Familiarisation conditions and the mechanisms that underlie improved recognition of dysarthric speech

This investigation evaluated the familiarisation conditions required to promote subsequent and more long-term improvements in perceptual processing of dysarthric speech and examined the cognitive-perceptual processes that may underlie the experience-evoked learning response. Sixty listeners were randomly allocated to one of three experimental groups and were familiarised under the following conditions: (1) neurologically intact speech (control), (2) dysarthric speech (passive familiarisation), and (3) dysarthric speech coupled with written information (explicit familiarisation). All listeners completed an identical phrase transcription task immediately following familiarisation, and listeners familiarised with dysarthric speech also completed a follow-up phrase transcription task 7 days later. Listener transcripts were analysed for a measure of intelligibility (percent words correct), as well as error patterns at a segmental (percent syllable resemblance) and suprasegmental (lexical boundary errors) level of perceptual processing. The study found that intelligibility scores for listeners familiarised with dysarthric speech were significantly greater than those of the control group, with the greatest and most robust gains afforded by the explicit familiarisation condition. Relative perceptual gains in detecting phonetic and prosodic aspects of the signal varied dependent upon the familiarisation conditions, suggesting that passive familiarisation may recruit a different learning mechanism to that of a more explicit familiarisation experience involving supplementary written information. It appears that decisions regarding resource allocation during subsequent processing of dysarthric speech may be informed by the information afforded by the conditions of familiarisation.

Familiarisation conditions and the mechanisms that underlie improved recognition of dysarthric speech

This investigation evaluated the familiarisation conditions required to promote subsequent and more long-term improvements in perceptual processing of dysarthric speech and examined the cognitive-perceptual processes that may underlie the experience-evoked learning response. Sixty listeners were randomly allocated to one of three experimental groups and were familiarised under the following conditions: (1) neurologically intact speech (control), (2) dysarthric speech (passive familiarisation), and (3) dysarthric speech coupled with written information (explicit familiarisation). All listeners completed an identical phrase transcription task immediately following familiarisation, and listeners familiarised with dysarthric speech also completed a follow-up phrase transcription task 7 days later. Listener transcripts were analysed for a measure of intelligibility (percent words correct), as well as error patterns at a segmental (percent syllable resemblance) and suprasegmental (lexical boundary errors) level of perceptual processing. The study found that intelligibility scores for listeners familiarised with dysarthric speech were significantly greater than those of the control group, with the greatest and most robust gains afforded by the explicit familiarisation condition. Relative perceptual gains in detecting phonetic and prosodic aspects of the signal varied dependent upon the familiarisation conditions, suggesting that passive familiarisation may recruit a different learning mechanism to that of a more explicit familiarisation experience involving supplementary written information. It appears that decisions regarding resource allocation during subsequent processing of dysarthric speech may be informed by the information afforded by the conditions of familiarisation.

A follow-up investigation into the mechanisms that underlie improved recognition of dysarthric speech

Differences in perceptual strategies for lexical segmentation of moderate hypokinetic dysarthric speech, apparently related to the conditions of the familiarization procedure, have been previously reported [Borrie et al., Language and Cognitive Processes (2012)]. The current follow-up investigation examined whether this difference was also observed when familiarization stimuli highlighted syllabic strength contrast cues. Forty listeners completed an identical transcription task following familiarization with dysarthric phrases presented under either passive or explicit learning conditions. Lexical boundary error patterns revealed that syllabic strength cues were exploited in both familiarization conditions. Comparisons with data previously reported afford further insight into perceptual learning of dysarthric speech.

Effect of speaker age on speech recognition and perceived listening effort in older adults with hearing loss

PURPOSE

Older adults exhibit difficulty understanding speech that has been experimentally degraded. Age-related changes to the speech mechanism lead to natural degradations in signal quality. We tested the hypothesis that older adults with hearing loss would exhibit declines in speech recognition when listening to the speech of older adults, compared with the speech of younger adults, and would report greater amounts of listening effort in this task.

METHOD

Nineteen individuals with age-related hearing loss completed speech recognition and listening effort scaling tasks. Both were conducted in quiet, when listening to high- and low-predictability phrases produced by younger and older speakers, respectively.

RESULTS

No significant difference in speech recognition existed when stimuli were derived from younger or older speakers. However, perceived effort was significantly higher when listening to speech from older adults, as compared with younger adults.

CONCLUSIONS

For older individuals with hearing loss, natural degradations in signal quality may require greater listening effort. However, they do not interfere with speech recognition-at least in quiet. Follow-up investigation of the effect of speaker age on speech recognition and listening effort under more challenging noise conditions appears warranted.

Perceptual learning of dysarthric speech: a review of experimental studies

PURPOSE

This review article provides a theoretical overview of the characteristics of perceptual learning, reviews perceptual learning studies that pertain to dysarthric populations, and identifies directions for future research that consider the application of perceptual learning to the management of dysarthria.

METHOD

A critical review of the literature was conducted that summarized and synthesized previously published research in the area of perceptual learning with atypical speech. Literature related to perceptual learning of neurologically degraded speech was emphasized with the aim of identifying key directions for future research with this population.

CONCLUSIONS

Familiarization with unfamiliar or ambiguous speech signals can facilitate perceptual learning of that same speech signal. There is a small but growing body of evidence that perceptual learning also occurs for listeners familiarized with dysarthric speech. Perceptual learning of the dysarthric signal is both theoretically and clinically significant. In order to establish the efficacy of exploiting perceptual learning paradigms for rehabilitative gain in dysarthria management, research is required to build on existing empirical evidence and develop a theoretical framework for learning to better recognize neurologically degraded speech.

Image fusion using CT, MRI and PET for treatment planning, navigation and follow up in percutaneous RFA

AIM

To evaluate the feasibility of fusion of morphologic and functional imaging modalities to facilitate treatment planning, probe placement, probe re-positioning, and early detection of residual disease following radiofrequency ablation (RFA) of cancer.

METHODS

Multi-modality datasets were separately acquired that included functional (FDG-PET and DCE-MRI) and standard morphologic studies (CT and MRI). Different combinations of imaging modalities were registered and fused prior to, during, and following percutaneous image-guided tumor ablation with radiofrequency. Different algorithms and visualization tools were evaluated for both intra-modality and inter-modality image registration using the software MIPAV (Medical Image Processing, Analysis and Visualization). Semi-automated and automated registration algorithms were used on a standard PC workstation: 1) landmark-based least-squares rigid registration, 2) landmark-based thin-plate spline elastic registration, and 3) automatic voxel-similarity, affine registration.

RESULTS

Intra- and inter-modality image fusion were successfully performed prior to, during and after RFA procedures. Fusion of morphologic and functional images provided a useful view of the spatial relationship of lesion structure and functional significance. Fused axial images and segmented three-dimensional surface models were used for treatment planning and post-RFA evaluation, to assess potential for optimizing needle placement during procedures.

CONCLUSION

Fusion of morphologic and functional images is feasible before, during and after radiofrequency ablation of tumors in abdominal organs. For routine use, the semi-automated registration algorithms may be most practical. Image fusion may facilitate interventional procedures like RFA and should be further evaluated.

Intervention for lateral /s/ using electropalatography (EPG) biofeedback and an intensive motor learning approach: a case report

BACKGROUND

Visual biofeedback using electropalatography (EPG) has been beneficial in the treatment of some cases of lateral /s/ misarticulation. While EPG intervention is motorically based, studies have not commonly employed a motor learning approach to treatment. Furthermore, treatment success is measured primarily by change to EPG tongue-palate contact patterns and listener ratings conducted by speech-language therapists. Studies have not commonly measured articulatory change without the palate in-situ using acoustic analysis and non-professional listeners.

AIMS

To determine if an intensive treatment programme including both visual biofeedback (EPG) and traditional articulation techniques within a motor learning paradigm would result in functional improvement to /s/ articulation in an 11-year-old girl with persistent lateral misarticulation.

METHODS & PROCEDURES

Treatment involved 12 sessions of therapist-delivered treatment over 4 weeks followed by a 6-week home programme. Outcomes of the treatment programme were measured primarily using naive listener ratings and acoustic analysis of /s/ spectra.

OUTCOMES & RESULTS

Improvements to both the perceptual and spectral characteristics of /s/ articulation occurred following the treatment programme.

CONCLUSIONS

The study highlighted the benefit of an intensive approach to intervention incorporating both visual biofeedback and traditional articulation approaches. The inclusion of a 6-week structured home-programme was beneficial and resulted in consolidation of treatment gains.

Treatment of articulatory impairment in a child with spastic dysarthria associated with cerebral palsy

BACKGROUND

A comparative study of treatment modalities for improving articulation in a 13-year-old child with severe spastic dysarthria associated with spastic cerebral palsy (SCP) was conducted.

METHOD

A multiple treatment design examined the effect of phonetic placement therapy (PPT) and sEMG-facilitated biofeedback relaxation therapy over a 6-week period. Treatment outcomes were measured using acoustic and perceptual analysis.

RESULTS

Results revealed significant improvement in single word intelligibility following PPT with the improvements maintained following sEMG treatment. sEMG-facilitated biofeedback relaxation treatment indicated the occurrence of a pre-cursor skill in increased motor control. Intelligibility at paragraph or sentence level did not change following either treatment. Perceptually, there was no change to any parameters of articulation following either treatment. However, subtle changes were observed on acoustic analysis. Functionally, the participant reported no changes to feelings of well-being or distress regarding her speech disorder over the period of intervention.

CONCLUSIONS

Clinically, the PPT and sEMG treatments demonstrated improvement in single word articulation, despite no perceptible changes to overall intelligibility. It is likely that the severity of the participant's dysarthria was a factor in the minimal changes observed following treatment. Future studies examining the treatments in children with mild and/or moderate dysarthria are required.

Acoustic and perceptual analysis of speech adaptation to an artificial palate

The study investigated adaptation to a standard electropalatographic (EPG) practise palate in a group of eight adults (mean age = 24 years). The participants read the phrase "a CVC" over four sampling conditions: prior to inserting the palate, immediately following insertion of the palate, 45 minutes after palate insertion, and 3 hours after insertion of the palate. Perceptual and acoustic analyses were conducted on the initial CV portion of the stimuli. Consonants examined included: /t/, /k/, /s/, and // followed by the /i/, /a/, and /u/ vowels. Results revealed that individuals within the group were able to adapt their speech articulation to compensate for the presence of the artificial palate. Perceptually, mild consonant imprecision was observed upon insertion of the palate; however, this resolved following 45 minutes to 3 hours of adaptation. Acoustic findings indicated that the palate did not affect segment durations or vowel formant frequencies. However, a significant reduction in M1 for /s/ persisted across the sampling periods. Overall, the results suggest that a period of between 45 minutes and 3 hours of adaptation is generally suitable for participation in EPG studies.

Brain volume measurements in patients with human T-cell lymphotropic virus-1–associated tropical spastic paraparesis

Human T-cell lymphotropic virus (HTLV)-1 is associated with a chronic progressive neurologic disease known as HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) that affects 0.2% to 3% of HTLV-1-infected people. The authors aimed at exploring, in vivo, whether brain volume reduction occurs in patients with HAM/TSP through the use of magnetic resonance imaging (MRI). T1 pre/postcontrast spin echo-weighted images (WIs) and T2WIs of the brain were obtained in 19 HAM/TSP patients and 14 age-and sex-matched healthy volunteers. Both patients and healthy individuals were imaged at a 1.5-Tesla magnet by employing a conventional head coil. Focal T1 and T2 abnormalities were calculated and two measurements of brain parenchyma fraction (BPF) were obtained by using SIENAx (Structural Image Evaluation,using Normalisation, of Atrophy; University of Oxford, Oxford, UK) and MIPAV (Medical Image Processing, Analysis, and Visualization; National Institutes of Health, Bethesda, USA) from T1WIs. No significant differences in BPF were found between patients and healthy subjects when using either SIENAx or MIPAV. Analysis of individual patients detected that BPF was lower by 1 standard deviation (SD) relative to patients' average BPF in one patient. The authors conclude that reductions in BPF do not occur frequently in patients with HAM/TSP. However, the authors believe that one individual case of significant brain atrophy raises the question as to whether atrophy selectively targets the spinal cord of HAM/TSP patients or may involve the brain as well. A larger patient population analyzing regional brain volume changes could be helpful in determining whether brain atrophy is a marker of disease in patients with HAM/TSP.

Speech production in Parkinson's disease: II. Acoustic and electropalatographic investigation of sentence, word and segment durations

Previous investigations employing electropalatography (EPG) have identified articulatory timing deficits in individuals with acquired dysarthria. However, this technology is yet to be applied to the articulatory timing disturbance present in Parkinson's disease (PD). As a result, the current investigation aimed to use EPG to comprehensively examine the temporal aspects of articulation in a group of nine individuals with PD at sentence, word and segment level. This investigation followed on from a prior study (McAuliffe, Ward and Murdoch) and similarly, aimed to compare the results of the participants with PD to a group of aged (n = 7) and young controls (n = 8) to determine if ageing contributed to any articulatory timing deficits observed. Participants were required to read aloud the phrase "I saw a _ today" with the EPG palate in-situ. Target words included the consonants /l/, /s/ and /t/ in initial position in both the /i/ and /a/ vowel environments. Perceptual investigation of speech rate was conducted in addition to objective measurement of sentence, word and segment duration. Segment durations included the total segment length and duration of the approach, closure/constriction and release phases of EPG consonant production. Results of the present study revealed impaired speech rate, perceptually, in the group with PD. However, this was not confirmed objectively. Electropalatographic investigation of segment durations indicated that, in general, the group with PD demonstrated segment durations consistent with the control groups. Only one significant difference was noted, with the group with PD exhibiting significantly increased duration of the release phase for /la/ when compared to both the control groups. It is, therefore, possible that EPG failed to detect lingual movement impairment as it does not measure the complete tongue movement towards and away from the hard palate. Furthermore, the contribution of individual variation to the present findings should not be overlooked.

The use of electropalatography in the assessment and treatment of acquired motor speech disorders in adults: current knowledge and future directions

Electropalatography (EPG) has been employed to measure speech articulation since the mid-1970s. This technique has predominately been used in experimental phonetic research and in the diagnosis and treatment of articulation disorders in children. However, there is a growing body of research employing EPG to diagnose and treat articulatory impairment associated with acquired motor speech disorder (MSD) in adults. The purpose of this paper was to (1) review the findings of studies pertaining to the assessment and treatment of MSDs in adults using EPG, (2) highlight current methodologies employed, and (3) discuss the potential limitations of EPG in the assessment and treatment of MSDs and examine directions for future applied research and treatment studies.

Speech production in Parkinson's disease: I. An electropalatographic investigation of tongue-palate contact patterns

Previous studies have indicated that consonant imprecision in Parkinson's disease (PD) may result from a reduction in amplitude of lingual movements or articulatory undershoot. While this has been postulated, direct measurement of the tongue's contact with the hard palate during speech production has not been undertaken. Therefore, the present study aimed to use electropalatography (EPG) to determine the exact nature of tongue-palate contact in a group of individuals with PD and consonant imprecision (n = 9). Furthermore, the current investigation also aimed to compare the results of the participants with PD to a group of aged (n = 7) and young (n = 8) control speakers to determine the relative contribution of ageing of the lingual musculature to any articulatory deficits noted. Participants were required to read aloud the phrase 'I saw a _ today' with the artificial palate in-situ. Target words included the consonants /l/, /s/ and /t/ in initial position in both the /i/ and /a/ vowel environments. Phonetic transcription of phoneme productions and description of error types was completed. Furthermore, representative frames of contact were employed to describe the features of tongue-palate contact and to calculate spatial palatal indices. Results of the perceptual investigation revealed that perceived undershooting of articulatory targets distinguished the participant group with PD from the control groups. However, objective EPG assessment indicated that undershooting of the target consonant was not the cause of the perceived articulatory errors. It is, therefore, possible that reduced pressure of tongue contact with the hard palate, sub-lingual deficits or impaired articulatory timing resulted in the perceived undershooting of the target consonants.

A Nonspeech Investigation of Tongue Function in Parkinson's Disease

BACKGROUND

Nonspeech investigations of tongue function in persons with Parkinson's disease (PD) have generally reported impaired tongue strength, endurance, and fine force control. However, these investigations did not specifically evaluate the relative contribution of age effects to the deficits in tongue function observed. Furthermore, the relationship between these nonspeech measures of tongue function and the speech disorder present in PD remains equivocal. Therefore, the current study investigated the strength, rate of repetitive movement, fine force control, and endurance of the tongue in three groups of participants.

METHODS

Participants in the study included 14 older adults with PD and imprecise consonant articulation, 11 neurologically healthy older adults, and 15 neurologically healthy young adults. All participants were assessed using a comprehensive nonspeech assessment battery of tongue function.

RESULTS

The results of the investigation revealed similar levels of tongue strength, rate of repetitive movement, and endurance between the persons with PD and the older control participants. Significant age effects were noted, with both groups demonstrating significantly reduced functioning on those measures when compared to young control participants. However, the three participant groups had similar levels of fine force control. No relationship was found between the nonspeech measures of tongue function employed and the severity of consonant imprecision.

CONCLUSION

The nonspeech measures used failed to provide useful diagnostic information regarding the physiologic basis of perceived articulatory dysfunction in the persons with PD who were examined.

Variation in articulatory timing of three English consonants: an electropalatographic investigation

Increasingly, electropalatography (EPG) is being used in speech pathology research to identify and describe speech disorders of neurological origin. However, limited data currently exists that describes normal articulatory segment timing and the degree of variability exhibited by normal speakers when assessed with EPG. Therefore, the purpose of the current investigation was to use the Reading EPG3 system to quantify segmental timing values and examine articulatory timing variability for three English consonants. Ten normal subjects repeated ten repetitions of CV words containing the target consonants /t/, /l/, and /s/ while wearing an artificial palate. The target consonants were followed by the /i/ vowel and were contained in the carrier phrase 'I saw a _.' Mean duration of the approach, closure/constriction, and release phases of consonant articulation were calculated. In addition, inter-subject articulatory timing variability was investigated using descriptive graphs and intra-subject articulatory timing variability was investigated using a coefficient of variation. Results revealed the existence of inter-subject variability for mean segment timing values. This could be attributed to individual differences in the suprasegmental features of speech and individual differences in oral cavity size and structure. No significant differences were reported for degree of intra-subject variability between the three sounds for these same phases of articulation. However, when this data set was collapsed, results revealed that the closure/constriction phase of consonant articulation exhibited significantly less intra-subject variability than both the approach and release phases. The stabilization of the tongue against the fixed structure of the hard palate during the closure phase of articulation may have reduced the levels of intra-subject variability.

Tongue-to-palate contact patterns and variability of four English consonants in an /i/ vowel environment

Minimal data exist describing tongue-to-palate contact patterns and their variability in normal speakers of English. Consequently, the aims of the present study were to examine, using a comprehensive profile of data analysis, tongue-to-palate contact patterns and their variability in a group of ten normal speakers of English using the Reading Electropalatography3 (EPG3) system. Each speaker produced ten repetitions of the target words tea, leap, sea, and key following the carrier phrase 'I saw a ...'. Results revealed that the contact patterns produced exhibited similar characteristics to those described in earlier research. Additionally, the lateral approximant /i/ exhibited the highest degree of intra-subject variability with the alveolar fricative /s/ exhibiting the least. The results of this study are discussed in relation to existing normative data.

Depletion of systemic macrophages by liposome-encapsulated clodronate attenuates striatal macrophage invasion and neurodegeneration following local endotoxin infusion in gerbils

CNS-localized inflammation with microglial activation and macrophage infiltration contributes to the pathogenesis of a broad spectrum of neurologic diseases. A direct injection of lipopolysaccharide (LPS) into the striatum of gerbils induced lectin-positive macrophage parenchymal invasion, minimal local microglial staining but extensive neurodegeneration (cresyl violet and silver staining) when evaluated 4 days later. In mice, LPS activated microglia (increased lectin staining of morphologically identified cells) with substantially less macrophage invasion but no neurodegeneration was seen at 4 days post LPS infusion. To evaluate the role of infiltrating macrophages in the neurodegenerative response in gerbils, peripheral macrophages were depleted by an intravenous injection of liposome-encapsulated clodronate. This preparation depleted spleen and liver macrophages (>95%), decreased blood monocytes by 55% and attenuated striatal macrophage infiltration (32 to 73% in five representative sections). Notably, the liposome-encapsulated clodronate reduced the severity of LPS-induced neurodegeneration, as visualized by cresyl violet staining and quantified in 20 serially stained silver sections (total volume, 1.32+/-0.41 mm(3) in liposome-encapsulated clodronate-treated versus 3.04+/-0.72 mm(3) in saline-treated controls). These results indicate that a local LPS infusion in gerbil brain may be a useful model in which to investigate the role of invading macrophages and other inflammatory responses in neurodegeneration in inflammatory neurological disease.

Functional speech outcomes after laryngectomy and pharyngolaryngectomy

OBJECTIVE

To compare and contrast functional speech outcomes of patients having undergone total laryngectomy and pharyngolaryngectomy who use tracheoesophageal speech as their primary mode of communication.

DESIGN

Group comparison design.

SETTING

Adult acute tertiary care hospital.

PATIENTS

Thirty patients who underwent total laryngectomy and 13 who underwent pharyngolaryngectomy with free jejunal interposition reconstruction. All patients used tracheoesophageal speech.

INTERVENTION

Group comparisons across measures of speech intelligibility, voice quality, tracheoesophageal speech use, voice satisfaction and levels of perceived voice disability, handicap, and well-being/distress.

MAIN OUTCOME MEASURE

The existence of any significant differences between the 2 groups on measures of intelligibility, voice quality, tracheoesophageal speech use, and voice satisfaction and levels of voice disability, handicap, and well-being/distress.

RESULTS

Statistical comparisons confirmed reduced functional intelligibility (P<.05), reduced vocal quality (P<.01), and higher levels of disability (P<.05) in the pharyngolaryngectomy group. However, no significant difference was observed between the proportion of patients classified as "successful" tracheoesophageal speech users in either group. Low levels of handicap and high levels of patient well-being were recorded in both groups.

CONCLUSION

Despite the perceptual differences in voice quality and intelligibility observed between the 2 groups, tracheoesophageal speech that is functional, effective, and perceived by the patients as satisfactory can be achieved after total laryngectomy and pharyngolaryngectomy with free jejunal interposition reconstruction.

Core-based portal image registration for automatic radiotherapy treatment verification

PURPOSE

Portal imaging is the most important quality assurance procedure for monitoring the reproducibility of setup geometry in radiation therapy. The role of portal imaging has become even more critical in recent years due to the migration of three-dimensional (3D) treatment planning technology, including high-precision conformal therapy, from the research setting to routine clinical practice. Unfortunately, traditional methods for acquiring and interpreting portal images suffer from a number of deficiencies that contribute to the well-documented observation that many setup errors go undetected, and some persist for a clinically significant portion of the prescribed dose. Significant improvements in both accuracy and efficiency of detecting setup errors can, in principle, be achieved by using automatic image registration for on-line screening of images obtained from electronic portal imaging devices (EPIDs).

METHODS AND MATERIALS

This article presents recent developments in a method called core-based image analysis that shows great promise for achieving the desired improvements in error detection. Core-based image analysis is a fundamental computer vision method that is capable of exploiting the full power of EPIDs by providing for on-line detection of setup errors via automatic registration of user-selected anatomical structures. We describe a robust method for automatic portal image registration based on core analysis and demonstrate an approach for assessing both accuracy and precision of registration methods using realistic, digitally reconstructed portal radiographs (DRPRs) where truth is known.

RESULTS

Automatic core-based analysis of a set of 20 DRPRs containing known, random field positioning errors was performed for a patient undergoing treatment for prostate cancer. In all cases, the reported translation was within 1 mm of the actual translation with mean absolute errors of 0.3 mm and standard deviations of 0.3 mm. In all cases, the reported rotation was within 0.6 degree of the actual rotation with a mean absolute error of 0.18 degree and a standard deviation of 0.23 degree.

CONCLUSION

Our results, using digitally reconstructed portal radiographs that closely resemble clinical portal images, suggest that automatic core-based registration is suitable as an on-line screening tool for detecting and quantifying patient setup errors.

Hyperthyroidism and thyroid storm

Thyrotoxicosis and thyroid storm are disease states that result from thyroid hormone-induced hypermetabolism. The excess thyroid hormone is released from the thyroid gland as a result of excess thyroid hormone production, or by processes that disrupt the follicular structure of the gland with subsequent release of stored hormone. True hyperthyroidism results from increased synthesis and release of thyroid hormone and can be distinguished from other causes of thyrotoxicosis by the thyroid 131I uptake. Graves' disease is the most common cause of hyperthyroidism and occurs most often in women aged 30 to 50 years. The classic features of a patient with fully developed Graves' disease are difficult to overlook, but the clinical features of thyrotoxicosis vary with the etiology of the disease and the sensitivity of the patient's peripheral tissues. Thyroid storm presents with an exaggeration of the features of uncomplicated thyrotoxicosis and, in addition, an alteration in mental status. Thyroid storm may lead to irreversible cardiovascular collapse and death if proper treatment is not initiated in the Emergency Department. Specific therapy of hyperthyroidism follows several strategies, including inhibition of hormone synthesis and release, inhibition of peripheral conversion of T4 to T3, and blocking of the systemic effects of excess thyroid hormone. Treatments directed at these ends may be initiated rapidly in the emergency setting.

Preadmission programs: development, implementation and evaluation

Preparation of children for hospitalization is utilized to mitigate the stresses which may accompany the experience. Preadmission programs provide preparation for the patient and family on a prehospital basis. The authors describe the development of family-centered, developmentally based programs which foster continuity and consistency in a large, pediatric tertiary care setting. Implementation and evaluation of the programs which contribute to quality patient care are discussed.