The Monosyllable Imitation Test for Toddlers: influence of stimulus characteristics on imitation, compliance and diagnostic accuracy

BACKGROUND

Although verbal imitation can provide a valuable window into the developing language abilities of toddlers, some toddlers find verbal imitation challenging and will not comply with tests that involve elicited verbal imitation. The characteristics of stimuli that are offered to toddlers for imitation may influence how easy or hard it is for them to imitate. This study presents a new test of elicited imitation-the Monosyllable Imitation Test for Toddlers (MITT)-comprising stimuli of varying characteristics and test features designed to optimize compliance.

AIMS

To investigate whether the stimulus characteristics of neighbourhood density and consonant complexity have independent and/or convergent influences on imitation accuracy; and to examine non-compliance rates and diagnostic accuracy of the MITT and an existing test, the Test of Early Nonword Repetition (TENR) (Stokes and Klee 2009a).

METHODS & PROCEDURES

Fifty-two toddlers (25-35 months) participated. Twenty-six had typically developing language (TDs) and 26 were defined as late talkers (LTs) based on parent-reported vocabulary. The MITT stimuli were created by manipulating both neighbourhood density (dense or sparse) and consonant complexity (early- or late-developing initial consonant). The MITT was designed to maximize compliance by: (1) using eight monosyllabic stimuli, (2) providing three exposures to stimuli and (3) embedding imitation in a motivating context: a computer animation with reasons for imitation.

OUTCOMES & RESULTS

Stimulus characteristics influenced imitation accuracy in TDs and LTs. For TDs, neighbourhood density had an independent influence, whereas for LTs consonant complexity had an independent influence. These characteristics also had convergent influences. For TDs, stimuli were all equally easy to imitate, except those that were both sparse and contained a late-developing consonant which were harder to imitate. For LTs, stimuli that were both dense and contained an early-developing consonant were easier to imitate than any other stimuli. Two LTs and no TDs were non-compliant with the MITT. With the TENR, five LTs and two TDs were non-compliant. The MITT and TENR yielded similar levels of diagnostic sensitivity, but the TENR offered higher specificity rates. Subsets of stimuli from the MITT and the TENR also showed diagnostic promise when explored post-hoc.

CONCLUSIONS & IMPLICATIONS

Stimulus characteristics converge to influence imitation accuracy in both TD and LT toddlers and therefore should be considered when designing stimuli. The MITT resulted in better compliance than the TENR, but the TENR offered higher specificity. Insights about late talking, elicited imitation and speech production capabilities are discussed.

Involvement of parents in intervention for childhood speech sound disorders: a review of the evidence

BACKGROUND

Internationally, speech and language therapists (SLTs) are involving parents and providing home tasks in intervention for phonology-based speech sound disorder (SSD). To ensure that SLTs' involvement of parents is guided by empirical research, a review of peer-reviewed published evidence is needed.

AIMS

To provide SLTs and researchers with a comprehensive appraisal and analysis of peer-reviewed published intervention research reporting parent involvement and the provision of home tasks in intervention studies for children with phonology-based SSD.

METHODS & PROCEDURES

A systematic search and review was conducted. Academic databases were searched for peer-reviewed research papers published between 1979 and 2013 reporting on phonological intervention for SSD. Of the 176 papers that met the criteria, 61 were identified that reported on the involvement of parents and/or home tasks within the intervention. These papers were analysed using a quality appraisal tool. Details regarding the involvement of parents and home tasks were extracted and analysed to provide a summary of these practices within the evidence base.

MAIN CONTRIBUTION

Parents have been involved in intervention research for phonology-based SSD. However, most of the peer-reviewed published papers reporting this research have provided limited details regarding what this involved. This paucity of information presents challenges for SLTs wishing to integrate external evidence into their clinical services and clinical decision-making. It also raises issues regarding treatment fidelity for researchers wishing to replicate published intervention research.

CONCLUSIONS & IMPLICATIONS

The range of tasks in which parents were involved, and the limited details reported in the literature, present challenges for SLTs wanting to involve parents in intervention. Further high-quality research reporting more detail regarding the involvement of parents and home tasks in intervention for SSD is needed.

Correlates of psychological care strategies for people with diabetes in the second Diabetes Attitudes, Wishes and Needs (DAWN2(™) ) study

AIMS

To assess the ways in which healthcare professionals address psychological problems of adults with diabetes in the second Diabetes Attitudes, Wishes and Needs (DAWN2(™) ) study.

METHODS

Approximately 120 primary care physicians, 80 diabetes specialists and 80 nurses and dietitians providing diabetes care participated in each of 17 countries (N=4785). Multiple regression analyses were used to evaluate independent statistically significant associations of respondent attributes concerning psychological care strategies, including assessment of diabetes impact on the patient's life, assessment of depression, provision of psychological assessment and support, and coordination with mental health professionals.

RESULTS

Psychological care strategies were positively associated with each other but differed by healthcare practice site and discipline; nurses and dietitians were less likely to assess depression than other healthcare professionals, while primary care physicians were less likely to coordinate with mental health specialists or ask patients how diabetes affects their lives. Psychological care was positively associated with healthcare professionals' beliefs that patients need help dealing with emotional issues and that clinical success depends on doing so, and also with level of psychological care training, multidisciplinary team membership and availability of resources for psychological care. There were significant between-country variations in psychological care strategies, before and after adjustment for individual-level factors, and significant country-by-covariate interactions for almost all individual-level factors investigated.

CONCLUSIONS

Improvements in training and resources, recognition and assessment of psychological problems, and increased belief in the efficacy of psychological support may enhance healthcare professionals' efforts to address psychological problems in adults with diabetes.

Evaluating the pragmatic language skills of children with ADHD and typically developing playmates following a pilot parent-delivered play-based intervention

BACKGROUND/AIM

Children with attention deficit hyperactivity disorder (ADHD) often present with pragmatic language deficits and difficulties with peer-peer friendships. Parents and typically developing peers (TDPs) may be able to assist via parent and peer-mediated intervention approaches when adequately supported by trained adult facilitators. This study investigated whether a parent-delivered play-based intervention supported by occupational therapists and speech language pathologists was feasible and improved the pragmatic language skills of children with ADHD and their TDPs.

METHODS

Nine children with ADHD paired with nine TDPs (mean age = 8.2 years) participated. The seven-week intervention was delivered by parents of children with ADHD at their home and consisted of weekly assigned home-based modules, supported play-dates between the pairs of children and supplemented by three clinic visits. Parent adherence to intervention activity was monitored on a weekly basis. Blinded ratings of observed peer-peer play interactions were used to detect changes in pragmatic language from pre-post intervention and one month follow-up using the Pragmatic Observation Measure (POM).

RESULTS

All parents reported completing the seven weekly home-based modules and attended all clinic visits. Significant improvements in observed pragmatic language skills were found from pre-follow-up for both the ADHD and TDP children and pre-post for the ADHD children.

CONCLUSION

The preliminary findings suggest that using parents to facilitate their child's pragmatic language skills was a feasible intervention approach with parents acting as agents of change to improve the pragmatic language of their children. This exploratory study identifies the need for further large-scale research to address the pragmatic language skills of children with ADHD using parent-delivery in a play-based, peer-peer context.

The role of elicited verbal imitation in toddlers' word learning

This study is about the role of elicited verbal imitation in toddler word learning. Forty-eight toddlers were taught eight nonwords linked to referents. During training, they were asked to imitate the nonwords. Naming of the referents was tested at three intervals (one minute later [uncued], five minutes, and 1-7 days later [cued]) and recognition at the last two intervals. Receptive vocabulary, nonword repetition, and expressive phonology were assessed. The accuracy of elicited imitation during training predicted naming at one and five minutes, but not 1-7 days later. Neither nonword repetition nor expressive phonology was associated with naming over time but extant vocabulary predicted performance at all time intervals. We hypothesize that elicited imitation facilitates word learning in its earliest stages by supporting encoding of the word form into memory and allowing practice of the articulatory-phonological plan. At later stages, vocabulary facilitates integration of the word form into the lexical network.

Factors influencing speech and language outcomes of children with early identified severe/profound hearing loss: Clinician-identified facilitators and barriers

PURPOSE

Early identification of severe/profound childhood hearing loss (HL) gives these children access to hearing devices and early intervention to facilitate improved speech and language outcomes. Predicting which infants will go on to achieve such outcomes remains difficult. This study describes clinician identified malleable and non-malleable factors that may influence speech and language outcomes for children with severe/profound HL.

METHOD

Semi-structured interviews were conducted with six experienced auditory verbal clinicians. A collective case study design was implemented. The interviews were transcribed and coded into themes using constant comparative analysis.

RESULT

Clinicians identified that, for children with severe/profound HL, early identification, early amplification and commencing auditory-verbal intervention under 6 months of age may facilitate child progress. Possible barriers were living in rural/remote areas, the clinicians' lack of experience and confidence in providing intervention for infants under age 6-months and belonging to a family with a culturally and linguistically diverse (CALD) background.

CONCLUSION

The results indicate that multiple factors need to be considered by clinicians working with children with HL and their families to determine how each child functions within their own environment and personal contexts, consistent with the International Classification of Functioning, Disability and Health (ICF) framework. Such an approach is likely to empower clinicians to carefully balance potential barriers to, and facilitators of, optimal speech and language outcomes for all children with HL.

Reliability and validity of the Pragmatics Observational Measure (POM): a new observational measure of pragmatic language for children

There is a need for a reliable and valid assessment of childhood pragmatic language skills during peer-peer interactions. This study aimed to evaluate the psychometric properties of a newly developed pragmatic assessment, the Pragmatic Observational Measure (POM). The psychometric properties of the POM were investigated from observational data of two studies - study 1 involved 342 children aged 5-11 years (108 children with ADHD; 108 typically developing playmates; 126 children in the control group), and study 2 involved 9 children with ADHD who attended a 7-week play-based intervention. The psychometric properties of the POM were determined based on the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) taxonomy of psychometric properties and definitions for health-related outcomes; the Pragmatic Protocol was used as the reference tool against which the POM was evaluated. The POM demonstrated sound psychometric properties in all the reliability, validity and interpretability criteria against which it was assessed. The findings showed that the POM is a reliable and valid measure of pragmatic language skills of children with ADHD between the age of 5 and 11 years and has clinical utility in identifying children with pragmatic language difficulty.

Incidence, worry and discussion about dosing irregularities and self-treated hypoglycaemia amongst HCPs and patients with type 2 diabetes: results from the UK cohort of the Global Attitudes of Patient and Physicians (GAPP2) survey

AIMS

The Global Attitude of Patients and Physicians 2 (GAPP2) survey sought to address gaps in understanding about real-world basal insulin-taking behaviour and self-treated hypoglycaemia in patients with type 2 diabetes mellitus.

MATERIALS AND METHODS

The Global Attitude of Patients and Physicians 2 was an international, online, cross-sectional study of patients aged at least 40 years with type 2 diabetes taking analogue insulins, and healthcare professionals (HCPs). Patients were recruited from general consumer online research panels, comprising a representative sample of the population to minimise bias. HCPs were recruited from online specialist research panels. The results of the UK cohort are presented here.

RESULTS

The UK cohort constituted 12% of the total GAPP2 population. In this cohort, 15-25% of patients reported that they had reduced, missed or mistimed at least one dose of insulin in the previous month. On the last occasion that patients had reduced a dose, 82% had done so intentionally - most frequently because of concerns about hypoglycaemia. HCP estimates of the numbers of patients with dosing irregularities were nearly fourfold higher than patient reports. More than one-third of HCPs believe their patients under-report the frequency of self-treated hypoglycaemia. Nevertheless, a proportion did not regularly discuss these concerns with their patients.

CONCLUSIONS

Healthcare professionals are in the best position to support patients in making appropriate insulin dose adjustments to help regularise blood glucose levels and reduce treatment-induced hypoglycaemic events. This can be achieved by initiating frequent discussions with all patients and providing education and training when appropriate.

An initial reliability and validity study of the Interaction, Communication, and Literacy Skills Audit

Early childhood educators (ECEs) have an important role in promoting positive outcomes for children's language and literacy development. This paper reports the development of a new tool, The Interaction Communication and Literacy (ICL) Skills Audit, and pilots its reliability and validity. Intra- and inter-rater reliability was examined by three speech-language pathologists (SLPs). Five skill areas relating to ECE language and literacy practice were rated. The face and content validity of the ICL Skills Audit was examined by expert SLPs (n = 8) and expert ECEs (n = 4) via questionnaire. The overall intra-rater reliability for the ICL Skills Audit was excellent with percentage close agreement (PCA) of 91-94. Inter-rater agreement was PCA 68-80. Expert SLPs and ECEs agreed that the content was comprehensive and practical. Based on this preliminary study, the ICL Skills Audit appears to be a promising tool that can be used by SLPs and ECEs in collaboration to measure the skills of ECEs in the areas of language and literacy support. Future psychometric and outcome research on the revised ICL Skills Audit is warranted.

Typical consonant cluster acquisition in auditory-verbal children with early-identified severe/profound hearing loss

Early-identified severe/profound hearing loss (HL) following universal newborn hearing screening (UNHS) has been associated with improved speech and language outcomes. However, speech outcome reports have typically been based on broad measures of speech intelligibility and/or singleton consonant accuracy, with little known about production of consonant clusters. Using a prospective design, the range and accuracy of consonant clusters produced by a homogenous cohort of 12 children early-identified with severe/profound HL aged 3- and 4-years were examined. All children demonstrated bilateral aided thresholds within a range of 15-25 dB HL across all frequencies, were optimally amplified with cochlear implants (11/12) or hearing aids (1/12), and attended auditory-verbal (AV) early intervention. Standardized speech and language assessments were administered. Consonant clusters were strategically sampled in single-word and conversational speech contexts. All standard scores for speech, receptive, and expressive language were within normal limits. All children produced consonant clusters commensurate with expectations for typically-developing hearing peers at 3- and 4- years-of-age. Children's production of phonetically complex morphophonemes (final consonant clusters marking grammatical morphemes) was also in keeping with developmental expectations. Factors which contributed to these encouraging outcomes require further investigation.

The pragmatic language abilities of children with ADHD following a play-based intervention involving peer-to-peer interactions

Children with Attention Deficit Hyperactivity Disorder (ADHD) commonly experience significant pragmatic language deficits which put them at risk of developing emotional and social difficulties. This study aimed to examine the pragmatic language exhibited in a peer-to-peer interaction between the children with ADHD and their playmates following a pilot play-based intervention. Participants were children (aged 5-11 years) diagnosed as having ADHD (n = 14) and their self-selected typically-developing playmate. Pragmatic language was measured using the Pragmatic Protocol (PP) and the Structured Multidimensional Assessment Profiles (S-MAPs). Children's structural language was also screened and compared against their pragmatic language skills pre-post play-based intervention. The pragmatic language of children with ADHD improved significantly from pre-post intervention as measured by both the PP and S-MAPs. Both children with and without structural language difficulties improved significantly from pre- to post-intervention using S-MAPs; only children with structural language difficulties improved significantly using PP. The findings support the notion that pragmatic skills may improve following a play-based intervention that is characterized by didactic social interaction. As pragmatic language is a complex construct, it is proposed that clinicians and researchers reconsider the working definition of pragmatic language and the operationalization thereof in assessments.

Diabetes Attitudes, Wishes and Needs second study (DAWN2™): cross-national comparisons on barriers and resources for optimal care--healthcare professional perspective

AIMS

The second Diabetes Attitudes, Wishes and Needs (DAWN2) study sought cross-national comparisons of perceptions on healthcare provision for benchmarking and sharing of clinical practices to improve diabetes care.

METHODS

In total, 4785 healthcare professionals caring for people with diabetes across 17 countries participated in an online survey designed to assess diabetes healthcare provision, self-management and training.

RESULTS

Between 61.4 and 92.9% of healthcare professionals felt that people with diabetes needed to improve various self-management activities; glucose monitoring (range, 29.3-92.1%) had the biggest country difference, with a between-country variance of 20%. The need for a major improvement in diabetes self-management education was reported by 60% (26.4-81.4%) of healthcare professionals, with a 12% between-country variance. Provision of diabetes services differed among countries, with many healthcare professionals indicating that major improvements were needed across a range of areas, including healthcare organization [30.6% (7.4-67.1%)], resources for diabetes prevention [78.8% (60.4-90.5%)], earlier diagnosis and treatment [67.9% (45.0-85.5%)], communication between team members and people with diabetes [56.1% (22.3-85.4%)], specialist nurse availability [63.8% (27.9-90.7%)] and psychological support [62.7% (40.6-79.6%)]. In some countries, up to one third of healthcare professionals reported not having received any formal diabetes training. Societal discrimination against people with diabetes was reported by 32.8% (11.4-79.6%) of participants.

CONCLUSIONS

This survey has highlighted concerns of healthcare professionals relating to diabetes healthcare provision, self-management and training. Identifying between-country differences in several areas will allow benchmarking and sharing of clinical practices.

The reliability of methodological ratings for speechBITE using the PEDro-P scale

BACKGROUND

speechBITE (http://www.speechbite.com) is an online database established in order to help speech and language therapists gain faster access to relevant research that can used in clinical decision-making. In addition to containing more than 3000 journal references, the database also provides methodological ratings on the PEDro-P (an adapted version of the PEDro) scale to assist clinicians in identifying the scientific quality of randomized (RCTs) and non-randomized control trials (NRCTs). While reliability of the PEDro scale has been established by similar allied health databases, the reliability of the PEDro-P scale has yet to be reported.

AIMS

To examine the reliability of PEDro-P scale ratings undertaken by raters on the speechBITE database and benchmark these results to the published reliability for the original PEDro scale. Both the total score (out of ten) as well as each of the 11 scale items were included in this analysis.

METHODS & PROCEDURES

speechBITE's volunteer rater network of 17 members rated the first 100 RCTs and NRCTs on the website. The criterion and overall scores for these ratings were compared with previously published reliability studies using the PEDro scale. Intra-class correlations and per cent agreement measures were used to establish and benchmark reliability.

OUTCOMES & RESULTS

The speechBITE PEDro-P ratings ranged from fair to excellent for both the total score and for each of the 11 scale items. Furthermore, reliability was equal to that of other databases.

CONCLUSIONS & IMPLICATIONS

speechBITE users can be confident of the reliability of ratings published on the website. Further analysis of differences between this study and previous PEDro scale reliability studies are discussed.

Listen up: children with early identified hearing loss achieve age-appropriate speech/language outcomes by 3 years-of-age

OBJECTIVES

Age-appropriate speech/language outcomes for children with early identified hearing loss are a possibility but not a certainty. Identification of children most likely to achieve optimal outcomes is complicated by the heterogeneity of the children involved in outcome research, who present with a range of malleable (e.g. age of identification and cochlear implantation, type of intervention, communication mode) and non-malleable (e.g. degree of hearing loss) factors. This study considered whether a homogenous cohort of early identified children (≤ 12 months), with all severities of hearing loss and no other concomitant diagnoses could not only significantly outperform a similarly homogenous cohort of children who were later identified (>12 months to <5 years), but also achieve and maintain age-appropriate speech/language outcomes by 3, 4 and 5 years of age.

METHODS

A mixed prospective/retrospective comparative study of a homogenous cohort of 45 early identified (≤ 12 months) and 49 late identified (> 12 months to < 5 years) children with hearing loss was conducted. The children all attended the same oral auditory-verbal early intervention programme. Speech/language assessments standardized on typically developing hearing children were conducted at 3, 4 and 5 years of age.

RESULTS

The early identified children significantly outperformed the late identified at all ages and for all severities of HL. By 3 years of age, 93% of all early identified participants scored within normal limits (WNL) for speech; 90% were WNL for understanding vocabulary; and 95% were WNL for receptive and expressive language. Progress was maintained and improved so that by 5 years of age, 96% were WNL for speech, with 100% WNL for language.

CONCLUSIONS

This study found that most children with all severities of hearing loss and no other concomitant diagnosed condition, who were early diagnosed; received amplification by 3 months; enrolled into AV intervention by 6 months and received a cochlear implant by 18 months if required, were able to "keep up with" rather than "catch up to" their typically hearing peers by 3 years of age on measures of speech and language, including children with profound hearing loss. By 5 years, all children achieved typical language development and 96% typical speech.

Scalp EEG-based discrimination of cognitive deficits after traumatic brain injury using event-related Tsallis entropy analysis

Traumatic brain injury (TBI) is the leading cause of death and disability in children and adolescents in the U.S. This is a pilot study, which explores the discrimination of chronic TBI from normal controls using scalp EEG during a memory task. Tsallis entropies are computed for responses during an old-new memory recognition task. A support vector machine model is constructed to discriminate between normal and moderate/severe TBI individuals using Tsallis entropies as features. Numerical analyses of 30 records (15 normal and 15 TBI) show a maximum discrimination accuracy of 93% (p-value = 7.8557E-5) using four features. These results suggest the potential of scalp EEG as an efficacious method for noninvasive diagnosis of TBI.

Training Secondary School Teachers in Instructional Language Modification Techniques to Support Adolescents With Language Impairment: A Randomized Controlled Trial

Purpose

This study evaluated the efficacy of a collaborative intervention where a speech-language pathologist (SLP) trained mainstream secondary school teachers to make modifications to their oral and written instructional language. The trained teachers' uptake of techniques in their whole-class teaching practices and the impact this had on the language abilities of students with language impairment (LI) were evaluated.

Method

Two secondary schools were randomly assigned to either a trained or a control condition. A cohort of 13 teachers (7 trained and 6 control) and 43 Year 8 students with LI (21 trained and 22 control) were tested at pre, post, and follow-up times—teachers by structured interview and students by standardized spoken and written language assessments.

Results

Significantly increased use of the language modification techniques by the trained teachers was observed when compared to the control group of untrained teachers, with this increased use maintained over time. Results from the trained group of students showed a significant improvement in written expression and listening comprehension relative to the control group of students.

Conclusion

This randomized controlled trial is one of the first investigations to evaluate a collaborative intervention that links changes in mainstream secondary teachers' instructional language practices with improvements in the language abilities of adolescents with LI.

Paediatric speech-language pathology service delivery: an exploratory survey of Australian parents

Consideration of client values and preferences for service delivery is integral to engaging with the evidence-based practice triangle (E(3)BP), but as yet such preferences are under-researched. This exploratory study canvassed paediatric speech-language pathology services around Australia through an online survey of parents and compared reported service delivery to preferences, satisfaction, and external research evidence on recommended service delivery. Respondents were 154 parents with 192 children, living across a range of Australian locations and socio-economic status areas. Children had a range of speech and language disorders. A quarter of children waited over 6 months to receive initial assessment. Reported session type, frequency, and length were incongruent with both research recommendations and parents' wishes. Sixty per cent of parents were happy or very happy with their experiences, while 27% were unhappy. Qualitative responses revealed concerns such as; a lack of available, frequent, or local services, long waiting times, cut-off ages for eligibility, discharge processes, and an inability to afford private services. These findings challenge the profession to actively engage with E(3)BP including; being cognisant of evidence-based service delivery literature, keeping clients informed of service delivery policies, individualizing services, and exploring alternative service delivery methods.

Why Word Learning is not Fast

Upon fast mapping, children rarely retain new words even over intervals as short as 5 min. In this study, we asked whether the memory process of encoding or consolidation is the bottleneck to retention. Forty-nine children, mean age 33 months, were exposed to eight 2- or-3-syllable nonce neighbors of words in their existing lexicons. Didactic training consisted of six exposures to each word in the context of its referent, an unfamiliar toy. Productions were elicited four times: immediately following the examiner's model, and at 1-min-, 5-min-, and multiday retention intervals. At the final two intervals, the examiner said the first syllable and provided a beat gesture highlighting target word length in syllables as a cue following any erred production. The children were highly accurate at immediate posttest. Accuracy fell sharply over the 1-min retention interval and again after an additional 5 min. Performance then stabilized such that the 5-min and multiday posttests yielded comparable performance. Given this time course, we conclude that it was not the post-encoding process of consolidation but the process of encoding itself that presented the primary bottleneck to retention. Patterns of errors and responses to cueing upon error suggested that word forms were particularly vulnerable to partial decay during the time course of encoding.

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.

RECURRENT OSTEOID OSTEOMA OF THE LUNATE: A CASE REPORT AND REVIEW OF THE LITERATURE

Osteoid osteoma is a benign tumour of bone that rarely localises in the carpal bones. Its treatment by curettage and bone grafting is considered to be curative and its recurrence is thought to be rare.

We report a case of an osteoid osteoma of the lunate, which recurred seven years after the initial operation. Recurrent osteoid osteoma of the lunate bone has not been reported in the literature. We present this case report for its atypical presentation and diagnostic difficulty and also to alert the readers of the possibility of an osteoid osteoma as a cause of the chronic unexplained wrist pain in young adults.

Accelerated MVAC as neoadjuvant chemotherapy for patients with muscle-invasive transitional cell carcinoma of the bladder

235

Background: Meta-analysis data demonstrate a 5% absolute survival benefit for the use of neoadjuvant chemotherapy (NAC) using cisplatin-based combination regimens in the radical treatment of muscle-invasive bladder cancer (MIBC). However, there is currently no randomized controlled trial data on the optimum regimen for this setting. Accelerated MVAC (AMVAC) is effective in advanced disease, and has the potential advantage over other NAC regimens of minimising delays to definitive, potentially curative therapy. We present data regarding its use as NAC in MIBC patients.

Methods: Retrospective analysis was performed on all 80 consecutive patients with muscle-invasive transitional cell carcinoma of the bladder, treated during a 50-month period at 2 U.K. centers. Patients received either 3 or 4 cycles of methotrexate 30mg/m2, vinblastine 3mg/m2, doxorubicin 30mg/m2 and 4-hour infusion of cisplatin 70mg/m2 at 2-week intervals, with G-CSF support, prior to definitive therapy with either radical surgery (RS) or radical radiotherapy (RT).

Results: All planned cycles of chemotherapy were completed in 84% of patients. All 80 patients received their planned definitive therapy. Pathological complete response (pCR) was seen in 43% of 60 patients treated with surgery following chemotherapy. There were no chemotherapy-related deaths and grade 3 or 4 toxicities were seen in 11% of patients. Median duration of chemotherapy was 34 days. Dose reduction or delay was required in 7% and 9% of patients, respectively. Objective radiological local response was seen in 75% of patients. At a median follow-up of 27.5 months, 25 (32%) patients have relapsed and 11 (14%) died. Two-year disease-free survival was 65% overall, and was statistically significantly superior in patients who were radiologically node-negative prior to chemotherapy.

Conclusions: AMVAC is a safe, well-tolerated, and easily deliverable regimen with excellent treatment outcomes and minimizes delays to definitive treatment. It is an appropriate comparator for future randomized trials.

No significant financial relationships to disclose.

The use of poison baits to control feral cats and red foxes in arid South Australia II. Bait type, placement, lures and non-target uptake

Context Poison baits are often used to control both foxes and feral cats but success varies considerably. Aims This study investigated the influence of bait type, placement and lures on bait uptake by the feral cat, red fox and non-target species to improve baiting success and reduce non-target uptake. Methods Six short field trials were implemented during autumn and winter over a five-year period in northern South Australia. Key results Results suggest that poison baiting with Eradicat or dried kangaroo meat baits was inefficient for feral cats due to both low rates of bait detection and poor ingestion rates for baits that were encountered. Cats consumed more baits on dunes than swales and uptake was higher under bushes than in open areas. The use of auditory or olfactory lures adjacent to baits did not increase ingestion rates. Foxes consumed more baits encountered than cats and exhibited no preference between Eradicat and kangaroo meat baits. Bait uptake by native non-target species averaged between 14 and 57% of baits during the six trials, accounting for up to 90% of total bait uptake. Corvid species were primarily responsible for non-target uptake. Threatened mammal species investigated and nibbled baits but rarely consumed them; however, corvids and some common rodent species ingested enough poison to potentially receive a lethal dose. Conclusions It is likely that several factors contributed to poor bait uptake by cats including the presence of alternative prey, a preference for live prey, an aversion to scavenging or eating unfamiliar foods and a stronger reliance on visual rather than olfactory cues for locating food. Implications Further trials for control of feral cats should concentrate on increasing ingestion rates without the requirement for hunger through either involuntary ingestion via grooming or development of a highly palatable bait.

Practical steps to improving the management of type 1 diabetes: recommendations from the Global Partnership for Effective Diabetes Management

The Diabetes Control and Complications Trial (DCCT) led to considerable improvements in the management of type 1 diabetes, with the wider adoption of intensive insulin therapy to reduce the risk of complications. However, a large gap between evidence and practice remains, as recently shown by the Pittsburgh Epidemiology of Diabetes Complications (EDC) study, in which 30-year rates of microvascular complications in the 'real world' EDC patients were twice that of DCCT patients who received intensive insulin therapy. This gap may be attributed to the many challenges that patients and practitioners face in the day-to-day management of the disease. These barriers include reaching glycaemic goals, overcoming the reality and fear of hypoglycaemia, and appropriate insulin therapy and dose adjustment. As practitioners, the question remains: how do we help patients with type 1 diabetes manage glycaemia while overcoming barriers? In this article, the Global Partnership for Effective Diabetes Management provides practical recommendations to help improve the care of patients with type 1 diabetes.

Insulin for type 2 diabetes: choosing a second-line insulin regimen

Guidance has been published on the choice of initial insulin regimen for patients with type 2 diabetes [NPH (isophane) insulin or a long-acting insulin analogue] but not on how to choose a second regimen when glycaemic control becomes unsatisfactory.

AIMS

To develop pragmatic clinical guidance for choosing a second-line insulin regimen tailored to the individual needs of patients with type 2 diabetes after failure of first-line insulin therapy.

METHODS

Formulation of a consensus by expert panel based on published evidence and best clinical practice, taking into account patient preferences, lifestyle and functional capacity.

RESULTS

Six patient-dependent factors relevant to the choice of second-line insulin regimen and three alternative insulin regimens (twice-daily premixed, basal-plus and basal-bolus) were identified. The panel recommended one or more insulin regimens compatible with each factor, emphasising the fundamental importance of a healthy lifestyle that includes exercise and weight reduction. These recommendations were incorporated into an algorithm to provide pragmatic guidance for clinicians.

CONCLUSION

The three alternative insulin regimens offer different benefits and drawbacks and it is important to make the right choice to optimise outcomes for patients.

Building vocabulary knowledge and phonological awareness skills in children with specific language impairment through hybrid language intervention: a feasibility study

BACKGROUND & AIMS

Preschool and early school-aged children with specific language impairment not only have spoken language difficulties, but also are at risk of future literacy problems. Effective interventions targeting both spoken language and emergent literacy skills for this population are limited. This paper reports a feasibility study of a hybrid language intervention approach that targets vocabulary knowledge and phonological awareness skills within the context of oral narrative, storybook reading, and drill-based games. This study also reports on two novel, experimental assessments that were developed to expand options for measuring changes in lexical skills in children.

METHODS & PROCEDURES

Seventeen children with specific language impairment participated in a pilot within-group evaluation of a hybrid intervention programme. The children's performance at pre- and post-intervention was compared on a range of clinical and experimental assessment measures targeting both spoken language and phonological awareness skills. Each child received intervention for six one-hour sessions scheduled on a weekly basis. Intervention sessions focused on training phonological awareness skills as well as lexical-semantic features of words within the context of oral and storybook narrative and drill-based games.

OUTCOMES & RESULTS

The children significantly improved on clinical measures of phonological awareness, spoken vocabulary and oral narrative. Lexical-semantic and sublexical vocabulary knowledge also significantly improved on the experimental measures used in the study.

CONCLUSIONS

The results of this feasibility study suggest that a larger scale experimental trial of an integrated spoken language and emergent literacy intervention approach for preschool and early school-aged children with specific language impairment is warranted.

A systematic review of the clinical effectiveness and cost-effectiveness and economic modelling of minimal incision total hip replacement approaches in the management of arthritic disease of the hip

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of minimal incision approaches to total hip replacement (THR) for arthritis of the hip.

DATA SOURCES

Major electronic databases were searched from 1966 to 2007. Relevant websites were also examined and experts in the field were consulted.

REVIEW METHODS

Studies of minimal (one or two) incision THR compared with standard THR were assessed for inclusion in the review of clinical effectiveness. A systematic review of economic evaluations comparing a minimal incision approach to standard THR was also performed and the estimates from the systematic review of clinical effectiveness were incorporated into an economic model. Utilities data were sourced to estimate quality-adjusted life-years (QALYs). Due to lack of data, no economic analysis was conducted for the two mini-incision surgical method.

RESULTS

Nine randomised controlled trials (RCTs), 17 non-randomised comparative studies, six case series and one registry were found to be useful for the comparison of single mini-incision THR with standard THR. One RCT compared two mini-incision THR with standard THR, and two RCTs, five non-randomised comparative studies and two case series compared two mini-incision with single mini-incision THR. The RCTs were of moderate quality. Most had fewer than 200 patients and had a follow-up period of less than 1 year. The single mini-incision THR may have some perioperative advantages, e.g. blood loss [weighted mean difference (WMD) -57.71 ml, p<0.01] and shorter operative time, of uncertain practical significance. It may also offer a shorter recovery period and greater patient satisfaction. Evidence on long-term outcomes (especially revision) is too limited to be useful. Lack of data prevented subgroup analysis. With respect to the two-incision approach, data were suggestive of shorter recovery compared with single-incision THR, but conclusions must be treated with caution. The costs to the health service, per patient, of single mini-incision THR depend upon assumptions made, but are similar at one year (7060 pounds sterling vs 7350 pounds sterling for standard THR). For a 40-year time horizon the costs were 11,618 pounds sterling for mini-incision and 11,899 pounds sterling for standard THR. Two existing economic evaluations were identified, but they added little, if any, value to the current evidence base owing to their limited quality. In the economic model, mini-incision THR was less costly and provided slightly more QALYs in both the 1- and 40-year analyses. The mean QALYs at 1 year were 0.677 for standard THR and 0.695 for mini-incision THR. At 40 years, the mean QALYs were 8.463 for standard THR and 8.480 for mini-incision. At 1 year the probabilistic sensitivity analyses indicate that mini-incision THR has a 95% probability of being cost-effective if society's willingness to pay for a QALY were up to 50,000 pounds sterling. This is reduced to approximately 55% for the 40-year analysis. The results were driven by the assumption of a 1-month earlier return to usual activities and a decreased hospital length of stay and operation duration following mini-incision THR. If mini-incision THR actually required more intensive use of resources it would become approximately 200 pounds sterling more expensive and would only be cost-effective (cost per QALY>30,000 pounds sterling) if recovery was 1.5 weeks faster. A threshold analysis around risk of revision showed, using the same cost per QALY threshold, mini-incision THR would have to have no more than a 7.5% increase in revisions compared with standard THR for it to be no longer considered cost-effective (one more revision for every 200 procedures performed). Further sensitivity analysis involved relaxing assumptions of equal long-term outcomes where possible. and broadly similar results to the base-case analysis were found in this and further sensitivity analyses.

CONCLUSIONS

Compared with standard THR, minimal incision THR has small perioperative advantages in terms of blood loss and operation time. It may offer a shorter hospital stay and quicker recovery. It appears to have a similar procedure cost to standard THR, but evidence on its longer term performance is very limited. Further long-term follow-up data on costs and outcomes including analysis of subgroups of interest to the NHS would strengthen the current economic evaluation.

Raising diabetes awareness in the public domain

Type 2 diabetes mellitus (T2DM) is a chronic, debilitating and costly disease associated with severe complications, and has been recognised as such by the United Nations (UN). But despite being a leading cause of death and serious disability worldwide, the public often perceive T2DM as a relatively mild condition. Furthermore, many people do not know that T2DM is preventable and that steps can be taken to minimise the risk of developing the disease. Improved public awareness of T2DM and its link with obesity and physical inactivity is critical, not only to prevention but also management of diabetes. Recognising this need, the UN has issued a resolution calling on member states to observe World Diabetes Day and implement education and mass media initiatives to raise public awareness of diabetes and its complications. This article reviews selected local, national and international public awareness campaigns to illustrate the range of initiatives that together can work towards the goals of the UN Resolution. By building understanding of diabetes, changing beliefs and attitudes and promoting positive behaviours, such initiatives can help combat the global diabetes epidemic and improve the health and wellbeing of people.

Improving glucose management: ten steps to get more patients with type 2 diabetes to glycaemic goal. Recommendations from the Global Partnership for Effective Diabetes Management

Despite increasingly stringent clinical practice guidelines for glycaemic control, the implementation of recommendations has been disappointing, with over 60% of patients not reaching recommended glycaemic goals. As a result, current management of glycaemia falls significantly short of accepted treatment goals. The Global Partnership for Effective Diabetes Management has identified a number of major barriers that can prevent individuals from achieving their glycaemic targets. This article proposes 10 key practical recommendations to aid healthcare providers in overcoming these barriers and to enable a greater proportion of patients to achieve glycaemic goals. These include advice on targeting the underlying pathophysiology of type 2 diabetes, treating early and effectively with combination therapies, adopting a holistic, multidisciplinary approach and improving patient understanding of type 2 diabetes. Implementation of these recommendations should reduce the risk of diabetes-related complications, improve patient quality of life and impact more effectively on the increasing healthcare cost related to diabetes.

Improving glucose management: ten steps to get more patients with type 2 diabetes to glycaemic goal

Despite increasingly stringent clinical practice guidelines for glycaemic control, the implementation of recommendations has been disappointing, with over 60% of patients not reaching recommended glycaemic goals. As a result, current management of glycaemia falls significantly short of accepted treatment goals. The Global Partnership for Effective Diabetes Management has identified a number of major barriers that can prevent individuals from achieving their glycaemic targets. This article proposes 10 key practical recommendations to aid healthcare providers in overcoming these barriers and to enable a greater proportion of patients to achieve glycaemic goals. These include advice on targeting the underlying pathophysiology of type 2 diabetes, treating early and effectively with combination therapies, adopting a holistic, multidisciplinary approach and improving patient understanding of type 2 diabetes. Implementation of these recommendations should reduce the risk of diabetes-related complications, improve patient quality of life and impact more effectively on the increasing healthcare cost related to diabetes.

Home range, activity and habitat use of European rabbits (Oryctolagus cuniculus) in arid Australia: implications for control

The home range, activity and habitat use of wild European rabbits in northern South Australia were compared during winter and summer, and results used to suggest improvements to control techniques. Average home range was significantly smaller in summer (2.1 ha) than winter (4.2 ha) and there was no significant difference between the sexes. Rabbits used both dune and swale habitat but most warrens and more surface fixes were recorded in dune habitat in both seasons. Proportionally more surface fixes were found in swale habitat at night than during the day. The proportion of diurnal fixes on the surface was not significantly influenced by season, averaging 47% in winter and 62% in summer. Only 30% of radio-collared rabbits flushed by humans retreated to warrens. Comparable levels of diurnal surface activity in both winter and summer suggest that the death rate from fumigation or warren destruction may be similar in both seasons. High levels of diurnal surface activity suggest that warren fumigation may be ineffective unless rabbits can first be flushed to their warrens. The use of dogs to flush rabbits before fumigation or ripping should increase the efficacy of control. Activity data suggest that fumigation or ripping should be conducted between 0900 and 1600 hours in winter and 1100 and 1800 hours in summer when radio-collared rabbits were most likely to be down their warrens. Home-range data suggest that the effectiveness of poison baiting may be increased by placing bait lines closer together in summer and, although bait lines should be concentrated in dune habitat, some poison should also be placed in swale feeding areas remote from warrens. The most successful control method for radio-collared rabbits was fumigation with phosphine gas tablets, with 10 of 11 rabbits successfully killed. Pressure fumigation with chloropicrin was also successful but 1080 poisoning and warren destruction using shovels were all relatively unsuccessful.

Is multidisciplinary learning effective among those caring for people with diabetes?

The role of multi-professional learning for those providing clinical services to people with diabetes has yet to be defined. Several assumptions are generally made about education in the context of multi-professional settings. It is argued that different professions learning together could potentially improve professional relationships, collaborative working practices and ultimately standards of care. Greater respect and honesty may emerge from a team approach to learning with a commensurate reduction in professional antagonism. Personal and professional confidence is reportedly enhanced through close contact with other professionals during team-based learning exercises. We have examined current evidence to support multidisciplinary learning in the context of medical education generally as well as in diabetes education. Previous investigation of available literature by Cochrane reviewers, aimed at identifying studies of interprofessional education interventions, yielded a total of 1042 articles, none of which met the stated inclusion criteria. Searches involving more recent publications failed to reveal more robust evidence. Despite a large body of literature on the evaluation of interprofessional education, studies generally lacked the methodological rigour needed to understand the impact of interprofessional education on professional practice and/or health care outcomes. Nevertheless, planners continue to advocate, and endorse, joint training between different groups of workers (including nurses, doctors and those in professions allied to medicine) with the objective of producing an integrated workforce of multidisciplinary teams. Whilst the concept of multi-professional learning has strong appeal, it is necessary for those responsible for educating health care professionals to demonstrate its superiority over separate learning experiences.

Pulmonary challenges in neurotrauma

Traumatic injury to the central nervous system presents a formidable clinical challenge to any practitioner. Part of that challenge is to anticipate the pulmonary sequelae that may occur in this patient population. Direct pulmonary trauma commonly occurs with CNS injury and requires immediate treatment to prevent further compromise of the patient's condition. Neurologic deficits can then be compounded by complications such as ARDS and aspiration pneumonia that can be minimized if not prevented. The nurse is a key health care professional who can implement these interventions and effect better patient outcomes.

Assessing validity in written tests of general practice - exploration by factor analysis of candidate response patterns to paper 1 of the MRCGP examination

OBJECTIVE

To investigate the content validity of Paper 1 of the MRCGP examination.

METHOD

Exploratory factor analysis was carried out on candidate responses to Paper 1 of the May and October MRCGP examination in 1998. Contribution of each test question across factors was assessed using a pattern matrix of the oblique rotation. Common dimensions and variations between factor sets were identified. Key testing areas were then matched against the 'domains of competence' intended to be assessed by Paper 1 (as defined within the examination blueprint matrix).

RESULTS

Whilst critical appraisal, disease prevention/evidence-based medicine and clinical management emerged as areas tested consistently, content variation was observed between factor sets extracted from both sittings. In addition, some overlap, in terms of domains tested, was seen among other assessment instruments used within the examination.

CONCLUSION

Paper 1 conforms to the majority of its stated intentions. However, further development of techniques for investigating validity will be required in order to minimize content variation between both sittings of the examination as well as to help more closely define areas of competence to be tested by Paper 1 of the MRCGP examination.

Single-strand conformation polymorphism analysis by capillary and microchip electrophoresis: a fast, simple method for detection of common mutations in BRCA1 and BRCA2

As a result of intensive studies on hereditary breast and ovarian cancers, two breast cancer susceptibility genes, BRCA1 and BRCA2, have been identified. In each gene, a small number of specific mutations have been found at relatively high frequency in certain ethnic populations. The mutations, 185delAG and 5382insC in BRCA1 and 6174delT in BRCA2, have been identified as common mutations in the Ashkenazi Jewish population, with a combined frequency of 2.0 to 2.5%. Women who have one of the above three common mutations are at a high risk of developing breast or ovarian cancer. Consequently, accurate and cost-effective detection of these three mutations may have important implications for risk assessment in susceptible women and men. In this report, we describe a fast and simple capillary electrophoresis (CE)-based method using a polymer network for screening the three common mutations in BRCA1 and BRCA2. Fluorescent dye-labeled primers (6-FAM-tagged) were used to amplify three DNA fragments of 258, 296, and 201 bp for detection of the 185delAG, 5382insC, and 6174delT mutations, respectively. After the PCR products were denatured, a single-strand conformation polymorphism (SSCP) profile could be obtained for each mutation in less than 10 min by CE in a polymer network. We demonstrate the potential provided by translating this assay to the microchip format where the SSCP analysis is complete in 120 s, representing only a fraction of the reduction in analysis time that can be achieved with microchip technology. The speed and simplicity of the SSCP methodology for detection of these mutations make it attractive for use in the clinical diagnostic laboratory.