Vocal Problems Research Articles

Subtracting to Add: Assessing Teaching Activities in Consideration of Student Outcomes

Abstract: Human nature predisposes us to solve problems by adding elements, even when the simplest or most efficient solution would involve subtracting elements. In this article, evidence is explored in order to investigate how deeply rooted this tendency is in the human condition and how it may pose challenges for singing teachers trying to help their students solve vocal problems.

Novel application of bone marrow mesenchymal stem cells combined with hepatocyte growth factor on subacute vocal fold wound healing

AbstractObjectivesVocal fold (VF) scar causes solemn vocal problems for patients with previous surgery or laryngeal injury. It is also a difficult management problem for clinicians since rare superior management methods are available at present. Previous research usually focuses on the acute period of VF wound repairing, with little attention on subacute period intervention. Bone marrow mesenchymal stem cells (BMMSCs) and hepatocyte growth factor (HGF) combinations that are applied to treat VF wounds are rarely reported. The current study investigated the effects of BMMSCs‐HGF application on the regeneration of the VF mucosa during the subacute period.MethodsA bilateral wound was generated by forceps in the VF of each New Zealand White rabbit. BMMSCs are based on the acellular dermal matrix as cell carriers. Various compounds (BMMSCs‐AMD complex with or without HGF) was injected into the wounded VF at 2‐ or 4‐weeks following injury. Animals were killed at 60 days postinjection. Imaging of excised larynges was performed with the transmission electron microscope (TEM), and Immunohistochemical (IHC) analysis was also conducted.ResultsCollectively, 18 rabbits accepted injury modeling, with two of them died before repairing intervention. IHC results indicated that type‐I collagen was significantly devalued in the cluster injected with BMMSCs‐HGF than simple application of BMMSCs. The results of TEM suggested that the BMMSCs‐HGF injection can significantly reduce the collagen score.ConclusionOur preliminary study suggests opening regenerative effects of intervention for VF subacute scaring, with BMMSCs‐HGF.

Associação entre limitação no trabalho por causa da voz, condições de trabalho e vulnerabilidade social de escolas metropolitanas no Brasil

ABSTRACT Purpose To verify the prevalence of limitations at work due to the voice of Brazilian basic education teachers in metropolitan schools and the association with working hours, self-reported noise and Social Vulnerability Index (SVI) in schools. Methods Cross-sectional observational study with a probabilistic sample of Brazilian teachers. A total of 4979 teachers from metropolitan schools participated and the following variables were analyzed: age, gender, level of education, workday for 40 hours/week or more, perception of intense noise with the need to raise the voice and SVI of the municipality. Descriptive analysis and multivariate Poisson regression model with robust variance were performed and a significance level of 5%. Results The Brazilian prevalence of limitation at work due to voice was 20.37%. It was found that there was a statistically significant difference between limitation at work due to voice and being female, elementary school level or combined levels, 40 or more working hours , perception of raising one’s voice in the presence of intense noise at work and medium and high/very high SVI. Conclusion Of every 100 teachers, approximately 20 reported limitations at work due to voice in Brazil, and considering the federative units, higher prevalences were observed in the North and Northeast regions. Being female, working 40 hours or more per week, teaching elementary school or at combined levels, perceiving raising one’s voice due to intense noise, and working in schools located in regions with medium, high/very high SVI increased the prevalence of perception of limitation at work due to vocal problems.

Evaluating the effect of masks on the vocal health and speech intelligibility of healthcare workers in various hospital unit

The COVID-19 pandemic has enforced mandatory mask usage, particularly in hospitals, and its impact on the vocal problems and speech intelligibility of healthcare workers was examined in this study. A total of 76 healthcare workers from various units, including emergency, inpatient, outpatient, and intensive care, participated in an online questionnaire survey to assess vocal issues experienced while wearing masks. The participants' self-assessed vocal handicaps were quantified using the Vocal Handicap Index (VHI) score. The findings revealed that healthcare workers in emergency units faced the most severe vocal problems, followed by those in outpatient units. The most reported vocal symptoms were clearing the throat and throat dryness. Additionally, noise levels were measured continuously for four hours in each unit, and sources of noise were identified. The measured sound pressure levels (SPL) in emergency, inpatient, outpatient, and intensive care units were 68.64, 63, and 72 dBA, respectively. These values exceeded the World Health Organization's recommended limit of 30-40 dBA, indicating significant discomfort. Lastly, to delve deeper into the increased vocal effort required when wearing masks, the Speech Transmission Index (STI) parameter was analyzed using the recorded SPL as background noise and audio recordings of healthcare workers in different mask-wearing conditions. The study discovered that using a mask considerably reduced speech intelligibility compared to not wearing a mask. Keyword: healthcare workers, vocal problems, noise level, pandemic

Vocal Problems and Burnout Syndrome in Nonuniversity Teachers in Galicia, Spain

Introduction: Voice disorders and burnout syndrome are common among teachers. This study aimed to explore the relationship among vocal problems, burnout syndrome, and some personal work factors. Methods: This cross-sectional descriptive study enrolled 90 nonuniversity teachers who completed the Multidimensional Vocal Scale for Teachers (EVM-D) to evaluate vocal problems and an adapted Spanish version of the Maslach Burnout Inventory-Educators Survey (MBI-ES) to detect burnout syndrome. Results: Overall, 16% of teachers expressed symptoms compatible with burnout, and 60% of them were in the interval above the 75th percentile of the EVM-D, i.e., they had a high risk of vocal problems. An association between burnout and more vocal problems was established among teachers, particularly between the vocal symptoms and vocal abuse dimensions with the emotional exhaustion subscale of the MBI-ES. A history of anxiety/depression and fewer years of professional experience were associated with more vocal problems. The burnout group perceived more “loss of vocal power,” “vocal fatigue,” “vocal effort,” and “hoarseness.” Vocal abuse items received the highest scores of EVM-D. However, only “shouting” in the classroom was significantly different between the groups with and without burnout. Conclusion: Emotional exhaustion of burnout syndrome, history of anxiety/depression, and a shorter professional experience were associated with vocal problems, which could limit the performance of teachers. Reducing classroom noise, establishing strategies to avoid shouting, or strengthening personal accomplishments in teachers could be useful in breaking the cycle of vocal problems and emotional exhaustion, particularly at the beginning of their professional experience.

Psychometric properties of the Vocal Fatigue Index – Thai Version

Background: Voice disorders can be found in many scenarios. Many people have experienced vocal problems in their lifetime. Such problems can occur occasionally or permanently during the course of life. Previous literature review showed that vocal fatigue usually occurs concurrently with voice disorders, though it could occur alone as well. Vocal fatigue is considered the first symptom of a vocal problem and usually improves after voice rest. Detecting vocal fatigue before an individual develops a voice disorder is extremely important. Objectives: This study aims to 1) translate the original VFI into the Thai version and 2) evaluate the psychometric properties of VFI-TH, including content validity, face validity, predictive validity (sensitivity and specificity), and reliability. Materials and methods: Participants in this study consisted of two groups comprising one group of 22 participants with voice disorders and another group of 60 participants with healthy voices. The age of participants was 18 years and older. Procedures: Cross-cultural protocol of translation was followed per Beaton, which consisted of five steps: Initial translation, synthesis of the translation, back translation, expert committee review, and pretesting. This study was divided into 2 phases. Phase I consisted of the first three steps of Beaton’s guideline, while Phase II was the evaluation of psychometric properties; content validity by expert committee review, face validity by data trial in ten participants with voice disorders, predictive validity through sensitivity and specificity by formula calculation, and reliability were examined by evaluating internal consistency through Cronbach’s Alpha co-efficiency. Results: The results showed that the VFI-TH had content validity, face validity, and predictive validity. For predictive validity, the percentages of sensitivity and specificity were 22.7 and 100, respectively, and internal consistency was 0.87-0.94, which meant very good or excellent. Conclusion: The VFI-TH had content validity, specificity, and reliability to detect vocal fatigue. However, the VFI-TH should be used along with other vocal assessments in adults aged 18 years and older.

Singing Voice Concern in Tertiary Laryngology Practice

To determine the prevalence and characteristics of patients who identify singing voice as a primary concern when presenting with general voice complaints to a voice clinic. Data were collected from medical records on demographics, medical history, laryngoscopy exam, diagnosis, and subsequent treatments; and from self-report questionnaires including the Voice Handicap Index-10 (VHI-10) and clinical voice questionnaire. A total of 17% of patients presenting to a voice clinic with general voice problems who completed a VHI-10 identified singing voice as a primary concern. Compared to the reference cohort, patients concerned about singing voice report greater handicap on several questions of the VHI-10, particularly in personal and social life impact, loss of income, unpredictability of vocal clarity, subjective upset, and subjective handicap. Those concerned with singing voice were also more concerned about their vocal problem, and both more likely to be recommended voice therapy and participate in voice therapy despite no statistical differences in categorical diagnoses. When considering both professional and recreational singers, voice concerns occurred in 17% of the cohort under study. Patients with singing voice concerns are accounted for largely by recreational singers, who remain poorly characterized in the literature. We underscore the importance of sensitivity and responsivity to the needs of this group of patients.

Futuros professores e a autopercepção de sintomas vocais e conhecimento em saúde e higiene vocal

ABSTRACT Purpose To analyze responses of future teachers regarding the self-perception of vocal symptoms and knowledge about vocal health and vocal hygiene, relating them to sociodemographic and occupational variables and previous knowledge about voice. Methods Observational, analytical and cross-sectional study. A total of 264 undergraduate students participated and the Vocal Health and Hygiene Questionnaire (QSHV), Vocal Symptoms Scale (ESV) and a questionnaire with sociodemographic, occupational and vocal questions were applied. Data were statistically analyzed considering a 5% significance level. Results QSHV of future teachers had a total mean score of 21.89, suggestive of lack of knowledge about vocal health and hygiene. The results of the ESV are above the instrument's cutoff score, in each of the three domains and in the total score, there was greater symptomatology in first-year students when compared to other students, in the emotional, limitation and total domains. There was a difference when comparing the QSHV with the year of graduation (p=0.001), in which third and fourth year students obtained higher scores. A positive correlation was observed between the total QSHV score and the age variable (p=0.019). Conclusion Future teachers present important vocal symptomatology, compatible with dysphonic individuals, and have insufficient knowledge about vocal health and hygiene. Knowledge is even lower among students in the early undergraduate years and at a younger age. Older future teachers demonstrate more knowledge about vocal health and hygiene. It is necessary to propose preventive actions with this population, even during the graduation period, aiming to reduce the risks of developing vocal problems in the medium or long term during teaching.

Prevalence of vocal problems among teachers of primary education and its relationship with the level of physical activity

Resumo Introdução A atividade física é benéfica para a manutenção da saúde, qualidade de vida, bem-estar físico e psicológico. No entanto, ainda são poucos os estudos que abordam a prática de atividade física e os problemas vocais. Objetivo Verificar a prevalência de problemas vocais e sua associação com o nível de atividade física em professores de escolas públicas da educação básica. Método Estudo transversal analítico com amostra probabilística por conglomerado em estágio único composta de 634 professores. A variável dependente referiu-se à existência de problemas vocais (quatro ou mais sinais/sintomas). As variáveis independentes foram relacionadas aos aspectos sociodemográficos, ocupacionais, hábitos de vida e saúde, consideradas na modelagem como fatores de ajuste. O nível de atividade física foi mensurado pelo International Physical Activity Questionnaire - IPAQ (versão curta). Procedeu-se à análise descritiva, bivariada e múltipla (Regressão de Poisson). Resultados Houve alta prevalência de sinais/sintomas vocais (79,2%), bem como daqueles com quatro ou mais sinais/sintomas, denominados de problemas vocais (27,3%). No modelo final ajustado, a prevalência de problemas vocais foi maior entre professores do sexo feminino (RP=1,9), com maior tempo de docência (RP=1,3), com qualidade de vida insatisfatória no domínio físico (RP=1,9) e no domínio psicológico (1,4) e entre os professores sedentários/insuficientemente ativos (RP=1,3). Conclusão A prática de atividade física mostrou relação com a saúde vocal mesmo após controle por outras variáveis, o que enfatiza a necessidade de conscientização e estímulo aos professores quanto à prática de atividade física.

Effectiveness of using the resonant vocal techniques in singing voice disorders

Singing voice disorders are an important segment of vocal pathology, targeting a niche of professional and amateur singers of all musical genres. The aim of this study is to evaluate the effectiveness of using the principles of vocal hygiene and the eclectic vocal therapy model by combining three resonant vocal techniques: humming, the method of disguised yawning and the chewing technique, in the corrective-recuperative vocal therapy program. The positive effects of the vocal therapy used in all five case studies were observed. If the initial assessment relates to altered vocal parameters, pain in the laryngeal muscles and a negative influence of vocal problems on quality of life, the final assessment found normalization of vocal parameters, decreased pain and improved the quality of life.

Regenerative Medicine and Amniotic Membrane Application for Vocal Fold Scars and Sulcus

Vocal fold scars and sulcus cause severe vocal problems, but no optimal treatment has been established. In severe cases, in which the entire lamina propria is occupied by severe fibrosis and the vibratory function is completely lost, more powerful regeneration materials should be used, or the mucosa should be totally replaced. Amniotic membrane is a scaffold material that is rich in stem cells and growth factors and has a high regenerative effect. It can be clinically applied in many fields. Several studies have already investigated the effects of amniotic membrane on the vocal fold in animal studies. These studies have shown that the amniotic membrane is effective for vocal fold regeneration. In particular, our study showed that the transplantation of an amniotic membrane to the rabbit vocal fold induced high hyaluronic acid retention and the suppression of collagen deposition after three months without rejection. We hope that the use of the amniotic membrane for vocal fold regeneration will be broadly applied in the future.

Predictions for Three-Month Postoperative Vocal Recovery after Thyroid Surgery from Spectrograms with Deep Neural Network.

Despite the lack of findings in laryngeal endoscopy, it is common for patients to undergo vocal problems after thyroid surgery. This study aimed to predict the recovery of the patient’s voice after 3 months from preoperative and postoperative voice spectrograms. We retrospectively collected voice and the GRBAS score from 114 patients undergoing surgery with thyroid cancer. The data for each patient were taken from three points in time: preoperative, and 2 weeks and 3 months postoperative. Using the pretrained model to predict GRBAS as the backbone, the preoperative and 2-weeks-postoperative voice spectrogram were trained for the EfficientNet architecture deep-learning model with long short-term memory (LSTM) to predict the voice at 3 months postoperation. The correlation analysis of the predicted results for the grade, breathiness, and asthenia scores were 0.741, 0.766, and 0.433, respectively. Based on the scaled prediction results, the area under the receiver operating characteristic curve for the binarized grade, breathiness, and asthenia were 0.894, 0.918, and 0.735, respectively. In the follow-up test results for 12 patients after 6 months, the average of the AUC values for the five scores was 0.822. This study showed the feasibility of predicting vocal recovery after 3 months using the spectrogram. We expect this model could be used to relieve patients’ psychological anxiety and encourage them to actively participate in speech rehabilitation.

Treating Audio Manipulation Effects like Photoshop: Exploring the Negative Impacts of a Lack of Transparency in Contemporary Vocal Music on Young Learners

Amidst the great and rapid advance in digital audio processing over recent decades, a range of new ‘manipulation’ software has problematised the popular music scene, both in terms of authenticity and achievability of performance. This paper will set out to define manipulation effects as separate from the more over-arching umbrella term of staging effects, under which they have been vaguely included for a number of years. By separating out the staging of vocals from the manipulation of their core content, by pitch correction for example, we can more specifically observe their impact on audience reception and vocal pedagogy. The reception element of this research would be largely related to that of authenticity and the presentation of liveness in online video, but this paper will focus on the effect of the unachievable on vocal learners. These could range from confidence issues to serious vocal problems. This paper explores the possibilities of music following the same trajectory as photography, where manipulation is concerned. Photoshop’s usage in media has provoked a great deal of controversy in recent years, with high profile campaigns resulting in legislative changes such as Israel’s Photoshop Law, which imposes certain restrictions for models and a disclaimer requirement for publishers. It’s a possibility that if the music industry were required to provide disclaimers for audio releases and online videos, that there would be more transparency in vocal pedagogy, with the potential for fewer vocal health problems related to copying unachievable performances. The aim of this paper is to open a conversation about the effect of a lack of transparency surrounding audio manipulation so that more can be done to address it.

Self-assessment of teachers with normal larynges and vocal and osteomuscular complaints

Teachers face vocal problems related to long periods of speech and increased sound pressure, as well as environmental noise, inadequate posture and tension of the cervical muscles. To verify the results of self-assessment of teachers with normal larynges and vocal and musculoskeletal complaints, and compare them with the reference values. Fifty-seven teachers, aged between 21 and 60 years (average 40.14 years) participated in the study. Anamnesis, otorhinolaryngological examination, hearing screening and self-assessment protocols were performed. In the Nordic musculoskeletal questionnaire, the majority of teachers had discomfort in most parts of the body and in the situations evaluated; on the voice-related quality of life, the total and physical subscores were lower than the normative values while the emotional subscore was higher; regarding voice symptoms scale and vocal tract discomfort scale, the scores were higher than the normative values; in the hospital anxiety and depression scale, there was alteration in the total score; in the Vocal Activity and Participation Profile, the effects on work and emotion were above the normative values; on the University of Rhode Island change assessment-voice and on the voice handicap index there were no significant differences. Most of the teachers presented vocal, musculoskeletal, and emotional complaints on the self-assessment results, what suggests excessive voice use as well as overload on the body muscles, including the larynx and vocal tract, and that they presented emotional changes. These aspects had an impact on their quality of life, but they showed no action in coping with the condition.

Evaluation of Physical Symptoms in Brazilian Conductors Through NMQ and DASH Instruments.

Few studies have investigated populations of conductors concerning their activity in general or work-related health aspects, although these individuals also face important work demands with the potential for develop¬ing hearing, physical, and vocal problems. This study was designed to assess physical symptoms (pain, tingling, numbness) in Brazilian conductors by applying the Nordic Musculoskeletal Questionnaire (NMQ) and the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire. The data were collected online from 166 Brazilian conductors who were actively working for at least 1 year. The NMQ results indicated a high prevalence of symptoms in the shoulder, neck, and lumbar and upper back regions. Participants also complained of pain in the upper limbs, especially on the right side, and spinal regions associated with conducting. Bivariate statistical tests indicated significant relationships between the presence of symptoms in the upper limbs and higher disability scores in the DASH instrument. The body regions mentioned by the participants are similar to those reported in the few studies of conductors in the literature, highlighting that conducting has a specific physical impact and the potential to affect the function of the upper limb in the conductors' daily activities.

Fatores associados aos problemas vocais em professores de Montes Claros, Minas Gerais

Teachers use their voices as a work tool and end up exposing themselves to risks of overload and vocal effort, which may impair professional performance. This study aimed to verify the prevalence and factors associated with vocal problems in teachers during the COVID-19 pandemic. This is a cross-sectional, analytical study, formed by 82 elementary school teachers from three state schools in Montes Claros, Minas Gerais, Brazil. To assess vocal problems, the Screening Index for Voice Disorder - SIVD was used. Data collection was carried out in July and August 2020, using the Google Forms Platform. A bivariate analysis was performed, followed by Poisson regression at a 5% significance level. The prevalence of vocal problems was 42.7% (n=35) and of possible vocal disorders was 11.0% (n=9). The most reported symptoms were phlegm (25.6%), hoarseness (19.5%), strained speech (17.1%), and dry throat (15.9%). In the final analysis of vocal problems, the diagnosis of gastroesophageal reflux (PR=2.245; 95%CI=1.548-3.256) and depressive symptoms (PR=1.722; 95%CI=1.020-1.907) were associated. The shift to remote classes showed the need for guidance for healthy vocal quality.

The Effects of Amniotic Membrane Transplantation on Vocal Fold Regeneration.

Vocal fold (VF) scar and sulcus cause severe vocal problems, but optimal methods have not been established. Total replacement of the mucosa is required particularly for cases in which the whole lamina propria is occupied by severe fibrosis and vibratory function is totally lost. The amniotic membrane (AM) has been proven to have regenerative potential, as it contains stem cells and growth factors. The current study investigated the biocompatibility and effects of AM for regeneration of the VF mucosa. In vitro and in vivo studies. Vocal fold fibroblasts (VFFs) from 13 Sprague-Dawley rats were seeded on AM and subjected to histology and immunohistochemistry, and gene expressions in the VFFs on AM were examined in in vitro study. Twelve New Zealand White rabbits were used in in vivo study. VFs were stripped down and were reconstructed with AM. The regenerative effects were examined 3months later by histological examination. In vitro study indicated VFFs survived on AM and stained positively for Ki67, vimentin, and fibronectin. Gene expressions of Has1, Has2, and Hgf were significantly increased in the VFFs on AM compared with the other groups. The in vivo study indicated AM-transplanted VFs showed a significantly higher density of hyaluronic acid and lower density of collagen compared with sham VFs. The current preliminary study suggests biocompatibility and possible regenerative effects of AM for VFs. NA Laryngoscope, 132:2017-2025, 2022.

Voice evaluation – contribution of the speech-language pathologist voice specialist – SLP-V: part A. History of the problem and vocal behaviour data, self-assessment and auditory perceptual judgement

The human voice is the product of a sophisticated interaction of aerodynamic and myoelastic forces, a perceptual phenomenon that is greatly influenced by vocal behaviour in interpersonal relationships. Vocal problems can be overly complex and can require a team approach, whether for diagnosis or treatment of the patient. This article describes the contribution of the speech-language pathologist, voice specialist SLP-V in the assessment of patients with vocal complaints. A clinical evaluation proposal developed in a 40- to 60-min session is presented. This proposal consists of the following steps: the history of the problem; the patient self-assessment; the auditory perceptual judgement and acoustic analysis; the physical examination; and finally, the correlation of all previously described steps with the medical diagnosis. Part A of this text explores the history of the problem with the focus to determine the influence of the vocal behaviour on the case; the self-assessment of the impact of the voice problem to verify the patient experience in living and coping with dysphonia; and the auditory perceptual judgement to describe the type and degree of vocal deviation. Worldwide published tendencies and specific comments of each step highlight the role of the SLP-V.

Impact of Face Masks on Speech Acoustics and Vocal Effort in Healthcare Professionals.

We investigated speech acoustics and self-reported vocal symptoms in mask-wearing healthcare professionals. We hypothesized that there would be an attenuation of spectral energies and increase in vocal effort during masked speech compared to unmasked speech. Within and between subject quasi-experimental design. We prospectively enrolled 21 healthcare providers (13 cisgender female, 8 cisgender male; M=32.9 years; SD=7.9 years) and assessed acoustics and perceptual measures with and without a face mask in place. Measurements included: 1) acoustic Vowel Articulation Index (VAI); 2) cepstral and spectral acoustic measures; 3) traditional vocal measures (e.g., fundamental frequency, intensity); 4) relative fundamental frequency (RFF); and 5) self-reported ratings of vocal effort and dyspnea. During masked speech, there was a significant reduction in VAI, high-frequency information (>4 kHz), and RFF offset 10, as well as a significant increase in cepstral peak prominence and perceived vocal effort. Further analysis showed that high-frequency attenuation was more pronounced when wearing an N95 mask compared to a simple mask. Face masks pose an additional barrier to effective communication that primarily impacts spectral characteristics, vowel space measures, and vocal effort. Future work should evaluate how long-term mask use impacts vocal health and may contribute to vocal problems. 3 Laryngoscope, 132:391-397, 2022.

Recovery of Vocal Cord Motion Among Pediatric Patients.

Patients with vocal cord paralysis can experience feeding, respiratory, and vocal problems leading to disability and decreased quality of life. Current evidence suggests waiting a period of 12 months for spontaneous recovery before permanent interventions. This study aims to determine the time to recover spontaneously and vocal cord movement in a pediatric population and create a model for evidence-based patient counseling. Retrospective longitudinal cohort study. The report is a single institution longitudinal study on vocal cord paralysis recovery. Patients were categorized based on spontaneous recovery with vocal cord movement or no recovery. Recovery rates were determined using the Kaplan-Meier method. Of 158 cases of vocal cord paralysis over a 4-year period, 36 had spontaneous recovery with symptom improvement and motion return. The average recovery was 8.8 months for those who recovered, and 78% recovered within 9 months. Two groups emerged from the data: an early recovery group with spontaneous recovery before 12 months and a late recovery group after 12 months. Children with dysphonia and paralysis due to cardiac surgery were less likely to recover, and children with aspiration were more likely to recover. Children with gastrointestinal comorbidities were less likely to recover; however, those who did recover were more likely to have recovered after 12 months. Based on our model, there is about a 3% chance of recovery between 9 and 12 months. Patients should be counseled about earlier interventions. Waiting the conventional 12 months for only a 3% chance of spontaneous recovery without intervention or laryngeal EMG may not be the preferred option for some patients and their families.