One mechanism of sudden sensorineural hearing loss after sildenafil and sexual activity.

OBJECTIVES: A case of sudden sensorineural hearing loss following use of sildenafil was examined in detail over a period of three days from first report to recovery. DESIGN: Case study. The subject presented with sudden sensorineural hearing loss and diplacusis a day after onset. Testing involved detailed interview, standard audiometry, detailed inter-octave audiometry, and measurement of detailed psychophysical frequency tuning curves during a two day recovery period. STUDY SAMPLE: One male aged in his thirties with otherwise normal hearing. RESULTS: Although standard audiometry was within normal limits, detailed inter-octave audiometry and psychophysical frequency tuning curves were consistent with a punctate unilateral intra-cochlear lesion that resolved over a period of three days. CONCLUSIONS: This is the first report of such a frequency-specific audiometric shift and diplacusis after sildenafil, and is not consistent with previous reports of direct ototoxic pharmacological effects. We propose that the lesion was most likely caused by a cochlear bleed, and may have been due to physical exertion rather than a direct pharmaceutical effect. The study highlights the important role of additional diagnostic testing that can be easily achieved in a clinical setting with minimal equipment.

Putative Auditory-Evoked Neurophonic Measurements Using a Novel Signal Processing Technique: A Pilot Case Study.

With changes to cochlear implant candidacy and improvements in surgical technique, there is a need for accurate intraoperative assessment of low-frequency hearing thresholds during cochlear implantation. In electrocochleography, onset compound action potentials (CAPs) typically allow estimation of auditory threshold for frequencies above 1 kHz, but they are less accurate at lower frequencies. Auditory nerve neurophonic (ANN) waveforms, on the other hand, may overcome this limitation by allowing phase-locked neural activity to be tracked during a prolonged low-frequency stimulus rather than just at its onset (Henry, 1995). Lichtenhan et al. (2013) have used their auditory nerve overlapped waveform (ANOW) technique to measure these potentials from the round windows of cats and guinea pigs, and reported that in guinea pigs these potentials originate in the cochlear apex for stimuli below 70 dB SPL (Lichtenhan et al., 2014). Human intraoperative round window neurophonic measurements have been reported by Choudhury et al. (2012). We have done the same in hearing impaired awake participants, and present here the results of a pilot study in which we recorded responses evoked by 360, 525, and 725 Hz tone bursts from the cochlear promontory of one participant. We also present a modification to the existing measurement technique which halves recording time, extracting the auditory neurophonic by recording a single averaged waveform, and then subtracting from it a 180° group-delayed version of itself, rather than using alternating condensation and rarefaction sound stimuli. We cannot conclude that the waveforms we measured were purely neural responses originating from the apex of the cochlea: as with all neurophonic measurement procedures, the neural responses of interest cannot be separated from higher harmonics of the cochlear microphonic without forward masking, regardless of electrode location, stimuli or post-processing algorithm. In conclusion, the extraction of putative neurophonic waveforms can easily be incorporated into existing electrocochleographic measurement paradigms, but at this stage such measurements should be interpreted with caution.

An evaluation of systematic reviews of palliative care services.

This review aimed to identify and appraise all systematic reviews of palliative care services, to examine their findings in relation to methods used, and to explore whether further methods such as meta-analysis and meta-regression may be worthwhile. Ten databases were searched and augmented by hand searching specific journals, contacting authors, and examining the reference lists of all papers retrieved. Five systematic reviews met the inclusion criteria, and the update electronic search identified a further systematic review which found similar studies. A total of 39 studies were identified by the five systematic reviews. Of the 39 studies, 15 were RCTS, and 12 of those were North American. In comparison, the majority of U.K. studies were retrospective. Each review concluded similarly that there was a lack of good quality evidence on which to base conclusions. The more recent reviews were more rigorous, but none used a quantitative analysis. Despite the difficulties in combining heterogeneous interventions and outcomes in meta-analysis or meta-regression, such techniques may be valuable. More high quality evidence is needed to compare the relative merits of the differences in models of palliative care services, so that countries can learn from other appropriate systems of care at end of life.

Do hospital-based palliative teams improve care for patients or families at the end of life?

To determine whether hospital-based palliative care teams improve the process or outcomes of care for patients and families at the end of life, a systematic literature review was performed employing a qualitative meta-synthesis and quantitative meta-analysis. Ten databases were searched. This was augmented by hand searching specific journals, contacting authors, and examining the reference lists of all papers retrieved. Studies were included if they evaluated palliative care teams working in hospitals. Data were extracted by two independent reviewers. Studies were graded using two independent hierarchies of evidence. A Signal score was used to assess the relevance of publications. Two analyses were conducted. In a qualitative meta-synthesis data were extracted into standardized tables to compare relevant features and findings. In quantitative meta-analysis we calculated the effect size of each outcome (dividing the estimated mean difference or difference in proportions by the sample's standard deviation). Nine studies specifically examined the intervention of a hospital-based palliative care team or studies. A further four studies considered interventions that included a component of a hospital or support team, although the total intervention was broader. The nature of the interventions varied. The studies were usually in large teaching hospitals, in cities, and mainly in the United Kingdom. Outcomes considered symptoms, quality of life, time in hospital, total length of time in palliative care, or professional changes, such as prescribing practices. Only one of the studies was a randomized controlled trial and this considered a hospital team as part of other services. Most method scores indicated limited research quality. Comparison groups were subject to bias and the analyses were not adjusted for confounding variables. In addition, there were problems of attrition and small sample sizes. Nevertheless, all studies indicated a small positive effect of the hospital team, except for one study in Italy, which documented deterioration in patient symptoms. The Signal scores indicated that the studies were relevant. No study compared different models of hospital team. This review suggests that hospital-based palliative care teams offer some benefits, although this finding should be interpreted with caution. The study designs need to be improved and different models of providing support at the end of life in hospital need comparison. Standardized outcome measures should be used in such research and in practice.