Work It Out Together: Preliminary Efficacy of a Parent and Adolescent DVD and Workbook Intervention on Adolescent Sexual and Substance Use Attitudes and Parenting Behaviors.

The purpose of the current study was to test an interactive DVD and workbook specifically designed for African-American parents and adolescents (ages 13-18), based on an efficacious face-to-face intervention, to address key factors associated with risk. A total of 170 parent-adolescent dyads were enrolled and randomly assigned to receive either the "Work It Out Together" DVD or a General Health Promotion DVD (HP). Parents and adolescents completed measures of HIV knowledge, self-efficacy, and parenting behaviors. Immediately after receiving the Work It Out Together intervention, parents and adolescents demonstrated higher HIV knowledge and greater HIV prevention self-efficacy. Three months after receiving the Work It Out Together intervention, parents and adolescents reported higher levels of parental monitoring and sexually active adolescents reported higher levels of condom use self-efficacy and a lower rate of recent sex. These outcomes provide preliminary evidence that the "Work It Out Together" DVD impacted individual attitudes and protective parenting behaviors.

Patient Safety Friendly Hospital Initiative: from evidence to action in seven developing country hospitals.

QUALITY PROBLEM: Recent evidence in the level of patient safety from hospitals in six developing countries in the Eastern Mediterranean Region has demonstrated the high prevalence of adverse events, the excessive rate of death and permanent disability and their high preventability. The Patient Safety Friendly Hospital Initiative (PSFHI) has been launched to respond to these challenges. INITIAL ASSESSMENT: The principal approach of the PSFHI has been to develop an assessment manual that has 140 patient safety standards across five domains--leadership and management, patients and public involvement, safe evidence-based clinical practices, safe environment and lifelong learning. CHOICE OF SOLUTION AND IMPLEMENTATION: Ministries of health of seven countries--Egypt, Jordan, Morocco, Pakistan, Sudan, Tunisia and Yemen were asked to nominate one hospital for assessment and then follow-up with an improvement plan. EVALUATION: The standards are divided into critical (20), core (90) and developmental (30). The range of critical standards, the compulsory standards with which a hospital has to comply, achieved by participating hospitals was 8-78%. Overall, in the domain of leadership and management the highest compliance was 47%, for patients and public involvement 25%, for safe evidence-based clinical practice 53%, for safe environment 64% and for lifelong learning 27%. LESSONS LEARNED: This is the first systematic multi-country initiative in the Eastern Mediterranean Region, which provides compelling evidence that assessment of patient safety standards is feasible and applicable in resource-poor settings and there are significant opportunities for improving the level of patient safety in these hospitals.

Real-ear polar patterns and aided directional sensitivity.

Real-ear directional sensitivity patterns were obtained from a group of eight subjects wearing in-the-ear and completely-in-the-canal-placed microphones to determine whether depth of microphone placement within the ear affects electroacoustic estimates of directionality. Both conventional and extended versions of the Unidirectional Index and the Directivity Index were used to estimate directional sensitivity, and results indicated that depth of microphone placement affects directionality in a region-specific as well as a frequency-specific manner. Results also indicated that conclusions about directional sensitivity vary when assumptions about signal and noise source locations, the orientation of the listener relative to them, and human perceptual abilities are taken into consideration. Results are discussed in terms of the utility of modified estimates of directional sensitivity to quantify directional sensitivity when measurements are made in real ears and on possible localization and speech recognition effects that may vary with depth of microphone placement in a regionally specific manner.

Acoustic and hearing aid circuit variables affecting the tolerability of aided impulsive-type sounds.

The tolerability of aided impulsive-type stimuli was investigated in a group of 13 hearing-impaired listeners. Two linear circuits (one with a class A and one with a class D output stage) and one adaptive frequency response (AFR) circuit (with a class D output stage) were investigated. In a three-way paired-comparison task, subjects chose the hearing aid that was most tolerable when 75 dB sound pressure level (SPL) impulsive-type sounds were presented. Real-ear measurements of rms SPL, peak SPL, crest factor, and spectral distribution were made to determine which of these variables was most closely associated with behavioral tolerability scores. Results indicated significant differences across hearing aids for tolerability scores, rms sound pressure levels, and spectral peak frequencies. Highest tolerability scores were associated with the hearing aid that produced the lowest rms sound pressure levels in the ear canal (class D AFR). Significant correlations were found between tolerability and both rms SPL and peak SPL. Results are discussed in terms of circuit algorithm and in terms of the possible effects of hearing aid saturation.

Hearing aid saturation, coherence, and aided loudness discomfort.

Real-ear measurements of the aided Loudness Discomfort Level (LDL) were obtained from five hearing-impaired listeners who were fit with two Class A and two Class D linear hearing aids, each with a different saturation sound pressure level (HFA SSPL90). These measurements were obtained with 75 dB SPL continuous discourse to determine whether saturation-induced distortion contributes to the sensation of loudness. Real-ear coherence measurements made at LDL were used to determine the extent of saturation, and sound quality judgments were used to determine whether the distortion present at LDL affected sound quality. Results indicated that the SPL, coherence, and sound quality ratings obtained at LDL were all higher for Class D hearing aids with relatively high HFA SSPL90 than for Class A hearing aids with relatively low HFA SSPL90. Overall results were generally consistent with the hypothesis that distortion affects both sound quality and the perception of loudness.

Automated Methods of Assessing Hearing Aid Performance in Listeners With Impaired Hearing.

The methods that have been described, although still under development, are intended to demonstrate that the issues of sound quality, speech intelligibility, and loudness may be addressed in a clinical setting in a reasonable amount of time. Being automated, these methods are relatively time-efficient, and may become more so as they are refined. Being database oriented, these methods make it easy to monitor individual clients over time, and also provide an efficient way to evaluate the success rate of individual circuits across listeners with similar hearing losses. Individually, these techniques provide only some of the information that may indicate whether a particular fitting may succeed. Taken together, these behavioral methods will provide a great deal of both subjective and objective information that will help the dispenser not only decide which of several hearing aids may be best for a user, but also how a given instrument may be adjusted to provide the maximum benefit. By including the formal assessment of sound quality, speech intelligibility, and loudness in the hearing aid evaluation, the needs of the user are more likely to be met, and the degree of satisfaction achieved is likely to be higher than if the evaluation consists solely of matching the real ear insertion response to a prescribed target.

Telephone triage: an Irish view.

This paper examines the issue of telephone triage for an Irish Emergency Department and includes definitions of triage and telephone triage. At St. James Hospital, Dublin the first attempt at formal telephone triage failed. In hindsight this was attributed to inadequate research into the topic and lack of staff motivation. This paper forms part of a larger literature review undertaken by the author following the first failed attempt. An overview of the international literature addresses both the positive and negative sides of a telephone helpline. The body of literature reviewed suggests telephone triage can be successful but advises the use of formal protocols, training of staff and accurate documentation. The purpose of this paper is therefore to investigate the benefits and recommended practices of implementing telephone triage with a view to successfully changing policy and practice in a busy Emergency Department.

Tourette's syndrome and treatment with clomipramine hydrochloride.

Clomipramine hydrochloride, a tricyclic antidepressant that blocks serotonin and norepinephrine reuptake, is indicated in the treatment of Obsessive-Compulsive Disorder. It has been reported that patients with Obsessive-Compulsive Disorder and a concomitant diagnosis of Tourette's Syndrome respond well to treatment with clomipramine (1). It has also been reported that these dually-diagnosed patients, when treated with clomipramine, receive relief from the symptoms of both disorders (2). Published reports of Tourette's patients, without a concomitant Obsessive-Compulsive Disorder, successfully responding to treatment with clomipramine are rare. To the authors' knowledge, no such report has been published since 1975. This article reports the case of a 41-year-old male Tourette's patient, without a dual diagnosis of Obsessive-Compulsive Disorder, who successfully responded to clomipramine therapy.

Aided growth of masking for speech and nonspeech signals.

OBJECTIVE: Growth of masking (GOM) functions for speech and nonspeech signals were obtained in normal and impaired ears, with an emphasis on aided listening conditions. The purpose of the investigation was to determine whether electroacoustic contrasts between hearing aid circuits would manifest themselves in aided GOM functions and to determine whether amplification alters the slopes of GOM functions in impaired ears. DESIGN: Five normal-hearing and 10 hearing-impaired listeners with sloping high-frequency losses participated. GOM functions were obtained in the sound field using a two-interval forced choice forward masking paradigm. Four sets of test signals consisted of narrowband noise maskers and sinusoidal probes. Two additional stimulus sets consisted of phonemes used as masker and probe. Both on-frequency and off-frequency masking conditions were examined. Test circuits included wide dynamic range compression (low compression threshold and low compression ratio) and output compression limiting (high compression threshold and high compression ratio), each adjusted to the DSL[i/o] prescriptive target. GOM slopes were calculated for normal-hearing and hearing-impaired subjects unaided, and for impaired subjects aided, in an effort to determined whether amplification compensates for abnormal growth of masking and whether electroacoustic contrasts between circuits differentially affect level-dependent masker effectiveness. RESULTS: Results indicated large differences between normal and impaired functions unaided. Under aided conditions, narrowband noise masked thresholds were reduced re: unaided at lower masker levels but not at higher masker levels. Masked thresholds for phoneme maskers were reduced at all masker levels. In general, aided GOM slopes changed in the direction of normal but did not match normal slopes. Aided results were highly dependent on stimulus test conditions and were consistent with the compression thresholds and release times of the aids under test. Circuit contrasts were more apparent when phonemes were used as masker and probe than when conventional signals were used. CONCLUSION: Results suggest that GOM functions can be altered by amplification in ways that are consistent with the electroacoustic characteristics of the circuits being used. Although these data address only a small number of conditions, they suggest a possible application for aided growth of masking in the evaluation of hearing aid performance.

Duration, compression, and the aided loudness discomfort level.

OBJECTIVE: The purpose of this investigation is to determine how the unaided and aided loudness discomfort level (LDL) varies with the duration of the input signal and whether the electroacoustic characteristics of compression circuits affect this relationship in a manner that may alter the listener's dynamic range for short duration sounds. DESIGN: Ten hearing-impaired and 20 normal-hearing listeners participated. LDLs were determined for noise bursts of durations ranging in six steps from 32 to 1024 msec, using a two-alternative, forced-choice adaptive tracking procedure in which input level varied until LDL was achieved. LDLs were also obtained for continuous discourse, using a clinical procedure. Subjects were also given the opportunity to self adjust maximum output SPL to their LDL using either output limiting or volume controls in response to fixed 90 dB SPL noise bursts. Testing was conducted unaided and with hearing aids representing two analog (output compression limiting, wide dynamic range compression) and four digital compression circuits. Primary circuit contrasts included compression threshold, compression ratio, attack time and the presence or absence of unity gain at high levels. RESULTS: For the unaided condition, both normal-hearing and hearing-impaired subjects showed increasing LDLs with decreasing signal duration. Under aided conditions, circuits with compression thresholds of 45 to 50 dB SPL and compression ratios of 2:1 produced LDL functions that were similar in slope to the impaired listener's unaided functions. Slopes were steeper when the attack time was slow (128 msec) than when it was fast (2 msec). Circuits with compression ratios of 8:1 produced flat LDL duration functions (i.e., a loss of duration-dependent effects). Similar duration-dependent LDL effects were also observed when subjects adjusted their own hearing aid output characteristics in response to 90 dB noise bursts. CONCLUSION: For the unaided condition, results suggest that normal-hearing and hearing-impaired listeners can tolerate short duration sounds at higher levels than long duration sounds, a finding that has implications for hearing aid design. Circuits that preserve the relationship between duration and LDL should allow brief phonemes to be presented at higher levels without discomfort than circuits that do not, possibly resulting in greater audibility or speech recognition. Current results suggest that circuits with low compression thresholds, low compression ratios, and slow attack times might accomplish this objective better than circuits with high compression thresholds, high compression ratios and fast attack times.

High-level psychophysical tuning curves: simultaneous masking by pure tones and 100-Hz-wide noise bands.

Simultaneous-masked psychophysical tuning curves were obtained from normal-hearing listeners using low-level (20-25 dB SPL) probe tones in quiet and high-level (60 dB SPL) probe tones, both in quiet and in the presence of a broad-band background noise. The background noise was introduced to eliminate combination tones or combination bands and other off-frequency listening cues that exist at high levels. Tuning curves were obtained using pure-tone maskers and 100-Hz-wide narrow-band noise maskers for probe tones at 1000 and 4000 Hz. High-level tuning curves for pure-tone maskers demonstrated large discontinuities or "notches" on the low-frequency sides of the tuning curves. Broad-band background noise eliminated those notches, indicating that the notches were due to the detection of off-frequency listening cues at combination-tone frequencies. High-level tuning curves for 100-Hz-wide narrow-band maskers also demonstrated notches on the low-frequency sides. Those notches were eliminated with broad-band background noise, which indicates that combination bands strongly influenced the shapes of high-level tuning curves obtained with narrow-band maskers. The influence of combination bands was dependent upon test frequency. At 1000 Hz, combination bands had very little influence on the shapes of high-level tuning curves. At 4000 Hz, where the masker bandwidth was substantially less than the critical bandwidth, combination bands strongly affected the low-frequency sides of the tuning curves. In 2 subjects tested at a probe frequency of 2000 Hz with 100-Hz-wide masking bands, combination bands also influenced the low-frequency sides of high-level tuning curves. The presence of combination-tone or combination-band cues essentially steepened the low-frequency slopes of tuning curves, resulting in sharper estimates of tuning. Comparisons of tuning curves obtained with pure-tone maskers and narrow-band maskers, in the same listeners, revealed that pure-tone maskers were more effective than narrow-band maskers when the masker frequencies were in the tail region of the tuning curve. The results of these experiments support the notion that tuning in the normal auditory system broadens notably with stimulus level, once off-frequency listening cues such as combination tones or combination bands are eliminated. The low-level simultaneously masked tuning curve demonstrates a sharp bandpass tuning characteristic, whereas the high-level simultaneously masked tuning curve in background noise demonstrates a broad low-pass tuning characteristic.(ABSTRACT TRUNCATED AT 400 WORDS)

High-level psychophysical tuning curves: simultaneous masking with different noise bandwidths.

Simultaneous-masked psychophysical tuning curves were measured with narrow-band noise maskers varying in bandwidth from 40 Hz to 800 Hz to determine the masker bandwidths at which combination-band detection cues no longer influence tuning-curve shapes. Tuning curves were obtained at 1000 and 4000 Hz from normal-hearing listeners using high-level (60 dB SPL) probe tones in quiet and in the presence of a broadband background noise to eliminate combination bands and other off-frequency listening cues that exist at high levels. High-level tuning curves revealed notches on the low-frequency sides. Those notches were eliminated with broad-band background noise, which indicates that combination bands can strongly influence the shapes of high-level tuning curves obtained with narrow-band maskers, primarily by steepening the low-frequency and tail slopes. Combination-band detection cues had a stronger influence at 4000 Hz than at 1000 Hz. As masker bandwidth increased, combination bands had less influence on tuning-curve shapes. These results suggest a possible relation between masker bandwidth and auditory critical bandwidth: combination bands affected the low-frequency sides of the tuning curves only when the masker bandwidth was less than the auditory critical bandwidth.

Hearing aid saturation and aided loudness discomfort.

Clinical measurements of the loudness discomfort level (LDL) are generally performed while the subject listens to a particular stimulus presented from an audiometer through headphones (AUD-HP). The assumption in clinical practice has been that the sound pressure level (SPL) corresponding to the sensation of loudness discomfort under AUD-HP conditions will be the same as the corresponding to LDL with the hearing aid. This assumption ignores the fact that the distortion produced by a saturating hearing aid could have an influence on the sensation of loudness. To examine these issues, 5 hearing-impaired subjects were each fit with four linear hearing aids, each having a different saturation sound pressure level (SSPL90). Probe-tube microphone measurements of ear canal SPL at LDL were made while the subjects listened to continuous discourse in quiet under aided and AUD-HP conditions. Also using continuous discourse, real-ear coherence measures were made at various output sound pressure levels near LDL. All four hearing aid types produced mean LDLs that were lower than those obtained under AUD-HP conditions. Those hearing aids with higher SSPL90 produced significantly higher LDLs than hearing aids with lower SSPL90. A significant negative correlation was found between real-ear SPL and real-ear coherence. Quality judgments made at LDL indicated that sound quality of hearing aids with higher SSPL90 was preferred to that of hearing aids with lower SSPL90. Possible fitting implications regarding the setting of SSPL90 from AUD-HP LDL measures are discussed.

A new technique for quantifying temporal envelope contrasts.

A new technique has been developed for precisely quantifying the temporal contrasts that exist between two sound samples. This technique is based on envelope subtraction, and generates an Envelope Difference Index that may be used to help clarify whether alteration of the natural speech envelope via amplification improves or degrades speech intelligibility. The Envelope Difference Index method may also be used to assess hearing aid saturation, and may have other applications as well. The technique is applicable whenever a precise quantification of the difference between two temporal envelopes is required, regardless of stimulus duration.

Strategies for enhancing the consonant to vowel intensity ratio with in the ear hearing aids.

Numerous investigators have suggested that increasing the consonant to vowel intensity ratio (CVR) may improve speech intelligibility. This investigation was designed to determine the extent to which analog circuits, small enough to fit into in the ear hearing aids, can increase the CVR, and whether CVR enhancement is of benefit to hearing-impaired listeners. Real ear CVRs, calculated from real ear recordings of nonsense syllables, were obtained from eight hearing-impaired listeners. Recordings from each listener were obtained through each of four hearing aid circuits: (1) an adaptive high-pass filter; (2) a faster acting adaptive high-pass filter; (3) the fast-acting adaptive high-pass filter with expansion; and (4) an infinite amplitude clipper. The amount of CVR enhancement was compared to performance of the subjects with a NST speech recognition task. Subjects also ranked the four circuits for amount of consonant emphasis provided. Results indicated that the four hearing aid circuits increased the real ear CVR by 4 to 6 dB, relative to unaided. Aided CVR varied, however, across circuits and between fricative and stop consonants. Performance on the NST recognition task was generally consistent with the amount of CVR increase provided. Rank ordering for consonant emphasis was consistent with aided CVR for stop consonants, but not for fricatives.