A regional-based newborn hearing screening program: the Emilia-Romagna model after ten years of legislation.

Background: Hearing loss, occurring in 1-3/1,000 newborns in the well-babies population, is one of the most common congenital diseases, and hearing screening at birth still represents the only means for its early detection. Since 2011 the Emilia Romagna Regional Health Agency has recommended Newborn Hearing Screening for all babies at its birth points and for newborns moving to the region. The aims of this study are to analyze the results of this regional-based Newborn Hearing Screening program and to discuss the impact of the legislative endorsement on the organization. Material and methods: This is an observational retrospective chart study. The recordings of well-babies and babies at Neonatal Intensive Care Units were collected during the period from January 1st 2015 to December 31st 2020. The following data were included: Newborn Hearing Screening coverage, percentage of refer at otoacoustic emissions, prevalence and entity of hearing loss, unilateral/bilateral rate, presence of audiological risk factors. Results: More than 99% of a total of 198,396 newborns underwent the Newborn Hearing Screening test during the period January 1st 2015 to December 31st 2020, with a coverage ranging between 99.6% and 99.9%. Overall, the percentage of confirmed hearing loss cases was about 17-30 % of refer cases, 745 children received a diagnosis of hearing loss (prevalence 3.7/1,000). Considering profound hearing loss cases, these represent 13% of bilateral hearing loss. Conclusion: A regional-based Newborn Hearing Screening program is valuable and cost-effective. In our experience, the centralization of the data system and of the data control is crucial in order to implement its efficiency and effectiveness. Healthcare policies, tracking systems and public awareness are decisive for a successful programme implementation.

Aspiration: diagnostic contributions from bedside swallowing evaluation and endoscopy.

The aim of this study was to identify which characteristics, collected by bedside swallowing evaluation (BSE) and fiberoptic endoscopic evaluation of swallowing (FEES), are a risk or a protective factor for aspiration. This retrospective study included data on 1577 consecutive patients, collected by BSE and FEES. Bivariate analysis was performed to verify the association of each variable with aspiration (Chi-Square test). The variables associated with aspiration were entered into a multivariate logistic model to quantify this association. Several variables were significantly associated (p < 0.05) with aspiration; cooperation, sensation, laryngeal elevation and direct therapy were found to be protective factors against aspiration. The regression model identified the most variables related with aspiration, among which tracheotomy, material pooling and spillage. Patients able to perform dry swallows were 77% less likely to aspirate (protective factor). Several variables are involved in protection of airways during swallowing. Their interaction, in patients with swallowing disorders, offers the clinician the best means of interpreting BSE and FEES.

The endoscopic evaluation of the oral phase of swallowing (Oral-FEES, O-FEES): a pilot study of the clinical use of a new procedure.

Oral FEES (O-FEES) is an endoscopic procedure conceived to directly visualise the oral phase of swallowing. In the perspective of clinical use, the feasibility, safety and acceptability of O-FEES has been evaluated. Subsequently, the procedure was compared with the radiological gold standard. The acceptability of O-FEES was compared to that of FEES using a 10 point questionnaire submitted to a sample of 52 outpatients complaining of swallowing disorders. Repeated measure analysis of variance (rm-ANOVA) models were used to test the mean difference of acceptability in the same subjects after FEES and O-FEES. Subsequently, another sample of 8 male outpatients underwent a simultaneous O-FEES and videofluoroscopic study (VFSS). The inter-rater reliability using 10 radiological landmarks, compared to O-FEES, was blindly determined between two raters. Inter-rater agreement between the two judges for O-FEES and VFSS scores was assessed with the single score intra-class correlation coefficient (ICC). Differences between FEES and O-FEES answers for each question and among all the items considered overall were statistically significant (rm-ANOVA; F-statistic p < 0.001). The inter-rater agreement concerning endoscopic and radiological evaluations between the two raters showed strong values of intra-class correlation coefficient (ICC) (95% confidence interval): 0.875 (0.373-0.979) and 0.921 (0.542-0.986), respectively. The Bland-Altman test showed a bias of -0.24 (95% limits of agreement; -1.77 to +1.19), which suggests that both methods produced almost identical results. In clinical practice and compared with FEES, O-FEES is a well tolerated and safe procedure. Compared with the radiological gold standard, O-FEES offers reliable information about oral preparation and oral propulsion of the bolus.

The Pooling-score (P-score): inter- and intra-rater reliability in endoscopic assessment of the severity of dysphagia.

This study evaluated the intra- and inter-rater reliability of the Pooling score (P-score) in clinical endoscopic evaluation of severity of swallowing disorder, considering excess residue in the pharynx and larynx. The score (minimum 4 - maximum 11) is obtained by the sum of the scores given to the site of the bolus, the amount and ability to control residue/bolus pooling, the latter assessed on the basis of cough, raclage, number of dry voluntary or reflex swallowing acts (< 2, 2-5, > 5). Four judges evaluated 30 short films of pharyngeal transit of 10 solid (1/4 of a cracker), 11 creamy (1 tablespoon of jam) and 9 liquid (1 tablespoon of 5 cc of water coloured with methlyene blue, 1 ml in 100 ml) boluses in 23 subjects (10 M/13 F, age from 31 to 76 yrs, mean age 58.56±11.76 years) with different pathologies. The films were randomly distributed on two CDs, which differed in terms of the sequence of the films, and were given to judges (after an explanatory session) at time 0, 24 hours later (time 1) and after 7 days (time 2). The inter- and intra-rater reliability of the P-score was calculated using the intra-class correlation coefficient (ICC; 3,k). The possibility that consistency of boluses could affect the scoring of the films was considered. The ICC for site, amount, management and the P-score total was found to be, respectively, 0.999, 0.997, 1.00 and 0.999. Clinical evaluation of a criterion of severity of a swallowing disorder remains a crucial point in the management of patients with pathologies that predispose to complications. The P-score, derived from static and dynamic parameters, yielded a very high correlation among the scores attributed by the four judges during observations carried out at different times. Bolus consistencies did not affect the outcome of the test: the analysis of variance, performed to verify if the scores attributed by the four judges to the parameters selected, might be influenced by the different consistencies of the boluses, was not significant. These initial data validate the clinical use of the P-score in the management of patients with deglutition disorders by a multidisciplinary team.

Endoscopic scale for evaluation of the severity of dysphagia: preliminary observations.

The finding of pooling of secretions is an important diagnostic finding in the evaluation of subjects with swallowing disorders. In patients at risk of aspiration the importance of this finding may be underestimated. We stress the usefulness of endoscopic investigation when evaluating subjects with swallowing disorders, or populations at risk for dysphagia, as well as for follow-up and management. Pooling, in global terms, is a significant criterion both for grading the severity of dysphagia, and providing indications for targeted referral to a speech therapist, and while tracking the disorder over time. The severity of dysphagia is expressed by scores that can consider endoscopic landmarks alone, or along with other parameters of bedside evaluation. The scores are represented by a simple number which refers to three degrees of severity: mild, moderate, and severe.

Pooling score: an endoscopic model for evaluating severity of dysphagia.

The finding of secretions and bolus pooling is of great diagnostic interest in the evaluation of subjects with swallowing disorders. Bedside evaluation alone, in subjects at risk for aspiration, can underestimate this parameter. The usefulness of endoscopic investigation for the evaluation of subjects with swallowing disorders is stressed, in order to plan treatment and follow-up. Based on endoscopic evaluation of material pooling we devised a score expressing the severity of dysphagia. This value takes into account endoscopic landmarks and other parameters of bedside evaluation. Endoscopic and bedside data were collected from a heterogeneous population of 520 consecutive patients seen in our Service over a 6-year period. By means of the test of equality of group means and logistic regression, parameters able to significantly predict aspiration in the series were identified. An ordinal number was attributed to each parameter in order to obtain scores expressing three degrees of severity of dysphagia: mild, moderate, severe. The scores can be used to guide the management of patients in a simple way, providing indications for targeted referral to the speech pathologist and for tracking the disorder over time. This investigation represents the basis for future research aimed at validating the scores in a larger case series.

The Swallowing Centre: rationale for a multidisciplinary management.

The need for professional management of dysphagic patients is growing. The scenario of patient care settings spans from the acute ward to chronic care facilities or home, requiring a health care network able to integrate hospital and community resources and optimise human and instrumental resources. This is also valid for Swallowing Centres, where admission, management, treatment and follow-up of discharged patients are a priority. The complexity of symptoms and the specificity of the underlying disease require a multidisciplinary approach to the patient. The coordinator of the Swallowing Centre is a phoniatrician working together with a logopedist. Patient management and personalized therapeutic options are discussed collegially. The logopedist, coordinating the activity of other therapists in the Centre, is responsible for patient treatment. In addition, the logopedist is responsible for counselling patients, nurses and informal caregivers.

Aspiration: the predictive value of some clinical and endoscopy signs. Evaluation of our case series.

Signs and symptoms obtained by clinical examination and endoscopic observations in consecutive subjects presenting at our Phoniatry and Logopedics Service from 1998 to 2003 for swallowing disorders were reviewed and evaluated statistically. The predictive power of these parameters is discussed in terms of short-term complications of dysphagia (aspiration). Epidemiological considerations are made based on a statistical model.

Morphometric investigation on osteocytes in human auditory ossicles.

An osteocyte lacunae differential count (1-lacunae with live osteocytes, 2-lacunae with degenerating osteocytes, 3-empty lacunae) was carried out on ear ossicles and clavicles from cadavers as well as on stapes removed by stapedotomy. The distance of the three types of lacunae from the vascular source was also determined by a computer-assisted light microscope. Results showed that the delayed fixation of bone from cadavers does not significantly interfere with osteocyte preservation, at least with the scope of this investigation. The results of osteocyte differential count show that the number of empty lacunae and lacunae with degenerating osteocytes: (a) is significantly higher in ear ossicles than in clavicles, (b) increases with age, (c) is higher in stapes than in incuses and mallei, (d) increases with the distance from the vascular sources in both ear ossicles and clavicles. Additionally it appeared that the process of osteocyte degeneration in ear ossicles is very rapid and widespread, over 40% of the cells being dead within the 2nd year of age. In the light of the recent literature and personal findings, which ascribe to osteocytes the function of mechanical detectors, and considering that bone remodeling occasionally occurs in ear ossicles, it is postulated that osteocyte death in these bones could be a programmed phenomenon (apoptosis?), due to which they lose the ability to react to strains and stresses and achieve the structural stability they need to perform their peculiar stereotyped function.

Electromagnetic stimulation of bone repair: a histomorphometric study.

The effect of pulsing electromagnetic fields (PEMFs) on bone repair was studied in principal metacarpal bones of eight adult male horses: Six horses were treated with PEMFs, and two horses were untreated. In treated horses, Helmholtz coils were applied during a 60-day period to the left metacarpal bones, bored with eight holes of equal diameter and depth, from the middiaphysis toward the distal metaphysis. Eight equal holes bored in the right metacarpal, surrounded by unactivated Helmholtz coils, were taken as controls. The two untreated horses were taken as additional control. The results of computer-assisted histomorphometric analysis indicate that (a) in diaphyseal levels, the amount of bone formed during 60 days is significantly greater (p less than 0.01) in PEMF-treated holes than in contralateral ones and those in control horses; (b) in metaphyseal levels, PEMF-treated holes are sometimes more closed, sometimes less, as compared with contralateral holes and those in control horses; in any case the statistical analysis indicates that the symmetry in the rate of hole repair, found between the two antimeres of control horses, is not appreciable at metaphyseal levels also; (c) there was no statistically significant difference between untreated holes in PEMF-treated horses and holes in control horses, neither at diaphyseal nor at metaphyseal levels. These preliminary findings indicate that PEMFs at low frequency influence the process of bone repair on both diaphysis and metaphysis, and seem to improve the process of bone repair in skeletal regions normally having a lower osteogenetic activity, i.e., in diaphyses as against metaphyses.