To compare the acceptability and effectiveness of topical and infiltrationanesthesia for placement of mini-implants used as temporary anchorage devices.The sample comprised 40 patients, 17 males and 23 females, whose mean age was 26years old and who were all undergoing orthodontic treatment and in need foranchorage reinforcement. Mini-implants were bilaterally placed in the maxilla ofall individuals, with infiltration anesthesia on one side and topical anesthesiaon the other. These 40 patients completed two questionnaires, one before andanother after mini-implant placement and pain was measured through a visual analogscale (VAS). The data collected were analyzed using descriptive statistics and themeasurements of pain were compared by means of the non-parametric test ofMann-Whitney.It was found that 60% of patients felt more comfortable with the use of topicalanesthesia for mini-implant placement; 72.5% of patients described the occurrenceof pressure during placement of the anchorage device as the most unpleasantsensation of the entire process; 62.5% of patients felt more pain with the use oftopical anesthesia.It was concluded that patients had less pain with the use of infiltrationanesthesia, and also preferred this type of anesthetic. According to Newton's third law, every action has a reaction of equal magnitude andtowards its opposite direction. Therefore, when a force is applied with the purpose ofachieving orthodontic movement, the teeth used as support (anchorage) will have areaction with the same intensity towards the opposite direction, which, in most cases,may generate undesirable effects.In order to avoid such undesirable effects in orthodontic mechanics, the clinicianshould carefully plan the anchorage to be employed during treatment. However, some typesof anchorage directly depend on patient's compliance, which may compromise the finalresults.With a view to solving the issues related to anchorage, dentists have had thepossibility of using devices that enable skeletal support for tooth movement.1Mini-implants and mini-plates are among the skeletal anchorage devices most commonlyused for orthodontic mechanics. The use of mini-plates and mini-implants enable dentalmovement to be safely performed, many times, without undesirable side effects, at thevertical, transverse, and anterior-posterior planes.3The orthodontic loads of continue and unidirectional nature and of low magnitude are notcapable of generating osteolytic activity on the bone interface of theimplant.4 Additionally, the association with osseointegrated implants isanother factor that contributes to increase the rejection and fear of patients withregard to the use of mini-implants. Several topical anesthetics are available to be usedbefore minor dental procedures are performed and they are largely accepted by thepatients.Assessment of patients' acceptance factors regarding the use of mini-implants duringorthodontic treatment reveals that the need for infiltrative anesthesia is one of thefactors that patients reject the most.5The ideal topical anesthetic would promote complete anesthesia, with fast action onsetand without any side effects. The agents currently available, however, are only close tothis ideal.7 Some authors have reported that mini-implants could besuccessfully and comfortably placed with the use of topical anesthetic, only.8 Two types of topical anesthetics used formini-implant placement have been compared, and one of them showed highly satisfactoryresults.9 Additionally, it hasbeen proved that 90% of patients undergoing mini-implant placement with the aid oftopical anesthesia only, would accept to have mini-implants replaced , if necessary. Inthis study, 40% of patients reported not having felt any type of pain during placementof the mini-implant, while 20% reported mild pain.11The possibility of placing mini-implants with the use of topical anesthetic only, hasalready been suggested in the literature.However, no study has been conducted to compare the acceptability and effectiveness ofinfiltrative and topical anesthetics. Thus, the aim of this study was to compare, bymeans of pre and post-operative questionnaires answered by the patients, theacceptability and discomfort of infiltrative and topical anesthetics used for placementof mini-implants as skeletal anchorage in Orthodontics.This study was approved by the Ingá School of Dentistry Institutional Review Board.Sample calculation was based on alpha error of 5% and beta error of 20%, so as toreach a power test of 80% in order to detect a significant difference of 1.00 cm inVAS scale, with a standard deviation of 1.5, resulting in 36 subjects required foreach group.The study sample comprised 40 patients, 17 males and 23 females, with mean age of 26years old . All patients underwentorthodontic treatment and needed bilateral absolute anchorage through mini-implantsin the maxilla.This was a prospective study of which patients were treated in the OrthodonticClinics of the Masters Course of the Ingá School of Dentistry, and required theplacement of bilateral maxillary mini-implants while the study was being carried out,until the number of 40 subjects was obtained.All patients had the mini-implants placed at the same appointment. The anesthetic wasused alternately, that is, the topical anesthetic was applied on one side, while theinfiltrative anesthetic was used on the other side. The anesthesia was applied by oneexaminer who had been previously trained by a Professor of the Masters Course inOrthodontics who, in turn, has extensive expertise in the mini-implant placementeither with infiltrative or topical anesthesia.Two questionnaires (one before and one after mini-implant placement) were given toeach patient in order to compare the efficiency of each anesthetic.Patients underwent two different anesthetic procedures for mini-implantplacement:» Infiltrative - lidocaine hydrochloride+ epinephrine 1:100,000  applied where themini-implant was placed, with the aid of a 0.30 x 21 mm gingival needle(Terumo) in the mucosa area, only, with 1/5 of the tube being injected.Mini-implant placement was performed 2 minutes after the infiltrativeanesthesia was applied.» Topical: on the opposite side, topical anesthetic gel with 20% lidocaine  was applied for 7minutes on the area of the mucosa that received the mini-implant. If thepatient reported great pain during mini-implant placement with topicalanesthetic, the procedure would be interrupted and the infiltrative anestheticwould be used.Self-drilling mini-implants 6 mm in length and 1.5 mm in diameter  were used in this study. To place the implants, a surgical kit withhand key  was used.All patients included in this study were submitted to the following protocol:» The patient answered the pre-operative questionnaire.» Drying with air jet and relative isolation was performed with cotton rolls tomove the lip away from the area where the mini-implant would be placed undertopical anesthetic.» Topical anesthesia with 20% lidocaine gel was applied on a cotton pelletplaced onto the mucosa where the mini-implant would be placed. The gel had tobe kept on the mucosa for 7 minutes.» Removal of excess gel with the aid of a gauze.» Mini-implant placement.» On the opposite side, infiltrative anesthesia with Alphacaine 100  was applied in the area where themini-implant would be placed.» Mini-implant placement 2 minutes after anesthesia.» The patient answered the post-operative questionnaire.The type of anesthesia that was applied first should be alternated for every otherpatient. All mini-implants were placed without the need for previous perforation.http://dpjo.dentalpresspub.com/editions/v19n2/076-083/).The patients included in the sample were submitted to questionnaires comprised ofobjective questions before and after mini-implant placement. ,A descriptive statistical analysis was performed. The comparison of the VAS resultsfor topical and infiltrative anesthetics was performed by means of the Mann-Whitneynon-parametric test.To evaluate the sexual dimorphism of the responses of VAS, the Mann-Whitneynon-parametric test was applied.All tests were performed with the aid of Statistica software . The level of significance was set at P < 0.05.Out of the 40 patients comprising the sample, 65% answered that they calmly acceptedthe proposal for mini-implant placement . 67.5% oWhen asked about the most worrying procedure, the responses "Mini-implant placement"and "Infiltrative anesthesia (needle)" were the most frequent ones with 37.5% and 35%respectively .Sixty percent (60%) of patients claimed to feel more comfortable towards havingmini-implants placed with topical anesthesia .Twenty-nine patients (72.5%) reported that pressure during mini-implant placement wasthe most unpleasant sensation they felt during treatment . When asAccording to the responses obtained, the anesthetic of choice of the majority ofpatients was the infiltrative anesthetic (23 patients), while 13 patients preferredthe topical anesthetic and 4 patients reported they did not have any preferenceregarding the anesthetic used .Only one patient claimed to refuse having mini-implant replaced, if necessary .Mean values of pain were obtained by assessment of the visual analogue scale used inquestion 4 of the post-operative questionnaire. The infiltrative anesthetic obtaineda mean value of 0.3125, while the topical anesthetic obtained a mean value of 3.0875.These data were compared through the Mann-Whitney non-parametric test, withstatistically significant differences. As a result, mini-implants placed with topicalanesthetic caused significantly more pain than those placed with topical anesthesia,as shown by the VAS scale . When th11 In thepresent study, the use of topical gel anesthetic (20% lidocaine)11 was chosen because it reaches good levels of analgesia, can beeasily handled and does not cause tissue damage, as previously reported by theliterature. The application protocol used in this study also followed therecommendations of a previous study,10 that is, the gel was kept in contact with the mucosa for 7minutes under relative isolation and care so that it did not surpass the area ofinterest.Many authors have suggested the possibility of using topical anesthetic formini-implant placement with a view to obtaining the analgesia required for completeinsertion of the anchorage device without blocking the sensibility of the surroundingstructures, thus, reducing the chances of damages if the mini-implants reaches thesestructures.®) was used due to the fact that it is largelyemployed in Dentistry with low toxicity rates and enough anesthetic effect. Theamount of anesthetic used was of 1/5 of the tube, injected in the area of the mucosawhere the mini-implant would be placed so as to allow a satisfactory anesthesia andprevent the surrounding structures from being anesthetized, as suggested by theliterature.14With regard to the infiltrative anesthetic, lidocaine hydrochloride + epinephrine1:100,000 (Alphacaine 100®), 6 mm in length and 1.5 in diameterwere used with the aid of a surgical kit (Conexão®). The sequence ofinsertion was carried out in turns: half of times infiltrative anesthesia was thefirst procedure, while half of times topical anesthesia was applied first. The sidesof insertion were also alternated in order to avoid any potential influences overpatients' responses.Self-drilling mini-implants  and did not aim at evaluating different types of anesthesia,which could have influenced the data obtained.15leading some of them to refuse being submitted to procedures of anchorage deviceplacement.Infiltrative anesthesia was reported by 14 subjects as one of the most fearfulprocedures, followed by the fear of mini-implant placement, chosen by 15 patients.Sixty percent of patients reported that the use of topical anesthetic made them feelmore comfortable with regard to the procedure, which proves that infiltrativeanesthesia applied with the aid of a needle causes certain discomfort in aconsiderably number of patients,4but disagrees with what was found by Santos et al11 who reported that patients did not feel anythingunpleasant.After mini-implant placement, patients reported that the most unpleasant sensationthey felt during the entire procedure was the pressure during placement, which wasalso observed by another study,Twenty-five patients pointed out that topical anesthesia caused the most painfulsensation, proving that infiltrative anesthesia resulted in greater anesthetic effectfor the patients of the sample.9 who compared two types of topical anesthetics, the failure rate was of 71% (12cases) when 20% benzocaine was used, whereas there was no failure when 20% lidocaine+ 4% tetracaine + 2% phenylephrine anesthetic was used.Mini-implant placement could not be completed in three patients who received topicalanesthetic. These patients reported severe pain, and for this reason, the procedurewas discontinued, following the methods of this study. Later on, these same patientsunderwent infiltrative anesthesia and in two of them, the mini-implants were placedunder infiltrative anesthesia. The other case was initiated by topical anesthetic. Inthe study conducted by Reznik et al,11 10% of patients would notaccept it, and according to Brandão and Mucha,4 10% of patients would not recommend this procedure to otherpatients.When patients were asked whether they would accept to have mini-implants replaced,97.5% (39 patients) gave affirmative answers, while in the study conducted by Santoset al,The analysis of the data obtained with the visual analogue scale demonstrated thatthe mean values exhibited by the infiltrative anesthesia were minimum andsignificantly lower than those of the topical anesthesia . MoreoveThe results of the visual analogue scale divided by sex demonstrated lower meanvalues for females when topical anesthetic was used. However, when the Mann-Whitneynon-parametric test was applied to verify sexual dimorphism, the values did not proveto be statistically significant .Failure was reported in three cases of mini-implant placement under topicalanesthesia. Following the methods established for this study, infiltrative anesthesiawas then applied and the anchorage device was installed. However, it was clear that,in all three cases of failure, the patients exhibited great anxiety while theprocedure was being carried out, and after infiltrative anesthesia, they did notreport any pain. The present study demonstrates that patients reported greatersensitivity in cases of mini-implant placement under topical anesthesia, without,however, reporting any discomfort during the anesthetic application. On the otherhand, in cases of mini-implant placement carried out under infiltrative anesthesia,patients reported certain degree of discomfort during anesthetic application, butsignificant comfort during mini-implant placement, which must be assessed by both thedentist and the patient in the decision for which type of anesthetic should beemployed.Mini-implant placement under topical anesthesia seems to be a viable option in casesin which patients refuse to undergo infiltrative anesthesia in fear of the needle,especially in less anxious patients.Based on the results of the present study, it is reasonable to conclude that:» The use of topical anesthetic results in more comfort to patients undergoingmini-implant placement procedures;» Patients considered pressure during mini-implant placement as the mostunpleasant sensation;» Pain sensitivity of mini-implant placement with topical anesthetic wassignificantly greater than that of infiltrative anesthesia;» Most patients submitted to mini-implant placement preferred the procedure underinfiltrative anesthesia.


Previous studies described cases of Ocriplasmin injections in patients with vitreo-macular traction and reduced central visual acuity. We describe the first case of a patient with 20/20 visual acuity and vitreo-macular traction treated with Ocriplasmin, and, for the first time in literature, we evaluated the functional changes of the macula in response to pharmacological treatment through multifocal-electroretinogram.p < 0.03). Visual acuity remained constant with resolution of symptoms and the appearance of vitreous floaters.We report the case of a female Caucasian patient aged 67 years with vitreo-macular traction in the right eye, treated with Ocriplasmin, at the Eye Clinic of the Second University of Naples. Visual acuity was 20/20 before treatment, associated with metamorphopsia. Two weeks after injection, optical coherence tomography showed the release of vitreo-macular traction and multifocal electroretinogram responses showed a significant increase of retinal density responses in all six rings  on a larger study sample are needed to confirm our results. The treatment of vitreomacular interface disorders, in particular vitreomacular adhesion (VMA), vitreomacular traction (VMT), and full-thickness macular hole, has traditionally been limited to either surgical or observational management. Recently, Ocriplasmin , a recombinant truncated form of human serine protease plasmin with activity against components of the vitreoretinal interface, including fibronectin and laminin, was approved for the treatment of symptomatic VMA . When inWe describe the case of a 67-year-old woman with VMT in the right eye, visual acuity of 20/20 and metamorphopsia, treated with intravitreal Ocriplasmin. This is the first time that a patient with preserved visual acuity is treated with Ocriplasmin and that morphological and functional changes of the macula are highlighted using both spectral domain optical coherence tomography (SD-OCT) and multifocal electroretinogram (mf-ERG).We present a clinical case of a 67-year-old-woman with VMT in the right eye. Two years previously, she underwent vitrectomy in the left eye for macular hole at the Eye Clinic of the Second University of Naples. On examination, the patient referred metamorphopsia in the right eye. A complete ophthalmic examination was performed, including best-corrected visual acuity (BCVA) by Snellen visual chart, slit lamp biomicroscopy, fundus examination, SD-OCT and mf-ERG before treatment, and at one and two weeks after intravitreal Ocriplasmin injection in the right eye. BCVA was 20/20 in the right eye. Fundus examination and SD-OCT revealed VMT with distortion of the foveal contour and cystoid changes within the retina in the right eye. The inner segment-outer segment (ellipsoid) photoreceptor layer was altered for morphology and reflectivity in the central portion corresponding to the VMT in the right eye Fig. .Fig. 1SpOne week after intravitreal injection of Ocriplasmin (0.125 mg/0.1 mL) in the right eye, BCVA was stable to 20/20 in the injected eye. SD-OCT demonstrated changes of retina with persistence of VMT and alteration of the ellipsoid layer Fig.  while mfp < 0.001) and a significant reduction of the latency at an estimated exponential rate of 0.4 % per week (p = 0.009).Two weeks after treatment, we observed VMT release, stable visual acuity and a preserved foveal profile showing a small cystic alteration and a continuous ellipsoid layer in right eye Fig. ; mf-ERG Our study analyzes the first case of Ocriplasmin treatment in a patient with VMT and 20/20 visual acuity. Our patient satisfied all inclusion and exclusion criteria of MIVI-TRUST clinical trials , with thRecent case reports , 6 have Our patient maintains a visual acuity of 20/20 but refers vitreous floaters after treatment. The release of VMT is documented through OCT. The morphological analysis showed an alteration of the ellipsoid layer only in the portion below the VMT with resolution following its release.Above all, our work shows that the anatomical result coincides with the functional improvement recorded by mf-ERG. The density response analysis demonstrated a significant increase in the foveal peak of the treated eye after injection compared to baseline testing. Moreover, mf-ERG responses showed a significant increase of P1 wave amplitude and a reduction of latency in all six rings compared to baseline values. mf-ERG reflects the electrophysiological response of cones, but also those of the inner retinal layers . VMT relIntravitreal injection of Ocriplasmin was a safe and effective treatment in our case, characterized by a preserved visual acuity. Our data show that the anatomical recovery with release of VMT is associated with a full functional recovery, without visual acuity loss. In fact, the electrical retinal density response of the macular area improved two weeks after Ocriplasmin injection. Appropriate attention to details is important in patient selection as such selection of suitable candidates could determine good outcomes following treatment with Ocriplasmin. Since the present study reports only one case, further studies on an adequate sample are needed in order to approve broader selection criteria including subjects with higher visual acuity.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.


Mammary analogue secretory carcinoma (MASC) is a recently recognized tumor of salivary glands characterized by the ETV6-NTRK3 fusion gene. This tumor is very rare in children and adolescents. We report a case of MASC in a 15-year-old girl, the fifth youngest case so far reported. The patient complained of a left infra-auricular mass that gradually enlarged for a year. Fine-needle aspiration cytology/imprint cytology showed individual tumor cells that had faintly eosinophilic granular cytoplasm with secretion granules sometimes seen adjacent to the tumor cells. These cytological features overlapped between those of zymogen granule-poor acinic cell carcinoma (AciCC) and MASC. In addition to the case report, we present a review of the related literature with a focus on the cytological features of MASC. The differential diagnostic clues are also discussed. Malignant tumors of the salivary gland are rare in the pediatric population. Of these, the most common histological types are mucoepidermoid carcinoma (MEC) and acinic cell carcinoma (AciCC) . Mammary ETV6-NTRK3 fusion gene by RT-PCR. A retrospective review of the cytology indicated convincing features of MASC. We discuss here what could aid the diagnosis of MASC and the differentiation from acinic cell carcinoma (ACiCC), one of the most difficult salivary gland tumors to differentiate. As far as we know, only 7 cases of MASC have been reported with molecular confirmation below 19 years of age [Herein, we report a case of parotid gland MASC in a 15-year-old girl along with a review of the literature on MASC in the young. Our case was cytologically diagnosed as “ACiCC, mostly composed of intercalated duct cell type.” After surgical resection, it was successfully diagnosed as MASC of the parotid gland, by the detection of ans of age , and thiA 15-year-old girl visited hospital for an otorhinolaryngology consultation because of a left infra-auricular mass, which had shown gradual enlargement for a year. Ultrasound-guided fine-needle aspiration (FNA) was performed and the diagnosis of possible ACiCC was rendered. The patient was introduced to our hospital in order to proceed onto surgery. The FNA materials obtained at the former hospital, consisting of 2 Papanicolaou-stained slides and 1 Giemsa-stained slide, were submitted to our hospital and ACiCC was again most strongly suspected by our cytological diagnosis. A CT scan showed a 2.8 cm sized mass in the left parotid gland . The patThe FNA specimen and imprint specimen showed similar cytological features; that is, the architecture of cells, individual cell appearance, and background were very similar between them. The cell clusters were mostly thin sheet-like, sometimes with slight accumulation, or were seen in an arborizing pattern with a vascular core . Tubule Cut sections of the surgical specimen showed a 3.0 × 2.8 × 2.5-cm sized, uncircumscribed, whitish, elastic hard mass in both lobes of the left parotid gland . HistopaPeriodic acid Schiff (PAS) stain showed positivity for the eosinophilic material inside the dilated tubule and the luminal site of the tumor tubules, but negativity for the cytoplasm, suggesting a lack of zymogen granules. Immunohistochemically, tumor cells were intensely positive for S-100 , GCDFP-1 ETV6-NTRK3 fusion transcript in this tumor (Figures A formalin-fixed, paraffin-embedded section obtained from the surgical specimen was submitted for RT-PCR studies. RNA was extracted and converted into cDNA. RT-PCR was performed using previously described primer pairs . This an Figures . The finMASC was first described by Skálová et al. in 2010  and moreThe cytological distinction between zymogen granule-poor ACiCC and MASC without molecular study or immunohistochemical study is very difficult, since the cytology of MASC has many overlapping features with AciCC. However, there seem to be several cytological features suggestive of MASC, such as papillary structure, extracellular and intracellular mucinous material, vacuolated cytoplasm, tumor cells with low-grade nuclear atypia, and abundant vascularity –8, 10–12In MASC, it is described that perineural invasion is uncommon and that lymphovascular invasion has not been reported; therefore, MASC is currently regarded as a low-grade carcinoma, and its prognosis appears to be favorable . The preIn conclusion, the cytological features of MASC of the salivary gland of a 15-year-old girl were reported. Since preoperative FNA is increasingly and widely used for tumors of the salivary gland owing to its simplicity and safety, it is necessary for cytologists and pathologists to be aware of the cytology of recently established tumors such as MASC.To the best of our knowledge, this is the fifth youngest case of MASC reported in the literature.


Disproportionality methods measure how unexpected the observed number of adverse events is. Time-to-onset (TTO) methods measure how unexpected the TTO distribution of a vaccine-event pair is compared with what is expected from other vaccines and events. Our purpose is to compare the performance associated with each method.For the disproportionality algorithms, we defined 336 combinations of stratification factors  and threshold values of the multi-item gamma Poisson shrinker (MGPS). For the TTO algorithms, we defined 18 combinations of significance level and time windows. We used spontaneous reports of adverse events recorded for eight vaccines. The vaccine product labels were used as proxies for true safety signals. Algorithms were ranked according to their positive predictive value (PPV) for each vaccine separately; amedian rank was attributed to each algorithm across vaccines.th rank overall, which was fully stratified and had a threshold value of 0.8. A TTO algorithm with roughly the same sensitivity as the highest-ranked MGPS had better specificity but longer time-to-detection.The algorithm with the highest median rank was based on TTO with a significance level of 0.01 and a time window of 60 days after immunisation. It had an overall PPV 2.5 times higher than for the highest-ranked MGPS algorithm, 16Within the scope of this study, the majority of the TTO algorithms presented a higher PPV than for any MGPS algorithm. Considering the complementarity of TTO and disproportionality methods, a signal detection strategy combining them merits further investigation. Suspected adverse reactions following immunisation with marketed vaccines are reported to a spontaneous report system allowing continuous monitoring to detect new safety signals. These reports, coming from sources including regulatory authorities, health care professionals and consumers, are related to the real-life, post-licensure use of these vaccines. Those related to GlaxoSmithKline (GSK) vaccines are stored in the company's safety database Operating Company Event Accession and Notification System (OCEANS).On 1 February 2010, OCEANS contained 147 015 spontaneous reports of 28 425 distinct vaccine-event pairs, involving 45 distinct GSK vaccines suspected and 4331 distinct MedDRAThe most frequent methods for analysing spontaneous reports in pharmacovigilance are numerator-based, disproportionality analyses (DPA) The multi-item gamma Poisson shrinker (MGPS) 9We recently demonstrated that these vaccine-event pairs could also be routinely screened for unexpected time-to-onset (TTO) distribution with a two-sample Kolmogorov-Smirnov test.The aim of this paper is two-fold. Firstly, we compare the performance of the two methods by taking into consideration the parameters that could play a role in their respective performance. Two parameters were selected for the TTO signal detection: the alpha level and the time window. A previous evaluation of the performance of MGPS using the same data set showed that the set of stratification factors and, especially, the cut-off value influenced MGPS performance directly 10A total of 336 different combinations of stratification factors ((S)ex, (A)ge, (R)egion and (Y)ear) and cut-off values for the MGPS usage were assessed .– the TTO distribution of the same vaccine but with other events reported (‘between events’)andTime-to-onset signal detection is a non-parametric data mining algorithm for detecting vaccine-event pairs presenting TTO distributions that differ significantly from:– the TTO distribution of the same event but reported after administration of other vaccines (‘between vaccines’)at a given significance alpha level and within a given time window.The TTO signal detection method aims at detecting patterns of TTO that deviate from the overall pattern of reported TTO assuming to be mainly driven by reporting biases and noise.Eighteen different combinations of alpha levels  and time windows  for TTO signal detection (SD) were investigated. Each TTO SD algorithm was labelled TTO-‘alpha level’-‘length of time window’.Rotarix™ (live paediatric), Engerix™ (inactivated for adults), Cervarix® , Fluarix™ (inactivated for adults), Infanrix™ (inactivated paediatric), Infanrix™ Hib (inactivated paediatric), Havrix™ (inactivated for adults) and Twinrix™ (inactivated for adults). These vaccines were selected for their heterogeneity of indications and their overall volume of reports. The characteristics of case reports are summarised for each vaccine in Table For practical reasons, the evaluation was restricted to eight different vaccines  in the GSK vaccines database and was not restricted to the eight vaccines described previously.The proportion of vaccine-event pairs with a TTO between 0 and 90 days varied between 36.4% and 78.9% Table . For eacTo assess the performance of each algorithm, a gold standard is needed to identify all events that are ‘truly causally’ related to the vaccine. This set of events is unknown but can be approximated by events listed in the Global Product Information (GPI). For each of the eight vaccines, each adverse reaction listed within the core company safety information of the GPI was mapped to one or more synonymous or medically equivalent MedDRA preferred terms (PTs). These MedDRA PTs were used as a proxy of the set of true signals.10Using the gold standard definition and signal detection scores, we classified each reported vaccine-MedDRA PT pair as true positive (TP), false positive (FP), true negative (TN) or false negative (FN).As described previously,The median rank of the PPV associated with each parameter was computed with its standard deviation of the rank across all vaccines to estimate robustness of the performance.p-value cut-off and for the 16 MGPS algorithms (with different combinations of stratification factors) by varying the cut-off on the EB05.Receiver operating characteristic (ROC) curves Another aspect in the performance of a signal detection algorithm is the timing of the detection. The detection dates of TP signals flagged by the highest PPV-ranked MGPS algorithm and by the TTO algorithm detecting approximately the same number of TP signals were compared to determine which algorithm detects TP signals more rapidly . For each of the two signal detection algorithms, we compared the number of spontaneous reports present in OCEANS at the time of first detection of a TP signal. We also compared the number of spontaneous reports actually used by each method at the time of first detection. Indeed, the spontaneous reports without TTO information in the time window of interest were not considered as ‘used’ by the TTO signal detection algorithm whereas they were considered as ‘used’ by the MGPS algorithm.th and was stratified by sex, age, region and year with a cut-off value of 0.8 (0.8-SARY), consistent with previous results where the range of investigated thresholds for the EB05 was between 0 and 2.th (2.4-SRY).The algorithm with the highest median PPV rank was a TTO algorithm with an alpha level of 0.01 for the Kolmogorov-Smirnov tests and a time window of 60 days after immunisation Table . The higp-value threshold from 0 to 1 by 0.01 and for each MGPS set of stratification factors by varying the EB05 threshold from 0 to 10 by 0.1  time window]. On the other hand, the highest ranking TTO signal detection algorithm TTO-01-60 did not detect TP signals from a zone characterised by a high percentage of reports with time-to-onset values outside of the  days interval or a low number of spontaneous reports. The highest ranking MGPS algorithm was able to detect some TP signals in this zone. A minimum of ten time-to-onset values in the interval  days discriminates the zone where signals are systematically missed by the highest ranking TTO signal detection method characterised by highest PPV. The TP signals detected by both algorithms are characterised by a higher number of spontaneous reports.The TTO-20-90 algorithm, which detected a similar number of TPs for fewer FPs than the highest-ranked MGPS algorithm 0.8-SARY Table , can detThe TTO-20-90 and 0.8-SARY algorithms detected approximately the same number of TP signals ; 104 were detected by both.The results of these two time-to-detection analyses showed that, on average, the algorithm 0.8-SARY needs less spontaneous reports (a median of 6.5 spontaneous reports less) than the algorithm TTO-20-90 for first detection of a TP signal Figure . HoweverThe highest-ranked TTO signal detection algorithm performs up to 2.5 times better, in terms of overall PPV, than the highest-ranked MGPS. This TTO signal detection algorithm, which uses an alpha level of 0.01 and a time window of 60 days, is also more specific than any MGPS algorithm and provides then a more manageable number of signals compared with the optimised MGPS fully stratified by sex, age, region and year with an EB05 cut-off of 0.8.11When looking at secondary performance measures, this highest-ranked TTO SD algorithm was characterised by lower sensitivity than the highest-ranked MGPS. However, other TTO SD algorithms with higher alpha levels (such as TTO-20-90) provided similar sensitivity and numbers of TP signals than the highest-ranked MGPS algorithm but with higher specificity and a higher PPV.The ROC curves highlighted that the performance of the TTO algorithms are above the performance of the MGPS algorithms whatever the choice of stratification factors and independently of a cut-off choice. However, for TTO algorithms, the sensitivity was truncated to 60%, and the only way to achieve 100% of sensitivity was to consider every reported vaccine-event pair as a TTO signal even if no TTO information in the time window under scrutiny was available.In terms of time-to-detection, the algorithm 0.8-SARY needed on average less spontaneous reports than the algorithm TTO-20-90 for first detection of a TP signal. However, the signals found by TTO-20-90 are on average based on a smaller number of case reports than those used by 0.8-SARY as this last one requires all spontaneous report data and not only the subset of those with non-missing time-to-onset information within a 90 days period after immunisation. Consequently, the fact that 0.8-SARY detects on average faster than the TTO-20-90 algorithm can be attributed to the fact it uses all spontaneous reports. The better performance of 0.8-SARY over TTO-20-90 in terms of time-to-detection could be challenged in case the quality of the reporting of time-to-onset information increases. The time-to-detection was assessed based only on the subset of TP signals detected by both algorithms. However, not all vaccine-event pairs presenting a causal association have the potential for being detected by both 0.8-SARY and TTO-20-90. Indeed, some events could have no specific temporal relationships in the 90 days period after immunisation but could still be characterised by a number of observed cases higher than expected. That could happen for long-term events or when the TTO is systematically missing. On the other hand, some events could be characterised by only a very small excess of observed (reported) cases not enough to be detected by 0.8-SARY but detectable by TTO-20-90 in case all the excess cases are in a very narrow time within the 90 days period after immunisation Consequently, the measure of relative performance of 0.8-SARY and TTO-20-90 depends of the events labelled and the related products. It could favour one method over the other, making the generalisation to other products (like drugs for example) hard.The overall performance was better for the TTO signal detection method than for the MGPS signal detection method. Although, the MGPS method used all vaccine-event pairs from OCEANS, the TTO signal detection method used only 55% of them. That could be explained by the fact that the TTO information may more closely predict causality than the strength of association. Indeed, a systematic review of the methods used for causality assessment of adverse drug reactions showed that the TTO was the most frequent criterion used to assess causality across different methods.The empirical comparison of the performance of the MGPS and TTO algorithms on the eight vaccines under study showed the promising potential of the TTO signal detection method. However, some limitations have to be kept in mind. Indeed, the comparison of performance was retrospective and used the GPI as gold standard. As the reporting of known adverse events following immunisation is likely to differ from that of unknown safety risks, either in reporting rate or in time-to-onset distribution, the assessed performance of each algorithm to detect listed events may differ from the performance in detecting unknown safety risks.Currently, the most widely used signal detection algorithms As stressed in the proof-of-concept study,a priori not consider this option as viable for a signal detection system. On the other hand, flagging signals that are detected by the MGPS or the TTO SD would result in a signal detection system with low specificity and high sensitivity. This may not be optimal considering the difference in performance between the TTO and MGPS signal detection algorithms.Only flagging signals that are detected by both MGPS and TTO SD methods would result in a system with lower sensitivity and higher specificity than either individual method. Knowing that we would systematically lose the ability to detect uncommon and long-term events, we would Consequently, further methodological research is needed to build a signal detection algorithm that accounts for both causality criteria: the strength of association estimated by a disproportionality measure and the unexpectedness of the time-to-onset distribution estimated by the two-sample Kolmogorov-Smirnov tests. As summarised by Manfred Hauben,Any spontaneous reporter of an adverse event  should be made aware of the importance of reporting as precise and complete TTO information as possible through spontaneous reporting systems. The coding of the TTO information into the spontaneous safety database should reflect the level of precision provided by the reporter: the reported precision unit could be minutes, hours, days, weeks, months or even years. As demonstrated here, TTO data may be used not only for causality assessment at the case level but also for signal detection.For the eight vaccines under study, the majority of the TTO algorithms provided a higher proportion of TP signals than any MGPS algorithm.Nevertheless, the TTO method is dependent on the quality of the TTO data, which depends on the safety database and the data provided by the reporter.We suggest using both TTO and disproportionality methods in parallel to benefit from the greater ability of the TTO method to detect TP signals and avoid signals being missed (or delayed) when TTO data are of low quality. However, additional research is still needed to build the statistical framework to facilitate this parallel usage.ROTARIX, ENGERIX, FLUARIX, INFANRIX, HAVRIX and TWINRIX are trademarks of the GSK group of companies.CERVARIX is a registered trademark of the GSK group of companies.Disproportionality methods measure the strength of association between a vaccine and an event.TTO signal detection methods measure how unexpected the TTO distribution of a vaccine-event pair is.A comparison of the different parameterization choices of both methods highlighted the better performance, in terms of PPV, of the TTO signal detection method over the disproportionality method on the GSK vaccine spontaneous report data.Because of the complementarity of the two methods, a signal detection strategy combining both of them merits further investigationBoth authors are employees of GSK vaccines.


In 7 studies, rates ranged from 26% to 44%; in 2 studies, rates were −3% and −4%, respectively. Enterobacteriaceae by using studies from around the world published before April 9, 2012. Attributable death was defined as the difference in all-cause deaths between patients with carbapenem-resistant infections and those with carbapenem-susceptible infections. Online databases were searched, and data were qualitatively synthesized and pooled in a metaanalysis. Nine studies met inclusion criteria: 6 retrospective case–control studies, 2 retrospective cohort studies, and 1 prospective cohort study. Klebsiella pneumoniae was the causative pathogen in 8 studies; bacteremia was the only infection in 5 studies. We calculated that 26%–44% of deaths in 7 studies were attributable to carbapenem resistance, and in 2 studies, which included bacteremia and other infections, −3% and −4% of deaths were attributable to carbapenem resistance. Pooled outcomes showed that the number of deaths was significantly higher in patients with carbapenem-resistant infections and that the number of deaths attributable to carbapenem resistance is considerable.We evaluated the number of deaths attributable to carbapenem-resistant  Enterobacteriaceae family (Klebsiella pneumoniae carbapenemase (KPC) and Verona integrin–encoded metallo-β-lactamase (VIM) (Enterobacteriaceae (CRE) have been recorded in health care facilities around the world (Carbapenem-resistant strains have emerged among species belonging to the Enterobacteriaceae (CSE)  and Scopus (http://www.scopus.com/home.url?zone=header&origin=searchbasic) databases on April 9, 2012, by using the following search terms: carbapenem-resistant or carbapenemase-producing or KPC and outcome or mortality. We also conducted a hands-on search of the reference lists of relevant studies to identify additional studies. Articles published in languages other than English, French, German, Italian, Spanish, or Greek were not evaluated.We performed a systematic search in the PubMed (Any article that compared death rates between CRE-infected patients and CSE-infected patients was considered eligible for inclusion in the review. Studies that reported only on carbapenem-resistant isolates (without comparison with susceptible isolates) were excluded, as were studies that compared patients who had carbapenem-resistant infections with patients who were not infected. Other excluded studies were those that did not distinguish the outcomes for infected patients from those for colonized patients and studies that reported on isolates resistant to a carbapenem other than imipenem, meropenem, or doripenem. Studies that compared infection-related but not all-cause deaths among CRE-infected patients with those among CSE-infected patients were excluded because of homogeneity of the outcome analysis. Unpublished studies presented as abstracts at scientific conferences were not eligible for inclusion because of the low quantity of information provided in these types of articles.Literature search, study selection, and data extraction were performed independently by 2 of the authors (G.S.T. and K.Z.V.). Any disagreement was resolved by consensus in meetings with all investigators and by reviewing the original articles to assess validity of the abstracted data. Extracted data included study characteristics  and patient characteristics . We also recorded the all-cause deaths in each group of patients (CRE and CSE), deaths attributable to carbapenem resistance, and the independent predictors of all-cause deaths evaluated in the total population of each study.For studies in which analyses were performed for the individual patient groups (CRE and CSE) rather than the study population as a whole, we could not conclude whether carbapenem resistance predicted death. Thus, we did not extract results from such studies.K. pneumoniae). The secondary outcome was deaths attributable to carbapenem resistance in Enterobacteriaceae infections. Attributable death was defined as the difference in all-cause deaths between the 2 compared groups.We compared 2 groups of patients: CRE-infected and CSE-infected patients. The primary outcome of our analysis was the comparison of all-cause deaths between CRE and CSE groups with the same type of infection  caused by the same species  and the I2 index (for assessing the degree of heterogeneity)  and 95% CIs regarding deaths. The statistical heterogeneity between studies was assessed by using the χA total of 364 articles were retrieved during the search process: 152 in PubMed, 207 in Scopus, and 5 from hands-on searches of the reference lists of relevant studies. Of the 364 articles, 9 were considered eligible for inclusion in the analysis . Subgroup analysis was performed for studies that included only or mostly patients with bacteremia. In 6 studies (718 patients), the patients who had bacteremia caused by CRE had higher death rates than those who had bacteremia caused by CSE  (I2 = 77%).Our pooled analysis of the 9 studies (985 patients) showed that the death rate was higher among CRE-infected than CSE-infected patients   Figure. 82–2.63)  Figure (82–2.63)  Figure. We performed a multivariable analysis of deaths for the total study population in 7 of the 9 studies  and the presence and expression of OmpK26 in the resistant isolates.Data regarding the association between carbapenem resistance and virulence are scarce. In vivo and in vitro findings from1 study argued that carbapenem-resistant Enterobacteriaceae isolates than among patients with infections caused by non–extended-spectrum β-lactamase or non–multidrug-resistant isolates  on death could not be detected in the pooled analysis because only unadjusted data were entered. Furthermore, 8 of the 9 included studies had a retrospective study design. Data from such studies may be suboptimal compared with data from prospective studies, but this could not be tested due to the lack of prospective studies.Enterobacteriaceae infections. Further original studies are needed to determine the reason(s) for the increased risk for death from carbapenem-resistant isolates versus carbapenem-susceptible isolates. Our findings imply a need for strict infection control measures and a need for new antibiotics to protect against CRE infections.In conclusion, our findings suggest that the number of deaths attributable to carbapenem resistance is considerably high among persons with Enterobacteriaceae infections and death risk ratios for patients infected with carbapenem-resistant Enterobacteriaceae versus carbapenem-susceptible Enterobacteriaceae.Characteristics and outcomes of studies included in a systematic review and metaanalysis of deaths attributable to carbapenem-resistant


Target speaker identification is essential for speech enhancement algorithms in assistive devices aimed toward helping the hearing impaired. Several recent studies have reported that target speaker identification is possible through electroencephalography (EEG) recordings. If the EEG system could be reduced to acceptable size while retaining the signal quality, hearing aids could benefit from the integration with concealed EEG. To compare the performance of a multichannel around-the-ear EEG system with high-density cap EEG recordings an envelope tracking algorithm was applied in a competitive speaker paradigm. The data from 20 normal hearing listeners were concurrently collected from the traditional state-of-the-art laboratory wired EEG system and a wireless mobile EEG system with two bilaterally-placed around-the-ear electrode arrays (cEEGrids). The results show that the cEEGrid ear-EEG technology captured neural signals that allowed the identification of the attended speaker above chance-level, with 69.3% accuracy, while cap-EEG signals resulted in the accuracy of 84.8%. Further analyses investigated the influence of ear-EEG signal quality and revealed that the envelope tracking procedure was unaffected by variability in channel impedances. We conclude that the quality of concealed ear-EEG recordings as acquired with the cEEGrid array has potential to be used in the brain-computer interface steering of hearing aids. Complex every-day acoustic scenes such as the cocktail party Cherry,  are chalThe preservation of acoustic cues is crucial for speech understanding in noise, with binaural cues being among the most imperative of these -guided selection of a to-be-attended speaker, which would in turn result in amplified processing of this stream, and hence facilitate listening. Next generation EEG technology, comprised of non-invasive surface sensors and miniature amplifier system, would be needed to acquire EEG signals in a concealed manner, with little hassle and high user comfort. At present, wireless mobile EEG systems are not small enough to fit behind the ear, but the quality of mobile EEG recordings acquired with head-mounted wireless EEG amplifiers can rival bulky, stationary lab systems  data were recorded concurrently with high-density state-of-the-art laboratory EEG (further referred to as cap-EEG) signals. This approach allowed us to replicate previous high-density cap-EEG envelope-tracking results, identify the possible loss in decoding accuracy that may be present in concealed ear-EEG recordings, and examine the impact of ear-EEG characteristics on target speaker identification.Twenty healthy, normal hearing, native German participants took part in this study . Participants reported no past or present psychological conditions. One participant was excluded from the analysis due to technical problems and another was excluded due to poor performance in the attention task, as revealed by questionnaire results. All participants signed informed consent and were paid for their participation. The study was approved by the University of Oldenburg ethics committee.To investigate if the speech envelope tracking method, which is explained below, could be successfully applied to ear-EEG data we implemented a competitive speaker paradigm. This paradigm was the second of three tasks participants performed; results for the other two paradigms will be reported elsewhere.The task was similar to the competitive speaker paradigm as used previously  from the corpus of Oldenburg University . The data were referenced to the nose tip and collected with a sampling rate of 5000 Hz, with an analog filter setting of 0.0153–250 Hz. After placing the high-density EEG cap the SMARTING mobile EEG amplifier was attached to the back of the participant's head with a rubber band over the cap, keeping participants' comfort in mind. Additionally, before and after the experiment the impedance on all cap-EEG and ear-EEG electrodes was recorded.The ear-EEG and cap-EEG signals as well as the marker stream sent from the Psychophysics toolbox were integrated using the Lab Recorder software Figure  from theDue to the hardware characteristics of both amplifiers and software filtering within the Brain Amp LSL driver, a latency shift between the two EEG systems could be expected. In order to verify good temporal precision of the set-up, sinusoidal signals were added to the beginning and end of 10-min long audio signals. The stimuli were presented via Psychophysics toolbox and the output of one eartone transducer was acquired with SMARTING and BrainAmp amplifiers and the signal from both combined into one output file by Lab recorder. This procedure revealed a constant latency shift of 50 ms between the two EEG streams, which was compensated for off-line.Nt = 50 trials per subject. Likewise, ear-EEG data were baseline corrected and re-referenced to algebraically linked mastoids . In order to keep the cEEGrid layout symmetrical, L4a electrode was removed from further analysis. As with the cap-EEG recordings ear-EEG data were then filtered from 2 to 8 Hz, downsampled to 64 Hz and divided into fifty 60 s non-overlapping trials. The envelopes of both audio streams were computed as the absolute value of the Hilbert transform, low-pass filtered below 8 Hz and downsampled to 64 Hz . Time shifts of different durations were simultaneously introduced through zero-padding of the EEG data matrix, resulting in several time-shifted EEG matrices which were subsequently concatenated into a data matrix R. The model, represented by the decoder g, which would associate matrix R to stimulus S, was trained for each 60 s trial using multivariate linear regression. Furthermore, the decoder was trained separately for cap-EEG and ear-EEG data.As previously mentioned, the model is trained on EEG recordings and the envelope of attended speech using a multivariate linear regression. The lag between the EEG signal and the auditory stream has to be accounted for in the model in order to temporally align them. A time lag between the stimulus presentation and the corresponding neural processing is taken into account by time shifting EEG recordings relative to the stimulus M used here is similar to that used in Mirkovic et al. . For the ear-EEG data, where the number of channels is lower, the risk of overfitting is also low, resulting in a smaller value for the regularization parameter. λcap and λear were estimated, separately, by grid search, resulting in maximal decoding accuracy for cap-EEG and ear-EEG, respectively. This resulted in a total of Nt = 50 decoders for each EEG setup which could be assessed using the leave-one-out validation procedure. For this purpose we averaged Nt-1 decoders and estimated the performance of the averaged decoder by applying it to the time-shifted EEG recordings (R) of the remaining trial, separately for both systems. In this way, for each trial k we obtained two estimated attended speech envelopes (further referred to as EASE), one resulting from cap-EEG and the other from ear-EEG.The regularization matrix c et al. . Due to t correlation coefficients ra) than with the envelope of the supposed to be unattended stream (ru). By comparing the coefficients ra and ru an informed decision can be made on which stream the participant was attending. Hence, we classified EASE for each of the Nt trials as attended or unattended, based on the higher of the two correlation values for corresponding trial. The decoding accuracy was calculated as the percentage of accurately classified trials, resulting in two values for each participant, DAcap and DAear.Note that the EASE is not a close replica of the envelope of the original audio stream. Nonetheless, it is expected to correlate more closely with the envelope of the supposed to be attended stream  with the accuracy achieved by reanalyzing our already published data /unattended (u) speech envelope.Decoding accuracy is an informative but sparse measure of performance. Keeping in mind that it is a classification based on the correlation of EASE and original sound envelopes, a complementary measure of participants' performance may be related to the r-values reflect both the enhancement of the attended stream and/or the suppression of the unattended stream and are consequently convenient estimates of participants' performance. This procedure provided two performance scores for each participant, one for the ear-EEG data (Pear) and one for the cap-EEG data (Pcap). Providing that the information necessary for speech decoding is indeed present in ear-EEG data, the ear-EEG performance scores should correlate with cap-EEG derived performance scores. To investigate this relationship, we calculated the corresponding Spearman rank correlation.The differences in To investigate the influence of electrode placement we defined six electrode clusters from cap-EEG data keeping the cluster size identical to the number of ear-EEG channels (16). The electrode clusters were defined as: (1) a frontal scalp area symmetric about the sagittal plane, (2) a posterior scalp area symmetric about the sagittal plane, (3) a central clustering around the Cz electrode, (4) left and right temporal areas in close proximity to cEEGrids, (5) a frontal and posterior area symmetric about the sagittal plane, and (6) wide scalp coverage. Furthermore, we looked into the possibility of speech decoding with the right cEEGrid only, in which case the data were not re-referenced.ear), we made a performance-based median split of participants and performed an independent samples t-test for each cEEGrid electrode impedance between the bad and good performers. Hereby, the impedance measurements were performed for 17 out of 18 previously analyzed participants. Impedance values for the remaining participant were absent due to technical reasons. The impedance values were calculated for each electrode as the mean of the impedances measured before and after the experiment. Furthermore, in order to investigate the difference in adherence of upper cEEGrid electrodes, which may be reflected in impedance values on cEEGrid electrodes located above the ears , we performed a paired sample t-test between these and the bottom cEEGrid electrodes , where the cEEGrid could be more firmly attached. Keeping the median split we also analyzed EEG frequency band activity for each ear-EEG channel. For this purpose we defined the following frequency bands: 1–3, 4–7, 8–12, 13–30, 31–80, 81–150, 151–200, and 201–250 Hz. The corresponding band power values were submitted to independent samples t-tests.To investigate the significance of electrode impedance on the ear-EEG recordings and correspondingly on overall performance (P23 and R23). The same was done for the bottom electrodes, resulting in two more positions on the sagittal plane (L67 and R67). The axes of cEEGrids were defined by positions L23 and L67 for the left cEEGrid and R23 and R67 for the right cEEGrid. Statistical analysis was performed on cEEGrid axis deviation from head axis using the independent samples t-test between good and bad performers.We further analyzed the influence of the angle at which the cEEGrid was placed on a participant's head. After EEG acquisition an infrared 3D digitizer was used to record the position of all cap and cEEGrid electrodes  as well as individual head shape coordinates. We used the digitized electrode positions to project the four cap electrodes positioned in line with Cz  onto the sagittal plane. The least square regression line of these projections was defined as the “head axis.” Next, the upper two electrodes of the left and right cEEGrids (L2–L3 and R2–R3) were projected onto the same plane. The mean positions between the projections of upper left/upper right cEEGrid electrodes were calculated , while they could not answer questions to the unattended story (< 0.1% correct answers on average).r-values revealed the optimal lag intervals for speech decoding to be between approximately 140 and 200 ms , and the same applied for lag patterns resulting from comparison of unattended speech envelope with EASEcap/EASEear . However, EASEear was not as strongly correlated with the envelopes of audio streams as EASEcap, reflected in noticeably lower correlation values as confirmed by paired-samples t-test .The time-lag analysis of s Figure . Furthert-test comparing decoding accuracy resulting from both datasets did not reveal a significant difference .In both cases all participants performed above chance level. Maximum decoding accuracy was reached by one participant in the previous study . Subsequent paired-samples t-test showed that the performance score was significantly lower for ear-EEG as compared to cap-EEG data . Further, six different clusters of 16 cap channels were considered. A cluster with 16 channels covering only posterior scalp sites resulted in lowest performance, which was 63.78%  = 0.22, p = 0.825]. A paired-samples t-test showed that performance was significantly better for the wide coverage than for a focal central coverage , which resulted in the mean of 79.78%. In both cases only one participant performed below chance and for the wide central coverage, maximum decoding accuracy was achieved for two participants. Data collected from the 16 cap channels closest to the cEEGrids  we split the participants into good and bad and compared the impedance on each electrode for these two groups. According to independent samples t-tests there was no significant difference (p > 0.1) between good and bad performers  did not reveal any significant difference (p > 0.05), even though the electrode-to-skin adherence conditions on upper and lower sites may have differed.The measured impedances on cEEGrid electrodes ranged from 0.6 to 83.6 kOhm with a median value of 13.5 kOhm. For each cEEGrid electrode we calculated the median impedance over participants. Based on the median ear-EEG performance , either from a particular channel or for a particular frequency band, which suggests that ear-EEG signal quality differences between individuals did not contribute significantly to decoding performance.Furthermore, the frequency band analysis showed that in both good and bad performers the spectrum resembled typical EEG characteristics with low energy in high-frequency bands Figure . Again, SD = 6.6°) and parallel to the head axes (right cEEGrid SD = 7.8° and left cEEGrid SD = 7.2°) in all participants.Finally, we analyzed the angle of the cEEGrid placement, which was individually adjusted to fit each participant's ear anatomy. The mean angle for both groups, and the mean angle difference between groups, is illustrated in Figure Aiming toward our ultimate goal of inconspicuous and hassle-free long-term EEG acquisition, we investigated the potential of ear-EEG for decoding the attended speaker in a competitive speaker paradigm. While participants were presented with two concurrent speech streams, two separate EEG recording systems were used for signal acquisition, a high-density cap-EEG system and a wireless head-mounted EEG system, the latter of which was combined with the cEEGrid sensor technology. Based on previous ear-EEG work in our lab . Our study provides evidence that unobtrusive miniaturized electrodes placed around the ear are sufficient to successfully decode the attended speaker in two-speaker scenarios. The main factor contributing to lower performance of ear-EEG compared to cap-EEG was the spatial location of electrodes placement. More advanced decoding algorithms may allow to combine cognitive state decoding with hearing devices, which would enable these devices to flexibly adjust to a user's listening demands.BM, MB, MD, and SD designed the experiment. BM and MB performed data acquisition. BM analyzed the data and wrote the manuscript to which MB, MD, and SD contributed with critical revisions. All authors approved the final version and agree to be accountable for this work.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In fact, it has been demonstrated that three days of ingestion of wheat-containing food induces the mobilization of memory T lymphocytes reactive against gliadin from gut-associated lymphoid tissue into peripheral blood of CD patients. Such antigen-specific T-cells releasing interferon-γ can be transiently detected by using the enzyme-linked immunospot (ELISPOT) assays or by flow cytometry tetramer technology. This paper discusses the suitability of this in vivo tool to investigate the repertoire of gluten pathogenic peptides, to support CD diagnosis, and to assess the efficacy of novel therapeutic strategies. A systematic review of all potential applications of short oral gluten challenge is provided.Celiac disease (CD) is a common lifelong food intolerance triggered by dietary gluten affecting 1% of the general population. Gliadin-specific T-cell lines and T-cell clones obtained from intestinal biopsies have provided great support in the investigation of immuno-pathogenesis of CD. In the early 2000 a new  Celiac Disease (CD) is one of the most common food intolerances affecting almost 1% of worldwide population .For decades, CD has been considered prevalently an intestinal disease, and the enteropathy the main clinical and histological outcome. Accordingly, the evaluation of small intestinal histology has been for many years the only diagnostic tool in CD . Howeverin vivo approach to detect in peripheral blood the gluten-specific T-cells of intestinal origin by using the sensitive enzyme-linked immunospot (ELISPOT) assay, widely and successfully used to study antigen-specific T cells secreting cytokines, as well as antibody-producing B cells, particularly in infectious diseases [For both diagnostic purposes, and to study the mechanisms leading to CD, the demonstration and characterization of gliadin-specific, pathogenic T-cell response is mandatory. In the early 2000s, Anderson and co-workers established an diseases . The prodiseases . Since idiseases ,8,9,10.The susceptibility to develop celiac disease is strongly influenced by inherited factors. The Human Leukocyte Antigen (HLA) class II genes encoding for DQ2.5  and for DQ8 heterodimers  are the main risk factors . AlthougIn CD patients the dietary ingestion of wheat gluten activates a strong immune response characterized by the lymphocytic infiltration in the proximal part of the small bowel . Gluten-Recent evidence has highlighted that the number of gluten-reactive T cells both in peripheral blood and in the small intestinal biopsy of CD patients positively correlated with the degree of histological intestinal damage. Similarly, the serum anti-TG IgA antibody levels have been found to significantly correlate to the Marsh grade of mucosal damage ,20.lamina propria compartment, the gluten peptides become substrate for the enzyme tissue transglutaminase type 2 (tTG2) [Furthermore, it is well known that T lymphocytes reacting to specific gluten peptides and releasing inflammatory cytokines, such as IFN-γ and IL-21, reside in the intestinal mucosa of subjects with CD but not in healthy controls  or parac2 (tTG2) . In part2 (tTG2) . After t2 (tTG2) . As a coThe great heterogeneity of gluten proteins accounts for the large diversity of T-cell epitopes found to be active in celiac patients ,30. The in vivo assay to assess the efficacy of emerging novel therapies to treat CD [To date, the only valid treatment for celiac patients is the GFD , based otreat CD .The gluten challenge is a clinical approach widely used in the last decades to have a diagnosis of celiac disease. It consists in the introduction of gluten containing foods in subjects previously on a gluten free diet, for a time frame necessary to provoke a clinical response (from two weeks up to four months). About 75% of adults received a clear diagnosis in at least two weeks , howeverin vivo approach to analyze T-cell response to gluten in peripheral blood, overcoming in this way all the technical problems related to the use of intestinal T-cells [For long time, all the efforts to isolate gliadin-specific memory T-cells from peripheral blood samples of CD patients gave poor results, due to the low frequency in the blood of gluten-primed intestinal CD4+ T-cells, and to a substantial functional differences (in particular a diverse HLA restriction) that has been reported between gliadin-specific T-cell clones raised from the gut or blood ,47,48. A T-cells . This pr T-cells ,50. Simiet al. After three to five months of gluten wash-out, the celiac cohort underwent a second cycle of wheat-containing food challenge. We found that the IFN-γ responses significantly increased in peripheral blood sampled six days after the second challenge, and interestingly, gliadin reactive cells were more frequent compared to the first challenge, most likely due to the increased frequency of memory T-cells activated upon the first gluten exposure [A subsequent study from our group performed in adolescent CD patients has reported that the SGC is a reproducible assay. To further demonstrate that the SGC is a valid instrument to investigate the gluten induced immune response, 14 young celiac patients on GFD underwent two separate gluten consumptions, with the same procedure described by Anderson exposure .in vitro read-outs different from ELISPOT assay to assess the specific immune response elicited by gluten challenge. Ontiveros et al. have developed a whole blood assay to detect gluten-specific T-cells by dosing IFN-γ in the serum by ELISA after stimulation of blood with gluten/peptides [Other studies have reported peptides . The sampeptides .Despite the central role given by HLA class II in CD, being the main genetic risk factor and the key restriction molecules of pathogenic CD4+ T-cells, studies from our group have demonstrated that gliadin contain peptides able to stimulate cytotoxic CD8+ T-cells in an antigen restricted manner when presented on surface of antigen presenting cells (APC), such as B- or enterocytes by HLA class I molecules . Of noteIn the recent years, much attention has been paid to the use of tetramers technology to dissect specific T-cell responses to a variety of antigenic sources . Tetramevs. HLA-matched controls) is comparable to that found in IFN-γ ELISPOT assay [DQ2-gliadin-tetramer tests were first used by Raki and co-workers to monitor CD4+ T lymphocyte specific for two immunodominant gluten epitopes, DQ2.5-glia-α1a and DQ2.5-glia-α2, in PBMCs of celiac patients underwent the SGC . The resOT assay . FrequenOT assay . More reOT assay . More spIn addition, a single cell-TCR sequence analysis performed on DQ2-gliadin-tetramer specific T-cells, mobilized upon the gluten challenge, has demonstrated how highly focused the TCR repertoire is of CD4+ T-cells specific for the immunodominant gluten epitopes ,56,57,58Since the first description, the short oral gluten challenge has become an attractive tool for all researchers interested in the identification of the complete repertoire of gluten (and of other prolamin) toxic sequences ,59 Tabl. Tye-Dinin vivo SGC between pediatric and adult CD can have a great potentiality for the applications also in celiac children of the peptide-based therapy designed for adults.A recent study from Hardy and co-workers  has expaMany studies aimed to identify new strategies to detoxify wheat gluten, and several of these are based on enzymatic technologies that degrade fragments or mask gluten immune-stimulatory sequences  Table 1Table 1. Other strategies have been developed to directly detoxify wheat flour, as the extensive hydrolysis during the sourdough fermentation with a mixture of acid bacteria proteases , or the et al. [In recent times, a great attention has been paid to develop clinical practices less invasive than endoscopy to diagnose celiac disease . Moreoveet al. . The autIn order to validate the SGC as a procedure to support diagnosis of celiac disease in uncertain cases, it is mandatory the assessment of its sensitivity and specificity. Regarding the sensitivity, there is a large variability in the cut-off applied to define subject responders to the gluten challenge among the different studies. In our recent experience of brief gluten challenge performed on a cohort of 36 DQ2+ CD adolescent celiacs ,60, eachin vivo procedure, less invasive than the endoscopy, has allowed the screening of large peptide library and provided a great help for the characterization of a repertoire of immunostimulatory gluten sequences, a fundamental step to constructing a peptide-base immunotherapy for the treatment of CD [The short (three days) gluten challenge is a validated tool for the evaluation and monitoring in peripheral blood of gluten-specific T-cell response that are elicited in the gut after gluten exposure. Since its first demonstration in early 2000 , this innt of CD ,32. FurtFinally, thanks to several sensitive assays to measure anti-gluten T response in blood cells, as IFN-γ ELISPOT/ELISA or tetramers-flow cytometry technologies, it is thinkable to apply this innovative approach to clinical practice, in order to help specialists in making a correct and definitive diagnosis of celiac disease in those cases in which subjects are arbitrarily on gluten free diet, or can help the diagnosis in case of potential celiac disease. To make this technique adapt to clinical practice, several parameters still have to be addressed. Further work is necessary to reach a high sensitivity, to keep lowest number of false negative subjects. So far, the main limitations playing against the wide use of oral challenge for clinical practice are less sensitivity and specificity compared to available serology tests, and the high cost of ELISPOT and tetramers immune assays. Notwithstanding, these limitations do not lessen the value of the oral challenge, as a rapid tool to assess the efficacy of several alternative therapies currently under investigation.


Although vascular pulsatile tinnitus (VPT) has been classified as “objective”, VPT is not easily recognizable or documentable in most cases. In response to this, we have developed transcanal sound recording (TSR) and spectro-temporal analysis (STA) for the objective diagnosis of VPT. By refining our initial method, we were able to apply TSR/STA to post-treatment outcome evaluation, as well as pre-treatment objective diagnosis.TSR was performed on seven VPT patients and five normal controls before and after surgical or interventional treatment. VPT was recorded using an inserted microphone with the subjects placed in both upright and supine positions with 1) a neutral head position, 2) head rotated to the tinnitus side, 3) head rotated to the non-tinnitus side, and 4) a neutral position with ipsi-lesional manual cervical compression. The recorded signals were analyzed in both time and time-frequency domains by performing a short-time Fourier transformation.The pre-treatment ear canal signals of all VPT patients demonstrated pulse-synchronous periodic structures and acoustic characteristics that were representative of their presumptive vascular pathologies, whereas those the controls exhibited smaller peaks and weak periodicities. Compared with the pre-treatment signals, the post-treatment signals exhibited significantly reduced peak- and root mean square amplitudes upon time domain analysis. Additionally, further sub-band analysis confirmed that the pulse-synchronous signal of all subjects was not identifiable after treatment and, in particular, that the signal decrement was statistically significant at low frequencies. Moreover, the post-treatment signals of the VPT subjects revealed no significant differences when compared to those of the control group.We reconfirmed that the TSR/STA method is an effective modality to objectify VPT. In addition, the potential role of the TSR/STA method in the objective evaluation of treatment outcomes in patients with VPT was proven. Further studies incorporating a larger sample size and more refined recording techniques are warranted. Tinnitus can be classified as either non-pulsatile subjective or pulsatile. Non-pulsatile subjective tinnitus originates from the inner ear, ascending auditory pathway, or cortical regions –6, wherePT is frequently equated with “objective tinnitus”, since some cases of PT can be detected by an observer ,8. HowevThe aim of precise evaluation for patients with VPT is to demonstrate treatable causes, since most causes of VPT are curable with precise evaluation and proper management of the responsible vascular structure . We receThis study comprised seven unilateral VPT patients who underwent surgical treatment at Seoul National University Bundang Hospital between January 2015 and August 2015 and five volunteered control subjects with no complaints of VPT. Patients were asked to note the tinnitus handicap inventory (THI) score , numericTSR was performed on all VPT subjects and controls. For the VPT subjects, the measurements were performed before and 3 months after surgical treatment. Pre-treatment recordings were performed before imaging examinations such as temporal bone CTA, brain MRI/A, and/or TFCA. VPT was measured in eight different head positions: 1) a neutral head position, 2) head rotated to the tinnitus side, 3) head rotated to the non-tinnitus side, and 4) a neutral position with manual cervical compression of the tinnitus side, all the four in both upright and supine positions. For the controls, the measurements were performed in the same positions as for the VPT subjects. To record the sound pressure waves generated by VPT, an external auditory canal (EAC)-sealing microphone was developed. We chose a type of small diaphragm condenser microphone  that was small enough to fit into the EAC. Additionally, an in-ear foam tip was attached to the end of the microphone to prevent noise input through the complete sealing of the subject’s EAC.The microphone has flat frequency responses up to 18 kHz with a sensitivity of -33.5 dB re 1 V/Pa (21.00 mV at 94 dB sound pressure level (SPL)), according to the accompanying datasheet. The signals were recorded using a battery-operated portable digital recorder  at a sampling rate of 44,100 Hz and the recorded signals were analyzed using MATLAB R2013a . To achieve a highly selective recording system, a battery-powered recording device was required to prevent noise generated from electricity or a magnetic field that may cause a ground loop problem.P-value < 0.05.The acquired signals were filtered by a Butterworth high-pass filter with a cut-off frequency of 20 Hz. The peak amplitudes were computed by finding the maximum instantaneous absolute value from the filtered signals, and a root mean square (RMS) amplitude was used to represent the effective output of the signal. To quantify the differences between pre- and post-treatment ear canal signals, the peak amplitudes and RMS amplitudes were calculated using 5-second-long periods. The Wilcoxon signed-rank sum test was used to analyze the differences between pre- and post-treatment ear canal signals with regard to peak amplitudes and RMS amplitudes. Statistical significance was set at a P-value < 0.05 was considered to indicate statistical significance.STA was performed with a short-time Fourier transform at a frequency range of 20 to 8,000 Hz. A Hanning window of ~50 ms  was used with a hop size of ~10 ms (512 samples). As the sounds were sampled by the digital recorder, the magnitudes of the frequencies were converted to dB SPL using a microphone calibrator. The frequency range was divided into 1/2-octave bands and five pulse-synchronized spectral bands  were chosen for the statistical observations for the comparison of changes in signal intensities between pre- and post-treatment signals. The Wilcoxon signed-rank sum test was used to analyze SPL differences in the five pulse-synchronized spectral bands between the pre- and post-treatment signals, whereas the Mann Whitney U-test was used to evaluate the differences between the pre-treatment signals and the control subjects’ signals and between the post-treatment signals and the control subjects’ signals. A The demographic characteristics of the seven VPT patients are summarized in Temporal bone CTA and/or brain MRI/A revealed a right sigmoid sinus diverticulum in Subjects 1 and 5, a dehiscent high jugular bulb in Subject 2 and 6, a dominant transverse sigmoid sinus without bony dehiscence with high jugular bulb in Subject 3, a dominant transverse sigmoid sinus with bony dehiscence in Subject 7, and a dural arteriovenous fistula in Subject 4 . AccordiP < 0.05, Wilcoxon signed-rank sum test). The RMS amplitude of the pre-treatment signals  also showed a significant decrease after treatment  . While the pre-treatment peak and RMS amplitudes of the VPT subjects were significantly larger than those of the controls, there were no significant differences between the signals measured after treatment in the VPT group and those of the control group with regard to both peak and RMS amplitudes.Of the signals recorded in eight different head positions, the signals acquired from the upright, neutral head position were selected and analyzed for signal comparison. As illustrated in STA of the recorded signals provided further observable information regarding each subject’s VPT and its improvement after treatment, in addition to that gained from the time domain analysis. The 2D and 3D spectrograms of the pre- and post-treatment signals are shown in P < 0.05, Wilcoxon signed-rank sum test), but the differences were starker at low frequencies  as compared with those at 1,000 and 2,000 Hz. Compared with the control group, as shown in P < 0.05, Mann Whitney U-test), but the post-treatment spectral bands showed no significant differences compared to the control group. In other words, postoperatively, the patients were not different from the controls with regard to pulse-synchronized spectral bands.Following surgical treatment, all subjects displayed no or much decreased pulse-synchronous signal in their spectrograms and, in particular, the low-frequency components of the signals were much decreased compared with the pre-treatment signals . This chAs mentioned previously, approximately 80% of VPT cases are not objectively detected by a conventional physical examination. With this in mind, we recently assessed five subjective VPT participants with presumptive vascular origins by applying the TSR/STA method and extracted objective acoustic features that were representative of the underlying vascular pathology . In otheIn the current study, we further evaluated the feasibility of the refined TSR/STA method, not only for pre-treatment objective diagnosis, but also for the post-treatment evaluation of the changes in seven VPT patients who were treated by surgical- or endovascular intervention. Namely, we compared the pre- and post-treatment ear canal signals to determine the differences in signal with regard to time and frequency domains, and also compared the pre- and post-treatment signals to the signals of normal controls without VPT. As stated above, reduced peak amplitudes and RMS amplitudes with statistical significance were observed using a time domain analysis among all patients after surgical treatment. In addition, in time-frequency domain analysis, the pulse-synchronous signal of all subjects was not identifiable and the SPL decrement was statistically significant at low frequencies, such as 125, 250, and 500 Hz. Moreover, while the pre-treatment peak and RMS amplitudes, as well as the SPL at low frequency spectral bands, were significantly larger than those of the controls, no significant differences were found between the post-treatment signals and the control group’s signal with regard to the same parameters.In the current case series, all seven subjects had “subjective” VPT that could not be confirmed by bare-ear auscultation. However, through the use of our refined portable transcanal recording system, which solves the ground loop problem, it was possible to obtain characteristic and documentable signals representative of the presumptive vascular pathologies responsible for VPT perception. That is, all seven VPT subjects exhibited pulse-synchronous ear canal signals Figs  and 3 thFor example, Subjects 1, 5 (sigmoid sinus diverticulum) and Subject 7 (dominant sigmoid sinus with bony dehiscence) showed a relatively large rise and fall compared with the other four subjects, and this may indicate a distinctly turbulent flow generated in the sigmoid sinus and transmitted to the middle ear through the bony dehiscence. In contrast, Subjects 2 and 3 showed pulse-synchronous signals, but these were less obvious than in Subjects 1, 5, and 7. This may be attributed to their pathologies  in that they may transmit venous blood flow to the middle ear but without any stark turbulence.The ear canal signal of Subject 4 had a unique bump-like rise and fall at approximately 1,000 Hz, which was also observed in the subject with dural arteriovenous fistula in our previous study. This may reflect sound conduction from fast blood flow in the fistulous tract to the middle ear. In summary, when distinct pathology exists in or near the middle ear, we can obtain disease-specific ear canal signals using the refined TSR/STA method in selected cases. These results may be of value in that they were able to replicate the results of our previous study with regard to signal detection and discrete characteristics according to pathology.In selected VPT cases with an obvious pathology, treatments such as surgical repair of the vascular pathology or endovascular embolization are applicable for the improvement of symptoms ,14,18,19Using the current methodology, we were able to objectively demonstrate post-treatment changes with regard to the spectral and temporal characteristics of the recorded signal. In time domain analysis, both peak amplitudes and RMS amplitudes significantly decreased in all subjects after surgical or interventional treatment. In addition, in time-frequency domain analysis, the pulse-synchronous signal of all subjects had abated and, in particular, the SPL significantly decreased at low frequencies. These changes in SPL at low frequency components may explain why most VPT patients perceive a low frequency humming sound and why they do not perceive such pulsatile sounds after proper intervention. Moreover, by comparing the pre- and post-treatment data to that of the control group, we could objectively explain why patients no longer heard their VPT after proper treatment. In other words, after proper treatment, the VPT subjects did not differ from the controls, with no history of VPT perception, with regard to the peak and RMS amplitudes, as well as the SPL, at low frequency spectral bands.These results confirmed, in an objective way, the successful control of VPT after treatment and were used for post-treatment patient consultation. By comparing the pre- and post-treatment signals objectively, clinicians can confirm the effectiveness of treatment and reassure patients with regard to the surgical outcome by visualizing the signal changes. The TSR/STA method may be of great value because it not only detects hidden objective VPT, but also objectively demonstrates post-treatment improvement and, therefore, the future management of similar vascular pathologies can be based on an objective treatment outcome.Although the current study demonstrated the potential of the TSR/STA method in evaluating treatment outcomes, several limitations should be addressed. First, in order to verify this method, future studies with a larger number of participants should be conducted to better characterize the role of the TSR/STA method. By accumulating a larger data set from future subjects with diverse etiologies, we may be able to further characterize and objectify presumed vascular pathologies and the expected treatment outcome. In addition, there are likely to be cases of VPT in which TSR shows no demonstrable signals, and in such cases the TSR/STA method may aid in choosing proper diagnostic imaging modalities, counseling the patients, and deciding proper therapeutic options. Second, the current method requires further refinement with regard to the insertion depth of the microphone and the inter-individual morphological variations in the external and middle ear. Although we used in-ear foam tips attached at the end of the microphone to fit the microphone maximally to the ear canal, the prototype recording system may become more objective and precise by individualizing the size of the inserted microphone or utilizing tympanic membrane contact-type microphones.Taken together, we further demonstrated that the TSR/STA method is an effective modality to objectify VPT. Additionally, the potential role of the TSR/STA method in the objective evaluation of treatment outcomes in patients with VPT was shown by comparing the pre- and post-treatment ear canal signals. For routine use of the current method in evaluating patients with VPT, future studies with a larger sample size and more refined recording techniques are warranted.S1 File(WAV)Click here for additional data file.S2 File(WAV)Click here for additional data file.S3 File(WAV)Click here for additional data file.S4 File(WAV)Click here for additional data file.S5 File(WAV)Click here for additional data file.S6 File(WAV)Click here for additional data file.S7 File(WAV)Click here for additional data file.S8 File(WAV)Click here for additional data file.S9 File(WAV)Click here for additional data file.S10 File(WAV)Click here for additional data file.S11 File(WAV)Click here for additional data file.S12 File(WAV)Click here for additional data file.S13 File(WAV)Click here for additional data file.S14 File(WAV)Click here for additional data file.S15 File(WAV)Click here for additional data file.S16 File(WAV)Click here for additional data file.S17 File(WAV)Click here for additional data file.S18 File(WAV)Click here for additional data file.S19 File(WAV)Click here for additional data file.