A Unique Case of Iatrogenic Femoral Arteriovenous Fistula associated with Deep Vein Thrombosis after Electrophysiological Procedure in a Kidney Transplanted Patient.

Iatrogenic femoral arteriovenous fistulas (AVFs) and deep venous thrombosis (DVT) can complicate femoral artery catheterization procedures. However, the co-occurrence of both is rare. We report the unique case of AVF with DVT, which occurred in the right femoral vessels of a 59-year-old man with a right iliac fossa kidney transplant, after percutaneous puncture for cardiac catheterization. Duplex ultrasound examination and computed tomography venography scan confirmed the diagnosis. Both the AVF and the DVT were managed surgically.

Acquisition of early auditory milestones with a cochlear implant.

OBJECTIVE: Speech acquisition after cochlear implant is a long process. Various studies have followed the auditory milestones in the early period after implantation. The aim of the present study was to track the development of hearing skills in the early period after cochlear implantation and evaluate which factors influence the process. METHODS: 195 records of children implanted in the Hadassah Medical Center were examined retrospectively. Data on etiology, age at implantation and type of implant were collected. In addition, information on the rate of progress was measured: the first time that there was detection and identification of Ling sounds, the first time it was possible to obtain SDT (speech detection threshold), SRT (speech reception threshold) and an audiogram, and the first accurate repetition of VCV (vowel consonant vowel) sounds. RESULTS: Results show a consistent pattern of auditory milestone acquisition similar to that of normal development, from milestones that do not require decoding beginning with SDT, detection of Ling sounds followed by an audiogram which requires cooperation, to tasks that involve decoding starting with SRT and repetition of Ling sounds and finally VCV repetition. The children implanted before 24 months of age achieved the auditory milestones later than children implanted between 2 and 6 years, apparently since these tasks involve cognitive abilities which are not yet developed in the youngest children. Previous hearing experience improved the rate of acquisition of the auditory milestones and progress was faster in the second implanted ear compared to the first implanted ear. CONCLUSION: More research is needed to address the relationship between acquisition of early auditory milestones and performance with the cochlear implant later on in life.

Improving implementation of infection control guidelines to reduce nosocomial infection rates: pioneering the report card.

BACKGROUND: Two detailed checklists were developed, based on published infection control guidelines, for daily use by infection control practitioners in departments and operating rooms. AIM: To assess the impact of the checklists on nosocomial infection rates in three hospitals over the course of one year. METHODS: The checklists included 20 subheadings (± 150 items). Project nurses conducted rounds in the study (but not control) departments; during each round, the nurses selected 15-20 items for observation, marked the checklists according to appropriateness of observed behaviour and provided on-the-spot corrective education. Rates of adherence to the checklist, antibiotic use, number of obtained and positive cultures, and positive staff hand and patient environment cultures were reported monthly as a report card to relevant personnel and administrators. The rate of nosocomial infections was determined in the first and last months. RESULTS: The baseline nosocomial infection rate was similar in the study and control departments: 37/345 (11%) and 26/270 (10%) respectively. In the last month, the rate in the study department decreased to 16/383 (4%) (P<0.01); in the control it decreased insignificantly to 21/248 (8%) (not significant). No significant trends were detected in the number of obtained cultures, positive cultures, or antibiotic use. Adherence to guidelines ranged from 75% to 94% between the hospitals (P<0.001): the overall rate increased from 80% to 91% (P<0.01). CONCLUSIONS: The use of checklists during the conduct of infection control rounds, combined with monthly reports, was associated with a significant decrease in nosocomial infections in study departments.

The Hebrew and the Arabic version of the LittlEARS® auditory questionnaire for the assessment of auditory development: results in normal hearing children and children with cochlear implants.

OBJECTIVE: With more children receiving cochlear implants at an early age, there is a need for evaluation and assessment of early auditory behavior. We present the translation of the LittlEARS® Auditory Questionnaire into Hebrew and into Arabic. First the validation of the LittlEARS® Auditory Questionnaire in normal hearing children was evaluated. Second, the auditory behavior and the progress in hearing skills of a group of children with cochlear implants were assessed. METHODS: A "back-translation" method was used to translate and adapt the LittlEARS® Auditory Questionnaire into Hebrew and into Arabic. Normal hearing participants included 70 Hebrew speaking and 97 Arabic speaking parents of children from 1 to 24 months of age with normal hearing. An additional group of 42 parents of children with cochlear implants with a hearing age of up to 24 months completed the LittlEARS® Auditory Questionnaire. 27 of them completed the questionnaire more than once at intervals, so that change and development could be recorded. Scores on the LittlEARS® Auditory Questionnaire were compared to results of SIR and CAP scales and other available auditory data. RESULTS: The results of the first study show that the curves found for the Hebrew and the Arabic translations of the LittlEARS® Auditory Questionnaire are essentially similar to those previously found for other languages. These curves reflect the age dependency of auditory skills. Furthermore, in the group with cochlear implants the developmental pattern was different than that of the normal hearing group, with an initial steep increase and a later slower improvement. This trend appeared both in curves of groups and in curves of individuals (individuals whose parents completed the questionnaire at several points in time). There was a high correlation between scores on the LittlEARS® Auditory Questionnaire and results of other audiologic tests, showing validity of results with the LittlEARS® Auditory Questionnaire. CONCLUSION: Both the Hebrew and Arabic versions of the LittlEARS® Auditory Questionnaire were found to be reliable and valid tools for assessment of the development of auditory behavior in children up to the age of 24 months. Furthermore, the LittlEARS® Auditory Questionnaire in both languages is useful in monitoring the progress of children with cochlear implant.

Morbidity and mortality of post-tonsillectomy bleeding: analysis of cases.

OBJECTIVES: To analyse the circumstances of mortality in post-tonsillectomy bleeding cases, in order to better manage serious problems during resuscitation. DESIGN: Reports of inquiry committees on post-tonsillectomy mortalities. SETTING: State of Israel Ministry of Health committees. PARTICIPANTS: Senior otolaryngologists and related professionals, and the involved medical staff who participated in the inquiry committees. MAIN OUTCOMES MEASURES: Identification of actions causing undesirable effects on resuscitation outcomes. RESULTS: In recent years, the post-tonsillectomy mortality rate in Israel has been one in 12,000. The two main causes of death have been severe haemorrhagic shock and airway obstruction. CONCLUSIONS: Active bleeding should be treated, rather than waiting for spontaneous resolution. An efficient airway should be established early during resuscitation, either by intubation (within two minutes) or by cricothyroidotomy. The two main factors endangering the patient's life during resuscitation are severe blood loss, interfering with effective cardiac output, and airway obstruction. Blood loss should be quickly substituted.

Bone conduction experiments in humans - a fluid pathway from bone to ear.

Animal experiments in this laboratory have led to the suggestion that a major pathway in bone conduction stimulation to the inner ear is via the skull contents (brain and CSF). This hypothesis was now tested in humans. Auditory nerve brainstem evoked responses could be recorded in neonates to bone conduction stimulation over the fontanelle and audiometric responses were obtained in neurosurgical patients with the bone vibrator on the skin over a craniotomy. There were no differences in threshold between these responses and those obtained to bone conduction stimulation over skull bone in the same subjects. Audiometric thresholds in response to bone vibrator stimulation of the eye (a 'natural craniotomy') were no different from those to bone stimulation delivered to several sites on the head. Thus there is no need to vibrate bone in order to obtain 'bone conduction' responses. Bone vibrator thresholds to stimulation at the head region with thinnest bone (temporal) were better than those to stimulation at the forehead region which has much thicker bone, implying that the vibrations penetrate the skull at the site of the vibrator. In addition, the magnitude of vibration (acceleration) measured at various sites around the head in response to bone vibrator stimulation at a fixed point on the forehead generally decreased with distance from the point of vibration. Therefore it seems that the vibrations produced by a bone vibrator at a point on the head are also able to penetrate the skull, setting up audio-frequency pressures in the CSF which spread by fluid communications to the inner ear fluids, exciting the ear.

Development of inner ear (cochlear and vestibular) function in the fetus-neonate.

The development of function in the various receptors in the inner ear was studied in the neonatal rat, which is altricious with respect to hearing, using short latency evoked potentials, both auditory (ABR) and vestibular (VsEP). It was found that VsEPs could be recorded from all the vestibular end-organs by post natal day (PND) 8, whilst ABR could only be recorded from all animals on PND 14, showing the earlier onset of vestibular function in the inner ear. These results are discussed with relation to onset of inner ear function in the human fetus.

Transient evoked otoacoustic emissions in newborns in the first 48 hours after birth.

Newborns are often discharged from hospital at the age of about 48 hours. At this age, transient evoked otoacoustic emissions (TEOAEs) are not necessarily recordable in all healthy newborns. In order to determine the factors which would enable the successful recording of TEOAEs before discharge to facilitate screening for hearing, 65 fullterm newborns under 48 hours of age were tested, the youngest being 10 hours old. The ears of those neonates in whom TEOAEs could not be obtained (N = 7 neonates bilaterally, 6 unilaterally) were examined otoscopically, cleaned of vernix and retested for TEOAEs. We were thus able to record in at least one ear in all neonates tested, if the ears were clean, if they were asleep and if the testing room was quiet.

Cooling induces a decrease in middle ear compliance.

The effects of cooling rats from 37 degrees C to 27 degrees C and rewarming to 37 degrees C on the conductive mechanism of the middle ear was studied by means of acoustic impedance measurements. Cooling reduced middle ear compliance reversibly, without an effect on external canal volume and middle ear pressure. These results provide evidence for an increase in the stiffness of the tympanic membrane and/or of the ossicular chain and/or a decrease in stapes mobility. Thus a small part of the decrease in the magnitude of otoacoustic emissions during cooling is due to an effect on the conductive mechanism of the middle ear.

The role of adrenocortical steroid hormones in the development of hearing.

Based on the findings that adrenocortical hormones are involved in the regulation of Na+, K(+)-ATPase in several tissues and the presence of receptors for these hormones in the ear during auditory development, it has been suggested that these hormones also induce Na+, K(+)-ATPase activity and the endocochlear potential in the ear, leading to auditory function in the fetus-neonate. In order to test this hypothesis, glucocorticoid and mineralocorticoid hormones were injected into rat pups and their auditory development, compared to control litter-mates, was tested by recording auditory nerve-brainstem evoked potentials (ABR). Those who received glucocorticoid hormones had elevated ABR thresholds on post-natal day (PND) 9, others on PND 11 and still others on PND 16, compared to control litter-mates. The ABR thresholds of those injected with mineralocorticoids were not different from those in controls. These results and additional considerations related to the time sequence of the natural appearance of these hormones in the plasma, of their receptors in the ear and the onset of hearing in rat pups makes it extremely unlikely that adrenocortical hormones are involved in the initiation of Na+, K(+)-ATPase pumps and thereby of the endocochlear potential in the inner ear. It is possible that these hormones and their receptors play a role in the later regulation of the number of pumps.

Human fetal auditory threshold improvement during maternal oxygen respiration.

It has been suggested that the near full-term fetus in-utero has a sensori-neural hearing loss compared to the neonate due to the relative hypoxia resulting from placental oxygenation compared to pulmonary oxygenation. This hypothesis was tested by estimating the threshold of the fetus to vibrio-acoustic stimulation applied to the maternal abdomen while the mother was breathing room air and again when breathing oxygen. Fetal response was assessed by maternal perception of fetal movement and by objective demonstration of movement by ultrasound. It has been shown that the fetal responses are to the acoustic component of the stimulus, that the acoustic stimulus is not overly attenuated or masked, and that maternal oxygen inhalation enhances fetal oxygenation. The results showed that the threshold was lower and/or the response was stronger when the mother was breathing oxygen compared to when she was breathing room air. Thus it is confirmed that in-utero the fetus has an hypoxia-induced sensori-neural hearing loss. At birth, with the shift to more efficient pulmonary oxygenation, there is an improvement in auditory threshold.

Thyroid hormone induces earlier onset of auditory function in neonatal rats.

The effect of thyroid hormone injection on the development of auditory function in neonatal rats was evaluated using auditory nerve-brainstem evoked responses (ABR). The hormone induced earlier onset of auditory function. In order to differentiate between conductive and sensorineural factors, both air-conducted (AC) and bone-conducted (BC) ABR responses were recorded. Neonatal rats were injected with thyroxine (T4), or with saline (control animals), from day of birth (post-natal day-PND-0), daily, until PND 9. AC- and BC-ABRs were recorded from PND 6 up to PND 20. It was found that both AC- and BC-ABR thresholds were lower in the T4-injected rats up to PND 15, after which no difference was found between the two groups. This indicated earlier maturity of both conductive (external and middle ears) and sensorineural (inner ear) factors and is probably due to the earlier appearance in the blood of higher T4 levels, following injection, than that occurring naturally during the neonatal period in these animals.

Development of hearing in neonatal rats: air and bone conducted ABR thresholds.

While the human full-term neonate can hear at birth, in the rat the onset of auditory function as monitored by recording auditory nerve-brainstem evoked responses (ABR) has been reported to begin on post-natal day (PND) 12-14 and reaches adult thresholds at about 22 days. In order to determine the factors involved in this late onset and then rapid threshold improvement in rats, the ABR to both air conducted (AC) and bone-conducted (BC) auditory stimulation was determined in neonatal rats. ABR to maximal intensity BC stimuli (55 dB above adult rat ABR threshold--55 dB HL*) could be recorded from PND 7-8 while AC responses to 80 dB HL* stimuli, only from PND 11. The air-bone gap (a measure of conductive immaturities only) disappeared on PND 15. This shows that there are both conductive (external and middle ear--Air-bone gap) and sensori-neural (inner ear--BC threshold) immaturities in the neonatal rat; the conductive factors are resolved by PND 15 while the sensori-neural continue after that. With respect to conductive factors, it seems that the state of the ear canal is not important while the chief conductive factors involved probably include mesenchyme resorption and/or ossicular ossification. The chief sensori-neural factor may be the development of the endocochlear potential. It is likely that the human fetus in-utero undergoes similar stages of development.

Improved chemotactic ability of neonatal polymorphonuclear cells induced by mild membrane rigidification.

Membrane lipid fluidity of peripheral blood polymorphonuclear cells (PMNs) of 24 newborn infants, 2-4 days after birth, was determined by steady-state fluorescence polarization with 1,6-diphenyl 1,3,5-hexatriene (DPH) as a probe and compared with that of PMNs from 23 adults. Measurements with intact cells, which correspond to all cellular lipid domains, did not display any statistically significant difference between PMNs of the two groups. However, application of bixinoyl glucosamine, a membrane-impermeable fluorescence quencher, revealed that the PMN plasma membrane of the newborn is about 23% more fluid than that of the adult. Total cholesterol-to-phospholipid ratio of newborn PMNs was found to be lower by about 10% than that of the adult, which could account for the difference in their plasma membrane fluidity. The possible implication of this finding for the deficit in chemotactic ability of leukocytes from newborns was tested with neonatal PMNs that have incorporated cholesteryl hemisuccinate (CHS), an efficient plasma membrane rigidifier. In all neonatal PMNs tested a mild incorporation of CHS (0.5-1 min incubation in 50 micrograms/ml dispersion) caused a significant improvement in their net chemotaxis, from an average value of 28 +/- 7 to 43 +/- 11. Longer incubations with CHS caused a gradual decrease in chemotactic ability that approached the basal level after about 5 min incubation. The net chemotaxis in adult PMNs was significantly higher than that of neonatal PMNs (72 +/- 13) and was gradually inhibited by incorporation of CHS without any initial augmentation. Based on these results it was estimated that about 27% of the chemotactic deficit of neonatal PMNs is mediated by their immature fluid membrane.