ESSD Commentary on Dysphagia Management During COVID Pandemia.

Since the World Health Organization declared the COVID-19 pandemic a Global Public Health Emergency, experts in swallowing are seeking guidance on service delivery and clinical procedures. The European Society for Swallowing Disorders provides considerations to support experts in swallowing disorders in clinical practice. During the COVID-19 pandemic, assessment and treatment of patients with oropharyngeal dysphagia should be provided, while at the same time balancing risk of oropharyngeal complications with that of infection of patients and healthcare professionals involved in their management. Elective, non-urgent assessment may be temporarily postponed and patients are triaged to decide whether dysphagia assessment is necessary; instrumental assessment of swallowing is performed only if processing of the instruments can be guaranteed and clinical assessment has not provided enough diagnostic information for treatment prescription. Assessment and management of oropharyngeal dysphagia is a high-risk situation as it must be considered an aerosol-generating procedure. Personal protective equipment (PPE) should be used. Telepractice is encouraged and compensatory treatments are recommended.

Comparison of videofluoroscopy and impedance planimetry for the evaluation of oesophageal stenosis: a retrospective study.

OBJECTIVES: To compare videofluoroscopy that included a tablet test with impedance planimetry (EndoFLIP®) for the evaluation of oesophageal stenosis in patients with dysphagia. METHODS: In 56 patients, videofluoroscopic examinations following the transit of a 14-mm tablet were retrospectively reviewed and correlated with impedance planimetry findings, a catheter-based method using impedance planimetry to display the oesophageal diameter estimates. Additional findings assessed were the occurrence of symptoms during tablet passage and evaluation of oesophageal motility. RESULTS: Impaction of the tablet occurred in 31/56 patients; nine showed a moderate delay (2-15 s), three a short delay (<2 s) and 13 no delay of tablet passage. Both methods showed a significant correlation between tablet impaction and oesophageal diameter <15.1 mm, as measured by impedance planimetry (p = 0.035). The feeling of the tablet getting stuck was reported by seven patients, six showing impaction of the tablet (four with an EndoFLIP-diameter < 13 mm, two with a diameter of 13-19 mm) and one showing delayed passage (EndoFLIP diameter of 17 mm). CONCLUSIONS: Videofluoroscopy and impedance planimetry correlate significantly regarding tablet impaction and residual oesophageal lumen. A standardized 14-mm tablet is helpful in demonstrating oesophageal strictures in dysphagic patients. Triggering of subjective symptoms provides valuable information during a videofluoroscopic study. KEY POINTS: • A 14-mm tablet can demonstrate oesophagogastric junction narrowing in patients with dysphagia. • Type of passage of a tablet enables estimation of oesophageal luminal diameter. • Videofluoroscopy and impedance planimetry correlate significantly regarding tablet impaction and residual oesophageal lumen.

Oesophageal fluoroscopy in adults-when and why?

Oesophageal fluoroscopy is a radiological procedure that uses dynamic recording of the swallowing process to evaluate morphology and function simultaneously, a characteristic not found in other clinical tests. It enables a comprehensive evaluation of the entire upper gastrointestinal tract, from the oropharynx to oesophagogastric bolus transport. The number of fluoroscopies of the oesophagus and the oropharynx has increased in recent decades, while the overall use of gastrointestinal fluoroscopic examinations has declined. Radiologists performing fluoroscopies need a good understanding of the appropriate clinical questions and the methodological advantages and limitations to adjust the examination to the patient's symptoms and clinical situation. This review provides an overview of the indications for oesophageal fluoroscopy and the various pathologies it can identify, ranging from motility disorders to structural abnormalities and assessment in the pre- and postoperative care. The strengths and weaknesses of this modality and its future role within different clinical scenarios in the adult population are discussed. We conclude that oesophageal fluoroscopy remains a valuable tool in diagnostic radiology for the evaluation of oesophageal disorders.

Diagnosis and treatment of neurogenic dysphagia - S1 guideline of the German Society of Neurology.

INTRODUCTION: Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies. RECOMMENDATIONS: This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with. CONCLUSIONS: The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online ( https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf ).

Designing virtual patient based self-study quizzes covering learning goals in clinical diagnostic sciences for undergraduate medical students - the radiology example.

Background: Diagnostic tests and examinations inform clinical decision making. Thus, an essential part of medical students' workplace-based training is dedicated to core skills in clinical diagnostic sciences. Due to a reduction of clinical internships for fifth-year students in the wake of COVID-19 learning activities replacing this aspect of training were needed. Project description: Virtual Patient online learning materials addressing clinical diagnostic sciences, specifically, radiology, were developed to prepare students for the transition to workplace-based learning. Three types of activities related to interprofessional patient treatment, showing how radiology knowledge improves the diagnosing and treatment of patients, were used to design the narrative of each virtual patient. The materials also showed students "how to learn" in the clinical workplace while showing "what to learn". Students complete relevant tasks and compare their approach with experts' approach in a self-directed way. Results: Twenty self-study quizzes, accompanied by nine interactive Webinars were developed, providing 13% of the overall available replacement learning materials for the summer term 2020. In June 2020, 486 students completed the program and collected a mean share of 16% (SD=10) of their required credits by choosing to learn with these materials. Conclusion: Developing virtual patients based on three types of clinical activities to prepare students for the transition to workplace based learning proved successful and allowed rapid development of learning materials. The presented online quiz format and webinar format showed high acceptance and interest among students.

Using patient cases to educate health professionals, patients, institutions, and society: the swallowing disorder example.

The problems and symptoms of patients are at the heart of medicine and pertinent to information, communication, and education. Patients present their problems to health professionals looking for relief and a cure, while institutions collect data about symptoms of patients and the way health professionals treated them to support society's care providers in administrating and managing care. The information on the problems of patients and the way health professionals treated them, which is gathered and stored in patient files, is valuable as educational material in the field of medicine. Driven by the fast developments of new technical tools case-based information, communication and education starts to enter educational domains beyond the field of medicine, such as school systems and public health services. In our discussion we seek to understand and outline how to use the material gathered and stored in patient files to educate health professionals. Additionally, this paper gives examples of case-based education for all members of society.

Taking the history in patients with swallowing disorders: an international multidisciplinary survey.

PURPOSE: Clinical assessment of swallowing disorders (dysphagia) requires accurate and comprehensive medical history-taking to further tailor the diagnostic work-up, but functional health care questionnaires show a large variability and various limitations. The aim of this study was to assess the way in which international swallowing experts from various disciplines asses swallowing problems in order to improve the radiologist´s ability to take a thorough medical history in this specific patient group. METHODS: A two-step Delphi method was used to collect swallowing experts' ways of taking the medical history in patients with swallowing disorders. The questions obtained in a first interview round were pooled and structured by dividing them into general and specific questions, including several subcategories, and these were scored by the experts in a second step based on to their clinical relevance. RESULTS: Eighteen experts provided 25 different questions categorized as general questions and 34 dimension-specific questions (eight attributed to 'suspicion of aspiration,' 13 to 'dysphagia,' six to 'globus sensation,' four to 'non-cardiac chest pain,' and three to 'effect of life.') In the second interview round, the experts´ average predictive values attributed to those questions showed the varying importance of the presented items. Seven general and 13 specific questions (six of them attributed to 'effect on life' and seven 'others') were also added. CONCLUSIONS: This collection of questions reflects the fact that a multidisciplinary approach when obtaining the medical history in patients with swallowing disorders may contribute to an improved technique for performing a symptom-oriented medical history-taking for radiologists of all training levels.

What is the role of radiological testing of lower esophageal sphincter function?

Radiological fluoroscopic evaluation remains the primary imaging modality of choice to evaluate patients with swallowing disorders, despite the increasing availability and technical advantages of nonradiological techniques and the current radiological focus on cross-sectional imaging studies, such as computed tomography and magnetic resonance imaging. The radiological swallowing evaluation should be tailored to assess the entire upper gastrointestinal tract, including the lower esophageal sphincter. Fluoroscopy enables the simultaneous assessment of esophageal motility disorders, as well as structural pathologies, including strictures, webs, rings, diverticula, and tumors. Mono- and double-contrast esophagrams and solid bolus tests together allow assessment of lower esophageal sphincter function and complement other methods, such as endoscopy, manometry, or impedance planimetry. Here we review the role of radiological studies for correct assessment of structural and functional pathologies at the level of the lower esophageal sphincter.

Information technology and social sciences: how can health IT be used to support the health professional?

Keeping up to date with the increasing amount of health-related knowledge and managing the increasing numbers of patients with more complex clinical problems is a challenge for healthcare professionals and healthcare systems. Health IT applications, such as electronic health records or decision-support systems, are meant to support both professionals and their support systems. However, for physicians using these applications, the applications often cause new problems, such as the impracticality of their use in clinical practice. This review adopts a social sciences perspective to understand these problems and derive suggestions for further development. Indeed, humans use tools to remediate the brain's weaknesses and enhance thinking. Available health IT tools have been shaped to fit administrative needs rather than physicians' needs. To increase the beneficial effect of health IT applications in health care, clinicians' style of thinking and their learning needs must be considered when designing and implementing such systems. New health IT tools must be shaped to fit health professionals' needs. To further ease the integration of new health IT tools into clinical practice, we must also consider the effects of implementing new tools on the wider social framework.

Acute colonic pseudo-obstruction (Ogilvie's-syndrome) and pneumatosis intestinalis in a kidney recipient patient.

Acute colonic pseudo-obstruction (Ogilvie's syndrome) is a clinical entity characterized by massive nontoxic dilatation of the colon in the absence of mechanical obstruction and is associated with increased morbidity and mortality in the immunosuppressed patient. We present a case of a kidney transplant recipient developing a life-threatening condition with acute colonic pseudo-obstruction associated with radiologic findings of a linear pneumatosis intestinalis (PI). Urgent laparotomy and resection of the dilated cecum, colon ascendens and transversum was performed because of bowel necrosis with multiple serosal defects. Stool cultures and special stains for microorganisms were all negative, and there was no evidence for viral or fungal infection. The patient was discharged 31 days after transplantation with normal renal function. In conclusion, this steroid-induced ileus (pseudo-obstruction) is a potentially malignant early form of colonic dysmotility rarely reported in transplant recipients. Awareness and early recognition of the condition are critical for a successful outcome. Colonoscopic decompression can achieve reversal of colonic dilatation in most cases, but in some patients prophylactic laparotomy is indicated for prevention of the catastrophic consequences of perforation.

Intraoperative ultrasonography in patients who undergo liver resection or transplantation for hepatocellular carcinoma.

Careful staging of hepatic tumors forms the basis of appropriate selection of, and is a precondition for, customized treatment. Advances in radiodiagnostic technology have increased the sensitivity of noninvasive liver staging by means of magnetic resonance imaging (MRI), computed tomography (CT), and helical CT (HCT). Nevertheless, surgical exploration and intraoperative ultrasonography (IOUS) are considered the "gold standard." The value of HCT and IOUS was investigated in patients who underwent orthotopic liver transplantation (OLT) (group A; n=23) or hepatic resection for hepatocellular carcinoma (HCC) (group B; n=52). In group A, the results of liver imaging (HCT performed immediately before OLT, IOUS) were compared with histopathological results after 3-mm slicing of the explanted liver. In group B, patients were evaluated by CT (n=8), HCT (n=43), MRI (n=18), or both, as indicated by the respective surgeon. The results were compared with those of surgical exploration and IOUS (n=52), as well as with the pathological examination of the resected liver specimen. In group A, 52 malignant lesions were detected by histopathology. By each of the preoperative examinations (IOUS, HCT), 54 lesions were suspected of being malignant. Thirteen HCCs were missed by HCT (for IOUS: n=4) and 15 lesions were false-positive (for IOUS: n=6). Thirty-nine of 52 lesions were verified to be true-positive by HCT in contrast to 48/52 by IOUS, which resulted in sensitivities of 75% (HCT) and 92% (IOUS, P=0.017), respectively. In group B, the sensitivity of CT was 77%, HCT 90%, MR 93%, and IOUS 99% (P<0.01). In 10%, the strategy of surgical treatment was changed because of IOUS findings. IOUS offered relevant additional information in 6%. Even after sufficient preoperative evaluation, IOUS can provide additional information that frequently has a remarkable impact on surgical decision-making. Identification of HCC is commonly hampered by coexistent cirrhosis. Identification of lesions and orientation of borders to non-tumorous tissue are assessed reliably by IOUS. Thus, IOUS remains a mandatory tool in patients treated by locoregional surgical modalities such as resection, cryotherapy, and intraoperative ethanol instillation for HCC even after refinement of radiological technologies.

Neurogenic [corrected] and oropharyngeal dysphagia.

Oropharyngeal dysphagia (OD) is a swallowing disorder caused by congenital abnormalities and structural damage and disease-associated damage of the oral cavity, pharynx, and upper esophageal sphincter. Patients with OD lack the protective mechanisms necessary for effective swallowing, exhibiting difficulty controlling food in the mouth and initiating a swallow, leading to choking, coughing, and nasal regurgitation. OD is a major risk factor for malnutrition, dehydration, and aspiration pneumonia. The following on OD includes commentaries on the application of simulation of oropharyngeal transient receptor potential vanilloid 1 (TRPV1) and maneuvers like the Shaker exercise to improve the safety and efficacy of swallow in OD patients; the prevalence of esophageal pathologies in OD patients and the need to evaluate the esophagus, esophagogastric junction, and stomach; and strategies for clinical screening to detect OD and aspiration among high-risk patients and to improve oral health care, maintain nutrition and hydration, and prevent aspiration pneumonia.

Upper esophageal sphincter dysfunction: diverticula-globus pharyngeus.

The following discussion of upper esophageal sphincter dysfunction includes commentaries on the role of the cricopharyngeus muscle in reflux disease; the etiology and treatment of Zenker diverticulum; the use of videofluoroscopy in patients with dysphagia, suspicion of aspiration, or globus; the role of pH-impedance monitoring in globus evaluation; and treatment for reflux-associated globus.

Innovative techniques in evaluating the esophagus; imaging of esophageal morphology and function; and drugs for esophageal disease.

This paper reporting on techniques for esophageal evaluation and imaging and drugs for esophageal disease includes commentaries on endoscopy techniques including dye-based high-resolution and dye-less high-definition endoscopy; the shift from CT to MRI guidance in tumor delineation for radiation therapy; the role of functional lumen imaging in measuring esophageal distensibility; electrical stimulation of the lower esophageal sphincter (LES) as an alternative to fundoduplication for treatment of gastroesophageal reflux disease (GERD); the morphological findings of reflux esophagitis and esophageal dysmotility on double-contrast esophagography; the value of videofluoroscopy in assessing protecting mechanisms in patients with chronic reflux or swallowing disorders; targeting visceral hypersensitivity in the treatment of refractory GERD; and the symptoms and treatments of nighttime reflux and nocturnal acid breakthrough (NAB).

A new blended learning concept for medical students in otolaryngology.

OBJECTIVE: To evaluate students' overall assessment and effectiveness of the web-based blended learning conception "Unified Patient Project" (UPP) for medical students rotating on their otolaryngology internship (ear, nose, and throat [ENT] tertiary). DESIGN: Prospective comparison group design of the quasiexperimental type. SETTING: Medical education. SUBJECTS: The experimental group (preintervention test [pretest], intervention, and postintervention test [posttest]) comprised 117 students, and the comparison group (pretest, alternative intervention, and posttest), 119. INTERVENTIONS: In the experimental group, lecturing of case studies was replaced by the blended learning concept UPP. A standardized questionnaire evaluated students' overall assessment of teaching otolaryngology. A pretest and posttest using multiple choice questions was administered to clarify whether the UPP has led to a knowledge gain. RESULTS: The comparison group was more satisfied with their teaching; however, this was not statistically significant (P = .26) compared with the UPP. Students with higher preknowledge benefitted from the UPP, while students with lower preknowledge did not (P = .01). On average, posttest results in the experimental group exceeded those of the comparison group by 8.7 percentage points for a 75% preknowledge of the maximum attainable score, while they fell below those of the comparison group by 8.1 percentage points for a 25% preknowledge. CONCLUSIONS: Students' satisfaction with the blended learning concept UPP was lower than in the face-to-face teaching, although this was not statistically significant. The new web-based UPP leads to an improved knowledge in clinical otolaryngology for all students. Students with lower preknowledge benefitted more from face-to-face teaching than from the UPP, while students with higher preknowledge benefitted more from the UPP. This implies students with poor preknowledge need special promotion programs.

Barrett's esophagus: treatments of adenocarcinomas I.

The following on the treatments of adenocarcinomas in Barrett's esophagus contains commentaries on endo mucosal resection; choice between other ablative therapies; the remaining genetic abnormalities following stepwise endoscopic mucosal resection and possible recurrences; the Fotelo-Fotesi PDT; the CT TNM classification of early stages of Barrett's carcinoma; the indications of lymphadenectomy in intramucosal cancer; the differences in lymph node yield in transthoracic versus transhiatal dissection; video-assisted lymphadenectomy; and the importance of the length of proximal esophageal resectipon; and indications of sentinel node dissection.

Videofluoroscopic assessment of patients with dysphagia: pharyngeal retention is a predictive factor for aspiration.

OBJECTIVE: This study evaluated the clinical significance of pharyngeal retention to predict aspiration in patients with dysphagia. MATERIALS AND METHODS: At videofluoroscopy, pharyngeal retention was found in 108 (28%; 73 males, 35 females; mean age, 60 years) of 386 patients with a suspected deglutition disorder. Swallowing function was assessed videofluoroscopically. The amount of residual contrast material in the valleculae or piriform sinuses was graded as mild, moderate, or severe. The frequency, type, and grade of aspiration were assessed. RESULTS: Pharyngeal retention was caused by pharyngeal weakness or paresis in 103 (95%) of 108 patients. In 70 patients (65%) with pharyngeal retention, postdeglutitive overflow aspiration was found. Aspiration was more often found in patients who had additional functional abnormalities such as incomplete laryngeal closure or impaired epiglottic tilting (p < 0.05). Postdeglutitive aspiration was diagnosed in 25% patients with mild, in 29% with moderate, and in 89% with severe pharyngeal retention (p < 0.05). CONCLUSION: Postdeglutitive overflow aspiration is a frequent finding in patients with pharyngeal retention, and the risk of aspiration increases markedly with the amount of residue. Functional abnormalities other than pharyngeal weakness, such as impaired laryngeal closure, may contribute to aspiration.

Dedicated multidetector CT of the stomach: spectrum of diseases.

Multidetector computed tomography (CT) offers new opportunities in imaging of the gastrointestinal tract. When thin collimation is used, near-isotropic imaging of the stomach is possible, allowing high-quality multiplanar reformation and three-dimensional reconstruction of gastric images. Proper distention of the stomach and optimally timed administration of intravenous contrast material are required to detect and characterize disease. In contrast to gastroscopy and double-contrast studies of the stomach, CT provides information about both the gastric wall and the extragastric extent of disease. Preoperative staging of gastric carcinoma appears to be the main clinical indication for multidetector CT. In addition, multidetector CT allows detection of other gastric malignancies (lymphoma, carcinoid tumors, metastases, gastrointestinal stromal tumors) and benign gastric tumors (neural tumors, polyps). Gastric inflammation (gastritis, ulcers, Ménétrier disease) and miscellaneous gastric conditions (emphysema, gastric outlet obstruction, varices) can also be visualized with multidetector CT. Multidetector CT is a valuable tool for the evaluation of gastric wall disease and serves as an adjunct to endoscopy.

Ultrasound of the appendix in children: is the child too obese?

The negative influence of obesity on the detection rate of the appendix for US in adults has been reported. It has been assumed that obesity is a limiting factor in the detection of the appendix with US in children as well, but this has not yet been proven. The aim of our study was to evaluate whether nutritional condition (defined by the body mass index-for-age percentiles: BMI-FAP) influences the detection of the appendix in children on US. One hundred twenty-six children (65 girls and 61 boys) with a mean age of 11.4 years with clinically suspected acute appendicitis underwent ultrasound on a commercially available high-end machine (HDI 5000, ATL, Bothell, Wash.). The BMI was calculated, and children were divided in three weight groups in accordance with the BMI-FAP, and were correlated with US findings. Evaluation of the three weight groups in accordance with the BMI-FAP demonstrated significant differences ( p=0.04) in the detection of the appendix. There was no statistical significance for the BMI, weight, height, and age solely for the detection of the appendix. In children there is a correlation between the nutritional condition as defined by the BMI-FAP and the detection of the appendix.

Guidelines and algorithms: strategies for standardization of referral criteria in diagnostic radiology.

Guidelines can be regarded as special forms of algorithms and have been shown to be useful tools for supporting medical decision making. With the Council Directive 97/43/Euratom recommendations concerning referral criteria for medical exposure have to be implemented into national law of all EU member states. The time- and cost-consuming efforts of developing, implementing, and updating such guidelines are balanced by the acceptance in clinical practice and eventual better health outcomes. Clearly defined objectives with special attention drawn on national and regional differences among potential users, support from organisations with expertise in evidence-based medicine, separated development of the evidence component and the recommendations component, and large-scale strategies for distribution and implementation are necessary. Editors as well as users of guidelines for referral criteria have to be aware which expectations can be met and which cannot be fulfilled with this instrument; thus, dealing with guidelines requires a new form of "diagnostic reasoning" based on medical ethics.