Information Sources and Attitudes Toward COVID-19 Vaccination at a Free Clinic in the State of Nebraska, USA.

The full impacts of the COVID-19 pandemic are yet to be determined. While highly effective vaccines are available to prevent and decrease the severity of COVID-19 infection, significant COVID-19 vaccine hesitancy remains. Understanding motivations, discouraging factors, opinions, and information sources regarding COVID-19 is essential to targeting vaccine hesitancy and improving vaccine uptake. A 25 question survey was administered to the patients of a free clinic in the Midwest to assess patient demographic data, opinions about and experience with COVID-19, the COVID-19 vaccines, and information sources. The main outcome of interest was if vaccination status influenced information sources and opinions regarding COVID-19. This study also analyzed motivating and discouraging factors for vaccination. The study had a total of 104 participants with 7 being excluded. There were a total of 97 survey responses included in this study, there were 79 vaccinated patients and 18 unvaccinated patients. This survey study found differences in information sources between vaccinated and unvaccinated groups. Opinions surrounding the COVID-19 vaccine, public health agencies, and perceived severity of COVID-19 also varied between vaccinated and unvaccinated groups. The differential information sources and opinions between vaccinated and unvaccinated groups emphasizes the importance of access to high-quality sources and educating the community to improve public health.

Pre- and post-operative voice therapy (PaPOV): Development of an intervention for patients with benign vocal fold lesions.

BACKGROUND: Pre- and post-operative voice therapy may improve voice and quality-of-life outcomes for patients undergoing phonosurgery to remove benign vocal fold lesions (BVFLs). However, what constitutes voice therapy in this population is poorly described, resulting in a poor evidence base, lack of clinical guidelines and unwarranted variation in management. In order to develop the evidence base, a robust, iterative process of intervention development work should precede feasibility testing and effectiveness studies. METHODS & PROCEDURES: Guidance for developing complex interventions, drawing on evidence, theory and modelling, was used to inform the development of a pre- and post-operative voice therapy intervention entitled 'PaPOV'. Data from four sources of evidence were synthesized using a published triangulation protocol. Data from a systematic review, national survey of current practice, expert interview study, and patient and public involvement conversations were used to populate a triangulation matrix, outlining components of a PaPOV. Data were coded to reflect areas of agreement, dissonance and silence with each component of the intervention. Based on this evidence, an assessment of convergence for each intervention component could be made. OUTCOMES & RESULTS: In total, 61 components of the PaPOV intervention were explored. Of these, 27 were categorized as having stability of consensus according to a priori criteria. A total of 34 failed to meet the criteria. This was more frequently due to silence (27) rather than dissonance (seven) in the data. By evidencing areas of agreement and stability of consensus across data sources, the validity of individual findings has been enhanced. Furthermore, the study has exposed specific areas of the intervention that lack consensus and require exploration through further intervention development studies. CONCLUSIONS & IMPLICATIONS: This systematic triangulation process has contributed to the development of a PaPOV intervention for patients with BVFLs. Exploration of specific components relating to the intervention will allow outstanding questions to be answered in preparation for feasibility testing. WHAT THIS PAPER ADDS: What is already known on the subject BVFLs cause dysphonia by preventing vocal fold closure, impacting on vibratory characteristics and increasing compensatory muscle tension. Management for these patients is variable with them being offered phonosurgery, voice therapy, pharmacological management or a combined approach. Pre- and post-operative voice therapy may improve both voice and quality-of-life outcomes. This patient group has unique complexities when considering voice therapy, including surgical preparation, wound healing and epithelial mobilization. What this paper adds to existing knowledge This study uses a robust triangulation process to synthesize current evidence and patient experiences in order to inform the development of a PaPOV. It outlines some of the key components and considerations when delivering pre- and post-operative voice therapy to adults with BVFLs. Furthermore, it serves as a methodological example for intervention development in complex interventions, highlighting key guidance and recommended processes for developing and evaluating complex interventions. What are the potential or actual clinical implications of this work? The 61 components discussed as potential 'ingredients' for a PaPOV enable clinicians to reflect on key considerations when planning and delivering voice therapy to adults with BVFLs. This study highlights the pitfalls both clinically and in research of failing to describe interventions adequately and the benefits of using accurate, specific and agreed terminology in clinical practice, such as that outlined in the Rehabilitation Treatment Specification System (TRSS).

COVID-19 and ENT SLT services, workforce and research in the UK: A discussion paper.

BACKGROUND: The COVID-19 pandemic and the UK government's subsequent coronavirus action plan have fundamentally impacted on every aspect of healthcare. One area that is severely affected is ear, nose and throat (ENT)/laryngology where speech and language therapists (SLTs) engage in a diverse range of practice with patients with a range of conditions, including voice disorders, airway problems, and head and neck cancers (HNCs). A large majority of these patients are in high-risk categories, and many specialized clinical practices are vulnerable. In addition, workforce and research issues are challenged in both the immediate context and the future. AIMS: To discuss the threats and opportunities from the COVID-19 pandemic for SLTs in ENT/laryngology with specific reference to clinical practice, workforce and research leadership. METHODS & PROCEDURES: The relevant sections of the World Health Organisation's (WHO) health systems building blocks framework (2007) were used to structure the study. Expert agreement was determined by an iterative process of multiple-group discussions, the use of all recent relevant policy documentation, and other literature and shared documentation/writing. The final paper was verified and agreed by all authors. MAIN CONTRIBUTION: The main threats to ENT/laryngology SLT clinical services include increased patient complexity related to COVID-19 voice and airway problems, delayed HNC diagnosis, reduced access to instrumental procedures and inequitable care provision. The main clinical opportunities include the potential for new modes of service delivery and collaborations, and harnessing SLT expertise in non-instrumental assessment. There are several workforce issues, including redeployment (and impact on current services), training implications and psychological impact on staff. Workforce opportunities exist for service innovation and potential extended ENT/SLT practice roles. Research is threatened by a reduction in immediate funding calls and high competition. Current research is affected by very limited access to participants and the ability to conduct face-to-face and instrumental assessments. However, research opportunities may result in greater collaboration, and changes in service delivery necessitate robust investigation and evaluation. A new national set of research priorities is likely to emerge. CONCLUSIONS & IMPLICATIONS: The immediate impact of the pandemic has resulted in major disruption to all aspects of clinical delivery, workforce and research for ENT/laryngology SLT. It is unclear when any of these areas will resume operations and whether permanent changes to clinical practice, professional remits and research priorities will follow. However, significant opportunity exists in the post-COVID era to re-evaluate current practice, embrace opportunities and evaluate new ways of working. What this paper adds What is already known on the subject ENT/laryngology SLTs manage patients with a range of conditions, including voice disorders, airway problems and HNCs. The diverse scope of clinical practice involves highly specialized assessment and treatment practices in patients in high-risk categories. A large majority of active research projects in this field are patient focused and involve instrumental assessment. The COVID-19 pandemic has created both opportunities and threats for ENT SLT clinical services, workforce and research. What this paper adds to existing knowledge This study provides a discussion of the threats and opportunities from the COVID-19 pandemic for ENT/laryngology SLT with specific reference to clinical practice, workforce and research leadership. What are the potential or actual clinical implications of this work? The COVID-19 pandemic has resulted in major disruption to all aspects of clinical delivery, workforce and research for ENT/laryngology SLT. Changes to clinical practice, professional remits and research priorities are of indeterminant duration at this time, and some components could be permanent. Significant clinical practice, workforce and research opportunities may exist in the post-COVID era.

Social functioning in schizotypy: How affect influences social behavior in daily life.

OBJECTIVE: Social deficits are already exhibited by people at risk for schizophrenia-spectrum disorders. Technological advances have made passive detection of social deficits possible at granular levels. METHOD: In this real-world study, we tested if schizotypy status (high/low) predicted two types of social behavior: (1) being around other people; and (2) actively socializing with others. We also examined if schizotypy influences relationships between social behavior and affect using subjective and objective instruments. RESULTS: Our findings revealed that socializing with others was significantly decreased in the high schizotypy group. Positive affect increased in social situations and predicted later social behavior in those low, but not high, in schizotypy. CONCLUSION: Decreased social behavior in schizotypy may be explained, in part, by these individuals being less incentivized than their peers to pursue social situations. Future studies should test this explanation in larger samples exhibiting elevated positive, negative, and disorganized schizotypy traits.

Genomic Competencies for Nursing Practice: Implications for Nursing Leadership.

Nurses must have appropriate knowledge and skills to provide safe and effective nursing care in recognition of evolving science. Knowledge of genomics is required to ensure appropriate referral and education of patients who would benefit from genetic services. This article describes the process the Veterans Healthcare Administration's (VHA's) Office of Nursing Services used to determine the nursing genomic competencies appropriate for VHA nurses and identify available resources for educating nurses on these nursing competencies and a strategic plan for long-term implementation.

Evidence-based practice: Embracing integration.

BACKGROUND: The Veterans Health Administration's Office of Nursing Services launched several initiatives to support evidence-based practice (EBP) initiatives throughout its system. From evaluation of these initiatives and reflection on discussions with nurse leaders and direct care nurses, our thinking about and approach to EBP has evolved from a project-focused to a practice-focused interpretation. PURPOSE: (a) Offer an expanded view that moves beyond interpreting EBP as process-driven projects to a "way of practicing" where nurses assume ownership for a practice that integrates best available evidence, clinical expertise, and patient preferences, and (b) describe and generate discussion on the educational, cultural, and role modeling implications of this expanded view. METHODS: We illustrate EBP integration using a point-of-care interaction scenario. CONCLUSION: Commitment to EBP is reflected at the point-of-care where each nurse demonstrates the ability to integrate evidence-based interventions, patient preferences, and clinical expertise to arrive at patient-centric health care decisions.

Integrating emerging areas of nursing science into PhD programs.

The Council for the Advancement of Nursing Science aims to "facilitate and recognize life-long nursing science career development" as an important part of its mission. In light of fast-paced advances in science and technology that are inspiring new questions and methods of investigation in the health sciences, the Council for the Advancement of Nursing Science convened the Idea Festival for Nursing Science Education and appointed the Idea Festival Advisory Committee to stimulate dialogue about linking PhD education with a renewed vision for preparation of the next generation of nursing scientists. Building on the 2010 American Association of Colleges of Nursing Position Statement "The Research-Focused Doctoral Program in Nursing: Pathways to Excellence," Idea Festival Advisory Committee members focused on emerging areas of science and technology that impact the ability of research-focused doctoral programs to prepare graduates for competitive and sustained programs of nursing research using scientific advances in emerging areas of science and technology. The purpose of this article is to describe the educational and scientific contexts for the Idea Festival, which will serve as the foundation for recommendations for incorporating emerging areas of science and technology into research-focused doctoral programs in nursing.

Emerging areas of science: Recommendations for Nursing Science Education from the Council for the Advancement of Nursing Science Idea Festival.

The Council for the Advancement of Nursing Science aims to "facilitate and recognize life-long nursing science career development" as an important part of its mission. In light of fast-paced advances in science and technology that are inspiring new questions and methods of investigation in the health sciences, the Council for the Advancement of Nursing Science convened the Idea Festival for Nursing Science Education and appointed the Idea Festival Advisory Committee (IFAC) to stimulate dialogue about linking PhD education with a renewed vision for preparation of the next generation of nursing scientists. Building on the 2005 National Research Council report Advancing The Nation's Health Needs and the 2010 American Association of Colleges of Nursing Position Statement on the Research-Focused Doctorate Pathways to Excellence, the IFAC specifically addressed the capacity of PhD programs to prepare nursing scientists to conduct cutting-edge research in the following key emerging and priority areas of health sciences research: omics and the microbiome; health behavior, behavior change, and biobehavioral science; patient-reported outcomes; big data, e-science, and informatics; quantitative sciences; translation science; and health economics. The purpose of this article is to (a) describe IFAC activities, (b) summarize 2014 discussions hosted as part of the Idea Festival, and (c) present IFAC recommendations for incorporating these emerging areas of science and technology into research-focused doctoral programs committed to preparing graduates for lifelong, competitive careers in nursing science. The recommendations address clearer articulation of program focus areas; inclusion of foundational knowledge in emerging areas of science in core courses on nursing science and research methods; faculty composition; prerequisite student knowledge and skills; and in-depth, interdisciplinary training in supporting area of science content and methods.

Emerging areas of nursing science and PhD education for the 21(st) century: response to commentaries.

We respond to commentaries from the American Academy of Nursing, the American Association of Colleges of Nursing, and the National Institute of Nursing Research on our thoughts about integrating emerging areas of science into nursing PhD programs. We identify areas of agreement and focus our response on cross-cutting issues arising from cautions about the unique focus of nursing science and how best to proceed with incorporation of emerging areas of science into nursing PhD programs.

Evaluating the Veterans Health Administration's Staffing Methodology Model: A Reliable Approach.

All Veterans Health Administration facilities have been mandated to use a standardized method of determining appropriate direct-care staffing by nursing personnel. A multi-step process was designed to lead to projection of full-time equivalent employees required for safe and effective care across all inpatient units. These projections were intended to develop appropriate budgets for each facility. While staffing levels can be increased, even in facilities subject to budget and personnel caps, doing so requires considerable commitment at all levels of the facility. This commitment must come from front-line nursing personnel to senior leadership, not only in nursing and patient care services, but throughout the hospital. Learning to interpret and rely on data requires a considerable shift in thinking for many facilities, which have relied on historical levels to budget for staffing, but which does not take into account the dynamic character of nursing units and patient need.

Genomics for Nursing Education and Practice: Measuring Competency.

BACKGROUND: Nurses lack genome literacy, skill, and self-confidence in applying genomics to health care. Standardized curricula and evaluation tools are needed for wide spread uptake and application of genome science in nursing education, practice, and research. AIM: To determine whether psychometrically robust survey instruments exist to assess knowledge, skills, attitudes, and self-confidence in applying genomic nursing competency among students and registered nurses. DESIGN: Psychometric systematic review. DATA SOURCES: Medline, CINAHL, Academic Search Elite, Web of Science, and ProQuest Dissertations were searched from 1995 to 2014, with an English language restriction. PROCEDURES: Critical analysis of the study elements and psychometric attributes was conducted after data were abstracted into analysis and synthesis tables. The synthesis assessed the design, methods, and measurement properties with a focus on reliability and validity using 16 criteria on a 4-point grading scale. FINDINGS: Twelve studies were included in a detailed review that focused on assessment of genomic nursing core competencies. Six studies met the inclusion criteria. In terms of psychometric quality of the instruments, one study scored high, two moderate, two low, and one very low. LINKING EVIDENCE TO ACTION: Most instruments assess self-perceived rather than objectively assessed competency. The highest quality instrument lacks clinical application. Knowledge-focused test questions based on up-to-date genome science that are relevant to practice need to be developed.

Impact of provider coordination on nurse and physician perceptions of patient care quality.

The objective of this study was to assess the role of provider coordination on nurse manager and physician perceptions of care quality, while controlling for organizational factors. Findings indicated that nurse-nurse coordination was positively associated with nurse manager perceptions of care quality; neither physician-physician nor physician-nurse coordination was associated with physician perceptions. Organizational factors associated with positive perceptions of care quality included facility support of education for nurses and physicians, and the use of multidisciplinary rounding.

Management of the Sequelae of Skin Grafting: Pruritis, Folliculitis, Pigmentation Changes, and More.

Scars commonly give rise to unpredictable, potentially irritating, cutaneous complications including pruritis, folliculitis, and pigment changes. These problems can be self-limiting and are prevalent in many burn cases, although their expression varies among individuals. A better understanding of the presentation, risk factors, and pathophysiology of these long-term sequelae allows for more comprehensive care of burn survivors.

Pre- and post-operative voice therapy for benign vocal fold lesions: protocol for a non-randomised, multicentre feasibility trial with embedded process evaluation.

BACKGROUND: Management of benign vocal fold lesions (BVFLs) is variable with individuals receiving surgery, voice therapy, or a combination of these approaches. Some evidence suggests that the best outcomes may be achieved when patients are offered pre- and post-operative voice therapy in addition to phonosurgery, but what constitutes pre- and post-operative voice therapy is poorly described. The pre- and post-operative voice therapy (PAPOV) intervention has been developed and described according to the TIDieR checklist and Rehabilitation Treatment Specification System (RTSS) for voice. The PAPOV intervention is delivered by specialist speech and language therapists trained in the intervention and comprises 7 essential and 4 additional components, delivered in voice therapy sessions with patients who are having surgery on their vocal folds for removal of BVFLs. STUDY DESIGN: Non-randomised, multicentre feasibility trial with embedded process evaluation. METHOD: Forty patients from two sites who are due to undergo phonosurgery will be recruited to receive the PAPOV intervention. Measures of feasibility, including recruitment, retention, and adherence, will be assessed. The feasibility of gathering clinical and cost effectiveness data will be measured pre-treatment, then at 3 and 6 months post-operatively. An embedded process evaluation will be undertaken to explain feasibility findings. DISCUSSION: This study will assess the feasibility of delivering a described voice therapy intervention protocol to patients who are undergoing surgery for removal of BVFLs. Findings will be used to inform the development and implementation of a subsequent effectiveness trial, should this be feasible. TRIAL REGISTRATION: This trial has been prospectively registered on ISRCTN (date 4th January 2023), registration number 17438192, and can be viewed here: https://www.isrctn.com/ISRCTN17438192 .

Pre and Post-operative Voice Therapy Intervention for Benign Vocal Fold Lesions: A Systematic Review.

Benign vocal fold lesions cause dysphonia by preventing vocal fold closure, causing irregular vibration and increasing compensatory muscle tension. Voice therapy delivered in addition to phonosurgery may improve voice and quality of life outcomes but the evidence base is lacking and what constitutes voice therapy for this population is not defined. The purpose of this systematic review is to critically evaluate the evidence for pre and post-operative voice therapy to inform the development of an evidence based intervention. STUDY DESIGN: Systematic Review. METHODS: Electronic databases were searched using key terms including dysphonia, phonosurgery, voice therapy and outcomes. Eligible articles were extracted and reviewed by the authors for risk of bias and for information regarding the content, timing and intensity of any pre and post-operative voice therapy intervention. RESULTS: Of the 432 articles identified, 35 met the inclusion criteria and were included in the review. 5 were RCTs, 2 were individual cohort studies, 1 was a case control study and 26 were case series. There was considerable heterogeneity in participant characteristics. Information was frequently lacking regarding the content timing and intensity of the reported voice therapy intervention, and where present, interventions were highly variable. CONCLUSION: Reporting in relevant literature is limited in all aspects of content, timing and intensity of intervention. Further intervention development work is required to develop a robust voice therapy treatment intervention for this population, before effectiveness work can commence.

Inflammatory Bowel Disease.

Crohn disease and ulcerative colitis, the predominant forms of inflammatory bowel disease (IBD), occur in approximately 1% of the population and are typically characterized by chronic diarrhea (with or without bleeding), abdominal pain, and weight loss. The diagnosis is based on history, physical examination, laboratory studies, and endoscopic evaluation. Extraintestinal manifestations may coincide with or precede IBD diagnosis. Treatments have markedly advanced in the past decade, resulting in improved outcomes. IBD, itself, as well as immunosuppressive therapy can increase rates of certain conditions, making collaboration between primary care and gastroenterology imperative for ensuring comprehensive patient care.

A mixed-method feasibility study of the use of the Complete Vocal Technique (CVT), a pedagogic method to improve the voice and vocal function in singers and actors, in the treatment of patients with muscle tension dysphonia: a study protocol.

BACKGROUND: Muscle tension dysphonia (MTD) results from inefficient or ineffective voice production and is the cause of voice and throat complaints in up to 40% of patients presenting with hoarseness. Standard treatment is voice therapy (SLT-VT) delivered by specialist speech therapists in voice disorders (SLT-V). The Complete Vocal Technique (CVT) is a structured, pedagogic method which helps healthy singers and other performers optimise their vocal function enabling them to produce any sound required. The aim of this feasibility study is to investigate whether CVT administered by a trained, non-clinical CVT practitioner (CVT-P) can be applied to patients with MTD before progressing to a pilot randomised control study of CVT voice therapy (CVT-VT) versus SLT-VT. METHODS/DESIGN: In this feasibility study, we use a mixed-method, single-arm, prospective cohort design. The primary aim is to demonstrate whether CVT-VT can improve the voice and vocal function in patients with MTD in a pilot study using multidimensional assessment methods. Secondary aims are to assess whether (1) a CVT-VT study is feasible to perform; (2) is acceptable to patients, the CVT-P and SLT-VTs; and (3) whether CVT-VT differs from existing SLT-VT techniques. A minimum of 10 consecutive patients with a clinical diagnosis of primary MTD (types I-III) will be recruited over a 6-month period. Up to 6 video sessions of CVT-VT will be delivered by a CVT-P using a video link. The primary outcome will be a change in pre-/post-therapy scores of a self-reported patient questionnaire (Voice Handicap Index (VHI)). Secondary outcomes include changes in throat symptoms (Vocal Tract Discomfort Scale), acoustic/electroglottographic and auditory-perceptual measures of voice. Acceptability of the CVT-VT will be assessed prospectively, concurrently and retrospectively both quantitatively and qualitatively. Differences from SLT-VT will be assessed by performing a deductive thematic analysis of CVT-P transcripts of therapy sessions. CONCLUSION: This feasibility study will provide important data to support whether to proceed with a randomised controlled pilot study focusing on the effectiveness of the intervention compared to standard SLT-VT. Progression criteria will be based on demonstrating a positive outcome in treatment, successful delivery of the pilot study protocol, acceptability to all stakeholders and satisfactory recruitment rates. TRIAL REGISTRATION: ClinicalTrials.gov website ( NCT05365126 Unique Protocol ID: 19ET004). Registered on 06 May 2022.

Pre- and Postoperative Voice Therapy for Benign Vocal Fold Lesions: An International Electronic Delphi Consensus Study.

INTRODUCTION: Voice therapy management of benign vocal fold lesions (BVFLs) is variable and there are currently no clinical guidelines. Poor descriptions of voice therapy interventions lead to unwarranted variation in treatment. Triangulation of the current evidence identifies a number of potential best practice elements, but also a number of outstanding questions to be explored. The aim of this study was to refine and gain global consensus on "best practice" for a pre- and postoperative voice therapy intervention for adults with BVFLs. METHODS: An international sample of expert voice therapists (n = 42) were recruited to take part in this three-round electronic modified Delphi study. Participants were presented with statements concerning a pre- and postoperative voice therapy intervention. Statements were developed from previous research and based on the TIDieR checklist (eg, why, when, what, how?) Participants rated the extent to which they agreed or disagreed with a statement and gave comments to support their response. Consensus was defined as >75% of participants agreeing or strongly agreeing with a given statement. If consensus was not reached, participant comments were used to generate new statements and were rated in the next round. Stability of consensus between rounds was assessed. RESULTS: The 42 international experts achieved consensus on 33 statements relating to components of a best practice pre- and postoperative voice therapy intervention for patients with BVFLs. Consensus on statements ranged from 81% to 100%. These statements were explicitly mapped to the TIDieR checklist to ensure that all aspects of the intervention were considered and the questions of "why, what, how, when and individual tailoring" were addressed. CONCLUSIONS: This study has significantly enhanced our understanding of what should be in a best practice pre- and postoperative voice therapy intervention. It is important to now test these findings for acceptability and feasibility, prior to considering effectiveness research.

Pre- and Postoperative Voice Therapy for Benign Vocal Fold Lesions: Factors Influencing a Complex Intervention.

OBJECTIVES: (1) To describe factors influencing the content, timing, and intensity of pre- and postoperative voice therapy for patients undergoing phonosurgery for benign vocal fold lesions. (2) To understand experts' rationale for decisions made. (3) To critically analyze factors influencing intervention in relation to the wider literature in order to contribute to the development of a complex intervention. DESIGN: Qualitative interview study. SETTING: Multidisciplinary voice clinics in England. PARTICIPANTS: Ten expert voice therapists with a mean of 22 years experience. MAIN OUTCOME MEASURES: Participants were asked to describe factors influencing their current practice and views on optimum treatment for patients undergoing phonosurgery for benign vocal fold lesions. Data were analyzed using the Framework Method of thematic analysis. RESULTS: Factors influencing intervention related to four key themes. Pathophysiological, Patient, Therapist, and Service factors influenced the content, timing, and duration of the voice therapy provided. Consensus on core elements included delivering indirect and direct therapy preoperatively to manage underlying causative factors and address patient expectations. Postoperative intervention focused on indirect therapy to facilitate wound healing and direct therapy to improve vibratory characteristics of the vocal fold. Elements of therapy were highly individualized within participants according to the four themes above, but similarity between participants on broad parameters of intervention was high. CONCLUSIONS: Expert voice therapists use direct and indirect methods pre- and postoperatively to treat patients with benign vocal fold lesions. Optimizing wound healing and mobilization of the epithelium postoperatively are concerns for expert voice therapists which distinguish postoperative patients from other dysphonic patients. This study provides an insight into the factors influencing clinician's intervention provision which can contribute to the development of an optimal pre- and postoperative voice therapy intervention. Further research to refine and test the effectiveness of an intervention is now required.

Extreme Vocals-A Retrospective Longitudinal study of Vocal Health in 20 Professional Singers Performing and Teaching Rough Vocal Effects.

BACKGROUND: Rough vocal effects, extreme, or extended vocal techniques to sound intentionally hoarse or rough are an integral part of many genres and styles, and research has recently demonstrated the involvement of supraglottic narrowing and vibrations to produce such sounds. The vocal health of singing with rough vocal effects is poorly documented, especially in a longitudinal manner, while much vocal pedagogy continuously treats the sounds as harming to or dangerous for the vocal mechanism. OBJECTIVE: To longitudinally investigate the vocal health of professional singers who perform the five rough-sounding vocal effects Distortion, Growl, Grunt, Rattle, and Creaking as part of their singing and teaching. METHODS: Twenty singers underwent nasoendoscopic examination, filled in SVHI questionnaires, and were assessed by GRBAS with a 14-year interval in a retrospective longitudinal study (from 2007 to 2021). Endoscopic materials were assessed by Reflux Finding Score and a hybrid version of the Stroboscopy Rating Scale. RESULTS: Singers presented at initiation of study with an average SVHI of 9.2 (±9), which decreased at time of follow up 14 years later to an average of 5.12 (±6). Laryngeal assessments (RFS and SRS) revealed low averages at initiation of study as well as at conclusion of the study with only small fluctuations in averages, with findings mainly relating to arytenoid asymmetry. CONCLUSION: The participating singers perform and teach rough vocal effects continually and present with healthy laryngeal mechanisms and within-normal SVHI and GRBAS scores. The findings suggest that controlled supraglottic narrowing and techniques to allow for supraglottic structures to engage in vibration as an additional noise source can be performed sustainable and in a healthy manner if performed with correct vocal technique.