OtoRhinoLaryngology by Alexandros G.Sfakianakis: Ιουνίου 2016

Πέμπτη 30 Ιουνίου 2016

Effects of Within-Talker Variability on Speech Intelligibility in Mandarin-Speaking Adult and Pediatric Cochlear Implant Patients

Cochlear implant (CI) speech performance is typically evaluated using well-enunciated speech produced at a normal rate by a single talker. CI users often have greater difficulty with variations in speech production encountered in everyday listening. Within a single talker, speaking rate, amplitude, duration, and voice pitch information may be quite variable, depending on the production context. The coarse spectral resolution afforded by the CI limits perception of voice pitch, which is an important cue for speech prosody and for tonal languages such as Mandarin Chinese. In this study, sentence recognition from the Mandarin speech perception database was measured in adult and pediatric Mandarin-speaking CI listeners for a variety of speaking styles: voiced speech produced at slow, normal, and fast speaking rates; whispered speech; voiced emotional speech; and voiced shouted speech. Recognition of Mandarin Hearing in Noise Test sentences was also measured. Results showed that performance was significantly poorer with whispered speech relative to the other speaking styles and that performance was significantly better with slow speech than with fast or emotional speech. Results also showed that adult and pediatric performance was significantly poorer with Mandarin Hearing in Noise Test than with Mandarin speech perception sentences at the normal rate. The results suggest that adult and pediatric Mandarin-speaking CI patients are highly susceptible to whispered speech, due to the lack of lexically important voice pitch cues and perhaps other qualities associated with whispered speech. The results also suggest that test materials may contribute to differences in performance observed between adult and pediatric CI users.

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Systematic review with meta-analysis: the efficacy of levofloxacin triple therapy as the first- or second-line treatments of Helicobacter pylori infection

Summary

Background

Levofloxacin triple therapy has been used for the first-line and second-line treatment of Helicobacter pylori infection for more than 10 years.

Aims

To systematically review the efficacy of levofloxacin triple therapy in the first- and second-line treatment, and to assess the time trend and factors that might affect its efficacy.

Methods

Prospective trials reporting the efficacy of levofloxacin triple therapy in either the first-line or second-line treatment of H. pylori infection in adults were searched from the PubMed and Cochrane database from January 2000 to September 2015. Meta-analysis was performed to calculate the cumulative eradication rate and the efficacies in subgroups.

Results

Of the 322 articles identified, a total of 4574 patients from 41 trials, including 16 trials in the first-line treatment and 25 trials in the second-line treatment were eligible for analysis. The cumulative eradication rate was 77.3% (95% confidence intervals, CI: 74.7–79.6) and was 80.7% (95% CI 77.1–83.7) in the first-line treatment and 74.5% (95% CI: 70.9–77.8) in the second-line treatment. The efficacies of levofloxacin triple therapy before 2008, between 2009 and 2011, and after 2012 were 77.4%, 79.6% and 74.8% respectively. The eradication rate was higher when levofloxacin was given once daily (80.6%, 95% CI: 77.1–83.7) than twice daily (73.6%, 95% CI: 69.7–77.2). The efficacy was significantly higher in levofloxacin-susceptible strains than resistant strains (81.1% vs. 36.3%, risk ratio 2.18, 95% CI: 1.6–3, P < 0.001).

Conclusion

The efficacy of levofloxacin triple therapy has been lower than 80% in many countries and it is not recommended when the levofloxacin resistance is higher than 5–10%.

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Liver stiffness measurement reliability and main determinants of point shear-wave elastography in patients with chronic liver disease

Summary

Background

Liver stiffness (LS) measured by transient elastography (TE) accurately predicts the severity of chronic liver diseases (CLD). Point quantification shear-wave elastography (pSWE) is a new technique incorporated into a conventional ultrasound system for measuring LS. We evaluated pSWE feasibility, reproducibility and diagnostic accuracy in consecutively recruited CLD patients who concomitantly underwent TE and liver biopsy.

Aim

To evaluate pSWE feasibility, reproducibility and diagnostic accuracy in consecutively recruited CLD patients who concomitantly underwent TE and liver biopsy.

Methods

Over 2 years 186 CLD patients (116 males, 132 viral hepatitis) consecutively underwent pSWE (10 valid measurements by ElastPQ) blindly performed by two raters. A further operator performed TE. Inter-observer agreement for pSWE was analysed by intraclass correlation coefficient (ICC) and correlated with histological liver fibrosis (METAVIR). Main determinants of pSWE were investigated by linear regression model.

Results

Three hundred and seventy-two (100%) reliable measurements were obtained by pSWE and 184 by TE (99%). LS was 8.1 ± 4.5 kPa for pSWE with the first rater and 8.0 ± 4.2 kPa with the second one vs. 8.8 ± 3.6 kPa for TE. pSWE ICC was 0.89 (95% CI 0.85‒0.91), not influenced by age, sex, BMI, liver enzymes, liver aetiology. ICC increased over time with year 1 at 0.86 and 95% CI 0.81–0.90 vs. year 2 at 0.92 and 95% CI 0.87–0.95. Liver fibrosis was the only independent determinant of LS on pSWE. The AUROCs for diagnosing F ≥ 2, F ≥ 3 and F = 4 were 0.77, 0.85 and 0.88 for pSWE vs. 0.81, 0.88 and 0.94 for TE. After 1-year training they were 0.86, 0.94 and 0.91.

Conclusion

Point quantification shear-wave elastography reliably and reproducibly evaluates LS, matching TE for accuracy after a 1-year learning curve or 130 examinations.

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Liver stiffness measurement using acoustic radiation force impulse elastography in overweight and obese patients

Summary

Background

Obesity and overweight are global health problems.

Aim

To evaluate the diagnostic accuracy of liver stiffness measurement (LSM) using acoustic radiation force impulse (ARFI) elastography in overweight and obese patients for staging liver fibrosis.

Methods

Ninety-seven patients (mean age: 50 years, 50% male) with body mass index (BMI) ≥25 kg/m² (mean BMI: 31 kg/m²) were prospectively enrolled. All patients underwent ARFI elastography and liver biopsy. In 87/97 patients, transient elastography (TE) was performed (M- and XL-probes). Patients were divided into two groups respectively: overweight: BMI <30 kg/m² (n = 61); and obese: BMI ≥30 kg/m² (n = 26).

Results

Acoustic radiation force impulse elastography correlated with liver fibrosis in overweight (r = 0.84, P < 0.0001) and obese patients (r = 0.85, P < 0.0001), while no correlation was observed with steatosis, steatohepatitis and BMI. Area under the curve detecting liver cirrhosis for ARFI and TE were 0.97 in overweight and 0.94 and 0.92 in obese patients. In both groups, the failure rate was lower for ARFI than TE. ARFI of liver segment 8 showed a lower discordance than TE in both groups (overweight: 3% vs. 12%, P = 0.002; obese: 8% vs. 27%, P = 0.034). Steatosis and steatohepatitis were neither predictors of discordance nor of performance in LSM by ARFI or TE in both groups.

Conclusions

In overweight and obese patients, acoustic radiation force impulse can diagnose liver cirrhosis and significant fibrosis with high diagnostic accuracy. Liver stiffness measurement using the XL-probe reduces the influence of BMI, steatosis and steatohepatitis. The failure and discordance rates were lower for acoustic radiation force impulse than transient elastography in both patients groups.

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A Two-Year Randomized Trial of Interventions to Decrease Stress Hormone Vasopressin Production in Patients with Meniere’s Disease—A Pilot Study

by Tadashi Kitahara, Hidehiko Okamoto, Munehisa Fukushima, Masaharu Sakagami, Taeko Ito, Akinori Yamashita, Ichiro Ota, Toshiaki Yamanaka

Meniere's disease, a common inner ear condition, has an incidence of 15–50 per 100,000. Because mental/physical stress and subsequent increase in the stress hormone vasopressin supposedly trigger Meniere's disease, we set a pilot study to seek new therapeutic interventions, namely management of vasopressin secretion, to treat this disease. We enrolled 297 definite Meniere's patients from 2010 to 2012 in a randomized-controlled and open-label trial, assigning Group-I (control) traditional oral medication, Group-II abundant water intake, Group-III tympanic ventilation tubes and Group-IV sleeping in darkness. Two hundred sixty-three patients completed the planned 2-year-follow-up, which included assessment of vertigo, hearing, plasma vasopressin concentrations and changes in stress/psychological factors. At 2 years, vertigo was completely controlled in 54.3% of patients in Group-I, 81.4% in Group-II, 84.1% in Group-III, and 80.0% in Group-IV (statistically I Trial Registration: ClinicalTrials.gov NCT01099046

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Initial Stop Voicing in Bilingual Children With Cochlear Implants and Their Typically Developing Peers With Normal Hearing

Purpose

This study focuses on stop voicing differentiation in bilingual children with normal hearing (NH) and their bilingual peers with hearing loss who use cochlear implants (CIs).

Method

Twenty-two bilingual children participated in our study (11 with NH, M age = 5;1 [years;months], and 11 with CIs, M hearing age = 5;1). The groups were matched on hearing age and a range of demographic variables. Single-word picture elicitation was used with word-initial singleton stop consonants. Repeated measures analyses of variance with three within-subject factors (language, stop voicing, and stop place of articulation) and one between-subjects factor (NH vs. CI user) were conducted with voice onset time and percentage of prevoiced stops as dependent variables.

Results

Main effects were statistically significant for language, stop voicing, and stop place of articulation on both voice onset time and prevoicing. There were no significant main effects for NH versus CI groups. Both children with NH and with CIs differentiated stop voicing in their languages and by stop place of articulation. Stop voicing differentiation was commensurate across the groups of children with NH versus CIs.

Conclusions

Stop voicing differentiation is accomplished in a similar fashion by bilingual children with NH and CIs, and both groups differentiate stop voicing in a language-specific fashion.

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Augmenting College Students' Study of Speech-Language Pathology Using Computer-Based Mini Quiz Games

Purpose

This study examined whether undergraduate college students' immediate recall and longer-term retention of introductory voice disorder concepts improved by using mini quiz games (MQGs; interactive knowledge tests in game format) compared with (a) traditional study alone, (b) MQGs and traditional study together, or (c) a no-study control condition.

Method

Ninety-three college students participated in proctored sessions in which they were given a pretest, viewed an online lecture on introductory voice disorder concepts, and then engaged in either no intervention or interventions including traditional study, MQG play, or both MQG play and traditional study, followed by an immediate recall posttest and longer-term retention follow-up test.

Results

Analyses suggested that the effects of all interventions (traditional study, MQG play, and the combination of the 2) were equivalent and resulted in significantly greater improvements from pretest to immediate recall posttest performance than the control condition. In contrast, MQGs and MQGs with traditional study, but not traditional study alone, showed better results for long-term retention than no study.

Conclusion

Results provide preliminary support for the idea that there may be multiple effective learning modes, beyond traditional study, that enhance recall and retention of knowledge foundational to speech-language pathology clinical training and practice.

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Case Studies of Multilingual/Multicultural Asian Deaf Adults: Strategies for Success.

Case Studies of Multilingual/Multicultural Asian Deaf Adults: Strategies for Success.

Am Ann Deaf. 2016;161(1):67-88

Authors: Wang Q, Andrews J, Liu HT, Liu CJ

Abstract
Case studies of adult d/Deaf or Hard of Hearing Multilingual Learners (DMLs) are few, especially studies of DMLs who learn more than one sign language and read logographic and alphabetic scripts. To reduce this paucity, two descriptive case studies are presented. Written questionnaires, face-to-face interviews, and self-appraisals of language-use rubrics were used to explore (a) the language and literacy histories of two adult Asian DMLs who had learned multiple languages: Chinese (spoken/written), English (written), Chinese Sign Language, and American Sign Language; and (b) how each language was used in different cultural communities with diverse conversational partners. Home literacy environment, family support, visual access to languages, peer and sibling support, role models, encouragement, perseverance, and Deaf identity all played vital roles in the participants' academic success. The findings provide insights into the acquisition of multiple languages and bi-literacy through social communication and academic content.

PMID: 27156919 [PubMed - indexed for MEDLINE]

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Assessment and d/Deaf and Hard of Hearing Multilingual Learners: Considerations and Promising Practices.

Assessment and d/Deaf and Hard of Hearing Multilingual Learners: Considerations and Promising Practices.

Am Ann Deaf. 2016;161(1):56-66

Authors: Pizzo L, Chilvers A

Abstract
The authors address considerations and promising practices relating to assessment of d/Deaf and Hard of Hearing Multilingual Learners. DMLs' unique culture(s), language(s), and learning needs must be considered when assessments of this population are being planned, conducted, and interpreted. The authors address theory and research on (a) general considerations for the overarching assessment process, (b) specific assessment approaches used to assess DMLs, and (c) assessment of language proficiency for diverse language learners. In addition, basic recommendations for the assessment of DMLs are made, including increased availability of assessments in various languages, use of multiple sources of individual and family data, assessment of all languages, and incorporation of a strong assessment component (that includes nondiscrimination practices) into teacher preparation programs.

PMID: 27156918 [PubMed - indexed for MEDLINE]

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Early Intervention: A Multicultural Perspective on d/Deaf and Hard of Hearing Multilingual Learners.

Early Intervention: A Multicultural Perspective on d/Deaf and Hard of Hearing Multilingual Learners.

Am Ann Deaf. 2016;161(1):33-40

Authors: Sandy KB

Abstract
Today's pluralistic society is characterized by families from many linguistic and cultural backgrounds, including families with infants and toddlers who are deaf or hard of hearing (d/Dhh). Taking a multicultural perspective, the author examines family-centered early intervention (FCEI) and the transition to school services for children who are d/Dhh. Working with d/Dhh Multilingual Learners (DMLs) and their families presents a unique challenge to early intervention professionals: ensuring that families have adequate information and resources to make informed choices, particularly regarding communication. The author presents information and research related to (a) family and professional partnerships, (b) cultural contexts for early intervention,

PMID: 27156916 [PubMed - indexed for MEDLINE]

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Healing of Erosive Esophagitis and Improvement of Symptoms of Gastroesophageal Reflux Disease After Esomeprazole Treatment in Children 12 to 36 Months Old.

http:--pt.wkhealth.com-pt-pt-core-templa

Healing of Erosive Esophagitis and Improvement of Symptoms of Gastroesophageal Reflux Disease After Esomeprazole Treatment in Children 12 to 36 Months Old.

J Pediatr Gastroenterol Nutr. 2015 Jul;60 Suppl 1:S31-6

Authors: Tolia V, Gilger MA, Barker PN, Illueca M

Abstract
OBJECTIVES: The aim of the study was to evaluate erosive esophagitis healing and symptom improvement with once-daily esomeprazole in children ages 12 to 36 months with endoscopically or histologically proven gastroesophageal reflux disease (GERD).
PATIENTS AND METHODS: Data from children ages 12 to 36 months were included in a post-hoc analysis of an 8-week, multicenter, randomized, and double-blind by dose strata study of patients ages 1 to 11 years with endoscopically or histologically confirmed GERD. Children were randomized to receive esomeprazole 5 or 10 mg once daily. Patients underwent endoscopy and, if required, mucosal biopsy at baseline. Patients who had erosive esophagitis (graded using the Los Angeles classification system) at baseline underwent a follow-up endoscopy at final study visit to assess healing of erosive esophagitis. Investigators scored severity of GERD symptoms at baseline and every 2 weeks using the Physician Global Assessment.
RESULTS: Thirty-one of 109 primary study patients ages 12 to 36 months were included in the post hoc analysis. At baseline, 15 patients (48.4%) had erosive esophagitis, underwent follow-up endoscopy, and were healed after 8 weeks of esomeprazole treatment. Of the 19 patients with moderate-to-severe baseline Physician Global Assessment symptom scores, 84.2% had lower scores by the final visit. Following esomeprazole treatment, GERD symptoms were significantly improved from baseline to final visit (P ≤ 0.0018).
CONCLUSIONS: Esomeprazole 5 or 10 mg may be used to successfully treat erosive esophagitis and symptoms of GERD in children as young as 1 year.Moreover, although not yet validated in pediatric patients, the Los Angeles classification system was useful in grading erosive esophagitis in children ages 12 to 36 months.

PMID: 26422096 [PubMed - indexed for MEDLINE]

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Esomeprazole for the Treatment of Erosive Esophagitis in Children: An International, Multicenter, Randomized, Parallel-Group, Double-Blind (for Dose) Study.

Esomeprazole for the Treatment of Erosive Esophagitis in Children: An International, Multicenter, Randomized, Parallel-Group, Double-Blind (for Dose) Study.

J Pediatr Gastroenterol Nutr. 2015 Jul;60 Suppl 1:S24-30

Authors: Tolia V, Youssef NN, Gilger MA, Traxler B, Illueca M

Abstract
BACKGROUND: Acid suppression with a proton pump inhibitor is standard treatment for gastroesophageal reflux disease and erosive esophagitis in adults and increasingly is becoming first-line therapy for children aged 1-17 years. We evaluated endoscopic healing of erosive esophagitis with esomeprazole in young children with gastroesophageal reflux disease and described esophageal histology.
METHODS: Children aged 1-11 years with endoscopically or histologically confirmed gastroesophageal reflux disease were randomized to esomeprazole 5 or 10 mg daily (<20 kg) or 10 or 20 mg daily (≥ 20 kg) for 8 weeks. Patients with erosive esophagitis underwent an endoscopy after 8 weeks to assess healing of erosions.
RESULTS: Of 109 patients, 49% had erosive esophagitis and 51% had histologic evidence of reflux esophagitis without erosive esophagitis. Of the 45 patients who had erosive esophagitis and underwent follow-up endoscopy, 89% experienced erosion resolution. Dilation of intercellular space was reported in 24% of patients with histologic examination.
CONCLUSIONS: Esomeprazole (0.2-1.0 mg/kg) effectively heals macroscopic and microscopic erosive esophagitis in this pediatric population with gastroesophageal reflux disease. Dilation of intercellular space may be an important histologic marker of erosive esophagitis in children.

PMID: 26422095 [PubMed - indexed for MEDLINE]

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Pharmacokinetics and Acid-suppressive Effects of Esomeprazole in Infants 1-24 Months Old With Symptoms of Gastroesophageal Reflux Disease.

Pharmacokinetics and Acid-suppressive Effects of Esomeprazole in Infants 1-24 Months Old With Symptoms of Gastroesophageal Reflux Disease.

J Pediatr Gastroenterol Nutr. 2015 Jul;60 Suppl 1:S2-8

Authors: Omari T, Davidson G, Bondarov P, Nauclér E, Nilsson C, Lundborg P

Abstract
OBJECTIVES: To evaluate the pharmacokinetics and acid-suppressive effects of esomeprazole in infants with gastroesophageal reflux disease (GERD).
PATIENTS AND METHODS: In this single-blind, randomized, parallel-group study, 50 infants 1 to 24 months old with symptoms of GERD, and ≥ 5% of time with intraesophageal pH <4 during 24-hour dual pH monitoring, received oral esomeprazole 0.25 mg/kg (n = 26) or 1 mg/kg (n = 24) once daily for 1 week. Intraesophageal and intragastric pH were recorded at 1 week, and blood samples were taken for pharmacokinetic analysis.
RESULTS: At baseline, mean percentages of time with intragastric pH >4 and intraesophageal pH <4 were 30.5% and 11.6%, respectively, in the esomeprazole 0.25 mg/kg group and 28.6% and 12.5% in the esomeprazole 1 mg/kg group. After 1 week of treatment, times with intragastric pH >4 were 47.9% and 69.3% in the esomeprazole 0.25 mg/kg and 1 mg/kg groups, respectively (P < 0.001 vs baseline), and times with intraesophageal pH <4 were 8.4% (P < 0.05 vs baseline) and 5.5% (P < 0.001 vs. baseline), respectively. The mean number of acid reflux episodes of >5 minutes duration decreased from 6 at baseline to 3 and 2 with esomeprazole 0.25 mg/kg and 1 mg/kg, respectively. The geometric mean AUC0-t of esomeprazole were 0.24 and 1.79 μmol · h/L for the 0.25 mg/kg and 1 mg/kg dosages of esomeprazole, respectively. Both esomeprazole dosages were well tolerated.
CONCLUSIONS: Oral treatment with esomeprazole 0.25 mg/kg and 1 mg/kg was well tolerated and provided dose-related acid suppression, dose-related exposure to esomeprazole, and decreased esophageal acid exposure in infants 1-24 months old with GERD.

PMID: 26422094 [PubMed - indexed for MEDLINE]

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Safety and Tolerability of Esomeprazole in Children With Gastroesophageal Reflux Disease.

Safety and Tolerability of Esomeprazole in Children With Gastroesophageal Reflux Disease.

J Pediatr Gastroenterol Nutr. 2015 Jul;60 Suppl 1:S16-23

Authors: Gilger MA, Tolia V, Vandenplas Y, Youssef NN, Traxler B, Illueca M

Abstract
OBJECTIVES: To evaluate safety, tolerability, and symptom improvement with once-daily esomeprazole in children with endoscopically proven gastroesophageal reflux disease (GERD).
PATIENTS AND METHODS: In this 8-week, multicenter, randomized, uncontrolled, double-blind study, children ages 1 to 11 years were stratified by weight to receive esomeprazole 5 or 10 mg (children < 20 kg) or 10 or 20 mg (children ≥ 20 kg) once daily. Safety and tolerability was assessed by evaluating adverse events (AEs; both treatment- and non-treatment-related AEs) and changes from baseline in medical history, physical examinations, and clinical laboratory tests. Investigators scored symptom severity every 2 weeks using the Physician's Global Assessment (PGA). Patients' parents rated GERD symptoms of heartburn, acid regurgitation, and epigastric pain (none to severe, 0-3) at baseline (based on past 72 hours) and daily (from past 24 hours).
RESULTS: Of 109 patients randomized, 108 had safety data. AEs were experienced by 68.0% and 65.2% of children <20 kg receiving esomeprazole 5 and 10 mg, respectively, and 83.9% and 82.8% of children ≥ 20 kg receiving esomeprazole 10 and 20 mg, respectively, regardless of causality. Overall, only 9.3% of patients reported 13 treatment-related AEs; the most common were diarrhea (2.8% [3/108]), headache (1.9% [2/108]), and somnolence (1.9% [2/108]). Vomiting, a serious AE in 2 patients, was not judged by the investigator to be related to treatment. At the final visit, PGA scores improved significantly from baseline (P < 0.001). Of 58 patients with moderate to severe baseline PGA symptom scores, 91.4% had lower scores by the final visit. GERD symptom scores were significantly improved from baseline to the final week of the study in all of the treatment groups (P < 0.01) CONCLUSIONS:: In children ages 1 to 11 years with endoscopically proven GERD, esomeprazole (at daily doses of 5, 10, or 20 mg) was generally well tolerated. The frequency and severity of GERD-related symptoms were significantly reduced during the active treatment period.

PMID: 26422093 [PubMed - indexed for MEDLINE]

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Introduction.

Introduction.

J Pediatr Gastroenterol Nutr. 2015 Jul;60 Suppl 1:S1

Authors: Illueca M

PMID: 26422092 [PubMed - indexed for MEDLINE]

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A Tunneled Subcricoid Approach for Anterior Cervical Spine Reoperation: Technical and Safety Results.

http:--linkinghub.elsevier.com-ihub-imag

A Tunneled Subcricoid Approach for Anterior Cervical Spine Reoperation: Technical and Safety Results.

World Neurosurg. 2016 Feb;86:328-35

Authors: Winkler EA, Rowland NC, Yue JK, Birk H, Ozpinar A, Tay B, Ames CP, Mummaneni PV, El-Sayed IH

Abstract
OBJECTIVE: Anterior cervical spine decompression and fusion are common neurosurgical operations. Reoperation of the anterior cervical spine is associated with increased morbidity. The authors describe a novel subcricoid approach to protect the recurrent laryngeal nerve in a cuff of tissue while facilitating surgical access to the anterior cervical spine.
METHODS: Single institution, consecutive case review of 48 patients undergoing reoperation in the anterior cervical region including the level of C5 and below. Univariable and multivariable regression analysis was used to determine predictors of postoperative morbidity.
RESULTS: No intraoperative complications were reported. Estimated blood loss for the approach was 13.6 ± 3.1 mL. Nine of 48 patients developed immediate postoperative complications, including vocal cord paresis (10.4%), moderate-to-severe dysphagia (10.4%), and neck edema requiring intubation (2.1%). No postoperative hematomas or death occurred. All complications occurred with 4 or more levels of exposure (1-3 disc levels, 0%, vs. ≥ 4 disc levels, 31%). Extension of the exposure to the upper thoracic spine was associated with odds for postoperative complications (adjusted odds ratio, 6.50; 95% confidence interval, 1.14-37.03) and prolonged hospital stay (adjusted increase 4.23 days, P < 0.01).
CONCLUSION: The tunneled subcricoid approach is a relatively safe corridor to reapproach the anterior cervical spine at the level of C5 and below. However, caution must be exercised when using this approach to expose 4 or more disc levels and with extension of the exposure to the upper thoracic spine. Future comparative studies are needed to establish patient selection criteria in determining the use of this technique compared with classic approaches.

PMID: 26409079 [PubMed - indexed for MEDLINE]

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Considerations in difficult-to-control asthma.

http:--media.wiley.com-assets-7315-19-Wi

Considerations in difficult-to-control asthma.

Int Forum Allergy Rhinol. 2015 Sep;5 Suppl 1:S57-60

Authors: Lanier BQ, Tierce M

Abstract
BACKGROUND: Difficult-to-control asthma includes those patients who require treatment with high-dose inhaled glucocorticosteroid (ICS) plus a second controller and/or systemic glucocorticosteroids to manage. The exact percentage of "difficult to treat," "refractory," "severe," or "brittle" asthma is 3% to 10% of all asthmatic patients, but this group of asthmatics use the majority of resources for the entire asthmatic population.
METHODS: Medline searches for the terms "difficult to control," "severe," "refractory," "brittle," and asthma were done and the results were reviewed.
RESULTS: Patterns for difficult-to-control asthma emerge from concepts of compliance, comorbidity, and endotypes, which give the practitioner pathways for analyzing this subset of asthma patients.
CONCLUSION: The ear, nose, and throat (ENT) physician can be of significant help to other asthma specialists in the recognition of the difficult-to-control asthmatic, as well as providing specific specialized diagnostic skills and the reinforcement of adherence to medical regimens.

PMID: 26335837 [PubMed - indexed for MEDLINE]

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[A difficult swallowing].

[A difficult swallowing].

Rev Med Interne. 2015 Sep;36(9):636-7

Authors: Bertolino J, Scemama U, Jean E, Frances Y, Granel B

PMID: 25908433 [PubMed - indexed for MEDLINE]

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Swallowing endoscopy findings in Huntington's disease: a case report.

Swallowing endoscopy findings in Huntington's disease: a case report.

Codas. 2016 Jun 23;0:0

Authors: Alves TC, Cola PC, Santos RR, Motonaga SM, Silva RG

Abstract
Huntington's disease (HD) is a degenerative genetic disorder with autosomal-dominant transmission. The triad of symptoms of this disease consists of psychiatric disorders, jerky movements, and dementia. Oropharyngeal dysphagia, which is more evident with disease progression, is also present. Few studies have addressed the swallowing characteristics using objective analysis in this population. The purpose of this research was to describe the swallowing endoscopic findings of the pharyngeal phase in HD. This is a cross-sectional study addressing a clinical case which included two individuals of the same family, male, 32 and 63 years old, designated as individual A and individual B, with progression of the disease for five and 13 years, respectively. Consistent liquid, nectar, and puree were offered during the evaluation. There was presence of posterior oral spillage in liquid and nectar, small amount of pharyngeal residues, and no laryngeal penetration or aspiration in the individuals with HD in this study.

PMID: 27356189 [PubMed - as supplied by publisher]

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Allied health professionals' perspectives of working with dysphagia in a rural paediatric team.

Allied health professionals' perspectives of working with dysphagia in a rural paediatric team.

N Z Med J. 2016;129(1435):87-89

Authors: Burgess A, Purdy SC, Jackson BN

PMID: 27355174 [PubMed - as supplied by publisher]

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Eagle Syndrome Causing Vascular Compression with Cervical Rotation: Case Report.

Eagle Syndrome Causing Vascular Compression with Cervical Rotation: Case Report.

Pol J Radiol. 2016;81:277-80

Authors: Demirtaş H, Kayan M, Koyuncuoğlu HR, Çelik AO, Kara M, Şengeze N

Abstract
BACKGROUND: Eagle syndrome is a condition caused by an elongated styloid process. Unilateral face, neck and ear pain, stinging pain, foreign body sensation and dysphagia can be observed with this syndrome. Rarely, the elongated styloid process may cause pain by compressing the cervical segment of the internal carotid and the surrounding sympathetic plexus, and that pain spreading along the artery can cause neurological symptoms such as vertigo and syncope.
CASE REPORT: In this case report we presented a very rare eagle syndrome with neurological symptoms that occurred suddenly with cervical rotation. The symptoms disappeared as suddenly as they occurred, with the release of pressure in neutral position. We also discussed CT angiographic findings of this case.
CONCLUSIONS: Radiological diagnosis of the Eagle syndrome that is manifested with a wide variety of symptoms and causes diagnostic difficulties when it is not considered in the differential diagnosis is easy in patients with specific findings. CT angiography is a fast and effective examination in terms of showing compression in patients with the Eagle syndrome that is considered to be atypical and causes vascular compression.

PMID: 27354882 [PubMed]

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Reirradiation of Head and Neck Cancers With Intensity Modulated Radiation Therapy: Outcomes and Analyses.

Reirradiation of Head and Neck Cancers With Intensity Modulated Radiation Therapy: Outcomes and Analyses.

Int J Radiat Oncol Biol Phys. 2016 Jul 15;95(4):1117-31

Authors: Takiar V, Garden AS, Ma D, Morrison WH, Edson M, Zafereo ME, Gunn GB, Fuller CD, Beadle B, Frank SJ, William WN, Kies M, El-Naggar AK, Weber R, Rosenthal DI, Phan J

Abstract
PURPOSE: To review our 15-year institutional experience using intensity modulated radiation therapy (IMRT) to reirradiate patients with head and neck squamous cell carcinomas (HNSCC) and identify predictors of outcomes and toxicity.
METHODS AND MATERIALS: We retrospectively reviewed the records of 227 patients who received head and neck reirradiation using IMRT from 1999 to 2014. Patients treated with noncurative intent were excluded. Radiation-related acute and late toxicities were recorded. Prognostic variables included performance status, disease site, disease-free interval, chemotherapy, and RT dose and volume. Correlative analyses were performed separately for surgery and nonsurgery patients.
RESULTS: Two hundred six patients (91%) were retreated with curative intent, and 173 had HNSCC histology; 104 (50%) underwent salvage resection, and 135 (66%) received chemotherapy. Median follow-up after reirradiation was 24.7 months. Clinical outcomes were worse for HNSCC patients, with 5-year locoregional control, progression-free survival, and overall survival rates of 53%, 22%, and 32%, respectively, compared with 74%, 59%, and 79%, respectively, for non-HNSCC patients. On multivariate analysis, concurrent chemotherapy and retreatment site were associated with tumor control, whereas performance status was associated with survival. Favorable prognostic factors specific to surgery patients were neck retreatment and lack of extracapsular extension, whereas for nonsurgery patients, these were a nasopharynx subsite and complete response to induction chemotherapy. Actuarial rates of grade ≥3 toxicity were 32% at 2 years and 48% at 5 years, with dysphagia or odynophagia being most common. Increased grade ≥3 toxicity was associated with retreatment volume >50 cm(3) and concurrent chemotherapy.
CONCLUSIONS: Reirradiation with IMRT either definitively or after salvage surgery can produce promising local control and survival in selected patients with head and neck cancers. Treatment-related toxicity remains significant. Prognostic factors are emerging to guide multidisciplinary treatment approaches and clinical trial design.

PMID: 27354127 [PubMed - in process]

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Muscle Tension Dysphagia: Symptomology and Theoretical Framework.

Muscle Tension Dysphagia: Symptomology and Theoretical Framework.

Otolaryngol Head Neck Surg. 2016 Jun 28;

Authors: Kang CH, Hentz JG, Lott DG

Abstract
OBJECTIVE: To identify symptoms, common diagnostic findings, pattern of treatments and referrals offered, and their efficacy in a group of patients with idiopathic functional dysphagia in an otolaryngology setting with multiple providers.
STUDY DESIGN: Case series with chart review.
SETTING: Tertiary academic center.
SUBJECTS AND METHODS: Following Mayo Clinic Institutional Review Board approval, a retrospective chart review was conducted of patients with dysphagia who had a videofluoroscopic swallow study between January 1, 2013, and April 30, 2015. Each patient's dysphagia symptomology, videofluoroscopic swallow study, flexible laryngoscopy, and medical chart were reviewed to identify the treatment paradigms that were utilized.
RESULTS: Sixty-seven adult patients met the inclusion criteria. Abnormal laryngeal muscle tension was present in 97% of patients. Eighty-two percent of patients also demonstrated signs of laryngeal hyperresponsiveness. Nonspecific laryngeal inflammation was evident in 52% of patients. Twenty-seven patients were referred to speech-language pathology for evaluation. Thirteen patients completed a course of voice therapy directed toward unloading muscle tension. All 13 patients self-reported resolution of dysphagia symptoms.
CONCLUSION: The study results suggest that laryngeal muscle tension may be a factor in the underlying etiology in patients with idiopathic functional dysphagia. We propose the diagnostic term muscle tension dysphagia to describe a subset of patients with functional dysphagia. Further prospective studies are needed to better evaluate potential gastroesophageal confounders in this group of patients and to identify an effective paradigm for treatment. In our limited series, speech-language pathology intervention directed toward unloading muscle tension appears effective.

PMID: 27352887 [PubMed - as supplied by publisher]

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Esomeprazole for the Treatment of GERD in Infants Ages 1-11 Months.

Esomeprazole for the Treatment of GERD in Infants Ages 1-11 Months.

J Pediatr Gastroenterol Nutr. 2015 Jul;60 Suppl 1:S9-15

Authors: Winter H, Gunasekaran T, Tolia V, Gottrand F, Barker PN, Illueca M

Abstract
OBJECTIVES: Gastroesophageal reflux disease (GERD) is present in pediatric patients when reflux of gastric contents causes troublesome symptoms and/ or complications. The present study evaluates the efficacy and safety of esomeprazole in infants ages 1 to 11 months with GERD.
METHODS: In this multicenter randomized, double-blind, placebo-controlled, parallel-group, treatment-withdrawal study, infants received open-label, weight-adjusted doses of esomeprazole (2.5-10 mg) once daily for 2 weeks. Infants with symptom improvement were randomized to esomeprazole (weight-adjusted doses [2.5-10 mg]) or placebo for 4 weeks. The primary endpoint was time to discontinuation owing to symptom worsening based on global assessments by the parent/guardian and physician. Adverse events were recorded.
RESULTS: Of the 98 patients enrolled, 81 (82.7%) experienced symptom improvement determined by physician global assessment (PGA) during open-label esomeprazole treatment; 80 entered the double-blind phase. During this phase, discontinuation rates owing to symptom worsening were 48.8% (20/41) for placebo-treated versus 38.5% (15/39) for esomeprazole-treated patients (hazard ratio 0.69; P = 0.28). Posthoc analysis of infants with symptomatic GERD (ie, no diagnostic procedure performed) revealed that time to discontinuation was significantly longer with esomeprazole than placebo (hazard ratio 0.24; P = 0.01); the complementary subgroup difference was not significant (hazard ratio 1.39; P = 0.48). Esomeprazole was well tolerated.
CONCLUSIONS: The discontinuation rate owing to symptom worsening did not differ significantly between infants receiving esomeprazole versus those receiving placebo. Improved diagnostic criteria in this age group are needed to identify infants with GERD who may benefit from acid suppression therapy.

PMID: 26422097 [PubMed - indexed for MEDLINE]

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Healing of Erosive Esophagitis and Improvement of Symptoms of Gastroesophageal Reflux Disease After Esomeprazole Treatment in Children 12 to 36 Months Old.

Healing of Erosive Esophagitis and Improvement of Symptoms of Gastroesophageal Reflux Disease After Esomeprazole Treatment in Children 12 to 36 Months Old.

J Pediatr Gastroenterol Nutr. 2015 Jul;60 Suppl 1:S31-6

Authors: Tolia V, Gilger MA, Barker PN, Illueca M

PMID: 26422096 [PubMed - indexed for MEDLINE]

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Esomeprazole for the Treatment of Erosive Esophagitis in Children: An International, Multicenter, Randomized, Parallel-Group, Double-Blind (for Dose) Study.

Esomeprazole for the Treatment of Erosive Esophagitis in Children: An International, Multicenter, Randomized, Parallel-Group, Double-Blind (for Dose) Study.

J Pediatr Gastroenterol Nutr. 2015 Jul;60 Suppl 1:S24-30

Authors: Tolia V, Youssef NN, Gilger MA, Traxler B, Illueca M

PMID: 26422095 [PubMed - indexed for MEDLINE]

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Pharmacokinetics and Acid-suppressive Effects of Esomeprazole in Infants 1-24 Months Old With Symptoms of Gastroesophageal Reflux Disease.

Pharmacokinetics and Acid-suppressive Effects of Esomeprazole in Infants 1-24 Months Old With Symptoms of Gastroesophageal Reflux Disease.

J Pediatr Gastroenterol Nutr. 2015 Jul;60 Suppl 1:S2-8

Authors: Omari T, Davidson G, Bondarov P, Nauclér E, Nilsson C, Lundborg P

PMID: 26422094 [PubMed - indexed for MEDLINE]

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speech and language; +26 new citations

26 new pubmed citations were retrieved for your search. Click on the search hyperlink below to display the complete search results:

speech and language

These pubmed results were generated on 2016/06/30

PubMed comprises more than 24 million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full-text content from PubMed Central and publisher web sites.

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Acknowledgement to Reviewers

Folia Phoniatr Logop 2015;67:324

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Contents Vol. 67, 2015

Folia Phoniatr Logop 2015;67:I-IV

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The Effect of Age and Type of Noise on Speech Perception under Conditions of Changing Context and Noise Levels

Objective: Everyday life includes fluctuating noise levels, resulting in continuously changing speech intelligibility. The study aims were: (1) to quantify the amount of decrease in age-related speech perception, as a result of increasing noise level, and (2) to test the effect of age on context usage at the word level (smaller amount of contextual cues). Patients and Methods: A total of 24 young adults (age 20-30 years) and 20 older adults (age 60-75 years) were tested. Meaningful and nonsense one-syllable consonant-vowel-consonant words were presented with the background noise types of speech noise (SpN), babble noise (BN), and white noise (WN), with a signal-to-noise ratio (SNR) of 0 and -5 dB. Results: Older adults had lower accuracy in SNR = 0, with WN being the most difficult condition for all participants. Measuring the change in speech perception when SNR decreased showed a reduction of 18.6-61.5% in intelligibility, with age effect only for BN. Both young and older adults used less phonemic context with WN, as compared to other conditions. Conclusion: Older adults are more affected by an increasing noise level of fluctuating informational noise as compared to steady-state noise. They also use less contextual cues when perceiving monosyllabic words. Further studies should take into consideration that when presenting the stimulus differently (change in noise level, less contextual cues), other perceptual and cognitive processes are involved.
Folia Phoniatr Logop 2016;68:16-21

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A Survey of Speech-Language-Hearing Therapists' Career Situation and Challenges in Mainland China

Aims: The aim of this survey was to investigate the background of speech-language pathologists and their training needs to provide a profile of the current state of the profession in Mainland China. Methods: A survey was conducted of 293 speech-language therapists. The questionnaire used asked questions related to their career background and had a 24-item ranking scale covering almost all of the common speech-language-hearing disorders. A summary of the raw data was constructed by calculating the average ranking score for each answer choice in order to determine the academic training needs with the highest preference among the respondents. Results: The majority of respondents were female, Conclusion: The results revealed that speech-language therapists in Mainland China tend to be young, with little total working experience and at the first stage of their career. This may be due to the lack of systematic educational programs and national certification systems for speech-language therapists.
Folia Phoniatr Logop 2016;68:10-15

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Implications of Untreated Cleft Palate in the Developing World: Adaptation of an Outcome Measure

Objectives: To identify the implications of living with untreated cleft palate and develop an outcome measure which reflects the broad impact of surgery but is sensitive to the physical impact, speech changes, and psychosocial implications of late intervention. Design, Participants, Setting: Focus groups and individual interviews were used to gather information on the implications of living with untreated cleft palate and the impact of subsequent surgery. Participants included 11 individuals attending a cleft department in India whose cleft had persisted into adolescence or adulthood, as well as 16 of their family members. The findings were used to assess whether the Therapy Outcome Measure (TOM) could capture the implications of untreated cleft palate and the impact of surgery beyond that of speech alone. Results: The findings indicated that the implications of living with untreated cleft palate revolved around difficulties with communication, reduced autonomy, and nasal regurgitation. These issues are encapsulated within the third and fourth domains of the TOM, but there is a need for an adapted version (TOM-clp) to use in the developing world, incorporating areas specific to cleft palate. Conclusion: The TOM has potential as a global tool for measuring the broad impact, including the psychosocial benefit, from attending to untreated cleft palate.
Folia Phoniatr Logop 2016;68:1-9

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Τετάρτη 29 Ιουνίου 2016

Prevalence and Predictors of Persistent Speech Sound Disorder at Eight Years Old: Findings From a Population Cohort Study

Purpose

The purpose of this study was to determine prevalence and predictors of persistent speech sound disorder (SSD) in children aged 8 years after disregarding children presenting solely with common clinical distortions (i.e., residual errors).

Method

Data from the Avon Longitudinal Study of Parents and Children (Boyd et al., 2012) were used. Children were classified as having persistent SSD on the basis of percentage of consonants correct measures from connected speech samples. Multivariable logistic regression analyses were performed to identify predictors.

Results

The estimated prevalence of persistent SSD was 3.6%. Children with persistent SSD were more likely to be boys and from families who were not homeowners. Early childhood predictors identified as important were weak sucking at 4 weeks, not often combining words at 24 months, limited use of word morphology at 38 months, and being unintelligible to strangers at age 38 months. School-age predictors identified as important were maternal report of difficulty pronouncing certain sounds and hearing impairment at age 7 years, tympanostomy tube insertion at any age up to 8 years, and a history of suspected coordination problems. The contribution of these findings to our understanding of risk factors for persistent SSD and the nature of the condition is considered.

Conclusion

Variables identified as predictive of persistent SSD suggest that factors across motor, cognitive, and linguistic processes may place a child at risk.

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Prevalence and Predictors of Persistent Speech Sound Disorder at Eight Years Old: Findings From a Population Cohort Study

Purpose

Method

Results

Conclusion

Variables identified as predictive of persistent SSD suggest that factors across motor, cognitive, and linguistic processes may place a child at risk.

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The Development of Morphological Awareness in Young Bilinguals: Effects of Age and L1 Background

Purpose

Current understanding about the effect of first language (L1) background on morphological awareness (MA) development in those who are bilingual is largely limited to school-aged second-language learners. This study examined the development of MA in bilingual Mandarin–English (ManEngBi) and Spanish–English (SpaEngBi) children ages 4 to 7 years, whose L1 is predominated by compounding and derivation, respectively.

Method

We targeted specific word formation rules that develop within different developmental time frames. Forty-two ManEngBi, 30 SpaEngBi, and 27 English monolingual children divided into 4- to 5-year-old and 6- to 7-year-old age groups produced English words using compounding, the derivational agentive –er suffix, and the derivational characteristic –y suffix for both real and novel word roots.

Results

The characteristic –y suffix consistently elicited the poorest performance. This finding held true regardless of language group, age, or novelty of prompts. Both older SpaEngBi and English monolingual children outperformed older ManEngBi children in the characteristic –y suffix, whereas the three groups performed comparably on the other two rules at both age intervals. Error analysis further suggested influence of cross-linguistic features.

Conclusions

L1 influence on English MA development is sensitive to the developmental time frame of word formation rules. Future studies on the development of MA in bilingual children should adopt a more fine-grained approach and include a wider age range.

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Polyglycolic acid sheet application for intractable acute hemorrhagic rectal ulcer

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Low-Dose Tricyclics for Esophageal Hypersensitivity: Is it all Placebo Effect?

Low-Dose Tricyclics for Esophageal Hypersensitivity: Is it all Placebo Effect?

Am J Gastroenterol. 2016 Feb;111(2):225-7

Authors: Keefer L, Kahrilas PJ

Abstract
Limsrivilai et al. report on a randomized control trial (RCT) testing the efficacy of imipramine for treating esophageal hypersensitivity and functional heartburn, the first RCT to test this therapy in this indication. Among 43 functional heartburn and esophageal hypersensitivity patients randomized to treatment with 25 mg qhs imipramine and 40 randomized to matched placebo, the response rates, judged by a 50% reduction in gastroesophageal reflux disease symptoms, were 37.2% and 37.5%, respectively, with no observed difference between patients with hypersensitivity and those with functional heartburn. On the positive side, imipramine treatment was associated with improvement in quality of life as assessed by total SF-36 score. Although negative at first glance, there are several important lessons from this study: (i) low-dose tricyclic is sufficient in these patients; (ii) proton pump inhibitors can (and should) be discontinued when they are ineffective; and (iii) distinguishing between functional heartburn and esophageal hypersensitivity is of unclear clinical relevance.

PMID: 26882945 [PubMed - indexed for MEDLINE]

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pH monitoring of gastro-oesophageal reflux before and after laparoscopic sleeve gastrectomy.

pH monitoring of gastro-oesophageal reflux before and after laparoscopic sleeve gastrectomy.

Br J Surg. 2016 Mar;103(4):399-406

Authors: Thereaux J, Barsamian C, Bretault M, Dusaussoy H, Lamarque D, Bouillot JL, Czernichow S, Carette C

Abstract
BACKGROUND: Gastro-oesophageal reflux disease (GORD) is a common obesity-related co-morbidity that is assessed objectively by 24-h pH monitoring. Some concerns have been raised regarding the risk of de novo GORD or exacerbation of pre-existing GORD after laparoscopic sleeve gastrectomy. Here, 24-h pH monitoring was used to assess the influence of laparoscopic sleeve gastrectomy on postoperative GORD in obese patients with or without preoperative GORD.
METHODS: From July 2012 to September 2014, all patients scheduled for laparoscopic sleeve gastrectomy were invited to participate in a prospective follow-up. Patients who underwent preoperative 24-h pH monitoring were asked to repeat the examination 6 months after operation. GORD was defined as an oesophageal pH < 4 for at least 4·2 per cent of the total time recorded.
RESULTS: Of 89 patients, 76 had preoperative pH monitoring for GORD evaluation and 50 had postoperative reassessment. Patients without (group 1, 29 patients) or with (group 2, 21 patients) preoperative GORD were similar regarding age, sex ratio and body mass index. In group 1, the median (i.q.r.) total time at pH < 4 was significantly higher after surgery than before: 5·6 (2·5-9·5) versus 1·6 (0·7-2·9) per cent (P < 0·001). Twenty of the 29 patients experienced de novo GORD as determined by 24-h pH monitoring (P < 0·001). In group 2, total time at pH < 4 after surgery was no different from the preoperative value: 5·9 (3·9-10·7) versus 7·7 (5·2-10·3) per cent (P = 0·296).
CONCLUSION: Laparoscopic sleeve gastrectomy was associated with de novo GORD in over two-thirds of patients, but did not seem to exacerbate existing GORD.

PMID: 26806096 [PubMed - indexed for MEDLINE]

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Pseudoachalasia: Still a Tough Clinical Challenge.

Pseudoachalasia: Still a Tough Clinical Challenge.

Am J Case Rep. 2015;16:768-73

Authors: Jia Y, McCallum RW

Abstract
BACKGROUND: Treatment of achalasia is focused on decreasing the resting lower esophageal sphincter by either pneumatic dilation or surgical myotomy. When patients symptomatically relapse after one or more pneumatic dilations, then one explanation is to consider the possibility of pseudoachalasia as the diagnosis.
CASE REPORT: We present a rare case of an elderly patient with a presentation of chronic dysphagia and severe weight loss, who had diagnostic findings consistent with achalasia, and who also responded very well to a series of pneumatic dilations, but for only brief intervals. Further investigations finally uncovered esophageal adenocarcinoma, thus making our patient an example of the entity "pseudoachalasia".
CONCLUSIONS: Pseudoachalasia secondary to an esophageal malignancy should be suspected when dysphagia progresses despite technically well-performed pneumatic dilations, and is particularly suspicious in the setting of an elderly patient with marked weight loss. Endoscopic ultrasound is a new diagnostic tool for detecting and staging malignancy by obtaining diagnostic tissue and allowing appropriate therapy to be planned.

PMID: 26510466 [PubMed - indexed for MEDLINE]

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An unusual cause of odynophagia.

An unusual cause of odynophagia.

Gut. 2016 Mar;65(3):399, 534

Authors: Moreman C, Budihal S, Ubhi S, de Caestecker J, Richards CJ

PMID: 26423111 [PubMed - indexed for MEDLINE]

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Constipation, fiber intake and incompliance contribute to inadequate colonoscopy bowel preparation: A prospective cohort study

Abstract

Background

Adequate bowel preparation is important for colonoscopy. Currently available evidence on the determinants of poor bowel preparation has largely emanated from studies conducted in western countries. We sought to identify risk factors for inadequate bowel preparation for colonoscopy in the Chinese population.

Methods

In this single-center study, patients who attended the out-patient department between March 2013 and December 2014, and had indications for colonoscopy, were prospectively enrolled. Questionnaires were administered to the patients. Demographic, clinical characteristics and Procedure-related parameters such as procedure time were recorded. Bowel preparation was assessed using Boston bowel preparation scale (BBPS) score.

Results

A total of 409 patients (mean age: 48.8 ± 12.9 years) of whom 61% were male participated in the study. On univariate analysis, poor educational status (P = 0.020), chronic constipation (P = 0.001), no physical exercises after medication (P < 0.001), high fiber diet during the 24 h period immediately preceding the colonoscopy (P < 0.001), incomplete intake of preparation (P < 0.001), passage of yellow or dark stools before colonoscopy (P < 0.001), waiting time (P = 0.001) and stool frequency after medication (P = 0.048) were associated with inadequate bowel preparation. On multivariate analysis, chronic constipation (Odds Ratio [OR] 2.05; 95% Confidence Interval [CI], 1.31-3.23), incomplete intake of the preparation (OR 2.77; 95% CI, 1.47-5.21) and high fiber diet (OR 2.15; 95% CI, 1.40-3.28) were independent risk factors for inadequate bowel preparation.

Conclusion

Chronic constipation, poor compliance with treatment and high fiber diet were predictors of poor bowel preparation. Patients with these risk factors require more effective strategies for bowel preparation.

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Increase Accuaracy and Improve Your “Sleep Bite” With The Ricketts Phonetic Bite Given To You By The Man Who Worked Alongside Of Him For Years-David Gergen

Oral appliance therapy is considered an effective treatment for snoring and obstructive sleep apnea (OSA). The appliance functions by supporting the jaw in a forward position to help maintain an open upper airway. When utilized properly, it is worn at night and fits like a mouth guard used in sports. The success of the appliance, however, depends largely on the quality of the bite registration taken. While many view the process as an uncomplicated procedure, if it is not done using the correct technique with precision it could negatively impact the treatment.

HOF RB Tony Dorsett with David Gergen

The late Dr. Robert Ricketts DDS, NMD who was a well-known and arguably the greatest orthodontist of all time, leader in orthodontic instruction as a professor and a noted researcher in many areas of dentistry including craniofacial growth and development, TMJ, orthodontics and esthetics invented what is known as the the Ricketts Phonetic Bite. The Ricketts Phonetic bite may be used for patients suffering from snoring or obstructive sleep apnea and it determines the position of the mandible that creates the so-called sweet spot for patients using oral appliance therapy. Instructions are as follows:

The dentist should instruct the patient to sit upright in the chair.

The dentist should instruct the patient to count out loud numbers 55-75. Notice numbers 5, 8, 9 for vertical opening and 66 for maximum anterior posterior positioning. If you do not get the desired AP with the "ss" sound, you can use the second "s" sound, "sh" to acquire the max AP. The "n" sound in 69 will drop their mandible vertically as well and give you their full natural opening. The "n" sound is a straight vertical drop wherever you're at in speech; using the word "shun" is another method for obtaining the best AP position.

The dentist should use a round surfaced instrument as opposed to a flat one (for anterior stabilization during the registration) between teeth #8 and #9 to hold that position of the jaw.

Use a fast set bite registration material to capture the bite.

You will always want to start with having the patient occlude their teeth a few times in order to make a mental image of their natural occlusion. Having the patient counting those numbers should give you a feel for the most balanced yet natural vertical opening.

All three types of basic classes of anterior occlusion must open to disclude the posterior teeth in order to allow a person to speak, and when "ss" sounds must be made, at least 1 to 1.5 mm of clearance must be developed between the upper and lower central incisors. Note that saying "s" will not be sufficient; you will actually have to force the sound to occur using it in a word, as seen during the count in numbers that contain the "ss" sound or like with the word "Mississippi".

The amount of disclusion depends on the degree of forward movement of the teeth from centric relation to their "ss" position. These movements define the incisal guide angle and represent vertical and horizontal overlaps of the teeth. Thus, the greater the forward movement, the greater the amount of posterior disclusion and the resultant "s" space – or posterior speaking space as found in the number "66" and word "Mississippi".

Once again, repeat these steps a few times to make sure you get the same results. It is important to capture the optimum vertical as it is much harder to adjust after the appliance is fabricated. After using this technique, utilize the Airway Metric System by placing the correct jigs correlating with the sleep bite for reference. Lean the patient back in the chair and see if they can snore. If they cannot, ball game over. I specifically instruct doctors to only use the Ricketts Phonetic Bite with NFL players because of the accuracy and rate of success. For example, Super Bowl Champion Derek Kennard's AHI went from a 72 to 2 on the first try using this technique.

This is demonstrated and practiced at the American Sleep and Breathing Academy annual meeting and study clubs in a workshop setting. Visit americansleepandbreathingacademy.com to learn more.

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Esophago-Cardial-Gastric Tunneling Peritoneoscopy: In Vivo Dog Survival Study.

Esophago-Cardial-Gastric Tunneling Peritoneoscopy: In Vivo Dog Survival Study.

J Laparoendosc Adv Surg Tech A. 2015 Nov;25(11):920-5

Authors: Liu BR, Song JT, Kong LJ, Ma X, Liu JY, Cui GX

Abstract
BACKGROUND: Diagnostic peritoneoscopy is typically performed by using a rigid laparoscope. Inspired by gastric submucosal tunneling for peritoneal natural orifice transluminal endoscopic surgery access and peroral endoscopic myotomy for the treatment of achalasia, we developed a novel esophago-cardial-gastric tunneling (ECGT) peritoneoscopy technique with a flexible endoscope. This study aims to evaluate its feasibility and safety.
MATERIALS AND METHODS: The study comprised 10 Beagle dogs. A longitudinal mucosal incision was made on the esophageal wall, and a submucosal tunnel was created through the cardia into the stomach. An incision was made in the muscular layer of the stomach, and then the endoscope was advanced into the peritoneal cavity. Peritoneoscopy with the flexible endoscope was performed. After intraperitoneal exploration, the esophageal mucosal entry was closed with endoclips. All dogs resumed food intake 12 hours after the procedures. Diets, behavior, and body temperature of all of the dogs were observed. Endoscopic examinations were performed 4 weeks after the procedure, and then the animals were sacrificed for necropsy.
RESULTS: The ECGT peritoneoscopy was successfully done in all dogs. Diets, behavior, and body temperature were normal in all dogs. The entry of the esophagus was healed well in 9 dogs; the mucosa of the entry was torn in 1 dog, but the submucosal tunnel was healed well at the cardia. Necropsy showed complete closure of the gastric serosal exit, and no intraperitoneal abscess was found. Histopathological examinations showed submucosal tunnels healed well.
CONCLUSIONS: The ECGT peritoneoscopy is feasible and safe for peritoneal exploration. It should be a good choice for the clinical application of diagnostic peritoneoscopy.

PMID: 26402572 [PubMed - indexed for MEDLINE]

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A Chinese randomized prospective trial of floppy Nissen and Toupet fundoplication for gastroesophageal disease.

A Chinese randomized prospective trial of floppy Nissen and Toupet fundoplication for gastroesophageal disease.

Int J Surg. 2015 Nov;23(Pt A):35-40

Authors: Wang B, Zhang W, Liu S, Du Z, Shan C, Qiu M

Abstract
INTRODUCTION: To evaluate the clinical outcomes of laparoscopic floppy Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF) for the treatment of gastroesophageal disease (GERD).
METHODS: A total of 84 patients with GERD were randomized to either LNF (n = 43) or LTF (n = 41) between January 2010 and January 2013. The primary endpoint measures were the DeMeester score, distal esophageal amplitude (DEA), peristaltic frequency, lower esophageal sphincter pressure (LESP), short-term and long-term postoperative dysphagia and recurrence rate. The secondary endpoints were improvements in symptom scores and quality of life (QoL), and perioperative complications.
RESULTS: LNF group had a lower DeMeester score and a higher LESP compared to LTF group after surgery (DeMeester score: P = 0.007; LESP: P = 0.027). The mean DEA and peristaltic frequency both improved significantly after surgery in 2 groups. There was no difference in the incidence of short-term adverse events (including dysphagia, heartburn, regurgitation et al.) between the two groups (P = 0.157). At the time of the latest follow-up, there was no difference in the incidence of symptomatic reflux symptom (heartburn and regurgitation) between the two groups (heartburn: P = 0.363; regurgitation: P = 1.000). A higher frequency of dysphagia was present in the LNF group compared with the LTF group (P = 0.023).
DISCUSSION: LNF is associated with an excessive elevation of LESP which may lead to further persistent dysphagia. Partial fundoplication may provide adequate reﬂux control, improve esophageal body motility and minimize complications associated with an 'over-tight' fundal wrap.
CONCLUSION: LTF seems to be as safe and effective on the long-term as LNF, but with a lower incidence of postoperative dysphagia (ChiCTR-TRC-13003945).

PMID: 26360740 [PubMed - indexed for MEDLINE]

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Long-term and 'patient-reported' outcomes of total esophagogastric dissociation versus laparoscopic fundoplication for gastroesophageal reflux disease in the severely neurodisabled child.

Long-term and 'patient-reported' outcomes of total esophagogastric dissociation versus laparoscopic fundoplication for gastroesophageal reflux disease in the severely neurodisabled child.

J Pediatr Surg. 2015 Nov;50(11):1828-32

Authors: Lansdale N, McNiff M, Morecroft J, Kauffmann L, Morabito A

Abstract
AIM: Fundoplication has high failure rates in neurodisability: esophagogastric dissociation (TOGD) has been proposed as an alternative. This study aimed to compare the long-term and 'patient-reported' outcomes of TOGD and laparoscopic fundoplication (LapFundo).
METHODS: Matched cohort comparison comprises (i) retrospective analysis from a prospective database and (ii) carer questionnaire survey of symptoms and quality of life (CP-QoL-Child). Children were included if they had severe neurodisability (Gross Motor Function Classification System five) and spasticity.
RESULTS: Groups were similar in terms of previous surgery and comorbidities. The TOGD group was younger (22 vs. 31.5months, p=0.038) with more females (18/23 vs. 11/24, p=0.036). TOGD was more likely to require intensive care: operative time, length of stay and time to full feeds were all longer (p<0.0001). Median follow-up was 6.3 and 5.8years. Rates of complications were comparable. Symptom recurrence (5/24 vs. 1/23, p=0.34) and use of acid-reducing medication (13/24 vs. 4/23, p=0.035) were higher for LapFundo. Carer-reported symptoms and QoL were similar.
CONCLUSIONS: TOGD had similar efficacy to LapFundo (with suggestion of lower failure), with comparable morbidity and carer-reported outcomes. However, TOGD was more 'invasive,' requiring longer periods of rehabilitation. Families should be offered both procedures as part of comprehensive preoperative counseling.

PMID: 26210817 [PubMed - indexed for MEDLINE]

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Significant pressure differences between solid-state and water-perfused systems in lower esophageal sphincter measurement.

http:--production.springer.de-OnlineReso

Significant pressure differences between solid-state and water-perfused systems in lower esophageal sphincter measurement.

Surg Endosc. 2015 Dec;29(12):3565-9

Authors: Gehwolf P, Hinder RA, DeVault KR, Edlinger M, Wykypiel HF, Klingler PJ

Abstract
OBJECTIVE: High-resolution manometry of the esophagus has gained worldwide acceptance, using different solid-state catheters. Thus, normal values for lower esophageal sphincter (LES) resting pressure in suspected gastroesophageal reflux disease patients have been established using water-perfused manometry. These standard values are commonly applied using also solid-state techniques, although they have never been compared before. The aim of the study was to compare LES measurements obtained with water-perfused manometry with a solid-state technique.
METHODS: Thirty healthy subjects were studied twice on the same day: Technique 1: Station pull through using a water-perfused catheter with ports arranged at 0°, 90°, 180° and 270° which were averaged to give a mean LES pressure. Technique 2: Solid-state circumferential probe with a single station pull through. Data were collected using the same computer system and program. The LES pressures were randomly and blindly analyzed.
RESULTS: Twenty-seven subjects out of 30 were analyzed. Using the solid-state system, the mean LES pressure was higher (15.0 vs. 23.3 mmHg, p = 0.003) and 19 of 27 (70%) individual measurements were higher. Two subjects had a hypertensive LES by solid state (58.6 resp. 47.5 mmHg), while their pressures were normal with water-perfused manometry (21.0 resp. 23.4 mmHg). The distal esophageal pressures (mean of pressure at 3 and 8 cm above LES) were the same with the two techniques.
CONCLUSION: In normal control subjects, LES measurement using circumferential solid-state transducers yields higher pressures than standard water-perfused manometry. Which system yields the "true" resting pressure of the physiologic LES remains to be determined.

PMID: 25701063 [PubMed - indexed for MEDLINE]

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Reflux control is important in the management of Barrett's Esophagus: results from a retrospective 1,830 patient cohort.

Reflux control is important in the management of Barrett's Esophagus: results from a retrospective 1,830 patient cohort.

Surg Endosc. 2015 Dec;29(12):3528-34

Authors: Brown CS, Lapin B, Wang C, Goldstein JL, Linn JG, Denham W, Haggerty SP, Talamonti MS, Howington JA, Carbray J, Ujiki MB

Abstract
BACKGROUND: It is unknown whether acid/reflux control prevents progression in Barrett's esophagus. In this study, we investigate whether medical or surgical control of reflux is associated with a decreased risk of progression to dysplasia/esophageal adenocarcinoma.
METHODS: We retrospectively collected and analyzed data from a cohort of Barrett's esophagus patients participating in this single-center study comprised of all patients diagnosed with Barrett's esophagus at NorthShore University Health System hospitals and clinics over a 10-year period. Patients were followed in order to identify those progressing from Barrett's esophagus to low-grade dysplasia, high-grade dysplasia, and esophageal adenocarcinoma. We collected information from the patient's electronic medical records regarding demographic, endoscopic findings, histological findings, smoking/alcohol history, medication use including proton-pump inhibitors, and history of bariatric and antireflux surgery. Risk-adjusted modeling was performed using multivariable logistic regression.
RESULTS: This study included 1,830 total Barrett's esophagus patients, 102 of which had their Barrett's esophagus progress to low-grade dysplasia, high-grade dysplasia, or esophageal adenocarcinoma (confirmed by biopsy) with an annual incidence rate of 1.1%. Mean follow-up period was 5.51 years (10,083 patient-years). Compared to the group that did not progress, the group that progressed was older (69.3 ± 13.7 vs. 63.9 ± 13.4 years. p < 0.001) and likely to be male (75 vs. 61%, p < 0.01). In the multivariable analysis, patients who had a history of antireflux surgery (n = 44) or proton-pump inhibitor use without surgery (n = 1,641) were found to progress at significantly lower rates than patients who did not have antireflux surgery or were not taking PPI's (OR 0.18, 95% CI 0.09-0.36).
CONCLUSIONS: Reflux control was associated with decreased risk of progression to low-grade dysplasia, high-grade dysplasia, or esophageal adenocarcinoma. These results support the use of reflux control strategies such as proton-pump inhibitor therapy or surgery in patients with non-dysplastic Barrett's esophagus for the prevention of progression to dysplasia/adenocarcinoma.

PMID: 25676204 [PubMed - indexed for MEDLINE]

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Analysis of p.V37I compound heterozygous mutations in the GJB2 gene in Chinese infants and young children.

Analysis of p.V37I compound heterozygous mutations in the GJB2 gene in Chinese infants and young children.

Biosci Trends. 2016 Jun 27;

Authors: Du Y, Huang L, Cheng X, Zhao L, Ruan Y, Ni T

Abstract
The p.V37I (c.109G>A) mutation in the GJB2 gene is the common frequent cause of congenital deafness; however, its pathogenicity is debated. The present study investigated the prevalence of p.V37I in Chinese infants and young children and associated clinical characteristics. The subjects of the present study were screened for mutations in GJB2 (235delC, 299delAT, 176dell6, 35delG), SLC26A4 (IVS7-2A>G, 2168A>G), GJB3 (538C>T), and in the mitochondrial 12S rRNA gene (1555A>G, 1494C>T). Subjects with p.V37I underwent an audiological evaluation. GJB2 exon sequencing revealed that 20 subjects had p.V37I compound heterozygous mutations, one of whom had a family history; the mutations included c.235delC/p.V37I (n = 12), c.299AT/p.V37I (n = 7), and c.176del16/p.V37I (n = 1). Of the 20 subjects, 12 were referred for Universal Newborn Hearing Screening (UNHS). Nine of the 20 subjects had mild hearing loss in the better ear and 5 had moderate hearing loss in the better ear while 4 had normal hearing. Among subjects with the c.235delC/p.V37I mutation, 5 had mild hearing loss and 2 had moderate hearing loss while 3 had normal hearing. Among subjects with the c.299AT/p.V37I mutation, 3 had mld hearing loss and 3 had moderate hearing loss while 1 had normal hearing. One subject with the c.176del16/p.V37I mutation had mild hearing loss. Few studies have reported on the clinical characteristics of Chinese infants with p.V37I compound heterozygous mutations identified via screening for deafness genes and GJB2 sequencing. The c.235delC/p.V37I mutation was the most prevalent mutation found in subjects. The degree of hearing loss associated with p.V37I compound heterozygous mutations was mainly mild to moderate.

PMID: 27350192 [PubMed - as supplied by publisher]

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Efficacy and Safety Evaluation on Arterial Thrombolysis in Treating Acute Cerebral Infarction.

Efficacy and Safety Evaluation on Arterial Thrombolysis in Treating Acute Cerebral Infarction.

Cell Biochem Biophys. 2015 Nov;73(2):297-304

Authors: Shen B, Liu Q, Gu Y, Wang Y, Zhang Z

Abstract
The objective of this study was to evaluate the efficacy and safety of intra-arterial thrombolysis in treating acute cerebral infarction and further discuss the indications of acute cerebral infarction treatment, in order to enhance the therapeutic effects of arterial thrombolysis. The data of 164 patients with acute cerebral infarction who accepted intra-arterial thrombolysis treatment by using rt-PA or reteplase between 2009 and 2014 at the Department of Neurology of our hospital, were collected, including patients' medical history, characteristics of the onset procedure, intervals between onset and intra-arterial thrombolysis, bleeding or death, and the changing process of patient's main neurologic function after the treatment. The neurological functions including muscle strength, speech, and level of consciousness were chosen for evaluation. Through a review of cerebral angiography, we collected the digital subtraction angiography (DSA) morphological changes of blood vessels before and after arterial thrombolysis to evaluate whether those blood vessels had been reperfused. Thereafter, we analyzed and statistically processed above-mentioned data. The mean time of arterial thrombolysis was 5.7 h. DSA results were as follows: 22 patients had complete internal carotid artery (ICA) occlusion; 49 patients middle cerebral artery's (MCA's) Ml or M2 segment occlusion; 6 patients anterior cerebral artery (ACA) occlusion; 58 patients reperfusion after thrombolysis, and the recanalization rate was 76 %. Based on vertebral-basilar artery (VBA) system, 18 patients had complete occlusion, 11 patients had reperfusion after thrombolysis, and the recanalization rate was 61 %. A total of 63 patients had severe stenosis, and they had significantly improved after thrombolysis. The clinical symptoms of patients were improved: 79 out of 164 patients with paralysis had partially recovered their limb muscle strength after operation, while 33 patients had completely recovered, and there was no recovery at all of the muscle strength in 4 patients after operation. In total, 59 out of 63 patients with aphasia had improved their language function, while 19 patients with disturbance of consciousness turned for the better after arterial thrombolysis. Only one patient experienced the cerebral hemorrhage, and 14 cases had gingival bleeding, oral mucosa bleeding, and urethrorrhagia. The overall effective rates of intra-arterial thrombolysis in treating the acute cerebral infarction by reteplase had no significant differences compared to those by rt-PA, and there were no hemorrhagic complications. It is safe and effective if the arterial thrombolysis using reteplase is performed within a few hours after acute cerebral infarction onset because reteplase has a higher clinical efficacy and lower hemorrhagic transformation, which suggests that it may become a new feasible option for clinical arterial thrombolysis.

PMID: 27352315 [PubMed - as supplied by publisher]

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Comparison of Long-term Differences in Dysphagia: Cervical Arthroplasty and Anterior Cervical Fusion.

Comparison of Long-term Differences in Dysphagia: Cervical Arthroplasty and Anterior Cervical Fusion.

Clin Spine Surg. 2016 Jun 27;

Authors: Smucker JD, Bassuener SR, Sasso RC, Riew KD

Abstract
STUDY DESIGN: Retrospective cohort study.
OBJECTIVE: This study investigates the incidence of long-term dysphagia in cervical disc arthroplasty, and anterior cervical discectomy and fusion (ACDF) patients.
SUMMARY OF BACKGROUND DATA: No long-term comparison of dysphagia between cervical arthroplasty and fusion patients has been published. Widely variable short-term postsurgical dysphagia rates have been reported.
MATERIALS AND METHODS: Cohorts for this study are patients with single-level cervical degenerative disc disease previously enrolled in a randomized clinical trial comparing cervical arthroplasty and ACDF. Subjective modified Bazaz Dysphagia Severity questionnaires were distributed to each patient at a minimum of 5 years postoperative for the long-term assessment. Dysphagia severity data were pooled to compare the rate of patients with dysphagia (grade>1) to asymptomatic (grade=1).
RESULTS: In the arthroplasty cohort, 15 of 22 (68%) patients completed long-term swallowing questionnaires with no reports of dysphagia. Eighteen of 25 (72%) ACDF patients completed questionnaires, with 5 of 18 (28%) reporting dysphagia. This is a statistically significant difference (P=0.042) favoring lower rates of long-term dysphagia after cervical arthroplasty at an average interval of 7 years postoperative (range, 5.5-8.5 y). No significant difference between rates of self-reported short-term dysphagia was noted with 12% (3/25) and 9% (2/22) in the ACDF and arthroplasty groups, respectively (P=0.56). All short-term dysphagia cases in the arthroplasty cohort reported complete resolution of symptoms within 12 months postoperative. In the ACDF cohort, persistent symptoms at 7 years were noted in all responding patients. Three ACDF patients reported new late-onset, which was not noted in the arthroplasty cohort.
CONCLUSIONS: To date, these findings represent the longest reported follow-up interval comparing rates of dysphagia between randomized cohorts of cervical arthroplasty and fusion patients. Our study suggests that cervical arthroplasty is less likely than ACDF to cause sustained long-term or late-presenting dysphagia.

PMID: 27352373 [PubMed - as supplied by publisher]

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Clinical and Radiographic Outcomes in Patients Undergoing Single-level Anterior Cervical Arthrodesis: A Prospective Trial Comparing Allograft to a Reduced Dose of rhBMP-2.

Clinical and Radiographic Outcomes in Patients Undergoing Single-level Anterior Cervical Arthrodesis: A Prospective Trial Comparing Allograft to a Reduced Dose of rhBMP-2.

Clin Spine Surg. 2016 Jun 27;

Authors: Burkus JK, Dryer RF, Arnold PM, Foley KT

Abstract
STUDY DESIGN: A prospective study with historical controls.
OBJECTIVES: To evaluate and compare the safety and effectiveness of recombinant human bone morphogenetic protein-2 (rhBMP-2) with allograft for anterior cervical discectomy and fusion (ACDF) in patients with symptomatic single-level cervical degenerative disk disease.
SUMMARY OF BACKGROUND DATA: rhBMP-2 is an osteoinductive protein that has been shown to induce fusion when used as an implant with a suitable carrier in spine surgery. However, some previous studies have shown rhBMP-2 use to be associated with a higher complication rate.
METHODS: Investigational patients (224) with single-level cervical degenerative disk disease underwent ACDF with rhBMP-2 at a dose of 0.6 or 1.05 mg and were compared with historical control patients (486) treated with allograft spacer and cervical plate.
RESULTS: At 24 months, improvement was significantly greater in the investigational group (37.1 points) than in the control group for Neck Disability Index (P=0.002) and arm pain (P=0.031). The overall neurological success rate was higher in the investigational group (P<0.001). Neck pain and general health status (SF-36 PCS and MCS) were similar. Fusion rate in the investigational group was higher than in the control group (99.4% vs. 87.2%, P=0.002).Cumulative adverse event rates at 24 months were similar; however, higher rates of dysphagia (P=0.001), local swelling (P=0.024), oropharyngeal pain (P=0.013), neck pain (P=0.019), and foraminal stenosis (P=0.002) were observed in the investigational group. Heterotopic ossification was also higher in the investigational group.
CONCLUSIONS: At doses of 0.6 or 1.05 mg in a PEEK interbody cage, rhBMP-2 was effective in inducing fusion and improving Neck Disability Index and arm pain in single-level ACDF patients; however, higher rates of certain adverse events were observed in the investigational group.
LEVEL OF EVIDENCE: Level 2.

PMID: 27352370 [PubMed - as supplied by publisher]

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Πληροφορίες

Πέμπτη 30 Ιουνίου 2016

Summary

Background

Aims

Methods

Results

Conclusion

Summary

Background

Aim

Methods

Results

Conclusion

Summary

Background

Aim

Methods

Results

Conclusions

Τετάρτη 29 Ιουνίου 2016

Abstract

Background

Methods

Results

Conclusion