Intramedullary fixation versus anatomically contoured plating of unstable ankle fractures: a randomized control trial.

AIM: This study compared functional outcomes between anatomical shaped fibular plates and intramedullary nail fixation of adult patients who sustained unstable ankle fractures. METHODS: A prospective randomized control trial was conducted between November 2013 and December 2016 on patients that presented with an unstable ankle fractures. They were randomized into a plate-and-screw group and a fibula nail group. At each post-operative visit the wounds were reviewed, and specific outcome measures were recorded, which included (i) the patient reported outcome measure (PROM) Olerud and Molander functional score, (ii) the Grimby score, (iii) swelling around the malleoli, (iv) plantar flexion, (v) dorsiflexion, (vi) inversion, and (vi) eversion. RESULTS: Significant differences were observed in scar size (p < 0.001) and screening time (p < 0.001) whilst no differences were observed in functional and PROM measures. Although not statistically significant, of clinical value is one deep infection that occurred in the plate group, whilst no infections occurred in the nail group. CONCLUSION: Both fixation methods yielded very similar functional results with differences only in scar size, screening time and swelling. Although none of these warrant a change in surgical decision-making processes, taken together, these factors potentially influence the decisions made in terms of surgical modalities used.

AAV-mediated gene transfer of a checkpoint inhibitor in combination with HER2-targeted CAR-NK cells as experimental therapy for glioblastoma.

Glioblastoma (GB) is the most common primary brain tumor, which is characterized by low immunogenicity of tumor cells and prevalent immunosuppression in the tumor microenvironment (TME). Targeted local combination immunotherapy is a promising strategy to overcome these obstacles. Here, we evaluated tumor-cell specific delivery of an anti-PD-1 immunoadhesin (aPD-1) via a targeted adeno-associated viral vector (AAV) as well as HER2-specific NK-92/5.28.z (anti-HER2.CAR/NK-92) cells as components for a combination immunotherapy. In co-culture experiments, target-activated anti-HER2.CAR/NK-92 cells modified surrounding tumor cells and bystander immune cells by triggering the release of inflammatory cytokines and upregulation of PD-L1. Tumor cell-specific delivery of aPD-1 was achieved by displaying a HER2-specific designed ankyrin repeat protein (DARPin) on the AAV surface. HER2-AAV mediated gene transfer into GB cells correlated with HER2 expression levels, without inducing anti-viral responses in transduced cells. Furthermore, AAV-transduction did not interfere with anti-HER2.CAR/NK-92 cell-mediated tumor cell lysis. After selective transduction of HER2+ cells, aPD-1 expression was detected at the mRNA and protein level. The aPD-1 immunoadhesin was secreted in a time-dependent manner, bound its target on PD-1-expressing cells and was able to re-activate T cells by efficiently disrupting the PD-1/PD-L1 axis. Moreover, high intratumoral and low systemic aPD-1 concentrations were achieved following local injection of HER2-AAV into orthotopic tumor grafts in vivo. aPD-1 was selectively produced in tumor tissue and could be detected up to 10 days after a single HER2-AAV injection. In subcutaneous GL261-HER2 and Tu2449-HER2 immunocompetent mouse models, administration of the combination therapy significantly prolonged survival, including complete tumor control in several animals in the GL261-HER2 model. In summary, local therapy with aPD-1 encoding HER2-AAVs in combination with anti-HER2.CAR/NK-92 cells may be a promising novel strategy for GB immunotherapy with the potential to enhance efficacy and reduce systemic side effects of immune-checkpoint inhibitors.

The incidence of fragility hip fractures in a subpopulation of South Africa.

BACKGROUND: Fragility hip fractures (FHFs) are associated with significant morbidity, mortality and burden on the healthcare system. European and North American literature suggests that the worldwide incidence of FHFs is increasing, but very little is known about the incidence of FHFs in Africa and South Africa (SA). Historically FHFs were believed to be uncommon in black African populations, but recent studies have shown a marked increase in the incidence compared with the early literature. OBJECTIVES: To investigate the age-, gender- and population group-specific incidences of FHFs in a subpopulation in Eastern Cape Province, SA. METHODS: A retrospective review of all patients presenting with FHFs was performed at a tertiary hospital in the Eastern Cape over a 1-year period. Age-, gender- and population group-specific incidence rates were calculated for 5-year age intervals using the age distribution data of the western region of the Eastern Cape (WREC) as a denominator for each age group. Overall crude incidence rates were calculated by using the sum total of FHFs, divided by the study population. All incidences were calculated as number of fractures per 100 000 people annually. RESULTS: A total of 253 patients with FHFs were included. The crude incidence rate of low-energy hip fractures in the WREC was 19.3 per 100 000 (males 14.6, females 23.4) over the study period. Population group-specific incidences were 15.1, 18.7, 19.9 and 46.6 per 100 000 for black, coloured, Indian and white population groups, respectively. The highest number of low-energy hip fractures in females occurred in the ≥85-year (19.6%) and 70 - 74-year (16.5%) age groups, with the highest number of male cases observed in the 60 - 64-year group (20.2%). The highest frequency distribution of FHFs was observed in black males aged 60 - 64 years (5.5%; n=14) and black females aged 70 - 74 years (6.3%; n=16). CONCLUSIONS: The local incidence of FHFs is higher than initially reported, but when compared with other countries remains on the lower end of spectrum. A large proportion of FHFs are occurring in young patients (<65 years). These findings warrant further investigation that may prompt the development of preventive strategies and optimal treatment programmes.

Prevalence of a postoperative troponin leak in patients with cardiac risk factors undergoing knee and hip arthroplasty in a South African population.

BACKGROUND: Patients undergoing arthroplasty may have comorbidities that put them at risk of myocardial injury after non-cardiac surgery (MINS). MINS, a new clinical concept that has a different pathophysiology from conventional myocardial infarction, is related to a supply-demand mismatch ischaemia in the perioperative setting. MINS is often a silent event, and the diagnosis relies on cardiac biomarker testing such as troponin T. The incidence is estimated at 40%, with a fourfold increase in morbidity and mortality risk 1 year post surgery. OBJECTIVES: To determine the prevalence of postoperative troponin leak in a single-centre arthroplasty unit in patients with various cardiac risk factors undergoing hip or knee arthroplasty and investigate the differences in troponin T levels between comorbidities and different types of arthroplasty, i.e. total hip replacement (THR), total knee replacement (TKR) and neck of femur (NoF) fracture hip replacement. METHODS: A prospective, cross-sectional study of patients with one or more cardiac risk factors undergoing replacement surgery was conducted from October 2017 to April 2018. Troponin levels of all included patients were recorded on days 1 and 3 post surgery using a high-sensitivity cardiac troponin T assay (Roche hs-cTnT). A level of >15 ng/L is considered abnormal and termed a positive troponin leak, while >100 ng/L is considered suspected acute coronary syndrome (ACS). RESULTS: One hundred and sixty patients (n=66 THR, n=55 NoF hip replacement, n=39 TKR) were included. Sixty-eight patients (42%) had a positive troponin leak, and in 6 of these cases ACS was suspected. The highest prevalence of troponin leak was recorded in patients undergoing NoF hip replacement (62%), followed by TKR (46%) and then THR (24%). Sixty-two patients (38%) had positive troponin levels on day 1 and 53 patients (33%) had positive levels on day 3. Important patient cardiac risk factors were identified in the presence of a positive troponin leak, with ischaemic heart disease, hypertension, diabetes, renal disease, age >65 years and atrial fibrillation being statistically most likely. CONCLUSIONS: Postoperative troponin surveillance is an inexpensive and reliable way to identify patients at risk of MINS and subsequently enhance early detection, medical optimisation and referral strategies. Simple interventions may improve outcomes and contribute to lower ACS rates and the timeous prevention of other complications. The prevalence of MINS in orthopaedic-specific patients in South Africa (SA) and other resource-constrained developing countries is unknown. Our finding of 42% positive troponin leaks raises awareness of this issue, and we recommend routine postoperative troponin surveillance for all arthroplasty units in SA.

Lost to follow-up: Challenges to conducting orthopaedic research in South Africa.

Loss to follow-up poses a major problem for clinicians and researchers, and several factors that may increase its risk have been postulated. The objective of this study was to describe potential factors that contribute to loss to follow-up as seen in orthopaedic patients participating in a research study and attending the sole public orthopaedic service provider in the Northern Cape Province of South Africa (SA). All patients who underwent ankle fracture surgery at Kimberley Provincial Hospital between January 2012 and July 2013 were included, and the number of follow-up visits attended by each participant was recorded prospectively. Demographic information pertaining to travel distance, social circumstances and comorbid conditions was captured and reviewed. A total of 268 patients (male n=112, 41.8% and female n=156, 58.2%) were included. The mean (standard deviation (SD)) age was 42.3 (13.8) years (95% confidence interval (CI) 40.6 - 43.9, n=266) and the mean body mass index (BMI, kg/m2) was 28.0 (6.5) (95% CI 27.2 - 28.8, n=251), the BMI for females being 30.2 (6.1) (95% CI 29.3 - 31.2, n=152) compared with 24.6 (5.7) (95% CI 23.4 - 25.7, n=99) for males. After excluding local patients living within 5 km of the hospital (n=77), the mean travel distance was 460 km (range 10 - 910). There was a significant association between the number of follow-up visits attended and travel distance (incidence rate ratio (IRR) 0.999, 95% CI 0.999 - 1.000; p=0.030), BMI (IRR 0.980, 95% CI 0.966 - 0.994; p=0.004) and HIV status (IRR 0.841, 95% CI 0.725 - 0.975; p=0.022). The main factors identified in this study that influenced the number of follow-up visits attended were travel distance, BMI and HIV status. BMI was a unique finding in our study. It was identified to be a significant contributing factor to the loss to follow-up. BMI was not a contributing factor in other studies.

Clinical determinants of biomechanics platform measures of balance in aged women.

The cross-sectional associations between clinical variables and biomechanics platform measures of balance (sway) were determined in a random sample of 50 aged single women living in high rise apartment buildings. A history of falling in the previous year was associated with increased areas of sway. Increased body mass was associated with decreased velocity of sway. Poor near, but not far, visual acuity was associated with increased areas of sway. A postural drop of 10 mmHg or more in diastolic pressure was associated with increased velocity of sway. The associations between these variables and the balance measures persisted after adjustment for age and each other to adjust for potential confounding. Slower hand reaction times and poor hearing were associated with increased areas of sway, but these associations were removed after adjustment for age and near visual acuity. There were no associations between any of the balance measures and postural changes in systolic pressure and heart rate. There were no associations between balance measures and base of support. The observed associations, if causal, can aid in development and testing of effective interventions to improve balance and prevent falls in the elderly.

Hearing impairment as a determinant of function in the elderly.

This clinical, practice-based study explores the research question: Is there a relationship between hearing loss and functional disturbance in elderly patients? We analyzed the impact of hearing impairment on 153 patients over 65 years of age screened in primary care practice. Functional and psychosocial impairment were measured using the Sickness Impact Profile (SIP), a standardized measure for assessing sickness related dysfunction. Hearing level was determined with pure tone audiometry. Multiple linear regression was used to adjust for patient case-mix differences and other clinical variables. After adjustment, a 10 dB increase in hearing loss was found to result in a 2.8 point increase in Physical SIP scores (95% confidence interval = 1.8-3.8), a 2.0 point increase in psychosocial SIP scores (95% confidence interval = 0.8-3.2) and a 1.3 point increase in overall SIP scores (95% confidence interval = 0.1-2.5). Poor hearing was associated with higher SIP scores and increased dysfunction. Thus, hearing impairment is an important determinant of function in the elderly.

Integrating substance abuse education in the medical student curriculum.

Physicians miss the diagnosis of substance abuse in significant numbers of patients, partly because of a lack of education about identifying and treating those patients. This article describes an attempt to integrate substance abuse into the curriculum of a traditionally organized medical school. Faculty selection, determination of the skills and knowledge needed, and methods for enriching the curriculum to include substance abuse are described. Problems encountered during the project, benefits of implementing the curriculum changes, and recommendations for other medical schools choosing to implement such a program also are provided.

Terminal care preferences: hospice placement and severity of disease.

National Hospice Study data for 1981-82 were used to predict the location of care for terminal cancer patients. Sites of care were conventional care in hospitals, hospital-based hospice care, and hospice care in the home. Subjects were terminal cancer patients with a prognosis of less than 6 months of life who were attended by a primary concerned person. There were 1,732 patients 18-99 years old-293 conventional care, 612 hospital-based hospice care, and 827 hospice home care patients. Data sources were the patient, the primary concerned person, the family, and the medical record. Data were obtained at initial interview for the study, 1-week followup, reassessment every 2 weeks, and bereavement interviews. Information was grouped in the following categories: patient functional status, patient psychological outlook, symptomatology, medical condition, and characteristics of the primary concerned person and family. Conclusions were reached by univariate and multivariate analysis. First, a progression of functional disability was found to exist among care sites, from hospice home care for the least disabled to hospital-based hospice care to conventional care for patients with the greatest disabilities. The location of care was best explained by the patient's functional capacity. Second, the location of care was found to be poorly explained by extent of organ involvement or specific symptoms. Third, the primary concerned persons of patients under hospice home care experienced more stress but reacted no differently when compared with primary concerned persons at other care sites. Fourth, patients under hospice home care survived the longest and reported greater family closeness than other care groups.

Effects of nifedipine GITS and atenolol monotherapy on serum lipids, blood pressure, heart rate, and weight in mild to moderate hypertension.

Forty-nine patients, with ages ranging from eighteen to seventy years and with mild to moderate primary hypertension (sitting diastolic blood pressure of greater than or equal to 95 mmgH and less than or equal to 115 mmHg) were randomized into a twenty-one-week, double-blind, prospective study to determine the effects of monotherapy of nifedipine GITS (gastrointestinal therapeutic system) versus atenolol on serum lipids, lipid subfractions, apolipoproteins, (apo), and blood pressure (BP). Nifedipine GITS and atenolol significantly reduced blood pressure, but nifedipine GITS reduced sitting and standing systolic BP significantly more than atenolol (p = .001). Sitting and standing heart rate decreased significantly (p = 0.001) during atenolol therapy but did not change significantly during nifedipine GITS therapy. Atenolol increased weight (mean change + 2.2 lb; p = 0.011), but nifedipine GITS decreased weight (mean change - 2.4 lb; p = 0.07). Nifedipine GITS had a more favorable effect on the lipid profile. High density lipoprotein cholesterol (HDL-C) and HDL2 subfractions were increased significantly (p = .001) as were apo A1 (p = 0.037) and apo A2 (p = 0.025). Nifedipine GITS increased HDL3 (NS), reduced triglycerides (TG) (NS), and had no significant effect on total cholesterol (TC) low density lipoprotein cholesterol (LDL-C) and apo B. Atenolol significantly increased serum total cholesterol (p = 0.039) and HDL-C and HDL2 (p = 0.049 and 0.048 respectively). Atenolol increased TG (NS) and apo B (NS) with little change in apo A1 and apo A2. It is concluded that nifedipine GITS had equal or better antihypertensive efficacy than atenolol and had a more favorable effect on the lipid profile. These effects may offer advantages in reducing CHD risk.

Deriving criteria for hearing impairment in the elderly: a functional approach.

We describe a method for deriving criteria for hearing impairment in the elderly based on self-reported handicap. Using the Sickness Impact Profile (SIP) and Hearing Handicap Inventory for the Elderly - Screening (HHIE-S) version as functional measures of handicap, the analysis proceeded in five steps: 1. Audiometric thresholds at various frequencies were inter-correlated. This was done both within and between ears. 2. Better and poorer ear thresholds were determined for each frequency, and these were correlated with the HHIE-S and SIP scores. 3. Using the HHIE-S and SIP scores as dependent variables, stepwise multiple linear regressions were used to select the frequencies that explained the most variance in the functional scales. 4. Using the HHIE-S and SIP as standards, receiver operating curves were constructed for each frequency to select the threshold level that provided the best test accuracy. 5. The newly-derived criteria were then compared against four other "traditional" criteria of hearing impairment. In general, the newly-derived criteria combined a relatively low frequency with a relatively high frequency, with the low frequency being functionally more important. Depending on the functional scale used, the threshold level was in the 25 to 35-dB range for the lower frequencies and 40 to 45-dB for the higher frequencies. These features provide a suitable compromise to the current debate over which threshold levels comprise the best discrimination of aged persons who are hearing-impaired. Future research should focus on developing consensus standards for functional hearing impairment and handicap in the elderly.

Nutritional effects of KT/V in children on peritoneal dialysis: are there benefits from larger dialysis doses?

Dialysis adequacy is monitored by urea kinetic modeling (UKM), in particular by calculation of KT/V (normalized whole body urea clearance) and PCRN (normalized protein catabolic rate). All children on peritoneal dialysis from our unit (7 children; mean age 7 years, 8 months) participated in our study (dialysis research program of the French Registry of Peritoneal Dialysis). Every month analysis of dialysate and urine collections and blood samples were compared to a 3-day diet survey to analyze the relations between doses of dialysis (KT/V) and nutrition [dietary protein intake (DPI) and caloric intake]. Calculated protein intake and DPI were also compared. Spearman correlation coefficients were used to assess the association between variables. KT/V values were spread over a wide range (0.8-2.8, mean 1.9). KT/V was positively (weakly) correlated to PCRN (p = 0.07, y = 0.24x + 1.08, r = 0.2), but not to DPI. No correlation could be found between PCRN and DPI, but doses of dialysis (KT/V) were positively correlated to caloric intake (p = 0.001, y = 28.97x + 13.66, r = 0.424). We assume that the correlation between KT/V and PCRN is not necessarily the reason, but only a calculation effect. On the contrary, the positive correlation between KT/V and caloric intake allows us to speculate that more efficient dialysis enhances appetite.

Adult age, information processing, and partial report performance.

Previous investigations using the partial report technique for examining adult age differences in iconic memory have suggested that older adults are less able to extract information stored in the icon than are young adults. The present study examined the hypothesis that poorer partial report performance on the part of older adults involves age-related differences in the speed of visual and auditory information processing. Elderly (M = 67 years) and young (M = 23.5 years) adults were contrasted on partial report, whole report, backward masking, and choice reaction time tasks. Results indicated that the older age group exhibited a smaller partial report advantage than did their younger counterparts. This age difference was found to be related in part to increases with age in the time required to encode and identify visual stimuli but was not related to the time required to translate auditory cues into recall instructions. In other words, the slowdown in visual information processing speed that accompanies increased age contributes to age differences in performance on tasks involving iconic memory.

PAX2 is an antiapoptotic molecule with deregulated expression in medulloblastoma.

PAX2 is a paired box transcription factor possessing a fundamental role in the embryogenesis of hindbrain and urinary tract. PAX genes are proto-oncogenes, PAX2 expression may contribute to the pathogenesis of renal cell carcinoma. Because of the expression of PAX2 in the developing hindbrain and its essential role in cerebellar development, it has been hypothesized that PAX2 may also be involved in medulloblastoma tumorigenesis. We investigated the expression pattern of PAX2 and various genes of the neuronal lineage in medulloblastoma and glioma cell lines. We found high expression of PAX2 mRNA and PAX2 protein in medulloblastoma cells and some glioma cell lines independent of their neuronal lineage gene expression signature. Gene suppression of PAX2 decreased the expression of the PAX2 transcriptional target GDNF in Daoy cells and had a profound cytotoxic effect in vitro on Daoy medulloblastoma and T98G glioma cells. Expression of PAX2 was then assessed in two separate medulloblastoma tissue microarrays with a total of 61 patient samples by immunohistochemistry. PAX2 expression was detected in the majority of medulloblastoma samples and correlated with less differentiated histology. Therefore, PAX2 is a biomarker for a more aggressive medulloblastoma phenotype and may represent a novel therapeutic target.

Aging, alcoholism, and performance on the Luria-Nebraska Neuropsychological Battery.

The Luria-Nebraska Neuropsychological Battery (LNNB) was used to test the hypothesis that alcoholism produces premature or accelerated aging. This hypothesis was tested by the interaction between age (in individuals ranging from 30 to 76 years of age) and alcoholism (nonalcoholics vs. alcoholics). No evidence was observed in support of the hypothesis. Additionally, the differences in LNNB performance found among age groups were different from those found between the alcoholics and nonalcoholics. This suggests that different mechanisms may be associated with age-related psychological deficits as compared with psychological dysfunction associated with alcoholism.

Central auditory processing in Alzheimer's disease.

OBJECTIVE: This investigation was designed to determine whether people in the early to middle phases of Alzheimer's disease (AD) show impaired central auditory processing as compared with nondemented elderly. DESIGN: A peripheral and central auditory test battery was administered to 10 subjects diagnosed with mild-to-moderate AD based on a neuropsychological test battery and radiographic techniques, and a control group of 10 subjects with no evidence of dementia, matched for age, gender, and average degree of hearing loss. Immittance audiometry, pure-tone and speech audiometry, and otoacoustic emissions were recorded in all subjects. Central auditory assessment included the synthetic sentence identification with ipsilateral competing message, dichotic digits, dichotic sentence identification, pitch patterns, and duration patterns. RESULTS: Peripheral auditory status was statistically similar between subject groups. Neither average high frequency hearing sensitivity nor mean speech recognition ability was significantly different. However, a significant difference was noted between groups for average low frequency hearing sensitivity in the left ear (p < 0.05). Subjects with AD showed slightly poorer low frequency thresholds versus matched controls. Based on analysis of performance on each measure of the central auditory test battery, the AD group scored significantly lower than the matched control group on four of the five measures utilized. Differences for right versus left ear performance were found among AD subjects. CONCLUSIONS: Overall patterns in findings cannot be easily explained as artifacts of cognitive decline. Results support screening for central auditory dysfunction in the AD population, since impaired processing could influence psychiatric assessment of cognitive deficit as well as audiologic management of peripheral hearing loss in this population.

Antecedent factors in urinary tract infections among nursing home patients.

By a retrospective relative risk analysis for conditions associated with urinary tract infection over a four-year period in a defined teaching nursing home population (n = 97), we reached the following conclusions: (1) UTI was associated with cerebrovascular accident (relative risk 2.2, 95% confidence interval 1.4 to 3.2), decreased activities of daily living (relative risk 2.6 to 3.2, 95% confidence interval 1.4 to 4.7), decreased mental status (relative risk 2.2, 95% confidence interval 1.2 to 3.1), urinary catheterization (relative risk 2.5, 95% confidence interval 1.3 to 3.7), and antibiotic prophylaxis (relative risk 2.1, 95% confidence interval 1.2 to 3.0). (2) Risk of UTI from urinary catheterization and antibiotic prophylaxis was additive for these functionally impaired patients. (3) Renal insufficiency, diabetes, anemia, malnutrition, age, and incontinence (without catheterization) were not related to risk of UTI.

Comparison of biomechanics platform measures of balance and videotaped measures of gait with a clinical mobility scale in elderly women.

Performance on the clinical mobility index developed by Tinetti (9) was compared with biomechanics platform measures of sway and videotaped measures of gait in a sample of 43 community-dwelling aged women. Area measures of sway, but not velocity, were associated with performance on the mobility index. When standing on one leg with eyes open, the correlation coefficients for radial area per second with the mobility indices ranged from -0.59 to -0.64 (p less than .001). Knee range of motion and stride length correlated with performance on the mobility index. Knee range of motion correlation coefficients ranged from 0.47 to 0.54 (p less than .001), whereas the range was 0.62 to 0.68 (p less than .001) for stride length. These data demonstrate that biomechanics platform measures of sway and videotaped measures of gait are associated with subject performance on a clinical mobility index and may themselves also be predictive of persons susceptible to falling.

Association of self-reported injury and alcohol consumption in medical outpatients.

OBJECTIVE: This study was designed to examine the association between minor injury and level of alcohol consumption among adult outpatients. DESIGN: Self-administered survey of alcohol use and level of injury in prior month. SETTING: Adult outpatients attending a university-based general internal medicine private practice. PATIENTS/PARTICIPANTS: During a four-month period, 1,011 patients aged 18-65 years were asked to complete questionnaires while waiting to see a physician. The 791 who completed all forms appropriately are included in this study. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The total number of drinks and the total number of injuries reported during the preceding month were calculated. Nondrinkers reported an average of 0.51 (SD = 1.18) injuries in the prior month; and drinkers, 0.92 (SD = 1.70) injuries. Minor injuries were reported more frequently by heavier alcohol consumers only among younger patients (RR = 1.88). There was no association between reported injury and alcohol consumption among patients over 50 years of age (RR = 0.90). CONCLUSIONS: Minor injury is associated with heavier alcohol consumption in younger patients attending a general medical practice, but not among older patients. Further research is needed to establish a causal relationship between alcohol drinking and minor injury.

Comparing criteria of hearing impairment in the elderly: a functional approach.

We determined and compared the associations of four commonly used audiometric criteria of hearing impairment with two functional outcome measures in 152 aged persons screened in primary care medicine practices. The outcome measures were the Sickness Impact Profile (SIP, a measure of global function), and the Hearing Handicap Inventory for the Elderly-Screening Version (HHIE-S, a communication-specific measure of functional impairment). There were five main findings. (1) The four criteria of hearing loss were not independent. (2) The criterion of loss chosen depends on the functional measure of impairment. (3) Functional hearing impairment may also be classified by the number of criteria met. (4) A large subset (21%) of aged persons met one criterion but had little in the way of communicative or global dysfunction. (5) Hearing handicap as measured by the HHIE-S was directly associated with global dysfunction as measured by the SIP.