CI decision making and expectations by older adults.

OBJECTIVE: To document and analyze the cochlear implant (CI) decision-making process of hearing-impaired older adults. The aim of this study is to assess what support could be helpful during this process in order to improve care delivery. METHODS: 32 older adult CI recipients (≥ 60 years) with severe to profound sensorineural hearing loss were interviewed about their CI decision-making process 3-12 months after obtaining their first CI. RESULTS: Minimal information was provided to CI candidates by hearing aid acousticians or patient associations. High to very high expectations were reported by patients concerning issues beyond hearing improvement per se. Even though not all expectations were fulfilled by the CI, nearly all recipients who used an implant for at least six months would recommend a CI to others. DISCUSSION: We identified an opportunity for those professionals to play a greater role in supporting older CI candidates during the decision-making process. It is desirable to establish a comprehensive network of hearing care professionals to collaborate with CI clinics. CONCLUSION: In order to support older patients adequately in deciding about CI, intensive training should be offered to hearing care professionals in order to provide realistic expectations and reduce fear and uncertainty about the implantation process. These topics need to be communicated in a professional manner and adapted to the candidate's age and personality.

Opportunities for primary and secondary prevention of excess gestational weight gain: General Practitioners' perspectives.

BACKGROUND: The impact of excess gestational weight gain (GWG) on maternal and child health outcomes is well documented. Understanding how health care providers view and manage GWG may assist with influencing healthy gestational weight outcomes. This study aimed to assess General Practitioner's (GPs) perspectives regarding the management and assessment of GWG and to understand how GPs can be best supported to provide healthy GWG advice to pregnant women. METHODS: Descriptive qualitative research methods utilising semi - structured interview questions to assess GPs perspectives and management of GWG. GPs participating in shared antenatal care in Geelong, Victoria and Sydney, New South Wales were invited to participate in semi - structured, individual interviews via telephone or in person. Interviews were digitally recorded and transcribed verbatim. Data was analysed utilising thematic analysis for common emerging themes. RESULTS: Twenty eight GPs participated, 14 from each state. Common themes emerged relating to awareness of the implications of excess GWG, advice regarding weight gain, regularity of gestational weighing by GPs, options for GPs to seek support to provide healthy lifestyle behaviour advice and barriers to engaging pregnant women about their weight. GPs perspectives concerning excess GWG were varied. They frequently acknowledged maternal and child health complications resulting from excess GWG yet weighing practices and GWG advice appeared to be inconsistent. The preferred support option to promote healthy weight was referral to allied health practitioners yet GPs noted that cost and limited access were barriers to achieving this. CONCLUSIONS: GPs were aware of the importance of healthy GWG yet routine weighing was not standard practice for diverse reasons. Management of GWG and perspectives of the issue varied widely. Time efficient and cost effective interventions may assist GPs in ensuring women are supported in achieving healthy GWG to provide optimal maternal and infant health outcomes.

Introducing real-life listening features into the clinical test environment: Part I: Measuring the hearing performance and evaluating the listening effort of individuals with normal hearing.

OBJECTIVE: Controlled clinical test environments are very different from real-life listening situations in which speaker and background noise level variations can hinder a person's ability to hear and follow conversations. This study was performed to evaluate the ability of people with normal hearing to follow a single speaker in the presence of background noise, and to explore relations between those measures and the listeners' subjective assessments, listening effort, and sound quality judgements. METHODS: A group of adults with normal hearing were evaluated using the following battery of tests: (i) Roving Level Test, (ii) the Just Understanding Speech Test, (iii) Performance Perceptual Test, (iv) the Visual Analogue Scale to evaluate listening effort, and (iv) with a sound quality questionnaire. RESULTS: The results show that people with normal hearing tend to accurately estimate their hearing abilities, and both the listening effort required and speech recognition thresholds tend to increase with increasing background noise. DISCUSSION: Implementing a battery of tests that evaluate speech-in-noise listening abilities, listening effort, and subjective hearing perception might provide greater insight into hearing performance than traditional measures. Additionally, the data generated in this study can be used for comparison with measures obtained from hearing impaired and hearing device listeners, and as such, has the potential to guide counselling and rehabilitation to a range of clinical populations. CONCLUSION: The examination of both the self-estimated and verified performance measurements in simulated real-life listening situations can provide audiologists with a comprehensive and realistic profile of a person's hearing performance.

Individual Variations in Effort: Assessing Pupillometry for the Hearing Impaired.

Assessing effort in speech comprehension for hearing-impaired (HI) listeners is important, as effortful processing of speech can limit their hearing rehabilitation. We examined the measure of pupil dilation in its capacity to accommodate the heterogeneity that is present within clinical populations by studying lexical access in users with sensorineural hearing loss, who perceive speech via cochlear implants (CIs). We compared the pupillary responses of 15 experienced CI users and 14 age-matched normal-hearing (NH) controls during auditory lexical decision. A growth curve analysis was applied to compare the responses between the groups. NH listeners showed a coherent pattern of pupil dilation that reflects the task demands of the experimental manipulation and a homogenous time course of dilation. CI listeners showed more variability in the morphology of pupil dilation curves, potentially reflecting variable sources of effort across individuals. In follow-up analyses, we examined how speech perception, a task that relies on multiple stages of perceptual analyses, poses multiple sources of increased effort for HI listeners, wherefore we might not be measuring the same source of effort for HI as for NH listeners. We argue that interindividual variability among HI listeners can be clinically meaningful in attesting not only the magnitude but also the locus of increased effort. The understanding of individual variations in effort requires experimental paradigms that (a) differentiate the task demands during speech comprehension, (b) capture pupil dilation in its time course per individual listeners, and (c) investigate the range of individual variability present within clinical and NH populations.

Evaluation of clinical quality improvement interventions: feasibility of an integrated approach.

BACKGROUND: Cardiovascular diseases (CVD) are the largest cause of death and disability in Australia. Australian national guidelines for the primary prevention of CVD recommend that all adults without CVD and aged 45 years or more are screened for their absolute risk of CVD every 2 years. Despite the compelling evidence to address CVD risk, treatment gaps remain and evidence suggests that much of the shortcomings are attributed to the performance of primary care practices. To address this issue, a quality improvement initiative is being implemented in a large urban multidisciplinary primary care practice in the South West region of Victoria, Australia. The key outcome of this intervention will be to increase the use and acceptability of CVD risk assessment guidelines. To ensure the intervention is tracking toward its objectives, a robust monitoring and evaluation framework was established. METHOD/DESIGN: A novel framework that assimilates key traditional and theory-driven evaluation practices was developed to assess the impact of the intervention. The framework approach is termed the integrated model of evaluation (IMoE). Researchers and stakeholders convened several times to discuss and develop the evaluation protocol and align it with the quality intervention. The main objective here is to explore the feasibility of an integrated approach to evaluating clinical quality improvement interventions. The sub-objectives are to test the alignment of the IMoE to clinical quality improvement projects and its ability to derive findings to the satisfaction of stakeholders. The design and establishment of the evaluation approach is discussed in further detail in this article. DISCUSSION: The novel feature of the IMoE is its emphasis on tracking 'change' in practices that lead to quality improvement. This emphasis suits the quality improvement theme of this initiative as identification of change elements and explanation behind change is necessary to sustain and promote quality improvement. The other principle behind development of this model, which emphasises practicality in implementation, is to ensure stakeholders gain greatest value from the commissioning of program evaluation. By incorporating practical components and leaving out esoteric concepts, this approach ensures evaluation can be undertaken in realistic timeframes. ETHICS APPROVAL: The quality improvement intervention and evaluation framework received approval from the Deakin University Human Research Ethics Committee (Approval Number: 2017-313).

Effects of electrode design and configuration on channel interactions.

A potential shortcoming of existing multichannel cochlear implants is electrical-field summation during simultaneous electrode stimulation. Electrical-field interactions can disrupt the stimulus waveform prior to neural activation. To test whether speech intelligibility can be degraded by electrical-field interaction, speech recognition performance and interaction were examined for three Clarion electrode arrays: the pre-curved, enhanced bipolar electrode array, the enhanced bipolar electrode with an electrode positioner, and the Hi-Focus electrode with a positioner. Channel interaction was measured by comparing stimulus detection thresholds for a probe signal in the presence of a sub-threshold perturbation signal as a function of the separation between the two simultaneously stimulated electrodes. Correct identification of vowels, consonants, and words in sentences was measured with two speech strategies: one which used simultaneous stimulation and another which used sequential stimulation. Speech recognition scores were correlated with measured electrical-field interaction for the strategy which used simultaneous stimulation but not the strategy which used sequential stimulation. Higher speech recognition scores with the simultaneous strategy were generally associated with lower levels of electrical-field interaction. Electrical-field interaction accounted for as much as 70% of the variance in speech recognition scores, suggesting that electrical-field interaction is a significant contributor to the variability found across patients who use simultaneous strategies.

Modulation detection interference in listeners with normal and impaired hearing.

Listeners were asked to detect amplitude modulation (AM) of a target (or signal) carrier that was presented in isolation or in the presence of an additional (masker) carrier. The signal was modulated at a rate of 10 Hz, and the masker was unmodulated or was modulated at a rate of 2, 10, or 40 Hz. Nine listeners had normal hearing, 4 had a bilateral hearing loss, and 4 had a unilateral hearing loss; those with a unilateral loss were tested in both ears. The listeners with a hearing loss had normal hearing at 1 kHz and a 30- to 40-dB loss at 4 kHz. The carrier frequencies were 984 and 3952 Hz. In one set of conditions, the lower frequency carrier was the signal and the higher frequency carrier was the masker. In the other set, the reverse was true. For the impaired ears, the carriers were presented at 70 dB SPL. For the normal ears, either the carriers were both presented at 70 dB SPL or the higher frequency carrier was reduced to 40 dB SPL to simulate the lower sensation level experienced by the impaired ears. There was considerable individual variability in the results, and there was no clear effect of hearing loss. These results suggest that a mild, presumably cochlear hearing loss does not affect the ability to process AM in one frequency region in the presence of competing AM from another region.

Speech dynamic range and its effect on cochlear implant performance.

This study examines optimal conversions of speech sounds to audible electric currents in cochlear-implant listeners. The speech dynamic range was measured for 20 consonants and 12 vowels spoken by five female and five male talkers. Even when the maximal root-mean-square (rms) level was normalized for all phoneme tokens, both broadband and narrow-band acoustic analyses showed an approximately 50-dB distribution of speech envelope levels. Phoneme recognition was also obtained in ten CLARION implant users as a function of the input dynamic range from 10 to 80 dB in 10-dB steps. Acoustic amplitudes within a specified input dynamic range were logarithmically mapped into the 10-20-dB range of electric stimulation typically found in cochlear-implant users. Consistent with acoustic data, the perceptual data showed that a 50-60-dB input dynamic range produced optimal speech recognition in these implant users. The present results indicate that speech dynamic range is much greater than the commonly assumed 30-dB range. A new amplitude mapping strategy, based on envelope distribution differences between consonants and vowels, is proposed to optimize acoustic-to-electric mapping of speech sounds. This new strategy will use a logarithmic map for low-frequency channels and a more compressive map for high-frequency channels, and may improve overall speech recognition for cochlear-implant users.