Telehealth-enabled auditory brainstem response testing for infants living in rural communities: the British Columbia Early Hearing Program experience.

Objective: The present study investigated a telehealth-enabled auditory-brainstem-response (TH-ABR) programme provided by the British Columbia Early Hearing Program (BCEHP) to families in a remote northern area who face barriers such as travel distance and access to audiologists trained in ABR testing. Objectives were to: (i) outline the design/implementation of a TH-ABR programme, (ii) summarise equipment/procedures, and (iii) report on results for the TH-ABR programme (cost/time effectiveness, testing accuracy/efficiency, and caregiver satisfaction). Design: TH-ABR implementation was described and TH-ABR results were compared to behavioural follow-up findings to evaluate TH-ABR test accuracy. Caregivers were invited to complete TH-ABR satisfaction surveys following their appointment(s). Study sample: One hundred and two infants (mean age: 2.3 months) were assessed via TH-ABR at four points-of-care; 41/66 caregivers completed surveys. Results: The TH-ABR programme was suitable, sustainable and scalable. After 29 TH-ABR events, the service was cost neutral to BCEHP ($91,250 averted after 102 TH-ABRs). Fifty infants were identified with hearing loss and TH-ABR accuracy and efficiency were comparable to face-to-face assessments. Parent survey results indicated a high level of satisfaction with the TH-ABR experience. Conclusions: TH-ABR is efficient, accurate, valued by parents, optimises availability to audiology resources, builds local service capacity, and reduces costs for northern BC communities.

Clozapine-induced myocarditis: recognizing a potentially fatal adverse reaction.

A 46-year-old man with a history of paranoid schizophrenia was admitted with a recurrence of psychotic symptoms. Improvement was noted after the initiation of clozapine. After 2 weeks of clozapine therapy, chest pressure and abnormal cardiac biomarkers (in the presence of a normal coronary angiogram) raised suspicion of myocarditis. That diagnosis was confirmed by means of cardiac magnetic resonance imaging. Discontinuation of the clozapine led to resolution of the cardiac symptoms. Clozapine-induced myocarditis is rare and can be missed for lack of specific clinical findings. In order to prevent disease progression and a possibly fatal outcome, early recognition of the condition and prompt discontinuation of clozapine are necessary.

Monotic versus dichotic multiple-stimulus auditory steady state responses in young children.

In their recent study on infant multiple auditory steady state responses (ASSR), the authors found that ASSR amplitudes unexpectedly decreased when switching from 1-ear stimulation to 2-ear stimulation, a result not present in adults. In addition, residual EEG noise levels increased in the 2-ear condition. In the present study, to determine whether to use 1-ear or 2-ear multiple ASSR Protocols clinically, the authors tested a new group of 19 young children to determine whether these unexpected findings could be replicated. ASSR amplitude and EEG noise were compared for 1-ear (4 stimuli) versus 2-ear (8 stimuli) multiple stimuli presented at 60 dBHL. Results indicated a small but significant decrease in amplitudes going from 1-ear (40.1 nV) to 2-ear (37.9 nV) multiple stimuli. EEG noise was not significantly different between the 2 conditions. Despite small amplitude decreases, the 2-ear stimulus condition was more efficient for infants and young children with normal hearing.

Auditory brainstem responses to bone-conducted brief tones in young children with conductive or sensorineural hearing loss.

The bone-conduction (BC) tone ABR has been used clinically for over 20 years. The current study formally evaluated the test performance of the BC tone-evoked ABR in infants with hearing loss. Method. By comparing BC-ABR results to follow-up behavioural results, this study addressed two questions: (i) whether the BC tone ABR was successful in differentiating children with conductive versus sensorineural hearing loss (Study A; conductive: 68 ears; SNHL: 129 ears) and (ii) the relationship between BC ABR and behavioural hearing loss severity (Study B: 2000 Hz: 104 ears; 500 Hz: 47 ears). Results. Results demonstrate that the "normal" BC-ABR levels accurately differentiated normal versus elevated cochlear sensitivity (accuracy: 98% for 2000 Hz; 98% for 500 Hz). A subset of infants in Study A with elevated BC-ABR (i.e., no response at normal level) had additional testing at higher intensities, which allowed for categorization of the degree of cochlear impairment. Study B results indicate that the BC ABR accurately categorizes the degree of cochlear hearing loss for 2000 Hz (accuracy = 95.2%). A preliminary dBnHL-to-dBHL correction factor of "0 dB" was determined for 2000 Hz BC ABR. Conclusions. These findings further support the use of BC tone ABR for diagnostic ABR testing.

Clinical Use of PPARgamma Ligands in Cancer.

The role of PPARgamma in adipocyte differentiation has fueled intense interest in the function of this steroid nuclear receptor for regulation of malignant cell growth and differentiation. Given the antiproliferative and differentiating effects of PPARgamma ligands on liposarcoma cells, investigation of PPARgamma expression and ligand activation in other solid tumors such as breast, colon, and prostate cancers ensued. The anticancer effects of PPARgamma ligands in cell culture and rodent models of a multitude of tumor types suggest broad applicability of these agents to cancer therapy. This review focuses on the clinical use of PPARgamma ligands, specifically the thiazolidinediones, for the treatment and prevention of cancer.

Depletion of CD4+ cells exacerbates the cutaneous response to acute and chronic UVB exposure.

Solid organ transplant recipients have a 60-250-fold increased likelihood of developing sunlight-induced squamous cell carcinoma (SCC) compared with the general population. This increased risk is linked to the immunosuppressive drugs taken by these patients to modulate T cell function, thus preventing organ rejection. To determine the importance of T cells in the development of cutaneous SCC, we examined the effects of selectively depleting Skh-1 mice of systemic CD4+ or CD8+ T cells, using monoclonal antibodies, on ultraviolet B (UVB) radiation-induced inflammation and tumor development. Decreases in systemic CD4+ but not CD8+ T cells significantly increased and prolonged the acute UVB-induced cutaneous inflammatory response, as measured by neutrophil influx, myeloperoxidase activity, and prostaglandin E2 levels. Significantly more p53+ keratinocytes were observed in UVB-exposed CD4-depleted than in CD4-replete mice, and this difference was abrogated in mice depleted of neutrophils before UVB exposure. Increased acute inflammation was associated with significantly increased tumor numbers in CD4-depleted mice chronically exposed to UVB. Furthermore, topical treatment with the anti-inflammatory drug celecoxib significantly decreased tumor numbers in both CD4-replete and CD4-depleted mice. Our findings suggest that CD4+ T cells play an important role in modulating both the acute inflammatory and the chronic carcinogenic response of the skin to UVB.

Effects of bone oscillator coupling method, placement location, and occlusion on bone-conduction auditory steady-state responses in infants.

OBJECTIVE: The aim of these experiments was to investigate procedures used when estimating bone-conduction thresholds in infants. The objectives were: (i) to investigate the variability in force applied using two common bone-oscillator coupling methods and to determine whether coupling method affects threshold estimation, (ii) to examine effects of bone-oscillator placement on bone-conduction ASSR thresholds, and (iii) to determine whether the occlusion effect is present in infants by comparing bone-conduction ASSR thresholds for unoccluded and occluded ears. DESIGN: Experiment 1A: The variability in the amount of force applied to the bone oscillator by trained assistants (n = 4) for elastic-band and hand-held coupling methods was measured. Experiment 1B: Bone-conduction behavioral thresholds in 10 adults were compared for two coupling methods. Experiment 1C: ASSR thresholds and amplitudes to multiple bone-conduction stimuli were compared in 10 infants (mean age: 17 wk) using two coupling methods. Experiment 2: Bone-conduction ASSR thresholds and amplitudes were compared for temporal, mastoid and forehead oscillator placements in 15 preterm infants (mean age: 35 wk postconceptual age (PCA)). Experiment 3: Bone-conduction ASSR thresholds, amplitudes and phase delays were compared in 13 infants (mean age: 15 wk) for an unoccluded and occluded test ear. All infants that participated had passed a hearing screening test. RESULTS: Experiment 1A: Coupling method did not significantly affect the variability in force applied to the oscillator. Experiment 1B: There were no differences in adult bone-conduction behavioural thresholds between coupling methods. Experiment 1C: There was no significant difference between oscillator coupling method or significant frequency x coupling method interaction for ASSR thresholds or amplitudes in the young infants tested. However, there was a nonsignificant 9-dB better threshold at 4000 Hz for the elastic-band method. Experiment 2: Mean bone-conduction ASSR thresholds for the preterm infants were not significantly different for the temporal and mastoid placements. Mean ASSR thresholds for the forehead placement were significantly higher compared to the other two placements (12-18 dB higher on average). Mean ASSR amplitudes were significantly larger for the temporal and mastoid placements compared to the forehead placement. Experiment 3: There was no difference in mean ASSR thresholds, amplitudes or phase delays for the unoccluded versus occluded conditions. CONCLUSIONS: Trained assistants can apply an appropriate amount of force to the bone oscillator using either the elastic-band or hand-held method. Coupling method has no significant effect on estimation of bone-conduction thresholds; therefore, either may be used clinically provided assistants are appropriately trained. For preterm infants, there are no differences in ASSRs when the oscillator is positioned at the temporal or mastoid placement. However, thresholds are higher and amplitudes are smaller for the forehead placement, consequently, a forehead placement should be avoided for clinical testing. There does not appear to be a significant occlusion effect in young infants; therefore, it may be possible to do bone-conduction testing with ears unoccluded or occluded without applying a correction factor, although further research is needed to confirm this finding.