Smart seat cushion feasibility pilot study: automated interface pressure modulation of individuals with spinal cord Injury.

This study investigates the functionality and feasibility of a novel smart seat cushion system designed for wheelchair users with spinal cord injuries. The cushion, equipped with air cells that serve as both sensors and actuators, was tested on 24 participants for its real-time pressure mapping, automated pressure redistribution, and pressure offloading functions. A commercial pressure mat was concurrently used to validate the cushion's pressure modulation functions. Additionally, the perceived comfort of the cushion was evaluated using General Discomfort Assessment (GDA) and Discomfort Intensity (DIS) scores, which provided insights into participants' overall comfort and discomfort levels. Real-time pressure profiles generated by the cushion resembled commercial pressure mat readings. During tests with individuals with spinal cord injury, the cushion was able to dynamically generate and display the real-time pressure profile of a seated individual with strong precision (correlation to commercial pressure mat: r ranging from 0.76 to 0.88), providing effective input into pressure modulation functions. Pressure redistribution algorithms eliminated peak pressure and reduced the overall pressure at the interface. Pressure offloading algorithms automatically identified the regions with the highest interface pressure and subsequently relieved the pressure from those areas. User feedback showed that the cushion was comfortable after redistribution and offloading. This work demonstrated the feasibility of an advanced smart seat cushion system for wheelchair users with spinal cord injuries. The cushion was capable of redistributing pressure evenly across the seating surface, ensuring user's comfort. Additionally, it identifies and eliminates high-pressure points, further improving comfort and reducing the risk of pressure injuries.

Majority of wheelchair users acquire pressure injuries in their lifetime, where the magnitude and duration of sitting interface pressure are major contributing factors to develop pressure injuries.Compliant cushions and frequent weight shifting can reduce the magnitude and duration of sitting interface pressure; however, the long-term effectiveness of these cushions and the user's lack of compliance to the weight shifting protocols impact their efficacy drastically.An automated cushion system that can reduce the magnitude of the pressure based on the user's current pressure profile and offload pressure from vulnerable areas would improve the effectiveness of the cushion and compensate for poor adherence to weight shifting protocols.Automated solutions will significantly improve the quality of care provided to wheelchair users and reduce the risk of developing pressure injuries.

Clinical Delivery of Overground Exoskeleton Gait Training in Persons With Spinal Cord Injury Across the Continuum of Care: A Retrospective Analysis.

Background: After spinal cord injury (SCI), inpatient rehabilitation begins and continues through outpatient therapy. Overground exoskeleton gait training (OEGT) has been shown to be feasible in both settings, yet its use as an intervention across the continuum has not yet been reported. Objectives: This study describes OEGT for patients with SCI across the continuum and its effects on clinical outcomes. Methods: Medical records of patients with SCI who completed at least one OEGT session during inpatient and outpatient rehabilitation from 2018 to 2021 were retrospectively reviewed. Demographic data, Walking Index for Spinal Cord Injury-II (WISCI-II) scores, and OEGT session details (frequency, "walk" time, "up" time, and step count) were extracted. Results: Eighteen patients [male (83%), White (61%), aged 37.4 ± 15 years, with tetraplegia (50%), American Spinal Injury Association Impairment Scale A (28%), B (22%), C (39%), D (11%)] completed OEGT sessions (motor complete, 18.2 ± 10.3; motor incomplete, 16.7 ± 7.7) over approximately 18 weeks (motor complete, 15.1 ± 6.4; motor incomplete, 19.0 ± 8.2). Patients demonstrated improved OEGT session tolerance on device metrics including "walk" time (motor complete, 7:51 ± 4:42 to 24:50 ± 9:35 minutes; motor incomplete, 12:16 ± 6:01 to 20:01 ± 08:05 minutes), "up" time (motor complete, 16:03 ± 7:41 to 29:49 ± 12:44 minutes; motor incomplete, 16:38 ± 4:51 to 23:06 ± 08:50 minutes), and step count (motor complete, 340 ± 295.9 to 840.2 ± 379.4; motor incomplete, 372.3 ± 225.2 to 713.2 ± 272). Across therapy settings, patients with motor complete SCI experienced improvement in WISCI-II scores from 0 ± 0 at inpatient admission to 3 ± 4.6 by outpatient discharge, whereas the motor incomplete group demonstrated a change of 0.2 ± 0.4 to 9.0 ± 6.4. Conclusion: Patients completed OEGT across the therapy continuum. Patients with motor incomplete SCI experienced clinically meaningful improvements in walking function.

Utilization of overground exoskeleton gait training during inpatient rehabilitation: a descriptive analysis.

BACKGROUND: Overground exoskeleton gait training (OEGT) after neurological injury is safe, feasible, and may yield positive outcomes. However, no recommendations exist for initiation, progression, or termination of OEGT. This retrospective study highlights the clinical use and decision-making of OEGT within the physical therapy plan of care for patients after neurological injury during inpatient rehabilitation. METHODS: The records of patients admitted to inpatient rehabilitation after stroke, spinal cord injury, or traumatic brain injury who participated in at least one OEGT session were retrospectively reviewed. Session details were analyzed to illustrate progress and included: "up" time, "walk" time, step count, device assistance required for limb swing, and therapist-determined settings. Surveys were completed by therapists responsible for OEGT sessions to illuminate clinical decision-making. RESULTS: On average, patients demonstrated progressive tolerance for OEGT over successive sessions as shown by increasing time upright and walking, step count, and decreased assistance required by the exoskeleton. Therapists place preference on using OEGT with patients with more functional dependency and assess feedback from the patient and device to determine when to change settings. OEGT is terminated when other gait methods yield higher step repetitions or intensities, or to prepare for discharge. CONCLUSION: Our descriptive retrospective data suggests that patients after neurological injury may benefit from OEGT during inpatient rehabilitation. As no guidelines exist, therapists' clinical decisions are currently based on a combination of knowledge of motor recovery and experience. Future efforts should aim to develop evidence-based recommendations to facilitate functional recovery after neurological injury by leveraging OEGT.

Prevention of posttraumatic stress during inpatient rehabilitation post spinal cord injury: Study protocol for a randomized controlled trial of Brief Prolonged Exposure Therapy (Brief PE).

Background: Scant research has focused on posttraumatic stress disorder (PTSD) in the SCI population, despite high prevalence estimates. Fortunately, prolonged exposure therapy (PE) is a well-researched and highly effective treatment for PTSD. Our recent clinical trial showed that standard 12-session PE was effective for PTSD treatment among inpatients with SCI. Early intervention with brief PE (3-sessions) delivered in the emergency department has also been effective for PTSD prevention, but has not been tested among people post-SCI. Thus, we aim to conduct the first test of the Brief PE intervention to prevent PTSD among patients with SCI. Methods: Adults who have experienced a SCI (N = 200) will be randomly assigned during inpatient rehabilitation to either: (a) 3 60-min sessions of Brief PE (intervention group) or (b) treatment as usual (control group). Results: The primary outcome measure (PTSD symptoms measured by the PSSI-5) and secondary outcome measures (depression, anxiety, pain, quality of life, sleep disturbance, and resilience) will be assessed at baseline, 1-month, 3-months, and 6-months. Hierarchical linear modeling (HLM) will be used to evaluate the effectiveness of the PE intervention on PTSD and secondary outcomes. Descriptive statistics will examine feasibility and will include the number of participants enrolled, the number of sessions completed, fidelity of Brief PE delivery, and average scores for difficulty and helpfulness of the intervention scales for those randomized to intervention. Conclusions: Successful completion of this study will provide an evidence-based program to alleviate posttraumatic distress post spinal cord injury and prevent long-term development of PTSD.

Foundational ingredients of robotic gait training for people with incomplete spinal cord injury during inpatient rehabilitation (FIRST): A randomized controlled trial protocol.

INTRODUCTION: As technological advances allow the use of robotic exoskeleton devices with gait training, there is a critical need to establish a robotic gait training (RGT) program to meet the needs of people with spinal cord injury (SCI) during inpatient rehabilitation. The purposes of this study are to prospectively examine the efficacy of a stakeholder informed RGT program compared to usual care gait training (UC) during inpatient rehabilitation in people with incomplete SCI and compare the intensity of RGT and UC gait training during inpatient rehabilitation. STUDY DESIGN: 128 patients with incomplete SCI admitted to our inpatient rehabilitation facility will be screened for eligibility and randomized to either the RGT or UC group. RGT sessions will use the Ekso robotic exoskeleton [class II medical device (United States FDA)]. UC sessions will use traditional gait training approaches such as manually assisted overground gait training with walkers and orthotics and body weight-supported treadmill training (BWSTT). Our primary outcome is gait function as characterized by the Walking Index for Spinal Cord Injury-II (WISCI-II). Secondary outcomes are gait speed, Spinal Cord Independence Measure (SCIM), Numeric Pain Rating Scale (NPRS), Fatigue Severity Scale (FSS), Penn Spasm Frequency Scale (PSFS), Patient Health Questionnaire-9 (PHQ-9), General Anxiety Disorder- 7 (GAD-7), International Spinal Cord Injury Quality of Life Basic Data Set, and a Qualitative Questionnaire. Assessments of primary and secondary outcomes will occur at admission and discharge from inpatient rehabilitation. General or generalized linear models will be used to analyze differences between groups for all measures. CLINICAL IMPACT: Successful completion of this study will provide a usable, replicable, stakeholder informed RGT intervention for use with individuals with incomplete SCI during inpatient rehabilitation.

Prolonged exposure therapy for PTSD among spinal cord injury survivors: Study protocol for a randomized controlled trial.

The National Spinal Cord Injury Statistical Center estimates 294,000 people in the US live with a spinal cord injury (SCI), with approximately 17,810 new cases each year. Although the physical outcomes associated with SCI have been widely studied, the psychological consequences of sustaining a SCI remain largely unexplored. Scant research has focused on posttraumatic stress disorder (PTSD) in this population, despite prevalence estimates suggesting that up to 60% of individuals with SCI experience PTSD post-injury, compared to only 7% of the general US population. Fortunately, prolonged exposure therapy (PE) is a well-researched and highly effective treatment for PTSD. However, no trauma focused exposure-based therapy for PTSD (e.g. PE) has not yet been tested in a SCI population. Thus, we aim to conduct the first test of an evidence-based intervention for PTSD among patients with SCI. Adults with SCI and PTSD (N = 60) will be randomly assigned to either: (1) 12-sessions of PE (2-3 sessions per week) or (2) a treatment as usual (TAU) control group who will receive the standard inpatient rehabilitation care for SCI patients. Primary outcomes will be assessed at 0, 6, 10, and 32 weeks.

Barriers and Facilitators to Lifestyle Intervention Engagement and Weight Loss in People Living With Spinal Cord Injury.

Background: Individuals living with spinal cord injury (SCI) have a high prevalence of obesity and unique barriers to healthy lifestyle. Objective: To examine barriers and facilitators to engagement and weight loss among SCI participants enrolled in the Group Lifestyle Balance Adapted for individuals with Impaired Mobility (GLB-AIM), a 12-month intensive lifestyle intervention. Methods: SCI participants (N = 31) enrolled in a wait-list, randomized controlled trial where all participants received intervention between August 2015 and February 2017. Analyses of pooled data occurred in 2020 to examine cross-sectional and prospective associations of hypothesized barriers and facilitators with (1) intervention engagement, comprised of attendance and self-monitoring, and (2) percent weight change from baseline to 12 months. We performed multivariable linear regression on variables associated with outcomes at p < .05 in bivariate analyses and controlled for intervention group. Results: Participants were middle-aged (mean age, 48.26 ± 11.01 years), equally male (50%) and female, White (80.7%), and unemployed (65.6%). In participants who completed baseline surveys (n = 30), dietary self-efficacy explained 26% of variance in engagement (p < .01); among the 12-month study completers (n = 22, 71.0%), relationship issues explained 23% of variance in engagement (p < .01). Money problems, health issues unrelated to SCI, lack of motivation, and experimental group explained 57% of variance in weight loss (p for model < .01), with lack of motivation uniquely explaining 24% of variance (p < .01). Conclusion: Improving engagement and weight loss for persons with SCI in the GLBAIM program may be achieved by addressing lack of motivation, relationship issues, and nutrition self-efficacy.

Takotsubo cardiomyopathy in a chronic spinal cord injury patient with autonomic dysreflexia: A case report.

Context: Takotsubo cardiomyopathy (TC) is a transient stress-induced cardiomyopathy with left ventricular dysfunction of unknown etiology. A well accepted theory for the pathophysiology of TC is attributed to a massive catecholamine release [1]. This case report will review a chronic tetraplegia patient who was diagnosed with TC after a severe episode of autonomic dysreflexia (AD). He experiences mild episodes of AD several times a day; however, he had never experienced the severity of symptoms that was associated with this episode which led to his hospitalization. Autonomic dysreflexia is a syndrome of imbalanced sympathetic input secondary to loss of descending central sympathetic control in spinal cord injury due to noxious stimuli below the level of the injury, which occurs when the injury level is at thoracic level 6 (T6) or above [2].Findings: In this specific case, it is presumed that the massive catecholamine release associated with this severe AD episode resulted in TC. Although TC has been diagnosed after other instances of acute stress, it is unknown for it to be diagnosed after AD in a chronic setting.Clinical Relevance: The long-term effects of AD have not been well studied, and this case illustrates the importance of education to recognize and manage AD in the spinal cord patient who frequently has episodes of AD.

The utilization of an overground robotic exoskeleton for gait training during inpatient rehabilitation-single-center retrospective findings.

Overground robotic exoskeleton gait training is increasingly utilized during inpatient rehabilitation yet without clear guidelines. We describe clinical characteristics associated with robotic exoskeleton gait training and examine outcomes of people with spinal cord injury and stroke who completed usual rehabilitation care with or without robotic exoskeleton gait training. Retrospective review of medical records over a 36 months period. Inpatients with spinal cord injury or stroke and ≥1 robotic exoskeleton gait training session were included. After obtaining a complete list of robotic exoskeleton gait training participants, medical records were reviewed for comparable matches as determined by gait functional independence measure score <4, age 18-100 years, meeting exoskeleton manufacturer eligibility criteria, and participating in usual care only. Functional independence measure was collected on all patients. For spinal cord injury, we collected the walking index for spinal cord injury II. For stroke, we collected the Stroke Rehabilitation Assessment of Movement Measure. Fifty-nine people with spinal cord injury (n = 31 robotic exoskeleton gait training; n = 28 usual care) and 96 people post-stroke (n = 44 robotic exoskeleton gait training; n = 52 usual care) comprised the medical record review. Fifty-eight percent of patients with spinal cord injury and 56% of patients post-stroke completed 5+ robotic exoskeleton gait training sessions and were included in analyses. Robotic exoskeleton gait training dosage varied between our patients with spinal cord injury and patients post-stroke. Robotic exoskeleton gait training utilization during inpatient rehabilitation required consideration of unique patient characteristics impacting functional outcomes. Application of robotic exoskeleton gait training across diagnoses may require different approaches during inpatient rehabilitation.

Feasibility of integrating robotic exoskeleton gait training in inpatient rehabilitation.

Objective: Learning to walk is a major goal of inpatient rehabilitation and robotic exoskeletons may provide a new gait training approach. Our purpose was to determine the feasibility of integrating the Ekso Gait Training device into inpatient rehabilitation in a neurologic population.Design: Longitudinal cohort design and convenience sample including physical therapists trained to use the Ekso Bionics Ekso GT™ robotic exoskeleton or inpatients with stroke or SCI. Therapists completed a focus group and survey at baseline and 6 months after initial Ekso training. Patients completed a survey indicating their satisfaction with using the Ekso.Results: Twenty-five patients used the Ekso an average of 4.5 sessions during their 38.5-day rehabilitation stay. Survey and focus group feedback revealed that therapists encountered measurement difficulties with the Ekso and limited treatment time influencing effectiveness of usage. After 6 months, therapists reported an improvement in feasibility. Patients tolerated Ekso sessions well, without any complications or adverse incidents, and reported improved mobility post session.Conclusion: Integrating Ekso gait training into clinical practice was not seamless but appears feasible. Barriers were addressed within the rehabilitation team and received administrative support in a process lasting several months. Patients enjoyed walking in Ekso and felt secure within the device.Implications for rehabilitationIntegrating Ekso gait training into clinical practice during inpatient rehabilitation is feasible.Overcoming barriers to implementation required administrative support and clinician persistence over several months.Patients tolerated Ekso sessions well, without any complications or adverse incidents.

Implementation of a Neurogenic Bowel Program for Spinal Cord Injury in the Acute Care Setting: Perceptions of Patients and Staff.

A prospect cohort and case-control was employed to (1) establish a neurogenic bowel (NB) program after spinal cord injury (SCI) in the acute care setting; (2) examine clinician knowledge ability to deliver the NB program; and (3) evaluate patient knowledge, satisfaction, and quality of life. Educational in-service describing NB clinical practice guidelines (CPGs) and order set was delivered to staff followed by a pre-/post-education, 3- and 12-month survey. The patient intervention followed 24 patients with NB to evaluate the program and compared to 28 retrospective case-control patients followed by a pre-/post-intervention survey to measure knowledge of SCI, NB program and quality of life. Injury information and bowel medication use was compared between cases and controls. Clinician knowledge of NB CPGs improved. There were no significant clinical differences between patient groups. Patient knowledge and satisfaction improved post-intervention. Education to staff and patients is imperative to facilitate a NB program to meet the needs for individuals with SCI.

Hemangiopericytoma of Gingiva in a 4-Year-Old Child: A Rare Case Report.

A hemangiopericytoma is a type of soft tissue sarcoma that originates in the pericytes in the walls of capillaries which was characterized in 1942. It is commonly seen in the age group of 5th-6th decades of adults and only 5-10% of cases occur in children with extreme rare occurrence in head and neck region (16%). A rare case of hemangiopericytoma in a 4-year-old female patient is presented here and its clinical, histopathological and immunohistochemically features are discussed. Though surgical resection remains the mainstay, excisional biopsy was primarily performed to reach the final diagnosis. Even in the follow-up phase of 1 year, no recurrence or no metastatic changes were observed.

Inconsistencies with screening for traumatic brain injury in spinal cord injury across the continuum of care.

OBJECTIVE: Explore how traumatic brain injury (TBI) is screened among spinal cord injury (SCI) patients across the continuum of care. DESIGN: Retrospective chart review Setting: Emergency department, trauma, inpatient rehabilitation Participants: 325 patients with SCI from inpatient rehabilitation facility (IRF) between March 1, 2011 and December 31, 2014 were screened. 49 eligible subjects had traumatic SCI and received care in adjoining acute care (AC) hospital. OUTCOME MEASURES: Demographic characteristics and variables that capture diagnosis of TBI/SCI included documentation from ambulance, emergency department, AC, and IRF including ICD-9 codes, altered mental status, loss of consciousness (LOC), Glasgow Coma Score, Post Traumatic Amnesia (PTA), neuroimaging, and cognitive assessments. RESULTS: Participants were male (81%), white (55%), privately insured (49%), and aged 39.3±18.0 years with 51% paraplegic and 49% tetraplegic. Mechanisms of injury were gunshot wound (31%), fall (29%), and motor vehicle accident (20%). TBI occurred in 65% of SCI individuals, however documentation of identification of TBI, LOC, and CT imaging results varied in H&P, discharge notes, and ICD-9 codes across the continuum. Cognitive assessments were performed on 16% of subjects. CONCLUSIONS: Documentation showed variability between AC and IRF and among disciplines. Imaging and GCS were more consistently documented than LOC and PTA. It is necessary to standardize screening processes between AC and IRF to identify dual diagnosis.

Healthcare utilization following spinal cord injury: Objective findings from a regional hospital registry.

OBJECTIVE: The purpose was to describe the prevalence and characteristics of healthcare utilization among individuals with spinal cord injury (SCI) from a Level I trauma center. DESIGN: Retrospective data analysis utilizing a local acute trauma registry for initial hospitalization and merged with the Dallas-Fort Worth Hospital Council registry to obtain subsequent health care utilization in the first post-injury year. SETTING: Dallas, TX, USA. PARTICIPANTS: Six hundred and sixty four patients were admitted with an acute traumatic SCI from January 2003 through June 2014 to a Level I trauma center. Fifty five patients that expired during initial hospitalization and 18 patients with unspecified SCI (defined by ICD-9 with no etiology or level of injury specified) were not included in the analysis, leaving a final sample of 591. OUTCOME MEASURES: Data included demographic and clinical characteristics, charges, and healthcare utilization. RESULTS: Mean age was 46.1 years (±18.9 years), the majority of patients were male (74%), and Caucasian (58%). Of the 591 patients, 345 (58%) had additional inpatient or emergency healthcare utilization accounting for 769 additional visits (median of 3 visits per person). Of the 769 encounters, 534 (69%) were inpatient and 235 (31%) were emergency visits not resulting in an admission. The most prevalent ICD-9 codes listed were pressure ulcer, neurogenic bowel, neurogenic bladder, urinary tract infection, fluid electrolyte imbalance, hypertension, and tobacco use. CONCLUSION: Individuals with SCI experience high levels of healthcare utilization which are costly and may be preventable. Increasing our understanding of the prevalence and causes for healthcare utilization after acute SCI is important to target preventive strategies.

Sacral examination in spinal cord injury: Is it really needed?

OBJECTIVE: To determine if a self-report measure of S4-5 motor and sensory function in patients with chronic SCI accurately predicts sacral examination results. DESIGN: Prospective, single-blinded self-report survey compared with sacral exam. SETTING: Outpatient SCI clinic. PARTICIPANTS: 116 patients aged 18+ with chronic SCI > 6 months who have undergone sacral exam. INTERVENTIONS: The survey included demographic/clinical and sacral function information such as light tough (LT), pinprick sensation (PP), deep anal pressure (DAP) and voluntary anal contraction (VAC). Survey results and sacral exam were compared and stratified by the patient's American Spinal Cord Injury Association Impairment Scale (AIS) category. OUTCOME MEASURES: Sacral self-report survey, AIS examination. RESULTS: Mean age was 41.3 ± 14.4 years with majority male (69%) and Caucasian (71.6%). Overall, Positive Predictive Value (PPV) ranged between 48% (VAC) to 73% (DAP) and Negative Predictive Value (NPV) between 92% (VAC) to 100% (LT). AIS-A had NPV of 100% across all categories, and AIS-D had PPV of 100% across all categories. CONCLUSION: Patient report of sacral sparing can predict negative sensation in patients with AIS-A and predict positive sensation in persons with AIS-D. Overall, the self-report of sacral sparing of motor and sensory function is not predictive enough to rely on for accurate classification.

Posttraumatic Stress Symptoms Among Spinal Cord Injury Patients in Trauma: A Brief Report.

Background: Attention has recently focused on posttraumatic stress disorder (PTSD) among individuals with traumatic spinal cord injury (SCI). Purpose: To examine characteristics of individuals with and without symptoms of PTSD following acute SCI. Methods: Data were collected on 23 patients (age, 34.5 ± 14.4 years) at a Level I trauma center (14.35 ± 18.48 days following injury). Results: There were 52.2% (n = 12) who experienced symptoms of PTSD post injury, with a significant association in patients with a history of psychological disorders (p = .0094). Conclusion: Findings suggest that patients with SCI who present with PTSD symptoms in the acute trauma care settting should be provided with specific cognitive behavioral interventions.

Association of Human Papilloma Virus 16 Infection and p53 Polymorphism among Tobacco using Oral Leukoplakia Patients: A Clinicopathologic and Genotypic Study.

BACKGROUND: Human papillomavirus (HPV) and p53 alterations are speculated to play a role in carcinogenesis. This study was carried out to find out the association of HPV and p53 with precancerous lesions of the oral cavity such as leukoplakia: The objective of this study was to find the association among human papilloma virus (HPV) 16 infections and p53 polymorphism in tobacco using the oral leukoplakia patients. METHODS: A total of 91 oral leukoplakia patients and 100 controls were randomly selected from the out-patient department of a tertiary care dental hospital of North-east India. Blood samples were drawn incisional biopsy was performed from the lesion proper and the tissue was processed for histopathological grading. Cytological smears were taken from the lesional site of leukoplakia patients and buccal mucosa of controls. The rate of HPV infection and p53 polymorphism was detected with the help of polymerase chain reaction, gel electrophoresis and deoxyribonucleic acid sequencing. RESULTS: The rate of HPV 16 infection was found significantly high in the oral leukoplakia patients. No particular p53 genotype at exon 4 of codon 72 was found to be associated with oral leukoplakia, but "C" allele (proline) at exon 4 of codon 72 was significantly raised in these patients. CONCLUSIONS: Oral leukoplakia, a well-known pre-cancerous lesion, has been shown to be associated with tobacco, but certain other factors like HPV infection and p53 polymorphism may play an important role in its development.

A review of histopathological and immunohistochemical parameters in diagnosis of metastatic renal cell carcinoma with a case of gingival metastasis.

The oral cavity constitutes a site of low prevalence for metastasis of malignant tumors. However, oral metastasis of a renal origin is relatively more common and represents 2% of all cancer deaths. Renal cancer may metastasize to any part of the body, with a 15% risk of metastasis to the head and neck regions, and pose one of the greatest diagnostic challenges in medical sciences. Approximately 25% of patients have a metastatic disease at initial assessment, which is often responsible for initiating the diagnosis in the first place. Here we present a review of literature of renal cell carcinoma along with a case of gingival metastasis.

Aggressive fibromatosis of anterior maxilla.

Aggressive fibromatosis is a comparitively rare tumor with unpredictable growth and varying local recurrence rates. It does not develop distant metastases but locally it shows an aggressive and infiltrative behavior. Clinically, aggressive fibromatosis manifests as a painless, firm, often rapidly enlarging mass, fixed to underlying bone or soft tissue. It is never encapsulated. Histologically, it is rich in collagen and fibroblastic cells that are devoid of hyperchromatic or atypical nuclei, but with more variable cellularity in different tumor sections.

Acoustic analyses support subjective judgments of vocal emotion.

Subjective human judgments of emotion in speech have been considered to be less reliable than acoustic analyses in scientific studies, but acoustic analyses have had limited ability to detect subtle vocal nuances that give useful social information about human intent and meaning to discourse partners. Two post hoc analyses were undertaken to determine if results from acoustic analyses of vocalizations were related to subjective judgments of vocal affect (affective prosody). Acoustic analyses of fundamental frequency (F(o)) and subjective judgments of emotional content of vocal productions from two studies underwent statistical analyses: Study 1-vocal repetition of sentences using 6 basic emotions in 24 detoxified alcoholics and 15 controls; study 2-quality/quantity of "motherese" speech directed to 52 infants in Cambridge, England. Ratings of emotion indicators for both studies were done by female researchers of different ages and cultural/language backgrounds. In both studies, acoustic analyses of F(o) elements in utterances accounted for approximately 50% of the effect when modeling subjective emotion accuracy and emotion intensity ratings, using linear regression analyses. Acoustic analyses of F(o) are positively associated with subjective judgments of emotion indicators, and speakers who cannot vary F(o) are unable to convey emotion accurately to communication partners. Yet acoustic analyses are limited in comparison to the exquisite complexity of the human auditory and cognitive systems. Subjective judgments of emotional meaning in speech can be a reliable variable in scientific inquiry and can be used for more complex, subtle studies of speech communication and intentionality than acoustic analyses.