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Survivors of neonatal infections are at risk of neurodevelopmental impairment (NDI), a burden not previously systematically quantified and yet important for program priority setting. We estimated cases of sepsis, meningitis, pneumonia, or no severe bacterial infection from among estimated cases of possible severe bacterial infection ((pSBI) step 1). Parameters required and three-step modeling process for the estimation of the burden of neonatal infection.
Estimated cases, with uncertainty of neonatal sepsis, meningitis, pneumonia, and tetanus in South Asia, sub-Saharan Africa, and Latin America, respectively. Regional burden of neonates with meningitis showing mortality, impairment, and the proportion with impairment-free survival.
Summary of outcomes in terms of deaths and disability for neonates with sepsis, meningitis, or pneumonia born in South Asia, sub-Saharan Africa, and Latin America in 2010.
Describing the burden of impairment after severe bacterial infection in neonates is an essential step to support rational individual care and public health policy. This article is part of a supplement including estimates for four other neonatal conditions.
Case definitions of pSBI and specific diagnoses of neonatal sepsis, meningitis, pneumonia, and tetanus are given in Table 1.
Systematic literature reviews were undertaken for each of the estimation parameters required by applying the general search strategy described elsewhere (8). Inclusion criteria were as follows: for incidence of pSBI, we included recent (median data collection year 2000 or later) studies, with a population denominator and diagnosis of pSBI consistent with our case definition.
A three-step model to estimate impairment specific to neonatal sepsis, meningitis, and pneumonia was developed (Figure 2), similar to the generic model described elsewhere (8). For cases of neonatal meningitis, we undertook a sensitivity analysis, using facility-based data to estimate incidence risk of neonatal meningitis where the number of facility live births was the denominator. Estimation of cases of neonatal tetanus was restricted by the limited availability of incidence data and the lack of concurrent tetanus toxoid vaccination data, especially given the recent scale up to high coverage of this vaccination in women of reproductive age (11,12).
DALYs are calculated as the sum of years of life lost due to mortality and years lived with disability (prevalence of a condition × disability weight). Estimation of DALYs and years lived with disability associated with neonatal meningitis, sepsis, pneumonia, and tetanus, as undertaken in estimates described elsewhere in this supplement (8), and in line with GBD estimates, were not completed for this study due to limitations in parameters and estimates, as described in the discussion. The sensitivity analysis of incidence of neonatal meningitis estimated from facility-based data was based on eight data sets (see Supplementary Information online).
CFRs for neonatal meningitis, neonatal sepsis, neonatal pneumonia, and neonatal tetanus in those who seek care.
We applied estimates from previously published work (2) to GBD regions defined here, estimating a total of 50,000 neonatal tetanus deaths.
We were unable to identify sufficient data on impairment after neonatal sepsis and neonatal pneumonia to estimate the burden from these severe bacterial infections. Key words: audiological rehabilitation, CaST, consonants, CVC, hearing impairment, Hearing in Noise Test, hearing loss, QuickSIN, sensorineural hearing loss, sentence reception threshold, signal-to-noise ratio, vowels. Abbreviations: ANOVA = analysis of variance, B = baseline, CaST = California Syllable Test, CV = consonant-vowel, CVC = consonant-vowel-consonant, HINT = Hearing in Noise Test, PTA = pure tone average, SeRT = sentence reception threshold, SIN = Speech-in-Noise, SNHL = sensorineural hearing loss, SNR = signal-to-noise ratio, SPL = sound pressure level, VA = Department of Veterans Affairs. The most common complaint of patients with hearing loss is difficulty understanding conversational speech in the presence of noise [1]. Thus, previous studies that have characterized consonant identification in noise have used methods that are too time-consuming for routine application.
Identifying consonant-vowel-consonant (CVC) tokens offers a more time-efficient method of assessing consonant-identification performance than testing with single-consonant syllables because each CVC can elicit two consonant-identification responses. This article describes the California Syllable Test (CaST), a 48 min test designed to assess a subject's ability to identify a large set of common American English consonants in noise.
Sixteen young subjects (eight females and eight males, aged 18-30 yr) with normal hearing (thresholds ? 20 dB hearing level at 250-4,000 Hz) each participated in three sessions over a period of 3 to 11 days. During each test session, 720 tokens were randomly selected without repetition from the syllable corpus of 9,600 tokens.
Consonants were presented at a consonant-specific SNR designed to equate the identifiability of different consonants.
On each day of testing, we measured sentence comprehension using the HINT [16] and the QuickSIN [17]. We also quantified the SNRs of each syllable presented during HINT by measuring the intensities of the vowel segment of each syllable and then quantifying the SNR relative to masking noise at each SeRT. We analyzed the data with analysis of variance (ANOVA) for repeated measures using the open-source CLEAVE program (T. Estimated signal-to-noise ratios (in dB) needed to produce identical consonant-identification performance (mean d? score = 1.6) in the California Syllable Test of all consonants in experiment I. Key words: anterior head translation, cervical posture, craniovertebral angle, Electronic Head Posture Instrument, forward head posture, mechanical neck pain, neck disability, Northwick Park Questionnaire, Numeric Pain Rating Scale, postural assessment, rehabilitation.
Abbreviations: AHT = anterior head translation, C2 = second cervical (vertebra), C7 = seventh cervical (vertebra), CI = confidence interval, CV = craniovertebral, EHPI = Electronic Head Posture Instrument, FHP = forward head posture, HPSCI = Head Posture Spinal Curvature Instrument, ICC = intraclass correlation coefficient, NPQ = Northwick Park Questionnaire, NPRS = Numeric Pain Rating Scale. Proper posture maintains the musculoskeletal balance equilibrium [4], and poor posture might result in muscle imbalance that causes a faulty relationship among various body parts [5]. Because of these associated problems, assessment of head posture has become increasingly important in clinical practices in evaluating and designing treatment regimens for patients with neck pain and the other conditions just listed [16].
Measuring craniovertebral (CV) angle is one of the common objective methods in assessing head posture [4,7].
The Head Posture Spinal Curvature Instrument (HPSCI), a noninvasive and simple instrument, was designed by Wilmarth and Hilliard [17].
Cervical curvature and alignment are commonly measured and obtained from a radiograph with standard configuration [24].
Anterior head translation (AHT) is the horizontal distance between the posterior superior body of the second cervical (C2) vertebra and a vertical line drawn superiorly from the posterior inferior body of the C7 vertebra (Figure 1).
Thirty participants aged >18 with a diagnosis of mechanical neck pain for at least 3 months without referred symptoms were recruited from the Physiotherapy Department of the Prince of Wales Hospital, Hong Kong. Each participant had a lateral cervical X-ray taken by an experienced radiographer at the Department of Diagnostic Radiology and Organ Imaging of the Prince of Wales Hospital immediately after his or her CV angle was measured.
Participants were asked to report their neck pain intensity on an 11-point NPRS, in which 0 is pain free and 10 is the most severe pain. Neck disability was measured with the Chinese version of NPQ that comprised nine questions.
Descriptive statistics of the age, sex, history of neck pain, CV angle, and AHT were calculated.
To investigate the criterion validity of the EHPI, we adopted the Pearson product moment correlation coefficient to determine the degree of associations between CV angle as measured with EHPI and AHT as measured with X-ray. The associations between AHT from X-ray measurement and CV angle measurement of the EHPI with NPQ and NPRS are listed in Table 2.
Pearson correlation (r) and p-value among anterior head translation (AHT), craniovertebral (CV) angle, Northwick Park Questionnaire (NPQ), and Numeric Pain Rating Scale (NPRS) of subjects (N = 30). The association between CV angle and AHT was also explored with Pearson product moment correlation coefficient. Average anterior head translation (AHT), craniovertebral (CV) angle, Northwick Park Questionnaire (NPQ), and Numeric Pain Rating Scale (NPRS) between male and female subjects. Poor head posture is generally accepted as one of the causes for neck pain because poor postural awareness and habitual poor postures may result in greater loading on the supporting structure and may cause sensitization and pain [33]. The measurements from the EHPI and that of the lateral cervical X-ray of the 30 subjects with chronic mechanical neck pain were compared in this study. The mean CV angle in patients with mechanical neck pain was 40.8A°, which is similar and consistent with the findings of Yip et al.
Validity was defined as the degree to which our test, or other measuring devices, is truly measuring what we intended it to measure [28]. One limitation of this study is that the sample group does not represent all types of patients with neck pain (such as acute whiplash injury) because some of the conditions were excluded.
The good negative correlation between CV angle measured with the EPHI and AHT revealed from X-ray as demonstrated in the present study supports the recommendation that the EHPI is a valid tool in clinically assessing and evaluating cervical posture in patients with chronic mechanical neck pain. Institutional Review: The ethics committee for the Chinese University of Hong Kong and for the Hong Kong Polytechnic University approved this study. Participant Follow-Up: The authors do not plan to inform participants of the publication of this study because of a lack of contact information.
The following pages contain current information about working with special learners and music. Events linked with the award include author visits, murder in the library, Drama days and of course the final award ceremony.
Resources created in this area by English Language Partners New Zealand are freely available. Please acknowledge the source when using our resources. A step-by-step photographic recipe resource made by a Waikato ESOL-Literacy class who cooked Bolani during one of their sessions. Dictionary A to C Vocabulary items, locations and adjectives representing letters A to C of the alphabet.
Dictionary I to M Vocabulary items, locations and adjectives representing letters I to M of the alphabet. Dictionary Q to SVocabulary items, locations and adjectives representing letters Q to S of the alphabet. New Zealand moneyPicture resources to become familiar with New Zealand notes and coins plus sentence starters to practice the ‘How much…?” structure. We applied respective case fatality risks ((CFRs) step 2) and the NDI risk among survivors (step 3). Note that impairment outcomes following neonatal sepsis could not be estimated due to lack of data. Severe bacterial infections have been estimated to account directly for approximately one-third of neonatal deaths in these regions (2). The Global Burden of Disease (GBD) exercise estimated impairment outcomes in 2010 for major neonatal conditions, including preterm birth, intrapartum-related neonatal encephalopathy, and neonatal infection (5). The definition of pSBI is based on the most recent WHO multisite study of severe illness in young infants. Detailed definitions within these criteria and comparison with GBD definitions are presented elsewhere (8).
Parameters required were as follows: incidence of pSBI, proportions of pSBI cases by specific infection diagnosis (sepsis, meningitis, or pneumonia), neonatal CFRs specific to each infectious clinical diagnosis (sepsis, meningitis, pneumonia, and tetanus), and proportions of survivors with long-term impairment outcomes. Snowball searching was used to identify further studies of interest by screening the reference lists of retrieved studies. For searches to apportion specific diagnoses (sepsis, meningitis, and pneumonia), we only included studies focusing on neonates with pSBI diagnosis based on the seven clinical signs and symptoms indicative of pSBI in the second WHO young infant study (9).
We calculated a quantitative assessment of the uncertainty surrounding these estimates using a statistical approach based on the compartmental model, taking 1,000 random draws at each step, assuming a normal distribution with mean equal to the point estimate of the parameter and SD equal to the estimated standard error of the parameter.
We applied this incidence risk, adjusting for care seeking, to live births in 2010 to provide an alternative estimate of total meningitis cases in 2010. Given the lack of reliable incidence data, we back calculated the incidence of tetanus from the estimated number of deaths, using estimated CFRs for neonatal tetanus (see Supplementary Information online for pooled estimate of CFR). The parameters and calculations at each step are detailed with a short summary of the results. Incidence of pSBI was determined from a meta-analysis, as described elsewhere (Seale et al., unpublished data). To apportion the envelope of pSBI cases to infection syndromes (meningitis, sepsis, or pneumonia), site-specific data from the second multicountry WHO Young Infant Study of Neonatal Sepsis (9) were used (Bolivia (13), Ghana (14), India (15,16), and South Africa (17).
Cases of neonatal tetanus were estimated based on estimated tetanus deaths by WHO region (2) adjusted for GBD regions defined here, and back calculated using the pooled estimate of CFR given in step 2. CFR estimates for neonatal sepsis were obtained from 7 data sets with 1,268 cases, for neonatal meningitis from 21 data sets with 1,642 cases, and for neonatal pneumonia from 2 data sets with 534 cases. Data on care-seeking behaviors in low- and middle-income countries were recently assessed and reported in a systematic review (19). Data were even more limited for mild impairment after neonatal tetanus, with widely differing estimates.
Our estimates of cases of true invasive bacterial disease are lower but still indicate a major burden from neonatal sepsis, meningitis, and pneumonia in SA, sSA, and LA. Here, we describe the California Syllable Test (CaST) that quantifies the identification of common American English consonants. Patients with mild to moderate sensorineural hearing loss (SNHL) have significantly higher sentence reception thresholds (SeRTs), even with hearing aids [2-5], than subjects with normal hearing. One common approach is to measure SeRTs with sentence tests such as the Hearing in Noise Test (HINT) [16] and QuickSIN (Speech-in-Noise test) (Etymotic Research; Elk Grove Village, Illinois) [17].
We recently found that the SNRs needed to equate the identification of 21 common American English consonants varied by >40 dB in young subjects with normal hearing [20]. Thus, at the SNRs that characterize SeRTs, almost all group A consonants will be identified, including many that will be identifiable even in words that occur later in sentences. Since SNHL typically produces greater audi-ometric deficits at high frequencies, disproportionate impairments in consonant identification would be expected for those consonants whose discrimination depends disproportionately on low-intensity, high-frequency acoustic cues [6,21-22].
Testing with word lists can reveal overall deficits in phonological processing [24-25], but word-recognition scores confound the identification of different consonants and are also influenced by word familiarity. In their original study, Miller and Nicely evaluated consonant confusions in five subjects using consonant-vowels (CVs) presented at seven different SNRs spanning a 35 dB range [27]. Alternative approaches, such as testing subsets of confusable consonants over more limited SNR ranges [30], are less time-consuming.

However, CVC tests are complicated by difficulties in creating the token corpora, by potential token-learning effects, and by potential differences in the identifiability of consonants in words and nonsense syllables. CaST CVC syllables were constructed by the exhaustive combination of 20 initial consonants, 3 vowels, and 20 final consonants and include both nonsense syllables and words. In a second experiment, we demonstrated the application of the CaST to understanding consonant-processing impairments in a subject with SNHL.
CaST tokens were obtained from four syllable sets (4,800 syllables each) that had been recorded from each of four phonetically trained talkers (two males and two females). We first obtained the average spectrum for each talker by averaging the spectra of all CVC tokens spoken by that talker.
Psychometric functions were measured for each initial and final consonant at three different SNRs: B (Baseline), B - 6, and B + 6 dB relative to the baseline SNR that was specific to each initial and final consonant.
Selection was constrained so that each initial and final consonant was presented 12 times at each SNR.
Syllables were selected based on the random combination of the initial consonant, vowel, and final consonant so that each token in the corpus had an equal probability of being presented.
Because of the variation in response criteria for different consonants, consonant-identification thresholds were quantified with a modified, multiresponse d? measure derived from signal detection theory [33].
HINT sentences were delivered through the loudspeakers at 70 dB SPL, with varying levels of speech-spectrum noise. The SNR levels required to equate the identifiability of different consonants varied by >40 dB. It also investigated the correlation of AHT and CV angle with the Chinese version of the Northwick Park Questionnaire (NPQ) and Numeric Pain Rating Scale (NPRS).
Forward head posture (FHP) is one of the most common cervical abnormalities that predisposes individuals toward pathological conditions, such as headache [6-7], neck pain [8-9], temporomandibular disorders [10], vertebral bodies disorders [11], soft-tissue length and strength alteration [12-13], or even scapula and shoulder dyskinesis [14-15]. It is the angle formed by a horizontal line drawn through the spinous process of the seventh cervical (C7) vertebra and a line joining the spinous process of C7 vertebra with the tragus of the ear [4,7,17]. Its measuring scale is accurate to one decimal place, and the electronic sensor reads the angle automatically.
In cervical biomechanics, AHT is increased with FHP, forward flexion (x-axis rotation), or a combination of both [26]. Subjects were excluded if they had experienced cervical fracture or trauma, cervical surgery, idiopathic scoliosis, bone cancer, spasmodic torticollis, neurological motion disorder, any hearing impairment, temporomandibular surgery, visual impairment not corrected by glasses, or systemic disorder, such as rheumatoid arthritis or systemic lupus erythematosus.
The electronic angle finder `SmartTool,' made by M-D Building Products, was fixed on a transparent plastic base. Standardized instruction for the neutral head posture, which was used in measuring CV angle, was given to each subject for taking the X-ray. Bias was eliminated by blinding each specialist to the subjects' identification, his or her previous measurement, and the measurement of the other specialist.
It provided a reliable and valid outcome measure for the patients with acute or chronic neck pain and demonstrated a very good content validity, a high degree of test-retest reliability, and internal consistency [30-31]. According to Portney and Watkins, we used ICC Model 3, Form 1, to determine the intrarater reliability and Model 2, Form 2, the interrater reliability of measuring AHT [32]. In addition, the associations between AHT and CV angle with NPQ and NPRS were also determined by Pearson correlation. Currently, upright posture evaluation is recommended as part of the comprehensive physical examination of the cervical spine [34]. The result showed a moderate to good negative correlation according to the criteria suggested by Portney and Watkins [32]. The present study has demonstrated that a significant correlation (p = 0.006) exists between AHT and NPRS in patients with neck pain.
We found good reverse correlation (r = -0.72) between the EHPI measurement of CV angle and the radiological measurement of AHT.
Another limitation is that the cause and effect relationship for head posture and pain and disability was not investigated in this study, which is crucial for clinicians to assess and treat their patients. Hammel is now available through James Madison University (VA) as a 3-credit course taught by Dr. The cool-reads site was designed and run by Chris and Tim when they themselves were in the cool-reads age range of 10-15. Some are appropriate for learners with hearing impairments. Created by Gillian Leigh and Ruth Woodley, ESOL-Literacy programme teachers (Christchurch centre). For neonatal tetanus, incidence estimates were based on the estimated deaths, CFRs, and risk of subsequent NDI. Lack of follow-up data for survivors of severe bacterial infections, particularly sepsis, was striking. This study reported that the presence of any one of the seven clinical signs and symptoms predicted severe illness requiring hospitalization in neonates aged 0–7 days, using physician judgment as gold standard, with a sensitivity of 85% and specificity of 75% (9). LA includes GBD regions LA central, LA Andean, LA southern, LA tropical, and the Caribbean (7).
For neonatal CFRs, we included studies reporting deaths associated with infection, based as far as possible on our case definitions (Table 1), from low-income countries from 1980 onwards. In step 2, to calculate the number of survivors among those estimated to seek care, CFRs were estimated based on facility data (using a pooled estimate). This approach has limitations, but as the numbers of deaths and cases are relatively small at the global level, it has less of an impact than using this approach for a more common condition such as neonatal sepsis.
A summary of the parameter inputs are shown in Table 2 and detailed in the Supplementary Information online. This is comparable with our estimate based on pSBI and proportionate split of neonatal meningitis at 200,000 cases (21,000–350,000), although both estimates have considerable uncertainty.
For neonatal tetanus, they were obtained from 5 data sets with 1,448 cases and from searches included and used in the GBD estimates (18). Of those who did not seek care, we estimated only 34,000 survivors of neonatal sepsis, 4,000 survivors of neonatal meningitis, and 10,000 survivors of neonatal pneumonia. Estimates of impairment following neonatal meningitis were mainly identified from studies in high-income settings.
One study reported 2 of 43 survivors with mild impairment, reviewed 6 mo to 4 y after recovery (20) and another identified 5 of 10 survivors (50%) with mild impairment (21).
These are the first estimates of severe bacterial infections derived from the estimated incidence of pSBI and align with recent estimates of severe pneumonia in young children, which suggested 3 million cases worldwide (23).
In experiment I, 16 young subjects with normal hearing identified 720 consonant-vowel-consonant (CVC) syllables in three test sessions.
This finding reflects a degradation of the acoustic cues that have their greatest impact on consonant discrimination [6]. However, SeRTs are relatively insensitive to consonant processing deficits for several reasons. In addition, some consonants from group B will be identifiable in well-articulated words that receive strong emphasis early in the sentence.
These consonants are primarily plosives and nonsibilant fricatives that generally require SNRs that are well above SeRTs for their identification.
The accurate measurement of consonant-identification performance for a complete set of American English consonants is a particularly challenging task that has resisted easy solution for several reasons. Each subject was tested over several months to provide 50 responses to each syllable at each SNR. However, because of the limited number of consonants and response alternatives, this approach may underestimate consonant confusions that complicate conversational listening. Boothroyd and Nittrouer developed phonetically matched sets of 120 CVC words and 120 nonsense syllables by combining 10 different initial consonants, 10 different vowels, and 10 different final consonants [18]. The CaST uses an extremely large corpus, since two recordings of each of the 1,200 syllables were obtained from each of four talkers to create a total of 9,600 tokens. The four talkers had been raised in different parts of the United States (two from the Midwest and two from California) and had slightly different American English speech patterns. We then used this spectrum to create a finite impulse response function for filtering broadband white noise. In anticipation of future studies of subjects with hearing impairment wearing hearing aids, we presented stimuli through loudspeakers (M-Audio Studiophile AV 40; Irwindale, California). Each trial began with a tone-burst cue (100 ms 1.0 kHz tone, 70 dB SPL) 1 s before the start of the noise (Figure 1). Following talker and syllable selection, one token was randomly selected from the two token exemplars for that talker. We adjusted SNRs to minimize variations in the identifiabilities of different consonants and set to produce a mean d? of 2.20 (approximately 65% correct).
Mean d? thresholds of 1.6 (generating an average hit rate of approximately 50%) were estimated from psychometric functions and are shown in Table 1, along with their associated variance measures (standard error of the mean). Thirty patients with diagnosis of mechanical neck pain for at least 3 months without referred symptoms were recruited in an outpatient physiotherapy clinic. A recent telephone survey in Hong Kong reported that the 1-year prevalence was 53.6 percent [3]. We evaluated their head postures by using both the EPHI and the traditional lateral cervical radiography.
To measure AHT on the X-ray film, two orthopedic specialists were recruited in the present study.
We conducted an independent-samples t-test to compare these parameters between males and females. However, head posture is a difficult concept to capture, which is usually assessed subjectively or by complicated procedures.
The mean AHT demonstrated in the present study was 18.0 mm, which lies within the range of 15 to 21 mm as revealed in the previous studies [27,35-36]. We demonstrated that CV angle had a similar negative correlation with AHT as with NPQ and NPRS. Because evaluation of head posture is recommended as an important part of the physical assessment for patients with neck or upper back pain, it may also provide an objective and reliable measurement of FHP for different therapists and medical professionals in assessing the progress of patients with neck pain. The prevalence of neck pain in the world population: A systematic critical review of the literature. The relationship between head posture and severity and disability of patients with neck pain.
Cervical headache: An investigation of natural head posture and upper cervical flexor muscle performance.
Head posture and neck pain of chronic nontraumatic origin: A comparison between patients and pain-free persons.
Thoracic position effect on shoulder range of motion, strength, and three-dimensional scapular kinematics. Given the high incidence of sepsis, even minor NDI would be of major public health importance. In resource-poor settings, where expertise and infrastructure are limited, diagnosis depends on simplified diagnostic algorithms with a focus on sensitivity rather than specificity, to allow early empiric antibiotic treatment of neonates with possible severe bacterial infection (pSBI) to prevent neonatal deaths. Estimates of impairment after meningitis were based on a recent systematic review, which excluded studies focusing on neonates (6). For sepsis, meningitis, and pneumonia, the primary clinical diagnosis, based on physician judgment and microbiological testing, was used, as far as possible according to the criteria in Table 1. For impairment outcomes after severe neonatal bacterial infection, to maximize the data available, we included studies worldwide reporting impairment outcomes after specific neonatal infection diagnoses, based as far as possible on our case definitions, from 1964 (the start of a computerized database of medical literature by the US National Library of Medicine) to February 2013.
This process included an adjustment for estimates of neonatal tetanus deaths to apply them to the GBD regions used here because the published estimates of neonatal tetanus deaths apply to slightly different WHO-defined regions (2).
This estimate does not take into account the estimated sensitivity of pSBI diagnosis (85%) (9). Estimated numbers of cases of neonatal sepsis, meningitis, and pneumonia by region are shown in Figure 3. There was one further study from Kenya, which reported 33 neonatal survivors, 2 of whom died after the neonatal period and 10 of whom moved away (22). After neonatal tetanus infection, there were an estimated 4,700 (1,700–8,900) neonatal survivors with moderate to severe impairment.
Consonants were identified slightly more accurately in words than nonsense syllables, and small interactions were found between the processing of initial and final consonants.
First, sentence context greatly enhances the accuracy of word report even when individual words cannot be clearly heard. However, group C consonants will almost never be presented at SNRs that would permit their identification in the absence of strong contextual cues. Paradoxically, sentence tests would thus appear to be largely insensitive to the identification of deficits in consonants most severely impaired by SNHL. First, a large consonant set must be used so that the full range of possible consonant confusions can be evaluated.
Wang and Bilger characterized consonant identification in subjects who underwent three successive 2.5 h test sessions following an orientation session [28].
Boothroyd and Nittrouer found significant differences in consonant-identification performance for words and nonsense syllables presented in separate lists. During the administration of the CaST, 720 tokens are pseudorandomly selected from the corpus for measuring the identification of each of 20 initial and final consonants across a range of SNRs needed for defining their psychometric functions.
Each filtered-noise file was trimmed of the first 0.5 s and cut into 100 different noise segments of 1,200 ms duration. Immediately before the first CaST session, subjects were briefed with written and oral instructions and received ~5 min of training in identifying CVCs presented without masking noise.

Talker-specific noise bursts of 1,200 ms duration were then presented independently from the left and right loudspeakers along with a single CVC presented from both loudspeakers. This procedure resulted in the presentation of 240 tokens (60 from each talker), at each of the three SNR levels (B - 6, B, and B + 6 dB) on each day of testing. We measured thresholds for each of the sentence blocks by initially decreasing SNRs in 4 dB steps until the first incorrect report. Further SNR declines were evident for syllable 7 in those longer sentences that included a seventh syllable. The original degrees of freedom are reported for each test with the significance levels adjusted with use of the Box-Greenhouse-Geisser correction for inhomogeneity of variance when appropriate [34]. AHT can eliminate the soft-tissue constraint when compared with the other surface landmark measuring method [19]. The neck pain intensity and disability were measured with the Numeric Pain Rating Scale (NPRS) [28-29] and the Chinese version of the Northwick Park Questionnaire (NPQ) [30], respectively.
Adhesive pin markers were used to locate the position of C7 spinous process and the tragus of the ear.
The posterior superior body of the C2 vertebra and the posterior inferior body of the C7 vertebra were marked in the radiograph by an erasable marker. After measuring each radiograph, an orthopedic specialist used alcohol preparation pads to erase any markings made on the radiographs to eliminate bias for further measurement. A clinically convenient, reliable, and valid assessment tool for head posture needs to be developed. Raine and Twomey reported that an FHP is not related to an extension of the upper-cervical spine in asymptomatic women and men [18]. The good negative correlation among CV angle, NPQ, and NPRS suggested that clinicians should pay special attention to patients with smaller CV angle because they are prone to higher pain intensity and neck disability. Results of the present study demonstrated that the EPHI is valid in measuring the position of head and neck. Also, responsiveness of the EHPI, or its capability to detect change over time, should be tested in a longitudinal study for subjects with neck pain.
Previous winners are 2009-10 Colony by J A Henderson, 2008-09 Teachers Dead by Benjamin Zephaniah.
Prevention of neonatal infection, improved case management, and support for children with NDI are all important strategies, currently receiving limited policy attention.
However, the burden of severe bacterial infection in neonates is not limited to mortality, and for those neonates who are treated and survive, the consequences of neonatal infection (defined in Table 1) may be long-term neurodevelopmental impairment (NDI) and disability, with excess mortality after the neonatal period (Figure 1). Outcomes for neonatal meningitis are likely to be different from outcomes after childhood meningitis due to differences in etiology and the effect on the developing brain. To estimate the number of impaired survivors (step 3), we used the estimated number of survivors from step 2 and pooled estimates of the risk of impairment associated with particular clinical infection syndromes. We were unable to include sex differences in further steps of the model due to the paucity of data by sex on specific diagnoses. We did not calculate estimates of uncertainty around deaths in those who did not seek care using this median value, with a large range in the data inputs (10–100%).
One of those who died had a history compatible with severe NDI, but none of those who were able to be followed up had moderate to severe impairment, and data on mild impairment outcomes were not comparable with our definitions and thus not included in the meta-analysis. The burden of neonatal infections in non-preterm babies in SA, sSA, and LA is very high compared with that in babies in resource-rich regions, where the numbers of sepsis and neonatal meningitis cases are much lower but still constitute a considerable burden of disease (24).There are limitations to these estimates and considerable uncertainty, particularly in apportioning of pSBI to the three infection syndromes (sepsis, pneumonia, and meningitis), because this split is based on just one multicountry study (9), with only two studies reporting meningitis outcomes.
Consonant-identification performance correlated strongly with sentence reception thresholds (SeRTs) measured with both the Hearing in Noise Test and QuickSIN (Etymotic Research; Elk Grove Village, Illinois). For example, Boothroyd and Nittrouer studied the relationship between phoneme-identification and SeRTs and found that the SeRTs for high-probability sentences occurred at signal-to-noise ratios (SNRs) where <50 percent of phonemes (including vowels) could be identified in isolated words [18]. This finding suggests that SeRTs primarily reflect a subject's ability to identify vowels and consonants in group A as well as some consonants in group B. This result leads to the prediction that many patients with SNHL may show relatively small elevations in SeRTs despite significant difficulties in identifying many consonants that occur frequently in American English. Second, because of systematic differences in the processing of initial and final consonants in syllables [20,26], consonant processing should be assessed in both the initial and final syllable positions. Four different groups of four subjects each were tested with different sets of 16 consonants. In group studies, the CaST provides information about consonant-identification thresholds, confusion patterns, and vowel- and syllable-position influences on consonant-feature processing [20]. The mixture of words and nonsense syllables containing the same consonants enabled us to examine the role of syllable type on consonant identification.
We reviewed the complete syllable sets and selected the two best exemplars of each syllable from each talker's corpus. Then we randomly sampled the 100 different noise segments during the testing sessions to mask CVCs spoken by that talker.
Syllable onset time was randomized with the constraint that each CVC began at least 100 ms after noise-burst onset and ended at least 100 ms before noise-burst offset. Thereafter, we increased SNRs by 2 dB following each incorrect report and decreased by 2 dB following each correct report. In these cases, the original degrees of freedom are reported along with corrected significance levels. Previous studies demonstrated that associations exist among FHP, neck pain, and disability [4-5,9,16,20]. However, the accuracy of the instrument is limited to whole digits only without decimal places because no marking exists between digits.
However, the criterion-related validity of the EHPI, which is vital for clinical measurement, is still pending an investigation.
AHT was measured as the horizontal distance of the posterior superior body of the C2 vertebra to a vertical line drawn superiorly from the posterior inferior body of C7 vertebra (Figure 1). We calculated the intrarater and interrater reliability to strengthen the validity of the study. We therefore developed the EHPI for assessing head posture and investigated the criterion-related validity of the EHPI in this study. The course includes numerous video examples, case studies, discussion boards, and frequent feedback from Dr. Little attention has been paid to the long-term morbidity associated with neonatal infections, particularly in resource-poor settings (3). We estimated that 95% of cases of neonatal sepsis, meningitis, or pneumonia would die if they did not seek care, so only a small proportion (5%) of meningitis survivors who did not seek care are included in impairment estimates (step 3). The young infant algorithm, which is also only 85% sensitive for pSBI, was based on those admissions, and admissions included other diagnoses such as hyperbilirubinemia, diarrhea, neonatal encephalopathy, and, in some cases, preterm birth (9). At SeRTs, subjects with normal hearing could identify 32.5% of consonants in isolated CVCs. As a result, improving consonant comprehension is a major focus of current research on hearing aid design [9-11] and adaptive perceptual training [12-15]. Consequently, even in subjects with normal hearing, SeRT testing will fail to evaluate the phonological processing of >50 percent of common American English consonants. Although impairments in the processing of these consonants may not increase SeRTs in the simple declarative sentences used in most sentence tests, they will impair comprehension and memory for less predictable spoken materials [23] and contribute to patient fatigue. Finally, testing consonant identification over a broad range of SNRs is necessary for assessing consonant processing over SNR ranges that produce hit rates (percentage of correct responses) of 40 to 70 percent for each consonant.
Two groups identified CVs and two groups identified vowel-consonants, using consonants randomly paired with three vowels. However, because only 240 of 1,000 possible CVC combinations were used in these experiments, they did not analyze the processing of initial and final consonants independent of each other and the accompanying vowel. Previous syllable tests have shown that subjects can more accurately identify consonants in words than in nonsense syllables when words and nonsense syllables are presented in separate blocks [18]. Then two listeners with normal hearing independently reviewed each of the 9,600 syllables in the absence of masking noise to assure the intelligibility of all tokens. After familiarizing themselves with a list of acceptable initial and final consonants and vowels posted in the testing room and practicing for 15 min to ensure understanding and accuracy, listeners attempted to repeat the CVC token correctly on each trial.
We then estimated thresholds by averaging the SNRs over the final 16 sentences in each block, with mean daily thresholds averaged over the four blocks. These measurements establish that the clarity of acoustic cues was greatest for syllables occurring early in sentences in both tests and declined substantially for words occurring later in the sentences. We found a negative correlation between CV angle measured with the EHPI and AHT measured with the X-ray lateral film as well as with NPQ and NPRS in patients with chronic mechanical neck pain. The studies found that subjects with head, neck, and shoulder discomfort are more likely to have a smaller CV angle that indicates an FHP than that of asymptomatic subjects. In resource-rich settings, contemporary work focuses on the strong association of infection in extremely low-birth-weight and preterm neonates and NDI, and there has been surprisingly little recent work addressing long-term outcomes after severe bacterial infections, in term or moderately preterm neonates (4).
However, the estimate of neonatal meningitis cases using facility-based data, and adjusting for care seeking, was comparable with that based on apportioning of the incidence of pSBI. In experiment II, a patient with moderate SNHL showed large elevations in consonant-identification thresholds and smaller elevations in SeRTs.
Second, the phonemes that are actually heard, rather than deduced from semantic context, come disproportionally from words that occur early in sentences. Since the SNRs needed to identify different consonants differ by >40 dB [20], consonant identification must be tested at many different SNRs.
In addition, because of the relatively small number of CVC tokens, they had to test separate subject groups at each SNR to avoid token repetition.
Similarly, previous investigators have also found interactions between the processing of initial and final consonants in words but not in nonsense syllables when both were presented in separate lists [18-19].
Whenever this intelligibility test failed, a new exemplar from the same talker was substituted and further testing was performed among laboratory staff to assure the intelligibility of the substituted tokens. Responses were spoken in quiet into a microphone and phonetically transcribed by an investigator listening through headphones in an adjacent room. The QuickSIN involved the delivery of six blocks, each containing six sentences in four-talker babble. EHPI is a valid tool in clinically assessing and evaluating cervical posture of patients with chronic mechanical neck pain. A number of studies also recommended that subjects with FHP were more prone to neck disorder or abnormal stress over the neck structure [4,16,19-20]. At SeRT levels, the patient could identify only 12.5% of consonants in isolated CVCs, indicating that sentence comprehension relied disproportionately on vowel cues and semantic constraints. For example, if testing is done at 6 dB intervals, at least seven different SNRs are needed for testing the full range of consonant-identification performance. Phatak and Allen investigated the processing of 16 consonants and 4 vowels in CVs presented at six different SNRs from -22 dB to quiet [29]. A number of other investigators have also used lists of CVC words to evaluate consonant processing in patients with hearing loss. The CaST presents word and nonsense-syllable tokens in random order, thus permitting the examination of word superiority effects and interactions in the processing of initial and final consonants in conditions where category-report bias was minimized. Speech-to-babble ratios were reduced by 5 dB on each sentence presentation within a block, and the number of words correctly reported was used for calculating thresholds.
FernA?dez-de-las-PeA±as and his colleagues compared the CV angle of tension-type headache and migraine patients with that of nondisabled subjects. Thus, this study evaluated the validity of the EHPI in measuring CV angle by correlating the measurements of CV angle with AHT in lateral cervical radiographs.
Consonant-profile analysis revealed disproportional impairments in identifying consonants dependent on high-frequency acoustic cues.
Since masking noise amplitudes are constant, SNRs are much higher for consonants that occur early in sentences than for consonants that occur later. Subjects (n = 14) required approximately 15 h to produce 56 responses to each consonant at each SNR. These tests require between 20 [31] and 54 min [32] to administer to subjects with hearing impairment to identify global phoneme deficits that are significantly correlated with SeRTs, but these tests fail to permit the isolation of consonant-specific identification deficits.
Results showed that the patient group had greater FHP, smaller CV angle [21-22], and lesser neck mobility than the control group [22]. We hypothesize that the measurement of the EPHI accurately represents the CV angle when compared with the radiographical measurement. Thus, sentence context is particularly necessary to perceive words that occur later in the sentence. Each intertrial interval (approximately 2 s) included the time needed for syllable transcription plus a small delay (0.5 s) before the delivery of the warning tone signaling the next trial. The CaST is a promising tool for evaluating consonant-specific processing deficits in patients with hearing impairment. Because of the critical role of semantic context, sentence tests may underestimate phonological impairments in patients with exceptional semantic skills and overestimate deficits in patients with cognitive impairments or impaired semantic processing of standard American English because of bilingualism or ethnic speech patterns.
The order of presentation of the three different sets of HINT and QuickSIN sentences was randomized across subjects.

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