The hearing-aid battery: a hazard to elderly patients

Summary Owing to the severity of its corrosive effects, an alkaline hearing-aid battery in the external auditory meatus is an otological emergency. This report emphasizes the particular risk to confused elderly patients and points out that a delay in diagnosis is common. Aetiology, clinical features and treatment are discussed with reference to three recent cases.

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Introduction Hearing loss presents a particular problem to the elderly population. Not only is the diagnosis often delayed but treatment with a hearing aid leads to new difficulties in management [1]. The role of the audiology department, and in some instances private companies, is to provide a proper fitting hearing aid and to give adequate instruction as to its use and to provide appropriate help in the months and years following the initial fitting.
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Ideally a full initial assessment of the capability of each recipient in fitting and adjusting the aid should be made and, if the patient is experiencing difficulties, a relative or friend may be put in charge of the hearing aid. However this is often not the case and elderly patients may be prescribed hearing aids that they do not understand owing to cognitive impairment, or they are unable to fit because of medical problems affecting dexterity. Related to these problems is the potentially serious hazard to those prescribed behind-the-ear or intra-canal hearing aids of impaction of a hearing-aid button battery in the external auditory meatus.

Since their introduction there have been a number of reports outlining the danger of battery ingestion and more recently cases of impaction in the nose and ear have occasionally been documented [2-5], usually involving children. We would like to draw attention to the specific danger to an elderly confused patient that may arise from the prescription and use of a hearing aid. If the battery comes to be lodged in the external auditory meatus (EAM) a severe tissue reaction develops and this is often compounded by a delay in diagnosis. Three such cases have recently presented to our department and are summarized in the Table.

Case Reports Although the actual time when each battery was inserted cannot be certain, patients 1 and 2 were in hospital at least 3

weeks prior to presentation to the ENT department and no aid had been used during this time (Table). It would appear extremely likely, therefore, that the batteries had been in the EAM at least 4 and 3 weeks, respectively, and in the third case the patient had suffered increasing ear symptoms for over 2 weeks prior to the battery being removed.

By the time of diagnosis, all patients had extensive necrosis of the external auditory meatus in addition to a swollen and erythematous pinna. During the weeks following diagnosis a marked granulomatous response was noted.

Discussion Button batteries such as those supplied with hearing aids are considerably more dangerous than most foreign bodies due to the extent and rapidity of their destructive effect. A battery in the ear is now well recognized as an otological emergency.

Button batteries vary in size between 0.5 and 1.5 cm diameter and are capable of delivering 1. 5 V of direct current. If placed in the ear a spontaneous leakage of alkaline electrolyte solution produces a low-voltage direct-current burn causing a tissue reaction within a few hours of impaction. Over a longer period, pressure necrosis potentiates the problem. The effect of a topical steroid/antibiotic solution (as used in case 3) potentiates the electrochemical reaction thus increasing corrosion, and can be illustrated by applying various T drops to the battery. Interestingly, Terra- [Cortry.sup.TM] ointment (which had been used in case 1 prior to the correct diagnosis being made) protects against corrosion presumably by providing an airtight seal. Once leakage is occurring the ultimate mechanism of injury, producing the most severe effects, is an alkaline burn. Alkali penetrates much deeper than acid into soft tissue producing an extensive liquefying necrosis [2].


The major aetiological factors leading to the insertion of foreign bodies in the ear have been shown to be associated irritation in the ear due to otitis externa, chronic middle-ear disease, or wax impaction [6]. However, probably of more importance in the cases of battery insertion is the confused state of the patient with regard to the workings and positioning of the hearing aid. Twenty peT cent of elderly patients over 85 years of age admit to lots of trouble' using their aid [1 ]. Mistakes can easily occur, including mistaking a button battery for an aid (in particular an intra-canal model) and inserting it into the ear.

The clinical picture is generally one of increasing pain and offensive otorrhoea with a worsening confusional state. In the cases mentioned above the delay in diagnosis in each case was approximately 3 weeks and this certainly potentiated the problem. During this period each patient had been assessed on more than one occasion by a medical practitioner (varying from GP to ENT surgeon) and, despite the fact that an ear problem had been focused upon, alternative diagnoses of otitis externa and advanced cholesteatoma were made. For reasons outlined above the use of topical steroid/ antibiotic drops may have made the situation worse whilst a battery was still in place.

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hazard aids

New state-of-the-art wind hazard maps for Caribbean islands and nearby coastal areas of Central and South America are critical aids when designing where to locate a new health facility or rebuild a damaged one. These maps can be useful in Haiti, where many hospitals will have to be built or retroffited after the earthquake of January 2010.

PAHO/WHO, together with Applied Research Associates, has developed the new Caribbean Basin wind hazard maps, which use the most up-to-date meteorological records and methods and are intended to replace older maps currently in use for structural design and risk assessment. They are an important aid for engineers, developers, and others whose work requires knowledge of wind hazards.

More about how and why the Caribbean Wind Hazard Maps were created:

Methodology used to produce the new Caribbean Basin Wind Hazard Maps: maps of hurricane-induced wind speeds developed using a peer-reviewed simulation model.
Maps containing predicted wind speeds for various return periods (mph at a height of 10 meters and three second gusts).
Location of referral hospitals in the Caribbean, as plotted on wind hazard maps.
Presentation of the CBWHM (Tony Gibbs).
Presentation of the CBWHM project at the US National Hurricane Conference 2008 (Peter Vickery).
Caribbean Application Document (Wind Hazards): Many Caribbean countries are using codes of the American Society of Civil Engineers (ASCE 7-05) when dealing with wind loading standards. However, ASCE-7 was written for the U.S., which has both hurricane and non-hurricane prone regions. This Caribbean Application Document eliminates all references to non-hurricane areas.
Case Study: Turn-key contracts for new hospital projects. This study outlines advantages and disadvantages of various “package” contracts for agencies/clients planning to build a new hospital. Contains a checklist of points to consider for “owners” of health infrastructure.
Read an article from the 2008 Newsletter Disasters: Preparedness and Mitigation in the Americas

Wind Hazard Maps: Valuable Instruments
for the Design and Construction of Safer Facilities

There is an underlying need for information on the hazard of winds, based on meteorological records and methodologies recognized by the scientific community. Precisely to meet this need, PAHO/WHO, together with Applied Research Associates, a U.S. institute, and experts from the Caribbean, created new wind hazard maps, with information on this hazard in the Caribbean islands, the Caribbean coasts of Central America and South America and the Yucatán Peninsula, a wider area than that covered in existing maps.

“Every day engineers in the Caribbean design projects that must be wind-resistant. …Clients wish to specify the levels of safety of their facilities, insurance brokers wish to know the risks they are taking on and financial institutions wish to include criteria regarding wind in their schemes”. Many of these decisions depend on the quality of information available regarding hazards, stated Tony Gibbs, regional coordinator of the project that created the new wind hazard maps.

The maps, updated with information collected over the last 20 years and using the most advanced meteorological methods, will replace those used since 1985 in the structural design of buildings and risk assessment.

Harmonization of norms

The new wind hazard maps yield information at a time when many countries in Latin America and the Caribbean are preparing to draw up new construction norms and this information can be included in codes and regulations for the design of health facilities.

Currently, a Caribbean Development Bank project (carried out by the Regional Caribbean Organization for Standards and Quality) is putting forth new regional standards; which will replace the construction code currently in force. The wind hazard maps complement this project, since they take into account international norms and provide information on the behavior of winds, an aspect that had not been previously included.

Methodology

Studies used to create the wind hazard maps were based on historical records of storms and hurricanes that took place from the mid-19th century; nevertheless, greater emphasis was placed on the period between 1970 and 2007. “Recent history is more reliable, as a result of which more emphasis was placed on this in the study. Even so, this information is insufficient to carry out statistical analyses and appropriate forecasts”, explains Gibbs. The study showed that there have not been significant changes in the cycles of cyclonic activity in the North Atlantic.

But the results are tremendously useful. With these, countries can adopt more effective procedures for monitoring standards in the design of health facilities with the aim of making them more resistant to winds and hurricanes. In addition, the information can be used to carry out vulnerability analysis of existing buildings or to take corrective actions. To date, the health sector had depended on the opinion of its advisors (engineers and architects) and the use of technical standards.

Because the maps are still relatively new (February 2008) and many consultants are still not familiar with them, work has begun to promote their use. The results of the studies used to prepare the maps were presented in international and regional meetings in Trinidad and Tobago, Belize, Saint Lucia, the British Virgin Islands, the Bahamas and Sint Maarten. Courses, seminars, conferences and dissemination through internet are some of the channels to be used in the process of spreading information on these manuals. Responsibility for the promotion and use of the information must be shared by all interest groups (health sector managers, donors, financial entities, engineers, architects, the insurance industry).

PAHO/WHO has promoted the use of ‘check consultants’ with technical knowledge to assess design and quality at different stages of building projects and they will ensure that information from the wind hazard maps is used appropriately in the construction of new health facilities.

The Office of U.S. Foreign Disaster Assistance of the United States Agency for International Development (OFDA/USAID) financed this project.

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People with HIV / AIDS in the city of Semarang Increase

The number of people living with HIV / AIDS in Semarang city continues to grow from year to year. Early detection of people at risk for this disease contributed to data collection on the number of patients.

reveals, the number of people living with HIV starting from the year 1995-2008 reached 674 people, while people with AIDS to 96 people. Of these, 18 patients of whom died.

Based on data from Semarang City Health Office, within the last four years, the trend number of people living with HIV continues to rise. For example, there were 50 patients with HIV in 2005, 179 people living with HIV in 2006, 195 patients in 2007, and 199 patients in 2008.

The number of people living with AIDS in the city of Semarang also go up. There are 11 carriers in 2005, 25 carriers in 2006, 33 carriers in 2007, and 15 carriers in 2008.

Tati said, the increasing number of patients indicates that people at risk of contracting HIV / AIDS began to open to participate in various examination tests of this disease.

Section Head of Prevention and Eradication of Communicable Diseases Jump DHO Semarang Tri Susilo Hadi said, of the total patients, 80 percent of whom were infected through sexual intercourse, while the rest of the use of hypodermic needles on narcotics and transmission from mother to child.

"As many as 60 percent of them are located in the productive age or between 20-40 years. No wonder, if the patient most of the commercial sex workers or people who frequently bergonta couples," he said.

Tri Susilo added, there are seven programs that can assist in combating the spread of HIV / AIDS, among others, behavior change communication, voluntary counseling and testing (VCT), care, support, and treatment (CST); prevention of transmission from HIV positive mothers to their children ; reducing the impact of injecting drug use; 100 percent condom use program, and community health education through media and schools. "We also distribute leaflets and posters in risky places such as localization and resorts," he said.

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Transvestite Request AIDS as the State Emergency Problems

In an effort to  tackle  the spread  of HIV  / AIDS, discrimination and violence on transvestites  transvestites, marginal transvestites  are doing the National  Conference  I in Bogor from 18 to 23 January  2009.

  Pernas Transvestite I conclude for equal rights and obligations of citizens can be done also for the transgendered. "Due to the existence of equal rights and obligations for the transvestite, then the transsexual can get treatment and decent work,"says Widodo Budidarmo of Arus Pelangi a news conference in Jakarta on Thursday.

Pernas also recommends that the Parliament urged the president to declare HIV / AIDS is a state of emergency problems, increase national budget for HIV penanggulan sustainably, and improve the status of AIDS prevention committee be chaired by the president.

 Based on Integrated Biological and Behavioral Surveillance (STBP 2007) by the Ministry of Health, shows HIV prevalence of transvestites in Jakarta, reached 34 percent or 1 in HIV-infected between 3 transvestites, then type Gonorrhoea prevalence reaching 55 percent in Bandung or 1 between 2 transvestites infected with this disease , and the prevalence of syphilis reached 30 percent in Surabaya or 1 in between 3 transvestites infected

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Of 478 Patients with HIV / AIDS in Karimun

the number of people living with HIV / AIDS on the island of Karimun Besar, Kabupaten Karimun, Riau Islands Province, from 2006 to 2008, carrying 478 people, according to survey results Yayasan Sri Mersing.
    
"From 2006 to 2008 the number of people living with HIV / AIDS, there were 478 people. They consisted of 293 HIV and 185 AIDS patients. In fact, 42 of the 185 people living with AIDS had already passed away," said Foundation Program managers Sri Mersing, Rustam Effendi, in Holding events IMS-epidemic of HIV and AIDS in the District Karimun in Tanjung Balai Karimun (TBK), Thursday.

Rustam Effendi explained that amount it earned on the basis of a survey in three districts located on the island of Karimun, Tanjung Balai Karimun district namely, Meral, and Cliff District.

Based on the data, the number of people living with HIV / AIDS is quite high if compared with the population in three districts of the island of Karimun, which is only about 130 thousand inhabitants.

Still based on the results of the survey, he said, the number of people living with HIV / AIDS for three years, the highest occurred in 2007 with a total of 167 people with HIV, while in second place in 2006 with the number of people living with HIV / AIDS 161, whereas in 2008 carrying as many as 150 people.

"Furthermore, the death rate is highest with AIDS occurred in 2006 that as many as 26 people, followed in 2007 with 9 people, and in 2008 as many as 8 people," he said.

He also said the group at high risk of contracting the HIV virus are sex workers (CSWs) and their clients

"The high number of people living with HIV / AIDS in Karimun caused by sex behavior and bad habits of users of prostitutes, because they are generally reluctant to use condoms during commercial sex workers using the service," he said.

The event was attended by 10 pimps of the three localization in Pulau Karimun Besar, Health Center employees and members of the Police Karimun.

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Already 478 People with HIV

The number of people living with HIV / AIDS on the island of Karimun Besar, Kabupaten Karimun, Riau Islands Province, from 2006 to 2008, carrying 478 people. "From 2006 to 2008 the number of people living with HIV / AIDS, there were 478 people. They consisted of 293 HIV and 185 AIDS patients. In fact, 42 of the 185 people living with AIDS had already passed away," said Foundation Program managers Sri Mersing, Rustam Effendi, in Holding events IMS-epidemic of HIV and AIDS in the District Karimun in Tanjung Balai Karimun (TBK),
  
Rustam Effendi explained that amount it earned on the basis of a survey in three districts located on the island of Karimun, Tanjung Balai Karimun district namely, Meral, and Cliff District. Based on the data, the number of people living with HIV / AIDS is quite high if compared with the population in three districts of the island of Karimun, which is only about 130 thousand inhabitants.

Still based on the results of the survey, he said, the number of people living with HIV / AIDS for three years, the highest occurred in 2007 with a total of 167 people with HIV, while in second place in 2006 with the number of people living with HIV / AIDS 161. While in 2008 there were 150 people.

"Furthermore, the death rate is highest with AIDS occurred in 2006 that as many as 26 people, followed in 2007 with 9 people, and in 2008 as many as 8 people," he said. Rustam Effendi also said the group at high risk of contracting the HIV virus are sex workers (CSWs) and their customers.

"The high number of people living with HIV / AIDS in Karimun caused by sex behavior and bad habits of users of prostitutes, because they are generally reluctant to use condoms during commercial sex workers using the service," he said.

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AIDS in NTT Aged 25-49 Years

A total of 446 cases of HIV / AIDS in East Nusa Tenggara befall residents aged 25-49 years or age. While children aged 0-5 years as many as 11 people. Staff Commission for HIV / AIDS NTT, Gusti Brewon in Kupang on Saturday (31 / 1) said data as of December 31, 2008 shows the development of  HIV / AIDS cases quite  large.

Reports from the 20 districts / cities in Sumba, NTT except Southwest and Central Sumba Nagekeo shows the number of HIV / AIDS as many as 538 cases. "This amount consisted of as many as 354 HIV and 184 AIDS cases, while the sufferer who died as many as 112 people. There is considerable growth rates compared to the previous three months only 400 of the case," said Brewon.

The increase showed the party who handles the issue of HIV / AIDS has been working quite like VCT or maximal voluntary HIV testing, Public Health Service, Health Center, and KPAD District as well as NGOs concerned with HIV / AIDS. Thanks to the hard work of these institutions they managed mengidentivikasi HIV / AIDS new.

Brewon mentioned, there are still many cases that have not been identified or reported. But it is believed, that number will continue to climb. It is time for NTT has a halfway house specifically to accommodate and deal with people living with HIV / AIDS and drug users.

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Banyumas Vulnerable HIV / AIDS

Banyumas position as a regional transit, tourism, and business center and services make this area has a high degree of vulnerability to spread the HIV virus. This terl're seeing from the data 253 cases of HIV in this region which mostly occurred in the six districts that are crossing the region, tourism and service centers.

Six districts are District Baturraden, four districts in Navan, and Wangon. From year to year, found the number of cases of HIV / AIDS in the region continues to increase.

Chairman of the National AIDS Commission (NAC) Banyumas, Kristin Lester, Tuesday (3 / 2), reveals, Banyumas now become the main crossing areas in the western part of Central Java. Many terminals and vehicle transportation and transit through this region.

In Wangon, for example, be a crossroads for the community that led to Bandung, Cilacap, and Yogyakarta. This area has always been a haven while the drivers transport goods or people.

This stopover become vulnerable because later there is interaction, especially with a truck driver. Transmission can be through sexual intercourse. In addition, rest stops also lead to social and cultural influences outside. "It's proven a lot of cases of HIV / AIDS in Wangon for through drug needles," said Kristin.

In Baturraden many transmission because of the region a center of prostitution in Banyumas. Transmission can be done faster with a lack of awareness of condom use by guests during a date with commercial sex workers in the region.

HIV-AIDS transmission is relatively high prostitution area indicated by the high percentage for heterosexual intercourse as the cause of HIV / AIDS, which reached 56 percent. This figure exceeds the other factors such as the use of syringes by 30 percent, 8 percent of homosexual relationships, and 3 percent of blood transfusions.

Navan Town, the capital of Banyumas in recent years developed cuku p rapidly. The city is the center of services and education. No doubt, many immigrants present in this city. Foreign cultures, such as drug use was rampant, one of them among the students and college students.

The data collected by KPA Banyumas, 12 percent of 253 HIV cases in Banyumas occurred among students. "Students and student vulnerable to HIV transmission, especially with the spread of injecting drug use," he said.

An estimated number of HIV cases in Banyumas 253 is only dipermukaa n. According to the Head of the PMI Headquarters Banyumas, Sutoro, in early January and PMI Banyumas found 72 bags of HIV-infected blood. Blood-blood came from donors. Unfortunately, not all donors can be identified.

PMI currently lack the budget to hold a blood processing. Operational test is also more expensive. If, blood tests can we optimize, sebernarnya will be more cases that could be found, he asserted.

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