Temporal Trends in Traumatic Brain Injury.

Aims Traumatic brain injury (TBI) is a leading cause of preventable mortality and morbidity. Our aim was to examine the demographics, injury characteristics and management of TBI patients treated in an intensive care unit (ICU) in an Irish tertiary-level hospital with a neurosurgical department. Methods A retrospective, longitudinal study of all TBI patients treated in ICU between 2013-2018. Results 77% (n=171) were male and median age was 46 (Q1-Q3: 28-62). The most common mechanism of injury was fall from less than two meters (<2m) followed by road traffic accident (RTA). The proportion of injuries due to RTA increased over the six-year period (p=0.006). 41.4% (n=92) of injuries had reported alcohol involvement. Patients with fall<2m had double the median age and double the rate of alcohol involvement compared to those suffering RTA (p<0.001, p<0.001). The neurosurgical intervention rate was 74% (n=165). The median duration of ICU admission and of intracranial-pressure monitoring, advanced ventilation and inotropic therapy increased over the six-year period (p=0.031, p=0.038, p=0.033, p<0.001). Discussion This study's findings could inform precise and impactful public prevention measures. The increasing duration of ICU admission and of other interventions should be examined further for their effect on patient outcome and resource consumption.

Recent advances in the management of cutaneous malignant melanoma: our case cohort.

Decades of research into the management of cutaneous malignant melanoma have proven it to be a 'tough nut to crack', and its incidence has continued to increase over the last 30 years. Surgery remains a gold standard for early-stage melanoma with five-year survival of 98% for stage I disease, and 90% for stage II. Nonetheless, patients with stage III disease are at a higher risk, resulting in local recurrence as well as distant metastasis. Research regarding the control of metastatic malignant melanoma of the head and neck has evolved. Currently the search is on to understand metastatic malignant melanoma as a heterogeneous disease both at the molecular and clinical level. This paper focuses on the latest systemic therapy for metastatic disease of the head and neck, including cytotoxic chemotherapy, immunotherapy, and target therapy. The new eighth edition of tumour staging, and the sequelae for malignant melanoma, sentinel lymph node biopsy (SLNB), surgical intervention, and its benefits and shortfalls, are discussed. Also, the outcome of our cohort series of patients with metastatic cutaneous malignant melanoma who were treated with systemic combination therapy in Dorset is presented.

Intercomparison of methods of coupling between convection and large-scale circulation: 2. Comparison over nonuniform surface conditions.

As part of an international intercomparison project, the weak temperature gradient (WTG) and damped gravity wave (DGW) methods are used to parameterize large-scale dynamics in a set of cloud-resolving models (CRMs) and single column models (SCMs). The WTG or DGW method is implemented using a configuration that couples a model to a reference state defined with profiles obtained from the same model in radiative-convective equilibrium. We investigated the sensitivity of each model to changes in SST, given a fixed reference state. We performed a systematic comparison of the WTG and DGW methods in different models, and a systematic comparison of the behavior of those models using the WTG method and the DGW method. The sensitivity to the SST depends on both the large-scale parameterization method and the choice of the cloud model. In general, SCMs display a wider range of behaviors than CRMs. All CRMs using either the WTG or DGW method show an increase of precipitation with SST, while SCMs show sensitivities which are not always monotonic. CRMs using either the WTG or DGW method show a similar relationship between mean precipitation rate and column-relative humidity, while SCMs exhibit a much wider range of behaviors. DGW simulations produce large-scale velocity profiles which are smoother and less top-heavy compared to those produced by the WTG simulations. These large-scale parameterization methods provide a useful tool to identify the impact of parameterization differences on model behavior in the presence of two-way feedback between convection and the large-scale circulation.

Intercomparison of methods of coupling between convection and large-scale circulation: 1. Comparison over uniform surface conditions.

As part of an international intercomparison project, a set of single-column models (SCMs) and cloud-resolving models (CRMs) are run under the weak-temperature gradient (WTG) method and the damped gravity wave (DGW) method. For each model, the implementation of the WTG or DGW method involves a simulated column which is coupled to a reference state defined with profiles obtained from the same model in radiative-convective equilibrium. The simulated column has the same surface conditions as the reference state and is initialized with profiles from the reference state. We performed systematic comparison of the behavior of different models under a consistent implementation of the WTG method and the DGW method and systematic comparison of the WTG and DGW methods in models with different physics and numerics. CRMs and SCMs produce a variety of behaviors under both WTG and DGW methods. Some of the models reproduce the reference state while others sustain a large-scale circulation which results in either substantially lower or higher precipitation compared to the value of the reference state. CRMs show a fairly linear relationship between precipitation and circulation strength. SCMs display a wider range of behaviors than CRMs. Some SCMs under the WTG method produce zero precipitation. Within an individual SCM, a DGW simulation and a corresponding WTG simulation can produce different signed circulation. When initialized with a dry troposphere, DGW simulations always result in a precipitating equilibrium state. The greatest sensitivities to the initial moisture conditions occur for multiple stable equilibria in some WTG simulations, corresponding to either a dry equilibrium state when initialized as dry or a precipitating equilibrium state when initialized as moist. Multiple equilibria are seen in more WTG simulations for higher SST. In some models, the existence of multiple equilibria is sensitive to some parameters in the WTG calculations.

Dementia care: using empathic curiosity to establish the common ground that is necessary for meaningful communication.

Over the past two decades the advocates of person-centred approaches to dementia care have consistently argued that some of the negative impacts of dementia can be ameliorated in supportive social environments and they have given lie to the common but unfounded, nihilistic belief that meaningful engagement with people with dementia is impossible. This discussion paper contributes to this welcome trend by exploring how carers can use empathic curiosity to establish the common ground that is necessary to sustain meaningful engagement with people who have mild to moderate dementia. The first section of the paper gives a brief theoretical introduction to the concept of empathic curiosity, which is informed by perceptual control theory and applied linguistics. Three case examples taken from the literature on dementia care are then used to illustrate what empathic curiosity may look like in practice and to explore the potential impact that adopting an empathic and curious approach may have.

Empathic curiosity: resolving goal conflicts that generate emotional distress.

The quality of the therapeutic alliance between therapist and client is consistently identified as a key component of cognitive behavioural interventions. However, relatively little is known about the causal mechanisms that generate the effects that are ascribed to the therapeutic alliance. This paper outlines how one such causal mechanism, empathic curiosity, may operate. The explanation is rooted in control theory, a theory that explains the link between our experiences and our goal-directed behaviour. Empathic curiosity is underpinned by the core skills of empathic listening and maintaining a curious attitude. From a control theory perspective, the value of this type of listening may be reinforced when speak to people about their salient concerns, as they perceive them in the current flow of their conscious thoughts. This can be facilitated by linking curious questions to the non-verbal disruptions in their body posture and conversational flow. The approach is illustrated using three case examples. In all three examples, the clients involved were able to reflect upon and re-organize conflicting goals that had been a source of significant emotional distress.

Tracheo-oesophageal fistula diagnosed with multidetector computed tomography.

This case highlights important issues in investigation of patients with suspected tracheo-oesophageal fistula including the value of multidetector computed tomography, the importance of thorough imaging evaluation when high clinical suspicion of tracheo-oesophageal fistula exists and the value of close interaction between radiologists and intensive care physicians in the investigation of these patients.

Effect of gestational nutrition on vascular integrity in the murine placenta.

Maternal undernutrition is thought to result in smaller offspring and programme disease in later life. It is not known whether gestational nutrition affects development and functioning of placental vessels. The aim of this study was to ascertain if disturbed angiogenesis and junctional integrity were features of the labyrinthine vessels of placenta taken from transgenic Tie2-GFP mice fed either 18% (control) or 9% (low protein; MLP) casein diet. MLP animals showed a significant decrease in fetal weight at E14.5 and in placental and fetal weight at E18.5, however, maternal weight and litter size remained unaffected. Stereological analyses revealed that the fraction of components of the placenta remained similar in both study groups. There was a significant reduction in labyrinthine blood vessel length but not in luminal diameter in the E18.5 MLP group. In both MLP groups, perturbation of vascular endothelial Cadherin and beta-catenin, regulators of junctional integrity, permeability and quiescence, was observed with higher percentage of vessels showing weak or no junctional immunoreactivity. The reduction in length of the labyrinthine vessels and the downregulation of the adhesion molecules suggest that gestational undernutrition causes vascular dysfunction in the murine placenta. This may play a role in the early life programming of disease risk.

An experimentally confirmed statistical model on arm movement.

The purpose of this research work was to develop a methodology to model arm movement in normal subjects and neurologically impaired individuals through the application of a statistical modelling method. Thirteen subjects with Parkinson's disease and 29 normal controls were recruited to participate in an arm motor task. An infrared optoelectronic kinematic movement analysis system was employed to record arm movement at 50 times per second. This study identified the modified extended Freundlich model as one that could be used to describe this task. Results showed that this model fit the data well and that it has a good correspondence between the observed and the predicted data. However, verification of the model showed that the residuals contained a sizeable autocorrelation factor. The Cochrane and Orcutt method was applied to remove this factor, which improved the fit of the model. Results showed that Parkinson's disease subjects had a higher autocorrelation coefficient than the normal subjects for this task. A positive correlation (r(s) = 0.72, p < 0.001) was found between the Langton-Hewer stage and the autocorrelation coefficient of PD subjects. This finding suggests that if autocorrelation is positively correlated with disease progression, clinicians in their clinical practice might use the autocorrelation value as a useful indicator to quantify the progression of a subjects' disease. Significant differences in model parameters were seen between normal and Parkinson's disease subjects. The use of such a model to represent and quantify movement patterns provides an important base for future study.

The COSTAR wheelchair study: a two-centre pilot study of self-propulsion in a wheelchair in early stroke rehabilitation. Collaborative Stroke Audit and Research.

OBJECTIVE: It is uncertain whether self-propulsion in a wheelchair should be encouraged or discouraged in the early stages of stroke rehabilitation. DESIGN: A two-centre pilot study to assess the feasibility of performing a multicentre randomized controlled trial on this subject. SETTING: Clatterbridge and Aintree Stroke Rehabilitation Units, Merseyside, UK. SUBJECTS: Forty early stroke patients (mean age 67 years) in whom it was uncertain whether self-propulsion in a wheelchair should be encouraged were studied. INTERVENTION: A central randomization service at Newcastle University was used to determine the policy about wheelchair provision and use for each patient. They were allocated to either an 'encouraged to self-propel' or a 'discouraged from self-propulsion group'. OUTCOME MEASURES USED: Independent outcome assessment was performed by postal questionnaire and telephone interview using the Barthel ADL Scale, Nottingham Extended ADL Scales and the shortened General Health Questionnaire (GHQ-12) at 3 and 12 months. Patient's length of stay and their Ashworth tone score were also measured either at three months or when they were discharged from hospital. RESULTS: After considerable preparation time it was possible to conduct a trial on self-propulsion in early stroke rehabilitation in the two-pilot centres. No major differences were found between the pilot groups for any of the outcome measures. CONCLUSIONS: A multicentre randomized controlled trial to assess this question is feasible but further work is being conducted before proceeding, to satisfy the concerns expressed to our group regarding the appropriateness of the intervention and the outcome measures.

The interrelationship of subglottic air pressure, fundamental frequency, and vocal intensity during speech.

In this study we have simultaneously measured subglottic air pressure, airflow, and vocal intensity during speech in nine healthy subjects. Subglottic air pressure was measured directly by puncture of the cricothyroid membrane. The results show that the interaction between these aerodynamic properties is much more complex that previously believed. Certain trends were seen in most individuals, such as an increase in vocal intensity with increased subglottic air pressure. However, there was considerable variability in the overall aerodynamic properties between subjects and at different frequency and intensity ranges. At certain frequencies several subjects were able to generate significantly louder voices without a comparable increase in subglottic air pressure. We hypothesize that these increases in vocal efficiency are due to changes in vocal fold vibration properties. The relationship between fundamental frequency and subglottic pressure was also noted to vary depending on vocal intensity. Possible mechanisms for these behaviors are discussed.

Cisapride does not alter gastric volume or pH in patients undergoing ambulatory surgery.

PURPOSE: To evaluate the efficacy of 20 mg cisapride p.o. in reducing residual gastric volume and pH in adult ambulatory surgical patients. METHODS: Using a prospective randomised double-blind controlled design, we administered either 20 mg cisapride p.o. or placebo preoperatively to 64 ASA 1-2 ambulatory surgical patients. Following induction of anesthesia we measured volume and pH of residual gastric contents, using blind aspiration through an orogastric tube. Parametric data were analysed using unpaired, one tail Students' t test. Non-parametric data were analysed using Fishers Exact test and Chi square analysis. Statistical significance was accepted at the probability level of < 0.05. RESULTS: Residual gastric volumes were similar in the two groups (19.5 +/- 23.8, 23.9 +/- 24.4 ml), in the cisapride and placebo groups respectively, P=0.24). Data shown are mean (+/- SD). The proportions of patients with a residual gastric volume exceeding 0.4 ml x kg(-1) were similar in the two groups (4 of 28, and 8 of 23 patients in the cisapride and placebo groups respectively, P=0.09). The pH of the residual gastric contents were similar in the cisapride and placebo groups (1.6 +/- 0.5, 1.4 +/- 0.5, respectively, P=0.26). The proportions of patients with pH < 2.5 was also similar in the cisapride and placebo groups (21 of 25, and 20 of 21 patients respectively, P=0.2). CONCLUSIONS: Preoperative administration of 20 mg cisapride p.o. to patients scheduled for outpatient surgery does not alter either the volume or the pH of gastric contents. Its use in this setting is of no apparent clinical benefit.

Topical amethocaine (Ametop) is superior to EMLA for intravenous cannulation. Eutectic mixture of local anesthetics.

PURPOSE: A eutectic mixture of local anesthetics (EMLA) is commonly used to provide topical anesthesia for intravenous (i.v.) cannulation. One of its side effects is vasoconstriction, which may render cannulation more difficult. A gel formulation of amethocaine (Ametop) is now commercially available. The aim of this study was to compare EMLA and Ametop with regard to the degree of topical anesthesia afforded, the incidence of vasoconstriction and the ease of i.v. cannulation. METHODS: Thirty two ASA I adult volunteers had a #16 gauge i.v. cannula inserted on two separate occasions using EMLA and Ametop applied in a double blind fashion for topical anesthesia. Parameters that were recorded after each cannulation included visual analogue pain scores (VAPS), the presence of vasoconstriction and the ease of cannulation, graded as: 1 = easy, 2 = moderately difficult, 3 = difficult and 4 = failed. RESULTS: The mean VAPS +/- SD after cannulation with Ametop M was 12+/-9.9 and with EMLA was 25.3+/-16.6 (P = 0.002). Vasoconstriction occurred after EMLA application on 17 occasions and twice after Ametop (P = 0.001). The grade of difficulty of cannulation was 1.44+/-0.88 following EMLA and 1.06+/-0.25 with Ametop (P = 0.023). CONCLUSIONS: Intravenous cannulation was less painful following application of Ametop than EMLA. In addition, Ametop caused less vasoconstriction and facilitated easier cannulation. Its use as a topical anesthetic agent is recommended, especially when i.v. access may be problematic.

Direct measurement of subglottic pressure and laryngeal resistance in normal subjects and in spasmodic dysphonia.

This study tested the accuracy of indirect methods of measurement of laryngeal airway resistance in normal subjects and in spasmodic dysphonia (SD). The indirect method assumes that subglottic air pressure remains constant during the voiced segment of a syllable. In this study subglottic air pressure was directly measured via puncture of the cricothyroid membrane in seven normal subjects and seven subjects with SD. The true laryngeal airway resistance was calculated and compared with airway resistance measured using indirect techniques based on intraoral air pressure. In five of the seven normal subjects, subglottic air pressure did not remain constant during the voiced segment. As a result, the error produced using indirect method of calculating average laryngeal resistance for the normal subjects varied from -44% to +50%. For SD subjects the error ranged from -49% to +22%. In general, the indirect technique overestimated laryngeal airway resistance in normal subjects and underestimated the resistance in subjects with SD.

Image analysis of benign and malignant neck masses.

Current techniques for differentiating benign and malignant neck masses in computed tomography scans rely on basic features such as size and image density. Advances in digital imaging have led to development of sophisticated computerized image processing tools. Four different image processing algorithms were used to compare 10 patients with neck masses positive for squamous cell carcinoma and 11 patients with benign neck nodes. Statistically significant differences were seen between the malignant and benign masses for edge analysis and Fourier analysis. Significant differences were also seen in several texture parameters, although these results were considered less reliable. There were no differences between the two groups when compared by histogram analysis. It is concluded that both edge analysis and Fourier analysis can provide additional information to distinguish benign and malignant neck masses.

Anatomy and physiology of swallowing in adults and geriatrics.

Key anatomic and physiologic features that play an important role in normal and abnormal swallowing in the adult are described. Highlighted topics include the neurologic afferent and efferent control mechanisms, the effect of stroke on these mechanisms, and the upper and lower esophageal sphincters.

Pullout strength of adaption screws in thyroid cartilage.

PURPOSE: To determine the pullout strength of adaption screws in laryngeal cartilage and its relationship to drill hole and screw diameter. MATERIALS AND METHODS: Screw pullout strength in human cadaver thyroid cartilage was measured using a load cell. Screw sizes of 1.3, 1.5, and 2.0 mm were tested using drill hole diameters of 0.76, 1.1, and 1.5 mm. RESULTS: Maximum pullout strength was achieved using a drill hole diameter of 0.76 mm and a 1.5 mm screw. Pullout strength for this combination was 27.5 N. CONCLUSION: Adaption screws can be used in thyroid cartilage but pullout strengths will be less than in bone. Drill holes for screws in thyroid cartilage should be smaller than those used for cortical bone. Maximum strength will be achieved using a 1.5 mm screw in a 0.76 mm drill hole.

Analysis of voice changes after thyroplasty using linear predictive coding.

Objective measurement of vocal quality is difficult in patients with severe voice disorders. Improved success has been reported using a modeling technique known as linear predictive coding. This technique uses an inverse filter to estimate a glottic excitation signal. The pitch amplitude is defined as the height of the first peak of the autocorrelation of the glottic excitation signal. In this study linear predictive coding was used to analyze voice disorders in patients with vocal fold immobility. Voice recordings were made in 16 patients undergoing vocal fold medialization and 10 patients who had no surgical procedure between measurements. The voice quality was rated by three speech pathologists. Five acoustic parameters were calculated from the samples. The best agreement with the listeners' perceptual analysis was achieved using the pitch amplitude. Both pitch amplitude and the perceptual ratings of voice quality improved in patients undergoing vocal fold medialization. Therefore the linear model of speech production and inverse filtering are useful in measuring vocal quality in patients with vocal fold immobility.

Computerised augmentative communication devices for people with dysphasia: design and evaluation.

Recent developments in low-cost computer technology suggest that substantial improvements are possible in communication aids for dysphasic patients. This study describes a recently developed communication aid and reports a case study of one application. The software (EasySpeaker for Windows) provides an easily customized and flexible icon-based communication aid, which does not require the ability to read text, but which automatically records in detail the use being made of the device. The aid was given to a dysphasic patient in his own home for 4 weeks. Regular activity sessions were held throughout the period and data obtained from these sessions to identify learning and improvement on the device. Although improvements were found in speed and accuracy of operation, the use made of the aid for real communication by this patient was limited. Several possible reasons are identified for this and, in particular, the importance of illustrating specifically how such a system can be of benefit is emphasised.

Initial motivations for alcohol treatment: relations with patient characteristics, treatment involvement, and dropout.

This study examines (a) the relation of initial treatment motivations to alcoholics' involvement in outpatient treatment and dropout and (b) the relations among patient characteristics, severity, alcohol expectancies, motivation, and treatment retention. A treatment motivation questionnaire (TMQ) was developed to assess both internalized and external motivations for treatment, as well as confidence in the treatment and orientation towards interpersonal help seeking. In Study 1, the TMQ was administered to 109 outpatients entering an alcoholism clinic. Based on these data the scale was revised and was administered to a subsequent sample of 98 subjects seeking treatment. Information about demographic variables, measures of substance use, alcohol expectancies, and psychiatric severity was also gathered. Eight weeks after intake, outcome was evaluated through attendance records and clinician ratings. Results revealed that internalized motivation was associated with greater patient involvement and retention in treatment. Subjects high in both internalized and external motivation demonstrated the best attendance and treatment retention while those low in internalized motivation showed the poorest treatment retention while those low in internalized motivation showed the poorest treatment response, regardless of the level of external motivation. Problem severity was also related to a greater degree of internalized motivation. The importance of initial motivations in understanding treatment response and dropout is discussed.