Intensive Stuttering Therapy with Telepractice Follow-Up: Longitudinal Outcomes.

PURPOSE: This study estimated the treatment outcomes of a behavioral stuttering therapy program that blended a combination of intensive face-to-face therapy with telepractice-based follow-up therapy. METHOD: A total of 17 participants (mean age = 22 years) who stutter participated in the program, preceded by an extended baseline period. The participants completed a series of assessments conducted over multiple time points, spanning a total of 42 weeks. Growth curve modeling was used to analyze the changes participants experienced in the frequency of stuttering, stuttering severity, communication attitudes, and quality of life. RESULTS: The participants demonstrated stability throughout the extended baseline period, and experienced positive outcomes from the intensive program and the gains in communication attitudes and quality of life were largely maintained with weekly follow-up telepractice sessions. However, stuttering frequency and severity increased when the telepractice follow-up session frequency transitioned to a biweekly basis. Neither gender nor age group predicted the treatment outcomes for frequency or severity of stuttering. Gender-based differences were found for the treatment outcomes of specific self-report measures, with male participants having demonstrated a greater proportional decline on their standard scores, relative to female participants. Outcomes were similar for both adolescents and adults. CONCLUSIONS: Participants attending the intensive stuttering therapy program experienced positive and significant changes in their speech, attitudes toward communication, and overall quality of life, which were maintained over time with structured, weekly telepractice follow-up sessions.

The Utility of Cinematherapy for Stuttering Intervention: An Exploratory Study.

This preliminary study explored the feasibility and benefits of using cinematherapy with adults who stutter to address affective and cognitive reactions to stuttering and their impact on the persons' life. A mixed methods research design was used to explore the impact of cinematherapy. Four clients completed a 4-week structured cinematherapy program. All clients completed two questionnaires: Unhelpful Thoughts and Beliefs about Stuttering and Overall Experience of the Speaker's Experience of Stuttering, before starting and after completing the program. At the end of the program, clients also completed a semistructured interview. The semistructured interviews provide insight on clients' perceptions of cinematherapy, and questionnaires provided quantitative insights on the clients' perceptions of change. Qualitative data analysis indicated that clients reported five themes related to perceptions of cinematherapy: Promoted Vulnerability; Nurtured Empowerment; Stimulated Self-Reflection; Incited Feelings of Belonging; and Diminished Self-Stigma. Overall, clients reported a clinically significant decrease in scores on both questionnaires after completion of the 4-week cinematherapy program. Results indicate that cinematherapy was well received and had a positive impact on cognitive and affective aspects of stuttering in the four adult clients. These results provide preliminary support for larger scale clinical trials of cinematherapy as an adjuvant to traditional stuttering therapy.

A cross-sectional investigation of disfluencies in typically developing Spanish-English bilingual children.

PURPOSE: This study examined the language skills and the type and frequency of disfluencies in the spoken narrative production of typically developing Spanish-English bilingual children. METHOD: A cross-sectional sample of 106 bilingual children (50 boys; 56 girls) enrolled in kindergarten through Grade 4, produced a total of 212 narrative retell language samples in English and Spanish. A specialized fluency coding system was implemented to index the percentage of total (%TD) and stuttering-like disfluencies (%SLD) in each language. Large-scale reference databases were used to classify children's dual language proficiency profiles (balanced, English dominant, Spanish dominant) based on language sample analysis measures of morphosyntax and lexical diversity. RESULTS: The bilingual Spanish-English children in this study did not demonstrate significant cross-linguistic differences for mean %TD or %SLD. However, the mean %TD and %SLD in both languages exceeded the risk threshold based on monolingual English-speaking norms. English dominant bilingual children demonstrated significantly lower %TD in English than Spanish. Spanish dominant children demonstrated significantly lower %SLD in Spanish than English. CONCLUSIONS: This study included the largest sample size of bilingual Spanish-English children investigated to date from a fluency perspective. The frequency of disfluencies was found to be variable across participants and change dynamically as a function of grade and dual language proficiency profiles, indicating the need for studies that employ larger sample sizes and longitudinal designs.

A novel non-word speech preparation task to increase stuttering frequency in experimental settings for longitudinal research.

PURPOSE: The variable and intermittent nature of stuttering makes it difficult to consistently elicit a sufficient number of stuttered trials for longitudinal experimental research. This study tests the efficacy of using non-word pairs that phonetically mimic English words with no associated meaning, to reliably elicit balanced numbers of stuttering and fluent trials over multiple sessions. The study also evaluated the effect of non-word length on stuttering frequency, the consistency of stuttering frequency across sessions, and potential carry-over effects of increased stuttering frequency in the experimental task to conversational and reading speech after the task. METHODS: Twelve adults who stutter completed multiple sessions (mean of 4.8 sessions) where they were video-recorded during pre-task reading and conversation, followed by an experimental task where they read 400 non-word pairs randomized for each session, and then a post-task reading and conversation sample. RESULTS: On average, across sessions and participants, non-word pairs consistently yielded a balanced distribution of fluent (60.7%) and stuttered (39.3%) trials over five sessions. Non-word length had a positive effect on stuttering frequency. No carryover effects from experimental to post-task conversation and reading were found. CONCLUSIONS: Non-word pairs effectively and consistently elicited balanced proportions of stuttered and fluent trials. This approach can be used to gather longitudinal data to better understand the neurophysiological and behavioral correlates of stuttering.

Impact of an acute coronary syndrome pathway in achieving target heart rate and utilization of evidence-based doses of beta-blockers.

Beta-blockers remain a cornerstone of therapy in the management of acute coronary syndrome (ACS). The 2007 American College of Cardiology/American Heart Association unstable angina/non-ST elevation myocardial infarction guideline revisions recommend a target heart rate (HR) of 50-60 beats per minute (bpm). Despite improved trends toward utilization of beta-blockers therapy, beta-blockers continue to be underdosed. Guideline-based tools have been shown to improve adherence to evidence-based therapy in patients with ACS. Implementation of a standardized ACS pathway would lead to titration of beta-blockers to recommended dosages with improved HRs in eligible patients. The ACS clinical protocol was implemented at the University of Toledo Medical Center in May 2007. A retrospective study of 516 patients admitted during a comparable 6-month period, before and after the institution of the protocol, was conducted. The preprotocol and protocol group included 237 and 279 patients, respectively. Patient information extracted from the medical records included age, gender, HR on admission, blood pressure on admission, duration of hospital stay, preadmission use of beta-blocker, type of beta-blocker and dosage, discharge beta-blocker and dosage, peak troponin levels, and therapeutic intervention. A target HR of less than 60 bpm was achieved in 19% of the protocol group, as compared with 6% in the preprotocol group (P < 0.001). The protocol group had a significantly lower mean discharge HR than the preprotocol group (67 vs. 74 bpm; P < 0.001). The mean discharge dose of metoprolol in the protocol group was noted to be significantly higher (118 vs. 80 mg/d; P < 0.001). The institution of an ACS clinical pathway led to utilization of beta-blockers in significantly higher dosages, resulting in improved HR control and increased attainment of target HR.

Spontaneous coronary artery dissection: to treat or not to treat--2 atypical cases and a review of the literature.

Spontaneous coronary dissection is an unusual cause of acute coronary syndrome and sudden death, with a predilection for otherwise healthy young women. Presentation during the peri-partum period accounts for a quarter of the cases. We describe 2 cases of spontaneous coronary dissection with some atypical features. Both patients differed in their demographics, clinical presentations, and management strategies. Posited pathogenetic mechanisms for spontaneous coronary dissection are varied and remain poorly understood. Optimal management strategies depend on the vessels involved and the presence of ongoing symptoms. Patients who survive to presentation typically have a good prognosis.

Multimodal explainable AI predicts upcoming speech behavior in adults who stutter.

A key goal of cognitive neuroscience is to better understand how dynamic brain activity relates to behavior. Such dynamics, in terms of spatial and temporal patterns of brain activity, are directly measured with neurophysiological methods such as EEG, but can also be indirectly expressed by the body. Autonomic nervous system activity is the best-known example, but, muscles in the eyes and face can also index brain activity. Mostly parallel lines of artificial intelligence research show that EEG and facial muscles both encode information about emotion, pain, attention, and social interactions, among other topics. In this study, we examined adults who stutter (AWS) to understand the relations between dynamic brain and facial muscle activity and predictions about future behavior (fluent or stuttered speech). AWS can provide insight into brain-behavior dynamics because they naturally fluctuate between episodes of fluent and stuttered speech behavior. We focused on the period when speech preparation occurs, and used EEG and facial muscle activity measured from video to predict whether the upcoming speech would be fluent or stuttered. An explainable self-supervised multimodal architecture learned the temporal dynamics of both EEG and facial muscle movements during speech preparation in AWS, and predicted fluent or stuttered speech at 80.8% accuracy (chance=50%). Specific EEG and facial muscle signals distinguished fluent and stuttered trials, and systematically varied from early to late speech preparation time periods. The self-supervised architecture successfully identified multimodal activity that predicted upcoming behavior on a trial-by-trial basis. This approach could be applied to understanding the neural mechanisms driving variable behavior and symptoms in a wide range of neurological and psychiatric disorders. The combination of direct measures of neural activity and simple video data may be applied to developing technologies that estimate brain state from subtle bodily signals.

An endobronchial lipoma mimicking asthma and malignancy.

Endobronchial lipomas are rare benign tumours of the lung. Bronchial occlusion may lead to a misdiagnosis of asthma or malignancy. We describe a 52-year-old man treated for asthma for several years, who presented with non-resolving right upper lobe pneumonia. Bronchoscopy proved to be diagnostic and therapeutic. Clinical characteristics of this unique entity are discussed.

Recurrent Pleural Effusions and Elevated PTHrP: An Unusual Case of Sarcoidosis.

A 63-year-old male with a past medical history of stage 3 chronic kidney disease, type 2 diabetes mellitus, hypertension, and coronary artery disease presented with recurrent symptomatic pleural effusions, low back pain and unintentional weight loss. Labs revealed elevated serum calcium and parathyroid hormone-related peptide, but normal parathyroid hormone, vitamin D, and angiotensin-converting enzyme levels. Malignancy workup was revealing for salt-and-pepper appearance of the bone marrow on MRI of the lumbar spine consistent with multiple myeloma. CT of chest, abdomen, and pelvis was negative for neoplastic process but showed a pleural effusion and calcified granulomas in hilar lymph nodes. Bone marrow biopsy of the lumbar region was subsequently conducted and revealed granulomas confirming the diagnosis of sarcoidosis. Treatment of sarcoidosis resulted in complete resolution of his symptoms and pleural effusion. This case highlights the variable presentation of sarcoidosis and its ability to mimic malignancy. Prompt recognition and treatment is essential in avoiding unnecessary costs and harm to the patient.

Propylthiouracil-induced leucocytoclastic vasculitis with pulmonary hemorrhage treated with plasmapheresis.

Propylthiouracil (PTU) can effectuate antineutrophil cytoplasmic antibodies (ANCA)-positive vasculitis. We report a case of severe, PTU-induced leucocytoclastic vasculitis with diffuse pulmonary hemorrhage within a month of initiating PTU. Emergent plasmapheresis was initiated with excellent clinical response. A clinical suspicion for this potential side effect coupled with early cessation of the drug is generally adequate. Clinical manifestations, posited pathogenetic mechanisms, and therapeutic strategies, including the role of plasmapheresis, are discussed.

Recurrent symptomatic pleural effusion due to a ventriculopleural shunt.

Ventriculopleural shunts are uncommonly used for the treatment of normal pressure hydrocephalus in adults. Pleural effusion has been reported to complicate the course of these ventriculopleural shunts in children. The pleural effusion should typically resemble the cerebrospinal fluid unless frankly infected. There are few good data on the nature of the pleural effusion. We, report a case of recurrent right-sided pleural effusion, 2 years after a ventriculopleural shunt insertion, for normal pressure hydrocephalus with no evidence of an underlying infection. The effusion abated after ligation of the shunt. We discuss the possible mechanisms in the development of the effusion. It is important to be aware of this unlikely complication of an uncommon procedure. Recognizing the origin of the pleural effusion can help in instituting close follow-up and early referral for revision of the ventriculopleural shunt.

Multiple myeloma and systemic lupus erythematosus in a young woman.

Although systemic lupus erythematosus (SLE) is associated with lymphoid malignancies, concurrent multiple myeloma and SLE are rare. We report a 28-year-old black woman with SLE who developed smoldering IgA kappa multiple myeloma. The coexistence of these conditions in this age and race has not been previously reported. A literature search was conducted and all 12 previously reported cases of concurrent SLE and multiple myeloma were reviewed. The demographic and clinical features of multiple myeloma in SLE are summarized. Possible mechanisms underlying this association are also discussed. In the appropriate clinical context, multiple myeloma should be considered in SLE patients irrespective of young age, race, SLE disease activity, or duration.

Single-Trial Classification of Disfluent Brain States in Adults Who Stutter.

Normal human speech requires precise coordination between motor planning and sensory processing. Speech disfluencies are common when children learn to talk, but usually abate with time. About 5% of children experience stuttering. For most, this resolves within a year. However, for approximately 1% of the world population, stuttering continues into adulthood, which is termed 'persistent developmental stuttering'. Most stuttering events occur at the beginning of an utterance. So, in principle, brain activity before speaking should differ between fluent and stuttered speech. Here we present a method for classifying brain network states associated with fluent vs. stuttered speech on a single trial basis. Brain activity was recorded with EEG before people who stutter read aloud pseudo-word pairs. Offline independent component analysis (ICA) was used to identify the independent neural sources that underlie speech preparation. A time window selection algorithm extracted spectral power and coherence data from salient windows specific to each neural source. A stepwise linear discriminant analysis (sLDA) algorithm predicted fluent vs. stuttered speech for 81% of trials in two subjects. These results support the feasibility of developing a brain-computer interface (BCI) system to detect stuttering before it occurs, with potential for therapeutic application.

Geographical assignment of hospitalists in an urban teaching hospital: feasibility and impact on efficiency and provider satisfaction.

OBJECTIVE: To evaluate whether implementation of a geographic model of assigning hospitalists is feasible and sustainable in a large hospitalist program and assess its impact on provider satisfaction, perceived efficiency and patient outcomes. METHODS: Pre (3 months) - post (12 months) intervention study conducted from June 2014 through September 2015 at a tertiary care medical center with a large hospitalist program caring for patients scattered in 4 buildings and 16 floors. Hospitalists were assigned to a particular nursing unit (geographic assignment) with a goal of having over 80% of their assigned patients located on their assigned unit. Satisfaction and perceived efficiency were assessed through a survey administered before and after the intervention. RESULTS: Geographic assignment percentage increased from an average of 60% in the pre-intervention period to 93% post-intervention. The number of hospitalists covering a 32 bed unit decreased from 8-10 pre to 2-3 post-intervention. A majority of physicians (87%) thought that geography had a positive impact on the overall quality of care. Respondents reported that they felt that geography increased time spent with patient/caregivers to discuss plan of care (p < 0.001); improved communication with nurses (p = 0.0009); and increased sense of teamwork with nurses/case managers (p < 0.001). Mean length of stay (4.54 vs 4.62 days), 30-day readmission rates (16.0% vs 16.6%) and patient satisfaction (79.9 vs 77.3) did not change significantly between the pre- and post-implementation period. The discharge before noon rate improved slightly (47.5% - 54.1%). CONCLUSIONS: Implementation of a unit-based model in a large hospitalist program is feasible and sustainable with appropriate planning and support. The geographical model of care increased provider satisfaction and perceived efficiency; it also facilitated the implementation of other key interventions such as interdisciplinary rounds.

Evidence-based guidelines for being supportive of people who stutter in North America.

PURPOSE: While many resources, particularly those available on the Internet, provide suggestions for fluent speakers as they interact with people who stutter (PWS), little evidence exists to support these suggestions. Thus, the purpose of this study was to document the supportiveness of common public reactions, behaviors, or interventions to stuttering by PWS.Methods 148 PWS completed the Personal Appraisal of Support for Stuttering-Adults. Additionally, a comparison of the opinions of adults who stutter based on gender and their involvement in self-help/support groups was undertaken. Results Many of the Internet-based suggestions for interacting with PWS are aligned with the opinions of the participants of this study. Significant differences were found amongst people who stutter on the basis of gender and involvement in self-help groups.Conclusions Lists of "DOs and DON'Ts" that are readily available on the Internet are largely supported by the data in this study; however, the findings highlight the need for changing the emphasis from strict rules for interacting with people who stutter to more flexible principles that keep the needs of individual PWS in mind.

Allogeneic Hematopoietic Stem Cell Transplantation as Treatment for Primary Granulocytic Sarcoma of the Breast.

Primary granulocytic sarcoma (GS) is an uncommon, extramedullary proliferation of myeloid cells, occurring in the absence of antecedent myeloproliferative disorder. Breast involvement is uncommon. A diagnosis of GS portends a poor prognosis. Even with intensive chemotherapy for AML, progression to overt leukemia can be delayed for 2-3 years. We, report a 29-year-old man who presented with a painless, left breast lump. A modified radical mastectomy followed by histopathological and immunohistochemical testing confirmed a granulocytic sarcoma. There was no evidence of a concurrent leukemia. Intensive chemotherapy for acute myelogenous leukemia was instituted. Allogenic hematopoietic stem cell transplantation was successfully given. The patient remains in complete remission at follow-up. We highlight the importance of timely diagnosis of this uncommon entity with institution of intensive therapy. Early use of allogenic bone marrow transplantation in the treatment of primary GS may be warranted.

Perceptions of voice disorders: a survey of Arab adults.

A disordered voice may lead to social stigma as well as reduced occupational opportunities. Much of the research on this topic has investigated the effects of voice disorders from a Western perspective. The societal attitudes of international populations toward people with voice disorders (PWVD) are less well known. The purpose of this study was to investigate the attitudes of adults living in Kuwait toward PWVD. Participants completed a questionnaire that addressed social, educational, and occupational aspects of life for PWVD. The results indicated that while Kuwaiti adults hold generally positive attitudes toward PWVD, they may also perceive PWVD as more likely to be emotionally disturbed, have difficulty making friends or getting married, and experience trouble in finding a good job.