Thomas G. Zullo

Development and validation of the voice handicap index-10.

Objectives/Hypothesis: The objective was to develop an abbreviated voice handicap assessment instrument and compare it with the Voice Handicap Index (VHI).

Obliterative bronchiolitis after lung and heart-lung transplantation: An analysis of risk factors and management

With a prevalence of 34% (55/162 at-risk recipients) and a mortality of 25% (14/55 affected recipients), obliterative bronchiolitis is the most significant long-term complication after pulmonary transplantation. Because of its importance, we examined donor-recipient characteristics and antecedent clinical events to identify factors associated with development of obliterative bronchiolitis, which might be eliminated or modified to decrease its prevalence. We also compared treatment outcome between recipients whose diagnosis was made early by surveillance transbronchial lung biopsy before symptoms or decline in pulmonary function were present versus recipients whose diagnosis was made later when symptoms or declines in pulmonary function were present. Postoperative airway ischemia, an episode of moderate or severe acute rejection (grade III/IV), three or more episodes of histologic grade II (or greater) acute rejection, and cytomegalovirus disease were risk factors for development of obliterative bronchiolitis. Recipients with obliterative bronchiolitis detected in the preclinical stage were significantly more likely to be in remission than recipients who had clinical disease at the time of diagnosis: 81% (13/15) versus 33% (13/40); p < 0.05). These results indicate that acute rejection is the most significant risk factor for development of obliterative bronchiolitis and that obliterative bronchiolitis responds to treatment with augmented immunosuppression when it is detected early by surveillance transbronchial biopsy.

Voice handicap index change following treatment of voice disorders

Outcome measurements of voice disorders is an important new area for both the evaluation of voice-disordered patients and evaluation of treatment efficacy. The Voice Handicap Index (VHI) measures the patients perception of the impact of his or her voice-disorder. The VHI was used in this study to measure the changes of the patients perception following treatment for four different voice disorders. The VHI showed a significant change following treatment for unilateral vocal fold paralysis, vocal cyst/polyp, and muscle tension dysphonia. Results of this paper indicate that the VHI is a useful instrument to monitor the treatment efficacy for voice disorders.

Critical thinking ability of new graduate and experienced nurses.

AIM This paper is a report of a study to identify critical thinking learning needs of new and experienced nurses. BACKGROUND Concern for patient safety has grown worldwide as high rates of error and injury continue to be reported. In order to improve patient safety, nurses must be able to recognize changes in patient condition, perform independent nursing interventions, anticipate orders and prioritize. METHODS In 2004-2006, a consecutive sample of 2144 newly hired nurses in a university-affiliated healthcare system completed the Performance Based Development System Assessment consisting of 10 videotaped vignettes depicting change in patient status. Results were reported as meeting or not meeting expectations. For nurses not meeting expectations, learning needs were identified in one of six subcategories. RESULTS Overall, 74.9% met assessment expectations. Learning needs identified for nurses not meeting expectations included initiating independent nursing interventions (97.2%), differentiation of urgency (67%), reporting essential clinical data (65.4%), anticipating relevant medical orders (62.8%), providing relevant rationale to support decisions (62.6%) and problem recognition (57.1%). Controlling for level of preparation, associate (P=0.007) and baccalaureate (P<0.0001) nurses were more likely to meet expectations as years of experience increased; a similar trend was not seen for diploma nurses (P=0.10). Controlling for years of experience, new graduates were less likely to meet expectations compared with nurses with >or=10 years experience (P=0.046). CONCLUSION Patient safety may be compromised if a nurse cannot provide clinically competent care. Assessments such as the Performance Based Development System can provide information about learning needs and facilitate individualized orientation targeted to increase performance level.

Predictors and impact of atrial fibrillation after isolated coronary artery bypass grafting

Objective Although an extensive number of studies have attempted to identify predictors of new-onset atrial fibrillation (AFIB) after coronary artery bypass grafting (CABG), a strong predictive model does not exist. Prior studies have included patients recruited from multiple centers with variant AFIB prevalence rates and those who underwent CABG in combination with other surgical procedures. Also, most studies have focused on pre- and perioperative characteristics, with less attention given to the initial postoperative period. The purpose of this study was to comprehensively examine pre-, peri-, and postoperative characteristics that might predict new-onset AFIB in a large sample of patients undergoing isolated CABG in a single medical center, utilizing data readily available to clinicians in electronic data repositories. In addition, length of stay and selected postoperative complications and disposition were compared in patients with AFIB and no AFIB. Design Retrospective, comparative survey. Setting University-affiliated tertiary care hospital. Patients Patients with new-onset AFIB who underwent isolated standard CABG or minimally invasive direct vision coronary artery bypass were identified from an electronic clinical data repository. Interventions None. Measurements and Main Results The prevalence of AFIB in the total sample (n = 814) was 31.9%. Predictors of AFIB included age (p = .0004), number of vessels bypassed (p = .013), vessel location (diagonal [p < .003] or posterior descending artery [p < .001]), and net fluid balance on the operative day (p = .015). Forward stepwise regression analysis produced a model that correctly predicted AFIB in only 24% of cases, with age (14%) and body surface area (9%) providing the most prediction. The incidence of embolic stroke was higher in AFIB (n = 8) vs. no AFIB (n = 4) patients, but stroke preceded AFIB onset in seven of eight cases. Subjects with AFIB had a longer stay (p = .0004), more intensive care unit readmissions (p = .0004), and required more assistance at hospital discharge (p = .017). Conclusions Despite attempts to examine comprehensively predictors of new-onset AFIB, we were unable to identify a robust predictive model. Our findings, in combination with prior work, imply that it may not be feasible to predict the development of new-onset AFIB after CABG using data readily available to the bedside clinician. In this sample, stroke was uncommon and, when it occurred, preceded AFIB in all but one case. As anticipated, AFIB increased length of stay, and patients with this complication required more assistance at discharge.

Utility of laryngeal electromyography in predicting recovery after vocal fold paralysis.

OBJECTIVES To determine the value of laryngeal electromyography in predicting recovery after vocal fold paralysis and to determine what elements of laryngeal electromyography are most predictive of outcome. DESIGN Cohort study with retrospective data review. SETTING University voice center. PARTICIPANTS Consecutive sample of 31 patients with vocal fold paralysis diagnosed by indirect laryngoscopy, using either nasal insertion with a flexible nasopharyngoscope or peroral with a 70 degrees Hopkins rod. Inclusion criteria were that laryngeal electromyography had to have been performed between 21 days and 6 months from the onset of symptoms and patients must have been followed a minimum of 6 months. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Vocal fold motion at 6 months from onset of symptoms. RESULTS Nine subjects (29%) had resolved vocal fold motion, whereas 22 (71%) had persistent vocal fold paralysis. By using our laryngeal electromyography paradigm, 4 of 6 patients with a laryngeal electromyography prognosis of excellent resolved. The predictive value for a negative test was 66.7%. For patients with a fair or poor prognosis, 5 of 25 resolved. The predictive value for a positive test was 80%. Only 8 of 22 patients with persistent vocal fold paralysis had fibrillations, and spontaneous activity was not significantly related to outcome. Patients with absent or greatly decreased motor unit recruitment had a significantly higher proportion of permanent vocal fold paralysis (P<.05). Stepwise forward logistic regression determined that prognosis by laryngeal electromyography and onset time were significant predictors of outcome (P<.01). The model predicted 44.4% of resolved cases, which represents a moderate prediction. CONCLUSIONS This study confirms the utility of laryngeal electromyography in assessing prognosis for recovery of vocal fold motion after laryngeal nerve injury. The results support our hypothesis that preset decision rules based on laryngeal electromyography data can be effectively used to determine a prognosis for recovery of vocal fold motion.

Home-based, upper-arm exercise training for patients with chronic obstructive pulmonary disease

Prior studies demonstrate the ability of upper extremity training to increase arm strength and endurance when incorporated into a pulmonary rehabilitation program. However, patients with severe chronic obstructive pulmonary disease (COPD) may have transportation or mobility problems that make it difficult to travel to a rehabilitation site to obtain this training. This pilot study was designed to determine whether a home-based, upper-arm exercise program could increase arm strength and endurance, and decrease perceptions of breathlessness and fatigue during five activities of daily living. Twenty patients with severe COPD (FEV1 0.80 +/- 0.42) were randomized to an experimental (n = 10) or control group (n = 10). The experimental-group training included three upper arm exercises five times a week for 8 weeks, with training level incremented during weekly home visits. Control-group subjects were contacted weekly to equalize attention from health care providers. During the upper-extremity endurance test for number of rings moved, no significant differences between groups were seen for interaction or treatment. However, there was a significant interaction between treatment and time for perceived fatigue (p = 0.0012), with the experimental group perceiving less fatigue during upper arm work than did the control group. No change was seen in perceived breathlessness. Findings of this study suggest that a home-based, upper-arm exercise program can reduce perceptions of fatigue for patients with severe COPD during activities involving upper arm work. Testing in a larger sample is indicated to determine whether this training can also improve ability to perform unsupported arm work.

Hypoalgesic effect of caffeine in experimental ischemic muscle contraction pain

It has been theorized that adenosine is a leading candidate for the metabolite responsible for ischemic muscle pain. The purpose of this study was to determine the effect of the non‐selective adenosine receptor antagonist, caffeine, on ischemic skeletal muscle contraction pain. Seven healthy adult volunteers with no history of pain disorders, systemic disease, or habitual caffeine use, were chosen for the two‐session, cross‐over, double‐blind study. Every subject received either 200 mg of caffeine (NoDoz ® , Bristol‐Myers) or identical placebo I hour before each of the two trials. Ischemia of the forearm was achieved by inflation of a blood pressure cuff to 250 mm Hg. Forearm muscle activity was generated by performance of wrist curls using a 5‐gram bar at a rate of 40 cycles per minute. Pain was rated at 15‐second intervals for I minute using a visual analog scale (0 to 10) with verbal descriptors. Significance was determined by univariate and multivariate analyses of variance and covariance including repeated measures. Pain ratings at 15 seconds in the caffeine trial were significantly lower (P<0.02) than those in the placebo trial. This effect continued at 30 seconds (P<0.05). However, by 45 seconds, pain in the caffeine trial was not significantly lower (P= ‐ 0.4) than that in the placebo trial. These results show that high‐dose caffeine exhibits considerable analgesic efficacy in experimental muscle pain, adding support for a role of adenosine in producing ischemic muscle contraction pain.

Quality of Life Assessment in Patients Undergoing Endovascular or Conventional AAA Repair

Purpose: To compare health-related quality of life outcomes in a cohort of abdominal aortic aneurysm (AAA) patients treated concurrently with either a conventional or endoluminal intervention. Methods: Between December 1997 and April 1999, 51 AAA patients treated by either open or endovascular techniques were enrolled in this prospective study. Conventional therapy was performed in 26 patients (19 men; mean age 70.4 ± 6.0 years) with anatomical features unsuitable for the endovascular approach. Twenty-five patients (23 men; mean age 70.7 ± 7.2 years) underwent endoluminal AAA exclusion using either the Ancure or bifurcated Enduring stent-grafts. The Medical Outcomes Study Short-Form 36-item health survey was administered preoperatively and at 1, 4, 8, and ≥52 weeks after discharge. Results: At 1 week, both groups showed significant reductions (p < 0.001) in mean scores compared to baseline in 4 dimensions (physical function, social function, role-physical, and vitality), but the decline was more pronounced in patients having open repair. Endoluminal patients returned to their baseline scores by the 4th postoperative week, whereas complete recovery to baseline in the conventional patients was delayed to the 8th week. Conclusions: Patients treated endoluminally exhibit better physical and functional scores as early as 1 week after discharge; they also return to baseline status significantly earlier than the conventional group. These findings document the perceived advantage of endovascular therapy over conventional AAA treatment.

Analysis of laryngeal framework surgery: 10-year follow-up to a national survey.

Laryngeal framework surgery, including medialization laryngoplasty (ML) and arytenoid adduction (AA), are common treatments for vocal fold paralysis and glottal incompetence. Little information is known about the incidence of ML/AA surgery nationwide, in particular the success and complication rates.