Vaccinations in sickle cell disease: An audit of vaccination uptake in sickle cell patients attending Newham University Hospital.

AIMS: To assess the level of adherence of patients with sickle cell disease to the advised vaccination schedule with respect to the Sickle Cell Society guidelines on vaccination [1,2]. METHODS: A retrospective audit of patients' vaccination records was carried out between July 2012 and June 2013 on a sample of 80 patients over the age of 16, who attended Newham University Hospital accident and emergency (A&E) department with a presenting complaint coded as "sickle cell". A re-audit was conducted from January 2014 to December 2014 to close the audit loop. Chi-squared and Fisher's exact tests were used to compare the results. RESULTS: The initial audit and re-audit identified 80 and 86 patients, respectively. Only 2 (2012-2013) and 7 (2014) patients had a complete up-to-date vaccination profile. 24 (30%) patients had up-to-date influenza vaccination, increasing to 43 (50%, P=0.0062) when re-audited. 33 (41%) had current pneumococcal vaccinations, increasing to 38 (44%, P=0.7874). Uptake rates for vaccinations against Meningococcal group C (MenC), Haemophilus influenzae B (HiB) and Hepatitis B virus (HBV) were under 31% in both audits. A significant improvement in vaccination rate was observed for all vaccinations except pneumococcal and HBV. CONCLUSIONS: Although significant improvements have been demonstrated, this audit shows a low level of adherence to the advised vaccination schedule. The study also highlighted a shortfall in appropriate record keeping, reducing the potential for detailed conclusions being drawn in relation to the childhood vaccinations against MenC, HiB and HBV. Implementation of a new database of vaccination history, raising GP awareness and patient education seminars has lead to a significant improvement in vaccination rates locally and the authors hope that this may be replicated in other centres. There may be potential to increase rates further by administering vaccinations to inpatients.

Laryngeal recovery following type I thyroplasty.

OBJECTIVE: To describe the pattern of laryngeal recovery and its relationship to voice improvement following thyroplasty. DESIGN: We used a 5-point scale to rate 5 laryngeal characteristics preoperatively and 1 day, 1 week, 1 month, and 3 months following thyroplasty. SETTING: A university-affiliated health center. PATIENTS: Forty-four patients who underwent thyroplasty to correct incomplete glottal closure. RESULTS: Improved glottal closure and reduced supraglottic activity followed thyroplasty. Although evidence of postoperative irritation (erythema, edema, or hematoma) was present in many patients, it resolved within the first 1 to 4 weeks postoperatively in 22 (73%) of the 30 subjects available for follow-up at 3 months following thyroplasty. CONCLUSIONS: Thyroplasty is an effective procedure in correcting incomplete glottal closure and works to reduce excessive supraglottic activity in some patients. Recovery from postoperative vocal-fold irritation occurs rapidly, typically between the first week to first month, depending on the type and severity of irritation. These findings may help explain variations in postoperative voice improvement.

Dynamic magnetic resonance imaging in the study of vocal tract configuration.

Studies of vocal tract configuration using magnetic resonance imaging (MRI) techniques have relied on static images. These images fail to identify transient movements and are subject to distortion from motion artifact limiting research application to stable motor events. This paper describes a dynamic MRI technique that permits study of transient movements within the vocal tract during speech and nonspeech tasks. Following description of the technique, results of two preliminary studies are presented. The initial study evaluated issues of measurement error and reliability. Results indicated that distance and area measurements obtained from this technique are accurate in reference to a calibration referent and reliable both within and among judges. The second study compared two aspects of vocal tract configuration in patients with adductor spasmodic dysphonia before and following treatment with Botox injection. Changes in vocal tract configuration are discussed in reference to prior observations of patients with spasmodic dysphonia. These preliminary investigations suggest that dynamic MRI has promise as a useful technique in the study of vocal tract configuration.

Laryngeal aerodynamic aspects of women with adductor spasmodic dysphonia.

OBJECTIVE: To determine if laryngeal aerodynamic parameters distinguish the voice of patients diagnosed as having adductor spasmodic dysphonia (SD) from individuals with normal voice production. DESIGN: A group comparison between 10 women diagnosed as having adductor SD and 10 women with no evidence of vocal abnormalities or vocal dysfunction. SETTING: University and university-affiliated health center. PATIENTS: Ten women (age range, 38 through 82 years) diagnosed as having adductor SD and 10 age-matched women (+/- 2 years) with no evidence of pathologic vocal features or vocal dysfunction. RESULTS: Multivariate statistical analysis revealed significantly higher values for amplitude-based glottal airflow measures of maximum flow declination rate, peak glottal airflow, and minimum glottal airflow. CONCLUSIONS: Spasmodic dysphonia affects the ability of the laryngeal mechanism to function effectively. To date, few empirical studies have examined glottal airflow characteristics associated with adductor SD. Results from our study demonstrate that certain amplitude-based glottal airflow parameters distinguish adductor SD from normal voice. Therefore, aerodynamic measures may offer additional objectivity for the study.

Intraoral air pressure of alaryngeal speakers during a no-air insufflation maneuver.

Intraoral air pressure was recorded during the production of the consonant cognate pairs /p/-/b, /t/-/d, and /s/-/z/ by eight esophageal speakers. These consonants were combined with the vowel /a/ to form CV, VCV, and VC syllables and produced under two experimental conditions: after the insufflation of air and without air insufflation. The purpose was to determine if the voiced-voiceless pressure difference associated with the production of cognate pairs would occur in the absence of an insufflated air flow source. The results revealed that peak intraoral air pressure magnitudes were significantly greater following the insufflation of air than without it. Moreover, the voiceless consonants were generally produced with greater peak air pressures than the voiced consonants under both experimental conditions, although not all contrasts were significantly different. Finally, peak air pressure magnitudes were significantly more variable in the air insufflation condition. The finding that the esophageal speakers exhibited a pressure difference relative to voicing in the absence of an insufflated air flow source provides support to the concept that intraoral air pressure may be an important variable in regulating and controlling consonant production.

Laryngeal complications after type 1 thyroplasty.

Type I thyroplasty has become a primary surgical choice for voice restoration in patients with glottal incompetence. This study examines factors associated with laryngeal complications after type I thyroplasty. Ten laryngoscopic variables were analyzed from preoperative, intraoperative, and postoperative videolaryngoscopies of 51 patients undergoing 58 medialization procedures. Ten patient and operative variables were examined by medical record review. Major complications were defined as wound hemorrhage, airway obstruction, or prosthesis extrusion. Minor complications were defined as vocal fold hematoma without airway obstruction or prosthesis movement. The major complication rate was 8.6%, and the minor complication rate was 29%. No delayed hemorrhage or airway obstruction occurred. Prosthesis extrusion occurred in five (8.6%) patients 1 week to 5 months after surgery. Extrusion was associated with suboptimal prosthesis placement in 80% of cases. Two patients retained excellent glottal closure despite extrusion. Vocal fold hematoma was identified in 14 (24%) cases and resolved within 1 week. Prosthesis movement occurred in three (5%) patients 1 week to 6 months after surgery and resulted in poor glottal closure. All patients with prosthesis extrusion or movement were female. Type I thyroplasty remains a safe outpatient procedure with few major complications. Prosthesis extrusion was associated with suboptimal prosthesis placement and may or may not result in poor glottal closure. Minor vocal fold hematomas were relatively frequent, resolved rapidly, and were not associated with airway obstruction. Female patients may be more prone to complications because of their small laryngeal size.

Hospital size: manage...be they large or small.

In this article R. Banyard, assistant hospital administrator, and M. Gorham, hospital administrator, at the Northern General Hospital, discuss Government statements on the size of future hospitals and relate these to the current debate on Patients First.