Community-based Participatory Research: A Practical Guide for Radiologists

Community-based participatory research (CBPR) is defined by the Kellogg Community Health Scholars Program as a collaborative process that equitably involves all partners in the research process and recognizes the unique strengths that each community member brings. The CBPR process begins with a research topic of importance to the community, with the goal of combining knowledge and action with social change to improve community health and eliminate health disparities. CBPR engages and empowers affected communities to collaborate in defining the research question; sharing the study design process; collecting, analyzing, and disseminating the data; and implementing solutions. A CBPR approach in radiology has several potential applications, including removing limitations to high-quality imaging, improving secondary prevention, identifying barriers to technology access, and increasing diversity in the research participation for clinical trials. The authors provide an overview with the definitions of CBPR, explain how to conduct CBPR, and illustrate its applications in radiology. Finally, the challenges of CBPR and useful resources are discussed in detail. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

A Culturally Adapted Depression Intervention for African American Adults: An Efficacy Trial

BACKGROUND

Major depressive disorder (MDD) is one of the most common, costly, and debilitating psychiatric disorders in the United States, and the World Health Organization has identified MDD as a leading cause of disability. Although the rates of MDD among African American and White populations in the US are comparable, African Americans in the US tend to experience higher rates of disability associated with MDD compared to White people. Despite the high burden of MDD among African Americans, their use of mental health services is low, in part due to suboptimal care.

OBJECTIVES

This study evaluated the efficacy of a culturally adapted depression intervention (Oh Happy Day Class [OHDC]) compared to an active control, the Coping with Depression (CWD) course.

METHODS

A clustered randomized controlled trial was conducted with a sample of 132 patients with mild to moderate depressive symptoms. They were randomly assigned in a 2-armed randomized controlled trial. They received 1 of 2 (OHDC or CWD) 12-week interventions in weekly in-person group sessions. The primary outcome was a change in depressive symptoms during and post-intervention, measured with the Center for Epidemiologic Studies Depression Scale (CES-D) and the Quick Inventory of Depression Symptoms (QIDS). Analyses included log-rank test and mixed effects linear regression models.

RESULTS

Both interventions were efficacious in reducing symptoms of depression. However, a greater dose of the culturally adapted intervention, Oh Happy Day Class, showed a greater reduction in depression symptoms.

CONCLUSION

This study represents the first randomized controlled trial evaluating the culturally adapted treatment depression intervention, Oh Happy Day Class. These findings provide evidence for and the need for culturally adapted treatments. Future research with larger samples of African Americans from different regions across the US could examine effectiveness and generalizability of the Oh Happy Day Class depression treatment.

Self-reported Dysphagia and Pharyngeal Volume Following Whiplash Injury

Difficulty swallowing has been reported following whiplash injury; however, the reasons remain poorly understood. A possible factor may be the observed changes in pharyngeal volume. The current exploratory study was designed to examine the prevalence of self-reported dysphagia after whiplash and the relationship with recovery status and change in pharyngeal volume. Data were available from a longitudinal study of adults with whiplash. Data included magnetic resonance imaging (MRI) of the cervical spine, the Dysphagia Handicap Index (DHI), and Neck Disability Index (NDI) collected over four timepoints (< 1 week, 2 weeks, 3 months, and 12 months post-injury). Initial cross-sectional analysis examined 60 patients with DHI data from at least one timepoint. A second, longitudinal analysis was conducted on 31 participants with MRI, NDI, and DHI data at both early (< 1-2 weeks) and late (3-12 months) timepoints. The pharynx was contoured on axial T2-weighted MRI slices using OsiriX image processing software and pharyngeal volume (mm³) was quantified. In the 60-patient cohort, prevalence of self-reported dysphagia (DHI ≥ 3) was observed in 50% of participants at least once in 12 months (M = 4.9, SD 8.16, range 0-40). In the longitudinal cohort (n = 31), mean total DHI significantly (p = 0.006) increased between early and late stages. There was no relationship (p = 1.0) between dysphagia and recovery status, per the NDI% score. Pharyngeal volume remained stable and there was no relationship between dysphagia and pharyngeal volume change (p = 1.0). This exploratory study supports the need for further work to understand the nature of dysphagia, extent of functional compromise, and the underlying pathophysiology post-whiplash.

Whiplash-Associated Dysphagia and Dysphonia: A Scoping Review

Swallowing and voice complaints after a whiplash injury have been observed and reported in several studies; however, variability in study design complicates current understanding of whether dysphagia and dysphonia should be recognised as potential adverse outcomes. A scoping review was conducted across six databases from 1950 to March 2019. A total of 18 studies were included for review. Data regarding study purpose, design, outcome measures, participant characteristics and outcomes reported were extracted. Level of evidence (LOE) was assessed by the American Speech-Language Language Association (ASHA)'s LOE system. All studies were exploratory, with 68% rated as poor (< 3) on quality ratings. Nearly half (n = 6) were single case reports. Only three studies investigated some type of swallow-related outcome specifically within the study aim/s. Incidence of swallow-related problems ranged from 2 to 29%, with unspecified complaints of "swallowing difficulty", "dysphagia" and fatigue and pain whilst chewing reported. Neither swallowing biomechanics nor the underlying pathophysiology of swallow or voice complaints was investigated in any study. Four case studies presented post-whiplash voice complaints; two of which described loss of pitch range. Others described hoarseness, loss of control and weak phonation. Most studies only mentioned swallow- or voice-related deficits when reporting a wider set of post-injury symptomatology and six did not describe the outcome measure used to identify the swallow and voice-related problems reported. The existing literature is limited and of low quality, contributing to an unclear picture of the true incidence and underlying mechanisms of whiplash-related dysphagia and dysphonia.

Culturally adapted depression intervention to manage depression among women with infertility in Ghana

This study tested the feasibility of a culturally adapted depression intervention among women with infertility. Women who were seeking medical treatment for infertility were randomized into treatment and control groups. Data were collected at baseline, 6 weeks, 12 weeks, and 3 months post intervention. General linear mixed model using empirical Bayesian estimates for repeated measures was used. The findings indicate an improvement in the women's psychosocial health in the treatment group as compared with the controls. These findings strongly suggest that the management of these psychosocial problems should be an integral part of the management of infertility.

Utilizing the common sense model to explore African Americans' perception of type 2 diabetes: A qualitative study

Illness perceptions, which are likely influenced by patients' cultural contexts, are associated with disease self-management and adherence. African American patients perceptions of type 2 diabetes is not well understood and no known studies has used a comprehensive evidence-based theoretical framework to explore what AAs with type 2 diabetes know, believe, and think about type 2 diabetes. Understanding perceptions of an illness shared by a group of people will be useful in developing culturally-appropriate interventions targeted to the needs of the community. The purpose of this study is to explore African Americans' perceptions of type 2 diabetes based on the common sense model of illness and self-regulation. Using a phenomenology qualitative approach and purposive sampling, 40 African American men and women, age 45-60 years old with diagnosed type 2 diabetes at least one year prior, and who took at least one prescription diabetes medication, participated in six semi-structured 90-minute focus groups conducted in a private space. Qualitative content analysis was conducted to explore African Americans beliefs about type 2 diabetes. Participants expressed that historical issues, e.g., slavery, healthcare providers, the government, and God influenced how they developed diabetes. Participants reported a loss of autonomy, a change of their identity as an employee, a social individual and sexual person, as well as anger and frustration due to having diabetes. Diabetes made the African American family bonding experience of eating difficult, and the disease diminished their cultural experiences. Concerns about diabetes ranged from fear of death and amputations to the inability to prevent the disease among their children/grandchildren. Participants perceived that medications, faith in God, and positive thinking about survival helped control diabetes. Conclusions: Improved diabetes self-management and medication adherence may depend on the meaning African Americans attach to diabetes, available psychosocial support for managing diabetes, and African Americans experience with diabetes.

"I did not want to take that medicine": African-Americans' reasons for diabetes medication nonadherence and perceived solutions for enhancing adherence

BACKGROUND

Diabetes is disproportionally burdensome among African-Americans (AAs) and medication adherence is important for optimal outcomes. Limited studies have qualitatively examined reasons for nonadherence among AAs with type 2 diabetes, though AAs are less adherent to prescribed medications compared to whites. This study explored the reasons for medication nonadherence and adherence among AAs with type 2 diabetes and examined AAs' perceived solutions for enhancing adherence.

METHODS

Forty AAs, age 45-60 years with type 2 diabetes for at least 1 year prior, taking at least one prescribed diabetes medication, participated in six semistructured 90-minute focus groups. Using a phenomenology qualitative approach, reasons for nonadherence and adherence, as well as participants' perceived solutions for increasing adherence were explored. Qualitative content analysis was conducted.

RESULTS

AAs' reasons for intentional nonadherence were associated with 1) their perception of medicines including concerns about medication side effects, as well as fear and frustration associated with taking medicines; 2) their perception of illness (disbelief of diabetes diagnosis); and 3) access to medicines and information resources. Participants reported taking their medicines because they valued being alive to perform their social and family roles, and their belief in the doctor's recommendation and medication helpfulness. Participants provided solutions for enhancing adherence by focusing on the roles of health care providers, patients, and the church. AAs wanted provider counseling on the necessity of taking medicines and the consequences of not taking them, indicating the need for the AA community to support and teach self-advocacy in diabetes self-management, and the church to act as an advocate in ensuring medication use.

CONCLUSION

Intentional reasons of AAs with type 2 diabetes for not taking their medicines were related to their perception of medicines and illness. Solutions for enhancing diabetes medication adherence among AAs should focus on the roles of providers, patients, and the church.

Perceived discrimination and health-related quality-of-life: gender differences among older African Americans

PURPOSE

Emerging data suggest that African-American women may fare worse than African-American men in health-related quality-of-life (HRQOL). Perceived discrimination is an important contributor to poor health overall among African Americans, but few studies examined the intersecting effects of perceived discrimination and gender in explaining HRQOL disparities. We investigated gender differences in HRQOL and tested whether perceived discrimination accounted for these differences.

METHODS

We examined data from the Chicago Health and Aging Project in which 5652 African-American adults aged 65 and older completed structured questionnaires about demographic and socioeconomic characteristics, HRQOL, perceived discrimination, and health-related variables. Logistic regression models were used to identify associations between perceived discrimination and gender differences in poor HRQOL outcomes (defined as 14+ unhealthy days in overall, physical, or mental health over the past 30 days) when controlling for the other variables.

RESULTS

More women reported poor overall HRQOL than men (24 vs. 16% respectively). Higher perceived discrimination was significantly associated with worse overall HRQOL (OR 1.11; 95% CI 1.08, 1.15), with stronger effects for women in overall and mental HRQOL. These gender disparities remained significant until controlling for potentially confounding variables. Perceived discrimination did not account for gender differences in poor physical HRQOL.

CONCLUSIONS

Perceived discrimination is associated with poor HRQOL in older African Americans, with this association appearing stronger in women than men for mental HRQOL. These findings warrant further investigation of effects of perceived discrimination in gender disparities in overall health, and such research can inform and guide efforts for reducing these disparities.

Mental Health in Women With Traumatic Brain Injury: A Systematic Review on Depression and Hope

The prevalence of traumatic brain injury (TBI) in women has recently increased from 25% to 40%. Current literature inadequately captures challenges women face after injury, including depression. The limited focus on depression is problematic as rates of depression are increasing simultaneously with rates of TBI. A disabling symptom of depression is lack of hope; thus, depression, comorbid with TBI, leads to disability among women. Unfortunately, depression and hope among women with TBI has yet to be systematically examined. The purpose of this systematic review is to examine and synthesize current literature focusing on women with TBI, comorbid with depression, and hope.

A culturally adapted depression intervention for African American adults experiencing depression: Oh Happy Day

The purpose of this article is to describe development of a culturally adapted depression intervention (Oh Happy Day Class, OHDC) designed for African American adults experiencing major depressive disorder (MDD). This project included 2 pilot studies testing the feasibility and acceptability of the OHDC and examining short-term effects of the OHDC in reducing symptoms of MDD. The OHDC is a 2.5-hr weekly, culturally specific, cognitive behavioral, group counseling intervention for 12 weeks. Cultural adaptations of the OHDC are based on the ecological validity and culturally sensitive framework, along with an Afrocentric paradigm. Fifty African American participants with MDD were enrolled (15 in Pilot I and 35 in Pilot II). All participants in Pilots I and II received the 12-week intervention and completed assessments at baseline, mid-intervention, end-intervention, and 3 months postintervention. General linear mixed modeling for assessment of pre-post longitudinal data analysis was conducted. Results for Pilot I showed 73% of participants completed the full OHDC, a statistically significant decline in depression symptoms from pre- to postintervention, and a 0.38 effect size. Participants were very satisfied with the OHDC. In Pilot II, 66% of participants completed the full OHDC, and there was a significant pre-post intervention decrease in depression symptoms. For men, the OHDC showed a 1.01 effect size and for women, a 0.41 effect size. Both men and women were very satisfied with the OHDC based on the satisfaction measure. These promising findings are discussed with a focus on future plans for examining efficacy of the OHDC in a large-scale, randomized, control trial.

Self-management priority setting and decision-making in adults with multimorbidity: a narrative review of literature

OBJECTIVES

The purpose of this narrative review was to synthesize current research findings related to self-management, in order to better understand the processes of priority setting and decision-making among adults with multimorbidity.

DESIGN

A narrative literature review was undertaken, synthesizing findings from published, peer-reviewed empirical studies that addressed priority setting and/or decision-making in self-management of multimorbidity.

DATA SOURCES

A search of PubMed, PsychINFO, CINAHL and SocIndex databases was conducted from database inception through December 2013. References lists from selected empirical studies and systematic reviews were evaluated to identify any additional relevant articles.

REVIEW METHODS

Full text of potentially eligible articles were reviewed and selected for inclusion if they described empirical studies that addressed priority setting or decision-making in self-management of multimorbidity among adults. Two independent reviewers read each selected article and extracted relevant data to an evidence table. Processes and factors of multimorbidity self-management were identified and sorted into categories of priority setting, decision-making, and facilitators/barriers.

RESULTS

Thirteen articles were selected for inclusion; most were qualitative studies describing processes, facilitators, and barriers of multimorbidity self-management. The findings revealed that patients prioritize a dominant chronic illness and re-prioritize over time as conditions and treatments change; that multiple facilitators (e.g. support programs) and barriers (e.g. lack of financial resources) impact individuals' self-management priority setting and decision-making ability; as do individual beliefs, preferences, and attitudes (e.g., perceived personal control, preferences regarding treatment).

CONCLUSIONS

Health care providers need to be cognizant that individuals with multimorbidity engage in day-to-day priority setting and decision-making among their multiple chronic illnesses and respective treatments. Researchers need to develop and test interventions that support day-to-day priority setting and decision-making and improve health outcomes for individuals with multimorbidity.

Older African American women's lived experiences with depression and coping behaviours

Little is known about older African American women's lived experiences with depression. What does depression mean to this group? What are they doing about their depression? Unfortunately, these questions are unanswered. This study examined older African American women's lived experiences with depression and coping behaviours. The common sense model provided the theoretical framework for present study. Thirteen community-dwelling African American women aged 60 and older (M = 71 years) participated. Using qualitative phenomenological data analysis, results showed the women held beliefs about factors that can cause depression including experiences of trauma, poverty and disempowerment. Results also indicated the women believed that depression is a normal reaction to life circumstances and did not see the need to seek professional treatment for depression. They coped by use of culturally sanctioned behaviours including religious practices and resilience. It appears these women's beliefs about depression and use of culturally sanctioned coping behaviours might potentially be a barrier to seeking professional mental healthcare, which could result in missed opportunities for early diagnosis and treatment of depression among this group. Implications for research, educational and clinical interventions are discussed.

African American Men’s Beliefs About Mental Illness, Perceptions of Stigma, and Help-Seeking Barriers

Little is known about African American men’s beliefs about mental illness. A descriptive qualitative study, using the common sense model (CSM), examined African American men’s beliefs about mental illness, perceptions of stigma associated with mental illness, and barriers to help-seeking. A total of 17 community-dwelling African American men participated in individual interviews. Dimensional analysis guided by the CSM showed most of the men identified mental illness causal factors consistent with the biopsychosocial model of mental disorders. They believed mental illness is a chronic disorder having negative consequences and reported experiencing barriers to help seeking. In contrast with previous studies, most men in the present study did not perceive stigma associated with mental illness and did not identify stigma as a barrier to help seeking. They were open to help seeking, were optimistic about professional treatment, encouraged others to seek treatment, and expressed strong interest in mental health research. Implications for counseling psychology research and practice are discussed.

Effects of an educational intervention on female biomedical scientists' research self-efficacy

Women and people of color continue to be underrepresented among biomedical researchers to an alarming degree. Research interest and subsequent productivity have been shown to be affected by the research training environment through the mediating effects of research self-efficacy. This article presents the findings of a study to determine whether a short-term research training program coupled with an efficacy enhancing intervention for novice female biomedical scientists of diverse racial backgrounds would increase their research self-efficacy beliefs. Forty-three female biomedical scientists were randomized into a control or intervention group and 15 men participated as a control group. Research self-efficacy significantly increased for women who participated in the self-efficacy intervention workshop. Research self-efficacy within each group also significantly increased following the short-term research training program, but cross-group comparisons were not significant. These findings suggest that educational interventions that target sources of self-efficacy and provide domain-specific learning experiences are effective at increasing research self-efficacy for women and men. Further studies are needed to determine the longitudinal outcomes of this effort.

African American Women's beliefs, coping behaviors, and barriers to seeking mental health services

Little is known about African American women's beliefs about mental illness. In this qualitative study we employed the Common Sense Model (CSM) to examine African American women's beliefs about mental illness, coping behaviors, barriers to treatment seeking, and variations in beliefs, coping, and barriers associated with aging. Fifteen community-dwelling African American women participated in individual interviews. Dimensional analysis, guided by the CSM, showed that participants believed general, culturally specific, and age-related factors can cause mental illness. They believed mental illness is chronic, with negative health outcomes. Participants endorsed the use of prayer and counseling as coping strategies, but were ambivalent about the use of medications. Treatment-seeking barriers included poor access to care, stigma, and lack of awareness of mental illness. Few age differences were found in beliefs, coping behaviors, and barriers. Practice and research implications are discussed.

African American women's beliefs about mental illness, stigma, and preferred coping behaviors

We examined African American women's representations/beliefs about mental illness, preferred coping behaviors if faced with mental illness, whether perceived stigma was associated with treatment-seeking, and if so, whether it was related to beliefs and coping preference, and whether these variables differed by age group. Participants were 185 community-dwelling African American women 25 to 85 years of age. Results indicated the women believed that mental illness is caused by several factors, including family-related stress and social stress due to racism, is cyclical, and has serious consequences but can be controlled by treatment. Participants endorsed low perceptions of stigma. Major preferred coping strategies included praying and seeking medical and mental health care. Age differences were found in all variables except stigma.

Examining differential treatment effects for depression in racial and ethnic minority women: a qualitative systematic review

OBJECTIVE

To examine effectiveness of depression treatment in racial and ethnic minority women.

REVIEW METHODS

INCLUSION CRITERIA

1) the study examined treatment of depression among racial and ethnic minority women age > 17, 2) data analysis was separated by race and ethnicity, and 3) the study was conducted in the United States. Interventions considered were: psychotropic medications, psychotherapy (including cognitive-behavioral, interpersonal therapy and any type of psychotherapy adapted for minority populations) and any type of psychotherapy combined with case management or a religious focus. Individual and group psychotherapy were eligible. Each study was critically reviewed to identify treatment effectiveness specific to racial and ethnic minority women.

RESULTS

Ten published studies met the inclusion criteria (racial and ethnic minority participants n = 2,136). Seven of these were randomized clinical trials, one was a retrospective cohort study, one was a case series, and the remaining one had an indeterminate study design. Participants' age ranged from 18-74 years, with a higher proportion > 40 years. Most were low income. Differences in treatment responses between African-American, Latino and white women were found. Adapted models of care, including quality improvement and collaborative care, were found to be more effective than usual care and community referral in treating depression. Although medication and psychotherapy were both effective in treating depression, low-income women generally needed case management to address other social issues.

CONCLUSION

Adapted models that allow patients to select the treatment of their choice (medication or psychotherapy or a combination) while providing outreach and other supportive services (case management, childcare and transportation) appear to result in optimal clinical benefits.

Dysarthria and dysphagia following treatment for a fourth ventricle choroid plexus papilloma

The present case report describes the presence of a persistent dysarthria and dysphagia as a consequence of surgical intervention for a choroid plexus papilloma (CPP). WM was a nine year ten month old male who at the time of the present study was seven years post-surgery. A comprehensive perceptual and instrumental test battery was used to document the nature of the dysarthria incorporating all components of speech production including respiration, phonation, resonance, articulation, and prosody. The nature of the dysphagia was evaluated through the use of videofluoroscopic evaluation of swallowing (VFS). Assessments confirmed the presence of a LMN dysarthria, marked by deficits in phonation, respiration, and prosody. Dysphagia assessment revealed deficits in oral preparatory, oral and pharyngeal stages of the swallow. The presence of persistent dysarthria and dysphagia in this case has a number of important implications for the management of children undergoing surgery for fourth ventricle CPPs, in particular the need for appropriate treatment, as well as counselling prior to surgery of the possible negative outcomes related to speech and swallowing.

Differential modes of alaryngeal communication and long-term voice outcomes following pharyngolaryngectomy and laryngectomy

Patterns of vocal rehabilitation for 37 pharyngolaryngectomy patients and 55 total laryngectomy patients over a 5-year period were compared. An electrolarynx (EL) was introduced as the initial communication mode immediately after surgery for 98% of patients, with 30% of pharyngolaryngectomy and 74% of laryngectomy patients subsequently developing tracheoesophageal speech (TES) as their primary mode of communication. Follow-up with 14 of 37 pharyngolaryngectomy patients and 36 of 55 laryngectomy patients was conducted 1-6 years following surgery and revealed that 90% of the pharyngolaryngectomy patients maintained the use of TES in the long term compared to 69% of the laryngectomy group. Long-term outcomes relating to communication disability and handicap did not differ significantly between the two surgical groups, however the laryngectomy patients had significantly higher levels of wellbeing. Across the whole group of patients, statistical comparison revealed that patients using TES had significantly lower levels of disability, handicap and distress than EL users. Considering that lower levels of disability, handicap and distress are associated with TES, and the data supports that suitably selected patients can maintain functional TES in the long term, increased application of this form of communication rehabilitation should be encouraged where viable for the pharyngolaryngectomy population.

Impact of malocclusion and orthognathic reconstruction surgery on resonance and articulatory function: an examination of variability in five cases

Articulatory patterns and nasal resonance were assessed before and 6 months after orthognathic reconstruction surgery in five patients with dentofacial deformities. Perceptual and physiological assessments showed disorders of nasality and articulatory function preoperatively, two patients being hyponasal, and one hypernasal. Four patients had mild articulatory deficits, and four had reduced maximal lip or tongue pressures. Operation resulted in different patterns of change. Nasality deteriorated in three patients and articulatory precision and intelligibility improved in only one patient and showed no change in the other four. Operation improved interlabial pressures in three patients, while its impact on tongue pressures varied, being improved in one case, deteriorating in one, and remaining unchanged in the other three. The variability in the results highlights the need for routine assessment of speech and resonance before and after orthognathic reconstruction.

Tongue-to-palate contact patterns and variability of four English consonants in an /i/ vowel environment

Minimal data exist describing tongue-to-palate contact patterns and their variability in normal speakers of English. Consequently, the aims of the present study were to examine, using a comprehensive profile of data analysis, tongue-to-palate contact patterns and their variability in a group of ten normal speakers of English using the Reading Electropalatography3 (EPG3) system. Each speaker produced ten repetitions of the target words tea, leap, sea, and key following the carrier phrase 'I saw a ...'. Results revealed that the contact patterns produced exhibited similar characteristics to those described in earlier research. Additionally, the lateral approximant /i/ exhibited the highest degree of intra-subject variability with the alveolar fricative /s/ exhibiting the least. The results of this study are discussed in relation to existing normative data.

Duration of dysphagic symptoms and swallowing outcomes after thermal burn injury

Levels of swallowing disability, patterns of dysphagia rehabilitation and swallowing outcomes on discharge were retrospectively reviewed for 30 patients with thermal burn injury (with or without inhalation injury), referred to speech pathology services for dysphagia management. The average total surface burn area of the group was 50%. All patients were mechanically ventilated for an average of 24 days, with 80% of patients requiring subsequent tracheostomy. Initial dysphagia assessment occurred approximately 20 days after admission, whereas first safe oral intake was achieved by approximately 30 days. Supplementary nutrition and hydration was necessary for all patients. The time to achieve oral intake without supplementation was 53 days. Outcome measures revealed a significant improvement in swallowing function throughout the duration of inpatient stay, with 90% of patients discharged safely tolerating a normal diet, 6.7% of patients managing soft diet consistencies, and 3.3% managing soft puree consistencies on discharge.

Functional speech outcomes after laryngectomy and pharyngolaryngectomy

OBJECTIVE

To compare and contrast functional speech outcomes of patients having undergone total laryngectomy and pharyngolaryngectomy who use tracheoesophageal speech as their primary mode of communication.

DESIGN

Group comparison design.

SETTING

Adult acute tertiary care hospital.

PATIENTS

Thirty patients who underwent total laryngectomy and 13 who underwent pharyngolaryngectomy with free jejunal interposition reconstruction. All patients used tracheoesophageal speech.

INTERVENTION

Group comparisons across measures of speech intelligibility, voice quality, tracheoesophageal speech use, voice satisfaction and levels of perceived voice disability, handicap, and well-being/distress.

MAIN OUTCOME MEASURE

The existence of any significant differences between the 2 groups on measures of intelligibility, voice quality, tracheoesophageal speech use, and voice satisfaction and levels of voice disability, handicap, and well-being/distress.

RESULTS

Statistical comparisons confirmed reduced functional intelligibility (P<.05), reduced vocal quality (P<.01), and higher levels of disability (P<.05) in the pharyngolaryngectomy group. However, no significant difference was observed between the proportion of patients classified as "successful" tracheoesophageal speech users in either group. Low levels of handicap and high levels of patient well-being were recorded in both groups.

CONCLUSION

Despite the perceptual differences in voice quality and intelligibility observed between the 2 groups, tracheoesophageal speech that is functional, effective, and perceived by the patients as satisfactory can be achieved after total laryngectomy and pharyngolaryngectomy with free jejunal interposition reconstruction.

Real-time continuous visual biofeedback in the treatment of speech breathing disorders following childhood traumatic brain injury: report of one case

The efficacy of traditional and physiological biofeedback methods for modifying abnormal speech breathing patterns was investigated in a child with persistent dysarthria following severe traumatic brain injury (TBI). An A-B-A-B single-subject experimental research design was utilized to provide the subject with two exclusive periods of therapy for speech breathing, based on traditional therapy techniques and physiological biofeedback methods, respectively. Traditional therapy techniques included establishing optimal posture for speech breathing, explanation of the movement of the respiratory muscles, and a hierarchy of non-speech and speech tasks focusing on establishing an appropriate level of sub-glottal air pressure, and improving the subject's control of inhalation and exhalation. The biofeedback phase of therapy utilized variable inductance plethysmography (or Respitrace) to provide real-time, continuous visual biofeedback of ribcage circumference during breathing. As in traditional therapy, a hierarchy of non-speech and speech tasks were devised to improve the subject's control of his respiratory pattern. Throughout the project, the subject's respiratory support for speech was assessed both instrumentally and perceptually. Instrumental assessment included kinematic and spirometric measures, and perceptual assessment included the Frenchay Dysarthria Assessment, Assessment of Intelligibility of Dysarthric Speech, and analysis of a speech sample. The results of the study demonstrated that real-time continuous visual biofeedback techniques for modifying speech breathing patterns were not only effective, but superior to the traditional therapy techniques for modifying abnormal speech breathing patterns in a child with persistent dysarthria following severe TBI. These results show that physiological biofeedback techniques are potentially useful clinical tools for the remediation of speech breathing impairment in the paediatric dysarthric population.

Persistent suppression of humoral and cell-mediated immunity in mice following exposure to the polycyclic aromatic hydrocarbon 7,12-dimethylbenz[a]anthracene

Carcinogen-induced immunosuppression has been implicated as an epigenetic mechanism in promoting the outgrowth and metastasis of neoplastic cells. It has previously been reported that the complete carcinogen 7,12-dimethylbenz[a]anthracene (DMBA) suppresses both humoral immunity (HI) and cell-mediated immunity (CMI) 3-5 days following exposure. Since persistent systemic immunosuppression may be more relevant in tumor outgrowth, assays quantitating HI and CMI, including those functions involved in tumor resistance, were performed 4 and 8 weeks following exposure to tumorigenic doses of DMBA. Adult B6C3F1 female mice were administered DMBA dissolved in corn oil subcutaneously at 5, 50 and 100 micrograms/g body weight in ten equal doses over 2 weeks (corn oil = vehicle control). The number of splenocytes producing IgM antibody to the T-dependent antigen, sheep erythrocytes, was suppressed up to 95% and 98% at 4 and 8 weeks, respectively. The IgG response was similarly depressed 75% and 98% at 4 and 8 weeks, respectively. Lymphoproliferation of splenocytes in response to the mitogens LPS, PHA and Con A were depressed up to 88%, 78% and 83% at 4 weeks and 63%, 63% and 67% respectively, at 8 weeks. In addition, alloantigen-induced proliferation of splenocytes in a one-way mixed lymphocyte culture was suppressed up to 90% at 8 weeks. The ability to generate cytotoxic T-lymphocytes (CTL) in vitro against P815 tumor cells was depressed at both time periods (88% and 60%, respectively) as was natural killer (NK) cell cytolysis of YAC-1 tumor targets (84% and 55%, respectively). The immunosuppression noted in these parameters was similar to that observed within 3-5 days following DMBA dosing. The persistent immunosuppression induced by the PAH carcinogen DMBA, including CTL and NK cell tumoricidal functions, may represent an important epigenetic mechanism contributing to tumor outgrowth or metastasis by this class of agents.

Immunosuppression following 7,12-dimethylbenz[a]anthracene exposure in B6C3F1 mice--II. Altered cell-mediated immunity and tumor resistance

We have previously demonstrated that the polycyclic aromatic hydrocarbons benzo[a]pyrene (B[a]P) and 7,12-dimethylbenz[a]anthracene (DMBA) produce a marked decrease in spleen weight, spleen and bone marrow cellularity and the number of IgM plaque forming cells generated in response to a T-dependent antigen. Exposure to DMBA, but not B[a]P, increased susceptibility to challenge with PYB6 tumor cells and Listeria monocytogenes suggesting that DMBA produces immune impairment involving cell-mediated immunity (CMI) and tumor resistance mechanisms. In this study, female B6C3F1 mice received total doses of 5, 50 and 100 micrograms DMBA/g of body weight in ten subcutaneous injections of 0.5, 5, or 10 micrograms/g over a 2 week period and CMI and tumoricidal functions were examined 3-5 days following the final injection of DMBA. DMBA exposed mice exhibited suppressed splenic cellularity (decreased 62%) and decreased numbers of resident peritoneal cells (down to 47% of control), although the proportion of T cell and T cell subsets, B cells and macrophages in spleens from exposed mice was not altered. Lymphocyte blastogenesis in response to mitogens was suppressed up to 49% with PHA, 48% with Con A and 76% with LPS. The response to alloantigens in unidirectional mixed lymphocyte culture was depressed as much as 73% following exposure to DMBA. Tumor cytolysis mediated by cytotoxic T cells (CTL) was impaired at doses of 50 and 100 micrograms DMBA/g body weight (88-95% suppressed respectively) as was natural killer cell (NK)-mediated tumor cytolysis (24% and 55% suppressed). Antibody-dependent cytotoxicity was significantly depressed in the highest exposure group. Peritoneal macrophage accumulation was decreased in DMBA-treated mice, but the macrophages present were pushed towards activation. The ability of DMBA-exposed mice to eliminate intravenously injected B16F10 tumor cells from the lungs was not impaired. Since NK- and M phi-mediated tumor cytotoxicity are thought to be primarily responsible for pulmonary elimination of B16F10 melanoma cells, the extent of NK suppression observed following DMBA exposure appeared to be insufficient to alter in vivo B16F10 pulmonary elimination. In contrast, the loss of the CTL tumoricidal response correlated with an increased frequency of tumors following challenge with PYB6 tumor cells.

Immunological studies in B6C3F1 mice following exposure to ethylene glycol monomethyl ether and its principal metabolite methoxyacetic acid

Exposure to glycol ethers has been associated with adverse effects in laboratory animals including thymus atrophy and mild leukopenia. These effects may involve depletion of immunoresponsive cells. This study examined possible alterations in immune function and host resistance of B6C3F1 mice following exposure to ethylene glycol monomethyl ether (EGME) or its principal metabolite, methoxyacetic acid (MOAA). EGME and MOAA were administered by gavage to mice in 10 doses over a 2-week period at total dosages of 250, 500, and 1000 micrograms/g of body weight. Following exposure, immunopathology, humoral immunity, cell-mediated immunity, macrophage function, and host resistance to Listeria monocytogenes bacterial challenge were examined. A 48% reduction in thymus weight was observed at the intermediate and high doses of both chemicals. No significant alterations in immune function or host resistance to L. monocytogenes were observed in animals exposed to either EGME or MOAA.

Immunosuppression following 7,12-dimethylbenz[a]anthracene exposure in B6C3F1 mice. I. Effects on humoral immunity and host resistance

It has previously been demonstrated that the polycyclic aromatic hydrocarbon (PAH), benzo(a)pyrene (B[a]P), suppresses the terminal step in B-cell differentiation, resulting in a decrease in antibody production to T-dependent and B-2 T-independent antigens. The purpose of this study was to ascertain if this effect was common to carcinogenic PAHs or specific for B[a]P. The PAH 7,12-dimethylbenz[a]anthracene (DMBA) was administered to B6C3F1 female mice by ten sc injections of 0.5, 5, or 10 micrograms/g over a 2-week period (i.e., total dose of 5, 50, and 100 micrograms/g). Immune function and host resistance assays were performed 3 to 5 days following the last injection. The 10 micrograms/g dosage resulted in a marked decrease in spleen weights and spleen and bone marrow cellularity, while thymus and body weights were not significantly altered. The ability to generate B-lymphocyte colonies in vitro from spleen precursor cells was also suppressed at the 10 micrograms/g dose. Exposure to DMBA at 5 micrograms/g or greater resulted in a reduction of up to 97% in the number of IgM plaque-forming cells in response to the T-dependent antigen sheep red blood cells (SRBC). The IgG response to SRBC was similarly depressed. The IgM response to the hapten-conjugated T-independent antigens trinitrophenyl-lipopolysaccharide (TNP-LPS) (specific for B-1 cells) and trinitrophenyl (TNP)-Ficoll (specific for B-2 cells) was also depressed (88 and 97%, respectively) at 10 micrograms/g. DMBA exposure resulted in an increased susceptibility to challenge with the PYB6 transplantable sarcoma and the bacterium Listeria monocytogenes, in contrast to B[a]P exposure, which had no effect on host resistance assays. Thus, DMBA, a more potent carcinogen than B[a]P, produces a more extensive B-cell suppression than B[a]P as well as alters host resistance to tumor and bacterial challenge.

Immunotherapy of a murine leukemia virus-infected, chemically induced murine sarcoma with antiviral antibodies

Many murine tumor models associated with murine leukemia virus(es) (MuLV) have been successfully treated by passive administration of antiviral antibodies. There is a large body of virus-negative tumors, however, which are lowly antigenic and thus refractory to such approaches. Therefore, an investigation was done for determination of whether such tumors could be rendered susceptible to passive serum therapy by introduction of MuLV antigens onto the tumor cell surface. For this purpose a 3-methylcholanthrene-induced fibro-sarcoma from inbred C57BL/6J mice was chosen. Following infection of the tumor in vitro with Friend murine leukemia virus (F-MuLV), the tumor was found to be susceptible to treatment with a high-titered heterologous anti-F-MuLV gp71 antiserum. The specificity of the treatment was determined by conduction of the therapy on the uninfected parental tumor, in which case there was no effect. In addition, therapy could be initiated at time points when demonstrable tumors were present and successfully treated animals were resistant to rechallenge with the infected tumor. Thus conversion of a lowly antigenic virus-negative tumor to an MuLV-positive antigenic tumor rendered such growths susceptible to immunologic management.

In vivo antigenic modification of tumor cells. I. Introduction of murine leukemia virus antigens on non-virus-producing murine sarcomas

Murine oncovirus antigens represent excellent targets for immune recognition, and virus-associated tumors are generally susceptible to various immunotherapy protocols. Virus-negative tumors, however, are nonimmunogenic and refractory to immunologic control. Therefore, the feasibility of the introduction of antigens onto non-virus-expressing tumors in situ in inbred C57BL/6J mice by systemic administration of nononcogenic murine retroviruses was investigated. Two classes of murine fibrosarcomas were studied: a 3-methylcholanthrene-induced fibrosarcoma syngeneic to C57BL/6 mice (MCA-FS) and a Harvey murine sarcoma virus-transformed, nonproducer fibrosarcoma syngeneic to C57BL/6 mice (H-NP). Both were found to be devoid of infectious ecotropic murine leukemia virus (MuLV) or MuLV antigens. A single dose of Friend murine leukemia virus (F-MuLV) was used to superinfect MCA-FS- and H-NP-induced tumors in vivo and converted these tumors to a highly productive, virus-positive state. In vivo superinfected tumors were indistinguishable from their preinfected counterparts by competition radioimmunoassays for the virion's major envelope glycoprotein, gp71, and its group-specific antigen, p30, and by assays for infectious virus. Analysis of virus from tumor extracts proved that the antigenic specificity of the superinfected tumor was provided by F-MuLV administered systemically to the animals. Finally, an immunoperoxidase technique, applied to tumor cross sections, demonstrated the uniform appearance of viral antigens in the superinfected tumors.

In vivo antigenic modification of tumor cells. II. Distribution of virus in sarcoma-bearing mice

Murine leukemia viruses were previously demonstrated to be able to infect efficiently non-virus-expressing tumors in vivo. In the present study the infectivity and tissue distribution of Friend murine leukemia virus (F-MuLV) in normal and tumor-bearing C57BL/6J (B6) mice were examined. Two syngeneic fibrosarcoma-inducing cell lines were used: Cells from a 3-methylcholanthrene-induced fibrosarcoma syngeneic to B6 mice (MCA-FS) and cells from a Harvey murine sarcoma virus-transformed, nonproducer sarcoma syngeneic to B6 mice (H-NP) were described in the preceding study. Both cell lines lacked ecotropic viral expression. F-MuLV produced in vitro was rarely able to infect normal adult B6 tissue in vivo and lacked pathogenic potential. Adult animals receiving F-MuLV remained clinically normal during 20 months of follow-up and had no detectable viremia, although some had persistently infected thymuses and long bones. In animals receiving a single dose of F-MuLV given to superinfect either the MCA-FS or the H-NP induced tumors, virion antigens were found only in tumor tissue and not in the normal host organs studied. Infectious virus was abundant in tumors; occasionally, it was found in thymuses and long bones of animals bearing superinfected H-NP tumors but rarely in other organs. Localization of F-MuLV in MCA-FS tumors appeared to be more selective with rare contamination of host organs. The presence of a rescuable sarcoma genome in H-NP may explain the discrepancy between MCA-FS and H-NP tumors. The possibility of increasing the efficiency and selectivity of infection as well as the therapeutic application of this technique are discussed.