The Kingdon model, based on the convergence of three streams  and the opening of a policy window, analyses the process by which a health issue is placed on the political agenda. We used this model to document the political agenda-setting process of the newborn hearing screening programme in Belgium.A qualitative study based on a document review and on semi-directed interviews was carried out. The interviews were conducted with nine people who had played a role in putting the issue in question on the political agenda, and the documents reviewed included scientific literature and internal reports and publications from the newborn hearing screening programme. The thematic analysis of the data collected was carried out on the basis of the Kingdon model’s three streams.The political agenda-setting of this screening programme was based on many factors. The problem stream included factors external to the context under study, such as the technological developments and the contribution of the scientific literature which led to the recommendation to provide newborn hearing screening. The two other streams (policy and politics) covered factors internal to the Belgian context. The fact that it was locally feasible with financial support, the network of doctors convinced of the need for newborn hearing screening, the drafting of various proposals, and the search for financing were all part of the policy stream. The Belgian political context and the policy opportunities concerning preventive medicine were identified as significant factors in the third stream. When these three streams converged, a policy window opened, allowing newborn hearing screening onto the political agenda and enabling the policy decision for its introduction.The advantage of applying the Kingdon model in our approach was the ability to demonstrate the political agenda-setting process, using the three streams. This made it possible to identify the many factors involved in the process. However, the roles of the stakeholders and of the context were somewhat inexplicit in this model. In public health, political agenda-setting and policy decision-making are analysed using various concepts and models. In many cases, this type of analysis tends to present what happened, but not how it happened. It ofteA more dynamic model explaining political agenda-setting for a specific health issue was developed by Kingdon,5. This The first stream is the problem stream-5: problIn the field of preventive medicine, the introduction of some systematic screening programmes has been performed by government decision. Whatever the target population, this type of screening involves looking for asymptomatic conditions using standard, systematic testing with the aim of identifying people likely to be suffering from the condition so that they can be referred for definitive diagnosis. When scFédération Wallonie-Bruxelles), formerly known as the French Community, officially launched its newborn hearing screening programme at the end of 2006, while the Flemish Community decided in 1998 to offer screening via its Mother and Child Welfare Agency[With the aim of early detection, screening newborns for certain metabolic diseases has been recommended for decades. In Belge Agency.The aim of this study was to document the political agenda-setting process that led to the introduction of the newborn hearing screening programme in the FWB. The context for the study was the FWB, which exercises its authority over the French-speaking citizens of Belgium.This was a qualitative study, based on a document review and on semi-directed interviews carried out with participants identified as having contributed to the political agenda-setting and introduction of the newborn hearing screening programme in the FWB.Office de la Naissance et de l’Enfance (ONE – the FWB’s Mother and Child Welfare Agency), a health insurance fund representative, and two representatives of the minister responsible for health prevention policy at the time of the decision to introduce the newborn hearing screening programme. These interviews took place between February and September 2012, after which an association of parents of hearing-impaired children, representing the patients’ point of view, was also contacted and included in the study. Thus, a purposeful sampling was used and no criterion of redundancy was defined.The participants were from the medical and political communities, from healthcare organisation services, or were patient representatives: they were ENT specialists working in university (n = 3) and non-university (n = 1) hospitals, a paediatrician from the The interview guide, with open-ended questions, was comprised of three parts. The first aimed to collect information on existing hearing screening activities in the FWB prior to the introduction of the newborn hearing screening programme and to identify any synergies between the stakeholders involved, the various actions carried out to implement the programme, and the context associated with this issue. The second part focused on the consultation process and the drafting of the programme’s organisation protocol, and the third aimed to understand the choices made in the drafting of the programme’s organisation protocol. The information collected in the first part of the guide was used in this analysis. It was supplemented by documents  identified during the review of the archives of the programme’s reference centre or during the semi-directed interviews. Scientific literature relating to hearing screening programmes and to hearing impairment in newborns was also reviewed.The methodological approach used followed the analysis process explained by Varvasovszky et al.. First, The problem stream centred around the fact that there was no universal hearing screening programme in the FWB, the aim of which is the early treatment of hearing-impaired children in order to allow them to develop to their full potential. Two key factors contributed to this first stream: the scientific literature and technological developments Figure .According to prevalence data found in the scientific literature, neonatal hearing impairment is a frequent condition: at least 1‰ of newborns suffer bilateral permanent childhood hearing impairment (≥40 dB). HoweverOn the basis of scientific studies and their expertise, North American and European professional groups have recommended, since 1994, the early diagnosis and treatment of hearing-impaired children along with universal hearing screening in newborns,15,16. AThis knowledge in the field of newborn and infant hearing (from the benefit of screening to the positive effects of treatment) has come about thanks to the development of new technologies. Hearing devices (hearing aids and cochlear implants) have greatly evolved in recent decades, giving hearing-impaired children more effective hearing systems. Since the 1990s, it has also been possible to screen children from birth using objective, reliable, painless, and rapid methods. These mThis problem stream developed over several decades. It did not include an exceptional event that might suddenly and unexpectedly have brought the issue of the absence of a newborn hearing screening programme in the FWB to the attention of policy makers. However, in light of the scientific and technological arguments, the absence of a newborn hearing screening programme was gradually identified as a shortcoming in preventive medicine in the FWB.This second stream falls within a context in which newborn hearing screening had been carried out for several decades in certain hospitals in the FWB. This consisted of local hospital initiatives or partnerships with intervention services for hearing-impaired children which delegated staff to carry out hearing tests in maternity units. Hearing screening was most often carried out using behavioural tests for which false positives and false negatives were high. Some of these screening programmes had been adapted, while others were terminated for organisational reasons or due to a lack of finances, especially as the Federal Sickness Fund had intervened in order to reduce the extra costs generated by these hearing tests. In 2003, ONE carried out a review of the local newborn hearing screening initiatives in the FWB and found that the protocols applied when screening was provided in maternity units varied. This diversity was apparent both in the methods , and in the choice of hearing tests used . Where hospitals were not offering hearing tests, reasons for the non-provision or termination of a hearing screening programme were mainly linked with the lack of reimbursement for the screening process and therefore financial difficulties in providing the screening. This situation showed that, in the local context specific to these hospitals and despite the diversity of the protocols, newborn hearing screening was feasible in the FWB if the financial conditions there were favourable , it was proposed that the hearing tests be carried out by ONE workers in maternity units, and it was then proposed that the newborn hearing screening be carried out in maternity units by hospital staff and that ONE coordinate the programme. The latter eliminated one of the problems raised by the previous proposals, as part of ONE workers in contact with newborns were not nurses but social workers, unqualified to carry out hearing tests. The proposals by ONE’s paediatric consultants were reported on several occasions to the executive bodies and the minister concerned, but it seems that the strategic decisions made for ONE by these bodies did not include the introduction of newborn hearing screening within the institution at that time.In order to overcome the financial barriers, health insurance funds were contacted and federal financing was considered, but these proposals were not taken up.In the development of the proposals, the reproducibility of the newborn hearing screening programmes established outside of the FWB was studied. The favoured example was the programme implemented in the Dutch-speaking part of Belgium (Flanders) since 1998, in which the newborn hearing screening programme is carried out by the Mother and Child Welfare Agency. HearingIn this second stream, the stakeholders supporting the proposals had a specific role: these doctors, who were not acting on behalf of a medical association, became involved in the project on an individual level. They did not have expert knowledge of political lobbying or the use of conclusive data for policy decision-making and do not seem to have used these tools to argue for the adoption of their proposals. The arguments used to promote the proposals were essentially scientific and feasibility arguments, and the proposals developed were only sent to policy makers after a long delay.Analysis of this policy stream revealed the following: i) the provision of newborn hearing screening was locally possible in maternity units in the FWB, with financial support; ii) a network of professionals  convinced of the need to provide newborn hearing screening had developed and had prepared several newborn hearing screening protocols, adapted to the context of the FWB; iii) ONE, which works in the field of preventive medicine and early childhood, had participated in the drafting of the newborn hearing screening proposals and played a major role in some of the proposals prepared; and iv) at the beginning of the 2000s, the lack of financial resources seems to have been the main obstacle to introducing a newborn hearing screening programme based on proposals from both hospital doctors and ONE’s paediatric consultants.Raising the awareness of policy makers on the issue of newborn hearing screening was introduced at the end of the 1990s. In 1999, the attention of policy makers was drawn to the need to provide newborn hearing screening via an awareness letter jointly signed by doctors requesting the funding for this screening. During this same period, but in the Brussels context, an ENT doctor approached the Brussels-Capital Health and Social Observatory to obtain backing to introduce newborn hearing screening in the region. This did not take place due to a lack of financial resources and the fear that some Brussels’ inhabitants would not buy into the screening, which would undermine its scientific relevance if it were not systematic and universal. Following this move, a feasibility study was carried out in 2001–2002, in three Brussels hospitals. This study concluded that providing newborn hearing screening was feasible if certain conditions were met, such as taking into account the complexities of the health system and the fragmentation of healthcare activities. In addition, as a result of an inter-ministerial conference of health ministers, a working group on newborn screening was created, but it was stopped at the beginning of the 2000s with no specific progress being made on the issue of newborn hearing screening Figure .Other stakeholders also raised awareness among policy makers on the need to introduce newborn hearing screening: in 2003, an association of parents of hearing-impaired children organised a political forum, and in 2004 and 2005 a working group from the FWB’s sign language advisory committee addressed members of parliament on the need to provide newborn hearing screening.In 2004, elections were held and the policy declaration of the FWB government for the 2004 to 2009 period planned to evaluate existing local newborn hearing screening projects in maternity units and to study the possibility of extending these across the FWB. During this period, ministerial authority in preventive medicine and health promotion was held by a doctor, an uncommon situation in Belgium.In this third stream, the role of the levels of power responsible for exercising authority in preventive medicine should not be overlooked. In the Belgian health system, the federal level manages issues related to curative medicine while the communities are responsible for preventive medicine and health promotion. The Communities  therefore have the opportunity to develop their own prevention policies, giving rise to a platform for comparison between the screening programmes available to the populations of the Communities. As regards newborn hearing screening, the Flemish Community has had a programme since 1998, which was not the case in the FWB, meaning that Belgian newborns had unequal chances of receiving a hearing test and early treatment in the event of hearing impairment depending on the Community (French or Flemish) to which they belonged. This discrepancy gave rise to political pressure for the FWB to catch up in the field of newborn hearing screening.At a particular moment, these three streams converged. The provision of newborn hearing screening was recognised as necessary to allow hearing-impaired children to develop to their full potential through early treatment. Technological developments had made it possible to effectively treat hearing-impaired children and carry out reliable hearing tests from birth. Local experiences in the FWB, and national and regional experiences outside the FWB, supported the feasibility of a newborn hearing screening programme. Various newborn hearing screening proposals had been issued with the aim of developing a programme in the FWB. These proposals had come from hospital doctors and ONE paediatric consultants but had not been put into practice, primarily for financial reasons. Lastly, policy makers were aware of preventive medicine issues and of newborn hearing screening, and when a new government came in in 2004, it was in a context of policy opportunities as regards preventive medicine.At the end of 2004, these different streams converged. A policy and possible decision window was opened when a newborn hearing screening proposal in partnership with ONE was submitted to the minister to request the funding required for its implementation.The policy decision by the minister responsible for prevention policy to introduce a newborn hearing screening programme in the FWB led to the creation of a working group. This group was responsible for preparing the protocol for the programme and was composed primarily of the ENT specialists, paediatricians (from ONE), and representatives of health insurance funds who had prepared the various proposals for providing newborn hearing screening. Financial resources were made available to subsidise this programme. In November 2006, the newborn hearing screening programme in the FWB was officially presented and proposed to hospitals: newborn hearing screening would be provided by hospitals with a maternity unit in order to achieve a high rate of coverage and to avoid a high proportion of newborns being lost to follow-up; the participation of the hospitals was voluntary. The programme would be coordinated, from the start, by a university team, with ONE’s role confined to raising parents’ awareness, particularly in the event of the absence of hearing tests or in the presence of non-conclusive results.The political agenda-setting and policy decision to provide a newborn hearing screening programme in the FWB were based on many factors. Some factors did not concern the context of the FWB, such as the data from scientific literature and the technological developments that were identified in the first stream, while other factors were specific to the context of the FWB: local operational feasibility, the newborn hearing screening proposals, the synergies between stakeholders, and the political context, all of which were analysed in the second and third streams.The factors external to the context of the FWB (problem stream) were based on studies and data from the literature. The evidence utilisation is put forward by various authors as a decision support component,25,26. TOne of the factors specific to the FWB context that contributed to the agenda-setting and decision for newborn hearing screening was the key role of the stakeholders in addressing policy makers; this ties in with Exworthy’s findings. In our In our analysis, the three streams evolved independently and reached maturity at a similar time, although the problem stream had been available before the others as its content fuelled the policy stream. The factors in our study are in line with those developed by Almeida et al., who stated that the transformation of technical and scientific proposals into policy decisions to implement involve much more than the willingness of the stakeholders or the technical quality of the scientific information that recommend such a change. Ideological, political, and economic factors are decisive in the formulation of proposals and the progress of the initiatives decided upon. Indeed,The use of the Kingdon model demonstrates the importance of the process that leads to a decision; each stream evolves at its own pace, which cannot be constant or linear. This analysis also identified overlaps between the factors contributing to the political agenda-setting, in which decision-making is a part of the process. HoweverThe collection of data dating back several years was a limitation of this study. The events that occurred may be re-interpreted retrospectively and in the light of the final decision to implement the screening. In order to limit recall bias, we favoured the collection of objective information from documents. Moreover, in addition to the scientific, political, and context factors presented, it is possible that personnel or policy strategy factors may have affected the decision-making process and that this has not been documented in the study. The exhaustiveness of the information collected is difficult to prove, the decision-making process can be unclear, and access to certain documents problematic. The selThe position of the researcher and their impact on the research process are also significant in this type of analysis, but they are rarely explained in policy analysis literature. There are two types of researcher position based on whether the researcher participated in the policy process (insider) or otherwise (outsider) and the results may vary between these two approaches. In thisBy applying the Kingdon model, our work made it possible to document the political agenda-setting process that led to the introduction of a newborn hearing screening programme in the FWB. Some factors were identified as not concerning the FWB while others resulted directly from the FWB and were related to the context and situation studied. The combination of all of these factors created a context conducive to the political agenda-setting and policy decision, in a process of evidence-informed health policy-making.Fédération Wallonie-Bruxelles ; ONE: Office de la Naissance et de l’Enfance (Mother and Child Welfare Agency).FWB: The authors declare that they have no competing interests.BV participated in the design of the study, collected the data, performed the qualitative analysis, and drafted the manuscript. RL and AL participated in the design of the study, in the redaction of the manuscript, and critically reviewed the text. All authors read and approved the final manuscript.BV has coordinated the newborn hearing screening programme in the FWB since January 2007, RL was the scientific promoter of the programme between September 2006 and November 2012, and AL has been the scientific promoter of the programme since November 2012.


To give a systematic review of the development of noise-induced hearing loss (NIHL) in working life.A literature search in MEDLINE, Embase, Web of Science, Scopus, and Health and Safety Abstracts, with appropriate keywords on noise in the workplace and health, revealed 22,413 articles which were screened by six researchers. A total of 698 articles were reviewed in full text and scored with a checklist, and 187 articles were found to be relevant and of sufficient quality for further analysis.Occupational noise exposure causes between 7 and 21 % of the hearing loss among workers, lowest in the industrialized countries, where the incidence is going down, and highest in the developing countries. It is difficult to distinguish between NIHL and age-related hearing loss at an individual level. Most of the hearing loss is age related. Men lose hearing more than women do. Heredity also plays a part. Socioeconomic position, ethnicity and other factors, such as smoking, high blood pressure, diabetes, vibration and chemical substances, may also affect hearing. The use of firearms may be harmful to hearing, whereas most other sources of leisure-time noise seem to be less important. Impulse noise seems to be more deleterious to hearing than continuous noise. Occupational groups at high risk of NIHL are the military, construction workers, agriculture and others with high noise exposure.The prevalence of NIHL is declining in most industrialized countries, probably due to preventive measures. Hearing loss is mainly related to increasing age.The online version of this article (doi:10.1007/s00420-015-1083-5) contains supplementary material, which is available to authorized users. Hearing loss due to noise exposure in the workplace is a significant health problem with economic consequences. Noise-induced hearing loss (NIHL) is the occupational disease most frequently reported to the Norwegian Labour Inspection Authority and the Petroleum Safety Authority. Every year the two authorities receive close to 2000 and 600 new reports of NIHL, respectively, accounting for 60 % of all reported work-related diseases , Ovid Embase (1974–), Web of Science (1950–), Scopus (1995–), and ProQuest Health and Safety Sciences Abstracts (1981–). A search strategy was developed for each database. In the databases that are indexed by a hierarchical controlled vocabulary (MEDLINE and Embase), we used a combination of free text terms and controlled vocabulary (MeSH and EMTREE). The search strategy was developed with low specificity to the advantage of high sensitivity, i.e., high probability of hits on potentially relevant studies. The search was completed in May 2013. For more information, see the supplementary file.Inclusion criteria were exposure to occupational noise alone or in combination with other factors, hearing loss and other health outcomes and the statistical association between occupational noise and hearing loss/other health outcomes. Papers in other languages than in English and animal studies were excluded.All titles and abstracts from the literature search were assessed against the inclusion criteria for possible relevance. References that we judged to be potentially relevant were read in full text and evaluated. Relevant original studies (698 papers) were quality-assessed by at least one researcher using a comprehensive checklist for observational studies developed by the National Institute of Occupational Health based on the checklist of Ariëns et al. , longitudinal studies (N = 52), reviews (N = 22) and others (N = 7). Figure As to the present review, only articles regarding noise and hearing but not other health outcomes were included, both cross-sectional and longitudinal studies. A total of 187 papers met the inclusion criteria. These were cross-sectional studies  for 10 years is 4 dB (2–5 dB for the 10–90 percentile) and after 40 years 5 dB (3–7 dB for 10–90 percentile) , where N is NIPTS and H the expected age-related permanent threshold shift There are also reference values of the hearing loss at different frequencies for different levels of noise exposure  ISO , b. Mosthift ISO , b. In aHearing loss is often familiar. Twin studies   for the period 1983–1990 with hearing in office workers  and found that among blue collar workers over the age of 50, only 8–28 % had a normal hearing, compared to 70 % among office workers , without the use of hearing protection, and with short service time, and compared their hearing with hearing in a control group. They found that most of the hearing loss occurred during the first 3 years of employment , 85 % men, mostly between 20 and 55 years, and with a daily noise exposure level between 86 and >105 dB, were examined in Austria. The strongest estimated effect of noise, adjusted for age, gender and other covariates, was a standardized regression coefficient of 0.08 for 4 kHz , whereas exposure >85 dB revealed a hearing loss of >25 dB in the frequency range 0.5–2 kHz in 9.6 % of the employees.In a longitudinal study of 113 Egyptian male cotton workers, Moselhi et al.  reportedN = 319), aged 26–40 years at the beginning of the study, with varying daily noise exposure levels from 80 to 100 dB, were followed with repeated audiometric examinations from 1959 and 20 years ahead. The hearing loss was most pronounced at 4 kHz, approximately 15 dB. There was only a small difference in hearing between high- and low-exposed subjects. The authors suggested that the small difference might reflect chemical exposure among the workers with low noise exposure. The importance of age as a possible cause of the hearing loss was not discussed in this study (Bergstrom and Nystrom Swedish pulp workers (N = 88) were examined in 1980 and then again 8 years later. They were exposed to a mean background noise, LAeq, of 90–94 dB and impulse noise, LA, peak of 112–139 dB with 20–50 “beats per minute” (bpm). They did not use any hearing protection, and the hearing loss was significant in 1980. Upon follow-up, the age-adjusted hearing loss had increased somewhat, particularly in the 0.5–2-kHz range. Most of the hearing loss in the higher frequencies (3–8 kHz) occurred in the first 10–15 years after employment  matched for age, initial hearing thresholds and noise exposure. The intervention group did not develop any hearing loss, while the control group who received no intervention, had a small hearing loss. The study shows that a close follow-up with the use of hearing protection may have a beneficial effect . Despite the fact that almost 90 % used hearing protection, about 60 % had a reduced hearing acuity. After individual age correction to the ISO 1999, there were still about 40 % with reduced hearing acuity, most of them with exposure >5 years. The authors conclude that the noise in shipyards with impulse noise is particularly damaging to hearing  from 2000 to 2010. At the last follow-up, the group was reduced to 258 in the building trades and 58 controls. The daily noise exposure level was 87 dB for the noise exposed and 70 dB for the students. An exposure increase of 10 dB gave a hearing loss of 2–3 dB after 10 years at 3–6 kHz. Most of the hearing loss had already occurred before the initial examination. Self-reported data on noise outside work had no impact on hearing. The author suggests that the limit of 90 dB does not assure good enough protection to prevent NIHL  with a daily noise exposure of 87–96 dB were examined longitudinally with respect to hearing and compared with an internal unexposed group. The hearing loss at 4 kHz ranged from 0 dB for the age group <25 years to about 7 dB for the 55–64 year group, compared with the internal control group, which corresponds very well to ISO 1999, Annex B (unscreened)  from 1992 to 2003. The study revealed a significant increase, from 1/1000 employed in 1992 to 9/1000 in 2003  had a normal hearing, compared to ISO 1999. A follow-up study showed that the hearing loss in this group was somewhat less than expected from the ISO 1999 , revealed a significant hearing loss compared with ISO 1999  and who had applied for financial compensation. Hearing in this group was compared with hearing in 150 men with continued exposure. Hearing in the noise trauma group stabilized after approximately 1 year, whereas the group with continued exposure had a continued hearing loss  (SPL), were followed over a 3-year period. Hearing was measured by pure tone audiometry and otoacoustic emissions (OAE) . The hearing loss in the 3-, 4- and 6-kHz ranges was slightly greater than expected according to ISO, but not compared to the air traffic controllers. Helicopter pilots had a normal hearing despite a significantly higher noise exposure, Qiang et al. followed 3019 pilots aged 45–54 years flying smaller aircrafts over a 10-year period. The noise exposure in smaller aircrafts was assessed to be slightly higher than in ordinary civil aviation. The flight time was used as a proxy measure of cumulative noise exposure. When adjusted for age, there was a positive trend for the effect of flying hours, but it was not statistically significant  and cabin crew (N = 936) with a daily noise exposure level of 75–81 dB was normal, compared to a Swedish reference population    1.41 (1.06–1.90), especially for the use of police motorcycles . The group had an average daily noise exposure of 90 dB. More than 40 % of them had a hearing loss that gave the right to workers’ compensation. This was less than in the period from 1982 to 1985, where 56 % had a right to compensation. The hearing loss was associated with age and exposure to noise. The use of hearing protection appeared to have some preventive effect , miners (10.9 dB), construction workers (9.2 dB), military personnel (8.2 dB) and farmers (5.3 dB), compared to teachers . Despite the fact that almost 90 % used hearing protection, about 60 % were judged to have a noise-induced hearing loss. After individual age correction according to ISO 1999, still about 40 % of them were diagnosed with hearing loss. The authors conclude that the impulse noise in shipyards is particularly damaging to hearing.In a Swedish cross-sectional study , the participants were asked about occupational noise and impulse noise, including shooting  compared with continuous noise. He also makes note that the USA use a 5-dB correction factor (“trading factor”) compared to the 3 dB in Europe, i.e., the amount of energy is considered to be doubled for every 3-dB increase in European computations compared to 5 dB at US calculations  showed that hearing loss, defined as an average hearing threshold of 25 dB or more for the range of 0.5–4 kHz, was significantly associated with high age, male gender, low education, noisy job, ear surgery and changes in the central vein of the retina of the eye (a measure of vascular changes). The hearing loss associated with a 5-year age increase was 2.4 dB, male gender was associated with a 5.9-dB loss, low versus high education with a 3.6-dB loss, noisy work with a 1.5-dB loss and having undergone surgery to the ear with 8.9-dB loss. A borderline significant association with hearing loss was reported for cardiovascular disease, diabetes, high blood pressure, smoking, lack of exercise and high cholesterol.Data from the “Beaver Dam Offspring Study”  was associated with a 1–3-dB hearing loss at 4 kHz in men and <0.7 dB in women, adjusting for relevant factors  that men without any occupational noise exposure had a better hearing of 1–7 dB at 4 kHz in men compared to those exposed, least for the youngest. The corresponding figures were negligible for women , Agrawal et al.    of the impaired hearing due to a number of factors, such as occupational noise, shooting, height, weight, smoking, cholesterol, diabetes, BMI, heart disease, hypertension and pigmentation/eye color. Adjusted for age and gender, hearing loss was associated with occupational noise, high BMI and smoking. Better hearing was associated with moderate alcohol intake and height . Factors in other studies that have been associated with hearing loss, such as shooting, high cholesterol, diabetes, exposure to solvents, heart disease, hypertension and pigmentation/eye color, had no significant effect on hearing in this study. Based on the fact that several factors were analyzed simultaneously, the requirements for statistical significance were set high. The authors conclude that age-induced hearing loss may be modestly reduced by the same recommended actions as for the prevention of cardiovascular disease.In 2008, Fransen et al. , with concomitant noise exposure, have for many years been considered as possible risk factors for developing hearing loss.Iki et al.  examinedN = 84) and without (N = 264) VWF  and shipyard workers (N = 171) that smoking, VWF and noise all contributed significantly to the age-adjusted hearing loss. Pyykkö et al.  with significant exposure to noise and vibration.Virokannas et al.  reportedLAeq >90 dB and vibration gave a greater temporary hearing loss (TTS) than exposure to noise only. Exposure to vibration only had no effect on hearing.In an experimental study of healthy young subjects, Zhu et al.  reportedMost of the studies we identified suggest that vibration and VWF are risk factors for getting hearing loss from noise exposure. It is difficult to distinguish vibration from noise since a lot of the noise comes from vibrating tools, such as chainsaws, power tools and pneumatic tools   are styrene, toluene, lead, mercury, carbon disulfide and carbon monoxide  and the American College of Occupational and Environmental Medicine (ACOEM) have recommended that exposure to ototoxic drugs and chemicals must be taken into account when risk assessments and hearing conservation programs are being made , Dalton et al. (In a population-based study from the USA (Beaver Dam) . It is well documented that shooting may affect hearing, while the effect of other types of leisure noise is uncertain. Use of hearing protection and noise reduction measures protects against NIHL. Certain drugs may cause a significant hearing loss. The impact on hearing of other chemical substances and vibration is probably of limited importance.Table This is a systematic review of a large number of studies within this field of research and included systematic assessment of the quality of eligible studies. Many of the included studies are cross-sectional, which may be considered a weakness. We regarded it necessary to include these studies to get a good enough description of occupations and hearing loss and because the majority of the population studies are cross-sectional. The studies are usually based on measurements of noise and hearing, not self-report. Thus, both exposure and outcome data come from objective data sources. Since hearing impairment rarely leads to relocation of the worker to another job or loss of employment, this probably represents a minor problem. We therefore believe that cross-sectional studies on noise and hearing provide relatively valid data.The diversity of the outcome measures, particularly the use of different definitions of NIHL, made comparisons between studies more difficult. We cannot exclude the possibility of publication bias. Studies with positive results are often easier to publish than studies with nonpositive results. We found articles from other sources that had not been identified in the literature search, which might imply that we may have missed some literature, in spite of our choice of a sensitive rather than a specific search strategy.Population studies generally have high-quality data on outcomes, such as hearing, and also fairly good quality on possible confounding or modifying factors, such as smoking, heart disease and blood pressure, but the noise exposure data are usually of a lower quality. Population studies show that age is by far the most important predictor of hearing loss. By age 60, age-related hearing loss (in the 3–6-kHz range) is approximately 30–40 dB for males and 20 dB for females. Determining whether hearing loss exceeds the age-expected decline is made feasible by comparison with age-related hearing levels for populations who have not been exposed to noise. At the group level, hearing loss in noise-exposed workers that exceeds the age norm can be ascribed to occupational noise exposure and other exposures and factors that may cause a hearing loss. On an individual level, however, it is not possible to distinguish between a hearing loss due to aging, genetic predisposition and noise exposure. Impulse noise is probably more damaging to hearing than continuous noise and can, if the exposure level is high enough, lead to a permanent hearing loss.Other factors, in addition to noise, may have an impact on hearing. Population studies show that men are more likely to experience hearing loss than women, and genetic factors also play an important role. Moreover, social economic background and ethnicity are of importance (African-Americans experience less hearing loss than Caucasians). Smoking, coronary heart disease, diabetes, high blood pressure and other risk factors for heart disease, such as elevated level of cholesterol, seem to lead to hearing damage, but here the research findings are more uncertain, and there are reasons to expect some publication bias. Exposure to chemicals  and certain medications may cause hearing loss, and it appears that concurrent vibration may enhance the harmful effects of noise on hearing. Noisy leisure activities, especially use of firearms, can also lead to hearing loss. Leisure noise from other sources  appears to have a small effect on hearing loss in population studies, but may still be harmful at the individual level if the exposure is high enough.Studies on hearing in various professions suggest that hearing loss due to workplace noise was a significant problem in the 1960s and 1970s in industrialized countries, whereas hearing loss has been a less frequent problem in subsequent decades. The reduced occurrence of hearing loss is probably a result of decreased noise exposure, improved regulation and use of protective equipment, but the evidence for this is still limited


The objectives of this research were to 1) summarize the available evidence on the impact of hearing loss on quality of life (QOL) among U.S. active-duty service members, 2) describe the QOL instruments that have been used to quantify the impact of hearing loss on quality of life, 3) examine national population-level secondary databases and report on their utility for studying the impact of hearing loss on QOL among active-duty service members, and 4) provide recommendations for future studies that seek to quantify the impact of hearing loss in this population. There is a lack of literature that addresses the intersection of hearing impairment, the military population, and quality of life measures. For audiological research, U.S. military personnel offer a unique research population, as they are exposed to noise levels and blast environments that are highly unusual in civilian work settings and can serve as a model population for studying the impact on QOL associated with these conditions. Our team recommends conducting a study on the active-duty service member population using a measurement instrument suitable for determining decreases in QOL specifically due to hearing loss. Auditory system disabilities are some of the leading diagnoses among the veterans of Operations Enduring Freedom and Iraqi Freedom, with tinnitus and hearing loss being the two most prevalent service-connected (SC) disabilities among veterans, both overall and among the new SC disability awards given during fiscal year (FY) 2013 [Recommendations from the 2005 Institute of Medicine report on Noise and Military Service included a call for studies to estimate the incidence, prevalence, and severity of noise-induced hearing loss (NIHL) and tinnitus . DespiteEpidemiological estimates on Americans living with auditory disorders vary based on the definition used and the population sampled, but studies agree that auditory disorders are a growing problem in the U.S., especially with a rapidly aging population , 7. A suOne of stated objectives of the Department of Defense Epidemiology and Economic Burden of Hearing Loss Study (DEEBoHLS), which is led by The University of Texas School of Public Health in conjunction with the Department of Defense Hearing Center of Excellence, is to comprehensively examine the economic losses and other burdens associated with auditory system disabilities . ThroughThe terminology used in this commentary includes “hearing impairment and noise-induced hearing injury” (HINIHI), which is based on our review of the peer-reviewed literature and congressionally mandated reports . Using tPublished studies include evidence on the social, psychological, cognitive, and health effects of HINIHI in the civilian population. HINIHI results in distorted or incomplete communication leading to isolation and withdrawal and subsequently results in lower sensory input. The feeling of a constricted lifestyle negatively impacts the psychosocial well-being of people with HINIHI. HINIHI has been associated with increased mortality  and can serve as an indicator of neurological decline in older populations . In persNumerous studies have reported a high incidence of depression, suicide, and post-traumatic stress disorder (PTSD) among the active-duty population . It is pThe study team performed a broad literature review, casting a wide net to gather all relevant hearing- and military-related articles from a variety of domains. The literature review was updated throughout the study period on a monthly basis. However, although it is comprehensive, this literature review is not intended to be a systematic review.The literature search regarding hearing loss in the military was carried out using PubMed and Ovid Medline for articles published between 1990 and September 2015 using an electronic key-word search complemented by manual searching. Search terms for the literature review included “hearing”, “hearing disorders”, “hearing loss”, “hearing tests”, “hearing aids”, “audiology”, “hearing injury”, “hearing trauma”, “hearing impairment”, “hearing sensitivity”, “audiological”, “auditory injury”, “auditory trauma”, “noise induced”, “dual sensory”, “hearing threshold”, “hearing conservation”, “hearing deficiency”, “deaf”, “tympanic membrane”, “tinnitus”, “military”, “military personnel”, “military medicine”, “military facilities”, “military science”, “army”, “marine”, “soldier”, “air force”, “navy”, “national guard”, “deployment”, “combat”, “active component”, “active duty”, “armed forces”, “department of defense”, “veterans’ health”, “veterans”, “united states department of veteran affairs”, “veterans”, “disability claims”, “veterans hospitals” and “quality of life”. In addition, a web search was also performed for government reports and reports from individual organizations that were related to hearing impairment and quality of life.A total of 300 articles and reports were identified by the literature search . Of these, Table Several studies have considered the association between QOL and HINIHI in veteran and civilian populations. A study by Mulrow et al. , consideThe majority of studies investigating the relationship between QOL measures, veteran status, and HINIHI used the SF-36, which is a validated survey that contains a standardized set of 36 questions developed by the Medical Outcomes Study (MOS) in America . Two sumFeeney et al.  used theMulrow et al.  used a cVeterans Affairs Canada (VAC) takes QOL into consideration when determining the total percentage of disability for SMs . The QOLThere are QOL measurement instruments that do not appear to have been used as frequently in HINIHI studies; they include the HHIE, QDS, SPMSQ, GDS, SELF, Mini-Mental State Examination (MMSE), Psychological General Well-being Index, International Outcome Inventory-Cochlear implant (IOI-CI), and the Nord-Trondelag Health Study (HUNT) Q1 and Q2 , 35–37. The following databases Table  were expThe NHIS-OHS is a survey on current workplace exposures and occupation-related health conditions that does not contain any topics related to noise exposure or HINIHI . The BRFThe NHANES is a battery of cross-sectional studies that assess the physical health and nutritional status of non-institutionalized adults and children. The NHANES standard survey contains some questions that are related to QOL indicators, which are given to all participants, and includes a physical examination and lab test component. The audiometric component is only given to those in the targeted age range, which varies from survey to survey. The audiometric component is not given during some years and the target age ranges have varied widely, from 6-11 years in 1963-1965, 20-69 years in 1999-2004, and 12-19 and 70+ years old in 2005-2006 and 2009-2010 . HoweverThe NHIS is a cross-sectional, household interview survey for the civilian non-institutionalized population that has been conducted continuously since 1957 . The NHIThe HRS is a longitudinal study of health, retirement, and aging sponsored by the National Institute on Aging . The UniFrom our review of these available national-level databases, none contain the data necessary to assess the association of HINIHI and QOL in the U.S. military population. Therefore, we make specific recommendations below to help fill this research gap.Given the lack of universal agreement on the definition of QOL, there is no consensus regarding the best method for determining QOL . Issues Studies focused on civilian populations have consistently detected an association between HINIHI and decreased QOL measures. Our findings suggest that the SF-36 was the most frequently cited survey instrument for assessing QOL in both civilian and veteran populations in relation to HINIHI and several other health conditions. However, as outlined previously, the utility of the results from the SF-36 have been mixed when the survey has been altered to specifically address certain health conditions –30, 32. Among the secondary databases evaluated, there was a lack of information that covered the intersection of HINIHI and QOL measures in active-duty military populations. These databases may, at best, be used to investigate the association between hearing impairment and some QOL measures  or hearing impairment and its association with the veteran status of a population (NHIS). None of these secondary databases contains QOL information that pertains to active-duty SMs in relation to HINIHI.Given the high prevalence and burden of HINIHI in military populations, it is imperative to conduct a study that captures the impact of these conditions on the QOL of active-duty SMs. It is our recommendation that future studies collect prospective and primary data from randomly sampled active-duty service members using 1) a generic QOL instrument, such as the SF-36, and 2) a specific QOL instrument for assessing HINIHI. To ensure that the results are generalizable, this study population should be stratified so that major demographic  and occupational characteristics  are appropriately represented. We also recommend that future studies determining and reporting on the burden of any health condition and/or evaluating interventional outcomes in active-duty service members incorporate appropriate QOL measures.


Congenital hearing impairment affects nearly 1 in every 1000 live births and is the most frequent birth defect in developed societies. Hereditary types of hearing loss account for more than 50% of all congenital sensorineural hearing loss cases and are caused by genetic mutations. HL can be either nonsyndromic, which is restricted to the inner ear, or syndromic, a part of multiple anomalies affecting the body. Nonsyndromic HL can be categorised by mode of inheritance, such as autosomal dominant , autosomal recessive (DFNB), mitochondrial, and X-linked (DFN). To date, 125 deafness loci have been reported in the literature: 58 DFNA loci, 63 DFNB loci, and 4 X-linked loci. Mutations in genes that control the adhesion of hair cells, intracellular transport, neurotransmitter release, ionic hemeostasis, and cytoskeleton of hair cells can lead to malfunctions of the cochlea and inner ear. In recent years, with the increase in studies about genes involved in congenital hearing loss, genetic counselling and treatment options have emerged and increased in availability. This paper presents an overview of the currently known genes associated with nonsyndromic congenital hearing loss and mutations in the inner ear. Hearing loss (HL) is a common disorder, and congenital hearing impairment affects nearly 1 in every 1000 live births; it is one of the most distressing disorders and the most frequent birth defect in developed societies . These cHereditary hearing loss accounts for almost 50% of all congenital sensorineural hearing loss cases, and it is caused by genetic mutations . Deafneshttp://hereditaryhearingloss.org/) [HL can be either nonsyndromic, which is restricted to the inner ear, or syndromic, a part of multiple anomalies affecting the body. Nonsyndromic HL can further be categorised by its mode of inheritance. Approximately 20% of nonsyndromic sensorineural hearing loss (NSSHL) is inherited as autosomal dominant, which is also referred to as DFNA; this type of hearing loss is usually delayed onset. Eighty percent of inherited HL is autosomal recessive (DFNB), in which hearing loss is generally congenital, but some forms may emerge later in life. The inheritance of the remaining types of HL is either mitochondrial or X-linked (DFN) (less than 1 percent) [ss.org/) .Many genes are involved in inner-ear function, and the ear is very sensitive to mutations in genetic loci. This is because the physiology and structure of the inner ear are unique and unlike other anatomical locations. Mutations in genes that control the adhesion of hair cells, intracellular transport, neurotransmitter release, ionic hemeostasis, and cytoskeletons of hair cells can lead to malfunctions of the cochlea and inner ear. GJB2, GJB6, SLC26A4, and OTOF, are frequently involved [ SLC17A8  was found to restore hearing in the mice. In another study, hair cell development and regeneration were induced by delivering the ATOH1 gene [In recent years, with the increase in studies of genes involved in congenital hearing loss, genetic counselling and treatment options have emerged and increased in availability. In diagnostic tests, genes that are common causes of hearing loss, such asinvolved . The resOH1 gene .This minireview has presented an overview and described the currently known genes associated with nonsyndromic congenital hearing loss and mutations that cause malfunctional proteins in the inner ear .CEACAM16 (carcinogenic antigen-related cell adhesion molecule 16)) [CDH23 (cadherin 23)) [STRC (stereocilin)) [USH1C (harmonin)) [OTOA (otoancorin)) [PCDH15 (protocadherin 15)) [WHRN (whirlin)) [TMHS (tetraspan membrane protein)) [PTPRQ (tyrosine phospate receptor Q)) [The stereocilia of hair cells in the cochlea are linked and interconnected to the tectorial membrane by different adhesion proteins. Hair bundles are stabilized by a set of temporary links such as transient lateral links and ankle links. These links also induce growth and maturation with signalling complexes . In matuule 16)) , DFNB12 ocilin)) , DFNB18 rmonin)) , 15, DFNrin 15)) , DFNB31 rotein)) , and DFNptor Q)) . PTPRQ and TMHS genes, as well as cadherin 23 and protocadherin 15, are parts of the transient lateral link. During development, they prevent the fusion of each stereocilium themselves [Theemselves . USH2α and VLGR1b, are also associated with Usher syndrome, and they are part of the stereocilial ankle link [Whirlin and harmonin regulate the link complexes and serve as scaffolding proteins. Mutations in these proteins cause autosomal recessive type hearing loss, but Sans, which is a third scaffolding protein, is related to a complex syndromic hearing loss, Usher syndrome. The other genes,kle link . CEACAM16. In a similar way, otoancrin also attaches nonsensory cells to the tectorial membrane [Stereocilin is an extracellular matrix protein that attaches the tallest stereocilia of the outer hair cells to the tectorial membrane . The attIn the inner ear, all parts of the myosin family can be used for the transportation of different proteins. When using ATP, these myosin proteins bind to the actin cytockeleton and move forward. Binding sites for carried proteins are on the carboxyl-terminal tails of the transport proteins . The myo SLC17A8 in the DFNA25 locus and related to autosomal recessive hearing loss [ OTOF) is a protein that works with myosin VI at the synaptic cleft of the inner hair cell and plays a role in the calcium-dependent fusion of vesicles to the plasma membrane. As a result, glutamate is released and the afferent neuron is excited [ OTOF and SLC17A8 knockout mice, there was a reduction in the number of postsynaptic ganglion cells, and it was concluded that these proteins are very important for the preservation and development of normal hearing [VGLUT3, which is a vesicular glutamate receptor, plays a role in the inner hair cells' synapses. It is encoded bying loss . This pr excited . In an a hearing . SLC26A5 and was first described by Zheng et al. in 2000 [ SLC26A5 are the cause of DFNB61 hearing loss [The cochlea is sensitive and selective to sounds delivered by the outer hair cells. This is introduced with a process called electromotility, and a protein called Prestin is thought to be responsible for this . It chan in 2000 . Mutatioing loss . ESPN (espin), RDX (radixin), TRIOBP (trio-binding protein), ACTG1 (γ-actin), TPRN (taperin), DIAPH1 (diaphanous), and SMPX .Mutations in some genes associated with the organisation of the cytoskeleton can cause NSSHL; these are ESPN can cause DFNB36 and autosomal dominant hearing loss [ RDX can cause DFNB24 and autosomal recessive deafness [γ-actin acts as a building block for the stereocilia of hair cells. These stereocilia are constantly undergoing depolymerisation at the base and actin polymerisation at the tip [ ACTG1 can cause DFNA20/26 and autosomal dominant hearing loss [ DIAPH1, and mutations in this gene can cause DFNA1 and autosomal dominant hearing loss [γ-actin at the base of stereocilia are provided by two isoforms of the TRIOBP gene. Mutations in isoforms that are TRIOBP4 and TRIOBP5 can cause DFNB28 and autosomal recessive type hearing loss [ SMPX (DFN4), has a function in stereocilial development and maintenance in response to the mechanical stress to which stereocilia are subjected [The protein espin provides stability to the stereocilial cytoskeleton. A mutation ining loss . More stdeafness . γ-actin the tip . Mutatioing loss , 43. Viaing loss . The bining loss , 46. Anoing loss . Small mubjected .TJP2), tricellulin (MARVELD2/TRIC), claudin 14 (CLDN14), KCNQ4 (KCNQ4), Barttin (BSND), ATP2b2 (ATP2b2/PMCA2), some connexins (GJBs), and pendrin (SLC26A4), and they are all related to hereditary hearing loss [The cochlea has two types of fluids: perilymph, which is high in sodium and low in potassium, and endolymph, which is high in potassium and low in sodium; this condition makes a highly positive potential (+80 mV) called endocochlear potential. Potassium influx into the hair cells causes depolarisation and, after that, the hair cell repolarises and moves cations back into the endolymph. This ion homeostasis involves tight junction protein 2  and nonsyndromic HL (DFNB4) are related to the extent of the mutation in SLC26A4 [ BSND can cause Bartter syndrome, associated with hearing loss and renal abnormalities, but DFNB73 has also been attributed to a mutation in BSND and causing nonsyndromic deafness [Barttin and pendrin, encoded as SLC26A4 . Barttindeafness . GJB2; it is encoded as connexin 26 (DFNA3a/DFNB1a) [GJB6, DFNA3b/DFNB1b) [GJB3, DFNA2b/DFNB91) [A gap junction is a channel extending over two adjacent membranes that enables the exchange of various molecules and ions in the cochlea. These junctions are made up of proteins called connexins. These junctions also play a role in the recycling of potassium ions needed for normal hearing. it is the most common cause of nonsyndromic HL and was the first identified gene is/DFNB1a) . Other c/DFNB1b) , 56 and /DFNB91) , 58. TECTA (α-tectorin), COL11A2 (type XI collagen α2), and COCH (cochlin), and transcription factors, such as POU4f3 (class 4 POU), POU3f4 (class 3 POU), MIR96 (microRNA 96), GRHL2 (grainy-head-like 2), ESRRB (oestrogen-related receptor β), and EYA4 (eyes absent 4) involved in hereditary HL.There are also extracellular matrix proteins, that is,This review presents an overview and description of the currently known genes related to hereditary NSSHL. The functions of these genes will be better understood with time, and more genes leading to hearing loss will be discovered soon. With new studies and continued examination, the function of the cochlea will be better understood, and novel molecular and gene therapies for human sensorineural HL will hopefully be developed.


Vibration perception threshold (VPT) examination using a neurothesiometer provides objective, sensitive and specific information, and has been utilized mainly in patients with diabetic polyneropathy.Explore the utility of VPT examination in CIDP patients.CIDP subjects attending the Neuromuscular clinic between 01/2013 and 12/2014 were evaluated. Demographic data, clinical history, physical examination, VPT values, and electrophysiologic data from their charts were extracted.70 charts were reviewed. 55 CIDP patients had elevated VPT, associated with higher frequency of abnormal sensory testing for various modalities , lower sensory and motor amplitudes and reduced conduction velocities on nerve conduction studies, and lower treatment response rates .VPT examination is a simple tool, which is a reliable and sensitive measure not only for diabetic neuropathy, but also for CIDP. Moreover, in CIDP, elevated VPT values are also associated with lower treatment response rates. Sensory system evaluation is an important part of the neurological examination. However, it might be occasionally challenging, as it depends on patient cooperation. Primary sensory modalities commonly examined include light touch, pain, temperature, proprioception and vibration sensation. There are 2 different approaches for sensory testing. The first is comparative, identifying relative differences between sites , or qualitative (e.g. presence or absence of vibration sensation), and the second is absolute, attempting to grade thresholds objectively. AbsolutChronic inflammatory demyelinating polyneuropathy (CIDP) is an immune-mediated neuropathy characterized by motor greater than sensory, proximal and distal peripheral neuropathy, with a slowly progressive or relapsing course. Subjective sensory disturbance is present in 68–80% of CIDP patients, with abnormal sensory examination in most, particularly for large-fiber modalities, such as vibration and proprioception, there iCIDP subjects attending the Neuromuscular clinic for management of their immune-mediated polyneuropathy between 01/2013 and 12/2014 were evaluated for this study. In this retrospective review we extracted demographic data, clinical history, physical examination, and electrophysiologic data from their charts. The Research Ethics Board of the University Health Network approved the current study protocol, based on chart review and collection of de-identified data.CIDP was diagnosed based on the clinical presentation, as judged by a neuromuscular expert (VB), and the presence of demyelination on NCS, as per the Koski criteria. FulfillTreatment responsiveness was assessed by combining data from the clinical history, neurological examination, and the electrodiagnostic tests results, which was performed as part of the routine follow up evaluation. Treatment responders were defined as those who stabilized after declining progressively, or improved after treatment, whereas treatment non-responders were defined as those who either worsened or did not change after treatment.Abnormal VQT was defined as absence vibration perception at the toes, using a standard 128 Hz tuning fork, as part of the routine neurological examination.VPT testing was performed with a Neurothesiometer, using the method of limits. The stiNCS were performed using the Sierra Wave instrument . Age- and height-adjusted NCS reference values were used, according to the standards of the Toronto General Hospital  electrophysiology laboratory. Limb temperature was measured prior to nerve conduction studies, and if required, warming was performed to ensure a surface temperature of ≥32.0°C in the hands and ≥31.0°C in the feet.Median, ulnar, peroneal, tibial and sural NCS were performed using surface stimulating and recording techniques according to the standards of the Canadian Society of Clinical Neurophysiology and the American Association of Neuromuscular and Electrodiagnostic Medicine. The eleStatistical analysis was performed using SAS version 9.2 for Windows . Clinical and electrophysiological characteristics were expressed as mean ± standard deviation (SD) for continuous variables, or as frequency and percent for ordinal variables. Comparisons between groups were made using the student’s t-test, the Wilcoxon rank-sum test, or the χ2-test, depending on the type and distribution of the variable. Receiver operating characteristic (ROC) curves for the identification of abnormal NCS parameters by VPT were generated as follows: At each upper limb site (the median sensory nerve and median motor nerve), VPT measured at the finger was the continuous “test variable”, and a separate ROC curve was generated for two dichotomous outcomes, one being abnormal amplitude, and the other being abnormal conduction velocity. Likewise, at each lower limb site , VPT measured at the toe was the continuous test variable, and abnormal conduction velocity and abnormal amplitude were the dichotomous outcome variables. Areas under the ROC curve (AUC) were calculated, and optimal operating thresholds for each test and outcome combination were chosen so as to maximize specificity while retaining high sensitivity. Additionally, VQT was treated as a dichotomous test for identifying the same abnormal NCS parameters. P-values less than 0.05 were considered statistically significant.70 CIDP patients’ charts were reviewed. Their demographic data is shown in Similar associations were observed in CIDP patients with abnormal VQT, showing high sensitivity for detecting lower limb sensory and motor nerve conduction abnormalities, and lower treatment response rates . However, VQT was less specific compared to VPT testing .VPT receiver operating characteristic ROC area under curves were generally high, especially for sural nerve amplitude (0.83), conduction velocity (0.84), and tibial nerve motor amplitude (0.87) Figs  and 2.The current study shows that elevated VPT in CIDP patients is associated with a more severe neuropathy, manifested by worse clinical and electrophysiological examinations Tables  and 2. AAs CIDP involves multiple sensory and motor nerves, it is not surprising that abnormal sensory testing in one sensory modality, such as vibration, is associated with sensory abnormalities in other modalities, and even with a trend for distal leg weakness. Similarly, there is electrophysiological evidence not only for worse sensory NCS, but also for worse motor NCS, manifested by reduced amplitudes and lower conduction velocities. These findings imply that VPT testing is a reliable and a sensitive measure for CIDP.An additional important finding in this study is the association of abnormal vibration testing and lower treatment response rates in CIDP patients. A similar association is shown after excluding CIDP patients with diabetes, although the have higher percentage of abnormal vibration sensation. Although 60 to 80 percent of CIDP patients are expected to respond to treatment, it is difficult to predict treatment responsiveness. Prediction of outcome has been related to the pattern of weakness, the preLower treatment response rates in CIDP patients with abnormal vibration perception might be expected at least theoretically, due to a more severe neuropathy, as reflected by worse clinical and electrophysiological findings, which might be associated with more widespread irreversible nerve fiber loss. However, the largest study of IVIG in CIDP patients to date has shown that advanced loss of axons does not lead to failure to respond to treatment,18. TherThe finding of an older age in CIDP patients with elevated VPT is not surprising, as age affects peripheral nerve function. In addition, higher VPT values were also found among older patients with diabetic polyneuropathy. In contThe current study has several limitations. First, although only statistically significant results were considered, the numbers are low, mainly in CIDP patients with normal vibration testing. In addition, misclassification and selection bias are potential errors, as there are no biomarkers to make a definitive diagnosis of CIDP. There are additional neuropathies causing proximal weakness, such as diabetic radiculoplexopathies, and slowing of conduction velocity might be due to loss of ion channels in the inter-nodal region or other factors without true demyelination. Current electrodiagnostic criteria for CIDP also have limited sensitivity, as they are research oriented, favouring specificity over sensitivity . And finIn conclusion, VPT examination is a simple tool, which is a reliable and sensitive measure not only for diabetic neuropathy, but also for evaluating CIDP severity. Moreover, in CIDP elevated VPT are also associated with lower treatment response rates, although still more than half of patients will respond to treatment. Prospective trials are required in order to confirm these findings, and further explore the utility of VPT testing in other neuropathies.S1 Database(XLS)Click here for additional data file.


Cognitive behavioral therapy (CBT) for voice-hearing  has, at best, small to moderate effects. One possible reason for this limited efficacy is that current CBT approaches tend to conceptualize voice-hearing as a homogenous experience in terms of the cognitive processes involved in AVH. However, the highly heterogeneous nature of voice-hearing suggests that many different cognitive processes may be involved in the etiology of AVH. These heterogeneous voice-hearing experiences do, however, appear to cluster into a set of subtypes, opening up the possibility of tailoring treatment to the subtype of AVH that a voice-hearer reports. In this paper, we (a) outline our rationale for tailoring CBT to subtypes of voice-hearing, (b) describe CBT for three putative subtypes of AVH , and (c) discuss potential limitations and problems with such an approach. We conclude by arguing that tailoring CBT to subtypes of voice-hearing could prove to be a valuable therapeutic development, which may be especially effective when used in early intervention in psychosis services. Auditory verbal hallucinations (AVH), or “voice-hearing,” refers to the experience of hearing a voice in the absence of an appropriate external stimulus and which “has a sufficient sense of reality to resemble a veridical perception, over which the subject does not feel s/he has direct and voluntary control, and which occurs in the awake state” David, , p. 110.Cognitive behavioral therapy .CBTp is recommended by the National Institute for Health and Care Excellence (NICE) in the UK , g = 0.57), while in studies where it appeared unlikely that masking was compromised, there was a non-significant effect of CBTp on positive symptoms (Hedges' g = 0.08). In terms of hallucinations, Jauhar et al. reported a large difference between the effect size of CBTp for auditory hallucinations between masked (Hedges' g = 0.18) and non-masked studies (Hedges' g = 0.91). Second, van der Gaag et al.'s meta-analysis has been criticized by Laws et al.  in trials are taken into account  s et al.  that soms et al. . It shous et al. . In summOne reason why CBT for voice-hearing may have limited effectiveness is that current interventions typically treat voice-hearing as a relatively homogenous experience in terms of underlying cognitive processes. While most researchers and clinicians acknowledge heterogeneity in voice-hearing and suggest that this must be addressed by interventions , it is unclear what specific facets of the diverse voice-hearing experience determine what kind of intervention is delivered. For example, the coping strategies and behavioral experiments employed in CBT for voice-hearing often refer to ways that a voice-hearer can interrupt inner speech, based on the assumption that if one is able to interfere with the production of inner speech, one can prevent the generation of the “raw material” of an AVH. This is demonstrated by one recent CBT for voice-hearing intervention, which included participants learning coping skills such as humming, singing, reading, reading out loud, and talking to someone  showing how a subtype of AVH may be identified, (b) explaining how CBT should be modified according to the subtype of AVH that has been identified, and (c) providing a theoretical rationale for why CBT should be tailored in a particular manner for each subtype. The manual is concerned with three of the subtypes proposed by McCarthy-Jones et al. —inner spAs in other forms of CBTp, the manual encourages the clinician to develop a shared problem list with a service-user and to respect their interpretation of their experiences . The manual  how inner speech develops, based on a Vygotskian  or the sound of the voice  may help to reduce the distress experienced by voice-hearers as it shows ways in which they can try to control AVHs when they occur. Beyond activities focused on inner speech, the manual encourages the avoidance of thought suppression strategies and rumination, and the use of effective emotion regulation strategies, such as distraction and seeking social support.Philip had become acutely unwell, leading to a hospital admission, where he described a belief that he had been kidnapped by psychologists for an experiment. He believed that he had been placed in a false town that copied his home town and his parents and family were imposters. Philip could hear and see the psychologists, particularly at night. Treatment initially focused on reducing the risk to his parents and testing out his delusional beliefs, before the focus turned to his voices. Philip described being distressed by conversations with the psychologists and also intrusive critical voices. Philip's experiences were classified as inner speech-based AVH as they typically provided a running commentary on his activities and happened more often when he was alone and focused on his own thoughts. Therapy involved presenting an explanation of how inner speech develops and an exercise on various ways people can experience inner speech, including forms of inner speech that “sound” like other people's voices. The role of the phonological loop in a person's inner speech was described and Philip was encouraged to try to block the loop with humming and listening to music in his head. The success of these strategies increased his belief that the voices were similar to his inner speech. Philip was then encouraged to summon the psychologists in his mind and transform both their voice and appearance. He enjoyed forcing them into comic voices and appearances, which provided further evidence that they were similar to his inner speech and that he could exercise control over them. When Philip experienced the voice he became adept at blocking the phonological loop or transforming the voice into something comic, which reduced his distress and the voices started to reduce in frequency.Memory-based AVH are thought to occur when a person experiences an intrusive  verbal cognition, through many of the process normally involved in generating auditory memories, and misattributes it to an external, non-self source  how memory normally works; (b) how memories of traumatic experiences tend to differ from normal memories; (c) how low effort cognitions are hard to identify as self-generated; (d) how ineffective thought suppression can be, and how it typically leads to a paradoxical increase in the suppressed thought; (e) how stress/negative affect can make it difficult to recognize cognitions as self-generated. Thus, a core aim of CBT for memory-based AVH is to help a voice-hearer to understand that AVH can be seen as a relatively normal response to some type of traumatic experience.Many of the coping strategies for memory-based AVH are drawn from interventions for PTSD . As a result, a person becomes very anxious, scans the environment for comments related to those beliefs, and begins to misinterpret environmental noise  as containing those comments  the role of top-down influences on perception; (b) how our perceptual systems have evolved to help us survive by quickly detecting threat; (c) how feelings of fear and anxiety make us more likely to misperceive threat to be present when it is not; and (d) how when our perceptual systems are dealing with degraded or noisy data, they are more likely to make mistakes. Thus, a core aim of psychoeducation for hypervigilance AVH is to help a voice-hearer understand that our perceptions are influenced by what we expect to see and hear, and that when we expect to find threats in our environment, we are very likely to find them, even when they are not present.The coping strategies suggested for hypervigilance AVH involve reducing physiological arousal, reducing perceived threat, reality testing, rational self-talk, and distraction. These coping strategies aim to help a person control feelings of fear and anxiety by either reducing bodily arousal  or their beliefs about the threats present in their environment . If this is achieved, the likelihood that a service-user will experience a hypervigilance AVH should be reduced. Moreover, should they experience an AVH, their ability to control their levels of fear and anxiety should enable a service-user to engage in rational self-talk, where they can question whether what they have heard could really have been said to them, and/or to use distraction techniques to divert their attention away from scanning for threat and thus reduce AVH-related distress.Rick had been involved in a violent confrontation with a local gang, where he had tried to protect his father. He became very vigilant for any signs that he was to be targeted in a reprisal attack. He began to hear comments from people passing his house at night suggesting that he would be assaulted and this created a vicious circle where he stayed awake throughout the night to listen for signs of threat and began to hear more signs of this threat. This vicious circle was broken when Rick was hospitalized and began medication. On discharge he felt stigmatized by his mental health problems, remained convinced that he was in danger, and was, therefore, reluctant to leave his house. His voice hearing experiences were classified as hypervigilance AVH, as they occurred when his attention was externally-focused and their content was consistent with the threat he predicted he was under. Therapy focused on providing a longitudinal formulation of what had happened to Rick prior to his admission. The formulation highlighted that it would be natural for him to become more conscious of threat after the violent incident. Rick's situation was likened to a soldier in a dangerous situation where hypervigilance for threat has more positive than negative effects . However, in Rick's situation, hypervigilance for threat had more negative than positive effects, and his sense of threat had escalated through sleep deprivation, substance misuse, and the onset of his voices. Psychoeducation included reviewing the importance of top-down processing or expectations on perception and error management theory. Rick found the formulation compelling and normalizing and it reduced the stigma he felt. Recognizing that the threatening comments he had heard were a result of him scanning his environment for threat, rather than genuine indicators of a threat, enabled him to reassess the level of danger he was in, allowing him to engage in graded exposure so that he was able to leave the house.The manual described here thus differs from traditional CBT for voice-hearing in that it provides multiple formulation templates that should aid the creation of a shared formulation concerning how a voice-hearer's AVH developed. These templates will reflect the individual factors for each voice-hearer , but they guide the clinician to consider that varied cognitive/emotional processes may be driving different types of AVH. Thus, the clinician should be more able to (a) provide psycho-education that is a better “fit” with a voice-hearer's experiences, (b) identify behavioral experiments that are more likely help to change a voice-hearer's appraisals of their AVH, and (c) suggest coping strategies that are more likely to reduce the frequency of AVH. That being said, the approach we describe is not intended to “replace” existing CBT for voice-hearing; rather, its aim is to complement and enhance the options available to clinicians. We envisage it being used in tandem with other CBTp interventions with a specific focus, such as those that attempt to improve self-esteem (e.g., Freeman et al., While there are reasons to believe that adopting the approach described here will lead to the development of more effective psychological interventions for voice-hearing, there are also a number of reasons to be cautious. First, there is a relatively long history of approaches that involve subtyping of hallucinatory experiences being of little practical use in terms of developing better interventions (Stephane, That being said, claims about these subtypes remain tentative and further research examining the subtypes of AVH described here is required. For example, it needs to be determined whether these subtypes can be reliably identified. While previous research (e.g., McCarthy-Jones et al., Another issue is that most voice-hearers report that they experience multiple subtypes of AVH. For example, McCarthy-Jones et al.  reportedA final concern is that the aims of this particular subtyping approach are to reduce the frequency of AVH and to reduce the distress associated with AVH. Aiming to reduce the frequency of AVH is, to some extent, inconsistent with one of the core tenet of CBT for psychosis: that clinicians should seek to reduce the distress associated with AVH by changing a voice-hearer's appraisals of their experience, and that reducing the frequency of psychotic experiences is not typically a target in therapy (Morrison and Barratt, At present CBT for voice-hearing has only limited effectiveness. There is growing evidence that AVHs may be usefully divided into a set of subtypes and the existence of these subtypes might, in part, account for this limited effectiveness of CBT for voice-hearing. In this article we have described how CBT for voice-hearing could be tailored for three putative subtypes of AVH. At present, we are examining the acceptability of this approach for both clinicians and service-users and, if acceptability is demonstrated, we will investigate its efficacy in a randomized controlled trial.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In the present study, we aimed to determine the effect of both active and passive smoking on the prevalence of the hearing impairment and the hearing thresholds in different age groups through the analysis of data collected from the Korea National Health and Nutrition Examination Survey (KNHANES).Cross-sectional epidemiological study.The KNHANES is an ongoing population study that started in 1998. We included a total of 12,935 participants aged ≥19 years in the KNHANES, from 2010 to 2012, in the present study. Pure-tone audiometric (PTA) testing was conducted and the frequencies tested were 0.5, 1, 2, 3, 4, and 6 kHz. Smoking status was categorized into three groups; current smoking group, passive smoking group and non-smoking group.In the current smoking group, the prevalence of speech-frequency bilateral hearing impairment was increased in ages of 40−69, and the rate of high frequency bilateral hearing impairment was elevated in ages of 30−79. When we investigated the impact of smoking on hearing thresholds, we found that the current smoking group had significantly increased hearing thresholds compared to the passive smoking group and non-smoking groups, across all ages in both speech-relevant and high frequencies. The passive smoking group did not have an elevated prevalence of either speech-frequency bilateral hearing impairment or high frequency bilateral hearing impairment, except in ages of 40s. However, the passive smoking group had higher hearing thresholds than the non-smoking group in the 30s and 40s age groups.Current smoking was associated with hearing impairment in both speech-relevant frequency and high frequency across all ages. However, except in the ages of 40s, passive smoking was not related to hearing impairment in either speech-relevant or high frequencies. Hearinging loss . In our ing loss .There are various risk factors for hearing loss; genetic causes, complications at birth, infectious disease, chronic ear infections, the use of ototoxic medications, exposure to noise, sex, ageing and so on. Among the different associated factors, ageing is a well-known and major factor in hearing loss , 5. Age-In this present study, we aimed to determine the effect of smoking on the prevalence of hearing impairment in different age groups among the general population. We also investigated the influence of both current and passive smoking on the prevalence of hearing impairment and hearing thresholds.The Korea National Health and Nutrition Examination Survey (KNHANES) commenced in 1998, and collates the general health and nutrition status of populations under the auspices of the Korean Ministry of Health and Welfare. KNHANES V is the fifth survey and represents data for the years 2010 to 2012. KNHANES V used a rolling sample design, so that the samples from each year were independent and represented the whole South Korean population. KNHANES V included 11,520 South Korean households. In the present study, a total of 12,935 individuals aged 19 years and above, representing a South Korean population of 27,435,476, were included.Pure-tone audiometric tests were conducted using a SA 203 audiometer . Tests were performed in a soundproof booth inside a mobile bus reserved for the KNHANES, using supra-auricular headphones. Otolaryngologists, who had been trained to operate the audiometer, provided instructions to participants and obtained the recordings. Automated testing was programmed according to a modified Hughson−Westlake procedure; it used a single pure tone of 1 to 2 seconds and the lowest level at which the subject responded to 50% of the pure tone was set as the threshold. The automated hearing test involving air-conducted pure tone stimuli showed good test–retest reliability and validity, comparable to the manual pure-tone audio test .ParticipWe assessed two types of hearing impairment for the analysis; speech-relevant frequency hearing impairment and high-frequency hearing impairment. Speech-relevant frequency hearing impairment was defined as a threshold of ≥25 decibel hearing level (dBHL) in pure tone audiometry (PTA) of frequencies at 0.5, 1, 2, 3, and 4 kHz. High-frequency hearing impairment often precedes speech-relevant hearing impairment since it is more susceptible to environmental ototoxic factors, and was defined as a threshold of ≥ 25 dBHL in PTA of frequencies at 3, 4, and 6 kHz.In the study, only bilateral hearing impairment cases were included; and the impairment was defined as a hearing threshold ≥25 dBHL in both ears. To minimize the influence of age on hearing level, we categorized the participants into similar age groups and evaluated the prevalence of hearing impairment and the decline in hearing thresholds.time regardless of the amount they inhale. The passive smoking group was described as participants who have never smoked in their lifetime, but were exposed to daily cigarette fumes daily at home and/or at work, regardless of the exposure time. The non-smoking group was characterized as individuals who had never smoked in their lifetime and were was not exposed to cigarette smoke at home or work.Smoking status was categorized into three groups. The current smoking group was defined as participants who smoke at present Medical history information and lifestyle habits were collected using physical examinations and self-report questionnaires. The experience of the work-related noise exposure was asked regardless of the exposure time. The prevalence of diabetes, hypertension, depression, and stress were identified. Regular exercise was defined as moderate physical activity performed for at least 30 minutes at a time at least five times a week.We estimated the prevalence of bilateral hearing impairment in both speech-relevant frequency and high-frequency according to the smoking status. Analysis was conducted under stratification by age group . We also calculated the PTA thresholds in both speech-relevant frequency and high-frequency according to the smoking status. The differences between groups were analyzed using the χ2 (chi-square) method and linear regression analysis with adjustment for age, sex, and work-related noise exposure. Logistic regression analysis was performed to determine the odds ratio (OR) and 95% confidence interval (CI), with adjustment for sex, age, and work-related noise exposure. We first adjusted for age and sex (model 1), and then adjusted for age, sex, and work-related noise exposure (model 2), and finally adjusted for age, sex, work-related noise exposure, diabete, hypertension, depression, stress and regular exercise (model 3). Statistical analyses were performed using the survey procedure instructions for the SAS 9.3 software . P-values < 0.05 were considered statistically significant. All data were analyzed using the survey sample weights assigned to represent the Korean population.,Among 12,935 participants analyzed, 3,374 (26.08%) were current smokers, 2,792 (21.58%) were passive smokers and 6,769 (52.33%) were non-smokers . Of the In age-stratified analysis, cigarette smoking was associated with speech-relevant frequency hearing impairment in 40s, 50s, and 60s age-group . The curAfter adjustment for age, and sex, the OR of smoking status was evaluated. The OR of the current smoking group was 1.48, with a 95% CI of 1.16 − 1.88 , Model 1In age-stratified analysis, cigarette smoking demonstrated a close relationship with the prevalence rate of high frequency hearing loss in the 30s, 40s, 50s, 60s, and 70s age groups . The curthe this difference was not significant .After adjustment for age, and sex, the OR of smoking status was evaluated. The OR of the current smoking group was 1.41, with a 95% CI of 1.13 − 1.74 , Model 1In order to investigate the impact of smoking on hearing thresholds, we compared the PTA thresholds of individuals in the three smoking categories.The association of smoking with hearing threshold was further examined with regression analysis. In the analysis of speech-relevant frequencies after adjusting for age, sex, and work-related noise exposure, the current smoking group had a 2.46 ± 0.33 dB higher PTA threshold than the non- smoking group, and a 1.64 ± 0.34 dB higher threshold than the passive smoking group . MoreoveTo our knowledge, this is the first study demonstrating the age-specific effect of both active and passive smoking on the prevalence of hearing impairment and hearing thresholds in a large population survey study. In this study, current smoking was found to increase the prevalence of speech-relevant frequency hearing impairment in individuals aged 40−69 years, and the rate of high frequency hearing impairment in individuals aged 30−79 years. Additionally, current smoking significantly affected hearing thresholds across all ages in both speech-relevant and high frequencies. On the other hand, passive smoking had a significant effect only on the prevalence of hearing impairment in individuals aged 40−49 years, and elevated the hearing threshold of speech-relevant frequencies and high frequencies in the 30s and 40s age groups. Moreover, regression analysis of the association between smoking and hearing threshold demonstrated that both the current smoking group and passive smoking group had higher hearing thresholds than the non-smoking group.data and other studies [Hearing impairment is affected by various social factors, such as smoking, alcohol use, occupational or leisure noise exposure, and occupational vibration, as well as different medical factors, such as hypertension, diabetes, and increased serum cholesterols , 15–18.  studies , 5 that We suggest that the reason that this rate was not increased in younger age groups is that the duration of smoking was not sufficiently long to develop speech-frequency hearing impairment. Additionally, the reason that current smoking did not affect the prevalence of speech-frequency hearing impairment in older groups may be related to the reduced number of participants, the effects of selective mortality and the influences of multiplicative factors in these age groups. These suggestions are supported by the fact that the influence of current smoking is greater in individuals in their 50s and 60s than those in their 40s.High frequency hearing impairment preceded the speech-relevant hearing impairment and the current smoking group showed increased prevalence of high frequency hearing impairment starting with individuals in the 30s age-groups and older. These results are consistent with other studies reporting that cigarette affects hearing levels more prominently at high frequencies –21. AnotSome studies have reported correlations between passive smoking and hearing loss prenatally, and in infants, children, and adolescents –24. ExpoAccording to our analysis, individuals in the passive smoking group  had significantly increased hearing thresholds compared to those in the non-smoking group, but passive smoking only increased the prevalence of both speech-relevant frequency and high frequency hearing impairment (hearing thresholds higher than 25dBHL) in the age group of 40−49 years. The reason for the affectation of this particular age group is unclear, but since this age group is considered to be the most socially active in Korea, it is possible that such individuals have a high chance of being exposed to large amounts of cigarette smoke in the working place. However, this result could also be biased as this analysis was based on data obtained from self-reported questionnaires regarding passive smoking, and it was not possible to quantitate the extent of the exposure.s of adults. To the best of our knowledge, there are few other studies reporting a national-level evaluation of the relationship of smoking and passive smoking with hearing loss using audiometric testing. There are some limitations to the present study. First, since it is a cross-sectional study, we cannot identify the causal relationship or the time-course of smoking and the development of hearing loss. Second, our study used KNHANES data, which uses self-reported questionnaires to examine the respondents’ lifestyle, which can create a recall bias. Third, since the amount and the duration of smoking exposure were not considered, we could not infer the quantitative relationship. Finally, we defined high frequency hearing loss as a hearing loss at 3, 4, and 6 kHz. Extended high-frequency audiometry above 8 kHz would provide clearer information regarding hearing loss at higher frequencies.A major advantage of our study is that this is an analysis of a large, population-based, nationally representative sampleCurrent smoking was associated with hearing impairment in both speech-relevant frequency and high frequency across all ages. However, except for individuals in their 40s, passive smoking was not related to hearing impairment in either speech-relevant or high frequencies.