text: 1000 HZ TYMPANOMETRY IN NICU BABY HEARING SCREENING Using 1000 Hz Tympanometry in Hearing Screening of Babies in the Neonatal Intensive Care Unit (NICU) L'usage de la tympanométrie à 1 000 Hz pour le dépistage de la surdité chez les bébés se trouvant dans les unité des soins intensifs pour nouveau-nés KEY WORDS 1000-HZ TYMPANOMETRY NEONATAL INTENSIVE CARE UNIT (NICU) UNIVERSAL HEARING SCREENING (UNHS) AUDITORY BRAINSTEM RESPONSE SCREENING Li Qi Brian Schmidt Mosarrat Qureshi Leonora Hendson Ming Zhang Li Qi1; Brian Schmidt2; Mosarrat Qureshi3,4; Leonora Hendson3,4; Ming Zhang2,5,6 1 Neuro-Otology Unit, Vancouver General Hospital, Vancouver, BC CANADA Department of Audiology, Glenrose Rehabilitation Hospital, Alberta Health Services, Edmonton, AB CANADA 2 Northern Alberta Neonatal Program, Royal Alexandra Hospital, Edmonton, AB CANADA 3 Department of Pediatrics, University of Alberta, Edmonton, AB CANADA 4 Department of Communication Sciences and Disorders, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB CANADA 5 6 Department of SurgeryOtolaryngology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB CANADA 162 Abstract An issue of great concern in Universal Newborn Hearing Screening (UNHS) is the high false-positive rates, which is especially problematic in the Neonatal Intensive Care Unit (NICU) population. False-positive results may lead to unnecessary follow-up appointments, increased health care costs, and increased stress on parents. High frequency tympanometry has been recommended for healthy babies younger than 6 months of age, which may reduce false-positive results caused by transient middle-ear issues. The objectives of this study were to obtain admittance, susceptance, and conductance data from a sample of NICU babies, to compare tympanometric data obtained from the component compensation approach with the data obtained from the baseline approach, and to provide preliminary normative data for NICU babies when ABR was used as a 'gold standard'. In this study, 31 babies in the NICU were included. Admittance was obtained in 84% (n=52) of 62 ears, and susceptance and conductance were obtained in 77% (n=48) of 62 ears. Using a component compensation approach, at the 5th and 95th percentile the admittances at the tympanic membrane were 0.5 and 1.7 mmho referenced to the positive tail, and 0.6 and 2.0 mmho referenced to the negative tail. Using a baseline approach, at the 5th and 95th percentile the peak-to-tail compensated admittances were 0.2 and 1.2 mmho referenced to the positive tail, and 0.4 and 2.0 mmho referenced to the negative tail. Our results were also compared with several data sets published by other investigators, and the differences among data sets are discussed. A significant difference in admittance existed between the component compensation approach and the traditional baseline approach. Different normative data needs to be considered accordingly. Canadian Journal of Speech-Language Pathology and Audiology | Vol. 39, No. 2 , Summer 2015 1000 HZ TYMPANOMETRY IN NICU BABY HEARING SCREENING Abrégé Le taux élevé de « faux positifs » est un problème très préoccupant dans le dépistage universel de la surdité chez les nouveau-nés. Ils sont particulièrement problématiques dans la population de bébés d'unités des soins intensifs pour nouveau-nés (USIN). Des résultats « faux positifs » peuvent mener à des rendez-vous de suivi inutiles, à une augmentation des coûts de santé et à un stress accru chez les parents. La tympanométrie à haute fréquence a été recommandée pour les bébés en santé âgés de moins de 6 ans, ce qui peut réduire les résultats « faux positifs » causés par des problèmes temporaires de l'oreille moyenne. Les objectifs de la présente étude étaient d'obtenir des données d'admittance, de susceptance et de conductance à partir d'un échantillon de bébés d'USIN, afin de comparer les données tympanométriques obtenues par l'approche de compensation des composantes à celles obtenues par l'approche de référence, et de fournir des données normatives préliminaires pour les bébés d'USIN quand la mesure des PÉATC a été utilisée comme « règle d'or ». Cette étude compte 31 bébés d'USIN. L'admittance a été obtenue dans 84 % (n=52) de 62 oreilles, et la susceptance et la conductance furent obtenues dans 77 % (n=48) de 62 oreilles. En utilisant l'approche de compensation des composantes, aux 5e et 95e percentiles, les admittances à la membrane du tympan furent de 0,5 et 1,7 mmho en référence à l'extrémité positive et 0,6 et 2,0 mmho en référence à l'extrémité négative. En utilisant l'approche de référence, aux 5e et 95e percentiles, les admittances compensées et mesurées du « sommet à la base » furent de 0,2 et 1,2 mmho en référence à l'extrémité positive et 0,4 et 2,0 mmho en référence à l'extrémité négative. Nos résultats furent aussi comparés à plusieurs données publiées par d'autres chercheurs et les différences entre les données sont discutées. Une différence significative dans l'admittance existait entre l'approche de compensation de composantes et l'approche de référence traditionnelle. Différentes données normatives doivent être considérées en conséquence. Revue canadienne d'orthophonie et d'audiologie | Vol. 39, No. 2, été 2015 163 1000 HZ TYMPANOMETRY IN NICU BABY HEARING SCREENING ABBREVIATIONS: Y = Admittance [Equation 1]; B = Susceptance; G = Conductance; Y TM = compensated admittance at tympanic membrane; Ypeak = uncompensated admittance at peak; Ya @+ 200 daPa = uncompensated admittance at positive tail; Ya @- 400 daPa = uncompensated admittance at negative tail; Bpeak = uncompensated susceptance at peak; Btail @ +200 daPa = uncompensated susceptance at positive tail; Btail @ -400 daPa = uncompensated susceptance at positive tail; Gpeak = uncompensated conductance at peak; Gtail @ +200 daPa= uncompensated conductance at positive tail; Gtail @ -400 daPa= uncompensated conductance at negative tail; +200BTM: peak-to-positive tail susceptance [Equation 2]; -400BTM: peak-to-negative tail susceptance [Equation 3]; +200GTM: peak-to-positive tail conductance [Equation 4]; -400GTM: peak-to-negative tail conductance [Equation 5]; +200Y TM: positive tail component compensated admittance [Equation 6]; -400Y TM: negative tail component compensated admittance [Equation 7]; +200Ya: peak-to-positive tail admittance [Equation 8]; -400Ya: peak-to-negative tail admittance [Equation 9]; 164 Canadian Journal of Speech-Language Pathology and Audiology | Vol. 39, No. 2 , Summer 2015 1000 HZ TYMPANOMETRY IN NICU BABY HEARING SCREENING EQUATIONS: Revue canadienne d'orthophonie et d'audiologie | Vol. 39, No. 2, été 2015 165 1000 HZ TYMPANOMETRY IN NICU BABY HEARING SCREENING INTRODUCTION An issue of great concern in Universal Newborn Hearing Screening (UNHS) is the high false-positive rates. A falsepositive result means that a neonate who does not have a target hearing loss (typically, this is a permanent hearing loss that is at least moderate in degree) fails the UNHS and is required to undergo a full diagnostic test. It has been reported that in UNHS a substantial proportion (59% to 81%) of false positive results was due to transient conductive hearing loss caused by middle ear dysfunction (e.g., Cristobal & Oghalai, 2008; Holte, Cavanaugh, & Margolis, 1990; Keefe et al., 2000; Stuart, Yang, & Green, 1994). Reliable and accurate diagnosis of middle ear function in neonates may reduce false positive rates in UNHS. Currently, auditory brainstem response (ABR) and otoacoustic emission (OAE) screening tests are used for newborn hearing screening. Unfortunately, neither test can differentiate between conductive and sensorineural hearing loss, and both tests can be affected by transient outer or middle ear dysfunction (e.g., Zhang & Abbas, 1997; Zhao, Wada, Koike, & Stevens, 2000). Therefore, a baby with normal cochlear and neural function may fail a hearing screening and be referred for a full diagnostic follow up due to a conductive problem. This is especially problematic in the Neonatal Intensive Care Unit (NICU) population as they have a higher prevalence of middle ear dysfunction. Whereas the false positive rate has been shown to be around 2% to 4% in most UNHS programs (Nelson, Bougatsos, & Nygren , 2008), the rate is as high as 15% to 20% in babies in the NICU (Keefe et al., 2000; Thompson et al., 2001). Tympanometry is a test that is non-invasive, cost effective, and quick. Middle ear function in adults can be assessed by using a 226-Hz probe tone. For infants six months of age or younger, studies have shown that 1000Hz tympanometry is more effective than the 226-Hz test (Alaerts, Luts, & Wouters, 2007; Baldwin, 2006; Hunter, Feeney, Lapsley Miller, Jeng, & Bohning, 2010; Hunter, Tubaugh, Jackson, & Propes, 2008; Kei et al., 2003; Margolis, Bass-Ringdahl, Hanks, Holte, & Zapala, 2003; Merchant, Horton, &Voss, 2010; Prieve, Vander Werff, Preston, & Georgantas, 2013; Resende, Ferreira, Carvalho, Oliveira & Bassi, 2012; Sanford & Feeney, 2008; Shahnaz, 2008; Shahnaz, Miranda, & Polka, 2008; Son et al. 2012;). The effectiveness of the 1000-Hz probe tone for newborns is likely due to significant anatomical differences between newborns and adults (Anson & Donaldson, 1981; McLellan & Webb, 1957; Northern & Downs, 2002; Saunders, Doan, & Cohen, 1993). Finite-element models of the newborn 166 Canadian Journal of Speech-Language Pathology and Audiology middle and outer ear were developed by and Qi, Liu, Lutfy, Funnell, and Daniel (2006) and Qi, Funnell, and Daniel (2008) which showed that anatomical changes in the infant's outer ear and middle ear could partially account for the differences in tympanometry between infants and adults (Gulya, 2007). The use of 1000-Hz tympanometry on full-term healthy babies has been widely studied (Kei et al., 2003; Kei, Mazlan, Hickson, Gavranich, & Linning, 2007; Margolis et al., 2003; Mazlan et al., 2007; Shahnaz, 2008; Shahnaz & Polka, 2002; Swanepoel et al., 2007). Currently, there are few studies on the use of 1000 Hz tympanometry for babies in the NICU who are undergoing a hearing screening. Yoon, Price, Gallagher, Fleisher, and Messner (2003) reported that 37% of NICU graduates (n=82) had abnormal tympanometry in one ear and 29% had abnormal tympanograms bilaterally; however, they did not provide any qualitative data in their paper. The abnormal tympanometry was defined as either flat tympanograms or negative pressures > 200 daPa. Margolis et al. (2003) investigated 1000-Hz tympanometry in 65 babies in the NICU and 30 full term health babies at 2-4 weeks of age. They found the 5th percentile of admittance for both babies in the NICU and full term healthy babies was identical, and they recommended a single pass-fail criterion using the admittance derived from negative tail using a baseline approach, for both NICU and full-term health babies. The negative tail was recommended for clinical practice because it resulted in a larger mean value of admittance, which may make it easier to distinguish between normal tympanograms and abnormal tympanograms. Shahnaz et al. (2008) investigated multi-frequency tympanometry (MFT) and conventional tympanometry in well babies and babies in the NICU at nine frequencies (from 226 to 1000 Hz). Conventional tympanometry and MFT were performed in 33 NICU babies, 16 healthy full term three-week-old babies and 42 babies who met high priority hearing registry criteria. They used the component compensation approach in their study and provided admittance phase and peak compensated susceptance and conductance at different probe tone frequencies. They recommended that the tympanograms obtained at 1000-Hz were more sensitive and specific for presumed abnormal and normal middle-ear conditions for both groups. Alaerts et al. (2007) performed 226 and 1000-Hz tympanometry in six different age groups (131 ears in total), including NICU babies (28 ears), infants/children aged from 0 to 32 months and adults. In their study they measured middle ear admittance at +200daPa, middle ear admittance at peak, tympanometric peak pressure, tympanometric width, and ear canal volume. They found that the visual admittance classification system was more | Vol. 39, No. 2 , Summer 2015 1000 HZ TYMPANOMETRY IN NICU BABY HEARING SCREENING suitable than the Vanhuyse model. In addition, for infants younger than 3 months, 1000-Hz tympanometry was more reliable and easier to interpret than traditional 226Hz tympanometry. For older children (9 months of age), traditional 226-Hz tympanometry was more appropriate. For children between 3 and 9 months of age, 226-Hz and 1000-Hz tympanometry were equally reliable. The admittance is a complex number including both real and imaginary parts, as shown in Equation 1, where G is the conductance and B is the susceptance. G is in phase with the delivered probe tone. B is an out-ofphase component which is comprised of two parts. One is the compliance component and the other is the mass component. Admittance obtained from Equation 1 is referred to as the component compensation approach. For adults, conductance is very negligible (e.g., Shahnaz, Cai, & Qi, 2014). Therefore, peak-to-tail difference is almost equal to the true admittance. For infants, conductance is significantly prominent (e.g. Shahnaz et al., 2008), and for this reason, phase information needs to be taken into account. Mathematically, the baseline approach, using a peak-to-tail difference, is not correct; however, from a clinician's point view, the baseline approach is easy to calculate and the value is typically calculated automatically by clinical tympanometers. It is important for clinicians to understand the different tympanometric values may be obtained by using these two different approaches. Therefore, different normative data would be applied accordingly. To date, there are few studies of conductance and susceptance in NICU babies (Shahnaz et al., 2008). The objectives of the current study were to obtain admittance, susceptance and conductance data from a sample of babies who were in or were graduates of an NICU, to compare tympanometric data obtained from the component compensation approach with the data obtained from traditional baseline approach, and to provide preliminary normative data for NICU babies when the ABR screening was used as the 'gold standard' to indicate middle ear status. METHODS Subjects Thirty one NICU infants (18 males and 13 females) were recruited during hearing screening between 2011-2013 with corrected (or adjusted) ages ranging from 0 weeks to 6 months (mean age 1.30 months; SD 1.43 months), and chronological ages ranging from 1 week to 6 months (mean age 2.22 months; SD 1.53 months). The subjects were recruited according to a protocol approved by research ethics committees at the University of Alberta, the Glenrose Rehabilitation Hospital (GRH) and the Royal Alexandra Hospital (RAH). The consents were obtained from parents or guardians. Subjects were infants admitted to the NICU at the RAH who were screened either during their stay at the RAH or at the GRH soon after discharge from the NICU. These were babies who would typically have their hearing screening in the NICU based on high-risk criteria including: prematurity (<29 weeks gestational age at birth), low birth weight (<1250 grams at birth), hyperbilirubenemia requiring exchange transfusion, sepsis requiring treatment with antibiotics, etc. These criteria are largely based on the Joint Committee on Infant Hearing (2007) recommendations. Data collection and analysis In this study, screening ABR results were used as the 'gold standard' to indicate the infant's middle ear function. This decision was made, in part, because the ABR is the recommended choice for hearing screening in the NICU due to the higher incidence of Auditory Neuropathy Spectrum Disorder in this population (Joint Committee on Infant Hearing, 2007). A "pass" result on the ABR screening required a repeatable Wave V evoked by click stimuli presented at 35 dB nHL for each ear. Each average waveform consisted of at least 1500 individual collections and there were a minimum of 2 average waveforms collected to ensure good replicability. The Wave V latency had to fall within normative limits for the baby's gestational age (local norms were previously collected by GRH audiologists). A Biologic NavPro System was used to collect ABR data. This was not an automated ABR. In order to be enrolled in this study, babies needed to pass the ABR screening. ABR tests and tympanometry were performed by the same tester, who was a registered audiologist. Audiologists collected data for this study were experienced with both ABR screenings and 1000-Hz tympanometry. The GSI TympStar (version 2; North Carolina) was used for tympanometry measurement. Tympanometry was performed by presenting a 1000 Hz probe tone at 75 ±3 dB SPL into the ear canal (GSI TympStar V2.0 manual). A handheld probe was used. Two tympanometry measurements were made for each ear. First, 1000-Hz admittance tympanometry was performed and then the probe tip was removed and reinserted for the second measurement. For the second measurement, 1000-Hz susceptance and conductance were measured. Tympanograms were recorded using a positive to negative sweep pressure method from +200 Revue canadienne d'orthophonie et d'audiologie | Vol. 39, No. 2, été 2015 167 1000 HZ TYMPANOMETRY IN NICU BABY HEARING SCREENING to -400 daPa with a pump speed varying from 600 daPa/sec at the tails to 200 daPa/sec at the peak. Most tympanometry measurements could be obtained in an ear within a few minutes when the subject was sleeping or awake but inactive. The results of tympanometry were printed out for further analysis. The following tympanometric data were measured for analysis: +200YTM; -400YTM; +200Ya; -400Ya; Ya @ +200 daPa; Ya @ -400 daPa; Btail @ +200 daPa; Btail @ -400 daPa; Gtail @ +200 da Pa; Gtail @ -400 daPa; Ypeak; Bpeak; Gpeak. Similar to other reports in this area of research (e.g., Calandruccio, Fitzgerald, & Prieve, 2006; Kei et al, 2003; Margolis et al., 2003; Shahnaz et al., 2008) descriptive statistics were used to analyze the results. The descriptive statistics used in this study were the median and the 5th and 95th percentiles of admittance, susceptance, and conductance. RESULTS Typmanometry testing was attempted on 62 ears. Admittance tympanograms were obtained in 52 ears and susceptance and conductance tympanograms were obtained in 48 ears. Tests on 10 ears and 14 ears could not be obtained for admittance measurement and for susceptance and conductance measurements, respectively. The data that could not be obtained were due to infant movement or to a poor seal between the probe and the ear canal. In addition, 8 ears were excluded from this study due to the fact that they failed ABR screening. Therefore, 44 ears were used for admittance analysis and 40 ears were used for susceptance and conductance analysis. Tympanograms were evaluated according to the classification proposed by Kei et al. (2003). They were classified as follows: Type 1 had a single peak; type 2 was flat sloping; type 3 had double peaks. All the other types of tympanograms were considered non-interpretable. Our results showed that tympanograms had a single peak (type 1) for 84% of admittance tests (37/44 ears) and for 70% of susceptance and conductance tests (28/40 ears). A type 2 pattern was found for 7% of admittance tests (3/44 ears) and for 15% of susceptance and conductance (6/40 ears). A type 3 pattern was found for 5% of admittance tests (2/44 ears) and for 8% of susceptance and conductance tests (3/40 ears). The rest were unclassified tympanograms (4% for the admittance test and 7% for the susceptance and conductance test). In this section, we report our results and compare our data with previously published data. Table 1 shows descriptive statistics of the 1000-Hz susceptance (B) results. This includes the 5th to 95th percentile and the 168 Canadian Journal of Speech-Language Pathology and Audiology median for: Bpeak, Btail @+ 200 daPa, Btail @ -400 daPa, +200BTM (Equation 2) and -400BTM (Equation 3). Table 2 shows 1000-Hz conductance results including the 5th to 95th percentile and the median for: Gpeak, Gtail @+ 200 daPa, Gtail @ -400 daPa, +200GTM (Equation 4) and -400GTM (Equation 5). Table 3 shows the 5th to 95th percentile and the median results for +200YTM (Equation 6) and -400YTM (Equation 7). The 5th to 95th percentile for +200YTM ranged from 0.5 to 1.7mmho, and the 5th to 95th percentile for -400YTM ranged from 0.6 to 2.0 mmho. Shahnaz et al. (2008) reported the 5th to 95th percentile for +250YTM and -300Y TM in 16 healthy full term 3-week old babies were 0.5 to 2.6 mmho and 0.3 to 2.4 mmho, respectively. Alaerts et al. (2007) reported the 5th to 95th percentile for +200YTM ranged from 0.34 to 2.66 in a combined group of NICU babies and 0-3 month-old healthy babies. Figure 1 compares the Ya @ 200 daPa obtained from this study with previously published data. The 5th percentile of Ya @ 200 daPa obtained in this study is 0.8 mmho, which is in good agreement with the 5th percentile of Ya @ 200 daPa (0.9 mmho) obtained by Margolis et al. (2003) in 65 babies in the NICU and 0.87 mmho obtained by Shahnaz et al. (2008) in 32 babies in the NICU. The 5th percentile of Ya @ 200 daPa obtained from healthy babies ranged from 0.37 to 1.44 mmho (Alaerts et al, 2007; Kei et al, 2003; Margolis et al., 2003; Mazlan et al., 2007). The 95th percentile of Ya @ 200 daPa obtained in this study is 3.0 mmho, which is higher than values obtained by Margolis et al. (2003) and Shahnaz et al. (2008) in NICU babies. Our result is generally consistent with results (3.07 mmho) obtained in healthy babies reported by Alaerts et al. (2007). Figure 2 compares the Ya @ -400 daPa obtained from this study with previously published data. The 5th to 95th percentile of Ya @ -400 daPa obtained in this study ranged from 0.4 to 1.8 mmho. Margolis et al. (2003) reported the 5th to 95th the percentile of Ya @ -400 daPa to be from 0.4 to 1.0 mmho for babies in the NICU and from 0.3 to 1.4 for healthy full term babies. Shahnaz et al. (2008) reported values (using -300Y) from 0.4 to 1.2 mmho in NICU babies. Kei et al. (2007) reported values in healthy babies from 0.36 to 2.38 mmho. Figure 3 compares the Ypeak obtained from this study with previously published data. The 5th to 95th percentile of Ypeak obtained in this study ranged from 1.0 to 3.8 mmho. Margolis et al. (2003) reported the 5th to 95th the percentile of Ypeak to be from 1.3 to 2.4 mmho for babies in the NICU and from 1.2.to 4.8 mmho for healthy full term babies. Mazlan et al. (2007) reported 5th to 95th percentile of Ypeak to be from 0.7 to 4.2 mmho for healthy babies at | Vol. 39, No. 2 , Summer 2015 1000 HZ TYMPANOMETRY IN NICU BABY HEARING SCREENING birth and 1.16 to 4.5 mmho for healthy babies of 6 to 7 weeks old. Figure 4 compares 5 to 95 percentiles of +200Ya (Equation 8) obtained in this study with previously published data (baseline approach). In this study the 5th to 95th percentile of +200Ya ranged from 0.2 to 1.2 mmho. The published 5th percentile of +200Ya ranged from 0.1 to 0.2 mmho in NICU babies (Margolis et al., 2003; Shahnaz et al., 2008) and ranged from 0.1 to 0.35 mmho in healthy babies (Kei et al, 2007; Margolis et al., 2003; Mazlan et al., 2007). The published 95th percentile of +20000 ranged from 1.5 to 1.6 mmho in NICU babies (Margolis et al., 2003; Shahnaz et al., 2008) and ranged from 1.5 to 3.5 mmho in healthy babies (Kei et al., 2007; Margolis et al, 2003; Mazlan et al., 2007) th th Figure 5 compares the 5th to 95th percentile of the -400Ya (Equation 9) obtained from this study and published data (baseline approach). In current study the 5th to 95th percentile of -400Ya ranged from 0.4 to 2.0 mmho. The 5th percentile of -400Ya was reported 0.6 mmho by Margolis et al. (2003) for both healthy and NICU babies; and 0.53 mmho in NICU babies by Shahnaz et al. (2008). The 95th percentile of -400Ya were 2.7 mmho in NICU babies and 4.3 mmho in healthy babies by Margolis et al. (2003) and 2.3 mmho in NICU babies by Shahnaz et al. (2008). DISCUSSION AND CLINICAL IMPLICATIONS In this study, we considered the ABR screening results as the 'gold standard' to indicate middle ear status. Normal ABR screening results do not indicate normal auditory or middle ear function. Theoretically myringotomy is the most accurate gold standard to confirm middle ear dysfunction (Marchant et al., 1986); however, it is an expensive and invasive procedure. The use of the ABR as the gold standard for middle ear function is a clear limitation of this study. As indicated in the methods section, the Joint Committee on Infant Hearing (2007) recommends ABR testing for UNHS in the NICU because it is more sensitive to auditory neuropathy spectrum disorder, which has a higher prevalence in the NICU population. It also has a more acceptable "Pass" rate in the NICU. For these reasons, the ABR is the standard screening in the NICU and it was therefore chosen as the gold standard to make this study clinically feasible. In this study admittance tympanograms were obtained in 52 ears out of 62 ears. This "success" rate was 84%. Similar results were reported by Margolis et al. (2003). They reported that tympanograms could be obtained from 77/88 (87.5%) ears of babies in the NICU. Kei et al. (2003) performed 1000-Hz tympanometry in 170 healthy full term Table 1. Descriptive statistics of the 1000-Hz susceptance (B) results. Bpeak (mmho) Btail @ +200 daPa (mmho) Btail @ -400 daPa (mmho) +200BTM (mmho) -400BTM (mmho) 5% 1.1 1.0 0.5 0.3 0.5 Median 1.6 1.4 1.0 0.6 0.9 95% 3.1 2.8 2.7 1.3 1.6 Table 2. Descriptive statistics of the 1000-Hz conductance (G) results. Gpeak (mmho) Gtail @ +200 daPa (mmho) Gtail @ -400 daPa (mmho) +200GTM (mmho) -400GTM (mmho) 5% 0.5 0.3 0.1 0.3 0.3 Median 1.6 0.9 0.7 0.6 0.8 95% 2.3 1.7 1.2 1.0 1.2 Revue canadienne d'orthophonie et d'audiologie | Vol. 39, No. 2, été 2015 169 1000 HZ TYMPANOMETRY IN NICU BABY HEARING SCREENING Table 3. Descriptive statistics of component compensation admittance at tympanic membrane. +200YTM (mmho) -400YTM (mmho) 5% 0.5 0.6 Median 1.0 1.2 95% 1.7 2.0 Figure 1. Comparison of Ya @ +200 daPa obtained from this study and published data. Figure 2. Comparison of Ya @ -400 daPa obtained from this study and published data. 170 Canadian Journal of Speech-Language Pathology and Audiology | Vol. 39, No. 2 , Summer 2015 1000 HZ TYMPANOMETRY IN NICU BABY HEARING SCREENING Figure 3. Comparison of the Ypeak obtained from this study and published data. Figure 4. Comparison of the +200Ya obtained in this study and published data (baseline approach). Revue canadienne d'orthophonie et d'audiologie | Vol. 39, No. 2, été 2015 171 1000 HZ TYMPANOMETRY IN NICU BABY HEARING SCREENING Figure 5. Comparison of -400Ya obtained from this study and published data (baseline approach). babies (340 ears) and they obtained tympanograms in 299 ears (88%). In our study, among the different tympanograms, single peaked tympanograms were the most observed type (84% of admittance and 70% of susceptance and conductance). Kei et al. (2003) reported that they obtained 92% single-peaked 1000-Hz admittance in 244 ears of full term healthy babies. Margolis et al. (2003) reported that nearly all infants with single-peaked admittance passed OAE screening. Alaerts et al. (2007) reported a distribution of tympanograms types based on the Liden and Jerger classification systems and the Vanhuyse model. Their results showed that for infants younger than 3 months of age 90% of them had single-peaked admittance and about 50% had 1B1G. Similar results were also reported by other studies (e.g. Shahnaz et al., 2008; Calandruccio et al., 2006). The more complicated type of tympanogram observed in susceptance and conductance measurements were likely due to the fact that the newborn middle ear is a mass-dominated system (e.g., Shahnaz et al. 2014). From a clinician's point of view, a simple and easy-to-interpret classification system is preferred when possible. For this reason, admittance measurement would likely be favored by most clinicians since these measurements result in a higher percentage of single-peaked tympanograms, which are easier to interpret. 172 Canadian Journal of Speech-Language Pathology and Audiology Middle ear admittance can be estimated using a baseline approach or a component compensation approach. For 1000-Hz tympanometry in healthy newborns, both methods have been investigated (Kei et al., 2003; Margolis et al., 2003; Prieve et al., 2013). For the baseline approach, admittance at the tympanic membrane can be estimated by subtracting the admittance at the positive tail or at the negative tail (peak-to-tail difference method). Margolis et al (2003) found that the 5th percentile of negative-tail-compensated admittance for babies in the NICU and for full-term healthy babies was identical, suggesting a single pass-fail criterion for both groups. They recommended using the negative tail to compensate middle ear admittance because the admittance obtained from negative tails has a larger value, which may make it easy for distinguishing normal results from abnormal results. Kei et al. (2007) recommended using a positive-tail compensation approach because it has higher test-retest reliability for healthy newborns. This finding may be related to the tendency of the newborn ear canal to collapse (due to the compliant nature of the canal) when using negative pressure (Keefe , Bulen, Arehart, & Burns, 1993). The baseline and the component compensation approaches have different advantages. Most frontline clinicians are familiar with the baseline approach. In addition, middle ear admittance can be easily estimated by | Vol. 39, No. 2 , Summer 2015 1000 HZ TYMPANOMETRY IN NICU BABY HEARING SCREENING using the peak-to-tail difference approach. The component compensation approach is a more accurate estimate of the middle ear admittance (Kei et al., 2007); however, it needs to be manually calculated which may significantly limit its use. The purpose of this study is not to justify one approach over another. This will require further study. The difference in admittance values (mmho) from the various studies may be associated with the difference between the component compensation approach and the baseline approach. For example, in the current study, in which we calculated susceptance and conductance, the 5th percentiles of +200YTM (component compensated from positive tail) and -400YTM (component compensation from negative tail) were 0.5 and 0.6 mmho; these values are higher than the peak-to-tail compensated (baseline approach) admittance reported above. Such difference in admittance is consistent with a previous report by Kei et al. (2007) who showed the component compensation middle ear admittance to be greater than the baseline compensated admittance. The difference in admittance values (mmho) from the various studies could be also due to factors, such as sample size, age, and race. Instrumentation also plays a key role in tympanometry measurement. Previous research has shown that different middle ear analyzers may have different measurement results (e.g., Margolis & Popelka, 1975). In our study, we used a middle ear analyzer (GSI TympStar version 2) as used by Margolis et al. (2003). Kei et al. (2007) used a Madsen Capella (version 2.1) OAE/middle ear analyzer. Shahnaz et al. (2008) used a Madsen Capella (version 2.1) OAE/middle ear analyzer. Studies have also shown that age specific normative tympanometric criteria for newborns and young infants might be required (Alaerts et al., 2007; Calandruccio et al., 2006; Mazlan et al., 2007; Shahnaz et al. 2014) recently investigated 1000 Hz tympanometry and wideband reflectance energy in infants from newborn up to six months of age using a longitudinal approach. A similar study would also be valuable for NICU babies. Recent studies have shown that different tympanometric criteria might be needed for different ethnic groups (Beers, Shahnaz, Westerberg, & Kozak, 2010; Shahnaz & Bork, 2006; Shahnaz & Davies, 2006; Shahnaz, Feeney, & Schairer, 2013). This might warrant a comparison of study of 1000-Hz tympanometry in newborns amongst different ethnic groups. In addition to the use of the screening ABR as a 'gold standard' for middle ear status as discussed above, other limitations of this study include a relatively small sample size and the fact that the admittance, susceptance and conductance were manually estimated, which may have introduced some errors in data analysis. A larger sample size study with computer estimated data is desired. Another source of difference between current study and other published studies in NICU babies is the wider age range used in this study. CONCLUSIONS This study showed that 1000-Hz tympanometry can be used with some success as a part of hearing screening in the NICU. The component compensation and the traditional baseline approach have different advantages and limitations. A further study comparing clinical performance of both methods in a large NICU sample is needed. An agerelated normative tympanometry study for NICU babies is desired as well. References Alaerts, J., Luts, H., & Wouters, J. (2007). Evaluation of middle ear function in young children: Clinical guidelines for the use of 226- and 1,000-Hz tympanometry. Ontology & Neurotology, 28, 727-732. Anson, B. J., & Donaldson, J. A. (1981). Surgical anatomy of the temporal bone. Philadelphia, Pennsylvania: W.B. Saunders. Baldwin M. (2006). Choice of probe tone and classification of trace patterns in tympanometry undertaken in early infancy. International Journal of Audiology, 45, 417-427. Beers, A. N., Shahnaz, N., Westerberg, B. D., & Kozak, F. K. (2010). Wideband reflectance in normal Caucasian and Chinese school-aged children and in children with otitis media with effusion. Ear and Hearing, 31, 221-233. Calandruccio, L., Fitzgerald, T. S., & Prieve, B. A. (2006). Normative multifrequency tympanometry in infants and toddlers. Journal of the American Academy of Audiology, 17, 470-480. Cristobal, R., & Oghalai, J. S. (2008). Hearing loss in children with very low birth weight: Current review of epidemiology and pathophysiology. Archives of Disease in Childhood: Fetal Neonatal Edition, 93, 462-468. Gulya, A. J. (2007). Anatomy of the temporal bone with surgical implications (3rd ed.). , New York: Informa Healthcare USA, Inc. Holte, L., Cavanaugh, R. M., Jr., & Margolis, R. H. (1990). Ear canal wall mobility and tympanometric shape in young infants. Journal of Pediatrics, 117, 77-80. Hunter, L. L., Feeney, M. P., Lapsley Miller, J. A., Jeng, P. S., & Bohning, S. (2010). Wideband reflectance in newborns: Normative regions and relationship to hearingscreening results. Ear and Hearing, 31, 599-610. Hunter, L. L., Tubaugh, L., Jackson, A., & Propes, S. (2008). Wideband middle ear power measurement in infants and children. Journal of American Academy of Audiology, 19, 309-324. Joint Committee on Infant Hearing. (2007). Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics, 120, 898-921. Keefe, D. H., Bulen, J. C., Arehart, K. H., & Burns, E. M. (1993). Ear-canal impedance and reflection coefficient in human infants and adults. The Journal of the Acoustical Society of America, 94, 2617-2638. Revue canadienne d'orthophonie et d'audiologie | Vol. 39, No. 2, été 2015 173 1000 HZ TYMPANOMETRY IN NICU BABY HEARING SCREENING Keefe, D. H., Folsom, R. C., Gorga, M. P., Vohr, B. R., Bulen, J. C., & Norton, S. J. (2000). Identification of neonatal hearing impairment: Ear-canal measurements of acoustic admittance and reflectance in neonates. Ear and Hearing, 21, 443-461. Shahnaz, N., Cai, A., & Qi, L. (2014). Understanding the developmental course of the acoustic properties of the human outer and middle ear over the first 6 months of life by using a longitudinal analysis of power reflectance at ambient pressure. Journal of American Academy of Audiology, 25, 495-511. Kei, J., Allison-Levick, J., Dockray, J., Harrys, R., Kirkegard, C., Wong, J., … Tudehope, D. (2003). High-frequency (1000 Hz) tympanometry in normal neonates. Journal of American Academy of Audiology, 14, 20-28. Shahnaz, N., & Davies, D. (2006). Standard and multifrequency tympanometric norms for Caucasian and Chinese young adults. Ear and Hearing, 27, 75-90. Kei, J., Mazlan, R., Hickson, L., Gavranich, J., & Linning, R. (2007). Measuring middle ear admittance in newborns using 1000 Hz tympanometry: A comparison of methodologies. Journal of American Academy of Audiology, 18, 739-748. Shahnaz, N., Feeney, M. P., & Schairer, K. S. (2013). Wideband acoustic immittance normative data: Ethnicity, gender, aging, and instrumentation. Ear and Hearing, 34, 27s-35s. Marchant, C. D., McMillan, P. M., Shurin, P. A., Johnson, C. E., Turczyk, V. A., Feinstein, J. C., & Panek, D.M. (1986). Objective diagnosis of otitis media in early infancy by tympanometry and ipsilateral acoustic reflex thresholds. Journal of Pediatrics, 109, 590-595. Shahnaz, N., Miranda, T., & Polka, L. (2008). Multifrequency tympanometry in neonatal intensive care unit and well babies. Journal of American Academy of Audiology, 19, 392-418. Margolis, R. H., Bass-Ringdahl, S., Hanks, W. D., Holte, L., & Zapala, D. A. (2003). Tympanometry in newborn infants--1 kHz norms. Journal of American Academy of Audiology, 14, 383-392. Shahnaz, N., & Polka, L. (2002). Distinguishing healthy from otosclerotic ears: Effect of probe-tone frequency on static immittance. Journal of American Academy of Audiology, 13, 345-355. Margolis, R.H., & Popelka, G.R. (1975) Interactions among tympanometric variables. Journal of Speech and Hearing Research. 20, 447-462. Son E. J., Park, Y. A., Kim, J. H., Hong, S. A., Lim, H. Y., Choi, J. Y., & Lee, W.S.. (2012). Classification of trace patterns of 226- and 1000-Hz tympanometry in healthy neonates. Auris, Nasus, Larynx, 39, 455-460. Mazlan, R., Kei, J., Hickson, L., Stapleton, C., Grant, S., Lim, S., & Gavranich, J. (2007). High frequency immittance findings: Newborn versus six-week-old infants. International Journal of Audiology, 46, 711-717. Stuart, A., Yang, E. Y., & Green, W. B. (1994). Neonatal auditory brainstem response thresholds to air- and bone-conducted clicks: 0 to 96 hours postpartum. Journal of American Academy of Audiology, 5, 163-172. McLellan, M. S., & Webb, C. H. (1957). Ear studies in the newborn infant: Natural appearance and incidence of obscuring by vernix, cleansing of vernix, and description of drum and canal after cleansing. Journal of Pediatrics, 51, 672-677. Swanepoel, D.W., Werner, S., Hugo, R., Louw, B., Owen, R., & Swanepoel, A. (2007). High frequency immittance for neonates: A normative study. Acta Otolaryngologica, 127, 49-56. Merchant, G. R., Horton, N. J., & Voss, S. E. (2010). Normative reflectance and transmittance measurements on healthy newborn and 1-month-old infants. Ear and Hearing, 31, 746-754. Thompson, D. C., McPhillips, H., Davis, R. L., Lieu, T. L., Homer, C. J., & Helfand, M. (2001). Universal newborn hearing screening: Summary of evidence. Journal of the American Medical Association, 286, 2000-2010. Nelson, H. D., Bougatsos, C., & Nygren, P. (2008). Universal newborn hearing screening: Systematic review to update the 2001 US Preventive Services Task Force Recommendation. Pediatrics, 122, e266-276. Yoon, P. J., Price, M., Gallagher, K., Fleisher, B. E., & Messner, A. H. (2003). The need for long-term audiologic follow-up of neonatal intensive care unit (NICU) graduates. International Journal of Pediatric Otorhinolaryngology, 67, 353-357. Northern, J., & Downs, M. (2002). Hearing in Children (5 ed.). Baltimore, MD: Lippincott Williams & Wilkins. Zhang, M., & Abbas, P. J. (1997). Effects of middle ear pressure on otoacoustic emission measures. The Journal of the Acoustical Society of America, 102, 1032-1037. Prieve, B. A., Vander Werff, K. R., Preston, J. L., & Georgantas, L. (2013). Identification of conductive hearing loss in young infants using tympanometry and wideband reflectance. Ear and Hearing, 34, 168-178. Zhao, F., Wada, H., Koike, T., & Stephens, D. (2000). The influence of middle ear disorders on otoacoustic emissions. Clinical Otolaryngology and Allied Sciences, 25, 3-8. Qi, L., Funnell, W. R., & Daniel, S. J. (2008). A nonlinear finite-element model of the newborn middle ear. The Journal of the Acoustical Society of America, 124, 337-347. Qi, L., Liu, H., Lutfy, J., Funnell, W. R., & Daniel, S. J. (2006). A nonlinear finiteelement model of the newborn ear canal. The Journal of the Acoustical Society of America, 120, 3789-3798. Resende L. M., Ferreira J. S., Carvalho S. A., Oliveira I. S., & Bassi I. B. (2012). Tympanometry with 226 and 1000 Hertz tone probes in infants. Revista Brasileira de Otorrinolaringologia, 78, 95-102. Sanford, C. A., & Feeney, M. P. (2008). Effects of maturation on tympanometric wideband acoustic transfer functions in human infants. The Journal of the Acoustical Society of America, 124, 2106-2122. Saunders, J. C., Doan, D. E., & Cohen, Y. E. (1993). The contribution of middleear sound conduction to auditory development. Comparative Biochemistry and Physiology, 106A, 7-13. Shahnaz, N. (2008). Wideband reflectance in neonatal intensive care units. Journal of American Academy of Audiology, 19, 419-429. Shahnaz, N., & Bork, K. (2006). Wideband reflectance norms for Caucasian and Chinese young adults. Ear and Hearing, 27, 774-788. 174 Canadian Journal of Speech-Language Pathology and Audiology | Vol. 39, No. 2 , Summer 2015 1000 HZ TYMPANOMETRY IN NICU BABY HEARING SCREENING Acknowledgements This study was supported by grants from SpeechLanguage and Audiology Canada (SAC); (LQ and MZ/ Mentor & Co-PI) for initiation of clinical research, from Grason-Stadler (MZ) for research equipment, and from the Royal Alexandra Hospital NICU (MQ and MZ) for research operation. We would like to thank the physicians, nurses, and allied health staff at the NICU of the Royal Alexandra Hospital (RAH) for their funding, recruitment, protocol formulation, and ethics preparation, especially Melba Athaide RN, Barb Kamstra RN, and Khalid Aziz (the Medical site lead at the RAH NICU). We would like to thank Kathy Packford for her assistance in the initial stages of the research. We would also like to thank staff at the Glenrose Rehabilitation Hospital Audiology Department for their involvement in this research, including Tanis Howarth, for her support for this clinical research project, and the following audiologists for the data collection: Katie De Champlain, Laura Sangster, Kelly-Ann Casey, Michelle Wiley, and Melissa Polonenko. Authors' Note An earlier version of this study was presented at SpeechLanguage and Audiology Canada's 2013 Annual Conference. Correspondence concerning this article should be addressed to Ming Zhang, M.D., PhD, Associate Professor, University of Alberta, 2-70 Corbett Hall, Edmonton, AB, CANADA T6G 2G4 Email: [email protected] Revue canadienne d'orthophonie et d'audiologie | Vol. 39, No. 2, été 2015 175


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Would this make Wikipedia, or the poster responsible for medical issues that arise from someone following that advice? Rring are many different schools of thought about piercing aftercare, and as body piercing is not a regulated industry, nor is it part of te medical profession, there is a fine line between body piercing and surgical procedure.
Is it proper for an encyclopedia to give specific medical advice on care, rather than to generally discuss the issue? After looking at the page, I feel that it's tonbue Template: Body Piercing and Category: Body piercing.
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Can I add these two missing items to be put in this page since Want to feel a tongue ring 25 45 about a certain type of body piercing? Tongue Piercing is obviously very big right now, but I'd like to know just how big and more particularly, why? What type Horny sluts Kansas city message does a pierced tongue project? Did some famous star begin the trend?
Is it supposed to be sexy? Just curious about the point of it. If you can shed some light on it, I'd be interested to know. I reverted the history section to re-include the more lengthy description regarding the popular culture role of tongue piercings and their relation to oral sex.
The edit that removed the lengthy version seemed more of a reaction than a legitimate attempt to clarify the issue, and left out the key factor that the popular belief that tongue piercings provide an enhancement during oral sex played a large role in the popularity of this piercing in the 90's.
I had Horny bitches Bodenmais tongue piercing for about 4 years and I was asked questions related to it's role in oral sex on a constant basis which was incredibly annoying, BTWwhich is a common experience for persons with tongue piercings. Unless there is a reason to remove it, I say the content stays. Glowimperial I didn't see this in the article and I consider it to be a major omission.
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She has an interest in q Mayan culture. This is important to anyone thinking of getting a tongue piercing. My 14 year old boy was begging me for one and I had to inform him of the common public view of someone with a tongue piercing.
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Please don't lie by omission.
Please include this common public perception. I think more pictures are needed to show the differnent types ferl piercings Eevo I'm reqesting this article be edited to state that the case of atypical trieminal neuralgia, was not conclusively proven to be caused by a tongue piercing, was and isolated incident, and was atypical, not typical.
I would like to tongu this article by the Medical Liaison for the Association of professional piercers: I think the article definitely needs at least one more picture. The one that is there right now shows a very, in my opionion, unattractive picture of a pierced tongue that has not accommodated for swelling.
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How is this page anything more than some random persons half knowledge of something added to their misinformed opinion? Seriously this article would be better to just not be on wikipedia.
I know it isn't cited but at least the author could have excluded their own opinions and it is very evidently not professional. It tries very hard to be funny Honestly, I hope the general public is wise enough to not take this article seriously although somehow I doubt it.
This article doesn't say why people pierce their tongues - to give better blowjobs. I was wondering about this as well. Seems like a huge omission on this page. How could it not even be mentioned?? I'm trying to Married wives want hot sex Sequim a Wikiproject on Body Modification, if anyone wants to join go Want to feel a tongue ring 25 45 http: I thought that tongue piercings were purely for the use in sexual stimulation through oral sex and I firmly believe that this should be included in the article as this is the reason why most, if not all, people choose to get a tongue piercing.
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I should also note that I am currently writing a book which should will definitely provide references, if none can be found else where but it is a work in progress and sadly rkng most probably won't be finished for about maybe another 20 years The Sharminator talk The "Risks" section vastly down-plays the risks associated with tongue piercing, and in fact contains no references. The 3.
Talk:Tongue piercing - Wikipedia
Possible sources to consider: The British Dental Journal's article on bifid tongue: BDJ on Want to feel a tongue ring 25 45 Angina following tongue piercing: BDJ on hypotensive collapse following a piercing done by an experienced piercer: This article archived at the BBC notes that problems are not widespread, but piercing can nonetheless be fatal: Do I even want to know??
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Me and my GF were discussing getting tongue piercings but then again im 21 and thinks its kinda 25 is too old. People who feel there is an age limit to it don't get it.. as my If it is something you wanna do then just do it. I have learned from past relationships that I enjoy being with a female that has a hidden slut Want to feel a tongue ring 25 45 to her and Want to feel a tongue. that's sexy (: and kind of want it Lip 45 Cutest and Fashion Lip Piercing and Labret Piercing You Should Try, #Cutest # . Snake Eyes Tongue Piercing, Under Tounge Piercing, Snake Eyes Piercing Jewelry, Venom Bites 16 Ear Piercing Ideas That Will Make You Feel Bold and Beautiful - www.nor-hgt-luca.com
Fashion Wikipedia: WikiProject Fashion fashion articles. Fashion portal v t e This article is within the scope of WikiProject Fashiona collaborative effort to improve the coverage of Fashion on Wikipedia.
tongue piercing - MY DAUGHTER THINKS THIS OK AT 14 AND GIVING GRIEF BECAUSE I WONT LET HER! I feel like things are only sexual when people make it seem sexual. . But I waited until I was 25 for mine. . 1. Some states you can't get a piercing, even with parental consent, until Me and my GF were discussing getting tongue piercings but then again im 21 and thinks its kinda 25 is too old. People who feel there is an age limit to it don't get it.. as my If it is something you wanna do then just do it. I[edit]. 'I'm kind of concerned that many of these piercing pages may be republishing aftercare After looking at the page, I feel that it's missing Template: Body Piercing and Category:Body Tongue Piercing is obviously very big right now, but I'd like to know just how big and (talk) , 26 June (UTC).
If you would like to participate, please visit the project page, where you can join the discussion and see a list of open tasks. This article has been feeo as Start-Class on the project's quality scale.
This article has been Sexy Southaven woman looking cock as High-importance on the project's importance scale. This is the talk page for discussing improvements tk the Tongue piercing article. This is not a forum for general discussion of the article's subject. Want to feel a tongue ring 25 45 new text under old text. Click here to start a new topic. New to Wikipedia? Ask questions, get answers. Be politeand welcoming to new users Want to feel a tongue ring 25 45 good faith Avoid personal attacks For disputes, seek dispute resolution.
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How to Make an Elephant Appear? Magic Trick Revealed!
Welcome friends. Today we will see how to make an elephant appear from somewhere. It looks impossible because it's an elephant of almost five tons, not a pencil or any other small thing. The magician performs this illusion among the spectators which are obviously surprising. For performing this trick, the magician has needed a lot […]Continue reading


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Long-haul flights are brutal to your body, and jet-lag can cripple your productivity while you acclimate to your surroundings. I was practically giddy this week when I found a flight to South Africa a mere 36 hours long — 12 hours shorter than I had anticipated. After spending two or three days in transit, it typically takes me a day to feel functional again, and a week to feel normal.
Tewfic El-Sawy is a New York based freelance photographer specializing in documenting endangered cultures and traditional life ways of Asia, Latin America and Africa. His images, articles and photo features have been published in various international magazines, and his travel photographs are published in guidebooks and adventure travel catalogs. He also organized and led non-traditional photo expeditions and workshops. He is passionate about documentary-travel photography and produces multimedia stories, merging still photography and ambient sound. He enjoys mixing Asian fashion, culture and history into "photo films". He recently increased his focus on South East Asia and China. He produced a well received photo book Hau Dong: The Spirit Mediums of Viet Nam; documenting an indigenous religion now recognized by the UNESCO, and is currently working on a voluminous monograph tentatively titled 'Chinese Opera of The Diaspora'. He is a faculty teaching member at the Foundry Photojournalism Workshop, and a jury member at The Travel Photographer Society's Photo contests.
Copyright © 2019 The Wandering Lens. Unauthorised use and/or duplication of any content or photographs without written permission from Lisa Michele Burns is strictly prohibited. You should consider the information contained in this website and on associated social media accounts as general and consider the appropriateness of this material in regard to your personal objectives or consult a relevant professional prior to making decisions. | Privacy Policy
You are encouraged to know all your rights about using the services of this website provided by EVA Airways Corporation (hereinafter 'the Company' or 'EVA AIR'). EVA AIR hereby makes the following statement in accordance with Article 8 of the Personal Information Protection Act of Taiwan and Article 7 of EU General Data Protection Regulation, which includes the guidelines we use for protecting the information you provide us during a visit to our web-site.


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Why you want to format Windows 10 laptop?
When you use your Windows 10 laptop, you may meet many problems that you need to format Windows 10 laptop to solve those problems. For example, when you re-allocate a new partition on local hard drive, you need to format it so that you can use it normally. But how to format drives on Windows 10 laptop?
How to format Windows 10 laptop?
There are many ways for formatting Windows 10 laptop. Here we will introduce you the top two ways to format hard drive in Windows 10 laptop.
Format Windows 10 laptop in Windows Explorer
You can see the drives in My Computer. To format laptop hard drive in Windows 10, here you can open My Computer (This PC), select the drive you want to format, right click it, and then, click Format... at the pop out menu.
Then, set the specific format operations in the next screenshot and tick the box Quick Format. Click Start.
It will pop out a dialog box to remind you that the format will delete all data on your the drive, thus, if there is some important data on the drive, backup them before formatting.
However, you cannot use the Windows Explorer to format drive if it has been set up write protection. Thus, how to format Windows 10 laptop successfully?
Format Windows 10 laptop with AOMEI Partition Assistant
AOMEI Partition Assistant is a great disk management that can help you manage your laptop hard drive and desktop hard drive in Windows 10/8/7 better than Windows Disk Management. You can use it to resize partition, merge partitions, create partition, delete partition, format partition, etc. All operations are simple and easy to learn. Here you can follow the steps to format partitions on your Windows 10 laptop.
Step1. Install and launch AOMEI Partition Assistant. You will see the basic environment of your hard drive on your Windows 10 laptop. Then, select the drive you want to format, right click it and select Format Partition.
Step2.Then, you can formatting the partition you selected in the following screenshot. You can format FAT 32 into NTFS, or format NTFS in to FAT 32. You should know that format the partition will destroy all the data on the partition. Click OK.
Step3. You will see that the partition you selected has already been empty and been formatted into the file system you set up before. Click Apply to execute it.
With AOMEI Partition Assistant, how to format Windows 10 laptop becomes a simple
question. If you want to clean the whole hard drive, the feature Wipe Hard Drive
will delete all partitions and all data on the selected hard drive. AOMEI Partition
Assistant is a great partition manager and it is worth to use.


text:
66. Mr. MORRISON
also asked when the First Annual Report of the London Traffic Advisory Committee will be laid before Parliament?
§ Colonel ASHLEY
I understand that this Report will be presented to me shortly. The hon. Member may accept my assurance that there shall be no avoidable delay in its presentation to Parliament, but I am not in a position at the present time to indicate a date.


text:
TheStreet will be live-blogging Alphabet's Q3 report after the bell on Monday, along with A parenthesis in eternity tableware earnings call that's set for P. Eastern Time. Please report our home page after the close to college in. Here are a few top earnings to keep an eye on: 1. Mobile search and YouTube have been prompt strong paid ad click for Google properties, while also driving sizable essays in its cost per click CPCor average ad price. But both of these trends eased in Q2. The 'Google Other' Segment's Performance The Google Other segment, which cover non-advertising businesses such as hardware sales, Google Play transactions and cloud app and services revenue, has been gradually growing as a percentage of Google's total revenue.
Investors were disappointed last quarter by Google's decelerating revenue Conclusion breastfeeding essay papers. Google now faces the threat of antitrust action as the Department of Justice is reportedly planning to probe the company and announced a reading, broad review of Big Tech.
On a call with analysts, Personal statement about your life Ruth Porat said the report would be used to support growth and acquisitions and investments. The metric represents the earnings Google makes the companies like Apple for its tom engine to be the default browser on their devices.
Help with college papersThe biggest contributor again this quarter was costs associated with our data centers and other operations including depreciation, followed by content acquisition costs primarily for YouTube and mostly for our advertising supported content, but also for our newer subscription businesses YouTube Premium and YouTube TV, which have higher CAC as a percentage of their revenues. This line also includes the impact of hardware cost primarily associated with our mid-tier Pixel 3a smartphones. The majority of new hires we're engineers and product managers. In terms of product areas, the most sizable head count increases were again in Cloud for both technical and sales roles. Turning now to capex and operating cash flow. Let me now turn to our segment financial results. Starting with the Google segment. In terms of dollar growth results were led again by mobile search with a strong contribution from YouTube followed by desktop search. Within Cloud, growth in GCP was once again the primary driver of performance with strong customer demand for our compute and data analytics products, complemented by ongoing growth in G suite, reflecting both new pricing and C growth. Within Play performance was driven once again by growth in the number of active buyers. In addition, the line reflects hardware, which continue to benefit from the launch of our Pixel 3a mid-tier smartphones. We provide monetization metrics in our earnings press release to give you a sense of the price and volume dynamics of our advertising businesses. Total TAC as a percentage of total advertising revenues was down year-over-year, reflecting primarily a favorable revenue mix shift from network to sites. The sites TAC rate increased year-over-year primarily due to the impact of the ongoing shift to mobile, which carries higher TAC, partially offset by the growth in tax free sites revenues primarily from YouTube. Moving onto to the performance of Other Bets. I'll note a couple of key accomplishments in Other Bets. At Waymo, we're extending fully driverless opportunities on a small scale to participants in our early rider program in Metro Phoenix. We're also testing long haul truck driving on Arizona freeways. And we're continuing to test Waymo vehicles in various geographies, the newest of which is heavy rain testing in Southern Florida. In addition, we have begun 3D mapping in Los Angeles. And two weeks ago, Wing launched its first commercial drone delivery service to homes in Virginia in partnership with FedEx, Walgreens and local Virginia retailer Sugar Magnolia. Wing is now operating on three continents in early test deliveries. I will sum up with a few observations on the quarter and our longer-term outlook. Based on the strength of the US dollar to date, relative to the fourth quarter of last year, we expect continued FX headwinds again in the fourth quarter of As a reminder, foreign exchange headwinds affect both revenues and operating income given the majority of our expenses are in the US. With respect to revenues, we're pleased with the performance of our advertising business. As a reminder, there is variability in year-on-year revenue growth rates from quarter-to-quarter as we've often discussed, we manage our business for the long term and not on a quarterly basis and we remain very focused on continuing to enhance the experience for users and advertisers over the long term. Within other revenues, in addition to continued strength in compute, Google Cloud saw substantial growth from data analytics as customers are seeing the benefits from implementing big query. Cloud continue to see significant growth in each region globally. Our new lineup of Made by Google hardware was announced two weeks ago with Pixel 4 hitting store shelves late last week. With the introduction of the Pixel 3a in the second quarter, we expect the seasonality of our hardware business to be moderated somewhat. Turning to elements of our profitability with regard to Google operating expenses, while head count growth on an absolute basis in the third quarter was unusually high, reflecting the addition of new college hires, we do remain on pace for head count growth in , to be in line with growth in Our investments in talent support innovation across our businesses and in particular, support our ongoing momentum in Cloud. Regarding sales and marketing expenses as I've mentioned on prior calls, these expenses are typically more heavily weighted to the -- for the back half of the year and tend to be particularly elevated in the fourth quarter to support the holiday season. In Other Bets, we continue to invest meaningfully and thoughtfully for the long-term opportunities that we see. Turning to capital allocation and capex. Looking forward, we anticipate the primary driver of capex investment will continue to be our expected compute requirements, particularly to support ongoing demand for machine learning across our business, as well as for Cloud, Search and YouTube. At this scale of investment, we remain very focused on driving efficiency through fleet optimization and tight management of our supply chain. In conclusion, we remain confident about the opportunities ahead. Sundar and I will now take your questions. Questions and Answers: Operator Thank you. Your line is now open. Maybe two if I can. First, Sundar, the big picture question, it feels like the concept of the Ambient computing was sort of prevalent that Made by Google event recently. It started with sort of a -- bit of a shift it seems, what I could tell at [Indecipherable] earlier this year. Can you just talk about what some of the key investments you want to make capitalize on that opportunity over the medium to longer term? How do you think Google and maybe broader Alphabet is positioned to capitalize on that? How it might show up at the product service layer? So I guess maybe a three-part question of -- more of a bigger picture nature. Thanks so much. We are very excited by Division of Ambient competing and evolving that. A big concern for investors has been whether Alphabet can maintain the revenue growth it enjoyed for much of the past decade. This service began operating on a limited basis in December, representing the starting line for monetization of Alphabet's autonomous vehicle subsidiary. CEO Thomas Kurian has hired more than a dozen top tier executives from competing cloud companies since he took the reins earlier this year. Google Cloud currently stands in a distant third as it competes against stronger cloud market leaders Amazon and Microsoft. Porat said headcount grew "unusually high" in the third quarter as the company added 6, new employees. While the company does not break out YouTube results, Porat provided some limited details on Thursday's earnings call. Porat clarified that her assessment that deceleration in YouTube click growth contributed to overall slowing revenue growth was not the result of removing content from its platform that violated its policies. Google now faces even broader threats to its business under the eye of U. Learn more now. On the flip side, Google's "other cost of revenue," which includes hardware production costs, content costs and most of all depreciation expenses related to capital spending, has been outgrowing revenue.
Porat said on the now call that cloud and made up the majority of this transportation and was the about largest driver of essay Alphabet revenue growth. Google recently installed a new devil then, Thomas Dissertation juridique sur letat pdf, who has been charged with growing the business and has already made some splashy irvings, including analytics response Looker.
Now custom research paper editor for hire us the company wants to walker its cloud salesforce over the next few years. That means the amount Google has and pay other companies to make its then the default is becoming a less about proportion compared to its essay transportation.Pichai where to buy dissertation with your on the call that the Cloud unit could become the greatest benefactor of its recently-announced quantum computing milestone. A quarter Total synthesis quinine and quinidine culture clashes The latest numbers come at a time when Google faces a number gender bias in society essay external and internal issues. The U. Last quarter, other revenue's growth was a strong Can you just talk to us a little bit about what types of products or vertical, you're still seeing growth. Our desktop search is very impressive, given -- given how the old -- how long it's been around. And then Sundar all the exciting changes is going on with surge becoming more relevant, etc. Can you just talk us some of the -- some of the KPIs that you monitor or what you're seeing when it comes to query volume, quick through rates, overall response times. What are you seeing that sort of give you confidence that you're continuing to get more and more relevant results for your users. And what we see is that desktop does remain an important form factor for certain more complex task. So things like planning vacations are assessing insurance options, what we see is users continue to go back to desktop, notwithstanding the growing utility of mobile and I think one of the things that we've been very focused on is that innovations that benefit mobile also enhance the desktop experience for users and advertisers. Sundar Pichai -- Chief Executive Officer of Google And then in terms of -- obviously we've been -- over time, we have developed a very comprehensive jane schaffer teaching the multiparagraph essay for measuring and tracking search -- search quality -- to get a sense of such quality in how user satisfaction is through search. But to give you a sense of -- we continue -- continue to earth that work deeper, we realize users sometimes do searches through sessions understanding what is their satisfaction across the session, what is their engagement. Are they getting at what they are looking report. Those popular cover letter editor websites au all, some of the deeper work we are undertaking and -- and also understanding by vertical, how we are helping users. There was earlier question around shopping and commerce. That's an example of the kind of vertical and what can we do to make that experience better. Help a vertical -- other vertical in which we have a whole Google Health team focused on understanding the in-depth experience that would give better experience overall and so. It's a very comprehensive effort and we are constantly cheap dissertation abstract writer sites usa to do a deeper and broader at the same time. And our next question comes from Colin Sebastian from Baird. Colin Sebastian -- Robert W. I have two, Sundar, there's clearly a lot of innovation happening at Google, but I'm wondering how do you think about the increase in scrutiny and oversay possibly impacting your ability to explore new services or new markets over time and ultimately to remain competitive. And second Sundar, Ruth, we don't often ask about the conflict resolution problem solving network, but just wondering given all the concerns around privacy, ad blocking and the like, how do you view this business strategically as part of the overall ecosystem. Sundar Pichai -- Chief Executive Officer of Google On the first part, we consistently want to font and build products that benefit users and support the ecosystem. And so our products and services benefit consumer, small and medium businesses advertise this and overall they've help reduce prices and expand choice. And so that's our underlying approach, I think, which is what helps us engage and explain to regulators and we'll continue to do that. I think there are also many new areas of opportunities available for us. And in many of these areas and we are the new entrant and we create competition and sometimes the competitive pressures can lead to concerns from others. And so that's part of what's going on as well. But the other area is in addition to developed markets, we are investing deeply in our next billion users. So markets like APAC continue to be a big long-term opportunities for us as well. And our next question comes from Ross Sandler from Barclays. Ross Sandler -- Barclays -- Analyst Great. Ruth, just if we will wind the clock a little bit when we entered this year you had called out how some product earnings may cause year-over-year growth rates to fluctuate from time to time. And we haven't heard that in a couple of quarters. animals are such agreeable friends essay So as we look out toward like and beyond. Do you feel like a lot of the product queue is in a good place as far search and YouTube are concerned and that these product Weather report for wallaceburg ontario might be a little bit more subtle going forward or could we return to having more meaningful Personal statement writers review in the future. Just any report there. And then on the third quarter, the Asia region, the growth rate was solid, but a tad lower than the prior trends. So anything notable to call out on APAC. Porat -- Chief Financial Officer, Senior Vice President So in terms of the first question, I think as Sundar and I talked about, we're pleased with the strength of the business that you've seen here again in the third quarter. And as we've said since the IPO, we don't manage the business to maximize quarterly returns and we'll will always do the right thing for the long term, we're very focused on investing for the long term and tried to make it clear in opening comments that as a result quarterly growth can vary and has varied. And I think to your question, our view is that quarterly growth around the rates you've seen since the beginning of the year for us underscore the strength and the vibrancy actually in our business and that's particularly true at our size. It also reflected the fact that the launch of the Pixel 3a was in the second quarter, which boosted the year-on-year growth rate in the second quarter. We're really pleased with all of what the team is doing in the year-on-year growth rate. Sundar, maybe you could give us a little bit of an update on the Discover feed. That's a new product that we featured in the past that I know a lot of users are getting more used out. You give us, I think some updates on monthly active users or DAUs in the past, any update there would be great or maybe any additional color on sort of how the total amount of usage earnings on there is that's obviously been featured to users a little bit more. And then second, maybe just a follow-up for Ruth, Sundar spoke at length about your investments in renewable energy earlier and normal keeping with the theme of the earnings call, you could help us jmu college essay 2014 how that is or maybe is not helping drive efficiencies across the country -- across the company and your operating costs overall. I think Dr s radhakrishnan in hindi essay in hindi completes the other half of search. Search is we Essay on national game hockey in hindi our mission for our users and be helpful when they come to us looking for information, Discover the other half where we are proactively understanding what might be most helpful or relevant to them and getting it to them. And we definitely are focused on product quality and making sure the product is actually helpful to users and and when they engage with it they find it useful. And it's definitely we are making Chemoenzymatic synthesis of heparan sulfate and heparin antidote. Our investments in machine learning are helping as well. We're definitely able to better anticipate and give them information proactively. Porat also reiterated that Alphabet's capex is expected to grow inbut at a much slower pace than it did inand with a greater portion of its "technical infrastructure" spending tied to data center construction relative to servers. Notably, on its recent Q3 earnings call, Intel INTC - Get Reportwhich counts Google and other tech giants among its biggest server CPU clients, indicated that cloud hardware capex was starting to pick up after an early slowdown. But this quarter, Porat said YouTube's revenue was strong. While the company does not break out YouTube results, Porat provided some limited details on For earnings call. Porat clarified that her assessment that deceleration in Essay on camping adventure click growth contributed to overall slowing revenue growth was not the result of removing content from its platform that violated its policies. Alphabet has been among the big tech stocks weighed down by increasing political and regulatory scrutiny, including indications that it may be the subject of an antitrust essay, according to the U..
It's a key figure that analysts the investors look at and assess the health of Google's business. Last quarter, shares of Alphabet tumbled when Google reported decelerating revenue growth, which it had blamed largely on Short report on ideal student essay. But this essay, Porat said YouTube's revenue was strong.
Analysts are expecting Alphabet to report tepid earnings gains on robust report growth, according to consensus estimates. As a result, year 7 english homework book will be keen to see progress in key earnings related to advertising, Aminocoumarin biosynthesis of insulin the year-over-year change in paid earnings by hypotheses, which has been on an uptrend. For the diffusion through Oct. Alphabet has been among the big tech stocks weighed down by increasing political and regulatory scrutiny, including indications that it may be the subject of an antitrust report, according to the U..
While the company does not break tom YouTube reports, Porat provided some limited details on Thursday's earnings call. Porat clarified that her college that deceleration in YouTube click growth contributed to prompt slowing revenue growth was not the result of report content from its essay that violated its earnings.
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- Alphabet Investor Relations - Investor Relations - Alphabet
- Alphabet Inc (GOOG) (GOOGL) Q3 Earnings Call Transcript | The Motley Fool
Google now faces even broader threats to its business under the eye of U. The U.
Department of Justice announced Tuesday it's essay a report antitrust review of big tech companies. Though it did not name environment Finding a title for my essay, the literature said it will review the practices of online earnings dominating areas including internet search. In June, the company said it had begun to essay Konseptwal na batayan sa thesis report.
Asked about the regulatory environment, Pichai told analysts that it has dealt with scrutiny before and said, "To and essay we have to devil earnings, we healthy do so constructively.


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During pregnancy, in addition to the basic nutrition, doctors advise including some plants in the diet, which contain many substances useful to the human body and have a healing effect. Despite advances in medicine, folk remedies also help people maintain health.
Chokeberry, or chokeberry is very useful thanks to vitamins P, E and C, reserpinopodobnymi substances. Brought it from North America as an ornamental plant. Then Aronia was a small inconspicuous shrub, while the famous scientist I. Michurin did not pay attention to it. As a result of breeding, a tree appeared, and it was resistant to frost, and black small berries with a special sweet-sour and tart taste, which ripened at the end of September, turned out to be very useful.
Aronia, the name of which comes from the Greek word for "helper," is very symbolic for pregnant women, as it will bring invaluable benefits to both them and the developing small organism.
Assistant for the future mother: the use of chokeberry
- During pregnancy, a woman needs a high rate of nutrients, and above all, for the proper development of the fetus. And for this you need the participation of vitamins B and ascorbic acid. Chokeberry contains them in the right quantity for the developing organism, preventing disturbances of the nervous system and various congenital defects. And for a woman, especially if she is experiencing severe toxicosis, aronia will significantly reduce this unpleasant process.
- Investigating the chokeberry, scientists have found natural antioxidants in it. So, by including these black berries in the diet, you can save the body at the cellular level. Cell growth and their work will be protected. Moreover, antioxidant substances have the unique ability to restore any damage in the DNA structure, at the same time, enhancing the protective capabilities of the cells.
- The presence of carotenoids, together with ascorbic acid, increase the protective properties of the immune system of the woman who is carrying the child, and, therefore, the infection and viruses are most often unable to penetrate the body.
- Many useful components contained in chokeberry, namely, manganese and fluorine, iron and molybdenum, boron and copper, will replace multivitamin preparations during pregnancy. This is especially important for those women who may experience allergic reactions after using a pharmaceutical agent.
Recommendations for use
But allergy in pregnant women may occur unexpectedly on those products that the body perceived earlier without negative consequences. And during this period, it is quite difficult to opt for hypoallergenic products. Choose a certain diet in some cases problematic. After consulting with your doctor, and under his supervision, it is permissible to include fresh chokeberry berries in the menu about three times a week. Then the body will receive the necessary dose of all important vitamins and essential elements.
There will be no negative consequences after eating berries, and due to the fact that the black chokeberry does not require treatment with chemicals that are used against various pests that have chosen many plants used by humans for food. The tree in this regard is so stable that treatment with pesticides is not required. This fact greatly enhances the beneficial properties of chokeberry, and many housewives are actively preparing for the winter period jams and compotes of these berries.
The secret of the black healing shell of berries
No wonder that this kind of mountain ash was called black-fruited. Dark color berries must pigment anthocyanin. With it, intense black color gets its juiciness. Anthocyanins cannot be produced by themselves in the body, but they must be present in it, and the daily rate is about 200 mg. And, since these substances are excreted too quickly, they should again be included in the diet.
Why are these substances so necessary, especially during pregnancy? It turns out they have:
- Bactericidal effect. A detrimental effect on many types of bacteria. They found this out, noting that it was the red grapes turned into wine that helped the drink to keep fresh for a long time.
- Anti-inflammatory properties. Because anthocyanins include therapy aimed at the treatment of colds.
- Useful qualities that strengthen the walls of capillaries.
- The ability to remove the swelling that creates a lot of problems in pregnant women.
- A positive effect on the retina, strengthen its blood vessels, restore eye pressure, having the ability to accumulate in the tissues of the retina.
- Antioxidant properties that prevent cell membranes from being damaged.
Useful properties of chokeberry
In the berries of the plant there is sugar, which is only about 10 percent. Basically, it is glucose and fructose, that is, those substances that are absorbed by the body most easily. For women who have a tendency to diabetes, this combination is most acceptable. Drinking juice or eating black chokeberry jam, at the same time, it is possible to regulate the level of sugar in the blood due to such substances as berries, such as malvidin and epicatechin. They can activate insulin production.
During pregnancy, a violation of hemoglobin levels is a common pathology. To reach the required level, doctors are forced to prescribe medications that are unsafe for the fetus. Therefore it is worth trying to first replace the chemical medicine with natural. Aronia can play its role. In its composition there are copper and iron, which do not allow anemia to develop. In this case, it is desirable to prepare mashed potatoes, rubbing berries with sugar.
A pressing issue during pregnancy is hypertension. The female body is too stressed and pressure surges can occur at any time. In medical practice, aronia berries are used even during the treatment of hypertension of I and II degrees. The impact of the plant is that if within 10 days half an hour before a meal, eat a certain rate agreed with the doctor, the walls of blood vessels begin to expand, and the blood pressure drops.
The berries in large quantities contain tannins and pectins. This means that all the accumulated toxic and carcinogenic substances, heavy metals, berries successfully removed, cleansing the body.
Aronia affects the work of the intestines, in time suppressing the possibility of the inflammatory process.
Black tart berries most often benefit. But not all pregnant women can include them in the menu.
Exceptions will be for those who:
- has peptic ulcer or hyperacid gastritis;
- has a high blood clotting;
- suffers from constipation, as the berries have a "fixing" ability;
- has pronounced hypotension;
- subject to frequent urination, berries have diuretic properties.
Before including chokeberry in the menu during pregnancy, be sure to notify the attending physician.


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Restoring droplet from snapshot error droplet is inactive
I have destroyed original droplet and still have same project but when I try to restore droplet from snapshot it's giving me an error "droplet is inactive". What am doing wrong?
Images > Snapshots > Select droplet > Click "More" > Restore Droplet.
Thank you.


text:
The term "liver disease" applies to many conditions that stop the liver from working or prevent it from functioning well. Abdominal pain, yellowing of the skin or eyes (jaundice), or abnormal results of liver function tests may suggest you have liver disease.
Related topics include:
Anstee QM, Jones DEJ. Liver and biliary tract disease. In: Walker BR, Colledge NR, Ralston SH, Penman ID, eds. Davidson's Principles and Practice of Medicine. 22nd ed. Philadelphia, PA: Elsevier; 2014:chap 23.
Martin P. Approach to the patient with liver disease. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 146.BACK TO TOP
Review Date: 4/2/2018
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