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The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has brought renewed attention to respiratory aerosol and droplet generation. While many studies have robustly quantified aerosol (20 µm diameter) generated by a cohort of 76 adults and children using a water-sensitive paper droplet deposition approach. Unvoiced and voiced activities spanning different levels of loudness, different lengths of sustained phonation, and a specific manner of articulation in isolation were investigated. We find that oral articulation drives >20 µm droplet generation, with breathing generating virtually no droplets and speaking and singing generating on the order of 250 droplets min−1. Lip trilling, which requires extensive oral articulation, generated the most droplets, whereas shouting “Hey,” which requires minimal oral articulation, generated relatively few droplets. Droplet size distributions were all broadly consistent, and no significant differences between the children and adult cohorts were identified. By comparing the aerosol and droplet emissions for the same participants, the full size distribution of respiratory aerosol (0.5–1000 µm) is reported. Although 20 µm droplets dominate the mass concentration. Accurate quantification of aerosol concentrations in the 10–70 μm size range remains very challenging; more robust aerosol analysis approaches are needed to characterize this size range.

Background Persistent throat symptoms are commonly attributed to ‘laryngopharyngeal reflux’. Despite a limited evidence base, these symptoms are increasingly being treated in primary care with proton pump inhibitors. Objective To assess the value of proton pump inhibitor therapy in patients with persistent throat symptoms. Design This was a double-blind, placebo-controlled, randomised Phase III trial. Setting This was a multicentre UK trial in eight UK ear, nose and throat departments. Participants A total of 346 participants aged ≥ 18 years with persistent throat symptoms and a Reflux Symptom Index score of ≥ 10, exclusive of the dyspepsia item, were recruited. Intervention Random allocation (1 : 1 ratio) to either 30 mg of lansoprazole twice daily or matched placebo for 16 weeks. Main outcome measure Symptomatic response (i.e. total Reflux Symptom Index score after 16 weeks of therapy). Results A total of 1427 patients were screened and 346 were randomised. The mean age was 52 years (standard deviation 13.7 years, range 20–84 years); 150 (43%) participants were male and 196 (57%) were female; 184 (53%) participants had a mild Reflux Symptom Index minus the heartburn/dyspepsia item and 162 (47%) had a severe Reflux Symptom Index minus the heartburn/dyspepsia item. A total of 172 patients were randomised to lansoprazole and 174 were randomised to placebo. Main outcomes A total of 267 participants completed the primary end-point visit (lansoprazole, n = 127; placebo, n = 140), of whom 220 did so between 14 and 20 weeks post randomisation (‘compliant’ group); 102 received lansoprazole and 118 received placebo. The mean Reflux Symptom Index scores at baseline were similar [lansoprazole 22.0 (standard deviation 8.0), placebo 21.7 (standard deviation 7.1), overall 21.9 (standard deviation 7.5)]. The mean Reflux Symptom Index scores at 16 weeks reduced from baseline in both groups [overall 17.4 (standard deviation 9.9), lansoprazole 17.4 (standard deviation 9.9), placebo 15.6 (standard deviation 9.8)]. Lansoprazole participants had estimated Reflux Symptom Index scores at 16 weeks that were 1.9 points higher (worse) than those of placebo participants (95% confidence interval –0.3 to 4.2; p adj = 0.096), adjusted for site and baseline severity. Secondary outcomes Ninety-five (43%) participants achieved a Reflux Symptom Index score in the normal range (n = 109; placebo, n = 117), of whom 181 were ‘compliant’. The mean Reflux Symptom Index scores at 12 months reduced from baseline in both groups [lansoprazole 16.0 (standard deviation 10.8), placebo 13.6 (standard deviation 9.6), overall 14.7 (standard deviation 10.2)]. A total of 87 (48%) participants achieved a Reflux Symptom Index score in the normal range at 12 months: 33 (40%) in the lansoprazole group and 54 (55%) in the placebo group. Likewise, the Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux – Health Related Quality of Life total scores and subscales all showed very similar changes in the lansoprazole and placebo cohorts at both 16 weeks and 12 months. Limitations Drop-out rate and compliance are issues in pragmatic clinical trials. The Trial Of Proton Pump Inhibitors in Throat Symptoms (TOPPITS) aimed to detect clinically relevant difference with 90% power. The 346 randomised participants reduced to 283 at the primary end point; 267 completed the primary outcome measure, 220 within the protocol time scale. Despite this, the powers to detect the clinically relevant difference in Reflux Symptom Index score at 16 weeks were 82% (compliant comparison) and 89% (pragmatic comparison). The lack of difference between lansoprazole and placebo is generalisable across NHS clinics. Conclusions Participants on lansoprazole did not report significantly better outcomes than participants on placebo on any of the three patient-reported outcome tools (Reflux Symptom Index, Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux – Health Related Quality of Life). This multicentre, pragmatic, powered, definitive Phase III trial found no evidence of benefit for patients by treating persistent throat symptoms with lansoprazole. Trial registration Current Controlled Trials ISRCTN38578686 and EudraCT number 2013-004249-17. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 3. See the NIHR Journals Library website for further project information.

Introduction.Voice assessment and treatment involve the manipulation of all the subsystems of voice production, and may lead to production of respirable aerosol particles that pose a greater risk of potential viral transmission via inhalation of respirable pathogens (e.g. SARS-CoV-2) than quiet breathing or conversational speech. Objective: To characterise the production of respirable aerosol particles during a selection of voice assessment therapy tasks.MethodsWe recruited 23 healthy adult participants (12 males, 11 females), 11 of whom were speech-language pathologists specialising in voice disorders. We used an aerodynamic and optical particle sizer to measure the number concentration and particle size distributions of respirable aerosols generated during a variety of voice assessment and therapy tasks. The measurements were carried out in a laminar flow operating theatre, with a near-zero background aerosol concentration, allowing us to quantify the number concentration and size distributions of respirable aerosol particles produced from assessment/therapy tasks studied. ResultsAerosol number concentrations generated while performing assessment/therapy tasks were log-normally distributed among individuals with no significant differences between professionals (speech-language pathologists) and non-professionals or between males and females. Activities produced up to 32 times the aerosol number concentration of breathing and 24 times that of speech at 70-80 dBA. In terms of aerosol mass, activities produced up to 163 times the mass concentration of breathing and up to 36 times the mass concentration of speech. Voicing was a significant factor in aerosol production; aerosol number/mass concentrations generated during voiced activities were 1.1-5 times higher than their unvoiced counterpart activities. Additionally, voiced activities produced bigger respirable aerosol particles than their unvoiced variants except the trills. Humming generated higher aerosol concentrations than sustained /a/, fricatives, speaking (70-80 dBA), and breathing. Oscillatory semi-occluded vocal tract exercises (SOVTEs) generated higher aerosol number/mass concentrations than activities without oscillation. Water resistance therapy (WRT) generated the most aerosol of all activities, ~10 times higher than speaking at 70-80 dBA and >30 times higher than breathing.ConclusionsAll activities generated more aerosol than breathing, although a sizeable minority were no different to speaking. Larger number concentrations and larger particle sizes appear to be generated by activities with higher suspected airflows, with the greatest involving intraoral pressure oscillation and/or an oscillating oral articulation (WRT or trilling).

The importance of bio-aerosols across the earth system has been known for some time. With the unfortunate situation arising from the COVID19 pandemic, attention has turned to appropriate detection technologies that could be used to better understand the contribution of aerosols generated from the lung in various settings. In this project, the wideband Integrated Bioaerosol Sensor (WIBS-NEO) was deployed in a zero-background clinical environment which permitted the aerosols measured to be directly ascribed to specific vocalisations undertaken. The fluorescent signatures of expelled aerosol from a variety of human participants were captured during individual speech and language therapy activities (speaking, humming, sustained phonation, fricatives, projection, and tongue trills). In this presentation we present the varying fluorescent signatures and particle morphologies.Furthermore, millions across the UK have now adopted face coverings into their day to day lives with one of the most widely adopted and commonplace being the disposable surgical face mask. Yet, questions still remain as to what types of vocalisations produce the most aerosols and the efficacy of the face mask in reducing transmission. To supplement this, measurements with the WIBS-NEO were conducted where participants did not wear a mask, and then subsequently repeated wearing a surgical mask. The fluorescent intensity, concentration (cm3), size (um), and asphericity were then compared for each activity with and without a mask. WIBS-NEO information:https://www.dropletmeasurement.com/product/wideband-integrated-bioaerosol-sensor/Example paper using the WIBS:E.Toprak and M. Schnaiter, Atmos. Chem. Phys., 2013, 13, 225–243.

Aerosol particles of respirable size are exhaled when individuals breathe, speak and sing and can transmit respiratory pathogens between infected and susceptible individuals. The COVID-19 pandemic has brought into focus the need to improve the quantification of the particle number and mass exhalation rates as one route to provide estimates of viral shedding and the potential risk of transmission of viruses. Most previous studies have reported the number and mass concentrations of aerosol particles in an exhaled plume. We provide a robust assessment of the absolute particle number and mass exhalation rates from measurements of minute ventilation using a non-invasive Vyntus Hans Rudolf mask kit with straps housing a rotating vane spirometer along with measurements of the exhaled particle number concentrations and size distributions. Specifically, we report comparisons of the number and mass exhalation rates for children (12–14 years old) and adults (19–72 years old) when breathing, speaking and singing, which indicate that child and adult cohorts generate similar amounts of aerosol when performing the same activity. Mass exhalation rates are typically 0.002–0.02 ng s−1from breathing, 0.07–0.2 ng s−1from speaking (at 70–80 dBA) and 0.1–0.7 ng s−1from singing (at 70–80 dBA). The aerosol exhalation rate increases with increasing sound volume for both children and adults when both speaking and singing.

INTRODUCTION ENT UK released guidelines in 2010 detailing the requisite structure for the creation of a laryngeal intervention clinic. The senior author's practice is the only one regionally that offers this service, and our objective was to review this to determine whether vocal cord medialization injections were showing an improvement in quality of voice for patients. MATERIALS AND METHODS Patients were reviewed in a specialist voice clinic prior to being offered vocal cord injection under local anaesthetic in a separate dedicated weekly clinic. They would be assessed by the senior author and a dedicated voice specialist speech and language therapist (SALT). This would include a preinjection grade, roughness, breathiness, asthenia, and strain (GRBAS), Voice Handicap Index (VHI)-10, and the measuring of maximum phonation time (MPT) with the aid of Opera Vox Apple iPad application. RESULTS Data were available for 186 injections, on patients with a median age of 66 years (interquartile range [IQR]: 51-75), of whom 61% were male. VHI-10 score improved significantly, from a mean of 26.7 to 12.5 (P

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has resulted in an unprecedented shutdown in social and economic activity, with the cultural sector particularly severely affected. Restrictions on musical performances have arisen from a perception that there is a significantly higher risk of aerosol production from singing than speaking, based upon high-profile examples of clusters of COVID-19 following choral rehearsals. However, comparing aerosol generation from different types of vocalization, including singing, across a range of volumes is a rapidly evolving area of research. Here, we measured aerosols from singing, speaking and breathing from a large cohort of 25 professional singers in a range of musical genres in a zero-background environment, allowing unequivocal attribution of aerosol production to specific vocalizations. We do not assess the relative volumes at which people speak and sing. However, both showed steep increases in mass concentration with increase in loudness (spanning a factor of 20–30 across the dynamic range measured, p < 0.001). At the quietest volume (50 to 60 dBA), neither singing (p = 0.19) nor speaking (p = 0.20) were significantly different to breathing. At the loudest volume (90 to 100 dBA), a statistically significant difference (p < 0.001) was observed between singing and speaking, but with singing only generating a factor of between 1.5 and 3.4 more aerosol mass. Guidelines for musical performances should be based on the loudness and duration of the vocalization, the number of participants and the environment in which the activity occurs, rather than the type of vocalization. Mitigations such as the use of amplification and increased attention to ventilation should be employed where practicable. Copyright © 2021 American Association for Aerosol Research

The performing arts have been significantly restricted due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. We report measurements of aerosol and droplet concentrations generated when playing woodwind and brass instruments and comparisons with breathing, speaking, and singing. These measurements were conducted in a room with zero number concentration aerosol background in the 0.5-20 µm diameter size range, allowing clear attribution of detected particles to specific activities. A total of 13 instruments were examined across 9 participants. Respirable particle number concentrations and size distributions for playing instruments are consistent with those from the participant when breathing, based on measurements with multiple participants playing the flute and piccolo as well as measurements across the entire cohort. Due to substantial interparticipant variability, we do not provide a comparative assessment of the aerosol generated by playing different instruments, instead considering only the variation in aerosol yield across all instruments studied. Both particle number and mass concentrations from playing instruments are lower than those from speaking and singing at high volume, and no large droplets >20 µm diameter are detected. Combined, these observations suggest that playing instruments generates less aerosol than speaking or singing at high volumes. Moreover, there is no difference between the aerosol concentrations generated by professional and amateur performers while breathing, speaking, or singing, suggesting conclusions for professional singers may also apply to amateurs.

In the setting of a voice clinic, the voice may be assessed in a number of different ways. As a bare minimum, assessment should include stroboscopic examination, patient self-reported questionnaires, and clinician-reported perceptual evaluation. In addition, recordings of the voice may be analyzed using computer software: several different measures exist, but the most widely used are jitter, shimmer, and noise-to-harmonic ratio. There are, however, significant limitations of these measures, including access to the equipment, inter-test reliability of the measurements, and a lack of correlation with clinical improvement. Other mathematical techniques (nonlinear algorithms) may provide more robust measurements. A pragmatic approach to assessment in the voice clinic suggests that stroboscopic examination should be accompanied by patient-reported questionnaires and clinician-rated voice assessments.

Seaweed has a long-associated history of use as a supplemented livestock feed, providing nutrients and vitamins essential to maintaining animal health. Some species of seaweed, particularly the fucoids, are well-known accumulators of the metalloid arsenic (As). Arsenic toxicity to humans is well established even at low exposure levels and is considered a class 1 human carcinogen. As mankind's appetite for livestock produce continues to grow unabated, there is a concern that consumption of livestock produce reared on a diet supplemented with seaweed animal feed (SAF) may pose a threat to the human population due to potentially high levels of As present in seaweed. To address this concern and provide end users, including industry, consumers, policymakers and regulators with information on the exposure associated with As in commercial seaweed animal feed, the estimated daily intake (EDI) of As was calculated to evaluate potential human exposure levels. Using As data from a commercially available seaweed meal over a five-year period (2012–2017) a population exposure assessment was carried out. A Monte Carlo simulation model was developed to characterise the feed to food transfer of As from animal feed to animal produce such as beef, milk, chicken, and eggs. The model examined initial levels in seaweed, inclusion rate in animal feed, animal feeding rates and potential transfer to food produced from a supplemented diet of SAF. The analysis of seaweed animal feed showed that inorganic As was a small fraction of the total As found in seaweed meal (80:1). Statistical analysis found significant differences in the concentration of As in seaweed animal feed depending on the grain size (p

In ophthalmology, there have been few reports of botulinum toxin type-A (BTX-A) injection into the lacrimal gland to treat epiphora. In ENT, adductor and abductor (ABSD) spasmodic dysphonia are often treated with BTX-A injections into the respective overacting vocal cord muscles. We describe a 53-year old male with Parkinson's disease who did not respond to BTX-A injections to either the lacrimal gland, for epiphora secondary to Parkinsonian-related blink lagophthalmos, or posterior cricoarytenoid (PCA) muscles for ABSD. Subsequent BTX type-B (BTX-B) injections into the lacrimal gland remarkably improved his epiphora. BTX-B injections into the PCA muscle also greatly improved his dysphonia. We describe the first reported case of (1) BTX-B injection into the lacrimal gland for epiphora, (2) use of Botox in treating epiphora due to blink lagophthalmos/reduced blink frequency secondary to Parkinson's disease, (3) BTX-B use in treating ABSD, and (4) association between ABSD and Parkinson's disease.

The management of unilateral vocal fold paralysis has undergone significant changes in the last 2 decades. This has largely been made possible by advances in endoscope technology and new injectable materials.This article will cover the main changes in management of patients with unilateral vocal fold paralysis and summarize the recent literature in relation to early intervention in this group. Several recent studies have suggested that early vocal fold injection medialization reduces the likelihood of needing open laryngeal framework surgery in future.Early injection medialization appears to give good long-term results with few complications and minimizes the need for future laryngeal framework surgery. It should be considered in centres wherein the equipment and trained staff are available.

Tapia syndrome, a rare complication of posterior cervical surgery, characterised by concurrent paralyses of recurrent laryngeal branch of vagus and hypoglossal cranial nerves, occurred in a patient after posterior cervical foraminotomies for radiculopathy. We discuss hypothesised pathophysiology, and diagnostic, therapeutic and avoidance strategies in relevance to prone neurosurgical procedures.

Background Patients with unilateral vocal fold paralysis (UVFP) usually present with dysphonia, but can also be breathless and have problems with their swallowing. Speech and language therapy forms the initial mainstay of management in cases of UVFP, since up to 60% of cases will resolve spontaneously. If vocal fold paralysis persists surgery, in the form of injection medialisation, has been shown to be an effective intervention. What is currently unclear is which is the most effective material available for injection. Objectives To assess the effectiveness of alternative injection materials in the treatment of UVFP. Search methods We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 23 March 2012. Selection criteria Randomised controlled trials (RCTs) of injectable materials in patients with UVFP. The outcomes of interest were patient and clinician-reported improvement, and adverse events. Data collection and analysis Two authors independently selected studies from the search results and extracted data. We used the Cochrane 'Risk of bias' tool to assess study quality. Main results We identified no RCTs which met the inclusion criteria for this review. We excluded 18 studies on methodological grounds: 16 non-randomised studies; one RCT due to inadequate randomisation and inclusion of non-UVFP patients; and one RCT which compared two different particle sizes of the same injectable material. Authors' conclusions There is currently insufficient high-quality evidence for, or against, specific injectable materials for patients with UVFP. Future RCTs should aim to provide a direct comparison of the alternative materials currently available for injection medialisation.

Foreign accent syndrome is a rare dysprosody in which pronunciation of a patient's speech is perceived by same-language listeners as sounding foreign. Sixty cases have been described between 1941 and 2009. It is commonly associated with an acquired brain injury (vascular insult/head injury), but also with psychogenic illness and has been described in two cases as a developmental problem. Here we describe a case secondary to a minor electrocution associated with no evidence of structural brain injury on imaging.

Clinical acoustic voice-recording analysis is usually performed using classical perturbation measures, including jitter, shimmer, and noise-to-harmonic ratios (NHRs). However, restrictive mathematical limitations of these measures prevent analysis for severely dysphonic voices. Previous studies of alternative nonlinear random measures addressed wide varieties of vocal pathologies. Here, we analyze a single vocal pathology cohort, testing the performance of these alternative measures alongside classical measures. We present voice analysis pre- and postoperatively in 17 patients with unilateral vocal fold paralysis (UVFP). The patients underwent standard medialization thyroplasty surgery, and the voices were analyzed using jitter, shimmer, NHR, nonlinear recurrence period density entropy (RPDE), detrended fluctuation analysis (DFA), and correlation dimension. In addition, we similarly analyzed 11 healthy controls. Systematizing the preanalysis editing of the recordings, we found that the novel measures were more stable and, hence, reliable than the classical measures on healthy controls. RPDE and jitter are sensitive to improvements pre- to postoperation. Shimmer, NHR, and DFA showed no significant change (P0.05). All measures detect statistically significant and clinically important differences between controls and patients, both treated and untreated (P0.001, area under curve [AUC]0.7). Pre- to postoperation grade, roughness, breathiness, asthenia, and strain (GRBAS) ratings show statistically significant and clinically important improvement in overall dysphonia grade (G) (AUC=0.946, P0.001). Recalculating AUCs from other study data, we compare these results in terms of clinical importance. We conclude that, when preanalysis editing is systematized, nonlinear random measures may be useful for monitoring UVFP-treatment effectiveness, and there may be applications to other forms of dysphonia.

This paper notes that the dynamics of public expenditure on health care is determined not only by changes in the age structure but also by a set of interrelated demand and supply factors, which are often exogenous to policy decisions. Therefore, reliable projections should account for such non-demographic factors. The authors first describe the projection methodology employed by the European Commission and the Aging Working Group and present the main results. They then discuss possible methodological improvements. In particular, they suggest that a better understanding of the interactions between public and private spending on health could improve the projections. Moreover, some efforts should be devoted to the analysis of supply side factors and to enhancing the comparability of the input data collected from national authorities. It would also be useful to attach probabilities to the shocks introduced in each scenario. Finally, linking the projection results to the institutional setting of each country would enhance the policy relevance of the exercise.

This paper presents an assessment of the budgetary impact of ageing for the EU Member States. It draws upon the macroeconomic assumptions developed jointly by the Ageing Working Group of the Economic Policy Committee and the European Commission-Directorate General for Economic and Financial Affairs for the purpose of making age-related expenditure projections. The paper presents and analyses projections of the impact of ageing populations on the main age-related public expenditure items. The projections are not forecasts, but nonetheless provide an indication of the potential timing and scale of budgetary changes that could result from ageing populations in a no-policy change scenario. The projections show where, (in which countries), when and to what extent ageing pressures will accelerate as the baby-boom generation retires. In doing so, the projections are helpful in highlighting the immediate and future challenges for governments posed by demographic trends. The projections point to pressing economic policy challenges for the EU. From an economic perspective, potential growth rates are projected to fall to levels below those observed in recent decades. Fiscal challenges will come from a higher share of the total population in older age cohorts and a decline in the share of the population that is economically active. The fiscal impact of ageing is projected to be substantial in almost all Member States, with the effects accelerating as of 2010. Overall, on the basis of current policies, age-related public expenditures are projected to increase on average by almost 4 percentage points of GDP by 2050 in the EU and rise considerably more in several Member States, especially through pension, health care and long-term care. Ageing populations are expected to lead to a substantial increase in public pension expenditure in some countries. In eleven EU Member States the increase is projected to be over 5 percentage points of GDP. However, reforms implemented in recent years in some other Member States are having visible positive impacts. They have sharply reduced the projected increase in expenditures, diminishing the budgetary impact of ageing. Nonetheless, in some countries, the scale of reforms has been insufficient and they need to be pursued further to cope with the budgetary challenge. At the same time, implementing other measures, for instance promoting higher employment rates of older workers that contribute to adequate retirement incomes in the future might be required in order to ensure the lasting success of the pension reforms. In the EU as a whole, the current fiscal positions coupled with the projected cost of ageing would lead to government debt being on an explosive path and it would reach some 130% of GDP in 2050. The required fiscal adjustment to set the public finances on a sustainable path, the so-called sustainability gap, is estimated to be about 2½ per cent of GDP. The situation however varies greatly among EU member states, as a result of the diversity and degree of maturity of their public pension arrangements and the effects of pension reforms enacted so far. Nearly all countries have sustainability gaps. This implies that based on the current budgetary position (in 2007) and with no changes in fiscal policies, an adjustment is necessary so as to render the public finances sustainable over the long term for most EU countries.In some EU Member States, there is a risk of unsustainable public finances even before the long-term budgetary impact of ageing populations is considered. Indeed, the current budgetary position, in addition to the long-term budgetary impact of ageing, affects the sustainability of public finances. However, for the EU as a whole and for several Member States, the current budgetary position contributes in part to cover the longer term budgetary impact of ageing. This clearly shows that the fiscal consolidation in recent year's bear fruit and that fiscal policy can affect strongly the sustainability position. As regards policy conclusions, the paper underlines the critical need for ensuring that retirement behaviour takes due account of future increases in life expectancy and the need for more efficient and cost-effective service provision, in particular in health care and long-term care, in order to reduce the main sources of potential fiscal pressure. Nonetheless, containing the observed trend increase in health-care spending above that motivated by ageing is likely to be challenging. Moreover, it shows that progress has been made in recent years in terms of consolidating the public finances, with a visible impact on the sustainability positions in the EU Member States. However, it also reveals that several Member States still have a long way to go. First, they need to reach the medium-term budgetary targets (the MTOs) that have been set; and second, seriously consider pursuing more ambitious fiscal policies so as to put the public finances on a more sustainable footing, for the benefit of enabling both the people currently working and especially for those who will do so tomorrow to embrace the future with greater confidence.

The paper examines the rationale for creating a database on labour market reforms and looks at the value-added of LABREF compared with existing datasets. In doing so, it considers recent developments in the economic literature as regards the design of labour market institutions. After a description of the coverage and structure of the database and of the information contained therein, the paper provides a summary overview of reforms enacted by EU Member States in 2004. On the base of the qualitative information in the database, the paper builds simple indicators of reform intensity and makes a tentative characterisation of the reforms strategy implemented by the Member States in 2004.

This paper presents an assessment of the overall economic impact of ageing for the EU Member States. It draws upon the macroeconomic assumptions developed by the Ageing Working Group attached to the Economic Policy Committee and the Directorate General for Economic and Financial Affairs for the purpose of making age related expenditure projections. The paper presents and analyses projections of the impact of ageing populations on the labour market using a refined cohort approach by age and gender, as well as projections for potential economic growth rates up to 2050. The projections point to pressing economic policy challenges for the EU. From an economic perspective, potential growth rates and living standards are projected to fall to levels below those observed in recent decades: moreover, the sources of economic growth will alter over time, with productivity becoming the dominant source. Fiscal challenges will come from both a higher share of the total population in older age cohorts and a decline in the share of the population that is economically active. As regards policy conclusions, the paper underlines the critical need for further labour market reforms, and the possible need for the EU to look beyond the Lisbon employment targets and deadlines. Even if the EU as a whole achieves the Lisbon employment targets, this will not be sufficient to offset the effects of demographic change and considerable unused labour capacity would remain in many Member States. The paper also argues that ageing is an evolving process, and that a key challenge will be to develop labour market and welfare state policies that are sustainable in the face of uncertain economic and demographic developments. Current financing problems in pension schemes stem to a large extent from the failure of contribution/entitlement parameters in public pension schemes to adjust in the face of increased life expectancy. It will be important to ensure that retirement behaviour takes due account of future increases in life expectancy.

A 52 year old man presented to the emergency department with a complete inability to swallow (absolute dysphagia) and pain in his throat. He described an acute onset of pain while eating “a nice piece of steak” three hours earlier. After this time he could not swallow without pain in the middle of his throat and was unable to manage fluids without regurgitation. He arrived in the emergency department carrying a bowl and was spitting out his own saliva. He reported no changes to his voice and no difficulty with breathing. He was otherwise fit and well, with no recent trauma, weight loss, or history of a similar presentation. Neck examination in the emergency department was unremarkable except that he regurgitated test drinks of water. Radiography was performed (fig 1⇓). ### 1. What radiographic view is shown? #### Short answer A lateral soft tissue radiograph of the neck. #### Long answer Figure 1 shows a lateral soft tissue radiograph of the neck. ### 2. What does the radiograph show? #### Short answer An opacity consistent with soft tissue in the upper oesophagus measuring about 2 cm in width, lying anterior to the C5-C6 vertebrae with air below. There is also mild loss of lordosis. #### Long answer Within the distal pharynx-proximal oesophagus at the level of C5-C6, there is a soft tissue opacity measuring 2 cm in width (fig 2), which may represent a wedged food bolus at about the level of the cricopharyngeus muscle. There is mild loss of lordosis (due to muscular spasm) and air below the mass in the oesophagus. No prevertebral soft tissue swelling or surgical emphysema (suggestive of perforation) is visible. Fig …

Political agreement on the Stability and Growth Pact (SGP)1 was reached at the Dublin European Council of December 1996, and was a defining moment in the decision to proceed with the launch of the single currency. Despite its complexity and sensitivity, the SGP (two Council Regulations and two political Resolutions2) was on the statute books in some eighteen months, a relatively short period for the adoption of secondary legislation at EU level.

Pharyngocele is defined as lateral pharyngeal wall herniation located in the piriform recess or at the valleculae and was first described in 1886. The phenomenon is rare. It is characterised by bulging of the pharynx locally and is associated with recurrent increase in intrapharyngeal pressure, reduced muscle resilience, and increasing age. The case describes a 51-year-old recreational trumpeter with bilateral pharyngoceles that demonstrated when blowing into his instrument, reminiscent of a bullfrog. Differential diagnosis included Zenker's diverticulum, (pharyngeal pouch), laryngocele, and jugular venous phlebectasia, which may be confirmed through clinical examination and investigation. The report includes remarkable images seen on examination and images of the swelling seen with plain film radiography, barium swallow, and computed tomography. We discuss the management options available, including repair and excision of the pouch, either as an open procedure or endoscopically, and explore the conservative measures as a basis in the management of even significant pharyngoceles.

A significant ageing trend can be observed in Europe and in other parts of the world. Fertility is decreasing and life expectancy increasing. The impact of migration is growing. The book deals with the implications for financial markets of these demographic trends. Leading economists and financial experts from Europe and the United States evaluate the challenges to public pension systems and the private pension industry. Based on long-term projections of productivity and employment they look at potential growth in GDP per capita and implications for savings and wealth. Pension fund portfolio management is discussed together with the ability of capital markets to serve retirement-financing purposes. Fiscal as well as financial sustainability are analysed in depth. The roles of global imbalances and international capital movements are included. Most chapters also discuss policy implications - in particular with regard to how pension saving incentives and rules and incentives for retirement should be in order to ensure fiscal and financial sustainability. All contributions in the book are based on presentations at the 26th SUERF Colloquium on "Money, Finance and Demography - the Consequences of Ageing" held on 12-14 October, 2006 in Lisbon sponsored by Banco de Portugal and Millennium bcp and in cooperation with the Universidade Nova de Lisboa.