Perspective on the Development of a Large-Scale Clinical Data Repository for Pediatric Hearing Research The use of “big data” for pediatric hearing research requires new approaches to both data collection and research methods. The widespread deployment of electronic health record systems creates new opportunities and corresponding challenges in the secondary use of large volumes of audiological and medical data. Opportunities include cost-effective hypothesis generation, rapid cohort expansion for rare conditions, and observational studies based on sample sizes in the thousands to tens of thousands. Challenges include finding and forming appropriately skilled teams, access to data, data quality assessment, and engagement with a research community new to big data. The authors share their experience and perspective on the work required to build and validate a pediatric hearing research database that integrates clinical data for over 185,000 patients from the electronic health record systems of three major academic medical centers. ACKNOWLEDGMENTS: The authors are grateful to the late Judith Gravel, Ph.D., for her efforts in the early conception and design of this project. This study was funded by the National Institute on Deafness and Other Communications Disorders Grant Number 1R24DC012207-01A1. J.W.P. oversaw informatics and technical aspects of the project and drafted the article; B.R. architected the database, implemented all software, and extracted data for CHOP; J.M.M. extracted all imaging data and implemented imaging software components; J.P. performed analysis of CHOP audiology clinic workflows and data and served as a subject matter expert on the interpretation of audiology data; B.X. performed statistical summarization and literature review for data validation; I.K. served as a subject matter expert on the interpretation of clinical and genetic data; J.M. defined data requirements, performed data quality assessment, and extracted BCH data; T.G. performed analysis of BCH audiology clinic workflows and data and served as a subject matter expert on the interpretation of audiology data; D.S. performed analysis of BCH audiology clinic workflows and data and served as a subject matter expert on the interpretation of audiology data; M.K. served as a subject matter expert on clinical care and hearing loss research, provided scientific direction, and oversaw the extraction of BCH data; L.J.H. served as a subject matter expert on clinical care and hearing loss research, provided scientific direction, made major revisions to the article, and oversaw the extraction of VU data; J.G. served as a subject matter expert on hearing loss research, led compliance efforts, and provided scientific direction; E.B.C. oversaw the project, performed data quality assessment, provided scientific direction, and made major revisions to the article. The authors have no conflicts of interest to disclose. Received October 4, 2016; accepted June 11, 2019. Address for correspondence: E. Bryan Crenshaw III, Children’s Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA 19104, USA. E-mail: crenshaw@email.chop.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Quantifying the Range of Signal Modification in Clinically Fit Hearing Aids Objectives: Hearing aids provide various signal processing techniques with a range of parameters to improve the listening experience for a hearing-impaired individual. In previous studies, we reported significant differences in signal modification for mild versus strong signal processing in commercially available hearing aids. In this study, the authors extend this work to clinically prescribed hearing aid fittings based on best-practice guidelines. The goals of this project are to determine the range of cumulative signal modification in clinically fit hearing aids across manufacturers and technology levels and the effects of listening conditions including signal to noise ratio (SNR) and presentation level on these signal modifications. Design: We identified a subset of hearing aids that were representative of a typical clinical setting. Deidentified hearing aid fitting data were obtained from three audiology clinics for adult hearing aid users with sensorineural hearing loss for a range of hearing sensitivities. Matching laboratory hearing aids were programmed with the deidentified fitting data. Output from these hearing aids was recorded at four SNRs and three presentation levels. The resulting signal modification was quantified using the cepstral correlation component of the Hearing Aid Speech Quality Index which measures the speech envelope changes in the context of a model of the listener’s hearing loss. These metric values represent the hearing aid processed signal as it is heard by the hearing aid user. Audiometric information was used to determine the nature of any possible association with the distribution of signal modification in these clinically fit hearing aids. Results: In general, signal modification increased as SNR decreased and presentation level increased. Differences across manufacturers were significant such that the effect of presentation level varied differently at each SNR, for each manufacturer. This result suggests that there may be variations across manufacturers in processing various listening conditions. There was no significant effect of technology level. There was a small effect of pure-tone average on signal modification for one manufacturer, but no effect of audiogram slope. Finally, there was a broad range of measured signal modification for a given hearing loss, for the same manufacturer and listening condition. Conclusions: The signal modification values in this study are representative of commonly fit hearing aids in clinics today. The results of this study provide insights into how the range of signal modifications obtained in real clinical fittings compares with a previous study. Future studies will focus on the behavioral implications of signal modifications in clinically fit hearing aids. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and text of this article on the journal’s Web site (www.ear-hearing.com). ACKNOWLEDGMENTS: The authors thank Kailey Durkin and Sarah Mullervy for conducting the hearing aid recordings, and Diane Novak and Pauline Norton for retrieving the hearing aid fitting data from Northwestern University Center for Speech, Language, & Learning. This study was supported by the National Institutes of Health Grant R01 DC012289 (to P.S. and K.A.). Portions of these data were presented at the 2018 International Hearing Aid Conference, Lake Tahoe, California, August 17, 2018. All authors contributed equally to this study. V.R., M.A., J.K., L.S., K.A., and P.S. contributed to the experimental design. V.R. and M.A. managed the experiment and supervised the hearing aid recordings. V.R. performed statistical analysis and wrote the main article. L.B. assisted with the design and interpretation of the statistical analysis and description of the results. M.A. and J.K. also contributed portions of the article. M.A. managed data retrieval at the University of Colorado Hospital, and L.S. managed data retrieval at I Love Hearing. P.S., M.A., K.A., J.K., L.S., and L.B. provided critical review of the article. All authors discussed the results and implications and contributed to the final article. The authors have no conflicts of interest to disclose. Received January 7, 2019; accepted June 4, 2019. Address for correspondence: Varsha Rallapalli, Department of Communication Sciences and Disorders, Northwestern University, 2240 Campus Drive, Evanston, IL 60208, USA. E-mail: varsha.rallapalli@northwestern.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Health-Related Quality of Life With Cochlear Implants: The Children’s Perspective Objectives: The objective of this study was to assess self-reported health-related quality of life (HR-QOL) in a group of children with cochlear implants (CIs) and to compare their scores to age- and gender-matched controls. The authors also assessed the agreement between proxy- and self-reported HR-QOL in the CI group and examined individual and environmental variables that could be associated with higher or lower self-reported HR-QOL in the CI group. Design: The sample consisted of 168 children between the ages of 5;6 and 13;1 (years;months), where 84 children had CIs (CI group) and 84 were age- and gender-matched controls with normal hearing (NH group). HR-QOL was assessed with the generic questionnaire Pediatric Quality of Life Inventory. Parents of the children in the CI group completed the same questionnaire as the children. In addition, the children in the CI group completed tests of language, hearing, and nonverbal I.Q. and background variables such as age at implantation and socioeconomic status were assessed. Results: On average, children with CIs rated their HR-QOL lower than peers with normal hearing on school functioning, social functioning, and overall HR-QOL. A higher percentage of children with CIs reported low levels of HR-QOL than did those in the NH group, 27% and 12%, respectively. The differences between groups were small, and fewer children than parents reported concerningly low HR-QOLs. Better spoken-language skills and older age at the time of testing was associated with better HR-QOL. Conclusions: Most children with CIs in this study reported HR-QOLs that were close to those of their age- and gender-matched normal-hearing peers. The children, however, reported concerns about social and school functioning, indicating that these areas require more attention to ensure children with CIs have good HR-QOL. Improving spoken-language skills in children with CIs may contribute to improved HR-QOL. ACKNOWLEDGMENTS: The authors thank the children and parents who participated in the study and the schools who allowed to recruit and test children in their facilities. The authors also thank the cochlear implant team at Oslo University Hospital for help with data collection and discussions during the writing progress. The authors thank Stefan Schauber at the University of Oslo for statistical help, Janet Olds at the Children’s Hospital of Eastern Ontario for valuable input, as well as to the people who helped collect data for the study, Marit Enny Gismarvik and Åsrun Valberg. The project was funded by the Norwegian Directory of Health and was executed in collaboration with Oslo University Hospital and the University of Oslo. The Regional Committees for Medical and Health Research Ethics in Norway and the Data Protection Official at Oslo University Hospital approved the study. The authors have no conflicts of interest to disclose. Received January 3, 2019; accepted May 20, 2019. Address for correspondence: Christiane Lingås Haukedal, Department of Special Needs Education, University of Oslo, P.O. Box 1140, Blindern, 0318 Oslo, Norway. E-mail: christiane.haukedal@isp.uio.no Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Links of Prosodic Stress Perception and Musical Activities to Language Skills of Children With Cochlear Implants and Normal Hearing Objectives: A major issue in the rehabilitation of children with cochlear implants (CIs) is unexplained variance in their language skills, where many of them lag behind children with normal hearing (NH). Here, we assess links between generative language skills and the perception of prosodic stress, and with musical and parental activities in children with CIs and NH. Understanding these links is expected to guide future research and toward supporting language development in children with a CI. Design: Twenty-one unilaterally and early-implanted children and 31 children with NH, aged 5 to 13, were classified as musically active or nonactive by a questionnaire recording regularity of musical activities, in particular singing, and reading and other activities shared with parents. Perception of word and sentence stress, performance in word finding, verbal intelligence (Wechsler Intelligence Scale for Children (WISC) vocabulary), and phonological awareness (production of rhymes) were measured in all children. Comparisons between children with a CI and NH were made against a subset of 21 of the children with NH who were matched to children with CIs by age, gender, socioeconomic background, and musical activity. Regression analyses, run separately for children with CIs and NH, assessed how much variance in each language task was shared with each of prosodic perception, the child’s own music activity, and activities with parents, including singing and reading. All statistical analyses were conducted both with and without control for age and maternal education. Results: Musically active children with CIs performed similarly to NH controls in all language tasks, while those who were not musically active performed more poorly. Only musically nonactive children with CIs made more phonological and semantic errors in word finding than NH controls, and word finding correlated with other language skills. Regression analysis results for word finding and VIQ were similar for children with CIs and NH. These language skills shared considerable variance with the perception of prosodic stress and musical activities. When age and maternal education were controlled for, strong links remained between perception of prosodic stress and VIQ (shared variance: CI, 32%/NH, 16%) and between musical activities and word finding (shared variance: CI, 53%/NH, 20%). Links were always stronger for children with CIs, for whom better phonological awareness was also linked to improved stress perception and more musical activity, and parental activities altogether shared significantly variance with word finding and VIQ. Conclusions: For children with CIs and NH, better perception of prosodic stress and musical activities with singing are associated with improved generative language skills. In addition, for children with CIs, parental singing has a stronger positive association to word finding and VIQ than parental reading. These results cannot address causality, but they suggest that good perception of prosodic stress, musical activities involving singing, and parental singing and reading may all be beneficial for word finding and other generative language skills in implanted children. ACKNOWLEDGMENTS: The authors thank the personnel, especially speech therapists (Nonna Virokannas, Sari Vikman, Satu Rimmanen, Teija Tsupari), of university hospital CI clinics in Helsinki, Tampere, Turku, and Kuopio, and the students who collected data. The authors also thank Professor Martti Vainio for his help with the prosodic experiments, and Professors Minna Huotilainen and Mari Tervaniemi for their help and advice. Above all, the authors thank the parents and children for their participation. This research was funded by the Signe and Ane Gyllenberg Foundation, the Finnish Concordia Fund, the Ella and Georg Ehrnrooth Foundation, National doctoral program Langnet, the Finnish Audiological Society, the Finnish doctoral program in language studies, funded by the Ministry of Education and Culture and the Emil Aaltonen Foundation. R. T. was responsible for experimental design, statistical analyses, performed most of experiments at University of Helsinki, and wrote the first version of the manuscript; A. F. designed the experiments on perception of word and sentence stress, participated in study design and statistical analyses, provided critical revision, and checked English language; M. L. was responsible for supervising students who carried out psychological assessments and I.Q. tests; J. L. was responsible for statistical analyses and provided critical revision; D.S. commented on statistical analyses and provided critical revision. All authors discussed the results and implications and commented on the article at all stages. The authors have no conflicts of interest to declare. Received August 16, 2018; accepted May 29, 2019. Address for correspondence: Ritva Torppa, Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, PL 21 (Haartmanink atu 3) 00014 Helsinki, Finland. E-mail: ritva.torppa@helsinki.fi This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

A Comparison of Intracochlear Pressures During Ipsilateral and Contralateral Stimulation With a Bone Conduction Implant Objectives: To compare contralateral to ipsilateral stimulation with percutaneous and transcutaneous bone conduction implants. Background: Bone conduction implants (BCIs) effectively treat conductive and mixed hearing losses. In some cases, such as in single-sided deafness, the BCI is implanted contralateral to the remaining healthy ear in an attempt to restore some of the benefits provided by binaural hearing. While the benefit of contralateral stimulation has been shown in at least some patients, it is not clear what cues or mechanisms contribute to this function. Previous studies have investigated the motion of the ossicular chain, skull, and round window in response to bone vibration. Here, we extend those reports by reporting simultaneous measurements of cochlear promontory velocity and intracochlear pressures during bone conduction stimulation with two common BCI attachments, and directly compare ipsilateral to contralateral stimulation. Methods: Fresh–frozen whole human heads were prepared bilaterally with mastoidectomies. Intracochlear pressure (PIC) in the scala vestibuli (PSV) and tympani (PST) was measured with fiber optic pressure probes concurrently with cochlear promontory velocity (VProm) via laser Doppler vibrometry during stimulation provided with a closed-field loudspeaker or a BCI. Stimuli were pure tones between 120 and 10,240 Hz, and response magnitudes and phases for PIC and VProm were measured for air and bone conducted sound presentation. Results: Contralateral stimulation produced lower response magnitudes and longer delays than ipsilateral in all measures, particularly for high-frequency stimulation. Contralateral response magnitudes were lower than ipsilateral response magnitudes by up to 10 to 15 dB above ~2 kHz for a skin-penetrating abutment, which increased to 25 to 30 dB and extended to lower frequencies when applied with a transcutaneous (skin drive) attachment. Conclusions: Transcranial attenuation and delay suggest that ipsilateral stimulation will be dominant for frequencies over ~1 kHz, and that complex phase interactions will occur during bilateral or bimodal stimulation. These effects indicate a mechanism by which bilateral users could gain some bilateral advantage. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and text of this article on the journal’s Web site (www.ear-hearing.com). ACKNOWLEDGMENTS: J.K.M., H.A.J., D.J.T., S.P.C., and N.T.G. designed and performed the experiments; H.A.J., D.J.T., and S.P.C. reviewed data and provided interpretive analysis; J.K.M., R.M.B.H., S.P.C., and N.T.G. analyzed data and wrote the paper. All authors discussed the results and implications and commented on the manuscript at all stages. This work was supported by AAO-HNSF Resident Research Grant from The Oticon Foundation (to J. K. M.) and NIH/NIDCD 1T32-DC012280 (to R. M. B. H. and N. T. G.). We appreciate the assistance of Dr. Michael Hall in constructing some of the custom experimental equipment (supported by National Institutes of Health grant P30 NS041854). S.P.C. is a consultant for Cochlear Corporation. The other authors have no conflicts of interest to disclose. Received January 8, 2018; accepted May 15, 2019. Address for correspondence: Nathaniel T. Greene, Department of Otolaryngology, University of Colorado School of Medicine, 12631 E. 17th Avenue, B205, Aurora, CO 80045, USA. E-mail: nathaniel.greene@ucdenver.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

10-Year Follow-Up Results of The Netherlands Longitudinal Study on Hearing: Trends of Longitudinal Change in Speech Recognition in Noise Objectives: Previous findings of longitudinal cohort studies indicate that acceleration in age-related hearing decline may occur. Five-year follow-up data of the Netherlands Longitudinal Study on Hearing (NL-SH) showed that around the age of 50 years, the decline in speech recognition in noise accelerates compared with the change in hearing in younger participants. Other longitudinal studies confirm an accelerated loss in speech recognition in noise but mostly use older age groups as a reference. In the present study, we determined the change in speech recognition in noise over a period of 10 years in participants aged 18 to 70 years at baseline. We additionally investigated the effects of age, sex, educational level, history of tobacco smoking, and alcohol use on the decline of speech recognition in noise. Design: Baseline (T0), 5-year (T1), and 10-year (T2) follow-up data of the NL-SH collected until May 2017 were included. The NL-SH is a web-based prospective cohort study which started in 2006. Central to the NL-SH is the National Hearing test (NHT) which was administered to the participants at all three measurement rounds. The NHT uses three-digit sequences which are presented in a background of stationary noise. The listener is asked to enter the digits using the computer keyboard. The outcome of the NHT is the speech reception threshold in noise (SRT) (i.e., the signal to noise ratio where a listener recognizes 50% of the digit triplets correctly). In addition to the NHT, participants completed online questionnaires on demographic, lifestyle, and health-related characteristics at T0, T1, and T2. A linear mixed model was used for the analysis of longitudinal changes in SRT. Results: Data of 1349 participants were included. At the start of the study, the mean age of the participants was 45 years (SD 13 years) and 61% of the participants were categorized as having good hearing ability in noise. SRTs significantly increased (worsened) over 10 years (p < 0.001). After adjustment for age, sex, and a history of tobacco smoking, the mean decline over 10 years was 0.89 dB signal to noise ratio. The decline in speech recognition in noise was significantly larger in groups aged 51 to 60 and 61 to 70 years compared with younger age groups (18 to 30, 31 to 40, and 41 to 50 years) (p < 0.001). Speech recognition in noise in participants with a history of smoking declined significantly faster during the 10-year follow-up interval (p = 0.003). Sex, educational level, and alcohol use did not appear to influence the decline of speech recognition in noise. Conclusions: This study indicated that speech recognition in noise declines significantly over a 10-year follow-up period in adults aged 18 to 70 years at baseline. It is the first longitudinal study with a 10-year follow-up to reveal that the increased rate of decline in speech recognition ability in noise already starts at the age of 50 years. Having a history of tobacco smoking increases the decline of speech recognition in noise. Hearing health care professionals should be aware of an accelerated decline of speech recognition in noise in adults aged 50 years and over. ACKNOWLEDGMENTS: The authors thank the participants on the Netherlands Longitudinal Study on Hearing (NL-SH). The authors also thank the assistance of Celina Henke in managing the database. The first measurement round of the Netherlands Longitudinal Study on Hearing (NL-SH) (2006–2010) was financially supported by the Heinsius Houbolt Foundation, The Netherlands. Sonova AG, Switzerland supported the data collection of the second measurement round (since 2011). Funding for data collection of the third measurement round (since 2016) came from the EMGO Institute for Health and Care Research, The Netherlands, and Sonova AG, Switzerland. T.P.M.G., M.S., P.M., U.L., C.S., and S.E.K. were involved in formulating the research questions and in designing the study. T.P.M.G. performed the analysis and M.S. and B.I.L.-W. verified the analytical methods. T.P.M.G. took the lead in writing the article. All authors provided critical feedback and helped shape the research, analysis, and article. Received June 28, 2018; accepted June 19, 2019. The authors have no conflicts of interest to disclose. Address for correspondence: Thadé P. M. Goderie, Department of Otolaryngology/Head and Neck Surgery, Section Ear and Hearing, Amsterdam University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands. E-mail: t.goderie@vumc.nl This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Role of Lexical Tone Information in the Recognition of Mandarin Sentences in Listeners With Hearing Aids Objectives: Lexical tone information provides redundant cues for the recognition of Mandarin sentences in listeners with normal hearing in quiet conditions. The contribution of lexical tones to Mandarin sentence recognition in listeners with hearing aids (HAs) is unclear. This study aimed to remove lexical tone information and examine the effects on Mandarin sentence intelligibility in HA users. The second objective was to investigate the contribution of cognitive abilities (i.e., general cognitive ability, working memory, and attention) on Mandarin sentence perception when the presentation of lexical tone information was mismatched. Design: A text-to-speech synthesis engine was used to manipulate Mandarin sentences into three test conditions: (1) a Normal Tone test condition, where no alterations were made to lexical tones within sentences; (2) a Flat Tone test condition, where lexical tones were all changed into tone 1 (i.e., the flat tone); and (3) a Random Tone test condition, where each word in test sentences was randomly assigned one of four Mandarin lexical tones. The manipulated sentence signals were presented to 32 listeners with HAs in both quiet and noisy environments at an 8 dB signal to noise ratio. Results: Speech intelligibility was reduced significantly (by approximately 40 percentage points) in the presence of mismatched lexical tone information in both quiet and noise. The difficulty in correctly identifying sentences with mismatched lexical tones among adults with hearing loss was significantly greater than that of adults with normal hearing. Cognitive function was not significantly related to a decline in speech recognition scores. Conclusions: Contextual and other phonemic cues (i.e., consonants and vowels) are inadequate for HA users to perceive sentences with mismatched lexical tone contours in quiet or noise. Also, HA users with better cognitive function could not compensate for the loss of lexical tone information. These results highlight the importance of accurately representing lexical tone information for Mandarin speakers using HAs. ACKNOWLEDGMENTS: Y.C., L.L.N.W, J.Q., V.K., and S.C.V. designed experiments. Y.C. analyzed data and wrote the article; L.L.N.W. provided critical revision. F.C. created the test materials. All authors discussed the results and implications and commented on the article at all stages. The study described in this article was partially supported by the Research Seed Fund 2018/2019 of the Department of Special Education and Counselling at the Education University of Hong Kong and by Phonak China. The authors have no conflicts of interest to disclose. Received September 24, 2018; accepted June 6, 2019. Address for correspondence: Yuan Chen, Department of Special Education and Counselling, The Education University of Education, Hong Kong SAR, China. E-mail: cheny@eduhk.hk Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Age Effects on Cochlear Reflectance in Adults Objectives: Cochlear reflectance (CR) is the cochlear contribution to ear-canal reflectance. CR is a type of otoacoustic emission that is calculated as a transfer function between forward pressure and reflected pressure. The purpose of this study was to assess effects of age on CR in adults and interactions among age, sex, and hearing loss. Design: Data were collected from 60 adults selected for their age (e.g., 20–29, 30–39, 40–49, 50–59, 60–69, 70–79 years) and normal middle ear status. A wideband noise stimulus presented at three stimulus levels (30, 40, 50 dB SPL) was used to elicit CR. Half-octave bands of CR signal magnitude (CRM), CR noise, and the CR signal-to-noise ratio (CR-SNR) were extracted from the wideband CR response. Regression analyses were conducted to assess interactions among CR, age, sex, and pure-tone thresholds at closely matched frequency bands across stimulus levels. Results: Although increased age was generally associated with lower CRM and CR-SNR at some band frequencies and stimulus levels, no significant effects of age remained after controlling for effects of pure-tone thresholds. Increases in pure-tone thresholds were associated with lower CRM and CR-SNR at most frequency bands and stimulus levels. Effects of hearing sensitivity were significant at some frequencies and levels after controlling for age and sex. Conclusions: When effects of age were controlled, adults with better hearing had significantly larger CRM and CR-SNR than those with poorer hearing. In contrast, when effects of hearing were controlled, no significant effects of age on CRM and CR-SNR remained. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and text of this article on the journal’s Web site (www.ear-hearing.com). ACKNOWLEDGMENTS: All authors contributed equally to this work. S. E. F. collected data and wrote the main paper; K. I. V. performed the modeling and statistical analysis and provided the Supplementary Materials (Supplemental Digital Content 1 and 2, http://links.lww.com/EANDH/A556 and http://links.lww.com/EANDH/A557); J. G. K. contributed to experiment design and revisions; J. R. D., S. T. N., and D. M. R. reviewed data and provided interpretive analysis and critical revisions. All authors discussed the results and implications and commented on the manuscript at all stages. We are grateful to Jayne Ahlstrom, Michael Gorga, Natalie Lenzen, and Matthew Waid for their contributions to study development, calibration, and data collection. This research was supported by grants R01 DC8318, R01 DC016348, P30 DC4662, R01 DC000184, and P50 DC000422 from the National Institute of Health/National Institute on Deafness and Other Communication Disorders The authors have no conflicts of interest to disclose. Received December 12, 2018; accepted May 31, 2019. Address for correspondence: Sara E. Fultz, Center for Hearing Research, Boys Town National Research Hospital, 555 N 30th St. Omaha, Nebraska 68131, USA. E-mail: sara.fultz@boystown.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Health Literacy and Self-Reported Hearing Aid Use in the Health and Retirement Study Objectives: Understanding the determinants of hearing aid use is important to improve the provision of hearing healthcare. Prior research has indicated that materials in the clinic and online, as well as audiologists’ language during appointments, require a higher literacy level than most patients possess. We hypothesized that low health literacy is a barrier to entry in hearing healthcare, and therefore that health literacy would be positively correlated with the probability of hearing aid use. Design: We performed retrospective analyses of the Health and Retirement Study, a longitudinal survey of American adults of retirement age. Objective health literacy was measured in different but overlapping subsamples using subsets of the Test of Functional Health Literacy in Adults and the Rapid Estimate of Adult Literacy in Medicine (n = 1240, n = 1586, and n = 2412). Subjective health literacy was assessed using a single-question screener in a larger sample (n = 8362). Separate discrete time models including common covariates of hearing aid use were constructed for each subsample. Results: Objective health literacy measures did not correlate significantly with hearing aid use when age, gender, race/ethnicity, self-assessed hearing ability, and net income were included in the models. Subjective health literacy did correlate significantly with hearing aid use in the complete model, with lower subjective health literacy correlated with lower odds of reporting hearing aid use. Conclusions: Taken at face value, the results provide mixed evidence for a link between health literacy and hearing aid use. The results from the analysis of the largest sample, using the subjective health literacy measure, were consistent with the hypothesis that low health literacy is a barrier to hearing aid use. However, this was not supported by the analysis of the objective health literacy measures in these samples. Further research using full health literacy measurement tools and capturing other relevant variables would offer clarification on this conflict. The literacy level of clinical materials and conversation is a modifiable potential factor in hearing aid uptake, so further clinical and research consideration is warranted. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and text of this article on the journal’s Web site (www.ear-hearing.com). ACKNOWLEDGMENTS: The Health and Retirement Study is supported by NIA U01AG009740 and the Social Security Administration. N.K., Z.M.S., and S.D. contributed to the analysis design. N.K. conducted the analysis. N.K. and Z.M.S. drafted the paper. All authors reviewed, edited, and approved the final paper. The authors have no conflicts of interest to disclose. Received August 28, 2018; accepted May 29, 2019. Address for correspondence: Niall Andre Munson Klyn, The Richard and Roxelyn Pepper Department of Communication Sciences and Disorders, Northwestern University, 2240 Campus Drive, Evanston, IL 60208, USA. E-mail: niall.klyn@northwestern.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

A Cross-Sectional Study of the Prevalence and Factors Associated With Tinnitus and/or Hyperacusis in Children Objectives: The aim of this study was to determine the prevalence of tinnitus and/or hyperacusis in Danish children aged 10 to 16 years, and to assess associations between tinnitus or hyperacusis and other relevant factors. Design: A cross-sectional study based on a previously established child cohort. A total of 501 children were enrolled in the project. The study was performed in eight mainstream schools and data were collected during an 8-week period from October 27, 2014 to December 16, 2014. Results: Using broad tinnitus research questions, the prevalence of any tinnitus was 66.9%; of noise-induced tinnitus (NIT) was 35.7%; and of spontaneous tinnitus (ST) was 53.7%. Bothersome tinnitus was reported by 34.6% of the children with any tinnitus, 23.2% of the whole population. Few children were severely bothered (2.4%, 1.6%, respectively). It was significantly more common for children with NIT to report tinnitus episodes lasting for minutes or longer than for children with ST (p = 0.01). Girls were more likely than boys to be bothered by tinnitus [Odds ratio (OR) = 2.96; 95% confidence interval (CI) 1.34 to 6.51; p = 0.01]. 14.6% of the children reported hyperacusis, and 72.6% of those reporting hyperacusis were bothered by it, 10.6% of the whole population. The odds of having hyperacusis were 4.73 (1.57, 14.21) times higher among those with ST compared with those without ST. Furthermore, hyperacusis was associated with sound avoidance behaviors such as experience of sound-induced pain in the ear (OR = 2.95, 95% CI 1.65 to 5.27; p < 0.001), withdrawal from places or activities (OR = 3.33; 95% CI 1.44 to 7.69; p = 0.01), or concerns about sound could damage the hearing (OR = 1.85, 95% CI 1.06 to 3.31; p = 0.03). Conclusions: Tinnitus and hyperacusis are common in children but prevalence is dependent on tinnitus definitions. Only a few children are severely bothered by tinnitus. In the case of hyperacusis, children may exhibit sound avoidance behavior. ACKNOWLEDGMENTS: First, we thank all the children and families participating in this study. We are also extremely grateful for the accept from the ALSPAC-study for collaboration in terms of providing their questionnaire and study protocol for us to use and their additional help. We also thank The Municipality of Svendborg and the Svendborg Project for including us in their project. SDE College Odense kindly participated with final-year students that provided all hearing measurements. A special thanks to technician Arne Hutflesz for his support and ongoing technical assistant. Rachel Humphriss and Amanda Hall were generous in sharing the protocol and definitions used in Humphriss et al. (2016). The present publication is the work of the authors, and Susanne Nemholt will serve as guarantor for the contents of this article. This study is part of the Ph.D. project Tinnitus and Hyperacusis Among Children and Adolescents in Denmark (THACAD), which has been funded by The Capital Region of Denmark, The University of Southern Denmark and The Danish Association of the Hard of Hearing. This particular study was additional funded by Oticon Fonden and GN Store Nord Fondet. This report is independent research, and David Baguley’s involvement is funded by the National Institute for Health Research. The views expressed in this publication are those of the authors, and not necessarily those of the NHS, the National Institute for Health Research, nor the UK Department of Health. The authors have no conflicts of interest to disclose. Received August 5, 2016; accepted May 20, 2019. Address for correspondence: Susanne Nemholt, Syddansk Universitet, Campusvej 55, DK-5230 Odense, Denmark. E-mail: snemholt@health.sdu.dk This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.