Qualitative Evaluation Informs the Implementation of a Telehealth Program to Manage Chronic Pain

In response to the opioid epidemic and high rates of chronic pain among the veteran population, the U.S. Department of Veterans Affairs implemented the TelePain-Empower Veterans Program (EVP), a nonpharmacological pain management program for veterans. Delivered virtually, TelePain-EVP incorporates integrated health components (Whole Health, Acceptance and Commitment Therapy, and Mindful Movement) through interdisciplinary personalized coaching. The objective of this quality improvement project was to evaluate the implementation of TelePain-EVP to identify determinants to implementation, benefits and challenges to participation, and recommendations for future direction. We used a qualitative descriptive design to conduct semistructured telephone interviews with TelePain-EVP leaders (n = 3), staff (n = 10), and veterans (n = 22). The interview guides aligned with the Consolidated Framework for Implementation Research (CFIR). Thematic content analysis organized and characterized findings. Several CFIR domains emerged as determinants relevant to program implementation, including innovation (eg, design); individuals (eg, deliverers, recipients); inner (eg, communications) and outer settings (eg, local conditions); and implementation process (eg, reflecting and evaluating). Identified determinants included facilitators (eg, virtual delivery) and barriers (eg, staff shortages). Participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use. Program improvement recommendations included using centralized staff to address vacancies, collecting electronic data, offering structured training, and providing course materials to veteran participants. Qualitative data can inform the sustained implementation of TelePain-EVP and other similar telehealth pain management programs. These descriptive data should be triangulated with quantitative data to objectively assess participant TelePain-EVP outcomes and associated participant characteristics. PERSPECTIVE: A qualitative evaluation of a telehealth program to manage chronic pain, guided by the CFIR framework, identified determinants of program implementation. Additionally, participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use.

Mobile and Web-Based Partnered Intervention to Improve Remote Access to Pain and Posttraumatic Stress Disorder Symptom Management: Recruitment and Attrition in a Randomized Controlled Trial

BACKGROUND

Increasing access to nonpharmacological interventions to manage pain and posttraumatic stress disorder (PTSD) is essential for veterans. Complementary and integrative health (CIH) interventions can help individuals manage symptom burden with enhanced accessibility via remotely delivered health care. Mission Reconnect (MR) is a partnered, self-directed intervention that remotely teaches CIH skills.

OBJECTIVE

The purpose of this paper is to describe the recruitment, onboarding phase, and attrition of a fully remote randomized controlled trial (RCT) assessing the efficacy of a self-directed mobile and web-based intervention for veterans with comorbid chronic pain and PTSD and their partners.

METHODS

A total of 364 veteran-partner dyads were recruited to participate in a mixed methods multisite waitlist control RCT. Qualitative attrition interviews were conducted with 10 veterans with chronic pain and PTSD, and their self-elected partners (eg, spouse) who consented but did not begin the program.

RESULTS

At the point of completing onboarding and being randomized to the 2 treatment arms, of the 364 recruited dyads, 97 (26.6%) failed to complete onboarding activities. Reported reasons for failure to complete onboarding include loss of self-elected partner buy-in (n=8, 8%), difficulties with using remote data collection methods and interventions (n=30, 31%), and adverse health experiences unrelated to study activities (n=23, 24%). Enrolled veterans presented at baseline with significant PTSD symptom burden and moderate-to-severe pain severity, and represented a geographically and demographically diverse population. Attrition interviews (n=10) indicated that misunderstanding MR including the intent of the intervention or mistaking the surveys as the actual intervention was a reason for not completing the MR registration process. Another barrier to MR registration was that interviewees described the mailed study information and registration packets as too confusing and excessive. Competing personal circumstances including health concerns that required attention interfered with MR registration. Common reasons for attrition following successful MR registration included partner withdrawal, adverse health issues, and technological challenges relating to the MR and electronic data collection platform (Qualtrics). Participant recommendations for reducing attrition included switching to digital forms to reduce participant burden and increasing human interaction throughout the registration and baseline data collection processes.

CONCLUSIONS

Challenges, solutions, and lessons learned for study recruitment and intervention delivery inform best practices of delivering remote self-directed CIH interventions when addressing the unique needs of this medically complex population. Successful recruitment and enrollment of veterans with chronic pain and PTSD, and their partners, to remote CIH programs and research studies requires future examination of demographic and symptom-associated access barriers. Accommodating the unique needs of this medically complex population is essential for improving the effectiveness of CIH programs. Disseminating lessons learned and improving access to remotely delivered research studies and CIH programs is paramount in the post-COVID-19 climate.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03593772; https://clinicaltrials.gov/ct2/show/NCT03593772.

Empower Veterans Program (EVP): a chronic pain management program demonstrates positive outcomes among veterans

BACKGROUND

Chronic pain is a highly prevalent health condition among veterans. Traditional pharmacological interventions present unique challenges for chronic pain management including prescription opioid addiction and overdose. In alignment with the 2016 Comprehensive Addiction and Recovery Act and VA's Stepped Care Model to meet veterans' pain management needs, the Offices of Rural Health and Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP) funded an enterprise-wide initiative to implement a Step 3 integrated tele-pain program: Empower Veterans Program (EVP). EVP provides veterans with chronic pain self-care skills using a whole health driven approach to pain management.

OBJECTIVES

The Comprehensive Addiction and Recovery Act prompted the strategic approach to offer non-pharmacological options to meet veterans' pain management needs. EVP, a 10-week interdisciplinary group medical appointment, leverages Acceptance and Commitment Therapy, Mindful Movement, and Whole Health to provide veterans with chronic pain self-care skills. This evaluation was conducted to describe participant characteristics, graduation, and satisfaction rates; and assess pre-post patient-reported outcomes (PRO) associated with EVP participation.

METHODS

A sample of 639 veterans enrolled in EVP between May, 2015 and December, 2017 provided data to conduct descriptive analyses to assess participant demographics, graduation, and satisfaction rates. PRO data were analyzed using a within-participants pre-post design, and linear mixed-effects models were used to examine pre-post changes in PRO.

RESULTS

Of 639 participants, 444 (69.48%) graduated EVP. Participant median program satisfaction rating was 8.41 (Interquartile Range: 8.20-9.20). Results indicate pre-post EVP improvements (Bonferroni-adjusted p < .003) in the three primary pain outcomes (intensity, interference, catastrophizing), and 12 of 17 secondary outcomes, including physical, psychological, health-related quality of life (HRQoL), acceptance, and mindfulness measures.

DISCUSSION

Data suggest that EVP has significant positive outcomes in pain, psychological, physical, HRQoL, acceptance, and mindfulness measures for veterans with chronic pain through non-pharmacological means. Future evaluations of intervention dosing effect and long-term effectiveness of the program is needed.

User Testing of the Veteran Delegation Tool: Qualitative Inquiry

BACKGROUND

Informal caregivers, or care partners, provide critical support to care recipients when managing health care. Veterans Health Administration (VHA) priorities identify care partners as vital in supporting veterans' care management. The Veteran Delegation Tool (VDT) is VHA's Health Insurance Portability and Accountability Act-compliant solution for care partners to comanage veterans' care through VHA's electronic health portal. Human-centered design approaches in VDT development are needed to inform enhancements aimed at promoting uptake and sustained use.

OBJECTIVE

The objective of this prospective descriptive quality improvement project was to use a human-centered design approach to examine VDT use perceptions and practical experiences.

METHODS

This project was conducted using a 4-phase approach: frame, discover, design, and deliver. The frame phase designed the protocol and prepared the VDT system for testing. This paper reports on the discover phase, which used semistructured and follow-up interviews and user testing to examine VDT's benefits, facilitators, and barriers. The discover phase data informed the design and deliver phases, which are underway.

RESULTS

Veterans (24/54, 44%), care partners (21/54, 39%), and individuals who represented dual roles (9/54, 17%)-namely veteran care partner (4/54, 7%), veteran clinical provider (2/54, 4%), and care partner provider (3/54, 6%)-participated in semistructured interviews in the discover phase. A subsample of these participants (3/54, 6%) participated in the follow-up interviews and user testing. Analysis of the semistructured interviews indicated convergence on the respondents' perceptions of VDT's benefits, facilitators, and barriers and recommendations for improving VDT. The perceived benefits were authorized access, comanagement of care needs on the web, communication with the clinical team, access to resources, and ease of burden. Perceived barriers were nonrecognition of the benefits of VDT, technical literacy access issues, increased stress in or burden on care partners, and personal health information security. Participant experiences across 4 VDT activity domains were upgrade to My HealtheVet Premium account, registration, sign-in, and use. User testing demonstrated users' challenges to register, navigate, and use VDT. Findings informed VDT development enhancements and recommendations.

CONCLUSIONS

Care partners need Health Insurance Portability and Accountability Act-compliant access to electronic health portals to assist with care management. VDT is VHA's solution, allowing communication among delegates, veterans, and clinical care teams. Users value VDT's potential use and benefits, while access and navigation improvements to ensure uptake and sustained use are needed. Future efforts need to iteratively evaluate the human-centered phases, design and deliver, of VDT to target audiences. Continued efforts to understand and respond to care partners' needs are warranted.

Primary care virtual resource use prior and post COVID-19 pandemic onset

Background

The COVID-19 pandemic has been a catalyst for rapid uptake of virtual care through the use of virtual health resources (VHR). In the Department of Veterans Affairs (VA) Healthcare System, virtual care has been critical to maintaining healthcare access for patients during COVID-19. In the current study we describe primary care patient aligned care team (PACT) VHR use patterns within one VA medical center (i.e., hospital facility and five community-based outpatient clinics) pre- and post-COVID-19 onset.

Methods

VHR provider and patient use data from 106 individual PACTs were extracted monthly between September 2019 to September 2020. Data were extracted from VHA web-based project application and tracking databases. Using longitudinal data, mixed effect models were used to compare pre- and post-COVID onset slopes.

Results

Findings highlight an increase in patient users of secure messaging (SM) and telehealth. The rate of utilization among these patients increased for SM but not for telehealth visits or online prescription refill (RxRefill) use. Finally, VetLink Kiosk check ins that are done at in person visits, diminished abruptly after COVID-19 onset.

Conclusions

These data provide a baseline of VHR use at the PACT level after the initial impact of the COVID-19 pandemic and can inform healthcare delivery changes within the VA systems over time. Moreover, this project produced a data extraction blueprint, that is the first of its kind to track VA VHR use leveraging secondary data sources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08790-w.

Provider reported value and use of virtual resources in extended primary care prior to and during COVID-19

Background

A proactive approach to delivering care using virtual resources, while reducing in-person contact, is needed during the COVID-19 pandemic.

Objective

In the current study we describe pre- to post- COVID-19 pandemic onset related changes in electronic delivery of primary care.

Methods

A longitudinal, pre-post within-subjects design was used. Patient-aligned care team providers from one VA medical center, a primary care annex, and four affiliated community-based outpatient clinics completed both a baseline and follow up survey (N = 62) or the follow-up survey only (N = 85). The follow-up survey contained questions about COVID-19.

Results

The majority of providers (88%) reported they would continue virtual care once pandemic restrictions were lifted. Most (83%) felt prepared to transition to virtual care when pandemic restrictions began. Use of My HealtheVet, Telehealth, and mobile apps showed a significant increase (22.7%; 31.1%; 48.5%). Barriers to virtual care included (1) internet connectivity; (2) patients’ lack of technology comfort and skills; and (3) technical issues. Main supports to provide virtual care to patients were (1) peers/ colleagues; (2) technology support through help desk; (3) equipment such as laptops and dual screens; (4) being able to use doximety and virtual care manager, and (5) training.

Conclusions

Overall, provider-use and perceptions related to using virtual care improved over time. Providers adapted quickly to providing virtual care during COVID-19 and planned to provide virtual care long-term.

Preliminary Evidence on the Association of Complementary and Integrative Health Care Program Participation and Medical Cost in Veterans

INTRODUCTION

Transforming Health and Resilience through Integration of Values-based Experiences (THRIVE) is a complimentary and integrative health program. THRIVE is delivered through shared medical appointments where participants engage in provider-led education and group discussion on wellness-related topics. THRIVE has been associated with improved patient-reported outcomes in a female veteran cohort. This quality improvement study evaluated the association between THRIVE participation and Veterans Health Administration (VHA) healthcare costs across a 1 year period.

MATERIALS AND METHODS

A cohort study design (n = 184) used VHA administrative data to estimate the cost difference between 1 year pre- and post-THRIVE participation. The 1 year post-cost of the THRIVE cohort was then compared to the 1 year cost of a quasi-experimental waitlist control group (n = 156). Data sources included VHA administrative and electronic health records.

RESULTS

Patients were roughly 51 years old, were typically White/Caucasian, and had a service priority level representing catastrophic disability. The adjusted post-THRIVE cost was $26,291 [95% confidence interval (CI): $23,014-29,015]; $1,720 higher than the previous year's cost but was not statistically significant (P = 0.289). However, a comparison between the THRIVE cohort and a group of waitlist THRIVE patients (n = 156) the intervention group on average was $8,108 more than the waitlist group (95% CI: $3,194-14,005; P < 0.01).

CONCLUSIONS

In summary, data analysis of veterans' annual healthcare cost trajectories were inconclusive. This preliminary study produced mixed results requiring more research with larger samples and randomized control trial methodology. Evidence of whether the THRIVE intervention can maintain cost effectiveness while maintaining its supported evidence of healthcare quality is needed.

Immersive Virtual Reality to Improve Outcomes in Veterans With Stroke: Protocol for a Single-Arm Pilot Study

BACKGROUND

Over the last decade, virtual reality (VR) has emerged as a cutting-edge technology in stroke rehabilitation. VR is defined as a type of computer-user interface that implements real-time simulation of an activity or environment allowing user interaction via multiple sensory modalities. In a stroke population, VR interventions have been shown to enhance motor, cognitive, and psychological recovery when utilized as a rehabilitation adjunct. VR has also demonstrated noninferiority to usual care therapies for stroke rehabilitation.

OBJECTIVE

The proposed pilot study aims to (1) determine the feasibility and tolerability of using a therapeutic VR platform in an inpatient comprehensive stroke rehabilitation program and (2) estimate the initial clinical efficacy (effect size) associated with the VR platform using apps for pain distraction and upper extremity exercise for poststroke neurologic recovery.

METHODS

This study will be conducted in the Comprehensive Integrated Inpatient Rehabilitation Program at the James A Haley Veterans' Hospital. Qualitative interviews will be conducted with 10 clinical staff members to assess the feasibility of the VR platform from the clinician perspective. A prospective within-subject pretest-posttest pilot design will be used to examine the tolerability of the VR platform and the clinical outcomes (ie, upper extremity neurologic recovery, hand dexterity, pain severity) in 10 veteran inpatients. A VR platform consisting of commercially available pain distraction and upper extremity apps will be available at the participants' bedside for daily use during their inpatient stay (approximately 4-6 weeks). Clinician interviews will be analyzed using qualitative descriptive analysis. Cohen d effect sizes with corresponding 95% CIs will be calculated for upper extremity neurologic recovery, hand dexterity, and pain. The proportion of participants who achieve minimal clinically important difference after using the VR platform will be calculated for each clinical outcome.

RESULTS

This study was selected for funding in August 2020. Institutional review board approval was received in October 2020. The project start date was December 2020. The United States Department has issued a moratorium on in-person research activities secondary to COVID-19. Data collection will commence once this moratorium is lifted.

CONCLUSIONS

Our next step is to conduct a large multi-site clinical trial that will incorporate the lessons learned from this pilot feasibility study to test the efficacy of a VR intervention in inpatient rehabilitation and transition to home environments. When VR is used in patients' rooms, it serves to provide additional therapy and may reduce clinician burden. VR also presents an opportunity similar to home-based practice exercises. VR can be implemented in both clinical settings and people's own homes, where engagement in ongoing self-management approaches is often most challenging. This unique experience offers the potential for seamless transition from inpatient rehabilitation to the home.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/26133.

A virtual reality intervention for fear of movement for Veterans with chronic pain: protocol for a feasibility study

BACKGROUND

A key concern for people with chronic pain is experiencing increased pain and/or re-injury. Consequently, individuals with chronic pain can develop a maladaptive fear of movement that leads to adverse functional consequences. A primary goal of chronic pain rehabilitation is re-engagement in feared movements through exposure. This is often challenging since safe movement can be uncomfortable. Virtual environments provide a promising opportunity to safely and gradually expose Veterans to movements that are avoided in the real world. The current study will utilize multiple virtual reality (VR) applications (APPs) of varying the intensity levels ranging from passive distraction from pain to active exposure to feared movement. The primary aims of this pilot are to examine VR as an adjunctive nonpharmacological intervention to assist with the adoption and implementation of skills to decrease fear of movement and increase overall functioning among Veterans with chronic pain. Second, to build a hierarchy of VR APPs to assist in gradual exposure to feared movements.

METHODS

This study will be conducted in the Chronic Pain Rehabilitation Program (CPRP) at the James A. Haley Veterans Hospital, a unique inpatient program within the VA system. Participants will include up to 20 Veterans who receive a VR intervention as part of their physical therapy. A rating form containing qualitative and quantitative experiences will be administered following each VR session to assess feasibility and to provide descriptive information for the proposed hierarchy. Effect sizes will be calculated from intake and discharge measures for the primary outcome fear of movement and secondary pain and functional outcomes.

DISCUSSION

This study will inform the feasibility of a randomized controlled trial examining the clinical utility of using VR to reduce fear of movement and increase function among Veterans with chronic pain. VR has the advantage of being easily implemented both within VA healthcare settings as well as in Veterans' own residences, where engagement in ongoing self-management approaches is often most challenging. Presumably, VR that is matched to patient needs, progresses in intensity, immerses Veterans in the applications, and is perceived positively by Veterans, will result in positive functional outcomes.

Virtual Reality as a Therapy Adjunct for Fear of Movement in Veterans With Chronic Pain: Single-Arm Feasibility Study

Background

Virtual reality (VR) has demonstrated efficacy for distraction from pain-related thoughts and exposure to feared movements. Little empirical VR research has focused on chronic pain management.

Objective

The purpose of this study was to examine the feasibility of VR as an adjunctive intervention for Veterans with chronic pain. We designed a hierarchy ranging from low-intensity pain distraction to high-intensity movement-based exposure for this purpose. VR apps were mapped onto the hierarchy.

Methods

Sixteen Veterans receiving inpatient chronic pain rehabilitation participated in daily VR sessions over a 3-week period. Trajectories across the distraction-to-exposure hierarchy and Veteran-reported intensity ratings were described and evaluated over time. Minimum clinically important differences (MCIDs), pre-post effect sizes, and 95% confidence intervals were examined for fear of movement using the Fear of Daily Activities Questionnaire (FDAQ) and Pain Outcomes Questionnaire-VA (POQ-VA; fear scale). This approach was applied to secondary outcomes: POQ-VA (pain intensity, interference, negative affect), Pain Catastrophizing Scale, and Patient-Specific Functioning Scale (PSFS). Session attendance, completion, and VR experiences were described.

Results

Ten of 14 Veterans (71%) who participated in three or more VR sessions completed the distraction-to-exposure hierarchy. Only three trajectories emerged more than once. Due to high completion rates, Veterans that completed the hierarchy could self-select nonhierarchy apps. Veterans rated all hierarchy levels (low, medium, high) near medium intensity. Self-selected activities were rated as high intensity. For kinesiophobia, six Veterans (38%) exceeded the MCID on the FDAQ and a small effect size improvement was observed (Cohen d=−0.35). The confidence interval (95% CI −0.71 to 0.01) indicated the possibility of a null effect. The POQ-VA fear scale yielded no effect (Cohen d=0.06, 95% CI −0.43 to 0.54). For secondary outcomes, Veterans exceeding MCID were calculated with complete data: pain intensity (1/15, 7%), pain catastrophizing (5/14, 36%), and patient-specific functioning (10/15, 67%). Effect sizes were large for patient-specific functioning (Cohen d=1.14, 95% CI 0.50-1.78), medium for mobility interference (Cohen d=−0.56, 95% CI −0.96 to −0.16), and small for pain intensity (Cohen d=−0.40, 95% CI −0.69 to −0.12) and catastrophizing (Cohen d=−0.41, 95% CI −0.79 to −0.02). No effects were observed for interference in daily activities (Cohen d=0.10, 95% CI −0.27 to 0.47) and negative affect (Cohen d=0.07, 95% CI −0.26 to 0.40). Veterans attended 85.2% (98/108) of VR sessions and completed 95% (93/96) of sessions attended. Twenty-minute sessions were rated as too short. No significant adverse events were reported.

Conclusions

Findings support the feasibility of VR as an adjunct for Veterans with chronic pain. However, the hierarchy will require modification, as evidenced by homogeneous intensity ratings. Veteran-selected activities presented the highest intensity ratings, largest outcome effect size (PSFS), and MCID. This highlights the important role of utilizing Veteran stakeholders in hierarchy modification, design of VR interventions, and outcome selection.

State anxiety as a moderator of real world grocery shopping performance among people with serious mental illness

Anxiety is frequently overlooked as a factor when examining task performance among individuals with serious mental illness. Given the known effects of anxiety on performance in general populations, it is important to examine anxiety and performance within a serious mental illness population. This study examined state anxiety during a grocery-shopping task among 106 individuals diagnosed with a serious mental illness. Results indicate that state anxiety may impact task performance through its relationship with knowledge about grocery-shopping skills. These data suggest the need to examine further the impact of anxiety on task performance in serious mental illness. Furthermore, the identification and treatment of anxiety in persons with SMI may serve to improve functional outcomes and rehabilitation efforts.

Differential interactions between IGFBP-3 and transforming growth factor-beta (TGF-beta) in normal vs cancerous breast epithelial cells

In addition to modulating insulin-like growth factors action, it is now clear that insulin-like growth factor-binding protein-3 also has intrinsic effects on cell growth and survival. We have compared the effects of insulin-like growth factor-binding protein-3 and transforming growth factor-beta on cell proliferation and death of Hs578T cells and the normal breast epithelial cell line, MCF-10A. The growth of MCF-10A cells was inhibited at low concentrations of insulin-like growth factor-binding protein-3 but stimulated at high concentrations. These differential effects were unaffected in the presence of an insulin-like growth factor-I receptor antagonist. A synthetic peptide corresponding to the serine phosphorylation domain of insulin-like growth factor-binding protein-3 (that does not bind to insulin-like growth factors) also mimicked these differential actions. The growth of both cell lines was significantly inhibited by transforming growth factor-beta, this was associated with a 14-fold increase of insulin-like growth factor-binding protein-3 secreted by the Hs578T cells but a five-fold decrease of insulin-like growth factor-binding protein-3 secreted by MCF-10A cells. Replacement doses of exogenous insulin-like growth factor-binding protein-3 overcame the transforming growth factor-beta-induced growth inhibition in the MCF-10A cells. Cell death induced by ceramide was significantly reduced by insulin-like growth factor-binding protein-3 in the MCF-10A cells and depleting insulin-like growth factor-binding protein-3 with transforming growth factor-beta in these cells consequently increased their susceptibility to ceramide. In contrast, insulin-like growth factor-binding protein-3 enhanced apoptosis induced by ceramide in the Hs578T cells but transforming growth factor-beta treated Hs578T cells were resistant to apoptosis. The addition of anti-sense mRNA to insulin-like growth factor-binding protein-3 significantly abrogated this effect of transforming growth factor-beta. These data indicate that insulin-like growth factor-binding protein-3 has intrinsic activity capable of inhibiting or enhancing the growth and survival of breast epithelial cells depending on the cell line and exposure to other cytokines.

Rapid determination of protein folds using residual dipolar couplings

Over the next few years, various genome projects will sequence many new genes and yield many new gene products. Many of these products will have no known function and little, if any, sequence homology to existing proteins. There is reason to believe that a rapid determination of a protein fold, even at low resolution, can aid in the identification of function and expedite the determination of structure at higher resolution. Recently devised NMR methods of measuring residual dipolar couplings provide one route to the determination of a fold. They do this by allowing the alignment of previously identified secondary structural elements with respect to each other. When combined with constraints involving loops connecting elements or other short-range experimental distance information, a fold is produced. We illustrate this approach to protein fold determination on (15)N-labeled Eschericia coli acyl carrier protein using a limited set of (15)N-(1)H and (1)H-(1)H dipolar couplings. We also illustrate an approach using a more extended set of heteronuclear couplings on a related protein, (13)C, (15)N-labeled NodF protein from Rhizobium leguminosarum.

Contrast effects do not underlie effects of preceding liquids on stop-consonant identification by humans

These experiments explored the claim by A. Lotto and K. Kluender (1998) that frequency contrast explains listeners' compensations for coarticulation in the case of liquid consonants coarticulating with following stops. Evidence of frequency contrast in experiments that tested for it directly was not found, but Lotto and Kluender's finding that high- and low-frequency precursor tones can produce contrastive effects on stop-consonant judgments were replicated. The effect depends on the amplitude relation of the tones to the third formant (F3) of the stops. This implies that the tones mask F3 information in the stop consonants. It is unknown whether liquids and following stops in natural speech are in an appropriate intensity relation for masking of the stop. A final experiment, exploiting the McGurk effect, showed compensation for coarticulation by listeners when neither frequency contrast nor masking can be the source of the compensations.

Insulin-like growth factor binding protein-3 (IGFBP-3) potentiates paclitaxel-induced apoptosis in human breast cancer cells

Variability in response to chemotherapy is poorly understood. Paclitaxel-induced apoptosis was assessed in human Hs578T breast cancer cells, using the MTT assay, cell counting, morphological features and flow cytometry. Pre-dosing cells with non-glycosylated insulin-like growth factor binding protein-3 (ngIGFBP-3) had no effect on the cells per se but accentuated paclitaxel-induced apoptosis. The apoptotic pathway was further examined by measuring caspase-3 activity in cell lysates at time points over 48 hr after dosing with paclitaxel. Activity increased significantly, and Western immunoblots for caspase-3 in conditioned media showed that the inactive precursor decreased after incubation with paclitaxel. Endogenous production of IGFBP-3 by the cells after incubation with paclitaxel was evaluated using Western ligand blotting, specific IGFBP-3 immunoblotting and radioimmunoassay. Paclitaxel increased endogenous IGFBP-3, which was further increased if the cells had been pre-dosed with ngIGFBP-3. These findings suggest that IGFBP-3 may be an important modulator of paclitaxel-induced apoptosis.

Direct measurement of 1H-1H dipolar couplings in proteins: a complement to traditional NOE measurements

An intensity-based constant-time COSY (CT-COSY) method is described for measuring 1H-1H residual dipolar couplings of proteins in weakly aligned media. For small proteins, the overall sensitivity of this experiment is comparable to the NOESY experiment. In cases where the 1H-1H distances are defined by secondary structure, such as 1H(alpha)-1H(N) and 1H(N)-1H(N) sequential distances in alpha-helices and beta-sheets, these measurements provide useful orientational constraints for protein structure determination. This experiment can also be used to provide distance information similar to that obtained from NOE connectivities once the angular dependence is removed. Because the measurements are direct and non-coherent processes, such as spin diffusion, do not enter, the measurements can be more reliable. The 1/r3 distance dependence of directly observed dipolar couplings, as compared with the 1/r6 distance dependence of NOEs, also can provide longer range distance information at favorable angles. A simple 3D, 15N resolved version of the pulse sequence extends the method to provide the improved resolution required for application to larger biomolecules.

Contrast effects do not underlie effects of preceding liquids on stop-consonant identification by humans

These experiments explored the claim by A. Lotto and K. Kluender (1998) that frequency contrast explains listeners' compensations for coarticulation in the case of liquid consonants coarticulating with following stops. Evidence of frequency contrast in experiments that tested for it directly was not found, but Lotto and Kluender's finding that high- and low-frequency precursor tones can produce contrastive effects on stop-consonant judgments were replicated. The effect depends on the amplitude relation of the tones to the third formant (F3) of the stops. This implies that the tones mask F3 information in the stop consonants. It is unknown whether liquids and following stops in natural speech are in an appropriate intensity relation for masking of the stop. A final experiment, exploiting the McGurk effect, showed compensation for coarticulation by listeners when neither frequency contrast nor masking can be the source of the compensations.

Perceptual parsing of acoustic consequences of velum lowering from information for vowels

Three experiments were designed to investigate how listeners to coarticulated speech use the acoustic speech signal during a vowel to extract information about a forthcoming oral or nasal consonant. A first experiment showed that listeners use evidence of nasalization in a vowel as information for a forthcoming nasal consonant. A second and third experiment attempted to distinguish two accounts of their ability to do so. According to one account, listeners hear nasalization in the vowel as such and use it to predict that a forthcoming nasal consonant is nasal. According to a second, they perceive speech gestures and hear nasalization in the acoustic domain of a vowel as the onset of a nasal consonant. Therefore, they parse nasal information from a vowel and hear the vowel as oral. In Experiment 2, evidence in favor of the parsing hypothesis was found. Experiment 3 showed, however, that parsing is incomplete.

On the relevance of locus equations for production and perception of stop consonants

We examined the possible relevance of locus equations to human production and perception of stop consonants. The orderly output constraint (OOC) of Sussman, Fruchter, and Cable (1995) claims that humans have evolved to produce speech such that F2 at consonant release and F2 at vowel midpoint are linearly related for consonants so that developing perceptual systems can form representations in an F2ons-by-F2vowel space. The theory claims that this relationship described by locus equations can distinguish consonants, and that the linearity of locus equations is captured in neural representations and is thus perceptually relevant. We investigated these claims by testing how closely locus equations reflect the production and perception of stop consonants. In Experiment 1, we induced speakers to change their locus equation slope and intercept parameters systematically, but found that consonants remained distinctive in slope-by-intercept space. In Experiment 2, we presented stop-consonant syllables with their bursts removed to listeners, and compared their classification error matrices with the predictions of a model using locus equation prototypes and with those of an exemplar-based model that uses F2ons and F2vowel, but not locus equations. Both models failed to account for a large proportion of the variance in listeners' responses; the locus equation model was no better in its predictions than the exemplar model. These findings are discussed in the context of the OOC.

Perceiving the causes of coarticulatory acoustic variation: consonant voicing and vowel pitch

Coarticulatory acoustic variation is presumed to be caused by temporally overlapping linguistically significant gestures of the vocal tract. The complex acoustic consequences of such gestures can be hypothesized to specify them without recourse to context-sensitive representations of phonetic segments. When the consequences of separate gestures converge on a common acoustic dimension (e.g., fundamental frequency), perceptual parsing of the acoustic consequences of overlapping spoken gestures, rather than associations of acoustic features, is required to resolve the distinct gestural events. Direct tests of this theory were conducted. These tests revealed mutual influences of (1) fundamental frequency during a vowel on prior consonant perception, and (2) consonant identity on following vowel stress and pitch perception. The results of these converging tests lead to the conclusion that speech perception involves a process in which acoustic information for coarticulated gestures is parsed from the stream of speech.

Intrinsic fO differences in spoken and sung vowels and their perception by listeners

We explore how listeners perceive distinct pieces of phonetic information that were conveyed in parallel by the fundamental frequency (fO) contour of spoken and sung vowels. In a first experiment, we measured differences in fO of /i/ and /a/ vowels spoken and sung by unselected undergraduate participants. Differences in "intrinsic fO" (with fO of /i/ higher than of /a/) were present in spoken and sung vowels; however, differences in sung words were smaller than those in spoken vowels. Four experiments tested a hypothesis that listeners would not hear the intrinsic fO differences as differences in pitch on the vowel, because they provide information, instead, for production of a closed or open vowel. The experiments provide clear evidence of "parsing" of intrinsic fO from the fO that contributes to perceived vowel pitch. However, only some conditions led to an estimate of the magnitude of parsing that closely matched the magnitude of produced intrinsic fO differences.

Listeners do hear sounds, not tongues

The paper first distinguishes the two perceptual theories, the motor theory and the theory of direct perception, that nearly agree in the claim that listeners to speech perceive vocal tract gestures. Next it justifies the claim of the direct realist theory that listeners perceive gestures and consider some experimental evidence in its favor. Finally it addresses evidence and arguments judged by Ohala to disconfirm the theory. The argument is made that most of the evidence put forward by Ohala is irrelevant to a distinction between theories that we perceive acoustic signals and theories that we perceive gestures. The arguments are inaccurate or highly selective in the data upon which they draw.

Choriocarcinoma presenting as a breast lump

A case of choriocarcinoma in a previously well 32-year-old woman presenting as a tender breast lump whilst she is breastfeeding.

Hemispheric contributions to the integration of visual and auditory information in speech perception

Differential hemispheric contributions to the perceptual phenomenon known as the McGurk effect were examined in normal subjects, 1 callosotomy patient, and 4 patients with intractable epilepsy. Twenty-five right-handed subjects were more likely to demonstrate an influence of a mouthed word on identification of a dubbed acoustic word when the speaker's face was lateralized to the LVF as compared with the RVF. In contrast, display of printed response alternatives in the RVF elicited a greater percentage of McGurk responses than display in the LVF. Visual field differences were absent in a group of 15 left-handed subjects. These results suggest that in right-handers, the two hemispheres may make distinct contributions to the McGurk effect. The callosotomy patient demonstrated reliable McGurk effects, but at a lower rate than the normal subjects and the epileptic control subjects. These data support the view that both the right and left hemisphere can make significant contributions to the McGurk effect.

Invariants, specifiers, cues: an investigation of locus equations as information for place of articulation

This experiment explored the information for place of articulation provided by locus equations--equations for a line relating the second formant (F2) of a vowel at midpoint of F2 of the formant at consonant-vowel (CV) syllable onset. Locus equations cue place indirectly by quantifying directly the degree of coarticulatory overlap (coarticulation resistance) between consonant and vowel. Coarticulation resistance is correlated with place. The experiment tested predictions that when coarticulation resistance varies due to properties of the consonant other than place of articulation (in particular, due to manner of articulation), locus equations would not accurately reflect consonantal place of articulation. These predictions were confirmed. In addition, discriminant analyses, using locus equation variables as classifiers, were generally unsuccessful in classifying a set of consonants representing six different places of articulation. I conclude that locus equations are unlikely to provide useful place information to listeners.

Coordination and coarticulation in speech production

In this article, we consider the concepts of coordination and coarticulation in speech production in the context of a task-dynamic model. Coordination reflects the transient establishment of constrained relationships among articulators that jointly produce linguistically significant actions of the vocal tract--that is phonetic gestures--in a flexible, context-sensitive manner. We ascribe the need for these constraints in part to the requirement of coarticulatory overlap in speech production. Coarticulation reflects temporally staggered activation of coordinative constraints for different phonetic gestures. We suggest that the anticipatory coarticulatory field for a gesture is more limited than look-ahead models have suggested, consistent with the idea that anticipatory coarticulation is the onset of activation of coordinative constraints for a forthcoming gesture. Finally, we ascribe much of the context-sensitivity in the anticipatory or carryover fields of a gesture (variation due to "coarticulation resistance") to low-level (below the speech plan) interactions among the coordinative constraints for temporally overlapping gestures.

Audiovisual integration in perception of real words

Three experiments follow up on Easton and Basala's (1982) report that the "McGurk effect" (an influence of a visibly mouthed utterance on a dubbed acoustic one) does not occur when utterances are real words rather than nonsense syllables. In contrast, with real-word stimuli, Easton and Basala report a strong reverse effect whereby a dubbed soundtrack strongly affects identification of lipread words. In Experiment 1, we showed that a strong McGurk effect does obtain when dubbed real words are discrepant with observed words in consonantal place of articulation. A second experiment obtained only a weak reverse effect of dubbed words on judgments of lipread words. A final experiment was designed to provide a sensitive test of effects of lipread words on judgments of heard words and of heard words on judgments of lipread words. The findings reinforced those of the first two experiments that both effects occur, but, with place-of-articulation information discrepant across the modalities, the McGurk effect is strong and the reverse effect weak.

Audiovisual investigation of the loudness-effort effect for speech and nonspeech events

There is some evidence that loudness judgments of speech are more closely related to the degree of vocal effort induced in speech production than to the speech signal's surface-acoustic properties such as intensity. Other researchers have claimed that speech loudness can be rationalized simply by considering the acoustic complexity of the signal. Because vocal effort can be specified optically as well as acoustically, a study to test the effort-loudness hypothesis was conducted that used conflicting audiovisual presentations of a speaker that produced consonant-vowel syllables with different efforts. It was predicted that if loudness judgments are constrained by effort perception rather than by simple acoustic parameters, then judgments ought to be affected by visual as well as auditory information. It is shown that loudness judgments are affected significantly by visual information even when subjects are instructed to base their judgments only on what they hear. A similar (though less pronounced) patterning of results is shown for a nonspeech "clapping" event, which attests to the generality of the loudness-effort effect previously thought to be special to speech. Results are discussed in terms of auditory, fuzzy logical, motor, and ecological theories of speech perception.

Listening with eye and hand: cross-modal contributions to speech perception

Three experiments investigated the "McGurk effect" whereby optically specified syllables experienced synchronously with acoustically specified syllables integrate in perception to determine a listener's auditory perceptual experience. Experiments contrasted the cross-modal effect of orthographic on acoustic syllables presumed to be associated in experience and memory with that of haptically experienced and acoustic syllables presumed not to be associated. The latter pairing gave rise to cross-modal influences when Ss were informed that cross-modal syllables were paired independently. Mouthed syllables affected reports of simultaneously heard syllables (and vice versa). These effects were absent when syllables were simultaneously seen (spelled) and heard. The McGurk effect does not arise from association in memory but from conjoint near specification of the same causal source in the environment--in speech, the moving vocal tract producing phonetic gestures.

Listening with eye and hand: Cross-modal contributions to speech perception

Three experiments investigated the "McGurk effect" whereby optically specified syllables experienced synchronously with acoustically specified syllables integrate in perception to determine a listener's auditory perceptual experience. Experiments contrasted the cross-modal effect of orthographic on acoustic syllables presumed to be associated in experience and memory with that of haptically experienced and acoustic syllables presumed not to be associated. The latter pairing gave rise to cross-modal influences when Ss were informed that cross-modal syllables were paired independently. Mouthed syllables affected reports of simultaneously heard syllables (and vice versa). These effects were absent when syllables were simultaneously seen (spelled) and heard. The McGurk effect does not arise from association in memory but from conjoint near specification of the same causal source in the environment--in speech, the moving vocal tract producing phonetic gestures.

Audiovisual investigation of the loudness-effort effect for speech and nonspeech events

There is some evidence that loudness judgments of speech are more closely related to the degree of vocal effort induced in speech production than to the speech signal's surface-acoustic properties such as intensity. Other researchers have claimed that speech loudness can be rationalized simply by considering the acoustic complexity of the signal. Because vocal effort can be specified optically as well as acoustically, a study to test the effort-loudness hypothesis was conducted that used conflicting audiovisual presentations of a speaker that produced consonant-vowel syllables with different efforts. It was predicted that if loudness judgments are constrained by effort perception rather than by simple acoustic parameters, then judgments ought to be affected by visual as well as auditory information. It is shown that loudness judgments are affected significantly by visual information even when subjects are instructed to base their judgments only on what they hear. A similar (though less pronounced) patterning of results is shown for a nonspeech "clapping" event, which attests to the generality of the loudness-effort effect previously thought to be special to speech. Results are discussed in terms of auditory, fuzzy logical, motor, and ecological theories of speech perception.

Young infants' perception of liquid coarticulatory influences on following stop consonants

Phonetic segments are coarticulated in speech. Accordingly, the articulatory and acoustic properties of the speech signal during the time frame traditionally identified with a given phoneme are highly context-sensitive. For example, due to carryover coarticulation, the front tongue-tip position for /1/ results in more fronted tongue-body contact for a /g/ preceded by /1/ than for a /g/ preceded by /r/. Perception by mature listeners shows a complementary sensitivity--when a synthetic /da/-/ga/ continuum is preceded by either /al/ or /ar/, adults hear more /g/s following /l/ rather than /r/. That is, some of the fronting information in the temporal domain of the stop is perceptually attributed to /l/ (Mann, 1980). We replicated this finding and extended it to a signal-detection test of discrimination with adults, using triads of disyllables. Three equidistant items from a /da/-/ga/ continuum were used preceded by /al/ and /ar/. In the identification test, adults had identified item ga5 as "ga,' and dal as "da,' following both /al/ and /ar/, whereas they identified the crucial item d/ga3 predominantly as "ga' after /al/ but as "da' after /ar/. In the discrimination test, they discriminated d/ga3 from da1 preceded by /al/ but not /ar/; compatibly, they discriminated d/ga3 readily from ga5 preceded by /ar/ but poorly preceded by /al/. We obtained similar results with 4-month-old infants. Following habituation to either ald/ga3 or ard/ga3, infants heard either the corresponding ga5 or da1 disyllable. As predicted, the infants discriminated d/ga3 from da1 following /al/ but not /ar/; conversely, they discriminated d/ga3 from ga5 following /ar/ but not /al/. The results suggest that prelinguistic infants disentangle consonant-consonant coarticulatory influences in speech in an adult-like fashion.

Duplex perception: a comparison of monosyllables and slamming doors

Duplex perception has been interpreted as revealing distinct systems for general auditory perception and speech perception. The systems yield distinct experiences of the same acoustic signal, the one conforming to the acoustic structure itself and the other to its source in vocal-tract activity. However, this interpretation has not been tested by examining whether duplex perception can be obtained for nonspeech sounds that are not plausibly perceived by a specialized system. In five experiments, we replicate some of the phenomena associated with duplex perception of speech using the sound of a slamming door. Similarities between subjects' responses to syllables and door sounds are striking enough to suggest that some conclusions in the speech literature should be tempered that (a) duplex perception is special to sounds for which there are perceptual modules and (b) duplex perception occurs because distinct systems have rendered different percepts of the same acoustic signal.

Duplex perception: A comparison of monosyllables and slamming doors

Duplex perception has been interpreted as revealing distinct systems for general auditory perception and speech perception. The systems yield distinct experiences of the same acoustic signal, the one conforming to the acoustic structure itself and the other to its source in vocal-tract activity. However, this interpretation has not been tested by examining whether duplex perception can be obtained for nonspeech sounds that are not plausibly perceived by a specialized system. In five experiments, we replicate some of the phenomena associated with duplex perception of speech using the sound of a slamming door. Similarities between subjects' responses to syllables and door sounds are striking enough to suggest that some conclusions in the speech literature should be tempered that (a) duplex perception is special to sounds for which there are perceptual modules and (b) duplex perception occurs because distinct systems have rendered different percepts of the same acoustic signal.

Duplex perception: some initial findings concerning its neural basis

Duplex perception is the simultaneous perception of a speech syllable and of a nonspeech "chirp," and occurs when a single formant transition and the remainder (the "base") of a synthetic syllable are presented to different ears. The current study found a slight but nonsignificant advantage for correct labeling of the fused syllable when the chirp was presented to the left ear. This advantage was amplified in the performance of a "split-brain" subject. A subject with a left pontine lesion performed at chance level when the chirp was presented to her left ear. These findings suggest that some, if not complete, ipsilateral suppression does occur in the dichotic fusion procedure, and that identification of the fused syllable is maximal when the left hemisphere fully processes the linguistic characteristics of the base (through contralateral presentation), and at least minimally processes the frequency transition information of the chirp (through ipsilateral presentation).

Differential shortening of repeated content words produced in various communicative contexts

Three experiments examined the conditions under which repeated words undergo durational shortening in speech. Previous research (Fowler and Housum, 1987) showed that repeated content words are shortened in spontaneous speech. One experiment in the present series found no shortening when words are produced in lists. in a second experiment, reductions were observed for the same words produced in meaningful prose. Words preceded by homophones did not undergo shortening. The findings suggest that shortenings reflect talkers' exploitation of a word's redundancy in the context of a discourse. A final experiment found more shortening of content words produced in a communicative context than in the same discourse, transcribed and read into a microphone. Possibly, the tendency to shorten is increased by the presence of a listener; alternatively, it may reflect the slower speech rate characteristic of spontaneous as compared to read speech.

A new burn area assessment chart

A series of body charts have been designed that are more representative of changing body proportion with increasing age. Being easier to use, these charts have led to a better estimate by the casualty doctor of the body surface area that has been burned.

Functionally specific articulatory cooperation following jaw perturbations during speech: evidence for coordinative structures

In three experiments we show that articulatory patterns in response to jaw perturbations are specific to the utterance produced. In Experiments 1 and 2, an unexpected constant force load (5.88 N) applied during upward jaw motion for final /b/ closure in the utterance /baeb/ revealed nearly immediate compensation in upper and lower lips, but not the tongue, on the first perturbation trial. The same perturbation applied during the utterance /baez/ evoked rapid and increased tongue-muscle activity for /z/ frication, but no active lip compensation. Although jaw perturbation represented a threat to both utterances, no perceptible distortion of speech occurred. In Experiment 3, the phase of the jaw perturbation was varied during the production of bilabial consonants. Remote reactions in the upper lip were observed only when the jaw was perturbed during the closing phase of motion. These findings provide evidence for flexibly assembled coordinative structures in speech production.

Functionally specific articulatory cooperation following jaw perturbations during speech: evidence for coordinative structures

In three experiments we show that articulatory patterns in response to jaw perturbations are specific to the utterance produced. In Experiments 1 and 2, an unexpected constant force load (5.88 N) applied during upward jaw motion for final /b/ closure in the utterance /baeb/ revealed nearly immediate compensation in upper and lower lips, but not the tongue, on the first perturbation trial. The same perturbation applied during the utterance /baez/ evoked rapid and increased tongue-muscle activity for /z/ frication, but no active lip compensation. Although jaw perturbation represented a threat to both utterances, no perceptible distortion of speech occurred. In Experiment 3, the phase of the jaw perturbation was varied during the production of bilabial consonants. Remote reactions in the upper lip were observed only when the jaw was perturbed during the closing phase of motion. These findings provide evidence for flexibly assembled coordinative structures in speech production.

Converging sources of evidence on spoken and perceived rhythms of speech: cyclic production of vowels in monosyllabic stress feet

The article reviews the literature from psychology, phonetics, and phonology bearing on production and perception of syllable timing in speech. A review of the psychological and phonetics literature suggests that production of vowels and consonants are interleaved in syllable sequences in such a way that vowel production is continuous or nearly so. Based on that literature, a hypothesis is developed concerning the perception of syllable timing assuming that vowel production is continuous. The hypothesis is that perceived syllable timing corresponds to the times sequencing of the vowels as produced and not to the timing either of vowel onsets as conventionally measured or of syllable-initial consonants. Three experiments support the hypothesis. One shows that information present during the portion of an acoustic signal in which a syllable-initial consonant predominates is used by listeners to identify the vowel. Compatibly, this information for the vowel contributes to the vowel's perceived duration. Finally, a measure of the perceived timing of a syllable correlates significantly with the time required to identify syllable-medial vowels but not with time to identify the syllable-initial consonants. Further support for the proposed mode of vowel-consonant production and perception is derived from the literature on phonology. Language-specific phonological conventions can be identified that may reflect exaggerations and conventionalizations of the articulatory tendency for vowels to be produced continuously in speech.

Converging sources of evidence on spoken and perceived rhythms of speech: cyclic production of vowels in monosyllabic stress feet

The article reviews the literature from psychology, phonetics, and phonology bearing on production and perception of syllable timing in speech. A review of the psychological and phonetics literature suggests that production of vowels and consonants are interleaved in syllable sequences in such a way that vowel production is continuous or nearly so. Based on that literature, a hypothesis is developed concerning the perception of syllable timing assuming that vowel production is continuous. The hypothesis is that perceived syllable timing corresponds to the times sequencing of the vowels as produced and not to the timing either of vowel onsets as conventionally measured or of syllable-initial consonants. Three experiments support the hypothesis. One shows that information present during the portion of an acoustic signal in which a syllable-initial consonant predominates is used by listeners to identify the vowel. Compatibly, this information for the vowel contributes to the vowel's perceived duration. Finally, a measure of the perceived timing of a syllable correlates significantly with the time required to identify syllable-medial vowels but not with time to identify the syllable-initial consonants. Further support for the proposed mode of vowel-consonant production and perception is derived from the literature on phonology. Language-specific phonological conventions can be identified that may reflect exaggerations and conventionalizations of the articulatory tendency for vowels to be produced continuously in speech.

Production and perception of coarticulation among stressed and unstressed vowels

A pair of experiments examines first the coarticulatory relations among certain stressed and unstressed vowels, and next the perception of coarticulated unstressed vowels. The first study finds the acoustic properties of unstressed medial and, to a substantially lesser extent, of stressed medial, to be assimilated to the properties of their flanking vocalic contexts. Both initial and final flanking vowels coarticulate with medial, but carryover coarticulatory effects tend to exceed anticipatory effects. In a secondary experiment, listeners' manners of perceiving the coarticulated unstressed vowels of the first experiment are shown to be coupled to, or to be compatible with, the talkers' coarticulatory strategies. In particular, perceivers hear acoustically identical vowels to be different when the vowels appear in different contexts of flanking vowels. Similarly, instances of that are acoustically different due to different coarticulatory influences on them sound the same to listeners as long as each appears in its appropriate context of flanking vowels.

Immediate compensation in bite-block speech

An experiment was conducted to examine whether a bite block affects the latency and/or the quality of spoken vowels. The results suggest that vowels spoken with the bite block and vowels spoken normally were (1) of the same latency, that is, the same time elapsed between visual presentation and initiation of response; and (2) of the same quality, and that is, the acoustic measures of the vowels did not differ substantially. Moreover, there was minimal evidence of improvement in either latency or quality with practice, and minimal evidence of an effect of time pressure on the quality of bite-block vowels. A detailed consideration is given to the implications of these and other findings for two recent perspectives on vowel production.