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The purpose of this review is to highlight recent advances in cochlear gene therapy over the past several years. Cochlear gene therapy has undergone tremendous advances over the past decade. Beginning with some groundbreaking work in 2005 documenting hair cell regeneration using virallymediated delivery of the mouse atonal 1 gene, gene therapy is now being explored as a possible treatment for a variety of causes of hearing loss.
Recent advances in cochlear gene therapy include improved methods of gene delivery with a better delineation of viral vectors that are suitable for this purpose, additional improvements in hair cell regeneration, and directed research towards autoimmune hearing loss, ototoxicity, spiral ganglion survival, and genetic forms of hearing loss.
If successful, cochlear gene therapy will dramatically alter our ability to treat a variety of forms of acquired and genetic hearing loss.
Hearing loss is one of the most common human sensory deficits, affecting over 200 million people worldwide. Acquired forms of hearing loss represent a majority of these cases, including such pathologies as presbycusis, noise-exposure, infection and ototoxicity. Congenital forms of hearing loss occur in approximately 1.5 in 1000 children.(1) Of these, about ½ are attributed to a genetic basis.(2) These genetic forms of hearing loss have been classified based upon associated systemic findings (syndromic forms of hearing loss), and in those with isolated cochlear findings, the mode of inheritance (autosomal dominant-DFNA; autosomal recessive DFNB; x-chromosome linked DFNX; and y-chromosome linked DFNY). Autosomal recessive inheritance dominates non-syndromic modes of hereditary deafness, comprising approximately 80% of all prelingual onset forms.(3) To date, elucidation of the mechanisms of genetic hearing loss has led to some fundamental advances in our understanding of auditory transduction and the critical molecular pathways involved in normal hearing.(4)
While our understanding of the causes of both genetic and acquired forms of sensorineural hearing loss has advanced tremendously over the past 20 years, treatments have advanced little over that same time period, and generally consist of hearing amplification for mild to severe losses, and cochlear implantation for severe to profound losses. There is no question that cochlear implantation has profoundly influenced our treatment of patients with deafness, but there are still significant limitations in function with an implant, and results cannot compare to normal hearing.(5) There thus remains intense interest in restoring normal organ of Corti function through such techniques as gene therapy.(2)
Gene therapy for inner ear disorders has developed along two major lines: hair cell or sensory regeneration and gene therapy for genetic deafness. To date, a majority of the research in this arena has focused on either the methodology of effective cochlear gene transfer or specific applications such as hair cell regeneration.
In order for gene therapy to be effective, the required gene must be appropriately delivered both temporally and spatially. Two methods can be used to drive protein expression in specific cell types: cell-specific promoters and specific viral subtypes. To date, a number of vectors have been tried for cochlear gene delivery. Non-viral vectors, including plasmids alone or packaged within lipids, have the theoretic advantage of reduced toxicity and inflammation associated with virally-mediated gene transfer. Unfortunately, these methods demonstrate low transduction efficiency and poor trans-gene expression patterns, limiting their usefulness.(6, 7) One recent novel approach used nanoparticles to successfully deliver hyperbranched polylysine particles into the rat cochlea.(8) Whether such an approach could be applied to gene delivery remains to be seen, however.
More recent efforts have focused on the use of specific viral subtypes to drive expression in particular cells. To date, adenovirus, adeno-associated virus, herpes simplex virus, vaccinia virus, retrovirus, helper-dependent adenovirus and lentivirus have all tested for cochlear gene delivery.(6) Of these, the one that has demonstrated the most potential is adeno-associated virus (AAV): it is nonreplicating, can efficiently transfer transgenes to the inner ear, and causes no ototoxicity.(6, 9-12) In particular, AAV can effectively transfect inner hair cells, a critical feature if one hopes to correct genetic defects due to hair cell-specific mutations. To date, a number of different AAV subtypes have been used with success for cochlear gene delivery, demonstrating little if any damage to the organ of Corti.(10) (13) A recent report studying AAV serotypes 1, 2, 5, 6 and 8 demonstrated successful gene expression in hair cells, supporting cells, the auditory nerve and spiral ligament, with hair cells being the most effectively transduced.(13) One of the greatest limitations of AAV is the maximum gene insert size of ~5kb, significantly limiting the number of genes that can be transduced.(14)
In contrast to AAV, adenovirus has several advantages for cochlear gene therapy, including larger potential insert size, greatly expanding the number of target genes, and the wide number of cochlear cell types that have been effectively transfected, including stria vascularis, spiral ligament, hair cells and organ of Corti supporting cells.(14) Lentivirus has also been recently suggested as an agent for cochlear gene therapy. One report has demonstrated that lentivirus injected into the rat scala tympani is limited to the cochlea without evidence of spread to the central nervous system, an important feature to minimize toxicity to tissues outside the cochlea.(15).
Advances have also been made with the technique of viral delivery. While a majority of studies describe viral delivery via a cochleostomy or through direct round-window injection, one study has shown that partial enzymatic digestion of the round window membrane with a collagenase solution greatly increases permeability of AAV delivery to the cochlea without causing hearing loss and was healed within 4 weeks.(16)
To date, hair cell regeneration has seen the greatest focus and successes in cochlear gene therapy, largely because it would be applicable to the most common forms of hearing loss, including presbycusis, noise-induced hearing loss, and hearing loss due to infection, trauma and ototoxicity. The most promising work involves studies on the atonal gene product Atoh1 (Math1 in the mouse), that encodes a transcription factor inducing the development of sensory hair cells from supporting cells in the cochlea.(17) Following the initial success reported by Izumikawa and colleagues(18) several studies have now demonstrated regeneration of hair cells with the virally-mediated delivery of Math1 in mice.(19-21) In addition to hair cell regrowth, Izumikawa et al also reported substantial improvement of hearing thresholds in deaf mice, thus demonstrating both cellular and functional rescue of hearing loss.(18) Studies in a mouse model of aminoglycoside vestibulotoxicity have also demonstrated hair cell regeneration and functional vestibular recovery following virally-mediated delivery of Math1.(6, 22, 23) Similar results have also been seen in the rat cochlea.(24)
While Atoh1 gene therapy could be useful for the late effects of aminoglycocide ototoxicity and hair cell death, some investigators are also exploring the possibility of ameliorating the ototoxicity of aminoglycocide at the outset of therapy. A recent study by Zheng et al(25) has shown that AAV2-mediated expression of activity-dependent neurotrophic factor-9 (ADNF-9) in transfected rat neonatal organ of Corti explants prevented hair cell loss induced by the addition of aminoglycocide antibiotics. Further, the authors documented that transfected ADNF-9 in dorsal root ganglia cultures from chicken ADNF-9 protein could promote neuronal survival and neurite outgrowth.
Preservation of spiral ganglion neurons has also been the focus of multiple cochlear gene therapy studies. One study by Wise et al, aiming to prevent spiral ganglion neuronal degeneration as a result of aminoglycocide ototoxicity, used AAV-mediated transfection of the neurotrophins brain derived neurotrophic factor (BDNF) and neurotrophin-3 (NT3), in animals deafened for up to 8 weeks prior to viral delivery.(26) Importantly, the authors demonstrated that viral transfection of cells was possible even after severe degeneration of the organ of Corti, including supporting cells (pillar and Deiters' cells), stria vascularis, spiral ligament, endosteal cells lining the scala compartments and interdental cells in the spiral limbus. Further, the authors documented a significant increase in spiral ganglion survival in the entire basal turn for cochleae that received gene therapy compared to controls, with decreasing spiral ganglion survival with a longer time between deafness and viral delivery, suggesting a 'window of opportunity' in which gene therapy can provide spiral ganglion support. Another study using AAV-mediated delivery of BDNF by Shibata et al.(12) demonstrated that forced expression of BDNF in epithelial or mesothelial cells in deafened guinea pigs induced regrowth of nerve fibers towards the cells that secrete the neurotrophin. Further, the authors demonstrated that this neuronal regeneration was accompanied by a preservation of the spiral ganglion neurons. One additional recent study, using a blast-exposure model of hearing loss in rats, used adenovirus-mediated human β-nerve growth factor (Ad-hNGFβ) gene transfer.(27) The group showed that the ABR threshold shifts in the NGFβ-transfected group were significantly smaller than that of nontransfected controls. Of note, transgene expression did not last beyond 8 weeks in these animals. Lastly the group showed that the number of spiral ganglions in the transfected group was significantly greater than that of the non-transfected controls.
Autoimmune hearing loss has also been the focus of some recent cochlear gene therapy studies. In one experimental model of autoimmune hearing loss in an interleukin-10 (IL-10) deficient mouse, the authors demonstrated that lack of IL-10 led to a more robust autoimmune response in the ear, while IL-10 directly delivered to the cochlea led to hearing improvement.(28)
While the efforts to regenerate or preserve auditory or vestibular sensory neuroepithelium in normal animals using such techniques as Math1 hair cell regeneration are quite important, they still do not address the problem of an underlying causative genetic mutation. In such a scenario, even successfully regenerated hair cells will still be subject to the innate genetic mutation that led to hair cell loss in the first place. Thus, for genetic disorders leading to congenital or early-onset hearing loss, the optimal solution is defective gene replacement. However, rescuing genetic deafness poses much greater challenges than these other forms of cochlear gene therapy. For example, in contrast to hair cell regeneration, where one needs only short-term expression of the appropriate gene(s), for genetic deafness, lifelong expression will be required. This likely accounts for the scant number of publications on gene therapy for genetic deafness.
To date, efforts to restore hearing in genetic types of hearing loss with gene therapy have met with limited, if any success. In one of the few studies to document some successful results, Maeda et al, attempted to restore the hearing loss in a model of Connexin 26-induced deafness using AAV-transduced antisense oligonucleotides for RNA interference (RNAi).(29) In this model, the hearing loss was induced first by introducing the defective gene in a normal animal, and then using RNAi to suppress the defective gene and reverse the hearing loss. According to Maeda et al, types of deafness in which these 'gain-of-function' mutations which would potentially be amenable to such RNAi techniques include DFNA2 (KCNQ4), DFNA3 (GJB2) and DFNA5 (DFNA5).(29) Another study reported that connexin-26 expressed in a bacterial artificial chromosome in a connexin-30 knockout mouse was able to restore hearing in this model. Since connexin-related deafness accounts for a majority of cases of genetic deafness, these results represent promising, though preliminary breakthroughs in this arena.
Beyond connexins, one study by Kesser et al evaluated the potassium channel KCNQ4, defective in the deafness seen in DFNA2, an isolated autosomal dominant form of deafness.(30) The authors demonstrated that adenoviral-mediated delivery of KCNQ4 can transfect cultured human vestibular tissue. To date no functional recovery data has been documented in animal models however.
The cochlea remains an ideal target for gene delivery, given its confined compartments in which the agent can be delivered, with minimal risk to surrounding tissues. To date the most important advances have occurred using virally-mediated delivery of the atonal gene to induce hair cell regeneration, and offers the most immediate promise of clinical application in selected forms of deafness and loss of vestibular function. As gene delivery methods improve, we can expect to see important advances in the treatment of a variety of causes of hearing loss over the coming decade.
We would like to acknowledge the support of Hearing Research, Inc (HRI) and the American Otologic Society.
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The dorsal cochlear nucleus (DCN) is the first neural site of bimodal auditory-somatosensory integration. Previous studies have shown that stimulation of somatosensory pathways results in immediate suppression or enhancement of subsequent acoustically-evoked discharges. In the unimpaired auditory system suppression predominates. However, damage to the auditory input pathway leads to enhancement of excitatory somatosensory inputs to the cochlear nucleus, changing their effects on DCN neurons (Zeng et al., 2009; Shore et al., 2008). Given the well described connection between the somatosensory system and tinnitus in patients we sought to determine if plastic changes in long lasting bimodal somatosensory-auditory processing accompany tinnitus. Here we demonstrate for the first time in vivo long-term effects of somatosensory inputs on acoustically-evoked discharges of DCN neurons in guinea pigs. The effects of trigeminal nucleus stimulation are compared between normal-hearing animals and animals overexposed with narrow band noise and behaviorally tested for tinnitus. The noise exposure resulted in a temporary threshold shift (TTS) in auditory brainstem responses but a persistent increase in spontaneous and sound-evoked DCN unit firing rates and increased steepness of rate-level functions (RLFs). Rate increases were especially prominent in buildup units. The long-term somatosensory enhancement of sound-evoked responses was strengthened while suppressive effects diminished in noise-exposed animals, especially those that developed tinnitus. Damage to the auditory nerve (ANF) is postulated to trigger compensatory long-term synaptic plasticity of somatosensory inputs that might be an important underlying mechanism for tinnitus generation.
In addition to ANF innervation, the DCN receives somatosensory inputs from head, neck, upper body and limbs via the trigeminal and dorsal column systems, which are transmitted by parallel fibers to synapse on fusiform and cartwheel cells (Itoh et al., 1987, Pfaller and Arvidsson, 1988, Shore et al., 2000, Zhou and Shore, 2004, Haenggeli et al., 2005, Zhan et al., 2006). In normal-hearing animals, paired somatosensory and auditory stimulation leads to suppression or enhancement of acoustically-evoked discharges with suppression dominating (Shore, 2005, Shore et al., 2007, Kanold et al., 2011, Koehler et al., 2011). While those studies described the immediate effects of trigeminal and dorsal column stimulation, long-term effects have not been studied in vivo in either normal or noise-damaged systems. Long-term somatosensory effects accumulating over time could be an important factor in tinnitus development. Auditory nerve damage leads to enhancements of somatosensory inputs and their physiological effects in the DCN (Shore et al., 2008, Zeng et al., 2009). Increased glutamatergic somatosensory innervation and increased sensitivity to those inputs after noise damage might be an underlying mechanism for tinnitus development, with tinnitus being a pathological auditory response to enhanced tonic somatosensory inputs. The connection between tinnitus and the somatosensory system is supported by (i) the observation that tinnitus patients can change the loudness and pitch of their tinnitus by somatosensory manipulations such as contractions or compression of the jaw, head, and neck muscles (Pinchoff et al., 1998, Sanchez et al., 2002, Biesinger et al., 2008), (ii) patients can develop tinnitus after somatosensory insults such as tooth abscess, whiplash, and TMJD (Rubinstein et al., 1990, Eggermont, 2005, Levine et al., 2007). Extensive auditory-somatosensory crossmodal interactions are also suggested by the observation that in normal people, auditory sensations can be evoked by contractions of the jaw, head, and neck muscles (Levine et al., 2003).
Here we studied immediate and long-term effects of somatosensory modulation of sound-evoked discharges in DCN neurons in vivo in control and noise-exposed guinea pigs. Results of a behavioral tinnitus test (Turner et al., 2006) were correlated with changes in somatosensory modulation. A comparison between animals with and without tinnitus was made to reveal changes in auditory-somatosensory processing as a neuronal correlate and possible underlying cause for tinnitus development. Noise exposure resulted in a TTS in auditory brainstem responses (ABRs), but long-term increases in spontaneous and sound-evoked DCN unit firing rates and steeper RLFs, which were especially prominent in buildup units of tinnitus animals. After paired somatosensory-auditory stimulation, the somatosensory enhancement/suppression of tone-evoked responses is long-term, persisting for up to 135 minutes (the longest interval tested). In the noise-exposed animals somatosensory enhancement was strengthened and more units showed enhancement. Chopper as well as buildup units in tinnitus animals showed a strong dominance of long-term enhancement over suppression by somatosensory inputs. This leads to a model of tinnitus development, in which increased excitatory somatosensory influence is triggered by central adjustments to acoustic trauma compensating for the loss of ANF input. The resulting plastic changes persist after hearing threshold recovers. Reverting or counter acting plastic changes in the somatosensory pathways might be an important factor for successful tinnitus therapies.
Male pigmented guinea pigs from Cady Ridge Farms (300 g at study onset; Chelmsford, MA, USA) were used in this study. All procedures were performed in accordance with the National Institutes of Health (NIH) Guidelines for the Use and Care of Laboratory Animals (NIH publication No. 80–23) and guidelines provided by the University Committee on Use and Care of Animals of the University of Michigan. Of the 20 animals used for DCN recordings, 11 were noise-exposed and 9 non-exposed controls. Eleven animals were tested behaviorally for tinnitus (7 noise-exposed and 4 sham-exposed control animals). The numbers of animals contributing to each analysis are indicated in the figure legends.
The gap detection test for tinnitus previously developed for rats (Turner et al., 2006) uses the acoustic startle response elicited by loud pulses and its suppression by preceding sub-startling prepulses, here gaps in noise bands. It is assumed that ongoing tinnitus masks the gap and results in impaired gap detection (Fig. 1). The gap detection testing was performed using a Kinder Behavioral Testing System (Poway, CA, USA). Testing chambers were placed within a single-walled sound-proofed booth. Oscillograms of the gap-in-background noise bands and their spectra were examined for reverberations, harmonics and frequency-specificity. The signal spectra outside the gap-carrier/noise pulse bands were between 19 dB SPL and 24 dB SPL for each of the frequency bands of the gap-carrier/noise pulses (4–6 kHz: 19 dB SPL, 8–10 kHz and 12–14 kHz: 23 dB SPL, 16–18 kHz: 24 dB SPL). Gap-carrier/noise pulse bands and startle pulses were calibrated with a microphone (B&K ¼ inch 4136), spectrum analyzer (SR760, Stanford Research Systems) and guinea pig cloth model inside the testing cage. A 15 ms gap (excluding 5 ms offset/onset ramps) was embedded in four different 2 kHz gap-carrier bands (4–6 kHz, 8–10 kHz, 12–14 kHz, 16–18 kHz) at 70 dB SPL. The startle pulse (115 dB SPL, BBN, 20 ms) followed the onset of the gap by 100 ms. Inter-stimulus trial time (without gap-carrier presentation) was varied pseudo randomly (from 0 to 5 seconds) to prevent anticipation of the startle and interval-based habituation. Detection of the gap results in a reduction in the startle amplitude; development of tinnitus in a specific frequency band impairs gap detection in the corresponding gap-carrier band and thus the startle amplitude reaches amplitudes elicited without the gap (Turner et al., 2006). Animals with normalized startle values (i.e., startle with gap / startle without gap) close to 1 after the noise exposure were grouped together as animals with tinnitus (normalized startles for 8–10 kHz: 0.98 up to 1.46 compared to values between 0.41 and 0.81 for the other animals; Fig. 4A). The startles of the noise-exposed group were compared to those of a sham-exposed control group. In addition to the gap detection test, animals were also tested with a noise pulse-PPI test, in which the startle pulse is preceded by a noise pulse at 70 dB SPL instead of the gap; with the same timing as the gap and the same frequency-composition as the gap carrier (Fig. 4B). Normal noise pulse detection validates that hearing loss is not the cause for diminished gap- PPI (Yang et al., 2007, Turner and Parrish, 2008). Behavioral testing was done twice a week and continued for the time between the two noise exposures.
The noise exposure was performed under anesthesia (14 mg/kg body weight Xylazine, AnaSed Injection, Akorn Inc., Decatur, IL, USA and 110 mg/kg Ketamine, Hospira Inc., Lake Forest, IL, USA; additional dose 4 mg/kg Xylazine and 13 mg/kg Ketamine). Body temperature was kept constant using a temperature-controlled heating pad. The left ear was exposed for two hours while the right ear was plugged with moldable silicon ear plugs. After the recovery of ABR thresholds, two weeks later, a second noise exposure was performed also leading to TTS. The repeated noise exposure was used to increase the incidence of tinnitus. The speaker (Beyer DT 48) was enclosed in a custom-made housing attached to a 3 cm silicon tube, which ended in a cone-shaped plastic tip that was inserted 2 mm tightly into the ear canal. The noise was generated with digital signal processing hardware (TDT, Alachua, FL, USA) and Matlab and calibrated by inserting the plastic tip into a tube attached to a B&K ¼ inch microphone (4136) and spectrum analyzer (SR760 Stanford Research Systems). The noise (Fig. 3) had a 7 kHz center frequency (maximum set to the geometrical mean) and 1/4 octave bandwidth (6.4–7.6 kHz) with a RMS level of 97 dB SPL. Pilot experiments in a separate group of animals showed no influence of the noise on the other ear.
Prior to ABRs all animals were routinely injected IM with an antibacterial solution to prevent infections (enrofloxacin, 10 mg/kg body weight, Baytril, Bayer, KS, USA). After the ABRs they were injected with 10 ml saline and treated with antibacterial eardrops (ofloxacin, 0.3%, Floxin Otic, Daiichi Sankyo Inc., Edison, NJ, USA). ABRs were collected using BioSigRP software and RX5/RA4LI hardware (TDT, Alachua, FL, USA). The speaker (Beyer DT 48) calibration and acoustic stimulation were performed with SigGenRP software and RX8/PA5 hardware (TDT, Alachua, FL, USA). The speaker was coupled to the animals' ear canal via a 2 cm plastic tube inserted into the ear canal. ABRs were recorded immediately before (left ear) and after the noise exposure (left and right ears). ABRs after the exposures were performed weekly on days following the behavioral testing (Tuesdays or Fridays) under anesthesia (5 or 10 mg/kg body weight Xylazine and 20 or 40 mg/kg body weight Ketamine). Body temperature was kept constant with a temperature controlled heating pad. Sanded 0.6 mm * 25 mm injection needles placed subdermally at vertex and on left and right masseter muscles were used for recording, grounding and reference electrodes. ABRs were recorded for 10 ms tone pips (2 ms ramp, 11 stimuli / sec; frequencies 4 – 16 kHz) starting at 90 dB SPL and decremented in 10 dB steps. Each level was repeated 250 times and the lower levels around threshold were rerun to record a second set of 250 presentations. ABR waveforms were visually inspected across levels; threshold was the lowest level of sound that resulted in one or more of the ABR waves being distinguishable by eye from the background noise. The second set of repetitions for the low levels was checked for consistency of the waveforms.
DCN recordings were performed 10 to 21 days (average 16 days) after the second noise exposure. Animals were anesthetized with Ketamine (40 mg/kg) and Xylazine (10mg/kg) and placed in a stereotaxic frame with hollow ear bars connected to the speakers (Beyer DT770pro). Following bilateral ABR recordings, a craniotomy and partial aspiration of the cerebellum overlying the DCN was performed to allow visual placement of the probes (4 shank/16 channel silicon, 177 μm2 sites, pitch 100 μm, Neuronexus, Ann Arbor, Michigan, USA) between 300 and 500 μm below the DCN surface. Stimulation and multiunit recordings were achieved using OpenEx software (TDT, Alachua, FL, USA), which controlled RX8 DSP and RX5 respectively. Thresholds and center frequencies (CFs) were determined online (OpenExplorer, TDT) from a receptive field generated from 10 repetitions of a 50 ms duration tone (200 ms stimulation period) at each frequency-level condition (0.1 octave steps between 100 Hz and 36 kHz, 5 dB steps 0 to 85 dB SPL). Rate level functions (RLFs) were generated for 50 repetitions of each 5 dB step. To assess immediate effects of bimodal stimulation, a tone RLF (a series of toneburst stimuli between 0 and 85 dB) was immediately followed by a bimodal RLF (electric Sp5 stimulation preceding each tone stimulus by 20 ms). To assess long-term effects, a tone RLF was followed by a bimodal RLF and then tone RLFs were subsequently repeated for up to 135 min (the longest time interval tested, minimum time interval 15 minutes, mean 35 minutes; Fig. 2). In some animals, RLFs were recorded before and after Sp5 stimulation alone to obtain control data (not shown) that indicated that the long-term effect was due to paired stimulation and not Sp5 stimulation alone. Post stimulus time histogram (PSTH) type was determined from the tone RLFs 20 – 40 dB above threshold and then averaged across units of all animals and within the groups of control, tinnitus and no-tinnitus animals.
The caudal and intermediate regions of Sp5 were electrically stimulated with a custom-made isolated high-voltage current source via concentric bipolar electrodes (FHC, Bowdoin, Maine, USA) placed stereotaxically (Koehler et al., 2011). The electrical stimulus at 60 μA preceded the tone stimulus by 20 ms and consisted of 2 biphasic square pulses, 100 μs per phase, with the negative phase first, 1000 Hz pulse frequency. The stimulating probe was dipped in Fluoro Gold prior to insertion. After the experiment current was passed through the stimulation probe and one site of the recording probe to create lesions and to transport the Fluoro Gold into the tissue. The animals were euthanized, decapitated and the head fixed in paraformaldehyde for 4 days. The brain was removed from the skull, fixed overnight, immersed in sucrose solution and then cryosectioned (100 μm thickness). Slices were stained with neutral red and the lesions and Fluoro Gold marks observed with light and fluorescent microscopy.
Waveforms were sorted using principle component and cluster analysis of the waveform shape (OpenSorter, TDT, Alachua, FL, USA). K-means clustering with a fixed variance (95%) and maximum of 5 clusters was used. Data from the respective recording sites was excluded if the shape and size of each cluster and average waveform across the recordings were not consistent. Responses were analyzed for the time window of the tone presentation. Electrical artifacts and ringing that occurred after the current pulses were not included in this time window.
To quantify the immediate and long-term effects of bimodal stimulation the mean rate differences across tone levels were calculated A) (i) between a tone RLF and an immediately subsequent bimodal RLF ("immediate" effect of bimodal stimulation) and (ii) between the first tone RLF and a second tone RLF on average 35 min after the bimodal stimulation ("long-term"). Data points (number of units * sound levels of RLFs) were grouped into rate-enhancement (white graphs; first tone response < bimodal response (i) or first tone response < later tone response (ii)) and rate-suppression (black graphs; first tone response > bimodal response (i) or first tone response > later tone response (ii)). The data was collapsed across tone level to form pie charts showing the number of data points with enhancement or suppression and the sum of rate changes of all data points (magnitude of rate change summed across units and all sound levels). Arrows and stars in the rate difference plots indicate the results of linear mixed model statistics comparing all observed rate differences of a group (either immediate or long-term effects of animals in the control, noise-exposed, tinnitus or no-tinnitus groups). Each unit is treated as a subject with two difference-RLFs (immediate and long-term): (i) comparison of noise-exposed (or tinnitus and no-tinnitus) versus control animals' data for within immediate rate differences or long-term rate differences. Random intercept for each unit, repeated factor is "sound level of the RLF". (ii) comparison of immediate versus long-term rate differences of control animals' data, noise-exposed animals' data, tinnitus animals' data or no-tinnitus animals' data. Random intercept for each unit, repeated factor is "immediate and long-term" and "sound level of the RLF". Pair wise comparison of immediate versus long-term or control versus exposed, tinnitus or no-tinnitus was done across all sound levels (significances labeled with stars), adjustment for multiple comparisons: Sidak, critical level p<0.05.
Data analysis, statistics and plotting were performed with OpenExplorer (TDT, Alachua, Florida, USA), SPSS (Version 17, SPSS Inc., Chicago, Illinois, USA) and SigmaPlot (Version 11.0, Systat Software Inc., San Jose, California, USA).
Over-exposure with a narrow band noise centered at 7 kHz resulted in an immediate ABR threshold shift between 6 and 16 kHz with a maximum of 50 dB mean threshold shift at 8 kHz (Fig. 3; mean of individual animal's ABR differences before versus immediately after the exposure; non-directional one-sample t-test against a mean threshold shift of 0 dB for each test frequency, df=9, minimum p<0.001, maximum p=0.002). Four out of the seven animals developed tinnitus for frequencies between 8 and 18 kHz by the time of recovery of ABR thresholds from the second exposure (Fig.4). The normalized startles of these "tinnitus" animals were increased towards or above one; and were maximal in the 8–10 kHz band. The "no-tinnitus" animals had decreased normalized startles in the gap and noise pulse test. Stars in Fig. 4 mark significance in two-way repeated measures ANOVA on ranks within one frequency of absolute startle data (with gap or noise pulse versus without gap or noise pulse, one mean value across trials of four days per animal). Factors are group ("control, tinnitus, no-tinnitus") and trial (repeated within subject factor "gap or no gap" and "prepulse or no prepulse"), post-hoc all pairwise multiple comparisons with Holm-Sidak, df=1, minimum p<0.001, maximum p=0.04.
Although the ABR thresholds had recovered by the time the DCN recordings were made (average 16 days after the second exposure, 10 to 21 days, mean of individual animal's ABR differences before versus at the day of DCN recording; non-directional one-sample t-test against a mean threshold shift of 0 dB for each test frequency, df=10, minimum p=0.111, maximum p=0.796), spontaneous rates (SR) were significantly elevated in noise-exposed animals compared to control animals for units with CFs between 4 and 10 kHz (Fig. 3). Pair wise comparisons were made between the SR of noise-exposed and control animals with ANOVA (red crosses in Fig. 3), between subject effects "group noise-exposed or control" and "CF-bin" and interaction between both, adjustment for multiple pairwise comparisons within 9 CF bins: Holm-Sidak, corrected total df=430, for CFs 4–10kHz: minimum p=0.029, maximum p=0.039.
Moreover, supra threshold discharge rates were elevated for tone levels up to 85 dB and CFs up to 16 kHz (Fig. 5). This resulted in steeper RLFs for the noise-exposed animals especially for tones above CF (Fig. 6). The difference was significant at all levels above CF, between 45 up to 85 dB at CF and 55 up to 85 dB below CF (ANOVA, between subject effects "noise-exposed or control" and "dB level" and interaction between both, adjustment for multiple pairwise comparisons at 18 dB levels: Holm-Sidak; above CF: corrected total df=5695, for 0 to 85 dB: minimum p=0.000, maximum p=0.003; at CF: corrected total df=2843, for 45 to 85 dB: minimum p=0.001, maximum p=0.039; below CF: corrected total df=4239, for 55 to 85 dB: minimum p=0.000, maximum p=0.033).
To explore changes in auditory-somatosensory integration in the DCN after cochlear damage, rate differences between tone-evoked responses before, during and after bimodal stimulation (trigeminal pulse preceding tone stimulation) were compared for noise-exposed and control animals (top and bottom row, Fig. 7 A, B, C). This comparison was done for the immediate and long-term rate differences (left and right column charts, Fig. 7 A, B, C).
The immediate mean enhancement and suppression are larger after noise exposure (Fig. 7 A, left column graphs). This, together with the larger number of data points with enhancement in the noise-exposed animals compared to the control animals (Fig. 7 B, left column pie charts), results in a greater bimodal enhancement in the noise-exposed group compared to the control animals (Fig. 7 C, left column pie charts). Comparing the immediate and long-term rate differences reveals a further increase in mean enhancement in the noise-exposed animals and in contrast, an increase in enhancement and especially suppression for the control animals (compare left versus right column graphs in Fig. 7 A). At the same time the number of data points with long-term enhancement is only slightly smaller than the number of data points for the immediate rate differences in the noise-exposed animals (Fig. 7 B, top row pie charts) while the number of data points showing suppression increases in the control animals (Fig. 7 B, bottom row pie charts). This opposite shift of enhancement and suppression between the noise-exposed and control animals from the immediate to the long-term effects results in a dominant long-term enhancement in noise-exposed animals, contrasting with a dominant long-term suppression in control animals (Fig. 7 C, right column; Fig. 7 A: significant difference of the long-term effect between noise-exposed vs. control indicated with arrow and star; linear mixed model statistics, details see methods/data analysis, adjustment for pairwise multiple comparisons: Sidak, df=140.942, p=0.000).
To assess the role of somatosensory-auditory integration in tinnitus, comparisons were made between the control animals and noise-exposed animals that developed tinnitus or did not develop tinnitus (Fig. 8). The mean immediate rate differences for the tinnitus group were the same as those of the control animals (Fig. 8 A, left column), whereas the no-tinnitus group showed larger enhancement as well as larger suppression exceeding the effect of the noise exposure shown in Fig. 7 A. The group of tinnitus animals stands out in terms of its long-term bimodal effect: comparing the immediate and long-term rate differences reveals an increase in enhancement over time in the tinnitus group (Fig. 8 A, bottom row). This results in a significant difference between the immediate and long-term data for the tinnitus group across sound levels (Fig. 8 A: significance of linear mixed model statistics indicated with arrow and star, details see methods/data analysis, adjustment for multiple pairwise comparisons: Sidak, df=943.340, p=0.000). This shift from the immediate to the long-term rate differences raises the mean rate enhancement for the tinnitus group above the level of enhancement for the control animals, resulting in a significant difference between the animals with tinnitus and the control animals of the long term rate differences across level (Fig. 8 A, compare bottom with middle row graphs; significance of linear mixed model statistics indicated with arrow and star, adjustment for multiple pairwise comparisons: Sidak, df=104.295, p=0.000). The increase in mean enhancement (Fig. 8 A, bottom row) together with an increase in the number of data points with enhancement (Fig. 8 B, bottom row pie charts) results in a dominant long-term enhancement in the tinnitus group (Fig.8 C, bottom pie charts). In contrast, the no-tinnitus group is characterized by a decrease in the mean suppression and smaller increase in the mean enhancement (Fig. 8 A, top row graphs: significance of linear mixed model statistics is indicated with arrow and star, details see methods/data analysis, adjustment for multiple pairwise comparisons: Sidak, df=1186.949, p=0.000). The control group shows an increase in suppression and enhancement (Fig. 8 A, middle row graphs). Moreover, the control animals and no-tinnitus animals show a decreased number of data points with enhancement and an increased number of data points with suppression (Fig. 8 B top and middle row pie charts) contrasting with the group of tinnitus animals, which shows an increased number of data points with rate enhancement. Together, these effects result in a clear dominance of long-term somatosensory (bimodal) enhancement in the animals with tinnitus in contrast to control animals and exposed no-tinnitus animals (Fig. 8 B: significant differences between the animal groups' long term rate differences in linear mixed model statistics indicated with arrows and stars, details see methods/data analysis, adjustment for multiple pairwise comparisons: Sidak, tinnitus vs. control: df=104.295, p=0.000; tinnitus vs. no-tinnitus: df=104.295, p=0.036).
Units were categorized based on the temporal response patterns at different sound levels. The two major response types were buildup and chopper (Fig. 9). In the tinnitus group, buildup units' spontaneous and tone-evoked rates were increased compared to control animals and no-tinnitus animals (Fig. 10, ,11).11). The increase was significant between 25 and 85 dB (Fig. 11, ANOVA, between subject effects "tinnitus, no-tinnitus, control" and "dB level" and interaction between both, adjustment for multiple pairwise comparisons at 18 dB levels: Sidak, corrected total df=596, control vs. tinnitus, 25 to 85 dB: minimum p=0.000, maximum p=0.044). This rate increase affected the onset and buildup portion of the response and prolonged the response-duration (Fig. 11B). Buildup units of the no-tinnitus animals were not different from the control group. In contrast to buildup units, chopper units of tinnitus and no-tinnitus animals did not show increased SR (Fig. 10, ANOVA, between subject effects "tinnitus, no-tinnitus, control" and "response type" and interaction between both, adjustment for pairwise multiple comparisons: Sidak, corrected total df=112; buildup control vs. buildup tinnitus: p=0.026; buildup no-tinnitus vs. buildup tinnitus: p=0.005). In chopper units the increase of sound-evoked rates in no-tinnitus animals were significantly different from the control animals only at 40 and 45 dB (Fig. 12, ANOVA, between subject effects "tinnitus, no-tinnitus, control" and "dB level" and interaction between both, adjustment for multiple pairwise comparisons at 18 dB levels: Sidak, corrected total df=1025; control vs. no-tinnitus, 40 dB: p=0.045, 45 dB: p=0.035). In the tinnitus group, the long-term somatosensory (bimodal) influence on buildup units as well as chopper units (Figs.13 and and14)14) was predominantly enhancing. Buildup units of the control and no-tinnitus animals showed predominantly suppressive long-term effects (Fig. 13). Chopper units in control animals showed predominantly suppressive long-term effects, whereas the chopper units in no-tinnitus animals showed more balanced enhancement and suppression (Fig. 14). Although the low number of units did not allow a statistical analysis within single response types and behavioral/noise exposure groups, the long-term somatosensory effects of buildup and chopper units (Figs. 13 and and14)14) were similar to each other. In both response types somatosensory (bimodal) enhancement predominated in animals with tinnitus. This similarity exists despite the different behavior of the tone and spontaneous responses, which are only increased in buildup units (Figs. 10, ,11,11, ,1212).
This study is the first to investigate long term effects of somatosensory-auditory processing in vivo and its plasticity after temporary noise-induced threshold shift. Long-term somatosensory effects shifted from dominant suppression in normal animals to enhancement in animals with tinnitus. This shift might explain the close connection between tinnitus and the somatosensory system and highlights the importance to incorporate the somatosensory system into tinnitus treatment strategies.
Narrow band noise exposure resulted in behavioral evidence of tinnitus in the 8–18 kHz bands with a maximum effect at 8–10 kHz. This correlates well with the TTS between 6 and 16 kHz with a maximum at 8 and 9 kHz and is consistent with studies showing the tinnitus spectrum overlapping the hearing loss region (Lockwood et al., 2002, Norena et al., 2002, Eggermont and Roberts, 2004, Roberts et al., 2006, Schaette and Kempter, 2009). The maximum TTS shifted 0.2–0.3 octaves extending to frequencies above 10 kHz. Elevated ABRs at and above the exposure frequency are commonly observed after acoustic trauma (Brozoski et al., 2002, Kujawa and Liberman, 2009, Mulders et al., 2011, Vogler et al., 2011).
The present study is the first to correlate the frequency profile of elevated SR with the tinnitus frequency after TTS. Although increased SR resided within the noise exposure band it was skewed to frequencies below the ABR threshold elevations. This agrees with shifts in the noise-induced SR elevation of DCN neurons over time from frequencies below the exposure frequency to higher frequency regions (Kaltenbach et al., 2000). Our data shows that tinnitus resides in bands at and above the maximum TTS and argues against the view that neurons with elevated SR reside precisely in CF regions of the tinnitus pitch (Kaltenbach et al., 2004).
Although ABRs had recovered by the time of neural recordings, DCN responses showed persistent increases in SRs and steeper tone RLFs across the DCN unit population. The increased spontaneous and suprathreshold firing rates were observed in buildup units in tinnitus animals. This corroborates previous results for pauser buildup and wide chopper units (Brozoski et al., 2002). In contrast, the chopper type in our study, which is comparable to choppers shown in (Stabler et al., 1996), did not show increased spontaneous and suprathreshold rates. In contrast to the steeper RLFs shown here after TTS, ANF RLFs were shallower after TTS (Kujawa and Liberman, 2009). While the shallower ANF slopes may be due to deficient hair cell-ANF synapses, the steeper DCN RLFs likely reflect central plasticity to counteract the reduced ANF inputs (Cai et al., 2009, Schaette and Kempter, 2009, Norena, 2011). Down regulation of inhibitory inputs accompanying tinnitus after auditory insults (Wang et al., 2009, Middleton et al., 2011) would further counteract the reduced ANF input; reduction in sideband inhibition could explain the larger increase in suprathreshold response-rates above CF found in our study.
The increase in tone-evoked responses across frequency regions after TTS might point to hyperacusis, which in humans affects all frequencies (Anari et al., 1999, Schaaf et al., 2003). Hyperacusis would likely result in decreased normalized startles as the gap carrier and noise-pulse are both well above hearing threshold. In addition it would increase the absolute startle in the absence of a preceding gap/noise pulse (Sun et al., 2009) as demonstrated by the no-tinnitus group in our study (Fig. 4). Tinnitus and hyperacusis often co-occur (Anari et al., 1999, Schaaf et al., 2003, Nelson and Chen, 2004, Dauman and Bouscau-Faure, 2005). If co-occuring in the no-tinnitus group, their effects on normalized startle responses in the gap-PPI test could counteract each other, with tinnitus increasing and hyperacusis decreasing the normalized startle.
Whereas the immediate effects of trigeminal and dorsal column stimulation have been described previously (Shore, 2005, Shore et al., 2007, Kanold et al., 2011, Koehler et al., 2011) long-term effects have not been studied in vivo. In the present study, bimodal enhancement or suppression of sound-driven responses was investigated ~ 35 min after repeated auditory-somatosensory stimulation. This timeframe is similar to that of long-term depression and potentiation (LTD/LTP) at the parallel fiber-cartwheel/fusiform cell synapses in vitro (Fujino and Oertel, 2003, Tzounopoulos et al., 2004, Tzounopoulos et al., 2007, Zhao et al., 2011). Although LTP/LTD was not shown at the auditory nerve-fusiform synapses (Fujino and Oertel, 2003, Zhao et al., 2011), several mechanisms could explain the long-term bimodal effects on auditory responses as consequences of long-term synaptic plasticity at the parallel fiber synapses. Assuming that spontaneously active parallel fibers regulate fusiform and cartwheel cell excitability, long-term plasticity at the parallel fiber synapses would modify the excitability of the cells and hence change their auditory responses. Moreover, changes in postsynaptic excitability as consequences or co-effects of LTP/LTD and the spread of LTP/LTD to neighboring synapses (Yang and Poo, 2006, Doiron et al., 2011) might also result in the long-term bimodal effects seen in our study. In cerebellar-like circuits LTP/LTD modifies parallel fiber input, thereby canceling expected sensory input (Oertel and Young, 2004, Bell et al., 2008). Plasticity of the parallel fiber input results in a "negative image", which is the inverse of the expected sensory input. In electrosensory systems the negative image can be stored for at least 38 min or until a changing parallel fiber input further modifies the negative image (Bell, 1986, 2001). The capability of cerebellar-like systems to store and retrieve effects of parallel fiber inputs' plasticity to create negative images might underlie the lasting effect of the bimodal stimulation on the acoustically evoked responses. However in vivo studies of synaptic plasticity are necessary to investigate plasticity and memory functions in the DCN.
In contrast to control animals, which showed predominant bimodal suppression, long-term bimodal enhancement predominated after noise exposure, was especially prominent in tinnitus animals, and was observed in chopper as well as buildup units. Predominant bimodal suppression in control animals is consistent with one proposed function of the somatosensory inputs, to suppress responses to self-generated inputs (Bell et al., 1997). The predominant bimodal enhancement after noise exposure points to plastic changes affecting somatosensory inputs to the DCN, which might result in tinnitus development: Strengthening of excitatory, somatosensory inputs or increasing the sensitivity to those inputs could reflect homeostatic plasticity of multisensory DCN neurons restoring normal discharge activity (Kaltenbach et al., 2005, Schaette and Kempter, 2009, Zeng et al., 2009, Norena, 2011) after reduction of ANF input (Kujawa and Liberman, 2009). The differential expression of distinct vesicular glutamate transporters (VGLUTs) in ANF and somatosensory terminals allows for examining this theory. Whereas ANF synapses in the deep layer of DCN express VGLUT1, non-auditory, glutamatergic inputs from cuneate and Sp5 nuclei in the granule cell domain express VGLUT2 (Zhou et al., 2007, Zeng et al., 2009, Zeng et al., 2011). Two weeks after unilateral cochlear damage, VGLUT2 immunoreactivity was upregulated and VGLUT1 downregulated in the ipsilateral cochlear nucleus (Zeng et al., 2009). Upregulation of somatosensory inputs to granule cells, which innervate fusiform cells, could explain the increased bimodal enhancement after noise exposure. Interestingly, animal models of neuropathic pain and epilepsy, both characterized by hyperexcitability, show increased VGLUT2 expression (Wallen-Mackenzie et al., 2010), suggesting that upregulation of VGLUT2 expression in auditory centers might lead to hyperexcitability underlying tinnitus. Indeed, increased responsiveness to somatosensory stimulation was demonstrated after broad-band noise exposure and permanent threshold shifts: thresholds and latencies to trigeminal ganglion stimulation were decreased and the response amplitudes increased (Shore et al., 2008). These findings are paralleled by heightened responses to somatosensory stimulation in tinnitus patients demonstrated by fMRI (Lanting et al., 2010). Increased excitatory somatosensory drive to DCN neurons could explain why loudness and pitch of tinnitus can be changed by somatosensory stimulation in the face, head and neck regions (Pinchoff et al., 1998, Levine, 1999). If the tinnitus percept is produced by a specific group of neurons with increased sensitivity to somatosensory inputs, somatosensory stimulation would change the response properties of those specific neurons, thereby changing the tinnitus percept.
The shift towards bimodal enhancement occurred in both buildup and chopper units, suggesting an enhancement of somatosensory input across unit types. In contrast, the increases in tone-evoked responses and spontaneous activity were only observed in buildup units. This could be explained by differences in the initial membrane potentials of these two unit types (Kanold and Manis, 1999), leading to differential effects of enhanced somatosensory inputs (Zeng et al., 2009) on sound-driven activity.
An increase in somatosensory-evoked DCN discharges after noise exposure (Shore et al., 2008) should also change the relative timing between presynaptic parallel fiber discharges and postsynaptic discharges of fusiform cells. A higher rate of shorter time delays between pre- and postsynatic events is likely to induce plasticity at the parallel fiber-fusiform cell synapse, which depends on the specific timing between and frequency of pairings of pre- and postsynaptic events (Fujino and Oertel, 2003, Tzounopoulos et al., 2004, Tzounopoulos et al., 2007). This, in addition to upregulation of VGLUT2 positive syapses, might explain the shift towards bimodal enhancement after noise exposure.
We are grateful to Chris Ellinger and Dwayne Vailliencort for technical assistance with the startle and recording setup. We would like to thank Malav Parikh and Kevin Anderson for their invaluable help with data analysis and Ben Yates for excellent graphic assistance. We thank Jeremy Turner for valuable discussions and comments on the manuscript. The work was supported by NIH R01DC004825 and P01DC00078 and the Tinnitus Research Initiative.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's Canada Institute for Scientific and Technical Information in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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Movie Date is a weekly podcast produced by The Takeaway in cooperation with Public Radio International and WNYC. It's hosted by Takeaway culture producer Kristen Meinzer and Newsday film critic Rafer Guzman.
Each podcast includes movie reviews, trivia, listener mail, and lots of banter.
Occasionally, celebrities like Scarlett Johansson, James Franco, Clive Owen, and Joss Whedon stop by, as do experts from the worlds of male stripping, zombie studies, ghost hunting, and tribute bands.
For listeners who prefer not to get dressed and leave the house in order to be entertained, Rafer and Kristen also offer weekly Sweatpants picks.
And at least once a month, Rafer and Kristen administer Movie Therapy (listeners write and call in seeking help with their life issues; Rafer and Kristen respond with a prescription of movies to help them through what ails them).
As co-hosts of the podcast, Rafer and Kristen appear live on The Takeaway every Friday; and on Soundcheck, BK Live, and the New York broadcast of All Things Considered several times a year. They've also appeared on The Brian Lehrer Show and Uptown Radio.
Movie Date has been written up by the Wall Street Journal, WomenInPodcasting.org, Babes of NPR, and other notable publications. It's been selected twice as the iTunes podcast of the day and was ranked by Stitcher as one of the top four podcasts covering The Hunger Games.
Subscribe to the Movie Date podcast, like Movie Date on Facebook, follow Kristen on Twitter, and leave a message for Rafer and Kristen anytime at 571-7MOVIES (571-766-8437).
You can also listen on-demand through Stitcher.
This week's Movie Date podcast is arriving a few days late, as Kristen was dedicating all of last week's working hours to covering the news in Boston. But it's still packed with Rafer and Kristen freshness! On the chopping block: "The Company You Keep," a thriller about what happens when radical terrorists hit middle age; and "Oblivion," a sci-fi adventure about what happens when Tom Cruise refuses to mature beyond his "Top Gun" years. Thanks for your patience, Movie Daters!
In this week's Movie Date podcast, Rafer and Kristen debate whether the new movie "42" is the story of Jackie Robinson, the story of the integration of baseball, or another story all together. They also discuss the new film, "The Place Beyond the Pines," which stars Ryan Gosling, Eva Mendes, and Bradley Cooper as a bunch of sad people living extremely sad lives. Guess which one made Kristen cry? And guess which one helped Rafer teach his son an important lesson?
In this week's Movie Date podcast, Rafer and Kristen look at three very different stories of survival, one of which is a reboot ("Jurassic Park 3D"), one of which is a remake ("Evil Dead"), and one of which is a serious documentary ("No Place on Earth").
This week's Movie Date podcast explores the complexities of "G.I. Joe: Retaliation," the cultural implications of "The Host," the role of geometry in romantic entanglements, and the race of ninjas in ancient Japan. Along the way, Rafer and Kristen ask: What the hell is going on at this moment on screen? Is that a good guy or bad guy? And can I make out during this film?
In this week's Movie Date podcast, Rafer points out a certain animated character's skimpy clothing, Kristen admits to more than Rafer can handle, and both of them sing the praises of Olivia Newton-John. It's all in honor of this weekend's big releases: "Admission," "The Croods," and "Olympus Has Fallen."
In this week's Movie Date podcast, Rafer confesses to being a magic nerd, Kristen talks about girl-on-girl action, Rafer admits to liking big beds, and Kristen uses some barnyard language. It's all in honor of "The Call," "The Incredible Burt Wonderstone," "Ginger and Rosa," and "Spring Breakers.
In this week's Movie Date podcast, Rafer and Kristen review "Dead Man Down," "Emperor," and "Oz: The Great and Powerful." Along the way, they contemplate the power of Tyler Perry, the scariness of The Incredible Hulk, and the style choices of Joan Crawford. A warning: this week's trivia question refers to a certain college past time involving marijuana, "The Wizard of Oz," and Pink Floyd.
In this week's Movie Date podcast, Rafer and Kristen are joined by Jeff Yang, who writes the Wall Street Journal's Tao Jones column. Jeff shares his thoughts on the new movie, "21 and Over" - from its depiction of race, to whether it's just a cheap mash-up of "Weekend at Bernie's" and "The Hangover." Along the way, Rafer admits he doesn't remember his twenty first birthday, Kristen falls asleep, and Jeff clarifies that he's not really Jackie Chan (even though he wrote a book called, "I Am Jackie Chan"). Other films discussed in this podcast include the Cold War thriller, "Phantom" and the fairy tale reboot "Jack the Giant Slayer."
In this week's Movie Date podcast, Rafer and Kristen's bickering isn't restricted to the online world. Instead, it's made available to radio listeners all over the country. It's their first hour-long special for the airwaves, and it's all in honor of Hollywood's biggest night. Ladies and gentleman, "Movie Date Presents: Oscar...Totally Naked."
And yes, Rafer and Kristen are naked throughout.
In this week's Movie Date podcast, Kristen and Rafer debate whether today is, in fact, a good day to die hard, or merely a fine one. They also discuss the merits of cuddling, creamy white stationary, witchcraft, and weird sexual hang-ups. It's all in honor of this week's releases: "Safe Haven," "Beautiful Creatures," and "A Good Day to Die Hard." Warning: if you don't know what plushies are now, you might after this podcast. Also, if you haven't already, check out this very special Valentine to Rafer, on Babes of NPR.
In this week's Movie Date podcast, Rafer and Kristen compare notes on their favorite pharmaceutical drug names. They also ask some big questions, including: Does volleyball really need to be seen in 3D? Should Steven Soderbergh retire? And if the only good part of a date is the kissing at the end...is it really a good date? It's all in honor of this week's big releases: "Top Gun 3D," "Side Effects," and "Identity Thief."
In this week's podcast, Rafer and Kristen play a game of would you rather involving racist hitmen versus zombie kidnappers. Will Rafer choose to be kidnapped? Will Kristen decide on racism? Find out, and along the way, get their thoughts on "Stand Up Guys," "Warm Bodies," and "Bullet to the Head."
In this week's Movie Date podcast, Rafer and Kristen review "Hansel and Gretel: Witch Hunters," and in the process, are forced to explore one of Rafer's least favorite movie themes in recent years: the sibling romance. Other movies discussed this week are "Parker," starring Jason Statham and Jennifer Lopez; and "Movie 43," starring Kate Winslet, Hugh Jackman, Halle Berry, Emma Stone, Kate Bosworth, Uma Thurman, and everyone else in Hollywood. Warning to the easily queasy: this podcast includes talk of fecal matter, brother-sister romance, brother-brother romance, misogyny, and menstruation.
Welcome to the third Movie Date Award Season Dispatch - in which Rafer and Kristen do not talk about award season at all, and instead focus on the strange intersections of politics and performance. Each dispatch is taken from a live interview, led by WNYC's Amy Eddings, and broadcast during All Things Considered on WNYC.
In this week's Movie Date podcast, Rafer responds to one of Kristen's harshest critics - with a giant spoonful of sugar. Rafer and Kristen also give their thoughts on this week's big releases: "Mama," starring Jessica Chastain; "Broken City," starring Russell Crowe, Mark Wahlberg, and Catherine Zeta Jones, and "The Last Stand," starring Arnold Schwarzenegger. Advanced warning: if you can't stand sincere soft rock, you might want to fast-forward through this week's trivia question.
Welcome to the second of several Movie Date Award Season Dispatches. Each dispatch is taken from a live interview, led by WNYC's Amy Eddings, and broadcast during All Things Considered on WNYC. In this dispatch, Rafer and Kristen share their thoughts on the Golden Globes - from the hosting to the winners to that speech by Lifetime Achievement winner Jodie Foster.
Welcome to the first of several Movie Date Award Season Dispatches. Each dispatch is taken from a live interview, led by WNYC's Amy Eddings, and broadcast during All Things Considered on WNYC. In this dispatch, Rafer and Kristen share their thoughts on the Oscar nominees - and whether they truly represent the best pictures of the year.
In this week's podcast, Rafer and Kristen talk about whether Gangster Squad is a horrible date, or merely a tolerable one. They also share their excitement about the Oscar nominations, the Razzie nominations, and this weekend's Golden Globe Awards. Welcome to red carpet season!
Rafer and Kristen answer just a few of the many letters they've received in recent weeks from Movie Date listeners, including questions about "The Hobbit," "Les Miserables," and "Django: Unchained." Plus, Kristen and Rafer talk about "On the Road," "The Impossible," and "Promised Land."
It's Christmas 2012, one of the most highly anticipated movie release days of the year, and Rafer and Kristen are prepared to throw down over two of the big ones: "Les Miserables" and "Django Unchained."


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Picture: Will Smith The Sports Dream Celebrity Poker Tournament at the Playboy Mansion Los Angeles, California - 10.07.07
I, ROBOT star Will Smith is glad he turned down the chance to play NEO in blockbuster The Matrix because he would have "ruined the movie".
The 35-year-old is relieved Hollywood hunk Keanu Reeves played the lead character in the trilogy - which starred Smith's wife Jada Pinkett-Smith as NIOBE - and confesses he would have "forced every moment" because he didn't understand the complex science-fiction script.
Smith admits, "I didn't get it when I read it. It's a hard movie to pitch. You know: 'Everybody lives inside a computer.' It was only when I saw it that I really got it.
"But every so often you see a performance you know you couldn't have given, and Keanu was brilliant as Neo. It was his role. I would have ruined the movie. I would have forced every moment."25/07/2004 21:28


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WASHINGTON (AP) - A federal judge struck down the District of Columbia's ban on carrying guns outside of a person's home, concluding it violates Second Amendment rights.
LOS ANGELES (AP) - A satellite study of blue-whale movements shows the endangered creatures cluster for long periods in busy shipping lanes off the California coast, putting them at risk for collisions with large vessels.
NEW YORK (AP) - A man dressed as Spider-Man was arrested on charges he slugged a police officer who told him to stop harassing tourists in Times Square.
PHILADELPHIA (AP) - The hunt for two Philadelphia carjackers who rammed a stolen SUV into a family, killing three children, entered its third day Sunday as officials offered a $110,000 reward for information leading to their capture.
PHILADELPHIA (AP) - A man accused of fatally shooting his caseworker and grazing his psychiatrist at a suburban Philadelphia hospital complex before the doctor returned fire has been charged with murder.
HOUSTON (AP) - Scammers have been preying on the relatives of unaccompanied young migrants being held at two U.S. military bases by conning them into paying nonexistent fees to be reunited with their loved ones, officials said.
NEW YORK (AP) - When it comes to preventing the spread of germs, maybe the president is on to something with his fondness for fist bumps.
CHICAGO (AP) - A costly drug given mostly to premature babies is at the center of a clash between the manufacturer and the nation's leading pediatrician's group, which recommends scaling back use of the medicine.
WICHITA, Kan. (AP) - A 10-month-old Kansas girl died after being strapped for more than two hours inside a sweltering car, and police arrested a foster parent who said he'd forgotten about her until something on TV jogged his memory, an official said Friday.
MEDIA, Pa. (AP) - A psychiatrist's patient ranted about a gun ban at a suburban medical complex before opening fire there, killing his caseworker and grazing his psychiatrist before the doctor pulled out his own weapon and fired back, authorities said Friday.
METAMORA TOWNSHIP, Mich. (AP) - The owner of two dogs that fatally mauled a man as he jogged along a rural Michigan road could be charged after the attack, which was the third since 2012 involving canines from the same property, officials said.
TALLAHASSEE, Fla. (AP) - A Florida law restricting what doctors can tell patients about gun ownership was deemed to be constitutional Friday by a federal appeals court, which said it legitimately regulates professional conduct and doesn't violate the doctors' First Amendment free speech rights.
TWISP, Wash. (AP) - About 300 homes - twice as many as previously estimated - have burned in the largest recorded wildfire in Washington state history, a county sheriff said Friday.
DENVER (AP) - Pot may be legal in some states - but the neighbors don't have to like it.
McCOMB, Miss. (AP) - Police say they have arrested a Mississippi couple found living with their two children and the children's grandmother in an overdue rental truck that had been reported stolen.
CHICAGO (AP) - President Barack Obama's health secretary announced proposed regulations Tuesday for Head Start that would expand the 50-year-old early-learning program to a full school day and a full school year to better prepare children for kindergarten.
INDIANAPOLIS (AP) - South Bend Mayor Pete Buttigieg came out as gay Tuesday, declaring in a lengthy and personal newspaper editorial that it took him years to accept that his sexuality is just "part of who I am."
ANCHORAGE, Alaska (AP) - Two wildfires burning north and south of Anchorage stretched Alaska firefighting resources Tuesday as crews scrambled to protect rural homes and cabins.
WHITE PLAINS, N.Y. (AP) - A cadet in his last year at West Point collected and traded photos and videos of boys being forced into sexual acts, a federal prosecutor said Tuesday.
SPOKANE, Wash. (AP) - Rachel Dolezal resigned as president of the NAACP's Spokane chapter Monday just days after her parents said she is a white woman posing as black - a dizzyingly swift fall for an activist credited with injecting remarkable new energy into the civil rights organization.
DENVER (AP) - Pot may be legal in Colorado, but you can still be fired for using it.
MINEOLA, N.Y. (AP) - A Sikh college student from New York said Monday he is excited about a federal court decision that will permit him to enroll in the U.S. Army's Reserve Officer Training Corps without shaving his beard, cutting his hair, or removing his turban.
JACKSONVILLE, Ark. (AP) - Guards shot and critically wounded a civilian outside a sprawling Air Force base in Arkansas on Monday after the man drove his SUV over a curb near the main gate, crashed through a sign and got out of the vehicle holding a rifle, the base commander said.
WASHINGTON (AP) - A government data warehouse that stores personal information on millions of HealthCare.gov customers is raising privacy concerns at a time when major breaches have become distressingly common.
OAK ISLAND, N.C. (AP) - Two teenagers were seriously injured in two separate shark attacks in the same North Carolina town on Sunday, terrifying beach goers and prompting one shocked witness to compare the scene to the movie "Jaws."
WASHINGTON (AP) - No one wants to make a repeat visit to the emergency room for the same complaint, but new research suggests it's more common than previously thought and surprisingly, people frequently wind up at a different ER the second time around.
DALLAS (AP) - The man linked to a violent assault on Dallas police headquarters was accused two years earlier of choking his mother, then fleeing to an East Texas town where schools were locked down out of fear he would attack them as "soft targets," according to accounts from police and family members.
LUBBOCK, Texas (AP) - The torrential storms of last month essentially ended one of Texas' worst-ever droughts, but much of the excess water has already flowed into the Gulf of Mexico or will evaporate by year's end.
DES MOINES, Iowa (AP) - The right to be drunk on the front porch of a private home was endorsed Friday by the Iowa Supreme Court, which said a woman can't be convicted of public intoxication while standing on her front steps.
HOUSTON (AP) - A former Texas prosecutor has been stripped of his law license after a panel of the State Bar of Texas determined he withheld evidence and used false testimony to win a capital murder conviction against a now-exonerated death row inmate.
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follow Dictionary.com
afield said no one knows why Julie Schenecker killed her children, except Julie Schenecker.
If Julie Schenecker is mentally ill, an insanity defense will be difficult for her to prove, afield said.
1590s, contraction of Middle English in felde, from Old English on felda "in the field" (especially of battle), from a- "on" (see a- (1)) + field (n.). Meaning "away from home" is attested by early 15c.


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12:57 pm Versartis (VSAR)
Versartis (VSAR) is rallying 27% on some positive clinical news from the FDA. What happened is that the FDA has removed the partial clinical hold on the VSAR's Investigational New Drug Application for VRS-317. With this action, the company will proceed with the Phase 3 registration trial, called Velocity, of VRS-317 in children with GHD.
Before getting into more detail, let's take a step back and explain what Versartis does. Versartis is an endocrine-focused biopharma company initially developing VRS-317, a long-acting form of recombinant human …More


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Members of the Taylorsville-Spencer County Fire Department rescued two young people Monday whose kayaks flipped in rough water on the Salt River downstream from the Taylorsville Lake spillway Sunday afternoon.
Chief Nathan Nation said emergency crews were called just after 4:30 p.m. Sunday after a report of the accident. Two juveniles, ages 14 and 11, were in the water.
"One was wearing a life jacket and one wasn't," said Nation. "They were able to get to a tree and hang on until we were able to get there."
Water was the focus of the Taylorsville City Commission during much of their meeting last Tuesday night, and not just from recent flooding.
Commissioners heard from Taylorsville-Spencer County Fire Chief Nathan Nation about the limitations the city has when it comes to water flow and the ability to fight a major fire in downtown Taylorsville.
He explained that the water pressure in Taylorsville would make it difficult for firefighters to have ample supply to knock down a large fire that engulfed a block of downtown.
Pastors and congregation members of the Foundation Christian Center In Elk Creek held hands and prayed Sunday after a ground-breaking ceremony for the church's new fellowship hall building expected to be erected this month. A new church building will be built on the site by 1997. The church was established In September, 1994.
Our recent articles on Dr. Furnish have triggered a letter concerning Dr. E. L. Branaman, another physician of note in Spencer County.
Earl Branaman writes from Cincinnati, mentioning that he grew up in Spencer County and pointing out that he is the son of Dr. Branaman.
He writes:
"Dr. Branaman had three of five children who graduated in the Taylorsville school system, namely Elizabeth, Williams and the writer. Another daughter, Lucy Mae, taught in the elementary school there in the '20s."
Earl continued:
Copyright © 2015
The Spencer Magnet is your source for local news, sports, events, and information in Spencer County, KY and the surrounding area.


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Performance of a Full-Scale Lateral Foundation with Fine and Coarse Gravel Backfills Subjected to Static, Cyclic, and Dynamic Lateral Loads
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Original recipe yields 4 servings
Amount per serving ({{servings}} total)
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Ready In
We loved this. We found the calabres cheese at the Spanish Table and, while we were there, picked up a couple bottles of Spanish red (a Rioja and a Ribera del Duero). They were both good matches...
Absolutley one of the best recipe on here. my whole family loved it even my 2 year old!!!!
Nam, nam. Kunne hatt i mer paprika. Brukte blå castello. OK Hadde båtpoteter. Godt


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American Portfolio Mortgage in Fairview Heights has added two employees. Tim Bohn has joined the firm as a mortgage loan officer and Jody Talick has been hired as a branch manager and loan consultant. The office is located at 331 Salem Place in Suite 260.
Vigilant Anesthesia Care & Pain Management Ltd. in Glen Carbon has hired Dr. Chad A. Ermis. Ermis will be seeing and treating patients through The Pain Center at Memorial Hospital in Belleville.
Karyn Graham has been named the technology coach for the Northwestern Mutual Network office in Clayton, Mo., where she will work with financial representatives in Fairview Heights as well as those in Clayton, Cape Girardeau, Mo. and Chesterfield, Mo.


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Category Archives: EATVENTS
[EATVENTS] MAY 2: Ramp Fest 2015
Dear Food Diary:
The wild onion aka ramp season is here again and I couldn't be more excited. I've already grilled a few batches at home and can't wait to have in all sorts of creative ways at the Ramp Fest 2015 coming up May 2nd in Hudson Valley.
We had such a fun time last year. Check out some of the highlights and get your tickets!
EATVENT: Meat Pies and other Thanksgiving goodies at M. Wells
Dear Food Diary:
French class is one of my favorite memories from Toronto public school. Mind you, when I finally made it to Paris, I couldn't parler any Francais. But those wonderful Tourtière (meat pies) our teacher – mademoiselle M – made for the holidays are still vivid enough, I can smell it. I haven't had one just like it since, but genuine nostalgia might be to blame…
These delicious memories came back while reading M.Wells ' Thanksgiving email – meat pie season has started!
[ RECIPE ] Best Bloody Mary in America with Absolut
Dear Food Diary:
Happy Halloween! I'm not big on the festivities but thought a good Bloody Mary recipe would come in handy tonight. What other drink shouts halloween like this red concoction? Plus, you can pretty much dress it up any way you want it!
A few weeks ago, I attended Absolut's Bloody Mary 80th birthday celebration. Did you know it was originally named "Red Snapper"?.
They had a recipe contest for the best bloody mary in America. Got to sample the winning one from Texas. And made my own Bloody Chubby.
EATVENT 9/11-9/28: New York Oyster Week
Oyster season kicked off last week. Check out all the event still going on and the participating restaurants!
UPCOMING 5/3: Ramp Fest 2014, Hudson NY
Dear Food Diary:
It's that time of the year again, when food lovers go crazy about these wild garlicky greens. I just had some simply grilled last night. So good.
This Saturday, the Ramp Fest 2014 is happening and you can munch on everything "ramps".


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Original recipe yields 12 servings
Amount per serving ({{servings}} total)
Based on a 2,000 calorie diet
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Like some of the other suggestions, I changed up the ratios. I used all 8 oz. of the cream cheese package and only 1 cup of sugar. The frosting turned out absolutely wonderful!!
I like the smooth creamy texture. I used the whole 8 oz creeam cheese though and a little more poweder sugar and still great. I also added just a drop of orange extract which I think complimen...
This was delicious but it is definitely only for cakes-and needs refrigeration! I used it for cupcakes and it didn't firmed up at all. We took the cupcakes somewhere and the icing got all over m...


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The Paw Paw Wine and Harvest Festival Board and the Village would like to thank all of the sponsors who make this event possible. We ask that you take time to thank the sponsors, as they the life line for the Paw Paw Community. They support everything from our festival to local little league to your Church event to the events local service clubs offer like the food pantry.
Event Sponsors:
St. Julian Wine Company – Parade Sponsor
Coca-Cola Refreshments – Grape Stomp Sponsor
Paw Paw Downtown Development Authority – Fireworks Sponsor
South Haven Convention & Visitors Bureau
Platinum Level Sponsors:
Midwest Energy Cooperative A Touchstone Energy Cooperative - Lakefront Entertainment
Hiemstra Optical
Warner Vineyards
Honor Credit Union
Car Zone
Old National Bank
Gold Level Sponsors:
Seelye of Paw Paw
Advia Credit Union
Silver Level Sponsors:
Educational Community Credit Union
Bronson Lakeview Hospital
Paw Paw Wine Distributors
Mercantile Bank
Brewster's at the Dyckman
Leduc Blueberries
Chemical Bank
John Tapper Automotive
Hospice Care of Southwest Michigan
Maple Lake Assisted Living
Golden Star Realty
Bestway Disposal
Tapper Towing
Comfort Inn of Paw Paw
Paw Paw Collision
Ace Hardware
Save A Lot
Family Fare
Bronze Level Sponsors:
IHS Distributing
Bronsink and Bos Equipment
Amore Pizza
Foune Well Drilling
Woodfield Apartments
Hills Prescription Shop
Cancun Mexican Restaurant
Betzler & Thompson Life Story Funeral Homes
Cody Kresta Vineyard & Winery
Copper Grille
Bloomingdale Communications
Elementray Edge
Travel Lodge
Paw Paw Brewing Company
Mite-E Exterminating
Willis & Willis Law
Crystal Flash Energy
Fifth Third Bank
LaCantina Ristorante Italiano
The Sugar Bear
Mattawan Pet Supplies
Maple Lake Chiropractic
Subway of Paw Paw
Meyer Wood Products
Illusions Hair Salon
Plain Jane's
Grace's Place
Pipe Dreams
Clifford's Perennial & Vine
Red's Root Beer
Walt & Marie's Country Market
Edward Jones Investments
Great Lakes Belting & Supply Co.
In-Kind Sponsors:
Best Way Disposal
Courier Leader
Oxley Farms
Mroczek Sod Farm
South Haven Packaging
The UPS Store
Dr. Pepper/Snapple
The Strand Theatre
Arvco Container
Thank you to all our sponsors, without you, the Wine & Harvest Festival would not be able to continue at the level the community and visitors currently enjoy each September.


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Affluent Lifestyle Guide
You might like Best Runway Models >
With the US Open drawing near, you should probably start working on your serve so you can compete alongside the pros from the comfort of your own court. Whatever your weakness is, whether it be your serve or backhand, Zepp Tennis can help. Much like the sensors designed to better your golf swing, just attach Zepp to the handle of your tennis racket and play. The gadget collects 3D data in real time and sends it to the accompanying app on your smartphone or tablet, measuring things like racket and ball speed, spin, backswing time, and impact time. There's even a "sweet spot" feature that shows you exactly where the racket makes contact with the ball, which helps you with quality and consistency. Zepp may or may not turn you into the next Novak Djokovic, but it will definitely help you get closer.
Finding the best in luxury can be a daunting task, which is why we've taken it on for you.


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PART 1 in a series of posts on Load Test Planning
As part of my work inside Microsoft, I have to interface with several different groups of people, from sales to account management to the technical delivery people, and also to different product group teams. I have learned some very valuable lessons from these conversations. The biggest single lesson I have learned is to not only ensure that everyone is speaking the same language, but to ensure that we also all understand the reason we are even speaking. In this blog series, I will attempt to show (at a high level) the thought process I use and some of the steps I and my former testing team follow when we work on customer engagements.
Please note that you will see me refer to several different types of resources throughout the series. This is a critical part of successful performance load testing since it is impossible for only one or two people to know enough to pull this off. My old team has a very simple slogan: "We test WITH you, not FOR you." That phrase sums up one of the most important reasons the engagements are so successful. It takes a team of skilled people to effectively design and execute performance load tests. I will also tell you that the people I have the privilege of working with all have several years of experience in their respective fields, which is also a key factor in success.
I find it critical to always ask the questions of the final goal(s) of a testing effort before doing any other work. If this question cannot be accurately answered, or if the answer does not make sense, then I start drilling into the specifics to get more clarification.
I recently bought a video series from O'Reilly books called "Software Architecture Fundamentals", delivered by Neal Ford and Mark Richards. In one of their segments, they talked about understanding the requirements of a project and they gave a great example of how you can change the entire dynamic of any engagement by asking the right question (Sorry Mark, but as you said in the video, I would rather re-use your example than make a new one). Please note I am paraphrasing here:
"The design team of the F-16 fighter plane was asked by the Air Force to design a plane that would fly at Mach 2-2.5. At the time this was very difficult to achieve. The team struggled a lot. Finally they went back to the Air Force and asked 'Why does it need to go so fast?' The Air Force said 'Because we need to be able to escape when we get into bad combat situations.' So the design team took that knowledge and offered an alternative. They designed a plane that had high acceleration and high maneuverability. The plane would not go Mach 2, but was still very successful because they realized that the acceleration and maneuverability were better than overall speed in those situations."
Here is the list of things I start with for every engagement I do. Sometimes it can take a few days to answer just these questions. Other times the customer can hand me the answers in their "ready to Use" state:
What are the GOALS/ OBJECTIVES of this testing effort?
A goal or objective is a "desired result or outcome" of an activity or endeavor. Defining this up front sets the stage for every other piece of work you will do. You need to make sure the goal(s) are realistic, and that they possible to obtain. They should also align with the team's skill sets, the business partner's needs, and the overall project. Here are a couple of goals to consider:
These goals all seem pretty good at first. However, I bet some of you are thinking that they are either too vague or that the first two are the same, or that there is some other problem.
The first one wants to figure out what load will cause the system to break. The second one wants to understand how the system will behave at a pre-defined load. The third one wants to find out how fast the client is. While they might all be easier to understand if we changed them a bit, you'll see that I will clarify them in the next step.
What are the SUCCESS CRITERIA for this testing effort?
Now that we have goals, we want to know "What determines if we have successfully achieved the goal or not." These are the success criteria. Continuing with the list of goals above, we can add the following:
What are the METRICS used to measure the success criteria?
This is the meat of the data collected. Metrics are concrete values obtained through specific tooling as part of the testing. The values are usually from the load test rig and/or from Performance Monitor collections or other monitoring tools. However, we still define them in the test plan in a generic fashion. Please note that I am only doing metrics for the FIRST goal above.
Looking at the above examples, you may notice that there is a big problem with one of my data points. Remember that I said I was going to remove the first Success Criteria for the first goal above? Here's why. When I am trying to find the breaking point of a system, one of the things that I am always trying to find is "What throughput can the system handle?" Throughput usually contains metrics like requests/second or transactions/second, etc. If this is the number I am trying to determine, it should not be one of my success criteria. The success criteria in this case should be listed as "Obtain the maximum TPS for CompleteTheSale without the other criteria reaching a fail point."
Think of it this way. The first goal is to define the acceptable behavior of the system and see how much load (throughput) it can handle. The second goal is to define the load (throughput) and see what the behavior is.
The bottom line for all of these is that they should be well defined, they need to make sense, they need to be measurable and the efforts and testing needs to be repeatable.
I will visit the considerations for designing a load pattern and how to model that load.
Thanks Geoff for this article. Well written, practical and clearly coming from field experience.


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Obstetrician & Gynecologist (OB/GYN)
22 years of experience
Accepting new patients
22 years of experience
Accepting new patients
12029 Sheraton Ln
Suite 100
Cincinnati, OH 45246 Phone number & directions
Suite 100
Cincinnati, OH 45246 Phone number & directions
License & Identifications
A medical license is required for a doctor to practice medicine in a particular state. Requirements vary by state but most require, at a minimum, post-graduate training in the doctor's specific specialty. An NPI number is a national identifier unique to an individual health care provider and is managed by the Center for Medicare & Medicaid Services (CMS).
Learn more about Dr. Lori Philip:
View the full profile to get information on:
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Patient Reviews
Patient comments (0)
The overall average patient rating of Dr. Lori Philip is Excellent.
Specialties & Research
Dr. Lori Philip, MD is board certified in Obstetrics & Gynecology.
- She has special expertise in 2 areas:
- Hot Flashes
- Menopause
Education & Awards
Dr. Philip graduated from Thomas Jefferson University, Philadelphia.
Dr. Philip has 6 hospital affiliations:
- Good Samaritan Hospital
- Mercy Hospital Western Hills
Home > Find an Obstetrician & Gynecologist > OH > Cincinnati Obstetricians & Gynecologists > Dr. Lori Philip, MD
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- Additional Information
- Dr. Lori Renee Philip MD is a female Obstetrician & Gynecologist, has 22 years of experience and practices in Obstetrics & Gynecology.
- Where does Dr. Lori R. Philip practice?
- Dr. Lori Philip has 3 office locations.
Dr. Lori Philip practices Obstetrics & Gynecology near Cincinnati, OH.
See Cincinnati Obstetricians & Gynecologists.


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BuckarooBonzai 51-55, F 8 Answers 3 Mar 6, 2012
green cards R us
Best Answer
Same with me. Unless EP is paying for my flight to meet these women I just ignore it
Best Answer
They wanted me, now they want me to ask a question... :P
Best Answer
Lol! I don't get why there are dating site ads on EP. That's literally all of their ads. lol
Best Answer
are you in the other world or what

Why should someone die to meet you

more so since you are a bad speller
Best Answer
it is the colour of limit
Best Answer
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