A CHANGE OF VENUE

After quite a few years at Charleston Memorial Hospital, the Transitional Care Unit (TCU) is moving into the main hospital. TCU will be located in 2 Center; and will be reduced from 20 beds to 14.

What this means for your practicum: Since this change is so new, I am not entirely certain of all changes upcoming.

I do know my office space will move to 7N Tower.

So, before the 2009 Spring practicum begins, I will update the introduction with new and improved information...

Stay tuned!

Change in November Schedule

November:

Still no clinical on Monday, November 3rd.
Now no clinical on Monday, November 10th. I will be here on the 12th for your presentation.

Everything else is the same.

Thanks.

November Practicum Schedule

November schedule:

Monday, November 3rd: No clinical
Wednesday, November 12th: No clinical
Thursday, November 20th: No clinical

Digit Span Forward, Digit Repetition in Testing

To keep a slow, steady pace during digit span forward or digit repetition task, try this:

Say 5 (then say 5 silently to yourself), say 7 (then say 7 to yourself), say 3 (then say 3 to yourself), say 9 (then say 9 to yourself)...

This will keep you on a steady, slow pace. This helps to prevent chunking by the person you are testing.

If you need to, tape record yourself to check accuracy.

Student Presentation Guidelines: Adult Clinical Rotations

Adult Clinical Rotations

Student Presentation Guidelines

Description: Students will be required to present a clinical topic to the adult speech pathologists. Oral and written components are required.

Topics: Teach us something new! Keep in mind, the point of the presentation is to enhance the staff’s knowledge. Maybe a disorder you had an experience with during your rotation (something we could learn more about); patient and/or family information packets; or a treatment strategy. If you decide to present a treatment strategy, please include the following information: treatment efficacy, cost efficiency, availability, reliability, etc.

If you have difficulty choosing a topic, ask your supervisor for suggestions.

Written requirement: Please prepare a summarized handout for clinicians (1-2 pages) or a packet for patients/families. Include references. Do not print something directly from a website. You should organize this information on your own. If creating a Pt/family packet, provide helpful web sites, phone numbers, support groups, etc.

Oral requirement: You will be given less than 10 minutes including a brief question-answer period. This is not a great deal of time, so plan accordingly.

Date: Presentations will be Wednesday, Nov 12th from 8-9:00 am.

Location: 202 Basic Science Building (rounds location)

No Clinic Monday

No clinical practicum on Monday, October 20th.

Straw Drinking

James L. Coyle, Ph.D., CCC-SLP, BRS-S
(Communication Science and Disorders
University of Pittsburgh) writes:

Stephanie Daniels and her colleagues published an interesting article on straw drinking in normals a few years back that describes three distinct patterns of straw-drinking. I don’t know if straw drinking in patients has been investigated and I am pretty sure that what goes on in the oral cavity has received little attention. This brings up an interesting observation (my own so take it for what it’s worth, and it is something that would make a great study).

Ask yourself this question and answer it: “how do humans establish the intraoral pressure necessary to draw liquid into the mouth through a straw?” before reading on.

Most people that I have asked (mostly students, nursing personnel and other SLP’s), when asked reply that it is through inhalation. In fact, to do so requires tight closure of the linguapalatal valve (tongue base to soft palate through palatoglossus muscles) together with retraction and depression of the anterior tongue and mandible depression (all together), which increases oral cavity volume and thereby decreases intraoral pressure, drawing in the liquid. Try it and attend to what your “parts” are doing.

Arguably, in some cases in which good linguapalatal closure is apparent (evidence: clinical assessment of oral facial sensorimotor function and speech production) and patient has a patent nasal cavity and nasopharynx for ventilation, the use of a straw might be (opinion here – no hard evidence to support) considered beneficial to some individuals who exhibit posterior oral containment impairments with liquids by forcing linguapalatal contact during the oral preparatory and early oral transit stages. I have used this logic successfully in some cases.

If linguapalatal closure is not adequate or evident then indeed inhalation will be used and the bolus directed to the airway.


Daniels, S. K., Corey, D. M., Hadskey, L. D., Legendre, C., Priestly, D. H., Rosenbek, J. C. et al. (2004). Mechanism of sequential swallowing during straw drinking in healthy young and older adults. Journal of Speech Language & Hearing Research, 47, 33-45.

Daniels, S.K. & Foundas, A. L. (2001). Swallowing physiology of sequential straw drinking. Dysphagia, 16, 176-182.

What is Patent Foramen Ovale?

What is PFO and is it related to a genetic syndrome? What effects does it have on speech and swallowing, if any?

What is Horner's Syndrome?

What is Endocarditis?

Look up endocarditis. Give us the lowdown, and how it may be related to speech pathology (if it is).

Questions

You give 3 exemplars such as "vase, swimming pool, and bucket" and ask what is the same about them.

You give 2 exemplars such as pictures of "shoes and boots" and ask what is the same about them.

You give a group name and ask the client/patient to add a member.

You give 3 exemplars and 1 foil and ask the client/patient to identify the foil.

Are these the same task?
Or, are these different task working toward the same objective?
How are they different, if they are?
What is the objective? i.e. what are you working on?

Examples of Verbal Feedback in Therapy

Examples of excellent (positive) verbal feedback: "That's right," "You're right," "Yep, that's right," "Great. That's a great answer," "Exactly," with specific information provided such as, "Good job; I like how you corrected yourself. That's what we want you to do."

Examples of good verbal feedback: "You're close; that's close," with an explanation of incorrect or missing information. "There you go," "You're doing great," and "Good job."

Examples of poor verbal feedback: "Hmm-mmm," "Okay," or silence.

Picture Description Tasks

Picture description task(s):

1. Use a photograph which depicts a scene of:

a) a person or people engaged in some sort of activity, or
b) a person engaged in an internal struggle or thought process.

2. Provide instruction aimed at obtaining:

a) a complete sentence that captures the gestalt of the scene and that is correct grammatically and semantically.
b) a story that relates events in a logical sequence again using complete and meaningful phrases and/or sentences.
c) a detailed description of elements within the photograph with appropriate names for objects, etc.

3. Provide timely and appropriate verbal feedback with restatements of correct utterances and cues for those that are incorrect or missing essential or secondary elements.

A Few Treatment Tips

Once you've asked a question such as "What month is it?" and you receive an answer that is incorrect such as "It's November" when it is actually October; then cue the individual with, "No that's not right. It's not November; it's the month before it. The month before November is ____________." Hopefully, this will enable the person to recall the correct month.

Give succinct introductions to new tasks. Don't go into great detail; sometimes it may be of benefit to give an example.

Always reinforce and praise requests for repetitions from your 'patient' or 'client.' So, if the person says, "Say that again." you should say, "I like the way you asked me to say that again. That's a great self-cue."

Don't be embarrassed by your questions. If they are too difficult (or too easy!) for your patient or client, adjust them.

Ascites - CSD Student Contribution

Ascites

What is ascites? Ascites (AKA peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum, or abdominal dropsy) is an accumulation of fluid in the peritoneal cavity (space between the tissues lining the abdomen and abdominal organs). It is most commonly due to cirrhosis and severe liver disease, and can present other significant medical problems. It can be treated with medications (diuretics), paracentesis or other treatments directed at the particular cause. Mild ascites can be hard to notice, but severe ascites leads to abdominal distension. Fluid accumulation in the abdominal cavity can lead to additional fluid retention by the kidneys due to the stimulatory effects on blood pressure hormones (i.e. aldosterone). Ascites can also produce spontaneous bacterial peritonitis (SBP) due to the decreased antibacterial agents in the fluid. Patient complaints include progressive abdominal heaviness and pressure, and shortness of breath due to stress on the diaphragm. Other signs of ascites may be present due to its underlying etiology. For instance, in portal hypertension (perhaps due to cirrhosis or fibrosis of the liver) patients may also complain of leg swelling, bruising, gynecomastia, hematemesis, or mental changes due to encephalopathy. Those with ascites due to cancer (peritoneal carcinomatosis) may complain of chronic fatigue or weight loss. Those with ascites due to heart failure may also complain of shortness of breath as well as wheezing and exercise intolerance.

So what is ascites’ impact on speech? Ascites can affect respiratory support to due stress placed on the diaphragm which can lead many signs, such as: short breath groups, decreased loudness, reduced fluency (effect on prosody), inspiratory stridor, and difficulty coordinating breathing with swallowing due to reduced lung volumes on inhalation and expiration.

Encephalopathy may cause “mental” changes which can result in deficits in cognition, speech, and language, depending on which areas of the brain are affected.

Cholangitis - CSD Student Contribution

Cholangitis

What is cholangitis? Cholangitis is an inflammation of the bile duct. It is usually caused by a bacterial infection which causes an ascending cholangitis. However, there are other types of cholangitis as well. In acute cholangitis, the bacterial infection is secondary to biliary tract obstruction which is commonly caused from a gallstone, but may also be associated with neoplasm, elevated intraluminal pressure, bile infection, or stricture of the biliary tract. This infection diminishes antibacterial defenses, which causes immune dysfunction, and thus small bowel bacterial colonization and further possible infection (such as into the biliary canaliculi, hepatic veins, and perihepatic lymphatics).

Fall Practicum 2008 - September

September schedule:

Off September 1st (Monday)

Off September 10th (Friday)

Off September 17th - 18th (Wednesday - Thursday)

Off September 22nd - 23rd (Monday - Tuesday)

Cholangitis

Another term to quickly look up and define for us.

Ascites and Its Impact on Speech Pathology

Look up 'ascites' and give us a quick medical dictionary definition. What impact might ascites have on us as speech language pathologists?

Fall 2008 Practicum

is fast approaching...

Senate Passes Medicare Relief Legislation

By a vote of 69-30 the Senate passed Medicare relief legislation H.R. 6331, which will avert a 10.6% payment cut and extend the therapy cap exceptions process through January 2010. The bill also includes language that will recognize private practice speech-language pathologist's ability to bill Medicare.

"Treating Aphasia in Bilingual and Spanish Speakers"

Maria L. Munoz, PhD CCC-SLP reported during SPEAKING OUT! National Aphasia Association on aphasia in Spanish speakers. She indicated that "Spanish aphasia is different than English aphasia."

For example, in Spanish aphasia, changes in vowels are fewer in phonological paraphasias than in English aphasia. In Spanish aphasia, voicing changes are also less common. More common are changes in manner of articulation (tenedor -> tedendor) and changes in place of articulation (bosina -> gosina).

Spanish is a heavily inflected language which adds parts to words to change their meanings. In semantic paraphasias in Spanish aphasia, errors are often within the same semantic field, are antonyms, superordinates, or have proximity. Strongest predictors for accuracy of naming in Spanish aphasia include: age of acquisition, word frequency, and visual complexity. Weak predictors, on the other hand, are: imageability, word length, and animacy. In Spanish, syntax is more complex than in English. Within verb morphology, there are 3 stem classes, 4 tenses, 3 persons, 2 numbers, 3 moods, 2 aspects while in English there are no stem classes, 2 tenses, 1 person, 1 plural (number) , and auxilary verbs for mood and aspect. In noun morphology, Spanish has 2 gender, and 1 number while English has no gender, and 1 number. As compared to English aphasia, in Spanish aphasia syntactic errors include: difficulty processing flexible word order, less difficulty processing subject-verb agreement, more difficulty processing both active and passive sentences, more difficulty processing negation, omission of articles, errors in noun and verb inflection, and an over-reliance on simple syntactic structures.

Spanish orthography is transparent so that it is read as it is spelled. There are no irregular words. In agraphia, Spanish aphasia shows homophone errors (casa -> kasa; brazo -> braso; boca -> voca) rather than non-homophone errors. In alexia, literal paralexias are common in Spanish aphasia while semantic paralexias are not (are common in English aphasia).

Treatment Strategies: 1) "Consider the specific features of each language."
2) "Consider what cues are important in that language."
3) "Consider how responsiveness to cues may depend on language proficiency."

ACT (modified) Beeson and Hillis, 2001: pick out syllables from field as in "pe ta lo" chosen from "lo pe mi ta so."

Anagram copy task.

CART Copy and Recall Task.

Response Elaboration Training: Present picture, cue: "Tell me about this..." Then elaborate the client's response via questions and then restatement.

With bilingual speakers, some say to target the stronger language; others say to target the weaker language because generalization will occur better.

The End Is Near

The end of your practicum is fast approaching. In the last days, begin to take control of the patients on our list. Think ahead a bit more; plan who you need to see and what you want to accomplish with those persons.

Be especially attentive to chart reviews and good data keeping.

Control your antecedents and consequents during therapy! Have fun.

Verbal Feedback in Testing and in Treatment

When testing, the idea is not to give verbal feedback that indicates whether the individual was correct or incorrect. The VF you give should be more of an encouraging kind: "You're doing well." "Just do your best."

During treatment, however, your verbal feedback is therapy. Without your verbal feedback, the individual you are treating does not know whether his or her responses are correct or incorrect. If you do not indicate incorrectness, then the person does not have an opportunity to learn the best response. If you do not indicate correctness, the individual also does not receive reinforcement for that correct response. In other words, no treatment is occurring.

Keep this in mind as you approach evaluation and therapy.

Student Presentations: Summer, 2008

Student presentations will be Wed, July 9th in ENT conference room on 11th floor of Rutledge Tower.

Doing An Awesome Chart Review

To get the most for the time you spend perusing a chart (i.e. medical record), try:

1) Reading over the entire discharge summary from the previous admission first, then take notes the second time around. Note major events whether or not they appear directly related to our field.

2) Note primary diagnosis (es) , date of onset, admission date, attending and referring physicians.

3) Note any previous speech pathology evaluations, treatments, notes, etc.

4) Review radiology reports on CT scans, MRI scans, etc.

5) Take a quick glance at labs.

6) Put the information all together in a succinct paragraph. Avoid abbreviations.

What is Aerophagia? How Come I Don't Have It?

Asked a great question. Now, look it up and give us the lowdown.

Tonic Bite Reflex

Tonic bite reflex - This is jaw closure accomplished by forceful, sustained upward movement of the mandible. It occurs following stimulation of the teeth or gums. It is accompanied by increased abnormal tone in the jaw muscles. It is difficult to release. Damage to the teeth or to the object placed in the mouth may occur. The tonic bite increases if the item is pulled on.

Do not confuse this pattern with a bite reflex which results in closing or approximation of closing following stimulation to the lips, gums or teeth. This normal reflex becomes integrated before age two, and is not associated with abnormally increased muscle tone.

NIH: Guillain Barre

What is Guillain-Barre Syndrome?

Guillain-Barré syndrome is a disorder in which the body's immune system attacks part of the peripheral nervous system. The first symptoms of this disorder include varying degrees of weakness or tingling sensations in the legs. In many instances, the weakness and abnormal sensations spread to the arms and upper body. These symptoms can increase in intensity until the muscles cannot be used at all and the patient is almost totally paralyzed. In these cases, the disorder is life-threatening and is considered a medical emergency. The patient is often put on a respirator to assist with breathing. Most patients, however, recover from even the most severe cases of Guillain-Barré syndrome, although some continue to have some degree of weakness. Guillain-Barré syndrome is rare. Usually Guillain-Barré occurs a few days or weeks after the patient has had symptoms of a respiratory or gastrointestinal viral infection. Occasionally, surgery or vaccinations will trigger the syndrome. The disorder can develop over the course of hours or days, or it may take up to 3 to 4 weeks. No one yet knows why Guillain-Barré strikes some people and not others or what sets the disease in motion. What scientists do know is that the body's immune system begins to attack the body itself, causing what is known as an autoimmune disease. Guillain-Barré is called a syndrome rather than a disease because it is not clear that a specific disease-causing agent is involved. Reflexes such as knee jerks are usually lost. Because the signals traveling along the nerve are slower, a nerve conduction velocity (NCV) test can give a doctor clues to aid the diagnosis. The cerebrospinal fluid that bathes the spinal cord and brain contains more protein than usual, so a physician may decide to perform a spinal tap.

Is there any treatment?

There is no known cure for Guillain-Barre syndrome, but therapies can lessen the severity of the illness and accelerate the recovery in most patients. There are also a number of ways to treat the complications of the disease. Currently, plasmapheresis and high-dose immunoglobulin therapy are used. Plasmapheresis seems to reduce the severity and duration of the Guillain-Barré episode. In high-dose immunoglobulin therapy, doctors give intravenous injections of the proteins that in small quantities, the immune system uses naturally to attack invading organism. Investigators have found that giving high doses of these immunoglobulins, derived from a pool of thousands of normal donors, to Guillain-Barré patients can lessen the immune attack on the nervous system. The most critical part of the treatment for this syndrome consists of keeping the patient's body functioning during recovery of the nervous system. This can sometimes require placing the patient on a respirator, a heart monitor, or other machines that assist body function.

What is the prognosis?

Guillain-Barré syndrome can be a devastating disorder because of its sudden and unexpected onset. Most people reach the stage of greatest weakness within the first 2 weeks after symptoms appear, and by the third week of the illness 90 percent of all patients are at their weakest. The recovery period may be as little as a few weeks or as long as a few years. About 30 percent of those with Guillain-Barré still have a residual weakness after 3 years. About 3 percent may suffer a relapse of muscle weakness and tingling sensations many years after the initial attack.

What research is being done?

Scientists are concentrating on finding new treatments and refining existing ones. Scientists are also looking at the workings of the immune system to find which cells are responsible for beginning and carrying out the attack on the nervous system. The fact that so many cases of Guillain-Barré begin after a viral or bacterial infection suggests that certain characteristics of some viruses and bacteria may activate the immune system inappropriately. Investigators are searching for those characteristics. Neurological scientists, immunologists, virologists, and pharmacologists are all working collaboratively to learn how to prevent this disorder and to make better therapies available when it strikes.

Questions and Answers Regarding Apraxia of Speech

What is integral stimulation?
An imitative treatment approach using multi-modal stimulation, including visual and auditory input. The instructions to the patient are key:
“Watch me, listen to me, do what I do.”


What are the four salient characteristics of apraxia of speech?

(1. Effortful, trial and error, groping articulatory movements with attempts at self-correction. 2. Prosodic disturbances or dysprosody 3. Inconsistency in articulation on repetitions of the same utterance. 4. Obvious initiation difficulties.)


What is the key diagnostic tool or step within the Mayo Clinic Evaluation of Apraxia of Speech for differential diagnosis of apraxia of speech from phonemic paraphasia or dysarthria?
What speech characterisitcs would be seen using this key diagnostic tool if the person has apraxia of speech?

1. Diadochokinetic rate – repetition of pa ta ka over time
2. Difficulty with initiation (stopping and restarting)
Difficulty with rate (slow) with equal and excess stress
Lots of substitutions or omissions

Oral Hygiene Information

Cut and paste this link into your browser as I couldn't get it to go live. Thanks.

http://www.perio.org/consumer/request.htm

Therapy: Verbal Feedback, Cueing, Etc.

Verbal feedback in therapy: Telling the patient "that's right," "you got it," or "that's correct" is great verbal feedback. Perfect feedback is: "That's right; it is a zebra!"

Rewording the stimulus is a helpful cue: Asking "if wood burns, what melts?" assists a patient to complete the verbal analogy "Burn is to wood as melt is to _________."

During a verbal fluency task, remain quiet while the patient is listing exemplars unless they pause, or deny ability to think of any more items.

During word retrieval tasks such as confrontational naming, should give a letter cue or phonemic cue prior to giving model.

June 6th ALS Clinic

Schedule for Friday, June 6th: We will be in the Amyotrophic Lateral Sclerosis clinic on the 9th floor of Rutledge Tower beginning at 8 a.m. You can page me Friday morning and ask me for directions, if you'd like.

Sample Practicum Goals

1. Administer treatment without constant use of aids.
2. Predict patient's abilities given information in medical chart.
3. Use accurate terminology when writing progress notes.
4. Perform Modified Barium Swallow Studies precisely.
5. Learn and use critical clinical skills, such as verbal feedback techniques and efficient data collection.

June, 2008 Practicum Schedule

In June, I will be at the SPEAKING OUT conference in New York City on Aphasia. I leave Wednesday, June 18th and return to MUSC on Tuesday, June 24th.

Terminology for Clinical Documentation

Refer to naming members of a category within a time limit as verbal fluency, exemplar generation, or generative naming. Animal naming on some aphasia batteries is an example of verbal fluency. Another frequently used task on examinations is naming as many words that start with a particular letter of the alphabet without including proper nouns.

To document unwanted repetitions in an exemplar generation task such as naming as many animals as possible in a minute, refer to these as perseverations. In other words, an unwanted repetition or perseveration is any repeat of a previously named item. An item not belonging in the category is called a frank error.

Naming objects from descriptions is called naming to description.
Answering wh-questions (who, what, where, how many, when) with one word is called responsive naming.
Naming an object or pictured object is called confrontational naming.

Answering yes versus no questions such as "Is water wet?" is referred to as answering short, concrete yes/no ?s whereas answering yes versus no questions involving comparison or before and after relations is referred to as answering moderately complex yes/no ?s re: comparatives, or before/after relations.

Practicum Goals

Please provide a written list of your goals for this practicum by Monday, June 2nd. Thanks!

Communicator 6000

May is Better Speech and Hearing Month

Masako and Effortful Swallow Maneuvers

Catriona M. Steele writes:

The Masako maneuver is described as a technique to enhance closure of the pharyngeal lumen at the level of the tongue base, however it works by eliciting greater movement of the posterior pharyngeal wall. To my knowledge, no one has yet shown that the tongue base moves more with the maneuver, and, indeed, the intention of the maneuver is to anchor the tongue further forward in the mouth to mimic a tongue base resection (the original maneuver was something observed as a spontaneous
compensation in patients with oral cancer). Additionally, as described
in the original articles by Masako Fujiu and Dr. Logemann, the Masako maneuver is recommended only as an exercise (with saliva swallows) and not advised with a bolus (because the tongue is anchored, the maneuver was reported to increase vallecular residue with a bolus). Fujiu M & Logemann JA. Effect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. American Journal of Speech-Language Pathology, 5(1):23-30, 1996.

...you might find some articles on the effortful swallow quite interesting with respect to addressing tongue base issues and vallecular residue. There are series of articles coming out of Dr. Maggie-Lee Huckabee's lab that suggest that the effortful swallow can address weakness in the region of the tongue base, and that by instructing the patient to emphasize a tongue-palate "press" at the beginning of an effortful swallow you get a greater increase in the resulting pharyngeal pressures.

- Huckabee ML, Hiss SG, Barclay M, Jit S: The relationship between submental semg measurement and pharyngeal pressures during normal and effortful swallowing. Arch Phys Med Rehabil 86(11):2144-2149, 2005
- Hiss SG, Huckabee ML: Timing of pharyngeal and upper esophageal sphincter pressures as a function of normal and effortful swallowing in young healthy adults. Dysphagia 20:149-156, 2005
- Huckabee, M.L. & Steele, C.M. (2006). An Analysis of Lingual Contribution to Submental sEMG Measures and Pharyngeal Biomechanics during Effortful Swallow. Archives of Physical Medicine and Rehabilitation, 87, 1067-1072.
- Steele, C.M. & Huckabee, M.L. (2007). The influence of oro-lingual pressure on the timing of pharyngeal pressure events. Dysphagia, 22(1), 30-36.

...it is really important to remember that excessively increased pharyngeal pressures may not be something you want to contribute to in a patient with a Zenker's. I don't have my fingers on specific references in this regard, but I would recommend an article by Jane Garcia and colleagues, that shows how effortful swallow can sometimes have an undesirable outcome:

Garcia, J. M., Hakel, M., & Lazarus, C. (2004). Unexpected consequence of effortful swallowing: Case study report. Journal of Medical Speech-Language Pathology, 12(2), 59-66.

Catriona M. Steele
Ph.D., M.H.Sc., S-LP(C), CCC-SLP, Reg. CASLPO

* Research Scientist, Toronto Rehabilitation Institute
* Corporate Practice Leader for Speech-Language Pathology and Audiology, Toronto Rehabilitation Institute
* CIHR New Investigator in Aging
* Assistant Professor, Department of Speech-Language Pathology, University of Toronto
* Coordinator, Special Interest Division 13 (Swallowing and Swallowing Disorders), American Speech-Language Hearing Association

References: MBS, modified Evans Blue Dye, FEES

Ajemian, M. S., Nirmul, G. B., Anderson, M. T., Zirlen, D. M., & Kwasnik, E. M. (2001). Routine fiberoptic endoscopic evaluation of swallowing following prolonged intubation: implications for management. Archives of Surgery., 136, 434-437.

Belafsky, P. C., Blumenfeld, L., LePage, A., & Nahrstedt, K. (2003). The accuracy of the modified Evan's blue dye test in predicting aspiration. Laryngoscope., 113, 1969-1972.

Brady, S. L., Hildner, C. D., & Hutchins, B. F. (1999). Simultaneous videofluoroscopic swallow study and modified Evans blue dye procedure: An evaluation of blue dye visualization in cases of known aspiration. Dysphagia., 14, 146-149.

Cameron, J. L., Reynolds, J., & Zuidema, G. D. (2007). Aspiration in patients with tracheotomies. Surgical Gynecology and Obstetrics, 136, 68-70.

deLarminat, V., Montravers, P., Dureuil, B., & Desmonts, J. M. (1995). Alteration in swallowing reflex after extubation in intensive care unit patients. Critical Care Medicine, 23, 486-490.

Donzelli, J., Brady, S., Wesling, M., & Craney, M. (2001). Simultaneous modified Evans blue dye procedure and video nasal endoscopic evaluation of the swallow. Laryngoscope., 111, 1746-1750.

Donzelli, J., Brady, S., Wesling, M., & Theisen, M. (2005). Effects of the removal of the tracheotomy tube on swallowing during the fiberoptic endoscopic exam of the swallow (FEES). Dysphagia, 20, 283-289.

O'Neil-Pirozzi, T. M., Lisiecki, D. J., Jack, M. K., Connors, J. J., & Milliner, M. P. (2003). Simultaneous modified barium swallow and blue dye tests: a determination of the accuracy of blue dye test aspiration findings. Dysphagia., 18, 32-38.

Peruzzi, W. T., Logemann, J. A., Currie, D., & Moen, S. G. (2001). Assessment of aspiration in patients with tracheostomies: comparison of the bedside colored dye assessment with videofluoroscopic examination. Respiratory Care, 46, 243-247.

The End Is Near

Hard to believe, but the end of your practicum is nearing. Next week, as you prepare for clinic, try to have in mind the patients you need to see, the goals you need to strive to accomplish, and the tasks which may assist the patients in reaching those goals.

Continue to keep excellent data.

Continue to formulate in your mind the modality which each task targets, whether the component or modality is speaking, listening, reading, writing, math or higher level reasoning and problem solving.

Good luck! And, have fun.

Student Presentations Update

Student Presentations have been moved to next Wednesday, April 2nd at 8am. I think they are to be held in Basic Sciences 202 where rounds are normally.

Hemochromatosis

From the Mayo Clinic:

Introduction
Of all the minerals you need for good health, iron is one of the most familiar. After all, the producers of everything from breakfast cereals to vitamin tonics tell us that iron builds rich, red blood. Iron does help form oxygen-carrying hemoglobin in your red blood cells, but it's also essential for a number of other body processes, including proper brain function, a strong immune system and healthy muscles. Yet for people with hereditary hemochromatosis (HH), even small amounts of iron can cause serious problems.

That's because hereditary hemochromatosis causes your body to absorb too much iron from the food you eat. The excess is stored in your organs, especially your liver, heart and pancreas. Sometimes the stored iron damages these organs, leading to life-threatening conditions such as cancer, heart problems and liver disease.

Signs and symptoms of hereditary hemochromatosis usually appear in midlife, although they may occur earlier. The most common complaint is joint pain, but hereditary hemochromatosis can also cause a number of other symptoms, including fatigue, abdominal pain and impotence. Though not always easy to diagnose, hereditary hemochromatosis can be effectively treated by removing blood from your body to lower the level of iron.

Signs and symptoms
Although the genetic defect that causes hemochromatosis is present at birth, most people don't experience signs and symptoms until later in life — usually between the ages of 30 and 50 in men and after age 50 in women. Women are more likely to have symptoms after menopause, when they no longer lose iron with menstruation and pregnancy.

Some people with hemochromatosis never have symptoms. Others experience a wide range of problems. These can vary considerably from person to person and may be different for men and women. In addition, early signs and symptoms of hemochromatosis mimic those of many other common conditions, making hemochromatosis difficult to diagnose. Signs and symptoms include:

Arthritis, especially in your hands
Chronic fatigue
Loss of sex drive (libido) or impotence
Lack of normal menstruation (amenorrhea)
Abdominal pain
High blood sugar levels
Low thyroid function (hypothyroidism)
Abnormal liver function tests, even if no other symptoms are present
In advanced stages of the disease, you may develop serious conditions such as:

Cirrhosis — a condition marked by irreversible scarring of the liver
Liver failure
Liver cancer
Diabetes
Congestive heart failure
Cardiac arrhythmia
Some people with advanced hemochromatosis develop a bronze color to their skin when iron deposits in the skin cells produce excess melanin — the pigment that gives skin its normal color. Visible iron deposits can also make skin appear gray.

Causes
Iron plays an essential role in the formation of hemoglobin — a protein in red blood cells that transports oxygen from your lungs to all the tissues of your body — and of myoglobin, a form of hemoglobin in your muscles. Iron is also necessary for energy production and a strong immune system and is a component of many important enzymes.

You normally consume about 10 milligrams (mg) of iron every day in the food you eat. Of that, your body absorbs about 1 mg, or 10 percent of the iron you ingest. Most of this is stored in the hemoglobin, but a small amount is stored in your bone marrow, spleen and liver. When these stores are adequate, your body reduces the amount of iron absorbed by your intestine so that you don't accumulate excess amounts.

But if you have hemochromatosis, you may absorb as much as 20 percent of the iron you ingest. Because your body can't use or eliminate this extra iron, it's stored in the tissues of major organs, especially your liver. Eventually you may accumulate five to 20 times as much iron as normal. Over a period of years, the stored iron can severely damage many organs, leading to organ failure and chronic diseases such as cirrhosis and diabetes.

Although excess iron (iron overload) is a common problem, it's not always the result of hemochromatosis. Several factors, including frequent blood transfusions, high amounts of dietary iron and certain types of anemia, can cause excess iron in your body. People with chronic liver disease may also have increased iron levels. But in the United States, hemochromatosis is the most frequent cause of high blood iron levels.

The genetics of hemochromatosis
You have approximately 30,000 genes — information centers in your cells that control your body's growth, development and function. A mutation in just one gene can drastically alter the way your body works.

The gene that controls the amount of iron you absorb from food is called HFE. The HFE gene has two common mutations, C282Y and H63D. In the United States, most people with hemochromatosis have inherited two copies of C282Y — one from each parent.

Inheriting just one gene with the C282Y mutation means you're a carrier. You aren't likely to develop the disease yourself, although you may absorb more iron than normal. About one in every 10 Caucasians carries one gene for hemochromatosis. If both your parents are carriers, you have a 25 percent chance of inheriting two mutated genes.

A few people inherit one copy of C282Y and one of H63D. Of these, a small percentage develop symptoms of hemochromatosis. An even smaller number of people inherit two copies of H63D. Whether they're at risk of hemochromatosis is a matter of debate.

Complicating matters further, not everyone with two C282Y gene mutations develops problems with iron overload. Experts aren't sure of the exact number of people who do, and it's not possible to determine who will experience symptoms and who won't.

In addition, researchers continue to discover new proteins and genes that are responsible for rare cases of iron overload and that may lead to symptoms in people with HFE-related disease.

E-Stimulation for Swallow Function: Reference List

E-Stimulation for Swallow Function: Reference List

Burnett, T. A., Mann, E. A., Cornell, S. A., & Ludlow, C. L. (2003). Laryngeal elevation achieved by neuromuscular stimulation at rest. Journal of Applied Physiology., 94, 128-134.

Burnett, T. A., Mann, E. A., Stoklosa, J. B., & Ludlow, C. L. (2005). Self-triggered functional electrical stimulation during swallowing. Journal of Neurophysiology, 94, 4011-4018.

Carnaby-Mann, G. D. & Crary, M. A. (2007). Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis. Archives of Otolaryngology Head & Neck Surgery, 133, 564-571.

Coyle, J. L. (2002). Critical appraisal of a treatment publication: electrical stimulation for the treatment of dysphagia. Perspectives on Swallowing and Swallowing Disorders, 11, 12-15.

Crary, M. A., Carnaby-Mann, G. D., & Faunce, A. (2007). Electrical stimulation therapy for dysphagia: descriptive results of two surveys. Dysphagia.22(3):165-73.

Freed, M. L., Freed, L., Chatburn, R. L., & Christian, M. (2001). Electrical stimulation for swallowing disorders caused by stroke. Respiratory Care, 46, 466-474.

Grill, W. M., Craggs, M. D., Foreman, R. D., Ludlow, C. L., & Buller, J. L. (2001). Emerging clinical applications of electrical stimulation: opportunities for restoration of function. Journal of Rehabilitation Research & Development., 38, 641-653.

Humbert, I. A., Poletto, C. J., Saxon, K. G., Kearney, P. R., Crujido, L., Wright-Harp, W. et al. (2006). The effect of surface electrical stimulation on hyolaryngeal movement in normal individuals at rest and during swallowing. Journal of Applied Physiology, 101, 1657-1663.

Leelamanit, V., Limsakul, C., & Geater, A. (2002). Synchronized electrical stimulation in treating pharyngeal dysphagia. Laryngoscope., 112, 2204-2210.

Ludlow, C. L., Hang, C., Bielamowicz, S., Choyke, P., Hampshire, V., & Selbie, W. S. (1999). Three-dimensional changes in the upper airway during neuromuscular stimulation of laryngeal muscles. Artificial Organs., 23, 463-465.

Ludlow, C. L., Humbert, I., Saxon, K., Poletto, C. J., Sonies, B., & Crujido, L. (2007). Effects of surface electrical stimulation both at rest and during swallowing in chronic pharyngeal dysphagia. Dysphagia, 22, 1-10.

Power, M., Fraser, C., Hobson, A., Singh, S., Tyrrell, P., Nicholson, D. et al. (2006). Evaluating oral stimulation as a treatment for dysphagia after stroke. Dysphagia, 21, 49-55.

Suiter, D., Leder, S., & Ruark, J. (2006). Effects of Neuromuscular Electrical Stimulation on Submental Muscle Activity. Dysphagia, 20, 1-5.

Neoesophago-tracheal Fistula After Esophagectomy For Cancer

Rather rare, but...

"after esophagectomy for cancer a fistula developed between the trachea and the pulled-up stomach because of the ischaemic effect of the tracheostomy tube. At single stage repairs, the fistulae were divided and the gastric defects were closed directly...Treatment of this potentially life threatening and rare condition yielded excellent results."

Source: Kalmar et al. "Non-malignant tracheo-gastric fistula following esophagectomy for cancer."

Ivor Lewis Esophagectomy

The esophagus is a hollow tube that moves food and liquids from the throat to the stomach. It is located just behind the trachea (windpipe) and, in an adult, is about 10 inches long. The wall of the esophagus is made up of several layers of tissue, including mucous membrane, muscle and connective tissue.

Esophagectomy is the surgical removal of part of the esophagus. The lower part of the esophagus and upper part of the stomach (fundus) are removed and the remaining parts are then connected to re-establish the digestive tract.

Reason for an Esophagectomy
Esophagectomy is the treatment of choice for esophageal cancers.

The Ivor Lewis Esophagectomy
The Ivor Lewis is a specific, two-stage surgical approach esophagectomy. The first stage is through an incision in the abdomen to “free up” and remove part of the stomach. This section of stomach will be formed into a replacement esophagus. The second stage is done through an incision in the chest to remove the diseased part of the esophagus, insert the newly formed esophagus, and re-attach the esophagus to the remainder of the stomach. The procedure takes about 5 hours.

The Ivor Lewis procedure is used for those who have tumors in the middle or lower third of the esophagus.

Not Necessarily Turning A Dead Horse Into A Rug: More On Vital Stim

With all due respect, and at the risk of turning the dead horse into a rug, the meta-analysis published by Carnaby-Mann and Crary, used excessively lax inclusion criteria, rendering the results very difficult if not impossible to generalize to the clinical setting. Here is one set of examples to support this comment, and there are several others that the discussion group certainly does not want to hear.

A meta-analysis is only as good as the criteria for allowing studies to be included. They need to be rigorous.

The use of the Physiotherapy Evidence Database scale (PEDro) scale for judging evidence quality, at a cutoff score of 4 on the scale, allowed studies such as Freed, et al. (2001) (we all know which study that was and all of its problems-it is only one example from this meta-analysis’s included studies), to be included in the meta-analysis. Freed et al. (2001), as we all are aware, a) violated intention to treat with 10% of their patients disappearing from the data analysis for unexplained reasons or because they could not pay for the treatment after insurance terminated coverage(PEDro item 9), used judges that were not masked to patient assignment (PEDro item 6 and 7), selectively assigned patients to electrical stimulation “because they were referred for the study” (PEDro items 3 and 5), compared dissimilar groups of heterogeneous patients and excluded patients for unexplained reasons (PEDro item 4), and did not randomly assign patients to groups (PEDro item 2). In addition the study was conducted by the owner of the patent for the technology investigated, a serious conflict of interest not even acknowledged as an important criterion for evidence quality assessment by the PEDro. These serious flaws notwithstanding Carnaby-Mann and Crary included this, and several other studies of poor evidence quality, in their meta-analysis. The results must be considered weak and ungeneralizable to the clinical setting, at best, given the inclusion of poor quality studies.

Meta-analysis is an effort to use the best literature available to answer important questions about cause and effect. This study did not accomplish that goal. The lack of good quality studies does not justify the use of poor quality studies to make important decisions about treatment effectiveness or efficacy. It is always possible for a faction to cherry pick results from various studies to support their point of view. That is not what meta-analysis is about. This is why Vioxx was such a colossal failure.

James L. Coyle

University of Pittsburgh

Thinking of Patients As Your Own

Of course, there is a caveat. Sometimes, we may be going to ART or MUH to see patients who normally may or may not be on our caseload. Therefore, expect to be flexible in your plans.

Vital Stim Research: Questions and Answers

There were several interesting findings from Dr. Ludlow's study looking at the effect of applying NMES to the anterior portion of the neck, including the improvement in swallowing from sensory stim alone that Dr. Day mentioned. Another outcome that is often not mentioned is the unexpected finding that the patients who had greatest hyoid depression had the greatest improvement in swallowing. I would be interested to see future research looking into the cause behind this counter-intuitive finding. While these findings could possibly suggest a positive effect from using NMES during tx, as the authors point out, this is not a treatment study but an effect study. Therefore, conclusions should not be made, either positive or negative, about the impact these findings may have on treatment.

Instead, we should make conclusions about treatment based on treatment studies. One study worth noting is Carnaby-Mann GD, Crary MA. Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis. Arch Otolaryngol Head Neck Surg. June 2007; 133 (6): 564-571.

With regards to the question "where is research on chronic dysphagia (1 year post)?"asked in an earlier posting , look for Dr. Carnaby-Mann and Dr. Crary's study "Adjunctive neuromuscular electrical stimulation for treatment refractory dysphagia: A phase I case series report" which will be published in the Annals of Otology, Rhinology & Laryngology soon. The patients in this study were an average of 5 years post onset.

With regards to any research, rather than focusing on the source of funding, I believe it is more productive to critically read the entire study, look at the research methodology, and then make decisions about if the the findings are applicable to what we do in treatment. Again, we should agree to disagree on what conclusions we will each make.

The debate about using NMES in swallowing tx has been good for our profession in that it has challenged us to look at the research behind what we do as clinicians. The caliber of research that we are requesting about VitalStim (randomized controls, studies that account for the possibility of spontaneous recovery) should be sought for all our therapies.

Jen Carter, M.Ed., CCC-SLP
Clinical Specialist, VitalStim Therapy

Cocaine and Amphetamine Abuse Increases Stroke Risk

Content provided by Health Day
MONDAY, April 9 2007 (HealthDay News) -- The abuse of stimulant drugs such as cocaine and amphetamines may increase the risk of stroke by raising blood pressure or triggering spasms in blood vessel walls that contribute to the narrowing of the vessels, a U.S. study says.

Researchers analyzed data on patients treated for stroke or drug abuse at Texas hospitals between 2000 and 2003. They concluded that amphetamine abuse was associated with a fivefold increased risk of hemorrhagic stroke (bleeding in the brain), but not ischemic stroke (blocked blood flow to the brain).

They also found that cocaine was associated with a greater than twofold increased risk of both hemorrhagic and ischemic stroke.

In addition, amphetamine abuse, but not cocaine use, was associated with a higher risk of death after hemorrhagic stroke, the study authors said.

"The public health implications of these findings are heightened by growing news accounts suggesting a recent increase in methamphetamine abuse, particularly in the southwestern, western and Midwestern states," they wrote.

"This concern was supported by our finding that, among hospitalized patients in Texas from 2000 to 2003, the rate of amphetamine abuse was increasing faster than that of any other drug, including cocaine, and the rate of strokes among amphetamine abusers was increasing faster than the rate of strokes among abusers of any other drug."

The study is in the April issue of the journal Archives of General Psychiatry.

Two Weeks Before Mid-Term

Two weeks before mid-term:
Time to start thinking of the TCU patients as your own. This, obviously, means knowing them. (If you need the daily patient sheet, I will happily print it for you. Just make sure the patients' names and MRNs are blacked out or cut off the page before you take it off campus.)

Come to clinic relatively prepared with these three questions in mind: e.g. which patients, what deficits, and with which treatment tasks?

Take a little time when you first arrive to select materials, then let's head out to your first patient. Remember, of course, that patient may not be available so be prepared to move on to another.

Thermal Tactile Stimulation

Thermal stimulation or thermal-tactile application has been investigated quite a bit and has largely been dismissed as it has been shown to produce only momentary and non-durable reductions in stage transition duration (pharyngeal delay time) (Hamdy et al., 2003; Miyaoka et al., 2006; Rosenbek et al., 1998; Rosenbek, Robbins, Fishback, & Levine, 1991; Rosenbek, Roecker, Wood, & Robbins, 1996). It is receiving more thought recently due to current questions about the role of sensory input on neuromuscular plasticity in adults with neurological diseases and stroke.

James L. Coyle
University of Pittsburgh

References



Hamdy, S., Jilani, S., Price, V., Parker, C., Hall, N., & Power, M. (2003). Modulation of human swallowing behaviour by thermal and chemical stimulation in health and after brain injury. Neurogastroenterology & Motility, 15, 69-77.

Miyaoka, Y., Haishima, K., Takagi, M., Haishima, H., Asari, J., & Yamada, Y. (2006). Influences of thermal and gustatory characteristics on sensory and motor aspects of swallowing. Dysphagia, 21, 1-11.

Rosenbek, J. C., Robbins, J. A., Fishback, B., & Levine, R. L. (1991). Effects of thermal application on dysphagia after stroke. Journal of Speech and Hearing Research, 34, 1257-1268.

Rosenbek, J. C., Robbins, J. A., Willford, W. O., Kirk, G., Schiltz, A., Sowell, T. W. et al. (1998). Comparing treatment intensities of tactile-thermal application. Dysphagia., 13, 1-9.

Rosenbek, J. C., Roecker, E. B., Wood, J. L., & Robbins, J. A. (1996). Thermal application reduces the duration of stage transition in dysphagia after stroke. Dysphagia, 11, 225-233.

Lateral Medullary Stroke (LMS)

James Coyle writes:

a lateral medullary stroke (LMS). These strokes damage the important brainstem nuclei that mediate sensory and motor functions in the pharynx as the interconnections between them and other centers. Immediately prior to pharyngeal stage onset the UES resting pressure is seen to drop a little, due to inhibition of the vagal motor outflow to the sphincter. This tight, resting pressure keeps the UES tightly closed all of the time except when we swallow. In LMS the patient may have no inhibition of UES resting pressure, hence the h yolaryngeal musculature cannot overcome the intertia of the tight UES.


One clue is the side to which bolus flow is preferential. You said right. If this is true then the right pyriform sinus is more compliant than the left. Provided that you have trained him in airway protection maneuvers, head rotation might be worth assessing. I would expect that rotation away from the compliant side would facilitate flow to the more compliant side, but you cannot always predict this outcome based on lesion site knowledge because if an upper motor neuron lesion has produced denervation of the hypopharynx you will have a spastic paresis and less compliance, while a flaccid paralysis caused by a lower motor neuron (nucleus or nerve root) lesion will make the sinus more compliant. You will need to evaluate it provided it is safe to do so based on airway protection ability.

...Nearly 90-95% of the dysphagia seen in most patients with LMS resolves to a functional swallow or one that can be compensated with intervention.



James L. Coyle

University of Pittsburgh

Billing Issues to Ponder

Medicare Part A recognizes concurrent therapy - treating more than one patient at one time on separate tasks / goals (sometimes called "dovetailing") AND group therapy - treating 2 to 4 patients at one time working on the same tasks / goals for the same time. For concurrent therapy, if both patients were in the session for one hour, they might be billed for up to one hour of individual treatment. If there were 4 patients in a group for one hour, all 4 patients would be billed for one hour of group. In the SNF environment, group therapy minutes are limited to 25% of the total treatment program for each discipline during the last 7 days (minutes recorded on the MDS).

Under Medicare Part B - which would cover outpatient therapy - concurrent therapy is not recognized and must be either billed as group or the time must be divided according to how the attention of the therapist is divided. Patients may participate in a group as defined above as well. There is no CPT code to reflect group therapy for dysphagia under Medicare Part B. 97150 is the code used by PT or OT,
92508 is the code used for speech/language/cognition intervention in a group.

Training Yes and No Responses

With some aphasias, yes and no responses may be unreliable. The person may nod negatively while verbalizing 'yes' or 'yeah' or 'okay.'

To train differentiation of the affirmative from the negative, show 4 pictured objects (e.g. hammer, saw, screwdriver, scissors) and tell the person "I am going to ask you a set of questions all of which you will answer with a "yes" and a head nod." Demonstrate this. Then point to 1 (i.e. hammer) of the 4 pictured objects, asking, "Is this a hammer?" The patient should say "yes." If so, verbally indicate that this is right. If not, then demonstrate the appropriate response. Continue.

After "yes" is established, switch to "no." Give the same instruction. "I am going to ask you a set of questions all of which you will answer with a "no" and a head nod." Demonstrate this. Then, take the same 4 pictures, point to the hammer as before, but now ask, "Is this a screwdriver?" If the person answers "no" praise and verbally indicate that is correct. If the person says "yes" then demonstrate the proper response. Continue.

Track percentage correct and establish 100% differentiation between yes and no responses with this sort of questioning.

Move to personal information or immediate situation yes no questions once you have an established differentiation.

MRSA

Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacteria that is resistant to certain antibiotics. These antibiotics include methicillin and other more common antibiotics such as oxacillin, penicillin and amoxicillin. Staph infections, including MRSA, occur most frequently among persons in hospitals and healthcare facilities (such as nursing homes and dialysis centers) who have weakened immune systems.

What is Respiratory Alkalosis?

Is Respiratory Alkalosis synonymous with metabolic alkalosis?

Severe Metabolic Alkalosis

Severe metabolic alkalosis (ie, blood pH >7.55) is a serious medical problem. Mortality rates have been reported as 45% in patients with an arterial blood pH of 7.55 and 80% when the pH was greater than 7.65.

Severe alkalosis causes diffuse arteriolar constriction with reduction in tissue perfusion. By decreasing cerebral blood flow, alkalosis may lead to tetany, seizures, and decreased mental status. Metabolic alkalosis also decreases coronary blood flow and predisposes persons to refractory arrhythmias.

Metabolic alkalosis causes hypoventilation, which may cause hypoxemia, especially in patients with poor respiratory reserve, and it may impair weaning from mechanical ventilation.

Alkalosis decreases the serum concentration of ionized calcium by increasing calcium ion binding to albumin. In addition, metabolic alkalosis is almost always associated with hypokalemia, which can cause neuromuscular weakness and arrhythmias, and, by increasing ammonia production, it can precipitate hepatic encephalopathy in susceptible individuals.

Tests for Review and Readings to Complete

Please note this post has been updated!

What are tachycardia and bradycardia?

Look these up!

Spring 2008 Practicum Schedule

Mondays: 8-12 Transitional Care Unit Patient Care
Tuesdays: 8-10:30 TCU Patient Care
10:30-Noon TCU Patient Care Conference
Wednesdays: 8-9 ETIVS Swallowing/Voice Rounds BSB 202
9-12 TCU Patient Care
Thursdays: 8-12 TCU Patient Care

What is an Empyema?

Look up empyema? What is it? Would it have any effect on voice and/or swallowing? Why or why not? Are empyemas usually on the right side of the body?

Adult Clinical Rotations: Student Presentation Guidelines

Adult Clinical Rotations

Student Presentation Guidelines

Description: Students will be required to present a clinical topic to the adult speech pathologists. Oral and written components are required.

Topics: Teach us something new! Maybe a disorder you had an experience with during your rotation (something we could learn more about); patient and/or family information packets; or a treatment strategy. If you decide to present a treatment strategy, please include the following information: treatment efficacy, cost efficiency, availability, reliability, etc. If you have difficulty choosing a topic, ask your supervisor for suggestions.

Written requirement: Please prepare a summarized handout for clinicians (1-2 pages) or a packet for patients/families. Include references. Do not print something directly from a website. You should organize this information on your own. If creating a Pt/family packet, provide helpful web sites, phone numbers, support groups, etc.

Oral requirement: You will be given approximately 5-7 minutes including a question-answer period. This is not a great deal of time, so plan accordingly.

Date: TBA

Location: 11th floor of Rutledge Towers (ENT conference room). Please bring your lunch.