A Holistic Approach to Managing Secondary Dysphagia Following Prolonged Intubation and Tracheostomy: A Case Report.

The ability to swallow and maintain the airway is a critical rehabilitation milestone for patients with swallowing disorders following prolonged tracheal intubation. Tracheostomy and dysphagia often coexist in critically ill patients and given the medical complexity analyzing the evidence to optimize swallowing assessment and management is challenging. It takes a holistic approach to dealing with issues in a critical care patient as we also need to deal with issues other than medical. We present a case of a 68-year-old gentleman who was admitted to the critical care unit following a double barrel ileostomy and had multiple complications and organ dysfunction requiring prolonged supportive management, tracheostomy, and mechanical ventilation. After recovering from primary illness and complications, he had a swallowing disorder (secondary dysphagia), which was managed successfully over the next month. The case highlights the need for screening, a multidisciplinary team, empathy, and effort as a part of a holistic management approach.

Hypoxic pulmonary vascular response can screen subclinical lifestyle disease in healthy population.

OBJECTIVE: Subclinical life style disease can cause endothelial dysfunction associated with perfusion abnormalities and reduced vascular compliance. Subclinical elevated beta type natriuretic peptide (BNP) has been associated with altered fluid shift from extra to intracellular space during acute hypoxia. Therefore we measured vascular response and BNP levels during acute hypoxia to study endothelial functions among healthy individuals. METHODS: Individuals were exposed to acute normobaric hypoxia of FiO2 = 0.15 for one hour in supine position and their pulmonary and systemic vascular response to hypoxia was compared. Individuals were divided into two groups based on either no response (Group 1) or rise in systolic pulmonary artery pressure to hypoxia (Group 2) and their BNP levels were compared. RESULTS: BNP was raised after hypoxia exposure in group 2 only from 18.52 ± 7 to 21.56 ± 10.82 picogram/ml, p < 0.05. Group 2 also showed an increase in mean arterial pressure and no fall in total body water in response to acute hypoxia indicating decreased endothelial function compared to Group 1. CONCLUSION: Rise in pulmonary artery pressure and BNP level in response to acute normobaric hypoxia indicates reduced endothelial function and can be used to screen subclinical lifestyle disease among healthy population.

Unilateral Sensorineural Hearing Loss (USNHL): A Retrospective Study of Incidence.

This retrospective study was carried out to know the incidence of unilateral sensorineural hearing loss (USNHL) (type and degree). (1) To know the incidence of USNHL (other ear being normal) in patients undergoing Pure Tone Audiometry (PTA) for hearing loss (HL). (2) To establish the type and degree of USNHL in patients. Study was conducted over a period of more than 4 years to find out the incidence and pattern of USNHL (other ear being normal) in the patients attending ear, nose, and throat outpatient department (OPD) with a complaint of HL. Pure tone audiometry data of 10,000 cases between August 2014 and December 2018 with HL were analyzed for this study. Demographic characteristics were compared with types and degrees of unilateral sensorineural hearing impairment. A total of 10,000 OPD cases who had a complaint of HL and had undergone pure tone audigram (PTA) in a period of more than 4 years in the Department of Otorhinolaryngology and Head and Neck Surgery were studied. SNHL type was the highest with 3935 cases (39.3%). Out of 3935 cases of SNHL, 1436 (36.50%) were USNHL-out of which, only 872 cases (60.72%) had USNHL with other ear being normal; this constituted the study group, i.e., 872 cases (8.72%) out of 10,000 PTA and 872/3935 (22.16%) of SNHL cases. Hence, incidence of USNHL (with other ear being normal) is 8.72% among all cases of HL and 22.16% among cases of SNHL. Age of cases ranged from 8 to 76 years (mean age - 39.5 years). Male:Female ratio was 1.6:1.0. Both ears were almost equally involved. 35.6% cases had profound (> 90 dB) hearing loss, followed by mild (25-40 dB) in 32.1%.

The Relationship of Respiratory Rate-Oxygenation (ROX) and Modified ROX Index With High-Flow Nasal Cannula Oxygen Therapy in COVID-19 Patients: An Observational Pilot Study.

Background and aim Respiratory Rate-Oxygenation (ROX) and modified ROX (mROX) indexes have been proposed to detect early high-flow nasal cannula (HFNC) therapy failure. We evaluated the utility and relationship of ROX and mROX indexes in COVID-19 patients started on HFNC oxygen therapy. Methods This pilot study collected data from adult COVID-19 patients requiring HFNC oxygenation from 29 Jan - 29 Jun 2021. The patients were divided into two cohorts based on HFNC therapy success. ROX and mROX were compared using statistical diagnostic testing, including receiver operating characteristics and area under the curve (AUC) using online Epitools (https://epitools.ausvet.com.au/) and MedCalc software (MedCalc Software Ltd, Ostend, Belgium, https://www.medcalc.org/); p<0.05 was considered significant. Results Twenty-seven patients fulfilled the inclusion criteria; 48.15% of therapy failed. The cohort's mean ± standard deviation age was 53.93 ± 10.67 years; 74.1% were male. The accuracy of predicting failure for mean ROX versus mROX at baseline and six-hour values was 59.81 versus 70.68 and 67.42 versus 74.88, respectively (all p>0.05). The AUC for ROX and mROX at baseline and at six hours were statistically indifferent. Only an mROX of 4.05 (mean value) and 3.34 (Youden's J cut-off) had a sensitivity plus specificity at 156% and 163%, respectively. Conclusion Both ROX and mROX at baseline and six hours had fair-to-good accuracies and AUC; the differences were insignificant. Both ROX and mROX had better accuracies at six hours. However, only mROX < 4.05 at six hours fulfilled the sensitivity plus specificity criteria to be a clinically valuable screener.

Heat-induced endoplasmic reticulum stress in soleus and gastrocnemius muscles and differential response to UPR pathway in rats.

The present study aimed to investigate the differential response of oxidative (soleus) and glycolytic (gastrocnemius) muscles to heat-induced endoplasmic reticulum (ER) stress. It was hypothesized that due to compositional and functional differences, both muscles respond differently to acute heat stress. To address this, male Sprague Dawley rats (12/group) were subjected to thermoneutral (25 °C) or heat stress (42 °C) conditions for 1 h. Soleus and gastrocnemius muscles were removed for analysis post-exposure. A significant increase in body temperature and free radical generation was observed in both the muscles following heat exposure. This further caused a significant increase in protein carbonyl content, AOPP, and lipid peroxidation in heat-stressed muscles. These changes were more pronounced in heat-stressed soleus compared to the gastrocnemius muscle. Accumulation of unfolded, denatured proteins results in ER stress, causing activation of unfolded protein response (UPR) pathway. The expressions of UPR transducers were significantly higher in soleus as compared to the gastrocnemius muscle. A significant elevation in resting intracellular calcium ion was also observed in heat-stressed soleus muscle. Overloading of cells with misfolded proteins in soleus muscle activated ER-induced apoptosis as indicated by significant upregulation of C/EBP homologous protein and Caspase12. The study provides a detailed mechanistic representation of the differential response of muscles toward UPR under heat stress. Data suggests that soleus majorly being an oxidative muscle is more prone to heat stress-induced insult indicated by enhanced apoptosis. This study may aid in devising mitigation strategies to improve muscle performance under heat stress.

Subclinical elevated B-type Natriuretic Peptide (BNP) indicates endothelial dysfunction contributing to hypoxia susceptibility in healthy individuals.

AIMS: Baseline elevated B-type Natriuretic Peptide (BNP) has been found in high altitude pulmonary edema susceptible population. Exaggerated pulmonary vascular response to hypoxia may be related to endothelial dysfunction in hypoxia susceptible. We hypothesize that baseline BNP levels can predict hypoxia susceptibility in healthy individuals. MAIN METHODS: The pulmonary vascular response to hypoxia was compared in 35 male healthy individuals divided into two groups based on BNP levels (Group 1 ≤ 15 and Group 2 > 15 pg/ml). Acute normobaric hypoxia was administered to both the groups, to confirm hypoxia susceptibility in Group 2. KEY FINDINGS: Unlike Group 1, Group 2 had elevated post hypoxia BNP levels (26 vs 33.5 pg/ml, p = 0.002) while pulmonary artery pressure was comparable. A negative correlation with tissue oxygen consumption (delta pO2) and compartmental fluid shift was seen in Group 1 only. Endothelial dysfunction in Group 2 resulted in reduced vascular compliance leading to elevation of mean blood pressure on acute hypoxia exposure. BNP showed a positive correlation with endothelial dysfunction in Group 2 and has been linked to pre-diabetic disorder (HbA1c 6 ± 0.44%) and may additionally represent a lower cross-sectional area of vascular bed related to vascular remodeling mediated by chronic hypoxia. SIGNIFICANCE: Hypoxia susceptibility in healthy individuals may be related to endothelial dysfunction that limits vascular compliance during hypoxic stress. BNP level showed positive correlation with HbA1c (r = 0.49, p = 0.04) and negative correlation with delta pO2 (r = -0.52, p = 0.04) can predict reduced microvascular compliance due to endothelial dysfunction contributing to hypoxia susceptibility in healthy individuals. BNP levels≤15 pg/ml at sea level is indicative of hypoxia resistance.

Raised HIF1α during normoxia in high altitude pulmonary edema susceptible non-mountaineers.

High altitude pulmonary edema (HAPE) susceptibility is associated with EGLN1 polymorphisms, we hypothesized that HAPE-susceptible (HAPE-S, had HAPE episode in past) subjects may exhibit abnormal HIF1α levels in normoxic conditions. We measured HIF1α levels in HAPE-S and HAPE resistant (HAPE-R, no HAPE episode) individuals with similar pulmonary functions. Hemodynamic responses were also measured before and after normobaric hypoxia (Fi02 = 0.12 for 30 min duration at sea level) in both groups. . HIF1α was higher in HAPE-S (320.3 ± 267.5 vs 58.75 ± 33.88 pg/ml, P < 0.05) than HAPE-R, at baseline, despite no significant difference in baseline oxygen saturations (97.7 ± 1.7% and 98.8 ± 0.7). As expected, HAPE-S showed an exaggerated increase in pulmonary artery pressure (27.9 ± 6 vs 19.3 ± 3.7 mm Hg, P < 0.05) and a fall in peripheral oxygen saturation (66.9 ± 11.7 vs 78.7 ± 3.8%, P < 0.05), when exposed to hypoxia. HIF1α levels at baseline could accurately classify members of the two groups (AUC = 0.87). In a subset of the groups where hemoglobin fractions were additionally measured to understand the cause of elevated hypoxic response at baseline, two of four HAPE-S subjects showed reduced HbA. In conclusion, HIF 1 α levels during normoxia may represent an important marker for determination of HAPE susceptibility.

Arterial baroreflex modulation influences postural sway.

OBJECTIVE: Although considered mainly a random function, postural sway is influenced by physiological factors such as respiration. A direct effect of the autonomic nervous system (ANS) on posture has never been demonstrated. To test this hypothesis, we used a pure motion-independent autonomic stimulus (neck suction) to modulate the carotid baroreceptors on a broad frequency range, distinct from that of respiration. METHODS: Thirteen healthy subjects (age 26 ± 5 years) were studied upright, eyes closed, and on a force platform during controlled breathing (15 breath/min, 0.25 Hz), with and without stimulation of arterial baroreceptors by sinusoidal neck suction (0 to -30 mmHg pressure) at different frequencies (0.05, 0.10, 0.125, 0.15, 0.175, 0.20, 0.30 Hz), for eight periods lasting 2 min each. The increase in sway, R-R interval and blood pressure induced at each stimulation frequency was measured by spectral analysis. RESULTS: With neck suction, we observed a significant (p < 0.05) increase in oscillations synchronous in the R-R interval (from 0.10 to 0.20 Hz), systolic and diastolic blood pressure (from 0.05 to 0.15 Hz) and sway (from 0.10 to 0.30 Hz in both the antero-posterior and medio-lateral planes). Changes were greater in the left than in the right foot. CONCLUSION: Our study shows that postural sway is modulated by the ANS and is influenced by phasic stimulation of the arterial (carotid) baroreceptors. Our findings have potentially important clinical implications in the development of treatment strategies for pathological conditions in which alterations in posture and autonomic function coexist and could be mutually influenced.