Monitoring Cochlear Health With Intracochlear Electrocochleography During Cochlear Implantation: Findings From an International Clinical Investigation.

OBJECTIVES: Electrocochleography (ECochG) is emerging as a tool for monitoring cochlear function during cochlear implant (CI) surgery. ECochG may be recorded directly from electrodes on the implant array intraoperatively. For low-frequency stimulation, its amplitude tends to rise or may plateau as the electrode is inserted. The aim of this study was to explore whether compromise of the ECochG signal, defined as a fall in its amplitude of 30% or more during insertion, whether transient or permanent, is associated with poorer postoperative acoustic hearing, and to examine how preoperative hearing levels may influence the ability to record ECochG. The specific hypotheses tested were threefold: (a) deterioration in the pure-tone average of low-frequency hearing at the first postoperative follow-up interval (follow-up visit 1 [FUV1], 4 to 6 weeks) will be associated with compromise of the cochlear microphonic (CM) amplitude during electrode insertion (primary hypothesis); (b) an association is observed at the second postoperative follow-up interval (FUV2, 3 months) (secondary hypothesis 1); and (c) the CM response will be recorded earlier during electrode array insertion when the preoperative high-frequency hearing is better (secondary hypothesis 2). DESIGN: International, multi-site prospective, observational, between groups design, targeting 41 adult participants in each of two groups, (compromised CM versus preserved CM). Adult CI candidates who were scheduled to receive a Cochlear Nucleus CI with a Slim Straight or a Slim Modiolar electrode array and had a preoperative audiometric low-frequency average thresholds of ≤80 dB HL at 500, 750, and 1000 Hz in the ear to be implanted, were recruited from eight international implant sites. Pure tone audiometry was measured preoperatively and at postoperative visits (FUV1 and follow-up visit 2 [FUV2]). ECochG was measured during and immediately after the implantation of the array. RESULTS: From a total of 78 enrolled individuals (80 ears), 77 participants (79 ears) underwent surgery. Due to protocol deviations, 18 ears (23%) were excluded. Of the 61 ears with ECochG responses, amplitudes were < 1 µV throughout implantation for 18 ears (23%) and deemed "unclear" for classification. EcochG responses >1 µV in 43 ears (55%) were stable throughout implantation for 8 ears and compromised in 35 ears. For the primary endpoint at FUV1, 7/41 ears (17%) with preserved CM had a median hearing loss of 12.6 dB versus 34/41 ears (83%) with compromised CM and a median hearing loss of 26.9 dB ( p < 0.014). In assessing the practicalities of measuring intraoperative ECochG, the presence of a measurable CM (>1 µV) during implantation was dependent on preoperative, low-frequency thresholds, particularly at the stimulus frequency (0.5 kHz). High-frequency, preoperative thresholds were also associated with a measurable CM > 1 µV during surgery. CONCLUSIONS: Our data shows that CM drops occurring during electrode insertion were correlated with significantly poorer hearing preservation postoperatively compared to CMs that remained stable throughout the electrode insertion. The practicality of measuring ECochG in a large cohort is discussed, regarding the suggested optimal preoperative low-frequency hearing levels ( < 80 dB HL) considered necessary to obtain a CM signal >1 µV.

Factors Contributing to Delays to Accessing Appendectomy in Low- and Middle-Income Countries: A Scoping Review.

BACKGROUND: Appendicitis is one of the most common emergency surgical conditions worldwide. Delays in accessing appendectomy can lead to complications. Evidence on these delays in low- and middle-income countries (LMICs) is lacking. The aim of this review was to identify and synthesise the available evidence on delays to accessing appendectomy in LMICs. METHODS: This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews framework. The delays and their interconnectivity in LMICs were synthesised and interpreted using the Three Delays framework. We reviewed Africa Wide EBSCOhost, PubMed-Medline, Scopus, Web of Science, African Journals Online (AJOL), and Bioline databases. RESULTS: Our search identified 21 893 studies, of which 78 were included in the final analysis. All of the studies were quantitative. Fifty per cent of the studies included all three types of delays. Delays in seeking care were influenced by a lack of awareness of appendicitis symptoms, and the use of self and alternative medication, which could be linked to delays in receiving care, and the barrier refusal of medical treatment due to fear. Financial concerns were a barrier observed throughout the care pathway. CONCLUSION: This review highlighted the need for additional studies on delays to accessing appendectomy in additional LMICs. Our review demonstrates that in LMICs, persons seeking appendectomy present late to health-care facilities due to several patient-related factors. After reaching a health-care facility, accessing appendectomy can further be delayed owing to a lack of adequate hospital resources.

Access to health care for people with stroke in South Africa: a qualitative study of community perspectives.

BACKGROUND: Incidence of stroke is increasing in sub-Saharan Africa. People who survive stroke experience disability and require long-term care. Health systems in South Africa (SA) are experiencing important challenges, and services in the public health system for people with stroke (PWS) are fragmented. We aimed to explore the perspectives and experiences of PWS related to stroke care services to inform health system strengthening measures. METHODS: In-depth interviews with 16 PWS in urban and rural areas in the Western and Eastern Cape Provinces of SA were conducted between August and October 2020. PWS were recruited through existing research networks, non-government organisations and organisations of persons with disabilities by snowball sampling. Interviews were transcribed, coded, and thematically analysed. We used the conceptual framework of access to health care as proposed by Levesque et al. to map and inform barriers to accessing health care from the user perspective. RESULTS: PWS recognised the need for health care when they experienced signs of acute stroke. Health literacy on determinants of stroke was low. Challenges to accessing stroke care include complex pathways to care, physical mobility related to stroke, long travel distances and limited transport options, waiting times and out of pocket expenses. The perceived quality of services was influenced by cultural beliefs, attitudinal barriers, and information challenges. Some PWS experienced excellent care and others particularly poor care. Positive staff attitude, perceived competence and trustworthiness went in hand with many technical and interpersonal deficits, such as long waiting times and poor staff attitude that resulted in poor satisfaction and reportedly poor outcomes for PWS. CONCLUSIONS: Strategic leadership, governance and better resources at multiple levels are required to address the unmet demands and needs for health care of PWS. Stroke care could be strengthened by service providers routinely providing information about prevention and symptoms of stroke, treatment, and services to patients and their social support network. The role of family members in continuity of care could be strengthened by raising awareness of existing resources and referral pathways, and facilitating connections within services.

Effect of Cochlear Implantation on Quality of Life in Adults with Unilateral Hearing Loss.

OBJECTIVE: Patients with moderate-to-profound sensorineural hearing loss in 1 ear and normal hearing in the contralateral ear, known as unilateral hearing loss (UHL) or single-sided deafness (SSD), may experience improved quality of life with the use of a cochlear implant (CI) in the affected ear. Quality of life assessment before and after implantation may reveal changes to aspects of hearing beyond those explicitly evaluated with behavioral measures. METHODS: The present report completed 2 experiments investigating quality of life outcomes in CI recipients with UHL. The first experiment assessed quality of life during the 1st year of device use with 3 questionnaires: the Speech, Spatial, and Qualities of Hearing Scale (SSQ), the Abbreviated Profile of Hearing Aid Benefit (APHAB), and the Tinnitus Handicap Inventory. Twenty subjects were evaluated preoperatively and 1, 3, 6, 9, and 12 months post-activation. Quality of life results were compared over the study period using traditional scoring methods and the SSQ pragmatic subscales. Subscales specific to localization and speech perception in noise were compared to behavioral measures at the preoperative and 12-month intervals. The 2nd experiment evaluated quality of life preoperatively and at the 12-month interval for CI recipients with UHL and CI recipients with bilateral hearing loss, including conventional CI users and those listening with electric-acoustic stimulation (EAS). The 3 cohorts differed in CI candidacy criteria, including the amount of residual hearing in the contralateral ear. RESULTS: For subjects with moderate-to-profound UHL, receipt of a CI significantly improved quality of life, with benefits noted as early as 1 month after initial activation. The UHL cohort reported less perceived difficulty at the pre- and postoperative intervals than the conventional CI and EAS cohorts, which may be due to the presence of the normal-hearing ear. Each group experienced a significant benefit in quality of life on the APHAB with CI use. CONCLUSIONS: Cochlear implantation in cases of substantial UHL may offer significant improvements in quality of life. Quality of life measures revealed a reduction in perceived tinnitus severity and subjective improvements in speech perception in noise, spatial hearing, and listening effort. While self-report of difficulties were lower for the UHL cohort than the conventional CI and EAS cohorts, subjects in all 3 groups reported an improvement in quality of life with CI use.

Cochlear Implantation in Cases of Unilateral Hearing Loss: Initial Localization Abilities.

OBJECTIVES: The present study evaluated early auditory localization abilities of cochlear implant (CI) recipients with normal or near-normal hearing (NH) in the contralateral ear. The goal of the study was to better understand the effect of CI listening experience on localization in this population. DESIGN: Twenty participants with unilateral hearing loss enrolled in a prospective clinical trial assessing outcomes of cochlear implantation (ClinicalTrials.gov Identifier: NCT02203305). All participants received the MED-EL Standard electrode array, were fit with an ear-level audio processor, and listened with the FS4 coding strategy. Localization was assessed in the sound field using an 11-speaker array with speakers uniformly positioned on a horizontal, semicircular frame. Stimuli were 200-msec speech-shaped noise bursts. The intensity level (52, 62, and 72 dB SPL) and sound source were randomly interleaved across trials. Participants were tested preoperatively, and 1, 3, and 6 months after activation of the audio processor. Performance was evaluated in two conditions at each interval: (1) unaided (NH ear alone [NH-alone] condition), and (2) aided, with either a bone conduction hearing aid (preoperative interval; bone conduction hearing aid + NH condition) or a CI (postoperative intervals; CI + NH condition). Performance was evaluated by comparing root-mean-squared (RMS) error between listening conditions and between measurement intervals. RESULTS: Mean RMS error for the soft, medium, and loud levels were 66°, 64°, and 69° in the NH-alone condition and 72°, 66°, and 70° in the bone conduction hearing aid + NH condition. Participants experienced a significant improvement in localization in the CI + NH condition at the 1-month interval (38°, 35°, and 38°) as compared with the preoperative NH-alone condition. Localization in the CI + NH condition continued to improve through the 6-month interval. Mean RMS errors were 28°, 25°, and 28° in the CI + NH condition at the 6-month interval. CONCLUSIONS: Adult CI recipients with normal or near-normal hearing in the contralateral ear experienced significant improvement in localization after 1 month of device use, and continued to improve through the 6-month interval. The present results show that binaural acclimatization in CI users with unilateral hearing loss can progress rapidly, with marked improvements in performance observed after only 1 month of listening experience.

Evaluating a novel patient pathway to manage symptomatic breast referrals (the blue flag clinic): a longitudinal observational study.

INTRODUCTION: A novel referral pathway for exhibited breast symptom (EBS) referrals to manage increasing referrals of urgent suspected cancer (USC) was implemented in our trust. We report on the safety and effect on compliance with the 2-week-wait rule (2WW). METHODS: A single-centre longitudinal observational study included all patients referred to a UK breast unit during 13 May 2019 to 27 March 2020 (period 1) and 8 February 2021 to 31 January 2022 (period 2). USC referrals were assessed in a one-stop clinic (red flag clinic [RFC]); EBS referrals were assessed in a new clinic in which clinical evaluation was performed and imaging occurred subsequently (blue flag clinic [BFC]). Patients were followed up to determine the symptomatic interval cancer rate. RESULTS: There were 9,695 referrals; 1,655 referrals (17%) were assessed in the BFC after 63 exclusions. Some 95.9% of patients had a benign clinical examination (P1/P2), 80.1% had imaging (mammogram or ultrasound) and 4% had a tissue biopsy. In total, 16/1,655 (0.97%) BFC patients and 510/7,977 (8.2%) RFC patients were diagnosed with breast cancer (breast cancer detection rate). Some 1,631 patients (with 1,639 referrals) were discharged and followed up for a median of 17 months (interquartile range 12-32) with one subsequent cancer diagnosis (symptomatic interval cancer rate, 0.06%). Implementation of the BFC pathway increased 3-month average trust performance of USC referrals with 2WW standard from 8.5% to 98.7% (period 1) and from 30% to 66% (period 2). CONCLUSIONS: The BFC pathway for EBS patients is safe and implementation led to improvement against the 2WW target for USC referrals, ensuring resources are prioritised to patients with the highest likelihood of breast cancer.

Randomized clinical trial on the effect of fibrin sealant on latissimus dorsi donor-site seroma formation after breast reconstruction.

BACKGROUND: Latissimus dorsi (LD) flap procedures comprise 50 per cent of breast reconstructions in the UK. They are frequently complicated by seroma formation. Fibrin sealants may reduce seroma volumes at the donor site. The aim was to investigate the effect of fibrin sealant (Tisseel(®)) on total seroma volumes from the breast, axilla and back (donor site) after LD breast reconstruction. Secondary outcomes were specific back seroma volumes together with incidence and severity of wound complications. METHODS: Consecutive women undergoing implant-assisted or extended autologous LD flap reconstruction were randomized to either standard care or application of fibrin sealant to the donor-site chest wall. All participants were blinded for the study duration but assessors were only partially blinded. Non-parametric methods were used for analysis. RESULTS: A total of 107 women were included (sealant 54, control 53). Overall back seroma volumes were high, with no significant differences between control and sealant groups over 3 months. Fibrin sealant failed to reduce in situ back drainage volumes in the 10 days after surgery, and did not affect the rate or volume of seromas following drain removal. CONCLUSION: This randomized study, which was powered for size effect, failed to show any benefit from fibrin sealant in minimizing back seromas after LD procedures.

Sound Opportunities: Factors That Impact Referral for Pediatric Cochlear Implant Evaluation.

OBJECTIVES/HYPOTHESIS: To identify barriers to and opportunities for referral among children who could be considered for cochlear implantation. STUDY DESIGN: Retrospective review. METHODS: Audiological and medical records were reviewed on all children who had diagnostic or hearing aid care through a statewide healthcare system over 5-year span to identify children who met newly established clinical cochlear implant (CI) referral criteria. Data were collected for 869 potential CI candidates regarding demographic, socio-economic, audiological, medical, and family factors that may influence referral. A binomial logistic regression was completed to investigate the potential contributions of these predictors toward referral for a CI evaluation. RESULTS: Children who met traditional candidacy criteria of severe-to-profound bilateral hearing loss were referred at very high rates, while nontraditional candidates were referred less frequently. Factors influencing referral included race, age, insurance source, hearing thresholds, audiologist, physician, and family request. CONCLUSIONS: Results suggest that bilateral traditional candidates are being referred at high percentages; however, current practices and trends in pediatric cochlear implantation should be shared with families and providers to increase referral rates for nontraditional candidates. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2904-E2910, 2021.

Long-Term Influence of Electrode Array Length on Speech Recognition in Cochlear Implant Users.

OBJECTIVES/HYPOTHESIS: Results from a prospective trial demonstrated better speech recognition for cochlear implant (CI) recipients implanted with a long lateral wall electrode array compared to subjects with a short array after 1 year of listening experience. As short array recipients may require an extended adaptation period, this study investigated whether differences in speech recognition continued through 4 years of CI use. STUDY DESIGN: Long-term follow-up of a prospective randomized trial. METHODS: Subjects were randomized to receive a MED-EL medium (24 mm) or standard (31.5 mm) array. Linear mixed models compared speech recognition between cohorts with word recognition in quiet and sentence recognition in noise at 1, 3, 6, 12, 24, and 48 months postactivation. Postoperative imaging and electric frequency filters were reviewed to assess the influence of frequency-to-place mismatch and angular separation between neighboring contacts, a metric associated with peripheral spectral selectivity. RESULTS: Long (31.5 mm) array recipients demonstrated superior speech recognition out to 4 years postactivation. There was a significant effect of angular separation between contacts, with more closely spaced contacts associated with poorer speech recognition. There was no significant effect of mismatch, yet this may have been obscured by changes in frequency filters over time. CONCLUSIONS: Conventional MED-EL CI recipients implanted with 31.5-mm arrays experience better speech recognition than 24-mm array recipients, initially and with long-term listening experience. The benefit conferred by longer arrays in the present cohort can be partially attributed to more widely spaced electrode contacts, presumably a result of reduced channel interaction. LEVEL OF EVIDENCE: 2 Laryngoscope, 131:892-897, 2021.

Speech Recognition as a Function of Age and Listening Experience in Adult Cochlear Implant Users.

OBJECTIVES/HYPOTHESIS: Speech recognition with a cochlear implant (CI) tends to be better for younger adults than older adults. However, older adults may take longer to reach asymptotic performance than younger adults. The present study aimed to characterize speech recognition as a function of age at implantation and listening experience for adult CI users. STUDY DESIGN: Retrospective review. METHODS: A retrospective review identified 352 adult CI recipients (387 ears) with at least 5 years of device listening experience. Speech recognition, as measured with consonant-nucleus-consonant (CNC) words in quiet and AzBio sentences in a 10-talker noise masker (10 dB signal-to-noise ratio), was reviewed at 1, 5, and 10 years postactivation. RESULTS: Speech recognition was better in younger listeners, and performance was stable or continued to improve through 10 years of CI listening experience. There was no indication of differences in acclimatization as a function of age at implantation. For the better performing CI recipients, an effect of age at implantation was more apparent for sentence recognition in noise than for word recognition in quiet. CONCLUSIONS: Adult CI recipients across the age range examined here experience speech recognition benefit with a CI. However, older adults perform more poorly than young adults for speech recognition in quiet and noise, with similar age effects through 5 to 10 years of listening experience. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2106-2111, 2021.

Hearing Preservation and Speech Outcomes After Cochlear Implantation in Meniere's Disease.

OBJECTIVES/HYPOTHESIS: To evaluate speech perception outcomes and hearing preservation after cochlear implantation in patients with Meniere's disease (MD). STUDY DESIGN: Retrospective chart review. METHODS: Fifty-one adult patients, accounting for a total of 63 implants, with MD treated at a tertiary care center were included in the study. Patients with unaided preoperative air-conduction thresholds ≤80 dB at 250 Hz were included in hearing preservation analyses. The primary outcome measure was Consonant-Nucleus-Consonant (CNC) score. Hearing preservation was assessed as follows: 1) maintenance of functional hearing, defined as a postoperative unaided air-conduction threshold ≤80 dB at 250 Hz and 2) low-frequency pure-tone average (LFPTA) shift. RESULTS: Speech perception scores improved significantly postimplantation; specifically, the CNC mean score was 9% preoperatively and increased to 57% by 1 year postoperatively (P < .001). Eighteen ears were included in hearing preservation analysis; the mean preoperative LFPTA was 65 dB (standard deviation [SD] = 10). The mean postoperative LFPTA at activation was 93 dB (SD = 21), and at 1 year was 102 dB (SD = 11). Twenty-seven percent of patients achieved short-term functional hearing preservation, whereas the longer-term outcomes were less favorable (11%). CONCLUSIONS: Speech perception scores improve after implantation in patients with MD. Hearing preservation is possible in patients with MD, albeit at lower rates than reported non-MD populations. Our data suggest that there can be degradation in acoustic hearing over time. LEVEL OF EVIDENCE: 4 Laryngoscope, 2019.

Low-Frequency Hearing Preservation With Long Electrode Arrays: Inclusion of Unaided Hearing Threshold Assessment in the Postoperative Test Battery.

Purpose The goal of this work was to evaluate the low-frequency hearing preservation of long electrode array cochlear implant (CI) recipients. Method Twenty-five participants presented with an unaided hearing threshold of ≤ 80 dB HL at 125 Hz pre-operatively in the ear to be implanted. Participants were implanted with a long (31.5-mm) electrode array. The unaided hearing threshold at 125 Hz was compared between the preoperative and postoperative intervals (i.e., initial CI activation, and 1, 3, 6, 9, and 12 months after activation). Results Eight participants maintained an unaided hearing threshold of ≤ 80 dB HL at 125 Hz postoperatively. The majority (n = 5) demonstrated aidable low-frequency hearing at initial activation, whereas 3 other participants experienced an improvement in unaided low-frequency hearing thresholds at subsequent intervals. Conclusions CI recipients can retain residual hearing sensitivity with fully inserted long electrode arrays, and low-frequency hearing thresholds may improve during the postoperative period. Therefore, unaided hearing thresholds obtained within the initial weeks after surgery may not reflect later hearing sensitivity. Routine measurement of postoperative unaided hearing thresholds-even for patients who did not demonstrate aidable hearing thresholds initially after cochlear implantation-will identify CI recipients who may benefit from electric-acoustic stimulation. Supplemental Material https://doi.org/10.23641/asha.11356637.

Subjective Benefits of Bimodal Listening in Cochlear Implant Recipients with Asymmetric Hearing Loss.

OBJECTIVE: To investigate the influence of cochlear implant (CI) use on subjective benefits in quality of life in cases of asymmetric hearing loss (AHL). STUDY DESIGN: Prospective clinical trial. SETTING: Tertiary academic center. SUBJECTS AND METHODS: Subjects included CI recipients with AHL (n = 20), defined as moderate-to-profound hearing loss in the affected ear and mild-to-moderate hearing loss in the contralateral ear. Quality of life was assessed with the Speech, Spatial, and Qualities of Hearing Scale (SSQ) pragmatic subscales, which assess binaural benefits. Subjective benefit on the pragmatic subscales was compared to word recognition in quiet and spatial hearing abilities (ie, masked sentence recognition and localization). RESULTS: Subjects demonstrated an early, significant improvement (P < .01) in abilities with the CI as compared to preoperative abilities on the SSQ pragmatic subscales by the 1-month interval. Perceived abilities were either maintained or continued to improve over the study period. There were no significant correlations between results on the Speech in Quiet subscale and word recognition in quiet, the Speech in Speech Contexts subscale and masked sentence recognition, or the Localization subscale and sound field localization. CONCLUSIONS: CI recipients with AHL report a significant improvement in quality of life as measured by the SSQ pragmatic subscales over preoperative abilities. Reported improvements are observed as early as 1 month postactivation, which likely reflect the binaural benefits of listening with bimodal stimulation (CI and contralateral hearing aid). The SSQ pragmatic subscales may provide a more in-depth insight into CI recipient experience as compared to behavioral sound field measures alone.

Cochlear Implantation in Cases of Asymmetric Hearing Loss: Subjective Benefit, Word Recognition, and Spatial Hearing.

A prospective clinical trial evaluated the effectiveness of cochlear implantation in adults with asymmetric hearing loss (AHL). Twenty subjects with mild-to-moderate hearing loss in the better ear and moderate-to-profound hearing loss in the poorer ear underwent cochlear implantation of the poorer hearing ear. Subjects were evaluated preoperatively and at 1, 3, 6, 9, and 12 months post-activation. Preoperative performance was evaluated unaided, with traditional hearing aids (HAs) or with a bone-conduction HA. Post-activation performance was evaluated with the cochlear implant (CI) alone or in combination with a contralateral HA (bimodal). Test measures included subjective benefit, word recognition, and spatial hearing (i.e., localization and masked sentence recognition). Significant subjective benefit was reported as early as the 1-month interval, indicating better performance with the CI compared with the preferred preoperative condition. Aided word recognition with the CI alone was significantly improved at the 1-month interval compared with preoperative performance with an HA and continued to improve through the 12-month interval. Subjects demonstrated early, significant improvements in the bimodal condition on the spatial hearing tasks compared with baseline preoperative performance tested unaided. The magnitude of the benefit was reduced for subjects with AHL when compared with published data on CI users with normal hearing in the contralateral ear; this finding may reflect significant differences in age at implantation and hearing sensitivity across cohorts.

Low-Frequency Pitch Perception in Cochlear Implant Recipients With Normal Hearing in the Contralateral Ear.

Purpose Three experiments were carried out to evaluate the low-frequency pitch perception of adults with unilateral hearing loss who received a cochlear implant (CI). Method Participants were recruited from a cohort of CI users with unilateral hearing loss and normal hearing in the contralateral ear. First, low-frequency pitch perception was assessed for the 5 most apical electrodes at 1, 3, 6, and 12 months after CI activation using an adaptive pitch-matching task. Participants listened with a coding strategy that presents low-frequency temporal fine structure (TFS) and compared the pitch to that of an acoustic target presented to the normal hearing ear. Next, participants listened with an envelope-only, continuous interleaved sampling strategy. Pitch perception was compared between coding strategies to assess the influence of TFS cues on low-frequency pitch perception. Finally, participants completed a vocal pitch-matching task to corroborate the results obtained with the adaptive pitch-matching task. Results Pitch matches roughly corresponded to electrode center frequencies (CFs) in the CI map. Adaptive pitch matches exceeded the CF for the most apical electrode, an effect that was larger for continuous interleaved sampling than TFS. Vocal pitch matches were variable but correlated with the CF of the 3 most apical electrodes. There was no evidence that pitch matches changed between the 1- and 12-month intervals. Conclusions Relatively accurate and asymptotic pitch perception was observed at the 1-month interval, indicating either very rapid acclimatization or the provision of familiar place and rate cues. Early availability of appropriate pitch cues could have played a role in the early improvements in localization and masked speech recognition previously observed in this cohort. Supplemental Material https://doi.org/10.23641/asha.8862389.

Electric-Acoustic Stimulation After Reimplantation: Hearing Preservation and Speech Perception.

OBJECTIVE: Hearing preservation after cochlear implantation allows for fitting of acoustic and cochlear implant technologies in the same ear, known as Electric-Acoustic Stimulation (EAS). Cochlear implant recipients with EAS who experience an internal device failure face the additional risk of residual hearing loss during reimplantation. This report reviews the case of an EAS recipient with long-term hearing preservation and significant benefit who experienced a device failure and underwent cochlear reimplantation. PATIENT: Case study who presented with an internal device failure after nearly 10 years of hearing preservation and significant benefit with an EAS device. INTERVENTION: Reimplantation with hearing preservation electrode array. MAIN OUTCOME MEASURES: Unaided residual hearing and aided speech perception with an EAS device using CNC words in quiet and CUNY sentences in noise. RESULTS: Low-frequency thresholds were similar when comparing residual hearing pre- and post-reimplantation. The patient does not use the acoustic portion of the EAS device due to normal low-frequency hearing sensitivity-even after two cochlear implantation procedures. At the 3-month follow-up interval, the patient demonstrated restoration of aided speech perception performance with the EAS device. CONCLUSIONS: Hearing preservation can be maintained with long-term use of EAS devices. Those with preserved low-frequency hearing who experience a device failure may maintain hearing preservation after reimplantation. Normal low-frequency hearing thresholds were maintained in the present case, and the patient continued to listen with the EAS device without the acoustic component. EAS recipients may experience rapid restoration in speech perception after reimplantation in the presence of hearing preservation.

Building capacity for antiretroviral delivery in South Africa: a qualitative evaluation of the PALSA PLUS nurse training programme.

BACKGROUND: South Africa recently launched a national antiretroviral treatment programme. This has created an urgent need for nurse-training in antiretroviral treatment (ART) delivery. The PALSA PLUS programme provides guidelines and training for primary health care (PHC) nurses in the management of adult lung diseases and HIV/AIDS, including ART. A process evaluation was undertaken to document the training, explore perceptions regarding the value of the training, and compare the PALSA PLUS training approach (used at intervention sites) with the provincial training model. The evaluation was conducted alongside a randomized controlled trial measuring the effects of the PALSA PLUS nurse-training (Trial reference number ISRCTN24820584). METHODS: Qualitative methods were utilized, including participant observation of training sessions, focus group discussions and interviews. Data were analyzed thematically. RESULTS: Nurse uptake of PALSA PLUS training, with regard not only to ART specific components but also lung health, was high. The ongoing on-site training of all PHC nurses, as opposed to the once-off centralized training provided for ART nurses only at non-intervention clinics, enhanced nurses' experience of support for their work by allowing, not only for ongoing experiential learning, supervision and emotional support, but also for the ongoing managerial review of all those infrastructural and system-level changes required to facilitate health provider behaviour change and guideline implementation. The training of all PHC nurses in PALSA PLUS guideline use, as opposed to ART nurses only, was also perceived to better facilitate the integration of AIDS care within the clinic context. CONCLUSION: PALSA PLUS training successfully engaged all PHC nurses in a comprehensive approach to a range of illnesses affecting both HIV positive and negative patients. PHC nurse-training for integrated systems-based interventions should be prioritized on the ART funding agenda. Training for individual provider behaviour change is nonetheless only one aspect of the ongoing system-wide interventions required to effect lasting improvements in patient care in the context of an over-burdened and under-resourced PHC system.

Effects of Cochlear Implantation on Binaural Hearing in Adults With Unilateral Hearing Loss.

A FDA clinical trial was carried out to evaluate the potential benefit of cochlear implant (CI) use for adults with unilateral moderate-to-profound sensorineural hearing loss. Subjects were 20 adults with moderate-to-profound unilateral sensorineural hearing loss and normal or near-normal hearing on the other side. A MED-EL standard electrode was implanted in the impaired ear. Outcome measures included: (a) sound localization on the horizontal plane (11 positions, -90° to 90°), (b) word recognition in quiet with the CI alone, and (c) masked sentence recognition with the target at 0° and the masker at -90°, 0°, or 90°. This battery was completed preoperatively and at 1, 3, 6, 9, and 12 months after CI activation. Normative data were also collected for 20 age-matched control subjects with normal or near-normal hearing bilaterally. The CI improved localization accuracy and reduced side bias. Word recognition with the CI alone was similar to performance of traditional CI recipients. The CI improved masked sentence recognition when the masker was presented from the front or from the side of normal or near-normal hearing. The binaural benefits observed with the CI increased between the 1- and 3-month intervals but appeared stable thereafter. In contrast to previous reports on localization and speech perception in patients with unilateral sensorineural hearing loss, CI benefits were consistently observed across individual subjects, and performance was at asymptote by the 3-month test interval. Cochlear implant settings, consistent CI use, and short duration of deafness could play a role in this result.

Time to go wireless? A 15-year single institution experience of radioisotope occult lesion localisation (ROLL) for impalpable breast lesions.

INTRODUCTION: Wire guided localisation (WGL) is the standard localisation technique for impalpable breast lesions. Radio-guided occult lesion localisation (ROLL) has been proposed as an alternative. We have been performing ROLL for therapeutic wide local excisions (WLE) and diagnostic excision biopsies (DEB) for the last 15 years. We present the largest reported consecutive series of ROLL excisions to date. PATIENTS AND METHODS: One thousand thirty nine consecutive patients who underwent ROLL for impalpable breast lesions were identified from a prospectively collected database. 673 patients underwent WLE and 366 patients underwent DEB. Data were analysed from proformas completed at the time of the procedure by the radiologist and operating surgeon. These data were supplemented with an analysis of patient electronic records including specimen radiograph and histopathology reports. RESULTS: 99.1% of ROLL WLE revealed histological diagnoses of invasive cancer or DCIS. 98.7% of radiological abnormalities were identified on WLE post-excision radiographs (97.5% following DEB). Complete excision was recorded in 79.0% of the WLE patients following histological evaluation. 31.7% of DEB cases were pathologically upgraded to a malignant diagnosis. The presence of microcalcification, preoperative underestimation of the lesion size and symptomatic referral predisposed to incomplete excision status. DISCUSSION: ROLL is a safe and effective technique to localise impalpable breast lesions. In addition ROLL has potential technical and logistic advantages over WGL.

Budesonide/formoterol and formoterol provide similar rapid relief in patients with acute asthma showing refractoriness to salbutamol.

BACKGROUND: To compare the efficacy and safety of budesonide/formoterol (Symbicort) with formoterol (Oxis) in the treatment of patients with acute asthma who showed evidence of refractoriness to short-acting beta2-agonist therapy. METHODS: In a 3 hour, randomized, double-blind study, a total of 115 patients with acute asthma (mean FEV1 40% of predicted normal) and a refractory response to salbutamol (mean reversibility 2% of predicted normal after inhalation of 400 microg), were randomized to receive either budesonide/formoterol (320/9 microg, 2 inhalations at t = -5 minutes and 2 inhalations at 0 minutes [total dose 1280/36 microg]) or formoterol (9 microg, 2 inhalations at t = -5 minutes and 2 inhalations at 0 minutes [total dose 36 microg]). The primary efficacy variable was the average FEV1 from the first intake of study medication to the measurement at 90 minutes. Secondary endpoints included changes in FEV1 at other timepoints and change in respiratory rate at 180 minutes. Treatment success, treatment failure and patient assessment of the effectiveness of the study medication were also measured. RESULTS: FEV1 increased after administration of the study medication in both treatment groups. No statistically significant difference between the treatment groups was apparent for the primary outcome variable, or for any of the other efficacy endpoints. There were no statistically significant between-group differences for treatment success, treatment failure or patient assessment of medication effectiveness. Both treatments were well tolerated. CONCLUSION: Budesonide/formoterol and formoterol provided similarly rapid relief of acute bronchoconstriction in patients with asthma who showed evidence of refractoriness to a short-acting beta2-agonist.