A regional-based newborn hearing screening program: the Emilia-Romagna model after ten years of legislation

Background

Hearing loss, occurring in 1-3/1,000 newborns in the well-babies population, is one of the most common congenital diseases, and hearing screening at birth still represents the only means for its early detection. Since 2011 the Emilia Romagna Regional Health Agency has recommended Newborn Hearing Screening for all babies at its birth points and for newborns moving to the region. The aims of this study are to analyze the results of this regional-based Newborn Hearing Screening program and to discuss the impact of the legislative endorsement on the organization.

Material and methods

This is an observational retrospective chart study. The recordings of well-babies and babies at Neonatal Intensive Care Units were collected during the period from January 1st 2015 to December 31st 2020. The following data were included: Newborn Hearing Screening coverage, percentage of refer at otoacoustic emissions, prevalence and entity of hearing loss, unilateral/bilateral rate, presence of audiological risk factors.

Results

More than 99% of a total of 198,396 newborns underwent the Newborn Hearing Screening test during the period January 1st 2015 to December 31st 2020, with a coverage ranging between 99.6% and 99.9%. Overall, the percentage of confirmed hearing loss cases was about 17-30 % of refer cases, 745 children received a diagnosis of hearing loss (prevalence 3.7/1,000). Considering profound hearing loss cases, these represent 13% of bilateral hearing loss.

Conclusion

A regional-based Newborn Hearing Screening program is valuable and cost-effective. In our experience, the centralization of the data system and of the data control is crucial in order to implement its efficiency and effectiveness. Healthcare policies, tracking systems and public awareness are decisive for a successful programme implementation.

Maternal and perinatal health in undocumented migrants: estimating access and outcomes through HMIS

Background

Vulnerability and inequality are exacerbated in undocumented migrants, the most invisible to health systems.

Objectives

To estimate maternal and perinatal health needs in undocumented migrants and test a methodology for systematic monitoring & evaluation.

Methods

Population-based retrospective cohort study based on routine data through maternity records and temporary registration code in a sub-national Health Management Information System.

Results

420924 deliveries including 1524 undocumented migrants having accessed maternity care through the NHS in Lombardy Region (Italy) from 2016 to 2021 were included. Demographics and social determinants: undocumented migrants were born in Europe (non-EU) (36%), Americas (30%), Africa (6%), Western Pacific (3%), South-East Asia (2%), Italy (2%), were stateless (7%); 52% had no/low schooling, 92% were unemployed and 52% non-married, compared to 15%, 20%, and 44% Italians. Obstetric history and antenatal care: 22% undocumented migrants had a previous abortion and 15% a previous cesarean delivery; 58% had ≥5 antenatal visits, 67% first ANC visit in trimester 1, 64% ≥ 2 ultrasounds incl. first in trimester 1, 6% full laboratory tests, compared to 90%, 97%, 97%, and 66% Italians. Intra-partum and perinatal care: 45% undocumented migrants delivered in a public hospital with neonatal intensive care unit; 69% had a normal delivery, 5% instrumental delivery, 10% and 27% emergency and total cesarean section; 2.6% neonates had emergency resuscitation and 49% were breastfed <2h from birth. Outcomes: 81% physiological pregnancies, 2.3% severe hemorrhage, 4.8% intra-uterine growth retardation, 9.3% pre-term delivery, 17% small for gestational age, 7% low birth weight, 0.6% poor Apgar score, 3% malformations.

Conclusions

Maternal and perinatal health was poor in undocumented migrants, varying by birthplace. Social determinants, health coverage and outcomes showed vulnerability and inequality compared to the general population.

Key messages

• Tailored interventions are needed: outreach health promotion on safe motherhood and neonatal care, healthcare provider training, cultural mediation, translation, and functional language learning.

• A systematic monitoring and evaluation system needs to routinely collect, integrate, and analyze data on key indicators.

The music-related quality of life: Italian validation of MuRQoL into MUSQUAV questionnaire and preliminary data from a cohort of postlingually deafened cochlear implant users

PURPOSE

Cochlear implant (CI) users do not receive much of the auditory information necessary for an accurate perception of music. This usually entails a dissatisfaction with the music they hear, so that their quality of life may potentially be affected. The main aim of this paper was to translate and validate into Italian an instrument to evaluate these aspects-The Music-Related Quality of Life Questionnaire (MuRQoL)-to help the work of clinicians and therapists.

METHODS

The translation of the MuRQoL into "Questionario Musica e Qualità della Vita" (MUSQUAV) was done according to the international guidelines. The translated questionnaire was administered to normal hearing (NH) and CI users adults. Exploratory factor analysis, confirmatory factor analysis and known group method were used to confirm construct validity and applicability of MUSQUAV.

RESULTS

We retrieved 225 results. The MUSQUAV questionnaire was acceptable according to the goodness-of-fit indices. The correlation between the items, evaluated using Cronbach's α coefficient, indicates a good internal consistency (> 0.80). The non-parametric Mann-Whitney test showed significant differences in the distinct populations tested.

CONCLUSIONS

The MUSQUAV questionnaire is a valid, low-cost and rapid instrument for professional workers in the audiological field, especially useful in the assessment of the patients' perception and musical engagement.

Multi-centric assessment of COVID-19 immunization access and demand among undocumented migrants

Background

Marginalization of undocumented migrants raises concerns about equitable access to COVID-19 immunization. This study describes their self-perceived accessibility of and demand for COVID-19 immunization.

Methods

A multi-centric cross-sectional survey was conducted in 4 health facilities providing care to undocumented immigrants in the USA, Switzerland, Italy, and France in February-April 2021. A convenience sample of minimum 100 patients per study site was recruited. Data was collected using an anonymous structured questionnaire including demographic variables, health status, and drivers/barriers for COVID-19 immunization. Descriptive statistics were used to characterize the primary and secondary outcomes: self-perceived accessibility of and demand for COVID-19 immunization.

Results

812 migrants completed the survey (54.3% Geneva, 17.5% Baltimore, 15.5% Milan, and 12.7% Paris). 60.9% were women, the median age was 40 years old (range 17-76), and 19 nationalities were represented: 55.9% Latin America, 12.7% Africa, 11.2% Western Pacific, 7.9% Eastern Mediterranean, 7.6% Europe, 4.7% Asia. Among participants, 14.1% and 26.2% reported prior COVID-19 infection and fear of developing severe COVID-19, respectively. Underlying co-morbidities were common (29.5%). Self-perceived accessibility of COVID-19 immunization was high (86.4%), yet demand was low (41.1%) correlating with age, co-morbidity, and views on immunization which were better for immunization in general (77.3%) than immunization against COVID-19 (56.5%). Hesitancy was mostly due to fear of adverse reactions (39.2%).

Conclusions

In this multi-centric study, undocumented migrants generally believed they would access local COVID-19 immunization programs. Yet, despite positive views about immunization in general, they reported limited confidence in COVID-19 immunization and willingness to be immunized.

Key messages

Self-perceived accessibility of COVID-19 immunization is high, yet demand is limited. COVID-19 immunization campaigns may engage communities and leverage confidence in immunization in general to address concerns about COVID-19 immunization.

Hearing loss in children with congenital cytomegalovirus infection: an 11-year retrospective study based on laboratory database of a tertiary paediatric hospital

Congenital cytomegalovirus infection is considered the main cause of infantile non-genetic neurosensory hearing loss. Although this correlation was described more than 50 years ago, the natural history of internal ear involvement has not yet been fully defined. Hearing loss is the most frequent sequela and is seen in a variable percentage up to 30%; the hearing threshold is characterised by fluctuations or progressive deterioration. The purpose of this study was to evaluate the prevalence of hearing loss in cases of congenital CMV infection from Modena county, starting from the database of the microbiology and virology reference laboratory. All children undergoing urine testing for suspected CMV infection or viral DNA testing on Guthrie Card in the period between January 2004 and December 2014 were enrolled in the study. Family paediatricians were contacted and asked about clinical information on the possible presence at birth or subsequent occurrence of hearing loss, excluding cases where this was not possible. The results showed an annual prevalence of congenital cytomegalovirus infection among suspected cases that was stable over time despite the progressive increase in subjects tested. The prevalence of hearing loss was in line with the literature, whereas in long-term follow-up cases of moderate, medium-to-severe hearing loss with late onset were not detected. The introduction of newborn hearing screening in the county has allowed early diagnosis of hearing loss at birth as non-TEOAE-born births underwent a urine virus test. Moreover, despite all the limitations of the study, we can conclude that European epidemiological studies are needed to better define the relationship between congenital CMV infection and internal ear disease as the impact of environmental and genetic factors is still not entirely clarified.

Aspiration: diagnostic contributions from bedside swallowing evaluation and endoscopy

The aim of this study was to identify which characteristics, collected by bedside swallowing evaluation (BSE) and fiberoptic endoscopic evaluation of swallowing (FEES), are a risk or a protective factor for aspiration. This retrospective study included data on 1577 consecutive patients, collected by BSE and FEES. Bivariate analysis was performed to verify the association of each variable with aspiration (Chi-Square test). The variables associated with aspiration were entered into a multivariate logistic model to quantify this association. Several variables were significantly associated (p < 0.05) with aspiration; cooperation, sensation, laryngeal elevation and direct therapy were found to be protective factors against aspiration. The regression model identified the most variables related with aspiration, among which tracheotomy, material pooling and spillage. Patients able to perform dry swallows were 77% less likely to aspirate (protective factor). Several variables are involved in protection of airways during swallowing. Their interaction, in patients with swallowing disorders, offers the clinician the best means of interpreting BSE and FEES.

A mild phenotype of sensorineural hearing loss and palmoplantar keratoderma caused by a novel GJB2 dominant mutation

Dominant GJB2 mutations are known to cause a syndromic form of sensorineural hearing loss associated with palmo-plantar skin manifestations. We present the genotype/phenotype correlations of a new GJB2 mutation identified in three generations of an Italian family (proband, mother and grandfather) whose members are affected by sensorineural hearing impairment associated with adult-onset palmoplantar keratoderma. In all affected members we identified a new heterozygous GJB2 mutation (c.66G > T, p.Lys22Asn) whose segregation, population frequency and in silico prediction analysis have suggested a pathogenic role. The p.Lys22Asn GJB2 mutation causes a dominant form of hearing loss associated with variable expression of palmoplantar keratoderma, representing a model of full penetrance, with an age-dependent effect on the phenotype.

Choosing the correct treatment for acute aortic type B dissection

Acute type B aortic dissection is a life threatening disease process, which remains a clinical dilemma despite advances in technology, surgical technique and postoperative management. The variability of presenting symptoms, lack of a consensus on indications for treatment and differing opinions about the optimal timing for repair have added to the management confusion. Medical management has been the standard of care for acute uncomplicated type B dissection. Surgical repair and endovascular intervention are reserved for those who present with, or subsequently develop, dissection-related complications. Complicated dissections occur in 25% of cases and may include organ malperfusion, aortic rupture, periaortic hematoma, and uncontrolled hypertension. In the past decade thoracic endovascular aortic repair (TEVAR) has gained widespread acceptance as the modality of choice for the treatment of complicated type B dissection. This transition is representative of advances in technology, physician experience with aortic endografts and lower morbidity and mortality rates associated with TEVAR. The best medical therapy remains the standard of care for uncomplicated dissection, however this strategy fails to prevent long-term aortic-related morbidity and mortality. Recent data suggest that early TEVAR lowers aortic-related events and improves long-term aortic specific survival by covering the entry tear, promoting false lumen thrombosis and inducing aortic wall remodeling. The paucity of supporting data has created controversy surrounding the optimal treatment strategy for acute type B dissection. Nonetheless, recent healthcare trends show a paradigm shift towards the utilization of early TEVAR in acute type B dissection.

Femoroacetabular impingement: role of imaging

The femoroacetabular impingement (FAI) is an impingement characterized by repetitive abutment between the femur and the acetabular rim during hip motion due to loss of joint clearance (Imam and Khanduja in Int Orthop 35(10):1427-1435, 2011; James et al. in AJR Am J Roentgenol 187(6):1412-1419, 2006). Femoroacetabular impingement (FAI) can be classified as either cam or pincer type, and it can be differentiated on the basis of a predominance of either a femoral or an acetabular abnormality (Pfirrmann et al. in Radiology 244(2):626, 2007; Ganz et al. in Clin Orthop Relat Res 466(2):264-272, 2008). In cases of cam FAI, the nonspherical shape of the femoral head at the femoral head-neck junction and reduced depth of the femoral waist lead to abutment of the femoral head-neck junction against the acetabular rim. In cases of pincer FAI, acetabular overcoverage limits the range of motion and leads to a conflict between the acetabulum and the femur. The most important role of preoperative MR evaluation in patients affected by FAI is the accurate assessment of the damage's extension.

Intestinal Ischemia: US-CT findings correlations

Background

Intestinal ischemia is an abdominal emergency that accounts for approximately 2% of gastrointestinal illnesses. It represents a complex of diseases caused by impaired blood perfusion to the small and/or large bowel including acute arterial mesenteric ischemia (AAMI), acute venous mesenteric ischemia (AVMI), non occlusive mesenteric ischemia (NOMI), ischemia/reperfusion injury (I/R), ischemic colitis (IC). In this study different study methods (US, CT) will be correlated in the detection of mesenteric ischemia imaging findings due to various etiologies.

Methods

Basing on experience of our institutions, over 200 cases of mesenteric ischemia/infarction investigated with both US and CT were evaluated considering, in particular, the following findings: presence/absence of arterial/venous obstruction, bowel wall thickness and enhancement, presence/absence of spastic reflex ileus, hypotonic reflex ileus or paralitic ileus, mural and/or portal/mesenteric pneumatosis, abdominal free fluid, parenchymal ischemia/infarction (liver, kidney, spleen).

Results

To make an early diagnosis useful to ensure a correct therapeutic approach, it is very important to differentiate between occlusive (arterial,venous) and nonocclusive causes (NOMI). The typical findings of each forms of mesenteric ischemia are explained in the text.

Conclusion

At present, the reference diagnostic modality for intestinal ischaemia is contrast-enhanced CT. However, there are some disadvantages associated with these techniques, such as radiation exposure, potential nephrotoxicity and the risk of an allergic reaction to the contrast agents. Thus, not all patients with suspected bowel ischaemia can be subjected to these examinations. Despite its limitations, US could constitutes a good imaging method as first examination in acute settings of suspected mesenteric ischemia.

Gastrointestinal perforation: ultrasonographic diagnosis

Gastrointestinal tract perforations can occur for various causes such as peptic ulcer, inflammatory disease, blunt or penetrating trauma, iatrogenic factors, foreign body or a neoplasm that require an early recognition and, often, a surgical treatment.Ultrasonography could be useful as an initial diagnostic test to determine, in various cases the presence and, sometimes, the cause of the pneumoperitoneum.The main sonographic sign of perforation is free intraperitoneal air, resulting in an increased echogenicity of a peritoneal stripe associated with multiple reflection artifacts and characteristic comet-tail appearance.It is best detected using linear probes in the right upper quadrant between the anterior abdominal wall, in the prehepatic space.Direct sign of perforation may be detectable, particularly if they are associated with other sonographic abnormalities, called indirect signs, like thickened bowel loop and air bubbles in ascitic fluid or in a localized fluid collection, bowel or gallbladder thickened wall associated with decreased bowel motility or ileus.Neverthless, this exam has its own pitfalls. It is strongly operator-dependant; some machines have low-quality images that may not able to detect intraperitoneal free air; furthermore, some patients may be less cooperative to allow for scanning of different regions; sonography is also difficult in obese patients and with those having subcutaneous emphysema. Although CT has more accuracy in the detection of the site of perforation, ultrasound may be particularly useful also in patient groups where radiation burden should be limited notably children and pregnant women.

No thyroid abnormalities in patients submitted to cardiac catheterization in the first eighteen months of life

BACKGROUND

No data are available about the risk of thyroid disturbance after exposure to low-dose radiation due to the use of cardiac catheterization in the first years of life.

AIM

To determine the risk of functional and morphological thyroid abnormalities in a homogeneous cohort of patients who underwent diagnostic low-dose radiation for heart catheterization during the first 18 months of life.

SUBJECTS AND METHODS

Fifty-five patients, submitted to cardiac catheterization during the first 18 months of life, underwent evaluation of the thyroid function and structure after a median period of 13 yr since the first radiation exposure. Sixty-eight unexposed controls matched for age and sex, underwent the same protocol. Twenty-two patients were then re-evaluated after a median period of 22 yr.

RESULTS

Thyroid function resulted normal in both patients and controls. The prevalence of small thyroid nodules and inhomogeneous structures in ultrasound study was not augmented in irradiated patients compared to controls. No thyroid tumors or reduced thyroid volume were observed.

CONCLUSIONS

Neither functional nor morphological disorders of the thyroid gland were demonstrated after a period up to 24 yr in patients exposed to diagnostic ionizing radiation for cardiac catheterization during the first 18 months of life.

Effect of a fixed combination of nimodipine and betahistine versus betahistine as monotherapy in the long-term treatment of Ménière's disease: a 10-year experience

Despite an abundance of long-term pharmacological treatments for recurrent vertigo attacks due to Ménière's disease, there is no general agreement on the their efficacy. We present the results of a retrospective study based on a 10-year experience with two long-term medical protocols prescribed to patients affected by Ménière's disease (diagnosed according to the American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium guidelines) who completed treatments in the period 1999-2009. A total of 113 medical records were analysed; 53 patients received betahistine-dihydrochloride at on-label dosage (32 mg die) for six months, and 60 patients were treated with the same regimen and nimodipine (40 mg die) as an add-therapy during the same period. Nimodipine, a 1,4-dihydropyridine that selectively blocks L-type voltage-sensitive calcium channels, has previously been tested as a monotherapy for recurrent vertigo of labyrinthine origin in a multinational, double-blind study with positive results. A moderate reduction of the impact of vertigo on quality of life (as assessed by the Dizziness Handicap Inventory) was obtained in patients after therapy with betahistine (p < 0.05), but a more significant effect was achieved in patients treated by combined therapy (p < 0.005). In the latter group, better control of vertigo was seen with a greater reduction of frequency of attacks (p < 0.005). Both protocols resulted in a significant improvement of static postural control, although a larger effect on body sway area in all tests was obtained by the fixed combination of drugs. In contrast, no beneficial effect on either tinnitus annoyance (as assessed by the Tinnitus Handicap Inventory) and hearing loss (pure-tone average at 0.5, 1, 2, 3 kHz frequencies of the affected ear) was recorded in patients treated with betahistine as monotherapy (p > 0.05), whereas the fixed combination of betahistine and nimodipine was associated with a significant reduction of tinnitus annoyance and improvement of hearing loss (p < 0.005). It was concluded that nimodipine represents not only a valid add-therapy for Ménière's disease, and that it may also exert a specific effect on inner ear disorders. Further studies to investigate this possibility are needed.

[Etiological, clinical and neuroradiological investigation of deaf children with additional neuropsychiatric disabilities]

AIM

Sensorineural hearing loss (SNHL) is complicated by additional disabilities in about 30% of cases, but the epidemiology of associated disorders, in terms of type, frequency and aetiology is still not clearly defined. Additional disabilities in a deaf child have important consequences in assessing and choosing a therapeutic treatment, in particular when considering cochlear implantation (CI) or hearing aids (HA). The aim of this paper was to evaluate frequency, type and severity of additional neurodevelopmental disabilities in children with profound bilateral sensorineural hearing loss and to investigate the relationship between disability and the etiology of deafness.

METHODS

Eighty children with profound bilateral sensorineural hearing loss (mean age 5.4 years) were investigated by means of a diagnostic protocol including clinical, neurodevelopmental, and audiological procedures together with genetic and neurometabolic tests and neuroradiological investigation by brain MRI.

RESULTS

Fifty-five percent of the sample exhibited one or more disabilities in addition to deafness, with cognitive, behavioural-emotional and motor disorders being the most frequent. The risk of additional disabilities varied according to aetiology, with a higher incidence in hereditary syndromic deafness, in cases due to pre-perinatal pathology (in comparison to unknown and hereditary non syndromic forms) and in the presence of major brain abnormalities at MRI.

CONCLUSION

Our results suggest that the aetiology of deafness may be a significant risk indicator for the presence of neuropsychiatric disorders. A multidimensional evaluation, including aetiological, neurodevelopmental and MRI investigation is needed for formulating prognosis and for planning therapeutic intervention, especially in those children candidated to cochlear implant.

Stimulation of the cholinergic neurotransmissions enhances the efficacy of vestibular rehabilitation

The primary aim of this study was to investigate the efficacy of vestibular rehabilitation in a cohort of elderly labyrinthine-defective patients also affected by a moderate cognitive impairment of vascular origin. A secondary aim was to establish whether additional treatment with a cholinergic precursor (choline alphascerate) might enhance the results of the physical therapy in these patients. A retrospective clinical design was employed and data were collected from the vestibular rehabilitation treatment charts of 42 selected elderly patients who attended the tertiary referral centre of the Audiology and Vestibology of the University Hospital of Modena, Italy, in the period 1998-2008. Two groups of patients, well-matched for sex, age, and as close as possible for the vestibular examination upon admittance, were selected; Group A included 20 patients who had undergone vestibular rehabilitation training for one month and Group B included 22 patients who had attended the same physical therapy sessions as the former and had also received daily medication with 1200 mg of choline alphascerate per os. The outcome measures of the two forms of treatments were obtained from comparisons between posturographic and electronystagmographic examinations at baseline and 3 weeks after the end of treatment. Instrumental findings were completed by recording scores of the Dynamic Gait Index, the Dizziness Handicap Inventory and the Hospital Anxiety and Depression Scale before and after treatment. A statistically significant improvement in postural control (p < 0.05) and gait and balance performances (p < 0.005) was recorded in both groups; a relevant and statistically significant reduction of the asymmetry of the vestibular-ocular reflexes was also observed (p < 0.005). The self-rated dizziness handicap and psychological distress were significantly reduced (p < 0.005). Comparisons between the two groups revealed that patients who had also received medication, had achieved significantly better results than the other patients with respect to postural control in response to optokinetic stimulations (p < 0.05) and to Dynamic Gait Index (p < 0.05), thus suggesting, a reinforcement of cholinergic stimulation on vestibular compensation when tested in clinical conditions that require complex perceptual-motor skills and make a significant demand upon cognitive spatial processing resources. Further applications of stimulation of the cholinergic neurotransmission are discussed with particular regard to vestibular compensation in patients with no cognitive impairment or recurrent vertigo attacks of labyrinthine origin.

[Renal liposarcoma clinical and pathological aspects. Case report and literature review]

Sarcomas of the retroperitoneum represent 0.2% of tumors and 15% of soft tissue sarcomas. Retro-peritoneal differentiated liposarcoma must be distinguished from the connective neoplasm of kidney. The main features of these tumors are: the rapid growth, infiltration of surrounding tissue, the tendency to local relapse and very fast metastasis (60-80%). Authors report a clinical case of a patient 61 old years with occasional reflected ultrasound is performed for lumbar pain a retro peritoneal mass. CT described a retro peritoneal mass that raised medially and displaced the left kidney. The patient was subjected to removal of the mass now to his kidney capsule, which was nevertheless preserved.The histological examination showed a picture of well-differentiated liposarcoma with areas of high-grade sarcoma with malignant morphology fibrohistiocytoma-like aspects and fibromyxomatosis. The well-differentiated liposarcoma has biological behavior similar to other sarcomas with high degree of adults with high local recurrence and distant metastases in 15-20% with overall mortality at 5 years about 30%. The most significant prognostic factor is the location of the cancer and the extent and degree of differentiation did not impact on the clinical prognosis is conditioned by the difficulty of obtaining a radical surgery in spite linfoadenectomia a retro peritoneal accurate.

Validity of the Italian adaptation of the Tinnitus Handicap Inventory; focus on quality of life and psychological distress in tinnitus-sufferers

The aim of this study was to determine the validity of the Italian translation of the Tinnitus Handicap Inventory (THI) by Newman et al. in order to make this self-report measure of perceived tinnitus handicap available both for clinical and research purposes in our country and to contribute to its cross-cultural validation as a self-report measure of perceived severity of tinnitus. The Italian translation of the Tinnitus Handicap Inventory (THI) was administered to 100 outpatients suffering from chronic tinnitus, aged between 20 and 82 years, who attended the audiological tertiary centres of the University Hospital of Modena and the Regional Hospital of Treviso. No segregation of cases was made on audiometric results; patients suffering from vertigo and neurological diseases were excluded. Pyschoacoustic characteristics of tinnitus (loudness and pitch) were determined and all patients also completed the MOS 36-Item Short Form Health Survey to assess self-perceived quality of life and the Hospital Anxiety and Depression Scale as a measure of self-perceived levels of anxiety and depression. The THI-I showed a robust internal consistency reliability (Cronbach's alpha = 0.91) that was only slightly lower than the original version (Tinnitus Handicap Inventory-US; Cronbach's alpha = 0.93) and its Danish (Cronbach's alpha = 0.93) and Portuguese (Cronbach's alpha = 0.94) translations. Also its two subscales (Functional and Emotional) showed a good internal consistency reliability (Cronbach's alpha = 0.85 and 0.86, respectively). On the other hand, the Catastrophic subscale showed an unacceptable internal consistency reliability as it is too short in length (5 items). A confirmatory factor analysis failed to demonstrate that the 3 subscales of the THI-I correspond to 3 different factors. Close correlations were found between the total score of the Italian translation of the Tinnitus Handicap Inventory and all the subscales of the MOS 36-Item Short Form Health Survey (SF-36) and the Hospital Anxiety and Depression Scale scores indicating a good construct validity. Moreover, these statistically significant correlations (p < 0.005) confirmed that the self-report tinnitus handicap is largely related to psychological distress and a deterioration in the quality of life. On the other hand, it was confirmed that the tinnitus perceived handicap is totally independent (p > 0.05) from its audiometrically-derived measures of loudness and pitch thus supporting previous studies that focused on the importance of non-auditory factors, namely somatic attention, psychological distress and coping strategies, in the generation of tinnitus annoyance. Finally the results of the present study suggest that the THI-I maintains its original validity and should be incorporated, together with other adequate psychometric questionnaires, in the audiological examination of patients suffering from tinnitus and that psychiatric counselling should be recommended for the suspected co-morbidity between tinnitus annoyance and psychological distress.

Psychological profile and social behaviour of working adults with mild or moderate hearing loss

In this study, an assessment was made of the global assumption that working adults with a mild to moderate sensorineural hearing loss experience more negative emotional reactions and socio-situational limitations than subjects with no hearing problems and that a deterioration of health-related quality of life on these specific domains would occur. Comparisons between 73 hearing-impaired subjects and 96 controls, well-matched for socio-demographic variables, were performed using the HHIA, MOS 36-Item Short Form Health Survey (SF-36) and SFQ questionnaires scores and revealed that the former experience a higher level of perceived hearing handicap and a deterioration of health-related quality of life while investigating emotional and socio-situational domains than the latter (p < 0.005). While investigating the psychological distress dimension of the hearing-impaired subjects by means of the Symptom Check List (SCL-90-R), it emerged that they are more prone to depression, anxiety, interpersonal sensitivity, and hostility than subjects with no hearing problems (p < 0.05). It is argued that the sensory impairment, with its associated disability, may discourage hearing-impaired individuals from exposing themselves to socially challenging situations, producing isolation that leads to depression, irritability, feelings of inferiority. The same psychological symptoms, on the other hand, can compound and worsen the picture by influencing social behaviour of the affected persons. Further prospective studies are needed to address this issue. Nevertheless, it is concluded that Audiology Services, despite the time and costs involved, should improve their diagnostic ability by exploring more areas of hearing-impaired subjects concerns in order not to overlook their potentially reduced psychosocial well-being.

Measuring the psychosocial consequences of hearing loss in a working adult population: focus on validity and reliability of the Italian translation of the hearing handicap inventory

Despite increasing demand for questionnaires for assessing hearing handicap and the effectiveness of some tools across different languages, empirical studies to evaluate the reliability and the validity of translations of original English questionnaires into an Italian version have not been reported in the literature, thus making comparisons of Italian experimental and clinical data across cultures and countries impossible. This study tested the global assumption that the Hearing Handicap Inventory for Adults (HHIA), that is one of the most widely used instruments in English-speaking countries, can be adapted to the Italian language maintaining the reliability and clinical validity of the original version. The English version of this 25-item, self-assessment questionnaire was developed by Newman et al. in 1990 and special emphasis was placed on emotional reaction and social limitations perceived by hearing-impaired subjects and scored separately. This tool was translated into the Italian language by a forward and backward technique, as established by the IQOLA (International Quality of Life Assessment) project. Overall, 94 subjects, aged 18-65 years, with acquired hearing impairment and 104 individuals with no hearing problems, well-matched for socio-demographic variables, were enrolled in the study in a case-control design. Reliability of the Italian version of HHIA was tested by measuring internal consistency and test-retest reproducibility. Validity was assessed by using construct, convergent and discriminant methods. A Cronbach's alpha coefficient near 0.90 confirmed a more than acceptable internal consistency and a highly statistically significant Spearman's correlation coefficient (< 0.005) between scores of the two administrations at an interval of one month documented an excellent stability of the questionnaire over time. Construct validity was demonstrated by a correlation between the severity of hearing loss and the score of questionnaire (< 0.005) and convergent validity was supported by a significant correlation between the scores of the emotional and socio/situational subscales of the HHIA to the analogous subscales of a health-related quality of life questionnaire (MOS 36-Item Short Form Health Survey) (< 0.005). Finally, since hearing-impaired subjects scored significantly higher than controls on HHIA (< 0.005), it clearly emerged that also the Italian version of HHIA differentiates the two populations (those with and those without hearing problems) demonstrating a robust discriminant validity. Given the lack of appropriate measures to assess hearing handicap in Italy, the results achieved in this study, confirm that the HHIA, Italian version, is suitable for both experimental and clinical use.

MRI and 1H-MRS findings in early-onset cobalamin C/D defect

OBJECT

Cobalamin C/D defect is an inborn error of cobalamin metabolism causing methylmalonic aciduria and homocystinuria. The early-onset form is characterized by severe neurological impairment. The aim of this study was to evaluate and monitor brain damage in early-onset cbl-C/D defect by conventional MRI and to assess the additional value of 1H-MRS.

METHODS

We retrospectively examined serial MRI studies of 7 patients, performed on a 1.5 T system. Four patients had the first evaluation within the first 4 months of life and three later. The imaging protocol included spin-echo T1-weighted, T2-weighted, IR, and FLAIR. Five patients underwent 1H-MRS, using chemical shift imaging (CSI) in three patients and single voxel spectroscopy (SVS) in two.

RESULTS

Three of the patients studied early showed tetraventricular hydrocephalus and diffuse swelling of supratentorial white matter with involvement of the "U" fibres. Two showed patchy cavitating lesions in the basal ganglia. White matter changes became evident at a later stage. In three cases 1H-MRS showed an abnormal peak of lactate in the basal ganglia or in the periventricular white matter.

CONCLUSIONS

Our study shows severe heterogeneous brain MR abnormalities in cbl-C/D defect. We observed unusual basal ganglia lesions in 30 % of our cases and also found a high incidence of hydrocephalus and supratentorial white matter abnormalities.

Repeated visually-guided saccades improves postural control in patients with vestibular disorders

One of the most recent and promising theoretical hypotheses for compensation of persistent asymmetry of dynamic vestibulo-ocular gain is sensory substitution. As a switch between oculomotor and vestibulo-ocular systems, saccadic eye movements are engaged in humans to compensate the angular displacement of the head towards the labyrinthine defective side thus preserving the foveal fixation of the target. This study focused on the possibility that saccadic eye movements might also compensate for the impaired vestibulo-spinal reflexes and force the postural system to a more effective control on upright stance and verified whether this sway-stabilizing effect could be applied to patients with vestibular disorders and balance dysfunction. In the first experiment, 27 patients with unilateral labyrinthine hypofunction, 24 patients with central vestibular disorders and 24 healthy volunteers were evaluated by static posturography in 3 different visual conditions: (a) eye open with fixation of a steady target, (b) eye closed, and (c) while performing horizontal visually-guided saccades. The percentage of individuals with a decreased body sway area during the oculomotor task was found to be higher in labyrinthine-defective patients as compared to those with central vestibular disorders and controls. In the second experiment, 46 patients with vestibular disorders both of central and peripheral origin, whose postural control improved by eye-tracking, as assessed by posturography, were later submitted to 12 consecutive training sessions based on repeated visually-guided saccades. Both the saccadic performances and postural control improved in all patients but a more pronounced effect was observed in those with peripheral vestibular disorders. Outcome of this rehabilitation technique was also corroborated by a general reduction of the perceived overall impairment from balance disorders as tested by a specific questionnaire.

Bilateral Gasser's ganglion sarcoidosis: diagnosis, treatment and unsolved questions

Magnetic resonance imaging is currently the best means for confirming clinical suspicion of neurosarcoidosis as well as being useful in the follow-up of corticosteroid-treated patients. We report the case of a 34 year old male presenting suspected Heerfordt's syndrome with concentric facial hypesthesia. Mediastinal and parotid sarcoidosis was diagnosed and magnetic resonance imaging showed bilateral sarcoid involvement of Gasser's ganglion cisternae (such involvement was not revealed by computed tomography). The patient received corticosteroid therapy, with a clinical and radiological improvement. Magnetic resonance imaging showed disappearance of Gasser's ganglion lesions despite the persistence of mild facial hypesthesia. This case is noteworthy for its extremely rare lesion site. Post-treatment discrepancy between the clinical picture and imaging results is probably due to low MRI resolution threshold. 18-FDG positron emission tomography imaging might perhaps overcome the limits of magnetic resonance imaging.

Magnetic resonance imaging of the hypothalamus-pituitary unit in childrensuspected of hypopituitarism: who, how and when toinvestigate

The magnetic resonance (MR) identification of pituitary hyperintensity in the posterior part of the sella has been the most striking recent finding contributing to the diagnosis of "idiopathic" and permanent GH deficiency (GHD). Moreover, advancements in DNA technology have shed new light on the study of the genetic causes of hypopituitarism. Abnormalities in two genes, the GH-N encoding the GH and the GHRH receptor (GHRH-R), have been identified, while mutations in five other gene-encoding transcription factors such as Pit-1, Prop-1, Hesx-1, Lhx-3 and Lhx-4 involved in anterior pituitary development, have also been described. MR imaging shows marked differences in pituitary morphology indicating different GHD etiologies and different prognoses. Ectopic posterior pituitary is a specific marker of permanent GHD. These patients do not have Pit-1, Prop-1, or Lhx-3 mutations and should be carefully monitored for evolving pituitary hormone defects, though they do not require GH re-evaluation in adulthood; selected cases may have Hesx-1 or Lhx-4 mutations. MR evidence of normal or small anterior pituitary gland, enlarged empty sella, pituitary hyperplasia and/or intrasellar or suprasellar mass when associated with combined pituitary hormone deficiency call for molecular analysis of Pit-1, Prop-1, Hesx-1, or Lhx-3. Limitation of neck rotation and Chiari-I malformation may suggest Lhx-3 or Lhx-4 mutations (exceedingly rare). In "idiopathic" isolated GHD, evidence of normal anterior or small anterior pituitary size with normal location of posterior pituitary and normal connection between the hypothalamus and pituitary gland is suggestive of "transitory" or false positive GHD; patients with such characteristics should be re-evaluated well before reaching adult height. In selected cases, anterior pituitary height that is 2 SD below age-adjusted normal pituitary height could be suggestive of GHRH-R gene defect; it is worth pointing out that normal pituitary MR together with severe GHD has been observed, though rarely, in subjects with a genetic origin of GHD.

Development of communication and speech skills after cochlear implant in a sign language child

In selecting patients to undergo cochlear implant, a pre-existing use of sign language gives rise to two problems that have been widely debated in the literature. First, the caution shown toward the candidacy of patients using this mode of communication, since it is considered a possible element of interference in the acquisition of speech. Secondly, refusal of the cochlear implant procedure, on the part of the deaf community, on the grounds both of cultural identity and of it being more "natural" for a deaf person to use an unimpaired visual channel rather than an impaired hearing channel. In order to establish whether knowledge of sign language does, indeed, affect speech production negatively and evaluate which mode of communication, oral or gestual, is preferred, the present investigation was carried out on a preverbal deaf child who had undergone cochlear implant at about 7 years of age and has always used both languages. His verbal skills were evaluated in the precochlear implant stage, then at 6 and 12 months after, together with the changes in his use of sign language and in the relationship between the two modes. Results, besides observing the presence of linguistic evolution at each level examined and already evident at 6 months, also documented a progressive reduction in the spontaneous use of sign language. In conclusion, the present experience revealed no temporal or qualitative differences in post-cochlear implant evolution of speech skills, in comparison with that observed in patients with an exclusively aural-oral approach. Furthermore, the increased use of the hearing pathway, made possible by cochlear implant, determined a spontaneous choice of verbal language as the most natural and economic mode of communication.

Pheromones, sexual attractiveness and quality of life in menopausal women

Pheromones, and their effects, are reviewed with a special emphasis on their potential contribution to sexual attractiveness in the menopause. Key topics included are biological functions of pheromones in animals and humans, the source of pheromones in humans, the axillary extract studies that led to the independent synthesis of pheromones, olfactory mechanisms for mediating pheromones, and aging, attractiveness and sexual dysfunction. Physical attractiveness is important for a better quality of life. Three separate, double-blind, placebo-controlled investigations, using the same protocol, all demonstrated that a synthesized pheromone, topically applied, increased sexual attractiveness. If partners are available, sexual attractiveness can increase affectionate intimate behavior, which, in turn, increases well-being and quality of life. More research is needed to address ways in which postmenopausal women can benefit from pheromones.

[Multidisciplinary approach to the patient with oropharyngeal dysphagia]

The Dysphagia Study Group of the Regional Hospital of Treviso uses a multidisciplinary approach to assess patients with oro-pharyngeal dysphagia. From 1996 to 2000, 208 patients with functional dysphagia were studied by the Group. Dysphagia was due to neurological disease in more than 50% of patients, to surgery in 25% and to a functional disease in 17%. In patients less than 20 years old the aetiology was due to the aftermath of traumas; in patients aged from 20 to 45 years the cause was a functional disease or achalasia, while in the majority of the older patients, aged over 45, had cerebral ischaemic lesions. The majority of patients (78%) were submitted to rehabilitation, 9.5% to medical treatment and 2.8% to surgery. Oro-pharyngeal dysphagia calls for a multidisciplinary approach in qualified centers with specialized facilities.