Assessment and management of dysphagia following pharyngolaryngectomy with free jejunal interposition: A series of eight case studies

The physiological and structural deficits contributing to swallowing complications in the pharyngolaryngectomy patient population are not homogeneous. Consequently, a team approach, involving medical investigations as well as clinical and radiological assessments of swallowing, is necessary to facilitate diagnosis of the underlying impairment and assist the medical/surgical and speech pathology team members in the process of individualizing the management plan for each patient. In the present study, the clinical assessment and management of eight pharyngolaryngectomy patients who presented with a decline in swallowing function unrelated to immediate postsurgical effects or direct effects of radiotherapy are reported. Clinical and radiological investigations revealed a heterogeneous group of factors contributing to their swallowing impairments and disability levels, including difficulty with graft and anastomotic patency and graft motility, impaired lingual coordination, increased bolus transit time, nasal and oral regurgitation, patient distress, and recurrence. Variation between the cases supported the need for differential intervention and management plans for all eight patients. Ratings of perceived swallowing disability, handicap, and well-being/distress levels at initial assessment and again six months following dysphagia intervention revealed a pattern of reduced levels of impairment, functional disability, and overall patient distress levels following informed intervention. The present case study data highlights the key role thorough clinical and radiological investigations play in the process of diagnosing the factors contributing to dysphagia and guiding the management of the resultant swallowing disability in the pharyngolaryngectomy population.

Articulatory dysfunction in multiple sclerosis: An electropalatographic study

Dysfunction of the articulatory subsystem (i.c.. the lips, tongue, and jaw) has bccn identified as a major contributor to the reduction in speech intelligibility experienced by a high proportion of people with multiple sclerosis (MS). In particular. consonant imprecision has been reported to be the articulatory deficit that contributes most to variations in overall intelligibility of MS speakers. Electropalatography(EPG) IS an instrurncntal technique that visually documents the location and timing of tongue-topalatc contacts during speech. Although such a technique would be valuablc in objectively assessing the articulatory disturbances exhibited by individuals with dysarthria ia motor speech disorder) associated with MS, to-date no such study ha< been reported. The aim of the present study was to use EPG to assess tongue-to-palate contact patterns and articulatory timing in patients with dysarthria associated with MS. A dysarthric participant with a diagnosis of definite MS was fitted with an acrylic EPG palate (Reading EPG.?) and asked to read aloud a list of single syllable words which contained lingual consonants in the word-initial position and in consonant clusters. Each mord was repeated five times. The EPG palate was specifically moulded to tit the participant's hard palate and contained 62 electrodes that detected the tongue contacts. A non-neurologically impaired participant matched for age and sex servcd as a control. The results of the study revealed that the tongue-to-palate contacts produced by the participant with MS varied from those produced by the control in a number of ways in regard to spatial configurations and timing characteristics exhibited. The rcsults arc discussed in relation to the neuropathophysiological effects of MS on speech production. The potcntial use of EPG in programs for treating speech disorders associated with MS will be highlightcd.

Telehealth and the diagnosis and management of cardiac disease

The financial and personal burden of chronic cardiac disease is high. Costs are likely to increase over the next few decades. Promising applications of telehealth have appeared in the diagnosis and management of cardiac disease and there are indications that telehealth services can improve the management of chronic cardiac disease as well as extend services to remote and rural populations. Telehealth has been applied to the capture of symptoms of cardiac disease with electrocardiography and echocardiography, to the management and rehabilitation of recently discharged patients, and in peer-to-peer consultation where remote expertise can facilitate diagnosis. Telehealth promises cost reductions in service delivery, although there is a need for properly controlled cost-effectiveness trials to underpin telehealth with a firm evidence base.

Significance of gaseous nitrogen loss from a tropical dairy pasture fertilised with urea

This paper reports a study in the wet tropics of Queensland on the fate of urea applied to a dairy pasture in the absence of grazing animals. A nitrogen balance was conducted in cylindrical plots with N-15-labelled urea, and ammonia volatilisation was determined using a mass balance micrometeorological method. The pasture plants took up 42% of the applied nitrogen in the 98 days between fertiliser application and harvest. At harvest 18% of the applied nitrogen was found in the soil, and 40% was lost from the plant-soil system. The micrometeorological study showed that 20% of the unrecovered nitrogen was lost by ammonia volatilisation. As there was no evidence for leaching or runoff losses it was concluded that the remaining 20% of the applied nitrogen was lost by denitrification. It is evident from these results that fertiliser nitrogen is not being used efficiently on dairy pastures, and that practices need to be changed to conserve fertiliser nitrogen and reduce contamination of the environment.

Loss as a universal concept: Review of the literature to identify common aspects of loss in diverse situations

It has long been recognized that loss and its associated grief are important elements of many adverse life events that affect the entire global population: death, disability, traumatic events, abuse., terminal and chronic illness, aging, addiction, unemployment, relationship breakdown, war, migration, and educational failure. While there is significant empirical evidence of the potential deleterious effects of specific situations of loss across the global community, systematic discussion concerning the common elements of loss that are associated with adverse life situations in general has been limited. This review of the theoretical and empirical literature concerning various losses and the recommendations for care of those affected by such losses identifies common aspects of situations of loss and common recommendations in the care of those confronted by such losses. These common themes of loss are described by simple summary statements that can be communicated to a broad audience, hence enhancing community education and, potentially, community-wide mental health promotion.

Advances in the diagnosis of primary immunodeficiency disorders in childhood

Primary immunodeficiency disorders in childhood usually present as unusual, recurrent or severe infections, symptomatic infections with organisms of low pathogenicity, or as recognizable syndromes which are known to have associated immunological abnormalities. In many of the primary immunodeficiency disorders, there are known patterns of inheritance, and other family members may be affected. Some primary immunodeficiency disorders are relatively common, such as selective IgA deficiency, and often do not lead to major morbidity. Others, such as the severe combined immune deficiency syndromes, are relatively rare, and are fatal in early life if not recognized and treated early. Diagnosis of a primary immunodeficiency disorder depends on appropriate use of laboratory investigations. Often there will be abnormalities detected on a complete blood film and measurement of immunoglobulin isotypes. More complex investigations should be undertaken in conjunction with a paediatric immunology service. In recent years, many of the clinically defined primary immunodeficiency disorders have been shown to have associated specific gene defects. For some, this has led to the identification and characterization of defective or absent gene products. The consequences of this new knowledge are more accurate diagnosis, early diagnosis including antenatal diagnosis, detection of undiagnosed disease in other family members, and the potential for new therapies including gene or gene product therapy.

A case study of partial agenesis of the corpus callosum: Audiological implications

This case study represents four years of audiological observations, testing and aural habilitation of a female child with a partial agenesis of the corpus callosum (ACC). The ACC was diagnosed by MRI scans to eliminate neurological causes for developmental delay at six months of age. This child was also born with a cleft palate and was diagnosed with Robinow Syndrome at 3 years and 3 months of age. The audiological results showed an improvement in hearing thresholds over the four-year period. The child’s opthamologist also reported an improvement in visual skills over time. The most interesting aspect of the child’s hearing was the discrepancy between the monaural and the binaural results. That is, when assessed binaurally she often presented with a mild to moderate mixed loss and when assessed monaurally she showed a moderate to severe mixed loss for the right ear and a severe mixed loss for the left ear. This discrepancy between binaural and monaural results was evident for both aided and unaided tests. Parental reports of the child’s hearing were consistent with the binaural clinical results. This case indicates the need for audiologists to: (a) carefully monitor the hearing of children with ACC, (b) obtain monaural and binaural hearing and aided thresholds results, and (c) compare these children’s functional abilities to the objective test results obtained. This case does question whether hearing aids are appropriate for children with ACC. If hearing aids are deemed to be appropriate, then hearing aids with compression characteristics should be considered.

Two-link approximation schemes for loss networks with linear structure and trunk reservation

Loss networks have long been used to model various types of telecommunication network, including circuit-switched networks. Such networks often use admission controls, such as trunk reservation, to optimize revenue or stabilize the behaviour of the network. Unfortunately, an exact analysis of such networks is not usually possible, and reduced-load approximations such as the Erlang Fixed Point (EFP) approximation have been widely used. The performance of these approximations is typically very good for networks without controls, under several regimes. There is evidence, however, that in networks with controls, these approximations will in general perform less well. We propose an extension to the EFP approximation that gives marked improvement for a simple ring-shaped network with trunk reservation. It is based on the idea of considering pairs of links together, thus making greater allowance for dependencies between neighbouring links than does the EFP approximation, which only considers links in isolation.

Maximum Likelihood Estimation of Mixture Densities for Binned and Truncated Multivariate Data

Binning and truncation of data are common in data analysis and machine learning. This paper addresses the problem of fitting mixture densities to multivariate binned and truncated data. The EM approach proposed by McLachlan and Jones (Biometrics, 44: 2, 571-578, 1988) for the univariate case is generalized to multivariate measurements. The multivariate solution requires the evaluation of multidimensional integrals over each bin at each iteration of the EM procedure. Naive implementation of the procedure can lead to computationally inefficient results. To reduce the computational cost a number of straightforward numerical techniques are proposed. Results on simulated data indicate that the proposed methods can achieve significant computational gains with no loss in the accuracy of the final parameter estimates. Furthermore, experimental results suggest that with a sufficient number of bins and data points it is possible to estimate the true underlying density almost as well as if the data were not binned. The paper concludes with a brief description of an application of this approach to diagnosis of iron deficiency anemia, in the context of binned and truncated bivariate measurements of volume and hemoglobin concentration from an individual's red blood cells.

Rapid diagnosis in pediatric infectious diseases: The past, the present and the future

The focus of rapid diagnosis of infectious diseases of children in the last decade has shifted from variations of the conventional laboratory techniques of antigen detection, microscopy and culture to that of molecular diagnosis of infectious agents. Pediatricians will need to be able to interpret the use, limitations and results of molecular diagnostic techniques as they are increasingly integrated into routine clinical microbiology laboratory protocols. PCR is the best known and most successfully implemented diagnostic molecular technology to date. It can detect specific infectious agents and determine their virulence and antimicrobial genotypes with greater speed, sensitivity and specificity than conventional microbiology methods. Inherent technical limitations of PCR are present, although they are reduced in laboratories that follow suitable validation and quality control procedures. Variations of PCR together with advances in nucleic acid amplification technology have broadened its diagnostic capabilities in clinical infectious disease to now rival and even surpass traditional methods in some situations. Automation of all components of PCR is now possible. The completion of the genome sequencing projects for significant microbial pathogens, in combination with PCR and DNA chip technology, will revolutionize the diagnosis and management of infectious diseases.

A comparison of Kodak Ultraspeed and Ektaspeed Plus dental X-ray films for the detection of dental caries

Background: Using the fastest dental X-ray film available is an easy way of reducing exposure to ionizing radiation. However, the diagnostic ability of fast films for the detection of proximal surface caries must be demonstrated before these films will become universally accepted. Methods: Extracted premolar and molar teeth were arranged to simulate a bitewing examination and radiographed using Ultraspeed and Ektaspeed Plus dental X-ray films. Three different exposure times were used for each film type. Six general dentists were used to determine the presence and depth of the decay in the proximal surfaces of the teeth radiographed. The actual extent of the decay in the teeth was determined by sectioning the teeth and examining them under a microscope. Results: There was no significant difference between the two films for the mean correct diagnosis. However, there was a significant difference between the means for the three exposure times used for Ultraspeed film. The practitioners used were not consistent in their ability to make a correct diagnosis, or for the film for which they got the highest correct diagnosis. Conclusions: Ektaspeed Plus dental X-ray film is just as reliable as Ultraspeed dental X-ray film for the detection of proximal surface decay. The effect of underexposure was significant for Ultraspeed, but not for Ektaspeed Plus. Patient exposure can be reduced significantly with no loss of diagnostic ability by changing from Ultraspeed X-ray film to Ektaspeed Plus X-ray film.