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Simple Summary: A study examined how noise affects cats undergoing surgery in hospitals. Cats exposed to louder noises showed higher stress levels. Monitoring their behavior and breathing helps assess stress. Minimizing hospital noise is crucial for cat welfare, supporting guidelines to make their stay more comfortable. This study emphasizes the importance of minimizing noise levels in hospitals to improve the welfare of hospitalized cats, aligning with existing recommendations for enhancing feline well-being. The study aimed to investigate the impact of noise levels in the hospital environment on the stress experienced by hospitalized cats undergoing elective ovariohysterectomy surgery. A total of 33 domestic female cats were included in the study, divided into four groups: a control group (CG) and three experimental groups based on ward noise levels: G1 (Quiet, <60 dB), G2 (Medium, between 60 and 85 dB), and G3 (Noisy, >85 dB). Behavioral assessments, respiratory rate (RR), and plasma cortisol levels ([Cort]p) were measured as indicators of stress. A composite measure of stress, termed the final stress value (FSV), was calculated by summing scores across various behavioral categories. Data collection occurred at three time points: immediately following surgery (T1), and at 2 h (T2) and 3 h (T3) post-surgery. FSV and RR were assessed at all three time points (T1, T2, and T3), while [Cort]p levels were measured at T1 and T3. The study observed that the median values of FSV, RR, and [Cort]p tended to increase with both higher noise levels and longer exposure durations to noise. Significant differences in RR were found between group pairs G1G2 at T1 (|D| = 0.63 < cut-off = 0.98), and G2G3 at T2 (|D| = 0.69 < cut-off = 0.97). Regarding [Cort]p, significant differences were noted between the CGG1 group pair at T0 (p < 0.01), and T3 (p = 0.03). Furthermore, an excellent Spearman correlation coefficient (rho = 0.91) was found between FSV and RR, indicating that RR can serve as an effective tool for assessing stress levels in cats. The findings of this study provide valuable insights into the welfare of cats in a hospital environment and support the scientific validity of existing recommendations aimed at improving their well-being. Specifically, the study underscores the importance of minimizing noise levels in hospitals as a means to reduce stress in cats. This conclusion aligns with existing guidelines and recommendations for enhancing the welfare of hospitalized cats. [ABSTRACT FROM AUTHOR]

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Purpose: In the present report, we reviewed the role of cortical auditory evoked potentials (CAEPs) as an objective measure during the evaluation and management process in children with auditory neuropathy spectrum disorder (ANSD). Method: We reviewed the results of CAEP recordings in 66 patients with ANSD aged between 2 months and 12 years and assessed the relationship between their characteristics (prevalence, morphology, latencies, and amplitudes) and various clinical features, including the mode of medical management. Results: Overall, the CAEPs were present in 85.2% of the ears tested. Factors such as prematurity, medical complexity, neuronal issues, or presence of syndromes did not have an effect on the presence or absence of CAEPs. CAEP latencies were significantly shorter in ears with cochlear nerve deficiency than in ears with a normal caliber nerve. Three different patterns of CAEP responses were observed in patients with bilateral ANSD and present cochlear nerves: (a) responses with normal morphology and presence of both P1-P2complex and N2 components, (b) responses with abnormal morphology and presence of the N2 component but undefined P1-P2complex peak, and (c) entirely absent responses. None of the patients with normal, mild, or moderate degree of hearing loss had a complete absence of CAEP responses. No significant differences were uncovered when comparing the latencies across unaided and aided children and children who later received cochlear implants. Conclusions: The CAEP protocol used in our ANSD program did inform about the presence or absence of central auditory stimulation. Absent responses typically fit into an overall picture of complete auditory deprivation and all of these children were ultimately offered cochlear implants after failing to develop oral language. Present responses, on the other hand, were acknowledged as a sign of some degree of auditory stimulation but always interpreted with caution given that prognostic implications remain unclear. [ABSTRACT FROM AUTHOR]

Earthquake-triggered fire domino scenarios (E-FDSs) arise frequently from the interaction between earthquakes and chemical installations, resulting in catastrophic multi-hazard coupling events. The complicated mutually amplified phenomena between natural disasters and chemical accidents significantly aggravates the escalation of domino accidents, which has posed great challenges for modeling and preventing E-FDSs. Under this impetus, this work proposes an advanced type-2 fuzzy probabilistic methodology to obtain the time-dependent failure probability of steel cylindrical tanks (SCTs) subjected to the earthquake-fire sequence. To cope with the limited prior knowledge on E-FDSs, a basic universal is established to describe the fire resistance attenuation caused by the seismic damage. The coupling failure criterion of SCTs is formulated by a type-2 fuzzy time-dependent limit state equation. A credibility-based stochastic simulation algorithm is developed for the hybrid uncertainty analysis (combining ambiguity and stochasticity). The proposed methodology is validated by case studies of a 5000 m3 fixed roof tank. Compared to the existing accident probability model, the proposed methodology can not only capture the fire resistance attenuation caused by the seismic damage but also provide a dynamic estimation of tank failure probability with respect to the fire exposure time. The proposed methodology can effectively and dynamically capture the accident evolution process, which in turn helps mitigate and prevent the spatiotemporal propagation of domino effects. • Pivotal insights on the multi-hazard amplified phenomena are provided. • The time-dependent evolution of earthquake-fire coupling fragility is revealed. • An advanced multi-hazard dynamic coupling fragility methodology is proposed. • Hybrid uncertainty analysis combining ambiguity and stochasticity is achieved. • Dynamic fire failure interval of seismic damaged tanks can be identified. [ABSTRACT FROM AUTHOR]

Significance: The stria vascularis, located in the inner ear, consists of three layers, one of which is the blood–labyrinth barrier (BLB). It is formed by endothelial cells, sealed together to prevent the passage of toxic substances from the blood to the inner ear, by pericytes and perivascular-resident macrophage-like melanocyte. Recent Advances: There are various causes that lead to hearing loss, and among these are noise-induced and autoimmune hearing loss, ear disorders related to ototoxic medication, Ménière's disease, and age-related hearing loss. For all of these, major therapeutic interventions include drug-loaded nanoparticles, via intratympanic or intracochlear delivery. Critical Issues: Since many pathologies associated with hearing loss are characterized by a weakening of the BLB, in this review, the molecular mechanisms underlying the response to damage of BLB cellular components have been discussed. In addition, insight into the role of hormetic nutrients against hearing loss pathology is proposed. Future Directions: BLB cellular components of neurovascular cochlear unit play important physiological roles, owing to their impermeable function against all ototoxic substances that can induce damage. Studies are needed to investigate the cross talk occurring between these cellular components to exploit their possible role as novel targets for therapeutic interventions that may unravel future path based on the use of hormetic nutrients. Antioxid. Redox Signal. 40, 542–563. [ABSTRACT FROM AUTHOR]

Binaural beats are a low-frequency form of acoustic stimulation that may be heard between 200 and 900 Hz and can help reduce anxiety as well as alter other psychological situations and states by affecting mood and cognitive function. However, prior research has only looked at the impact of binaural beats on state and trait anxiety using the STA-I scale; the level of anxiety has not yet been evaluated, and for the removal of artifacts the improper selection of wavelet parameters reduced the original signal energy. Hence, in this research, the level of anxiety when hearing binaural beats has been analyzed using a novel optimized wavelet transform in which optimized wavelet parameters are extracted from the EEG signal using the flower pollination algorithm, whereby artifacts are removed effectively from the EEG signal. Thus, EEG signals have five types of brainwaves in the existing models, which have not been analyzed optimally for brainwaves other than delta waves nor has the level of anxiety yet been analyzed using binaural beats. To overcome this, deep convolutional neural network (CNN)-based signal processing has been proposed. In this, deep features are extracted from optimized EEG signal parameters, which are precisely selected and adjusted to their most efficient values using the flower pollination algorithm, ensuring minimal signal energy reduction and artifact removal to maintain the integrity of the original EEG signal during analysis. These features provide the accurate classification of various levels of anxiety, which provides more accurate results for the effects of binaural beats on anxiety from brainwaves. Finally, the proposed model is implemented in the Python platform, and the obtained results demonstrate its efficacy. The proposed optimized wavelet transform using deep CNN-based signal processing outperforms existing techniques such as KNN, SVM, LDA, and Narrow-ANN, with a high accuracy of 0.99%, precision of 0.99%, recall of 0.99%, F1-score of 0.99%, specificity of 0.999%, and error rate of 0.01%. Thus, the optimized wavelet transform with a deep CNN can perform an effective decomposition of EEG data and extract deep features related to anxiety to analyze the effect of binaural beats on anxiety levels. [ABSTRACT FROM AUTHOR]

Objective: Investigate the prevalence of hearing protection (HP) use and behavioral motivations and barriers among adults attending music venues. Study Design: Cross‐sectional online survey study. Setting: Noise exposure levels at popular social music venues often exceed national guidelines. Methods: Surveys were distributed on online music communities. Respondents (n = 2352) were asked about demographics, HP use at music venues, knowledge about noise exposure impact, and perceptions of HP use. Data were characterized through descriptive statistics. Multivariable regression analysis explored differences in knowledge and perception between HP users and nonusers. Results: In this cohort (mean age 29 ± 7 years, 61% male), HP users were significantly more aware of the impact of music venues on hearing (P <.01), believed their hearing ability had decreased after attending music venues (P < 0.01), and believed HP could protect from hearing loss (P <.01) than non‐HP users. HP nonusers most frequently cited never considering HP (14.45%) and apathy about it affecting music quality (12.71%). Common sources of HP information were recommended by a friend/peer. Multivariable regression analysis accounting for demographics, medical history, and attendance characteristics found belief that HP use at music venues could protect from hearing loss (β = 0.64, 95% confidence interval [CI] = [0.49‐0.78]) and HP use (β = 1.73, 95% CI = [1.47‐1.98]) were significantly associated with increased subjective enjoyment while wearing HP. Conclusion: HP users and nonusers have significantly different perceptions of HP use and its impact. Our findings have implications for understanding motivations and barriers related to HP use and developing strategies to promote HP use at music venues. [ABSTRACT FROM AUTHOR]

Deaf people communicate naturally through sign languages and often face barriers to communicating with hearing people and accessing information in written languages. These communication difficulties are aggravated in the health domain, especially in a hospital emergency, when human sign language interpreters are unavailable. This paper proposes a solution for automatically recognizing signs in Brazilian Sign Language (Libras) in the health context to reduce this problem. The idea is that the system could assist in the communication between a Deaf patient and his doctor in the future. Our solution involves a multiple-stream architecture that combines convolutional and recurrent neural networks, dealing with sign languages' visual phonemes individual and specialized ways. The first stream uses the optical flow as input for capturing information about the "movement" of the sign; the second stream extracts kinematic and postural features, including "handshapes" and "facial expressions"; and the third stream process the raw RGB images to address additional attributes about the sign not captured in the previous streams. Thus, we can process more spatiotemporal features that discriminate the classes during the training stage. The computational results show that the solution can recognize signs in Libras in the health context, with an average accuracy, precision, recall, and f1-score of 99.80%, 99.81%, 99.80%, and 99.80%, respectively. Our system also performed better than other works in the literature, obtaining an average accuracy of 100% in an Argentine Sign Language (LSA) dataset, which is usually used for comparison purposes. [ABSTRACT FROM AUTHOR]

Simple Summary: Imepitoin is a medication that can be used to treat anxiety in dogs. Previous studies have shown that imepitoin when given at a dose of 30 mg/kg PO BID (milligram per kilogram of body weight by mouth twice a day), can reduce noise-related anxiety in dogs. However, this dosage may be higher than needed for some dogs. We aimed to determine how safe and effective this medication is for the treatment of storm-related fear and anxiety in dogs when started at a lower dose (10 mg/kg PO BID) and, if needed, when increased to a higher dose of 20 or 30 mg/kg PO BID. We determined the three dosages were safe and reduced clinical signs of storm related fear and anxiety in this study design. More side effects were seen in the 20 mg/kg PO BID group than in the 10 mg/kg PO BID group, which supports the use of this medication at an individually titrated dose starting at 10 mg/kg PO BID. Imepitoin is a low-affinity partial agonist for benzodiazepine binding sites of gamma-aminobutyric acid receptors with anxiolytic effects. It has been shown to reduce anxiety during noise-related events in dogs when given at 30 mg/kg PO BID, although this dose was associated with ataxia and increased appetite in some cases. The objective of this study was to assess its safety and efficacy for storm anxiety when started at 10 mg/kg PO BID and titrated to effect up to 30 mg/kg PO BID during storm season. Significant decreases in anxiety scores were seen in weekly surveys and storm logs (SLs) at 10, 20 and 30 mg/kg PO BID. Serious adverse events (AEs) were not reported in any subject. Ataxia was the most commonly reported non-serious AE (14/33), followed by increased hunger (13/33). The frequency of AEs was higher in the 20 mg/kg PO BID group than in the 10 mg/kg group PO BID. No clinically significant changes were seen in lab work pre- and post-study. In conclusion, Imepitoin given during storm season at doses ranging from 10 to 30 mg/kg PO BID reduced clinical signs of fear and anxiety during storms for the dogs in this study. These findings support the use of an individually titrated dose. [ABSTRACT FROM AUTHOR]

Objective: External auditive exostosis (EAE), known as surfer's ear, is a temporal bone outgrowth resulting from ear exposure to cold air and water. This review aims to shed light on the prevalence of EAE among worldwide surfers. Methods: By a thorough retrieval of the PubMed, we found all original investigations performed on EAE among suffers. The retrieval time was from the construction of the database to December 2022. Agency for Healthcare Research and Quality (AHRQ) methodology checklist for assessing the quality of cross-sectional/prevalence study was performed. Results: 19 articles were selected involving 2997 surfers on whom 2032 presented EAE. The prevalence of EAE was ranged from 53 to 90% with a mean at 67.8%. 3 investigations were performed from USA, five from UK and Ireland, five from Australia and New Zealand and six from Japan and Europe. Conclusion: Cold water exposure, combined with wind and prolonged surfing activity, contributes to the development of EAE. Symptoms range from mild discomfort to hearing loss and recurrent infections. Preventive measures, such as raising awareness and promoting the use of ear protection, are crucial. Further research is needed to improve prevention strategies and understand the underlying mechanisms of EAE. [ABSTRACT FROM AUTHOR]

Background: Poor quality sleep in hospitals may be problematic for patients, negatively impacting their recovery and wellbeing. This project aimed to investigate the effectiveness of codesign in addressing key issues affecting sleep disruption in the healthcare setting. Methods: Codesign with patients, staff and consumer representatives was conducted in an acute metropolitan tertiary public hospital in Sydney, Australia. Through a four‐stage process, a multimodal intervention to address and reduce the impact of sleep disruptions among hospital inpatients was created. Pre‐ and post‐intervention evaluation was used to determine changes in patient‐reported sleep disruption. Results: 'The HUSH Project' (Help Us Support Healing) intervention resulted from the codesign process, which included the provision of HUSH Sleep Packs (with earplugs, eye masks and herbal tea), patient information resources, and ward‐based Sleep Champions. Survey data from 210 patients revealed a statistically significant decrease in patient‐reported noise disturbances for patients in shared rooms following the 4‐week intervention period of the HUSH program. Conclusion: The HUSH Project demonstrated that a novel multimodal intervention may be valuable in reducing sleep disruption in hospitals. These findings also indicate the benefits of using codesign methodology to support improvement projects that seek to enhance patient experiences of care. Patient or Public Contribution: This project utilised codesign methodology, which involved significant contributions from patients and consumer representatives, from research conceptualisation into intervention design, implementation and project evaluation. [ABSTRACT FROM AUTHOR]

Ensuring the safety of forestry workers is a key challenge, particularly when working with partly mechanized harvesting systems. Cable yarding is typically used in steep terrain timber harvesting. For long-distance extraction, one of the few alternatives is to use sledge yarders, but these machines may expose workers to high doses of noise. The goal of this study was to model haulers' exposure to noise in sledge-based cable yarding operations, based on a simulation approach that considered variable factors such as the yarding distance, lateral yarding distance, and average skyline height. Taken into consideration were 165 scenarios developed by examining the variation in yarding distance (500 to 1500 m, with a step of 100 m), lateral yarding distance (10 to 50 m, with a step of 10 m), and average skyline height above the ground (10, 15, and 20 m). The simulations assumed an 8-h working day with a break of 1 h. The models and statistics published by other studies were used to calculate the time consumption and number of work cycles completed within a working day. These data were used to compute the equivalent exposure to noise (LAeq) for each scenario, as well as for those work elements that were likely to expose the haulers to noise the most. The presented findings indicated that (i) the exposure to noise was higher than 100 dB(A), irrespective of variation in the considered factors; (ii) the trend in exposure was characterized by polynomials in relation to the extraction distance, and the magnitude of exposure was consistently affected by variation in the considered factors; and (iii) without hearing protection, the empty and loaded turns exposed workers to noise over the permissible limits. These findings strongly suggest the use of hearing protection when working in close proximity to sledge-based cable yarding operations. The methods proposed in this study in the form of simulation may help benchmark other forest operations. [ABSTRACT FROM AUTHOR]

Objective: This study evaluated the potential of high-molecular-weight hyaluronic acid (HHA) as an intratympanic (IT) drug delivery vehicle for dexamethasone (D) in treating acute hearing loss. We compared the efficacy, safety, and residence time of HHA to the standard-of-care IT drug delivery method. Methods: Endoscopic examinations were used to track tympanic membrane (TM) healing post-IT injection. Micro-computed tomography (CT) was used to gauge drug/vehicle persistence in the bulla air space. Histological analyses covered the middle ear, TM, and hair cell counts. Auditory brainstem responses (ABR) were used to measure hearing thresholds, while high-performance liquid chromatography (HPLC) was employed to quantify cochlear perilymph dexamethasone concentrations. Results: The HHA + D group had a notably prolonged drug/vehicle residence time in the bulla (41 ± 27 days) compared to the saline + D group (1.1 ± 0.3 days). Complete TM healing occurred without adverse effects. Histology revealed no significant intergroup differences or adverse outcomes. Hearing recovery trends favored the HHA + D group, with 85.0% of ears showing clinically meaningful improvement. D concentrations in cochlear perilymph were roughly double in the HHA group. Conclusion: HHA is a promising vehicle for IT drug delivery in treating acute hearing loss. It ensures extended residence time, augmented drug concentrations in targeted tissues, and safety. These results highlight the potential for HHA + D to excel beyond existing standard-of-care treatments for acute hearing loss. [ABSTRACT FROM AUTHOR]

Background: In 2016, we developed a pediatric parent advisory group to inform our research program which creates innovative knowledge translation (KT) tools for parents on priority topics related to acute childhood illness. We implemented a mixed methods strategy to evaluate the experiences of group members. The purpose of this paper is to present the findings from parent evaluations over four years and to discuss our experiences collaborating with the group over a multi-year period. Methods: We conducted year-end surveys and interviews of group members to understand parents' perceptions of their experiences, group management, researcher interaction, and other outcomes of advisory group participation from 2018 to 2021. We applied a mixed methods approach, collecting and analyzing both quantitative (survey) and qualitative (survey/interview) data. Survey data were analyzed by term using descriptive statistics (i.e., frequencies, percentages). Open-ended survey responses were analyzed by conventional content analysis. Interview data were analysed thematically. Results: Year-end survey response rates and interview participation varied over the years. Responses to evaluation questions were generally positive and most improved over time. Results prompted changes to improve P-PAG operations, such as changes to location of meetings, communications about the group's purpose, offering sufficient context for discussion items, and providing feedback about how members' input was used. Themes identified from the qualitative data related to the importance of certain aspects of group functioning, positive views of the group's current management, and potential areas for improvement. Parents regularly expressed a desire for more diversity in the group's membership and an interest in hearing more about how the research program's activities fit into the broader healthcare system and their impacts on health outcomes. Conclusions: Our experience in establishing, managing, and evaluating a parent advisory group over many years has resulted in valuable insights regarding patient engagement in health research and sustaining an advisory group over time. We have learned that an intentional and iterative approach with regular evaluations and responsive changes has been essential for fostering meaningful engagement. Significant resources are required to maintain the group; in turn, the group has made substantial and diverse contributions to the research program and its outputs. Plain English summary: We developed a parent advisory group in 2016 to support our research program in knowledge translation (KT, i.e., sharing research in accessible ways to inform decision-making) for child health. The purpose of the group is to involve parents in co-developing, evaluating, and sharing KT tools (e.g., videos, infographics). The group has also worked with researchers to inform methods and provide input on research projects and products. The group has been running for seven years and has involved different types of evaluations, including parent surveys and interviews. Parents had generally positive views of their experience with the group (including the group's management, interactions with researchers, etc.) and their responses mostly improved over the years. Based on parents' feedback, we made changes to improve the group's operations, such as changing the frequency and location of meetings, regular communications about the group's purpose, offering more context and time for individual discussion items, and providing feedback to parents about how their input was used. Parents regularly expressed a desire for more diversity in the group's membership. They also expressed an interest in hearing more about how the research program fit into the broader healthcare system and impacts on health outcomes. We have learned that it takes a large amount of time, effort, and funding to run the group; however, the parent contributions have been valuable and wide-reaching. We feel that the evaluations and responsive changes to the group over time have been essential to sustain and foster meaningful engagement and achieve the group's objectives. [ABSTRACT FROM AUTHOR]

Road accidents have become one of the most controversial issues in the field of transportation due to heavy human and financial costs to families and countries. For this reason, analyzing the effective factors in increasing this type of accident is highly significant. The present study aimed to identify the factors affecting the occurrence and increase of road accidents in the Sistan and Baluchestan province. In this descriptive study, the factors affecting road accidents in Sistan and Baluchestan province were classified into human factors, vehicle status, road status, and environmental factors after studying and interviewing experts familiar with the subject. In this study, the pairwise comparison questionnaire and network analysis process technique were used to collect data and rank its criteria and indicators. In addition, 30 people were selected as the sample size related to the specialists and experts. The findings indicated, human factors are the most significant factor in increasing road accidents in Sistan and Baluchestan province, while vehicle status, road status, and environment were in the second to fourth ranks, respectively. Furthermore, decision-making was in the first rank, while the ability of sight and hearing power, haste, high speed, as well as tire wear and air were in the next rank. [ABSTRACT FROM AUTHOR]

OTOF mutations are the principal causes of auditory neuropathy. There are reports on Otof‐related gene therapy in mice, but there is no preclinical research on the drug evaluations. Here, Anc80L65 and the mouse hair cell‐specific Myo15 promoter (mMyo15) are used to selectively and effectively deliver human OTOF to hair cells in mice and nonhuman primates to evaluate the efficacy and safety of OTOF gene therapy drugs. A new dual‐AAV‐OTOF‐hybrid strategy to transfer full‐length OTOF is generated, which can stably restore hearing in adult OTOFp.Q939*/Q939* mice with profound deafness, with the longest duration being at least 150 days, and the best therapeutic effect without difference in hearing from wild‐type mice. An AAV microinjection method into the cochlea of cynomolgus monkeys without hearing impairment is further established and found the OTOF can be safely and effectively driven by the mMyo15 promoter in hair cells. In addition, the therapeutic dose of AAV drugs has no impact on normal hearing and does not cause significant systemic toxicity both in mouse and nonhuman primates. In summary, this study develops a potential gene therapy strategy for DFNB9 patients in the clinic and provides complete, standardized, and systematic research data for clinical research and application. [ABSTRACT FROM AUTHOR]

Quantum key distribution (QKD) enables two remote parties to share encryption keys with security based on the laws of physics. Continuous-variable (CV) QKD with coherent states and coherent detection integrates well with existing telecommunication networks. Thus far, long-distance CV-QKD has only been demonstrated using a highly complex scheme where the local oscillator is transmitted, opening security loopholes for eavesdroppers and limiting potential applications. Here, we report a long-distance CV-QKD experiment with a locally generated local oscillator over a 100-kilometer fiber channel with a total loss of 15.4 decibels. This record-breaking distance is achieved by controlling the phase noise-induced excess noise through a machine learning framework for carrier recovery and optimizing the modulation variance. We implement the full CV-QKD protocol and demonstrate the generation of keys secure against collective attacks in the finite-size regime. Our results mark a substantial milestone for realizing CV quantum access networks with a high loss budget and pave the way for large-scale deployment of secure QKD. [ABSTRACT FROM AUTHOR]

Hearing protection device (HPD) fit-testing is a recommended best practice for hearing conservation programs as it yields a metric of the amount of attenuation an individual achieves with an HPD. This metric, the personal attenuation rating (PAR), provides hearing health care, safety, and occupational health personnel the data needed to select the optimal hearing protection for the occupational environment in which the HPD will be worn. Although commercial-off-the-shelf equipment allows the professional to complete HPD fit tests in the field, a standard test methodology does not exist across HPD fit-test systems. The purpose of this study was to compare the amount of attenuation obtained using the "gold standard" laboratory test (i.e., real-ear attenuation at threshold [REAT]) and three commercially available HPD fit-test systems (i.e., Benson Computer Controlled Fit Test System [CCF-200] with narrowband noise stimuli, Benson CCF-200 with pure tone stimuli, and Michael and Associates FitCheck Solo). A total of 57 adults, aged 18 to 63, were enrolled in the study and tested up to seven earplugs each across all fit-test systems. Once fitted by a trained member of the research team, earplugs remained in the ear throughout testing across test systems. Results revealed a statistically significant difference in measured group noise attenuation between the laboratory and field HPD fit-test systems (p <.0001). The mean attenuation was statistically significantly different (Benson CCF-200 narrowband noise was +3.1 dB, Benson CCF-200 pure tone was +2.1 dB, and Michael and Associates FitCheck Solo was +2.5 dB) from the control laboratory method. However, the mean attenuation values across the three experimental HPD fit-test systems did not reach statistical significance and were within 1.0 dB of one another. These findings imply consistency across the evaluated HPD fit-test systems and agree with the control REAT test method. Therefore, the use of each is acceptable for obtaining individual PARs outside of a laboratory environment. [ABSTRACT FROM AUTHOR]

Introduction: Hearing protection devices (HPDs) are standard personal protective equipment in military settings, but many service members may choose to not use HPDs because they impair spatial hearing and situation awareness. In an effort to reduce barriers to compliance by improving situation awareness while wearing HPDs, this study investigated whether brief training could counteract spatial hearing deficits when wearing HPDs. Participant's ability to correctly apply the HPDs across days was also examined. Materials and Methods: Young adults were randomly assigned to one of two groups: training or control (n = 25/group). Participants in each group performed a spatial hearing task while wearing HPDs and in an open ear condition without HPDs. Individual targets were battlefield sounds or white noise presented from a speaker array that surrounded the participant in the horizontal plane. After presentation of each target sound, the participant then controlled a white noise "auditory pointer," which they moved to the perceived location of the target. The two primary measures were the percent of trials with very large errors (> 45°), which were usually due to confusing front and back locations, and absolute localization, which is the difference between the pointer location and the true sound location. Both groups were tested on Days 1 (baseline) and 5 (post-test). On Days 2 to 4, the training group wore HPDs while receiving auditory and visual feedback after each trial. Results: Across all participants on Day 1, wearing HPDs increased the frequency of very large errors by about 3× and impaired localization by about 40%, relative to the open ear condition. When comparing performance at baseline (Day 1) and post-training Day 5, the training group with HPDs had significant reductions in very large errors and improved absolute localization (P values < .001). The training group also had significant improvements from Days 1 to 5 in the open ear condition. When the control group wore HPDs, there were also significant improvements from Days 1 to 5 (fewer very large errors and better localization), with smaller effect sizes vs. the training group. Controls did not have significant improvement in the open ear condition, but had similar trends. Most participants consistently applied the HPDs, but a subset of ∼20% frequently failed to achieve the criterion attenuation of 15 dB (over 0.25–4.0 kHz) in both ears. Conclusions: These findings show that simple, relatively brief practice and training can substantially reduce HPD impairments on spatial hearing and situation awareness. The gains from training and practice can inform the development of relatively simple, brief methods to reduce HPD spatial hearing impairments, potentially leading to increased HPD compliance. Longitudinal data show that a subset of participants would not have received the full benefit of hearing protection because of improper application of the HPDs. [ABSTRACT FROM AUTHOR]

Background: Noise and lighting are prime factors of poor sleep quality in critically ill patients, which impair recovery and increase the risk of delirium or complications. Aim: To identify and rank the effectiveness of sound and darkness interventions on the sleep quality of critically ill patients. Study Design: This systematic review and component network meta‐analysis was based on the Preferred Reporting Items for Systematic Reviews incorporating the Network Meta‐Analyses (PRISMA‐NMA) Statement. The Embase, MEDLINE, Cochrane CENTRAL, CINAHL, Airiti Library, and Google Scholar databases were searched from inception to August 10, 2021, for randomized controlled trials (RCTs) on sound and darkness interventions targeting critically ill patients' sleep quality. We applied standard and component NMA to determine the effects of interventions. The certainty of evidence was evaluated using the Cochrane risk‐of‐bias tool (V.2.0) and the online Confidence in Network Meta‐Analysis (CINeMA) application. Results: Twenty‐four RCTs with 1507 participants who used combined interventions constituting seven competing interventions were included in the standard NMA. The combination of earplugs, eye masks, and music; eye masks alone; earplugs combined with eye masks; and music alone had beneficial intervention effects. The combination of earplugs, eye masks, and music was the best intervention, and these components had no interaction effect. An eye mask had the best relative effect, followed by music, quiet time, and earplugs. Conclusions: This study provides clinical evidence of the effectiveness of using eye masks, music, and earplugs to improve sleep quality in critically ill patients. We also recommend future research using bedtime music, nocturnal eye masks, and quiet time, which had the best relative effects on sleep quality. Relevance to clinical practice: This study provides recommendations for interventions that nurses can use to improve critically ill patients' sleep quality. [ABSTRACT FROM AUTHOR]

Objective: This study investigated the frequency of ear canal protection use and looked at its influence on external auditory exostosis severity and knowledge about external auditory exostosis among windsurfers and kitesurfers on the German coast. Method: This retrospective cross-sectional study interviewed 130 windsurfers and kitesurfers along the German coast on knowledge of external auditory exostosis, exposure time, use of neoprene hoods and earplugs, and otological complaints. Participants underwent bilateral video-otoscopic examination. Results: Knowledge of external auditory exostosis was 'good' or 'excellent' in 78 of 130 (60 per cent) individuals and 'poor' or non-existent in 52 of 130 (40 per cent) individuals. Knowledge was positively correlated with hours of exposure, otological complaints and frequency of ear canal protection use. A significant negative influence of neoprene hood use on external auditory exostosis severity was shown. Conclusion: The positive effect of external auditory exostosis knowledge on the frequency of ear canal protection and the reduction of external auditory exostosis risk implies a need for health education on this topic. [ABSTRACT FROM AUTHOR]

Objective: Oticon Medical cochlear implant (CI) systems were evaluated for noise reduction effectiveness using voice track (VT) and adaptive directional microphones to determine the optimum CI fitting parameters, especially in noisy environments. Methods: Ten CI users (3 females, mean age 28.22; 7 males, mean age 36.71) participated in the study. Speech recognition in noise was evaluated in different test conditions with 2-syllable word lists in stationary speech-shaped noise. Five different test conditions were determined for each participant using a combination of software-based VT and directional microphone technology. In the first condition, the omnidirectional microphone (M) was selected and VT was turned off. The fully directional M and strong VT combination were activated in the second condition. In the third condition, the omnidirectional M and strong VT were set. In the fourth condition, automatic adaptive directional M and medium VT were used. Finally, omnidirectional M and medium VT were selected. Results: Speech comprehension scores obtained in a quiet environment were significantly better than those of the other 4 conditions in a noisy environment (P < .01). In addition, the best noise comprehension score (44%) was obtained in the fourth condition, although this was not statistically significant (P < .05). Conclusion: The VT technology was more effective in understanding speech in noise when used in the medium setting and with an automatic adaptive directional microphone. [ABSTRACT FROM AUTHOR]

The efficacy of the adaptive immune system in the middle ear (ME) is well established, but the mechanisms are not as well defined as those of gastrointestinal or respiratory tracts. While cellular elements of the adaptive response have been detected in the MEs following infections (or intranasal immunizations), their specific contributions to protecting the organ against reinfections are unknown. How immune protection mechanisms of the MEs compares with those in the adjacent and attached upper and lower respiratory airways remains unclear. To address these knowledge gaps, we used an established mouse respiratory infection model that we recently showed also involves ME infections. Bordetella bronchiseptica delivered to the external nares of mice in tiny numbers very efficiently infects the respiratory tract and ascends the Eustachian tube to colonize and infect the MEs, where it causes severe but acute inflammation resembling human acute otitis media (AOM). Since this AOM naturally resolves, we here examine the immunological mechanisms that clear infection and protect against subsequent infection, to guide efforts to induce protective immunity in the ME. Our results show that once the MEs are cleared of a primary B. bronchiseptica infection, the convalescent organ is strongly protected from reinfection by the pathogen despite its persistence in the upper respiratory tract, suggesting important immunological differences in these adjacent and connected organs. CD4+ and CD8+ T cells trafficked to the MEs following infection and were necessary to robustly protect against secondary challenge. Intranasal vaccination with heat killed B. bronchiseptica conferred robust protection against infection to the MEs, even though the nasopharynx itself was only partially protected. These data establish the MEs as discrete effector sites of adaptive immunity and shows that effective protection in the MEs and the respiratory tract is significantly different. This model system allows the dissection of immunological mechanisms that can prevent bacteria in the nasopharynx from ascending the ET to colonize the ME. [ABSTRACT FROM AUTHOR]

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The purpose of this study was to estimate the prevalence of occupational noise exposure and risk factors of occupational noise-induced hearing loss (NIHL) in Hispanic/Latino adults included in the baseline wave of the Hispanic Community Health Study/Study of Latinos collected from 2008 to 2011. Sequential multiple linear regression modeled the relationship between occupational NIHL (defined as a 3-, 4-, 6-kHz pure-tone average [PTA]) and occupation type, self-reported noise exposure, cardiovascular disease (CVD) risk score, and hearing protective device (HPD) use. The final model controlled for sex, age, and recreational noise exposure. Among 12,851 included participants, approximately 40% (n = 5036) reported occupational noise exposure "Sometimes" (up to 50% of the time) or "Frequently" (75–100% of the time). In the final fitted model, longest-held occupation and CVD risk were associated with poorer hearing. Specifically, those in non-skilled, service, skilled, and military/police/other job categories had between 2.07- and 3.29-dB worse PTA than professional/office workers. Additionally, a shift in the CVD risk score category from low to medium was associated with a 2.25- and 8.20-dB worse PTA for medium and high CVD risk, respectively. Age and sex were also significantly associated with poorer hearing, such that men presented with 6.08 dB worse PTA than women, and for every one-year increase in age, PTA increased by 0.62 dB (ps <.001). No interactions were seen between noise*sometimes or frequent exposure to other ototoxic agents and PTA (ps =.33 &.92, respectively). The prevalence of occupational noise exposure was high in this cross-sectional investigation of adults from Hispanic/Latino backgrounds. Findings contribute to the extant literature by demonstrating that risk factors for occupational NIHL in adults from varying Hispanic/Latino backgrounds are consistent with those of other previously studied groups. [ABSTRACT FROM AUTHOR]

Background: Noise-Induced Hearing Loss (NIHL) is a prevalent occupational hazard among healthcare professionals, including medical students. Despite its detrimental effects, the awareness and utilization of hearing protection measures among medical students in Saudi Arabia remain understudied. Objective: Is to determine the level of awareness and understanding of NIHL among medical students in Saudi Arabia, as well as their knowledge and usage of hearing protection measures and to identify potential barriers and facilitators for hearing protection utilization. Methods: A mixed-methods approach was employed, involving a questionnaire survey and semi-structured interviews. The survey collected data on demographics, knowledge of NIHL, and hearing protection practices among medical students. Subsequently, a semi-structured interview was conducted to obtain in-depth insights into the students' experiences, attitudes, and beliefs regarding NIHL and the use of hearing protection. Results: The level about NIHL was 59.32%. Better access to information is associated with increased odds of awareness (odds ratio=3.07, p=0.012). Having relatives with hearing loss increases the odds of awareness (odds ratio =2.49, p=0.034). Individuals with hearing loss or impairment have higher odds of awareness (odds ratio =2.27, p=0.046). Ear Pain, temporary hearing loss, tinnitus, or ringing in the ear: These factors are not significantly associated with awareness of noise-induced hearing loss (p>0.05). Using hearing aids is strongly associated with increased odds of awareness (odds ratio =3.94, p=0.006). The quantitative analysis provided statistical information on the prevalence rates and factors influencing hearing protection usage, while the qualitative analysis uncover nuanced perspectives and experiences. Conclusion: This research will contribute to the understanding of NIHL and hearing protection practices among medical students in Saudi Arabia. Improving hearing protection awareness and practices among medical students can ultimately reduce the incidence of NIHL and promote a healthier work environment within the healthcare sector. [ABSTRACT FROM AUTHOR]

Noise-induced hearing loss (NIHL) is a major cause of hearing impairment and is linked to dementia and mental health conditions, yet no FDA-approved drugs exist to prevent it. Downregulating the mitogen-activated protein kinase (MAPK) cellular pathway has emerged as a promising approach to attenuate NIHL, but the molecular targets and the mechanism of protection are not fully understood. Here, we tested specifically the role of the kinases ERK1/2 in noise otoprotection using a newly developed, highly specific ERK1/2 inhibitor, tizaterkib, in preclinical animal models. Tizaterkib is currently being tested in phase 1 clinical trials for cancer treatment and has high oral bioavailability and low predicted systemic toxicity in mice and humans. In this study, we performed dose–response measurements of tizaterkib’s efficacy against permanent NIHL in adult FVB/NJ mice, and its minimum effective dose (0.5 mg/kg/bw), therapeutic index (>50), and window of opportunity (

Hearing loss is one of the most common types of disability; however, there is only one FDA-approved drug to prevent any type of hearing loss. Treatment with the highly effective chemotherapy agent, cisplatin, and exposure to high-decibel noises are two of the most common causes of hearing loss. The mitogen-activated protein kinase (MAPK) pathway, a phosphorylation cascade consisting of RAF, MEK1/2, and ERK1/2, has been implicated in both types of hearing loss. Pharmacologically inhibiting BRAF or ERK1/2 is protective against noise- and cisplatin-induced hearing loss in multiple mouse models. Trametinib, a MEK1/2 inhibitor, protects from cisplatin-induced outer hair cell death in mouse cochlear explants; however, to the best of our knowledge, inhibiting MEK1/2 has not yet been shown to be protective against hearing loss in vivo. In this study, we demonstrate that trametinib protects against cisplatin-induced hearing loss in a translationally relevant mouse model and does not interfere with cisplatin’s tumor-killing efficacy in cancer cell lines. Higher doses of trametinib were toxic to mice when combined with cisplatin, but lower doses of the drug were protective against hearing loss without any known toxicity. Trametinib also protected mice from noise-induced hearing loss and synaptic damage. This study shows that MEK1/2 inhibition protects against both insults of hearing loss, as well as that targeting all three kinases in the MAPK pathway protects mice from cisplatin- and noise-induced hearing loss.

The objective of this study is (1) to assess whether the presentation level of the antiphasic digits-in-noise (DIN) test affects the speech recognition threshold (SRT), (2) to evaluate how accurately simulated unilateral and bilateral conductive hearing loss is detected (CHL) and (3) to determine whether increasing the presentation level normalises the antiphasic DIN SRT. Participants performed antiphasic and diotic DINs at different presentation levels with unilateral, bilateral or no earplugs. Twenty-four and twelve normal hearing adults. Without earplugs, antiphasic DIN SRTs did not differ between 60 and 80 dB SPL. At 60 dB SPL, the antiphasic DIN correctly classified 92% of the unilateral earplug cases; the diotic DIN 25%. The binaural intelligibility level difference did not differ between the no-earplug condition and the condition with bilateral earplugs when the presentation was increased with the attenuation level. In normal hearing participants, diotic and antiphasic DIN SRTs are independent of presentation level above a minimum level of 60 dB SPL. The antiphasic DIN is more sensitive than the diotic DIN for detecting unilateral CHL; not for bilateral CHL. The effect of CHL on DIN SRTs can be largely compensated by increasing the presentation level. Audibility plays an important role in the antiphasic and diotic DIN. [ABSTRACT FROM AUTHOR]

Workers rely on hearing protection devices to prevent occupational noise-induced hearing loss. This study aimed to evaluate changes in attenuation over time for properly fit devices when worn by workers exposed to hazardous noise. Earplug fit testing was accomplished on 30 workers at a brewery facility with three types of foam and three types of premolded earplugs. The personal attenuation ratings (PARs) were measured before and after a 2-hour work period while exposed to hazardous noise levels. The minimum acceptable initial PAR was 15 dB. Average decreases in PAR ranged from −0.7 to −2.6 dB across all six earplug types. Significant changes in PAR were observed for the Foam-1 (p = 0.009) and Premold-3 (p = 0.004) earplugs. A linear mixed regression model using HPD type and study year as fixed effects and subject as random effect was not significant for either fixed effect (α = 0.05). Ninety-five percent of the final PAR measurements maintained the target attenuation of 15 dB. Properly fitting earplugs can be effective at reducing worker's noise exposures over time. The potential for a decrease in attenuation during the work shift should be considered when training workers and establishing the adequacy of protection from hazardous noise exposures. [ABSTRACT FROM AUTHOR]

Noise-induced hearing loss (NIHL) continues to be a pervasive problem for the nation's workforce, particularly the nation's mining personnel. As one of the leading health and safety organizations in the world, the National Institute for Occupational Health and Safety (NIOSH) in Pittsburgh maintains a Hearing Loss Prevention Program (HLPP) to conduct research to reduce NIHL loss among the nation's miners. This document provides a brief overview of this HLPP, describing some of the research techniques involved in the development of engineering noise controls, methods for the development of administrative noise controls, and some of the products available to the public to protect the nation's workers hearing. [ABSTRACT FROM AUTHOR]

The National Institute for Occupational Safety and Health (NIOSH) evaluated continuous and impact noise exposures and hearing loss among workers at a hammer forge company. Full-shift personal noise exposure measurements were collected on forge workers across 15 different job titles; impact noise characteristics and one-third octave band noise levels were assessed at the forge hammers; and 4,750 historic audiometric test records for 483 workers were evaluated for hearing loss trends. Nearly all workers' noise exposures exceeded regulatory and/or recommended exposure limits. Workers working in jobs at or near the hammers had full-shift time-weighted average noise exposures above 100 decibels, A-weighted. Impact noise at the hammers reached up to 148 decibels. Analysis of audiometric test records showed that 82% of workers had experienced a significant threshold shift, as defined by NIOSH, and 63% had experienced a standard threshold shift, as defined by the Occupational Safety and Health Administration (OSHA). All workers with an OSHA standard threshold shift had a preceding NIOSH significant threshold shift which occurred, on average, about 7 years prior. This evaluation highlights forge workers' exposures to high levels of noise, including impact noise, and how their hearing worsened with age and length of employment. [ABSTRACT FROM AUTHOR]

For more than 50 years, the National Institute for Occupational Safety and Health (NIOSH), part of the United States (U.S.) Centers for Disease Control and Prevention (CDC), has been actively working to reduce the effects of noise and ototoxic chemicals on worker hearing. NIOSH has pioneered basic and applied research on occupational hearing risks and preventive measures. The Institute has issued recommendations and promoted effective interventions through mechanisms ranging from formal criteria documents to blogs and social media. NIOSH has conducted surveillance and published statistics to guide policy and target prevention efforts. Over the past five decades, substantial progress has been made in raising awareness of noise as a hazard, reducing the risk of occupational hearing loss, improving the use of hearing protection, and advancing measurement and control technologies. Nevertheless, noise remains a prevalent workplace hazard and occupational hearing loss is still one of the most common work-related conditions. NIOSH continues to work toward preventing the effects of noise and ototoxicants at work and has many resources to assist audiologists in their hearing loss prevention efforts. [ABSTRACT FROM AUTHOR]

Objectives: To estimate the prevalence of tinnitus and hyperacusis in children aged 9–12 years in Flanders, as well as to explore the associations with hearing abilities and listening behaviours. Design: A cross-sectional survey was undertaken in four different Flemish schools. The questionnaire was distributed among 415 children, with a response rate of 97.3%. Results: The prevalence of permanent tinnitus was 10.5% and of hyperacusis was 3.3%. The hyperacusis prevalence was higher in girls (p <.05). Some children reported effects of tinnitus in terms of anxiety (20.1%), sleep (36.5%), and concentration (24.8%). When listening to personal listening devices, 33.5% of the children reported to listen for at least 1 h at 60% or higher of the volume range. Moreover, 54.9% of children stated to never wear hearing protection. Conclusions: Tinnitus and hyperacusis are prevalent in children aged 9–12 years. Some of these children might be overlooked and, as such, not receiving the required follow-up or counselling. Development of guidelines for the assessment of these auditory symptoms in children would help to determine the prevalence numbers with greater accuracy. Sensibility campaigns for safe listening are warranted, as more than half of the children never use hearing protection. [ABSTRACT FROM AUTHOR]

Background The objective of the online survey was to determine worker attitudes towards, perceptions on hearing loss, and management of workplace noise; and to identify barriers within current strategies that prevent effective management of hearing health in Australian mines. Design This cross-sectional study utilized a modified survey design, initially designed for use by Safe Work Australia for a broader study published in 2010. Study Sample The survey questionnaire was made available online to volunteer participants, recruited with the assistance of State and National Health and Safety, and mining organizations. Volunteer participants were required to be proficient in English, be employed by an Australian underground or open cut mine, including coal processing plants; or work as a contractor on one of the specified mine sites. All mining employees, regardless of occupation, job title, and occupational hearing loss classification or status, were invited to complete the questionnaire. Results Almost 60% of respondents indicated that they had high noise exposure for than 10 yr or more, and have some trouble hearing, mostly associated with infrequent tinnitus. Nearly 71% of these workers believe that the noise control strategies in their workplaces are effective, but this mostly refers to the use of hearing protection devices. Conclusion The results indicate that general knowledge on the cause and effect of noise exposure in the workplace is well understood. However, due to the long latency associated with the development of noise-induced hearing loss (NIHL), there is an issue urgency in terms of risk management. It is surprising that most of the respondents recommended more inspections and administrative controls, especially since most respondents were health, safety, and environment (HSE) professionals. HSE professionals should be advocating for higher order, more permanent solutions, and not purely administrative controls and personal protective equipment. These findings raise the question of whether there is a multifaceted working-culture issue that needs to be addressed, in combination with higher order control implementation. [ABSTRACT FROM AUTHOR]

Background: Post-lingual deafness represents a critical challenge for adults' well-being with substantial public health burdens. One treatment of choice has been cochlear implants (CI) for people with severe to profound hearing loss (HL). Since 2018, Chile has implemented a high-cost policy to cover CI treatment, the "Ley Ricarte Soto" (LRS) health policy. However, wide variability exists in the use of this device. To date, no related study has been published on policy evaluation in Chile or other Latin American countries. Objectives: This study aimed to evaluate the impact of the LRS policy on the treatment success and labour market inclusion among deaf or hard of hearing (DHH) adults using CI. We examined and characterised outcomes based on self-reports about treatment success and occupation status between 2018 and 2020. Design: We performed a prospective study using hospital clinical records and an online questionnaire with 76 DHH adults aged >15 who had received CIs since the introduction of the LRS policy in 2018. Using univariate and multivariate regression models, we investigated the relationship between demographic, audiological, and social determinants of health and outcomes, including treatment success for social inclusion (International Outcome inventory for Hearing Aids and CIs assessment: IOI-HA) and occupation status for labour market inclusion. Results: Our study showed elevated levels of treatment success in most of the seven sub-scores of the IOI-HA assessment. Similarly, around 70% of participants maintained or improved their occupations after receiving their CI. We found a significant positive association between treatment success and market inclusion. Participants diagnosed at younger ages had better results than older participants in both outcomes. Regarding social determinants of health, findings suggested participants with high social health insurance and a shorter commute time to the clinic had better results in treatment success. For labour market inclusion, participants with high education levels and better pre- CI occupation had better post-CI occupation status. Conclusions: In evaluating the LRS policy for providing CIs for DHH adults in Chile, we found positive effects relating to treatment success and occupation status. Our study supports the importance of age at diagnosis and social determinants of health, which should be assessed by integrating public services and bringing them geographically closer to each beneficiary. Although evidence-based guidelines for candidate selection given by the LRS policy might contribute to good results, these guidelines could limit the policy access to people who do not meet the requirements of the guidelines due to social inequalities. [ABSTRACT FROM AUTHOR]

The risk of explosion due to gas leakages and its human, environmental and economic losses in accident scenarios constitute serious safety hazards in industries. Fast location of leak sources enables quick corrective maintenance, avoiding the most hazardous cases. In the present study, gated recurrent units were developed to identify CH 4 leaks in a chemical process module. The training and test databases were obtained through 3D-CFD simulations for four leaks and a non-leakage scenario. The inputs utilised were the concentration profiles at eleven sensors for four leak sources, four wind speeds, and eight wind directions using different temporal lengths. Additionally, noise was added to the database to assess the performance in more realistic cases. The findings indicated better performance with higher values of input time-steps, and accuracy over 93.9% for unseen data, indicating good generalisation of the models and their potential of predicting the leaks applying easily acquired inputs. [ABSTRACT FROM AUTHOR]

The article presents a study on the effects of background noise and hearing attenuation due to earplugs during interactive communication in older people. Among the metrics measured in the research are heart rate variability, skin conductance, and pupil size. Based on the results, there are potential markers of communication difficulty like pupillometry and electrodermal measures.