Service delivery approaches related to hearing aids in low- and middle-income countries or resource-limited settings: A systematic scoping review

Hearing loss is an important global public health issue which can be alleviated through treatment with hearing aids. However, most people who would benefit from hearing aids do not receive them, in part due to challenges in accessing hearing aids and related services, which are most salient in low- and middle-income countries (LMIC) and other resource-limited settings. Innovative approaches for hearing aid service delivery can overcome many of the challenges related to access, including that of limited human resources trained to provide ear and hearing care. The purpose of this systematic scoping review is to synthesize evidence on service delivery approaches for hearing aid provision in LMIC and resource-limited settings. We searched 3 databases (PubMed, Scopus, Ovid MEDLINE) for peer-reviewed articles from 2000 to 2022 that focused on service delivery approaches related to hearing aids in LMIC or resource-limited settings. Fifteen peer-reviewed articles were included, which described hospital-based (3 studies), large-scale donation program (1 studies), community-based (7 studies), and remote (telehealth; 4 studies) service delivery approaches. Key findings are that hearing aid services can be successfully delivered in hospital- and community-based settings, and remotely, and that both qualified hearing care providers and trained non-specialists can provide quality hearing aid services. Service delivery approaches focused on community-based and remote care, and task sharing among qualified hearing care providers and trained non-specialists can likely improve access to hearing aids worldwide, thereby reducing the burden of untreated hearing loss.

Malignant Mixed Germ Cell Tumor of the Testis with Associated Nephroblastoma: A Rare Entity

Introduction/Objective

While nephroblastoma is the most common primary childhood renal malignancy, it rarely occurs at extra-renal sites. Testicular nephroblastoma is exceedingly rare, with only 5 previously reported cases arising in association with primary testicular teratoma (4 of which arising in non-atrophic, and 1 arising in atrophic testis). We report a case of testicular nephroblastoma with multiple associated germ cell components.

Methods/Case Report

The case is that of a 28-year-old male presenting with an enlarging, painless right scrotal swelling. Laboratory results showed elevated serum AFP with normal LDH and beta-HCG, and imaging confirmed the presence of a heterogenous testicular mass. A radical orchiectomy was performed, revealing a tan-white, fleshy, nodular 5.5 cm mass almost entirely replacing the testicular parenchyma. Microscopically, the tumor consisted of multiple components. The nephroblastoma component was associated with teratoma with immature elements and consisted of epithelial tubular structures, small blue blastemal cells, and pale mesenchymal stroma which demonstrated pan-cytokeratin and patchy WT1 expression by immunohistochemistry. Additional components included yolk sac tumor and minor component of seminoma. Foci of germ cell neoplasia in-situ were also identified, supported by immunohistochemical stains for PLAP and OCT3/4. The patient’s post-resection tumor markers normalized, and further assessment for metastasis and chemotherapy is pending.

Results (if a Case Study enter NA)

NA

Conclusion

Malignant mixed germ cell tumors of the testis with associated nephroblastoma are exceedingly rare, further studies nand followup are required to determine prognostic values and achieve a more complete understanding of this combination of entities.

One-eartip solution for pure-tone audiometry and acoustic immittance measurements: using insert earphone with an immittance probe ear tip

OBJECTIVE

Two consecutive studies sought to determine the (1) Equivalent Threshold Sound Pressure Levels (ETSPLs) and, (2) real ear attenuation thresholds (REAT) for the KUDUwave earcup configured with an insert earphone using a typical immittance probe tip (TPT).

DESIGN

(1) Hearing thresholds were measured for frequencies 125 to 8000 Hz using the TPT. ETSPLs were calculated in an IEC 60318-4 occluded ear simulator. (2) REAT were obtained by measuring sound field thresholds with ears uncovered and covered with the investigational transducer. The attenuation values were used to determine the maximum permissible ambient noise levels (MPANLs).

STUDY SAMPLE

(1) Study 1 included twenty-five adult participants with no otologic diseases (8 females; 18 - 33 years). (2) Study 2 included fifteen normal hearing participants aged 21-31 years.

RESULTS

Established ETSPLs, REAT, and MPANLs for the TPT are presented in this paper. The determined TPT ETSPLs differed from the ER-3A foam tip insert earphone's RETSPLs reported in ISO 389-2.

CONCLUSIONS

The investigational transducer can be used for pure-tone audiometry provided the reported MPANLs are adhered to, and ETSPL values are employed for calibration purposes. The advantage is to achieve a cost-effective one-probe tip solution for pure tone audiometry and immittance measurement.

Large Vestibular Aqueduct Syndrome: A Case Study

A 23-month-old female was referred for hearing aid fitting after failing newborn hearing screening and being diagnosed with significant hearing loss through subsequent diagnostic testing. Auditory brainstem response (ABR) and behavioral testing revealed a moderate-to-severe bilateral mixed hearing loss. Prior to the hearing aid evaluation, tympanostomy tubes had been placed bilaterally with little or no apparent change in hearing sensitivity. Initial testing during the hearing aid fitting confirmed earlier findings, but abnormal middle ear results were observed, requiring referral for additional otologic management. Following medical clearance, binaural digital programmable hearing aids were fit using Desired Sensation Level parameters. Behavioral testing and probe microphone measures showed significant improvements in audibility. Decrease in hearing sensitivity was observed six months following hearing aid fitting. Radiological studies, ordered due to the mixed component and decreased hearing sensitivity, revealed large vestibular aqueduct syndrome (LVAS). Based on the diagnosis of LVAS, a cochlear implant was placed on the right ear; almost immediate speech-language gains were observed.

Effect of Ear Canal Occlusion on Pure-Tone Threshold Sensitivity

This study sought to quantify the effects of varying the degree of ear canal occlusion on pure-tone threshold sensitivity. Thresholds were obtained from each ear of five normal-hearing adults without occlusion, with complete occlusion, and with partial occlusion estimated to be 40–60% and 60–80%. A commercial lubricant was used in the completely occluded condition to eliminate possible acoustic leakage. Results showed a reduction of threshold sensitivity in all occluded conditions, with the greatest effect in frequencies above 1000 Hz. Only in the completely occluded condition were frequencies below 1000 Hz affected. In the partially occluded conditions, thresholds decreased by an average 7.5 dB and 13.0 dB across frequency for the 40–60% and 60–80% conditions respectively. At frequencies above 1000 Hz, the average threshold shifts for the two partially occluded conditions were 10.0 dB and 16.8 dB respectively. The implications of these findings on routine pure-tone audiometric procedures, with specific relevance for industrial hearing conservation programs, are discussed.

Ethics and Etiquette in Humanitarian Engagement-101

As the travel industry continues to grow, so does the creation and proliferation of voluntourism opportunities offered to individuals who want to impact the lives of populations due to adversities or misfortunes of war, weather, or poverty. A more popular form of tourism for individuals to volunteer professional or personal expertise in a chartable manner is often termed "voluntourism." Unquestionably, there is a lure to volunteer for a short-term experience in exotic lands with the hopes of improving living conditions. This article aims to identify how an individual can move from being a well-meaning voluntourist to an engaged and dedicated humanitarian by following professional ethical principles and etiquette behavior.

Social Network Organization, Structure, and Patterns of Influence Within a Community of Transgender Women in Lima, Peru: Implications for Biomedical HIV Prevention

Understanding social network structures can contribute to the introduction of new HIV prevention strategies with socially marginalized populations like transgender women (TW). We conducted 20 semi-structured interviews and four focus groups (n = 32) with TW from selected social networks in Lima, Peru between May and July, 2015. Participants described layers of social influence from diverse actors in their social networks. The majority identified a close relative as their primary social support, with whom they confided secrets but avoided issues of transgender identity, sexuality, and sex work. Participants described close circles of TW friends with whom they shared information about gender identity, body modification, and sexual partners, but avoided issues like HIV. Community leadership included political leaders (who advocated for transgender rights) as well as social leaders (who introduced TW to hormone therapy, body modification, and commercial sex). Detailed analysis of TW social networks can contribute to implementation and acceptability of new HIV prevention technologies.

Pure-tone audiometry outside a sound booth using earphone attentuation, integrated noise monitoring, and automation

OBJECTIVE

Accessibility of audiometry is hindered by the cost of sound booths and shortage of hearing health personnel. This study investigated the validity of an automated mobile diagnostic audiometer with increased attenuation and real-time noise monitoring for clinical testing outside a sound booth.

DESIGN

Attenuation characteristics and reference ambient noise levels for the computer-based audiometer (KUDUwave) was evaluated alongside the validity of environmental noise monitoring. Clinical validity was determined by comparing air- and bone-conduction thresholds obtained inside and outside the sound booth (23 subjects).

STUDY SAMPLE

Twenty-three normal-hearing subjects (age range, 20-75 years; average age 35.5) and a sub group of 11 subjects to establish test-retest reliability.

RESULTS

Improved passive attenuation and valid environmental noise monitoring was demonstrated. Clinically, air-conduction thresholds inside and outside the sound booth, corresponded within 5 dB or less > 90% of instances (mean absolute difference 3.3 ± 3.2 SD). Bone conduction thresholds corresponded within 5 dB or less in 80% of comparisons between test environments, with a mean absolute difference of 4.6 dB (3.7 SD). Threshold differences were not statistically significant. Mean absolute test-retest differences outside the sound booth was similar to those in the booth.

CONCLUSION

Diagnostic pure-tone audiometry outside a sound booth, using automated testing, improved passive attenuation, and real-time environmental noise monitoring demonstrated reliable hearing assessments.

Objective and perceptual comparisons of two bluetooth hearing aid assistive devices

PURPOSE

With the advent of Bluetooth technology, many of the assistive listening devices for hearing have become manufacturer specific, with little objective information about the performance provided.

METHOD

Thirty native English-speaking adults (mean age 29.8) with normal hearing were tested pseudo-randomly with two major hearing aid manufacturers' proprietary Bluetooth connectivity devices paired to the accompanying manufacturer's specific hearing aids. Sentence recognition performance was objectively measured for each system with signals transmitted via a land-line to the same iPhone in two conditions.

RESULTS

There was a significant effect of participant's performance according to listening condition. There was no significant effect between device manufacturers according to listening condition, but there was a significant effect in participant's perception of "quality of sound".

CONCLUSIONS

Despite differences in signal transmission for each devise, when worn by participants both the systems performed equally. In fact, participants expressed personal preferences for specific technology that was largely due to their perceived quality of sound while listening to recorded signals. While further research is necessary to investigate other measures of benefit for Bluetooth connectivity devices, preliminary data suggest that in order to ensure comfort and compatibility, not only should objective measures of the patient benefit be completed, but also assessing the patient's perception of benefit is equally important. Implications for Rehabilitation All professionals who work with individuals with hearing loss, become aware of the differences in the multiple choices for assistive technology readily available for hearing loss. With the ever growing dispensing of Bluetooth connectivity devices coupled to hearing aids, there is an increased burden to determine whether performance differences could exist between manufacturers. There is a growing need to investigate other measures of benefit for Bluetooth hearing aid connectivity devices that not only include objective measures, but also patient perception of benefit.

Technology for hearing loss--as We Know it, and as We Dream it

PURPOSE

Worldwide demand for accessible hearing health technology continues to increase while the numbers of hearing healthcare specialists are grossly inadequate to meet this demand. Proliferation of innovative technology and the advent of greater access to global connectivity are providing an opportunity to identify and harness new resources that may change current audiological service delivery methods to maximize access, efficiency and impact.

METHODS

By searching through the most current literature and engaging in discussions with industry experts, it is possible to identify avenues that could increase services to those who have hearing loss with innovative healthcare technology. This article aims to review the current state as well as future trends of hearing health technology by addressing: Technology as We Know it; and Technology as We Dream it.

RESULTS

Some of the newer technologies we have recently witnessed include: micro processors; personalized computing devices (e.g. smartphones); web-based applications; an expanding clinical repertoire with integrated test equipment; and globalization of telecommunications that opens the door to telehealth; and self-fitting of hearing aids. Yet, innovation continues scaffolding on recent successes with innovations for hearing healthcare expected to increase into the future.

CONCLUSION

As technology and connectivity continue to evolve so should the practice of audiology adapt to the global needs by capitalizing on these advances to optimize service delivery access and sustainability.

IMPLICATIONS FOR REHABILITATION

Capital investment in equipment will be dramatically reduced with smaller, lighter, less costly and more portable equipment. Individuals who live in remote regions with little or no hearing healthcare access can undergo valid assessments by a professional via telehealth. Web-based applications allow clinicians to expand their repertoire and reach of services.

Risk factors for the spread of HIV and other sexually transmitted infections among men who have sex with men infected with HIV in Lima, Peru

OBJECTIVES

To assess the prevalence of sexually transmitted infections (STIs), the frequency of sexual risk behaviours, and the relation between knowledge of HIV infection status and sexual risk behaviour among men who have sex with men (MSM) infected with HIV attending an STI clinic in Peru.

METHODS

We recruited a convenience sample of 559 MSM from a municipal STI clinic in Lima, Peru. Participants completed a survey and provided blood for HIV, syphilis and HSV-2 antibody testing, and urine for gonorrhoea and chlamydia nucleic acid testing.

RESULTS

Among 124 MSM with HIV, 72.6% were aware that they were infected with HIV. Active syphilis (RPR> or =1:8) was diagnosed in 21.0% of men infected with HIV, HSV-2 in 79.8%, urethral gonorrhoea in 1.6% and chlamydia in 1.6%. Among 41 participants reporting insertive anal intercourse with their last sex partner, 34.2% did not use a condom. Of the 86 participants reporting receptive anal intercourse, 25.6% did not use a condom. At least one episode of insertive unprotected anal intercourse (UAI) with a partner uninfected with HIV during the past 6 months was reported by 33.6% (35/104) of participants, and receptive UAI with a partner uninfected by HIV was reported by 44.6% (45/101). There was no difference in frequency of UAI with partners infected or uninfected with HIV observed between men who knew their serostatus compared with those who were previously undiagnosed (all p values >0.05).

CONCLUSIONS

MSM with HIV in Peru engaged in high-risk behaviours for spreading HIV and STIs. Knowledge of whether someone was infected with HIV was not associated with a decreased frequency of UAI. Additional efforts to reduce risk behaviour after the diagnosis of HIV infection are necessary.

Hearing loss in Mozambique: current data from Inhambane Province

Mozambique is a developing African country recuperating from a lengthy civil war. As a result, documenting the incidence of hearing loss has remained a low priority. This paper provides results from work being carried out by the Mozambique Audiology Program (MAP), which is a philanthropic effort established in 1997 to introduce audiology services and identify auditory disorders in the country. Some decades before the MAP, another program reported extremely high incidence rates of otitis media in 1000 primary school students in the capital city of Maputo. This paper presents the MAP results from mass hearing screenings conducted over a two year period on a cohort group of 2685 students ranging in age from 3-18 years at a preschool and primary school in Chicuque and Maxixe, Mozambique. This current study showed a prevalence of 5% of the total 2685 students across ages with varying degrees of hearing loss resulting from multiple etiologies. External auditory canal obstruction was the greatest otoscopic abnormality (regardless of age), followed by severely limited tympanic membrane mobility (i.e. flat tympanogram) in the absence of EAC obstruction in those students identified with hearing loss. Of the 145 student identified with hearing loss, there were 27 found to have active drainage. Some of the benefits of conducting mass hearing screening in this population are discussed.

Assessment of the solubility and bioaccessibility of barium and aluminum in soils affected by mine dust deposition

Barium is a heavy metal to which human and animal receptors may be exposed in various settings--for example, in mineral extraction industries where the mining and milling of ores occurs. Aluminum is also an element abundant in soil and dust to which human and animal receptors may be exposed in association with such industries. This study investigated the solubility and bioaccessibility of barium and aluminum in simulated gastric fluids using an in vitro test method previously validated for lead. Soil samples were collected from the vicinity of a mine and transport road that generated fugitive dust containing barium as barite (BaSO4). It was found that barium bioaccessibility in different tundra soil and fugitive dust source materials varied greatly, between 0.07 and 66.0%, depending on sample location, grain size, solid-to-fluid ratio used in the in vitro experiments, and the analytical method selected for determining total barium concentrations in the sample substrates. For X-ray fluorescence spectrometry (XRF) analytical methods and a solid-to-fluid ratio of 1:100, barium bioaccessibility from the barite-rich mine waste rock and gyro crusher ore dust source materials was very low (0.07-0.36%). By contrast, the bioaccessibility of barium in tundra soil samples affected by fugitive dust deposition ranged from 3.8 to 19.5%. The relative solubility of barium measured in the simulated gastric fluids of this study is consistent with time-dependent dissolution of barite in mine waste rock and ore dust, and the presence of more soluble chemical forms in tundra soil. Laboratory XRF analysis was the only analytical method used in this study that accurately characterized total barium concentrations for all sample substrates. Aluminum bioaccessibility was distinguished from barium bioaccessibility by its generally lower values and smaller dependence on grain size and solid-to-fluid ratios. The range of aluminum bioaccessibility values (0.31-4.0%) is consistent with the predominance of aluminum in relatively insoluble aluminosilicate minerals.

Molecular recognition in cyclodextrin complexes of amino acid derivatives. 2. A new perturbation: the room-temperature crystallographic structure determination for the N-acetyl-p-methoxy-L-phenylalanine methyl ester/beta-cyclodextrin complex

Cyclodextrins (CDs) are cyclic oligosaccharides that encapsulate various small organic molecules, forming inclusion complexes. Because CD complexes are held together purely by noncovalent interactions, they function as excellent models for the study of chiral and molecular recognition mechanisms. Recently, room-temperature crystallographic studies of both the 2:2 N-acetyl-L-phenylalanine methyl ester/beta-CD and 2:2 N-acetyl-L-phenylalanine amide/beta-CD complexes were reported. The effect of changes in carboxyl backbone functional group on molecular recognition by the host CD molecule was examined for the nearly isomorphous supramolecular complexes. A new perturbation of the system is now examined, specifically perturbation of the aromatic side chain. We report a room-temperature crystal structure determination for the 2:2 N-acetyl-p-methoxy-L-phenylalanine methyl ester/beta-CD inclusion complex. The complex crystallizes isomorphously with the two previously reported examples in space group P1; the asymmetric unit consists of a hydrated head-to-head host dimer with two included guest molecules. The crystal packing provides both a nonconstraining extended hydrophobic pocket and an adjacent hydrophilic region, where hydrogen-bonding interactions can potentially occur with primary hydroxyl groups of neighboring CD molecules and waters of hydration. The rigid host molecules show no sign of conformational disorder, and water of hydration molecules exhibit the same type of disorder observed for the other two complexes, with a few significant differences in locations of water molecules in the hydrophilic region near guest molecules. There is evidence for modest disorder in the guest region of an electron density map. In comparing this system with the two previously reported complexes of phenylalanine derivatives, it is found that the packing of the guest molecules inside the torus of the CD changes upon substitution of a methoxy group at the para position of the aromatic phenyl ring. Backbone hydrogen-bonding interactions for the guest molecules with the CD primary hydroxyls and waters also change. This structure determination is a new and revealing addition to a small but growing database of amino acid and peptidomimetic interactions with carbohydrates.

Molecular recognition in cyclodextrin complexes of amino acid derivatives. 1. Crystallographic studies of beta-cyclodextrin complexes with N-acetyl-L-phenylalanine methyl ester and N-acetyl-L-phenylalanine amide pseudopeptides

Cyclodextrins (CDs) are widely utilized in studies of chiral and molecular recognition. By changing the functionality of the guest molecule, the effect of such changes on recognition by the host CD molecule can be examined. We report crystal structure determinations for two nearly isomorphous complexes of phenylalanine derivatives: beta-CD/N-acetyl-L-phenylalanine methyl ester and beta-CD/N-acetyl-L-phenylalanine amide. The complexes crystallize as hydrated head-to-head host dimers with two included guest molecules in space group P1. The crystal packing is such that it presents a nonconstraining hydrophobic pocket adjacent to a hydrophilic region, where potential hydrogen-bonding interactions with hydroxyl groups of neighboring cyclodextrin molecules and waters of hydration can occur. The two host molecules display very similar conformations; only a few of the primary hydroxyl groups are conformationally disordered. There are a number of changes in the location of water of hydration molecules, some of which are the result of different hydrogen-bonding interactions. For the different guest molecules, similar modes of penetration are observed in the CD torus; however, there is a 0.985-A shift in the position of the guest molecules in the host torus, which takes place without changing the hydrophobic interactions displayed by the phenyl side chains. This observation and the thermal motion of the guest molecules in the ester complex are taken as evidence that complex binding forces are weak. The pseudopeptides experience a significant degree of flexibility in the crystalline environment provided by CD dimers. Conformational differences of the pseudopeptide backbones and the presence of disordered water molecules in the host-guest interface provide examples of different hydrogen-bonding schemes of similar potential energy. The crystal system presents an opportunity to establish a database of molecular interactions for small peptides and peptide analogues with waters of hydration and functional groups in nonconstraining binding environments.

Ventral incisional hernia recurrence

During the period October 1993 to December 1996, 31 patients were operated on by the author for primary or recurrent ventral incisional hernia (VIH). Three patients were excluded from analysis because their records were unavailable for review. The median age of the 28 remaining patients at their initial procedure was 57.5 years (range, 37-78 years). The repair was performed with interrupted O-Ethibond sutures in all but 3 cases where Prolene suture was used secondary to noniatrogenic contamination or recurrent hernia. There were no unplanned enterotomies in the entire series and prophylactic intravenous antibiotics were used in all cases. The only significant complications were skin hyperemia after five repairs in 3 patients who were treated empirically with intravenous antibiotics, and 1 patient who had an antibiotic-associated rash. There were no 30-day mortalities. Prolene mesh was used exclusively in all repairs performed with mesh. Seven of these repairs (25%) were for recurrent VIH. Three of these seven patients had previous mesh repairs. Six of these seven patients who presented with recurrent VIH had a mesh repair and four developed a recurrence. Five of seven were active smokers, with one having severe obstructive lung disease. Four of seven related significant occupational lifting. Of the 21 patients having initial repair of VIH, mesh was used in 8 (38%). After a median follow-up of 13 months, there were 2 recurrent hernias (25%). The remaining 13 patients had primary closure of their hernias. After median follow-up of 25 months, there were 5 recurrences (38%). A total of 34 VIH repairs were performed on these 28 patients, of which 13 were for recurrent hernias. Five of thirteen (38%) of the mesh repairs for recurrent VIH failed. The median body mass index (BMI) for the 13 patients having primary repair was 26.4, and that for all 21 cases having mesh repair was 28.8. Patients with recurrent VIH frequently recur despite use of mesh, avoidance of contamination, and consistent technique. No difference in BMI was apparent in those who recurred. Continued smoking and occupational lifting may be important risk factors for recurrent VIH.

Invasive properties of murine squamous carcinoma cells: secretion of matrix-degrading cathepsins is attributable to a deficiency in the mannose 6-phosphate/insulin-like growth factor II receptor

Penetration of basement membrane layers is a hallmark feature of metastatic tumor cells. The invasive propensity of murine SCC-VII squamous carcinoma cells is in part attributable to the extracellular action of the lysosomal cysteine proteinase cathepsin B. Although most noncancerous cells store this enzyme in the lysosomes, we found that SCC-VII cells release a large fraction (42%) of their newly synthesized procathepsin B into the culture medium. Procathepsins D and L, the precursors of other major lysosomal proteinases, are also secreted in significant amounts (24 and 75%, respectively). In contrast, normal murine 3T3-L1 fibroblasts exocytose only minor amounts of their newly synthesized procathepsins B (10%), D (<1%), and L (16%). Western blotting analysis revealed that SCC-VII cells are deficient in the 300 kDa mannose 6-phosphate/insulin-like growth factor-II receptor (M6P/IGF2R), a tumor suppressor with a central role in the intracellular transport of lysosomal enzymes. Consistent with the absence of M6P/IGF2R, SCC-VII cells lack dense lysosomes, with the bulk of intracellular acid hydrolases residing in late endosomes/ prelysosomes. On the other hand, the synthesis of the M6P recognition marker on lysosomal enzymes is not impaired in SCC-VII cells, because [33P]Pi is incorporated into the carbohydrate moieties of procathepsins B, D, and L. Furthermore, 69% of the phosphorylated N-linked oligosaccharides synthesized by SCC-VII cells carry phosphomonoester groups and as such constitute high-affinity ligands for M6P receptors. SCC-VII cells express the 46 kDa cation-dependent M6P receptor (MPR46), but intracellular retention of procathepsins B, D, and L is not affected by ammonium chloride and chloroquine, agents known to perturb the M6P receptor system. Our results indicate that failure to express the 300 kDa M6P/IGF2R may enhance the metastatic capacity of tumor cells by inducing the secretion of procathepsins B, D, and L.

Prognostic variables in male breast cancer

The prognostic role of ploidy status, S phase fraction, estrogen and progesterone receptor status, and the expression of p53 and erbB-2 protein in male breast carcinoma (MBC) remains controversial. The primary objective of this study was to determine which of the common prognostic factors for female breast cancer predict prognosis in MBC. A secondary objective was to assess the impact of comorbid illnesses on survival. A retrospective review of demographic data, surgical treatment, pathological staging, adjuvant treatment and follow-up was completed for 16 patients with MBC (1 intraductal and 15 invasive). Formalin-fixed, paraffin-embedded tissue was processed for ploidy, S phase fraction, and immunohistochemical detection of estrogen and progesterone receptors plus expression of p53 and erbB-2 protein. Six of 15 patients with infiltrating ductal carcinoma are currently alive without evidence of disease and a median survival of 61 months. Nine patients died after a median survival of 52 months, with 6 patients having no evidence of recurrent breast cancer. Two of 3 deaths secondary to advanced breast cancer occurred in patients who initially presented with T4 lesions and were staged IIIB. Two of 15 tumors were erbB-2 positive, whereas only 1 tested weakly positive for p53 protein. We observed that MBCs express erbB-2 and p53 proteins infrequently. Neither ploidy status, S phase fraction, nor erbB-2/p53 status provided any apparent improvement in establishing prognosis beyond routine pathological staging. Advanced TNM stage was associated with diminished survival. The majority of MBCs express estrogen and progesterone receptors. Survivals in MBC were reduced in association with comorbid medical conditions.

Modulation of invasive properties of murine squamous carcinoma cells by heterologous expression of cathepsin B and cystatin C

Murine SCC-VII squamous carcinoma cells have the capacity to penetrate reconstituted basement membranes (Matrigel) in vitro. The invasion of Matrigel layers by SCC-VII cells was significantly reduced by E-64, a specific inhibitor of lysosomal cysteine proteinases. The cathepsin-B-selective E-64 derivative, CA-074, inhibited penetration of Matrigel by SCC-VII cells to the same extent, indicating a major role for this particular lysosomal enzyme in extracellular-matrix degradation during squamous-carcinoma-cell invasion. SCC-VII cells were stably transfected with a cDNA encoding human procathepsin B, in an attempt to modulate the invasive properties of the cell line. The transfected cells expressed the heterologous gene, secreted increased amounts of procathepsin B and displayed enhanced invasive potential. In vivo, the activity of cathepsin B is strictly regulated by endogenous inhibitors. SCC-VII cells were therefore also stably transfected with a cDNA encoding human cystatin C, the most potent cysteine-proteinase inhibitor in mammalian tissues. The expression of this transgene resulted in the production of active recombinant cystatin C and a pronounced reduction in Matrigel invasion. These studies demonstrate that the invasive properties of squamous-cell carcinomas can be changed by modulation of the balance between cathepsin B and its endogenous inhibitors, and provide further evidence for the involvement of this lysosomal cysteine proteinase in tumour invasion and metastasis.

Population genetics and phylogenetic analysis of Colorado Borrelia burgdorferi

Borrelia burgdorferi is transmitted in an enzootic cycle in Colorado between the tick Ixodes spinipalpis and the woodrat Neotoma mexicana. The genetic relationship of Colorado isolates to other B. burgdorferi isolates is unknown nor have relationships among various Colorado isolates been determined. Portions of the flagellin (fla), 66-kD protein, and outer surface protein A (ospA) genes were amplified from 71 Colorado isolates, screened for genetic variability using single strand conformation polymorphism analysis, and unique alleles were sequenced. Colorado isolates were most similar to tick isolates from California and New York isolate 25015. Genetic distances among Colorado ospA sequences were the same or higher than distances among other isolates whereas distances among fla sequences tended to be the same or lower. The index of association (I(A)) was calculated among all loci as a measure of clonality. The I(A) among Colorado isolates was similar to I(A) previously estimated among other United States isolates.

Real-ear characteristics of the ALGO2 acoustic transducer assembly

Clinical reports regarding the use of the ALGO2 neonatal automated auditory brainstem response (AABR) screening device have been concerned only with issues of sensitivity and specificity. This study was undertaken to evaluate how couplers and their placement affect the ALGO2 click spectral properties. Although not recommended by the manufacturer, substituting less expensive, uncalibrated couplers for the standard earphone may be a tempting alternative in clinical practice. Click spectra of an ALGO2 were analyzed with a real-ear system so that comparisons could be made between probe tips and the standard coupler. In addition, ALGO2 screening data from neonates using the standard earphone and a substitute probe tip were compared. The results are in agreement with the manufacturer's specifications when the ALGO2 is used as prescribed. However, with probe tip couplers, SPL values were markedly increased, particularly as insertion depth of the probes varied. The neonatal AABR results show that coupler type and placement can also produce inaccurate screening evaluations and erroneous conclusions.

Drug therapy in haemodialysis patients. Special considerations in the elderly

End-stage renal disease (ESRD) is the stage of renal failure at which an individual requires dialysis therapy or a renal transplant to survive. The prevalence of ESRD is disproportionately higher among patients aged > 65 years, and the average age of new ESRD patients is continually rising in the US Medicare population. Medication management in this population is challenging because of the combination of multiple comorbid disease states, a plethora of medications and the added dimension of dialysis therapy, as well as pharmacokinetic and pharmacodynamic changes attributable to the aging process. Cardiovascular disorders such as hypertension, coronary artery disease, congestive heart failure and arrhythmias are common in elderly patients with ESRD, and account for most of the deaths in this population. Constipation is common in patients aged > 65 years, and its incidence is even higher among those receiving dialysis. Pain management is of particular concern because elderly dialysis patients are frequently prescribed inappropriate pain relief regimens. Many healthcare practitioners do not realise that patients with uraemia are at a higher risk of bleeding caused by nonsteroidal anti-inflammatory drugs than are patients with normal renal function. In addition, most practitioners do not appreciate that virtually all opioids (narcotics) and their active metabolites accumulate in patients with renal failure, leading to an increased risk of narcosis. Infectious complications are frequent in the ESRD population, with dialysis access infections and pneumonia being the 2 most common infections seen in hospitalized patients receiving dialysis treatment. The establishment of vaccination programmes for the prevention of hepatitis B, influenza and pneumococcal infections is important because of the increased risk of these disease in this population. Unfortunately, these high-risk patients display, in general, a decreased immunogenic response to vaccinations. This article addresses some of the practical issues that surround the medication management or prevention of these particular diseases in elderly patients undergoing haemodialysis. Specifically, we discuss the pharmacokinetic and pharmacodynamic changes that occur with specific medications in such patients. Drug dialysability is also discussed.

Interaural time effects on the frequency-following response

Frequency-following responses (FFRs) were recorded to evaluate differences between monaural and binaural waveforms and waveforms evoked by stimuli with interaural time disparities. Eight normal-hearing adult females served as subjects. The stimuli were monaural and binaural 450-Hz tonebursts at 65 and 60 dB SL and interaural time differences of 0 and 660 microseconds, respectively. Normalized amplitudes and periodicities of FFR waveforms within and between subjects were compared. The results showed asymmetric FFR to the various stimuli used in this study. Binaural FFR waveforms were greater than monaural but smaller than summed monaural FFRs. Binaural FFR amplitudes evoked by a zero time difference were greater than amplitudes evoked by a 660-microseconds difference. Additionally, tight phase-locked periodicities were evoked in the FFR monaurally and binaurally. The averaged FFR periodicity to all stimulus conditions from all subjects was 2.29 msec, differing only 6.8 microseconds from the period of the 450-Hz stimulus. In contrast, monaural and binaural neurons in the lower brain stem typically exhibit much less synchroneities to low-frequency tones than the FFR. These data provide evidence that the FFR is not simply a sum of neuronal action potentials. The findings suggest instead the presence of brainstem neuronal networks. Such putative neuronal ensembles apparently maintain a closer correspondence to the period of a low-frequency sound, whether monaural or binaural, than the discharge patterns of single neurons.

Culturing selects for specific genotypes of Borrelia burgdorferi in an enzootic cycle in Colorado

In Colorado, Borrelia burgdorferi sensu stricto, the etiologic agent of Lyme disease, is maintained in an enzootic cycle between Ixodes spinipalpis ticks and Neotoma mexicana rats (27). The frequencies of flagellin (fla), 66-kDa protein (p66), and outer surface protein A (ospA) alleles were examined in 71 B. burgdorferi isolates from samples from Colorado. Approximately two-thirds of these samples were isolates from I. spinipalpis ticks that had been cultured in BSK-H medium prior to DNA extraction. The remaining samples were from total DNA extracted directly from infected I. spinipalpis ticks. A portion of each gene was amplified by PCR and screened for genetic variability by single-strand conformation polymorphism (SSCP) analysis. We identified three alleles in the fla gene, seven in the p66 gene, and seven in the ospA gene. Sequencing verified that the amplified products originated from B. burgdorferi template DNA and indicated 100% sensitivity and specificity of the SSCP analysis. The frequencies of the p66 and ospA alleles were significantly different between cultured and uncultured spirochetes. The number of three-locus genotypes and the genetic diversity of alleles at all loci were consistently lower in cultured spirochetes, suggesting that culturing of B. burgdorferi in BSK-H medium may select for specific genotypes.

Preclinical antitumor activity of water-soluble paclitaxel derivatives

PURPOSE

Five water-soluble paclitaxel derivatives were extensively evaluated for their antitumor activities relative to the parent drug.

METHODS

Both subcutaneous (s.c.) murine (M109 lung) and human (A2780 ovarian, L2987 lung) tumor models were used for this purpose.

RESULTS

Consecutive daily intravenous (i.v.) paclitaxel therapy of mice bearing s.c. M109, beginning on day 4 or 5 posttumor implant and continuing for 5 days, resulted in a range of maximum gross log cell kill (LCK) values (reflective of delays in tumor growth) and maximum relative median survival time (% T/C) values (reflective of increases in lifespan) of 1.0-2.1 and 132-162% (and one outlying result of 235%), respectively. Against the same tumor model, using the same treatment schedule, each of the water-soluble derivatives was active, with maximum LCK of 1.3-2.5 and T/C of 124-254%. These LCK and %T/C values were always within 0.5 LCK and 15%, respectively, of the concomitantly obtained maximum effects of paclitaxel. When tested in several experiments against staged (50-100 mg) s.c. A2780 tumors, using various i.v. treatment schedules, the water-soluble derivatives achieved a maximum LCK of 1.4-3.8. Evaluated in parallel, paclitaxel achieved a maximum LCK of 2.1-4.5 following every other day x 5 i.v. therapy. When paclitaxel was assayed in several experiments using the staged (50-100 mg) s.c. L2987 tumor model, maximum LCK of 0.9->4.1 were produced following every other day x 5 i.v. therapy. Concomitant testing of the water-soluble derivatives, using the same i.v. treatment schedule, resulted in maximum LCK of 0.2->4.1. In each of the tumor models used, the consistently active, and usually the most active, water-soluble derivative was BMS-185660. The levels of activity observed were comparable (within 1 LCK) to those achieved concomitantly using paclitaxel, and its potency was only slightly inferior to the parent drug.

CONCLUSIONS

Based on the evaluations performed in three distal site tumor models, we conclude that BMS-185660 is a water-soluble paclitaxel derivative with preclinical antitumor activity comparable to that of the parent drug.

Phase II trial of etoposide, doxorubicin, and cisplatin combination in advanced measurable gastric cancer. An Eastern Cooperative Oncology Group study

A phase II study was performed to determine the efficacy and toxicity of the etoposide, doxorubicin, cisplatin (EAP) regimen in the treatment of patients with advanced measurable gastric cancer in a multi-institutional cooperative group setting. Thirty-one evaluable patients with advanced measurable gastric adenocarcinoma were treated with etoposide 120 mg/m2 on days 3, 4, and 5, doxorubicin 20 mg/m2 on days 1 and 8, and cisplatin 40 mg/m2 on days 2 and 9. The treatment was repeated every 28 days. Objective responses were seen in 7 (23%) patients, all achieving partial remissions. Median survival was 9 months for the entire group. Toxicity was mostly hematologic, with grade 3 leukopenia in 26% and grade 4 leukopenia in 55% of the patients. There were 4 treatment-related deaths that were attributable to severe leukopenia and sepsis. Because of the high toxicity and moderate response rate, this regimen is not superior to other less toxic regimens and cannot be recommended for the treatment of advanced gastric cancer outside of an investigational protocol.

Apoptosis in 7-hydroxystaurosporine-treated T lymphoblasts correlates with activation of cyclin-dependent kinases 1 and 2

7-Hydroxystaurosporine (UCN-01) is a potent inhibitor of protein kinase C (PKC) isozymes alpha, beta, and gamma [Seynaeve et al., Mol. Pharmacol, 45: 1207-1214, 1994] that also has antitumor effects in vivo. To determine whether inhibition of PKC can be related to inhibition of cell growth with induction of apoptosis, we compared the effects of UCN-01 to those of the highly selective bisindolylmaleimide PKC antagonist GF 109203X in leukemic T-cell lines. Both compounds potently inhibited PKC activity when added to T-cell membrane preparations and reversed phorbol ester-induced c-fos gene expression in intact cells. However, whereas UCN-01 potently inhibited growth of Jurkat, Molt-3, Molt-4, and Hut-78 cells (IC50 = 20-65 nM, irreversible after 24 h of exposure), GF 109203X had IC50s for cell growth of 3.6-5.0 muM. Less than 3 h after addition, UCN-01 but not GF 109203X-treated cells displayed loss of cells with G2-M DNA content, appearance of a hypodiploid DNA fraction, and evidence of internucleosomal DNA fragmentation. Six h after treatment, cells appeared to accumulate with S-phase DNA content. These effects correlated with selective UCN-01 but not GF 109203X-induced decrease in total and tyrosine phosphorylation of cyclin-dependent kinases (cdks) 1 and 2, and with increases in the histone H1 kinase activities of cdk1 and cdk2. UCN-01 was relatively less potent in inhibition of properly activated cdk1 and cdk2 when added in vitro to H1 kinase assays (IC50 = 1000 and 600 nM, respectively). We conclude that inhibition of PKC alone is not sufficient to account for the actions of UCN-01 and are led to the hypothesis that inappropriate cdk activation either correlates with or actually mediates cell growth inhibition with apoptosis in T lymphoblasts exposed to UCN-01.

Effective treatment of severe cancer pain of the head using low-dose ketamine in an opioid-tolerant patient

We report the case of a 39-year-old man with severe pain due to unresectable squamous-cell carcinoma of the maxillary sinus that had invaded cranial bone and had metastasized to the cervical spine. Tolerance to opioids had developed, and high doses of transdermal, continuous intravenous, and epidural opioids did not control his pain. An acute episode of extremely severe head pain was immediately controlled with a subanesthetic dose of ketamine after failure of a stress dose of corticosteroid and intravenous lidocaine. Because the patient was terminally ill and invasive procedures were not options, we controlled his pain using a low-dose ketamine infusion until his death 13 days later. Ketamine may be a good co-analgesic for breakthrough pain and for severe pain caused by terminal cancer when invasive techniques are inappropriate. Its mechanism of action may include reversal of opioid tolerance in addition to an inherent analgesic effect.

Near-drowning

Near-drowning and drowning are major causes of neurologic injury and death in young persons. Most victims aspirate water, and pulmonary edema develops in many of these cases. Prolonged submersion causes cerebral asphyxia and adversely affects the brain within five minutes. Immediate ventilation and oxygenation are essential in the reversal of cerebral anoxia. During field resuscitation, precautions should be taken to protect the cervical spine because of the possibility of injury. The Heimlich maneuver is used only after unsuccessful attempts at ventilation suggest foreign-body obstruction. Prehospital advanced cardiac life support with tracheal intubation is indicated in patients with severe injuries. On arrival at the hospital, ventilation with continuous positive airway pressure or positive end-expiratory pressure enhances pulmonary function. Many water submersion accidents are avoidable; close supervision of infants and toddlers, installation of a fence around home swimming pools, and abstinence from alcohol during participation in water sports are some practical precautions.

Management of genital herpes

Genital herpes affects over 30 million persons in the United States. Genital herpes has three distinct presenting syndromes, depending on the patient's immune status with regard to the herpes simplex virus. Current diagnostic strategy relies on clinical findings and the selective use of viral culture. Acyclovir is the drug of choice for the treatment of genital herpes. Drug resistance is an increasing problem, requiring the use of newer agents. Treatment of the immunocompromised patient is a special area of concern. In addition to the medical aspects in the treatment of genital herpes, psychosocial requirements should also be addressed.

Management of common anxiety disorders

Anxiety disorders affect 16 percent of the U.S. population. Family physicians treat 90 percent of patients presenting with one or more anxiety disorders. Common anxiety disorders include generalized anxiety disorder, panic disorder and social phobia. Differentiation among these disorders may be difficult, since symptoms and presentations are often similar. Underlying medical disorders and depressive illness may mimic or coexist with anxiety disorders. The chronic, remitting and relapsing nature of anxiety disorders requires the institution of a long-term plan of care. The integration of pharmacologic and psychotherapeutic interventions generally produces the greatest benefit to patients. Pharmacotherapeutic options frequently prescribed by family physicians include benzodiazepines, beta blockers, monoamine oxidase inhibitors, tricyclic antidepressants and azapirones. Useful psychotherapeutic models featuring brief interventions include supportive and cognitive approaches, and behavioral therapies, such as biofeedback, in vivo exposure and systematic desensitization.

Retrospective assessment of solvent exposure in paint manufacturing

This paper describes how exposure to solvents at two large paint making sites was assessed in a study carried out to investigate the possibility of neuropsychological effects resulting from long term exposure to organic solvents. A job exposure matrix was constructed by buildings and year. A detailed plant history was taken and this was used to identify uniform exposure periods during which workers' exposure to solvents was not thought to have changed significantly. Exposure monitoring data, collected by the company before the study, was then used to characterise exposure within each uniform exposure period. Estimates were made for periods during which no air monitoring was available. Individual detailed job histories were collected for subjects and controls. The job histories were used to estimate exposure on an individual basis with the job exposure matrix. Exposure was expressed as duration, cumulative dose, and intensity of exposure. Classification of exposure by duration alone was found to result in misclassification of subjects.

The personality typology of black college students: evidence for a characteristic cognitive style?

This study examined the distributions across personality types (as assessed by the Myers-Briggs Type Indicator) of two samples of black college students (ns = 315 and 447) in comparison to norming data from two manuals. Major differences were found between the black and white samples with regard to the proportions classified as Extroversion-Intuition-Feeling-Perception (ENFP) and Introversion-Sensing-Thinking-Judging (ISTJ). Much higher proportions of the black samples were also clustered at the sensing pole of the perceptual dimension. The findings are discussed in terms of their implications for the existence of a unique black "cognitive style."

Laser midline glossectomy as a treatment for obstructive sleep apnea

Multiple site specific procedures have been proposed to treat obstructive sleep apnea syndrome (OSAS). Midline glossectomy (MLG) is a procedure that directly enlarges the hypopharyngeal airspace using the carbon dioxide laser. The initial experience of 12 patients is presented. Midline glossectomy as the sole procedure was performed on 11 patients who had failed uvulopalatopharyngoplasty (UPPP) and who were felt to have significant hypopharyngeal collapse on physical examination and Müller's maneuver. One patient with primary hypopharyngeal narrowing underwent MLG. Five (42%) were considered responders with Respiratory Disturbance Index (RDI) decreasing from 60.6 per hour to 14.5 per hour. In seven nonresponders, there was no significant change in the RDI (62.6 events per hour to 48.4 events per hour). Cephalometric analysis showed that responders tended to be more retrognathic (sella-nasion-supramentale (S-N-B = 74.4 degrees)) than nonresponders (S-N-B = 79.3 degrees). Responders were significantly less obese (body mass index (BMI = 30.6)) than nonresponders (BMI = 37.9). There were five minor complications including minor bleeding (n = 3), prolonged odynophagia (n = 1), and minor change in taste (n = 1). There were no major complications, and no persistent difficulties with speech or swallowing. These results demonstrate that direct surgical modification of the tongue base and associated structures can significantly impact obstructive apnea. Midline glossectomy or similar procedures may be useful in a subset of patients with OSAS.

Impact of splenectomy on survival following gastrectomy for adenocarcinoma

From 1972 to 1985, 161 palliative and 99 curative gastrectomies were performed, including splenectomy (SPL), in 49 and 42 patients, respectively. The relative contribution of tumor histology and location of primary tumor within the stomach to median survival times in months (MST) was examined by chi-square analysis for patients who had SPL and those who did not. MST for the 40 patients treated by curative gastrectomy and SPL was 33 months compared with 43.5 months in the 56 patients treated by curative gastrectomy without SPL (P = .24). Three postoperative deaths were excluded from this analysis. Neither tumor location nor the histological type had a statistically significant impact on MST within these two groups. SPL was not found to have statistically significant impact on survival following curative gastrectomy. In 46 patients treated by palliative gastrectomy with SPL the MST was 10.5 months compared with 15.5 months in 110 patients who were treated by palliative gastrectomy without SPL (P = .007). Five postoperative deaths and three patients in which primary tumor location could not be accurately determined were excluded from this analysis. The MST of 23 patients treated by SPL who had poor or undifferentiated histology was 8 months, compared with 15 months in 73 patients with similar histology not treated by SPL (P = .02). There was no statistically significant difference in MST between palliative gastrectomy patients who had well or moderately differentiated histology treated with (n = 23) and without (n = 37) SPL (P = .11). The impact of SPL on MST following palliative gastrectomy was not significantly influenced by tumor location in the stomach.(ABSTRACT TRUNCATED AT 250 WORDS)

Serologic evidence of subclinical pertussis in immunized children

Incidental to a vaccine study involving 783 immunized children conducted at two study sites, inner city children had significantly higher geometric mean pertussis agglutinin titers compared with suburban children just before the fourth dose of diphtheria-tetanus-whole cell pertussis vaccine (47 vs. 25; P less than 0.001). Higher titers in the inner city were correlated with residence in census tracts where cases of pertussis were reported. Three hundred thirty-two children in a placebo arm of the study who were clinically observed and had paired serum samples taken during a 2- to 4-month period were analyzed for evidence of natural Bordetella infection. Twelve (11%) inner city children and three (1.3%) suburban children had spontaneous 4-fold or greater rises in at least two different pertussis antibodies measured (agglutinin, antitoxin or enzyme-linked immunosorbent assay for IgG to pertussis toxin, IgG and IgA to filamentous hemagglutinin). Eighty percent of these children had IgA to filamentous hemagglutinin. Nine of 12 inner city children with serologic evidence of pertussis lived within 6 blocks of a case of pertussis reported within 1 month of the observed antibody rise in study subjects; none had a household member with pertussis and none had symptomatic disease.