Vascular access and clinical competency: Which elements matter? The development of three bottom-up and evidence-grounded self-assessment tools.

BACKGROUND: Assessing competency in the speciality of vascular access is still limited, and few valid and reliable tools are available. Therefore, this study aimed to develop and validate three different tools for assessing competency in managing the care of short peripheral cannulas (SPCs), midlines, peripherally inserted central catheters (PICCs), centrally inserted central catheters (CICCs), and arterial catheters (ACs) (tool one), placing SPCs (tool two), placing PICCs and midlines (tool three). METHODS: A two-phase and multi-method design was adopted. Phase one was implemented to develop the initial pool of items for each tool, starting from a literature overview. Panel discussions were adopted for developing the items. In phase two, the developed items were tested for content and face validity, involving a panel of 10 experts. Once obtained adequate content validity, a cross-sectional data collection was implemented to enroll three samples of healthcare workers who had to assess their competency through the developed tools. Dimensionality was assessed by performing a principal component analysis (PCA) and assessing internal consistency (Cronbach's α). RESULTS: Tool one had 26 items, and the dimensionality was given by placement, risk assessment, procedure conformity and traceability, and patient education to self-care. Tool two had 35 items; its principal components were: risk evaluation, identification, clinical assessment and orientation to self-care, placement, and procedure registration shaped the competency of placing SPCs. Tool three had 31 items; its principal components were: risk assessment, placement, conformity to standards and procedure traceability, education, and orientation to self-care were the essential elements for adequately placing midlines and PICCs. Cronbach's α values ranged between 0.806 and 0.959. CONCLUSIONS: The three developed tools reflected the core elements of competency in each application area, representing an initial framework that could be useful in future research and educational projects. Cross-national investigations are required to corroborate the described results.

Artificial intelligence for the recognition of benign lesions of vocal folds from audio recordings.

Objective: The diagnosis of benign lesions of the vocal fold (BLVF) is still challenging. The analysis of the acoustic signals through the implementation of machine learning models can be a viable solution aimed at offering support for clinical diagnosis. Materials and methods: In this study, a support vector machine was trained and cross-validated (10-fold cross-validation) using 138 features extracted from the acoustic signals of 418 patients with polyps, nodules, oedema, and cysts. The model's performance was presented as accuracy and average F1-score. The results were also analysed in male (M) and female (F) subgroups. Results: The validation accuracy was 55%, 80%, and 54% on the overall cohort, and in M and F, respectively. Better performances were observed in the detection of cysts and nodules (58% and 62%, respectively) vs polyps and oedema (47% and 53%, respectively). The results on each lesion and the different patterns of the model on M and F are in line with clinical observations, obtaining better results on F and detection of sensitive polyps in M. Conclusions: This study showed moderately accurate detection of four types of BLVF using acoustic signals. The analysis of the diagnostic results on gender subgroups highlights different behaviours of the diagnostic model.

Evaluation of the Electroglottographic Signal Variability in Organic and Functional Dysphonia.

OBJECTIVES: To confirm the data reported in our previous studies on the analysis of the variability of the electroglottographic signal in the pathological voice; to evaluate possible differences in variability between organic and functional pathologies; to identify any distinctive/typical EGG patterns for these pathologies. METHODS: One hundred twenty-five subjects were enrolled (36 euphonic and 89 pathological: 24 functional dysphonia, 21 bilateral vocal nodules, 23 unilateral polyps and 21 unilateral cysts). All subjects were studied with videolaryngostroboscopy, spectrographic analysis of voice and electroglottography (EGG). The EGG signal variability was then investigated using amplitude-speed combined analysis, by means of a proprietary software algorithm. Amplitude and Speed variation were expressed as a new parameter, the Variability Index (VI), calculated both for the whole EGG signal recorded (VI-tot) and in each phase of the glottic cycle (VI-Q, absolute value; VI-Q%, percentage value). RESULTS: In the comparison of VI values between pathological and normal groups, VI-tot and VI-Q2% (which corresponds to the final phase of vocal fold contact) were significantly greater in pathological subjects (P= 0.002). The comparison of VI values among subgroups of the various pathologies showed a difference for VI-tot (P< 0.0001) and VI-Q2% (P= 0.001); this difference was more marked in the cysts than in the functional dysphonia. The cut-off values of VI-tot and VI-Q2% were 0.191 and 18.17%, respectively (sensitivity and specificity 65.2% and 66.7% for VI-tot and 84.3% and 77.8% for VI-Q2%). CONCLUSIONS: The variability of the EGG signal investigated through the combined analysis of the amplitude and the speed of vibration using a proprietary algorithm software has proved useful not only to distinguish the normal voice from the pathological voice, but also to characterize which phases are more altered in the various voice pathologies studied, both functional and organic. Furthermore, the analysis of the VI parameter allowed to propose cut-off values characterized by a good sensitivity and specificity to discriminate dysphonia from the euphonic voice. Larger groups of patients will be needed to confirm these results.

Respiratory retraining therapy in long-term treatment of paradoxical vocal fold dysfunction.

OBJECTIVES: Paradoxical vocal fold dysfunction (PVFD) is a disorder in the larynx featuring involuntary adduction of the vocal folds during the inspiratory phase of breathing. The symptoms include acute episodes of dyspnea and bouts of coughing. To date, there is no universally acknowledged treatment for PVFD, though respiratory retraining therapy is the treatment of choice. AIMS: The purpose of this work was to evaluate the results of long-term respiratory retraining therapy in cases of PVFD. PATIENTS AND METHODS: We treated 20 patients with PVFD for 2 years: 10 subjects were submitted to a cycle of respiratory retraining therapy every 12 months (receiving a total of 3 cycles) while 10 were given a cycle every 3 months (for a total of 9 cycles) no matter what their clinical conditions were. RESULTS: The results show that long-term respiratory retraining is particularly efficacious if the cycles of treatment are repeated, no matter what clinical conditions are present. In fact, when only one cycle of retraining treatment is given a year, there is initial improvement followed by progressive worsening. CONCLUSIONS: Long-term respiratory rehabilitation is effective, especially if the treatment is given at least once every 3 months.

Sex hormone receptors in vocal fold tissue: a theory about the influence of sex hormones in the larynx.

OBJECTIVE: The larynx is considered a secondary sexual organ. To demonstrate that sex hormones can directly influence laryngeal function, specific receptors in the vocal cord must be identified. MATERIALS AND METHODS: We searched for estrogen, progesterone and androgen receptors, using an immunohistochemical method, in normal human vocal cords (from 3 cadavers) and in samples of healthy vocal cords and of laryngeal carcinomas from 15 live subjects. Breast and prostate carcinoma were used as controls. RESULTS: In all the normal samples tested, the results were negative; there was only a nonspecific cytoplasmatic response in the subepithelial glands (false positives). In the neoplastic tissue, 2 samples had a weak nuclear focal positivity for estrogen and progesterone receptors; all 15 subjects studied were negative for androgen receptors. CONCLUSIONS: Since our data show that sex hormone receptors are absent in the vocal cords, other theories must be considered to explain the fact that hormones influence the quality of the voice. This study discusses the possibility that the changes of voice according to gender and throughout life might be linked with a different expression of some growth factors in the laryngeal tissue and that this expression might in turn be influenced by hormonal variations.

Elevated antithyroid peroxidase and antinuclear autoantibody titers in Ménière's disease patients: more than a chance association?

OBJECTIVE/HYPOTHESIS: The aim of this prospective study is to evaluate the possible association between Ménière's disease (MD) and autoantibodies. METHODS: Fifty-five patients with definite MD (51 unilateral and 4 bilateral) were matched with 55 patients with unilateral vestibular paresis without cochlear involvement and 55 healthy subjects. Blood samples were collected from all study subjects for the determination of serum TSH, free triiodothyronine, free thyroxine, anti-TSH receptor antibody, antithyroperoxidase antibody, antithyroglobulin antibody and of antibodies to non-organ-specific antigens, namely antinuclear antibodies, antibodies to extractable nuclear antigens and antineutrophilic cytoplasmic antibodies. RESULTS: Thirty-three subjects (60%) of the MD group had 1 or more elevated serum autoantibody levels, both organ and non-organ specific; 16 patients (29.1%) with unilateral vestibular paresis had 1 or more elevated serum autoantibody levels, while 13 healthy subjects (23.6%) had 1 or more elevated serum autoantibody levels. CONCLUSIONS: Based on our data we speculate that there is a more than a chance association between MD and 'autoimmunity', thus suggesting a hypothetical role of the immune system in MD pathogenesis. In other words, a pathogenetic role of an 'immune dysregulation' in MD patients can be hypothesized.

Expression of 3-nitrotyrosine, a marker for peroxynitrite, in nasal polyps of nonatopic patients.

BACKGROUND: Several works have reported that nitric oxide and free oxygen radicals are up-regulated in nasal polyposis. This study aimed to assess the distribution of peroxynitrite in nasal polyps from nonatopic patients. Occurrence of peroxynitrite also was analyzed in relation with eosinophil infiltration and epithelial alterations. MATERIAL/METHODS: Hematoxylin and eosin staining was used for histologic study. Peroxynitrite was assessed by 3-nitrotyrosine immunohistochemistry. Quantitative evaluation was done by measuring the total number of eosinophils, the number of 3-nitrotyrosine-positive eosinophils, and the extension of the various epithelial alterations. RESULTS: Hematoxylin and eosin staining showed that the nasal polyp epithelium is characterized by progressive disruption or squamous metaplasia. In both cases, infiltrating eosinophils were found in the epithelium and lamina propria. The regions featuring epithelial disruption exhibited 3-nitrotyrosine immunostaining in eosinophils and epithelial cells; hematoxylin-and-eosin - stained eosinophils and 3-nitrotyrosine - positive eosinophils showed conspicuous variations in number. Within the regions featuring squamous metaplasia, 3-nitrotyrosine-positive eosinophils were rarely found, and the epithelium exhibited 3-nitrotyrosine only in the superficial cells. In these regions, hematoxylin-eosin - stained eosinophils showed slight variations in number. CONCLUSIONS: Peroxynitrite plays a pivotal role in the pathophysiology of nasal polyps. In fact, strong expression of peroxynitrite is associated with epithelial disruption, while poor expression of peroxynitrite is associated with squamous metaplasia. Peroxynitrite could influence afflux of eosinophils in the nasal mucosa; moreover, the total number of eosinophils is not critical in generating alterations of nasal polyp mucosa.

Endoscopic and Phoniatric Evaluation in Singing Students.

OBJECTIVES: In To analyze laryngostroboscopic findings and ENT/phoniatric examination results in a group of singing students and in a control group of non-singing subjects to emphasize the importance of ENT/phoniatric examination and of laryngostroboscopy before taking up singing. METHODS: 56 singing students and 60 healthy euphonic non-singer volunteers were recruited. In each subject a perceptual assessment and a self-assessment (VHI) of the voice were performed. The singing students filled out the Singing-VHI. All subjects underwent flexible fiberoptic endoscopy and laryngostroboscopy. All subjects were evaluated through the Reflux Symptom Index (RSI) and the Reflux Finding Score (RFS). RESULTS: At laryngostroboscopy, 60.7% of students presented pathological findings, versus 20% of controls (P < 0.0001). Incomplete glottic closure (35.7% vs. 13.3%), supraglottic hypertonus (16.1% vs. 5%), organic lesions (bilateral nodules, cysts, sulcus vergeture) (17.9% vs. 3.3%), posterior erythema (16.1% vs. 5%) and laryngeal edema (14.3% vs 3.3%) were more frequent in the students. The most common symptoms in singers were phonasthenia (37.5 % vs 6.7%; P = 0.0001) and mucus sensation (17.9% vs. 5%, P = 0.03). S-VHI showed higher values in students with pathological laryngostroboscopy (P < 0.0001). Finally, average RSI and RFS were higher in students. CONCLUSIONS: Due to the high percentage of organic and functional voice disorders in singing students, it would be desirable that every subject who is going to start singing underwent an ENT/phoniatric investigation with videostrobolaryngoscopy to ascertain vocal folds healthy condition.

The role of 99mTc-tetrofosmin scintigraphy for staging patients with laryngeal cancer.

Diagnosis and staging of laryngeal cancer is currently based on physical examination, endoscopy, and imaging techniques such as computed tomography (CT) and/or magnetic resonance (MR) and histology. While imaging techniques have a pivotal role for defining the size of the primary tumor, they are less accurate for defining metastatic involvement of regional lymph nodes, especially if lymph nodes are smaller than 10-15 mm. The aim of this study was to comparatively assess the relevance of (99m)Tc-tetrofosmin scintigraphy for the staging of laryngeal tumors versus the CT scan. We evaluated the sensitivity of imaging with (99m)Tc-tetrofosmin in 28 consecutively enrolled patients with squamous cell laryngeal carcinoma. Total-body scintigraphy with 99mTc-tetrofosmin was performed preoperatively, and the results were compared to CT images of the neck and mediastinum. CT and (99m)Tc-tetrofosmin scintigraphy were equally sensitive (96%) in identifying the primary tumor. While CT was more sensitive for detecting metastatic lymph nodes (100% versus 50%), (99m)Tc-tetrofosmin scintigraphy was more specific (100% versus 56%; p < 0.04). The overall diagnostic capabilities of the two techniques for detecting lymph node metastases were comparable (Youden Index: J = 0.56 for CT and J = 0.50 for (99m)Tc-tetrofosmin scintigraphy). (99m)Tc-tetrofosmin scintigraphy is a useful complement to CT for staging laryngeal tumors, especially for detecting metastatic lymph nodes and distant metastases.

Immunohistochemical localization of 3-nitrotyrosine in the nasal respiratory mucosa of patients with vasomotor rhinitis.

CONCLUSION: This study demonstrates that, in the nasal respiratory mucosa of patients with vasomotor rhinitis, oxidative stress following peroxynitrite formation is confined to the respiratory epithelium. This suggests that the role of peroxynitrite in vasomotor rhinitis differs from its role in other diseases of the respiratory tract. The results of this study also support the concept that different pathogenetic mechanisms are probably involved in vasomotor rhinitis. OBJECTIVE: Previous studies indicated that nitric oxide (NO) is involved in the pathogenesis of vasomotor rhinitis, strong expression of NO synthase being detected in the smooth muscle cells of the cavernous sinuses and in the respiratory epithelium. However, most adverse effects of high levels of NO originate from the reaction of NO with superoxide anions to form peroxynitrite. Therefore, in this study we evaluated the involvement of peroxynitrite in the pathogenesis of vasomotor rhinitis. MATERIAL AND METHODS: Sites of peroxynitrite formation were identified by immunolabelling for 3-nitrotyrosine (3NT), its footprint in tissues. Samples of nasal mucosa were obtained from vasomotor rhinitis patients and from control subjects who had undergone corrective surgery of the nasal septum. All samples were obtained by reduction of the inferior turbinate. RESULTS: Examination of specimens from vasomotor rhinitis patients revealed that 3NT is absent in epithelium with a normal appearance, cells of the subepithelial connective tissue, the glands and the blood vessels, including the cavernous sinuses. In contrast, intense 3NT immunolabelling was found in the disrupted respiratory epithelium. 3NT was not present in any of the specimens from control subjects.

Ultrastructural and ultracytochemical study of the human nasal respiratory epithelium in vasomotor rhinitis.

OBJECTIVES: Several pieces of evidence have suggested that nitric oxide (NO) fulfills important functions in the respiratory mucosa, under both normal and pathological conditions. This study was performed to investigate the role of NO in the nasal respiratory epithelium of patients affected by vasomotor rhinitis. The structure and ultrastructure of the epithelium were also examined. MATERIAL AND METHODS: The localization of NO synthase activity was determined by means of reduced nicotinamide adenine dinucleotide phosphate (NADPH)-diaphorase ultracytochemistry. Nasal mucosa was obtained from patients who had undergone surgical therapy for reduction of the inferior turbinate. RESULTS: Examination of hematoxylin-eosin-stained sections revealed that most of the nasal mucosa covering the surgical samples was characterized by severe epithelial damage. The ultrastructural study confirmed the light microscopic observations. Ciliary loss, absence of the intercellular junctions and distension of the intercellular spaces were found in the damaged epithelium. The basement membrane was frequently interrupted. Some epithelial cells were identified as basal cells. Other cells of the damaged epithelium were probably involuted ciliated and goblet cells. The ultracytochemical study showed that the basal cells were NADPH-diaphorase-negative in healthy subjects and strongly NADPH-diaphorase-positive in subjects with vasomotor rhinitis. CONCLUSIONS: It is suggested that NO has cytotoxic effects and causes inhibition of mitotic activity in the basal cells, leading to epithelial disruption and breakdown of the protective functions of the epithelium.

Relevance of plasma D-dimer measurement in patients with acute peripheral vertigo.

The aetiopathogenesis of acute unilateral peripheral vestibular dysfunction (APV), also known as vestibular neuritis, is still debated: the principal cause is viral infection with vascular factors second in importance. Plasmatic D-dimer, considered a plasmatic index of hypercoagulation, was measured in a group of 45 APV patients and in a group of 25 patients suffering from Ménière's disease. Measurements were taken both during the acute stage and after a four to six week period of pharmacological washout. The mean D-dimer levels were significantly higher than those measured in the controls both during the acute phase (301 SD161 vs 202 SD113 ng/mL) and after follow up (304 SD211 vs 192 SD111 ng/mL) (p = 0.008). Moreover, during the acute stage 23 of the APV patients (51.1 per cent) had plasmatic D-dimer levels above the upper normal limit (i.e.: <300 ng/mL), compared to four of those with Ménière's disease (16 per cent). Our results lead us to postulate an involvement of the haemostatic system in APV.

Acupuncture treatment of whiplash injury.

We evaluated by computerized static posturography the postural changes after acupuncture treatment in a group of 27 patients (12 men and 15 women; mean age, 35.7+/-6.8 SD) having balance disorders caused by cervical torsion due to whiplash injury. Acupuncture was performed by piercing deeply and bilaterally acupuncture points bladder 10 and gall bladder 20 with steel needles that were twirled manually for 20 seconds. All patients underwent posturographic evaluations before and just after each session of acupuncture. The posturography was performed with open eyes (OE), closed eyes (CE), and closed eyes with retroflexed head (CER). The control group consisted of 25 patients complaining of the same symptoms as those recorded by the study group due to whiplash injury but treated with nonsteroidal anti-inflammatory drugs and myorelaxation or with physiotherapy only. The data presented in this study revealed a considerable difference between the two groups as regards the reduction of the CE and CER length of the statokinesigram just before each session of acupuncture; the frequency oscillation on the sagittal plane in CER was reduced in the study group, whereas we noticed a progressive increase of its values in the control group. The high percentage of positive results in whiplash injury patients leads us to advocate acupuncture for balance disorders due to cervical pathology.

Acute peripheral vertigo: involvement of the hemostatic system.

Viral infection is the most frequent cause of unilateral acute peripheral vestibulopathy (APV). Another possible cause is a vascular disorder in the labyrinth area associated with alterations in hemostasis. In a group of 45 patients with APV and in a series of 25 patients with Ménière's disease (control group), we evaluated blood parameters, including total cholesterol, triglycerides, apolipoprotein A and B, lipoprotein (a), homocysteine, folate, prothrombin time, activated partial thromboplastin time. D-dimer, fibrinogen, antithrombin III, protein C, protein S, activated protein C resistance, and anticardiolipin antibodies. In the acute phase of their disease, the patients with APV exhibited increased plasma levels of fibrinogen (341.5 +/- 136.8 standard deviation [SD] versus 268.1 +/- 72.6 SD mg/dl; p = .05); increased plasma levels of D-dimer (305 +/- 158 SD versus 201 +/- 106 SD ng/dl; p = .008); enhanced plasma levels of lipoprotein (a) (42.6 +/- 38.5 SD versus 16.9 +/- 17.7 SD mg/dl; F = 5.67, p = .02); high leukocyte count (9.2 +/- 2.7 SD versus 6.4 +/- 1.2 SD x 10(3)/microliter; F = 8.42, p < .006); and low serum folate concentration (5.1 +/- 1.7 SD versus 7.2 +/- 2.6 SD ng/ml; F = 4.34, p = .04). During follow-up, the prothrombin time was prolonged (p = .04), and leukocyte count was decreased (p < .019) in the patients with APV, whereas fibrinogen, D-dimer, lipoprotein (a), and folate were unchanged. In this study, we demonstrated that patients with APV exhibit significant involvement of the hemostatic system.

Sensorineural deafness, hydrocephalus and structural brain abnormalities in two sisters: the Chudley-McCullough syndrome.

We describe an Italian family in which two sisters have macrocephaly due to hydrocephalus, and sensorineural hearing loss in addition to other brain abnormalities demonstrated by Magnetic resonance imaging (MRI). The girls, born to healthy non-consanguineous parents, have borderline psychomotor development delay (probably due to hearing defect) and minor dysmorphisms. The clinical picture fits the Chudley-McCullough syndrome, an autosomal recessive condition, to date described in only five families. Our data, in particular the neuroradiological findings, include all brain anomalies variably reported in previous works (hydrocephalus, corpus callosum partial agenesis, interhemispheric cyst, cerebral and cerebellar cortex dysplasia), thus illustrating the full phenotype of the syndrome.

Assessment of swallowing by oropharyngoesophageal scintigraphy in patients with amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is the most common degenerative motor neuron disease in adults, and dysphagia is one of its most frequent and disabling symptoms. Oropharyngoesophageal scintigraphy (OPES) permits a functional and semiquantitative study of the various stages of swallowing. We studied 28 ALS patients (12 females and 16 males; mean age = 63.57 +/- 10.39 yr SD), who were clinically rated against the ALSFRS scale (Amyotrophic Lateral Sclerosis Functioning Rating Scale) and underwent OPES with (99m)Tc-nanocolloid using either a liquid or a semisolid bolus. The semiquantitative parameters we analyzed were Oral Transit Time (OTT), Pharyngeal Transit Time (PTT), Esophageal Transit Time (ETT), Retention Index (RI), and Esophageal Emptying Rate (EER(10s)). Hence, the OPES performed with a semisolid bolus produced a higher proportion of pathologic values for the swallowing variables than when liquid bolus was used. Analyzed by grouping the patients into classes according to their bulbar ALSFRS scores, we found a significant increase in the OTT (p < 0.005), PTT (p < 0.02), and Oropharyngeal Retention Index (OPRI) (p < 0.0004) variables in ALS patients with more severe bulbar involvement. OPES has turned out to be a very important examination for detecting tracheal-bronchial inhalation and it also offers the possibility of acquiring a semiquantitative evaluation of the amount of food inhaled. In our experience, OPES in patients with ALS has been easy to use, economic, well tolerated, and capable of supplying precise indications with regard to the extent of the swallowing disorder, which permits a better clinical definition of the ALS patient.