Art and science: impact of semioccluded vocal tract exercises and choral singing on quality of life in subjects with congenital GH deficiency.

Objective: Currently, not much is known about the interactions between voice and growth hormone (GH). We have described large kindred with isolated GH deficiency (IGHD) due to a GHRH receptor mutation, resulting in severe short stature and high-pitched voice. These IGHD individuals have little interest in GH treatment, as they consider themselves "short long-lived people", rather than patients. Interestingly, they report normal general quality of life, but they rate their Voice-Related Quality of Life (V-RQOL) as low. Here, we assessed the social and auditory-perceptual impacts of artistic-intervention voice therapy with semioccluded vocal tract exercises (SOVTE) and choral singing, on their voices. Methods: Seventeen GH-naïve adult IGHD individuals were enrolled in a single-arm interventional pre-post study with 13 weekly sessions of choir singing over 90 days. Outcome measures were V-RQOL scores, self-assessment of voice, and auditory-perceptual analysis (GRBAS scale, G: grade of the severity of dysphonia; R: roughness; B: breathiness; A: asthenia; and S: strain). Results: Marked improvements in total (p = 0.0001), physical (p = 0.0002), and socioemotional (p = 0.0001) V-RQOL scores and in self-assessment of voice (p = 0.004) were found. The general grades of vocal deviation (p = 0.0001), roughness (p = 0.0001), breathiness (p = 0.0001) and strain (p = 0.0001) exhibited accentuated reductions. Conclusion: Voice therapy with semioccluded vocal tract exercises and choral training improved social impact and perceptual voice assessments in IGHD subjects and markedly improved their voice-related quality of life. This is particularly important in a setting where GH replacement therapy is not widely accepted.

Spatial analysis of cerebral palsy in children and adolescents and its association with health vulnerability.

Cerebral Palsy (CP) is commonly associated with low socioeconomic status. Use of spatial statistics and a Geographic Information Systems (GIS) are scarce and may contribute to the understanding of CP in a social context. To that end a spatial analysis of CP in children and adolescents was performed to analyze the association of CP with levels of vulnerability in a city (Aracaju, Sergipe) in north-eastern Brazil. In addition, an ecological study was conducted with data obtained from a populationbased survey and secondary data. Exploratory spatial data analysis and linear regression were used. A total of 288 CP cases were identified, with a prevalence of 1.65/1,000 and differences among city neighbourhoods ranging from 0-4/1,000. The mean age of cases studied was 9 years 1 month, with a standard deviation of 5 years 2 months. Most study subjects with cerebral palsy (163) were male (56.4%). The distribution of CP in the study population was not homogeneous throughout the territory. Some areas had clusters, with more cases associated with areas of high vulnerability. Spatial data analysis using GIS was useful to gain an epidemiological understanding of CP distribution that can guide decisionmaking with respect to production, distribution, and regulation of health goods as well as services at the local level.

Effects of Therapy With Semi-occluded Vocal Tract and Choir Training on Voice in Adult Individuals With Congenital, Isolated, Untreated Growth Hormone Deficiency.

OBJECTIVES: Voice is produced by the vibration of the vocal folds expressed by its fundamental frequency (Hz), whereas the formants (F) are fundamental frequency multiples, indicating amplification zones of the vowels in the vocal tract. We have shown that lifetime isolated growth hormone deficiency (IGHD) causes high pitch voice, with higher values of most formant frequencies, maintaining a prepuberal acoustic prediction. The objectives of this work were to verify the effects of the therapy with a semi-occluded vocal tract (SOVTT) and choir training on voice in these subjects with IGHD. We speculated that acoustic vocal parameters can be improved by SOVTT or choir training. STUDY DESIGN: This is a prospective longitudinal study without control group. METHODS: Acoustic analysis of isolated vowels was performed in 17 adults with IGHD before and after SOVTT (pre-SOVTT and post-SOVTT) and after choir training (post training), in a 30-day period. RESULTS: The first formant was higher in post training compared with the pre-SOVTT (P = 0.009). The second formant was higher in post-SOVTT than in pre-SOVTT (P = 0.045). There was a trend of reduction in shimmer in post-choir training in comparison with pre-SOVTT (P = 0.051), and a reduction in post-choir training in comparison with post-SOVTT (P = 0.047). CONCLUSIONS: SOVTT was relevant to the second formant, whereas choir training improved first formant and shimmer. Therefore, this speech therapy approach was able to improve acoustic parameters of the voice of individuals with congenital, untreated IGHD. This seems particularly important in a scenario in which few patients are submitted to growth hormone replacement therapy.

Voice Formants in Individuals With Congenital, Isolated, Lifetime Growth Hormone Deficiency.

OBJECTIVE: To analyze the voice formants (F1, F2, F3, and F4 in Hz) of seven oral vowels, in Brazilian Portuguese, [a, ε, e, i, ɔ, o, and u] in adult individuals with congenital lifetime untreated isolated growth hormone deficiency (IGHD). STUDY DESIGN: This is a cross-sectional study. METHODS: Acoustic analysis of isolated vowels was performed in 33 individuals with IGHD, age 44.5 (17.6) years (16 women), and 29 controls, age 51.1 (17.6) years (15 women). RESULTS: Compared with controls, IGHD men showed higher values of F3 [i, e, and ε], P = 0.006, P = 0.022, and P = 0.006, respectively and F4 [i], P = 0.001 and lower values of F2 [u], P = 0.034; IGHD women presented higher values of F1 [i and e] P = 0.029 and P = 0.036; F2 [ɔ] P = 0.006; F4 [ɔ] P = 0.031 and lower values of F2 [i] P = 0.004. IGHD abolished most of the gender differences in formant frequencies present in controls. CONCLUSIONS: Congenital, severe IGHD results in higher values of most formant frequencies, suggesting smaller oral and pharyngeal cavities. In addition, it causes a reduction in the effect of gender on the structure of the formants, maintaining a prepubertal acoustic prediction.

Epidemiology of mechanical ventilation: analysis of the SAPS 3 database.

OBJECTIVE: To evaluate current practice of mechanical ventilation in the ICU and the characteristics and outcomes of patients receiving it. DESIGN: Pre-planned sub-study of a multicenter, multinational cohort study (SAPS 3). PATIENTS: 13,322 patients admitted to 299 intensive care units (ICUs) from 35 countries. INTERVENTIONS: None. MAIN MEASUREMENTS AND RESULTS: Patients were divided into three groups: no mechanical ventilation (MV), noninvasive MV (NIV), and invasive MV. More than half of the patients (53% [CI: 52.2-53.9%]) were mechanically ventilated at ICU admission. FIO2, VT and PEEP used during invasive MV were on average 50% (40-80%), 8 mL/kg actual body weight (6.9-9.4 mL/kg) and 5 cmH2O (3-6 cmH2O), respectively. Several invMV patients (17.3% (CI:16.4-18.3%)) were ventilated with zero PEEP (ZEEP). These patients exhibited a significantly increased risk-adjusted hospital mortality, compared with patients ventilated with higher PEEP (O/E ratio 1.12 [1.05-1.18]). NIV was used in 4.2% (CI: 3.8-4.5%) of all patients and was associated with an improved risk-adjusted outcome (OR 0.79, [0.69-0.90]). CONCLUSION: Ventilation mode and parameter settings for MV varied significantly across ICUs. Our results provide evidence that some ventilatory modes and settings could still be used against current evidence and recommendations. This includes ventilation with tidal volumes >8mL/kg body weight in patients with a low PaO2/FiO2 ratio and ZEEP in invMV patients. Invasive mechanical ventilation with ZEEP was associated with a worse outcome, even after controlling for severity of disease. Since our study did not document indications for MV, the association between MV settings and outcome must be viewed with caution.

Modeling in-hospital patient survival during the first 28 days after intensive care unit admission: a prognostic model for clinical trials in general critically ill patients.

OBJECTIVE: The objective of the study was to develop a model for estimating patient 28-day in-hospital mortality using 2 different statistical approaches. DESIGN: The study was designed to develop an outcome prediction model for 28-day in-hospital mortality using (a) logistic regression with random effects and (b) a multilevel Cox proportional hazards model. SETTING: The study involved 305 intensive care units (ICUs) from the basic Simplified Acute Physiology Score (SAPS) 3 cohort. PATIENTS AND PARTICIPANTS: Patients (n = 17138) were from the SAPS 3 database with follow-up data pertaining to the first 28 days in hospital after ICU admission. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The database was divided randomly into 5 roughly equal-sized parts (at the ICU level). It was thus possible to run the model-building procedure 5 times, each time taking four fifths of the sample as a development set and the remaining fifth as the validation set. At 28 days after ICU admission, 19.98% of the patients were still in the hospital. Because of the different sampling space and outcome variables, both models presented a better fit in this sample than did the SAPS 3 admission score calibrated to vital status at hospital discharge, both on the general population and in major subgroups. CONCLUSIONS: Both statistical methods can be used to model the 28-day in-hospital mortality better than the SAPS 3 admission model. However, because the logistic regression approach is specifically designed to forecast 28-day mortality, and given the high uncertainty associated with the assumption of the proportionality of risks in the Cox model, the logistic regression approach proved to be superior.