Feasibility of the HEAR-aware App for Hearing Loss Self-Management: A Nonrandomized Intervention Study to Examine Intervention Acceptability and the Stages-of-Change Concept

OBJECTIVES

The HEAR-aware project targets adults ≥50 years who were recently diagnosed with hearing loss and declined hearing aids, but were open for support via a smartphone app on different target behaviors (TBs). The HEAR-aware app, based on Ecological Momentary Assessment and Ecological Momentary Intervention (EMA, EMI), contains educational materials ("snippets") tailored partly to the user's experienced listening situations. The app aims to increase adults' TB-specific readiness to take action on hearing problems. The present study focused on examining feasibility regarding three novel aspects: (1) the app's acceptability, mainly regarding its EMA and EMI elements (compliance, usability, usefulness, satisfaction), (2) psychometric properties of 10 new TB-specific stages-of-change (SoC) measures (test-retest reliability, construct validity), and (3) the potential of tailoring snippets on a person's SoC.

DESIGN

A nonrandomized intervention study including four measurements with 2-week intervals (T0-T3). (1) The intervention period lasted 4 weeks. App usage data were collected throughout (T1-T3). Usability, usefulness, and satisfaction were measured at T3 (n = 26). (2) Reliability concerned T0 and T1 data, in between which no intervention occurred. Intraclass correlation coefficients (ICCs) were calculated (n = 29). Construct validity was examined by calculating correlations between the different TB-specific scales (at T0), and also between each of them and self-reported hearing disability (n = 29). (3) Person-tailoring by SoC was examined using T0 and T1 data. Linear mixed models were applied to test whether users rated snippets corresponding to their SoC as more interesting and useful than noncorresponding snippets (n = 25).

RESULTS

(1) The percentage of participants that complied with the intended usage varied across the five predefined compliance criteria (lowest: 8%; highest: 85%). Median snippet satisfaction scores were reasonably positive (3.5 to 4.0 of 5). Usability was good (System Usability Score, mean = 72.4, SD = 14.3) and usefulness satisfactory (Intrinsic Motivation Inventory, mean = 4.4, SD = 1.4), but showed large variance. (2) The 10 TB-specific scales showed fair-to-excellent reliabilities (range ICCs = 0.51 to 0.80). Correlations between the TB-specific scales ranged between -0.17 ( p > 0.05) and 0.74 ( p < 0.001), supporting only partly overlap between their underlying constructs. Only the correlation between TB-specific readiness for hearing aid uptake and self-reported hearing disability was significant. (3) Correspondence of a snippet's SoC with the person's SoC significantly related to "interesting" ratings ( p = 0.006). Unexpectedly, for snippets with a lower SoC than the participant's, further deviation of the snippet's SoC from the participant's SoC, increased the participant's interest in the snippet. The relationship with "usefulness" was borderline significant.

CONCLUSIONS

(1) Overall usability, usefulness, and satisfaction scores indicated sufficient app acceptability. The high variance and fairly low compliance showed room for improving the app's EMA/EMI parts for part of the participants. (2) The 10 new TB-specific SoC measures showed sufficient reliability, supporting that they measured different types of readiness to take action on hearing problems (construct validity). (3) The unexpected findings regarding tailoring educational app materials to individuals' SoC deserve further study.

Impact of the anaerobic feeding mode on substrate distribution in aerobic granular sludge

There is a growing interest to implement aerobic granular sludge (AGS) in existing conventional activated sludge (CAS) systems with a continuous flow-through configuration. The mode of anaerobic contact of raw sewage with the sludge is an important aspect in the adaptation of CAS systems to accommodate AGS. It remains unclear how the distribution of substrate over the sludge by a conventional anaerobic selector compares to the distribution via bottom-feeding applied in sequencing batch reactors (SBRs). This study investigated the effect of the anaerobic contact mode on the substrate (and storage) distribution by operating two lab-scale SBRs; one with the traditional bottom-feeding through a settled sludge bed similar to full-scale AGS systems, and one where the synthetic wastewater was fed as a pulse at the start of the anaerobic phase while the reactor was mixed through sparging of nitrogen gas (mimicking a plug-flow anaerobic selector in continuous flow-through systems). The distribution of the substrate over the sludge particle population was quantified via PHA analysis, combined with the obtained granule size distribution. Bottom-feeding was found to primarily direct substrate towards the large granular size classes (i.e. large volume and close to the bottom), while completely mixed pulse-feeding gives a more equal distribution of substrate over all granule sizes (i.e. surface area dependant). The anaerobic contact mode directly controls the substrate distribution over the different granule sizes, irrespective of the solids retention time of a granule as an entity. Preferential feeding of the larger granules will enhance and stabilise the granulation compared to pulse-feeding, certainly under less advantageous conditions imposed by real sewage.

Process Evaluation of an Online SUpport PRogram for Older Hearing Aid Users Delivered in a Cluster Randomized Controlled Trial

Objectives: To evaluate the process of implementing a web-based support program (SUPR) for hearing aid users in the Dutch dispensing setting in order to allow interpretation of the randomized controlled trial's results (positive effects on hearing-aid related outcomes; no effects on psychosocial outcomes).

Design: Measures: context of implementation, recruitment, SUPR's: reach, implementation fidelity, dose delivered, dose received, satisfaction, and benefit. Data collection: quantitative and qualitative.

Study Sample: One hundred thirty-eight clients (mean age 68.1 years; 60% male) and 44 dispensers completed questionnaires. Five clients and 6 dispensers participated in interviews and focus groups.

Results: Clients and dispensers were generally satisfied with SUPR's usefulness. SUPR-videos were watched by 7–37% of the clients. Around half of the dispensers encouraged clients to watch them or informed them about SUPR. Some clients found the SUPR-materials suboptimal, and changes in personnel and limited dispenser-training were barriers acting on a contextual level.

Conclusions: This study identified several factors that contributed to the success of SUPR. Others factors, acting on various levels (e.g., intervention material, dispensers, and implementation context), were suboptimal and may explain the absent psychosocial effects. The identified factors are important to consider in further development of SUPR, and in other web-based support programs.

Operationalization of the Brief ICF Core Set for Hearing Loss: An ICF-Based e-Intake Tool in Clinical Otology and Audiology Practice

OBJECTIVES

According to the International Classification of Functioning, Disability and Health (ICF), functioning reflects the interplay between an individual's body structures and functions, activities, participation, environmental, and personal factors. To be useful in clinical practice, these concepts need to be operationalized into a practical and integral instrument. The Brief ICF Core Set for Hearing Loss (CSHL) provides a minimum standard for the assessment of functioning in adults with hearing loss. The objective of the present study was to operationalize the Brief CSHL into a digital intake tool that could be used in the otology-audiology practice for adults with ear and hearing problems as part of their intake assessment.

DESIGN

A three-step approach was followed: (1) Selecting and formulating questionnaire items and response formats, using the 27 categories of the Brief CSHL as a basis. Additional categories were selected based on relevant literature and clinical expertise. Items were selected from existing, commonly used disease-specific questionnaires, generic questionnaires, or the WHO's official descriptions of ICF categories. The response format was based on the existing item's response categories or on the ICF qualifiers. (2) Carrying out an expert survey and a pilot study (using the three-step test interview. Relevant stakeholders and patients were asked to comment on the relevance, comprehensiveness, and comprehensibility of the items. Results were discussed in the project group, and items were modified based on consensus. (3) Integration of the intake tool into a computer-based system for use in clinical routine.

RESULTS

The Brief CSHL was operationalized into 62 items, clustered into six domains: (1) general information, including reason for visit, sociodemographic, and medical background; (2) general body functions; (3) ear and hearing structures and functions; (4) activities and participation (A&P); (5) environmental factors (EF); and (6) personal factors (mastery and coping). Based on stakeholders' responses, the instructions of the items on A&P and EF were adapted. The three-step test interview showed that the tool had sufficient content validity but that some items on EF were redundant. Overall, the stakeholders and patients indicated that the intake tool was relevant and had a logical and clear structure. The tool was integrated in an online portal.

CONCLUSIONS

In the current study, an ICF-based e-intake tool was developed that aims to screen self-reported functioning problems in adults with an ear/hearing problem. The relevance, comprehensiveness, and comprehensibility of the originally proposed item list was supported, although the stakeholder and patient feedback resulted into some changes of the tool on item-level. Ultimately, the functioning information obtained with the tool could be used to promote patient-centered ear and hearing care taking a biopsychosocial perspective into account.

Pre-processing tissue specimens with a tissue homogenizer: clinical and microbiological evaluation

BACKGROUND

Tissues are valuable specimens in diagnostic microbiology because they are often obtained by invasive methods, and effort should thus be taken to maximize microbiological yield. The objective of this study was to evaluate the added value of using tissue pre-processing (tissue homogenizer instrument gentleMACS Dissociator) in detecting microorganisms responsible for infections.

METHODS

We included 104 randomly collected tissue samples, 41 (39.4 %) bones and 63 (60.6 %) soft tissues, many of those (42/104 (40.4 %)) were of periprosthetic origins. We compared the agreement between pre-processing tissues using tissue homogenizer with routine microbiology diagnostic procedure, and we calculated the performance of these methods when clinical infections were used as reference standard.

RESULTS

There was no significant difference between the two methods (McNemar test, p = 0.3). Among the positive culture using both methods (n = 62), 61 (98.4 %) showed at least one similar microorganism. Exactly similar microorganisms were found in 42/62 (67.7 %) of the samples. From the included tissues, 55/ 104 (52.9 %) were deemed as infected. We found that the sensitivity of homogenized tissue procedure was lower (83.6 %) than when tissue was processed using tissue homogenizer (89.1 %). Sub-analysis on periprosthetic tissues and soft or bone tissues showed comparable results.

CONCLUSIONS

The added value of GentleMACS Dissociator tissue homogenizer is limited in comparison to routine tissue processing.

Effectiveness of a web-based SUpport PRogramme (SUPR) for communication partners of persons with hearing loss: results of a two-arm, cluster randomised controlled trial and process evaluation

OBJECTIVES

To examine the effects of web-based SUpport PRogram (SUPR) for communication partners (CPs) of persons with hearing loss (PHLs) in a HA dispensing setting.

DESIGN

Cluster randomised controlled trial (cRCT) with two arms (SUPR: Booklet, online videos; care as usual: no support) plus process evaluation. Measurements: baseline, and immediately-, six, and 12 months post-intervention. Outcomes: Significant Other Scale for Hearing Disability (SOS-HEAR), International Outcome Inventory for HAs/Alternative Interventions for Significant Others (IOI-HA/AI-SO). Process evaluation: dose-received, satisfaction, and benefit.

STUDY SAMPLE

The cRCT included 73 (SUPR) and 57 (care as usual) CPs. In the process evaluation study, 41 CPs (SUPR) participated.

RESULTS

There were no significant effects of SUPR for third-party disability (SOS-HEAR), the proxy report (IOI-HA-SO item "use"), and third-party disability (IOI-HA-SO items "satisfaction", and "quality of life"). SUPR-videos were watched by 15-22% of the CPs. SUPR materials were rated as moderately beneficial and useful.

CONCLUSIONS

Low baseline disability (floor effect) and low intervention dose-received may explain the findings. Directly targeting CPs rather than via their PHLs and providing intervention materials specifically for CPs may improve their engagement and contribute to SUPR's value supplementary to standard HA care.

Impact of aerobic availability of readily biodegradable COD on morphological stability of aerobic granular sludge

Operational disturbances in aerobic granular sludge (AGS) systems can result in aerobic availability of readily biodegradable COD (rbCOD). Different from activated sludge, morphological consequences on the short and long term are not well described in literature. This study investigated the effect of incomplete anaerobic uptake of acetate on the morphological and process stability of AGS using a lab-scale reactor. A fraction of the total acetate load was dosed aerobically, which was increased stepwise while monitoring granular morphology. A good granular morphology and an SVI of 40 ml/g were obtained during initial enrichment and maintained for ≤20% aerobic acetate load dosed at 4 mg COD/g VSS/h. Biological phosphorus removal efficiency was initially unaffected, but the aerobic acetate dosage rate did decrease the aerobic phosphate uptake rate. This led to loss of phosphorus removal for >20% aerobic acetate load dosed at 8 mg COD/g VSS/h over the course of 12 days. Subsequently, significant outgrowth formed on the granular surfaces and developed over time into finger-like structures. Under these high aerobic acetate loads the SVI increased to 80 ml/g and resulted in significant biomass washout due to deteriorating settling properties of the sludge. The sludge settleability and biological phosphorus removal recovered 10 days after aerobic feeding of acetate was stopped. Aerobic presence of rbCOD can be tolerated if mostly anaerobic acetate uptake is maintained, thereby ensuring stable granular morphology and good settleability. The high enrichment of phosphate accumulating organisms in the granular sludge through bottom-feeding and selective wasting of flocs makes aerobic granular sludge resilient to morphological deterioration in aerobic presence of rbCOD.

Audiological approaches to address the psychosocial needs of adults with hearing loss: perceived benefit and likelihood of use

OBJECTIVE

To explore the perceived benefit and likely implementation of approaches used by audiologists to address their adult clients' psychosocial needs related to hearing loss.

DESIGN

Adults with hearing loss and audiologists completed separate, but related, surveys to rate their perceived benefit and also their likely use of 66 clinical approaches (divided over seven themes) that aim to address psychosocial needs related to hearing loss.

STUDY SAMPLE

A sample of 52 Australian adults with hearing loss, and an international sample of 19 audiologists.

RESULTS

Overall, participants rated all of the approaches highly on both benefit and likelihood of use; the highest ranked theme was Providing Emotional Support. Cohort comparisons showed that audiologists ranked the approaches significantly higher than did adults with hearing loss. Overall, participants ranked the themes higher on benefit than on the likelihood to use scales.

CONCLUSIONS

Adults with hearing loss and audiologists recognise the importance of approaches that address the psychosocial impacts of hearing loss in audiological rehabilitation. However, both groups placed slightly greater value on the internal-based approaches (the clients own emotional response, empowerment, and responsibility), and slightly less emphasis on the external-based approaches (being supported by communication partners, support groups or other health professionals).

Effectiveness of a Web-Based SUpport PRogram (SUPR) for Hearing Aid Users Aged 50+: Two-Arm, Cluster Randomized Controlled Trial

BACKGROUND

Hearing aid (HA) use is known to improve health outcomes for people with hearing loss. Despite that, HA use is suboptimal, and communication issues and hearing-related activity limitations and participation restrictions often remain. Web-based self-management communication programs may support people with hearing loss to effectively self-manage the impact of hearing loss in their daily lives.

OBJECTIVE

The goal of the research is to examine the short- and long-term effects of a web-based self-management SUpport PRogram (SUPR) on communication strategy use (primary outcome) and a range of secondary outcomes for HA users aged 50 years and older.

METHODS

Clients of 36 HA dispensing practices were randomized to SUPR (SUPR recipients; n=180 HA users) and 34 to care as usual (controls; n=163 HA users). SUPR recipients received a practical support booklet and online materials delivered via email over the course of their 6-month HA rehabilitation trajectory. They were encouraged to appoint a communication partner and were offered optional email contact with the HA dispensing practice. The online materials included 3 instruction videos on HA handling, 5 videos on communication strategies, and 3 testimonial videos. Care as usual included a HA fitting rehabilitation trajectory only. Measurements were carried out at baseline, immediately postintervention, 6 months postintervention, and 12 months postintervention. The primary outcome measure was self-reported use of communication strategies (3 subscales of the Communication Profile for the Hearing Impaired [CPHI]). Secondary outcome measures included self-reported personal adjustment to hearing loss (CPHI); use, satisfaction and benefit of HAs and SUPR (use questionnaire; International Outcome Inventory for Hearing Aids [IOI-HA], Alternative Interventions [IOI-AI]); recommendation of HA dispensing services; self-efficacy for HA handling (Measure of Audiologic Rehabilitation Self-Efficacy for Hearing Aids [MARS-HA]); readiness to act on hearing loss (University of Rhode Island Change Assessment adapted for hearing loss [URICA-HL]); and hearing disability (Amsterdam Inventory for Auditory Disability and Handicap [AIADH]).

RESULTS

Linear mixed model analyses (intention to treat) showed no significant differences between the SUPR and control group in the course of communication strategy use (CPHI). Immediately postintervention, SUPR recipients showed significantly higher self-efficacy for advanced HA handling than the controls, which was sustained at 12 months (MARS-HA; mean difference immediately postintervention: 5.3, 95% CI 0.3 to 10.4; P=.04). Also, SUPR recipients showed significantly greater HA satisfaction than controls immediately postintervention (IOI-HA; 0.3, 95% CI 0.09 to 0.5; P=.006), which was sustained at 12 months, and significantly greater HA use than the controls immediately postintervention (IOI-HA; 0.3, 95% CI 0.02 to 0.5; P=.03), which was not sustained at 12 months.

CONCLUSIONS

This study provides ground to recommend adding SUPR to standard HA dispensing care, as long-term, modest improvements in HA outcomes were observed. Further research is needed to evaluate what adjustments to SUPR are needed to establish long-term effectiveness on outcomes in the psychosocial domain.

TRIAL REGISTRATION

ISRCTN77340339; http://www.isrctn.com/ISRCTN77340339.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2016-015012.

Experiences With and Lessons Learned From Developing, Implementing, and Evaluating a Support Program for Older Hearing Aid Users and Their Communication Partners in the Hearing Aid Dispensing Setting

Purpose The SUpport PRogram (SUPR) study was carried out in the context of a private academic partnership and is the first study to evaluate the long-term effects of a communication program (SUPR) for older hearing aid users and their communication partners on a large scale in a hearing aid dispensing setting. The purpose of this research note is to reflect on the lessons that we learned during the different development, implementation, and evaluation phases of the SUPR project. Procedure This research note describes the procedures that were followed during the different phases of the SUPR project and provides a critical discussion to describe the strengths and weaknesses of the approach taken. Conclusion This research note might provide researchers and intervention developers with useful insights as to how aural rehabilitation interventions, such as the SUPR, can be developed by incorporating the needs of the different stakeholders, evaluated by using a robust research design (including a large sample size and a longer term follow-up assessment), and implemented widely by collaborating with a private partner (hearing aid dispensing practice chain).

Rationale, Theoretical Underpinnings, and Design of HEAR-aware: Providing Adults With Hearing Loss With Tailored Support to Self-Manage Their Hearing Problems via a Smartphone App, as an Alternative to Hearing Aids

Purpose An alarming two thirds of adults aged 50 years or over with hearing impairment who could benefit from hearing aids do not own any, leaving these adults with no support to self-manage their hearing problems. In the HEAR-aware project, it is hypothesized that self-management can be facilitated via a smartphone app if its educational content is tailored to a person's dynamic stage of readiness to take action on their hearing (stage of change) and to a person's dynamic acoustical situations (as measured via a wearable microphone) and associated challenges (as captured via ecological momentary assessment). As such, the HEAR-aware app would be an ecological momentary intervention. This research note describes the rationale and theoretical underpinnings of the app, as well as the rationale for planning a series of studies to develop and evaluate it. Study Designs After a preparatory phase, Study 1 includes qualitative group interviews to assess user needs. Next, a creative session will be held, in which all stakeholders involved will work toward a specified version of the app. Subsequently, prototypes of the app will be developed and pilot-tested (Pilot Studies 2A and 2B). Users' usage and ratings (usability and quality indicators) of the app's elements will be examined and processed in the app. Lastly, the effectiveness of the app's final version will be examined in a randomized controlled trial (Study 3). Discussion The project's merits and challenges will be discussed.

Identifying the approaches used by audiologists to address the psychosocial needs of their adult clients

OBJECTIVE

To identify the approaches taken by audiologists to address their adult clients' psychosocial needs related to hearing loss.

DESIGN

A participatory mixed methods design. Participants generated statements describing the ways in which the psychosocial needs of their adult clients with hearing loss are addressed, and then grouped the statements into themes. Data were obtained using face-to-face and online structured questions. Concept mapping techniques were used to identify key concepts and to map each of the concepts relative to each other.

STUDY SAMPLE

An international sample of 65 audiologists.

RESULTS

Ninety-three statements were generated and grouped into seven conceptual clusters: Client Empowerment; Use of Strategies and Training to Personalise the Rehabilitation Program; Facilitating Peer and Other Professional Support; Providing Emotional Support; Improving Social Engagement with Technology; Including Communication Partners; and Promoting Client Responsibility.

CONCLUSIONS

Audiologists employ a wide range of approaches in their attempt to address the psychosocial needs associated with hearing loss experienced by their adult clients. The approaches described were mostly informal and provided in a non-standardised way. The majority of approaches described were not evidence-based, despite the availability of several options that are evidence-based, thus highlighting the implementation gap between research and clinical practice.

Predictors of Purchasing a Hearing Aid After an Evaluation Period: A Prospective Study in Dutch Older Hearing Aid Candidates

Purpose The current study aimed to identify factors that distinguish between older (50+ years) hearing aid (HA) candidates who do and do not purchase HAs after having gone through an HA evaluation period (HAEP). Method Secondary data analysis of the SUpport PRogram trial was performed (n = 267 older, 1st-time HA candidates). All SUpport PRogram participants started an HAEP shortly after study enrollment. Decision to purchase an HA by the end of the HAEP was the outcome of interest of the current study. Participants' baseline covariates (22 in total) were included as candidate predictors. Multivariable logistic regression modeling (backward selection and reclassification tables) was used. Results Of all candidate predictors, only pure-tone average (average of 1, 2, and 4 kHz) hearing loss emerged as a significant predictor (odds ratio = 1.03, 95% confidence interval [1.03, 1.17]). Model performance was weak (Nagelkerke R ² = .04, area under the curve = 0.61). Conclusions These data suggest that, once HA candidates have decided to enter an HAEP, factors measured early in the help-seeking journey do not predict well who will and will not purchase an HA. Instead, factors that act during the HAEP may hold this predictive value. This should be examined.

Longitudinal Relationships Between Decline in Speech-in-Noise Recognition Ability and Cognitive Functioning: The Longitudinal Aging Study Amsterdam

Purpose Various directional hypotheses for the observed links between aging, hearing, and cognition have been proposed: (a) cognitive load on perception hypothesis, (b) information degradation hypothesis, (c) sensory deprivation hypothesis, and (d) common cause hypothesis. Supporting evidence for all 4 hypotheses has been reported. No studies have modeled the corresponding 4 causal pathways into 1 single model, which would be required to evidence that multiple directional hypotheses apply. The aim of the current study was to tease out which pathways apply for 5 different cognitive measures. Method Data from 1,029 respondents of the Longitudinal Aging Study Amsterdam were used spanning a maximum follow-up of 7 years (3 measurements). Speech-in-noise recognition ability (digit triplet speech-in-noise test) was included as a measure of auditory function. Cognitive measures included global cognitive functioning, fluid intelligence, information processing speed, and verbal memory (immediate recall and retention). Bivariate dual change score modeling was used to model the causal pathways between hearing, cognition, and baseline age. Results For information processing speed, global cognitive functioning, fluid intelligence, and memory-immediate recall, all pathways except for the sensory deprivation pathway were supported. For memory-retention, only the common cause and the sensory deprivation pathways were supported. Conclusions Causal pathways corresponding to all 4 hypotheses were supported. Support for the common cause hypothesis, the information degradation hypothesis, and the cognitive load on perception hypotheses was found for 4 of 5 cognitive measures. This was unexpected in some cases (e.g., support for the information degradation pathway for cognitive measures that do not rely on auditory stimuli). The sensory deprivation pathway that emerged for memory-retention might point toward processes related to early stages of dementia. In summary, the results show that the links between decline in auditory function, cognition, and aging are complex and most likely are captured by pathways belonging to various directional hypotheses.

Predictors of Entering a Hearing Aid Evaluation Period: A Prospective Study in Older Hearing-Help Seekers

This study aimed to determine the predictors of entering a hearing aid evaluation period (HAEP) using a prospective design drawing on the health belief model and the transtheoretical model. In total, 377 older persons who presented with hearing problems to an Ear, Nose, and Throat specialist (n = 110) or a hearing aid dispenser (n = 267) filled in a baseline questionnaire. After 4 months, it was determined via a telephone interview whether or not participants had decided to enter a HAEP. Multivariable logistic regression analyses were applied to determine which baseline variables predicted HAEP status. A priori, candidate predictors were divided into ‘likely’ and ‘novel’ predictors based on the literature. The following variables turned out to be significant predictors: more expected hearing aid benefits, greater social pressure, and greater self-reported hearing disability. In addition, greater hearing loss severity and stigma were predictors in women but not in men. Of note, the predictive effect of self-reported hearing disability was modified by readiness such that with higher readiness, the positive predictive effect became stronger. None of the ‘novel’ predictors added significant predictive value. The results support the notion that predictors of hearing aid uptake are also predictive of entering a HAEP. This study shows that some of these predictors appear to be gender specific or are dependent on a person’s readiness for change. After assuring the external validity of the predictors, an important next step would be to develop prediction rules for use in clinical practice, so that older persons’ hearing help-seeking journey can be facilitated.

Barriers to and enablers of the implementation of an ICF-based intake tool in clinical otology and audiology practice-A qualitative pre-implementation study

The authors are developing an intake tool based on the Brief International Classification of Functioning Disability and Health Core Set for Hearing Loss, by operationalizing its categories into a Patient Reported Outcome Measure. This study was aimed at identifying enablers and barriers to using this tool as perceived by hearing health professionals (HHPs) and patients. Focus groups and interviews were held with HHPs (ENT surgeons, N = 14; audiologists, N = 8) and patients (N = 18). Interview questions were based on the Capability-Opportunity-Motivation-Behavior (COM-B) model. Using the COM-B model and the Theoretical Domains Framework (TDF), transcript fragments were divided into meaning units, which were then categorized into capability-, opportunity- and motivation-related barriers and enablers. These were further specified into TDF domains. HHP barriers included: lack of time to use the tool (O); and fear of being made responsible for addressing any emerging problems, which may be outside the expertise of the HHP (M). Enablers included integration of the tool in the electronic patient record (O); opportunity for the patient to be better prepared for the intake visit (M); and provision of a complete picture of the patient’s functioning via the tool (M). Patient’ barriers included fear of losing personal contact with the HHP (M); and fear that use of the tool might negatively affect conversations with the HHP (M). Enablers included knowledge on the aim and relevance of the tool (C); expected better self-preparation (M); and a more focused intake (M). These findings suggest that an intervention is needed to enhance HHPs’ knowledge, skills and motivation regarding the relevance and the clinical usefulness of the tool. Providing clear and specific information on the purpose of the tool can also enhance patient motivation. For both HHPs and patients, opportunities relating to the (digital) administration and the design of the tool provide additional targets for successful implementation.

Explaining Discrepancies Between the Digit Triplet Speech-in-Noise Test Score and Self-Reported Hearing Problems in Older Adults

PURPOSE

The purpose of this study is to determine which demographic, health-related, mood, personality, or social factors predict discrepancies between older adults' functional speech-in-noise test result and their self-reported hearing problems.

METHOD

Data of 1,061 respondents from the Longitudinal Aging Study Amsterdam were used (ages ranged from 57 to 95 years). Functional hearing problems were measured using a digit triplet speech-in-noise test. Five questions were used to assess self-reported hearing problems. Scores of both hearing measures were dichotomized. Two discrepancy outcomes were created: (a) being unaware: those with functional but without self-reported problems (reference is aware: those with functional and self-reported problems); (b) reporting false complaints: those without functional but with self-reported problems (reference is well: those without functional and self-reported hearing problems). Two multivariable prediction models (logistic regression) were built with 19 candidate predictors. The speech reception threshold in noise was kept (forced) as a predictor in both models.

RESULTS

Persons with higher self-efficacy (to initiate behavior) and higher self-esteem had a higher odds to being unaware than persons with lower self-efficacy scores (odds ratio [OR] = 1.13 and 1.11, respectively). Women had a higher odds than men (OR = 1.47). Persons with more chronic diseases and persons with worse (i.e., higher) speech-in-noise reception thresholds in noise had a lower odds to being unaware (OR = 0.85 and 0.91, respectively) than persons with less diseases and better thresholds, respectively. A higher odds to reporting false complaints was predicted by more depressive symptoms (OR = 1.06), more chronic diseases (OR = 1.21), and a larger social network (OR = 1.02). Persons with higher self-efficacy (to complete behavior) had a lower odds (OR = 0.86), whereas persons with higher self-esteem had a higher odds to report false complaints (OR = 1.21). The explained variance of both prediction models was small (Nagelkerke R2 = .11 for the unaware model, and .10 for the false complaints model).

CONCLUSIONS

The findings suggest that a small proportion of the discrepancies between older individuals' results on a speech-in-noise screening test and their self-reports of hearing problems can be explained by the unique context of these individuals. The likelihood of discrepancies partly depends on a person's health (chronic diseases), demographics (gender), personality (self-efficacy to initiate behavior and to persist in adversity, self-esteem), mood (depressive symptoms), and social situation (social network size). Implications are discussed.

Reading Behind the Lines: The Factors Affecting the Text Reception Threshold in Hearing Aid Users

PURPOSE

The visual Text Reception Threshold (TRT) test (Zekveld et al., 2007) has been designed to assess modality-general factors relevant for speech perception in noise. In the last decade, the test has been adopted in audiology labs worldwide. The 1st aim of this study was to examine which factors best predict interindividual differences in the TRT. Second, we aimed to assess the relationships between the TRT and the speech reception thresholds (SRTs) estimated in various conditions.

METHOD

First, we reviewed studies reporting relationships between the TRT and the auditory and/or cognitive factors and formulated specific hypotheses regarding the TRT predictors. These hypotheses were tested using a prediction model applied to a rich data set of 180 hearing aid users. In separate association models, we tested the relationships between the TRT and the various SRTs and subjective hearing difficulties, while taking into account potential confounding variables.

RESULTS

The results of the prediction model indicate that the TRT is predicted by the ability to fill in missing words in incomplete sentences, by lexical access speed, and by working memory capacity. Furthermore, in line with previous studies, a moderate association between higher age, poorer pure-tone hearing acuity, and poorer TRTs was observed. Better TRTs were associated with better SRTs for the correct perception of 50% of Hagerman matrix sentences in a 4-talker babble, as well as with better subjective ratings of speech perception. Age and pure-tone hearing thresholds significantly confounded these associations. The associations of the TRT with SRTs estimated in other conditions and with subjective qualities of hearing were not statistically significant when adjusting for age and pure-tone average.

CONCLUSIONS

We conclude that the abilities tapped into by the TRT test include processes relevant for speeded lexical decision making when completing partly masked sentences and that these processes require working memory capacity. Furthermore, the TRT is associated with the SRT of hearing aid users as estimated in a challenging condition that includes informational masking and with experienced difficulties with speech perception in daily-life conditions. The current results underline the value of using the TRT test in studies involving speech perception and aid in the interpretation of findings acquired using the test.

The acid soluble extracellular polymeric substance of aerobic granular sludge dominated by Defluviicoccus sp

A new acid soluble extracellular polymeric substance (acid soluble EPS) was extracted from an acetate fed aerobic granular sludge reactor operated at 35 °C. Acid soluble EPS dominated granules exhibited a remarkable and distinctive tangled tubular morphology. These granules are dominated by Defluviicoccus Cluster II organisms. Acetic acid instead of the usually required alkaline extraction medium was needed to dissolve the granules and solubilise the polymeric matrix. The extracted acid soluble EPS was analysed and identified using various instrumental analysis including ¹H and ¹³C Nuclear Magnetic Resonance, Fourier Transform Infrared Spectroscopy and Raman spectroscopy. In addition, the glycoconjugates were characterized by fluorescence lectin-binding analysis. The acid soluble EPS is α-(1 → 4) linked polysaccharide, containing both glucose and galactose as monomers. There are OCH₃ groups connected to the glucose monomer. Transmission and scanning electron microscopy (TEM, SEM) as well as confocal laser scanning microscopy (CLSM) showed that the acid soluble EPS was present as a tightly bound capsular EPS around bacterial cells ordered into a sarcinae-like growth pattern. The special granule morphology is decided by the acid soluble EPS produced by Defluviicoccus Cluster II organisms. This work shows that no single one method can be used to extract all possible extracellular polymeric substances. Results obtained here can support the elucidation of biofilm formation and structure in future research.

Effectiveness of an online SUpport PRogramme (SUPR) for older hearing aid users: study protocol for a cluster randomised controlled trial

BACKGROUND

An educational SUpport PRogramme called SUPR has been developed for hearing aid users (HAUs) and their communication partners (CPs) offering care beyond hearing aid fitting. SUPR teaches its users communication strategies, hearing aid handling skills and personal adjustment to hearing impairment.

METHODS/DESIGN

Using a cluster randomised controlled trial design, 70 Dutch hearing aid dispenser practices were randomised into hearing aid fitting (care as usual, 34 practices) and hearing aid fitting including SUPR (36 practices). The aim was to recruit a total of 569 older (aged 50+ years) first-time (n=258) and experienced (n=311) HAUs and their CPs. SUPR consists of a Practical Support Booklet and online material offered via email over a period of 6-7 months. The booklet provides practical information on hearing aids, advice on communication strategies and home exercises. The online material consists of educational videos on hearing aid functionality and usage, communication strategies and peer testimonials. Finally, noncommittal email contact with the dispenser is offered. Every HAU is asked to assign a CP who is advised to be involved intensively. Effect measurements for HAUs and their CPs will occur at baseline and at 6, 12 and 18 months follow-up via online questionnaires. The primary outcomes for HAUs will be the use of communication strategies as measured by the subscales of the Communication Profile for the Hearing Impaired. A process evaluation will be performed.

ETHICS AND DISSEMINATION

The study was approved by the Dutch Institutional Review Board of the VU Medical University Center Amsterdam. This intervention could contribute to lowering the hearing impairment burden in our ageing society. The results will be disseminated through peer-reviewed publications and scientific conferences.

TRIAL REGISTRATION NUMBER

ISRCTN77340339; Pre-results.

Full scale performance of the aerobic granular sludge process for sewage treatment

Recently, aerobic granular sludge technology has been scaled-up and implemented for industrial and municipal wastewater treatment under the trade name Nereda(®). With full-scale references for industrial treatment application since 2006 and domestic sewage since 2009 only limited operating data have been presented in scientific literature so far. In this study performance, granulation and design considerations of an aerobic granular sludge plant on domestic wastewater at the WWTP Garmerwolde, the Netherlands were analysed. After a start-up period of approximately 5 months, a robust and stable granule bed (>8 g L(-1)) was formed and could be maintained thereafter, with a sludge volume index after 5 min settling of 45 mL g(-1). The granular sludge consisted for more than 80% of granules larger than 0.2 mm and more than 60% larger than 1 mm. Effluent requirements (7 mg N L(-1) and 1 mg P L(-1)) were easily met during summer and winter. Maximum volumetric conversion rates for nitrogen and phosphorus were respectively 0.17 and 0.24 kg (m(3) d)(-1). The energy usage was 13.9 kWh (PE150·year)(-1) which is 58-63 % lower than the average conventional activated sludge treatment plant in the Netherlands. Finally, this study demonstrated that aerobic granular sludge technology can effectively be implemented for the treatment of domestic wastewater.

Effect of sludge age on methanogenic and glycogen accumulating organisms in an aerobic granular sludge process fed with methanol and acetate

The influence of sludge age on granular sludge formation and microbial population dynamics in a methanol- and acetate-fed aerobic granular sludge system operated at 35°C was investigated. During anaerobic feeding of the reactor, methanol was initially converted to methane by methylotrophic methanogens. These methanogens were able to withstand the relatively long aeration periods. Lowering the anaerobic solid retention time (SRT) from 17 to 8 days enabled selective removal of the methanogens and prevented unwanted methane formation. In absence of methanogens, methanol was converted aerobically, while granule formation remained stable. At high SRT values (51 days), γ-Proteobacteria were responsible for acetate removal through anaerobic uptake and subsequent aerobic growth on storage polymers formed [so called metabolism of glycogen-accumulating organisms (GAO)]. When lowering the SRT (24 days), Defluviicoccus-related organisms (cluster II) belonging to the α-Proteobacteria outcompeted acetate consuming γ-Proteobacteria at 35°C. DNA from the Defluviicoccus-related organisms in cluster II was not extracted by the standard DNA extraction method but with liquid nitrogen, which showed to be more effective. Remarkably, the two GAO types of organisms grew separately in two clearly different types of granules. This work further highlights the potential of aerobic granular sludge systems to effectively influence the microbial communities through sludge age control in order to optimize the wastewater treatment processes.

Efficacy of tenofovir and efavirenz in combination with lamivudine or emtricitabine in antiretroviral-naive patients in Europe

BACKGROUND

The combination of tenofovir and efavirenz with either lamivudine or emtricitabine (TELE) has proved to be highly effective in clinical trials for first-line treatment of HIV-1 infection. However, limited data are available on its efficacy in routine clinical practice.

METHODS

A multicentre cohort study was performed in therapy-naive patients initiating ART with TELE before July 2009. Efficacy was studied using ITT (missing or switch = failure) and on-treatment (OT) analyses. Genotypic susceptibility scores (GSSs) were determined using the Stanford HIVdb algorithm.

RESULTS

Efficacy analysis of 1608 patients showed virological suppression to <50 copies/mL at 48 weeks in 91.5% (OT) and 70.6% (ITT). Almost a quarter of all patients (22.9%) had discontinued TELE at week 48, mainly due to CNS toxicity. Virological failure within 48 weeks was rarely observed (3.3%, n = 53). In multilevel, multivariate analysis, infection with subtype B (P = 0.011), baseline CD4 count <200 cells/mm³ (P < 0.001), GSS <3 (P = 0.002) and use of lamivudine (P < 0.001) were associated with a higher risk of virological failure. After exclusion of patients using co-formulated compounds, virological failure was still more often observed with lamivudine. Following virological failure, three-quarters of patients switched to a PI-based regimen with GSS <3. After 1 year of second-line therapy, viral load was suppressed to <50 copies/mL in 73.5% (OT).

CONCLUSIONS

In clinical practice, treatment failure on TELE regimens is relatively frequent due to toxicity. Virological failure is rare and more often observed with lamivudine than with emtricitabine. Following virological failure on TELE, PI-based second-line therapy was often successful despite GSS <3.

Adult hearing screening: follow-up and outcomes1

PURPOSE

To screen hearing and evaluate outcomes in community-dwelling older adults.

METHOD

Three thousand and twenty-five adults responded to an invitation to be screened by questionnaire, otoscopy, and pure-tone audiometry. Pure-tone average (PTA) >35 dB HL in the worse ear, unilateral hearing loss, or otoscopic findings were the criteria for referral for services. A questionnaire related to compliance with referral recommendations was completed by telephone interview for 160 randomly selected participants after 1-2 years from referral.

RESULTS

The referral rate for audiologic/hearing aid evaluation was 46%, and referral for cerumen removal/medical evaluation was 17%. Of the people referred for audiologic/hearing aid evaluation, 18% tried a hearing aid; 2 years later, 11% were using a hearing aid. Screening recommendations affected participants' decision to seek help. Study participants stated that the screening was helpful, it should be offered to everybody, and they would participate in future screenings.

CONCLUSION

Although adult hearing screening offered timely identification of hearing loss for adults seeking help, follow-up with hearing aid treatment was low.

Hearing Status in Older Persons: A Significant Determinant of Depression and Loneliness? Results From the Longitudinal Aging Study Amsterdam

Purpose

In this study, the authors' aims were to (a) determine the longitudinal relationships between baseline hearing status and 4-year follow-up depression and loneliness in an older population and (b) investigate possible differences across subgroups in these relationships.

Method

The authors used data from 2 waves of the Longitudinal Aging Study Amsterdam (4-year follow-up, baseline ages 63–93 years). Sample sizes were 996 (self-report analyses) and 830 (speech-in-noise test analyses). The authors used multiple linear regression analyses to assess the associations between baseline hearing status and 4-year follow-up of depression, social loneliness, and emotional loneliness. Hearing was measured by self-report and by a speech-in-noise test. Age, gender, hearing aid use, baseline depression or loneliness, and relevant confounders and effect modifiers were incorporated.

Results

Both hearing measures showed significant associations with loneliness ( p < .05), but these effects were confined to specific subgroups of older persons. For instance, adverse effects were confined to nonusers of hearing aids (self-report, social loneliness model) and men (self-report and speech-in-noise test, emotional-loneliness model). No significant effects appeared for depression.

Conclusion

Significant adverse effects of poor hearing on loneliness were found for specific subgroups of older persons. In future research, investigators should further examine the subgroup effects observed. Eventually, this may contribute to the development of tailored prevention programs.

The effect of the Nintendo Wii Fit on balance control and gross motor function of children with spastic hemiplegic cerebral palsy

OBJECTIVE

To study the impact of training using the Nintendo Wii Fit in 14 children with spastic hemiplegic cerebral palsy.

METHODS

A single-subject single blinded design with multiple subjects and baselines was utilised. Interactive video gaming (IVG) in lieu of regular physiotherapy was given for 3 weeks. Outcome measures included modified balance and running speed and agility (RSA) scales of the Bruininks-Oserestky test of Motor Performance 2 and the timed up and down stairs (TUDS).

RESULTS

Balances score improved significantly (F(2, 26) = 9.8286, p = 0.001). Changes over time in the RSA (F(2, 26) = 0.86198, p = 0.434) and the TUDS (F(2, 26) = 1.3862, p = 0.268) were not significant. Ten children preferred the intervention to conventional physiotherapy.

CONCLUSION

Most children preferred the IVG but as the effect did not carry over into function, IVG should not be used in place of conventional therapy and further research is needed into its use as an adjunct to therapy.

Effect of elevated salt concentrations on the aerobic granular sludge process: linking microbial activity with microbial community structure

The long- and short-term effects of salt on biological nitrogen and phosphorus removal processes were studied in an aerobic granular sludge reactor. The microbial community structure was investigated by PCR-denaturing gradient gel electrophoresis (DGGE) on 16S rRNA and amoA genes. PCR products obtained from genomic DNA and from rRNA after reverse transcription were compared to determine the presence of bacteria as well as the metabolically active fraction of bacteria. Fluorescence in situ hybridization (FISH) was used to validate the PCR-based results and to quantify the dominant bacterial populations. The results demonstrated that ammonium removal efficiency was not affected by salt concentrations up to 33 g/liter NaCl. Conversely, a high accumulation of nitrite was observed above 22 g/liter NaCl, which coincided with the disappearance of Nitrospira sp. Phosphorus removal was severely affected by gradual salt increase. No P release or uptake was observed at steady-state operation at 33 g/liter NaCl, exactly when the polyphosphate-accumulating organisms (PAOs), "Candidatus Accumulibacter phosphatis" bacteria, were no longer detected by PCR-DGGE or FISH. Batch experiments confirmed that P removal still could occur at 30 g/liter NaCl, but the long exposure of the biomass to this salinity level was detrimental for PAOs, which were outcompeted by glycogen-accumulating organisms (GAOs) in the bioreactor. GAOs became the dominant microorganisms at increasing salt concentrations, especially at 33 g/liter NaCl. In the comparative analysis of the diversity (DNA-derived pattern) and the activity (cDNA-derived pattern) of the microbial population, the highly metabolically active microorganisms were observed to be those related to ammonia (Nitrosomonas sp.) and phosphate removal ("Candidatus Accumulibacter").

Ammonium adsorption in aerobic granular sludge, activated sludge and anammox granules

The ammonium adsorption properties of aerobic granular sludge, activated sludge and anammox granules have been investigated. During operation of a pilot-scale aerobic granular sludge reactor, a positive relation between the influent ammonium concentration and the ammonium adsorbed was observed. Aerobic granular sludge exhibited much higher adsorption capacity compared to activated sludge and anammox granules. At an equilibrium ammonium concentration of 30 mg N/L, adsorption obtained with activated sludge and anammox granules was around 0.2 mg NH4-N/g VSS, while aerobic granular sludge from lab- and pilot-scale exhibited an adsorption of 1.7 and 0.9 mg NH4-N/g VSS, respectively. No difference in the ammonium adsorption was observed in lab-scale reactors operated at different temperatures (20 and 30 °C). In a lab-scale reactor fed with saline wastewater, we observed that the amount of ammonium adsorbed considerably decreased when the salt concentration increased. The results indicate that adsorption or better ion exchange of ammonium should be incorporated into models for nitrification/denitrification, certainly when aerobic granular sludge is used.

Interventions following hearing screening in adults: a systematic descriptive review

OBJECTIVE

Adult hearing screening may be a solution to the under-diagnosis and under-treatment of hearing loss in adults. Limited use and satisfaction with hearing aids indicate that consideration of alternative interventions following hearing screening may be needed. The primary aim of this study is to provide an overview of all intervention types that have been offered to adult (≥ 18 years) screen-failures.

DESIGN

Systematic literature review. Articles were identified through systematic searches in PubMed, EMBASE, Cinahl, the Cochrane Library, private libraries, and through reference checking.

RESULTS

Of the initial 3027 papers obtained from the searches, a total of 37 were found to be eligible. The great majority of the screening programmes (i.e. 26) referred screen-failures to a hearing specialist without further rehabilitation being specified. Most of the others (i.e. seven) led to the provision of hearing aids. Four studies offered alternative interventions comprising communication programme elements (e.g. speechreading, hearing tactics) or advice on environmental aids.

CONCLUSIONS

Interventions following hearing screening generally comprised referral to a hearing specialist or hearing aid rehabilitation. Some programmes offered alternative rehabilitation options. These may be valuable as an addition to or replacement of hearing aid rehabilitation. It is recommended that this be addressed in future research.

Formation of aerobic granules and conversion processes in an aerobic granular sludge reactor at moderate and low temperatures

Temperature changes can influence biological processes considerably. To investigate the effect of temperature changes on the conversion processes and the stability of aerobic granular sludge, an aerobic granular sludge sequencing batch reactor (GSBR) was exposed to short-term and long-term temperature changes. Start-up at 8 degrees C resulted in irregular granules that aggregated as soon as aeration was stopped, which caused severe biomass washout and instable operation. The presence of COD during the aerobic phase is considered to be the major reason for this granule instability. Start-up at 20 degrees C and lowering the temperature to 15 degrees C and 8 degrees C did not have any effect on granule stability and biomass could be easily retained in the system. The temperature dependency of nitrification was lower for aerobic granules than usually found for activated sludge. Due to decreased activity in the outer layers of granules at lower temperatures, the oxygen penetration depth could increase, which resulted in a larger aerobic biomass volume, compensating the decreased activity of individual organisms. Consequently the denitrifying capacity of the granules decreased at reduced temperatures, resulting in an overall poorer nitrogen removal capacity. The overall conclusion that can be drawn from the experiments at low temperatures is that start-up in practice should take place preferentially during warm summer periods, while decreased temperatures during winter periods should not be a problem for granule stability and COD and phosphate removal in a granular sludge system. Nitrogen removal efficiencies should be optimized by changes in reactor operation or cycle time during this season.

Persistence of the lactate paradox over 8 weeks at 3,800 m

The arterial blood lactate [La] response to exercise increases in acute hypoxia, but returns to near the normoxic (sea level, SL) response after 2 to 5 weeks of altitude acclimatization. Recently, it has been suggested that this gradual return to the SL response in [La], known as the lactate paradox (LP), unexpectedly disappears after 8 to 9 weeks at altitude. We tested this idea by recording the [La] response to exercise every 2 weeks over 8 weeks at altitude. Five normal, fit SL-residents were studied at SL and 3,800 m (Pbar = 485 torr) in both normoxia (PIO2 = 150 torr) and hypoxia (PIO2 = 91 torr approximately air at 3,800 m). Arterial [La] and blood gas values were determined at rest and during cycle exercise at the same absolute workloads (0, 25, 50, 75, 90, and 100% of initial SL-VO2Max) and exercise duration (4, 4, 4, 2, 1.5, and 0.75 min, respectively) at each time point. [La] curves were elevated in acute hypoxia at SL (p < 0.01) and at 3,800 m fell progressively toward the SL-normoxic curve (p < 0.01). On the same days, [La] responses in acute normoxia showed essentially no changes over time and were similar to initial SL normoxic responses. We also measured arterial catecholamine levels at each load and found a close relationship to [La] over time, supporting a role for adrenergic influence on [La]. In summary, extending the time at this altitude to 8 weeks produced no evidence for reversal of the LP, consistent with prior data obtained over shorter periods of altitude residence.