Providing Mindful and Informed Health Care for Patients Who Are LGBTQ+: Perspectives for Clinical Audiology

PURPOSE

More than 7% of the U.S. population identifies as LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and other identities), meaning clinical audiologists in all settings are likely to encounter LGBTQ+ patients seeking audiological services. This conceptual clinical focus article (a) introduces contemporary LGBTQ+ terms, definitions, and pertinent issues; (b) summarizes the current state of knowledge on barriers to equitable hearing health care access and utilization for people who identify as LGBTQ+; (c) explores the legal, ethical, and moral obligations for audiologists to provide equitable care to people who identify as LGBTQ+; and (d) provides resources to continue to learn about salient LGBTQ+ issues.

CONCLUSIONS

This clinical focus article provides actionable guidance to clinical audiologists on providing inclusive equitable care to LGBTQ+ patients. Practical actionable guidance on how clinical audiologists can make their clinical practice more inclusive for their patients who identify as LGBTQ+ is provided.

Ototoxicity prognostic models in adult and pediatric cancer patients: a rapid review

PURPOSE

A cornerstone of treatment for many cancers is the administration of platinum-based chemotherapies and/or ionizing radiation, which can be ototoxic. An accurate ototoxicity risk assessment would be useful for counseling, treatment planning, and survivorship follow-up in patients with cancer.

METHODS

This systematic review evaluated the literature on predictive models for estimating a patient's risk for chemotherapy-related auditory injury to accelerate development of computational approaches for the clinical management of ototoxicity in cancer patients. Of the 1195 articles identified in a PubMed search from 2010 forward, 15 studies met inclusion for the review.

CONCLUSIONS

All but 1 study used an abstraction of the audiogram as a modeled outcome; however, specific outcome measures varied. Consistently used predictors were age, baseline hearing, cumulative cisplatin dose, and radiation dose to the cochlea. Just 5 studies were judged to have an overall low risk of bias. Future studies should attempt to minimize bias by following statistical best practices including not selecting multivariate predictors based on univariate analysis, validation in independent cohorts, and clearly reporting the management of missing and censored data. Future modeling efforts should adopt a transdisciplinary approach to define a unified set of clinical, treatment, and/or genetic risk factors. Creating a flexible model that uses a common set of predictors to forecast the full post-treatment audiogram may accelerate work in this area. Such a model could be adapted for use in counseling, treatment planning, and follow-up by audiologists and oncologists and could be incorporated into ototoxicity genetic association studies as well as clinical trials investigating otoprotective agents.

IMPLICATIONS FOR CANCER SURVIVORS

Improvements in the ability to model post-treatment hearing loss can help to improve patient quality of life following cancer care. The improvements advocated for in this review should allow for the acceleration of advancements in modeling the auditory impact of these treatments to support treatment planning and patient counseling during and after care.

Audiologists' perceived value of ototoxicity management and barriers to implementation for at-risk cancer patients in VA: the OtoMIC survey

PURPOSE

Platinum-based chemotherapies used to treat many types of cancers are ototoxic. Ototoxicity management (OtoM) to mitigate the ototoxic outcomes of cancer survivors is recommended practice yet it is not a standard part of oncologic care. Although more than 10,000 patients each year are treated with platinum-based chemotherapies at the US Veterans Health Administration (VA), the current state of OtoM in VA is not well-defined. This study reports on a national survey of VA audiologists' perceptions regarding OtoM in cancer patients.

METHODS

A 26-item online survey was administered to VA audiologists and service chiefs across the VA's 18 regional systems of care. Descriptive statistics and deductive thematic analysis were used to analyze the data.

RESULTS

The 61 respondents included at least one from each VA region. All reported they felt some form of OtoM was necessary for at-risk cancer patients. A pre-treatment baseline, the ability to detect ototoxicity early, and management of ototoxic effects both during and after treatment were considered high value objectives of OtoM by respondents. Roughly half reported routinely providing these services for patients receiving cisplatin and carboplatin. Respondents disagreed regarding appropriate hearing testing schedules and how to co-manage OtoM responsibilities with oncology. They identified barriers to care that conformed to three themes: care and referral coordination with oncology, audiology workload, and lack of protocols.

CONCLUSIONS

Although VA audiologists value providing OtoM for cancer patients, only about half perform OtoM for highly ototoxic treatment regimens. The OtoMIC survey provides clinician perspectives to benchmark and address OtoM care gaps.

IMPLICATIONS FOR CANCER SURVIVORS

Collaboration between oncology and audiology is needed to improve current OtoM processes, so that cancer survivors can have more control over their long term hearing health.

Hearing Loss in Offspring Exposed to Antiretrovirals During Pregnancy and Breastfeeding

Over 27 million people worldwide currently receive daily antiretroviral therapy for the management of HIV/AIDS. In order to prevent the continued spread of HIV, the World Health Organization (WHO) recommends the use of highly active antiretroviral therapy by pregnant and nursing women. There is currently little research into the auditory effects of this therapy on children exposed during pregnancy and breastfeeding, and research to date on the direct effects of antiretroviral exposure on the auditory system is inconclusive. The current study examined the effects of WHO-recommended first-line antiretrovirals in a well-controlled animal model to evaluate the potential for auditory damage and dysfunction following these exposures. Female breeding mice were each exposed to one of four antiretroviral cocktails or a vehicle control once daily during pregnancy and breastfeeding. Offspring of these mice had their auditory status evaluated after weaning using auditory brainstem responses and distortion-product otoacoustic emissions (DPOAEs). Auditory brainstem response thresholds following antiretroviral exposure during gestation and breastfeeding showed elevated thresholds and increased wave latencies in offspring of exposed mice when compared to unexposed controls, but no corresponding decrease in DPOAE amplitude. These differences in threshold were small and so may explain the lack of identified hearing loss in antiretroviral-exposed children during hearing screenings at birth. Minimal degrees of hearing impairment in children have been correlated with decreased academic performance and impaired auditory processing, and so these findings, if also seen in human children, suggest significant implications for children exposed to antiretrovirals during development despite passing hearing screenings at birth.

Cochlear Preconditioning as a Modulator of Susceptibility to Hearing Loss

Significance: Acquired sensorineural hearing loss is a major public health problem worldwide. The leading causes of sensorineural hearing loss are noise, aging, and ototoxic medications, with the key underlying pathology being damage to the cochlea. The review focuses on the phenomenon of preconditioning, in which the susceptibility to cochlear injury is reduced by exposing the ear to a stressful stimulus. Recent Advances: Cochlear conditioning has focused on the use of mono-modal conditioning, specifically conditioning the cochlea with moderate noise exposures before a traumatic exposure that causes permanent hearing loss. Recently, cross-modal conditioning has been explored more thoroughly, to prevent not only noise-induced hearing loss, but also age-related and drug-induced hearing losses. Critical Issues: Noise exposures that cause only temporary threshold shifts (TTSs) can cause long-term synaptopathy, injury to the synapses between the inner hair cells and spiral ganglion cells. This discovery has the potential to significantly alter the field of cochlear preconditioning with noise. Further, cochlear preconditioning can be the gateway to the development of clinically deployable therapeutics. Therefore, understanding the underlying mechanisms of conditioning is crucial for optimizing clinical protection against sensorineural hearing loss. Future Directions: Before the discovery of synaptopathy, noise exposures that caused only TTSs were believed to be either harmless or potentially beneficial. Any considerations of preconditioning with noise must consider the potential for injury to the synapses. Further, the discovery of different methods to precondition the cochlea against injury will yield new avenues for protection against hearing loss in the vulnerable populations. Antioxid. Redox Signal. 36, 1215-1228.

Mild hearing loss in C57BL6/J mice after exposure to antiretroviral compounds during gestation and nursing

OBJECTIVE

There is evidence of ototoxicity from antiretrovirals (ARVs), and ARV therapy in pregnant/nursing mothers can expose offspring to these compounds. The current work modelled whether exposure to ARVs in utero and during nursing altered the functioning of the auditory system in offspring mice.

DESIGN

The females of seven breeding pairs of C57BL6/J mice were given daily doses of ARVs lamivudine and tenofovir disoproxil fumarate by oral gavage during gestation and nursing. Three breeder females were given equivalent volumes of water as controls. At wean age (3 weeks after birth), the offspring mice were tested with auditory brainstem responses (ABRs). At the conclusion of the experiment, the offspring mice's cochleae were examined for hair cell counts.

STUDY SAMPLE

Ten breeder female C57BL6/J mice and 69 offspring mice.

RESULTS

The offspring mice exposed to ARVs during development showed higher ABR thresholds than the control offspring. No differences were found in supra-threshold ABRs. There was no evidence of missing hair cells.

CONCLUSIONS

Hearing impairment may be a possible consequence of exposure to ARVs during gestation and development. Because the threshold differences were not large, if they are occurring in humans, it is unlikely they would be identified in any hearing screening tests.

Changing the time intervals between cisplatin cycles alter its ototoxic side effect

Various methods have been tested and deployed clinically to identify and minimize cisplatin ototoxicity. Upon early identification of hearing loss, one of the possible approaches to reducing future ototoxicity is to increase the gaps or breaks between cycles or doses of cisplatin. However, recent findings about the retention of cisplatin in the cochlea and the potential for its long-term ototoxic effects call into question whether such an approach is effective in reducing hearing loss. The current study was undertaken to determine whether increasing the rest intervals between cycles of cisplatin altered the resulting ototoxicity. CBA/CaJ mice were exposed to a cumulative dose of 48 mg/kg cisplatin delivered in three cycles of 16 mg/kg (4 mg/kg per day for 4 consecutive days). The cycles were separated by either 10, 17, or 87 days to determine if the inter-cycle rest intervals affected resulting ototoxicity. Ototoxicity was measured using auditory brainstem response threshold shifts and hair cell losses. Results indicated that longer intervals between cycles of cisplatin led to lower threshold shifts and outer hair cell lesions. The results support the principle that 'slowing down' cisplatin dosing by increasing rest intervals between doses can reduce the ototoxic side effect. Further testing is needed to optimize the timing and to determine the impact of longer inter-cycle intervals on cisplatin's anti-tumor efficacy.

The Impact of Speech Recognition Testing on State Anxiety in Young, Middle-Age, and Older Adults

Purpose This study assessed state anxiety as a function of speech recognition testing using three clinical measures of speech in noise and one clinical measure of dichotic speech recognition. Method Thirty young adults, 30 middle-age adults, and 25 older adults participated. State anxiety was measured pre- and post-speech recognition testing using the State-Trait Anxiety Inventory. Speech recognition was measured with the Revised Speech Perception in Noise Test, the Quick Speech-in-Noise Test, the Words-in-Noise Test, and the Dichotic Digits Test (DDT). Results Speech recognition performance was as expected: Older adults performed significantly poorer on all measures as compared to the young adults and significantly poorer on the Revised Speech Perception in Noise Test, the Quick Speech-in-Noise Test, and the Words-in-Noise Test as compared to the middle-age adults. On average, State-Trait Anxiety Inventory scores increased posttesting, with the middle-age adults exhibiting significantly greater increases in state anxiety as compared to the young and older adults. Increases in state anxiety were significantly greater for the DDT relative to the speech-in-noise tests for the middle-age adults only. Poorer DDT recognition performance was associated with higher levels of state anxiety. Conclusions Increases in state anxiety were observed after speech-in-noise and dichotic listening testing for all groups, with significant increases seen for the young and middle-age adults. Although the exact mechanisms could not be determined, multiple factors likely influenced the observed increases in state anxiety, including task difficulty, individual proficiency, and age.

Pharmaceutical otoprotection strategies to prevent impulse noise-induced hearing loss

One of the ongoing challenges for hearing researchers is successful protection of the ear from noise injury. For decades, the most effective methods have been based on modifying the acoustic properties of the noise, either by reducing noise output from various sources, interfering in the acoustic exposure path with environmental controls, or altering the noise dose for the individual with personal hearing protection devices. Because of the inefficiencies of some of the acoustic modification procedures, pharmaceutical otoprotection is targeted at making the cochlea less susceptible to injury. Short-duration, high-level impulse noises, typically caused by small-scale explosions, cause different sets of injuries in the ear than long-duration, low-variance noise exposures. Therefore, the expectation is that the ears exposed to impulse noise may need different pharmaceutical interventions, both in type of compounds used and the time course of administration of the compounds. The current review discusses four different classes of compounds that have been tested as impulse noise otoprotectants. In the process of describing those experiments, particular emphasis is placed on the acoustic properties of the impulses used, with the goal of providing context for evaluating the relevance of these different models to human impulse noise-induced hearing loss.