Addressing generalization and maintenance of stuttering treatment in the schools: a critical look

Generalization and maintenance are a widely recognized challenge for stuttering treatment. There are many reasons why this is the case. First, there is no accepted model of recovery, though self-efficacy may be a helpful construct and, secondly, the client's age, stuttering severity, and negative attitudes may be complicating factors. Three strategies for promoting generalization and maintenance in school settings are suggested based on current research evidence. They include probing and training for generalization, incorporating real-life elements into therapy, and training clients to self-regulate their behavior. These strategies appear to be viable and practical, but further research is needed to fully evaluate their effectiveness for school settings.

LEARNING OUTCOMES

Readers will learn about (1) typical approaches to managing stuttering in the school setting, (2) barriers to generalization and maintenance of stuttering treatment gains, and (3) three strategies for promoting generalization and maintenance.

Early and late reactions following the use of iopamidol 340, iomeprol 350 and iodixanol 320 in cardiac catheterization

GOAL

To investigate the incidence of early (< 24 hours) and late (> 24 hours to 7 days) reactions to 3 contrast agents commonly used in cardiac catheterization.

METHODS AND RESULTS

A total of 2,108 patients undergoing cardiac catheterization in a Regional Cardiothoracic Unit were randomly assigned to receive 1 of 3 commonly used contrast agents in a prospective, double-blind study. The contrast agents were iopamidol 340 (Niopam ), a nonionic monomer; iomeprol 350 (Iomeron ), a nonionic dimer; and iodixanol 320 (Visipaque ), a nonionic dimer. The main outcome measures were the incidence of early (< 24 hours) reactions following catheterization and the incidence of late (24 hours to 7 days) reactions. Early reactions, excluding patients with heat on left ventriculography as the sole symptom, were relatively common (7.4%), but there was no significant difference between the 3 agents (p = 0.35). Late skin reactions, excluding reactions solely at the site of the arterial puncture and continuations of early urticarial reactions, were also relatively common (5.4%), but the incidence differed between the 3 agents. Such reactions occurred in 2.7% of those receiving iopamidol 340 (Niopam ), 3.5% of those receiving iomeprol 350 (Iomeron ) and 10.4% of those receiving iodixanol 320 (Visipaque ) (p < 0.01).

CONCLUSION

The incidence of early adverse reactions is similar with these 3 contrast agents. However, late skin reactions are significantly more common with iodixanol 320 (Visipaque ) than with the other 2 agents. Although such reactions were rarely troublesome, patients should be advised accordingly.

Self-regulation and the management of stuttering

Self-regulation refers to a process by which individuals learn to direct and control their own behavior, thoughts, and feelings to manage or eliminate their stuttering. As a concept, it has been a vital and enduring component of most approaches to managing persistent and chronic stuttering. The theoretical basis for self-regulation is briefly reviewed and the main principles of self-regulation--goal setting, cue management, self-monitoring, and self-evaluation--are described and illustrated with clinical examples. Factors related to self-regulatory failure are also discussed.

A randomized, placebo-controlled, double-blind trial of ondansetron in renal itch

BACKGROUND

Renal itch is a relatively common and distressing problem for patients with chronic renal failure. Ondansetron, a serotonin type 3 receptor antagonist was developed for relief of chemotherapy induced nausea. Recently, anecdotal reports describe relief of renal itch with ondansetron.

OBJECTIVES

We performed a double-blind randomized placebo-controlled trial to objectively assess the effectiveness of ondansetron in renal itch.

PATIENTS AND METHODS

With approval from the local ethical committee, 24 patients on haemodialysis were enrolled in the trial. On a random basis 14 patients were blindly allocated to the ondansetron-placebo sequence and 10 to the placebo-ondansetron sequence. Baseline values for itch were obtained for 7 days before the treatment period and there was a 7-day washout between the treatment periods. During the treatment patients received either 8 mg of ondansetron three times a day or a placebo tablet three times a day for 2 weeks. Patients were asked to record the severity of their pruritus on a visual analogue scale (VAS) twice a day. At the end of the study patients were asked blindly which treatment they had preferred.

RESULTS

Seventeen patients completed the trial. Pruritus decreased by 16% (95% CI: 0.5-32%) during active treatment and by 25% (95% CI: 9-41%) during treatment with placebo. The change in VAS scores during treatment with ondansetron (P = 0.04) and placebo (P = 0.01) were both significant. Eleven patients expressed a preference, seven for placebo and four for ondansetron.

CONCLUSIONS

Our results show that ondansetron is no better than placebo in controlling renal itch.

Evidence-based treatment of stuttering: II. Clinical significance of behavioral stuttering treatments

An evidence-based framework can be described as an empirically-driven, measurement-based, client-sensitive approach for selecting treatments. It is believed that using such a framework is more likely to result in a clinically significant outcome. For this paper, a clinically significant outcome was defined as a meaningful treatment change. It was suggested that there are at least three groups for whom a treatment's outcome is meaningful. These groups include clinicians/clinical researchers, the clients, and relevant others who have some interest in the outcome (e.g., parents of a child who stutters). The meaning and measurement of clinical significance was discussed for each of these three groups, based on research from the behavioral stuttering treatment literature.

EDUCATIONAL OBJECTIVES

The reader will learn about and be able to (1) broadly define a clinically significant outcome and identify some of the groups who are interested in such an outcome and (2) describe how clinical significance has been evaluated in stuttering treatment within an evidence-based framework.

Towards a functional neural systems model of developmental stuttering

This paper overviews recent developments in an ongoing program of brain imaging research on developmental stuttering that is being conducted at the University of Texas Health Science Center, San Antonio. This program has primarily used H(2)15O PET imaging of different speaking tasks by right-handed adult male and female persistent stutterers, recovered stutterers and controls in order to isolate the neural regions that are functionally associated with stuttered speech. The principal findings have emerged from studies using condition contrasts and performance correlation techniques. The emerging findings from these studies are reviewed and referenced to a neural model of normal speech production recently proposed by Jürgens [Neurosci. Biobehav. Rev. 26 (2002) 235]. This paper will report (1) the reconfiguration of previous findings within the Jürgens Model; (2) preliminary findings of an investigation with late recovered stutterers; (3) an investigation of neural activations during a treatment procedure designed to produce a sustained improvement in fluency; and (4) an across-studies comparison that seeks to isolate neural regions within the Jürgens Model that are consistently associated with stuttering. Two regions appear to meet this criterion: right anterior insula (activated) and anterior middle and superior temporal gyri (deactivated) mainly in right hemisphere. The implications of these findings and the direction of future imaging investigations are discussed.

EDUCATIONAL OBJECTIVES

The reader will learn about (1) recent uses of H(2)15O PET imaging in stuttering research; (2) the use of a new neurological model of speech production in imaging research on stuttering; and (3) initial findings from PET imaging investigations of treated and recovered stutterers.

Bacillus cereus cellulitis from contaminated heroin

Concern exists over recent unexplained deaths among intravenous drug users. This report describes a patient with crepitant cellulitis who was admitted complaining of severe pain in the right forearm. Ultrasonography demonstrated gas in the tissues and he was referred for early surgical debridement of the arm. He was treated with intravenous benzyl penicillin, gentamicin and metronidazole and made a full recovery. Aspirate samples grew Bacillus cereus, morphologically similar to the isolate obtained from a sample of the patient's own heroin. Antibiogram and API 50CHB profiles were also similar. Further typing included 'H' flagellar serotyping, which found both blood and heroin strains to be non-typable, and amplified fragment polymorphism analysis, which showed that the strains were indistinguishable. Genotyping of two selected genes from B. cereus confirmed almost certain identity between the two strains. This case illustrates the potential virulence of B. cereus when inoculated into tissues, and to our knowledge, is the first report to demonstrate a conclusive microbiological link between contaminated heroin and serious sepsis in a drug user due to B. cereus.

The modification of speech naturalness during rhythmic stimulation treatment of stuttering

This study investigated the modification of speech naturalness during stuttering treatment. It systematically replicated an earlier study (Ingham & Onslow, 1985) that demonstrated that unnatural-sounding stutter-free speech could be shaped into more natural-sounding stutter-free speech by using regular feedback of speech-naturalness ratings during speaking tasks. In the present study, the some procedure was used with three persons who stutter-2 adolescent girls and 1 adult man-during rhythmic stimulation conditions. The two adolescent participants spoke only English, but Spanish was the first and English the second language (ESL) of the adult participant. For the 2 adolescents, it was demonstrated that their unnatural-sounding rhythmic speech could be shaped to levels found among normally fluent speakers without losing the fluency-inducing benefits of rhythmic speech. The findings indicate that speech-naturalness feedback may be a powerful procedure for overcoming a problematic aspect of rhythmic speech treatments of stuttering. However, it was not possible to deliver reliable speech-naturalness feedback to the adult ESL speaker, who also displayed a strong dialect. The study highlights the need to find strategies to improve interjudge agreement when using speech naturalness ratings with speakers who display a strong dialect.

Activation of Cardiac c-Jun NH 2 -Terminal Kinases and p38-Mitogen–Activated Protein Kinases With Abrupt Changes in Hemodynamic Load

Abstract —The role of mitogen-activated protein kinase (MAPK) pathways as signal transduction intermediates of hemodynamic stress leading to cardiac hypertrophy in the adult heart is not fully established. In a rat model of pressure-overload hypertrophy, we examined whether activation of MAPK pathways, namely, the extracellular signal–regulated protein kinase (ERK), c-Jun NH 2 -terminal kinase (JNK), and the p38-MAPK pathways, occurs during rapid changes in hemodynamic load in vivo. A slight activation of ERK2 and marked increases in JNK1 and p38-MAPK activities were observed 30 minutes after aortic banding. The increase in p38-MAPK activity was accompanied by an increase in the phosphorylation of the p38 substrate MAPK–activated protein kinases 2 and 3. Activation of these kinases was coincident with an increase in phosphorylation of c-Jun and activating transcription factor-2 (ATF-2) and enhanced DNA binding of activator protein-1 factors. Thus, hemodynamic stress of the adult rat heart in vivo results in rapid activation of several parallel MAPK kinase cascades, particularly stress-activated MAPK and p38-MAPK and their target transcription factors c-Jun and ATF-2.

Early and late reactions after the use of iopamidol 340, ioxaglate 320, and iodixanol 320 in cardiac catheterization

BACKGROUND

Although modern contrast agents have tolerability superior to older agents, significant differences remain between the agents currently in use.

METHODS

To investigate the incidence of early (<24 hours) and late (>24 hours to 7 days) reactions to 3 contrast agents commonly used in cardiac catheterization, we performed a randomized, prospective, double-blind trial in which 2001 patients received one of the following agents: iopamidol 340, a nonionic monomer; ioxaglate 320, an ionic dimer; and iodixanol 320, a nonionic dimer. Possible reactions to contrast were recorded during the hospital admission and after discharge by means of a questionnaire, telephone follow-up, or both.

RESULTS

Early reactions occurred in 22.2% of those receiving ioxaglate, 7.6% of those receiving iodixanol, and 8.8% of those receiving iopamidol (P <.0001). Late skin reactions occurred in 12.2% of those receiving iodixanol, 4.3% of those receiving ioxaglate, and 4.2% of those receiving iopamidol (P <.0001).

CONCLUSIONS

The early side effect profile of certain ionic contrast agents suggests that these agents should no longer be used routinely in cardiac catheterization. The use of nonionic agents, however, is associated with late skin reactions, but there are notable differences between the monomeric and dimeric compounds. Although the skin reactions are generally benign, this is not always the case. Patients should be advised accordingly.

Alcohol and behavioral control: cognitive and neural mechanisms

This article represents the proceedings of a symposium at the 2000 RSA Meeting in Denver, Colorado. The organizer/chair was Muriel Vogel-Sprott. The presentations were (1) Alcohol-induced impairment of inhibitory control: Some commonalities with attention deficit hyperactivity disorder, by Mark Fillmore; (2) Neural interactions that underlie response inhibition under alcohol: A functional magnetic resonance imaging investigation, by Craig Easdon; (3) Intentional control of behavior under alcohol, by Muriel Vogel-Sprott; and (4) Working memory and the disinhibiting effects of alcohol on passive avoidance learning, by Alicia Justius and Peter Finn.

Temporal dissociation of left ventricular function and remodeling following experimental myocardial infarction in rats

BACKGROUND

Left ventricular function early after myocardial infarction (MI) predicts subsequent clinical outcome. Nevertheless, the relationship between early changes in left ventricular function and subsequent left ventricular remodeling has not been well defined.

METHODS AND RESULTS

To explore the temporal relationship between left ventricular function and remodeling after MI, rats (n = 63) underwent coronary artery ligation with and without reperfusion at 45 or 180 minutes or a sham operation. All animals were followed up by serial echocardiography preligation; 4, 24, and 48 hours; and 1, 2, 3, 4, 6, and 9 weeks after MI. Measures of global left ventricular size and function and regional wall motion were obtained at physiological heart rates. Histological infarct sizes (range, 0% to 52%) were determined in all animals. Within 4 hours of MI, fractional area change (FAC) decreased dramatically in association with an increase in left ventricular systolic cavity area, whereas diastolic area increased more gradually. Early FAC was related to infarct size (r = -0.82; P < .000), predicted the extent of left ventricular enlargement (P = .0001), and remained depressed throughout the duration of follow-up. Regional wall motion excursion and systolic wall thickness decreased in the infarcted and noninfarcted regions in animals with large infarctions.

CONCLUSIONS

The rate of left ventricular dilatation after MI in rats is proportional to initial left ventricular function, although left ventricular function remains relatively constant as the ventricle progressively enlarges. Regional myocardial function after a large MI is abnormal in noninfarcted as well as infarcted regions.

Levo-Alpha Acetyl Methadol (LAAM). Its advantages and drawbacks

Levo-Alpha Acetyl Methadol, or LAAM, is a medication therapy for individuals addicted to opiates that provides an alternative to methadone. Because it is administered only three times a week and, therefore, requires fewer clinic trips, patient acceptance can be higher than with methadone. While blocking the effects of other opiates and preventing withdrawal, LAAM does not produce a subjective high. However, because most patients are not familiar with LAAM, they may be initially more anxious and need more counseling and support when receiving the medication than they would with the more familiar methadone medication. On balance, LAAM enables clinic administrators and counselors to offer an alternative medication to methadone that some clients prefer once they become adjusted to it because of LAAM's even, stable effect. Through hypothetical but true-to-life case studies of LAAM use, it is possible to gain a clearer understanding of the advantages and drawbacks of using LAAM.

Cardiac myocyte membrane wounding in the abruptly pressure-overloaded rat heart under high wall stress

The potential role of transient sarcolemmal membrane wounding as a signal transduction event for cardiomyocyte hypertrophy was evaluated in rats with short-term pressure overload caused by banding of the proximal aorta. This procedure resulted in significant increases in left ventricular systolic (1.5-fold) and end-diastolic (2.6-fold) pressures and wall stresses that were associated with significant wall thinning and cavitary enlargement. Quantitative image analysis of frozen sections of the stressed ventricles obtained 60 minutes after banding demonstrated a 6- to 10-fold increase in cytosolic staining with a horseradish peroxidase-labeled anti-albumin antibody compared with sham-operated controls, indicating that an increase in transient sarcolemmal membrane permeability (wounding) is an early response to an abrupt increase in hemodynamic load in vivo. We conclude that an intense hemodynamic stress in vivo can result in histologically detectable cardiomyocyte wounding.

Children recovered from stuttering without formal treatment: perceptual assessment of speech normalcy

Current evidence suggests that young children who recover from stuttering are essentially stutter-free. However, there is no evidence to indicate if their speech is perceptually indistinguishable from normally fluent peers or whether they retain perceptually unusual speech. One important example of recovery from stuttering is children who have recovered without receiving formal treatment. An investigation was conducted to determine if the speech of these children is perceptually different from the speech of children who have never stuttered. Speakers consisted of 10 preschool and early school-age children documented as recovered from stuttering without benefit of formal treatment. In a series of studies they were compared with 10 children who had never stuttered. Three groups of judges-sophisticated, unsophisticated, and experienced-were separately asked, using videotaped speech samples of the children, to decide which samples were from children who used to stutter. Results revealed that the children who recovered from stuttering were perceptually indistinguishable from the normal controls. The same result was obtained regardless of whether the samples were presented in paired-stimulus or single-stimulus mode. Two of the groups of judges were also instructed to rate the speech naturalness of the speech samples. The speakers were not distinguished on this measure either. Methodological issues and the implications of the findings are discussed.

Adults recovered from stuttering without formal treatment: perceptual assessment of speech normalcy

The purpose of this study was to determine if the speech of adults who self-judged that they were recovered from stuttering without the assistance of treatment is perceptually different from that of adults who never stuttered. Fifteen adult speakers verified as persons who had recovered from a valid stuttering problem without the assistance of treatment were compared with 15 adult speakers verified as persons with normally fluent speech. Judges viewed videotaped speech samples of all speakers and were instructed to decide whether a speaker used to stutter or never stuttered. A separate group of judges rated the same samples for speech naturalness. Various speech behavior measures were also obtained. Results revealed that the speech of speakers who used to stutter was perceptually different from that of speakers who never stuttered. This difference was correlated with unnatural sounding speech and a high frequency of part-word repetitions.

Effect of speech dialect on speech naturalness ratings: a systematic replication of Martin, Haroldson, and Triden (1984)

This study investigated the effect of speech dialect on listeners' speech naturalness ratings by systematically replicating Martin, Haroldson, and Triden's (1984) study using three groups of speaker samples. Two groups consisted of speakers with General American dialect--one with persons who stutter and the other with persons who do not stutter. The third group also consisted of speakers who do not stutter but who spoke non-General American dialect. The results showed that speech naturalness ratings distinguished among the three speaker groups. The variables that appeared to influence speech naturalness ratings were type of dialect, speech fluency, and speaking rate, though they differed across speaker groups. The findings also suggested that strength of speech dialect may be a scaleable dimension that judges can rate with acceptable levels of reliability. Dialect may also be an important factor that needs to be incorporated or controlled within systems designed to train speech naturalness ratings. It may also be an important factor in determining the extent to which stuttering treatment produces natural sounding speech.

Establishing the validity of recovery from stuttering without formal treatment

There is no empirical basis for determining goals for stuttering treatment. One approach that might resolve this issue is to systematically investigate persons who claim to have recovered from stuttering without the assistance of treatment. However, critical methodological and conceptual issues must be overcome first in order to assure these persons had a valid stuttering problem and that their recovery was independent of treatment. This study examined a validation procedure for solving these issues based on the combination of two methods: independent verification and self-reports. Forty-two subjects participated: 14 adults who recovered from stuttering without assistance, 14 adults with persistent stuttering, and 14 adults who were normally fluent speakers. For the independent verification, a Speech Behavior Checklist was administered to 42 individuals familiar with the recovered subjects' past speech and the other subjects' current speech. Results indicated that persons who knew the recovered subjects when they used to stutter recalled speech behaviors consistent with subjects who still stuttered, but not the same as speech behaviors consistent with subjects who never stuttered. These findings were supported by an objective analysis of the recovered subjects' descriptions of their past stuttering. Furthermore, a content analysis of subjects' self-reports indicated that recovery was independent of treatment.

Substance-free residence halls: the promise and the practice

Binge drinking is a serious problem on many college campuses. A number of schools have established substance-free residence halls as one strategy for coping with the problem. The schools have configured these halls very differently. Administrators agree that following certain guidelines can help ensure that substance-free housing succeeds. These guidelines include starting small, involving students in their design and development, keeping the areas separate, considering carefully whether to offer special programming, and enforcing the rules. Administrators have identified effective responses to the various concerns and objections to establishing substance-free residence halls that have sometimes been heard.

Effectiveness of short-term specialized inpatient treatment for war-related posttraumatic stress disorder: a role for adventure-based counseling and psychodrama

Psychological tests were administered to 24 participants of an inpatient posttraumatic stress disorder (PTSD) treatment program both immediately before and following completion of treatment. Responses were compared to a treatment/wait list comparison group composed of 24 subjects awaiting entry into the program. All treatment/wait list comparison group subjects received weekly PTSD outpatient group therapy. Significant improvements were found in the inpatient treatment group in areas of hopelessness, feelings of guilt and shame, loneliness, and emotional expressiveness. Other indices of psychological functional, including interpersonal skills, gender role stress, anxiety, anger, and PTSD symptomatology did not change significantly in response to treatment. No positive changes in any area of psychological function occurred in the treatment/wait list comparison group. Implications for PTSD and areas of future research are discussed.

Program administrator and medical staff attitudes toward six hypothetical medications for substance abuse treatment

There is growing interest in a number of medications with proven clinical efficacy or potential for treating substance abuse. At the same time, many treatment programs make little, if any, use of pharmacotherapy. The reasons for this circumstance are not clear. An exploratory survey using focus groups and telephone interviews with medical personnel and administrators from 38 programs and three professional associations suggests that program staff perceive a variety of drawbacks to pharmacotherapy, which may help account for the lack of more widespread use of this treatment modality.

Cultural responsiveness of drug user treatment programs: approaches to improvement

Many drug user treatment programs have difficulty recruiting, retaining, and successfully treating minority clients. Coupled with the fact that cultural diversity among clients is likely to increase, this consideration makes it critical that programs take steps to increase their responsiveness to minority clients. Among the steps which administrators and clinicians recommend that programs take are conducting a needs assessment; implementing special outreach approaches; hiring additional minority staff; providing staff training and education in cultural sensitivity; and identifying client cultural characteristics at intake.

Addressing the needs of cultural minorities in drug treatment

Many drug treatment programs have difficulty recruiting, retaining, and successfully treating minority clients. Coupled with the fact that cultural diversity among clients is likely to increase, this consideration makes it critical that counselors systematically consider the client's ethnic and racial background during treatment. Experienced clinicians have recommended a number of approaches that counselors can adopt for increasing their cultural responsiveness to minority clients, thereby improving treatment effectiveness with this population of substance abusers.