Accuracy of Dysphagia Screening by Non-clinical Research Staff in the Emergency Department.

Although the emergency department (ED) is the initial care setting for the majority of older adults requiring hospital admission, there is a paucity of ED-based dysphagia research in this at-risk population. This is driven by barriers to dysphagia evaluation in this complex care environment. Therefore, we assessed the reliability of trained, non-clinical ED research staff in administering dysphagia screening tools compared to trained speech pathologists (SLPs). We also aimed to determine perceptual screening discrepancies (e.g. voice change) between clinical and non-clinical staff. Forty-two older adults with suspected pneumonia were recruited during an ED visit and underwent dysphagia (Toronto Bedside Swallow Screening Tool; TOR-BSST©) and aspiration (3-oz water swallow test; 3-oz WST) screening by trained non-clinical research staff. Audio-recordings of screenings were re-rated post-hoc by trained, blinded SLPs with discrepancies resolved via consensus. Cohen's kappa (unweighted) revealed moderate agreement in pass/fail ratings between clinical and non-clinical staff for both the TOR-BSST© (k = 0.75) and the 3 oz WST (k = 0.66) corresponding to excellent sensitivity and good specificity for both the TOR-BSST (SN = 94%, SP = 85%) and the 3 oz WST (SN = 90%, SP = 81%). Further analysis of TOR-BSST perceptual parameters revealed that most discrepancies between clinicians and non-clinicians resulted from over-diagnosis of change in vocal quality (53%). These results support the feasibility of non-clinical research staff administering screening tools for dysphagia and aspiration in the ED. Dysphagia screening may not necessitate clinical staff involvement, which may improve feasibility of large-scale ED research. Future training of research staff should focus on perceptual assessment of vocal quality.

Dysphagia Is an Underrecognized Risk Factor for Viral Pneumonia Severity.

The aim of this study was to examine the role of pre-existing dysphagia as a risk factor for COVID-19 severity among adults ≥50 years of age presenting to the emergency department (ED). This was a retrospective cohort study that used electronic health record data from two Midwestern EDs in the same health care system. The sample included patients ≥50 years of age who tested positive for SARS-COV-2 during an ED visit between March 15, 2020 and November 19, 2020. Patients were dichotomized based on documented history of dysphagia. The primary outcome was the highest World Health Organization COVID-19 clinical severity score within 30-days of ED arrival. Patients with a score of <4 were classified as non-severe whereas a score ≥4 was considered severe. Chi-square tests were used to assess differences in clinical severity scores between patients with and without dysphagia. A logistic regression model was created to estimate the odds of a severe COVID-19 clinical score. The sample included 126 patients without dysphagia and 40 patients with dysphagia. Patients with a history of dysphagia were more likely to develop severe COVID-19 disease compared to patients without (65.0% vs. 41.3%, p = 0.015). In multivariable analysis, patients with preexisting dysphagia (OR 2.38, 95% CI: 1.05-5.42; p = 0.038) and diabetes (OR 2.42 95% CI: 1.15-5.30; p = 0.021) had significantly increased odds of developing severe COVID-19. This study showed that a pre-existing diagnosis of dysphagia was independently associated with COVID-19 severity in adults ≥50 years of age.

Ready for Discharge, but Are They Ready to Go Home? Examining Neighborhood-Level Disadvantage as a Marker of the Social Exposome and the Swallowing Care Process in a Retrospective Cohort of Inpatients With Dementia.

PURPOSE: Socioeconomically disadvantaged areas are more resource poor, impacting adherence to swallowing care recommendations. Neighborhood-level disadvantage metrics, such as the Area Deprivation Index (ADI), allow for examination of social determinants of health (SDOH) in a precise region. We examined ADI in a cohort of persons living with dementia (PLWD) to determine representation of those residing in areas of socioeconomic disadvantage (high ADI), distribution of swallowing care provided, and frequency of SDOH-related counseling or resource linking prior to discharge. METHOD: A retrospective chart abstraction was performed for all inpatients with a diagnosis of dementia (N = 204) seen by the Swallow Service at a large academic hospital in 2014. State ADI Deciles 1 (least) to 10 (most socioeconomic disadvantage) and decile groups (1-3, 4-7, and 8-10) were compared with the surrounding county. Frequency of videofluoroscopic swallowing evaluations (VFSEs) based on ADI deciles was recorded. To determine whether SDOH-related counseling or resource linking occurred for those in high ADI (8-10) neighborhoods, speech-language pathology notes, and discharge summaries were reviewed. Descriptive statistics, independent samples t tests, and one-way analysis of variance were calculated. RESULTS: ADI was significantly higher in this cohort (M = 3.84, SD = 2.58) than in the surrounding county (M = 2.79, SD = 1.88, p = .000). There was no significant difference in utilization of swallowing services across decile groups (p = .88). Although the majority (85%) in high ADI areas was recommended diet modifications or alternative nutrition likely requiring extra resources, there was no documentation indicating that additional SDOH resource linking or counseling was provided. CONCLUSIONS: These findings raise important questions about the role and responsibility of speech-language pathologists in tailoring swallowing services to challenges posed by the lived environment, particularly in socioeconomically disadvantaged areas. This underscores the need for further research to understand and address gaps in postdischarge support for PLWD in high-ADI regions and advocate for more equitable provision of swallowing care.

Marrow-Derived Autologous Stromal Cells for the Restoration of Salivary Hypofunction (MARSH): A pilot, first-in-human study of interferon gamma-stimulated marrow mesenchymal stromal cells for treatment of radiation-induced xerostomia.

BACKGROUND AIMS: Xerostomia, or the feeling of dry mouth, is a significant side effect of radiation therapy for patients with head and neck cancer (HNC). Preliminary data suggest that mesenchymal stromal/stem cells (MSCs) can improve salivary function. We performed a first-in-human pilot study of interferon gamma (IFNγ)-stimulated autologous bone marrow-derived MSCs, or MSC(M), for the treatment of radiation-induced xerostomia (RIX). Here we present the primary safety and secondary efficacy endpoints. METHODS: A single-center pilot clinical trial was conducted investigating the safety and tolerability of autologous IFNγ-stimulated MSC(M). The study was conducted under an approved Food and Drug Administration Investigational New Drug application using an institutional review board-approved protocol (NCT04489732). Patients underwent iliac crest bone marrow aspirate and MSC(M) were isolated, cultured, stimulated with IFNγ and cryopreserved for later use. Banked cells were thawed and allowed to recover in culture before patients received a single injection of 10 × 106 MSC(M) into the right submandibular gland under ultrasound guidance. The primary objective was determination of safety and tolerability by evaluating dose-limiting toxicity (DLT). A DLT was defined as submandibular pain >5 on a standard 10-point pain scale or any serious adverse event (SAE) within 1 month after injection. Secondary objectives included analysis of efficacy as measured by salivary quantification and using three validated quality of life instruments. Quantitative results are reported as mean and standard deviation. RESULTS: Six patients with radiation-induced xerostomia who had completed radiation at least 2 years previously (average 7.8 years previously) were enrolled in the pilot study. The median age was 71 (61-74) years. Five (83%) patients were male. Five patients (83%) were treated with chemoradiation and one patient (17%) with radiation alone. Grade 1 pain was seen in 50% of patients after submandibular gland injection; all pain resolved within 4 days. No patients reported pain 1 month after injection, with no SAE or other DLTs reported 1 month after injection. The analysis of secondary endpoints demonstrated a trend of increased salivary production. Three patients (50%) had an increase in unstimulated saliva at 1 and 3 months after MSC(M) injection. Quality of life surveys also showed a trend toward improvement. CONCLUSIONS: Injection of autologous IFNγ-stimulated MSC(M) into a singular submandibular gland of patients with RIX is safe and well tolerated in this pilot study. A trend toward an improvement in secondary endpoints of salivary quantity and quality of life was observed. This first-in-human study provides support for further investigation into IFNγ-stimulated MSC(M) injected in both submandibular glands as an innovative approach to treat RIX and improve quality of life for patients with HNC.

Dysphagia Profiles Among Inpatients with Dementia Referred for Swallow Evaluation.

BACKGROUND: Alzheimer's disease and related dementias (ADRD) patients who are hospitalized often develop oropharyngeal dysphagia, increasing risk for adverse outcomes, such as aspiration pneumonia. However, prevalence estimates of dysphagia are highly variable and often based on patient report or clinical testing rather than visualization of the swallow. OBJECTIVE: The aims of this study were to determine prevalence and severity of dysphagia among inpatients with ADRD referred for swallowing evaluation. METHODS: Electronic health record (EHR) abstraction of ADRD diagnosis and presence and severity of clinically-determined dysphagia on bedside swallow evaluation (BSE) and videofluoroscopic swallow study (VFSS). RESULTS: 16% (n = 268) had an ADRD diagnosis or were taking dementia-specific medication based on the EHR. 75% (n = 202) were diagnosed with dysphagia on the BSE. 60% subsequently underwent VFSS (n = 122) with dysphagia confirmation in 92% (n = 112). ADRD inpatients were significantly more likely to be diagnosed with dysphagia based on the BSE (p < 0.0001) than those without ADRD. Additionally, dysphagia on the VFSS was more severe in the ADRD group (p < 0.03). DISCUSSION: ADRD individuals may be vulnerable to developing or worsening dysphagia during hospitalization. Results underscore the importance of evaluating swallowing function in hospitalized patients with ADRD in order to facilitate targeted intervention.

Detecting Aspiration and Penetration Using FEES With and Without Food Dye.

The objective of this investigation was to determine if there were differences in identifying airway invasion (penetration or aspiration) during fiberoptic endoscopic evaluations of swallowing (FEES) for green-dyed versus non-dyed liquids. Forty adult inpatients in an acute care hospital underwent FEES, with both green-dyed liquids and naturally white liquids. Three speech-language pathologists rated aspiration and penetration for trials of nectar-thick milk and thin milk, both with and without green food dye. A subset of participants having excess pharyngeal/laryngeal secretions, as measured by the Secretions Severity Scale, were also analyzed for a difference in the detection of airway invasion and pharyngeal residue. No significant differences were found between dyes in airway invasion across all bolus types within participants. Significant differences were found in penetration ratings for large volumes of thin liquids (90 ml), between participants. When examining only discrepant airway invasion judgments for green-white swallow pairs, statistically significantly deeper airway invasion was measured for green-dyed boluses versus white for three of the five bolus types. Repeat rater reliability was better for dyed versus undyed liquids. Findings suggest that the use of green dye may allow for improved judgment of airway invasion.