Efficacy and Effectiveness of Advanced Hearing Aid Directional and Noise Reduction Technologies for Older Adults With Mild to Moderate Hearing Loss

Objectives: The purpose of the present study was to investigate the laboratory efficacy and real-world effectiveness of advanced directional microphones (DM) and digital noise reduction (NR) algorithms (i.e., premium DM/NR features) relative to basic-level DM/NR features of contemporary hearing aids (HAs). The study also examined the effect of premium HAs relative to basic HAs and the effect of DM/NR features relative to no features. Design: Fifty-four older adults with mild-to-moderate hearing loss completed a single-blinded crossover trial. Two HA models, one a less-expensive, basic-level device (basic HA) and the other a more-expensive, advanced-level device (premium HA), were used. The DM/NR features of the basic HAs (i.e., basic features) were adaptive DMs and gain-reduction NR with fewer channels. In contrast, the DM/NR features of the premium HAs (i.e., premium features) included adaptive DMs and gain-reduction NR with more channels, bilateral beamformers, speech-seeking DMs, pinna-simulation directivity, reverberation reduction, impulse NR, wind NR, and spatial NR. The trial consisted of four conditions, which were factorial combinations of HA model (premium versus basic) and DM/NR feature status (on versus off). To blind participants regarding the HA technology, no technology details were disclosed and minimal training on how to use the features was provided. In each condition, participants wore bilateral HAs for 5 weeks. Outcomes regarding speech understanding, listening effort, sound quality, localization, and HA satisfaction were measured using laboratory tests, retrospective self-reports (i.e., standardized questionnaires), and in-situ self-reports (i.e., self-reports completed in the real world in real time). A smartphone-based ecological momentary assessment system was used to collect in-situ self-reports. Results: Laboratory efficacy data generally supported the benefit of premium DM/NR features relative to basic DM/NR, premium HAs relative to basic HAs, and DM/NR features relative to no DM/NR in improving speech understanding and localization performance. Laboratory data also indicated that DM/NR features could improve listening effort and sound quality compared with no features for both basic- and premium-level HAs. For real-world effectiveness, in-situ self-reports first indicated that noisy or very noisy situations did not occur very often in participants' daily lives (10.9% of the time). Although both retrospective and in-situ self-reports indicated that participants were more satisfied with HAs equipped with DM/NR features than without, there was no strong evidence to support the benefit of premium DM/NR features and premium HAs over basic DM/NR features and basic HAs, respectively. Conclusions: Although premium DM/NR features and premium HAs outperformed their basic-level counterparts in well-controlled laboratory test conditions, the benefits were not observed in the real world. In contrast, the effect of DM/NR features relative to no features was robust both in the laboratory and in the real world. Therefore, the present study suggests that although both premium and basic DM/NR technologies evaluated in the study have the potential to improve HA outcomes, older adults with mild-to-moderate hearing loss are unlikely to perceive the additional benefits provided by the premium DM/NR features in their daily lives. Limitations concerning the study's generalizability (e.g., participant's lifestyle) are discussed. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and text of this article on the journal's Web site (www.ear-hearing.com). ACKNOWLEDGMENTS: Yu-Hsiang Wu is currently receiving grants from the National Institute on Deafness and Other Communication Disorders, the National Institute on Disability, Independent Living, and Rehabilitation Research, and the Retirement Research Foundation. Octav Chipara is currently receiving grants from the National Institute on Disability, Independent Living, and Rehabilitation Research and the National Science Foundation. Jacob Oleson is currently receiving grants from the National Institute on Deafness and Other Communication Disorders, National Heart, Lung, and Blood Institute, Department of Defense, Centers for Disease Control and Prevention, Fogarty International Center, and the Iowa Department of Public Health. The current research was supported by National Institute on Deafness and Other Communication Disorders (R03DC012551) and the National Institute on Disability, Independent Living, and Rehabilitation Research (90RE5020-01-00). The current research was supported by NIH/NIDCD R03DC012551 (title: Minimal Technologies for Hearing Aid Success in Elderly Adults) and the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) 90RE5020-01-00 (title: RERC on Improving the Accessibility, Usability, and Performance of Technology for Individuals Who are Deaf or Hard of Hearing). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this article do not necessarily represent the policy of NIDILRR, ACL, HHS, and the reader should not assume endorsement by the Federal Government. Portions of this paper were presented at the annual conference of the American Auditory Society, March 3, 2016, Scottsdale, AZ. Y.-H.W. designed experiments, interpreted data, and wrote the article; E.S. collected data; O.C. and S.S.H. developed EMA software and processed EMA data; S.D. and J.O. provided statistical analysis. All authors discussed the results and implications and commented on the manuscript at all stages. The authors have no conflicts of interest to declare. Address for correspondence: Yu-Hsiang Wu, 125C SHC, Department of Communication Sciences and Disorders, The University of Iowa, Iowa City, IA 52242, USA. E-mail: yu-hsiang-wu@uiowa.edu Received March 8, 2018; accepted August 29, 2018. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Perinatal antibiotic exposure alters composition of murine gut microbiota and may influence later responses to peanut antigen

Accumulating evidence suggests that the gut microbiota shapes developmental processes within the immune system. Early life antibiotic use is one factor which may contribute to immune dysfunction and the recent...

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Anaphylactic reaction in patient allergic to mango

An allergy to mango is extremely rare. The antigenic composition of the fruit is not fully known. Profilin from mango has a structure similar to birch tree profiling: it is responsible for cross-reactions betw...

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Alternative adsorbents applied to the removal of natural hormones from pig farming effluents and characterization of the biofertilizer

Abstract

Pig farming has a very strong economic importance in Brazil. The residues from this activity are applied to the soil because of their excellent characteristics as biofertilizers. The present study aimed at studying the estrone, 17β-estradiol, and estriol natural hormones, emerging contaminants present in this type of residue that are not mentioned in the current legislation. The characterization of the pig farming effluent presented high concentrations of hormones (mg L⁻¹). The objective was to apply the biosorbents to the removal of the hormones in batch systems directly in the manure heaps without affecting the potential of the effluent as a fertilizer. It was verified that the adsorption of hormones using the rice husk biomass in natura and soybean hull in natura, abundant alternative adsorbents, presented a good capacity of removal of hormones. The presence of the organic materials (rice husk and soybean hull) caused few alterations in the biofertilizer characteristics, demonstrating that these adsorbents present a potential of application in batch treatment systems, with possible applications related to pig farming effluents containing natural hormones.

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Respiratory Complications of Adenotonsillectomy for Obstructive Sleep Apnea in the Pediatric Population

Objective. To determine the prevalence of respiratory complications in the early postoperative period of children with sleep apnea who required adenotonsillectomy at a tertiary pediatric hospital and to establish recommendations for postoperative monitoring. Methods. Retrospective cohort study of children with obstructive sleep apnea (OSA) diagnosed by polysomnogram (PSG), who underwent adenotonsillectomy for treatment of OSA. The prevalence of respiratory complications in the first 24 postoperative hours was measured. Patients with craniofacial malformations, obesity, and severe cardiovascular comorbidities were excluded. The prevalence of postoperative respiratory complications was compared with the severity of OSA according to the Apnea Hypopnea Index (AHI) and NADIR. All data were taken in patients residing in Bogotá city, Colombia, at 2.640 meters above sea level (m.a.s.l). Results. Between May 2014 and February 2017, 167 patients (108 males) required adenotonsillectomy for OSA, with an age range of 1 and 15 years (mean 5.3 years +/- 2.7). The prevalence of postoperative respiratory complications was 3.59% (6/167). There was a statistically significant relationship between the presence of respiratory complication and AHI greater than 44/h (p

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Implications for the migraine SNP rs1835740 in a Swedish cluster headache population

Abstract

Background

Cluster headache is a severe headache disorder with unknown aetiology. The pathophysiology and symptoms present certain common features with migraine. Specifically, activation of the trigeminal vascular system seems to be involved in both disorders, which is hypothesized to result in neurogenic inflammation and vasodilation of the cerebral vessels. In addition, genetic factors have been implicated in both migraine and cluster headache.

Objective

In order to determine whether or not migraine and cluster headache share genetic risk factors, we screened two genetic variants known to increase the risk of migraine in Sweden in a Swedish cluster headache case-control study population.

Methods

In all, 541 patients and 581 control subjects were genotyped for rs1835740 in close proximity to MTDH (metadherin) and rs2651899 in the PRDM16 (PR/SET domain 16) gene, using TaqMan® real-time PCR and pyrosequencing. In addition, we analyzed MTDH gene expression in a subset of the material, using reverse transcription real-time PCR to determine relative mRNA levels in primary fibroblast cell lines from patients and controls.

Results

We found a trend for association between rs1835740, which is reported to affect MTDH mRNA levels, and cluster headache in our Swedish case-control material (p = 0.043, Χ² = 4.102). This association was stronger in a subgroup of patients suffering from both cluster headache and migraine (p = 0.031, Χ² = 6.964). We could further confirm that rs1835740 has an effect on the transcriptional activity of MTDH. In this Swedish cluster headache cohort we did not find an association with the rs2651899 variant.

Conclusions

We conclude that rs1835740 is a potential risk factor for cluster headache in Sweden. Our data indicates that rs1835740 and MTDH might be involved in neurovascular headaches in general whilst rs2651899 is specifically related to migraine.

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Clinical Indices to Drive Quality Improvement in Otolaryngology

A Pediatric Tracheostomy Care Index (PTCI) was developed by the authors to standardize care and drive quality improvement efforts at their institution. The PTCI comprises 9 elements deemed essential for safe care of children with a tracheostomy tube. Based on the PTCI scores, the number of missed opportunities per patient was tracked, and interventions through a "Plan-Do-Study-Act" approach were performed. The establishment of the PTCI has been successful at standardizing, quantifying, and monitoring the consistency and documentation of care provided at the authors' institution. (Source: Otolaryngologic clinics of North America)

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Contents

Sujana S. Chandrasekhar (Source: Otolaryngologic clinics of North America)

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Patient Safety and Quality Improvement

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA (Source: Otolaryngologic clinics of North America)

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Contributors

SUJANA S. CHANDRASEKHAR, MD, FACS, FAAOHNS (Source: Otolaryngologic clinics of North America)

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Copyright

Elsevier (Source: Otolaryngologic clinics of North America)

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Forthcoming Issues

Implantable Auditory Devices (Source: Otolaryngologic clinics of North America)

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CME Accreditation Page

(Source: Otolaryngologic clinics of North America)

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Button Battery Safety

The pediatric button battery (BB) hazard has been recognized for several decades. In 2012, the National Button Battery Task Force was established, and most manufacturers have improved warning labels, more secure packaging, and made BB compartments in products are more secure. Tissue neutralization before BB removal (ie, honey or sucralfate/Carafate ®) is an effective way to reduce the rate of BB injury. In absence of visible perforation, 0.25% sterile acetic acid esophageal tissue irrigation at time of BB removal is recommended as a neutralization strategy to mitigate injury progression. Future BB design changes could eliminate esophageal tis sue injury. (Source: Otolaryngologic clinics of North America)

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Self-Reported Benefit and Satisfaction with a Beamforming Body-Worn Hearing Aid for Elderly Adults

Hearing impairment is a leading cause of disability globally and is particularly prevalent in elderly populations. Hearing aids are commonly recommended to mitigate the adverse effects on communication associated with hearing loss. However, the acceptability of hearing aids to elderly individuals is low and the majority of potential users do not wear hearing aids. Most hearing aids are designed with a discreet form factor in mind, to minimize device visibility. Given the range of comorbidities associated with hearing loss in the elderly, this conventional form factor may not always be optimal. The present study examined the experiences of elderly individuals with a recently developed, unconventional, body-worn hearing instrument, the EasyHear™ Grand (Logital Co. Ltd., Hong Kong). The bilaterally fitted instrument incorporates large controls, a color display, beamforming sound processing, and Bluetooth capabilities. Forty-three elderly participants (mean age=71; range 46-88 years) were surveyed to gauge level of benefit and satisfaction with the device and opinions regarding the hearing aid. They were assessed using three standardized questionnaires (the International Outcome Inventory-Hearing Aids, the Profile of Hearing Aid Benefit, and the Client Oriented Scale of Improvement) and through open-ended, structured interviews. Participants rated their EasyHear device fitting highly for hours of use and improved quality of life and rated the device favorably for improved communication and benefit in background noise. A majority of users felt the device improved listening ability in their expressed area of greatest need, and also for their second highest prioritized area of greatest need. Less than 10% of users felt their listening was only occasionally or hardly ever improved when using the body-worn device. Benefit and satisfaction ratings with the EasyHear Grand were comparable to those in studies involving conventional form factor devices. Interviews highlighted areas where users felt the device could be improved—extra noise reduction, changes to device dimensions, receiver/eartip fit, and cableless technology were among the areas mentioned. Many participants valued smartphone linkage and Bluetooth capability. The EasyHear Grand, with its body-worn design and large, simple controls, was well accepted by the majority of participants. Hearing aids that break from conventional design formats may benefit many elderly individuals with hearing impairment and promote increased user acceptability.

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Satisfaction level in dental-phobic patients with implant-supported rehabilitation performed under general anaesthesia: a prospective study

Abstract

Background

Phobic patients avoid dental treatment impairing their oral health and making it challenging to offer them prosthetic rehabilitation. This study evaluated patients' experience of implant-supported prosthetic treatment after implantation performed under general anaesthesia due to dental phobia and severe pharyngeal reflexes (SPR). The effect of gender, age and location of implantation on patient satisfaction was tested.

Methods

Two hundred five patients underwent implantation under general anesthesia both in maxilla and mandible, respectively. After a trans-gingival healing period of 6–8 weeks, fixed implant bridges were inserted. Patients completed oral health impact profile questionnaire (OHIP-14). An additional set of six special questions was also developed and considered. Analysis of the OHIP-14 total score was made using logistics regression. Wald chi-square test was used to analyse the effect of age, gender and location of implantation. Effect sizes were estimated as odds-ratios and associated 95% Wald confidence intervals.

Results

Eighty two of 205 patients were included after prosthetic treatment. After start, 38 patients were excluded (4 died and 34 couldn't be reached). OHIP-14-analyses were made by 43 patients (30–90 years). 67% of patients were totally satisfied with the whole implant rehabilitation (scoring 0). Mean of total score was 2.5. Only age affected significantly (p = 0.014) patients satisfaction. The obtained data indicate that younger patients (30–64 years) especially women are less satisfied (4.95) than older patients (0.3) for age group (65–90 years).Special questions' data showed that 94.5% were satisfied with their treatment. 77.3% continued regular check-up after treatment and 96.9% would undergo the same treatment again. 95.5% would recommend implants to a friend of colleague.

Conclusion

Gender and location of implantation have no significant influence on patient satisfaction. Younger patients especially women are less satisfied than older patients. Phobic patients are totally satisfied with implant rehabilitation under general anaesthesia which means that this treatment can be considered as a treatment of choice giving these patients the same opportunity like others to improve their oral health and well-being.

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Factors associated with future dental care utilization among low-income smokers overdue for dental visits

Abstract

Background

Smokers are at increased risk of oral disease. While routine dental care can help prevent and treat oral health problems, smokers have far lower rates of dental care utilization compared with non-smokers. We sought to better understand which factors may facilitate or hinder dental care utilization among low-income smokers participating in a randomized intervention trial in order to inform future intervention planning.

Methods

This is a secondary analysis of data collected between 2015 and 2017 as part of the OralHealth4Life trial. Participants were eligible callers to the Louisiana, Nebraska, and Oregon state tobacco quitlines who had no dental appointment in the prior or upcoming six months. We examined the association between participants' baseline characteristics and their receiving professional dental care between baseline and the 6-month follow-up survey.

Results

Participants were racially diverse (42% non-White) and two-thirds had an annual household income under $20,000. Most (86.7%) had not had a dental cleaning in more than one year. Commonly cited barriers to dental care included cost (83.7%) and no dental insurance (78.1%). Those with dental insurance were more likely to see a dentist at follow-up (RR 1.66). Similarly, those reporting a dental insurance barrier to care were less likely to see a dentist at follow-up (RR 0.69); however, there was no significant utilization difference between those reporting a cost barrier vs. those who did not. After controlling for these financial factors, the following baseline characteristics were significantly associated with a higher likelihood of dental care utilization at 6 months: higher motivation (RR 2.16) and self-efficacy (RR 1.80) to visit the dentist, having a disability (RR 1.63), having a higher education level (RR 1.52), and having perceived gum disease (RR 1.49). Factors significantly associated with a lower likelihood of dental care utilization included being married (RR 0.68) and not having a last dental cleaning within the past year (RR 0.47).

Conclusions

Our findings provide important insight into factors that may facilitate or deter use of professional dental care among low-income smokers. This information could inform the development of future interventions to promote dental care utilization.

Trial registration

ClinicalTrials.gov: NCT02347124; registered 27 January 2015.

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Determination of effective half-life of 131 I in patients with differentiated thyroid carcinoma: comparison of cystatin C and creatinine-based estimation of renal function

Abstract

Purpose

Renal function and effective half-life (t_1/2,eff) of I-131 have not been fully elucidated in patients undergoing radioiodine therapy (RAIT) for differentiated thyroid cancer (DTC). Aim of the present analysis was to evaluate the potential of cystatin C-based estimated glomerular filtration rate (eGFR_CysC) in comparison to conventional creatinine (eGFR_Crea) and to verify which methods to determine t_1/2,eff are most accurate to predict t_1/2,eff.

Methods

Forty-eight patients receiving whole-body I-131-scintigraphy were included. eGFR_CysC was compared to eGFR_Crea with regard to accuracy of t_1/2,eff prediction. Three different methods (i.e. blood-based, gamma camera-based and probe-based) and two protocols with either three (short period,SP; up to 42 h) or four (long period,LP; up to 114 h) time points were compared using the Akaike's information criterion.

Results

The eGFR_CysC measurement is more likely than eGFR_Crea in predicting the t_1/2,eff. High correlation coefficients were found between t_1/2,eff assessed by gamma camera and probe measurements and blood-based determination revealed lower values. Patients with normal eGFR showed higher values of t_1/2,eff of LP compared to SP.

Conclusions

eGFR_CysC should be included in further study protocols. As camera and probe measurements lead to almost superimposable results, one of the methods is expendable. Blood-based results of t_1/2,eff were lower, presumably due to unspecific iodine retention, whereas the lower correlation with renal function may be caused by individual differences in intestinal iodine resorption. SP-protocols up to 42 h after I-131 administration are sufficient to determine t_1/2,eff. Further studies are necessary for specific recommendations regarding I-131 activity reduction during RAIT in patients with DTC and renal insufficiency.

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Self-Reported Benefit and Satisfaction with a Beamforming Body-Worn Hearing Aid for Elderly Adults

Hearing impairment is a leading cause of disability globally and is particularly prevalent in elderly populations. Hearing aids are commonly recommended to mitigate the adverse effects on communication associated with hearing loss. However, the acceptability of hearing aids to elderly individuals is low and the majority of potential users do not wear hearing aids. Most hearing aids are designed with a discreet form factor in mind, to minimize device visibility. Given the range of comorbidities associated with hearing loss in the elderly, this conventional form factor may not always be optimal. The present study examined the experiences of elderly individuals with a recently developed, unconventional, body-worn hearing instrument, the EasyHear™ Grand (Logital Co. Ltd., Hong Kong). The bilaterally fitted instrument incorporates large controls, a color display, beamforming sound processing, and Bluetooth capabilities. Forty-three elderly participants (mean age=71; range 46-88 years) were surveyed to gauge level of benefit and satisfaction with the device and opinions regarding the hearing aid. They were assessed using three standardized questionnaires (the International Outcome Inventory-Hearing Aids, the Profile of Hearing Aid Benefit, and the Client Oriented Scale of Improvement) and through open-ended, structured interviews. Participants rated their EasyHear device fitting highly for hours of use and improved quality of life and rated the device favorably for improved communication and benefit in background noise. A majority of users felt the device improved listening ability in their expressed area of greatest need, and also for their second highest prioritized area of greatest need. Less than 10% of users felt their listening was only occasionally or hardly ever improved when using the body-worn device. Benefit and satisfaction ratings with the EasyHear Grand were comparable to those in studies involving conventional form factor devices. Interviews highlighted areas where users felt the device could be improved—extra noise reduction, changes to device dimensions, receiver/eartip fit, and cableless technology were among the areas mentioned. Many participants valued smartphone linkage and Bluetooth capability. The EasyHear Grand, with its body-worn design and large, simple controls, was well accepted by the majority of participants. Hearing aids that break from conventional design formats may benefit many elderly individuals with hearing impairment and promote increased user acceptability.

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Masthead

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Table of Contents

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Clinical Indices to Drive Quality Improvement in Otolaryngology

A Pediatric Tracheostomy Care Index (PTCI) was developed by the authors to standardize care and drive quality improvement efforts at their institution. The PTCI comprises 9 elements deemed essential for safe care of children with a tracheostomy tube. Based on the PTCI scores, the number of missed opportunities per patient was tracked, and interventions through a "Plan-Do-Study-Act" approach were performed. The establishment of the PTCI has been successful at standardizing, quantifying, and monitoring the consistency and documentation of care provided at the authors' institution.

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Patient Engagement in Otolaryngology

Patient engagement, which involves incorporating the patient and family as partners in their care, is a growing focus in otolaryngology and surgery. Attention to patient and family centeredness, shared decision making, and patient experience together improves the overall tenor of patient engagement. Patient engagement promotes safety through improving quality of electronic health record data, error detection, and treatment decisions and adherence. In this article, we review specific areas of importance for patient engagement in otolaryngology as well as areas needing more research and development.

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Forthcoming Issues

Implantable Auditory Devices

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Contents

Sujana S. Chandrasekhar

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Contributors

SUJANA S. CHANDRASEKHAR, MD, FACS, FAAOHNS

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Patient Safety and Quality Improvement

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

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Regional Node Distribution in Papillary Thyroid Cancer with Microscopic Metastasis

Background. Optimal neck lymphadenectomy in patients with papillary thyroid cancer (PTC) and microscopic lymph node metastasis needs to be defined in order to aid surgeons in their decision about the best way to proceed in these cases. Methods. Patients who underwent total thyroidectomy and lymphadenectomy at levels IIa to VI were divided into two groups: Group 1 (G1) with macroscopic metastasis detected before surgery and Group 2 (G2) with microscopic metastasis detected in sentinel node during surgery. Odds ratio (OR) was computed for age, sex, tumor size, multicentricity, capsular invasion, vascular/lymphatic permeation, and nodes with metastasis. Results. Primary tumor size was (G1 versus G2, respectively) 3.8 cm versus 1.98 cm (P

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Determination of effective half-life of 131 I in patients with differentiated thyroid carcinoma: comparison of cystatin C and creatinine-based estimation of renal function

Abstract

Purpose

Renal function and effective half-life (t_1/2,eff) of I-131 have not been fully elucidated in patients undergoing radioiodine therapy (RAIT) for differentiated thyroid cancer (DTC). Aim of the present analysis was to evaluate the potential of cystatin C-based estimated glomerular filtration rate (eGFR_CysC) in comparison to conventional creatinine (eGFR_Crea) and to verify which methods to determine t_1/2,eff are most accurate to predict t_1/2,eff.

Methods

Forty-eight patients receiving whole-body I-131-scintigraphy were included. eGFR_CysC was compared to eGFR_Crea with regard to accuracy of t_1/2,eff prediction. Three different methods (i.e. blood-based, gamma camera-based and probe-based) and two protocols with either three (short period,SP; up to 42 h) or four (long period,LP; up to 114 h) time points were compared using the Akaike's information criterion.

Results

The eGFR_CysC measurement is more likely than eGFR_Crea in predicting the t_1/2,eff. High correlation coefficients were found between t_1/2,eff assessed by gamma camera and probe measurements and blood-based determination revealed lower values. Patients with normal eGFR showed higher values of t_1/2,eff of LP compared to SP.

Conclusions

eGFR_CysC should be included in further study protocols. As camera and probe measurements lead to almost superimposable results, one of the methods is expendable. Blood-based results of t_1/2,eff were lower, presumably due to unspecific iodine retention, whereas the lower correlation with renal function may be caused by individual differences in intestinal iodine resorption. SP-protocols up to 42 h after I-131 administration are sufficient to determine t_1/2,eff. Further studies are necessary for specific recommendations regarding I-131 activity reduction during RAIT in patients with DTC and renal insufficiency.

https://ift.tt/2Qg7ePy

Clinical Indices to Drive Quality Improvement in Otolaryngology

A Pediatric Tracheostomy Care Index (PTCI) was developed by the authors to standardize care and drive quality improvement efforts at their institution. The PTCI comprises 9 elements deemed essential for safe care of children with a tracheostomy tube. Based on the PTCI scores, the number of missed opportunities per patient was tracked, and interventions through a "Plan-Do-Study-Act" approach were performed. The establishment of the PTCI has been successful at standardizing, quantifying, and monitoring the consistency and documentation of care provided at the authors' institution.

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Patient Engagement in Otolaryngology

Patient engagement, which involves incorporating the patient and family as partners in their care, is a growing focus in otolaryngology and surgery. Attention to patient and family centeredness, shared decision making, and patient experience together improves the overall tenor of patient engagement. Patient engagement promotes safety through improving quality of electronic health record data, error detection, and treatment decisions and adherence. In this article, we review specific areas of importance for patient engagement in otolaryngology as well as areas needing more research and development.

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Copyright

Elsevier

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CME Accreditation Page

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Contents

Sujana S. Chandrasekhar

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Contributors

SUJANA S. CHANDRASEKHAR, MD, FACS, FAAOHNS

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Patient Safety and Quality Improvement

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

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Three-dimensional soft tissue prediction in orthognathic surgery: a clinical comparison of Dolphin, ProPlan CMF, and probabilistic finite element modelling

Three-dimensional surgical planning is used widely in orthognathic surgery. Although numerous computer programs exist, the accuracy of soft tissue prediction remains uncertain. The purpose of this study was to compare the prediction accuracy of Dolphin, ProPlan CMF, and a probabilistic finite element method (PFEM). Seven patients (mean age 18years; five female) who had undergone Le Fort I osteotomy with preoperative and 1-year postoperative cone beam computed tomography (CBCT) were included. The three programs were used for soft tissue prediction using planned and postoperative maxillary position, and these were compared to postoperative CBCT. (Source: International Journal of Oral and Maxillofacial Surgery)

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Regional Node Distribution in Papillary Thyroid Cancer with Microscopic Metastasis

Background. Optimal neck lymphadenectomy in patients with papillary thyroid cancer (PTC) and microscopic lymph node metastasis needs to be defined in order to aid surgeons in their decision about the best way to proceed in these cases. Methods. Patients who underwent total thyroidectomy and lymphadenectomy at levels IIa to VI were divided into two groups: Group 1 (G1) with macroscopic metastasis detected before surgery and Group 2 (G2) with microscopic metastasis detected in sentinel node during surgery. Odds ratio (OR) was computed for age, sex, tumor size, multicentricity, capsular invasion, vascular/lymphatic permeation, and nodes with metastasis. Results. Primary tumor size was (G1 versus G2, respectively) 3.8 cm versus 1.98 cm (P

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What factors affect the severity of permanent tooth impaction?

Abstract

Background

The aim of this study was to investigate the association between the severity of permanent tooth impaction and a number of predefined factors, including tooth type, age, gender, tooth agenesis, microdontia of maxillary lateral incisor, and retained deciduous predecessors.

Methods

A sample of 2979 dental patients, aged 15 to 40 years, was surveyed by two calibrated examiners for permanent tooth impaction (excluding third molars). On panoramic radiographs, the impacted teeth were initially ranked based on their vertical, horizontal, and angular positions, and the ranking was then analysed for distribution by the predefined factors. To test the age factor, patients were divided into younger (15 to 25 yr) and older (between 25 and 40 yr) age groups. The statistical significance of the ranked vertical, horizontal, and angular positions of impacted teeth by the investigated factors was determined using the Wilcoxon-Mann-Whitney U test.

Results

The angular position of the impacted teeth was more severe in the older age group (P = 0.012) and in females (P = 0.018). The maxillary canine had more severe horizontal (P = 0.001) and angular (P = 0.003) impactions in females. Tooth agenesis was associated with less severe horizontal impaction (P = 0.041) in the mandibular second premolar. In addition, microdontia of the maxillary lateral incisor was associated with more severe horizontal impaction in general, and more severe horizontal (P = 0.024) and angular (P = 0.010) impaction of the mandibular second premolar in particular. Finally, our results showed that a retained deciduous predecessor was linked to a less severe vertical impaction of the mandibular second premolar (P = 0.030) and horizontal impaction of the maxillary second premolar (P = 0.037) but more severe angular impaction of the mandibular canine.

Conclusions

This study suggests that the more delayed the treatment, being a female, the presence of maxillary lateral incisor with microdontia, and retained lower deciduous canines might be associated with more severe position of the impacted teeth. Because the severity of tooth impaction would follow different patterns when considering the investigated factors, it is mandatory to include such factors during dental diagnoses and the planning of preventive or interceptive interventions for young patients.

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A prospective clinical study to evaluate the performance of zirconium dioxide dental implants in single-tooth edentulous area: 3-year follow-up

Abstract

Background

Traditionally, dental implants have been made from titanium or titanium alloys. Alternatively, zirconia-based ceramic implants have been developed with similar characteristics of functional strength and osseointegration. Ceramic implants offer advantages in certain settings, e.g. in patients who object to metal dental implants. The aim of this study was to investigate the mid-term (36 months) clinical performance of a ceramic monotype implant in single-tooth edentulous area.

Methods

This was a prospective, open-label, single-arm study in patients requiring implant rehabilitation in single-tooth edentulous area. Ceramic implants (PURE Ceramic Implant, Institut Straumann AG, Basel, Switzerland) with a diameter of 4.1 mm were placed following standard procedure and loaded with provisional and final prostheses after 3 and 6 months, respectively. Implant survival rate and implant success rate were evaluated and crestal bone levels were measured by analysing standardized radiographs during implant surgery and at 6, 12, 24 and 36 months.

Results

Forty-four patients received a study implant, of whom one patient withdrew consent after 3 months. With one implant lost during the first 6 months after surgery, the implant survival rate was 97.7% at 6 months. No further implants were lost over the following 30 months, and 3 patients were lost to follow-up during this time frame. This led to a survival rate of 97.5% at 36 months.

Six months after implant surgery 93.0% of the implants were considered "successful", increasing to 97.6% at 12 months and remaining at this level at 24 months (95.1%) and 36 months (97.5%).

Bone loss was most pronounced in the first half-year after implant surgery (0.88 ± 0.86 mm). By contrast, between 12 and 36 months the mean bone level remained stable (minimal gain of 0.06 [± 0.60] mm). Hence, the overall bone loss from implant surgery to 36 months was 0.97 (± 0.88) mm.

Conclusions

In the follow-up period ceramic implants can achieve favourable clinical outcomes on a par with titanium implants. For instance, these implants can be recommended for patients who object to metal dental implants. However, longer term studies with different edentulous morphology need to confirm the present data.

Trial registration

Registered on www.clinicaltrials.gov: NCT02163395.

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Combining virtual model and cone beam computed tomography to assess periodontal changes after anterior tooth movement

Abstract

Background

Orthodontic force may affect not only periodontal ligaments, but also the alveoloar bone and the gingiva according to the type of tooth movements. The authors assessed changes in gingival thickness (GT) and alveolar bone thickness (ABT) after orthodontic treatment using a new method.

Methods

This study included 408 teeth (208 central incisors, 200 lateral incisors) from the upper and lower 4 anterior teeth of 52 patients who had completed orthodontic treatment. GT and ABT were measured using virtual casts fabricated from impressions and cone beam computed tomography (CBCT). Two sectioned images of every tooth axis were acquired by partitioning each tooth with a line connecting the midpoint of the incisal edge to the midpoint of the cementoenamel junction in the virtual models and the root apex in CBCT images. After superimposing the two sectioned images, GT and ABT were measured before and after orthodontic tooth movement. Correlations between GT and ABT before and after treatment, and changes in GT and ABT associated with sex, tooth arch, tooth position, orthognathic surgery, and tooth inclination and rotation were assessed.

Results

Before orthodontic treatment, GT and ABT were significantly correlated. Patients who underwent orthognathic surgery exhibited an increase in GT thickness compared with those who did not. ABT was significantly decreased in proclined teeth and in rotated teeth.

Conclusions

GT and ABT can be affected by the nature of tooth movement and can be accurately assessed by comparing sectioned CBCT images and virtual models.

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What can food-image tasks teach us about anorexia nervosa? A systematic review

Abstract

A salient feature of anorexia nervosa (AN) is the persistent and severe restriction of food, such that dietary intake is inadequate to maintain a healthy body weight. Experimental tasks and paradigms have used illness-relevant stimuli, namely food images, to study the eating-specific neurocognitive mechanisms that promote food avoidance. This systematic review, completed in accordance with PRISMA guidelines, identified and critically evaluated paradigms involving images of food that have been used to study AN. There were 50 eligible studies, published before March 10^th 2018, identified from Medline and PsychINFO searches, and reference screening. Studies using food image-based paradigms were categorised into three methodologic approaches: neuropsychology, neurophysiology, and functional magnetic resonance imaging (fMRI). Paradigms were reviewed with a focus on how well they address phenomena central to AN. Across tasks, differences between individuals with AN and healthy peers have been identified, with the most consistent findings in the area of reward processing. Measuring task performance alongside actual eating behaviour, and using experimental manipulations to probe causality, may advance understanding of the mechanisms of illness in AN.

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Themes arising during implementation consultation with teams applying family-based treatment: a qualitative study

Abstract

Background

This study describes themes arising during implementation consultation with teams providing Family-Based Treatment (FBT) to adolescents with eating disorders.

Methods

Participants were implementation teams (one lead therapist, one medical practitioner and one administrator) at four sites. These teams agreed to support the implementation of FBT, and participated in monthly consultation calls which were audio-recorded, transcribed verbatim and coded for themes. Twenty percent of the transcripts were double-coded to ensure consistency. Fundamental qualitative description guided the sampling and data collection.

Results

Twenty-five (average per site = 6) transcripts were coded using thematic content analysis. Six major themes emerged: 1) system barriers and facilitators 2) the role of the medical practitioner, 3) research implementation, 4) appropriate cases, 5) communication, and 6) program impact.

Conclusions

Implementation themes aligned with previous research examining the adoption of FBT, and provide additional insight for clinical programs seeking to implement FBT, emphasizing the importance of role clarity, and team communication.

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Doxercalciferol Alleviates Bone Deteriorations and Cartilage Degeneration in Aging Mice

Exp Clin Endocrinol Diabetes
DOI: 10.1055/a-0754-1956

Background Age-related bone deteriorations are the common endocrine disorders in the elderly population, leading to an increased risk of fractures. Therefore, effective treatment strategies provide a way to prevent bone loss and improve the quality of life in the elderly population. The present study aimed to investigate the anti-osteoporotic effects of doxercalciferol (DOX) in aging mice. Methods Bone metabolism-related markers were measured by ELISA assay. The expression of bone formation and resorption-related genes was performed by RT-qPCR analysis. Hematoxylin and eosin (H&E) and Safranin O staining were performed to analyze the trabecular bone and cartilage degeneration. Results Aging resulted in urine Ca excretion, a decrease in bone Ca content and reduction of biomechanical strength in mice. We also found that the level of PTH was increased in aging mice, while DOX administration markedly down-regulated serum PTH in aging mice. H&E and Safranin O staining showed that DOX protected against aging-induced bone loss and cartilage regeneration in the tibia from aging mice. Furthermore, DOX treatment resulted in an increase in Runx2, osterix and Col1a1 mRNA expression and a decrease in Ctsk, MMP-9 and CAII mRNA expression in the tibia from aging mice. Conclusion These findings indicated that DOX had a beneficial effect on age-related bone deteriorations in aging mice by promoting osteoblast activity and cartilage regeneration and inhibiting osteoclast-specific genes expression.
[...]

© Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text

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Broadening the operative field: the extent of surgery beyond the patient`s informed consent (the so-called therapeutic exception)

W artykule omówiono przesłanki tzw. wyjątku terapeutycznego, uregulowanego w art. 35 ustawy z dnia 5 grudnia 1996 r. o zawodach lekarza i lekarza dentysty. Konstrukcja ta pozwala lekarzowi, w trakcie operacji, na zmianę zakresu zabiegu ponad zgodę wyrażoną przez pacjenta. Ponadto poruszono kwestię tzw. zgody antycypacyjnej oraz warunki jej skuteczności oraz wyjaśniono, czy w wypadku realizacji przesłanek wyjątku terapeutycznego lekarz jedynie może dokonać odpowiedniej modyfikacji czynności operacyjnych, czy też jest to jego obowiązek. Wskazano również, że w omawianej sytuacji lekarz nie może powoływać się na tzw. stan wyższej konieczności. Prezentowane treści zostały wzbogacone o przedstawienie konkretnych spraw sądowych i ich rozstrzygnięć.

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Inter-arm differences in blood pressure among subjects with disseminated atherosclerosis scheduled for vascular surgery

Background: The measurement of blood pressure (BP) is routinely performed in perioperative care. The reliability of results is essential for the implementation of treatment ensuring haemodynamic stability. The aim of the present study was to assess the prevalence and basic determinants of inter-arm BP differences among patients with advanced peripheral atherosclerosis undergoing vascular surgical procedures of the lower limbs. Methods: The prospective study was carried out in patients scheduled for elective lower limb vascular surgery. One-time non-invasive BP measurements were performed sequentially on the brachial arteries of both upper extremities before the induction of anaesthesia, maintaining the shortest possible interval between measurements. The systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were recorded. Results: The results of 173 patients (including 123 men aged 67 ± 8 years) were analysed. In 16 (9.3%) patients, an inter-arm difference in BP was already observed during the preoperative examination. SBP and DBP was higher in the right limb in 86 (49.7%) an 80 (46.3%) patients, respectively. Moreover, the medians of inter-arm differences in SBP, DBP and MAP were 9 (IQR 4–17), 5 (IQR 3–10) and 7 mm Hg (IQR 3–12), respectively. An evaluation of the determinants of BP differences related to the presence of additional diseases demonstrated that patients with arterial hypertension were characterised by higher SBP and MAP disproportions (P = 0.04 and P = 0.01). Conclusions: In the population of patients with disseminated atherosclerosis, the inter-arm differences in BP substantially exceed the measurement error limits and are likely to be associated with arterial hypertension. If in doubt about BP disproportions, intraoperative monitoring of BP should be recommended using an invasive method on the limb presenting higher non-invasively measured values.

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Risk factors for occurrence of failed interscalene brachial plexus blocks for shoulder arthroscopy using 20 mL 0.5% ropivacaine: a randomised trial

Background: The red blood cell distribution width index (RDW) is one of several parameters routinely analysed in peripheral blood counts. The aim of the study was to assess the usefulness of RDW in the prediction of in-hospital mortality in patients undergoing high-risk gastroenterological surgery. Methods: Prospective observation covered 229 patients who underwent surgery, for whom the risk of cardiovascular complications was high due to the type of procedure. The patient's individual risk was assessed using the criteria of the American Society of Anesthesiologists (ASA-PS). Peripheral blood for morphological examination was collected preoperatively. The following parameters of the red blood cell system were evaluated: red blood cell count (RBC), haemoglobin (Hgb), haematocrit (Hct), mean corpuscular volume (MCV), RDW expressed as a standard deviation (SD) and a coefficient of variation (CV). The occurrence of hospital death was the main endpoint. Results: Patients who died had had statistically significantly lower RBC, Hgb and Hct values, as well as higher RDW-SD and RDW-CV values. Both the preoperative RDW-SD and RDW-CV values predicted the outcome, respectively: AUC_RDW-SD = 0.744 (95% CI: 0.683–0.799; P RDW-CV = 0.762 (95% CI: 0.702–0.816; P RDW-SD = 1.21; P RDW-CV = 1.62; P = 0.01), even after adjustment for individual risk and other erythrocyte parameters. Conclusion: RDW is a valuable screening predictor of in-hospital mortality in patients undergoing high-risk gastroenterological surgery, regardless of the estimated individual risk and the value of other erythrocyte parameters. Evaluation of the RDW may be helpful in the identification of patients requiring correction of haematological disorders in the pre-operative period, as well as, in particular, surveillance in the perioperative period.

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Use of noninvasive mechanical ventilation with pressure support guaranteed with average volume in de novo hypoxaemic respiratory failure. A pilot study

Background: This study was designed to determine the results associated with the use of noninvasive mechanical ventilation (NIV) using the BiPAP S/T-AVAPS ventilation strategy in subjects with mild to moderate de novo hypoxaemic respiratory failure. Methods: This is a prospective study that includes subjects with de novo hypoxaemic respiratory failure (not produced by acute exacerbations of COPD, chronic lung disease, or congestive heart failure) with mild to moderate PaO₂/FiO₂, who were admitted to the Intensive Care Unit (ICU) of Santa Maria Clinic in Guayaquil, Ecuador. Subjects were divided into two groups and compared according to their PaO₂/FiO₂: higher than 100 and up to 200 mm Hg (moderate ARDS) or between 200 and 300 mm Hg (mild ARDS) (both groups were ventilated with the BiPAP S/T-AVAPS strategy). A value of P Results: A total of 38 subjects were analysed in this study. The total rate of intubation was 34.2% while the mortality rate was 28.9%. Significant differences were observed when comparing success versus failure in exhaled tidal volumes (P = 0.04), peak inspired pressure (P 2 (P 2 (P 2/FiO₂ (P P P = 0.029) measured at baseline and at 12-hour, 24-hour and 48-hour intervals. Conclusion: The BiPAP S/T-AVAPS ventilatory mode can be used in subjects with de novo hypoxaemic respiratory failure with special vigilance concerning exhaled tidal volumes and inspired pressure.

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Peri-anaesthetic cardiac arrest with administration of enalapril, spironolactone and β-blocker

none

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Postoperative pain after spinal surgery in the paediatric population

Introduction: Postoperative pain is a major aftereffect of surgery. Especially severe occurs after extensive operations within the spine. The goal of the study was to investigate the laboratory predictive factors of intensive postoperative pain in children undergoing extensive surgery Patients and methods: We recruited 41 children, age median 13 years (IQR:10-15 years) undergoing extensive spine surgery. The subjects were divided into two groups based on the intensity of postoperative pain measured using the 10-point numerical rating scale (NRS), visual analog scale (VAS) or faces pain scale-revised (FPS-R). Patients with a score of 5 or higher were included in the study group and those with NRS of less than 5 were included in the control group. We collected detailed clinical and laboratory data before, during and after surgery. Results: The highest intensity of pain was observed in the first 6 hours after surgery. The postoperative pain was associated with a higher drop in hemoglobin concentration and hematocrit level in peri-operative period (p=0.006 and p=0.019 respectively) as well as higher changes in mean arterial pressure during surgery. Additionally, we found that children with intensive pain had higher total protein concentration after surgery. Conclusions: We reported that the drop in hemoglobin and hematocrit level, fluctuation in mean arterial pressure as well as total protein concentration could be useful prognostic factors of early postoperative pain.

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A case report of inadvertent intranasal submucosal injection of concentrated epinephrine with no long-term sequelae

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Preoperative Vascular Interventions to Improve Donor Leg Perfusion: a Report of Two Fibula Free Flaps Used in Head and Neck Reconstruction

For the reconstruction of head and neck defects, the fibula free flap is the first choice at many institutions. The main contraindication for fibula harvest is the lack of three vessel run-off leading to post-operative vascular compromise of the lower extremity. Atherosclerosis is the most common disease which can limit the use of this donor site. In general, vascular interventions, which includes angioplasty, atherectomy, and stenting, have been utilized to fix the arterial supplies using endovascular methods.

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The Good, The Bad & The Ugly - now available for CE Credits on DentalTown

In case you missed this Inner Space Seminar presented at Superstition Springs Endodontics, it is now available on DentalTown.

1.5 Hrs of CE credit available. Click Here



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Cone-beam Computed Tomographic Analysis of Canal Transportation and Centering Ability of Single-file Systems

The purpose of this study was to compare canal transportation and the centering ability of Reciproc (VDW, Munich, Germany), WaveOne (Dentsply Maillefer, Ballaigues, Switzerland), and EdgeFile (EdgeEndo, Albuquerque, NM) rotary systems using cone-beam computed tomographic imaging.

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Accuracy of High-Resolution Small-Volume Cone-Beam Computed Tomography in Detecting Complex Anatomy of the Apical Isthmi: Ex Vivo Analysis

The purpose of this study was to evaluate the accuracy of small-volume cone-beam computed tomography (CBCT) to detect and measure isthmi in the apical root canals of mandibular molars by using micro–computed tomography (μ-CT) as the reference standard.

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Impact and Fracture Strength of Simulated Immature Teeth Treated with Mineral Trioxide Aggregate Apical Plug and Fiber Post Versus Revascularization

Immature necrotic teeth are at a high risk of fracture, especially at the cervical region, after treatment. This study aimed to compare the impact and fracture strength of immature permanent teeth treated with revascularization versus a mineral trioxide aggregate (MTA) plug and fiber post.

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Healing of Apical Periodontitis in Patients with Inflammatory Bowel Diseases and under Anti–tumor Necrosis Factor Alpha Therapy

We evaluated healing after nonsurgical primary/secondary endodontic treatment of apical periodontitis (AP) in patients with inflammatory bowel diseases (IBDs) treated with anti–tumor necrosis factor alpha biologic medications (BMs).

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A Micro–computed Tomographic Evaluation of the Accuracy of 3 Electronic Apex Locators in Curved Canals of Mandibular Molars

This study evaluated the accuracy of 3 electronic apex locators (EALs) (CanalPro [Coltene-Endo, Cuyahoga Falls, OH], Apex ID [SybronEndo, Glendora, CA], and Root ZX Mini [J Morita, Tokyo, Japan]) in curved mesial canals of extracted mandibular molars using micro–computed tomographic (micro-CT) scanning.

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Mechanical Properties of Orifice Preflaring Nickel-titanium Rotary Instrument Heat Treated Using T-Wire Technology

This study examined whether the use of T-Wire heat treatment enhanced the resistance to torsional force, cyclic fatigue, and bending stiffness of orifice preflaring nickel-titanium instruments.

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In Vitro Evaluation of a Novel Root Canal Endoscope for Visualizing the Apex of Curved Root Canal Models and an Extracted Tooth

In straight root canals, intraradicular structures around the root canal orifice and apical foramen can be visualized with a dental operating microscope and commercially available root canal endoscopes. However, the root apex area, including the apical foramen, in a curved root canal cannot be visualized using these devices. In the present study, the potential of a newly developed root canal endoscope implementing an image fiber was examined in 3 types of root canal models and extracted teeth.

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Real-time Intracanal Temperature Measurement During Different Obturation Techniques

The purpose of this study was to assess temperature development in endodontic sealers during different obturation techniques in a closed system simulating the surrounding biological structures at body temperature.

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Morphological study of the changes after sagittal split ramus osteotomy in patients with facial asymmetry: measurements of 3-dimensional modelling

The effects of bilateral sagittal split ramus osteotomy (BSSRO) on the temporomandibular joint (TMJ) are still not well understood. The aim of this study was to compare the morphological differences among unaffected subjects on the one hand, and patients with facial asymmetry before and after BSSRO on the other. Ten Chinese patients (preoperative and postoperative groups, mean (SD) age 25 (5) years) diagnosed with facial asymmetry and 10 unaffected subjects (control group, mean (SD) age 27 (5) years) were recruited prospectively.

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Morphological study of the changes after sagittal split ramus osteotomy in patients with facial asymmetry: measurements of 3-dimensional modelling

The effects of bilateral sagittal split ramus osteotomy (BSSRO) on the temporomandibular joint (TMJ) are still not well understood. The aim of this study was to compare the morphological differences among unaffected subjects on the one hand, and patients with facial asymmetry before and after BSSRO on the other. Ten Chinese patients (preoperative and postoperative groups, mean (SD) age 25 (5) years) diagnosed with facial asymmetry and 10 unaffected subjects (control group, mean (SD) age 27 (5) years) were recruited prospectively.

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Evaluation of Speed and Accuracy of Next-Generation Auditory Steady State Response and Auditory Brainstem Response Audiometry in Children With Normal Hearing and Hearing Loss

Objectives: The first objective of this study was to compare the predicted audiometric thresholds obtained by auditory steady state response (ASSR) and auditory brainstem response (ABR) in infants and toddlers when both techniques use optimal stimuli and detection algorithms. This information will aid in determining the basis for large discrepancies in ABR and ASSR measures found in past studies. The hypothesis was that advancements in ASSR response detection would improve (lower) thresholds and decrease discrepancies between the thresholds produced by the two techniques. The second objective was to determine and compare test times required by the two techniques to predict thresholds for both ears at the 4 basic audiometric frequencies of 500, 1000, 2000, and 4000 Hz. Design: A multicenter clinical study was implemented at three university-based children's hospital audiology departments. Participants were 102 infants and toddlers referred to the centers for electrophysiologic testing for audiometric purposes. The test battery included wideband tympanometry, distortion-product otoacoustic emissions, and threshold measurements at four frequencies in both ears using ABR and ASSR (randomized) as implemented on the Interacoustics Eclipse systems with "Next-Generation" ASSR detection and FMP analysis for ABR. Both methods utilized narrow band CE-Chirp stimuli. Testers were trained on a specialized test battery designed to minimize test time for both techniques. Testing with both techniques was performed in one session. Thresholds were evaluated and confirmed by the first author and correction factors were applied. Test times were documented in system software. Results: Corrected thresholds for ABR and ASSR were compared by regression, by the Bland–Altman technique and by matched pairs t tests. Thresholds were significantly lower for ASSR than ABR. The ABR–ASSR discrepancy at 500 Hz was 14.39 dB, at 1000 Hz was 10.12 dB, at 2000 Hz was 3.73 dB, and at 4000 Hz was 3.67 dB. The average test time for ASSR of 19.93 min (for 8 thresholds) was found to be significantly lower (p

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Using Objective Metrics to Measure Hearing Aid Performance

Objectives: The performance of hearing aids is generally characterized by a small set of standardized measurements. The primary goals of these procedures are to measure basic aspects of the hearing aid performance and to ascertain that the device is operating properly. A more general need exists for objective metrics that can predict hearing aid outcomes. Such metrics must consider the interaction of all the signal processing operating in the hearing aid and must do so while also accounting for the hearing loss for which the hearing aid has been prescribed. This article represents a first step in determining the clinical applicability of the hearing aid speech perception index (HASPI) intelligibility and hearing aid speech quality index (HASQI) speech quality metrics. The goals of this article are to demonstrate the feasibility of applying these metrics to commercial hearing aids and to illustrate the anticipated range of measured values and identify implementation concerns that may not be present for conventional measurements. Design: This article uses the HASPI intelligibility and HASQI speech quality metrics to measure the performance of commercial hearing aids. These metrics measure several aspects of the processed signal, including envelope fidelity, modifications of the temporal fine structure, and changes in the long-term frequency response, all in the context of an auditory model that reproduces the salient aspects of the peripheral hearing loss. The metrics are used to measure the performance of basic and premium hearing aids from three different manufacturers. Test conditions include the environmental factors of signal to noise ratio and presentation level, and the fitting configurations were varied to provide different degrees of processing from linear to aggressive nonlinear processing for two different audiograms. Results: The results show that the metrics are capable of measuring statistically significant differences across devices and processing settings. HASPI and HASQI measure both audibility and nonlinear distortion in the devices, and conditions are identified where predicted intelligibility is high but predicted speech quality is substantially reduced. The external signal properties of signal to noise ratio and presentation level are both statistically significant. Hearing loss is significant for HASPI but not for HASQI, and degree of processing is significant for both metrics. A quadratic model for manufacturer showed large effect sizes for HASPI and HASQI, but basic versus premium hearing aid model is not significant. Conclusions: The results presented in this article represent a first step in applying the HASPI and HASQI metrics to commercial hearing aids. Modern hearing aids often use several different processing strategies operating simultaneously. The proposed metrics provide a way to predict the total effect of this processing, including algorithm interactions that may be missed by conventional measurement procedures. The measurements in this article show significant differences between manufacturers, processing settings, and adjustment for different hearing losses. No significant differences were found between basic and premium hearing aid models. Further research will be needed to determine the clinical relevance of these measurements and to provide target values appropriate for successful fittings.

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Letter to the Editor: Comments on the Ear and Hearing Ban on Certain Auditory Processing Disorder Articles Re Moore, D. R. (2018) Editorial Auditory Processing Disorder, Ear Hear, 39, 617–620

No abstract available

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Tinnitus, Depression, Anxiety, and Suicide in Recent Veterans: A Retrospective Analysis

Objectives: The purpose of this project was to investigate whether there is an association between tinnitus diagnosis and suicide and whether depression and anxiety strengthen that association. Given that tinnitus is the top service–connected disability among U.S. Veterans (Veterans Benefits Administration, 2016) and that suicide among Veterans has been occurring at a higher frequency as compared with community suicide rates (Hoffmire et al., 2015), the possible associations between tinnitus and suicide will be explored. Co-occurring physical conditions also will be examined to determine if they increase the risk of suicide in the context of tinnitus. Design: Administrative health care data related to Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) were used to identify Veterans who accessed the Veterans Administration (VA) health care system from January 1, 2002, to December 31, 2011. Veterans who were deceased as of December 2011 were identified using the National Death Index (NDI) files. Tinnitus cases were followed until either they were deceased or to the end of the study period. The International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM) codes were used to identify all conditions and diseases. As per mortality research standards, International Classification of Diseases 10th Revision (ICD-10) codes were used to identify cause of death. Results: Of 769,934 OEF/OIF/OND Veterans receiving VA care January 2002 to December 2011, 15% (n =116,358) were diagnosed with tinnitus. Of these Veterans diagnosed with tinnitus, 21% were also diagnosed with depression, another 8% with anxiety, and another 17% with both depression and anxiety. Fifty-four percentage were identified as having tinnitus without depression or anxiety. Among individuals with tinnitus, 41.9% had co-occurring hearing loss. Suicide rates were lower among Veterans with tinnitus than Veterans without tinnitus. Co-occurring diagnoses of mental-health conditions did not significantly increase the risk of suicide. Conclusions: The study results do not confirm clinical and anecdotal reports that tinnitus could be related to suicide among Veterans. However, tenets from rehabilitation psychology suggest that the onset of chronic impairment or disability does not predict an individual's subsequent psychological states; other personal attributes may be more influential. Health care professionals, such as audiologists and psychologists, should be cognizant of the associations between tinnitus and mental health issues and be prepared to address the psychological needs of individuals who have tinnitus.

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No Reliable Association Between Recreational Noise Exposure and Threshold Sensitivity, Distortion Product Otoacoustic Emission Amplitude, or Word-in-Noise Performance in a College Student Population

Objectives: The purpose of this study was to evaluate the relationship between recreational sound exposure and potentially undiagnosed or subclinical hearing loss by assessing sound exposure history, threshold sensitivity, distortion product otoacoustic emission (DPOAE) amplitudes, and performance on the words-in-noise (WIN) test. Design: Survey data were collected from 74 adult participants (14 male and 60 female), 18 to 27 years of age, recruited via advertisements posted throughout the University of Florida campus. Of these participants, 70 completed both the survey and the additional functional test battery, and their preferred listening level was measured in a laboratory setting. Results: There were statistically significant relationships between hearing thresholds and DPOAE amplitude. In contrast, performance on the WIN was not reliably related to threshold sensitivity within this cohort with largely normal hearing. The two most common exposures included bars or dance clubs, followed by music player use. There were no statistically significant relationships between individual or composite measures of recreational sound exposure, including preferred listening level, years of music player use, number of reported sound exposures, previous impulse noise exposure, or previous noise-induced change in hearing, and functional measures including threshold, DPOAE amplitude, and WIN measures. Some subjects were highly consistent in listening level preferences, while others were more variable from song to song. Conclusions: No reliable relationships between common recreational sound exposure or previous noise-induced changes in hearing were found during analysis of threshold sensitivity, DPOAE amplitude, or WIN performance in this cohort. However, the study sample was predominantly female and Caucasian, which limits generalizability of the results.

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Comparisons of IQ in Children With and Without Cochlear Implants: Longitudinal Findings and Associations With Language

Objectives: To make longitudinal comparisons of intelligence quotient (IQ) in children with cochlear implants (CIs) and typical hearing peers from early in development to the school-age period. Children with additional comorbidities and CIs were also evaluated. To estimate the impact of socioeconomic status and oral language on school-age cognitive performance. Design: This longitudinal study evaluated nonverbal IQ in a multicenter, national sample of 147 children with CIs and 75 typically hearing peers. IQ was evaluated at baseline, prior to cochlear implantation, using the Bayley Scales of Infant and Toddler Development and the Leiter International Performance Scale. School-age IQ was assessed using the Wechsler Intelligence Scales for Children. For the current study, only the Perceptual Reasoning and Processing Speed indices were administered. Oral language was evaluated using the Comprehensive Assessment of Spoken Language. Results: Children in the CI group scored within the normal range of intelligence at both time points. However, children with additional comorbidities scored significantly worse on the Processing Speed, but not the Perceptual Reasoning Index. Maternal education and language were significantly related to school-age IQ in both groups. Importantly, language was the strongest predictor of intellectual functioning in both children with CIs and normal hearing. Conclusion: These results suggest that children using cochlear implants perform similarly to hearing peers on measures of intelligence, but those with severe comorbidities are at-risk for cognitive deficits. Despite the strong link between socioeconomic status and intelligence, this association was no longer significant once spoken language performance was accounted for. These results reveal the important contributions that early intervention programs, which emphasize language and parent training, contribute to cognitive functioning in school-age children with CIs. For families from economically disadvantaged backgrounds, who are at-risk for suboptimal outcomes, these early intervention programs are critical to improve overall functioning.

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Optimizing Clinical Interpretation of Distortion Product Otoacoustic Emissions in Infants

Objectives: The purpose of this study was to analyze distortion product otoacoustic emission (DPOAE) level and signal to noise ratio in a group of infants from birth to 4 months of age to optimize prediction of hearing status. DPOAEs from infants with normal hearing (NH) and hearing loss (HL) were used to predict the presence of conductive HL (CHL), sensorineural HL (SNHL), and mixed HL (MHL). Wideband ambient absorbance was also measured and compared among the HL types. Design: This is a prospective, longitudinal study of 279 infants with verified NH and HL, including conductive, sensorineural, and mixed types that were enrolled from a well-baby nursery and two neonatal intensive care units in Cincinnati, Ohio. At approximately 1 month of age, DPOAEs (1–8 kHz), wideband absorbance (0.25–8 kHz), and air and bone conduction diagnostic tone burst auditory brainstem response (0.5–4 kHz) thresholds were measured. Hearing status was verified at approximately 9 months of age with visual reinforcement audiometry (0.5–4 kHz). Auditory brainstem response air conduction thresholds were used to assign infants to an NH or HL group, and the efficacy of DPOAE data to classify ears as NH or HL was analyzed using receiver operating characteristic (ROC) curves. Two summary statistics of the ROC curve were calculated: the area under the ROC curve and the point of symmetry on the curve at which the sensitivity and specificity were equal. DPOAE level and signal to noise ratio cutoff values were defined at each frequency as the symmetry point on their respective ROC curve, and DPOAE results were combined across frequency in a multifrequency analysis to predict the presence of HL. Results: Single-frequency test performance of DPOAEs was best at mid to high frequencies (3–8 kHz) with intermediate performance at 1.5 and 2 kHz and chance performance at 1 kHz. Infants with a conductive component to their HL (CHL and MHL combined) displayed significantly lower ambient absorbance values than the NH group. No differences in ambient absorbance were found between the NH and SNHL groups. Multifrequency analysis resulted in the best prediction of HL for the SNHL/MHL group with poorer sensitivity values when infants with CHL were included. Conclusions: Clinical interpretation of DPOAEs in infants can be improved by using age-appropriate normative ranges and optimized cutoff values. DPOAE interpretation is most predictive at higher F2 test frequencies in young infants (2–8 kHz) due to poor test performance at 1 to 1.5 kHz. Multifrequency rules can be used to improve sensitivity while balancing specificity. Last, a sensitive middle ear measure such as wideband absorbance should be included in the test battery to assess possibility of a conductive component to the HL.

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Association Between Vestibular Vertigo and Motor Vehicle Accidents: Data From the 2016 National Health Interview Survey

Recent evidence has shown that individuals with vestibular impairment have higher rates of self-reported driving difficulty compared with individuals without vestibular impairment. However, it is unknown whether individuals with vestibular impairment are more likely to be involved in motor vehicle accidents. We used data from the 2016 National Health Interview Survey of U.S. adults to evaluate whether individuals with vestibular vertigo are more likely to experience motor vehicle accidents relative to individuals without vestibular vertigo. In multivariate analysis, vestibular vertigo was associated with an over threefold increased odds of motor vehicle accidents (odds ratio, 3.5; 95% confidence interval, 1.7–7.3). This study supports an association between vestibular dysfunction and driving impairment, and provides a relative risk of motor vehicle accidents associated with vestibular vertigo that clinicians may utilize in counseling patients on the potential safety hazards of driving.

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Speech Recognition Abilities in Normal-Hearing Children 4 to 12 Years of Age in Stationary and Interrupted Noise

Objectives: The main purpose of this study was to examine developmental effects for speech recognition in noise abilities for normal-hearing children in several listening conditions, relevant for daily life. Our aim was to study the auditory component in these listening abilities by using a test that was designed to minimize the dependency on nonauditory factors, the digits-in-noise (DIN) test. Secondary aims were to examine the feasibility of the DIN test for children, and to establish age-dependent normative data for diotic and dichotic listening conditions in both stationary and interrupted noise. Design: In experiment 1, a newly designed pediatric DIN (pDIN) test was compared with the standard DIN test. Major differences with the DIN test are that the pDIN test uses 79% correct instead of 50% correct as a target point, single digits (except 0) instead of triplets, and animations in the test procedure. In this experiment, 43 normal-hearing subjects between 4 and 12 years of age and 10 adult subjects participated. The authors measured the monaural speech reception threshold for both DIN test and pDIN test using headphones. Experiment 2 used the standard DIN test to measure speech reception thresholds in noise in 112 normal-hearing children between 4 and 12 years of age and 33 adults. The DIN test was applied using headphones in stationary and interrupted noise, and in diotic and dichotic conditions, to study also binaural unmasking and the benefit of listening in the gaps. Results: Most children could reliably do both pDIN test and DIN test, and measurement errors for the pDIN test were comparable between children and adults. There was no significant difference between the score for the pDIN test and that of the DIN test. Speech recognition scores increase with age for all conditions tested, and performance is adult-like by 10 to 12 years of age in stationary noise but not interrupted noise. The youngest, 4-year-old children have speech reception thresholds 3 to 7 dB less favorable than adults, depending on test conditions. The authors found significant age effects on binaural unmasking and fluctuating masker benefit, even after correction for the lower baseline speech reception threshold of adults in stationary noise. Conclusions: Speech recognition in noise abilities develop well into adolescence, and young children need a more favorable signal-to-noise ratio than adults for all listening conditions. Speech recognition abilities in children in stationary and interrupted noise can accurately and reliably be tested using the DIN test. A pediatric version of the test was shown to be unnecessary. Normative data were established for the DIN test in stationary and fluctuating maskers, and in diotic and dichotic conditions. The DIN test can thus be used to test speech recognition abilities for normal-hearing children from the age of 4 years and older.

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How to Optimally Fit a Hearing Aid for Bimodal Cochlear Implant Users: A Systematic Review

Objectives: Bimodal hearing has shown to improve speech recognition in quiet and in noise and to improve sound localization compared with unilateral cochlear implant (CI) use alone. Fitting the CI and hearing aid (HA) separately has been described well, but HA fitting procedures for bimodal CI users are not well researched or widely accepted. The aim of the present study was to systematically review the literature on the effect of different HA fitting strategies on auditory performance in bimodal CI users. Design: Original articles, written in English, were identified through systematic searches in Medline (OvidSP), Embase, Web of Science, Scopus, CINAHL, Cochrane, PubMed publisher, and Google Scholar. The quality of the studies was assessed on five aspects: methodologic quality (with the methodological index for nonrandomized studies score), number of subjects, quality of the description of contralateral hearing loss, quality of HA verification, and direct comparison of HA fitting procedures based on auditory performance. Results: A total of 1665 records were retrieved, of which 17 were included for systematical reviews. Critical appraisal led to three high-quality studies, 10 medium-quality studies, and four low-quality studies. The results of the studies were structured according to four topics: frequency response, frequency translation/transposition, dynamic range compression, and loudness. In general, a bimodal benefit was found in most studies, using various strategies for the HA fitting. Using a standard prescription rule such as National Acoustics Laboratory formula-non-linear 1, National Acoustics Laboratory formula-non-linear 2, or desired sensation level is a good starting point in children and adults. Conclusions: Although a bimodal benefit was found in most studies, there is no clear evidence how certain choices in HA fitting contribute to optimal bimodal performance. A generally accepted HA prescription rule is an essential part of most fitting procedures used in the studies. Current evidence suggests that frequency lowering or transposition is not beneficial. Individual fine tuning based on loudness or general preference is often applied, but its additional value for auditory performance should be investigated more thoroughly. Good quality comparative studies are needed to further develop evidence-based fitting procedures in case of bimodal listening.

https://ift.tt/2qjXdFs

School-Age Hearing Screening Based on Speech-in-Noise Perception Using the Digit Triplet Test

Objectives: This study aims to investigate the large-scale applicability of the Digit Triplet test (DTT) for school-age hearing screening in fifth grade elementary (5E) (9 to 12 years old) and third grade secondary (3S) (13 to 16 years old) school children. The reliability of the test is investigated as well as whether pass/fail criteria need to be corrected for training and/or age, and whether these criteria have to be refined with respect to referral rates and pure-tone audiometry results. Design: Eleven school health service centers participated in the region of Flanders (the Northern part of Belgium). Pure-tone screening tests, which are commonly used for hearing screening in school children, were replaced by the DTT. Initial pass/fail criteria were determined. Children with speech reception thresholds (SRT) of −7.2 dB signal to noise ratio (SNR) (5E) and −8.3 dB SNR (3S) or worse were referred for an audiogram and follow-up. In total, n = 3412 (5E) and n = 3617 (3S) children participated. Results: Population SRTs (±2 SD) were −9.8 (±1.8) dB SNR (5E) and −10.5 (±1.6) dB SNR (3S), and do not need correction for training and/or age. Whereas grade-specific pass/fail criteria are more appropriate, a linear regression analysis showed an improvement of 0.2 dB per year of the SRT until late adolescence. SRTs could be estimated with a within-measurement reliability of 0.6 dB. Test duration was also grade-dependent, and was 6 min 50 sec (SD = 61 sec) (5E) and 5 min 45 sec (SD = 49 sec) (3S) on average for both ears. The SRT, test reliability, and test duration were comparable across centers. With initial cut-off values, 2.9% (5E) and 3.5% (3S) of children were referred. Based on audiograms of n = 39 (5E) and n = 59 (3S) children, the diagnostic accuracy of the DTT was assessed. A peripheral hearing loss was detected in 31% (5E) and 53% (3S) of the referred children. Hearing losses found were mild. Less strict pass/fail criteria increased the diagnostic accuracy. Optimal pass/fail criteria were determined at −6.5 dB SNR (5E) and −8.1 dB SNR (3S). With these criteria, referral rates dropped to 1.3% (5E) and 2.4% (3S). Conclusions: The DTT has been implemented as the new hearing screening methodology in the Flemish school-age hearing screening program. Based on the results of this study, pass/fail criteria were determined and optimized to be used for systematic hearing screening of 5E and 3S school children. Furthermore, this study provides reference values for the DTT in children 9 to 16 years of age. Reliable SRTs can be obtained with the test, allowing accurate monitoring of hearing over time. This is important in the context of a screening guideline, which aims to identify children with noise-induced hearing loss. Validation of the screening result should go beyond taking an audiogram, as a peripheral hearing impairment cannot always be found in children with a failed test.

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Visual Performance and Perception as a Target of Saccadic Strategies in Patients With Unilateral Vestibular Loss

Objectives: To evaluate the ability of saccadic strategies developed during vestibular compensation to reduce the effect of an impaired vestibulo-ocular reflex (VOR) on a retinal smear and image motion sensation. Design: Twenty patients with unilateral vestibular loss were examined with a video head impulse test before and after vestibular rehabilitation (VR) with the use of gaze stabilization and refixation saccades training. Head and eye velocity functions were processed to infer the retinal eccentricity, and through its correlation with visual acuity (VA), several measurements are proposed to evaluate the influence of VR on saccades behavior and visual performance. To isolate the effect of saccades on the findings and avoid bias because of gain differences, only patients whose VOR gain values remained unchanged after VR were included. Results: Improved contribution of covert saccades and reduction of overt saccades latency were measured after VR. We found significant differences when assessing both the interval less than 70% VA (50.25 ms), which is considered the limit of a moderate low vision, and less than 50% VA (39.515 ms), which is the limit for severe low vision. Time to recover a VA of 75% (near normal) was reduced in all the patients (median: 56.472 ms). Conclusion: Despite the absence of VOR gain improvement, patients with unilateral vestibular loss are able to develop saccadic strategies that allow the shortening of the interval of retinal smear and image motion. The proposed measurements might be of use to evaluate VR outcomes and visually induced impairment.

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Development of a Diagnostic Prediction Model for Conductive Conditions in Neonates Using Wideband Acoustic Immittance

Objectives: Wideband acoustic immittance (WAI) is an emerging test of middle-ear function with potential applications for neonates in screening and diagnostic settings. Previous large-scale diagnostic accuracy studies have assessed the performance of WAI against evoked otoacoustic emissions, but further research is needed using a more stringent reference standard. Research into suitable quantitative techniques to analyze the large volume of data produced by WAI is still in its infancy. Prediction models are an attractive method for analysis of multivariate data because they provide individualized probabilities that a subject has the condition. A clinically useful prediction model must accurately discriminate between normal and abnormal cases and be well calibrated (i.e., give accurate predictions). The present study aimed to develop a diagnostic prediction model for detecting conductive conditions in neonates using WAI. A stringent reference standard was created by combining results of high-frequency tympanometry and distortion product otoacoustic emissions. Design: High-frequency tympanometry and distortion product otoacoustic emissions were performed on both ears of 629 healthy neonates to assess outer- and middle-ear function. Wideband absorbance and complex admittance (magnitude and phase) were measured at frequencies ranging from 226 to 8000 Hz in each neonate at ambient pressure using a click stimulus. Results from one ear of each neonate were used to develop the prediction model. WAI results were used as logistic regression predictors to model the probability that an ear had outer/middle-ear dysfunction. WAI variables were modeled both linearly and nonlinearly, to test whether allowing nonlinearity improved model fit and thus calibration. The best-fitting model was validated using the opposite ears and with bootstrap resampling. Results: The best-fitting model used absorbance at 1000 and 2000 Hz, admittance magnitude at 1000 and 2000 Hz, and admittance phase at 1000 and 4000 Hz modeled as nonlinear variables. The model accurately discriminated between normal and abnormal ears, with an area under the receiver-operating characteristic curve (AUC) of 0.88. It effectively generalized to the opposite ears (AUC = 0.90) and with bootstrap resampling (AUC = 0.85). The model was well calibrated, with predicted probabilities aligning closely to observed results. Conclusions: The developed prediction model accurately discriminated between normal and dysfunctional ears and was well calibrated. The model has potential applications in screening or diagnostic contexts. In a screening context, probabilities could be used to set a referral threshold that is intuitive, easy to apply, and sensitive to the costs associated with true- and false-positive referrals. In a clinical setting, using predicted probabilities in conjunction with graphical displays of WAI could be used for individualized diagnoses. Future research investigating the use of the model in diagnostic or screening settings is warranted.

https://ift.tt/2QaaITt

Toward Optimizing VEMP: Calculating VEMP Inhibition Depth With a Generic Template

Objectives: Cervical vestibular evoked myogenic potentials (cVEMP) indirectly reveal the response of the saccule to acoustic stimuli through the inhibition of sternocleidomastoid muscle electromyographic response. VEMP inhibition depth (VEMPid) is a recently developed metric that estimates the percentage of saccular inhibition. VEMPid provides both normalization and better accuracy at low response levels than amplitude-normalized cVEMPs. Hopefully, VEMPid will aid in the clinical assessment of patients with vestibulopatholgy. To calculate VEMPid a template is needed. In the original method, a subject's own cVEMP was used as the template, but this method can be problematic in patients who do not have robust cVEMP responses. We hypothesize that a "generic" template, created by assembling cVEMPs from healthy subjects, can be used to compute VEMPid, which would facilitate the use of VEMPid in subjects with pathological conditions. Design: A generic template was created by averaging cVEMP responses from 6 normal subjects. To compare VEMPid calculations using a generic versus a subject-specific template, cVEMPs were obtained in 40 healthy subjects using 500, 750, and 1000 Hz tonebursts at sound levels ranging from 98 to 123 dB peSPL. VEMPids were calculated both with the generic template and with the subject's own template. The ability of both templates to determine whether a cVEMP was present or not was compared with receiver operating characteristic curves. Results: No significant differences were found between VEMPid calculations using a generic template versus using a subject-specific template for all frequencies and sound levels. Based on the receiver operating characteristic curves, the subject-specific and generic template did an equally good job at determining threshold. Within limits, the shape of the generic template did not affect these results. Conclusions: A generic template can be used instead of a subject-specific template to calculate VEMPid. Compared with cVEMP normalized by electromyographic amplitudes, VEMPid is advantageous because it averages zero when there is no sound stimulus and it allows the accumulating VEMPid value to be shown during data acquisition as a guide to deciding when enough data has been collected.

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A Dynamically Focusing Cochlear Implant Strategy Can Improve Vowel Identification in Noise

Objectives: The standard, monopolar (MP) electrode configuration used in commercially available cochlear implants (CI) creates a broad electrical field, which can lead to unwanted channel interactions. Use of more focused configurations, such as tripolar and phased array, has led to mixed results for improving speech understanding. The purpose of the present study was to assess the efficacy of a physiologically inspired configuration called dynamic focusing, using focused tripolar stimulation at low levels and less focused stimulation at high levels. Dynamic focusing may better mimic cochlear excitation patterns in normal acoustic hearing, while reducing the current levels necessary to achieve sufficient loudness at high levels. Design: Twenty postlingually deafened adult CI users participated in the study. Speech perception was assessed in quiet and in a four-talker babble background noise. Speech stimuli were closed-set spondees in noise, and medial vowels at 50 and 60 dB SPL in quiet and in noise. The signal to noise ratio was adjusted individually such that performance was between 40 and 60% correct with the MP strategy. Subjects were fitted with three experimental strategies matched for pulse duration, pulse rate, filter settings, and loudness on a channel-by-channel basis. The strategies included 14 channels programmed in MP, fixed partial tripolar (σ = 0.8), and dynamic partial tripolar (σ at 0.8 at threshold and 0.5 at the most comfortable level). Fifteen minutes of listening experience was provided with each strategy before testing. Sound quality ratings were also obtained. Results: Speech perception performance for vowel identification in quiet at 50 and 60 dB SPL and for spondees in noise was similar for the three tested strategies. However, performance on vowel identification in noise was significantly better for listeners using the dynamic focusing strategy. Sound quality ratings were similar for the three strategies. Some subjects obtained more benefit than others, with some individual differences explained by the relation between loudness growth and the rate of change from focused to broader stimulation. Conclusions: These initial results suggest that further exploration of dynamic focusing is warranted. Specifically, optimizing such strategies on an individual basis may lead to improvements in speech perception for more adult listeners and improve how CIs are tailored. Some listeners may also need a longer period of time to acclimate to a new program.

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