Can we perceptually rate alaryngeal voice? Developing the Sunderland Tracheoesophageal Voice Perceptual Scale.

OBJECTIVE: To investigate the inter and intra reliability of raters (in relation to both profession and expertise) when judging two alaryngeal voice parameters: 'Overall Grade' and 'Neoglottal Tonicity'. Reliable perceptual assessment is essential for surgical and therapeutic outcome measurement but has been minimally researched to date. DESIGN: Test of inter and intra rater agreement from audio recordings of 55 tracheoesophageal speakers. SETTING: Cancer Unit. PARTICIPANTS: Twelve speech and language therapists and ten Ear, Nose and Throat surgeons. MAIN OUTCOME MEASURES: Perceptual voice parameters of 'Overall Grade' rated with a 0-3 equally appearing interval scale and 'Neoglottal Tonicity' with an 11-point bipolar semantic scale. RESULTS: All raters achieved 'good' agreement for 'Overall Grade' with mean weighted kappa coefficients of 0.78 for intra and 0.70 for inter-rater agreement. All raters achieved 'good' intra-rater agreement for 'Neoglottal Tonicity' (0.64) but inter-rater agreement was only 'moderate' (0.40). However, the expert speech and language therapists sub-group attained 'good' inter-rater agreement with this parameter (0.63). The effect of 'Neoglottal Tonicity' on 'Overall Grade' was examined utilising only expert speech and language therapists data. Linear regression analysis resulted in an r-squared coefficient of 0.67. Analysis of the perceptual impression of hypotonicity and hypertonicity in relation to mean 'Overall Grade' score demonstrated neither tone was linked to a more favourable grade (P = 0.42). CONCLUSIONS: Expert speech and language therapist raters may be the optimal judges for tracheoesophageal voice assessment. Tonicity appears to be a good predictor of 'Overall Grade'. These scales have clinical applicability to investigate techniques that facilitate optotonic neoglottal voice quality.

Swallowing problems in Parkinson disease: frequency and clinical correlates.

BACKGROUND: Changes to the efficiency and integrity of swallowing mechanisms are inevitable in Parkinson disease (PD); however, it remains unclear how many people with PD are at risk of dysphagia. The aim of this study was to establish the frequency of impaired swallowing in people with PD and the relationship between swallowing performance and indicators of disease progression. METHODS: A community-based and hospital-based cohort of 137 individuals with PD were asked to drink 150 ml of water as quickly as possible while in an 'off drug' state. RESULTS: Thirty-one (23%) patients could not completely drink the full 150 ml. Swallowing rate (ml/sec) fell to more than 1 SD below published norms for 115 (84%) patients and to more than 2SD below for 44 (32%) individuals. There were moderate correlations between rate of swallowing and disease severity, depression and cognition, but not between swallowing speed and disease duration. There was poor correlation between subjective reports of dysphagia and performance on the water swallow test. CONCLUSIONS: Swallowing problems are frequent in PD. Self-report of 'no difficulty' is not a reliable indicator of swallowing ability. Studies employing more-objective assessment of aspiration risk to compare with water swallow test performance are advocated.

Entry site neovascularization and vitreous cavity hemorrhage after diabetic vitrectomy. The predictive value of inner sclerostomy site ultrasonography.

OBJECTIVE: To assess the incidence of neovascularization of the inner sclerostomy wound and occurrence of postoperative vitreous cavity hemorrhage (POVCH) after vitrectomy for proliferative diabetic retinopathy (PDR). DESIGN: Consecutive prospective longitudinal clinical study. PARTICIPANTS: Seventy-three eyes (58 patients) undergoing primary vitrectomy for PDR. METHODS: Twenty-megahertz (MHz) high-resolution anterior segment ultrasonography was performed on all sclerostomy sites 2 months postoperatively and repeated at the time of any POVCH. The appearance of the inner sclerostomy wound was divided into 4 classes (normal, spheroidal, tent, and trapezoidal, representing entry site neovascularization). The occurrence, degree, and duration of POVCH and need for revision surgery with vitreous cavity washout (VCW) were recorded. Postoperative vitreous cavity hemorrhage was divided into 3 groups-namely, mild, moderate, and major. MAIN OUTCOME MEASURES: Inner sclerostomy wound appearance on ultrasonography, degree and timing of POVCH, and need for VCW. RESULTS: There were 15 eyes in total with POVCH (20%): one patient had a persistent POVCH that required VCW. Fourteen other eyes (19%) had recurrent POVCH. Four (28%) of these 14 eyes with recurrent POVCH were classified as mild and 3 (21%) moderate: all cleared spontaneously with no further intervention needed. None of these had a trapezoidal image. Seven of the 14 eyes with recurrent POVCH were classified as major. Five of these 7 eyes had a trapezoidal image at 2 months postoperatively, and 4 required VCW (5.5% of total no. of eyes in study). All patients with a trapezoidal image experienced some degree of recurrent vitreous cavity hemorrhage (P = 0.0000024). The odds ratio was approximately 330:1. There was a significant correlation between the severity of POVCH and entry site appearance on ultrasound. In the first year of follow-up, all patients requiring VCW after recurrent POVCH had a trapezoidal image present at 2 months postoperatively (P = 0.009). CONCLUSION: The appearance of a trapezoidal image on 20-MHz high-resolution anterior segment ultrasonography at a sclerostomy site after vitrectomy for PDR was highly correlated with the occurrence of nonclearing POVCH and need for VCW. Conversely, the absence of a trapezoidal image in patients with POVCH was associated with spontaneous hemorrhage clearance.

Measuring symptom load in Idiopathic Parkinson's disease.

This study evaluated the symptom burden experienced by patients with Idiopathic Parkinson's Disease (IPD) by using a standard palliative care assessment tool (PACA) and comparing it with the Unified Parkinson's Disease Rating Scale (UPDRS). These tools together with the Mini-Mental State Examination, Beck Depression Inventory and the Schedule for the Evaluation of Individual Quality of Life were used in 123 IPD patients. The PACA demonstrated broad coverage of both motor and non motor symptoms (mean=14.3 symptoms per patient) whereas the UPDRS predominantly assessed motor symptoms. Implications for symptom assessment and palliative care provision in IPD are discussed.

Postkeratoplasty emergency visits--a review of 100 consecutive visits.

PURPOSE: Preoperative counselling for penetrating keratoplasty should include awareness of symptoms and signs of possible complications as early presentation can enhance long-term success. In our corneal transplantation service, all patients are routinely instructed to arrange a same day emergency visit through a dedicated telephone line if they experience any symptoms in eyes that have undergone keratoplasty. This study was designed to evaluate the reason for presentation, management outcome of each visit and the efficiency of the system in management of postkeratoplasty complications. METHODS: A review of 100 consecutive emergency visits by postpenetrating keratoplasty (PKP) patients in a tertiary eye care centre was included. RESULTS: Sixty-two patients with varied preoperative diagnoses presented during the review period. Sixteen visits were within the first month after surgery and 40 visits within the first year. Ten patients (16%) sought consultation more than twice during the study period with one patient presenting five times. Pain and grittiness were the main presenting symptoms (68%). Loose corneal suture (25%) necessitating removal was the most common diagnosis. Sixteen visits resulted in hospital admission for treatment. The graft survived in all patients and the visual acuity was preserved in 95% of our patients. CONCLUSION: Most corneal surgeons educate their patients to seek prompt treatment for symptoms such as redness, sensitivity to light, loss of vision, pain, or any other symptoms in eyes that have undergone keratoplasty. Early intervention of sight threatening complications increases the chance of graft survival and best-obtained vision. This review shows a simple open access system facilitates early presentation and successful management of postgraft complications.

Reducing waiting times for GU medicine appointments: the impact of a new appointment system.

Our objective was to reduce the 'did not attend' (DNA) rates and waiting times by introducing a new confirmatory appointment system prior to their attendance at both Hartlepool and Middlesbrough genitourinary (GU) medicine departments. In Middlesbrough it was previous day appointment confirmation, whereas at Hartlepool it was 10 days. Both systems achieved significant attendance rates of 83.4% and 79.1% at Hartlepool and Middlesbrough, in comparison to 68.7% and 75.0% prior to the new system. The new system will improve the departmental capacity.

A prospective, randomised, controlled study examining binaural beat audio and pre-operative anxiety in patients undergoing general anaesthesia for day case surgery.

Pre-operative anxiety is common and often significant. Ambulatory surgery challenges our pre-operative goal of an anxiety-free patient by requiring people to be 'street ready' within a brief period of time after surgery. Recently, it has been demonstrated that music can be used successfully to relieve patient anxiety before operations, and that audio embedded with tones that create binaural beats within the brain of the listener decreases subjective levels of anxiety in patients with chronic anxiety states. We measured anxiety with the State-Trait Anxiety Inventory questionnaire and compared binaural beat audio (Binaural Group) with an identical soundtrack but without these added tones (Audio Group) and with a third group who received no specific intervention (No Intervention Group). Mean [95% confidence intervals] decreases in anxiety scores were 26.3%[19-33%] in the Binaural Group (p = 0.001 vs. Audio Group, p < 0.0001 vs. No Intervention Group), 11.1%[6-16%] in the Audio Group (p = 0.15 vs. No Intervention Group) and 3.8%[0-7%] in the No Intervention Group. Binaural beat audio has the potential to decrease acute pre-operative anxiety significantly.

Improving prostate cancer detection with an extended-core transrectal ultrasonography-guided prostate biopsy protocol.

OBJECTIVE: To investigate whether taking two transition zone (TZ) and four lateral peripheral zone (PZ) biopsies in addition to routine parasaggital sextant biopsies would improve detection rates in men with suspected prostate cancer. PATIENTS AND METHODS: The study included 493 consecutive men (mean age 68.7 years, sd 8.2) with elevated serum prostate-specific antigen (PSA) levels and/or abnormal findings on a digital rectal examination who underwent transrectal ultrasonography-guided prostate biopsy. In addition to sextant biopsies, six further biopsies were obtained, two from the TZ (mid-gland) and four from the lateral PZ (base and mid-gland). Pathological findings for the additional biopsies were compared with those of the sextant regions. RESULTS: Prostatic adenocarcinoma was diagnosed in 164 of the 493 (33%) men biopsied. Men with cancer were older, had smaller prostates and higher median PSA levels than men with negative biopsies. Sextant biopsies were positive for cancer in 133 of 164 (81%) men. All three sets of biopsies were positive in 53 (32%) cases. In 50 (30%) men both the sextant and lateral PZ biopsies were positive, while in six (4%) men, both sextant and TZ biopsies were positive. Thirty-one (19%) tumours were not detected by sextant biopsies, 10 (6%) where the lateral PZ biopsies alone were positive, 17 (10%) where the TZ biopsies alone were positive and four (3%) where both the TZ and lateral PZ together were positive. There were no differences in median PSA concentration, total prostate volume or TZ volume between men with an isolated TZ cancer and men with cancer elsewhere in the prostate. However, 77% of men with TZ cancer had a PSA of > 10 ng/mL, compared with 60% of men with cancer at other sites within the prostate (P = 0.015). CONCLUSION: An extended-core biopsy protocol significantly improves the detection rate for prostate cancer when compared with the standard sextant biopsy protocol alone. Routine TZ biopsies should be considered for men with serum PSA levels of >10 ng/mL.

Quality of life in laryngectomees: a post-treatment comparison of laryngectomy alone versus combined therapy.

Patients with advanced and recurrent laryngeal and hypopharyngeal cancer often need combined therapy, which is associated with greater morbidity than single modality treatment. The aim of this study was to assess the quality of life in laryngectomees and to assess whether differences exist between the irradiated and the non-irradiated patients. The University of Michigan Head and Neck Quality of Life questionnaire, a validated instrument for assessing the head and neck cancer related functional status and well-being, was used for this purpose. Subjects for the study included patients who had undergone total laryngectomy for laryngeal or hypophyarngeal squamous cancer. No significant difference between the groups was evident in the various domain scores, although a trend towards higher scores was seen in the combined therapy group. This study suggests that long-term side effects induced by radiotherapy do not adversely affect the quality of life in laryngectomised patients.

Surgical accuracy in Le Fort I maxillary osteotomies.

UNLABELLED: The surgical outcome of planned movements of Le Fort I osteotomies is dependent on the surgeon's ability to achieve such movements intraoperatively. Our aim was to assess the surgical accuracy achieved for 30 consecutive patients undergoing Le Fort I osteotomies treated by one maxillofacial surgeon and his team. METHOD: Intraoperative control of the mobilized maxilla vertically was achieved by a combination of a nasion screw as the external reference point and bony marks above and below the osteotomy cuts intraorally. Movements horizontally and transversely were controlled with occlusal wafers. The surgical accuracy of maxillary movements vertically and horizontally (anteroposteriorly) were assessed by standard lateral cephalometric tracings of radiographs taken within two weeks prior to operation and 48 hours afterwards. Audit targets were arbitrarily set to be satisfactory when the difference between planned movements and actual movements as measured on the cephalometric tracings were 2 mm or less. RESULTS: The mean (SD) difference from planned vertical movements of the anterior maxilla was 0.37 mm (SD 0.64) and horizontal movements 0.85 mm (SD 0.91). Ninety-seven percent (29/30) of anterior maxillary movements in the vertical dimension, 90% (27/30) of anterior maxillary movements in the horizontal dimension and 87% (26/30) of movements in both dimensions had a difference of 2 mm or less. These results were comparable with the reported 'gold standard'. CONCLUSION: Good surgical accuracy in positioning the mobilized maxilla in Le Fort I osteotomies can be achieved with the use of external and internal reference points.

The Comorbidity Symptom Scale: a combined disease inventory and assessment of symptom severity.

OBJECTIVES: To develop and evaluate a scale to quantify the presence and severity of symptoms arising from comorbid diseases in older people. DESIGN: A validation cohort study of hospital inpatients and outpatients aged 65 years and older. SETTING: A Hospital and community in Northeast England. PARTICIPANTS: Development of the Comorbidity Symptom Scale-Convenience sample of 50 hospital inpatients and outpatients aged 65 years and older. Evaluation of the Comorbidity Symptom Scale- Convenience sample of 183 patients aged 65 years and older either awaiting cataract surgery or attending a geriatric day hospital. MEASUREMENTS: For development of the Comorbidity Symptom Scale, 22 comorbid conditions were identified and incorporated into a questionnaire (the CmSS). Evaluation of the Comorbidity Symptom Scale-Assessments included the CmSS, activities of daily living, perceived health status, and anxiety and depression. RESULTS: A 23-item scale was developed. Reliability of the CmSS was demonstrated by a test-retest correlation coefficient for the total instrument score of r = 0. 87 (P < .001). The CmSS scores correlated with assessments of activities of daily living, perceived health status, and anxiety and depression. CONCLUSIONS: The CmSS is a simple interviewer-administered tool for use in older people and provides an objective measure of the presence of comorbid disease and the patient's perception of severity of associated symptoms.

Lower limb occlusive arterial disease in the North of England: workload and development of management guidelines. The Northern Regional Vascular Surgeons.

BACKGROUND: in 1997 the vascular surgeons across the North of England commenced a study to examine various aspects of the management of lower limb occlusive arterial disease (LLOAD). Two aspects of this work were to assess workloads between hospitals and develop guideline parameters for managing intermittent claudication (IC) and critical limb ischaemia (CLI). The guidelines were to be developed, tested and modified by this study. METHOD: prospective inclusion of all patients admitted for investigation of LLOAD to nine hospitals by 19 surgeons over a period of 12 months. RESULTS: the hospitals admitted an average of 106 legs per 100 000 population (range 53-149) with LLOAD. Legs with IC (n=1351) were revascularised slightly less frequently than predicted (actual 76%, guideline 80%) and radiological treatment was used more frequently than predicted (radiology/surgery, actual 69/32%, guideline 40/60%). For limbs with CLI, revascularisation was undertaken more often (actual 70%, guideline 60%) and radiological intervention used more frequently (radiology/surgery, actual 45/58%, guideline 35/65%) than anticipated. Primary amputation, overall mortality and limb salvage were better than the predicted guidelines. CONCLUSION: large variations in workloads and clinical practice were observed between hospitals for the management of LLOAD. Developing guidelines for the management of limbs with IC was not considered appropriate, whereas suitable guidelines for legs with CLI were developed, tested and modified.

Predictors of asthma severity in the elderly: results of a community survey in Northeast England.

A number of risk factors for the development and severity of asthma in childhood are known. Particularly, there is information on allergens, excessive use of beta2- agonists, and indoor environmental pollutants. Similar information on elderly patients is lacking. We examined the risk factors for current asthma and for the severity of asthma in 95 elderly subjects (>65 years old) compared to 274 elderly subjects with obstructive spirometry who did not have asthma as defined by the following criteria: symptoms of episodic wheeze, cough, or chest tightness and forced expiratory volume in 1 sec/vital capacity (FEV1/VC) <70% with >15% or 200 mL reversibility in FEV1 to 200 microg salbutamol given from a metered-dose inhaler. The severity of airflow limitation was graded on the basis of the FEV1/VC ratio as mild (60%-70%), moderate (40%-60%), and severe (<40%). Asthma history was collected using the Medical Research Council respiratory questionnaire and a follow-up postal questionnaire. Data were analyzed using multiple logistic regression and the overall goodness-of-fit of the model was checked using the Hosmer-Lemeshow (HL) statistic. History of allergy (to one or more of the following allergens: cat, house dust, or grass or tree pollen) (odds ratio [OR] 25; 95% confidence interval [CI] 13-51; p = 0.0001) and history of childhood wheeze (OR 8; 95% CI 4-9; p = 0.004) were strong predictors of current asthma. Duration of wheezing, smoking history, indoor heating, history of working in coal mines, and sex were not predictors (HL 6.75, degrees of freedom [df] = 8, p = 0.56). Use of >4 puffs of salbutamol/ day (OR 5.3; 95% CI 2-14; p = 0.005), more than 10 years of asthma symptoms (OR 4.2; 95% CI 4.1-36.2; p = 0.0001), and >500 mL reversibility in FEV1 (OR 4.2; 95% CI 1.2-14.3; p = 0.05) were independent predictors of moderate to severe asthma. History of atopy was the strongest predictor of asthma in the elderly population studied. Indoor heating, presence of pets at home, sex, smoking history, and history of working in coal mines were not predictors of asthma. The severity of asthma as assessed by measurement of airflow limitation was related to the frequency of use of beta2-agonists, duration of symptoms of asthma, and increased reversibility of FEV1 to beta2-agonist.

Measuring visual symptoms in British cataract patients: the cataract symptom scale.

AIMS: To develop and validate a scale for the measurement of visual symptoms and functional disability due to cataract in older UK residents. METHODS: In depth semistructured interviews were undertaken with 44 consecutive patients awaiting cataract surgery. Patients were asked to describe visual symptoms and problems with social functioning which were then incorporated into a questionnaire, the cataract symptom scale (CSS). The CSS was further examined in a cohort of 118 consecutive cataract patients awaiting surgery. Further assessments in these patients included visual acuity, visual function using an existing scale (the VF-14), activities of daily living, perceived health status, anxiety and depression, and a global assessment of how much patients felt their visual symptoms affected their daily life. RESULTS: A 15 item scale was derived which was simple to administer to older patients and had a high internal consistency. The test-retest correlation coefficient for the total instrument score was r = 0.91 (p<0.0001). The CSS correlated well with the VF-14 and to a lesser extent with visual acuity in the better eye, activities of daily living, perceived health status, anxiety and depression, and the patients' global assessment of visual symptoms. CONCLUSION: The CSS provides information regarding the symptomatic and functional status of older cataract patients resident in the UK which cannot be obtained by measurement of visual acuity alone.

Intermaxillary fixation is not usually necessary to reduce mandibular fractures.

We undertook a retrospective study of all isolated mandibular fractures which had required active management over a 1-year period at the Maxillofacial Unit at Newcastle General Hospital. Patients with single or multiple fractures of the mandible were included in the study, if there were other simultaneous fractures of the facial skeleton, those patients were excluded. All case notes and radiographs were reviewed by a single operator. A total of 202 cases of fractured mandible were identified of which 115 fulfilled the selection criteria of: isolated fracture, no previous facial fracture, treatment by open reduction and internal fixation using titanium osteosynthesis miniplates, and all case notes and radiographs available to study. Sixty-six patients had their fractures reduced manually to obtain anatomical reduction without the use of peroperative intermaxillary fixation (IMF). Forty-nine were treated conventionally using peroperative IMF. The two groups were broadly similar in severity and type of fracture, and the method of reduction seemed to be decided by the operator according to their preference. IMF was not used routinely postoperatively. Overall there were significantly fewer occlusal discrepancies in the early postoperative period in those patients treated by anatomical reduction (6/66 compared with 16/49, P = 0.002) but there was no difference in the final outcome of the occlusion between the two methods of reduction. Avoidance of the use of peroperative IMF is more economical in time and cost, is safer for the operator, and more comfortable for the patient. As this technique produces comparable results in the long term with fewer early complications, we conclude that IMF is not usually necessary to reduce fractures confined to the mandibular bone.

Validating the Ontario Child Health Scale in a UK population.

The Ontario Child Health Scale (OCHS) was one of the first scales to seek to assess a broad range of formally defined psychiatric disorders using a checklist format. The performance of the teacher version of this instrument is reported in a UK population of children attending a special educational provision for emotionally and behaviourally disordered (EBD) pupils. Against DSM-IV criteria the instrument proved to have retained its convergent and discriminant validity, although it was somewhat less effective in detecting internalizing disorders and discriminating oppositional defiance from other behavioural disorders. Overall the results confirm the usefulness of this instrument as a screening tool in a UK population.

Does voided urine cytology have biological significance?

OBJECTIVE: To (i) define any correlation between the result of voided urine cytology (VUC) at presentation and the biological behaviour of Ta/T1 transitional cell carcinoma (TCC) of the bladder; and (ii) observe the natural history of Ta/T1 bladder cancer in relation to new prognostic groupings. PATIENTS AND METHODS: The study comprised 109 patients with newly diagnosed Ta/T1 TCC of the bladder, all of whom had VUC assessed at presentation. Information on the number of tumours at presentation and the subsequent tumour recurrence rate during clinical follow-up was compared with the outcome of VUC. RESULTS: Of the 109 patients, 67 (61%) had Ta and 42 (39%) had T1 tumours. At presentation, there were 75 (69%) solitary (Ta=50, T1=25) and 34 (31%) multifocal (Ta=17, T1=17) tumours. At presentation, VUC was negative in 71 (65%), suspicious in 22 (20%) and positive for urothelial carcinoma in 16 (15%) patients. During follow-up, 58% of patients with Ta tumours and 83% of patients with T1 tumours developed recurrences (median follow-up 43.5 months, P=0.01), although there was no significant difference in the recurrence rate between these groups (P=0.096). In addition, for those patients with Ta tumours that were multifocal at presentation, there was a significantly higher recurrence rate (P=0.003). Although there was no correlation between the result of VUC and the number of tumours at presentation, there was a significantly higher tumour recurrence rate for those patients with suspicious/positive VUC than for those whose VUC was negative (P<0.05). CONCLUSION: This study shows the impact of tumour multifocality at presentation on subsequent tumour recurrence rate. In addition, the VUC result at presentation correlated with tumour recurrence in patients with Ta/T1 TCC of the bladder.

Asthma in the elderly: underperceived, underdiagnosed and undertreated; a community survey.

Bronchial asthma is now increasingly recognized in the elderly and is associated with significant morbidity and mortality. The aims of this study were two-fold: first, to assess the prevalence and, second, to evaluate diagnostic awareness, therapeutic management and patient perception of bronchial asthma among elderly patients in the community. From the age-sex register of an urban general practice in NE England, 2004 patients aged > 65 years were eligible for inclusion. Response to an initial screening questionnaire on respiratory symptomatology was 68% (n = 1362). Of these, 869 patients had respiratory symptoms: 390 voluntarily agreed to be evaluated further including assessment of airway physiology. In this group 369/390 had obstructive spirometry and, of these, 95 patients fulfilled clinical and physiological criteria of bronchial asthma. Prevalence of asthma within this age cohort was minimally and rather crudely assigned at 4.5% (95/2004). Among the 95 patients so-defined patients with asthma [age 70 +/- 8 years (mean +/- SD), FEV1 = 0.96 +/- 0.41, 33 male, 75 life-long non-smokers], subjective awareness, perception and attribution of pulmonary symptoms were poor. Further, despite tangible evidence of reversible and significant airflow limitation, only 21 were receiving inhaled glucocorticoid therapy (median daily dose 400 micrograms). Asthma in the elderly remains poorly perceived, poorly recognized and suboptimally treated. These findings are particularly apposite in the light of current epidemiological trends in asthma mortality and morbidity in elderly age cohorts.