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Now this False contraindications to immunization: control vial and test vial (suspect vial) are taken • Minor illness discount mildronate 250 mg without prescription medicine while breastfeeding, chronic diseases (heart purchase 500mg mildronate mastercard symptoms zollinger ellison syndrome, lung order mildronate 500 mg line medications 2, kidney) order mildronate 250mg treatment 6th february. Effective communication has been recognized to freezing that contributes to the degradation of as a major constraint in universal immunization. These additional the child if he continues to be exposed to diarrheal components pertain to acute respiratory diseases, infections or unprotected drinking water supply. A system of training, • Children below 6 years orientation, continued education, functional monitoring, • Pregnant and lactating women evaluation and research has been evolved to fulfil the • Women in the age group 15 to 44 years. Services of senior teachers of pediatrics and psychological and social development of the child. Though success has about 41% of total population) is as follows not been uniform throughout the country, favourable (Table 30. Supplementary feeding support monitoring, sick or malnourished children, in need of is given for 300 days in a year. The anganwadi worker caloric gap between the national recommended and has also been oriented to detect disabilities in young average intake of children and women in low income children. Each children of 6 to and refers them to the medical officer of the Primary 72 months will get 500 kcal energy and 12 to 15 gm Health Center/ Subcenter. Pregnant women and Nursing mothers will and ensuring a natural, joyful and stimulating get 600 kcal energy and 18 to 20 gm protein daily. It also contributes to the for all children below six years that helps to detect universalization of primary education, by providing to growth faltering and helps in assessing nutritional status. Besides, the medical officers, Auxiliary Nurse a group of slums in urban areas (Table 30. An Anganwadi normally covers a population of 1,000 in both rural and urban areas and Funding Pattern 700 in tribal areas. She is assisted by a helper who were to provided out of their own resources, was being is also a local woman and is also paid a small provided by the Government of India. The sharing pattern of supplementary • Organizing supplementary feeding for children nutrition in respect of North-eastern States between under six, pregnant women, and nursing mothers. Center and States has been changed from 50:50 to • Giving health and nutrition education to mothers. Ideally, the Health growth chart there has been increase in total of Worker’s service area will correspond to that of the normal weight children, increase in severely Mukhya Sevika in order to facilitate joint visits to the underweight children and increase in underweight Anganwadis. Utilization of Health Care Services for meeting their requirement for supple- by Scheduled Caste Population in Rural Area. Government of India partners with the following Central Bureau of Health Intelligence, Ministry of Health international agencies to supplement interventions and Family Welfare, 1998. Office of Registrar • Cooperative for Assistance and Relief Everywhere General, India. In olden times, the attempts at birth control unit of society and the members are dependent on each were based on coitus interruptus, douches, postures, safe other for all-round health and welfare-physical, period and the insertion of cotton, lemon or other odd mental, social and economic. Abortion and infanticide were also resorted to self- restraint or abstinence was also advocated. Birth control services involve guidance about the Most parents in India have limited physical, social and timing, spacing and number of children, education regar- economic resources, adequate only for a limited number ding contraceptive methods and the provision of facilities of children. The aim should be to produce children patible with health and socioeconomic resources of the by choice and not by chance. If there are too many children in a poor family, married or unmarried women are associated with higher they are deprived of adequate care and tend to be illno- morbidity and mortality in mothers and children. Large family size adversely affects abortion rate clearly indicates a high rate of unwanted the health and happiness of each member of the family. Neonatal and fetal deaths knowledge, attitudes and responsible decisions by are lowest for mothers in their twenties. Congenital individuals and couples, in order to promote the health anomalies are more common in children born to elderly and welfare of the family groups and thus contribute 1 mothers. Thus the safest time for conception is when the effectively to the social development of a country”. Late fetal and early neonatal mortality are lowest • To control the time at which births occur in relation when the interval between the termination of one to the ages of the parent pregnancy and the beginning of the next is not less than • To determine the number of children in the family. Epidemiological studies in Punjab have shown that the infant mortality rate was highest when Scope of Family Planning Services the birth interval was less than 24 months. Maternal mortality risk is slightly less with the second and third pregnancy than with the first. This term was coined by Margaret Sanger, the great Two or three children per couple is an ideal number American lady who championed the cause of family from the point of view of health and welfare of the family. Average Management of Sterility and Low Fertility age of marriage in India in 1971 was 17. The world Education about Sexuality population had risen to 250 million by the time of Christ and doubled to 500 million by 1650. By 1750, it was 791 million, by different ages as regards anatomical, physiological, 1850, 1262 million and by 1950, 2486 million. In psychological, hygienic, social and ethical aspects of 1987, it was estimated to be 4998 million with annual sexuality. The current estimate (2000) of world population is 6 billion with annual increase of Advice Regarding Wise Parenthood 1. However, the rate of increase is not the young persons, the future parents, about the same in all parts of the world. The global • Genetic counseling • Premarital advice and examination population was 6 billion in 2000. Qualities of a Good Contraceptive Demographic Considerations The wide variety of contraceptives available today in Family Planning reflects the fact that an ideal contraceptive is yet to be developed. The desirable qualities in a good contra- In most of the developing countries, including India, the ceptive are listed below. This • Low cost was done on demographic and economic • Convenience: Long acting methods are generally considerations, since it was realized that though the convenient for the user. Methods which are difficult country had made all-round progress in the fields of to understand or use, those which must be used at education, health, economy, communications and social the time of coitus, those which must be used daily welfare, the fruits of this progress had not percolated and those which need availability of supplies at hand down to the masses because of the simultaneous are usually inconvenient. Only temporary male gross domestic product but one-sixth of the world’s contraceptive in use today is the condom, over which 606 population. Development of female of resources fell far short of the population increase and contraceptives, which they can safely use themselves, hence decided to make all efforts to promote facilities will go a long way in promoting family planning. These Cap 18 Sponge women are considered to have unmet need for Parous women 28 contraception. The concept of unmet need points to gap Nulliparous women 18 between some women reproductive intention and their Diaphragm 18 contraceptive behavior. The effectiveness of contraceptive methods is measured in terms of pregnancies per 100 users per It was recommended by Francis Place, who started the year. Ways to determine the approximate time of ovulation • Terminal Methods – Vasectomy and the fertile period include: a calendar method; a – Tubectomy basal body temperature method; a cervical mucus • Spacing or Nonterminal Methods method (Billings ovulation method); and a sympto- – Periodic abstinence – Barrier methods thermal method.

Frequent headaches may require prophylaxis buy mildronate 250mg on line medicine 7253 pill, and as palliative in patients with occipital neuralgia buy 500 mg mildronate with visa symptoms 1dp5dt, supraor- amitriptyline or other tricyclic antidepressants in relatively bital neuralgia generic mildronate 500 mg mastercard treatment 5th metatarsal base fracture, and Eagle’s syndrome generic mildronate 500 mg line treatment 4 anti-aging. Trigger point injection, particularly in patients with cervicalgia, can also be effective in selected cases. Refractory daily or frequent severe headaches may The evaluation and management of patients with posttrau- require hospitalization. Repetitive intravenous dihydro- matic headache must be individualized and comprehen- ergotamine as described by Raskin (1986) can be dra- sive. Other intravenous protocols include and familiarity with all of the various therapeutic modal- chlorpromazine and valproate (Mathew et al. Ap- ities available enable the initiation of a treatment plan that propriate selection and performance of these regimens of- should alleviate symptoms and minimize disability. The re- ferral of the patient to a knowledgeable headache expert or mainder can still be helped by a symptom-based approach headache center may be the most efficient way to manage that is both competently applied and compassionate. Such referrals are usually appropriate for those ioral, cognitive, sleep-related, and other typical postcon- patients with unusual conditions, unclear diagnoses, poor cussion symptoms to achieve meaningful improvement response to therapies, or failure to improve over time. Headache tween exposure to rear-end collision and future health com- 37:142–152, 1997 plaints. J Emerg Med 1:5–11, to posttraumatic headache and its possible implications for 1993 treatment. Injury 10:225– feedback-assisted relaxation therapy in patients with post- 230, 1978 traumatic headache. Biofeedback Self Regul 21:93–104, Takagi K, Bölke E, Peiper M, et al: Chronic headache after cranio- 1996 cervical trauma: hypothetical pathomechanism based upon International Headache Society, Headache Classification Sub- neuroanatomical considerations. Eur J Med Res 12:249–254, committee: The international classification of headache dis- 2007 orders, 2nd Edition. Clin Neu- Kirk C, Nagiub G, Abu-Arafeh I: Chronic post-traumatic headache rosci 5:50–54, 1998 after head injury in children and adolescents. Entangled and often inseparable, further complicated by physical injury to the somatosen- these symptoms represent a complex continuum of sequelae sory systems, such as the head, neck, or extremities, or by that cross vestibular, cognitive, and psychosocial domains. Overview The multifactorial influence of these symptoms may be seen across a multitude of physical, cognitive, and psycho- The vestibular system consists of both peripheral and cen- social dimensions. Recent literature in a variety of disci- tral components that function to sense and control motion. These signals are carried along the vestibulo- cochlear nerve (cranial nerve eight) to the brain stem. Studies performed since is readily evaluated clinically through optokinetics and 351 352 Textbook of Traumatic Brain Injury nystagmus. In addition, peripheral vestibular signals in- movement away leads to the opposite: a decrease or inhi- teract with both cervical and lower spinal motor neurons bition of resting discharge rate. A variety of neurotransmit- to generate the vestibulocolic and vestibulospinal re- ters exist throughout the peripheral and central vestibular flexes. These function to maintain and modulate posture, system with glutamate and related amino acids dominat- gait, and head position. The cerebellum also plays a criti- ing the afferent vestibular synapses (Highstein and Hol- cal role in coordination and the ability to adapt to vestib- stein 2006). Finally, while their exact function remains a near the utricle, thus utriculo- or ampullopedal flow subject of ongoing investigation, both cortical and auto- causes an increase in firing, while flow in the opposite nomic pathways are believed to play a role in various vis- direction (ampullo- or utriculofugal) is inhibitory. Con- ceral responses to vertigo, such as nausea, as well as the versely, the opposite is true in the posterior and superior conscious sense of motion. Here the kinocilium is located near the canal side, and deflection of the cupula away from the utricle leads to an excitatory response, whereas deflection toward (utric- The Peripheral Vestibular System ulo- or ampullopedal) is inhibitory. As most head move- The peripheral vestibular system is composed of three ment exists in multiple planes, typically all three canals semicircular canals-the horizontal (or lateral), the poste- are stimulated simultaneously. Using the bilateral planar- rior (or inferior), and the anterior (or superior)-and two paired canals mentioned previously, complex integration otolithic organs-the utricle and saccule (Figure 22–1). Each acceleration are detected by the otolithic organs, the utri- canal is paired with the canal in the opposite ear that lies cle and saccule. In each, the neuroepithe- within each fluid-filled bony framework is the membra- lium is found in a specialized region called the macula, nous labyrinth or the vestibular end-organ. Overlying the mac- fluid of bony labyrinth, has an electrolyte composition ulae is the otoconial membrane, a gel-like matrix similar to similar to extracellular fluid with a greater ratio of sodium the cupula, into which the kino- and stereocilia of the hair to potassium. Embedded in the otoconial membrane are rate from the perilymph and enclosed within the mem- deposits of calcium carbonate called otoliths. Gravita- branous labyrinth, contains a greater concentration of tional and linear acceleration cause movement of these potassium relative to sodium. Ultimately, the vestibular crystals, leading to deflection of the hair cell stereocilia. As in the ampullae of the semicircular canals, Each semicircular canal contains an eccentric dilated movement of the kinocilium with respect to the stereocilia or ampullated end, in which the vestibular sensory recep- allows modulation of neural firing. These ampullae are sepa- polarization in the macula is complex and centered rated from the rest of the canal by a perpendicular septum, around an irregular line called the striola. As in the semi- the cristae ampularis, containing neuroepithelium, blood circular canals, the integration of inhibitory and excitatory vessels, and connective tissue. Vestibular hair cells sit signals in neural firing allows translation of gravitational within the crista, and their cilia protrude into the endo- or linear movement into mechanical stimuli and, ulti- lymphic space topped by a gelatinous mass called the cu- mately, electrical impulses. This leads to release of neurotransmitters and of cranial nerve eight, the vestibulocochlear nerve. Specif- depolarization of the afferent nerve fibers that innervate ically, impulses from the neuroepithelium of the lateral the hair cells. Each hair cell has approximately 70 short and anterior canals, as well as the macula of the utricle and stereocilia and one longer kinocilium that project into the part of the saccule, are carried along the superior vestibu- gelatinous cupula. It is the laterally located kinocilium lar nerve, while information from posterior canal and re- that is the primary determinant of the direction of polar- maining saccular macula are transmitted by the inferior ization. At rest, there is a high baseline firing rate for the ves- Inferior and superior nerve fibers transmit afferent vestib- tibular nerve in each canal. Head movement, leading to ular input from the periphery to four vestibular nuclei in deflection of the kinocilium, causes modulation of this the pontomedullary junction. Deflection of the kinocilium toward that the initial integration and distribution sensory affer- the stereocilia causes an increase in neurotransmitter re- ent input occurs. Focused view of the dilated, or ampullated, end of a semicircular canal showing the cristae ampullaris, neuroepithelium (including the hair cells), and the cupula. Fluid motion, generated by head rotation, generates forces across the cupula that bend the stereocilia of the hair cells, resulting in release of neurotransmitter into the vestibular synapse. Each hair cell has approximately 70 short stereocilia and one longer kinocil- ium that project into the gelatinous cupula. It is the laterally located kinocilium that is the primary determinant of the direction of po- larization.

Due to their high allergy rate and poor pressure lowering effect purchase mildronate 250mg line treatment nail fungus, epinephrine and dipivefrin are rarely used today order mildronate 250mg on line symptoms stroke. It works as well as a nonselective b-blocker at peak effect discount mildronate 250mg symptoms 0f a mini stroke, although less well at trough 6–12 hours later order mildronate 500 mg on-line treatment 8th march, and almost all patients have some reduction in pressure. There is also some evidence from animal models of glaucoma that brimonidine may protect ganglion cells from death. There is no evidence of this property in humans, but this drug has sparked interest in treating glaucoma by mechanisms other than pressure reduction. The same sort of side effects can be seen with the topical medications, but they are extremely rare. However, twice-daily usage gives an adequate response when combined with a topical b-blocker, which diminishes the wash-out effect of aqueous production. Brimonidine can often be used 2x/day when combined with another aqueous suppressant. This may help reduce the impact of free radicals that have been postulated to be a cause of glaucoma. Allow 5 minutes between drops to prevent one drug from washing the other out of the eye. Punctal occlusion can dramatically reduce systemic side effects of glaucoma drugs. A patient on glaucoma drugs with dry or irritated eyes may be developing a medication allergy. Most ophthalmologists believe that compliance becomes increasingly more difficult the more medicines are used. Most consider the combination of a prostaglandin analog, timolol/ dorzolamide, and brimonidine to represent maximum medical therapy (5 drops/day). In selected cases additional medicines such as miotics or oral medication can be tried. It becomes harder to space three- and four-times-a-day medicines equally, but an effort should be made to try. The patient puts a finger adjacent to the nose where the two lids come together and pushes down on the bone. Because a drug coming into contact with the nasal mucosa is absorbed rapidly and almost completely, it attains serum levels quite similar to those achieved by intravenous administration. Absorption through the nasal mucosa also prevents a first pass by hepatic enzymes, which gives the liver a chance to metabolize or detoxify the medication. An important rule to remember is that topical medications should be initially prescribed as a one-eye therapeutic trial. This will help sort out a true drug effect from the patient’s underlying diurnal intraocular pressure fluctuation. Although there can be some crossover effect (about 1–2 mmHg) in the fellow eye, the one-eyed therapeutic trial is the best way to determine the drug’s effect. Unfortunately, the response in the first eye doesn’t always correlate with the response in the fellow eye once the drug is used bilaterally. Still, most glaucoma specialists believe that a therapeutic trial provides critical evidence to justify the use of a medication. Pilocarpine contracts the longitudinal muscle of the ciliary body, pulling on the scleral spur and mechanically opening the trabecular meshwork. However, it also pulls the lens-iris diaphragm forward, shallowing the anterior chamber. The contraction of the circular muscle of the ciliary body relaxes the stress on the zonules, allowing the lens to become more round, to float forward on a longer tether, and to act more like a natural cork in the pupil. This effect increases pupillary block and blows the peripheral iris closer to the trabecular meshwork. All of these effects tend to shallow the anterior chamber and narrow the anterior-chamber angle. Luckily, these effects are balanced by the miosis caused by the contraction of the sphincter muscle of the iris. Therefore, in most patients, although the anterior-chamber depth is decreased by pilocarpine, the peripheral angle is slightly widened. In some patients, however, shallowing of the peripheral angle may be more of a problem than angle crowding. Therefore, one should gonioscope all patients with a narrow angle for whom a miotic is prescribed, both initially and periodically thereafter. If a patient does not show an expected response to a topical glaucoma medication, what should the ophthalmologist consider as the reason? The chip was camouflaged, and patients did not know that their drop use was being monitored. Six percent of patients took less than 25% of the drops, whereas 15% took only 50%. However, 97% of his patients reported that they were taking all of their medication. This behavior can explain why many patients have completely controlled intraocular pressures in the ophthalmologist’s office but evidence progressive glaucoma damage. What should the treating ophthalmologist include as a routine part of the examination of all patients taking topical medication? The treating ophthalmologist should examine the lower lid and observe the conjunctiva. If there is a significant follicular reaction, especially if follicles are present on the bulbar conjunctiva, the patient is more than likely allergic to the topical drops. Brimonidine is well known for this but such a late reaction is commonly underappreciated and unrecognized. Among the topical nonselective b-blockers, carteolol seems to be the least irritating. In a patient with an ocular allergy secondary to topical medication, which is the most likely offender? Among the medications now in use, apraclonidine has the highest incidence of allergic reaction, followed (in order) by epinephrine, dipivefrin, brimonidine (less with the 0. Stopping the medicines in that order will usually help sort out which is the offender. Alternatively, have patients instill one drop in one eye and a different one in the fellow eye. There are, in general, few data about the safety of glaucoma medicines in pregnancy. Most specialists would strongly consider stopping all glaucoma medicines during pregnancy and either forgoing treatment for the duration or considering a surgical option. Because the fetal effects of most glaucoma drops have not been adequately tested, the use of an endogenous compound like epinephrine is reassuring.

Limits on acute medication intake possible therapeutic mechanisms 500 mg mildronate fast delivery treatment ulcerative colitis, including vascular con- should be set to avoid causing analgesic rebound and inad- striction and suppression of neurogenic inflammation vertently prolonging the clinical course discount mildronate 250mg with visa symptoms 5th disease. Currently buy mildronate 500 mg cheap medications ending in zole, almotriptan generic mildronate 500mg line medical treatment 80ddb, naratriptan, progress should be monitored regularly and any new prob- rizatriptan, sumatriptan, zolmitriptan, eletriptan, and fro- lems or setbacks dealt with promptly. Patients must understand may be useful if given early in the attack and at high that optimal treatment is often a team effort, with various enough doses. A gastric motility–enhancing drug such as consultants involved for the management of specific prob- metoclopramide may improve absorption and increase ef- lems as they are identified. We have found hydroxyzine a useful adjunct for In general, nonpharmacological measures are nearly headache pain and associated nausea. These may enhance compliance, help neous, or intramuscular dihydroergotamine remains use- identify problems, and reduce the need for medication. Lifestyle adjustments such as sleep regulation, avoidance Selecting the correct route of drug administration is im- of trigger activities, discontinuation of nicotine and alco- portant. It is also important to consider nonoral routes for hol, and regular appropriate exercise should be encour- medication if there is prominent nausea, vomiting, or aged. Injections, nasal sprays, and suppositories may be graphic biofeedback, imagery, and hypnotherapy, have appropriate (Ward 1998). Cognitive-behavioral type headache in patients with migraine may respond to programs can also be highly effective but are clearly lim- triptan drugs, whereas these headaches in nonmigraineurs ited in patients with significant cognitive impairment. Drug selection is best made with consider- changes but can also provide effective pain-coping strate- ation of comorbid and coexistent medical conditions (see gies. A useful ous electrical nerve stimulation and acupuncture may be strategy is to start with a low dose of medication, monitor helpful in some patients as well. This must be monitored carefully be low initially and advanced as necessary and as toler- by both the patient and family members. Adverse-effect profiles should be tailored to the in- Cluster headache is rarely triggered by trauma. Multiple symptoms isodic form is characterized by bouts of headaches typically should be targeted with the minimum of medications (e. Daily preventive med- oxygen, subcutaneous sumatriptan, and transnasal butor- ications should be challenged for effectiveness and dis- phanol. An occipital nerve block performed ipsilateral cological and pharmacological options. Chronic cluster headache is the form based on the morphology of the headache, so in patients that occurs essentially without a significant remission for with typical migraine features, recommended migraine longer than a year. Occasionally, inpatient therapy with re- treatment seems reasonable, albeit somewhat speculative. Truly medically in- For tension-type headaches that occur intermittently, tractable cases may require neurosurgery. These may include over-the-counter Neuralgic syndromes can frequently co-occur with other or prescription drugs. Local nerve infiltra- cle relaxants may be used if significant neck discomfort is tion with lidocaine or bupivacaine can be diagnostic as well present. Each hair cell is innervated by vestibular afferent neurons that allow transmission of positional information to the brain. Connections between the vestibular nuclei and ocu- complished by activation of left lateral and right medial lomotor nuclei allow maintenance of clear vision during rectus muscles and inhibition of left medial and right lat- head movement (see Figure 22–2). The neural circuitry included in this reflex starts ical states such as trauma, nystagmus can yield informa- with the vestibular nuclei and ultimately involves both tion on the location of the vestibulopathy. Inte- stem, projections from vestibular nuclei synapse on the oc- gration of these signals takes place directly in the medial ulomotor, trochlear, and abducens nuclei (cranial nerves longitudinal fasciculus and indirectly in the pontine retic- three, four, and six, respectively). Smooth hibitory peripheral signals depending on the direction of pursuit is responsible for maintaining a moving target on motion. Simply put, these signals ultimately translate to the fovea, while saccadic movements allow quick redirec- synchronized contraction and relaxation of the extraocu- tion of gaze from one target to another. Connections among the vestibular, abducens, and oculomotor nuclei allow maintenance of vision during head movement. Rotational head movement yields both excitatory and inhibitory peripheral signals depending on the direction of motion. In this example, main- tenance of an image on the retina during head rotation to the right requires conjugate leftward gaze. This is accomplished by stimulation of the right lateral semicircular canal and subsequent activation of the vestibular, abducens, and oculomotor nuclei. Ultimately, this neural circuitry culminates in activation of the left lateral and right medial rectus muscles and inhibition of left medial and right lateral recti. Integration of these signals takes place directly in the medial longitudinal fasciculus and indirectly in the pontine reticular for- mation (not shown). Comprehensive neurologic exam as well as op- Vertigo, from the Latin vertere meaning “to spin,” re- tokinetic testing can assist with localization of pathology fers to a hallucination of rotary movement, either of the pa- or injury. These reflexes result from multifaceted thology related to the semicircular canals. A sensation of interactions between peripheral afferent stimuli from the falling forward or linear motion can suggest problems with semicircular canals and otolithic organs and the somatic the otolithic organs. These complex tionary objects are moving during head motion, is indica- pathways allow maintenance of gait, posture, and balance. The meaning of the term light-headedness directly, from the superior vestibular nuclei, and indi- is extremely variable; it can represent vestibular, cerebral, rectly, to the cerebellum. More specifically, ance, the cerebellum is critical to adaptation after vestibu- it is often representative of presyncopal sensations and lar injury. Unsteadi- ness, imbalance, lack of coordination, and disequilibrium and Physical Examination are terms used to describe inability to confidently navigate in one’s environment. This vocabulary is, again, nonspe- cific and can suggest cerebellar, cortical, pyramidal, or spi- Vestibular Vocabulary nal tract etiology. In general, it is unusual for a peripheral injury to cause unsteadiness without vertigo. When interviewing a dizzy pa- History tient, the examiner needs to take a detailed, highly specific history because each term may be a clue to the location of A comprehensive history is crucial to diagnosis of vestibu- the underlying injury. Vestibular history taking: questions to assist mediately after injury or many months later in an outpatient in diagnosis setting. If appropriate, patients should be encouraged to Ask the patient to describe the first episode of dizziness in describe the first “spell” or a typical experience in detail. Did the patient experience vertigo or a sensation of or associated symptoms can spur patients to remember ad- spinning or is it better characterized as light-headedness or ditional critical details they may otherwise not offer. How 22–1 highlights specific questions to guide vestibular his- long did the first episode last? Were there any associated tory taking, including a thorough discussion of past medical symptoms, such as headache, facial nerve injury, tinnitus, or and surgical histories and a complete list of current medi- hearing loss?

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