Cytotoxic screening of plants from the Brazilian Atlantic Forest has led to the identification of Casearia arborea and Sorocea hilarii as sources of antitumor compounds

In the present study, we have evaluated the cytotoxic activity of 282 extracts from 72 native plant species of the Brazilian Atlantic Forest biome. As a result, Casearia arborea and Sorocea hilarii leaves extracts showed cytotoxic activity against three tumour cell lines tested (B16F10, SW480 and Jurkat). After bioassay-guided fractionation, the bioactive fractions were submitted to the dereplication study via High-performance Liquid Chromatography, connected to High-resolution Mass Spectrometry (HPLC-ESI-QTOF/MS) analysis, combined with a Global Natural Products Social Molecular Networking (GNPS) tool. A combination of bioactivity-guided and dereplication approaches resulted in the putative annotation of 27 clerodane diterpenes and 9 flavonoids as main compounds present in the cytotoxic fractions of C. arborea. Regarding the active fraction of S. hilarii, 10 megastigmans, 17 spirostane steroids derivatives and 2 lignans were putatively identified. In conclusion, Casearia arborea and Sorocea hilarii are potential sources of antitumor compounds.

Vocal Tract Discomfort Scale-Brazil (VTDS-BR): Validation Based on Internal Consistency, Reliability, and Accuracy

OBJECTIVE

To validate the Vocal Tract Discomfort Scale for the Brazilian Portuguese (VTDS-BR), based on internal consistency, reliability, and accuracy.

METHODS

The participants were 431 adults of both sexes, divided in two groups: dysphonia (DG) and vocally healthy (VHG). We built a digital database with personal, professional information and the item-by-item VTDS-BR responses of the participants. We applied Cronbach's alpha, exploratory factor analysis; confirmatory factor analysis; Item Response Theory (IRT) using the Samejima model; and ROC (Receiver Operating Characteristic) curve analysis to obtain the VTDS-BR cut-off point.

RESULTS

The VTDS-BR has an eight-item structure and two factors: vocal hyperfunction without phonotraumatic injury and with phonotraumatic injury. Each item is evaluated based on two facets related to frequency and intensity, with a Likert scale response key. There are four possible answers: never, sometimes, often, and always for frequency and none, mild, moderate, and intense for intensity. We applied an IRT model, which allowed the identification of which items are more related to dysphonia, based on higher values in the parameters discrimination (a) and difficulty (b), which contributed to the calculation of each participant's aptitude for the development of voice problems, by means of a score. The cut-off value was determined using the ROC curve, in which values greater than - 1.432 indicate a higher probability of voice alterations.

CONCLUSION

VTDS-BR went through the stages of validation of internal consistency, reliability, and accuracy. It presents an 8-item, two-factor, and two-facet structure to assess frequency and intensity of vocal tract discomfort symptoms. VTDS-BR is suitable for clinical use or in screening activities, as it is quick to apply and its interpretation is indicative of people with and without phonotraumatic injury.

Voice Acoustic Parameters as Predictors of Depression

OBJECTIVE

To analyze whether voice acoustic parameters are discriminant and predictive in patients with and without depression.

METHODS

Observational case-control study. The following instruments were administered to the participants: Self-Reporting Questionnaire (SRQ-20), Beck Depression Inventory-Second Edition (BDI-II), Voice Symptom Scale (VoiSS) and voice collection for subsequent extraction of the following acoustic parameters: mean, mode and standard deviation (SD) of the fundamental frequency (F0); jitter; shimmer; glottal to noise excitation ratio (GNE); cepstral peak prominence-smoothed (CPPS); and spectral tilt. A total of 144 individuals participated in the study: 54 patients diagnosed with depression (case group) and 90 without a diagnosis of depression (control group).

RESULTS

The means of the acoustic parameters showed differences between the groups: F0 (SD), jitter, and shimmer values were high, while values for GNE, CPPS and spectral tilt were lower in the case group than in the control group. There was a significant association between BDI-II and jitter, shimmer, CPPS, and spectral tilt and between CPPS and the class of antidepressants used. The multiple linear regression model showed that jitter and CPPS were predictors of depression, as measured by the BDI-II.

CONCLUSION

Acoustic parameters were able to discriminate between patients with and without depression and were associated with BDI-II scores. The class of antidepressants used was associated with CPPS, and the jitter and CPPS parameters were able to predict the presence of depression, as measured by the BDI-II clinical score.

What Factors Determine the Use of Volitional and Non-Volitional Devices in Vocal Interventions Performed by Brazilian Speech-Language Pathologists?

OBJECTIVE

To analyze the determining factors for using devices in vocal interventions and characterize their use by Brazilian speech-language pathologists (SLPs).

METHODS

This cross-sectional observational study had a sample of 148 SLPs with clinical practice in voice. They answered an online questionnaire via Google Forms about sociodemographic data, training, work in the area, and the use of devices in vocal interventions. Data were analyzed descriptively and inferentially.

RESULTS

Tubes, straws, and masks were the most commonly used devices. SLPs specializing in voice are more inclined to use thermotherapy and kinesio tapings while being less inclined to use therapeutic ultrasounds and nebulizers. Voice specialists are less likely to employ electrostimulation. The choice to use photobiomodulation and auditory monitoring devices is influenced by the years of clinical experience, whereas the speech-language therapy training duration affects the use of electrostimulation. The age of the professional also plays a role in the utilization of vibratory stimulation. Vibratory stimulation, auditory monitoring devices, thermotherapy, and nebulization are more frequently utilized among individuals who rely on their voices for occupational purposes, whereas electrostimulation is less common. The use of photobiomodulation is infrequent in children; vibratory stimulation is more common in adolescents, and thermotherapy is relatively common among older individuals. Most of these devices are typically prescribed in execution time during vocal intervention.

CONCLUSION

The specialization, the time since graduation and in the occupation, and the target population of the service are the determining factors for the use of devices. They are used in vocal therapy and training, targeting vocal function.

Urica-VV Scale: A New Research Perspective of The Stage of Readiness for Treatment in Patients with Dysphonia

OBJECTIVE

To obtain evidence of validity for the URICA-V scale and estimate the psychometric properties of its items based on item response theory (IRT).

METHOD

A total of 658 individuals of both sexes over 18 years of age were allocated into two groups: with dysphonia group (WDG) and vocally healthy group (VHG). A digital database was constructed with personal and professional data and item-by-item responses on the URICA-V scale. Subsequently, Cronbach's alpha, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), application of IRT using Samejima's model and ROC curve analysis were used to obtain the cutoff point for the URICA-V scale.

RESULTS

A different version of the original URICA-V scale was obtained. Of the 32 items from the original protocol, 25 better explained the instrument and were regrouped into two domains: contemplation and maintenance. It was possible to identify which items generated higher difficulty (b) and discrimination (a) values and which contributed to the presentation of a calculation based on the theta of each participant. The ROC curve was analyzed, and a cutoff point of -0.236 was established; establishing a cutoff point facilitates the decision of which individuals are in a state of readiness for voice treatment.

CONCLUSION

The present study provided evidence that allows us to propose the URICA-Voice validated (URICA-VV) scale within a more contemporary perspective and with a reduced number of items and domains. In addition, a cutoff point was obtained based on IRT to measure, with greater accuracy, sensitivity and specificity, the stage of readiness and to differentiate individuals who have an indication for speech therapy.

Spectrographic Voice Analysis Protocol (SAP): Convergent, Concurrent, and Accuracy Validity

OBJECTIVE

To verify the convergent and concurrent validity of the Spectrographic Voice Analysis Protocol (SAP) and its accuracy to discriminate dysphonic from nondysphonic patients.

METHOD

The study used 82 vowel /Ɛ/ samples and their respective narrowband spectrograms, analyzed with SAP. Cepstral peak prominence (CPP) and cepstral peak prominence smoothed (CPPS) verified the convergent validity of the SAP total score, while the general grade of vocal deviation (GG) verified the concurrent validity of the SAP total score. The ROC (receive operator curve) curve and its accuracy, sensitivity, and specificity values, positive predictive value (PPV) and negative predictive value (NPV), and positive likelihood ratio (LR+) and negative likelihood ratio (LR-) verified the accuracy of the SAP score to discriminate dysphonic from nondysphonic individuals.

RESULTS

Dysphonic and nondysphonic had different SAP total scores. In the convergent validity, the SAP score had a weak and moderate negative correlation, respectively, with CPP and CPPS, as well as a moderate positive correlation with GG. SAP performed well in discriminating dysphonic from nondysphonic individuals (area under the curve = 82.0%; sensitivity = 91.7%; specificity = 51.7%; PPV = 93.7%; NPV = 44.0%; LR+ = 6.21; LR- = 0.53) based on the 8-point cutoff score.

CONCLUSION

SAP has convergent validity with CPP and CPPS and concurrent validity with GG. The SAP total score performed well in discriminating dysphonic from nondysphonic individuals. However, the specificity, NPV, and LR- values justify cautiously using SAP, always in combination with other information in clinical voice assessment.

Differences and Reliability of Linear and Nonlinear Acoustic Measures as a Function of Vocal Intensity in Individuals With Voice Disorders

PURPOSE

Linear acoustic indices are significantly influenced by speaking voice intensity. The main aim of this work was to compare acoustic measures based on linear and nonlinear models in different speaking voice intensity levels and to analyze the reliability of those measures in different intensity levels in subjects with voice disorders.

METHODS

435 samples from subjects (314 women, 121 men with a mean age of 41.07 ± 13.73) diagnosed with various voice disorders were used. In total, 17 acoustic measures were derived from the vowel /ɛ/ sustained at three intensity levels (soft, comfortable, and loud). Five were linear (standard deviation of the fundamental frequency (f0), jitter, shimmer, harmonics-to-noise ratio (HNR) and smoothed cepstral peak prominence (CPPS)), and twelve were nonlinear measures, namely correlation dimension (D2), correlation entropy (H2), first minimum of the mutual information function (FMMI), relative entropy (ENTR-R), largest Lyapunov exponent (Lyap), determinism (DET), transitivity, mean diagonal line length (Lmed), Shannon entropy (ENTR-S), mean length of vertical structures, also known as trapping time (TT), laminarity (LAM) and recurrence period density entropy (RPDE). Differences between speaking voice intensity levels were assessed by Friedman's test and Nemenyi as posthoc test. Intraclass correlation coefficient was used to investigate if each acoustic measure remains in agreement (reliability) between different voice intensity levels.

RESULTS

There were significant differences in all acoustic measures about vocal intensity level (P < 0.001). Intraclass correlation coefficient was very good for HNR (>0.61) and good for Lyap, DET, ENTR-S, Lmed, RPDE, and TT (0.41-0.60).

CONCLUSIONS

All acoustic measures varied as a function of vocal intensity in voice disordered adults, while this relation was different for linear and nonlinear measures. Only the measures HNR, Lyap, DET, ENTR-S, Lmed, RPDE and TT had an acceptable reliability between different voice intensity levels. Therefore, patient`s voice SPL should be controlled or indicated during acoustic vocal assessment.

Comparison of efficiency of different self-assessment instruments for screening dysphonia

PURPOSE

To compare the efficiency of different vocal self-assessment instruments for dysphonia screening.

METHODS

262 dysphonic and non-dysphonic individuals participated in the research. The mean age was 41.3 (±14.5) years. The diagnosis of dysphonia was based on the auditory-perceptual analysis of the sustained vowel "é" and on laryngological diagnosis. The responses of the instruments were collected: Voice-Related Quality of Life (V-RQOL), Voice Handicap Index (VHI), VHI-10, Voice Symptoms Scale (VoiSS), and the Brazilian Dysphonia Screening Tool, (Br-DST) called in Brazilian Portuguese Instrumento de Rastreio da Disfonia (IRDBR). To analyze assertiveness in relation to the presence of dysphonia, the cutoff points of each instrument and the decision rule recommended by the IRDBR were used. An exploratory analysis was performed to compare mean scores of instruments and verify associations between variables.

RESULTS

The instruments evaluated were sensitive to capture the impact of dysphonia in a similar way regardless of professional voice use and type of dysphonia. There was a difference only in VoiSS scores for the variable gender, with a higher score for females. Regarding global assertiveness, the instruments showed high rates of success in classification, with emphasis on the VoiSS, which had the highest rate (86.3%), followed by the IRDBR (84.0%), VQL (80.9%), VHI (78.2%), and VHI-10 (75.2%).

CONCLUSION

The VoiSS has the highest assertiveness index in the identification of dysphonia, followed by the IRDBR. The IRDBR is a short, simple, and easy-to-apply tool for screening procedures.

Validation of the Brazilian Scale of Perceived Control Over Voice in the Present using Item Response Theory

OBJECTIVE

this study aims to verify the stages of evidence of validity of the voice-adapted present perceived control scale (V-APPCS) in its translated and cross-culturally adapted version for the Brazilian Portuguese "Voice-Adapted Present Perceived Control Scale" and to estimate the psychometric measurements of the properties of its items based on the item response theory (IRT).

METHODS

the instrument underwent a process of translation and cross-cultural adaptation for the Brazilian Portuguese, the process was carried out by two qualified translators, native in the destination language, and fluent in the language and culture of origin. The first translated version of the protocol was forwarded to a back-translation, performed by a third bilingual Brazilian translator. The translations were analyzed and compared by a committee composed of five speech therapists who are specialists in voice and with proficiency in the English language. The empirical study used data from 168 individuals, 127 had voice problems and 41 vocally healthy ones. For the stages of validity evidence, the following analyses were performed: Cronbach's alpha, exploratory factor analysis, confirmatory factor analysis and IRT.

RESULTS

The stages of translation and cross-cultural adaptation allowed linguistic adjustments to be made so that the items were understandable and suitable for use in Brazil. The adequacy, structure, and application of the items were confirmed through the application of the final version of the scale in twenty individuals in a real context. The instrument in its Brazilian version presented good internal consistency, with bifactorial structure the exploratory factor analysis, besides presenting satisfactory values in the adjustment indexes of the model, confirming the structure of the confirmatory factor Analysis. The IT was applied to evaluate the parameters discrimination (a) and difficulty (b) of the items of the instrument; item 5 "I have control over my day-to-day reactions to the voice problem." Presented itself as a more discriminative item and item 8 "My reaction to the voice problem is not under my control." As an item of greater difficulty.

CONCLUSION

The V-APPCS, translated, cross-culturally adapted, and validated, is robust and adequate to represent the construct in the Brazilian versions.

Brazilian Dysphonia Screening Tool (Br-DST): An Instrument Based on Voice Self-Assessment Items

OBJECTIVE

To propose a short instrument for the screening of dysphonia in the Brazilian population through the investigation of traditional voice self-assessment instrument items.

METHODS

We analyzed the medical records of 139 individuals with an average age of 37.4 years and a minimum and maximum age of 18 and 77 years, respectively. The participants were classified as dysphonic (D) or non-dysphonic (ND) according to an analysis of the combination of vocal complaints and laryngological reports. Responses to the items of the following self-assessment instruments were collected: the Questionário de Qualidade de Vida em Voz - QVV (Voice-Related Quality of Life - V-RQOL), the Índice de Desvantagem Vocal - IDV (Voice Handicap Index - VHI) and the Escala de Sintomas Vocais - ESV (Voice Symptom Scale - VoiSS). These items were analyzed regarding their predictive capacities for dysphonia through logistic regression models.

RESULTS

The model containing items of the QVV was not observed to be valid. The model for the IDV produced a set of three items (10, 13, and 14), and the ESV model showed two items (4 and 20) to be significant. A Global model combining the previous models shows that items I feel as though I have to strain to produce voice from the IDV and "Is your voice hoarse?" from the ESV are the most significant in the classification of the presence of dysphonia. This decision-making model was considered the most efficient to identify the dysphonia, with the highest level of accuracy compared to the other models investigated (83.4%).

CONCLUSION

Dysphonia screening can be performed using a simple, rapid protocol with a high-efficiency index that includes two items taken from traditional voice self-assessment instruments.

Comparison of efficiency of different self-assessment instruments for screening dysphonia

PURPOSE

To compare the efficiency of different vocal self-assessment instruments for dysphonia screening.

METHODS

262 dysphonic and non-dysphonic individuals participated in the research. The mean age was 41.3 (±14.5) years. The diagnosis of dysphonia was based on the auditory-perceptual analysis of the sustained vowel "é" and on laryngological diagnosis. The responses of the instruments were collected: Voice-Related Quality of Life (V-RQOL), Voice Handicap Index (VHI), VHI-10, Voice Symptoms Scale (VoiSS), and the Brazilian Dysphonia Screening Tool, (Br-DST) called in Brazilian Portuguese Instrumento de Rastreio da Disfonia (IRDBR). To analyze assertiveness in relation to the presence of dysphonia, the cutoff points of each instrument and the decision rule recommended by the IRDBR were used. An exploratory analysis was performed to compare mean scores of instruments and verify associations between variables.

RESULTS

The instruments evaluated were sensitive to capture the impact of dysphonia in a similar way regardless of professional voice use and type of dysphonia. There was a difference only in VoiSS scores for the variable gender, with a higher score for females. Regarding global assertiveness, the instruments showed high rates of success in classification, with emphasis on the VoiSS, which had the highest rate (86.3%), followed by the IRDBR (84.0%), VQL (80.9%), VHI (78.2%), and VHI-10 (75.2%).

CONCLUSION

The VoiSS has the highest assertiveness index in the identification of dysphonia, followed by the IRDBR. The IRDBR is a short, simple, and easy-to-apply tool for screening procedures.

Predictive Factors of Listeners' Attitudes Related to Dysphonic Voices in Native Brazilian Portuguese

OBJECTIVES

To verify whether there are differences in the judgments of listeners' attitudes as a function of the presence, severity, and type of vocal deviation, and to identify the predictive factors of listeners' attitudes toward dysphonic voices in Brazilian Portuguese speakers.

METHODS

A sample of CAPE-V sentences was used from 44 subjects of both genders. The samples presented different severities of vocal deviation (general grade - GG) (healthy, mild, moderate, and severe) and different degrees of roughness (GR), breathiness (GB), and strain (GS), characterized by a perceptual-auditory judgment performed by speech therapists. The samples were presented to 152 listeners of both genders who performed the judgment of 12 attitudes inserted in a semantic differential scale previously validated for this study. Here, we used a Logistic Regression Model.

RESULTS

There was no association between listener's gender and the judgment of attitudes. Subjects with vocal quality deviation were judged more negatively in relation to vocally healthy individuals. We observed that higher the GG, higher the negative judgment of listeners in relation to the speakers. Listeners judged breathy and strained voices as more negative. In the general model for female and male voices, the increase in GB and GG reduced the chance of a voice being evaluated positively by 16 and 20%, respectively. For female voices, GB and GS reduced the chance of a female voice being evaluated positively by 36 and 19%, respectively. GG reduces the chance of a male voice being evaluated positively by 46%, while GR increases the chance of a male voice being judged positively by 62 %.

CONCLUSIONS

There is an association between the presence, severity, and type of vocal deviation and listeners' attitudes. We identified a predictive model of listeners' attitudes related to dysphonic voices among Brazilian Portuguese speakers. In general, GG and GB were predictors of negative attitudes toward listeners. GB and GS were predictors of negative attitudes toward female voices. The GG is a predictor of negative attitudes toward male voices, while the GR increases the chance of positive judgments.

Reducing the gap between science and clinic: lessons from academia and professional practice - part B: traditional vocal therapy techniques and modern electrostimulation and photobiomodulation techniques applied to vocal rehabilitation

This text is the continuation of the XVIII SBFa Congress publication. In part "A" we presented the analyses on clinical vocal evaluation. Part "B" focuses on vocal rehabilitation: 4. Traditional techniques of vocal therapy; 5. Modern techniques of electrostimulation and photobiomodulation applied to vocal rehabilitation. The numerous studies on the various programs, methods, and techniques of traditional rehabilitation techniques, and many with high quality of evidence, allow us to consider such procedures relatively well described, safe, and with known effects, accounting for the treatment of various vocal disorders. The scientific evidence with traditional techniques is recognized worldwide. New fronts of evolution, with electrostimulation or photobiomodulation used to handle voice problems, seem to be promising as coadjutant approaches. There are more studies on electrostimulation in vocal rehabilitation than with photobiomodulation; however, scientific evidence for these two modern techniques is still limited. Knowledge and caution are required for the application of either technique.

Reducing the GAP between science and clinic: lessons from academia and professional practice - part A: perceptual-auditory judgment of vocal quality, acoustic vocal signal analysis and voice self-assessment

During the XXVIII Brazilian Congress of SBFa, 24 specialists met and, from a leading position on scientific research as a tool for connecting laboratory and clinic, five fronts of knowledge of the voice specialty were discussed as following: Perceptual-auditory judgment of vocal quality; 2. Acoustic analysis of the vocal signal; 3. Voice self-assessment; 4. Traditional techniques of therapy; 5. Modern techniques of electrostimulation and photobiomodulation (PBMT) in voice. Part "a" of this publication was associated with the consolidation of the analyses of the first three aspects. The trend in the perceptual-auditory judgment of vocal quality was related to the use of standard protocols. The acoustic evaluation of the vocal signal is accessible and can be done descriptively or by extraction of parameters, thus preferring multiparametric measures. Finally, the analysis of the individual himself closes this triad of voice documentation, which will be the basis for the conclusion of the evaluation, reference for monitoring progress, and evaluation of treatment results.

Immediate effect of different exercises in the vocal space of women with and without vocal nodules

PURPOSE

To investigate the immediate effect of voiced tongue vibration (VSL), high-resistance straw in the air (CAR), and overarticulation (OA) on the vocal space of vocally healthy women (MVS) and with vocal nodules (MNV).

METHODS

12 women participated in the MNV and 12 women in the MVS, allocated to perform the vocal exercises of VSL, CAR, and OA. Each participant performed only one of the three proposed exercises, for 5 minutes, preceded and followed by recording a sequence of vehicle sentences for extracting formants (F1 and F2) from the vowel segments [a, i, u]. The vowel space was analyzed through the differences between the measures of the formants of the vowels.

RESULTS

we observed a reduction of F1 in the interval [a]-[i] and [i]-[u] and of F2 between the vowels [a]-[u] and [i]-[u] in the MVS, after performing the CAR. In MNV, we observed a reduction of F2 in the interval [a]-[i] after VSL. In the intergroup analysis, there were higher F1 values between the intervals of the vowels [a]-[i] and [i]-[u] in the MVS, before performing the CAR, and after exercise only in the interval [a]-[i]. A higher value of F1 and F2 was observed in the interval between the vowels [i]-[u] in the MNV after VSL.

CONCLUSION

The VSL exercise reduced the vowel space in MNV women. CAR reduced the vocal space of women in the MVS. The MNV had a smaller vowel space compared to the MVS before and after the CAR. We observed a reduction in the vowel space in the MNV compared to the MNV after the VSL exercise.

Immediate effect of different exercises in the vocal space of women with and without vocal nodules

ABSTRACT Purpose To investigate the immediate effect of voiced tongue vibration (VSL), high-resistance straw in the air (CAR), and overarticulation (OA) on the vocal space of vocally healthy women (MVS) and with vocal nodules (MNV). Methods 12 women participated in the MNV and 12 women in the MVS, allocated to perform the vocal exercises of VSL, CAR, and OA. Each participant performed only one of the three proposed exercises, for 5 minutes, preceded and followed by recording a sequence of vehicle sentences for extracting formants (F1 and F2) from the vowel segments [a, i, u]. The vowel space was analyzed through the differences between the measures of the formants of the vowels. Results we observed a reduction of F1 in the interval [a]-[i] and [i]-[u] and of F2 between the vowels [a]-[u] and [i]-[u] in the MVS, after performing the CAR. In MNV, we observed a reduction of F2 in the interval [a]-[i] after VSL. In the intergroup analysis, there were higher F1 values between the intervals of the vowels [a]-[i] and [i]-[u] in the MVS, before performing the CAR, and after exercise only in the interval [a]-[i]. A higher value of F1 and F2 was observed in the interval between the vowels [i]-[u] in the MNV after VSL. Conclusion The VSL exercise reduced the vowel space in MNV women. CAR reduced the vocal space of women in the MVS. The MNV had a smaller vowel space compared to the MVS before and after the CAR. We observed a reduction in the vowel space in the MNV compared to the MNV after the VSL exercise.

Reducing the GAP between science and clinic: lessons from academia and professional practice - part A: perceptual-auditory judgment of vocal quality, acoustic vocal signal analysis and voice self-assessment

ABSTRACT During the XXVIII Brazilian Congress of SBFa, 24 specialists met and, from a leading position on scientific research as a tool for connecting laboratory and clinic, five fronts of knowledge of the voice specialty were discussed as following: Perceptual-auditory judgment of vocal quality; 2. Acoustic analysis of the vocal signal; 3. Voice self-assessment; 4. Traditional techniques of therapy; 5. Modern techniques of electrostimulation and photobiomodulation (PBMT) in voice. Part “a” of this publication was associated with the consolidation of the analyses of the first three aspects. The trend in the perceptual-auditory judgment of vocal quality was related to the use of standard protocols. The acoustic evaluation of the vocal signal is accessible and can be done descriptively or by extraction of parameters, thus preferring multiparametric measures. Finally, the analysis of the individual himself closes this triad of voice documentation, which will be the basis for the conclusion of the evaluation, reference for monitoring progress, and evaluation of treatment results.

Reducing the gap between science and clinic: lessons from academia and professional practice - part B: traditional vocal therapy techniques and modern electrostimulation and photobiomodulation techniques applied to vocal rehabilitation

ABSTRACT This text is the continuation of the XVIII SBFa Congress publication. In part “A” we presented the analyses on clinical vocal evaluation. Part “B” focuses on vocal rehabilitation: 4. Traditional techniques of vocal therapy; 5. Modern techniques of electrostimulation and photobiomodulation applied to vocal rehabilitation. The numerous studies on the various programs, methods, and techniques of traditional rehabilitation techniques, and many with high quality of evidence, allow us to consider such procedures relatively well described, safe, and with known effects, accounting for the treatment of various vocal disorders. The scientific evidence with traditional techniques is recognized worldwide. New fronts of evolution, with electrostimulation or photobiomodulation used to handle voice problems, seem to be promising as coadjutant approaches. There are more studies on electrostimulation in vocal rehabilitation than with photobiomodulation; however, scientific evidence for these two modern techniques is still limited. Knowledge and caution are required for the application of either technique.

Factor Analysis of the Brazilian Version of the Voice-Related Quality of Life (V-RQOL) Questionnaire

OBJECTIVE

To investigate the psychometric properties of the Voice-Related Quality of Life (V-RQOL) questionnaire in Brazilian Portuguese by assessing its reliability and conducting exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).

METHODS

This research was carried out in two stages: (1) a document-based retrospective approach and (2) a field study step. The study included 566 dysphonic and vocally healthy individuals. For data collection, the Vocal Screening Protocol and the V-RQOL questionnaire were used, and these measures were later statistically analyzed through descriptive analysis, reliability tests, CFA, and EFA. Ethical issues were considered.

RESULTS

A Cronbach's alpha coefficient of 0.916 was observed, indicating good internal consistency for the V-RQOL questionnaire. The item-total correlation coefficient indicated that the items had good correlation with each other and with the construct, with values higher than 0.30. EFA was performed based on the Kaiser-Meyer-Olkin index and Bartlett's test of sphericity, which indicated the adequacy of the tested sample. The items presented commonality of >0.30 and satisfactory factor loadings, resulting in a single factor. The unifactorial structure of the V-RQOL questionnaire was confirmed by CFA.

CONCLUSION

EFA and CFA indicated that a single factor should be adopted to encompass all the items of the V-RQOL questionnaire.

Quantitative Ultrasound Assessment of Hyoid Bone Displacement During Swallowing Following Thyroidectomy

The aim of this study was to investigate temporal ultrasound measurements of the hyoid bone displacement during swallowing following thyroidectomy in women and to relate these measures to age, clinical outcomes, and upper digestive airway symptoms. The sample was divided into an experimental group (EG) of 20 women who underwent thyroidectomy (mean age = 49.55 years ± 15.14) and a control group (CG) of 20 healthy women volunteers (mean age = 40.75 years ± 15.92). Both groups were submitted to ultrasound assessment to obtain four temporal measurements of hyoid bone displacement during swallowing: elevation, anteriorization, maximum displacement, and maintenance of maximum displacement. In both groups, swallowing of ten milliliters of liquid and the same volume of thickened liquid (honey) were analyzed. The images were recorded on video (30 frames/second) and analyzed according to a standardized protocol. Temporal measurements of hyoid bone elevation and maximum displacement during swallowing of thickened liquid were significantly shorter in EG (p = 0.034 and p = 0.020, respectively). There were no differences in the swallowing of liquid, and no other variable was related to the ultrasound temporal measurements investigated. This study concludes that women who undergo thyroidectomy have a shorter time of hyoid bone elevation and maximum displacement during swallowing of 10 mL of thickened liquid.

Voice and Self-Regulation: Integrating Review of the Literature

OBJECTIVE

To verify the relationship between self-regulation and voice behavior according to national and international literature.

METHODS

A literature survey was performed using the PubMed, LILACS, and SciELO databases. The search terms used were the following: self-regulation, self-control, combined with voice, voice disorders, and dysphonia, in Portuguese, English, and Spanish. Articles that addressed self-regulation and voice behavior or voice disorders published in English, Spanish, or Portuguese were included, without restriction of date. The variables preselected for the data organization were authors, database, country, impact factor, journal, type of study, sample size, sample characteristics, methods for data collection, group comparison, objective, and outcome.

RESULTS

A total of 10,176 articles were identified in the databases, of which 10 were selected based on title, read in full, and kept for data analysis. The studies were found predominantly in American journals and were published between 2013 and 2019. The United States published most articles, and the predominant methodological aspect was observational and cross-sectional.

CONCLUSION

Despite the small number of articles, the studies analyzed can show self-regulation as an important factor in vocal behavior and call attention to its performance in voice disorders.

Factorial Analysis of the Brazilian Version of the Vocal Tract Discomfort Scale in patients with dysphonia

OBJECTIVES

To investigate the psychometric properties of the Brazilian version of the Vocal Tract Discomfort Scale, known as Escala de Desconforto do Trato Vocal (EDTV), based on factor analysis, in patients with dysphonia.

METHODS

This was a retrospective documentary and cross-sectional study. The study database contained sociodemographic variables, laryngeal diagnosis, auditory-perceptual evaluation and EDTV items. All of these variables were extracted from the medical records of 310 patients seen at the Integrated Laboratory of Voice Studies. A descriptive statistical analysis, exploratory factor analysis (EFA), and confirmatory factor analysis (CFA) were performed.

RESULTS

The sample consisted of patients of both sexes with a mean age of 39.36 (SD = 15.80) years; the majority were female and were nonvoice professionals. The EFA grouped the EDTV items into four factors according to the interitem correlations. The CFA grouped the EDTV items into three factors because the last two factors found in the EFA were correlated and constituted a single factor. Thus, the CFA revealed that the EDTV was organized as follows: Factor 1, "Hybrid," comprised the items corresponding to the frequency and severity of the symptoms of burning, sore, and irritated throat; Factor 2, "Inflammatory process/tissue lesion," comprised the items related to throat itching and throat sensitivity; and Factor 3, "Muscle discomfort," comprised the items related to symptoms of tightness, dryness, and the sensation of a lump in the throat. Item responses are dichotomous (High/Low), and the result is determined by the sum of the responses, in which high frequency/severity is assigned two points and reduced frequency/severity assigned one point.

CONCLUSIONS

The CFA allows the proposal of an adjustment to the EDTV and suggests that the described changes be made to the instrument to make it a scale with three factors that behave differently but are related.

Tinnitus evaluation: relationship between pitch matching and loudness, visual analog scale and tinnitus handicap inventory

Introduction

Tinnitus is a subjective auditory symptom usually associated with a sound, even in the absence of external sound sources. Its diagnosis is complex, and some of the forms of measurement alone or in combination, include self-assessment questionnaires, such as the tinnitus handicap inventory, the visual analog scale and/or pitch and loudness matching.

Objective

To analyze the correlation among three tinnitus measurement methods: tinnitus handicap inventory, visual analog scale and pitch and loudness matching.

Methods

The study consisted of 148 patients complaining of chronic tinnitus. An otorhinolaryngological evaluation, anamnesis directed to tinnitus, audiometry (pure tone and speech), imitanciometry, tinnitus handicap inventory, visual analog scale, and pitch and loudness matching were performed. The study was registered in the Ethics Committee of the Institution with no. 0129/12.

Results

Regarding the frequency of tinnitus handicap inventory responses, a higher occurrence of the mild degree was observed. An average of 6 points was observed on the visual analog scale. The mean loudness matching in the right ear was 20 dBNS, and in the left ear was 17 dBNS. As for the type of stimulus, the most found was continuous pure tone. The frequency of the pitch sensation was 6000 Hz in the largest number of cases. Regarding the measures of tinnitus handicap inventory and the visual analogical scale, a significant correlation was observed, and as one value increases the other also increases. Pitch and loudness matching and the visual analogical scale results are also significant.

Conclusion

There was a significant correlation between the values measured by the tinnitus handicap inventory, visual analogical scale (annoyance) and loudness matching in the evaluation of tinnitus. The selection of any one of the three evaluative methods for tinnitus investigation provides different dimensions of the tinnitus and complements the others.

Cepstral measures in the assessment of severity of voice disorders

PURPOSE

To analyze whether there is an association between the presence, intensity and type of voice disorder and the cepstral measures in samples of individuals with voice complaints.

METHODS

We used 376 vowel /Ɛ/ samples from individuals of both genders that had voice complaints. An analogue-visual scale was used for the auditory-perceptual analysis of voices regarding the overall grade of dysphonia (G) and the grades of roughness (R), breathiness (B), and strain (S), including a determination of voice quality (rough, breathy or strained). Measures related to cepstral peak prominence smoothed (CPPS) and spectral decline of vocal samples were extracted.

RESULTS

There were differences in the CPPS values between the groups with or without voice disorders as well as between the different intensities and types of voice disorder. CPPS values were lower because of the presence and intensity of voice disorders. The CPPS values differentiated the following voices: rough x breathy, rough x strained, and breathy x strained. The spectral decline only differentiated breathy x strained voices. CPPS correlated positively and strongly with G and B; moderately and negatively with R, and negatively and weakly with S. The spectral decline had a moderate positive correlation with S and a weak negative correlation with B.

CONCLUSION

There is association between voice disorder, G, predominant voice quality, and CPPS. In particular, G is strongly correlated with CPPS. Spectral decline is associated only with the parameters B and S.

Group Voice Therapy Reduces Anxiety in Patients With Dysphonia

OBJECTIVE

To evaluate the impact of group therapy in patients with dysphonia, as well as to verify the correlation between vocal symptoms and levels of anxiety.

METHODS

The study was composed of 52 patients subdivided into two groups, named the Experimental Group (EG) with 28 volunteers and the Control Group (CG) with 24 volunteers. Anxiety and voice protocols were used for data collection. The State-Trait Anxiety Inventory (STAI) was used to measure trait levels of anxiety that after collection were categorized according to the variation in scores value: low anxiety (20-40 points); average anxiety (40-60 points); high anxiety (60-80 points). In addition, the Voice Symptom Scale (VoiSS) was used for voice assessment. Inferential statistical analysis from the Student's t test for paired and independent data, in order to compare the average scores of STAI trait levels and VoiSS domains of the pre- and postmoments, intra- and intergroups, EG and CG, respectively. For that purpose, the program Statistical Package for Social Sciences (SPSS) was used.

RESULTS

Half of the patients in the survey presented an average trait level of anxiety. Regarding the EG, there was a significant reduction of state anxiety when comparing the moments before and after group therapy. There was also a significant reduction in the values of the VoiSS-Total and VoiSS-Physical domains when compared to the pre- and postgroup therapy moments. It was verified the existence of a positive correlation between the levels of anxiety after group therapy and VoiSS-Total, VoiSS-Limitation, and VoiSS-Physical domains. As for the CG, there was an increase in anxiety levels as well as in all domains of the VoiSS scale when compared to the pre- and postmoments.

CONCLUSIONS

Group voice therapy was effective for a significant reduction of vocal symptoms and anxiety - common conditions in patients with dysphonia. It was possible to perceive the positive correlation between anxiety levels and vocal symptoms.

Condições de trabalho e de voz em professores de escolas públicas e privadas

RESUMO Objetivo Identificar se existe correlação entre o Índice de Triagem para Distúrbio de Voz e as condições de trabalho de professores das escolas públicas e privadas e compará-las entre os professores das duas redes de ensino. Métodos Participaram 183 professores, sendo 122 de escolas públicas e 61 de uma escola privada, que responderam ao questionário Condição de Produção Vocal do Professor, composto por 81 questões. Destas, entretanto, foram analisadas as questões referentes à identificação pessoal, funcional, condições vocais e de trabalho. Foi realizada análise estatística descritiva e inferencial. Resultados Quando analisados em relação às condições vocais, a maioria dos professores das escolas públicas relatou queixa vocal. O Índice de Triagem para Distúrbio de Voz dos professores das escolas públicas correspondeu a mais sintomas vocais do que os da escola privada. Além disso, os docentes das escolas públicas relataram piores condições de trabalho, em relação aos docentes da escola privada. Conclusão Existe uma correlação negativa entre o Índice de Triagem para Distúrbio de Voz e as condições de trabalho dos professores de escola pública e particular. Os professores das escolas públicas relataram piores condições de trabalho do que os da escola privada, bem como referiram maior ocorrência de distúrbio da voz e apresentaram maior pontuação no Índice de Triagem para Distúrbio de Voz.

Distribution and environmental assessment of trace elements contamination of water, sediments and flora from Douro River estuary, Portugal

The present study evaluated the content and distribution of several trace elements (Li, Be, Al, V, Cr, Co, Ni, Cu, Zn, Se, Mo, Ag, Cd, Sb, Ba, Tl, Pb, and U) in the Douro River estuary. For that, three matrices were collected (water, sediments and native local flora) to assess the extent of contamination by these elements in this estuarine ecosystem. Results showed their occurrence in estuarine water and sediments, but significant differences were recorded on the concentration levels and pattern of distribution among both matrices and sampling points. Generally, the levels of trace elements were higher in the sediments than in the respective estuarine water. Nonetheless, no correlation among trace elements was determined between water and sediments, except for Cd. Al was the trace element found at highest concentration at both sediments and water followed by Zn. Pollution indices such as geo-accumulation (I_geo), enrichment factor (EF) and contamination factor (CF) were determined to understand the levels and sources of trace elements pollution. I_geo showed strong contamination by anthropogenic activities for Li, Al, V, Cr, Ni, Cu, Zn, Ba and Pb at all sampling points while EF and CF demonstrated severe enrichment and contamination by Se, Sb and Pb. Levels of trace elements were compared to acceptable values for aquatic organisms and Sediment Quality Guidelines. The concentration of some trace elements, namely Al, Pb and Cu, were higher than those considered acceptable, with potential negative impact on local living organisms. Nevertheless, permissible values for all trace elements are still not available, demonstrating that further studies are needed in order to have a complete assessment of environmental risk. Furthermore, the occurrence and possible accumulation of trace elements by local plant species and macroalgae were investigated as well as their potential use as bioindicators of local pollution and for phytoremediation purposes.

Performance of the phonatory deviation diagram in the evaluation of rough and breathy synthesized voices

Introduction

Voice disorders alter the sound signal in several ways, combining several types of vocal emission disturbances and noise. The phonatory deviation diagram is a two-dimensional chart that allows the evaluation of the vocal signal based on the combination of periodicity (jitter, shimmer, and correlation coefficient) and noise (Glottal to Noise Excitation) measurements. The use of synthesized signals, where one has a greater control and knowledge of the production conditions, may allow a better understanding of the physiological and acoustic mechanisms underlying the vocal emission and its main perceptual-auditory correlates regarding the intensity of the deviation and types of vocal quality.

Objective

To analyze the performance of the phonatory deviation diagram in the discrimination of the presence and degree of roughness and breathiness in synthesized voices.

Methods

871 synthesized vocal signals were used corresponding to the vowel /ɛ/. The perceptual-auditory analysis of the degree of roughness and breathiness of the synthesized signals was performed using visual analogue scale. Subsequently, the signals were categorized regarding the presence/absence of these parameters based on the visual analogue scale cutoff values. Acoustic analysis was performed by assessing the distribution of vocal signals according to the phonatory deviation diagram area, quadrant, shape, and density. The equality of proportions and the chi-square tests were performed to compare the variables.

Results

Rough and breathy vocal signals were located predominantly outside the normal range and in the lower right quadrant of the phonatory deviation diagram. Voices with higher degrees of roughness and breathiness were located outside the area of normality in the lower right quadrant and had concentrated density.

Conclusion

The normality area and the phonatory deviation diagram quadrant can discriminate healthy voices from rough and breathy ones. Voices with higher degrees of roughness and breathiness are proportionally located outside the area of normality, in the lower right quadrant and with concentrated density.

Performance of Phonatory Deviation Diagrams in Synthesized Voice Analysis

OBJECTIVE

To analyze the performance of a phonatory deviation diagram (PDD) in discriminating the presence and severity of voice deviation and the predominant voice quality of synthesized voices.

METHOD

A speech-language pathologist performed the auditory-perceptual analysis of the synthesized voice (n = 871). The PDD distribution of voice signals was analyzed according to area, quadrant, shape, and density.

RESULTS

Differences in signal distribution regarding the PDD area and quadrant were detected when differentiating the signals with and without voice deviation and with different predominant voice quality. Differences in signal distribution were found in all PDD parameters as a function of the severity of voice disorder.

CONCLUSION

The PDD area and quadrant can differentiate normal voices from deviant synthesized voices. There are differences in signal distribution in PDD area and quadrant as a function of the severity of voice disorder and the predominant voice quality. However, the PDD area and quadrant do not differentiate the signals as a function of severity of voice disorder and differentiated only the breathy and rough voices from the normal and strained voices. PDD density is able to differentiate only signals with moderate and severe deviation. PDD shape shows differences between signals with different severities of voice deviation.

Adaptação cultural do Questionário Reduzido de Autorregulação: sugestões de aplicação para área de voz

RESUMO Objetivo Apresentar a versão traduzida e adaptada linguística e culturalmente para o português brasileiro do Short Self-Regulation Questionnaire (SSRQ) e verificar sua aplicabilidade para pacientes com disfonia. Método O SSRQ é um instrumento para avaliar a capacidade de autorregular o comportamento; possui 31 itens e gera três escores: o índice total da capacidade de autorregulação individual e os escores estabelecimento de objetivos e controle de impulsos. Cada item deve ser graduado por meio de uma escala de Likert de 5 pontos; o escore total varia de 29 a 145 pontos. O instrumento original foi traduzido e adaptado culturalmente para o português brasileiro por duas fonoaudiólogas fluentes em inglês, que combinaram suas traduções e realizaram ajustes linguísticos para compor uma versão única final. Essa versão foi retrotraduzida para o inglês por uma terceira fonoaudióloga com experiência em estudos de validação e sem conhecimento do instrumento original. A tradução e a retrotradução foram comparadas entre si e ao instrumento original em inglês por cinco fonoaudiólogas que chegaram a um consenso para mudanças adicionais. Dessa forma, produziu-se a versão final, chamada Questionário Reduzido de Autorregulação (QRAR), que foi aplicado em 45 indivíduos com e sem disfonia, escolhidos de forma aleatória em uma clínica escola. Resultados Nenhum item teve de ser eliminado, já que os respondentes não encontraram dificuldades em marcar suas respostas. Conclusão O Questionário Reduzido de Autorregulação (QRAR) foi traduzido e adaptado cultural e linguisticamente para o português brasileiro e pode ser aplicado, com êxito, em indivíduos com problemas de voz.

Sintomas vocais e causas autorreferidas em professores

RESUMO Objetivo: associar os sintomas vocais e suas possíveis causas autorreferidas por professores de escolas públicas do município de João Pessoa-PB. Métodos: 121 professores de quatro escolas de ensino fundamental e médio da rede pública responderam ao questionário de autopercepção Condição de Produção Vocal do Professor. Neste questionário foram analisados dados pessoais (idade, sexo, estado civil, escolaridade); situação funcional (carga horária e tempo de magistério) e aspectos vocais, principalmente relacionados aos sintomas e causas. A análise dos dados foi realizada por meio do teste de associação Qui-Quadrado. Resultados: os sintomas vocais mais referidos foram rouquidão, falha na voz, voz grossa, voz fraca e falta de ar. As causas mais citadas foram uso intensivo da voz, estresse, alergia e exposição ao barulho. Foi possível constatar que, na opinião dos professores, a rouquidão está associada ao uso intensivo da voz e à infecção respiratória; a perda da voz ao uso intensivo da voz; a falta de ar à alergia; a falha na voz ao uso intensivo da voz; e a voz fraca está associada à infecção respiratória, à exposição ao barulho e ao uso intensivo da voz. Conclusão: os dados indicam, portanto, que os professores participantes desta pesquisa percebem que tanto os fatores externos (exposição ao barulho) interferem na produção vocal, assim como os relacionados à saúde e a voz (alergia, infecções respiratórias e o uso intensivo da voz).

Determination of memantine in human plasma by liquid chromatography–electrospray tandem mass spectrometry: Application to a bioequivalence study

A simple, sensitive and specific liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the quantification of memantine (I) in human plasma is presented. Sample preparation consisted of the addition of amantadine (II) as internal standard (IS), liquid-liquid extraction in basic conditions using a mixture of diethyl ether-chloroform (7:3, v/v) as extracting solvent, followed by centrifugation, solvent evaporation and sample reconstitution in methanol. Both I and II (internal standard) were analyzed using a C18 column and a mobile phase composed of methanol-water-formic acid (80:20:0.1, v/v/v). Eluted compounds were monitored using positive mode electrospray (ES) tandem mass spectrometry. The analyses were carried out by selected reaction monitoring (SRM) using the parent to daughter combinations of m/z 180>163 (memantine) and m/z 152>135 (amantadine). The peak areas from the analyte and IS were used for quantification of I. The achieved limit of quantification (LOQ) was 0.1 ng/mL; the assay exhibited a linear dynamic range of 0.1-50.0 ng/mL with a determination coefficient (r2) of at least 0.98. Validation results on linearity, specificity, accuracy, precision and stability, as well as on application to the analysis of samples taken up to 320 h after oral administration of 20mg (two 10mg capsules) of I in healthy volunteers demonstrated the applicability to bioequivalence studies.

Developmental lead exposure in rats: is a behavioral sequel extended at F2 generation?

Lead toxicity was studied in rats exposed from conception until weaning and assessed by monitoring offspring behavior in both the open field and elevated plus maze and by determining tissue lead in an assessment schedule extended to first (F1) and second (F2) generations. Dams utilized for the F1 generation were submitted to 750 ppm of lead (acetate) in drinking water during pregnancy and lactation. For F1 pups, behavioral alterations were not detected in the elevated plus maze, while in the open field, spontaneous locomotor activity as well as time of both grooming and rearing increased, while freezing time decreased in 30- and 90-day-old rats. Lead content was higher in tissues of 1- and 30-day-old pups. However, in 90-day-old rats, lead was detected only in the femur. F2 generation was lead-free but still presented alterations in both locomotor activity and grooming in 30- and 90-day-old pups. It appears that developmental lead exposure may cause behavioral effects during the developmental stage of the F1 generation, which remains throughout the animal's adult life as a sequel, regardless of lead accumulation, and is extended to the F2 generation of rats.

Minimally invasive aortic valve replacement via hemi-sternotomy: a preliminary report

OBJECTIVE

Aortic valve replacement has been approached by standard sternotomy. We described a technique of aortic valve replacement where the aortic valve is exposed through a hemi-sternotomy. Good exposure is obtained for aortic valve surgery with standard aortic and right atrial cannulation to establish cardiopulmonary bypass (CPB).

METHODS

From October 1996 to April 1997, 19 consecutive aortic valve replacements (AVR) via hemi-sternotomy were performed by one surgeon. The results were collected and analysed prospectively. Results are expressed as mean +/- standard deviation. Nineteen patients (13 male, 6 female) had AVR with this approach. Two cases were redo AVR. The mean age was 58+/-15 years. The New York Heart Association (NYHA) class was 2.8+/-0.7.

RESULTS

Aortic cross clamp time was 54+/-13 min. One of six patients requiring defibrillation after reperfusion needed conversion to full sternotomy. Four patients were extubated at the conclusion of surgery. One patient died 4 h postoperatively from low cardiac output. All patients had normal valvular function demonstrated on postoperative transoesophageal echocardiography. There were no neurological events.

CONCLUSIONS

Minimally invasive aortic valve replacement can be safely performed via hemi-sternotomy with standard equipment. Less surgical trauma to the sternum has the potential benefit of less pain and shorter intensive care and hospital stay.

Haemodynamics and left ventricular mass regression: a comparison of the stentless, stented and mechanical aortic valve replacement

OBJECTIVE

Our objective was to compare the degree of change in hemodynamics and left ventricular mass (LVM) regression after aortic valve replacement (AVR) with stentless, stented and mechanical valves.

METHODS

Patients greater than 59 years of age had AVR for aortic stenosis with the stentless xenograft (Cryolife-O'Brien, CLOB), stented xenograft (Carpentier-Edwards, C-E) or mechanical valve (ATS). One-hundred and forty-two patients received stentless, 40 stented, and 69 mechanical valves (mean age 74 +/- 6 vs. 72 +/- 7 and 67 +/- 6 years, respectively). Serial echocardiography was performed.

RESULTS

The left ventricular outflow tract diameter was similar pre-operatively in the stentless versus the stented versus the mechanical groups (2.2 +/- 0.4 vs. 2.3 +/- 0.2 vs. 2.2 +/- 0.3 cm; P, n.s). The effective orifice area was larger immediately post-operatively in the stentless versus the stented or the mechanical group (2.4 +/- 0.4 vs. 2.0 +/- 0.6 vs. 2.0 +/- 0.7 cm2, P = 0.0001 for both comparisons). The peak aortic gradient at 6 months was significantly less in the stentless versus the stented and mechanical groups (15 +/- 7 vs. 25 +/- 9 vs. 22 +/- 9 mmHg, P < 0.0001). LVM regressed over 6 months in all subgroups: stentless 272 +/- 64 g vs. 220 +/- 72 g, P = 0.0001, stented 257 +/- 58 vs. 230 +/- 74 g, P = 0.02, and mechanical 267 +/- 95 vs. 204 +/- 54 g, P = 0.003. The reduction in LVM was greater in the stentless versus the stented (P = 0.05) but similar to the mechanical group.

CONCLUSIONS

AVR with the stentless xenograft results in superior hemodynamics compared to the stented and mechanical valve replacements. AVR in all three groups leads to a significant regression of left ventricular hypertrophy within 6 months. However the reduction in LVM is greater in subjects with stentless and mechanical valves, which may have prognostic significance.

Transesophageal echocardiography in an operation for pulmonary arteriovenous malformation

Transesophageal echocardiography has been described as a useful tool in the diagnosis of pulmonary arteriovenous malformations. We describe a case in which intraoperative transesophageal echocardiography was used to aid localization and ensure complete surgical ligation.

Minimally invasive aortic valve replacement via partial sternotomy

A technique for aortic valve replacement is described in which the aortic valve is exposed through a partial sternotomy without transecting ("T'ing" off) the sternum. Aortic valve replacement can be performed with standard aortic and right atrial cannulation.

Pharmacological properties of a new kinin-potentiating peptide generated from human serum proteins

A kinin-potentiating peptide (KPP) generated from human plasma proteins on trypsin incubation was partially purified by ultrafiltration and ion-exchange chromatography and was characterized through some of its pharmacological properties. KPP itself was devoid of any action but it potentiated the guinea-pig ileum contractions elicited by several kinins, including an analog resistant to angiotensin-converting enzyme (ACE). In contrast, contractions induced by angiotensin II, histamine, acetylcholine, barium chloride and substance P were not potentiated. Not only did KPP have high specificity towards kinins, but its action started immediately and induced kinin potentiation in a dose-dependent and reversible manner. Furthermore KPP potentiated the bradykinin contracting effects on the rat uterus, a preparation with very poor ACE activity, and on guinea-pig ileum previously incubated with 1.10-phenanthroline, a metal chelator able to inhibit ACE and kininase I activities and with phosphoramidon, a specific inhibitor of neutral endopeptidase (NEP). The results suggest that the potentiating effect of KPP is due to a mechanism different from the inhibition of kinin metabolism by ACE, NEP and kininase I.