Dysphagia is the Greek word for 'bad eating,' and is used in English for problems with swallowing. Specifically, taking food or liquid into the lungs instead of the stomach. A lot of people that have had strokes, tumors, traumatic brain injuries, cancers, or long term debilitating diseases are at risk for dysphagia.
Aspiration is the word used to describe food or liquid below the level of the vocal chords. So if you aspirate food or liquid, you have dysphagia. Identifying dysphagia is a role of the Speech Language Pathologist (SLP). It isn't always easy, because it's important to get the diagnosis right. Patients that have dysphagia may have to change what they eat and drink, including thickening water, soda, juice, coffee, etc, as well as blending solid foods to make them softer. Obviously nobody likes to have green beans that were put in the blender and then the resulting puree put in a mold so that they'll still look like green beans...
Recent research by Debra M. Suiter and Steven B. Leder has indicated that a 3 ounce water swallow test can help rule out dysphagia. The patient drinks 3 ounces of water. If they can drink it all at once with no choking, coughing, or a wet sounding voice, then it is fairly certain that the person doesn't have dysphagia. Specifically, thousands of patients were given the Fiberoptic Endoscopic Evaluation of the Swallow (FEES), where a tube with a camera goes through the nose and into the throat, from where a clinician can see anything going into the airway before or after the swallow. They were marked either pass or fail according to their ability to swallow 6 boluses (bites) of stuff. Three 5 ml boluses of thin liquid (water), and three 5 ml boluses of puree (applesauce consistency stuff) Then, regardless of passing or failing the FEES, the patients were the 3 ounce swallow test, and it was noted again who passed and failed.
Of those that did not aspirate on the 3 ounce swallow test, 96% were shown to not aspirate on the FEES. This is really good, because it supposedly means that if you can drink down 3 ounces of water and not show signs of aspiration, you're good to eat and drink and it won't go to your lungs. Of those that did not pass the 3 ounce water test, around half passed the FEES, which means that if you fail the 3 ounce test (can't finish, choke, cough, have wet voice afterwards) then the 3 ounce water test doesn't indicate if you really have dysphagia, or if you're alright.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has just become The Joint Commission (TJC) Wow. I just learned that. www.jointcommission.org Anyway JCAHO as I will continue to call them, has recently followed the advice of Steven B. Leder and Debra M. Suiter and required that nurses be trained to give and interpret the 3 ounce water swallow test as a dysphagia screening for all stroke patients. If the patient passes, then they get the regular diet with all liquids, and if they fail, they get referred to the speech therapists (synonymous with speech language pathologist) This may mean that some patients get to resume a normal diet much sooner, because nurses are around 24/7, where SLPs work the more traditional 9-5 ish schedule.
There are some negatives to this however, that may not have been considered. 1) Some nurses may not know/remember how to administer and interpret results. Nurses have a lot to do without adding this to their load. 2) There is a tendency by nurses and doctors to use this screening on non-stroke patients. In most cases this will be ok. In some cases, it is definitely not ok. SLPs are trained to know the difference. Doctors and nurses are not. 3) The difference between a screening and an evaluation is easily lost. Passing the screening should be able to allow a general diet and all liquids. But this is not the case. Many patients have cognitive and other health issues that would prohibit regular food even if they can swallow it alright. For example, if a patient take a sip of soda and then tunes out of the world without swallowing, it may well end up in his lungs. This is a major problem, not a minor one. 4) There is such a thing as silent aspiration. A large number of studies suggest that around half of patients will aspirate without coughing, throat clearing, wet voice, etc. These patients don't exist in Leder's study. His hypothesis is that the large bolus size makes silent aspiration impossible. A study by Cathy Lazarus refutes this. She had (has?) people drink 3 ounces of thin liquid (barium) and takes side view X-rays of it going down (this is called an MBS or VFSS) and, as of March 2009, had found that 7 of 10 aspirators did so silently. 5) The 3 ounce water test only shows if water is aspirated. Many people with a weak swallow and reduced sensation have food residue in their mouths and throats, and this often falls into the airway later, resulting in aspiration. These guys may be fine swallowing water, but thick solids cause aspiration. This is another group that has dissappeared in this study. Where are they? 6) 3 ounces is a lot of liquid. Many SLPs never use the 3-ounce water test. In an extremely dysphagic patient, 3 ounces of water in the lungs is enough to cause immediate and severe repercussions to the health of a patient.
Much of my source material for this blog came from the following link which is an ASHA article from May 2009 by Nancy B Swigert entitled "Hot Topics in Dysphagia." http://www.asha.org/Publications/leader/2009/090526/f090526a.htm
Additionally, the Leder article about the results of the 3 ounce swallow test, titled "Clinical Utility of the 3-ounce Water Swallow Test," published in Dysphagia (2008) has some significant issues. 1) the research has not been duplicated by other researchers. In science, everything needs to be looked at by many eyes, and a lot of findings are found to be false with time in this way. 2) the study was not randomized. Everyone had it done, so factors of time, place, and referrals become relevant. 3) the study was not blinded: Leder did both the FEES and the 3 ounce water test and knew the results of one before administering the other. 4) the order in which they were administered never varied. Having the FEES first may have tired borderline and severely dysphagic patients, such that only the healthiest (and non-dysphagic) swallowers passed the 3 ounce water swallow test. Note that in real life, weakened patients won't be as tired when they get it, increasing the chance that they'll pass it but still aspirate at a full meal. 5) The article itself claims that the 3 ounce water swallow test will be wrong in saying a patient has a safe swallow 5 percent of the time. What about those 5% of people? 6) The study was done by an internationally renowned swallowing expert. Shouldn't the 3 ounce water screenings be done in a study by nurses to see if the results are similar before requiring hospitals across the country to have their nurses implement it? How often will busy nurses giving the screening be wrong?
At the end of the day, the 3-ounce water test solves some problems, but causes others. I think the Leder study needs replication with improved methods.
Monday, March 28, 2011
Sunday, March 27, 2011
Thoughts on Libya
I was watching the news along with many others about the events in Libya over the past months. For those that weren't, here is a brief refresher: An angry street vendor in Tunisia lights himself on fire. Most Tunisians feel the same way, demonstrate and protest, and the dictatorship style government is overthrown. The same thing happens in Egypt. Tunisia is West of Libya and Egypt is East of Libya. Libyans begin to demonstrate and protest to overthrow the government. As far as we can tell, they, along with Egyptians and Tunisians, want a greater say in the government. As of now, huge protests are also going on in Yemen and Bahrain, which may also overthrow their non-democratic governments. Many neigboring countries in the middle east have also had protests, some of which may result in more overthrown governments. Here's a map: 
Map from ocw.nd.edu
... ...
In Libya, unlike Tunisia and Egypt, the dictator was ok with killing any and all protesters. The protests and demonstrations went from angry and peaceful to angry and violent as protesting individuals were jailed, killed, etc. An apparent majority of the people, including a sizable chunk of the military, sided against Qaddafi, the "brother" leader. They got armed, and started moving towards Tripoli, the capital, and Qaddafi's base of power.
... ...
Qaddafi kept all his best military equipment, especially the new stuff he'd gotten in the past 8 years or so after major sanctions were ended, in Tripoli, in the hands of the most loyal part of the army. As far as I can tell, there are about 3 tribes that are loyal to Qaddafi, as well as mercenaries and those that believe what they see on state run TV, and those that are too afraid to rebel. Since the most loyal group had the best weapons, they opened up a can on the rebel military groups. These rebel military groups, made up of defected military and people wanting more freedoms for themselves, stopped advancing and started retreating or being killed, or both. Qaddafi's men followed them and began to retake cities.
... ...
The United States, along with France and Britain, and with grudging support from Arabic and African neighbors, decided to put a stop to Qaddafi's offensive. So it did. As of right now, the tides have turned again, and the rebel forces are advancing towards Tripoli for the second time.
... ...
There are some questions that Americans might have about our support for the rebels.
... ...
"Don't they (Libyans, Arabs, etc.) hate us?" I think the answer to this question is yes. At least as a whole. There is a small percentage that doesn't. Just because a lot of them hate us doesn't mean the first thing they'll do is start thinking of ways to kill us once their form of government has changed. I think "Death to America" is probably a ways down the list, after things like food, jobs, a voice in government, etc.
... ...
"All this support won't end Qaddafi's rule!" It's possible that Qaddafi could continue to have power in Tripoli for some time to come. This isn't the worst possible outcome, but it is a bad one. Hopefully the rebels will be able to take Tripoli, and then reunite the government with the people, and then vote on their government...
... ...
"What's worse than Qaddafi staying in power in Tripoli?" I think the worst possible outcome would be if another kind of extremist comes to power after Qaddafi goes, and they don't get democracy, and then women and minority groups are even worse off. I don't think the idea that 'Islamic extremists will take over' is the most probable outcome of all of this. I wouldn't say it's impossible, but I think there is a large group that sees extremism as, well, extreme.
... ...
"Why should the US put lives and money on the line for Libya?" In my opinion, it's because 1) innocent (pro-democracy) lives will be saved, 2) we know democracy is good, and it is better for Libya than what they have, 3) once upon a time it was the US that was rebelling, and we needed and got help from France to stave off England. We can help others in the same way, can't we?, 4) Showing that the US and the international community won't put up with murdering peaceful protestors will dissuade other area governments from using the same tactics, or at least it will make them do it less. Hopefully. 5) This isn't Vietnam. It isn't Somalia. It isn't Iraq, or Afghanistan. If we can nudge Libya back to they Egypt and Tunisia path, with a more peaceful transition of governments, we won't need to be there for years.
... ...
The United States of America was, and still is, the flagship of democracy. Since its founding, the democratic ideal, imperfect as it is, has been adopted by more than half of the planet to some degree or another. It is possible that democracy won't be the final outcome in Libya. These things can never be completely foreseen. But there is a chance that democracy will prevail without Qaddafi. With Qaddafi, the chance is zero. Qaddafi was a threat only because of far superior firepower. This firepower is the result of Western democratic research and development. It would be totally sick and wrong if Qaddafi were allowed to kill pro-democracy citizens of Libya with weapons that result from technology that comes from the world's foremost democracies.
Map from ocw.nd.edu ... ...
In Libya, unlike Tunisia and Egypt, the dictator was ok with killing any and all protesters. The protests and demonstrations went from angry and peaceful to angry and violent as protesting individuals were jailed, killed, etc. An apparent majority of the people, including a sizable chunk of the military, sided against Qaddafi, the "brother" leader. They got armed, and started moving towards Tripoli, the capital, and Qaddafi's base of power.
... ...
Qaddafi kept all his best military equipment, especially the new stuff he'd gotten in the past 8 years or so after major sanctions were ended, in Tripoli, in the hands of the most loyal part of the army. As far as I can tell, there are about 3 tribes that are loyal to Qaddafi, as well as mercenaries and those that believe what they see on state run TV, and those that are too afraid to rebel. Since the most loyal group had the best weapons, they opened up a can on the rebel military groups. These rebel military groups, made up of defected military and people wanting more freedoms for themselves, stopped advancing and started retreating or being killed, or both. Qaddafi's men followed them and began to retake cities.
... ...
The United States, along with France and Britain, and with grudging support from Arabic and African neighbors, decided to put a stop to Qaddafi's offensive. So it did. As of right now, the tides have turned again, and the rebel forces are advancing towards Tripoli for the second time.
... ...
There are some questions that Americans might have about our support for the rebels.
... ...
"Don't they (Libyans, Arabs, etc.) hate us?" I think the answer to this question is yes. At least as a whole. There is a small percentage that doesn't. Just because a lot of them hate us doesn't mean the first thing they'll do is start thinking of ways to kill us once their form of government has changed. I think "Death to America" is probably a ways down the list, after things like food, jobs, a voice in government, etc.
... ...
"All this support won't end Qaddafi's rule!" It's possible that Qaddafi could continue to have power in Tripoli for some time to come. This isn't the worst possible outcome, but it is a bad one. Hopefully the rebels will be able to take Tripoli, and then reunite the government with the people, and then vote on their government...
... ...
"What's worse than Qaddafi staying in power in Tripoli?" I think the worst possible outcome would be if another kind of extremist comes to power after Qaddafi goes, and they don't get democracy, and then women and minority groups are even worse off. I don't think the idea that 'Islamic extremists will take over' is the most probable outcome of all of this. I wouldn't say it's impossible, but I think there is a large group that sees extremism as, well, extreme.
... ...
"Why should the US put lives and money on the line for Libya?" In my opinion, it's because 1) innocent (pro-democracy) lives will be saved, 2) we know democracy is good, and it is better for Libya than what they have, 3) once upon a time it was the US that was rebelling, and we needed and got help from France to stave off England. We can help others in the same way, can't we?, 4) Showing that the US and the international community won't put up with murdering peaceful protestors will dissuade other area governments from using the same tactics, or at least it will make them do it less. Hopefully. 5) This isn't Vietnam. It isn't Somalia. It isn't Iraq, or Afghanistan. If we can nudge Libya back to they Egypt and Tunisia path, with a more peaceful transition of governments, we won't need to be there for years.
... ...
The United States of America was, and still is, the flagship of democracy. Since its founding, the democratic ideal, imperfect as it is, has been adopted by more than half of the planet to some degree or another. It is possible that democracy won't be the final outcome in Libya. These things can never be completely foreseen. But there is a chance that democracy will prevail without Qaddafi. With Qaddafi, the chance is zero. Qaddafi was a threat only because of far superior firepower. This firepower is the result of Western democratic research and development. It would be totally sick and wrong if Qaddafi were allowed to kill pro-democracy citizens of Libya with weapons that result from technology that comes from the world's foremost democracies.
Americanos vs. Latinos guest blog by Islena Keyes
This is a guest blog by Islena Keyes in Spanish, comparing Latino men to American men. Esto es un blog de Islena, mi esposa, tratando de las diferencias entre hombres latinos y hombres gringos. ...
...
Casarse con un gringo es en elgunas maneras como estar casado con un latino, pero en algunas cosas es diferente. Es igual porque son hombres y los hombres casi todos son iguales. Siempre esperan que es la esposa que hace la mayoria y la que tiene que cocinar y limpiar. Ellos son los que van a trabajar y esperan que la esposa mas que todo cuida la casa. Son diferentes mas que todo en cuanto a la cultura o la forma en que fueron criados. Los Americanos han sido criados mas independientes que los hombres latinos. Los hombres latinos la mayoria viven en la casa hasta cuando quieren y los americanos la mayoria salen de su casa para la universidad o algo. Viven solos por mucho tiempo. ...
...
Lo otro tambien es que yo pienso que los gringos son un poquito menos detallistas. Los latinos siempre estan pendientes de que es el dia de la madre y un regalo, o que es un dia por asi, solo traen un regalo y yo no se si todos pero Jeff es un poquito no super detallista y el no sabe tampoco que regalos darme. Un latino sabria mas en cuanto a que son los regalos que serian buenos para la mujer. ...
...
En cuanto a ser cariñosos yo pienso que es mas que todo algo de costumbre. Al principio con Jeff y yo, él no le gustaba tanto abrasadero o besadera. En cambio a mi si siempre me gustaba estar abrasada con caricios y todo. Pero yo pienso que es mas que todo cuestión por que ellos son independientes. Por eso es que son asi, pero yo pienso que es mas que todo costumbre y querer cambiar. Jeff ha cambiado mucho eso él ahorita es pegajosito, y le gusta caricios y besos. ...
...
La diferencia tambien es el hombre latino. No todos pero la mayoria no respetan mucho a su esposa. Ven otras mujeres en las calles o siempre estan mirando a las mujeres si son bonitas en las calles o a veces echan pirópos. Los gringos son mas centrados en eso. No es que no vean muchachas afuera y las miren, pero no lo hacen casi al frente de uno o no las dicen nada, o sea, son mas respetuosos. ...
...
Los gringos ayudan mas en la casa en cuanto a cuidar los ninos y a limpiar que los latinos. Los latinos mas que todo siempre piensan que es el trabajo de la mama o de la mujer. Los gringos son mas dispuestos a ayudar en las cosas de cuidar a los ninos. ...
...
Los gringos son criados a ser mas centrados en ellos, y son un poquito mas egoistas que los latinos. Los latinos siempre les gusta dar y son abiertos y nos gusta compartir mas. Los gringos son un poquito mas tacaños. No les gusta gastar plata mucho, pero pienso que lo demas en si los hombres son iguales. ...
...
Fisicamente, que se puede decir. Yo no pienso que los gringos son mas guapos que los latinos, ni los latinos son mas guapos que los gringos. Yo pienso que eso depende del hombre. Personalmente me gusta los hombres mas altos que yo y no gorditos. Otra diferencia es el cuidado personal. Los latinos se enfocan mucho en verse bien, en vestirse bien, y en oler bien. Eso es muy importante para ellos. Los americanos no les importa eso tanto. Son aseados y se bañan y todo… algunos… pero no son tan enfocados en como se ven mucho. Yo pienso que algunos si. Algunos les importa como se ven y todo eso pero a la mayoria no les importa tanto el verse. ...
...
Lo que hacen en tiempo libre… Bueno los latinos se dirian si no son miembros de la iglesia, o aun si son miembros de la iglesia tienen sus cosas. Se van a jugar futbol con los amigos. Los que no son miembros de la iglesia se van con los amigos de parranda cada fin de semana. Yo pienso que eso es un poco diferente con los latinos. Los gringos son mas caseros en esa cuestión. Dedican un poco mas tiempo a la familia. Claro que gastan mucho tiempo jugando video games. Juegan en la computadora y todas esas cosas que los latinos casi no. Personalmente yo no veia mucho eso. Yo se que los habrán pues si encuanto a eso yo pienso que los latinos son mas envolucrados en cosas sociales. Los gringos son mas solitarios y mas independientes. Pasan tiempo solo y estan bien con eso. ...
...
Todo esto es lo que pienso yo, basado en la experiencia que yo he tenido con Jeff. Puede ser diferente con diferentes personas en cuanto a como son los gringos.
...
Casarse con un gringo es en elgunas maneras como estar casado con un latino, pero en algunas cosas es diferente. Es igual porque son hombres y los hombres casi todos son iguales. Siempre esperan que es la esposa que hace la mayoria y la que tiene que cocinar y limpiar. Ellos son los que van a trabajar y esperan que la esposa mas que todo cuida la casa. Son diferentes mas que todo en cuanto a la cultura o la forma en que fueron criados. Los Americanos han sido criados mas independientes que los hombres latinos. Los hombres latinos la mayoria viven en la casa hasta cuando quieren y los americanos la mayoria salen de su casa para la universidad o algo. Viven solos por mucho tiempo. ...
...
Lo otro tambien es que yo pienso que los gringos son un poquito menos detallistas. Los latinos siempre estan pendientes de que es el dia de la madre y un regalo, o que es un dia por asi, solo traen un regalo y yo no se si todos pero Jeff es un poquito no super detallista y el no sabe tampoco que regalos darme. Un latino sabria mas en cuanto a que son los regalos que serian buenos para la mujer. ...
...
En cuanto a ser cariñosos yo pienso que es mas que todo algo de costumbre. Al principio con Jeff y yo, él no le gustaba tanto abrasadero o besadera. En cambio a mi si siempre me gustaba estar abrasada con caricios y todo. Pero yo pienso que es mas que todo cuestión por que ellos son independientes. Por eso es que son asi, pero yo pienso que es mas que todo costumbre y querer cambiar. Jeff ha cambiado mucho eso él ahorita es pegajosito, y le gusta caricios y besos. ...
...
La diferencia tambien es el hombre latino. No todos pero la mayoria no respetan mucho a su esposa. Ven otras mujeres en las calles o siempre estan mirando a las mujeres si son bonitas en las calles o a veces echan pirópos. Los gringos son mas centrados en eso. No es que no vean muchachas afuera y las miren, pero no lo hacen casi al frente de uno o no las dicen nada, o sea, son mas respetuosos. ...
...
Los gringos ayudan mas en la casa en cuanto a cuidar los ninos y a limpiar que los latinos. Los latinos mas que todo siempre piensan que es el trabajo de la mama o de la mujer. Los gringos son mas dispuestos a ayudar en las cosas de cuidar a los ninos. ...
...
Los gringos son criados a ser mas centrados en ellos, y son un poquito mas egoistas que los latinos. Los latinos siempre les gusta dar y son abiertos y nos gusta compartir mas. Los gringos son un poquito mas tacaños. No les gusta gastar plata mucho, pero pienso que lo demas en si los hombres son iguales. ...
...
Fisicamente, que se puede decir. Yo no pienso que los gringos son mas guapos que los latinos, ni los latinos son mas guapos que los gringos. Yo pienso que eso depende del hombre. Personalmente me gusta los hombres mas altos que yo y no gorditos. Otra diferencia es el cuidado personal. Los latinos se enfocan mucho en verse bien, en vestirse bien, y en oler bien. Eso es muy importante para ellos. Los americanos no les importa eso tanto. Son aseados y se bañan y todo… algunos… pero no son tan enfocados en como se ven mucho. Yo pienso que algunos si. Algunos les importa como se ven y todo eso pero a la mayoria no les importa tanto el verse. ...
...
Lo que hacen en tiempo libre… Bueno los latinos se dirian si no son miembros de la iglesia, o aun si son miembros de la iglesia tienen sus cosas. Se van a jugar futbol con los amigos. Los que no son miembros de la iglesia se van con los amigos de parranda cada fin de semana. Yo pienso que eso es un poco diferente con los latinos. Los gringos son mas caseros en esa cuestión. Dedican un poco mas tiempo a la familia. Claro que gastan mucho tiempo jugando video games. Juegan en la computadora y todas esas cosas que los latinos casi no. Personalmente yo no veia mucho eso. Yo se que los habrán pues si encuanto a eso yo pienso que los latinos son mas envolucrados en cosas sociales. Los gringos son mas solitarios y mas independientes. Pasan tiempo solo y estan bien con eso. ...
...
Todo esto es lo que pienso yo, basado en la experiencia que yo he tenido con Jeff. Puede ser diferente con diferentes personas en cuanto a como son los gringos.
Subscribe to:
Posts (Atom)