Telepractice application for the overt stuttering assessment of children aged 6-15 years old.

BACKGROUND: Despite the importance of delivering speech and language therapy services to children who stutter (CWS), there are barriers to accessing speech and language therapy. One way to improve access for those who may otherwise be deprived of speech and language therapy services, including CWS, is through telepractice (TP). However, there is currently no evidence as to the viability of TP stuttering assessments for CWS. AIM: To investigate the validity and reliability, and acceptability of using a TP application to assess overt stuttering behaviour children aged 6-15 years. METHODS & PROCEDURE: A total of 30 CWS, aged between 6 and 15 years, were recruited from a speech therapy clinic in King Abdulaziz University Hospital in Riyadh, Saudi Arabia. Children were divided into two testing conditions, either face-to-face (f2f)-led or TP-led testing, and the Stuttering Severity Instrument (SSI-IV) was administered, percentage of syllables stuttered (%SS) was calculated, and severity ratings (SR) assigned, either via f2f or via TP using two laptops with webcams, video conference software and a broadband internet connection. Agreement and reliability of scoring in the two testing conditions were reported in addition to findings from questionnaires exploring children's and their caregivers' perceptions both before and immediately after the TP assessment was carried out. OUTCOME & RESULTS: A total of 30 sessions were successfully carried out, with results revealing unsatisfactory levels of agreement when applying the Bland and Altman method. However, when discrepancies were found, these were comparable with those from traditional f2f studies. Generally, parents and children exhibited high levels of satisfaction and held a positive view regarding TP pre- and post-assessment. CONCLUSIONS & IMPLICATIONS: The results of the study suggest that conducting an overt stuttering assessment via TP for 6-15-year-olds CWS is reliable and valid. Although the TP model posed some (mainly technical) challenges for executing the assessment, high levels of satisfaction were recorded by parents and children alike. The TP system and equipment chosen in this study has provided a basis for the delivery of TP overt stuttering assessment in a clinical setting, thus addressing the barriers to access that are present for CWS. These results are preliminary, but they can be seen as a building block for future research in TP assessment studies for CWS. WHAT THIS PAPER ADDS: What is already known on the subject Stuttering treatment via TP has been proven to be feasible and successful across a variety of treatment programs (e.g., Lidcombe, Camperdown). However, the viability of assessing stuttering via videoconferencing has never been explored in children. What this paper adds to existing knowledge Preliminary support for the assessment of overt stuttering in CWS aged 6-15 years via video conferencing. The results justify larger scale studies of this service delivery method. What are the potential or actual clinical implications of this work? The TP system and equipment chosen in this study has provided a basis for the delivery of TP overt stuttering assessment in a clinical setting, thus addressing the barriers to access that are present for CWS aged 6-15 years.

Evolution, diversity, and disparity of the tiger shark lineage Galeocerdo in deep time.

Sharks have a long and rich fossil record that consists predominantly of isolated teeth due to the poorly mineralized cartilaginous skeleton. Tiger sharks (Galeocerdo), which represent apex predators in modern oceans, have a known fossil record extending back into the early Eocene (ca. 56 Ma) and comprise 22 recognized extinct and one extant species to date. However, many of the fossil species remain dubious, resulting in a still unresolved evolutionary history of the tiger shark genus. Here, we present a revision of the fossil record of Galeocerdo by examining the morphological diversity and disparity of teeth in deep time. We use landmark-based geometric morphometrics to quantify tooth shapes and qualitative morphological characters for species discrimination. Employing this combined approach on fossil and extant tiger shark teeth, our results only support six species to represent valid taxa. Furthermore, the disparity analysis revealed that diversity and disparity are not implicitly correlated and that Galeocerdo retained a relatively high dental disparity since the Miocene despite its decrease from four to one species. With this study, we demonstrate that the combined approach of quantitative geometric morphometric techniques and qualitative morphological comparisons on isolated shark teeth provides a useful tool to distinguish between species with highly similar tooth morphologies.

Preferences of livestock owners for sharing the cost of brucellosis control in Tajikistan.

In the context of significant public health benefits of brucellosis control and shrinking public resources for livestock vaccination, this paper considers the willingness of small ruminant livestock owners to pay for vaccination of their animals against brucellosis. The willingness to pay is estimated through a binary choice contingent valuation approach using data from a rural household survey specially designed for this purpose. The survey was conducted in southern Tajikistan, one of its poorest regions, in March 2009. The study used a non-parametric method for estimating the willingness to pay and a parametric (Probit) model for identifying determinants. The results show that households, including poor households, were willing to pay for continuing vaccination of their sheep and goats against brucellosis. Controlling for other attributes of willingness to pay, there was practically no correlation between willingness to pay and household asset level. This means both poor and rich alike are willing to pay for the service. On the other hand, the results also show that the willingness to pay was comparatively higher in households with relatively higher levels of education of adult females. This suggests that an awareness campaign targeted at female members of households would enhance the ownership and coverage of cost recovery programs and should form an integral part of any efforts towards introducing financial participation from sheep and goat owners for brucellosis vaccination.

Relationship between input and output in acute medicine - secondary analysis of the Society for Acute Medicine's benchmarking audit 2013 (SAMBA '13).

The performance of acute medical units (AMUs) against published quality indicators is variable. We aimed to identify the impact of case-mix and unit resources on timely assessment and discharge of patients admitted to 43 AMUs on a single day in June 2013, as part of the Society for Acute Medicine's benchmarking audit 2013. Performance against quality indicators was at its worst in the early evening hours. Units admitting fewer than 40 patients performed better. Patients who were more frail, as measured by the Clinical Frailty Scale, were also more likely to have significant physiological abnormalities and a higher risk of death, as measured by the National Early Warning Score. Our analysis suggests that resource allocation at the front door is related to quality indicators. Teams will need strengthening in the evening hours and if looking after higher numbers of frail patients.

Assessment of the Siksika chronic disease nephropathy-prevention clinic.

OBJECTIVE: To determine if a community-based multifactorial intervention clinic led by a nurse practitioner would improve management of First Nations people at risk of developing chronic kidney disease. DESIGN: Qualitative descriptive study. SETTING: A nephropathy-prevention clinic in Siksika Nation, Alta. PARTICIPANTS: First Nations people with diabetes, hypertension, or dyslipidemia who were referred to the clinic. MAIN OUTCOME MEASURES: Changes in blood pressure (BP), hemoglobin A(1c), and low-density lipoprotein levels, as well as in use of antiplatelet therapy, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker medications, and statin therapy. RESULTS: Members of the Siksika Nation were treated according to clinical practice guidelines. A total of 78 patients had at least 2 visits to the clinic and were included in this analysis (61.5% were women; mean age 56 years). Among those initially above target, a significant reduction was achieved in mean hemoglobin A(1c) (0.96%; P < .01), systolic BP (15.84 mm Hg; P < .05), diastolic BP (7.16 mm Hg; P < .001), and low-density lipoprotein (0.62 mmol/L; P < .01) levels. There was a significant increase in the proportion of patients with clinical indications who were treated with acetylsalicylic acid (42.4%; P < .01), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker medications (35.9%; P < .01), or statin therapy (35.9%; P < .01). CONCLUSION: A community-based, nurse practitioner-led clinic can improve many clinically relevant factors in patients at risk of developing chronic kidney disease. Studies have shown that achieving treatment targets is associated with a reduced risk of early death and cardiovascular events; the effect in the First Nations population on these hard clinical end points remains to be determined.

Interaction between ungulates and bruchid beetles and its effect on Acacia trees: modeling the costs and benefits of seed dispersal to plant demography.

Integrative studies of plant-animal interactions that incorporate the multiple effects of interactions are important for discerning the importance of each factor within the population dynamics of a plant species. The low regeneration capacity of many Acacia species in arid savannas is a consequence of a combination of reduction in seed dispersal and high seed predation. Here we studied how ungulates (acting as both seed dispersers and herbivores) and bruchid beetles (post-dispersal seed predators) modulate the population dynamics of A. raddiana, a keystone species in the Middle East. We developed two simulation models of plant demography: the first included seed ingestion by ungulates and seed predation by bruchids, whereas the second model additionally incorporated herbivory by ungulates. We also included the interacting effects of seed removal and body mass, because larger ungulates destroy proportionally fewer seeds and enhance seed germination. Simulations showed that the negative effect of seed predation on acacia population size was compensated for by the positive effect of seed ingestion at 50 and 30% seed removal under scenarios with and without herbivory, respectively. Smaller ungulates (e.g., <35 kg) must necessarily remove tenfold more seeds than larger ungulates (e.g., >250 kg) to compensate for the negative effect of seed predation. Seedling proportion increased with seed removal in the model with herbivory. Managing and restoring acacia seed dispersers is key to conserving acacia populations, because low-to-medium seed removal could quickly restore their regeneration capacity.

Mapping brucellosis risk in communities in the Republic of Armenia.

We describe the geographical patterns and identified factors associated with serological evidence of brucellosis in ruminants in Armenian communities during 2006 and 2007. The data comprised the two first complete years of the current national test-and-slaughter control programme for cattle, sheep and goats. Overall, 29% and 21% of the 858 communities involved in this study reported brucellosis in their respective cattle and small ruminant populations. The national brucellosis control data showed a widespread and uneven distribution of brucellosis throughout the Republic of Armenia for both cattle and small ruminants. The geographical areas of greater risk of communities having seropositive animals were different for cattle and small ruminant populations but most of the associated factors were similar. Several areas where the likelihood of disease occurrence was predicted poorly by the statistical models were also identified. These latter findings are indicative of either less than perfect testing and reporting procedures or unexplained epidemiological factors operating in those particular areas. The analyses provided valuable insights into understanding the brucellosis epidemiology at the community level which operates in small ruminant and cattle populations, and identified priority areas for implementing targeted risk-based surveillance and disease control interventions.

Can fluorescence spectrometry be used as a surrogate for the Biochemical Oxygen Demand (BOD) test in water quality assessment? An example from South West England.

The fluorescence intensities of tryptophan-like, tyrosine-like and humic-like materials were determined using excitation-emission-matrices (EEMs) for a wide range of samples including natural surface waters, sewage and industrial effluents and waters that have experienced known pollution events from the South West of England (n=469). Fluorescence intensities reported in arbitrary fluorescence units (AFU) were correlated with standard five day Biochemical Oxygen Demand (BOD(5)) values which were used as an indicator of the amount of biodegradable organic material present. Tryptophan-like fluorescence, which has been found to relate to the activity of the biological community, showed the strongest correlation with BOD(5). Fluorescence analysis of the tryptophan-like peak (excitation/emission wavelength region 275/340 nm) is found to provide an accurate indication of the presence, and relative proportions of bioavailable organic material present (natural or anthropogenic). It therefore provides an insight relating to its oxygen depleting potential. Thus fluorescence spectroscopy is recommended as a portable or laboratory tool for the determination of the presence of biodegradable organic matter with intrinsic oxidising potential in natural waters. The novel application of Geographically Weighted Regression (GWR) to the data illustrates that strong local relationships exist between the two parameters and that site specific character may be a strong factor in the strength of the tryptophan-like fluorescence/BOD(5) relationship.

Mortality reduction benefits of a comprehensive cardiac care program for patients with occlusive coronary artery disease.

STUDY OBJECTIVE: To determine the effect of early and sustained enrollment in a comprehensive cardiac care (CCC) program on all-cause mortality in patients with coronary artery disease (CAD). DESIGN: Retrospective, longitudinal cohort study. DATA SOURCE: Kaiser Permanente Colorado tracking database. PATIENTS: A total of 4896 patients with an incident occlusive CAD event (index event), defined as acute myocardial infarction and/or percutaneous coronary intervention with or without stent placement, between January 1, 1996 and June 30, 2004. MEASUREMENTS AND MAIN RESULTS: All patients were categorized into one of four cohorts by time to enrollment into the CCC program relative to the index event: early CCC-enrolled less than 90 days after the index event (1630 patients), delayed CCC--enrolled 90 days or more after the index event (1211 patients), intermittent CCC--enrolled intermittently with noncontinuous care (483 patients), and no CCC--never enrolled (1572 patients). The primary outcome was all-cause mortality. Patients were censored at death from all causes, end of health plan membership, or study end (December 31, 2005), whichever came first. Patients with any exposure to the CCC were less likely to die compared with the no CCC cohort (p<0.001). After adjusting for baseline covariates, the early, delayed, and intermittent CCC cohorts had reduced hazard rate ratios for all-cause mortality of 0.11 (95% confidence interval [CI] 0.08-0.14), 0.35 (95% CI 0.29-0.44), and 0.54 (95% CI 0.41-0.70), respectively, compared with the no CCC cohort (all p<0.001). CONCLUSIONS: Compared with those not enrolled in the CCC program, patients enrolled in the early CCC were 89% less likely to die. The earlier the program is started after a coronary event, the better the mortality reduction benefit.

The path to fusion power.

Fusion is potentially an environmentally responsible and intrinsically safe source of essentially limitless power. It should be possible to build viable fusion power stations, and it looks as if the cost of fusion power will be reasonable. But time is needed to further develop the technology and to test in power station conditions the materials that would be used in their construction. Assuming no major adverse surprises, an orderly fusion development programme could lead to a prototype fusion power station putting electricity into the grid within 30 years, with commercial fusion power following some 10 or more years later. In the second half of the century, fusion could therefore be an important part of the portfolio of measures that are needed to cope with rising demand for energy in an environmentally responsible manner. In this paper, we describe the basics of fusion, its potential attractions, the status of fusion R&D, the remaining challenges and how they will be tackled at the International Tokamak Experimental Reactor and the proposed International Fusion Materials Irradiation Facility, and the timetable for the subsequent commercialization of fusion power.

Dimensional assessment of X-bearing and Y-bearing haploid and disomic human sperm with the use of fluorescence in situ hybridization and objective morphometry.

OBJECTIVE: To explore the dimensional attributes of haploid and disomic X-bearing and Y-bearing spermatozoa. DESIGN: Morphometric evaluation of more than 2,000 X-bearing and Y-bearing spermatozoa after identification of the genotype with fluorescence in situ hybridization. SETTING: Academic clinical and research andrology laboratory. MAIN OUTCOME MEASURE(S): Sperm head area, perimeter, long axis, short axis, shape factor, elliptical form factor (long axis/short axis), and tail length. RESULT(S): We found no differences in dimensions or dimensional distributions between X-bearing and Y-bearing spermatozoa, whether in the native or the decondensed state, or in oligozoospermic or normozoospermic men. There were inconsistent differences and a 70% overlap in the dimensions of haploid and disomic spermatozoa. The other 30% of sperm with disomic nuclei were either smaller or larger compared to haploid spermatozoa. CONCLUSION(S): There are no differences, or distinguishing characteristics, in dimensions or dimensional distributions between X-bearing and Y-bearing spermatozoa. Dimensional attributes do not discriminate between dysomic and haploid spermatozoa.

Treatment costs for youths receiving multisystemic therapy or hospitalization after a psychiatric crisis.

OBJECTIVE: The authors conducted a cost analysis for multisystemic therapy, an evidence-based treatment that is used as an intensive community-based alternative to the hospitalization of youths presenting with psychiatric emergencies. METHODS: Data from a randomized clinical trial that compared multisystemic therapy with usual inpatient services followed by community aftercare were used to compare Medicaid costs and clinical outcomes during a four-month period postreferral and a 12-month follow-up period. Data were from 115 families receiving Medicaid (out of 156 families in the clinical trial). RESULTS: During the four months postreferral, multisystemic therapy was associated with an average net savings per youth treated of $1,617 compared with usual services. Costs during the 12-month follow-up period were similar between treatments. Multisystemic therapy demonstrated better short-term cost-effectiveness for each of the clinical outcomes (externalizing behavior, internalizing behavior, and global severity of symptoms) than did usual inpatient care and community aftercare. The two treatments demonstrated equivalent long-term cost-effectiveness. CONCLUSIONS: Among youths presenting with psychiatric emergencies, multisystemic therapy was associated with better outcomes at a lower cost during the initial postreferral period and with equivalent costs and outcomes during the 12-month follow-up period.

The case for the use of evidence-based management research for the control of hospital costs.

This article explores the current state of the creation and use of evidence by managers for cost containment in hospitals. We assert that hospitals do not know enough about what things cost, and until they get evidence on costs, it is not likely that much can be done to narrow the chasm between common practice and best practice. Part of the problem is that managers do not seek out available evidence that exists, and part of the problem is a lack of sufficient research efforts to generate evidence for managers to use. The article strives to help direct future efforts by researchers and managers in the area of evidence-based cost containment research by presenting a framework for priorities that managers and researchers can use to increase the amount of research done to generate evidence and to increase the use of evidence by health care managers.

Evidence-based financial management.

Like the practice of evidence-based medicine, evidence-based financial management can be used by providers to improve results. The concept provides a framework that managers and researchers can use to help direct efforts in gathering and using evidence to support management decisions in health care.