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To systematically review all the literature, focusing on instrumental quantitative assessment of voice in patients with Parkinson's disease (PD). Furthermore, a meta-analysis was performed to identify the main characteristics of voice disturbances in PD.Literature searches with the keywords «Parkinson» and «voice» were conducted in PubMed, EMBASE, Cochrane Library and Web of Science. Main inclusion criteria were: clinically confirmed PD and instrumented measurement of voice parameters with acoustic analysis of voice.Fourteen publications met the inclusion criteria and were included in the meta-analysis. The data within the meta-analysis revealed that several voice parameters including jitter, shimmer and fundamental frequency variation presented significant variations between patients with EP and healthy controls. Significant variations of fundamental frequency, maximum phonation time, harmonic to noise ratio, standard deviation of fundamental frequency were observed, but with a high heterogeneity between the studies. On the other hand, significant variations of noise to harmonic ratio, s/z ratio, variation of amplitude were not observed.Acoustic analysis of voice, using an electronic system, allows the identification of changes in voice parameters for predicting the worsening of disease and for targeting specific intervention. Among the voice parameters, jitter and shimmer significantly increased in patients with PD.Análisis acústico de la voz en la enfermedad de Parkinson: revisión sistemática de la discapacidad vocal y metaanálisis de estudios.Objetivo. Revisar de manera exhaustiva la bibliografía referente a la evaluación instrumental cuantitativa de la voz en pacientes con enfermedad de Parkinson (EP) y realizar un metaanálisis para definir las principales características de los trastornos de la voz en la EP. Pacientes y métodos. Búsquedas bibliográficas con las palabras clave «Parkinson» y «voice» en PubMed, EMBASE, Cochrane Library y Web of Science. Los principales criterios de aceptación fueron: EP con confirmación clínica y medición instrumentada de los parámetros de la voz mediante análisis acústico. Resultados. Catorce publicaciones cumplieron los criterios de aceptación y se incluyeron en el metaanálisis. De los datos incorporados al metaanálisis, se dedujo que varios parámetros vocales, como el jitter, el shimmer y la variación de la frecuencia fundamental, presentan variaciones significativas en los pacientes con EP frente a los controles sanos. Se hallaron variaciones significativas de la frecuencia fundamental y de su desviación estándar, del tiempo máximo de fonación y de la razón armónicos-ruido, si bien con una alta heterogeneidad entre los estudios. En cambio, no se observaron variaciones sustanciales de la razón ruido-armónicos, en el índice s/z ni en la variación de la amplitud. Conclusión. El análisis acústico de la voz por medio de un sistema electrónico permite detectar los cambios de los parámetros vocales de cara a predecir el empeoramiento de la enfermedad y elegir una intervención específica. Entre dichos parámetros, el jitter y el shimmer aumentaron significativamente en los pacientes con EP.

Since 1798, the men and women of the Commissioned Corps of the US Public Health Service (USPHS), one of the seven US uniformed services, have served on the front lines of public health. Two hundred years after the start of the USPHS, the first physician assistant (PA) entered the service to carry on the tradition of protecting, promoting, and advancing the health and safety of the nation. These dedicated clinicians are involved in healthcare delivery to underserved and vulnerable populations, disease control and prevention, biomedical research, food and drug regulation, and national and international response efforts for natural and man-made disasters. This article describes how PAs in the Commissioned Corps of the USPHS have impacted the health and safety of not only the United States but also the international community.

The Instructional Hierarchy (IH) has proven useful for understanding the functional properties of empirically valid instructional strategies. Investigators have relied heavily on the IH as a heuristic in conceptualizing instructional components used in brief experimental analyses. To date, only one investigation has applied brief experimental analysis results to small group reading interventions. The purpose of this paper is to describe two studies which used single session instructional trials to identify interventions that were subsequently applied to small group reading instruction. In both studies, individualized instructional trials that probed for skill and performance deficits were carried out and results suggested that all students benefited from the instructional intervention. Next, the intervention was implemented in a small group format. In Experiment 2, however, validation of the instructional package was carried out by the classroom teacher who delivered the instructional package to the small group. In both cases, extended experimental analyses suggested that the intervention was effective at improving all participants’ generalized reading fluency. Results of both studies are discussed in terms of how future studies can refine procedures for validating instructional and motivational components before classroom applications.

The technology of brief experimental analysis is just beginning to be used for identification of effective treatments for individual students who experience difficulty with oral reading fluency. In this study, the effect of a reading fluency treatment package was examined on easy and hard passages, and generalization was assessed on passages with high content overlap. The results suggest that the treatment package increased reading fluency for all 3 students. Effects were moderated by difficulty level for all 3 students. Results are discussed in terms of future refinements to the procedures, validation of the methods, and potential applications in clinical and school settings.

The current study examined the effects of several combinations of instructional and motivational interventions on oral reading fluency in the context of small group reading instruction. A treatment package consisting of acquisition, fluency, and motivational components was examined and then dismantled. Results were evaluated individually for each participant using a multiple-probe design in order to identify the most effective, yet efficient reading intervention package for each member of the group. The results indicated that, although all potential combinations of the package were effective, the experimental analysis was able to identify an effective yet more efficient package that produced substantial increases in performance across all students. Results are discussed in terms of effective instructional components in small group instruction and how to adapt methods for the experimental analysis of behavior to make decisions about the effectiveness of small group instruction in reading.

Experimental analyses for improving reading fluency deficits have rarely targeted generalized increases in academic responding. As a consequence, the variables that may help students to generalize newly learned forms of academic responding like reading are not well understood. Furthermore, experimental analyses of reading fluency interventions have not systematically examined difficulty level as a variable that may affect instructional outcomes. The experiment reported in this paper expands (a) the measurement of the dependent variables to include generalized increases across tasks (reading passages) and (b) the combination of independent variables used to produce measurable generalized increases. The results demonstrate the importance of combining reward and instructional variables (including difficulty level) to produce generalized increases and how those variables can be meaningfully investigated prior to making treatment recommendations.

The purpose of the current study was to examine blending and segmenting of phonemes as an instance of small, textual response classes that students learn to combine to produce whole word reading. Using an A/B/A/B design, a phoneme segmenting and blending condition that included differential reinforcement for response classes at the level of phonemes was compared to a control condition which was equated for differential reinforcement of reading words and opportunities to respond. The critical difference between conditions was the size of the responses that were brought under stimulus control (phonemes versus whole words). Findings clearly supported the superiority of the phoneme blending treatment condition over the control condition in producing generalized increases in word reading. The results are discussed in terms of the behavioral mechanisms that govern early literacy behaviors and the essential role that targeting measured increases in academic responses plays in furthering our understanding of how to improve the analysis and instruction of students who need to learn these important skills.

The GISTs are rare tumours but even rarer is the localization in some districts. We reported two GISTs of the duodenum, two of the omentum and peritoneum, one of the rectum and one of a Meckel’s diverticulum. These exceptional locations are confirmed by the relative difficult diagnosis, obtained in some cases only by the surgical treatment despite the CT and MR. The endoscopy is useful in hemorrhagic and duodenum forms, only for the diagnosis and for the control of blood loss. Surgical treatment in all cases was decisive without the need to make use of adjuvant therapy, with positive long-term results, which excluded the disappearance of relapses or secondary lesions.

The GISTs are rare tumours but even rarer is the localization in some districts. We reported two GISTs of the duodenum, two of the omentum and peritoneum, one of the rectum and one of a Meckel's diverticulum. These exceptional locations are confirmed by the relative difficult diagnosis, obtained in some cases only by the surgical treatment despite the CT and MR. The endoscopy is useful in hemorrhagic and duodenum forms, only for the diagnosis and for the control of blood loss. Surgical treatment in all cases was decisive without the need to make use of adjuvant therapy, with positive long-term results, which excluded the disappearance of relapses or secondary lesions.

Osteoblastoma is a solitary, benign bone tumor that is rarely localized in the frontal sinus. It consists of hypocellular mineralized tissue that may form large masses or irregular trabeculae. A 31 year old man came to our attention with a 7 month history of diplopia, photophobia, frontal headhaches and progressive exophthalmos with proptosis of the left eye. The patient was submitted to computed tomography (CT) which allowed to appraise the extension of the lesion. The mass expanded inside the left frontal sinus and the upper ethmoidal cells invading the left orbital roof. Considering the extension of the tumor, the site and the connections with contiguous structures, a combination of endoscopic endonasal technique with intraorbital approach was performed. At histological examination typical features of benign osteoblastoma were observed. The sites of predilection for the tumor are the long bones, vertebral column, and small bones of hands and feet. Its occurrence in the skull and jaw bones is relatively rare and represents only 15% of all osteoblastomas. To our knowledge, only 5 cases of osteoblastoma of the frontal sinus have been previously reported in the English-language literature. This report describes a case of benign osteoblastoma in a rare site, namely, the frontal sinus with particular attention about the differential diagnosis and the treatment.

This study examined the generalized effects of three treatment conditions (performance based, skill based, and a combination of the two) on oral reading fluency by an elementary school student. Results indicated equal effectiveness of all treatments, maintenance, and possible evidence of generalization across passages.

Fungal infections have become one of the emerging complications in intensive care patients and the morbidity and mortality linked to these infections underlines the importance of managing these pathologies.The clinical and laboratory difficulties of diagnosing candidiasis prompted us to identify patients at risk and to intervene as soon as possible, where there was the "suspicion" of active infection, using adequate, so-called "empiric" treatment. The major risk factors include the use of invasive devices (central venous catheters), the administration of multiple antibiotic treatment and parenteral nutrition. In our Intensive Care ward (multi-purpose), we examined 1933 patients who had undergoing 1211 urine cultures (following consolidated clinical criteria). "Empiric treatment" was used in 378 high-risk patients with unstable clinical symptoms and positive urinary fungal colonisations using high-dose fluconazole (800 mg/die) according to the guidelines set down by BSAC. The mean duration of treatment was 12+2 days and urine cultures became negative in all patients after 1 or 2 weeks of treatment.We observed that fluconazole was generally well tolerated: only 10% of patients presented augmented hepatic transaminase. This phenomenon was always transient. Renal function remained unchanged (creatinine clearance). A severe infection with hematogenous dissemination was reported in 6 cases: "empiric treatment" was used in 5 cases with 800 mg/die of fluconazole and 1 case received amphotericin B 1 mg/kg/die (because no clinical improvement was observed after 48-72 hours of fluconazole treatment). Three of these 6 cases died, 2 of which were not directly linked to fungal infection, and 3 patient were discharged from the ward.We found that fluconazole offers a treatment option that is less toxic, less expensive and equally effective for these infections, provided that it is used at an adequate dose and that high-risk patients are identified for "empiric treatment". No significant increases in resistance were noted, as is demonstrated by the fact that only 1 case of candidemia required conversion to amphotericin B.

The incidence of paraaortic lymph node metastasis (N4) in relation with the site of the tumour, and survival in patients with gastric cancer who underwent gastric resection and superextended lymphadenectomy (D4), have been analyzed.The frequency of paraaortic lymph node metastasis was studied in 132 patients who underwent gastrectomy with D4 lymphadenectomy during the period June 1988 - December 2000. Six patients with plastic linitis and 3 with carcinoma of the gastric stump were excluded from the analysis.In personal experience the most frequent postoperative morbidity were respiratory complication (7.6%) and pancreatic fistula (6.8%). Among the 132 patients the total number of dissected nodes was 6362 and the mean number of dissected nodes per case was 48.2. The total number of retrieved lymph nodes from the paraaortic station was 755 with a mean number 5.7 per patients. N4 nodal involvement was found in 25 (19%) of 132 patients: 14 (36%) patients with carcinoma located in the proximal third, 5 (13%) with tumour located in the middle third and 6 (11%) with carcinoma of the distal third of the stomach. The median survival time and the overall cumulative 5-year survival rate for curatively (R0) resected patients were 74 months and 52% respectively.The presence of metastasis in paraaortic lymph nodes in 19% of our patients, the low morbidity and mortality, the good survival after superextended lymphadenectomy, suggest that this lymphadenectomy should be considered in the curative surgical treatment of advanced gastric cancer, especially if located in the proximal third of the stomach (N4 in 36% of cases).

To assess an additional prognostic value of Goseki histological classification to TNM staging system in adenocarcinoma of the cardia.Sixty-one patients curatively resected for advanced (T2, T3 and T4) cardia cancer at the I Division of General Surgery, University of Verona were classified in four different grades according to Goseki. Survival curves were estimated with Kaplan-Meier method and compared by the log-rank test. Multivariate analysis was performed by Cox regression model. c2 test was used to compare Goseki to Lauren classification and grading. After discharge from hospital all patients were followed with a mean follow-up of 39.5 months.Lauren classification and grading were significantly related to tubular differentiation (p0.01). Kaplan-Meier estimates of survival showed a better 5-year outcome for tumors with good tubular differentiation (19%), even though the difference with poor tubular differentiated tumors was not statistically significant (p'0.06). Diffuse type carcinomas and tumors with poor cytological differentiation showed a worse prognosis at univariate analysis (p0.01). Multivariate analysis showed no additional prognostic significance of any of the histological classification analyzed. Only T (p0.02; RR 2.2; IC 1.2-4) and N (p0.01; RR 5; IC 2.4-11) were independent prognostic factors.In adenocarcinoma of the cardia, Goseki classification did not add any information to Lauren classification and to TNM staging system.

To determine the significance of superextended lymphadenectomy (D4) in patients with gastric cancer. The incidence of para-aortic lymph node metastases (N4) was analysed as well as its relationship to the site of the tumour.The frequency of para-aortic lymph node metastases was assessed in 110 patients who underwent gastrectomy with D4 lymphadenectomy during the period from June 1988 to October 1999; five patients with plastic linitis and three with carcinoma of the gastric stump were excluded from the study.The postoperative mortality rate was 2.7% (n = 3) and the postoperative morbidity rate was 29.1% (n = 32). In our experience the most frequent postoperative complications were pancreatic fistulas (7.3%) and respiratory complications (6.4%). Among the 110 patients, the total number of dissected nodes was 5245 and the mean number of dissected nodes per case was 47.7. The total number of retrieved lymph nodes from the para-aortic station level was 639, with a mean number of 5.8 per patient. N4 nodal involvement was found in 20 (18.2%) out of 110 patients: 12 (33%) patients with a carcinoma located in the proximal third, two (6%) with a tumour located in the middle third and six (15%) with a carcinoma of the distal third of the stomach.The presence of para-aortic lymph node involvement in 18.2% of the patients suggests that D4 lymphadenectomy should be considered in the curative surgical treatment of advanced gastric cancer, especially if located in the proximal third of the stomach (N4 + in 33% of the patients).

The aim of the study was to verify the long term results obtained in primary gastric lymphoma with a strategy consisting in surgery as first-line treatment. Over the period from January 1988 to December 1999, 44 patients with histologically proven primary gastric lymphoma underwent surgical treatment in the First Department of General Surgery of the University of Verona. Tumours were staged according to the Ann Arbor classification and divided, according to the Kiel classification, into high- and low-grade lymphoma. Patients received adjuvant chemotherapy depending on the grade of malignancy and/or completeness of resection. Of the 44 patients, 40 (90.9%) underwent curative resections, i.e. with complete macroscopic and microscopic tumour removal (R0), consisting in total gastrectomy in 34 cases and subtotal gastrectomy in 6. Twenty-five of 40 patients had stage IE and 15 stage IIE tumours. Adjuvant chemotherapy was given to 33 patients (30 high-grade lymphomas and 3 low-grade lymphomas with N2 metastases). The overall cumulative 10-year survival rate in patients who underwent R0 resection was 79% without any significant differences in 10-year survival between patients with high- and low-grade malignancy (both 79%; P = 0.582) or between patients with or without lymph node metastases (91% and 70%, respectively; P = 0.426). In conclusion, the present investigation suggests that surgery yields prolonged complete remission in a high percentage of patients affected by gastric lymphoma irrespective of histopathologic grade of the disease and nodal involvement.

Microsatellite instability (MIN) has been found both in advanced and early gastric cancer. To find out the step played by MSI in gastric carcinogenesis, links between RER+ phenotype and clinical and pathological aspects have been studied. In this work our purpose is to analyze the relationship between MIN+ advanced gastric cancer and prognosis at 5 years after radical surgery. We investigated 34 patients affected by gastric cancer who underwent R0 surgical resection from February 1991 to October 1994. After that, they underwent a four-monthly follow-up for a minimum of 5 years. Genetic abnormalities have been searched including (a) those occurring in common-type CIN carcinomas and (b) those characteristic of MIN cancers. DNA extraction showed the presence of microsatellite instability (MIN) in 9 (26%) of the samples (vs. 74% of chromosomal instability CIN); none of them was M+ (vs. 12% of CIN cancers). Recurrence occurred in 2 out of 9 of the MIN cancers (22%) and in 21 out of 25 CIN cancers (84%). In conclusion, our data suggest that advanced gastric cancers with mutator phenotype show a better outcome at 5 years than the CIN phenotype.

We evaluated the performances of three methods (urease-test, cytology and culture) for the detection of Helicobacter pylori infection Fifty-five patients, 28 men and 27 women (ages, 19-77 years) were included in the study. Helicobacter pylori have been detected by urease-test in 41 patients (74.5%), by culture in 39 patients (70.9%), by cytology in 32 patients (58.1%). Urease-test and culture are direct and specific methods in diagnosing Helicobacter pylori infection.

A 13-year-old girl presented with a 2-year history of chronic pain affecting the leg due to a large lytic distal tibial metaphyseal lesion which upon biopsy proved to be a bone abscess. The case emphasizes the importance of the correlation of clinical radiographic imaging and pathological studies to arrive at the diagnosis and proper treatment.

Twenty-one patients were treated with Zickel nail for neoplastic pathological fracture or impending pathological fracture: in the femoral neck in three, in the intertrochanteric region in three, and in the subtrochanteric region in fifteen. Nineteen patients were restored to bed-chain status by the third postoperative day, and twenty were able to walk. Failure of fixation did not occur and there were no infections.

In a tri-institutional, retrospective study with long-term follow-up, forty-four patients who had multiple enchondromas were identified. Thirty-seven patients did not have hemangiomas (Ollier disease) and seven did (Maffucci syndrome). Of the thirty-seven patients who had Ollier disease, a low-grade chondrosarcoma developed in four; an astrocytoma, in one; and a granulosa-cell ovarian tumor, in one. In four of the seven patients who had Maffucci syndrome, there were six low-grade chondrosarcomas, one high-grade osteosarcoma, one pancreatic adenocarcinoma, one biliary adenocarcinoma, and one astrocytoma. None of the patients in either group died of the skeletal sarcoma, but four of five patients who had a non-skeletal malignant lesion died. From life-table analyses of these patients, we estimated that the incidence of secondary chondrosarcoma in patients who have Ollier disease is about 25 per cent at the age of forty years, and that malignant degeneration is almost a certainty in patients who have Maffucci syndrome. We concluded that periodic surveillance of the brain and abdomen for occult malignant lesions is indicated in patients who have enchondromatosis.

Roentgenograms of 1,410 hips from 705 alcoholics were compared with those of 200 hips from 100 controls for changes consistent with non-traumatic (idiopathic) necrosis of the femoral head according to the findings diagnostic of necrosis of bone that were outlined by the Decompression Sickness Panel of the British Medical Research Council. Abnormalities were found in 45.3 per cent of the alcoholics and 49 per cent of the controls. None of the findings showed any statistical difference between the controls and the alcoholics. It was concluded that the roentgenographic findings used were not valid in detecting the early or subtle changes of necrosis of the femoral head and that the changes found in both groups are common and probably non-specific.

A study of twenty-five new cases of osteoblastoma and a review of 172 previously reported cases demonstrated the wide spectrum of manifestations of the lesion. The ratio of males to females was 2:1, with 80 per cent of the patients being under thirty years of age. The duration of complaints prior to diagnosis averaged seventeen months. The majority of the lesions were found in the spine or major long bones of the lower extremity. When complete excision of the tumor was done a cure always was the result, but incomplete curettage also affected a cure in some cases. Three cases presented in detail emphasize the wide variation in biological behavior which this lesion may exhibit. Histological characteristics of aneurysmal bone cyst may frequently appear in the tumor tissue. Radiotherapy does not alter the course of the disease and appears to be contraindicated.

In a tri-institutional, retrospective study with long-term follow-up, forty-four patients who had multiple enchondromas were identified. Thirty-seven patients did not have hemangiomas (Ollier disease) and seven did (Maffucci syndrome). Of the thirty-seven patients who had Ollier disease, a low-grade chondrosarcoma developed in four; an astrocytoma, in one; and a granulosa-cell ovarian tumor, in one. In four of the seven patients who had Maffucci syndrome, there were six low-grade chondrosarcomas, one high-grade osteosarcoma, one pancreatic adenocarcinoma, one biliary adenocarcinoma, and one astrocytoma. None of the patients in either group died of the skeletal sarcoma, but four of five patients who had a non-skeletal malignant lesion died. From life-table analyses of these patients, we estimated that the incidence of secondary chondrosarcoma in patients who have Ollier disease is about 25 per cent at the age of forty years, and that malignant degeneration is almost a certainty in patients who have Maffucci syndrome. We concluded that periodic surveillance of the brain and abdomen for occult malignant lesions is indicated in patients who have enchondromatosis.

In 2 cases of impending pathologic fracture of the proximal femur, the treatment was resection of the metastatic site. The diagnoses were metastatic pheochromocytoma and metastatic renal cell carcinoma. Successful stabilization in th proximal femur was achieved with the Zickel device, wire mesh, and methylmethacrylate.

Seven cases of synovial sarcoma were studied by electron microscopy. The 4 cases of the monophasic spindle type contained elongated cells arranged in sheets and cords; ultrastructurally the cells contained many cytoplasmic processes and were scattered in an amorphous matrix. The monophasic spindle type demonstrates ultrastructural characteristics that are unique and serve to differentiate it from the biphasic pattern and from fibrosarcoma. Three cases of the biphasic variety demonstrated cytologic characteristics of a true glandular epithelium and a malignant spindle cell stroma. The epithelial nature of the biphasic variety is a feature that raises doubt whether synovium is the stem cell.

The authors performed a retrospective study of 33 patients to assess the effect of pregnancy on the behavior of primary bone malignancies, and to develop a strategy for pregnant women with such malignancies focusing on decisions concerning the fetus. This study indicates that pregnancy has no effect on the clinical behavior of bone sarcomas, and, therefore, there is no reason to perform an abortion because of their simultaneous occurrence. However, optimal treatment of the tumor may cause irreparable harm to the fetus. Three main medical factors need to be considered when the future of the fetus is being decided: (1) the trimester at the time of diagnosis; (2) the anatomic site of the tumor; and (3) the type and grade of the tumor, as it relates to the expected treatment of the tumor.

The orthopedist is most likely to encounter solitary or multiple forms of eosinophilic granuloma of bone. Management includes curettage for diagnosis and treatment with insertion of autogenous bone. Radiation therapy and chemotherapy are reserved for patients with multiple lesions and for the less common forms of histiocytosis X, i.e., Hand-Schüller-Christian disease and Letterer-Siwe disease.

A case of a malignant phenochromocytoma of the organ of Zuckerkandl is reported. There was a solitary functional metastasis in the left femur, which was treated by hip disarticulation after removal of the primary. The patient is asymptomatic and free of further metastases after 3 years. Other reported cases of solitary metastases from malignant pheochromocytomas are cited. These occurred most frequently in the skeleton system, which is the most common site of distant metastases in malignant pheochromocytoma. The reported case and the review of the literature indicate that solitary or limited metastatic lesions should be treated surgically by partial or, when possible, complete resection.