bluuebunny/crossref_metadata_2025 huggingface dataset:
Improvements in methodology for the pitch-shifting technique
Authors: Bauer Jay J. , Larson Charles R.
Published: February 2014

In recent years several studies have been published on voice control that utilized the pitch-shifting technique. The technique requires averaging of multiple vocalizations to repeated presentations of pitch-shifted feedback in order to eliminate random fluctuations in voice fundamental frequency. Time-locked reflexive responses to a stimulus parameter are observed quite clearly after averaging. The present study was undertaken to improve the pitch-shift methodology for data acquisition and analysis. Auditory pitch stimuli were presented at rates of 10, 5, and 2 per 5-sec vocalization, as opposed to previous studies that used one stimulus per vocalization. Results of testing these rates of stimulus presentation on a group of 22 subjects indicated there was no difference in reflex magnitude or latency between the present methods and rates up to 5/vocalization. Rates of 10/vocalization led to a reduction in reflex magnitude. Using the 5/vocalization rate, it was possible to reduce the number of vocalizations required of each subject per experimental condition with no loss of data accuracy. These improvements allowed for a greater amount of data collection in a shorter period of time, while possibly reducing the effects of subject fatigue and vocal instability. [Research supported by NIH Grant No. DC02764.]
Evaluating consonant errors in automatic speech recognition programs
Authors: Tull Renetta G. , Molin Erin E. , Lindstedt Meaghan M. , Dykstra Jessica R.
Published: February 2014

Many voice-enabled computer applications (e.g., voice-controlled web commands, automatic call centers) use automatic speech recognition (ASR) software that allow users to command the computer by voice. Problems occur because ASR does not exhibit 100% accuracy for all speech patterns. In preparation for future evaluation of nonprototypical voices and speech technology, this project used three subjects with prototypical (no known speech pathology) to test three commercially available ASR software programs: Voice Xpress(R), Naturally Speaking(R), and Via Voice(R). Phonetic analyses revealed consonant errors in each of the three programs. Vowel errors are not addressed in this study. Naturally Speaking(R) 4 was the most accurate of the ASR programs tested. Errors were identified at the word level and analyzed by phoneme and manner of articulation. Similarities among the consonant errors were found in each program. Tests showed stop-to-stop (e.g., /t, d, b, p, g, k/), fricative-to-fricative (e.g., /s, z, f, v, sh, zh/), and fricative-to-stop errors. Nasal to nasal exchanges (e.g., /m/ /n/) were noted for each software package in each of the initial tests. Constant errors are expected to decrease as errors are identified and disseminated among software developers and User Centered Design is employed. [Work supported by NIDRR.]
Noise-robust spectral estimation using nonlinear transform filters
Authors: Aikawa Kiyoaki , Ishizuka Kentaro
Published: February 2014

This paper proposes a new spectral estimation method for robust speech recognition. The new method suppresses the noise superposed on a speech spectrum using a novel nonlinear-transform-filtering algorithm. Vocal energy is concentrated at the harmonic components in a voiced portion of speech. Therefore, the signal-to-noise ratio (SNR) is high at the harmonic frequencies. If these high-SNR components selectively contribute to obtaining a spectral envelope, then the overall SNR will be improved compared to conventional spectral estimation methods. The new algorithm is composed of two stages of nonlinear-transform-filtering. In the first stage, the spectral gain is nonlinearly converted using the power of a real number. This nonlinear conversion emphasizes the high-energy components of the spectrum. The converted spectrum is smoothed in the frequency domain by a linear filter. The impulse responses of the high-energy components spread over noisy portions with this filtering. The second stage uses the nonlinear conversion performed using the power of the inverse of the exponent used in the first stage. Linear filtering follows after the conversion to compensate the smoothing filter used in the first stage. Simulation experiments demonstrated that the proposed algorithm successfully suppressed the noises superposed at the valleys of harmonic-structured speech spectra.
Chemical impairment measure from speech
Authors: Hayre Harb S.
Published: February 2014

Speech involves over 67.5% of cerebral functions, and chemical intake is sensed by nerve cells connected to various cerebral subsystems, therefore speech is an optimum representation of cerebral signal with chemical impairment correlates of cognition, reaction time, coordination, and motor function degradation. Five clean words were selected to avoid nasal, throat or th or sh sounds. Impairment measure was then subject normalized. This measure does not identify chemicals ingested. First field test involved 20 DWI arrestees by a local police unit, their BAC levels were compared with impairment measure, and everyone with BAC over 1.0 were found impaired. Furthermore individuals with the same BAC levels had different impairment levels. It can be explained on the basis of varying tolerance levels, food intake, weight, and medicine use. Similarly in a study of 40 university student binge drinkers were found to be not impaired at 1.0 BAC, and many others were impaired at much lower BAC levels, thus demystifying the alleged safety of 0.6 BAC for drivers! Over 6000 subjects have been tested in north America and Europe, and nearly 30% of polydrug/chemical users passing DOT drug tests were found impaired or unfit to function safely.
Human performance in a multisource environment with a frequency-banded minimum-variance beamforming algorithm
Authors: Larsen Jeffery B. , Lockwood Michael E. , Lansing Charissa R. , Bilger Robert C. , Wheeler Bruce C. , O’Brien William D. , Jones Douglas L. , Feng Albert S.
Published: February 2014

The effectiveness of a newly developed signal-processing algorithm to extract speech in the presence of multiple interferers was evaluated through intelligibility ratings from normal- and hearing-impaired listeners. Sentences were presented with competing speech and multitalker babble (MTB) at four different SNRs to groups of individuals with sensorineural hearing loss and normal hearing. The sentences and competition had been processed through a real-time, frequency-banded minimum-variance beamforming (FBMVB) algorithm in multitalker environments (Lockwood et al., 1999). Competing messages and MTB were simulated at +22 and +45 azimuths relative to the target source. Each target sentence with competing messages was submitted to the FBMVB algorithm to yield a set of 24 ‘‘processed’’ and 24 ‘‘unprocessed’’ sentences per SNR condition. Listeners rated the intelligibility (0%–100%) of the target sentences and repeated the last word of each sentence. Results from the ratings and the word recognition scores show improvement for every listener when the ensemble speech and competition were processed through the FBMVB algorithm. Results from these experiments indicate the advantage of the algorithm in selective extraction of speech in complex environments. Continued evaluation of the algorithm under real-room conditions is in progress. [Work supported by R21DC04840 ONR N00014-99-1-0612.]
Beamformer improvement with increasing number of sensors
Authors: Berry Matthew J. , Lockwood Michael E. , Jones Douglas L. , Bilger Robert C. , Lansing Charissa R. , O’Brien William D. , Wheeler Bruce C. , Feng Albert S.
Published: February 2014

The two-sensor frequency-banded minimum-variance beamformer (FBMVB) [Lockwood et al., J. Acoust. Soc. Am. 106, 2278 (1999)], shown to extract a target speech signal from multiple interfering speech sources, is extended to three and four sensors. The extended FBMVB retains the real-time computational advantages of the two-sensor FBMVB. Results from a battery of simulated and real acoustic environment tests suggest that the extended FBMVB offers better extraction of the target speech than the two-sensor FBMVB. Measuring the quality of extraction as signal-to-noise ratio gain and intelligibility-weighted signal-to-noise ratio gain, the extended FBMVB demonstrates performance improvements of 2–3 dB over the already high performance of the two-sensor FBMVB for most tests. In general, results suggest that the extended FBMVB is more robust with respect to crowded interferer settings and room reverberation.
Time-reversed reverberation focusing in a waveguide
Authors: Lingevitch J. F. , Song H. C. , Kuperman W. A.
Published: February 2014

Time reversal mirrors have been demonstrated to focus acoustic energy in the ocean at ranges of tens of kilometers from a probe source [W. A. Kuperman et al., J. Acoust. Soc. Am. 103, 25–40 (1998)]. Time reversal has also been exploited to focus acoustic energy at discrete scatters of unknown location using the eigenvectors of the time reversal operator which can be formed by measuring the interelement transfer function of a source/receiver array [C. Prada et al., J. Acoust. Soc. Am. 99, 2067–2076 (1996)]. This paper extends these principles to the case of reverberation from a rough interface in a waveguide. The reverberation data collected on a source/receiver array are used to form a time reversal operator. The most energetic eigenvector of this operator focuses to a specific range along the rough interface. Improved signal-to-noise measurements of the time reversal operator can be obtained by probing the water column with orthogonal array beams. Since this method does not depend upon a priori environmental information, it is applicable to complex shallow water environments. Numerical simulations with a Pekeris waveguide are used to demonstrate this method. [Work supported by ONR.]
Effect of seawater salt on compressional wave in dry beach sand
Authors: Chamuel Jacques R.
Published: February 2014

At the previous ASA meeting, quantitative results were presented revealing the effect of water content on compressional wave velocity in beach sand. New ultrasonic compressional wave results are presented demonstrating the effect of salt crystals bonding beach sand grains as seawater is evaporated. Wave velocity and attenuation results are compared with beach sand rinsed with distilled water. Although the salinity of seawater is only about 35 parts per thousand, the salt concentration increases rapidly as the seawater is evaporated. The sand grains become covered with a glaze and solid salt bonds are formed connecting the grains. The acoustic properties of salt crystals (compressional wave velocity 4.53 km/s, and density 2.165×103 kg/m3) are close to those of a sand grain. Results from controlled experiments using spherical particles and plates bonded with evaporated salt water are also discussed. The author is not aware of any publication describing the adhesion of sea salt to beach sand. The new findings contribute to understanding the propagation of high-frequency compressional waves in granular materials leading to reliable seismoacoustic detection of buried objects in beach sand. [Work supported by ONR.]
Old-age stage evolution of intense cylindrical and spherical acoustic noise
Authors: Gurbatov Sergey N. , Cherepennikov Valery V. , Enflo Bengt O.
Published: February 2014

The investigation of the old-age behavior of an intense periodic spreading wave was one of the significant contributions of Crighton in nonlinear acoustics. By him and his co-workers a classification of different regimes of evolution was done and it was shown at which condition the saturation of the amplitude takes place. Here the evolution of intense spreading acoustic noise is considered on the base of generalized Burgers’ equations. It is shown that at the old-age (linear) stage the energy spectrum of the noise has a universal structure: it is proportional to the second power of the frequency at small frequencies and decreases exponentially at high frequencies. The proportionality coefficient does not depend on the distance and is determined by the nonlinear effects on the initial stage of the propagation. It is shown that even for a small acoustical Reynolds number the energy of the noise at the old-age stage is proportional to the third power of the initial energy for cylindrical waves and to the power 5/2 with some logarithmic correction for spherical waves. The analytical estimations are supported by numerical simulation. [Work supported by RFBR and INTAS grants.]
Comparing perception and production vowel spaces of cochlear implant users
Authors: Wright Richard , Harnsberger James D. , Pisoni David B. , Svirsky Mario A. , Kaiser Adam R.
Published: February 2014

This study investigates the relationship between speech production and auditory feedback by comparing vowel production and perception in normal hearing and cochlear implant (CI) using populations. CI users vary greatly in their improvement in speech production after implantation, indicating varying benefit from the CI device. This study examines the degree to which distortions in CI users’ speech can be attributed to perceptual distortions. Three predictions are tested in this study: (1) perceptual distortions will correlate with distortions in speech, (2) there will be a tendency to collapse towards the middle of the vowel space, (3) there will be hyperarticulation of vowels analogous to the Lombard effect. Three measures were used in relation to gender and dialect matched normal hearing subjects: (1) overlap between vowel categories, (2) the distortions of the vowel space centers, (3) vowel space compression. Results indicate that there is little correlation between individual CI users’ spoken vowel spaces and the range of variability in the perceptual vowel space. However, there is a tendency to collapse towards the middle of the vowel space. This behavior is unlike the normal hearing response to noise in which production vowel categories tend to expand away from the middle of the space.
Predictors of visual enhancement and lipreading ability in older and younger adults
Authors: Sommers Mitchell S. , Sawyer Debra
Published: February 2014

The present study was designed to examine the importance of several factors in predicting visual enhancement (auditory-visual compared with auditory-only performance) and lipreading abilities in older and younger adults. Thirteen consonants were presented in an aCa context and participants responded using a closed-set response format. Stimuli were presented in auditory-only, visual-only, and auditory-visual conditions to each participant. Predictor variables included measures of education, vocabulary, verbal working memory, spatial working memory, and processing speed. For both younger and older adults, the two measures of working memory (verbal and spatial) and overall processing speed accounted for a significant percentage of the variance in visual-only performance. None of the predictor variables accounted for significant variance in visual enhancement for young adults. Preliminary results for older participants indicated that speed of processing and verbal working memory were reliable predictors of visual enhancement. Neither group exhibited a significant relationship between visual-only performance and visual enhancement, suggesting that the ability to integrate across modalities, rather than lipreading ability, is the principal factor contributing to individual differences in visual enhancement. Implications of these findings for improving the speech perception abilities of hearing-impaired older adults are discussed. [Work supported by NIA and the Brookdale Foundation.]
Perception of dynamic speech sounds by normal hearing listeners and cochlear implant recipients
Authors: Hawks John W. , Fourakis Marios S.
Published: February 2014

In a continuing series of experiments aimed at identifying factors that influence speech perception by cochlear implant (CI) users, we are currently investigating the reception and utilization of relevant perceptual information available for place of articulation of stop consonants in synthetic stop-vowel sequences. Normal hearing subjects and adults fitted with clarion and nucleus cochlear implant (CI) devices provided identification responses for synthetic CVs which varied in (1) initial onset frequencies of F2 and F3, (2) duration of frequency transition from onset to steady-state target, and (3) steady-state target F2 and F3 frequencies of the following vowel. While resembling stop-vowel sequences, no burst or aspiration parameters were included, thus forcing listeners to use only transition information as the primary cue to place of articulation. The results demonstrate the potential diagnostic value afforded from mapping dynamic speech sounds in an acoustic space using synthetic tokens.
Inhibitors of TonB Function Identified by a High-Throughput Screen for Inhibitors of Iron Acquisition in Uropathogenic Escherichia coli CFT073
Authors: Yep Alejandra , McQuade Thomas , Kirchhoff Paul , Larsen Martha , Mobley Harry L. T.
Published: February 2014

The urinary tract is one of the most common sites of infection in humans, and uropathogenic
Escherichia coli
(UPEC) is the main causative agent of urinary tract infections. Bacteria colonizing the urinary tract face extremely low iron availability. To counteract this, UPEC expresses a wide variety of iron acquisition systems. To exploit iron acquisition in UPEC as a global target for small-molecule inhibition, we developed and carried out a whole-cell growth-based high throughput screen of 149,243 compounds. Our primary assay was carried out under iron-limiting conditions. Hits in the primary screen were assayed using two counterscreens that ruled out iron chelators and compounds that inhibit growth by means other than inhibition of iron acquisition. We determined dose-response curves under two different iron conditions and purchased fresh compounds for selected hits. After retesting dose-response relationships, we identified 16 compounds that arrest growth of UPEC only under iron-limiting conditions. All compounds are bacteriostatic and do not inhibit proton motive force. A loss-of-target strategy was employed to identify the cellular target of these inhibitors. Two compounds lost inhibitory activity against a strain lacking TonB and were shown to inhibit irreversible adsorption of a TonB-dependent bacteriophage. Our results validate iron acquisition as a target for antibacterial strategies against UPEC and identify TonB as one of the cellular targets.

IMPORTANCE
Half of women will suffer at least one episode of urinary tract infection (UTI) during their lifetime. The current treatment for UTI involves antibiotic therapy. Resistance to currently used antibiotics has steadily increased over the last decade, generating a pressing need for the development of new therapeutic agents. Since iron is essential for colonization and scarce in the urinary tract, targeting iron acquisition would seem to be an attractive strategy. However, the multiplicity and redundancy of iron acquisition systems in uropathogenic
Escherichia coli
(UPEC) make it difficult to pinpoint a specific cellular target. Here, we identified 16 iron acquisition inhibitors through a whole-cell high-throughput screen, validating iron acquisition as a target for antibacterial strategies against UPEC. We also identified the cellular target of two of the inhibitors as the TonB system.
Anabolic steroids abuse-induced cardiomyopathy and ischaemic stroke in a young male patient
Authors: Shamloul Reham Mohammed , Aborayah Ahmed Fathy , Hashad Assem , Abd-Allah Foad
Published: February 2014

We report a case of a 37-year-old man presented with acute stroke and hepatorenal impairment which were associated with anabolic-androgenic steroids (AAS) abuse over 2 years. Despite the absence of apparent symptoms and signs of congestive heart failure at presentation, an AAS-induced dilated cardiomyopathy with multiple thrombi in the left ventricle was attributed to be the underlying cause of his condition. Awareness of the complications of AAS led to the prompt treatment of the initially unrecognised dilated cardiomyopathy, and improved the liver and kidney functions. However, the patient was exposed to a second severe ischaemic event, which led to his death. This unique and complex presentation of AAS complications opens for better recognition and treatment of their potentially fatal effects.
DIPNECH presenting on a background of malignant melanoma: new lung nodules are not always what they seem
Authors: Killen Helen
Published: February 2014

The coexistence of lung nodules on a CT scan with worsening respiratory symptoms in the context of previous malignant melanoma would usually signify metastatic disease. The cause of the lung nodules in this 69-year-old woman turned out to be diffuse idiopathic neuroendocrine cell hyperplasia (DIPNECH) with tumourlets. DIPNECH is extremely rare, with fewer than 100 cases reported in the literature worldwide. The key to making this diagnosis was that the nodules were not avid on a positron emission tomography-CT scan, as would have been expected in metastatic melanoma. This led to a biopsy diagnosis. At the time of writing, the patient remains symptomatic with stable disease.
Patient-reported confidence in primary healthcare: are there disparities by ethnicity or language?
Authors: Wong Sabrina T , Black Charlyn , Cutler Fred , Brooke Rebecca , Haggerty Jeannie L , Levesque Jean-Frederic
Published: February 2014

Objective

To examine whether confidence in primary healthcare (PHC) differs among ethnic–linguistic groups and which PHC experiences are associated with confidence.

Design

A cross-sectional study where patient surveys were administered using random digit dialling. Regression models identify whether ethnic–linguistic group remains significantly associated with confidence in PHC.

Setting

British Columbia, Canada.

Main outcome measures

Confidence in PHC measured using a 0–10 scale, where a higher score indicates increased confidence in the ability to get needed PHC services.

Participants

Community-dwelling adults in the following ethnic–linguistic groups: English-speaking Chinese, Chinese-speaking Chinese, English-speaking South Asians, Punjabi-speaking South Asians and English-speakers of presumed European descent.

Findings

Based on a sample of 1211 respondents, confidence in PHC differed by ethnicity and the ability to speak English. Most of the differences in confidence by ethnic–linguistic group can be explained by various aspects of care experience. Patient experiences associated with lower confidence in PHC were: if care was received outside Canada, having to wait months to see their regular doctor and rating the quality of healthcare as good or fair/poor. Better patient experiences of their doctor being concerned about their feelings and being respectful and if they found wait times acceptable were associated with higher levels of confidence in PHC. The final regression model explained 30% of the variance.

Conclusions

Improving the delivery of PHC services through positive interactions between patients and their usual provider and acceptability of wait times are examples of how the PHC system can be strengthened.
CARING FOR THOSE WHO DIE AT HOME – THE USE AND VALIDATION OF ‘CARE OF THE DYING EVALUATION’ (CODE) WITH BEREAVED RELATIVES
Authors: Mayland Catriona , Lees Carolyn , Germain Alison , Jack Barbara , Cox Trevor , Mason Stephen , West Angela , Ellershaw John
Published: February 2014

Background

‘CODE’ is a 40-item self-completion post-bereavement questionnaire, focused on the last days of life and based on key components of best practice for care of the dying. CODE is a shortened, more user-friendly version of an original validated instrument, ‘Evaluating Care and Health Outcomes–for the Dying’ (ECHO-D).

Aim

To assess the validity and reliability of CODE by conducting: cognitive ‘think aloud’ interviews; test-retest analysis; and assessing internal consistency and construct validity of three key composite sub-scales–‘CARE’; ‘ENVIRONMENT’; and ‘COMMUNICATION’.

Methods

A post-bereavement survey was conducted with 291 next-of-kin (NOK) to patients who died at home in Northwest England from advanced incurable illness. All NOK were invited to complete the CODE questionnaire and also asked if willing to undertake a cognitive interview and/or complete CODE for a second time a month later.

Test-retest reliability was assessed using: percentage agreement; Kappa statistic and Spearman's correlation co-efficient. For each sub-scale, Cronbach's alpha and item-total correlations were used to assess internal consistency. Confirmatory factor analysis was used to assess construct validity.

Results

72 bereaved relatives (24.7% response rate) returned the completed CODE questionnaire, and 25 completed CODE for a second time. 15 cognitive interviews were undertaken. All interviewees found CODE sensitively worded and easy to understand. Minor revisions were suggested to provide additional clarity. Test-retest analysis showed all except two questions had moderate or good stability. Although the ENVIRONMENT scale was not perceived as relevant within the home setting, all three sub-scales scales showed good construct validity and internal consistency (Cronbach's alpha>0.79).

Conclusions

‘CODE’ represents a user-friendly, comprehensive outcome measure for care of the dying. This preliminary data, despite small numbers, builds on previous work with ECHO-D and provides support for CODE's validity and reliability. CODE could potentially be used to benchmark individual organisations and identify areas for improvement.
EVALUATING CURRENT ASSESSMENT AND TREATMENT OF DELIRIUM BY UK PALLIATIVE CARE PHYSICIANS
Authors: Elliot Victoria , Lowe Emma , Owen Rebecca , Adams Charlotte , Sheils Rachel
Published: February 2014

Background

Delirium is a common condition seen in all areas of clinical medicine, particularly in patients with advanced disease. Its prevalence is expected to rise from the current level of 28-90% with the use of more aggressive anti-cancer treatments. The condition is often under recognised but can be distressing for both patients and their relatives.

Aims

The objective of this study was to establish how palliative care physicians in the UK assess and treat delirium (including drug treatment).

Methods

A questionnaire was developed and sent via the Association of Palliative Medicine to all UK members. The questionnaire contained 10 questions with multiple choice answers but also allowed space for free text.

Results

The results highlighted that currently physicians most commonly use no screening tools for diagnosing delirium (35%). They also highlighted that when treating delirium, conservative measures, such as quiet environment and reassurance, are opted for first, as well as identifying and treating reversible causes. However, when drug treatments are required haloperidol is the most popular choice (88.1%).

Conclusions

There is current consensus amongst surveyed UK palliative care physicians that conservative management of delirium should be used prior to medications, and that all reversible causes should be investigated. When drug treatment is required Haloperidol is the most popular drug which is in keeping with current NICE guidance. Recommendations for broader research include a screening tool for distress that could be validated in a palliative care population. It is also recognised that there is a lack of high quality evidence about which drugs to use when trying to restore cognitive function in palliative care patients. However, it may be that we should consider extrapolating the evidence from the NICE guidance to our patients, given the characteristics of the patients in the studies included.
THE BURDEN OF END OF LIFE CARE—PROMOTING THE PSYCHOLOGICAL RECOVERY OF INFORMAL CARE GIVERS
Authors: Brown Michelle , Brock Martin
Published: February 2014

Background

The National End of Life Programme (DOH 2010) has set out a direction of travel for social care at the end of life and important targets include commissioning and delivery of person centred and integrated care for both patients care givers and families.

From the point of view of care giving the burden is likely to increase as there will likely be fewer carers and more people dying at home with complex care needs (Seale 2000 )

Carers are a valuable part of care delivery in the UK and valuing and supporting them with compassionate philosophy should be a key strategy (Brown 2012) yet the Health Care Commission in 2008 found that the most consistent complaint from caregivers was related to end of life care.

There is a body of research describing the adverse effects of care giving including stress, anxiety and mortality (Gaugleret al2004).

Integrating relative and family in end of life care decisions and increasing understanding of the end of life process appears to be beneficial for both the patient experience and the psychological recovery of the relatives (Schulzet al2003).

Aims

Improve psychological recovery of informal care givers

Facilitate informal care givers' awareness of the end of life process

Assist informal care givers in developing self-compassion and coping strategies

Framework: Development of a 6 week psycho-educational support group for informal care givers either during or post end of life care

Format of group will include educational components and peer support activities.

Group Facilitated by Palliative Care Expert & CBT Psychotherapist.

Conclusion

Considering the increase of care giving at home, including end of life, informal caregivers require more comprehensive support than currently available to enable their psychological recovery.

Increasing awareness of the end of life process and development of self-compassion is likely to enable this recovery.
RECOGNITION OF THE DETERIORATING AND DYING PATIENT
Authors: Meredith Joanne , Kendall Margaret , Waller Gwen
Published: February 2014

Background

The trust has been committed to the Transforming End of Life Care (EOLC) programme for over a year and is required to collect data for the matrix developed by the programme and for Merseyside and Cheshire clinical network. The matrix is a valuable way to measure the implementation of tools/enablers at the end of life, both nationally and locally.

Gathering evidence through audit has demonstrated the need for quality tools/enablers or End of Life Care facilitation at Trust level and supports the sustainability of such tools/facilitation by identifying gaps in knowledge and skills and training requirements of the health care professionals caring for patients.

Aim

The overall aim of the audit supports a process of continuous improvement in the care of persons at the end of life, including their families against the Quality Standards for End of Life Care NICE (2012) and Good Practice Guide towards EOLC (GMC) 2010 in the acute setting.

This is achieved through the following measures:

The use of recognised EOLC tools and enablers as part of the National End of Life Care Transform Programme guidance for acute trusts.

Assessing the quality of documentation as a patient deteriorates and dies.

Method

A hand search of the case notes was undertaken for all patients who had died within the trust during May 2013. Evidence was sought for a written medical plan with escalation decisions, diagnosis of dying, documented conversations with the patient or the family about deterioration and/or dying and use of EOLC tools.

Results

There is very limited evidence within the case notes that imminent death was recognised and documented. However the majority of patients who died did have a Do Not Attempt Resuscitiation (DNAR) status documented. Low rates of referral to Specialist palliative care teams were noted, and anticipatory medication was prescribed in a limited number of cases.

Conclusion

The use of tools or enablers support and guide recognition and documentation of the dying phase.
MANAGEMENT OF METASTATIC SPINAL CORD COMPRESSION: AUDIT
Authors: Hanchanale Sarika , Neoh Karen , Waldock Joy , Lenton James , Naik Jay
Published: February 2014

Introduction

Metastatic spinal cord compression (MSCC) is a medical emergency, prompt management is required to preserve neurological function. A retrospective audit of MSCC management in the Mid Yorkshire NHS trust in 2012 was conducted.

Aims

To compare current practice to NICE guidance, and also record patients' diagnosis, signs, symptoms and three month survival. MRI and radiotherapy time from request were calculated. The prescription of dexamethasone, Low molecular weight heparin (LMWH), analgesia and gastric protection were assessed.

Results

Twenty seven patients were identified as having MSCC. The most common cancers were lung, prostate and breast, but 15% of patients had no malignant diagnosis at the time of presentation. Most patients had back pain (23), with duration from one day to three months. Fifteen patients had reduced mobility and four patients had bladder dysfunction. Twenty three patients were suspected of having MSCC, three were suspected of having spinal metastasis and one patient was thought to have a slipped disc. Only 53% of the patients with suspected MSCC had an MRI performed within 24 hours. The regional oncology team was contacted in all cases. LMWH and analgesia were given in 96% of the patients. All patients received steroids, but dexamethasone prescribing and dose reduction was inconsistent. Two thirds of patients had radiotherapy within one day. Three month survival was 56%.

Conclusion

MRI scan within 24 hours was just over 50% and should be 100%; reasons for delay include patients being too unwell to transfer and transport issues, but these were only in a few cases. This is a complex problem, especially if patients are out patients, and requires improved radiology capacity. We recommended staff education and a local protocol, which should include guidelines on standardisation of dexamethasone prescribing. The audit should be repeated once the protocol has been in place for 6–12 months.
IMPACT OF A CANCER OF UNKNOWN PRIMARY (CUP) SERVICE ON END OF LIFE PLANNING FOR PATIENTS WITH METASTATIC DISEASE
Authors: Marshall Jackie , Stewart James , Hancock Louise , Gillmore Roopinder
Published: February 2014

Background

NICE recommends every cancer centre should establish a consultant-led CUP team (oncology, palliative care consultants and specialist nurse) (NICE CG 104). One of the aims of this service is to ensure patients with imaging suggestive of metastatic disease have early review by oncology and palliative care.

Table 1

Outcome measures comparing the two time period.

20092012Number of patients915Mean age (range) (years)73 (35–92)82 (46–94)Mean LOS (range) (days)18.6 (4–51)6.7 (2–15)p<0.004% Died in hospital (absolute numbers)67 (6/9)7 (1/15)p<0.002% Readmission33 (1/3)14 (2/14)p>0.4% Oncology review33 (3/9)100 (15/15)p<0.0005% Palliative care33 (3/9)100 (15/15)p<0.0005

p<0.05 significant Age and LOS were analysed using t-test other data were compared using a chi-squared test.

Aim

This analysis assessed the impact of a CUP service on patients diagnosed with metastatic cancer who were not fit enough for active treatment.

Methods

Clinical notes were reviewed for all acute hospital admissions with an imaging-based diagnosis of metastatic cancer, who did not go onto receive active treatment. A retrospective analysis performed prior to the establishment of the CUP team (January-April 2009), was compared to prospective data following the launch of the CUP service (June-December 2012).

Results

Following establishment of the CUP team – mean length of stay was significantly reduced (6.7 days, 18.6 days, p<0.004) and only one patient was unable to be discharged to their preferred place of death. Furthermore all patients were reviewed by palliative care to optimise symptom control (Table 1).

Conclusions

Early assessment by the CUP service facilitates specialist input from oncology and palliative care, successful discharge planning, with reduced length of stay and rates of readmission.
CAUSES OF SLEEP DISTURBANCE IN A SPECIALIST PALLIATIVE CARE UNIT
Authors: Glynn Jayne , Gale Sue , Tank Shila
Published: February 2014

Background

Sleep disturbance is a common and distressing problem in patients who are terminally ill and may intensify symptoms such as pain, depression, and/or anxiety. Staff in a Specialist Palliative Care inpatient unit felt that they were inadvertently and partly responsible for unnecessarily disturbing patients during the night, however, the frequency and precise nature of what caused patients to wake was unknown. A survey was undertaken to identify causes of disturbance and explore ways of reducing them.

Methods

Data were collected on all direct patient contact between 10pm and 6am. Data including time of disturbance, mode of seeking attention, and the primary reason for nurse assistance were recorded along with secondary data relating to additional needs and outcomes.

Results

301 disturbances occurred in 27 nights. 86% (60/70) of inpatients had at least one need (range 1–4). Most needs were between 22:01–24:00 hrs (29%) followed by 00:01–02:00 hrs (25%) and 02:01–04:00 hrs (23%). Patients used their call bell (58%), called out (18%) or were observed by a healthcare professional. Primary reason for seeking help related to elimination (31%), symptomatic (26%), wanted food/drink (13%), repositioning (10%), confused/talking in their sleep (6%), others (15%). Of the 10 symptoms reported pain was the most common followed by breathlessness, insomnia, cough/hiccups. Patients frequently articulated additional needs once their primary need had been met, for example, wanted analgesia, then asked for hot drink, assistance to the toilet, fan, etc. These subsequent needs resulted in 500 activities being carried out. Nurses and/or their activities were not reported as a cause for waking patients, however, when meeting an individual's needs other patients opportunistically expressed help/needs.

Conclusion

Nursing activities do not appear to disturb patients. Ways of reducing nocturia in this client group are limited, however, more could be done to explore symptom management, such as prophylactic medication use. Pre-bedtime snacks should be provided and encouraged.
ESTABLISHING AN IMPROVING CARE GROUP IN HOSPICE: TRANSLATING RESEARCH INTO PRACTICE
Authors: Wijenayake Erandi , Hookey Claire
Published: February 2014

Background

Integrating research into daily practice is a challenge. Keeping up-to-date with the latest research and guidelines can help clinicians improve quality and safety of care. Following the Palliative Care Congress in 2012, an 'Improving Care Group' (ICG) was set up at Douglas Macmillan Hospice in Stoke-on-Trent.

Aims

The ICG aims to improve care through utilising evidence based research. It is a multidisciplinary group with medical, nursing, physiotherapy, social work and psychology representatives.

Methods

The group identified several areas for which to examine the evidence base. Task groups were established for:

Exercise

Holistic Assessment Tools

Sex and Sexuality

Fan Therapy for Breathlessness

Clinical Ethics Committees

Each task group reported back to the ICG and an action plan was agreed.

Results

Literature review in some areas reinforced existing practice. For example, no evidence of benefit for use of holistic assessment tools within specialist palliative care was identified. However, the ICG identified that within the current holistic assessment, sex and sexuality were not well explored leading to a further task group.

Examples of changes implemented by the ICG include:

Training for hospice staff in assessment of needs and concerns around sex and sexuality.

Development of patient information leaflets on sex and intimacy.

Increased focus on exercise particularly for day therapy unit patients, including the “Tour of Stoke-on-Trent challenge”.

A pilot of fan therapy for breathlessness.

Teaching on management of breathlessness for hospice staff.

Teaching on clinical ethics for hospice staff and identification of a group interested in becoming a hospice clinical ethics committee.

Conclusions

The Improving Care Group has provided a vehicle for enabling staff from different backgrounds and departments to work together to integrate research into practice, across all areas of the hospice.
EVALUATING THE IMPACT OF DAY THERAPY USING ST CHRISTOPHER'S HOSPICE INDEX OF PATIENT PRIORITIES (SKIPP)
Authors: Rayment Clare , Gordon Jean , Lepp Lydia
Published: February 2014

Aims

To evaluate patients' perceived global impact of day therapy and the impact of day therapy on patients' quality of life (QOL) and concerns using SKIPP.

Methods

SKIPP was completed at a patients' second attendance and thereafter 6 weekly for all new patients attending day therapy at Marie Curie Hospice, Bradford between January and July 2013.

Results

43 new attendees: 39 completed SKIPP. 24 completed one SKIPP, 15 two and 5, three. 28 patients continue to attend, 7 have died and 4 were discharged. SKIPP was completed by patients alone or with staff. Data was missing for SKIPP one for 9 patients. Average QOL, on a 1–7 (excellent) score, at SKIPP one was 3, SKIPP two, 5, and SKIPP three, 6. At SKIPP one, 77% of patients felt day therapy had improved things for them: 8% felt it had not helped much and 5% didn't know. At SKIPP two these figures had changed to 87% felt day therapy had helped: 13% not at all. At SKIPP three, 4 patients felt it had helped to a very great extent, 1 not at all. At SKIPP two, 10 felt that day therapy had made their concern better, 3 had no change and 2 felt it was a little worse. At SKIPP three, 3 patients felt their concern was better, 1 much worse and data was missing for 1 patient.

Conclusions

SKIPP demonstrates that average QOL improves during day therapy attendance and most patients' think day therapy is helping them overall. However, a third of patients' main concern remained the same or a little worse at SKIPP 2. Only a small number completed a second SKIPP and this will influence the results. SKIPP appears to be useful in demonstrating the benefits of day therapy for some aspects of patient care.
PRIOR AND PROPER PREPARATION: FUNDAMENTAL STEPS WHEN IMPLEMENTING THE GOLD STANDARDS FRAMEWORK (GSF) IN A TERTIARY CANCER CENTRE
Authors: Griffiths Ann , Coackley Alison , Noble Agnes , Howarth Susan , Hampton-Matthews Julian , Foulkes Margaret , Lee Heather
Published: February 2014

Background

The GSF was developed in 2000 to improve palliative care in primary care. National dissemination was facilitated through a cascade approach with a Central Team supporting local facilitators. GSF has been shown to improve:-

1. Quality of care

2. Co-ordination and communication

3. Patient outcomes and cost effectiveness.

Acute hospitals have been described as the missing link in providing seamless, co-ordinated high quality end of life care. At present there has been no experience of implementing GSF into a tertiary cancer centre. Identification of patients in the last 12 months of life was recognised to be challenging for staff.

Aim

To analyse the knowledge and skills of health care professionals working in a tertiary cancer centre in identification of patients in the last twelve months of life and the use of advance care planning tools.

Method

Three questionnaires were distributed to health care professionals

1. A base line survey assessing the knowledge and skills of health care professionals recognising patients in the last twelve months

2. An organisational questionnaire assessing the knowledge of the senior managers

3. An after death analysis for deaths within the Centre

Results

The baseline questionnaire was distributed to 152 staff. The response rate was 76%. The organisational questionnaire was distributed to 3 wards and the Head of Nursing. The Response rate was 100%.

The After Death Analysis examined 86 deaths in the Trust

Complete results from the three questionnaires will be presented with details of the subsequent action plan

Conclusion

Interim results from the surveys have demonstrated that healthcare professionals require further training in the identification of patients at the end of life and the use of advance care planning tools. A comprehensive education package delivered over 6 months will aim to address the needs of staff.
ANTIBIOTIC STEWARDSHIP IN PALLIATIVE CARE — DEVELOPMENT OF ANTIBIOTIC PRESCRIBING GUIDELINES FOR A HOSPICE INPATIENT UNIT
Authors: Donald Leila , Lindsay Fiona
Published: February 2014

Background

The incidence of infections in palliative care patients is high due to immunocompromise from underlying disease processes and treatments including chemotherapy and steroids. An earlier audit of hospice notes revealed poor documentation of antibiotic prescribing and poor adherence to hospital antimicrobial guidelines.

Aims

To promote antibiotic stewardship through the development of local antimicrobial guidelines specific to palliative care and inpatient hospice setting. To provide a simple, pragmatic approach and promote the safe, effective and economic use of antibiotics in palliative care patients.

Methods

A literature search of Embase, Medline, the Cochrane Library and NHS evidence using the search terms ‘palliative care’ or ‘palliative therapy’ and ‘antibacterial agents’ or ‘antibiotic agent’ was completed National antibiotic guidance (BNF), published antibiotic guidance specific to palliative care (palliativedrugs.com) and local antimicrobial guidelines (PCT and Hospital) were also reviewed in development of the hospice antibiotic prescribing guidelines. The guidelines were discussed with the hospice pharmacist and presented to the medical and nursing staff, providing peer review and education.

Results

The literature search identified 10 articles meeting the search criteria but the focus was on antibiotic use in the last few days of life and was unsuitable. No definitive guidelines for antibiotic prescribing in palliative care were identified. The developed hospice antibiotic prescribing guidelines provide guidance for first and second line treatment of 12 specific infections of the lower respiratory tract, urinary tract, skin and soft tissue and other miscellaneous infections including clostridium difficile and intrabdominal sepsis. Clear documentation is emphasised with requisite information stipulated. The guidelines were introduced in May 2013.

Conclusions

The innovative multi-disciplinary approach used to develop the antibiotic guidelines will encourage consistent prescribing and documentation to produce safe, effective and economic antibiotic use in hospice inpatients. The rigorous development process allows the guidelines to be transferable to other specialist palliative care inpatient settings.