Strategies for treating hyperacusis, an anomolous condition of loudness perception, paradoxically seek either to minimize or enhance listeners' sound exposures. We show that these reciprocal treatment approaches, implemented with similar amounts of background sound attenuation and enhancement, produce diametrically opposite perceptual effects in normal listeners. Specifically, we show after continuous, 2-week earplugging and low-level noise treatments that listeners become more and less sensitive, respectively, to the loudness of sounds. This simple demonstration of adaptive plasticity is consistent with modification of a theoretical gain control process, which is the basis for desensitizing sound therapies used in treating hyperacusis and related sound tolerance problems.

In this report, the authors highlight clinically significant improvements in sound tolerance observed over the past decade among patients who were enrolled in tinnitus retraining therapy (TRT) at the University of Maryland Tinnitus and Hyperacusis Center. Pretreatment and TRT followup audiometric threshold, loudness discomfort level (LDL), and dynamicrange (DR) data are documented for (1) a group of 68 tinnitus patients who presented with primary complaints of sound intolerance, and (2) a second group of 70 patients who reported only tinnitus (and no sound tolerance problems). TRT-related increases in sound tolerance are (1) due to increases in LDLs and occur independently of changes in audiometric threshold, which were invariant with treatment; (2) statistically significant in tinnitus patients with and without sound tolerance problems, and with and without hearing loss; (3) observed among 81% of the patients with sound tolerance complaints and 44% of the patients who reported primary tinnitus; (4) independent of audiometric frequency over the range 1000 to 8000 Hz; and (5) seemingly independent of TRT treatment duration, which is consistent with recent experimental evidence of a rapid treatment effect (within the first month of TRT). The TRT treatment effects were clinically meaningful, offering new opportunities for expanding the auditory DR and improving sound tolerance in the general hearing-impaired population. The mechanism responsible for the plasticity underlying these treatment effects is uncertain, but appears consistent with a centrally mediated auditory gain control process. Sound tolerance problems were overpredicted among the authors' sample of tinnitus-only patients when existing objective audiometric criteria were used. This finding promoted the development of a new

A vexing problem in audiology has been the modification of sound tolerance. Sound intolerance and restricted dynamic ranges are common conditions that audiologists encounter daily in the hearingimpaired population, especially in the fitting of hearing aids. To date, no clinical protocol has proven to be successful for modifying sound tolerance among the hearing-impaired population. This report describes the use of low-level, broadband sound in a habituation-based treatment protocol termed Tinnitus Retraining Therapy (TRT). Over the past decade, TRT has become increasingly popular as an intervention for severe tinnitus and hyperacusis. One of the primary treatment effects from TRT is that over the course of the intervention the patient's loudness discomfort levels (LDLs) routinely shift to higher levels. Ostensibly, the resulting higher LDLs reflect treatment effects associated with the resetting of a plastic and adaptive auditory gain process that somehow regulates the suprathreshold sensitivity of the auditory system in response to chronic changes in the sound input from the auditory periphery to the central auditory pathways. Tinnitus patients with significant hearing losses and sound tolerance problems respond successfully to TRT and, as a consequence, their LDLs are usually elevated (improved) and, concomitantly, their dynamic ranges are expanded. Many of these patients, who before the TRT intervention could not tolerate amplified sound, then have been able to make a comfortable transition into appropriate amplification after treatment. In principle, TRT would seem to offer a viable intervention strategy for modifying sound tolerance in the general hearing-impaired population. If so, then clinical applications of TRT principles may extend well beyond the treatment of tinnitus and hyperacusis.This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Background: Electronic evaluation portfolios may play a role in learning and evaluation in clinical settings and may complement other traditional evaluation methods (bedside evaluations, written exams and tutor-led evaluations).

Surgical risk increases with age, primarily from loss of cardiac and pulmonary reserve. Complications are tolerated poorly by the elderly, emphasizing the importance of their prediction and prevention. Surgical risk in this population is significant, but with careful preoperative assessment and perioperative management acceptable morbidity and mortality are possible. This review proposes a general approach to the elderly surgical patient and applies it to the most significant sources of morbidity and mortality: pulmonary and cardiac complications. Risk assessment based on validated tools is utilized, and perioperative management recommendations based on the state of the art are examined. In addition, pulmonary embolism and postoperative confusion are examined separately with the same overall strategy.