Voice

Prevalence, Characteristics and Impact of Dysphonia in US Marine Corps Drill Instructors Prior studies have evaluated various populations at increased risk of voice impairment. However, minimal data is available for military Drill Instructors, a population known to have significant vocal demands.

Adaptation and Validation of Vocal Fatigue Index (VFI) to Malayalam Language The purpose of the present study was to translate and validate the English version of the Vocal Fatigue Index (VFI) in to Malayalam language.

Perceptual Judgment of Voice Quality in Nondysphonic French Speakers: Effect of Task-, Speaker- and Listener-Related Variables Several perceptual scales have been developed to assess voice quality in dysphonic voices, among which the Grade Roughness Breathiness Asthenia Strain and a Rate of Dysphonia scale is probably the most frequently used. However, this clinical tool has not been properly validated with a normophonic population yet. The aim of the present study was to provide a first set of reference data gathered from a normal population, to serve as a basis of comparison for vocologists and laryngologists working with French-speaking patients.

Detection of Muscle Tension Dysphonia Using Eulerian Video Magnification: A Pilot Study To determine whether Eulerian Video Magnification software is useful in diagnosis of muscle tension dysphonia (MTD).

A Comparison of the s/z Ratio to Instrumental Aerodynamic Measures of Phonation The purpose of this study was to examine how the s/z ratio and instrumental measures of laryngeal valving and voicing efficiency.

Auditory-Perceptual Evaluation of Deep Brain Stimulation on Voice and Speech in Patients With Dystonia To determine the effects of globus pallidus interna (GPi) deep brain stimulation (DBS) on speech and voice quality of patients with primary, medically refractory dystonia.

Laryngeal and Pharyngeal Movements During Inner Singing: A Cross-Sectional Study Laryngeal and pharyngeal activity during inner singing is discussed in the context of vocal hygiene. Inner singing is defined as imagined singing, reading music silently, and listening to vocal music. When vocal rest is prescribed, doctors, speech therapists, and voice pedagogues recommend avoiding listening to music or reading music silently, since it is suggested that inner singing unconsciously influences the glottis, and thus moves the vocal folds involuntarily. The aim of this study was to compare the degree to which involuntary laryngeal and/or pharyngeal activity occur during inner singing, inner speech, and at rest, and to evaluate if current recommendations concerning vocal hygiene are still reasonable.

Electroglottography – An Update Electroglottography (EGG) is a low-cost, noninvasive technology for measuring changes of relative vocal fold contact area during laryngeal voice production. EGG was introduced about 60 years ago and has gone through a "golden era" of increased scientific attention in the late 1980s and early 90s. During that period, four eminent review papers were written. Here, an update to these reviews is given, recapitulating some earlier landmark contributions and documenting noteworthy developments during the past 25 years.

Effect of Functional Endoscopic Sinus Surgery on Voice and Speech Recognition Functional Endoscopic Sinus Surgery (FESS) is the surgery of choice for nasal polyposis and chronic rhinosinusitis. The aim of our study is to assess the influence of this surgery in the acoustic parameters of voice, and their implications in the systems of identification or verification of the speaker through the speech.

Pediatric Voice Handicap Index Profiles in Patients With Benign Vocal Fold Lesions Benign vocal fold lesions (BVFL), including nodules, polyps, and cysts, are the most common etiology of dysphonia in the pediatric population. Voice surveys, such as the Pediatric Voice Handicap Index (PVHI), have become instrumental in the evaluation and monitoring of pediatric patients with dysphonia; however the symptom profiles reported in surveys have not yet been well correlated to specific etiologies for dysphonia. In a retrospective chart review of 95 patients with PVHI surveys and laryngoscopic exams, we sought to correlate the PVHI results with findings of BVFL. TOC PDF (207 KB) Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Journal of Voice, Volume 33, Issue 2 DOI: https://doi.org/10.1016/S0892-1997(19)30046-3 © 2019 Elsevier Ltd. Published by Elsevier Inc. All rights reserved. Editorial Board PDF (58 KB) Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Journal of Voice, Volume 33, Issue 2 DOI: https://doi.org/10.1016/S0892-1997(19)30047-5 © 2019 Elsevier Ltd. Published by Elsevier Inc. All rights reserved. Calendar Listings PDF (26 KB) Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Journal of Voice, Volume 33, Issue 2 DOI: https://doi.org/10.1016/S0892-1997(19)30048-7 © 2019 Elsevier Ltd. Published by Elsevier Inc. All rights reserved. Calendar PDF (49 KB) Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Journal of Voice, Volume 33, Issue 2 DOI: https://doi.org/10.1016/S0892-1997(19)30071-2 © 2019 Elsevier Ltd. Published by Elsevier Inc. All rights reserved. Impact Factor and the Journal of Voice Full Text References PDF (40 KB) Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Robert T. Sataloff*,†,‡,§,*,Correspondence information about the author Robert T. SataloffEmail the author Robert T. Sataloff Journal of Voice, Volume 33, Issue 2 DOI: https://doi.org/10.1016/j.jvoice.2019.02.003 In late June of 2018, Clarivate Analytics, formerly Thomson Reuters, notified us that they had decided to "suppress" the Journal of Voice (JOV) from the 2017 Journal Citation Reports (JCR), hence disqualifying the journal from having its 2017 Journal Impact Factor (JIF) (https://clarivate.com/essays/impact-factor/) calculated and published as usual. Clarivate claimed they had calculated Journal of Voice's journal-level self-citations made in the 2017 JIF calculation window at 47%, which apparently resulted in a "distortion" of its ranking in the Otorhinolaryngology journal category. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Acoustic Analysis of Soccer Fans in Acute Phonotrauma After the Match Full Text Images References PDF (406 KB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Mehmet Ozgur Pinarbasli*,*,Correspondence information about the author Mehmet Ozgur PinarbasliEmail the author Mehmet Ozgur Pinarbasli ,  Ercan Kaya* ,  Erkan Ozudogru* ,  Melek Kezban Gurbuz* ,  Ertugrul Colak† ,  Mehmet Akif Aksoy* ,  Leman Birdane‡ ,  Fatma Ozgur Guney* Journal of Voice, Volume 33, Issue 2 Accepted: October 4, 2017; Published online: November 13, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.10.004 Summary Objectives Acute phonotrauma is the result of sound production by shouting or straining one's voice. In this study, we aimed to investigate the acute changes in the vocal folds and voices of soccer fans who voluntarily applied to our clinic after the soccer match where they engaged in acute phonotrauma. There are no other studies in the literature conducted on a similar sample group. Study design This is a case-control study. Methods Videolaryngostroboscopic (VLS) examination, acoustic voice analysis, and Voice Handicap Index (VHI) questionnaire were performed on 29 voluntary soccer fans included to the study before the match and at the first hour after the match. The values obtained were compared statistically with each other and with 29 control groups without voice pathology. Results The jitter, shimmer, and normalized noise energy values measured after the match increased significantly statistically compared with the pre-match level, but harmonic noise ratio value decreased significantly (P < 0.05). VHI scores increased significantly after the match according to the pre-match scores (P < 0.05). In the VLS examinations, there was no difference in the images before and after the match. Conclusions It has been concluded that people who are using their voices loudly and intensely by shouting during the match are exposed to sound changes after the match, and if this situation becomes persistent, it may cause permanent voice pathologies. It is thought that VHI and acoustic voice analysis should be done together with VLS for diagnosis and follow-up of voice changes for which the VLS examination alone is not sufficient. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Endoscopic and Phoniatric Evaluation in Singing Students Full Text Images References PDF (583 KB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (1) Request Permissions Order Reprints(100 minimum order) Andrea Nacci*,*,Correspondence information about the author Andrea NacciEmail the author Andrea Nacci ,  Giovanna Baracca† ,  Salvatore Osvaldo Romeo* ,  Maria Denise Cavaliere* ,  Maria Rosaria Barillari‡ ,  Stefano Berrettini*,§ ,  Francesco Ursino¶ ,  Bruno Fattori* Journal of Voice, Volume 33, Issue 2 Accepted: October 5, 2017; Published online: December 11, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.10.006 Summary Objectives In To analyze laryngostroboscopic findings and ENT/phoniatric examination results in a group of singing students and in a control group of non-singing subjects to emphasize the importance of ENT/phoniatric examination and of laryngostroboscopy before taking up singing. Methods 56 singing students and 60 healthy euphonic non-singer volunteers were recruited. In each subject a perceptual assessment and a self-assessment (VHI) of the voice were performed. The singing students filled out the Singing-VHI. All subjects underwent flexible fiberoptic endoscopy and laryngostroboscopy. All subjects were evaluated through the Reflux Symptom Index (RSI) and the Reflux Finding Score (RFS). Results At laryngostroboscopy, 60.7% of students presented pathological findings, versus 20% of controls (P < 0.0001). Incomplete glottic closure (35.7% vs. 13.3%), supraglottic hypertonus (16.1% vs. 5%), organic lesions (bilateral nodules, cysts, sulcus vergeture) (17.9% vs. 3.3%), posterior erythema (16.1% vs. 5%) and laryngeal edema (14.3% vs 3.3%) were more frequent in the students. The most common symptoms in singers were phonasthenia (37.5 % vs 6.7%; P =  0.0001) and mucus sensation (17.9% vs. 5%, P = 0.03). S-VHI showed higher values in students with pathological laryngostroboscopy (P < 0.0001). Finally, average RSI and RFS were higher in students. Conclusions Due to the high percentage of organic and functional voice disorders in singing students, it would be desirable that every subject who is going to start singing underwent an ENT/phoniatric investigation with videostrobolaryngoscopy to ascertain vocal folds healthy condition. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Comparing Videostroboscopy and Direct Microlaryngoscopy: An Argument for Flexible Consent and Operative Plan Full Text Images References PDF (503 KB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (1) Request Permissions Order Reprints(100 minimum order) William Greg Young*,† ,  Liat Shama*,‡ ,  Brian Petty*,§ ,  Matthew R. Hoffman* ,  Seth H. Dailey*,*,Correspondence information about the author Seth H. DaileyEmail the author Seth H. Dailey Journal of Voice, Volume 33, Issue 2 Accepted: October 5, 2017; Published online: November 27, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.10.005 Summary Introduction Office-based evaluation of glottic lesions has progressed significantly, but there can still be discrepancies compared with direct microlaryngoscopy (DML) in the operating room. We performed a prospective evaluation comparing diagnosis of epithelial and lamina propria glottic lesions on rigid telescopic strobovideolaryngoscopy (RTS) with DML. Methods Fifty subjects were enrolled and underwent RTS followed by DML. We compared presence and extent (unilateral or bilateral) of lamina propria and epithelial lesions. Primary (diagnoses motivating an operation) and secondary (diagnoses not requiring an operation) were considered. Changes in diagnosis and operative plan based on DML findings were evaluated. Results Sixty-eight lesions were identified on RTS, including 53 primary (15 epithelial, 38 lamina propria) and 15 secondary diagnoses. RTS was accurate in only 36% of subjects. Ten subjects had a different primary pathology identified on DML. A change in surgical management occurred in 16% of subjects. Conclusions This is the first prospective study evaluating how both diagnosis and operative plan for epithelial and lamina propria glottic lesions differ based on RTS and DML. Despite significant advances in office-based diagnosis of glottic lesions, there are still notable limitations. Clinicians should consider these findings when counseling patients on interpretation and plan for findings based on RTS. Obtaining a flexible surgical consent and counseling patients on the potential for new diagnoses and interventions based on DML is warranted. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Association Between Pepsin in the Saliva and the Subjective Symptoms in Patients With Laryngopharyngeal Reflux Full Text References PDF (88 KB) Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (1) Request Permissions Order Reprints(100 minimum order) Ah Ra Jung* ,  Oh Eun Kwon* ,  Jung Min Park† ,  Sung Hwa Dong* ,  Su Young Jung† ,  Young Chan Lee*,† ,  Young-Gyu Eun*,†,*,Correspondence information about the author Young-Gyu EunEmail the author Young-Gyu Eun Journal of Voice, Volume 33, Issue 2 Accepted: October 18, 2017; Published online: November 24, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.10.015 Summary Objectives Our study was designed to further evaluate the relationships between the saliva pepsin level and the symptoms and quality of life of patients with laryngopharyngeal reflux (LPR). Study design A prospective cohort study without controls. Setting Tertiary teaching hospital. Subjects and methods We analyzed 50 patients diagnosed with LPR by 24-hour multichannel intraluminal impedance pH monitoring. All subjects were instructed to collect saliva samples upon waking in the morning. The saliva pepsin levels were analyzed using enzyme-linked immunosorbent assay. The Reflux Symptom Index, Reflux Finding Score, Laryngopharyngeal Reflux-Health-Related Quality of Life, and Short Form 36 survey were administered. Results The pepsin was detected in the saliva of 41 patients with LPR (17.15 ± 20.42 ng/mL). Nine patients did not have pepsin in the saliva. There were no significant associations between the pepsin level in the saliva and Reflux Symptom Index, Laryngopharyngeal Reflux-Health-Related Quality of Life, or Short Form 36 of patients with LPR. Conclusion The saliva pepsin level is not significantly correlated with LPR symptoms or quality of life in LPR patients. It may be true that there is no association between pepsin levels and LPR symptoms, but this lack of association does not prove the lack of pathophysiological effect. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Lipoid Proteinosis: A Rare Cause of Hoarseness Full Text Images References PDF (746 KB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Elke Loos*,† ,  Liliane Kerkhofs‡ ,  Griet Laureyns*,*,Correspondence information about the author Griet LaureynsEmail the author Griet Laureyns Journal of Voice, Volume 33, Issue 2 Accepted: May 26, 2017; Published online: October 29, 2018 DOI: https://doi.org/10.1016/j.jvoice.2017.05.024 Summary Lipoid proteinosis is a rare cause of voice problems. Hoarseness is often the first clinical manifestation of this disorder and can present years before any other symptom. Therefore, it is very important as an otorhinolaryngologist to be familiar with the main characteristics of this disease. We present a case report and a review of current literature to provide a concise overview of this frequently missed diagnosis. © 2019 Published by Elsevier Inc. Multidose Botulinum Toxin A for Intralaryngeal Injection: A Cost Analysis Full Text References PDF (68 KB) Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Mark R. Gilbert ,  VyVy N. Young ,  Libby J. Smith ,  Clark A. Rosen*,Correspondence information about the author Clark A. RosenEmail the author Clark A. Rosen University of Pittsburgh Voice Center, Division of Laryngology, Department of Otolaryngology, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania Journal of Voice, Volume 33, Issue 2 Accepted: November 6, 2017; Published online: January 04, 2018 DOI: https://doi.org/10.1016/j.jvoice.2017.11.004 Summary Objectives Botulinum toxin A (BtxA) injection is the mainstay treatment for laryngeal dystonias. BtxA product labeling states that reconstituted toxin should be used within 4 hours on a single patient despite several studies that have demonstrated multidose BtxA to be safe and effective. Many insurance carriers mandate the use of an outside pharmacy which necessitates a single-use approach. This study compares the cost savings of multidose BtxA for laryngeal dystonia compared to single-use. Study Design This is a retrospective review and projected cost savings analysis. Methods Records and billing information were reviewed for patients receiving BtxA for intralaryngeal injection at a single laryngology division in 2015. Inclusion criteria included CPT 64617 or J0585; exclusion criteria included CPT 64616. The price of BtxA 100 unit vial for calculation was $670. Results A total of 142 patients were seen for intralaryngeal BtxA injection resulting in 337 visits over 1 year. The average BtxA dose per visit was 2.86 units with an average of 3.06 procedure visits per year. The calculated cost of BtxA treatment using a single vial approach was found to be $2,050 per patient per year. If billed instead for $7/unit with 5 units wastage charge per visit, the yearly per patient charge is $168. Single vial-use of BtxA injection thus represents a 1,118% price increase versus multidose use. When estimated for yearly prevalence of spasmodic dysphonia, multidose BtxA use would save almost $100 million annually. Conclusions Multidose botulinum toxin A application utilizing per unit billing is significantly less expensive than per single-use vial billing and would save the health-care system significant amount of money without any sacrifice in safety or effectiveness. © 2019 Published by Elsevier Inc. Pin-up Glottoplasty: Feasibility Study of a Novel Approach Medializing or Lateralizing Immobile Vocal Folds Full Text Images References PDF (2 MB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Christina Pflug* ,  Almut Niessen*,*,Correspondence information about the author Almut NiessenEmail the author Almut Niessen ,  Frank Müller*,† ,  Clarissa Precht‡ ,  Julie C. Nienstedt* ,  Markus Hess*,† Journal of Voice, Volume 33, Issue 2 Accepted: October 11, 2017; Published online: November 24, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.10.010 Summary Principles in medializing and lateralizing vocal folds have not changed a lot within the last decades (Isshiki et al, 1974; Bruenings, 1911). We present a feasibility study for a completely new approach to perform medialization and lateralization of immobile vocal folds. The method was tested on 20 human larynges by inserting a 21G needle into the vocal fold, medializing (or, in other cases, lateralizing) the vocal cord and fixing the needle at the cricoid cartilage posteriorly. The anterior and posterior fixation points of the needle allow for a stable positioning of the needle, which we consider necessary in both cases of medialization or lateralization. The needle position was examined visually as well as three-dimensionally via cone beam computed tomography. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Evaluation of a Shorter Follow-up Time to Capture Benefit of a Trial Vocal Fold Augmentation Full Text Images References PDF (239 KB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Thomas L. Carroll, MD *,Correspondence information about the author MD Thomas L. CarrollEmail the author MD Thomas L. Carroll ,  Elizabeth Faudoa ,  Maxine Van Doren, MS, CCC-SLIP Department of Surgery, Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts Journal of Voice, Volume 33, Issue 2 Accepted: October 19, 2017; Published online: January 18, 2018 DOI: https://doi.org/10.1016/j.jvoice.2017.10.017 Summary Objective Trial vocal fold injection (TVFI) is employed diagnostically for patients with subtle glottic insufficiency to explore potential for improvement. Clinical experience demonstrates the time to and length of peak benefit of the TVFI is variable. Previous studies collected data 4 weeks or more after TVFI. The aim of this study was to compare subjectively successful and unsuccessful TVFI patient groups. It is hypothesized that patients with subjectively reported success will also have significant improvements in Voice Handicap Index-10 (VHI-10), phase closure percentage, and aerodynamic measures 2 weeks after trial augmentation. Methods/Design Subjects with glottic insufficiency were included in this retrospective review if they underwent office-based, per-oral vocal fold injection augmentation specifically for trial purposes. Patients were divided into "successful" and "unsuccessful" groups based on their subjective experience during the 2-week post-TVFI period. VHI-10, subjective report, phase closure evaluation using frame-by-frame analysis, and aerodynamic data were collected pre- and 2 weeks post-TVFI. Results Of the subjects, 15 of 23 (65%) reported a successful subjective improvement of their symptom, whereas 8 (35%) were unsuccessful (only partial improvement or no improvement). The number of subjects with an improvement in VHI-10 by 5 or more points was not significantly different between groups. The number of subjects that demonstrated complete, long phase closure was significantly higher in the successful group (P = 0.021). Conclusions The understanding of how to more precisely determine the success of TVFI remains incomplete. Subjective improvement of successful TVFI was captured with basic clinical questioning, yet the VHI-10 was unable to confidently demonstrate this reported success 2 weeks after TVFI. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Long-term Voice Outcome Following Radiation Versus Laser Microsurgery in Early Glottic Cancer Full Text References PDF (112 KB) Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (3) Request Permissions Order Reprints(100 minimum order) Yue Ma* ,  Rebecca Green† ,  Stephanie Pan* ,  Daniel McCabe* ,  Leanne Goldberg* ,  Peak Woo*,*,Correspondence information about the author Peak WooEmail the author Peak Woo Journal of Voice, Volume 33, Issue 2 Accepted: October 25, 2017; Published online: December 08, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.10.018 Summary Objectives Long-term voice outcome (LTVO) after radiation (XRT) or trans-oral laser microsurgery (TLM) is unclear. This study is a multi-modality analysis of LTVO following XRT or TLM in patients with early glottic cancer. We hypothesize that as compared with TLM, LTVO is worse in the XRT group because of progressive fibrosis in the glottic tissue Material and Methods One hundred and two patients with early glottic carcinoma (carcinoma in situ, T1, T2) were included. Multi-modality voice analyses were performed with self-perception using Voice Handicap Index-10, objective analysis using Analysis of Dysphonia in Speech and Voice Software (Cepstral Spectral Index of Dysphonia score for Consensus Auditory-Perceptual Evaluation of Voice sentences), and perceptual rating by two blinded speech language pathologists (GRBAS scale). Results Fifty-five patients received TLM (mean follow-up = 52 months) and 47 patients had XRT (mean follow-up = 65 months). There is no difference between the two groups in sex, age, stage, and follow-up time. Intraclass correlation coefficient between raters was high at 0.94. Controlling for age and stage, XRT increases total GRBAS score by 1.38 points (P = 0.006) and increases Cepstral Spectral Index of Dysphonia score by 13.7 points (P < 0.001) when compared with the TLM group. No significant differences were found in the Voice Handicap Index score between the XRT and the TLM groups. Conclusions This is the first multi-modality voice analysis to suggest TLM results in better LTVO than XRT in GRBAS score and objective voice analysis but not in self-perception. These differences may reflect the progressive effects of XRT on glottic tissue. A randomized controlled study is required to confirm our findings. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Exploring the Neural Bases of Primary Muscle Tension Dysphonia: A Case Study Using Functional Magnetic Resonance Imaging Full Text Images References PDF (1 MB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Nelson Roy*,*,Correspondence information about the author Nelson RoyEmail the author Nelson Roy ,  Maria Dietrich† ,  Michael Blomgren* ,  Amanda Heller* ,  Daniel R. Houtz‡ ,  James Lee§ Journal of Voice, Volume 33, Issue 2 Accepted: November 16, 2017; Published online: December 19, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.11.009 Summary Primary muscle tension dysphonia (pMTD) is a voice disorder that occurs in the absence of laryngeal pathology. Dysregulated activity of the paralaryngeal muscles is considered the proximal cause; however, the central origin of this aberrant laryngeal muscle activation is unclear. The Trait Theory (Roy and Bless, 2000a,b) proposed that specific personality traits can predispose one to laryngeal motor inhibition and pMTD, and this inhibition is mediated by a hyperactive "behavioral inhibition system (BIS)" composed of limbic system structures (and associated prefrontal connections). This case study used functional magnetic resonance imaging to detect brain activation changes associated with successful management of pMTD, thereby evaluating possible neural correlates of this poorly understood disorder. Method A 61-year-old woman with moderate-to-severe pMTD underwent functional magnetic resonance imaging scans before and immediately after successful treatment using manual circumlaryngeal techniques. Experimental stimuli were blocks of repeated vowel production and overt sentence reading. Results Significantly greater activation was observed pre- versus posttreatment in all regions of interest during sentence production, that is, periaqueductal gray, amygdala, hypothalamus, anterior cingulate cortex, hippocampus, dorsolateral prefrontal cortex, Brodmann area 10, and premotor and inferior sensorimotor cortex. Conclusions Our findings are compatible with overactivation of neural regions associated with the BIS (cingulate cortex, amygdala, hypothalamus, periaqueductal gray) and motor inhibition networks (eg, [pre-]supplementary motor area) along with the dorsolateral prefrontal cortex and medial prefrontal cortex. Heightened input from limbic regions combined with dysfunctional prefrontal regulation may interfere with laryngeal motor preparation, initiation, and execution thereby contributing to disordered voice in pMTD. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Voice Acoustic Analysis of Pediatric Vocal Nodule Patients Using Ratios Calculated With Biomedical Image Segmentation Full Text Images References PDF (1 MB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Nagihan Bilal*,*,Correspondence information about the author Nagihan BilalEmail the author Nagihan Bilal ,  Turab Selcuk† ,  Selman Sarica* ,  Ahmet Alkan† ,  İsrafil Orhan* ,  Adem Doganer‡ ,  Saime Sagiroglu* ,  Mehmet Akif Kılıc§ Journal of Voice, Volume 33, Issue 2 Accepted: November 16, 2017; Published online: December 19, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.11.010 Summary Objective The aim of this study was to determine nodules using newly developed software with a computer-assisted visual process technique for the calculation of size. The effects of the ratios of nodule base and width were evaluated with voice acoustic analysis. Methods A total of 72 patients with pediatric vocal nodule were evaluated. Nodules were marked with the ImageJ News program on photographs obtained from the video recordings in the videostroboscopic examination and classified according to the Shah et al scale. Segmentation was applied automatically. The ratios were taken as base of nodule/width and base of nodule/vocal cord. In the voice acoustic analysis, basic frequencies (mean F0), jitter (local %), shimmer (local %), and harmonicity (mean harmonics-to-noise [mean HNR]) were evaluated. Results A statistically significant negative correlation was determined between the mean F0 value and the nodule base/width ratio (P = 0.042, r = −0.240). A negative statistically significant relationship was determined between jitter (%) and vocal nodule base/width (P = 0.009, r = −0.305). A statistically significant positive correlation was determined between mean HNR and vocal nodule base/width (P = 0.034, r = 0.324). In discriminant analysis, correct classification of the Shah et al scale degrees of the classifying variables was 73.6%. Conclusion Through collaboration with the biomedical engineering department, the results of this study determined new ratios in patients with pediatric vocal nodule. In voice acoustic analysis, the mean F0 was more affected by the width of the nodule, mean HNR was affected by the length of the base of the nodule, and jitter (%) was affected by the width of the nodule. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. The Perception of Breathiness in the Voices of Pediatric Speakers Full Text Images References PDF (624 KB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Lisa M. Kopf* ,  Mark D. Skowronski† ,  Supraja Anand‡ ,  David A. Eddins‡,*,Correspondence information about the author David A. EddinsEmail the author David A. Eddins ,  Rahul Shrivastav§ Journal of Voice, Volume 33, Issue 2 Accepted: September 28, 2017; Published online: November 20, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.09.024 Summary Background The perception of pediatric voice quality has been investigated using clinical protocols developed for adult voices and acoustic analyses designed to identify important physical parameters associated with normal and dysphonic pediatric voices. Laboratory investigations of adult dysphonia have included sophisticated methods, including a psychoacoustic approach that involves a single-variable matching task (SVMT), characterized by high inter- and intra-listener reliability, and analyses that include bio-inspired models of auditory perception that have provided valuable information regarding adult voice quality. Objectives To establish the utility of a psychoacoustic approach to the investigation of voice quality perception in the context of pediatric voices? Methods Six listeners judged the breathiness of 20 synthetic vowel stimuli using an SVMT. To support comparisons with previous data, stimuli were modeled after four pediatric speakers and synthesized using Klatt with five parameter settings that influence the perception of breathiness. The population average breathiness judgments were modeled with acoustic measures of loudness ratio, pitch strength, and cepstral peak. Results Listeners reliably judged the perceived breathiness of pediatric voices, as with previous investigations of breathiness in adult dysphonic voices. Breathiness judgments were accurately modeled by loudness ratio (r2 = 0.93), pitch strength (r2 = 0.91), and cepstral peak (r2 = 0.82). Model accuracy was not affected significantly by including stimulus fundamental frequency and was slightly higher for pediatric than for adult voices. Conclusions The SVMT proved robust for pediatric voices spanning a wide range of breathiness. The data indicate that this is a promising approach for future investigation of pediatric voice quality. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. The Influence of Noise on the Vocal Dose in Women Full Text Images References PDF (898 KB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Alessandra Terra Vasconcelos Rabelo* ,  Juliana Nunes Santos† ,  Bárbara Oliveira Souza‡ ,  Ana Cristina Côrtes Gama‡,1,*,Correspondence information about the author Ana Cristina Côrtes GamaEmail the author Ana Cristina Côrtes Gama ,  Max de Castro Magalhães* Journal of Voice, Volume 33, Issue 2 Accepted: October 31, 2017; Published online: December 28, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.10.025 Summary Objective The objective of this study was to evaluate if noise interferes with the vocal dose in women without vocal complaints. Study design This is an experimental and comparative study. Methods Data were collected on 27 women between 22 and 50 years of age without vocal complaints in a university classroom. Speech-language pathology evaluation was performed employing auditory-perceptual analysis and a vocal symptom questionnaire. The acoustics of the classroom were evaluated via both observation of the characteristics of the room and the quantification of background noise and reverberation time. Two distinctive acoustic conditions were created for evaluations: condition 1, a room without acoustic treatment and without noise reproduction, and condition 2, a room without acoustic treatment with noise reproduction. Each participant was evaluated individually in both acoustic conditions. To obtain vocal dose data, a vocal dosimeter was used. Subjects were asked to perform two 10-minute readings, one in each acoustic condition. The order of conditions was randomized between subjects. Subjects were instructed to complete the reading tasks at the vocal intensity deemed appropriate to be heard by a listener in the back of the room. t Tests and the Wilcoxon test were employed to compare parameters across subjects and conditions. Results Fundamental frequency, vocal intensity, percentage of phonation, and cycle dose significantly increased in the background noise condition. Conclusion A positive relation between vocal dose and the presence of excessive noise in the environment was observed. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Effect of Auditory-Perceptual Training With Natural Voice Anchors on Vocal Quality Evaluation Full Text Images References PDF (402 KB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (1) Request Permissions Order Reprints(100 minimum order) Priscila Campos Martins dos Santos*,*,Correspondence information about the author Priscila Campos Martins dos SantosEmail the author Priscila Campos Martins dos Santos ,  Maurílio Nunes Vieira† ,  João Pedro Hallack Sansão‡ ,  Ana Cristina Côrtes Gama* Journal of Voice, Volume 33, Issue 2 Accepted: October 26, 2017; Published online: January 10, 2018 DOI: https://doi.org/10.1016/j.jvoice.2017.10.020 Summary Purpose To analyze the effects of auditory-perceptual training with anchor stimuli of natural voices on inter-rater agreement during the assessment of vocal quality. Study design This is a quantitative nature study. Methods An auditory-perceptual training site was developed consisting of Programming Interface A, an auditory training activity, and Programming Interface B, a control activity. Each interface had three stages: pre-training/pre-interval evaluation, training/interval, and post-training/post-interval evaluation. Two experienced evaluators classified 381 voices according to the GRBASI scale (G-grade, R-roughness, B-breathiness, A-asthenia, S-strain, I-instability). Voices were selected that received the same evaluation by both evaluators: 57 voices for evaluation and 56 for training were selected, with varying degrees of deviation across parameters. Fifteen inexperienced evaluators were then selected. In the pre-, post-training, pre-, and postinterval stages, evaluators listened to the voices and classified them via the GRBASI scale. In the stage interval evaluators read a text. In the stage training each parameter was trained separately. Evaluators analyzed the degrees of deviation of the GRBASI parameters based on anchor stimuli, and could only advance after correctly classifying the voices. To quantify inter-rater agreement and provide statistical analyses, the AC1 coefficient, confidence intervals, and percentage variation of agreement were employed. Results Except for the asthenia parameter, decreased agreement was observed in the control condition. Improved agreement was observed with auditory training, but this improvement did not achieve statistical significance. Conclusion Training with natural voice anchors suggest an increased inter-rater agreement during perceptual voice analysis, potentially indicating that new internal references were established. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. The Design and Assessment of a Multiparametric Model for the Dysphonia Severity Index for Persian-speaking Populations Full Text References PDF (117 KB) Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Akbar Darouie* ,  Mahshid Aghajanzadeh*,†,*,Correspondence information about the author Mahshid AghajanzadehEmail the author Mahshid Aghajanzadeh ,  Payman Dabirmoghaddam‡ ,  Abolfazl Salehi* ,  Mehdi Rahgozar§ Journal of Voice, Volume 33, Issue 2 Accepted: November 13, 2017; Published online: December 18, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.11.007 Summary Objectives In instrumental voice assessment, multiparametric models reflect the multidimensional nature of voice and are therefore better than models that reflect only a single dimension of voice. The Dysphonia Severity Index (DSI) is one of the most common multiparametric models. In voice assessment, race, language, and structural and physiological features affect the acoustic, aerodynamic, and voice range profile measures. Given these differences, this study was conducted to design and evaluate a multiparametric and objective model for assessing the severity of dysphonia in Persian-speaking populations. Material and Methods This study examined 300 participants with several types of dysphonia (104 women and 196 men) and 100 healthy individuals (63 women and 37 men). Five acoustic parameters, three aerodynamic parameters, and seven voice range profile parameters were measured for designing the model. Perceptual evaluation was performed using the grade, roughness, breathiness, asthenia, strain scale. The logistic regression analysis was used to determine the factors affecting the DSI and each component's coefficient. Results Of the 15 parameters assessed, shimmer, vital capacity, semitone range, and voice onset time of /pa/ remained in the model with their coefficients. This section presents the DSI model for the examined population. The discriminant analysis showed that this combination corresponds to 47.8 of the perceptual assessment: DSI = 0.289 (shimmer) + 0.0001 (VC) − 0.059 (STR) − 13.278 (VOT_Pa). Conclusion In this study, the DSI corresponded to the physiological, linguistic, and racial characteristics of the Persian-speaking population with or without voice disorder. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Development and Validation of the Voice Catastrophization Index Full Text Images References PDF (396 KB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (2) Request Permissions Order Reprints(100 minimum order) Hagit Shoffel-Havakuk* ,  Steven Chau† ,  Edie R. Hapner* ,  Madeleine Pethan‡ ,  Michael M. Johns III*,*,Correspondence information about the author Michael M. JohnsEmail the author Michael M. Johns Journal of Voice, Volume 33, Issue 2 Accepted: September 29, 2017; Published online: November 10, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.09.026 Summary Introduction Catastrophization is a cognitive distortion that has been studied in pain patients and found to be a significant factor in their disability and response to treatment. Dysphonia patients may demonstrate a similar behavior, suggesting the existence of voice catastrophization. Objective To establish the validity of the Voice Catastrophization Index (VCI), a new instrument estimating voice symptoms catastrophization. Methods A prospective study. Patients with and without voice conditions were administered with the VCI, Voice-Related Quality of Life (V-RQOL), and the Generalized Anxiety Disorder-7 (GAD-7)questionnaires. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) rating was determined for patients with voice conditions. Results Ninety-one patients participated, 65 with voice conditions and 26 without. 61.5% were females; mean age was 49.8 ± 15.7 years. The VCI score for patients with voice conditions was significantly higher, 22.46 ± 16.56, compared with 3.96 ± 10.79, respectively (P value < 0.0001). The VCI demonstrated moderate correlation with both V-RQOL and GAD-7 scores: −0.562 and 0.560, respectively (P value < 0.000001); however, it showed no correlation with the CAPE-V. The VCI's internal consistency with each of its three dimensions and 13 items was acceptable to strong. The reproducibility and stability was demonstrated in a subgroup of 26 patients; 81% of these patients had a difference of 10 or less points between the two evaluations. Conclusions The VCI accomplished the requirements of a scale's validity for estimation of voice symptoms catastrophization in voice patients. The potential role of voice catastrophization as a predictor of treatment response and tailoring can now be investigated using the VCI. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Show and Tell: Video Modeling and Instruction Without Feedback Improves Performance but Is Not Sufficient for Retention of a Complex Voice Motor Skill Full Text Images References PDF (621 KB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Clarisse Look ,  Patricia McCabe ,  Robert Heard ,  Catherine J. Madill*,Correspondence information about the author Catherine J. MadillEmail the author Catherine J. Madill University of Sydney, Lidcombe, New South Wales, Australia Journal of Voice, Volume 33, Issue 2 Accepted: September 27, 2017; Published online: February 02, 2018 DOI: https://doi.org/10.1016/j.jvoice.2017.09.023 Summary Purpose Modeling and instruction are frequent components of both traditional and technology-assisted voice therapy. This study investigated the value of video modeling and instruction in the early acquisition and short-term retention of a complex voice task without external feedback. Method Thirty participants were randomized to two conditions and trained to produce a vocal siren over 40 trials. One group received a model and verbal instructions, the other group received a model only. Sirens were analyzed for phonation time, vocal intensity, cepstral peak prominence, peak-to-peak time, and root-mean-square error at five time points. Results The model and instruction group showed significant improvement on more outcome measures than the model-only group. There was an interaction effect for vocal intensity, which showed that instructions facilitated greater improvement when they were first introduced. However, neither group reproduced the model's siren performance across all parameters or retained the skill 1 day later. Conclusions Providing verbal instruction with a model appears more beneficial than providing a model only in the prepractice phase of acquiring a complex voice skill. Improved performance was observed; however, the higher level of performance was not retained after 40 trials in both conditions. Other prepractice variables may need to be considered. Findings have implications for traditional and technology-assisted voice therapy. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Clinical Features of Psychogenic Voice Disorder and the Efficiency of Voice Therapy and Psychological Evaluation Full Text References PDF (78 KB) Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Zahide Çiler Tezcaner*,Correspondence information about the author Zahide Çiler TezcanerEmail the author Zahide Çiler Tezcaner ,  Muhammed Fatih Gökmen ,  Sibel Yıldırım ,  Gürsel Dursun Department of Otorhinolaryngology, Medical School, Ankara University, Ankara, Turkey Journal of Voice, Volume 33, Issue 2 Accepted: September 26, 2017; Published online: November 06, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.09.022 Summary Objectives The aim of this study was to define the clinical features of psychogenic voice disorder (PVD) and explore the treatment efficiency of voice therapy and psychological evaluation. Method Fifty-eight patients who received treatment following the PVD diagnosis and had no organic or other functional voice disorders were assessed retrospectively based on laryngoscopic examinations and subjective and objective assessments. Epidemiological characteristics, accompanying organic and psychological disorders, preferred methods of treatment, and previous treatment outcomes were examined for each patient. A comparison was made based on voice disorders and responses to treatment between patients who received psychotherapy and patients who did not. Results Participants in this study comprised 58 patients, 10 male and 48 female. Voice therapy was applied in all patients, 54 (93.1%) of whom had improvement in their voice. Although all patients were advised to undergo psychological assessment, only 60.3% (35/58) of them underwent psychological assessment. No statistically significant difference was found between patients who did receive psychological support concerning their treatment responses and patients who did not. Relapse occurred in 14.7% (5/34) of the patients who applied for psychological assessment and in 50% (10/20) of those who did not. There was a statistically significant difference in relapse rates, which was higher among patients who did not receive psychological support (P < 0.005). Conclusion Voice therapy is an efficient treatment method for PVD. However, in the long-term follow-up, relapse of the disease is observed to be higher among patients who failed to follow up on the recommendation for psychological assessment. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Evaluation of the Supraglottic and Subglottic Activities Including Acoustic Assessment of the Opera-Chant Singers Full Text Images References PDF (910 KB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Emine Petekkaya*,*,Correspondence information about the author Emine PetekkayaEmail the author Emine PetekkayaEmail the author Emine Petekkaya ,  Ahmet Hilmi Yücel† ,  Özgür Sürmelioğlu‡ Journal of Voice, Volume 33, Issue 2 Accepted: October 30, 2017; Published online: December 28, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.10.023 Summary Opera and chant singers learn to effectively use aerodynamic components by breathing exercises during their education. Aerodynamic components, including subglottic air pressure and airflow, deteriorate in voice disorders. This study aimed to evaluate the changes in aerodynamic parameters and supraglottic structures of men and women with different vocal registers who are in an opera and chant education program. Vocal acoustic characteristics, aerodynamic components, and supraglottic structures were evaluated in 40 opera and chant art branch students. The majority of female students were sopranos, and the male students were baritone or tenor vocalists. The acoustic analyses revealed that the mean fundamental frequency was 152.33 Hz in the males and 218.77 Hz in the females. The estimated mean subglottal pressures were similar in females (14.99 cmH2O) and in males (14.48 cmH2O). Estimated mean airflow rates were also similar in both groups. The supraglottic structure compression analyses revealed partial anterior-posterior compressions in 2 tenors and 2 sopranos, and false vocal fold compression in 2 sopranos. Opera music is sung in high-pitched sounds. Attempts to sing high-pitched notes and frequently using register transitions overstrain the vocal structures. This intense muscular effort eventually traumatizes the vocal structures and causes supraglottic activity. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. F0 Characteristics of Newsreaders on Varied Emotional Texts in Tamil Language Full Text References PDF (109 KB) Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Nishanthi Gunasekaran* ,  Prakash Boominathan†,*,Correspondence information about the author Prakash BoominathanEmail the author Prakash Boominathan ,  Jayashree Seethapathy† Journal of Voice, Volume 33, Issue 2 Accepted: November 9, 2017; Published online: December 26, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.11.005 Summary Objective The objective of this study was to profile speaking F0 and its variations in newsreaders on varied emotional texts. Study design This study has a prospective, case-control study design. Methods Fifteen professional newsreaders and 15 non-newsreaders were the participants. The participants read the news bulletin that conveyed different emotions (shock, neutral, happy, and sad) in a habitual and "newsreading" voice. Speaking fundamental frequency (SFF) and F0 variations were extracted from 1620 tokens using Praat software (version 5.2.32) on the opening lines, headlines, news stories, and closing lines of each news item. Paired t test, independent t test, and Friedman test were used for statistical analysis. Results Both male and female newsreaders had significantly (P ≤ 0.05) higher SFFs and standard deviations (SDs) of SFF in newsreading voice than speaking voice. Female non-newsreaders demonstrated significantly higher SFF and SD of SFF in newsreading voice, whereas no significant differences were noticed in the frequency parameters for male non-newsreaders. No significant difference was noted in the frequency parameters of speaking and newsreading voice between male newsreaders and male non-newsreaders. A significant difference in the SD of SFF was noticed between female newsreaders and female non-newsreaders in newsreading voice. Female newsreaders had a higher frequency range in both speaking voice and newsreading voice when compared with non-newsreaders. Conclusions F0 characteristics and frequency range determine the amount of frequency changes exercised by newsreaders while reading bulletins. This information is highly pedagogic for training voices in this profession. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Long-term Average Speech Spectra of Postlingual Cochlear Implant Users Full Text Images References PDF (893 KB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Mustafa Yüksel*,Correspondence information about the author Mustafa YükselEmail the author Mustafa Yüksel ,  Bülent Gündüz Audiology, Marmara University, Fevzi Cakmak Mah., Pendik, Turkey Journal of Voice, Volume 33, Issue 2 Accepted: October 18, 2017; Published online: January 09, 2018 DOI: https://doi.org/10.1016/j.jvoice.2017.10.013 Summary Long term average speech spectra (LTASS) is a commonly used voice analysis method for different purposes. This method offers an acoustic representation of the language in daily conservations. Results of that method can be altered by the deteriorations in the auditory feedback loop. Hearing losses occurred in the post lingual stage of life have some serious negative effects on the auditory feedback loop. Cochlear implantation may help these patients with regards to auditory feedback loop. Therefore, we aimed to evaluate the LTASS of cochlear implant users whose have a post lingual hearing loss. We assessed the LTASS of 24 cochlear implant users and compared our findings with normal hearing subjects. Our findings revealed that cochlear implant users have similar LTASS findings with normal hearing subjects. We conclude that cochlear implantation helps to the recovery of auditory feedback loop in patients with post lingual hearing losses. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Popular and Classical Female Singers: Acoustic Comparison of Voice Use in the Song Melodia Sentimental (Sentimental Melody) by Heitor Villa-Lobos Full Text Images References PDF (3 MB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (1) Request Permissions Order Reprints(100 minimum order) Natalia Eugenia Sanchez Escamez ,  Ana Paula Guimarães Silva*,Correspondence information about the author Ana Paula Guimarães SilvaEmail the author Ana Paula Guimarães Silva ,  Marta Assumpção de Andrada e Silva Pontifical Catholic University of São Paulo, São Paulo, Brazil Journal of Voice, Volume 33, Issue 2 Accepted: November 9, 2017; Published online: December 29, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.11.006 Summary Objective This study aims to compare acoustic characteristics of classical and popular female singers' vocal performances in Heitor Villa-Lobos' Melodia Sentimental (Sentimental Melody). Method Long-term average spectrum acoustic analysis and long-term voice onset time (VOT) were performed for two consonants /d/ in the first six verses of Melodia Sentimental sang by 10 professional singers: five classical (GC) and five popular (GP). Results Classical singers presented prominence in the region of the frequencies between 2.5 and 3.5 kHz, not observed in the majority of the popular singers' group. The GC group showed lighter spectral decline curves and the numerical value of decline was also lower. Classical singers presented lower long-term voice onset time values, which indicates a longer period of glottic closure. Conclusion Acoustic analysis revealed that classical singers have more energy in glottic closure associated with a shorter duration of glottic coaptation. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. The Effect of a Voice Therapy Program Based on the Taxonomy of Vocal Therapy in Women with Behavioral Dysphonia Full Text Images References PDF (670 KB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (1) Request Permissions Order Reprints(100 minimum order) Vanessa Veis Ribeiro* ,  Amanda Gabriela de Oliveira* ,  Jhonatan da Silva Vitor* ,  Larissa Thais Donalonso Siqueira† ,  Pamela Aparecida Medeiros Moreira* ,  Alcione Ghedini Brasolotto* ,  Kelly Cristina Alves Silverio*,*,Correspondence information about the author Kelly Cristina Alves SilverioEmail the author Kelly Cristina Alves Silverio Journal of Voice, Volume 33, Issue 2 Accepted: October 26, 2017; Published online: January 18, 2018 DOI: https://doi.org/10.1016/j.jvoice.2017.10.019 Summary Objective This study aims to propose and analyze the effect of a voice therapy program (VTP) in women with behavioral dysphonia. Materials and Methods This is a controlled, blinded, and nonrandomized cohort study. Participants of this study were 22 women with behavioral dysphonia divided into two groups: G1, 11 women with behavioral dysphonia who received the VTP, and G2, 11 women with behavioral dysphonia who did not receive any intervention. Before and after 6 weeks, the outcome variables evaluated in both groups were auditory-perceptual evaluation of the global degree of vocal quality (vowel /a/ and counting), instrumental acoustic parameters, Voice-Related Quality of Life, vocal and larynx symptoms, and musculoskeletal pain. The statistical analysis used the Wilcoxon, chi-square, and Mann-Whitney tests (P < 0.05). Results After 6 weeks, we observed a significantly higher improvement in the general degree of vocal deviation in vowels, a reduced F0 and symptom of "fatigue while talking" in G1, and an increased "shoulder" pain intensity in G2. Both groups showed improvement in the socioemotional domain of Voice-Related Quality of Life. In addition, the comparison between the groups showed a significantly greater reduction in fundamental frequency and the "voice loss" symptom in G1 compared with G2. Conclusions The VTP using semioccluded vocal tract exercises obtained a positive effect on voice quality, symptoms, and musculoskeletal pain in women with behavioral dysphonia. The proposal, based on the taxonomy of voice therapy, seems to have promoted a phonatory balance, muscle relaxation, and improvement in the vocal resistance of this population. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. On Exploring Vocal Ornamentation in Byzantine Chant Full Text Images References Supplemental Materials PDF (1 MB) Download Images(.ppt)About Images & Usage Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Dimitrios S. Delviniotis*,Correspondence information about the author Dimitrios S. DelviniotisEmail the author Dimitrios S. Delviniotis ,  Sergios Theodoridis Department of Informatics and Telecommunications, University of Athens, Ilisia, Athens, Greece Journal of Voice, Volume 33, Issue 2 Accepted: October 18, 2017; Published online: December 05, 2017 DOI: https://doi.org/10.1016/j.jvoice.2017.10.016 Summary Objectives A special vocal ornament in Byzantine chant (BC), the single cycle ornamentation structure (SCOS), is defined and compared with the vibrato with respect to its time (rate, extent) and spectral (slope [SS], relative speaker's formant [SPF] level, formant frequencies [Fi] and bandwidths [Bi], and noise-to-harmonics ratio [NHR]) characteristics. Study Design This is a comparative study between the vocal ornaments of SCOS and vibrato, of which time and spectral acoustic parameters were measured, statistically analyzed, and compared. Methods From the same hymn recordings chanted by four chanters, the SS, SPF level, FFi, FBi, and NHR difference values between the vocal ornament and its neighbor steady note, and the rate and extent, were compared with those of vibrato. Results The mean extent values for SCOS were found to be almost double the corresponding values for vibrato, and the rate of SCOS tends to be different from the rate of vibrato. The difference values of: 1) the NHR, 2) the spectral slope, and 3) the SPF level, between the vocal ornament and its neighbor steady note were found to be: 1) higher for SCOS, 2) mainly lower for SCOS, and 3) lower for SCOS, respectively. No significant differences were detected for the FFi and FBi. The FF1 differences tend to be negative in both ornaments indicating a formant tuning effect. Conclusions A new vocal ornament (SCOS) in BC is studied, of which the extent, NHR (HNR), the spectral slope, and the SPF level are different compared to those of vibrato. © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. Instructions for Contributors PDF (69 KB) Email Article Add to My Reading List Export Citation Create Citation Alert Cited by in Scopus (0) Request Permissions Order Reprints(100 minimum order) Journal of Voice, Volume 33, Issue 2 DOI: https://doi.org/10.1016/S0892-1997(19)30049-9 © 2019 Elsevier Ltd. Published by Elsevier Inc. All rights reserved.

Nephrology and Transplantation

Plasminogen activator inhibitor-1 gene polymorphisms in systemic lupus erythematosus: is there a risk for lupus nephritis among Egyptians? Ahmed A Eldeeb, Alaa Sabry, Elshahat A Yousef, Rasha Mahmoud, Ahmed B Ibrahim, Wael Alkhiary Journal of The Egyptian Society of Nephrology and Transplantation 2019 19(1):1-7 Background Systemic lupus erythematosus (SLE) is a systemic autoimmune disease characterized by immune complexes formation and body organs damage. Recently, plasminogen activator inhibitor-1 (PAI-1) has been proposed recently to modulate the immune response. Aim of the study To elucidate whether there is possible role of two genetic polymorphisms in the PAI-1 gene: −675 4G/5G and HindIII C>G in lupus nephritis (LN) disease in Egyptian patients. Patients and methods Using PCR-restriction fragment length polymorphism, we genotyped 170 Egyptian patients with SLE; 80 fulfill the American College of Rheumatology criteria of LN and 90 SLE patients without LN for two polymorphisms of PAI-1 gene: −675 4G/5G and HindIII C>G. Results The 4G4G genotype, 4G allele of PAI 4G/5G polymorphism, and the G allele of the PAI-1 HindIII C>G polymorphism, all exhibited significant risks for proliferative LN [odds ratio (OR)=2.55; 95% confidence interval (CI): 1.02–21.11; P=0.022); (OR=2.43; 95% CI: 1.18–5.01; P=0.015); (OR=2.37; 95% CI: 1.01–5.58; P=0.045), respectively]. Moreover, PAI-1 4G/5G polymorphism was related to the chronicity index for LN (P<0.001), while PAI-1 HindIII C>G polymorphism was associated with the activity (P=0.016) and the chronicity (P<0.001) indices of LN in SLE patients. Conclusion Egyptian patients with SLE with a polymorphism for −675 4G/5G and HindIII C>G of PAI-1 gene might have a higher susceptibility for the development of proliferative LN.

Analysis of different treatments and their outcomes in idiopathic membranous nephropathy: a single-center observational study Avinash Rao, Abhijit Konnur, Umapati Hegde, Milind Dakate Journal of The Egyptian Society of Nephrology and Transplantation 2019 19(1):8-12 Background Although there are multiple treatment modalities for idiopathic membranous nephropathy (IMN) which have been studied in different streams of populations, there is no single convincing answer for the best accepted modality. In the study presented, we have made an effort to compare the different treatment regimens and analyze the results obtained. Patients and methods This was a retrospective observational study. A total number of 54 patients with idiopathic membranous nephropathy were included in the study. Five different treatment groups were made, which included modified Ponticelli regime, oral cyclophosphamide, oral mycophenolate mofetil, oral tacrolimus, and intravenous rituximab therapy, and were followed up for 1 year. Urine protein to creatinine ratio, serum albumin, creatinine, and estimated glomerular filtration rate were noted at 1, 3, 6, 9, and 12 months. Results Among the 54 patients, 10 of 16 patients in modified Ponticelli group, 9 of 18 in oral cyclophosphamide group, 4 of 9 in oral mycophenolate mofetil group, 3 of 6 in oral tacrolimus group, and 3 of 5 in intravenous rituximab group achieved remission. There was statistically significant improvement in renal function in modified Ponticelli group (P=0.02) and oral cyclophosphamide group (P=0.01) as compared with the other groups. Conclusion Patients who received modified Ponticelli regime had superior outcomes in terms of improvement in renal function and renal survival as compared with other different therapies. Large studies with long-term follow ups are needed to support the outcome.

Serum hepcidin levels and erythropoietin resistance in hemodialysis patients Walid M Afifi, Ezzat Mostafa, Mohamed Elsaid, Ghada Elakad, Huda F Ebian Journal of The Egyptian Society of Nephrology and Transplantation 2019 19(1):13-18 Introduction Erythropoietin (EPO) resistance is an important cause of anemia in patients with chronic kidney disease. Enhancement of erythropoiesis by EPO requires intact EPO signaling and effective mobilization of iron stores. Enhanced synthesis of hepcidin leads to reduction of iron absorption in the small intestine and sequestering of iron in macrophages. Hepcidin may contribute to EPO resistance through a direct inhibitory effect on erythroid progenitor proliferation and survival. Objective To assess serum hepcidin levels in patients undergoing hemodialysis (HD) treatment and to distinguish its analogous association with anemia parameters and EPO resistance. Patients and methods A cross-sectional study was carried out among HD patients at Nephrology Unit of the Zagazig University Hospital from 2017 to 2018. The study included 90 participants, meeting our inclusion criteria, who had end stage renal disease (ESRD) and were on regular HD three times weekly. All patients were subjected to full history taking and clinical and laboratory assessment. It included routine investigations, with complete blood picture, calcium, phosphorus, parathyroid hormone (PTH), lipid profile, iron panel, and c reactive peptide (CRP). Specific investigations included the EPO resistance index and serum hepcidin measurement. Results Hepcidin is positively related to EPO resistance index. EPO resistance index as well as ferritin were significant determinants of hepcidin in HD patients. Conclusion Hepcidin is associated with anemia, iron status, and microinflammation in HD patients. If used as a diagnostic tool, it might improve iron therapy during periods of reticuloendothelial blockage of iron transport. This is important to avoid iron overload and to improve EPO response in patients with ESRD.

Regulatory T-cells dysregulation in type 2 diabetic nephropathy Walaa H.M Ibrahim, Mostafa G Aly, Ahmad B Ahmad, Noha G Sayed, Heba S Galal, Muhammad H Al-Maghraby Journal of The Egyptian Society of Nephrology and Transplantation 2019 19(1):19-23 Background An immune-mediated process has been postulated to be involved in the pathogenesis of diabetic nephropathy (DN). Regulatory T-cells (Tregs) mediate self-tolerance and allogeneic tolerance and alteration in its expression was supposed to mediate the development of type 2 DN. We are interested in studying the expression of Treg cells in type 2 DN patients. Patients and methods We conducted a cross-sectional study carried out on 25 type 2 DN patients and 23 nondiabetic control patients. Demographic data were recorded in predefined data sheets. Blood samples for laboratory variables were collected and measured using the standard methods. Flow cytometry analysis was used to assess the phenotype and function of Treg cells from blood samples. Results In the current study, DN patients had a statistically significant higher Treg expression (P=0.038). There were insignificant associations between Treg cells and both proteinuria and duration of diabetes mellitus (P>0.05). Although univariate analysis showed that absolute Treg cell count and duration of diabetes were independent predictors of estimated glomerular filtration rate (P=0.028, 0.039, respectively), multivariate analysis showed that only the absolute Treg cell count was an independent predictor of estimated glomerular filtration rate with a just borderline statistical significance (P=0.048). Conclusion The current study did not support the immunological base of DN and we recommend testing the expression of other T-cell subtypes and cytokines in type 2 DN patients to be more confident about this thinking.

Practical approach to urine leak after kidney transplant Ravi Mohanka, Lokesh Sinha, Jitendra Jagtap, Ajay Sharma, Ahmed Halawa Journal of The Egyptian Society of Nephrology and Transplantation 2019 19(1):24-29 Urological complications can cause significant morbidity after kidney transplant but can be prevented by following well-known good surgical principles and techniques. The key is early identification and appropriate intervention. This article discusses clinical presentation, investigations, and principles of management of a urine leak after kidney transplant on the background of a clinical case. The presence of a ureteric catheter, double J ureteric anastomotic stent, vascularity of transplanted ureter, and bladder capacity is critical for differential diagnosis, choice of investigation, and management of ureteral leak. The given case demonstrates an early extraperitoneal high-volume urinary leak. Additional information about the surgery, graft quality, and postoperative clinical course may help in differential diagnosis. Drain fluid creatinine and potassium analysis compared with serum can confirm the leak, whereas radiological imaging can localize it. Depending on the cause and site of leak identified, a conservative management approach using maximal decompression or surgical repair or reconstruction may be appropriate.

Cancer Research and Therapeutics

Computed tomography-guided percutaneous microwave ablation: A new weapon to treat ground-glass opacity–lung adenocarcinoma Yancu Hertzanu, Xin Ye Journal of Cancer Research and Therapeutics 2019 15(2):265-266

Programmed cell death protein-1 inhibitor for the treatment of hepatocellular carcinoma: "A sharp sword" Xin Li, Ping Liang, Xin Ye Journal of Cancer Research and Therapeutics 2019 15(2):267-268

Translational epidemiology: The powerful tool for precision cancer medicine Zhenming Fu, Rui Zhang, Ping Li, Mingfang Jia Journal of Cancer Research and Therapeutics 2019 15(2):269-271 Although this is an exciting time for translational medicine, systematic approaches and strategies to conduct translational research are sparse. We highlight in this editorial the opportunities to collaborate across disciplines and to forge new interdisciplinary collaborative ventures from the perspective of epidemiology. We specifically outline some feasible research areas, wherein Translational Epidemiology may readily speed up the translation of research for Precision Medicine.

Targeting the canonical Wnt/β-catenin pathway in cancer radioresistance: Updates on the molecular mechanisms Yu Yang, Huandi Zhou, Ge Zhang, Xiaoying Xue Journal of Cancer Research and Therapeutics 2019 15(2):272-277 Radiation resistance is an important factor that affects the efficacy of radiotherapy; it could even lead to its failure. In recent years, the relationship between the classical Wnt signaling pathway and radiation resistance has gradually attracted attention from scholars. Although most of the findings are comprehensive, they are fragmented and disorganized. This review explores the relationship between classical Wnt signaling pathways and cancer radiation resistance. Previous literature regarding the classical Wnt signaling pathways and cancer radiation resistance from the past decades had been summarized in this article. Moreover, the molecular mechanisms and functions of the canonical Wnt signaling pathway involved in the formation of radioresistance were systemically analyzed and sorted out. Certain rules and internal relationships among different pathways have been further clarified; this is expected to provide valuable clues for further research. The Wnt/β-catenin pathway is closely associated with the formation of cancer radioresistance, which may be a target for improving the effects of radiotherapy.

Role of miRNA in transformation from normal tissue to colorectal adenoma and cancer Guangkuo Liu, Bingqing Li Journal of Cancer Research and Therapeutics 2019 15(2):278-285 Although many modalities can be used to prolong the remission of colorectal cancer (CRC), early diagnosis is essential to improve the therapeutic outcomes. The conventional ways of diagnosing and monitoring the progresses from adenoma to CRC are colonoscopy and fecal occult blood test (FOBT). However, colonoscopy is expensive and invasive; while the FOBT is not sensitive. miRNAs may be a new modality to monitor the transition from adenoma to CRC. We reviewed publications of miRNA profile differences from colorectal normal mucosa (NM) to adenoma, and to CRC and tried to find the roles of miRNA in these transitions. This review also highlighted the possibility of serum miRNAs as markers for monitoring these transitions. The miRNA profiles are different from normal colorectal mucosa to adenoma and to CRC. The miRNAs may have pro- or anti-CRC effects through oncogenes such as c-Met and KRAS. Others may interfere with the immune system. More interestingly, some miRNAs are continuously increased from NM to adenoma and to CRC; others, such as miRNA-30b, are consequently decreased. The literature shows that miRNAs are involved in the whole process of the colorectal carcinogenesis. The miRNAs may be the biomarkers in monitoring the transition from adenoma to CRC.

Experimental study in vivo ablation of swine pancreas using high-intensity focused ultrasound Guanghui Huang, Xin Ye, Xia Yang, Aimin Zheng, Wenhong Li, Jiao Wang, Xiaoying Han, Zhigang Wei, Min Meng, Yang Ni, Chengkun Qin, Xingbo Fei, Liulin Xiong Journal of Cancer Research and Therapeutics 2019 15(2):286-290 Objective: The objective of this study is to evaluate the feasibility and safety of high-intensity focused ultrasound (HIFU) for ablation of swine pancreas and to detect the pathological variations in pancreas damage. Materials and Methods: (a) Eight swine were involved and randomly divided into two groups (Group A and B). HIFU was applied on swine in both groups for in vivo ablation of pancreas. The animals were anesthetized, and the artificial acoustic window was built. Then, the irradiation of FEP-BY02 type HIFU on pancreas was applied. (b) Swine in Group A were euthanized immediately after treating with HIFU to examine variations in pancreas. The biochemical evidence of pancreatitis was evaluated by blood samples collected from swine in Group B before and after HIFU. Then, the pancreas of swine in Group B was euthanized on day 5 after treatment to examine the pancreas. All specimens were visually inspected for both ultrasonic focal damage region (UFDR) and pathological routine by a skilled pathologist. Results: (a) The vital signs of all animals were stable during HIFU treatment and recovered well after treatment. (b) UFDR were observed in all HIFU irradiation region of the specimens, without significant size difference between the two groups. The coagulation nucleus pyknosis, cytochylema vacuolation, and nucleus membrane disruption were observed after HIFU in both groups. Membranous structure dissolution and inflammatory cell infiltration were also found after HIFU in swine of Group B. (c) There was no significant difference in the levels of blood amylase in swine of Group B before and after HIFU treatment. Conclusions: It was feasible and safe to use HIFU for ablation of the pancreas in swine.

Precision dose measurement of 125I seed in solid water through SPECT/CT detecting Hongtao Zhang, Yansong Liang, Gang Qiu, Zeyang Wang, Devjoy Dev, Zezhou Liu, Huijuan Li, Huimin Yu, Jingshi Chen, Aixia Sui, Juan Wang, Gaofeng Shi Journal of Cancer Research and Therapeutics 2019 15(2):291-297 Purpose: The aim of the study is to study the feasibility of gamma-ray-detection-based precision dose measurement of 125I seed brachytherapy in solid water. Materials and Methods: Seven group 125I seeds with different activities were put into a hole in the center of solid water individually. Each group had ten seeds, and the seed activity ranged from 1.48 × 107 Bq to 3.7 × 107 Bq. Single-photon emission computed tomography/computed tomography (SPECT/CT) was used to scan the seeds perpendicular to the long axis of the seed, with a slice thickness of 3.75 mm. The radioactive count values (x) of the radioactive concentration around the seeds were collected at a distance of 1–15 mm from the center of the seeds, while the corresponding doses (Y) (Gy) were calculated. SPSS 18.0 was used to analyze the relationship between the count value and the dose. Results: With the same seed activity, the count values became smaller according to the distance from the center of the seeds. The count values at the same point had an increasing trend according to the activity. This is similar to the doses calculated at the same point. There was an exponential relationship between the dose around the 125I seeds, and the radioactive count value detected by SPECT/CT. Correlative curves between the dose and radioactive count value detected by SPECT/CT of different-activity 125I seeds were fitted. The formulas of the dose and radioactive count with different seed activity were in the form of Y = b0 (b1)x. The constant b0 ranged from 1.48 to 3.93, according to the seed activity, while b1 was 1.006 for every seed's activity. Conclusion: The count value around the 125I seed can be detected accurately by SPECT/CT, and then can be quantified. This study provided useful experiment data for the precision measurement of 125I seed implantation. Radiation detection-based dose measurement may become a new noninvasive technology for the dynamic dosimetry verification method after brachytherapy.

Prospective and prognostic factors for hepatic metastasis of gastric carcinoma: A retrospective analysis Jin Cheng Song, Xiao Lei Ding, Yang Zhang, Xian Zhang, Xiu Hua Sun Journal of Cancer Research and Therapeutics 2019 15(2):298-304 Aims: The aim of the study was to prospectively explore the prognostic factor for gastric cancer with liver metastasis (GCLM), since no prognostic factor was reported to be consistently significant across studies. Patients and Methods: One hundred and five patients with GCLM treated at our center between January 1, 2010, and March 31, 2016, were included and their clinical data were retrospectively analyzed. The univariate analyses were first applied for identify the potential independent prognostic and predictive factors for liver metastasis. These factors were further evaluated with Cox proportional-hazard regression model testing. Finally, survival curves were estimated. Results: The Eastern Cooperative Oncology Group (ECOG) score, number of other distant metastases, levels of cancer antigen (CA), and carcinoembryonic antigen (CEA) were independent prognostic factors (adjusted relative risk [RR]: 1.362–2.887; P = 0.000–0.027). The survival of patients who received radical gastrectomy would be associated with the ECOG score, staging (T stage and N stage), CA 19-9, and CEA levels (RR: 2.169–3.787; P = 0.000–0.027). Patients with following indicators 1 month postoperatively were prone to liver metastasis after radical gastrectomy (median, 6.9–12.03 months; P = 0.007–0.042): Venous/lymphatic invasion, pathological Stage IV (especially combined with T4 stage), intestinal Lauren type, and combined elevation of CEA and CA 19-9 levels. Conclusions: The therapy design for patients with GCLM should consider the general conditions and personal clinicopathological characters of patients. After balancing the benefit and risk factors, multidisciplinary treatment and individual treatment should be developed based on evidence-based medicine model for each patient.

Transcatheter arterial chemoembolization experience for advanced hepatocellular carcinoma with right atrial tumor thrombus Linzhong Zhu, Renjie Yang, Xu Zhu Journal of Cancer Research and Therapeutics 2019 15(2):305-311 Background: Hepatocellular carcinoma (HCC) with tumor thrombus extending to the inferior vena cava (IVC) and right atrium (RA) is rare, which is generally associated with serial syndromes and poor prognosis. The results of earlier observations revealed that the median survival was 1–5 months after diagnosis for untreated patients. The prognosis was poor with surgery, radiotherapy, transarterial chemoembolization (TACE), and chemotherapy. Methods: A total of 1850 patients received TACE for advanced HCC at our institution from October 2011 to September 2016. Among them, 18 cases presented tumor thrombus extended from hepatic vein to IVC and RA. TACE was performed to deal with the tumor thrombus inside the RA, and angiography was performed for characterizing. The successful rate, survival, safety, and clinical adverse events were retrospectively studied. Results: A total of 56 interventional procedures were conducted for the 18 cases of tumor thrombus extending to IVC and RA. TACE were successfully performed in all patients without significant complications. One case died of pneumonia, and no severe adverse effect was observed in the other 17 cases. The 1- and 3-year overall survival rates were 50% and 16.7%, respectively. The average survival from diagnosis of right atrial tumor thrombus (RATT) was 15.2 months. The blood supply was rich for all RATT. There were seven cases with single-feeding artery and 11 cases with two or three feeding arteries that originated from intra- or extra-hepatic arteries. The extrahepatic artery played a critical role in the blood supply of RATT, including right inferior phrenic artery (8/18), left inferior phrenic artery (1/18), and the left gastric artery (2/18). Conclusion: For HCC with tumor thrombus in the IVC and RA, TACE could safely improve the prognosis of these patients. Searching for multiple feeding arteries are essential for ensuring efficacy. In addition, careful examination and appropriate embolization technique are essential for safety and efficacy. Lipiodol was a safe and ideal agent for the embolization in RATT.

Nimotuzumab plus chemotherapy with docetaxel, cisplatin, 5-fluorouracil for locally advanced head and neck squamous cell carcinoma: A clinical study Xing Wang, Jianmin Gu, Cuiling Shao, Kun Han, Jian Meng Journal of Cancer Research and Therapeutics 2019 15(2):312-316 Background: A clinical study was conducted to determine the efficacy of nimotuzumab combined with docetaxel, cisplatin, and 5-fluorouracil (TPF) for patients with locally advanced head and neck squamous cell carcinoma (HNSCC) after surgery and conformal radiotherapy. Methods: Thirty-one HNSCC patients received three courses of chemotherapy every 21 days, at a dose of 75 mg/m2 of docetaxel and cisplatin on day 1 and 750 mg/m2 of 5-fluorouracil on days 1–5 followed by 200 mg/m2/week of nimotuzumab on week 1–2 (day 6–21). Results: After sequential therapy, complete and partial responses were observed in 10 (32.3%) and 17 (54.8%) patients, respectively. The overall response rate was 87.1%. A progression-free survival of 71.2% (95% confidence interval [CI] 51.6%–93.7%) and an overall survival of 78.3% (95% CI 58.9%–89.5%) were achieved at 2nd year. The most common Grade 3–4 toxicities during the complete treatment were lymphopenia (25.8%), neutropenia (22.6%), anemia (12.9%), and diarrhea (16%). In addition, no rash and treatment-related death occurred during this study. Conclusions: Nimotuzumab in combination with TPF has been well tolerated as a treatment program for locally advanced HNSCC.

Nursing and Midwifery Sciences

Comparison the effect of multimedia and peer training methods on the anxiety of Trans Esophagus Echocardiography candidate Zahra Ranjbar Katie Lateh, Hedayat Jafari, Reza Ali Mohammadpour, Rozita Jalalian, Akbar Nikpajouh, Ravanbakhsh Esmaeili Journal of Nursing and Midwifery Sciences 2019 6(1):1-7 Context: Transesophageal echocardiography (TEE) is an invasive method that causes anxiety. Studies have shown that education is effective in reducing anxiety. Aims: This study aimed to compare the effect of two educational methods of multimedia and peer training on the anxiety of patients who are candidates for TEE. Setting and Design: This study was a randomized controlled clinical trial conducted in 2018 Mazandaran Heart Center, Sari. Materials and Methods: 46 Patient seeking TEE (16 in the multimedia group(ME), 16 in the peer group(PE) and 14 in the control group) and randomly divided into three groups. The data collection tool was personal information form and the Spielberger State Anxiety Inventory. All groups received routine training. In addition,one intervention group, received PE and another intervention group received ME. Statistical Analysis Used: Data were analyzed using SPSS 25. The significance level was considered below 0.05. Results: There was no significant difference between groups in terms of personal and medical characteristics. The mean of anxiety scores before training was 44.6± 2.2, 46.18± 2.7, 46.5± 2 in the peer group, multimedia and control group (P = 0.826). The mean of anxiety scores in the peer group, multimedia and control group after intervention was 42.2 ± 3.3, 41.6 ± 2.6, and 47 ± 7 (P = 0.354). This difference was not statistically significant. Conclusions: Both PE and ME groups decreased anxiety in patients with TEE. But it was not statistically and the use of these techniques required more studies.

Effectiveness of cognitive behavioral counseling-based film therapy on the communication skills of females with low sexual Desire Mahnaz Alizadeh, Naeimeh Akbari Turkestani, Behnam Oohadi, Fateme Mehrabi Rezveh Journal of Nursing and Midwifery Sciences 2019 6(1):8-14 Context: Several researchers emphasized to develop cost-effective and easy interventions in this field as communicating about the relationship is the first step of healing. Aims: This study was aimed to evaluate the effectiveness of cognitive behavioral counseling based on film therapy on the communication skills of females with low sexual function. Setting and Design: In this clinical trial study, fifty subjects selected among females referred to health centers of Gonbad-e Kavus City-Iran. Materials and Methods: Samples randomized through permuted block randomization into two intervention (N=25) and control (N=25) groups. The intervention group participated in eight sessions of cognitive behavioral counseling (CBC)-based film therapy while the control group did not receive any intervention. All participants assessed by demographic, Arizona Sexual Experience Scale and Jerabeck Communication Skills Scales in pre and post intervention stages. Statistical Analysis Used: Data is analyzed using descriptive& independent t-test. Results: Findings showed that the two groups did not differ significantly in terms of age, education, and duration of marriage. The control (65.65 ± 6.75) and intervention groups (66.18 ± 7.32) were not significantly different in terms of communication skills before the intervention. However, in the postintervention phase, there was a significant difference between the control (66.04 ± 7.29) and intervention (74.95 ± 6.12) groups in term of communication skills (P < 0.05). Conclusion: Based on the findings of this study, CBT based on film therapy can improve communication skills among females with low sexual function in all aspects. Therefore, it is recommended to use this therapeutic approach to improve couples' relationships with low sexual performance.

Tuberculosis and HIV Co-infection and associated factors among HIV reactive patients in Ethiopia Robera Olana Fite, Tesfaye Yitna Chichiabellu, Birhanu Wondimeneh Demissie, Lolemo Kelbiso Hanfore Journal of Nursing and Midwifery Sciences 2019 6(1):15-20 Context: The most common opportunistic infection among Human Immunodeficiency Virus (HIV) reactive patients is tuberculosis (TB). TB has an impact on the prognosis of the disease. However, developing countries have not paid much attention to the problem. Aims: The study was conducted with the aim of determining the level of TB/HIV co-infection and associated factors. Setting and Design: A cross sectional study design was used in Wolaita Sodo Teaching and Referral Hospital from March 15 to May 15, 2017. Materials and Methods: Three hundred and seventy three patients were selected using simple random sampling. Statistical Analysis Used: Frequencies and proportions were computed. Logistic regressions were carried out and associations were considered statistically significant at P < 0.05. Results: The study revealed that 17.4% of the patients were co-infected with HIV and TB. Educational status (adjusted odds ratio [AOR] =0.472 and 95% confidence interval [CI] =0.253, 0.883), drug dependency (AOR = 2.366 and 95% CI = 1.129, 4.957), World Health Organization stage (AOR = 3.031 and 95% CI = 1.326, 6.930), and baseline CD4 (AOR = 0.351 and 95% CI = 0.153, 0.803) were predictors of the TB/HIV co-infection. Conclusion: Educational status, drug dependency, WHO clinical stage, and baseline CD4 count were found as significant predictors of co-infection. Therefore, health education about the lifestyle modification, counseling, and close monitoring of pharmacological therapy adherence is recommended.

Effectiveness of positive thinking training on anxiety, depression and quality of life of mothers of children with leukemia Hoda Esmaeili Douki, Forouzan Elyasi, Ramezan Hasanzadeh Journal of Nursing and Midwifery Sciences 2019 6(1):21-26 Context: Leukemia is the most common pediatric cancer. Diagnosis and treatment of childhood cancer may have adverse psychological effects on children and their families. Aim: We examined the effectiveness of positive thinking education on anxiety, depression, and quality of life of mothers of children with leukemia. Settings and Design: This randomized control trial has been conducted during August-September 2017, on 30 mothers of children with leukemia who randomly allocated into two groups using 30 random numbers produced by computer software and assigned to intervention (n = 15) and control (n = 15) groups. Materials and Methods: Data collection tools included depression, anxiety, stress scale-21, and MOS 36-Item Short-Form Health Survey quality of life questionnaire. Statistical Analysis Used: The normality of data distribution examined using the Kolmogorov–Smirnov test. Then, data were analyzed using descriptive methods (mean, frequency, and percentage), Chi-square, and independent t-test. Results: There were no statistically significant differences between the study groups in depression, anxiety, and quality of life variable at baseline (P > 0.05). However after the intervention, results showed significant differences between the study groups in all the three variables in posttest compared to the pretest. The mean scores of depression and anxiety respected, in the intervention group were significantly lower than the control group (P < 0.001) and (P < 0.004). Furthermore, significant differences were found between the study groups in quality of life score (P < 0.05). Conclusion: Positive thinking training reduced anxiety and depression and increased the quality of life of mothers of children with leukemia.

Behavioral brain systems activation with postpartum blue: According revised reinforcement sensivity theory Bahman Alimoradi, Hamid Nejat Journal of Nursing and Midwifery Sciences 2019 6(1):27-31 Context: Mood disorders such as postpartum blue are very prevalent in the postnatal period, while the underlying mechanism of postpartum blue is not well known. Aim: This research aimed to investigates the role of brain-behavioral systems activation in postpartum blue according to revised reinforcement sensitivity theory in mothers referring to Mashhad health-care centers. Settings and Design: This correlational study has been conducted during February–March 2018, on 172 cases who diagnosed with postpartum blue were chosen through the purposive sampling method. Materials and Methods: Participants completed demographic questionnaire, Jackson five-factor questionnaire, and the Edinburgh depression scale. Statistical Analysis Used: The normality of data distribution examined using the Kolmogorov–Smirnov test. After, data were analyzed using descriptive methods (mean and standard deviation), Pearson confiscation, and stepwise regression method. Results: The results showed that brain-behavioral systems, including behavioral inhibition system (BIS) (P < 0.001; R = 0.31) and behavioral activation system (BAS), had a significant correlation with postpartum blue (P < 0.05; R = 0.39), while there was no significant relationship between fight-flight systems with postpartum blue. BAS (R2 = 0.15,P < 0.05) and BIS (,R2 = 0.08,P < 0.001), the predictive potential of BIS and BAS was equal to 21% of variance of postpartum blue. Conclusion: The findings suggest that behavioral-brain systems play a role in mothers' “postpartum psychological disorders such as postpartum blue and in the conception of mothers” distress after maternal delivery, the effects of these systems can be used in short-term interventions.

Lifestyle and its related factors in elderly Sharareh Asadi Brojeni, Ehteram-Sadat Ilali, Zohreh Taraghi, Nouroeddin Mousavinasab Journal of Nursing and Midwifery Sciences 2019 6(1):32-37 Context: Lifestyle recognition is important because of its ability to prevent diseases and promote the health of the body and mind. Aims: The aim of this study was to determine the lifestyle and its related factors in elderly in Babol health centers. Settings and Design: This study was a descriptive-analytic study that was carried out on the elderly population of Babol health centers in 2018. Materials and Methods: The sample size was 500 elderly people over 60 years of age who were selected by systematic random cluster sampling method and entered the study. The research tools were the demographic questionnaire, the Iranian elderly lifestyle questionnaire. Statistical Analysis Used: Data were Analyzed by SPSS 21 software using descriptive statistics, Pearson's correlation coefficient test, one-way ANOVA, and independent t-test. Results: The findings of this study showed that the mean ± standard deviation score of healthy lifestyle in the elderly was 155.73 ± 16.28. Of included population, 243 (48.6%) indicated moderate lifestyle and 257 persons (51.4%) had a desirable lifestyle. The Chi-squared test showed that men had better lifestyle than women (P < 0.001), also elderly lifestyle was significantly associated with gender,education, income level, marital status, living arrangement, housing status, and age (P < 0.001). Conclusion: Regarding the study results, some demographic factors must be addressed in intervention program, aimed at life style promotion in elderly people.

Sexual and reproductive health education needs and its associated factors in couples participating in premarital counseling Zeinab Hamzehgardeshi, Zohreh Shahhosseini, Sara Tonekaboni, Fereshteh Yazdani Journal of Nursing and Midwifery Sciences 2019 6(1):38-43 Context: Lack of satisfaction of sexual instinct is one of the main factors of couples' divorce in many countries. One of the formal methods of sexual education in Iran is premarital counseling education. Therefore, premarital counseling should meet the needs and wishes of couples. Aim: This study aimed to investigate sexual and reproductive health (SRH) needs and its associated factors in couples participating in premarital counseling. Setting and Design: This descriptive study was conducted with 240 women and 233 men referred to a premarital counseling center in Sari, North of Iran. Materials and Methods: After consideration of the ethical aspects of data collection, the questionnaire developed by Pourmarzi et al. was used for data collection. This questionnaire measures sexuality and reproductive health needs. Statistical Analysis Used: Descriptive and inferential statistics were used for data analysis through the SPSS software (version 21). Results: The mean of SRH education needs in both genders was 24 ± 10, which was not statistically significant (P = 0.19). In men, the major need was related to “genetic counseling and importance of performing it before pregnancy.” On the other hand, in women, the main training need was related to: “Pregnancy prevention methods.” Conclusion: The results of this study showed that the couples before marriage felt more need to education about SRH. Since that the most common method of education on sexual health in Iran is premarital counseling, it should be devised based on the provision of the main reproductive and sexual needs of couples such as genetic counseling and family planning.

Knowledge, attitude, and practices of medical science students about tobacco use Fahimeh Hamzehi, Zahra Aliakbarzadeh Arani, Somayeh Momenyan, Zeynab Karimi Journal of Nursing and Midwifery Sciences 2019 6(1):44-49 Context: Tobacco products' consumption among students seems to have increased, which threatens their health as a cultural and social harm. Aims: The present study aimed to determine the knowledge, attitude, and practice of students in Qom University of Medical Sciences about tobacco. Setting and Design: A cross-sectional study was performed in Qom University of Medical Sciences, Iran, from December 2017 to January 2018. Material and Methods: Subjects accommodates 499 individuals who were selected through the simple random sampling. Data were collected using demographic and Global Youth Tobacco Survey (knowledge, attitude, and practice on tobacco) questionnaire. Statistical Analysis Used: Descriptive statistics, mean, and standard deviation were used to describe the status of the individuals. Pearson correlation coefficient and independent t-test, Chi-square, and ANOVA were used to analyze the relationships in SPSS-20 software. Results: The mean age of the samples was 21.32 ± 3.89 years. Men were 272 (54.4%), 438 (87.6) were single, and the rest were married. Average student knowledge was 6.65 (2.22), and their positive attitude was 40.16 (11.02). About practice, 76.9%, 93.5%, and 76% of people never used smoke, pipe, and hookah, respectively. T-test showed that there is a significant relationship between positive attitude and gender (P < 0.001); however, there is no significant relationship between knowledge scores and gender (P = 0.068). Chi-square test indicates that the difference between the two groups of girls and boys is not significant compared to the age of start of smoking (P = 0.86). Conclusion: Female students' knowledge was slightly higher than male; however, the positive attitude of male students was more than the female students about tobacco. It is necessary that the authorities and counseling centers of the university found underlying causes and work hard to solve the students' problems.

Urology

Augmented intelligence: A synergy between man and the machine Mahendra Bhandari, Madhu Reddiboina Indian Journal of Urology 2019 35(2):89-91

Round up Santosh Kumar Indian Journal of Urology 2019 35(2):92-93

Update on managing anterior urethral strictures Constantin Fuehner, Roland Dahlem, Margit Fisch, Malte W Vetterlein Indian Journal of Urology 2019 35(2):94-100 A number of techniques have been described for managing anterior urethral strictures in men. In this review, we aimed to summarize contemporary considerations regarding the holistic management of such strictures. The efficacy of reported outcomes is compared to provide evidence-based treatment recommendations. For anterior urethral strictures, durable long-term success rates of >90% may be achieved if the procedure is performed in capable hands at a high-volume referral center, even in recurrent strictures after previous open reconstruction. A one-stage urethroplasty is preferable to avoid a protracted treatment course with multiple interventions after dilation and direct vision internal urethrotomy. Staged urethroplasties are useful in complex anterior strictures providing durable success rates. In addition, perineal urethrostomy represents a valid last resort option with sufficient objective and subjective results. A follow-up evaluation should incorporate objective assessments such as radiographic and functional diagnostics as well as subjective, validated, and disease-specific patient-reported outcome measurement tools to allow for a better comparability and to improve individual risk prediction.

Efficacy and safety of programmed cell death-1/programmed cell death ligand-1 inhibitors in advanced urothelial malignancy: A systematic review and meta-analysis Smita Pattanaik, Sumit Dey, Nishant Jaiswal, Rachna Rohilla, Shrawan Kumar Singh, Arup Kumar Mandal, Ravimohan Suryanarayan Mavuduru Indian Journal of Urology 2019 35(2):101-115 Introduction: Programmed cell death-1/programmed cell death ligand-1 (PD-1/PDL-1) inhibitors are the newest class of approved drugs for advanced urothelial cancer (AdUC). This review aims to collate the evidence for their efficacy and safety in various treatment settings. Methods: Extensive search of databases was performed (updated May 2018) and the protocol was registered on PROSPERO (CRD42017081568). The review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement. STATA (v 12) and Revman 5.3.5 were used for data analysis. Results: Ten nonrandomized, open-label clinical trials were included in this review. PD-1/PD-L1 inhibitors were used as second-line, stand-alone in eight trials and as first-line in cisplatin-ineligible in two trials. Heterogeneity was observed for study design, PDL-1 testing methods, cutoff criterias used and translational markers evaluated. The pooled objective response rate (ORR) was 18.2% (95% confidence interval [CI] 15.1–21.2, n = 1785) with PD-1/PDL-1 inhibitors in second-line settings as compared to 12.6% (95% CI 10.3–14.9, n = 736) with second-line chemotherapy and 23.7% (95% CI 19.9–27.4, n = 489) with PD-1/PDL-1 inhibitors as first-line therapy in cisplatin-ineligible patients. The median progression-free survival and overall survival was similar with PD-1/PD-L1 inhibitors in both second- and first-line treatment settings (1.5–2.9 vs. 2.0–2.7 months and 7.9–18.2 vs. 15.9 months) and second-line chemotherapy (3.3–4.0 months and 7.4–8 months). Odds of achieving ORR was 0.10 (95% CI 0.03–0.31, n = 229) in the second-line, stand-alone setting with a combined positive score (CPS) cutoff of 25% and was 0.34 (95% CI 0.19–0.62, n = 265) with a CPS cut-off of 10% in first-line setting in the cisplatin-ineligible. Conclusions: PD-1/PDL-1 inhibitors appear to be promising in the treatment of AdUC and CPS may be a potentially reliable biomarker for predicting response but needs validation. Caution needs to be exercised until more data are available on imAEs and further studies are required to prove their worth as the standard of care.

Attitude and perceived barriers towards the practice of evidence-based urology amongst urological trainees in India Partho Mukherjee, Kapil Chaudhary, Bijesh Kumar Yadav, Santosh Kumar, Nitin Kekre, Antony Devasia Indian Journal of Urology 2019 35(2):116-119 Introduction: Evidence-based medicine requires systematic access and appraisal of contemporary research findings, followed by their application in clinical practice. It assumes an even greater significance in the current era of aggressive, industry-driven marketing. Methods: A questionnaire was designed combining the McColl questionnaire and Barrier scale with relevant modifications and was administered to the urology trainees attending a continuing urological education program. Statistical analysis was performed using SPSS version 25. Results: The meeting was attended by 110 urological trainees from 55 urological training centers all over India. One hundred and three of them agreed to participate in the study. About 92% of the questionnaires were fully completed. Less than half of the participants (47%) had access to reliable urological literature at work. Only 11% of the respondents claimed to have been formally trained in evidence-based urology (EBU). The inability to understand statistical analysis was the most common (67.4%) perceived barrier to EBU. Conclusion: The urological trainees in India are positively inclined towards EBU. The lack of formal training in appraising the available literature and lack of protected time, and portals to access the literature at workplaces hinder them from improving their compliance to EBU.

Editorial comment Apul Goel Indian Journal of Urology 2019 35(2):119-120

Radical cystectomy and W-shaped ileal orthotopic neobladder reconstruction with serosa-lined tunneled ureteroileal anastomoses: A critical analysis of the short-term voiding patterns and urodynamic and functional outcomes Uday Pratap Singh, Rahul Jena, Kumar Madhavan, Naveen Kumar, Sanjay Kumar Sureka, Aneesh Srivastava Indian Journal of Urology 2019 35(2):121-128 Introduction: We present the short-term voiding patterns and functional and urodynamic outcomes of W-shaped ileal orthotopic neobladder (ONB) following radical cystectomy (RC). Materials and Methods: Forty-one patients who underwent RC and W-shaped ONB creation between July 2015 and January 2018 were enrolled. Data were analyzed in terms of voiding patterns, urodynamic findings, and functional outcomes at 6 months after surgery. Pouch-related quality of life (QoL) was assessed using European Organization for Research and Treatment of Cancer (EORTC) Generic (QLQ C30), Bladder Cancer-Specific Instruments (QLQ BM30), and IONB–Patient-Reported Outcome (IONB-PRO). Results: The mean length of follow-up was 19.4 months. At first follow-up, three patients had developed acidosis and rising serum creatinine, and one of them required temporary hemodialysis. One patient developed urethral-pouch anastomotic stricture, which required bladder neck incision. Balloon dilatation was performed for ureteroileal anastomotic stricture and mesh repair for incisional hernia was required in one patient each. Upper tract changes were observed in two patients. During the first and second follow-up, maximum flow rate, voided volume, and postvoid residual urine were 12 ± 4.7 mL/s, 212 ± 120 mL, and 72 + 81 mL and 14.7 ± 5.3 mL/s, 254 ± 168 mL, and 123.7 ± 42.5 mL, respectively. The mean pouch capacity and compliance were 436 ± 103.5 mL and 50.6 ± 17.8 mL/cm H2O. No patient required clean intermittent catheterization for bladder emptying. In EORTC QLQ-C30 questionnaire, the “Cognitive” domain had the highest and “global QoL” domain had the lowest level of functional scores. “Nausea and vomiting and abdominal bloating and flatulence” domain had the lowest level and “financial difficulties and urinary symptoms” had the highest level of symptomatology in EORTC QLQ questionnaire. The IONB-PRO questionnaire showed the highest level of functioning in “relation life” and the lowest level in “emotional life” domain. Conclusion: The Ghoneim pouch has a low complication rate with near-normal voiding patterns with an acceptable QoL impairment.

Linguistic and cultural validation of ureteral stent symptom questionnaire in Hindi Pushpendra Baghel, RD Sahu, Goto Gangkok, HB Joshi, Vinay Tomar, SS Yadav Indian Journal of Urology 2019 35(2):129-133 Introduction: In the year 2003, Joshi et al. developed a validated outcome assessment tool to measure the ureteral stent-related symptoms. The original English language Ureteral Stent Symptom Questionnaire (USSQ) has been validated in various languages worldwide. Our objective was to develop the USSQ in Hindi, a commonlyused language in India, by validating it in patients undergoing ureteroscopic lithotripsy. Materials and Methods: A final Hindi version of the USSQ was derived from the original English version to apply to the study population by translation, back translation, and face-to-face interviews. The Hindi and English versions were completed by 70 patients undergoing ureteroscopic lithotripsy with stent in situ, on postoperative days 7 and 8, and 4 weeks after stent removal. Similarly, discriminant validity was checked among 50 healthy individuals. A detailed statistical analysis was used to correlate results (Cronbach's α coefficient, Spearman's correlation, and Mann–Whitney U-test). Results: A total of 70 patients were enrolled in the study and 61 completed the final assessment. The median age was 35 years (range: 18–60 years). The USSQ domain scores with the stent in situ were higher than poststent status. The test–retest reliability checked by Cronbach's α coefficient (>0.44) and Spearman's correlation coefficient (>0.44) were acceptable to good. We found high discriminant validity of the questionnaire between patients with stent and the healthy controls (P < 0.05). Conclusion: Our results demonstrate satisfactory validity for the Hindi version of the USSQ for the assessment of quality of life in patients with stent. This is ready for application in the clinical studies and the future stent-related research in Hindi language.

Everted saphenous vein graft for long anterior urethral strictures in men with tobacco-exposed oral mucosa: A prospective nonrandomized study Swatantra Nagendra Rao, Nikhil Khattar, Arif Akhtar, Hemant Goel, Anuj Varshney, Rajeev Sood Indian Journal of Urology 2019 35(2):134-140 Introduction: Oral mucosal graft (OMG) is the gold standard for urethral substitution but has poor results in long anterior urethral strictures and chronic tobacco-exposed oral mucosa. Saphenous vein has been recently described for long-segment anterior urethral stricture with successful initial results. Our objective was to compare the early outcomes of everted saphenous vein graft (eSVG) substitution urethroplasty in patients with tobacco-exposed oral mucosa and OMG urethroplasty in patients with nontobacco-exposed oral mucosa for long anterior urethral strictures. Materials and Methods: 30 patients with long anterior urethral strictures underwent substitution urethroplasty using Dorsolateral onlay approach. Fifteen patients with healthy oral mucosa underwent OMG urethroplasty (Group 1) and 15 patients who had unhealthy oral mucosa due to chronic tobacco exposure underwent eSVG urethroplasty (Group 2). Outcomes were assessed with the International Prostate Symptom Score (IPSS); uroflowmetry; donor and recipient site complications at 1, 3, and 6 months; and symptomatic assessment thereafter. Retrograde urethrogram was done at 3 months in both the groups. Successful urethroplasty was defined as satisfactory voiding (Qmax>15 ml/s) and no need for endoscopic dilatation/direct vision internal urethrotomy in follow-up. Results: Mean stricture and harvested graft length were 10.8 cm and 12.33 cm in Group 1, while in Group 2 were 13.6 cm and 15.73 cm, respectively. Nine of 13 patients in Group 1 (69.2%) and 11 of 14 in Group 2 (78.5%) with a minimum follow-up till 18 months had successful outcome at an average follow-up of 23.13 months. Donor and recipient site complications were comparable in both the groups. At 18 months, mean IPSS and Qmax in successful patients were 7.9 and 25.6 ml/s in Group 1, while in Group 2 were 8.0 and 22.6 ml/s. Conclusions: Outcomes of great saphenous vein graft urethroplasty are comparable to OMG, and it is an acceptable option in long-segment anterior urethral stricture patients with chronic tobacco-exposed oral mucosa.

Protocol-based perioperative antimicrobial prophylaxis in urologic surgeries: Feasibility and lessons learned Aditya Prakash Sharma, Sudheer Kumar Devana, Girdhar S Bora, Ravimohan Suryanarayan Mavuduru, Balvinder Mohan, Neelam Taneja, Shrawan K Singh, Arup K Mandal Indian Journal of Urology 2019 35(2):141-146 Introduction: Rational use of antibiotics and strict adherence to practice guidelines is essential to prevent antibiotic resistance. The best surgical prophylaxis protocol requires tailoring of the available guidelines in accordance to the local bacterial flora. We designed a protocol for surgical prophylaxis to check the rampant abuse of antibiotics in the department of urology and evaluated its feasibility. Materials and Methods: Patients admitted for elective major surgeries under a single unit of our department over a period of 5 months were included in the study. A protocol for antibiotic prophylaxis was designed based on the European Association of Urology guidelines and the local hospital antibiogram. Single-dose intravenous cefuroxime was administered to the patients undergoing clean and clean-contaminated surgeries. Extended protocols were formulated for contaminated surgeries. Postoperative course and complications were recorded. Effectiveness was defined as adherence to the protocol (without an addition or a change in antibiotic regimen) along with an uneventful postoperative course. Prospectively maintained data were analyzed using descriptive statistics. Results: Data of 277 patients were analyzed. The mean age was 48.37 ± 17.39 years and 27.1% had comorbidities. Majority of the surgeries were clean contaminated (81%), and 60.3% of the total were endoscopic. The protocol was effective in 89.5% of the patients (248/277). The failure rate was higher for the contaminated procedures (41.7%) (odds ratio – 6.43; confidence interval = 1.51–27.2, P < 0.001). Post-operative sepsis with or without shock was the commonest cause (16/29, 55.2%) of protocol failure. Fourteen out of the 16 patients who developed sepsis had undergone endourological surgeries. Conclusions: Protocol-based perioperative antibiotic prophylaxis in urological surgeries is feasible. Similar protocols should be developed and validated at other major centers to limit the unnecessary use of antibiotics and prevent the emergence of antibiotic resistance.

Musculoskeletal Surgery and Research

Educational leadership and choice of postgraduate surgical training Mohamed Khalid Journal of Musculoskeletal Surgery and Research 2019 3(2):177-178

Surgical versus nonsurgical treatment of distal femur physeal fractures: A systematic review and meta-analysis Abduljabbar Alhammoud, Manaf HS Younis, Abdulaziz F Ahmed, Talal Ibrahim Journal of Musculoskeletal Surgery and Research 2019 3(2):179-183 Distal femur physeal fractures can lead to growth disturbance such as premature physeal closure (PPC), leg length discrepancy (LLD), and angular deformity (AD). This study aims to systematically review the literature to assess whether surgical management is associated with a different rate of growth disturbances compared to nonsurgical treatment. We searched several databases from 1966 to 2018 for studies that evaluated surgical versus nonsurgical treatment of distal femur physeal fractures. Descriptive and quantitative data were extracted, and a meta-analysis was performed using a random-effects model to pool odds ratio (OR) for the comparison of PPC, LLD, and AD rate between children undergoing surgical versus nonsurgical treatment. Of the 470 articles identified, 11 case series were eligible, with a total of 527 distal femur physeal fractures. The pooled OR of PPC between surgical and nonsurgical treatments showed no statistically significant difference (OR = 0.30, 95% confidence interval [CI]: 0.30–3.03; I2 = 73.4%, P = 0.01). No significant difference in the rates of LLD (OR = 1.03, 95% CI: 0.36–2.94; I2 = 0%, P= 0.87) and AD (OR = 0.40, 95% CI: 0.10–1.57; I2 = 0%, P = 0.79) was detected between surgical and nonsurgical treatments. Despite the current evidence to date does not support an association between the method of treatment of distal femur physeal fractures and the risks of PPC, LLD, and AD, a significant clinical relevance cannot be carried out. Surgeons can use both treatment methods as dictated case by case.

Burnout syndrome among orthopedic surgery residents in Saudi Arabia: A multicenter study Khalid A Alsheikh, Faisal A Alhabradi, Faisal F Almalik, Abdulrahman A Alsalim, Faris E Ahmed, Ali A Alhandi Journal of Musculoskeletal Surgery and Research 2019 3(2):184-188 Objective: This study aimed to identify burnout syndrome prevalence among orthopedic surgery residents from different levels in different training centers of Saudi Arabia. Methods: A survey was sent to all orthopedic surgery residents in the Central, Western, and Eastern regions of Saudi Arabia in late September/early October 2018. The Maslach Burnout Inventory for Medical Personnel was used as a data collection tool. A three subscale questionnaire based on emotional exhaustion, depersonalization, and personal accomplishment determined the level of burnout syndrome. High, moderate, or low were the parameters reported after calculating the score of each subscale. Results: A total of 142 out of 301 residents completed the survey (response rate: 47.2%). The majority of the sample (90.1%, n = 128) were male. The sample had a mean of 6 on-call days per month, 2 clinic days per week, 2.3 operation days per week, and slept a mean of 5.5 h per night. More than two-thirds of the sample (68.3%) were not satisfied with their work-life balance. Around one-fifth (21.8%) of residents would not choose orthopedic surgery again as career choice and less than half of them (43%) would not choose medicine again for their graduate-level study. The results indicated that more than 56.3% of the sample scored positive for burnout syndrome. Conclusion: The study demonstrated that more than half of the studied orthopedic surgery residents in Saudi Arabia experienced burnout syndrome, which may have negative consequences for patient care, physician's efficacy, and the health-care system.

Outcomes in virtual reality knee arthroscopy for residents and attending surgeons Claudia Arroyo-Berezowsky, Armando Torres-Gómez, Ranulfo Romo-Rodríguez, José O Ruiz-Speare Journal of Musculoskeletal Surgery and Research 2019 3(2):189-195 Objectives: Arthroscopic surgery is one of the most common procedures in orthopedic surgery. It is prone to simulation training, which has consistently shown improvement in the trainees' motor skills. The objective of this study was to compare the differences in absolute values for virtual reality diagnostic knee arthroscopy with and without a probe for residents and attending surgeons at our hospital. Moreover, quantify the difference in results between an initial and final assessment for all participants. Methods: Eighteen residents and twenty attending orthopedic surgeons completed a sequence of exercises that included a diagnostic knee arthroscopy with and without a probe on the ARTHRO Mentor™ virtual reality simulator. The variables analyzed were as follows: time to complete the task, distance traveled by the arthroscope and the probe, arthroscope and probe roughness, and overall task score. We compared residents' scores with attending surgeons' scores and quantified the difference in all participants' results for the initial and final assessment. Results: There was no statistically significant difference in results between residents and attending surgeons. There was a statistically significant improvement in some variables for the knee diagnostic arthroscopy without a probe for all participants in the final assessment. Conclusions: There were no differences between attending surgeons and residents in the virtual reality knee diagnostic arthroscopy with and without a probe. There was an improvement in some variables for the knee diagnostic arthroscopy without a probe for all the participants. With constant training, anyone can improve their simulation motor skills. External validation studies are necessary.

Outcome of primary cemented bipolar hemiarthroplasty in older patients with unstable hip fracture: A prospective study  Ahmed S Elhadi, Ammar H Abdelgadir, Emad M Elbushra, Yasir N Gashi Journal of Musculoskeletal Surgery and Research 2019 3(2):196-199 Objective: Internal fixation as a classical method of treatment for unstable intertrochanteric fractures in older patients has significant complications and failure rate. This raises the need for a method that overcomes these difficulties and gives a better outcome. This study aims to evaluate the outcome of the use of primary cemented bipolar hemiarthroplasty in older patients with unstable intertrochanteric fracture both clinically and functionally. Methods: A prospective case series study conducted from January 2014 to February 2016 including 60 patients (>65-year-old) who were treated by primary cemented bipolar hemiarthroplasty for unstable intertrochanteric fractures (Kyle 3 and 4). Main outcome measurements were clinical and mechanical complications, mortality rate, and functional outcome. Results: Early mobilization was good, that 93.3% of patients started partial weight-bearing on the 1st postoperative day. At the final follow-up (mean 13.66 ± 5.9 months), the general and mechanical complications were few; 1-year mortality rate was 16.7%; the mean Harris Hip score was 91.14 ± 5.7. Conclusions: Primary cemented bipolar hemiarthroplasty offers early, pain-free mobility with minimal complications and good functional outcome in older patients with unstable intertrochanteric fracture.

Correlation between body mass index and quadruple hamstring autograft size Wazzan S Aljuhani, Seba G Alamri, Shomoukh AM Alsharif, Monerah M Annaim Journal of Musculoskeletal Surgery and Research 2019 3(2):200-203 Objectives: Anterior cruciate ligament (ACL) tear is a common sports injury affecting the knee joint in the Middle East and worldwide. Providing an adequate graft is required to prevent revision surgery. This study aims to determine if the body mass index (BMI) can be used as a predictor of the hamstring autograft size. Methods: Data of 48 consecutive patients, who underwent ACL reconstruction using quadruple hamstring autograft technique in the same institute by the same surgeon, were retrospectively reviewed. Skeletally immature patients and those who underwent revision ACL surgeries were excluded. Patients' anthropometric measurements were collected. Quantitative data from the patients' charts were included in the descriptive statistics. Results: The mean age of our cohort was 30.3 ± 6.3 years, with a mean height of 1.7 ± 7.8 m and a mean weight of 81.3 ± 14.6 kg. Mean BMI was 27.8 ± 5, and mean graft size was 7.8 ± 0.5 mm. Results showed that the correlation between the BMI and the autograft size was statistically insignificant. Other variables have no association with the autograft size in the linear regression model. Conclusion: Our study showed no correlation between anthropometric measurements and the autograft size; therefore, these measurements were not able to determine the diameter of the autograft. Further studies looking into thigh diameter and ethnicity and radiological studies with a larger sample size are recommended.

Flatfoot among school-age children in Almadinah Almunawwarah: Prevalence and risk factors Abdullah M Alsuhaymi, Faisal F Almohammadi, Osama A Alharbi, Ahmed H Alawfi, Meyasser M Olfat, Omar A Alhazmi, Khalid I Khoshhal Journal of Musculoskeletal Surgery and Research 2019 3(2):204-208 Objectives: Children with flatfoot are more vulnerable to have foot pain, foot injury, stress fractures, knee pain, and poor exercise performance. Some children may not experience any of these symptoms and the only predominant complaint would be foot pain. Flatfoot is considered a health issue that was not studied well in Saudi Arabia. The study aims to determine flatfoot prevalence among school-age children 7–14 years in Almadinah Almunawwarah and to know the effect of age, gender, and body mass index on the prevalence of flatfoot. Furthermore, a secondary aim is to find if there is a relationship between flatfoot and postactivity foot pain and participation in sports. Methods: This is a cross-sectional analytic study conducted on children aged 7–14 years living in Almadinah Almunawwarah, Saudi Arabia. Flatfoot was diagnosed using Staheli's Plantar Index. Binary logistics regression was used to predict the likelihood effect of sociodemographic data among children with flatfoot. Results: A total of 403 children had been voluntarily recruited in this study. Boys were 193 (47.9%) while 210 (52.1%) were girls. The prevalence of flatfoot was 29.5% (119), 96.6% of them were flexible flatfeet and a relatively very low incidence (3.4%) of rigid flatfeet. Age has a significant relationship on the prevalence of flatfoot (P = 0.050) where 7–8-year-old group was rated highest among other age groups in the prevalence of flatfoot. Conclusion: We found 29.5% of the children had flatfoot in the study sample. This prevalence is still high in comparison to developed countries. Furthermore, this study found a significant association between age and flatfoot in children.

High-Resolution ultrasound of knee osteoarthritis in a Southwest Nigerian population: Our experience Samuel O Oyamakinde, Bolanle O Ibitoye, Oluwadare Esan, Olusola C Famurewa, Adeniyi S Aderibigbe Journal of Musculoskeletal Surgery and Research 2019 3(2):209-215 Objective: High-resolution musculoskeletal ultrasound (MSKUS) is more sensitive than conventional radiography (CR) in evaluating early knee osteoarthritis (OA). The aim of this study is to determine the US findings in knee OA and also to compare these with CR, which is the gold standard. Methods: One hundred and twenty patients with primary knee OA and 120 controls were examined. They all had knee US. CR included weight-bearing anterioposterior and lateral knee radiographs. Kellgren and Lawrence (K–L) grades were assessed, and tibiofemoral joint space width was measured. Data were analyzed using SPSS Version 20. Results: Two hundred and fifteen knees had OA. US findings were tibial osteophytes (67.4%), femoral osteophytes (66.5%), effusion (61.4%), synovitis (46%), medial meniscal protrusion (38.2%), Baker's cysts (34.4%), and lateral meniscal protrusion (27.5%). US detected femoral osteophytes in 13 knees that were not detected in CR. CR detected femoral osteophytes in 12 knees, which US could not. Agreement between US and CR was 74% (P < 0.001). US detected tibial osteophytes in 10 knees which CR film could not. CR detected tibial osteophytes in 9 knees, which the US could not. Agreement between US and CR was 80% (P < 0.001). Sensitivity and specificity of US in detecting femoral and tibial osteophytes were 91.6% and 82.2% for the femur and 93.8% and 85.9% for the tibia, respectively. Student's t-test showed a significant difference (P < 0.001) between femoral condylar thickness in OA patients and controls. Conclusion: MSKUS complements CR in evaluating knee OA.

Factors that influence orthopedic surgeons when choosing their subspecialty in Saudi Arabia Khalid A Bakarman, Kholoud O Al Zain, Nawaf A Alotaibi, Ahmed A Aldakhil, Abdullatif M Alhassan Journal of Musculoskeletal Surgery and Research 2019 3(2):216-220 Objectives: The objectives of this study were to highlight the factors that influence orthopedic trainees in Saudi Arabia to choose their subspecialties and to determine the most desired residents' subspecialty and the percentage of residents who are planning to pursue a fellowship program. Methods: We formatted an online questionnaire using a Likert-type scale. The survey contained 21 questions. The study was conducted in multiple cities in Saudi Arabia. The survey was distributed to orthopedic surgeons. We used WhatsApp Messenger, which is the most popular texting application in Saudi Arabia and the most guaranteed method to ensure that more participants would answer the survey. The survey was closed after 4 weeks for data analysis. Results: The number of surgeons included in this study was 108 out of 175 contacted, including residents, fellows, and consultants. Overall, personal interest in a specialty and a patient's prognosis were the most influential factors that motivated surgeons to choose their careers, while lack of competition was the least important factor. For the 37 (90.2%) residents who chose to continue their training, pediatric orthopedics (26.8%) and foot and ankle surgery (14.6%) were the most desired subspecialties whereas sports medicine (7.3%) and oncology (0%) were the least. The female doctors represented 5.6% among orthopedic surgeons included in our study. Conclusion: Orthopedic residents must be guided to the subspecialties needed in their communities as the fact that general orthopedics is disappearing very soon from clinical practice in tertiary care hospitals in big cities of Saudi Arabia.

Elastic stable intramedullary nailing as a treatment option for comminuted proximal humeral shaft fractures in adults: A report of two cases and a review of the literature Abdulmuhsen N Alshammari, Mohammad A Altayeb, Eilaf M Alnazer Journal of Musculoskeletal Surgery and Research 2019 3(2):221-227 Despite the success of nonoperative treatment in the majority of adult-comminuted proximal third humeral shaft fractures, surgical intervention is preferable in selected cases in order to avoid specific potential disadvantages associated with nonoperative treatment, including shoulder and elbow stiffness, poor compliance, and nonunion. Elastic stable intramedullary nailing (ESIN) is commonly used in the treatment of children's long-bone fractures and is known to achieve a high union rate with minimal complications. The literature review of the use of percutaneous ESIN treatment of comminuted proximal third humeral shaft fractures reveals that while it is not a common procedure, it can still produce favorable results with limited complications. This paper evaluates the use of ESIN in two patients with comminuted proximal third humeral shaft fractures. The patients were aged 56 and 72 and both had experienced comminuted proximal third humeral shaft fractures. In this report, the management of these cases is presented, along with a review of other studies, which used ESIN in the treatment of humeral shaft fractures in adults.