Clinical Assessment of Functional Hearing Deficits: Speech-in-Noise Performance

Objective: The clinical evaluation of hearing loss, using a pure-tone audiogram, is not adequate to assess the functional hearing capabilities (or handicap) of a patient, especially the speech-in-noise communication difficulties. The primary objective of this study was to measure the effect of elevated hearing thresholds on the recognition performance in various functional speech-in-noise tests that cover acoustic scenes of different complexities and to identify the subset of tests that (a) were sensitive to individual differences in hearing thresholds and (b) provide complementary information to the audiogram. A secondary goal was to compare the performance on this test battery with the self-assessed performance level of functional hearing abilities. Design: In this study, speech-in-noise performance of normal-hearing listeners and listeners with hearing loss (audiometric configuration ranging from near-normal hearing to moderate-severe hearing loss) was measured on a battery of 12 different tests designed to evaluate speech recognition in a variety of speech and masker conditions, and listening tasks. The listening conditions were designed to measure the ability to localize and monitor multiple speakers or to take advantage of masker modulation, spatial separation between the target and the masker, and a restricted vocabulary. Results: Listeners with hearing loss had significantly worse performance than the normal-hearing control group when speech was presented in the presence of a multitalker babble or in the presence of a single competing talker. In particular, the ability to take advantage of modulation benefit and spatial release from masking was significantly affected even with a mild audiometric loss. Elevated thresholds did not have a significant effect on the performance in the spatial awareness task. A composite score of all 12 tests was considered as a global metric of the overall speech-in-noise performance. Perceived hearing difficulties of subjects were better correlated with the composite score than with the performance on a standardized clinical speech-in-noise test. Regression analysis showed that scores from a subset of these tests, which could potentially take less than 10 min to administer, when combined with the better-ear pure-tone average and the subject’s age, accounted for as much as 93.2% of the variance in the composite score. Conclusions: A test that measures speech recognition in the presence of a spatially separated competing talker would be useful in measuring suprathreshold speech-in-noise deficits that cannot be readily predicted from standard audiometric evaluation. Including such a test can likely reduce the gap between patient complaints and their clinical evaluation. ACKNOWLEDGMENTS: The authors thank Jennie Canan, Victoria Bugtong, Michele Spencer, Alice Franklin, and Lina Kubli for their assistance in data collection. This research was funded by the US Army Center for Health Promotion and Preventive Medicine (USACHPPM) through a Health Promotion and Preventive Initiative (HPPI) program grant. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. The identification of specific products, scientific instrumentation, or organizations is considered an integral part of the scientific endeavor and does not constitute endorsement or implied endorsement on the part of the author, the Department of Defence or any component agency. The authors have no conflicts of interest to disclose. Address for correspondence: Sandeep A. Phatak, Building 19, Room 5504, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA. E-mail: s.a.phatak@gmail.com Received December 21, 2017; accepted May 24, 2018. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

from #Audiology via ola Kala on Inoreader https://ift.tt/2N8mkos
via IFTTT

Early Hearing Detection and Intervention: Timely Diagnosis, Timely Management

Objective: A quality improvement study was completed to assess the impact of three clinical practice changes on the timing of diagnosis and intervention for congenital hearing loss. Design: A retrospective chart review was conducted for 800 infants evaluated for congenital hearing loss before and after implementing three clinical practice changes: the use of Kalman-weighted signal averaging for auditory brainstem response testing, a tone burst-prioritized testing protocol, and expediting scheduling of initial assessment. The impact of middle ear involvement on age at diagnosis and history of neonatal intensive care unit stay on age at treatment was also examined. Results: The use of Kalman-weighted signal averaging for auditory brainstem response testing, a tone burst-prioritized testing protocol, and expedited scheduling of initial assessment each resulted in a decrease of age at diagnosis. Ultimately, the age at initial assessment was the only significant predictor related to decreased timeline for diagnosis. Middle ear pathology significantly increased age at diagnosis, while history of time in the neonatal intensive care unit significantly increased the age at provision of amplification as a treatment for permanent hearing loss. Conclusions: The technology used for assessment, clinical protocol, and timing of assessment of infants can impact the timeline for diagnosis and treatment of congenital hearing impairment. Given the significant sequelae of delayed or missed diagnosis of hearing loss in infancy, implementing clinical practice changes should be considered at pediatric diagnostic centers. ACKNOWLEDGMENTS: U. M. F. designed the study, collected and analyzed the data, and wrote the paper; G. M. H. implemented the three clinical practice changes and provided critical revision; E. A. provided statistical analysis and critical revision; O. F. A. helped design the clinical protocol changes and provided critical revision. The authors would like to thank Meghan Springer for her dedicated work on data collection as well as all of the staff in The Hearing Program at Nationwide Children’s Hospital who contributed to improving outcomes for our infants as a part of this process. Additionally, the authors would like to thank the Business Process Improvement Department at Nationwide Children’s Hospital and, specifically, the Operational Excellence program for their support during the implementation of access initiatives contributing to the results of this study. Lastly, the authors would like to thank Drs. Shuman He and Melody Davis for their thoughtful critique and input for the revision of this manuscript. Portions of this manuscript were presented at AudiologyNOW! 2017 in Indianapolis, IN and as a part of a 3-day hands-on workshop sponsored by National Center for Hearing Assessment and Management (NCHAM) and hosted by Cincinnati Children’s Hospital in June 2017 entitled “Diagnostic Protocols for Diagnostic Audiological Assessment Follow-up to Newborn Hearing Screening.” The authors have no conflicts of interest to disclose. Address for correspondence: Ursula M. Findlen, Nationwide Children’s Hospital, 700 Children’s Drive, Suite T3D, Columbus, OH 43205, USA. E-mail: ursula.findlen@nationwidechildrens.org Received October 27, 2017; accepted June 19, 2018. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

from #Audiology via ola Kala on Inoreader https://ift.tt/2PujETR
via IFTTT

Clinical Assessment of Functional Hearing Deficits: Speech-in-Noise Performance

Objective: The clinical evaluation of hearing loss, using a pure-tone audiogram, is not adequate to assess the functional hearing capabilities (or handicap) of a patient, especially the speech-in-noise communication difficulties. The primary objective of this study was to measure the effect of elevated hearing thresholds on the recognition performance in various functional speech-in-noise tests that cover acoustic scenes of different complexities and to identify the subset of tests that (a) were sensitive to individual differences in hearing thresholds and (b) provide complementary information to the audiogram. A secondary goal was to compare the performance on this test battery with the self-assessed performance level of functional hearing abilities. Design: In this study, speech-in-noise performance of normal-hearing listeners and listeners with hearing loss (audiometric configuration ranging from near-normal hearing to moderate-severe hearing loss) was measured on a battery of 12 different tests designed to evaluate speech recognition in a variety of speech and masker conditions, and listening tasks. The listening conditions were designed to measure the ability to localize and monitor multiple speakers or to take advantage of masker modulation, spatial separation between the target and the masker, and a restricted vocabulary. Results: Listeners with hearing loss had significantly worse performance than the normal-hearing control group when speech was presented in the presence of a multitalker babble or in the presence of a single competing talker. In particular, the ability to take advantage of modulation benefit and spatial release from masking was significantly affected even with a mild audiometric loss. Elevated thresholds did not have a significant effect on the performance in the spatial awareness task. A composite score of all 12 tests was considered as a global metric of the overall speech-in-noise performance. Perceived hearing difficulties of subjects were better correlated with the composite score than with the performance on a standardized clinical speech-in-noise test. Regression analysis showed that scores from a subset of these tests, which could potentially take less than 10 min to administer, when combined with the better-ear pure-tone average and the subject’s age, accounted for as much as 93.2% of the variance in the composite score. Conclusions: A test that measures speech recognition in the presence of a spatially separated competing talker would be useful in measuring suprathreshold speech-in-noise deficits that cannot be readily predicted from standard audiometric evaluation. Including such a test can likely reduce the gap between patient complaints and their clinical evaluation. ACKNOWLEDGMENTS: The authors thank Jennie Canan, Victoria Bugtong, Michele Spencer, Alice Franklin, and Lina Kubli for their assistance in data collection. This research was funded by the US Army Center for Health Promotion and Preventive Medicine (USACHPPM) through a Health Promotion and Preventive Initiative (HPPI) program grant. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. The identification of specific products, scientific instrumentation, or organizations is considered an integral part of the scientific endeavor and does not constitute endorsement or implied endorsement on the part of the author, the Department of Defence or any component agency. The authors have no conflicts of interest to disclose. Address for correspondence: Sandeep A. Phatak, Building 19, Room 5504, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA. E-mail: s.a.phatak@gmail.com Received December 21, 2017; accepted May 24, 2018. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

from #Audiology via ola Kala on Inoreader https://ift.tt/2N8mkos
via IFTTT

Early Hearing Detection and Intervention: Timely Diagnosis, Timely Management

Objective: A quality improvement study was completed to assess the impact of three clinical practice changes on the timing of diagnosis and intervention for congenital hearing loss. Design: A retrospective chart review was conducted for 800 infants evaluated for congenital hearing loss before and after implementing three clinical practice changes: the use of Kalman-weighted signal averaging for auditory brainstem response testing, a tone burst-prioritized testing protocol, and expediting scheduling of initial assessment. The impact of middle ear involvement on age at diagnosis and history of neonatal intensive care unit stay on age at treatment was also examined. Results: The use of Kalman-weighted signal averaging for auditory brainstem response testing, a tone burst-prioritized testing protocol, and expedited scheduling of initial assessment each resulted in a decrease of age at diagnosis. Ultimately, the age at initial assessment was the only significant predictor related to decreased timeline for diagnosis. Middle ear pathology significantly increased age at diagnosis, while history of time in the neonatal intensive care unit significantly increased the age at provision of amplification as a treatment for permanent hearing loss. Conclusions: The technology used for assessment, clinical protocol, and timing of assessment of infants can impact the timeline for diagnosis and treatment of congenital hearing impairment. Given the significant sequelae of delayed or missed diagnosis of hearing loss in infancy, implementing clinical practice changes should be considered at pediatric diagnostic centers. ACKNOWLEDGMENTS: U. M. F. designed the study, collected and analyzed the data, and wrote the paper; G. M. H. implemented the three clinical practice changes and provided critical revision; E. A. provided statistical analysis and critical revision; O. F. A. helped design the clinical protocol changes and provided critical revision. The authors would like to thank Meghan Springer for her dedicated work on data collection as well as all of the staff in The Hearing Program at Nationwide Children’s Hospital who contributed to improving outcomes for our infants as a part of this process. Additionally, the authors would like to thank the Business Process Improvement Department at Nationwide Children’s Hospital and, specifically, the Operational Excellence program for their support during the implementation of access initiatives contributing to the results of this study. Lastly, the authors would like to thank Drs. Shuman He and Melody Davis for their thoughtful critique and input for the revision of this manuscript. Portions of this manuscript were presented at AudiologyNOW! 2017 in Indianapolis, IN and as a part of a 3-day hands-on workshop sponsored by National Center for Hearing Assessment and Management (NCHAM) and hosted by Cincinnati Children’s Hospital in June 2017 entitled “Diagnostic Protocols for Diagnostic Audiological Assessment Follow-up to Newborn Hearing Screening.” The authors have no conflicts of interest to disclose. Address for correspondence: Ursula M. Findlen, Nationwide Children’s Hospital, 700 Children’s Drive, Suite T3D, Columbus, OH 43205, USA. E-mail: ursula.findlen@nationwidechildrens.org Received October 27, 2017; accepted June 19, 2018. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

from #Audiology via ola Kala on Inoreader https://ift.tt/2PujETR
via IFTTT

Cognitive Abilities Contribute to Spectro-Temporal Discrimination in Children Who Are Hard of Hearing

Objectives: Spectral ripple discrimination tasks have received considerable interest as potential clinical tools for use with adults and children with hearing loss. Previous results have indicated that performance on ripple tasks is affected by differences in aided audibility [quantified using the Speech Intelligibility Index, or Speech Intelligibility Index (SII)] in children who wear hearing aids and that ripple thresholds tend to improve over time in children with and without hearing loss. Although ripple task performance is thought to depend less on language skills than common speech perception tasks, the extent to which spectral ripple discrimination might depend on other general cognitive abilities such as nonverbal intelligence and working memory is unclear. This is an important consideration for children because age-related changes in ripple test results could be due to developing cognitive ability and could obscure the effect of any changes in unaided or aided hearing over time. The purpose of this study was to establish the relationship between spectral ripple discrimination in a group of children who use hearing aids and general cognitive abilities such as nonverbal intelligence, visual and auditory working memory, and executive function. It was hypothesized that, after controlling for listener age, general cognitive ability would be associated with spectral ripple thresholds and performance on both auditory and visual cognitive tasks would be associated with spectral ripple thresholds. Design: Children who were full-time users of hearing aids for at least 1 year (n = 24, ages 6 to 13 years) participated in this study. Children completed a spectro-temporal modulated ripple discrimination task in the sound field using their personal hearing aids. Threshold was determined from the average of two repetitions of the task. Participants completed standard measurements of executive function, nonverbal intelligence, and visual and verbal working memory. Real ear verification measures were completed for each child with their personal hearing aids to determine aided SII. Results: Consistent with past findings, spectro-temporal ripple thresholds improved with greater listener age. Surprisingly, aided SII was not significantly correlated with spectro-temporal ripple thresholds potentially because this particular group of listeners had overall better hearing and greater aided SII than participants in previous studies. Partial correlations controlling for listener age revealed that greater nonverbal intelligence and visual working memory were associated with better spectro-temporal ripple discrimination thresholds. Verbal working memory, executive function, and language ability were not significantly correlated with spectro-temporal ripple discrimination thresholds. Conclusions: These results indicate that greater general cognitive abilities are associated with better spectro-temporal ripple discrimination ability, independent of children’s age or aided SII. It is possible that these relationships reflect the cognitive demands of the psychophysical task rather than a direct relationship of cognitive ability to spectro-temporal processing in the auditory system. Further work is needed to determine the relationships of cognitive abilities to ripple discrimination in other populations, such as children with cochlear implants or with a wider range of aided SII. ACKNOWLEDGMENTS: The authors would also like to thank Jenna Browning for her contributions to data collection. Financial support for this project was provided by the National Institutes of Health/National Institute on Deafness and Other Communication Disorders under awards R01 DC013591, P30 DC-4662, P20 GM109023, F32 DC015159, and the Andrew Hetzel Research Fund. The authors have no conflicts of interest to disclose. Address for correspondence: Benjamin Kirby, 215E Fairchild Hall, Illinois State University, Normal, IL 61790, USA. E-mail: bjkirby@ilstu.edu Received December 28, 2017; accepted June 12, 2018. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

from #Audiology via ola Kala on Inoreader https://ift.tt/2MpPraL
via IFTTT

Service Preferences of Parents of Children With Mild Bilateral or Unilateral Hearing Loss: A Conjoint Analysis Study

Objective: Universal newborn hearing screening results in substantially more children with mild bilateral and unilateral hearing loss identified in the early years of life. While intervention services for children with moderate loss and greater are generally well-established, considerable uncertainty and variation surrounds the need for intervention services for children with milder losses. This study was undertaken with parents of young children with permanent mild bilateral and unilateral hearing loss to examine their preferences for characteristics associated with intervention services. Design: Conjoint analysis, a preference-based technique, was employed to study parents’ strength of preferences. Using a cross-sectional survey that consisted of eight hypothetical clinic scenarios, we invited parents to make a discrete choice (to select one of two or more different services) between available services with different characteristics. The survey was informed by qualitative interviews conducted for this purpose. The questionnaire was administered to parents receiving intervention services in the province of Ontario, Canada, who were enrolled in a mixed-methods longitudinal study examining outcomes in early-identified children with mild bilateral/unilateral hearing loss. Data were analyzed using a generalized linear model (probit link) to identify attributes of interest for the respondents. Characteristics of the children were entered into the model to control for differences in age of diagnosis, sex, laterality of hearing loss, and hearing aid use. Results: A total of 51 of 62 invited parents completed the questionnaire. All four attributes of care that were included in the survey were found to be statistically significant, that is, parents valued support for amplification, support for speech-language development, emotional support, and communication from professionals. Analysis showed greater preference for enhanced levels relating to support for speech-language development than for support for amplification. Preference for attributes relating to emotional support and communication were also greater than for support for amplification use. Conclusions: Conjoint analysis was used to quantify parents’ preferences for service attributes. Parents’ values provide insights into the aspects of a service model that should receive consideration in the development of intervention programs for young children with mild bilateral or unilateral hearing loss and their families. Although parents of young children with mild bilateral or unilateral hearing loss valued several components of care, they indicated a clear preference for speech-language support compared with support for amplification use. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and text of this article on the journal’s Web site (www.ear-hearing.com). ACKNOWLEDGMENTS: The authors are grateful to the families who participated in this research and to the many providers in early intervention and education programs in Ontario who informed parents about the study and assisted with institutional ethics requirements. The authors also thank the clinicians at the Children’s Hospital of Eastern Ontario for their input into the conjoint analysis questionnaire. E.M.F. designed the study, guided the questionnaire development, and wrote the first draft of the manuscript; D.C. assisted with the questionnaire an provided interpretive analysis and critical revision. I.G. carried out the statistical analyses and provided interpretive analysis. A.D.-S. provided guidance in the study design and critical revision. J.W. managed data collection and descriptive statistical analyses. V.G., E.N., and M.S. managed the development and piloting of the questionnaire. All authors commented on the final manuscript. This study was funded through a Canadian Institutes of Health Research (CIHR, grant number 93705) and was supplemented by a CIHR New Investigator Award (2009–14) and Canadian Child Health Clinician Scientist Award (2009-4) to E.M.F. The authors declare no conflicts of interest. Address for correspondence: Elizabeth M. Fitzpatrick, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada K1H 8M5. E-mail: elizabeth.fitzpatrick@uottawa.ca Received November 23, 2017; accepted June 30, 2018. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

from #Audiology via ola Kala on Inoreader https://ift.tt/2OVcyGC
via IFTTT

Cognitive Abilities Contribute to Spectro-Temporal Discrimination in Children Who Are Hard of Hearing

Objectives: Spectral ripple discrimination tasks have received considerable interest as potential clinical tools for use with adults and children with hearing loss. Previous results have indicated that performance on ripple tasks is affected by differences in aided audibility [quantified using the Speech Intelligibility Index, or Speech Intelligibility Index (SII)] in children who wear hearing aids and that ripple thresholds tend to improve over time in children with and without hearing loss. Although ripple task performance is thought to depend less on language skills than common speech perception tasks, the extent to which spectral ripple discrimination might depend on other general cognitive abilities such as nonverbal intelligence and working memory is unclear. This is an important consideration for children because age-related changes in ripple test results could be due to developing cognitive ability and could obscure the effect of any changes in unaided or aided hearing over time. The purpose of this study was to establish the relationship between spectral ripple discrimination in a group of children who use hearing aids and general cognitive abilities such as nonverbal intelligence, visual and auditory working memory, and executive function. It was hypothesized that, after controlling for listener age, general cognitive ability would be associated with spectral ripple thresholds and performance on both auditory and visual cognitive tasks would be associated with spectral ripple thresholds. Design: Children who were full-time users of hearing aids for at least 1 year (n = 24, ages 6 to 13 years) participated in this study. Children completed a spectro-temporal modulated ripple discrimination task in the sound field using their personal hearing aids. Threshold was determined from the average of two repetitions of the task. Participants completed standard measurements of executive function, nonverbal intelligence, and visual and verbal working memory. Real ear verification measures were completed for each child with their personal hearing aids to determine aided SII. Results: Consistent with past findings, spectro-temporal ripple thresholds improved with greater listener age. Surprisingly, aided SII was not significantly correlated with spectro-temporal ripple thresholds potentially because this particular group of listeners had overall better hearing and greater aided SII than participants in previous studies. Partial correlations controlling for listener age revealed that greater nonverbal intelligence and visual working memory were associated with better spectro-temporal ripple discrimination thresholds. Verbal working memory, executive function, and language ability were not significantly correlated with spectro-temporal ripple discrimination thresholds. Conclusions: These results indicate that greater general cognitive abilities are associated with better spectro-temporal ripple discrimination ability, independent of children’s age or aided SII. It is possible that these relationships reflect the cognitive demands of the psychophysical task rather than a direct relationship of cognitive ability to spectro-temporal processing in the auditory system. Further work is needed to determine the relationships of cognitive abilities to ripple discrimination in other populations, such as children with cochlear implants or with a wider range of aided SII. ACKNOWLEDGMENTS: The authors would also like to thank Jenna Browning for her contributions to data collection. Financial support for this project was provided by the National Institutes of Health/National Institute on Deafness and Other Communication Disorders under awards R01 DC013591, P30 DC-4662, P20 GM109023, F32 DC015159, and the Andrew Hetzel Research Fund. The authors have no conflicts of interest to disclose. Address for correspondence: Benjamin Kirby, 215E Fairchild Hall, Illinois State University, Normal, IL 61790, USA. E-mail: bjkirby@ilstu.edu Received December 28, 2017; accepted June 12, 2018. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

from #Audiology via ola Kala on Inoreader https://ift.tt/2MpPraL
via IFTTT

Service Preferences of Parents of Children With Mild Bilateral or Unilateral Hearing Loss: A Conjoint Analysis Study

Objective: Universal newborn hearing screening results in substantially more children with mild bilateral and unilateral hearing loss identified in the early years of life. While intervention services for children with moderate loss and greater are generally well-established, considerable uncertainty and variation surrounds the need for intervention services for children with milder losses. This study was undertaken with parents of young children with permanent mild bilateral and unilateral hearing loss to examine their preferences for characteristics associated with intervention services. Design: Conjoint analysis, a preference-based technique, was employed to study parents’ strength of preferences. Using a cross-sectional survey that consisted of eight hypothetical clinic scenarios, we invited parents to make a discrete choice (to select one of two or more different services) between available services with different characteristics. The survey was informed by qualitative interviews conducted for this purpose. The questionnaire was administered to parents receiving intervention services in the province of Ontario, Canada, who were enrolled in a mixed-methods longitudinal study examining outcomes in early-identified children with mild bilateral/unilateral hearing loss. Data were analyzed using a generalized linear model (probit link) to identify attributes of interest for the respondents. Characteristics of the children were entered into the model to control for differences in age of diagnosis, sex, laterality of hearing loss, and hearing aid use. Results: A total of 51 of 62 invited parents completed the questionnaire. All four attributes of care that were included in the survey were found to be statistically significant, that is, parents valued support for amplification, support for speech-language development, emotional support, and communication from professionals. Analysis showed greater preference for enhanced levels relating to support for speech-language development than for support for amplification. Preference for attributes relating to emotional support and communication were also greater than for support for amplification use. Conclusions: Conjoint analysis was used to quantify parents’ preferences for service attributes. Parents’ values provide insights into the aspects of a service model that should receive consideration in the development of intervention programs for young children with mild bilateral or unilateral hearing loss and their families. Although parents of young children with mild bilateral or unilateral hearing loss valued several components of care, they indicated a clear preference for speech-language support compared with support for amplification use. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and text of this article on the journal’s Web site (www.ear-hearing.com). ACKNOWLEDGMENTS: The authors are grateful to the families who participated in this research and to the many providers in early intervention and education programs in Ontario who informed parents about the study and assisted with institutional ethics requirements. The authors also thank the clinicians at the Children’s Hospital of Eastern Ontario for their input into the conjoint analysis questionnaire. E.M.F. designed the study, guided the questionnaire development, and wrote the first draft of the manuscript; D.C. assisted with the questionnaire an provided interpretive analysis and critical revision. I.G. carried out the statistical analyses and provided interpretive analysis. A.D.-S. provided guidance in the study design and critical revision. J.W. managed data collection and descriptive statistical analyses. V.G., E.N., and M.S. managed the development and piloting of the questionnaire. All authors commented on the final manuscript. This study was funded through a Canadian Institutes of Health Research (CIHR, grant number 93705) and was supplemented by a CIHR New Investigator Award (2009–14) and Canadian Child Health Clinician Scientist Award (2009-4) to E.M.F. The authors declare no conflicts of interest. Address for correspondence: Elizabeth M. Fitzpatrick, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada K1H 8M5. E-mail: elizabeth.fitzpatrick@uottawa.ca Received November 23, 2017; accepted June 30, 2018. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

from #Audiology via ola Kala on Inoreader https://ift.tt/2OVcyGC
via IFTTT