Dawn Konrad-Martin

Objective: Develop and validate a model for predicting complete audiograms of individual patients that also supports cisplatin-ototoxicity forecasting and early identification using any existing diagnostic and classification criteria. Study design: Prospective observational study Setting: Veterans Administration hospital cancer ambulatory care Patients: One hundred thirty-one Veterans undergoing cisplatin chemotherapy or chemoradiation Main outcome measures: Predicted 0.5 to 8 kHz audiogram thresholds in both ears. Hearing changes were derived from the predicted audiograms using American Speech-Language Hearing Association (ASHA) and Common Terminology Criteria for Adverse Events (CTCAE) criteria. Results: The VA Hearing Loss Evaluation and Risk Screener (VA HEARS) is a Bayesian multivariate linear mixed model trained on cisplatin patient audiograms collected from 2010-2022 and validated with data from 2019-2024. Audiogram thresholds are forecast conditional on the pretreatment audiogram, patient age, and prescribed cisplatin chemoradiation. Each patient had 1 to 8 audiograms measured before, during, and after cancer treatment. Forty-seven percent of patients received concurrent cochlear radiation. Forecasted thresholds achieved average prediction errors of 5.2 to 10.6 dB across frequencies. Ears were accurately diagnosed as having changed hearing with an area under the receiver operating characteristic curves of 0.79 and 0.78 for ASHA and CTCAE grade 1 predictions in validation data. After 280 mg/m² cumulative cisplatin, 8 kHz thresholds increase by an average of 12 dB with concurrent radiation versus 8 dB without. Conclusion: The VA HEARS is the first validated model for forecasting cisplatin-related audiogram changes in adult cancer patients and to output multiple ototoxicity classification criteria simultaneously. This model is intended to personalize pretreatment counseling and guide timely interventions for patients receiving ototoxic medications.

Purpose: Identify factors influencing audiological care for chemotherapy‐induced ototoxicity from the perspectives of oncology providers in the Veterans Health Administration (VA), and quantify audiology service use among Veterans receiving ototoxic chemotherapies. Methods: We surveyed VA oncology providers to identify barriers and facilitators to ototoxicity management (OtoM). We also conducted a VA‐wide retrospective cohort analysis over a 5‐year period to quantify audiology service use among Veterans who received cisplatin, carboplatin, or oxaliplatin chemotherapy. Results: A total of 30,643 Veterans received platinum‐based chemotherapy from 2014 to 2019. Few of them (< 10% on cisplatin, < 5% on carboplatin or oxaliplatin) accessed audiology services within a year of treatment. Of the 8702 patients on cisplatin, only 9.6% had two or more audiology encounters. Thirty‐six oncology providers completed our survey. Most providers believed OtoM should be routine for patients on cisplatin (97%) or carboplatin (70%), but they overestimated audiology service provision levels relative to our analysis. Most providers would consider giving a different chemotherapy drug (73%) or decrease the dose (56%) for patients with ototoxicity, yet only 36% routinely referred patients to audiology. Access, perceived need, and resources were major barriers to OtoM, while care coordination was a primary facilitator. Conclusions: OtoM is a care‐gap for Veterans with cancer, despite its perceived value to VA oncology providers. Cisplatin and carboplatin frequently add hearing loss and tinnitus to survivors' treatment burdens. This study offers insights into oncology providers' views on OtoM, guiding efforts to address the identified care gap.

This special issue consists of eight articles from leading auditory and vestibular researchers based in U.S. Department of Veterans Affairs (VA) medical centers across the country. The VA is one of the nation's leaders in health research, conducting thousands of research studies in a given year.[1] VA researchers and the VA Office of Research & Development support the health-related priorities of Veterans and the VA as set out in the VA Secretary's strategic plan.[2] In this plan, Strategic Objective 2.4: (Innovative Care) dictates, “VA will improve understanding of Veterans specific illnesses and injuries to develop and adopt innovative new treatments that prevent future illness and enhance Veteran Outcomes.” Tinnitus and hearing loss deemed to be likely caused, at least in part, by otopathologic exposures experienced during military training and service, are the number 1 and number 3 most prevalent service-connected disabilities of all compensated injuries, at 2,500,850 and 1,377,713 recipients, respectively.[3] To support the healthcare needs of Veterans, VA promotes audiological services as a direct schedule service. An important component of research conducted at the VA has been a focus on rehabilitative aspects of care that can optimize function and quality of life. The purpose of this Special Issue is to highlight VA's continued commitment to research on hearing, tinnitus, and balance problems that afflict the Veteran population in large numbers. The articles are organized into two broad topics that reflect current trends in VA healthcare: (1) changing needs of the Veteran patient population base and (2) innovations in diagnostics and rehabilitation. To increase understanding of the changing auditory healthcare needs of Veterans, the special issue opens with an overview of tinnitus research conducted at the ORD-funded, National Center for Rehabilitative Auditory Research (NCRAR)[4] since conception of NCRAR in 1997. In this review, James Henry, Robert Folmer, Tara Zaugg, Sarah Theodoroff, Candice Quinn, Kelly Reavis, Emily Thielman, and Kathleen Carlson outline rehabilitative tinnitus research findings spanning the past 25 years. This article describes the research conducted in tinnitus assessment and intervention, epidemiology and survey studies, clinical trials, pilot studies, and narrative publications that highlight NCRAR's commitment to the development of tinnitus clinical management. This article ends with a description of an ongoing multisite study in Veterans who served in the most recent conflicts (Operation Enduring Freedom, OEF; Operation Iraqi Freedom, OIF; and Operation New Dawn, OND). This population is unique in that it is composed of an all-volunteer force, with many of those serving or conducting multiple deployments.[5] In “Rehabilitation Service Needs and Preferences among Veterans with Tinnitus: A Qualitative Study,” authors Khaya Clark, Tara Zaugg, Susan DeFrancesco, Christine Kaelin, James Henry, and Kathleen Carlson explore tinnitus rehabilitation by assessing barriers for Veterans seeking this service within the VA. These insights have implications for creating more effective and valued tinnitus healthcare service delivery models by better understanding Veteran preferences. Next, Laura Coco, Elizabeth Hooker, Tess Gilbert, Graham Harker, Khaya Clark, Kelly Reavis, James Henry, Tara Zaugg, and Kathleen Carlson provide insights into tinnitus assessment with measures of tinnitus impact on work function. Their article “The Impact of Tinnitus Severity on Work Functioning among U.S. Military Veterans with Tinnitus” outlines a national survey of Veterans that resulted in novel associations between tinnitus severity and tinnitus-related impairment in work functioning, allowing healthcare providers to better understand struggles faced by Veterans with tinnitus in the work environment. The second theme is “innovations in diagnostics and rehabilitation.” The lead-off article for this theme investigates methods currently used by VA audiologists to assess their patients' speech-in-noise understanding. In their article, “Speech-in-noise testing: an introduction for audiologists,” Curtis Billings, Tessa Olsen, Lauren Charney, Brandon Madsen, and Corrie Holmes provide a resource for audiologists to gain a deeper understanding of the utility of these testing measures and guide them in their clinical decision-making. In the second article, “Clinical gaps-in-noise measures in blast-exposed Veterans: associations with electrophysiological and behavioral responses” written by Melissa Papesh and Tess Koerner, the authors examine mechanisms of auditory processing impairment following blast exposure and brain injury. They summarize their findings of underlying sensory and/or cognitive performance gained by performing both behavioral and neural measures. This is followed by an article outlining innovative technology being used for structural and functional evaluations of the ear. In this article, “Imaging the ear anatomy and function using optical coherence tomography vibrometry,” authors Wei Dong and Sebastiaan Meenderink explain the exciting possibilities of using optical coherence tomography vibrometry for noninvasive audiologic and otologic evaluation of middle and inner ear structures. Next, the effect of aging on multisensory integration is explored by Alexander Malone, Michelle Hungerford, Spencer Smith, Nai-Yuan N. Chang, Rosalie Uchanski, Yong-Hee Oh, Richard Lewis, and Timothy Hullar in “Age-related changes in temporal binding involving auditory and vestibular inputs.” By utilizing testing measures that quantify the ability to perceive time-differences in sensory signals, these authors highlight the importance of multisensory integration in relation to overall balance function and outline changes observed during the aging process. The last article for this theme is a pilot...

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.

Purpose: Several military occupations, particularly those within the U.S. Air Force, require working with or around jet fuels. Jet fuels contain components that are known to affect central nervous function, yet effects of these fuels on auditory function, specifically auditory processing of sound, are not well understood at this time. Animal studies have demonstrated that exposure to jet fuels prior to noise exposure can exacerbate the noise exposure's effects, and service members exposed to jet fuels are at risk of noise exposure within their work environments. The purpose of this article was to give a brief synopsis of the evidence on the ototoxic effects due to jet fuel exposure to aid audiologists in their decision making when providing care for populations who are occupationally exposed to fuels or while during military service. Conclusions: Exposure to jet fuels impacts central nervous function and, in combination with noise exposure, may have detrimental auditory effects that research has yet to fully explain. Additional longitudinal research is needed to explain the relationships, which have clinical implications for service members and others exposed to jet fuels. In the meantime, audiologists can gain useful information by screening for chemical exposures when obtaining patient case histories. If jet fuel exposure is suspected, the Lifetime Exposure to Noise and Solvents Questionnaire can be used to estimate a noise exposure ranking and identify other potentiating agents such as jet fuel and industrial chemicals. A history of jet fuel exposure should inform the selection of hearing tests in the audiometric evaluation and when devising the treatment plan.

Measures of signal-in-noise neural encoding may improve understanding of the hearing-in-noise difficulties experienced by many individuals in everyday life. Usually noise results in weaker envelope following responses (EFRs); however, some studies demonstrate EFR enhancements. This experiment tested whether noise-induced enhancements in EFRs are demonstrated with simple 500- and 1000-Hz pure tones amplitude modulated at 110 Hz. Most of the 12 young normal-hearing participants demonstrated enhanced encoding of the 110-Hz fundamental in a noise background compared to quiet; in contrast, responses at the harmonics were decreased in noise relative to quiet conditions. Possible mechanisms of such an enhancement are discussed.

Objective: Distortion-product otoacoustic emissions (DPOAEs) provide a rapid, noninvasive measure of outer hair cell damage associated with chemotherapy and are a key component of pediatric ototoxicity monitoring. Serial monitoring of DPOAE levels in reference to baseline measures is one method for detecting ototoxic damage. Interpreting DPOAE findings in this context requires that test–retest differences be considered in relation to normal variability, data which are lacking in children. This study sought to (1) characterize normal test–retest variability in DPOAE level over the long time periods reflective of pediatric chemotherapy regimens for a variety of childhood ages and f2 primary frequencies using common clinical instrumentation and stimulus parameters; (2) develop level-shift reference intervals; and (3) account for any age-related change in DPOAE level or measurement error that may occur as the auditory system undergoes maturational change early in life. Design: Serial DPOAE measurements were obtained in 38 healthy children (25 females and 13 males) with normal hearing and ranging in age from one month to 10 years at the initial (baseline) visit. On average, children were tested 5.2 times over an observation period of 6.5 months. Data were collected in the form of DP grams, in which DPOAE level was measured for f2 ranging from 1.4 to 10 kHz, using a fixed f2/f1 ratio of 1.22 and stimulus level of 65/55 dB SPL for L1/L2. Age effects on DPOAE level and measurement error were estimated using Bayesian regression of the longitudinal data. The raw and model-based distribution of DPOAE test–retest differences were characterized using means and standard error of the measurement for several ages and f2’s. Results: DPOAE test–retest differences for the children in this study are at the high end of those previously observed in adults, as reflected in the associated shift reference intervals. Further, although we observe substantial child-specific variation in DPOAE level, the pattern of age-related changes is highly consistent across children. Across a wide range of f2’s, DPOAE level decreases by 3 to 4 dB from 1 to 13 months of age followed by a more gradual decline of <1 dB/year. An f2 of 6 kHz shows the smallest decrease during the early rapid maturation period. DPOAE measurement error is fairly constant with age. It is 3 to 4 dB at most f2’s and is greater (indicating poorer reliability) at 1.5, 8, and 10 kHz. Conclusions: DPOAE level decreases with childhood age, with the greatest changes observed in the first year of life. Maturational effects during infancy and greater measurement error at very low and high f2’s affect test–retest variability in children. An f2 of 6 kHz shows minimal maturation and measurement error, suggesting it may be an optimal sentinel frequency for ototoxicity monitoring in pediatric patients. Once validated with locally developed normative data, reference intervals provided herein could be used to determine screen fail criteria for serial monitoring using DPOAEs. Employing state-of-the-art calibration techniques might reduce variability, allowing for more sensitive screen fail criteria.

Objectives: To promote establishment of effective ototoxicity monitoring programs (OMPs), this report reviews the U.S. national audiology guidelines in relation to “real world” OMP application. Background is provided on the mechanisms, risks and clinical presentation of hearing loss associated with major classes of ototoxic medications. Design: This is a non-systematic review using PubMed, national and international agency websites, personal communications between ototoxicity experts, and results of unpublished research. Examples are provided of OMPs in various healthcare settings within the U.S. civilian sector, Department of Defense (DoD), and Department of Veterans Affairs (VA). Study Sample: The five OMPs compared in this report represent a convenience sample of the programs with which the authors are affiliated. Their opinions were elicited via two semi-structured teleconferences on barriers and facilitators of OMP, followed by a self-administered questionnaire on OMP characteristics and practices, with responses synthesized herein. Preliminary results are provided from an ongoing VA clinical trial at one of these OMP sites. Participants were 40 VA patients who received cisplatin chemotherapy in 2014–2017. The study arms contrast access to care for OMP delivered on the treatment unit versus usual care as provided in the audiology clinic. Results: Protocols of the OMPs examined varied, reflecting their diverse settings. Service delivery concerns included baseline tests missed or completed after the initial treatment, and monitoring tests done infrequently or only after cessation of treatment. Perceived barriers involved logistics related to accessing and testing patients, such as a lack of processes to help patients enter programs, patients’ time and scheduling constraints, and inconvenient audiology clinic locations. Use of abbreviated or screening methods facilitated monitoring. Conclusions: The most effective OMPs integrated audiological management into care pathways of the clinical specialties that prescribe ototoxic medications. More OMP guidance is needed to inform evaluation schedules, outcome reporting, and determination of actionable ototoxic changes. Guidance is also lacking on the use of hearing conservation approaches suitable for the mass testing needed to support large-scale OMP efforts. Guideline adherence might improve with formal endorsement from organizations governing the medical specialty stakeholders in OMP such as oncologists, pulmonologists, infectious disease specialists, ototolaryngologists and pharmacists.

Objectives: Integrating audiological management into the care pathways of clinical specialties that prescribe ototoxic medications for essential, often life-preserving medical care that is critical for early hearing loss identification and remediation. Research shows that successful implementation of a new health service or intervention requires alignment of goals among provider groups, institutional leadership and patients. Thoughtful consideration of the physician’s viewpoints about ototoxicity and its implications for treatment planning is, therefore, important for the implementation and enduring success of an ototoxicity monitoring programme (OMP). Design: This discussion paper uses qualitative methods to explore the perspectives of four physicians on OMP provision in their patient populations. Study sample: Three pulmonologists and one oncologist completed the written survey or survey-based interview described in this report. Results: Each physician indicated that (i) ototoxicity is a potential problem for their patients; (ii) monitoring hearing is important to ensure good quality of life among their patients and (iii) treatment modification would be considered if an alternative treatment option were available. The physicians differed in their approaches to ototoxicity monitoring, from routine referrals to audiology, to relying on patient self-referral. Conclusion: Physician provider input is needed to optimise monitoring schedules and OMP care coordination with audiology.

Objectives: (1) To characterize the influence of type 2 diabetes mellitus (DM) on cortical auditory-evoked potentials (CAEPs) separate from the effects of normal aging, and (2) to determine whether the disease-related effects are modified by insulin dependence. Design: A cross-sectional study was conducted in a large cohort of Veterans to investigate the relationships among type 2 DM, age, and CAEPs in randomly selected participants with (N = 108) and without (N = 114) the disease and who had no more than a moderate hearing loss. Participants with DM were classified as insulin-dependent (IDDM, N = 47) or noninsulin-dependent (NIDDM, N = 61). Other DM measures included concurrent serum glucose, HbA1c, and duration of disease. CAEPs were evoked using a passive homogeneous paradigm (single repeating stimulus) by suprathreshold tones presented to the right ear, left ear, or both ears. Outcome measures were adjusted for the pure-tone threshold average for frequencies of 0.5, 1, and 2 kHz and analyzed for differences in age effects between participant groups using multiple regression. Results: There is little variation across test ear conditions (left, right, binaural) on any CAEP peak in any of the groups. Among no-DM controls, P2 latency increases about 9 msec per decade of life. DM is associated with an additional delay in the P2 latency of 7 and 9 msec for the IDDM and NIDDM groups, respectively. Moreover, the slope of the function relating P2 latency with age is similar across participant groups and thus the DM effect appears constant across age. Effects on N1 latency are considerably weaker, with age effects of less than 4 msec per decade across all groups, and DM effects of only 2 (IDDM) or 3 msec (NIDDM). In the NIDDM group, the slope relating N1 latency to age is steeper relative to that observed for the no-DM group, providing some evidence of accelerated “aging” for this CAEP peak. DM does not substantially reduce N1–P2 amplitude and age relationships with N1–P2 amplitude are effectively absent. There is no association between pure-tone average at 0.5, 1, and 2 kHz and any aspect of CAEPs in this cohort. Conclusions: In a large cohort of Veterans, we found that type 2 DM is associated with prolonged N1 and P2 latencies regardless of whether insulin is required to manage the disease and independent of peripheral hearing thresholds. The DM-related effects on CAEP latencies are threefold greater for P2 compared with N1, and there is little support that at the cortical level, IDDM participants had poorer responses compared with NIDDM participants, although their responses were more variable. Overall, these results indicate that DM is associated with slowed preattentive neural conduction. Moreover, the observed 7 to 9 msec P2 latency delay due to DM is substantial compared with normal age changes in P2, which are 9 msec per decade of life in this cohort. Results also suggest that whereas N1 latency changes with age are more pronounced among individuals with DM versus without DM, there was no evidence for more rapid aging of P2 among patients with DM. Thus, the damage responsible for the major DM-related differences may occur early in the DM disease process. These cross-sectional results should be verified using a longitudinal study design.