Effectiveness of voice therapy in reflux-related voice disorders

Gastroesophageal reflux (GER) with laryngopharyngeal reflux plays a significant role in voice disorders. A significant proportion of patients attending ear, nose, and throat clinics with voice disorders may have gastresophageal reflux disease (GERD). There is no controlled study of the effect of voice therapy on GERD. We assessed the effect of voice therapy in patients with dysphonia and GERD. Thirty‐two patients with dysphonia and GERD underwent indirect laryngoscopy and voice analysis. Esophageal and laryngeal symptoms were assessed using the reflux symptom index (RSI). At endoscopy, esophagitis was graded according to Los Angeles classification. Patients were randomized to receive either voice therapy and omeprazole (20 mg bid) (n = 16, mean [SD] age 36.1 [9.6] y; 5 men; Gp A) or omeprazole alone (n = 16, age 31.8 [11.7] y; 9 men; Gp B). During voice analysis, jitter, shimmer, harmonic‐to‐noise ratio (HNR) and normalized noise energy (NNE) were assessed using the Dr. Speech software (version 4 1998; Tigers DRS, Inc). Hoarseness and breathiness of voice were assessed using a perceptual rating scale of 0–3. Parameters were reassessed after 6 weeks, and analyzed using parametric or nonparametric tests as applicable. In Group A, 9 patients had Grade A, 3 had Grade B, and 1 had Grade C esophagitis; 3 had normal study. In Group B, 8 patients had Grade A, 2 had Grade B esophagitis, and 6 had normal study. Baseline findings: median RSI scores were comparable (Group A 20.0 [range 14–27], Group B 19.0 [15–24]). Median rating was 2.0 for hoarseness and breathiness for both groups. Values in Groups A and B for jitter 0.5 (0.6) versus 0.5 (0.8), shimmer 3.1 (2.5) versus 2.8 (2.0), HNR 23.0 (5.6) versus 23.1 (4.2), and NNE ?7.3 (3.2) versus ?7.2 (3.4) were similar. Post‐therapy values for Groups A and B: RSI scores were 9.0 (5–13; P < 0.01 as compared with baseline) and 13.0 (10–17; P < 0.01), respectively. Ratings for hoarseness and breathiness were 0.5 (P < 0.01) and 1.0 (P < 0.01) and 2.0. Values for jitter were 0.2 (0.0; P = 0.02) versus 0.4 (0.7), shimmer 1.3 (0.7; P < 0.01) versus 2.3 (1.2), HNR 26.7 (2.3; P < 0.01) versus 23.7 (3.2), and NNE ?12.3 (3.0, P < 0.01) versus ?9.2 (3.4; P < 0.01). Improvement in the voice therapy group was significantly better than in patients who received omeprazole alone. Dysphonia is a significant problem in GER. Treatment for GER improves dysphonia, but in addition, voice therapy enhances the improvement.     

An Investigation of Factors Predictive of Continued Self‐Injurious Behaviour in an Intellectual Disability Service

Background Self‐injurious behaviour (SIB) is among the most serious problems faced by intellectual disability services. It is very difficult to treat and can become a chronic problem. Method Information on a number of variables was collected through a survey of service‐users identified as displaying SIBs. Clinical opinion and a literature review guided the selection of potential predictors of continued SIB. Univariate statistical analyses were used to investigate associations between continued SIB and each of the variables identified. Variables shown to have a significant association with continued SIB were subjected to a multivariate analysis to isolate those variables that still predicted continued SIB once the influence of the others had been accounted for. Results Two factors, self‐biting and verbal ability, were found to independently predict continued SIB. Conclusion The results have implications for intellectual disability services, in terms of the importance of multidisciplinary team working, training and guidelines for problem management.     

Parents' and therapists' opinion on features that make a chair useful for a young disabled child

Children who fail to develop postural skills within a normal time scale are prescribed special seating to position them appropriately. For children to derive benefit from such seating, they must use it at home as well as in therapy sessions. A study was undertaken to explore the opinions of therapists and parents concerning the effectiveness and acceptability of a sample of special seating available on the UK market for young children. Each of the ten chairs selected to represent the range of possible styles and features was tested by 12 or 16 children in their homes (total sample of 40) for a week each, and four therapy centres for a fortnight each. Results obtained from these two populations were compared to determine whether chair features considered useful differed when used in a therapy centre or family home. Parents' rating for overall usefulness was affected by their perception of the child's comfort, as well as the child's posture, the level of support the chair offered, and other factors. Therapists' response, in contrast, seemed to be mainly influenced by the quality of posture children achieved in the chair.     

The role of the duodenal microflora as a determinant of persistent diarrhoea

It has been suggested that proliferation of enterobacteriaceae and/or anaerobes in the duodenum of some children with acute diarrhoea determines whether the episode becomes persistent. A review of published studies and the comparison of cultures of duodenal aspirates from Peruvian children with acute and persistent diarrhoea and diarrhoea-free children did not support this hypothesis. Although many children had enterobacteriaceae and/or anaerobes cultured there was no correlation with clinical and nutritional outcome. Age, nutritional status, the environment and the aetiology of the episode were determinants of the duodenal microflora independent of diarrhoea. Culture of the duodenal aspirates did not increase the yield of enteropathogens which were isolated more frequently from stools than from the duodenum. Despite the presence of a single strain or serotype of enterobacteriaceae suggesting that these bacteria were colonizing the duodenum, we were unable to demonstrate any adherence mechanisms in the majority of them. Two often bacteria with no other evidence of virulence caused diarrhoea in the RITARD rabbit model.     

A randomised dose escalation study of subcutaneous interleukin 2 with and without levamisole in patients with metastatic renal cell carcinoma or malignant melanoma.

We have examined the efficacy, toxicity and host immunological response of two different dose schedules of interleukin 2 (IL-2) given subcutaneously, daily for 3 months in patients with renal cell carcinoma (RCC) or metastatic melanoma (MM). We also examined the effect of adding the immune modulator levamisole to the two different schedules of IL-2. Thirty-nine patients were entered into two sequential phase I/II studies. Eighteen patients entered study 1 and were randomised to receive IL-2, 3 x 10(6) IU m-2 day-1, subcutaneously for 3 months with or without levamisole 50 mg t.d.s. p.o. on days 1-3 on alternate weeks. Twenty-one patients entered study 2 and were randomised to receive 5.4 x 10(6) IU m-2 day-1 subcutaneously for 3 months with or without levamisole 50 mg t.d.s. p.o. on days 1-3 on alternate weeks. Blood was taken for peripheral blood lymphocyte (PBL) phenotype analysis, and measurement of IL-2, soluble IL-2 receptor (sIL-2R) and neopterin concentration. Two patients with metastatic melanoma, one in each study, responded (11.8%); both received IL-2 alone. Observations of immunological parameters showed that treatment with subcutaneous IL-2 resulted in a significant rise in the percentage of PBLs bearing CD25, CD3/HLA-DR, CD56 and levels of IL-2 receptor and neopterin. The total white blood cell count (WBC) and total lymphocyte count rose significantly on day 18 compared with pretreatment levels. The addition of levamisole to either IL-2 schedule resulted in no significant changes in any immunological parameters. This study illustrates that prolonged subcutaneous IL-2 can be given safely in the outpatient setting. There was no evidence that levamisole acts as an immunomodulator in this study.     

Refractive lensectomy for hyperopia

PURPOSE: The purpose of this study was to evaluate refractive lensectomy as a surgical procedure for the treatment of hyperopia. DESIGN: A retrospective noncomparative case series. PARTICIPANTS: Twenty-nine patients were included in the study. Fifty eyes underwent extraction of the crystalline lens and intraocular lens implantation. METHODS: Operations were performed by the same surgeon with the patient under general anesthetic. All lenses were removed by phacoemulsification with insertion of lens implants singly or as piggyback lenses. The Holladay2 formula was used to calculate lens powers. Results are compared with other methods of treating hyperopia. MAIN OUTCOME MEASURES: The main parameters assessed were safety, efficacy, predictability, stability, and complications. RESULTS: Eyes were divided into group A (n = 26), with an average preoperative spherical equivalent (SE) of +2.26 +/- 0.94, and group B (n = 24), with an average preoperative SE of +6.32 +/- 1.32. In group A, after refractive lensectomy, 80.7% had no change in best-corrected visual acuity (BCVA) or gained a line, whereas 11.5% lost one line; 88.5% had an uncorrected visual acuity (UCVA) of 20/40 or better, and 88.5% were within 1 diopter (D) of intended postoperative SE. In group B, 70.9% of eyes had no change or gained a line in BCVA, whereas 29.2% lost a line of BCVA; 62.5% had UCVA of 20/40 or better postoperatively, and 58.3% were within 1 D of the intended SE. In one eye the posterior capsule was breached intraoperatively. One eye had a symptomatic episode of cystoid macula edema that settled spontaneously. To date, seven eyes have required secondary refractive procedures, and three eyes have required yttrium-aluminum-garnet capsulotomy. CONCLUSIONS: In the presbyopic age group refractive lensectomy may be a realistic alternative to photorefractive keratectomy or laser in situ keratomileusis, with certain potential advantages.     

Role of endocervical curettage in colposcopy

Two-thousand three-hundred and four patients with abnormal cervical cytology were evaluated by colposcopy, cervical biopsy, and endocervical curettage. The endocervical curettage was more accurate than the cervical biopsy in 1.2% of patients with satisfactory colposcopic examinations, 15.7% of patients with unsatisfactory examinations, and 30.5% of patients with no lesions observed. The endocervical curettage contained neoplastic epithelium in all 15 of the patients with invasive cancer and in seven patients it was the only diagnostic parameter that indicated invasion. The information from the endocervical curettage, when correlated with the cervical cytology, colposcopic findings, and cervical biopsy, eliminated the need to do a diagnostic conization in 76% of patients with unsatisfactory examinations and 79% of patients with no lesion identified. It is recommended that the endocervical curettage be a part of every colposcopic examination.