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January 2010 Download this article
Dysphagia Dysphagia
Featured Journal Interview

According to Essential Science IndicatorsSM from Thomson Reuters, the journal Dysphagia is having a growing influence in the field of Clinical Medicine. Its citation record in this field includes 399 papers cited a total of 2,772 times between January 1, 1999 and August 31, 2009.

Dysphagia is published by Springer and is the official journal of both the Dysphagia Research Society and the Japanese Society of Dysphagia Rehabilitation.

In this interview, correspondent Gary Taubes talks with Bronwyn Jones, the Editor-in-Chief, Reza Shaker, Deputy Editor, Laura Walsh, Publishing Editor, and Andrea Schaffeler, Journal Coordinator, about Dysphagia's publication history and citation achievements.

  Can you define dysphagia for us and tell us about the disorder?

Jones: This is difficulty in swallowing. It encompasses a lot of causes, anything from functional things like strokes or neurological disorders or amyotrophic lateral sclerosis (Lou Gehrig's disease), structural things such as strictures, or cancers. It can be caused by out-pouchings, which are also known as diverticula. And, of course, people who have a very common disorder, gastroesophageal reflux, can also have difficulty swallowing.

It can affect anyone from babies a few days old, to 95-year-olds having a stroke. Another interesting fact is that if you do a survey of in-patients in a regular hospital, you'll find about 15-20% have some difficulty swallowing. If you do a survey in nursing homes or long-term care facilities, it can be up to 90%. In the general population, the prevalence is about 7%.

  Would you tell us about the history of Dysphagia?

Jones: The journal was founded by Martin Donner, who was chairman of radiology at Johns Hopkins for many years. He had a longstanding interest in patients with swallowing disorders. He founded the journal jointly with James Bosma, a pediatric neurophysiologist, who was interested in pediatric and adult dysphagia. Dr. Bosma was originally at the National Institutes of Health and then he moved over to Johns Hopkins. He was interested more in the theory of swallowing, although he and Dr. Donner did see some patients together. The journal was founded about 1985 and the first volume covered 1986 and 1987. After that the journal got more up to speed. I came on as a board member in 1985, as a co-editor in 1987 and then as editor in 1989.

  Did the founding of the journal have an effect on how the study of dysphagia evolved, or just on where researchers and physicians chose to publish?

Shaker: Until Dr. Donner established the journal, the research in this field was not concentrated in any way. People had worked on the physiology of deglutition—i.e., swallowing—and deglutition disorders in a very haphazard way. There were a few people doing systematic work, but not many. The development of the journal and the founding of the Dysphagia Research Society (DRS) together had the effect of making researchers gravitate to the field. They helped to popularize the field of study of deglutition and its disorders worldwide. Now you have hundreds of people who work in this field at all different levels.

And, as you may know, deglutition and respiration and speech are intertwined. They go hand in hand. When the deglutition process goes awry and the patients become dysphagic, their airway is affected; they aspirate—that's how they get lung problems. The field of research avalanched from the periphery—just looking at the end result of the condition—all the way to the brain stem. Now investigators are looking at the cerebral cortex that controls the swallowing act, hoping they can learn more about it and come up with new ways to help these patients. Because of the journal Dysphagia and the DRS, a good number of techniques, maneuvers, and exercises have been developed that are really helping our patients.

  When was the society itself founded?

Shaker: Work began in earnest about 1990 and we had the first inaugural meeting in 1992.

"We think as people get more and more interested in dysphagia and the various ways of looking at how things go wrong, we'll have more and more people coming to our meetings, more and more papers being written and more and more citations."

Jones: Reza [Shaker] is the founder and was the first president of the society for two years. The journal is affiliated with the society as the official journal as well. It's also the official journal for Japan's Society of Rehabilitation. What Reza has not referred to yet is that up until the journal was launched and the society was founded, a person with dysphagia might see one of a number of specialists. They might go to an ear, nose, and throat specialist; they might see a gastroenterologist, a rehabilitation specialist; they might go see a neurologist.

A pivotal role of the journal has been to get all these specialists together, to reach out to these different specialties, and get them to work together and to publish in the same place. It's a very multidisciplinary journal. The people who submit to it and publish in it might belong to any one of 15 or so different specialties.

  So the journal was founded with the intent of being multidisciplinary?

Shaker: Absolutely. This was the vision of Dr. Donner, Dr. Bosma, and Dr. Jones. They understood early on that dysphagia and deglutition are multidisciplinary issues. They're not single disease issues. It's not like if you have a heart problem, you just go to a cardiologist. If you have a GI problem, you go to a gastroenterologist. When you have dysphagia, there are several disciplines involved. That was the difficulty in the field and the journal addressed that. And through this process, all of us involved have become multidisciplinary researchers ourselves.

Jones: There are special swallowing centers, as Dr. Shaker has at Wisconsin, where people from multiple specialties can now all work together. At Johns Hopkins, we also have a swallowing center. The central participants are gastroenterologists, ENT specialists, radiologists, speech pathologists, who are really the therapy side of rehabilitative medicine, and neurologists. We have weekly meetings in which we all gather to discuss five, six, seven, maybe eight patients. All these different specialists are present to give their input. What we're trying to do with the journal is get input from all specialties.

  How do you account for the increasing citation rate of your journal?

Jones: That's a tough question to answer. I think it goes along with this increasing awareness of how common dysphagia is, the awareness that we are an aging society and that as we age, more and more people become dysphagic. What's more, the Dysphagia Research Society brings people together once a year for a meeting. Every year, there are more and more people interested in this subject. In Japan, there are now two major groups interested in dysphagia—rehabilitation doctors and dentists. There's a meeting in Japan once a year on dysphagia, and they get about 10,000 participants. There are now groups interested in swallowing and its disorders around the world.

Before the journal was founded, people would publish in their own specialty journals. It was fragmented among the different specialties. Now the great proportion of these articles will go to Dysphagia.

  Was there a change in policy or editorial direction that might also account for this?

Jones: We do encourage people who present at the Dysphagia Research Society meetings to send their papers to Dysphagia. But we haven't made it mandatory. We felt it might inhibit people from submitting to the meeting. We've also encouraged some review articles, knowing that review articles do improve citations rates and impact factor. But we know in this busy world, it's very hard to get them to do review articles, unless someone really has a passion about a particular subject.

Shaker: It's getting tougher and tougher, particularly for physicians, to write reviews because of their increased clinical responsibility.

  Have there been specific developments in the fields served by your journal that may have contributed?

Jones: There's been an increasing interest in the neurological control of swallowing and also in the application of newer technologies to evaluate dysphagic patients—ultrasound, for example. People are also working now on the ultrasound evaluation of swallowing physiology. There's also work on functional MRI imaging—sort of a hot field—to understand the control of swallowing. The backbone of the evaluation of the swallowing patient, the accepted gold standard, is still a radiology technique—video fluoroscopy, which uses a contrast agent and then real-time imaging with x-ray.

Another factor is that there's a group of maybe 50,000 people in the US who are interested in speech primarily, but a subgroup of them are very interested in swallowing. One of our associate editors now is Jeri Logemann, a Ph.D. in speech and language-pathology and she is one of the leaders in this specialty.

  How would you describe the goal of the journal today?

Shaker: As we said, dysphagia and deglutition are multidisciplinary fields. Investigators from different disciplines look at different aspects of dysphagia or the pathology of dysphagia and then they might want to publish in the journals of their discipline. If they're looking from the perspective of the brain control of swallowing, they may send that paper to Neuroscience or some other journal like that or they might send it to Dysphagia. If they're looking at brainstem control of swallowing, it may go to the American Journal of Physiology, or the Journal of Physiology, or it might go to Dysphagia.

Our intention is, or our desire is, to help bring all this wealth of knowledge and science on deglutition and its disorders into Dysphagia so people can access it in a one-stop shop. That also helps clinicians in the field, because doctors and speech pathologists, those who see patients, do not read all the journals. It's good to have all that knowledge in one journal, where readers can subscribe, look it up, and it's done. And this would be one reason why the Dysphagia citation rate has gone up. People have started to recognize this notion that Dysphagia is a good vehicle for the dissemination of their work. The customers of the knowledge, the clinicians and other researchers, can go there, one-stop shop and review the journal on a regular basis to get what they need, instead of searching around. We're not there fully, but this is one of our primary goals.

  What are you doing inside the journal to make that happen?

Jones: One thing we're doing with the editorial board is to have it represent all the individual fields that are interested in dysphagia, and also have members from around the world, not just the US. The DRS is already an international society, but we're aiming in 2012, which will be the 20th anniversary of the Dysphagia Research Society, to have as many overseas people as possible attend our annual meeting, which will be in Toronto. There's been a lot of discussion among the various European groups, the Japanese group, the American group, and the groups in South America and Australia, trying to get this idea spread around the world much more.

We think as people get more and more interested in dysphagia and the various ways of looking at how things go wrong, we'll have more and more people coming to our meetings, more and more papers being written and more and more citations. We didn't expect this kind of growth when we first started the journal. As I said, things were slow coming in and the first volume was actually spread over two years. Now we have a lot of papers coming in—touch wood—and the quality of papers has increased dramatically over the years.

Walsh: It's a testament to the journal that it's been there, stable and steady, always looking for good quality papers. And the fact is that if someone goes online now and types in deglutition or dysphagia, they'll find the journal very quickly—probably in the top few items. And this is a matter of the long loyalty and devotion of a small group of people, now expanding, all clinicians and researchers who are working in multidisciplinary ways and working together more and more. This group was doing it before multidisciplinary research was in fashion.

Jones: Another thing that's accelerated this process is that, working with Andrea Schaffeler, we're now managing the journal online in a program called Editorial Manager. When papers come in, I get an e-mail saying a new paper is there or a revision is there. Andrea gets an e-mail to say the paper is there. Then she and I work together to take the paper from submission through to decision and publication and it's all done electronically.

  Has this accelerated the time to publication significantly?

"Because of the journal Dysphagia and the [Dysphagia Research Society], a good number of techniques, maneuvers, and exercises have been developed that are really helping our patients."

Jones: I'd say dramatically so.

Schaffeler: I worked with the journal for a short time before it went online, but even so it was incredible not only the increase in the number of manuscripts, but the widening of the reviewer pool and the quickness of the turnaround because it was now all electronic. And people very quickly became aware of how fast this information was coming out, and how quickly they could access it. The time from submission to first decision is now at about six weeks.

  How do you see dysphagia research itself evolving in the next few years?

Shaker: I can answer that because I was part of a group that the National Institutes of Health invited to look at the future of gastrointestinal research. I think now everybody involved—the government, the payers, the physicians and research institutes—realize that dysphagia is on the rise for the reasons that Bronwyn [Jones] alluded to. We are an aging society. I don't have the statistics at my fingertips, but the proportion of individuals over the age of 85 has been increasing dramatically. And the health care expenditures resulting from the complications of dysphagia have also been exponentially rising in the past decade.

Everybody involved now recognizes that we do need to better understand the physiology of deglutition and, based on that, to learn the pathophysiology and devise new treatment modalities. The big push is on that side. This is on the agenda as an area of interest at NIDDK, where research in oral and pharyngeal motility is being encouraged. It's on the agenda of all the different societies of the different disciplines involved in this area. If you go to laryngology meetings, you'll find research on dysphagia is on the agenda. If you go to rehabilitative medicine meetings, you'll find it. In Japan, it's phenomenal how much interest there is and how much research is initiated there. The Europeans are catching up and forming research societies. As third-world countries become more prosperous and infections diseases and malnutrition are no longer such devastating problems, disorders like dysphagia become more and more recognized and the people have the resources to deal with them.

Jones: We can also see this geographical expansion in the authorship of the papers that are coming into our journal. We're now seeing papers from Japan, from China, from Korea, Brazil, from all different parts of the world, which is very exciting.

  Is there anything else you'd like to add about Dysphagia or about dysphagic research that we haven't covered?

Shaker: There may be another good analogy to wrap up the role of our journal in this area. The big elephant here is deglutition and its disorder, namely dysphagia. It used to be that investigators in each discipline would study a piece of it—one would look at the trunk, another the body, another the tail, the leg, etc. That was all fine, but it wasn't functional. There was no way to connect this research and help the field progress. Dysphagia created a platform to put the individual pieces of the elephant together. Now people are being educated as well that this is what has to be done to make progress. We're not completely there yet, but we're getting there. People have to realize that they have to look at the whole structure, from lips to stomach, the entire apparatus and what controls it. That we have to look upstream through the nerves to the brainstem, the cortex. This is what Dysphagia is trying to put together. As such, that's a unique contribution. The job is not finished yet, but we're continuing to work on it.

Jones: If I can give an example: think about speech pathologists, who are basically people interested in the therapy for patients who can't swallow. Not just aspiration or things going down the wrong way, but how the physiology of swallowing has been changed by the patient's problem. They're really interested in the mouth and the pharynx. But they've now realized, as we all have, that they can't just examine that part of the swallowing mechanism. You have to look at the whole thing. You have to look, for example, at the esophagus, particularly if the pharynx looks normal.

We had a patient here just a few days ago who lost about 50 pounds. We looked at his pharynx and it was abnormal. But then we still looked at his esophagus and his stomach, which is now our normal procedure. It turned out the patient had an infiltrating tumor of the stomach that was actually invading up to the lower end of his esophagus. Had he gone to a speech pathologist just 10 years ago, they would have looked at the pharynx and said the pharynx is abnormal, this is what we have to do to allow him to swallow. They would have missed the fundamental problem.

Now people realize that there is this spectrum from the lips, as Reza says, through to the stomach and up to the cortex. And part of the role of Dysphagia, the journal, is to educate people first how to diagnose their patients, looking at this entire spectrum, this whole elephant, as Reza says, and then how to treat them.

Bronwyn Jones, Editor-in-Chief
Reza Shaker, Deputy Editor
Laura Walsh, Publishing Editor
Andrea Schaffeler, Journal Coordinator
Springer, publishers


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Journal Interviews : 2010 : The Editorial Team of Dysphagia Discusses the Success of the Journal