Otology & Neurotology

The Impact of Canalplasty on Outcomes of Medial Graft Tympanoplasty Objective: Both medial and lateral graft techniques are commonly employed in tympanoplasty with acceptable closure rates. Canalplasty is routinely performed to obtain adequate exposure in the lateral graft technique; this usually entails removal of the anterior canal wall skin with subsequent replacement as a free graft. While formal canalplasty can also be performed in conjunction with medial graft technique to improve exposure, it is not commonly described. The current study seeks to examine the impact of canalplasty on outcomes of medial graft tympanoplasty. Methods: A retrospective chart review was performed for patients undergoing tympanoplasty for chronic otitis media with the senior author. Audiometric data were recorded both preoperatively and postoperatively. Primary outcome measure was perforation closure with audiometric outcomes examined as secondary outcome measures. Results: One hundred seventy tympanoplasties without ossiculoplasty were included in our study. The overall rate of perforation closure postoperatively was 77%. Cartilage use portended a higher closure rate (100%) when compared with nonuse (75%) (p = 0.04). The success rates with lateral grafts (94%) and medial grafts with canalplasty (92%) were considerably higher than obtained with medial grafts without canalplasty (69%) (p = 0.005 and 0.02, respectively). In cases with anterior perforations greater than 25% of the tympanic membrane, our results demonstrated a significant advantage in performing canalplasty (p = 0.04). Conclusions: Data from the current study suggest that canalplasty offers benefit regarding closure rate in medial graft tympanoplasty. Use of cartilage also portended a higher rate of perforation closure. Canalplasty should be considered when using medial graft techniques if exposure is limited due to bony canal anatomy. Address correspondence and reprint requests to Paul R. Lambert, M.D., Department of Otolaryngology, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425; E-mail: lambertp@musc.edu The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Easy Stapes Subluxation in 22q11.2 Deletion Syndrome: A Clinical Capsule and Literature Review Objectives: This report describes iatrogenic stapes subluxation in a 22q11 deletion syndrome patient and reviews the human and murine literature for evidence that these patients have stapes malformations. We aim to alert otologic surgeons regarding the possibility of stapes footplate abnormalities in 22q11 deletion patients. Patient: An adult woman with known 22q11 deletion syndrome. Additionally, the literature review focused on other patients with 22q11 deletion syndrome as well as mouse models of this disorder. Interventions: A combination of diagnostic and therapeutic interventions were conducted consisting of middle ear exploration, removal of ossicular chain adhesions, and ultimately ossicular reconstruction. Results: The stapes footplate was poorly attached to the oval window in our patient. During removal of ossicular adhesions, the entire stapes subluxed requiring placement of a stapes prosthesis. The postoperative audiogram was similar to the preoperative audiogram. Literature review identified one other case of stapes subluxation in a patient with 22q11 deletion syndrome, and mouse models suggest that the stapes footplate has an abnormal connection to the oval window in those affected by 22q11 deletion syndrome. Conclusions: Patients with 22q11 deletion syndrome have chronic middle ear pathology, and if middle ear exploration is undertaken, the surgeon should be aware that the stapes may have a weak attachment to the oval window. This could put the stapes at risk of injury and contribute to conductive hearing loss. Address correspondence and reprint requests to Arnaldo L. Rivera, M.D., Department of Otolaryngology, One Hospital Drive, Columbia, MO 65212; E-mail: riveraal@health.missouri.edu This report has been submitted for presentation at the American Otological Society's Annual Meeting portion of the Combined Otolaryngology Spring Meetings, May 3–5, 2019. This case report received institutional review board approval by the University of Missouri IRB. No funding sources were utilized for this study. A.R., C.K. and J.C. has no competing interests to disclose. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Comprehensive Analysis of Factors Leading to Poor Performance in Prelingual Cochlear Implant Recipients Objective: To comprehensively analyze the prognostic factors responsible for affecting outcomes following cochlear implantation in prelinguals. Study Design: Retrospective cohort study from June 2004 to November 2015. Setting: Tertiary care center. Patients: Patients who had undergone cochlear implantation during June 2004 to November 2015 for prelingual sensorineural hearing loss with a minimum follow-up of 2 years. Intervention: Patients were evaluated for the presence of 20 risk factors possibly influencing postimplantation outcomes using a questionnaire. Main Outcome Measures: Assessment for speech and auditory function was done at the last follow-up with speech intelligibility ratings (SIR) and categories of auditory performance (CAP) scores, respectively. Results: One hundred fifty-one patients were included in this study. On univariate analysis for CAP, age at implantation, noncompliance to pre and postimplantation auditory and speech habilitation, poor parental motivation, socioeconomic status and literacy were found to be associated with lower scores (p < 0.05). Whereas, for SIR, additionally, attention deficit hyperactivity disorder and inner ear malformation were statistically significant negative predictors on univariate analysis. Finally, factors responsible for low CAP scores on multivariate analysis were poor parental literacy, poor socioeconomic status, irregular pre/postimplantation rehabilitation, and attention deficit hyperactivity disorder. While for SIR, additionally age at implantation was also a significant negative predictor. Increasing IQ and duration of implant use were associated with higher CAP (univariate) and SIR scores (univariate and multivariate) (p < 0.05). Conclusion: We were able to demonstrate negative impact of higher age at implantation, minimal cognitive disorder, adverse parental/socioeconomic profile, and poor compliance to pre/postimplantation auditory verbal habilitation on auditory and speech outcomes. Address correspondence and reprint requests to Kapil Sikka, M.S., Associate Professor, Department of Otorhinolaryngology and Head and Neck Surgery, Teaching Block, 4th Floor, All India Institute of Medical Sciences, Ansari Nagar, East, New Delhi 110029, India; E-mail: Kapil_sikka@yahoo.com The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Evaluating the Long-Term Hearing Outcomes of Cochlear Implant Users With Single-Sided Deafness Objectives: To investigate the long-term outcomes of cochlear implantation in individuals with single-sided deafness (SSD) in terms of speech perception, subjective hearing performance, and sound localization. Methods: Thirty-four subjects with SSD were recruited across two large cochlear implant (CI) centers (Antwerp, Belgium and Perth, Australia). The long-term hearing outcomes (between 4 and 10 years of CI use) were evaluated using speech in noise tests, a subjective hearing performance questionnaire (Speech, Spatial and Qualities Questionnaire [SSQ12]), and sound localization tests. Results: Statistically significant improvements were observed in speech perception in noise and sound localization results postoperatively with the use of a CI in comparison to preoperative measurements. Subjective hearing abilities also significantly improved after long-term CI use. Conclusion: Access to binaural hearing is important for subjects with SSD. CI users with SSD experience long-term benefits in speech understanding, sound localization, and quality of life. Address correspondence and reprint requests to Dayse Távora-Vieira, Otolaryngology, Head & Neck Surgery, Medical School, University of Western Australia, Perth, 102 - 118 Murdoch Drive, Murdoch WA 6150, Australia; Fiona Stanley Hospital, Perth, Australia; E-mail: dayse.tavora@gmail.com The authors report no conflicts of interest Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Application of Kaizen Principles to a Large Cochlear Implant Practice: A Continuous Quality Improvement Initiative at Mayo Clinic Objective: To remove barriers and improve access for patients seeking cochlear implantation. Study Design: Prospective quality improvement study at a large tertiary academic care center. Methods: A Kaizen quality improvement model was applied over the course of a year. Four weeklong meetings were used to identify areas for improvement and remediation. Data were collected at baseline, 90-days, and 1-year postcompletion of the project. Outcome measures included lead times, defined as the wait time between first contact with the clinic and the first appointment, and the wait time between surgery and activation, and cycle times defined as the total test time needed to determine cochlear implant candidacy, and total time needed to complete initial activation. The total inventory kept as clinic stock was also calculated Results: Kaizen team members collected data for each outcome measure. After the Kaizen principles were applied, the following outcomes were observed: median lead times between first contact with the clinic to candidacy testing, candidacy testing to surgery, and surgery to activation of the implant remained stable from baseline to 1-year follow-up. Median cycle time for candidacy testing decreased from 7.3 hours at baseline to 3.0 hours at 1-year follow-up. Cycle times for initial activation of the device did not change over time. The total inventory of clinic stock was reduced by 31%. Conclusions: Though outcomes for lead and cycle times varied, implementation of Kaizen principles was found to be an effective method for completing this quality improvement project at a large cochlear implant program overall. Level of Evidence: 3a Address correspondence and reprint requests to Douglas P. Sladen, Ph.D., Department of Communication Sciences and Disorders, Western Washington University, 516 High Street, Bellingham, WA 98225; E-mail: douglas.sladen@wwu.edu This project was funded through a grant provided by MED EL GMBH. M.L.C. is a consultant for Advanced Bionics Corp., Cochlear Corp., and MED-EL GmbH. M.D.D. is a consultant for MED-EL GmbH. The authors disclose no conflicts of interest. Supplemental digital content is available in the text. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://journals.lww.com/otology-neurotology). Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Quality of Life in Jugular Paraganglioma Following Radiosurgery Objective: The treatment paradigm for jugular paraganglioma (JP) has changed considerably over time with the wider adoption of stereotactic radiosurgery (SRS). To the best of the authors' knowledge, there are no published studies that use validated patient-reported outcome measures to ascertain quality of life (QoL) outcomes following SRS for JP when used in single or combined modality treatment regimens. Study Design: Cross-sectional survey. Setting: Tertiary referral center. Patients: Adult patients with JP treated with primary SRS or SRS following primary surgery between 1990 and 2017. Interventions(S): Surgery and/or Gamma Knife SRS. Main Outcome Measures: Global and treatment-related QoL and differences in QoL based on treatment approach. Results: Sixty-nine surveys were distributed and a total of 26 completed surveys were received (38% response rate). Among respondents, the median age at SRS was 53 years and 16 of the 26 patients (62%) were female. Median follow-up was 97 months. Nineteen patients (73%) were treated with primary SRS or staged SRS following intentional subtotal resection (STR; hereafter referred to as "staged SRS"), while the remainder (n = 7, 27%) were treated with SRS for recurrent JP. Median physical and mental health QoL PROMIS-10 T-scores regardless of treatment strategy were 39.8 and 38.8, respectively, while median SF36 physical and mental component subscores were similar to national averages and non-tumor controls. When comparing general physical and mental health QoL scores, there was no significant difference between patients treated with primary or staged SRS and those treated with SRS for recurrent JP. However, age-adjusted swallowing function among patients treated with primary or staged SRS was better than in those patients treated with SRS for recurrent JP (p = 0.05). Conclusions: Patients treated with primary or staged SRS for JP tend to exhibit better swallowing outcomes than those treated with SRS for recurrent JP. However, the majority of overall and disease-specific quality of life measures were not different between groups. Based on the low incidence of new cranial neuropathy following SRS, it is likely that initial surgical morbidity is the primary contributor to this outcome. Disease-specific overall quality of life measures, akin to those already used for other benign skull base tumors, are necessary to better gauge physical and mental health outcomes following treatment for JP. Though limited by small sample size, this represents the first study to gauge QoL outcomes following treatment for JP. Address correspondence and reprint requests to Matthew L. Carlson, M.D., Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905; E-mail: carlson.matthew@mayo.edu Internal departmental funding was used without commercial sponsorship or support. Mayo Clinic IRB Approval 16-002291. Presented at the 2018 American Academy of Otolaryngology – Head and Neck Surgery Meeting, October 7–10, Atlanta, GA. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Bilateral Posterior Canal Benign Paroxysmal Positional Vertigo Tends to Reoccur Objective: We analyzed the clinical characteristics of quite a large cohort of patients with bilateral posterior canal benign paroxysmal positional vertigo (bil-BPPV) with respect to the rate and types of recurrence. Study Design: Retrospective case review. Setting: Outpatient dizziness clinic. Patients: About 2,050 patients diagnosed with BPPV during the years 2003 to 2018 were reviewed. Results: Sixty (2.9%) were diagnosed with bil-BPPV. Fifty three (88%) were idiopathic and seven (12%) posttraumatic. Multiple BPPV episodes were encountered in 28 (47%) patients. Patients with bil-BPPV and multiple BPPV episodes were comparable with patients with a single attack of bil-BPPV except for older age and longer follow up. The most frequent type of recurrence following a bil-BPPV episode was posterior canal canalolithiasis (37.5%) and bil-BPPV (31.3%). Combined (posterior and horizontal) BPPV was encountered in 12.5% while horizontal canal involvement was found in only 7% of recurrences. Conclusions: The prevalence of bil-BPPV amongst all BPPV patients was lower than previously reported possibly due to stricter selection criteria. Older age and longer follow up of patients with multiple BPPV episodes than those with a single episode of bil-BPPV is in accordance with the theory of degenerative otoconia loosening. In contrast to the general consensus regarding random recurrences of BPPV side and subtypes, bil-BPPV recurred more frequently than expected. This might be the consequence of individual vulnerability to head movements, increased bone metabolism or an underlying vestibular pathology. Address correspondence and reprint requests to Lea Pollak, M.D., Kibutz Galuyot 4, Nes Ziona 74012, Israel; E-mail: lea.pollak@gmail.com The authors declare no funding sources or acknowledgments. The authors have no conflicts of interest to disclose. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Serum Bilirubin Level as a Potential Marker for the Hearing Outcome in Severe-Profound Bilateral Sudden Deafness Objective: To investigate the association of serum bilirubin level with hearing outcomes in bilateral sudden sensorineural hearing loss (BSSHL) patients. Participants: One hundred thirteen in-patient BSSHL patients were consecutively enrolled between July 2008 and December 2015 in a tertiary center. Main Outcome Measures: Multivariable linear regression, generalized estimating equations (GEE), and stratified analyses were applied to examine the association between serum bilirubin level and hearing outcome measures such as final hearing threshold and absolute and relative hearing gains in BSSHL. Results: After full adjustment for potential confounders, total bilirubin levels (TBIL) were observed to be positively and independently associated with hearing outcomes as measured by final hearing (β [95% confidence interval {CI}]: −1.5 [−2.7, −0.2] dB HL per 1 μmol/L increase in TBIL) and absolute and relative hearing gains (β [95% CI]: 1.4 [0.2, 2.7] dB and 1.6 [0.2, 3.1] dB, respectively) in the severe to profound hearing loss subpopulation. Conclusions: Higher TBIL levels, within the normal or mildly elevated ranges, were independently and significantly associated with better hearing outcome in BSSHL patients with severe to profound hearing loss. Given bilirubin elevation treatments exist, our finding suggests a novel pharmacological strategy for this specific subpopulation. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Address correspondence and reprint requests to Qiu-Ju Wang, M.D., Ph.D., Department of Otolaryngology–Head and Neck Surgery, Institute of Otolaryngology, Chinese PLA General Hospital, 100853, Beijing, China; E-mail: wqcr301@vip.sina.com Source of Funding: The work was supported by the National Natural Science Foundation of China (No.81530032 and No.81500794), the National Key Basic Research Program of China (No.2014CB943001), the China Postdoctoral Science Foundation (No. 2017M613326) and the New Researcher Foundation of the PLA General Hospital (No. 14KMZ04). The authors have no conflicts of interest to disclose. Supplemental digital content is available in the text. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://journals.lww.com/otology-neurotology). Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Incus Necrosis and Blood Supply: A Micro-CT and Synchrotron Imaging Study Background: Incus necrosis is a common complication following stapes surgery and is associated with impaired microcirculation. The objective of this study was to investigate the vascular anatomy of the human incus by using light microscopy, micro-computed tomography (micro-CT), and synchrotron phase-contrast imaging (SR-PCI) for a novel three-dimensional (3D) analysis of the middle ear, mucosal folds, major vascular pathways, and intraosseous vascular bone channels. Methods: One-hundred-and-fifty temporal bones from the Uppsala collection were analyzed under light microscopy. Twenty temporal bones underwent high-resolution micro-CT scanning, and an additional seven specimens underwent SR-PCI at the Canadian Lightsource in Saskatoon, Canada. One of these specimens was from an individual who had undergone stapes surgery. Data were processed with volume-rendering software to create 3D reconstructions using scalar opacity mapping for bone transparency, cropping, and soft tissue analyses. Results: Micro-CT and SR-PCI with 3D rendering revealed the extensive vascular plexus within the un-decalcified incus bone communicating with the exterior surface. The relationship between the vessels, lenticular process, and incudostapedial joint were clearly observed. SR-PCI allowed for histologic-level detail while preserving the specimen and its 3D relationships. Conclusion: SR-PCI with 3D reconstructions confirmed the main vascular supply to the lenticular process along the intraosseous lenticular vessels. This is the first synchrotron analysis of a patient having undergone stapes surgery, and it suggests that incus necrosis associated with stapes surgery may be caused by a disruption of the lenticular blood flow induced by the prosthesis loop, and not by strangulation of mucosal vessels as has been previously described. Address correspondence and reprint requests to Helge Rask-Andersen, M.D., Ph.D., Department of Surgical Sciences, Head and Neck Surgery, Section of Otolaryngology, and Departments of Otolaryngology, Uppsala University Hospital, SE-751 85, Uppsala, Sweden; E-mail: helge.rask-andersen@surgsci.uu.se H.M.L., H.R.-A., and S.A. are co-senior authors. Funding: This study was supported by ALF grants from Uppsala University Hospital, Uppsala University and by the Foundation of "Tysta Skolan," the Swedish Deafness Foundation (Hörselskadades Riksförbund – HRF), the Ingrid Löwenström Foundation. Part of the research described in this article was performed at the BioMedical Imaging and Therapy (BMIT) facility at the Canadian Light Source, which is funded by the Canada Foundation for Innovation, the Natural Sciences and Engineering Research Council of Canada, the National Research Council Canada, the Canadian Institutes of Health Research, the Government of Saskatchewan, the Western Economic Diversification Canada, and the University of Saskatchewan. The authors disclose no conflicts of interest. Supplemental digital content is available in the text. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://journals.lww.com/otology-neurotology). Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

From Mid 16th Century French Court to End 18th Century Danish Court: The Fatal Power of the Mammillary Process Objectives/Hypothesis: Two Royal events marked the history of the mastoid process between the 16th and 18th centuries. The first was the death of François II, King of France, following a complication of a chronic running left ear at the age of 16 years, and the second the death of Justus von Berger, Court physician of Christian VII, King of Denmark, after a trepanation of the mastoid process to heal his right-sided deafness at the age of 68 years. The aim of this study is to analyze these two events again with only original references and to replace them in their historical context. Method: Historical review of original literature dealing with the subject. Results/Conclusion: These two Royal events marked the history of the mastoid process, but they were unlikely to have been avoided during their specific era. Medical knowledge was insufficient to avoid these fatal outcomes. Because of their societal impact, they were known of and largely discussed, notably in the medical world, leading to the eventual modification of medical practice during that time. François II's death had no medical impact but von Berger's death practically stopped, for more than a half century, the development of mastoid surgery. Address correspondence and reprint requests to Albert Mudry, M.D., Ph.D., School of Medicine, Stanford University, Stanford, CA 94305-5739; E-mail: amudry@stanford.edu The author discloses no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
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6948891480

alsfakia@gmail.com

Medical Sciences

Stress, coping, and immunologic relevance: An empirical literature review Chandra Sekhar Tripathy, Sarvodaya Tripathy, Bandna Gupta, Sujita Kumar Kar Journal of Medical Sciences 2019 39(3):107-113 Stress is an inevitable phenomenon in life. Stress plays a pivotal role in regulating the body's physiology. Stress also improves the survival skills of an individual. However, when stress becomes unmanageable, it starts affecting the individual adversely. The adverse effects of the stress alter the normal physiology and the mental well-being of the individual. People attempt to cope with their stressor using various coping strategies. Adapting coping strategies may help in successful handling of stress. Maladaptive coping strategies, on the other hand, though control stress, are often transient and may result in the impairment of mental health. Evidences suggest that stress significantly affects the immune system of the body. The effect of stress on the immune system may depend on the nature and severity of the stressor. Ineffective regulation of stress results in immune dysregulation. Effective coping strategies for handling stress might be useful to correct the immune dysregulation.

Descriptive study of snakebite patients in Northern Taiwan: 2009 to 2016 Cheng-Hsuan Ho, Yan-Chiao Mao, Yi-Da Tsai, Chin-Sheng Lin, Shing-Hwa Liu, Liao-Chun Chiang, Yuan Hung, Shih-Hung Tsai Journal of Medical Sciences 2019 39(3):114-120 Background: Taiwan is located in a subtropical area where there are approximately 50 kinds of land snakes and six principal kinds of venous snakes. Snakebite envenomation is not an uncommon issue in Taiwan. We design a study to obtain an understanding of the characteristics of snakebites and snakebite patients in a medical center in northern Taiwan. Materials and Methods: This was a retrospective medical records study of an 8-year period. We used the key word “snake” to search the emergency department (ED) diagnosis of all patients and then used antivenom management codes to select patients for inclusion. The species of snake involved, time and site of the bite, geographic data of the patients and patient outcomes were recorded. Results: In total, there were 125 snakebite patients (male 70%, female 30%). The snakes involved were Protobothrops mucrosquamatus (50%), followed by Trimeresurus stejnegeri (7%). The feet and ankles were the most frequently bitten areas (42.4%). The peak months were July and October. The average ED stasis time was 2 hours and 45 minutes, and 65.6% of snakebite patients received antivenom. In patients bitten by P. mucrosquamatus, there was a high surgical rate, 23.8% higher than those reported in other studies. No mortalities or side effects of antivenom were reported in these patients. Conclusion: We propose a clinical flow chart for physicians who are treating patients bitten by P. mucrosquamatus. Snakebites, especially those inflicted by P. mucrosquamatus, induce severe soft tissue swelling, which can mimic compartment syndrome. Antivenom for P. mucrosquamatus is the first and only choice of treatment. The amount of antivenom needs to match the clinical symptoms. Patients bitten by P. mucrosquamatus may need longer observation times than patients bitten by other species of snakes, in addition to toxicologist consultations, sonographic examinations, and measurement of the objective compartment pressure before surgery.

Lower incidence of prolonged extubation in propofol-based total intravenous anesthesia compared with desflurane anesthesia in laparoscopic cholecystectomy: A retrospective study Hou-Chuan Lai, Nan-Kai Hung, Bo-Feng Lin, Jia-Lin Chen, Yi-Hsuan Huang, Zhi-Fu Wu Journal of Medical Sciences 2019 39(3):121-126 Background: Reducing anesthesia-controlled time (ACT) such as extubation time may improve operating room (OR) efficiency result from different anesthetic techniques. However, the information about the difference in ACT between desflurane (DES) anesthesia and propofol-based total intravenous anesthesia (TIVA) techniques for laparoscopic cholecystectomy (LC) under general anesthesia (GA) is not available in the literature. Methods: This retrospective study uses our hospital database to analyze the ACT of elective LC after either DES anesthesia or TIVA via target-controlled infusion (TCI) with propofol from January 2010 to December 2011. The various time intervals including waiting for anesthesia time, anesthesia time, surgical time, extubation time, exit from OR after extubation, total OR time, postanesthetic care unit (PACU) stay time, and percentage of prolonged extubation (≥15 min) were compared between the two anesthetic techniques. Results: We included data from 622 patients undergoing LC, with 286 patients receiving TIVA and 336 patients receiving DES anesthesia. The extubation time was faster (7.8 ± 0.4 vs. 10.9 ± 0.4 min; P < 0.001) and the exit from OR after extubation was faster (6.8 ± 0.5 vs. 9.3 ± 0.5 min, P < 0.001) in the TIVA group than that in the DES group. Besides, the incidence of prolonged extubation was lower (4.5% vs. 10.1%, P = 0.014) in the TIVA group than that in the DES group. The prolonged extubation was associated with age, sex, anesthetic technique, and anesthesia time. Conclusions: In our hospital, propofol-based TIVA by TCI provided faster extubation time, faster exit from OR after extubation, and lower prolonged extubation rate compared with DES anesthesia in LC. Besides, older age, female, DES anesthesia, and lengthy anesthesia time were factors affecting prolonged extubation.

Shoulder pain and risk of developing hypertension and cardiovascular disease: A nationwide population-based cohort study in Taiwan Kuen-Tze Lin, Shiue-Wei Lai, Sheng-Der Hsu, Chao-Yueh Fan, Hong-Jaan Wang, Pi-Kai Chang, Wei-Hsiu Liu, Yen-Lin Chen, I-Chuan Yen, Shih-Yu Lee Journal of Medical Sciences 2019 39(3):127-134 Background: Shoulder pain is a common complaint across the population. It is associated with co-morbidities such as depression, diabetes mellitus, musculoskeletal disorders or cancer. However, there has been no study on the association of shoulder symptoms with future development of diseases. This nationwide population-based study aimed to investigate and clarify this association. Materials and Methods: A total of 76,304 patients with shoulder symptoms during 2000 and 2013 were selected from the National Health Insurance Research Database in Taiwan. Clinical endpoints such as hypertension (HTN) and cardiovascular disease (CVD) were evaluated by hazard ratio (HR) with 95% confidence interval (CI) after adjusting any confounding factors in Cox regression analysis. Results: Among the registered subjects, 16,570 (21.72%) and 8,453 (11.08%) patients developed HTN and CVD, respectively. After adjusting gender, age, household income, catastrophic illness, season, urbanization level and level of care, patients with shoulder symptoms aged ≥65 years had the highest risk of HTN (adjusted HR = 5.806, 95% CI = 5.464-6.169, P < 0.001), and CVD (adjusted HR = 4.371, 95% CI = 4.047-4.721, P < 0.001), with reference to younger age group of 22-44. The association of older age persisted in other cardiovascular problems (P < 0.001). Conclusions: Shoulder symptoms were associated with HTN and CVD. Future studies are required to elucidate the clinicopathogenesis.

Predict fluid responsiveness by stroke volume variation in patients undergoing protective one-lung ventilation in pressure-controlled ventilation mode Wei-Hung Chan, Tsai-Wang Huang, Chiao-Pei Cheng, Go-Shine Huang, Yung-Chi Hsu, Yi-Hsuan Huang, Zhi-Fu Wu Journal of Medical Sciences 2019 39(3):135-139 Objective: The aim of this study is to use stroke volume variation (SVV) as an indicator to predict fluid responsiveness in patients undergoing protective one-lung ventilation (OLV) in pressure-controlled ventilation mode. Design and Setting: A prospective clinical study in an operating room in a medical center. Patients: Fourteen patients receiving video-assisted thoracic surgery while undergoing OLV in pressure-controlled ventilation mode. Methods: After starting OLV in pressure-controlled ventilation mode, all patients were administered 6 ml/kg 6% hydroxyethyl starch for 20 min. Vigileo-FloTrac system was used to record hemodynamic variables before and after volume loading. The ability of SVV to predict fluid responsiveness was tested by calculating the area under the receiver operating characteristic (ROC) curve for an increase in stroke volume index of ≥10% after volume loading, and the optimal threshold value of SVV was calculated. Results: The area under the ROC curve for SVV to discriminate between responders and nonresponders was 0.89 (95% confidence interval, 0.700–1; P = 0.03). The optimal threshold value of SVV was 8.5% (sensitivity 88.89%; specificity 75%). Conclusions: SVV may be suitable for predicting fluid responsiveness in patients undergoing protective OLV in pressure-controlled ventilation mode.

Acute Type B aortic dissection with right hemothorax Jui-Tsung Chang, Yi-Chang Lin Journal of Medical Sciences 2019 39(3):140-142 Normal descending aorta is in the left thorax. Thus, ruptured type B aortic dissection more commonly presents with left hemothorax. However, there is a case of type B dissection complicated with right hemothorax.

Polypoid basal cell carcinoma on the right groin: A case report and review of literature Shou-En Wu, Yi-Hsien Chen, Hong-Wei Gao, Chien-Ping Chiang Journal of Medical Sciences 2019 39(3):143-145 Basal cell carcinoma (BCC) is the most common type of skin cancer. Polypoid BCC is very rare and distinguishes from other types of BCC by being female predominant, locating on nonsun-exposed areas, prevailing in dark-skinned races, and having large average size, but considered nonaggressive. We report a case of BCC presenting as an inconspicuous polyp. A 40-year-old female sustained a slowly growing mass at the left groin for many years. Physical examination revealed a polypoid mass over the right groin without specific symptoms. Surgical removal with simple polypectomy was performed, whereas the pathological features revealed BCC with polyp feature. There has been no recurrence after the surgery. This case highlights the importance of remaining clinically alert to differentiate a benign-looking polyp.

A patient presenting with isolated psychotic depression due to the ischemic stroke of centrum semiovale Halil Onder, Emre Misir Journal of Medical Sciences 2019 39(3):146-149 Post-stroke depression (PSD) is the most common neuropsychiatric complication of stroke, such that it can occur in one-third of stroke survivors. It has been tried to be explained by the disruption in the neural circuits involved in the mood regulation in the setting of some additional clinical risk factors. However, there is no consensus in this regard. Herein, we present a 58-year-old male patient presenting with isolated psychotic depression which was finally found to be associated with acute ischemic stroke of bilateral centrum semiovale. This report constitutes an extremely rare illustration of acute onset organic psychotic depression which was clearly demonstrated to be associated with ischemic stroke. Through the presentation of this patient and limited literature, we propose some discussions regarding the pathophysiology of PSD. We also remark the need for future reports of neuroimaging methods to clarify the unknown neural correlates in these manifestations.

Acute hemothorax secondary to chest tube-related diaphragmatic injury in a patient with traumatic liver laceration Wei-Cheng Tseng, Wei-Cheng Tseng, Ting-Yi Sun, Ti-Hei Wu, Shing-Hwa Huang, Zhi-Fu Wu Journal of Medical Sciences 2019 39(3):150-153 Despite its many benefits, there are several potentially significant complications inherent to chest tube insertion (CTI), a commonly used invasive procedure to evacuate air or fluid from the pleural space. The average rate of complications following CTI ranges from 5% to 10%, whereas insertion-related complications are rare. Here, we present the case of a 45-year-old female suffering from a motor vehicle accident who developed Grade IV liver laceration complicated with intra-abdominal hemorrhage and right-sided fractures from the fourth to the ninth rib. Misplacement of the preventive CTI for potential hemopneumothorax during the first attempt was observed by computed tomography and simultaneously led to diaphragmatic penetration. Subsequently, massive bloody pleural effusion from the abdominal cavity through the defect in the right hemidiaphragm was noted through a newly inserted chest tube when the patient coughed due to endotracheal suctioning. This case illustrates the significance of identification of patients at high risk for complications related to CTI and the utility of ultrasound guidance during CTI.

Unintentional pediatric trauma in the emergency department Beuy Joob, Viroj Wiwanitkit Journal of Medical Sciences 2019 39(3):154-154

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Integrative Nephrology and Andrology

Acute kidney injury: A definition with a rich past and an evolution Dimitrios C Karathanasis, C Androula Karaolia Journal of Integrative Nephrology and Andrology 2018 5(4):121-125 The term acute kidney injury (AKI) appeared in the society of nephrology in 2004 mirroring a key station of the constant development of the whole entity of acute renal failure. The long route from “acute Bright's disease” in the 19th century to modern “acute kidney stress” reflects the continuous effort of the society of nephrology to set the appropriate criteria and finally to formulate a precise and consensus definition in nomenclature of kidney injury. The most important definitions were the Risk, Injury, Failure, Loss of Kidney Function, and End-Stage Kidney Disease in 2004, Acute Kidney Injury Network (AKIN) in 2007, and Kidney Disease Improving Global Outcomes (KDIGO) in 2012 which had been proposed by the committees of Acute Dialysis Quality Initiative, AKIN, and KDIGO, respectively. Common basis of the above definitions was the clinical-laboratory criteria of urine output and serum creatinine while the target of every newer attempt was to increase the sensitivity of AKI and to offer a globally unified perception in terms of diagnosis and prevention. Since the emersion of KDIGO definition, the interest in defining AKI has been focused on the stage that precedes renal damage by the detection of clinically reliable biomarkers. Subsequently, the concept of acute injury is being lately realized as an attack in correspondence with heart attack or even more as an acute stress which can only be witnessed by the appropriate biomarkers. Recent research is focusing on the discovery of the ideal biomarker which must meet the requirements of high specificity, low cost, and ease of application.

To study the prevalence of thyroid disorders in chronic renal disease patients Upendra Nath Gupta, Apoorva Jain, Prashant Prakash, Prabhat Agrawal, Ravi Kumar, Maaz Farooqui Journal of Integrative Nephrology and Andrology 2018 5(4):126-129 Background and Objectives: The high prevalence of thyroid dysfunction in chronic kidney disease (CKD) patients reveals significant association between CKD progression and thyroid dysfunction. The aim was to study the thyroid dysfunction in patients of CKD for the prevalence of subclinical hypothyroidism (SCH) and clinical hypothyroidism and study the correlation between thyroid dysfunction and severity of renal diseases. In view of the variability of thyroid profile in CKD patients in previous studies, a prospective study of various thyroid function has been undertaken to establish a correlation if any between thyroid dysfunction and severity of renal diseases. Materials and Methods: A total of 100 patients with CKD on conservative management fulfilling the criteria for CKD who were admitted at the Department of Medicine, SNMC, Agra, Uttar Pradesh, India, during the period of July 2016–June 2017, were selected in this study. Descriptive analysis of the collected data was done and association of various parameters with the presence or absence of SCH or overt hypothyroidism was studied using Chi-square test and correlated. Results: Results showed that out of the 100 patients with CKD, 53 patients had thyroid dysfunction which accounted for 53%. The prevalence of SCH and clinical hypothyroidism was 33% and 20%, respectively. The number of patients with hypothyroidism progressively increased with increased severity of renal failure. Conclusions: We observed a high prevalence of thyroid dysfunction in our CKD patients and revealed significant association between CKD progression and thyroid dysfunction.

Clinical profile of acute kidney injury in a tertiary care center in the Tropical Region Utkarsh Rajesh Patel, Amit S Pasari, Manish Ramesh Balwani, Amol Bhawane, Priyanka R Tolani, Shaurya Acharya Journal of Integrative Nephrology and Andrology 2018 5(4):130-133 Objective: The objectives of the study were to study etiology, manifestations, and outcome of acute kidney disease in the tropical region in a tertiary care center. Materials and Methods: In the present prospective study, patients with acute kidney disease admitted to JNMC, Wardha, India, between January 2017 and December 2017 were studied with a detailed history, general physical examination, and systemic examination. Data were collected and analyzed. Statistical analysis was performed using descriptive and inferential statistics using the Chi-square test and Student's unpaired t-test and software used in the analysis was SPSS 22.0 version and Graph Pad Prism 6.0 version. Results: This study showed male-to-female ratio of 1.8:1. Maximum incidence was seen in patients aged >60 years. As per the Kuppuswamy's scale, most of the patients belonged to lower-middle and upper lower class. The study showed various etiological factors associated with acute kidney injuries (AKIs) such as renal causes (most common), heart failure, respiratory failure, cirrhosis, malaria, snake bite, acute gastroenteritis, poisoning, drug nephrotoxicity, and sepsis. Common symptoms were oliguria followed by pedal edema and dyspnea. The most common comorbid illness was hypertension followed by diabetes mellitus which may have made them prone to AKI. About 81.42% of patients survived and 18.58% expired. Of 70, 56 patients were managed conservatively, whereas 14 underwent hemodialysis. Mean duration of hospitalization was 11.01 ± 8.60 days. Conclusion: Intrinsic renal causes followed by heart failure were the common causes of AKI as against infective causes a few years earlier. This shows the changing trend of AKI causes in a developing nation. Average duration of hospitalization was 11 days in the study.

Study of some electrocardiographic and echocardiographic data in toddelers and children with primary glomerulonephropathy Mohamed Abdelaziz El-Gamasy, Walid El-Shehabi Journal of Integrative Nephrology and Andrology 2018 5(4):134-139 Background and Objective: Primary glomerulonephropathy mainly acute poststreptococcal glomerulonephritis (APSGN) is the most common cause of hypertensive heart failure in the pediatric age as APSGN may involve various systems including cardiovascular system. There are few research publications on electrocardiographic (ECG) and echocardiographic (two-dimensional [2D]-echo) data in childrenwith primary glomerulonephropathy. The aim is to study some ECG and 2D-echo data in Egyptian pediatric patients with ANS). Subjects and Methods: Sixty children with ANS were included and subjected to clinical, laboratory, ECG for corrected QT (QTc) interval and 2D echocardiographic study on admission and repeated at 6 and 12 weeks using GE Vivid 7 (GE Medical System, Horten, Norway with a 3.5-MHz multifrequency transducer) to measure left ventricular ejection fraction (LVEF), left atrium to aorta ratio and E/A ratio. Results: Prolonged QTc interval was reported in 22 patients (37%), of whom 18 had hypertension. Fourteen of the 60 children had LVEF <60%. The same children also had left atrium/aorta ratio >2 and E/A ratio more than two. LVEF became within normal values by 1½ month (6 weeks) in 12 patients, two become normal by three months of follow-up. Four (28.6%) from 14 children with low LVEF had normal arterial blood pressure. All the 14 children had completely recovered on follow-up period of 3 months. Conclusion: Changes in ECG and echo data which were reported in the acute phase of ANS appear to be temporary (transient) as they became within normal values in almost all children by 12 weeks period of follow-up. Although elevated blood pressure was the most common etiology of congestive heart failure in children with ANS, the impact of primary myocardial functional disturbance could also be put into consideration.

Paroxysmal nocturnal hemoglobinuria manifesting as hemolytic anemia with acute kidney injury Amol Bhawane, Manish Ramesh Balwani, Amit S Pasari, Priyanka R Tolani Journal of Integrative Nephrology and Andrology 2018 5(4):140-142 Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired disorder characterized by low-grade, chronic hemolytic anemia accompanied by either thrombocytopenia or leukopenia with usually benign kidney involvement secondary to chronic tubular deposition of hemosiderin. Acute kidney injury (AKI) may be seen during hemolytic crisis. We report the case of a 45-year-old man with PNH who developed reversible AKI requiring temporary hemodialysis support following herpes zoster infection.

Serum magnesium concentration a need for revision especially in renal failure Majid Malaki Journal of Integrative Nephrology and Andrology 2018 5(4):143-144

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Clinical Trials: Nervous System Diseases

Influence of bladder management on long-term quality of life in patients with neurogenic lower urinary tract dysfunction Jürgen Pannek, Jörg Krebs, Jens Wöllner Asia Pacific Journal of Clinical Trials: Nervous System Diseases 2019 4(2):29-32 Background and objective: Patients with spinal cord injury suffer from neurogenic lower urinary tract dysfunction (NLUTD). NLUTD is associated with a considerable morbidity and mortality, but also affects the quality of life (QoL). We aimed to evaluate the longitudinal course of QoL in persons with NLUTD in relation to their bladder management. Subjects and methods: In a prospective self-controlled case series study. Patients with chronic NLUTD managing their bladder either by intermittent catheterization (n = 21), reflex voiding (n = 8), anterior root stimulation (n = 7), straining (n = 7) or suprapubic catheter (n = 4) were asked to fill in the Qualiveen® questionnaire at two time points with a time span of at least 1 year. Eleven patients were tetraplegic, and 36 persons suffered from paraplegia. The study was approved by the Ethics Committee of the Ethikkommission Nordwestund Zentralschweiz (approval No. PB_2016-02657) on September 24, 2007. Results: In total 47 patients returned both questionnaires and their data were therefore evaluated. The mean age at the first evaluation was 52 ± 12.8 years. The mean duration of NLUTD was 20.4 ± 12.3 years. A mean 2.4 ± 0.5 years had elapsed from the first to the second evaluation. None of the Qualiveen questionnaire domains showed a significant change between the two evaluation time points. The lesion level had a significant (P ≤ 0.023) effect on the domains constraints and QoL index. Conclusion: QoL in patients with chronic NLUTD seems to remain stable in long-term follow-up. Trial registration: ClinicalTrials.gov (NCT02179073) on July 1, 2014.

Efficacy of entacapone and pramipexole in treating non-motor symptoms of Parkinson's disease: a prospective randomized controlled trial Zheng Bei, Guo-Qiang Wen, Yi Chen, Ning Bei Asia Pacific Journal of Clinical Trials: Nervous System Diseases 2019 4(2):33-39 Background and objective: Individuals with Parkinson’s disease exhibit a variety of non-motor symptoms that can negatively impact quality of life. Although both entacapone and pramipexole can be used to treat Parkinson’s disease via modulation of dopamine metabolism, the ways in which these treatments differ in terms of their effects on the non-motor symptoms of Parkinson’s disease are unknown. Participants and methods: This prospective, randomized, controlled trial will be conducted in the Geriatric Hospital of Hainan, Haikou, China. A total of 388 patients with idiopathic Parkinson’s disease will be randomly assigned to receive entacapone (n = 194) or pramipexole (n = 194). This study was approved by the Ethics Committee of the Geriatric Hospital of Hainan, China on August 30, 2013 (approval number: S2013-038-01) on August 30, 2013. Written informed consent regarding the study protocol and surgical procedure will be obtained from all participants. Results: The primary outcome measure will be the rate of improvement of non-motor symptoms 3 weeks after treatment. Secondary outcome measures will be soluble interleukin-2 receptor and homocysteine levels in serum, which reflect inflammation, and adverse events before and 3 weeks after treatment. Our self-controlled pilot study involving 100 patients showed that incidences of autonomic neurological symptoms such as postural hypotension, urinary urgency, urinary frequency, sexual dysfunction, dry mouth, and salivation, psychiatric symptoms such as cognitive dysfunction, hallucination, depression, and anxiety, and sensory abnormalities such as spasm, pain, and restless leg syndrome were remarkably reduced. Meanwhile, levels of serum soluble interleukin-2 receptor and homocysteine had noticeably decreased after treatment with entacapone and pramipexole. Conclusion: This trial will confirm the efficacy of entacapone and pramipexole in the treatment of non-motor symptoms of Parkinson’s disease. We hope that our findings will provide direction for future clinical treatment of non-motor symptoms of Parkinson’s disease, leading to improved patient quality of life. Trial registration: This study was registered with the Chinese Clinical Trial Registry on April 15, 2019 (registration number: ChiCTR1900022534). Protocol version is 1.0.

Effect of transcranial direct current stimulation on the level of consciousness in patients with traumatic coma: study protocol for a self-controlled trial Nilpadma Sarkar, Subhasish Chatterjee, Ajay Gehlot Asia Pacific Journal of Clinical Trials: Nervous System Diseases 2019 4(2):40-43 Background and objectives: Traumatic brain injury patients suffer from coma, which leads to changes in behavior and consciousness. There is a paucity of available treatments which can improve the level of consciousness. Transcranial direct current stimulation (tDCS) is one of the non-invasive techniques to stimulate the motor cortex and improve the level of consciousness. The purpose of the study will be to assess the effect of tDCS on consciousness in patients with traumatic coma. Subjects and methods: The single-subject ABA design single-center study will be conducted in the Neuro-Surgery ICU, Maharishi Markandeshwar Hospital, India. Comatose patients associate with traumatic brain injury will be recruited. After baseline assessment all patients will get treatment with tDCS for 20 minutes twice a day for consecutive 5 days. Follow-up assessment will be taken on every first day of the consecutive 1st, 3rd and 5th weeks post-treatment. Ethical approval has been obtained from the Institutional Ethical Committee (IEC) of Maharishi Markandeshwar (Deemed to be University) (IEC/MMDU/2018/1183) on June 6, 2018. Outcome measures: JFK Coma Recovery Scale-Revised (CRS-R). Discussion: The study will investigate the possible effect of tDCS in improving level of consciousness in patients with traumatic brain injury. Trial registration: The study was registered with ctri.nic.in (CTRI/2019/01/017186) on January 22, 2019. It is the official website for registration of clinical trials in India regulated by Indian Council of Medical Research.

Efficacy and safety of traditional Chinese medicine combined with western medicine for early-phase treatment of acute ischemic stroke based on the primary syndrome elements: protocol for a randomized controlled trial Fu-Sheng Liu, Xiao-Lei Fang, Zhi-Rui Cheng, Jin Liu, Zhi Liu, Chen-Chen Sun, Lei Sun, Hui Jin Asia Pacific Journal of Clinical Trials: Nervous System Diseases 2019 4(2):44-50 Background and objective: Acute ischemic stroke is a major cause of disability among adults. Although traditional Chinese medicine and western medicine have been widely used for the treatment of acute ischemic stroke, their efficacy when used in combination for the treatment of acute ischemic stroke during the early phase is poorly understood. According to traditional Chinese medicine theory, the primary syndrome elements of acute ischemic stroke during the early stage include three pathogens, “wind,” “fire,” and “phlegm,” and treatments that target these primary syndrome elements contribute to recovery from the condition. We have designed a randomized controlled trial to investigate the efficacy and safety of traditional Chinese medicine combined with western medicine in the treatment of acute ischemic stroke during the early phase based on the primary syndrome elements. Subjects and methods: This prospective, single-center, assessor-blinded, randomized controlled trial will enroll 120 eligible patients with acute ischemic stroke who will receive treatment in the Department of Emergency, Dongfang Hospital of Beijing University of Chinese Medicine, China. Participants will be randomly assigned to a combined treatment group or a control group. Both groups will undergo treatment with conventional western medicine, and patients in the combined treatment group will also receive traditional Chinese medicine (i.e., oral stroke initial state decoction, intravenous Gastrodin injection, and Tanreqing injection; Xingnaojing injection will be added for patients who are unconscious). Immediately after admission, patients will undergo 3-day treatment for early-phase ischemic stroke and subsequently undergo a 2-week follow up. This study was approved by Hospital Ethics Committee, Dongfang Hospital, Beijing University of Traditional Medicine, China (approval No. JDF-IRB-2016033602) on November 2, 2016. Written informed consent will be obtained from conscious patients or the legal guardians of unconscious patients. Outcome measures: The primary outcome measures of this study are the National Institute of Health Stroke Scale score and traditional Chinese medicine stroke scale score on days 1, 3, 7, and 14 after treatment. Secondary outcome measures include National Institute of Health Stroke Scale score, Barthel index, Modified Rankin scale score, Glasgow coma scale score on days 1, 3, 7, and 14 after treatment, serum matrix metalloproteinase-9 and vascular endothelial growth factor levels on days 1 and 3 after treatment. Safety outcomes on days 1 and 3 after treatment and adverse events on days 3, 7, and 14 after treatment are also evaluated. Discussion: The results of this study will provide evidence to support the rationale for using traditional Chinese medicine combined with western medicine for the treatment of acute ischemic stroke during the early phase, and may indicate the underlying mechanism in this treatment strategy. Trial registration: This study was registered with the Chinese Clinical Trial Registration (registration number: ChiCTR-INR-16010075) on December 4, 2016. Study protocol refers to 1.0. Patient recruitment began in December 2016 and will be ended in November 2019.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Computers, Informatics, Nursing

Structure and Characteristics of Diabetes Self-management Applications: A Systematic Review of the Literature Diabetes is one of the most common chronic conditions, and a good self-management regimen is needed in order to control the disease and prevent complications. In the last few years, the number of health information technologies has increased, and while there are many smartphone applications for diabetic patients, their effectiveness is still unclear. This systematic review aims to outline structure and characteristics that can make an application for diabetes management effective and safe and improve usability and the chances of success for a mobile health service. Applications found in the literature have been analyzed to evaluate the different features. Findings of the review suggest that patients seem to be more attracted by tools that are helpful in everyday management of diabetes, and that allow them to save time and increase safety. The personalization of the application is essential to obtain success in promoting use, and applications should be based upon patients' predisposition to use technological tools that will ensure better outcomes. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding authors: Sara Angelini, MSN, RN, Department of Public Health and Infectious Diseases, Sapienza University of Rome, P.le Aldo Moro 5, 00185 Rome, Italy (sarangelini.s@icloud.com); Marco Di Muzio, PhD, RN, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Italy (marco.dimuzio.uniroma1.it). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Evaluation of Nursing Practice in Patients With HIV/AIDS With the Omaha System Electronic-Based Information Program: A Retrospective Study The Omaha System is a standardized health care terminology that has been used in many different settings for nursing care worldwide for more than 20 years. In Turkey, it has been used mainly in nursing education and research. In this context, the purpose of this study was to examine paper-based nursing care plans of inpatients with HIV/AIDS according to the Omaha System and to assess the clinical suitability of the Omaha System. The study has a descriptive-retrospective design and was carried out at the Department of Infectious Diseases and Clinical Microbiology in a hospital. The sample consisted of 30 patients with HIV/AIDS who were chosen randomly from patients hospitalized between January 2007 and April 2017. Nursing care plans were reevaluated and encoded according to the Omaha System. The five most frequently diagnosed problems were oral health (27.2%), neuromusculoskeletal function (20.2%), communicable/infectious condition (19.4%), skin condition (13.2%), and circulation (5.7%). A total of 4409 nursing interventions were applied to solve the problems, and almost 74% of the interventions were categorized in the surveillance. Among the targets, physical signs/symptoms were indicated for more than 68% (3.026). The results confirmed the clinical suitability of the Omaha System. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Ozlem Koseoglu Ornek, PhD, RN, Department of Nursing, Faculty of Health Sciences, Istanbul Bilgi University, Dolapdere Kampus, Haciahmet Mahallesi, Pir Hüsamettin Sokak, No. 20, 34440 Beyoğlu, Istanbul, Turkey (ozlem.koseoglu@bilgi.edu.tr; ozlem.koseoglu62@gmail.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

eHealth Services in the Near and Distant Future in Swedish Home Care Nursing Sweden and other developed countries are putting deliberate efforts into eHealth and digitalization of home care nursing. eHealth services have big potential in this area because they can provide mobile access to healthcare information. This study explores the eHealth services that home care nursing providers in Sweden currently use, plan to use, and have discarded. It also investigates their eHealth visions for the future. We sent a survey to the 264 Swedish municipalities responsible for home care nursing and received 144 responses (55%). The results show a large diversity of eHealth services in use. A few can be considered core services since they are broadly implemented or will be in the near future. Trials are also being carried out with more specialized services. The respondents envision more automation and remote monitoring services, while technical and usability issues are the main obstacles to implementation today. Much knowledge can be gained from proper evaluation of the ongoing work. More research is needed regarding (1) what eHealth can offer home care nursing, (2) the effects of using eHealth in home care nursing, and (3) if and how home care nursing organizations need to adapt to best make use of eHealth. The work presented in this study was funded by AFA Insurance. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Christofer Rydenfält, PhD, Department of Design Sciences, Faculty of Engineering, Lund University, PO Box 118, SE-221 00 Lund, Sweden. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Evaluating the Development Processes of Consumer mHealth Interventions for Chronic Condition Self-management: A Scoping Review Innovative, patient-centered mHealth interventions have the potential to help with the burden of chronic conditions. This review aims to describe the development of consumer mHealth interventions for chronic condition self-management. A scoping review methodology was used to search medical databases for eligible reports, published between January 1, 2010, and December 31, 2017, that provided information on consumer mHealth interventions for respiratory disease, cancer, diabetes, and cardiovascular disease. Twenty-one reports were included, representing the development of 14 mHealth interventions. Most were developed collaboratively, using user-centered and participatory design processes. Predesign work involved a thorough needs assessment, and redesign processes were described as iterative, engaging with usability testing and design improvements. Tensions from competing priorities between patients and healthcare professionals were uncovered, with the intention to develop a useful product for the patient while ensuring clinical relevance. This review provides clear evidence that consumer mHealth interventions are developed inconsistently even when engaging with participatory or user-centered design principles, sometimes without direct involvement of patients themselves. Further, the incomplete description of the development processes presents challenges to furthering the knowledge base as healthcare professionals need timely access to quality information on mHealth products in order to recommend safe, effective consumer mHealth interventions. Corresponding author: Leanna Woods, BN (Hons), Patient Care Level 6, St Vincent's Private Hospital Sydney, 406 Victoria St, Darlinghurst, New South Wales, Australia 2010 (Leanna.Woods@svha.org.au). L.W. is supported by a St Vincent's Clinic Foundation Grant and the University of Tasmania's Elite Research Scholarship funded by The District Nurses. The remaining authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Bedside Usability Surveys: Adding Authentic User Detail to the Assessment Errors in healthcare are a leading cause of death in the United States. Equipment usability and user interfaces remain an area not fully elucidated. Infusion pumps play a vital role in care delivery, often essential for critical therapies. While pump function is comparatively simple, their programming, configuration, and form provide opportunity for error. Our purpose was to assess qualities nurses identified as important to pump operation by electronic survey. A self-developed usability survey was distributed to a random sample of 500 nurses, stratified by unit type and employed at the large academic quaternary care hospital. The overall response rate was 48% (n = 240). Descriptive and inferential statistics describe the responses and represent more than 5500 weekly infusions. Nurses described confident use of the system with some differences by unit type. Ninety percent of respondents indicated they have omitted use of the dose error reduction system, which should raise safety concerns. Users reported issues with the user interface and error prevention systems. Qualitative items elicited suggestions for improving aspects of the pump. Employing a usability survey in a clinical area proved to be a simple, inexpensive way to gather more information on the use and potential improvements of infusion pumps. Corresponding author: Krisanne Graves, PhD, RN, CPHQ, Texas Children's Hospital, 6621 Fannin St, Suite A270, Houston TX 77030 (kxgraves@texaschildrens.org). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.cinjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Current Trends in Robotics in Nursing Patents—A Glimpse Into Emerging Innovations The purpose of this study was to describe the current evidence found through a patent search about robotics used to assist nurses in providing care. The authors used a modified seven-step strategy of searching patents according to the US Patent and Trademark Office guidelines. The nursing robotic search was performed in four databases including the US Patent and Trademark Office issued patent database, the US Patent and Trademark Office published patent application database, the European Patent Office database, and Relecura. Keywords reflecting the scope of the term "robot" were defined for the purposes of this specific search. This broad search yielded large numbers of patents germane to nursing care. These results were narrowed using keywords and the Cooperative Patent Classification schemes to determine relevance, ensure rigor, and capture the most relevant results. This review of patents suggests robots for nursing care are proliferating. The opportunity for robotics in nursing is emerging in industry. Although nursing will likely benefit from robotics, we must determine the appropriate place to include robots in nursing care delivery. Partial support of the project was provided by The University of Alabama's Office for Research and Economic Development through NSF (IIP-1450293). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Rachel M. Frazier, PhD, Graphenics, LLC, Williamsburg, VA (rachel@graphenics.net). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Usability of a Disease Management Mobile Application as Perceived by Patients With Diabetes The use of mobile applications in chronic disease management has grown significantly over the past decade. When properly designed, these apps provide a convenient, safe, high-quality service to patients. In this study, a health management app was developed, and its usability among patients with diabetes mellitus was examined. A convenience sample of 136 patients, referred to two academic centers from December 2016 to July 2017, was enrolled. Upon completion of informed consent, the participants were asked to install the app on their smartphone. Two weeks later, they were required to complete a postapplication usability questionnaire, comprising 21 questions classified into six domains. The response rate was 89%. The highest scores were given for "ease of use and learnability"; the lowest-scored domains were "interaction quality" and "reliability." Urban residents, participants with lower educational qualifications, and retirees were significantly more satisfied with the app. Overall, patients with diabetes mellitus perceived the app as useful for disease management. However, the overall usability of health apps is expected to improve when a multidisciplinary team (health professionals, computer engineers, art designers) is involved in the development process. This work was a master's degree project approved at and founded by Guilan University of Medical Sciences, Iran (registration no. 951010). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Rasoul Tabari-Khomeiran, PhD, RN, Social Determinants of Health Research Center, Guilan University of Medical Sciences, Nursing & Midwifery Faculty, Danshjoo Rd, Rasht, Postal 41469-39841, Iran (rtabari@gums.ac.ir; rasooltabari@gmail.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Sequential Two-Stage Network and Thematic Analysis for Exploring an Interdisciplinary Care Approach in Nursing Homes Since various groups of older adults with different conditions and levels of function coexist in nursing homes, it is necessary to develop integrated care strategies through collaboration among experts across related fields. The purposes of this study are to identify the regularity of information sharing in managing daily function for older adults, with a special focus on interdisciplinary cooperation, and to explore a practical care strategy for nursing home residents. The collaborative methods of network and thematic analysis were done by conducting in-depth interviews with 33 interdisciplinary experts working at seven nursing homes. This study proposed three relationships and three themes as interrelated key factors for providing interdisciplinary care to the elderly at various levels of function based on the experiences accumulated by the practitioners. First, independent sharing is required to make professional judgments about how daily function in older adults changes from reported baselines. Second, practitioners accurately judge clinical situations and supplement experts' judgments through partial sharing. Finally, all interdisciplinary consensus through complete sharing achieves the ultimate goal of maintaining remaining function in older adults. These findings can be the first step in developing practical care guidelines for interdisciplinary use, and the results can be used to develop integrated assessment and intervention strategies. Corresponding author: Sung Ok Chang, PhD, RN, College of Nursing, Korea University, 145 Anam-ro, Seongbuk-Gu, Seoul, Republic of Korea 02841 (sungok@korea.ac.kr). This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2015R1D1A1A01057258). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Quality Improvement in Online Course Development: Igniting the Online Teaching Team Online courses and programs in higher education, including nursing education, continue to multiply exponentially in the United States. In order to meet accreditation standards and build internal standards of quality in online course delivery, nursing administrators and faculty must keep abreast of evidence and best practice in online course design. Awareness and adoption of online standards of excellence may be a departure from standard operating procedure with faculty adept at creating face-to-face courses and mavericks self-taught in online course development. The Plan-Do-Study-Act process for improvement is a viable and scalable method to achieve national certification of online course quality, improving ability to compete in a dynamic online education environment. Considerations of infrastructure and multiple stakeholder groups are critical to successful implementation. The case of one nursing program that used faculty development, team building, and continuous quality improvement to successfully reach national online quality benchmarks is presented. The authors are certified as peer reviewers for Quality Matters, a scholarly activity for which they have received no personal remuneration. They have both presented at Quality Matters conferences. They have received no funding for this work. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Tara Spalla King, PhD, The Ohio State University College of Nursing, 1585 Neil Ave, Columbus, OH 43210 (king.2541@osu.edu). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Do Brief Educational Sessions Increase Electronic Health Literacy of Low-Income Persons Living With HIV/AIDS? This research explored whether participating in a brief educational intervention using the National Library of Medicine video, Evaluating Health Information: A Tutorial From the National Library of Medicine, would increase electronic health literacy. A quasi-experimental longitudinal design was used in two randomly selected settings of a treatment program for low-income persons living with HIV/acquired immune deficiency syndrome (N = 100). Individuals in both intervention groups watched the video and completed an at-home assignment brought to the second session 1 week later; one group received an additional 15 minutes with an HIV nurse clinician who reinforced video content. Generalized linear models were used in order to account for the longitudinal nature of the data; a full model was fitted first that included age, gender, race, ethnicity, education, acquired immune deficiency syndrome diagnosis, time, group, and the interaction of time by intervention group with electronic health literacy as the dependent variable. Group means were not significantly different, and the overall group pattern were the same; the only significant variable was older age, which is consistent with the findings of other literature. Electronic health literacy can be increased by viewing a free video; making this video available in a variety of settings and encouraging clients to use the Internet as a source of health information may improve self-management strategies of persons living with chronic illnesses. Corresponding author: Kathleen M. Nokes, PhD, RN, FAAN, Graduate Center, CUNY, 868 Buck Rd, Stone Ridge, NY 12484 (kathynokes@aol.com). Sources of funding: Jonas Center for Nursing and Veterans Healthcare and Alpha Phi Chapter of Sigma Theta Tau Research grant. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Ear and Hearing

Test-Retest Variability in the Characteristics of Envelope Following Responses Evoked by Speech Stimuli Objectives: The objective of the present study was to evaluate the between-session test-retest variability in the characteristics of envelope following responses (EFRs) evoked by modified natural speech stimuli in young normal hearing adults. Design: EFRs from 22 adults were recorded in two sessions, 1 to 12 days apart. EFRs were evoked by the token /susa∫ i/ (2.05 sec) presented at 65 dB SPL and recorded from the vertex referenced to the neck. The token /susa∫ i/, spoken by a male with an average fundamental frequency [f0] of 98.53 Hz, was of interest because of its potential utility as an objective hearing aid outcome measure. Each vowel was modified to elicit two EFRs simultaneously by lowering the f0 in the first formant while maintaining the original f0 in the higher formants. Fricatives were amplitude-modulated at 93.02 Hz and elicited one EFR each. EFRs evoked by vowels and fricatives were estimated using Fourier analyzer and discrete Fourier transform, respectively. Detection of EFRs was determined by an F-test. Test-retest variability in EFR amplitude and phase coherence were quantified using correlation, repeated-measures analysis of variance, and the repeatability coefficient. The repeatability coefficient, computed as twice the standard deviation (SD) of test-retest differences, represents the ±95% limits of test-retest variation around the mean difference. Test-retest variability of EFR amplitude and phase coherence were compared using the coefficient of variation, a normalized metric, which represents the ratio of the SD of repeat measurements to its mean. Consistency in EFR detection outcomes was assessed using the test of proportions. Results: EFR amplitude and phase coherence did not vary significantly between sessions, and were significantly correlated across repeat measurements. The repeatability coefficient for EFR amplitude ranged from 38.5 nV to 45.6 nV for all stimuli, except for /∫/ (71.6 nV). For any given stimulus, the test-retest differences in EFR amplitude of individual participants were not correlated with their test-retest differences in noise amplitude. However, across stimuli, higher repeatability coefficients of EFR amplitude tended to occur when the group mean noise amplitude and the repeatability coefficient of noise amplitude were higher. The test-retest variability of phase coherence was comparable to that of EFR amplitude in terms of the coefficient of variation, and the repeatability coefficient varied from 0.1 to 0.2, with the highest value of 0.2 for /∫/. Mismatches in EFR detection outcomes occurred in 11 of 176 measurements. For each stimulus, the tests of proportions revealed a significantly higher proportion of matched detection outcomes compared to mismatches. Conclusions: Speech-evoked EFRs demonstrated reasonable repeatability across sessions. Of the eight stimuli, the shortest stimulus /∫/ demonstrated the largest variability in EFR amplitude and phase coherence. The test-retest variability in EFR amplitude could not be explained by test-retest differences in noise amplitude for any of the stimuli. This lack of explanation argues for other sources of variability, one possibility being the modulation of cortical contributions imposed on brainstem-generated EFRs. ACKNOWLEDGMENTS: This study was funded by a Collaborative Health Research Project grant from the Canadian Institutes of Health Research and the Natural Sciences and Engineering Research Council of Canada (grant no. 493836-2016). V.E. designed the study, performed the experiment, analyzed data, and wrote the article. D.P. discussed study design, helped with response analysis, and edited the article. S.S. and S.A. discussed results, and edited the article. The authors have no conflicts of interest to disclose. Received October 20, 2018; accepted March 8, 2019. Address for correspondence: Vijayalakshmi Easwar, 541 Waisman Centre, The University of Wisconsin-Madison, 1500 Highland Ave, Madison, WI 53705, USA. E-mail: veaswar@wisc.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Revised Hearing Handicap Inventory and Screening Tool Based on Psychometric Reevaluation of the Hearing Handicap Inventories for the Elderly and Adults Objectives: The present study evaluates the items of the Hearing Handicap Inventory for the Elderly and Hearing Handicap Inventory for Adults (HHIE/A) using Mokken scale analysis (MSA), a type of nonparametric item response theory, and develops updated tools with optimal psychometric properties. Design: In a longitudinal study of age-related hearing loss, 1447 adults completed the HHIE/A and audiometric testing at baseline. Discriminant validity of the emotional consequences and social/situational effects subscales of the HHIE/A was assessed, and nonparametric item response theory was used to explore dimensionality of the items of the HHIE/A and to refine the scales. Results: The HHIE/A items form strong unidimensional scales measuring self-perceived hearing handicap, but with a lack of discriminant validity of the two distinct subscales. Two revised scales, the 18-item Revised Hearing Handicap Inventory and the 10-item Revised Hearing Handicap Inventory—Screening, were developed from the common items of the original HHIE/A that met the assumptions of MSA. The items on both of the revised scales can be ordered in terms of increasing difficulty. Conclusions: The results of the present study suggest that the newly developed Revised Hearing Handicap Inventory and Revised Hearing Handicap Inventory—Screening are strong unidimensional, clinically informative measures of self-perceived hearing handicap that can be used for adults of all ages. The real-data example also demonstrates that MSA is a valuable alternative to classical psychometric analysis. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and text of this article on the journal's Web site (www.ear-hearing.com). ACKNOWLEDGMENTS: The authors thank Jayne Ahlstrom for editorial assistance. The authors thank the subjects who participated in this study. This work was supported (in part) by research grant P50 DC000422 from NIH/NIDCD and by the South Carolina Clinical and Translational Research (SCTR) Institute, with an academic home at the Medical University of South Carolina, NIH/NCATS Grant number UL1 TR001450. This investigation was conducted in a facility constructed with support from Research Facilities Improvement Program Grant Number C06 RR14516 from the NIH/NCRR. Portions of this article were presented at the Hearing Across the Lifespan 2018 conference, Cernobbio, Lake Como, Italy, June 7, 2018. The authors have no conflicts of interest to declare. Received December 31, 2018; accepted March 25, 2019. Address for correspondence: Christy Cassarly, Department of Public Health Sciences, Medical University of South Carolina, 135 Cannon St., Ste 303, MSC 835, Charleston, SC 29425, USA. E-mail: cassarly@musc.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Effects of GJB2 or SLC26A4 Gene Mutations on Neural Response of the Electrically Stimulated Auditory Nerve in Children Objectives: This study aimed to (1) investigate the effect of GJB2 and SLC26A4 gene mutations on auditory nerve function in pediatric cochlear implant users and (2) compare their results with those measured in implanted children with idiopathic hearing loss. Design: Participants included 20 children with biallelic GJB2 mutations, 16 children with biallelic SLC26A4 mutations, and 19 children with idiopathic hearing loss. All subjects except for two in the SLC26A4 group had concurrent Mondini malformation and enlarged vestibular aqueduct. All subjects used Cochlear Nucleus devices in their test ears. For each subject, electrophysiological measures of the electrically evoked compound action potential (eCAP) were recorded using both anodic- and cathodic-leading biphasic pulses. Dependent variables (DVs) of interest included slope of eCAP input/output (I/O) function, the eCAP threshold, and eCAP amplitude measured at the maximum comfortable level (C level) of the anodic-leading stimulus (i.e., the anodic C level). Slopes of eCAP I/O functions were estimated using statistical modeling with a linear regression function. These DVs were measured at three electrode locations across the electrode array. Generalized linear mixed effect models were used to evaluate the effects of study group, stimulus polarity, and electrode location on each DV. Results: Steeper slopes of eCAP I/O function, lower eCAP thresholds, and larger eCAP amplitude at the anodic C level were measured for the anodic-leading stimulus compared with the cathodic-leading stimulus in all subject groups. Children with GJB2 mutations showed steeper slopes of eCAP I/O function and larger eCAP amplitudes at the anodic C level than children with SLC26A4 mutations and children with idiopathic hearing loss for both the anodic- and cathodic-leading stimuli. In addition, children with GJB2 mutations showed a smaller increase in eCAP amplitude when the stimulus changed from the cathodic-leading pulse to the anodic-leading pulse (i.e., smaller polarity effect) than children with idiopathic hearing loss. There was no statistically significant difference in slope of eCAP I/O function, eCAP amplitude at the anodic C level, or the size of polarity effect on all three DVs between children with SLC26A4 mutations and children with idiopathic hearing loss. These results suggested that better auditory nerve function was associated with GJB2 but not with SLC26A4 mutations when compared with idiopathic hearing loss. In addition, significant effects of electrode location were observed for slope of eCAP I/O function and the eCAP threshold. Conclusions: GJB2 and SLC26A4 gene mutations did not alter polarity sensitivity of auditory nerve fibers to electrical stimulation. The anodic-leading stimulus was generally more effective in activating auditory nerve fibers than the cathodic-leading stimulus, despite the presence of GJB2 or SLC26A4 mutations. Patients with GJB2 mutations appeared to have better functional status of the auditory nerve than patients with SLC26A4 mutations who had concurrent Mondini malformation and enlarged vestibular aqueduct and patients with idiopathic hearing loss. ACKNOWLEDGMENTS: We gratefully thank all subjects and their parents for participating in this study. J.L. participated in data collection and patient testing, prepared the initial draft of this article, provided critical comments, and approved the final version of this article. L.X., X.C., and R.W. participated in the data collection and patient testing, provided critical comments, and approved the final version of this article. X.B. conducted genetic tests in all study participants, provided critical comments, and approved the final version of this article. A.P. and Z.F. provided critical comments and approved the final version of this article. H.W. participated in designing this study, provided critical comments, and approved the final version of this article. S.H. designed the study, participated in data collection and patient testing, and drafted and approved the final version of this article. The authors have no conflicts of interest to declare. Received September 18, 2018; accepted March 17, 2019. Address for correspondence: Haibo Wang, Department of Otolaryngology—Head and Neck Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Duanxing West Road, Huaiyin, Jinan 250022, Shandong, People's Republic of China. E-mail: Whboto11@163.Com or Shuman He, Eye and Ear Institute, Department of Otolaryngology – Head and Neck Surgery, The Ohio State University, 915 Olentangy River Road, Columbus, OH 43212, USA. E-mail: shuman.he@osumc.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Use of Commercial Virtual Reality Technology to Assess Verticality Perception in Static and Dynamic Visual Backgrounds Objectives: The Subjective Visual Vertical (SVV) test and the closely related Rod and Disk Test (RDT) are measures of perceived verticality measured in static and dynamic visual backgrounds. However, the equipment used for these tests is variable across clinics and is often too expensive or too primitive to be appropriate for widespread use. Commercial virtual reality technology, which is now widely available, may provide a more suitable alternative for collecting these measures in clinical populations. This study was designed to investigate verticality perception in symptomatic patients using a modified RDT paradigm administered through a head-mounted display (HMD). Design: A group of adult patients referred by a physician for vestibular testing based on the presence of dizziness symptoms and a group of healthy adults without dizziness symptoms were included. We investigated degree of visual dependence in both groups by measuring SVV as a function of kinematic changes to the visual background. Results: When a dynamic background was introduced into the HMD to simulate the RDT, significantly greater shifts in SVV were found for the patient population than for the control population. In patients referred for vestibular testing, the SVV measured with the HMD was significantly correlated with traditional measures of SVV collected in a rotary chair when accounting for head tilt. Conclusions: This study provides initial proof of concept evidence that reliable SVV measures in static and dynamic visual backgrounds can be obtained using a low-cost commercial HMD system. This initial evidence also suggests that this tool can distinguish individuals with dizziness symptomatology based on SVV performance in dynamic visual backgrounds. Acknowledgment: The work was supported by Defense Health Affairs in support of the Army Hearing Program. The views expressed in this article are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. The identification of specific products or scientific instrumentation does not constitute endorsement or implied endorsement on the part of the author, DoD, or any component agency. The views expressed in this presentation are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. The authors have no conflicts of interest to disclose. Received March 27, 2018; accepted March 2, 2019. Address for correspondence: Ashley Zaleski-King, Walter Reed National Military Medical Center (WRNMMC), 8901 Rockville Pike, Bethesda, MD 20889, USA. E-mail: ashley.c.king8.civ@mail.mil Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Predicting Speech-in-Noise Deficits from the Audiogram Objectives: In occupations that involve hearing critical tasks, individuals need to undergo periodic hearing screenings to ensure that they have not developed hearing losses that could impair their ability to safely and effectively perform their jobs. Most periodic hearing screenings are limited to pure-tone audiograms, but in many cases, the ability to understand speech in noisy environments may be more important to functional job performance than the ability to detect quiet sounds. The ability to use audiometric threshold data to identify individuals with poor speech-in-noise performance is of particular interest to the U.S. military, which has an ongoing responsibility to ensure that its service members (SMs) have the hearing abilities they require to accomplish their mission. This work investigates the development of optimal strategies for identifying individuals with poor speech-in-noise performance from the audiogram. Design: Data from 5487 individuals were used to evaluate a range of classifiers, based exclusively on the pure-tone audiogram, for identifying individuals who have deficits in understanding speech in noise. The classifiers evaluated were based on generalized linear models (GLMs), the speech intelligibility index (SII), binary threshold criteria, and current standards used by the U.S. military. The classifiers were evaluated in a detection theoretic framework where the sensitivity and specificity of the classifiers were quantified. In addition to the performance of these classifiers for identifying individuals with deficits understanding speech in noise, data from 500,733 U.S. Army SMs were used to understand how the classifiers would affect the number of SMs being referred for additional testing. Results: A classifier based on binary threshold criteria that was identified through an iterative search procedure outperformed a classifier based on the SII and ones based on GLMs with large numbers of fitted parameters. This suggests that the saturating nature of the SII is important, but that the weights of frequency channels are not optimal for identifying individuals with deficits understanding speech in noise. It is possible that a highly complicated model with many free parameters could outperform the classifiers considered here, but there was only a modest difference between the performance of a classifier based on a GLM with 26 fitted parameters and one based on a simple all-frequency pure-tone average. This suggests that the details of the audiogram are a relatively insensitive predictor of performance in speech-in-noise tasks. Conclusions: The best classifier identified in this study, which was a binary threshold classifier derived from an iterative search process, does appear to reliably outperform the current thresholds criteria used by the U.S. military to identify individuals with abnormally poor speech-in-noise performance, both in terms of fewer false alarms and a greater hit rate. Substantial improvements in the ability to detect SMs with impaired speech-in-noise performance can likely only be obtained by adding some form of speech-in-noise testing to the hearing monitoring program. While the improvements were modest, the overall benefit of adopting the proposed classifier is likely substantial given the number of SMs enrolled in U.S. military hearing conservation and readiness programs. ACKNOWLEDGMENTS: The authors thank Dr. Gary Kidd for sharing his TDT data and Dr. Ken Grant for sharing his SPRINT data. The authors also thank Kari Buchanan and the Hearing Center of Excellence for sharing the DOEHRS-HC data. All authors contributed equally to this work. All authors were involved in the data analysis and discussed the results and implications and commented on the manuscript at all stages. The views expressed in this article are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. The authors have no conflicts of interest to disclose. Received December 3, 2017; accepted March 14, 2019. Address for correspondence: Daniel E. Shub, National Military Audiology and Speech Center, Walter Reed National Military Medical Center, 4954 North Palmer Road, Bethesda, MD 20889, USA. E-mail: daniel.e.shub.civ@mail.mil Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Children With Normal Hearing Are Efficient Users of Fundamental Frequency and Vocal Tract Length Cues for Voice Discrimination Background: The ability to discriminate between talkers assists listeners in understanding speech in a multitalker environment. This ability has been shown to be influenced by sensory processing of vocal acoustic cues, such as fundamental frequency (F0) and formant frequencies that reflect the listener's vocal tract length (VTL), and by cognitive processes, such as attention and memory. It is, therefore, suggested that children who exhibit immature sensory and/or cognitive processing will demonstrate poor voice discrimination (VD) compared with young adults. Moreover, greater difficulties in VD may be associated with spectral degradation as in children with cochlear implants. Objectives: The aim of this study was as follows: (1) to assess the use of F0 cues, VTL cues, and the combination of both cues for VD in normal-hearing (NH) school-age children and to compare their performance with that of NH adults; (2) to assess the influence of spectral degradation by means of vocoded speech on the use of F0 and VTL cues for VD in NH children; and (3) to assess the contribution of attention, working memory, and nonverbal reasoning to performance. Design: Forty-one children, 8 to 11 years of age, were tested with nonvocoded stimuli. Twenty-one of them were also tested with eight-channel, noise-vocoded stimuli. Twenty-one young adults (18 to 35 years) were tested for comparison. A three-interval, three-alternative forced-choice paradigm with an adaptive tracking procedure was used to estimate the difference limens (DLs) for VD when F0, VTL, and F0 + VTL were manipulated separately. Auditory memory, visual attention, and nonverbal reasoning were assessed for all participants. Results: (a) Children' F0 and VTL discrimination abilities were comparable to those of adults, suggesting that most school-age children utilize both cues effectively for VD. (b) Children's VD was associated with trail making test scores that assessed visual attention abilities and speed of processing, possibly reflecting their need to recruit cognitive resources for the task. (c) Best DLs were achieved for the combined (F0 + VTL) manipulation for both children and adults, suggesting that children at this age are already capable of integrating spectral and temporal cues. (d) Both children and adults found the VTL manipulations more beneficial for VD compared with the F0 manipulations, suggesting that formant frequencies are more reliable for identifying a specific speaker than F0. (e) Poorer DLs were achieved with the vocoded stimuli, though the children maintained similar thresholds and pattern of performance among manipulations as the adults. Conclusions: The present study is the first to assess the contribution of F0, VTL, and the combined F0 + VTL to the discrimination of speakers in school-age children. The findings support the notion that many NH school-age children have effective spectral and temporal coding mechanisms that allow sufficient VD, even in the presence of spectrally degraded information. These results may challenge the notion that immature sensory processing underlies poor listening abilities in children, further implying that other processing mechanisms contribute to their difficulties to understand speech in a multitalker environment. These outcomes may also provide insight into VD processes of children under listening conditions that are similar to cochlear implant users. ACKNOWLEDGMENTS: The authors wish to acknowledge the contribution of the following undergraduate students from the Department of Communication Disorders at Tel Aviv University for assisting in data collection: Feigi Raiter, Feigi Grinvald, Shani Rabia, Adi Amsalem, Miri Rotem, Lea pantiat, Daniel Lex Rabinovitch, and Orpaz Shariki. The authors wish to thank Steyer grant (School of Health Professions, Tel-Aviv University) for their financial support. The authors specially thank all the adults and children who participated in the present study. All authors contributed to this work to a significant extent. All authors have read the article and agreed to submit it for publication after discussing the results and implications and commented on the article at all stages. All authors are, therefore, responsible for the reported research and have approved the final article as submitted. The authors have no conflicts of interest to declare. Received September 30, 2018; accepted March 17, 2019. Address for correspondence: Yael Zaltz, Department of Communication Disorders, The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. E-mail: yaelzaltz@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Switching Streams Across Ears to Evaluate Informational Masking of Speech-on-Speech Objectives: This study aimed to evaluate the informational component of speech-on-speech masking. Speech perception in the presence of a competing talker involves not only informational masking (IM) but also a number of masking processes involving interaction of masker and target energy in the auditory periphery. Such peripherally generated masking can be eliminated by presenting the target and masker in opposite ears (dichotically). However, this also reduces IM by providing listeners with lateralization cues that support spatial release from masking (SRM). In tonal sequences, IM can be isolated by rapidly switching the lateralization of dichotic target and masker streams across the ears, presumably producing ambiguous spatial percepts that interfere with SRM. However, it is not clear whether this technique works with speech materials. Design: Speech reception thresholds (SRTs) were measured in 17 young normal-hearing adults for sentences produced by a female talker in the presence of a competing male talker under three different conditions: diotic (target and masker in both ears), dichotic, and dichotic but switching the target and masker streams across the ears. Because switching rate and signal coherence were expected to influence the amount of IM observed, these two factors varied across conditions. When switches occurred, they were either at word boundaries or periodically (every 116 msec) and either with or without a brief gap (84 msec) at every switch point. In addition, SRTs were measured in a quiet condition to rule out audibility as a limiting factor. Results: SRTs were poorer for the four switching dichotic conditions than for the nonswitching dichotic condition, but better than for the diotic condition. Periodic switches without gaps resulted in the worst SRTs compared to the other switch conditions, thus maximizing IM. Conclusions: These findings suggest that periodically switching the target and masker streams across the ears (without gaps) was the most efficient in disrupting SRM. Thus, this approach can be used in experiments that seek a relatively pure measure of IM, and could be readily extended to translational research. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and text of this article on the journal's Web site (www.ear-hearing.com). ACKNOWLEDGMENTS: The authors thank Rachel Ellinger and Andrea Cunningham for their help with data collection. This work was supported by NIH R01 DC 60014 grant awarded to P. S., and an iCARE ITN (FP7-607139) European fellowship to A. C. The authors have no conflict of interest to disclose. Received June 4, 2018; accepted March 17, 2019. Address for correspondence: Axelle Calcus, Ecole Normale Supérieure, 29 rue d'Ulm, 75005 Paris, France. E-mail: axelle.calcus@ens.fr Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Genetic Inheritance of Late-Onset, Down-Sloping Hearing Loss and Its Implications for Auditory Rehabilitation Objectives: Late-onset, down-sloping sensorineural hearing loss has many genetic and nongenetic etiologies, but the proportion of this commonly encountered type of hearing loss attributable to genetic causes is not well known. In this study, the authors performed genetic analysis using next-generation sequencing techniques in patients showing late-onset, down-sloping sensorineural hearing loss with preserved low-frequency hearing, and investigated the clinical implications of the variants identified. Design: From a cohort of patients with hearing loss at a tertiary referral hospital, 18 unrelated probands with down-sloping sensorineural hearing loss of late onset were included in this study. Down-sloping hearing loss was defined as a mean low-frequency threshold at 250 Hz and 500 Hz less than or equal to 40 dB HL and a mean high-frequency threshold at 1, 2, and 4 kHz greater than 40 dB HL. The authors performed whole-exome sequencing and segregation analysis to identify the genetic causes and evaluated the outcomes of auditory rehabilitation in the patients. Results: There were nine simplex and nine multiplex families included, in which the causative variants were found in six of 18 probands, demonstrating a detection rate of 33.3%. Various types of variants, including five novel and three known variants, were detected in the MYH14, MYH9, USH2A, COL11A2, and TMPRSS3 genes. The outcome of cochlear and middle ear implants in patients identified with pathogenic variants was satisfactory. There was no statistically significant difference between pathogenic variant-positive and pathogenic variant-negative groups in terms of onset age, family history of hearing loss, pure-tone threshold, or speech discrimination scores. Conclusions: The proportion of patients with late-onset, down-sloping hearing loss identified with potentially causative variants was unexpectedly high. Identification of the causative variants will offer insights on hearing loss progression and prognosis regarding various modes of auditory rehabilitation, as well as possible concomitant syndromic features. ACKNOWLEDGMENTS: This study was provided with bioresources from the National Biobank of Korea, Centers for Disease Control and Prevention, Republic of Korea (4845-301, 4851-302 and -307). This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning (2015R1A1A1A05001472 to S.M.H., 2017M3A9E8029714 to J.J.S., 2014M3A9D5A01073865 to C.J.Y., 2018R1A5A2025079 to H.Y.G.) M.H.S., J.J., H.Y.G., and J.Y.C. designed the study conception. J.J, J.H.R., H.J.C., and J.S.L. performed the experiment. M.H.S., J.J., H.J.L., and B.N. analyzed and interpreted the data. M.H.S., J.J., H.J.L., B.N., H.Y.G., and J.H.R. wrote the article. The authors have no conflicts of interest to disclose. Received July 25, 2018; accepted March 2, 2019. Address for correspondence: Jae Young Choi, Department of Otorhino laryngology, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, Seoul 120–752, Republic of Korea. E-mail: jychoi@yuhs.ac Address for correspondence: Heon Yung Gee, Department of Pharmacology and Brain Korea 21 Project for Medical Sciences, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, Seoul 120–752, Republic of Korea. E-mail: hygee@yuhs.ac Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Improving Clinical Outcomes in Cochlear Implantation Using Glucocorticoid Therapy: A Review Cochlear implant surgery is a successful procedure for auditory rehabilitation of patients with severe to profound hearing loss. However, cochlear implantation may lead to damage to the inner ear, which decreases residual hearing and alters vestibular function. It is now of increasing interest to preserve residual hearing during this surgery because this is related to better speech, music perception, and hearing in complex listening environments. Thus, different efforts have been tried to reduce cochlear implantation-related injury, including periprocedural glucocorticoids because of their anti-inflammatory properties. Different routes of administration have been tried to deliver glucocorticoids. However, several drawbacks still remain, including their systemic side effects, unknown pharmacokinetic profiles, and complex delivery methods. In the present review, we discuss the role of periprocedural glucocorticoid therapy to decrease cochlear implantation-related injury, thus preserving inner ear function after surgery. Moreover, we highlight the pharmacokinetic evidence and clinical outcomes which would sustain further interventions. ACKNOWLEDGMENTS: The authors have no conflicts of interest to disclose. Received October 8, 2018; accepted March 14, 2019. Address for correspondence: Cecilia Engmér Berglin, Department of Otorhinolaryngology, B53, Karolinska University Hospital, 141 86 Stockholm, Sweden. E-mail: cecilia.engmer-berglin@sll.se Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Effect of Hearing-Protection Devices on Auditory Situational Awareness and Listening Effort Objectives: Hearing-protection devices (HPDs) are made available, and often are required, for industrial use as well as military training exercises and operational duties. However, these devices often are disliked, and consequently not worn, in part because they compromise situational awareness through reduced sound detection and localization performance as well as degraded speech intelligibility. In this study, we carried out a series of tests, involving normal-hearing subjects and multiple background-noise conditions, designed to evaluate the performance of four HPDs in terms of their modifications of auditory-detection thresholds, sound-localization accuracy, and speech intelligibility. In addition, we assessed their impact on listening effort to understand how the additional effort required to perceive and process auditory signals while wearing an HPD reduces available cognitive resources for other tasks. Design: Thirteen normal-hearing subjects participated in a protocol, which included auditory tasks designed to measure detection and localization performance, speech intelligibility, and cognitive load. Each participant repeated the battery of tests with unoccluded ears and four hearing protectors, two active (electronic) and two passive. The tasks were performed both in quiet and in background noise. Results: Our findings indicate that, in variable degrees, all of the tested HPDs induce performance degradation on most of the conducted tasks as compared to the open ear. Of particular note in this study is the finding of increased cognitive load or listening effort, as measured by visual reaction time, for some hearing protectors during a dual-task, which added working-memory demands to the speech-intelligibility task. Conclusions: These results indicate that situational awareness can vary greatly across the spectrum of HPDs, and that listening effort is another aspect of performance that should be considered in future studies. The increased listening effort induced by hearing protectors may lead to earlier cognitive fatigue in noisy environments. Further study is required to characterize how auditory performance is limited by the combination of hearing impairment and the use of HPDs, and how the effects of such limitations can be linked to safe and effective use of hearing protection to maximize job performance. ACKNOWLEDGMENTS: This work is sponsored by the US Army Natick Soldier Research, Development, and Engineering Center under Air Force Contract FA8721-05-C-0002 and/or FA8702-15-D-0001. Any opinions, findings, conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the Department of the Army. Distribution Statement A: Approved for public release. Distribution is unlimited. C.J.S. designed and performed experiments, analyzed data, provided statistical analysis and wrote the article; P.T.C provided data analysis and wrote the article; A.P.D, J.P.P., T.P., and J.B. collected and analyzed data; T.F.Q. and M.M. provided contributions to conception of the work and critical editing; P.P.C provided editing and final approval of the version to be published. The authors have no conflicts of interest to disclose. Received June 4, 2018; accepted February 21, 2019. Address for correspondence: Bioengineering Systems and Technologies Group, MIT Lincoln Laboratory, 244 Wood St. Lexington, MA 02421, USA. E-mail: christopher.smalt@ll.mit.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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