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This technical report was developed by the American Speech-Language-Hearing Association (ASHA) Working Group on Loss to Follow-Up and was approved by ASHA's Board of Directors (BOD 46-2008) on December 9, 2008. Members of the group were Anne Marie Tharpe (chair), John Eichwald, Janet Farrell, Jeffrey Hoffman, Meredith Isola, Patti Martin, Amy M. Robbins, Lynn Spivak, Susan Wiley, and Pam Mason (ex officio). Gwendolyn D. Wilson, ASHA vice president for audiology practice (2007–2009), served as the monitoring officer.
Congenital, permanent childhood hearing loss affects 2%–4% of infants who spend time in neonatal intensive care units (NICUs) and 1–3 of every 1,000 infants in well-baby nurseries ( Baroch, 2003; Centers for Disease Control and Prevention [CDC], 2008). In an attempt to improve outcomes for children with hearing loss and their families, the National Institutes of Health and the Joint Committee on Infant Hearing (JCIH) in 1993 and 1994, respectively, and the United States Preventive Services Task Force (2008) endorsed the goal of universal detection of hearing loss in infants. The American Academy of Pediatrics (AAP) Task Force on Newborn and Infant Hearing (1999) and JCIH (2000, 2007) endorsed universal newborn hearing screening (UNHS) and the early hearing detection and intervention (EHDI) goals of screening no later than 1 month, confirmation of hearing loss no later than 3 months, and receipt of appropriate intervention no later than 6 months of age. Today, it is estimated that UNHS is provided to 92%–95% of babies born in the United States and its territories ( CDC, 2008; National Center for Hearing Assessment and Management [NCHAM], 2007).
Although screening for hearing loss in the newborn period is a good start, it is recognized that a fully functional and comprehensive EHDI program must include professional and family education and short- and long-term follow-up, following the example of newborn dried bloodspot screening programs. In those programs, short-term follow-up has been described as confirmatory diagnoses for newborns who do not pass the screens and referral and connection of infants and their families to treatment, and long-term follow-up as ongoing medical management through the medical home, evidence-based treatment, continuous program evaluation and quality improvement, and new knowledge discovery ( Hoff, Hoyt, Therrell, & Ayoob, 2006; Kemper et al., 2008).
Based on national data ( CDC, 2008) reported by 45 states, two territories, and the District of Columbia, nearly half (46.3%) of the infants born in 2006 who did not pass their final newborn hearing screen (32,496 infants) did not complete follow-up and were categorized as lost to follow-up (LTF)/lost to documentation (LTD). The percentage of infants who were documented as having received their recommended diagnostic evaluation in 2006 ranged from 1% to 99% among those jurisdictions reporting. Of those infants who were reported as having received an audiological evaluation, only 47% could be documented as having been seen before 3 months of age. Furthermore, more than one-third (39.3%) of infants with diagnosed hearing loss could not be documented as having been enrolled in Part C Early Intervention or having received other early intervention services.
Numerous recommendations have been proffered for reducing the LTF rate. However, there is a dearth of research literature demonstrating that such measures are effective. The purposes of this report are to
define the terminology associated with LTF
delineate and define the factors that have been identified as contributing to LTF rates
delineate and define the factors that have been identified as decreasing LTF rates
provide results of a current systematic review of research literature in the area of LTF.
Many jurisdictions recognize any baby who did not receive or complete the recommended diagnostic or intervention process as lost to follow up (LTF). [1] However, perhaps the most obvious difficulty encountered in tracking such infants stems from the variability in how the term is defined from site to site, as well as on the state and national levels. In an effort to obtain a more comprehensive view of operational definitions used by states, an informal review was undertaken in February 2008 of 23 state definitions ( Hoffman & Farrell, 2008). The durational dimension of the definition varied among jurisdictions. For example, some states designated a child as LTF because of incorrect, incomplete, or expired contact information if not located within 2 months of age, while others attempted to follow a child until 3 years of age before classifying as LTF. Other jurisdictions, rather than using age of the child, declared a child as LTF according to the time transpired from the last EHDI system activity with the family—for example, 3–6 months with no known follow-up activity resulted in a designation of LTF. Inclusion of specific groups, such as babies who have expired, moved to another state, or whose parents refused the screening, in the LTF category varied among the states reporting.
In 2006, in an effort to provide more consistent reporting among EHDI jurisdictions, the CDC launched a national survey to better define the timelines for EHDI milestones based on recommendations of the Directors of Speech and Hearing Programs in State Health and Welfare Agencies (2004) and the CDC EHDI Data Committee ( CDC, 2008). This survey, designed to report data for Healthy People 2010 and the EHDI 1-3-6 goals on a national basis, requested data that could be documented by the EHDI jurisdictions and might differ from that which is defined and collected specific to their locale and reporting needs (e.g., adjusted or corrected age for preterm infants).
In that CDC survey, "no documented diagnosis" included infants (1) who are in process, (2) who died, (3) whose parents declined services, (4) who are nonresidents, (5) who moved out of the jurisdiction, (6) who cannot be contacted, (7) whose parents are unresponsive, and (8) who have no documented diagnosis for unknown reasons.
Clearly, there is not yet general consensus on how we record and report infants as LTF. This lack of consensus results in difficulty comparing old data to new data and comparing data across jurisdictions.
The designation of lost to documentation (LTD) is becoming increasingly accepted as being distinct from LTF ( Mason, Gaffney, Green, & Grosse, 2008). LTD includes those infants who did not pass their hearing screening and whose diagnostic or intervention status has not been reported to the EHDI program; thus, their status remains unknown by the EHDI program despite the fact that they may have received services. There are multiple points in the EHDI process at which a child might become LTD (e.g., following screening, following diagnosis, following referral to intervention). Although the factors contributing to LTD in NHS programs have not been thoroughly delineated at this time, factors identified as contributing to LTD in the parallel newborn dried bloodspot screening programs included, primarily, name changes and, to a lesser degree, data mismatches. In addition, inadequate or erroneous parental contact information and/or unknown or changed primary care provider contribute to LTD ( Hoff et al., 2006). An additional factor contributing to LTD includes those infants who receive services in a jurisdiction different from the jurisdiction of the EHDI system in which they reside or in which they were born. These are often termed "border babies."
Combining the designations LTF and LTD under the broad heading of lost to system (LTS) has been suggested as a viable option to reduce the confusion and variability in capturing this data set within and across EHDI systems and to increase the effectiveness of follow-up strategies ( Beauchaine & Hoffman, 2008).
In early 2008, the ASHA National Center for Evidence-Based Practice in Communication Disorders (N-CEP) completed a review of the evidence related to LTF after initial identification by newborn hearing screening programs. The full report of that review is included in the Appendix. Specifically, their review addressed the following questions:
What characteristics of individuals, families, or populations have been found to be associated with risk of delays or LTF for infants with positive initial screens for hearing loss and evidence of need for an audiologic evaluation by 3 months?
What characteristics of individuals, families, or populations have been found to be associated with risk of delays or LTF for children with a positive diagnosis of hearing loss and evidence of need for audiologic intervention by 6 months?
What has been the effectiveness of initiatives designed to increase follow-up for appropriate audiologic evaluation by 3 months of age?
What has been the effectiveness of initiatives designed to increase follow-up for appropriate audiologic intervention by 6 months of age?
Studies pertaining to intervention were evaluated for methodological quality. The authors independently appraised each study on eight quality indicators:
adequate description of protocol for replication
adequate description of subjects (within-subject design) or groups comparable at baseline (between-subjects design)
assessors blinded
random sample adequately described
evidence of treatment fidelity
p value reported or calculable
effect size and confidence interval reported or calculable
analyzed by intention to treat (controlled trials only)
Studies received 1 point for each quality indicator, for a maximum possible score of 8. Fourteen studies were included in the final analysis—11 that investigated the characteristics of infants categorized as LTF and 3 that investigated actions to prevent LTF.
The authors concluded that the small number, substantial methodological shortcomings, and inconsistent findings within the available evidence do not provide meaningful direction for clinicians or policy makers in identifying the patients or families at the highest risk of LTF, nor how to decrease that risk.
In the absence of strong evidence to identify the factors contributing to LTF, it is reasonable to seek additional guidance beyond those articles included in the systematic review (see the Appendix) to allow for broader acceptance of lower levels of evidence and expert opinion. Therefore, outlined herein are also those factors that have been suggested by other sources, including consensus data and policy statements, as possible contributors to LTF rates that warrant further consideration by professionals within the EHDI system but that were not included in the systematic review. It is recognized that reducing LTF will require the involvement of numerous groups and individuals, including, but not limited to, parents and other family members, physicians, audiologists, speech-language pathologists, educators of the deaf, early interventionists, and state and territory departments of health. Issues related to both short-term and long-term follow-up are considered here, and these are divided into systems and family issues.
The Newborn Screening Authoring Committee published a clinical report on recommendations for pediatricians and the medical home regarding newborn screening programs in 2008. They recommended that PCPs receive timely and accurate access to information about their patients to avoid missed opportunities for follow-up at multiple points of contact with the child and family. Furthermore, it has been recommended that PCPs develop strategies to use should newborn screening systems fail ( AAP, 2008). More specifically, the National Initiative for Children's Healthcare Quality (NICHQ) Learning Collaborative found that failure by hospital personnel to identify the newborn's PCP or clinic was a contributing factor to LTF ( Health Resources and Services Administration [HRSA], in press). In addition, PCPs can familiarize themselves with referral resources in their communities in collaboration with an otologist ( Cunningham & Cox, 2003) and can form collaborative relationships with their EHDI American Academy of Pediatrics Chapter Champions ( AAP, 2002).
Most parents learn of newborn screening programs while in the hospital, not prenatally ( Arnold et al., 2006). Through a series of focus groups and interviews, Arnold and colleagues found that all stakeholders (i.e., parents of infants experiencing the newborn hearing screening (NHS) process, parents of children with hearing loss, audiologists, technicians, nurses, PCPs) preferred having communication about the NHS process occur before birth and preferred that user-friendly patient education materials be used. However, clinicians had limited knowledge or awareness of current NHS practices. The providers did not consider family education about hearing screening to be a priority. Parents in the study recommended that expectant and new parents be informed prior to the screening of what the screening entails, the urgency of early diagnosis, and what the follow-up process will be ( Alexander & van Dyck, 2006). This expanded parental education will require additional training of personnel.
Parents who have been through the NHS process expressed a strong desire to be present during the screening but were not given the opportunity ( MacNeil, Liu, Stone, & Farrell, 2007). A survey by Kim, Lloyd-Puryear, and Tonniges (2003) revealed that states seldom defined who has the role and responsibility for informing and educating parents about newborn dried bloodspot screening. In addition, the approaches to parental education and the content of screening educational materials were variable across states. There is also no assurance that health care providers have the necessary tools to guide parents in the decision-making process.
A lack of communication between and among health care providers, families, and screening programs poses a barrier for follow-up success ( Hoff et al., 2006). Furthermore, a lack of integrated data management and tracking systems creates barriers to sharing information among providers and between states ( JCIH, 2007; Pool, 1996).
Privacy regulations, including Health Insurance Portability and Accountability Act ( HIPAA, 1996), Family Education Rights and Privacy Act ( FERPA, 2004), Part C Privacy Regulations ( IDEA, 2004), and state privacy reporting laws, may adversely affect the sharing of information among service providers. However, there has been some misunderstanding regarding HIPAA's and FERPA's influence on the disclosure of information from screening programs to primary referral sources. Because disclosure is mandated by law (i.e., IDEA 2004) and the information is to be shared for public health purposes, written authorization for referrals to Part C may not be required ( Houston, Behl, & White, 2008; Surprenant, 2006). Furthermore, signed consent is not needed (under FERPA) to disclose general contact information, enrollment status, and attendance of children served ( Houston et al., 2008). However, Part C has more privacy protections than FERPA and HIPAA. Signed consent is needed for Part C to share any personal information with nonparticipating providers (i.e., outside of the Part C system) but it is not needed for Part C to share information with participating providers. State laws can require more privacy protections, but not less. The NICHQ has recommended that any required consent for release of information be obtained at first contact with early intervention so that information can be entered into an EHDI database ( HRSA, in press).
Agencies and committees have recognized the need for maintaining consistent and stable state and federal funding for EHDI programs, including the AAP, JCIH, HRSA/Maternal and Child Health Bureau (HRSA/MCHB), and National Institutes of Health ( JCIH, 2007; Lloyd-Puryear et al., 2006). A shortage of professionals with skills in pediatrics and hearing loss has been noted, as well as poor reimbursement of audiology services ( JCIH, 2007; Lieu, Karzon, & Mange, 2006).
In a recent study of NHS program performance, Thomson (2007) found that when infants were born in hospitals where audiologists were involved in the NHS programs, they were 27% more likely to receive the outpatient rescreen when recommended as compared to those programs without audiologist involvement.
Possible family factors contributing to LTF examined by studies included in the ASHA systematic review of evidence (see the Appendix) addressed educational and literacy levels of mothers and the age of mothers, maternal marital status, maternal substance abuse, maternal smoking, number of children at home, insurance status, family history of hearing loss, receipt of prenatal care, and poverty level ( Folsom et al., 2000; Liu, Farrell, MacNeil, Stone, & Barfield, 2008; Oghalai, Chen, Brennan, Tonini, & Manolidis, 2002; Prince, Miyashiro, Weirather, & Heu, 2003). Child factors that might contribute to LTF that were examined by studies included in the review were severity of hearing loss, birth weight, race, gender, resident of neonatal intensive care or well-baby nursery, and neonatal surgery and ventilator status ( Davis & Wood, 1992; Folsom et al., 2000; Liu et al., 2008; Prieve et al., 2000; Prince et al., 2003; Shoup, Owen, Jackson, & Laptook, 2005; Stein, Jabaley, Spitz, Stoakley, & McGee, 1990; Stewart et al., 2000; Uus & Bamford, 2006).
Factors that were not examined by studies included in the systematic review but that have been considered in other documents include the following:
Proximity to resources: In a survey of approximately 1,000 families whose babies received NHS in Massachusetts, those families who were compliant with follow-up revealed that a long travel time to their appointments could be a barrier to follow-up. Related to this concern was that the appointments might not be convenient and the time parents spent away from work for these appointments could be problematic ( MacNeil et al., 2007).
Difficulty scheduling appointments: At least two surveys have suggested that difficulties scheduling appointments for follow-up have posed barriers for families ( Harrison, Roush, & Wallace, 2003; MacNeil et al., 2007). The difficulties included making the telephone calls, finding someone to care for other children, and transportation.
The CDC emphasizes the importance of an EHDI tracking and surveillance system that can minimize LTF ( CDC, 2003). Specifically, they set forth the following program objectives:
Comprehensive system: Each state will have a computerized system that (1) maintains current information on all babies screened, including those who do not pass the screen, (2) contains diagnostic results for babies who were referred based on the results of their NHS test, and (3) documents interventions for those infants who were diagnosed with hearing loss.
Policies and procedures: Each state will have written policies and procedures regarding their EHDI tracking and surveillance system.
Privacy and confidentiality: Each state will develop policies, procedures, and informed-consent requirements regarding privacy and confidentiality of data in the EHDI tracking and surveillance system.
Inclusion of all births: Each state will ensure that all live births in the state are included in the state EHDI tracking and surveillance system by matching with the state's birth certificate registry as allowed.
Risk factors for hearing loss: The state EHDI tracking and surveillance system will ascertain risk factors for hearing loss for every infant by linkage with other state data systems.
NHS results: The EHDI tracking and surveillance system will capture all hearing screening results at the birthing hospital within 1 week of discharge or transfer.
Reporting mechanism for health care providers: Each state will provide a mechanism for hospitals, audiologists, and other health care providers to report NHS results, evaluations, and interventions.
Identifying children who need screening and follow up: The state EHDI tracking and surveillance system will be able to identify, on a weekly basis, all infants and children who need initial hearing screening, rescreening, evaluation, follow-up, or intervention.
Access to information: The state EHDI tracking and surveillance system will allow case managers and authorized health care providers to access relevant information about infants and children.
Today, 92%–95% of babies born in the United States and its territories receive hearing screening in the newborn period ( CDC, 2008; NCHAM, 2007). Successful outcomes for children with hearing loss are within reach as a result of advanced knowledge, skills, and hearing technology available to these children and their families. However, only slightly more than half of the infants who do not pass hearing screening receive follow-up diagnostic testing and only a third diagnosed with hearing loss receive intervention by 6 months of age ( NCHAM, 2005). Clearly, positive outcomes can only be achieved if babies identified with hearing loss receive appropriate early intervention services in a timely manner.
This report has included a systematic review of evidence as well as consensus data and policy statements. It remains unclear which babies are at greatest risk for LTF and how to lower that risk. There is a dearth of evidence to support effective and reliable models of follow-up in EHDI programs. Until such time that evidence-based guidance is available to inform professionals in the EHDI systems, it is recommended that ASHA develop practice guidelines, based on the best available evidence and expert opinion at this time, designed for improving short-term and long-term follow-up practices by audiologists, speech-language pathologists, and other professionals involved in the diagnostic and habilitative management of infants with permanent hearing loss.
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Kim, S., Lloyd-Puryear, M. A., & Tonniges, T. F. (2003). Examination of the communication practices between state newborn screening programs and the medical home. Pediatrics, 111, e120–e126.
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Rob Mullen, Tobi Frymark, and Hillary Leech
National Center for Evidence-Based Practice in Communication Disorders
American Speech-Language-Hearing Association
In 2000 and 2007, the Joint Committee on Infant Hearing released position statements supporting universal newborn hearing screening (UNHS) as a means to improve early hearing detection and intervention (EHDI). The Joint Committee recommended that all newborns be screened for hearing loss by 1 month of age. The U.S. Department of Health and Human Services (2000) gave further support to this effort by promoting the Healthy People 2010 "1-3-6" initiative. That is, in addition to being screened by 1 month of age, infants should receive diagnostic follow-up by 3 months of age and appropriate audiological intervention by 6 months of age.
Today, the importance and benefits of universal hearing screening at birth have reached national recognition. Endorsements from a number of federal agencies and advocacy organizations have led to marked improvements in the identification of infants with hearing loss. Since the release of the Joint Committee's position statement, the percentage of infants screened for hearing loss has risen dramatically. Currently, 95% of all newborns are receiving hearing screens at birth, compared to 38% in 2000 ( Centers for Disease Control and Prevention [CDC], 2005). In addition, 42 states now have legislation in place related to UNHS ( National Center for Hearing Assessment and Management, 2008).
Although tremendous progress has been made as a result of these efforts, UNHS is only the first step in the "1-3-6" initiative. There still is little known about what happens to those infants who fail the initial hearing screen at birth and are in need of further audiological services. Despite the progress made in the proportion of newborns receiving an initial hearing screen at birth, it is not clear that similar success has been achieved with the recommended follow-up services. Research by Yoshinaga-Itano, Sedey, Coulter, and Mehl (1998) revealed that infants who received intervention by 6 months of age performed significantly better in language development compared to infants identified after 6 months.
Bridging the gaps between identification of hearing loss at birth, diagnostic follow-up, and intervention is crucial. Further measures must be taken to ensure that infants commonly referred to as "lost to follow-up" receive timely and appropriate audiological services. As a result, the aim of this systematic review was to examine the current state of the evidence pertaining to loss to follow-up after initial identification of newborn hearing loss. In constructing the questions for review, two important components related to loss to follow-up were considered: the characteristics of those populations at risk for loss to follow-up and the effectiveness of interventions targeted at improving follow-up rates. This review focused on four clinical questions:
What characteristics of individuals, families, or populations have been found to be associated with risk of delays or loss to follow-up for children with a positive initial screen for hearing loss and in need of an audiologic evaluation by 3 months?
What characteristics of individuals, families, or populations have been found to be associated with risk of delays or loss to follow-up for children with a positive diagnosis of hearing loss and in need of an audiologic intervention by 6 months?
What has been the effectiveness of initiatives designed to increase follow-up for appropriate audiologic evaluation by 3 months of age?
What has been the effectiveness of initiatives designed to increase follow-up for appropriate audiologic intervention by 6 months of age?
A systematic search of the literature was conducted from September 2007 to January 2008. Studies were considered for the review if they were published in a peer-reviewed journal from 1990 to 2008, were written in English, and contained original data addressing one or more of the four clinical questions. Twenty-two electronic databases were searched in addition to all ASHA journals, the EHDI Publications Database, the National Center on Birth Defects and Developmental Disabilities Publications Database, and a full search of relevant references and authors. Databases searched included CINAHL, Cochrane Library, CRD database, DIMDI, EBM Guidelines, Education Abstracts, EMBASE, ERIC, Health Source: Nursing/Academic Edition, Linguistics and Language Behavior Abstracts, Medline, National Electronic Library for Health, National Rehabilitation Information Center, PsycARTICLES, PsycBITE, Psychology and Behavioral Sciences Collection, PubMed, Science Citation Index, Social Science Citation Index, SUMSearch, Teacher Reference Center, and TRIP Database. A total of 24 expanded search terms were used to review the UNHS and EHDI literature, including key words related to newborn hearing screening, early intervention, and hearing screening follow-up.
The search schematized in Figure 1 includes a total of 238 articles. Two authors (RM and TF), blind to one another's results, reviewed each abstract and identified 26 articles as meeting the initial inclusion criteria, with 91% agreement. Of those initially accepted, 12 were subsequently excluded after review of the full text article. A total of 14 studies were included in the final analysis.
Studies pertaining to intervention were evaluated for methodological quality. The authors (RM and TF) independently appraised each study on eight quality indicators:
adequate description of protocol for replication
adequate description of subjects (within-subject design) or groups comparable at baseline (between-subjects design)
assessors blinded
random sample adequately described
evidence of treatment fidelity
p value reported or calculable
effect size and confidence interval reported or calculable
analyzed by intention to treat (controlled trials only).
Reliability of appraisal ratings between authors was assessed, and any discrepancies were resolved via consensus. Studies received one point for each quality marker that met the above criteria. Studies incorporating controlled trials could obtain a maximum quality score of eight. All other study designs where intention to treat analysis was not applicable could obtain a maximum quality score of seven.
Question 1. What characteristics of individuals, families, or populations have been found to be associated with increased risk of delays or loss to follow-up for children with a positive initial screen for hearing loss and in need of an audiologic evaluation by 3 months of age?
The 11 studies included in this section of the review reported findings on a total of 19 different risk factors. As shown in Table 1, 6 of the studies ( Davis & Wood, 1992; Prieve et al., 2000; Shoup, Owen, Jackson, & Laptook, 2005; Stein, Jabaley, Spitz, Stoakley, & McGee, 1990; Stewart et al., 2000; Uus & Bamford, 2006) compared follow-up in infants who had been in neonatal intensive care units (NICUs) with infants who had been exclusively in well-baby nurseries (WBNs).
In four of the six studies ( Prieve et al., 2000; Shoup et al., 2000; Stewart et al., 2000; Uus & Bamford, 2006), findings were reported in terms of rates of follow-up during the study period (see Table 2). Prieve et al. found a significantly lower rate of follow-up in WBN infants, whereas in the other three studies no statistically significant differences were found between the populations. Interpretation of the findings across studies is difficult because none of the studies specified the time frame or cut-off for designating an infant as lost to follow-up. For example, in the Uus and Bamford study data are presented for the infant's age on the date of the evaluation, and the ages ranged up to 31 weeks. Data on age are not reported in the other studies, and one cannot tell whether an infant evaluated at 31 weeks would have been within or outside the parameters for designation as followed-up or lost in other studies.
In addition to Uus and Bamford (2006), two other studies ( Davis & Wood, 1992; Stein et al., 1990) reported data on the infant's age at evaluation (see Table 3). In those two studies, the authors found that the age at evaluation for WBN infants was significantly higher than for NICU infants, whereas Uus and Bamford found a statistically significant difference in the opposite direction.
The Folsom et al. (2000); Prince, Miyashiro, Weirather, and Heu (2003); and Liu, Farrell, MacNeil, Stone, and Barfield (2008) studies reported data on maternal age. Folsom et al. found a mean maternal age of 27.5 years among mothers whose infants were followed up, compared to 26.0 years among mothers of infants lost to follow-up, a statistically significant difference. Liu et al. found significantly lower follow-up in mothers aged younger than 20. In contrast, Prince et al. (2003) found the lowest rates of follow-up among infants whose mothers were age 35 or older, but none of the differences in that study's follow-up rates by maternal age were statistically significant.
The same three studies also reported data on the infants' race, again with conflicting results. Folsom et al. (2000) found significantly higher rates of follow-up in non-Hispanic White infants (64.8%) than in infants of other racial/ethnic groups (51.5%). Liu et al. (2008) also found significantly higher follow-up in non-Hispanic White infants (92% vs. 85%). Prince et al. (2003) found significantly lower rates of follow-up in White infants (75.9%) than in infants of other races (85.6%).
The Davis and Wood (1992) and Uus and Bamford (2006) studies both looked at follow-up by severity of hearing loss. Davis and Wood found statistically significant differences in the mean age at evaluation: 9 months for infants with a hearing loss of 80+ dB, 17 months for hearing loss between 50 db and 79 dB, and 35 months for <50 dB. Uus and Bamford found no significant differences by degree of loss.
Folsom et al. (2000) and Liu et al. (2008) both looked at follow-up by insurance status. Folsom et al. found significantly higher follow-up in infants with health insurance (60.7%) than in those with no insurance (42.4%). Liu et al. compared private insurance, public insurance, and no insurance, and found that follow-up of infants with private insurance (94% follow-up) was similar to that of infants with no insurance (92% follow-up), and both were significantly higher than in infants with public health insurance (81% follow-up).
The Prince et al. (2003) and Liu et al. (2008) studies both looked at follow-up by birth weight. Prince et al. found significantly higher follow-up in infants weighing at least 2,500 g at birth (83.6%) than in infants weighing less than 2,500 g (72.0%). The Liu et al. study found no statistically significant differences by birth weight.
The Prince et al. (2003) and Liu et al. (2008) studies also looked at follow-up by mother's marital status. Prince et al. found no significant difference in follow-up by marital status, whereas Liu et al. found significantly higher follow-up in married versus unmarried mothers (93% vs. 83%).
Finally, the same two studies looked at follow-up by maternal education. Both studies found significantly higher follow-up in mothers who had completed high school or beyond. The Prince et al. (2003) study found 84.1% follow-up in high school graduates compared to 74.5% in nongraduates. The rates reported in the Liu et al. (2003) study were 92% in graduates and 79% in nongraduates.
Data on 12 other risk factors were included in only one study each. Delayed or no follow-up was found to be statistically significant in families with the following characteristics:
more than two children at home ( Folsom et al., 2000)
mother had no or late prenatal care ( Folsom et al., 2000)
mother was a substance abuser (type of substance not specified; Folsom et al., 2000)
mother smoked during pregnancy ( Liu et al., 2008)
infant underwent surgery during the neonatal period ( Folsom et al., 2000)
infant had not been on a ventilator ( Folsom et al., 2000)
no family history of hearing loss ( Folsom et al., 2000)
infant was born in a community hospital rather than an obstetric Level 2 or 3 medical center ( Prince et al., 2003).
Single studies reported no significant differences in follow-up associated with these factors:
infant's risk for hearing loss ( Parving, 1993)
laterality of hearing referral ( Liu et al., 2008)
gender ( Prince et al., 2003)
poverty ( Oghalai, Chen, Brennan, Tonini, & Manolidis, 2002).
Question 2. What characteristics of individuals, families, or populations have been found to be associated with increased risk of delays or loss to follow-up for children with a positive diagnosis of hearing loss and in need of an audiologic intervention by 6 months of age?
Three studies reported data on the NICU versus WBN comparison (see Table 4). The Davis and Wood (1992) and Stein et al. (1990) studies both found 100% follow-up from evaluation to hearing aid fitting in both groups, and both studies found that the significant differences in mean age that had been observed at the time of diagnosis (see Table 3) were no longer evident at the time of habilitation. Davis and Wood reported a mean age at habilitation of 19.7 months in NICU infants versus 25.0 months in WBN infants. Stein et al. reported means of 20.0 and 20.8 months, respectively. Uus and Bamford (2006) reported a mean age of 25.7 weeks in NICU infants and 19.8 weeks in WBN infants (statistical significance was not reported).
Davis and Wood (1992) also reported findings on the relationship between the severity of hearing loss and follow-up. Here, the significant differences in follow-up observed at the time of evaluation continued to be reflected in age at time of habilitation. Mean age was 12 months in children with hearing loss of 80+ dB, 25 months with hearing loss between 50 dB and 79 dB, and 37 months with hearing loss of <50 dB. However, the gap between diagnosis and habilitation was not significantly different by severity of hearing loss. Uus and Bamford (2006) also reported findings of delayed habilitation in moderate, compared with profound, hearing loss, although data were not presented.
The Oghalai et al. (2002) study, which found no impact of poverty on age at diagnosis, found that infants born at a hospital serving a primarily indigent population had a significantly later mean age at time of habilitation (49.6 weeks vs. 28.2 weeks; p = .041).
The Liu et al. (2008) study reported findings on the same nine variables it addressed in Question 1. Loss to follow-up from diagnosis to early intervention services was significantly higher among the following groups:
infants weighing <2,500 g at birth
infants with unilateral hearing loss
infants with mild/moderate hearing loss.
The following factors did not reflect significantly different rates of follow-up in the Liu et al. study:
maternal age
mother's marital status
mother smoked during pregnancy
mother's education
insurance status
Question 3. What has been the effectiveness of initiatives designed to increase follow-up for appropriate audiologic evaluation by 3 months of age?
No studies were found related to this question.
Question 4. What has been the effectiveness of initiatives designed to increase follow-up for appropriate audiologic intervention by 6 months of age?
No studies were found related to this question.
Because no intervention studies directly relevant to Questions 3 or 4 were found, we made the decision to amend the inclusion criteria to include studies of interventions designed to reduce loss to follow-up from initial to repeat screen. We thought that the issues might be sufficiently closely related that the findings from those studies could have implications for follow-up from screening to evaluation.
Three studies ( Françozo, Fernandes, Marconi Pinheiro Lima, & Rossi, 2007; Korres et al., 2005; Wittmann-Price & Pope, 2002) investigated the effectiveness of interventions to improve follow-up rates from initial to repeat screens. The three studies (see Table 5) examined three different types of interventions.
Françozo et al. (2007) compared the effectiveness of small-group versus individual counseling of mothers by a social worker. The results were not statistically significant. In the small-group cohort, follow-up was 60.2% (95% confidence interval [CI] = 52.5%–67.6%), and in the individual counseling cohort, follow-up was 74.3% (95% CI = 57.8%–86.0%).
The Korres et al. (2006) study was the only one of the three to report statistically significant findings. In one cohort, parents received a written report of the screening results and recommendation for rescreening. That cohort had follow-up of 27.8% (95% CI = 24.6%–31.3%). The second cohort received, in addition to the written report, written comments in their discharge papers, personal contact, and monitoring of their compliance with rescreening appointments. Follow-up in that cohort was 41.8% (95% CI = 37.7%–46.0%). The changes to the protocol were bundled, and no data on the relative impact of the three individual changes were reported.
The Whittman-Price and Pope (2002) study examined the effectiveness of adding a 20-minute educational module on UNHS to a hospital-based prenatal class. In the cohort that did not receive the module, 7 of the 9 infants were rescreened. It was not reported whether the parents of those children attended the prenatal class before the addition of the UNHS module, whether they attended a different class, or whether they did not attend a class at all. In the cohort that did receive the module, all 5 infants were rescreened. These results were not statistically significant.
Questions 1 and 2, that is, those that dealt specifically with the characteristics of individuals or populations, were developed in part in anticipation that cultural and linguistic factors might be an important influence on follow-up. These factors, including educational level, poverty, race, and others were addressed by a small number of studies, and with little consistency among results. Table 6 describes the context in which these studies were conducted.
Nine of the 14 studies were conducted in the United States. In only one instance would separate consideration of the findings result in somewhat different conclusions. Of the six studies comparing follow-up from screening to evaluation in NICU versus WBN infants, five were conducted in the United States and one in England. The English study found better follow-up in WBN infants, whereas of the five U.S. studies, three found better follow-up in NICU infants and two found no differences. This raises at least the possibility that the contrasting findings between these studies could have been influenced by the different health care systems.
The diversity of study populations may have also influenced another aspect of the overall findings. As noted under Question 1, the three studies examining the rates of follow-up by infant race reached different conclusions. The Folsom et al. (2000) and Liu et al. (2008) studies found higher follow-up in non-Hispanic White infants, whereas the Prince et al. (2003) study found significantly lower follow-up in non-Hispanic Whites. There is some indication, though, that the non-Hispanic White populations may not have been comparable across the three studies. Although all three studies were conducted in the United States, Prince et al. pointed out that "a small percentage of White women [in the outer islands of Hawaii] may choose 'alternative lifestyles' preferring nontraditional health care rather than traditional services" (p. 1205).
To affect clinical practice and/or policy, it is desirable to have an evidence base of multiple studies of high methodological quality with generally consistent findings. The available evidence on issues surrounding loss to follow-up in newborn hearing screening programs fails on all three counts.
No studies were found that were directly relevant to Questions 3 and 4. Of the 20 potential risk factors examined in the studies from Questions 1 and 2, most were examined in only one or two studies, and only one (NICU status) was examined in more than two studies.
Methodological quality was low. In none of the three intervention studies was subject comparability addressed, none were blinded, none had random samples, and none addressed treatment fidelity. In only one of the three intervention studies ( Françozo et al., 2007) was the protocol described with sufficient detail for replication.
In the epidemiologic studies related to Questions 1 and 2, quality concerns were also evident. None of the studies using rate of follow-up (as opposed to age), for example, specified the time frames for designation of an infant as lost to follow-up. If the de facto cut-off date for followed-up or lost was based on the data collection period, rather than each child's age, then individual children within a study could have been inconsistently categorized, depending on when within the study period they were born.
A second quality concern among the epidemiologic studies involved another type of confounding. The Folsom et al. (2000) study is an example of one that addressed a number of different potential risk factors. The factors, though, included items such as insurance status and prenatal care. Given the possible interaction between a lack of health insurance and the availability and nature of prenatal care, it would be important in the analysis of the data to control for possible interactions. Only in the Liu et al. (2008) study, however, were such controls evident.
A third quality concern involves some confusion as to whether additional risk factors were studied, but the results were not reported in the studies because they were not statistically significant. The Prince et al. (2003) and Liu et al. (2008) studies, for example, did report that some of the factors they studied, such as mother's marital status, were not significant. Folsom et al. (2000), on the other hand, reported data on nine risk factors that had statistically significant results. It is not clear whether those were the only nine factors they studied, and all were significant, or whether those were the only factors found to be significant out of a larger total number that were studied.
The final quality concern involves multisite studies. It was noted earlier that the consistency of findings across studies is an important consideration. Also important is the consistency of findings across sites within a single study. The Stewart et al. (2000) study, for example, involved more than 200 infants at five sites. The overall findings indicated a nonsignificant difference between NICU and WBN in follow-up from screening to evaluation. Data were not presented separately for the five sites, however, and as a result it is unclear whether the findings were consistent across sites.
There were eight instances of multiple studies examining the same intervention or risk factor (in this case, risk factors). For only one of the eight factors were the findings completely consistent. In these two studies, both found that mothers who completed high school were more likely to follow up from screening to evaluation. One of these two studies, however, found no significant differences in follow-up from evaluation to treatment by mother's education.
In summary, the small number, poor quality, and inconsistent findings within the available evidence do not provide meaningful direction for clinicians or policy makers in identifying the patients/families at the highest risk of loss to follow-up, nor how to decrease that risk. More high quality epidemiologic studies with precise definitions of terminology and incorporation of multivariate statistical analyses are needed, as are high quality experimental or quasi-experimental studies of well-defined interventions targeted at increasing follow-up.
References marked with an asterisk indicate studies included in the systematic review.
American Speech-Language-Hearing Association. (2007). Year 2007 position statement: Principles and guidelines for early detection and intervention programs. Available from www.asha.org/policy/.
Centers for Disease Control and Prevention. (2005). Final summary of 2005 national EHDI data (Version 6). Retrieved from www.cdc.gov/ncbddd/ehdi/documents/Nat_EHDI_Summ_2005_Web_v6.pdf.
*Davis, A., & Wood, S. (1992). The epidemiology of childhood hearing impairment: Factor relevant to planning of services. British Journal of Audiology, 26, 77–90.
*Folsom, R. C., Widen, J. E., Vohr, B. R., Cone-Wesson, B., Gorga, M. P., Sininger, Y. S., & Norton, S. J. (2000). Identification of neonatal hearing impairment: Recruitment and follow-up. Ear and Hearing, 21, 462–470.
*Françozo, M., Fernandes, J., Marconi Pinheiro Lima, C. M., & Rossi, T. (2007). Improvement of return rates in a neonatal hearing screening program: The contribution of social work. Journal of Health Care Social Work, 44, 179–190.
Joint Committee on Infant Hearing. (2000). Year 2000 position statement. Principles and guidelines for early hearing detection and intervention programs. Pediatrics, 106, 798–817.
*Korres, S., Balatsouras, D. G., Vlachou, S., Kastanioudakis, I. G., Ziavra, N. V., & Ferekidis, E. (2005). Overcoming difficulties in implementing a universal newborn hearing screening program. Turkish Journal of Pediatrics, 47, 203–212.
*Lui, C., Farrell, J., MacNeil, J., Stone, S., & Barfield, W. (2008). Evaluating loss to follow-up in newborn hearing screening in Massachusetts. Pediatrics, 121, e335–e343.
National Center for Hearing Assessment and Management. (2008). EHDI legislation. Available from www.infanthearing.org/legislative/index.html.
*Oghalai, J. S., Chen, L., Brennan, M. L., Tonini, R., & Manolidis, S. (2002). Neonatal hearing loss in the indigent. Laryngoscope, 112, 281–286.
*Parving, A. (1993). Congenital hearing disability—epidemiology and identification: A comparison between two health authority districts. International Journal of Pediatric Otorhinolaryngology, 27, 29–46.
*Prieve, B., Dalzell, L., Berg, A., Bradley, M., Cacace, A., Campbell, D., et al. (2000). The New York State universal newborn hearing screening demonstration project: Outpatient outcome measures. Ear and Hearing, 21, 104–117.
*Prince, C. B., Miyashiro, L., Weirather, Y., & Heu, P. (2003). Epidemiology of early hearing loss detection in Hawaii. Pediatrics, 111, 1202–1206.
*Shoup, A., Owen, K., Jackson, G., & Laptook, A. (2005). The Parkland Memorial Hospital experience in ensuring compliance with universal newborn hearing screening follow-up. Journal of Pediatrics, 146, 66–72.
*Stein, L. K., Jabaley, T., Spitz, R., Stoakley, D., & McGee, T. (1990). The hearing-impaired infant: Patterns of identification and habilitation revisited. Ear and Hearing, 11, 201–205.
*Stewart, D. L., Mehl, A., Hall, J. W., Thomson, V., Carroll, M., & Hamlett, J. (2000). Universal newborn hearing screening with automated auditory brainstem response: A multi-site investigation. Journal of Perinatology, 20, S128–S131.
U.S. Department of Health and Human Services. (2000). Healthy People 2010. Washington, DC: U.S. Public Health Service.
*Uus, K., & Bamford, J. (2006). Effectiveness of population-based newborn hearing screening in England: Ages of interventions and profile of cases. Pediatrics, 117, e887–e893.
*Wittmann-Price, R., & Pope, K. (2002). Universal newborn hearing screening: One hospital's project improved follow-up rates for infants who didn't pass the initial test. American Journal of Nursing, 102, 71–77.
Yoshinaga-Itano, C., Sedey, A., Coulter, D. K., & Mehl, A. L. (1998). Language of early and later identified children with hearing loss. Pediatrics, 102, 1161–1171.
[1] For purposes of this document, the term lost to follow-up refers to infants and the term loss to follow-up refers to the EHDI programmatic issues related to follow-up. The abbreviation LTF is used interchangeably to represent both terms in this document.
Index terms: newborns, infants and toddlers, hearing loss, screening, early intervention
Reference this material as: American Speech-Language-Hearing Association. (2008). Loss to follow-up in early hearing detection and intervention [Technical Report]. Available from www.asha.org/policy.
© Copyright 2008 American Speech-Language-Hearing Association. All rights reserved.
Disclaimer: The American Speech-Language-Hearing Association disclaims any liability to any party for the accuracy, completeness, or availability of these documents, or for any damages arising out of the use of the documents and any information they contain.


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Political Extremists May Sound Mad, But They're Actually Happier Than Moderates
While political extremists may froth at the mouth and march around in a huff, research suggests that they are actually happier than those who take more moderate political views.
In Arthur C. Brooks' book 'Gross National Happiness,' he uses survey data to determine what makes for happiness. He found that "correcting for income, education, age, race, family situation and religion, the happiest Americans are those who say they are either 'extremely conservative' (48 percent very happy) or 'extremely liberal' (35 percent). Everyone else is less happy, with the nadir at dead center "moderate" (26 percent)."
The fact that extreme conservatives are more likely to be happy than extreme liberals is keeping with a general trend of conservatives being content than liberals.
Now it is up for the happy extremists on both sides to argue angrily about why that is.

subset: commoncrawl


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Home > Gluten Free Travel Stories > Gluten free traveling around Sri Lanka
Gluten free traveling around Sri Lanka
TweetBy Ton Nederhof
A few years ago, Sri Lanka (formerly known as Ceylon) attempted to forbid the import of wheat - in order to try to protect its position as a rice-producing country. Nothing came of this bold plan, however, and in the large supermarkets (e.g., Cargills) I visited, I noticed that wheat flour amounted to about 50% of the flour offered for sale. On the positive side, quite a range of gluten free flours were on offer, such as besan, gram (both chickpea), mealimeal (corn), dal (made from vegetables), and bajri (millet), in addition to rice flour.
Celiac disease is not very well known in Sri Lanka, and I could not find a Celiac association with a website. I did not manage to obtain a gluten free restaurant card in one of the main Sri Lankan languages, Singhalese and Tamil, so instead I took the English language one along.
Unfortunately, many Sri Lankans at restaurants did not know English very well if at all, and even fewer could read English (Singhalese has its own script). Those who spoke English frequently used a variant, Sri Lankan English. "Flour" was understood as "flower", and the Sri Lankan English term used for flour was "fla:" (phonetically spelt) pronounced as in 'flask'. "fla:" seemed to include wheat in general as well. This word usually triggered the right response.
It is really necessary to speak to the cook though. The hierarchical nature of Sri Lankan hotel and catering establishments sometimes led to me speaking with five persons (servant, main servant, restaurant chief, chief cook and cook on duty) to get the message across. Just addressing the servant - usually the lowest in rank, with often poor command of English - frequently led to disappointing results when changes in the meal were requested.
Gluten Free Breakfasts
Many hotels offer toast for breakfast. Some hotels offered rice as a choice for breakfast, including the delightful gluten free milk rice (with coconut milk), but most did not. I often had boiled eggs, and fried eggs only when baked in front of me using fresh oil. Once or twice there was hard cheese, and often fruit. There was no yoghurt.
Diet replacements for bread cannot be found in Sri Lankan shops, not even rice crackers, so you have to bring your own.
What's for Lunch?
For lunch, I frequently had 'fried rice with vegetables', a simple but trustworthy meal. Along speedways, this might be difficult to obtain, so one should always bring along some gluten free food.
Once I enjoyed 'nasi goreng', a rice dish introduced from Indonesia in the Dutch colonial period, but this has many ingredients, increasing the risk for gluten.
I ate lamprais too, rice boiled in stock and baked with meat (chicken in my case, but there is also a variant with sausage that contains gluten) in banana-leaf.
At Dinner Time...
I was travelling with a group on an organized tour around Sri Lanka visiting culture sites such as Anuradhapura, Polonnaruwa, Kandy and Galle, as well as several National Parks. One advantage of group travel is that the tour leader carries some weight with the hotel and catering authorities. Our tour leader was Ellen Romeijn, a seasoned and determined hand stationed in Kyrgyz Republic where she has her own travel company Horizon (www.horizon.elcat.kg), working throughout Asia as travel agent or tour leader (for instance for Baobab).
Although no expert in celiac disease, she understood the problem. Frequently, she was able to arrange a meal of plain grilled fish or chicken with rice and vegetables (the latter frequently to be taken from a buffet) so that I did not have to rely too much on what the usual dinner buffet provided and on how well people behaved with the serving cutlery.
If there was a buffet, I tried to be there early, minimizing the risk of contamination. Given the presence of wheat in many dishes, I avoided French fries and other fried food, not being sure what might have been in the baking oil before. In trusted places, a side-dish of plain salad (without vinegar or sauce) might be ordered; otherwise, bacterial contamination of the water used to wash the salad presents a problem.
Although I managed to avoid being ill due to gluten on my three week trip, I and most of my non-celiac travel companions got ill once from food-poisoning, all on the same day. Being sick lasted just six hours for me, after which my Schär gluten free pocket crackers helped me through the day. It was a pity that I had to miss out on the game-drive through the Udawalawe National Park though.
On some occasions, the buffet included local food (often presented in earthenware pots), such as dhal (the yellow sauce consists of just dissolved lentils), eggplant, chickpea sauce, sea weed with garlic, and so on (to be sure, I had checked these dishes with the cooks beforehand). Clear curries should be save, but usually I avoided these as it is not completely sure that no wheat flour has been used. When in doubt, I let my wife (a non-Celiac) taste first.
Once, there was a barbecue, but sausages and meat were on the same grill and were handled with the same pair of tongues. Fortunately, gluten free fish was grilled on a separate grill.
Sometimes, I had a vegetarian meal with rice. Sri Lankan food tends to be heavily spiced, but for foreigners this is usually tempered a bit. Usually, unadulterated fruit was present (such as small bananas, delightful pineapple and / or papaya).
Although I never got ill from gluten, it must be stated that there were many occasions on which gluten were either present or suspected. For instance, it was frequently stated that rice noodles were on the menu - but usually these were thicker, opaque wheat noodles instead of transparent rice noodles. Both a card and, regrettably, the person serving it insisted that the latter were involved, but the next day the same dish was labeled as wheat noodles ...
It certainly helps to have a broad experience concerning food products in general, and those of the (broad) region in particular. As usual, I prepared by perusing travel guides for the main dishes (the food section of the 2009 Rough Guide to Sri Lanka being somewhat more extensive and informative than the corresponding 2009 Lonely Planet section), and by checking regional cook books for recipes. The Wikipedia section on Sri Lankan cuisine was also helpful.
To be avoided are dishes such as chappati, roti / rotti, semolina, as well as atta, laps (fada), maida, poories, sevian, and sooji halva, which all contain gluten. The omnipresent poppadoms and hoppers are traditionally made of rice flour, but increasingly from wheat flour, and they may be fried in contaminated oil, so I avoided them.
Fortunately, Sri Lankan customs at the time of writing did not forbid bringing along food, so my big load of Teff Schwarzbrot, Teff crackers and hard cheese (three pieces varying in maturing, sealed vacuum) presented no problem. All held up well during three weeks of 30 plus degrees C, and very high humidity. Towards the end of the trip, the cheese got a little rancid, but was still fit for consumption.
Gluten Free Hotels and Notes
I flew with Arkefly, that offered just one (partially) gluten free meal both to and from Colombo. Regrettably, diner included wheat cream crackers (fortunately in transparent plastic) on one of the legs. Passengers were required to buy further snacks on the 12-13 hour trips, none of which were gluten free. Miserable.
The Paradise Holiday Village hotel (154/9 Porutota Road, 031-2274588; www.paradiseholidayvillage.com) at Negombo prepared a tasty grilled piece of fish. I cannot recommend the Randiya Hotel in Anurathapura, as a staff member adamantly insisted that their wheat noodles were rice noodles. The nasi goreng in the Rukmali Restaurant and Guesthouse, Sigiriya Junction, Moragaswewa, Habarana (firstname.lastname@example.com; 066-2270059) turned out OK.
Having a great view on the lake, I enjoyed a clear vegetable soup and grilled fish with dhal and beetroot side-dishes at the Giritale Hotel (027-2246311; email@example.com), Giritale. Food at hotel the Village at Pollonnaruwa (027-4924824; www.villapol.com) was good, and I had a fried rice with vegetables lunch at the Rest House (027-2222299; www.ceylonhotels.lk) at the lake.
In Dambulla, I had the usual lunch at the Gimanhala hotel restaurant (066-2284864; firstname.lastname@example.com). At the Queen's Hotel in Kandy (Dalada Vidiya 081-222 2813; www.queenshotel.lk) I had good food after discussions with five staff-members.
Had the usual lunch at the Lyons restaurant (27 Peradenya Road, Kandy), at the first floor. Also lunched at the Ramboda Falls hotel (052-59582) south of Kandy, and had lamprais at the White House (21 Dalada Veediya, Kandy, 081-2232765; www.whitehouse.lk). Dined at the Hotel Silver Falls in Nuwara-Eliya (23 Nanuoya Road, 052-2235859).
Next day, had the usual lunch in Ella at the Grand Ella Motel restaurant (057-2228655; www.ceylonhotels.ln; about 200 meters from the bus stop) that offers a great view on the Ella Gap. Stayed and dined at the Centauria Tourist Hotel, Embilipitiya (047-2230514; www.centauriatouristhotel.com).
Lunched next day at the Blue Magpie Lodge, Kudawa, Veddagala (045 - 5670498). Had to eat vegetarian as the meat was not gluten free. Stayed several nights at the Giragala Village (041-2250496) at Mirissa. Juicy grilled fish and prawns, but the lobster was overcooked.
Traveling gluten free around Sri Lanka is doable, although a good knowledge of food products helps a great deal as problems are often encountered. There is little knowledge about celiac disease in Sri Lanka and many don't read English well.
It was my impression that the more upgrade the hotel, the larger the risk of being offered food with gluten. In simple, traditional eateries and restaurants, gluten are less often encountered. That being said, cooks at the better hotels and restaurants were better able to communicate in English whether or not they had used products containing gluten.
Wherever you're going, remember to take a free gluten free restaurant card with you.
I hope that this celiac travel story has helped you. You can help other celiacs travel more safely by telling me about getting gluten free food in your area - remember where you live is a destination too! Send me a report and I'll let thousands of celiacs know.
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Vitex offers rare true-blue blooms in state landscapes
One of my true favorites for the early summer season is coming soon to our Mississippi landscapes. Starting mid-May through June, this plant will have some of the few, almost true-blue flowers in the plant world. So what is this plant?
The common name is chaste tree or vitex, and it was named a Mississippi Medallion winner in 2002. The bloom period begins around Memorial Day on the Gulf Coast and soon afterwards in north Mississippi. The main flowering period lasts up to six weeks.
The flowers are composed of many clusters of small, individual flowers grouped together on a long inflorescence, or flower cluster. In some varieties, this inflorescence can be up to 18 inches long. The color varies from lavender to lilac and pale violet. It can even be a brilliant, nearly fluorescent blue.
During the initial flush, the show of flowers may resemble a hazy blue or purplish cloud. On days when there is just the gentlest breeze, you can enjoy the blooms' delicate, slightly floral scent.
We have a couple of different vitex plantings at the Mississippi State University Coastal Research and Extension Center in Biloxi. One is out by the main road, and passersby often stop or call to ask about the plants. The other is right outside my office window.
The straight species Vitex is a great summer plant for us, but be on the lookout for the improved Shoal Creek selection. The vigorous spring/summer flush of flower spikes are some of the largest, and they are a more intense and deeper blue than the regular species.
In 2011, Shoal Creek vitex was named a Louisiana Super Plant. The adventurous and persistent gardener can find pink and white varieties.
The sweet, aromatic foliage is arranged on square stems in clusters of palmate leaves. The foliage is dark gray-green on top and bluish gray underneath. When mature, the leaves have slightly fuzzy bottoms.
Vitex thrives in our hot and humid weather extremely well, which makes this an outstanding small tree for our Mississippi landscapes. It is also a good plant for the periods of drought we have each summer.
While vitex can be grown as a single-trunked tree, I think it is more attractive in the landscape when grown as a multitrunk specimen. Vitex tolerates a wide range of pruning styles and can be easily maintained as an 8- to 10-foot tree. Pruning actually promotes compact branching, resulting in a thicker, bushier plant.
Since vitex flowers on new wood, which is the current season's growth, pruning actually encourages and enhances flowering. I prefer to keep chaste tree as a small- to medium-sized shrub, and I suggest you prune it as you would your butterfly bush. Prune back to 12 to 18 inches in the early spring just as new growth is starting.
Plant vitex in partial shade to full sun for best flowering performance. These plants tolerate a wide variety of soil conditions and textures, but make sure the planting bed has well-drained soil.


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Emacs can convert unibyte text to multibyte; it can also convert multibyte text to unibyte, provided that the multibyte text contains only ASCII and 8-bit raw bytes. In general, these conversions happen when inserting text into a buffer, or when putting text from several strings together in one string. You can also explicitly convert a string's contents to either representation.
Emacs chooses the representation for a string based on the text from which it is constructed. The general rule is to convert unibyte text to multibyte text when combining it with other multibyte text, because the multibyte representation is more general and can hold whatever characters the unibyte text has.
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This converts the unibyte character char to a multibyte character, assuming char is either ASCII or raw 8-bit byte.


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Holding a Ph.D. and Masters in Human and Organizational Systems from Fielding Graduate University, Tamara Myatt has spent more than a decade transforming the professional and educational lives of young and disadvantaged people in some of the poorest and most dangerous regions of the world, championing the causes of women, and orchestrating locally and globally scaled initiatives in the business sphere. The specialized focus of her Ph.D. in Human and Organizational Development was in in women's entrepreneurship in regions of war. She is currently pursuing advanced studies/research in entrepreneurship in emerging economies, family business, innovation, and enterprise digital transformation.
The former Executive Director of Goldman Sachs 10,000 Women in Afghanistan and Chair of Entrepreneurship and Assistant Professor of Small and Medium Enterprises at the American University of Nigeria, Tamara is an internationally recognized pioneer in enterprise development. She has led enterprise development initiatives in nations such as Afghanistan, Nigeria, Pakistan, Bosnia, Kenya, Croatia, Uganda, India, Myanmar, Liberia, and Rwanda.
In her spirit of 'giving back' Tamara founded a critical mentorship program for Nigeria's Chibok girls. Tapping into her passion for women's causes, Tamara has developed the framework needed to support these women as they reorient themselves and navigate PTSD. Many of these women are now enrolled in universities in their homeland and abroad. As well, Tamara is lauded internationally as the founder of Afghanistan's first-of-kind mentoring program for women entrepreneurs as well as the male support group for Afghan women in business. She has succeeded in establishing and edifying a robust support network for sustainable women-owned businesses, and many of her graduates have gone on to exceptional successes including participation in Barack Obama's Entrepreneurship Summit and the Clinton Global Initiative, as well as recognition with Global Leadership Awards, Fortune Magazine's Most Powerful Women, and Time Magazine's Most Influential People. For her work with women and enterprise development, Tamara received the Woman of Excellence Award for her home province of Nova Scotia, Canada, and commendation for her leadership in establishing the mentoring program for Nigeria's Chibok girls.
With a formidable background of experience including laying the groundwork for Saudi Arabia's first university for women and the first entrepreneurship studies program for women in post conflict Rwanda and Afghanistan, as well as conflict-ridden Northeastern Nigeria, Tamara is well-prepared to begin tearing down the significant barriers impeding the economic advancement of young people. She embodies both the executive operational leadership qualities and fundamental teaching and instruction expertise to begin making meaningful changes while navigating cultural and social challenges. A proactive team builder, principled leader, and exceptional motivator, she is a superlative professional for senior academic leadership and instructional roles.
- Ph.D. in Human and Organizational Systems from Fielding Graduate University
- Masters in Human & Organizational Systems from Fielding Graduate University
- Executive Director of the Goldman Sachs 10,000 Women and the American University of Afghanistan Consultant for the Women in the Economy at Flag International
- Certificate in Educational Leadership from Michigan State University
- Former Chair of Entrepreneurship, School of Business and Entrepreneurship, American University of Nigeria


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In the dawn of August 15, 1975, Bangabandhu Sheikh Mujibur Rahman made one of his final phone calls to his military secretary Col Jamil Uddin Ahmad. He had been attacked, Bangabandhu told Col Jamil, and the residence on Road 32 was surrounded. Then the line went dead.
On a night when conspiracy was afoot and uncertainty gripped the city, and with the country's leadership seemingly paralysed, Col Jamil did not shrink from doing his duty. He called senior officers, including the chief of army staff, Gen Shafiullah, and told them to send in troops. He then ordered the Presidential Guard Regiment, charged to defend Bangabandhu, and headed for Road 32 immediately.
Calmly holstering his service revolver, Jamil tried to reassure his wife and children: "Bangabandhu is in danger. How can I not go?"
"Look after my daughters," was his final request before he mounted his jeep and headed off into the darkness.
Arriving in front of Sobhanbagh mosque, Col Jamil found that the PGR convoy had halted. He demanded to know the reason, and was told that there were army units ahead and that there was gunfire. He tried to convince the troops to march forward. Then realising that time was running out, he got into his jeep and prepared to drive into Road 32 himself.
The valiant patriot was shot dead as he sat in his jeep and embraced martyrdom, trying to save the leader whom he had, like many others, sworn to protect. It was the steadfast adherence to his principles that guided Col Jamil in the final moments of his life. On a night when many brave souls hesitated, Jamil did not waver. It was the supreme test of courage and honour - and he passed with flying colours.
It was not until about 2:00 pm on August 16, 1975 that the family of Col Jamil learnt anything definitive about his fate.
A call came from Gen Shafiullah, whom Col Jamil had asked at dawn to send troops to Bangabandhu's rescue. Mrs Jamil answered the phone and the chief of army choked as he broke the news of her husband's death. Bangladesh had lost a true patriot.
A man of extraordinary character, Col Jamil had been held hostage in Pakistan during the Liberation War. But his integrity and professionalism as a career army officer led him to be appointed military secretary to Bangabandhu Sheikh Mujibur Rahman in an independent Bangladesh.
Gen Shafiullah, who had trained with Jamil at the Pakistan Military Academy, had this to say when remembering his slain comrade many years later: "Jamil Bhai, myself, and the few Bangalee officers who were in Pakistan in those days had a regular liaison among ourselves. That was the time when Bangalee nationalism was at its budding stage.
As members of the majority of the population of Pakistan, we saw it the hard way how small our representations had been in the armed forces. Whenever we met, we used to talk about this. Jamil Bhai's sense of nationalism was the strongest among us, and at times he would burst out in anger and desperation."
In 2010, Jamil was promoted posthumously to the rank of Brig General, and awarded the Bir Uttam in recognition of his valour as he was killed trying to save Bangabandhu Sheikh Mujib on the fateful morning of August 15, 1975.
That the recognition was so late in coming is a sign of the polarisation of our country, where even supreme act of courage and sacrifice are seen through the lens of partisanship. For the nation it's a belated reminder of the man's greatness. And it also is a time to reflect on what the actions of this true hero mean to Bangladesh's history in general.
"Jamil's soul will be in peace and I will also die in peace," Jamil's eldest daughter Tehmina Enayet said. "My father was an honest officer. I'm proud that my father sacrificed his life for such a great leader."
Brig Gen Jamil's deeds outlive his mortal existence. He answered his country's call, and did not hesitate to lay down his life in the line of duty. When the nation stood at a crossroads, Brig Gen Jamil displayed the moral courage that marks a great soldier and a true hero.
Enayetullah Khan is Editor-in-Chief, Dhaka Courier and United News of Bangladesh (UNB).
© 2024 - All Rights with The Financial Express


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The research team projects that the Malt Ingredient market size will grow from XXX in 2019 to XXX by 2027, at an estimated CAGR of XX. The base year considered for the study is 2019, and the market size is projected from 2020 to 2027.
The prime objective of this report is to help the user understand the market in terms of its definition, segmentation, market potential, influential trends, and the challenges that the market is facing with 10 major regions and 30 major countries. Deep researches and analysis were done during the preparation of the report. The readers will find this report very helpful in understanding the market in depth. The data and the information regarding the market are taken from reliable sources such as websites, annual reports of the companies, journals, and others and were checked and validated by the industry experts. The facts and data are represented in the report using diagrams, graphs, pie charts, and other pictorial representations. This enhances the visual representation and also helps in understanding the facts much better.
By Market Players:
Malteurop Group
Simpsons Malt
Bairds Malt
Glen Grant
The Malt Miller
Castle Malting
EDME Food Ingredients
BSG Craft Brewing.
By Type
Dried Malt Extract
Liquid Malt Extract
Malt Syrup
Malt Flours
Kibbled Malt/Flakes
Malt Vinegar
By Application
Non-Alcoholic Beverages
By Regions/Countries:
North America
United States
East Asia
South Korea
United Kingdom
South Asia
Southeast Asia
Middle East
Saudi Arabia
South Africa
South America
Points Covered in The Report
The points that are discussed within the report are the major market players that are involved in the market such as market players, raw material suppliers, equipment suppliers, end users, traders, distributors and etc.
The complete profile of the companies is mentioned. And the capacity, production, price, revenue, cost, gross, gross margin, sales volume, sales revenue, consumption, growth rate, import, export, supply, future strategies, and the technological developments that they are making are also included within the report. This report analyzed 12 years data history and forecast.
The growth factors of the market is discussed in detail wherein the different end users of the market are explained in detail.
Data and information by market player, by region, by type, by application and etc, and custom research can be added according to specific requirements.
The report contains the SWOT analysis of the market. Finally, the report contains the conclusion part where the opinions of the industrial experts are included.
Key Reasons to Purchase
To gain insightful analyses of the market and have comprehensive understanding of the global market and its commercial landscape.
Assess the production processes, major issues, and solutions to mitigate the development risk.
To understand the most affecting driving and restraining forces in the market and its impact in the global market.
Learn about the market strategies that are being adopted by leading respective organizations.
To understand the future outlook and prospects for the market.
Besides the standard structure reports, we also provide custom research according to specific requirements.
The report focuses on Global, Top 10 Regions and Top 50 Countries Market Size of Malt Ingredient 2015-2020, and development forecast 2021-2027 including industries, major players/suppliers worldwide and market share by regions, with company and product introduction, position in the market including their market status and development trend by types and applications which will provide its price and profit status, and marketing status & market growth drivers and challenges, with base year as 2019.
Key Indicators Analysed
Market Players & Competitor Analysis: The report covers the key players of the industry including Company Profile, Product Specifications, Production Capacity/Sales, Revenue, Price and Gross Margin 2015-2020 & Sales by Product Types.
Global and Regional Market Analysis: The report includes Global & Regional market status and outlook 2021-2027. Further the report provides break down details about each region & countries covered in the report. Identifying its production, consumption, import & export, sales volume & revenue forecast.
Market Analysis by Product Type: The report covers majority Product Types in the Malt Ingredient Industry, including its product specifications by each key player, volume, sales by Volume and Value (M USD).
Market Analysis by Application Type: Based on the Malt Ingredient Industry and its applications, the market is further sub-segmented into several major Application of its industry. It provides you with the market size, CAGR & forecast by each industry applications.
Market Trends: Market key trends which include Increased Competition and Continuous Innovations.
Opportunities and Drivers: Identifying the Growing Demands and New Technology
Porters Five Force Analysis: The report will provide with the state of competition in industry depending on five basic forces: threat of new entrants, bargaining power of suppliers, bargaining power of buyers, threat of substitute products or services, and existing industry rivalry.
COVID-19 Impact
Report covers Impact of Coronavirus COVID-19: Since the COVID-19 virus outbreak in December 2019, the disease has spread to almost every country around the globe with the World Health Organization declaring it a public health emergency. The global impacts of the coronavirus disease 2019 (COVID-19) are already starting to be felt, and will significantly affect the Malt Ingredient market in 2020. The outbreak of COVID-19 has brought effects on many aspects, like flight cancellations; travel bans and quarantines; restaurants closed; all indoor/outdoor events restricted; over forty countries state of emergency declared; massive slowing of the supply chain; stock market volatility; falling business confidence, growing panic among the population, and uncertainty about future.


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A young female elementary education teacher was giving an assignment to her 6th grade class one day. It was a large assignment so she started writing high up on the chalkboard. Suddenly there was a giggle from one of the boys in the class. She quickly turned and asked, "What's so funny, Pat?"
"I just saw one of your garters!"
"Get out of my classroom," she yells, "I don't want to see you for three days!"
The teacher turns back to the chalkboard. Realizing she had forgotten to title the assignment, she reaches to the very top of the chalkboard. Suddenly there is an even louder giggle from another male student. She quickly turns and asks, "What's so funny, Billy?"
"I just saw both of your garters!"
Again, she yells, "Get out of my classroom! This time the punishment is more severe, I don't want to see you for three weeks!"
Embarrassed and frustrated, she drops the eraser when she turns around again. So she bends over to pick it up. This time there is an burst of laughter from another male student. She quickly turns to see Little Johnny leaving the classroom.
"Where do you think you're going?" she asks.
"From what I just saw, my school days are over!"
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