Language development in deaf or hard-of-hearing children with additional disabilities: type matters!

BACKGROUND: This study examined language development in young children with hearing loss and different types of additional disabilities (ADs). METHOD: A population-based cohort of 67 children who were enrolled in the Longitudinal Outcomes of Children with Hearing Impairment study took part. Language ability was directly assessed at 3 and 5 years of age using the Preschool Language Scale, Fourth Edition and the Peabody Picture Vocabulary Test, Fourth Edition. Standard scores were used to enable comparison with age-based expectations for typically developing children. RESULTS: Analysis of variance showed that, across the total cohort, children's language scores remained stable over the 2-year period. However, this overall stability masked a significant difference between children with different types of ADs; in particular, children with autism, cerebral palsy and/or developmental delay showed a decline in standard scores, whereas children with other disabilities showed a relative improvement. In addition, larger improvements in receptive vocabulary were associated with use of oral communication only. CONCLUSIONS: The results suggest that type of AD can be used to gauge expected language development in the population of children with hearing loss and ADs when formal assessment of cognitive ability is not feasible.

FBXL4 defects are common in patients with congenital lactic acidemia and encephalomyopathic mitochondrial DNA depletion syndrome.

Mutations in FBXL4 have recently been recognized to cause a mitochondrial disorder, with clinical features including early onset lactic acidosis, hypotonia, and developmental delay. FBXL4 sequence analysis was performed in 808 subjects suspected to have a mitochondrial disorder. In addition, 28 samples from patients with early onset of lactic acidosis, but without identifiable mutations in 192 genes known to cause mitochondrial diseases, were examined for FBXL4 mutations. Definitive diagnosis was made in 10 new subjects with a total of 7 novel deleterious variants; 5 null and 2 missense substitutions. All patients exhibited congenital lactic acidemia, most of them with severe encephalopathic presentation, and global developmental delay. Overall, FBXL4 defects account for at least 0.7% (6 out of 808) of subjects suspected to have a mitochondrial disorder, and as high as 14.3% (4 out of 28) in young children with congenital lactic acidosis and clinical features of mitochondrial disease. Including FBLX4 in the mitochondrial diseases panel should be particularly important for patients with congenital lactic acidosis.

Vaccine-associated varicella and rubella infections in severe combined immunodeficiency with isolated CD4 lymphocytopenia and mutations in IL7R detected by tandem whole exome sequencing and chromosomal microarray.

In areas without newborn screening for severe combined immunodeficiency (SCID), disease-defining infections may lead to diagnosis, and in some cases, may not be identified prior to the first year of life. We describe a female infant who presented with disseminated vaccine-acquired varicella (VZV) and vaccine-acquired rubella infections at 13 months of age. Immunological evaluations demonstrated neutropenia, isolated CD4 lymphocytopenia, the presence of CD8(+) T cells, poor lymphocyte proliferation, hypergammaglobulinaemia and poor specific antibody production to VZV infection and routine immunizations. A combination of whole exome sequencing and custom-designed chromosomal microarray with exon coverage of primary immunodeficiency genes detected compound heterozygous mutations (one single nucleotide variant and one intragenic copy number variant involving one exon) within the IL7R gene. Mosaicism for wild-type allele (20-30%) was detected in pretransplant blood and buccal DNA and maternal engraftment (5-10%) demonstrated in pretransplant blood DNA. This may be responsible for the patient's unusual immunological phenotype compared to classical interleukin (IL)-7Rα deficiency. Disseminated VZV was controlled with anti-viral and immune-based therapy, and umbilical cord blood stem cell transplantation was successful. Retrospectively performed T cell receptor excision circle (TREC) analyses completed on neonatal Guthrie cards identified absent TREC. This case emphasizes the danger of live viral vaccination in severe combined immunodeficiency (SCID) patients and the importance of newborn screening to identify patients prior to high-risk exposures. It also illustrates the value of aggressive pathogen identification and treatment, the influence newborn screening can have on morbidity and mortality and the significant impact of newer genomic diagnostic tools in identifying the underlying genetic aetiology for SCID patients.

The role of metabolic imaging in radiation therapy of prostate cancer.

The goal of this study was to correlate prostatic metabolite concentrations from snap-frozen patient biopsies of recurrent cancer after failed radiation therapy with histopathological findings, including Ki-67 immunohistochemistry and pathologic grade, in order to identify quantitative metabolic biomarkers that predict for residual aggressive versus indolent cancer. A total of 124 snap-frozen transrectal ultrasound (TRUS)-guided biopsies were acquired from 47 men with untreated prostate cancer and from 39 men with a rising prostate-specific antigen and recurrent prostate cancer following radiation therapy. Biopsy tissues with Ki-67 labeling index ≤ 5% were classified as indolent cancer, while biopsy tissues with Ki-67 labeling index > 5% were classified as aggressive cancer. The majority (15 out of 17) of cancers classified as aggressive had a primary Gleason 4 pattern (Gleason score ≥ 4 + 3). The concentrations of choline-containing phospholipid metabolites (PC, GPC, and free Cho) and lactate were significantly elevated in recurrent cancer relative to surrounding benign tissues. There was also a significant increase in [PC] and reduction in [GPC] between untreated and irradiated prostate cancer biopsies. The concentration of the choline-containing phospholipid metabolites was significantly higher in recurrent aggressive (≈ twofold) than in recurrent indolent cancer biopsies, and the receiver operating characteristic (ROC) curve analysis of total choline to creatine ratio (tCho/Cr) demonstrated an accuracy of 95% (confidence interval = 0.88-1.00) for predicting aggressive recurrent disease. The tCho/Cr was significantly higher for identifying recurrent aggressive versus indolent cancer (tCho/Cr = 2.4 ± 0.4 versus 1.5 ± 0.2), suggesting that use of a higher threshold tCho/Cr ratio in future in vivo (1)H MRSI studies could improve the selection and therapeutic planning for patients who would benefit most from salvage focal therapy after failed radiation therapy.

Association of increased postoperative opioid administration with non-small-cell lung cancer recurrence: a retrospective analysis.

BACKGROUND: Evidence suggests that opioid-sparing anaesthetic techniques might be associated with increased cancer-free postoperative survival. This could be related to suppression of natural killer cells by opioid analgesics in the perioperative period. This retrospective analysis tested the hypothesis that greater opioid use in the postoperative period is associated with a higher incidence of recurrences after surgery for lung cancer. METHODS: The medical records of 99 consecutive patients who underwent video-assisted thoracoscopic surgery with lobectomy for Stage I or IIa biopsy-proven non-small-cell lung cancer (NSCLC) were reviewed. Perioperative information including patient characteristics, laboratory data, and surgical, anaesthetic, nursing, and pharmacy reports were collected. Doses of opioids administered intra-operatively and for the first 96 h after operation were converted into equianalgesic doses of oral morphine using a standard conversion table. Data were then compared with the National Cancer Registry's incidence of disease-free survival for 5 yr. RESULTS: A total of 99 patients with similar characteristics were included in the final analysis, 73 of whom were NSCLC recurrence-free at 5 yr and 26 had NSCLC recurrence within 5 yr. Total opioid dose during the 96 h postoperative period was 124 (101) mg of morphine equivalents in the cancer-free group and 232 mg (355) mg in the recurrence group (P=0.02). CONCLUSIONS: This retrospective analysis suggests an association between increased doses of opioids during the initial 96 h postoperative period with a higher recurrence rate of NSCLC within 5 yr.

Next-generation sequencing for disorders of low and high bone mineral density.

UNLABELLED: To achieve an efficient molecular diagnosis of osteogenesis imperfecta (OI), Ehlers-Danlos syndrome (EDS), and osteopetrosis (OPT), we designed a next-generation sequencing (NGS) platform to sequence 34 genes. We validated this platform on known cases and have successfully identified the causative mutation in most patients without a prior molecular diagnosis. INTRODUCTION: Osteogenesis imperfecta, Ehlers-Danlos syndrome, and osteopetrosis are collectively common inherited skeletal diseases. Evaluation of subjects with these conditions often includes molecular testing which has important counseling and therapeutic and sometimes legal implications. Since several different genes have been implicated in these conditions, Sanger sequencing of each gene can be a prohibitively expensive and time-consuming way to reach a molecular diagnosis. METHODS: In order to circumvent these problems, we have designed and tested a NGS platform that would allow simultaneous sequencing on a single diagnostic platform of different genes implicated in OI, OPT, EDS, and other inherited conditions, leading to low or high bone mineral density. We used a liquid-phase probe library that captures 602 exons (~100 kb) of 34 selected genes and have applied it to test clinical samples from patients with bone disorders. RESULTS: NGS of the captured exons by Illumina HiSeq 2000 resulted in an average coverage of over 900X. The platform was successfully validated by identifying mutations in six patients with known mutations. Moreover, in four patients with OI or OPT without a prior molecular diagnosis, the assay was able to detect the causative mutations. CONCLUSIONS: In conclusion, our NGS panel provides a fast and accurate method to arrive at a molecular diagnosis in most patients with inherited high or low bone mineral density disorders.

Nanostructured magnonic crystal with magnetic-field tunable bandgap.

Most experimental investigations into magnonic bandgaps are based on structures composed of single-constituent magnetic materials. Here we report Brillouin and numerical studies of the spin dynamics of a bi-component magnonic crystal, viz. a one-dimensional periodic array of alternating permalloy and cobalt 150 nm-wide nanostripes. Our measurements, together with those for a similar crystal composed of 250 nm-wide nanostripes, suggest that for a stripe width ratio of 1:1, the bandgap width of such magnonic arrays increases with crystal lattice constant. The bandgap parameters are strongly dependent on external magnetic field. This magnetic-field tunability of the bandgap is expected to be a crucial property of devices based on magnonic crystals. The agreement between numerical calculations, based on finite element analysis, and the experimental data is generally good.

Feasibility of diffusion and probabilistic white matter analysis in patients implanted with a deep brain stimulator.

Deep brain stimulation (DBS) for Parkinson's disease (PD) is an established advanced therapy that produces therapeutic effects through high frequency stimulation. Although this therapeutic option leads to improved clinical outcomes, the mechanisms of the underlying efficacy of this treatment are not well understood. Therefore, investigation of DBS and its postoperative effects on brain architecture is of great interest. Diffusion weighted imaging (DWI) is an advanced imaging technique, which has the ability to estimate the structure of white matter fibers; however, clinical application of DWI after DBS implantation is challenging due to the strong susceptibility artifacts caused by implanted devices. This study aims to evaluate the feasibility of generating meaningful white matter reconstructions after DBS implantation; and to subsequently quantify the degree to which these tracts are affected by post-operative device-related artifacts. DWI was safely performed before and after implanting electrodes for DBS in 9 PD patients. Differences within each subject between pre- and post-implantation FA, MD, and RD values for 123 regions of interest (ROIs) were calculated. While differences were noted globally, they were larger in regions directly affected by the artifact. White matter tracts were generated from each ROI with probabilistic tractography, revealing significant differences in the reconstruction of several white matter structures after DBS. Tracts pertinent to PD, such as regions of the substantia nigra and nigrostriatal tracts, were largely unaffected. The aim of this study was to demonstrate the feasibility and clinical applicability of acquiring and processing DWI post-operatively in PD patients after DBS implantation. The presence of global differences provides an impetus for acquiring DWI shortly after implantation to establish a new baseline against which longitudinal changes in brain connectivity in DBS patients can be compared. Understanding that post-operative fiber tracking in patients is feasible on a clinically-relevant scale has significant implications for increasing our current understanding of the pathophysiology of movement disorders, and may provide insights into better defining the pathophysiology and therapeutic effects of DBS.

Imaging considerations for in vivo 13C metabolic mapping using hyperpolarized 13C-pyruvate.

One of the challenges of optimizing signal-to-noise ratio (SNR) and image quality in (13)C metabolic imaging using hyperpolarized (13)C-pyruvate is associated with the different MR signal time-courses for pyruvate and its metabolic products, lactate and alanine. The impact of the acquisition time window, variation of flip angles, and order of phase encoding on SNR and image quality were evaluated in mathematical simulations and rat experiments, based on multishot fast chemical shift imaging (CSI) and three-dimensional echo-planar spectroscopic imaging (3DEPSI) sequences. The image timing was set to coincide with the peak production of lactate. The strategy of combining variable flip angles and centric phase encoding (cPE) improved image quality while retaining good SNR. In addition, two aspects of EPSI sampling strategies were explored: waveform design (flyback vs. symmetric EPSI) and spectral bandwidth (BW = 500 Hz vs. 267 Hz). Both symmetric EPSI and reduced BW trended toward increased SNR. The imaging strategies reported here can serve as guidance to other multishot spectroscopic imaging protocols for (13)C metabolic imaging applications.

Reproductive and Environmental Drivers of Time and Activity Budgets of Striped Skunks.

The regulation of daily and circannual activity patterns is an important mechanism by which animals may balance energetic requirements associated with both abiotic and biotic variables. Using collar-mounted accelerometers, we assess the relative importance of reproductive stage and environmental conditions on the overall dynamic body acceleration (ODBA) of free-living striped skunks (Mephitis mephitis). We found that activity timing relative to photoperiod varied across seasonal stages for both sexes. Surprisingly, male skunks did not commence activity earlier than females during the mating interval. Moreover, while female skunks began activity before dusk and terminated activity after dawn during mid- through late summer (lactation period), the duration of activity bouts in females during this period was not different from other seasons. Both male and female skunks exhibited high variability and fragmentation in daily activity rhythms except during the lactation period, when females appear to switch to prolonged bouts of nocturnal activity. Overall, ODBA varied by season and sex, with changes in ODBA indicative of seasonal reproductive requirements such as conspecific competition for mates in males and lactation in females. Weather conditions had little effect on skunk activity levels except during the winter season, when snow cover and temperature negatively influenced daily ODBA. Taken together, the activity patterns of striped skunks appear to be primarily driven by seasonal investment in reproduction and secondarily by thermoregulatory constraints during the non-winter months. Our results highlight the importance of considering how environmental and reproductive drivers may interact to affect activity across both the daily and seasonal cycle.

Regulación de la energía en mofetas rayadas ante la reproduccin y el ambiente La regulación de los patrones de actividad diaria y circanual es un mecanismo importante mediante el cual los animales pueden equilibrar los requerimientos energéticos asociados con las variables bióticas y abióticas. Usando acelerómetros montados en collar, evaluamos la importancia relativa de la etapa reproductiva y las condiciones ambientales en la aceleración global dinámica del cuerpo (ODBA, por sus siglas en inglés) de las mofetas rayadas (Mephitis mephitis). Encontramos que el tiempo de actividad en relación con el fotoperíodo varió a lo largo de las etapas estacionales para ambos sexos. Sorprendentemente, las mofetas macho no comenzaron la actividad antes que las hembras durante el intervalo de apareamiento. Además, las mofetas hembra comenzaron la actividad antes del anochecer y terminaron la actividad después del amanecer durante la mitad del verano (período de lactancia), la duración de los episodios de actividad en las hembras durante este período no fue diferente de otras estaciones. Tanto las mofetas macho como las hembra mostraron una alta variabilidad y fragmentación en los ritmos de la actividad diaria, excepto durante el período de lactancia, cuando las hembras parecen cambiar a episodios prolongados de actividad nocturna. En general, la ODBA varió según la temporada y el sexo, con cambios en la ODBA indicativos de los requisitos reproductivos estacionales, como la competencia específica para los machos en los machos y la lactancia en las hembras. Las condiciones climáticas tuvieron poco efecto en los niveles de actividad de la mofeta, excepto durante la temporada de invierno, cuando la capa de nieve y la temperatura influyeron negativamente en la ODBA diaria. Tomados en conjunto, los patrones de actividad de las mofetas rayadas parecen estar impulsados principalmente por la inversión estacional en la reproducción y, en segundo lugar, por las restricciones de termorregulación durante los meses que no son de invierno. Nuestros resultados resaltan la importancia de considerar cómo los impulsores ambientales y reproductivos pueden interactuar para afectar la actividad a lo largo del ciclo diario y estacional. Translated to Spanish by S Hinojosa (hinojosa.silvia@gmail.com).

Time-frequency analysis of click-evoked otoacoustic emissions by means of a minimum variance spectral estimation-based method.

This paper proposes a new minimum variance spectral estimation (MVSE)-based time-frequency analysis (TFA) technique for click-evoked otoacoustic emissions (CEOAEs). The MVSE is a popular spectrum analysis method which can yield a high frequency resolution compared to other nonparametric spectral analysis procedures. The conventional MVSE is extended to a TFA method by windowing the observation data to obtain a time-frequency representation for the signal under study. Inspired by the adaptive window selection process in wavelet transform and based on the time-frequency characteristics of CEOAEs, the window size of the windowed MVSE (WMVSE) is given a small value at high frequencies and a large value at low frequencies. The adaptive window size selection yields the proposed frequency-dependent WMVSE (FDWMVSE). The FDWMVSE method integrates the advantages of the adaptive window selection in wavelet transform with the fine frequency resolution of MVSE. Experimental results show that the FDWMVSE can achieve satisfactory time-frequency resolution and reveal meaningful time-frequency features when applied to synthesized and real CEOAEs.

Enhancement of spin-wave nonreciprocity in magnonic crystals via synthetic antiferromagnetic coupling.

Spin-wave nonreciprocity arising from dipole-dipole interaction is insignificant for magnon wavelengths in the sub-100 nm range. Our micromagnetic simulations reveal that for the nanoscale magnonic crystals studied, such nonreciprocity can be greatly enhanced via synthetic antiferromagnetic coupling. The nonreciprocity is manifested as highly asymmetric magnon dispersion curves of the magnonic crystals. Furthermore, based on the study of the dependence of the nonreciprocity on an applied magnetic field, the antiparallel alignment of the magnetizations is shown to be responsible for the enhancement. Our findings would be useful for magnonic and spintronics applications.

Pathologic Variants of the Mitochondrial Phosphate Carrier SLC25A3: Two New Patients and Expansion of the Cardiomyopathy/Skeletal Myopathy Phenotype With and Without Lactic Acidosis.

Variants in the SLC25A3 gene, which codes for the mitochondrial phosphate transporter (PiC), lead to a failure of inorganic phosphate (Pi) transport across the mitochondrial membrane, which is required in the final step of oxidative phosphorylation. The literature described two affected sibships with variants in SLC25A3; all cases had skeletal myopathy and cardiomyopathy (OMIM 610773). We report here two new patients who had neonatal cardiomyopathy; one of whom did not have skeletal myopathy nor elevated lactate. Patient 1 had a homozygous splice site variant, c.158-9A>G, which has been previously reported in a Turkish family. Patient 2 was found to be a compound heterozygote for two novel variants, c.599T>G (p.Leu200Trp) and c. 886_898delGGTAGCAGTGCTTinsCAGATAC (p.Gly296_Ser300delinsGlnIlePro). Protein structure analysis indicated that both variants are likely to be pathogenic. Sequencing of SLC25A3 should be considered in patients with isolated cardiomyopathy, even those without generalized skeletal myopathy or lactic acidosis.

Prostaglandin H synthase and lipoxygenase gene families in the epithelial cell barrier.

Epithelial barrier cells (in skin, gut, and airway) are both active modulators and important targets of the inflammatory response, and some of these cellular events may be regulated at a molecular level by products of phospholipid-arachidonic acid metabolism. Accordingly, we have defined some of the characteristics of gene expression and enzyme regulation for distinct members of the PGH synthase and lipoxygenase gene families in normal and inflamed epithelial tissues and in epithelial cells isolated from mucosal and epidermal tissue (Table 1). A unifying scheme for our findings includes the following enzymatic systems: (i) a PGH synthase-1/PG isomerase pathway responsible for constitutive generation of prostaglandins (e.g., PGE2) and maintenance of physiologic epithelial function; (ii) a PGH synthase-2/PG isomerase and synthase pathway capable of producing additional prostaglandins (e.g., excess PGE2 and/or PGF2 alpha and PGD2) especially after stimulation by growth factors and cytokines; and (iii) a family of arachidonate 12- and 15-lipoxygenases that may serve to generate hydroxy acids (e.g., 12- and 15-HETE) as mediators of basal epithelial function and that (after overexpression and oxidant activation) may also catalyze membrane peroxidation that contributes to epithelial damage during inflammation. The regulatory mechanisms inherent in the control of this scheme provide a biochemical rationale for balancing constitutive and inducible oxygenation activities and maintaining epithelial barrier function.

Theoretical study of surface acoustic waves in (n11) GaAs-cuts.

The propagation characteristics of true and leaky or pseudo surface acoustic waves (TSAW and PSAW=LSAW) on (n11) GaAs-cuts, n=1, 2, 3 and 4, are theoretically calculated as a function of propagation direction. They include phase velocity (V), electromechanical coupling constant (K(2)), and attenuation factor (alpha) of wave propagation on a metallized surface. The results show that PSAW mode velocities are significantly higher than corresponding TSAW velocities, and for certain propagation directions the attenuation factor is extremely small (10(-5) dB/lambda). Highly coupled PSAW modes exist for propagation directions where the TSAW are very poorly coupled. For certain isolated directions, attenuation of the wave is null (alpha=0), PSAW becoming a non-leaky SAW with partial polarization. And in this case the corresponding TSAW are decoupled from the surface electric excitation. Analysis of relations between various modes (TSAW, PSAW and SSBW, surface skimming bulk wave) is made with the help of the effective surface permittivity function and the generalized slowness diagram. A coupling constant definition different from the usual 2DeltaV/V is used, its validity and application conditions are discussed.

Acoustic wave propagation in continuous functionally graded plates: an extension of the Legendre polynomial approach.

The propagation of guided waves in continuous functionally graded plates is studied by using Legendre polynomials. Dispersion curves, and power and field profiles are easily obtained. Our computer program is validated by comparing our results against other calculations from the literature. Numerical results are also given for a graded semiconductor plate. It is felt that the present method could be of quite practical interest in waveguiding engineering, non-destructive testing of functionally graded materials (FGMs) to identify the best inspection strategies, or by means of a numerical inversion algorithm to determine through-thickness gradients in material parameters.

A unified formalism using effective surface permittivity to study acoustic waves in various anisotropic and piezoelectric multilayers.

A unified formalism is presented that uses the effective surface permittivity (ESP) to study surface acoustic waves (SAW) in layered substrates and guided waves in layered plates. Based on known mathematical tools, such as ordinary differential equation and transfer matrix, a generalized surface impedance (GSI) concept is developed and exploited to investigate the acoustic propagation in various anisotropic and piezoelectric layered structures. The ESP function, originally defined for the surface of a homogeneous and semi-infinite piezoelectric substrate, is extended to both the top surface of and an interface in a layered half space, as well as to either surface of a finite-thickness plate. General ESP expressions for all mentioned configurations are derived in terms of an equivalent GSI matrix. It is shown that, when using the appropriate GSI matrices, the same form of the ESP expressions applies no matter whether the structure is a homogeneous half space alone or coated with a layered plate or a layered plate alone. GSI matrices are explicitly given in terms of the bulk partial mode solutions for a substrate and via the transfer matrix for a plate. Modified GSI matrices for structures consisting of both a plate and a substrate are also specified. Analytical development is fully detailed to suit program implementation. To illustrate its versatility, the formalism is also applied to two-substrate configurations, allowing one to analyze guided waves in a plate sandwiched between and interfacial waves existing along the boundary of two different media. Numerical examples are given to illustrate the spectrum features that the ESP shows for various structures. Deduced ESP expressions allow one to locate directly all piezoelectrically active waves in any structure including at least one piezoelectric layer. Acoustic modes that are not piezoelectrically active and those in non-piezoelectric materials can be also obtained by using the intermediate results, such as derived GSI matrices.

Use of Matrigel in culture affects cell phenotype and gene expression in the first trimester trophoblast cell line HTR8/SVneo.

There is inconsistent use of Matrigel for experiments with the HTR8/SVneo first trimester trophoblast and other cell lines. We quantified the effects of Matrigel on the expression of genes considered to be markers of extravillous cytotrophoblast (EVT) differentiation and invasive potential. Culture on Matrigel promoted formation of "endothelial-like" tubes and reduced mRNA expression of matrix metalloproteinase 2 (MMP2), cytokeratin 7 (KRT7) and integrin alpha 1 (ITGA1), while increasing VE-cadherin (CDH5) expression consistent with a vascular phenotype. This process may constitute part of the endothelial cell mimicry exhibited by endovascular EVTs invading the maternal spiral arteries. HTR8/SVneo appears to be phenotypically polymorphic and adopt endovascular morphology on Matrigel.

Detection improvement for neonatal click evoked otoacoustic emissions by time-frequency filtering.

This study employed a time-frequency filtering technique to improve click evoked otoacoustic emission (CEOAE) detection at lower frequency bands, and hence to reduce the number of referral cases in neonatal OAE screening. Using this approach the detectability of CEOAEs, in terms of lower frequency SNRs and whole wave reproducibility, was significantly improved. Evaluations of screening outcomes demonstrated this method significantly reduced the overall referral rate, by 2.5 percentage points in initial CEOAE hearing screening. This approach may have potential application in OAE technology and in neonatal hearing screening programmes.