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Background: The biopharmaceutical industry operates at the intersection of life sciences, clinical research, clinical care, public health, and business, which presents distinct operational and ethical challenges. This setting merits focused bioethics consideration to complement legal compliance and business ethics efforts. However, bioethics as applied to a biopharmaceutical industry setting often is construed either too broadly or too narrowly with little examination of its proper scope., Main Text: Any institution with a scientific or healthcare mission should engage bioethics norms to navigate ethical issues that arise from the conduct of biomedical research, delivery of clinical care, or implementation of public health programs. It is reasonable to assume that while bioethics norms must remain constant, their application will vary depending on the characteristics of a given setting. Context "specification" substantively refines ethics norms for a particular discipline or setting and is an expected, needed and progressive ethical activity. In order for this activity to be meaningful, the scope for bioethics application and the relevant contextual factors of the setting need to be delineated and appreciated. This paper defines biopharmaceutical bioethics as: the application of bioethics norms (concepts, principles, and rules) to the research, development, supply, commercialization, and clinical use of biopharmaceutical healthcare products. It provides commentary on this definition, and presents five contextual factors that need to be considered when applying bioethics norms to a biopharmaceutical industry setting: (1) dual missions; (2) timely and pragmatic guidance; (3) resource stewardship; (4) multiple stakeholders; and (5) operational complexity., Conclusion: Understanding the scope of the biopharmaceutical enterprise and contextual factors of a biopharmaceutical industry setting is foundational for the application of bioethics norms. Establishing a common language and approach for biopharmaceutical bioethics will facilitate breadth and depth of discussion and subsequent implementation to benefit patients, the healthcare system and society.

Pharmaceutical human biomedical research is a multi-dimensional endeavor that requires collaboration among many parties, including those who sponsor, conduct, participate in, or stand to benefit from the research. Human subjects' protections have been promulgated to ensure that the benefits of such research are accomplished with respect for and minimal risk to individual research participants, and with an overall sense of fairness. Although these protections are foundational to clinical research, most ethics guidance primarily highlights the responsibilities of investigators and ethics review boards. Currently, there is no published resource that comprehensively addresses bioethical responsibilities of industry sponsors; including their responsibilities to parties who are not research participants, but are, nevertheless key stakeholders in the endeavor. To fill this void, in 2010 Eli Lilly and Company instituted a Bioethics Framework for Human Biomedical Research. This paper describes how the framework was developed and implemented and provides a critique based on four years of experience. A companion article provides the actual document used by Eli Lilly and Company to guide ethical decisions regarding all phases of human clinical trials. While many of the concepts presented in this framework are not novel, compiling them in a manner that articulates the ethical responsibilities of a sponsor is novel. By utilizing this type of bioethics framework, we have been able to develop bioethics positions on various topics, provide research ethics consultations, and integrate bioethics into the daily operations of our human biomedical research. We hope that by sharing these companion papers we will stimulate discussion within and outside the biopharmaceutical industry for the benefit of the multiple parties involved in pharmaceutical human biomedical research.

Current ethics and good clinical practice guidelines address various aspects of pharmaceutical research and development, but do not comprehensively address the bioethical responsibilities of sponsors. To fill this void, in 2010 Eli Lilly and Company developed and implemented a Bioethics Framework for Human Biomedical Research to guide ethical decisions. (See our companion article that describes how the framework was developed and implemented and provides a critique of its usefulness and limitations.) This paper presents the actual framework that serves as a company resource for employee education and bioethics deliberations. The framework consists of four basic ethical principles and 13 essential elements for ethical human biomedical research and resides within the context of our company's mission, vision and values. For each component of the framework, we provide a high-level overview followed by a detailed description with cross-references to relevant well regarded guidance documents. The principles and guidance described should be familiar to those acquainted with research ethics. Therefore the novelty of the framework lies not in the foundational concepts presented as much as the attempt to specify and compile a sponsor's bioethical responsibilities to multiple stakeholders into one resource. When such a framework is employed, it can serve as a bioethical foundation to inform decisions and actions throughout clinical planning, trial design, study implementation and closeout, as well as to inform company positions on bioethical issues. The framework is, therefore, a useful tool for translating ethical aspirations into action - to help ensure pharmaceutical human biomedical research is conducted in a manner that aligns with consensus ethics principles, as well as a sponsor's core values.

Until recently, estimation of β-amyloid plaque density as a key element for identifying Alzheimer's disease (AD) pathology as the cause of cognitive impairment was only possible at autopsy. Now with amyloid-positron emission tomography (amyloid-PET) neuroimaging, this AD hallmark can be detected antemortem. Practitioners and patients need to better understand potential diagnostic benefits and limitations of amyloid-PET and the complex practical, ethical, and social implications surrounding this new technology. To complement the practical considerations, Eli Lilly and Company sponsored a Bioethics Advisory Board to discuss ethical issues that might arise from clinical use of amyloid-PET neuroimaging with patients being evaluated for causes of cognitive decline. To best address the multifaceted issues associated with amyloid-PET neuroimaging, we recommend this technology be used only by experienced imaging and treating physicians in appropriately selected patients and only in the context of a comprehensive clinical evaluation with adequate explanations before and after the scan.

Expanded access is a regulatory mechanism by which an investigational drug can be made available outside of a clinical trial to treat patients with serious or life-threatening conditions for which there are no satisfactory treatment options. An expanded access program (EAP) is the formal plan under which preapproval access to an investigational drug can be provided to a group of patients. Although an EAP is a regulated program, the decision to authorize an EAP is the responsibility of the biopharmaceutical sponsor. Because of the significant impact an EAP can have on current patients, drug development, and future patients, we propose that a sponsor's decision must be based not only on regulatory criteria but also on ethical and practical considerations regarding implementation of an EAP. Such an approach will help ensure that decisions and plans uphold ethical precepts such as fairness, promoting good, and minimizing risk of harm., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article. All contributors are employees and stockholders of Eli Lilly and Company.

Background : Bioethics consultations are conducted in varied settings, including hospitals, universities, and other research institutions, but there is sparse information about bioethics consultations conducted in corporate settings such as pharmaceutical companies. The purpose of this article is to describe a bioethics consultation service at a pharmaceutical company, to report characteristics of consultations completed by the service over a 6-year period, and to share results of a consultation feedback survey. Methods : Data on the descriptive characteristics of bioethics consultations were collected from 2008 to 2013 and analyzed in Excel 2007. Categorical data were analyzed via the pivot table function, and time-based variables were analyzed via formulas. The feedback survey was administered to consultation requesters from 2009 to 2012 and also analyzed in Excel 2007. Results : Over the 6-year period, 189 bioethics consultations were conducted. The number of consultations increased from five per year in 2008 to approximately one per week in 2013. During this time, the format of the consultation service was changed from a committee-only approach to a tiered approach (tailored to the needs of the case). The five most frequent topics were informed consent, early termination of a clinical trial, benefits and risks, human biological samples, and patient rights. The feedback survey results suggest the consultation service is well regarded overall and viewed as approachable, helpful, and responsive. Conclusions : Pharmaceutical bioethics consultation is a unique category of bioethics consultation that primarily focuses on pharmaceutical research and development but also touches on aspects of clinical ethics, business ethics, and organizational ethics. Results indicate there is a demand for a tiered bioethics consultation service within this pharmaceutical company and that advice was valued. This company's experience indicates that a bioethics consultation service raises awareness about bioethics, empowers employees to raise bioethical concerns, and helps them reason through challenging issues.

Background: The scientific publishing practices of the pharmaceutical industry have been heavily criticized in recent years due to the inherent conflict of interest that arises when a pharmaceutical company publishes findings around its own drugs., Scope: Eli Lilly and Company ('Lilly') strives for transparency in its day-to-day activities, and, here, shares its principles, policies and practices on publishing "Lilly-sponsored" research., Findings: A conflict of interest does not necessarily equate to biased presentation of research findings, and operating a successful, for-profit business and maintaining a focus on improving the health of patients are not mutually exclusive goals. There is, however, potential for bias, and it is incumbent upon a for-profit to develop publication principles, policies and practices to address this. To this end, Lilly's Principles of Medical Research states that 'Lilly discloses publicly all medical research results that are important to patients, healthcare providers or payers--whether favorable or unfavorable to a Lilly product--in an accurate, objective, and balanced manner ...' The preparation of publications of Lilly-sponsored research involves close collaboration between external (i.e., academic or otherwise non-industry employees) and Lilly scientific researchers (including scientific writers), with both serving as authors. Lilly does not support 'ghost' or 'guest' authorship. Authorship is not just recognition of contribution but also public acknowledgement of responsibility for content, and all authors are expected to take an active role in developing the manuscript in line with the International Committee of Medical Journal Editors-based authorship requirements. This is agreed to by authors before the manuscript is started. Lilly provides external authors with access to the trial data for manuscript development. Lilly does not pay external authors for their involvement in manuscript development. Scientific writers at Lilly, often with advanced scientific degrees, offer both scientific and writing expertise in manuscript development and play a project management role. Their role is transparent, and they are included as authors or appropriately acknowledged., Conclusion: Lilly has an ongoing commitment to appropriate publishing practices. Sharing company publication principles, policies and practices is one way to demonstrate this commitment and encourage and facilitate open dialogue among all those involved in drug development.

Objectives: The current analysis investigated the onset of antidepressant effect of olanzapine/fluoxetine combination., Methods: Data for these post hoc analyses were obtained from a clinical trial comparing olanzapine, placebo, and olanzapine/fluoxetine combination in bipolar depression (BD). Subjects were 833 patients with a DSM-IV diagnosis of bipolar I disorder, depressed. The Montgomery-Asberg Depression Rating Scale measured depressive symptoms. Multiple analytic methods were applied, including traditional (mean differences) analysis, pattern analysis, survival analysis of sustained response, mixed-effects regression, and area-under-the-curve analysis., Results: Traditional analysis showed significantly greater improvement in depression scores at week 1 for olanzapine/fluoxetine combination versus placebo (-9.55 versus -5.08, p < 0.001) and for olanzapine versus placebo (-8.31 versus -5.08, p < 0.001). Pattern analysis revealed olanzapine/fluoxetine combination had a significantly greater percentage of early persistent responders than placebo or olanzapine (32.4% versus 12.7%, p < 0.001; and 18.3%, p < 0.05, respectively). Survival analysis showed a significantly shorter time to sustained response for the combination versus placebo (p < 0.001), for olanzapine versus placebo (p = 0.04), and for the combination versus olanzapine (p = 0.03). Mixed-effects regression analysis revealed a significant therapy-by-time interaction (p < 0.001). Early area-under-the-curve analysis revealed a significantly greater percentage of improvement for the combination versus placebo (26.7% versus 13.9%, p < 0.001) and for olanzapine versus placebo (22.0% versus 13.9%, p < 0.001)., Conclusions: Based on consistent results from related methods of measuring onset, olanzapine/fluoxetine combination demonstrated rapid onset of antidepressant effect (within 7 days) compared to placebo that was sustained over 8 weeks of treatment in a sample of BD patients. Using multiple statistical techniques may help profile a drug's onset of effect.

Background: This 8-week, double-blind, multicenter study was undertaken to replicate, in a larger sample of patients with treatment-resistant major depressive disorder (MDD; DSM-IV criteria), the results of a pilot study of the olanzapine/fluoxetine combination., Method: The study was begun in August 1999. The primary entry criterion was a history of failure to respond to a selective serotonin reuptake inhibitor (SSRI). Patients (N = 500) who subsequently failed to respond to nortriptyline during an open-label lead-in phase were randomly assigned to 1 of 4 treatment groups: olanzapine (6-12 mg/day) plus fluoxetine (25-50 mg/day) combination, olanzapine (6-12 mg/day), fluoxetine (25-50 mg/day), or nortriptyline (25-175 mg/day). The primary outcome measure was baseline-to-endpoint mean change in score on the Montgomery-Asberg Depression Rating Scale (MADRS)., Results: At the 8-week study endpoint, MADRS total scores decreased by a mean 8.7 points from baseline (28.5) with the olanzapine/fluoxetine combination, 7.0 points from baseline (28.4) with olanzapine (p = .08), 8.5 points from baseline (28.4) with fluoxetine (p = .84), and 7.5 points from baseline (28.8) with nortriptyline (p = .30), with no significant differences among the therapies. The olanzapine/fluoxetine combination was associated with significantly (p < or = .05) greater improvement (decrease) in MADRS scores than olanzapine at weeks 2, 4, 6, and 7; than fluoxetine at weeks 2 through 5; and than nortriptyline at weeks 1 through 4. A post hoc analysis of a subgroup of patients who had an SSRI treatment failure during their current MDD episode (N = 314) revealed that the olanzapine/fluoxetine combination group had a significantly (p = .005) greater decrease in MADRS scores than the olanzapine group at endpoint. Safety data for the olanzapine/fluoxetine combination were similar to those for its component monotherapies., Conclusions: The olanzapine/fluoxetine combination did not differ significantly from the other therapies at endpoint, although it demonstrated a more rapid response that was sustained until the end of treatment. The results raised several methodological questions, and recommendations are made regarding the criteria for study entry and randomization.

The National Institute for Occupational Safety and Health (NIOSH) conducted a series of surveys to evaluate occupational exposure to noise and potentially ototoxic chemical agents among members of a professional stock car racing team. Exposure assessments included site visits to the team's race shop and a worst-case scenario racetrack. During site visits to the race team's shop, area samples were collected to measure exposures to potentially ototoxic chemicals, including, organic compounds (typical of solvents), metals, and carbon monoxide (CO). Exposures to these chemicals were all below their corresponding Occupational Safety and Health Administration (OSHA) permissible exposure limits (PELs), NIOSH recommended exposure limits (RELs), and American Conference of Governmental Industrial Hygienists (ACGIH) threshold limit values (TLVs). During site visits to the racetrack, area and personal samples were collected for organic compounds, lead, and CO in and around the "pit" area where the cars undergo race preparation and service during the race. Exposures to organic compounds and lead were either nondetectable or too low to quantify. Twenty-five percent of the CO time-weighted average concentrations exceeded the OSHA PEL, NIOSH REL, and ACGIH TLV after being adjusted for a 10-hour workday. Peak CO measurements exceeded the NIOSH recommended ceiling limit of 200 ppm. Based on these data, exposures to potentially ototoxic chemicals are probably not high enough to produce an adverse effect greater than that produced by the high sound pressure levels alone. However, carbon monoxide levels occasionally exceeded all evaluation criteria at the racetrack.

The National Institute for Occupational Safety and Health (NIOSH) surveyed noise exposure for a professional stock car team at their race shop and during two races at one racetrack. At the team's shop, area sound pressure levels (SPLs) were measured for various work tasks. Equivalent levels (Leqs) ranged from 58 to 104 decibels, A-weighted (dBA). Personal noise dosimetry was conducted for at least one employee for each job description in race car assembly (n = 9). The Occupational Safety and Health Administration (OSHA) permissible exposure limit (PEL) of 90 dBA for an 8-hour, 5-dB exchange rate time-weighted average (TWA) was never exceeded, but in two instances values exceeded OSHA's action level of 85 dBA for hearing conservation implementation. The NIOSH recommended exposure limit (REL) of 85 dBA for a 3-dB exchange rate Leq was exceeded for five of the measured jobs. During the races, SPLs averaged above 100 dBA in the pit area where cars undergo adjustments/refueling, both before and during the race. Peak levels reached 140 dB SPL. NIOSH REL was exceeded for every personal noise dosimetry measurement. Recommendations for hearing protection and communication are presented.

The purpose of this study was to compare the efficacy and safety of olanzapine (OLZ) monotherapy and an olanzapine/fluoxetine combination (OFC) with placebo (PLA) for unipolar major depression with psychotic features. Under a single protocol, two 8-week, double-blind trials were conducted at 27 sites. Patients (n = 124 trial 1, n = 125 trial 2) were randomized to 1 of 3 treatment groups: OLZ (5 to 20 mg/d), PLA, or OFC (olanzapine 5 to 20 mg/d + fluoxetine 20 to 80 mg/d). The primary outcome measure was the 24-item Hamilton Depression Rating Scale total score. For trial 1, endpoint improvement for the OLZ group (-14.9) was not significantly different from the PLA or OFC groups. The OFC group had significantly greater endpoint improvement (-20.9) than the PLA group (-10.4, P = 0.001); this significant difference was present within 7 days of therapy and maintained at every subsequent visit. The OFC group also had significantly higher response rate (63.6%) than the PLA (28.0%, P = 0.004) or OLZ (34.9%, P = 0.027) groups. For trial 2, there were no significant differences among treatment groups on the 24-item Hamilton Depression Rating Scale total scores or response rates. The combination exhibited a comparable safety profile with OLZ monotherapy and no significant increases in extrapyramidal symptoms compared with placebo. Patients with major depression with psychotic features treated with OLZ monotherapy did not demonstrate significant depressive symptom improvement compared with placebo in either trial; however, an olanzapine/fluoxetine combination was associated with significant improvement compared with placebo in one trial and was well tolerated., (Copyright 2004 Lippincott Williams and Wilkins)

Background: The olanzapine/fluoxetine combination has demonstrated effectiveness in treatment-resistant depression (TRD). Although this combination is being used by prescribers, this is the first study to examine long-term use. Long-term efficacy and safety were therefore investigated in a group of patients with major depressive disorder (MDD) with and without TRD., Method: 560 patients who met DSM-IV diagnostic criteria for MDD were enrolled in this 76-week, open-label study (Feb. 2000-July 2002). The Montgomery-Asberg Depression Rating Scale (MADRS) total score was the primary efficacy measure. Safety was assessed via adverse events, vital signs, laboratory analytes, electrocardiography, and extrapyramidal symptom measures., Results: MADRS mean total scores decreased 7 points from baseline (31.6 [N = 552]) at 1/2 week of treatment, 11 points at 1 week of treatment, and 18 points at 8 weeks of treatment. This effect was maintained to endpoint with a mean decrease of 22 points at 76 weeks. Response and remission rates for the total sample were high (62% and 56%, respectively), and the relapse rate was low (15%). Response, remission, and relapse rates for TRD patients (N = 145) were 53%, 44%, and 25%, respectively. The most frequently reported adverse events were somnolence, weight gain, dry mouth, increased appetite, and headache. At endpoint, there were no clinically meaningful changes in vital signs, laboratory analytes, or electrocardiography. There were no significant increases on any measure of extrapyramidal symptoms., Conclusions: The olanzapine/fluoxetine combination showed rapid, robust, and sustained improvement in depressive symptoms in patients with MDD, including patients with TRD. The long-term safety profile of the combination was similar to that of its component monotherapies.

Increasing evidence suggests that noise-induced hearing loss may be reduced or prevented with antioxidant therapy. Biochemical markers of reactive oxygen species (ROS)-induced damage can help elucidate possible treatment timing constraints. This study examined the time course of ROS damage following a 2-h, broad-band noise exposure resulting in permanent threshold shift in 35 Long-Evans rats. Cochlea, brain, liver, serum and urine were analyzed at 1, 3, 8, 72, and 672 h (28 days) after exposure. Oxidative DNA damage was assessed by measuring 8-hydroxy-2'-deoxyguanosine (8OHdG) by high performance liquid chromatography with electrochemical detection. Lipid peroxidation was measured via the thiobarbituric acid-reactive substances (TBARS) colorimetric assay for detection of aldehydes (e.g., malondialdehyde). Auditory brainstem response and distortion product otoacoustic emission thresholds showed progressive elevation for the 3- and 8-h groups, then notable recovery for the 72-h group, and some worsening for the 672-h group. 8OHdG was significantly elevated in cochlea in the 8-h group, and in brain and liver for the 72-h group. TBARS were significantly elevated in serum for the 72-h group. Based upon oxidative DNA damage present in cochlea following intense noise, we postulate that the first 8 h following exposure might be a critical period for antioxidant treatment.

This multisite investigation assessed subjective, behavioral, and objective balance function in 30 blast survivors. Subjects with vertigo, dizziness, or imbalance were screened (n = 6) or evaluated (n = 27) during 1 year. Tests included a questionnaire, electronystagmography (ENG), and computerized dynamic posturography (CDP). Ninety-seven percent of subjects were located inside a building during the blast, and 63 percent of subjects experienced dysequilibrium within 48 hours. Forty-three percent of symptoms could not be attributed to head injury. Sixty percent of subjects had abnormal ENG and/or CDP; ENG abnormalities mostly were peripheral or nonlocalizing, whereas CDP patterns were "vestibular," "surface dependent," and "physiologically inconsistent." At 1-year postblast, 55 percent of initially abnormal CDP results were normal, and 72 percent of subjects said symptoms were unchanged or occurred intermittently. A serial, test battery approach is recommended to assess symptoms. Blast-related dysequilibrium had clinically significant manifestations and should be considered a valid component of aural blast injury.

This longitudinal study evaluated subjective, behavioral, and objective auditory function in 83 explosion survivors. Subjects were evaluated quarterly for 1 year with conventional pure-tone and extended high-frequencies audiometry, otoscopic inspections, immittance and speech audiometry, and questionnaires. There was no obvious relationship between subject location and symptoms or test results. Tinnitus, distorted hearing, loudness sensitivity, and otalgia were common symptoms. On average, 76 percent of subjects had predominantly sensorineural hearing loss at one or more frequencies. Twenty-four percent of subjects required amplification. Extended high frequencies showed evidence of acoustic trauma even when conventional frequencies fell within the normal range. Males had significantly poorer responses than females across frequencies. Auditory status of the group was significantly compromised and unchanged at the end of 1-year postblast.

Schwannomas of the eighth cranial nerve are rare in children. We report a 4 10/12 - year-old girl with no evidence of neurofibromatosis who presented with facial droop. Radiographic studies revealed a large cerebellopontine angle tumor. At surgery, the tumor was attached to the eighth cranial nerve and histologically was a schwannoma. This is the youngest reported case of unilateral eighth cranial nerve schwannoma in a patient without the stigmata of neurofibromatosis.

Offset auditory brainstem response (ABR) traditionally has been thought to be an artifactual response elicited by stimulus acoustic ringing. Additionally, offset ABR's sensitivity to stimulus rise-fall time has been associated with concurrent changes in acoustic ringing. The present study tested the validity of offset ABR by recording the response in 40 young, normal-hearing adults using tone burst stimuli with varying degrees of acoustic ringing and various rise-fall times. Stimuli were computer-generated 10-ms tone bursts of 500 and 2000 Hz. In Experiment 1, offset ABR was recorded using stimuli with no acoustic ringing, normal ringing, and excessive ringing. Rise-fall time was held constant at 0.5 ms. In Experiment 2, rise-fall time was manipulated in a stimulus with no ringing. In Experiment 3, only rise time was manipulated in a no-ringing stimulus, while fall time was held constant at 0.5 ms. Reliable offset ABRs were recorded for all degrees of acoustic ringing, including the "no-ringing' condition. Offset ABR was sensitive to rise and fall times, and was elicited best with a 500-Hz stimulus. The results indicate that offset ABR is a real response and not an artifact produced by acoustic ringing.

Transient acoustic stimuli are used for generating auditory evoked responses (AERs). Common transducers do not accurately reproduce transient stimuli, since the transducer diaphragm oscillates at its resonant frequency at the abrupt initiation or termination of a stimulus. These oscillations are called "acoustic ringing." This paper discusses methods for reducing and canceling acoustic ringing, and describes one method, a systems approach, in detail. It also delineates one method for enhancing acoustic ringing. The methods described provide effective techniques for empirical study of the effects of acoustic ringing on AERs or for any application requiring accurate transduction of a transient stimulus.

There are few systematic comparisons of Etymotic ER-3A insert earphones versus supra-aural earphones in auditory brainstem response (ABR) measurement. We compared ER-3A insert earphones and two types of supra-aural earphones (TDH-39P and TDH-49P) in a group of normal hearing adults. Acoustic analyses revealed spectral and temporal differences among earphones. Behavioral and ABR thresholds to click stimuli were slightly elevated with the ER-3A compared to the TDH earphones. The ER-3A earphones produced a latency delay, relative to the TDH earphones, that varied from about 0.8 to 1.0 msec, and increased at lower stimulus intensity levels. In addition, ABR wave I amplitude was significantly reduced with the ER-3A earphone. Based on these data, we recommend collection of normative data with the ER-3A earphones prior to their use in ABR measurement.

Click interaural attenuation (IA) was measured behaviorally and with the auditory brain stem response (ABR) in two unilaterally deaf adults with Etymotic ER-3A insert earphones, and TDH-39P and TDH-49P supraaural earphones. Stimulus crossover for each set of earphones was also determined with pure-tone audiometry. Pure-tone results agreed with previous research, showing that the ER-3A provided substantially greater IA than the supraaural earphones, particularly for low frequencies. For click stimuli, behavioral and ABR results revealed only modest, if any, improvement in IA with the ER-3A relative to the supraaural earphones. The results of this study suggest that while the ER-3A earphones provide a clear IA advantage for behavioral pure-tone audiometry, they do not eliminate the need for contralateral masking of click stimuli in ABR testing.