Imaging swallowing function and the mechanisms driving dysphagia in inclusion body myositis.

Sporadic inclusion body myositis (IBM) is a progressive condition which commonly affects patients aged above 40. IBM does not respond to immunosuppression and no proven treatments are available. Up to 80% of patients develop some degree of swallowing impairment during the disease course. Dysphagia is a source of marked morbidity in IBM and predisposes patients to life-threatening complications such as aspiration pneumonia. The pathophysiology behind dysphagia in IBM is not fully understood. Evidence from imaging demonstrates that impaired swallowing is predominantly underpinned by oropharyngeal deficits. Changes in cricopharyngeal physiology is thought to be an important factor influencing dysphagia in IBM. However, it is unclear whether this is secondary to structural changes within the cricopharyngeus itself or driven by impairment of the muscles promoting pharyngeal clearance. The approach to dysphagia in IBM patients is limited by a lack of validated instruments to reliably assess swallowing function and an absence of effective therapeutic interventions derived from controlled trials targeting dysphagia. Imaging modalities such as the video fluoroscopic swallowing study (VFSS) are commonly used to evaluate dysphagia in IBM. Whilst VFSS is a commonly used technique in clinical practice; cumulative radiation exposure with repeated testing can be a limitation. Alternative imaging techniques could be developed further as outcome measures for assessing swallowing.In this review, we provide an overview of imaging techniques used to assess swallowing and the insight provided from such investigations into the mechanisms behind dysphagia in IBM. We suggest future directions for evaluation and outcome measurement of dysphagia in this population.

Living with Dysphagia: A Survey Exploring the Experiences of Adults Living with Neuromuscular Disease and their Caregivers in the United Kingdom.

Background: Dysphagia is common in adults living with neuromuscular disease (NMD). Increased life expectancy, secondary to improvements in standards of care, requires the recognition and treatment of dysphagia with an increased priority. Evidence to support the establishment of healthcare pathways is, however, lacking. The experiences of people living with NMD (pplwNMD) and their caregivers are valuable to guide targeted, value-based healthcare. Objective: To generate preliminary considerations for neuromuscular dysphagia care and future research in the United Kingdom, based on the experiences of those living with, or caring for, people with NMD. Methods: Two surveys (one for adults living with NMD and dysphagia, and a second for caregivers) were co-designed with an advisory group of people living with NMD. Surveys were electronically distributed to adults living with NMD and their caregivers between 18th May and 26th July 2020. Distribution was through UK disease registries, charity websites, newsletters, and social media. Results: Adults living with NMD receive little information or education that they are likely to develop swallowing difficulties. Most respondents report wanting this information prior to developing these difficulties. Difficulties with swallowing food and medication are common in this group, and instrumental assessment is considered a helpful assessment tool. Both adults living with NMD and caregivers want earlier access to neuromuscular swallowing specialists and training in how best to manage their difficulties. Conclusions: Improvement is needed in the dysphagia healthcare pathway for adults living with NMD to help mitigate any profound physical and psychological consequences that may be caused by dysphagia. Education about swallowing difficulties and early referral to a neuromuscular swallowing specialist are important to pplwNMD and their caregivers. Further research is required to better understand the experiences of pplwNMD and their caregivers to inform the development of dysphagia healthcare pathways.

Successful development and implementation of a clinical practice site with community partners to engage family nurse practitioner students in health equity.

BACKGROUND: Family nurse practitioner (FNP) student clinical practice site availability is limited. Concurrently, many populations lack healthcare access, a common health inequity. Collaboration with community partners to develop clinical practice sites offer students active learning opportunities to increase their engagement and understanding of health equity. PURPOSE: Using community collaboration, develop and implement an FNP student clinical practice site that can provide learning opportunities in addressing health equity. METHODS: Local health data was reviewed, and health gaps were associated with social determinant of health inequities. A community partner was identified with the goal of facilitating students to provide proactive health care to homeless women. Health promotion and disease identification has been the focus of care provided by FNP students and faculty during an early-program clinical course, increasing access to care for an underserved population. CONCLUSION: A community-academic partnership has developed where FNP students provide health promotion and safety net health care to homeless women since 2017. Student reflections have shown a positive impact on their understanding of health equity. The community partner has identified positive impacts to client health. This partnership has impacted health equity by increasing healthcare access for an underserved population while facilitating FNP student learning.

An initial framework for use of ultrasound by speech and language therapists in the UK: Scope of practice, education and governance.

Background: There is growing evidence to support the use of ultrasound as a tool for the assessment and treatment of speech, voice and swallowing disorders across the Speech and Language Therapy profession. Research has shown that development of training competencies, engagement with employers and the professional body are vital to progressing ultrasound into practice. Methods: We present a framework to support translation of ultrasound into Speech and Language Therapy. The framework comprises three elements: (1) scope of practice, (2) education and competency and (3) governance. These elements align to provide a foundation for sustainable and high-quality ultrasound application across the profession. Results: Scope of practice includes the tissues to be imaged, the clinical and sonographic differentials and subsequent clinical decision-making. Defining this provides transformational clarity to Speech and Language Therapists, other imaging professionals and those designing care pathways. Education and competency are explicitly aligned with the scope of practice and include requisite training content and mechanisms for supervision/support from an appropriately trained individual in this area. Governance elements include legal, professional and insurance considerations. Quality assurance recommendations include data protection, storage of images, testing of ultrasound devices as well as continuous professional development and access to a second opinion. Conclusion: The framework provides an adaptable model for supporting expansion of ultrasound across a range of Speech and Language Therapy specialities. By taking an integrated approach, this multifaceted solution provides the foundation for those with speech, voice and swallowing disorders to benefit from advances in imaging-informed healthcare.

Translating Ultrasound into Clinical Practice for the Assessment of Swallowing and Laryngeal Function: A Speech and Language Pathology-Led Consensus Study.

Ultrasound (US) has an emerging evidence base for the assessment of swallowing and laryngeal function. Accessibility and technological advances support the use of US as a clinical assessment tool; however, there is insufficient evidence to support its translation into clinical practice. This study aimed to establish consensus on the priorities for translation of US into clinical practice for the assessment of swallowing and laryngeal function. Nominal Group Technique (NGT) was used as a formal method of consensus development. Clinicians and academics, all members of an international US working group, were invited to participate in the study. Two NGT meetings were held, where participants silently generated and then shared ideas. Participants anonymously ranked items. Rankings were aggregated before participants re-ranked items in order of priority. Discussions regarding rankings were recorded and transcribed to inform analysis. Member-checking with participants informed the final analysis. Participants (n = 15) were speech and language pathologists, physiotherapists and sonographers representing six countries. Fifteen items were identified and prioritised 1-13 (including two equally ranked items). Reliability, validity and normative data emerged as key areas for research while development of training protocols and engagement with stakeholders were considered vital to progressing US into practice. Analysis revealed common themes that might be addressed together in research, in addition to the ranked priority. A measured approach to the translation of US into clinical practice will enable effective implementation of this tool. Priorities may evolve as clinical and professional contexts shift, but this study provides a framework to advance research and clinical practice in this field.

Enhanced rapid review of the applicability of ultrasound in the assessment of sucking, swallowing and laryngeal function in the paediatric population.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has renewed interest in the use of ultrasound (US) amongst dysphagia-trained clinicians working with infants and children. US is a portable, minimally intrusive tool which carries reduced risk of aerosol-generation provoked by other instrumental swallowing assessment tools such as fibreoptic endoscopic evaluation of swallowing (FEES). For this reason, US could be a valuable addition to the dysphagia assessment toolkit. A recently published rapid review of US evidence for the assessment of swallowing and laryngeal function in the adult population provided a framework for this neonatal and paediatric review. AIMS: This enhanced rapid review aimed to establish the applicability of US as an instrumental assessment tool for sucking, swallowing and laryngeal function in the neonatal and paediatric populations. METHODS & PROCEDURES: A rapid review of six electronic databases was conducted to identify articles using US to assess sucking, swallowing or laryngeal function in the selected populations, compared with varied reference tests. Abstract screening was completed according to pre-defined inclusion/exclusion criteria with 10% of articles assessed by a second screener. Data was extracted from the included studies using a pre-developed form. A modified QUADAS-2 tool was used to assess study quality. Results from the included studies were summarised and grouped into sucking, swallowing and laryngeal function data. OUTCOMES & RESULTS: Twelve studies using US in the assessment of swallowing and/or laryngeal function met inclusion criteria. No studies using US for assessment of sucking met the inclusion criteria. All were peer-reviewed, primary studies across a range of clinical populations and with a wide geographical spread. Five studies had an overall low risk of bias. Seven studies had at least one domain where risk of bias was judged as high. All studies had high applicability. The two studies assessing swallowing differed in terms of aims and use of US. The studies assessing laryngeal function predominately investigated vocal fold movement and laryngeal pathology. Sensitivity and specificity data were provided or calculated from raw data for nine of the laryngeal function studies (respective ranges of 75%-100% and 80%-100%). CONCLUSIONS & IMPLICATIONS: Emerging evidence exists to support the use of US as adjunct to clinical assessment of swallowing and laryngeal function in the neonatal and paediatric population. A paucity of evidence to support use of US in the assessment of sucking exists. Further research is needed to establish evidence-based assessment and analysis protocols as well as development of paediatric data.

Ultrasound: an emerging modality for the dysphagia assessment toolkit?

PURPOSE OF REVIEW: Videofluoroscopy (VFSS) and fibreoptic endoscopic evaluation of swallowing (FEES) are established instrumental techniques to support differential diagnosis and treatment of oropharyngeal dysphagia. Whilst their value is undisputed, each tool is not without limitations. The COVID-19 pandemic has restricted access to VFSS and FEES leading clinicians to explore alternative or augmentative tools to support swallowing assessment.Ultrasound (US) is an established tool for visualisation of head and neck anatomy, including structures implicated in swallowing. Although US has been utilised in swallowing research for many years, its application has not translated into common clinical practice. This review presents and debates the evidence for and against use of US for clinical swallowing assessment. RECENT FINDINGS: Evaluation of swallowing muscle morphometry and measurement of isolated swallowing kinematics are two primary uses of US in swallowing assessment that have been identified in the literature. Use of US to detect bolus flow, aspiration and residues is in its early stages and needs further research. SUMMARY: US shows promise as an adjunctive modality to support assessment of swallowing. With standardisation, these measurements may have potential for transition into clinical care. Reliability and validity testing and development of normative data are imperative to ensure its use as an evidence-based instrumentation.

Understanding the most commonly billed diagnoses in primary care: Generalized musculoskeletal pain.

ABSTRACT: Musculoskeletal pain is a common chief complaint in primary care and contributes to disability and a loss of independence. Musculoskeletal pain can be a diagnostic challenge for NPs. A thorough understanding of the pathophysiologic processes involved can help clinicians link the clinical manifestations and treatment for musculoskeletal injury causing pain.

Expiratory muscle strength training improves measures of pressure generation and cough strength in a patient with myotonic dystrophy type 1.

Expiratory muscle strength training (EMST) exercise programmes aim to improve respiratory function by increasing the force generating capability of expiratory muscles by resistance training. In neuromuscular conditions, in which cough flow generation is often decreased, there is increasing interest in EMST as a therapeutic intervention. We present data showing efficacy of EMST in a patient with adult onset Myotonic Dystrophy Type 1 (DM1). A domiciliary training programme (5 days per week over 32 weeks) resulted in increases in maximum expiratory mouth pressure (from 15 cmH2O to 38 cmH2O) and peak cough flow (300 L/min to 390 L/min). Improvements were also seen in maximum inspiratory mouth pressure (26 cmH2O to 52 cmH2O) and sniff nasal inspiratory pressure (40 cmH2O to 69 cmH2O). No changes were detected in speech or swallowing. This novel study demonstrates that cough flow generation in DM1 may be increased by a programme of expiratory muscle training. A clinical trial of EMST in DM1 is warranted.

Understanding the most commonly billed diagnoses in primary care: Type 2 diabetes mellitus.

This next installment in the series on the most commonly billed diagnoses in primary care focuses on type 2 diabetes mellitus (T2DM). This article discusses the pathophysiologic processes of T2DM as well as how the clinical manifestations and treatments are linked to the pathogenesis of the disease.

Experiences of homeless women in accessing health care in community-based settings: a qualitative systematic review.

INTRODUCTION: Homelessness among women is on the rise in the US and continues to be a concern globally. The challenges homeless women face are unique and vast, yet how they experience health care can greatly affect their desire to access health care in the future. The ability to shed light on what is meaningful to homeless women in their health care experiences can guide the changes necessary to provide appropriate patient-centered, impactful care with the goal of increasing access by this vulnerable population. OBJECTIVE: This review aimed to identify, appraise and synthesize existing qualitative evidence on the experiences of homeless women when accessing community-based health care services. INCLUSION CRITERIA: This review included studies on homeless women, both previously or currently, aged 18 or older. The phenomena of interest were homeless women's health care experiences, including perspectives, narratives and/or reflections, at any time during their period of homelessness. The review included health care services received by homeless women in community-based settings, shelter-based clinics and/or mobile clinics. Qualitative data including, but not limited to, the designs of phenomenology, grounded theory, ethnography, qualitative description, action research and feminist research were considered. METHODS: Using a three-step search strategy, databases of published and unpublished articles were searched from database inception to 2018. All included studies were assessed by two independent reviewers for methodological quality, and data was extracted and pooled using the JBI System for the Unified Management, Assessment and Review of Information. Findings were rated according to their level of credibility, categorized based on similarity in meaning, and subjected to a meta-synthesis. Two reviewers utilized a meta-aggregative approach. RESULTS: A total of 196 qualitative articles were identified of which 24 were included after critical appraisal. Meta-synthesis generated three synthesized findings: (1) Homeless women who access health care services at community-based settings feel as if their homelessness qualifies them as second-class citizens, which impedes future access; (2) Homeless women have an expectation of therapeutic communication from their health care providers, the lack of which can incite negative emotional responses, fear and knowledge deficits; (3) Homeless women with limited resources struggle to prioritize competing needs, such as transportation, time and money, which influences their ability to access health care. These synthesized findings were derived from 47 study findings that were subsequently aggregated into 10 categories. Of the 47 study findings, 32 were rated as unequivocal and 15 were rated as credible. The overall ConQual for each of the three synthesized findings was low due to common dependability issues across the included studies. A total of 454 participants were included. The included studies were published from 1997 to 2017. CONCLUSION: The review identified that homeless women's experiences when accessing health care in community-based settings, particularly in the US, have been poor and have negatively affected their desire to access health care in the future. The synthesized findings illustrate clear indicators for use of cultural competence and addressing provider bias in the delivery of health care to homeless women. This review also highlights the importance of understanding clinical experiences of providing direct care for these women in order to shed light on the type of advocacy needed to ensure equitable access to health care services. While this review uncovered issues with some global health care systems, the predominance of system constraints within the US highlights the need for health policy reform to improve the experiences of homeless women when accessing health care.

Considerations for chest clearance and cough augmentation in severe bulbar dysfunction: a case study.

This case study describes a 21-year-old male with congenital myotonic dystrophy referred to respiratory physiotherapy with a weak cough and upper respiratory tract secretions. Mechanical insufflation-exsufflation (MI-E) was prescribed. Post initiation, the patient described a worsening of secretions and increased attendances to hospital with suspected chest infection. He also described difficulties with speaking after use of MI-E. Multidisciplinary assessment of cough as well as bulbar and swallow function resulted in a primary diagnosis of oro-pharyngeal dysphagia as well as weak cough. An alternative prophylactic therapy programme including active cycle of breathing, chest wall percussions, and manually assisted cough, was prescribed to facilitate clearance of upper airway secretions and patient comfort. The case highlights some of the risks associated with cough augmentation techniques derived from single-discipline intervention in the neuromuscular patient population. Comprehensive multidisciplinary assessment and management were key to redefining this patient's diagnosis, allowing effective and individualised treatment.

Cyclin D1 in ASM Cells from Asthmatics Is Insensitive to Corticosteroid Inhibition.

Hyperplasia of airway smooth muscle (ASM) is a feature of the remodelled airway in asthmatics. We examined the antiproliferative effectiveness of the corticosteroid dexamethasone on expression of the key regulator of G(1) cell cycle progression-cyclin D1-in ASM cells from nonasthmatics and asthmatics stimulated with the mitogen platelet-derived growth factor BB. While cyclin D1 mRNA and protein expression were repressed in cells from nonasthmatics in contrast, cyclin D1 expression in asthmatics was resistant to inhibition by dexamethasone. This was independent of a repressive effect on glucocorticoid receptor translocation. Our results corroborate evidence demonstrating that corticosteroids inhibit mitogen-induced proliferation only in ASM cells from subjects without asthma and suggest that there are corticosteroid-insensitive proliferative pathways in asthmatics.

Corticosteroids reduce IL-6 in ASM cells via up-regulation of MKP-1.

The mechanisms by which corticosteroids reduce airway inflammation are not completely understood. Traditionally, corticosteroids were thought to inhibit cytokines exclusively at the transcriptional level. Our recent evidence, obtained in airway smooth muscle (ASM), no longer supports this view. We have found that corticosteroids do not act at the transcriptional level to reduce TNF-alpha-induced IL-6 gene expression. Rather, corticosteroids inhibit TNF-alpha-induced IL-6 secretion by reducing the stability of the IL-6 mRNA transcript. TNF-alpha-induced IL-6 mRNA decays at a significantly faster rate in ASM cells pretreated with the corticosteroid dexamethasone (t(1/2) = 2.4 h), compared to vehicle (t(1/2) = 9.0 h; P < 0.05) (results are expressed as decay constants [k] [mean +/- SEM] and half-life [h]). Interestingly, the underlying mechanism of inhibition by corticosteroids is via the up-regulation of an endogenous mitogen-activated protein kinase (MAPK) inhibitor, MAPK phosphatase-1 (MKP-1). Corticosteroids rapidly up-regulate MKP-1 in a time-dependent manner (44.6 +/- 10.5-fold increase after 24 h treatment with dexamethasone; P < 0.05), and MKP-1 up-regulation was temporally related to the inhibition of TNF-alpha-induced p38 MAPK phosphorylation. Moreover, TNF-alpha acts via a p38 MAPK-dependent pathway to stabilize the IL-6 mRNA transcript (TNF-alpha, t(1/2) = 9.6 h; SB203580 + TNF-alpha, t(1/2) = 1.5 h), exogenous expression of MKP-1 significantly inhibits TNF-alpha-induced IL-6 secretion and MKP-1 siRNA reverses the inhibition of TNF-alpha-induced IL-6 secretion by dexamethasone. Taken together, these results suggest that corticosteroid-induced MKP-1 contributes to the repression of IL-6 secretion in ASM cells.