Impact of big data on oral health outcomes

Abstract

Biomedical big data amasses from different sources such as electronic health records, health research, wearable devices and social media. Recent advances in data capturing, storage and analysis techniques have facilitated conversion of a wealth of knowledge in biomedical big data into evidence‐based actionable plans to enhance population health and wellbeing. The delay in reaping the benefits of biomedical big data in dentistry is mainly due to the slow adoption of electronic health record systems, unstructured clinical records, tattered communication between data silos and perceiving oral health as a separate entity from general health. Recent recognition of the complex interplay between oral and general health has acknowledged the power of oral health big data to glean new insights on disease prevention and management. This review paper summarizes recent advances, limitations and challenges in biomedical big data in health care with emphasis on oral health and discusses the potential future applications of oral health big data to improve the quality and efficiency of personalized health care.

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Effects of equibiaxial mechanical stretch on extracellular matrix‐related gene expression in human calvarial osteoblasts

Mechanical stretch commonly promotes craniofacial suture remodeling during interceptive orthodontics. The mechanical responses of osteoblasts in craniofacial sutures play a role in suture remodeling. Moreover, the extracellular matrix (ECM) produced by osteoblasts is crucial for the transduction of mechanical signals that promote cell differentiation. Therefore, we aimed to investigate the effect of mechanical stretch on cell viability and ECM‐related gene‐expression changes in human osteoblasts. Human calvarial osteoblasts (HCObs) were subjected to 2% deformation. Caspase activity, MTT, and cell viability assays were used to estimate osteoblast apoptosis, proliferation, and viability, respectively. Real‐time RT‐PCR (RT²‐PCR) arrays were used to assess expression of cytoskeletal‐, apoptosis‐, osteogenesis‐, and ECM‐related genes. We found that mechanical stretch significantly increased osteoblast viability and cell proliferation, and decreased the activities of caspases 3 and 7. Moreover, the expression of 18 genes related to osteoblast differentiation, apoptosis, and ECM remodeling changed by more than two‐fold in a time‐dependent manner. Therefore, mechanical stretch promotes HCOb viability and alters expression of genes that are closely related to suture remodeling under mechanical stretch.

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Calendar Listings

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TOC

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Instructions for Contributors

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Editorial Board

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Author index

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Subject Index

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CCR10+ ILC2s with ILC1‐like properties exhibit a protective function in severe allergic asthma

Abstract

Background

We previously showed that patients with severe allergic asthma have high numbers of circulating ILC2s expressing CCR10.

Method

Herein, CCR10⁺ ILC2s were further analyzed in the blood of healthy individuals or patients with allergic and non−allergic asthma. Characteristics of human CCR10⁺ and CCR10⁻ ILC2s were assessed by flow cytometry as well as single‐cell multiplex RT‐qPCR. The role of CCR10⁺ ILC2s in asthma pathophysiology was studied in allergen‐treated mice.

Results

When compared to healthy controls, CCR10⁺ ILC2s are enriched in the blood of both allergic and non‐allergic severe asthmatic patients, and these cells are recruited to the lungs. Plasma concentrations of the CCR10 ligand CCL27 are significantly increased in severe asthmatics when compared to non‐asthmatic patients. CCR10⁺ ILC2s secrete little T_H2 cytokines, but exhibit ILC1‐like properties, including a capacity to produce IFN‐γ. Also, single cell analysis reveals that the CCR10⁺ ILC2 subset is enriched in cells expressing Amphiregulin. CCR10⁺ ILC2s depletion, as well as blocking of IFN‐γ activity, exacerbates airway hyperreactivity in allergen‐challenged mice, providing evidence for a protective role of these cells in allergic inflammation.

Conclusions

Frequencies of circulating CCR10⁺ ILC2s and CCL27 plasma concentrations represent candidate markers of asthma severity. The characterization of CCR10⁺ ILC2s in human samples and in mouse asthma models suggests that these cells downregulate allergic inflammation through IFN‐γ production.

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RNA is taking its Toll – Impact of RNA‐specific Toll‐like receptors on health and disease

Abstract

RNA‐sensing Toll‐like receptors (TLRs) are often described as anti‐viral receptors of the innate immune system. However, the past decade has shown that the function and importance of these receptors is far more complex. These receptors were found to be relevant for the detection of various bacterial, archaeal, and eukaryotic microorganisms and facilitate the discrimination between dead and living microbes. The cytokine and interferon response profile that is triggered has the potential to improve the efficacy of next‐generation vaccines and may prevent the development of asthma and allergy. Nevertheless, the ability to recognize foreign RNA comes with a cost as also damaged host cells can release nucleic acids that might induce an inappropriate immune response. Thus, it is not surprising that RNA‐sensing TLRs play a key role in various autoimmune diseases. However, promising new inhibitors and antagonists are on the horizon to improve their treatment.

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All items of the Food Allergy Quality of Life Questionnaires are relevant for peanut‐allergic patients

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An Integrative Analysis of Spontaneous Storytelling Discourse in Aphasia: Relationship With Listeners' Rating and Prediction of Severity and Fluency Status of Aphasia

Purpose

This study investigated which of the three analytic approaches of oral discourse, including linguistically based measures, proposition-based measures, and story grammar, best correlated with aphasia severity and with naïve listeners' ratings on aphasic productions. The predictive power of these analytic approaches to aphasia severity and fluency status of people with aphasia (PWA) was examined. Finally, which approach best discriminated fluent versus nonfluent PWA was determined.

Method

Audio files and orthographic transcriptions of the storytelling task "The Boy Who Cried Wolf" from 68 PWA and 68 controls were extracted from the Cantonese AphasiaBank. Each transcript was analyzed using these 3 systems.

Results

The linguistic approach of discourse analysis best correlated with aphasia severity and naïve listeners' subjective ratings. Although both linguistically based and proposition-based measures significantly predicted aphasia severity, a subset of linguistic measures focusing on the quantity and efficiency of production were particularly useful for clinical estimation of the fluency status of aphasia.

Conclusions

The linguistically based measures appeared to be the most clinically effective and powerful in reflecting PWA's performance of spoken discourse.

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Acquired Velopharyngeal Dysfunction: Survey, Literature Review, and Clinical Recommendations

Purpose

The aim of this study was to describe the clinical assessment recommendations for acquired velopharyngeal dysfunction (AVPD) and, through a literature review and online survey, summarize current practice patterns for evaluation and treatment pathway determination for this target population.

Method

An online survey to query current assessment procedures and treatment pathway recommendations for AVPD was developed. Following survey results, a literature review was completed to determine evidence-based recommendations for assessment procedures and intervention recommendations based on assessment findings. Literature search terms included the following: acquired velopharyngeal dysfunction, hypernasality, non–cleft velopharyngeal dysfunction, velopharyngeal dysfunction, velopharyngeal dysfunction AND iatrogenic, velopharyngeal dysfunction AND neurogenic, velopharyngeal dysfunction AND assessment OR evaluation, velopharyngeal dysfunction AND treatment OR intervention, velopharyngeal dysfunction AND practice patterns OR clinical guidelines, velopharyngeal insufficiency. Inclusion criteria were limited to practice patterns/recommendations for assessment and/or treatment recommendations for AVPD, English language articles published between 2000 and 2017, and peer-reviewed journals. Studies regarding solely congenital or cleft palate velopharyngeal dysfunction and intervention outcome studies were excluded. Forty articles met inclusionary criteria.

Results

The online survey results indicated lack of consensus for AVPD assessment and treatment recommendation protocols, with 93% of respondents indicating the need for a clinical guide for developing treatment recommendations. The majority of recommendations were filtered into an algorithm for clinical decision making.

Conclusions

Clinical uncertainty among speech-language pathologists surveyed and the paucity of published clinical guidelines for assessing individuals with AVPD indicate the need for additional clinical research for this disorder, one that is heterogeneous and distinct from those with congenital velopharyngeal dysfunction. The proposed evidence-based clinical worksheet may assist in determining management for patients with AVPD and may serve as a starting place for validation of a clinical guideline.

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Sense of Effort and Fatigue Associated With Talking After Total Laryngectomy

Purpose

Sense of effort and fatigue associated with talking was compared in individuals with and without a total laryngectomy.

Method

An online survey of individuals using tracheoesophageal speech (TES; n = 222), electrolaryngeal speech (ELS; n = 132), esophageal speech (n = 41), and laryngeal speech (LS; n = 112) asked about 3 domains of effort when talking: frequency of occurrence, withdrawal from talking, and location in the body. Three aspects of fatigue were explored: frequency of occurrence, fatigue type, and duration of talking before fatigue.

Results

Alaryngeal groups reported significantly more talking-related effort and fatigue than the LS group. Sixty-three percent of all respondents indicated that effort caused them to talk less, with no group differences on this item. Significantly more effort was localized to the lips and tongue by ELS compared with TES and LS groups. Both the ELS and TES groups had higher shoulder/arm effort when talking compared with the esophageal speech and LS groups. ELS respondents reported less fatigue than the TES group. When fatigue was present, the TES group had more physical and less mental fatigue than the ELS group. The duration of talking before experiencing fatigue was significantly shorter for the alaryngeal groups compared with the LS group.

Conclusions

Effort and fatigue associated with talking are a common report for individuals using alaryngeal speech. The location of effort within the body and the type of fatigue experienced vary to some extent across alaryngeal speaking methods.

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Clinical Progression in Four Cases of Primary Progressive Apraxia of Speech

Purpose

This case series details the clinical progression of patients with primary progressive apraxia of speech (PPAOS) to illustrate, using several methods and supplemental material examples, the changes that occur in speech and language functioning in this patient population.

Method

Four patients who presented with PPAOS were followed between 5 and 6 years. Two patients had predominant articulatory abnormalities (termed phonetic PPAOS), 1 had predominant prosodic abnormalities (prosodic PPAOS), and 1 had relatively equal articulatory and prosodic abnormalities (mixed PPAOS). Detailed speech (including acoustics), language, neurologic, and neuropsychological data were collected.

Results

At initial exam, the patients ranged from 60 to 77 years old, with presenting disease duration of 1.5–10 years. Although all patients presented with an isolated apraxia of speech, all developed varying degrees of aphasia and dysarthria. Patients with phonetic PPAOS developed relatively more severe aphasia than the other 2 patients. All patients eventually had severe functional communication limitations and required alternative or augmentative means of communication, although at varying times postonset of their initial speech problem. Two patients developed dysphagia, 3 showed mild–moderate Parkinsonism, and 2 developed depression. For all patients, simple temporal acoustic measurements documented slowed speech rate over time.

Conclusions

This case series demonstrates that patients who initially present with PPAOS may develop aphasia and dysarthria, cognitive and behavioral changes, and other neurologic signs. Whether these changes can be predicted by the perceptual characteristics of the apraxia of speech is yet to be determined. The detailed longitudinal profiles provide valuable clinical insight into the progression of disease in people with PPAOS.

Supplemental Material

https://doi.org/10.23641/asha.7051616

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How Gender Stereotypes May Limit Female Faculty Advancement in Communication Sciences and Disorders

Purpose

The field of communication sciences and disorders (CSD) faces a critical shortage of the faculty essential to train the future workforce of speech-language pathologists and audiologists. Despite a predominance of women in the field, men receive doctoral degrees, tenure status, academic leadership positions, and American Speech-Language-Hearing Association awards at disproportionately higher rates than women. The purpose of this review is to explore how implicit gender bias may contribute to female faculty advancement, including current and projected faculty workforce shortages, and to propose tangible solutions.

Method

The authors present proportions of men and women who receive doctoral degrees, advance to each faculty rank, receive tenure status, hold department chairs in CSD, and receive American Speech-Language-Hearing Association honors and awards. They review ways in which cultural stereotypes give rise to implicit gender bias and discuss myriad ways that implicit gender bias may influence the decisions of students considering an academic career in CSD and their career trajectories.

Conclusions

Cultural stereotypes about men and women lead to implicit gender bias that may have real consequences for female faculty advancement in CSD. Such implicit bias can influence career selection and outcomes within the field in multiple ways. To ensure that CSD continues to attract top talent and maintain a robust pipeline of future faculty in doctoral training programs, the field must recognize the existence of implicit gender bias and implement evidence-based strategies to minimize its potentially damaging effects on the future of the profession.

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The Accuracy of Smartphone Sound Level Meter Applications With and Without Calibration

Purpose

The purpose of this study is to determine the accuracy of smartphone sound level meter applications (SLMAs) with calibration features across stimulus levels and for ambient room noise measures in the clinical setting.

Method

The accuracy of 3 iOS-based smartphone SLMAs (SLMA1: Analyzer [Version 2.7.2, DSP Mobile], SLMA2: Sound Level Meter Pro [Version 2.2, Mint Muse LLC], and SLMA3: SPL Meter [Version 9.3, Andrew Smith, Studio Six Digital]), using a single smartphone device (iPhone 6S Model A1688, iOS 9.3.4, Apple), was evaluated with and without calibration using a 1000-Hz narrowband noise (NBN) and white noise (WN) stimuli over a range of sound levels (20–100 dB) and in ambient noise measures of 8 speech and hearing room environments. A simultaneous and corresponding SLMA and Type 1 sound level meter (SLM) measure per condition were documented with a photo image; each condition was replicated 5 times. Mean SLMA and SLM measures were compared. SLMA measures were considered accurate if within ± 2 dB of the SLM.

Results

Measures of NBN and WN signals using these SLMAs were accurate at levels above 40–50 dB when calibrated. NBN and WN signals using some SLMAs were significantly (p < .05) more accurate with calibration at levels > 40 to 50 dB. SLMA measures with or without calibration adjustment were inaccurate and overestimated room ambient noise levels < 50 dB.

Conclusions

These findings suggest that some SLMAs are accurate for measuring NBN and WN stimuli within the range of 50–100 dB in sound-treated environments when calibrated. However, outcomes indicated that some SLMAs, even with calibration, overestimated low ambient noise levels and may not accurately verify quiet room environments < 50 dB for clinical services. These results should not be generalized for all smartphone types, and continued research on SLMAs using next-generation smartphone devices is warranted.

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Modifying Food Textures: Practices and Beliefs of Staff Involved in Nutrition Care

Purpose

Modifying food texture is an important part of dysphagia management, yet less is known about the day-to-day practices that might impact the nutritional well-being of patients. This study surveyed staff involved in the service delivery of texture-modified foods with the objectives to gain information about roles and responsibilities, instruction and knowledge about modifying foods, and beliefs about the use of texture-modified foods in nutrition care.

Method

We created a 21-item survey about texture-modified foods. Recruitment efforts focused on both professional and frontline staff involved in service delivery. Practice groups and organizations provided the means of recruiting professionals from different disciplines. Because frontline staff (e.g., certified nursing assistants, cooks) do not have similar membership groups, we recruited them through direct contacts with health care agencies.

Results

A total of 175 individuals completed the survey. Respondents included 107 professionals (primarily certified dietary managers, registered dietitians, speech-language pathologists) and 68 frontline staff (mostly certified nursing assistants/home health aides). Although the frontline and professional staff showed generally similar patterns of opinions and beliefs about modified food textures, differences emerged in reported experiences, roles, and responsibilities in service delivery.

Conclusions

Survey respondents conveyed generally positive attitudes and opinions about the use of texture-modified foods, and respondents perceived them to be easy to execute and beneficial to the nutritional well-being of patients. Survey findings clearly highlight the contributions of frontline staff in the service delivery of modified food textures. Consideration must be given to continued reliance on informal, limited instruction about texture-modified foods and possible implications for safe nutrition care. Both professional and frontline staff convey a willingness to customize or alter food textures and the belief that patients should be able to choose the level of texture modification that they want to eat.

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Current Practice of Child Grammar Intervention: A Survey of Speech-Language Pathologists

Purpose

The aim of this study was to better understand current grammatical intervention approaches. Despite grammatical language being a common weakness among children with language impairment, relatively little is known about current grammatical intervention practices of speech-language pathologists (SLPs). Such information is needed to guide the development and evaluation of grammatical interventions and to identify areas in which the current practice is not empirically supported.

Method

Participants included 338 SLPs working primarily with children. Participants completed an online survey regarding their implementation of nine different grammatical intervention components, including goals, procedures, dosage, agents, contexts, goal attack strategies, service delivery models, activities, and outcome measurements. Participants also indicated how they would alter the intervention setting and dosage if resources were unlimited.

Results

We grouped participants based on the ages of children that represent the largest percentage of their caseload resulting in an early education group (n = 114) and an elementary group (n = 224). We aggregated responses from each question to gain an estimate of current implementation practices associated with each intervention component queried.

Conclusions

This study provides general guidelines of current clinical practices to help guide research on grammatical interventions for children and to promote successful translation and implementations of evidence-based treatment approaches. Results may also help clinicians and researchers better understand misalignments between empirically supported intervention approaches and current approaches for treating grammatical weaknesses.

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Writing Changes and Perceptions After Traumatic Brain Injury: “Oh, by the way, I can't write”

Purpose

Language and cognitive disruptions following traumatic brain injury (TBI) can negatively affect written expression and may result in increased difficulty achieving academic, vocational, social, and personal goals; however, scarce literature exists about TBI's effect on writing abilities. The purpose of this qualitative study was to describe the experiences and perceptions of people with TBI regarding their engagement in writing activities.

Method

A transcendental phenomenological design structured the research. Data collection from 11 adults with TBI included gathering demographic and background information, completion of a TBI Symptom Checklist, and engagement in semistructured interviews.

Results

Four major themes and 21 subthemes about postinjury writing recovery and current writing status emerged from the data analysis. Participants reported the extent to which writing difficulties interfered with daily activities and identified support strategies used to address persistent challenges.

Conclusion

Understanding the writing experiences and perceptions of people with TBI can guide professionals in designing assessments and interventions to facilitate educational, vocational, social, and personal success following injury.

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A Case Study Using a Multimodal Approach to Melodic Intonation Therapy

Purpose

The purpose of this study was to assess the efficacy. of increasing spontaneous expressive language using a modified melodic intonation therapy (MIT) approach with a male participant diagnosed with acquired aphasia and apraxia who was 10 years post onset.

Method

A therapeutic protocol consisting of vocal and linguistic tasks was administered. The participant attended two 50-min individual sessions and a 4-hr/week socialization program for three 12-week semesters. Measures of speech and language were administered before intervention and at the completion of each of the 3 semesters.

Results

At the completion of the study, the participant demonstrated reduced apraxia of speech as measured by The Apraxia Battery for Adults, Second Edition (Dabul, 2000). He also showed improvements in auditory comprehension skills as measured on the Boston Diagnostic Aphasia Evaluation (Goodglass, Kaplan, & Barresi, 2000). His spontaneous utterances were characterized by an increased number of complete sentences and questions. Several language parameters including mean length of utterance, total number of spontaneous (untrained) utterances, and number of different words spoken were also improved as revealed through language analysis.

Conclusions

Integration of melodic intonation therapy through the addition of musical elements may result in improved speech and expressive language skills when administered over a 9-month period in conjunction with a group socialization program.

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Children's Consonant Acquisition in 27 Languages: A Cross-Linguistic Review

Purpose

The aim of this study was to provide a cross-linguistic review of acquisition of consonant phonemes to inform speech-language pathologists' expectations of children's developmental capacity by (a) identifying characteristics of studies of consonant acquisition, (b) describing general principles of consonant acquisition, and (c) providing case studies for English, Japanese, Korean, and Spanish.

Method

A cross-linguistic review was undertaken of 60 articles describing 64 studies of consonant acquisition by 26,007 children from 31 countries in 27 languages: Afrikaans, Arabic, Cantonese, Danish, Dutch, English, French, German, Greek, Haitian Creole, Hebrew, Hungarian, Icelandic, Italian, Jamaican Creole, Japanese, Korean, Malay, Maltese, Mandarin (Putonghua), Portuguese, Setswana (Tswana), Slovenian, Spanish, Swahili, Turkish, and Xhosa.

Results

Most studies were cross-sectional and examined single word production. Combining data from 27 languages, most of the world's consonants were acquired by 5;0 years;months old. By 5;0, children produced at least 93% of consonants correctly. Plosives, nasals, and nonpulmonic consonants (e.g., clicks) were acquired earlier than trills, flaps, fricatives, and affricates. Most labial, pharyngeal, and posterior lingual consonants were acquired earlier than consonants with anterior tongue placement. However, there was an interaction between place and manner where plosives and nasals produced with anterior tongue placement were acquired earlier than anterior trills, fricatives, and affricates.

Conclusions

Children across the world acquire consonants at a young age. Five-year-old children have acquired most consonants within their ambient language; however, individual variability should be considered.

Supplemental Material

https://doi.org/10.23641/asha.6972857

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Read, Understand, Learn, & Excel (RULE): Development and Feasibility of a Reading Comprehension Measure for Postsecondary Learners

Purpose

There is a lack of quick, reliable, and valid standardized reading comprehension assessments appropriate for postsecondary readers. We attempted to address this gap by designing Read, Understand, Learn, & Excel (RULE), a reading comprehension measure that employs sentence verification and recall tasks to assess reading comprehension. This article describes the exploratory study undertaken to construct RULE and then examines the preliminary concurrent validity and alternate form reliability of this measure.

Method

The RULE measure was first developed by designing reading stimuli, test items for the sentence verification task, and directions for the recall test for 2 forms based on previous work (Griffiths, Sohlberg, Kirk, Fickas, & Biancarosa, 2016). Thirty undergraduate students who identified themselves as typical readers were administered the RULE measure as well as the Nelson–Denny Reading Test (Brown, Fishco, & Hanna, 1993). Students also completed questionnaires and participated in informal interviews to provide information regarding study and learning habits and academic background.

Results

There was preliminary evidence of alternate form reliability between the sentence verification task sets of 2 chapters of RULE (r = .38, p < .05). Preliminary evidence for concurrent validity between RULE and the Nelson–Denny Reading Test was provided by correlation coefficients in the low to moderate range (.03–.38).

Conclusion

RULE design and preliminary findings of concurrent validity and alternate form reliability provide "proof of concept" for an ecologically valid testing format that assesses comprehension skills appropriate for the postsecondary level. Suggestions for strengthening validity and reliability of the tool are provided, and clinical contributions of RULE are discussed.

Supplemental Material

https://doi.org/10.23641/asha.6987371

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Changing Nonstuttering Preschool Children's Stuttering Attitudes

Purpose

Negative or uninformed stuttering attitudes proliferate among the general public, and bourgeoning research has shown that such attitudes might emerge as early as the preschool years. Much remains unknown about young children's stuttering attitudes, and conclusive recommendations to improve attitudes toward stuttering have yet to be advanced. This study sought to determine the effect of a new educational program on improving stuttering attitudes among preschool children using objective measures.

Method

Thirty-seven preschool children learned about stuttering and sensitive peer interactions by participating in the newly developed Attitude Change and Tolerance program. The program teaches children about human differences with an emphasis on stuttering and how to interact with people who stutter. Children's stuttering attitudes were measured using the Public Opinion Survey of Human Attributes–Stuttering/Child (Weidner & St. Louis, 2014) before and after the program.

Results

Pre–post comparisons showed statistically significant improvements in children's overall stuttering attitudes. In particular, children demonstrated gains relative to their perceptions of and reactions toward people who stutter.

Conclusion

This study provides empirical evidence that young children's stuttering attitudes can be improved using the Attitude Change and Tolerance program. In addition, it supports previous research that negative stuttering attitudes emerge as early as preschool.

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Effects of Submental Surface Electrical Stimulation on Swallowing Kinematics in Healthy Adults: An Error-Based Learning Paradigm

Purpose

Hyoid bone and laryngeal approximation aid airway protection (laryngeal vestibule closure) while moving toward their peak superior and anterior positions during swallowing. Submental surface electrical stimulation (SES) is a therapeutic technique that targets the muscles that move the hyoid bone during swallowing. It is unknown whether submental SES only increases peak hyoid bone swallowing positions but not peak laryngeal swallowing positions, which could require faster or greater laryngeal movement to achieve adequate laryngeal vestibule closure.

Method

We examined the effects of submental SES on hyo-laryngeal kinematics in 30 healthy adults who swallowed 50 times using an error-based learning paradigm.

Results

Submental SES did not alter any hyo-laryngeal swallowing kinematic. However, submental SES significantly changed the starting position of the hyoid bone just prior to the swallow onset (more anterior; p = .003). On average, submental SES immediately prior to swallow onset can position the hyoid approximately 20% closer to its peak swallowing point.

Conclusions

These findings indicate that electrical stimulation of the agonists for hyoid movement might not alter swallowing outcomes tested in this study. However, submental SES could have clinical utility by minimizing swallowing impairments related to reduced hyoid swallowing range of motion in individuals with dysphagia.

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Communicative Accessibility in Aphasia: An Investigation of the Interactional Context of Long-Term Care Facilities

Purpose

The purpose of this study was to examine the ability of persons with aphasia to access interaction and be included in social encounters in long-term care facilities (LTCFs).

Method

Four persons with aphasia were the focus of this investigation. A qualitative research approach using ethnographic methods was used to conduct participant observation, semistructured interviews, and artifact analysis. Expanded field notes from observations, transcribed interviews, and artifacts were then coded to identify patterns in the data.

Results

The interactional context of LTCFs negatively influenced the ability of persons with aphasia to communicate with others and develop meaningful relationships. Three major themes emerged from the data detailing the contextual elements leading to communication accessibility and inclusion: (a) lack of support, (b) social hierarchy, and (c) focus on performance.

Conclusions

Findings highlighted several barriers in LTCFs that worked to discourage persons with aphasia from living social and expressive lives. Specific obstacles included a misunderstanding of aphasia and its influence on communicative exchanges and performance-oriented environment that overlooked psychosocial needs. Speech-language pathologists have an important role for advocacy in LTCFs. Clinical implications for assessment and treatment in institutions are discussed.

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Patient, Parent, and Speech-Language Pathologists' Perceptions of Pediatric Voice Therapy Through Interviews

Purpose

Voice therapy is heavily reliant on patient adherence for success, and patient perceptions are an important piece of understanding adherence. Patient perceptions of voice therapy have not been studied in the pediatric population. The purpose of this study was to examine patient, parent, and speech-language pathologists' experiences and perceptions of voice therapy and how they reflect barriers to and facilitators of adherence to therapy.

Method

Participants took part in semistructured interviews, which were transcribed, and content analysis was completed using established qualitative methods of content analysis to identify themes and subthemes related to voice therapy adherence.

Participants

Thirty-four voice therapy patients (of ages 4–18) and their parents and 5 pediatric speech-language pathologists were included in the study.

Results

Seven primary themes with multiple subthemes were identified. The primary themes identified were as follows: (a) voice therapy is fun, (b) voice therapy is easy, (c) voice therapy is worthwhile, (d) the clinician–patient match matters, (e) support systems are helpful, (f) fitting it in, and (g) changing behavior is hard.

Conclusions

Adherence to voice therapy in pediatric populations is complex and depends on multiple intrinsic and extrinsic factors. Identification of themes related to adherence in voice therapy should serve to assist clinicians in planning therapy and in developing treatment programs.

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Phonological Development in a Bilingual Arabic–English-Speaking Child With Bilateral Cochlear Implants: A Longitudinal Case Study

Purpose

This longitudinal study examined the phonological development of a bilingual Arabic–English-speaking child with bilateral cochlear implants (CIs). The focus of the study was to observe the interaction between her two languages and to observe the effect of CIs on the acquisition of two speech sound systems.

Method

This study followed a 3;6-year-old (2;5 hearing age) bilingual Arabic–English-speaking child with bilateral CIs to age 4;4 (3;2 hearing age). Single-word samples were collected bimonthly in both languages. Phon software (Rose et al., 2006) was used to transcribe and analyze speech samples. Measures derived included Percent Consonants Correct–Revised (Shriberg & Kwiatkowski, 1994), percent vowels correct, phonetic inventory complexity, and common phonological patterns for both English and Arabic.

Results

Our findings supported previous research on phonological development exhibited by children with CIs, with the gradual suppression of typical and atypical error patterns and gradual increase in segmental accuracy with maturation. In addition, language interaction and separation between English and Arabic were found, supporting previous cross-linguistic work on bilingual phonological acquisition (e.g., Fabiano-Smith & Goldstein, 2010b).

Conclusion

Bilingual children with CIs have the capability to learn both of their languages and perform similarly to, and even surpass in accuracy, monolingual children with CIs; however, it is also possible to exhibit a slower rate of acquisition of segmental accuracy as compared to their typically developing, hearing peers. Clinical implications of bilingual early intervention are discussed.

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Speech Impairment in Boys With Fetal Alcohol Spectrum Disorders

Background

Fetal alcohol spectrum disorders (FASD) are a highly prevalent spectrum of patterns of congenital defects resulting from prenatal exposure to alcohol. Approximately 90% of the cases involve speech impairment. Yet, to date, no detailed symptom profiles nor dedicated treatment plans are available for this population.

Purpose

This study set out to chart the speech and speech motor characteristics in boys with FASD to profile the concomitant speech impairment and identify possible underlying mechanisms.

Method

Ten boys with FASD (4.5–10.3 years old) and 26 typically developing children (4.1–8.7 years old; 14 boys, 12 girls) participated in the study. Speech production and perception, and oral motor data were collected by standardized tests.

Results

The boys with FASD showed reduced scores on all tasks as well as a deviant pattern of correlations between production and perception tasks and intelligibility compared with the typically developing children. Speech motor profiles showed specific problems with nonword repetition and tongue control.

Conclusions

Findings indicate that the speech impairment in boys with FASD results from a combination of deficits in multiple subsystems and should be approached as a disorder rather than a developmental delay. The results suggest that reduced speech motor planning/programming, auditory discrimination, and oral motor abilities should be considered in long-term, individually tailored treatment.

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Continuous Vocal Fry Simulated in Laboratory Subjects: A Preliminary Report on Voice Production and Listener Ratings

Purpose

Vocal fry is prevalent in everyday speech. However, whether the use of vocal fry is detrimental to voice production is unclear. This preliminary study assessed the effects of using continuous vocal fry on voice production measures and listener ratings.

Method

Ten healthy individuals (equal male and female, mean age = 22.4 years) completed 2 counterbalanced sessions. In each session, participants read in continuous vocal fry or habitual voice quality for 30 min at a comfortable intensity. Continuous vocal fry was simulated. Phonation threshold pressure (PTP₁₀ and PTP₂₀), cepstral peak prominence, and vocal effort ratings were obtained before and after the production of each voice quality. Next, 10 inexperienced listeners (equal male and female, mean age = 24.1 years) used visual analog scales to rate paired samples of continuous vocal fry and habitual voice quality for naturalness, employability, and amount of listener concentration.

Results

PTP₁₀ and vocal effort ratings increased after 30 min of continuous vocal fry. Inexperienced listeners rated continuous vocal fry more negatively than the habitual voice quality.

Conclusions

Thirty minutes of simulated, continuous vocal fry worsened some voice measures when compared with a habitual voice quality. Samples of continuous vocal fry were rated as significantly less employable, less natural, and requiring greater listener concentration as compared with samples of habitual voice quality. Future studies should include habitual users of vocal fry to investigate speech stimulability and adaptation with cueing to further understand pathogenesis of vocal fry.

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Concatenation of the Moving Window Technique for Auditory-Perceptual Analysis of Voice Quality

Purpose

The purpose of this study is to develop a program to concatenate acoustic vowel segments that were selected with the moving window technique, a previously developed technique used to segment and select the least perturbed segment from a sustained vowel segment. The concatenated acoustic segments were compared with the nonconcatenated, short, individual acoustic segments for their ability to differentiate normal and pathological voices. The concatenation process sometimes created a clicking noise or beat, which was also analyzed to determine any confounding effects.

Method

A program was developed to concatenate the moving window segments. Listeners with no previous rating experience were trained and, then, rated 20 normal and 20 pathological voice segments, both concatenated (2 s) and short (0.2 s) for a total of 80 segments. Listeners evaluated these segments on both the Grade, Roughness, Breathiness, Asthenia, and Strain scale (GRBAS; 8 listeners) and the Consensus Auditory-Perceptual Evaluation of Voice (Kempster, Gerratt, Abbott, Barkmeier-Kraemer, & Hillman, 2009) scale (7 listeners). The sensitivity and specificity of these ratings were analyzed using a receiver-operating characteristic curve. To evaluate if there were increases in particular criteria due to the beat, differences between beat and nonbeat ratings were compared using a 2-tailed analysis of variance.

Results

Concatenated segments had a higher sensitivity and specificity for distinguishing pathological and normal voices than short segments. Compared with nonbeat segments, the beat had statistically similar increases for all criteria across Consensus Auditory-Perceptual Evaluation of Voice and GRBAS scales, except pitch and loudness.

Conclusions

The concatenated moving window method showed improved sensitivity and specificity for detecting voice disorders using auditory-perceptual analysis, compared with the short moving window segment. It is a helpful tool for perceptual analytic protocols, allowing for voice evaluation using standardized and automated voice-segmenting procedures.

Supplemental Material

https://doi.org/10.23641/asha.7100951

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Are antithrombotic agents necessary for head and neck microvascular surgery?

The aim of this prospective study was to determine the effect of antithrombotic agents in preventing thrombosis after head and neck reconstructive surgery. A randomized clinical trial of referred patients undergoing free flap surgery between February 2015 and July 2017 was conducted. Four hundred and fifty-four patients were randomly assigned to group A (n=153), administered aspirin and low molecular weight dextran; group B (n=150), administered low molecular weight heparin; and group C (n=151), not administered any antithrombotic agent.

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Approach to Neonates and Young Infants with Fever without a Source Who Are at Risk for Severe Bacterial Infection

Introduction. Among neonates and infants

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The TGF-β1 Signaling Pathway as an Attractive Target in the Fibrosis Pathogenesis of Sjögren’s Syndrome

Transforming growth factor β1 (TGF-β1) plays a crucial role in the induction of fibrosis, often associated with chronic phases of inflammatory diseases contributing to marked fibrotic changes that compromise normal organ function. The TGF-β1 signal exerts its biological effects via the TGF-β/SMAD/Snail signaling pathway, playing an important pathogenic role in several fibrotic diseases. It has as yet been poorly investigated in the chronic autoimmune disease Sjögren's syndrome (SS). Here, we firstly tested, by immunohistochemistry, whether the TGF-β1/SMAD/Snail signaling pathway is triggered in human pSS salivary glands (SGs). Next, healthy salivary gland epithelial cell (SGEC) cultures derived from healthy donors were exposed to TGF-β1 treatment, and the relative gene and protein levels of SMAD2/3/4, Snail, E-cadherin, vimentin, and collagen type I were compared by semiquantitative RT-PCR, quantitative real-time PCR, and Western blot analysis. We observed, both at gene and protein levels, higher expression of SMAD2, 3, and 4 and Snail in the SGEC exposed by TGF-β1 compared to untreated healthy SGEC. Additionally, in TGF-β1-treated samples, we found a significant reduction in the epithelial phenotype marker E-cadherin and an increase in the mesenchymal phenotype markers vimentin and collagen type I compared to those in untreated SGEC, indicating that TGF-β1 induces the EMT via the TGF-β1/SMAD/Snail signaling pathway. Therefore, by using the specific TGF-β receptor 1 inhibitor SB-431542 in healthy SGEC treated with TGF-β1, we showed a significant reduction of the fibrosis markers vimentin and collagen type I while the epithelial marker E-cadherin returns to levels similar to untreated healthy SGEC. These data demonstrate that TGF-β1 is an important key factor in the transition phase from SG chronic inflammation to fibrotic disease. Characteristic changes in the morphology and function of TGF-β1-treated healthy SGEC further confirm that TGF-β1 plays a significant role in EMT-dependent fibrosis.

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The Effect and Mechanism of KLF7 in the TLR4/NF-κB/IL-6 Inflammatory Signal Pathway of Adipocytes

Objective. To investigate the role and possible molecular mechanism of Krüppel-like factor 7 (KLF7) in the TLR4/NF-κB/IL-6 inflammatory signaling pathway activated by free fatty acids (FFA). Methods. The mRNA and protein expression levels of KLF7 and the factors of TLR4/NF-κB/IL-6 inflammatory signal pathways were detected by qRT-PCR and Western blotting after cell culture with different concentrations of palmitic acid (PA). The expression of KLF7 or TLR4 in adipocytes was upregulated or downregulated; after that, the mRNA and protein expression levels of these key factors were detected. KLF7 expression was downregulated while PA stimulated adipocytes, and then the mRNA and protein expressions of KLF7/p65 and downstream inflammatory cytokine IL-6 were detected. The luciferase reporter assay was used to determine whether KLF7 had a transcriptional activation effect on IL-6. Results. (1) High concentration of PA can promote the expression of TLR4, KLF7, and IL-6 in adipocytes. (2) TLR4 positively regulates KLF7 expression in adipocytes. (3) KLF7 positively regulates IL-6 expression in adipocytes. (4) PA promotes IL-6 expression via KLF7 in adipocytes. (5) KLF7 has a transcriptional activation on IL-6. Conclusion. PA promotes the expression of the inflammatory cytokine IL-6 by activating the TLR4/KLF7/NF-κB inflammatory signaling pathway. In addition, KLF7 may directly bind to the IL-6 promoter region and thus activate IL-6.

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Glymphatic Pathway of Gadolinium-Based Contrast Agents Through the Brain: Overlooked and Misinterpreted

Background The "glymphatic system" (GS), a brain-wide network of cerebrospinal fluid microcirculation, supplies a pathway through and out of the central nervous system (CNS); malfunction of the system is implicated in a variety of neurological disorders. In this exploratory study, we analyzed the potential of a new imaging approach that we coined delayed T2-weighted gadolinium-enhanced imaging to visualize the GS in vivo. Methods Heavily T2-weighted fluid-attenuated inversion recovery (hT2w-FLAIR) magnetic resonance imaging was obtained before, and 3 hours and 24 hours after intravenous gadolinium-based contrast agent (GBCA) application in 33 neurologically healthy patients and 7 patients with an impaired blood-brain barrier (BBB) due to cerebral metastases. Signal intensity (SI) was determined in various cerebral fluid spaces, and white matter hyperintensities were quantified by applying the Fazekas scoring system. Findings Delayed hT2w-FLAIR showed GBCA entry into the CNS via the choroid plexus and the ciliary body, with GBCA drainage along perineural sheaths of cranial nerves and along perivascular spaces of penetrating cortical arteries. In all patients and all sites, a significant SI increase was found for the 3 hours and 24 hours time points compared with baseline. Although no significant difference in SI was found between neurologically healthy patients and patients with an impaired BBB, a significant positive correlation between Fazekas scoring system and SI increase in the perivascular spaces 3 hours post injection was shown. Interpretation Delayed T2-weighted gadolinium-enhanced imaging can visualize the GBCA pathway into and through the GS. Presence of GBCAs within the GS might be regarded as part of the natural excretion process and should not be mixed up with gadolinium deposition. Rather, the correlation found between deep white matter hyperintensities, an imaging sign of vascular dementia, and GS functioning demonstrated feasibility to exploit the pathway of GBCAs through the GS for diagnostic purposes. Received for publication September 5, 2018; and accepted for publication, after revision, October 9, 2018. Conflicts of interest and sources funding: none declared. Correspondence to: Alexander Radbruch, MD, JD, Department of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany. E-mail: a.radbruch@dkfz.de. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Negligible Risk of Acute Renal Failure Among Hospitalized Patients After Contrast-Enhanced Imaging With Iodinated Versus Gadolinium-Based Agents

Introduction The potential adverse renal outcome among patients undergoing iodine-based contrast-enhanced computerized tomography (CT) has been questioned recently, given the caution undertaken in patients' selection, hydration protocols, and the low radiocontrast volume, used with advanced imaging equipment. Materials and Methods This study is a retrospective assessment of renal outcome in 12,580 hospitalized patients undergoing contrast-enhanced CT, compared with 754 patients subjected to gadolinium-based magnetic resonance imaging, with subsequent propensity matching for clinical characteristics and potential risk factors. Results The risk of postcontrast acute kidney injury (PC-AKI) was found to be negligible as compared with patients undergoing enhanced magnetic resonance imaging studies, before and after propensity matching (8% vs 7.3% rate of AKI in the nonmatched iodine-based contrast agents [IBCAs] and gadolinium-based contrast agents [GBCAs], respectively, P = 0.3, and 7% in the matched IBCA group, P = 0.9), including comparisons among subgroups with well-defined risk factors such as chronic renal failure, diabetes, older age, and hypertension. However, lower systolic blood pressure before imaging was associated with higher risk to develop PC-AKI after IBCA administration but not with GBCA (for systolic blood pressure lower than 110 mm Hg, odds ratio for AKI after IBCA was 1.49; 95% confidence interval, 1.16–1.88, and after GBCA; odds ratio, 0.12; 95% confidence interval, 0.003–0.73). Conclusions With the current precautions undertaken, the real-life risk of PC-AKI among inpatients undergoing CT is insignificant. Possible reasons for the diverse impact of blood pressure on the propensity to develop acute kidney failure after iodine-based but not gadolinium-based enhancement imaging are discussed. Received for publication September 24, 2018; and accepted for publication, after revision, October 17, 2018. Conflicts of interest and sources of funding: none declared. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (https://ift.tt/2kq7jVD). Correspondence to: Samuel N. Heyman, MD, Department of Medicine, Hadassah Hebrew University Hospital, Mt Scopus, PO Box 24035, Jerusalem 91240, Israel. E-mail: Heyman@cc.huji.ac.il. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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