Prof. U Thein Aung

Prof. U Khin Maung Aye

Dr. Tin Nyunt

Prof. U Saw Win

Prof. Daw Mya Thida

Prof. U Ne Win

Issue 15 November, 2012

Advisory Group

Holistic, Compassionate and Quality Health Care

Editorial Board

Dr. Myint Lwin

Dr. Shwe Baw

Dr. Zay Ya Aye

Dr. Shein Myint

Dr. Tin Moe Phyu

Dr. Khin Than Htay

Dr. Thida Oo

Dr. Nyein Moe Thaw

Dr. Hnin Thuzar Aung

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Dr. Shein MyintParami Hospital - Yangon

The Auditory Brainstem Response is most commonly abbreviated "ABR", but also referred to as the BAER (brainstem auditory evoked response, BAEP (brainstem auditory evoked potential), BER (brainstem evoked response), etc. The ABR represents electrical activity generated by the eighth cranial (vestibulo-cochlear) nerve and neural centres and tracts within the brainstem that are responsive to auditory stimulation.

The ABR has primary clinical application in two areas :

(a) Identificationof neurological abnormalities in the eighth cranial nerve and auditory pathways of the brainstem.

(b) Estimation of hearing sensitivity based on the presence of a response at various intensity levels.

The ABR is most robust in identifying tumours of the eighth nerve that are greater than one centimeter (cm), whereas less success has been experienced with diffuse demyelinating disease like multiple sclerosis.

TherearetwoprimarygroupsofpatientswhowillbenefitfromABRtesting:

(a) Those patients with suspected neural problems.

(b) Those patients for whom accurate behavioural evaluation of hearing sensitivity is not possible.

AnormalABRwaveformischaracterizedbyfivetosevenvertexpositivepeakthatoccur on the time period from 1.4 to 8.0 multi second after the onset of a stimulus.

Thus, wave (I) corresponds, to recording from the distal position of the eighth nerve and wave (II) originates mainly from the proximal position of the eighth nerve with a possible small contribution from more distal positions of the auditory nerve.

Recording from the cochlear nucleus correspounds with the surface-recorded wave (III), suggesting that wave (III) is generated mainly by neurons in the cochlear nucleus, withpossibleadditionalcontributionsfromfibresenteringthecochlearnucleus.Theneuralgenerations of wave (IV) are uncertain, although third order neurons in the superior olivary complex are most likely involved; other contributors may include the cochlear nucleus and the nucleus of the lateral lemniscus. The wave (V) may be related to activity in the lateral lemniscus and inferior colliculus, but it should be emphasized that peaks IV, V, VI and VII of the ABR are complex, with more than one anatomical structure contributing to each peak

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Audiology Brainstem Response " ABR "

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Page - 2Issue - 15, November 2012 Parami Hospital - Yangon, Newsletter

Once at the bus-stand, she has to wait for sometime–at least ten minutes before the bus she usually catches comes into view. She lives in down-town. Usually she used to go to the university by the school-bus. But now she has graduated and has started working in a newly established company. Her work takes her daily (except Sundays) to the outskirts of the city. She is happy. In fact she is feeling on top of the world! Who wouldn’t be happy when one gets a job a few monthsafterone’sgraduation.Anditisanewoffice–anew company – everything new! Her job starts at nine in themorningandfinishesatfiveintheevening.Shehasto work six days in a week. Naturally she does not have to work on Sundays and of course neither on government-gazetted holidays. It was one gazetted holiday – a religious day: a full-moon day when Myanmar people celebrate their kasone nyaung-yé-thunfestival.ItwasaholidayforMay’sofficetoo.Butshemustgototheoffice–sheneededtohelpherjunior colleagues who were engaged in cleaning up the new office.She caught thebus afterwaiting for sometime atthe bus-stand. There were few people in the bus because it was a holiday but those inside were well-dressed and some wereequippedwithbouquetsofflowers:onlythendidsheremember that it was a religious holiday. She got a seat in the front line at the back of the driver and she no longer

Day in day out! It’s not easy to travel daily by bus. But when one doesn’t own a car, there’s no way but to take a bus to get to your destination!

The start of another day! By 8 o’clock, lunch-box in hand, May starts her day – she walks out to her bus – stand, a few kilometers away from her apartment. Actually, she lives in an eight-storeyed building – her apartment being in the topmostfloor.Shehastomakesureshedoesn’tforgettobringalongeverythingasshelefthome.Orelse,shemighthave to run up the stairs again to pick up whatever she has forgotten to bring along with her, making her all in before she could even go to the bus-stand.

noticed the scarcity of the passengers. It took some forty-fiveminutestoreachthebus-standwheresheshouldgetofftoreachheroffice.Shewasengrossedinherthoughts,happyandcontentwithherendeavourtohelptheofficegirls at work – imagining herself as an outstanding worker, reachingtheofficeearlierthanothersandorganizingherstaff. No, she had not forgotten she was in a bus. She was not used to going to this surroundingwhere her officewas and she had a time trying to remember the bus-stand which preceded the one that she should really get off. It is common practice to walk to the bus doorway when one reaches the stop preceding the one where one should get off, to be ready to get off when the bus stops at the next stand – one’s destination. No bus drivers nor bus conductors wouldfindtimeforpassengerswhoareslowandnotactiveenough to jump into the bus or off the bus – they are all in a hurry to do their chores of bus-round and overtaking their fellow buses. Soon the bus rushed passed many bus-stands and May could well remember that she was almost there – heroffice-building,butshedidnothearthebusconductorshoutthe name of the bus-stand she was to get off. Anyway, the bus usually let down the passengers at the crossroads where thetrafficlightsturnedred.Shestoodupfromherseatandwalked to the bus doorway although the bus was not at all

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I’ll report this……!

Page - 3Issue - 15, November 2012 Parami Hospital - Yangon, Newsletter

1. Lead by example from the front of the formation. Take your performance personally – if you are proud to be average, so too will be your troops.

2. A leader must provide a vision – clear and achievable '' big ideas " combined in a strategic concept – and communicate those ideas throughout the entire organization and to all other stakeholders.

3. A leader needs to give energy; don't be an oxygen thief.

4. There is an exception to every rule, standard operating procedure, and policy; it is up to leaders to determine when exceptions should be made and to explain why they made them.

5. We all make mistakes. The key is to recognize them and admit them, to learn from them, and to take off the rearview mirrors – drive on and avoid making them again.

6. Be humble. The people you'll be leading already haveon-the-groundconflictexperience."Listenandlearn. "

7. Be a team player. " Your team's triumphs and failures will, obviously, be yours. " Take ownership of both.

8. Don't rely on rank. If you rely on rank, rather than on the persuasiveness of your logic, the problem

" Rules For Living As A Good Leader "could be you and either your thinking or your communication skills. Likewise, sometimes the best ideas come from bottom-up information sharing (i.e., "Need to share" not "Need to know"). Use "directed telescopes" to improve situational awareness.

9. Leaders should be thoughful but decisive. Listen to subordinates' input, evaluate courses of action and second-and third-order effects, but be OK with an "80 percent solution." "There will be many moments when all eyes turn to you for a decision. Be prepared for them. Don't shrink from them. Embrace them." Sometimes the best move is the bold move.

10. Stayfittofight.Yourbodyisyourultimateweaponssystem.Physicalfitnessforyourbodyisessentialformentalfitness.

11. The only thing better than a little competition is a lot of competition. Set challenges for your subordinates to encourage them to excel.

12. Everyone on the team is mission critical. Instill in your team members a sense of great self-worth-that each, at any given time, can be the most important onthebattlefield.

Ref : Lessons on leadership from General David Petraeus. By Paula Broadwell.

Children with the worst reading skills could improve their literacy with daily supplements of fatty acids found infish,seafoodandsomealgae,researchersclaim.Scientistsgaveadaily600mgomega-3fattyacidpilltochildrenagedseventonineandfoundthatthosewhosereadingskillswereinthelowestfifthofthenormalrangeimprovedoverthefour months of the study. On average, the children in the bottom 20% for literacy boosted their reading age by three weeks more than a control group taking a daily placebo. Those in the lowest 10% for literacy improved their reading age by 1.9 months compared with the placebo group. The study was funded by a company called DSM Nutritional Lipids, which makes omega-3 supplements, though the study was performed at Oxford independently. Ref : http://www.guardian.co.uk/science/2012/sep/06/reading-fatty-acids-controversy

Omega-3 may help struggling children to read, says study

Page - 4Issue - 15, November 2012 Parami Hospital - Yangon, Newsletter

slowingdownatthecrossroads.Perhapsthetrafficlightswere still green, she thought. But even as she walked to the doorway, the bus did not come to a halt at the oncoming bus-stop that she was to get off:

“Stop! Stop! This is the stop I am to get off!”, she raised her voice in distress, but to no avail. Surprised, she looked at the direction of the conductor who did not seem to care at all, “You did not get up from your seat in due time. You can catch the return bus, it’s quite easy”, he muttered.

May stared at the bus conductor, and suddenly burst out in anger, “Why don’t your bus halt at the bus-stop? It’s a job of every bus to stop at the bus-stop! I am going to report this!”. Her eyes wavered onto the inside of the car’s

roof {the bus’ ceiling} searching for the phone number allowing passengers to send a complaint; this being usually presentinbuses.Buthereshecouldnotfindit.Thismadeher more frustrated: “I’ll report this to your headquarters! How dare you do like this! Give me back the bus fare”. She shouted at the top of her voice oblivious of the passengers whose eyes were on her. The conductor was surprised: he seemed to think it was no problem for one to catch back a bus just for one stop! But May was angry especially because shehadwanted toreachherofficeearly,earlier than theappointed time! Now, with the time wasted to catch another bus,howcouldshereachtheofficeearly?Noteasyevento arrive in time!

She jumped off the bus when it came to a halt at the next stand. But even as she did so, she felt a sensation of dull pain in her left knee - " Ah-h-h! ", she landed in a limp making her more angry as she remembered the day before yesterday when she was injured as she caught the bus to go to her new job: she had landed on all fours at that time as she got into the bus because soon after she had stepped

onto it, the bus had swayed and swerved in trying to overtake theone in front.

“Yes, I’ll report this!” she shouted again and looked up at the bus which had disappeared from her view – too late, she had not even noted down its ‘registered number plate’……..! - ktt -

Continued from Audiology Brainstem Response " ABR " (Page - 1)

and each structure contributing to more than one peak. The only obligatory synaptic sites in the human brainstem pathway are the cochlear nuclei and the inferior colliculus, and between these pathways there are series of parallel pathway.

However auditory evoked potential provides powerful, objective methods of assessing the neural integrity of the auditory pathways from the eight cranial nerve to the cortex. Figure showing Normal ABR waveform responser

Continued from I’ll report this……! (Page - 2)

Ref: (1) Hood, L.J (1998) Clinical applications of the Auditory Brainstem Response. Singular Publishing group. (2) Katz. J. (2002). Handbook of CLINICAL AUDIOLOGY Lippincott Williams + Wilkins.