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The addition of cough reflex testing (CRT) to a comprehensive clinical swallowing evaluation has the potential to substantially contribute to the management of patients with dysphagia, by providing insights into the integrity of the cough response to airway invasion and risk of silent aspiration. This “Spotlight on: Cough Reflex Testing in Clinical Dysphagia Practice” outlines the theoretical and practical considerations of using CRT as a screening tool to identify patients’ risk of silent aspiration. The following clinical questions are addressed: (1) What is coughing? (2) What is CRT? (3) What CRT method should I use? (4) How is the citric acid CRT conducted? (5) Can CRT be repeated to monitor changes in cough sensitivity? (6) What are the benefits of CRT in clinical dysphagia practice? This information is intended to support clinicians in implementing and interpreting CRT as a screening tool to identify patients’ risk of silent aspiration in clinical dysphagia practice.

Early and accurate dysphagia diagnosis is essential for reducing the risk of associated co-morbidities and mortalities. Barriers to current evaluation methods may alter the effectiveness of identifying at-risk patients. This preliminary study evaluates the feasibility of using iPhone X-captured videos of swallowing as a non-contact dysphagia screening tool. Video recordings of the anterior and lateral necks were captured simultaneously with videofluoroscopy in dysphagic patients. Videos were analyzed using an image registration algorithm (phase-based Savitzky–Golay gradient correlation (P-SG-GC)) to determine skin displacements over hyolaryngeal regions. Biomechanical swallowing parameters of hyolaryngeal displacement and velocity were also measured. Swallowing safety and efficiency were assessed by the Penetration Aspiration Scale (PAS), Residue Severity Ratings (RSR), and the Normalized Residue Ratio Scale (NRRS). Anterior hyoid excursion and horizontal skin displacements were strongly correlated with swallows of a 20 mL bolus (rs = 0.67). Skin displacements of the neck were moderately to very strongly correlated with scores on the PAS (rs = 0.80), NRRS (rs = 0.41–0.62), and RSR (rs = 0.33). This is the first study to utilize smartphone technology and image registration methods to produce skin displacements indicating post-swallow residual and penetration-aspiration. Enhancing screening methods provides a greater chance of detecting dysphagia, reducing the risk of negative health impacts.

Purpose of Review The purpose of this review is to consolidate evidence related to the use of biofeedback in swallowing rehabilitation. Rather than a comprehensive review, we provide a historical and conceptual justification for integration of biofeedback modalities in the treatment of dysphagia. Recent Findings Although biofeedback has been used for decades in/as an adjunct to muscle strengthening rehabilitation programmes, advances in our understanding of swallowing neural control provide potential for new applications of technology to facilitate swallowing recovery. New research highlights the emergence of skill-based swallowing training, which focuses on adaptation of specific components of timing and coordination in the swallowing motor plan. This research suggests positive clinical outcomes using feedback that is impairment specific and is designed with principles of neuroplasticity in mind. Summary The emerging emphasis on motor control, rather than muscle strength, implicates a critical role for the use of biofeedback modalities to allow conscious insights into specific aspects of the generally obscure swallowing process.

The use of ultrasound as an adjunct to clinical swallowing evaluation provides quantitative physiological and morphological data. As a low-risk procedure, ultrasound imaging can be performed outside of a medical setting. This is particularly important for patients living in rural areas with restricted access to a hospital. Technical advances have produced pocket-sized ultrasound technology that is more affordable, and therefore within the fiscal reach of most allied health services.To explore the validity and reliability of pocket-sized ultrasound technology in dysphagia assessment.Data were acquired from 43 patients with dysphagia using the Clarius ultrasound device. Ultrasound and videofluoroscopic measures of hyoid and laryngeal displacement during liquid and puree swallowing were collected concurrently to quantify correlation and agreement between identical measures derived from the two instruments. Reliability of ultrasound was assessed for measures of hyoid and laryngeal displacement, tongue thickness, and size of the submental muscles in eight patients. Reliability was evaluated for the entire process of data acquisition including scanning and online measurement using an iPad in a clinical setting and for offline measurement on a computer screen to explore environmental influences on reliability.Results revealed poor correlation between the measures of interest across instruments. Reliability of the entire process of data acquisition in a clinical setting was insufficient while reliability was more promising for offline measurements.The clinical use of pocket-sized ultrasound devices, such as the Clarius system, for swallowing evaluation is not indicated at this time. Enhanced validity and reliability of the entire process of data acquisition are needed prior to clinical translation of such technology.What is already known on the subject The use of ultrasound allows for radiation-free, non-invasive swallowing assessment. Some data suggest that ultrasound is valid and reliable in the evaluation of swallowing using standard-sized equipment. Insufficient validity and reliability have been reported for pocket-sized ultrasound technology in the assessment of healthy swallowing. What this paper adds to existing knowledge This research is the first to provide validity and reliability data of the pocket-sized Clarius technology in the evaluation of swallowing in patients with dysphagia. Insufficient validity and reliability of online data acquisition in a clinical environment were found. Reliability for offline measurement was more promising. What are the potential or actual clinical implications of this work? The clinical use of pocket-sized ultrasound devices, such as the Clarius system, for swallowing assessment is not indicated at this time.

Use of topical nasal anesthetic (TNA) is common in high-resolution impedance manometry (HRIM). This study investigated the effect of TNA on swallowing and procedure tolerability during HRIM with a 4.2-mm catheter, a more commonly used catheter size with impedance capabilities.Randomised experimental study with blinding of participants.Twenty healthy participants (mean age = 33 years, 16 female) were randomized to undergo HRIM using the ManoScan™ ESO Z 4.2-mm catheter twice, 1 week apart, under two conditions: with TNA (viscous lidocaine) and with placebo. Analyses included esophageal data of three saliva, three saline (5 mL), and three bread swallows (2 cm × 2 cm) performed while reclined 45°, and pharyngeal data under the same conditions while seated upright. Pharyngeal and upper esophageal sphincter (UES) HRIM parameters were analyzed using the Swallow Gateway analysis platform. Visual analogue scale (VAS) scores rating procedural comfort were analyzed.There were no significant physiological differences in pharyngeal and UES parameters between conditions. There were also no significant differences in VAS scores under placebo (mean = 54.8, standard deviation (SD) = 19.3) and TNA (mean = 60.0, SD = 21.9) (t[19] = -0.9, P = .4) conditions; however, there was a significant difference in the first versus second session (t[19]) = 5.1, P .05).TNA did not improve comfort, but it also did not significantly affect swallowing behavior. There was, however, a practice effect regardless of TNA use with improved tolerance of the 4.2-mm catheter and likely more natural swallowing behavior during the second session of HRIM.3 Laryngoscope, 132:2124-2131, 2022.

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Through this scoping review, we will answer the question of how cough testing is used in deglutition research. For this project, the field of deglutition refers to research that is contributing to the literature around the assessment or management of eating, drinking and swallowing. This includes studies that describe an aim of reducing the occurrence or risk of silent aspiration, or pneumonia. In this review, cough testing refers to a test in which a tussive agent is inhaled by a participant to attempt to evoke a cough response. Here 'tussive agent' refers to solutions of citric acid, capsaicin, tartaric acid, or distilled water (fog).

Chronic traumatic encephalopathy (CTE) is a neuropathological diagnosis defined by a unique pattern of hyperphosphorylated tau (p-tau) accumulation that begins in neocortical regions of the brain. It is associated with a range of neuropsychological symptoms, but a definitive diagnosis can only be made by postmortem brain examination. In 2018, we instituted CTE screening for all autopsy brains as part of our routine departmental protocol by performing p-tau immunohistochemistry on a restricted set of 3 neocortical blocks (frontal, temporal, and parietal). This strategy allowed us to identify 4 cases of low-stage CTE from 180 consecutive autopsies. Two of the 4 cases had a documented history of brain injury; for the remaining 2 cases, there was a long history of treatment-resistant tonic/clonic epilepsy suggesting that undocumented brain injuries may have occurred. Our experience indicates that 3-block CTE screening is useful in identifying CTE in routine practice. The results of this study further support the association between prior head injuries and CTE and demonstrate that, albeit uncommon, CTE does occur in the general population. Our findings suggest that p-tau screening should be routinely pursued in brain autopsy, particularly where there is a documented or likely history of traumatic brain injury.

Over the past four decades, our understanding of swallowing neural control has expanded dramatically. However, until recently, advances in rehabilitation approaches for dysphagia have not kept pace, with a persistent focussing on strengthening peripheral muscle. This approach is no doubt very appropriate for some if not many of our patients. But what if the dysphagia is not due to muscles weakness? The purpose of this clinical manuscript is to reflect on where we have been, where we are now and perhaps where we need to go in terms of our understanding of swallowing motor control and rehabilitation of motor control impairments. This compilation is presented to clinicians in the hope that suggesting approaches “outside the box” will inspire clinicians to focus their attention “inside the box” to ultimately improve rehabilitation and long-term outcomes for patients with dysphagia.

Routine examination of entire histological slides at cellular resolution poses a significant if not insurmountable challenge to human observers. However, high-resolution data such as the cellular distribution of proteins in tissues, e.g., those obtained following immunochemical staining, are highly desirable. Our present study extends the applicability of the PathoFusion framework to the cellular level. We illustrate our approach using the detection of CD276 immunoreactive cells in glioblastoma as an example. Following automatic identification by means of PathoFusion’s bifocal convolutional neural network (BCNN) model, individual cells are automatically profiled and counted. Only discriminable cells selected through data filtering and thresholding were segmented for cell-level analysis. Subsequently, we converted the detection signals into the corresponding heatmaps visualizing the distribution of the detected cells in entire whole-slide images of adjacent H&E-stained sections using the Discrete Wavelet Transform (DWT). Our results demonstrate that PathoFusion is capable of autonomously detecting and counting individual immunochemically labelled cells with a high prediction performance of 0.992 AUC and 97.7% accuracy. The data can be used for whole-slide cross-modality analyses, e.g., relationships between immunochemical signals and anaplastic histological features. PathoFusion has the potential to be applied to additional problems that seek to correlate heterogeneous data streams and to serve as a clinically applicable, weakly supervised system for histological image analyses in (neuro)pathology.

Swallowing is a vital function that serves to safely transport food and fluid to the stomach, while simultaneously protecting our airways. Evaluation of swallowing is important for the diagnosis and rehabilitation of individuals with dysphagia, a disorder of swallowing. Flexible high-density surface electromyography (HD sEMG) arrays were designed and fabricated to span the floor of mouth and neck muscles. These arrays were applied on 6 healthy participants over duplicate recording sessions. During each recording session, participants performed three different swallowing motor tasks. The HD sEMG signals were filtered and tasks extracted. For each task, the RMS amplitude was computed, visualized, and compared. Dynamic motor coordination was evident in the filtered signals traces, with different electrode locations showing unique temporal activations. The 2D topographical maps allowed the location of different RMS intensities to be visualized, revealing qualitatively similar patterns across participants and tasks. These motor task trends were also seen within RMS quantifications. The RMS metric across all participants identified significant differences between non-effortful 3 ml and effortful 3 ml swallow tasks ( p=0.006) and there was a minimal variation of 3.1±1.9 μV RMS for repeated recording sessions by each participant. The HD-sEMG array successfully recorded differences in muscle activations during swallowing and was able to discern between two different motor tasks. The arrays offers a spatially detailed non-invasive assessment of the neuromuscular performance of swallowing. Clinical Relevance- The utility of HD-sEMG arrays for evaluation of the muscles involved in swallowing could enable diagnosis and rehabilitation of individuals with dysphagia.

Timely treatment response assessment of high-grade gliomas (HGG), crucial for driving therapeutic decisions, remains a challenge; as HGGs exhibit variable response to treatment within different sub-regions. Current assessment using multi-parametric MRI (mpMRI) depends largely upon follow-up (FU) imaging timepoints for achieving diagnostic certainty, which delays therapeutic interventions. Mathematical modeling (MM) of tumor growth and treatment response can provide spatiotemporal information of HGG evolution in response to treatment, thus allowing for prospective early identification of resilient tumor subregions. AIMS: We aim to initialize and calibrate an image-driven MM framework to forecast HGG response, both at the end of chemoradiotherapy (CRT) and at 3-month FU. METHODS In a prospective clinical study, weekly mpMRIs (post-contrast T1, T2 FLAIR, and diffusion) for patients with HGG receiving CRT were used to describe tumor extent and cellularity. This data collected from baseline (pre-CRT) till week 3 (mid-CRT) was used to calibrate a model family to forecast HGG response for each individual patient at week 6 (end CRT) and at 3-month FU. RESULTS Error between the forecasted and observed responses was assessed globally using percent error in tumor volume, and at the local level by Pearson correlation coefficient (PCC). In an initial cohort of 11 patients, our MM framework predictions had a percent error in tumor volume of less than 8.6% and at week 6 RT and less than 20% at 3 months FU. The PCCs were 0.84 at week 6 RT and 0.72 at 3 months FU. CONCLUSIONS Temporal consistency across this early evaluation of the model predictions show promise of image-driven MM for HGG response forecasting to guide timely personalized assessment and adjustment of treatment.

BACKGROUND IDH-mutant astrocytomas with CDKN2A/B homozygous deletions (HD) are now categorized as grade 4 astrocytomas. It is unclear how these HD astrocytomas should be treated. We aimed to compare 3-year outcomes for HD versus heterozygous deleted (HeD) IDH-mutant astrocytomas, describe the prognostic impact of deletions relative to histologic grade and describe differences in outcomes based on treatment regimen. METHODS Molecular and clinical data concerning IDH-mutant glioma patients +/-CDKN2A/B deletions were retrieved across four neuro-oncology centers and two tumor banks from 01/2016-07/2021. RESULTS 48 patients with HD or HeD were identified. Median follow-up time was 4.0 years, median age 33 (range 20-74) years. Sixteen astrocytomas were histologic grade 4, remainder were grade 2 (n= 9) and grade 3 (n= 23). HD were detected in 16 patients. Survival data were unavailable in n= 1 HD and n= 2 HeD patients. 3-year OS for CDKN2A/B HD and HeD groups were 47% versus 67% (log-rank p= 0.004). For grades 2, 3 and 4, 3-year OS for HD were 100% (n= 1), 57% (n= 7) and 29% (n= 7) respectively, 3-year OS for HeD were 100% (n= 7), 56% (n= 16) and 57% (n= 7) respectively. In HD patients, six were treated with concurrent temozolomide-radiotherapy (3-year OS 50%) and five with radiotherapy and sequential temozolomide only (3-year OS 80%, log-rank p= 0.38). Treatment data were unavailable in two patients and three were treated with “other” regimens. Sequential regimens were preferentially used in histologic grade 2 and 3 cases. CONCLUSION Preliminary data are in keeping with current literature and are one of the first to describe outcomes based on clinical regimen. There was insufficient evidence of OS differences between concurrent and sequential therapy, though conclusions are limited by sample size and data maturity. Additional follow-up data are required to further define optimal treatment for these patients.