Clinical evaluation of conversational speech fluency in the acute phase of acquired childhood aphasia: does a fluency/nonfluency dichotomy exist?

Traditional neurologic tenets claim that the clinical picture of acquired childhood aphasia is nonfluent irrespective of lesion location. In the past 20 years, however, several case studies have shown that fluent aphasic patterns can be observed in children with acquired childhood aphasia. But the question remains open as to whether the pattern of their speech characteristics is similar to the one described in adult aphasics as studies addressing spontaneous speech fluency characteristics in larger series of children with acquired childhood aphasia are scarce. The objective of this study was to investigate whether an analysis of spontaneous speech fluency as has previously been performed in adult aphasics by other investigators would also yield two distinct groups of aphasic children and, if so, whether the distribution of the different speech characteristics in both groups would reflect the rank order found in adults, that is, whether nonfluent verbal output characteristics would predominate in one group and fluent features in the other. Audiotaped and videotaped recordings of 24 cooperative children with acute acquired childhood aphasia unselected for age, gender, etiology, and aphasia severity ratings were analyzed according to 10 different speech characteristics. A cluster analysis (two-means clustering) was performed to seek the existence of two distinct groups of aphasic children. Results were confirmed, and exact P values were computed with Mann-Whitney U-tests. A two-means clustering created two distinct classes. Mann-Whitney U-tests ranked the speech characteristics according to their discriminating power between clusters. Comparing this rank order with the one previously found in adults revealed a high correlation (Spearman's rank correlation: r = .915, P << .005), thus indicating that the clusters we found were highly similar to the adult clusters. Thus, the use of the speech variables proposed to evaluate adult aphasic spontaneous speech enabled us to demonstrate a fluent/nonfluent dichotomy in a childhood aphasic population as well. This study shows that the traditional views on the uniformity of the clinical picture of acquired childhood aphasia are obsolete. Our findings corroborate data issued from several case reports of fluent acquired childhood aphasia and from the few studies focusing on speech fluency in acquired childhood aphasia, which all point to the existence of an adultlike heterogeneity of childhood aphasic syndromes. Current clinical evidence no longer supports the hypotheses of equipotentiality and progressive lateralization but favors the notion that the anatomic substrate for language representation in the child is similar to that in adults, even in young subjects.

Clinical utility of the judgment of line orientation test and facial recognition test in children with acquired unilateral cerebral lesions.

In unselected adult patients with brain damage, the Judgment of Line Orientation Test and the Facial Recognition Test are considered valid instruments for detecting right cerebral hemisphere lesions. It is unknown, however, whether this applies to children as well. Performance levels on the Judgment of Line Orientation Test and the Facial Recognition Test of 18 children with acquired left cerebral lesions and 14 children with acquired right cerebral lesions were reviewed. Subjects were unselected for age, sex, or etiology. Age-related norms were obtained in 81 normal controls, aged 7 to 14 years. Judgment of Line Orientation Test and Facial Recognition Test performance levels did not predict the presence of cerebral pathology per se in our unselected groups with demonstrated unilateral cerebral lesions, nor did they contribute to the prediction of the side of the lesion within the two groups with cerebral lesions. These results cast serious doubt on an important aspect of the clinical utility of both tests in children, namely their discriminative validity in the assessment of etiologically unselected populations with brain damage.

Treatment of patent ductus arteriosus with ibuprofen.

AIM: To evaluate the efficiency and side effects of ibuprofen for the early treatment of patent ductus arteriosus (PDA) and compare it with indomethacin. METHODS: Forty preterm infants with gestational ages of less than 33 weeks, with respiratory distress syndrome (RDS) and echocardiographically confirmed PDA, were randomly assigned at days 2 to 3 of life to receive either intravenous indomethacin 3 x 0.2 mg/kg at 12 hour intervals or intravenous ibuprofen 1 x 10 mg/kg, followed by 5 mg/kg 24 and 48 hours later. RESULTS: PDA closed in 15 of 20 patients from the indomethacin group (75%) and in 16 of 20 (80%) from the ibuprofen group. Seven patients (three indomethacin, four ibuprofen) required a second treatment with indomethacin and in five (three in the indomethacin group and two in the ibuprofen group) the duct was ultimately ligated. Ibuprofen patients had a better urinary output and showed no increase in serum creatinine concentrations compared with the indomethacin group. Ibuprofen was not associated with any other side effect. CONCLUSIONS: Ibuprofen treatment seems to be as efficient as indomethacin in closing PDA on the third day of life in preterm infants with respiratory distress syndrome and seems to have fewer renal side effects.

Study of the bronchodilating effect of three doses of nebulized oxitropium bromide in asthmatic preschool children using the forced oscillation technique.

UNLABELLED: The aim of this study was to evaluate the bronchodilating capacity of nebulized oxitropium bromide (OB) in preschool asthmatic children and to determine an appropriate dose for usage in this age group. The trial enrolled 20 patients with moderate to severe stable asthma aged between 3.2 and 6.2 years (mean 4.7). Applying a placebo controlled, double-blind design, the effect of placebo was compared with three different doses of OB (375, 750 and 1500 micrograms) and with 400 micrograms fenoterol. The three different doses of OB resulted in a highly significant bronchodilation within 15 min after administration. The observed bronchodilation was comparable between the three doses during the first 2 h. However, after 4 h the lowest dose was significantly less powerful than the highest dose. Compared to the additional bronchodilation induced by fenoterol, no difference was found with the degree of bronchodilation of OB which occurred during the first 2 h. Furthermore, after 4 h only the lowest dose of OB was significantly less powerful than fenoterol assessed 10 min following a single 400 micrograms dose. CONCLUSION: Oxitropium bromide is a potent and long-acting bronchodilator in preschool children at a dose of 750 micrograms and 1500 micrograms. No side-effects were observed. The exact duration of action remains uncertain, but even 4 h after inhaling 750 or 1500 micrograms of OB no additive bronchodilation induced by fenoterol could be observed.

Functional residual capacity in healthy preschool children.

The purpose of this study was to evaluate the feasibility of routine functional residual capacity (FRC) measurements in healthy preschool children aged 2.7-6.4 yrs. Furthermore, accuracy and reproducibility were investigated and normal values were collected. A mass-produced closed-circuit helium dilution device (rolling seal) was used. Selection of the 113 healthy children (from the 571 measured) was based on an extensive personal and family history questionnaire and on clinical examination before measurements were performed. With three successive attempts it was possible to achieve at least two reproducible measurements in 73% of the children (repeatability coefficient 95.3 mL). The main problems were leakage at the corner of the mouth and irregular breathing pattern. The mean time to perform a measurement was 113 s. Mean FRC was significantly higher in boys than in girls: 778 versus 739 mL for a body length of 110 cm (p<0.05). FRC correlated with height (H) (r=0.69), weight (W) (r=0.56), age (A) (r=0.62) and all three combined (r=0.70): FRC = -534.89 + 1.84 x W (kg) + 10.07 x H (cm) + 2.51 x A (months). When a power or exponential function was used to describe FRC as a function of height, the results were not superior to the linear regression (r=0.69): FRC (mL) = -766.2 + 13.8 x H (cm) (r=0.69) or FRC (L) = 0.620 x H (m)(2.03) (r=0.69) or FRC (mL)= 99.5 x e(0.018xH (cm)) (r=0.69). Among these, we recommend the power function because it will better fit broader height ranges. Reliable functional residual capacity measurements can be routinely performed in preschool children with a mass-produced device. Reference values were collected for children 95-125 cm in height.

An analysis of spontaneous conversational speech fluency in children with acquired aphasia.

We report on an instrumental analysis of spontaneous conversational speech (SCS) fluency in acquired childhood aphasia (ACA). Tape-recorded SCS samples of 25 children with ACA (clinical judgment: 12 nonfluent and 13 fluent), and of 12 dysarthric and 12 nonaphasic and nondysarthric right hemisphere injured children were analysed in order to: (1) investigate whether a more refined analysis can objectively contribute to the differentiation of patients who were labelled as fluent or nonfluent on the basis of a clinical judgment: (2) verify whether an instrumental analysis of phonation duration does confirm the subjective estimation of verbal rate (i.e. the number of words produced in a unit of time) in groups of children with acquired neurogenic speech/language disorders frequently met in clinical practice. The results are: (1) phonation rate (i.e. the vocalization percentage) seems to represent an adequate variable to distinguish clinically diagnosed nonfluent aphasic children from speech/language impaired children belonging to other clinical groups of acquired neurogenic speech/language disorders; (2) the verbal rate is highly correlated to the phonation rate in all investigated groups except the dysarthric one. We suggest the instrumental method discussed here might contribute to the differential diagnosis between dysarthric and aphasic disturbances in the acute stage of the disease. Concerning the study of ACA, the main issue of the present investigation is that an objective fluency measurement has succeeded in identifying aphasic children who obviously do not fit in with the standard doctrine on ACA, which claims that ACA is invariably nonfluent irrespective of lesion location.

Hypertension in obese and non-obese non-insulin dependent diabetics a matter of regional adiposity?

There is growing evidence that differences in fat distribution can be predictive for differences in the prevalence of metabolic disturbances, cardio-vascular disease, stroke and death, independent of commonly used indices of obesity. This study evaluates regional body fat distribution as a possible main reason for hypertension in obese and non-obese type II diabetics. 42% of normal weight diabetics with abdominal obesity are hypertensive versus 47% of obese diabetics; only 5% hypertension could be found when a lower body segment fat distribution is present. A significant (p less than 0.001) correlation exists between fat mass topography and both systolic (r = 0.49) and diastolic (r = 0.49) blood pressure. This correlation remains true after correction for body mass index and percent glycosylated hemoglobin. These results suggest that localization of fat in the upper body segment should be considered as a additive risk for hypertension.

Multifrequency tympanometry in normal ears.

Susceptance and conductance tympanograms were recorded from 10 normal subjects with probe frequencies ranging from 220 to 910 Hz. Tympanometric shapes progressed through an orderly sequence of patterns, becoming more complex with increasing probe frequency. When the direction of ear-canal air pressure change was from negative to positive values, more complicated tympanometric shapes occurred for all subjects, compared to the positive to negative direction. The results are discussed in relation to the Vanhuyse et al. [Scand. Audiol. 4:45-50, 1975] model of tympanometric shapes. In general, the model is a good first approximation to the distribution of tympanometric patterns from normal ears.

Immittance audiometry. Normative data at 220 and 660 Hz.

Normative immittance data for normal ears were collected at 220 and 660 Hz probe tone frequencies. The experimental set-up enabled conversion of simultaneously recorded susceptance and conductance data to resistance, reactance, admittance and phase angle tympanograms. Special attention was given to the subtraction of the ear canal admittance and to the pump speed. This paper demonstrates first the frequent occurrence (43.2%) of W-shaped tympanograms at 660 Hz probe tone in healthy ears. This percentage is not influenced by age, sex or pump direction. Normative data of the central extremum of the tympanogram are reported only for those immittance components in which W-notching does not occur. The wide variance of measurements in the population precludes the creation of subcategories. The intra-individual variation is much smaller and the authors advocate to use the value of the contralateral healthy ear as a reference.

Tympanometric middle-ear pressure determination with two-component admittance meters.

Exact tympanometric determination of the middle-ear pressure based on the location of the (central) extremum of susceptance, conductance, admittance, impedance, reactance or phase-angle tympanograms is not possible. None of these immittance components reaches its extremum exactly at middle-ear pressure neither at 220 nor at 660 Hz, due to the hysteresis caused by the viscoelastic behaviour of the soft biological tissue of the middle-ear structures. These effects cannot be avoided by lowering the rate of the pressure change during the recordings. The error on the middle-ear pressure determinations using a tympanometric method can be estimated to be of the order of 15 daPa.

A search for the most suitable imminent components and probe tone frequency in tympanometry.

The relative occurrence of bell-shaped and various types of W-shaped susceptance-conductance and admittance-phase tympanograms at a probe-tone frequency of 660 Hz was determined from registrations on normal ears. The diagnostic value of the susceptance-conductance versus the admittance-phase representation of tympanograms was studied on pathological middle-ear systems. Using probe-tone frequencies from 510 Hz up to 910 Hz, tympanograms for all four imminent components were recorded on 10 pathological ears and the diagnostic value compared. From the combination of these studies we conclude that the admittance-phase approach at a probe tone frequency between 500 and 700 Hz is a good choice.

Optimizing tympanometric variables for detecting middle ear traumas.

The combination of the results of different studies lead to the conclusion that the susceptance-conductance immittance audiometer at 660 Hz is not the only useful instrument for the detection of middle-ear traumas. Measurements at probe-tone frequencies from 510 up to 910 Hz prove that the admittance tympanogram combined with the electrical phase angle tympanogram recorded in the 500-700 Hz frequency range have definite advantages.

Incudo-stapedial joint pathology: a tympanometric approach.

Two-component tympanometry with a high probe-tone frequency enables a better distinction to be made between mobile but normal middle-ear systems and middle-ear systems suffering from necrosis, luxation, or disruption. Susceptance and conductance tympanograms obtained from 14 patients with confirmed pathological middle-ear lesions and 8 postmortem temporal bones, experimentally manipulated either surgically or with a 1 N HCl solution, were compared to tympanograms obtained from 80 normal subjects of an earlier study. With a 660-Hz probe tone, normal middle ears generate bell-shaped or normal sharp W-shaped patterns, whereas the pathologies of the middle ear give rise to irregular multi-extrema tympanograms. The differences between the two types of multi-extrema curves are discussed in detail. The use of phase-angle tympanometry is recommended to enable a quick and accurate distinction between normal and abnormal types of multi-extrema tympanograms. This study also points out clearly that 220-Hz tympanograms do not allow clear differentiation between pathological and normal middle ears.

The diagnostic value of phase-angle tympanograms.

The diagnostic value of susceptance, conductance, resistance, reactance, admittance and phase-angle tympanograms is compared. Phase-angle tympanograms seem to be best suited for the discrimination between normal W patterns and broad irregular curves obtained from ossicular disruptions, luxations and necroses. Several possibilities are proposed: phase-angle tympanograms at the drum, phase-angle tympanograms at the tip of the measuring probe and corresponding phasor curves. The best choice will depend on the kind of data processing and/or measuring equipment available.

Tympanometry-detection of middle ear pathologies.

Two component susceptance-conductance tympanometry at a probe tone frequency of 660 Hz is superior to admittance tympanometry at 220 Hz for the detection of an ossicular discontinuity, a luxation or a necrosis. It is, however, essential to understand well the difference between non-pathological W-patterns and pathological broad multi-extrema tympanograms. The systematics of normal W-patterns is reviewed and the influence of the sign and magnitude of the pumpspeed on the shape of both types of tympanograms is discussed.

On the asymmetry of susceptance tympanograms.

The origin of the tail asymmetry of susceptance tympanograms was investigated. A flow-measuring device enabled an accurate determination of ear-canal volume changes produced during tympanometry. From these measurements one finds that not only is the asymmetry due to the earcanal volume change but that finite drum susceptances exist at high transtympanic pressures. This residual susceptance was found to differ in the two tails of the tympanogram. Although no absolute values of those drum susceptances can be computed, it is possible to indicate which pressure side has the greater residual susceptance.

Impedance and admittance tympanometry. II. Mathematical approach.

The W-notching of susceptance, conductance and admittance tympanograms, as well as inverted-V shapes, found at high probe tone frequencies are explained, starting from realistic assumptions on the shape of resistance and reactance tympanograms. Necessary conditions for obtaining the different types of tympanograms are given. The theory shows that no pathology is necessary to explain W-notching or inverted-V shapes at higher-frequency probe tones.

Impedance and admittance tympanometry. I. Experimental approach.

In this experimental study a procedure is developed which enables the conversion of susceptance and conductane tympanograms to reactance and resistance tympanograms. Special attention was given to the subtraction of the ear canal admittance. The procedure was applied to bell-shaped and W-notched susceptance and conductance tympanograms. Computed reactance curves showed always an inverted-V shape, computed resistance curves were always flat.