Stakeholder views on cognitive communication assessment and intervention for a person living independently in the community with severe traumatic brain injury.

BACKGROUND: Cognitive communication disorder (CCD) following traumatic brain injury (TBI) is well documented and these communication problems impede successful re-integration into community living. While there is growing evidence for intervention to both detect and treat the impact of these deficits across the rehabilitation continuum, there are barriers to accessing services. Cognitive communication impairments may be missed because the person can talk, and this may mask the subtle but debilitating impact of a CCD. Referral to a speech and language therapist (SLT) may be overlooked or not timely, which prevents the individual accessing evidence-based interventions. Inadequate treatment provision and an under- or overestimation of communication capability can potentially undermine the effectiveness of wider team assessment and intervention. AIMS: To report stakeholder views on specialist SLT input for CCD within a multidisciplinary team intervention for a community-dwelling individual with severe TBI. The investigation explored perspectives on understanding of CCD, on practice and on outcomes, in order to inform professional groups on perceived impacts of the evidence-to-practice gap. METHODS AND PROCEDURES: A semi-structured interview methodology was employed with 11 stakeholder participants involved in a single case. Data were evaluated using a thematic framework method. Themes were inductively derived from the stakeholder narratives. OUTCOMES: Stakeholders reported the following outcomes from specialist SLT input for CCD within a collaborative team approach: improved engagement with rehabilitation and support teams, improved health-related quality of life and well-being, and increased client participation in community activities of personal relevance. Stakeholders also reported inequities in wider service provision where limitations in professional understanding of CCD and knowledge of best practice recommendations preclude access to specialist SLT services. CONCLUSIONS: CCDs are under-recognised and this can have a devastating effect on people with CCD and on those around them. Stakeholder reports provide evidence for the effectiveness of SLT practice recommendations for the treatment of CCD following TBI. They also provide additional evidence of persisting barriers to accessing treatment. Future research to explore ways to close this evidence-to-practice gap is required. WHAT THIS PAPER ADDS: What is already known on this subject Cognitive communication difficulties are a well-documented consequence of TBI. There is evidence for the effectiveness of person-centred interventions for CCD across the recovery continuum. International evidence-based practice recommendations are in place for CCD assessment and management. Barriers to accessing SLT expertise for CCD have previously been reported. What this paper adds to existing knowledge This investigation explores the views of a diverse group of stakeholders involved in a single case of a community-dwelling individual with severe TBI. Stakeholders report positive real-world outcomes from SLT interventions for CCD within a coordinated multidisciplinary rehabilitation team. Stakeholder reports also indicate inequities in wider service provision and CCD knowledge gaps amongst professional groups providing rehabilitation services for people with TBI. What are the potential or actual clinical implications of this work? CCDs are under-recognised, with devastating effect for people with CCD and those around them. These findings underscore the importance of raising professional awareness of CCD and best practice recommendations, in order to improve access to SLT expertise for people with CCD following TBI.

Randomized, placebo-controlled evaluation of Cerumenex and Murine earwax removal products.

OBJECTIVE: To evaluate the efficacy of 2 ceruminolytic products, Cerumenex Eardrops (Purdue Frederick Company, Norwalk, Conn) and Murine Ear Drops (Abbott Laboratories, Abbott Park, Ill), in subjects with partial or complete occlusion of the ear canal due to cerumen. DESIGN: Randomized, subject- and observer-blind, placebo-controlled, clinical trial. SETTING: Corporate research clinic. PARTICIPANTS: From among 230 volunteers screened, 74 subjects (age, 22-66 [mean, 45] years) were enrolled in the study. Participants had baseline occlusion levels of mild (n = 10), moderate (n = 26), or complete (n = 38) impairment of tympanic membrane visualization. INTERVENTIONS: Subjects were randomly assigned to 1 of 3 treatments: Cerumenex (10% triethanolamine polypeptide oleate-condensate), Murine (6.5% carbamide peroxide), and a placebo, BSS Sterile Irrigating Solution (Alcon Laboratories Inc, Ft Worth, Tex). The test medication was instilled into 1 occluded ear for up to two 15-minute applications. Following the treatment, the subject's ear was irrigated with 50 mL of lukewarm water delivered at low pressure via a WaterPik irrigator equipped with a Grossan irrigator tip. Main Outcome Measure The degree of occlusion, measured against a previously established 4-point scale, was assessed and recorded at baseline and after each instillation and irrigation procedure. RESULTS: Neither Cerumenex nor Murine was superior to saline placebo. By the end of treatment, 29.2%, 15.4%, and 41.7% of subjects treated with Cerumenex, Murine, and placebo, respectively, experienced resolution of cerumen occlusion. These values were not statistically significantly different from one another. CONCLUSION: The currently marketed ceruminolytic products, Cerumenex and Murine, are no more effective than a saline placebo in removing earwax.

A new Stroop-like measure of inhibitory function development: typical developmental trends.

BACKGROUND: Difficulties with inhibition are increasingly regarded as central to pathological behavioural and learning disorders in childhood. However, few measures are available to assist in the assessment of young children's inhibitory competence. METHOD: A new, Stroop-like measure of inhibitory function is described which was designed to be appropriate for use with children from 3 years of age. One hundred and fifty-five school children aged between 3 and 16 years took part in a study to examine the developmental characteristics and behavioural correlates of task performance. RESULTS: The task appears to provide a robust measure of inhibitory function across the age range, 3 to 16 years. Furthermore, the animal-stroop task appears to identify those at risk of hyperactive symptomatology within a school-based sample. CONCLUSIONS: The clinical and developmental applications of this new measure are discussed.

Simple technique for tracheocutaneous fistula closure in the pediatric population.

To review our experience with cauterization of persistent tracheocutaneous fistulas in children, we performed a retrospective review of patients who underwent cauterization of tracheocutaneous fistulas by the senior author (O.E.B.) from 1986 to 2001 in an academic, tertiary care children's hospital. We studied 13 pediatric patients ranging in age from 2.5 to 17.5 years of age at the time of surgery. Twelve patients underwent cauterization under endoscopic visualization. One patient underwent superficial cauterization of the tract without endoscopy. All patients had at least a 1-year history of an indwelling tracheotomy. All patients were decannulated at least 1 year before fistula cauterization. Of the 12 patients who underwent intraoperative airway endoscopy, the internal orifice of the fistula tract was specifically visualized and seen to be patent in 10. One patient was noted to have internal mucosalization of the tract, and no discrete opening to the trachea was noted in the other patient. Eleven patients had complete closure of the fistula site at follow-up (range, 2 weeks to 2 years). One patient developed a leak during a coughing spell 2 days after the operation, and the fistula was noted to be closing with a small leak at follow-up. Another patient (with Treacher Collins syndrome) ultimately required a repeat tracheotomy for persistent obstructive sleep apnea. This patient was the only one admitted after the operation, for a pulmonary infiltrate. No other patients required airway support in the immediate postoperative period. Cauterization of tracheocutaneous fistulas in children is a relatively simple, effective, and safe technique.

Electrocochleography and intranasal allergen challenge as investigational tools in patients with inhalant allergy and Ménière's disease.

OBJECTIVES: To expand on a prior study investigating the relation between inhalant allergy and Ménière's disease using electrocochleography and to present data from five patients heretofore unmentioned in previous reports. STUDY DESIGN: Prospective study of five patients identified with Ménière's disease and inhalant allergy in the practices of two faculty otolaryngologists. METHODS: Patients were tested twice using electrocochleography: once as a baseline and again 20 minutes following intranasal challenge with the allergen to which they were most sensitive. RESULTS: Three patients had no prior history of immunotherapy, and all were found to have a >15% increase in summating potential (SP)/action potential (AP) ratio after antigen challenge. However, only one of these patients developed audiovestibular symptoms. Two patients had a history of immunotherapy. One of these patients was tested using three different antigens to which she was highly sensitive on skin testing, one of which provoked audiovestibular symptoms on environmental exposure. Postchallenge electrocochleography, however, demonstrated normal SP/AP ratios with only one antigen causing a >15% increase. The other patient had elevated SP/AP ratios both before and after challenge and developed no audiovestibular symptoms despite a >15% increase. CONCLUSIONS: Previous work using this investigational tool has identified that all patients with a normal electrocochleography were asymptomatic from an audiovestibular standpoint at the time of postchallenge testing. An elevated SP/AP was not reliably correlated with audiovestibular symptoms in this group of patients. Further investigation in this area will examine the utility of using the variability of the SP and AP to predict audiovestibular symptoms.