Anesthetic Considerations for Patients with Locked-In Syndrome Undergoing Endoscopic Procedures

BACKGROUND Delivering safe anesthetic care to a patient unable to communicate easily and effectively with the anesthesia team presents many unique challenges. Communication may be limited by language, which can be resolved with translation services, or neurological conditions, such as stroke or traumatic brain injury, which are not easily remedied. In such patients, the inability to communicate effectively can lead to anxiety and negatively impact the patient-anesthesiologist relationship, especially when higher cognitive functions are preserved. CASE REPORT We present a case of a patient with locked-in syndrome (LIS), who presented to our endoscopy unit for a routine colonoscopy. The patient could only communicate with eye movements and blinking, thus limiting our ability to assess their pain or other needs in the perioperative period; however, she was otherwise cognitively intact. By utilizing the patient's home healthcare team and quickly adapting their unique communication methods during the perioperative period, we were able to provide an appropriate, safe anesthetic for this patient with LIS. CONCLUSIONS Many patients requiring an anesthetic are unable to effectively communicate due to language issues, hearing loss/mutism, neurological injury/stroke (aphasia), or developmental disabilities. The unique communication needs of this patient with LIS went beyond utilizing a translator and required the healthcare team to quickly learn a new communication method. We also discuss forms of intraoperative monitoring that can be used to differentiate consciousness from the anesthetized state in LIS patients, as well as making recommendations for future care of such patients.

Determinants of Communication Failure in Intubated Critically Ill Patients: A Qualitative Phenomenological Study from the Perspective of Critical Care Nurses

AIM

To explore what factors determine communication with awake intubated critically ill patients from the point of view of critical care nursing professionals.

BACKGROUND

Impaired communication frequently affects mechanically ventilated patients with artificial airways in the intensive care unit. Consequences of communication breaches comprise emotional and ethical aspects as well as clinical safety, affecting both patients and their conversation partners. Identification of determining factors in communication with awake intubated patients is needed to design effective action strategies.

DESIGN

A qualitative phenomenological approach was used.

METHODS

Semi-structured interviews were used as the data collection method. A total of 11 participants from three intensive care units of three Majorcan public hospitals, selected by purposive sampling, were interviewed.

FINDINGS

Three major themes regarding the communication determinants of the awake intubated critically ill patients were identified from the interviewees' statements: factors related to the patient (physical and cognitive functionality to communicate, their relational and communicative style and their personal circumstances), to the context (family presence, ICU characteristics, workload, availability/adequacy of communication aids, features of the messages and communication situations) and, finally, those related to the professionals themselves (professional experience and person-centredness).

CONCLUSIONS

The present study reveals determinants that influence communication with the awake intubated patient, as there are attitudes and professional beliefs.

RELEVANCE TO CLINICAL PRACTICE

The discovery of relations between different kinds of determinants (of patient, context or professionals) provides a multi-factor perspective on the communicative problem which should be considered in the design of new approaches to improve communicative effectiveness. This study is reported according to the COREQ checklist.

Picture Exchange Communication System (PECS) Implementation Program for children with autism spectrum disorder

PURPOSE

The aim of this study was to evaluate a program for implementing of the PECS in children with non-verbal ASD or with minimal verbalization in a school clinic belonging to the Unified Health System - SUS.

METHODS

This is a longitudinal study. The sample consisted of 22 children with nonverbal ASD or with minimal verbalization; 17 boys and 5 girls, aged 6 to 12 years old. The program consisted of 24 sessions of individual speech language therapy with the presence of the family member and followed the six phases originally proposed by the PECS Training Manual.

RESULTS

All children reached the first three phases. About 82% reached phase IV; 64% phase V and 19% phase VI. Family adherence was 96%.

CONCLUSION

It was possible to test a PECS implementation program in 24 sessions and verify that children were able to achieve phases of discrimination and sentence construction, besides demonstrating gain in their lexical repertoire and reduction of non-adaptative behaviors.

Oral Health and Dental Care in Deaf and Hard of Hearing Population: A Scoping Review

PURPOSE

To compile the literature available about the oral health and dental care of the deaf and hard of hearing (DHH) population.

MATERIALS AND METHODS

The study question of this scoping review was 'What are the main findings reported in the literature about oral health and dental care of the DHH population?' The following databases were included: Web of Science, LILACS, SciELO, MEDLINE, Scopus, EMBASE, GoogleScholar and Redalyc. Full-text articles published in peer-reviewed journals, in Spanish, Portuguese, and English, from the January 2000 to January 2018 were selected with qualitative and quantitative methods. All study designs were included in the review with the exception of letters to the editor and case reports.

RESULTS

A total of fifty articles were selected for analysis. DHH population has poorer oral hygiene and a higher prevalence of caries than their non DHH peers. DHH also report significant struggles with oral health and dental access. Most dentists experienced difficulties communicating with their DHH patients.

CONCLUSIONS

This scoping review is the first known that centers on DHH oral health and their dental care. Efforts to develop accessible dental health programmes are needed to address apparent oral health inequities in the DHH population.

The development of an augmented reality device for the autonomous management of the electric bed and the electric wheelchair for patients with amyotrophic lateral sclerosis: a pilot study

PURPOSE

The main aim of this Human Centred Design project was to develop the Environment COntrol in Amyotrophic Lateral Sclerosis (ECO-ALS) System, a new device which could improve ALS patient's autonomy in controlling the environment. Moreover, we verified the feasibility and usability of this technology in ALS patients in advanced stages of the disease.

MATERIAL AND METHODS

Twelve ALS patients in advanced disease stage were recruited, two patients for the development phase and ten patients and their caregivers for the two weeks' trial phase. We evaluated the impact of the ECOALS system by administering the Psychosocial Impact of Assistive Devices Scale (PIADS), the Individual Prioritised Problem Assessment (IPPA), the McGill Quality of Life Questionnaire (MQOL) and the Caregiver Burden Inventory (CBI).

RESULTS

In the trial phase, patients were very satisfied for having recovered their autonomy in the management of the EAB, that enabled patients to reduce calls to their caregivers to change their bed position. The IPPA questionnaire showed a significant improvement in patients' participation and management of the system. Moreover, the PIADS questionnaire showed that patients perceived a progress in competence, adaptability and areas of self-esteem, confirming a positive psychosocial impact of the patients' assistance device.

CONCLUSION

The project has collected some useful information for technological system development to face the need for autonomy ALS patients. Patients were satisfied with the tested aids and were interested in the future developments. Further studies are needed to improve the system and overcome some technical problems that occurred during the project.IMPLICATIONS FOR REHABILIATIONThe ECO-ALS system seems to improve the patients' perceived autonomy.The ECO-ALS system seems to improve the patients' perceived progress in competence, adaptability and areas of self-esteem, confirming a positive psychosocial impact of the assistance device.The ECO-ALS system seems to improve the patients' perceived quality of life.Patients were satisfied with the tested aids and were interested in the future developments.

Effects of simulated visual acuity and ocular motility impairments on SSVEP brain-computer interface performance: An experiment with Shuffle Speller

Individuals with severe speech and physical impairments may have concomitant visual acuity impairments (VAI) or ocular motility impairments (OMI) impacting visual BCI use. We report on the use of the Shuffle Speller typing interface for an SSVEP BCI copy-spelling task under three conditions: simulated VAI, simulated OMI, and unimpaired vision. To mitigate the effect of visual impairments, we introduce a method that adaptively selects a user-specific trial length to maximize expected information transfer rate (ITR); expected ITR is shown to closely approximate the rate of correct letter selections. All participants could type under the unimpaired and simulated VAI conditions, with no significant differences in typing accuracy or speed. Most participants (31 of 37) could not type under the simulated OMI condition; some achieved high accuracy but with slower typing speeds. Reported workload and discomfort were low, and satisfaction high, under the unimpaired and simulated VAI conditions. Implications and future directions to examine effect of visual impairment on BCI use is discussed.

Influence of Telecommunication Modality, Internet Transmission Quality, and Accessories on Speech Perception in Cochlear Implant Users

Background

Telecommunication is limited or even impossible for more than one-thirds of all cochlear implant (CI) users.

Objective

We sought therefore to study the impact of voice quality on speech perception with voice over Internet protocol (VoIP) under real and adverse network conditions.

Methods

Telephone speech perception was assessed in 19 CI users (15-69 years, average 42 years), using the German HSM (Hochmair-Schulz-Moser) sentence test comparing Skype and conventional telephone (public switched telephone networks, PSTN) transmission using a personal computer (PC) and a digital enhanced cordless telecommunications (DECT) telephone dual device. Five different Internet transmission quality modes and four accessories (PC speakers, headphones, 3.5 mm jack audio cable, and induction loop) were compared. As a secondary outcome, the subjective perceived voice quality was assessed using the mean opinion score (MOS).

Results

Speech telephone perception was significantly better (median 91.6%, P<.001) with Skype compared with PSTN (median 42.5%) under optimal conditions. Skype calls under adverse network conditions (data packet loss > 15%) were not superior to conventional telephony. In addition, there were no significant differences between the tested accessories (P>.05) using a PC. Coupling a Skype DECT phone device with an audio cable to the CI, however, resulted in higher speech perception (median 65%) and subjective MOS scores (3.2) than using PSTN (median 7.5%, P<.001).

Conclusions

Skype calls significantly improve speech perception for CI users compared with conventional telephony under real network conditions. Listening accessories do not further improve listening experience. Current Skype DECT telephone devices do not fully offer technical advantages in voice quality.

Development of a Low-Cost, Noninvasive, Portable Visual Speech Recognition Program

OBJECTIVES

Loss of speech following tracheostomy and laryngectomy severely limits communication to simple gestures and facial expressions that are largely ineffective. To facilitate communication in these patients, we seek to develop a low-cost, noninvasive, portable, and simple visual speech recognition program (VSRP) to convert articulatory facial movements into speech.

METHODS

A Microsoft Kinect-based VSRP was developed to capture spatial coordinates of lip movements and translate them into speech. The articulatory speech movements associated with 12 sentences were used to train an artificial neural network classifier. The accuracy of the classifier was then evaluated on a separate, previously unseen set of articulatory speech movements.

RESULTS

The VSRP was successfully implemented and tested in 5 subjects. It achieved an accuracy rate of 77.2% (65.0%-87.6% for the 5 speakers) on a 12-sentence data set. The mean time to classify an individual sentence was 2.03 milliseconds (1.91-2.16).

CONCLUSION

We have demonstrated the feasibility of a low-cost, noninvasive, portable VSRP based on Kinect to accurately predict speech from articulation movements in clinically trivial time. This VSRP could be used as a novel communication device for aphonic patients.

A Kinect-Based Sign Language Hand Gesture Recognition System for Hearing- and Speech-Impaired: A Pilot Study of Pakistani Sign Language

Sign language provides hearing and speech impaired individuals with an interface to communicate with other members of the society. Unfortunately, sign language is not understood by most of the common people. For this, a gadget based on image processing and pattern recognition can provide with a vital aid for detecting and translating sign language into a vocal language. This work presents a system for detecting and understanding the sign language gestures by a custom built software tool and later translating the gesture into a vocal language. For the purpose of recognizing a particular gesture, the system employs a Dynamic Time Warping (DTW) algorithm and an off-the-shelf software tool is employed for vocal language generation. Microsoft(®) Kinect is the primary tool used to capture video stream of a user. The proposed method is capable of successfully detecting gestures stored in the dictionary with an accuracy of 91%. The proposed system has the ability to define and add custom made gestures. Based on an experiment in which 10 individuals with impairments used the system to communicate with 5 people with no disability, 87% agreed that the system was useful.

A multi-purpose brain-computer interface output device

While brain-computer interfaces (BCIs) are a promising alternative access pathway for individuals with severe motor impairments, many BCI systems are designed as stand-alone communication and control systems, rather than as interfaces to existing systems built for these purposes. An individual communication and control system may be powerful or flexible, but no single system can compete with the variety of options available in the commercial assistive technology (AT) market. BCls could instead be used as an interface to these existing AT devices and products, which are designed for improving access and agency of people with disabilities and are highly configurable to individual user needs. However, interfacing with each AT device and program requires significant time and effort on the part of researchers and clinicians. This work presents the Multi-Purpose BCI Output Device (MBOD), a tool to help researchers and clinicians provide BCI control of many forms of AT in a plug-and-play fashion, i.e., without the installation of drivers or software on the AT device, and a proof-of-concept of the practicality of such an approach. The MBOD was designed to meet the goals of target device compatibility, BCI input device compatibility, convenience, and intuitive command structure. The MBOD was successfully used to interface a BCI with multiple AT devices (including two wheelchair seating systems), as well as computers running Windows (XP and 7), Mac and Ubuntu Linux operating systems.