SBP) were all positively correlated with PTA at intermediate and high frequencies (p<0.05). Each SD increase in SSD, SCV, and VIMSBP was also positively associated with hearing loss at intermediate and high frequencies. No significant correlation was observed between variations of DBP and hearing. These findings suggest that increase in long-term BPV is associated with hearing and hearing loss. Trial registration number: Kailuan study (ChiCTRTNC-11001489).Blood pressure (BP) has been well documented to be associated with hearing loss previously. However, the role of blood pressure variability  on hearing remains unknown. We aimed to evaluate the relationship between BPV and hearing in Chinese population. We included 8646 male subjects from a population-based study (the Kailuan study). BP was measured every two years at routine physical examinations from 2006 to 2015. Based on five annual BP measurements, BPV was estimated by standard deviation of BP (SD), coefficient of the variation of BP (CV), and variation independent of mean of BP (VIM). Hearing was estimated by pure-tone average threshold (PTA) at low, intermediate, and high frequencies in the year of 2014. Regression models were used to evaluate the relationship between BPV and hearing. The results showed that PTAs and percentages of hearing loss at low, intermediate, and high frequencies grew gradually with increasing systolic SD (SSD) (p<0.05). After adjusting for multiple covariates, multivariate regression analyses demonstrated that variations of SBP (SSD, SCV, and VIM Hearing loss ranks as the fifth leading cause of years lived with disability, affecting 360 million people worldwide . While nHypertension is a major global health burden and a leading risk factor for cardiovascular diseases and premature death –11. HoweChiCTR-TNC-11001489), we adopted pure-tone average thresholds (PTAs) and hearing loss as indexes to investigate whether BPV can affect cochlear function of individuals.Clinical and experimental studies have demonstrated that arterial hypertension was an independent risk factor for the hearing loss. Patients with higher BP had worse pure-tone thresholds –25. ExpoThis study was performed based on the Kailuan Community in Tangshan. Physical examinations were conducted every two years on both in-service and retired workers of Kailuan Community. Eleven hospitals participated in the physical examination. A total of five physical examinations were performed during 2006-2007, 2008-2009, 2010-2011, 2012-2013, and 2014-2015, respectively. The measurement of PTAs was performed in 2014-2016.The inclusion criteria were as follows: giving signed informed consent to participate in the current study, providing complete information from at least three of the five physical examinations, and providing complete information of PTA measurements. The exclusion criteria were as follows: history of stroke, history of head injury, history of myocardial infarction, history of atrial fibrillation, missing BP data from more than two of the five physical examinations, missing data of the measurements of PTA, and female individuals .The questionnaire was completed by individuals and then verified by research doctors. The questionnaire items were consisted of demographic information, occupation situation , employing conditions (serving or retired), labor intensity , occupational hazard ), lifestyle , disease history and family history, and physical examination profiles . Smoking was defined as ≥1 cigarette/day, continuous smoking ≥1 year, or giving up smoking ≤1 year. Alcohol consumption is defined as continuous drinking≥1 year . Physical exercise is defined as aerobic exercise  ≥3 times/weeks and ≥ 30min/times. Occupational noise exposure is defined as working places equivalent environmental noise level ≥85 decibel (dB) at least 8 hours per day.2 was defined as normal weight, while BMI ≥ 24 kg/m2 was defined as overweight [Standard protocols were used for all of the measurements as described earlier by our group . Anthroperweight . All bioBP was measured between 7:00 and 9:00. Individuals were asked to refrain from smoking and drinking tea or coffee for more than 30 min and to sit and rest for 15 min prior to measurement. During BP measurement, individuals sat with their arms and feet flat and their upper arms at the height of their heart. Right brachial artery BP was measured by a corrected mercury sphygmomanometer with an appropriate sized cuff. Systolic blood pressure (SBP) was recorded on hearing the phase I Korotkoff sound. Diastolic blood pressure (DBP) was recorded on hearing the phase V Korotkoff sound. Sitting BP was measured two times first with a 30s interval. If two measurements differed by <5 mmHg, BP was recorded as the mean of the two measurements. If two measurements differed by >5 mmHg, BP was remeasured and the final BP in each examination was calculated as the mean of three measurements. Hypertension in each examination was defined as SBP≥140 mmHg and/or DBP≥90 mmHg or BP<140 mmHg and DBP<90 mmHg with regular antihypertensive drugs usage. Individuals were regarded as having hypertension if they were recorded as having hypertension in at least two examinations.∗100%. The CV of SBP was recorded as coefficient of the variation of SBP (SCV), and the CV of DBP was recorded as coefficient of the variation of DBP (DCV). (3) The variation independent of mean (VIM) was calculated as SD/x (x was derived from curve fitting).BPV was calculated by three methods. (1) Standard deviation (SD) of the BP levels is obtained from the physical examinations. The SD of SBP was recorded as SSD, and the SD of DBP was recorded as DSD. (2) The coefficient of the variation of BP (CV) was calculated as SD/mean of BP levels obtained from the physical examinations BPV levels in the current study were calculated based on the BP levels measured every two years. Several previous studies have demonstrated that the two-year BP measurement interval can sufficiently reflect the BP fluctuation over time –37 and mTrained professional staff performed audiometric testing in a sound-isolating room using the Otometrics MADSEN Xeta audiometer . Air-conduction hearing thresholds were measured for each ear using pure tone at six frequencies . 1KHz was used as the first pure-tone frequency from an intensity of -20 dB. If no response was observed, 5dB was added each time until response is observed. Then pure-tone frequencies at 0.5, 2, 3, 4, and 6 KHz were measured. PTAs were measured at low, intermediate, and high frequencies, respectively. PTA of low frequency was calculated by the mean of PTA at 0.5 and 1 KHz. PTA of intermediate frequency was calculated by the mean of PTA at 1 and 2 KHz. PTA of high frequency was calculated by the mean of PTA at 3, 4, and 6 KHz . The finThe testing should begin at relatively low frequencies ranging from 0.5 to 1 KHz, because this frequency is easily heard by most patients and has the greatest test-retest reliability. After that, the hearing test is performed at frequencies ranging from 1 to 2 KHz, which represent the intermediate frequencies of speech range. Then, the hearing test is performed at high frequencies ranging from 3 to 6 KHz. In clinical settings, many factors, such as sound injury, ototoxic drugs, and senile auditory system degeneration, may firstly affect the function of basal gyrus of cochlea. Consequently, early manifestation is the change of high-frequency hearing threshold .The design of the current study is cross-sectional rather than a cohort one and the aim of this study is to reflect the distribution of BPV at the specific time-point (the year of 2014) and uncover the correlation between BPV and hearing ability. Therefore, we only focus on the relationship between BPV and hearing ability instead of their causal relationship. Consequently, only one hearing measurement is sufficient to identify the correlation between BPV and hearing ability.Data were entered in the terminal of each hospital and then uploaded to the computer room of the Kailuan General Hospital for storage in an Oracle 10.2g database. SPSS 13.0 statistical software was utilized for statistical analysis. Normally distributed measurement data were recorded as mean±SD. Trend test was used to compare differences of multiple groups. If the variance is homogeneous, the LSD test is used. If the variance is not homogeneous, Dunnett's T3 test is used. Categorical variables were described as percentages and compared by the chi-square test. Multivariate linear regression analysis was used to investigate the impacts of BPV on PTAs and hearing loss. The collinearity was analyzed using variance inflation factor (VIF). Multivariate logistic regression analysis was used to analyze the effect of each SD increase in different BPV measurements on hearing loss. Sensitivity analyses were performed by removing individuals with occupational noise exposure and individuals with hypertension, respectively. P<0.05  was considered as statistically significant.Among the 101510 workers who participated in the 2006-2007 health examination, a total number of 8875 subjects participated in at least three physical examinations and had complete pure-tone threshold measurement data. In the 8875 individuals, 229 were excluded for female gender (n=138), the history of head injury (n=36), the history of stroke (n=24), myocardial infarction, or history of atrial fibrillation (n=31). As a result, a total of 8646 participants were included in the final statistical analysis.As the Kailuan Group Corporation is a highly industrialized enterprise, the vast majority of the employees of the Kailuan Group Corporation are men (more than 80%). Moreover, the measurement of PTAs was performed on employees who work in coal mines. Since female employees rarely work in mines, the number of women is significantly less than that of men. Consequently, we excluded the 138 female subjects from further analyses. See SBP, VIMDBP, TC, higher hypertension and antihypertensive drug usage percentages, higher diabetes mellitus percentage, higher dyslipidemia percentage, and lower education percentage (p for trend <0.001).The 8646 participants were divided into four groups according to the quartiles of their SSD levels: (1) quartile 1 (n=2165): SSD<6.38; (2) quartile 2 (n=2156): 6.38≤SSD<9.07; (3) quartile 3 (n=2166): 9.07≤SSD<12.31; and (4) quartile 4 (n=2159): SSD≥12.31. Participants' PTA values and hearing loss percentages in different BPV groups are shown in SBP, and VIMDBP. In the analysis, we adjusted for BP level, age, BMI, FBG, TC, occupational noise exposure, cigarette smoking, alcohol consumption, physical exercise, and antihypertensive drug usage. Multivariate linear regression analysis between BPV and PTA is shown in To identify the factors associated with PTA values, we performed a multivariate linear regression analysis with PTA as dependent variable. Independent variables included SSD, DSD, SCV, DCV, VIMSBP) were generally positively correlated with PTAs at low (P=0.035 for SCV), intermediate , and high frequency . However, for variations of DBP, no significant relationship was revealed between DSD, DCV, VIMDBP, and PTAs.The results showed that variations of SBP  and hypertension group (n=3491) and reanalyzed the relationship between BPV and PTA by multivariate linear regression model. In nonhypertension group, the results showed that variations of SBP (SSD and SCV) were positively correlated with PTAs at intermediate (p=0.017 for SSD) and high frequency . However, no significant relationship was revealed in hypertension group. See Supplementary SBP, and VIMDBP. In the multivariate logistic regression analysis, we adjusted for BP level, age, BMI, cigarette smoking, alcohol consumption, physical exercise, diabetes mellitus, dyslipidemia, antihypertensive drug usage, and occupational noise exposure. Multivariate logistic regression analysis between BPV and hearing loss is shown in To further demonstrate the relationship between BPV and hearing loss, multivariate logistic regression analysis was performed with the existence of hearing loss as dependent variable . Independent variables included each SD increase of SSD, DSD, SCV, DCV, VIMSBP was also positively associated with hearing loss at intermediate frequencies (OR (95% CI)=1.07 (1.004-1.14)). However, no correlation was found between DBP variations and hearing loss.The results indicated that each SD increase in SSD was positively associated with hearing loss at intermediate and high frequencies (OR (95% CI)=1.09 (1.02-1.17) for intermediate frequency; OR (95% CI)=1.07 (1.01-1.14) for high frequency). For CV, the results showed that each SD increase in SCV was positively associated with hearing loss at intermediate and high frequencies (OR (95% CI)=1.08 (1.01-1.15) for intermediate frequency; OR (95% CI)=1.06 (1.003-1.12) for high frequency). In terms of VIM, the results suggested that each SD increase in VIMWe also divided the individuals into nonhypertension group (n=5111) and hypertension group (n=3491) and reanalyzed the relationship between BPV and hearing loss by multivariate logistic regression model. In nonhypertension group, the results showed that variations of SBP (SSD and SCV) were positively correlated with hearing loss at intermediate (OR (95% CI)=1.12 (1.02-1.24) for SSD; OR (95% CI)=1.09 (1.00-1.19) for SCV) and high frequency (OR (95% CI)=1.11 (1.01-1.21) for SSD; OR (95% CI)=1.08 (1.001-1.17) for SCV). However, no significant relationship was observed in hypertension group. See Supplementary SBP) remain positively correlated with hearing loss at intermediate frequency. The relationship between SSD and hearing loss at low frequency gained significance, while the correlation between VIMSBP and hearing loss at high frequency lost significance. For variations of DBP, no significant correlation was identified.As occupational noise exposure is one of the predominant risk factors for hearing loss ; in the SBP) were all positively correlated with PTAs at intermediate and high frequencies. Logistic regression analysis identified that each SD increase in SSD, SCV, and VIMSBP was also positively associated with hearing loss at intermediate and high frequencies. These results indicated that BPV indeed had a positive relationship with PTA and hearing loss, especially at intermediate and high frequencies.In this large-scale population-based cross-sectional study, we firstly investigated the relationship between BPV and hearing and found that PTAs and percentages of hearing loss at low, intermediate, and high frequencies grew gradually with increasing BPV levels. After adjusting for multiple covariates, multivariate linear regression analysis demonstrated that variations of SBP  positively correlated with PTA at intermediate and high frequencies. Each SD increase in SBP variants all contributed to greater risk of hearing loss at intermediate and high frequencies. Results of our study may explain the effect of BPV on hearing.This is the first and largest-scale population-based study to analyze the relationship between long-term BPV and hearing. After adjusting for multiple factors, we found that variations of SBP (SSD, SCV, and VIM


R = −0.76; p < 0.0001). These data suggest that Functional-OCT may provide a novel approach to assess sympathetic activity and intrinsic vascular responsiveness . Given that sympathetic nervous system activity is the main determinant of autonomic function, sympathetic excitation is associated with severe cardiovascular/cardiorespiratory diseases and autoregulation is critical for brain health, we suggest that the use of our new Functional-OCT technique will be of broad interest to clinicians and researchers.Sympathetic nervous system dysregulation and vascular impairment in neuronal tissue beds are hallmarks of prominent cardiorespiratory diseases. However, an accurate and convenient method of assessing SNA and local vascular regulation is lacking, hindering routine clinical and research assessments. To address this, we investigated whether spectral domain optical coherence tomography (OCT), that allows investigation of retina and choroid vascular responsiveness, reflects sympathetic activity in order to develop a quick, easy and non-invasive sympathetic index. Here, we compare choroid and retina vascular perfusion density (VPD) acquired with OCT and heart rate variability (HRV) to microneurography. We recruited 6 healthy males (26 ± 3 years) and 5 healthy females (23 ± 1 year) and instrumented them for respiratory parameters, ECG, blood pressure and muscle sympathetic nerve microneurography. Choroid VPD decreases with the cold pressor test, inhaled hypoxia and breath-hold, and increases with hyperoxia and hyperpnea suggesting that sympathetic activity dominates choroid responses. In contrast, retina VPD was unaffected by the cold pressor test, increased with hypoxia and breath hold and decreases with hyperoxia and hyperpnea, suggesting metabolic vascular regulation dominates the retina. With regards to integrated muscle sympathetic nerve activity, HRV had low predictive power whereas choroid VPD was strongly (inversely) correlated with integrated muscle sympathetic nerve activity ( Abnormal sympathetic nervous system activity damages local vascular regulation, including the ability of the microvasculature to resist associated changes in blood pressure  and respond appropriately to local metabolic demands. Concurrently, impaired local microvascular regulation reduces tissue perfusion within vital organs, causing tissue damage and organ dysfunction, triggering sympathetic excitation. Consequently, abnormal sympathetic nervous system activity and impoverished microvascular regulation are associated with, and causal to a host of common cardiovascular, cardiorespiratory and metabolic diseases including sleep apnea, hypertension, metabolic diseases, stroke, heart failure and dementia .Available methods to measure sympathetic responses suffer from poor time resolution , multiple neuronal inputs , are invasive  and/or do not completely reflect sympathetic activity  . MethodsThe posterior segment of the eye is an extension of the brain, but with two distinct vascular beds. The vascular beds of the retina and choroid differ in their local vascular responses and sympathetic innervation . SpecifiModern OCT devices can easily image both the retina and choroid . OpticalTo test our hypothesis, we used OCT to compare the microvascular responses of the choroid and retina to different conditions  designed to disentangle sympathetic and local metabolic vascular control mechanisms. The inspiratory challenges were chosen to stimulate the central and peripheral chemoreflexes reflective of reflex stimulation and mimic sympathetic activation encountered with cardiorespiratory diseases; the cold pressor causes sympathetic activation independent of changes to blood gases. Experiments were performed in 11 healthy human participants while recording ventilation, blood pressure, heart rate and direct measures of sympathetic nerve activity using microneurography, the only method to record from the sympathetic nervous system in directly.n = 2) associated with microneurography in the seated position as assessed by cardiovascular indices of pre-syncope  18–36 years of age were recruited from the University of Calgary community. All participants were normotensive, non-smokers and free of respiratory, cardiovascular, neurological diseases, and provided written informed consent prior to study. Data from 11 participants  were analyzed; 6  participants did not complete the protocol because of difficulty locating and maintaining stable sympathetic recordings and/or, the onset of vasovagal reflexes (-syncope .3 cube of the eye. All OCT scans were acquired by the same operator (RH) with the Cirrus OCT device (software version 6.5.0772). Image acquisition of the Cirrus OCT system, averages 1024 scans within ∼3 s using active eye-tracking features and centred around the fovea, thus standardizing each image to the anatomical characteristics of each individual eye, to produce a single image set. For each participant, the baseline scan was used to establish a slice which encased the large vessels of the choroid as identified by visual inspection. Once anatomical parameters for the slice were established from the baseline scan, the same parameters were maintained for scans from all subsequent perturbations for that subject. The average slice thickness across subjects was 86 ± 3 μm . The retina circulation was measured from images obtained from the 3D visualization mode by capturing the aggregate of the retina vessels on a 2D “flattened” image. Retina thickness was measured using the automatic segmentation values of the Cirrus HD OCT software. Two images were collected during each stimulus. A single image chosen from paired scans was selected for each intervention from each participant. Image selection and image analysis were performed independently by different team members .Left eyes were scanned with a Cirrus HD 4000 spectral domain optical coherence tomography system . The Cirrus HD 4000 uses near-infrared laser interferometry, enabling an optical reconstruction of a 6 mmPeripheral muscle SNA (MSNA) was assessed using microneurography. Briefly, a tungsten recording electrode with an uninsulated 1–5 μm diameter tip was inserted transcutaneously into the peroneal nerve at or distal to the fibular head. A reference electrode was inserted subcutaneously 1–3 cm from the recording site. The recording electrode was manipulated into position within a sympathetic nerve fascicle, which produced pulse-synchronous bursts of activity characteristic of sympathetic vasoconstrictor neurons innervating skeletal muscle. The sympathetic signal was verified by an increase in firing frequency during voluntary apnoea and lack of responsiveness during arousal to a loud noise. The raw sympathetic signal was amplified by a preamplifier (1000×) and secondary isolated amplifier , band-pass–filtered (700–2000 Hz), rectified and integrated (time constant: 0.1 s) as per standardized methods . All recHeart rate was measured using a 3-lead ECG. Respiratory flow was monitored by a pneumotachometer  and end-tidal gas concentrations were measured via an oxygen and carbon dioxide analyzer . Blood pressure was measured continuously using finger photoplethysmography  and calibrated to baseline blood pressure values obtained using manual sphygmomanometry. Manual blood pressures were assessed at the brachial artery just proximal to the elbow (arm straight or in mild elbow flexion) using a mercury sphygmomanometer and a medium-sized blood pressure cuff performed by a clinician (RH). Calibrated pressure waveforms were analyzed to determine beat-by-beat MAP and systolic and diastolic blood pressures. Blood oxygen saturation was measured with a pulse oximeter .Participants were instructed to refrain from caffeine (12 h), exercise (24 h), and alcohol (24 h), and ingest their last meal at least 3 h prior to the laboratory visit. All female participants were tested during the midluteal phase (21 ± 2 days) of their menstrual cycle where minimal effects of the menstrual cycle on sympathetic activity have been demonstrated ; 4/5 wer2, balance N2, 3 min), hyperoxia , hyperoxic-hypercapnia , hyperpnea , voluntary end-expiratory sub maximal breath hold (∼10 s) and cold pressor test . The hypoxic challenge was always performed last due to the long lasting hemodynamic and sympathetic changes associated with hypoxia  defined as a static index of perfusion within the image, was calculated for the choroid and retina of each image for each participant within each condition. The resulting images were analyzed offline using Image J software . Choroid images were obtained from the RPEFIT mode. All images were subject to the same analysis involving the Iterative Self- Organizing Data Analysis Technique Algorithm (ISODATA). This algorithm provides unsupervised determination of a threshold to classify background and objects . Images All hemodynamic and neurographic data were stored for offline data analysis . Heart rate variability was assessed by utilizing 3-min bins (time of each perturbation) and analyzed with built-in heart rate variability software . Hemodynamic and neurographic responses to gas challenges and cold pressor test were averaged over 2 min  while tht-test. Differences between sympathetic provocations were tested with the Friedman’s non-parametric one-way repeated measures ANOVA using raw values (data are presented as percent change from baseline). When significant F-ratios were found, Student Newman Keuls post hoc test was used to discern differences from the baseline condition. Relationships between indices were assessed with Pearson product correlation; and select relationships were analyzed with partial correlation in order to account for gender. Multiple regression analysis was performed when more than one index was used to relate to sympathetic nervous activity. Assessment of inter-measurement agreement was completed using Bland-Altman analysis. A p-value < 0.05 was considered statistically significant. All data are expressed as mean ± SEM.Differences between sexes were tested with independent 3 block of tissue. As blood absorbs near-infrared light, blood appears dark in OCT images; to assist in comparisons, the raw images are false colored such that tissues which have high vascular perfusion appear blue whereas tissues with low vasculature perfusion appear red. In the choroid, conditions that result in low sympathetic activity  tend to increase vascular perfusion (appearing bluer), whereas conditions expected to activate the sympathetic nervous system  reduce vascular perfusion (appearing greener). Note that the choroid has far greater vascular perfusion (blue-green) than the retina (yellow-red). Although the effects of the different conditions on the retina are subtler, hypoxia resulted in higher vascular perfusion compared to hyperoxia (during which less perfusion is anticipated). As expected this effect was predominantly demonstrated in distal portions of arteriolar branches .To use OCT for quantitative assessment of changes in microvascular perfusion, we adopted a measure of vascular perfusion density (VPD) based on pixel intensities in the processed images , appliedp = 0.083, Retina VPD, choroid VPD, MSNA and cardiorespiratory parameter responses to the six test conditions in 11 participants are illustrated in With regards to the retina, hypoxia significantly increased retina VPD compared to baseline ; despiteImages were also used to measure the retina thickness; no differences between sexes were identified at baseline . Retina R = −0.76, p < 0.0001). Even when accounting for gender with a partial correlation, the relationship between choroid VPD and MSNA remains unchanged . This relationship was even stronger when mean data for each condition was used . The predictive capability of choroid VPD is further exemplified by a tight agreement with Bland-Altman analysis for both absolute (R = 0.54 (p < 0.00001) for all individual and R = 0.93 (p = 0.007) for mean data. Thus, for individuals, choroid VPD is a better predictor of MSNA than blood pressure. This is further supported by the fact that, though choroid VPD has an inverse relationship with both MSNA and MAP, the relationship between choroid VPD and MSNA is stronger for both individual . Notwithstanding that choroid VPD is a better predictor of MSNA than MAP, combining MAP and choroid VPD responses in a multiple regression analysis improved the power to predict sympathetic responses, compared with using choroid VPD responses alone .To further examine the linear correlation between changes in VPD and sympathetic activity, we plotted choroid VPD and retina VPD against MSNA for individual and mean data across all conditions . As showabsolute  and percabsolute . For comdividual  vs. 3C adividual  vs. 3D. R = 0.13, p = 0.28). When the cold pressor data were removed , a weak positive relationship between retina VPD and MSNA was indicated ; this relationship was improved, but not significantly so, when mean data were used . Use of mean data did not reveal a correlation between retina VPD and MAP . Generally, retina VPD increased with hypoxia and decreased with hyperoxia, but the correlation to MSNA was lesser . As expected for two vascular beds differentially controlled by sympathetic inputs and local vascular control mechanisms, the VPD of the choroid and retina were inversely related when interrogated with inspired oxygen .The divergent vascular regulation between the choroid and the retina in response to changes in inspired oxygen is also demonstrated in R = −0.34, p = 0.005; LF: R = −0.01, p = 0.96; LF/HF: R = 0.08, p = 0.51; SD1: R = −0.34, p = 0.005; SD2: R = −0.27, p = 0.03; Mean data- RMSSD: R = −0.25, p = 0.63; LF: R = −0.37, p = 0.48; LF/HF: R = 0.15, p = 0.77; SD1: R = −0.31, p = 0.55; SD2: R = −0.09, p = 0.87).Finally, the relationship between choroid VPD and MSNA was far stronger than common indices of HRV widely used as non-invasive, though increasingly controversial , measureThis study confirms the divergent behavior of the choroid and retina in response to sympathetic stimuli and strongly suggests that ophthalmic Functional-OCT can be used to measure the divergent effects of sympathetic and local regulation of microvascular physiology within neuronal tissue in conscious humans. Our data suggest that the relationship between MSNA and OCT-derived choroid VPD far surpasses that between MSNA and HRV. This illustrates the potential for Functional-OCT as a novel non-invasive method to monitor sympathetic responsiveness in clinical and research settings that are often ill-suited for microneurography and suggests this technique as a new method to assess overall microvascular health.n = 17, of which we were only able to obtain stable recordings sufficient to complete the protocol in 6 females and 5 males (65%).The data herein where obtained by combining MSNA recording and ophthalmic OCT imaging which raised several technical challenges. MSNA recording and OCT imaging required participants to remain stationary in a seated position while breathing gas mixtures through a mouth piece. The seated position and mouth piece likely increased participant discomfort and compounding the difficulty of making stable MSNA recordings. However, that we found no evidence to suggest that scanning with the OCT device caused additional stress (see “Limitations”). In addition, while requiring MSNA recording, two of our participants experienced vasovagal reflexes that were rapidly resolved by placing in a horizontal position ; this en2 and increased PaCO2; voluntary hyperpnea, i.e., increased PaO2 and decreased PaCO2), or thermal afferent stimulation (sympathetic stimulation independent of chemoreceptors). MSNA responses to these perturbations were consistent between males and females and with previous human studies measuring MSNA with microneurography during similar sympathetic stressors , central brainstem chemoreceptor activity with carotid bodies inactivated (hypercapnia with hyperoxic background), combined chemoreceptor activity  associated with their MSNA responses, consistent with robust choroid vascular sympathetic regulation. This is in accordance with human  and animeceptors , and choeceptors  and increceptors  in anestPrevious studies suggest that sympathetic outputs to muscle , heart and renal vascular beds are differentially regulated . This re2, 95% O2) and voluntary hyperpnea both increased MSNA, yet neither had a significant effect on choroid VPD. Some previous studies also reported no change  – but not the cold pressor test – suggest that retina vessels are solely governed by local metabolic control mechanisms. For example, during hypoxia the retina blood vessels dilate in response to a metabolic stimulus to increase the supply of oxygen to the surrounding tissue, whereas the converse occurs when the metabolic stimulus is reduced during hyperoxia . The retChoroid VPD provides distinct advantages and disadvantages in comparison to other methods of assessing sympathetic activity in humans such as galvanic skin responses, pupil diameter, catecholamine measurements in blood, HRV or microneurography . DistingOn a practical level, unlike catecholamine measurements in blood, OCT is non-invasive and provides a temporal resolution better than or equal to fast blood sampling (∼3 s), but OCT does not allow continuous sampling like microneurography and HRV. Although microneurography provides a direct measurement of SNA and is the only method to directly record sympathetic activity directly and in real-time in humans, its invasive nature and other operational limitations  minimize its use in research and clinical settings. Galvanic skin responses and pupil diameter appear to be associated with autonomic activity but may suffer from sensory, emotional and higher cortical influences . Heart rCurrent methods to image/assess microcirculatory function are insufficient to resolve microvascular morphometry and, MRI and CT machines are too costly to use broadly . Other mt-test, p = 0.34). (3) Another potential issue is that shadowing from large diameter vessels in the retina may obscure the signal used to measure choroid responses. In the current study, we circumvented this issue by assessing each choroid image for shadow of retinal vessels. In the few cases where this was a factor, we excluded the regions affected from the choroid analysis. (4) Changes to perfusion in one vascular bed may affect the perfusion in the other vascular bed. Sympathetic activation of the choroid does not affect retina VPD, as the cold pressor test had an independent effect on the choroid. We cannot exclude the converse possibility that changes in retina VPD affect choroid VPD. Nonetheless, we note that responses of the choroid and retina to hypoxia and hyperoxia are diametrically opposed, thus any effect on the choroid of microcirculatory changes in the retina in response to metabolic stimuli must be limited to magnitude.The use of the Functional-OCT provides many advantages over other techniques as listed above. However, the technique has several potential limitations which require consideration. (1) This technique requires the head to be fixed in relation to the OCT machine. Modern OCT devices include eye tracking software that allow movement of the rest of the body, which minimize such distortions. (2) Although OCT is used clinically, the scan itself may impose stress. To gain a bearing on this possibility, we compared our MSNA data (a measure of stress response) before and during OCT scans whilst breathing room air . The change in MSNA between the scan vs. no scan condition was −2.7 ± 4.6% and not different between conditions (analyzed with paired two-sided The data herein demonstrate the ability of OCT to assess the divergent behavior of ophthalmic vascular beds to provocations designed to disentangle sympathetic from local vascular control mechanisms. Thus, Functional-OCT may provide a novel, fast, non-invasive and relatively affordable imaging solution to assess sympathetic activity and microvascular function, supplementing currently available autonomic measurements. Given dysregulation of the sympathetic nervous system and metabolic/myogenic vascular control are linked to, and often precede clinical identification of serious cardiorespiratory disease , we suggThe datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by the University of Calgary Conjoint Health Research Ethics Board. The patients/participants provided their written informed consent to participate in this study.NJ, RH, WT, FC, and RW were responsible for research conception and edited and approved the final version of the manuscript. NJ, RH, CS, and RW designed and performed the experiments. NJ, RH, and RW analyzed the data and interpreted the results of the experiments. NJ and RW prepared the figures and drafted the manuscript.NJ, CS, RH, WT, FC, and RW have submitted a patent application for the use of optical coherence tomography as a method to interrogate cardiorespiratory function.


Objective: Hearing impairment is linked to increased fatigue, yet little is known about the real-world impact of this fatigue. This qualitative study investigated the experience of daily-life fatigue in people with a hearing impairment.Design: Individual face-to-face semi-structured interviews were conducted. Thematic analysis was then used to analyse the data.Study sample: Fourteen hearing impaired participants (aged 44–70 years) who varied in terms of hearing loss, hearing aid status, age and gender.Results: The themes and sub-themes that emerged from the transcripts were: Fatigue , Effort , Coping Strategies , Relationships and Emotions, Hearing Aid Impact.Conclusions: The study highlights that hearing impairment-related fatigue is experienced by many but not all, and to different extents. Hearing aids were weakly linked to a beneficial effect on fatigue. In addition to the more widely researched effort-driven fatigue, participants described fatigue linked to the negative emotions related to having a hearing impairment. These findings, in conjunction with the widespread utilisation of different coping strategies, demonstrate that the experience of fatigue is varied and likely dependent on personal factors and lifestyle. Hearing loss affects ∼1 in 6 adults in the UK  was used to ensure coverage of all relevant research question areas. During the interviews, brief field notes were taken to outline the impressions of the interviews as extra information for stage 1 of the analysis process. The interviews were transcribed verbatim. The transcriptions were conducted by author JH for the first four interviews, and by a professional transcription service for the rest. The interviews ranged in duration from 18:36 to 42:51 min (average 28:12).All interviews were conducted face-to-face by author JH, who was a male Ph.D. student, in a closed room with no observers at the hospital department. Participants were informed that the study would form part of a Ph.D. thesis. Before the interview, an administrative questionnaire was completed as well as a pure tone audiometric hearing test. The questionnaire asked about hearing aid status, tinnitus and work status. After the interviews, participants were asked to list any other potentially fatiguing conditions they have. Interviews were recorded using a digital voice recorder. An interview question guide (Participants were hearing impaired adults (>18 years old) who had previously reported to NHS audiology with hearing problems, and were contacted via mail. Interviews took place over the course of three months. The participants were recruited using stratified purposeful sampling which involves sampling based on key variables within the initial major variable sample . Their age range was 44–70 years (mean: 58). The worse-ear and better-ear four frequency average hearing loss ranges were 21–65 dBHL (mean: 42) and 16–61 dBHL (mean: 36), respectively. With regards to employment status, five were not in work, six worked part-time and three worked full-time (>30 h per week). Six of the participants wore bilateral hearing aids, four unilateral aids, and four had no hearing aids. No invited participants who replied subsequently declined to take part or dropped out.This study was approved by the West of Scotland Research Ethics Service (18/WS/0030). All participants provided written informed consent .Questions were designed to answer the three research questions. In order to minimise any biasing of participants, the explicit questions regarding fatigue were embedded within wider questions about the impact of hearing impairment on everyday life which included prompts to further investigate responses. This made it possible to examine whether fatigue was brought up without prompting. At the outset it was stated to participants that the goal of the research was to study the impact of hearing impairment on everyday life. The responses to questions about the general impact of hearing impairment were also expected to be potentially insightful with regards to fatigue. In order to cover all important aspects of everyday life, regular prompts were used to ask about home, work and social life. At the end of the interviews, participants were debriefed regarding the exact goals of the research in addition to summarising the main points raised. This allowed the participants the opportunity to clarify or build on their responses. Participants were not followed up for further interviews or input regarding transcripts or findings.Supplementary Appendix 1).The question guide went through several stages of development, beginning with one to one discussions between JH and GN. The guide was then presented in front of the wider research group in the same department to dissect and discuss. Finally, the guide was scrutinised by a researcher from out-with the department who had experience running semi-structured interviews in a different clinical population. The guide was then pilot tested once to ensure clarity and comprehensiveness. This resulted in a final question guide . Thematic analysis was used to analyse the transcripts. Thematic analysis comprises of six stages designed to identify important themes that emerge from the data (Braun and Clarke Supplementary Appendix 2). This represents the ultimate results of the qualitative analysis.A key stage at the end of the process was the creation of the coding manual. The purpose of the manual is for other researchers to apply it to the transcripts in order to ascertain the validity and reliability of the results of the thematic analysis (Joffe and Yardley Supplementary Appendix 3). COREQ is a 32 item checklist designed for explicit, comprehensive and transparent reporting of qualitative studies  sleep disruption. Additionally, participants described fatigue-specific need for breaks and recovery, and expressed their opinion on the perceived relationship between hearing impairment and fatigue. Descriptions of fatigue were most common in work and social situations. Through the interviews, it became apparent that different participants undertook different levels and types of activity during an average week, both in terms of occupation  and sociParticipants often described feelings of tiredness or weariness that arose as a direct result of the need for extra concentration and mental effort when listening. This was most usually described as a general or mental tiredness. While certain situations were labelled as tiring, the fatigue was often stated as being felt upon resolution of the event or at the end of the day, with direct causation being attributed by participants to the difficulties caused by their hearing impairment.I do find it tiring [hearing impairment] because I feel that I've got to put additionally an extra focus on when people are speaking, maybe it's because I'm in like a fairly responsible job you know, it's not as if I just can’t not be seen to not listen you know I've got to really listen and understand people and carve out my own instructions for my own workload. So, by the end of a working day for me or any day in general I feel quite tired with it because I feel I'm having to focus more, lip read more or you know face people more that sort of thing and I would say it adds a certain amount of stress to you (P008).It was also suggested that increased physical effort due to a hearing impairment was sometimes responsible for fatigue. It is therefore meaningful to draw a distinction between concentration/focus and movement or repetition. Positioning and movement in order to hear, as well as the need for repetition, were the main reasons for effort-related fatigue that was not exclusively linked to cognitive effort.Having to concentrate more and going in and out of the room when I’m doing something else is tiring (P004).I’m trying to do a new job just now and trying to get - the guy that’s showing me stuff whispers, so I have to say a couple of times, what was that or say that again. That’s extra effort, so I’m feeling a bit exhausted now with just learning stuff (P001).In addition to fatigue resulting from increased effort, participants mentioned that sometimes fatigue was the result of negative emotions associated with participants’ experiences of living with a hearing impairment. Emotion-driven fatigue was reported predominantly as a consequence of frustration and stress experienced during conversation with others. These fatiguing emotions were suggested to be a direct result of not being able to hear, or to occur indirectly due to social pressure . There was also an example of fatigue directly linked to tinnitus, due to the negative emotions resulting from the perceived noise.Frustration I think does make me tired, sometimes I find myself losing interest in the conversation, I find myself losing interest in the company I'm with (P010).It [social situations] can be a wee bit, mentally tiring. Like I say, if I’m in a group of people I don’t really know, it can – I get a wee bit stressed (P002).Yes, double check, so you know it is frustrating as a person when you have that and it is tiring because it's always in the back of your mind psychologically you know, you're thinking people think I'm not interested or they're not showing any interest so you know, you probably think too much and become paranoid in a way (P008).Some participants gave accounts of challenging listening situations which resulted in them taking breaks or having spells of recovery. These accounts, while not mentioning fatigue directly, suggest that hearing impairment is a significant contributory factor to the fatigue experienced by participants.And it’s almost like after that you want to just go into a total quiet place and just go right okay, give me five minutes (P003).Difficulty going to sleep was described as a cause of fatigue the next morning by those participants who stated that they experience tinnitus. For some, this tiredness persisted throughout the next day, but others mitigated it.At night I’m not sleeping with it [tinnitus] as it seems to be worse at night (P004).It would make me certainly start off the day tired, but because you work with children you’ve got to – you’re always very, very aware of not bringing your home into your school… So the professionalism kicks in at that stage and you just have to get on with it (P003).Throughout the interviews, the experience of hearing impairment-related fatigue across participants varied considerably. Some participants explained that hearing impairment-related fatigue was a major issue that they faced. A few participants did not experience it at all. Others felt that it contributed to their tiredness but that it was either not the major cause of fatigue in their lives or that they had never thought about the possibility of their hearing impairment contributing to fatigue. Therefore it seems likely that hearing-related fatigue is not experienced by all people with a hearing impairment.I'm sure there's a cross link maybe between the two together you know, it's maybe not just all down to hearing all the time it's probably a bit of demands of the job and you're trying to deal with that as well (P008).I: Were there any levels of tiredness in those situations? P: I don’t know, I’ve never put it together. It’s a bit draining (P007).Probably the most tiring thing for me in my everyday life is a group conversation (P008).Increased effort was mentioned directly as one of the most common reasons for hearing impairment-related fatigue. Participants, however, went into more detail about how hearing impairment results in an increased effort, which may, therefore, be relevant to its impact on fatigue.Participants regularly discussed that extra mental effort was needed in conversation with others due to their hearing impairment. Added concentration and focus on listening was stated as well as the need to watch lips, facial expressions and body language in order to maintain conversations.Yes, but I’ve still got to concentrate and look at people more. Now, when people speak to me, I look at their face. Before, you could have talked to me and if I was writing something then I wouldn’t bother looking at them. Now, I have to look at people when they talk to me (P005).Participants stated that in order to aid comprehension they would move to hear clearer. This was sometimes by walking closer to the person speaking, changing room or leaning closer.And then as they were trying to speak to me, if they were over there, I would say hold on a wee minute. And I would be right up close to them so I could pick up what they were saying (P012).Participants reported regularly needing to check the information they were receiving. Checking of information was most commonly a verbal request for repetition. Re-listening to electronic messages such as voicemail was also mentioned.…having to maybe double check any messages that are on the phone, rather than having to just pick up on the first case scenario you know I'm always judging myself did he say that or did she say that (P008).The impact of hearing impairment on relationships and emotions was probed specifically during the interviews. Participants regularly reported that hearing impairments have had a negative impact on their personal relationships and emotions. This is distinct from the emotion-driven fatigue identified in theme 1.Emotions and feelings experienced as a result of hearing impairment were overwhelmingly negative. Emotions that were expressed ranged from frustration and embarrassment to sadness and resentment and were suggested to result from the limitations imposed on everyday life by the hearing impairment.It does make me sad that this is it and it’s not going to get any better (P005).I’m missing bits you know and that’s very frustrating (P009).While there were no positive emotions that arose from having a hearing impairment, there were some statements that demonstrated a level of acceptance of the problem.I’m getting used to it, so it doesn’t really bother me now (P001).The closest that any participant got to a positive statement was that hearing very little meant that they got a better night’s sleep than their partner.Hearing impairment and the consequent reduction in conversational ability can result in emotions such as frustration and anger for both the person with hearing impairment and others in the conversation. Participants cited a lack of empathy and understanding from friends, family and colleagues as one of the main causes of friction in relationships. This is the extension of the negative emotions that hearing impairments can cause, into psychosocial consequences.My son gets annoyed with me because when he phones me up and I give him all the wrong answers (P011).There can be quite a point of blowing up at each other but I can understand where she’s coming from but I don’t think she understands how I feel about it (P008).Participants revealed several different coping strategies linked to difficult listening situations. The strategies were sometimes described specifically as addressing fatigue and effort, however, strategies were on occasion reported with no specific insight into the reason for their utilisation. Participants reported mentally or physically avoiding or withdrawing from difficult listening or communication situations, and a need to plan and prepare for listening tasks. Coping strategies were most commonly reported for work and social situations.A strategy of mental withdrawal was often mentioned as being utilised in order to deal with experienced fatigue and effort. In conversational situations, particularly group conversations, participants would stop engaging in listening. This was usually described as a response to the situation being “not worth it” anymore. Sometimes this would be accompanied by nodding along so as to appear engaged in the conversation.The noise level goes up and up and up and if I’m talking to you, I can’t hear you clearly and I’d miss out on every third word you say. Then I get frustrated and start switching off (P006).I can find myself getting tired with getting back to what I said earlier on, I have to step back a bit from the conversation sometimes (P010).Occasionally participants described physically removing themselves from a challenging situation, rather than mental withdrawal. Again this tended to be due to a decision that the conversation was not worth the bother anymore, particularly in noisy group environments.I find it difficult and I’ll think, ‘Why am I doing this?’ It’s different when you’re in a car and you can’t just open the door and get out. I make the excuse of going for a cup of tea or start mingling (P006).As well as withdrawing, participants also pre-emptively avoided events due to expected problems resulting from their hearing impairments. The reasoning for avoidance was the same as for withdrawing, but avoidance was a strategy that was introduced ahead of time. Some found this to be a dilemma between their dislike for challenging situations and their wish to maintain a social life or not offend people.I think it could be a combination thing, you know if I knew where we were going was going to be noisy, things like ceramic floors and just a general din and I was really tired I might decline the offer, I might decline the offer, it is unlikely because I'm quite a social person (P009).I feel stupid, you know if somebody is saying something and I don't know how to answer it so I try to avoid situations where I'm going to be in close contact with people (P013).A more specific occurrence that was raised by some participants was the decision not to engage with others when they were already in a social situation. This was usually at group events such as restaurant meals or weddings where there are multiple potential conversational options with a decision already having been made to attend. It would then be decided that to avoid negative effects such as increased fatigue or embarrassment, certain people would not be engaged with.But, but if you’re in a group, you can choose, so if I was at a wedding I would pick out people that I was going to have a conversation with (P003).Participants detailed different ways in which they plan ahead of time to mitigate challenging listening situations. Examples include identifying what location to go to, who was going to be there, and whether or not to wear hearing aids. Planning, in general, could plausibly be interpreted as additional effort rather than as a coping strategy, however, planning was almost always described as a way to avoid negative outcomes rather than being a negative outcome in itself.I analyse who’s going to be there (P001).When I go out with my husband and this friend he has a hearing loss so we’re inclined to go for places that we know are not going to be noisy (P009).A specific but common example of planning deemed necessary due to a hearing impairment was deciding where to sit. Participants would position themselves so that they could see faces and improve audibility.There’s a lot of thought that goes into it before; before I meet the person and we get to the venue, I scan the table for the best place to sit (P004).Occasionally it was mentioned that having a hearing impairment resulted in participants putting in additional efforts ahead of time in order to make the situation easier, usually a work scenario or event for which they were responsible.I’d try to prepare in advance and build on names, who they were etc. I would do a lot of preparation that other people wouldn’t do in order to help myself (P004).While not all participants had hearing aids, those that did described the impact hearing aids have on their everyday life and how they affect the outcomes from having a hearing impairment.Hearing aids were primarily described as improving audibility. This, in turn, led to a general feeling of improved well-being as well as improved social participation and reduced effort and fatigue. Although never stated unprompted, when asked specifically, every participant who experienced hearing impairment-related fatigue said that wearing hearing aids lessened their experienced fatigue. Improved conversational ability was one of the most common unprompted responses. Participants struggled to report on the relative impact of hearing aids on fatigue that arises due to effort, emotion or sleep disruption.If I’ve not got them, I won’t put myself in the situation. I’ve always got at least one in. I wouldn’t dream of going out without them, I would hate it (P007).Well it makes it a bit clearer because I can actually hear music and people talking the same as, I could only hear the music and not hear people but now I can hear both (P012).Participants also mentioned that hearing aids have negative effects on their everyday lives. The negative effects consisted of distorted and unpleasant sounds, physical pain when wearing them, amplification of background noise and embarrassment to be seen wearing them. There were no specific negative effects mentioned in relation to fatigue.No, they actually made it [conversation] worse. The clanking of the cutlery or glasses on the table when I was out for a meal was booming. Background music as well, if it’s to one side of me then it’s particularly bad (P004).Many, but not all, participants were aware of experiencing hearing-impairment related fatigue.Hearing impairment-related fatigue can result from increased effort, negative emotions or disruption to sleep. There is great variation among individuals regarding the impact their hearing impairment has on their fatigue, however, altered behaviour and utilisation of coping strategies are some of the described effects.Hearing aid fitting does seem to have a beneficial impact on fatigue, however, the magnitude of benefit is not clear.Hearing impairment has been shown in previous literature to be linked to increased levels of fatigue. Directly through reference to fatigue, and indirectly through reference to concomitant emotions and behaviours, this study addresses the three research questions: (1) Do all people with hearing impairment experience hearing impairment-related fatigue in everyday life? (2) How does hearing impairment-related fatigue manifest and what effects does it have on everyday life? (3) What effect does hearing aid fitting have on fatigue? This is achieved with the findings that:The finding that hearing-impairment related fatigue is not experienced by all people matches the reporting of fatigue by some but not all participants in previous research into hearing impaired populations  and differing utilisation of coping strategies. Future research is needed to investigate the fatigue associated with specific listening activities, and how hearing-related fatigue is impacted by an individual’s motivation to engage in given situations. Additionally, given that the extent of fatigue attributable to hearing impairment varies widely amongst people, more research is needed to investigate the impact hearing aid fitting has on fatigue.


Self-esteem is a good predictor of mental health and is crucial for well-being and psychological functioning. It is especially important in situations where there are potential mental health problems, such as in people suffering from hearing loss or total deafness. This study aims to gauge the level of self-esteem in adults with hearing problems, in particular those who, in adulthood, had received a cochlear implant (CI). The subjects had different onset  and amount  of hearing loss, and their current level of self-esteem was compared to that of the general population. The association of self-esteem with other deafness-related variables  and sociodemographic factors was also investigated.t-test, ANOVA), investigated correlations, and applied linear regression.Data were obtained from questionnaires mailed to patients who, when adult, had received a CI. The subjects were divided into four subgroups: subjects with pre-lingual deafness, post-lingual deafness, pre-lingual partial deafness, and post-lingual partial deafness. To evaluate their self-esteem, the Rosenberg Self-Esteem Scale (RSES) was used. For data on sociodemographic status and information related to deafness and CI, we used our own Information Inquiry form. For statistical analysis of the results, we compared means . Also men had higher self-esteem than women. Those with higher levels of education, and those working or studying, had higher self-esteem than those who did not. RSES was found to have a single-factor structure.Deafness and partial deafness appear to be risk factors for lower self-esteem, a finding that rehabilitation, medical, educational, and employment communities should be made aware of. Medical intervention in the form of a CI supplies the person with improved hearing, but it is not a panacea: their self-esteem is still vulnerable, and reinforcement of self-esteem is an aspect that professionals should focus on. Psychological, psycho-educational, and psychotherapeutic interventions have important roles to play for CI recipients. Self-esteem, according to Rosenberg ,2 is an RSES has commonly been used to measure global self-esteem in the deaf and hard of hearing (DHH) population –9. It haThe present study on global self-esteem concerns adults with deafness or partial deafness. For our purposes, deaf adults are considered here to be those whose hearing loss meets the criteria of severe or profound hearing loss . Adults In many studies of global self-esteem, the concept has been associated with how well people function in the psychosocial sphere , 25–26. Pre-lingual deafness is usually associated with childhood difficulties in developing speech and language –34. SurpIn the case of people with acquired deafness, i.e. those that are post-lingually deaf, hearing can be lost suddenly or gradually, but in either case the loss is often traumatic , 44–45. A meta-analysis of self-esteem in the DHH population in the 1990s concluded that self-esteem was lower than, or perhaps similar to, those with normal hearing . HoweverOf particular interest, previous studies found that deaf adults whose parents used to communicate with them using sign language had generally higher self-esteem than those who used oral communication . The latIn initial studies on DHH, it was argued that social benefits, including better self-esteem, were provided by education in schools for the deaf, even though integrated schools provide academic advantages . Later sWhen considering the relationship between self-esteem and various deafness-related factors, the role of Deaf identity or Deaf acculturation also needs to be taken into account. Research shows that deaf people who are culturally Deaf but who also have bicultural identities appear to show higher self-esteem ,61–62, wdo not play a role in deaf people’s self-esteem: whether the person communicates in sign language or speech  does not appear to matter; similarly, neither does age or sex [On the other hand, many factors e or sex ,9,38,56.One would think that the degree of hearing loss would be a major factor in self-esteem, but findings indicate that the degree of hearing loss is unrelated to psychological distress (taking note that distress is itself negatively correlated with self-esteem of DHH subjects) ,64. In jIn view of the previous findings mentioned above, there is much about self-esteem that still needs to be clarified, particularly when the CI factor is added. Few studies focus on the global self-esteem of DHH adults in general, and research on the self-esteem of DHH individuals who have opted for a CI is scant e.g. ,54. IndeThe purpose of the study was to assess the global self-esteem of deaf and partially deaf subjects who have used one CI from adulthood. To achieve this, the RSES was used in its Polish adaptation –3. In paThe study group consisted of 120 CI users aged 22 to 60 years old. Sociodemographic information on them is presented in Data related to deafness and CI use was also recorded: time of onset of hearing impairment ; amount of hearing loss ; years of CI experience; configuration of hearing prosthesis (CI or CI+HA); and satisfaction with their CI . SatisfaAs a reference, a group with normal hearing (1121 persons aged 15 to 55 years) and tested with the Polish adaptation of RSES was used [M = 29.1 years, SD = 13.8, range = 1–56) and age at the time of implantation . The duration of hearing loss in pre-lingual subjects was identical to age, and age at the time of implantation was very strongly correlated with age .Data on the duration of hearing loss was also collected for post-lingual subjects  who are still recognized in Poland as members of the deaf population, even if they have a CI. The subjects here did not know sign language (there was a specific question on this in the survey form), they had completed mainstream or integrated education with hearing persons at various levels, and, as can be inferred indirectly, they had hearing acculturation. In terms of language and communication, they used only spoken Polish. They were therefore a homogeneous group which can be considered audiologically deaf . Subjects who acquired a CI during childhood or adolescence were also not included, because such people are young, and the present study wanted to focus on subjects in early to middle adulthood (18 to 60 years).All procedures were approved by the ethics committee of the Institute of Physiology and Pathology of Hearing, Warsaw . No written consent was provided, since the study was based on anonymous questionnaires.A survey form was used to collect information on sociodemographic variables , and variables related to deafness and CI, such as when hearing loss occurred and how long a CI had been used. One question asked about satisfaction with the CI, and the respondents marked the extent to which they were satisfied with their CI on a visual analog scale . The line, 161-mm long, fitted across the page of the form. The respondent’s response was measured in millimeters and converted to a percentage. This variable did not meet the assumptions of a normal distribution and was converted to a logarithm. More about the method of measuring satisfaction with a CI can be found elsewhere . FinallyThe research was conducted by mail. Respondents received a letter requesting anonymous and voluntary participation, questionnaires, and a survey form. The study was conducted in two stages: the first reached out to people with pre- or post-lingual deafness, for which the response rate was 64.0%. The second stage was addressed to subjects with partial deafness, for which there was a very similar response rate (63.5%).χ2(34) = 87.42; p<0.001; CFI = 0.89; NFI = 0.84; RMSEA = 0.12. According to Hu and Bentler [χ2-values. For CFI, the cut-off value should be 0.90 or greater; for NFI a value above 0.90 is considered acceptable. Good model fit is indicated by an RMSEA value of 0.06 or less. According to these criteria, a bi-factor model for RSES verified in people with hearing loss must be considered inadequate.The Rosenberg Self-Esteem Scale (RSES) ; in Poli Bentler  a good mIn the RSES, respondents consider each statement and indicate to what extent it applies to themselves. It uses a 4-point Likert scale, ranging from strongly agree (4) to strongly disagree (1). RSES scores are therefore in the range of 10 to 40 points, and the higher the score, the higher the self-esteem. Rosenberg considers that high self-esteem means that the subject is convinced that he is "good enough", a valued person.In the present study, Cronbach alpha for all subjects was 0.88 and in the subgroups with different hearing loss and with different onset  ranged from 0.86 to 0.91 .M = 28.20, standard deviation SD = 4.87. The distribution of the variable was normal .Global self-esteem in the study group ranged from 17 to 40 points . The mean self-esteem level was M = 29.17, SD = 4.89) than women . Self-esteem was also related to education: deaf people with higher education had higher self-esteem  than people with basic or secondary education . Marital (partnership) status was another important factor for high self-esteem: deaf people in a relationship had higher self-esteem  than those who were not . Self-esteem was also related to occupation: deaf workers (and students) had higher self-esteem  than non-working (or non-studying) people . All these differences were significant (p <0.05).Global self-esteem for subgroups with different sociodemographic characteristics is presented in F = 5.76; p = 0.018; e2 = 0.05.As the unemployed were significantly older than the employed, an analysis of covariance taking age into account was also performed, which confirmed that self-esteem was related to employment (or study): It was also found that self-esteem tended to decrease with age, but the correlation was not significant.Individual results of RSES for all subjects are shown in A two-way analysis of variance was performed to test whether self-esteem is related to time of onset and degree of deafness. Time of onset of deafness, the amount of hearing loss, and their interaction, were statistically insignificant.r = 0.28; p = 0.002. The configuration of the hearing prosthesis (CI vs CI+HA) was not significant for self-esteem. There was also no significant relationship between self-esteem and duration of CI experience.Self-esteem was positively correlated with satisfaction with the CI: Dzwonkowska et al.  reportedM = 27.23, SD = 4.69) than normally hearing females , whereas male CI users did not differ in self-esteem from normally hearing males  than those with normal hearing , and this difference was primarily due to lower self-esteem in those with profound hearing loss and post-lingual onset  = 4.15; p <0.001. The sociodemographic factors explained 27.9% of self-esteem variance (R2 adjusted = 24.0%), and after entering the variables associated with hearing loss, the explained self-esteem variance increased to 34.4% (R2 adjusted = 26.1%). The change in R2 was not statistically significant: F = 1.43; p = 0.211, so the contribution of predictors associated with hearing loss and CI use to explain variance of self-esteem was rather small. The regression model was statistically significant: p = 0.089, for employment status p = 0.050, for educational status p = 0.055); so being male, being employed, and having better education are associated with higher self-esteem.In the case of gender, the reference group was women; for education it was primary and secondary; for marital (partnership) status it was not in a relationship; for employment (or study) status it was unemployed. Regression results indicate that marital (partnership) status (presently in a relationship), and satisfaction with CI are significant predictors of self-esteem. They are associated with higher self-esteem, with the greatest impact on self-esteem (highest beta) among CI users being marital (partnership) status. Gender, employment (or study) status, and educational status tended to be significant predictors of self-esteem  and levels . All these participants received their CI only after they had become adult.In overview, the subjects who had been using a CI since adulthood had lower self-esteem compared to the general normally hearing population. This finding corresponds with the existing literature on deafness , 74–75. Why should these people be so vulnerable? The present study has shown that neither the time of onset of hearing loss  nor level of hearing loss  explained why their level of global self-esteem was so low. Interestingly, earlier similar studies in the DHH population have shown no correlation between degree of hearing loss and psychological distress , 75, 78.The crux of the matter appears to be the attitude of the user towards their CI. Our results show that from the variables associated with hearing loss and CI use, the only highly significant predictor of high self-esteem was a high level of satisfaction with their CI. Of course, this is only a correlation, and it may be that those with higher self-esteem are likely to be more satisfied with their CI. One could imagine this may be because they perform tasks better, are more persistent, more active, or bring a more positive attitude than those with lower self-esteem ,25,79. ITurning now to the difference between pre- and post-lingually deafened subjects, our results showed that the post-lingually deafened had the lowest self-esteem of all CI users. For some reason, they were most affected by the negative, devastating effects–the “trauma” as a number of our subjects called it–of profound or total loss of hearing –45,48,81Although the CI “works” in terms of acting as a hearing prosthesis and enabling perception of surroundings sounds and speech ,21,71,82On the other hand, global self-esteem in other CI users–people with pre-lingual profound deafness or with partial deafness of pre- or post-lingual origin–was comparable to the self-esteem of the general population. This indicates that, among other things, a CI can certainly help these people achieve a good quality of life and high self-esteem. Motivation and a positive attitude are therefore essential to overcome the inherent limitations of a CI. In this respect it should be remembered that people who volunteer for CI surgery may already have higher than average self-esteem and a stronger desire to improve their quality of life, particularly as it relates to health and hearing . Again, Among the group of sociodemographic variables it was found that being in a relationship was the biggest factor in elevating a CI user’s level of self-esteem. However, among the study group only 47.5% were in a relationship, which is appreciably less than in the general Polish population, about 62% . The lowWe found that higher levels of education was another important factor promoting self-esteem. The same sort of relationship was obtained in Carter's 2016 study of self-esteem in deaf people of varying degrees and etiologies  . A similIn our study, male CI users tended to have significantly higher self-esteem than females, with the men having a level of self-esteem not much different to men in the general population. Female CI users not only had lower self-esteem than men, but also lower than that of normally hearing women from the general population. Most self-esteem studies of deaf people do not show such a difference between the genders. On the other hand, some studies of the general population do show that men tend to have higher self-esteem than women ,14.Our findings showed that occupational activity (or learning) also appeared to be linked to global self-esteem, although it should be stressed that this sociodemographic variable had borderline predictive properties. However, in general, CI users who were professionally active, or studying, had higher levels of self-esteem. In our group, those who were actively working or studying were 59.2% of the total, which is similar to the percentage of those of working age in Poland– 56.1% in 2016 . The relBased on the results of the CFA, we can say that the two-way model (in which positive and negative items are placed in separate groups) was not confirmed with respect to the RSES results obtained in our study for DHH CI users. Perhaps this result reveals the specificity of the study population, which is expressed by a one-factor solution.These studies are among the first to address the self-esteem of the DHH  who had used a CI from adulthood. However, the relatively small sample size is a limiting factor. In the future, it would be interesting to look at adult CI users who received a CI in early childhood and grew up with a CI. There are still only a few studies that have examined long-term outcomes based on reports from the patients themselves ,95. Of cAn interesting population are those DHH people who are CI users but identify with the Deaf community, an important linguistic and cultural minority ,43,54,64A limitation of the presented study relates to its cross-sectional design and the purely correlational approach. This means we cannot say for sure that use of a CI contributes to raising global self-esteem, although the two factors are at least correlated. It seems reasonable to assume that the CI, through its ability to provide a form of hearing , will support psychosocial processes such as language development and interaction with the environment, and therefore help improve the quality of life of DHH people. In doing that, it appears to contribute to their global self-esteem.Self-esteem is important, especially for populations at risk of mental health problems, which is the DHH population. Despite all the unquestionable benefits of a CI as a hearing prosthesis, not all CI users deal completely with the trauma of hearing loss. Thus, as de Graaf and Bijl (2002) postulated more than 15 years ago , every eS1 File(XLSX)Click here for additional data file.