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Disorders of the motor programming of speech ( Fig. 1 ) have a different clinical significance from true word-finding difficulty. Nevertheless such deficits frequently co-occur, and this assists in anatomical localization and diagnosis. Here we consider these deficits at some length, because they are difficult to characterize with precision and because they entail several concepts which continue to stimulate controversy in the literature on progressive aphasias. One example is apraxia of speech (AOS). This term has been used to describe a motor speech disorder which (by analogy with other ‘apraxias’) can be defined operationally as impairment of the motor gestures of speech that is not attributable to a primary motor deficit (Darley, 1969 ; Ogar et al ., 2005 ). Although the cognitive basis of AOS remains controversial, it is likely to arise at the level of cortical programming of phonetics, the step in speech production where the phonological structure is converted into an ‘articulatory score’ that directs the relevant muscles of the vocal tract to produce the word or phrase. AOS is probably therefore synonymous with phonetic breakdown or disintegration. The characteristic features of AOS are slow speech rate with hesitancy (difficulty initiating utterances), effortfulness (with articulatory groping, i.e. multiple attempts at trying to get to the right word and self-correction, worse with longer words), phonetic errors (errors in the shaping, timing and ordering of individual syllables) and dysprosody (abnormal rhythm, stress and intonation, attributable to poor phonetic sequencing rather than a primary prosodic deficit) (Dabul, 2000 ; Duffy, 2005 ; Ogar et al ., 2005 ; Duffy, 2006 ). Patients may describe the problem as a stutter or stammer and there may be re-emergence of a childhood stutter. In a recent review of AOS in degenerative disease, only 10% of cases occurred in an isolated fashion, independently of aphasia or dysarthria (Duffy, 2006 ). It is associated particularly with PNFA (Josephs et al ., 2006 a ; Duffy, 2006 ).

In principle, phonetic errors (errors in the execution of a programmed speech sound) are distinct from phonemic errors (errors in the selection of speech sounds to be executed): speech sounds may be selected correctly during the programming of an utterance but then articulated incorrectly or conversely, speech sounds may be selected incorrectly but then articulated correctly. However, in practice this is a difficult distinction to make at the bedside, and the two types of error frequently coexist. Clues to phonetic errors include the presence of distortions (commonly either distorted substitutions e.g. ‘brop-er-ty’ for the target word ‘property’, or additions e.g. prop-er-ta-ty’) and the co-occurrence of other features of AOS. This is in contrast to patients with pure phonological or phonemic breakdown: true phonemic errors are not distorted and speech is not effortful (Caramazza et al ., 2000 ).

The organization of brain knowledge systems, in particular the extent to which different modalities and categories of knowledge are dissociable, remains a core theoretical issue in contemporary cognitive neuropsychology. Category-specific deficits of verbal knowledge have been documented in degenerative disease, but category effects are unusual and occur much less frequently than with acute pathologies. There may be selective impairment of the ability to comprehend the names of living things (McCarthy and Warrington, 1988 ; Lambon Ralph et al ., 2003 ) or inanimate items (Silveri et al ., 1997 ), or concrete versus abstract words (Warrington, 1975 ). Conversely, there may be relatively preserved comprehension of the names of body parts (Coslett et al ., 2002 ), colours (Robinson and Cipolotti, 2001 ) or countries (Incisa della Rochetta et al ., 1998 ). Though rare, category-specific deficits are of theoretical importance: the existence of such category effects, together with the consistency of deficits observed in SD and evidence for retention of partial knowledge in SD and AD (Murre et al ., 2001 ; Garrard et al ., 2005 ), argues for degradation of stored concepts (i.e. direct involvement of the knowledge store) rather than loss of access to the knowledge store. One well-established category effect in degenerative disease is the dissociation between noun and verb knowledge. Impairments of noun retrieval and comprehension are well documented (Silveri et al ., 2003 b ) and usually are most salient in SD. Conversely, selective impairments of verb retrieval and comprehension have been demonstrated in patients with frontal dementia syndromes including frontotemporal dementia associated with motor neuron disease (FTD-MND) (Bak et al ., 2001 ). Such patients have particular difficulty in processing verb phrases, and may rely more heavily on noun phrases (such as ‘laddering’ for ‘climbing’) and ‘superordinate’ verbs (such as ‘being’, ‘making’ or ‘having’).

Under most circumstances in daily life, words must be processed not in isolation but combined into sentences. Difficulty with sentence comprehension may occur despite normal single-word comprehension. This pattern suggests that the processing of grammatical relations is deficient, and it may also be associated with particular difficulty understanding verbs rather than nouns (Price and Grossman, 2005 ). Having established that the comprehension of single words (nouns) is normal, the sentence level of comprehension can be assessed by asking the patient to perform a short sequence of actions according to different syntactic rules (e.g. ‘put the paper underneath the pen that is on the book’, ‘you pick up the watch and then give me the book’). Alternatively, the patient can be asked to identify a picture based on a syntactical sentence description (e.g. ‘point to the boy being chased by the dog’). The comprehension of grammar involves a number of different procedures (including determination of tense and number, interpretation of pronouns and prepositions, analysis of word order and subject-object relations and parsing of clauses). These procedures can be broadly classified as syntactical (relations between words) and morphological (word modifications according to grammatical context) and may have distinct neural bases. Some aspects of grammar processing may be dissociable from sentence comprehension (Cotelli et al ., 2007 ) and can be assessed by asking the patient to detect grammatical errors within written sentences.

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doi: 10.4037/ajcc2009686

+ Author Affiliations

Margo A. Halm Melissa Gleaves Corresponding author:

A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on health care practices where little evidence exists. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature and encourage the submission of questions for future review.

Clinical Evidence Review www.ajcconline.org

Occasionally, nurses perform phlebotomy via intravenous catheters, especially to improve efficiency in short-stay or procedural units. The intent of this practice is to reduce the number of venipunctures and thus increase patients’ comfort. However, obtaining laboratory specimens from peripheral intravenous catheters may hemolyze the specimens, and can even dislodge catheters and necessitate restarts. Both of these scenarios may lead to multiple needle sticks and delayed treatment, not only reducing patients’ satisfaction but also increasing costs of care. 1

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In vitro hemolysis interferes with tests such as blood bank/coagulation testing and measurement of levels of creatine kinase, lactate dehydrogenase, potassium, iron, digoxin, alanine and aspartate aminotransferase, and β-human chrorionic gonadotropin. Womens Knoll StretchCotton Triangle Bra Sleepy Jones Clearance Store Online Classic Cheap Price 03UjpX
Depending on the level of hemolysis, specimens may need to be rejected and another sample would need to be collected.

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a 2% hemolysis rate is considered best practice. In this review, we synthesize available evidence about the effect of collecting blood samples for laboratory tests from peripheral intravenous catheters on hemolysis rates in the specimens.

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Methods

MEDLINE and CINAHL were the search engines used. Key search words were phlebotomy, intravenous catheters, Vacutainers (Becton, Dickinson, and Company, Franklin Lakes, New Jersey), and hemolysis. Both research evidence and manufacturers’ evidence were included.

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