Audiology by Alexandros G. Sfakianakis: 01/04/17

A computational model of cat auditory nerve fiber (ANF) responses to electrical stimulation is presented. The model assumes that (1) there exist at least two sites of spike generation along the ANF and (2) both an anodic (positive) and a cathodic (negative) charge in isolation can evoke a spike. A single ANF is modeled as a network of two exponential integrate-and-fire point-neuron models, referred to as peripheral and central axons of the ANF. The peripheral axon is excited by the cathodic charge, inhibited by the anodic charge, and exhibits longer spike latencies than the central axon; the central axon is excited by the anodic charge, inhibited by the cathodic charge, and exhibits shorter spike latencies than the peripheral axon. The model also includes subthreshold and suprathreshold adaptive feedback loops which continuously modify the membrane potential and can account for effects of facilitation, accommodation, refractoriness, and spike-rate adaptation in ANF. Although the model is parameterized using data for either single or paired pulse stimulation with monophasic rectangular pulses, it correctly predicts effects of various stimulus pulse shapes, stimulation pulse rates, and level on the neural response statistics. The model may serve as a framework to explore the effects of different stimulus parameters on psychophysical performance measured in cochlear implant listeners.

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Synthesizing Information From Language Samples and Standardized Tests in School-Age Bilingual Assessment

Purpose

Although language samples and standardized tests are regularly used in assessment, few studies provide clinical guidance on how to synthesize information from these testing tools. This study extends previous work on the relations between tests and language samples to a new population—school-age bilingual speakers with primary language impairment—and considers the clinical implications for bilingual assessment.

Method

Fifty-one bilingual children with primary language impairment completed narrative language samples and standardized language tests in English and Spanish. Children were separated into younger (ages 5;6 [years;months]–8;11) and older (ages 9;0–11;2) groups. Analysis included correlations with age and partial correlations between language sample measures and test scores in each language.

Results

Within the younger group, positive correlations with large effect sizes indicated convergence between test scores and microstructural language sample measures in both Spanish and English. There were minimal correlations in the older group for either language. Age related to English but not Spanish measures.

Conclusions

Tests and language samples complement each other in assessment. Wordless picture-book narratives may be more appropriate for ages 5–8 than for older children. We discuss clinical implications, including a case example of a bilingual child with primary language impairment, to illustrate how to synthesize information from these tools in assessment.

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Synthesizing Information From Language Samples and Standardized Tests in School-Age Bilingual Assessment

Purpose

Method

Results

Conclusions

Synthesizing Information From Language Samples and Standardized Tests in School-Age Bilingual Assessment

Purpose

Method

Results

Conclusions

Tests and language samples complement each other in assessment. Wordless picture-book narratives may be more appropriate for ages 5–8 than for older children. We discuss clinical implications, including a case example of a bilingual child with primary language impairment, to illustrate how to synthesize information from these tools in assessment.

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Old News, Still Fizzy

The joy of finishing a year and starting a new one was once symbolized by the taking down of the old wall calendar and the hanging of the new one. There still are the walls, but calendars have a new home on our computers, phones, and watches. Luckily one other tradition that marks this completion of yet another collective ellipse around the sun is still alive and well. We will still hear the pop and the fizz at many a celebration in these coming days. Pop, we will deal with another time. Let’s talk about the fizz today.

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Anemia and hearing loss: Is there a link?

Evidence is mounting of a relationship between iron deficiency anemia and hearing loss. New research takes a fresh look and bolsters the connection.

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Anemia and hearing loss: Is there a link?

Evidence is mounting of a relationship between iron deficiency anemia and hearing loss. New research takes a fresh look and bolsters the connection.

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Anemia and hearing loss: Is there a link?

Recurrent Ataxia in Children and Adolescents.

Recurrent Ataxia in Children and Adolescents.

Can J Neurol Sci. 2017 Jan 03;:1-9

Authors: Salman MS, Klassen SF, Johnston JL

Abstract
BACKGROUND: Recurrent ataxia is encountered infrequently in clinical pediatric neurology practise and presents with diagnostic challenges. It is caused by several disorders. Our aims were to describe the epidemiology and clinical features in children with recurrent ataxia.
MATERIALS AND METHODS: A retrospective review was undertaken in 185 children with chronic ataxia, who presented during 1991 to 2008. Several databases were searched to ensure optimum ascertainment. Patients with brain tumors or isolated disorders of the peripheral nerves or vestibular system were excluded.
RESULTS: Recurrent ataxia was reported in 21 patients. Their age range was between 6 and 32.75 years (males=12). The crude period prevalence rate for the 18-year study period was 7.44/100,000. Eight patients had episodic ataxia and seven had inflammatory and metabolic disorders. In the rest the etiology was unknown. Many patients presented with ataxia, dizziness, and vertigo. The frequency and duration of the ataxic episodes varied from several per day to one every few months. Other clinical features included developmental delay and seizures. Neuroimaging in episodic ataxia was normal and abnormal in inflammatory or metabolic disorders. Acetazolamide provided symptomatic relief in patients with episodic ataxia, while steroids were beneficial in patients with an inflammatory etiology. One child with a metabolic disorder died.
CONCLUSIONS: Recurrent ataxia is an uncommon presentation in children and mortality is rare. Genetic, metabolic, and inflammatory disorders should be considered in these patients. Neuroimaging is essential. Acetazolamide in selected patients provides good symptomatic relief.

PMID: 28043238 [PubMed - as supplied by publisher]

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A Retrospective Multicentre Cohort Review of Patient Characteristics and Surgical Aspects versus the Long-Term Outcomes for Recipients of a Fully Implantable Active Middle Ear Implant

Objective: To summarise treatment outcomes compared to surgical and patient variables for a multicentre recipient cohort using a fully implantable active middle ear implant for hearing impairment. To describe the authors' preferred surgical technique to determine microphone placement. Study Design: Multicentre retrospective, observational survey. Setting: Five tertiary referral centres. Patients: Carina recipients (66 ears, 62 subjects) using the current Cochlear® Carina® System or the legacy device, the Otologics® Fully Implantable Middle Ear, with a T2 transducer. Methods: Patient file review and routine clinical review. Patient outcomes assessed were satisfaction, daily use and feedback reports at the first fitting and ≥12 months after implantation. Descriptive and statistical analysis of correlations of variables and their influence on outcomes was performed. Independently reported preferred methods for microphone placement are collectively summarised. Results: The average implant experience was 3.5 years. Satisfaction increased significantly over time (p p p Conclusion: Carina recipients in this study present as satisfied consistent daily users with very few reports of persistent feedback. As microphone location is an influencing factor, a careful surgical consideration of microphone placement is required. The authors prefer a posterior inferior mastoid line position whenever possible.
Audiol Neurotol 2016;21:333-345

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Rehabilitation of treated TB patients: Social, psychological and economic aspects.

Rehabilitation of treated TB patients: Social, psychological and economic aspects.

Int J Mycobacteriol. 2016 Dec;5 Suppl 1:S129-S130

Authors: Kumar BA

Abstract
AIM AND OBJECTIVE: To highlight the need for post-treatment rehabilitation of TB patient; including social psychological and economic aspects.
METHODS: Patient interaction, informal interviews, field observations and secondary research. The minimum duration of treatment (for drug-susceptible TB) is 6months. Treatment for drug-resistant TB can be from anywhere between 18 and 24months. In some cases treatment can last for more than 5years. Despite this, little attention is given to the social, psychological and economic impact extended treatment can have on the lives of individuals. Due, to a large extent, to the high levels of stigma that continue to exist in many high-burden countries, people affected must face obstacles even before diagnosis. These challenges persist at every stage of the treatment process (diagnosis, accessing appropriate care, treatment and post-treatment), but impact the individual's lives in various ways. Research has shown that despite diagnosis and treatment being provided for free, most individuals have to face high out-of-pocket expenditure (on transport, additional medication, nutritional supplementation etc.). In many countries, these expenses often have a significant negative impact on family finances. In most national programs, pre-treatment counselling is not included. This means that those affected are not prepared for the implications (in terms of time, money and physiological effects) that their treatment can have.
RESULTS: The side effects of TB medication (especially DR-TB) are sometimes extreme, and require extensive therapy and/or rehabilitation. Some side effects such as hearing-loss are often permanent. Nutritional support is another key factor that receives little attention in national programs. Adding to all these physiological challenges is the constant stigma and discrimination that individuals face from friends, family and even healthcare workers. Returning to jobs or to their education is a challenge as many workplaces and educational institutions do not provide for extended periods of leave or absence. This is costly both in terms of time and money. In families where the primary "bread winner" needs to undergo intensive treatment, the reduced income can have a devastating effect.
CONCLUSION: Therefore despite having completed treatment, many people continue to suffer. Hence it is necessary that robust systems for post-treatment rehabilitation are put in place, and are designed based on the needs of those affected. Peer to peer counselling can be a low-cost high-impact strategy to address some of these issues. Institutional provisions, under the national response in each country, must be put in place if individuals are to successfully complete treatment, and return to their normal lives.

PMID: 28043504 [PubMed]

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Dental issues in lacrimo-auriculo-dento-digital syndrome: An autosomal dominant condition with clinical and genetic variability.

Dental issues in lacrimo-auriculo-dento-digital syndrome: An autosomal dominant condition with clinical and genetic variability.

J Am Dent Assoc. 2016 Dec 30;:

Authors: Hajianpour MJ, Bombei H, Lieberman SM, Revell R, Krishna R, Gregorsok R, Kao S, Milunsky JM

Abstract
BACKGROUND AND OVERVIEW: Lacrimo-auriculo-dento-digital (LADD) syndrome is an autosomal dominant disorder with variable lacrimal and salivary gland hypoplasia and aplasia, auricular anomalies and hearing loss, dental defects and caries, and digital anomalies.
CASE DESCRIPTION: The authors present the cases of 2 unrelated children with enamel defects and history of dry mouth leading to recurrent dental caries. The referring diagnoses were Sjögren disease and hypohidrotic ectodermal dysplasia, respectively. The geneticist suspected LADD syndrome, which was confirmed by means of molecular studies showing mutations of 2 genes: fibroblast growth factor receptor 2 and fibroblast growth factor 10, respectively. Similarly affected relatives indicated an autosomal dominant inheritance. These relatives needed multiple dental rehabilitations during childhood and dentures in adulthood.
CONCLUSIONS AND PRACTICAL IMPLICATIONS: Dry mouth, multiple caries, enamel defects, and abnormal tooth morphology were the reasons for seeking care from dentists. However, clinical evaluation and diagnostic imaging studies helped identify anomalies of the lacrimal and salivary glands, ears, and digits, indicating involvement of different areas of the body, compatible with LADD syndrome. Accordingly, dentists should consider genetic disorders in patients with multiple anomalies. For instance, oculodentodigital syndrome, oral-facial-digital syndrome, and LADD syndrome (among others) may have dental issues as the major clinical manifestation. Accurate identification of a particular syndrome is now commonplace with the use of genetic testing. When a patient has multiple anomalies suggestive of a syndromic condition, appropriate genetic testing can help verify the clinical diagnosis. Keeping genetics in mind helps earlier identification of other affected family members with diagnostic genetic testing and appropriate treatment; the economic advantage is to shorten the diagnostic odyssey and possibly preserve dentition.

PMID: 28043400 [PubMed - as supplied by publisher]

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Resonance Tube or Lax Vox?

Publication date: Available online 3 January 2017
Source:Journal of Voice
Author(s): Jaana Tyrmi, Vojtěch Radolf, Jaromír Horáček, Anne-Maria Laukkanen
ObjectiveThis study compares the flow resistance of Resonance tube (RT) and Lax Vox tube (LVT) when submerged 2 cm and 10 cm in water, as well as phonation into the tubes in these conditions.MethodsIn the in vitro experiment, the air pressure for flow rates of 60–600 mL/s was measured at the tube inlet, when the outer end of the tube was submerged 2 cm and 10 cm below water surface in 30°, 45°, and 90° angle. In the in vivo experiment, 14 subjects phonated in habitual loudness and loudly into both tubes, with the outer end 2 cm and 10 cm in water. RT was immersed in a 45° angle and LVT in a 90° angle in water. Oral pressure, contact quotient from electroglottographic signal, and sound pressure level were studied. Sensations during phonation were reported in an interview.ResultsFlow resistance was slightly lower with LVT than with RT, and slightly lower for smaller immersion angles. In habitual loudness, transglottic pressure and frequency of oral pressure variation were lower for LVT phonation and amplitude of oral pressure variation was higher for LVT 2 cm in water. Some subjects preferred RT, whereas others preferred LVT or reported no differences between them.ConclusionsThe tubes differed slightly in flow resistance. Higher oral pressure oscillation with LVT 2 cm in water may offer stronger massage effect on vocal folds.

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Association Between Facial Length and Width and Fundamental Frequency

Publication date: Available online 3 January 2017
Source:Journal of Voice
Author(s): Anthony T. Macari, Ingrid A. Karam, Georges Ziade, Dollen Tabri, Doja Sarieddine, Elie S. Alam, Abdul-Latif Hamdan
ObjectiveThis study aimed to evaluate the association between facial width and length and fundamental frequency (F0) and habitual frequency.Study designProspective cross-sectional study.SubjectsA total of 50 subjects (35 females;15 males) were included in this study.MethodsLateral and posteroanterior cephalometric measurements included: facial height (N–Me); widths of the maxilla (J–J), mandible (AG–AG), and face (Zyg–Zyg); ratios J–J to AG–AG, N–Me to Zyg–Zyg, and lower face to total face heights. All subjects underwent acoustic analysis using Visi-Pitch IV. Sample was stratified according to age and gender.ResultsIn the total group (mean age: 14.19±6.49 years; range 6-35 years), a significantly moderate negative correlation existed between Zyg–Zyg, J–J, and AG–AG, and F0 and habitual pitch. Similarly, N-Me moderately correlated with habitual pitch. In males, there was a significant moderate negative correlation between Zyg–Zyg and J–J, and habitual pitch, and between J–J and F0 (−0.571;p=0.026). In females, a significant moderate correlation existed between Zyg–Zyg and AG–AG, and habitual pitch, and between AG–AG and F0 (−0.347;p=0.041). In the prepubertal group (n=25), a negative moderate correlation occurred between J–J and AG–AG, N–Me and habitual frequency, and between J–J and F0 (−0.407;p=0.043). In the postpubertal group, there was a significant moderate correlation only between AG–AG and F0 (−0.403;p=0.046).ConclusionFacial length correlates significantly with habitual frequency, and facial width correlates significantly with both F0 and habitual pitch. A larger sample of adult subjects is needed to substantiate this conclusion.

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Local stability and kinematic variability in walking and pole walking at different speeds

Publication date: March 2017
Source:Gait & Posture, Volume 53
Author(s): Luca Zoffoli, Massimiliano Ditroilo, Ario Federici, Francesco Lucertini
This study investigated the kinematic variability and the local stability of walking and pole walking using two tri-axial accelerometers placed on the seventh cervical (C7) and the second sacral (S2) vertebrae of twenty-one adults. Each participant performed three 1-min trials of walking and pole walking on a motorized treadmill (60, 80, 100% of the preferred walk-to-run transition speed). Forty strides per trial were used to calculate, in all directions of C7 and S2, the median of the stride-to-stride median absolute deviation (medMAD) and the local divergence exponent (λ). Generalised estimating equations and pairwise contrasts revealed, during pole walking, a higher medMAD (all directions, most speeds, C7 level only), and a lower λ (all directions, all speeds, both C7 and S2 level). As speed increased, so did medMAD (all directions, both walking with or without poles), with higher values at C7 compared to S2 level. A similar effect was observed for λ in the vertical direction (walking and pole walking), and in the anterior-posterior direction (only pole walking). An increase in speed brought about a λ reduction in the medial-lateral direction (C7 level only), especially during walking. Finally, both medMAD and λ were higher at C7 than S2 level (all directions, both walking and pole walking) except for λ in the anterior-posterior direction, which resulted higher in walking (C7 level only).In conclusion, despite a higher kinematic variability, pole walking appears to be more locally stable than walking at any speed, especially at C7 level.

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The effect of weight-bearing asymmetry on dynamic postural stability in people with chronic stroke

Publication date: March 2017
Source:Gait & Posture, Volume 53
Author(s): Digna de Kam, Jip. F. Kamphuis, Vivian Weerdesteyn, Alexander C.H. Geurts
After stroke, weight-bearing asymmetry (WBA) towards the non-paretic side is associated with postural instability. It remains unknown whether WBA is a cause or consequence of postural instability, as both phenomena depend on stroke severity. We investigated the effect of WBA on the ability to recover from balance perturbations in people with stroke. Fourteen people in the chronic phase of stroke underwent multidirectional translational perturbations at three levels of initial WBA (0, 10 and 20% of body weight unloading of the paretic leg). We iteratively determined the highest perturbation intensity that could be sustained with a feet-in-place response (i.e. stepping threshold) for each WBA condition and in four perturbation directions (forward, backward, towards paretic and towards non-paretic side). For perturbations above the stepping threshold we determined the choice of stepping leg. WBA increased the stepping threshold for perturbations towards the paretic side, whereas it decreased the stepping threshold for perturbations towards the non-paretic side (p<0.05). No effects of WBA were found on forward or backward stepping thresholds. Yet, the frequency of stepping with the paretic leg in the anteroposterior directions increased with greater WBA. Similarly, greater initial WBA resulted in a larger number of side steps towards the paretic side. In conclusion, the results suggest that people with stroke can benefit from some paretic leg unloading when perturbed towards the paretic side. It remains to be investigated, however, to what extent these benefits outweigh the potentially detrimental effects of WBA that were observed when recovering from perturbations in the other directions.

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Local stability and kinematic variability in walking and pole walking at different speeds

The effect of weight-bearing asymmetry on dynamic postural stability in people with chronic stroke

Local stability and kinematic variability in walking and pole walking at different speeds

Publication date: March 2017
Source:Gait & Posture, Volume 53
Author(s): Luca Zoffoli, Massimiliano Ditroilo, Ario Federici, Francesco Lucertini
This study investigated the kinematic variability and the local stability of walking and pole walking using two tri-axial accelerometers placed on the seventh cervical (C7) and the second sacral (S2) vertebrae of twenty-one adults. Each participant performed three 1-min trials of walking and pole walking on a motorized treadmill (60, 80, 100% of the preferred walk-to-run transition speed). Forty strides per trial were used to calculate, in all directions of C7 and S2, the median of the stride-to-stride median absolute deviation (medMAD) and the local divergence exponent (λ). Generalised estimating equations and pairwise contrasts revealed, during pole walking, a higher medMAD (all directions, most speeds, C7 level only), and a lower λ (all directions, all speeds, both C7 and S2 level). As speed increased, so did medMAD (all directions, both walking with or without poles), with higher values at C7 compared to S2 level. A similar effect was observed for λ in the vertical direction (walking and pole walking), and in the anterior-posterior direction (only pole walking). An increase in speed brought about a λ reduction in the medial-lateral direction (C7 level only), especially during walking. Finally, both medMAD and λ were higher at C7 than S2 level (all directions, both walking and pole walking) except for λ in the anterior-posterior direction, which resulted higher in walking (C7 level only).In conclusion, despite a higher kinematic variability, pole walking appears to be more locally stable than walking at any speed, especially at C7 level.

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The effect of weight-bearing asymmetry on dynamic postural stability in people with chronic stroke

Publication date: March 2017
Source:Gait & Posture, Volume 53
Author(s): Digna de Kam, Jip. F. Kamphuis, Vivian Weerdesteyn, Alexander C.H. Geurts
After stroke, weight-bearing asymmetry (WBA) towards the non-paretic side is associated with postural instability. It remains unknown whether WBA is a cause or consequence of postural instability, as both phenomena depend on stroke severity. We investigated the effect of WBA on the ability to recover from balance perturbations in people with stroke. Fourteen people in the chronic phase of stroke underwent multidirectional translational perturbations at three levels of initial WBA (0, 10 and 20% of body weight unloading of the paretic leg). We iteratively determined the highest perturbation intensity that could be sustained with a feet-in-place response (i.e. stepping threshold) for each WBA condition and in four perturbation directions (forward, backward, towards paretic and towards non-paretic side). For perturbations above the stepping threshold we determined the choice of stepping leg. WBA increased the stepping threshold for perturbations towards the paretic side, whereas it decreased the stepping threshold for perturbations towards the non-paretic side (p<0.05). No effects of WBA were found on forward or backward stepping thresholds. Yet, the frequency of stepping with the paretic leg in the anteroposterior directions increased with greater WBA. Similarly, greater initial WBA resulted in a larger number of side steps towards the paretic side. In conclusion, the results suggest that people with stroke can benefit from some paretic leg unloading when perturbed towards the paretic side. It remains to be investigated, however, to what extent these benefits outweigh the potentially detrimental effects of WBA that were observed when recovering from perturbations in the other directions.

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Effects of Stimulus Polarity and Artifact Reduction Method on the Electrically Evoked Compound Action Potential.

Objective: Previous research from our laboratory comparing electrically evoked compound action potential (ECAP) artifact reduction methods has shown larger amplitudes and lower thresholds with cathodic-leading forward masking (CathFM) than with alternating polarity (AltPol). One interpretation of this result is that the anodic-leading phase used with AltPol elicits a less excitatory response (in contrast to results from recent studies with humans), which when averaged with responses to cathodic-leading stimuli, results in smaller amplitudes. Another interpretation is that the latencies of the responses to anodic- and cathodic-leading pulses differ, which when averaged together, result in smaller amplitudes than for either polarity alone due to temporal smearing. The purpose of this study was to separate the effects of stimulus polarity and artifact reduction method to determine the relative effects of each. Design: This study used a within-subjects design. ECAP growth functions were obtained using CathFM, anodic-leading forward masking (AnodFM), and AltPol for 23 CI recipients (N = 13 Cochlear and N = 10 Advanced Bionics). N1 latency, amplitude, slope of the amplitude growth function, and threshold were compared across methods. Data were analyzed separately for each manufacturer due to inherent differences between devices. Results: N1 latencies were significantly shorter for AnodFM than for CathFM and AltPol for both Cochlear and Advanced Bionics participants. Amplitudes were larger for AnodFM than for either CathFM or AltPol for Cochlear recipients; amplitude was not significantly different across methods for Advanced Bionics recipients. Slopes were shallowest for CathFM for Cochlear subjects, but were not significantly different among methods for Advanced Bionics subjects. Thresholds with AltPol were significantly higher than both FM methods for Cochlear recipients; there was no difference in threshold across methods for the Advanced Bionics recipients. Conclusions: For Cochlear devices, the smaller amplitudes and higher thresholds observed for AltPol seem to be the result of latency differences between polarities. These results suggest that AltPol is not ideal for managing stimulus artifact for ECAP recordings. For the Advanced Bionics group, there were no significant differences among methods for amplitude, slope, or threshold, which suggests that polarity and artifact reduction method have little influence in these devices. We postulate that polarity effects are minimized for symmetrical biphasic pulses that lack an interphase gap, such as those used with Advanced Bionics devices; however, this requires further investigation. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Prevalence, Incidence Proportion, and Heritability for Tinnitus: A Longitudinal Twin Study.

Objectives: The purpose of this longitudinal twin study was to explore the effect of tinnitus on hearing thresholds and threshold shifts over two decades and to investigate the genetic contribution to tinnitus in a male twin cohort (n = 1114 at baseline and 583 at follow-up). The hypothesis was that participants with faster hearing deterioration had a higher risk for developing tinnitus and there is an underlying role of genetic influences on tinnitus. Design: Male mono- and dizygotic twin pairs, born between 1914 and 1958 were included. Mixed models were used for comparison of hearing threshold shifts, adjusted for age. A co-twin comparison was made within pairs discordant for tinnitus. The relative influence of genetic and environmental factors was estimated by genetic modeling. Results: The overall prevalence of tinnitus was 13.5% at baseline (x age 50) and 34.4% at follow-up (x age 67). The overall incidence proportion was 27.8%. Participants who reported tinnitus at baseline or at both time points were older. At baseline, the hearing thresholds differed between tinnitus cases and controls at all frequencies. New tinnitus cases at follow-up had the greatest hearing threshold shift at the high-frequency area compared with the control group. Within pairs, the tinnitus twin had poorer hearing than his unaffected co-twin, more so for dizygotic than monozygotic twin pairs. The relative proportion of additive genetic factors was approximately 0.40 at both time points, and the influence of individual-specific environment was 0.56 to 0.61. The influence of genetic factors on tinnitus was largely independent of genetic factors for hearing thresholds. Conclusions: Our hypotheses were confirmed: The fastest hearing deterioration occurred for new tinnitus cases. A moderate genetic influence for tinnitus was confirmed. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Effect of Context and Hearing Loss on Time-Gated Word Recognition in Children.

Objectives: The purpose of this study was to examine word recognition in children who are hard of hearing (CHH) and children with normal hearing (CNH) in response to time-gated words presented in high- versus low-predictability sentences (HP, LP), where semantic cues were manipulated. Findings inform our understanding of how CHH combine cognitive-linguistic and acoustic-phonetic cues to support spoken word recognition. It was hypothesized that both groups of children would be able to make use of linguistic cues provided by HP sentences to support word recognition. CHH were expected to require greater acoustic information (more gates) than CNH to correctly identify words in the LP condition. In addition, it was hypothesized that error patterns would differ across groups. Design: Sixteen CHH with mild to moderate hearing loss and 16 age-matched CNH participated (5 to 12 years). Test stimuli included 15 LP and 15 HP age-appropriate sentences. The final word of each sentence was divided into segments and recombined with the sentence frame to create series of sentences in which the final word was progressively longer by the gated increments. Stimuli were presented monaurally through headphones and children were asked to identify the target word at each successive gate. They also were asked to rate their confidence in their word choice using a five- or three-point scale. For CHH, the signals were processed through a hearing aid simulator. Standardized language measures were used to assess the contribution of linguistic skills. Results: Analysis of language measures revealed that the CNH and CHH performed within the average range on language abilities. Both groups correctly recognized a significantly higher percentage of words in the HP condition than in the LP condition. Although CHH performed comparably with CNH in terms of successfully recognizing the majority of words, differences were observed in the amount of acoustic-phonetic information needed to achieve accurate word recognition. CHH needed more gates than CNH to identify words in the LP condition. CNH were significantly lower in rating their confidence in the LP condition than in the HP condition. CHH, however, were not significantly different in confidence between the conditions. Error patterns for incorrect word responses across gates and predictability varied depending on hearing status. Conclusions: The results of this study suggest that CHH with age-appropriate language abilities took advantage of context cues in the HP sentences to guide word recognition in a manner similar to CNH. However, in the LP condition, they required more acoustic information (more gates) than CNH for word recognition. Differences in the structure of incorrect word responses and their nomination patterns across gates for CHH compared with their peers with NH suggest variations in how these groups use limited acoustic information to select word candidates. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Normative Wideband Reflectance, Equivalent Admittance at the Tympanic Membrane, and Acoustic Stapedius Reflex Threshold in Adults.

Objectives: Wideband acoustic immittance (WAI) measures such as pressure reflectance, parameterized by absorbance and group delay, equivalent admittance at the tympanic membrane (TM), and acoustic stapedius reflex threshold (ASRT) describe middle ear function across a wide frequency range, compared with traditional tests employing a single frequency. The objective of this study was to obtain normative data using these tests for a group of normal-hearing adults and investigate test-retest reliability using a longitudinal design. Design: A longitudinal prospective design was used to obtain normative test and retest data on clinical and WAI measures. Subjects were 13 males and 20 females (mean age = 26 years). Inclusion criteria included normal audiometry and clinical immittance. Subjects were tested on two separate visits approximately 1 month apart. Reflectance and equivalent admittance at the TM were measured from 0.25 to 8.0 kHz under three conditions: at ambient pressure in the ear canal and with pressure sweeps from positive to negative pressure (downswept) and negative to positive pressure (upswept). Equivalent admittance at the TM was calculated using admittance measurements at the probe tip that were adjusted using a model of sound transmission in the ear canal and acoustic estimates of ear-canal area and length. Wideband ASRTs were measured at tympanometric peak pressure (TPP) derived from the average TPP of downswept and upswept tympanograms. Descriptive statistics were obtained for all WAI responses, and wideband and clinical ASRTs were compared. Results: Mean absorbance at ambient pressure and TPP demonstrated a broad band-pass pattern typical of previous studies. Test-retest differences were lower for absorbance at TPP for the downswept method compared with ambient pressure at frequencies between 1.0 and 1.26 kHz. Mean tympanometric peak-to-tail differences for absorbance were greatest around 1.0 to 2.0 kHz and similar for positive and negative tails. Mean group delay at ambient pressure and at TPP were greatest between 0.32 and 0.6 kHz at 200 to 300 [mu]sec, reduced at frequencies between 0.8 and 1.5 kHz, and increased above 1.5 kHz to around 150 [mu]sec. Mean equivalent admittance at the TM had a lower level for the ambient method than at TPP for both sweep directions below 1.2 kHz, but the difference between methods was only statistically significant for the comparison between the ambient method and TPP for the upswept tympanogram. Mean equivalent admittance phase was positive at all frequencies. Test-retest reliability of the equivalent admittance level ranged from 1 to 3 dB at frequencies below 1.0 kHz, but increased to 8 to 9 dB at higher frequencies. The mean wideband ASRT for an ipsilateral broadband noise activator was 12 dB lower than the clinical ASRT, but had poorer reliability. Conclusions: Normative data for the WAI test battery revealed minor differences for results at ambient pressure compared with tympanometric methods at TPP for reflectance, group delay, and equivalent admittance level at the TM for subjects with middle ear pressure within +/-100 daPa. Test-retest reliability was better for absorbance at TPP for the downswept tympanogram compared with ambient pressure at frequencies around 1.0 kHz. Large peak-to-tail differences in absorbance combined with good reliability at frequencies between about 0.7 and 3.0 kHz suggest that this may be a sensitive frequency range for interpreting absorbance at TPP. The mean wideband ipsilateral ASRT was lower than the clinical ASRT, consistent with previous studies. Results are promising for the use of a wideband test battery to evaluate middle ear function. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Effects of Stimulus Polarity and Artifact Reduction Method on the Electrically Evoked Compound Action Potential.

Objective: Previous research from our laboratory comparing electrically evoked compound action potential (ECAP) artifact reduction methods has shown larger amplitudes and lower thresholds with cathodic-leading forward masking (CathFM) than with alternating polarity (AltPol). One interpretation of this result is that the anodic-leading phase used with AltPol elicits a less excitatory response (in contrast to results from recent studies with humans), which when averaged with responses to cathodic-leading stimuli, results in smaller amplitudes. Another interpretation is that the latencies of the responses to anodic- and cathodic-leading pulses differ, which when averaged together, result in smaller amplitudes than for either polarity alone due to temporal smearing. The purpose of this study was to separate the effects of stimulus polarity and artifact reduction method to determine the relative effects of each. Design: This study used a within-subjects design. ECAP growth functions were obtained using CathFM, anodic-leading forward masking (AnodFM), and AltPol for 23 CI recipients (N = 13 Cochlear and N = 10 Advanced Bionics). N1 latency, amplitude, slope of the amplitude growth function, and threshold were compared across methods. Data were analyzed separately for each manufacturer due to inherent differences between devices. Results: N1 latencies were significantly shorter for AnodFM than for CathFM and AltPol for both Cochlear and Advanced Bionics participants. Amplitudes were larger for AnodFM than for either CathFM or AltPol for Cochlear recipients; amplitude was not significantly different across methods for Advanced Bionics recipients. Slopes were shallowest for CathFM for Cochlear subjects, but were not significantly different among methods for Advanced Bionics subjects. Thresholds with AltPol were significantly higher than both FM methods for Cochlear recipients; there was no difference in threshold across methods for the Advanced Bionics recipients. Conclusions: For Cochlear devices, the smaller amplitudes and higher thresholds observed for AltPol seem to be the result of latency differences between polarities. These results suggest that AltPol is not ideal for managing stimulus artifact for ECAP recordings. For the Advanced Bionics group, there were no significant differences among methods for amplitude, slope, or threshold, which suggests that polarity and artifact reduction method have little influence in these devices. We postulate that polarity effects are minimized for symmetrical biphasic pulses that lack an interphase gap, such as those used with Advanced Bionics devices; however, this requires further investigation. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Prevalence, Incidence Proportion, and Heritability for Tinnitus: A Longitudinal Twin Study.

Objectives: The purpose of this longitudinal twin study was to explore the effect of tinnitus on hearing thresholds and threshold shifts over two decades and to investigate the genetic contribution to tinnitus in a male twin cohort (n = 1114 at baseline and 583 at follow-up). The hypothesis was that participants with faster hearing deterioration had a higher risk for developing tinnitus and there is an underlying role of genetic influences on tinnitus. Design: Male mono- and dizygotic twin pairs, born between 1914 and 1958 were included. Mixed models were used for comparison of hearing threshold shifts, adjusted for age. A co-twin comparison was made within pairs discordant for tinnitus. The relative influence of genetic and environmental factors was estimated by genetic modeling. Results: The overall prevalence of tinnitus was 13.5% at baseline (x age 50) and 34.4% at follow-up (x age 67). The overall incidence proportion was 27.8%. Participants who reported tinnitus at baseline or at both time points were older. At baseline, the hearing thresholds differed between tinnitus cases and controls at all frequencies. New tinnitus cases at follow-up had the greatest hearing threshold shift at the high-frequency area compared with the control group. Within pairs, the tinnitus twin had poorer hearing than his unaffected co-twin, more so for dizygotic than monozygotic twin pairs. The relative proportion of additive genetic factors was approximately 0.40 at both time points, and the influence of individual-specific environment was 0.56 to 0.61. The influence of genetic factors on tinnitus was largely independent of genetic factors for hearing thresholds. Conclusions: Our hypotheses were confirmed: The fastest hearing deterioration occurred for new tinnitus cases. A moderate genetic influence for tinnitus was confirmed. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Effect of Context and Hearing Loss on Time-Gated Word Recognition in Children.

Objectives: The purpose of this study was to examine word recognition in children who are hard of hearing (CHH) and children with normal hearing (CNH) in response to time-gated words presented in high- versus low-predictability sentences (HP, LP), where semantic cues were manipulated. Findings inform our understanding of how CHH combine cognitive-linguistic and acoustic-phonetic cues to support spoken word recognition. It was hypothesized that both groups of children would be able to make use of linguistic cues provided by HP sentences to support word recognition. CHH were expected to require greater acoustic information (more gates) than CNH to correctly identify words in the LP condition. In addition, it was hypothesized that error patterns would differ across groups. Design: Sixteen CHH with mild to moderate hearing loss and 16 age-matched CNH participated (5 to 12 years). Test stimuli included 15 LP and 15 HP age-appropriate sentences. The final word of each sentence was divided into segments and recombined with the sentence frame to create series of sentences in which the final word was progressively longer by the gated increments. Stimuli were presented monaurally through headphones and children were asked to identify the target word at each successive gate. They also were asked to rate their confidence in their word choice using a five- or three-point scale. For CHH, the signals were processed through a hearing aid simulator. Standardized language measures were used to assess the contribution of linguistic skills. Results: Analysis of language measures revealed that the CNH and CHH performed within the average range on language abilities. Both groups correctly recognized a significantly higher percentage of words in the HP condition than in the LP condition. Although CHH performed comparably with CNH in terms of successfully recognizing the majority of words, differences were observed in the amount of acoustic-phonetic information needed to achieve accurate word recognition. CHH needed more gates than CNH to identify words in the LP condition. CNH were significantly lower in rating their confidence in the LP condition than in the HP condition. CHH, however, were not significantly different in confidence between the conditions. Error patterns for incorrect word responses across gates and predictability varied depending on hearing status. Conclusions: The results of this study suggest that CHH with age-appropriate language abilities took advantage of context cues in the HP sentences to guide word recognition in a manner similar to CNH. However, in the LP condition, they required more acoustic information (more gates) than CNH for word recognition. Differences in the structure of incorrect word responses and their nomination patterns across gates for CHH compared with their peers with NH suggest variations in how these groups use limited acoustic information to select word candidates. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Normative Wideband Reflectance, Equivalent Admittance at the Tympanic Membrane, and Acoustic Stapedius Reflex Threshold in Adults.

Objectives: Wideband acoustic immittance (WAI) measures such as pressure reflectance, parameterized by absorbance and group delay, equivalent admittance at the tympanic membrane (TM), and acoustic stapedius reflex threshold (ASRT) describe middle ear function across a wide frequency range, compared with traditional tests employing a single frequency. The objective of this study was to obtain normative data using these tests for a group of normal-hearing adults and investigate test-retest reliability using a longitudinal design. Design: A longitudinal prospective design was used to obtain normative test and retest data on clinical and WAI measures. Subjects were 13 males and 20 females (mean age = 26 years). Inclusion criteria included normal audiometry and clinical immittance. Subjects were tested on two separate visits approximately 1 month apart. Reflectance and equivalent admittance at the TM were measured from 0.25 to 8.0 kHz under three conditions: at ambient pressure in the ear canal and with pressure sweeps from positive to negative pressure (downswept) and negative to positive pressure (upswept). Equivalent admittance at the TM was calculated using admittance measurements at the probe tip that were adjusted using a model of sound transmission in the ear canal and acoustic estimates of ear-canal area and length. Wideband ASRTs were measured at tympanometric peak pressure (TPP) derived from the average TPP of downswept and upswept tympanograms. Descriptive statistics were obtained for all WAI responses, and wideband and clinical ASRTs were compared. Results: Mean absorbance at ambient pressure and TPP demonstrated a broad band-pass pattern typical of previous studies. Test-retest differences were lower for absorbance at TPP for the downswept method compared with ambient pressure at frequencies between 1.0 and 1.26 kHz. Mean tympanometric peak-to-tail differences for absorbance were greatest around 1.0 to 2.0 kHz and similar for positive and negative tails. Mean group delay at ambient pressure and at TPP were greatest between 0.32 and 0.6 kHz at 200 to 300 [mu]sec, reduced at frequencies between 0.8 and 1.5 kHz, and increased above 1.5 kHz to around 150 [mu]sec. Mean equivalent admittance at the TM had a lower level for the ambient method than at TPP for both sweep directions below 1.2 kHz, but the difference between methods was only statistically significant for the comparison between the ambient method and TPP for the upswept tympanogram. Mean equivalent admittance phase was positive at all frequencies. Test-retest reliability of the equivalent admittance level ranged from 1 to 3 dB at frequencies below 1.0 kHz, but increased to 8 to 9 dB at higher frequencies. The mean wideband ASRT for an ipsilateral broadband noise activator was 12 dB lower than the clinical ASRT, but had poorer reliability. Conclusions: Normative data for the WAI test battery revealed minor differences for results at ambient pressure compared with tympanometric methods at TPP for reflectance, group delay, and equivalent admittance level at the TM for subjects with middle ear pressure within +/-100 daPa. Test-retest reliability was better for absorbance at TPP for the downswept tympanogram compared with ambient pressure at frequencies around 1.0 kHz. Large peak-to-tail differences in absorbance combined with good reliability at frequencies between about 0.7 and 3.0 kHz suggest that this may be a sensitive frequency range for interpreting absorbance at TPP. The mean wideband ipsilateral ASRT was lower than the clinical ASRT, consistent with previous studies. Results are promising for the use of a wideband test battery to evaluate middle ear function. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Effects of Stimulus Polarity and Artifact Reduction Method on the Electrically Evoked Compound Action Potential.

Objective: Previous research from our laboratory comparing electrically evoked compound action potential (ECAP) artifact reduction methods has shown larger amplitudes and lower thresholds with cathodic-leading forward masking (CathFM) than with alternating polarity (AltPol). One interpretation of this result is that the anodic-leading phase used with AltPol elicits a less excitatory response (in contrast to results from recent studies with humans), which when averaged with responses to cathodic-leading stimuli, results in smaller amplitudes. Another interpretation is that the latencies of the responses to anodic- and cathodic-leading pulses differ, which when averaged together, result in smaller amplitudes than for either polarity alone due to temporal smearing. The purpose of this study was to separate the effects of stimulus polarity and artifact reduction method to determine the relative effects of each. Design: This study used a within-subjects design. ECAP growth functions were obtained using CathFM, anodic-leading forward masking (AnodFM), and AltPol for 23 CI recipients (N = 13 Cochlear and N = 10 Advanced Bionics). N1 latency, amplitude, slope of the amplitude growth function, and threshold were compared across methods. Data were analyzed separately for each manufacturer due to inherent differences between devices. Results: N1 latencies were significantly shorter for AnodFM than for CathFM and AltPol for both Cochlear and Advanced Bionics participants. Amplitudes were larger for AnodFM than for either CathFM or AltPol for Cochlear recipients; amplitude was not significantly different across methods for Advanced Bionics recipients. Slopes were shallowest for CathFM for Cochlear subjects, but were not significantly different among methods for Advanced Bionics subjects. Thresholds with AltPol were significantly higher than both FM methods for Cochlear recipients; there was no difference in threshold across methods for the Advanced Bionics recipients. Conclusions: For Cochlear devices, the smaller amplitudes and higher thresholds observed for AltPol seem to be the result of latency differences between polarities. These results suggest that AltPol is not ideal for managing stimulus artifact for ECAP recordings. For the Advanced Bionics group, there were no significant differences among methods for amplitude, slope, or threshold, which suggests that polarity and artifact reduction method have little influence in these devices. We postulate that polarity effects are minimized for symmetrical biphasic pulses that lack an interphase gap, such as those used with Advanced Bionics devices; however, this requires further investigation. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Prevalence, Incidence Proportion, and Heritability for Tinnitus: A Longitudinal Twin Study.

Objectives: The purpose of this longitudinal twin study was to explore the effect of tinnitus on hearing thresholds and threshold shifts over two decades and to investigate the genetic contribution to tinnitus in a male twin cohort (n = 1114 at baseline and 583 at follow-up). The hypothesis was that participants with faster hearing deterioration had a higher risk for developing tinnitus and there is an underlying role of genetic influences on tinnitus. Design: Male mono- and dizygotic twin pairs, born between 1914 and 1958 were included. Mixed models were used for comparison of hearing threshold shifts, adjusted for age. A co-twin comparison was made within pairs discordant for tinnitus. The relative influence of genetic and environmental factors was estimated by genetic modeling. Results: The overall prevalence of tinnitus was 13.5% at baseline (x age 50) and 34.4% at follow-up (x age 67). The overall incidence proportion was 27.8%. Participants who reported tinnitus at baseline or at both time points were older. At baseline, the hearing thresholds differed between tinnitus cases and controls at all frequencies. New tinnitus cases at follow-up had the greatest hearing threshold shift at the high-frequency area compared with the control group. Within pairs, the tinnitus twin had poorer hearing than his unaffected co-twin, more so for dizygotic than monozygotic twin pairs. The relative proportion of additive genetic factors was approximately 0.40 at both time points, and the influence of individual-specific environment was 0.56 to 0.61. The influence of genetic factors on tinnitus was largely independent of genetic factors for hearing thresholds. Conclusions: Our hypotheses were confirmed: The fastest hearing deterioration occurred for new tinnitus cases. A moderate genetic influence for tinnitus was confirmed. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Effect of Context and Hearing Loss on Time-Gated Word Recognition in Children.

Objectives: The purpose of this study was to examine word recognition in children who are hard of hearing (CHH) and children with normal hearing (CNH) in response to time-gated words presented in high- versus low-predictability sentences (HP, LP), where semantic cues were manipulated. Findings inform our understanding of how CHH combine cognitive-linguistic and acoustic-phonetic cues to support spoken word recognition. It was hypothesized that both groups of children would be able to make use of linguistic cues provided by HP sentences to support word recognition. CHH were expected to require greater acoustic information (more gates) than CNH to correctly identify words in the LP condition. In addition, it was hypothesized that error patterns would differ across groups. Design: Sixteen CHH with mild to moderate hearing loss and 16 age-matched CNH participated (5 to 12 years). Test stimuli included 15 LP and 15 HP age-appropriate sentences. The final word of each sentence was divided into segments and recombined with the sentence frame to create series of sentences in which the final word was progressively longer by the gated increments. Stimuli were presented monaurally through headphones and children were asked to identify the target word at each successive gate. They also were asked to rate their confidence in their word choice using a five- or three-point scale. For CHH, the signals were processed through a hearing aid simulator. Standardized language measures were used to assess the contribution of linguistic skills. Results: Analysis of language measures revealed that the CNH and CHH performed within the average range on language abilities. Both groups correctly recognized a significantly higher percentage of words in the HP condition than in the LP condition. Although CHH performed comparably with CNH in terms of successfully recognizing the majority of words, differences were observed in the amount of acoustic-phonetic information needed to achieve accurate word recognition. CHH needed more gates than CNH to identify words in the LP condition. CNH were significantly lower in rating their confidence in the LP condition than in the HP condition. CHH, however, were not significantly different in confidence between the conditions. Error patterns for incorrect word responses across gates and predictability varied depending on hearing status. Conclusions: The results of this study suggest that CHH with age-appropriate language abilities took advantage of context cues in the HP sentences to guide word recognition in a manner similar to CNH. However, in the LP condition, they required more acoustic information (more gates) than CNH for word recognition. Differences in the structure of incorrect word responses and their nomination patterns across gates for CHH compared with their peers with NH suggest variations in how these groups use limited acoustic information to select word candidates. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Normative Wideband Reflectance, Equivalent Admittance at the Tympanic Membrane, and Acoustic Stapedius Reflex Threshold in Adults.

Objectives: Wideband acoustic immittance (WAI) measures such as pressure reflectance, parameterized by absorbance and group delay, equivalent admittance at the tympanic membrane (TM), and acoustic stapedius reflex threshold (ASRT) describe middle ear function across a wide frequency range, compared with traditional tests employing a single frequency. The objective of this study was to obtain normative data using these tests for a group of normal-hearing adults and investigate test-retest reliability using a longitudinal design. Design: A longitudinal prospective design was used to obtain normative test and retest data on clinical and WAI measures. Subjects were 13 males and 20 females (mean age = 26 years). Inclusion criteria included normal audiometry and clinical immittance. Subjects were tested on two separate visits approximately 1 month apart. Reflectance and equivalent admittance at the TM were measured from 0.25 to 8.0 kHz under three conditions: at ambient pressure in the ear canal and with pressure sweeps from positive to negative pressure (downswept) and negative to positive pressure (upswept). Equivalent admittance at the TM was calculated using admittance measurements at the probe tip that were adjusted using a model of sound transmission in the ear canal and acoustic estimates of ear-canal area and length. Wideband ASRTs were measured at tympanometric peak pressure (TPP) derived from the average TPP of downswept and upswept tympanograms. Descriptive statistics were obtained for all WAI responses, and wideband and clinical ASRTs were compared. Results: Mean absorbance at ambient pressure and TPP demonstrated a broad band-pass pattern typical of previous studies. Test-retest differences were lower for absorbance at TPP for the downswept method compared with ambient pressure at frequencies between 1.0 and 1.26 kHz. Mean tympanometric peak-to-tail differences for absorbance were greatest around 1.0 to 2.0 kHz and similar for positive and negative tails. Mean group delay at ambient pressure and at TPP were greatest between 0.32 and 0.6 kHz at 200 to 300 [mu]sec, reduced at frequencies between 0.8 and 1.5 kHz, and increased above 1.5 kHz to around 150 [mu]sec. Mean equivalent admittance at the TM had a lower level for the ambient method than at TPP for both sweep directions below 1.2 kHz, but the difference between methods was only statistically significant for the comparison between the ambient method and TPP for the upswept tympanogram. Mean equivalent admittance phase was positive at all frequencies. Test-retest reliability of the equivalent admittance level ranged from 1 to 3 dB at frequencies below 1.0 kHz, but increased to 8 to 9 dB at higher frequencies. The mean wideband ASRT for an ipsilateral broadband noise activator was 12 dB lower than the clinical ASRT, but had poorer reliability. Conclusions: Normative data for the WAI test battery revealed minor differences for results at ambient pressure compared with tympanometric methods at TPP for reflectance, group delay, and equivalent admittance level at the TM for subjects with middle ear pressure within +/-100 daPa. Test-retest reliability was better for absorbance at TPP for the downswept tympanogram compared with ambient pressure at frequencies around 1.0 kHz. Large peak-to-tail differences in absorbance combined with good reliability at frequencies between about 0.7 and 3.0 kHz suggest that this may be a sensitive frequency range for interpreting absorbance at TPP. The mean wideband ipsilateral ASRT was lower than the clinical ASRT, consistent with previous studies. Results are promising for the use of a wideband test battery to evaluate middle ear function. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Πληροφορίες

Τετάρτη 4 Ιανουαρίου 2017

Abstract