The neuroanatomy of developmental language disorder: a systematic review and meta-analysis

Developmental language disorder (DLD) is a common neurodevelopmental disorder with adverse impacts that continue into adulthood. However, its neural bases remain unclear. Here we address this gap by systematically identifying and quantitatively synthesizing neuroanatomical studies of DLD using co-localization likelihood estimation, a recently developed neuroanatomical meta-analytic technique. Analyses of structural brain data (22 peer-reviewed papers, 577 participants) revealed highly consistent anomalies only in the basal ganglia (100% of participant groups in which this structure was examined, weighted by group sample sizes; 99.8% permutation-based likelihood the anomaly clustering was not due to chance). These anomalies were localized specifically to the anterior neostriatum (again 100% weighted proportion and 99.8% likelihood). As expected given the task dependence of activation, functional neuroimaging data (11 peer-reviewed papers, 414 participants) yielded less consistency, though anomalies again occurred primarily in the basal ganglia (79.0% and 95.1%). Multiple sensitivity analyses indicated that the patterns were robust. The meta-analyses elucidate the neuroanatomical signature of DLD, and implicate the basal ganglia in particular. The findings support the procedural circuit deficit hypothesis of DLD, have basic research and translational implications for the disorder, and advance our understanding of the neuroanatomy of language.

Resting state electroencephalography power correlates with individual differences in implicit sequence learning

Neuroimaging resting state paradigms have revealed synchronised oscillatory activity is present even in the absence of completing a task or mental operation. One function of this neural activity is likely to optimise the brain's sensitivity to forthcoming information that, in turn, likely promotes subsequent learning and memory outcomes. The current study investigated whether this extends to implicit forms of learning. A total of 85 healthy adults participated in the study. Resting state electroencephalography was first acquired from participants before they completed a serial reaction time task. On this task, participants implicitly learnt a visuospatial-motor sequence. Permutation testing revealed a negative correlation between implicit sequence learning and resting state power in the upper theta band (6-7 Hz). That is, lower levels of resting state power in this frequency range were associated with superior levels of implicit sequence learning. This association was observed at midline-frontal, right-frontal and left-posterior electrodes. Oscillatory activity in the upper theta band supports a range of top-down processes including attention, inhibitory control and working memory, perhaps just for visuospatial information. Our results may be indicating that disengaging theta-supported top-down attentional processes improves implicit learning of visuospatial-motor information that is embedded in sensory input. This may occur because the brain's sensitivity to this type of information is optimally achieved when learning is driven by bottom-up processes. Moreover, the results of this study further demonstrate that resting state synchronised brain activity influences subsequent learning and memory.

Neural basis of implicit motor sequence learning: Modulation of cortical power

Implicit sequence learning describes the acquisition of serially ordered movements and sequentially structured cognitive information, that occurs without awareness. Theta, alpha and beta cortical oscillations are present during implicit motor sequence learning, but their role in this process is unclear. The current study addressed this gap in the literature. A total of 50 healthy adults aged between 19 and 37 years participated in the study. Implicit motor sequence learning was examined using the Serial Reaction Time task where participants unknowingly repeat a sequence of finger movements in response to a visual stimulus. Sequence learning was examined by comparing reaction times and oscillatory power between sequence trials and a set of control trials comprising random stimulus presentations. Electroencephalography was recorded as participants completed the task. Analyses of the behavioral data revealed participants learnt the sequence. Analyses of oscillatory activity, using permutation testing, revealed sequence learning was associated with a decrease in theta band (4-7 Hz) power recorded over frontal and central electrode sites. Sequence learning effects were not observed in the alpha (7-12 Hz) or beta bands (12-20 Hz). Even though alpha and beta power modulations have long been associated with executing a motor response, it seems theta power is a correlate of sequence learning in the manual domain. Theta power modulations on the serial reaction time task may reflect disengagement of attentional resources, either promoting or occurring as a consequence of implicit motor sequence learning.

Effects of non-invasive brain stimulation in dystonia: a systematic review and meta-analysis

Background

Deep brain stimulation is a highly effective treatment of dystonia but is invasive and associated with risks, such as intraoperative bleeding and infections. Previous research has used non-invasive brain stimulation (NIBS) in an attempt to alleviate symptoms of dystonia. The results of these studies, however, have been variable, leaving efficacy unclear.

Objectives

This study aimed to evaluate the effects of NIBS on symptoms of dystonia and determine whether methodological characteristics are associated with variability in effect size.

Methods

Web of Science, Embase, and MEDLINE Complete databases were searched for articles using any type of NIBS as an intervention in dystonia patients, with changes in dystonia symptoms the primary outcome of interest.

Results

Meta-analysis of 27 studies demonstrated a small effect size for NIBS in reducing symptoms of dystonia (random-effects Hedges' g = 0.21, p = .002). Differences in the type of NIBS, type of dystonia, and brain region stimulated had a significant effect on dystonia symptoms. Meta-regression revealed that 10 sessions of active stimulation and the application of concurrent motor training programs resulted in significantly larger mean effect sizes.

Conclusion

NIBS has yielded small improvements to dystonic symptoms, but effect sizes depended on methodological characteristics, with more sessions of stimulation producing a larger response. Future research should further investigate the application of NIBS parallel to motor training, in addition to providing a greater quantity of sessions, to help define optimal parameters for NIBS protocols in dystonia.

Registration

PROSPERO 2020, CRD42020175944.

Built environment color modulates autonomic and EEG indices of emotional response

Understanding built environment exposure as a component of environmental enrichment has significant implications for mental health, but little is known about the effects design characteristics have on our emotions and associated neurophysiology. Using a Cave Automatic Virtual Environment while monitoring indoor environmental quality (IEQ), 18 participants were exposed to a resting state (black), and two room scenes, control (white) and condition (blue), to understand if the color of the virtual walls affected self-report, autonomic nervous system, and central nervous system correlates of emotion. Our findings showed that exposure to the chromatic color condition (blue) compared to the achromatic control (white) and resting-state (black, no built environment) significantly increased the range in respiration and skin conductance response. We also detected a significant increase in alpha frontal midline power and frontal hemispheric lateralization relative to blue condition, and increased power spectral density across all electrodes in the blue condition for theta, alpha, and beta bandwidths. The ability for built environment design to modulate emotional response has the potential to deliver significant public health, economic, and social benefits to the entire community. The findings show that blue coloring of the built environment increases autonomic range and is associated with modulations of brain activity linked to emotional processing.

Moral content influences facial emotion processing development during early-to-middle childhood

Facial emotions are often processed in light of moral information, which can assist in predicting and interpreting the intentions of another. Neurophysiological measures of facial emotion processing (FEP) may be sensitive to moral content. Relatively little is known, however, about the relationship between moral content and FEP during early-to-middle childhood, and how this relationship may change across development. Eighty-four children aged 4-12 years completed a task assessing whether child faces primed within the moral harm/care domain influenced face sensitive event-related potentials (ERPs; N170 and LPP). Results demonstrated that N170 amplitude decreased with age for faces primed with positive moral content, whilst LPP amplitude decreased with age for faces primed with negative moral content. Collectively, this suggests that morally relevant content within the harm/care domain is integrated during the early stages of FEP in early-to-middle childhood. Moreover, stronger language ability was positively correlated with the LPP for fearful faces primed with negative moral content. Overall, findings provide novel evidence to suggest that FEP development may be modulated by moral content, and emotion-specific results may be influenced by language. Findings from this research highlight the complex relationship between broader social cognitive skills during child development.

Resting state electroencephalography (EEG) correlates with children's language skills: Evidence from sentence repetition

Spontaneous neural oscillatory activity reflects the brain's functional architecture and has previously been shown to correlate with perceptual, motor and executive skills. The current study used resting state electroencephalography to examine the relationship between spontaneous neural oscillatory activity and children's language skills. Participants in the study were 52 English-speaking children aged around 10-years. Language was assessed using a sentence repetition task. The main analysis revealed resting state theta power negatively correlated with this task. No significant correlations were found in the other studied frequency bands (delta, alpha, beta, gamma). As part of typical brain development, spontaneous theta power declines across childhood and adolescence. The negative correlation observed in this study may therefore be indicating children's language skills are related to the maturation of theta oscillations. More generally, the study provides further evidence that oscillatory activity in the developing brain, even at rest, is reliably associated with children's language skills.

Periodic and aperiodic neural activity displays age-dependent changes across early-to-middle childhood

The neurodevelopmental period spanning early-to-middle childhood represents a time of significant growth and reorganisation throughout the cortex. Such changes are critical for the emergence and maturation of a range of social and cognitive processes. Here, we utilised both eyes open and eyes closed resting-state electroencephalography (EEG) to examine maturational changes in both oscillatory (i.e., periodic) and non-oscillatory (aperiodic, '1/f-like') activity in a large cohort of participants ranging from 4-to-12 years of age (N = 139, average age=9.41 years, SD=1.95). The EEG signal was parameterised into aperiodic and periodic components, and linear regression models were used to evaluate if chronological age could predict aperiodic exponent and offset, as well as well as peak frequency and power within the alpha and beta ranges. Exponent and offset were found to both decrease with age, while aperiodic-adjusted alpha peak frequency increased with age; however, there was no association between age and peak frequency for the beta band. Age was also unrelated to aperiodic-adjusted spectral power within either the alpha or beta bands, despite both frequency ranges being correlated with the aperiodic signal. Overall, these results highlight the capacity for both periodic and aperiodic features of the EEG to elucidate age-related functional changes within the developing brain.

Facial emotion processing and language during early-to-middle childhood development: An event related potential study

Facial emotion processing (FEP) is critical to social cognitive ability. Developmentally, FEP rapidly improves in early childhood and continues to be fine-tuned throughout middle childhood and into adolescence. Previous research has suggested that language plays a role in the development of social cognitive skills, including non-verbal emotion recognition tasks. Here we investigated whether language is associated with specific neurophysiological indicators of FEP. One hundred and fourteen children (4-12 years) completed a language assessment and a FEP task including stimuli depicting anger, happiness, fear, and neutrality. EEG was used to record key event related potentials (ERPs; P100, N170, LPP at occipital and parietal sites separately) previously shown to be sensitive to faces and facial emotion. While there were no main effects of language, the P100 latency to negative expressions appeared to increase with language, while LPP amplitude increased with language for negative and neutral expressions. These findings suggest that language is linked to some early physiological indicators of FEP, but this is dependent on the facial expression. Future studies should explore the role of language in later stages of neural processing, with a focus on processes localised to ventromedial prefrontal regions.

The development of neural responses to emotional faces: A review of evidence from event-related potentials during early and middle childhood

Facial emotion processing (FEP) develops throughout childhood and provides crucial social information necessary for the interpretation and prediction of others' behaviour. This systematic review, which includes a meta-regression component, sought to explore the development of FEP event-related potentials (P100, N170, and late positive potential [LPP]) in children aged three to twelve years. Thirty-four studies, representing data from 1511 children, were included in the review. The combination of meta-regression and systematic review suggest that P100 amplitude decreases with increasing age in response to emotional facial stimuli. P100 latency may show a gradual decrease around the age of ten. In terms of the N170, it is suggested that amplitude follows a non-linear trend with age, and latency may decrease in early childhood before plateauing during middle childhood. Of note, review of the literature indicates that substantial methodological differences and high levels of heterogeneity exist. We suggest future research considers these results within the context of emotion-specific development, whilst also acknowledging how this may relate to individual social functioning skills across early-to-middle childhood.

A Daytime Nap Does Not Enhance the Retention of a First-Order or Second-Order Motor Sequence

This study examined the effects of a daytime nap on the retention of implicitly learnt “first-order conditional” (FOC) and “second-order conditional” (SOC) motor sequences. The implicit learning and retention of a motor sequence has been linked to the neural processes undertaken by the basal ganglia and primary motor cortex (i.e., procedural memory system). There is evidence, however, suggesting that SOC learning may further rely on the hippocampus-supported declarative memory system. Sleep appears to benefit the retention of information processed by the declarative memory system, but not the procedural memory system. Thus, it was hypothesized that sleep would benefit the retention of a SOC motor sequence but not a FOC sequence. The implicit learning and retention of these sequences was examined using the Serial Reaction Time Task. In this study, healthy adults implicitly learnt either a FOC (n = 20) or a SOC sequence (n = 20). Retention of both sequences was assessed following a daytime nap and period of wakefulness. Sleep was not found to improve the retention of the SOC sequence. There were no significant differences in the retention of a FOC or a SOC sequence following a nap or period of wakefulness. The study questions whether the declarative memory system is involved in the retention of implicitly learnt SOC sequences.

Implicit manual and oculomotor sequence learning in developmental language disorder

Procedural memory functioning in developmental language disorder (DLD) has largely been investigated by examining implicit sequence learning by the manual motor system. This study examined whether poor sequence learning in DLD is present in the oculomotor domain. Twenty children with DLD and 20 age-matched typically developing (TD) children were presented with a serial reaction time (SRT) task. On the task, a visual stimulus repeatedly appears in different positions on a computer display which prompts a manual response. The children were unaware that on the first three blocks and final block of trials, the visual stimulus followed a sequence. On the fourth block, the stimulus appeared in random positions. Manual reaction times (RT) and saccadic amplitudes were recorded, which assessed sequence learning in the manual and oculomotor domains, respectively. Manual RT were sensitive to sequence learning for the TD group, but not the DLD group. For the TD group, manual RT increased when the random block was presented. This was not the case for the DLD group. In the oculomotor domain, sequence learning was present in both groups. Specifically, sequence learning was found to modulate saccadic amplitudes resulting in both DLD and TD children being able to anticipate the location of the visual stimulus. Overall, the study indicates that not all aspects of the procedural memory system are equally impaired in DLD.

Large-scale analysis of interindividual variability in single and paired-pulse TMS data

OBJECTIVE

This study brought together over 60 transcranial magnetic stimulation (TMS) researchers to create the largest known sample of individual participant single and paired-pulse TMS data to date, enabling a more comprehensive evaluation of factors driving response variability.

METHODS

Authors of previously published studies were contacted and asked to share deidentified individual TMS data. Mixed-effects regression investigated a range of individual and study level variables for their contribution to variability in response to single and paired-pulse TMS data.

RESULTS

687 healthy participant's data were pooled across 35 studies. Target muscle, pulse waveform, neuronavigation use, and TMS machine significantly predicted an individual's single-pulse TMS amplitude. Baseline motor evoked potential amplitude, motor cortex hemisphere, and motor threshold (MT) significantly predicted short-interval intracortical inhibition response. Baseline motor evoked potential amplitude, test stimulus intensity, interstimulus interval, and MT significantly predicted intracortical facilitation response. Age, hemisphere, and TMS machine significantly predicted MT.

CONCLUSIONS

This large-scale analysis has identified a number of factors influencing participants' responses to single and paired-pulse TMS. We provide specific recommendations to minimise interindividual variability in single and paired-pulse TMS data.

SIGNIFICANCE

This study has used large-scale analyses to give clarity to factors driving variance in TMS data. We hope that this ongoing collaborative approach will increase standardisation of methods and thus the utility of single and paired-pulse TMS.

The mediating effect of language on the development of cognitive and affective theory of mind

Theory of mind (ToM) development is critical to effective social functioning and appears to depend on complementary language abilities. The current study explored the mediating influence of language on the development of both cognitive and affective ToM. A total of 151 children aged 5-12 years completed ToM (cognitive and affective) and language assessments, and parents provided ratings of their children's empathic ability. Results showed that language mediated the relationship between age and both cognitive and affective ToM but not parent-reported cognitive empathy. Examination of younger and older subgroups revealed that language mediated cognitive and affective ToM differently across developmental periods. Findings highlight the dynamic role that language plays in the development of both cognitive and affective ToM throughout early and middle childhood.

The effect of empathy and context on face-processing ERPs

The investigation of emotional face processing has largely used faces devoid of context, and does not account for within-perceiver differences in empathy. The importance of context in face perception has become apparent in recent years. This study examined the interaction of the contextual factors of facial expression, knowledge of a person's character, and within-perceiver empathy levels on face processing event-related potentials (ERPs). Forty-two adult participants learned background information about six individuals' character. Three types of character were described, in which the character was depicted as deliberately causing harm to others, accidently causing harm to others, or undertaking neutral actions. Subsequently, EEG was recorded while participants viewed the characters' faces displaying neutral or emotional expressions. Participants' empathy was assessed using the Empathy Quotient survey. Results showed a significant interaction of character type and empathy on the early posterior negativity (EPN) ERP component. These results suggested that for those with either low or high empathy, more attention was paid to the face stimuli, with more distinction between the different characters. In contrast, those in the middle range of empathy tended to produce smaller EPN with less distinction between character types. Findings highlight the importance of trait empathy in accounting for how faces in context are perceived.

Large-scale analysis of interindividual variability in theta-burst stimulation data: Results from the 'Big TMS Data Collaboration'

BACKGROUND

Many studies have attempted to identify the sources of interindividual variability in response to theta-burst stimulation (TBS). However, these studies have been limited by small sample sizes, leading to conflicting results.

OBJECTIVE/HYPOTHESIS

This study brought together over 60 TMS researchers to form the 'Big TMS Data Collaboration', and create the largest known sample of individual participant TBS data to date. The goal was to enable a more comprehensive evaluation of factors driving TBS response variability.

METHODS

118 corresponding authors of TMS studies were emailed and asked to provide deidentified individual TMS data. Mixed-effects regression investigated a range of individual and study level variables for their contribution to iTBS and cTBS response variability.

RESULTS

430 healthy participants' TBS data was pooled across 22 studies (mean age = 41.9; range = 17-82; females = 217). Baseline MEP amplitude, age, target muscle, and time of day significantly predicted iTBS-induced plasticity. Baseline MEP amplitude and timepoint after TBS significantly predicted cTBS-induced plasticity.

CONCLUSIONS

This is the largest known study of interindividual variability in TBS. Our findings indicate that a significant portion of variability can be attributed to the methods used to measure the modulatory effects of TBS. We provide specific methodological recommendations in order to control and mitigate these sources of variability.

The Effect of Visual Articulatory Information on the Neural Correlates of Non-native Speech Sound Discrimination

Behavioral studies have shown that the ability to discriminate between non-native speech sounds improves after seeing how the sounds are articulated. This study examined the influence of visual articulatory information on the neural correlates of non-native speech sound discrimination. English speakers’ discrimination of the Hindi dental and retroflex sounds was measured using the mismatch negativity (MMN) event-related potential, before and after they completed one of three 8-min training conditions. In an audio-visual speech training condition (n = 14), each sound was presented with its corresponding visual articulation. In one control condition (n = 14), both sounds were presented with the same visual articulation, resulting in one congruent and one incongruent audio-visual pairing. In another control condition (n = 14), both sounds were presented with the same image of a still face. The control conditions aimed to rule out the possibility that the MMN is influenced by non-specific audio-visual pairings, or by general exposure to the dental and retroflex sounds over the course of the study. The results showed that audio-visual speech training reduced the latency of the MMN but did not affect MMN amplitude. No change in MMN amplitude or latency was observed for the two control conditions. The pattern of results suggests that a relatively short audio-visual speech training session (i.e., 8 min) may increase the speed with which the brain processes non-native speech sound contrasts. The absence of a training effect on MMN amplitude suggests a single session of audio-visual speech training does not lead to the formation of more discrete memory traces for non-native speech sounds. Longer and/or multiple sessions might be needed to influence the MMN amplitude.

Concussion incidence and time-loss in Australian football: A systematic review

OBJECTIVES

Australian football is associated with a risk of concussion. However, despite the extensive and varied nature of literature devoted to this issue, concussion incidence has not been systematically evaluated. To address this, we aimed to conduct a meta-analysis of concussion incidence in Australian football.

DESIGN

Systematic review. Prospero registration number: CRD42017064290.

METHODS

A systematic search of 14 databases using the terms 'concussion', and 'Australian football' (and variations) was used to obtain records that reported concussion incidence per 1000 players hours across age, sex, and level-of-play. Data were grouped based on how time-loss was applied to the concussion definition.

RESULTS

Forty-two studies met inclusion criteria. Incidence rates based on a possible time-loss definition per 1000 player hours, ranged from 2.24 to 17.63 at the elite level, and 0.35 to 14.77 at the community/amateur level. Return-to-play details were reported by six studies and only two studies measured head-impacts in real-time. Several limitations were identified with this literature. First, insufficient return-to-play details precluded a meta-analysis of incidence rates. Second, no longitudinal studies across levels-of-play were found. Third, concussion incidence data for junior and female players were notably scarce.

CONCLUSIONS

There was limited scope to determine concussion burden (i.e., incidence and severity) and only preliminary data for player exposure to head-impacts. To address these limitations, injury surveillance should capture sufficient information to permit comparisons within and across levels-of-play. This will also help determine the influence of interventions aimed at reducing the frequency and severity of concussive-injuries.

Learning to Expect: Predicting Sounds During Movement Is Related to Sensorimotor Association During Listening

Sensory experiences, such as sound, often result from our motor actions. Over time, repeated sound-producing performance can generate sensorimotor associations. However, it is not clear how sensory and motor information are associated. Here, we explore if sensory prediction is associated with the formation of sensorimotor associations during a learning task. We recorded event-related potentials (ERPs) while participants produced index and little finger-swipes on a bespoke device, generating novel sounds. ERPs were also obtained as participants heard those sounds played back. Peak suppression was compared to assess sensory prediction. Additionally, transcranial magnetic stimulation (TMS) was used during listening to generate finger-motor evoked potentials (MEPs). MEPs were recorded before and after training upon hearing these sounds, and then compared to reveal sensorimotor associations. Finally, we explored the relationship between these components. Results demonstrated that an increased positive-going peak (e.g., P2) and a suppressed negative-going peak (e.g., N2) were recorded during action, revealing some sensory prediction outcomes (P2: p = 0.050, ηp2 = 0.208; N2: p = 0.001, ηp2 = 0.474). Increased MEPs were also observed upon hearing congruent sounds compared with incongruent sounds (i.e., associated to a finger), demonstrating precise sensorimotor associations that were not present before learning (Index finger: p < 0.001, ηp2 = 0.614; Little finger: p < 0.001, ηp2 = 0.529). Consistent with our broad hypotheses, a negative association between the MEPs in one finger during listening and ERPs during performance of the other was observed (Index finger MEPs and Fz N1 action ERPs; r = −0.655, p = 0.003). Overall, data suggest that predictive mechanisms are associated with the fine-tuning of sensorimotor associations.

Dissociable implicit sequence learning mechanisms revealed by continuous theta-burst stimulation

The primary motor area (M1) has been implicated in visuomotor sequence learning. However, it has been suggested there are multiple neural networks that undertake visuomotor sequence learning. The role of M1 in sequence learning may be specific to learning simple sequences comprising predictable associations between adjacent movements. This study aimed to investigate the role of M1 in learning simple ("first-order conditional") and more complex ("second-order conditional") sequences. It was hypothesized that continuous theta burst stimulation (cTBS) over M1 would result in poorer learning of the simple sequence only. Forty-eight healthy adults received cTBS to either M1 or the parietal lobe or received sham cTBS before immediately completing 2 visuomotor sequence learning tasks. The tasks only differed in relation to the structure (i.e., simple vs. complex) of the sequence. The group who received cTBS over M1 demonstrated significantly poorer learning of the simple sequence in comparison to the more complex sequence. The parietal lobe stimulation and sham stimulation did not affect learning of either sequence. This is the first study to show differential involvement of M1 in visuomotor sequence learning, dependent on sequence structure. The study provides new evidence that sequence learning might be supported by different networks in the brain. Specifically, M1 sequence learning appears to be important for learning simple item-to-item associations but not for more complex sequences. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Visuospatial sequence learning on the serial reaction time task modulates the P1 event-related potential

This study examined whether the P1, N1, and P3 ERP components would be sensitive to sequence learning effects on the serial reaction time task. On this task, participants implicitly learn a visuospatial sequence. Participants in this study were 35 healthy adults. Reaction time (RT) data revealed that, at the group level, participants learned the sequence. Specifically, RT became faster following repeated exposure to the visuospatial sequence and then slowed down in a control condition. Analyses of ERP data revealed no evidence for sequence learning effects for the N1 or P3 component. However, sequence learning effects were observed for the P1 component. Mean P1 amplitude mirrored the RT data. The analyses showed that P1 amplitude significantly decreased as participants were exposed to the sequence but then significantly increased in the control condition. This suggests that visuospatial sequence learning can modulate visual attention levels. Specifically, it seems that, as sequence knowledge is acquired, fewer demands are placed on visual attention resources.

Transcranial direct current stimulation enhances retention of a second (but not first) order conditional visuo-motor sequence

This study examined the role of the left inferior frontal gyrus in the implicit learning and retention of a 'simple' first order conditional (FOC) sequence and a relatively 'complex' second order conditional (SOC) sequence, using anodal transcranial direct current stimulation (a-tDCS). Groups of healthy adults received either a-tDCS (n = 18) over the left inferior frontal gyrus or sham/placebo (n = 18) stimulation. On separate days, participants completed a serial reaction time (SRT) task whilst receiving stimulation. On one of the days, participants were presented with a FOC sequence and in another, a SOC sequence. Both the learning and short-term retention of the sequences were measured. Results showed a-tDCS enhanced the short-term retention of the SOC sequence but not the FOC sequence. There was no effect of a-tDCS on the learning of either FOC or SOC sequences. The results provide evidence of prefrontal involvement in the retention of a motor sequence. However, its role appears to be influenced by the complexity of the sequence's structure. Additionally, the results show a-tDCS can enhance retention of an implicitly learnt motor sequence.

A Lysosomal Pepstatin-Insensitive Proteinase as a Novel Biomarker for Breast Carcinoma

Lysosomal proteinases play an important role in the turnover of intracellular proteins, and acidic proteinases such as cathepsin D are known to be increased in breast carcinoma. In the present study the activity of a newly discovered acidic lysosomal pepstatin-insensitive proteinase (CLN2p) was measured in breast tissues by the most sensitive and highly specific assay that we had developed for the diagnosis of late-infantile neuronal ceroid lipofuscinosis (LINCL) (2). Samples from eight normal subjects undergoing reductive mammoplasty and 200 patients with primary breast carcinoma were analyzed. The results suggest a two- to seventeen-fold higher CLN2p activity in tumors, which was significantly and positively correlated with already known breast cancer biomarkers such as levels of cathepsin D, estrogen receptor and progesterone receptor. These results suggest a diagnostic and prognostic potential for this novel acid proteinase in breast cancer.

Procedural memory and speed of grammatical processing: Comparison between typically developing children and language impaired children

BACKGROUND

Procedural memory has been proposed to underlie the acquisition of a range of skills including grammar, reading, and motor skills. In developmental language disorder (DLD) it has been suggested that procedural memory problems lead to the difficulties with grammar in this group.

AIMS

This study aimed to extend previous research by exploring associations between procedural memory and a range of cognitive skills, in children with and without language impairments.

METHODS AND PROCEDURES

Twenty children with DLD and 20 age-matched non-language impaired children undertook tasks assessing procedural memory, grammatical processing speed, single word and nonword reading, and motor skills (as indexed by a pegboard task).

OUTCOMES AND RESULTS

For the DLD group, no significant correlations between procedural memory and any of the variables were observed. The typically developing group showed a significant correlation (r=.482, p<0.05) between the measure of procedural memory and grammatical processing speed. Correlations between procedural memory and the remaining variables were all non-significant for this group.

CONCLUSIONS AND IMPLICATIONS

This study provides new evidence showing that grammatical processing speed is correlated with procedural memory in typically developing children. Furthermore, results suggest that the relationship with procedural memory does not extend to reading or the types of motor skills used on a pegboard task. For the DLD group the pattern of result indicate grammatical processing, reading, and motor sequencing are not supported by procedural memory or a common memory system.

Using Pupillometry to Investigate Sentence Comprehension in Children With and Without Specific Language Impairment

PURPOSE

In this study pupillometry was used to investigate the allocation of attentional resources associated with sentence comprehension in children with and without specific language impairment (SLI).

METHOD

Eighteen children with SLI (age: M = 6.4 years) and 18 typically developing (TD) children (age: M = 6.3 years) participated in the study. A sentence comprehension task was presented that comprised items designated as easy or hard. Easy sentences contained 4 or 5 words, and hard sentences contained 6 or 7 words.

RESULTS

For the TD group, pupil size was significantly larger when comprehending hard sentences compared with easy sentences. There was no effect of sentence difficulty on pupil size in the SLI group. Comparisons between groups revealed pupil sizes for the SLI group were significantly larger than those for the TD group for easy sentences. There were no group differences for the hard sentences.

CONCLUSION

In TD children, pupillometry was sensitive to the attentional demands associated with sentence comprehension. Between-subjects comparisons indicated that the TD group allocated less attention than did the children with SLI for the easy sentences but not for the hard sentences. This study provides evidence of attentional differences between children with SLI and TD children under conditions of low processing demands.

First-order and higher order sequence learning in specific language impairment

OBJECTIVE

A core claim of the procedural deficit hypothesis of specific language impairment (SLI) is that the disorder is associated with poor implicit sequence learning. This study investigated whether implicit sequence learning problems in SLI are present for first-order conditional (FOC) and higher order conditional (HOC) sequences.

METHOD

Twenty-five children with SLI and 27 age-matched, nonlanguage-impaired children completed 2 serial reaction time tasks. On 1 version, the sequence to be implicitly learnt comprised a FOC sequence and on the other a HOC sequence.

RESULTS

Results showed that the SLI group learned the HOC sequence (η_p² = .285, p = .005) but not the FOC sequence (η_p² = .099, p = .118). The control group learned both sequences (FOC η_p² = .497, HOC η_p2= .465, ps < .001).

CONCLUSIONS

The SLI group's difficulty learning the FOC sequence is consistent with the procedural deficit hypothesis. However, the study provides new evidence that multiple mechanisms may underpin the learning of FOC and HOC sequences. (PsycINFO Database Record

Comparison of Two Cochlear Implant Speech-Processing Strategies

Speech processors extracting either the fundamental frequency (F0) alone, or the fundamental frequency combined with second formant information (F0-F2), have been evaluated on a totally deaf patient using a multiple-channel cochlear implant. A closed set test using 16 spondees and a modified rhyme test showed that for electrical stimulation alone the F0-F2 speech processor was significantly better than the F0 processor. The open set tests using phonetically balanced words and Central Institute for the Deaf everyday sentences showed that for electrical stimulation alone and electrical stimulation combined with lipreading, the results with the F0-F2 speech processor were all significantly better than with the F0 processor. Information transmission for consonant speech features was also better when using the F0-F2 processor.

Midbrain responses to micro-stimulation of the cochlea using high density thin-film arrays

A broader activation of auditory nerve fibres than normal using a cochlear implant contributes to poor frequency discrimination. As cochlear implants also deliver a restricted dynamic range, this hinders the ability to segregate sound sources. Better frequency coding and control over amplitude may be achieved by limiting current spread during electrical stimulation of the cochlea and positioning electrodes closer to the modiolus. Thin-film high density microelectrode arrays and conventional platinum ring electrode arrays were used to stimulate the cochlea of urethane-anaesthetized rats and responses compared. Neurophysiological recordings were taken at 197 multi-unit clusters in the central nucleus of the inferior colliculus (CIC), a site that receives direct monaural innervation from the cochlear nucleus. CIC responses to both the platinum ring and high density electrodes were recorded and differences in activity to changes in stimulation intensity, thresholds and frequency coding of neural activation were examined. The high density electrode array elicited less CIC activity at nonspecific frequency regions than the platinum ring electrode array. The high density electrode array produced significantly lower thresholds and larger dynamic ranges than the platinum ring electrode array when positioned close to the modiolus. These results suggest that a higher density of stimulation sites on electrodes that effectively 'aim' current, combined with placement closer to the modiolus would permit finer control over charge delivery. This may equate to improved frequency specific perception and control over amplitude when using future cochlear implant devices.

Surgical implications of perimodiolar cochlear implant electrode design: avoiding intracochlear damage and scala vestibuli insertion

OBJECTIVE

To review the mechanisms and nature of intracochlear damage associated with cochlear implant electrode array insertion, in particular, the various perimodiolar electrode designs. Make recommendations regarding surgical techniques for the Nucleus Contour electrode to ensure correct position and minimal insertion trauma.

BACKGROUND

The potential advantages of increased modiolar proximity of intracochlear multichannel electrode arrays are a reduction in stimulation thresholds, an increase in dynamic range and more localized neural excitation. This may improve speech perception and reduce power consumption. These advantages may be negated if increased intracochlear damage results from the method used to position the electrodes close to the modiolus.

METHOD

A review of the University of Melbourne Department of Otolaryngology experience with temporal bone safety studies using the Nucleus standard straight electrode array and a variety of perimodiolar electrode array designs; comparison with temporal bone insertion studies from other centres and postmortem histopathology studies reported in the literature. Review of our initial clinical experience using the Nucleus Contour electrode array.

RESULTS

The nature of intracochlear damage resulting from electrode insertion trauma ranges from minor, localized, spiral ligament tear to diffuse organ of Corti disruption and osseous spiral lamina fracture. The type of damage depends on the mechanical characteristics of the electrode array, the stiffness, curvature and size of the electrode in relation to the scala, and the surgical technique. The narrow, flexible, straight arrays are the least traumatic. Pre-curved or stiffer arrays are associated with an incidence of basilar membrane perforation. The cochleostomy must be correctly sited in relation to the round window to ensure scala tympani insertion. A cochleostomy anterior to the round window rather than inferior may lead to scala media or scala vestibuli insertion.

CONCLUSION

Proximity of electrodes to the modiolus can be achieved without intracochlear damage provided the electrode array is a free fit within the scala, of appropriate size and shape, and accurate scala tympani insertion is performed.

Rate-of-processing ability in children using cochlear implants and its relevance to speech perception

The aim was to assess the ability of young children using cochlear implants to process a change in place of stimulation under conditions of shortened stimulus duration and shortened interstimulus interval. The study investigated whether or not this ability accounted for a significant amount of the variance in the speech performance of the children additional to the variance accounted for by electrode discrimination ability (measured in a previous study). An adaptation of the play audiometry procedure was used to assess 'rate-of-processing' ability in 17 children aged between 4 and 10 years. Initially the child was required to respond with a game-like motor response when a repeating stimulation on a reference electrode 'changed' to a different electrode in relatively 'slow' conditions. The child was then required to respond to the 'change', when the duration of the stimuli and the time interval between the stimuli were decreased. All but one of the children using cochlear implants scored significantly above chance for all conditions of stimulus duration and interstimulus interval assessed. That is, they were able to discriminate place pitch changes when these changes occurred more rapidly in time. A stepwise regression was computed to determine the relative contributions of a number of variables, including rate-of-processing ability, in accounting for variance in the children's speech perception performance (measured in a previous study). Rate-of-processing ability did not account for any variance additional to that accounted for by electrode discrimination ability, which was found to be the most significant predictor of speech perception performance for this group of children in the previous study.

A multi-channel hearing prosthesis for profound-to-total hearing loss

A multi-channel cochlear implant hearing prosthesis providing 22 separate channels of stimulation has been developed. The electronics for the implantable receiver-stimulator have been incorporated on a single chip, using digital circuits and employing CMOS technology. The chip is enclosed in a titanium capsule with platinum/ceramic electrode feed-throughs. A pocket-sized speech processor and directional microphone extract the following speech parameters: signal amplitude, fundamental frequency and formant frequency. The fundamental frequency is coded as electric pulse rate, and formant frequency by electrode position. The speech processor has been realized using hybrid circuits and CMOS gate arrays. The multi-channel prosthesis has undergone a clinical trial on four postlingually deaf patients with profound-total hearing losses. The speech perception results indicate that they were able to obtain open-set speech recognition scores for phonetically balanced words, CID sentences and spondees. In all cases the tests showed significant improvements when using the cochlear prosthesis combined with lipreading compared to lipreading alone.

3D finite element analyses of insertion of the Nucleus standard straight and the Contour electrode arrays into the human cochlea

Previous experimental studies of insertion of the Nucleus standard straight and the Contour arrays into the scala tympani have reported that the electrode arrays cause damage to various cochlear structures. However, the level of insertion-induced damage by these electrode arrays to cochlear structures (the spiral ligament, the basilar membrane and the osseous spiral lamina) has not been quantified. Although it has been suggested that rotation can overcome this resistance and prevent the basilar membrane from being pierced by the tip of the Nucleus standard straight array, there has not been any attempt to study the relationship between the rotation and the reduction of damage to the basilar membrane. In this study, 3D finite element analyses of insertions of the Nucleus standard straight array and the Contour array into the scala tympani have been undertaken. The perforation of the basilar membrane by the tip of the Nucleus standard straight array at the region of 11-14 mm from the round window appears to be compounded by the geometry of the spiral passage of the scala tympani. Anti-clockwise rotations between 25 degrees and 90 degrees applied at the basal end of the electrode array (for the right cochlea) were shown to significantly reduce the contact stresses exerted by the tip on the basilar membrane which support the practice of applying small rotation partway through insertion of electrode array to minimize damage to the basilar membrane. Although the Contour array (with its stylet intact) is stiffer than the Nucleus standard straight array, a slight withdrawal of the stylet from the Contour array before insertion was found to significantly reduce damage by the electrode array to the spiral ligament and the basilar membrane.

Reporting recommendations for tumor marker prognostic studies (remark)

Despite years of research and hundreds of reports on tumor markers in oncology, the number of markers that have emerged as clinically useful is pitifully small. Often, initially reported studies of a marker show great promise, but subsequent studies on the same or related markers yield inconsistent conclusions or stand in direct contradiction to the promising results. It is imperative that we attempt to understand the reasons that multiple studies of the same marker lead to differing conclusions. A variety of methodologic problems have been cited to explain these discrepancies. Unfortunately, many tumor marker studies have not been reported in a rigorous fashion, and published articles often lack sufficient information to allow adequate assessment of the quality of the study or the generalizability of study results. The development of guidelines for the reporting of tumor marker studies was a major recommendation of the National Cancer Institute - European Organisation for Research and Treatment of Cancer (NCI - EORTC) First International Meeting on Cancer Diagnostics in 2000. As for the successful CONSORT initiative for randomized trials and for the STARD statement for diagnostic studies, we suggest guidelines to provide relevant information about the study design, preplanned hypotheses, patient and specimen characteristics, assay methods, and statistical analysis methods. In addition, the guidelines suggest helpful presentations of data and important elements to include in discussions. The goal of these guidelines is to encourage transparent and complete reporting so that the relevant information will be available to others to help them to judge the usefulness of the data and understand the context in which the conclusions apply.

REporting recommendations for tumour MARKer prognostic studies (REMARK)

Despite years of research and hundreds of reports on tumour markers in oncology, the number of markers that have emerged as clinically useful is pitifully small. Often initially reported studies of a marker show great promise, but subsequent studies on the same or related markers yield inconsistent conclusions or stand in direct contradiction to the promising results. It is imperative that we attempt to understand the reasons that multiple studies of the same marker lead to differing conclusions. A variety of methodological problems have been cited to explain these discrepancies. Unfortunately, many tumour marker studies have not been reported in a rigorous fashion, and published articles often lack sufficient information to allow adequate assessment of the quality of the study or the generalisability of the study results. The development of guidelines for the reporting of tumour marker studies was a major recommendation of the US National Cancer Institute and the European Organisation for Research and Treatment of Cancer (NCI-EORTC) First International Meeting on Cancer Diagnostics in 2000. Similar to the successful CONSORT initiative for randomised trials and the STARD statement for diagnostic studies, we suggest guidelines to provide relevant information about the study design, preplanned hypotheses, patient and specimen characteristics, assay methods, and statistical analysis methods. In addition, the guidelines suggest helpful presentations of data and important elements to include in discussions. The goal of these guidelines is to encourage transparent and complete reporting so that the relevant information will be available to others to help them to judge the usefulness of the data and understand the context in which the conclusions apply.

Hormone receptor status of a contralateral breast cancer is independent of the receptor status of the first primary in patients not receiving adjuvant tamoxifen

PURPOSE

To determine whether the hormone receptor status of the primary breast cancer (PBC) is predictive of the hormone receptor status of the subsequent contralateral breast cancer (CBC).

PATIENTS AND METHODS

We identified patients in our database with known estrogen receptor (ER; n = 193) and/or progesterone receptor (PgR; n = 178) status in their PBC and in their subsequent CBC. One hundred twenty-six of these patients had received no adjuvant therapy, 34 had received adjuvant tamoxifen, and 33 had received adjuvant chemotherapy alone. The median interval between the first diagnosis of PBC and the development of the subsequent CBC was 3 years. ER and PgR assays were assessed biochemically in two central reference laboratories using identical quality-controlled ligand-binding methods.

RESULTS

Among systemically untreated patients (n = 126), 88% of patients with ER-positive PBC and 75% of patients with ER-negative PBC developed an ER-positive CBC (P = .11). Among the tamoxifen-treated patients, those with an ER-positive PBC were almost equally likely to develop an ER-positive (47%) or ER-negative (53%) CBC (P = .99). PgR status was similar. In the untreated group (n = 112), 59% of patients with a PgR-positive PBC and 66% with a PgR-negative PBC developed a PgR-positive CBC (P = .48). Among tamoxifen-treated patients (n = 33), 50% of patients with a PgR-positive PBC versus 27% of patients with a PgR-negative PBC developed a PgR-positive CBC (P = .28).

CONCLUSION

ER and PgR status of the primary tumor does not predict the hormone receptor status of the subsequent CBC in the absence of selective pressure of adjuvant therapy. Thus, other reasons should be considered to clarify the failure of tamoxifen to reduce the incidence of CBC in patients with a receptor-negative PBC.

Stiffness properties for Nucleus standard straight and contour electrode arrays

Trauma and damage during insertion of electrode arrays into the human cochlea are strongly related to the stiffness of the array. The stiffness properties of electrode arrays, which were determined by three-point flexural bending and buckling tests, are reported in this paper. To date there has been limited publication on mechanical properties of these electrode arrays. Previous studies mainly focused on characterizing the stiffness of the tip of the Nucleus straight array with little emphasis on characterizing the stiffness of its whole length. In this study, stiffnesses of the Nucleus straight and contour electrode arrays have been determined along their length. Young's modulus of elasticity of the Nucleus straight array has been found to increase from the tip (182 MPa) to the rear end (491 MPa), whereas the stiffness of the contour array is greatest near the tip (480 MPa) and is fairly uniform in the middle and rear sections of the electrode array (380-400 MPa). Buckling experiments have shown that the contour array has much higher critical buckling load (about four times) than the Nucleus straight array. The results from three-point flexural bending and buckling experiments provide significant data for the development of electrode arrays, from which new array designs with improved flexibility can be developed. The results of stiffness properties are also important input for use in finite element models to predict the trajectories during insertion and to help evaluate the effects of different electrode array designs on damage sustained during insertion.

A study of intra-cochlear electrodes and tissue interface by electrochemical impedance methods in vivo

This paper presents methods, results and analysis for measurements of the electrochemical impedance of platinum electrodes (approximately 0.43 mm2) over a 6-month implantation in the cat cochlea. The study aimed to improve our understanding of the effects of tissue response on impedance behaviour. An increase in impedance in the post-operative period was evident with a rise of the distorted arc at high frequencies in the complex plane, correlating to anomalous charge transport at the electrode-tissue interface. The impedance at low frequencies generally showed a capacitive dispersion modelled as a constant phase element, indicating a blocking characteristic of the electrodes. The study suggests that a reduction and changes in composition of perilymph or extracellular fluid adjacent to the electrodes, as a consequence of tissue response, causes the elevated "contact impedance". This affects the efficiency and quality of neural stimulating electrodes and neural recording electrodes. The finding of the crucial role of perilymph or extracellular fluid thin layer provides a new strategy for surface materials of neural electrodes, which is discussed in the paper. The interface characteristics must be considered during interpretation of studies undertaken in vitro or in acute experiments in vivo, where physiological fluid is abundant.

Evaluation of trajectories and contact pressures for the straight nucleus cochlear implant electrode array - a two-dimensional application of finite element analysis

A two-dimensional (2D) finite element analysis has been used in this study to model the insertion of the Nucleus electrode array with different stiffness properties in order to evaluate the propensity of damage by visualizing the predicted trajectories and by comparing the buckling stresses and the contact pressures at the tip (and its distribution along the length) of the electrode array. Previous temporal bone studies have shown that damage during insertion of an electrode array around the basal turn of the cochlear spiral could be related to the design and the stiffness properties of the electrode array. However, it is difficult to evaluate different designs of electrode arrays purely by experimental methods as the experimental conditions and their results are difficult to reproduce. Three electrode arrays with different mechanical properties, i.e. uniform stiffness, graded stiffness, and a soft tip have been modelled. Buckling stress and contact pressure at the tip of the electrode array were found to be highest for the arrays with uniform stiffness. The contact pressures at the tip of the electrode array appeared strongly influenced by the stiffness profile and were optimal for graded stiffness. The results indicate the importance of the electrode array design and stiffness properties in minimizing trauma. However, there are a number of limitations in the present 2D evaluation which will require further analysis using a three-dimensional model to obtain definitive results.

Idoxifene versus tamoxifen: a randomized comparison in postmenopausal patients with metastatic breast cancer

BACKGROUND

More efficacious and safer hormonal agents are needed for breast cancer treatment and prevention. Idoxifene is a novel selective estrogen receptor modulator (SERM) that, in preclinical models, has greater antiestrogenic but lower estrogenic activity than tamoxifen.

PATIENTS AND METHODS

Three hundred and twenty-one postmenopausal patients with hormone receptor-positive or -unknown metastatic breast cancer were randomized to receive either tamoxifen or idoxifene as initial endocrine therapy for advanced disease. Data were analyzed based on intention to treat and all the responses were subject to independent review.

RESULTS

At the time of a second planned interim analysis, the trial was stopped for economic considerations, not for reasons related to safety or efficacy. Complete data for the 219 patients included in the second interim analysis are fully available and reported here. Median age was 59.1 years for idoxifene patients and 59.9 years for tamoxifen patients. Complete response (CR) plus partial response (PR) rates were as follows: tamoxifen, 9%; idoxifene, 13% (P = 0.39). Clinical benefit rate [CR + PR + stable disease (SD) >or=6 months] was 34.3% for idoxifene and 38.7% for tamoxifen (P = 0.31). Median time to progression and duration of response were 140 days and 151.5 days, respectively, for tamoxifen compared with 166 days and 218 days for idoxifene. None of these endpoints was significantly different for the two drugs, nor was survival. Adverse events (lethal, serious but not lethal and important but not life threatening) were similar in the two arms.

CONCLUSIONS

Idoxifene was both active and well tolerated in postmenopausal women with metastatic breast cancer. Idoxifene had similar efficacy and toxicity to tamoxifen in this randomized comparison.

Cyclo-oxygenase-2 (COX-2) mRNA expression correlates with progesterone receptor positivity in human breast cancer

BACKGROUND

We previously presented evidence showing that cyclo-oxygenase 2 (COX-2) plays an important role in mammary carcinogenesis and angiogenesis in human breast cancer. The present study aims to compare COX-2 mRNA expression with hormone receptor status, S-phase fraction, telomerase activity, and DNA ploidy in human breast cancer.

METHODS

Total cellular RNA was extracted from frozen breast tissue samples according to standard methodology. The mRNA copy numbers for COX-2 were determined in 18 infiltrating carcinomas using quantitative RT-PCR and TaqMan methodology. The oestrogen receptor (ER) and progesterone receptor (PgR) status was determined using the ligand-binding technique (ER+ = > 3 fmol/mg, PgR+ = > 5 fmol/mg). We also determined DNA ploidy status (diploid or aneuploid), S-phase fraction (< 6% = low, 6-10% = intermediate, > 10% = high), and telomerase activity (total protein generated by TRAP assay).

RESULTS

The median COX-2 mRNA copy number per micro g of RNA was 126 713 (range = 15 717-2 022 050). COX-2 expression was significantly associated with PgR positivity (p = 0.013). The association between COX-2 and DNA diploidy failed to reach a statistical significance (p = 0.085). No significant association was detected between COX-2 and S-phase fraction, ER status, or telomerase activity.

CONCLUSIONS

COX-2 mRNA expression is associated with PgR positivity in human breast cancer. This observation is consistent with the hypothesis that COX-2 upregulates aromatase activity.

Short-term auditory memory in children using cochlear implants and its relevance to receptive language

The aim of this study was to assess auditory sequential, short-term-memory (SSTM) performance in young children using cochlear implants (CI group) and to examine the relationship of this performance to receptive language performance. Twenty-four children, 5 to 11 years old, using the Nucleus 22-electrode cochlear implant, were tested on a number of auditory and visual tasks of SSTM. The auditory memory tasks were designed to minimize the effect of auditory discrimination ability. Stimuli were chosen that children with cochlear implants could accurately identify with a reaction time similar to that of a control group of children with normal hearing (NH group). All children were also assessed on a receptive language test and on a nonverbal intelligence scale. As expected, children using cochlear implants demonstrated poorer auditory and visual SSTM skills than their hearing peers when the stimuli were verbal or were pictures that could be readily labeled. They did not differ from their peers with normal hearing on tasks where the stimuli were less likely to be verbally encoded. An important finding was that the CI group did not appear to have a sequential memory deficit specific to the auditory modality. The difference scores (auditory minus visual memory performance) for the CI group were not significantly different from those for the NH group. SSTM performance accounted for significant variance in the receptive language performance of the CI group. However, a forward stepwise regression analysis revealed that visual spatial memory (one of the subtests of the nonverbal IQ test) was the main predictor of variance in the language scores of the children using cochlear implants.