Clinical Voice Outcomes for Two Voice Rest Protocols after Phonomicrosurgery.

OBJECTIVES: Voice rest is commonly recommended for patients with benign vocal fold lesions (BVFLs) after phonomicrosurgery. The study compares the clinical voice outcomes of two protocols, 7-day complete voice rest (CVR) and 3-day CVR followed by 4-day relative voice rest (CVR + RVR), for patients with BVFLs after phonomicrosurgery. STUDY DESIGN: Prospective, randomized controlled trial. METHOD: Patients with BVFLs undergoing phonomicrosurgery were recruited prospectively and randomly assigned to either protocol. Outcomes were assessed on objective measures of acoustics (fundamental frequency, frequency range, mean intensity, cepstral peak analysis) and aerodynamics (vital capacity, airflow rate, subglottal pressure, phonation threshold pressure), as well as subjective measures, both provider-reported through the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), and patient-reported through the Voice Handicap Index (VHI). Clinical measures were collected at three-time points: preoperatively, 1-week postoperatively (on voice rest), and 1-month postoperatively. In addition, adherence was estimated using a vocal dosimeter. RESULTS: Twenty-five patients were recruited and randomized to 7-day CVR (n = 13) and CVR + RVR regimen (n = 12). Statistically significant changes were found within both groups for subglottal pressure (p = 0.03) and VHI score (p < 0.001) comparing pre-operative baseline to 1-month postoperative follow-up. There were no statistically significant differences between the groups. Regardless of group assignment, a significant decrease in overall severity ratings for the CAPE-V was found by comparing the preoperative scores to postoperative scores at 1-week (p < 0.001) and 1-month (p < 0.001). CONCLUSION: Both groups improved their overall voice quality comparably 1 month after undergoing phonomicrosurgery as measured by objective and subjective parameters. LEVELS OF EVIDENCE: 2. Laryngoscope, 134:2812-2818, 2024.

Association of reproductive risk factors and breast cancer molecular subtypes: a systematic review and meta-analysis.

BACKGROUND: Associations between reproductive factors and breast cancer (BC) risk vary by molecular subtype (i.e., luminal A, luminal B, HER2, and triple negative/basal-like [TNBC]). In this systematic review and meta-analysis, we summarized the associations between reproductive factors and BC subtypes. METHODS: Studies from 2000 to 2021 were included if BC subtype was examined in relation to one of 11 reproductive risk factors: age at menarche, age at menopause, age at first birth, menopausal status, parity, breastfeeding, oral contraceptive (OC) use, hormone replacement therapy (HRT), pregnancy, years since last birth and abortion. For each reproductive risk factor, BC subtype, and study design (case-control/cohort or case-case), random-effects models were used to estimate pooled relative risks and 95% confidence intervals. RESULTS: A total of 75 studies met the inclusion criteria for systematic review. Among the case-control/cohort studies, later age at menarche and breastfeeding were consistently associated with decreased risk of BC across all subtypes, while later age at menopause, later age of first childbirth, and nulliparity/low parity were associated with increased risk of luminal A, luminal B, and HER2 subtypes. In the case-only analysis, compared to luminal A, postmenopausal status increased the risk of HER2 and TNBC. Associations were less consistent across subtypes for OC and HRT use. CONCLUSION: Identifying common risk factors across BC subtypes can enhance the tailoring of prevention strategies, and risk stratification models can benefit from subtype specificity. Adding breastfeeding status to current BC risk prediction models can enhance predictive ability, given the consistency of the associations across subtypes.

Socioeconomic disparities in immunotherapy use among advanced-stage non-small cell lung cancer patients: analysis of the National Cancer Database.

Socioeconomic and racial disparities exist in access to care among patients with non-small cell lung cancer (NSCLC) in the United States. Immunotherapy is a widely established treatment modality for patients with advanced-stage NSCLC (aNSCLC). We examined associations of area-level socioeconomic status with receipt of immunotherapy for aNSCLC patients by race/ethnicity and cancer facility type (academic and non-academic). We used the National Cancer Database (2015-2016), and included patients aged 40-89 years who were diagnosed with stage III-IV NSCLC. Area-level income was defined as the median household income in the patient's zip code, and area-level education was defined as the proportion of adults aged ≥ 25 years in the patient's zip code without a high school degree. We calculated adjusted odds ratios (aOR) with 95% confidence intervals (95% CI) using multi-level multivariable logistic regression. Among 100,298 aNSCLC patients, lower area-level education and income were associated with lower odds of immunotherapy treatment (education: aOR 0.71; 95% CI 0.65, 0.76 and income: aOR 0.71; 95% CI 0.66, 0.77). These associations persisted for NH-White patients. However, among NH-Black patients, we only observed an association with lower education (aOR 0.74; 95% CI 0.57, 0.97). Across all cancer facility types, lower education and income were associated with lower immunotherapy receipt among NH-White patients. However, among NH-Black patients, this association only persisted with education for patients treated at non-academic facilities (aOR 0.70; 95% CI 0.49, 0.99). In conclusion, aNSCLC patients residing in areas of lower educational and economic wealth were less likely to receive immunotherapy.

Association of racial residential segregation with all-cause and cancer-specific mortality in the reasons for geographic and racial differences in stroke (REGARDS) cohort study.

•Increased racial residential segregation increased the risk of all-cause mortality among White participants.•Higher interaction lowered the risk of all-cause mortality among White participants.•Higher isolation lowered the risk of cancer mortality among Black participants.

Exploring Personality and Perceived Present Control as Factors in Postsurgical Voice Rest: A Case Comparison.

OBJECTIVE: This case comparison explored the relation between personality, perceived present control, and postoperative voice rest (as estimated by self-report and objective voice use) following surgery for benign vocal fold lesions. METHOD: Two participants were included. Both participants were diagnosed with benign vocal fold pathology, underwent phonosurgery, and were assigned to either complete voice rest (CVR) or relative voice rest (RVR) postoperatively. During voice rest (VR), a visual analog scale (VAS) and a dosimeter (the Vocalog2) were used daily to estimate self-perceived and objective voice use, respectively. The participants also completed questionnaires on voice-related demographics, the Voice Handicap Index (VHI), Ten-Item Personality Inventory (TIPI), and Perceived Present Control (PPC). After 7 days of CVR or RVR, participants completed a postoperative questionnaire and a final VAS for overall voice use. RESULTS: A wide discrepancy was observed in one of two participant's subjective perception of voice use (using the VAS) versus objective dosimetry data wherein she reported significantly more voice use than was observed objectively. Differences in personality and PPC between the participants did not appear to affect their voice use following the VR protocols. CONCLUSION: The amount of voice use in both VR protocols for these two participants suggests that personality and PPC did not affect their adherence to recommendations of VR. Patients may perceive their voice use differently across time, which might play a role in their adherence to voice rest recommendations: voice use measured as instances versus a unit of time (seconds).

COVID-19: Acoustic Measures of Voice in Individuals Wearing Different Facemasks.

AIM: The global health pandemic caused by the SARS-coronavirus 2 (COVID-19) has led to the adoption of facemasks as a necessary safety precaution. Depending on the level of risk for exposure to the virus, the facemasks that are used can vary. The aim of this study was to examine the effect of different types of facemasks, typically used by healthcare professionals and the public during the COVID-19 pandemic, on measures of voice. METHODS: Nineteen adults (ten females, nine males) with a normal voice quality completed sustained vowel tasks. All tasks were performed for each of the six mask conditions: no mask, cloth mask, surgical mask, KN95 mask and, surgical mask over a KN95 mask with and without a face shield. Intensity measurements were obtained at a 1ft and 6ft distance from the speaker with sound level meters. Tasks were recorded with a 1ft mouth-to-microphone distance. Acoustic variables of interest were fundamental frequency (F0), and formant frequencies (F1, F2) for /a/ and /i/ and smoothed cepstral peak prominence (CPPs) for /a/. RESULTS: Data were analyzed to compare differences between sex and mask types. There was statistical significance between males and females for intensity measures and all acoustic variables except F2 for /a/ and F1 for /i/. Few pairwise comparisons between masks reached significance even though main effects for mask type were observed. These are further discussed in the article. CONCLUSION: The masks tested in this study did not have a significant impact on intensity, fundamental frequency, CPPs, first or second formant frequency compared to voice output without a mask. Use of a face shield seemed to affect intensity and CPPs to some extent. Implications of these findings are discussed further in the article.

Healthcare Access Domains Mediate Racial Disparities in Ovarian Cancer Treatment Quality in a US Patient Cohort: A Structural Equation Modelling Analysis.

BACKGROUND: Ovarian cancer survival disparities have persisted for decades, driven by lack of access to quality treatment. We conducted structural equation modeling (SEM) to define latent variables representing three healthcare access (HCA) domains: affordability, availability, and accessibility, and evaluated the direct and indirect associations between race and ovarian cancer treatment mediated through the HCA domains. METHODS: Patients with ovarian cancer ages 65 years or older diagnosed between 2008 and 2015 were identified from the SEER-Medicare dataset. Generalized SEM was used to estimate latent variables representing HCA domains by race in relation to two measures of ovarian cancer-treatment quality: gynecologic oncology consultation and receipt of any ovarian cancer surgery. RESULTS: A total of 8,987 patients with ovarian cancer were included in the analysis; 7% were Black. The affordability [Ω: 0.876; average variance extracted (AVE) = 0.689], availability (Ω: 0.848; AVE = 0.636), and accessibility (Ω: 0.798; AVE = 0.634) latent variables showed high composite reliability in SEM analysis. Black patients had lower affordability and availability, but higher accessibility compared with non-Black patients. In fully adjusted models, there was no direct effect observed between Black race to receipt of surgery [ß: -0.044; 95% confidence interval (CI), -0.264 to 0.149]; however, there was an inverse total effect (ß: -0.243; 95% CI, -0.079 to -0.011) that was driven by HCA affordability (ß: -0.025; 95% CI, -0.036 to -0.013), as well as pathways that included availability and consultation with a gynecologist oncologist. CONCLUSIONS: Racial differences in ovarian cancer treatment appear to be driven by latent variables representing healthcare affordability, availability, and accessibility. IMPACT: Strategies to mitigate disparities in multiple HCA domains will be transformative in advancing equity in cancer treatment.

Development and Psychometric Evaluation of Healthcare Access Measures among Women with Ovarian Cancer.

Several proposed theoretical frameworks have defined the complex nature of healthcare access (HCA) [...].

Healthcare Access Dimensions and Guideline-Concordant Ovarian Cancer Treatment: SEER-Medicare Analysis of the ORCHiD Study.

BACKGROUND: Racial disparities exist in receipt of guideline-concordant treatment of ovarian cancer (OC). However, few studies have evaluated how various dimensions of healthcare access (HCA) contribute to these disparities. METHODS: We analyzed data from non-Hispanic (NH)-Black, Hispanic, and NH-White patients with OC diagnosed in 2008 to 2015 from the SEER-Medicare database and defined HCA dimensions as affordability, availability, and accessibility, measured as aggregate scores created with factor analysis. Receipt of guideline-concordant OC surgery and chemotherapy was defined based on the NCCN Guidelines for Ovarian Cancer. Multivariable-adjusted modified Poisson regression models were used to assess the relative risk (RR) for guideline-concordant treatment in relation to HCA. RESULTS: The study cohort included 5,632 patients: 6% NH-Black, 6% Hispanic, and 88% NH-White. Only 23.8% of NH-White patients received guideline-concordant surgery and the full cycles of chemotherapy versus 14.2% of NH-Black patients. Higher affordability (RR, 1.05; 95% CI, 1.01-1.08) and availability (RR, 1.06; 95% CI, 1.02-1.10) were associated with receipt of guideline-concordant surgery, whereas higher affordability was associated with initiation of systemic therapy (hazard ratio, 1.09; 95% CI, 1.05-1.13). After adjusting for all 3 HCA scores and demographic and clinical characteristics, NH-Black patients remained less likely than NH-White patients to initiate systemic therapy (hazard ratio, 0.86; 95% CI, 0.75-0.99). CONCLUSIONS: Multiple HCA dimensions predict receipt of guideline-concordant treatment but do not fully explain racial disparities among patients with OC. Acceptability and accommodation are 2 additional HCA dimensions which may be critical to addressing these disparities.

Race, Affordability and Utilization of Supportive Care in Ovarian Cancer Patients.

OBJECTIVE: Lack of access to supportive care (SC) among cancer patients have been well documented. However, the role of affordability in this disparity among ovarian cancer (OC) patients remain poorly understood. METHODS: Patients with OC between 2008 and 2015 were identified from the SEER-Medicare dataset. Racial disparities in utilization of SC medications within the six months of OC diagnosis among patients with Medicare Part D coverage was examined. Multivariable log-binomial regression models were used to examine the associations of race, affordability and SC medications after adjusting for clinical covariates among all patients and separately among patients with advanced-stage disease. RESULTS: The study cohort included 3697 patients: 86% non-Hispanic White (NHW), 6% non-Hispanic Black (NHB), and 8% Hispanic. In adjusted models, NHB and Hispanic patients were less likely to receive antidepressants compared to NHW patients (NHB: aOR 0.46; 95% CI 0.33-0.63 and Hispanic: aOR 0.79; 95% CI 0.63-0.99). This association persisted for NHB patients with advanced-stage disease (aOR 0.42; 95% CI 0.28-0.62). Patients dual enrolled in Medicaid were more likely to receive antidepressants (overall: aOR 1.34; 95% CI 1.17-1.53 and advanced-stage: aOR 1.29; 95% CI 1.10-1.52). However, patients residing in areas with higher vs. lower proportions of lower educated adults (overall: aOR 0.82; 95% CI 0.70-0.97 and advanced-stage: aOR 0.82; 95% CI 0.68-0.99) were less likely to receive antidepressants. CONCLUSION: Black OC patients and those living in lower educated areas were less likely to receive antidepressants as SC. Given the importance of post-primary treatment quality of life for cancer patients, interventions are needed to enhance equitable access to SC.

PCOS and the risk of pre-eclampsia.

RESEARCH QUESTION: What is the association between polycystic ovary syndrome (PCOS) and pre-eclampsia? Data suggest that patients with PCOS are at increased risk of developing pre-eclampsia; however, several studies have not found an independent association between the two. DESIGN: A retrospective case-control study of singleton deliveries at a tertiary care hospital from 2011 to 2015. Patients with pre-eclampsia (cases) were matched to the next delivery without pre-eclampsia (controls) on gestational age week. Medical history data, a diagnosis or clinical features of PCOS and obstetric data, including pre-eclampsia, were abstracted from the medical record. Groups were compared with the chi-squared test, and conditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (95% CI). OR were adjusted for maternal age at delivery and race/ethnicity. RESULTS: This study included 435 cases and 435 controls. Cases were more likely to be Black compared with controls. Age, comorbidities, features of PCOS and use of IVF were similar between groups. Patients with pre-eclampsia were not more likely to have PCOS (8.3%) than those without pre-eclampsia (6.2%, adjusted OR 1.40, 95% CI 0.81-2.30). Sensitivity analyses for body mass index and parity suggested an increased pre-eclampsia risk for patients with PCOS and these additional factors, however no group showed a statistically significant association between PCOS and pre-eclampsia. CONCLUSIONS: In this study, a history of PCOS was not associated with the risk of pre-eclampsia. Further investigation is necessary to determine whether there are subgroups of PCOS patients who are at increased risk of pre-eclampsia.

A hierarchy of needs for remote undergraduate medical education: lessons from the medical student experience.

PURPOSE: The disruption of undergraduate medical education (UME) by the COVID-19 pandemic has sparked rapid, real-time adjustments by medical educators and students. While much is known about online teaching in general, little guidance is available to medical educators on how to adapt courses not originally designed for the online environment. To guide our faculty in this transition we conducted a needs assessment of students enrolled in virtual courses across all 4 years of UME training. METHODS: Using a mixed-methods approach, we conducted a single-institution virtual learning needs assessment in May and June of 2020. We developed and disseminated a survey to assess student experiences with virtual learning. We conducted quantitative and qualitative analysis of responses (n = 255 or 39%) to identify emergent themes. RESULTS: We identified six interdependent themes that need to be met for medical students to fully reach their learning potential: access to stable internet and quiet study spaces, flexible course design with asynchronous, self-paced components, clear expectations for engagement with content and each other, a sense of connectedness with faculty and peers, synchronous classes that maximize interactivity, and assessments that foster a sense of learning over performance. Interpersonal relationships with faculty and peers affected students' sense of learning more than any other factor. CONCLUSIONS: Based on our findings we propose a hierarchy of needs for virtual learning that provides guidance on adapting existing medical school courses to the remote setting and overcoming common challenges. We highlight opportunities for how virtual elements may enrich in-person courses going forward, including in the clinical setting. Although the solutions required to meet the threshold of need at each level may differ based on the context, attending to these same fundamental needs can be extrapolated and applied to learners across a range of environments beyond the virtual.

Association of area-level socioeconomic status and non-small cell lung cancer stage by race/ethnicity and health care-level factors: Analysis of the National Cancer Database.

BACKGROUND: This study examined whether the association of socioeconomic status (SES) and non-small cell lung cancer (NSCLC) stage varied by race/ethnicity and health care access measures. METHODS: This study used data from the 2004-2016 National Cancer Database for patients aged 18-89 years who had been diagnosed with Stage 0-IV NSCLC. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated for the associations of area-level SES with an advanced stage at diagnosis via multilevel, multivariable logistic regression. The stage at diagnosis was dichotomized into early (0-II) and advanced (III-IV) stages, and area-level SES was categorized on the basis of the patient's zip code level: (1) the proportion of adults aged ≥25 years without a high school degree and (2) the median household income. The models were stratified by race/ethnicity (non-Hispanic [NH] White, NH Black, Hispanic, Asian, American Indian/Alaskan Native, and Native Hawaiian/Pacific Islander), insurance status (none, government, and private), and health care facility type (community, comprehensive community, academic/research, and integrated network). RESULTS: The study population included 1,329,972 patients. Although only 17% of the NH White patients were in the lowest income quartile, 50% of the NH Black patients were in this group. Lower area-level education and income were associated with higher odds of an advanced-stage diagnosis (aOR for education, 1.12; 95% CI, 1.10-1.13; aOR for income, 1.13; 95% CI, 1.11-1.14). These associations persisted among NH White, NH Black, Hispanic, and Asian patients; among those with government and private insurance (but not the uninsured); and among those treated at each facility type. CONCLUSIONS: Area-level income and education are strongly associated with an advanced NSCLC diagnosis regardless of the facility type and among those with government and private insurance.

Analysing Subgroups and Treatment Discontinuation in a Finnish Cohort of Patients with Neovascular AMD.

PURPOSE: We aimed to study the regional detailed visual outcome and treatment discontinuation of neovascular age-related macular degeneration (nAMD). METHODS: Clinical records of 110 patients treated for nAMD at the sole referral centre in the Helsinki region were analysed retrospectively. The follow-up was up to the fourth year. RESULTS: The mean visual acuity (VA) at baseline was 56.3 (SD 16.2) letters. The mean last VA at the first year was 59.7 (20.2), and the corresponding values for the second, third, and fourth years were 60.8 (20.6), 60.0 (19.0), and 59.7 (19.3). The mean difference from baseline was +3.39 (SD 14.6), +3.59 (17.6), +0.08 (18.9), and +3.08 (14.3). The number of patients declined each year, with only 51% of the patients being in treatment until the fourth year. The patients with shorter duration of follow-up tended to have a lower baseline VA, lesser gains, and an earlier decline in VA. The VA levels at the last visit were poorer in the shorter follow group. The initial VA response predicted later VA, whereas VA at baseline, age, or sex had no effect. However, the effect vanished with a longer time in treatment. CONCLUSIONS: Long-term VA stabilization was obtained in a regional material. Patients with neovascular AMD consist of cohorts with varying visual outcome and treatment time. Many of the patients benefit from the treatment for some time, however. When comparing real-world results, the outcome of the different follow-up time cohorts should be considered. This calls for new methods for analysing real-world nAMD treatment results.

An inhibitor of RORγ for chronic pulmonary obstructive disease treatment.

The role of RORγ as a transcription factor for Th17 cell differentiation and thereby regulation of IL-17 levels is well known. Increased RORγ expression along with IL-17A levels was observed in animal models, immune cells and BAL fluid of COPD patients. Increased IL-17A levels in severe COPD patients are positively correlated with decreased lung functions and increased severity symptoms and emphysema, supporting an urgency to develop novel therapies modulating IL-17 or RORγ for COPD treatment. We identified a potent RORγ inhibitor, PCCR-1 using hit to lead identification followed by extensive lead optimization by structure-activity relationship. PCCR-1 resulted in RORγ inhibition with a high degree of specificity in a biochemical assay, with > 300-fold selectivity over other isoforms of ROR. Our data suggest promising potency for IL-17A inhibition in human and canine PBMCs and mouse splenocytes with no significant impact on Th1 and Th2 cytokines. In vivo, PCCR-1 exhibited significant efficacy in the acute CS model with dose-dependent inhibition of the PD biomarkers that correlated well with the drug concentration in lung and BAL fluid, demonstrating an acceptable safety profile. This inhibitor effectively inhibited IL-17A release in whole blood and BALf samples from COPD patients. Overall, we identified a selective inhibitor of RORγ to pursue further development of novel scaffolds for COPD treatment.

Associations of Healthcare Affordability, Availability, and Accessibility with Quality Treatment Metrics in Patients with Ovarian Cancer.

BACKGROUND: Differential access to quality care is associated with racial disparities in ovarian cancer survival. Few studies have examined the association of multiple healthcare access (HCA) dimensions with racial disparities in quality treatment metrics, that is, primary debulking surgery performed by a gynecologic oncologist and initiation of guideline-recommended systemic therapy. METHODS: We analyzed data for patients with ovarian cancer diagnosed from 2008 to 2015 in the Surveillance, Epidemiology, and End Results-Medicare database. We defined HCA dimensions as affordability, availability, and accessibility. Modified Poisson regressions with sandwich error estimation were used to estimate the relative risk (RR) for quality treatment. RESULTS: The study cohort was 7% NH-Black, 6% Hispanic, and 87% NH-White. Overall, 29% of patients received surgery and 68% initiated systemic therapy. After adjusting for clinical variables, NH-Black patients were less likely to receive surgery [RR, 0.83; 95% confidence interval (CI), 0.70-0.98]; the observed association was attenuated after adjusting for healthcare affordability, accessibility, and availability (RR, 0.91; 95% CI, 0.77-1.08). Dual enrollment in Medicaid and Medicare compared with Medicare only was associated with lower likelihood of receiving surgery (RR, 0.86; 95% CI, 0.76-0.97) and systemic therapy (RR, 0.94; 95% CI, 0.92-0.97). Receiving treatment at a facility in the highest quartile of ovarian cancer surgical volume was associated with higher likelihood of surgery (RR, 1.12; 95% CI, 1.04-1.21). CONCLUSIONS: Racial differences were observed in ovarian cancer treatment quality and were partly explained by multiple HCA dimensions. IMPACT: Strategies to mitigate racial disparities in ovarian cancer treatment quality must focus on multiple HCA dimensions. Additional dimensions, acceptability and accommodation, may also be key to addressing disparities.

Lessons learned from a fatal case of tuberculous meningitis with a rapid decline in an infant.

Tuberculous meningitis is a highly lethal, often underrecognized disease with characteristic clinical and imaging features which can be cured if the diagnosis and subsequent treatment are begun at early stages. Frequently, there is a delayed diagnosis of this condition due to unfamiliarity of clinicians in non-endemic areas about its presentation and diagnostic workup. This article presents a case of rapid decline and fatality due to tuberculous meningitis in an 11-month-old child from a non-TB-endemic area and describes the characteristic clinical presentation, imaging findings, and diagnostic pitfalls associated with this condition.

Vocal Health Care amongst Hindustani Classical Singers- A Mixed Methods, Cross-Sectional Survey.

OBJECTIVES: The objective of the present survey was to profile the knowledge, attitude, and practices towards vocal health care amongst Hindustani classical singers. STUDY DESIGN: Mixed-methods, cross-sectional questionnaire-based study. METHODS: A self-reported questionnaire was developed and used to gather data on the knowledge, attitude, and practices of Hindustani classical singers towards vocal health care. An online survey link was generated, and responses were collected from self-identified trained Hindustani classical singers. Descriptive statistics was carried out for the closed-ended questions and inductive approach was used to analyse the responses of open-ended questions. RESULTS: Ninety-four self-identified trained Hindustani classical singers participated in the study. The responses indicate good knowledge towards vocal health measures and positive attitudes towards vocal health care. The open-ended responses were analysed using an inductive approach. Although, 70% were aware about role of a speech language pathologist, only 9.7% reported of consulting one in the event of voice problem. Further, 70% singers reported of following precautions to avoid voice problems while 85.1% considered voice rest as necessary before a performance. The singers reported of using home remedies, vocal and non-vocal measures as a part of vocal health measures. CONCLUSIONS: The present study helps to profile the knowledge, attitude, and practices towards vocal health care amongst Hindustani classical singers. It also helps to provide a basis for further studies to establish an empirical basis for the reported practices towards vocal health care.

Cultural Competency in Voice Evaluation: Considerations of Normative Standards for Sociolinguistically Diverse Voices.

AIM: Significant differences exist in anatomical, acoustic, and aerodynamic parameters for nonspeech tasks between culturally and linguistically diverse sample populations. There is a need for expansion of the normative acoustic data to include sociolinguistically diverse groups to ensure that clinical objective measurements are accurately classifying the voice quality of all individuals. This study examined objective measures of voice quality assessment of monolingual speakers of Standard American English (SAE) with sequential bilingual, native (L1) French and Spanish speakers on perturbation, noise, spectral/cepstral analyses, and compared ratings on auditory-perceptual assessment with acoustic data secondary to degree of accentedness. METHOD: Thirty speakers with normal voice quality were rated on the Consensus Auditory-Perceptual Evaluation of Voice scale. Voice quality measures were analyzed using the Multi-Dimensional Voice Program and Analysis of Dysphonia in Speech and Voice. A measure of accentedness of SAE was calculated using an informal task by two evaluators. RESULTS: Objective acoustic measures of jitter and all-voiced cepstral peak prominence were statistically significant between SAE speakers and L1 Spanish and French speakers. SAE speakers demonstrated significantly higher group mean cepstral peak prominence for the all-voiced sentence ("We were away a year ago.") than native French and Spanish speakers. There were no significant differences in perception of voice quality and acoustic measures secondary to degree of accentedness of the non-native SAE speakers. CONCLUSION: It is important to engage and strengthen voice diagnostic measures to support culturally competent service delivery for the diversifying clinical population. Normative databases established on SAE speakers should reflect the statistically significant differences evidenced between diverse sociolinguistic populations in anatomical, auditory-perceptual, aerodynamic, and acoustical parameters.

Twelve tips for clinical teaching with telemedicine visits.

Telemedicine is now an established mode of clinical care for most medical specialties, and clinical teachers must teach and precept learners in this modality. However, faculty need training on how best to teach students when caring for patients via telemedicine. Effectively incorporating learners into telemedicine visits to optimize their education is a critical skill for clinical teachers. In this article, we review 12 practical tips unique to telemedicine to engage and educate undergraduate medical education learners in building their clinical skills. We outline synchronous and asynchronous elements before, during, and after the patient encounter to facilitate teaching while improving patient care. These principles can also be adapted for teaching in other health professions as well as postgraduate medical education.