CT-based pathological lung opacities volume as a predictor of critical illness and inflammatory response severity in patients with COVID-19.

Objective: The aim of the study was to assess the impact of CT-based lung pathological opacities volume on critical illness and inflammatory response severity of patients with COVID-19. Methods: A retrospective, single center, single arm study was performed over a 30-day period. In total, 138 patients (85.2%) met inclusion criteria. All patients were evaluated with non-contrast enhanced chest CT scan at hospital admission. CT-based lung segmentation was performed to calculate pathological lung opacities volume (LOV). At baseline, complete blood count (CBC) and inflammation response biomarkers were obtained. The primary endpoint of the study was the occurrence of critical illness, as defined as, the need of mechanical ventilation and/or ICU admission. Mann-Whitney U test was performed for univariate analysis. Logistic regression analysis was performed to determine independent predictors of critical illness. Spearman analysis was performed to assess the correlation between inflammatory response biomarkers serum concentrations and LOV. Results: Median LOV was 28.64% (interquartile range [IQR], 6.33-47.22%). Correlation analysis demonstrated that LOV was correlated with higher levels of D-dimer (r = 0.51, p < 0.01), procalcitonin (r = 0.47, p < 0.01) and IL6 (r = 0.48, p < 0.01). Critical illness occurred in 51 patients (37%). Univariate analysis demonstrated that inflammatory response biomarkers and LOV were associated with critical illness (p < 0.05). However, multivariate analysis demonstrated that only D-dimer and LOV were independent predictors of critical illness. Furthermore, a ROC analysis demonstrated that a LOV equal or greater than 60% had a sensitivity of 82.1% and specificity of 70.2% to determine critical illness with an odds ratio of 19.4 (95% CI, 4.2-88.9). Conclusion: Critical illness may occur in up to 37% of the patients with COVID-19. Among patients with critical illness, higher levels of inflammatory response biomarkers with larger LOVs were observed. Furthermore, multivariate analysis demonstrated that pathological lung opacities volume was an independent predictor of critical illness. In fact, patients with a pathological lung opacities volume equal or greater than 60% had 19.4-fold increased risk of critical illness.

Predicting restriction of life-space mobility: a machine learning analysis of the IMIAS study.

BACKGROUND: Some studies have employed machine learning (ML) methods for mobility prediction modeling in older adults. ML methods could be a helpful tool for life-space mobility (LSM) data analysis. AIM: This study aimed to evaluate the predictive value of ML algorithms for the restriction of life-space mobility (LSM) among elderly people and to identify the most important risk factors for that prediction model. METHODS: A 2-year LSM reduction prediction model was developed using the ML-based algorithms decision tree, random forest, and eXtreme gradient boosting (XGBoost), and tested on an independent validation cohort. The data were collected from the International Mobility in Aging Study (IMIAS) from 2012 to 2014, comprising 372 older patients (≥ 65 years of age). LSM was measured by the Life-Space Assessment questionnaire (LSA) with five levels of living space during the month before assessment. RESULTS: According to the XGBoost algorithm, the best model reached a mean absolute error (MAE) of 10.28 and root-mean-square error (RMSE) of 12.91 in the testing portion. The variables frailty (39.4%), mobility disability (25.4%), depression (21.9%), and female sex (13.3%) had the highest importance. CONCLUSION: The model identified risk factors through ML algorithms that could be used to predict LSM restriction; these risk factors could be used by practitioners to identify older adults with an increased risk of LSM reduction in the future. The XGBoost model offers benefits as a complementary method of traditional statistical approaches to understand the complexity of mobility.

A Moderated Mediation Model of Wellbeing and Competitive Anxiety in Male Marathon Runners.

Running marathons is an increasingly popular activity with an ever-increasing number of events and participants. Many participants declare that they pursue a variety of goals by running, namely, the maintenance of good health, the development of strength and improvement of fitness, the management of emotions, and the achievement of resilience and psychological wellbeing (PWB). The research has examined marathon running, like many other sports, and has studied various factors that reduce athletic performance, such as the experience of anxiety, and that enhance such performance, such as an increase in general wellbeing. This article reports the results of a study on the experience of competitive anxiety among 238 male marathon runners who participated in Seville's (Spain) 26th Marathon race on February 23, 2020, and investigates the relationship between anxiety and key dimensions of wellbeing as measured by the Spanish-adapted 20-item PWB Scale. We hypothesized that participating athletes who rated high on the dimensions of PWB would experience lower levels of competitive anxiety with respect to this race. We also proposed that PWB would function as a mediating factor with respect to the experience of anxiety. The results show, as hypothesized, that marathon running enhances wellbeing and reduces anxiety. The data showed significant negative correlations between four of five wellbeing dimensions and the three types of anxiety measured, namely, somatic anxiety, worry, and concentration-impairing anxiety. Other findings supported our hypothesis that wellbeing, as measured, functions as a mediating factor for the moderation of competitive anxiety. Generalization of these findings is limited by the fact that the low number of female participants recruited did not permit valid statistical analyses in this respect. It is known that both anxiety and wellbeing are subjects to variation by gender. The future inclusion of male and female subjects in equivalent studies will undoubtedly add valuable information concerning the dynamics of anxiety and wellbeing. The implications of these findings and the limitations of the study will be discussed.

Do workers negative self-select when they commute? Evidence for the Chilean case of long-distance commuting.

Long-distance commuting (LDC) as a strategy of labor factor mobility has become relevant in recent decades, mainly in those economies characterized by a significant relative weight of extractive activities. The phenomenon is key to understanding the current structure and dynamics of these labor markets, although little is known about self-selection in LDC. This document addresses this knowledge gap by analyzing the case of Chile using functional areas. Chile is a country where LDC has become the principal strategy of labor mobility and is closely linked to the mining and construction sectors. The results obtained show a pattern of negative self-selection, meaning that it is the least qualified who have the highest probability of commuting between functional areas. Commuting could therefore be more than just a mechanism for accessing qualified labor, allowing less qualified individuals access job opportunities when the labor market where they come from is more qualified.

Emotional Reactions and Adaptation to COVID-19 Lockdown (or Confinement) by Spanish Competitive Athletes: Some Lesson for the Future.

The Coronavirus Covid 19 (SARS-CoV-2) pandemic has produced terrible effects in the world economy and is shaking social and political stability around the world. The world of sport has obviously been severely affected by the pandemic, as authorities progressively canceled all level of competitions, including the 2020 Olympic Games in Tokyo. In Spain, the initial government-lockdown closed the Sports High-performance Centers, and many other sports facilities. In order to support athlete's health and performance at crises like these, an online questionnaire named RECOVID-19, was designed to assess how athletes were living their lives during such periods of home confinement. The main purpose of the questionnaire was to assess the impact of prolongued confinement on athlete's psychological, emotional, and behavioral performance. One thousand, two hundred forty-eight athletes participated in the survey. They had the fllowing characteristics: (Mean age = 22.31 ± 11.49, Female: 53%), who compete at National (N: 1017, Mean age = 21.58 ± 11.42, Female: 52%) and International level (N: 231, Mean age = 25.56 ± 11.22, Female: 57%). Results showed that during the confinement period, those athletes who lacked motivation reported a higher level of stressful thoughts, more behavioral problems, and greater emotional upheaval (anger, fatigue, tension, and depression). However, those athletes who accepted confinement measures as necessary, and were in favor of respecting the rules of social isolation, fostered positive emotional states such as feelings of friendship. In addition, the availability of some sport equipment together with the ability to continue some training, were (1) protective factors against emotional stress, lack of motivation and behavioral problems; and (2) they were associated with greater respect for, and adherence to, confinement rules. Gender differences, tested by multigroup analysis, revealed that coping activities were more often associated to negative emotional states among women, whereas the ongoing availability of training information and future conditions were equally protective factors for both genders. This study also showed that receiving coaching, support and completing frequent training routines seem to be valuable tools to prevent or reduce some of the harmful effects of isolation on athlete's emotional well-being. The conclusions derived from this research would possibly help sport authorities to design supporting policies and plans to support athletes and trainers in future disruptive health crises.

The Effectiveness of the Psychological Intervention in Amateur Male Marathon Runners.

Background: The Marathon runners must have the proper technical preparation to reach excellence and to achieve adequate psychological preparation for the race. Against this background, the current study aims to describe the implementation results of a cognitive-behavioral intervention based on psychological skills training for marathon runners. Methods: Fourteen amateur male marathoners with an average age of 30 (SD = 5.75) were trained with various emotional and cognitive control techniques to enhance their performance in competition. Various psychological variables, related to the subjects level of perceived stress, and to qualitative characteristics of their thoughts were measured before and after the target marathon race. Results were analyzed through non-parametric tests for two related samples. The Cohen's d effect size for single-group pretest-posttest repeated measures were also performed. Results: Statistical analysis reveals that, controlling for age and running experience, the intervention decreased significantly the level of perceived stress and the occurrence of negative thoughts before the race, during, and after the race. Conclusion: Training in cognitive control and relaxation techniques, as part of the psychological skills training could determine the quality of performance of marathon runners.

Computed Tomography-based Lung Residual Volume and Mortality of Patients With Coronavirus Disease-19 (COVID-19).

RATIONALE AND OBJECTIVES: To assess the effect of computed tomography (CT)-based residual lung volume (RLV) on mortality of patients with coronavirus disease 2019 (COVID-19). MATERIALS AND METHODS: A single-center, retrospective study of a prospectively maintained database was performed. In total, 138 patients with COVID-19 were enrolled. Baseline chest CT scan was performed in all patients. CT-based automated and semi-automated lung segmentation was performed using the Alma Medical workstation to calculate normal lung volume, lung opacities volume, total lung volume, and RLV. The primary end point of the study was mortality. Univariate and multivariate analyses were performed to determine independent predictors of mortality. RESULTS: Overall, 84 men (61%) and 54 women (39%) with a mean age of 47.3 years (±14.3 y) were included in the study. Overall mortality rate was 21% (29 patients) at a median time of 7 days (interquartile range, 4 to 11 d). Univariate analysis demonstrated that age, hypertension, and diabetes were associated with death (P<0.01). Similarly, patients who died had lower normal lung volume and RLV than patients who survived (P<0.01). Multivariate analysis demonstrated that low RLV was the only independent predictor of death (odds ratio, 1.042; 95% confidence interval, 10.2-10.65). Furthermore, receiver operating characteristic curve analysis demonstrated that a RLV ≤64% significantly increased the risk of death (odds ratio, 4.8; 95% confidence interval, 1.9-11.7). CONCLUSION: Overall mortality of patients with COVID-19 may reach 21%. Univariate and multivariate analyses demonstrated that reduced RLV was the principal independent predictor of death. Furthermore, RLV ≤64% is associated with a 4-fold increase on the risk of death.

Early Ambulation After Microsurgical Reconstruction of the Lower Extremity.

Successful outcomes after microsurgical reconstruction of the lower extremity include timely return to ambulation. Some combination of physical examination, ViOptix tissue oxygen saturation monitoring, and the implantable venous Doppler have shown promise in increasing sensitivity of current flap monitoring. We have incorporated this system into our postoperative monitoring protocol in an effort to initiate earlier dependency protocols. A prospective analysis of 36 anterolateral thigh free flap and radial forearm flaps for lower extremity reconstruction was performed. Indications for reconstruction were acute and chronic wounds, as well as oncologic resection. Twenty-three patients were able to ambulate and 3 were able to dangle their leg on the first postoperative day. One flap showed early mottling that improved immediately after elevation. After reelevation and return to baseline, the dependency protocol was successfully implemented on postoperative day 3. All flaps went on to successful healing. Physical examination, implantable venous Doppler, and ViOptix can be used reliably as an adjunct to increase the sensitivity of detecting poorly performing flaps during the postoperative progression of dependency.

Changes in arterial partial pressure and end-expired pressure of carbon dioxide in prepubescent and adult bitches undergoing ovariohysterectomy by videolaparoscopy or conventional laparotomy / Variações nas pressões parciais arteriais e expiradas de dióxido de carbono em cadelas pré-púberes e adultas submetidasà ovário histerectomiavídeo laparoscópica ou convencional

ABSTRACT: This paper aimed to determine arterial partial pressure of carbon dioxide (PaCO2), end-expired CO2 pressure (ETCO2), and the difference between arterial and end-expired CO2 pressure (Pa - ETCO2) in prepubescent and adult bitches undergoing videolaparoscopic or conventional ovariohyterectomy (OH). Forty bitches were randomly assigned to four groups: Conventional Adult (CA), Conventional Pediatric (CP), Videolaparoscopic Adult (VA) and Videolaparoscopic Pediatric (VP). Pulse rate (PR), respiratory rate (RR), systolic, mean, and diastolic arterial pressures (SAP, MAP, DAP), ETCO2, peak inspiratory pressure (PIP), pH, arterial partial pressure of oxygen (PaO2), PaCO2, base excess (BE) and HCO3 - were measured. Based on the PaCO2 and ETCO2 values, Pa-ETCO2 was determined. There was no significant difference in PaCO2 between the VA (42.5±5.2 to 53.7±5.2) and VP (48.4±5.4 to55.4±5.7) groups. During the postoperative period, all groups presented with hypertension. However, mild hypertension (SAP 150 to 159mmHg) was observed in the VP group as compared to severe hypertension (SAP>180mmHg) in the CA group, suggesting that both the age range and videolaparoscopic OH are associated with lower levels of hypertension during the postoperative period in dogs.

RESUMO: O objetivo deste estudo foi determinar a pressão parcial de dióxido de carbono (PaCO2), pressão ao final da expiração de CO2 (ETCO2) e diferença artério-alveolar de CO2 (Pa-ETCO2) em cadelas pré-púberes e adultas submetidas à ovário-histerectomia (OH) videolaparoscópica ou convencional. Foram distribuídas 40 cadelas em quatro grupos: Convencional Adulto (CA), Convencional Pediátrico (CP), Videolaparoscópico Adulto (VA) e Videolaparoscópico Pediátrico (VP). Foram mensurados frequência de pulso (FP), frequência respiratória (FR), pressões arteriais sistólica (PAS), média (PAM) e diastólica (PAD), ETCO2, pressão de pico inspiratória (PIP), pH, pressão parcial arterial de oxigênio (PaO2), PaCO2, excesso de bases (EB) e HCO3 -. Com base nos valores de PaCO2 e ETCO2 encontrados, foi determinada a Pa-ETCO2. Não foram encontradas diferenças significativas nos valores de PaCO2 entre os grupos VA (42.5±5.2-53,7±5,2) e VP (48.4±5.4 - 55,4±5,7). Todos os grupos apresentaram hipertensão arterial no período pós-operatório. Entretanto, o grupo VP apresentou hipertensão moderada (PAS 150-159mmHg) em comparação ao grupo CA, que apresentou hipertensão severa (PAS>180 mmHg), sugerindo que tanto a faixa etária, quanto a execução de OH por videolaparoscopia, estão associadas a menores taxas de hipertensão pós-operatória em cadelas.

Gender-Based Cerebral Perfusion Differences in 46,034 Functional Neuroimaging Scans.

BACKGROUND: Studies have reported that females have widespread increases in regional cerebral blood flow, but the studies were relatively small and inconsistent. OBJECTIVE: Here we analyzed a healthy and a very large clinical psychiatric population to determine the effect of gender, using single photon emission computed tomography (SPECT). METHODS: Whole brain and region of interest (ROI) gender differences were analyzed in a total of 46,034 SPECT scans at baseline and concentration. The sample included 119 healthy subjects and 26,683 patients (60.4% male, 39.6% female); a subset of 11,587 patients had complete diagnostic information. A total of 128 regions were analyzed according to the AAL Atlas, using ROI Extract and SPSS statistical software programs, controlling for age, diagnoses, and correcting for multiple comparisons. RESULTS: Compared to males, healthy females showed significant whole brain (p < 0.01) and ROI increases in 65 baseline and 48 concentration regions (p < 0.01 corrected). Healthy males showed non-significant increases in 9 and 22 regions, respectively. In the clinical group, there were widespread significant increases in females, especially in the prefrontal and limbic regions, and specific increases in males in the inferior occipital lobes, inferior temporal lobes, and lobule 7 and Crus 2 of the cerebellum. These findings were replicated in the subset of 11,587 patients with the effect of diagnoses removed. CONCLUSIONS: Our results demonstrated significant gender differences in a healthy and clinical population. Understanding these differences is crucial in evaluating functional neuroimaging and may be useful in understanding the epidemiological gender differences among psychiatric disorders.

Fertility and Economic Development: Quantile Regression Evidence on the Inverse J-shaped Pattern.

This paper analyses empirically the relationship between economic development and fertility. Through a new sample selection and quantile regression, it investigates whether there is an inverse J-shaped pattern between these two variables, and, if so, whether it depends on development and fertility levels. Our results confirm that the inverse J-shaped pattern exists, but only when a certain level of economic development is attained. Results also suggest an innovative finding: the J-shape depends not only on the development but also on the fertility level. The higher the fertility rate, the higher the GDP per capita needed to reverse fertility decline, and the faster the negative and positive segments of the J-shape fall and grow.

Educating psychiatry residents about cultural aspects of care: a qualitative study of approaches used by U.S. expert faculty.

BACKGROUND/OBJECTIVE: Almost no literature compares current approaches to teaching cultural issues across U.S. psychiatry residency programs; the authors addressed this comparison. METHODS: The authors administered semistructured interviews of 20 instructors with substantial experience in the teaching of cultural issues in U.S. psychiatry residency programs, regarding the content, teaching techniques, institutional context, and evaluation of their curricula over time. RESULTS: Approaches varied according to the local populations served and the background of the instructors, all of whom were either cross-trained in social sciences and humanities or were themselves ethnic, racial, or sexual minorities. Common themes emerged, including the use of experiential approaches, the lack of integration of cultural issues into clinical supervision or courses on other topics, and the absence of formal course evaluation. DISCUSSION: Findings indicate a need for integration of cultural concepts into a variety of settings throughout residency, for development of faculty who are cross-trained in social sciences and humanities, and for curriculum-evaluation strategies.

A new time limited psychotherapy for BPD: preliminary results of a randomized and controlled trial.

INTRODUCTION: Psychic Representation focused Psychotherapy (PRFP) is a new time limited dynamic psychotherapy for the treatment of Borderline Personality Disorder. It is a psychodynamic technique based on brief psychoanalytic psychotherapy principles. It is manualized and designed to be applied in the framework of public health care services. A randomized and controlled study with a sample of 53 patients was conducted to assess PRFP efficacy. This work presents the results for the first 44 trial completers at termination of treatment. METHODS: Both groups, the experimental (n= 18) and control group (n= 26), received treatment as usual. The experimental group received an additional 20 (PRFP) sessions, conducted by four therapists with homogenous characteristics specifically trained in this technique. The main outcome variables measures were: Severity global index of SCL-90-R, Barrat Impulsivity Scale scores and Social Adaptation (SASS score). Baseline and final condition at termination was compared. CONCLUSIONS: Preliminary results showed significantly better outcomes for the experimental group in all the main variables measured and in most of the secondary ones. PRFP may represent an important contribution for the treatment of BPD patients. Follow-up assessment at 6 and 12 months is planned.

Public psychiatry fellowships: a developing network of public-academic collaborations.

In response to the expanding public behavioral health care system, a network of 15 public-community psychiatry fellowships has developed over the past six years. The fellowship directors meet yearly to sustain and develop fellowships to recruit and retain psychiatrists in the public sector. This column describes five types of public-academic collaborations on which the fellowships are based. The collaborations focus on structural and fiscal arrangements; recruitment and retention; program evaluation, program research, and policy; primary care integration; and career development. These collaborations serve to train psychiatrists who will play a key role in the rapidly evolving health care system.

Specific ways brain SPECT imaging enhances clinical psychiatric practice.

Our objective was to ascertain in a prospective case series how often brain single photon emission computed tomography (SPECT) neuroimaging adds relevant information for diagnosis and/or treatment beyond current standard assessment tools in complex psychiatric cases. Charts of 109 consecutively evaluated outpatients from four psychiatrics clinics that routinely utilize SPECT imaging for complex cases were analyzed in two stages. In stage one, psychiatrists reviewed detailed clinical histories, mental status exams, and the structured clinical interview for DSM-IV, but not the results of SPECT studies, assigned a diagnosis based on DSM-IV criteria, and then developed a comprehensive treatment plan. In stage two, evaluators were given access to the SPECT studies for each patient. The addition of SPECT modified the diagnosis or treatment plan in 78.9% (n=86; rated level 2 or 3 change) of cases. The most clinically significant changes were undetected brain trauma (22.9%), toxicity patterns (22.9%) and the need for a structural imaging study (9.2%). Specific functional abnormalities were seen as follows that potentially could impact treatment: temporal lobe dysfunction (66.1%) and prefrontal hypoperfusion (47.7%). SPECT has the potential to add clinically meaningful information to enhance patient care beyond current assessment tools in complex or treatment resistant cases.

Brain SPECT Imaging in Complex Psychiatric Cases: An Evidence-Based, Underutilized Tool.

Over the past 20 years brain Single Photon Emission Computed Tomography (SPECT) imaging has developed a substantial, evidence-based foundation and is now recommended by professional societies for numerous indications relevant to psychiatric practice. Unfortunately, SPECT in clinical practice is utilized by only a handful of clinicians. This article presents a rationale for a more widespread use of SPECT in clinical practice for complex cases, and includes seven clinical applications where it may help optimize patient care.

Surgical and medical treatment of hearing loss in mixed otosclerosis.

OBJECTIVES: We assessed the effect of using preoperative sodium fluoride (NaF) on the difficulty of working with the footplate during stapedectomy and its effect on the postsurgical hearing gain in patients with mixed otosclerosis (i.e., otosclerosis and/or otospongiosis). METHODS: There were 2 groups of patients with mixed otosclerosis. The experimental group was made up of patients with an active focus of the disease; they received NaF for 6 months and then underwent stapedectomy. The control group was made up of patients with an inactive focus of the disease; they underwent stapedectomy without administration of NaF. RESULTS: The difference between the study groups in the degree of difficulty in extracting the footplate was not found to be statistically significant. Both groups had hearing gains in bone and air conduction. The level of posttreatment hearing gain in the group exposed to NaF was greater than that in the nonexposed group. CONCLUSIONS: Sodium fluoride administered to patients with mixed otosclerosis and an active focus of disease does not increase the difficulty of working with the footplate during stapedectomy, and it increases the hearing gain after the procedure.

Assessment of spirituality and its relevance to addiction treatment.

The prominence of Twelve-Step programs has led to increased attention on the putative role of spirituality in recovery from addictive disorders. We developed a 6-item Spirituality Self-Rating Scale designed to reflect a global measure of spiritual orientation to life, and we demonstrated here its internal consistency reliability in substance abusers on treatment and in nonsubstance abusers. This scale and the measures related to recovery from addiction and treatment response were applied in three diverse treatment settings: a general hospital inpatient psychiatry service, a residential therapeutic community, and methadone maintenance programs. Findings on these patient groups were compared to responses given by undergraduate college students, medical students, addiction faculty, and chaplaincy trainees. These suggest that, for certain patients, spiritual orientation is an important aspect of their recovery. Furthermore, the relevance of this issue may be underestimated in the way treatment is framed in a range of clinical facilities.

Evaluation of a model for the treatment of combined mental illness and substance abuse: the Bellevue model for peer-led treatment in systems change.

The present study evaluated a model program at Bellevue Hospital Center incorporating a peer-led self-help (PLSH) approach which can be applied to bring about systems-level change in a variety of settings where persons with dual diagnosis are encountered. A total of 461 consecutive MICA inpatient admissions were evaluated to compare the PLSH unit with two standard psychiatric units. The PLSH program was associated with a higher rate of acceptance of aftercare referral (93% vs. 74%) and aftercare attendance (52% vs. 30%) among patients with no prior psychiatric hospitalizations (N = 111). In addition, the PLSH program appeared to benefit chronically impaired MICA patients (N = 350) or those with a history of prior psychiatric hospitalizations, as they were more likely to accept referral to aftercare treatment than were chronic patients discharged from the standard psychiatric units (96% vs. 81%). Such a program, when more widely applied, could yield decreased recidivism and considerably lower medical, psychiatric, and economic cost.

Poststapedectomy hearing gain: comparison of a Teflon (fluoroplastic ASTM F 754) prosthesis with a Schuknecht-type wire/Teflon prosthesis.

We conducted a retrospective study to compare poststapedectomy hearing gain in study-eligible patients who had received a Teflon (fluoroplastic ASTM F 754) prosthesis (study group; n = 76) with hearing gain achieved in a matched group (by age, sex, and degree of hypoacusis) of patients who had received a Schuknecht-type wire/Teflon prosthesis (control group; n = 70). All procedures had been performed by the authors at our institution between Jan. 2, 1994, and Dec. 31, 1997. Airway averages at low, medium, and high frequencies were estimated on the basis ofpre- and postoperative audiologic evaluations, as were total air-bone gaps at 7 frequencies between 125 and 8, 000 Hz. We found that the study group achieved a significantly greater degree of hearing gain at 125 and 250 Hz and significantly better closure of the air-bone gap at 250, 500, 1,000, 2,000, and 4,000 Hz. The hearing outcomes among patients in the study group were excellent.