Influence of the volume of soft tissue herniation on clinical symptoms of patients with orbital floor fractures.

INTRODUCTION: One of the most important complications of orbital floor fractures is diplopia and restricted ocular movement. The role of the volume of soft tissue herniation on these clinical symptoms after orbital floor fractures is unclear and potentially may predict development of persistent clinical symptoms. Therefore the aim of this study was to assess pre- and postoperative complications associated to the volume of soft tissue herniation, with special interest to diplopia and bulbus motility impairment. MATERIAL AND METHODS: 204 untreated patients with orbital floor fractures from 2009 to 2011 were included in this retrospective study. Contingency tables and χ2-test were performed to analyze associations between two qualitative variables. p-Values p < 0.05 were considered as significant. Volume measurement was performed in a semiautomatic segmentation method with the software "ITK-Snap". RESULTS: The volume of soft tissue herniation correlated significantly with pre- and postoperative diplopia (p = 0.003; p = 0.002), persistent diplopia (p = 0.009) as well as pre- and postoperative bulbus motility impairment (both p < 0.001). Furthermore we found out significant associations between the volume of soft tissue herniation and pre- and postoperative complications depending on fracture type and reconstruction technique. CONCLUSIONS: Volume measurement of soft tissue herniation may help to predict postoperative complications, particularly bulbus motility restriction and persistent diplopia. The risk for these symptoms rises with increasing volume of soft tissue herniation after orbital floor fractures. Therefore we recommend for these patients within indication an early repair and/or closer observation.

Integrated care in Norway: the state of affairs years after regulation by law.

INTRODUCTION: A mandatory multidisciplinary plan for individual care, the 'Individual care Plan', was introduced by law in Norway in 2001. The regulation was established to meet the need for improved efficiency and quality of health and social services, and to increase patient involvement. The plan was intended for patients with long-term and complex needs for coordinated care. The aim of this study was to elaborate on knowledge of such planning processes in Norwegian municipalities. METHOD: A piloted questionnaire was sent to 92 randomly selected municipalities in 2005-2006, addressing local organization and participation in the work with individual care plans. Local political governance, size of the population, funds available for health care, and problems related to living conditions were indicators for analysing the extent to which the individual care plan was used five years after the regulation was introduced. RESULTS: Our results showed that 0.5% as opposed to an expected 3% of the population had an individual care plan. This was independent of the political, social and financial situation in the municipalities or the way the planning process had been carried out. The planning process was mostly taken care of by local health and social care professionals, rather than by hospital staff and general practitioners. DISCUSSION AND CONCLUSION: The low number of care plans and the oblique responsibility among professionals for planning showed that the objectives of the national initiative had not been achieved. More research is needed to determine the reasons for this lack of success and to contribute to solutions for improved multidisciplinary cooperation.

The effect of instantaneous input dynamic range setting on the speech perception of children with the nucleus 24 implant.

OBJECTIVE: The purpose of this study was to examine the effects of a wider instantaneous input dynamic range (IIDR) setting on speech perception and comfort in quiet and noise for children wearing the Nucleus 24 implant system and the Freedom speech processor. In addition, children's ability to understand soft and conversational level speech in relation to aided sound-field thresholds was examined. DESIGN: Thirty children (age, 7 to 17 years) with the Nucleus 24 cochlear implant system and the Freedom speech processor with two different IIDR settings (30 versus 40 dB) were tested on the Consonant Nucleus Consonant (CNC) word test at 50 and 60 dB SPL, the Bamford-Kowal-Bench Speech in Noise Test, and a loudness rating task for four-talker speech noise. Aided thresholds for frequency-modulated tones, narrowband noise, and recorded Ling sounds were obtained with the two IIDRs and examined in relation to CNC scores at 50 dB SPL. Speech Intelligibility Indices were calculated using the long-term average speech spectrum of the CNC words at 50 dB SPL measured at each test site and aided thresholds. RESULTS: Group mean CNC scores at 50 dB SPL with the 40 IIDR were significantly higher (p < 0.001) than with the 30 IIDR. Group mean CNC scores at 60 dB SPL, loudness ratings, and the signal to noise ratios-50 for Bamford-Kowal-Bench Speech in Noise Test were not significantly different for the two IIDRs. Significantly improved aided thresholds at 250 to 6000 Hz as well as higher Speech Intelligibility Indices afforded improved audibility for speech presented at soft levels (50 dB SPL). CONCLUSION: These results indicate that an increased IIDR provides improved word recognition for soft levels of speech without compromising comfort of higher levels of speech sounds or sentence recognition in noise.

Relation of electrically evoked compound action potential thresholds to behavioral T- and C-levels in children with cochlear implants.

OBJECTIVE: This study examined the relation of electrically evoked compound action potential thresholds obtained using neural response telemetry (NRT) to T- and C-levels in children's speech processor programs optimized for recognition of very soft to loud sounds while ensuring tolerance of very loud sounds. DESIGN: Forty-one children (age 2 to 14 yr) with stable electrical hearing participated. All children were Nucleus 24 System recipients and attended one of three auditory-oral schools that have on-site pediatric audiologists experienced at cochlear implant programming. Speech processor MAPs were created and adjusted over a period of months until aided warble-tone thresholds were between 10 and 30 dB HL at octave frequencies between 250 and 4000 Hz, and understanding of speech was maximized for many listening situations. At least 1 yr postactivation, visual (vNRT) and predicted (tNRT) thresholds were obtained on 9 to 11 electrodes and compared to each child's T- and C-level values on these electrodes in their MAPs. Test-retest stability of NRT thresholds was compared for two test sessions 1 mo apart. RESULTS: NRT-based evoked compound action potential thresholds could be obtained from 36 of the 41 children. vNRT and tNRT test-retest reliability was high; average correlation coefficients (r) across subjects were 0.90 (range: 0.64 to 0.99) and 0.88 (range: 0.31 to 1.00), respectively. Group average correlation coefficients between vNRT and T-level, vNRT and C-level, tNRT and T-level, and tNRT and C-level were low (0.18, 0.21, 0.24, and 0.26, respectively). Group mean tNRT thresholds were four current levels lower than the group mean vNRT thresholds. Subsequent analysis was performed with the vNRT thresholds because the range of test-retest correlation coefficients for individual subjects was narrower than with tNRT. Hierarchical linear modeling was used to determine if vNRT could be used to predict T- and C-levels. This analysis indicated a significant average relation between vNRT and T-levels and between vNRT and C-levels, but significant heterogeneity in the individual-level estimates of those relations. In other words, subjects varied significantly in the size of the relation between their individual vNRT values and both T- and C-levels. Attempts to account for that heterogeneity did not identify any subject characteristics that were significantly related to the individual-level parameters. CONCLUSIONS: The position of the group average vNRT and tNRT thresholds in the upper half of the dynamic range between Ts and Cs agrees with previous studies. The fact that the profile of vNRT thresholds did not parallel the profiles of Ts and Cs across electrodes for most children suggests that simply shifting the NRT profile to select T- and C-levels in initial MAPs is likely to result in a loudness imbalance for certain speech frequencies and/or tolerance issues for many children. This was verified by the hierarchical linear modeling analysis, which showed substantial and significant heterogeneity in the relations between vNRT and T-levels and between vNRT and C-levels. In summary, vNRT is not related to T- or C-levels in a simple and uniform way that would allow it to guide MAP fine tuning with any precision. Consequently, it is recommended that MAP fine tuning be based on the child's behavioral responses on individual electrodes.