Rehabilitation Treatment Specification System: Content and Criterion Validity Across Evidence-Based Voice Therapies for Muscle Tension Dysphonia

PURPOSE

Systematically improving voice therapy outcomes is challenging as the clinician actions (i.e., active ingredients) responsible for improved patient functioning (i.e., targets) are relatively unknown. The theory-driven Rehabilitation Treatment Specification System (RTSS) and standard, voice-specific terminology based on the RTSS (RTSS-Voice) may help address this problem. This qualitative study evaluated if the RTSS and RTSS-Voice can describe four evidence-based voice therapies for muscle tension dysphonia without missing critical aspects (content validity) and identify commonalities and differences across them (criterion validity).

METHOD

Qualitative interviews were completed between the clinicians (protocol experts) who developed and/or popularized the vocal function exercises, laryngeal reposturing, circumlaryngeal massage, and conversation training therapies as well as RTSS experts to produce RTSS specifications that met two consensus criteria: (a) The protocol expert agreed that the specification represented their treatment theory, and (b) the RTSS experts agreed that the specifications correctly adhered to both the RTSS framework and the RTSS-Voice's standard terminology.

RESULTS

The RTSS and RTSS-Voice comprehensively described voice therapy variations across and within the four diverse treatment programs, needing only the addition of one new target: overall auditory-perceptual severity.

CONCLUSIONS

The RTSS and RTSS-Voice exhibited strong content validity. The standard RTSS-Voice terminology helped identify, for the first time, commonalities and differences in treatment ingredients, targets, and mechanisms of action across four treatments developed for the same patient population. In the long term, the RTSS and RTSS-Voice could provide the framework for an ever-growing collection of clinically meaningful and evidence-based therapy algorithms with potential to improve research, education, and clinical care.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25537624.

Prevalence of Anxiety as a Variable in Treatment Outcomes for Individuals With Chronic Refractory Cough

PURPOSE

Anxiety is a mental state characterized by an intense sense of tension, worry, or apprehension relative to something adverse that might happen in the future. Anxiety is a known comorbidity in cough patients, yet its prevalence among those with chronic refractory cough (CRC) is unknown. Anxiety is not typically assessed during evaluation for CRC, but treatments for CRC such as neuromodulators and behavioral cough suppression therapy (BCST) may potentially attenuate anxiety. This preliminary study investigates the potential prevalence of anxiety in CRC and its possible role in treatment outcomes.

METHOD

CRC patients seen in a specialty clinic at the University of Utah or the University of Montana completed the Leicester Cough Questionnaire (LCQ) pre- and post-BCST treatment. Participants were dichotomized into positive anxiety screen (PAS) and negative anxiety screen (NAS) groups based on presence or absence of documented anxiety within electronic medical records at the University of Utah and based on a Generalized Anxiety Disorder-7 score > 5 at the University of Montana.

RESULTS

Of the 86 total participants, 37 (43%) were in the PAS group (29 females, Mage = 56 ± 13) and 49 (57%) were in the NAS group (36 females, Mage = 64 ± 14). Eighty-nine percent of CRC participants with a PAS reported a clinically meaningful improvement in LCQ total score following treatment compared to 65% of NAS participants. Furthermore, mean pre- to posttreatment change scores on the LCQ were significantly greater within the PAS group (p = .002, Cohen's d = 0.7, indicating a moderate to large effect size).

CONCLUSION

This preliminary study suggests that (a) anxiety may be prevalent among those with CRC and (b) those patients who screen positive for anxiety report greater benefit from BCST.

Gaussian Process-based prediction of memory performance and biomarker status in ageing and Alzheimer's disease-A systematic model evaluation

Neuroimaging markers based on Magnetic Resonance Imaging (MRI) combined with various other measures (such as genetic covariates, biomarkers, vascular risk factors, neuropsychological tests etc.) might provide useful predictions of clinical outcomes during the progression towards Alzheimer's disease (AD). The use of multiple features in predictive frameworks for clinical outcomes has become increasingly prevalent in AD research. However, many studies do not focus on systematically and accurately evaluating combinations of multiple input features. Hence, the aim of the present work is to explore and assess optimal combinations of various features for MR-based prediction of (1) cognitive status and (2) biomarker positivity with a multi-kernel learning Gaussian process framework. The explored features and parameters included (A) combinations of brain tissues, modulation, smoothing, and image resolution; (B) incorporating demographics & clinical covariates; (C) the impact of the size of the training data set; (D) the influence of dimensionality reduction and the choice of kernel types. The approach was tested in a large German cohort including 959 subjects from the multicentric longitudinal study of cognitive impairment and dementia (DELCODE). Our evaluation suggests the best prediction of memory performance was obtained for a combination of neuroimaging markers, demographics, genetic information (ApoE4) and CSF biomarkers explaining 57% of outcome variance in out-of-sample predictions. The highest performance for Aβ42/40 status classification was achieved for a combination of demographics, ApoE4, and a memory score while usage of structural MRI further improved the classification of individual patient's pTau status.

Measurements of neutrino oscillation parameters from the T2K experiment using 3.6×1021 protons on target

The T2K experiment presents new measurements of neutrino oscillation parameters using 19.7 ( 16.3 ) × 10 20 protons on target (POT) in (anti-)neutrino mode at the far detector (FD). Compared to the previous analysis, an additional 4.7 × 10 20 POT neutrino data was collected at the FD. Significant improvements were made to the analysis methodology, with the near-detector analysis introducing new selections and using more than double the data. Additionally, this is the first T2K oscillation analysis to use NA61/SHINE data on a replica of the T2K target to tune the neutrino flux model, and the neutrino interaction model was improved to include new nuclear effects and calculations. Frequentist and Bayesian analyses are presented, including results on sin 2 θ 13 and the impact of priors on the δ CP measurement. Both analyses prefer the normal mass ordering and upper octant of sin 2 θ 23 with a nearly maximally CP-violating phase. Assuming the normal ordering and using the constraint on sin 2 θ 13 from reactors, sin 2 θ 23 = 0 . 561 - 0.032 + 0.021 using Feldman-Cousins corrected intervals, and Δ m 32 2 = 2 . 494 - 0.058 + 0.041 × 10 - 3 eV 2 using constant Δ χ 2 intervals. The CP-violating phase is constrained to δ CP = - 1 . 97 - 0.70 + 0.97 using Feldman-Cousins corrected intervals, and δ CP = 0 , π is excluded at more than 90% confidence level. A Jarlskog invariant of zero is excluded at more than 2 σ credible level using a flat prior in δ CP , and just below 2 σ using a flat prior in sin δ CP . When the external constraint on sin 2 θ 13 is removed, sin 2 θ 13 = 28 . 0 - 6.5 + 2.8 × 10 - 3 , in agreement with measurements from reactor experiments. These results are consistent with previous T2K analyses.

Exploring Personality and Perceived Present Control as Factors in Postsurgical Voice Rest: A Case Comparison

OBJECTIVE

This case comparison explored the relation between personality, perceived present control, and postoperative voice rest (as estimated by self-report and objective voice use) following surgery for benign vocal fold lesions.

METHOD

Two participants were included. Both participants were diagnosed with benign vocal fold pathology, underwent phonosurgery, and were assigned to either complete voice rest (CVR) or relative voice rest (RVR) postoperatively. During voice rest (VR), a visual analog scale (VAS) and a dosimeter (the Vocalog2) were used daily to estimate self-perceived and objective voice use, respectively. The participants also completed questionnaires on voice-related demographics, the Voice Handicap Index (VHI), Ten-Item Personality Inventory (TIPI), and Perceived Present Control (PPC). After 7 days of CVR or RVR, participants completed a postoperative questionnaire and a final VAS for overall voice use.

RESULTS

A wide discrepancy was observed in one of two participant's subjective perception of voice use (using the VAS) versus objective dosimetry data wherein she reported significantly more voice use than was observed objectively. Differences in personality and PPC between the participants did not appear to affect their voice use following the VR protocols.

CONCLUSION

The amount of voice use in both VR protocols for these two participants suggests that personality and PPC did not affect their adherence to recommendations of VR. Patients may perceive their voice use differently across time, which might play a role in their adherence to voice rest recommendations: voice use measured as instances versus a unit of time (seconds).

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Emotional Adjustment in Children with Vocal Fold Nodules

INTRODUCTION

Vocal fold nodules (VNs) in children are benign, bilateral, callous-like lesions at the junction of the anterior third and posterior two-thirds of the true vocal folds. Chronic, repetitive, and intense vocal behavior is often cited as the primary etiology; however, difficulties with emotional adjustment may predispose some children towards extreme and possibly phonotraumatic vocal activity, thereby contributing secondarily to the development of VNs.

OBJECTIVES

This case-control study examined the association between features of emotional adjustment and VNs in children.

METHODS

Parents of children with VNs (N = 40, Mage = 7.5, SDage = 2.03) and two medical control groups [ie, voice disordered, but not VNs (VDCs; N = 40, Mage= 7.09, SDage = 2.01) and vocally normal controls (VNCs; N = 40, Mage = 7.6, SDage = 1.54)] participated in the study. Features of emotional adjustment were assessed using two inventories: the Parent Rating scale for Reactive and Proactive Aggression and the Revised Child Anxiety and Depression Scale - Parent version.

RESULTS

As compared with the VNCs, children with VNs were significantly more aggressive (P = 0.042, Cohen's d = 0.47) whereas the VDCs were more depressed (P = 0.013, Cohen's d = 0.60). Furthermore, VDCs experienced more separation anxiety than VNs (P = 0.038, Cohen's d = 0.45) and VNCs (P = 0.021, Cohen's d = 0.55). No other significant between-group differences were identified between the VNs and VDCs.

CONCLUSIONS

When present, elevated aggression may represent a risk factor for VNs formation in children, and possibly influence treatment outcomes. Therefore, the current results highlight the importance of understanding the role of emotional adjustment in the evaluation and treatment of dysphonia in children.

Behavioral Treatment Approaches to Lowering Pitch in the Female Voice

PURPOSE

To assess the outcomes of three voice therapy treatment approaches with an emphasis on lowering speaking pitch. Transmasculine and cisgender individuals may desire to lower their speaking pitch, yet there has not been a method described in the literature to do this effectively using only behavioral techniques.

METHOD

To investigate these approaches, we enrolled 32 adult cisgender females and randomly assigned them to one of four treatment groups: vocal function exercises (VFE), resonant voice therapy (RVT), lip-rounding therapy (LRT), and a control group. Participants received individual instruction and feedback on the given exercise program, and they continued to practice daily for 4 weeks.

RESULTS

Acoustic recordings were collected before treatment, immediately after the first session, and after 4 weeks of treatment. Results showed a lower minimum pitch in the physiological range, lower speaking fundamental frequency (SFF) in reading, and lower SFF in spontaneous speech-with treatment groups performing better than the control group. Additionally, participants' self-rating of the vocal effort expended to speak in a low pitch decreased over the treatment period.

CONCLUSIONS

Each treatment approach (VFE, RVT, and LRT) was successful in lowering the speaking pitch of cisgender females. These methods would likely be useful for clients seeking to speak in a lower pitch. Future research may expand results to include clinical populations, such as transmasculine individuals.

Self-regulation in children with vocal fold nodules: A multilevel analysis

INTRODUCTION

Vocal fold nodules (VNs) represent the most common cause of voice disorders in children. Phonotrauma related to chronic, repetitive, intense vocal activity is often cited as the proximate cause of VNs. However, diminished self-regulation (SR) may predispose some children toward extreme phonotraumatic voice use, thereby contributing secondarily to their development. This case-control study examined the association between features of SR and VNs in children.

METHOD

Parents of children with VNs (N = 40, Age Mean = 7.5, SD = 2.03 years) and vocally normal, medical controls (VNCs; N = 40, Age Mean = 7.6, SD = 1.54 years) completed the Behavior Rating Inventory of Executive Function, Second Edition (BRIEF2; Gioia, Isquith, Guy & Kenworthy, 2015), an inventory that evaluates components of SR in children.

RESULTS

Children with VNs, as compared with the vocally normal control group, were described as (i) impulsive (i.e., scoring significantly worse on the Behavior Regulation Index, BRI; P < 0.001, Cohen's d = 0.86), and (ii) emotionally dysregulated (i.e., scoring significantly worse on the Emotional Regulation Index, ERI; P < 0.001, Cohen's d = 0.81).

CONCLUSIONS

Diminished SR in some children with VNs may contribute to phonotraumatic vocal behaviors and potentially attenuate the effectiveness of voice therapy.

Relationships Among Personality, Daily Speaking Voice Use, and Phonotrauma in Adult Female Singers

PURPOSE

This study sought to determine whether personality traits related to extraversion and impulsivity are more strongly associated with singers with nodules compared to vocally healthy singers and to understand the relationship between personality and the types of daily speaking voice use.

METHOD

Weeklong ambulatory voice recordings and personality inventories were obtained for 47 female singers with nodules and 47 vocally healthy female singers. Paired t tests investigated trait differences between groups. Relationships between traits and weeklong speaking voice measures (vocal dose, sound pressure level [SPL], neck surface acceleration magnitude [NSAM], fundamental frequency, cepstral peak prominence [CPP], and the ratio of the first two harmonic magnitudes [H 1 -H 2]) were examined using pairwise Pearson r coefficients. Multiple regressions were performed to estimate voice parameters that correlated with two or more traits.

RESULTS

Singers with nodules scored higher on the Social Potency scale (reflecting a tendency toward social dominance) and lower on the Control scale (reflecting impulsivity) compared to the vocally healthy singers. In vocally healthy singers, vocal dose measures were positively correlated with a combination of Wellbeing (i.e., happiness) and Social Potency, mean SPL was positively correlated with Wellbeing, SPL variability was positively correlated with Social Potency and negatively with Harm Avoidance, and CPP mean was positively correlated with Wellbeing. Singers with nodules had a negative correlation between NSAM skewness and Social Potency. Both groups had negative correlations between H 1 -H 2 mean and Social Potency and Social Closeness.

CONCLUSIONS

Singers with nodules are more socially dominant and impulsive than vocally healthy singers. Personality traits are related to daily speaking voice use, particularly in vocally healthy singers. Individuals with higher levels of traits related to happiness and social dominance and lower Harm Avoidance tended to speak more, with higher laryngeal forces, with more SPL variability, and with more pressed glottal closure, which could increase risk of phonotrauma.

Return to work and quality of life after trauma: A systematic review

Background

Globally, one-tenth of the disability-adjusted life-years (DALYs) are due to injuries. Injuries can reduce employment opportunities and significantly affect the quality of life (QOL). Most research on these outcomes tend to focus on specific mechanisms of injury like road traffic crashes or falls, or body regions affected such as brain or limbs. But rarely do patients come with just body region injured nor does the healthcare system only treat one specific mechanism of injury. Therefore, we aimed to assess and provide a systematic overview of current knowledge about return to work (RTW) and QOL among adult injured patients up to 1-year after discharge.

Methods

We conducted a systematic review of the literature published since 2010 on RTW and QoL among injured patients. Three databases (MEDLINE, EMBASE, the Cochrane Library) were used. Meta-analysis was performed based on outcome, measurement tool, and the effect measure. Methodological quality of the studies were evaluated using the Joanna Briggs Institute (JBI) Critical Appraisal Tool Checklist.

Results

41 articles were included in this review. More than one-third (36%) of patients had not yet returned to back to work even after 1-year. Those who did get back to work took an average time of more than 3 months. The QOL scores of the injured patients had not reached the general population or pre-injury levels even up to a year post-discharge. Women and the elderly tended have poorer outcomes and were under-represented in the studies. Over 75% of the included studies were from high-income countries (HICs) and had higher methodological quality. There were no studies from low-income countries (LICs).

Conclusions

RTW and QOL continue to remain a challenge even up to year since discharge after an injury, more so among women and the elderly. Health policy and practice should address this burden. Future studies should focus on building of high-quality evidence from LMICs on RTW and QOL among injury survivors.

Key messages

Return to work and quality of life were significantly low even after 1-year in trauma patients, especially among elderly and females. Larger representation of elderly, females, and participants from low- and middle-income setting in future long-term research on trauma patients.

Personality in Children With Vocal Fold Nodules: A Multitrait Analysis

Purpose Vocal fold nodules (VNs) are bilateral, symmetrical, callous-like lesions secondary to phonotrauma and possibly related to specific personality traits. This case-control study examined the relation between personality and VNs in children within the context of the Trait Theory of VNs. Method Parents of children with VNs (N = 39, M = 7.43, SD = 2.01 years) and two medical control groups (i.e., voice disordered controls, but not VNs [VDCs; N = 40, M = 7.09, SD = 2.01 years] and vocally normal controls [VNCs; N = 40, M = 7.6, SD = 1.54 years]) completed the Inventory of Child Individual Differences, a personality instrument that describes the Big Five superfactors as well as 15 lower order personality traits. Results Children with VNs, as compared with VNCs, were (a) emotionally reactive (i.e., higher N-Neuroticism, p < .005, Cohen's d = 0.53), (b) Antagonistic, Strong-Willed, and less Compliant (i.e., lower A-Agreeableness, p < .014, Cohen's d = 0.59), and (c) Distractible and Disorganized (i.e., lower C-Conscientiousness, p < .009, Cohen's d = 0.62). Both voice disordered groups displayed elevated scores on the personality superfactor of Neuroticism (N; and the "Negative Emotions" lower order trait). Conclusions The combination of personality traits identified in this study (i.e., high N, low A and C) may play a central role in VNs development and possibly attenuate voice therapy success. Children with VNs displayed a similar personality typology as women with VNs, with the exception of elevated Extraversion (E), thereby providing support for the relevance of the Trait Theory of VNs in both children and adults. Clinicians treating children with voice disorders, including VNs, should consider their underlying personality traits in assessment and management.

Management of functional communication, swallowing, cough and related disorders: consensus recommendations for speech and language therapy

Communication problems (eg, dysphonia, dysfluency and language and articulation disorders), swallowing disorders (dysphagia and globus), cough and upper airway symptoms, resulting from functional neurological disorder (FND), are commonly encountered by speech and language professionals. However, there are few descriptions in the literature of the most effective practical management approaches. This consensus document aims to provide recommendations for assessment and intervention that are relevant to both adults and young people. An international panel of speech and language professionals with expertise in FND were approached to take part. Participants responded individually by email to a set of key questions regarding best practice for assessment and interventions. Next, a video conference was held in which participants discussed and debated the answers to these key questions, aiming to achieve consensus on each issue. Drafts of the collated consensus recommendations were circulated until consensus was achieved. FND should be diagnosed on the basis of positive clinical features. Speech and language therapy for FND should address illness beliefs, self-directed attention and abnormal movement patterns through a process of education, symptomatic treatment and cognitive behavioural therapy within a supportive therapeutic environment. We provide specific examples of these strategies for different symptoms. Speech and language professionals have a key role in the management of people with communication and related symptoms of FND. It is intended that these expert recommendations serve as both a practical toolkit and a starting point for further research into evidence-based treatments.

Voice Therapy According to the Rehabilitation Treatment Specification System: Expert Consensus Ingredients and Targets

Purpose Clinical trials have demonstrated that standardized voice treatment programs are effective for some patients, but identifying the unique individual treatment ingredients specifically responsible for observed improvements remains elusive. To address this problem, the authors used a taxonomy of voice therapy, the Rehabilitation Treatment Specification System (RTSS), and a Delphi process to develop the RTSS-Voice (expert consensus categories of measurable and unique voice treatment ingredients and targets). Method Initial targets and ingredients were derived from a taxonomy of voice therapy. Through six Delphi Rounds, 10 vocal rehabilitation experts rated the measurability and uniqueness of individual treatment targets and ingredients. After each round, revisions (guided by the experts' feedback) were finalized among a primary reader (a voice therapy expert) and two external readers (rehabilitation experts outside the field of voice). Consensus was established when the label and definition of an ingredient or target reached a supramajority threshold (≥ 8 of 10 expert agreement). Results Thirty-five target and 19 ingredient categories were agreed to be measurable, unique, and accurate reflections of the rules and terminology of the RTSS. Operational definitions for each category included differences in the way ingredients are delivered and the way individual targets are modified by those ingredients. Conclusions The consensus labels and operationalized ingredients and targets making up the RTSS-Voice have potential to improve voice therapy research, practice, and education/training. The methods used to develop these lists may be useful for other speech, language, and hearing treatment specifications. Supplemental Material https://doi.org/10.23641/asha.15243357.

Acoustic Variability in the Healthy Female Voice Within and Across Days: How Much and Why?

Purpose The aims of this study were (1) to quantify variability in voice production (as measured acoustically) within and across consecutive days in vocally healthy female speakers, (2) to identify which acoustic measures are sensitive to this variability, and (3) to identify participant characteristics related to such voice variability. Method Participants included 45 young women with normal voices who were stratified by age, specifically 18-23, 24-29, and 30-35 years. Following an initial acoustic and auditory-perceptual voice assessment, participants performed standardized field voice recordings 3 times daily across a 7-day period. Acoustic analyses involved 32 cepstral-, spectral-, and time-based measures of connected speech and sustained vowels. Relationships among acoustic data and select demographic, health, and lifestyle (i.e., participant-based) factors were also examined. Results Significant time-of-day effects were observed for acoustic analyses within speakers (p < .05), with voices generally being worse in the morning. No significant differences were observed across consecutive days. Variations in voice production were associated with several participant factors, including improved voice with increased voice use; self-perceived poor voice function, minimal or no alcohol consumption, and extroverted personality; and worse voice with regular or current menstruation, depression, and anxiety. Conclusions This acoustic study provides essential information regarding the nature and extent to which healthy voices vary throughout the day and week. Participant-based factors that were associated with improved voice over time included increased voice use, self-perceived poor voice function, minimal or no alcohol consumption, and extroverted personality. Factors associated with worse voice production over time included regular or current menstruation, and depression and anxiety.

A Field-Based Approach to Establish Normative Acoustic Data for Healthy Female Voices

Purpose The primary aim of this study was to obtain high-quality acoustic normative data in natural field environments for female voices. A secondary aim was to examine acoustic measurement variability in field environments. Method This study employed a within-subject repeated-measures experimental design that included 45 young female adults with normal voices. Participants were stratified by age (18-23, 24-29, and 30-35 years). After initial evaluation and instruction, participants completed voice recordings during seven consecutive days using a standard protocol, including both connected speech and sustained vowels. Thirty-two cepstral-, spectral-, and time-based acoustic measures were acquired using Praat and the Analysis of Dysphonia in Speech and Voice. Results Among the 958 total recordings, greater than 90% satisfied inclusion criteria based on protocol compliance, peak clipping, and signal-to-noise ratio. Significant differences were observed for age (p < .05). For 19 acoustic measures, values improved significantly as signal-to-noise ratio increased. Cepstral- and spectral-based measures demonstrated less measurement variability as compared with time-based measures. Conclusions With adequate training, field audio recordings represent a viable option for clinical voice management. The significant age effects observed in this study support the need for more specific criteria when collecting and applying normative data. Cepstral- and spectral-based measures demonstrated the least measurement variability. This study provides additional evidence for multiparameter acoustic voice measurement, specifically toward ecologically valid sampling in natural environments. Future studies should expand on these findings in other populations with normal and disordered voices.

Perceived Control, Voice Handicap, and Barriers to Voice Therapy

OBJECTIVE

To characterize the associations of perceived control with voice outcomes and self-reported likelihood of attending voice therapy using a national practice-based research network.

STUDY DESIGN

Cross-sectional study of prospectively enrolled adult patients seen for dysphonia.

SETTING

Creating Healthcare Excellence through Education and Research (CHEER) network of community and academic practice sites.

SUBJECTS AND METHODS

Data collected included patient-reported demographics, outcome measures of voice (Voice Handicap Index-10), perceived control (present control subscale of voice-specific Perceived Control over Stressful Events Scale), personality (Ten Item Personality Inventory), likelihood of attending voice therapy if recommended, and barriers to attending voice therapy.

RESULTS

Patients (N = 247) were enrolled over 12 months from 10 sites, of whom 170 received a recommendation for voice therapy. The majority (85%) of this group planned to attend voice therapy. Voice-specific perceived control and VHI-10 were inversely related (r = -0.31, P < 0.001), even when controlling for personality. No study variables were associated with self-reported likelihood of attending voice therapy, but perceived control was the most consistent correlate of specific barriers to attending voice therapy (eg, "hard to translate into everyday use") and was inversely related to these barriers.

CONCLUSIONS

Patients scoring higher on a voice-specific measure of perceived control reported less voice handicap, independent of personality, and higher perceived control was associated with having fewer concerns about voice therapy goals and process. Perceived control is a potential target for intervention in patients with voice disorders.

Rehabilitation Treatment Specification System: Methodology to Identify and Describe Unique Targets and Ingredients

Although significant advances have been made in measuring the outcomes of rehabilitation interventions, comparably less progress has been made in measuring the treatment processes that lead to improved outcomes. A recently developed framework called the Rehabilitation Treatment Specification System (RTSS) has potential to identify which clinician actions (ie, ingredients) actively improve specific patient functions (ie, targets). However, the RTSS does not provide methodology for standardly identifying specific unique targets or ingredients. Without a method to evaluate the uniqueness of an individual target or ingredient, it is difficult to know whether variations in treatment descriptions are synonymous (ie, different words describing the same treatment) or meaningfully different (eg, different words describing different treatments or variations of the same treatment). A recent project used vocal rehabilitation ingredients and targets to create RTSS-based lists of unique overarching target and ingredient categories with underlying dimensions describing how individual ingredients and targets vary within those categories. The primary purpose of this article is to describe the challenges encountered during the project and the methodology developed to address those challenges. Because the methodology was based on the RTSS's broadly applicable framework, it can be used across all areas of rehabilitation regardless of the discipline (speech-language pathology, physical therapy, occupational therapy, psychology, etc) or impairment domain (language, cognition, ambulation, upper extremity training, etc). The resulting standard operationalized lists of targets and ingredients have high face and content validity. The lists may also facilitate implementation of the RTSS in research, education, interdisciplinary communication, and everyday treatment.

Two-sex life table and feeding dynamics of Spilosoma obliqua Walker (Lepidoptera: Arctiidae) on three green gram cultivars

The effect of three green gram cultivars (PDM 54, PUSA BAISAKHI and SAMRAT) on the biology of Spilosoma obliqua Walker (Lepidoptera: Arctiidae) was studied using age-stage, two-sex life table. We also studied food utilization efficiency measures of larvae on green gram cultivars. The nutritional and antinutritional factors of leaves of green gram cultivars were determined. The preadult development time of S. obliqua was shortest on PDM 54 (35.54 days) and longest on SAMRAT (39.29 days). The fecundity was highest on PDM 54 (318.32) and lowest on SAMRAT (250.20). The net reproductive rate (R0) ranged from 37.53 on SAMRAT to 79.58 on PDM 54. The intrinsic rate of increase (r) was higher on PDM 54 (0.1148 day-1) and PUSA BAISAKHI (0.1018 day-1) than SAMRAT (0.0875 day-1). The finite rate of increase (λ) was lowest on SAMRAT (1.0915 day-1). Mean generation time (T) was shortest on PDM 54 (38.12 days) and longest on SAMRAT (41.42 days). Population projection revealed that the population growth was slowest on SAMRAT. The growth rate of sixth instar larvae was highest on PDM 54 and lowest on SAMRAT. The lower level of nutritional factors such as total carbohydrates, proteins, lipids, amino acids and nitrogen content, and a higher level of antinutritional factors such as total phenols, flavonols and tannins influenced higher development time and lower fecundity of S. obliqua on SAMRAT than other cultivars. These findings suggested that SAMRAT is a less suitable cultivar to S. obliqua than other cultivars, and this cultivar can be promoted for cultivation.

Evidence of Possible Irritable Larynx Syndrome in Obstructive Sleep Apnea: An Epidemiologic Approach

OBJECTIVE

"Irritable larynx syndrome" (ILS) often refers to a constellation of laryngeal-based symptoms including chronic cough (CC), diurnal dyspnea, and dysphonia. In patients with OSA, we examined: (1) the frequency, severity, comorbidity, risks and triggers of each problem, (2) whether these symptoms were compatible with stereotypic ILS and (3) the role of CPAP in their expression.

STUDY DESIGN

Cross-sectional, descriptive epidemiology study.

SETTING

Sleep-Wake Center at University of Utah Health Care, Salt Lake City, UT.

SUBJECTS AND METHODS

Ninety-four individuals with OSA (53 men, 41 women; mean age 54.7 ± 12.8 yrs.) underwent an extensive telephone interview that addressed study objectives.

RESULTS

Long-term CC, daytime breathing and voice problems were common, especially among women despite less severe OSA. Women, more than men, reported all three chronic conditions alone or in combination: CC (44% vs 11.3%), diurnal dyspnea (41.5% vs 13.2%) and voice disorders (41.5% vs 13.2%). Symptoms were not associated with age, BMI or Apnea Hypopnea Index after adjusting for sex. Although evidence supporting stereotypic ILS symptomatology was inconsistent, those participants with a voice disorder were 3.3 (95% CI = 1.8-6.0) times more likely to report CC and 2.4 (95% CI = 1.3-4.4) times more likely to experience diurnal dyspnea. Esophageal reflux, post-nasal drip, and frequent sinus infections were significantly associated with all three conditions. Triggers that provoked or made symptoms worse varied by condition and sex. Nightly, humidified CPAP use was associated with fewer symptoms overall and improved quality of life.

CONCLUSIONS

Symptoms suggestive of possible ILS are common in OSA, especially among women, and lessened by nightly CPAP use.

Is quality of life after mastectomy comparable to that after breast conservation surgery? A 5-year follow up study from Mumbai, India

PURPOSE

Breast cancer is the commonest cancer in women worldwide. Surgery is a central part of the treatment. Modified radical mastectomy (MRM) is often replaced by breast conserving therapy (BCT) in high-income countries. MRM is still the standard choice, in low- and middle-income countries (LMICs) as radiotherapy, a mandatory component of BCT is not widely available. It is important to understand whether quality of life (QOL) after MRM is comparable to that after BCT. This has not been studied well in LMICs. We present, 5-year follow-up of QOL scores in breast cancer patients from India.

METHODS

We interviewed women undergoing breast cancer surgery preoperatively, at 6 months after surgery, and at 1 year and 5 years, postoperatively. QOL scores were evaluated using FACT B questionnaire. Average QOL scores of women undergoing BCT were compared with those undergoing MRM. Total scores, domain scores and trends of scores over time were analyzed.

RESULTS

We interviewed 54 women with a mean age of 53 years (SD 9 ± years). QOL scores in all the women, dipped during the treatment period, in all subscales but improved thereafter and even surpassed the baseline in physical, emotional and breast-specific domains (p < 0.05) at 5 years. At the end of 5 years, there was no statistically significant difference between the MRM and BCT groups in any of the total or domain scores.

CONCLUSION

QOL scores in Indian women did not differ significantly between MRM and BCT in the long term. Both options are acceptable in the study setting.

A checklist for trauma quality improvement meetings: A process improvement study

BACKGROUND

Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM.

METHODS

This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop.

RESULTS

There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7; 95% CI:1.4-9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001) and agreed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001).

CONCLUSION

This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients.

[An independent observatory in Vendée on ST-elevated acute myocardial infarction (the OVISCA Register). A Departmental evaluation of demographic trends, mortality and delays before treatment]

AIM

Mortality from acute myocardial infarction has been falling during the past 30 years. The aim of the study was to evaluate the temporal trends of demographics, mortality rates, and time to treatment in patients admitted for acute ST elevation myocardial infarction (STEMI) in Vendée.

PATIENTS AND METHODS

From 2008 to 2016, 1994 patients hospitalised in CHD Vendée for STEMI <48hours were included. Two groups were compared, 838 patients admitted between 2008 and 2011 (group 1), and 1156 admitted between 2013 and 2016 (group 2).

RESULTS

Between the 2 periods, mean age was comparable (63.8 vs. 64.4 years), the gender ratio decreased (from 3.15 to 2.79 ; P=0.25). The mean duration of hospital stay was 0.8 day shorter (P=0.008). Treatment at discharge was optimum in 97.5% patients versus 92% (P<0.001). Left ventricular ejection fraction was comparable (50.6% vs. 50.2%). There was a non-significant trend to a decrease in hospital mortality (from 6.3% to 4.4%; p=0.12), and 6-month mortality (from 6.9% to 5.9%; P=0.51). There was a reduction in the use of emergency call-outs (74.9% to 68.9%; P<0.01), but an increase in direct presentations from 44% to 48.7% (P<0.05). The time before calling was comparable (2.5hours vs. 2.3hours; P=04.7). The "door-to-balloon" time decreased (0.71 vs. 0.55hour; P<0.001). The mean time between pain and angioplasty increased (5.7 vs. 6.8hours; P<0.05).

CONCLUSIONS

In vendee, from 2011 to 2016, hospital and 6-month mortality of STEMI trend to decrease non-significantly. The door to balloon time decreased, although emergency call-out rates and delays did not. Considerable efforts are still required with respect to patient information and education. Our registry offers an excellent tool to improve practices, the aim being to ensure its integration in the CRAC-France PCI registry.

A 36-year-old Man with Limb Weakness and Dimness of Vision (NMO)

Neuromyelitis Optica (NMO) previously known as Devic disease is inflammatory disorder of central nervous system characterized by severe immune mediated demyelination and axonal damage predominating targeting optic nerves and spinal cord leading to blindness and paralysis. The spectrum of the disease has expanded based on the specificity of the autoimmune response to the aquaporin-4 (AQP-4) water channel expressed on the end feet of astrocytes in the central nervous system. The coordinated immunological attack against aquaporin-4 is mediated by B & T cells, innate cells including neutrophils and eosinophils and complement system as well as pathogenic antibodies.

A 20 Years Young Lady with Recurrent Convulsion since Childhood (Sturge-Weber Syndrome)

Sturge Weber Syndrome (SWS) is a sporadic neurocutanous disease characterized by facial port wine stain, ocular abnormalities and leptomengealangioma. We present here a 20 year old normotensive, non-diabetic lady hailing from Sarishabari, Jamalur District, Bangladesh got admitted in Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh on 15 July 2018 with the complaints of recurrent convulsion since 3 months of her life, weakness of the right side of the body for same duration according to the statement of the patients mother she was reasonably well until 3 months of her age. The precise pathogenesis is unknown. Clinical feature vary from gentle to full blown sickness with facial stain, seizures and glaucoma.

Lessons for all from the early years of the global surgery initiative

Six elements for future success

Voice Disorders in Obstructive Sleep Apnea: Prevalence, Risk Factors, and the Role of CPAP

OBJECTIVE

Obstructive sleep apnea (OSA) is characterized by frequent interruptions in breathing related to upper airway collapse during sleep and may adversely affect phonatory function. This study aimed to: (1) establish the prevalence, risks, and quality of life burden of voice disorders in OSA and (2) explore the relation between voice disorders and positive airway pressure (PAP) therapy.

STUDY DESIGN

Cross-sectional, descriptive epidemiology study.

METHODS

Analyses were based on 94 individuals with OSA (53 men, 41 women; mean age = 54.7 ± 12.8 years) who completed a telephone interview.

RESULTS

Twenty-eight percent of participants reported having a current voice disorder. Of those with a current voice disorder, 83% had experienced symptoms for at least a year, and 58% had symptoms for at least 4 years. The prevalence of a current voice disorder was greater in women than men (44% vs 15%, P = .0020) but did not vary significantly across different age groups, body mass index (BMI), apnea/hypopnea index (AHI) severity, or medical history. After adjusting for sex, consistent use of PAP therapy (with humidification) was associated with (1) lower occurrence of voice disorders in women (Mantel-Haenszel [MH] χ²P = .0195), (2) reduced snoring severity accompanied by fewer voice disorders in men (MH χ²P = .0101), and (3) fewer reports of acid reflux as a possible trigger for voice problems (MH χ²P = .0226). Patients with OSA who also had a current voice disorder experienced lower overall quality of life compared to those without.

CONCLUSIONS

Chronic, longstanding voice disorders are common in women with OSA and produce significant adverse effects on quality of life. Nightly PAP use (with humidification) was associated with fewer voice symptoms and reduced severity of snoring and acid reflux as possible contributors. Further research is necessary to better understand the origin of these voice disorders in OSA and their potential response to treatment.

Personality, Psychological Factors, and Behavioral Tendencies in Children With Vocal Nodules: A Systematic Review

OBJECTIVES

This systematic review examined the evidence linking vocal nodule development in children to personality traits, psychological factors, and associated behavioral tendencies.

METHODS

Four electronic databases-PubMed, Scopus, ScienceDirect, EBSCO Host-as well as the reference lists from articles (including online sources) were searched. After screening for relevance, eight comparative, case-control studies were identified that met inclusion criteria. The quality of each study was evaluated by two raters using a modified, standardized checklist.

RESULTS

Four studies were rated as "good quality" and four were "fair". The questionnaires used to measure personality or psychological factors varied widely among the studies, and the results linking personality dispositions (and associated behavioral inclinations) to vocal nodule development in children were mixed.

CONCLUSIONS

Fair to good quality evidence exists to suggest that psychological factors or personality traits related to extraversion and impulsivity (and their related behavioral inclinations) might predispose children to vocal nodules and deserve further attention. Clinical implications, limitations of the current systematic review, and recommendations for future research are also discussed.

Associations between Community-Acquired Pneumonia and Proton Pump Inhibitors in the Laryngeal/Voice-Disordered Population

OBJECTIVES

To examine the relationship between community-acquired pneumonia (CAP) and proton pump inhibitor (PPI) treatment among patients with laryngeal/voice disorders.

STUDY DESIGN

Retrospective cohort analysis.

SETTING

Large national administrative US claims database.

SUBJECTS AND METHODS

Patients were included if they were ≥18 years old; had outpatient treatment for a laryngeal/voice disorder from January 1, 2010, to December 31, 2014 (per International Classification of Diseases, Ninth Revision, Clinical Modification codes); had 12 months of continuous enrollment prior to the index date (ie, first diagnosis of laryngeal/voice disorder); had no preindex diagnosis of CAP; and had prescription claims captured from 1 year preindex to end of follow-up. Patient demographics, comorbid conditions, index laryngeal diagnosis, number of unique preindex patient encounters, and CAP diagnoses during the postindex 3 years were collected. Two models-a time-dependent Cox regression model and a propensity score-based approach with a marginal structural model-were separately performed for patients with and without pre-index date PPI prescriptions.

RESULTS

A total of 392,355 unique patients met inclusion criteria; 188,128 (47.9%) had a PPI prescription. The 3-year absolute risk for CAP was 4.0% and 5.3% among patients without and with preindex PPI use, respectively. For patients without and with pre-index date PPI use, the CAP occurrence for a person who had already received a PPI is 30% to 50% higher, respectively, than for a person who had not yet had a PPI but may receive one later.

CONCLUSIONS

Patients without and with pre-index date PPI use experienced a roughly 30% to 50% increased likelihood of CAP, respectively, as compared with patients who had not had PPI prescriptions.

Precision Oncology With Radiogenomics: Non-invasive Interrogation of Liver Cancer Genomics to Select Drug Therapy and Monitor Patient Response

Background: Significant intratumoral heterogeneity is present in hepatocellular carcinoma (HCC) and single biopsy samples severely underread the genomic profile of the tumor. This confounds drug development in HCC and makes it extremely challenging to stratify and prognosticate patients to select therapy on the basis of genomic biomarkers. Multiregion sampling of surgically resected HCC allows for these intratumoral heterogeneity to be unraveled and this is currently carried out in our prospective PLANET (Precision Medicine in Liver Cancer across an Asia-Pacific Network) program. However, multiregion sampling is not practical in unresectable HCC cases, which comprise 80% of the disease burden. Radiogenomics studies on liver, lung and head-and-neck cancers have established the capability of radiomics analysis in capturing intratumor heterogeneity with the identification of radiomics signatures that are representative of underlying gene expression patterns. Aim: On this basis, our PLANET program has adopted a radiogenomics approach to characterize the intratumoral heterogeneity in HCC. Methods: This approach will leverage on the correlation of distinctive imaging traits in CT scans against the gene expression profiles of surgically resected HCC patients. Our PLANET program and the data-science enterprise Holmusk have embarked on close collaborative efforts to develop an algorithm that characterizes intratumoral heterogeneity based on distinctive traits in the CT scans. Results and conclusion: The development of such an algorithm is potentially ground-breaking as it allows for the noninvasive interrogation of liver cancer genomics and prognostication of HCC patients. This allows the easy screening of patients for therapeutic targets in vivo and will significantly improve the selection of drug therapy and monitoring of therapeutic response in HCC.

Spectrum of connectivity fluctuations including the effect of activity-dependent feedback

The spatiotemporal spectrum of feedback-driven fluctuations of brain connectivity is investigated using nonlinear neural field theory of the corticothalamic system. Weakly nonlinear dynamics of neural feedbacks are expanded in terms of first order perturbations of neural activity relative to a fixed point. Susceptibilities are used to quantify the change in connectivity per unit change in presynaptic or postsynaptic activity caused by nonlinear feedbacks such as facilitation, depression, sensitization, potentiation, and the effects of discrete eigenmode structure are included for a spherical brain geometry. Spectral signatures such as resonances are identified that allow the presence of particular presynaptic and postsynaptic feedback effects to be inferred. These include additional resonances at high frequencies and shifts of existing spectral peaks, mostly visible in the lowest spatial modes of the response.

Epidemiology of Swallowing Disorders in Rheumatoid Arthritis: Prevalence, Risk Factors, and Quality of Life Burden

Objective:

This investigation examined the prevalence, symptoms, risk factors, and quality-of-life burden of swallowing disorders in rheumatoid arthritis (RA), a chronic, progressive autoimmune inflammatory disease.

Methods:

One hundred individuals with RA (84 women, 16 men; mean age = 61.1 years, SD = 13.1) were interviewed regarding the presence, nature, and impact of swallowing symptoms and disorders. Associations between swallowing disorders, medical factors, RA disease severity, and quality of life were examined.

Results:

Forty-one percent of participants reported a current swallowing disorder that began gradually and was longstanding (most experiencing symptoms on a daily basis for at least 4 years). Symptoms compatible with solid food dysphagia contributed disproportionately to reporting a current swallowing disorder. Risk factors for dysphagia included a self-reported voice disorder, thyroid problems, esophageal reflux, and being physically inactive. Swallowing disorders increased with self-reported RA disease severity and contributed to a significantly greater burden on overall quality of life.

Conclusion:

Chronic, longstanding swallowing disorders are common in individuals with RA and appear to increase with disease severity. Those individuals with dysphagia reported greater reductions in quality of life as compared to those without, highlighting the need for improved awareness, exploration, and management of swallowing disorders in this population.

Spectral signatures of activity-dependent neural feedback in the corticothalamic system

The modulation of neural quantities by presynaptic and postsynaptic activities via local feedback processes is investigated by incorporating nonlinear phenomena such as relative refractory period, synaptic enhancement, synaptic depression, and habituation. This is done by introducing susceptibilities, which quantify the response in either firing threshold or synaptic strength to unit change in either presynaptic or postsynaptic activity. Effects on the power spectra are then analyzed for a realistic corticothalamic model to determine the spectral signatures of various nonlinear processes and to what extent these are distinct. Depending on the feedback processes, there can be enhancements or reductions in low-frequency and/or alpha power, splitting of the alpha resonance, and/or appearance of new resonances at high frequencies. These features in the power spectra allow processes to be fully distinguished where they are unique, or partly distinguished if they are common to only a subset of feedbacks, and can potentially be used to constrain the types, strengths, and dynamics of feedbacks present.

Discrimination and internalised feelings experienced by people who stutter in Jordan

PURPOSE

This study investigated the internalised feelings and discrimination experienced by people who stutter in Jordan.

METHOD

Five adult speakers who stutter were interviewed as a focus group. The participants were asked about their feelings related to stuttering and discrimination. The participants' responses in the focus group and items adapted from the extant literature formed the basis of a 20-item questionnaire. The questionnaire was administered to 20 additional adults who stutter to assess their internalised feelings about stuttering and their perceived rejecting behaviours (discrimination) associated with their impairment.

RESULT

Feeling "annoyed" was the item that received the highest percentage of negative internalised feelings, followed by "embarrassed," "shame," "disappointed," "nervous, "sad," "pessimistic," "fearful," "worried" and "lonely." The results of the discrimination experiences indicated that "getting a leadership position" was the item that most people who stutter reported being worried about, followed by "participation in the classroom," "getting a job," "getting married," "being fully paid in their jobs," "teased," "promoted" and "renting a house."

CONCLUSION

These findings provide further evidence of the universality that stuttering is more than the core surface features of speech, but also include aspects that exist below the surface such as negative internalised feelings and various discrimination experiences.

Pharmacologic management of voice disorders by general medicine providers and otolaryngologists

OBJECTIVES

1) To compare laryngeal diagnoses from general medical providers (GMP) to otolaryngologists following GMP-based medication trial, and 2) to evaluate associations between GMP medication trials and pharmacologic treatment by otolaryngologists.

METHODS

Retrospective cohort analysis using large, national administrative U.S. claims database. Patients with laryngeal/voice disorders as per the International Classification of Diseases, Ninth Revision, Clinical Modification codes from January 1, 2010, to December 31, 2012, seen by a GMP and then an otolaryngologist between 2 weeks to 3 months after the GMP visit, were included. Patient demographics, comorbid conditions, medication use, and initial GMP and otolaryngology laryngeal diagnoses were collected. Logistic regression was performed to evaluate the association between GMP and otolaryngologist medication trials.

RESULTS

A total of 12,475 unique laryngeal/voice-disordered patients met inclusion criteria. At the initial GMP visit, 15.3% received an antibiotic, 14.0% a proton pump inhibitor (PPI), and 7.7% an oral steroid. After the otolaryngology visit, increased diagnoses of vocal fold paralysis/paresis, benign vocal fold/laryngeal pathology, chronic laryngitis, and multiple diagnoses occurred. The adjusted odds for an otolaryngologist prescribing an antibiotic, PPI, or oral steroid, respectively, given that a GMP prescribed an antibiotic, PPI, or oral steroid, was roughly two to three times higher that of a GMP not prescribing the given medication.

CONCLUSION

Patients with structural and neuromuscular laryngeal disorders were treated with medications by GMPs, and similar mediations often were repeated after otolaryngology evaluation. These findings suggest potential areas of unnecessary pharmacologic treatment of laryngeal/voice-disordered patients.

LEVEL OF EVIDENCE

2b. Laryngoscope, 128:682-689, 2018.