Developing an Evidence-Based Military Auditory Fitness-for-Duty Standard Based on the 80-Word Modified Rhyme Test.

OBJECTIVES: One important function of military audiology is to conduct evaluations of service members (SMs) with hearing loss to ensure they are fit for deployment in dangerous operational environments. The objective of this study was to establish evidence-based auditory fitness-for-duty criteria based on speech-in-noise performance on the 80- and 160-word clinical versions of the Modified Rhyme Test (MRT 80 and MRT 160 ). DESIGN: Approximately 2400 SMs with various levels of hearing loss were recruited to complete the MRT 80 in conjunction with their annual hearing conservation evaluations. These SMs were also asked to perform one or more operationally-relevant listening tasks based on audio recordings made in highly realistic military training environments. The scores on these tests were compared to determine how well a proposed cutoff criterion for the MRT 80 was able to identify individuals who are hard of hearing with an exceptionally high risk of abnormally poor performance on operationally-relevant hearing tasks. RESULTS: The results show that a cutoff criterion that combines the percent correct score on two lists of the MRT 80 (i.e. MRT 160 ) with information about the better-ear threshold at 2 kHz is generally able to separate listeners with hearing loss into those who are likely to perform relatively well on operational listening tests and those who are likely to perform poorly on these tasks. This is consistent with current military acquisition standards, which identify the MRT as the preferred test for evaluating speech intelligibility for radios, headsets, and other communication equipment. It is also consistent with prior studies conducted in high-fidelity military simulations which have shown a significant correlation between MRT performance and operational outcomes. CONCLUSIONS: The proposed selection criteria, along with the new hearing profile standards that were recently adopted by the US Army, appear to provide an effective evidence-based methodology for identifying those SMs with hearing loss who are most at risk for poor performance on hearing-critical military tasks.

Leukocytoclastic Vasculitis as a Rare Manifestation of Staphylococcal Osteomyelitis.

Leukocytoclastic vasculitis (LCV), also known as small-vessel cutaneous vasculitis, is rarely seen in the setting of staphylococcal infection without bacteremia. Here, we present a case of LCV in a 61-year-old male with chronic staphylococcal osteomyelitis without any evidence of bacteremia. The rash resolved with the treatment of osteomyelitis. As seen in this case, local infection should be considered in the differential diagnosis of LCV even when there is no evidence of bacteremia.

Precarious Essential Work, Immigrant Dairy Farmworkers, and Occupational Health Experiences in Vermont.

Migrant dairy workers in Vermont face a wide range of occupational and health hazards at work. This research examines the environmental risks, occupational health hazards, and health outcomes experienced by migrant dairy farm workers in Vermont. This research draws on a triangulation of sources including analysis of data-surveys and interviews with migrant dairy farmworkers gathered by the organization Migrant Justice since 2015 as well as relevant key informant interviews with community organizations across the state to characterize the occupational health experiences of migrant dairy workers in Vermont. Our results show that Vermont migrant dairy farmworkers received poor health and safety training and lacked sufficient protective gear. Over three quarters of the respondents reported experiencing harm from chemical and biological risks. Close to half the survey respondents reported headaches, itchy eyes and cough; a quarter reported breathing difficulties; three fourths reported being hurt by animal-related risks. These exposures and existing health concerns are avoidable. Migrant workers require better social representation and advocates to negotiate better work-related protection and training, access to health services, and social welfare to ensure their health and safety.

The current state of training in psychiatry of intellectual disability: perspectives of trainees and trainers.

AIMS AND METHOD: Twelve intellectual disability psychiatry trainee representatives and 13 training programme directors were surveyed to assess the current state of training, to establish what motivated specialty trainees to choose intellectual disability psychiatry, and to explore issues that might affect retention. RESULTS: The combined survey response rate was 83%. All trainees had chosen intellectual disability psychiatry after experience in either their personal or working life. Overall, specialty trainees were satisfied with their training; the majority felt supported to meet training requirements. Trainee isolation was the main concern for current trainees. CLINICAL IMPLICATIONS: Recruitment for specialty training in intellectual disability psychiatry is acknowledged to be a concern for workforce planning and could affect access to and quality of psychiatric care for people with intellectual disability. The results of this survey could be used as a guide to improve efforts to attract trainees. Acknowledging and reducing trainee isolation could improve trainee morale.

Binaural advantages in a real-world environment on speech intelligibility, response time, and subjective listening difficulty.

This study examined the speech-related advantages of binaural listening for individuals conversing in a noisy restaurant. Young, normal-hearing adults were tested in groups of four during monaural and binaural listening conditions. Monosyllabic word stimuli were presented in a closed-set format. Speech intelligibility, response time (RT), and self-reported difficulty were measured. Results showed a speech intelligibility advantage of 17%, a 0.26 s decrease in RT, and a reduction in reported difficulty in binaural compared to monaural listening. These data suggest the binaural advantage obtained in real-world settings compares favorably with that observed in the laboratory, indicating that speech testing in laboratories approximates real-world performance.

The cafeteria study: Effects of facial masks, hearing protection, and real-world noise on speech recognition.

The objective of this study was to evaluate the impact of wearing various types of personal protective equipment on speech recognition in a real-world, noisy listening environment. Groups of four young, normal-hearing adults participated in a live version of the Modified Rhyme Test in a noisy public cafeteria with and without the use of a non-medical disposable facial mask or combat earplugs in two different modes. Speech recognition, response time, and subjective difficulty were measured per individual. In addition, the signal-to-noise ratio was estimated during the interval when the talker spoke the target word. Results showed that the listeners' speech recognition performance declined not only when the listener wore earplugs, but also when the talker wore earplugs. The measured signal-to-noise ratio significantly decreased when the talker wore earplugs, suggesting that occlusion may have caused the talkers to reduce their voice levels. Results also showed a decline in speech recognition performance when the talker wore a facial mask. Listeners rated all conditions in which talkers and listeners wore personal protective equipment as more difficult than the baseline condition. These data suggest that speech recognition in real-world listening environments can be impaired by personal protective equipment worn by both talkers and listeners.

Objective Assessment of Speech Intelligibility in Crowded Public Spaces.

The objective of this study was to obtain a normative database of speech intelligibility data for young normal-hearing listeners communicating in public spaces. A total of 174 listeners participated in an interactive speech intelligibility task that required four-person groups to conduct a live version of the Modified Rhyme Test in noisy public spaces. The public spaces tested included a college library, a college cafeteria, a casual dining restaurant during lunch hour, and a crowded bar during happy hour. At the start of each trial, one of the participants was randomly selected as the talker, and a tablet computer was used to prompt them to say a word aloud from the Modified Rhyme Test. Then, the other three participants were required to select this word from one of six rhyming alternatives displayed on three other tablet computers. The tablet computers were also used to record the SPL at each listener location during and after the interval where the target talker was speaking. These SPL measurements were used to estimate the signal-to-noise ratio (SNR) in each trial of the experiment. As expected, the results show that speech intelligibility decreases, response time increases, and perceived difficulty increases as the background noise level increases. There was also a systematic decrease in SNR with increasing background noise, with SNR decreasing 0.44 dB for every 1 dB increase in ambient noise level above 60 dB. Overall, the results of this study have demonstrated how low-cost tablet computer-based data collection systems can be used to collect live-talker speech intelligibility data in real-world environments. We believe these techniques could be adapted for use in future studies focused on obtaining ecologically valid assessments of the effects of age, hearing impairment, amplification, and other factors on speech intelligibility performance in real-world environments.

Relationship Between Subjective Reports of Temporary Threshold Shift and the Prevalence of Hearing Problems in Military Personnel.

Traditional hearing conservation programs are based on the premise that noise dose, as measured by the time-weighted average noise level, is the primary risk factor associated with occupational hearing loss and that permanent threshold shifts are the most relevant outcome measures for determining when a noise-related hearing loss has occurred. However, recent studies in animal models have suggested that significant neurological damage to the hearing system can occur from noise exposures even when they are not severe enough to result in permanent threshold shifts. This has led to a number of studies attempting to relate subjective measures of noise exposure to subjective measures of hearing difficulty and suprathreshold measures of hearing performance (e.g., speech-in-noise tests). In this study, 3,330 U.S. service members volunteered to complete a survey on noise exposure, subjective hearing complaints, and tinnitus in conjunction with their annual hearing tests. Two questions were also included about the frequency and duration of temporary hearing losses that may have been experienced by the service member. The results show that subjective reports of temporary threshold shifts were substantially more predictive of tinnitus and other hearing complaints than more traditional questions based on the frequency of noise exposure.

Clinicopathologic and Immunohistochemical Study of Combined Small Cell Carcinoma and Urothelial Carcinoma Molecular Subtype.

Muscle invasive bladder cancer, an aggressive disease with heterogeneous molecular profiles, has recently been subclassified into three major molecular subtypes -basal, luminal and "p53-like" urothelial carcinomas (UCas), which bear prognostic and therapeutic implication. Similar to breast cancer, basal and luminal subtype UCas are designated by basal (CK5/14) and luminal (CK20) markers. The "p53-like" subtype presents with wild-type p53 gene with upregulated p53 pathways and is implicated in chemoresistance. Urinary bladder is one of the most common primary sites of extrapulmonary small cell carcinoma (SmCC). Bladder SmCC frequently coexists with UCa; however, the relation of SmCC with specific UCa molecular subtypes has not been studied. The aim of this study is to investigate the clinicopathology and immunophenotypes of the combined SmCC and UCa molecular subtypes. A total of 22 combined SmCC and UCa cases were studied for the clinicopathology and immunohistochemical (IHC) profiles by luminal and basal cell markers as well as Her2/Neu and p53. Our results demonstrated that all the urinary bladder SmCCs were associated with high grade UCas. They were more commonly seen in older male patients with a smoking history and had a poor prognosis. Based on the reported molecular subtyping, the UCas could be immunohistochemically subclassified into luminal, basal, dual and null types, which showed different clinicopathologic and IHC features. Compared to non-SmCC associated UCa, the subtypes of UCa in the combined SmCCs and UCas were characterized by: 1) Although overall luminal type was still relatively more common in men, basal marker-expressing subtypes were significantly increased in incidence and were more common in women. 2) Her2/Neu overexpression was more commonly observed in luminal than basal cell marker-expressing UCas. 3) IHC overexpression of p53 was common in all the subtypes, with UCas and SmCCs sharing the same p53 expression pattern. Although limited by relatively a small number of cases, the results of this study will enhance our understanding of the combined SmCC and UCa entity and potentially lead to a future therapeutic management.

Linearized solar elastosis of the legs: A novel presentation and review of the literature.

There exists a spectrum of solar elastotic variants based on the clinical and histopathologic findings. We present here a peculiar case of solar elastosis that is unusual in its anatomic location, relative lack of background actinic damage, and pattern of linearization. Its presentation suggests that other factors in addition to ultraviolet radiation may play a role in the pathogenesis of solar elastosis.

Erythema Nodosum Leprosum-Like Lesions Are a Histopathologic Pattern in Whipple's Disease and a Sign of the Immune Reconstitution Inflammatory Syndrome: A Case Series and Review of the Literature.

Inflammatory and subcutaneous nodules can arise in treated and untreated cases of Whipple disease (WD). The inflammatory immune reconstitution syndrome describes paradoxical clinical inflammatory worsening of a preexisting condition because of a return of immune function. Clinicopathologic examination of 4 patients with WD who presented with erythema nodosum leprosum (ENL)-like lesions and the findings of a systematic review of this phenomenon revealed that ENL-like lesions occurred in predominantly middle-aged male patients who suffered from WD, mostly on the legs. Patients showed a nonvasculitic, mostly septal panniculits with neutrophils, macrophages, and lymphocytes. Numerous bacteria-laden periodic acid-Schiff + macrophages and free bacilli were detected in the dermis, as well as subcutaneous septae and adipose lobules. These lesions occurred in both untreated and treated patients as part of inflammatory immune reconstitution syndrome. In conclusion, ENL-like lesions represent a characteristic histopathologic pattern associated with WD, which can occur in different contexts whenever there is a change in the immunological status of the patient. This change can be triggered by antimicrobial treatment, immunomodulatory and immunosuppressant therapy, or occur spontaneously, rarely.

Lymphomatoid Papulosis Type D: Report of a Case in a Child and Review of the Literature.

Lymphomatoid papulosis (LyP) is a cutaneous CD30-positive T-cell lymphoproliferative disorder that occurs primarily in adults and presents with crops of papules that become necrotic and spontaneously regress. It is classified according to the histopathologic findings; currently recognized subtypes include A, B, C, D, and E. LyP is uncommon in children. Herein we describe a child with an unusual clinical presentation of LyP type D and review the literature of reported cases in children.

Untrained listeners experience difficulty detecting interaural correlation changes in narrowband noises.

Interaural correlation change detection was measured in untrained normal-hearing listeners. Narrowband (10-Hz) noises were varied by center frequency (CF; 500 or 4000 Hz) and diotic level roving (absent or present). For the 500-Hz CF, 96% of listeners could achieve threshold (79.4% correct at the easiest testing level) if roving was absent, but only 36% of listeners could if level roving was present. No one could achieve threshold at the 4000-Hz CF, unlike trained listeners in the literature. The results raise questions about how individual differences affect learning and generalization of monaural and binaural cues related to interaural correlation detection.

Lymphocytic Arteritis in Epstein-Barr Virus Vulvar Ulceration (Lipschütz Disease): A Report of 7 Cases.

Epstein-Barr virus (EBV) infection can rarely present as painful genital ulcers, mostly in young female adolescents. Typically diagnosed by clinical findings, EBV vulvar ulceration (EBVVU) is rarely biopsied. Herein, the authors report the histopathology in 8 biopsies from 7 EBVVU patients, all serologically confirmed for acute (4/7) or reactivated-chronic (3/7) EBV infection. The 7 women all presented with 1 or more painful, punched-out vulvar ulcers. Only patients with acute EBV infection showed other clinical findings: fever and/or atypical lymphocytosis affected 75% (3/4); lymphadenopathy in 50%; and malaise/fatigue, dysuria and/or hepatomegaly in 25%. All reactivated-chronic EBVVU had a solitary ulcer, and 2 had history of a similar episode of vulvar ulceration (aphthosis). Histopathologically, lymphocytic arteritis was identified in 88% (7/8); a submucosal scar was found in the eighth specimen. Other histopathologies included venulitis (62%), endarteritis obliterans (38%), thrombosis (25%), neutrophilic sebaceous adenitis (25%), and mucosal lymphoid hyperplasia (12%). Dense angiocentric CD3 CD4 T-cell lymphocyte-predominant infiltrates were found, regionally or diffusely. In 2 specimens, neutrophils compromised half of the infiltrate. Minor components of CD8, CD20, and CD30 lymphocytes, CD123 plasmacytoid monocytes, CD68 macrophages, and plasma cells were present. Small-vessel endothelium and smooth muscle adjacent to the ulcers faintly expressed cytoplasmic EBV latent membrane protein-1 (LMP1). In situ hybridization for early EBV mRNA (EBER) identified rare solitary or scattered clustered positive lymphocytes in 38%. Polymerase chain reaction for EBV DNA was positive in one EBER positive biopsy. EBV infection has been documented in muscular vessel vasculitis. Based on the aforementioned, EBVVU appears to be the consequence of localized lymphocytic arteritis.

A clinicopathologic study of labia minora hypertrophy: signs of localized lymphedema were universal.

OBJECTIVE: To describe the clinical and pathologic features of women undergoing labioplasty for labia minora hypertrophy (LH) and to determine whether localized lymphedema plays a role in its pathogenesis. MATERIALS AND METHODS: A retrospective case series of consecutive cases of labioplasties performed for LH was retrieved from a 10-year period. Clinical, histopathologic, and immunohistochemical features were evaluated. RESULTS: Thirty-four labioplasty specimens from 31 women were identified. The women had a median/mean age of 36/35 years (range = 14-62 y) and had noted the presence of LH for a median/mean period of 36/86 months (range = 5-264 mo). A minority of patients had antecedent vaginal delivery (29%) and vulvar trauma (12%) and were either overweight (20%) or obese (27%). About half complained of vulvar appearance and approximately a third each had symptoms of pain, dyspareunia, or irritation. After a median/mean follow-up time of 40/44 months, 3 patients had recurrent LH (9%). The volume of excised tissue was greater for the patients with recurrent LH, than those without (mean of 9.8 vs 5.6 mL, respectively); however, no clinicopathologic finding predicted recurrence of LH. Histopathologically, all LH specimens showed diagnostic signs of chronic lymphedema, and compared with vulvar controls, LH had a significantly greater number of lymphangiectases (mean 15/mm vs 3/mm, p = .001) and showed greater mean maximal lymphatic dilation (0.12 vs 0.04 mm, p = .004), respectively. In addition, lichenification (94%), indicating chronic irritation, and sebaceous hyperplasia (60%), perisebaceous inflammation, and Demodex folliculorum infestation (3%), a constellation of findings commonly seen in phymatous rosacea, were evident. CONCLUSIONS: Rather than an anatomic variant, LH seems to be a manifestation of chronic lymphedema, either acquired or primary with delayed onset. Because persistent lymphedema can lead to functional debilitation, recurrent skin infections, elephantiasis, and, rarely, malignancy, early excision and treatment of factors that promote lymphedema would be effective management of this rare condition.

The relationship between carers' report of autistic traits and clinical diagnoses of autism spectrum disorders in adults with intellectual disability.

It is often difficult to determine the triad of impairments and whether autistic features are the consequence of intellectual impairment or autism spectrum disorders in people with intellectual disability (ID). The aim of the current study was to investigate the relationship between carer-reported autistic traits and independent diagnoses of autism spectrum disorders (ASD). Data were collected on carers' subjective report of autistic traits and clinical diagnoses of ASD. Of 1145 adults with ID identified, 220 (19%) individuals had a diagnosis of ASD, and 778 (68%) individuals had at least one autistic trait. Optimal sensitivity and specificity were achieved with two or more autistic traits (sensitivity 63%; specificity 79%) and the positive predictive value increased substantially as the number of autistic traits increased. However, a significant proportion of individuals with ID who did not have a diagnosis of ASD also displayed autistic traits. Our findings suggest that in the absence of other measures, the presence of autistic traits can serve as a useful proxy measure for ASD in research (and/or clinical settings). However, although information on autistic traits may help healthcare practitioners to identify people with possible ASD, it cannot be used alone to make a formal diagnosis.