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Employing a participatory arts-based research approach, we examined an innovative program from rural Ontario, Canada, designed to address social isolation among older people. Older socially isolated adults were matched to trained volunteers, where in dyads, the eight pairs created expressive art in their home setting over the course of 10 home visits. With thematic and narrative inquiry, we analysed the experiences and perceptions of the program leader, older participants, and older volunteers via their artistic creations, weekly logs, evaluations, and field notes. The findings reveal a successful intervention that positively influenced the well-being of older adult participants and older volunteers, especially in regards to relationships, personal development, and creating meaning as well as extending the intervention's impact beyond the program's duration. We also discuss opportunities for similar programs to inform policy and enable positive community-based health and social service responses to rural social isolation.

Guided intubation using a tracheal tube and semi-rigid introducer is associated with technical difficulties, failure and traumatic complications. We describe the development of a new system of guidewire-assisted tracheal intubation that may circumvent these problems. A reinforced silicone tracheal tube was modified with a guide channel built inside its wall, and a nitinol non-kinking guidewire was matched to this channel. Both anterograde and retrograde tracheal intubation were evaluated in a test rig, an airway manikin and then in preserved and fresh cadavers. There was minimal resistance to passage of the guidewire through the guide channel when the modified tube was in an anatomical configuration, in contrast to moderate resistance when an Airway Exchange Catheter was passed through a PVC tracheal tube. Intubation using the new equipment required increased force in the manikin and preserved cadavers, but minimal force in fresh cadavers. Resistance to tracheal tube advancement in preserved cadavers was overcome by withdrawal followed by 90° rotation, but this manoeuvre was not required in fresh cadavers. We suggest that the combination of the modified tracheal tube and matching guidewire may allow easy and reliable single-step guided tracheal intubation when used in patients., (© 2015 The Association of Anaesthetists of Great Britain and Ireland.)

This paper contributes to the literature on Indigenous health, human dimensions of climate change, and place-based dimensions of health by examining the role of environment for Inuit health in the context of a changing climate. We investigated the relationship between one key element of the environment - sea ice - and diverse aspects of health in an Inuit community in northern Canada, drawing on population health and health geography approaches. We used a case study design and participatory and collaborative approach with the community of Nain in northern Labrador, Canada. Focus groups (n = 2), interviews (n = 22), and participant observation were conducted in 2010-11. We found that an appreciation of place was critical for understanding the full range of health influences of sea ice use for Inuit. Negative physical health impacts were reported on less frequently than positive health benefits of sea ice use, which were predominantly related to mental/emotional, spiritual, social, and cultural health. We found that sea ice means freedom for sea ice users, which we suggest influences individual and collective health through relationships between sea ice use, culture, knowledge, and autonomy. While sea ice users reported increases in negative physical health impacts such as injuries and stress related to changing environmental conditions, we suggest that less tangible climate change impacts related to losses of health benefits and disruptions to place meanings and place attachment may be even more significant. Our findings indicate that climate change is resulting in and compounding existing environmental dispossession for Inuit. They also demonstrate the necessity of considering place meanings, culture, and socio-historical context to assess the complexity of climate change impacts on Indigenous environmental health., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Resource-dependent communities in hinterland regions of Australia, Canada and elsewhere are rapidly aging, yet many features that distinguish them (e.g., geographic remoteness, small populations, infrastructure built with younger persons in mind) also pose significant challenges for healthy aging. These challenges can lead to substantial gaps in access to formal health and social services, with negative implications for older residents aging-in-place and the development aspirations of resource frontier communities. In this paper, we explore the efforts of voluntary sector leaders to transform resource communities into more livable and supportive places for older adults. We offer a case study of two small towns in Canada׳s aging resource frontier; one forestry-dependent and the other dependent on coal mining. Our findings suggest that place integration develops through volunteer work and explains how voluntarism works as both a process and outcome of 'placemaking'. We argue that greater attention to place integration is needed to bring into focus the transformative potential of the voluntary sector in creating supportive and sustainable environments for healthy aging., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Unintentional injury and trauma rates are disproportionately high in Inuit regions, and environmental changes are predicted to exacerbate injury rates. However, there is a major gap in our understanding of the risk factors contributing to land-based injury and trauma in the Arctic. We investigated the role of environmental and other factors in search and rescue (SAR) incidents in a remote Inuit community in northern Canada using a collaborative mixed methods approach. We analyzed SAR records from 1995 to 2010 and conducted key consultant interviews in 2010 and 2011. Data showed an estimated annual SAR incidence rate of 19 individuals per 1,000. Weather and ice conditions were the most frequent contributing factor for cases. In contrast with other studies, intoxication was the least common factor associated with SAR incidents. The incidence rate was six times higher for males than females, while land-users aged 26-35 had the highest incidence rate among age groups. Thirty-four percent of individuals sustained physical health impacts. Results demonstrate that environmental conditions are critical factors contributing to physical health risk in Inuit communities, particularly related to travel on sea ice during winter. Age and gender are important risk factors. This knowledge is vital for informing management of land-based physical health risk given rapidly changing environmental conditions in the Arctic.

Qualitative research offers important insights into the subjectivity, complexity, and relationality of care. In this article, we examine the particular processes and relationships involved in doing qualitative research about care with older people in rural places. We draw on our experience completing two related qualitative studies of rural care in Canada to extend discussions about responsible research practice in relation to participant recruitment, interviews, and focus groups. By applying Hankivsky's principles of care ethics in our reflection on research practices, we make explicit the role of emotions in connecting with research participants, collecting and participating in narrative-based research, and negotiating identity. We conclude with a discussion of the distinct ways in which applying care ethics throughout the research process can augment reflexive practice and enhance the integrity and theoretical contributions of qualitative health research while developing more inclusive understandings of vulnerability in older rural populations.

This paper extends the burgeoning interest in emotion, health and place by investigating the emotionally complex experiences of aging and care in rural settings. Featuring a thematic analysis of 44 semi-structured interviews and two focus groups with older people and their carers in rural Ontario (Canada) we examine the importance and implications of emotions within and across multiple scales at which care relationships, expectations and responsibilities are negotiated. With the aim of broadening the discussion surrounding geographical dimensions of ethical care, our approach draws on feminist care ethics to understand the multifaceted ways in which emotions shape and are shaped by experiences of aging and caring at the interpersonal, household and community scales. The findings reveal how emotions are central, yet often-overlooked and even hidden within care relationships among older rural people and their carers. We argue that ethical care is contingent on recognizing and valuing the situated emotions involved in doing care work, sustaining care relationships and asking for care. In doing so, we demonstrate how qualitative research on the emotional geographies of care can contribute to the development of informed policies that are contextually sensitive and, ultimately, have the potential to build more ethical rural conditions of care., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

This practice-based paper describes an innovative program from Ontario, Canada that explored the potential for volunteer-facilitated expressive arts to contribute to the well-being of socially isolated rural seniors. Inspired by Arts on Prescription initiatives in the UK and coordinated by a Registered Expressive Arts Consultant/Educator, the program involved eight older volunteers and eight older participants engaged in a 10-week series of one-on-one intermodal art-making activities in the participants' homes and institutional settings in 2009-2010. An evaluation of the program design and implementation is presented and the challenges and opportunities of expressive arts with isolated seniors using trained volunteers are discussed.

This paper addresses the gap in health services and policy research about the implications of everyday weather for health care work. Building on previous research on the weather-related challenges of caregiving in homes and communities, it examines the experiences of 'seasonal bad weather' for health care workers in long-term care institutions. It features a hermeneutic phenomenology analysis of six transcripts from interviews with nurses and personal support workers from a qualitative study of institutional long-term care work in rural Canada. Focussing on van Manen's existential themes of lived experience (body, relations, space, time), the analysis reveals important contradictions between the lived experiences of health care workers coping with bad weather and long-term care policies and practices that mitigate weather-related risk and vulnerability. The findings contribute to the growing concern for rural health issues particularly the neglected experiences of rural health providers and, in doing so, offer insight into the recent call for greater attention to the geographies of health care work., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: A great deal of variability exists in the speech-recognition abilities of postlingually deaf adult cochlear implant (CI) recipients. A number of previous studies have shown that duration of deafness is a primary factor affecting CI outcomes; however, there is little agreement regarding other factors that may affect performance. The objective of the present study was to determine the source of variability in CI outcomes by examining three main factors, biographic/audiologic information, electrode position within the cochlea, and cognitive abilities in a group of newly implanted CI recipients., Design: Participants were 114 postlingually deaf adults with either the Cochlear or Advanced Bionics CI systems. Biographic/audiologic information, aided sentence-recognition scores, a high resolution temporal bone CT scan and cognitive measures were obtained before implantation. Monosyllabic word recognition scores were obtained during numerous test intervals from 2 weeks to 2 years after initial activation of the CI. Electrode position within the cochlea was determined by three-dimensional reconstruction of pre- and postimplant CT scans. Participants' word scores over 2 years were fit with a logistic curve to predict word score as a function of time and to highlight 4-word recognition metrics (CNC initial score, CNC final score, rise time to 90% of CNC final score, and CNC difference score)., Results: Participants were divided into six outcome groups based on the percentile ranking of their CNC final score, that is, participants in the bottom 10% were in group 1; those in the top 10% were in group 6. Across outcome groups, significant relationships from low to high performance were identified. Biographic/audiologic factors of age at implantation, duration of hearing loss, duration of hearing aid use, and duration of severe-to-profound hearing loss were significantly and inversely related to performance as were frequency modulated tone, sound-field threshold levels obtained with the CI. That is, the higher-performing outcome groups were younger in age at the time of implantation, had shorter duration of severe-to-profound hearing loss, and had lower CI sound-field threshold levels. Significant inverse relationships across outcome groups were also observed for electrode position, specifically the percentage of electrodes in scala vestibuli as opposed to scala tympani and depth of insertion of the electrode array. In addition, positioning of electrode arrays closer to the modiolar wall was positively correlated with outcome. Cognitive ability was significantly and positively related to outcome; however, age at implantation and cognition were highly correlated. After controlling for age, cognition was no longer a factor affecting outcomes., Conclusion: There are a number of factors that limit CI outcomes. They can act singularly or collectively to restrict an individual's performance and to varying degrees. The highest performing CI recipients are those with the least number of limiting factors. Knowledge of when and how these factors affect performance can favorably influence counseling, device fitting, and rehabilitation for individual patients and can contribute to improved device design and application.

For 50 years, the World Federation of Hemophilia (WFH) has been working globally to close the gap in care and to achieve Treatment for All patients, men and women, with haemophilia and other inherited bleeding disorders, regardless of where they might live. The WFH estimates that more than one in 1000 men and women has a bleeding disorder equating to 6,900,000 worldwide. To close the gap in care between developed and developing nations a continued focus on the successful strategies deployed heretofore will be required. However, in response to the rapid advances in treatment and emerging therapeutic advances on the horizon it will also require fresh approaches and renewed strategic thinking. It is difficult to predict what each therapeutic advance on the horizon will mean for the future, but there is no doubt that we are in a golden age of research and development, which has the prospect of revolutionizing treatment once again. An improved understanding of "optimal" treatment is fundamental to the continued evolution of global care. The challenges of answering government and payer demands for evidence-based medicine, and cost justification for the introduction and enhancement of treatment, are ever-present and growing. To sustain and improve care it is critical to build the body of outcome data for individual patients, within haemophilia treatment centers (HTCs), nationally, regionally and globally. Emerging therapeutic advances (longer half-life therapies and gene transfer) should not be justified or brought to market based only on the notion that they will be economically more affordable, although that may be the case, but rather more importantly that they will be therapeutically more advantageous. Improvements in treatment adherence, reductions in bleeding frequency (including microhemorrhages), better management of trough levels, and improved health outcomes (including quality of life) should be the foremost considerations. As part of a new WFH strategic plan (2012-2014) the WFH has identified several key initiatives for particular emphasis - continuation of the Global Alliance for Progress (GAP) program, a new initiative to address underserved countries and regions (The Cornerstone Initiative), enhancing health outcomes research and analysis, and a new research mentorship program. Despite our progress to date in closing the global gap in care, our work is not complete. Too many patients remain undiagnosed and too few receive adequate treatment. This paper will also discuss historical, present and future challenges and opportunities to close the gap in care and achieve Treatment for All., (© 2012 Blackwell Publishing Ltd.)

Objectives: In order to maximize the impact and outcome of comprehensive care, it is important to track the identification of people with bleeding disorders and to evaluate their health outcomes over a long-term period., Methods: Establishment of a comprehensive care program for the care of patients with bleeding disorders is an essential feature of national health systems desiring to achieve the best health outcomes for their patients. Implementation of a surveillance system in conjunction with a comprehensive care program allows assessments to be made on data, with regards to optimizing resources and outcomes for the patients., Results: This data provides governments with answers about the bleeding disorders population, and indicates what the trends are, what the best practices are and what interventions may be required., Discussion: The challenges of answering government and payer demands for evidence-based medicine and cost justification for the introduction and enhancement of treatment and care are ever-present and growing. To sustain and continue the expansion of access to care globally it is critical to build the body of outcome data for individual patients, within HTCs, nationally, regionally and globally. Doing so will not only improve clinical practices and support the allocation of scare resources, but most importantly, the well-being of patients will improve as well.

Drawing on the results of community-based research with a local hospice organisation, this article addresses the need to enhance social support for caregivers of people with life-threatening illnesses. The goal of the research was to involve palliative care stakeholders in the identification, prioritisation and implementation of social support interventions for caregivers who provide palliative care support as hospice volunteers and as family members of those at end-of-life. Guided by a community-based participatory research approach, primary data were collected from 39 volunteer and family member caregivers through four focus groups and nine personal diaries in July 2008. Content analysis and modified constant comparison techniques resulted in emergent themes and priorities relating to challenges, existing coping strategies and resources, and potential support interventions. The findings revealed communication, emotional support, education, advocacy and personal fatigue as the most important challenges to be addressed through support interventions at the organisational (professional support, volunteer mentoring and continuing education) and household levels (caregiver assessments, telephone support and follow-up). There was convergence in how caregivers perceived and access existing social supports, yet a crucial divergence in the availability of resources among volunteers and family members. The findings are discussed in the light of the capacity for hospices to implement social supports and the potential efficacy of the community-based participatory research approach for enhancing social support for caregivers in other parts of health-care and social care., (© 2011 Blackwell Publishing Ltd.)

For nearly 50 years, the goal of the World Federation of Hemophilia (WFH) has been to achieve 'Treatment for All' patients with inherited bleeding disorders, regardless of where they live. With proper diagnosis, management and care, people with bleeding disorders can live perfectly healthy lives. Without treatment, the reality is that many will die young or, if they survive, suffer joint damage that leaves them with permanent disabilities. Only about 25% of the estimated 400 000 people with haemophilia worldwide receive adequate treatment. The percentage is far lower for those with von Willebrand Disease (VWD) and the rarer bleeding disorders. The achievements of the WFH to close the gap in care for people with bleeding disorders are measureable over time by using three key indicators; the difference in the estimated and actual number of people known with bleeding disorders, the amount of treatment products needed versus that available, and the number of people born with bleeding disorders and the number who reach adulthood. There are five essential elements to achieve a sustainable national care programme: ensuring accurate laboratory diagnosis, achieving government support, improving the care delivery system, increasing the availability of treatment products, and building a strong national patient organization., (© 2011 Blackwell Publishing Ltd.)

This paper examines the potential for prevailing Anglo-American perspectives on voluntarism to inform understanding of health and social care internationally. Focusing on the économie sociale et solidaire and its involvement in the secteur médico-social in France, it evaluates the transferability of a theorization about the evolving role of voluntary organizations and volunteers for the purpose of interpreting research on service provision in ageing communities. A case study of local associations is analyzed to uncover their emergence within evolving spaces of care, how they facilitate adjustment and create opportunities for resistance to the dual challenges of ageing and restructuring as well as the complexity underlying their multifaceted responses. The findings contribute to understanding the link between voluntarism, health and place, and address calls to expand the international scope of health geography within the 'voluntary turn' in health policy and research., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Featuring a review of health geography contributions to the recent 'voluntary turn' in the health and social sciences, this paper introduces a theme section comprising five other papers that explore the links among voluntarism, health and place. The introductory paper elucidates the emergence of health voluntarism as a field of study within geography and highlights the crucial difference 'place' makes to understanding voluntary activity in the context of health, care and wellbeing. Questions are raised about theoretical, methodological and policy contributions and potential avenues for fulfilling a more inclusive 'health geographies of voluntarism' are discussed., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Summary: Building our global family by reaching out to women, children and youth and those in sub-Saharan Africa to achieve Treatment for All. The World Federation of Hemophilia (WFH) has committed to recognizing and incorporating the critical and important challenges that are faced by women with bleeding disorders within our global family. The next crucial steps include the development of outreach and registry programmes which can be adapted globally to accelerate the identification of such women, and to educate and guide them to the appropriate clinical care setting. Equally important, awareness must be raised within the broader medical community where women would typically first present with clinical symptoms. Family practitioners, nurse-midwives, obstetricians, gynaecologists and community health clinics will increasingly be strategic and central to WFH outreach efforts, in addition to serving as new care partners essential to the multidisciplinary model of care. Adapting and implementing the WFH development model regionally within Africa is proving to be a successful approach both for the introduction as well as the development of sustainable national care programmes for patients with bleeding disorders. The targeted development of solid national programmes such as in South Africa, Senegal and Kenya has expanded the training capacity of the WFH, as well as providing key regional examples. Local medical professionals are now responsible for providing the training in many regional programmes. Children with bleeding disorders in low-income countries are at great risk of dying young. WFH data demonstrate that among such patients, as the economic capacity of a country decreases so does the ratio of adults to children. The organization of care, training of a multi-disciplinary healthcare team, and education of patients and their families lead to improved mortality independent of economic capacity or increased clotting factor concentrate availability. Additionally, through enhanced youth education, awareness and engagement, we will assure continuity within WFH national member organizations, build greater unity within our global family and capture the innovation and creativity of their ideas to improve Treatment for All.

While 3-dimensional (3D) imaging by computed tomography has long been desirable for research and treatment of cochlear-implant patients, technical challenges have limited its wide application. Recent developments in scanner hardware and image processing techniques now allow image quality improvements that make clinical applications feasible. Validation experiments were performed to characterize a new methodology and its imaging performance.

The World Federation of Hemophilia (WFH) has been the cornerstone of global development for 45 years. The WFH has identified and optimized the essential elements of a model for the development of a sustainable national care programme. The five elements of the WFH Development Model are integrated and interdependent: ensuring accurate laboratory diagnosis, achieving government support for a national programme, improving the care delivery system, increasing the availability of treatment products and building a strong national patient organization. It can been demonstrated that patient organizations, healthcare providers and the Ministry of Health working together in coalition is essential to achieving sustainable care. Equally important, the provision of care by a multidisciplinary team of trained professionals within a comprehensive care setting is fundamentally important to optimize outcomes. Using data from the WFH Global Survey, it is evident that the WFH Development Model brings about sustainable improvements in care. To support the Model, the WFH has created a vast range of tools, guides and programmes tailored to specific development needs. The Global Alliance for Progress is the preeminent WFH development program. Five years of outcomes data document a narrowing of the care gap between developed and developing nations. To ensure the continued advance towards the WFH vision of Treatment for All, it is vital that global collaboration occur on the research front as well. The WFH is well positioned to meet the challenges ahead and to continue serving as the cornerstone of global collaboration and development.

Objectives: A new technique for determining the position of each electrode in the cochlea is described and applied to spiral computed tomography data from 15 patients implanted with Advanced Bionics HiFocus I, Ij, or Helix arrays., Methods: ANALYZE imaging software was used to register 3-dimensional image volumes from patients' preoperative and postoperative scans and from a single body donor whose unimplanted ears were scanned clinically, with micro computed tomography and with orthogonal-plane fluorescence optical sectioning (OPFOS) microscopy. By use of this registration, we compared the atlas of OPFOS images of soft tissue within the body donor's cochlea with the bone and fluid/ tissue boundary available in patient scan data to choose the midmodiolar axis position and judge the electrode position in the scala tympani or scala vestibuli, including the distance to the medial and lateral scalar walls. The angular rotation 0 degrees start point is a line joining the midmodiolar axis and the middle of the cochlear canal entry from the vestibule., Results: The group mean array insertion depth was 477 degrees (range, 286 degrees to 655 degrees). The word scores were negatively correlated (r = -0.59; p = .028) with the number of electrodes in the scala vestibuli., Conclusions: Although the individual variability in all measures was large, repeated patterns of suboptimal electrode placement were observed across subjects, underscoring the applicability of this technique.

Purpose: This study examined the relation of audibility for frequency-specific sounds and the Speech Intelligibility Index (SII) to speech perception abilities of children with sensorineural hearing loss using digital signal-processing hearing aids with wide dynamic range compression., Method: Twenty-six children age 5-15 years with pure-tone averages (0.5, 1.0, and 2.0 kHz) from 60-98 dB HL participated. Three subgroups were created based on the compression characteristics of each hearing aid. Minimum audibility was determined using aided thresholds for frequency-modulated tones and the SII calculated at 55 and 70 dB SPL using the simulated real-ear output of the hearing aid. The Lexical Neighborhood Test (LNT; K. I. Kirk, D. B. Pisoni, & M. J. Osberger, 1995) was presented at 50 and 70 dB SPL., Results: LNT scores at 70 dB SPL were significantly higher than at 50 dB SPL. Average aided thresholds at 0.5, 1.0, and 2.0 kHz were negatively correlated with LNT scores at 50 dB SPL, and SIIs at 55 and 70 dB SPL were positively correlated with LNT scores at 50 and 70 dB SPL., Conclusions: Results support using aided thresholds and speech test scores at soft to loud levels as part of the amplification fitting process.

This paper contributes to the current debates surrounding private delivery of health care services by addressing the distinctive challenges, constraints and opportunities facing for-profit and non-profit providers of long-term care in rural and small town settings. It focuses on the empirical case of Ontario, Canada where extensive restructuring of long-term care, under the rubric of managed competition, has been underway since the mid-1990s. In-depth interviews with 72 representatives from local governments, public health institutions and authorities, for-profit and non-profit organisations, and community groups during July 2003 to December 2003 form the platform for a qualitative analysis of the implications of managed competition as it relates to the provision of long-term care in the countryside. The results suggest that the introduction and implementation of managed competition has accentuated the problems of service provision in rural communities, and that the long-standing issues of caregiving in rural situations transcend the differences, perceived or otherwise, between for-profit and non-profit provision. Understanding the implications of market-oriented long-term care restructuring initiatives for providers, and their clients, in rural situations requires a re-focussing of research beyond the for- versus non-profit dichotomy.

The World Federation of Hemophilia (WFH) has defined a new strategic plan which maps out where the organization is going and what it can do for our members. The plan embraces the vision of Treatment for All; i.e. one day, treatment will be available for all those with inherited bleeding disorders, regardless of where they live. Treatment for All means proper diagnosis, management, and care by a multidisciplinary team of trained specialists. It means safe, effective treatment products are available for all people with inherited bleeding disorders. It means expanding services beyond haemophilia, to those with von Willebrand's disease, rare factor deficiencies, and inherited platelet disorders. Today, more than 75% of the global bleeding disorders community receive either inadequate or no treatment whatsoever. Our mission is to improve treatment where it is limited or does not exist. At the same time, we must sustain the many gains we have achieved thus far. The challenge is immense. Making our vision a reality requires us to be focused and deliberate about the programmes we undertake and the commitments we make. Building on past strategic plans, this plan presents a vision for the continued success of the WFH over the next 3-5 years.

One of the difficulties faced by cochlear implant (CI) recipients is perception of low-intensity speech cues. A. E. Vandali (2001) has developed the transient emphasis spectral maxima (TESM) strategy to amplify short-duration, low-level sounds. The aim of the present study was to determine whether speech scores would be significantly higher with TESM than with the advanced combination encoder (ACE) strategy fitted using procedures that optimize perception of soft speech and other sounds. Eight adult recipients of the Nucleus 24 CI system participated in this study. No significant differences in scores were seen between ACE and TESM for consonant-vowel nucleus-consonant (CNC) words presented at 55 and 65 dB SPL, for sentences in noise presented at 65 dB SPL at 2 different signal-to-noise ratios, or for closed-set vowels and consonants presented at 60 dB SPL. However, perception of stop consonants within CNC words presented at the lower level (55 dB SPL) was significantly higher with TESM than ACE. In addition, percentage of information transmitted for words at 55 dB SPL was significantly higher with TESM than with ACE for manner and voicing features for consonants in the initial word position. Analysis of closed-set consonants presented at 60 dB SPL revealed percentage of information transmitted for manner was significantly higher with TESM than with ACE. These improvements with TESM were small compared with those reported by Vandali for recipients of the Nucleus 22 CI system. It appears that mapping techniques used to program speech processors and improved processing capabilities of the Nucleus 24 system contributed to soft sounds being understood almost as well with ACE as with TESM. However, half of the participants preferred TESM to ACE for use in everyday life, and all but 1 used TESM in specific listening situations. Clinically, TESM may be useful to ensure the audibility of low-intensity, short-duration acoustic cues that are important for understanding speech, for recipients who are difficult to map, or if insufficient time precludes the use of mapping techniques to increase audibility of soft sound.

The absence of adequate treatment for most of the world's 400 000 individuals with haemophilia makes the development of a cure compelling. Advances in the basic molecular sciences over the past 20 years have resulted in the feasibility of curing haemophilia through the application of gene therapy. However, the reality of this therapeutic strategy is highly complex. In addition, challenges to achieving a cure exist beyond the basic scientific hurdles. Thoughtful attention must also be given to a number of interrelated issues, including ethical considerations in patient recruitment, informed consent and geographical variables of global clinical trials. The global inequalities in healthcare mean that the ethics of international medical research, especially when it includes countries where people usually do not receive quality care, become much more complicated. The majority of haemophiliacs lives in developing countries and is a valuable resource of human subjects who could be enrolled in clinical trials. When recruiting subjects globally, investigators must be ever mindful that the patient population is a precious resource, which must be treated with respect and care. This presents a major challenge for investigators engaged in trials of haemophilia gene therapy to ensure that the informed consent process is current and comprehensive, that therapeutic misconceptions are appropriately managed, and that the roles of the researcher and physician are clear. Global clinical gene-therapy trials are an important and appropriate component in the quest to achieve a cure for haemophilia. When trials follow identical internationally accepted standards, a successful outcome can be achieved for trials including developing countries, if country specific cultural and economic aspects are considered.

This observational study assessed the potential role of the intubating laryngeal mask airway (ILMA) for use by emergency care givers with limited laryngoscopy skills. Six ambulance officers with advanced airway training, five doctors with intubation experience and five doctors without intubation experience were given a short instruction course on the use of the ILMA. They subsequently used the device on 80 consenting subjects anaesthetized for elective surgery after the application of cricoid pressure and manual in-line stabilization of the cervical spine. All patients were successfully ventilated via the ILMA. Mean (SD) times in seconds to ventilation were 27 (10), 33 (18) and 47 (22) respectively in the occasional intubator ambulance officers, occasional intubator doctor and naive intubator groups. The numbers (percentage) failures to intubate via the ILMA in each group were 2 (7%), 5 (20%) and 4 (16%) respectively. Mean (SD) times in seconds to intubation were 32 (23), 32 (17) and 36 (25). There was no evidence of "learning" with repeated use. The feedback forms were strongly supportive of a prehospital trial and also of having an ILMA available during all intubations. Participants almost universally rated the ILMA as easy to use. This study supports further evaluation of the ILMA in a large prehospital trial.

To discriminate fine anatomical features in the inner ear, it has been desirable that spiral computed tomography (CT) may perform beyond their current resolution limits with the aid of digital image processing techniques. In this paper, we develop a blind deblurring approach to enhance image resolution retrospectively without complete knowledge of the underlying point spread function (PSF). An oblique CT image can be approximated as the convolution of an isotropic Gaussian PSF and the actual cross section. Practically, the parameter of the PSF is often unavailable. Hence, estimation of the parameter for the underlying PSF is crucially important for blind image deblurring. Based on the iterative deblurring theory, we formulate an edge-to-noise ratio (ENR) to characterize the image quality change due to deblurring. Our blind deblurring algorithm estimates the parameter of the PSF by maximizing the ENR, and deblurs images. In the phantom studies, the blind deblurring algorithm reduces image blurring by about 24%, according to our blurring residual measure. Also, the blind deblurring algorithm works well in patient studies. After fully automatic blind deblurring, the conspicuity of the submillimeter features of the cochlea is substantially improved.

This study extended the findings of Ketten et al. [Ann. Otol. Rhinol. Laryngol. Suppl. 175:1-16 (1998)] by estimating the three-dimensional (3D) cochlear lengths, electrode array intracochlear insertion depths, and characteristic frequency ranges for 13 more Nucleus-22 implant recipients based on in vivo computed tomography (CT) scans. Array insertion depths were correlated with NU-6 word scores (obtained one year after SPEAK strategy use) by these patients and the 13 who used the SPEAK strategy from the Ketten et al. study. For these 26 patients, the range of cochlear lengths was 29.1-37.4 mm. Array insertion depth range was 11.9-25.9 mm, and array insertion depth estimated from the surgeon's report was 1.14 mm longer than CT-based estimates. Given the assumption that the human hearing range is fixed (20-20,000 Hz) regardless of cochlear length, characteristic frequencies at the most apical electrode (estimated with Greenwood's equation [Greenwood DD (1990) A cochlear frequency--position function of several species--29 years later. J Acoust. Soc. Am. 33: 1344-1356] and a patient-specific constant as) ranged from 308 to 3674 Hz. Patients' NU-6 word scores were significantly correlated with insertion depth as a percentage of total cochlear length (R = 0.452; r2 = 0.204; p = 0.020), suggesting that part of the variability in word recognition across implant recipients can be accounted for by the position of the electrode array in the cochlea. However, NU-6 scores ranged from 4% to 81% correct for patients with array insertion depths between 47% and 68% of total cochlear length. Lower scores appeared related to low spiral ganglion cell survival (e.g., lues), aberrant current paths that produced facial nerve stimulation by apical electrodes (i.e., otosclerosis), central auditory processing difficulty, below-average verbal abilities, and early Alzheimer's disease. Higher scores appeared related to patients' high-average to above-average verbal abilities. Because most patients' scores increased with SPEAK use, it is hypothesized that they accommodated to the shift in frequency of incoming sound to a higher pitch percept with the implant than would normally be perceived acoustically.

A recently developed blind deblurring algorithm based on the edge-to-noise ratio has been applied to improve the quality of spiral CT images. Since the discrepancy measure used to quantify the edge and noise effects is not symmetric, there are several ways to formulate the edge-to-noise ratio. This article is to investigate the performance of those ratios with phantom and patient data. In the phantom study, it is shown that all the ratios share similar properties, validating the blind deblurring algorithm. The image fidelity improvement varies from 29% to 33% for different ratios, according to the root mean square error (RMSE) criterion; the optimal iteration number determined for each ratio varies from 25 to 35. Those ratios that are associated with most satisfactory performance are singled out for the image fidelity improvement of about 33% in the numerical simulation. After automatic blind deblurring with the selected ratios, the spatial resolution of CT is substantially refined in all the cases tested.

With use of radiopaque implanted objects as internal fiducial markers, the authors developed and evaluated a technique for coregistering computed tomographic (CT) and computed radiographic images to help determine three-dimensional location information for implant electrodes in the cochlea in phantoms and patients. Three-dimensional positional data from CT were assigned on a radiograph, which permitted identification of individual cochlear electrode locations that were not depicted at CT.

Many operating theatre staff believe that the surgical face mask protects the healthcare worker from potentially hazardous biological infections. A questionnaire-based survey, undertaken by Leyland' in 1993 to assess attitudes to the use of masks, showed that 20% of surgeons discarded surgical masks for endoscopic work. Less than 50% did not wear the mask as recommended by the Medical Research Council. Equal numbers of surgeons wore the mask in the belief they were protecting themselves and the patient, with 20% of these admitting that tradition was the only reason for wearing them. Policies relating to the wearing of surgical masks by operating theatre staff are varied. This indicates some confusion about the role of the surgical mask in modern surgical and anaesthetic practice. This review was undertaken to collate current evidence and make recommendations based on this evidence.

Objective: Severe to profound hearing impairment affects one-half to three-quarters of a million Americans. To function in a hearing society, hearing-impaired persons require specialized educational, social services, and other resources. The primary purpose of this study is to provide a comprehensive, national, and recent estimate of the economic burden of hearing impairment., Methods: We constructed a cohort-survival model to estimate the lifetime costs of hearing impairment. Data for the model were derived principally from the analyses of secondary data sources, including the National Health Interview Survey Hearing Loss and Disability Supplements (1990-91 and 1994-95), the Department of Education's National Longitudinal Transition Study (1987), and Gallaudet University's Annual Survey of Deaf and Hard of Hearing Youth (1997-98). These analyses were supplemented by a review of the literature and consultation with a four-member expert panel. Monte Carlo analysis was used for sensitivity testing., Results: Severe to profound hearing loss is expected to cost society $297,000 over the lifetime of an individual. Most of these losses (67%) are due to reduced work productivity, although the use of special education resources among children contributes an additional 21%. Lifetime costs for those with prelingual onset exceed $1 million., Conclusions: Results indicate that an additional $4.6 billion will be spent over the lifetime of persons who acquired their impairment in 1998. The particularly high costs associated with prelingual onset of severe to profound hearing impairment suggest interventions aimed at children, such as early identification and/or aggressive medical intervention, may have a substantial payback.

Multielectrode, intracochlear implant systems are effective treatment for profound sensorineural hearing loss. In some cases, these systems do not perform well, which may be partially due to variations in implant location within the cochlea. Determination of each electrode's position in a patient's inner ear provides an in vivo basis for both the cochlear modeling of electrical fields and the future design of electrode arrays that deliver electrical stimulation to surviving auditory neurons, and may improve speech processor programming for better speech recognition. We developed an X-ray stereophotogrammetric approach to localize implanted electrodes in three dimensions. Stereophotogrammetry of implanted electrodes is formulated in weak perspective geometry, with knowledge of a three-dimensional (3-D) reference structure and electrode positions in each of two digital stereo-images. The localization error is theoretically, numerically, and experimentally quantified. Both numerical and experimental results demonstrate the feasibility of the technique.

Three-dimensional (3-D) modeling and visualization of the cochlea using the World Wide Web (WWW) is an effective way of sharing anatomic information for cochlear implantation over the Internet, particularly for morphometry-based research and resident training in otolaryngology and neuroradiology. In this paper, 3-D modeling, visualization, and animation techniques are integrated in an interactive and platform-independent manner and implemented over the WWW. Cohen's template shape with mean cross-sectional areas of the human cochlea is extended into a 3-D geometrical model. Also, spiral computer tomography data of a patient's cochlea is digitally segmented and geometrically represented. The cochlear electrode array is synthesized according to its specification. Then, cochlear implantation is animated with both idealized and real cochlear models. Insertion length, angular position, and characteristic frequency of individual electrodes are estimated online during the virtual insertion. The optimization of the processing parameters is done to demonstrate the feasibility of this technology for clinical applications.

Clinically, speech processor programs are created using electrical thresholds and maximum acceptable loudness levels (MALs) at several different stimulation rates to determine what rate will provide cochlear implant recipients with the best speech recognition when using fast-rate speech coding strategies. This study was designed to determine the difference in thresholds and MALs (expressed in the clinical unit, Current Level [CL]) for pairs of six rates spanning those available with the Nucleus 24 device (i.e., 250 to 2,400 pps/ch) using monopolar, 25 microsec/phase stimulation. Test-retest measures of threshold and MAL for each rate were obtained from seven adult Nucleus 24 recipients on each of 11 electrodes. The difference in threshold and in MAL between pairs of rates was dependent on the absolute CL. Below approximately 190 CL, thresholds and MALs decreased with increasing rate; above 210 CL, there was little change in threshold or MAL with increasing rate. Based on these findings, an approach to estimating threshold and MAL from one rate to another is suggested, pending further research.

Multielectrode cochlear implantation is the most effective treatment for profound sensorineural hearing loss. In vivo three-dimensional 3-D localization of cochlear implant electrodes is important for modeling of the electrical field in the cochlea, design of electrode arrays, and may improve speech processor programming for better speech recognition. The prerequisite for 3-D localization of the electrodes is their 2-D localization in x-ray radiographs. In this paper, we develop a practical method to localize the electrodes with high efficiency, accuracy, and reproducibility. In this method, a priori knowledge of the electrodes and their approximate positions are utilized, an intelligent thresholding and segmentation mechanism is embedded, and the electrode center is computed as the weighted geometric center of segmented electrode pixels. Experiments with physical phantoms and human data demonstrate the feasibility and utility of this method. The PC-based program developed for this project is disseminated on the Web.

Minimum stimulation levels for active electrodes in a Nucleus 22 cochlear implant were set at threshold (clinical default value) and raised levels (M = +2.04 dB) to determine if raised levels would improve recipients' understanding of soft speech sounds with the SPEAK speech coding strategy. Eight postlinguistically deaf adults participated in a 4-phase A1B1A2B2 test design. Speech recognition was evaluated with consonant-vowel nucleus-consonant (CNC) words in quiet and sentences in noise, both presented at 50, 60, and 70 dB SPL during 2 weekly sessions at the end of each phase. Group mean scores were significantly higher with the raised level program for words and phonemes at 50 and 60 dB SPL and for sentences at 50 and 70 dB SPL. All participants chose to use the raised level program in everyday life at the end of the study. The results suggest that clinical use of a raised level program for Nucleus 22 recipients has the potential to make soft sounds louder and, therefore, more salient in everyday life. Further research is needed to determine if this approach is appropriate for other cochlear implant devices.

Three-dimensional cochlear canal lengths, electrode array intracochlear insertion depths, and characteristic frequency ranges were estimated for 20 Nucleus implant recipients on the basis of in vivo computed tomography (CT) scans. Ultra-high resolution images were reconstructed from spiral CT data with 0.1-mm slicing and expanded attenuation scales. Canal length estimates (mean 33.01 mm; SD 2.31) were consistent with previous findings for normal human temporal bones. Intracochlear array insertion depths estimated by 3-dimensional (3-D) spiral calculations (mean 20.19 mm; SD 2.86) and by a computerized array tracking algorithm (mean 20.36 mm; SD 2.66) were not significantly different. Estimates from surgical observations were significantly longer (mean 21.03 mm; SD 2.31) because array compressions were not detectable. Characteristic frequencies at apical electrodes estimated from Greenwood's equations ranged from 387 Hz to 2,596 Hz. The results show that significant variations in cochlear anatomy and array distribution among implant patients that may impact implant performance can be reliably detected and quantified by using in vivo high-resolution CT and 3-D reconstructions.

Cochlear implantation is the standard treatment for profound hearing loss. Preimplantation and postimplantation spiral computed tomography (CT) is essential in several key clinical and research aspects. The maximum image resolution with commercial spiral CT scanners is insufficient to define clearly anatomical features and implant electrode positions in the inner ear. In this paper, we develop an expectation-maximization (EM)-like iterative deblurring algorithm to achieve spiral CT image super-resolution for cochlear implantation, assuming a spatially invariant linear spiral CT system with a three-dimensional (3-D) separable Gaussian point spread function (PSF). We experimentally validate the 3-D Gaussian blurring model via phantom measurement and profile fitting. The imaging process is further expressed as convolution of an isotropic 3-D Gaussian PSF and a blurred underlying volumetric image. Under practical conditions, an oblique reconstructed section is approximated as convolution of an isotropic two-dimensional (2-D) Gaussian PSF and the corresponding actual cross section. The spiral CT image deblurring algorithm is formulated with sieve and resolution kernels for suppressing noise and edge artifacts. A typical cochlear cross section is used for evaluation, demonstrating a resolution gain up to 30%40% according to the correlation criterion. Physical phantoms, preimplantation and postimplantation patients are reconstructed into volumes of 0.1-mm cubic voxels. The patient images are digitally unwrapped along the central axis of the cochlea and the implanted electrode array respectively, then oblique sections orthogonal to the central axis formed. After deblurring, representation of structural features is substantially improved in all the cases.

Speech coding strategy, frequency boundary assignment table, and speech processor program minimum and maximum stimulation levels are parameters of the Nucleus Cochlear Implant System whose selection affects speech recognition performance in adults and children. Research studies show that speech recognition is significantly better with (1) the Spectral Peak than with the Multipeak speech coding strategy and (2) frequency boundary assignment Table 7 than with Table 9 in an individual's speech processor program (MAP). Minimum and maximum stimulation levels in this MAP are based on psychophysical measurements on each electrode but often need to be modified for optimum use in everyday life. Many children and adults have increases, decreases, or fluctuations in electrical hearing that require changes in the MAP minimum and maximum levels to maintain their ability to recognize speech and other sounds.

Ten postlinguistically deaf adults who used the Nucleus Cochlear Implant System and SPEAK speech coding strategy responded to vowels, consonants, words, and sentences presented sound-only at 70, 60, and 50 dB sound-pressure level. Highest group mean scores were at a raised-to-loud level of 70 dB for consonants (73%), words (44%), and sentences (87%); the highest score for vowels (70%) was at a conversational level of 60 dB. Lowest group mean scores were at a soft level of 50 dB for vowels (56%), consonants (47%), words (10%), and sentences (29%); all except subject 7 had some open-set speech recognition at this level. For the conversational level (60 dB), group mean scores for sentences and words were 72% and 29%, respectively. With this performance and sound-pressure level, it was observed that these subjects communicated successfully in a variety of listening situations. Given these subjects' speech recognition scores at 60 dB and the fact that 70 dB does not simulate the vocal effort used in everyday speaking situations, it is suggested that cochlear implant candidates and implantees be evaluated with speech tests presented at 60 dB instead of the customary 70 dB sound-pressure level to simulate benefit provided by implants in everyday life. Analysis of individuals' scores at the three levels for the four speech materials revealed different patterns of speech recognition among subjects (e.g., subjects 1 and 5). Future research on the relation between stimuli, sound processing, and subjects' responses associated with these different patterns may provide guidelines to select parameter values with which to map incoming sound onto an individual's electrical dynamic range between threshold and maximum acceptable loudness level to improve speech recognition.

The Spectra 22 Speech Processor and spectral peak (SPEAK) speech-coding strategy provide Nucleus 22 Channel Cochlear Implant (Cochlear, Corp., Englewood, Colo.) users with a better understanding of speech than the previous Mini Speech Processor and Multipeak (MPEAK) speech-coding strategy. On the NU-6 Monosyllabic Word Test, subjects scored 13% higher for words and 14% higher for phonemes with the SPEAK strategy than with the MPEAK strategy. On the Connected Speech Test and the CID Everyday Sentence Test, subjects scored 32% and 37% higher, respectively, with SPEAK than with MPEAK.

Multielectrode, intracochlear implants were designed for individuals with profound sensorineural hearing loss who derive little or no benefit form acoustic hearing aids. Determination of each electrode's position in a patient's inner ear may improve speech processor programming to maximize speech recognition. In this paper, an approach is described to use as input a volumetric spiral computed tomography (CT) image of the Nucleus electrode array (Cochlear Pty. Ltd, Lane Cove, NSW, Australia) to unwrap it, and to measure its implanted length given starting and end points. Representative curvilinear structures were digitally synthesized in image volumes of isotropic 0.1-mm voxels. The electrode array was spirally CT-scanned in vitro and in vivo, and reconstructed on an isotropic grid in 0.1-mm steps. Two algorithms were constructed to track and measure these curvilinear structures. The first algorithm is Karhunen-Loeve (K-L)-transform based, in which the K-L transform is locally applied at a current main axis position to determine the eigenvectors of the main axis voxels, the next main axis position is estimated from the current position along the principal eigendirection, adjusted to the mass center of the orthogonal cross section passing through the estimated position, and then scaled to have a prespecified step. The second algorithm is similar to the first one but avoids use of the K-L transform. In the second algorithm, the next position is directly estimated along the local direction and then processed with the same correction and scaling operations. With user-specified starting and end points as well as a local direction at the starting point, a curvilinear structure can be automatically tracked using either of the algorithms. The first algorithm is more robust, while the second one is more efficient. In the numerical and in vitro studies, the lengths of the curvilinear structures were accurately measured. Given local directions determined in the tracking process, an electrode array image can be unwrapped into a linear array with the central electrode axis as the abscissa. The unwrapping approach allows longitudinally and cross-sectionally accurate measurement and better visualization of cochlear implant images. With preimplantation knowledge of length, width, and center electrode distance, the position of individual electrodes can be estimated after unwrapping.