The relationship between hearing status and the participation in different categories of work: demographics.

OBJECTIVE: To investigate the association between hearing status, socioeconomic status and work status. PARTICIPANTS: Cross-sectional data of 18-64 year old participants (N=1888) from the National Longitudinal Study on Hearing (NL-SH) were used. Both normal hearing and hearing impaired subjects participated. METHODS: Hearing ability in noise was measured with the National Hearing test, an online speech-in-noise test. Educational level, monthly income, being primary income earner and working status (i.e. paid employment, unemployed and looking for work, unfit for work, voluntary work, household work, being a student, or taking early retirement, and the type of work contract) were assessed with a questionnaire. Logistic regression analyses were applied. RESULTS: Participants with poorer hearing ability were less likely to be found in the upper categories of educational level and income, having paid work > 12 hours per week, being a student, or taking early retirement. On the other hand they were more likely to look for work or to be unfit for work. No associations were found with voluntary work and household work. DISCUSSION: Hearing ability seems to be related to both socioeconomic status and being employed. Our findings underline the importance of rehabilitation programs in audiology, aimed at supporting people with hearing impairment to help them to successfully enter or re-enter the workforce.

Pharmacokinetics of inhaled monodisperse beclomethasone as a function of particle size.

AIMS: For optimal efficacy, antiasthma drugs should be delivered to the desired region in the airways. To date, the optimal particle size for steroids in adults is not known. The aim of the study was to evaluate the pulmonary bioavailability for inhaled beclomethasone dipropionate (BDP) aerosols of different particle sizes. METHODS: In a randomized single-blind crossover trial, 10 mild asthmatic patients inhaled monodisperse BDP aerosols with mass median aerodynamic diameters (MMADs) of 1.5, 2.5 and 4.5 microm. Gastrointestinal absorption was blocked by activated charcoal. Plasma concentrations of 17-beclomethasone monopropionate (17-BMP) were measured by liquid chromatography plus mass spectrometry. RESULTS: Aerosols with MMADs of 1.5 microm, 2.5 microm, and 4.5 microm gave mean maximum concentrations (C(max)) of 17-BMP of 475 pg ml(-1), 1300 pg ml(-1), and 1161 pg ml(-1), respectively. The area under the curve (AUC) values of 17-BMP for MMADs of 1.5 microm, 2.5 microm, and 4.5 microm were 825 pg ml(-1) h, 2629 pg ml(-1) h, and 2276 pg ml(-1) h, respectively. The mean terminal half-time of 17-BMP for all three aerosol sizes was around 1.5 h. CONCLUSIONS: Monodisperse BDP aerosols with a MMAD of 1.5 microm gave two-three fold lower values for C(max) and AUC than those with MMADs of 2.5 and 4.5 microm.

Analysis of failure of voice production by a sound-producing voice prosthesis.

OBJECTIVE: To analyse the cause of failing voice production by a sound-producing voice prosthesis (SPVP). METHODS: The functioning of a prototype SPVP is described in a female laryngectomee before and after its sound-producing mechanism was impeded by tracheal phlegm. This assessment included: perceptual voice evaluation of read-aloud prose by an expert listener; inspection of the malfunctioning SPVP; and aero-acoustical in vivo registrations using a computer-based data acquisition system. RESULTS: Sound-producing voice prosthesis speech is higher pitched, stronger, contains less aperiodic noise and requires a lower airflow rate than the patient's regular tracheoesophageal (TE) shunt speech. Tracheal phlegm caused malfunction of the vibrating silicone lip of the SPVP by causing it to stick to its stainless steel container in an opened position, thereby reducing the SPVP to no more than a regular TE shunt valve from a functional point of view. Tracheal phonatory pressure and dynamic vocal intensity range were not affected by the functional status of the SPVP. CONCLUSIONS: To exploit the advantages an SPVP could offer female laryngectomees with an atonic or severely hypotonic pharyngoesophageal segment, the sound-producing mechanism of the SPVP needs to be less vulnerable to tracheal phlegm.

Assessment of alaryngeal speech using a sound-producing voice prosthesis in relation to sex and pharyngoesophageal segment tonicity.

BACKGROUND: A pneumatic artificial sound source incorporated in a regular tracheoesophageal shunt valve may improve alaryngeal voice quality. METHODS: In 20 laryngectomees categorized for sex and pharyngoesophageal segment tonicity, a prototype sound-producing voice prosthesis (SPVP) is evaluated for a brief period and compared with their regular tracheoesophageal shunt speech. RESULTS: Perceptual voice evaluation by an expert listener and acoustical analysis demonstrate a uniform rise of vocal pitch when using the SPVP. Female laryngectomees with an atonic pharyngoesophageal segment gain vocal strength with the SPVP. Exerted tracheal pressure and airflow rate are equivalent to those required for regular tracheoesophageal shunt valves. However, communicative suitability and speech intelligibility deteriorate by the SPVP for most patients. Tracheal phlegm clogging the SPVP is a hindrance for most patients. CONCLUSIONS: The SPVP raises vocal pitch. Female laryngectomees with an atonic or severely hypotonic pharyngoesophageal segment can benefit from a stronger voice with the SPVP.

Effect of a facemask leak on aerosol delivery from a pMDI-spacer system.

The objective of this investigation was to study the relation between size and position of a mask leak on spacer output and lung dose. An upper-airway model (SAINT model, Erasmus MC) was connected to a breathing simulator. Facemasks with leaks ranging between 0 and 1.5 cm(2) were examined. Leaks were located close to the nose or close to the chin. During simulated breathing, 200 microg budesonide (Pulmicort, AstraZeneca) was delivered to the model via NebuChamber (AstraZeneca) with facemask. Spacer output and lung dose were measured by placing a filter between spacer and facemask or between model and breathing simulator, respectively. Budesonide trapped on the filter was quantified by means of HPLC, and expressed as percentage of the nominal dose. Mean spacer output doses for the nose position were 50, 38, 28, 12, 10, 6, and 0%, and for the chin position were 50, 40, 31, 11, 9, 4, and 0% for leaks of 0, 0.05, 0.1, 0.16, 0.2, 0.3, and larger than 0.4 cm(2), respectively. Mean lung doses for the nose position were 10, 8, 6, 3, 3, 1, 0, 0, 0, and 0%, and for the chin position were 10, 9, 8, 6, 6, 5, 1, 1, 0, and 0% for leaks of 0, 0.05, 0.1, 0.16, 0.2, 0.3, 0.4, 0.5, 1, and 1.5 cm(2). Efficiency of a pMDI-spacer facemask strongly depends on the size of a facemask leak. Spacer output did not depend on the position of the leak. Lung dose was higher for leaks near the chin than for leaks near the nose.

A speech enhancement scheme incorporating spectral expansion evaluated with simulated loss of frequency selectivity.

Hearing-impaired listeners often suffer from supra-threshold speech perception deficits. One such deficit is reduced frequency selectivity. We applied a speech enhancement scheme that incorporated spectral expansion in an attempt to reduce the effects of this deficit. The speech processing could contain up to three stages, a first in which the peak-valley ratio of the speech spectrum was enlarged to counteract the broadening of the auditory filtering, and a second in which the overall speech spectrum was modified to counteract the effects of upward-spread-of-masking, using a linear filter. The third stage was a noise suppression stage, applied before the spectral enhancement. The effectiveness of the speech processing with and without noise suppression was evaluated for various parameter settings by measuring the speech reception threshold (SRT) in noise, i.e., the signal-to-noise ratio at which listeners repeat 50% of presented sentences correctly. We used normal-hearing subjects. To simulate the loss of frequency selectivity we applied spectral smearing to the stimuli presented to the subjects. The speech material of the SRT tests was mixed with the noise before processing, and, when present, the smearing was applied last. The results indicated that for one specific parameter setting the SRT values decreased (i.e., improved) by approximately 1 dB when incorporating the spectral expansion together with the linear filtering. Employing either of these two stages separately did not improve the SRT. The application of the noise suppression stage did not further improve the SRT. A pilot study using hearing-impaired listeners showed more promising results for a female than for a male speaker.

Pleural small cell carcinoma in pre-existent asbestos related pleural disease.

Extrapulmonary small cell carcinoma (SCC) is a very rare disease, and a primary pleural manifestation is extremely rare. A case of SCC of the pleura in a 66-year-old man with pre-existent asbestos-related pleural plaques is presented. This is the first case of pleural SCC in a patient with asbestos-induced pleural disease and the third reported case of a pleural SCC. The SCC developed in an area with pre-existent pleural thickening, underlining the need for careful analysis of alterations in the manifestation of pleural disease in patients with asbestos exposition.

Female-pitched sound-producing voice prostheses--initial experimental and clinical results.

In order to improve voice quality in female laryngectomees and/or laryngectomees with a hypotonic pharyngo-oesophageal segment, a sound-producing voice prosthesis was designed. The new source of voice consists of either one or two bent silicone lips which perform an oscillatory movement driven by the expired pulmonary air that flows along the outward-striking lips through the tracheo-oesophageal shunt valve. Four different prototypes of this pneumatic sound source were evaluated in vitro and in two female laryngectomees, testing the feasibility and characteristics of this new mechanism for alternative alaryngeal voice production. In vivo evaluation included acoustic analyses of both sustained vowels and read-aloud prose, videofluoroscopy, speech rate, and registration of tracheal phonatory pressure and vocal intensity. The mechanism proved feasible and did not result in unacceptable airflow resistance. The average pitch of voice increased and clarity improved in female laryngectomees. Pitch regulation of this prosthetic voice is possible with sufficient modulation to avoid monotony. The quality of voice attained through the sound-producing voice prostheses depends on a patient's ability to let pulmonary air flow easily through the pharyngo-oesophageal segment without evoking the low-frequency mucosal vibrations that form the regular tracheo-oesophageal shunt voice. These initial experimental and clinical results provide directions for the future development of sound-producing voice prostheses. A single relatively long lip in a container with a rectangular lumen that hardly protrudes from the voice prosthesis may have the most promising characteristics.

Treatment and survival of patients with non-small cell lung cancer Stage IIIA diagnosed in 1989-1994: a study in the region of the Comprehensive Cancer Centre East, The Netherlands.

The purpose of this study was to gain insight into the treatment policy and survival of patients with non-small cell lung cancer (NSCLC) clinical stage IIIA in daily practice. We selected 212 patients, who had been diagnosed between 1989 and 1994 and registered by the Cancer Registry, Comprehensive Cancer Centre East (CCCE). Diagnostic tests comprised chest X-ray and bronchoscopy in all cases but one, computed tomography in 89%, mediastinoscopy in 55% and conventional tomography of the chest in 16%. NSCLC had been verified histologically in 88% and cytologically in 12%. The initial treatment for the primary tumor had been surgery alone in 13% of the patients, surgery plus radiotherapy in 8%, radiotherapy alone in 56%, chemotherapy in 1% (three patients, one in addition to surgery); 22% received none of these treatments. Median survival of the 212 patients was 9.4 months (95% confidence interval 8.3-11.0 months). Overall survival rates after 1, 2 and 3 years were 41, 17 and 8%, respectively. Three-year survival of the patients who had undergone surgery, surgery plus radiotherapy, radiotherapy alone and no treatment was 18, 19, 6 and 4%, respectively. Treatment was an independent prognostic factor (multivariate Cox's proportional hazards analysis adjusted for sub-stage, age, number of co-morbid diseases and hospital). In the same model, the Hazard rate ratio for one hospital relative to the five others was 1.9 (95% confidence interval 1.2-2.8). Surgery (whether or not in combination with radiotherapy) independently gave the best results. In conclusion, policies varied between hospitals, although the variation in overall survival was small except at one hospital. New regional management guidelines are in preparation. Physicians will be encouraged to follow these guidelines, both with regard to diagnostic tests and to treatment policies, as our study showed that differences in policy might lead to differences in survival.

Deviant vocal fold vibration as observed during videokymography: the effect on voice quality.

Videokymographic images of deviant or irregular vocal fold vibration, including diplophonia, the transition from falsetto to modal voice, irregular vibration onset and offset, and phonation following partial laryngectomy were compared with the synchronously recorded acoustic speech signals. A clear relation was shown between videokymographic image sequences and acoustic speech signals, and the effect of irregular or incomplete vocal fold vibration patterns was recognized in the amount of perceived breathiness and roughness and by the harmonics-to-noise ratio in the speech signal. Mechanisms causing roughness are the presence of mucus, phase differences between the left and right vocal fold, and short-term frequency and amplitude modulation. It can be concluded that the use of simultaneously recorded videokymographic image sequences and speech signals contributes to the understanding of the effect of irregular vocal fold vibration on voice quality.

Effects of degradation of intensity, time, or frequency content on speech intelligibility for normal-hearing and hearing-impaired listeners.

Many hearing-impaired listeners suffer from distorted auditory processing capabilities. This study examines which aspects of auditory coding (i.e., intensity, time, or frequency) are distorted and how this affects speech perception. The distortion-sensitivity model is used: The effect of distorted auditory coding of a speech signal is simulated by an artificial distortion, and the sensitivity of speech intelligibility to this artificial distortion is compared for normal-hearing and hearing-impaired listeners. Stimuli (speech plus noise) are wavelet coded using a complex sinusoidal carrier with a Gaussian envelope (1/4 octave bandwidth). Intensity information is distorted by multiplying the modulus of each wavelet coefficient by a random factor. Temporal and spectral information are distorted by randomly shifting the wavelet positions along the temporal or spectral axis, respectively. Measured were (1) detection thresholds for each type of distortion, and (2) speech-reception thresholds for various degrees of distortion. For spectral distortion, hearing-impaired listeners showed increased detection thresholds and were also less sensitive to the distortion with respect to speech perception. For intensity and temporal distortion, this was not observed. Results indicate that a distorted coding of spectral information may be an important factor underlying reduced speech intelligibility for the hearing impaired.

The effect of intensity perturbations on speech intelligibility for normal-hearing and hearing-impaired listeners.

Hearing-impaired listeners are known to suffer from reduced speech intelligibility in noise, even if sounds are above their hearing thresholds. This study examined the possible contribution of reduced acuity of intensity coding to this problem. The "distortion-sensitivity model" was used: the effect of reduced acuity of auditory intensity coding on intelligibility was mimicked by an artificial distortion of the speech intensity coding, and the sensitivity to this distortion for hearing-impaired listeners was compared with that for normal-hearing listeners. Stimuli (speech plus noise) were wavelet coded using a Gaussian wavelet (1/4-octave bandwidth). The intensity coding was distorted by multiplying the modulus of each wavelet coefficient by a random factor. Speech-reception thresholds (SRTs) were measured for various degrees of intensity perturbation. Hearing-impaired listeners were classified as suffering from suprathreshold deficits if intelligibility of undistorted speech was worse than predicted from audibility by the speech intelligibility index model [ANSI, ANSI S3.5-1997 (1997)]. Hearing-impaired listeners without suprathreshold deficits were as sensitive to the intensity distortion as the normal-hearing listeners. Hearing-impaired listeners with suprathreshold deficits appeared to be less sensitive. Results indicate that reduced acuity of auditory intensity coding may be a factor underlying reduced speech intelligibility in noise for the hearing impaired.

Relations between intelligibility of narrow-band speech and auditory functions, both in the 1-kHz frequency region.

Relations between perception of suprathreshold speech and auditory functions were examined in 24 hearing-impaired listeners and 12 normal-hearing listeners. The speech intelligibility index (SII) was used to account for audibility. The auditory functions included detection efficiency, temporal and spectral resolution, temporal and spectral integration, and discrimination of intensity, frequency, rhythm, and spectro-temporal shape. All auditory functions were measured at 1 kHz. Speech intelligibility was assessed with the speech-reception threshold (SRT) in quiet and in noise, and with the speech-reception bandwidth threshold (SRBT), previously developed for investigating speech perception in a limited frequency region around 1 kHz. The results showed that the elevated SRT in quiet could be explained on the basis of audibility. Audibility could only partly account for the elevated SRT values in noise and the deviant SRBT values, suggesting that suprathreshold deficits affected intelligibility in these conditions. SII predictions for the SRBT improved significantly by including the individually measured upward spread of masking in the SII model. Reduced spectral resolution, reduced temporal resolution, and reduced frequency discrimination appeared to be related to speech perception deficits. Loss of peripheral compression appeared to have the smallest effect on the intelligibility of suprathreshold speech.

Alternative voice after laryngectomy using a sound-producing voice prosthesis.

OBJECTIVE: To improve the voice quality of female laryngectomees and/or laryngectomees with a hypotonic pharyngoesophageal (PE) segment by means of a pneumatic artificial source of voice incorporated in a regular tracheoesophageal (TE) shunt valve. STUDY DESIGN: Experimental, randomized, crossover trial. METHODS: The new sound source consists of a single silicone lip, which performs an oscillatory movement driven by expired pulmonary air flowing along the outward-striking lip through the TE shunt valve. A prototype of this pneumatic sound source is evaluated in vitro and in six laryngectomees. In vivo evaluation includes speech rate, maximal phonation time, perceptual voice evaluation of read-aloud prose by an expert listener, speech intelligibility measurements with 12 listeners, and self-assessment by the patients. Moreover, extensive acoustical and aerodynamic in vivo registrations are performed using a newly developed data acquisition system. RESULTS: The current prototype seems beneficial in female laryngectomees with a hypotonic PE segment only. For them the sound-producing voice prosthesis improves voice quality and increases the average pitch of voice, without decreasing intelligibility or necessitating other pressure and airflow rates than regular TE shunt speech. Pitch regulation of this prosthetic voice is possible, yet limited. CONCLUSIONS: The mechanism is feasible and does not result in unacceptable airflow resistance. For this new mechanism of alaryngeal voice to become an established technique for postlaryngectomy voice restoration, a voice suitably pitched for male laryngectomees has to be generated and a large part of the melodic and dynamic range of the sound source has to be attainable within physiological airflow rates.

Aero-acoustics of silicone rubber lip reeds for alternative voice production in laryngectomees.

To improve voice quality after laryngectomy, a small pneumatic sound source to be incorporated in a regular tracheoesophageal shunt valve was designed. This artificial voice source consists of a single floppy lip reed, which performs self-sustaining flutter-type oscillations driven by the expired pulmonary air that flows through the tracheoesophageal shunt valve along the outward-striking lip reed. In this in vitro study, aero-acoustic data and detailed high-speed digital image sequences of lip reed behavior are obtained for 10 lip configurations. The high-speed visualizations provide a more explicit understanding and reveal details of lip reed behavior, such as the onset of vibration, beating of the lip against the walls of its housing, and chaotic behavior at high volume flow. We discuss several aspects of lip reed behavior in general and implications for its application as an artificial voice source. For pressures above the sounding threshold, volume flow, fundamental frequency and sound pressure level generated by the floppy lip reed are almost linear functions of the driving force, static pressure difference across the lip. Observed irregularities in these relations are mainly caused by transitions from one type of beating behavior of the lip against the walls of its housing to another. This beating explains the wide range and the driving force dependence of fundamental frequency, and seems to have a strong effect on the spectral content. The thickness of the lip base is linearly related to the fundamental frequency of lip reed oscillation.

Gemcitabine and cisplatin as induction regimen for patients with biopsy-proven stage IIIA N2 non-small-cell lung cancer: a phase II study of the European Organization for Research and Treatment of Cancer Lung Cancer Cooperative Group (EORTC 08955).

PURPOSE: Our objective was to better define the activity/feasibility of gemcitabine/cisplatin (GC) as induction chemotherapy in patients with stage IIIA N2 non-small-cell lung cancer (NSCLC) followed by surgery or radiotherapy within a large, ongoing comparative study (EORTC 08941). PATIENTS AND METHODS: Forty-seven chemotherapy-naive patients with NSCLC, median age of 58 years, stage IIIA N2 disease, World Health Organization performance status of 0 or 1, and the ability to tolerate a pneumonectomy received gemcitabine 1,000 mg/m(2) on days 1, 8, and 15 and cisplatin 100 mg/m(2) on day 2, every 4 weeks. Patients received induction chemotherapy (three cycles) before re-evaluation and randomization to surgery or radiotherapy. RESULTS: Grade 3/4 thrombocytopenia, the main hematologic toxicity, occurred in 60% of patients but was not associated with bleeding. Full-dose gemcitabine was given in 48% of the courses. Severe nonhematologic toxicity was uncommon. Two patients with preexisting, autoimmune pulmonary fibrosis had deterioration of pulmonary function after radiotherapy. Thirty-three (70.2%; 95% confidence interval, 55.1% to 82.7%) of the 47 eligible patients had objective responses (three complete responses and 30 partial responses). Mediastinal nodes were tumor-free after induction therapy in 53% of cases. Resections were considered complete in 71% of the patients who underwent thoracotomy after induction therapy. Median survival for all recruited patients (N = 53) was 18.9 months, with an estimated 1-year survival rate of 69%. CONCLUSION: In patients with N2 stage IIIA NSCLC, GC is a highly active and well-tolerated induction regimen. GC should be explored in combination with surgery or radiotherapy in stage I and II patients.

Measuring the threshold for speech reception by adaptive variation of the signal bandwidth. II. Hearing-impaired listeners.

In a previous study [Noordhoek et al., J. Acoust. Soc. Am. 105, 2895-2902 (1999)], an adaptive test was developed to determine the speech-reception bandwidth threshold (SRBT), i.e., the width of a speech band around 1 kHz required for a 50% intelligibility score. In this test, the band-filtered speech is presented in complementary bandstop-filtered noise. In the present study, the performance of 34 hearing-impaired listeners was measured on this SRBT test and on more common SRT (speech-reception threshold) tests, namely the SRT in quiet, the standard SRT in noise (standard speech spectrum), and the spectrally adapted SRT in noise (fitted to the individual's dynamic range). The aim was to investigate to what extent the performance on these tests could be explained simply from audibility, as estimated with the SII (speech intelligibility index) model, or require the assumption of suprathreshold deficits. For most listeners, an elevated SRT in quiet or an elevated standard SRT in noise could be explained on the basis of audibility. For the spectrally adapted SRT in noise, and especially for the SRBT, the data of most listeners could not be explained from audibility, suggesting that the effects of suprathreshold deficits may be present. Possibly, such a deficit is an increased downward spread of masking.

Method for the selection of sentence materials for efficient measurement of the speech reception threshold.

A method is described to select sentence materials for efficient measurement of the speech reception threshold (SRT). The first part of the paper addresses the creation of the sentence materials, the recording procedure, and a listening experiment to evaluate the new speech materials. The result is a set of 1272 sentences, where every sentence has been uttered by two male and two female speakers. In the second part of the paper, a method is described to select subsets with properties that are desired for an efficient measurement of the SRT. For two speakers, this method has been applied to obtain two subsets for measurement of the SRT in stationary noise with the long-term average spectrum of speech. Lastly, a listening experiment has been conducted where the two subsets (each comprising 39 lists of 13 sentences each) are directly compared to the existing sets of Plomp and Mimpen [Audiology 18, 43-52 (1979)] and Smoorenburg [J. Acoust. Soc. Am. 91, 421-437 (1992)]. One of the outcomes is that the newly developed sets can be considered as equivalent to these existing sets.

Polymorphous low grade adenocarcinoma with distant metastases and deletions on chromosome 6q23-qter and 11q23-qter: a case report.

Polymorphous low grade adenocarcinomas (PLGAs) are thought to be indolent tumours that are localised preferentially to the palate and affect the minor salivary glands almost exclusively. Metastases to locoregional lymph nodes occur in only 6-10% of cases. Recently, two cases of PLGA with microscopically confirmed distant metastases have been reported. This study reports a third case of PLGA with histologically and immunohistochemically confirmed distant metastases. It is the first case with multiple pleural, as well as pulmonary parenchymal, metastases and metastases in cervical and paraoesophageal lymph nodes. In most cases, PLGAs are salivary gland tumours with limited potential to metastasis and a good prognosis after local treatment. However, the recently reported cases reveal that the tumour can give rise to widely spread metastases. To obtain more information about the incidence of distant metastases, periodic chest x ray examination during follow up is desirable.