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 < 0.001) than the ABR test time of 32.15 min. One half of the subjects were found to have normal hearing. ASSR thresholds plotted in dB nHL for normal-hearing children in this study were found to be the lowest yet described except for one study which used the same technology. CONCLUSIONS: This study found a reversal of previous findings with up to 14 dB lower thresholds found when using the ASSR technique with "Next-Generation" detection as compared with ABR using an automated detection (FMP). The test time for an audiogram prediction was significantly lower when using ASSR than ABR but was excellent by clinical standards for both techniques. ASSRs improved threshold performance was attributed to advancements in response detection including utilization of information at multiple harmonics of the modulation frequency. The stimulation paradigm which utilized narrow band CE-Chirps also contributed to the low absolute levels of the thresholds in nHL found with both techniques.

Ecological regime shift drives declining growth rates of sea turtles throughout the West Atlantic.

Somatic growth is an integrated, individual-based response to environmental conditions, especially in ectotherms. Growth dynamics of large, mobile animals are particularly useful as bio-indicators of environmental change at regional scales. We assembled growth rate data from throughout the West Atlantic for green turtles, Chelonia mydas, which are long-lived, highly migratory, primarily herbivorous mega-consumers that may migrate over hundreds to thousands of kilometers. Our dataset, the largest ever compiled for sea turtles, has 9690 growth increments from 30 sites from Bermuda to Uruguay from 1973 to 2015. Using generalized additive mixed models, we evaluated covariates that could affect growth rates; body size, diet, and year have significant effects on growth. Growth increases in early years until 1999, then declines by 26% to 2015. The temporal (year) effect is of particular interest because two carnivorous species of sea turtles-hawksbills, Eretmochelys imbricata, and loggerheads, Caretta caretta-exhibited similar significant declines in growth rates starting in 1997 in the West Atlantic, based on previous studies. These synchronous declines in productivity among three sea turtle species across a trophic spectrum provide strong evidence that an ecological regime shift (ERS) in the Atlantic is driving growth dynamics. The ERS resulted from a synergy of the 1997/1998 El Niño Southern Oscillation (ENSO)-the strongest on record-combined with an unprecedented warming rate over the last two to three decades. Further support is provided by the strong correlations between annualized mean growth rates of green turtles and both sea surface temperatures (SST) in the West Atlantic for years of declining growth rates (r = -.94) and the Multivariate ENSO Index (MEI) for all years (r = .74). Granger-causality analysis also supports the latter finding. We discuss multiple stressors that could reinforce and prolong the effect of the ERS. This study demonstrates the importance of region-wide collaborations.

Protocol for Rapid, Accurate, Electrophysiologic, Auditory Assessment of Infants and Toddlers.

BACKGROUND: Audiologists often lack confidence in results produced by current protocols for diagnostic electrophysiologic testing of infants. This leads to repeat testing appointments and slow protocols which extend the time needed to complete the testing and consequently delay fitting of amplification. A recent publication (Sininger et al50) has shown how new technologies can be applied to electrophysiologic testing systems to improve confidence in results and allow faster test protocols. Average test times for complete audiogram predictions when using new technologies and protocols were found to be just over 32 minutes using auditory brainstem response (ABR) and just under 20 minutes using auditory steady-state response (ASSR) technology. PURPOSE: The purpose of this manuscript is to provide details of expedited test protocols for infant and toddler diagnostic electrophysiologic testing. SUMMARY: Several new technologies and their role in test speed and confidence are described including CE-Chirp stimuli, automated detection of ABRs using a technique called F MP, Bayesian weighting which is an alternative to standard artifact rejection and Next-Generation ASSR with improved response detection and chirp stimuli. The test protocol has the following features: (1) preliminary testing includes impedance measures and otoacoustic emissions, (2) starting test levels are based on Broad-Band CE-Chirp thresholds in each ear, (3) ABRs or ASSRs are considered present based on automated detection rather than on replication of responses, (4) number of test levels is minimized, (5) ASSR generally evaluates four frequencies in each ear simultaneously with flexibility to change all test levels independently. CONCLUSIONS: Combining new technologies with common-sense strategies has been shown to substantially reduce test times for predicting audiometric thresholds in infants and toddlers (Sininger et al50). Details and rationales for changing test strategies and protocols are given and case examples are used to illustrate.

Reflections on Lake Como Conferences (2000-2016).

PURPOSE: We present an overview of the conceptualization and development of the Newborn Hearing Screening and Hearing Across the Lifespan (Lake Como) conferences from 2000 to 2016.

Partnering with nursing service improves health care worker influenza vaccination rates.

BACKGROUND: Increasing the influenza vaccination rate in health care workers (HCWs) promotes patient safety as well as employee health. The average HCW influenza vaccination rate is approximately 35%. Various studies have analyzed the reasons for the low vaccination rate in HCWs and developed strategies aimed at increasing this rate. METHODS: At the study hospital, the Nursing Department was contacted to recruit influenza (flu) coordinators from the various hospital departments to coordinate administration of influenza vaccinations in their respective departments, with the aim of increasing HCW vaccination rates. The flu coordinators received education about the influenza vaccine along with lists of employees, vaccination supplies, and consent/declination forms. Each flu coordinator was responsible for contacting the employees in his or her department/unit. Both consent and declination responses were documented. RESULTS: Of the hospital's 3238 employees (including physicians), a total of 2534 were contacted (78%). Of these, 2008 consented to receive the influenza vaccine and 526 declined. This represented a 37% increase in the total number of HCWs contacted and a 20% increase in vaccine recipients over the previous influenza season. CONCLUSIONS: Partnering with the Nursing Department increased the accessibility to and acceptance of influenza vaccination among HCWs. The HCWs reported positive experiences about receiving the vaccine in the work environment.

Improved health and development of children who are deaf and hard of hearing following early intervention.

Infants begin to learn language in the earliest months of life. In the absence of early identification and intervention, infants who are deaf or hard-of-hearing experience significant and lasting deficits in language learning, academic achievement, social-emotional development, and quality of life. Evidence is mounting that early identification of infants who are deaf or hard of hearing through newborn hearing screening and intervention by the age of 6 months improves developmental outcomes for these children, especially in the area of language proficiency. Newborn screening programmes, including newborn hearing screening, are typically public health activities aimed at the early identification of infants who are affected by certain congenital disorders: including genetic, metabolic, haematologic, and infectious diseases. Early identification of these conditions is critical, as timely intervention can lead to a significant reduction of morbidity, mortality and associated disabilities in affected infants. For infants with hearing loss, the goal of early identification is to provide early intervention leading to language development and academic achievement commensurate with cognitive ability, and ultimately an improved quality of life. For newborn hearing screening, the definition of early intervention is initiation of intervention by the age of 6 months. Initiatives for newborn hearing screening have spread to every continent and many countries now have well-developed, comprehensive programmes of screening, diagnosis, and early intervention for childhood hearing loss. Although no exact statistics currently exist, tens of millions of infants probably receive newborn hearing screening each year. Because the developmental effects of early intervention for hearing loss are improved and sustained language development, large-scale studies documenting the language outcomes in early-identified children take decades to collect. Furthermore, because full-scale implementation of universal newborn hearing screening has occurred only within the last 5 years in most countries, many early-identified children are still at preschool-age. Thus, documenting these youngsters' language development is a work in progress. Despite these limitations, evidence is mounting that early intervention for childhood hearing loss improves the developmental outcome of these children.

Screening methods: current status.

Two technologies are currently used to screen newborn infants for hearing, auditory brainstem response (ABR), and otoacoustic emissions (OAEs). Each technology is based on detecting the infant's physiologic response to auditory stimulation. ABR is a short-latency auditory evoked response originating from eighth nerve and brainstem auditory pathway structures and detected by scalp surface electrodes. OAEs are auditory signals generated by cochlear outer hair cells in response to acoustic stimulation and detected by a miniature microphone coupled to the infant's ear. Although each technique requires specific sound generation and response recording technologies, advances in computerized stimulus delivery and response detection algorithms allow these tests to be performed by trained technicians or volunteers under the supervision of an audiologist. Results of test performance, and the advantages and disadvantages of each technique are described.