Search

Anterior cord syndrome is a rare yet critical neurological condition that poses significant challenges in clinical management. We present the case of a 71-year-old male with a medical history of hypertension, uncontrolled type II diabetes mellitus, hypothyroidism, and end-stage renal disease requiring dialysis who presented to the emergency department with complaints of chills, back pain, abdominal pain, and vomiting episodes. Based on the severity of the patient's illness, it was decided that inpatient admission would be best. At the beginning of the patient's hospital stay, blood cultures grew methicillin-resistant Staphylococcus aureus. In addition, the results of the MRI revealed progressive vertebral body osteomyelitis and discitis at the T10-T11 level, along with surrounding inflammation and edema. During the patient's hospital stay, the patient's neurological condition worsened, and he presented with the onset of bilateral lower limb flaccid paralysis, numbness, and weakness. An MRI of the thoracic spine with and without contrast revealed worsening osteomyelitis and discitis at T10-T11. Given these findings, neurology and orthopedic surgery were consulted. The neurology team diagnosed the patient with anterior cord syndrome. The orthopedic surgery team recommended decompression and a posterior laminectomy. Due to the patient's pre-existing pulmonary issues, uncontrolled type II diabetes mellitus, and chronic kidney disease, the orthopedic surgery team decided to proceed with a posterior decompression through the transpedicular route. Given the presence of bacteremia, a Hickman catheter was placed in the right subclavian vein for continued IV antibiotic treatment. On the last day of hospitalization, the patient was discharged to a long-term acute care facility for continued treatment. Collaboration amongst hospitalists, infectious disease specialists, neurosurgeons, and rehabilitation teams is required in order to facilitate early recognition of critical clinical symptoms in managing complex MRSA-induced spinal cord infections. The complexity of this case is due to the patient's comorbid conditions. Correlating the symptoms of constipation and bladder dysfunction to a neurogenic cause was a challenge for this patient in the setting of hypothyroidism and opioid usage. In summary, early detection of infection and promptly working with physical therapy are critical in order to prevent catastrophic neurological consequences in patients with multiple comorbidities., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Patel et al.)

Both urinary tract infection (UTI) and asymptomatic bacteriuria (ASB) are common problems among elderly adults and represent a significant health care burden. Despite their frequency, differentiating between ASB and true UTI remains controversial among health care providers. Several challenges exist in the evaluation of urinary symptoms in the elderly patient. Symptoms of UTI are variable; problems are encountered in the collection, testing, and interpretation of urine specimens; and results of urinalysis are often misinterpreted and mishandled. Multiple studies have shown no morbidity or mortality benefit to antibiotic therapy in either community or long-term care facility residents with ASB., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: Normal voiding in neurologically intact patients is triggered by the release of tonic inhibition from suprapontine centers, allowing the pontine micturition center to trigger the voiding reflex. Supraspinal mechanisms of voluntary voiding in humans are just beginning to be described via functional neuroimaging. We further elucidated brain activity processes during voiding using functional magnetic resonance imaging in normal females to gain better understanding of normal voiding as well as changes that may occur in voiding dysfunction., Materials and Methods: We screened 13 healthy premenopausal female volunteers using baseline clinic urodynamics to document normal voiding parameters. We then recorded brain activity via functional magnetic resonance imaging and simultaneous urodynamics, including the pressure flow voiding phase. After motion correction of functional magnetic resonance images we performed activation and connectivity analyses in 10 subjects., Results: Group analysis revealed consistent activation areas, including regions for motor control (cerebellum, thalamus, caudate, lentiform nucleus, red nucleus, supplementary motor area and post-central gyrus), emotion (anterior/posterior cingulate gyrus and insula), executive function (left superior frontal gyrus) and a focal region in the pons. Connectivity analysis demonstrated strong interconnectivity of the pontine micturition center with many short-range and long-range cortical clusters., Conclusions: Our study is one of the first reports of brain activation centers associated with micturition initiation in normal healthy females. Results show activation of a brain network consisting of regions for motor control, executive function and emotion processing. Further studies are planned to create and validate a model of brain activity during normal voiding in women., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: Our aims were to determine the prevalence of renal ultrasound (RUS) abnormalities over time in multiple sclerosis (MS) patients with lower urinary tract symptoms (LUTS)., Methods: Data were examined retrospectively from MS patients with LUTS, from 2000-2009. Study inclusion requirements were both baseline urodynamics (UD) and RUS data, with followup RUS at ≥ 12 months. Age, time since diagnosis (TSD), MS subtype and the UD/RUS results were evaluated for associations., Results: At presentation, 173 subjects underwent UD and RUS, but only 89 had a repeat RUS at ≥ 12 months. Median followup was 61 months. Initial RUS abnormalities were found in 10 (5.8%) subjects. At followup, upper urinary tract (UUT) abnormalities were seen in 11 (12.4%) subjects. Patients > 49 years old were more likely to have an abnormality (OR 0.181, 95% CI 0.037-0.892, p = 0.04). Patients with abnormal compliance were also more likely to have an abnormal followup RUS (OR 0.185, 95% CI 0.037-0.924, p = 0.04). No other demographic or UD factor was associated with RUS abnormalities., Conclusions: The development of structural UUT changes is low in MS patients. Urodynamic studies are useful for LUTS treatment strategies in complicated patients, but UD does not appear to have much impact with regard to upper tract changes.

Overactive bladder (OAB) is a common condition that affects many adults, and prevalence increases with age in both men and women. It is characterized by symptoms of urinary frequency and urgency with or without urge incontinence in the absence of another proven etiology. As a diagnosis based solely on urinary symptoms, proper evaluation of OAB often depends on the use of psychometrically validated questionnaires to assess symptom severity and degree of bother. General urinary assessment forms can evaluate many urinary symptoms while modular questionnaires can focus on the most bothersome complaints. Many questionnaires have been formulated and validated to achieve these goals. Currently, the ideal questionnaire does not exist. This review attempts to outline the range of questionnaires available to the clinician to assist in evaluating symptoms as well as degree of impact on quality of life.

Objectives: The use of synthetic mesh for transvaginal pelvic organ prolapse (POP) repair is associated with the rare complication of mesh erosion into hollow viscera. This study presents a single-institution series of complex rectovaginal fistulas (RVFs) after synthetic mesh-augmented POP repair, as well as strategies for identification and management., Methods: Institutional review board approval was obtained for this retrospective study. Data were collected and analyzed on all female patients undergoing RVF repair from 2000 to 2011 at our institution., Results: Thirty-seven patients underwent RVF repair at our multidisciplinary center for restorative pelvic medicine. Of these, 10 (27.0%) were associated with POP repairs using mesh. The POP repairs resulting in RVF were transvaginal repair with mesh (n = 8), laparoscopic sacrocolpopexy with concomitant traditional posterior repair (n = 1), and robotic-assisted laparoscopic sacrocolpopexy (n = 1). Time to presentation was an average of 7.1 months after POP repair. Patients underwent a mean of 4.4 surgeries for definitive RVF repair, with 40% of patients requiring a bowel diversion (3 temporary ileostomies and 1 long-term colostomy). Mean follow-up time after last surgery was 9.2 months. On follow-up, 1 patient has a persistent fistula with vaginal mesh extrusion. One patient has persistent pelvic pain., Conclusions: This series highlights the significant impact of synthetic mesh complications in the posterior compartment. These complications should be cautionary for synthetic graft use by those with limited experience, particularly when an alternate choice of traditional repair is available. When symptoms of RVF are present, collaboration with a colon and rectal specialist should be initiated as soon as possible for evaluation and definitive repair.

Objective: To evaluate the use of a modified Indiana continent urinary reservoir, the Indiana augmentation cystoplasty (IAC), for patients with neurogenic bladder (NGB). NGB with incontinence can be devastating for patients with neurologic illness. Augmentation cystoplasty with a continent catheterizable stoma creates a continent, low-pressure storage system, with catheterizable cutaneous stoma, leading to decreased urinary tract morbidity and increased quality of life., Methods: Retrospective chart review of the IAC procedure in a single center from 1993 to 2010 was performed and included subjects with NGB and minimum 1-year follow up. Patients' demographics, NGB diagnosis, surgery details, urodynamic findings, concurrent operations, complications, and continence outcomes were recorded., Results: Thirty-four patients met the inclusion criteria. Mean age at time of surgery was 39.8 years. Neurologic diagnoses included multiple sclerosis (n = 12), spina bifida (n = 9), and spinal cord injury (n = 14). Concurrent surgeries included: bladder neck closure (n = 3), pubovaginal sling (n = 4), hysterectomy (n = 3), artificial urinary sphincter (n = 1), and cystolithotomy (n = 1). Mean estimated blood loss was 461.8 mL. Short-term postoperative complications were prolonged ileus (n = 2), wound infection (n = 1), and transfusion (n = 1). Median follow-up was 31 months. Long-term complications occurred in 15 (44.1%) patients: recurrent urinary tract infections (n = 4), pyelonephritis (n = 1), pelvic abscess (n = 1), seroma (n = 1), bladder stones (n = 2), and stomal revision in (n = 4). All patients were continent at latest follow-up., Conclusion: This modification of the Indiana continent urinary reservoir is an excellent surgical option providing a low-pressure reservoir with a reliable continence mechanism and easily catheterizable stoma, with few complications or need for reoperation., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: Overactive bladder (OAB) symptoms often accompany pelvic organ prolapse. While there seems to be a relationship between symptom resolution and anatomic repair, a subset of patients will not experience improvement in OAB symptoms. Our aim was to identify preoperative demographic and urodynamic (UD) parameters related to persistence of OAB symptoms after anterior vaginal prolapse (AVP) repair., Methods: This retrospective cohort study examined demographic and UD data from patients undergoing AVP surgery. Pre- and post-operative Urogenital Distress Inventory (UDI-6) scores for frequency, urge urinary incontinence (UUI), and difficulty voiding were analyzed, as were correlations between scores and pre-operative UD data., Results: From 2002 to 2008, 88 patients underwent AVP repair and were included in the final analysis. Surgery resulted in a reduction of frequency (33%), UUI (49%), and difficulty voiding (74%) at median 21 months follow-up. Change in symptom scores was unrelated to age, parity, BMI, or AVP grade, although older women reported greater improvement in difficulty emptying after repair. Improvement in difficulty emptying was related to a larger pre-operative post-void residual (PVR) (129 ml vs. 31 ml, P = 0.0008). Persistent UUI after repair was significantly related to a higher preoperative P(det)Q(max) (OR 1.056, 95% CI 1.003-1.11, P = 0.04). Other pre-operative UDS variables were not significantly related to the persistence of OAB symptoms., Conclusions: AVP repair reduces lower urinary tract symptoms (LUTS); however, 67% and 51% of patients will report persistent frequency and UUI, respectively, post-operatively. In this cohort, persistent OAB symptoms were not related to age, parity, BMI, or prolapse grade, but rather to pre-operative P(det)Q(max)., (© 2010 Wiley-Liss, Inc.)

Chronic pelvic pain in women can be caused by a host of gynecological, gastrointestinal, musculoskeletal, neurologic, as well as urologic disorders. An initial broad differential diagnosis is essential. At times, overlapping symptoms and vague physical findings necessitate a multidisciplinary diagnostic approach. A thorough history, which is careful to characterize all aspects of the patient's symptoms, can usually direct the differential toward the bladder when this organ is the source of the pain. Interstitial cystitis/painful bladder syndrome (IC/PBS) should be included in the differential diagnosis, but it should not be used as an expeditious diagnosis when pain coexists with frequency and urgency. Multiple other urologic conditions such as overactive bladder, urinary tract infection, urethral diverticulum, periurethral masses (Skene gland cyst or abscess), and even urethral stricture disease, have overlapping symptom complexes with IC/PBS, and they must not be overlooked as they are much more easily diagnosed and treated. By using a stepwise approach and an evidence-based thought process, the obscurity of chronic bladder and urethral pain can evolve into a progressively narrowing differential.

Multiple sclerosis (MS) is the most common cause of progressive neurological disability in young adults. In addition to spasticity, tremors, weakness, sensory disturbances, depression, cognitive problems, and bladder or bowel dysfunction, sexual dysfunction (SD) is also a prevalent and destructive manifestation of the disease that severely affects quality of life. Evaluation of this disorder requires insight into the primary (changes that directly affect libido, sexual response and orgasm due to direct damage to the nervous system), secondary (complaints which are related to the physical disability of MS, such as fatigue, muscle rigidity, weakness and spasms), and tertiary (emotional, social and cultural aspects of MS) components of MS-associated SD. Given the complexity and multifactorial nature of SD, a multidisciplinary approach is necessary when treating patients with MS. The aim of this Review is to provide a holistic approach to the evaluation and management of SD in patients with MS, incorporating the latest data from the fields of urology, neurology, nursing, social work, and psychology. What is currently known regarding the evaluation and management of SD in patients with MS will be presented from the perspective of these specialties.

It has not yet been definitively demonstrated that preoperative evaluation of women with stress urinary incontinence (SUI) with urodynamic testing (UDS) enhances surgical outcomes. Nonetheless, UDS is frequently utilized in the assessment of women with SUI in the hopes that results will shed light on preoperative risk factors for failure or postoperative voiding dysfunction. Poorer outcomes for stress incontinence surgery are primarily attributed to intrinsic sphincter deficiency (ISD), detrusor overactivity (DO), and voiding dysfunction. The ability of UDS to identify and characterize those parameters reliably remains under investigation. Furthermore, debate continues regarding the association of each of those factors with postoperative success for various SUI procedures. Since UDS is invasive, costly, and not always available, it is imperative that its benefit be carefully explored. In this review, we discuss the value of UDS in identifying risk factors for poor outcome and how those risk factors are associated with surgical failure.

Due to their rarity, benign masses of the periurethral tissues and anterior vaginal wall are poorly understood. Arriving at the proper evaluation and treatment is challenging because many of these masses have similar presenting signs and symptoms, as well as overlapping differential diagnoses. The literature regarding these lesions mainly consists of level III evidence, mostly involving case reports and series. Clinical management has traditionally been based on established surgical principles and expert opinion. This review presents the pertinent embryologic and anatomic background for these benign masses, as well as other pertinent etiological processes. Furthermore, the most current evidence is reviewed regarding the differential diagnosis, evaluation, and treatment for each mass.

Inflammatory pseudotumor of the bladder is a benign proliferative lesion of the submucosal stroma that cannot be distinguished from malignant tumors of the bladder either endoscopically or radiographically. Although benign, the proliferative nature of the inflammatory pseudotumor histopathology has led others to recommend open surgical removal or complete transurethral resection for definitive treatment. A limited number of case reports have described inflammatory pseudotumor of the bladder in either adults or children. This is a case of biopsy-proven inflammatory pseudotumor in the bladder of a child that regressed after medical management alone.

Purpose: Few studies critically compare current radiotherapy techniques to surgery for patients with locally advanced prostate cancer, despite an urgent need to determine which approach offers superior cancer control. Our objective was to compare rates of biochemical relapse-free survival (BFS) and surrogates of disease specific survival among men with high risk adenocarcinoma of the prostate as a function of treatment modality., Methods and Materials: Retrospective data from 409 men with prostate-specific antigen (PSA) > or =10 or Gleason 7-10 or Stage > or =T2b cancer treated uniformly at one university between March 1988 and December 2000 were analyzed. Patients had undergone radical prostatectomy (RP), brachytherapy implant alone (BTM), or external beam radiotherapy with brachytherapy boost with short-term neoadjuvant and adjuvant androgen deprivation therapy (BTC). From the total study population a 1:1 matched-cohort analysis (208 patients matched via prostate-specific antigen, Gleason score) comparing RP with BTC was performed as well., Results: Estimated 4-year BFS rates were superior for patients treated with BTC (BTC 72%, BTM 25%, RP 53%; p < 0.001). Matched analysis of BTC vs. RP confirmed these results (BTC 73%, BTM 55%; p = 0.010). Relative risk (RR) of biochemical relapse for BTM and BTC compared with RP were 2.92 (1.95-4.36) and 0.56 (0.36-0.87), (p < 0.001, p = 0.010). RR for BTC from the matched cohort analysis was 0.44 (0.26-0.74; p = 0.002)., Conclusions: High-risk prostate cancer patients receiving multimodality radiation therapy (BTC) display apparently superior BFS compared with those receiving surgery (RP) or brachytherapy alone (BTM).

Purpose: To increase prompt access to routine office visits the concept of the group appointment was developed in the primary care setting. Drop-in group medical appointments have been piloted at our department. We hypothesized that 1) efficiency could be improved by seeing 6 to 14 patients at 1 appointment, 2) access to appointment times would increase and 3) patient satisfaction would be enhanced with 60 minutes of didactic contact and discussion with the urologist., Materials and Methods: Patients were invited to participate in a drop-in group medical appointment. Appointments were made based on sex and not on diagnosis. A 60-minute group teaching session was followed by a private 2 to 5-minute physical examination or further testing, as indicated. Confidential satisfaction surveys were administered to drop-in group medical appointment participants and patients seen at traditional individual (solo) appointments. Results were compared., Results: From September 22, 2003 to August 30, 2004, 279 patients attended a drop-in group medical appointment. Mean patient age was 63 years and 142 patients were 65 years or older. Most diagnoses were prostate cancer, erectile dysfunction, benign prostatic hyperplasia, incontinence, neurogenic bladder and chronic discomfort syndromes. Of the patients 287 were surveyed, including 177 at drop-in group medical appointments and 110 at solo appointments. Patient satisfaction with the drop-in group medical appointment format was as high as that of solo patients with 87% of drop-in group medical appointment patients rating their experience as excellent or very good vs 88% by solo patients., Conclusions: Drop-in group medical appointments can be implemented successfully in a urological practice with high patient satisfaction despite the sensitive nature of topics discussed. Ideal patients are those with chronic or complex conditions and those requiring repetitive discussions, such as elderly individuals.

Introduction: To date, randomized trials comparing radiotherapy to surgery for adenocarcinoma of the prostate are few. Lacking, are randomized comparisons between treatment modalities for the patient with high-risk locally advanced disease. Hence, there is a need to determine which approach offers superior results in these patients who comprise a significant proportion of those dying of prostate cancer. In this short review we highlight key studies that may provide interim answers while awaiting definitive results from randomized studies., Material and Methods: A MEDLINE literature review was performed of studies evaluating current treatment modalities for high-risk (TNM stage >T2b, PSA>10, Gleason > or =8) prostate cancer. Publications from 1975 to present were searched using the keywords: prostate cancer, locally advanced prostate cancer, high-risk prostate cancer, prostatectomy, external beam radiation, brachytherapy, and PSA-doubling time., Results: Comparisons of different treatment modalities are difficult due to many factors, from uncertainties in clinical staging to the questionable equivalence of PSA failure. However, the general consensus is that low dose rate brachytherapy monotherapy is not ideal for high-risk patients. There are several options for combination therapy which show moderately good survival results. Because of the lack of prospective randomized trials comparing these approaches, matched analyses with uniform patient treatment and pathological review may provide an interim answer., Conclusion: The optimal management for patients with locally advanced prostate cancer is unclear. While randomized clinical trials will eventually shed light on this question, interim solutions may provide some answers in the short term.

Two groups of nine children with profound hearing impairments and low intelligibility were taught to produce the consonants /t,d,k,g,s,z,S/ using either electropalatographic (palatometry) or traditional aural-oral techniques. Testing was completed pre-, immediately post-, and 6 months post-treatment by examining productions of CV syllables (V = /i,a/) using electropalatography-determined linguapalatal contacts and listener identifications. Intelligibility was also measured using the CID Picture Speech Intelligibility Evaluation (SPINE) test. Both groups improved their consonant productions as a result of 26 50-minute sessions. Sessions were given twice daily over 3- to 4-week training periods. Immediately post-treatment, the electropalatography-trained subjects produced better consonants as measured by linguapalatal contact patterns and listener identifications. The linguapalatal-contact patterns learned by the electropalatography-trained group better matched normal speaker productions than did those of the traditionally trained group. Both groups showed equal improvement for both post-treatment conditions when tested with the CID SPINE test. Although further research is needed, the results of this study suggest that electropalatographic techniques are, at least, equal alternatives to traditional aural-oral speech training techniques for speakers with profound hearing impairments.

Esophageal talker linguapalatal contact patterns and durations during /s/ and /z/ productions were examined using dynamic palatometry instrumentation. It was found that sibilant groove narrowing is a physiologic compensation for a reduced air supply in esophageal speech. The place of esophageal /s, z/ articulation was on the anterior portion of the alveolar ridge as seen in normal speakers. Average medial groove width for esophageal /s/ was narrower than the 5-7-mm groove characteristic of normal speakers. Groove widths averaged 3 mm for /s/ and 4 mm for /z/. Systematic changes in groove widths across speech sounds, syllable position, and vowel context were also observed. Use of a narrower lingual groove was interpreted as a significant articulatory maneuver to meter out a limited intraoral air supply and effect more normal fricative durations.

Five profoundly hearing-impaired children were taught the consonants /t,d,k,g,s,z integral of/ using palatometry. Changes in linguapalatal contact patterns and listener perceptions showed significant improvement in the place and manner of consonants produced by all subjects. Velar stops were as easily and accurately learned as alveolar stops. Distinctive sibilants were also found by the end of training. Sounds not previously present in a subject's phonetic repetoire were learned more accurately than those present but inaccurate prior to therapy. Voicing errors persisted. Two of the subjects showed evidence of newly established, unsolicited coarticulated movements. The results indicated that visual articulatory modeling and feedback of linguapalatal contact patterns is an effective means of teaching consonants and improving speech intelligibility.

Glossometry was used to teach the four point vowels (/i,ae,u,a/) to 6 profoundly hearing-impaired children. Prior to treatment, all subjects evidenced centralized tongue positions during vowel productions. After 15 to 20 fifty-minute training sessions over 3- to 4-week time periods, all subjects showed greater diversification of tongue postures for the vowels, especially in tongue height. Listener identifications were generally better after therapy. The training results suggested that visually presented models and feedback of tongue positions can facilitate more appropriate tongue postures and improve vowel intelligibility by hearing-impaired speakers.

Sibilant groove place and width were initially examined during [s] [s] in isolation and in CV and VC syllables. The [s] was found to be produced through a 6- to 8-mm-wide groove near the front of the alveolar ridge by one talker and near the back of the ridge by the other. [s] was produced through a 10- to 12-mm groove behind the posterior border of the alveolar ridge by both. In the second experiment three subjects used visual articulatory feedback to vary sibilant groove width and place systematically. One subject was able to do this with comparatively few retrials; one had difficulty with certain targeted grooves; one had difficulty with many targeted grooves. The noises generated were replayed to 14 listeners who labeled them as "s," "probably s," "probably sh," or "sh." They usually heard the sound as [s] when the grooves were narrow and near the front of the alveolar process, [s] when the groove was wider and behind the alveolar process. Noise through grooves that matched natural speech places and widths usually produced higher listener recognition scores. Exceptions were found when the subjects had unusual difficulty in achieving stipulated groove widths and places.

A computer-based instrumental system is described for continuous palatometry. Thin pseudopalatal plates (approximately 0.2 mm) with embedded electrodes are used to detect linguapalatal contact during speech articulation. Geometric configurations of such contacts are then derived and displayed to reveal articulatory characteristics.

Patients who have had surgical removal of part of the tongue are left with varying degrees of speech deficiencies. Augmentation of the palate has been suggested as a means of compensation for this deficiency. This pilot study suggests a technique for evaluating prosthodontic efforts to improve speech for partial glossectomy patients. Although firm conclusions cannot be based on the observations of one patient, it appears that both the shape of the palatal surface and the contour of the cavity size anterior to the tongue are important factors to be considered in prosthodontic efforts to optimize fricative sound production for partial glossectomy patients. Further studies with patients who have a wider variety of tongue resections are indicated. The technique described is an effective one for further studies.

This investigation used palatometry to study stops, sibilants, and affricates in CV syllables (C = t,d,k,g,tf,d3; V = i,a) spoken by nine normal 6- to 14-year-old children. The measures focused on place, manner, timing, and area of linguapalatal contact. Similarities and differences between the sound classes, actions across segments of the articulatory gestures, and age effects were identified and described. The affricates were observed to have stop and sibilant portions demarcated by a partial plateau in the linguapalatal contact releasing gesture. The sibilant portion was formed in the same place and with the same groove dimensions as /f,3/. The older subjects reached initial articulatory positions faster, produced the consonant sounds more quickly, generated vowels with shorter durations, and articulated more posteriorly than did younger ones.

Changes in the dimensions and patterns of articulation used by three speakers to compensate for different amounts of tongue tissue excised during partial glossectomy were investigated. Place of articulation was shifted to parts of the vocal tract congruent with the speakers' surgically altered lingual morphology. Certain metrical properties of the articulatory gestures, such as width of the sibilant groove, were maintained. Intelligibility data indicated that perceptually acceptable substitute sounds could be produced by such transposed gestures.

The aim of this study was to identify maneuvers and strategies that enabled an adult speaker to produce "pressure" consonants intelligibly despite an open cleft of the palate. Dynamic palatometry indicated that this was achieved in part by increasing linguapalatal contact in stop sound production and narrowing the linguapalatal groove in sibilant sound production. These adaptations apparently enabled the talker to compensate for reduced air supply in a manner similar to that identified previously in responses of subjects with esophageal speech. Oral motor skill was examined in a nonspeech task that involved tongue tip placement at six points along the palate with and without visual feedback. This revealed precise control of the tongue even in the region of the cleft. Less accurate tongue placement skills were found in the central palatal region despite intactness of the palate. This supports the hypothesis that phonetic inventories of human languages are shaped by oral motor capabilities.

Twelve students at the Kentucky School for the Deaf were studied using a bioelectronic instrument to provide visual feedback of the degree of nasal resonance, thereby guiding them toward reduction of excessively nasal voice quality. The subjects were given a maximum of fourteen 20-min sessions of training. The results indicated that the feedback information was used very effectively by five subjects and somewhat effectively by four others. The remaining three subjects did not demonstrate a consistent relationship between periods of training and reduction in nasal resonance. Pre- and post-training testing using stimuli not included in the training material demonstrated significant generalization of the nasalance control gained in the training sessions.

Baseline physiologic, acoustic, and phonetic data are presented to characterize speech production of a 3 1/2-year-old deaf girl prior to a visual articulatory modeling and feedback program. These observations suggest that she used an articulatory strategy based on visual information about lip and jaw movements rather than tongue positions as a primary means of differentiating speech sounds. The training program which followed used instrumentally generated displays of tongue position and movements to teach production of the (i) and (a) vowels in single and bisyllable word contexts. Linguapalatal contact patterns for the consonant (t) were then introduced and taught in combinations with the vowels. Goal articulatory gestures were learned rapidly with respect to both positional and timing features of speech.

Instrumental comparisons of sound from the nose and mouth expressed in percent nasalance, articulation errors, and speech rate are used in this study to contrast utterances of 50 speakers with severe hearing impairment and 64 with normal hearing. Results of the study revealed that 54% of the hearing-impaired subjects had nasalance ratio scores greater than two standard deviations above the mean of the group with normal auditory acuity. No general relationship was found between the number or type of articulation errors and the nasalance scores. Rate of speaking was significantly related to the nasalance scores of the normal group but not those of the hearing-impaired group. Tonagrams displaying the variations in nasalance revealed small, 1 to 50% spike-shaped fluctuations in the displays of the utterances from both groups. Additional prolonged bursts of nasalance in excess of a 30% change in the ratio between the nasal and oral signal were common in the displays from the hearing-impaired group did not in those of the group with normal acuity. Possible sources and perceptual effects of these phenomena are discussed.

Interplay between visual feedback and lip-positioning skill was studied in 10 5- to 14-year-old children with normal hearing and 10 with severe to profound hearing impairment. With visual feedback, the subjects in both groups had similar response times and accuracy in matching six visually specified lip separation "targets." Special skill in processing visual information by the hearing-impaired subjects was suggested by higher velocities of lip movement toward the targets and shorter latencies in reaching the goal positions. In the responses of the hearing children, lip-closing movements were executed more accurately than opening movements both with and without visual feedback. In general, the findings showed that, given visually displayed lip-position targets and feedback from positioning actions, children can achieve the targets with high accuracy regardless of hearing status or prior speaking experience.

In this article, judgements of nasality from sound field recorded utterances of 23 children with repaired palatal clefts are compared with "nasalance" values derived from TONAR II analyses of parallel sound separated recordings. For the nasality judgements, the sound field recordings were presented in forward reproduced mode to 20 "naive" listeners and in backward reproduced mode to 10 naive listeners. A four-level task progression was followed in each mode of presentation: sorting the responses by "normal" or "abnormal" nasality, ranking them by severity of nasality, classifying them within five degrees of nasality, and, finally, assigning a discrete score to the magnitude of nasality perceived in each recording. Scores from the individual judges were highly variable, especially in the first listening task. They were consitently more variable when nasality was judged from backward reproduced recordings. As the listeners gained experience and as the listening tasks demanded more precision in nasality judgements, variability was reduced. Correlations computed between the nasality ratings and nasalance measurements increased and variability decreased. Highest agreement between physical and perceptual measurements was found when variability among the judges was reduced by pooling the scores and comparing the mean scores of nasality with the nasalance scores. Using this procedure, a correlation of .91 was obtained between listener judgemental scores of forward reproduced speech and nasalance scores. Under these conditions, the instrumental score could apparently account for over 80 per cent of the variability in the listener judgements of nasality. From the findings of this study, it was concluded that listeners without prior training are capable of judging nasality reliably and that nasalance scores provide a valid correlate of perceived nasality. The use of backward reprodeced recordings was questioned as a means of assessing nasality.

Electropalatography was used to monitor linguapalatal contact patterns in /s/ and /t/. Talkers often compensated incompletely for a bite block, both immediately after its insertion (sample B1) and after 10 min of practice (sample B2). Significant differences in the number of sensors contacted were noted between normal and bite-block samples for both /s/ and /t/. Differences in length of constriction in /t/, and the A-P location and width of the groove in /s/ were also noted. The two native English subjects compensated better than three Arabic subjects, perhaps because English /s/ and /t/ are formed more posteriorily and with a smaller contact area than their Arabic counterparts. A significant correlation existed between the area and A-P location of linguapalatal contact. All five subjects formed a groove for /s/ in sample B2, but two often did not produce /t/ with complete constriction. This suggests a groove is critical for /s/, but complete constriction is not critical for /t/. The contact patterns in sample B2 more closely resembled normal speech than those in sample B1 in some instances, while in other instances the reverse was true. The conclusion that subjects sometimes overcompensated in sample B2 was supported by the results of detailed acoustic and perceptual analyses for one subject. Taken together, the results suggest that compensation for a bite block is not instantaneous, and that specific parameter values may be encoded in central phonetic representations.

A series of experiments are reported that contrast vocal/verbal reaction-time measures from 16 normal-hearing and 25 hearing-impaired children 7 to 14 years old. Sixteen of the hearing-impaired children were enrolled in a residential school, 9 in a day school. Vocal reaction time of the children in response to visually presented stimuli was measured in four tasks: phonating "uh", saying the word "one", counting to digits, and naming digits. No significant differences were found between the response latencies of the two hearing-impaired groups on any task. Nor were differences found between the normal and hearing-impaired groups when the task was simply phonating "uh". Differences between these groups began to emerge when the word "one" was spoken. These differences increased systematically with the phonetic complexity of the task. Hearing level, latency in the counting responses, and magnitude of a ratio between phonating and digit counting latencies were identified as major predictors of speech intelligibility. The results suggest that central phonetic processing functions may be related to the quality of speech production by hearing-impaired talkers.