Health-related quality-of-life outcomes from adult cochlear implantation: a cross-sectional survey

PURPOSE

The purpose of this study was to examine the extent to which cochlear implants and related rehabilitation improve health-related quality-of-life (HRQoL) and social participation for deafened adults and their partners.

METHOD

A cross-sectional survey was used to examine HRQoL and social participation experiences of 202 deafened adults (148 with implants and 54 without) and 136 partners associated with cochlear implant clinics in Australia and New Zealand. Respondents completed a mailed survey consisting of the Assessment of Quality of Life instrument (a utility instrument), the Participation Scale and questions concerning their socioeconomic status. Both univariate and multivariate analyses were performed.

RESULTS

Controlling for socioeconomic factors, people with cochlear implants reported improved HRQoL and social participation when compared with non-implantees. Implantees reported a relative gain in health utility of 50%, and a relative improvement in social participation of 31%. Such differences were not reported by partners, although patient and partner HRQoL were weakly correlated.

CONCLUSION

The results of this cross-sectional study suggest that cochlear implantation contributes significantly to improvements for deafened adults in everyday communication settings and makes a major contribution to their HRQoL. Nonetheless, when compared with population-based studies, this population continues to report considerably reduced quality of life. Partners also report significantly reduced quality of life when compared to population norms.

Multifactorial processes in recovery from aphasia: developing the foundations for a multileveled framework

This paper develops the foundations for a framework of recovery from aphasia which attempts to integrate knowledge from several domains to form a basis for an approach to treatment as managed recovery. We still have a mainly operational appreciation of recovery derived from atheoretical group investigations using psychometric batteries and generic definitions of aphasia and a lack of clarity in the use of the terms restoration, compensation, and reorganization. There is a failure to appreciate the interrelation of different levels (e.g., neural, cognitive, behavioral) and the importance of different perceptions (e.g., patient, relative, clinician) in individual recovery. The multileveled framework may improve understanding of what underlies individual recovery and form a framework for mapping interactions between levels as a basis for intervention.

The public awareness of aphasia: an international survey

We surveyed 929 shoppers in Exeter (England), Louisiana (USA) and Sydney (Australia) to determine what they knew of aphasia. Between 10% and 18% said they had heard of aphasia but only between 1.5% and 7.6% had even some basic knowledge of aphasia. We found that more females knew something about aphasia than males and that older people were more likely to have heard of it, although those with some knowledge were significantly younger. Informants had heard of aphasia mainly through their work or the media and were mainly professionals like teachers, nurses, therapists, managers and administrators, followed by a retired/student group. We found some differences in awareness levels in the different locations we sampled. Results have implications for targeting awareness raising and campaigning.

Profiling the membership of self-help groups for aphasic people

We surveyed the membership of aphasia self-help groups in England. We wanted to know what kinds of people become members and the factors associated with taking an active role. So we aimed to describe the membership in terms of age, aphasia severity, physical state, socio-economic status and group roles. We collected data on 135 members and found them relatively less severe but mainly chronically aphasic, living in their own homes and close to the group meeting place, using their own or public transport, with little community or state aid. While hemiplegia was common, few were wheelchair bound. Those taking active roles were younger and less severely aphasic and from more professional and managerial socio-economic groups.

The functional neuroanatomy of simple calculation and number repetition: A parametric PET activation study

We examined cerebral activation patterns with positron emission tomography (PET) in 12 right-handed normal volunteers while they were completing simple calculation tasks or merely repeating numbers. Using a parametric experimental design, during calculation we found activation in the medial frontal/cingulate gyri, left dorsolateral prefrontal cortex, left anterior insular cortex and right anterior insular cortex/putamen, left lateral parietal cortex, and the medial thalamus. Number repetition engaged bilateral inferior sensorimotor cortex, bilateral temporal areas, and left inferior frontal cortex. These results suggest a functional anatomical network for simple calculation, which includes aspects of attention, auditory, and motor processing and the phonological store and articulatory loop components of working memory; they add some support for a special role of the parietal cortex in calculation tasks.

Risk of acquiring Creutzfeldt-Jakob disease from blood transfusions: systematic review of case-control studies

OBJECTIVE

To determine the strength of association between history of blood transfusion and development of Creutzfeldt-Jakob disease.

DATA SOURCES

English and non-English language articles published from January 1966 to January 1999 were retrieved using a keyword search of Medline and Embase. These were supplemented by handsearching key journals and searching bibliographies of reviews.

STUDY SELECTION

Two independent reviewers selected the relevant abstracts and articles. Articles were chosen that reported the results of case-control studies trying to identify rates of prior blood transfusion in patients with Creutzfeldt-Jakob disease and in controls.

DATA EXTRACTION

Odds ratios and information on study quality were extracted from the selected articles by two independent reviewers.

DATA SYNTHESIS

Five studies containing data on 2479 patients were included. Three of the five studies used medical or neurological patients as controls, the other two used population controls. Odds ratios for developing Creutzfeldt-Jakob disease from blood transfusion ranged from 0.54 to 0.89. Four of the five studies had confidence intervals that crossed 1.0. The combined odds ratio was 0.70 (95% confidence interval 0.54 to 0.89).

CONCLUSIONS

Case-control studies do not suggest a risk of developing Creutzfeldt-Jakob disease from blood transfusion. Rather, a trend seems to exist towards a lower frequency of previous blood transfusion in patients with Creutzfeldt-Jakob disease than in controls. However, it is important to be aware of these studies' methodological limitations-primarily the choice of control population and reliability of recall of transfusion status.

A multinational comparison of aphasia management practices

The effect of restructuring of healthcare on the quality, quantity, and nature of aphasia management is largely unknown. The current study is the first to examine access, diagnostic, treatment, and discharge patterns of patients with aphasia in Australia, Canada, the UK, the US private sector (US-Private), and the US Veterans Health Administration in the Department of Veterans Affairs (US-VA). The authors developed a 37-item survey to be completed by clinicians working with aphasic patients. The survey focused on eight areas: access to care, evaluation procedures, group treatment, number and duration of treatment sessions, limitations of the number of sessions, termination of treatment, follow-up practices, and resumption of treatment. 394 surveys were distributed and 175 were returned completed (44% return rate). Respondents represented a range of ages, work experiences, and work settings. There was considerable consistency among respondents from our five healthcare systems. Results suggest that patients may be routinely denied treatment in direct contradiction to the research literature. Just as we carefully monitor the progress of patients receiving our treatment, we are obliged to monitor the effects of managed care on our patients, fellow clinicians, and our profession.

The emotional impact of aphasia

In this article we review the negative impact of aphasia on emotional well-being. Depression is the emotional response that has been examined most, and we examine the different causes of depression for people with aphasia. We discuss the relationships between recovery and emotional state and the clinical implications of these relationships, then review briefly issues of drug treatment for depression. We conclude that the emotional impact of aphasia can have a marked negative impact on recovery, response to rehabilitation, and psychosocial adjustment.

Perceptions of psychosocial adjustment to aphasia: applications of the Code--Müller Protocols

We review research that has examined people's perceptions of likely psychosocial adjustment of aphasia. People's perceptions differ depending on whether they have aphasia themselves, are related closely to a person with aphasia, or work with the aphasic person in a professional capacity. In addition, people differ in what they perceive are the most important or relevant factors for psychosocial adjustment, and this too depends on whether they have aphasia themselves, are a relative or "significant other" in the aphasic person's life, or are a health professional working with the person with aphasia. Furthermore, there are marked differences in the way individuals predict likely psychosocial adjustment, and these perceptions can change over time. Most of this research has used the Code-Müller Protocols (CMP) to examine these perceptions. This article describes the development and application of the CMP in aphasia.

Perceptions of psychosocial adjustment to acquired communication disorders: applications of the Code-Müller Protocols

The 'Code-Müller protocols' (CMP) were introduced in 1983 and originally aimed to compare perceptions of psychosocial adjustment to aphasia and related disorders from the separate perspectives of patients, relatives and speech and language therapists as a basis for counselling. In later studies the items of the CMP were also used to examine perceptions of their importance as possible therapy targets in the rehabilitation of people with communication disorders. This paper describes the development of the CMP and presents an overview of their application in aphasia, laryngectomy and acquired deafness and discusses some clinical implications. Studies published in the past 15 years show that aphasic people and their relatives or significant others are significantly more optimistic concerning psychosocial adjustment than their therapists. Furthermore, optimism changes during the course of illness. The relative weightings given for therapy or rehabilitation targets significantly differ between different professional groups concerned with aphasia rehabilitation (speech and language therapists/pathologists, physiotherapists, occupational therapists, psychologists and physicians) and are influenced by clinical experience.

Specific temporoparietal gyral atrophy reflects the pattern of language dissolution in Alzheimer's disease

The aim of this study was to determine the topography and degree of atrophy in speech and language-associated cortical gyri in Alzheimer's disease. The post-mortem brains of 10 patients with pathologically confirmed Alzheimer's disease and 21 neurological and neuropathological controls were sectioned in serial 3 mm coronal slices and grey and white matter volumes were determined for specific cortical gyri. All Alzheimer's disease patients had prospectively documented impairments in verbal and semantic memory with concomitant global decline. The cortical regions of interest included the planum temporale, Heschl's gyri, the anterior superior temporal gyri, the middle and inferior temporal gyri, area 37 at the inferior temporoparietal junction, areas 40 and 39 (supramarginal and angular gyri) and Broca's frontal regions. Although most patients had end-stage disease, the language-associated cortical regions were affected to different degrees, with some regions free of atrophy. These included Broca's regions in the frontal lobe and Heschl's gyri on the superior surface of the temporal lobe. In contrast, the inferior temporal and temporoparietal gyri (area 37) were severely reduced in volume. The phonological processing regions in the superior temporal gyri (the planum temporale) were also atrophic in all Alzheimer's disease patients while the anterior superior temporal gyri were only atrophic in female patients. Such atrophy may underlie the more severe language impairments previously described in females with Alzheimer's disease. The present study is the first to analyse the volumes of language-associated gyri in post-mortem patients with confirmed Alzheimer's disease. The results show that atrophy is not global but site-specific. Atrophied gyri appear to reflect a specific network of language and semantic memory dissolution seen in the clinical features of patients with Alzheimer's disease. Females showed greater atrophy than males in the anterior superior temporal gyri.

Thinking nuclear medicine--PET activation

PET activation, although restricted to a limited number of research centers, is currently the gold standard for mapping functional areas of the brain. This paper outlines how and why activation studies are performed and reviews the major uses of this technique. Special emphasis is on cognitive neuropsychology including the results of a project designed to map the areas of the brain responsible for controlling automatic counting and simple calculation. These fascinating studies are, by definition, a part of nuclear medicine. As such, we argue that knowledge of PET activation is an essential component of professional development and that, given opportunity, commitment and the will to learn, nuclear medicine technologists have the potential for involvement, collaboration or leadership in this area of research.

Can the right hemisphere speak?

While a capacity for the right hemisphere in language and language related functions is established, a role for the right hemisphere in speech production is controversial. The question of the nature of a possible right hemisphere speech production capability has centered mainly on the Jacksonian notion of nonpropositional speech. In this paper I examine whether the right hemisphere does have-a particular role in nonpropositional speech through an exploration of the neurophysiological evidence, research in aphasic speech automatisms, and degree of propositionality in the retained speech of adult left hemispherectomy patients.

Analysing discourse in the traumatic brain injury population: telephone interactions with different communication partners

A range of discourse analyses are effective in identifying features which are aberrant following traumatic brain injury (TBI). We examined the exchanges of five traumatically brain-injured subjects and five matched controls across four speaking situations which included speaking to a therapist, to the bus timetable information service, to the police, and to their mothers on the telephone. Transcripts were analysed using the exchange structure analysis of systemic functional grammar. This analysis provided an indication of information giving (K1 moves per minute); information requesting and receiving (K2 moves per minute) and the amount of negotiation that was needed for the messages to be conveyed (dynamic moves per minute). Results indicated that the TBI subjects performed differently across the four conditions, and were differentiated from the matched controls on a number of measures. The role of different communication partners is also addressed. Communication partners were noted to interact differently with TBI subjects when compared with controls. This included increased information-giving to control subjects; more requests for information by police from TBI subjects and a greater use of dynamic moves by therapists with controls. The potential of exchange structure analysis is discussed as a useful way of examining the discourse of TBI subjects and their communication partners. Exchange structure analysis highlighted the dynamic nature of information exchange and the subtle ways speakers responded to familiarity and power imbalance in social interaction. This study has implications for family and community education regarding communication with people with TBI.

A new perspective on the relationship between communication impairment and disempowerment following head injury in information exchanges

Communication disorders following closed head injury (CHI) have been described in terms of the impairments that affect the individual's ability to produce words, sentences and discourse. Rather than focusing on impairments, this paper examines the disability experienced by one CHI subject. Comparison is made between M. R., who has sustained a severe CHI, and his brother, S. R. during four telephone calls to their mother, a therapist, the police and the bus timetable information service, using exchange structure analysis. Results indicated that social distance between communication partners, and the nature of the interaction, affected the language choices made by both subjects. The communication partner was found to have a profound impact on the way each subject was able to negotiate each interaction. Results are discussed in terms of the ways in which therapists and society in general view disability and how this shapes social encounters, which in turn affects the outcomes which are made possible for people with CHI.

Interactions between recovery in aphasia, emotional and psychosocial factors in subjects with aphasia, their significant others and speech pathologists

Associations between clinical and functional aphasia recovery and perceptions of emotional and psychosocial adjustment accompanying aphasia were examined in five subjects at 3 and 9 months post-onset of stroke using a range of objective and subjective measures. The subjective well-being and optimism of significant others of aphasic patients was also examined, and speech pathologists completed measures of optimism. Unique patterns of individual emotional and psychosocial adjustment were found over time in patients and their significant others, even in patients with similar aphasia type and severity. Individual variability in emotional and psychosocial adjustment and their impact on recovery from aphasia are discussed.

Weightings of items on the Code-Müller Protocols: the effects of clinical experience of aphasia therapy

One hundred and twenty-two professionals engaged in aphasia therapy (graduates and undergraduates) ranked and weighted the relevance of the items of the Code-Müller Protocols (CMP) for assessing perceptions of psychosocial adjustment to aphasia using the multiattribute utility technique (MAUT). The degree of clinical experience with aphasia had a significant influence on participants' weightings of the items 'ability to follow interests and hobbies' and 'receiving speech therapy'.

Quantification of cortical atrophy in a case of progressive fluent aphasia

A patient with a rapidly developing fluent progressive aphasia was tested prospectively up to the time of death and examined neuropathologically. Severe impairment in accessing semantic skills with substantially intact phonological, syntactic and discourse skills was found. Some social behavioural difficulties were also noted. This case presented a unique opportunity to relate this significant language impairment to the pattern of neurodegeneration, a difficult task in most neuropathological studies of severe end-stage dementia. A detailed neuropathological examination revealed focal atrophy with neuronal loss without neuronal inclusions (Pick bodies, Lewy bodies, neurofibrillary tangles or senile plaques) or neuronal changes (shrinkage or swelling). In addition, spongiform degeneration (confined to layer two of the cortex) and gliosis were detected at atrophic sites. To establish the amount of tissue loss and pathology associated with the focal language deficit, volume analyses were performed and compared with two age- and sex-matched, neurologically normal controls. Both the left and right angular gyri and Brodmann's area 37 showed marked volume reduction compared with controls. The predominant language impairment seen in this case is likely to reflect these marked changes in the posterior parieto-temporal areas. The milder unilateral atrophy was concentrated in the right temporal lobe as well as the right hemisphere homologue of Broca's area. Recent work suggests a relationship between such unilateral changes and the social behavioural difficulties which were noted in this case. The hippocampus and other gyri such as the supramarginal gyrus showed no volume loss compared with controls correlating with the relative preservation of other language skills.

Asymmetries in ear movements and eyebrow raising in men and women and right- and left-handers

The abilities to move ears and eyebrows were examined in 442 subjects (204 men, 238 women) categorized as right-handed (n = 382) and left-handed (n = 60, including mixed and ambidextrous-handed subjects). Approximately 22% could move one or the other ear and about 18% could move both ears simultaneously, but significantly more men could move both ears simultaneously. Significantly more men than women were able to move both the left and right eyebrow and the left ear. No differences were observed between right- and left-handers. Significant contingency correlations were observed between raising eyebrows and moving ears. Results are discussed with reference to a possible left ear-right hemisphere advantage for localising environmental sounds, primitive ear-moving abilities no longer functional in modern humans, and epiphenomenal by-products of other adaptive sex differences.

Predicting recovery from aphasia with connectionist networks: preliminary comparisons with multiple regression

We trained a series of simulated neural networks with the raw scores on the Western Aphasia Battery from 91 aphasic patients. Patients were tested at 3 and at 12 months post onset. The most successful network we trained is able to predict AQ for an individual in 12 months from the raw scores at 3 months post-onset to a tolerance of + or -4.5. We then compared the relative success of a small range of trained networks to predict recovery with linear multiple regression. With the small groups of subjects involved in this preliminary study, the networks appeared to be more successful at predicting recovery.

Language in dementia of recent referral

Twenty-four recently referred patients with dementia were assessed on a range of language tests and a mental status test. The tasks which appeared to present the most difficulties for the patients were written spelling, pragmatic processing tasks like sentence disambiguation and proverb interpretation. 'Straight' linguistic processing tasks sensitive to aphasia, like oral reading, serial identification of objects, naming and correction of semantically incorrect sentences, appeared to present fewer problems. It is concluded that certain language tasks may be useful and sensitive detectors of developing dementia, and that in early dementia those aspects of language which depend on straight linguistic processing can be relatively preserved.

On the origins of recurrent utterances in aphasia

The origin of the two linguistically distinct recurrent utterance types--real word recurrent utterances (RWRUs) and non-meaningful recurrent utterances (NMRUs) - is discussed. It is argued that the origins of RWRUs may have more to do with post-onset factors than with activities being pursued at the time of onset, and the origins of NMRUs are probably best explained in phonetic terms. It may be the case that the right hemisphere is involved to different degrees in the production of the two linguistically distinct classes of recurrent utterances.

Neurolinguistic analysis of recurrent utterance in aphasia

A linguistic analysis of 97 recurrent utterances (RUs) is reported which delineates 2 separate types of RU - Real Word Recurrent Utterances (RWRUs) and Non-Meaningful Recurrent Utterances (NMRUs). The range, frequency and distribution of phonemes occurring in RUs is similar to normal English in RWRUs, but not in NMRUs. NMRUs do not break the phonotactic constraints of the language and RWRUs rarely break the syntactic rules. It appears to be possible to classify RWRUs into certain groups among which a Pronoun + Verb and an Expletive group are the most interesting. Expletive RUs were all produced by male subjects and Pronoun + Verb RUs deserve further investigation. Implications for rehabilitation are discussed.