The neural representation of an auditory spatial cue in the primate cortex.

Humans make use of small differences in the timing of sounds at the two ears-interaural time differences (ITDs)-to locate their sources. Despite extensive investigation, however, the neural representation of ITDs in the human brain is contentious, particularly the range of ITDs explicitly represented by dedicated neural detectors. Here, using magneto- and electro-encephalography (MEG and EEG), we demonstrate evidence of a sparse neural representation of ITDs in the human cortex. The magnitude of cortical activity to sounds presented via insert earphones oscillated as a function of increasing ITD-within and beyond auditory cortical regions-and listeners rated the perceptual quality of these sounds according to the same oscillating pattern. This pattern was accurately described by a population of model neurons with preferred ITDs constrained to the narrow, sound-frequency-dependent range evident in other mammalian species. When scaled for head size, the distribution of ITD detectors in the human cortex is remarkably like that recorded in vivo from the cortex of rhesus monkeys, another large primate that uses ITDs for source localization. The data solve a long-standing issue concerning the neural representation of ITDs in humans and suggest a representation that scales for head size and sound frequency in an optimal manner.

Implementation of a Trauma Bay Checklist Improves Antibiotic Prophylaxis Compliance in Open Extremity Fractures.

BACKGROUND: Best practice guidelines from the ACS recommend that patients with open fractures receive antibiotics within 1-hour of presentation. Checklists are effective mechanisms for improving safety and compliance in surgical settings. The current study investigates implementation of a trauma bay checklist, referred to as MARTY, to improve administration of antibiotics in open extremity fractures at a level I trauma center. METHODS: Retrospective pre-post design. Population consisted of trauma alerts from January to December 2021 (pre-MARTY) and 2022 (post-MARTY) with open fractures. Outcome measures included antibiotics administered within 1-hour of presentation and in the trauma bay. Bivariate and multivariate analyses were performed to estimate differences in both measures. RESULTS: Our sample included 339 encounters, 174 pre-MARTY and 165 post-MARTY implementation. In the pre-MARTY period, 57.5% of encounters received antibiotics within 1-hour of presentation with 46.0% occurring in the trauma bay, in comparison to 65.5% and 54.5% in the post-MARTY period. In adjusted models, there were greater odds of antibiotic administration within 1-hour (OR = 1.654, P = .038) and prior to leaving the trauma bay (OR = 1.660, P = .041) than pre-MARTY. Encounters with higher-grade fractures were more likely to receive timely antibiotics (P<=.001). DISCUSSION: Our study estimates improved compliance of antibiotic administration after implementation of MARTY after adjusting for encounter characteristics. Findings from this study demonstrate improved compliance, but this compliance is often still lacking in those with higher injury severity scores. Findings from this study may be used to inform approaches to further improve trauma care.

Cortical haemodynamic responses predict individual ability to recognise vocal emotions with uninformative pitch cues but do not distinguish different emotions.

We investigated the cortical representation of emotional prosody in normal-hearing listeners using functional near-infrared spectroscopy (fNIRS) and behavioural assessments. Consistent with previous reports, listeners relied most heavily on F0 cues when recognizing emotion cues; performance was relatively poor-and highly variable between listeners-when only intensity and speech-rate cues were available. Using fNIRS to image cortical activity to speech utterances containing natural and reduced prosodic cues, we found right superior temporal gyrus (STG) to be most sensitive to emotional prosody, but no emotion-specific cortical activations, suggesting that while fNIRS might be suited to investigating cortical mechanisms supporting speech processing it is less suited to investigating cortical haemodynamic responses to individual vocal emotions. Manipulating emotional speech to render F0 cues less informative, we found the amplitude of the haemodynamic response in right STG to be significantly correlated with listeners' abilities to recognise vocal emotions with uninformative F0 cues. Specifically, listeners more able to assign emotions to speech with degraded F0 cues showed lower haemodynamic responses to these degraded signals. This suggests a potential objective measure of behavioural sensitivity to vocal emotions that might benefit neurodiverse populations less sensitive to emotional prosody or hearing-impaired listeners, many of whom rely on listening technologies such as hearing aids and cochlear implants-neither of which restore, and often further degrade, the F0 cues essential to parsing emotional prosody conveyed in speech.

Introduction to the shared near infrared spectroscopy format.

Significance: Functional near-infrared spectroscopy (fNIRS) is a popular neuroimaging technique with proliferating hardware platforms, analysis approaches, and software tools. There has not been a standardized file format for storing fNIRS data, which has hindered the sharing of data as well as the adoption and development of software tools. Aim: We endeavored to design a file format to facilitate the analysis and sharing of fNIRS data that is flexible enough to meet the community's needs and sufficiently defined to be implemented consistently across various hardware and software platforms. Approach: The shared NIRS format (SNIRF) specification was developed in consultation with the academic and commercial fNIRS community and the Society for functional Near Infrared Spectroscopy. Results: The SNIRF specification defines a format for fNIRS data acquired using continuous wave, frequency domain, time domain, and diffuse correlation spectroscopy devices. Conclusions: We present the SNIRF along with validation software and example datasets. Support for reading and writing SNIRF data has been implemented by major hardware and software platforms, and the format has found widespread use in the fNIRS community.

Cross-modal functional connectivity supports speech understanding in cochlear implant users.

Sensory deprivation can lead to cross-modal cortical changes, whereby sensory brain regions deprived of input may be recruited to perform atypical function. Enhanced cross-modal responses to visual stimuli observed in auditory cortex of postlingually deaf cochlear implant (CI) users are hypothesized to reflect increased activation of cortical language regions, but it is unclear if this cross-modal activity is "adaptive" or "mal-adaptive" for speech understanding. To determine if increased activation of language regions is correlated with better speech understanding in CI users, we assessed task-related activation and functional connectivity of auditory and visual cortices to auditory and visual speech and non-speech stimuli in CI users (n = 14) and normal-hearing listeners (n = 17) and used functional near-infrared spectroscopy to measure hemodynamic responses. We used visually presented speech and non-speech to investigate neural processes related to linguistic content and observed that CI users show beneficial cross-modal effects. Specifically, an increase in connectivity between the left auditory and visual cortices-presumed primary sites of cortical language processing-was positively correlated with CI users' abilities to understand speech in background noise. Cross-modal activity in auditory cortex of postlingually deaf CI users may reflect adaptive activity of a distributed, multimodal speech network, recruited to enhance speech understanding.

Optical imaging and spectroscopy for the study of the human brain: status report.

This report is the second part of a comprehensive two-part series aimed at reviewing an extensive and diverse toolkit of novel methods to explore brain health and function. While the first report focused on neurophotonic tools mostly applicable to animal studies, here, we highlight optical spectroscopy and imaging methods relevant to noninvasive human brain studies. We outline current state-of-the-art technologies and software advances, explore the most recent impact of these technologies on neuroscience and clinical applications, identify the areas where innovation is needed, and provide an outlook for the future directions.

Contralateral dominance to speech in the adult auditory cortex immediately after cochlear implantation.

Sensory deprivation causes structural and functional changes in the human brain. Cochlear implantation delivers immediate reintroduction of auditory sensory information. Previous reports have indicated that over a year is required for the brain to reestablish canonical cortical processing patterns after the reintroduction of auditory stimulation. We utilized functional near-infrared spectroscopy (fNIRS) to investigate brain activity to natural speech stimuli directly after cochlear implantation. We presented 12 cochlear implant recipients, who each had a minimum of 12 months of auditory deprivation, with unilateral auditory- and visual-speech stimuli. Regardless of the side of implantation, canonical responses were elicited primarily on the contralateral side of stimulation as early as 1 h after device activation. These data indicate that auditory pathway connections are sustained during periods of sensory deprivation in adults, and that typical cortical lateralization is observed immediately following the reintroduction of auditory sensory input.

Human cortical processing of interaural coherence.

Sounds reach the ears as a mixture of energy generated by different sources. Listeners extract cues that distinguish different sources from one another, including how similar sounds arrive at the two ears, the interaural coherence (IAC). Here, we find listeners cannot reliably distinguish two completely interaurally coherent sounds from a single sound with reduced IAC. Pairs of sounds heard toward the front were readily confused with single sounds with high IAC, whereas those heard to the sides were confused with single sounds with low IAC. Sounds that hold supra-ethological spatial cues are perceived as more diffuse than can be accounted for by their IAC, and this is accounted for by a computational model comprising a restricted, and sound-frequency dependent, distribution of auditory-spatial detectors. We observed elevated cortical hemodynamic responses for sounds with low IAC, suggesting that the ambiguity elicited by sounds with low interaural similarity imposes elevated cortical load.

Development of an Australian behavioural method for assessing listening task difficulty at high speech intelligibility levels.

OBJECTIVE: To develop and validate an Australian version of a behavioural test for assessing listening task difficulty at high speech intelligibility levels. DESIGN: In the SWIR-Aus test, listeners perform two tasks: identify the last word of each of seven sentences in a list and recall the identified words after each list. First, the test material was developed by creating seven-sentence lists with similar final-word features. Then, for the validation, participant's performance on the SWIR-Aus test was compared when a binary mask noise reduction algorithm was on and off. STUDY SAMPLE: All participants in this study had normal hearing thresholds. Nine participants (23.8-56.0 years) participated in the characterisation of the speech material. Another thirteen participants (18.4-59.1 years) participated in a pilot test to determine the SNR to use at the validation stage. Finally, twenty-four new participants (20.0-56.9 years) participated in the validation of the test. RESULTS: The results of the validation of the test showed that recall and identification scores were significantly better when the binary mask noise reduction algorithm was on compared to off. CONCLUSIONS: The SWIR-Aus test was developed using Australian speech material and can be used for assessing task difficulty at high speech intelligibility levels.

Characterization of Mayer-wave oscillations in functional near-infrared spectroscopy using a physiologically informed model of the neural power spectra.

Significance: Mayer waves are spontaneous oscillations in arterial blood pressure that can mask cortical hemodynamic responses associated with neural activity of interest. Aim: We aim to characterize the properties of oscillations in the functional near-infrared spectroscopy (fNIRS) signal generated by Mayer waves in a large sample of fNIRS recordings. Further, we aim to determine the impact of short-channel correction for the attenuation of these unwanted signal components. Approach: Mayer-wave oscillation parameters were extracted from 310 fNIRS measurements using the fitting oscillations and one-over-f method to compute normative values. The effect of short-channel correction on Mayer-wave oscillation power was quantified on 222 measurements. The practical benefit of the short-channel correction approach for reducing Mayer waves and improving response detection was also evaluated on a subgroup of 17 fNIRS measurements collected during a passive auditory speech detection experiment. Results: Mayer-wave oscillations had a mean frequency of 0.108 Hz, bandwidth of 0.04 Hz, and power of 3.5 µ M 2 / Hz . The distribution of oscillation signal power was positively skewed, with some measurements containing large Mayer waves. Short-channel correction significantly reduced the amplitude of these undesired signals; greater attenuation was observed for measurements containing larger Mayer-wave oscillations. Conclusions: A robust method for quantifying Mayer-wave oscillations in the fNIRS signal spectrum was presented and used to provide normative parameterization. Short-channel correction is recommended as an approach for attenuating Mayer waves, particularly in participants with large oscillations.

The use of broad vs restricted regions of interest in functional near-infrared spectroscopy for measuring cortical activation to auditory-only and visual-only speech.

As an alternative to fMRI, functional near-infrared spectroscopy (fNIRS) is a relatively new tool for observing cortical activation. However, spatial resolution is reduced compared to fMRI and often the exact locations of fNIRS optodes and specific anatomical information is not known. The aim of this study was to explore the location and range of specific regions of interest that are sensitive to detecting cortical activation using fNIRS in response to auditory- and visual-only connected speech. Two approaches to a priori region-of-interest selection were explored. First, broad regions corresponding to the auditory cortex and occipital lobe were analysed. Next, the fNIRS Optode Location Decider (fOLD) tool was used to divide the auditory and visual regions into two subregions corresponding to distinct anatomical structures. The Auditory-A and -B regions corresponded to Heschl's gyrus and planum temporale, respectively. The Visual-A region corresponded to the superior occipital gyrus and the cuneus, and the Visual-B region corresponded to the middle occipital gyrus. The experimental stimulus consisted of a connected speech signal segmented into 12.5-sec blocks and was presented in either an auditory-only or visual-only condition. Group-level results for eight normal-hearing adult participants averaged over the broad regions of interest revealed significant auditory-evoked activation for both the left and right broad auditory regions of interest. No significant activity was observed for any other broad region of interest in response to any stimulus condition. When divided into subregions, there was a significant positive auditory-evoked response in the left and right Auditory-A regions, suggesting activation near the primary auditory cortex in response to auditory-only speech. There was a significant positive visual-evoked response in the Visual-B region, suggesting middle occipital gyrus activation in response to visual-only speech. In the Visual-A region, however, there was a significant negative visual-evoked response. This result suggests a significant decrease in oxygenated hemoglobin in the superior occipital gyrus as well as the cuneus in response to visual-only speech. Distinct response characteristics, either positive or negative, in adjacent subregions within the temporal and occipital lobes were fairly consistent on the individual level. Results suggest that temporal regions near Heschl's gyrus may be the most advantageous location in adults for identifying hemodynamic responses to complex auditory speech signals using fNIRS. In the occipital lobe, regions corresponding to the facial processing pathway may prove advantageous for measuring positive responses to visual speech using fNIRS.

Analysis methods for measuring passive auditory fNIRS responses generated by a block-design paradigm.

Significance: Functional near-infrared spectroscopy (fNIRS) is an increasingly popular tool in auditory research, but the range of analysis procedures employed across studies may complicate the interpretation of data. Aim: We aim to assess the impact of different analysis procedures on the morphology, detection, and lateralization of auditory responses in fNIRS. Specifically, we determine whether averaging or generalized linear model (GLM)-based analysis generates different experimental conclusions when applied to a block-protocol design. The impact of parameter selection of GLMs on detecting auditory-evoked responses was also quantified. Approach: 17 listeners were exposed to three commonly employed auditory stimuli: noise, speech, and silence. A block design, comprising sounds of 5 s duration and 10 to 20 s silent intervals, was employed. Results: Both analysis procedures generated similar response morphologies and amplitude estimates, and both indicated that responses to speech were significantly greater than to noise or silence. Neither approach indicated a significant effect of brain hemisphere on responses to speech. Methods to correct for systemic hemodynamic responses using short channels improved detection at the individual level. Conclusions: Consistent with theoretical considerations, simulations, and other experimental domains, GLM and averaging analyses generate the same group-level experimental conclusions. We release this dataset publicly for use in future development and optimization of algorithms.

Neural Modulation Transmission Is a Marker for Speech Perception in Noise in Cochlear Implant Users.

OBJECTIVES: Cochlear implants (CIs) restore functional hearing in persons with a severe hearing impairment. Despite being one of the most successful bionic prosthesis, performance with CI (in particular speech understanding in noise) varies considerably across its users. The ability of the auditory pathway to encode temporal envelope modulations (TEMs) and the effect of degenerative processes associated with hearing loss on TEM encoding is assumed to be one of the reasons underlying the large intersubject differences in CI performance. The objective of the present study was to investigate how TEM encoding of the stimulated neural ensembles of human CI recipients is related to speech perception in noise (SPIN). DESIGN: We used electroencephalography as a noninvasive electrophysiological measure to assess TEM encoding in the auditory pathway of CI users by means of the 40-Hz electrically evoked auditory steady state response (EASSR). Nine CI users with a wide range of SPIN outcome were included in the present study. TEM encoding was assessed for each stimulation electrode of each subject and new metrics; the CI neural modulation transmission difference (CIMTD) and the CI neural modulation transmission index (CIMTI) were developed to quantify the amount of variability in TEM encoding across the stimulated neural ensembles of the CI electrode array. RESULTS: EASSR patterns varied across the CI electrode array and subjects. We found a strong correlation (r = 0.89, p = 0.001) between the SPIN outcomes and the variability in EASSR amplitudes across the array as assessed with CIMTD/CIMTI. CONCLUSIONS: The results of the present study show that the 40-Hz EASSR can be used to objectively assess the neural encoding of TEMs in human CI recipients. Overall reduced or largely variable TEM encoding of the neural ensembles across the electrode array, as quantified with the CIMTD/CIMTI, is highly correlated with speech perception in noise outcome with a CI.

Stability of Auditory Steady State Responses Over Time.

OBJECTIVES: Auditory steady state responses (ASSRs) are used in clinical practice for objective hearing assessments. The response is called steady state because it is assumed to be stable over time, and because it is evoked by a stimulus with a certain periodicity, which will lead to discrete frequency components that are stable in amplitude and phase over time. However, the stimuli commonly used to evoke ASSRs are also known to be able to induce loudness adaptation behaviorally. Researchers and clinicians using ASSRs assume that the response remains stable over time. This study investigates (1) the stability of ASSR amplitudes over time, within one recording, and (2) whether loudness adaptation can be reflected in ASSRs. DESIGN: ASSRs were measured from 14 normal-hearing participants. The ASSRs were evoked by the stimuli that caused the most loudness adaptation in a previous behavioral study, that is, mixed-modulated sinusoids with carrier frequencies of either 500 or 2000 Hz, a modulation frequency of 40 Hz, and a low sensation level of 30 dB SL. For each carrier frequency and participant, 40 repetitions of 92 sec recordings were made. Two types of analyses were used to investigate the ASSR amplitudes over time: with the more traditionally used Fast Fourier Transform and with a novel Kalman filtering approach. Robust correlations between the ASSR amplitudes and behavioral loudness adaptation ratings were also calculated. RESULTS: Overall, ASSR amplitudes were stable. Over all individual recordings, the median change of the amplitudes over time was -0.0001 µV/s. Based on group analysis, a significant but very weak decrease in amplitude over time was found, with the decrease in amplitude over time around -0.0002 µV/s. Correlation coefficients between ASSR amplitudes and behavioral loudness adaptation ratings were significant but low to moderate, with r = 0.27 and r = 0.39 for the 500 and 2000 Hz carrier frequency, respectively. CONCLUSIONS: The decrease in amplitude of ASSRs over time (92 sec) is small. Consequently, it is safe to use ASSRs in clinical practice, and additional correction factors for objective hearing assessments are not needed. Because only small decreases in amplitudes were found, loudness adaptation is probably not reflected by the ASSRs.

Source analysis of auditory steady-state responses in acoustic and electric hearing.

Speech is a complex signal containing a broad variety of acoustic information. For accurate speech reception, the listener must perceive modulations over a range of envelope frequencies. Perception of these modulations is particularly important for cochlear implant (CI) users, as all commercial devices use envelope coding strategies. Prolonged deafness affects the auditory pathway. However, little is known of how cochlear implantation affects the neural processing of modulated stimuli. This study investigates and contrasts the neural processing of envelope rate modulated signals in acoustic and CI listeners. Auditory steady-state responses (ASSRs) are used to study the neural processing of amplitude modulated (AM) signals. A beamforming technique is applied to determine the increase in neural activity relative to a control condition, with particular attention paid to defining the accuracy and precision of this technique relative to other tomographies. In a cohort of 44 acoustic listeners, the location, activity and hemispheric lateralisation of ASSRs is characterised while systematically varying the modulation rate (4, 10, 20, 40 and 80Hz) and stimulation ear (right, left and bilateral). We demonstrate a complex pattern of laterality depending on both modulation rate and stimulation ear that is consistent with, and extends, existing literature. We present a novel extension to the beamforming method which facilitates source analysis of electrically evoked auditory steady-state responses (EASSRs). In a cohort of 5 right implanted unilateral CI users, the neural activity is determined for the 40Hz rate and compared to the acoustic cohort. Results indicate that CI users activate typical thalamic locations for 40Hz stimuli. However, complementary to studies of transient stimuli, the CI population has atypical hemispheric laterality, preferentially activating the contralateral hemisphere.

Kalman Filter Based Estimation of Auditory Steady State Response Parameters.

Auditory steady state responses (ASSRs) are brain responses to modulated or repetitive stimuli that can be captured in the EEG recording. ASSRs can be used as an objective measure to clinically determine frequency specific hearing thresholds, to quantify the sensitivity of the auditory system to modulation, and have been related to speech intelligibility. However, the detection of ASSRs is difficult due to the low signal to noise ratio of the responses. Moreover, minimizing measurement time is important for clinical applications. Traditionally ASSRs are analyzed using discrete Fourier transform (DFT) based methods. We present a Kalman filter based ASSR analysis procedure and illustrate several benefits over traditional DFT based methods. We show on a data set of 320 measurements that the proposed method reaches valid amplitude estimates significantly faster than the state of the art DFT method. Further, we provide two extensions to the proposed method. First, we demonstrate information can be incorporated from multiple recording electrodes by extending the system model. Secondly, we extend the model to incorporate artifacts from cochlear implant (CI) stimulation and demonstrate electrically evoked auditory steady state responses (EASSRs) can be accurately measured.

Efficacy of a hospital-wide environmental cleaning protocol on hospital-acquired methicillin-resistant Staphylococcus aureus rates.

BACKGROUND: Environmental contamination has been associated with over half of methicillin-resistant Staphylococcus aureus (MRSA) outbreaks in hospitals. We explored if a hospital-wide environmental and patient cleaning protocol would lower hospital acquired MRSA rates and associated costs. OBJECTIVE: This study evaluates the impact of implementing a hospital-wide environmental and patient cleaning protocol on the rate of MRSA infection and the potential cost benefit of the intervention. METHODS: A retrospective, pre-post interventional study design was used. The intervention comprised a combination of enhanced environmental cleaning of high touch surfaces, daily washing of patients with benzalkonium chloride, and targeted isolation of patients with active infection. The rate of MRSA infection per 1000 patient days (PD) was compared with the rate after the intervention (Steiros Algorithm®) was implemented. A cost-benefit analysis based on the number of MRSA infections avoided was conducted. RESULTS: The MRSA rates decreased by 96% from 3.04 per 1000 PD to 0.11 per 1000 PD (P <0.0001). This reduction in MRSA infections, avoided an estimated $1,655,143 in healthcare costs. DISCUSSION: Implementation of this hospital-wide protocol appears to be associated with a reduction in the rate of MRSA infection and therefore a reduction in associated healthcare costs.

Assessing temporal modulation sensitivity using electrically evoked auditory steady state responses.

Temporal cues are important for cochlear implant (CI) users when listening to speech. Users with greater sensitivity to temporal modulations show better speech recognition and modifications to stimulation parameters based on modulation sensitivity have resulted in improved speech understanding. Behavioural measures of temporal sensitivity require cooperative participants and a large amount of time. These limitations have motivated the desire for an objective measure with which to appraise temporal sensitivity for CI users. Electrically evoked auditory steady state responses (EASSRs) are neural responses to periodic electrical stimulation that have been used to predict threshold (T) levels. In this study we evaluate the use of EASSRs as a tool for assessing temporal modulation sensitivity. Modulation sensitivity was assessed behaviourally using modulation detection thresholds (MDTs) for a 20 Hz rate. On the same stimulation sites, EASSRS were measured using sinusoidally amplitude modulated pulse trains at 4 and 40 Hz. Measurements were taken using a bipolar configuration on 12 electrode pairs over 5 participants. Results showed that EASSR amplitudes and signal-to-noise ratios (SNRs) were significantly related to the MDTs. Larger EASSRs corresponded with sites of improved modulation sensitivity. This relation was driven by across-subject variation. This result indicates that EASSRs may be used as an objective measure of site-specific temporal sensitivity for CI users.

It is chloride depletion alkalosis, not contraction alkalosis.

Maintenance of metabolic alkalosis generated by chloride depletion is often attributed to volume contraction. In balance and clearance studies in rats and humans, we showed that chloride repletion in the face of persisting alkali loading, volume contraction, and potassium and sodium depletion completely corrects alkalosis by a renal mechanism. Nephron segment studies strongly suggest the corrective response is orchestrated in the collecting duct, which has several transporters integral to acid-base regulation, the most important of which is pendrin, a luminal Cl/HCO(3)(-) exchanger. Chloride depletion alkalosis should replace the notion of contraction alkalosis.

The use of tags and tag clouds to discern credible content in online health message forums.

BACKGROUND: Web sites with health-oriented content are potentially harmful if inaccurate or inappropriate medical information is used to make health-related decisions. Checklists, rating systems and guidelines have been developed to help people determine what is credible, but recent Internet technologies emphasize applications that are collaborative in nature, including tags and tag clouds, where site users 'tag' or label online content, each using their own labelling system. Concepts such as the date, reference, author, testimonial and quotations are considered predictors of credible content. An understanding of these descriptive tools, how they relate to the depiction of credibility and how this relates to overall efforts to label data in relation to the semantic web has yet to emerge. PURPOSE: This study investigates how structured (pre-determined) and unstructured (user-generated) tags and tag clouds with a multiple word search feature are used by participants to assess credibility of messages posted in online message forums. The targeted respondents were those using web sites message forums for disease self-management. We also explored the relevancy of our findings to the labelling or indexing of data in the context of the semantic web. METHOD: Diabetes was chosen as the content area in this study, since (a) this is a condition with increasing prevalence and (b) diabetics have been shown to actively use the Internet to manage their condition. From January to March 2010 participants were recruited using purposive sampling techniques. A screening instrument was used to determine eligibility. The study consisted of a demographic and computer usage survey, a series of usability tests and an interview. We tested participants (N=22) on two scenarios, each involving tasks that assessed their ability to tag content and search using a tag cloud that included six structured credibility terms (statistics, date, reference, author, testimonial and quotations). MORAE Usability software (version 3.1) was employed to record participants' use of the study environment. The surveys were analyzed using SPSS version 17. Interviews with participants were transcribed, coded and analyzed using thematic text analysis with the aid of NVivo8. FINDINGS: Most participants had experience with Internet resources. However, less than one quarter of this sample had seen or used tags or a tag clouds. The ways in which participants used tags to label the content posted in the message forums varied. Some participants were tagging the information for their own subsequent use, whereas others viewed this process from the perspective of others: they tagged the content in ways that they thought other users would find beneficial. Many participants did not use the structured credibility tags when asked to search for credible content. The interviews corroborated these findings by confirming participants were not considering credibility foremost when tagging. CONCLUSION: Many participants in this study focused on assessing whether the information was relevant to their current circumstances, after which they would proceed to determine its credibility by corroborating with other sources. The use of structured tags to label information may not be a useful way to encourage the use of tagging, or to indicate credibility in this context. Current applications used in the semantic web automate this process. Therefore it may be useful to engage consumers of online content, in particular health-related content, to be more directly involved in the annotation of this content.