Development, implementation and evaluation of a multinational FLS mentorship programme in Latin America.

Realising the benefits of systematic secondary fracture prevention requires supporting local sites to get started and becoming effective. We here describe the development, implementation and impact of a regional fracture liaison service (FLS) mentorship programme in Latin America that led to 64 FLS getting started and coverage of 17,205 patients. INTRODUCTION: Despite treatments and service models to deliver effective secondary fracture prevention, most patients are left untreated after a fragility fracture. To improve the capability to get FLS started and more effective, we describe the development, implementation and evaluation of an international programme to develop national communities of FLS mentors as part of the Capture the Fracture Partnership in Latin America. METHODS: The IOF regional team and the University of Oxford developed the curriculum and associated resources for training mentors in setting up FLS, service improvement and mentorship. Mentors were selected during a preparatory meeting, trained using live online sessions followed by regular mentor-led post-training meetings. The programme was evaluated using a pre-training needs assessment and post-training evaluation based on Moore's outcomes. RESULTS: The mentorship programme was initiated in Mexico, Brazil, Colombia and Argentina. The mentors were multidisciplinary, including orthopaedic surgery, rehabilitation, rheumatology, endocrinology, geriatrics, gynaecology and internal medicine. There was 100% participation in training sessions and reported satisfaction with the training. Since the initiation of the training programme, 22 FLS have been set up in Mexico, 30 in Brazil, 3 in Colombia and 9 in Argentina, in comparison with two in Chile and none in any other LATAM countries that were not involved in the mentorship programme. This equates to approximately 17,025 additional patients identified from 2019 to 2021 after initiation of mentorship. The mentors have engaged with 58 FLS for service development. Post-training activities include two published national best practice guidelines and other country-specific resources for FLS in the local language. CONCLUSION: Despite the COVID pandemic, the mentorship pillar of the Capture the Fracture Partnership has developed a community of FLS mentors with measurable improvement in national FLS provision. The programme is a potentially scalable platform to develop communities of mentors in other countries.

Characterization of pulse amplitude and pulse rate modulation for a human vestibular implant during acute electrical stimulation.

OBJECTIVE: The vestibular system provides essential information about balance and spatial orientation via the brain to other sensory and motor systems. Bilateral vestibular loss significantly reduces quality of life, but vestibular implants (VIs) have demonstrated potential to restore lost function. However, optimal electrical stimulation strategies have not yet been identified in patients. In this study, we compared the two most common strategies, pulse amplitude modulation (PAM) and pulse rate modulation (PRM), in patients. APPROACH: Four subjects with a modified cochlear implant including electrodes targeting the peripheral vestibular nerve branches were tested. Charge-equivalent PAM and PRM were applied after adaptation to baseline stimulation. Vestibulo-ocular reflex eye movement responses were recorded to evaluate stimulation efficacy during acute clinical testing sessions. MAIN RESULTS: PAM evoked larger amplitude eye movement responses than PRM. Eye movement response axes for lateral canal stimulation were marginally better aligned with PRM than with PAM. A neural network model was developed for the tested stimulation strategies to provide insights on possible neural mechanisms. This model suggested that PAM would consistently cause a larger ensemble firing rate of neurons and thus larger responses than PRM. SIGNIFICANCE: Due to the larger magnitude of eye movement responses, our findings strongly suggest PAM as the preferred strategy for initial VI modulation.

[Vestibular function: the 6th sense... ignored]. / La fonction vestibutaire: le sixième sens... ignoré.

Dizzy patients are often misunderstood by doctors. Those with a complete vestibular deficit and whose function is restored by a vestibular implant use all kinds of words to describe what they feel when the neuroprosthesis is turned on. Their feeling varied from a strong emotion to a feeling of heat. The notion of dizziness or motion was rare. How to describe the sensations provided by an ignored and unconscious sense? With the eyes, one sees; with the ears one hears; no term exists that describes what we do with the vestibular system! Should we say we vestibulise? The notion traditionally taught that patients suffering from a vestibular disorder should describe an imbalance or a rotatory vertigo, be able specify the direction of rotation, etc. is inadequate, unrealistic.

Vestibular implants: Hope for improving the quality of life of patients with bilateral vestibular loss.

The vestibular system plays an essential role in crucial tasks such as postural control, gaze stabilization, and spatial orientation. Currently, there is no effective treatment for a bilateral loss of the vestibular function (BVL). The quality of life of affected patients is significantly impaired. During the last decade, our group has explored the potential of using electrical stimulation to artificially restore the vestibular function. Our vestibular implant prototype consists of a custom modified cochlear implant featuring one to three vestibular electrodes implanted in the proximity of the ampullary branches of the vestibular nerve; in addition to the main cochlear array. Special surgical techniques for safe implantation of these devices have been developed. In addition, we have developed stimulation strategies to generate bidirectional eye movements as well as the necessary interfaces to capture the signal from a motion sensor (e.g., gyroscope) and use it to modulate the stimulation signals delivered to the vestibular nerves. To date, 24 vestibular electrodes have been implanted in 11 BVL patients. Using a virtual motion profile to modulate the "baseline" electrical stimulation, vestibular responses could be evoked with 21 electrodes. Eye movements with mean peak eye velocities of 32°/s and predominantly in the plane of the stimulated canal were successfully generated. These are within the range of normal compensatory eye movements during walking and were large enough to have a significant effect on the patients' visual acuity. These results indicate that electrical stimulation of the vestibular nerve has a significant functional impact; eye movements generated this way could be sufficient to restore gaze stabilization during essential everyday tasks such as walking. The innovative concept of the vestibular implant has the potential to restore the vestibular function and have a central role in improving the quality of life of BVL patients in the near future.

[The benefit of systematic hearing screening of school-age children]. / Bénéfice d'un dépistage systématique de la surdité chez l'enfant en âge scolaire.

The hearing is routinely tested in all newborns in most European countries. Thereafter, no hearing test is performed in a systematic way, despite the many conditions that can cause hearing loss in the first years of life. If language acquisition is possible with only one ear, even a unilateral hearing loss can be the cause of learning difficulties at school. In Geneva, a screening program for hearing deficit was introduced in 1955 in all primary schools of the canton. This paper shows the efficiency of the program, which can detect unnoticed deafness, sometimes in children whose neonatal screening had proved normal. Such a program should be applied to all private schools and to schools for disabled children.

[Aspirin ototoxicity: a rare situation today]. / Ototoxicité à l'Aspirine: une situation rare de nos jours.

Aspirin is commonly used most often at low daily doses. We report a case of acute aspirin intoxication resulting in a transitory hearing loss, tinnitus, and vertigo. Such intoxications occur at doses of several grams. The disorders caused by aspirin are fortunately reversible. The mechanisms of ototoxicity appear to involve, in part, electro-mobility of the outer hair cells of the inner ear by inhibiting the movement of prestin.

[Odd stories of patients suffering from Menière's disease]. / Les étranges histoires des patients... et de leurs docteurs (!) dans le tourbillon du Menière!

The cause of Meniere's disease is unknown. The postmortem examination of the temporal bone reveals an "endolymphatic hydrops" of the inner ear. Classically, patients describe episodes of vertigo, fluctuations of hearing and tinnitus. But some report "strange stories" that deserve doctor's attention. This article explains why their history (as those suffering from any other vestibular disorder) is often particular, to recall the few knowledge of the disease, how the endolymphatic hydrops was considered as the cause of the disorder, while it is rather an epiphenomenon, and to show how one can believe, wrongly, that a therapy is efficient after a study that seems however at first correctly performed.

[Causal relationship: and if "yes", and if "not"... on basis of which criterias?]. / Relation de cause à effet: et si "oui", et si "non", ... sur la base de quels critères?

A woman was referred to us 4 days after the sudden onset of continuous rotatory vertigo. The diagnosis of a left vestibular neuronitis was made. During the investigations, a meningioma of the contralateral posterior fossa was discovered. Is there any relationship between the two disorders? The etiology of peripheral vestibular disorders remains poorly understood in most cases. Anomalies of cells surrounding the sensory organs have been demonstrated in post-mortem examination of the inner ear of patients with a vestibular deficit that could be caused by a "biological stress". Therefore there may be a link between left vestibular deficit and the mass of the right posterior fossa, considered as a fortuitous discovery, at first.

Vestibular implants: the first steps in humans.

Currently there is no efficient treatment for patients with severe bilateral vestibular function impairment. Presence of oscillopsia is their main complaint. It has a significant negative impact on their quality of life. Recently it has been shown that angular vestibulo-ocular reflex can be partially restored in animals. In humans it is possible to elicit a nystagmic response by electric stimulation of ampullary parts of the vestibular nerve. Controlled eye movements can be generated by frequency and intensity modulation of the restored baseline firing rate of the vestibular nerve. During adaptation phase to the electric stimulus, patients experience nystagmus with associated inconveniences. By repetition of "on/off periods" the duration of the adaptation phase can be significantly decreased. Results show that permanent electric stimulation is necessary to maintain this "optimal" adaptation state.

[Have we made progress in the development of a vestibular implant?]. / Queues avancées cette année dans le développement d'un implant vestibulaire?

The concept of a vestibular implant to restore balance in patients suffering from bilateral loss of function is similar to that of a cochlear implant. Motion sensors will capture head movements and this information will be transmitted to the central nervous system via electrodes implanted in the vestibular system. However, several key questions must be answered before such prosthesis could be used in humans. One is to restore a baseline neural activity in the system that can be then adequately modulated by the prosthesis, without causing unbearable symptoms. We showed that this is possible in human. This is an important prerequisite for the feasibility of a vestibular implant.

Atypical presentations of malignant otitis externa.

INTRODUCTION: Malignant otitis externa is a life-threatening infection of the skull base. Its presentation is not always typical. CASE REPORTS: We report three cases of malignant otitis externa which illustrate the diversity of its clinical manifestations and the difficulties in its diagnosis. DISCUSSION: The perception of malignant otitis externa as an infection caused by Pseudomonas aeruginosa in diabetic patients is not always correct. The adoption of diagnostic criteria could be helpful in identifying atypical cases.

[Development of a vestibular implant for the rehabilitation of bilateral deafness]. / Développement d'un implant vestibulaire pour la réhabilitation des déficits vestibulaires bilatéraux.

The development of a vestibular implant for the rehabilitation of bilateral vestibular loss is funded on a concept comparable to that of the cochlear implant used in the rehabilitation of bilateral deafness. This paper carries an overview of the main aspects of such a development and describes the first experiments done in human subjects in Geneva.

[Cervical vertigo: myth or reality?]. / Vertiges d'origine cervicale: mythe ou réalité?

Patients displaying vertigo associated with cervical symptoms: what is the origin? Diagnosis of cervical vertigo is sometimes retained. It remains very controversial. Indeed there is neither a convincing pathological mechanism nor a diagnostic test. Despite lack of strong benefit evidence, manual therapy can be offered to selected patients.

[A series of tumors of the posterior fossa]. / Processus expansifs de la fosse postérieure.

This article presents a series of tumors of the posterior fossa. Imbalance or dizziness motivate patients to consult while they often neglect a hearing loss. However, any unilateral hearing impairment of any kind, even transitory, requires testings to rule out a retrocochlear lesion. In this series, 23% of vestibular schwannomas manifested by a sudden deafness, with a recovery of hearing in half of them.

[Neonatal hearing screening program and school education for deaf children in Switzerland]. / Dépistage systématique néonatal de la surdité et mode de scolarisation des enfants malentendants en Suisse.

A national hearing screening in newborns was introduced in Switzerland in the early 2000s. Since then, the number of maternities which applies has considerably increased. Test results are collected in a national database, giving a good overview of the quality of screening and incidence of deafness in Switzerland. The diagnosis and rehabilitation of deafness is earlier than before. This, combined to modem technologies allows mainstream integration of almost every deaf child.