-third of the tumor volume with increasing paclitaxel concentrations to achieve 0.48, 1.0, and 2.0 mg paclitaxel/cm tumor volume. Subsequent to injection, RT was initiated (50.4 Gy in 1.8 Gy fractions). Pharmacokinetic sampling was performed. All patients completed the study. No dose-limiting toxicities were reported. Dysphagia improved and tumor size decreased in most patients. Biopsies were negative for carcinoma in 4 of 11 patients. Peak paclitaxel plasma concentrations were low (0.53-2.73 ng/ml) and directly related to the absolute amount of paclitaxel administered. Paclitaxel was detectable in plasma for 24 h in all patients and for 3 weeks in six patients. OncoGel given as an adjunct to RT was well tolerated in patients with inoperable esophageal cancer and provided prolonged paclitaxel release with minimal systemic exposure. OncoGel plus RT seemed to reduce tumor burden as evidenced by dysphagia improvement, tumor size reduction, and negative esophageal biopsies. The addition of OncoGel to combined modality therapy merits continued clinical development.

Efficacy of Early Endoscopic Intervention for Restoring Normal Swallowing Function in Patients with Lateral Medullary Infarction.

Dysphagia is considered to be a significant barrier for recovery after lateral medullary infarction (LMI). However, there is still no gold standard treatment for dysphagia. The aim of this study was to explore an effect of an early treatment options for swallowing dysfunction after acute LMI. Medical records of acute LMI patients who had been admitted to the department of rehabilitation medicine from January 2014 to December 2017 were reviewed retrospectively. We compared the clinical efficacy of conventional dysphagia rehabilitation to early endoscopic intervention using either botulinum toxin injection into cricopharyngeal muscle or endoscopic balloon dilatation of the muscle. Outcomes, such as duration of parental feeding, albumin level at diet transition to enteral feeding, and complications, were analyzed. A total of 18 patients with LMI were included. While eight patients (8/9, 88.89%) in the endoscopic group were capable of orally ingesting their diet after intervention, the conversion from tube feeding to an oral diet was possible in only five patients (5/9, 55.56%) of the conventional group during hospitalization. However, the difference between the two groups was not significant (p-value ≤ 0.147, chi-square test). Only the final dietary level at the time of discharge was higher level in endoscopic group. The conversion interval from tube feeding to oral diet was also comparable between groups. There was no re-conversion from the oral diet to tube feeding in patients of either group during the median follow-up period of 20 months. Early endoscopic intervention may be a better option for dysphagia with LMI, compared to conventional dysphagia rehabilitation. However, a larger and prospective trial may be needed to confirm our observations.

Vanishing bile duct and Stevens-Johnson syndrome associated with ciprofloxacin treated with tacrolimus.

Stevens-Johnson syndrome (SJS) is a serious and potentially life-threatening disease. Vanishing bile duct syndrome (VBDS) is a rare cause of progressive cholestasis. Both syndromes are mostly related with drugs. We report a case of a patient with ciprofloxacin-induced SJS and acute onset of VBDS, and reviewed the related literature. It is the first case of ciprofloxacin-induced VBDS successfully treated with tacrolimus. This case reminds physicians of the importance of drug reactions, their severity, techniques for diagnosis and methods of management.

Transdermal scopolamine to reduce salivation and possibly aspiration after stroke.

We report two cases illustrating a potential use of transdermal scopolamine to reduce salivation in acute stroke. We speculate that this may lead to reduced aspiration and possibly also less pneumonia. However, the treatment is associated with side effects. Finally, we suggest that this use of transdermal scopolamine in stroke may be a topic for a randomized clinical trial.

[Functional and motor gastrointestinal disorders]. / Trastornos funcionales y motores digestivos.

Functional gastrointestinal (GI) and motility disorders generate a large volume of consultations in gastroenterology and primary care offices. The present article summarizes the most interesting studies presented in the annual meeting of the American Gastroenterological Association 2008. For all functional GI disorders, studies were presented that evaluated the applicability of diagnostic criteria in clinical practice and new data were presented on physiopathology (for example, mediation by neuromodulators such as serotonin, microinflammation, alterations in intestinal microbiota, and psychological factors). More specifically, the therapeutic results of new prokinetic agents in functional dyspepsia, such as acotiamide, were presented. This agent has been demonstrated to have good efficacy in symptom control, especially in patients with postprandial distress syndrome. In irritable bowel syndrome, data were presented on several drugs that act through diverse mechanisms of action and have been shown to be more effective than placebo in symptom control. These drugs include antiinflammatory agents such as mesalazine, antibiotics such as rifaximin, probiotics with distinct bacterial strains, and prokinetic agents such as lubiprostone. Highly promising results have been obtained in the treatment of constipation with prokinetics such as prucalopride and with novel laxatives such as linaclotide, as well as with techniques that continue to be shown to be effective such as anorectal biofeedback, which is also highly useful in patients with fecal incontinence. Another disorder that is less frequent but highly difficult to treat is gastroparesis. For several years, treatment in the most severe cases has consisted of implantation of a gastric pacemaker. Although the results are far from perfect, new data were presented that allow better patient selection to achieve greater symptom control. The list of new advances, both in knowledge of the physiopathology of these disorders and on their treatments, is extensive. Consequently, 2008 has been a good year in terms of the useful information gathered for physicians interested in functional GI and motor disorders.

Route of Feeding as a Proxy for Dysphagia After Stroke and the Effect of Transdermal Glyceryl Trinitrate: Data from the Efficacy of Nitric Oxide in Stroke Randomised Controlled Trial.

Post-stroke dysphagia is common, associated with poor outcome and often requires non-oral feeding/fluids. The relationship between route of feeding and outcome, as well as treatment with glyceryl trinitrate (GTN), was studied prospectively. The Efficacy of Nitric Oxide in Stroke (ENOS) trial assessed transdermal GTN (5 mg versus none for 7 days) in 4011 patients with acute stroke and high blood pressure. Feeding route (oral = normal or soft diet; non-oral = nasogastric tube, percutaneous endoscopic gastrostomy tube, parenteral fluids, no fluids) was assessed at baseline and day 7. The primary outcome was the modified Rankin Scale (mRS) measured at day 90. At baseline, 1331 (33.2%) patients had non-oral feeding, were older, had more severe stroke and more were female, than 2680 (66.8%) patients with oral feeding. By day 7, 756 patients had improved from non-oral to oral feeding, and 119 had deteriorated. Non-oral feeding at baseline was associated with more impairment at day 7 (Scandinavian Stroke Scale 29.0 versus 43.7; 2p < 0.001), and worse mRS (4.0 versus 2.7; 2p < 0.001) and death (23.6 versus 6.8%; 2p = 0.014) at day 90. Although GTN did not modify route of feeding overall, randomisation ≤6 h of stroke was associated with a move to more oral feeding at day 7 (odds ratio = 0.61, 95% confidence intervals 0.38, 0.98; 2p = 0.040). As a proxy for dysphagia, non-oral feeding is present in 33% of patients with acute stroke and associated with more impairment, dependency and death. GTN moved feeding route towards oral intake if given very early after stroke. Clinical Trial Registration Clinical Trial Registration-URL: http://www.controlled-trials.com . Unique identifier: ISRCTN99414122.

A comparative study on the therapeutic effect of TRPV1, TRPA1, and TRPM8 agonists on swallowing dysfunction associated with aging and neurological diseases.

BACKGROUND: Oropharyngeal sensory impairment is a potential target to treat swallowing dysfunction in patients with oropharyngeal dysphagia (OD). AIM: To assess the therapeutic effect of stimulating oropharyngeal sensory afferents with TRPV1, TRPA1, or TRPM8 agonists vs increasing bolus viscosity in older and neurologic patients with OD by comparing four studies of similar experimental design. METHODS: Swallow function of 142 older patients with impaired safety of swallow at nectar ([50-350] mPa·s) viscosity was evaluated with videofluoroscopy (VFS) while treated with TRPV1 (150 µmol/L), TRPV1/A1 (150 µmol/L and 1 mmol/L), or TRPM8 (1 mmol/L or 10 mmol/L) agonists or modified starch (MS) at spoon thick viscosity (>1750 mPa·s). RESULTS: TRPV1 stimulation with capsaicinoids reduced penetrations by 50%, pharyngeal residue by 80%, and LVC time by 24.38% and increased bolus velocity by 36.51%. TRPV1/A1 stimulation with piperine reduced penetrations by 56.32%, LVC time by 25.55% and increased bolus velocity by 23.63%. TRPM8 stimulation with menthol 1 mmol/L reduced penetrations by 37.5% while 10 mmol/L reduced LVC time by 18.44%. Thickeners reduced penetrations by 77.11%, but increased pharyngeal residue by 19.89%, delayed LVC by 41.73%, and reduced bolus velocity by 13.44%. CONCLUSION: Natural capsaicinoids have a stronger therapeutic effect on VFS signs and swallow response by stimulating TRPV1 than TRPV1/A1 or TRPM8 agonists. While TRP stimulants increased bolus velocity and reduced swallow response times, thickeners reduced bolus velocity and further delayed the swallow response. This study sets the bases to develop new pharmacologic strategies for older patients with OD, moving away from compensation toward the recovery of swallow function.

Oesophageal lichen planus: the efficacy of topical steroid-based therapies.

BACKGROUND: Oesophageal lichen planus is an idiopathic inflammatory disorder characterized by significant oesophageal stricturing. Oesophageal lichen planus is a rare, difficult to diagnose, and likely an under recognized disease. As a result, there is no standardized approach to therapy and treatment strategies vary. AIM: To examine the utility of topical steroid therapy (fluticasone or budesonide) in the management of oesophageal lichen planus. METHODS: A retrospective chart review was conducted of patients diagnosed with oesophageal lichen planus who underwent baseline and follow up endoscopy pre and post topical steroid therapy between 1995 and 2016 at Mayo Clinic, Rochester MN. Average time between upper GI endoscopy was 3.2 months (0.7-11.7). Swallowed steroid preparations included fluticasone 880 µg twice daily or budesonide 3 mg twice daily. Patients were reviewed for symptomatic response to therapy using the Dakkak-Bennett dysphagia score (0-4, no dysphagia to total aphagia). Pre- and post-endoscopic findings were assessed. Additional baseline demographic, endoscopic, and histologic data were also obtained. RESULTS: We identified 40 patients who met the inclusion criteria. A significant reduction in median dysphagia score from 1 (0-4) to 0 (0-3) after steroid therapy (P < 0.001) was noted. 62% of patients reported resolution of their dysphagia after receiving topical corticosteroids. 72.5% had an endoscopic response to steroid therapy. CONCLUSION: Topical swallowed budesonide or fluticasone appear to effective treatment for oesophageal lichen planus.