[Deviant language development following cochlear implantation? Applicability of the parent questionnaire ELFRA-2]. / Abweichende Sprachentwicklung nach Cochleaimplantation? Zur Anwendbarkeit des Elternfragebogens ELFRA-2.

BACKGROUND: The parent questionnaire ELFRA-2 is considered a valid tool for early detection of delayed language development in 2-year-old children. Applicability for children treated with cochlear implants (CI) is to be investigated. METHODS: By means of the ELFRA-2 we documented longitudinally for up to 24 months post implantation language development in 27 children treated before 3 years of age. The critical developmental criteria (related to age) were applied to CI children (related to duration of CI use) and gender-related normative data were taken as a reference. RESULTS: Only two boys were identified as showing a language delay after 2 years of CI use. However, using normative data 11-44% of the children performed below average. Development in girls was faster than in boys. The influence of preoperative hearing experience declined over time. CONCLUSION: The critical developmental criteria of ELFRA-2 have proved to be unreliable for the identification of varying development after CI. Modified and gender-related evaluation is necessary.

[Acute psychotic productivity in cerebral imaging]. / Akute psychotische Produktivität in der zerebralen Bildgebung1.

Regional cerebral blood flow (rCBF) was analysed in 24 neuroleptically never treated schizophrenics by 99m-Tc-HMPAO-SPECT. Psychopathological symptoms (PANSS) were correlated with rCBF-measures using multidimensional scaling (MDS). Highest degrees of correlation were found for ideas of grandiosity and formal thought disorders compared to different regions of interest (ROIs). An adynamic cluster was defined by basic symptoms which showed signs of deficiency. This cluster was by the highest degree correlated with a cluster defined by rCBF compared to four different clusters of basic symptoms. A fMRI-study was performed in schizophrenic patients with auditive hallucinations in comparison to healthy controls. We offered simple acoustic stimuli perceived as coming from the outside versus inside. For the outside condition, controls activated the medial temporal gyrus on the left side and the rightsided precuneus and postcentral gyrus which represent the auditive source locating and the stimulus processing systems, for inside, they activated the left insula. Hallucinating schizophrenic neither activated the one nor the other system. We discussed the findings as a possible explanation of the schizophrenics' tendency to misinterpret hallucinations as real perceptions.

[Test set for the evaluation of hearing and speech development after cochlear implantation in children]. / Evaluationsset zur Hör-/Sprachentwicklung nach Cochlea-Implantation bei Kindern.

BACKGROUND: Since autumn 1998 the multicenter interdisciplinary study group "Test Materials for CI Children" has been compiling a uniform examination tool for evaluation of speech and hearing development after cochlear implantation in childhood. METHODS USED: After studying the relevant literature, suitable materials were checked for practical applicability, modified and provided with criteria for execution and break-off. For data acquisition, observation forms for preparation of a PC-version were developed. RESULTS: The evaluation set contains forms for master data with supplements relating to postoperative processes. The hearing tests check supra-threshold hearing with loudness scaling for children, speech comprehension in silence (Mainz and Göttingen Test for Speech Comprehension in Childhood) and phonemic differentiation (Oldenburg Rhyme Test for Children), the central auditory processes of detection, discrimination, identification and recognition (modification of the "Frankfurt Functional Hearing Test for Children") and audiovisual speech perception (Open Paragraph Tracking, Kiel Speech Track Program). The materials for speech and language development comprise phonetics-phonology, lexicon and semantics (LOGO Pronunciation Test), syntax and morphology (analysis of spontaneous speech), language comprehension (Reynell Scales), communication and pragmatics (observation forms). The MAIS and MUSS modified questionnaires are integrated. CONCLUSIONS: The evaluation set serves quality assurance and permits factor analysis as well as controls for regularity through the multicenter comparison of long-term developmental trends after cochlear implantation.

Comparison of the TEMPO+ ear-level speech processor and the cis pro+ body-worn processor in adult MED-EL cochlear implant users.

A study was conducted to compare the new MED-EL TEMPO+ ear-level speech processor with the CIS PRO+ body-worn processor in the COMBI 40/COMBI 40+ implant system. Speech tests were performed in 46 experienced subjects in two test sessions approximately 4 weeks apart. Subjects were switched over from the CIS PRO+ to the TEMPO+ in the first session and used only the TEMPO+ in the time between the two sessions. Speech tests included monosyllabic word tests and sentence tests via the telephone. An adaptive noise method was used to adjust each subject's scores to approximately 50%. Additionally, subjects had to complete a questionnaire based on their 4 weeks of experience with the TEMPO+. The speech test results showed a statistically significant improvement in the monosyllabic word scores with the TEMPO+. In addition, in the second session, subjects showed a significant improvement when using the telephone with the TEMPO+, indicating some learning in this task. In the questionnaire, the vast majority of subjects found that the TEMPO+ allows equal or better speech understanding and rated the sound quality of the TEMPO+ higher. All these objective and subjective results indicate the superiority of the TEMPO+ and are mainly attributed to a new coding strategy called CIS+ and its implementation in the TEMPO+. In other words, based on the results of this study, it appears that after switching over from the CIS PRO+ to the TEMPO+, subjects are able to maintain or even improve their own speech understanding capability.

The neural correlates of 'deaf-hearing' in man: conscious sensory awareness enabled by attentional modulation.

Attentional modulation of normal sensory processing has a two-fold impact on human brain activity: activation of a network of localized brain regions is associated with paying attention, and activation of specific sensory regions is enhanced relative to passive stimulation. The mechanisms underlying attentional modulation of perception in patients with lesions of sensory cortices are less well understood. Here we report a unique patient suffering from extensive bilateral destruction of the auditory cortices (including the primary auditory fields) who demonstrated conscious perception of the onset and offset of sounds only when selectively attending to the auditory modality. This is the first description of such an attentively modulated 'deaf-hearing' phenomenon and its neural correlates, using H(2)(15)O-PET. Increases in cerebral blood flow associated with conscious awareness of sound that was achieved by listening attentively (compared with identical auditory stimulation presented when the patient was inattentive) were found bilaterally in the lateral (pre)frontal cortices, the spared middle temporal cortices and the cerebellar hemispheres. We conclude that conscious awareness of sounds may be achieved in the absence of the primary auditory cortex, and that selective, 'top-down' attention, associated with prefrontal systems, exerts a crucial modulatory effect on auditory perception within the remaining auditory system.

Assessment of auditory skills in hearing-impaired children: theoretical foundations and a practical approach.

A proposal of a performance profile for the assessment of auditory skills of hearing-impaired children with cochlear implants or hearing-aids is described here. The associated tests have been realized either with conventional material or on the Auditory Visual Test and Therapy System developed by the Aachen research group. Acoustic stimuli and answering tasks have been chosen according to the special needs of hearing-impaired children in the age range of 3-6 years of developmental age. Two tests will be described exemplary.

Amplitude modulation following response in children as a clinical audiometric tool.

The current study was designed to investigate the clinical application of amplitude modulation following response (AMFR) in cochlear implant candidates. A new digital signal processor (DSP)-assisted PC-based hardware and software was developed to perform both simultaneous generation of amplitude-modulated stimuli and the recording, and synchronized signal processing of the electrode signals. Our first results show that AMFR can be recorded in adults as well as in children without any contamination by response-like stimulus artifacts. Very high sound pressure levels can be applied, allowing frequency-specific assessment of residual hearing. Response threshold detection, using spectral analysis, proved to be superior compared to visual evaluation of average time waveforms.

The functional anatomy of recovery from auditory agnosia. A PET study of sound categorization in a neurological patient and normal controls.

H2(15)O-PET was used to investigate the functional anatomy of recovery in a patient (J.B.) with bilateral perisylvian strokes and auditory agnosia, who partially regained the ability to recognize environmental sounds, but remained clinically word-deaf. The patient and a group of six normal volunteers were scanned in the following three conditions: (i) passive listening to environmental sounds; (ii) categorization of environmental sounds; (iii) at rest. In normal subjects, passive listening as compared with rest was associated with significant activations in the auditory cortices and posterior thalami, and in the inferior parietal lobe and anterior insula/frontal opercular region on the right. In J.B., activations were observed in the spared auditory cortex and inferior parietal lobe of the right hemisphere and in regions adjacent to the perisylvian lesion in the left hemisphere (anterior insula/frontal opercular region, middle temporal gyrus and inferior parietal lobe). The recovered function, as measured by categorization of sounds compared with passive listening, in J.B. was associated with bilateral activation of a distributed network comprising (pre)frontal, middle temporal and inferior parietal cortices, as well as the right cerebellum and the right caudate nucleus. In addition, there was a left-sided activation of the anterior cingulate gyrus. In normal subjects, the same categorization task led to activation of a network comprising (pre)frontal, middle temporal and inferior parietal cortices in the left hemisphere only. These results suggest that bilateral activation (with recruitment of areas homologous to those known to be responsible for normal function), the engagement of peri-infarct regions, and the involvement of a more widespread neocortical network, are mechanisms of functional reorganization after injury that may enable recovery from, or compensation for, cognitive deficits.

Multicentric field evaluation of a new speech coding strategy for cochlear implants.

In a multicentric study involving 4 European cochlear implant centers, the speech perception abilities of 20 native German-speaking individuals implanted with the Nucleus 22 Channel Cochlear Implant System when using a new spectral peak (SPEAK) speech coding strategy were investigated. This strategy continuously analyzes the speech signal using 20 digital programmable bandpass filters and presents up to 10 spectral maxima to the 22 implanted electrodes. Each subject's performance on a variety of auditory perceptual tasks was evaluated with the experimental encoder (SPEAK), relative to his or her performance in a reference condition. An ABAB experimental design was used whereby each strategy was reversed and replicated. The reference levels of auditory performance were established using the multipeak (MPEAK) speech-processing strategy of the Nucleus speech processor. Only subjects who achieved open-set monosyllable word recognition in the reference condition were included in this study. Significant differences in group mean scores for most speech recognition subtests were obtained for the SPEAK versus the MPEAK strategy. The largest overall improvements were observed for the sentence tests under noisy conditions.

Safety observations from the pilot phase of the randomized r-Hirudin for Improvement of Thrombolysis (HIT-III) study. A study of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK)

BACKGROUND: Adjunctive therapy for thrombolysis in acute myocardial infarction consists of platelet inhibition with aspirin and thrombin inhibition with heparin. Thrombin inhibition may be improved by the use of hirudin as indicated by experimental and phase II clinical studies. The randomized, double-blind phase III r-Hirudin for Improvement of Thrombolysis study (HIT III) compared a recombinant hirudin (HBW 023) with heparin. The primary end point was the incidence of death or reinfarction. METHODS AND RESULTS: Seven thousand patients with acute myocardial infarction and a duration of symptoms of less than 6 hours were to be randomized to receive intravenous heparin (70 IU/kg body wt bolus and 15 IU.kg-1.h-1) or hirudin (0.4 mg/kg body wt bolus and 0.15 mg.kg-1.h-1) infused over 48 to 72 hours and adjusted to an activated partial thromboplastin time of 2 to 3.5 times baseline values. In a pilot phase, 1000 patients receiving front-loaded alteplase for thrombolysis were to be recruited by 93 German centers. After enrollment of 302 patients, the trial was stopped after an increased rate of intracranial bleeding was observed in the hirudin group (5 of 148, 3.4%) compared with the heparin group (0 of 154). The overall stroke rate was 3.4% in the hirudin group and 1.3% in the heparin group. Other major bleeding occurred in five versus three patients and ventricular rupture occurred in three versus one patient in the hirudin and heparin groups, respectively. There were 19 in-hospital deaths, with 13 of them from the hirudin group. CONCLUSIONS: Although the number of patients was too small for a definite benefit-risk assessment, at the dosage tested, hirudin in combination with front-loaded alteplase and aspirin may be associated with an increased rate of intracranial hemorrhage. Our findings are consistent with the observations of the GUSTO-II and TIMI-9 trials, where higher doses of another recombinant hirudin were used. Therefore, the therapeutic range of hirudin as an adjunct to thrombolysis may be smaller than previously thought, and reappraisal of dose finding should be considered.

[How badly does the "normal-hearing" young man of 1992 hear in the high frequency range?]. / Wie schlecht hört der "normalhörende" junge Mann des Jahres 1992 im Hochtonbereich?

In the course of a clinical study we examined young men believed to have normal hearing. Volunteers with a positive history for noise deafness were excluded from further study. Normal hearing was verified by pure-tone audiometry if the hearing loss did not exceed 15 dB for each test tone between 250 Hz and 8000 Hz. As this limit is far below normative threshold values (DIN ISO 7029) we expected to find a large number of otological normal subjects. Using pure-tone audiometry, ABR and noise exposure, we found that 65% of the young male volunteers (mean age 25 years) did not meet the criteria for audiologic normality. The pure-tone thresholds for these subjects were comparable to the expected levels of their fathers' generation.

[Hearing screening in neonates and infants using brain stem evoked acoustic potentials]. / Hörscreening bei Neugeborenen und Säuglingen mittels Ableitung akustisch-evozierter Hirnstammpotentiale.

Reported failure rates of screening using the conventional brainstem auditory response (BAER), audiometry range from 5% to 60% with about 30% of the babies having normal hearing sensitivity on follow-up. The results of testing by an automated infant screener using advanced evoked response technology are compared with those of a conventional evoked response system operated by skilled personnel. 50 newborn were tested at a gestational age of 40-42 weeks. Normal results were obtained in all 25 newborn (50 ears) of the control group using both testing procedures. Out of 25 newborn (50 ears) at risk for congenital perinatal or postnatal hearing disorder, abnormal results for either screening or conventional BAER recording were seen in 6 ears with both methods.

[Ultrasonic diagnosis of the pseudoglottis in laryngectomized patients]. / Die Ultraschalluntersuchung der Pseudoglottis bei Kehlkopflosen.

The validity of ultrasonic imaging as a tool for the investigation of pseudoglottal movements was studied in five good to excellent esophageal speakers. The length of pseudoglottis and vibration rate during phonation of vowels was evaluated by means of B-mode and M-mode sonography respectively. The pseudoglottal vibration rate as seen in M-mode sonography was in high agreement with the fundamental frequency of the simultaneously recorded sound as assessed by speech analysis. Ultrasound imaging is a promising diagnostic and therapeutic tool for the control and development of esophageal speech.

[Ultrasound study of disorders of coordination in tongue movement in swallowing]. / Ultraschalluntersuchung von Koordinationsstörungen der Zungenbewegung beim Schlucken.

Ultrasound imaging of tongue movements permits real-time observation of swallowing and articulation without risk for the patient. The ultrasound images of the tongue motions were recorded on video-tape and then analyzed frame by frame. We were able to detect regular phases of tongue motion during normal swallowing. Clear deviations from normal motion patterns were found in a patient with anarthria, despite absence of swallowing difficulties in every day life.

Intravascular leiomyomatosis: report of a case and review of the literature.

So far, only 13 cases with extension of an intravascular leiomyoma into the heart have been reported. We present the second known case of leiomyomatosis with extension of the tumor through the tricuspid valve into the right ventricle, which was first removed successfully. Ten years after an abdominal hysterectomy for a myomatous uterus, a 53-year old woman presented with a intracavitary mass in the right-sided heart chambers which could be followed retrogradely into the inferior vena cava and right pelvic veins, representing an intravasal extension from the pelvic leiomyoma. The clinical picture, the two-stage operative management, and the postoperative course are reviewed and the literature on the subject is presented.

[Pericarditis in chronic compensated renal insufficiency]. / Perikarditis bei chronisch kompensierter Niereninsuffizienz.

In 80 patients with renal insufficiency we found 15 cases of pericarditis, demonstrated by the diagnostic means of echocardiography. The incidence of pericarditis increased with the rise in serum-creatinin and the severity of hypalbuminemia. These findings confirm the assumption that toxic capillary damage combined with lowered oncotic pressure might be a cause of pericardial effusion. Echocardiography as a reliable and non-invasive diagnostic method should be applied routinely in patients with chronic renal insufficiency--regarding potential therapeutic consequences--especially in patients with a concomitant incidence of hypalbuminemia and pleural effusion.

[Directional hearing and understanding of speech in noise uith "normal hearing" people (author's transl)]. / Richtungshören und Sprachverstehen unter Störschall-einfluss bei "normalhörenden".

Directional hearing and the ability to understand speech against a noisy background depend among other factors on the binaural signal processing mechanisms in human hearing. In present the practical audiometry can not prove completely the operation of binaural signal processing. This fact will be shown here with three patients who complain of bad understanding speech, but in audiometric tests seem to hear normally. In free field tests of directional hearing and understanding speech against a noisy background they differ clearly from a reference group of normal hearing people.