Consistently inconsistent: commercially available starch-based Dysphagia products

Individuals with dysphagia may be prescribed thickened fluids to promote a safer and more successful swallow. Starch-based thickening agents are often employed; however, these exhibit great variation in consistency. The aim of this study was to compare viscosity and the rheological profile parameters complex (G*), viscous (G″), and elastic modulus (G′) over a range of physiological shear rates. UK commercially available dysphagia products at “custard” consistency were examined. Commercially available starch-based dysphagia products were prepared according to manufacturers’ instructions; the viscosity and rheological parameters were tested on a CVOR Rheometer. At a measured shear rate of 50 s−1, all products fell within the viscosity limits defined according to the National Dysphagia Diet Task Force guidelines. However, at lower shear rates, large variations in viscosity were observed. Rheological parameters G*, G′, and G″ also demonstrated considerable differences in both overall strength and rheological behavior between different batches of the same product and different product types. The large range in consistency and changes in the overall structure of the starch-based products over a range of physiological shear rates show that patients could be receiving fluids with very different characteristics from that advised. This could have detrimental effects on their ability to swallow.

Description of a multifaceted strategy for recruiting general practitioners and community pharmacists to talk about medication errors

Objective: To describe the use of a multifaceted strategy for recruiting general practitioners (GPs) and community pharmacists to talk about medication errors which have resulted in preventable drug-related admissions to hospital. This is a potentially sensitive subject with medicolegal implications. Setting: Four primary care trusts and one teaching hospital in the UK. Method: Letters were mailed to community pharmacists and general practitioners asking for provisional consent to be interviewed and permission to contact them again should a patient be admitted to hospital as a result of a medication error. In addition, GPs were asked for permission to approach their patients should they be admitted to hospital. A multifaceted approach to recruitment was used including gaining support for the study from professional defence agencies and local champions. Key findings: Eighty-five percent (310/385) of GPs and 62% (93/149) of community pharmacists responded to the letters. Eighty-five percent (266/310) of GPs who responded and 81% (75/93) of community pharmacists who responded gave provisional consent to participate in interviews. All GPs (14 out of 14) and community pharmacists (10 out of 10) who were subsequently asked to participate, when patients were admitted to hospital, agreed to be interviewed. Conclusion: The multifaceted approach to recruitment was associated with an impressive response when asking healthcare professionals to be interviewed about medication errors which have resulted in preventable drug-related morbidity.

Protocol for the PINCER trial: a cluster randomised trial comparing the effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices

Background: Medication errors are an important cause of morbidity and mortality in primary care. The aims of this study are to determine the effectiveness, cost effectiveness and acceptability of a pharmacist-led information-technology-based complex intervention compared with simple feedback in reducing proportions of patients at risk from potentially hazardous prescribing and medicines management in general (family) practice. Methods: Research subject group: "At-risk" patients registered with computerised general practices in two geographical regions in England. Design: Parallel group pragmatic cluster randomised trial. Interventions: Practices will be randomised to either: (i) Computer-generated feedback; or (ii) Pharmacist-led intervention comprising of computer-generated feedback, educational outreach and dedicated support. Primary outcome measures: The proportion of patients in each practice at six and 12 months post intervention: - with a computer-recorded history of peptic ulcer being prescribed non-selective non-steroidal anti-inflammatory drugs - with a computer-recorded diagnosis of asthma being prescribed beta-blockers - aged 75 years and older receiving long-term prescriptions for angiotensin converting enzyme inhibitors or loop diuretics without a recorded assessment of renal function and electrolytes in the preceding 15 months. Secondary outcome measures; These relate to a number of other examples of potentially hazardous prescribing and medicines management. Economic analysis: An economic evaluation will be done of the cost per error avoided, from the perspective of the UK National Health Service (NHS), comparing the pharmacist-led intervention with simple feedback. Qualitative analysis: A qualitative study will be conducted to explore the views and experiences of health care professionals and NHS managers concerning the interventions, and investigate possible reasons why the interventions prove effective, or conversely prove ineffective. Sample size: 34 practices in each of the two treatment arms would provide at least 80% power (two-tailed alpha of 0.05) to demonstrate a 50% reduction in error rates for each of the three primary outcome measures in the pharmacist-led intervention arm compared with a 11% reduction in the simple feedback arm. Discussion: At the time of submission of this article, 72 general practices have been recruited (36 in each arm of the trial) and the interventions have been delivered. Analysis has not yet been undertaken.

Steady-spectrum contexts and perceptual compensation for reverberation in speech identification

Perceptual compensation for reverberation was measured by embedding test words in contexts that were either spoken phrases or processed versions of this speech. The processing gave steady-spectrum contexts with no changes in the shape of the short-term spectral envelope over time, but with fluctuations in the temporal envelope. Test words were from a continuum between "sir" and "stir." When the amount of reverberation in test words was increased, to a level above the amount in the context, they sounded more like "sir." However, when the amount of reverberation in the context was also increased, to the level present in the test word, there was perceptual compensation in some conditions so that test words sounded more like "stir" again. Experiments here found compensation with speech contexts and with some steady-spectrum contexts, indicating that fluctuations in the context's temporal envelope can be sufficient for compensation. Other results suggest that the effectiveness of speech contexts is partly due to the narrow-band "frequency-channels" of the auditory periphery, where temporal-envelope fluctuations can be more pronounced than they are in the sound's broadband temporal envelope. Further results indicate that for compensation to influence speech, the context needs to be in a broad range of frequency channels. (c) 2007 Acoustical Society of America.

Perceptual compensation for reverberation in speech identification: effects of single-band, multiple-band and wideband noise contexts

Perceptual effects of room reverberation on a "sir" or "stir" test-word can be observed when the level of reverberation in the word is increased, while the reverberation in a surrounding 'context I utterance remains at a minimal level. The result is that listeners make more "sit" identifications. When the context's reverberation is also increased, to approach the level in the test word, extrinsic perceptual compensation is observed, so that the number of listeners' "sir" identifications reduces to a value similar to that found with minimal reverberation. Thus far, compensation effects have only been observed with speech or speech-like contexts in which the short-term spectrum changes as the speaker's articulators move. The results reported here show that some noise contexts with static short-term spectra can also give rise to compensation. From these experiments it would appear that compensation requires a context with a temporal envelope that fluctuates to some extent, so that parts of it resemble offsets. These findings are consistent with a rather general kind of perceptual compensation mechanism; one that is informed by the 'tails' that reverberation adds at offsets. Other results reported here show that narrow-band contexts do not bring about compensation, even when their temporal-envelopes are the same as those of the more effective wideband contexts. These results suggest that compensation is confined to the frequency range occupied by the context, and that in a wideband sound it might operate in a 'band by band' manner.

Perceptual compensation for effects of reverberation in speech identification

Listeners were asked to identify modified recordings of the words "sir" and "stir," which were spoken by an adult male British-English speaker. Steps along a continuum between the words were obtained by a pointwise interpolation of their temporal-envelopes. These test words were embedded in a longer "context" utterance, and played with different amounts of reverberation. Increasing only the test-word's reverberation shifts the listener's category boundary so that more "sir"-identifications are made. This effect reduces when the context's reverberation is also increased, indicating perceptual compensation that is informed by the context. Experiment I finds that compensation is more prominent in rapid speech, that it varies between rooms, that it is more prominent when the test-word's reverberation is high, and that it increases with the context's reverberation. Further experiments show that compensation persists when the room is switched between the context and the test word, when presentation is monaural, and when the context is reversed. However, compensation reduces when the context's reverberation pattern is reversed, as well as when noise-versions of the context are used. "Tails" that reverberation introduces at the ends of sounds and at spectral transitions may inform the compensation mechanism about the amount of reflected sound in the signal. (c) 2005 Acoustical Society of America.

Perceptual compensation for effects of echo and of reverberation on speech identification

In an ideal "reverberant" room, the energy of the impulse responses decays smoothly, at a constant rate of dB/s, so that gradually-decaying tails are added at the ends of sounds. Conversely, a single echo gives a flat energy-decay up to the echo's arrival time, which then drops abruptly, so that sounds with only echoes lack the decaying-tail feature of reverberation. The perceptual effects of these types of reflection pattern were measured with test-words from a continuum of steps between "sir" and "stir", which were each embedded in a carrier phrase. When the proportion of reflected sound in test-words is increased, to a level above the amount in the carrier, the test words sound more like "sir". However, when the proportion of reflected sound in the carrier is also increased, to match the amount in the test word, there can be a perceptual compensation where test words sound more like "stir" again. A reference condition used real-room reverberation from recordings at different source to receiver distances. In a synthetic-reverberation condition, the reflection pattern was from a "colorless" impulse response, comprising exponentially-decaying reflections that were spaced at intervals. In a synthetic-echo condition, the reflection pattern was obtained from the synthetic reverberation by removing the intervals between reflections before delaying the resulting cluster relative to the direct sound. Compensation occurred in the reference condition and in different types of synthetic reverberation, but not in synthetic-echo conditions. This result indicates that the presence of tails from reverberation informs the compensation mechanism.

The neural processing of masked speech: evidence for different mechanisms in the left and right temporal lobes

It has been previously demonstrated that extensive activation in the dorsolateral temporal lobes associated with masking a speech target with a speech masker, consistent with the hypothesis that competition for central auditory processes is an important factor in informational masking. Here, masking from speech and two additional maskers derived from the original speech were investigated. One of these is spectrally rotated speech, which is unintelligible and has a similar (inverted) spectrotemporal profile to speech. The authors also controlled for the possibility of "glimpsing" of the target signal during modulated masking sounds by using speech-modulated noise as a masker in a baseline condition. Functional imaging results reveal that masking speech with speech leads to bilateral superior temporal gyrus (STG) activation relative to a speech-in-noise baseline, while masking speech with spectrally rotated speech leads solely to right STG activation relative to the baseline. This result is discussed in terms of hemispheric asymmetries for speech perception, and interpreted as showing that masking effects can arise through two parallel neural systems, in the left and right temporal lobes. This has implications for the competition for resources caused by speech and rotated speech maskers, and may illuminate some of the mechanisms involved in informational masking.

For better or worse: the effect of levodopa on speech in Parkinson's disease

While the beneficial effect of levodopa on traditional motor control tasks have been well documented over the decades. its effect on speech motor control has rarely been objectively examined and the existing literature remains inconclusive. This paper aims to examine the effect of levodopa on speech in patients with Parkinson's disease. It was hypothesized that levodopa would improve preparatory motor set related activity and alleviate hypophonia. Patients fasted and abstained from levodopa overnight. Motor examination and speech testing was performed the following day, pre-levodopa during their "off' state, then at hourly intervals post-medication to obtain the best "on" state. All speech stimuli showed a consistent tendency for increased loudness and faster rate during the "on" state, but this was accompanied by a greater extent of intensity decay. Pitch and articulation remained unchanged. Levodopa effectively upscaled the overall gain setting of vocal amplitude and tempo, similar to its well-known effect on limb movement. However, unlike limb movement, this effect on the final acoustic product of speech may or may not be advantageous, depending on the existing speech profile of individual patients. (C) 2007 Movement Disorder Society.

Reverberant auditory environments: the effects of multiple echoes on distraction by 'irrelevant' speech

Two experiments examine the effect on an immediate recall test of simulating a reverberant auditory environment in which auditory distracters in the form of speech are played to the participants (the 'irrelevant sound effect'). An echo-intensive environment simulated by the addition of reverberation to the speech reduced the extent of 'changes in state' in the irrelevant speech stream by smoothing the profile of the waveform. In both experiments, the reverberant auditory environment produced significantly smaller irrelevant sound distraction effects than an echo-free environment. Results are interpreted in terms of changing-state hypothesis, which states that acoustic content of irrelevant sound, rather than phonology or semantics, determines the extent of the irrelevant sound effect (ISE). Copyright (C) 2007 John Wiley & Sons, Ltd.

From dichotic listening to the irrelevant sound effect: a behavioural and neuroimaging analysis of the processing of unattended speech

The assumption that ignoring irrelevant sound in a serial recall situation is identical to ignoring a non-target channel in dichotic listening is challenged. Dichotic listening is open to moderating effects of working memory capacity (Conway et al., 2001) whereas irrelevant sound effects (ISE) are not (Beaman, 2004). A right ear processing bias is apparent in dichotic listening, whereas the bias is to the left ear in the ISE (Hadlington et al., 2004). Positron emission tomography (PET) imaging data (Scott et al., 2004, submitted) show bilateral activation of the superior temporal gyrus (STG) in the presence of intelligible, but ignored, background speech and right hemisphere activation of the STG in the presence of unintelligible background speech. It is suggested that the right STG may be involved in the ISE and a particularly strong left ear effect might occur because of the contralateral connections in audition. It is further suggested that left STG activity is associated with dichotic listening effects and may be influenced by working memory span capacity. The relationship of this functional and neuroanatomical model to known neural correlates of working memory is considered.

The irrelevant sound phenomenon revisited: what role for working memory capacity?

High-span individuals (as measured by the operation span [CSPAN] technique) are less likely than low-span individuals to notice their own names in an unattended auditory stream (A. R. A. Conway, N. Cowan, & M F. Bunting, 2001). The possibility that OSPAN accounts for individual differences in auditory distraction on an immediate recall test was examined. There was no evidence that high-OSPAN participants were more resistant to the disruption caused by irrelevant speech in serial or in free recall. Low-OSPAN participants did, however, make more semantically related intrusion errors from the irrelevant sound stream in a free recall test (Experiment 4). Results suggest that OSPAN mediates semantic components of auditory distraction dissociable from other aspects of the irrelevant sound effect.