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The fitting of amputated and nonamputated diabetic feet. A French experience at the Villiers-Saint-Denis Hospital.

The Villiers-Saint-Denis Hospital in France specializes in the rehabilitation of and fitting of orthoses for lower-limb amputees, who frequently have diabetes mellitus. The percentage of partial-foot amputations has increased relative to the percentage of transtibial or transfemoral amputations. This article describes a complete range of orthoses and prostheses, adapted to each patient, that allow recovery of the standing position, gait ability, and physical activity.

Amputation, Surgical↗

Recordkeeping and contact lens practice.

Recordkeeping in contact lens practice may be based on a problem-oriented system that emphasizes the use of forms. Fitting agreements and informed consent agreements are the most important components of such a system. Progress notes are also used to document the episodic care that is an integral part of contact lens practice. Examination findings should be described with descriptive language whenever possible; warnings, diagnoses, patient management, and recall and referral appointments should be conscientiously documented in the record of care.

Contact Lenses↗

Closeness of fit of uncemented stems improves the strain distribution in the femur.

Differences in the cross-sectional shapes of intramedullary stems are expected to affect the strains in the femur, a close proximal fit being proposed as particularly advantageous. We compared uncemented femoral stems of different designs, as well as a cemented stem, using the intact femur as a control. The collarless stems were custom-made, standard asymmetric, symmetric (i.e., neutral), and cemented symmetric. These different types of stem were inserted in sequence into eight cadaver femurs. A photoelastic coating technique was used to give a measure of the shear strains over the bone surface. The mean reductions of maximum shear strains in the upper 30 mm of the proximal-medial regions for the custom, asymmetric, symmetric, and cemented stems were 11, 24, 6, and 75%, respectively. The strains for the symmetric stem were concentrated in the proximal-medial region just below the neck resection line and then decreased rapidly below that level. For the asymmetric stems, the relative strains in the proximal-anterior and proximal-medial regions were dependent on the tightness of fit in the anterior-posterior and medial-lateral directions. The custom stems consistently produced a pattern of strain distribution that, overall, was closer to normal than that of the other stems; extremes at the anterior and medial regions were avoided. The strains down the entire medial side of the cemented stem were significantly less than for the intact femur or for the uncemented stems.

Biomechanical Phenomena↗

Adaptation to loudness and environmental stimuli in three newly fitted hearing aid users.

Hearing aid fitting strategies can be categorized according to whether a loudness normalization or a loudness equalization rationale is employed. Regardless of the underlying rationale, the amount of patient participation in determining the initial hearing aid settings will vary when an audiologist-driven (AD) versus a patient-driven protocol is employed. When an AD protocol is used, few changes are made during the initial fitting session based on user feedback. It is assumed that the patient will adapt to the loudness and/or sound quality provided by the hearing aids if not immediately acceptable. The following three case reports document varying degrees of adaptation to hearing aid settings derived using an AD approach. Clinical implications will be discussed.

Adaptation, Physiological↗

A major Italian force in the ENT diagnostic field and in hearing rehabilitation.

Amplifon, a leading italian company operating for over 40 years in the field of ENT diagnostic, hearing aid fitting and hearing rehabilitation, provides a major support to the health care and scientific world by means of a capillary sales and customer service network, an advanced R&D Service, a qualified Center for Research and Studies (CRS), an outstanding quality control and highly skilled personnel; its product lines comprise hearing aids and biomedical equipment.

Biomedical Engineering↗

[Assessment of implant position of CTX-custom-made stems with EBRA-FCA in 107 cases of total joint replacement].

AIM: The aim of this study was to assess the ratio of correct and malpositioned stems in a THR population with custom-made stems. Furthermore, any relation of the extent of deviation from the exact stem position and defined patient variables was evaluated. METHODS: Preoperatively, in three-dimensional virtual reality, CTX-individual hip stems were positioned in femora reconstructed from the individual patient's CT data until a stable cortical fit was achieved. Postoperative femoral stem position was measured with EBRA-FCA (EinzelBildRontgenAnalyse-Femoral Component Analysis). Differences of planned and actual depth of stem position were calculated for 107 CTX-custom-made hip stems implanted at one institution. RESULTS: Compared to preoperative planning 59 hip stems were placed too high, while 16 were placed exactly to within one millimeter and 32 were positioned too low. Deviations of postoperative stem position from preoperative planning did not correlate with previous femoral osteotomy found in one-third of femora or femoral anteversion exceeding 25 degrees as present in two-thirds of patients. CONCLUSION: In 71 % the intraoperative stem position did match the preoperative CTX-implant fitting into virtual patient femora. 29 % of implanted stems were malpositioned, i. e., deviations were greater plus or minus 5 mm to preoperative computer planning. None of the examined variables such as body mass index, previous femoral osteotomy, surgical approach, abnormal anteversion angle served as a predictive value for CTX-stem position in this cohort.

Bone Malalignment↗

Clinical study of hearing instruments: a cross-sectional longitudinal audit based on consumer experiences.

The objective of the present audit was to document improvements/changes in hearing instrument (HI) benefit in terms of use and satisfaction throughout the 1990s and compare the benefit in consumers fitted with analogue (A), programmable (P), and digital signal processing (DSP) HIs. The audit data are based on a questionnaire mailed to subjects fitted with HIs 3 to 4 months after the fitting, including questions concerning satisfaction with the HI, use of the HI, ability to manage the HI, and satisfaction with the overall services in the department. Information was obtained from 32,694 subjects (i.e., 71.2 per cent of those fitted with HIs throughout the last decade), with a median age at fitting of 78 years (range, 18-102), with a preponderance of females. No significant differences in age, gender distribution, and hearing instrument distribution were found between the respondents and non-respondents. The audit shows that there are no significant differences in any of the benefit parameters throughout the decade, irrespective of the introduction of P-HIs in 1995 and of the DSP-HIs in 1998. Thus, from the consumers' perspective, no changes have appeared in the last decade. A comparative analysis of the A-HIs, P-HIs, and DSP-HIs shows that among those provided with P-HIs and DSP-HIs, only 69.6 per cent (CI 68.1-71.0) and 65.5 per cent (CI 60.2-78.8), respectively, were very satisfied/satisfied with the HI, which is significantly less than the 73.5 per cent (CI 72.4-74.5) in those fitted with A-HIs. The daily/weekly use of all three types of HIs was similar. However, the group fitted with DSP-HIs was significantly less satisfied with the general services compared with those fitted with A-HIs and P-HIs, respectively. Based on these audit data, it is concluded that, according to the consumers, the outcome from HIs has not changed over the last decade, and a comparison between the traditional A-HIs with both P-HIs and DSP-HIs is in favour of the traditional A-HIs.

Aged↗

Gait, cost and time implications for changing from PTB to ICEX sockets.

The ICEX system (Ossur, Iceland), allows a socket to be manufactured directly onto the stump and is thought to provide improved comfort due to better pressure distribution whilst being easier to fit and manufacture. The aims of this project were to a) compare gait performance by measuring several gait characteristics, b) compare production and fitting times, c) investigate financial implications and d) attempt to gauge the amputees' subjective opinions of socket comfort. A randomised, controlled trial was conducted on 27 trans-tibial amputees with an existing patellar tendon bearing (PTB) socket on the Endolite system (Chas A. Blatchford, UK). Twenty one (21) subjects completed the study. Of these, 10 in the control group received new PTB sockets while 11 in the experimental group received ICEX. Gait analysis wearing existing sockets was performed and kinetic data obtained from a force plate. This was repeated with the new sockets after a 6 week period of adjustment. Mann-Whitney tests were used in statistical evaluations with a significance level of 5%. Subjects were asked to score their prosthesis for comfort using the Socket Comfort Score (Hanspal et al., 2003) and the frequency of visits for socket adjustments over a three-month period post-delivery of the sockets was recorded. This study demonstrates no significant difference in any of the gait parameters measured. Though the time required to manufacture a PTB prosthesis was found to be considerably longer than the ICEX, the overall cost for producing the ICEX was significantly greater. Subjects showed only minor comfort preference for the ICEX design and there was no significant difference in the mean number of visits for socket adjustments. In view of the considerable additional cost of providing ICEX and the lack of evidence of improvement in any parameter tested, the routine provision of ICEX prostheses to unselected trans-tibial amputees cannot be recommended.

Adolescent↗

[Fitting hearing aids in early childhood based on auditory evoked potentials in steady states].

The purpose of the Newborn Hearing Screening Program is to achieve early. Identification and appropriate intervention for hearing loss. Hearing aids are the most frequent intervention for deafness. Paediatric specific clinical protocols for fitting hearing aids always recommend accurate characterisation of hearing thresholds in newborns. In this sense, electrophysiological procedures are specially indicated in determined hearing sensibility from the first age of life since it is an objective and reliable procedure. 20 normal hearing subject and 17 hearing loss subjects participated in this study. Auditory Steady State Responses (ASSR) were obtained from all of them. Hearing aid fitting was established from the electrophysiological responses. Dynamic range, gain, compression ratio and maximum output of the hearing aid were obtained from the intensity amplitude function of the ASSR. The procedure discussed in this study is specially indicated in newborns and very young children in which other test are not suitable.

Adolescent↗

Impact of compression and hearing aid style on directional hearing aid benefit and performance.

OBJECTIVE: To evaluate the impact of low-threshold compression and hearing aid style (in-the-ear [ITE] versus behind-the-ear [BTE]) on the directional benefit and performance of commercially available directional hearing aids. DESIGN: Forty-seven adult listeners with mild-to-moderate sensorineural hearing loss were fit bilaterally with one BTE and four different ITE hearing aids. Speech recognition performance was measured through the Connected Speech Test (CST) and Hearing in Noise Test (HINT) for a simulated noisy restaurant environment. RESULTS: For both the HINT and CST, speech recognition performance was significantly greater for subjects fit with directional in comparison with omnidirectional microphone hearing aids. Performance was significantly poorer for the BTE instrument in comparison with the ITE hearing aids when using omnidirectional microphones. No differences were found for directional benefit between compression and linear fitting schemes. CONCLUSIONS: No systematic relationship was found between the relative directional benefit and hearing aid style; however, the speech recognition performance of the subjects was somewhat predictable based on Directivity Index measures of the individual hearing aid models. The fact that compression did not interact significantly with microphone type agrees well with previously reported electroacoustic data.

Acoustic Stimulation↗

Stump problems in traumatic amputation.

Stump problems in amputations resulting from employment related injuries were investigated in 397 cases in the Chugoku and Shikoku districts of Japan between 1987 and 1991. Ninety-seven patients (24%) had stump problems which interfered the prosthetic fitting. Stump problems of the upper extremity were seen in about 9% (17 amputees), two thirds of which were skin troubles. Stump problems of the lower extremity were seen in about 37% (80 amputees). Certain complaints were associated with specific methods of amputation; abnormal keratosis in Syme's amputation, equinus deformity in Chopart's amputation, reduced muscle power in above the knee (A/K) amputation and joint dysfunction in below the knee (B/K) amputation. Adequate prosthetic fitting was achieved by the modification of the socket and alignment in almost all amputees with stump problems. In only two cases, Chopart's amputation required subsequent Syme's amputation due to equinus deformity with abnormal keratosis. In almost every case, stump problems are avoidable by means of surgeons' deliberate evaluation of the affected limb and adequate choice of the amputation level.

Accidents, Occupational↗

Die relief, seating methods and fit of full crowns.

This study investigated the influence of different frequencies of vibration supplied by an electropneumatic condenser on the seating rate and vertical discrepancy of full crowns with four different internal configurations: A) unrelieved; B) four layers of die spacer; C) eight layers of die spacer and D) unrelieved but vented occlusally. Crowns were luted with zinc phosphate cement under a static 5 Kg load alone and with three frequencies of vibration. The seating process was monitored electronically to determine seating rate and final fit. Venting and die relief enhanced seating under static load. Vibration increased the seating rate and reduced vertical discrepancy of groups B to D crowns compared to group A crowns. Medium frequency vibration with group C and D crowns gave the smallest vertical discrepancies. Vibration did not improve the final seating of group A crowns. This suggests that vibration is only effective when an escapeway of some kind is provided.

Cementation↗

Factors ensuring consistent audibility in pediatric hearing aid fitting.

Ensuring consistent audibility is an important objective when fitting hearing aids to children. This article reviews the factors that could affect the audibility of the speech signals to children. These factors range from a precise determination of the child's hearing loss to an accurate specification of gain in the chosen hearing aids. In addition, hearing aid technology and features such as multichannel processing, directional microphones, and feedback cancellation that could affect the achievement of consistent audibility are reviewed.

Child↗

An examination of cingulum rest seats in incisor and canine teeth.

This study examined rest seats prepared in the cingula of incisor and canine teeth in terms of their form and their ability to offer denture support. Fifty rest seats prepared in vivo were examined and the fit of the denture framework was assessed at the trial insertion stage. Twenty two of the rests investigated showed no approximation (within 0.1 mm) between the casting and the floor of the rest seat. Investigations in vitro showed the provision of rest seats reduced the labial displacement of incisor and canine abutments under transmitted load compared to the same teeth without preparations.

Cuspid↗

Variables affecting rigid contact lens comfort in the collaborative longitudinal evaluation of keratoconus (CLEK) study.

PURPOSE: To identify factors associated with rigid contact lens comfort in keratoconus. METHODS: Baseline data from the 16 Collaborative Longitudinal Evaluation of Keratoconus (CLEK) Study clinical sites were analyzed for all patients wearing a rigid contact lens in their more severely keratoconic eye (as determined by steep keratometry). Corneal transplant patients, patients who did not wear a rigid contact lens in either eye, patients who did not wear a rigid lens in their worse eye, and patients with missing contact lens comfort data were excluded from the sample. A total of 751 eyes were included. Variables assessed included measures of disease severity, visual acuity through the patients' habitual rigid contact lenses, contact lens wearing time, the apical fitting relationship of the contact lens, the degree of peripheral clearance, and the presence of corneal scarring and staining. Comfort was measured by asking the patients "In general, how comfortable are your contact lenses?" (1 = very comfortable through 5 = very irritating). RESULTS: Measures of disease severity (steep keratometry and the first definite apical clearance lens) were not associated with lens comfort. There was no difference in self-reported contact lens comfort between patients fitted with apical touch vs. apical clearance. Patients with a peripheral clearance rating of "minimal unacceptable" (more common among patients with milder keratoconus) were approximately half as likely to report good contact lens comfort compared with patients with "average" peripheral clearance (unadjusted odds ratio, 0.39; 95% confidence interval, 0.19 to 0.79). There was no association between contact lens comfort and the other peripheral clearance ratings compared with ratings of average. CONCLUSIONS: There does not appear to be an association between decreasing patient-reported rigid lens comfort and increasing disease severity as measured by steep keratometry or first definite apical clearance lens in this sample. The apical fitting relationship (flat vs. steep) does not appear to be associated with patient-reported comfort. Minimal peripheral clearance may contribute to decreased rigid contact lens comfort in keratoconus.

Adult↗

Measuring hearing aid outcomes using the Satisfaction with Amplification in Daily Life (SADL) questionnaire: Australian data.

The aims of this study were to investigate hearing aid satisfaction for a group of older Australians fitted with government-funded hearing aids using the Satisfaction with Amplification in Daily Life (SADL) questionnaire; to compare the Australian data gathered with the provisional normative data reported by Cox and Alexander (1999); and to investigate the relationship between SADL satisfaction and several participant variables, hearing aid variables, and other outcome measures. The SADL questionnaire and a Client Satisfaction Survey (CSS) were distributed by mail to 1284 adults fitted with government-funded hearing aids three to six months previously. 1014 surveys were returned. The mean age of participants was 75.32 years; 54.4% of participants were male, and 54.8% were fitted binaurally. Participants were fitted primarily with digitally programmable hearing aids of various styles (22.5% BTEs, 34.8% ITEs, 41.8% ITCs, 0.9% nonstandard [NS] devices). Overall, participants reported a considerable level of satisfaction with their devices. SADL Global and subscale scores were significantly higher for the Australian sample than the U.S. norms described by Cox and Alexander (1999).

Adult↗

Clinical experience with the Vibrant Soundbridge implant device.

OBJECTIVE: To evaluate the full degree and range of benefits provided by the Vibrant Soundbridge (VSB; Symphonix Devices, Inc., San Jose, CA, U.S.A.) and analyze pre-and postoperative results of audiologic tests. STUDY DESIGN: Single-subject study with each subject serving as his or her own control. SETTING: Multicenter clinical study conducted at 10 centers in Europe. PATIENTS: 47 patients who met the selection criteria for participation in the study. INTERVENTIONS: Implantation of the VSB direct-drive middle ear hearing device. MAIN OUTCOME MEASURES: Average change in unaided thresholds with the patient wearing headphones at each frequency pre-and postsurgery was measured. A mean threshold change less than 5 dB across all frequencies was considered clinically nonsignificant. RESULTS: 47 patients had successful surgery for implantation and fitting with the VSB device. CONCLUSION: The VSB is a new middle ear implant device that can be used safely in the treatment of patients with moderate to severe sensorineural hearing loss.

Acoustic Stimulation↗

Basic fitting and evaluation parameters of a newly designed cochlear implant electrode.

OBJECTIVE: To validate a newly designed cochlear implant electrode (TRACE) in the standard monopolar mode and compare it to a patient group implanted with a standard Nucleus Contour cochlear implant electrode. The electrode contacts of the TRACE electrode have the same active surface area for stimulation, but the position in the scala tympani is different from that of the Nucleus Contour electrode. MATERIAL AND METHODS: The following parameters, used in cochlear implant fitting and evaluation procedures, were determined: the threshold and comfort stimulation current levels; the electrode impedances; and the phoneme discrimination and speech recognition scores using the ACE speech algorithm. CONCLUSION: The new electrode does not differ significantly from the standard Nucleus Contour electrode in terms of the investigated parameters within the test group.

Acoustic Impedance Tests↗