Quantifying Laryngopharyngeal Reflux in Singers: Perceptual and Objective Findings.

This study examines the relationship between laryngopharyngeal reflux (LPR) symptoms and oropharyngeal pH levels in singers. We hypothesized that reported symptoms would correlate with objective measures of pH levels from the oropharynx, including the number and total duration of reflux episodes. Twenty professional/semiprofessional singers completed the Reflux Symptom Index (RSI) and underwent oropharyngeal pH monitoring. Mild, moderate, or severe pH exposure was recorded during oropharyngeal pH monitoring. Correlations were performed to examine potential relationships between reflux symptoms and duration of LPR episodes. Symptom severity did not correlate with pH levels; however, we found a number of covariances of interest. Large sample sizes are necessary to determine if true correlations exist. Our results suggest that singers may exhibit enhanced sensitivity to LPR and may therefore manifest symptoms, even in response to subtle changes in pH. This study emphasizes the importance of sensitive and objective measures of reflux severity as well as consideration of the cumulative time of reflux exposure in addition to the number of reflux episodes.

Designing Real-time Decision Support for Trauma Resuscitations.

BACKGROUND: Use of electronic clinical decision support (eCDS) has been recommended to improve implementation of clinical decision rules. Many eCDS tools, however, are designed and implemented without taking into account the context in which clinical work is performed. Implementation of the pediatric traumatic brain injury (TBI) clinical decision rule at one Level I pediatric emergency department includes an electronic questionnaire triggered when ordering a head computed tomography using computerized physician order entry (CPOE). Providers use this CPOE tool in less than 20% of trauma resuscitation cases. A human factors engineering approach could identify the implementation barriers that are limiting the use of this tool. OBJECTIVES: The objective was to design a pediatric TBI eCDS tool for trauma resuscitation using a human factors approach. The hypothesis was that clinical experts will rate a usability-enhanced eCDS tool better than the existing CPOE tool for user interface design and suitability for clinical use. METHODS: This mixed-methods study followed usability evaluation principles. Pediatric emergency physicians were surveyed to identify barriers to using the existing eCDS tool. Using standard trauma resuscitation protocols, a hierarchical task analysis of pediatric TBI evaluation was developed. Five clinical experts, all board-certified pediatric emergency medicine faculty members, then iteratively modified the hierarchical task analysis until reaching consensus. The software team developed a prototype eCDS display using the hierarchical task analysis. Three human factors engineers provided feedback on the prototype through a heuristic evaluation, and the software team refined the eCDS tool using a rapid prototyping process. The eCDS tool then underwent iterative usability evaluations by the five clinical experts using video review of 50 trauma resuscitation cases. A final eCDS tool was created based on their feedback, with content analysis of the evaluations performed to ensure all concerns were identified and addressed. RESULTS: Among 26 EPs (76% response rate), the main barriers to using the existing tool were that the information displayed is redundant and does not fit clinical workflow. After the prototype eCDS tool was developed based on the trauma resuscitation hierarchical task analysis, the human factors engineers rated it to be better than the CPOE tool for nine of 10 standard user interface design heuristics on a three-point scale. The eCDS tool was also rated better for clinical use on the same scale, in 84% of 50 expert-video pairs, and was rated equivalent in the remainder. Clinical experts also rated barriers to use of the eCDS tool as being low. CONCLUSIONS: An eCDS tool for diagnostic imaging designed using human factors engineering methods has improved perceived usability among pediatric emergency physicians.

Management of Dysphagia Pre- and Postoperatively in a Case of Eagle's Syndrome.

Eagle's syndrome (ES) is rare condition, most frequently described within the context of case study presentation. ES results from elongation of the styloid process, contributing to symptoms such as globus sensation in the throat, as well as pain localized to the ear, neck, face, or tongue. Additional symptoms can include hypersalivation, change in vocal quality, submandibular swelling, and dysphagia. This report discusses evaluation, diagnosis, and surgical intervention with respect to Eagle's Syndrome in a patient presenting with moderate-severe dysphagia.

Successful patient diabetes education in the emergency department.

PURPOSE: The purpose of this study was to examine the effect of diabetes self-management education (DSME) provided in a large urban emergency department (ED) by a certified diabetes educator using a "learner-centered" approach to teaching survival skills. It was hypothesized that an intervention providing learner-centered education in the ED would significantly improve diabetes knowledge and self-management skills. METHODS: Participants were patients who presented to the ED with uncontrolled blood glucose with type 2 diabetes mellitus (T2DM). A learner-centered DSME approach was developed. Baseline knowledge and skills were assessed in the ED with a 5-question test and a request to demonstrate meter and insulin injection technique. Education focused on identified gaps in knowledge and skills and incorporated an opportunity for the patient to exercise control in the treatment process. At outpatient follow-up, knowledge retention was assessed with the same 5-question test, and skills again were tested. RESULTS: Patients with T2DM who were provided learner-centered DSME in the ED demonstrated a significant increase in knowledge-related test scores on all questions at follow-up. Significantly fewer patients required meter and insulin injection instruction postintervention, compared to the baseline. CONCLUSION: Study results provide evidence supporting the effectiveness of learner-centered DSME delivered in the ED at imparting critical knowledge and skills to patients with T2DM.

Reducing healthcare-associated infections in an ambulatory dialysis unit: Identification and alignment of work system factors.

BACKGROUND: Patients undergoing hemodialysis have experienced a 43% increase in rate of hospitalization due to infection during the past 20 years. Research in other industries has shown that safe systems are achieved by considering the entire system to enable performance specifications to be met. METHOD: A sociotechnical systems framework was applied through the Macroergonomic Analysis and Design method to evaluate a 54-chair ambulatory dialysis unit to decrease healthcare-associated infections. Fifty-seven system discrepancies across 6 healthcare-associated infection risk factors were identified. A multicomponent intervention was developed to address 44 of the variances across 4 of the risk factors. RESULTS: Access-related bloodstream infections and access site infections did not improve. Bacterial surface contamination decreased. Process measures for the individual components of the intervention demonstrated varying adherence to the intervention. CONCLUSIONS: Inconsistent compliance with interventions is hypothesized to be due to organizational and external environment factors.

Improved voluntary cough immediately following office-based vocal fold medialization injections.

OBJECTIVES/HYPOTHESIS: This study examined changes in voluntary cough airflow measures immediately following in-office injection of Radiesse in patients diagnosed with glottic insufficiency. Due to significant comorbidities, these patients were poor candidates for medialization under general anesthesia. Each patient presented with dysphonia and dysphagia and ineffective voluntary cough, resulting in a poor clearing of secretions and a presence of ingested fluids on examination. STUDY DESIGN: Prospective cohort and case series study. METHODS: Three patients with a diagnosis of glottic insufficiency were included for study based on flexible endoscopy and laryngostroboscopic examination. Voluntary cough airflow measures were obtained approximately 30 minutes before and after the Radiesse injections. The airflow measures were: compression phase duration (CPD), expiratory rise time (EPRT), expiratory phase peak airflow (EPPF), and cough volume acceleration (CVA). RESULTS: Injection of Radiesse was found to improve voluntary cough airflow measures. CONCLUSION: The immediate increase in the objective airflow measures obtained from voluntary cough production after Radiesse injections can be used to document airway protection improvements. Cough airflow is a straightforward measure to obtain and is considered an objective measure of cough function. LEVEL OF EVIDENCE: 4.

An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions.

Root cause analysis (RCA) after adverse events in healthcare is a standard practice at many institutions. However, healthcare has failed to see a dramatic improvement in patient safety over the last decade. In order to improve the RCA process, this study used systems safety science, which is based partly on human factors engineering principles and has been applied with success in other high-risk industries like aviation. A multi-institutional dataset of 334 RCA cases and 782 solutions was analyzed using qualitative methods. A team of safety science experts developed a model of 13 RCA solutions categories through an iterative process, using semi-structured interview data from 44 frontline staff members from 7 different hospital-based unit types. These categories were placed in a model and toolkit to help guide RCA teams in developing sustainable and effective solutions to prevent future adverse events. This study was limited by its retrospective review of cases and use of interviews rather than clinical observations. In conclusion, systems safety principles were used to develop guidelines for RCA teams to promote systems-level sustainable and effective solutions for adverse events.

The role of the speech-language pathologist in the schools for the treatment of voice disorders: working within the framework of the individuals with disabilities education improvement act.

The role of the speech-language pathologist (SLP) has developed considerably over the past 20 years given the medical and technological advances in life-sustaining procedures. Children born with congenital, surgical, or "medically fragile" conditions become mainstreamed into regular school-based settings, thus extending the traditional role of the treating SLP and multidisciplinary team. Understanding the impact of associated voice disorders on educational performance requires dissemination of additional and important information, as eligibility decisions for students in school-based settings must be made within the framework of the federal legislation and regulations governing the provision of services for students with disabilities. This article discusses how to identify children with voice disorders under the Individuals with Disabilities Education Improvement Act (IDEA), the role of the SLP in various triaging scenarios, and how models of voice therapy can be integrated in a school-based setting.

Defining the pharmaceutical system to support proactive drug safety.

The military, aviation, nuclear, and transportation industries have transformed their safety records by using a systems approach to safety and risk mitigation. This article creates a preliminary model of the U.S. pharmaceutical system using available literature including academic publications, policies, and guidelines established by regulatory bodies and drug industry trade publications. Drawing from the current literature, the goals, roles, and individualized processes of pharmaceutical subsystems will be defined. Defining the pharmaceutical system provides a vehicle to assess and address known problems within the system, and provides a means to conduct proactive risk analyses, which would create significant pharmaceutical safety advancement.

A roundtable discussion: home healthcare-not a hospital in the home.

Home healthcare is vital for a large percentage of the population. According to data from the U.S. Food and Drug Administration (FDA) and the Centers for Disease Control (CDC), 7 million people in the United States receive home healthcare annually. The use of medical devices in the home and other nonclinical environments is increasing dramatically. By the year 2050, an estimated 27 million people will need continuing care in the home or in the community and not in a controlled clinical environment. 1 The FDA recently announced its Home Use Devices Initiative and issued the document, "Draft Guidance for Industry and FDA Staff-Design Considerations for Devices Intended for Home Use" on Dec. 12, 2012. 2 The Center for Devices and Radiological Health (CDRH) regulates medical devices, but that regulatory authority alone is not enough to ensure safe and effective use of devices in the home. To address these and other issues, AAMI and FDA will co-host a summit on healthcare technology in nonclinical settings Oct. 9-10, 2013.

Increased age is an independent risk factor for radiographic aspiration and laryngeal penetration after thoracotomy for pulmonary resection.

OBJECTIVES: Aspiration is an increasingly recognized complication after thoracotomy for pulmonary resection, but mechanisms of postoperative aspiration are poorly characterized. This study sought to evaluate risk factors to better define postthoracotomy aspiration. METHODS: Three hundred twenty-one consecutive patients underwent clinical bedside swallowing evaluations after thoracotomy for pulmonary resection on postoperative day 1. Results of videofluoroscopic swallowing studies were independently reviewed by 2 speech pathologists and were assigned aspiration-penetration scores of either 1 (normal) or greater than 1 (abnormal) based on the worst swallow. Operative, demographic, and outcomes data were abstracted for each patient, and multivariate regression analysis was performed. RESULTS: Seventy-three (22.7%) patients failed bedside evaluation and proceeded to undergo videofluoroscopic swallowing studies. Forty-four (60.3%) patients had an abnormal videofluoroscopic swallowing study result with a mean aspiration-penetration score of 3.9 +/- 0.3. Multivariate analysis showed that older age (68.8 vs 56.2 years, P = .002), prior premature spillage (P = .0006), and vallecular residuals after the swallow (P < .0002) were all associated with aspiration. Interestingly, certain variables were not independently associated with aspiration, including presence of gastroesophageal reflux disease, operative approach or degree of resection, mediastinal lymphadenectomy, preoperative thoracic radiation, same hospitalization reoperation, and pathology. CONCLUSIONS: Postoperative risk of aspiration after thoracotomy for pulmonary resection is characterized by repeatable episodes of oropharyngeal discoordination on videofluoroscopic swallowing studies. We recommend routine videofluoroscopic swallowing studies for all patients older than 67 years before the initiation of oral intake to diminish the incidence of postoperative aspiration.

What information do clinicians use in recommending oral versus nonoral feeding in oropharyngeal dysphagic patients?

There is little evidence regarding the type(s) of information clinicians use to make the recommendation for oral or nonoral feeding in patients with oropharyngeal dysphagia. This study represents a first step toward identifying data used by clinicians to make this recommendation and how clinical experience may affect the recommendation. Thirteen variables were considered critical in making the oral vs. nonoral decision by the 23 clinicians working in dysphagia. These variables were then used by the clinicians to independently recommend oral vs. nonoral feeding or partial oral with nonoral feeding for the 20 anonymous patients whose modified barium swallows were sent on a videotape to each clinician. Clinicians also received data on the 13 variables for each patient. Results of clinician agreement on the recommendation of full oral and nonoral only were quite high, as measured by Kappa statistics. In an analysis of which of the 13 criteria clinicians used in making their recommendations, amount of aspiration was the criterion with the highest frequency. Recommendations for use of postures and maneuvers and the effect of clinician experience on these choices were also analyzed.

Mass psychogenic illness presenting as acute stridor in an adolescent female cohort.

OBJECTIVES: We describe a cohort of patients with an unusual presentation of stridor, their evaluation and management, and their outcome. We review the pertinent English-language literature. METHODS: We performed a retrospective review of the records of 12 adolescent patients treated for acute-onset inspiratory stridor at the Departments of Otolaryngology-Head and Neck Surgery and Allergy and Immunology at the University of South Florida and the Department of Speech Pathology at the H. Lee Moffitt Cancer Center and Research Institute. Two additional patients received treatment elsewhere. Demographic, historical, and laboratory data, physical examination findings, and follow-up information were extracted. A review of both the Hillsborough County Department of Health epidemiological report and the English-language literature was performed. RESULTS: Fourteen female patients who attended a local high school developed audible inspiratory noise. Twelve of the 14 were seen at the University of South Florida Ear, Nose and Throat Center. The remaining 2 patients were evaluated by outside otolaryngologists but were included in all reports from the Department of Health. Environmental studies did not find noxious chemical or biological agents in the students' environments to explain the development of the symptoms. Physical and videostroboscopic examination identified two distinct laryngeal findings causing the audible stridor. One involved paradoxical vocal fold movement, and the other, supraglottic mucosal collapse into the airway. All patients underwent rigorous speech pathology intervention and structured treatment with either complete resolution or significant improvement, seen both clinically and on videostroboscopic evaluation. CONCLUSIONS: Audible stridor can arise from numerous disease processes. In the vast majority of presentations it occurs sporadically and on an individual basis. Our cohort is especially unusual because of the sheer number of patients. Our presentation of a case of mass psychogenic illness as the cause of vocal cord dysfunction with additional findings of laryngomalacia within a group of adolescent girls is the first in the English-language literature. The key to the diagnosis is recognition of the disorder and susceptible individuals by using a thorough physical examination with emphasis on the laryngoscopic and videostroboscopic findings. The systematic approach, undertaken by a team including an otolaryngologist, an allergist, a speech pathologist, and an epidemiologist, proved to be effective in the management of this complex disorder and highly unusual situation.

Routine evaluation for aspiration after thoracotomy for pulmonary resection.

BACKGROUND: The purpose of this study was to evaluate the role of a routine protocol for evaluation of oropharyngeal aspiration after thoracotomy for pulmonary resection. METHODS: Demographic, operative, and outcomes data were collected prospectively for consecutive patients undergoing thoracotomy for pulmonary resection starting in April 2005. Starting on postoperative day one, patients underwent evaluation by a licensed speech therapist before per os intake. Patients failing clinical examination were referred for radiographic evaluation. Diets were advanced on the basis of results from both clinical and radiographic evaluation. Data analysis included descriptive statistics, Student's t test, and chi2 test when appropriate. RESULTS: One hundred forty patients were prospectively evaluated during this period. Thirty-two patients (22.9%) failed initial clinical swallowing evaluation and were referred for dynamic videofluoroscopic esophagram. Twenty-five patients (17.8%) had evidence of potential oropharyngeal aspiration on videofluoroscopic esophagram. Only 1 patient (0.7%) aspirated after a negative clinical evaluation. Univariate risk factor analysis revealed that patients demonstrating aspiration were older (67.7 +/- 1.6 years versus 64.4 +/- 1.1 years; p = 0.10) and had a higher incidence of head and neck malignancy (p < 0.001). Patients without radiographic aspiration had a shorter median hospital stay when compared with those who did (6 days versus 5 days). CONCLUSIONS: Aspiration after thoracotomy for pulmonary resection may affect nearly 20% of patients and is likely underrepresented in the surgical literature. The institution of a protocol to evaluate risk of aspiration has characterized patients at high risk and led to an increased awareness of the potential for aspiration after thoracotomy.