Eating and drinking experience in patients with idiopathic pulmonary fibrosis: a qualitative study

OBJECTIVE

To explore eating and drinking experiences of patients with idiopathic pulmonary fibrosis (IPF), the impact of any changes associated with their diagnosis and any coping mechanisms developed by patients.

SETTING

Pulmonary fibrosis support groups around the UK and the regional Interstitial Lung Diseases Clinic, Newcastle upon Tyne.

PARTICIPANTS

15 patients with IPF (9 men, 6 women), median age 71 years, range (54-92) years, were interviewed. Inclusion criteria included competent adults (over the age of 18 years) with a secure diagnosis of IPF as defined by international consensus guidelines. Patients were required to have sufficient English language competence to consent and participate in an interview. Exclusion criteria were a history of other lung diseases, a history of pre-existing swallowing problem of other causes that may be associated with dysphagia and individuals with significant communication or other memory difficulties that render them unable to participate in an interview.

DESIGN

A qualitative study based on semistructured interviews used purpose sampling conducted between February 2021 and November 2021. Interviews were conducted via video videoconferencing call platform or telephone call, transcribed and data coded and analysed using a reflexive thematic analysis.

RESULTS

Three main themes were identified, along with several subthemes, which were: (1) Eating, as such, is no longer a pleasure. This theme mainly focused on the physical and sensory changes associated with eating and drinking and their effects and the subsequent emotional and social impact of these changes; (2) It is something that happens naturally and just try and get on with it. This theme centred on the self-determined strategies employed to manage changes to eating and drinking; and (3) What is normal. This theme focused on patients seeking information to better understand the changes in their eating and drinking and the patients' beliefs about what has changed their eating and drinking.

CONCLUSIONS

To our knowledge, this is the first study to report on IPF patients' lived experience of eating and drinking changes associated with their diagnosis. Findings demonstrate that some patients have substantial struggles and challenges with eating and drinking, affecting them physically, emotionally and socially. There is a need to provide better patient information for this area and further study.

Effectiveness of septoplasty compared to medical management in adults with obstruction associated with a deviated nasal septum: the NAIROS RCT

Background

The indications for septoplasty are practice-based, rather than evidence-based. In addition, internationally accepted guidelines for the management of nasal obstruction associated with nasal septal deviation are lacking.

Objective

The objective was to determine the clinical effectiveness and cost-effectiveness of septoplasty, with or without turbinate reduction, compared with medical management, in the management of nasal obstruction associated with a deviated nasal septum.

Design

This was a multicentre randomised controlled trial comparing septoplasty, with or without turbinate reduction, with defined medical management; it incorporated a mixed-methods process evaluation and an economic evaluation.

Setting

The trial was set in 17 NHS secondary care hospitals in the UK.

Participants

A total of 378 eligible participants aged > 18 years were recruited.

Interventions

Participants were randomised on a 1: 1 basis and stratified by baseline severity and gender to either (1) septoplasty, with or without turbinate surgery (n = 188) or (2) medical management with intranasal steroid spray and saline spray (n = 190).

Main outcome measures

The primary outcome was the Sino-nasal Outcome Test-22 items score at 6 months (patient-reported outcome). The secondary outcomes were as follows: patient-reported outcomes - Nasal Obstruction Symptom Evaluation score at 6 and 12 months, Sino-nasal Outcome Test-22 items subscales at 12 months, Double Ordinal Airway Subjective Scale at 6 and 12 months, the Short Form questionnaire-36 items and costs; objective measurements - peak nasal inspiratory flow and rhinospirometry. The number of adverse events experienced was also recorded. A within-trial economic evaluation from an NHS and Personal Social Services perspective estimated the incremental cost per (1) improvement (of ≥ 9 points) in Sino-nasal Outcome Test-22 items score, (2) adverse event avoided and (3) quality-adjusted life-year gained at 12 months. An economic model estimated the incremental cost per quality-adjusted life-year gained at 24 and 36 months. A mixed-methods process evaluation was undertaken to understand/address recruitment issues and examine the acceptability of trial processes and treatment arms.

Results

At the 6-month time point, 307 participants provided primary outcome data (septoplasty, n = 152; medical management, n = 155). An intention-to-treat analysis revealed a greater and more sustained improvement in the primary outcome measure in the surgical arm. The 6-month mean Sino-nasal Outcome Test-22 items scores were -20.0 points lower (better) for participants randomised to septoplasty than for those randomised to medical management [the score for the septoplasty arm was 19.9 and the score for the medical management arm was 39.5 (95% confidence interval -23.6 to -16.4; p < 0.0001)]. This was confirmed by sensitivity analyses and through the analysis of secondary outcomes. Outcomes were statistically significantly related to baseline severity, but not to gender or turbinate reduction. In the surgical and medical management arms, 132 and 95 adverse events occurred, respectively; 14 serious adverse events occurred in the surgical arm and nine in the medical management arm. On average, septoplasty was more costly and more effective in improving Sino-nasal Outcome Test-22 items scores and quality-adjusted life-years than medical management, but incurred a larger number of adverse events. Septoplasty had a 15% probability of being considered cost-effective at 12 months at a £20,000 willingness-to-pay threshold for an additional quality-adjusted life-year. This probability increased to 99% and 100% at 24 and 36 months, respectively.

Limitations

COVID-19 had an impact on participant-facing data collection from March 2020.

Conclusions

Septoplasty, with or without turbinate reduction, is more effective than medical management with a nasal steroid and saline spray. Baseline severity predicts the degree of improvement in symptoms. Septoplasty has a low probability of cost-effectiveness at 12 months, but may be considered cost-effective at 24 months. Future work should focus on developing a septoplasty patient decision aid.

Trial registration

This trial is registered as ISRCTN16168569 and EudraCT 2017-000893-12.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/226/07) and is published in full in Health Technology Assessment; Vol. 28, No. 10. See the NIHR Funding and Awards website for further award information.

Psychosocial impacts of being nil-by-mouth as an adult: A scoping review

AIM

To map existing evidence and identify gaps in the literature concerning psychosocial impacts of being nil by mouth (NBM) as an adult.

DESIGN

A scoping review of the literature was undertaken using JBI guidance. A protocol was registered on the Open Science Framework (osf.io/43g9y). Reporting was guided by Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR).

METHODS

A comprehensive search of six databases (CINAHL, Embase, MEDLINE, PsycINFO, SCOPUS and Web of Science) was performed for studies published up to February 2023, with no restriction to study type. A scope of the grey literature was also undertaken. Two authors independently assessed eligibility and extracted data. Descriptive statistical analysis and narrative synthesis were used, and patient and public involvement included in funding discussions.

RESULTS

A total of 23 papers were included in the review, consisting of 14 primary studies (7 qualitative and 7 quantitative) and 9 grey literature. Both global psychological distress and distress specific to being NBM (thirst, missing food and drink) were reported. Caregivers also experience distress from their family member being NBM. Furthermore, social impacts were reported for both patient and caregiver, primarily social isolation and subsequent low mood.

CONCLUSION

Furthermore, research is needed to understand the prevalence of this population, how best to measure psychosocial impacts and to explore whether (and how) psychosocial impacts change over time. Advancement in this area would enable better service development to optimize care for this patient group. WHAT IS KNOWN ABOUT THIS TOPIC?: Eating and drinking provides more than nutrition and hydration. A wide range of conditions can lead to recommendations for no longer eating and drinking (nil by mouth). Being nil by mouth (NBM) for short periods such as pre-operative fasting causes distress; however, little is understood about impact on longer-term abstinence from eating and drinking. WHAT THIS PAPER ADDS?: Psychosocial consequences of being nil by mouth (NBM)have been investigated by both quantitative and qualitative studies. Being NBM impacts both patients and caregivers in various psychosocial aspects, including distress and social isolation. Several gaps remain, however, regarding ways to measure psychosocial impact of being NBM.

Can we use machine learning to improve the interpretation and application of urodynamic data?: ICI-RS 2023

INTRODUCTION

A "Think Tank" at the International Consultation on Incontinence-Research Society meeting held in Bristol, United Kingdom in June 2023 considered the progress and promise of machine learning (ML) applied to urodynamic data.

METHODS

Examples of the use of ML applied to data from uroflowmetry, pressure flow studies and imaging were presented. The advantages and limitations of ML were considered. Recommendations made during the subsequent debate for research studies were recorded.

RESULTS

ML analysis holds great promise for the kind of data generated in urodynamic studies. To date, ML techniques have not yet achieved sufficient accuracy for routine diagnostic application. Potential approaches that can improve the use of ML were agreed and research questions were proposed.

CONCLUSIONS

ML is well suited to the analysis of urodynamic data, but results to date have not achieved clinical utility. It is considered likely that further research can improve the analysis of the large, multifactorial data sets generated by urodynamic clinics, and improve to some extent data pattern recognition that is currently subject to observer error and artefactual noise.

Clinical effectiveness of septoplasty versus medical management for nasal airways obstruction: multicentre, open label, randomised controlled trial

OBJECTIVE

To assess the clinical effectiveness of septoplasty.

DESIGN

Multicentre, randomised controlled trial.

SETTING

17 otolaryngology clinics in the UK's National Health Service.

PARTICIPANTS

378 adults (≥18 years, 67% men) newly referred with symptoms of nasal obstruction associated with septal deviation and at least moderate symptoms of nasal obstruction (score >30 on the Nasal Obstruction and Symptom Evaluation (NOSE) scale).

INTERVENTIONS

Participants were randomised 1:1 to receive either septoplasty (n=188) or defined medical management (n=190, nasal steroid and saline spray for six months), stratified by baseline symptom severity and sex.

MAIN OUTCOME MEASURES

The primary outcome measure was patient reported score on the Sino-Nasal Outcome Test-22 (SNOT-22) at six months, with 9 points defined as the minimal clinically important difference. Secondary outcomes included quality of life and objective nasal airflow measures.

RESULTS

Mean SNOT-22 scores at six months were 19.9 (95% confidence interval 17.0 to 22.7) in the septoplasty arm (n=152, intention-to-treat population) and 39.5 (36.1 to 42.9) in the medical management arm (n=155); an estimated 20.0 points lower (better) for participants randomised to receive septoplasty (95% confidence interval 16.4 to 23.6, P<0.001, adjusted for baseline continuous SNOT-22 score and the stratification variables sex and baseline NOSE severity categories). Greater improvement in SNOT-22 scores was predicted by higher baseline symptom severity scores. Quality of life outcomes and nasal airflow measures (including peak nasal inspiratory flow and absolute inhalational nasal partitioning ratio) improved more in participants in the septoplasty group. Readmission to hospital with bleeding after septoplasty occurred in seven participants (4% of 174 who had septoplasty), and a further 20 participants (12%) required antibiotics for infections.

CONCLUSIONS

Septoplasty is a more effective intervention than a defined medical management regimen with a nasal steroid and saline spray in adults with nasal obstruction associated with a deviated nasal septum.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN16168569.

Screening for silent aspiration in hyperacute stroke: A feasibility study of clinical swallowing examination and cough reflex testing

BACKGROUND

Silent aspiration (SA) is common post-stroke and associated with increased risk of pneumonia, length of stay and healthcare costs. Clinical swallow examinations (CSEs) are unreliable measures of SA. There is no consensus on the clinical components that best detect SA. Cough reflex testing (CRT) is an alternative/adjunct whose SA detection accuracy also lacks consensus.

AIMS

To investigate the feasibility of CSE versus CRT against gold standard flexible endoscopic evaluation of swallowing (FEES) for SA identification and to estimate its prevalence in a hyperacute stroke setting.

METHODS & PROCEDURES

A single-arm preliminary, prospective, feasibility study of patients less than 72 h post-stroke, over a 31-day period on a hyperacute stroke unit: the Royal Victoria Infirmary, Newcastle-upon-Tyne, UK. Ethical approval for the study was obtained. The study tested the feasibility and acceptability of introducing CRT and developing a standardized CSE. Consent/assent was obtained for all participants. Patients unfit for study were excluded.

OUTCOMES & RESULTS

A total of 62% of patients less than 72 h post-stroke (n = 61) were eligible. A total of 75% of those approached (n = 30) consented. A total of 23 patients completed all tests. The principal barrier was anxiety regarding FEES. Mean test time for CRT = 6 min; CSE = 8 min; FEES = 17 min. Patients rated CRT and FEES on average as moderately uncomfortable. A total of 30% (n = 7) of participants who received FEES presented with SA.

CONCLUSIONS & IMPLICATIONS

CRT, CSE and FEES are feasible in 58% of hyperacute stroke patients in this setting. FEES anxiety is the main recruitment barrier and is not always well tolerated. Results support further work to establish optimum methods and differential sensitivity/specificity of CRT and CSE in hyperacute stroke for SA identification.

WHAT THIS PAPER ADDS

What is already known on this subject SA significantly increases the risk of pneumonia in the early days post-stroke. CSEs are unreliable for identification of SA risk in this population. CRT is gaining popularity as a potential tool to identify stroke patients at risk of SA, though there are questions regarding the efficacy of the clinical protocol currently being used in the UK. What this study adds to existing knowledge This study demonstrates that it is practical and feasible to carry out a larger scale study in this setting to compare CSE and CRT including a consideration of an approach combining both methods for clinical identification of SA versus FEES. Preliminary findings suggest that CSE may have higher levels of sensitivity than CRT for SA identification. What are the potential or actual clinical implications of this work? The results of this study suggest that further work is needed to establish the optimum methods and differential sensitivity/specificity of clinical tools for SA detection in hyperacute stroke.

Oropharyngeal swallowing physiology and safety in patients with Idiopathic Pulmonary Fibrosis: a consecutive descriptive case series

Introduction

Dysphagia occurs in multiple respiratory pathophysiologies, increasing the risk of pulmonary complications secondary to aspiration. Reflux associated aspiration and a dysregulated lung microbiome is implicated in Idiopathic Pulmonary Fibrosis (IPF), but swallowing dysfunction has not been described. We aimed to explore oropharyngeal swallowing in IPF patients, without known swallowing dysfunction.

Methods

Fourteen consecutive outpatients with a secure diagnosis of IPF were recruited and the 10-item Eating Assessment Tool (Eat 10) used to assess patient perception of swallowing difficulty. Oropharyngeal swallowing was assessed in ten patients using Videofluoroscopy Swallow Studies (VFSS). The studies were rated using validated scales: Penetration-Aspiration Scale (PAS); standardised Modified Barium Swallow Impairment Profile (MBSImP).

Results

EAT-10 scores indicated frank swallowing difficulty in 4/14 patients. Videofluoroscopy Studies showed that 3/10 patients had airway penetration, and one aspirated liquid without a cough response. Median MBSImp for oral impairment was 5, range [3–7] and pharyngeal impairment 4, range [1–14] indicating, overall mild alteration to swallowing physiology.

Conclusion

We conclude that people with IPF can show a range of swallowing dysfunction, including aspiration into an unprotected airway. To our knowledge, this is the first report on swallowing physiology and safety in IPF. We believe a proportion of this group may be at risk of aspiration. Further work is indicated to fully explore swallowing in this vulnerable group.

Shrinkage of the non-malignant prostate gland volume after receiving incidental radiotherapy for rectal cancer

Background

The purpose of this study was to assess the impact of coincidental radiotherapy on the volume of the non-malignant prostate gland in rectal cancer patients treated with neo-adjuvant radiotherapy.

Materials and methods

In this retrospective analysis, thirty male patients with rectal cancer who had neoadjuvant radiotherapy met the inclusion criteria. These patients had pre-treatment magnetic resonance imaging (MRI) and at least one post-treatment MRI of the pelvis and the whole of their prostate volume received the full prescribed radiotherapy dose; 45 Gy in 25 fractions (n = 22), 45 Gy in 20 fractions (n = 4) and 25 Gy in 5 fractions (n = 4).

Results

The median age of this patient cohort was 66 years (range: 30–87). With a median interval between pre-treatment MRI and first MRI post-treatment of 2 months (range: 1–11), the mean prostate volume reduced from 36.1 cm³ [standard deviation (SD) 14.2] pre-radiotherapy to 31.3 cm³ (SD 13.0) post radiotherapy and this difference was significant (p = 0.0004).

Conclusion

Radiotherapy may cause shrinkage in volume of normal (non-malignant) prostate. Further research is required in this field, since these results may be of some comfort to men contemplating the consequences of radiotherapy on their quality of life. The authors suggest recording flow-rate and international prostate symptom score (IPSS) during rectal radiotherapy as a next step.

Custom Three-Dimensional-Printed CPAP Mask Development, Preliminary Comfort and Fit Evaluation

Obstructive sleep apnea (OSA) is an acute breathing disorder, which causes soft tissue inside the throat to collapse, thus blocking the airways while sleeping. This syndrome is usually treated by the supply of pressurized air delivered by a pump, which is connected to the patient via mouth and/or nose using a mask as an interface. While most of the literature on OSA is focused on the pressure pump and the therapy conditions (pressure, humidity, velocity, etc.) there has been an increased interest in the mask/interface as a key contributing factor to the treatment's effectiveness. Mask-related issues such as skin damage, allergic reactions, or air leaking due to poor fit can deter OSA patients from following this treatment. This study presents a preliminary evaluation of customized mask designs, which are tailored to specific wearer's facial contours. The development process includes the use of three-dimensional scanning/modeling/printing as an integrated workflow. Individual facial features have been digitally acquired and used to generate a custom device, which conforms to predefined facial landmarks of interest, which delimit the mask contour. A trial study was undertaken by recruiting two healthy volunteers for the fit and comfort evaluation of custom mask designs using a randomized fit test with a series of three-dimensional (3D) printed versus commercial standard mask. Results indicate that custom masks exhibit a higher level of comfort compared to conventional continuous positive airway pressure (CPAP) masks particularly on fit, contact pressure and comfort.

Conducting invasive urodynamics in primary care: qualitative interview study examining experiences of patients and healthcare professionals

BACKGROUND

Invasive urodynamics is used to investigate the causes of lower urinary tract symptoms; a procedure usually conducted in secondary care by specialist practitioners. No study has yet investigated the feasibility of carrying out this procedure in a non-specialist setting. Therefore, the aim of this study was to explore, using qualitative methodology, the feasibility and acceptability of conducting invasive urodynamic testing in primary care.

METHODS

Semi-structured interviews were conducted during the pilot phase of the PriMUS study, in which men experiencing bothersome lower urinary tract symptoms underwent invasive urodynamic testing along with a series of simple index tests in a primary care setting. Interviewees were 25 patients invited to take part in the PriMUS study and 18 healthcare professionals involved in study delivery. Interviews were audio-recorded, transcribed verbatim and analysed using a framework approach.

RESULTS

Patients generally found the urodynamic procedure acceptable and valued the primary care setting due to its increased accessibility and familiarity. Despite some logistical issues, facilitating invasive urodynamic testing in primary care was also a positive experience for urodynamic nurses. Initial issues with general practitioners receiving and utilising the results of urodynamic testing may have limited the potential benefit to some patients. Effective approaches to study recruitment included emphasising the benefits of the urodynamic test and maintaining contact with potential participants by telephone. Patients' relationship with their general practitioner was an important influence on study participation.

CONCLUSIONS

Conducting invasive urodynamics in primary care is feasible and acceptable and has the potential to benefit patients. Facilitating study procedures in a familiar primary care setting can impact positively on research recruitment. However, it is vital that there is a support network for urodynamic nurses and expertise available to help interpret urodynamic results.

Development and reliability of the revised Patterson Edema Scale

OBJECTIVE

The Patterson Edema scale was developed in 2007 to address the lack of a reliable, sensitive scale to measure laryngeal and pharyngeal oedema in patients with head and neck cancer. The objective of this study was to revise the existing Patterson scale to improve its reliability and utility.

DESIGN

Prospective investigation.

SETTING

Academic medical center.

PARTICIPANTS

Speech-Language Pathologists, Otolaryngologists, and Radiation Oncologists.

MAIN OUTCOME MEASURES

Ratings using the Revised Patterson Edema Scale.

METHODS

A consensus group reviewed existing literature regarding the performance of the original Patterson scale and revised the existing scale in regard to items to be included and descriptors for each severity level. The scale was then utilised by 18 speech language pathologists from the US and UK with >2 years-experience working with dysphagia and dysphonia with endoscopy. Each SLP rated a total of eight parameters (epiglottis, vallecula, pharyngoepiglottic folds, aryepiglottic folds, arytenoids, false vocal folds, true vocal folds and pyriform sinuses) using the Revised Patterson Edema Scale. Feedback was solicited from raters regarding areas where clarity was lacking for further scale revision. Scale revisions were completed and additional ratings were completed by otolaryngologists, radiation oncologists and less experienced SLP providers to establish reliability across disciplines. Quadratic weighted Kappa values were obtained to establish interrater reliability.

RESULTS

Feedback received from raters included suggestions for clarification of how to rate unilateral oedema, use of a standard task battery to visualise and rate structures consistently, and clarification of true vocal fold oedema rating parameters. Overall interrater reliability was established using quadratic weighted Kappa with good agreement noted for the epiglottis, vallecula, arytenoids and false vocal folds; moderate agreement noted for aryepiglottic folds, pharyngoepiglottic folds and pyriform sinuses; and fair agreement noted for true vocal folds.

CONCLUSIONS

The Revised Patterson Edema Scale demonstrates moderate-substantial interrater reliability for most parameters across multiple disciplines and experience levels, with the exception of the true vocal folds where agreement was fair. We believe the Revised Patterson Oedema Scale provides a reliable tool for clinicians and researchers to rate oedema in the supraglottic larynx and pharynx following treatment for head and neck cancer.

Development of a smart-fit system for CPAP interface selection

Continuous Positive Airway Pressure (CPAP) therapy is commonly prescribed for longstanding, acute cases of Obstructive Sleep Apnea (OSA) during which patients must wear a tight-fitting breathing mask overnight for the duration of the treatment. Because this condition frequently leads to the permanent use of CPAP masks, interface selection is a crucial factor influencing the treatment quality and effectiveness. Masks/interface selection is normally performed on a trial an error basis with clinicians informing their selection based on OSA-related factors with basic fitting feedback from patients. However, it is not uncommon for patients to abandon the treatment or request additional consultations due to ill-fitting CPAP mask with the main sources of discomfort being perceived air leakage and mask/strap overtightening leading to skin damage. This work introduces a novel system (Smart-Fit), for CPAP interface selection using advanced digital technologies, such as Reverse Engineering and Computational Modeling (Finite Element Analysis) which are paired to evaluate and determine the best fitting interface for each clinical case. The model simplifies the number of 3D facial landmarks to 12 and established that a 2 mm scan resolution is enough for accurate scans. The Von Mises stress map in ANSYS serves as an indicator of potential high-pressure areas, triggering the need for a chance of mask size. Current results indicate the Smart Fit System can enable a "best fit CPAP interface" to be selected considering individual's physical characteristics and existing CPAP interface configurations. The development of the Smart Fit System is an evolution compared to traditional CPAP interface selection approach, which optimizes the CPAP interface selection process.

PRImary care Management of lower Urinary tract Symptoms in men: protocol for development and validation of a diagnostic and clinical decision support tool (the PriMUS study)

INTRODUCTION

Lower urinary tract symptoms (LUTS) is a bothersome condition affecting older men which can lead to poor quality of life. General practitioners (GPs) currently have no easily available assessment tools to help effectively diagnose causes of LUTS and aid discussion of treatment with patients. Men are frequently referred to urology specialists who often recommend treatments that could have been initiated in primary care. GP access to simple, accurate tests and clinician decision tools are needed to facilitate accurate and effective patient management of LUTS in primary care.

METHODS AND ANALYSIS

PRImary care Management of lower Urinary tract Symptoms (PriMUS) is a prospective diagnostic accuracy study based in primary care. The study will determine which of a number of index tests used in combination best predict three urodynamic observations in men who present to their GP with LUTS. These are detrusor overactivity, bladder outlet obstruction and/or detrusor underactivity. Two cohorts of participants, one for development of the prototype diagnostic tool and other for validation, will undergo a series of simple index tests and the invasive reference standard (invasive urodynamics). We will develop and validate three diagnostic prediction models based on each condition and then combine them with management recommendations to form a clinical decision support tool.

ETHICS AND DISSEMINATION

Ethics approval is from the Wales Research Ethics Committee 6. Findings will be disseminated through peer-reviewed journals and conferences, and results will be of interest to professional and patient stakeholders.

TRIAL REGISTRATION NUMBER

ISRCTN10327305.

A systematic review and meta-analysis of antimicrobial resistance in paediatric acute otitis media

OBJECTIVE OF REVIEW

Acute otitis media (AOM) is the largest cause of antimicrobial prescriptions amongst children in developed countries. Excessive and inappropriate prescribing is known to drive antimicrobial resistance, but less is known of antimicrobial resistance in AOM-associated bacteria.

TYPE OF REVIEW & SEARCH STRATEGY

We conducted a systematic review and meta-analysis of bacterial prevalence and antimicrobial resistance in studies of paediatric AOM identified from Ovid Medline, Embase and the Cochrane library.

RESULTS

From 48 unique studies, 15,871 samples were included. Only 0.67 (CI 0.63-0.71) of all ear samples grew a bacterial pathogen. The most common bacterial causes of AOM in children were Streptococcus pneumoniae 0.30 (CI 0.27-0.32), Haemophilus influenza 0.23 (CI 0.20-0.26), and Moraxella catarrhalis 0.05 (CI 0.04-0.06). Resistance patterns varied amongst organisms and antimicrobial agents. The pooled proportion of bacterial culture-positive episodes of AOM that could be effectively treated with amoxicillin was 0.85 (CI 0.76-0.94), erythromycin was 0.64 (0.48-0.78) and amoxicillin-clavulanate was 0.95 (CI 0.85-0.98).

CONCLUSION

We have demonstrated the bacteriology and antimicrobial resistance patterns of AOM. Of samples which grew bacteria, on average approximately 15% of isolates demonstrated resistance to amoxicillin; a typical first-line agent. Greater understanding of local bacteriology and resistance patterns is needed to enable improved antimicrobial stewardship.

Mask interface for continuous positive airway pressure therapy: selection and design considerations

INTRODUCTION

Continuous positive airway pressure (CPAP) therapy is a clinical treatment for moderate or severe obstructive sleep apnea (OSA). Commercial CPAP mask designs normally come in standard sizes and the configuration is not commonly tailored to the patients' characteristics such as face topology, skin sensitivity, and severity of OSA syndrome; however, an optimal mask/interface selection is a key factor influencing the compliance and effectiveness of CPAP treatment.

AREAS COVERED

This review investigates the conventional CPAP mask design, its effect on OSA treatment, and the related risk factors that can lead to skin damage after long-term repeated use. Through a literature search on common databases, Scopus, PubMed, and Google Scholar, we identified reported facts on the influence of the mask interface and current trends toward customized devices.

EXPERT COMMENTARY

There is potential for optimizing the CPAP mask fit by adapting the interface to the patients' individual characteristics. This holds particularly true for users with abnormal features or simply outside conventional industry sizing standards. Enabling technologies for undertaking this adaptation include reverse engineering, computational modeling, and additive manufacturing. There is to date no integrated system that integrates those elements into a standard solution, but several studies have shown its effectiveness for specific cohorts.

Extreme long-term voice outcomes after concurrent chemoradiotherapy for advanced non-laryngeal head and neck cancer: Eight-year post-treatment analysis

BACKGROUND

The long-term effect of concurrent chemoradiation on voice outcomes in the context of non-laryngeal head and neck cancer is not established.

METHODS

A prospective, observational study to evaluate the voice quality in disease-free patients receiving concurrent chemoradiation for advanced non-laryngeal squamous cell carcinoma of the upper aerodigestive tract. Voice assessment occurred at four distinct time-points: pretreatment, 3, 12 and 92.6 months (mean) post-treatment in 34, 21 and nine patients, respectively. The authors used a combination of subjective (VoiSS questionnaire), expert rater-assessed (GRBAS scale) and acoustic analysis of the fundamental frequency to assess voice outcomes. Ethical approval was obtained from the United Kingdom National Research Ethics Service.

RESULTS

Both the VoiSS impairment and GRBAS domains continued to deteriorate over time from pre-treatment to 92.6 months post-treatment (P = 0.03). There was a strong correlation between increase in total VoiSS and GRBAS scores (r = 0.93). Acoustic analysis demonstrated no statistically significant variation in fundamental frequency.

CONCLUSION

Radiation therapy for advanced non-laryngeal head and neck has a significant, deleterious effect on voice, which is apparent up to eight years post-treatment.

An Investigation of the Post-laryngectomy Swallow Using Videofluoroscopy and Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

This study investigates the post-laryngectomy swallow. Presence and degree of residue on the post-laryngectomy swallow as observed on videofluoroscopy and FEES is described. In addition, videofluoroscopy and FEES are assessed for reliability and inter-instrument agreement. 30 laryngectomy subjects underwent dysphagia evaluation using simultaneous videofluoroscopy and FEES. These were reviewed post-examination by three expert raters using a rating scale designed for this purpose. Raters were blinded to subject details, type of laryngectomy surgery, pairing of FEES and videofluoroscopy examinations and the scores of other raters. There was a finding of residue in 78% of videofluoroscopy ratings, and 83% of FEES ratings. Comparison of the tools indicated poor inter-rater reliability and poor inter-instrument agreement. Dysphagia is an issue post laryngectomy as measured by patient self-report and by instrumental evaluation. However, alternative dysphagia rating tools and dysphagia evaluation tools are required to enable accurate identification and intervention for underlying swallow physiology post laryngectomy.

Individualized volume-corrected maximum flow rate correlates with outcome from bladder outlet surgery in men with lower urinary tract symptoms

OBJECTIVES

To develop a per-patient volume correction for maximum flow rate using multiple home uroflowmetry, and to carry out a pilot study to determine the most prognostically useful volume at which to evaluate this measurement and estimate its relationship with outcome from disobstructive bladder outlet surgery.

METHODS

A total of 30 men carried out home uroflowmetry using a portable device and completed symptom scores before surgery. This was repeated at least 4 months after surgery. For each man's presurgery flow data, voided volume was plotted against maximum flow rate, and a line of best fit with logarithmic form calculated. This allowed maximum flow rate to be corrected for any volume. Percentage reduction in symptom score and increase in mean maximum flow rate were correlated with volume-corrected maximum flow rates.

RESULTS

Corrected maximum flow rate at all volumes showed the expected negative correlation with both outcome measures. A statistically significant correlation occurred for volumes >190 mL, with the best performance at volumes >300 mL.

CONCLUSIONS

We have devised a novel method allowing estimation of maximum flow rate at any volume, which is a step forward for non-invasive diagnostics. We found this volume-corrected maximum flow rate to correlate significantly with treatment outcome at sufficiently high volumes.

Cognitive Behavioral Therapy for Functional Dysphonia: A Pilot Study

Objectives:

We sought to investigate whether a brief period of training in cognitive behavioral therapy (CBT) can improve the treatment of functional dysphonia by a speech and language therapist and ameliorate the psychological distress associated with this condition.

Methods:

In a consecutive cohort design, a speech and language therapist treated a small cohort (n = 15) of dysphonic patients with voice therapy alone. After a brief period of CBT training, she treated the next cohort of dysphonic patients (n = 13) with CBT-enhanced voice therapy. Pretreatment and posttreatment measures were taken of voice quality and voice-related quality of life. The General Health Questionnaire 28 and the Hospital Anxiety and Depression Scale were used to assess psychological distress and general well-being.

Results:

All voice measures improved significantly in both cohorts. Both groups improved significantly on the General Health Questionnaire 28, with the CBT group improving significantly more than the control group. Only the CBT group improved significantly on the Hospital Anxiety and Depression Scale (depression subscale).

Conclusions:

Despite limitations of size, design, and between-group baseline differences, the results support the hypothesis that the addition of CBT skills to existing voice therapy is both feasible and clinically effective in the treatment of functional dysphonia.

Evaluation of Potential Predictors of Outcome of Laser-Assisted Uvulopalatoplasty for Snoring

OBJECTIVE: Laser-assisted uvulopalatoplasty (LAUP) is a common treatment for snoring, but up to 50% of patients obtain little or no sustained benefit. We investigated whether pre-operative measurements from lateral cephalometry, acoustic rhinometry, analysis of snoring sounds, and body mass index (BMI) could predict which snorers benefited from LAUP.

STUDY DESIGN AND SETTING: Fifty-five snoring patients were assessed pre- and 6 months post-LAUP. Snoring severity was assessed by objective sound level recorded during polysomnography, and a Snoring Symptoms Inventory (SSI) questionnaire.

RESULTS: The outcome of surgery was assessed by changes in objective sound measurements and in SSI, 6 months after LAUP.

CONCLUSIONS: Relationships between the predictive measurements and outcome were at best only weak and none had sufficient predictive value to be useful in clinical practice.

EBM rating: C-4

The Development of a Snoring Symptoms Inventory

OBJECTIVES: To develop a patient-derived snoring questionnaire, the Snoring Symptoms Inventory (SSI), and explore its structure and relationship to the Epworth Sleepiness Scale (ESS); and to assess the sensitivity of the SSI to change.

STUDY DESIGN AND SETTING: The SSI was developed from an open-ended questionnaire given to 120 habitual snorers. The 25 symptoms reported compose the SSI. This study examines 261 subsequent snorers assessed between April 1998 and August 2002, who completed both the SSI and the ESS. Fifty-five of them underwent laser uvulopalatoplasty and their preoperative and postoperative SSI results were compared.

RESULTS: The total SSI score is the key outcome derived. Principal component analysis identified two further dimensions, one contrasting family/social with work-related problems and another comparing physical problems with embarrassment. The total score correlated weakly with the ESS. Laser uvulopalatoplasty significantly reduced patients' overall symptom severity and family and socially related problems.

CONCLUSION: The SSI is a comprehensive and sensitive measure for assessing snoring, making it a useful clinical outcome tool for snoring treatment.

SIGNIFICANCE: The SSI is a new, useful snoring questionnaire.

EBM rating: B-2b

Psychometric evaluation of the Swallowing Outcomes After Laryngectomy (SOAL) patient-reported outcome measure

BACKGROUND

The purpose of this study was to evaluate the psychometric properties of the Swallowing Outcomes After Laryngectomy (SOAL) in a large group of people who underwent a laryngectomy.

METHODS

We conducted a cross-sectional psychometric study of laryngectomy patients (minimum 3 months posttreatment) attending routine hospital follow-up for the psychometric evaluation of SOAL.

RESULTS

One hundred ten people participated in this study. Thirteen percent of the patients had a laryngectomy, 63% had laryngectomy with radiotherapy, and 24% had laryngectomy with chemoradiation therapy. The SOAL showed good quality of data (minimal missing data and floor effects); good internal consistency (α = 0.91); and adequate test-retest reliability (intra-class correlation coefficient = 0.73). In terms of validity, it differentiated people by treatment group (F(2,85) = 8.02; p = .001) and diet texture group (t(102) = -7.33; p < .001).

CONCLUSION

The SOAL demonstrates good validity and has potential for use in research. Further study is required to determine its clinical application. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1639-E1645, 2016.

Detrusor after-contraction on ambulatory urodynamics in symptomatic women

OBJECTIVES

To investigate the association between detrusor after-contraction and urodynamic parameters in a cohort of patients undergoing urodynamic studies by ambulatory monitoring.

METHODS

All symptomatic adult female patients with non-neurogenic lower urinary tract dysfunction having ambulatory monitoring over the period January 1998 to January 2014 were included. Urodynamic traces were reviewed to identify detrusor after-contraction. Measured urodynamic variables were Qmax (mL/s), V(void) (mL) and P(det.Qmax) (cmH(2)O). Student's unpaired t-test was used to compare the mean of the variable in the detrusor after-contraction and non-detrusor after-contraction groups.

RESULTS

We identified 331 women with a median age of 50 years (range 16-82). Detrusor after-contraction was seen after at least one void in 122 patients giving a prevalence of 37%. A total of 167 (51%) patients had detrusor overactivity. Diagnosis of detrusor overactivity was associated with the presence of detrusor after-contraction (P < 0.05). Overall, patients with detrusor after-contraction had a statistically higher mean P(det.Qmax) (32 vs 28 cmH(2)O, P = 0.04) and lower mean voided volume (300 vs 378 mL, P < 0.001).

CONCLUSION

These findings suggest a relatively high prevalence of detrusor after-contraction during ambulatory monitoring, and an association between detrusor overactivity, V(void), P(det.Qmax) and detrusor after-contraction recorded during ambulatory monitoring. Therefore, a link between detrusor after-contractions and the syndrome of overactive bladder can be postulated.

A pilot study of a new spectrophotometry device to measure tissue oxygen saturation

Tissue oxygen saturation (SO2) measurements have the potential for far wider use than at present but are limited by device availability and portability for many potential applications. A device based on a small, low-cost general-purpose spectrophotometer (the Harrison device) might facilitate wider use. The aim of this study was to compare the Harrison device with a commercial instrument, the LEA O2C.Measurements were carried out on the forearm and finger of 20 healthy volunteers, using a blood pressure cuff on the upper arm to induce different levels of oxygenation. Repeatability of both devices was assessed, and the Bland-Altman method was used to assess agreement between them.The devices showed agreement in overall tracking of changes in SO2. Test-retest agreement for the Harrison device was worse than for O2C, with SD repeatability of 10.6% (forearm) or 18.6% (finger). There was no overall bias between devices, but mean (SD) difference of 1.2 (11.8%) (forearm) or 4.4 (11.5%) (finger) were outside of a clinically acceptable range.Disagreements were attributed to the stability of the Harrison probe and the natural SO2 variations across the skin surface increasing the random error. Therefore, though not equivalent to the LEA O2C, a probe redesign and averaged measurements may help establish the Harrison device as a low cost alternative.

International Continence Society guidelines on urodynamic equipment performance

These guidelines provide benchmarks for the performance of urodynamic equipment, and have been developed by the International Continence Society to assist purchasing decisions, design requirements, and performance checks. The guidelines suggest ranges of specification for uroflowmetry, volume, pressure, and EMG measurement, along with recommendations for user interfaces and performance tests. Factors affecting measurement relating to the different technologies used are also described. Summary tables of essential and desirable features are included for ease of reference. It is emphasized that these guidelines can only contribute to good urodynamics if equipment is used properly, in accordance with good practice.

Haemodialysing babies weighing <8 kg with the Newcastle infant dialysis and ultrafiltration system (Nidus): comparison with peritoneal and conventional haemodialysis

BACKGROUND

To compare the efficacy of the Newcastle infant dialysis and ultrafiltration system (Nidus) with peritoneal dialysis (PD) and conventional haemodialysis (HD) in infants weighing <8 kg.

METHODS

We compared the urea, creatinine and phosphate clearances, the ultrafiltration precision, and the safety of the Nidus machine with PD in 7 piglets weighing 1-8 kg, in a planned randomised cross-over trial in babies, and in babies for whom no other therapy existed, some of whom later graduated to conventional HD.

RESULTS

Two babies entered the randomised trial; 1 recovered rapidly on PD, the other remained on the Nidus as PD failed. Additionally, 9 babies were treated on the Nidus on humanitarian grounds: 3 because of failed PD, and 3 with permanent kidney failure later converted to conventional HD. We haemodialysed 10 babies weighing between 1.8 and 5.9 kg for 2,475 h during 354 Nidus sessions without any clinically important incidents, and without detectable haemolysis. Single-lumen vascular access was used with no blood priming of circuits. The urea, creatinine and phosphate clearances using the Nidus were around 1.5 to 2.0 ml/min in piglets and babies, and were consistently higher than PD clearances, which ranged from about 0.2 to 0.8 ml/min (p ≤ 0.0002 for each chemical). Ultrafiltration was achieved to microlitre precision by the Nidus, but varied widely with PD. Fluid removal using conventional HD was imprecise and resulted in some hypovolaemic episodes requiring correction.

CONCLUSION

The Nidus can provide HD in the Pediatric Intensive Care Unit (PICU) and outpatient intermittent HD without blood priming for babies weighing <8 kg, It generates higher dialysis clearances than PD, and delivers more precise ultrafiltration control than either PD or conventional HD.

Development and preliminary validation of a patient-reported outcome measure for swallowing after total laryngectomy (SOAL questionnaire)

OBJECTIVES

To develop and validate a laryngectomee-specific questionnaire to investigate swallowing function. This paper describes the generation of questionnaire items, pretesting with laryngectomees and a preliminary validation.

DESIGN

This study employed 2 phases: questionnaire development and questionnaire validation. Items were developed from patient (n = 10) and clinician (n = 6) focus groups. Content checking, acceptability and face validity were determined through pretesting with 10 laryngectomees and via consensus feedback from 35 speech and language therapists. During preliminary validation, the 17-item final questionnaire was administered to 3 different groups. Discrimination amongst groups was established by comparing questionnaire responses of a laryngectomee group (n = 19) with known dysphagic (n = 19) and non-dysphagic groups (n = 20). Questionnaire responses from the reference dysphagic group were compared with an instrumental assessment of swallowing, the modified barium swallow (MBS).

SETTING

Large urban teaching hospital.

PARTICIPANTS

Speech and language therapists, laryngectomees, non-dysphagic volunteers, post-radiotherapy dysphagic patients.

MAIN OUTCOME MEASURE

Preliminary validation of SOAL questionnaire.

RESULTS

Normal, laryngectomee and dysphagic groups had significantly different SOAL scores, as did laryngectomees with different degrees of swallowing impairment (Kruskall Wallis, P << 0.001). The subjective SOAL score had a strong positive correlation with the reference measure of ratings on the MBS (r = 0.5; P = 0.03).

CONCLUSIONS

The swallowing outcome after laryngectomy (SOAL) questionnaire is a simple, self-administered tool to assess swallowing function post-total laryngectomy. Further specific testing with a laryngectomy cohort is necessary for full validation. Its potential value lies in screening for dysphagia in clinics or during long-term follow-up of laryngectomees.

Efficacy of the Two-Week Wait Referral System for Head and Neck Cancer: A Systematic Review

The publication of the NHS Cancer Plan by the Department of Health in September 2000 led to an increase in the number of urgent referral clinics as the guidelines stipulated that cancer patients should not wait more than two months from referral to initiation of treatment. 1 following the implementation of these guidelines for head and neck cancer (HNC) referrals in December 2000, the National Institute for Health and Clinical Excellence (NICE) released an update as part of Clinical Guidance 27 in 2005 2 outlining eight key symptoms that should prompt urgent referral to secondary care.

Voice outcomes after concurrent chemoradiotherapy for advanced nonlaryngeal head and neck cancer: a prospective study

BACKGROUND

The voice impact of treatment for nonlaryngeal head and neck primary sites remains unknown.

METHODS

We conducted a prospective study of a consecutive sample of patients undergoing chemoradiation for nonlaryngeal head and neck cancer. The Voice Symptom Scale (VoiSS) was completed, and voice recordings were made at 3 time-points.

RESULTS

Of 42 recruited patients, 34 completed the measures before and in the early posttreatment phase (mean 16.5 weeks), while 21 patients were assessed at the final time-point (mean, 20.4 months). VoiSS scores showed statistically significant progressive deterioration in the total score (p = .02) and impairment subscale (p < .0001) through to the final assessment. Acoustic measures and perceptual ratings deteriorated significantly (p < .001) in the early posttreatment weeks and improved at the final assessment, but not to the baseline. Interrater agreement was excellent for expert measures.

CONCLUSION

To the best of our knowledge, this is the first prospective study to show that chemoradiation therapy for nonlaryngeal head and neck cancer has a significant effect on the patients' self-reported voice quality, even in the long term.

A new voice rating tool for clinical practice

AIMS

Perceptual rating of voice quality is a key component in the comprehensive assessment of voice, but there are practical difficulties in making reliable measurements. We have developed the Newcastle Audio Ranking (NeAR) test, a new referential system for the rating of voice parameters. In this article, we present our first results using NeAR.

METHODS

We asked five experts and 11 naive raters to assess 15 male and 15 female voices using the NeAR test. We assessed: validity with respect to the GRBAS scale; interrater reliability; sensitivity to subtle voice differences; and the performance of expert versus naïve raters.

RESULTS

There was a uniformly excellent agreement with GRBAS (r=0.87) and interrater agreement (intraclass correlation coefficient=0.86). Considering each GRBAS grade of voice separately, there was still good interrater agreement in NeAR, implying it has good sensitivity to subtle changes. All these results were equally true for expert and naive raters.

CONCLUSION

The NeAR test is a promising new tool in the assessment of voice disorders.

Continuous non-invasive measurement of bladder voiding pressure using an experimental constant low-flow test

PURPOSE

We developed a prototype device using an automatically controlled inflatable penile cuff to measure bladder voiding pressure continuously and non-invasively in men. The purpose of this study was to validate the pressure measurements made by this device by comparison to those during simultaneous invasive PFS.

METHODS

A device was developed to automatically modulate flow rate by controlling pressure in a penile cuff. Men undergoing conventional urodynamics studies were recruited to have an additional fill-void cycle whilst using the new device. We report on 40 men using a standardized protocol. Pressure measured by this device was compared with simultaneous vesical pressure by evaluating maximum pressure during voiding, and calculating the root mean square (RMS) difference between p(cuff) and p(ves) .

RESULTS

We recruited 80 men of whom 18 were excluded, 22 were involved in initial development phase and 40 in the standard protocol. Mean (SD) difference between maxima of p(cuff) and p(ves) (1.3 (15.6) cmH(2) O) was not significant. In 20 (50%) men, agreement between p(cuff) and p(ves) throughout the void was moderate or good (RMS difference <20 cmH(2) O). Causes of unsuccessful measurements were identified.

CONCLUSIONS

Although a prototype device, this technique appears to be promising for continuous non-invasive bladder pressure measurement. From the results of this study a number of improvements have been recommended and implemented. The next generation of this technique will allow assessment of clinical application.

The penile cuff test: A clinically useful non-invasive urodynamic investigation to diagnose men with lower urinary tract symptoms

Objectives:

To summarize the development of a novel non-invasive test to categorize voiding dysfunction in men complaining of lower urinary tract symptoms (LUTS) - the penile cuff test.

Methods:

The test involves the controlled inflation of a penile cuff during micturition to interrupt voiding and hence estimate isovolumetric bladder pressure (p_ves.isv). The validity, reliability, and clinical usefulness of the test were determined in a number of studies in men with LUTS.

Results:

The penile cuff test can be successfully performed in over 90% of men with LUTS. The reading of cuff pressure at flow interruption (p_cuff.int) gives a valid and reliable estimate of invasively-measured p_ves.isv and when combined with the reading for maximum flow rate obtained during the test (Q_max) produces an accurate categorization of bladder outlet obstruction (BOO). Use of this categorization prior to treatment allows improved prediction of outcome from prostatectomy.

Conclusion:

The penile cuff test fulfils the criteria as a useful clinical measurement technique applicable to the diagnosis and treatment planning of men with LUTS.

Interobserver agreement for noninvasive bladder pressure flow recording with penile cuff

PURPOSE

We assessed variability in interpreting noninvasive measurements of bladder pressure and urine flow between experienced and novice users of the penile cuff.

MATERIALS AND METHODS

Urodynamicists at 6 sites were asked to use the penile cuff test as part of clinical assessment in 30 men presenting with lower urinary tract symptoms. After a short training period they measured maximum flow rate and cuff interruption pressure from penile cuff test recordings to enable categorization of bladder outlet obstruction using a nomogram. Similar measurements were then made on the same traces by 2 expert observers from the originating center. Interobserver differences were assessed.

RESULTS

Complete agreement on obstruction categorization was seen in 77% of subjects, which increased to 86% when plots positioned on category boundary lines were allocated to the favored category. The 95% confidence limits of interobserver variability in maximum flow rate and cuff interruption pressure measurements were +/- 1.7 ml per second and +/- 13 cm H(2)O, respectively, although a small number of studies yielded discrepancies between observers that were larger than expected. They arose from complex recordings but were equally likely between experts as between expert and novice. Investigation of the causes suggested in some cases how such discrepancies may be avoided in the future.

CONCLUSIONS

The excellent level of agreement in measurement and categorization after a short training period suggests that introducing the penile cuff test as part of assessment in men with lower urinary tract symptoms would be straightforward.

The voice handicap index with post-laryngectomy male voices

BACKGROUND

Surgical treatment for advanced laryngeal cancer involves complete removal of the larynx ('laryngectomy') and initial total loss of voice. Post-laryngectomy rehabilitation involves implementation of different means of 'voicing' for these patients wherever possible. There is little information about laryngectomees' perception of their changed voice quality and communication status. Surgical voice restoration (SVR) has become the 'gold standard' rehabilitation, but there continue to be patients who use other methods of communication. There is no clear evidence comparing patients' perception of their voice handicap across different types of alaryngeal communication.

AIMS

To compare the self-assessed vocal handicap of laryngectomees using SVR with those using non-SVR methods of post-laryngectomy communication.

METHODS & PROCEDURES

Potential participants were identified from one Head and Neck cancer centre in South Wales. They included both male and female participants using all methods of post-laryngectomy communication. Each patient's Voice Handicap Index (VHI) score, sub-set scores, and group means were calculated. Two major confounding factors: age and time since surgery, and communication method (SVR/non-SVR), were considered to identify factors, other than method of communication, which may influence rehabilitation outcomes.

OUTCOMES & RESULTS

A total of 71 questionnaires were sent out and 62 (82%) were returned from 35 patients who had undergone SVR and 27 patients who used non-SVR methods of communication. Of the non-SVR group, twelve used oesophageal voice, eleven an electrolarynx, two writing and two mouthing for communication. The gender ratio (53:9), age (43-90 years) and time since surgery (1-40 years) were broadly representative of this population, but because of the small number of females, we excluded the women from further analysis. Individual VHI scores ranged from 4 to 106. Both the SVR and non-SVR group mean scores: 44.7 and 50.9, were within the range of moderately severe voice handicap. There was no significant difference between the groups for total VHI scores or two of the three sub-domains, nor any significant effect on voice handicap due to the confounding factors assessed: age or time since surgery. The total VHI score was better by 6.5 ( - 4.9 to 17.9) points in the SVR group (p = 0.3), probably reflecting the literature reporting superior voice in SVR.

CONCLUSIONS & IMPLICATIONS

The data suggest that where patient-assessed quality of life is concerned, SVR and non-SVR outcomes are comparable. This is an important consideration when planning and carrying out treatment recommendations. The study has clear clinical implications; understanding the potential of all methods of post-laryngectomy communication is essential for holistic patient management.

Modeling the clinical assessment of men with suspected obstructed voiding using Bayes' Theorem

AIMS

Pressure-flow studies (PFS) are the only reliable way to diagnose bladder outlet obstruction (BOO) in men with lower urinary tract symptoms (LUTS). However, in routine clinical practice, BOO is usually inferred by any of a number of tests (symptoms, flow rate, prostate size...). Bayes' Theorem provides a mathematical method, which may be similar to the process used by clinicians, for combining the results of multiple tests to reach a diagnosis. We have applied Bayes' Theorem to the results of several tests known weakly to predict BOO in men with LUTS to assess if they improve the diagnostic accuracy of a flow rate test which alone is known to predict obstruction moderately well.

METHODS

We applied Bayes' Theorem to data from 50 patients using Q(max) alone and with the inclusion of additional variables (IPSS, PSA, and residual urine), to establish individual probabilities of BOO. The chi-squared statistic (with trend) was used to compare the relative diagnostic values, against the BOO index calculated from the results of subsequent PFS.

RESULTS

The diagnostic value of Q(max) alone (chi-squared = 9.2, P = 0.002), was superior than that for the Bayesian model using the combination of tests available (chi-squared = 4.9, P = 0.026).

CONCLUSIONS

Although in our sample relevant additional tests do not improve the diagnostic power of Q(max) as a predictor of BOO, we believe the Bayesian approach is conceptually suited to modeling clinical decision making but may be better tested for a more clinically relevant outcome such as treatment response.