Assessment of recurrent laryngeal nerve function during thyroid surgery

INTRODUCTION

There is disparity in the reported incidence of temporary and permanent recurrent laryngeal nerve (RLN) palsy following thyroidectomy. Much of the disparity is due to the method of assessing vocal cord function. We sought to identify the incidence and natural history of temporary and permanent vocal cord palsy following thyroid surgery. The authors wanted to establish whether intraoperative nerve monitoring and stimulation aids in prognosis when managing vocal cord palsy.

METHODS

Prospective data on consecutive thyroid operations were collected. Intraoperative nerve monitoring and stimulation, using an endotracheal tube mounted device, was performed in all cases. Endoscopic examination of the larynx was performed on the first postoperative day and at three weeks.

RESULTS

Data on 102 patients and 123 nerves were collated. Temporary and permanent RLN palsy rates were 6.1% and 1.7%. Most RLN palsies were identified on the first postoperative day with all recognised at the three-week review. No preoperative clinical risk factors were identified. Although dysphonia at the three-week follow-up visit was the only significant predictor of vocal cord palsy, only two-thirds of patients with cord palsies were dysphonic. Intraoperative nerve monitoring and stimulation did not predict outcome in terms of vocal cord function.

CONCLUSIONS

Temporary nerve palsy rates were consistent with other series where direct laryngoscopy is used to assess laryngeal function. Direct laryngoscopy is the only reliable measure of cord function, with intraoperative monitoring being neither a reliable predictor of cord function nor a predictor of eventual laryngeal function. The fact that all temporary palsies recovered within four months has implications for staged procedures.

Changes in saccadic eye movement and memory function after mild closed head injury in children

AIM

The aim of this study was to determine whether volitional saccadic impairments are present in children with mild closed head injury (mCHI) and whether these deficits are predictive of ongoing cognitive impairment.

METHOD

We analysed a sample of 26 children with mCHI (20 males, 6 females; mean age 13y 1mo, SD 2y) and 29 age-matched comparison children (20 males, 9 females; mean age 12y 2mo, SD 2y). Participants completed a battery of saccadic eye movement tasks and a set of computer-based cognitive tasks at three time points: within 2 weeks of mCHI, and at 3 months and 6 months.

RESULTS

The group with mCHI made fewer errors on the antisaccade task at the first time point and showed increased latencies on prosaccades, correct antisaccades, and corrected antisaccade errors at the third time point (6mo). The group with mCHI also showed poorer performance on the cognitive tasks assessing memory.

INTERPRETATION

Even very mild, uncomplicated mCHI in children may persistently affect aspects of executive control and visual processing.

Serum total hCGβ level is an independent prognostic factor in transitional cell carcinoma of the urothelial tract

Background:

Serum total human chorionic gonadotrophin β subunit (hCGβ) level might have prognostic value in urothelial transitional cell carcinoma (TCC) but has not been investigated for independence from other prognostic variables.

Methods:

We utilised a clinical database of patients receiving chemotherapy between 2005 and 2011 for urothelial TCC and an independent cohort of radical cystectomy patients for validation purposes. Prognostic variables were tested by univariate Kaplan–Meier analyses and log-rank tests. Statistically significant variables were then assessed by multivariate Cox regression. Total hCGβ level was dichotomised at < vs ⩾2 IU l⁻¹.

Results:

A total of 235 chemotherapy patients were eligible. For neoadjuvant chemotherapy, established prognostic factors including low ECOG performance status, normal haemoglobin, lower T stage and suitability for cisplatin-based chemotherapy were associated with favourable survival in univariate analyses. In addition, low hCGβ level was favourable when assessed either before (median survival not reached vs 1.86 years, P=0.001) or on completion of chemotherapy (4.27 vs 0.42 years, P=0.000002). This was confirmed in multivariate analyses and in patients receiving first- and second-line palliative chemotherapy, and in a radical cystectomy validation set.

Conclusions:

Serum total hCGβ level is an independent prognostic factor in patients receiving chemotherapy for urothelial TCC in both curative and palliative settings.

An exploration of novice and experienced problem-based learning facilitators' perceptions of their roles in a speech-language pathology programme. Does experience matter?

Recruitment and training of skilled facilitators is critical to the success of a problem-based learning (PBL) curriculum. However, facilitation skills do not come naturally to all staff and it remains unclear whether experience in the role contributes to competency. PBL facilitators in a Speech Pathology Masters programme were surveyed via questionnaire and open ended questions regarding their perceptions of the competencies needed to facilitate. Novice and experienced facilitators responses were then compared. The survey response rate was 82% (7/14 experienced and 7/14 novices). Two significant differences were evident between the groups consistent with the amount of facilitation experience. Role conflict, challenges associated with managing group dynamics, knowledge of the curriculum and the significance of social congruence were themes that emerged. Our findings suggest that both novice and experienced PBL facilitators benefit from continuing learning opportunities and mapping of facilitators' perceptions can be useful in delineating professional development needs.

'If I haven't got any smell … I'm out of work': consequences of olfactory impairment following traumatic brain injury

PRIMARY OBJECTIVE

Although estimates of the incidence of post-traumatic olfactory dysfunction range from 10-66.8%, there has been little research into its functional implications. The objective of this study was to describe the impact of olfactory impairment on daily activities and social participation from the perspective of adults who are living with the impairment.

RESEARCH DESIGN

A qualitative research design based on a constructivist grounded theory approach.

METHODS AND PROCEDURES

Purposive sampling of five participants with severe traumatic brain injury (TBI) who reported post-injury changes in their olfactory function was utilized. No participant had a pre-injury history of olfactory disturbance. The presence of olfactory disturbance was confirmed using the University of Pennsylvania Smell Identification Test (UPSIT). A semi-structured interview was employed to ascertain the participants' experiences. All interviews were transcribed verbatim and thematic analyses applied.

CONCLUSIONS

The themes that emerged demonstrated olfactory dysfunction has significant impact on a range of activities and social roles.

Wing shape and size of the western corn rootworm (Coleoptera: Chrysomelidae) is related to sex and resistance to soybean-maize crop rotation

The western corn rootworm, Diabrotica virgifera virgifera LeConte, is a major pest of maize in the United States and more recently, Europe. Understanding the dispersal dynamics of this species will provide crucial information for its management. This study used geometric morphometric analysis of hind wing venation based on 13 landmarks in 223 specimens from nine locations in Illinois, Nebraska, Iowa, and Missouri, to assess whether wing shape and size differed between rotated and continuously grown maize where crop rotation-resistant and susceptible individuals are found, respectively. Before assessing differences between rotation-resistant and susceptible individuals, sexual dimorphism was investigated. No significant difference in wing (centroid) size was found between males and females; however, females had significantly different shaped (more elongated) wings compared with males. Wing shape and (centroid) size were significantly larger among individuals from rotated maize where crop-rotation resistance was reported; however, cross-validation of these results revealed that collection site resistance status was an only better than average predictor of shape in males and females. This study provides preliminary evidence of wing shape and size differences in D. v. virgifera from rotated versus continuous maize. Further study is needed to confirm whether wing shape and size can be used to track the movement of rotation-resistant individuals and populations as a means to better inform management strategies.

A model of processes that underpin positive relationships for adults with severe intellectual disability

BACKGROUND

Relationships develop through social interaction and assist with participation and inclusion. Little is known about how relationships develop between people with severe intellectual disability who have limited communication and others.

METHOD

Interactions were observed between 6 adults with severe intellectual disability and paid workers or family members with whom those adults had positive relationships. Workers and family members were interviewed. The data were analysed through a grounded theory approach.

RESULTS

Data analysis led to the identification of 5 processes that underpin positive relationships: recognising individuality, sharing the moment, connecting, feeling good, and sharing the message.

CONCLUSIONS

A relationship model with clearly identified processes and sub-elements provides a framework for teaching others how to have positive relationships with people with severe intellectual disability. The model could be applied in training to support relationships between workers and people with a disability and more widely with other community members.

Targeted adenoviral vectors for cancer gene therapy (Review)

In order to realise the full potential of gene therapy as a rational approach to the treatment of cancer, it will be necessary to achieve delivery of the therapeutic gene selectively to target tumour cells. Such cancer cell-specific gene delivery is mandated in the context of locoregional or compartmentalised carcinomas, and is also an absolute requirement for the treatment of disseminated disease. Moreover, underlying any cancer gene therapy approach is the need to achieve a high level of efficiency of gene transfer to the target cells. Of the existing viral and nonviral gene delivery vehicles, the adenoviral vector uniquely fulfils two requirements of an intravenously administered vector for cancer gene therapy: systemic stability and the ability to accomplish efficient transduction of cancer cells. However, it is necessary to modify native adenoviral tropism in order to achieve selective transduction of target tumour cells. A number of strategies have been developed for this purpose, involving genetic or immunological modifications to either of two adenoviral capsid proteins, the fibre and penton base. These strategies are designed to generate a targetable, injectable vector which would represent a major advance in the field of cancer gene therapy.

Measuring participation after stroke: a review of frequently used tools

OBJECTIVE

To identify and critique the measures currently used to assess participation in clinical stroke studies.

DATA SOURCES

Relevant articles published between January 2001 and April 2012 identified through Medline, CINAHL, and ProQuest Central databases.

STUDY SELECTION

Published articles involving poststroke assessment of participation. Case studies, cohort studies, and randomized controlled trials were included.

DATA EXTRACTION

The most frequently used measures were identified and the psychometric properties evaluated. Three raters independently evaluated each measure relative to the first and second coding levels of the International Classification of Functioning, Disability and Health (ICF) Activities and Participation domain categories.

DATA SYNTHESIS

Thirty-six measures were identified. The Stroke Impact Scale (SIS), London Handicap Scale, Assessment of Life Habits (LIFE-H), Frenchay Activities Index, and Activity Card Sort (ACS) were used most frequently. No single measure met criteria across all psychometric indices, and not one covered all 9 of the ICF Activities and Participation domains. The SIS, LIFE-H, and ACS covered the widest range. The domains covered most frequently were Community, Social and Civic Life, Domestic Life, and Mobility. Learning and Applying Knowledge, General Tasks and Demands, and Communication were the domains less frequently covered.

CONCLUSIONS

This review identified and evaluated the most frequently used participation measures in clinical stroke studies. The SIS, LIFE-H, and ACS covered the ICF Activities and Participation domain categories most comprehensively. However, none of the measures covered all the ICF Activities and Participation domain categories. The information provided in this systematic review can be used to guide the selection of participation measures to meet specific clinical and research purposes.

Early sucking and swallowing problems as predictors of neurodevelopmental outcome in children with neonatal brain injury: a systematic review

AIM

Early sucking and swallowing problems may be potential markers of neonatal brain injury and assist in identifying those infants at increased risk of adverse outcomes, but the relation between early sucking and swallowing problems and neonatal brain injury has not been established. The aim of the review was, therefore, to investigate the relation between early measures of sucking and swallowing and neurodevelopmental outcomes in infants diagnosed with neonatal brain injury and in infants born very preterm (<32wks) with very low birthweight (<1500g), at risk of neonatal brain injury.

METHOD

We conducted a systematic review of English-language articles using CINAHL, EMBASE, and MEDLINE OVID (from 1980 to May 2011). Additional studies were identified through manual searches of key journals and the works of expert authors. Extraction of data informed an assessment of the level of evidence and risk of bias for each study using a predefined set of quality indicators.

RESULTS

A total of 394 abstracts were generated by the search but only nine studies met the inclusion criterion. Early sucking and swallowing problems were present in a consistent proportion of infants and were predictive of neurodevelopmental outcome in infancy in five of the six studies reviewed.

LIMITATIONS

The methodological quality of studies was variable in terms of research design, level of evidence (National Health and Medical Research Council levels II, III, and IV), populations studied, assessments used and the nature and timing of neurodevelopmental follow-up.

CONCLUSIONS

Based upon the results of this review, there is currently insufficient evidence to clearly determine the relation between early sucking and swallowing problems and neonatal brain injury. Although early sucking and swallowing problems may be related to later neurodevelopmental outcomes, further research is required to delineate their value in predicting later motor outcomes and to establish reliable measures of early sucking and swallowing function.

The challenges and benefits of using participant observation to understand the social interaction of adults with intellectual disabilities

Observation methods have been used in both communication and interaction research. Qualitative interpretive approaches are rare where participants have complex communication needs. Issues for qualitative researchers utilizing participant observation research methods have been well documented, but a similar discussion is lacking where the participants are people with severe intellectual disability. Observational data collected from a study of adults with severe intellectual disabilities in interaction with their social network members were scrutinized to identify challenges and benefits of participant observation. Challenges identified include the consent process, changing roles, and researcher intrusion. The use of participant observation with adults with severe intellectual disabilities allows for unexpected insights and provides context and credence for other lines of inquiry. Participant observation may be useful with other groups of people.

‘School's a big part of your life …’: Adolescent Perspectives of Their School Participation Following Traumatic Brain Injury

Sustaining a traumatic brain injury (TBI) as an adolescent has a significant impact on life roles and most notably on that of school participation. In the literature there is a wide range of studies that provide clinicians with information regarding recommendations for assisting students in their return to school. However this information has predominantly been provided from the perspectives of educators and rehabilitation staff. The aim of this preliminary project was to hear the stories of three male adolescent students as they reflected on their own experiences of what it was like to go back to school after sustaining a severe TBI. Using a qualitative research design and in-depth interviews, the students' stories were transcribed and coded using grounded theory principles. Despite persisting communication difficulties, the students were able to provide rich stories indicative of their personal experiences. Three key themes emerged from the interviews: theadolescent student's sense of self, changesthe students noted; andsupportsthe students identified. A tentative model illustrating the relationship between these areas was developed. It is anticipated that this model will assist clinicians and educators to develop a holistic picture of a student's school participation from transition to ongoing school life.

Anosmia After Traumatic Brain Injury: A Clinical Update

Most people only recognise the value of olfactory function after it is lost. In the context of traumatic brain injury with its far-reaching physical, cognitive, behavioural and emotional sequelae, posttraumatic olfactory dysfunction is an additional consequence that many survivors have to face as they adjust to a changed life situation. The aim of this article is to provide an update on posttraumatic anosmia for clinicians working in the area of brain injury rehabilitation. Brief reviews of incidence studies and causal mechanisms of olfactory impairment after brain injury are provided. Consequences of anosmia in the domains of safety, eating, personal hygiene, leisure, work and relationships with associated adaptive strategies are described.

Is Aphasia Therapy Effective? Exploring the Evidence in Systematic Reviews

In December 1999, Greener, Enderby and Whurr reported the findings of their Cochrane review to assess the effects of formal speech and language therapy for people with aphasia following stroke. They concluded that aphasia therapy had not been shown to be “clearly effective or clearly ineffective within a randomised controlled trial (RCT)” (p. 1). Their conclusion led to much discussion among speech pathologists with some expressing grave concern that the outcome of the review would undermine the provision of services for people with aphasia and their carers. In this paper, evidence for the effectiveness of aphasia therapy that has been provided by published systematic reviews is critically explored. Clearly, challenges remain with respect to provision of evidence-based aphasia therapy. However, the weight of evidence accumulated over the years and synthesised in systematic reviews supports the broad conclusion that aphasia therapy is effective.

Use of Reporting Guidelines in Scientific Writing: PRISMA, CONSORT, STROBE, STARD and Other Resources

In this special article we describe a number of reporting guidelines endorsed by the CONSORT (Consolidated Standards of Reporting Trials) group for a range of research designs that commonly appear in scientific journals: systematic reviews, clinical trials with and without randomisation, observational studies, n-of-1 (or single-case experimental design) trials, and diagnostic studies. We also consider reporting guidelines for studies using qualitative methodology. In addition to reporting guidelines, we present method quality rating scales, which aim to measure risk of bias that threatens the internal validity of a study. Advantages of reporting guidelines and method quality rating scales for authors include the provision of a structure by which to improve the clarity and transparency of report writing; for reviewers and readers advantages include a method by which to critically appraise an article.Brain Impairmentendorses these reporting guidelines and applies them within the review process for submissions to the journal.

Social interaction with adults with severe intellectual disability: having fun and hanging out

BACKGROUND

Social interaction is integral to social inclusion. Little is known about the nature of social interaction between adults with severe intellectual disability and those with whom they engage.

METHOD

Participants were six adults with intellectual disability and people identified as those with whom they shared demonstrable pleasurable interactions. Data were collected through observation and interviews, and data were analysed using a constructivist grounded theory approach.

RESULTS

An overarching category of sharing time together with two main sub-categories of Having fun and Hanging out emerged. Having fun was composed of routines and comedic interaction; hanging out was comprised of contact and presence.

CONCLUSIONS

Legitimizing mirth and sharing time in social interactions may supplement paid worker job satisfaction and increase opportunities for social inclusion by people with severe intellectual disability.

Evidence-based practice in speech-language pathology curricula: a scoping study

This scoping study investigated how evidence-based practice (EBP) principles are taught in Australian speech-language pathology (SLP) teaching and learning contexts. It explored how Australian SLP university programs: (1) facilitate student learning about the principles of EBP in academic and clinical settings, and (2) self-evaluate their curricula in relation to EBP. The research involved two surveys. Survey 1 respondents were 131 academic staff, program coordinators, and on-campus and off-campus clinical educators. This survey gathered information about EBP teaching and learning in SLP programs as well as future EBP curriculum plans. Survey 2 investigated how clinical educators incorporated EBP into the way they taught clinical decision-making to students. Surveys responses from 85 clinical educators were analysed using descriptive and non-parametric statistics and thematic grouping of open-ended qualitative responses. Both surveys revealed strengths and gaps in integrating EBP into Australian SLP curricula. Perceived strengths were that respondents were positive about EBP, most had EBP training and access to EBP resources. The perceived gaps included the academic staff's perceptions of students' understanding and application of EBP, respondents' understanding of research methodologies, communication and collaboration between academic staff and clinical educators, and a lack of explicit discussion by clinical educators and students of EBP in relation to clients.

Visual Scanning in the Recognition of Facial Affect in Traumatic Brain Injury

We investigated the visual scanning strategy employed by a group of individuals with a severe traumatic brain injury (TBI) during a facial affect recognition task. Four males with a severe TBI were matched for age and gender with 4 healthy controls. Eye movements were recorded while pictures of static emotional faces were viewed (i.e., sad, happy, angry, disgusted, anxious, surprised). Groups were compared with respect to accuracy in labelling the emotional facial expression, reaction time, number and duration of fixations to internal (i.e., eyes + nose + mouth), and external (i.e., all remaining) regions of the stimulus. TBI participants demonstrated significantly reduced accuracy and increased latency in facial affect recognition. Further, they demonstrated no significant difference in the number or duration of fixations to internal versus external facial regions. Control participants, however, fixated more frequently and for longer periods of time upon internal facial features. Impaired visual scanning can contribute to inaccurate interpretation of facial expression and this can disrupt interpersonal communication. The scanning strategy demonstrated by our TBI group appears more ‘widespread’ than that employed by their normal counterparts. Further work is required to elucidate the nature of the scanning strategy used and its potential variance in TBI.

The pearl in the middle: a case study of social interactions in an individual with a severe intellectual disability

BACKGROUND

People with severe intellectual disability have limited communication skills, small social networks, and may experience isolation. Little is known about how interactions occur with social network members and the role of social support.

METHOD

An adult with a severe intellectual disability was observed in her daily environments. Her social network members were identified and interviewed. Data were analysed using a grounded theory approach.

RESULTS

Fourteen social network members were identified. People with severe intellectual disability interact in different ways, which may not be understood by network members or conform to normative expectations. Still, network members experienced enjoyment, personal satisfaction, and love in their interactions.

CONCLUSIONS

Social interactions with people with severe intellectual disability are challenging. The results point to the benefits of a focus on learning that makes interactions meaningful for each individual, sharing that information with network members, and considering ways to increase interactions and extend the social network.

Constitutional translocation breakpoint mapping by genome-wide paired-end sequencing identifies HACE1 as a putative Wilms tumour susceptibility gene

BACKGROUND

Localisation of the breakpoints of chromosomal translocations has aided the discovery of several disease genes but has traditionally required laborious investigation of chromosomes by fluorescent in situ hybridisation approaches. Here, a strategy that utilises genome-wide paired-end massively parallel DNA sequencing to rapidly map translocation breakpoints is reported. This method was used to fine map a de novo t(5;6)(q21;q21) translocation in a child with bilateral, young-onset Wilms tumour.

METHODS AND RESULTS

Genome-wide paired-end sequencing was performed for approximately 6 million randomly generated approximately 3 kb fragments from constitutional DNA containing the translocation, and six fragments in which one end mapped to chromosome 5 and the other to chromosome 6 were identified. This mapped the translocation breakpoints to within 1.7 kb. Then, PCR assays that amplified across the rearrangement junction were designed to characterise the breakpoints at sequence-level resolution. The 6q21 breakpoint transects and truncates HACE1, an E3 ubiquitin-protein ligase that has been implicated as a somatically inactivated target in Wilms tumourigenesis. To evaluate the contribution of HACE1 to Wilms tumour predisposition, the gene was mutationally screened in 450 individuals with Wilms tumour. One child with unilateral Wilms tumour and a truncating HACE1 mutation was identified.

CONCLUSIONS

These data indicate that constitutional disruption of HACE1 likely predisposes to Wilms tumour. However, HACE1 mutations are rare and therefore can only make a small contribution to Wilms tumour incidence. More broadly, this study demonstrates the utility of genome-wide paired-end sequencing in the delineation of apparently balanced chromosomal translocations, for which it is likely to become the method of choice.

Prospective analysis of neuropsychiatric events in an international disease inception cohort of patients with systemic lupus erythematosus

OBJECTIVES

To determine the frequency, accrual, attribution and outcome of neuropsychiatric (NP) events and impact on quality of life over 3 years in a large inception cohort of patients with systemic lupus erythematosus (SLE).

METHODS

The study was conducted by the Systemic Lupus International Collaborating Clinics. Patients were enrolled within 15 months of SLE diagnosis. NP events were identified using the American College of Rheumatology case definitions, and decision rules were derived to determine the proportion of NP disease attributable to SLE. The outcome of NP events was recorded and patient-perceived impact determined by the SF-36.

RESULTS

1206 patients (89.6% female) with a mean (+/-SD) age of 34.5+/-13.2 years were included in the study. The mean disease duration at enrollment was 5.4+/-4.2 months. Over a mean follow-up of 1.9+/-1.2 years, 486/1206 (40.3%) patients had > or =1 NP events, which were attributed to SLE in 13.0-23.6% of patients using two a priori decision rules. The frequency of individual NP events varied from 47.1% (headache) to 0% (myasthenia gravis). The outcome was significantly better for those NP events attributed to SLE, especially if they occurred within 1.5 years of the diagnosis of SLE. Patients with NP events, regardless of attribution, had significantly lower summary scores for both mental and physical health over the study.

CONCLUSIONS

NP events in patients with SLE are of variable frequency, most commonly present early in the disease course and adversely impact patients' quality of life over time. Events attributed to non-SLE causes are more common than those due to SLE, although the latter have a more favourable outcome.

Microbiology of infected arthroplasty: implications for empiric peri-operative antibiotics

PURPOSE

To classify the spectrum and antibiotic susceptibility of bacteria isolated from infected hip and knee arthroplasty specimens, and to recommend appropriate empiric peri-operative antibiotics.

METHODS

From January 1999 to August 2006, specimens from revision hip and knee arthroplasties (with or without suspected infection) were routinely collected for identifying possible organisms and their susceptibility patterns. During the period, 147 patients had positive specimens yielding 248 micro-organisms (from 195 tissue specimens, 43 fluid specimens, and 10 swabs). 140 isolates were from hips and 108 from knees.

RESULTS

Most isolates were Gram-positive; their distribution was similar in hip and knee specimens. Of the 248 micro-organisms isolated, Staphylococcus was the most common genus encountered (131, 53%), followed by Gram-negative isolates (24%). 88% of Gram-negative organisms were detected within 48 hours of inoculation and 94% of Gram-positive organisms within 96 hours. Overall, 46% of isolates were susceptible to cephalothin. Only 35% of coagulase-negative staphylococci were sensitive to cephalothin. No Gram-positive vancomycin resistance was encountered.

CONCLUSION

Empiric prophylactic antibiotics for revision hip and knee arthroplasties should include vancomycin to cover Gram-positive organisms and gentamicin for most Gram-negative bacteria.