Results of a 6-Month Field Trial of a Transitional Intervention for Debilitating Hyperacusis.

PURPOSE: We present results from a 6-month field trial of a transitional intervention for debilitating primary hyperacusis, including a combination of structured counseling; promotion of safe, comfortable, and healthy sound exposure; and therapeutic broadband sound from sound generators. This intervention is designed to overcome barriers to successful delivery of therapeutic sound as a tool to downregulate neural hyperactivity in the central auditory pathways (i.e., the maladaptive mechanism believed to account for primary hyperacusis) and, together with the counseling, reduce the associated negative emotional and physiological reactions to debilitating hyperacusis. METHOD: Twelve adults with normal or near-normal audiometric thresholds, complaints consistent with their pretreatment loudness discomfort levels ≤ 75 dB HL at multiple frequencies, and hearing questionnaire scores ≥ 24 completed the sound therapy-based intervention. The low-level broadband therapeutic sound was delivered by ear-level devices fitted bilaterally with either occluding earpieces and output-limiting loudness suppression (LS; to limit exposure to offensive sound levels) or open domes to maximize comfort and exposure to sound therapy. Thresholds for LS (primary outcome) were incrementally adjusted across six monthly visits based on treatment-driven change in loudness judgments for running speech in sound field. Secondary outcomes included categorical loudness judgments, speech understanding, and questionnaires to assess the hyperacusis problem, quality of life, and depression. An exit survey assessed satisfaction with and benefit from the intervention and the counseling, therapeutic sound, and LS components. RESULTS: The mean change in LS (34.8 dB) was highly significant (effect size = 2.045). Eleven of 12 participants achieved ≥ 16-dB change in LS, consistent with highly significant change in sound-based questionnaire scores. Exit surveys indicated satisfaction with and benefit from the intervention. CONCLUSION: The transitional intervention was successful in improving the hyperacusis conditions of 11 of 12 study participants while reducing their sound avoidance behaviors and reliance on sound protection.

Device and Fitting Protocol for a Transitional Intervention for Debilitating Hyperacusis.

PURPOSE: This report describes a hearing device and corresponding fitting protocol designed for use in a transitional intervention for debilitating loudness-based hyperacusis. METHOD: The intervention goal is to transition patients with hyperacusis from their typical counterproductive sound avoidance behaviors (i.e., sound attenuation and limited exposure to healthy low-level sounds) into beneficial sound therapy treatment that can expand their dynamic range to the point where they can tolerate everyday sounds and experience an improved quality of life. This requires a combination of counseling and sound therapy, the latter of which is provided via the hearing device technology, signal processing, and precision fitting approach described in this report. The device combines a miniature behind-the-ear sound processor and a custom earpiece designed to maximize the attenuation of external sounds. Output-limiting loudness suppression is used to restrict exposure to offending high-level sounds while unity gain amplification maximizes exposure to healthy and tolerable lower level sounds. The fitting process includes measurement of the real-ear unaided response, the real-ear measurement (REM) system noise floor, the real-ear occluded response, real-ear insertion gain, and the output limit. With these measurements, the device can achieve the prescribed unity gain needed to provide transparent access to comfortable sound levels. It also supports individualized configuration of the therapeutic noise from an on-board sound generator and adaptive output limiting based on treatment-induced increases in dynamic range. RESULTS AND CONCLUSION: The utility of this device and fitting protocol, in combination with structured counseling, is highlighted in the outcomes of a successful 6-month trial of the transitional intervention described in a companion report in this issue.

Antibiofilm Activity of Eugenol-Loaded Chitosan Coatings against Common Medical-Device-Contaminating Bacteria.

The formation of pathogenic biofilms on medical devices is a major public health concern accounting for over 65% of healthcare-associated infections and causing high infection morbidity, mortality, and a great burden to patients and the healthcare system due to its resistance to treatment. In this study, we developed a chitosan-based antimicrobial coating with embedded mesoporous silica nanoparticles (MSNs) to load and deliver eugenol, an essential oil component, to inhibit the biofilm formation of common bacteria in medical-device-related infections. The eugenol-loaded MSNs were dispersed in a chitosan solution, which was then cross-linked with glutaraldehyde and drop-casted to obtain coatings. The MSNs and coatings were characterized by dynamic light scattering, Brunauer-Emmett-Teller analysis, attenuated-total-reflectance Fourier transform infrared spectroscopy, X-ray photoelectron spectroscopy, 3D optical profilometry, and scanning electron microscopy. The release behavior of eugenol-loaded MSNs and coatings and the antibiofilm and antimicrobial activity of the coatings against adherent Staphylococcus aureus, methicillin-resistant S. aureus, and Pseudomonas aeruginosa were investigated. Eugenol was released from the MSNs and coatings in aqueous conditions in a controlled manner with an initial low release, followed by a peak release, a decrease, and a plateau. While the chitosan coatings alone or with unloaded MSNs demonstrated limited antimicrobial effects and still supported biofilm formation after 24 h, the coating containing eugenol not only reduced biofilm formation but also killed the majority of the attached bacteria. It also showed biocompatibility in indirect contact with NIH/3T3 fibroblasts and a high percentage of live cells in direct contact. However, further investigations into cell proliferation in direct contact are recommended. The findings indicated that the chitosan-based coating with eugenol-loaded MSNs could be developed into an effective strategy to inhibit biofilm formation on medical devices.

Acoustic deprivation modulates central gain in human auditory brainstem and cortex.

Beyond reduced audibility, there is convincing evidence that the auditory system adapts according to the principles of homeostatic plasticity in response to a hearing loss. Such compensatory changes include modulation of central auditory gain mechanisms. Earplugging is a common experimental method that has been used to introduce a temporary, reversible hearing loss that induces changes consistent with central gain modulation. In the present study, young, normal-hearing adult participants wore a unilateral earplug for two weeks, during which we measured changes in the acoustic reflex threshold (ART), loudness perception, and cortically-evoked (40 Hz) auditory steady-state response (ASSR) to assess potential modulation in central gain with reduced peripheral input. The ART decreased on average by 8 to 10 dB during the treatment period, with modest increases in loudness perception after one week but not after two weeks of earplug use. Significant changes in both the magnitude and hemispheric laterality of source-localized cortical ASSR measures revealed asymmetrical changes in stimulus-driven cortical activity over time. The ART results following unilateral earplugging are consistent with the literature and suggest that homeostatic plasticity is evident in the brainstem. The novel findings from the cortical ASSR in the present study indicates that reduced peripheral input induces adaptive homeostatic plasticity reflected as both an increase in central gain in the auditory brainstem and reduced cortical activity ipsilateral to the deprived ear. Both the ART and the novel use of the 40-Hz ASSR provide sensitive measures of central gain modulation in the brainstem and cortex of young, normal hearing listeners, and thus may be useful in future studies with other clinical populations.

Re-starting elective orthopaedic services in NHS Tayside during the COVID-19 pandemic.

BACKGROUND: Elective orthopaedic operations were suspended at the start of the COVID-19 lockdown. Three pathways were created to allow patients to undergo urgent elective operations in NHS Tayside as soon as it was deemed safe to do so. METHODS: We examined elective orthopaedic activity in NHS Tayside during and immediately after the Scottish lockdown. Elective operations performed between 27 March 2020 and 10 August 2020 were included and compared with cases performed between 27 March and 10 August in both 2018 and 2019. Primary outcomes were 30-day mortality, 30-day complications, and nosocomial infection rates of COVID-19. FINDINGS: Fewer elective operations were performed in 2020 (258) compared with 2019 (1196) and 2018 (1261). The rate of nosocomial infection in the 2020 cohort was 0%. The 30-day mortality rate was 0%. Over 98% of patients agreed to undergo surgery after a detailed consenting process. INTERPRETATION: We were able to re-start a safe elective orthopaedic service in the early stages of recovery from the COVID-19 pandemic, compatible with the guidelines set by the Royal College of Surgery of England and the British Orthopaedic Association. Our findings will serve to reassure regions with sufficient resources that it is acceptable to restart elective surgery for urgent priority cases. They may provide a template for planned surgical care in the event of further pandemics.

Measuring the Implementation of Youth Empowerment Solutions.

Scholars have increasingly emphasized the importance of using evidence-based programs to promote health and prevent disease. While theoretically and empirically based programs may be effective in carefully controlled conditions, many fail to achieve desired outcomes when implemented in real-world settings. Ensuring high-quality implementation of health promotion programs is critically important as variation in implementation is closely associated with program effectiveness. The purpose of this article is to present methods used to document and assess the implementation of the Youth Empowerment Solutions (YES) program. We collected process evaluation data on 25 YES groups from 12 schools over a period of 4 years. The evaluation assessed four key aspects of delivery: fidelity, dose delivered, dose received, and program quality. We found wide variations in delivery for some measures, while others were more consistent across groups. These indicators of program delivery provided a strong basis for evaluating program implementation, taking actions to improve it, and ultimately, deepening understanding of program effectiveness. The study suggests a model for using multiple methods to collect and analyze data about aspects of program delivery to guide future implementations.

Improving primary palliative care in Scotland: lessons from a mixed methods study.

BACKGROUND: Since 2012, all GP practices across Scotland have been supported to take a systematic approach to end-of-life care, by helping them to identify more patients for palliative care through a Palliative Care Directed Enhanced Service (DES). We aimed to understand the impact of this initiative. METHODS: Routine quantitative data from the 2012/13, and 2013/14 DES were collected from regional health boards, analysed and discussed. Qualitative data were collected from a sample of 2012/13 DES returns and analysed using Thematic Analysis. RESULTS: Data were received from 512 practices in nine Scottish Health boards for the 2012-13 DES and 638 practices in 11 Health boards for 2013-14. A sample of 90 of the returns for 2012-13 was selected for qualitative analysis. In 2012-13, 72 % of patients who died of cancer were listed on the palliative care register (PCR) before death while 27 % of patients who died as a result of non-malignant conditions were listed on the PCR. In 2013-14, cancer identification remained the same but identification of people dying with other long-term conditions had improved to 32.5 %. We identified several key issues needed to improve palliative care in the community. The need for training to identify patients with palliative care needs (particularly non-cancer); communication skills training; improvements in sharing information across the NHS; under-resource of and lack of coordination with district nurses; improvements in information technology; and tools for working with enlarged palliative care registers. CONCLUSIONS: The DES helped more patients with long-term conditions (LTC) receive generalist palliative care. Approaching generalist palliative care as anticipatory care could facilitate communication between GPs and patients/families and remove some barriers to early identification of palliative care needs. Improvement of information technology and use of identification tools like the SPICT™ may improve professionals' communication with each other and help may make identification and management of patients easier.

Flint Photovoice: community building among youths, adults, and policymakers.

Flint Photovoice represents the work of 41 youths and adults recruited to use a participatory-action research approach to photographically document community assets and concerns, critically discuss the resulting images, and communicate with policymakers. At the suggestion of grassroots community leaders, we included policymakers among those asked to take photographs. In accordance with previously established photovoice methodology, we also recruited at the project's outset another group of policymakers and community leaders to provide political will and support for implementing photovoice participants' policy and program recommendations. Flint Photovoice enabled youths to express their concerns about neighborhood violence to policymakers and was instrumental in acquiring funding for local violence prevention. We note salutary outcomes produced by the inclusion of policymakers among adults who took photographs.