Variability in Swallowing Biomechanics in Infants with Feeding Difficulties: A Videofluoroscopic Analysis.

Clinicians performing feeding evaluations in infants often report swallow variability or inconsistency as concerning. However, little is known about whether this represents pathological incoordination or normal physiologic variance in a developing child. Our retrospective study explored quantitative videofluoroscopic measures in 50 bottle-fed infants (0-9 months) referred with feeding concerns. Our research questions were as follows: Is it possible to assess swallow to swallow variability in an infant with feeding concerns, is there variability in pharyngeal timing and displacement in infants referred for videofluoroscopy, and is variability associated with aspiration risk? Measures were taken from a mid-feed, 20-s loop recorded at 30 frames per second. Each swallow within the 20-s loop (n = 349 swallows) was analysed using quantitative digital measures of timing, displacement and coordination (Swallowtail™). Two blinded raters measured all swallows with strong inter-rater reliability (ICC .78). Swallow frequency, suck-swallow ratio, residue and aspiration were also rated. Variability in timing and displacement was identified across all infants but did not correlate with aspiration (p > .05). Sixteen infants (32%) aspirated. Across the cohort, swallow frequency varied from 1 to 15 within the 20-s loops; suck-swallow ratios varied from 1:1 to 6:1. Within-infant variability in suck-swallow ratios was associated with higher penetration-aspiration scores (p < .001). In conclusion, pharyngeal timing and displacement variability is present in infants referred with feeding difficulties but does not correlate with aspiration. Suck-swallow ratio variability, however, is an important risk factor for aspiration that can be observed at bedside without radiation. These objective measures provide insight into infant swallowing biomechanics and deserve further exploration for their clinical applicability.

Treating Agricultural Runoff with a Mobile Carbon Filtration Unit.

Several classes of pesticides have been shown to impair water quality in California, including organophosphates, pyrethroids and neonicotinoids. Vegetative treatment systems (VTS) can reduce pesticide loads and associated toxicity in agricultural runoff, but many water-soluble pesticides such as neonicotinoids are not effectively treated by VTS, and VTS installation is not always an option for growers required to remove non-crop vegetation for food safety concerns. Recent studies have shown that biochar filtration can be used to remove soluble contaminants, especially when coupled with other VTS components. We evaluated a mobile carbon filter system consisting of a trailer-mounted tank containing approximately 600L (~ 180 kg) of biochar. Input water from a 437-hectare agricultural drainage was pre-filtered and treated with biochar during two multi-week study periods. Laboratory toxicity tests and chemical and nutrient analyses were conducted on input and output water. Pesticide concentrations were initially reduced by greater than 99%. Treatment efficacy declined linearly and was expected to remain at least 50% effective for up to 34 weeks. Toxicity was assessed with Ceriodaphnia dubia, Hyalella azteca and Chironomus dilutus. Significant input toxicity was reduced to non-toxic levels in 6 of 16 samples. Some input concentrations of the neonicotinoid imidacloprid and the pyrethroid cypermethrin exceeded organism-specific toxicity thresholds and benchmarks, but the overall causes of toxicity were complex mixtures of agricultural chemicals. Nutrients were not reduced by the biochar. Results demonstrate the utility of biochar in treating agricultural runoff and provide measures of the longevity of biochar under field conditions.

The Test of Masticating and Swallowing Solids (TOMASS): reliability, validity and international normative data.

BACKGROUND: Clinical swallowing assessment is largely limited to qualitative assessment of behavioural observations. There are limited quantitative data that can be compared with a healthy population for identification of impairment. The Test of Masticating and Swallowing Solids (TOMASS) was developed as a quantitative assessment of solid bolus ingestion. AIMS: This research programme investigated test development indices and established normative data for the TOMASS to support translation to clinical dysphagia assessment. METHODS & PROCEDURES: A total of 228 healthy adults (ages 20-80+ years) stratified by age and sex participated in one or more of four consecutive studies evaluating test-retest and interrater reliability and validity to instrumental assessment. For each study the test required participants to ingest a commercially available cracker with instructions to 'eat this as quickly as is comfortably possible'. Further averaged measures were derived including the number of masticatory cycles and swallows per bite, and time per bite, masticatory cycle and swallow. Initial analyses identified significant differences on salient measures between two commercially available crackers that are nearly identical in shape, size and ingredients, suggesting the need for separate normative samples for specific regional products. Additional analyses on a single cracker identified that the TOMASS was sensitive at detecting changes in performance based on age and sex. Test-retest reliability across days and interrater reliability between clinicians was high, as was validation of observational measures to instrumental correlates of the same behaviours. Therefore, normative data are provided for the TOMASS from a minimum of 80 healthy controls, stratified by age and sex, for each of seven commercially available crackers from broad regions worldwide. OUTCOMES & RESULTS: Analyses on a single cracker identified Arnott's Salada, and that TOMASS measures were sensitive for detecting changes in performance based on age and sex. Interrater and test-retest reliability across days were high, as was validation of observational measures to instrumental correlates of the same behaviours. Significant differences were identified between two commercially available crackers, nearly identical in shape, size and ingredients, thus normative samples for specific regional products were required. Normative data were then acquired for the TOMASS from a minimum of 80 healthy controls, stratified by age and sex, for each of seven commercially available crackers from broad regions worldwide. CONCLUSIONS & IMPLICATIONS: The TOMASS is presented as a valid, reliable and broadly normed clinical assessment of solid bolus ingestion. Clinical application may help identify dysphagic patients at bedside and provide a non-invasive, but sensitive, measure of functional change in swallowing.

Methylene blue, midodrine, and pseudoephedrine: a review of alternative agents for refractory hypotension in the intensive care unit.

Hypotensive episodes are common among patients in the intensive care unit and can lead to multiorgan failure if uncontrolled. Fluid administration and continuous infusion of vasoactive agents are frequently used for management of hypotension; however, both therapies may be associated with adverse effects including pulmonary edema and tissue necrosis. In addition, availability of these first-line agents has been impacted by the increasing occurrence of drug shortages. Methylene blue, pseudoephedrine, and midodrine have been considered potential alternatives to standard therapy. These agents may not only be used when first-line agents are unavailable due to shortages, but they may also aid in reducing the cumulative dose of other vasoactive agents used. The purpose of this review was to discuss strategies for the safe and effective use of methylene blue, pseudoephedrine, and midodrine for the treatment of hypotension in the critically ill.

A Sierra Leone 2021 Midwifery Clinical Training Needs Assessment: A Call to Action to Augment Clinical Precepting.

Objective: Sierra Leone has one of the highest maternal mortality and infant mortality rates globally. We share findings from a Midwifery Clinical Training Needs Assessment, conducted in 2021 as a collaboration between the Government of Sierra Leone and Seed Global Health. The assessment identified existing needs and gaps in midwifery clinical training at health facilities in Sierra Leone from various stakeholders' perspectives. Methods: The descriptive needs assessment utilized mixed methods, including surveys, focus group discussions (FGDs), interviews, and reviews of maternal medical records. Results: The following showed needs and gaps in labor and delivery management; record keeping; triage processes; clinical education for students, recent graduates, and preceptors; and lack of infrastructure and resources. Conclusion: The knowledge gained from this needs assessment can further the development of midwifery clinical training programs in Sierra Leone and other low-income countries facing similar challenges. We discuss the implication of our findings.

Developing a Protocol for Quantitative Analysis of Liquid Swallowing in Children.

PURPOSE: Objective measures in videofluoroscopic swallow studies (VFSSs) can quantify swallow biomechanics. There are a wide array of validated measures studied in infants, children, and adults. There is a need for a pediatric VFSS protocol that consists of a small number of vital, time efficient, and clinically relevant measures. In this study, we aimed to establish a standard protocol for quantitative VFSS analysis in children. METHOD: Protocol development began with a systematic literature review, which identified 22 quantitative and eight descriptive measures available in the literature. A pediatric VFSS database of 553 children was collected using a standardized VFSS protocol. Studies were evaluated using the 30 previously reported measures covering displacement and timing parameters as well as penetration-aspiration and residue. Measures were tested for rater reliability and internal consistency. Measures meeting acceptable values for protocol inclusion were included in the final protocol (Cronbach's alpha > .53). RESULTS: Interrater and intrarater reliability of 17 measures met acceptable reliability levels. During internal consistency testing, we removed six further measures based on Cronbach's alpha levels indicating that two or more measures were equivalent in measuring the same aspect of swallow biomechanics in children. A VFSS protocol of reliable, valid, and obtainable objective quantitative (n = 6) and descriptive measures (n = 3) with separate protocols for young infants (≤ 9 months) and older children was established. CONCLUSIONS: A standardized quantitative VFSS protocol for children has been developed to suit two age groups (≤ 9 and > 9 months old). Consistent VFSS administration and reporting support assessment over time and across disease groups. Future research should focus on how this information can be used by clinicians to produce individualized treatment plans for children with swallowing impairment.

Quantitative video-fluoroscopic analysis of swallowing in infants.

OBJECTIVES: To utilize objective, quantitative videofluoroscopic swallow measures to profile swallowing in infants and to determine the likelihood of objective swallow measures to predict risk of swallow impairments such as airway violation, reflux and post swallow residue. STUDY DESIGN: Our single center retrospective observational study used a cohort of 146 bottle-fed infants (0-9 months) referred for VFSS with any kind of feeding related concern. Frame-by-frame analysis of 20-s video loops of mid-feed sucking was completed to obtain quantitative timing, displacement and coordination measures as well as presence of other findings including aspiration, residue and naso-pharyngeal reflux (NPR) and esophago-pharyngeal reflux (EPR). Spearman correlation, Mann-Whitney U test and binomial logistic regression were conducted to determine statistical associations between swallow measures and binary reporting of swallow impairments. RESULTS: Videofluoroscopic data of 146 infants were reviewed and analyzed. 49% of infants demonstrated at least one penetration or aspiration event. Total pharyngeal transit time (TPT) and suck-swallow ratio were associated with aspiration (p < .05). Infants with >3 sucks per swallow had significantly longer TPT and their risk of aspiration was greater than those with <3 sucks per swallow (RR 1.23, 95% CI 0.43-8.507, p = .03). Pharyngeal constriction ratio (PCR) and bolus clearance ratio (BCR) were associated with residue, NPR and EPR (p < .05). CONCLUSION: Objective measures provide clinicians with reliable timing and displacement data even in the very young. These measures correlate with swallowing safety and may help to identify enhanced risk in some infants, which may influence management recommendations.

Age-related alterations in GABA(A) receptor subunits in the nonhuman primate hippocampus.

Pharmacological studies have documented that altered drug responses, particularly to benzodiazepines, are common in elderly populations. While numerous factors may contribute to changes in drug response, age-related alterations in the molecular composition of GABA(A) receptors may be a key factor in regulating these responses. We employed quantitative densitometry to examine the cytological features and density of highly prevalent hippocampal GABA(A) receptor subunits (alpha1 and beta2/3) in young and aged rhesus monkeys. alpha1 and beta2/3 subunit immunostaining was differentially distributed throughout the hippocampus. In addition, beta2/3 immunolabeling in aged monkeys was characterized by marked intersubject variability in labeling intensity, with dramatic reductions present in 3 of 5 samples. alpha1 immunolabeling in aged monkeys was significantly reduced in the CA2 and CA3 subregions, and in hilus/polymorphic layer of the dentate gyrus. Collectively, our findings demonstrate that not only are GABA(A) receptor subunits differentially distributed throughout the hippocampus, but they are also differentially altered with increased age--changes that may have an important impact on the binding properties of GABA(A) receptor pharmacological agents.

Beyond gait speed: a case report of a multidimensional approach to locomotor rehabilitation outcomes in incomplete spinal cord injury.

BACKGROUND: The efficacy of locomotor rehabilitation studies has largely been based on clinical measures of gait speed and walking performance. Although critical, gait speed does not fully capture the multidimensional benefits associated with walking recovery. The International Classification of Function, Disability and Health (ICF) model of rehabilitation emphasizes the role of personal and environmental factors in affecting quality of life and personal health status and advocates a broad approach in the assessment and treatment of people with disabling conditions. OBJECTIVE: The purpose of this case report is to describe a multidimensional approach to outcome measurement reflecting the ICF model. SUBJECT: The participant was a 59-year-old man with C7 American Spinal Injury Association impairment D tetraplegia, 16 months after injury. INTERVENTION: The participant completed a 45-session, five days per week locomotor training program. Comprehensive evaluations were completed pre- and post-training targeting all elements of the ICF model. OUTCOMES: The participant achieved negligible increases in gait speed, but increased self-elected walking activity from 26 steps per day to 1273 steps per day. His assistive device changed from a platform to a rolling walker, representing a Walking Index for Spinal Cord Injury (WISCI) increase from 8/20 to 13/20. Qualitative interviews illustrated an attitudinal shift, leading to improved motivation, confidence, self-esteem, problem-solving, and increased activities/participation in the community. Ultimately, the participant was able to transition from nursing home placement to living independently. CONCLUSIONS: This case report emphasizes the need to move beyond traditional models for evaluation at the impairment and clinical level to examine the effects of interventions on independence, community integration, and quality of life.