Sensitivity and specificity of auditory steady-state response testing

INTRODUCTION:

The ASSR test is an electrophysiological test that evaluates, among other aspects, neural synchrony, based on the frequency or amplitude modulation of tones.

OBJECTIVE:

The aim of this study was to determine the sensitivity and specificity of auditory steady‐state response testing in detecting lesions and dysfunctions of the central auditory nervous system.

METHODS:

Seventy volunteers were divided into three groups: those with normal hearing; those with mesial temporal sclerosis; and those with central auditory processing disorder. All subjects underwent auditory steady‐state response testing of both ears at 500 Hz and 2000 Hz (frequency modulation, 46 Hz). The difference between auditory steady‐state response‐estimated thresholds and behavioral thresholds (audiometric evaluation) was calculated.

RESULTS:

Estimated thresholds were significantly higher in the mesial temporal sclerosis group than in the normal and central auditory processing disorder groups. In addition, the difference between auditory steady‐state response‐estimated and behavioral thresholds was greatest in the mesial temporal sclerosis group when compared to the normal group than in the central auditory processing disorder group compared to the normal group.

DISCUSSION:

Research focusing on central auditory nervous system (CANS) lesions has shown that individuals with CANS lesions present a greater difference between ASSR‐estimated thresholds and actual behavioral thresholds; ASSR‐estimated thresholds being significantly worse than behavioral thresholds in subjects with CANS insults. This is most likely because the disorder prevents the transmission of the sound stimulus from being in phase with the received stimulus, resulting in asynchronous transmitter release. Another possible cause of the greater difference between the ASSR‐estimated thresholds and the behavioral thresholds is impaired temporal resolution.

CONCLUSIONS:

The overall sensitivity of auditory steady‐state response testing was lower than its overall specificity. Although the overall specificity was high, it was lower in the central auditory processing disorder group than in the mesial temporal sclerosis group. Overall sensitivity was also lower in the central auditory processing disorder group than in the mesial temporal sclerosis group.     

(Central) Auditory Processing: the impact of otitis media

OBJECTIVE:

To analyze auditory processing test results in children suffering from otitis media in their first five years of age, considering their age. Furthermore, to classify central auditory processing test findings regarding the hearing skills evaluated.

METHODS:

A total of 109 students between 8 and 12 years old were divided into three groups. The control group consisted of 40 students from public school without a history of otitis media. Experimental group I consisted of 39 students from public schools and experimental group II consisted of 30 students from private schools; students in both groups suffered from secretory otitis media in their first five years of age and underwent surgery for placement of bilateral ventilation tubes. The individuals underwent complete audiological evaluation and assessment by Auditory Processing tests.

RESULTS:

The left ear showed significantly worse performance when compared to the right ear in the dichotic digits test and pitch pattern sequence test. The students from the experimental groups showed worse performance when compared to the control group in the dichotic digits test and gaps-in-noise. Children from experimental group I had significantly lower results on the dichotic digits and gaps-in-noise tests compared with experimental group II. The hearing skills that were altered were temporal resolution and figure-ground perception.

CONCLUSION:

Children who suffered from secretory otitis media in their first five years and who underwent surgery for placement of bilateral ventilation tubes showed worse performance in auditory abilities, and children from public schools had worse results on auditory processing tests compared with students from private schools.     

Formal auditory training in adult hearing aid users

INTRODUCTION

Individuals with sensorineural hearing loss are often able to regain some lost auditory function with the help of hearing aids. However, hearing aids are not able to overcome auditory distortions such as impaired frequency resolution and speech understanding in noisy environments. The coexistence of peripheral hearing loss and a central auditory deficit may contribute to patient dissatisfaction with amplification, even when audiological tests indicate nearly normal hearing thresholds.

OBJECTIVE

This study was designed to validate the effects of a formal auditory training program in adult hearing aid users with mild to moderate sensorineural hearing loss.

METHODS

Fourteen bilateral hearing aid users were divided into two groups: seven who received auditory training and seven who did not. The training program was designed to improve auditory closure, figure-to-ground for verbal and nonverbal sounds and temporal processing (frequency and duration of sounds). Pre- and post-training evaluations included measuring electrophysiological and behavioral auditory processing and administration of the Abbreviated Profile of Hearing Aid Benefit (APHAB) self-report scale.

RESULTS

The post-training evaluation of the experimental group demonstrated a statistically significant reduction in P3 latency, improved performance in some of the behavioral auditory processing tests and higher hearing aid benefit in noisy situations (p-value < 0,05). No changes were noted for the control group (p-value <0,05).

CONCLUSION

The results demonstrated that auditory training in adult hearing aid users can lead to a reduction in P3 latency, improvements in sound localization, memory for nonverbal sounds in sequence, auditory closure, figure-to-ground for verbal sounds and greater benefits in reverberant and noisy environments.     

Noise-induced tinnitus: auditory evoked potential in symptomatic and asymptomatic patients

OBJECTIVES:

We evaluated the central auditory pathways in workers with noise-induced tinnitus with normal hearing thresholds, compared the auditory brainstem response results in groups with and without tinnitus and correlated the tinnitus location to the auditory brainstem response findings in individuals with a history of occupational noise exposure.

METHOD:

Sixty individuals participated in the study and the following procedures were performed: anamnesis, immittance measures, pure-tone air conduction thresholds at all frequencies between 0.25–8 kHz and auditory brainstem response.

RESULTS:

The mean auditory brainstem response latencies were lower in the Control group than in the Tinnitus group, but no significant differences between the groups were observed. Qualitative analysis showed more alterations in the lower brainstem in the Tinnitus group. The strongest relationship between tinnitus location and auditory brainstem response alterations was detected in individuals with bilateral tinnitus and bilateral auditory brainstem response alterations compared with patients with unilateral alterations.

CONCLUSION:

Our findings suggest the occurrence of a possible dysfunction in the central auditory nervous system (brainstem) in individuals with noise-induced tinnitus and a normal hearing threshold.     

Audiological manifestations in HIV-positive adults

OBJECTIVE:

To characterize the findings of behavioral hearing assessment in HIV-positive individuals who received and did not receive antiretroviral treatment.

METHODS:

This research was a cross-sectional study. The participants were 45 HIV-positive individuals (18 not exposed and 27 exposed to antiretroviral treatment) and 30 control-group individuals. All subjects completed an audiological evaluation through pure-tone audiometry, speech audiometry, and high-frequency audiometry.

RESULTS:

The hearing thresholds obtained by pure-tone audiometry were different between groups. The group that had received antiretroviral treatment had higher thresholds for the frequencies ranging from 250 to 3000 Hz compared with the control group and the group not exposed to treatment. In the range of frequencies from 4000 through 8000 Hz, the HIV-positive groups presented with higher thresholds than did the control group. The hearing thresholds determined by high-frequency audiometry were different between groups, with higher thresholds in the HIV-positive groups.

CONCLUSION:

HIV-positive individuals presented poorer results in pure-tone and high-frequency audiometry, suggesting impairment of the peripheral auditory pathway. Individuals who received antiretroviral treatment presented poorer results on both tests compared with individuals not exposed to antiretroviral treatment.     

Development and evaluation of a brief self-completed family history screening tool for common chronic disease prevention in primary care

Background

Family history is an important risk factor for many common chronic diseases, but it remains underutilised for diagnostic assessment and disease prevention in routine primary care.

Aim

To develop and validate a brief self-completed family history questionnaire (FHQ) for systematic primary care assessment for family history of diabetes, ischaemic heart disease, breast cancer, and colorectal cancer.

Design and setting

Two-stage diagnostic validation study in 10 general practices in eastern England.

Method

Participants aged 18–50 years were identified via random sampling from electronic searches of general practice records. Participants completed a FHQ then had a three-generational ‘gold standard’ pedigree taken, to determine disease risk category. In stage 1, the FHQ comprised 12 items; in stage 2 the shorter 6-item FHQ was validated against the same ‘gold standard’.

Results

There were 1147 participants (stage 1: 618; stage 2: 529). Overall, 32% were at increased risk of one or more marker conditions (diabetes 18.9%, ischaemic heart disease 13.3%, breast cancer 6.2%, colorectal cancer 2.2%). The shorter 6-item FHQ performed very well for all four conditions: pooled data from both stages show diabetes, sensitivity = 98%, specificity = 94%; ischaemic heart disease, sensitivity = 93%, specificity = 81%; breast cancer, sensitivity = 81%, specificity = 83%; colorectal cancer, sensitivity = 96%, specificity = 88%, with an area under the receiver operating characteristic curve of 0.90 for males and 0.89 for females.

Conclusion

This brief self-completed FHQ shows good diagnostic accuracy for identifying people at higher risk of four common chronic diseases. It could be used in routine primary care to identify patients who would be most likely to benefit from a more detailed pedigree and risk assessment, and consequent management strategies.     

The role of KIR2DL3/HLA-C*0802 in Brazilian patients with rheumatoid vasculitis

OBJECTIVES:

Rheumatoid arthritis is a polygenically controlled systemic autoimmune disease. Rheumatoid vasculitis is an important extra-articular phenotype of rheumatoid arthritis that can result in deep cutaneous ulcers. The objective of this study was to establish a correlation between the frequency of major histocompatibility complex class I/II alleles and killer immunoglobulin-like receptor genotypes in patients with cutaneous rheumatoid vasculitis.

METHODS:

Using the Scott & Bacon 1984 criteria to diagnose rheumatoid vasculitis and after excluding any other causes such as diabetes, atherosclerosis, adverse drug reactions, infection, and smoking, patients who met the criteria were selected. All of the selected rheumatoid vasculitis patients presented deep cutaneous ulcers. Identification of the major histocompatibility complex class I/II and killer immunoglobulin-like receptor genotypes was performed by polymerase chain reaction assays of samples collected from the 23 rheumatoid vasculitis patients as well as from 80 controls (40 non-rheumatoid vasculitis RA control patients and 40 healthy volunteers).

RESULTS:

An association between the presence of the HLA-DRB1*1402 and HLA-DRB1*0101 alleles and cutaneous lesions in rheumatoid vasculitis patients and a correlation between the inhibitor KIR2DL3 and the HLA-C*0802 ligand in rheumatoid vasculitis patients were found.

CONCLUSION:

An association was found between the presence of the HLA-DRB1*1402 and HLA-DRB1*0101 alleles and the development of cutaneous lesions in rheumatoid vasculitis patients. Additionally, the HLA-C*0802 ligand protects these individuals from developing cutaneous lesions.     

Non-flat audiograms in sensorineural hearing loss and speech perception

OBJECTIVE:

The audibility thresholds for the sound frequency of 137 upward- and downward-sloping audiograms showing sensorineural hearing loss were selected and analyzed in conjunction with speech recognition thresholds obtained from individuals seen at a public otolaryngology clinic to determine which frequencies in slope audiograms best represent speech recognition thresholds.

METHOD:

The linear regression model and mean square error were used to determine the associations between the threshold values.

RESULT:

The mean square error identified larger errors when using thresholds of 500, 1000, and 2000 Hz than when using audibility thresholds of 500, 1000, 2000, and 4000 Hz. The linear regression model showed a higher correlation (91%) between the audiogram thresholds for frequencies of 500, 1000, 2000, and 4000 Hz than for the frequencies of 500, 1000, and 2000 Hz (88%).

CONCLUSION:

Frequencies of 500, 1000, 2000, and 4000 Hz were the most significant in predicting the speech recognition threshold.     

Auditory evoked potentials: predicting speech therapy outcomes in children with phonological disorders

OBJECTIVES:

This study investigated whether neurophysiologic responses (auditory evoked potentials) differ between typically developed children and children with phonological disorders and whether these responses are modified in children with phonological disorders after speech therapy.

METHODS:

The participants included 24 typically developing children (Control Group, mean age: eight years and ten months) and 23 children clinically diagnosed with phonological disorders (Study Group, mean age: eight years and eleven months). Additionally, 12 study group children were enrolled in speech therapy (Study Group 1), and 11 were not enrolled in speech therapy (Study Group 2). The subjects were submitted to the following procedures: conventional audiological, auditory brainstem response, auditory middle-latency response, and P300 assessments. All participants presented with normal hearing thresholds. The study group 1 subjects were reassessed after 12 speech therapy sessions, and the study group 2 subjects were reassessed 3 months after the initial assessment. Electrophysiological results were compared between the groups.

RESULTS:

Latency differences were observed between the groups (the control and study groups) regarding the auditory brainstem response and the P300 tests. Additionally, the P300 responses improved in the study group 1 children after speech therapy.

CONCLUSION:

The findings suggest that children with phonological disorders have impaired auditory brainstem and cortical region pathways that may benefit from speech therapy.     

Carotid stenosis: what is the high-risk population?

OBJECTIVE:

Prevention is the best treatment for cerebrovascular disease, which is why early diagnosis and the immediate treatment of carotid stenosis contribute significantly to reducing the incidence of stroke. Given its silent nature, 80% of stroke cases occur in asymptomatic individuals, emphasizing the importance of screening individuals with carotid stenosis and identifying high-risk groups for the disease. The aim of this study was to determine the prevalence and the most frequent risk factors for carotid stenosis.

METHODS:

A transversal study was conducted in the form of a stroke prevention campaign held on three non-consecutive Saturdays. During the sessions, carotid stenosis diagnostic procedures were performed for 500 individuals aged 60 years or older who had systemic arterial hypertension and/or diabetes mellitus and/or coronary heart disease and/or a family history of stroke.

RESULTS:

The prevalence of carotid stenosis in the population studied was 7.4%, and the most frequent risk factors identified were mean age of 70 years, carotid bruit, peripheral obstructive arterial disease, coronary insufficiency and smoking. Independent predictive factors of carotid stenosis include the presence of carotid bruit or peripheral obstructive arterial disease and/or coronary insufficiency.

CONCLUSIONS:

The population with peripheral obstructive arterial disease and/or coronary insufficiency and carotid bruit should undergo routine screening for carotid stenosis.     

Differentiation between tuberculosis and leukemia in abdominal and pelvic lymph nodes: evaluation with contrast-enhanced multidetector computed tomography

PURPOSE:

To compare the characteristics of tubercular vs. leukemic involvement of abdominopelvic lymph nodes using multidetector computed tomography (CT).

MATERIALS AND METHODS:

We retrospectively reviewed multidetector computed tomography features including lymph node size, shape, enhancement patterns, and anatomical distribution, in 106 consecutive patients with newly diagnosed, untreated tuberculosis (55 patients; 52%) or leukemia (51 patients; 48%). In patients with leukemia, 32 (62.7%) had chronic lymphocytic leukemia, and 19 (37.3%) had acute leukemias; of these, 10 (19.6%) had acute myeloid leukemia, and 9 (17.6%) had acute lymphocytic leukemia.

RESULTS:

The lower para-aortic (30.9% for tuberculosis, 63.2% for acute leukemias and 87.5% for chronic lymphocytic leukemia) and inguinal (9.1% for tuberculosis, 57.9% for acute leukemias and 53.1% for chronic lymphocytic leukemia) lymph nodes were involved more frequently in the three types of leukemia than in tuberculosis (both with p <0.017). Tuberculosis showed peripheral enhancement, frequently with a multilocular appearance, in 43 (78.2%) patients, whereas patients with leukemia (78.9% for acute myeloid leukemia and acute lymphocytic leukemia, 87.5% for chronic lymphocytic leukemia) demonstrated predominantly homogeneous enhancement (both with p <0.017). For the diagnosis of tuberculosis, the analysis showed that a peripheral enhancement pattern had a sensitivity of 78.2%, a specificity of 100%, and an accuracy of 88.7%. For the diagnosis of leukemia, the analysis showed that a homogeneous enhancement pattern was associated with a sensitivity of 84.3%, a specificity of 94.5%, and an accuracy of 89.6%.

CONCLUSION:

Our findings indicate that the anatomical distribution and enhancement patterns of lymphadenopathy seen on multidetector computed tomography are useful for differentiating between untreated tuberculosis and leukemia of the abdominopelvic lymph nodes.     

Neurophysiology of hearing in patients with mucopolysaccharidosis type IV

Background

Hearing impairment is a common problem in patients with mucopolysaccharidosis IV (MPS IV) throughout their life. Many of the adult patients with MPS IV exhibit permanent or severe hearing loss. However, there has been no systematic review of detailed audiological test results in MPS IV.

Arch height and maximum rearfoot eversion during jogging in 2 static neutral positions

Context:

Clinically, lowering of the medial longitudinal arch is believed to be closely related to rearfoot eversion. However, the relationship between arch height and rearfoot eversion during gait is unclear.

Objectives:

(1) To examine the influence of 2 reference positions (weight-bearing neutral position [WBNP] and subtalar neutral position [STNP]) on maximum rearfoot eversion, tibial internal rotation, knee flexion, knee internal rotation, and dorsiflexion-plantar flexion of ankle joint measures during jogging and (2) to compare the relationships among static arch height, navicular drop, and the 2 maximum rearfoot eversion measures.

Design:

Crossover study.

Setting:

Gait laboratory.

Patients or Other Participants:

Thirty-three volunteers between 18 and 40 years of age.

Intervention(s):

Each participant stood on the treadmill in 2 static positions: WBNP and STNP. Kinematic data were obtained using a 10-camera motion analysis system (120 Hz) when participants jogged at 2.65 m/s on the treadmill in bare feet.

Main Outcome Measure(s):

Rearfoot and shank angular kinematics, navicular drop, and static arch height.

Results:

Maximum rearfoot eversion was greater (WBNP: 4.03° ± 2.58°, STNP: 10.91° ± 5.34°) when STNP was the static reference (P < .001). A strong correlation was seen between maximum STNP eversion and navicular drop (r = 0.842) but not between WBNP and navicular drop (r = 0.216). Differences were noted in dorsiflexion and knee kinematics during gait between the static references; however, the effect sizes were low, and the mean differences were smaller than 2°, which was less than 5% of total excursion during gait.

Conclusions:

Using STNP rather than WBNP as the reference position affects estimates of frontal-plane rearfoot movement but not other ankle or knee motions in jogging.     

The negative prognostic impact of bone metastasis with a tumor mass

OBJECTIVE:

Typically, bone metastasis causes osteolytic and osteoblastic lesions resulting from the interactions of tumor cells with osteoclasts and osteoblasts. In addition to these interactions, tumor tissues may grow inside bones and cause mass lesions. In the present study, we aimed to demonstrate the negative impact of a tumor mass in a large cohort of patients with bone metastatic cancer.

METHODS:

Data from 335 patients with bone metastases were retrospectively reviewed. For the analysis, all patients were divided into three subgroups with respect to the type of bone metastasis: osteolytic, osteoblastic, or mixed. The patients were subsequently categorized as having bone metastasis with or without a tumor mass, and statistically significant differences in median survival and 2-year overall survival were observed between these patients (the median survival and 2-year overall survival were respectively 3 months and 16% in patients with a tumor mass and 11 months and 26% in patients without a tumor mass; p<0.001).

RESULTS:

According to multivariate analysis, the presence of bone metastasis with a tumor mass was found to be an independent prognostic factor (p=0.011, hazard ratio: 1.62, 95% confidence interval: 1.11–1.76). Bone metastasis with a tumor mass was more strongly associated with osteolytic lesions, other primary diseases (except for primary breast and prostate cancers), and spinal cord compression.

CONCLUSION:

Bone metastasis with a tumor mass is a strong and independent negative prognostic factor for survival in cancer patients.     

Is the measurement of inferior thyroid artery blood flow velocity by color-flow Doppler ultrasonography useful for differential diagnosis between gestational transient thyrotoxicosis and Graves' disease? A prospective study

OBJECTIVE:

To determine the role of peak systolic velocity, end-diastolic velocity and resistance indices of both the right and left inferior thyroid arteries measured by color-flow Doppler ultrasonography for a differential diagnosis between gestational transient thyrotoxicosis and Graves'' disease during pregnancy.

METHODS:

The right and left inferior thyroid artery-peak systolic velocity, end-diastolic velocity and resistance indices of 96 patients with thyrotoxicosis (41 with gestational transient thyrotoxicosis, 31 age-matched pregnant patients with Graves'' disease and 24 age- and sex-matched non-pregnant patients with Graves'' disease) and 25 age- and sex-matched healthy euthyroid subjects were assessed with color-flow Doppler ultrasonography.

RESULTS:

The right and left inferior thyroid artery-peak systolic and end-diastolic velocities in patients with gestational transient thyrotoxicosis were found to be significantly lower than those of pregnant patients with Graves'' disease and higher than those of healthy euthyroid subjects. However, the right and left inferior thyroid artery peak systolic and end-diastolic velocities in pregnant patients with Graves'' disease were significantly lower than those of non-pregnant patients with Graves'' disease. The right and left inferior thyroid artery peak systolic and end-diastolic velocities were positively correlated with TSH-receptor antibody levels. We found an overlap between the inferior thyroid artery-blood flow velocities in a considerable number of patients with gestational transient thyrotoxicosis and pregnant patients with Graves'' disease.

CONCLUSIONS:

This study suggests that the measurement of inferior thyroid artery-blood flow velocities with color-flow Doppler ultrasonography does not have sufficient sensitivity and specificity to be recommended as an initial diagnostic test for a differential diagnosis between gestational transient thyrotoxicosis and Graves'' disease during pregnancy.     

Implementation of pay for performance in primary care: a qualitative study 8 years after introduction

Background

Pay for performance is now a widely adopted quality improvement initiative in health care. One of the largest schemes in primary care internationally is the English Quality and Outcomes Framework (QOF).

Aim

To obtain a longer term perspective on the implementation of the QOF.

Design and setting

Qualitative study with 47 health professionals in 23 practices across England.

Method

Semi-structured interviews.

Results

Pay for performance is accepted as a routine part of primary care in England, with previous more individualistic and less structured ways of working seen as poor practice. The size of the QOF and the evidence-based nature of the indicators are regarded as key to its success. However, pay for performance may have had a negative impact on some aspects of medical professionalism, such as clinical autonomy, and led a significant minority of GPs to prioritise their own pay rather than patients’ best interests. A small minority of GPs tried to increase their clinical autonomy with further unintended consequences.

Conclusion

Pay for performance indicators are now welcomed by primary healthcare teams and GPs across generations. Almost all interviewees wanted to see a greater emphasis on involving front line practice teams in developing indicators. However, almost all GPs and practice managers described a sense of decreased clinical autonomy and loss of professionalism. Calibrating the appropriate level of clinical autonomy is critical if pay for performance schemes are to have maximal impact on patient care.     

Compensatory sweating after restricting or lowering the level of sympathectomy: a systematic review and meta-analysis

OBJECTIVE:

To compare compensatory sweating after lowering or restricting the level of sympathectomy.

METHOD:

A systematic review and meta-analysis were conducted of all randomized controlled trials published in English that compared compensatory sweating after lowering or restricting the level of sympathectomy. The Cochrane collaboration tool was used to assess the risk of bias, and the Mantel-Haenszel odds ratio method was used for the meta-analysis.

RESULTS:

A total of 11 randomized controlled trials were included, including a total of 1079 patients. Five of the randomized controlled trials studied restricting the level of sympathectomy, and the remaining six studied lowering the level of sympathectomy.

CONCLUSIONS:

The compiled randomized controlled trial results published so far in the literature do not support the claims that lowering or restricting the level of sympathetic ablation results in less compensatory sweating.