Associations Between Traumatic Brain Injury and Severity of Tinnitus-Related Functional Impairment Among US Military Veterans: A National, Population-Based Study.

OBJECTIVE: To describe associations between a history of traumatic brain injury (TBI) and the severity of tinnitus-related functional impairment among a national, stratified random sample of veterans diagnosed with tinnitus by the Department of Veterans Affairs (VA) healthcare system. SETTING: A multimodal (mailed and internet) survey administered in 2018. Participants: VA healthcare-using veterans diagnosed with tinnitus; veterans with comorbid TBI diagnosis were oversampled. DESIGN: A population-based survey. MAIN MEASURES: TBI history was assessed using International Classification of Diseases (ICD) diagnosis codes in veterans' VA electronic health records. The severity of participants' overall tinnitus-related functional impairment was measured using the Tinnitus Functional Index. Population prevalence and 95% confidence intervals (CIs) were estimated using inverse probability weights accounting for sample stratification and survey nonresponse. Veterans' relative risk ratios of very severe or moderate/severe tinnitus-related functional impairment, versus none/mild impairment, were estimated by TBI history using bivariable and multivariable multinomial logistic regression. RESULTS: The population prevalence of TBI was 5.6% (95% CI: 4.8-6.4) among veterans diagnosed with tinnitus. Veterans with a TBI diagnosis, compared with those without a TBI diagnosis, had 3.6 times greater likelihood of rating their tinnitus-related impairment as very severe (95% CI: 2.1-6.3), and 1.5 times greater likelihood of rating their impairment as moderate/severe (95% CI: 1.0-2.4), versus none/mild. CONCLUSIONS: These findings suggest an important role of TBI in the severity of tinnitus-related functional impairment among veterans. This knowledge can help inform the integration of tinnitus management services into the care received by veterans with TBI.

Metatarsal Fractures.

Metatarsal fractures are some of the most common fractures reported in the human body. Recent advances in surgical techniques and fixation have helped facilitate healing and improved outcomes for our patients. The treatment goals of metatarsal fractures are to maintain the metatarsal parabola, sagittal position of the metatarsal heads, and a congruent metatarsophalangeal joint. Most of these injuries can be treated nonoperatively, but displaced fractures require surgical intervention to preserve normal gait biomechanics.

The Impact of Tinnitus Severity on Work Functioning among U.S. Military Veterans with Tinnitus.

Tinnitus is highly prevalent among military Veterans. Severe tinnitus can be associated with negative impacts on daily life. Veterans with severe tinnitus may also have greater difficulties in functional roles, including work. However, few studies have explicitly explored this relationship. Traumatic brain injury (TBI), also prevalent among Veterans, is associated with tinnitus and can additionally impair work functioning. This quantitative investigation used a population-based survey to assess the relationship between tinnitus severity, measured using the Tinnitus Functional Index (TFI), and the impact of tinnitus on work, measured using a composite score from the Tinnitus History Questionnaire, among a stratified random sample of VA healthcare-using Veterans diagnosed with tinnitus, with and without comorbid TBI. Analyses were weighted to account for sampling design and Veteran non-response; multiple imputation was used to account for missing data. Results indicated that for every 1-point increase in TFI score, there was an average 8% increase in the odds of reporting a high level of impact on work functioning (OR: 1.08; 95% CI: 1.06, 1.11). Veterans with a comorbid TBI diagnosis, compared with those without, were more likely to have high tinnitus-related impact on work functioning (OR: 2.69, 95% CI: 1.85, 3.91), but the relationship between tinnitus severity and the impact of tinnitus on work functioning did not differ by TBI status. These data can help researchers and clinicians understand complex symptoms experienced by Veterans with tinnitus, with and without TBI, supporting the improved provision of clinical services to these patients.

Rehabilitation Service Needs and Preferences among Veterans with Tinnitus: A Qualitative Study.

Tinnitus is prevalent among military Veterans, yet there is a gap between the demand and the provision of services for tinnitus rehabilitation services within the Veterans Health Administration (VHA). We sought to understand tinnitus rehabilitation service needs and preferences among Veterans with bothersome tinnitus who use Veterans Affairs (VA) services. We conducted semistructured telephone interviews in 2019 with Veterans diagnosed with tinnitus, who reported it as bothersome. Veterans were purposively sampled to represent national VA users, with and without comorbid traumatic brain injury (TBI), and who were or were not interested in tinnitus rehabilitation services. Qualitative data were analyzed using a modified grounded theory approach. Among 40 Veterans interviewed (32 men, 8 women; 50% with TBI), 72.5% endorsed being somewhat/very likely to be interested in tinnitus rehabilitation services while 27.5% were very/somewhat unlikely. Themes related to Veterans' interest in tinnitus rehabilitation services included barriers and facilitators to participation and preferences for receiving tinnitus services (e.g., individual vs. group-based; in-person vs. remote access). Our findings highlight factors that influence Veterans' reported need and preferences for, and readiness to engage in, rehabilitation services for tinnitus. Personalized or otherwise adaptable approaches to program delivery may help ensure maximal uptake among Veterans.

A Pilot Study to Evaluate a Residual Inhibition Technique in Hearing Aids for Suppression of Tinnitus.

Tinnitus acoustic therapy is defined as any use of sound where the intent is to alter the tinnitus perception and/or the reactions to tinnitus in a clinically beneficial way. The parameters of sound that may cause beneficial effects, however, are currently only theorized with limited data supporting their effectiveness. Residual inhibition is the temporary suppression or elimination of tinnitus that is usually observed following appropriate auditory stimulation. Our pilot study investigated the effects of a therapeutic acoustic stimulus that was individually customized to maximize residual inhibition of tinnitus and extend its duration to determine if there could be a sustained suppression of the tinnitus signal (i.e., reduced tinnitus loudness) and a reduction in the psychological and emotional reactions to tinnitus. This pilot study had two objectives: (1) to evaluate the feasibility of residual inhibition technique therapy through daily use of hearing aids and (2) to determine its effects by measuring reactionary changes in tinnitus with the Tinnitus Functional Index (TFI) and perceptual changes in tinnitus loudness. A total of 20 adults (14 males, 6 females; mean age: 58 years, SD = 12.88) with chronic tinnitus were enrolled in a four-visit study that consisted of the following: (1) baseline visit and initiation of the intervention period, (2) a 1-month postintervention visit, (3) 2-month postintervention visit and initiation of a wash-out period, and (4) a 3-month visit to assess the wash-out period and any lasting effects of the intervention. The intervention consisted of fitting bilateral hearing aids and creating an individualized residual inhibition stimulus that was streamed via Bluetooth from a smartphone application to the hearing aids. The participants were instructed to wear the hearing aids and stream the residual inhibition stimulus all waking hours for the 2-month intervention period. During the wash-out period, the participants were instructed to use the hearing aids for amplification, but the residual inhibition stimulus was discontinued. At all visits, the participants completed the TFI, study-specific self-report measures to document perceptions of tinnitus, a psychoacoustic test battery consisting of tinnitus loudness and pitch matching, and a residual inhibition test battery consisting of minimum masking and minimum residual inhibition levels. At the end of the trial, participants were interviewed about the study experience and acceptability of the residual inhibition treatment technique. Repeated measures analyses of variance (ANOVA) were conducted on the two main outcomes (TFI total score and tinnitus loudness) across all four visits. The results showed a significant main effect of visit on the TFI total score ( p < 0.0001). Specifically, the results indicated a significant reduction in TFI total scores from baseline to the 1-month post-intervention period, which remained stable across the 2-month post-intervention period and the wash-out period. The ANOVA results did not show a significant change in tinnitus loudness as a function of visit ( p = 0.480). The majority of the participants reported a positive experience with the study intervention at their exit interview. This pilot study demonstrated that residual inhibition as a sound therapy for tinnitus, specifically through the daily use of hearing aids, was feasible and acceptable to individuals suffering from chronic tinnitus. In addition, participants showed improvement in reactions to tinnitus as demonstrated by sustained reduction in TFI scores on average over the course of the treatment period. Achieving residual inhibition may also provide patients a feeling of control over their tinnitus, and this may have a synergistic effect in reducing the psychological and emotional distress associated with tinnitus. There was no significant reduction in long-term tinnitus loudness resulting from the residual inhibition treatment; however, the current pilot study may not have had sufficient power to detect such a change. The combination of tinnitus suppression and improved psychosocial/emotional reactions to tinnitus may result in a better quality of life in both the short and long term. A larger-scale study is needed to determine the validity of using residual inhibition as a clinical therapy option and to ascertain any effects on both perception and reactions to tinnitus.

History of Tinnitus Research at the VA National Center for Rehabilitative Auditory Research (NCRAR), 1997-2021: Studies and Key Findings.

The Veterans Affairs (VA) Rehabilitation Research & Development (RR&D) National Center for Rehabilitative Auditory Research (NCRAR) was first funded by the RR&D Service in 1997 and has been funded continuously since that time. The overall purpose of the NCRAR is to "improve the quality of life of Veterans and others with hearing and balance problems through clinical research, technology development, and education that leads to better patient care" ( www.ncrar.research.va.gov ). An important component of the research conducted at the NCRAR has been a focus on clinical and rehabilitative aspects of tinnitus. Multiple investigators have received grants to conduct tinnitus research and the present article provides an overview of this research from the NCRAR's inception through 2021.

Prevalence and Risk Factors of Self-reported Dizziness in Post-9/11 Service Members and Veterans.

INTRODUCTION: Dizziness is prevalent in the general population, but little is known about its prevalence in the U.S. military population. Dizziness is commonly associated with blast exposure and traumatic brain injury (TBI), but the potential independent contributions of blast and TBI have yet to be evaluated. This study's goal was to estimate the prevalence of dizziness among post-9/11 service members and Veterans and to examine independent and joint associations between military TBI history, blast exposure, and self-reported dizziness. MATERIALS AND METHODS: The study sample consisted of service members (n = 424) and recently separated (< ∼2.5 years) Veterans (n = 492) enrolled in the Noise Outcomes in Service members Epidemiology (NOISE) Study. We examined associations between self-reported history of probable TBI and blast exposure and recent dizziness using logistic regression. Models were stratified by service member versus Veteran status and adjusted to account for potentially confounding demographic and military characteristics. RESULTS: Overall, 22% of service members and 31% of Veterans self-reported dizziness. Compared to those with neither TBI nor blast exposure history, both service members and Veterans with TBI (with or without blast) were three to four times more likely to self-report dizziness. Those with blast exposure but no TBI history were not more likely to self-report dizziness. There was no evidence of an interaction effect between blast exposure and a history of TBI on the occurrence of dizziness. CONCLUSION: Self-reported dizziness was prevalent in this sample of service members and Veterans. Probable TBI history, with or without blast exposure, was associated with dizziness, but blast exposure without TBI history was not. This suggests that treatment guidelines for TBI-related dizziness may not need to be tailored to the injury mechanism. However, future efforts should be directed toward the understanding of the pathophysiology of TBI on self-reported dizziness, which is fundamental to the design of treatment strategies.

A Qualitative Study of Veterans' Perspectives on Tinnitus: An Invisible Wound.

PURPOSE: Tinnitus is highly prevalent among U.S. military Veterans, yet referral to, and use of, tinnitus rehabilitation services to improve quality of life and functional status with tinnitus is low. Veterans with tinnitus often have other health issues that overlap or exacerbate the impact of tinnitus, potentially complicating referral and rehabilitative pathways. This qualitative study explores views on the daily impacts of tinnitus and experiences with tinnitus-related health care among Veterans. The goal of this research is to amplify the voices of Veterans regarding their experiences with tinnitus to illuminate the physiological and socioemotional sequelae associated with the condition and to increase clinician awareness of the complex, interdisciplinary rehabilitative needs among Veterans with bothersome tinnitus. METHOD: This qualitative study was part of a larger study about tinnitus and traumatic brain injury (TBI). Veterans were sampled to represent national Department of Veterans Affairs (VA) users with and without comorbid TBI, and who were or were not interested in tinnitus rehabilitation services. Forty Veterans with tinnitus were interviewed (32 men, eight women). Data were analyzed using a modified grounded theory approach. RESULTS: Major themes across the Veteran interviews included (a) functional effects of tinnitus on daily life, (b) tinnitus and other health conditions, (c) reactions to the lack of a cure for tinnitus, (d) strategies to improve quality of life and function, and (e) use of VA services for tinnitus. CONCLUSIONS: Our findings highlight that bothersome tinnitus negatively impacted various aspects of daily functioning, including communication, sleep, concentration, and mood, suggesting a need for audiologists to work closely with mental health services to improve quality of life and functional status for those negatively impacted by the condition. Future work is needed to obtain the viewpoints of clinicians and other health care partners to better understand the barriers and facilitators to providing evidence-based tinnitus treatment in VA and non-VA settings.

Directed Attention and Habituation: Two Concepts Critical to Tinnitus Management.

PURPOSE: Directed attention and habituation are key concepts pertaining to clinical intervention for bothersome tinnitus. Directed attention is the strategy of distracting attention away from the tinnitus. Habituation is the process of learning to stop paying attention to stimuli that are irrelevant or meaningless. Although tinnitus may be intrusive, it usually does not reflect some underlying condition requiring medical attention. Tinnitus in most instances is therefore considered an irrelevant, meaningless stimulus that is best treated by facilitating habituation to the phantom sound. This tutorial describes directed attention and habituation and how they relate to major behavioral methods of tinnitus intervention. METHOD: Arguably, the four major behavioral methods of tinnitus intervention with the strongest research evidence are cognitive behavioral therapy (CBT), tinnitus retraining therapy (TRT), tinnitus activities treatment (TAT), and progressive tinnitus management (PTM). Each of these four methods was evaluated to determine the role of directed attention as a treatment strategy and habituation as a treatment goal. RESULTS: All four of the methods (CBT, TRT, TAT, and PTM) utilize some form of directed attention as a component of their counseling. Habituation is the explicit or implicit goal of each of these methods. CONCLUSIONS: Directed attention and habituation are essential concepts for all of the major methods of behavioral intervention for tinnitus that were studied. It would therefore seem appropriate to include directed attention as a universal treatment strategy for bothersome tinnitus. Likewise, the commonality of habituation as the objective of treatment would suggest that habituation should be the universal goal of any method that is intended to mitigate the emotional and functional effects of tinnitus.

Culture intelligent workflow, structure, and steps.

Introduction: Technologies abstract intelligence and provide predictor and precision insight in workflows that manage disorders, similar to cardiology and hematological disease. Positive perceptions of Artificial Intelligence (AI) that support Machine Learning (ML) and Deep Learning (DL) manage transformations with a safe system that improves wellbeing. In sections, workflow introduces an eXamination (X = AI) as an end-to-end structure to culture workstreams in a step-by-step design to manage populace health in a governed system. Method: To better healthcare outcomes, communities and personnel benefit from an explanation and an interpretive that elucidates workflow for citizens or practitioners to comprehend personalized platforms. Therefore, the author undertook structure and practice reviews and appraised perspectives that impact the management of AI in public health and medicine. Results: Figures for the management of AI workflow illustrate and inform on the model, structure, culture, assurance, process steps, values, and governance required for abstract insights in public health and medicine. The papers' end-to-end structure with explanans in a work culture interprets the step-by-step designs that manage the success of AI. Personalized care graphics offer an explanandum in the management of biological analytic value. Discussion: Healthcare leadership collaboratives plan population health with an upstream, workplace and workstream format. Secure workflow and safety wellbeing system requirements prove that genomics and AI improve medicine. Therefore, the paper discusses group understanding of current practice, ethics, policy, and legality. Conclusion: "Culture, intelligent workflow, structure, and steps" improve wellbeing with personalized care and align a percept for national opportunities, regional control, and local needs. Personalized practice cultures support analytic systems to describe, predict, precision, and prescript medicine in population health management eXaminations.

The Risk of Acute Infection Following Intra-Articular Corticosteroid Injection During Total Knee Manipulation Under Anesthesia.

BACKGROUND: Manipulation under anesthesia (MUA) is an established option for improving motion in patients presenting with early stiffness following total knee arthroplasty (TKA). Intra-articular corticosteroid injections (IACI) are sometimes administered adjunctively, yet literature examining their efficacy and safety remains limited. STUDY DESIGN: Retrospective, Level IV. METHODS: A total of 209 patients (TKA = 230) were retrospectively examined to determine the incidence of prosthetic joint infections within 3 months following manipulation with IACI. Approximately 4.9% of initial patients had inadequate follow-up where the presence of infection could not be determined. Range of motion was assessed in patients who had follow-up at or beyond one year (n = 158) and was recorded over multiple time points. RESULTS: No infections (0 of 230) were identified within 90 days of receiving IACI during TKA MUA. Before receiving TKA (preindex), patients averaged 111° of total arc of motion and 113° of flexion. Following index procedures, just prior to manipulation (pre-MUA), patients averaged 83° and 86° of total arc and flexion motion, respectively. At final follow-up, patients averaged 110° of total arc of motion and 111° of flexion. At six weeks following manipulation, patients had gained a mean of 25° and 24° of their total arc and flexion motion found at 1 year. This motion was preserved through a 12-month follow-up period. CONCLUSION: Administering IACI during TKA MUA does not harbor an elevated risk for acute prosthetic joint infections. Additionally, its use is associated with substantial increases in short-term range of motion at six weeks following manipulation, which remain preserved through long-term follow-up.

Tinnitus Screener: Short-Term Test-Retest Reliability.

PURPOSE: The Tinnitus Screener was introduced in 2015 as a four-item algorithmic instrument to assess the temporal characteristics of a person's reported tinnitus. The Tinnitus Screener was then revised as a six-item version to include a new temporal category and to capture tinnitus duration (acute < 6 months vs. chronic ≥ 6 months). When contrasted with audiologist assessment, the four-item Tinnitus Screener was determined to be highly valid, but the short-term reliability of either version remained unknown. The present analysis focused on determining the test-retest reliability of the six-item Tinnitus Screener. Additionally, we sought to determine whether reliability differed by respondent age, sex, military status, and hearing loss. METHOD: The Tinnitus Screener was administered to 190 military Service members and 250 military Veterans at two time points separated by 7-31 days. Our analysis focused on test-retest reliability of responses as measured by the kappa coefficient, overall and within subsamples. Percent agreement of tinnitus categorization (temporal categories) and classification (positive/negative) between the two time points was also evaluated. RESULTS: Constant or intermittent tinnitus was found in 31% of Service members and 53% of Veterans. Overall, kappa reliability coefficients were high, near .80, indicating substantial reliability. The majority (96%) of reliability coefficients for the Tinnitus Screener within subsamples were similarly high, ranging from .68 to .88. CONCLUSIONS: The updated version of the Tinnitus Screener is shown to be a reliable instrument. The Tinnitus Screener is recommended to inform clinical decision making by determining the temporal characteristics of tinnitus.

Cardiac arrest in diving: The key to success.

This case report describes the successful management of an out-of-hospital arrest in a diver following a suspected arterial gas embolism (AGE). It illustrates both the inherent risks of diving and the importance of prompt and effective implementation of the "chain of survival" from bystanders. Rapid on-scene responses from paramedics and helicopter emergency medical services facilitated prompt evacuation to a Category 1 (multiplace) recompression chamber (RCC) where specialists in cardiology and hyperbaric medicine were available. Alternative causes of cardiac arrest were considered, with a presumed AGE successfully treated with multiple rounds of hyperbaric oxygen therapy. The key factors which led to this successful outcome are discussed, including early recognition and call for help, competent cardiopulmonary resuscitation, and direct evacuation to a Category 1 RCC, with additional consideration of the diagnosis leading to cardiac arrest. The case clearly illustrates the need for all those involved in diving regularly to be competent and confident in performing basic life support, as well as the awareness of the emergency services of the need for diving casualties to be treated at appropriate hyperbaric facilities. Were it not for the simple, prompt and effective treatment this diver received, both on scene and in hospital, it is highly unlikely that such a positive outcome would have been achieved.

Associations between medical conditions and auditory dysfunction in US Veterans.

OBJECTIVE: To examine associations between non-otologic medical conditions and auditory dysfunction. DESIGN: Cross-sectional analysis of baseline data from the Noise Outcomes in Service members Epidemiology (NOISE) study. Logistic regression was used to estimate the association between medical conditions (0, 1, and 2 or more conditions) and auditory dysfunction (hearing loss pure tone average ≥20 dB HL and tinnitus), adjusting for key confounders including noise exposure. Secondarily, the association between specific medical conditions and auditory dysfunction was examined. All variables were self-reported. STUDY SAMPLE: United States military Veterans (n = 580) with mean age 34.1 years (standard deviation = 9.2), who were within approximately 2.5 years of separation from service. RESULTS: Compared to Veterans reporting no medical conditions, Veterans reporting two or more had increased odds on low-frequency hearing loss and on tinnitus but not on high or extended-high frequency hearing loss. Furthermore, specific conditions sleep disorder and arthritis were associated with auditory dysfunction. CONCLUSIONS: Non-otologic medical conditions were associated with low-frequency hearing loss and tinnitus in this sample of young Veterans. This suggests medical conditions may play a role in Veterans' hearing health. Whether management of medical conditions earlier in life reduces the risk of hearing loss and tinnitus requires further study.

The influence of tinnitus and hearing loss on the functional status of military Service members and Veterans.

OBJECTIVE: This study evaluated the influence of tinnitus and hearing loss on the functional status of military Service members and Veterans. DESIGN: Participants completed audiologic testing and self-report instruments to assess tinnitus, hearing, and general functioning. We conducted multiple linear regression analyses using cross-sectional data with functional status as the dependent variable. The primary independent variables were tinnitus and average low-, high-, and extended high-frequency hearing thresholds. Secondary independent variables were subjective tinnitus severity and hearing difficulties. Each of the independent variables was modelled separately for Service members and Veterans; covariates for each multivariable model were identified a priori and, depending on the association being modelled, included age, gender, blast-wave exposure, and history of military traumatic brain injury. STUDY SAMPLE: Data were analysed from 283 Service members and 390 Veterans. RESULTS: After controlling for potential confounders, presence of tinnitus, tinnitus severity, average low-frequency hearing thresholds, and subjective hearing difficulties were significantly associated with functional status in Service members and Veterans. CONCLUSIONS: These results suggest that tinnitus and poorer low-frequency hearing, and the perceived severity of tinnitus and hearing difficulties, may be associated with poorer functional status among Service members and Veterans.

Enhanced piroctone olamine retention from shampoo for superior anti-dandruff efficacy.

BACKGROUND: Dandruff is a pervasive chronic condition which negatively impacts quality of life. Effective treatment requires efficient delivery of scalp benefit agents that control commensal scalp Malassezia levels. Delivery of benefit agents from shampoos requires balancing many technical parameters to achieve the desired outcome without sacrificing secondary parameters, such as cosmetic attributes. AIM: To develop formulation technologies that increase the shampoo delivery efficiency of the scalp benefit agent piroctone olamine (PO). Increased delivery should result in increased anti-dandruff efficacy. METHODS: Micellar Stability and Association parameters were quantified via dynamic surface tension and nuclear magnetic resonance (NMR) diffusion parameters, respectively. PO delivery has been assessed in vivo both on the scalp surface and follicular infindibula using extraction procedures and analytical analysis. Clinical anti-dandruff efficacy was assessed for an advanced delivery technology prototype in comparison to standard delivery technology. RESULTS: Shampoo prototypes have been developed that increase the delivery efficiency of PO. Both surfactant and polymer coacervate-based approaches have been developed. Decreased micellar stability results in weaker association between PO and micelles, resulting in more efficient PO retention on the scalp surface and delivery to the infundibula. Increased charge density of cationic polymers optimizes coacervation enabling improved PO delivery as well. Increased PO delivery has been shown clinically to result in higher anti-dandruff efficacy as measured by both visible flakes and underlying biomarkers. CONCLUSION: Increased efficiency PO delivery shampoos have been developed by optimization of both surfactant and coacervate parameters. The increased deposition efficiency results in significantly more products with significantly greater anti-dandruff efficacy.

CONTEXTE: Les pellicules sont une maladie chronique omniprésente qui a un impact négatif sur la qualité de vie. Un traitement efficace nécessite une administration efficace d'agents bénéfiques pour le cuir chevelu qui contrôlent les niveaux commensaux de Malassezia. L'administration d'agents bénéfiques à partir de shampooings nécessite d'équilibrer de nombreux paramètres techniques pour obtenir le résultat souhaité sans sacrifier des paramètres secondaires tels que les attributs cosmétiques. BUT: Développer des technologies de formulation qui augmentent l'efficacité d'administration du shampooing de l'agent bénéfique pour le cuir chevelu piroctone olamine (PO). Une livraison accrue devrait entraîner une efficacité antipelliculaire accrue. MÉTHODES: La stabilité micellaire et les paramètres d'association ont été quantifiés via les paramètres de tension superficielle dynamique et de diffusion RMN, respectivement. L'administration de PO a été évaluée in vivo à la fois sur la surface du cuir chevelu et sur l'indibula folliculaire à l'aide de procédures d'extraction et d'analyses analytiques. L'efficacité antipelliculaire clinique a été évaluée pour un prototype de technologie d'administration avancée par rapport à la technologie d'administration standard. RÉSULTATS: Des prototypes de shampooing ont été développés pour augmenter l'efficacité de livraison des PO. Des approches à base de tensioactifs et de coacervats polymères ont été développées. Une diminution de la stabilité micellaire entraîne une association plus faible entre le PO et les micelles, ce qui entraîne une rétention plus efficace du PO sur la surface du cuir chevelu et une livraison à l'infundibula. L'augmentation de la densité de charge des polymères cationiques optimise la coacervation, permettant également une meilleure administration de PO. Il a été démontré cliniquement que l'augmentation de l'administration de PO entraîne une efficacité antipelliculaire plus élevée, mesurée à la fois par les squames visibles et les biomarqueurs sous-jacents. CONCLUSION: Des shampooings à libération de PO à efficacité accrue ont été développés en optimisant à la fois les paramètres du tensioactif et du coacervat. L'efficacité de dépôt accrue se traduit par beaucoup plus de produits avec une efficacité antipelliculaire nettement supérieure.

Sound Therapy to Reduce Auditory Gain for Hyperacusis and Tinnitus.

PURPOSE: Hyperacusis is the most common of the different types of sound tolerance conditions. It has been defined as physical discomfort or pain when any sound reaches a certain level of loudness that would be comfortable for most people. Because hyperacusis and tinnitus occur together so often, it has been theorized that they have a common neural mechanism. A leading contender for that mechanism is enhancement of auditory gain. The purpose of this tutorial is to review the evidence that sound/acoustic therapy can reduce auditory gain and, thereby, can increase loudness tolerance for people with hyperacusis and/or suppress the percept of tinnitus. METHOD: The scientific literature was informally reviewed to identify and elucidate relationships between tinnitus, hyperacusis, sound therapy, and auditory gain. RESULTS: Evidence exists, both in animal and human studies, that enhanced auditory gain is associated with hyperacusis and tinnitus. Further evidence supports the theory that certain forms of sound therapy can reduce neural hyperactivity, thereby reducing auditory gain. The evidence for sound therapy reducing auditory gain is stronger for hyperacusis than it is for tinnitus. CONCLUSIONS: Based on results from numerous studies, sound therapy clearly has application as a method of desensitization for hyperacusis. Enhanced auditory gain might be responsible for tinnitus, but other mechanisms have been theorized. A review of the relevant literature leads to the conclusion that some form(s) of sound therapy has the potential to suppress or eliminate tinnitus on a long-term basis. Systematic research is needed to evaluate this premise.

Differences in Fourth-Year Orthopaedic Away Rotation Opportunities and Fees Among Osteopathic and Allopathic Medical Students 1 Year After the Implementation of the Single Accreditation System.

Fourth-year away rotations are well recognized as an important modifiable variable that has been shown to increase a student's opportunity to match into orthopaedic surgery. The purpose of this article was to determine whether allopathic (MD) and osteopathic (DO) medical students have equal opportunities for away rotations in terms of (1) eligibility and (2) fees associated with rotations after the single accreditation merger. Methods: A cross-sectional study was performed during the 2021 application cycle (April to November) by reviewing all nonmilitary, Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery programs (n = 194). Each program's website, affiliated school of medicine's website, and visiting student applications service portal were searched. Eligibility criteria for an away rotation and associated fees were recorded. Results: Of the 194 programs, 18 (9.3%) of programs were found to have publicly published eligibility for away rotations that prohibited students based on applicant degree. Five (2.6%) programs/medical schools had fees that were larger for DO medical students compared with MD medical students ranging for $50 to $5,000. No programs/medical schools had larger fees for MD medical students compared with DO medical students. Conclusions: Although DO and MD degrees are equivalent degrees for licensing and credentialing and graduate medical education has transitioned to a single accrediting body, there remained discord in the opportunities for fourth-year away rotations between osteopathic and allopathic medical students. This study highlights the necessity for greater reform, consistency, and transparency among orthopaedic surgery residency programs and their affiliated institutions.

Progressive Tinnitus Management Level 3 Skills Education: A 10-Year Clinical Retrospective.

PURPOSE: The purpose of this study was to examine progressive tinnitus management (PTM) Level 3 skill utilization among Veterans in the Bay Pines Veterans Affairs Healthcare System 6-10 years after completing the PTM workshops. METHOD: In fiscal year 2020, the Tinnitus Workshop Follow-Up form was mailed to Veterans who completed the workshops during fiscal years 2010-2014. Veterans were identified as receiving care via the traditional face-to-face method or clinical video telehealth (CVT). Data were compiled to determine which, if any, PTM skills were being used 6-10 years later and the impact on self-reported ratings of well-being. RESULTS: More than half of the respondents reported using all four self-management skills up to 10 years postcompletion; relaxation was utilized by more Veterans than the other three skills. Approximately 69% reported improved ability to control reactions to tinnitus. At least half reported ratings of improved well-being. Eighty-eight percent of the respondents said they would recommend the workshops to someone with bothersome tinnitus. Veterans who received care via CVT reported using fewer skills than those who received care face-to-face; however, the CVT respondents reported the same or slightly better ability to cope with tinnitus, less bothersome tinnitus, and improved ratings of well-being. Finally, most participants who responded to an open-ended question about their workshop experience reported it as positive. CONCLUSIONS: This clinical focus project suggests that PTM Level 3 skills continue to be utilized up to 10 years after participation in the workshops. Although there were reductions in the number of skills used, Veterans' ability to manage reactions to tinnitus and improvement in self-reported ratings of well-being indicate successful ongoing tinnitus management efforts. Respondents who received care via CVT did not report lower self-reported ratings of well-being or appear less likely to recommend Level 3 group PTM to other Veterans with bothersome tinnitus.

Sound Tolerance Conditions (Hyperacusis, Misophonia, Noise Sensitivity, and Phonophobia): Definitions and Clinical Management.

Purpose: For some people, exposure to everyday sounds presents a significant problem. The purpose of this tutorial was to define and differentiate between the various sound tolerance conditions and to review some options for their clinical management. METHOD: We informally reviewed the literature regarding sound tolerance conditions. The terminology and definitions provided are mostly consistent with how these terms are defined. However, many inconsistencies are noted. Methods of assessment and treatment also differ, and different methodologies are briefly described. RESULTS: Hyperacusis describes physical discomfort or pain when any sound reaches a certain level of loudness that would be tolerable for most people. Misophonia refers to intense emotional reactions to certain sounds (often body sounds such as chewing and sniffing) that are not influenced by the perceived loudness of those sounds. Noise sensitivity refers to increased reactivity to sounds that may include general discomfort (annoyance or feeling overwhelmed) due to a perceived noisy environment, regardless of its loudness. Phonophobia, as addressed in the audiology profession, describes anticipatory fear of sound. Phonophobia is an emotional response such as anxiety and avoidance of sound due to the "fear" that sound(s) may occur that will cause a comorbid condition to get worse (e.g., tinnitus) or the sound itself will result in discomfort or pain. (Note that phonophobia is a term used by neurologists to describe "migraineur phonophobia"-a different condition not addressed herein.) Conclusions: The literature addresses sound tolerance conditions but reveals many inconsistencies, indicating lack of consensus in the field. When doing an assessment for decreased sound tolerance, it is important to define any terms used so that the patient and all health care professionals involved in the care of the patient are aligned with the goals of the treatment plan. Treatment generally involves gradual and systematic sound desensitization and counseling. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.20164130.