Inpatient education reduces length of outpatient oxygen therapy in bronchopulmonary dysplasia: A quality improvement project.

BACKGROUND: Patients discharged on home oxygen therapy (HOT) for bronchopulmonary dysplasia (BPD) often receive months of this therapy. A previous trial comparing two methods of HOT weaning showed that increased parent involvement in HOT weaning decreased HOT duration. Our outpatient team uses a standard protocol for outpatient HOT weaning, starting at the first clinic visit 4-6 weeks after discharge. AIM: To shorten HOT duration by teaching parents the outpatient HOT weaning process before neonatal intensive care unit (NICU) discharge. METHODS: We launched a quality improvement program in April 2021 for preterm infants with BPD without significant comorbidities who were stable on ≤0.5 L nasal cannula. Eligible infants started the outpatient HOT weaning protocol while inpatient, with education for parents and nurses. The outcome measure was the duration of HOT after discharge. Process measures focused on protocol adherence. Balancing measures included NICU length of stay and appropriateness of parent-directed HOT weaning. RESULTS: During the study period, there were a total of 133 eligible patients discharged on home oxygen, with 75 in the baseline group and 58 in the intervention group. Forty-five (78%) participated in the HOT weaning protocol while inpatient. HOT was reduced from an average of 27 to 12 weeks after May 2021. We observed no change in NICU length of stay or inappropriate HOT weaning. CONCLUSION: Early introduction of HOT weaning with a focus on caregiver education is associated with a decreased duration of HOT.

Femtosecond laser lenticule transplantation in rabbit cornea: experimental study.

PURPOSE: To evaluate the feasibility of femtosecond laser-induced lenticule transplantation in the rabbit cornea and to observe the relative histologic characteristics of corneal tissue and nerve repair after transplantation. METHODS: Eight healthy, purebred, New Zealand white rabbits underwent femtosecond laser small-incision lenticule extraction (SMILE) surgery in the right eye. Lenticules were inserted into a femtosecond laser-created corneal stromal pocket in the left eye, which was defined as femtosecond laser corneal lenticule transplantation. Postoperative observation and examination were completed to evaluate the surgery. RESULTS: In the early postoperative period, inflammation of the cornea was noted, tissue around the lenticule was edematous, and cells were activated. Tissue edema remained at postoperative day 10. By 1 month, edema had resolved, activated cells gradually became quiescent, and nerve fiber regeneration was observed. By 3 months, the lenticule integrated into the recipient cornea, extracellular matrix gradually cleared, and thicker nerve fibers were noted. By 6 months postoperative, morphology and distribution of the corneal stromal fibers were close to normal, and the number of nerve fibers was reduced. CONCLUSIONS: Femtosecond laser corneal lenticule transplantation in rabbits is feasible, as the lenticule was shown to thrive and integrate with the recipient stroma. Nerve regeneration begins after 1 month.

Effect of preoperative retinal sensitivity and fixation on long-term prognosis for idiopathic macular holes.

BACKGROUND: To study the roles of preoperative retinal sensitivity and fixation exams in predicting the long-term prognosis of idiopathic macular hole (IMH) patients after successful vitrectomy. METHODS: A total of 39 IMH patients (39 eyes) were included in this prospective cohort case series study. Twenty-three gauge pars plana vitrectomy was performed on each patient. Results of best-corrected visual acuity (BCVA), macular hole diameter, MP - 1 microperimetry (MP - 1) tests, and continuity of the photoreceptor inner and outer segment (IS/OS) junction were recorded for analysis. RESULTS: Postoperative BCVA at 12 months was significantly correlated with macular hole diameters (p < 0.05), preoperative BCVA (p = 0.020), mean retinal sensitivity (p < 0.001), and fixation location percentage (p < 0.001). However, merely preoperative mean retinal sensitivity (r = 0.5448, p < 0.001) and fixation location percentage (r = 0.5624, p < 0.001) were suggested to be quantitatively predictive for the visual prognosis by multiple stepwise linear regression analysis. Moreover, patients that had smaller hole sizes (p < 0.01), better mean retinal sensitivity (p = 0.003), higher fixation quality scores, and higher fixation location percentage (p = 0.008) before surgery were prone to get continuous IS/OS junction 12 months after surgery. CONCLUSIONS: MP-1 exams evaluate the dysfunctional hole margin and thus provide more comprehensive information of the preoperative visual function of IMH patients. Both mean retinal sensitivity and fixation behaviors are ideal measurements in predicting the prognosis after successful macular hole surgery.

Delirium in the Neonate.

Delirium is likely present in the neonatal intensive care unit and has been largely unrecognized. There are several risk factors for delirium including illness severity, neurosedative exposure, and environmental disruptions that put infants at risk for delirium. Regular use of scoring systems should be considered to improve delirium detection. When identified, initial steps in management should include resolving underlying causes and implementation of standard nonpharmacologic measures. Mounting pediatric evidence suggests that the atypical antipsychotics, as well as the α-2 agonists, may be additionally beneficial in treating delirium as well as improving the ability to wean off other neurosedative medications.

Quality Improvement Approach to Reducing Admission Hypothermia Among Preterm and Term Infants.

BACKGROUND: Newborns, particularly premature newborns, are susceptible to hypothermia when transitioning from birth to admission to the NICU, potentially leading to increased mortality and morbidity. Despite attention to this issue, our rate of admission hypothermia was 39.8%. METHODS: We aimed to reduce the rate of admission hypothermia for all inborn infants admitted to our institution to <10%. We undertook a quality improvement effort that spanned from 2013 through 2019 in our level IV NICU. Current state analysis involved investigating patient risk factors for hypothermia and staff understanding of hypothermia prevention. Improvement cycles included auditing processes, an in-hospital relocation of our NICU, expanded use of chemical heat mattresses and polyethylene bags, and staff education. Improvement was evaluated by using Shewhart control charts. RESULTS: We demonstrated a reduction in admission hypothermia from 39.8% to 9.9%, which was temporally related to educational efforts and expanded use of chemical heat mattresses and polyethylene bags. There was not an increase in admission hyperthermia over this time period. We found that our group at highest risk of admission hypothermia was not our most premature cohort but those infants born between 33 and 36 6/7 weeks' gestation and those infants prenatally diagnosed with congenital anomalies. CONCLUSIONS: Expanded use of polyethylene bags and chemical heat mattresses can improve thermoregulation particularly when combined with staff education. Although premature infants have been the focus of many hypothermia prevention efforts, our data suggest that older infants, and those infants born with congenital anomalies, require additional attention.

Updating signal typing in voice: addition of type 4 signals.

The addition of a fourth type of voice to Titze's voice classification scheme is proposed. This fourth voice type is characterized by primarily stochastic noise behavior and is therefore unsuitable for both perturbation and correlation dimension analysis. Forty voice samples were classified into the proposed four types using narrowband spectrograms. Acoustic, perceptual, and correlation dimension analyses were completed for all voice samples. Perturbation measures tended to increase with voice type. Based on reliability cutoffs, the type 1 and type 2 voices were considered suitable for perturbation analysis. Measures of unreliability were higher for type 3 and 4 voices. Correlation dimension analyses increased significantly with signal type as indicated by a one-way analysis of variance. Notably, correlation dimension analysis could not quantify the type 4 voices. The proposed fourth voice type represents a subset of voices dominated by noise behavior. Current measures capable of evaluating type 4 voices provide only qualitative data (spectrograms, perceptual analysis, and an infinite correlation dimension). Type 4 voices are highly complex and the development of objective measures capable of analyzing these voices remains a topic of future investigation.

Objective acoustic analysis of pathological voices from patients with vocal nodules and polyps.

OBJECTIVE: We aim to examine the abilities of objective acoustic analysis methods (nonlinear dynamic and traditional perturbation measures) to describe voices from individuals with vocal nodules and polyps. SUBJECTS AND METHODS: Sustained vowel recordings from normal subjects, patients with vocal nodules, and patients with vocal polyps were analyzed. Perturbation measures of jitter and shimmer were obtained with the Multi-Dimensional Voice Program (MDVP) and CSpeech. Signal-to-noise ratio was calculated using CSpeech. Nonlinear dynamic measures of phase space reconstruction and correlation dimension were also applied to analyze the voices. RESULTS: A significant difference between normal and polyp groups was found in jitter and shimmer obtained from MDVP, as well as in jitter and signal-to-noise ratio from CSpeech. However, no parameters significantly differentiated between normal and nodule groups. Shimmer from CSpeech did not reveal any significant differences among any of the groups. Correlation dimension values for the nodule and polyp groups were significantly higher than the normal group. CONCLUSION: Nonlinear dynamic analysis has great potential value for the characterization of voice from patients with vocal nodules and polyps. The combination of traditional perturbation and nonlinear dynamic measures may improve our ability to provide objective clinical analysis of voices with vocal mass lesions.

The effect of segment selection on acoustic analysis.

OBJECTIVE/HYPOTHESIS: Acoustic analysis is a commonly used method for quantitatively measuring vocal fold function. Voice signals are analyzed by selecting a waveform segment and using various algorithms to arrive at parameters such as jitter, shimmer, and signal-to-noise ratio (SNR). Accurate and reliable methods for selecting a representative vowel segment have not been established. STUDY DESIGN: Prospective repeated-measure experiment. METHODS: We applied a moving window method by isolating consecutive, overlapping segments of the raw voice signal from onset through offset. Ten normal voice signals were analyzed using acoustic measures calculated from the moving window. The location and value of minimum perturbation/maximum SNR was compared across individuals. The moving window method was compared with data from the whole vowel excluding onset and offset, the mid-vowel, and the visually selected steadiest portion of the voice signal. RESULTS: Results showed that the steadiest portion of the waveforms, as defined by minimum perturbation and maximum SNR values, was not consistent across individuals. Perturbation and nonlinear dynamic values differed significantly based on what segment of the waveform was used. Other commonly used segment selection methods resulted in significantly higher perturbation values and significantly lower SNR values than those determined by the moving window method (P<0.001). CONCLUSIONS: The selection of a sample for acoustic analysis can introduce significant inconsistencies into the analysis procedure. The moving window technique may provide more accurate and reliable acoustic measures by objectively identifying the steadiest segment of the voice sample.

A new method of reconstructing the human laryngeal architecture using micro-MRI.

OBJECTIVES/HYPOTHESIS: A realistic three-dimentional (3D) model of the larynx could be of value for the understanding of normal laryngeal motion and for studying pathological changes as well as in modeling potential therapy outcomes. The objective of this research was to present a new method of creating a computer model of the human larynx using data obtained through micro-magnetic resonance imaging (MRI) scanning. STUDY DESIGN: Prospective study. METHODS: A 7-T micro-MRI scanner was used to scan an excised larynx obtained postmortem from a 68-year-old woman. MRI data was manually segmented and compiled into 3D images using Mimics12.1 reconstruction software. Measurements of the reconstructed structures were also calculated using Mimics12.1. RESULTS: The 3D laryngeal model contained the thyroid, cricoid, and arytenoid cartilages. Nearly all of the intrinsic muscles could be segmented. Although the cricoarytenoid joint could be visualized, the features of the cricothyroid joint were not clear. Muscle and cartilage volumes and surface areas were calculated from the 3D model. CONCLUSIONS: The combination of MRI and 3D reconstruction generates promising results in the hopes of creating a highly realistic and detailed model of the human larynx.

Perturbation and nonlinear dynamic analysis of adult male smokers.

OBJECTIVE: Smoking results in a voice change, and the perception by smokers of an abnormal voice may encourage quitting behavior. Moreover, a disordered voice is often the first sign of vocal pathology. Efforts to evaluate voice have focused on classical acoustic analysis; however, nonlinear dynamic analysis has been shown to be a reliable objective method for the evaluation of voice. We compare the discriminatory ability of these two methods when applied to normal and smokers' voices. STUDY DESIGN: Prospective study. METHODS: The study included 73 subjects, 36 nonsmokers and 37 smokers. A segment of sustained vowel production was obtained from each subject. Acoustic dimension and correlation dimension (D2) analyses were applied to the data. Results were compared with a Mann-Whitney rank sum test, logistic regression, and receiver operating characteristics (ROC) analysis. RESULTS: D2 values for smokers were significantly higher than D2 values for nonsmokers (P<0.001). Jitter and shimmer analysis showed higher values for these parameters among smokers. Logistic regression indicated a higher predictive power with D2, and ROC analysis found no significant difference between the analysis methods. DISCUSSION: This study indicated that D2 is highly sensitive to changes associated with smoking and has the potential to be implemented clinically as an indicator of abnormal voice. Further research could focus on using nonlinear dynamic analysis to create a normative database, producing standards for monitoring voice changes caused by cigarette smoking.

Implantation of gelatin sponge combined with injection of autologous fat for sulcus vocalis.

OBJECTIVE: To evaluate the effectiveness of gelatin sponge implantation combined with the injection of autologous fat for the treatment of sulcus vocalis. STUDY DESIGN: Prospective cohort study. SETTING: The research was conducted at the Eye, Ear, Nose, and Throat Hospital of Fudan University. SUBJECTS AND METHODS: Twelve cases of sulcus vocalis were treated. The fibrotic tissue was dissected and a gelatin sponge was implanted into the affected vocal fold followed by injection of autologous fat. Videostroboscopy, maximum phonation time (MPT), and acoustic data were completed before and after surgery. RESULTS: One month after surgery, the affected vocal fold displayed mild swelling, without evidence of a sulcus and with satisfactory glottal closure. Three months later, vocal vibration and mucosal wave were improved with the vocal fold displaying a more normal shape. Although voices did not achieve complete normalcy, the patients exhibited a better voice, with improved fundamental frequency, jitter, shimmer, normalized noise energy, and a significantly longer maximum phonation time (P < 0.05). CONCLUSION: Implantation of gelatin sponge combined with injection of autologous fat can be used to treat sulcus vocalis. The absorbable gelatin sponge can be used to fill the superficial lamina propria temporarily to prevent the readhesion of the detached mucosa at the bottom of the sulcus to the underlying tissue, while the injected fat adequately diminishes the insufficient glottal closure.

Acoustic analysis of the tremulous voice: assessing the utility of the correlation dimension and perturbation parameters.

UNLABELLED: Acoustic analysis may provide a useful means to quantitatively characterize the tremulous voice. Signals were obtained from 25 subjects with diagnoses of either Parkinson's disease or vocal polyps exhibiting vocal tremor. These were compared to signals from 24 subjects with normal voices. Signals were analyzed via correlation dimension and several parameters from the Multi-Dimensional Voice Program (MDVP): percent jitter, percent shimmer, amplitude tremor intensity index (ATRI), frequency tremor intensity index (FTRI), amplitude tremor frequency (Fatr), and fundamental frequency tremor frequency (Fftr). No significant difference was found between the tremor and control groups for ATRI and Fatr. Percent jitter, percent shimmer, FTRI, Fftr, and correlation dimension values were found to be significantly higher in the tremor group than in the control group. We conclude that these parameters may have utility for the clinical quantification of tremor severity and treatment effects. LEARNING OUTCOMES: The reader will understand the utility of applying select perturbation parameters and the nonlinear measure of correlation dimension for the characterization of the tremulous voice.

Transoral laser surgery for anterior commissure involvement: a study in canines.

OBJECTIVE: To present laser surgery techniques to address anterior commissure involvement and evaluate recovery. METHODS: Twelve canines were divided into three groups. In group A the right ventricular band and vocal fold, the anterior third of the left vocal fold, and anterior commissure were cauterized. In group B cauterization was extended to the thyroid cartilage and a 5 mm x 5 mm area of the anterior commissural to half the cartilage thickness. In group C the 5 mm x 5 mm window was extended through the thyroid cartilage. Surgical lesions were observed after surgery and at 1 and 4 weeks post-surgery. RESULTS: Post-operative gross examination confirmed target scopes. One week after surgery, the lesions in group A were completely covered by neo-mucosa, while group B and C wounds were only partially covered. After 4 weeks, a laryngeal web was seen at the anterior commissure and the vocal fold length was shortened. Lesions in all three groups were completely covered by neo-mucosa. Collagen proliferation was most prominent in group C with limited scarring in group A. There were no major complications. CONCLUSIONS: The three operative methods demonstrated satisfactory outcomes; the lesions recovered well over the course of 4 weeks, and no severe complications occurred. The laser surgery protocol was successfully extended into the thyroid cartilage.

Inhibitory effect on LPS-induced retinal microglial activation of downregulation of t-PA expression by siRNA interference.

PURPOSE: This study investigated the expression and release of tissue plasminogen activator (t-PA) in lipopolysaccharide (LPS)-induced retinal microglia activation. We evaluated change in microglia activation following down-regulation of t-PA expression by siRNA interference. METHODS: The primary cultured microglia cells were isolated from retinas of S-D rats and activated with different concentration of LPS (0, 3, 10, 30, 100, and 300 ng/ml). Double immunofluorescence (OX42 and tPA) and Western blot were used to detect t-PA expression. Next, tPA expression was down-regulated by siRNA interference, the microglia transfected with tPA siRNA lentivirus or blank control lentivirus were activated with 30 ng/ml of LPS, the culture supernatant was collected 1, 3, 6, 12, and 24 hours after LPS treatment for IL-1beta and TNF-alpha ELISA assays, and the cells were collected 24 hours later for immunocytochemistry of microglia markers (OX42 and Iba-1) and quantitative real-time PCR to determine the inhibitory efficiency of t-PA siRNA. Transfection efficiency was evaluated with flow cytometry by EGFP expression. RESULTS: The microglia expressed t-PA when treated with LPS in a dose-dependent pattern. The expression was down-regulated by siRNA interference markedly; the inhibitory efficiency was 80% as determined by quantitative real-time PCR. Transfection efficiency during siRNA interference was 88%. The expression of Iba-1 and the release of IL-1beta and TNF-alpha were inhibited significantly when the t-PA expression was knocked down. CONCLUSIONS: Activated microglia express t-PA. Down-regulation of t-PA expression can inhibit the activation of microglial cell.

Phonation threshold flow measurements in normal and pathological phonation.

OBJECTIVES/HYPOTHESIS: Phonation threshold flow (PTF) may provide a tool to assess laryngeal function and could differentiate between normal and pathological voices. Both polyps and nodules contribute to an increased PTF by creating an incomplete glottal closure and increased vocal fold mass and thickness. STUDY DESIGN: Prospective study. METHODS: The Kay Elemetrics Phonatory Aerodynamic System (PAS) (Kay Elemetrics Corp., Lincoln Park, NJ) was used to collect mean flow rate (MFR) and PTF measurements from 40 normal subjects, 21 patients with vocal fold nodules, and 23 patients with vocal fold polyps. Gender-based differences were assessed using a t test. The effect of vocal pathology on PTF and MFR was determined with an ANOVA. Diagnostic potential was evaluated using a receiver operation characteristics (ROC) analysis. RESULTS: Both PTF (P = .047) and MFR (P = .008) were significantly affected by gender. Using a two-way ANOVA and correcting for gender differences, the influence of pathology on PTF was determined to be significant (P < .001). Post hoc tests found a significant difference between normal and polyp subjects (P < .001) but not normal and nodule subjects (P = .177) or nodule and polyp subjects (P = .246). ROC analysis found that PTF (area under the curve [AUC] = 0.691) and MFR (AUC = 0.684) had a similar diagnostic utility. CONCLUSIONS: PTF can be used to differentiate between normal and pathological voices. As a parameter that is experimentally sensitive to the biomechanical parameters providing its theoretical basis, it could be used clinically to analyze laryngeal functionality. Future research could focus on measuring PTF in other pathologies, such as paralysis or scarring, which would also affect the effort required to produce voice.