CHInese Medicine NeuroAiD Efficacy on Stroke Recovery - Extension Study (CHIMES-E): A Multicenter Study of Long-Term Efficacy

BACKGROUND

The CHInese Medicine NeuroAiD Efficacy on Stroke recovery (CHIMES) study was an international randomized double-blind placebo-controlled trial of MLC601 (NeuroAiD) in subjects with cerebral infarction of intermediate severity within 72 h. CHIMES-E (Extension) aimed at evaluating the effects of the initial 3-month treatment with MLC601 on long-term outcome for up to 2 years.

METHODS

All subjects randomized in CHIMES were eligible for CHIMES-E. Inclusion criteria for CHIMES were age ≥18, baseline National Institute of Health Stroke Scale of 6-14, and pre-stroke modified Rankin Scale (mRS) ≤1. Initial CHIMES treatment allocation blinding was maintained, although no further study treatment was provided in CHIMES-E. Subjects received standard care and rehabilitation as prescribed by the treating physician. mRS, Barthel Index (BI), and occurrence of medical events were ascertained at months 6, 12, 18, and 24. The primary outcome was mRS at 24 months. Secondary outcomes were mRS and BI at other time points.

RESULTS

CHIMES-E included 880 subjects (mean age 61.8 ± 11.3; 36% women). Adjusted OR for mRS ordinal analysis was 1.08 (95% CI 0.85-1.37, p = 0.543) and mRS dichotomy ≤1 was 1.29 (95% CI 0.96-1.74, p = 0.093) at 24 months. However, the treatment effect was significantly in favor of MLC601 for mRS dichotomy ≤1 at 6 months (OR 1.49, 95% CI 1.11-2.01, p = 0.008), 12 months (OR 1.41, 95% CI 1.05-1.90, p = 0.023), and 18 months (OR 1.36, 95% CI 1.01-1.83, p = 0.045), and for BI dichotomy ≥95 at 6 months (OR 1.55, 95% CI 1.14-2.10, p = 0.005) but not at other time points. Subgroup analyses showed no treatment heterogeneity. Rates of death and occurrence of vascular and other medical events were similar between groups.

CONCLUSIONS

While the benefits of a 3-month treatment with MLC601 did not reach statistical significance for the primary endpoint at 2 years, the odds of functional independence defined as mRS ≤1 was significantly increased at 6 months and persisted up to 18 months after a stroke.

Atresia and sudden sensorineural hearing loss

This case study summarizes findings in an adult male, aged 57, who presented to the Adult Audiology Clinic with aural atresia in the right ear resulting in a conductive hearing loss and a sudden sensorineural hearing loss in the left ear. Treatment options included reconstruction surgery in the right ear, bone anchored hearing aid in the right ear to overcome the conductive hearing loss, bone anchored hearing aid in the left ear for single sided deafness, and intratympanic steroid injections in the left ear to salvage hearing. This case study highlights that when a patient is educated on all available options the patient is then able to make a decision comfortable to him and to help improve his hearing.

[Chondrocalcinosis of the temporomandibular joint revealed by a hearing loss: a case report]

INTRODUCTION

Chondrocalcinosis is a microcrystalline arthropathy that principally affects the knee. It is a rare disorder, usually asymptomatic, that occurs mainly in the elderly people.

PURPOSE

To report a case of a temporomandibular joint chondrocalcinosis with ossicular contact revealed by a conductive hearing loss.

CASE REPORT

We describe the case of a 57-year-old man with a right conductive sudden hearing loss of 15 dB. The CT scan revealed a lytic lesion in the right attic extended to the middle cerebral fossa in contact with the ossicles with a suspicion of lysis of the head of the malleus. MRI showed a lesion enhancing after gadolinium injection on T1 weighted images. A biopsy revealed a chondrocalcinosis of the temporomandibular joint. Due to the complexity of surgical excision and the benin character of the lesion, a medical treatment and a radiologic follow-up every six months were proposed.

CONCLUSION

Chondrocalcinosis of the temporo-mandibular joint is rare especially when it is revealed by a hearing loss. We present here a review of the literature.

Hearing loss in Fabry disease: data from the Fabry Outcome Survey

Hearing loss is a common symptom in Fabry disease, but neither its natural course nor its aetiology has been defined precisely. The aim of this study was to provide a detailed epidemiological description of hearing impairment in patients in the Fabry Outcome Survey (FOS), which is the largest available database of Fabry patients. Questionnaires were completed by 566 Fabry patients, of whom 316 reported ear-related symptoms. Pure-tone audiograms from 86 patients, performed before starting enzyme replacement therapy, were analysed and compared with age- and sex-specific normal values (International Organization for Standardization, ISO 7029). When compared to an age-matched population (ISO 7029), 74% of patients had a threshold elevated above the 95th centile in at least one tested frequency. All frequencies were affected to a similar degree. However, only 14 patients (16%) were clinically affected by hearing impairment according to the age-independent World Health Organization (WHO) classification (mean threshold at 0.5, 1 and 2 kHz worse than 25 dB). Hearing loss was sensorineural in 63 patients (73%) of whom 7 patients (8%) had also a conductive component. One patient had a purely conductive hearing loss. Episodes of sudden hearing loss seemed to occur more frequently than in the general population. Men were affected earlier and more severely than women. Hearing in Fabry disease is significantly worse than in an age-matched general population but leads to clinically relevant hearing impairment in only 16% of cases. It resembles accelerated presbycusis with an additional Fabry-specific strial-type hearing loss.

Hearing loss in Fabry disease: the effect of agalsidase alfa replacement therapy

The aim of this study was to describe the nature and prevalence of hearing loss in Fabry disease (McKusick 301500), a rare X-linked lysosomal storage disorder, and its response to enzyme replacement therapy with agalsidase alfa. Fifteen hemizygous male Fabry patients (aged 25-49 years) were randomized to receive placebo or enzyme replacement therapy for 6 months; all have received open-label enzyme replacement therapy for an additional 24 months thus far. Pure-tone audiometry, impedance audiometry and otoacoustic emission testing were performed at 0 (baseline), 6, 18 and 30 months. Four patients (27%) had bilateral and 7 (47%) had unilateral high-frequency sensorineural hearing loss (SNHL). Two (13%) had unilateral middle ear effusions with conductive losses persisting beyond 6 months. Only 3 (20%) had normal hearing. High-frequency SNHL deteriorated over the first 6 months in both placebo and active treatment groups by a median 4.3 dB ( p =0.002, Wilcoxon matched pairs). This hearing loss subsequently improved above baseline by 2.1 dB at 18 months ( p =0.02) and by 4.9 dB at 30 months ( p =0.004). In conclusion, significant hearing loss, usually high-frequency SNHL, is a common manifestation of Fabry disease in adults. alpha-Galactosidase A replacement therapy with agalsidase alfa appears to reverse the hearing deterioration in these patients. This improvement is gradual, however, suggesting the need for long-term enzyme replacement therapy.

[Sudden deafness in sickle cell anemia: a case report]

The non-expected deafness is quite obvious or easily diagnosed cause. The sickle cell disease is one of the aetiologies of this one. We present one case observed on a 30 years old patient. There is a close connection between the vascular factor of the non-expect deafness and the erythrocytic falciformation of sickle cell anaemia causing the obliteration of the terminal auditory internal artery and generating the ischaemia of the cochlea anoxia. The high sensitivity of the cochlea to anoxia and its great fragility require an early therapy in order to recover auditory capacity. Patients suffering from sickle cell disease should be encouraged to have a regular assessment of audition.

Paediatric hearing loss in rural Pakistan

OBJECTIVE

The present study was designed to generate population-based data on the prevalence and causes of hearing loss in rural Pakistani children. A community screening programme was utilized to identify and evaluate the hearing impaired.

METHODS

The study was performed in conjunction with the Ministry of Population Welfare in Sialkot District, Punjab Province. School-aged children between the ages of 5 and 15 years were screened and examined for hearing impairment according to World Health Organization (WHO) protocols. Case-control analysis of audiometric, physical examination, and risk factors for hearing loss were performed, followed by chi-square analyses.

RESULTS

A total of 607 children comprised the study population, with an overall point prevalence of hearing impairment of 7.9%. Fifty percent of all hearing loss was conductive in nature, amenable to either medical or surgical therapy. The risk factors most associated with conductive hearing loss were otorrhea and multiple ear infections greater than 5. In cases of severe hearing loss, 70% were the result of consanguinous marriages. Almost no cases of hearing loss were attributable to measles, mumps, rubella, and the TORCH infections.

CONCLUSION

This study has generated some badly needed population-based data on the magnitude of the problem of hearing loss in rural Pakistan. It is hoped that the results of this work will stress the importance of hearing health in Pakistan and to encourage other professionals to pursue similar projects.

Auditory brainstem responses of CBA/J mice with neonatal conductive hearing losses and treatment with GM1 ganglioside

Exogenous administration of GM1 ganglioside to CBA/J mice with a neonatal conductive hearing loss ameliorates the atrophy of spiral ganglion neurons, ventral cochlear nucleus neurons, and ventral cochlear nucleus volume. The present investigation demonstrates the extent of a conductive loss caused by atresia and tests the hypothesis that GM1 ganglioside treatment will ameliorate the conductive hearing loss. Auditory brainstem responses were recorded from four groups of seven mice each: two groups received daily subcutaneous injections of saline (one group had normal hearing; the other had a conductive hearing loss); the other two groups received daily subcutaneous injections of GM1 ganglioside (one group had normal hearing; the other had a conductive hearing loss). In mice with a conductive loss, decreases in hearing sensitivity were greatest at high frequencies. The decreases were determined by comparing mean ABR thresholds of the conductive loss mice with those of normal hearing mice. The conductive hearing loss induced in the mice in this study was similar to that seen in humans with congenital aural atresias. GM1 ganglioside treatment had no significant effect on ABR wave I thresholds or latencies in either group.

[Hearing disorders in children less than 16 months of age after bacterial meningitis with reference to cerebrospinal fluid elastase]

Hearing impairment as a sequela of acute bacterial meningitis is a well known complication. Dexamethasone therapy in addition to antibiotics is beneficial in the reduction of deafness, implicating that inflammation may be one reason for hearing impairment. The risk of hearing impairment in different types of bacterial meningitis is well studied. In very young children < 1.5 years of life the incidence of hearing loss and the possible correlation of laboratory data with the development of deafness is yet unknown. We therefore examined the brainstem auditory evoked potentials in 25 children between the first month and the 16th month of life who we treated for meningitis during 3 years in our hospital. 11 children were treated with dexamethasone. In 9 children we found abnormal brainstem auditory evoked potentials, which we controlled every 3 months. 7 children had transient conductive hearing impairment with good recovery during the first year after the disease. In 2 cases we found permanent bilateral sensorineural hearing loss. There was a significant relationship between hearing loss and elastase in cerebrospinal fluid. Dexamethasone reduced this relationship. A screening of hearing should be performed as routine control in all patients with acute meningitis. The association of high elastase in cerebrospinal fluid and later hearing impairment indicates a pathophysiological relation between activation of granulocytes and hearing loss.

Mixed hearing loss in otosclerosis: indication for long-term follow-up

This retrospective study of 146 ears with long-term follow-up after otosclerosis surgery evaluated the stability of hearing results, the incidence of sensorineural hearing loss, and the effect of fluoride treatment. Follow-up was at least 15 years (mean, 25.2 yr; range, 15-44 yr). There were 97 large fenestra stapedectomy operations, 23 lateral canal fenestrations, 7 mobilizations, and 19 revision stapes operations. The level of air-bone gap achieved at surgery remained stable over time; the mean deterioration rate was only 0.2 dB per year. Profound sensorineural hearing loss ( > or = 65 dB bone conduction average) at the most recent follow-up occurred in 13 ears (8.9%). Such hearing loss occurred in all operative groups. Mean bone conduction average immediately postoperatively was significantly higher in these ears than in others in the study. This finding indicates that a mixed hearing loss at surgery is a factor that increases the risk of later profound cochlear loss. Only 3 percent of ears with pure conductive hearing loss, but 28 percent of patients with mixed hearing loss at surgery eventually suffered profound cochlear loss. Sodium fluoride was used to treat 11 ears with progressive cochlear loss. The rate of bone conduction hearing deterioration decreased in all ears after treatment, and none developed profound hearing loss. Follow-up after the first postoperative year is not necessary if pure conductive hearing loss is present at surgery. Annual follow-up with audiograms is recommended if a mixed hearing loss is present. Fluoride treatment is recommended if inner ear hearing loss progresses.

[Allergic reaction in therapy with naftidrofuryl (Dusodril). A case report]

There are many drugs marketed for the purpose of altering vascular blood flow in various regions, especially of the central nervous system and in peripheral arterial insufficiency. More than 50 different methods are described for the treatment of sudden deafness. Considerations of the therapy of sudden deafness are influenced by the fact that the cause of the disease is unknown. The dysfunction of the hair-cells of the organ of CORTI is thought to be caused by a deficit of oxygen due to disorders of micro-circulation in the inner ear. The infusion of vaso-active drugs in the early state of disease can lead to a remarkable improvement of hearing whereas the prospect of improvement without treatment remains uncertain. Nevertheless it may be difficult to distinguish the beneficial effects of vasodilator agents from spontaneous improvement. Naftidrofuryl oxalate (dusodril) has been in use for many years and proved its therapeutic value in many studies. It is regarded as non-toxic and is used extensively in Europe. Side effects are only reported rarely, and include decrease of cerebral blood flow, abdominal distension, diarrhoea, oesophageal ulceration, epileptic seizures, aphasia, disturbances of consciousness, hypotension, hypertensive crisis, vertigo and dizziness, depression of cardiac conduction, thrombophlebitis, and allergy. This case report of allergic reaction in a young female patient demonstrates that the intravenous application of this drug may lead to severe complications.

[Therapeutic trial in acute cochlear deafness. A comparative study of Ginkgo biloba extract and nicergoline]

Ischemia and the metabolic disorder it entails would seem to be the pathogenic mechanism behind acute cochlear deafness, irrespective of the triggering process. The prognosis is entirely dependent on the rapid initiation of an effective treatment. At the end of a double-blind therapeutic trial comparing Ginkgo biloba extract and a standard alpha blocker (nicergoline), a significant recovery was observed in both therapeutic groups, but improvement was distinctly better in the Ginkgo biloba group.

Lack of effects of human calcitonin in osteogenesis imperfecta

The effects of human calcitonin on bone mineral content and certain biochemical markers of bone metabolism were evaluated in a 2-12 month treatment period in seven patients with osteogenesis imperfecta. S-calcium, S-alkaline phosphatase, S-immuno-reactive parathyroid hormone and the urinary excretion of calcium were found to be within the normal range before and during the treatment period. After 4-5 months of therapy, a slight increase in the urinary excretion of hydroxyproline was observed, but the values were still within the normal range. The bone mineral content, measured in the forearm, remained unchanged during the treatment period. Side effects were common, in two cases resulting in discontinuation of the treatment. We concluded that, with the dose of human calcitonin used, it was impossible to detect any beneficial effect in patients with osteogenesis imperfecta.

Hearing loss and treatment in young Down's syndrome children

Twenty-four home-reared Down's syndrome children aged 9-32 months were assessed by trained audiologists on three separate occasions (summer, autumn and spring 1977-1978). Distraction test procedures were used; all failed to pass the screening test and 80-85% registered as having moderate to profound losses. Seventy-five per cent were categorized as having a conductive loss and some improvements were found over the test sessions as a result of surgical and decongestant treatment. Approximately 50% of the infants had been passed on similar screening procedures by the local health services. The results are discussed in relation to language development and service needs.

Hearing impairment and facial palsy as initial signs of Wegener's granulomatosis

In two patients with Wegener's granulomatosis, treatment-resistant serous otitis media was followed by unilateral facial nerve palsy. Later both patients developed uraemia due to extracapillary glomerulonephritis. In one of them, who was treated with prednisone and cyclophosphamide, renal function improved, while in the other patient it remained impaired. Both patients suffered lasting hearing impairment in spite of general improvement during the course of the disease. The facial nerve palsy improved slightly in one, while no improvement was seen in the other. The possibility of Wegener's granulomatosis of other autoimmune collagen diseases should be considered in cases of treatment-resistant serous otitis media. Early diagnosis and treatment can possibly save the patient from the life-threatening consequences of these diseases.

Continuing management of conductive hearing loss during language development

Recently greater attention has been focussed on the possibility that mild fluctuating or intermittent hearing loss, as seen in one of early childhood's most common illnesses, otitis media, may have long-lasting and sometimes devastating effects on language development and learning. Conductive hearing loss in serous otitis media most affects frequencies below 2000 Hz, and the duration of hearing loss after an acute episode of otitis media may last 6-24 months in up to 30% of affected children. The first principle of management of this problem and congenital conductive hearing loss is detection prior to language delay. Special attention should be given to neurologically handicapped, retarded, learning disabled or physically frail children since their deficient speech and language are often attributed to abnormal neurologic or intellectual status. Treatment includes limited use of vasoactive decongestants; for acute suppurative otitis media antibiotics may be chosen empirically with a high percentage of good results. Other measures include speech and language evaluation, home stimulation language programs and temporary or longterm amplification. The surgeon assesses the patient for potential operability. Surgery to correct a congenital conductive lesion should not be attempted in an only hearing ear.

[A pilot study of sulfur hexa fluoride (sf6) injection into middle ears. An alternative to prevent atelectatic ears (author's transl)]

A new method to prevent middle ear atelectasis is presented. Sulfur Hexa Fluoride (SF6), a synthetic inert gas with a very low water solubility, has been injected into the middle ears of two patients with a long-standing conductive hearing loss due to nasopharyngeal carcinoma. The hearing gain expressed as lowered air-bone gaps lasted 6--10 weeks. No side effects were noted. In a later serie children with serous otitis media will be treated in the same way and followed with tympanograms and gas analyses of the gas mixture within their middle ears.