Word-final complexity in speech sound intervention: two case studies.

In speech sound intervention, consonant clusters promote generalisation (i.e. improvement in untreated sounds and words), ostensibly due to their relative complexity compared to other phonological targets. However, our understanding of clusters as intervention targets is largely restricted to those in word-initial position (e.g. [fl-], flip). The present study extends available work to consider the effects of word-final consonant cluster targets (e.g. [-ks]). Phonologically complex word-final clusters may be morphologically simple (e.g. mix) or morphologically complex (e.g. packs, inflected with third-person singular) - yet this cross-domain complexity remains an understudied phenomenon. Presently, two case studies provide an initial investigation of word-final cluster intervention targets for children with phonologically based speech sound disorders. Intervention targets for both Anna (3;7 [years;months]) and David (4;1) featured the phonologically complex word-final cluster [-ks], with Anna's target being morphologically simple and David's being morphologically complex. Intervention was provided in 45-minute, individual sessions three times per week for a maximum of 18 sessions. Both children demonstrated high target accuracy by intervention's end. Following intervention, both children demonstrated progress in intelligibility and ability to produce word-final consonant clusters; David further demonstrated generalisation across multiple measures. Results are interpreted with consideration of individual differences and existing research on complexity in phonological intervention. Overall, present findings motivate continued research, as manipulation of word-final complexity allows for emphasis on a context that is relevant for children with speech sound disorders, for peers with difficulties in morphology (including word-final grammatical morphemes) and for the substantial proportion of children demonstrating weaknesses in both domains.

A non-randomised pragmatic trial for the early detection and prevention of surgical wound complications using an advanced hydropolymer wound dressing and smartphone technology: The EDISON trial protocol.

Total hip or knee arthroplasty is a highly effective intervention for treating the symptoms of degenerative joint disease or osteoarthritis (OA), often an unwelcome consequence of obesity. A safe and common surgical procedure, hip and knee arthroplasty procedures are not immune to the occurrence of postoperative complications such as surgical site infection (SSI) or surgical wound dehiscence (SWD). While published rates of SSI following hip or knee arthroplasty are low, 1% to 2% in some cases, it is the resulting wound complication and its clinical management and the impact on patient well-being and return to daily life for the 1% to 2% that is of concern. Postoperative complications such as SSI are a major cost driver to the health care system following arthroplasty and often result in extended lengths of stay, readmission for further surgery, primary and community nursing visits, and are a costly burden to health care settings. Early identification of a wound complication through post-discharge surveillance using a fully transparent dressing and smartphone technology and patient education may ameliorate contributing factors or reduce the likelihood of a complication occurring in the first instance. This clinical trial is a non-randomised pragmatic convenience sample carried out in 200 participants of both sexes receiving either a TKA or THA. There will be equal allocation to two groups (100 hips and 100 knees), with 50 in each allocation receiving the interventional dressing and 50 as control. The dressing will be applied prior to discharge and participants will be provided with education on postoperative wound care, when to contact home care nursing for a potential wound problem, and use of their smartphone to capture and send images of their incision site to the study nurses. Participants will also be followed up by home care nursing services at day 14 for suture removal and wound assessment. Participants will complete a patient-reported outcomes survey on day 14 and followed up on day 30 after surgery for wound assessment. The results of this trial may provide a novel pathway using a fully transparent dressing and digital technologies for the prevention of acute readmissions because of wound complications through early detection and intervention.

Automated phonological analysis and treatment target selection using AutoPATT.

Automated analyses of speech samples can offer improved accuracy and timesaving advantages that streamline clinical assessment for children with a suspected speech sound disorder. In this paper, we introduce AutoPATT, an automated tool for clinical analysis of speech samples. This free, open-source tool was developed as a plug-in for Phon and follows the procedures of the Phonological Analysis and Treatment Target Selection protocol, including extraction of a phonetic inventory, phonemic inventory with corresponding minimal pairs, and initial consonant cluster inventory. AutoPATT also provides suggestions for complex treatment targets using evidence-based guidelines. Automated analyses and target suggestions were compared to manual analyses of 25 speech samples from children with phonological disorder. Results indicate that AutoPATT inventory analyses are more accurate than manual analyses. However, treatment targets generated by AutoPATT should be viewed as suggestions and not used to substitute necessary clinical judgement in the target selection process.

Quantifying phonological knowledge in children with phonological disorder.

Generative phonologists use contrastive minimal pairs to determine functional phonological units in a language. This technique has been extended for clinical purposes to derive phonemic inventories for children with phonological disorder, providing a qualitative analysis of a given child's phonological system that is useful for assessment, treatment, and progress monitoring. In this study, we examine the single-word productions of 275 children with phonological disorder from the Learnability Project (Gierut, 2015b) to confirm the relationship between phonemic inventory - a measure of phonological knowledge - and consonant accuracy - a quantitative, relational measure that directly compares a child's phonological productions to the target (i.e. adult-like) form. Further, we identify potential percentage accuracy cutoff scores that reliably classify sounds as in or out of a child's phonemic inventory in speech-sound probes of varying length. Our findings indicate that the phonemic function of up to 90% of English consonants can be identified from percentage accuracy for preschool-age children with phonological disorder when a sufficiently large and thorough speech sample is used.

Hereditary Creutzfeldt-Jakob Disease: A Case Presentation of a Rare Stroke Mimic.

Acute ischemic cerebrovascular accident (CVA) is a time-sensitive emergent diagnosis, requiring rapid diagnosis and consideration of thrombolytic administration. However, a myriad of cerebrovascular mimics creates a diagnostic challenge. A rare CVA mimic is Creutzfeldt-Jakob disease (CJD), a rapidly progressive fatal dementia due to protein misfolding. Magnetic resonance imaging (MRI) and neurology consultation for electroencephalogram (EEG) and specialized cerebrospinal fluid (CSF) studies are diagnostic while the patient is alive. All forms are fatal within months, and diagnosis can be confirmed on postmortem brain testing. While incredibly uncommon, emergency clinicians should consider this diagnosis in the proper patient to advocate for specialized CSF testing and potential palliative care consultation.

Point of Care Ultrasounds Obtained by Novice Physician Assistant Residents (POCUS ON PAR).

INTRODUCTION: The integration of Point of Care Ultrasound (POCUS) into the care of trauma patients, specifically the E-FAST, has improved the accuracy of initial diagnoses and improved time to surgical intervention in critically ill patients. Physician assistants (PAs) are critically important members of any military trauma resuscitation team and are often team leaders in a pre-hospital setting. They may receive training in ultrasound but there are little data to support their use or evaluate their effectiveness in using POCUS. We designed a study to evaluate the image quality of an E-FAST Exam performed by Emergency Medicine Physician Assistant (EMPA) Fellows and Emergency Medicine (EM) Interns following identical training. Our hypothesis is that image quality obtained by EMPAs will be non-inferior to those images obtained by EM Interns. MATERIALS AND METHODS: This is a prospective single-blinded study comparing the image quality of E-FAST exams performed by first year EM interns and first year EMPA fellows. All participants completed standard POCUS training prior to enrollment in the study. A total of 8 EMPAs and 8 EM first year residents completed 10 recorded E-FAST exams to be used as study images. Participants also viewed a 15-question slide show containing images of positive (6) and negative (9) E-FAST exams and recorded their interpretations. Images were reviewed by expert reviewers who were blinded to which images were collected by which group. An image quality score was recorded for each view as well as an overall image quality score. Image quality was rated on a 1 to 5 image quality scale. RESULTS: For overall image quality, the mean score for EMPAs was 3.6 ± 0.5 and for EM residents was 3.2 ± 0.5 with statistical significance favoring better image quality from the EMPAs. The time to completion for the EFAST exam for EMPAs was 4.8 ± 1.3 minutes and for interns it was 3.4 ± 1.4 minutes (P value = 0.02). There was no difference in image interpretation quiz scores between the groups (mean score 92% among interns and 95% among PAs). CONCLUSIONS: POCUS is an imaging modality which is very portable and relatively inexpensive which makes it ideal for military medicine. PAs are essential members of military trauma teams, and often run an initial trauma resuscitation. Being able to correctly identify patients who have free fluid early in the course of treatment allows for more correct evacuation criteria to ensure the sickest patients get to care the fastest. Although there are limited data to support POCUS use by non-physicians, our data support a growing body of evidence that it is not the profession or baseline medical education that determines an individual's ability to use and incorporate ultrasound into bedside and clinical practice. Our study shows that with training and experience PAs or other members of the military health care team can use the EFAST to better care for trauma patients.

Substitution Errors and the Role of Markedness in Bilingual Phonological Acquisition.

PURPOSE: The purpose of this study was to (a) provide evidence for a theoretical model of between-language interaction in bilingual phonological production through the examination of substitution error patterns and to (b) provide developmental data on bilingual children with and without speech sound impairments for use in clinical assessment and diagnosis. Through the lens of markedness, or relative featural complexity, patterns of between-language interaction were observed to provide a foundation for clinical decision making in phonological assessment. METHOD: Seventy children, ages 3;11-6;7 (years; months), participated in this study: 63 typically developing bilingual Spanish-English-speaking children (x¯ = 5;2) and seven bilingual Spanish-English-speaking children with speech sound impairments (x¯ = 4;6). Substitution errors in single-word speech samples were analyzed in relation to their language-specific markedness values in terms of both targets avoided and substitutes produced. Both quantitative and descriptive analyses of substitution errors were performed. RESULTS: Bilingual children, regardless of impairment status, abided by the phonological rules of their languages in English and Spanish productions. Findings indicated both typically developing children and children with speech sound impairments preferred the use of unmarked sounds that are shared across languages over the use of marked, language-specific sounds. CONCLUSIONS: Through the examination of substitution errors, evidence of between-language interaction and recognition of relative complexity emerged. These results have implications for clinical assessment and diagnosis of speech sound impairments in bilingual children. SUPPLEMENTAL MATERIAL AND PRESENTATION VIDEO: https://doi.org/10.23641/asha.24640200.

Complexity and cross-linguistic transfer in intervention for Spanish-English bilingual children with speech sound disorder.

With bilingual children, intervention for speech sound disorders must consider both of the child's phonological systems, which are known to interact with each other in development. Further, cross-linguistic generalization following intervention for bilingual children with speech sound disorders (i.e., the impact of treatment in one language on the other) has been documented to varying degrees in some prior studies. However, none to date have documented the cross-linguistic impact of treatment with complex targets (e.g., consonant clusters) for bilingual children. Because complex phonological targets have been shown to induce system-wide generalization within a single language, the potential for bilingual children to generalize learning across languages could impact the efficiency of intervention in this population. This pilot intervention study examines the system-wide, cross-linguistic effects of treatment targeting consonant clusters in Spanish for two Spanish-English bilingual children with phonological disorder. Treatment was provided with 45-minute sessions in Spanish via teletherapy, three times per week for six weeks. Comprehensive phonological probes were administered in English and Spanish prior to intervention and across multiple baselines. Pre-intervention data were compared to data from probes administered during and after intervention to generate qualitative and quantitative measures of treatment outcomes and cross-linguistic generalization. Results indicate a medium effect size for system-wide generalization in Spanish (the language of treatment) and English (not targeted in treatment), for both participants (mean effect size in Spanish: 3.6; English 4.3). These findings have implications for across-language transfer and system-wide generalization in treatment for bilingual children.

A comparison of word lexicality in the treatment of speech sound disorders.

The goal of this research programme was to evaluate the role of word lexicality in effecting phonological change in children's sound systems. Four children with functional speech sound disorders (SSDs) were enrolled in an across-subjects multiple baseline single-subject design; two were treated using high-frequency real words (RWs) and two were treated using (low-frequency) non-words (NWs). Dependent variables were learning during treatment, generalization of treated and untreated sounds post-treatment and error consistency indices. The oldest child in the NW group demonstrated slightly greater increases in learning during treatment, and both children demonstrated increases in generalization as well as large decreases in sound error variability. In comparison, one child in the RW group demonstrated untreated sound generalization, as well as decreases in sound error variability. These results suggest that NWs may be useful in helping children learn the sound structure of words containing treated sounds. These findings are interpreted within an established connectionist model accounting for phonological and lexical representations.

A Hard Case to Swallow: Crucifix Esophageal Foreign Body in a Nonverbal Patient.

Delayed presentation of esophageal foreign bodies places patients at high risk for esophageal perforation and infection. In nonverbal patients as well as children and adults with other concomitant illnesses, it is important to consider a broad differential diagnosis for presentations with upper respiratory complaints. The authors present a case of a nonverbal, elderly woman who presented after several days of mild, dry cough and was ultimately found to have a large esophageal foreign body that had been present for an unclear amount of time.

Sympathetic Joint Effusion in an Urban Hospital.

OBJECTIVE: Sympathetic joint effusion (SJE) and sympathetic synovial effusion (SSE) are recognized as causes of noninflammatory effusion with <2000 white blood cell (WBC) WBC/mm3 in the joint and bursa, respectively. Data on normal range SJE/SSE with <200 WBC/mm3 are unknown. We aimed to investigate the incidence, disease characteristics, and associated triggers of normal range SJE/SSE and to propose diagnostic criteria. METHODS: This retrospective study included patients hospitalized at Temple University Hospital who underwent a diagnostic arthrocentesis for joint or bursal effusion of unclear etiology from 31 January 2010 to 10 December 2016. A cohort of 72 patients with normal range synovial fluid (<200 WBC/mm3) fulfilled all inclusion criteria for detailed chart review. RESULTS: Annualized incidence of SJE/SSE was 1.2%. All 72 patients presented with joint pain and swelling. Twenty-three (32%) also had warmth and 12 (17%) had erythema. Symptom onset was hours to within 6 days in 45 (63%) patients. The most commonly affected joint was the knee (61, 85%). Concurrent pathology in close anatomical proximity to SJE/SSE in the same limb was documented in 29 (40%) patients, most of which (26 of 29, 89%) were infection, deep venous thrombosis, intramuscular fluid collection, and trauma. Less common pathology included adjacent recent hip surgery, loosening of hip prosthesis, and extracorporeal membrane oxygenation catheters. CONCLUSION: SJE/SSE is not uncommon in hospitalized patients and mimics both inflammatory and septic arthritis. It is seen with normal and noninflammatory synovial fluid. A search for a root cause in the same limb is warranted when evaluating acute or subacute painful joint effusions with normal range synovial fluid WBC count.

Questions Posed by Residents in the Operating Room: A Thematic Analysis.

OBJECTIVE: Questioning behavior is a type of intraoperative communication for which little information exists on the types of questions that residents ask. The purpose of this study is to describe and identify themes of questions asked by residents in the operating room. DESIGN: Trained observers documented questions asked by residents during operations. Thematic analysis was applied. SETTING: University of Utah Hospital (Salt Lake City, Utah) operating rooms; institutional. PARTICIPANTS: A total of 10 general surgical residents (postgraduate year 1 to 5) were observed along with 10 attending general surgeons. Cases were purposefully selected to be broadly representative of general surgery cases. RESULTS: Thematic saturation occurred following examination of 16 operative cases, which included 178 questions asked by residents. Two broad categories of questions emerged: case-related (71%) and noncase-related (29%), with multiple subcategories within the 2 groups. Case-related subcategories included operative techniques, logistics, patient care, and other. Questions unrelated to the case included subcategories of social, work-related but unrelated to case, other. Less than 1% of questions asked by residents during operations were reflective. CONCLUSIONS: Most questions related to the case were technical and most of those unrelated to the case were social; almost all questions were transactional in nature. Our identification of questioning themes by residents expands understanding of resident questioning behaviors, and therefore may enable residents and faculty to be more effective in establishing entrustment.

Treatment Targets for Co-Occurring Speech-Language Impairment: A Case Study.

PURPOSE: The intersection of speech and language impairments is severely understudied. Despite repeatedly documented overlap and co-occurrence, treatment research for children with combined phonological and morphosyntactic deficits is limited. Especially little is known about optimal treatment targets for combined phonological-morphosyntactic intervention. We offer a clinically focused discussion of the existing literature pertaining to interventions for children with combined deficits and present a case study exploring the utility of a complex treatment target in word-final position for co-occurring speech and language impairment. METHOD: Within a school setting, a kindergarten child (age 5;2) with co-occurring phonological disorder and developmental language disorder received treatment targeting a complex consonant cluster in word-final position inflected with third-person singular morphology. RESULTS: For this child, training a complex consonant cluster in word-final position resulted in generalized learning to untreated consonants and clusters across word positions. However, morphological generalization was not demonstrated consistently across measures. CONCLUSION: These preliminary findings suggest that training complex phonology in word-final position can result in generalized learning to untreated phonological targets. However, limited improvement in morphology and word-final phonology highlights the need for careful monitoring of cross-domain treatment outcomes and additional research to identify the characteristics of treatment approaches, techniques, and targets that induce cross-domain generalization learning in children with co-occurring speech-language impairment.

Influences of Phonological Context on Tense Marking in Spanish-English Dual Language Learners.

Purpose: The emergence of tense-morpheme marking during language acquisition is highly variable, which confounds the use of tense marking as a diagnostic indicator of language impairment in linguistically diverse populations. In this study, we seek to better understand tense-marking patterns in young bilingual children by comparing phonological influences on marking of 2 word-final tense morphemes. Method: In spontaneous connected speech samples from 10 Spanish-English dual language learners aged 56-66 months (M = 61.7, SD = 3.4), we examined marking rates of past tense -ed and third person singular -s morphemes in different environments, using multiple measures of phonological context. Results: Both morphemes were found to exhibit notably contrastive marking patterns in some contexts. Each was most sensitive to a different combination of phonological influences in the verb stem and the following word. Conclusions: These findings extend existing evidence from monolingual speakers for the influence of word-final phonological context on morpheme production to a bilingual population. Further, novel findings not yet attested in previous research support an expanded consideration of phonological context in clinical decision making and future research related to word-final morphology.

Age of acquisition and allophony in Spanish-English bilinguals.

This study examines age of acquisition (AoA) in Spanish-English bilinguals' phonetic and phonological knowledge of /l/ in English and Spanish. In English, the lateral approximant /l/ varies in darkness by context [based on the second formant (F2) and the difference between F2 and the first formant (F1)], but the Spanish /l/ does not. Further, English /l/ is overall darker than Spanish /l/. Thirty-eight college-aged adults participated: 11 Early Spanish-English bilinguals who learned English before the age of 5 years, 14 Late Spanish-English bilinguals who learned English after the age of 6 years, and 13 English monolinguals. Participants' /l/ productions were acoustically analyzed by language and context. The results revealed a Spanish-to-English phonetic influence on /l/ productions for both Early and Late bilinguals, as well as an English-to-Spanish phonological influence on the patterning of /l/ for the Late Bilinguals. These findings are discussed in terms of the Speech Learning Model and the effect of AoA on the interaction between a bilingual speaker's two languages.

Dialect Density in Bilingual Puerto Rican Spanish-English Speaking Children.

It is still largely unknown how the two phonological systems of bilingual children interact. In this exploratory study, we examine children's use of dialect features to determine how their speech sound systems interact. Six monolingual Puerto Rican Spanish-speaking children and 6 bilingual Puerto Rican Spanish-English speaking children, ages 5-7 years, were included in the current study. Children's single word productions were analyzed for (1) dialect density and (2) frequency of occurrence of dialect features (after Oetting & McDonald, 2002). Nonparametric statistical analyses were used to examine differences within and across language groups. Results indicated that monolinguals and bilinguals exhibited similar dialect density, but differed on the types of dialect features used. Findings are discussed within the theoretical framework of the Dual Systems Model (Paradis, 2001) of language acquisition in bilingual children.

Effects of Neighborhood Density on Adult Word Repetition.

Presumable lexical competition has been found to result in higher perceptual accuracy for words with few versus many neighbors. Previous studies have typically only analyzed the lexical-semantic level, however. In order to also explore the possibility of phonological effects, a word repetition task was administered to 46 typical adults in which 80 stimuli differed only in neighborhood density. In contrast to previous studies, verbal responses were elicited in order to analyze productions holistically and segmentally at the phonological level. An additional error analysis examined differences in neighborhood density between target words and substitutions. Findings revealed that words with more neighbors facilitated recognition, and were more accurately repeated than those with fewer neighbors. When a target word was misperceived, its substitution tended to be higher in neighborhood density, unrelated to word frequency. In order to interpret these results, an account of lexical competition is re-visited with consideration of characteristics of the lexicon discovered using graph theory (Vitevitch, 2008).

Age-related changes in acoustic characteristics of adult speech.

UNLABELLED: This paper addresses effects of age and sex on certain acoustic properties of speech, given conflicting findings on such effects reported in prior research. The speech of 27 younger adults (15 women, 12 men; mean age 25.5 years) and 59 older adults (32 women, 27 men; mean age 75.2 years) was evaluated for identification of differences for sex and age group across measures of fundamental and formant frequencies (F0, F1, F2 and F3) and voice onset time (VOT). There were significant sex-by-age group interactions for F0, F1, and VOT, some of which were specific to individual speech sounds. The findings suggest that further research on aging speech should focus on sex differences and the potential influence such changes may have on communication abilities of older adults with hearing loss. LEARNING OUTCOMES: The reader will be able to understand and describe (1) possible changes in specific acoustic properties with age, (2) how these changes may differ for women and men, and (3) the potential impact these changes may have on the speech understanding of older individuals with hearing loss.

A retrospective study of phonetic inventory complexity in acquisition of Spanish: implications for phonological universals.

This study evaluates 39 different phonetic inventories of 16 Spanish-speaking children (ages 0;11 to 5;1) in terms of hierarchical complexity. Phonetic featural differences are considered in order to evaluate the proposed implicational hierarchy of Dinnsen et al.'s phonetic inventory typology for English. The children's phonetic inventories are examined independently and in relation to one another. Five hierarchical complexity levels are proposed, similar to those of English and other languages, although with some language-specific differences. These findings have implications for theoretical assumptions about the universality of phonetic inventory development, and for remediation of Spanish-speaking children with phonological impairments.