Introduction: The approval process for MRI safety of implants includes physical observations and an experimental evaluation in artificial settings to simulate the in vivo effect. This contains the observation of temperature changes and artificial current generation by the magnetic field. From these findings, the safety of an implant and its effect on the patient can be estimated. MRI safety is based on an in vivo evaluation of adverse events after the approval process, but an actual analysis of the effect on different tissues is not followed. The effect of MRI scanning in cochlea implantees on their residual hearing as the correlate of the hair cell function is so far unknown, therefore the aim of the present study was to observe the effect of 3 T MRI on the residual hearing of cochlea implantees. Material and Methods: In this prospective study, we performed a 3 T MRI T2 2D MS Drive sequence in eight cochlea-implanted ears. Before and after the MRI scan, a bone conduction pure tone audiogram (BC PTA) was performed. All cochlea implantees had a pre-scanning threshold of low frequency residual hearing between 20 dB and 65 dB. Results: Low frequency mean residual hearing was not affected by the 3 T T2 2D MS Drive sequence. We observed a pre-scanning threshold at 250 Hz of 42.9 (SD 3.9) dB and for 500 Hz 57.1 (SD 6.4) dB. Post-scanning BC PTA was for 250 Hz 42.1 (SD 3.9) dB and for 500 Hz 57.1 (SD 5.7) dB. Conclusion: 3 T MRI scanning has no significant functional effect on the hair cells in cochlea implantees in low frequencies with a T2 2D MS Drive sequence. Cochlea implantation is the treatment of choice for deaf individuals and patients with residual hearing and insufficient speech perception with hearing aids.The behavioral safety and security of implantable devices in humans, during and after MRI scanning, is of central importance for the usability of such medical devices. MRI is an important clinical tool, and its growing use makes unfavorable MRI behavior a factor which significantly limits the usability of a medical device. MRI behaviour of cochlea implant devices developed from a categorization as “MRI- un-safe”  to the rThe underlying approval process is complex. The approval for MRI safety of active implantable devices involve numerous tests which evaluate different parameters of the implant , but the in vivo effects on the surrounding tissue, and especially sensitive structures like hair cells, are so far unknown.The approval process includes observations of temperature changes and artificially induced electric currents by the applied magnetic field. These observations before approval are based on a structured experimental setting, evaluating theoretical borders in which an occurrence of the effect of the surrounding tissue function is unlikely. A period of clinical observation is not part of the approval process.The inserted cochlea implant electrode is very close to the neural structures of the cochlea, and the distance to the sensory hair cells of the cochlea could be less than a millimeter. In comparison to the pacemaker field, which has a comparable approval process, this relationship between the electrode and surrounding tissue is substantially different because the pacemaker field is without sensory hair cells. This constellation in the inner ear is of great interest, because of the evolving indications of implants in patients with residual hearing. Therefore, the effect of MRI on the hair cell function of cochlea implantees need to be considered, since it addresses the potential risk of hearing loss causation by the MRI scan.The aim of the present study was to observe the effect of 3 T MRI on the postoperative substantial residual hearing of cochlea implantees.In this prospective study, we observed 8 cochlea-implanted ears operated on in 2021/2022 . The length of insertion was up to 28 mm . All patients had a substantial residual hearing at 250 and 500 Hz between 20 dB and 65 dB, postoperatively.All patients included in the study had a bone conductive pure tone audiogram (BC PTA) before and after the MRI scanning. The period between the MRI scanning and secondary BC PTA was between 5 min and 4 days (mean 1.9 days). During the scan, all patients wore a protective headphone to decrease the risk of a noise-induced hearing loss. A frequency threshold comparison was performed for 250 Hz and 500 Hz since it was present for all patients. Single patients had additional persisting frequency thresholds which were not included for a better comparability.The MRI is part of our routine postoperative protocol for the evaluation of the intra-cochlea electrode position .MRI: Achieva, Philips Medical System, Best, The NetherlandSequence: T2 2D Drive MS, voxel size 0.3 × 0.3 × 0.9; FOV 150 × 150, TE 100 ms TR 3000, TSE tact 17, multi shot, flip angle 90°, refocus control 120, metric 512; NSA 5, foldover: AP, SAR: <1.6 W/kg whole bodyEstimation of insertional depth in angle was performed by a NEW TOM VGI, Verona, Italy.Parameter: FOV 15 × 15 cm, 10.48–20.52 mAS, KV 110, 360° followed by a 2D and 3D reconstruction at an external workstation .Statistics: we used the Wilcoxon matched pairs signed-rank test .Procedures conformed to the World Medical Association’s Declaration of Helsinki and were approved by the University of Münster Faculty of Medicine and Health Sciences Research Ethics Committee (reference: 135-f-S-Amendment). All participants gave their written informed consent.p > 0.9999 for both). The mean pre-scanning BC PTA was for 250 Hz 42.9 (SD 3.9) dB and for 500 Hz 57.1 (SD 6.4) dB. The post-scanning BC PTA was for 250 Hz 42.1 (SD 3.9) dB and for 500 Hz 57.1 (SD 5.7) dB. A loss of a frequency response was not observed. The mean insertional angle was 442.5°, ranging from 370° to 560°.We observed no significant difference between the pre- and post-scanning BC PTA at 250 and 500 Hz.   from MRI-unsafe  over-recThe approval process of the devices is complex and contains numerous tests based on a standardized protocol.The ISO TS 10974:2018  protocol evaluates multiple factors .One limitation of the approval process for cochlea implants is a lack of an in vivo evaluation of the surrounding tissue, especially the labyrinthine hair cell function. These cells (even without a cochlea implant) are known to be affected temporarily by MRI scans and can be stimulated by the magnetic field ,12.While MRI scans without a cochlea implant have been shown to affect the hearing function, relating to the scanner-generated noise exposure at 1.5 T , the addWe observed in our study no statistically significant BC threshold difference between the mean pre- and post-scanning observation, focusing on a short time period of up to four days . By thisHair cells are known to be temperature sensitive, and their function is temporary affected by a temperature increase of more than 1.4 °C  in humanThis finding is of great importance since not only are the number of MRI scans is increasing , but theA physical overlap of the residual hearing region in our group (to 500 Hz) and electrode insertion depth  can be assumed to be present based on the observations of Stakhovskaya  for mostA further limitation of our study is the use of only a single MRI sequence (T2 2D MS Drive). This sequence is commonly used in our department for a postoperative evaluation  and is tThree T MRI scanning has no significant negative effect on the hair cell function in cochlea implantees in low frequencies with a T2 2D MS Drive sequence.


The disease has emerged in recent years and coincides generally with immunosuppression on the patient side. Mucormycosis is still rarely recognized in the clinical because of its unspecific symptoms which often triggers misdiagnosis with bacterial or viral infections leading to prolonged therapeutic cycles and loss of valuable time to manage mucormycosis properly. Infected patients develop various clinical forms, most notably ranging from rhinocerebral via pulmonary to gastrointestinal forms. Traditional diagnosis is based on culture and histopathologic examinations of the affected tissue. But, the achievement of a precise result is time-consuming, labor-intensive, requires mycological expertise and the finding appears often too late. A rapid and precise diagnosis is mandatory because symptoms are non-specific and the disease is rapidly progressing with often fatal outcome. Mucormycosis was increasingly associated with other infections and underlying conditions and risk factors causing comorbidities, which are difficult to successfully manage. This mini-review summarizes the current knowledge on the epidemiology and causative agents of mucormycosis, transmission, risk factors, clinical presentation, diagnosis, and highlights the lack of appropriate biomarkers on the pathogen and the host sides for rapid pathogen and host susceptibility detection, respectively. Fungal antigens and single nucleotide polymorphisms (SNPs) in human host genes are useful for the assessment of susceptibility. This mini-review addresses possibilities for early prediction of susceptibility to mucormycosis based on forecasting of the risk of infection with fungal pathogens other than Mucorales. The topic of early prediction and diagnosis of mucormycosis represents a current research gap and highlights the importance of potential future developments in the area of risk assessment, susceptibility prognosis in conjunction with early diagnosis to reduce mortality in patients suffering from mucormycosis.Mucormycosis is a fungal disease caused by members of the fungal order Mucorales, which are abundantly found in terrestrial environments. The fungi propagate clonally  The infections are caused by filamentous fungi of the order Mucorales, a dominant group among zygosporic fungi which were formerly summarized as zygomycetes. The fungi are ubiquitous and predominate in the decomposition of organic matter. Among the clinically important genera (1) siformis .Although inhalation of spores is the most common route of transmission, the disease can also be acquired cutaneously and gastrointestinally . This liThis mini-review will outline the various fields of research targeting risk assessment, prediction, and prognosis based on human-derived biomarkers and their variants.In patients with mucormycosis, cellular immunity has been shown to be critical in combating these filamentous fungi. Therefore, comorbidities or diseases that compromise immunity and surface barrier integrity count as risk factors for acquiring the infection. The study by On the other hand, in patients without comorbidities, the main risk factors were shown in the population that used voriconazole, suffered injection sites, had a car accident, used corticosteroids, used fluconazole, had neutropenia, among others . IncreasCOVID-19 patients suffering from mucormycosis have raised the alarm worldwide, with a focus on India. Indeed, it is important to note that India already had a 70-fold higher risk of mucormycosis compared with developed countries. Despite this, an Indian multicenter epidemiologic study reported a two-fold increase in mucormycosis cases in 2019 compared with 2020 . The risRegarding its anatomical localization, mucormycosis is divided into six forms: (1) rhinocerebral, (2) pulmonary, (3) cutaneous, (4) gastrointestinal, (5) disseminated, and (6) uncommon forms. The appearance and clinical manifestations vary according to this classification and are described below .The patients in whom the rhinocerebral variant occurs are usually diabetics and/or patients with ketoacidosis. This variant is characterized by unilateral involvement accompanied by facial pain, retro-orbital headache, fever, hyposmia, numbness, and nasal congestion. Within a few days, this condition develops into a black discharge. Later, invasion of orbital nerves and vessels may be observed, including diplopia and loss of vision, nasal cavity, palate, and face with black eschar, among others. The neurological presentation may include brain involvement and loss of consciousness, which unfortunately means a poor prognosis .This pulmonary presentation is common in patients with hematologic malignancies and a history of neutropenia. Concurrent sinusitis and pulmonary disease may be expected. Pulmonary infection presents with non-specific symptoms of cough, fever, dyspnea, and hemoptysis in patients with necrosis. Auscultation reveals rales and a decreased vesicular murmur. The infection may even be so aggressive that it exceeds the values for mortality compared with other infectious agents. Cellulitis of the affected chest wall may occur in these patients .Skin diseases are often associated with trauma and loss of the skin barrier. Cases have even been reported in association with biomedical devices such as catheters, insulin use, etc. Initially, it manifests as cellulitis that progresses to necrosis of the affected tissue with the formation of a black scab. This necrosis, as in other manifestations, is the expression of vascular invasion that clogs blood vessels and leads to tissue damage .Gastrointestinal infections occur in the severely malnourished patients undergoing organ transplantation. They usually involve mainly the stomach, ileum, colon, and liver. The clinical manifestations are non-specific, characterized by abdominal pain, nausea, vomiting, abdominal distension, and may even present with hematochezia or obstruction. In case of rupture of intestinal integrity, patients present symptoms of peritonitis .To a lesser extent, disseminated forms of the disease may also occur, affecting the kidneys, heart, and other organs. The symptoms are related to the site of infection .Clinical criteria, risk factors, histopathologic findings, cultures, and imaging studies should be considered in the diagnosis of mucormycosis, especially in health centers treating patients with COVID-19. For direct microscopic, cultural, and histopathologic analysis, it is advisable to obtain a sample of the affected tissue, preferably by biopsy, although fine-needle aspiration is also possible. Histopathological examination of tissue infected with Mucorales shows damage to the tissue and invasion of the blood vessels, accompanied by the presence of hyphae with the following characteristics:•Broad, pauciseptate hyphae.•Coenocytic to irregular branching of hyphae.•Large branching angle, approximately rectangular.Fungal culture has a variable sensitivity for diagnosis, it is advisable to send a biopsy fragment of the infected tissue. Unfortunately, the yield of mucormycosis pathogens is low, and these microorganisms may also have slow growth. Another disadvantage of biopsy is that more invasive endoscopic procedures may be required to obtain tissue, especially for infections of the lung and gastrointestinal tract, to name a few.Complementary laboratory tests may be useful and may reveal neutropenia in the white blood count, low blood pH in diabetic ketoacidosis, and positive urinary ketone levels in diabetic ketoacidosis. Imaging studies can aid in diagnosis, although it should be noted that computed tomography (CT) of the sinuses is less sensitive than magnetic resonance imaging (MRI) for detecting soft tissue invasion. CT thoracic examination with intravenous contrast is a sensitive test for detecting abnormalities in pulmonary mucormycosis, and CT of the brain may not be able to distinguish between abscesses and early infarcts .Laboratory and imaging studies are helpful, but they are not foolproof, as other pathologies may yield similar results. Early diagnosis is critical for treatment and improving prognosis. Biomarkers have been poorly studied and lack clinically approved options. Therefore, early diagnosis and monitoring of mucormycosis by detection of circulating DNA in serum is mandatory to manage the disease. A cohort study of a total 44 patients described the detection of circulating DNA in one patient with mucormycosis, which demonstrated the diagnostic utility and the accurate quantification of the fungal DNA load enabling therapeutic monitoring .Mucor/Rhizopus, Lichtheimia, or Rhizomucor, which showed very high variability and was detectable from day 9 of infection, with elevation peaks at days 15 and 38 (Cunninghamella elegans (synonym: C. bertholletiae), in which detection of Cunninghamella bertholletiae DNA in serum was highest on day 1 at 18.0 copies/ml and on day 4 (101.0 copies/ml)  .Especially in the context COVID-19 of evaluating hospital trends in mucormycosis and other fungal infections, this may become essential today. An evaluation of trends for all fungal infections should be considered which uses denominator data to calculate incidence and seasonality. It is recommended that hospitals review 12- to 24-month back microbiologic cultures and histopathologic specimens with evidence of tissue invasion by fungal hyphae to obtain an epidemiologic curve and associated hospital services or areas. If mucormycosis outbreaks are suspected, the environment should also be reviewed through a general inspection for mold, leaks, dirty HVAC systems, cleaning of the environment, construction and maintenance areas, indoor air temperature, and humidity records, including any days when humidity exceeded 60%, dates of air filter changes, etc .Aspergillus, Penicillium, Paracoccidioides, Histoplasma, Fonsecaea, and Cryptococcus). (1→3)-β-D-glucan . Candida mannan   .It is important to remember that the galactomannan levels are low in mucormycosis because Mucorales do not expose gluconic cell wall sugars on the surface of their hyphae . It has In vitro studies of specific T cells in Mucorales-infected patients could be detected only in patients with invasive mucormycosis which represented elevated production of IL-4, IFN-γ, IL-10, and to a lesser extent IL-17 and belonged to CD4+ subsets or CD8+. Nevertheless, CD8 + Mucorales-specific T cells can produce either IL-4 or IL-10, predominantly in the late phase of infection. These studies should be recruited in a larger population to demonstrate their clinical utility in diagnosing patients, especially in early forms of the disease ( disease .Rhizopus arrhizus (synonym: R. delemar and R. oryzae), L. corymbifera, M. circinelloides and C. elegans (synonym: C bertholletiae). Samples collected 3 and 4 days post-infection were positive, demonstrating the ability of LFA to provide early positive results. The highest reactivity was observed in urine samples . For this purpose, a sandwich enzyme-linked immunosorbent assay (ELISA) was developed to detect RSA levels in the serum of vaccinated mice. This proved to be of interest as RSA levels were higher in mice with mucormycosis (15.1 ng/ml) than in mice with aspergillosis (0.53 ng/ml), the latter having levels close to the negative control (0.49 ng/ml) (Another recently described possibility is the detection of 9 ng/ml) .Aspergillus fumigatus mannoprotein 1 (AFMP1), suggesting that the protein is a target for host humoral immunity  is associated with a higher risk of pneumonia and invasive fungal infections in patients with acute myeloid leukemia undergoing chemotherapy (n = 12) is associated with a higher risk of pneumonia and invasive fungal infections in patients with acute myeloid leukemia receiving chemotherapy , islet cell damage, elevated ferritin, and corticosteroid use in mainly patients with diabetes patients have led to a doubling of mucormycosis cases in India compared to 2019 and 2020. There are several clinical presentations in these patients, and the rhinocerebral form clearly predominates, although almost any organ can be affected in patients with risk factors. Diagnosis is complex, and late effects, risk factors, clinical presentation, histologic criteria, culture, molecular evidence, imaging, and laboratory testing must be considered. Currently, isolation of the fungus in an axenic culture and detection of fungal structures in histopathology are used to confirm infection. However, it is important to keep in mind that not all hospitals have staff trained in mycological diagnosis and do not have a budget for molecular detection of associated microorganisms, especially in low-resource countries, so biomarkers may be a more viable option for rapid diagnosis.In patients infected with Mucorales, time is a valuable commodity to reduce mortality. Therefore, SNPs could be of great help in determining which patients are more susceptible to mucormycosis due to mutations in TLRs. Another option could be the detection of early-emerging antigens, such as CotH or Fucomannan. Both detection of SNPs in TLRs and detection of antigens that could be a predictive factor and/or early diagnosis, especially in patients with hematologic and oncologic diseases, diabetics with ketoacidosis, and other high-risk groups. However, these possibilities should be explored in the future. Finally, epidemiologic surveillance and investigation of suspected outbreaks of mucormycosis in health care settings have again become very important, especially because of the increase in COVID-19 associated mucormycosis.JA-E and KV drafted and revised the manuscript. Both authors contributed to the article and approved the submitted version.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Presidents and executive branch agencies often have adversarial relationships. Early accounts suggest that these antagonisms may have been deeper and broader under President Trump than under any recent President. Yet careful appraisals have sometimes shown that claims about what President Trump has done to government and politics are over-stated, require greater nuance, or are just plain wrong. In this article, we use federal employment records from the Office of Personnel Management to examine rates of entry and exit at agencies across the executive branch during President Trump’s term. A key challenge in this endeavor is that agencies vary in size dramatically, and this variability makes direct comparisons of rates of entry and exit across agencies problematic. Small agencies are overrepresented among agencies with large and small rates. Yet small agencies do important work and cannot simply be ignored. To address such small-area issues, we use a Bayesian hierarchical model to generate size-adjusted rates that better reflect the fundamental uncertainty about what is happening in small agencies as well as the substantial likelihood that these entities are less unusual than raw statistics imply. Our analysis of these adjusted rates leads to three key findings. First, total employment at the end of the Trump administration was largely unchanged from where it began in January of 2017. Second, this aggregate stability masks significant variation across departments, with immigration-focused bureaus and veterans-affairs bureaus growing significantly and certain civil-rights focused bureaus exhibiting signs of stress. Finally, compared to the first terms of Presidents Bush and Obama, separation rates under President Trump were markedly higher for most agencies. New York Times, the statement was prompted by threats from Secretary of Commerce Wilbur Ross to fire top officials unless they fixed the “perceived contradiction of the President” . However, individuals’ decisions to leave their agency may also be driven by idiosyncratic personal situations such as reaching retirement-age. Similarly, an individual’s decision to seek federal employment may be driven by a desire to support a presidential administration or relocating due to a spouse’s new job. Our goal is to use rates of separation and accession to make inferences about the effect of agency-level management choices on civil servants’ career decisions across the executive branch during the Trump administration.Making inferences about agency-level management choices that affect employees’ career decisions directly using raw rates is problematic, as the following example illustrates. Suppose an agency with ten employees loses two people over some period. It will have a separation rate of 20 per 100, or more informally we might say a separation rate of 20%. If an agency staffed by a thousand loses one hundred employees over the same period, it will have a separation rate of 10%. The small agency’s raw separation rate is higher than the larger agency’s. Yet, it is not unlikely that one of the exiting employees at the smaller agency left for idiosyncratic reasons unrelated to management decisions at the agency. At the start of the Trump administration, federal agencies ranged in size from 2 non-seasonal full-time permanent employees at the Council of Economic Advisers to 680,237 at the Department of Defense. A single idiosyncratic turnover decision may have a larger influence on raw rates of smaller agencies than larger ones. Consider the bureaus of the 15 executive departments. Of the bureaus in the top 10% of separation rates, 36% have fewer than 100 employees. Similarly, of the bureaus in the bottom 10% of separation rates, 70% have fewer than 100 employees. However, only 22% of all bureaus have fewer than 100 employees. . Small bureaus are thus over-represented among bureaus with both very low and very high separation rates. Such a statistical artifact is unsurprising given their small size. Even so, it makes naive comparison of percentage changes in employment problematic.Si in agency i is driven by (a) idiosyncratic career decisions related to a civil servants’ personal situations  and by (b) environmental conditions created by Presidents and their appointees. Because of such environmental pressures, each agency is assumed to have a particular separation rate parameter μi. The actual number of separations an agency experiences over some time-frame T represents a draw from a probability distribution that depends on (i) the agency’s rate μi, (ii) the number of employees an agency has Ni, and (iii) the duration T that employment figures are observed across agencies. An agency’s separation rate parameter is related to the broader political environment of the executive branch as well as idiosyncratic factors particular to the agency. Therefore, the separation rate is itself a draw from some distribution that depends on latent, government-wide factors that are (by assumption) roughly constant throughout the Trump administration.Our approach to addressing this small-area issue relies on Bayesian hierarchical modeling. Our model formalizes intuitions and assumptions rooted in theories of political science and public administration. For ease of exposition, we will in this section refer primarily to separation rates, but conceptually the approach applies equally to accession rates. We assume that the process generating observed separation counts The following hierarchical model formalizes these notions:Si is count data. The Poisson distribution’s rate is the product of T, Ni, and μi, the former variables being observed constants and only μi being a statistical parameter. . We have assumed there exists a common distribution for each executive department for our bureau-level analysis. Bayesian methods similar to ours could be adapted to other assumptions about the appropriate grouping of agencies and bureaus. For example, agencies could be grouped by policy domain or their location in the executive establishment  to reflect different assumptions about which agencies share a common environment.μi for bureaus within the Department of Agriculture (USDA). Raw rates and posterior means are indicated to illustrate the size of the Bayesian adjustment. As expected, for small bureaus the adjustment is substantial, while for large bureaus the adjustment is negligible. The Office of the Budget and Program Analysis (OBPA) had 46 members prior to the start of the Trump administration and had 19 separations over the 4 years of our data. Its raw annual rate is 10.3 separations per 100 employees. A 90% credible interval on the bureau’s adjusted separation rate per 100 employees ranges from as low as 6.83 to as high as 11.9, with an expected rate of 9.21. Substantively, this credible interval is very wide. It goes from below the USDA’s average annual separation rate  to as much as 144% of the USDA’s average. The observed rate is at the tail-end of a 90% credible interval. Indeed, the probability of observing a rate as large or bigger under the model is only 0.08. One could argue that the small Bayesian p-value may indicate that OBPA is truly different from the others, so that the model-based adjustment for OBPA is inappropriate. However, one should bear in mind that a small number of agencies outside a 90% credible interval is expected. There are only 3 bureaus out of 29 bureaus within USDA whose raw rate is outside the 90% credible interval for that agency’s μi. Importantly, one of those bureaus—the Economic Research Service—was geographically relocated during the Trump administration causing a very high separation rate, as discussed below. Additionally, the Bayesian adjusted rates for Economic Research Service remains similar to the raw rate because of its relatively large size. For small reporting units like OBPA, one benefit of the model is that it reveals the sensitivity of the raw rates to small changes in individual employment decisions. If just a handful of people had stayed at OBPA, its raw separation rate would change drastically. The model-based adjustments are also useful in so far as it makes it harder for small agencies to drive aggregate patterns by pushing them toward the overall mean. The way the model handles larger agencies, such as the Agricultural Marketing Service (AMS), is quite different. The AMS had 1,943 employees prior to the start of the Trump administration and lost 716 over 4 years. Its raw annual separation rate of 9.21 differs little from its adjusted rate of 9.18, with a 90% credible interval ranging from 8.6 to 9.8. These rates were close to the average of all bureaus in USDA, however the fact that the AMS was “typical” is not the major explanation for its small adjustment. A brief inspection of Our initial exploratory analysis begins with an investigation into how the Bayesian adjusted separation (accession) rates differ from the raw rates. As the scatter plots on the left show, there is a pronounced size trend in the raw rates. The clusters of bureaus near 50 on the y-axes show that small bureaus experienced both relatively greater raw rates of accessions and separations and relatively lesser raw rates of separations and accessions under Trump. In other words, small bureaus are disproportionately likely to have either very low or very high rates, which we regard as a statistical artifact. The right panels show the Bayesian adjusted rates. The cluster of small bureaus near 50 has been eliminated in both figures. While there remains a significant relationship between size and these rates in both cases, the magnitudes of the slope coefficients decline by 19% for separations and 69% for accessions. In terms of separations, the trend actually reverses. Analysis of the Bayesian rates suggests that larger bureaus on average faced higher separation and lower hiring rates than smaller bureaus.We now put the Bayesian adjusted separation and accession rates to use in characterizing employment trends during the the Trump administration among permanent career civil servants. As a reminder, we subset the OPM data to non-seasonal full-time permanent civil servants, excluding non-career members of the Senior Executive Service, Schedule C appointees, and employees on the Executive Schedule pay plan. We also exclude certain small independent agencies listed in Table S.3 in the The Economic Research Service (ERS) and National Institute of Food and Agriculture (NIFA) within the Department of Agriculture are two bureaus one would expect to be deep in the lower right portion of One priority of the Trump administration that did have clear effects on personnel is immigration. The United States Citizenship and Immigration Services (USCIS), the agency in Homeland Security responsible for managing lawful immigration, experienced large net growth. Similarly, the Executive Office for Immigration Review, the agency in the Department of Justice responsible for adjudicating immigration cases, also experienced large net growth. Both of these agencies would have required more employees to enforce the Trump administration’s immigration policies. These bureaus standout relative to other bureaus within the same department.A final observation from It is difficult to see variation in Departments with a net positive growth rate or near break-even net rate that contain bureaus with heterogeneous growth rates—VA, HHS, DHS, and DOD;Departments with a net negative growth rate that contain bureaus with heterogeneous growth rates—DOC, DOT, and HUD.Departments with a net negative growth rate that contain bureaus with mostly negative growth rates—DOI, DOJ, DOL, ED, TREAS, and USDA.When interpreting Figs Our analysis thus far characterizes employment trends in the Trump administration, but does not place the Trump administration in historical context. For example, are the accession and separation rates at the EPA in the Trump administration typical of Republican administrations? To answer questions like this, we applied our Bayesian hierarchical model to data for the first terms of Presidents George W. Bush and Barack Obama. Figs In Three departments—Justice, Labor, and State—experienced a significant reversal in trend during the Trump administration. Numerous agencies have experienced significant staff reductions during the course of the Trump administration. Members of Congress, the media, and other watchdogs have previously identified some of these agencies as in crisis, notably the State Department and Environmental Protection Agency. Our analysis shows that the loss of employees at the State Department and Environmental Protection Agency are not outliers. Other agencies have suffered significant loss of staff according to our analysis—in particular the Departments of the Interior, Labor, and the Treasury—but have received much less attention.The relocation of the Economic Research Service and the National Institute of Food and Agriculture also received significant attention from the press and Congress . Our anaOur analysis also identified agencies that have been subject to intense political conflict which has had minimal effect on staffing. For example, the Federal Bureau of Investigation had a net rate of -0.98 with separation and accession rates of about 6. Similarly, Immigration and Customs Enforcement had a net rate of -0.18 also with separation and accession rates of about 6. The lack of growth at ICE despite efforts by the Trump administration that began in 2017 to hire 10,000 additional agents suggest that ICE’s stability may indicate that ICE is a bureau without sufficient staff to accomplish its mission during the Trump administration. Customs and Border Protection, which was paired with ICE in the hiring push for agents, had a net rate of 1.66. Had the hiring push at ICE been successful, the agency would have grown by about 50% , which may have been unrealistic given the hiring process at ICE.  and the Minority Business Development Agency (MBDA), which work to further civil rights, also exhibited stress due to personnel changes. The EEOC  had accession and separation rates near the 60th percentile for all agencies despite its small net loss rate, indicating a high rate of churn. The MBDA in DOC , the only federal agency solely dedicated to the growth and global competitiveness of minority business enterprises per its website, had a large net loss rate due to a separation rate at the 78th percentile and an accession rate at the 28th percentile among all bureaus. Similarly, the Offices, Boards and Divisions reporting unit in DOJ , which includes the Civil Rights Division, had a separation rate at the 71th percentile and an accession rate at the 11th percentile among all bureaus.Finally, we compared employment trends in the executive departments and EPA in the Trump administration to the Obama and Bush administrations. The primary difference between the Trump administration and the prior two administrations is the elevated separation rates under Trump at nearly all of these agencies, leaving relative net rates in the Trump administration compared to the other two to be determined by whether the agency had a similarly elevated accession rate.Many members of Congress, journalists, and scholars expressed concern about turnover in the federal workforce during the Trump administration. Our analysis helps such individuals understand employment trends across the vast executive branch and places them in recent historical context. While the federal workforce ended the Trump administration essentially where it began, that observation belies significant heterogeneity across agencies and bureaus. Some of these concerned observers focused attention on the State Department and EPA, but our analysis shows that the net loss rates at these agencies were not uncommon. Agencies like the Department of Interior and bureaus like the Minority Business Development Agency experienced larger net loss rates and have received much less attention. We also highlighted that a net rate near zero may mask large, near equal separation and accessions rates indicative of a high rate of employee churn that may harm performance. Simply looking at net changes in employee counts will not identify these cases.The personnel policies of the Trump administration have focused public attention on staffing at federal agencies. We explained that using raw counts to calculate separation and accession rates at federal agencies to make inferences about the effect of these personnel policies on working conditions is problematic due to significant heterogeneity in agency size. We presented a method to estimate rates that can be used to make reasonable interagency comparisons. Similar methods can be applied to make comparisons of other types of rates among agencies of varying sizes, including using survey data  or measures of agency politicization based on counts of appointees in an agency. We then used these estimates to characterize the impact of the Trump administration’s policies on staffing at federal agencies. We are making available our Bayesian adjusted separation and accession rates for 80 agencies and 250 bureaus in the Trump administration as well as the corresponding rates in the Bush and Obama administrations.Our study yields three primary conclusions. Total government employment at the end of the Trump presidency was approximately where it was when his presidency began. However, there was significant variation in growth rates across departments (and bureaus) with some growing, others stable, and many shrinking materially. Although this variation was in many cases not as strongly related to the policy priorities of the Trump Presidency as one might expect, we do note that the large growth rates in immigration-focused and veteran-focused agencies were consistent with these priorities. Further, signs of stress at offices focused on civil rights are also consistent with the Trump administration priorities, at least as articulated by administration critics. Finally, we show that relative to the first terms of the previous two presidents, separation rates in the Trump administration were markedly higher.S1 File(PDF)Click here for additional data file.


Rehabilitation of hearing perception in cochlear implant (CI) patients is a challenging process. A comprehensive analysis of the characteristics of hearing rehabilitation in Mandarin-speaking CI patients was conducted. We measured the aided hearing threshold (AHT) and the speech perception accuracy (SPA) and collected clinical data. A total of 49 CI patients were included. Significant linear relationships existed between the AHT and SPA. The SPA increased by about 5–7% when the AHT decreased by 5 dB. An apparent individual difference in the SPA was observed under the same AHT, which in some patients was lower than the reference value fitted by the regression model. The timing of both of cochlear implantation and rehabilitation training was found to lead to significant improvement in SPA. The SPA increases by 2.1–3.6% per year of cochlear implantation and 0.7–1.5% per year of rehabilitation training. The time of auditory deprivation can significantly reduce the SPA by about 1.0–1.6% per year. The SPA was still poor in some CI patients when the hearing compensation seemed satisfying. Early cochlear implantation and post-operative rehabilitation are essential for recovery of the patient’s SPA if the indications for cochlear implantation are met. Cochlear implantation is the most effective way to help patients with severe or extremely severe sensorineural hearing loss (SNHL) reconstruct their hearing function. However, “hearing” is not equal to “understanding”, and cochlear implant (CI) patients may still find it difficult to recover to the same level of hearing perception as ordinary people ,2,3. HeaWith the emergence of government aid policy and corporate social responsibility funding, the number of CI surgeries in China has increased. Many studies have been conducted in recent years targeting the hearing rehabilitation issue of CI patients and revealing deficits in Mandarin speech perception and pronunciation. After summarizing the research, we found that some knowledge gaps still need to be filled. First, some Western scholars have described that the improvement of surgical techniques and the upgrading and iteration of the cochlear device make hearing quality different from the past ; thus, tTherefore, a comprehensive and in-depth analysis of the characteristics of hearing rehabilitation in CI patients was conducted. We measured the AHT and the SPA and collected clinical data on hearing loss and pre- or post-operative treatment and rehabilitation. We aimed to reveal the hearing aid condition after cochlear implantation and the quantitative relationships between the AHT and SPA. Finally, we used multiple linear regression models to calculate the functional relationship between the accuracy of consonants, vowels, tones, sentence perception, and related influencing factors after controlling for the effects of AHT. The results can provide support for clinicians to improve treatment methods and guide patients to recover.From August 2020 to April 2022, CI patients who were admitted to the Department of Otorhinolaryngology—Head and Neck Surgery, Tianjin First Central Hospital, were recruited. These patients fit the indications for cochlear implantation and had undergone cochlear implantation surgery in our department . The ageEligible participants completed a structured questionnaire concerning socio-demographics, course of hearing loss, surgery, and post-operative rehabilitation with the help of medical staff.This study complied with the Declaration of Helsinki in that the Medical Ethics Committee of Tianjin First Central Hospital approved the research protocol. The review number is 2020N114KY.Before collecting the results from the AHT and SPA tests, the audiologist used an otoscope to check the ear canal for cerumen and foreign matters and checked the working condition of the hearing aid (HA) or cochlea. The audiologist also needed to adjust the parameters of the HA or the cochlea according to the patient’s AHT test results and complaints to achieve the appropriate amount of stimulation.The test was conducted in a soundproof room with a background noise of less than 30 dB (A). The subjects were seated in the middle of the room. The intersection point of the connecting line between the center of both ears and the midline of the room was used as the reference test point. The center point of the connecting line between the two loudspeakers was 1 m from the reference test point with a 45° angle of incidence and at the same height. The test sound signal was selected as a continuous warble tone, and the test began according to the frequency sequence of 1000, 2000, 4000, 1000, 500, and 250 Hz. Subjects were required to cooperate with the audiologist to complete the test and raise their hands immediately after hearing the sound. The audiologist sent a signal 20 dB below the audible hearing level, and if no response was detected, this was incremented at 5 dB until a reaction was generated. The AHT of the frequency was defined as a certain intensity that could be responded to at least twice in the three occurrences of the stimuli. The hearing threshold test for the remaining frequencies was performed according to the above steps.The test software was the “Xin Ai Fei Yang” Chinese speech testing platform, and the signal intensity was 70 dB SPL. The test contents used in this study were monosyllabic words and sentences under quiet conditions. Each test contained 25 syllables and 10 sentences with 50 keywords. Subjects were required to repeat what they heard immediately after hearing the monosyllabic words and sentences released by the loudspeaker. Monosyllabic words were scored by consonant, vowel, and tone. Sentences under quiet conditions were scored by the keywords contained in the sentence. The audiologist selected “true” or “false” in the testing platform based on the repetition of the subjects. The system calculated the correct rate of consonant, vowel, tone, and quiet sentences.Questionnaire data collected through the online data collection software could be directly converted into a structured database. The AHT and SPA test results were input through Epidata 3.1  software and were generated in the results database. To meet the statistical analysis requirements of this study, some variables were sorted out and defined. First, the frequencies of 0.5, 1, and 2 kHz accounted for 70% of language intelligibility. The World Health Organization (WHO) issued a classification standard in 1997, adding another hearing threshold of 4 kHz to fully consider the higher-frequency hearing loss of deaf people. Therefore, in this study, the average AHT of these four frequencies were taken as the AHT of the ear side (in dB). Second, the “Xin Ai Fei Yang” Chinese speech audiometric platform was used to test the perception accuracy rate or threshold of monosyllabic words, spondee words, sentences under quiet conditions, and sentences under noise. To improve the testing efficiency, this study only tested the perception accuracy rate of monosyllabic words and quiet sentences. The perception accuracy rates of monosyllabic words were divided into three dimensions for statistical analysis: (1) consonants, (2) vowels, and (3) tones. Third, the subjects were divided into unilateral and bilateral CI patients. Unilateral CI patients were subdivided into CI with HA dual-mode and wearing only a CI. When sorting out the data, the AHT and SPA of the subjects were divided into the cochlear and HA sides for statistical calculation, while for the bilateral cochlea, the average value of the AHT and SPA of both sides was used for statistical calculation. Finally, to calculate the quantitative relationship between SPA and potential influencing factors, this study selected four continuous variables to include in linear regression models: (1) time of auditory deprivation, (2) age of cochlear implantation, (3) time of cochlear implantation, and (4) time of rehabilitation training. Time of auditory deprivation was defined as the time interval (weeks) during which the patient started to feel conscious hearing loss on the side of the ear with the cochlear implantation. The time of rehabilitation training (hours) was defined as the duration (weeks) of rehabilitation training after the cochlear implantation multiplied by the average training times per week and multiplied by the average training time (hours) of each training. If the subject was still performing rehabilitation training when participating in this study, the training deadline was defined as the survey date to calculate the duration (weeks).t-test was used to compare the difference in AHT and SPA between the cochlear side and the HA side. The linear relationships between SPA of different speech dimensions and AHT were fitted by unary linear regression, and regression equations, correlation test results, and the goodness of fit (R2) were considered output. Multivariate linear regression was used to calculate the effect of time of auditory deprivation, age of cochlear implantation, time of cochlear implantation, and time of rehabilitation training on perception accuracy of consonant, vowel, and tone of monosyllabic words and sentences under quiet conditions. The variance inflation factor (VIF) was collinearity diagnostic. This multivariate linear regression adopted a three-level model correction method: (1) model 1: the SPA was used as the dependent variable, and time of auditory deprivation, age of cochlear implantation, time of cochlear implantation, and time of rehabilitation training were defined as the independent variables, and linear regression analysis was performed; (2) model 2: AHT was adjusted and added to model 1; and (3) model 3: age was adjusted and added to model 2. Because of the significant collinearity between age and age of cochlear implantation (variance inflation factor (VIF) > 10), the linear regression calculation of the age of cochlear implantation and the SPA was not determined in model 3. IBM SPSS Statistics 20.0 (IBM Inc.) was used for the statistical analysis, and p < 0.05 was defined as a statistical difference. Graphpad Prism 5 (Graph Pad Software Inc.) was used to construct forest maps and scatter maps.A one-way analysis of variance (ANOVA) was used to compare the differences in AHT of different frequencies and the differences in SPA on different speech dimensions. An independent sample A total of 49 CI patients were included in this study, of which 27 had unilateral cochlear implantation (55.1%), 16 had cochlea with HA dual mode (32.7%), and 6 underwent bilateral cochlear implantation (12.2%). The median age of the subjects was 17.2 (10.7–39.2) years old. SNHL (53.1%) and large vestibular aqueduct syndrome (LVAS) with SNHL (36.7%) were the leading causes of hearing loss. The median duration from self-reported conscious hearing loss to severe hearing loss was 0.0 (0–8.8) years. The median time of auditory deprivation was 3.0 (0.7–7.3) years, and the highest proportion was auditory deprivation within 1 year (36.7%). The median age of cochlear implantation was 13.6 (4.5–39.0) years, and the median time of cochlear implantation was 1.8 (0.1–7.4) years. Thirty-one patients (63.3%) received speech rehabilitation training after cochlear implantation. The median training intensity was 9.0 (3.3–40.0) hours per week, and the median length of the rehabilitation training was 82.7 (24.5–325.1) weeks. Other clinical characteristics of the subjects are shown in t = −3.3; p = 0.001). The forest map showed that the AHTs were lower at low frequencies than at high frequencies both on the CI and HA sides, and this characteristic seems more evident on the HA side. The analysis of variance (ANOVA) showed significant differences in AHTs at different frequencies , as shown in The AHT and SPA on the HA side of the dual-mode subjects were taken as the control group (16 cases) and compared with those on the cochlear side of all subjects. The average AHT of the cochlear side was significantly lower than that of the HA side . The ANOVA yielded no significant differences in the SPA of consonants, vowels, tones, and sentences under quiet conditions on the cochlear side . However, there is a significant difference in those on the HA side (F = 3.6: p = 0.011). The accuracy of the consonants perception was the worst (46.2% ± 23.4%), while the accuracy of the perception of the tone was the best (82.2% ± 20.6%), as shown in The average SPA of consonants, vowels, tones, and sentences in quiet conditions was 58.5% ± 34.4% on the cochlea side and 65.0% ± 29.7% on the HA side. There is no significant difference between the two sides , b = 0.04–0.07; that is, the SPA increases by 0.04% to 0.07% per week after cochlear implantation (2.1–3.6% per year). The time of auditory deprivation can significantly reduce the perception accuracy of consonants, vowels, and tones (p < 0.05), b = −0.03–(−0.02); that is, the perception accuracy decreases 0.02–0.03% per week of auditory deprivation (about 1.0–1.6% per year). However, the effect on perception accuracy of sentences under quiet conditions was not statistically significant (p = 0.132). The time of rehabilitation training could significantly improve the perception accuracy of consonants and vowels (p < 0.05) but had no significant effect on tone and sentences under quiet conditions, b = 0.001–0.002; that is, the perception accuracy of consonants and vowels increases by 0.001% to 0.002% per hour of rehabilitation training . The age of cochlear implantation had no significant effect on the perception accuracy of consonants, vowels, tones, and sentences under quiet conditions . More details shown in The time of cochlear implantation can significantly improve the perception accuracy of consonants, vowels, tones, and sentences under quiet conditions. Especially after adjusting for AHT and age, the effect is still robust . The time of auditory deprivation can significantly reduce patients’ SPA by 1.0% to 1.6% per year. Moreover, the accuracy of sentence perception did not appear to be susceptible to auditory deprivation or rehabilitation training.By comparing the difference in AHT and SPA between the cochlear and the HA sides, two characteristics were found. First, both CI and HA showed that the hearing compensation of low frequencies was better than that of high frequencies, and it seems that the cochlea has better high-frequency hearing compensation when compared with the HA . AlthougWe found a significant linear relationship between AHT and SPA. For every 5 dB decrease in the AHT, the SPA increased by 5% to 7% . PreviouIn addition, we found that this phenomenon shows different characteristics of the relationship between the accuracy of sentence perception under quiet conditions and the AHT on the cochlear and HA sides. The scatter plot shows that the increase in AHT at the HA side did not significantly affect the accuracy of sentence perception, and the accuracy of most patients is still close to 100%; however, on the cochlear side, decreasing the AHT did not lead to a significant improvement in the accuracy of sentence perception, and the accuracy of most patients was still less than 20%. Some scholars have previously described the concept of “integration of multiple language cues”. The auditory center will integrate multiple language cues of sentences and combine them with its own auditory experience to conduct a comprehensive perception . Thus, ip = 0.057). This phenomenon is similar to the aforementioned functional relationship between the AHT and sentence perception accuracy, suggesting that sentence perception requires more complex “multiple language cues integration”. The improvement or reduction in monosyllabic word perception caused by factors such as hearing rehabilitation training and auditory deprivation may not significantly affect the perception accuracy of a whole sentence in a short time, so we deduced that sentence perception might require a higher rehabilitation threshold of hearing.The available research has proven that many related factors may affect SPA after cochlear implantation ,7,8,9,10Although this study is as rigorous as possible from the point of view of the test of AHT and SPA in addition to the collection and estimation of clinical data on hearing loss and pre- or post-operative treatment and rehabilitation, some limitations should still be described. First, as the number of patients with CIs is relatively low in our daily practice, especially the CI with HA dual-mode patients, the number of samples included in this study cannot lead to an unbiased estimation of the characteristics of the entire CI population. Limited sample size is not competent for more sophisticated analysis to reveal the different characteristics among different age populations. However, the available data have already preliminarily revealed speech perception characteristics in CI patients so that an enlarged sample size may yield a more accurate prediction. Second, many factors of hearing loss and pre- or post-operative treatment and rehabilitation affect hearing rehabilitation, and an interaction between different factors amplifying or antagonizing the effect on speech perception may exist. This study only analyses the clinical data we can collect and controls the effect of AHT and age through multivariate linear regression to diminish the confounding effect. Third, the characteristics of hearing loss, the degradation of the hearing center after hearing deprivation, and the restoration of hearing function after cochlear implantation in patients are very complex, dynamic change processes. The functional model cannot accurately fit this process. We showed that factors of hearing loss and pre- or post-operative treatment and rehabilitation might have different levels of effect on hearing rehabilitation and then preliminarily quantified the intensities of these factors. Due to the limited number of samples, this study did not calculate the functional relationship in each subgroup after stratified grouping of the subjects according to such characteristics as age or hearing loss.Decreasing AHT could lead to an increase in SPA in CI patients. However, some patients’ speech perception was still poor when the hearing compensation seemed satisfactory. Some factors of hearing loss and pre- or post-operative treatment and rehabilitation other than the cochlear device could significantly affect speech perception. This study quantifies the effect intensity of these factors, suggesting that if the indications for cochlear implantation are met, cochlear implantation and post-operative rehabilitation training can be carried out as early as possible, which is efficacious in improving speech perception.


Pre-operative assessments before cochlear implantation (CI) includes the examination of both tone hearing, and the level of the cochlear reserve indicated by speech understanding. The goal of this study was to explore the predictive influence of tone hearing and cochlear reserve in CI.We did a retrospective cohort study, which included adult patients who had undergone CI between January 2012 and December 2019 in a tertiary care center. The pre-operative tone hearing, unaided maximum monosyllabic word recognition score (WRSmax), aided hearing gain, aided monosyllabic word recognition score at 65 dB (WRS65(HA)), and speech perception gap (SPG) were measured. The duration of unaided hearing loss (UHL) was also assessed. These variables were compared with post-operative monosyllabic word recognition score after CI at 65 dB (WRS65(CI)).103 patients and 128 ears were included in this study. Regardless of tone hearing, patients with better pre-operative WRSmax and WRS65(HA) performed better post-operatively. WRSmax was found to be the most important factor that was statistically significantly associated with WRS65(CI). SPG was statistically significantly associated with WRSmax and SPG ≥ 20% group performed better post-operatively. Any duration of unaided hearing loss was statistically significantly inversely associated with WRSmax above 0%.Cochlear reserve represented by WRSmax may play the most important role as a predictive factor in outcomes after CI. SPG should be considered for indicating CI in patients, when WRS65(HA) does not reach WRSmax. Early rehabilitation with hearing aids and duration of hearing aid usage might play an important role in preserving cochlear reserve in adults. Hearing loss affects more than 70% of the population aged 60 years and above worldwide and thus poses a significant threat to the quality of life and cognitive outcomes, particularly as life expectancy increases , 27. HeaRecent technological advances of various components of the implant systems and improvements in surgical techniques have resulted in massive changes in candidacy criteria for CI in the last years. During the initial years of CI, only patients who were functionally profoundly deaf and had no speech perception with best-fitting hearing aids were considered as candidates for a CI. In recent years, the audiological indication criteria have become increasingly wider , 13.In today’s context, many patients still have enough residual hearing and yet receive CI, since they do not benefit from hearing aids. Particularly for these patients, the individual prognosis of post-operative speech perception with respect to the preoperative assessment is an absolute clinical necessity. Patients need to be counselled accordingly before CI, since there is always the risk of impaired residual hearing , 18.The pre-operative assessment before CI in patients includes the examination of both tone hearing, as well as the level of cochlear reserve, as indicated by speech understanding. Although it may seem intuitive that patients with better pre-operative tone hearing and a better pre-operative speech understanding should be associated with an improved speech comprehension after treatment with CI, viewpoints among otologists regarding the significance of each pre-operative parameter vary and the definitive identification of predictive factors remains elusive .In daily clinical practice, we often experience that when patients with bilateral severe to profound sensorineural hearing loss and bad speech understanding receive CI on one side, the post-operative speech understanding seems to vary widely, with an outcome of the hearing rehabilitation ranging from absolutely unsatisfying to quite satisfactory . This vaThe goal of this study was to explore the predictive influence of tone hearing, as well the influence of the cochlear reserve, indicated by pre-operative speech understanding, on speech comprehension after hearing rehabilitation. Included were patients with unilateral CI and contralateral severe to profound sensorineural hearing loss. Further, the study aims to explore the role of the duration of deafness and the duration of usage of hearing aids prior to CI for hearing outcome.After obtaining approval of ethics committee of the medical faculty at the University (114/21), audiometric data from CI recipients were retrospectively queried using the electronic medical record and the CI registry. This was a retrospective cohort study which included patients who received CI from January 2012 to December 2019 at a tertiary care and cochlear implant center in Germany. The inclusion criteria were (1) Adults 18 or older of age, (2) Contralateral ear showed at least moderate or severe to profound hearing loss, (3) German speaker and (4) Post-lingual hearing loss. The exclusion criteria were (1) No cognitive disabilities, (2) No cochlear malformations, (3) No left corner hearing curve that is less than 40 dB hearing threshold across low frequencies and severe to profound hearing loss at high frequencies.In the German speaking countries, monosyllabic and sentence tests are routinely used to evaluate patients with hearing aid and patients who receive CI. The Freiburg monosyllabic test is universally used in Germany, and it is conducted with headphones within the standardized speech audiogram as well as in the free field situation with hearing aids or with CI. This yields information about speech intelligibility at conversation levels and at the maximum frequency possible close to discomfort level.In our center, the usual pre-operative audiological tests include the unaided pure ton audiogram and the aided hearing gain. The pure tone audiogram without hearing aid was measured and an average of the decibels measured at 500 Hz, 1, 2 und 4 kHz was taken as PTA4 (pure ton average of four frequencies). Similarly, the hearing again with hearing aid was measured and an average of the gains measured at 500 Hz, 1, 2 und 4 kHz was taken as FNA4 (fresh noise average of four frequencies). Then the unaided maximum recognition score (WRSmax) for phonemically balanced monosyllabic words was measured near the discomfort level using air-conduction headphones, which was usually at 110 decibels. Following WRSmax, the score for recognition of phonemically balanced monosyllabic words at conversation level of 65 dB with hearing aid was measured and referred to as WRS65(HA). WRS65(HA) was usually measured in free field in a non-echoic booth at 65 dB. The contralateral ear was always masked appropriately with wideband noise also presented using headphones. It was ensured that the hearing aid provided adequate amplification to ensure best aided hearing possibly achieved in the given patient. The speech perception gap (SPG) was measured for each ear from subtracting WRS65(HA) from WRSmax. A SPG equal to or greater than 20% was considered as a ‘high SPG’ based on prior literature and the cohort was grouped accordingly for further analysis [y- and x-axis, respectively, and the cohort was divided into four groups . The cut-off for PTA4 was taken at 80 dB to differentiate moderate and severe hearing loss from profound hearing loss. A cut-off value for WRSmax was taken at 50% to differentiate relatively better speech perception from bad speech perception, since 50% was originally used as the cut-off value for CI indication. Following this, FNA4 and the WRS65(HA) were plotted across y- and x-axis, respectively, and the cohort was again divided into four groups . The cut-off for FNA4 was 60 dB to differentiate relatively better hearing gain with hearing aid from lesser gain with hearing aid. The cut-off for WRS65(HA) was taken at 50%, since a speech perception above 50% was considered too good for CI until recently.PTA4 and WRSmax were plotted across Based on the WRSmax for each ear the cohort was again divided into two groups: (1) ears with 0% WRSmax were designated as WRSmax0 and (2) ears with more than 0% WRSmax were designated as WRSmax > 0.An approximate duration of hearing loss and duration of hearing aid usage in months were extracted from the patient files. The duration of hearing aid usage was subtracted from the duration of hearing loss and the results were taken as the duration of unaided hearing loss (UHL) in months. UHL was then categorized into two groups: group 1 with zero values where in it was assumed that the ear had very minimal unaided hearing loss in months (UHL0) and group 2 where in the ear with hearing loss for any duration and was not supported with the help of a hearing aid during this time (UHL > 0). Group 1 with no UHL does not necessarily mean that the patients with any hearing loss immediately received hearing aid, since this variable was taken retrospectively, where patients were asked the question “since how long do you suffer from debilitating hearing loss and since how long do you use hearing aid?”.t test and chi square tests. The post-operative speech audiometry results were compared among the three groups using Mann–Whitney test. The characteristics of the three distinct groups were compared using Chi-square test. Univariate linear regression was used to identify the possible associations between preoperative audiological tests, pre-operative duration of deafness and duration of hearing aid usage and post-operative outcome. Finally, correlation between pre-operative duration of deafness in years and the post-operative outcome were assessed using Spearman’s correlation coefficient. Group differences were considered significant if p value was less than 0.05. All analyses were performed using Stata 14.0 .Pre-operative speech audiometry results, obtained using high power hearing aids, were compared with post-operative speech audiometry results using two sample From January 2012 to December 2019, 471 patients received cochlear implantation in the tertiary care center. From these, 103 adult patients fulfilled the inclusion criteria. Of these, 25 patients received bilateral CI.The study population included 55 females and 44 males with the mean age of 63 ± 7 years. We analyzed each ear as an entity and thus 128 ears were included. The contralateral ear showed moderate or severe to profound hearing loss. The mean PTA4 was 93.7 ± 17 decibels . The mean FNA4 was 61.3 ± 18 decibels . The mean unaided WRSmax was 28 ± 28.8%  and the mean WRS65(HA) was 23 ± 20% . The overall SPG for the cohort was 6.3% .The four groups  and the post-CI results for these groups are shown in Table Similarly, the other four groups  and the post-CI results are shown in Table The size of the WRSmax0 group was 41 (32%) and WRSmax > 0 was found in 78 ears (61%). The mean WRS65(CI) for WRSmax0 was 47.3 ± 30% (median = 55%) showing varied results with a minimum of 0% and a maximum of 90%. In comparison the WRSmax > 0 group performed better with a mean WRS65(CI) of 61.3 ± 26% . Although the difference in median between the two groups was minimal, the difference in means between two groups was statistically significant (Difference 14 (95%CI 3.5–24.5) t statistic 2.646, P value 0.0093). Thus, in a normally distributed population, WRSmax > 0 group performed statistically significantly better with CI than WRSmax0 group.p value = 0.000) as shown in Graph p value = 0.050).The results of analysis of WRS65(CI) are shown in Table p value = 0.000), but no associations were found between SPG and WRS65(HA)  . To conclude as WRSmax increases, SPG increases significantly with SPG ≥ 20% group performing better than SPG < 20% group post-operatively.SPG was analyzed across two variables (WRSmax and WRS65(HA)). A positive linear association exists between SPG and WRSmax  was 78.1 ± 152 months, while the median was found to be 0 showing that more than 50% of the ears had minimal UHL and, therefore, minimal auditory deprivation. There was no statistically significant association between UHL and WRS65(CI). UHL was not associated with SPG. After categorization, the number of ears with UHL0 was 58 and UHL > 0 was 40 . There was no difference between the mean WRS65(CI) for the two groups . Group UHL > 0 was statistically significantly inversely associated with WRSmax > 0 in the univariate linear regression . Group UHL > 0 was not associated with CI65(HA) or with SPG. Thus, in patients with any time duration, wherein the hearing loss was unaided, WRSmax > 0 was significantly lower.The mean UHL  received a bilateral CI. This reflects the where a lot of adult patients who receive a CI are affected on both sides, but receive CI on only one side and continue to function with hearing aids on the opposite side, termed as bimodal hearing [Especially in these cases, predicting outcomes after unilateral CI plays an important role in pre-operative counselling. The usual predictors quoted in literature are first, duration of deafness, where in more than 10 years of deafness is a negative factor, and second, pre-operative audiological scores and third, etiology of deafness . In caseAmong the various pre-operative speech understanding tests, even though WRS65(HA) is main the test used for CI indication, WRSmax plays a more important role in predicting the post-operative outcomes especially in post-lingually deaf adults . WRSmax When discussing WRSmax in detail it should not be forgotten that there are always inherently two groups when considering CI: group with no reserve that is 0% WRSmax and a group with some reserve that is WRSmax above 0%. These groups have been reported to perform differently after CI; the cochlear reserve group understandably performing better than the group with no reserve , 15. ThiWhen fitting hearing aids, patients are not routinely placed back in the testing booth to determine whether WRS65(HA) approaches WRSmax. Hearing aid providers typically operate under the assumption that the real-life hearing aid performance reaches the WRSmax. This is also because the recommendations tend to only include WRS65(HA) as an important means to verify the function of hearing aids , 8. ThisEven though the duration of hearing loss is an established factor affecting the outcome after CI, our study did not show such results. We attribute this to our small study population. The variable was collected from patient history and was perhaps not reliable. Another important factor in this study was the duration of hearing aid usage across the time the patients suffered from hearing loss. This could represent auditory deprivation and play a role in preserving the cochlear reserve and thus indirectly affect the outcome after CI. Our study measured this auditory deprivation as UHL. We found that even though there is no significant difference in outcome between minimal auditory deprivation group (UHL0) and the group with some to significant auditory deprivation (UHL > 0), the second group (UHL > 0) with a minimum of 12 months to a maximum of 624 months UHL was statistically significantly inversely associated with WRSmax > 0. This result should be interpreted with caution, since these data were also gathered from patient history and presents only an approximate value. Further research in this area is needed to determine the exact effect of the hearing aid usage on results after CI. However, early rehabilitation of patients with hearing aid who suffer from bad speech understanding regardless of tone hearing should still be considered.As more and more patients with cochlear reserve are considered for hearing rehabilitation, superior hearing performance is the ultimate goal. Combining electrical stimulation through CI and acoustic amplification through hearing aids can enhance hearing performance. CI allows the damaged parts of the cochlea to be bypassed and provides electrical representation of the sound directly to the hearing nerve which is in turn interpreted by the brain. While the cues that are needed for speech understanding are usually extracted and preserved in patients receiving CI, full representation of the signal can still be limited. This is especially true for low frequency cues. While mid- and high frequency cues of consonant articulation are well conveyed by the CI, low frequency cues of voicing and fundamental frequency are conveyed poorly . The quaAnother form of combining electric stimulation and acoustic amplification is through the use of hybrid implants . Hybrid In this study we have only looked at the role of tone and hearing and speech understanding in patients with CI. Other factors such as surgical techniques, device factors and implant models used haven been shown to affect post-operative performance after CI. These were not included in this study and this may limit the interpretation of the multivariate analysis. Relatively small sample size is another limitation of the study. We, therefore, included all patients in the analysis and the outliers (extremely good or bad performers after CI) were not analyzed separately. This might reduce the generalizability of the results.Cochlear reserve represented by WRSmax may play the most important role as a predictive factor of outcomes after CI and to a lesser extent WRS65(HA) and SPG. Tone hearing on the other hand seems to play a very minimal role, if any, in determining outcomes after CI. We suggest fitting hearing aids based on both WRSmax and WRS65(HA), with SPG being routinely measured. SPG may be considered when rehabilitating patients with good tone hearing and bad speech understanding. Further studies in exploring duration of usage of hearing aid in preserving cochlear reserve and thus improvement in optimal hearing aid usage are needed.


Hearing loss is a global public health issue with disproportionate negative impacts on those who live in rural regions, such as Appalachia. This commentary provides an overview of hearing health and healthcare disparities in rural regions along with discussion of the significance of recent research findings which highlight the incidence of hearing loss and the shortage of hearing specialists in Appalachia. Journal of Appalachian Health by Pudrith et al.Hearing loss is a major global public health problem. According to the 2021 World Report on Hearing, approximately 1.5 billion people, including adults and children, worldwide have hearing loss.Hearing loss is medical condition that involves multi-specialty hearing healthcare specialists such as otolaryngologists and audiologists and may be managed with a variety of medical, surgical, and technological treatments. The lack of hearing healthcare access, utilization, and affordability continues to play a major role in preventing timely diagnosis and treatment of hearing loss. The inaccessibility and under-utilization of hearing healthcare is amplified in vulnerable populations, such as rural adults. Approximately 20% of the US population reside in rural areas and rural Americans tend to be poorer, less educated, suffer higher rates of disease and disability, and are more likely to be uninsured than their urban counterparts.19Against this backdrop of hearing loss significance and long-standing rural hearing healthcare disparities, this manuscript presents novel findings regarding hearing loss prevalence and audiological disparities in Appalachia. Much of what we know about rural hearing loss prevalence and accessibility to hearing healthcare specialists in rural regions is based on work outside the Unites States or in non-Appalachian regions of the U.S. This manuscript utilizes a combination of population databases to conduct their univariate and multivariate analysis comparing Appalachian regions with non-Appalachian regions. The authors have quantified the higher incidence of subjective hearing loss among Appalachian residents and through their multiple linear regression analyses have presented data that demonstrates that Appalachian residence, apart from rural residence, is independently associated with a higher incidence of hearing loss. Furthermore, their pairwise linear regression data provides us with a deeper understanding of the disparity at hand by quantifing that relationship between rurality, prevalence of hearing loss, and the shortage of audiologists. While we neither understand the causes underlying this health disparity nor the solution to this problem, this study gives us clearly articulated evidence that helps us understand this disparity better. This data pushes us to consider how specialty care can be delivered to vulnerable populations in remote locations. Considerable innovation is needed to address rural and Appalachian hearing health and healthcare disparities. New models and methods for care delivery are needed to explore how to deliver specialty healthcare when there are no or very few specialists nearby. Research related to hearing loss may be less familiar for the readers of this journal; however, I encourage readers to consider the importance of work such as this to define and describe a complex health disparity issue within a resource-limited region such as Appalachia.